Promote Palliative care and make it available to every cancer patient
It is exactly 30 years since I received a letter from the J&K Government to commission the oncology department at the prestigious SKIMS. We loved Edinburgh. The environment, schools, honesty and dedication of the people were exemplary. The University of Edinburgh, where I worked, was one of the world’s top most teaching medical institutions. Nay, attraction of going back to your roots and staying with your parents is always so strong. Balance tipped in favor of heading home.
It was an uphill task to start the oncology department at SKIMS. Cancer has never been a priority for decision makers, who have more pressing health care indicators to mend. Snags were expected; institutional rivalries, as in any set up, were present here as well. Eventually these were overcome with steadfastness and where necessary, intervention by right-minded persons. Dedicated staff around me, medical, paramedical and nursing, many of them leaders in their respective fields today, made it possible for us to report some of the initial research work, in the management of cancer from Kashmir in international journals.
A documentary in Kashmiri language prepared in collaboration with the then TV station (a copy is still lying somewhere despite 2014 floods) and multiple radio programs with Radio Kashmir, Srinagar marked our attempt at improving public awareness about cancer in Kashmir. When delegates from more than 11 countries participated to discuss the strategies to manage cancer in developing countries in an international conference in August 1989, organized by the Oncology Department at SKIMS, the ultimate point of entry in the international arena of cancer care had been reached. It has been an onward journey since. When I returned after a long sojourn abroad, on seeing the stature this department had achieved, I felt proud to have been a part of this success story.
We do see worrying press reports about cancer in Kashmir. Despite the concern, we should look at the issue a bit differently. Increasing burden of cancer is not a healthcare problem in Kashmir alone; it is a worldwide issue. WHO, UICC and similar international bodies have frequently pointed that out. Hence, in 2012, 14 million new cases were registered and with 8.2 million deaths world over in that year, cancer has become one of the leading causes of death. The number of cases will continue to increase and Kashmir is no exception. In the absence of a population-based registry, assuming the highest age adjusted rate of110/100,000 new cases, from neighboring regions, we should be seeing around 8000 new cases yearly. This number is going to increase by 70% in the next two decades. Cancer pattern has changed in the last three decades. When I came from UK in 80s, paucity of breast, colon and lung cancers in our clinics and wards surprised me. Today most of our patients suffer from these cancers. This again is not a local phenomenon. World over urbanization, adaptation of western culture and their dietary and social habits, have triggered this change. Studies conducted in Israel, Iran and USA confirm the impact of changed environment on cancer pattern and incidence in immigrants.
Largely, the cancer pattern in Kashmir is like other areas of South Asia with lung, breast, esophagus, stomach and colon cancers being common. However, Kashmir has a much lower incidence of oral and cervical cancers. Kangri cancer, once a unique local malady frequently seen in oncology clinics, is gradually declining. Nearly 75-80% of our patients present themselves for treatment in an advanced stage, beyond cure. This is probably due to Ignorance on the part of the community and doctors, social taboos and the inherent nature of cancer prevalent in this region. A study from Pakistan has confirmed the relationship of socioeconomic status and survival from cancer. Literacy rate of community has a similar deleterious effect on cancer survival. Most of the cancers in Kashmir occur at a younger age than west, it is because our population is younger. More than 30% of our population is younger than 14 years of age.
Tongue cancer caused by chewing tobacco
What causes it?
Three factors work together: Nature, Nurture and Fate. Nature, what we are born with (genetic predilection). Nurture, what we do to ourselves from womb to tomb; and lastly, Fate. Recent scientific models have reiterated that extrinsic factors are responsible from 70-90% of mutations we see in cancers. Smoking causes at least one third of all cancers we see. Alcohol intake is another important carcinogen. Dietary factors, a major arena of discussion in social media and press, have no definite scientific evidence as either causative or protective factors. Based on available scientific evidence, a few observations can be made safely. Obesity, lack of physical activity, consumption of red meat cooked at high temperatures (barbequing for example), intake of foods at high temperatures, moldy foods, salt cured, salt preserved foods especially fish, as prepared in East Asia; are related to high incidence of various cancers. Nutritional deficiencies, infections, pesticides, herbicides, insecticides, food adulteration, pollution, high voltage current, asbestos pollution and radiation exposure are other known factors related to high cancer incidence. Indeed, many other less understood environmental factors play an important role.
Can We Prevent It?
The answer is yes we can. Nature and fate cannot be altered. Obviously many of the factors mentioned as causes are modifiable. Active smoking as a cause of cancer is well known, however, we must not ignore passive smoking. Often I see young men in my clinic with advanced lung cancer, who have never smoked. It is only when the father admits, that he held him to his chest as a baby while puffing his favorite hooka, that I make the connection. They are the unfortunate victims of passive smoking.
How to Face Increasing Burden?
Cancer is going to be a major cause of mortality and morbidity. Cancer care comes at a very high cost. Even in USA, 124 billion dollars were spent in 2010 for cancer treatment (not research), and the cost is rising. Policy makers are raising questions about the utilization of huge amount of public money for this purpose. NICE of UK has already modified its guidelines for different cancers, keeping the cost factor in mind. New drugs, costing a fortune, may help add a few weeks to months to overall survival of some patients with advanced cancer. Expensive drugs and expensive technology may not be the right approach to improve cancer care in resource-limited set up.
First and foremost, we need to work on preventive strategies. This should be the major area of our attention. Known causes, like smoking, alcohol, infections, pollution should be prioritized for intervention. NGOs need to be roped in to ensure success and continuation of this process. Prevention will bear fruit in the long run.
Early detection of treatable and curable cancers is essential. It will decrease both the burden of mortality, morbidity as well as the cost of care. The chances of long-term survival (cure) of a breast cancer decrease from 90% if it is of small size (peanut) to 20% and if it grows to the size of a small lemon. Doctors and public should be made cognizant of this factor. Media can play a major role in this direction. An alert clinician can save many lives. We have seen nurses saving lives due to cervical cancer in India. Early gastric cancer of Japan is another such success story.
Accurate management of cancer begins with an accurate diagnosis. Quality controlled basic diagnostic facilities have to be made available. Techniques like cell block, liquid biopsy are cost effective additions immediately needed. Updating and modernizing our laboratory facilities is a small investment that could pay rich dividends. It is true of basic radiology services also. We should decrease our waiting time for procedures by increasing the number of available units and manpower. A cancer curable today may not be so tomorrow.
Number of dedicated surgical theaters has to match the need. Specialized units dealing with the surgical care of cancer patients have to be strengthened. The outcome of complicated oncological surgical procedures is direly proportional to the volume of the unit. Capacity building by enhancing qualified and trained manpower for all sectors of cancer care is equally important. Treatment of cancer must be standardized. Multimodality management of most cancers, by experienced teams, improves survival rates.
Follow up of patients and prevention of financial toxicity of cancer must be addressed too. Cancer does not only kill the patients, it kills the whole family and destroys their economic fabric. Palliative care has to be promoted, utilized, facilitated and made available to every patient. Introduction of palliative care early in the course of cancer care is shown to improve quality of care.
Care of cancer is the responsibility of both the government as well as private sector. As in the west, charitable organizations need to strengthen hands of government run institutions and plug any existing lacunae. A lot can be done within our limited resources, if there’s goodwill, dedication and determination.
Author is a renowned Medical Oncologist, Founder and Ex Head, Department of Medical Oncology, SKIMS. Presently he’s Director, Hakim Sanaullah Cancer Centre