About 20 percent of cancers are genetic. For instance cancers of breast, prostate, ovaries, colon, rectum, pancreas and some types of brain cancer 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. Renal and eye cancers also have genetic links and can occur in younger people and adults. But genetics are not the only factor, since a large number of cancers occur because of environmental factors, eating habits, infection and lifestyle. Therefore, any planning around cancer treatment must take these factors into account.
Sadly, our 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 itself, and the challenges confronted by health planners in our country.
Eating habits of ethnic communities
Eating habits play an important role in many types of cancers. It is seen that cancer of the oesophagus is more common in Quetta and some parts of Balochistan and Khyber Pakhtunkhwa (KP), where people prefer having hot food and drinks because of cold weather. In some parts of KP, Balochistan and along the Seraiki belt in Punjab, smoked meat — part of the regular diet — can cause stomach cancer. People who eat lots of overcooked and burnt meat in barbecues are prone to cancer.
Prostate cancer is more common in men who eat too many dairy products, especially among the cattle-farming community. Cancer of the mouth and throat are more common in Karachi among consumers of paan, gutka and betel nut. In recent years, these cancers have become more common in rural Sindh where the use of gutka and different kinds of paan masalas are spreading like an epidemic. Of course, smoking cigarettes, beerri and huqqa is associated with lung cancer. In Pakistan, smoking is one of the major causes of early lung cancer and death, particularly in males.
Various lifestyles lead to different kinds of cancers. for example, the lack of a good night’s sleep and high levels of stress weaken the immune system, causing the body to lose its ability to fight early development of cancers. Lack of exercise or low physical activity, along with high consumption of heavy foods, leads to extra insulin in the body, 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, we need to understand what causes the disease and streamline our healthcare system with efficient policies
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 kinds of cancers in the cervix, anogenital area, skin, nasopharynx and liver.
About 15 percent of the Pakistani population is infected with HBV and HCV. These viruses can lead to liver cancer and even death among a relatively young population.
A polluted environment can also cause cancer. Polycyclic aromatic hydrocarbons (PAH) are 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 is associated with certain types of cancers. High levels of chlorine in water can cause cancer with long-term drinking, especially among children. Long-term UV radiation causes cancer in farmers working in fields. Electromagnetic radiation and x-rays are also responsible for cancer. Non-protective x-rays of the 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 a 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.
The government should also strictly enforce measures to discourage the use of cigarettes, gutka, betel nuts and paan masalas. It goes 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 hence it is possible to save millions of rupees that would be spent in treatment. There is also a need for carrying out preventive campaigns on electronic and social media regarding cancer-causing eating habits in different parts of the country.
Health planners must also accept their failure in the prevention and control of HBV and HCV; they need to reinforce their efforts in this regard. A vaccine is available for the prevention of HBV which should be provided to the public.
Presently, the federal health ministry is trying hard to initiate a plan for safe blood banking and the use of disposable syringes in hospitals and medical camps. There is also a need to create awareness about blades for shaving at barber shops, sharing of miswaak in mosques and using blades during maatam in Muharram.
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 between ages 11 to 13 to prevent this cancer.
A healthy and hygienic lifestyle can prevent 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, while our vegetables are grown in riverbeds laden with carcinogenic chemicals.
The cost of inaction
Some of these points may sound like stating the obvious, but doing this work is of utmost importance. Cancer treatment is very expensive and there are only a few trained cancer surgeons, competent oncologists, radiologists and dedicated nurses available in Pakistan. In March 2010, a group of Karachi doctors started the City Tumour Board Karachi which meets every alternate Sunday to provide free consultation from experts to cancer patients. Other cities too should have this kind of arrangement for patients who are unable 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 as the number of patients increase each year. In Karachi, KIRAN, the cancer treatment centre of PAEC, treats more than 6,000 cancer patients for free.
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. The Pakistan Nursing Council should come forward with plans for training of these health cadets. Clearly, we have our work cut out for us.
The writer is ex-Secretary General Pakistan Medical Association
Published in Dawn, EOS, March 1st, 2020