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Cover Story

Cell attack

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It was 2007 and Minal Shah remembers being busy as she prepared for her wedding. She was happy - she was going to marry her boyfriend. But even as she fussed over never-ending shopping lists and home remedies for glowing skin and hair like any other would-be bride, her salivary gland was threatening to upset all her plans - a freak mutation in the DNA of a cell was making its division go haywire. While a normal, healthy cell divides into two every 120 days, a mutant cell with 'wild DNA' divides at a much faster pace. Soon, that one cell in Minal's body became an unruly mass that started 'eating up' any healthy cell that came its way. When that mass reached the value of 10, Minal felt a slight swelling below her chin. She told her mother about it, but it was dismissed as some sort of boil or eruption. As the days passed, the 25-year-old could feel the lump grow big, making it difficult for her to even swallow liquids. When she finally consulted a doctor, she was diagnosed with cancer of the salivary gland. Minal was lucky, though. It wasn't too late. Surgery and radiation therapy helped her get rid of the unruly, autonomous throng of life-threatening cells. She's married and healthy. At about the same time in Kolkata, Sharmistha Modak, caught up in the daily grind of domesticity, juggling job and family and taking care of her one-year-old daughter, ignored a harmless-looking white spot that suddenly seemed to appear on her tongue. But when more such spots surfaced, she consulted a physician. The doctor dismissed it as a symptom of vitamin deficiency. That his conclusion was way off the mark was evident when Sharmistha's tongue swelled up and started colliding with the molars, leading to lacerations. Her condition was diagnosed as cancer of the tongue. Sharmistha, then just 31, had never smoked a cigarette in her life or consumed alcohol. She wondered how she got the disease. Though her husband took her to the best oncologists, all of them told him it was too late. Deep in his heart, he believed that his wife would recover and she did battle the disease bravely for 18 months, tolerating an intensely painful treatment that involved surgeries and radiation. But Sharmistha wasn't as fortunate as Minal. She finally succumbed. Minal and Sharmistha are not alone as India battles a scourge that's as deadly as it is rampant. Even as you read this story, 30 lakh Indians are straining under the sustained attack of this disease. Next year, another 8 lakh patients will queue up at oncologists' clinics seeking explanations for their unexplained lumps, ulcers and bleeding. As the decade progresses, the numbers are expected to treble by 2020 (projection of World Cancer Report, 2008). By then fresh cases are expected to grow by a staggering 20 per cent every year. The world over, too, the scenario is frightening. According to a recent World Health Organisation report, one in three persons in the world will be affected by some form or the other of cancer by 2020. Statistics speak India may truly be on the verge of a cancer epidemic. A first-of-its-kind study, 'Time Trends in Cancer Incidence Rates 1982-2005 ', released last year by the Indian Council of Medical Research (ICMR), puts cancer trends in India in perspective. The study, which covered Delhi, Mumbai, Chennai, Bangalore, Bhopal and Barshi (in Maharashtra), stated that India in the last 10 years had seen a two per cent annual increase in the incidence of breast cancer in urban areas - even as rural India recorded an equally disturbing rise in the number of cervical cancer cases.
