Oropharyngeal squamous cell carcinoma is a cancer arising from the oropharynx (back of the mouth) which includes the tonsils, base of tongue, soft palate, and posterior pharyngeal wall. Over 90% of oropharyngeal cancers are squamous cell carcinomas. HPV has been found to cause cancer of the genital organs in both men and women, oropharynx, as well as benign conditions like genital and cutaneous warts.

Epidemiology and Risk Factors  

The recent analyses of cancer registry data show dramatic increases in the incidence of oropharyngeal carcinomas during the past 15–20 years as the incidence of oral cavity carcinomas has remained constant or declined. 

HPV+ OPSCC typically affects younger patients, often nonsmokers. HPV-negative disease still occurs, mainly in older adults with heavy smoking and alcohol history.

Oral HPV infection was independently linked to factors such as age, sex, number of sexual partners and the current number of cigarettes smoked per day.(19) In recent times it was also found to be linked to alcohol, genetic polymorphisms. Smoking is known to decrease the clearance of oral HPV infections.

The incidence of human papillomavirus-associated oropharyngeal cancer (HPV+OPSCC) is continuing to rise over the coming decades until the benefits of gender-neutral prophylactic HPV vaccination begin to become manifest.  

 Clinical Presentation  

High-risk HPV infections are asymptomatic, and most persons exposed to HPV will clear the infection and never develop carcinoma.

Common symptoms include a painless neck mass, sore throat, dysphagia, otalgia, trismus, and voice changes. Primary tumors can be subtle, especially at the base of tongue.  Importantly, OPSCC is often detected at an advanced stage owing to a lack of symptoms in the early stages; therefore, a need exists to identify and validate possible diagnostic biomarkers to aid in earlier detection.

Diagnosis and Staging  

Diagnosis requires biopsy of the primary or node, with p16 testing to determine HPV status. Workup includes CT/MRI neck, PET-CT, and EUA with biopsies. 

Prevention, Prognosis and Management  

With the advent of vaccines that can prevent HPV infection, the World Health Organization has made eliminating HPV and its related cancers a global health priority. Treatment decisions depend on exact staging , patient fitness , smoking history  and surgical resectability.

Early stages can be treated with surgery or RT with post op adjuvant RT or CT RT.

Locally advanced stages are treated with concurrent CTRT or induction chemo.

Recurrence and metastasis are treated with immunotherapies.

HPV+ OPSCC has markedly better outcomes, with 3-year survival ∼85-90% for early stage vs ∼60% for HPV-negative.  Because HPV+ patients are younger and live longer, treatment de-escalation trials are ongoing to reduce long-term toxicity.

Dr Saumya Verma 

MBBS, DNB 

Immunotherapy is a form of cancer treatment that enhances the body's natural immune defenses to recognize and destroy cancer cells. The immune system, which consists of white blood cells along with the organs and tissues of the lymphatic system, plays a vital role in the body against infections and diseases. It keeps track of what normally belongs in the body. When it finds something that it either doesn’t recognize, or recognizes as “foreign,” the immune system raises an alarm and attacks it. This is called the immune response. Under normal conditions, it identifies and eliminates abnormal cells, thereby helping to prevent the development and progression of many cancers.

Immunotherapy is a form of biological therapy that utilizes naturally occurring or laboratory-produced substances to enhance the body's immune response against cancer. These laboratory-made agents mimic components of the immune system, helping it recognize and attack cancer cells more effectively. Although the immune system can detect and control the growth of cancer, cancer cells can develop mechanisms to evade immune surveillance and destruction. Immunotherapy works by strengthening or restoring the immune system’s ability to identify and eliminate cancer cells more effectively.

Types of Immunotherapy

Immune checkpoint inhibitors are drugs that block immune checkpoints, which normally regulate the immune system and prevent overactive immune responses.

T-cell transfer therapy (also called adoptive cell therapy or immune cell therapy) is a type of immunotherapy that enhances the ability of a patient's T cells to recognize and destroy cancer cells.

Monoclonal antibodies (therapeutic antibodies) are laboratory-produced immune proteins designed to target specific molecules on cancer cells. Some of these antibodies help the immune system by marking and attack cancer cells more effectively.

Treatment vaccines, which work against cancer by boosting your immune system’s response to cancer cells.

