Understanding cancer

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According to the International Agency for Research on Cancer, in many countries, cancer will affect one in two men and one in three women during their lifetime. The World Health Organization estimates that the disease is responsible for nearly one in six deaths worldwide.

Those are daunting statistics. Yet most of us known little about this malady that can suddenly affect any of our lives.

To mark World Cancer Day, we spoke to renowned consultant oncologist and haematologist Dr. Muhammad Arif – the owner of the Razia Sultana Memorial Cancer and Blood Associates clinic in Lahore – and asked him about the disease, what triggers it, and how to prevent it.

Us: What is cancer?

Dr. Muhammad Arif: Cancer is a disease which involves the abnormal, uncontrolled growth of cells. It eventually becomes visible with testing or even to the naked eye. Cancer can start anywhere in the body and spread to other organs. It can be fatal if not caught and treated early.

Us: What causes cancer?

Dr. Arif: There are a number of theories regarding what causes cancer to develop.

The most widely accepted one nowadays is that the number one reason for cancer is likely to be lifestyle, which includes factors like diet, nutrition, exercise, weight, and stress. It is believed that about 60 to 70 percent of the cancer cases in the world are because of unhealthy lifestyle.

There are also some cancers that are triggered by a gene you get from your parents, but only about three to five percent of cancers in general are inherited. The rest of the cancers are incidental and sporadic.

Cancer starts when a cell changes its behaviour. Usually it starts with a mutation. But first mutation never causes cancer; the mutations accumulate over time.

These mutations are either acquired or inherited.

For instance, in our Pakistani context, we see a lot of hepatitis in the general population, which leads to a very high risk of liver cancer in those patients. In Western countries, it happens because of lifestyle; a condition known as fatty liver leads to a high risk of liver cancer.

Us: What are the most common types of cancer?

Dr. Arif: In women, breast cancer is considered the most common type of cancer. In men, it’s generally lung cancer.

Overall, the most common cancer is skin cancer – like squamous cell carcinoma or basal cell cancer – but most of the time, these are not deadly cancers; they are very easily treatable, so that’s why we don’t hear too much about them. The other skin cancer, melanoma … that’s rare, especially in Pakistan, but that’s actually a very deadly cancer.

In Pakistan, the most common cancers after breast and lung cancer are lymphomas. Then we have a lot of people with blood cancers, like myeloma. In some areas, we have a lot of cancers of the head and neck area – like tongue or mouth – especially in people who chew tobacco or smoke.

Other cancers aren’t uncommon either. We see a lot of stomach, pancreatic, and colon cancer, and liver cancer is among the most common ones in Pakistan because of hepatitis. 

Us: What are the main risk factors for cancer? You mentioned lifestyle…

Dr. Arif: Yes, the number one factor is lifestyle, which includes diet, exercise, weight, and stress.

Eating healthy and getting proper nutrition is essential. The second most important thing is probably exercise and weight management. Exercise leads to a lot of benefits – 30 to 45 minutes of brisk walk or light exercise every day, four to five days minimum per week, can reduce cancer risk by about 20 to 30 percent. So that’s recommended. Exercise also helps to maintain weight.

Third would be stress. Healthy stress, like exam stress or a little bit of competition stress, is ok. But unnecessary stresses – which have a lot of impact on your overall health – should be avoided.

Sleep is another important thing, especially in teenagers and youngsters. People who get a good night’s sleep are generally overall very healthy.

Other risk factors include – particularly since hepatitis is very common here – needle sharing. We should make sure there is no reuse of syringes and ensure that hygiene is maintained during medical procedures.

Us: What are the signs and symptoms of cancer?

Dr. Arif: Most cancers are initially silent, but when the cancer gets to a point where it starts to show symptoms, the most common symptom is a gradual decline in overall health. People might feel fatigue, tiredness; they might start to lose weight or lose appetite; they might notice a change in the colour of their eyes (which could become yellow if somebody has jaundice) or urine; they may become pale; or they might start to feel shortness of breath when they walk.
In practical terms, any symptom – from pain to a lump – which is new and persistent – more than a week or so – should be evaluated. 

Us: But many of these symptoms could suggest a different disease…
Dr. Arif: Yes, definitely. You shouldn’t be scared if you have some lump. It may be something else, like an infection or something benign. Similarly, if you have weight loss, it doesn’t necessarily mean that you have cancer; some people who have thyroid disease start to lose weight. But if the symptom persists, it should be investigated to make sure it doesn’t have a serious underlying cause.

Us: How important is early detection?
Dr. Arif: Early detection is definitely the only way, at present, to cure a cancer. Cancer can be detected early through screening. When the disease has started in the body but you don’t have any symptom and cannot detect it with your eye or by examination, you do these tests, like mammogram, Pap smear, and coloscopy. If the disease is detected early – Stage I and II – and surgery is performed, a majority of the cases are curable.
Take the example of colon cancer. If you diagnose it by screening through colonoscopy that finds a small polyp in the colon and you take it out – that’s all you need, surgery – then you’re cured. About 95 percent people are cured in Stage I colon cancer. In Stage II, it drops by about 20 to 30 points. In Stage III, there’s an about 40 percent cure rate; in the rest of the cases, the disease comes back at some point. Stage IV is not curable. Very, very rarely, if somebody has very limited stage IV and it has not advanced too much, then it might be possible to control with surgery. 

