Common Neoplastic Disorders and Their Management, with the Role of Ayurveda in Cancer and Palliative Care (25-mark note)

1. Introduction and definitions

• Neoplasm is an abnormal, autonomous, purposeless new growth of cells that persists after the stimulus is removed.
• Benign neoplasms are localised, encapsulated, slow-growing and do not metastasise. Malignant neoplasms invade, metastasise and show anaplasia.
• Classification by tissue of origin:
  • Epithelial: carcinoma (squamous cell, adenocarcinoma)
  • Mesenchymal: sarcoma
  • Haematological: leukaemia, lymphoma, myeloma
  • Neural and germ cell tumours
• Tumour growth: tumours follow a Gompertzian curve. A tumour is usually detected at about 10^9 cells (1 cm³), and the patient dies at about 10^12 cells (about 1 kg). The fastest growth occurs before the tumour can be detected (Harrison's Principles of Internal Medicine 22E, Ch. 78).

2. Aetiology and risk factors

3. Common neoplastic disorders

4. General management strategy

Principles

1. Confirm the diagnosis: history, examination, imaging, tissue biopsy (histology, immunohistochemistry, molecular markers).
2. Stage the disease: TNM staging, performance status (ECOG), comorbidities.
3. Define the goal: "The goal of cancer treatment is first to eradicate the cancer. If this is not possible, the goal shifts to palliation: amelioration of symptoms and preservation of quality of life while striving to extend life" (Harrison's 22E, Ch. 78).
4. Multidisciplinary tumour board decision.

Modalities

• Surgery: the most effective single modality, curing at least 40% of patients. It aims for an R0 resection (clear margins). Types are curative, debulking, palliative, prophylactic and reconstructive. R1 means microscopic and R2 means macroscopic residual tumour.
• Radiotherapy: external beam, brachytherapy, radioisotopes. It is used with curative, adjuvant, neoadjuvant or palliative intent (bone pain, bleeding, cord compression, SVC obstruction).
• Chemotherapy: cytotoxic drugs (alkylating agents, antimetabolites, anthracyclines, taxanes, platinum compounds, vinca alkaloids). It can be neoadjuvant, adjuvant, curative (lymphoma, testicular cancer, ALL) or palliative. Toxicities are myelosuppression, nausea and vomiting, mucositis, alopecia and organ toxicity.
• Hormonal therapy: tamoxifen, aromatase inhibitors, androgen deprivation.
• Targeted therapy: imatinib, trastuzumab, EGFR/ALK inhibitors, rituximab, bevacizumab.
• Immunotherapy: checkpoint inhibitors (anti-PD-1/PD-L1, anti-CTLA-4), CAR-T cells.
• Supportive care: antiemetics, G-CSF, transfusions, nutrition, infection control, psychosocial support.

Prevention

• Primary: tobacco cessation, HPV and HBV vaccination, diet, exercise.
• Secondary (screening): Pap smear or HPV testing, mammography, colonoscopy, oral visual examination.

5. Palliative care in cancer

Pain (the commonest and most feared symptom)

• Causes are somatic (bone metastases), visceral (tumour infiltration) and neuropathic (nerve infiltration, chemotherapy or radiotherapy injury).
• Management is a stepwise approach that targets both the cause and the symptom: non-opioids (NSAIDs, paracetamol), then opioids (tramadol, oxycodone, morphine, fentanyl patches, methadone). Adjuvants are steroids (bone metastases, cord compression), antidepressants, gabapentin or pregabalin, bisphosphonates, and strontium-89 or samarium-153 for bone pain. Interventional options include nerve blocks, neuroablation and regional analgesic infusions (The Washington Manual of Medical Therapeutics, p. 878-879).
• WHO analgesic ladder: Step 1 non-opioid, Step 2 weak opioid, Step 3 strong opioid, each with adjuvants. Dose "by the clock, by the mouth, by the ladder, for the individual."
• Opioid side effects are constipation, nausea, sedation and respiratory depression. Give a prophylactic laxative (senna with docusate). If constipation occurs, use lactulose, polyethylene glycol or enemas (Washington Manual, p. 879).

