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Cancer Awareness: Cancer Prevention

Report on the keynote address, "Cancer Perspectives: What can you do to Protect Yourself?" by Dr. Ketayun Dinshaw, Director, TMH at the seminar organised by FICCI Ladies Organisation (FLO)

An analysis of population statistics shows that by 2020, the population of the world will increase from 6.1 billion today to 9.3 billion. Of this 88% of the growth will be in less developed countries, resulting in a tripling of the population in the 48 poorest countries while population in the west either stabilizes or even declines. Developing countries are facing a double burden of disease in that infectious diseases such as malaria and TB are reappearing in more and more resistant forms while there is an epidemic brewing of non-infectious diseases such as cancer, heart disease and diabetes. As far as cancer is concerned, numbers are projected to increase from 10 million globally today to 20 million in 2020 and of these 70% will be from developing nations as against 53% today. This translates into a staggering number of patients in countries who can least afford it.

What has caused this rise? From 1991 to 2000 there has been a 21% increase in the population, at the same time life expectancy has increased to 63 years today, resulting in a larger proportion of the elderly. In India a large number of cancers are tobacco or infection related and is directly attributable to environmental degradation or diet and malnutrition. The common cancers are oral, pharyngeal, lung, oesophagus and larynx in men and cervix, breast, oral, ovary and oesophagus in women. The estimated cancer burden in India is 8 lakh new cases every year and 5.5 lakh deaths. There are 2-2.5 million patients at any given point of time, 30% new cases are tobacco related, 30% are cervical cancers and 20% are breast cancers and over 70% are diagnosed in the last stages. Analysis shows that the cost to society is as much as Rs. 3.5 lakhs per patient.

What is cancer? A cancer is an uncontrolled, unruly unbridled growth of a cell, a cell in revolt evading the basic laws of nature, having uninhibited multiplication which destroys well ordered regulatory rules, invades surrounding tissues and migrates to other locations in the body. Where normal cells are subject to order, symmetry and control, cancer cells have anarchy. Who can get cancer? Anyone can get cancer in any organ or tissue, although there is a peak between ages 30-50 and again at 65+.

So how does one protect oneself against cancer? By maintaining a high index of suspicion. Anything that does not get better in the required period of time-a sore, a lump, bleeding, discharge, a change in a wart/mole, persistent indigestion/dysphagia (difficulty in swallowing), hoarseness of voice or cough (especially with blood), change in normal bowel habits are all indications for deeper investigations.

Why is cancer so dreaded? There is an inbred fear and total ignorance about the disease that leads to delay-a fear of dieing, of the treatment, deformity, and loss of body function, belief that there is no benefit of treatment and hence patients only come forward when symptoms cannot be borne any longer. The truth is that if detected early, cancer can be cured or controlled in 80% cases, but 80% patients present only in II or III stages making treatment difficult. In the present scenario, instead of treatment of cancer in advanced stages, resources are used up for palliation. There are inadequate facilities across the country and limited access especially for those in the lower socioeconomic strata. Cancer is anyway a low priority and not much importance is given to detection. It therefore devolves upon the individual to maintain a high degree of suspicion by performing regular self-examinations, clinical check ups and simple radiological examinations. Women's cancers such as cervical and breast are especially amenable to this simple rule.

The statement "As is your Lifestyle, so is your cancer" is very true. Tobacco is a major cause of even non-cancer deaths. There are 1.1 billion smokers worldwide. Smoking causes cancers of the lung, larynx, oral cavity, oesophagus, pancreas, bladder and kidney among others. 66% Indian men use tobacco in different forms. 2.5 of 6 million oral cancer cases in the world are found in India. Dental hygiene in India is poor; tobacco powder is used in many forms, including for cleaning teeth and is kept in the same place day after day. As a result, there are 5 lakh new tobacco related cancer cases which lead to 1lakh deaths every year. In the west, lung cancer is more common than breast cancer among women. There advertisements portray an enviable lifestyle revolving around smoking. We must prevent children from starting, avoid exposure as non-smokers, fight for regulation of tobacco products and try to treat those addicted to the habit. Addictions have been found to start in school. As many as 13% students use tobacco, 5 % smoke, 12% use other forms. 1 in 3 children live in homes where others smoke. Children can be the main agents of change-they can be educated to not start themselves and to motivate their parents to stop. Tobacco control boils down to intervention, behavioural modifications and application of taxes, banning of use in public places, legislation and increased statutory warnings as well as instituting tobacco crop substitution.The contribution of NGOs in this effort is important.

