Cancer: Big C in the city -

Cancer: Big C in the city

Nita Jatar Kulkarni

Published in the Sunday Express, New Delhi, on the 13th of May 2012.

She has ridden sleighs in the North Pole. She loves elk refuges. She has lost money in casinos but doesn’t complain. She is happy cheering the Chennai Super Kings at IPL matches. She is an engineer who runs a multinational startup in India. She is also a two-time cancer survivor. Her motto is, “Play the best hand possible with the cards that you have been dealt with.” Chennai cancer survivor Ramya was first diagnosed with breast cancer six months after her mother: they were treated together, and Ramya survived. Seven years later she was diagnosed again with a new cancer. After sixteen chemotherapy sessions, radiation therapy and multiple surgeries Ramya is still fighting.

Ramya has started ‘Cancer Pals in India: A Community of Young Survivors’ . “The challenges for young survivors are unique. Careers are interrupted even before they have had a chance to take off, formal education perhaps not yet complete, plans for marriage and kids may have taken a backseat, insurance and other financial ramifications boggle the mind, the lost fitness levels are so much more raw for being so recent etc. People in the 20-35 age group I think, especially feel these factors. So the goal of the site is to offer a way for people who were 35 or under at the time of diagnosis to connect,’ she says. Her tip: ‘Don’t let cancer be your life, put it on the backburner’.

Cancer numbers are climbing rapidly, especially in urban India. It’s also affecting the young. In 2011, there were over half a million officially recorded cancer cases in India — 5.35 lakh as against 5.24 lakh in 2010 and 5.21 lakh in 2010. In 2011, no less than 89,224 cancer deaths were reported from Uttar Pradesh; Maharashtra had 50,989. Union health ministry records show there are about 28 lakh cases of cancer at any given point of time in India. Ten lakh new cases are being reported every year. According to the World Health Organization (WHO), the estimated cancer deaths in India are projected to increase to 7 lakh by 2015. The Kidwai Memorial Institute of Oncology states the number of new cancers in India annually is about 7 lakh and over 3.5 lakhs people die of cancer each year. Out of these 7 lakhs are new cancers.

Yet there is good news for cancer patients. Prices of cancer medicines have plunged dramatically. Last week, Swiss-based Roche Holding AG and Cipla Ltd announced they will be lowering prices for five of their expensive cancer-fighting drugs after Hyderabad’s Natco Pharma Ltd started selling a copy of German firm Bayer AG’s patented cancer drug Nexavar under compulsory licensing norms. It sells the generic medicine sorafenib, a liver and kidney cancer drug for `8,800 — the cost of a month’s treatment — against `2.8 lakh for a month’s supply of Bayer’s. Bayer is worried about the price cuts: it has filed an appeal with the Intellectual Property Appellate Board against the compulsory licence granted to Natco. “The company hasn’t taken a decision on the Indian price yet,” Bayer spokesman Aloke Pradhan said last week.

THE HERO IN EVERY PATIENT 

The price for fighting cancer is courage. In 2009, Akash Dube was a 17-year-old high school student in Chennai. He topped the Math class at the Harvard University faculty of arts and sciences, where he spent the summer. He had near perfect SAT scores and was one of the youngest members of Mensa. “I thought I was well on my way to realising my dream of following my brother to Stanford University. Suddenly, on the 30th of January 2009 little blood spots on my forearm seemingly shattered my hopes and dreams,” Akash wrote in his appeal while organising the first Terry Fox Run in Chennai — an event to promote cancer awareness. It was leukemia; he did indeed go to Stanford. He is in remission now and needs a bone marrow transplant. Frenetic campus activity is on in Stanford to help Akash. 

There seems to be a perverse advantage, too, in the rise of cancer in urban India: a number of high profile activities are turning the spotlight on the disease, spreading awareness that it is not the end of life. The annual Terry Fox Run at IIT Madras organised by the Rotary Club of Madras East in August — held in memory of the Canadian athlete and cancer activist Terry Fox — is gaining in numbers every year. On Facebook, Akash mentions Burt Munro’s words from The World’s Fastest Indian, “You live more in five minutes on a bike like this going flat out than some people live in a lifetime.” 

Many runners of Terry Fox Run are from infotech companies such as Tata Consultancy Services, Cognizant Technology Solutions, Infosys and Wipro; employees of software companies make sure anti-cancer messages and activities go viral. Akash’s motto is borrowed from T J Miller: “Don’t let the door hit you on the time you go out of the exit.”