Other symptoms

• Fatigue affects about 80% of patients with advanced cancer. Treat the causes (anaemia, pain, poor sleep, depression) and offer exercise and nutrition. Psychostimulants (methylphenidate, modafinil) help selected patients.
• Anorexia and cachexia: nutritional support. Megestrol acetate, glucocorticoids or dronabinol can raise appetite (Washington Manual, p. 879).
• Nausea and vomiting: ondansetron, metoclopramide, dexamethasone, olanzapine.
• Dyspnoea: opioids, oxygen, fan therapy, treatment of effusions.
• Malignant bowel obstruction, ascites, pleural effusion: drainage, octreotide, stenting.
• Psychosocial and spiritual care: anxiety, depression, counselling, family support, advance care planning, and end-of-life care (hospice, home-based care, dignity at death).

6. Role of Ayurveda in cancer care, including palliative care

Ayurvedic concept

• Cancer-like swellings are described as Arbuda (malignant or large swelling) and Granthi (nodular or benign swelling).
• Pathogenesis is attributed to vitiated tridosha (Vata, Pitta, Kapha) acting on Rakta, Mamsa and Meda dhatus, with impaired Agni (digestion and metabolism) and Ama accumulation.
• The approach is individualised and aims to restore dosha balance, strengthen Ojas (immunity and vitality) and improve resilience.

Where Ayurveda can contribute

Palliative Ayurvedic measures

• Pain: Vata-pacifying measures such as Abhyanga (oil massage), Swedana (mild fomentation) and medicated oil Basti (enema). Herbs include Guggulu, Shallaki (Boswellia), Ashwagandha, Haridra (turmeric) and Dashamoola preparations. Local application of medicated oils is used for painful lesions.
• Anorexia and weakness: Deepana-Pachana herbs (ginger, pippali), Amalaki-based Rasayanas, light and easily digestible warm food.
• Constipation: Triphala, Eranda taila (castor oil) or gentle Basti. This is useful alongside opioids.
• Nausea: ginger, cardamom, Shunthi preparations.
• Insomnia and anxiety: Brahmi, Jatamansi, Ashwagandha, Shirodhara, pranayama, meditation.
• Psychological and spiritual support: Sattvavajaya (psychotherapy), yoga, music, spiritual counselling.
• Rule for palliative use: use gentle, Brimhana (nourishing) and Shamana (palliating) therapies. Avoid strong Shodhana (Panchakarma purification such as Vamana and Virechana) in frail, cachectic or neutropenic patients.

Commonly studied herbs

Limitations and safety

• The evidence is mostly preclinical, case reports (e.g., standalone Ayurvedic treatment of lymphoma and prostate cancer, PMID 37865054 and PMID 41923104) and small trials. Case reports cannot establish efficacy.
• Herb-drug interactions:
  • Turmeric may increase bleeding risk.
  • Ashwagandha has been linked to liver injury and can affect thyroid function.
  • Herbs may alter CYP-mediated metabolism of chemotherapy and targeted drugs.
  • Antioxidant-rich herbs could theoretically interfere with radiotherapy and some chemotherapy.
• Some Rasa-shastra (herbo-mineral, "bhasma") products can contain heavy metals if poorly processed. Use only standardised, quality-tested products.
• Delaying or refusing proven oncologic treatment for Ayurveda alone worsens outcomes.
• Clinicians should ask every patient about herbal use. Ayurvedic and oncology teams should coordinate, with treatment timing set around chemotherapy and surgery.
• Even enthusiastic reviews state that Ayurveda is supportive and not a primary anticancer therapy. The library psychiatry text similarly defines complementary and alternative medicine as practices outside standard cancer therapy, and notes that the NCI is sponsoring trials of them (Kaplan & Sadock's Comprehensive Textbook of Psychiatry, "Alternative Treatments").

7. Recent evidence check

8. Summary

• Cancer care combines early diagnosis and staging, curative or palliative intent, multimodality treatment and supportive care.
• Palliative care runs alongside disease-directed treatment from diagnosis. Symptom control follows the WHO ladder and the psychosocial and spiritual dimensions.
• Ayurveda is a complementary supportive adjunct. Its main roles are symptom relief, improving quality of life, nutrition, Rasayana for recovery, and mind-body support. It is not a replacement for surgery, chemotherapy or radiotherapy.