Immune system modulators, which enhance the body’s immune response against cancer.

Some others are Chimeric Antigen Receptor (CAR) T cell therapy and Cytokines

Commonly Used Immunotherapy Drugs

Several immune checkpoint inhibitors are currently used in routine oncology practice. These include:

• Pembrolizumab

• Nivolumab

• Atezolizumab

• Durvalumab

• Ipilimumab

• Cemiplimab

Many of these agents are available in India and are increasingly being incorporated into treatment protocols for a variety of cancers.

How Is Immunotherapy Different from Chemotherapy?

 Chemotherapy acts by directly damaging rapidly dividing cells. While effective against many cancers, it can also affect normal tissues such as the bone marrow, gastrointestinal tract, and hair follicles, resulting in familiar side effects such as low blood counts, nausea, and hair loss.

Immunotherapy works through a different mechanism. Rather than directly attacking the tumor, it stimulates immune cells to recognize and respond to cancer.

Uses of immunotherapy in Cancer

Immunotherapy has been approved for the treatment of various cancers, It is most often employed in advanced-stage cancers and  particularly when conventional treatments are not working. Also there is upcoming established role in locally advanced stages also in few cancers. It is now anestablished treatment option for several malignancies, including:

• Lung cancer

• Head and neck squamous cell carcinoma

• Melanoma

• Kidney cancer

• Bladder cancer

• Cervical cancer

• Endometrial cancer

• Esophageal cancer

• Gastric cancer

• Hodgkin lymphoma

• Certain colorectal cancers

In India, immunotherapy has assumed particular importance in the management of lung cancer and head and neck cancers, which together account for a substantial proportion of the country's cancer burden.

Research continues to identify new indications and treatment combinations, further expanding the role of immunotherapy in cancer care.

Contraindications of Immunotherapy

·        Active Autoimmune Disease like Active Lupus, Rheumatoid Arthritis, Chron’s disease, Ulcerative Colitis, Myasthenia Gravis, Vasculitis

·        Solid Organ Transplant

·        Need for high dose steroids for systemic immunosuppression

·        Pregnancy and Breastfeeding

·        History of severe immune related toxicity to prior immunotherapy treatment

Goal of immunotherapy

If immunotherapy is recommended, it is important to understand the purpose of the treatment. The treatment goal depends on the type and stage of cancer, as well as the extent of its spread. Immunotherapy may be used with one of three objectives:

1. Cure the cancer (curative intent)

2. Control its growth and progression

3. Relieve symptoms and improve quality of life (palliative intent)

One of the most encouraging observations from clinical studies is that a subset of patients experiences prolonged disease control, even in the setting of advanced cancer. While such outcomes cannot be guaranteed, they have contributed substantially to the growing enthusiasm surrounding immunotherapy.

Side effects of immunotherapy

About 70 to 80 % of patients experience no side effects, while 20 to 30 % of patients experience minimal to mild side effects like skin reactions, flu like symptoms or changes in thyroid function.

Most common skin reactions seen are pain, swelling, soreness, redness, itchiness or rash. Flu-like symptoms mainly fever, chills, weakness, dizziness, muscle and joint pain, fatigue and headache. Most symptoms improve over time with supportive medications.

Some types of immunotherapies may rarely cause severe or fatal allergic and inflammation-related reactions like hepatitis, pneumonitis, colitis, adrenal insufficiency, nephritis are seen in 1 to 2 % population.

Most immune-related side effects can be managed successfully when identified early. For this reason, patients receiving immunotherapy should promptly report new symptoms to their healthcare team. Early recognition and treatment remain critical to ensuring patient safety.

How often do you receive immunotherapy?

This depends on the type of cancer, its stage and grade, the type of immunotherapy and mainly how your body reacts to treatment.  Immunotherapy infusions are typically scheduled every 2, 3, 4 or 6 weeks, depending on the treatment regimen.

How can you tell if immunotherapy is working?

 You will have medical tests, such as blood tests and different types of scans. These tests will measure the size of your tumor, and the doctor will look for changes in your blood work.

Is there a possibility that the treatment plans will change after starting immunotherapy once? 

