On this World Health Day, let’s resolve to eliminate it
A few days ago, one of my colleagues sought permission to leave early as she wanted to visit a friend of her who was diagnosed with breast cancer. The next day, I asked her about the visit and the condition of her friend. What she told depicts the level of awareness on cancer in our society as well as our flawed social and cultural compulsions. It was unbelievable for me that my colleague did go to her friend’s house but despite being at home, she refused to meet. She told that the behaviour of the members of her friend’s family, and that of even herself, showed that they wanted to conceal her ailment. That’s why she would not meet any visitor and her family, too, wanted her to stay away from others. Upon further inquiry, I was told that the said patient is a highly-qualified lady serving as a teacher in a well-reputed school. But, due to lack of proper awareness, she could not foreknow about her illness. And, social constraints too compelled her to not share her problem with anyone, not even her husband. When her condition deteriorated, she went for a medical checkup where she was told that she had contracted breast cancer and that was, then, in an advanced stage. But, the lady did not want to get treated for that. The most excruciating aspect of this is the inhumane behaviour of her husband who is unwilling to take her to his home and she is currently living with her parents.
After knowing about this agonizing story, the first thought that crossed my mind was that in spite of being well educated, most of us sometimes act like mindless people; it’s our apathy that we do not take abnormal changes in our body and bodily functions seriously. We do not share this with others, go to the doctor but belatedly and make allopathic treatment our least priority as we try to find solace in home remedies or go to quacks, but it can prove fatal especially when one is suffering from a killer disease that cancer is. And, if a person is diagnosed with cancer, we quarantine him/her, killing him/her before actual death with our callousness.
Nonetheless, it is only one side of the picture; the other, and a more important, side is creating awareness on prevention of cancer, provision of better health facilities, making arrangements for looking after the cancer patients and making of effective policies, as well as their implementation thereupon. Highlighting the second side of the picture is important also for drawing up policies for the betterment of the sector and to call the attention of those at the helm of affairs to the oft-neglected problem of cancer and also to the theme of World Health Day 2018: “Universal Health Coverage: Everyone, Everywhere.”
For prevention of cancer and its treatment, maintaining data on cancer from various perspectives – more rightly a cancer registry – is of pivotal importance. But, unfortunately, we do not have such a system in place yet that may help us know about the actual state of affairs regarding cancer and drawing up of comprehensive policies thereupon.
The Federal Ministry of National Health Services & Regulations has tasked Pakistan Health Research Council (PHRC) with establishing a cancer registry consisting of data collected by country’s important public and private sector hospitals. The PHRC website suggests that eight hospitals – Jinnah Postgraduate Medical Center, Karachi; Civil Hospital, Karachi; National Institute of Child Health, Karachi; Nishtar Hospital, Multan; Allied Hospital, Faisalabad; Bolan Hospital, Quetta; Khyber Teaching Hospital, Peshawar and Armed Forces Institute of Pathology, Rawalpindi – have been sending data to the PHRC on a quarterly basis since May 2015, but the figures are not available on the website. Hence, finding out the actual number of cases of cancer or that of deaths is, indeed, an uphill task. However, in 2012, GLOBOCAN, a project of the International Agency for Research on Cancer (IARC) of World Health Organization, published data collected from 184 countries on new cases of cancer and cancer-related deaths. It revealed that during 2012, 184,000 new cases were reported from Pakistan making it the 16th largest country in the world in these terms. A major chunk of the patients consisted of women as they accounted for 57 percent of the reported cases. In 2013, 84,590 new such cases were reported among women, making Pakistan the world’s 15th largest country. For men, however, we were at 21st position with 63,451 cases. In addition, Pakistan witnessed 101,113 cancer-related deaths during 2012, the thirteenth largest number of such deaths in the world. As per the data, women accounted for 52 percent of cancer-related deaths, putting Pakistan at 12th position worldwide whereas this ratio for men got us the 19th position, with 48,449 mortalities.
In Pakistan, the most prevalent type of cancer among women is breast cancer. The WHO reported that 34,030 Pakistani women contracted this disease in 2012 – the twelfth largest number in the world. In the same year, 16,232 women died of breast cancer – the 8th largest number worldwide. However, among men lip or oral cavity cancer is common. In 2012, as many as 7,068 men contracted this type of cancer – the sixth largest number in the world. And, 4046 men died of this cancer – the fifth largest number worldwide. However, most cancer-related deaths are caused by lung cancer for which the number in 2012 was 5,097 – the 29th largest worldwide.
