World Cancer Day is observed every year on 4 February to raise awareness concerning cancer, and to encourage its prevention, detection and treatment. Professor Zafor Md Masud, head of the Department of Oncology at Bangladesh Medical College, talks to Prothom Alo about the growing incidence of cancer in Bangladesh, the advances being made in the field, the shortfalls, and the way ahead.
Prothom Alo: It seems that there has been an increase in the incidence of cancer in recent years. Why is this so?
Zafor Masud: Firstly, yes, the incidence rate of cancer is certainly much higher than before. Secondly, patients are a bit more aware about cancer. Thirdly, we have more diagnostic facilities now, in comparison with even five or ten years ago. So it seems that cancer has increased much more than before because of all of these factors. And the incidence of cancer has actually increased, not just in Bangladesh, but worldwide.
Prothom Alo: Can you pinpoint the reasons why the incidence of cancer has actually increased?
Zafor Masud: There are certain general causes of cancer and each and every general cause of cancer is present in Bangladesh. Cancer usually occurs in two ways. One is genetic or hereditary cancer. And another is because of carcinogens, the risk factor.
The risk factors in Bangladesh, particularly in urban areas, are firstly, air pollution. Dhaka city has the top most air pollution in the world. And we are all exposed to this pollution in the air. We spend a long time of our daily lives on the road, in traffic jams. As long as we are on the streets, we are exposed to the polluted air. We are inhaling this air. So this is one of the leading causes.
Another hidden side of pollution is water pollution. One of the disasters in Bangladesh is arsenicosis, excessive arsenic content in water. Arsenicosis leads to lung cancer, bladder cancer, kidney cancer and skin cancer. Before skin cancer wasn’t common here, but now it is. All these cancers have increased because of arsenicosis. Water is no longer checked for arsenic anymore, but over the last two or three years we have been getting a lot of arsenic-induced cancer.
Another cause is that we are not aware about cancer prevention. Our lifestyle is very important in this regard. You will note that nowadays in Bangladesh, the younger generation has started to suffer from cancer more than the elderly. The cancers that we would see in a patient after 50 or 60 years of age, is now appearing in persons just over 30. Fast food diets are harmful and that is what the young are eating. Fast food contains nitrates, in preserved meat, in high cooked meat, burgers, hot dogs, canned food and other products used in fast food. This turns to nitrous urea in the colon, causing colon cancer, rectal cancer and so on. There has been high incidence of rectal and colon cancer among young people.
Lifestyle is a main factor for cancer incidence. No one is following any preventive diet. They are following a diet that causes cancer, and on the other hand they are not following a diet to combat cancer. Such a diet is important and includes fibre, anti-oxidants, that is fruits. You go to the market and get some fruit, but you need a fruit group, not just one fruit. There is a lack of awareness in this regard. People think they have eaten a lot of fruit if they eat four or five mangoes during the mango season. That is not how it works. You should take at least four types of fruits and four servings a day. That is the recommended diet to combat cancer. We are lacking in a preventive diet.
Fibres are important. This is in brown wheat flour, in fresh vegetables, yet people are scared to eat fresh vegetables, thinking these are filled with formalin or carbides or some other preservatives. So if they don’t eat this, where will they get fibre?
So on one hand we are eating food that causes cancer, fatty diets, processed meats and all these are cancer containing diets, carcinogens. And again, we are not having any preventive diet. Our lifestyle, where food is concerned, is a total disaster.
It’s the same about exercise. It is recommended that to prevent cancer, people should walk at moderate speed at least 40 minutes per day, 5 days a week. But they are not being able to do that. There is the matter of safety, particularly relevant for a woman. Then again, if you do go for a walk, you get the exercise, true, but then you also inhale all the carcinogens from the polluted air. So, people don’t want to walk on the roads. Jogging in the morning is good, but at least 40 minutes walking at a moderate speed is recommended. Just this exercise helps in preventing breast cancer, colon cancer and stomach cancer.
We can prevent at least one-third of the cancer by modifying our lifestyles. One third is treatable and one third is untreatable. That is the recent statistics in Bangladesh. But we are not being able to stop this preventable cancer because we are taking all carcinogen food, we are not taking diets against cancer, and have no exercise. Drink is also needed and people perhaps do drink enough, carrying a bottle of water with them. We should drink 8 to 10 glasses of water per day to wash out the waste material in the body.
Prothom Alo: Is there any awareness campaign from the government level or from any other level?
Zafor Masud: The campaign is very inadequate. Some are campaigning on a personal level, NGOs, or doctors personally. But cancer is a disaster. From the government, they may have some TV programmes on World Cancer Day, but this is needed on a regular basis through mass media and campaigning and awareness programmes.
We need to develop awareness from a school and college level. Before maximum cancers would appear after a person was 40 or 50, not including childhood cancer of course, but now cancer is appearing at much lower ages. We are seeing cancer patients after 25. Breast cancer would appear after 40 years of age, but now women of 25 or 30 years have breast cancer.
