Saving lives is our collective responsibility

• September 24 was World Cancer Research Day

By Rev. Dr. Sumeth Perera

World Cancer Research Day was celebrated on September 24th. This year’s theme celebrates, “cancer research works: driving progress together.” It is a positive affirmation based on evidence that researching on cancer has improved our understanding, treatment procedures, caring and the quality of survival of cancer. Therefore, our collective efforts will drive this progress together.

The World Cancer Research Day declaration draws attention to a number of key issues in cancer research around the world: enhancing sustainable funding for cancer research, promoting international collaboration to enable global advances, providing training in cancer research and encouraging the development of cancer research infrastructures for each country.

Statistical projections show that cancer will become the leading cause of death worldwide by 2030. Accordingly, 21.6 million new cases will occur annually. The global increase of the cancer burden will cause escalated levels of suffering and deaths. Many will lose the expected quality of life as individuals and families. And their years of productivity will be unexpectedly curtailed bringing about the largest economic loss on a global scale.

Being a low and middle-income country Sri Lanka will be gravely affected too. WHO predicts that 70% of cancer related deaths will occur in low and middle-income countries. Unless evidence based cancer science is built up, and preventive measures are fortified using research-based inquiries, Sri Lanka’s quality of life will be at stake. This article highlights the need to build better care strategies for screening, diagnosis, and treatment of cancer. We need to take collective measures to fortify cancer research especially in low and middle-income countries like Sri Lanka by developing sustainable programmes.

Cancer as a disease

The earliest written evidence about cancer goes back to the Pyramid Age (3000-2500 BC) A transcription of a manuscript known as the Edwin Smith Papyrus, is thought of as the collected teachings of architect-physician-statesman Imhotep. The papyrus gives an account of breast tumour as a bulging mass spread over the breast as a disease with no treatment. Over the years, with growing cancer research around the world, we have got to know that cancers of this type has the capacity to invade, survive and metastasize.

There are more than 200 different types of cancer with their subtypes. But some cancers are clearly outcompeting others in a population. Breast cancer is the most commonly diagnosed cancer in Australia while lung cancer exceeds in the USA. In Sri Lanka, breast cancer among females and oral cancer among men are commonly observed. Such cancer types may be categorised under five groups: carcinoma involving skin or tissues overlaying organs; sarcomas affecting the connective tissues such as bone and cartilage; leukaemia pertaining to white blood cells; lymphoma and myeloma affecting the immune cells and brain and spinal cord involving the nerve cells. Therefore, as a disease, the nature of cancer is extensive, potentially affecting any cell in the body.

With growing cancer research we have begun to understand that genomic changes affect the way cells divide, grow and behave.  Therefore, all cancers arise as a result of acquired DNA changes in a cell. These acquired DNA changes, known as driver mutations, are responsible of cancer formation. Driver mutations enable clonal selection of cancer cells and expand further. In 2005, with the ambition of uncovering such mutations in cancer, The Cancer Genome Atlas (TCGA) was launched by the National Institutes of Health (NIH), USA. NIH’s two major arms, National Human Genome Research Institute (NHGRI) and the National Cancer Institute spearheaded it involving 150 researchers from more than two dozen institutions at the expense of $300 million to map the key genomic changes in 33 types of cancer.  In the end, The PanCancer Atlas with 27 highly valuable scientific publications summed up TCGA discoveries. Scientists were able to identify 10 key modes of communication through signalling pathways that control various stages of cell’s life, growth and death. They found that 89% of tumours had at least one significant change in these pathways.

Some external agents cause cancer

One in eight deaths worldwide occurs because of cancer. Apart from internal genetic factors we have learned that there are external agents which cause cancer. Until 1775 humanity was completely unaware that soot could cause cancer. Dr Pott noticed how chimney sweepers (“climbing boys”) coming from poor social background had developed scrotal cancer. Soot was identified as a devastating carcinogen. This discovery led to passing of the The Chimney Sweepers Act in the English Parliament in 1788 and under this legislation it was forbidden to use young children for this purpose by in 1875.