FIGHTING BREAST CANCER 

Exit from cancer is painful and takes an agonising amount of time: but what doesn’t kill you makes you stronger. Two-time cancer survivor and cancer counsellor Neerja Malik has a broken rib that cannot be healed even with a graft, because of the high amounts of radiation she has received in the past. Her positive attitude marks her out as a fighter: the aerobics aficionado is prevented by her broken rib from exercising, but a cheery Neerja sees it only as ‘a minor irritant.’ The fear is rising numbers show women in urban areas are more at risk: breast cancer numbers are rising in India, with around 80,000 new cases annually, an increase of approximately 50 per cent since 1965. 

A WHO report says this increase is largely because of greater urbanisation and improved life expectancy. Whether India is going through a breast cancer epidemic or not, the geographic distribution of breast cancer clearly points to the fact that urbanisation and modernisation has something to do with the disease. “The West has realised the ills of urbanisation and we should take a lesson,” says Dr Rakesh Gupta, senior oncologist and public health expert.

More than 200,000 patients with histopathologically confirmed cancers were surveyed in the WHO report: gall bladder cancer in women from New Delhi is 10.6 per 100 000 of the population – the world’s highest rate for women for this type of cancer. “Cancer is scary because of the dreadful stories spun around it,’ Neerja says. “A person with a positive and correct attitude doesn’t have to be bogged down with fear. Fear is all about false emotions appearing real.”

When a recurring sensation under her armpit began to bother Neerja, the mother of twins went in for an oncological test. While in hospital, she was advised by her uncle to talk to a depressed fellow patient. This gave her inspiration to start a support group. It happened only six years later, when she was diagnosed with cancer for the second time. Neerja is currently a consultant counsellor at Apollo Speciality Hospital in Chennai and heads the Cancer Support group.

They thrive mainly in the cities, though there are not many online support groups. ‘Children with Cancer Support Group’ at Cancer Institute, Adyar, Chennai, and headed by Dr Anita Chandra addresses issues on education and answering basic questions on cancer. Both Adayar Cancer Institute and Apollo hospitals have cancer support facilities. Can Stop tries to fulfill the wishes of critically ill children. 

The Pink Hope Patient Support Group is a Bengaluru-based informal support group for breast cancer patients. Deepa Muthaiya of Dean Foundation hospice was inspired by The Tibetan Book of Living and Dying by Sogyal Rinpoche to start work with dying cancer patients. Hitaishini in Calcutta is affiliated to the International Breast Cancer Support Service Network in Switzerland, and Cancer Sahayog in New Delhi provides emotional support to cancer patients and subsidised drugs. 

Mastectomy association and Tej Ram Memorial Cancer Society in Delhi provide prostheses for breast cancer survivors. Home Care provides free home care service, free medicines, nutritional supplements, and food rations to patients. Dr Reddy’s Laboratories has five breast cancer Helplines, the latest being at Jaslok Hospital, in association with Helping Hand, a Mumbai-based NGO. 

Many organise events to spread cancer awareness. As Neerja said at one such event recently, “Life isn’t fair but one shouldn’t give up.”

NEW CANCERS AND TREATMENTS 

What needs to be given up in India’s fast growing cityscape are detrimental lifestyle habits. Breast cancer could be linked to obesity, lack of physical activity, delayed childbirth, lack of breastfeeding and increased alcohol consumption. About 79 per cent of urban men and 83 per cent urban women surveyed in the Indian Heart Watch study were found to be physically inactive, while 51 per cent of the men and 48 per cent of the women had high-fat diets. It’s not surprising that breast cancer cases have doubled in the four metros between 1982 and 2005 (ICMR data). However doctors believe more diagnosis centres are responsible for this revelation.

“More people are coming for cancer screening, unlike the old days when they died quietly at home,” says Dr V M Bapat, consultant onco-pathologist. Today, new cancer treatments are customising the medicine for the patient. 

“One has to tackle the microenvironment, not just the tumour,” explains Dr. S D Banavali, head of the Medical Oncology department at Tata Memorial Hospital. Recent research has shown that the effectiveness of certain anti-cancer drugs can also depend on race. Knowing the exact subtype of cancer and combining this knowledge with the medical and genetic history of the patient allows the doctor to tailor the treatment according to the patient. Cancer recovery is more than merely about surgery and medicine. Dr Banavali advises a holistic approach to cancer as a systemic disease. A healthy diet, a positive approach, even yoga, all of it helps. He believes it’s important to control stress. 