"We are clearly seeing double the number of patients we saw a decade ago, " says Dr S H Advani, one of India's top oncologists. Dr P Jagannath, the cancer surgeon who was called to operate on actor Amitabh Bachchan's diverticulitis (a digestive disorder) in 2005, agrees with Advani and adds, "Worldwide, more than 6 million people die of cancer every year and the incidence is 10. 6 million. There is no doubt we are in a dangerous situation. " Cancer is known to be a disease that rises in incidence with increasing age. And since life expectancy in India has gone up, it has exposed more people to the risk. "The number of cases of breast cancer in the 70-plus age bracket has seen a spurt, " says Dr Siddharth Sahni, a breast cancer specialist. Not that the younger lot is any safer, like 18-year-old Ankit Parmar. (See Back From The Brink) In addition to traditional risk factors like tobacco use, bad food habits, stress and pollution, urbanisation and corresponding lifestyle changes have contributed to what's now seen in medical circles as an alarming trend. Dr A Nandakumar, the Bangalore-based chief of the National Cancer Registry Programme, says: "While we can't definitely blame lifestyle for all cancers, studies of certain cancers, like of the breast, have shown that it could be attributable to the fact that more women now marry late, have children even later and breast feed for a shorter period than what women did even 20 years ago. " (See Going Bust) Dr Anshuman Kumar, a consultant oncosurgeon, adds: "Because of lifestyle changes, the cancers that were more common in the West are now showing up in India too. Environmental factors like depletion of the ozone layer and contaminated water are also increasingly being linked to various forms of cancer. All these factors lead to formation of free radicals - rogue particles that cause mutation of cellular DNA which further leads to cancers. " Unlike heart diseases, for which Indians can blame their faulty genes, cancers are not governed much by genetics. Of course, having an immediate family member who has suffered from it puts one in a highrisk category. But "genetic causes account for just one to two per cent of all cases worldwide, " says Dr Surendra Shastri, head of preventive oncology, Tata Memorial Hospital, Mumbai. Poison on a platter A landmark joint international study - 'Food, Nutrition, Physical Activity and the Prevention of Cancer' - commissioned by the World Cancer Research Fund and the American Institute of Cancer Research in 2007 found that 40 per cent of all cancers are a direct result of our diet, body structure and exercise habits. A perfectly healthy cell turns into a raging carcinoma (mass of cells) due to mutation in its genetic expression. In simple terms, the DNA of the cell goes out of whack either due to an inside (' genetic' ) factor or an outside (' epigenetic' ) factor like food. Nutrition may also alter the cellular milieu by triggering changes in hormones that may further lead to creation of cancers. So how does food lead to genetic mutation? One of the reasons could be increased levels of pesticides in what we consume. In a recent study conducted by the Post Graduate Institute of Medical Education and Research, Chandigarh, it was found that there was a distinct correlation between use of fertilisers and pesticides and the spread of cancer. Researchers came to this conculsion after analysing water and food samples in the cotton-rich Malwa belt of Punjab, notorious for its excessive use of fertilisers. High levels of heavy metals like cadmium, chromium and mercury along with pesticides were found not only in the drinking water, but also in locally-produced vegetables. The capital city of Delhi wasn't any better. Early this week, two NGOs, Hazards Centre and Water Aid, tested 53 water samples in Delhi and found only two were potable. The rest contained heavy metals and pesticides. Dr Rajan Badwe, director of the Tata Memorial Hospital, emphasises the linkage when he says, "In areas where the municipality provides running water, incidence of cancer is known to be low. " Most doctors TOI-Crest spoke to complained that higher consumption of junk and processed foods - especially meats - was adding to the cancer burden. Dr Niranjan Naik, a consultant oncosurgeon, says, "Most processed foods contain salt and sugar in excess and have reduced nutritional value. With opening up of the retail sector, processed meats like sausages and salami have become staple in urban households. It's best to limit red meat consumption to 500 gm a week. More than 64 per cent non-vegetarians in India have more than the recommended amount. Red meats, including mutton, beef, pork and lamb, have been found to have a direct relationship with colon cancer." But being a vegetarian doesn't exempt one from susceptibility to the disease either. A bowl of dal 20 years ago was 42 per cent more nutritious than what it is today. The growing burden of population on arable land is depleting the nutrition profile of soil. "Modern agricultural practices like monocropping are robbing the soil of a chance to replenish itself with nutrients, " says Jayashree Joshi Eashwer, an organic farmer based in Delhi. "When you add urea and fertilisers to crops, they need much more irrigation to avoid the side effects of chemicals. But excess irrigation leads to flooding and as a result the roots of the crops spread laterally, absorbing nutrients only from the top-most layers of the soil. With normal irrigation (in the absence of excess urea and fertilisers) the roots grow deep down into the soil to absorb water and are able to dig up more nutrients. To get the best from the soil, it is important to grow crops in a bio-dynamic manner. " The downside of the high life Ironical as it may sound, cancer is a paradox of modern, urban life. We are supposedly living