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TITLE OF CASE

A successful integrative approach for cancer care - A case report

Dr Zankhana Buch

ABSTRACT

A 57-year-old female patient, presented with difficulty in swallowing food, loss of appetite and significant weight loss for 4-5 months. She was able to take only a soft diet and liquids. She aslo had abdominal pain on & off. There was no prior consultation. The patient consulted Dr Zankhana, who recommended Invasive investigations like OGD/HPE/PET-CT Scan. Based on the reports, the biomedical diagnosis was confirmed as moderately differentiated squamous cell carcinoma of the esophagus, grade -2. She was directed to an Oncologist, who advised Chemotherapy and Radiation therapy followed by surgical resection. An integrative approach was advocated for the management of this clinical condition. The Ayurvedic diagnosis was Arbuda.  The line of ayurvedic treatment followed was dipana, pacana, balya and ojo vardhana. The medicines also targeted at addressing the symptoms like lack of sleep, colic and stress. The Chemo and radiation therapy were also carried on as scheduled by her oncologist. Based on the Patient-reported outcome scale and the Physician outcome scale, it was evident that there was a significant change in the symptoms. After 1 month of treatment, she was able to take solid food. There were no episodes of vomiting or burning sensation in the abdomen. VAS recorded 10 at baseline reduced to 3. After 2 months of treatment, there was a significant improvement in the WBC and platelet count. After 3 months of treatment,  she underwent surgery for tumour removal. Last follow-up done was after 7 months, which revealed the patient was fully back to her normal routine. PET revealed a tumor-free status. This case report demonstrates the successful intergrative management of Esophageal cancer. 

KEYWORDS

Integrative, cancer, arbuda, case report

INTRODUCTION

Esophageal cancer is cancer that occurs in the esophagus — a long, hollow tube that runs from your throat to your stomach. Your esophagus helps move the food you swallow from the back of your throat to your stomach to be digested.Esophageal cancer usually begins in the cells that line the inside of the esophagus. Esophageal cancer can occur anywhere along the esophagus. More men than women get esophageal cancer.

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Incidence rates vary within different geographic locations. In some regions, higher rates of esophageal cancer may be attributed to tobacco and alcohol use or particular nutritional habits and obesity.

Signs and symptoms of esophageal cancer include:

• Difficulty swallowing (dysphagia)
• Weight loss without trying
• Chest pain, pressure or burning
• Worsening indigestion or heartburn
• Coughing or hoarseness

Early esophageal cancer typically causes no signs or symptoms.

Causes

It's not exactly clear what causes esophageal cancer. Esophageal cancer occurs when cells in the esophagus develop changes (mutations) in their DNA. The changes make cells grow and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body.

Types of Esophageal cancer: It can be adenocarcinoma, squamous cell carcinoma, or rare types like sarcoma, lymphoma, melanoma and choriocarcinoma.  

Complications

As esophageal cancer advances, it can cause complications, such as:

• Obstruction of the esophagus. Cancer may make it difficult for food and liquid to pass through your esophagus.
• Pain. Advanced esophageal cancer can cause pain.
• Bleeding in the esophagus. Esophageal cancer can cause bleeding. Though bleeding is usually gradual, it can be sudden and severe at times.

Diagnosis: Barium swallow study, endoscopy and biopsy are the common diagnostic tools used. To determine the extent of the spread of cancer, Bronchoscopy, Endoscopic ultrasound (EUS), Computerized tomography (CT) and Positron emission tomography (PET) will be done. With these techniques, the stage of the cancer will be determined, that also plays a crucial role in deciding the treatment.

Treatment & prognosis: The treatment chosen will vary depending upon the stage, and the condition of the patient. The general treatments advocated are Therapies like  endoscopic mucosal resection, radiofrequency ablation or photodynamic therapy. These treatments cause minimal esophageal trauma, have a low risk of complications and preserve the esophagus. The other options includes chemotherapy, radiation therapy, proton beam therapy, and minimally invasive and traditional operations, such as esophagectomy. About 15% of people diagnosed with esophageal cancer will survive for at least 5 years. Relative survival looks at how likely people with cancer are to survive after their diagnosis compared to people in the general population who do not have cancer, but who share similar characteristics. 

PATIENT INFORMATION

In this case report, a 57 year old female patient presented with difficulty  in swallowing food, loss of appetite and significant weight loss since 4-5months. She was able to take only soft diet, liquids.

There was no prior consultation or medication. The Ayurvedic doctor, referred the patient to a Multispecialty hospital, for invasive investigations and the Biomedical diagnosis was confirmed as Carcinoma Oesophagus/GEJ. She was prescribed a schedule of chemotherapy, and an intergrative approach was followed to manage the condition of the patient. 

No relevant Family/surgical/genetic history.

