Continuing our series with The Kandy Society of Medicine

Cancer - that abnormal growth

By Dr. Sarath Wattegama

Cancer is an abnormal growth arising from our own cells, which is free of body control, purposeless and tends to invade tissues locally and sometimes shoot out pieces to distant organs.

Cancer is frequently not perceived as a significant health problem in most countries where infectious and prenatal and maternal mortality have received more attention. But it has become one of the leading causes of death in both developed and developing countries. In adults, cancer is responsible for 20 percent of the 11 million annual deaths in developed countries and 13 percent of the 22 million annual deaths in developing countries.

The causes of cancer can be broadly divided into two groups

a. Environmental (75%)
b. Genetic (25%)

Environmental factors (Carcinogens)

a. Physical agents...eg sunlight, radiations, x-rays
b. Chemical agents..eg. tobacco, dyes, tar, asbetos
c. Biological agents..eg. virueses
d. Dietary agents...eg. low fibre diet, high fat intake
e Drugs..eg. anti-cancer drugs, immunosuppresives.

Genetic factors are responsible for certain familial cancers.

It is important to remember that our body has a remarkable ability to prevent a person from getting a cancer. It is extremely difficult to avoid carcinogens in the environment. We are constantly exposed to radiation from several sources; sunlight, terrestrial gamma rays and nuclear tests are few examples. It is our body mechanisms that prevent abnormal cell proliferations which can lead to cancer.

Human cells have millions of genetic material called genes. Of these few are responsible for cellular growth, proliferation and cell death. They are known as oncogenes. When there is an insult to oncogenes by either environmental carcinogens or genetic factors, abnormal cell growth is possible.

However, such abnormal growths are most of the time arrested by several body mechanisms. They are suppressor oncogenes, gene repair and immune cells (natural killer cells).

As long as the above three mechanisms operate well, transformation of normal cell to an abnormal cell is blocked.

Carcinogenesis or cancer formation is a long drawn process, time varies from one tumour to another. During this period changes at cellular level occurs. Also certain chemical substances are generated by the tumour cells. They can be detected in our blood. Cell number too, increases.Under these circumstances, the person who harbours cancer may develop few symptoms. They are known as "cancer warning signals".

They are:

1. an obvious change in a wart or mole
2. a change in bowel or bladder habits
3. a nagging cough or hoarseness
4. indigestion or difficulty in swallowing
5. a sore that does not heal
6. unusual bleeding or discharge from any orifice
7. unusual thickening or lump.

As you know most cancers if detected at an early stage a lasting cure can be expected. Therefore, one should consult a doctor if any one or more of the above mentioned symptoms are noticed.

The challenge facing the global health services in the years ahead is development of appropriate strategies for the control of cancers through primary prevention. In other words, elimination of causative factors.

A sound knowledge of the epidemology of cancer is essential for planning services because it provides information on the nature, extent, and evolution of the cancer problem in particular areas and provides information on corresponding causative factors, which can be used to assess the likely impact of preventive measures.

In Sri Lanka the most common adult cancers are listed below in the order of frequency.

Male

1 oral cavity 28%
2 Lung 10%
3 Larynx (voice box) 8%
4 Oesophagus 6%
5 Colorectal 6%

Female

1 Uterine cervix (womb) 30%
2 Breast 29%
3 Oesophagus(gullet) 10%
4 Oral cavity 10%
5 Ovary 8%

The major known risk factors for the first four cancers in males in Sri Lanka are use of tobacco or beedi smoking, alcohol drinking and tobacco or betel chewing.

Colorectal cancer is more frequent in the industrialized world than in in developing countries. In most developing countries, time-trend analysis suggest an increase in the occurrence in both sexes and the suspected causative factors are lack of fibre diet, high intake of animal fat, and a sedentary life style.

In females, cancer of the cervix is the commonest and the known risk factors are infection with the human papilloma virus, age at first intercourse and number of sexual partners. The causes of breast and ovarian cancer are uncertain even though studies have revealed reproductive, hormonal factors and the latest being, high intake of fat contributing to a larger extent.

In Sri Lanka, it is very interesting to note the high incidence of gullet cancers in the female population than in males. Our statistics indicate that it is more frequent in the poorer section of the population. As smoking is uncommon among females here, use of smokeless tobacco (betel chewing) may contribute to it. There is evidence in countries like China that lack of micro-nutrients in the diet can cause gullet cancers.

The impact of cancer of a given population can be lessened by prevention, early detection and effective treatment. The potential improvements in mortality by implementation of state-of-the art therapy are relatively small for many cancers (it was estimated that a reduction of nine percent was posible in the United States betweeen 1985 and 2000) and can be achieved only at a cost that developing countries cannot afford.

Therefore cancer prevention measures should be directed to the environmental factors which can be controlled.

The Swedish Cancer Committee (1994) has published their estimates of different environmental factors for the incidence of cancer as follows.

