Being diagnosed with cancer is overwhelming, especially in the first few days where it can feel like being on a rollercoaster when you are sent from pillar to post for different blood tests and scans and seeing a myriad of different specialists in a very short space of time. It’s important to understand why the team caring for you insists on certain tests before treatment can start.
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Confirming the Big C
The most important workup required is pathology confirmation of a diagnosis of cancer. An example is the breast biopsy, that is done after a suspicious lump is seen on a mammogram and sonar, where the radiologist does a sonar-guided core biopsy (thick needle inserted under local anaesthetic).
Similarly, a suspicious prostate-specific antigen (PSA) blood test may lead a urologist to do a prostate biopsy to get a tissue sample of the prostate.
Where possible, it’s always better to do a core biopsy than a fine needle aspirate, as you get more tissue which is more accurate and can guide treatment decisions better.
Different kinds of imaging are done depending on the type of cancer diagnosed. Some cancers may not require any further workup, for example, small fully excised non-melanoma skin cancers. Most cancers will have some scans done as part of the staging workup before deciding on the best treatment options.
Guidelines about eating and drinking before your scan or preparing for it by taking oral contrast will vary between the types of scans. Unless you are told otherwise, take your regular medications as usual. Leave jewellery at home and wear loose, comfortable clothing. You may be asked to wear a gown. Female patients please always inform your doctor and the radiology/nuclear medicine unit if there is any possibility that you may be pregnant or are breastfeeding. If you have a known allergy to intravenous contrast, the radiologist may prescribe medications to reduce the risk of an allergic reaction.
Ultrasound is often one of the first scans you may have, for example, a breast, prostate or gynae ultrasound. The doctor holds a probe in their hand that sends sound waves and looks at a screen in real-time to interpret images. It’s painless, quick, and non-invasive and is often the first screening scan followed by other scans that give better anatomical accuracy.
You may be sent for a chest X-ray to check the lungs before surgery or as part of the staging workup. Some cancers may have multiple areas of bone involvement, such as in multiple myeloma, and a skeletal survey (all the bones) may be requested.
Computerised tomography (CT) scans are often deployed to get a good overall picture (staging CT) of the stage of the cancer. Not all cancers need a staging CT scan; CT scans are requested according to international guidelines. CT scanning is quick (10 – 15 minutes), painless, non-invasive (except for a drip if intravenous contrast is given) and accurate. During cancer treatment, you may go for a staging CT scan a few times a year.
Magnetic resonance imaging (MRI) is a type of scan that uses a strong magnetic field to create images that are often more accurate than a CT scan for specific areas, for example the brain. The radiology department will give you a questionnaire before the MRI. Most surgical implants and cardiac pacemakers are now MRI compatible, but it’s important to discuss them with the radiology team. You would need to remove all metal before going into the MRI room.
Since MRIs can show soft tissue very well, it’s often used to define the size and invasion of some cancers to help prepare for surgery or to decide on preoperative treatment e.g. a pelvic or breast MRI. MRIs will typically take longer than CT scans, about an hour or two, and may be claustrophobic for you. It also makes a constant knocking noise that can disturb you. If you have claustrophobia, it’s advisable to discuss a mild anti-anxiety medication with your doctor before the MRI.
Nuclear medicine scans, for example, positron emission tomography (PET) scans, uses low doses of radioactive materials called radiotracers or radiopharmaceuticals to image organ and tissue function with a special camera that detects gamma ray emissions from the radiotracer. It’s non-invasive and painless, apart from the intravenous injections. It gives metabolic information and can be used both for diagnostic and therapeutic purposes.
Blood tests will depend on the type of cancer and may also be done to check kidney function before imaging or to prepare for surgery.
Dr Mia Hugo is a radiation oncologist in private practice. She participates in weekly multi-disciplinary oncology team meetings for breast, urology, gastrointestinal, gynaecological, and head and neck cancers. She provides radiation to patients at Wits Donald Gordon, Netcare Milpark, Pinehaven and Olivedale hospitals, as well as at Busamed and 200 Rivonia Medical Centre.
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