Coming to actual facts and figures, breast cancer overtook cervical cancer in Mumbai as the most common cancer in 1978. Cervical cancer is caused by early marriage, multiple partners, infections and can be diagnosed early by Pap tests. In Finland, cervical cancer is extremely rare since all women must have Pap smears regularly. Tomorrow's cancers can be prevented today. Tata Memorial Hospital has a Preventive Oncology Department to promote early detection and prevention in Mumbai. There is also a programme in Barshi for the rural population. Breast cancer is linked to early menarche, late menopause, nulliparity. Mammography is not really appropriate in India, self-examination is important. It must also be emphasized that a mastectomy is no longer considered essential in breast cancer treatment. Liver cancers have been shown to be related to virus and fungus infections; oesophageal cancer to hot spicy foods; cancer of the colon and rectum to red meat and low fibre intake. A high standard of personal hygiene, a diet that includes green leafy vegetables and avoiding pollution can help prevent cancer. We all need a change in attitude, lifestyle, regular self-examination and we must fight for a better environment.

At TMH, the focus is on prevention for which school education programmes, propagation of information through women's groups, NSS and NGOs are ongoing projects. Besides special target groups are regularly addressed. 8th March is observed as Women's Day and March is Cervical Cancer Awareness month; 31st May is World No Tobacco Day and June is Tobacco Awareness month; 9th October is Breast Cancer Awareness day and during October free mammograms are made available. The strategy at Tata is Prevention-Detection-Diagnosis-Treatment-Palliation. Cancer therapy includes surgery, radiation and chemotherapy. While treatment can be difficult, doctors must be cruel to be kind. Treatment has been shown to reduce mortality, increase survival and quality of life.

Report on the Proceedings of ESMO Workshop on Palliative Care in Oncology held on 8th February at TMH

The quality of life for people with incurable cancers could be improved by simple measures to relieve symptoms such as pain and depression through palliative care. TMH joined hands with the European Society for Medical Oncology to organise a workshop on Palliative Care that was addressed by speakers from Belgium, Israel, Germany and India.

Dr. Dirk Schrijvers from Belgium said that medical oncologists should be involved in the treatment and care of the entire disease process of a cancer patient, including palliative care and how to implement it in their contact with their patient, the family and other professional health care takers. The organisation can be at home, in a hospice or hospital depending on the unique needs of the patient. Dr. Schrijvers also spoke on "Skin Problems in Palliative Care and Oncology." Such problems are seen frequently in patients with cancer and may be caused by the disease itself (primary tumour, metastatic disease or paraneoplastic syndromes), by the anti-cancer treatment or by the condition of the patient. Pressure sores, for example, are an important problem which can be prevented by adequate care and should be treated as soon as they occur.

Dr. Nathan I. Cherny from Israel spoke on the principles of assessment and syndromes of cancer pain. Surveys indicate that 30-60% of cancer patients experience pain during active therapy and more than 70% with advanced disease. The relationship between pain and psychological well being is complex and can provoke or exacerbate distress, disturb normal processes of coping and adjustment and augment a sense of vulnerability, contributing to a preoccupation with the potential of catstrophic consequences. Relief of pain is an ethical imperative and clinicians must maximize their knowledge, skill and diligence to attend to this task. Too many times pain remains under treated mainly due to inadequate assessment. Assessment must be an ongoing and dynamic process to include accurate characterization of the pain, the syndrome and inferred pathophysiology as well as the evaluation of the impact of the pain and the role it plays in the overall suffering of the patient.