Us: But screening can be expensive…
Dr. Arif: There is cost analysis on that, and if you look at the value of the test, there is a positive correlation – it is very, very cost effective instead of having the disease diagnosed at an advanced, late stage.
Treatments – medicines, surgery – are so expensive. When it’s diagnosed in early stage, most people won’t need very extensive treatments, like chemotherapies and targeted therapies; they might need just a small surgery. Compared to early disease, advanced disease will cost a lot, plus it’s not curable. If you add up these things, it’s very cost effective to do screening tests.
In women, yearly mammograms are recommended after the age of around 40 or 45. Coloscopy is recommended for both men and women who are 50 and above. In men, prostate cancer can be detected early. Similarly, cervical cancer and uterine cancer can be detected by Pap smear which is recommended for women who are married.

Us: Are there any other ways to prevent cancer, like vaccines?
Dr. Arif: Yes. There is, for instance, a hepatitis vaccine which provides almost 80 to 90 percent protection against the disease, so even if someone is exposed to the virus, it won’t cause problems like cancer and liver diseases.
In Western cultures, they recommend cervical and oral cancer prevention with a vaccine that they give to youngsters which has been shown to reduce the risk of cervical cancer.

Us: What are the treatment options available for cancer?
Dr. Arif: The classic three ways of cancer treatment are surgery (if possible), radiation, and medicines called chemotherapy.
Nowadays, there are many new advances, especially immunotherapy and targeted therapies. They are very effective in some people.
For example, five to seven years ago, people with Stage IV lung cancer survived only a year or so; now about 20 to 25 percent people survive over five years. Similarly, the survival rate for myeloma was two years on average a few years ago; now it is about eight to 10 years. 

Us: Why is there no actual cure for this disease?
Dr. Arif: By its very nature, in cancer, there are some cells that mutate all the time. Once that process starts, you treat one type of cell, it changes into a different type of cell and becomes resistant to the treatment you are using. So it continues to progress over time. Although you may be able to control it for a long time, eventually it is not possible [to stop it].
Still, there are, say, on average about 30 percent people who are cured of their cancer. It’s getting better – from zero percent to 30 percent – but there’s obviously still a long way to go.
We are hoping that cancer eventually becomes a chronic disease, like other incurable conditions such as diabetes and heart disease; people get long-term treatment for it, but it is no longer an automatic death sentence. That will be a great success, I think.

Us: Do you have any recommendations for the readers?
Dr. Arif: I would say that prevention is probably the best strategy. Be proactive about your health – think about your well-being, make sure what you put in your body is not harmful, do not abuse your body, exercise, sleeping well, avoid unnecessary stresses. Don’t get exposed to risk factors which you can avoid, like hepatitis, unnecessary radiation exposures, unnecessary medications.
The next best strategy is that when you are in the appropriate age range, get screening done so that even if you develop cancer, it is caught early, treated promptly, and you hopefully get rid of the disease for good.

- By Sameen Amer

Us Magazine, The News - 2nd February 2024 * 

“Early diagnosis could save lives”

pinktober

To observe Breast Cancer Awareness Month, we speak to Dr. Muhammad Arif about the disease, its symptoms and treatment options, and the very significant importance of early detection

Breast cancer is a pesky interloper that has a cruel habit of cutting lives short in the most unfair of ways. It can sit silently in a person’s body, spreading its tentacles till it eventually strikes with vicious force. It can take over the lives of those in treatment as well as those around them for months, if not years. It can ravage the body and spirit of the patient and leave a permanent scar on the hearts of their loved ones.

But it doesn’t have to.

If detected early, the disease is fairly easy to control with extremely promising chances of survival. But in a country like Pakistan, where awareness levels are low and the healthcare system severely lacking, the outlook is often more grave. By the time most women realize they have the disease, it is already at an advanced stage and far more difficult to manage.

“As a nation, there is a delay in diagnosis and many patients do not survive because by the time they are diagnosed their disease is late-stage,” Dr. Muhammad Arif tells Instep. He is the owner of the Razia Sultana Memorial Cancer and Blood Associates clinic, named in honour of his late mother who also battled the disease.

So what exactly is this nasty malady that seems single-mindedly hell-bent on causing misery? Cancer is basically a group of diseases characterised by the uncontrolled division of cells (which are the basic building blocks of a living being). And what causes this unregulated cell multiplication? “There are a lot of theories,” Dr. Arif replies. “The old theory was that this is genetically determined. But after research into DNA and mutations, we found out that cancer is not necessarily genetic. It is mostly caused by metabolic problems in the body which then trigger cell growth.”