Today we know the causal link between tobacco smoking and lung cancer development. Similarly, we are becoming increasingly aware of betel quid chewing and oral cancer. In addition to tobacco in the quid, areca nut itself has been shown to cause early signs of cancer development. In fact, oral cancer is highest among men in Sri Lanka who are also addicted to betel quid chewing, one of the main risk factors. It must be noted that areca nut related commercial products are rampant in South Asian markets and schoolgoing children have become victims of these cancer causing habits. Legal barricades were promulgated against tobacco, and areca nut products in healthcare facilities in 2018 and in all government institutes in 2019 in Sri Lanka.

However, looking at the current scenario in Sri Lanka, even after more than a century following Dr Pott’s discovery of soot cancer in England, as a nation we have not learned the art of policy adaptation and executing legal measures to prevent cancer for better health outcome.

Does cancer research transform and save lives?

Cancer research has come a long way while dissecting out this rather elusive disease affecting multitudes in the world. If there was no scientific research into understanding the biology of cancer, novel therapies would not have seen the light of the day. As a matter of fact, cancer treatment today is heavily built upon translational cancer research. Recent advances in molecular biology and genetics have uncovered a plethora of novel insights to be used for cancer therapies which are more effective, targeted and prevention strategies.

One of the ground breaking discoveries is CAR-T Cell Therapy which involves modifying patient’s own T-cells (Immune cells in blood) to target cancer cells in acute lymphoblastic leukaemia and lymphomas. Moreover, the discovery of certain anticancer drugs like Herceptin (Trastuzumab) targeting HER2 positive breast cancer cells; Imatinib in the treatment of chronic myeloid leukaemia have challenged the dominion of cancer. Immunotherapy drugs especially in inhibiting cell cycle checkpoints (Pembrolizumab and Nivolumab) have significantly changed melanoma and lung cancer treatment today.  Novel approaches in precision medicine to tailor treatment for individual genetic variations and liquid biopsies specific for early and on-going detection of cancer are making breakthroughs.

Despite colossal efforts by scientists throughout the world, cancer treatment is still facing a number of challenges. In this, cost-effective cancer diagnoses and therapies for low and middle-income countries are a priority. Similarly, low cost, early detection strategies are required for deciding upon malignant changes. Such strategies will enable suitable therapies at early stages for better treatment outcome. In addition, creation of precise imaging modalities, of sustainable funding models, of oncology research training opportunities to bring bench-side research to bedside applications are critically required today.

Dr Ortis Brawley, Bloomberg Distinguished Professor and Professor of Oncology at Sidney Kimmel Comprehensive Cancer Center (USA), in a recent interview drew attention to a CISNET NCI study in which, of the 43,000 or so women who die every year from breast cancer, about 10,000 deaths are due to lack of good treatment and about 5000 deaths are due to lack of screening. Evidently, the lack of good treatments has led to more deaths of women after diagnosis; probably true of many cancer cases worldwide.

At the same time, he warned the scientific community to develop comprehensive screening strategies.  Elaborating with a case he said that a woman who had gone through lung cancer screening for years but in the end was diagnosed with full blown cervical cancer because screening strategy missed the critical cues. Cancer screening needs to consider the whole person not just a part, he critically emphasised. It is admirable if the on-going patient based community research can become comprehensive and about the whole person.

Cancer research is a collective response

The declaration of the World Cancer Research Day states that we have a collective responsibility in saving lives. But we also realize that major decision taking machinery lies with governmental agencies and policy makers. However, if cancer rise is an imminent danger to public health at a global scale, it is our responsibility to actively take measures in preventing greater harm by awareness building, supporting cancer research by raising funds, and developing compassionate approaches towards cancer patients in our society. Moreover, education programmes for building evidence-based learning about cancer therapies and information sharing must be encouraged so that better health care models can be promoted in our communities.

In the current Sri Lankan context with our immediate social challenges one may be lukewarm about promoting cancer research awareness.  Despite the gloom around, the people of goodwill need to come together, may be in small pockets, to promote cancer awareness and to actively promote cancer research in this country. Saving lives is our collective responsibility.

(The writer is a Senior Lecturer, Department of Biochemistry, Faculty of Medicine, Sabaragamuwa University )