In Pakistan, breast cancer accounts for nearly 23 percent of the new cases. Similarly, the ratio of deaths of breast cancer is 16.1 percent whereas the largest ratio of 5-year prevalence is also related to breast cancer i.e. 34.8 percent.
In Pakistan, the National Cancer Control Plan started in 1994 but like many other health programmes, it has been on the backburner since long. Paucity of cancer-treatment facilities, lack of awareness on the illness, and non-availability of authentic data raise questions on the effectiveness of this programme. Prof Dr Abul Fazal Ali Khan, ex-chief surgeon Allama Iqbal Medical College and Jinnah Hospital, Lahore, stresses on the significance of collecting data in the following words:
“Due to unavailability of authentic data, we cannot know what type of cancer is most prevalent. In other countries, the authorities amply know what type of cancer has affected how many people, the disease attacks which segment of society and patients fall within which age group. So, first of all, we will have to establish a cancer registry so that every new diagnosis is made a part of the record. Just after the pattern of our national institution NADRA, we should also have a national institution for cancer so as to have a complete data of the patients – how many cases have been reported in Punjab, KP or other provinces, what cancers are related to women or children. These figures would be of pivotal importance in research being conducted in this domain because every day we see a new case having somewhat different symptoms. We have to find the cure for them.” He pointed out many positive developments in this field as according to him many types of cancer are curable now. He added: “Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) and other diagnostic facilities, which were once found at a few select places only, are now easily available in almost all hospitals.”
Prof Dr Khan, however, rued the insufficient resources that make a big impediment to treatment of all cancer patients by saying, “Cancer hospitals are not so common mainly because there are hardly any NGOs that work exclusively in this domain. It is taken as a mighty task but if we put in concerted efforts, we can tackle it successfully.” On the role of governments, he said, “Another general election is just around the corner and aspirants for national and provincial legislatures will come to our doorsteps, so social media and doctors should fervently lobby for inclusion of health facilities as a priority sector in their respective manifestos. The governments usually pay attention only to those areas that are in public sight but if we will raise our voice on provision of treatment facilities, they will definitely pay attention to this sector as well.” He further said that in the post-Eighteenth Amendment scenario, providing cancer treatment facilities to the people is now an exclusive responsibility of the provinces. For that purpose, it is necessary that all teaching hospitals are elevated to the status of comprehensive cancer hospitals, proper training is given to human resources and proper infrastructure is built on a war footing.
“Furthermore,” he said, “most new doctors want to become surgeons and physicians but hardly any would aspire to join the oncology field. When I ask my students if they would join this field, they do not have any surgeon or physician as a role model. So, we need to create them so that the young doctors get inspiration from them to join this field. For this purpose, physicians and surgeons should be given awards in recognition of their services to this field because young minds are always inspired by these things.”
Prof Dr Khan rightly pointed out that besides deficient cancer treatment facilities, we face an acute lack of trained human resource, especially oncologists. Information available on the website of Cancer Care Hospital and Research Center suggests that by 2015, there were only 1,200 beds available for cancer patients all over Pakistan, and only 84 oncologists were available to provide treatment to patients. The scant availability of such facilities in a country where the number of cancer patients is rising with every passing day is no less than a tragedy.
Prof Dr Muhammad Abbas Khokhar, head oncology department of the King Edward Medical University and Mayo Hospital opines that almost all possible cancer treatment facilities are available in Pakistan, the only problem is that they are though too scant to treat the huge number of cancer patients. He said, “Most people who come to us for treatment have a Stage 4 cancer which requires continuous treatment. For this, we need beds, medicines and other facilities. We humbly take pride in the fact that Allah Almighty has chosen us for the service of the patients who would come here as a last resort but there also are some limitations to our capacity. Suppose we even work round the clock, but still we have only 60-70 beds and those too are occupied almost every time. In these circumstances, if a patient, who must be admitted for proper treatment, comes to us, we cannot treat him/her even if we want to do so. Hence, there is a pressing need to establish more and more centres, especially for those patients who cannot afford treatment at private hospitals.”
