Toilet ki ek aur katha- Personal hygiene and Prevention of Cervical cancer

Good news is that Cervical Cancer incidence and mortality is decreasing steadily.

However most of the reduction happened in the developed countries as this graph shows.(GLOBOCAN)

All this happened even before HPV vaccine was introduced . Even pap smear screening was not total in some countries.

How did this happen?

Its clear that improved personal hygiene due to access to toilets with privacy was an important factor . Personal genital hygiene in both men and women can reduce cervical cancer.

Just compare with the countries with least number of toilets per capita ( WHO/UNICEF)

20150708_Toilets_FoGLOBOCAN_BSC_87648723

All  in the areas with high cervical cancer.

Of course there are other factors like unprotected sexual activity and HPV does spread due to poor habits. There was a nice study way back in 1999 from Kerala, in a survey based in Trivandrum centre,  that highlighted the correlation of cervical dysplasia to  lack of access to hygiene with toilets, sanitary napkins etc .

Expensive vaccines and even more expensive population screening are not suitable for large rural populations like India and Africa.

The fact however is that the rural and urban poor ARE AWARE of the ill effects of poor hygiene but just don’t have the access.

That’s a preventable tragedy!

Its time for action !!

Conflict of interest:

I know Akshay Kumar but was neither influenced or approached to write. The  thought developed for sometime in discussion with Dr Anita Borges.

Challenging the Conventions in Cancer

On World Cancer Day but I thought I will share a few ‘contrarian’ thoughts :

Facts :

  1. Cancer incidence is rising
  2. We are not making great headway in management of cancer so overall cancer mortality remains nearly static inspite of trillion dollar spend
  3. We have to discard the current conventions and adopt a different approach

On the basis of this, l challenge some conventional concepts to start thinking for alternate strategies.

1) Bigger surgery is NOT better. 

This is a concept which has been challenged, thanks to surgeons who were keen observers who collaborated with their pathology colleagues and came to the conclusion that removing large chunks of tissue around the tumour would not be necessary. This led to less mutilating surgery.  Classic example being breast surgery in which William Halsted, the pioneer, proposed the Radical Mastectomy with removal of muscles.  Even without the modern chemotherapy or radiation therapy came the modifications involving less

aggressive surgeries.  Yes, there was a time  ultra radical surgeries were done but soon surgeons realised that it is unnecessary mutilation and resorted to more organ preservation techniques.  The same thing also happened in rectal  cancer surgery, where without having a permanent bag or colostomy, normal on using basic common sense and good pathology normal passage could be restored.

2) Population screening is NOT necessary – mass screenings is not an answer for early diagnosis because there is no way a population based screening can be done in a country of 1.2 billion people and this will lead to a lot more false positive results and lead to a panic amongst people.  Then, is there any answer for this?  I would again urge a selective screening.  It doesn’t matter if a mammography detects a breast lump or a woman detects a breast lump after a little while at a 1 cm. or 1.5 cm. site.  It is not a late detection. Likewise many of the tumours can be detected early if only we are aware of our body.  That is the fundamental approach.  We should be aware of our body and any change to be noticed and medical attention sought.

Selective screening is the mantra

3) Randomized trials in drug treatment  are NOT way forward

     This is the biggest hurdle for progress and also it is the most expensive part.  Do you know that 90% of the randomized trials are neither   conclusive  nor have been completed particularly if you comparing Drug A with Drug B. It is a total waste of resources and giving a false hope to patient recruited.  Drug companies spend millions of dollars on trials and obviously the cost of drugs, get passed on to the hapless patients.

4) Targeted therapy is NOT a miracle 

      Targeted therapy in  limited instances has been helpful, rest of the time it has proven to be of marginal benefit and extremely expensive and also many times, toxic.  So, chasing these targeted agents is the biggest myth. the intelligence of a cancer cell is far superior that that of a drug company and it immediately changes into different pathways which no longer are inhibited by the expensive chemotherapy drugs.  So let us stop  this chasing these targeted agents and stop doing these trials which have marginal benefits.

5) Genetic testing for every cancer is NOT necessary

The full page ads on gene testing is marketing gimmick without a scientific basis. I have not come across a single patient benefited by so called personalised treatment as the number of active drugs same few whatever the profile may say. The long reports have no value in practice.

Now that brings us to the big question – Do we spend the money on advanced cancers with diminishing returns or early cancers.  Answer to this is obviously early cancers. 

So stop investing funds on chemotherapy and targeted therapy.  It is much better if we can only develop diagnostic techniques which are less invasive or non invasive which will detect cancers which are not symptomatic and that will be the biggest shift to bring us closer to reducing mortality in cancer. 