Studies have shown a link between stress and cancer recovery. Stress relief might help in cancer recovery, but is stress a risk factor for getting cancer? This question has plagued researchers for years but the connection has not been scientifically proved. There are those who believe that most studies have measured external stressors, not chronic stress. Chronic stress arises from feelings of helplessness, anxiety, feelings of isolation or simply suppression and/or denial of negative emotions. Many studies have proved chronic stress lowers immunity. They have shown that lowered immunity can result in an increased risk of developing cancers from infections.

The level of stress may not always be in our control, and nor are all the risk factors. If we cannot prevent cancer, the least we can do is ensure that it’s nipped in the bud. If caught in time, survival rates are over 90 per cent for some cancers. Doctors advise cancer screening should be a part of yearly medical check-ups. If there is a symptom, it’s best not to depend on one test. Errors can happen, and a lot depends on the sample tested. Says Dr Bapat, “Two concurrent opinions are advisable. If the first two doctors differ, go to a third.”

INDIAN C-SCAPE A WHO study found the world’s highest number of tobacco related cancers are in central, south, and northeast India. Wardha has the highest number of mouth cancer patients in the world. Says Dr Gupta, “Modern educated young Indians are increasingly taking to smoking and aping Western lifestyles.” This may not be entirely correct, since smokers are ostracised in most Western countries. 

In Pondicherry, 8.9 of 100,000 men have mouth cancer, one of the highest rates in the world. Men in Bengaluru and Chennai have the highest incidence of stomach cancer in India. Stomach cancer has various causes; even bacteria can cause it. It can get into people through faeces, sewage, contaminated water and food, which is not washed or cooked properly. 

In India, the rural and the less educated are more at risk. Stomach cancer is found to be the second highest killer cancer for Indian men after oral cancer in the age group of 30-69. Such high death rates do not reflect in ICMR data thanks to a smaller number of government cancer registries representing rural areas. Doctors say if stomach cancer cases could be over-estimated, the overall cancer mortality statistics in some states could also be misrepresented. How can the poorer states of Bihar, Jharkhand and Orissa have a lower cancer death rate than other states? 

According to doctors, cancer patients in the countryside may not be even reaching hospitals. Dr Purvish Parikh, Medical Oncologist & Haematologist in Mumbai, says “Most cancer related deaths in Bihar probably go unreported and with high mortality from other causes and lower life expectancy means, people will die of other causes before cancer can get them.” There is even a “belt” of thyroid cancer in women in coastal districts of Kerala, Karnataka, and Goa. Breast cancer has replaced cervical cancer as the leading cancer among women in Indian cities. Among men, lung cancer is the most common cancer in Calcutta, Mumbai and New Delhi.

The MDS (Million Death Study) conducted by Global Health Research and Mumbai’s Tata Memorial Hospital says a 30-year-old Indian man has a 4·7 per cent chance of dying of cancer before he hits 70. For a 30-year-old Indian woman, the figure is 4·4 per cent, Less than 5 per cent may not sound like much, but if burdened with cancer risk factors, the 5 per cent hits closer to home. The popular belief that one gets cancer because of bad luck or bad genes does not hold true. Errant genes instigate a very small percentage of cancers; most are caused by damage to DNA that builds up over a lifetime. 

Apart from smoking or heavy drinking, being overweight, exposure to pollution, toxins and infections, a faulty diet, and/or lack of physical activity are cancer accelerators. The disease is actually a group of more than 200 diseases, and each type has risk factors peculiar to its type. “Over 70 per cent of cancers in India like tobacco-related, cervical and breast cancers are either preventable or have good screening techniques, lending themselves to prevention,” says Prof. Surendra S. Shastri, the Preventive Oncology department head at Tata Memorial Hospital, Mumbai.

Adult cancer builds up slowly over time, taking multiple steps as it progresses. “This means multiple factors to deal with. Prevention is a better option,” says Dr. Banavali. He points out that although more aggressive, childhood cancers have a higher cure rate if treated in time. Adult cancers can pop up after years, even after a complete cure.

Cancer causes are complex, many unknown, and thus there’s no iron-clad guarantee that an absence of risk factors gives protection from the disease, but the link between lifestyle/diet and cancer cannot be ignored. It’s brought out vividly by the differences in cancer types amongst urbanites and villagers, between communities and religious groups, and different geographic regions of India as well as the world.

WESTERN LESSONS

Global statistics tell an indicative story. A story about how different diets, different climates and different lifestyles affect cancerous growths.