Prof Dr Khokhar appreciated government’s efforts to produce more and more oncologists as they will be available to staff the new cancer-treatment centres. He said, “I am sure the situation would be a lot better in the next 4-5 years. If we formulate a pragmatic policy in this regard and start its implementation without any delay, we will have a large workforce only within 2-3 years. But, if we do not provide jobs to new doctors, they will surely go abroad in search of greener pastures. And, since today there is an open-market competition, we will keep facing an acute shortage of oncologists.”
On the issue of provision of better facilities to patients, Prof Dr Khokhar said, “At the Mayo Hospital, nearly 80 percent patients receive costly medicines absolutely free of cost, thanks to the Punjab government and the hospital management. At present, there is not a single centre in Lahore that provides free medicines to the patients except the Mayo Hospital. But, this sometimes overburdens us in terms of finances. Since a patient has to take medicines for a long time after surgery or chemo, the Government of Punjab has, quite encouragingly, made great headway by taking on board the pharmaceutical companies to provide free medicines to patients who have been taking them for more than ten years. However, a follow-up in this regard is still needed as a number of medicines are still not covered by this programme.”
Cancer is the second biggest cause of mortalities and, in 2015, 8.8 million people died of this disease – quite harrowingly, one out of six deaths. And, it is because most patients in Pakistan are diagnosed with cancer when it had already reached its last stage. However, if cancer is diagnosed in its early stages, the likelihood of its effective treatment increases manifolds. This is the crux of the opinion held by Prof Dr Muhammad Arshad Cheema, the founding Chairman of Surgical Oncology Society of Pakistan. He stressed on the inevitability of awareness on cancer and said that only 10 percent patients suffer from genetic cancer. The biggest cause of it is our environment and our lifestyles. Cancer can be prevented by disseminating awareness among the people.
Prof Dr Cheema highlighted the need for establishing comprehensive cancer centres as it is inevitable for providing better cancer treatment to patients. He said that in such centres, “all facilities including surgery, chemotherapy, radiotherapy, etc. should be made available under one roof. And, there must be, at least, one such centre for every one million population. Due to the sheer unavailability of such centres, a patient who is already fed up of his life, is treated like a football; his surgery will be done at one place, chemo at another and radiation at yet other, and it adds up to the patient’s agony and ordeal.” Prof Dr Cheema explained, “Treatment of cancer is done in two ways: one is the curative method in which the principal aim is to cure cancer; it is possible for some patients only. And, where curing cancer had become impossible, the patient is palliated which is a treatment to relieve rather than cure. In this method we focus on improving the quality of a patient’s life; for example, if he is vomiting, is in pain, has contracted hepatitis, is suffering from constipation, and so on, medicines are administered to relieve him of these disorders. Hence, not only his quality of life will improve, but that of the care-givers will also get better.
It is especially so because at an advanced stage, the cancer had usually spread to such an extent that even the members of a patient’s family stay away from him due to the stink coming out of the patient’s body.”
On the issue of modern cancer treatment techniques, Prof Dr Cheema said, “We have started advanced cancer operation for abdominal cancer and with the help of this technique we do chemotherapy session directly to the abdomen. This is relatively a new technique that has gained currency during the past 10 years or so, and we have established its first centre in Lahore.”
According to the WHO estimates, breast cancer is most prevalent n Pakistan as it accounts for 23 percent of new cases. A number of studies conducted in various parts of Pakistan in order to know the level of awareness among women on the issue of breast cancer have revealed that women do not have sufficient knowledge. Most women have never undergone mammography – the screening for breast cancer. As per a research article “Awareness, knowledge and attitude towards breast cancer, breast screening and early detection techniques among women in Pakistan,” published in a PMDC (Pakistan Medical & Dental Council) Journal, “poor knowledge and inadequate level of awareness regarding the disease amongst educated young women in the urban centres of the country is quite concerning. Knowledge deficit among educated women suggests apparent lack of knowledge and awareness among the masses … Some of the factors that add to this knowledge debacle are cultural norms. Conservative societal and religious beliefs do not allow people to talk about breast cancer publicly. The topic is considered a taboo in the society and this has resulted in increased mortality among Pakistani women. The society is not welcoming to discuss breast cancer openly.”