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Hope for those without hope
The World Health Organisation (WHO) says that about 10 million new cases of cancer are detected annually the world over. This includes 4.7 million cases in developed countries and 5.5 million cases in the less developed ones. It is also predicted that by the year 2020 there will be 15 million new cancer cases every year, and the yearly number of cancer-related deaths will rise from the current 6 to 10 million.
Pakistan too is under significant risk. The actual figures for new cancer cases, deaths and related factors are not available. However, the WHO has estimated 61,624 cancer incident cases and 42,684 cancer deaths among males and 75,095 incident cases and 43,188 deaths in females annually.
The Karachi Cancer Registry (KCR) — the first population-based registry in Pakistan — has taken an initiative to collect data relating to cancers in the country. For this purpose, information relating to the-then District South, Karachi, was collected for the patients registered for cancer.
Since this area represents almost all the ethnic and socioeconomic groups and a socio-demographic population distribution similar to that of Pakistan, it was found suitable as a representative sample for the entire country.
The survey of KCR reveals a disturbing fact: the figures for reported cancer incident cases in the year 2000 in males and females were 138,343 and 135,054, respectively, which are twice as much as the ones cited by WHO.
The actual figures for cancer incidents could be much higher than the quoted figures. The reason is that owing to low literacy rates and expensive medical facilities, very few people suffering from cancer approach the health services. Also, until recently there was no organised system for collecting, verifying and storing statistics.
According to the KCR, cases involving brain and neural cancerous tumours account for 2.1 per cent of all registered cases. In this context, four Pakistani scientists in their study reported that brain tumour occurs mostly during the second and third decades of life, as compared to the incidence of tumour in other Asian countries, which occur mostly in the fourth decade of life. In western countries, the age hovers between the fifth and sixth decades.
Brain or other tumours know no socio-economic boundaries and do not discriminate between gender or ethnicity. A number of factors determine the prognosis of brain tumour and play an important role in the survival or otherwise of the patients.
These include genetic composition, type and location of the tumour and age and general health of the patient. However, survival generally decreases as age advances, while children and young adults have higher survival rates.
Brain tumours may be benign or malignant. Benign tumours are not cancerous and do not invade tissue. In fact, 80 per cent of the malignant brain tumours do not originate in the brain, but come from cancerous cells that have spread from other primary cancers in the body.
This type of brain tumour is called metastatic tumour. Both types put pressure on brain tissues, making life difficult for the patient. Both are troublesome and often painful — either physically or psychologically or both — for the patient.
Once the illness is diagnosed, the patient and his or her family are unavoidably exposed to its immense psychosocial and economic impacts. In a developing country like Pakistan, where a majority of the people are poor or belong to the lower middle class, the cost of coping with the illness is high.
The costs do not just include direct healthcare costs but also indirect and recurring costs. The fear associated with cancer itself almost shatters a personality. Frequent and long stays at the hospital, painful surgery, low recovery rates together with expensive medicine add to the agony of the patient and his family, making the picture more dismal.
Stereotactic radiosurgery
In this unavoidably sad state of affairs, the technique of stereotactic radiosurgery has emerged as a comforting antidote for those suffering from brain tumour. The technique was developed in 1951 by Prof Lars Leksell of the Karolinska Institute in Stockholm, Sweden, and Prof Borje Larsson of the Gustaf Werner Institute at the University of Uppsala in Sweden.
It involves delivering a single, highly focussed dose of gamma radiation to a small, critically located target in the brain. The first Gamma Knife was made in the US at the University of Pittsburgh in 1951 and the first patient was treated in 1958.
The development of sophisticated imaging techniques like computerised tomography (CT scan), magnetic resonance imaging (MRI) and angiography have enabled a pre-eminent usage of the Gamma Knife technique for more maladies than ever before. Gamma Knife today has become the standard treatment procedure for common neurological diseases, arteriovenous malformations and a wide array of functional disorders including Parkinson’s disease, chronic pain and trigeminal neuralgia (facial pain). But its mainstay remains the treatment of brain tumour.