Marianne Kloke from Germany spoke on Respiratory System Symptom Control. She said that functional and structural alterations of the respiratory system cause both physical complaints and existential suffering and fear. At the same time, unresolved psychic, spiritual and social problems can cause respiratory symptoms. The most common symptoms are cough (37-50%), dyspnoea (15-79%), haemoptysis (24-70%) and death rattle (23-80%) and their palliation is an urgent and important task. Dr. Kloke also covered the topic of gastrointestinal symptom control. The most frequently reported symptoms are dry mouth, taste change, anorexia, early satiety, weight loss, nausea, vomiting, diarrhea and constipation. They may occur together, often reinforcing each other. Good symptom control requires physiologic pharmacological understanding. Symptom evaluation, especially for those that are completely subjective in perception, need a careful physical assessment.

Dr. Ozgur Ozyilkan of Turkey spoke on Quality of Life (QOL) issues. Over the last decade, clinicians have accepted that while survival and disease-free survival are both critical factors for cancer patients, overall QOL is fundamental. The diagnosis and treatment are major stresses for any patient. While directed towards prolongation of patients survival, treatment may reduce QOL. Surgery can be mutilating; radiotherapy can cause tiredness, skin injury; chemotherapy, given over long periods of time, causes considerable toxicity such as hair loss, nausea, vomiting, fatigue and emotional problems. It has become increasingly evident that the impact of all these side effects on a patient's QOL is an important measure of effective cancer management. Oncologists must not concentrate all their expertise on the scientific application of medical knowledge and forget that emotional and psychosocial supports are also essential. They must consider the impact of therapy on each patient's life style. He also spoke about fatigue, a symptom which is inherently subjective. Despite the high prevalence and distress associated there has been little recognition as an important issue for research. Very little is known about its epidemiology, etiologies and management.

Dr. Maryanne Muckaden from TMH spoke on the difference between end of life care in India versus the west. The positive strengths are the Indian family network, strong religious background and spiritual values. However, the Union Health budget remains low; medical facilities, while available in the private sector, are beyond the reach of the common man; and drugs are unavailable. A number of representatives from NGOs, including CPAA's Mrunal Marathe spoke on their experiences as a part of the Palliative Care departments counseling team at TMH. Dr. Muckaden praised the involvement of NGOs that helps to enhance the resources of cash starved governments.

Mrunal Marathe conducted three awareness lectures for the benefit of social workers who will go on to spread the information through their own organisations. The first lecture was organised at Dhanwantari covering female cancers. Mrunal also gave a lecture for volunteers at Nirmala Niketan. An international audience consisting of people from Turkey, Denmark and England attended her lecture on Palliative Care at the European Society for Medical Oncology conference organised by Tata Memorial Hospital. About 200 persons underwent these "Train the Trainer" type of lectures.

31 camps and OPDs were held during the month of February. Camps were held at Godfrey Clinic, naval Dockyard (6); Mid-Day Multimedia, Tardeo and Lower Parel (4 each); Friends Club, Vasai and Atmajyot/Lioness Club of Silvassa (2 each) and Chemical Terminal, Trombay (1).

A total of 969 people, 393 males and 576 females were screened in the camps and clinics in February. 303 people were advised follow up. 12 OPDs and clinics were held during February. 108 males and 180 females were screened. 77 people were advised follow up.

The Smt. Lila Kishanchand Shahani Clinical Diagnostic Centre screened 297 persons during February. 577 tests were performed, out of which 398 were pathology tests. 117 sonography, 30 x-ray and 28 mammography investigations were carried out. 4 ECG investigations were carried out. 76 patients were screened in the OPDs.

During February, 102 people were examined, of whom 66 had come for the first check-up and 36 for renewal check up. 5 claims were settled during the month and an amount of Rs. 1,25,699 was disbursed. 139 claims have been settled to date.

771 patients were aided, counseled and given guidance at our locations in Mumbai-Srimati Panadevi Dalmia Cancer Management Centre; at Nair Hospital Radiation Centre; Cama & Albless, Wadia and Tata Memorial Hospitals during February. 454 patients availed of ambulance facilities, including 52 patients who availed of the service for long distances. 45 persons were given clothes, 25 packets of biscuits and 20 boxes of Complan, Bournvita and Feredol were distributed. 9 home and institutional visits were made. 5 of our patients expired during the month.