The disaster is colon cancer. Almost 30 to 40 per cent cancer patients have colon cancer or rectal cancer – colorectal cancer - and the patients are young people, under 40. So it would be effective if at the school and college level and university level we can run this campaign.
Then there is the cervical cancer vaccine. We can prevent at least 70 per cent of the cervical cancer by vaccination. But there is not much campaigning about this vaccination schedule. There is no awareness at all. And cervical cancer is one of the leading cancers in females, after breast cancer.
I personally give my patients handouts on the signs and symptoms of cancer. This is important not only for the general people, but for the doctors too. We are getting a lot of patients in an advanced stage of cancer, firstly because of the lack awareness of the general people, and secondly because of the lack of awareness of doctors, other than oncologists. So if these doctors keep these symptoms in mind, they can diagnose cancer in the early stage and save lives.
Prothom Alo: We have advanced considerably in medical science and have modern hospitals too, but still people go abroad for cancer treatment or any complicated disease. Why don’t they have confidence in our doctors, especially when it comes to cancer?
Zafor Masud: Before the patients would go abroad for treatment of their heart ailments, that is cardiac problems, but now the cardiac side is developed here. Now they go for cancer. Before 70 per cent would go to the neighbouring countries for cardiac treatment, and 30 per cent would be treated in Bangladesh. It is the reverse now, 70 per cent are treated in Bangladesh and 30 per cent, who are likely to be well-off, go abroad.
In the case of cancer, it is still how it was in the first stage of cardiac treatment, with 70 per cent, from the upper class, upper middle class and middle class, going to the neighbouring country or to Singapore and Bangkok. And 30 per cent stay back in Bangladesh. Why is this so? Is there no cancer treatment in Bangladesh? Of course there is. The government has established cancer departments in all the medical colleges.
However, we still do not have an adequate number of cancer specialists in our country, only about 400 to 500 oncologists for 16 crore people. That’s a very negligible number. So it is difficult. But there are facilities. Before it was centralised and patients would have to come to Dhaka, but now there are cancer centres at the periphery in government medical colleges.
The private sector is also setting up cancer centres at the periphery such as the Khwaja Yunus Ali Medical College in Sirajganj, there is one in Chattogram, in Sylhet there is the North East Hospital, and so cancer centres are developing in the private sector too.
Despite all this, why are people migrating? It is because we don’t have any one-stop service. One-stop means total diagnosis of the cancer. We have cancer specialists for the treatment of cancer, chemotherapy and radiotherapy machines and everything, but if the cancer isn’t being diagnosed, how will we get the patients?
In our country the diagnostic tools are missing. Nowadays it is not just a matter if biopsy. For the total cancer diagnosis there has to be a large number of blood tests, that is immunohistochemistry, all the tumour markers, all the receptor tests, but these are not done in Bangladesh, perhaps only in a couple of centres in Dhaka.
In our country, general pathologists do the biopsy. In India when cancer is diagnosed or suspected, the biopsy reports are seen by an onco-pathologist. Cancer pathology still hasn’t been developed in Bangladesh. So diagnosis is a serious lacking here. That is why people go abroad, because cancer isn’t being detected. There are CT scans and MRI, but we don’t have any cancer imaging specialists for this. So we are lacking in the basic tools for diagnosing before treatment.
Worldwide cancer is a disaster. We don’t call any disease disaster other than cancer. It is a disaster for the patient and a disaster for the family. It is both a mental and an economic disaster. Worldwide the government has subsidies for cancer patients, very good subsidies. The government doesn’t have subsidies here though it is now trying to arrange for subsidies for the cancer patients, and chemotherapy drugs are given in some centres. Around 10 or 20 per cent of the patients are getting free radiotherapy, but the majority has to pay. The people can’t take this burden because it is a long-term treatment, six-month to one-year treatment. This is a problem.
It is not only oncologists that treat cancer. You need onco-surgeons. There are about only 10 to 15 onco-surgeons in the country now. General surgeons are doing onco-surgery. They are doing well, but it should be by a specialist surgeon.
We do not have a multidisciplinary approach in our country. There needs to be one centre where you can get a surgeon, a radiation oncologist, a medical oncologist, an onco-pathologist and an imaging specialist. This teamwork has been not been developed here.
Prothom Alo: Are you hopeful that this will change, as in the case of cardiac treatment?
Zafor Masud: It is changing. The corporate hospitals in our country are already trying to develop these kinds of centres. The government sector has created certain posts for medical and surgical oncology in every medical college, but so far these posts remain vacant.
The best thing in our country is we have all the drugs and all made in Bangladesh. Before we would bring in all the drugs from abroad, even 10 years ago 80 per cent of the drugs were foreign. But the government has stopped all of that because we are sufficient enough in cancer drug production. In fact, Bangladesh is even exporting a lot of cancer drugs. That is amazing, a matter of pride. These drugs have high efficacy and are readily available in the market. And the prices are affordable. That is good news for us. But we need molecular diagnosis to use these drugs which we do not have. We do not have any molecular lab. It’s like having a gun without bullets.