Gamma Knife has become the standard treatment procedure for common neurological diseases and a wide array of functional disorders. But its main focus remains the treatment of brain tumour
The Gamma Knife
This is not a “knife” in the literal sense of the word. It is a sophisticated replacement for a surgeon’s scalpel where a single, high dose of extremely focused gamma radiation subjects the diseased area to the same effect as a traditional scalpel. However, it can reach the required target without making an incision, safely, effectively and with absolute precision, inflicting minimal damage to the surrounding healthy tissues.
And herein lies its profound uniqueness: it is a revolutionary new-age radiation tool for the treatment of brain tumour with numerous benefits over the conventional open-wound surgery.
Being non-invasive, any surgery using Gamma Knife is prone to lesser complications, which are very likely in open surgeries. It is also cost-efficient, as it is administered on an outpatient basis, requiring at the most a one-night-stay at the hospital.
This real, significant reduction in long hospital stays cuts down hospital expenses drastically, besides easing the difficulties of attending to the patient at the hospital during prolonged stays. Furthermore, as this treatment is minimally invasive, most patients need little recuperation and resume normal activities the very next day.
The treatment, therefore, results in long-term pain relief and minimises the many side effects that are common to other treatments and surgeries. It also has the great advantage of saving money and allowing the patient to quickly return to normal daily activities.
The Gamma Knife treatment is not just an experimental phenomenon. It has been in use for nearly half a century with a host of success stories to its list of credits. Millions of patients all over the world have opted for it and have been successfully treated.
The Gamma Knife attacks malignant or benign tumours that cannot be reached through conventional surgery, are multiple in number or are resistant to radiation therapy.
Treatment can be performed just as well on patients with a previous record of open brain surgery, radiation therapy and chemotherapy and the results can be better than or comparable to conventional neurosurgery. It is also a ray of hope for those brain tumour patients who were once considered inoperable, and is an alternative remedy when the patient’s age or other illnesses are a complicating factor.
The treatment procedure usually takes one to four hours, while the actual delivery of and exposure to radiation is only around 20 minutes or even lesser. The patient needs to arrive on the day of the surgery and not necessarily before. The most important part of the procedure is the arrangements and determination of the precise location of the affected area. This is imperative to accurately delivering radiation to the target area without damaging surrounding tissue.
Treatment procedure involves fixing a frame to the patient’s head, which is attached to the imaging machines — magnetic resonance (MRI), CT and/or angiography — and a hemispherical helmet. The imaging instruments give precise 3-dimensional details of the exact location of the target area. These details are communicated to the helmet, which acts as a guiding device, ensuring that Gamma rays are focused exactly upon the area that needs to be treated. To enable this, the helmet is equipped with 201 portals that are evenly distributed around the patient’s head and radiation beams are delivered through these portals.
Thus equipped with supreme 3-D precision, the Gamma Knife targets tumours or malformations with the radiations emitted by Cobalt-60 source. The radiation sources are positioned in the hemispherical helmet so that all the beams converge on a single point. The shape and dose of the radiation are optimised to hit the target only, without damaging any surrounding tissue.
Throughout surgery, communication is maintained with the patient via video cameras and intercom. Once the treatment is complete, the Gamma Knife is removed and the patient is free to move. After a few hours of post-treatment observation, the patient may go home, unless he needs a medicinal treatment, for which an overnight stay is required. Once discharged, the patient can resume daily activities the very next day.
It is an accepted fact that health and education are the two disciplines considered vital for the development of a country. In Pakistan not a single unit of Gamma Knife exists, although India is making full use of the technology.
Once resource constraints stood as a hurdle in the path of technological advancement. But at a time when huge amounts are being spent on providing computers and internet facilities to even far-flung areas, it is important that a little amount is set aside for making available such computerised tools as are essential for mitigating the suffering of the sick.
The author is a retired scientist
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