Factor            %of Cancer

Diet                          30
Tobacco                   15
Sex & reproduction  10
UV light                     5

In Sri Lanka, as I mentioned previously, tobacco, in the smoke and smokeless form has contibuted to more than fifty percent of cancers and our efforts should be directed to reduced tobacco consumption. It is also necessary to note that appropriate diets and associated lifestyles could reduce overall cancer incidence by about one third, although the specific mechanisms by which individual constituents of diet affect the cancer process are often not fully understood.

What are the dietary guidelines for cancer prevention?

* Reduce fat intake to less than30% of calories.

* Increase the fibre intake to 35 grms/day

*Include a variety of vegetables and fruits in daily diet.

*Avoid obesity.

*Consume alcohol beverages in moderation if at all.

* Minimize consumption of salt,curd, pickles or smoked foods

The author is the Consultant in Cancer Medicine at General Hospital, Kandy.

Let's talk about Cholesterol

'Cholesterol' is a much used - and abused - word in medical practice. Many believe high Cholesterol levels indicate a potential heart attack.

But, what is Cholesterol and what does it do? Here are the answers to some common questions:

What is Cholesterol?

Cholesterol is a type of fat. The body needs it to make cells, bile acids and hormones.

Your body breaks down fat from the food you eat into different types of Cholesterol. 'LDL' is the type that blocks blood vessels ("bad" Cholesterol). 'HDL' takes Cholesterol back to your liver which removes it from your body ("good" Cholesterol!)

Normally, the body balances the Cholesterol levels. But if you are overweight, or have too much fat in your diet, this balance is lost and Cholesterol levels rise.

What does a high fat diet do?

A high fat diet increases the risk of heart attack, stroke, kidney failure, high blood pressure by blocking blood vessels.

It is also known to cause constipation and increase the risk of cancer of the colon and rectum.

When should you check Cholesterol levels?

Check Cholesterol levels if you have a family history of heart disease, have had a heart attack or recurrent chest pain on exertion, or if you have high blood pressure, or diabetes. Smoking, being over-weight and a high consumption of fatty foods are other indications for testing.

When you get your Cholesterol levels checked, ask for total Cholesterol, HDL and LDL and triglyceride levels. Always consult a doctor with the report.

How do you reduce Cholesterol by modifying your diet?

If your Cholesterol levels are high, always see a doctor.

But you can change your eating habits as well:

- Cut down on fast food.

- Read food labels carefully. Foods that are labelled "low" or "no Cholesterol" may still be high in saturated fat. Avoid them.

- Eat fish instead of meats whenever you can.

- Use low fat milk instead of full-cream milk.

- Spread butter and margarine thinly.

- Cut down on salt, sugar and alcohol in the diet.

- Increase the fibre content of the diet. Green leaves are a good source.

However, remember to see your doctor who will decide whether you need medication or not.

Computers can make you sick

By Gaya Gamhewage

Computers, which have revolutionised the way we live and work, may be bad for our health.

The Institute for Occupational Health and Safety (IOHS), a foreign-funded non-governmental organization which works in the field of prevention, detection and treatment of occupational problems and diseases, has identified ill-health and disease amongst computer users.

Computer users suffer from poor vision and other eye problems, chronic backache as well as muscle and joint pains and have skin problems, the IOHS says.

The eye is commonly affected. It has already been found that the eyes of computer users blink less and have difficulty focusing on objects close at hand (disturbances in near vision). Those users who already wear glasses or contact lenses find they have to have their prescriptions changed more often. This is because the eyes become strained and tired staring at the screen for hours on end and slowly lose their ability to accommodate itself to seeing different objects.

The results are eye pain, redness and tearing, heaviness of the eyes and headache. Some users even complain of seeing flashes of "colours" when they remove their gaze from the screen.

But correct use and adhering to a few ground rules can minimize these problems, the IOHS advices.

The room should be well lit and the light source should not reflect on the computer screen. The screen should be clear and the illumination should be adequate. A flickering, blurred screen can damage eyes. The level of illumination should be adjusted so that the individual user is comfortable. For every 60 minutes at the computer, you must take off 15 minutes to "rest and recover", they advise.

Almost all computer users experience some symptom or other due to sitting for hours at the computer. Back, shoulder and joint pain and stiffness in the neck and headache arise from sitting in the same position for long periods of time.

The most important rule, experts say, is taking a break from time to time to stretch and change the body's position. Your chair should be the right size for you, comfortable and adjustable. Your lower back should be supported and you should be able to place your elbows on the arms of your chair comfortably, the IOHS suggests. The table should be the correct height with the keyboard at a comfortable level. In developed countries, these requirements are met when constructing office furniture but Sri Lanka has yet to do so.

Also, remember to exercise your joints even while you are working. Clenching and opening your hands, making circular movements with your wrists and ankles, bending and stretching your elbows and knees can be done while seated.

Some computer users find they get skin rashes when using the computer. This, the IOHS says, is due to the deposition of electromagnetic particles on the skin. It causes itching, hives and small swellings.

