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.

Door to door screening for cancer ??

Today there is an announcement on a door to door screening for Cancer, diabetes and cardiac illness in 100 districts in India costing 250 crores ( 37.5 million dollars) .  I was astonished. I don’t know about diabetes and cardiac diseases, but door to door screening for CANCER ??

Thats not logical or rational nor is it cost effective. I wrote in my earlier blog that screening for cancer is NOT the answer. Sweden is a classic example. Its a country with small population, social health care and all the people are followed up throughout their life. The infrastructure is excellent.

So when mammography screening for population was introduced, it was believed that breast cancer would be detected early. Once detected early, the treatment can be effective and lives  can be saved. It seems so logical and simple. But…

After two decades, the breast cancer mortality did not come down.The women undergoing screening had many false alarms and procedures. Lots of stress and tension and finally NO DIFFERENCE.

Why did this Happen??

There are many biases in screening. Lead time bias is just one of them. Cancer is so much like the human organism and cell. It has finite cycle and also ages. so whether you detect a 5 mm tumour now or a 1 cm tumour after six months, the outcome does not change.

It does not mean that you keep waiting once the tumour is detected. Soon there will be spread to lymph nodes etc.

But screening raises a lot of questions. When to test ? Whom to test? and how frequently should we test?

Pap smear was one such screening  technique and all women above 40 were advised to undergo PAP smear. But logistics of doing a pap smear, once in life time of a lady, are so enormous. It is just not possible.

The cost and the ability to handle doubtful lesions are so much that population based screening like the one planned as door to door testing, is just NOT cost-effective or feasible.

Instead, as I wrote earlier ( Jan 2014) , seven warning signals  can alert us to seek medical attention or undergo tests.

 

 

 

CAUTION AND ACTION – 7 Warning Signals of Cancer

 

Recently I participated in a meeting of Cancer NGOs ‘Can India Conclave’.  There was a panel discussion conducted by Sanjay Pugalia of IBN 7.   I was asked to make the final comments on how to tackle the oncoming ‘Cancer Tsunami’ .  First of all let me assure you that it is not a  tsunami, a national disaster of high magnitude.  The increase in cancer incidence is the price we pay for development. As the lifespan and longevity increase, communicable diseases decrease, non-communicable disease like diabetes, cardiac disease and cancer will take the forefront.  We will have to obviously change our strategy, as earlier the focus of healthcare was mostly on controlling diarrheas and dysenteries and now it has to shift to control of diabetes, cancer and cardiac diseases, a similar lifestyle related issues. 

I asked the learned audience a simple question – how many  know the 7 warning signals of cancer ? Very few hands went up. That only shows our own lack of important knowledge.  The only thing I can stress is that every NGO, every work place and every organization should just get this simple message across. 7 warning signals of Cancer. 

It is not just enough to have the warning signals but we also need to act on them.   CAUTION is the acronym developed by American Cancer Society to list the 7 warning signals. I strongly advise that every point in CAUTION has to be followed by an ACTION. 

Here are the CAUTION  and ACTION  on the 7 warning signals of cancer. 

 

Symptom or Sign

Action to be taken

C hange in bowel or bladder habits

Ultrasononograhy and endoscopy

A sore that does not heal

Biopsy and oral and skin examination

nusual bleeding or discharge in stool

U nusual bleeding in between periods

 

Rectal exam and colonoscopy

Gynaec examination for cervix and biopsy

hickening or lump in the breast, testicles, or elsewhere

 

Ultrasonography and FNAC if abnormal

ndigestion or difficulty swallowing

 

Endoscopy

bvious change in the size of mole, or mouth sore

 

Biopsy

agging cough or hoarseness

 

ENT examination and X ray chest

 

With this information I am sure many can benefit by early diagnosis.  I must emphasize that these symptoms may not mean cancer, may be something which is much less risky.  But when there is a symptom it is best to get checked and be reassured that there is no  malignancy. Early diagnosis has a high potential for cure and should not be missed.

 So  make note of these warning signals and the actions to be taken and pass it on to as many people as you can.

That is the best way to beat the Big C. Many lives can be saved.

Why do good people have a bad outcome in Cancer?

I do not know Atul Chitnis.  I have not even heard of him earlier, till Sharat told me about his accomplishments in helping start-ups by open source software.

http://atulchitnis.net/

I read about a remarkable highly motivated and energetic person wanting to help others.   What really struck me on reading about him is that unfortunately he succumbed to colorectal cancer.  I read an update on his health in January 2013 and I started wondering on 2 issues:

  1. How can someone who is educated, well informed, well connected be

diagnosed  with Stage IV Cancer.

  1. The same issues which plague many of our patients like Chemotherapy toxicity and  expense, have affected Mr. Chitnis.

It is indeed a tragedy that good people like Atul Chitnis had a late diagnosis, a bad outcome and succumbed to the disease.

Let me put it in a proper perspective ‘How do you diagnose or how do you suspect colon cancer’?  I always ask  my patients are there any symptoms and how long did they have symptoms?  They invariably have at least 6-8 months of symptoms – like feeling lethargic and weight loss,which are really warning signals.  Then there can be dark stools, sometimes blood in stools and the bowel does not behave as it should.  The alteration of bowel habits would alert one to do a simple test for occult blood in stools.  If occult blood is present in the stools for 3 consecutive days, then colonoscopy is necessary and perhaps CT Scan too. Colonoscopy is quite simple and takes half a day. Its not painful at all. Here’s how its done.

Should all normal people undergo a colonoscopy, like in the West after the age of 50. (American cancer society guidelines attached). As a health policy on population based screening it would be an enormous load and not cost effective. Those who are conscious and want a clean chit every year can do so. But certainly those who have symptoms like the GI upsets that do not respond in a couple of weeks and have anaemia(low hemoglobin) for unexplained reasons should be on alert. Its difficult to lose weight. I know it to well.  Unexplained weight loss is an important pointer as the tumor starts drawing energy from whatever nutrition is consumed.  So let me say that the message is: ‘Please be on the look out for these early warning signals and seek medical advice early’.  Then perhaps we will be able to save more good people in our society.

Here is simple message for  your treating  doctor. Don’t’ assume that bleeding is due to ‘Piles”, a rectal examination and sigmoidocopy are a must for those who have symptoms. A visit in time will save many years of life.

My sympathies to Mr. Chitnis’ close and extended family and I do hope that the good work he started continues.

American Cancer Society guidelines for early detection of Colorectal cancer:

Beginning at age 50, both men and women should follow one of these testing schedules:

Tests that find polyps and cancer

  • Flexible sigmoidoscopy every 5 years  or
  • Colonoscopy every 10 years, or CT scan with contrast

Tests that primarily find cancer

  • Yearly fecal occult blood test (gFOBT)