In Japan, studies have shown that regular intake of highly salted foods like salted fish and pickled vegetables predisposes people to colon and stomach cancers. Prostate cancer cases in developed nations have been linked to a high intake of red meats and dairy foods along with a lesser intake of vegetables. Breast cancer has been correlated with obesity, alcohol consumption, and lifestyle choices like late marriages. 

Skin cancer is caused by excessive exposure to ultra-violet radiation from the sun and is compounded by the outdoor lifestyles of Australians. If we can’t change our lifestyles, the least that can be done is to follow the lead of the developed countries and catch the cancer when it counts.

In India even affluent urban Indians avoid cancer screening, even if they suspect cancer. Fifty-nine-year-old Swati Joshi noticed a small growth in her breast but chose to ignore it. “I thought that if this is cancer there’s no cure. If I die, I die.” She also feared that the treatment would drain the family finances and told family members almost a year later. Luckily, it was not too late. 

Dr. Shastri rues the fact that people go late for testing “despite the existence of better treatment facilities in cities.” Swati’s case brings to life another statistic. Seventy-one per cent of cancer deaths in India are in the age group of 30 to 69. Most of these happen because of a reluctance to test on time. Swati is fine now, but regrets the delay. “The body gives you a signal and you need to pay attention to it,” she says.

BEING CAREFUL

Along with cheaper drugs, cheaper new treatments are being used to fight the disease in India. Metronomic (a low-dose and low-cost) chemotherapy is a good alternative as it cuts costs to a few hundred rupees monthly and has few side effects. This therapy is being tried out at Tata Memorial, and works for some type of cancers. “It cuts off the blood supply to the tumour,” explains Dr Banavali. Low-dose chemo is all the more relevant because questions are being raised about the effectiveness of chemotherapy itself, although more research is being done in this area.

When Pallavi Deshmukh went for a cancer test after noticing a lump in her breast, the result was negative. “But I knew something was wrong and my family physician advised another test,” says Pallavi. The second test and third tests were positive.

Tests can throw up wrong positives, resulting in needless mutilating surgery, painful chemotherapy and wasteful expenditure. Studies have shown that 10-12 per cent of cancer patients are initially misdiagnosed. This is happening worldwide. Earlier this year, Argentine president Cristina Fernandez discovered she didn’t have cancer, but after her thyroid was removed. Misdiagnosis can happen to anyone, and having the best doctors at hand does not ensure a correct diagnosis. “It’s a 100% subjective diagnosis,” says Dr. Bapat.

Regular screening and additional consultation should be routine. It’s the reason why developed nations have the highest five-year survival rates for all cancers.

Exposure to pesticides, chemicals and environmental toxins have been linked to cancer but the agricultural, manufacturing, transportation and the medical industries are permitted by governments to put a humongous number of chemicals into food, toiletries, and in the home. This is not counting the pollution of air, water and the earth by industries. The only way for individuals to counter the adverse effects of air, water and food pollution is to lead a simpler and more regulated lifestyle. And a positive attitude. Strangely for a country which is deeply into social networking, India doesn’t have many online cancer support resources. 

Ramya writes on her website: 

I believe the day you are diagnosed with cancer, you are a survivor.” It’s a good message to pass on to those who are living the darkness of cancer’s looming shadow.

Behind the C word

Some cancer risk Factors

■ Tobacco use ■ Alcohol use ■ Being overweight ■ Low fruit-and vegetable-intake ■ High intake of red and processed meats ■ High intake of high-fat dairy products ■ Lack of physical activity ■ Urban air pollution ■ Infections by cancer-causing viruses or bacteria ■ Indoor smoke from household use of solid fuels ■ Genetic predisposition

Cancer Symptoms

If you have some symptom, it’s most likely not caused by cancer. If you have any of the symptoms given below, please see a doctor. Remember, some cancers do not show outward symptoms until the cancer has advanced.

■ Unexplained weight loss

■ Fatigue

■ Pain 

■ Skin changes, including changes in warts and moles. 

■ Changes in bowel habits or bladder function 

■ Sores that do not heal 

■ White patches inside the mouth or white spots on the tongue 

■ Unusual bleeding or discharge 

■ Thickening or lump in parts of the body

■ Recurrent indigestion or trouble swallowing 

■ Nagging cough or hoarseness 

Coping with Cancer 

■ Accept and seek out the support of loved ones and also others suffering from cancer. 

■ Be mentally prepared for physical changes and necessary changes in your lifestyle and diet. You may be loathe to give up your usual lifestyle, but certain modifications may be necessary. 

■ Eat a nourishing diet and exercise, but be sure to take sufficient rest. 

■ Remain calm and feel positive about the outcome of the cancer.

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