Computers are here to stay and are essential tools in the development of mankind and civilization. But the IOHS advises employers to remember that this high technology is operated by humans who are and will most probably remain vulnerable to ill health and disease.

Take a shower in the morning

Having a shower or a bath in the morn ing may help some people with atopic dermatitis. Reporting in a Research Letter in this week's Lancet, New Zealand researchers found that the concentration of house-dust mite antigen on the skin of volunteers was directly related to the concentration of the mite antigen on their beds. Dr. P. Fitzharris and her colleagues suggest that "there may be some patients for whom it is therapeutic to shower or bathe after leaving bed".

Atopic dermatitis (also known as atopic eczema) is a common skin disease that particularly affects infants and children. It results in itchy, red, inflamed skin and is often associated with other allergic conditions such as asthma, hayfever, or food allergy. Treatment is difficult and usually involves several creams and additives to the bath, many of which will need to be used for months or even years. Many possible causes of atopic dermatitis have been identified, including house-dust mite, and reduction of exposure to the mite does benefit some patients with atopic dermatitis.

Dr. Fitzharris and colleagues studied 25 adults without atopic dermatitis. Each volunteer vacuumed their trunk and limbs (but not their head or neck) for 2 minutes with a 1000 Watt vacuum cleaner after getting up in the morning and taking off any clothes worn in bed. The entire undersheet surface was then vacuumed for 2 minutes into a fresh collection bag. They found that the concentration of house-dust mite antigen (Der p 1) on the skin of the volunteers was related to that found on the sheets. As well as attempting to reduce the concentration of house-dust mite in the bed, washing the skin may be helpful to some patients with atopic dermatitis.

Second Opinion

Who are the quacks?

Earlier this month, the country's first ever directory of medical and dental professionals was launched, under the guidance of the Government Medical Officers Association (GMOA), the powerful trade union of state sector doctors.

It is not always that one can commend the GMOA, but on this issue, the Association has done a worthy service to the country.

The aim of the project, the GMOA says, was to list qualified doctors, so subscribers of the directory could know who the "quacks" are.

What is alarming though, is not what is listed in the directory, but what is not listed:

When the GMOA called for applications for listing, it received several thousand applications from unqualified persons who are merrily practising medicine in Sri Lanka - and endangering the lives of innocent patients on a daily basis.

Recently, Health Minister Nimal Siripala de Silva proposed new laws that impose tough penalties - including jail sentences - for those convicted of engaging in medical practice fraudulently.

Now, therefore, the Health Ministry must take the initiative to act on the information on "quacks" that is available with the GMOA. We are sure that prosecution of a few offenders, with due publicity will have a profound effect on the rest of the "trade".

Time and again, we hear the Health Minister pontificating to the GMOA on the need to avoid strike action, to avert putting patients' lives in jeopardy.

But several thousand quacks practising throughout the country with no surveillance or control over them also puts patients' lives in peril. The Minister should know which is the lesser of the two evils.

Deeds are always better than words. Over to you, Mr. Health Minister. You now know who the culprits are.

You have enacted the laws necessary to punish them. So, let us see what you do with them.

And, if you have the courage to weed out the impostors from a noble profession, you will earn the eternal gratitude of a few thousand doctors and millions of "ordinary" people. More importantly, you would be protecting the lives of many who would be otherwise at risk!

Therapy for common allergies

Allergies are caused by an over-reaction of the immune system to otherwise harmless substances. Immunotherapy, an allergy treatment, seeks to "retrain" the immune system by exposure to small then larger amounts of the allergy-producing protein, commonly by injection under the skin.

Treatment can decrease patients' symptoms. Unfortunately, the injections must be given frequently, sometimes more than once a week, for many months to years.

In this week's Lancet, Dr. Giovanni Passalacqua and colleagues at Genoa University, Italy, report the results of a trial in which patients received immunotherapy as tablets placed under the tongue (sublingual) for a short time, then swallowed.

Twenty patients with allergies to house-dust mites that caused itchy, runny noses, and itchy eyes (rhinoconjunctivitis) participated. Ten patients were randomly assigned sublingual immunotherapy, a tablet containing the dust-mite allergen, and ten an inactive placebo tablets that would produce no effect.

Patients recorded symptoms in diaries and underwent a series of tests to assess changes in their immune responses to the allergen before starting the trial, and after 12 and 24 months of treatment. The investigators found that the patients on immunotherapy reported significantly fewer symptoms of rhinoconjunctivitis during the winter months, when these allergies are their worst, than those on placebo.

In addition, when patients were exposed to allergens directly on to the eye after one year of treatment, laboratory tests showed that the signs of inflammation were significantly fewer in the patients receiving immunotherapy

In a commentary, Dr. Patrick Holt and colleagues of the Institute for Child Health and Research in West Perth, Australia, wrote that, although there has been considerable scepticism about sublingual/oral immunotherapy, there is increasing experimental evidence that suggests this form of therapy may indeed be effective.

"What is needed," they write, "are more and larger controlled clinical trials" similar to that conducted by the researchers in Genoa.

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