Dr. Arunabha Sengupta_pic Dr. Arunabha Sengupta (Surgical Oncologist)

Battling the Emperor of Malady

The Telegraph

7th February 2018


In its penultimate year the Obama presidency declared the Cancer Moonshot programme, an audaciously ambitious leap to compress ten years of research in five years of time and solve cancer by 2020. The strategy is to break the barriers between differently poised research groups and form a truly altruistic alliance of hospitals, universities, and drug companies to share technological advances in real time for the better good of humanity.  The motivating force behind this programme is  Joe Biden, who lost his son to cancer, but such an idea of forming a global alliance against cancer, stretching up to the last citizen, has been mooted before.  On 4 February 2000 all countries got together in Paris, at the World Summit Against Cancer For The New Millennium, and adopted The Paris Charter to stimulate and speed up activities to control cancer.  In its article 10 The Paris Charter marked 4th February as the World cancer Day, to be observed by citizens across the globe so that the Charter of Paris and its objectives “would remain in the hearts and minds of people around the world.” 

Two decades since, the world is still looking askance and trying to figure out, amongst much hype, propaganda, and myths, whither cancer treatment. Faced with the stark reality that  cancer is here to stay and everyday touching more lives with its  variable, and often times cataclysmic behaviours, people ask in despair , ‘Why, instead of sermonising us about moderating our lives, the medical science cannot cure this malady?’ The reason is that it is a number game that involves the propensity of genes, carried in human DNA with all instructions for growth and functions of a human being, to get damaged and form mutants with distorted instructions. Other than a few inherited ones, these structural faults or mutations of genes are acquired later in life, much like vulnerable school kids spoiled by outside influences, by mutagenic substances or by some oncogenic virus. Or even by a ‘chance’ miscopy of genetic code during cell division.  The genes acquire successive faults or mutations over the years as one lives, the way one lives.  It is  a simple law of arithmetic then, that as one lives longer, more is the chance of that catastrophic event of a couple of genes getting mutated and ultimately hoodwinking the body’s security guards to initiate an unruly growth. Combination of a gradually ageing population and incremental additions of substances capable of causing genetic damage in life alone makes that hand of chance stronger.  

Not living long surely cannot be a desired option, but living well is. And therein lies the rub for living well would mean different things to different people. Many consider a descent life should include a bit of indulgences, here and there, a drop of an amber liquid, a succulent mutton piece, and a care free drag. That is a coveted entitlement most people would not like to part with. Besides, one argues, what about the inherited genes that are faulty?  And then there is global warming, polluted streets, electromagnetic waves from myriad of devices surrounding us, the artificial flavours in packaged food!  Well they are unhealthy, no doubt and some are in the list of suspects but the evidence against them is still weak. Genetically inherited cancers account for not more than five percent of total cases, although history of certain cancers in the immediate family makes one more susceptible at times.  ‘Blame it on others’, attitude would come with a price, says WHO. What matters more is how one lives; the actual age of a person might be the number of mutations his or her genes have acquired. That is why Mizoram, with local habits of smoking from an early age by both men and women, cooking in closed rooms, eating smoked red meats etc records the highest incidence of four types of cancer. Tobacco and betel quid chewing oral cancers in Indian coastal regions; prevalence of uterine cervical cancer amongst rural Indian women with the exception of Muslim ladies to a notable degree; the soaring incidence of breast cancer, a disease mostly prevalent in white Caucasian women, in urban Indian - Asian women with changed social practices, all point out that some curses are self-induced. The importance of   a regularised life style and diet has been further accentuated by the recent discoveries about the association between human genome (all genes put together) and genome of the microbiome, the collection of trillion micro organisms that reside in human body outnumbering it in counts of both cells and genes. Through many years of evolution that microbiome had stabilised to live in symbiosis with human bodies, strongly influencing genetic stability and immune system of humans mainly through the micro flora in the gut.  Causing dysbiosis with microbiome through dietary indiscretion and alteration of life style, some believe, allow cancers to develop.

Does that mean a life of abstinence is a guarantee against cancer? No, it does not. Ascetics do get cancers too, for a variety of reasons. The starting point might well be a simple ‘chance miscopy’ of a genetic code, and then it is  a multi factorial, multi step, multi pathway process leading to a diverse group of diseases with completely different biological behaviours. Breast cancer causing genes, for example, in different women, can go through different sets of mutations and finally lead to five different types of cancers with different outcomes. Sheer complicacies of cancer precludes any generalisation but avoidance  of known carcinogens  significantly reduce the number of acquired mutations in human  genome and an intact  immune system  kept up and going by proper diet and exercise will reduce the chance of those  genetic damage or mutations going unattended.  Growing rotund and slothful, on the other hand, is a scientifically proven multiplier of that chance.  The International Agency for Research on Cancer estimates the number of cancers in India to nearly double by 2035, forty percent of which are preventable by most estimates.  Can prevention really work in real life, in a vibrant evolving community?  A look at the data presented by the Annual report to Nation by the collaboration of American cancer organisation finds a decrease of 2.3% per year between 2008-20013 of cancer incidence in men attributable to moderation in individual life style factors whereas the incidence rate has remained stable in women in the same racial and age groups. Vaccination for hepatitis B and HPV virus and treatment for Helicobacter pylori  have reduced incidence of  liver , cervical , and stomach cancers in some parts of the world.

What is worrying in Indian scenario is the death rate.  The mortality: incidence ratio is 0.68 in India versus 0.38 in high income countries mostly due to reporting for treatment at late stages. The survival rates for most common cancers have improved substantially in past few decades but not so much for metastatic diseases or late stages.  Two new methods of treatment namely, genetic engineering and modulation of  immune system, the two main prongs of Cancer Moonshot programme, look promising but difficult to imbibe in routine clinical practice at sometime soon in this country  - both on counts of the sophistication needed and the price of the drugs ‘that are not affordable anywhere’.  Possibilities of science are immense and rapidity of technological development often surpasses the best guess, but all things considered, the fruits of modern cancer research will remain beyond reach for most. But research in preventive oncology has reached a stage to identify people at high risk and take measures to scuttle that risk or to detect the disease at an early and curable stage and treat it at a much lesser cost.

It is prudent to be aware of that and remain in control.  That is the message of World Cancer Day.

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