As long as there is civilization, cancer will exist.  The only thing we can do is reduce the deaths from cancer. 

A selfie that can save you

Mr. Brahma Rao, a bank executive noticed a small ulceration on the border of his tongue. He was not a smoker and never chewed tobacco. He thought perhaps she has injured his tongue by teeth bite and continued with normal activities. After nearly 4 months he suddenly noticed severe pain in his right ear which alarmed him and the ulcer also had increased in size. He was worried and contacted me. As he was abroad and visiting his family and was due to return, I asked him to send me the pic of the border of the tongue like ‘a selfie of the tongue’ which he did.

tongue-pic

It clearly showed a small 1 cm. ulcer and the edges were elevated. It is a very important symptom and sign as lesions on the tongue having what is called ‘referred pain ‘ of the ear is because of nerve infiltration. I diagnosed him as early tongue cancer and he underwent treatment. Fortunately there was no spread at all and he recovered very well.

 

It is an important pointer for all. The tongue is so visible and can be easily seen and felt. Any kind of nodule or ulcer or nodule that is persistent for more than a month is not to be taken lightly. Tongue cancer is painless and has referred pain to the ear. In vitamin deficiency or an aphthous ulcer is more painful, superficial and small.

It is easy to document by a pic and sent to a doctor.

Ultimately you are responsible for your own health and sooner the diagnosis, the safer you will be.

Beware of sudden deterioration of ‘diabetes’ and loss of weight

 

Recently a colleague of mine frantically phoned up saying that someone who is very close to him has to be seen by me. The patient was a mild diabetic and recently his sugars shot up. He was then taken to a diabetologist who started him on  insulin dose. Then he started losing weight and in the next 4 months he lost 4 kgs. The diabetologist opined “It is because of control of diabetes and it is good that he is losing weight”. However after his sugars came to near normal he continued to lose weight and he lost 4 kgs over the next 3 months by which time there was a sense of urgency.

It was then that he underwent CT Scan and was found to have pancreatic cancer which was inoperable. My colleague was devastated, that inspite of availability of medical expertise diagnosis was delayed.

This is not unusual. It is very important to remember that sudden deterioration of diabetic status suggests either ‘infection’ or ‘tumour’. It is very important at this stage to get a scan done so as to rule out the presence of tumour. Early diagnosis is most important for management of pancreatic cancer as surgery remains the only most useful treatment.

Once again I have to re-iterate that weight loss is not to be taken lightly and any significant weight loss has to be investigated thoroughly including a scan.

Can anyone ‘sense’ cancer?

Can anyone feel that they may have a serious illness and it could be cancer?

You may think ‘Its not possible’, but yes cancer can be ‘sensed’

I ask all the patients, whether they felt ‘not normal’ and that there is a serious illness lurking around. Most of them say  ‘yes’. There is a feeling that something is wrong. the body is becoming weaker and the energy is going down. Or loss of weight and stamina.Many times visit to doctor is postponed or get treated with some usual medications.

Its a combination of nonspecific symptoms, but one does feel ” definitely unwell” .

I am reading the book” when breath becomes air” by a young neurosurgeon Paul Kalanithi, who is diagnosed with advanced lung cancer. He also realises that there is some serious illness, may be ‘cancer’. Its a moving story of an aspiring surgeon who works hard and is about to realize his dreams, when cancer strikes him. He writes his own story , perhaps mirroring the stories of many patients he had seen.

I recall a professor of surgery, a well known teacher, who one day suddenly declared that he had pancreatic cancer. His family and friends were surprised as he looked healthy.

‘Why  do you think so?’

‘For years I have taught students that migratory phlebitis  (red streaks on legs ) is a sign of pancreatic cancer and I have show them in my patients’.

“Now I have the same sign”.

He was investigated in disbelief, but the diagnosis was confirmed.

The first response however is denial, even more amongst doctors. No it cannot be. Then as time goes, the inevitable symptoms like pain set in and  the diagnostic tests are done.

I see many like him. So many experience that loss of energy as though slowly the life is getting squeezed. Its is best to  get investigated at the suspicion and not wait for full blown symptoms. Time indeed is the most critical as stage of diagnosis is the only major predictor of prognosis. Earlier the better.

You may be a busy corporate executive or your children have board exams. Something is always happening, but your health is a super priority. Nothing else matters.

The same thing happens to Paul in the novel. Loss of weight is due to ‘overwork’. Acidity is ascribed to ‘too many coffees and  stress’. Not eating well as ‘no time’.

