Cancer is a frightening name that can unnerve any person, but it remains a common ailment that can strike both young and old. As cancer is one of the common causes (amongst the non-communicable diseases) of death in any society, the fight against this menace should be an essential part of any healthcare delivery system. Developed countries like the USA, Japan, and Europe have a detailed systematic approach to this healthcare problem and have greatly been successful in setting an agenda for a fight against cancer. Has the same been done in our community? In this article, I shall define a ten-point agenda that should be employed to make a fight to a finish against cancer.
Population-based cancer registry
Cancer incidence (occurrence per 100,000 populations per year) varies substantially from one country to another and from one region to another. There is also marked geographical variation in cancer of one organ of the body to another. Thus, each country/region must know the total and organ-wise load of cancer and cancer impact on society. This can be accomplished by cancer registries. Cancer registration can either be a population-based cancer registry (PBCR) or a hospital-based cancer registry (HBCR). PBCR is the gold standard for obtaining accurate cancer incidence in any given population but is more resource intensive compared to HBCR. PBCR enrolls all cancers and cancer deaths in the population and determines age-standardized incidence rates per 100,000 per year and truncated (35 to 64 years) incidence rates per 100,000 per year. These rates can be employed to make comparisons with other regions of the country, and world. This helps health departments define strategies to fight disease and assess the impact of control measures. Currently, there are a few population-based cancer registries available in India (Example: National Cancer Registry Program by ICMR 1982). As against PBCR, HBCR evaluates cancer load in the community by hospital admissions/deaths. The focus of the HBCR is on improving patient care at that hospital and cannot be employed in evaluating and comparing cancer load in the community and making comparisons with other regions of the country or world.
Identifying causal agents
Cancer is broadly caused by fixed (age, sex, genetic) and modifiable (diet, lifestyle, infections) factors. Each community must define the factors which initiate, promote, and worsen the growth of common cancers prevalent in society. This is done by epidemiological (case-control, longitudinal and interventional studies) studies for each cancer. Cancer control in the community can be done by targeting modifiable factors through intensive public awareness programs.
Basic research in cancer biology
Cancer biology studies involve advanced cutting-edge research to define the biological factors which give an understanding as to how a tissue under controlled organised growth turns into such an unorganized invasive growth to hurt or even kill the host. Same cancer in different regions may have different biological behavior and thus such studies need to be innovative and original. Studies that repeat what has been done in the West usually have no impact on the understanding of cancers in the East. Such studies help define new therapies including drug treatment or specially administered therapies.
Obesity; alcohol; smoking; a diet high in fats and mutton and low in fiber, fruits, and vegetables are major modifiable factors that cause cancers in various organs of the body. Public awareness and dedicated programs about these factors must form essential topics to control cancers in any community.
Chemoprevention / vaccination programs.
Many cancers of the body can be prevented by long-term prophylactic drug therapy. A classic example is long-term aspirin intake to prevent colon cancer. Similarly, control of hepatitis B infection by mass hepatitis B vaccination therapy has nearly abolished the occurrence of liver cancer in high endemic zones like Korea, China, Saudi Arabia, and a few African countries. Liver cancer was the leading cause of cancer-related deaths in these countries a few years back. Control of Helicobacter pylori infection has a major impact on the occurrence of gastric cancer in some countries. Gastric cancer is a major killer and commonest cause of cancer-related death in our community.
Most cancers are curable/ treatable if detected early on before the disease causes local invasion and distant spread (metastasis). Early detection programs for many cancers have revolutionized their management and control. Of significance are: (i) gastric cancer in Japan: over 80% cancers are detected early with 100% cure; (ii) esophageal cancer in China; (iii) cervical cancer in North India; (iv) breast cancer in West etc.
Case management units
Cancer management involves detection (by history & physical evaluation, laboratory tests, and imaging), evaluation (by an advanced lab and imaging tools), and multimodal management through chemotherapy, radiotherapy, surgery, newer treatment modalities, etc. Thus, cancer management should be incorporated in every primary, secondary, and tertiary care healthcare facility to get optimum results. Limiting cancer management to oncology units is detrimental to the overall management of cancer in society. Yes, oncology should define drug treatment protocol results for the medical fraternity to pursue and involve in highly specialized treatment protocols like Bone marrow transplants, etc. Radiotherapy units are dedicated units in treating cancers and should develop newer and safer modes (other than cobalt usually available) of delivering radiation like Linear accelerators, etc. Surgeons must define safer modes of surgery for advanced cancers in patients who are malnourished and include laparoscopic and robotic means of removing cancer-bearing internal organs. Limiting cancer management to specific units like oncology units or cancer hospitals overloads the facility and makes the system inefficient.
Most cancers detected in our community are detected late where cure or even control of the disease is not possible and the fight against cancer is lost. Such patients need to spend life with dignity and without pain. This is accomplished through dedicated palliative care units that understand the delivery of painkillers and other supportive care with compassion and which is culturally and religiously accepted by the individual and the family. More than dedicated cancer hospitals we need palliative care units in every medical facility involved in cancer management so that patients with advanced cancer care optimally.
Public awareness programs
Fighting against cancer cannot be done by introducing cancer societies or cancer hospitals in the community. Fighting against cancer is a public issue and needs to be introduced into society at schools, in factories, offices, mosques, radio, TV, press, and at every corner where society meets or ends. The health department needs an intensive awareness program of prevalent cancers and their impact on our community and the means to control them. This of course can be done when we have the requisite correct data accumulated by dedicated studies.
Surveillance, healthcare planning, and budgeting
How can these above items be incorporated together to make an agenda for a fight against cancer to the finish? This is the responsibility of the Govt: and health planners who should look at cancer as a menace to society and use every means detailed above to raise a fight against it. Active surveillance programs need to be monitored to assess that each rupee that is spent bears fruits and makes every program cost-effective and efficient. The future planning needs to be done depending upon data generated by the population-based cancer registry, cutting-edge research on cancer biology generated locally, evaluation of causal agents through case-control and longitudinal studies and dedicated interventional studies to define their value in controlling cancer load. Also, early detection programs need strict monitoring to reduce the diagnosis of advanced cancer. Budgeting must be optimum and cost-effective and spending ex-chequer for fancy equipment needs evaluation and monitoring.
With all this, we can set an agenda for a fight against cancer to a finish. Strategies to be employed against individual cancers needs a closer look at each of them most prevalent in our community.
Prof. Mohammad Sultan Khuroo, Former Dean & Director SKIMS and Ex-officio Secretary to Govt. Director, Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic, Srinagar.