Yes indeed. There may be times when there are serious side effects which will require changes in the dose or timing of the medications or including supportive medications which will give your body more time to recover.  It’s important, whenever possible, to get the full course of immunotherapy, the full dose, and keep the cycles on schedule. This gives you the best chance of getting the maximum benefit from treatment.

Sometimes, cancer cells develop resistance to a certain immunotherapy and a different treatment might be tried.

Conclusion

Immunotherapy represents a major milestone in oncology. By harnessing the body's own immune system to combat cancer, it has created new treatment opportunities for patients with a wide range of malignancies. Although it is not suitable for every patient and does not replace traditional treatment modalities, immunotherapy has significantly improved outcomes for many individuals and continues to reshape the future of cancer treatment.

As research progresses, the promise of more effective, personalized, and durable cancer therapies is becoming increasingly achievable.

Dr. Saumya Verma

MBBS, DNB 

References

https://www.cancer.gov/about-cancer/treatment/types/immunotherapy

https://www.cancer.org/cancer/managing-cancer/treatment-types/immunotherapy.html

Most of us hear the word “palliative care” and immediately think of the very last days of life. It’s one of the most common misconceptions in healthcare field. Palliative care does not mean “giving up” or “nothing more can be done.” It is an active branch of medicine that focuses on relieving suffering and improving quality of life for anyone facing a serious illness, often alongside curative treatment.

This blog will focus on what palliative care actually means, who should consider it, and what it involves so that patients and families can ask for it earlier, and get more out of it.

The Modern Definition
The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing the challenges of a life-threatening illness. It does this through early identification, thorough assessment, and treatment of pain and other problems  like physical, psychosocial, and spiritual.

A few principles from this definition are as follows:
• It affirms life and treats dying as a natural process without hastening or postponing death.
• It is applicable early in the course of illness, alongside treatments meant to treat/prolong life, such as chemotherapy or dialysis.
• It addresses the patient as whole, in body, mind, and spirit.
• It supports the family too, both during the illness and through grief.

In 2023, palliative care organisations worldwide reaffirmed and broadened this understanding:

    Palliative care is now recognized as relevant to anyone experiencing serious health-related suffering, not only cancer patients or those at the very end of life.

    The International Association for Hospice and Palliative Care describes it as holistic, active care that improves quality of life for patients, families, and caregivers, applicable at any stage of a serious illness, at any age. This is why palliative care can now be opted at any point of time from diagnosis till the last resort.

Who Should Seek Palliative Care?
Palliative care is appropriate for anyone living with a serious, disabling, life-limiting, or life-threatening condition where physical and emotional symptoms are affecting quality of life.

This includes:
• Cancer patients, at any stage, including alongside curative treatment
• Advanced heart disease, including heart failure
• Chronic lung disease, such as COPD
• Kidney failure, especially those on or considering dialysis
• Advanced liver disease
• Neurological conditions — stroke, Parkinson’s disease, motor neuron disease, advanced dementia
• HIV/AIDS
• Drug-resistant tuberculosis
• Frailty of old age, with multiple coexisting illnesses
• Children with life-limiting conditions, from diagnosis onward, including congenital and perinatal conditions

A simple rule of thumb clinicians use: if the burden of disease symptoms is significantly affecting their daily life and limiting their life expectancy, it’s time to have a palliative care conversation. It should never be reserved only for the final days or weeks. It’s also the care provided for the family and caregivers of the patient who experience burnout, grief, and the practical burden of long-term illness.

The Core Components of Palliative Care
Good palliative care is built on a few interlocking pillars. Together, they reflect the idea of “total care” — physical, emotional, social, and spiritual.
1. Physical symptom management
This is often the entry point: control of pain, breathlessness, nausea, fatigue, loss of appetite, and other distressing symptoms using medication (including opioids where appropriate), procedures, and physical therapies. The WHO’s stepwise approach to pain relief is a well-known example of this in action.
2. Psychological and emotional support
Serious illness brings anxiety, depression, fear and grief for the patient and the family. Palliative care teams include counselling and mental health support as a core part of the care plan.
3. Social support
This covers practical concerns: navigating the healthcare system, financial strain, caregiving arrangements, and helping families access community resources or government schemes where relevant.
4. Spiritual and existential care
Serious illness often raises questions of meaning, faith, and purpose. Palliative care respects each person’s individual beliefs and offers space to process these questions as a part of core patient care
5. Communication and decision-making support
Helping patients and families understand the illness, clarify goals of care, and make informed decisions through an advanced care plan
6. Family and caregiver support, including bereavement care
Support doesn’t end with the patient. Caregivers are guided through the practical and emotional demands of caregiving, and families are supported through bereavement after death.
7. Team-based, coordinated care
Palliative care is inherently multidisciplinary — typically involving physicians, nurses, counsellors or psychologists, social workers, and sometimes spiritual care providers, working together.