I recently saw a CEO with symptoms and its only after six months that he went for investigations. Work deadlines,travel, annual reports , social life – so many ‘important’ things- more important than our health. we have so many proverbs but hardly ever care.

Health is wealth ( proverbial sense) , but it only ‘depreciates’ and not ‘appreciate’ like real ‘wealth’ in the bank.

Well the bank balances can evaporate with a single illness.

I see this also in elderly. ‘why bother my son or daughter when they are so busy with their jobs’. That’s not correct. Most families care for their parents and would be devastated if they find an advanced cancer . Many just ask the question” Can my mother or father be cured?”. No matter how old, even 80s, but they want the parents to be with them a bit longer.

Thats normal and human, just push the line a bit. A little more time , just a little !

So when you sense ‘something is wrong’, don’t brush it away.

An early check up can save your precious life.

 

 

 

 

Is cancer incidence increasing?

I met Roopa the other day and she asked me, “Doc, every friend or relative seems to be having cancer. Why? Is cancer incidence increasing?”

I am asked this question very frequently and I keep giving same answers to explain ( not convincingly ) the increasing numbers. With increasing longevity of life there is likely to be more cancer & non-communicable diseases. Life styles have changed and may contribute.

I recently went to the Indian Cancer Society Meeting on the Cancer Registry Project.   The Mumbai Cancer Registry records only residents of Mumbai and not migrant population and has plotted the incidence over the last three decades. Great work and a tough one too!

Breast and Lung cancers are increasing. There is  increase also in rectal and colon cancer.There is a continuous and constant increase in liver and gall bladder cancer in Mumbai. It is likely due to migrant population from north settling in Mumbai. Cervical cancer is decreasing as the hygiene is improving and parity is decreasing. In short we are transforming into a western pattern of incidence.

The worrying feature, however,  is the increase in mortality due to cancer. Stage to stage, more patients succumb in India than in other countries.

We have not made a significant dent overall in treatment. Its not that we don’t have facilities or expertise. We just continue to see patients in advanced stages.

I chaired a panel of experts.. The panel felt that prevention and early detection are the key. What is required is better diagnostic facilities for early detection

  • Creating awareness among people
  • Lifestyle modifications
  • Physician awareness and referal

These are not really difficult and if we concentrate on this perhaps we can start showing decrease as it is already happening in some of the countries in the West, in gastric, lung and cervical cancer.

More thoughts on these later.

 

 

 

‘Be aware’ of anaemia or Low hemoglobin

 

Jai is a regular donor to our Foundation. He is one of those who donates every year without asking. This time he came with a cheque earlier than ;usual and I asked him, “you normally would put in a cheque in March.” He said, “No, this is from my wife. Whenever she wins a kitty party she donates the whole amount to CACF. This is a remarkable way of using kitty money rather than on clothes or fancy things.

I asked Jai who is a businessman the sequence of events that led his coming for surgery. He is already 3 years post-surgery and doing well. Obviously he could detect the disease early and this is his story….

“I am part of the walking club and every morning I go walking for 60 min on Carter road but slowly I started becoming slightly breathless. My friends used to jokingly say that I am getting old and unable to keep up with them. I really could not keep pace with them. I started becoming breathless whilst walking up a flight of stairs too. Initially I thought its because of my heart but my ECG, everything was normal. I went to my general physician who ordered usual tests and to my utter surprise haemoglobin was just 8 gms against normal of 12 gms. So obviously I was feeling breathless because not enough oxygen was being carried by low haemoglobin. This started a series of investigations and fortunately my general physician got a scan done which showed mass in the colon and subsequently endoscopy confirmed Colon cancer and I came for surgery.”

This is a very important story and also brings out a valuable point on being aware of some of the signs and symptoms and taking necessary action on them.

Anaemia or low haemoglobin is one of the classical presentations of gastro-intestinal cancer and it should not be taken as lack of iron or nutrition or due to any other cause. Many times anaemia can be manifested by just tiredness, weakness and breathlessness. Once anaemia is detected it NECESSARY to have a sonography or scan done which can pick up any lesion. It is also good to test the stool for occult blood. If occult blood is positive in any of the 3 samples, colonoscopy or endoscopy are warranted. In this way we are can pick up GI cancers very early.

The best part about GI cancers is that when detected early they just need surgery and good surgery will ensure a long time survival. Most of them, nearly 90%, survive for 5-10 years. Even chemotherpy can be avoided.

So just be aware of these symptoms. The symptoms should not alarm you but should alert you for investigations.

Take care of your health.