Psychosocial History- Socio economic status - Poor

Addictions- Nil

CLINICAL FINDINGS

General condition: Stable, Afebrile P0 E0 N0 C0 I0 L0 GENERAL FINDINGS:
Sleep: Disturbed Appetite: Manda
Bowel: Saama: Micturition: Normal: Vitality: Poor: Well-being: Poor:
Blood pressure:130/80 mm of Hg: Pulse:78/min:
SpO2: 97% 

Clinical examination:
CVS: S1, S2 heard
RS: left side reduced breath sounds PA: Soft, non-tender
CNS: Stable, oriented, drowsy
MS: Not-Affected: 

Samprapti ghataka

DOSHA: Pitta Kapha
DUSHYA: Rasa, Rakta, Mamsa
AMA: Both Jatharagni & Dhatuagni
SROTAS: Rasa, Rakta, Mamsa
SROTODUSHTI: Sanga, Vimargagamana

TIMELINE

Image 1. Timeline of events added below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter; The patient had a confirmed biomedical diagnosis based on OGD, Biopsy and PET CT SCAN REPORTS.  

Image 2. Proof of diagnosis at baseline from the multispecialty hospital dated 23.6.2021

Image 3. Advanced endoscopy imaging dated 23.6.2021

Ayurvedic Assessment was done based on the presenting complaints and clinical evaluation. The treating physician confirmed the Ayurvedic diagnosis as Arbuda. 

Baseline evaluation 

Table 1. Physician outcome scale before treatment 

Criteria	Before Treatment
Difficulty in swallowing 50%	1
Feels always an empty stomach, burning sensation in stomach 50%	1

Differential Diagnosis- Achalasia, Esophageal stricture, Esophageal leiomyoma. In this case report, OGD and upon further Biopsy– GE Junction which revealed moderately differentiated squamous cell carcinoma, Grade -2.

Prognosis: Esophageal cancer is a deadly malignancy with very low survival, even with treatment. Surgery has slightly increased survival rates, but the postoperative complications are often serious, and the quality of life is poor. In this case report, integrative treatment could enhance the quality of life, minimise the side effects after CT RT, No delay in CT RT. After Surgical resection there was no history of secondary infections reported and the patient resumed normalcy faster.

THERAPEUTIC INTERVENTION

Refer the tab ‘Treatment’ in the Portal. 

FOLLOW-UP AND OUTCOMES

The patient had 21 follow ups in total. The subjective and objective parameters were the primary assessment modality. 

Clinician-based assessment; 

Enhanced quality of life
Minimum side effects during 5 weeks of CT RT
No delay in CT RT
Surgical resection as planned
Post surgery : PET CT : Excellent Response: Tumor Free Status
No history of secondary infections reported
Resumed normalcy faster

Physician, Patient and outcome scale were documented before, during and after treatment to analyse the outcome of the treatments. 

Patient-assessed; Not relevant

Image 4. Physician outcome scale before, during and after treatment charted

Image 5. Patient outcome scale before, during and after treatment charted

Image 6. WBC count monitored throughout the treatment 

Image 7. PET-CT Scan dated 17.09.2021 indicated a tumor free status

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well. 

Method of assessment- Lab investigations, images, questionnaire and symptom evaluation were the primary assessment criteria. 

Adverse and unanticipated events; None reported

DISCUSSION: 

Esophageal cancer is a deadly malignancy with very low survival, even with treatment. Surgery has slightly increased survival rates, but the postoperative complications are often serious, and the quality of life is poor. In this case report, integrative treatment could enhance the quality of life, minimise the side effects after CT RT, No delay in CT RT. After Surgical resection there was no history of secondary infections reported and the patient resumed normalcy faster.

The rationale of treatment as explained by the physician for selecting the particular medicine and therapy is elaborated. 

Dhanwantaram gutika- Improves sleep quality, induces relaxation by relieving stress thereby promotes healing

Aswagandhadi lehyam- To relieve pain in abdomen, increase appetite, improve digestion and absorption.

Astachurnam- To improve sleep, relieve stress, promote healing 

Shiro abhyangam- Increases strength by activating metabolism, relieves stress, brings relaxation 

Sarvanga Ksheera dhara - Vatapittahara, improve strength and mobility

Sarvanga Jambeera Pinda sweda- To improve blood circulation, muscle relaxation

Sarvanga Abhyanga- Vatahara, Balya, Brimhana

Bashpa Sweda- To improve Range of movement

Shiro basti- To relive stress, improve sleep and QOL

Shirodhara- To relieve stress, Vatashamana

Matra vasti- Balajanana, Vatahara

PATIENT’S PERSPECTIVE

Not available. 

LEARNING POINTS/TAKE HOME MESSAGES 

This case underscores the significant clinical efficacy of Ayurveda as a supportive therapy in cancer treatment, ensuring an enhanced quality of life with minimal side effects during the 5 weeks of CT RT. Post-surgery, the PET CT scan showed an excellent response with a tumor-free status, and there were no reported secondary infections. Patients also resumed normalcy faster with the use of Ayurveda alongside conventional cancer treatments.

INFORMED CONSENT

Written consent obtained from patient for publishing of the case report in the Portal 

ACKNOWLEDGEMENTS

None

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. https://www.mayoclinic.org/diseases-conditions/esophageal-cancer/symptoms-causes/syc-20356084
2. https://www.mayoclinic.org/tests-procedures/esophagectomy/about/pac-20385084
3. Sushruta Samhita. Nidanam Chapter 11. 
4. https://www.easyayurveda.com/2014/01/22/cancer-ayurvedic-understanding-hopeful-treatment-modalities/