 
Where Does Palliative Care Happen?
Contrary to the assumption that it only happens in a hospice, palliative care can be delivered in hospitals, outpatient clinics, at home, and in long-term care facilities. In India, primary palliative care given at a patient’s home with help of physicians, nurses and axillary caregivers is growing area of focus given the burden of patients requiring the same. Organisations like the Indian Association of Palliative Care have been working since 1994 to expand training, awareness, and access to services across the country.

The Bottom Line
Palliative care is not about stopping treatment or accepting the worst. It’s about making sure that however long the journey with a serious illness is, it’s lived with as much comfort, dignity, and support. The earlier it’s brought into the conversation, the less a patient and their families suffer through the course of illness.

If you or a loved one is living with a serious illness and symptoms are affecting daily life, it’s worth asking your treating doctor about a palliative care options for a better quality of life and minimalized suffering.

Dr Durgesh Makhawana 

Pain and Palliative Care Physician 

Cancer treatment is not only about removing the disease; it is also about protecting the quality of life that follows. Lymphedema is one of the important long-term complications of cancer treatment.

What is lymphedema?

The lymphatic system is the body’s drainage network, carrying fluid from tissues back into the circulation. When lymph nodes or lymphatic vessels are removed, damaged or blocked, lymphatic fluid can accumulate, causing swelling, heaviness, tightness and discomfort, followed by skin and tissue changes over time.

What Causes Lymphedema?

Lymphedema develops from an acquired cause and may affect the arm, leg, breast, face, neck or genital region, depending on the lymphatic pathways involved. Few causes known

• Cancer or tumour: May block lymphatic drainage.

• Surgery: Removal or damage to lymph nodes and vessels can disrupt lymphatic flow.

• Radiotherapy: Can cause scarring and damage to lymphatic pathways.

• Other causes: Infection, trauma or other conditions affecting the lymphatic system.

The evolution of cancer surgery

Modern oncology has progressively moved from extensive lymph-node removal towards selective lymph-node assessment and surgical de-escalation.

The development of Sentinel Lymph Node Biopsy (SLNB) was a major step forward. Instead of routinely removing multiple lymph nodes, surgeons identify the first draining node(s) and assess them for cancer.

SLNB is an established standard in selected patients with breast, melanoma, endometrial, penile, vulvar and cervical cancers, with its role evolving in colorectal, gastric and other cancers.

In breast cancer, one systematic review reported lymphedema rates of approximately 19.9% after axillary lymph-node dissection compared with 5.6% after SLNB.

Treatment of lymphedema

• Early assessment and staging

• Compression therapy with garments or bandaging

• Exercise and movement to promote lymphatic drainage

• Complete Decongestive Therapy (CDT), including compression, exercise, skin care and specialised lymphatic therapy

• Skin care to reduce the risk of infection and cellulitis

• Pneumatic compression in selected patients

• Weight management, where appropriate

• Surgical options for selected persistent cases, including lympho-venous bypass, vascularised lymph-node transfer and liposuction

Conclusion

Lymphedema should not be considered an inevitable price of cancer treatment.

Successful cancer care is not only about helping patients survive cancer—it is also about helping them live well after it.

Dr Reena Anto Jhonson

References:

1)      Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of The International Society of Lymphology. Lymphology. 2023;56(4):133-151. PMID: 39207406.

2)      National Cancer Institute. Lymphedema and Cancer. (Cancer.gov)

3)      Wong HCY, Wallen MP, Chan AW, Dick N, Bonomo P, Bareham M, Wolf JR, van den Hurk C, Fitch M, Chow E, Chan RJ; MASCC BCRAL Expert Panel and the Oncodermatology and Survivorship Study Groups. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations. EClinicalMedicine. 2024 Feb 2;68:102441. doi: 10.1016/j.eclinm.2024.102441. PMID: 38333542; PMCID: PMC10850412.