better lives, are better fed, well-travelled and enjoy more choices, but it's precisely these that land us in the sick bay. Nothing has empowered us as much as technology has. On the flip side, though, it has exposed us to an array of health hazards. We are surrounded by gadgets like microwave ovens and cell phones that emit radiation, and it is an established fact that exposure to radiation kicks in mutations in the cell structure. IIT-Madras sociologist Prema Rajagopalan says, "It's the vicious circle of modernisation. Today, the same technology that makes life easier is also creating problems. These problems then become the driving force to develop better technologies, which again come with a new set of problems. " She also blames 'cultural lag' for the gamut of lifestyle diseases - cancer is now labelled as one - that are posing the biggest health challenge for India. "Lifestyles are closely linked with geography and culture. But globalisation has created a universal lifestyle that is often at crosspurposes with indigenous ways of life. We have adopted new eating habits without knowing whether they are suitable for us or not. The mismatch manifests itself in health problems. " Experts say the shift from a rural to an urban lifestyle has also affected the epidemiology of the disease. Nothing is more indicative of this than how breast cancer has replaced cervical cancer in Delhi and Mumbai as the number one killer of women. Lung cancer gets this dubious distinction in males, although it's now adenocarcinoma - cancer in the small airways of the lungs - that's becoming more common in cities. "This is because now more men smoke filter cigarettes, which give out tinier smoke particles. These, in turn, get lodged in the smaller airways. Earlier, larger particles of smoke from unfiltered cigarettes would cause cancer in the bigger airways, called squamous carcinoma of the lungs, " says Dr Radhe Shyam Nayak, medical oncologist. Though better hygiene in urban areas has brought down the level of infections, which has further led to a dip in the cases of stomach cancer, Nayak says more cases of colon cancer are being noticed. "Obesity and inadequate fibre in diets are believed to be behind escalation in the number of such cases. " Obesity, meanwhile, has emerged as a major risk factor, just as it has in the case of heart disease and diabetes. Nearly sixty crore Indian women are believed to be overweight and studies have shown that about one in 12 new cases of cancer is because of excess weight. Fat cells produce oestrogen, which causes cancer cells to multiply faster. Use of both smoking and non-smoking tobacco continues to be the leading cause of cancer deaths in males. The WHO predicts that if tobacco use is stopped in all countries, it will immediately reduce the cancer burden by 46 per cent. The silver lining But in all this grimness and fear of a looming epidemic, there is a sliver of hope. The good news is that awareness about cancer has never been greater in India. "In the last five years, I have seen a 25 per cent dip in the number of cancers being reported at later stages, " says oncosurgeon Sameer Kaul. "This is a good sign. This has been possible thanks to progress made in oncology as a medical specialty and billions of dollars being spent on research the world over. Treatment protocol is standardised and cancer cases are now clinically audited. " Globally, 200 molecules are being studied for their potential use in cancer treatment. The development of a vaccine for cervical cancer is seen as a watershed in the cure of the disease. "Cervarix and Gardasil are two vaccines that are directed against the human pappilloma virus, which is responsible for 90 per cent of cervical cancer cases, " says Dr Shyam Agarwal, medical oncologist. While they are now available in India, doctors are still awaiting the final word on it as the girls who were administered the vaccine during trials at a pre-puberty stage are yet to grow up to the age of 30-35 when cancer normally rears its ugly head. While vaccines are the next step of cancer treatment, the new generation of drugs has also managed to reduce the side effects of chemotherapy and, in some cases, cut the risk of relapse. Unfortunately, these are very expensive and are out of reach for most cancer patients in India. Herceptin, for example, which is used to treat breast cancer, costs up to Rs 1. 5 lakh for a month's dosage. It is said to slash the risk of relapse by 50 per cent. (See Deadly Disease, Killer Costs) Battle plan Taking cognisance of the high costs involved, the health ministry has set up a National Cancer Fund - the first such financial pool in the country for a single disease - that will cover all expenses incurred by below poverty line (BPL) patients hit by the affliction. The Centre has also sanctioned Rs 2, 500 crore under the 11th Five Year Plan for the National Cancer Control Programme - a 10-fold increase compared to the 10th Plan allocation of a mere Rs 250 crore. The assistance will mainly be utilised to improve diagnostic tools in government hospitals so that cases can be detected earlier and better.
To encourage doctors in the country's 4, 045 community health centres to do this, the Union health ministry has floated a proposal to financially reward them.
Amid the cacophony of figures, projections, arguments and counter-arguments on the prognosis of the cancer epidemic, it is important to remember what the foundation of a healthy life is - respecting your body and listening to it. Go for regular health check-ups and tests like mammography and pap smear. An early diagnosis is your best bet against the disease. The cell that turns cancerous is within us. So is the solution. shobita.dhar@timesgroup.com With reports from Malathy Iyer (Some names have been changed)
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