PATIENT CARE AND REHABILITATION (SUMMARY)

334 patients were aided, guided and counseled by CPAA's Halima Aurangabadkar at Tata Memorial Hospital's Golden Jubilee Block Room No. 189 during February. 450 packets of biscuits were distributed. 34 patients were given clothes, 8 kgs of sweets were distributed. 5 referred cases were helped. 12 ward visits and 10 home visits were made. 40 patients were given medicines and toys were distributed to 20 children. 310 patients were given Complan and Horlicks. 452 patients utilized the ambulance facility including 400 who used the shuttle service between TMH and Dadar station. 5 kgs of rice, 2 kgs. of dal and 4 cartons of soap were distributed.

CPAA's Mrunal Marathe counseled 10 patients, 7 males and 3 females during the month of February. There were 4 cases of head and neck and liver each and one each of neuroblastoma and osteosarcoma.

Mrunal counseled the family of a terminally ill two-year-old child with retinoblastoma. The disease is one which is known have a high genetic risk and the mother's brother had earlier died of the disease. The couple's first offspring was a healthy girl and hence when their son was born, they hoped that he too would not suffer from this deadly disease. However, the fates willed otherwise and when the child was hardly eight months old, his eyes showed signs of swelling and he began to hit his head against the wall due to severe headaches. Tests showed conclusively that he did indeed have retinoblastoma. The child's mother finds herself isolated since her in-laws blame her for her son's disease, which is associated with her family. Repeated reminders about her family's history serve to rub salt in the wounds of this unfortunate mother. She shared with Mrunal, "My child will die once but I will die every minute that I live."

Given the high degree of hereditary risk associated with some cancers, Tata Memorial Hospital has started a clinic for genetic counseling of patients or healthy individuals who have a strong family history and hence added risk of contracting a particular type of cancer. The clinic sits every Thursday between 10-12. Dr. J.P. Agarwal and Dr. Rajiv Sarin take individual histories and counsel them on what warning signs to look out for.

19 new patients each were registered during the month of February. 294 patients attended follow up of whom 81 patients are undergoing chemotherapy. 25 patients were counseled and given guidance and Vinaya Chacko visited 5 patients in the wards. 4 group meetings were held. 10 patients were given packets of Complan, 10 persons were given biscuits and 10 patients were given cooking oil. 20 sets of clothes were distributed.

61 patients were counseled and given guidance by Iva Athavia during February. 49 ward visits were made. 32 patients were provided guidance regarding alternative therapy. 23 patients were counseled regarding hygiene issues. 2 patients availed of our ambulance service. 4 terminally ill patients were referred to Shanti Avedana Ashram. Rs. 13,791 was donated towards medicines and radiation costs. 2 packets of chocolates, 10 litres of oil and 15 sets of clothes were distributed among the patients.

65 patients were counseled and given guidance at the Counseling Cell at Nair Hospital Radiation Department by Iva Athavia during February. 35 ward visits were made. 6 terminally ill patients were referred to Shanti Avedana Ashram. 11 patients were given information about alternative forms of medicines and 3 lectures were held on hygiene issues. Rs. 14,393 was donated towards radiation treatment. 3 packets of chocolates, 16 bottles of Feredol, 6 sets of clothes and 24 litres of cooking oil were distributed.

Iva Athavia counsels patients at Bharat Sevashram Sangh, Vashi every Friday evening. 26 patients were counseled and guided during February. 14 patients were visited in their rooms. 6 patients were given guidance regarding alternative therapy. 7 group meetings attended by 7-8 patients were held regarding hygiene and diet.

A total of 70 patients were given assistance at CPAA's Rehabilitation Centre during February. 10 cases of mastectomy were attended and breast prostheses were provided. 182 patients were given rations worth Rs.26.060. Rs.14,730 was spent on teachers' salaries, for patient education and vocational training. Rs.1.24 lakh was spent on patients' wages and Rs.28,174 was spent on welfare activities, conveyance and diet supplements during the month.

Cancer Patients Aid Association Monthly Review is compiled by Dr. Shubha Maudgal and printed by Mr. Suresh Mishra at Saraswati Printing Press

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