4)      Cancer-related lymphedema. BMJ. 2025. (bmj.com)

The word cancer often brings fear, uncertainty, and a lot of questions. Among the treatments that patients are introduced to, radiation therapy can sometimes be the least understood. 

One of the most common questions I get from patients is, "What exactly is radiation therapy? Will it hurt? Is it safe?" 

As a Radiation Oncologist, my role is to answer these questions and help patients understand that radiation therapy is one of the most effective and precise treatments available for cancer today. 

What is Radiation Therapy? 

Radiation therapy uses high-energy X-rays to kill cancer cells or stop them from growing. Unlike surgery, it does not involve an incision, and unlike chemotherapy, it usually treats only the specific area where the tumor is located. Modern radiation treatment is highly targeted. Advanced technologies allow us to deliver radiation with very high precision to the tumor, while minimizing exposure to surrounding healthy tissues. 

When is Radiation Therapy Used? 

Radiation therapy plays an important role in treating many types of cancer, including: 

• Head and neck cancers 

• Breast cancer 

• Cervical cancer 

• Prostate cancer 

• Brain tumors 

• Lung cancer 

• Rectal cancer 

• Esophageal cancer 

• Many other cancers and some benign diseases 

Depending on the type and stage of cancer, radiation may be used: 

• As the main treatment 

• Before surgery to shrink the tumor 

• After surgery to reduce the risk of recurrence 

• Along with chemotherapy for better results 

• To relieve symptoms such as pain, bleeding, breathlessness or difficulty swallowing in advanced cancers. 

Every treatment plan is individualized because no two patients or cancers are exactly alike. 

What Happens Before Treatment? 

Before starting radiation therapy, patients undergo a planning session called CT Simulation. During this session, we determine the exact position in which the patient will receive treatment. Using specialized treatment planning software, we carefully identify the tumor and nearby normal organs. The radiation dose is then determined specifically for that patient's tumor and anatomy. 

This planning process ensures maximum effectiveness by delivering the required dose to tumor while protecting the nearby healthy tissues as much as possible. 

Does Radiation Therapy Hurt? 

Patients do not see or feel the radiation and there is no pain while it is being delivered. Each treatment session usually lasts only a few minutes, and most patients can return home shortly afterward. 

What About Side Effects? 

Like every medical treatment, radiation therapy can have side effects. However, these depend on the area being treated, the radiation dose, technique and individual patient factors. 

For example: 

• Radiation to the breast may cause temporary skin redness. 

• Radiation to the head and neck can lead to mouth soreness, difficulty or painful swallowing or dryness of mouth. 

• Pelvic radiation may cause bowel or bladder irritation. 

The encouraging news is that most side effects are temporary and manageable with appropriate medications, nutrition, and supportive care. Throughout treatment, patients are reviewed regularly so that any side effects can be identified and managed early. 

Advances in Modern Radiation Therapy 

Radiation oncology has evolved tremendously over the past few decades. Today, technologies such as Image-Guided Radiation Therapy (IGRT), Intensity-Modulated Radiation Therapy (IMRT), Volumetric Modulated Arc Therapy (VMAT), and Stereotactic Body Radiation Therapy (SBRT)/ Stereotactic Radiotherapy (SRT)/ Stereotactic Radiosurgery (SRS) enable us to treat tumors with greater precision than ever before. These advances have improved cure rates while reducing treatment-related side effects and improving patients' quality of life. 

A Message to Patients

 Receiving a cancer diagnosis can feel overwhelming, but you are not alone. Modern cancer care combines expertise, technology, and teamwork to provide the best possible outcomes. Our role extends beyond planning treatmentwe strive to educate, reassure, and support patients and their families throughout their cancer journey. Radiation therapy has helped millions of patients around the world achieve cure, control their disease, or improve their quality of life. 

If your doctor has recommended radiation therapy, do not hesitate to ask questions. Understanding your treatment is the first step toward facing it with confidence. Together, with knowledge, hope, and the right care, we can move forward one step at a time.

Dr Anjali Uniyal

Radiation Oncologist

A child’s world is supposed to be filled with school bells, birthday cakes, playground adventures, scraped knees, bedtime stories, and dreams of what they might become. A cancer diagnosis can suddenly make that world feel very different.