According to the oncologist, about seventy percent of cancers in general are now attributed to lifestyle issues, such as what we consume and how active we are.

Our diet, he says, is one of the fundamental driving forces behind the ailment. “The so-called industrial diet of today, products which are far from natural foods, [damage our bodies],” he explains. He lists the overconsumption of sugar and sweets, bakery products, vegetable oils, chicken and other meats, and Western-styled junk food as contributing factors and explains that we simply are not used to the chemically processed items we are now consuming. “We have evolved millions of years to get to this level, but in the last 100 years or so, our diet has been turned upside down. Things like over-processed oils are a huge factor in this, as are the chemicals and preservatives that are used to enhance the taste and shelf life of food [but that aren’t good for the human body].”

Unhealthy and fatty diets alongside a lack of activity, like exercise and walking, lead inevitably to weight gain. “In breast cancer, one of the highest risk factors is obesity and inactivity,” he says. Stress can also make the disease worse in patients who already have it. And then there are elements that cause a disruption in our internal metabolism but which we can’t easily influence, like our environment, the toxic chemicals that have been sprayed on the vegetables and fruit we consume, fertilizers, pollution, and water supplies contaminated with factory runoffs.

Specific to breast cancer, a woman’s familial history (first degree relatives with breast cancer) as well as reproductive history (early menarche, late menopause, and late first pregnancies) are often cited as risk factors. 

Altogether, these elements play a role in triggering a disease that disrupts the lives of millions of women – and even some men – every year. According to the World Health Organization, in 2020, there were 2.3 million women diagnosed with breast cancer as well as 685,000 deaths globally. While real data about the prevalence of breast cancer in Pakistan is not available, Dr. Arif says that according to estimates, about 1 in 7 or 8 Pakistani women will develop this disease in their lifetime, with Pakistan being among the highest risk countries in the breast cancer category worldwide. 

Detecting the disease in its earliest possible stage is the best way to combat this life-threatening adversary. And awareness of the symptoms certainly helps. “The most common sign of breast cancer is a lump in the breast. Sometimes there is a discharge from the nipple, swelling, or skin discolouration,” the doctor details. If the disease has spread, then it can cause any sign or symptom anywhere in the body, like pain in the back or in a bone (bone metastasis), a cough (if it has spread to the lungs), or swelling in the neck (if there are tumours in the neck nodes). “I think, as a general rule, any symptom that is new and persists beyond a few weeks should be investigated properly by a qualified physician,” he says. 

Thanks to scientific advances, we now have several treatment options for breast cancer. Surgery can remove a tumour; chemotherapy kills cancer cells with medication; radiation therapy sterilizes the area affected by the disease and destroys the cells responsible for the growth; and targeted treatment, like hormone therapy and immunotherapy, attacks specific elements to slow down or eliminate the growth. 

Treatment options are dictated by how advanced the disease is. If diagnosed at an early stage, the treatment is likely to be less taxing and more effective. With metastatic disease, surgery is no longer an option and the symptoms are basically managed with medication and radiation but the intent is generally palliate and no longer curative.

“Stage I breast cancer – where there is a small tumour in the breast which is less than 2 centimetres in size – has an 85 percent rate of survival. In Stage II, the chances of survival go into the 60s and 70s. Once it’s Stage III, it’s not only in the breast but is in the axilla as well, having spread through the lymph nodes, and the survival rate drops to less than 50 percent. When the disease is at Stage IV and has gone beyond the breast region and spread to another organ, then the five year survival is less than 10 percent.”

Dr. Arif strongly suggests that women, especially those who have close relatives – mother, sister, aunt – with breast cancer, pay special attention to any and all changes in their breasts. “In other countries, there is a lot of screening which leads to early detection and people get treated. [The lack of screening here] is a major factor why our mortality rate is very high,” he says. “By Western standards, the recommendation is that any woman who has a strong family history of breast cancer should get a mammogram every year after the age of 50. In the Pakistani context, I think it is not feasible to perform a mammo on every woman every year [because of high costs and lack of facilities]. So I think the most important thing for a woman would be to pay attention to the symptoms, pay attention to any lump they feel in the breast, and get the lumps investigated with an ultrasound and mammogram immediately.”

He also reasserts that special attention should be paid to prevention. “[It is essential] to take care of the lifestyle factors, like a proper diet, weight control, exercise, and stress management. Then there is self-examination; if you notice anything new, any symptoms at all, try to pay attention to it right away so that there is no delay. Early diagnosis could save lives.”

So try your best to take good care of your bodies. And no matter what your age, gender, or lifestyle habits – this disease can affect anyone, irrespective of their risk factors, after all – monitor any changes in your breasts (or elsewhere), get regular clinical examinations, follow the advice of the experts, and encourage your family and friends to do the same. Be vigilant, and spread the message. It could ultimately make a world of difference.

- By Sameen Amer

Instep, The News on Sunday - 30th October, 2022 *