About 20 percent of cancers are familial and genetic. Breast, prostate, ovaries, colon, rectum, pancreases and some type of brain cancers have a genetic connection and run from one generation to the next. Blood cancer, which is common in some families, can occur during childhood, after puberty or at later stages of life. Bilateral renal and eye cancers also have genetic links and can occur in younger people and adults. But genetics are not the only factor. A large number of cancers occur because of environmental factors, eating habits, infection and lifestyle. Therefore, any planning around cancer treatment must take them into account.
Worryingly, the federal and provincial health departments have no strategy for prevention, diagnosis, treatment and terminal management of patients with malignancies. To understand cancer and its management in Pakistan, it is important to know some basic facts about the disease and the challenges confronted by health planners in our country.
Eating habits play an important role in many types of cancers. Cancer of the oesophagus is more common in Quetta and some parts of Balochistan and Khyber Pakhtunkhwa, where people prefer having hot food and drinks because of the cold weather. Cancer of the mouth and throat are more common among consumers of paan, gutka and betel nut in Karachi. In recent years, these cancers are becoming more common in rural Sindh where gutka and different kinds of paan masalas are spreading like an epidemic. In some parts of Khyber Pakhtunkhwa, Balochistan and along the Saraiki belt in Punjab, smoked meat is a part of regular diet which can cause stomach cancer. People eating lots of overcooked and burnt meat in barbecues are also prone to cancer. Prostate cancer is more common in men who eat too many dairy products, especially among the cattle farming community. Of course, smoking cigarettes, beerri and huqqa is also associated with lung cancer. And in Pakistan, smoking is one of the major causes of early lung cancer and death, particularly in males.
Lifestyle is also implicated in different kinds of cancers. The lack of a good night’s sleep and high levels of stress cause a failure of the immune system, causing the body to lose its ability to fight the early development of cancers. Lack of exercise can also put one in danger. People with low physical activity and high consumption of heavy food have extra insulin in their bodies which is another known cause of cancer. Obesity is another important factor, especially when it comes to cancer among young people. Cancer risk can be reduced by losing weight and increasing physical activity.
To win the battle against cancer, it is imperative that we understand the enemy and develop policies accordingly
Infection is also a major cause of cancer in humans and responsible for thousands of deaths in Pakistan every year. Human papillomavirus (HPV), Epstein-Barr virus, herpes, HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are associated with different kind of cancers in the cervix, the anogenital area, the skin, the nasopharynx and the liver.
About 15 percent of the Pakistani population is infected with HBV and HCV. These viruses can lead to liver cancer and even deaths in our relatively young population.
Recently, a UN summit on environment and climate has highlighted the risk to life on earth, which may vanish if world leaders don’t do anything about global warming. A polluted environment causes cancer. Polycyclic aromatic hydrocarbons (PAH) are the chemicals from industrial waste present in the outer environment which attach to fine carbon particles and their inhalation causes lung cancer.
Additionally, there are other PAH-type chemicals associated with cancers in industrial countries despite strict environmental regulations. Polluting the body with benzene, food preservatives, nitrates, pesticides and some cosmetics are associated with certain types of cancers. High levels of chlorine in water can also cause cancer with long-term drinking, especially among children. Long-term UV radiation causes cancer in farmers working on fields. Electromagnetic radiation and x-rays are also responsible for cancer. Non-protective x-rays of abdomen in young girls during puberty can cause ovarian and breast cancer.
A time for change
It is about time we had a national policy to fight cancer in Pakistan. Health planners should think about cancer and its management in light of people’s lifestyles and their exposure to chemicals. Familial cancers are another big challenge and it is important to create awareness about these among the masses for early detection, diagnosis and management. Teaching about familial cancer in school and using media for awareness can lead to early detection, thereby decreasing instances of cancer-related deaths in a high-risk population. Nowadays, it is possible to diagnose cancer of the breast, ovaries, colon, rectum and prostate at early stages. Early detection makes curative treatment possible.
Of course, the government should also strictly enforce measures to discourage use of cigarettes, gutka, betel nuts and paan masalas. It should go without saying that children should not have any access to these cancerous materials. A massive campaign is required to create awareness about cancer of the mouth, tongue, larynx, nasopharynx, mandible, nose and lungs. These cancers are preventable and by their prevention it is possible to save millions of rupees that would be spent in treatment. There is also a need for carrying out electronic and social media preventive campaigns regarding cancer-causing eating habits in different parts of country.
Health planners should also accept their failure in prevention and control of HBV and HCV and redouble their efforts to remedy this. A vaccine is available for the prevention of HBV which should be provided to every citizen of Pakistan.
Presently, the federal health ministry is also trying hard to initiate a plan for safe blood banking and the use of disposable syringes in hospitals and the community. There is also a need to create awareness about safe shaving at barber shops, the use of the same miswaak in the mosque and sharing of blades during azadar in Moharram.
Furthermore, policymakers must recognise that cervical cancer in women is 100 percent preventable because of a vaccine against the cancer-causing virus. Every girl in the country should get vaccinated at the age of 11/13 to eradicate this cancer from the community.
A healthy and hygienic lifestyle is a preventive measure against different viral infections. Clean drinking water should be another high priority for health planners. In our country we have no policy regarding cancer-causing chemicals and industrial waste. Our environment is polluted with chemicals, our rivers are used as reservoirs for industrial waste, our vegetables are grown in river beds laden with cancer-causing chemicals.
The cost of inaction
Some of these points may sound like stating the obvious, but doing this work is of the utmost importance. Cancer treatment is very expensive and there are a few trained cancer surgeons, competent oncologists, radiologist and dedicated nursing staff available in Pakistan. A group of Karachi doctors started the City Tumour Board Karachi in March 2010, which meets every alternate Sunday to provide free consultation to cancer patients from the experts in the field. Other cities should have this kind of arrangement for the patients who are not able to afford treatment in private hospitals.
Most teaching hospitals provide services for cancer patients but lack human resources, medicine and modern radiotherapy units. The Pakistan Atomic Energy Commission (PAEC) has 18 centres in different cities of Pakistan providing free services to patients, but they confront a financial crisis with an increasing number of patients each year. In Karachi, KIRAN, the cancer treatment centre of PAEC, treats more than 6,000 cancer patients without any charges.
Unfortunately, there is also no recognition of palliative care (care for terminally ill patients and their families) in our country. Health planners should invest in the training of oncology nurses and palliative care technicians who can help doctors in the management of cancer patients as is being done in developed countries. And the Pakistan Nursing council should come forward with the plans for training of these health cadets.
Clearly, we have our work cut out for us.
The writer is ex-Secretary General of Pakistan Medical Association
Published in Dawn, EOS, January 5th, 2020