September is observed in many countries as Childhood Cancer Awareness Month, a time to recognise children living with cancer, remember those we have lost, celebrate survivors, and remind families that childhood cancer is not a hopeless diagnosis. Behind every diagnosis is a child not just a patient. And behind every child is a family learning to navigate fear, treatment, uncertainty, and hope.

What is childhood cancer?

Childhood cancer refers to cancers that develop during childhood and adolescence. Unlike many adult cancers, childhood cancers are generally not caused by lifestyle choices such as smoking, alcohol consumption, or poor diet. Some of the more common childhood cancers include leukaemia, brain and spinal cord tumours, lymphomas, neuroblastoma, Wilms tumour (kidney cancer), bone cancers, and certain soft-tissue cancers.

The symptoms can sometimes resemble common childhood illnesses like persistent fever, unusual tiredness, unexplained weight loss, frequent infections, headaches, unusual bruising, swelling, persistent pain, or changes in vision. This does not mean that every child with these symptoms has cancer. Most childhood symptoms have much more common explanations. But symptoms that are persistent, unusual, or worsening should be discussed with a paediatrician.

Common myths about childhood cancer

Myth 1: “Cancer in children is caused by something the parents did.”

Fact: In most cases, there is no clear reason why a child develops cancer. Certain genetic conditions can increase risk, but blaming parents or children is neither accurate nor helpful.

Myth 2: “Cancer always means the worst.”

Fact: Many childhood cancers can be treated successfully, especially when diagnosed and treated appropriately. Outcomes vary depending on the type of cancer, its extent, the child's age and overall health, and how the cancer responds to treatment.

Myth 3: “Cancer treatment is the same for every child.”

Fact: Treatment is highly individualised. A child's cancer type and specific characteristics determine the treatment plan.

Myth 4: “Children cannot understand what is happening.”

Fact: Children understand illness in different ways depending on their age and development. Honest, age-appropriate communication can help them feel safer and more involved.

What does treatment involve?

Childhood cancer treatment is not one single road. It is more like a carefully planned journey, with different paths depending on the diagnosis.

Treatment may include:

Chemotherapy – medicines that destroy or control cancer cells. It may be given through a vein, by mouth, or in other ways depending on the cancer.

Surgery – used to remove a tumour when this is possible and appropriate.

Radiation therapy – uses carefully targeted high-energy radiation to destroy cancer cells. Its use depends on the type and location of the cancer.

Targeted therapy – medicines designed to act on specific features of cancer cells.

Immunotherapy – treatments that help the body's immune system recognise and fight cancer.

Stem cell transplantation – in selected cancers, healthy blood-forming stem cells may be given after intensive treatment.

Children may receive one treatment or a combination of several treatments. Their care is usually provided by a multidisciplinary team, which may include paediatric oncologists, surgeons, radiation specialists, nurses, psychologists, nutritionists, physiotherapists, and other professionals.

And treatment is not only about eliminating cancer. It is also about helping a child keep being a child.

The invisible side of childhood cancer:

Hospital visits can interrupt school. Treatment can change appearance, energy levels, friendships, and routines. Fear of needles, procedures, separation from parents, or uncertainty about the future can create significant emotional stress. This is why psychological and social support matters.

Play therapy, age-appropriate explanations, maintaining contact with friends and school, creative activities, counselling, and family support can help children express feelings that they may not have words for. Parents need support too. A frightened parent may feel that they must remain strong every moment. But parents are human. They can be scared, exhausted, angry, and hopeful—all at the same time.

Let children keep their childhood

Sometimes support does not have to be complicated.

A favourite story before a procedure.

A drawing taped beside the hospital bed.

A video call with classmates.

A birthday celebrated in the hospital.

A nurse who remembers a child's favourite cartoon.

A parent saying, “You can be scared. I'm staying right here.”

These moments may seem small, but to a child, they can make an unfamiliar world feel a little more like home. Childhood cancer changes many things. But with timely diagnosis, appropriate treatment, compassionate care, and strong emotional support, children can continue to learn, play, dream, and grow.

Cancer may become a chapter in a child's story. It does not have to be the whole story.

Parnavi Kherade 

Onco Psychologist

Consultant at Renatus Cancer Centre