Gastric cancer is the fourth most common form of cancer and the second most common cause of death from cancer; a ten-fold variation in its occurrence across the world records four-six lakh cases in Africa, North America, western and northern Europe and Australia, 10-15 lakh cases in Central America and 30-35 lakh cases in eastern Asia. Three-quarters of new cases are in Asia with more than two-fifths being in China.
There are many contributing factors, prime among them being one’s lifestyle. A medical study using the South Indian population found some of the common contributing factors to be the reuse of cooking oil, a high intake of salt, consumption of red meat, low intake of fruits and vegetables, improperly preserved food, smoking, alcohol, and H.Pylori infection.
Unfortunately, data available in India, through tumour registries and institutions maintaining a database, cover only 7 per cent of the population with cancer. The common age at presentation is between 50 and 70, though it can occur even in people under 40, with there being a clear male predominance. Our study showed a 14.84 per cent incidence in the under-40 age group and 7.7 per cent in the above 70 age group.
Most patients, especially from suburban and rural areas, present themselves when in an advanced stage. The major contributing factor for delayed presentation is “ignoring” warning symptoms. Other factors are access to centres with specialists, myths about cancer, resorting to native treatment without proper medical advice, and socio-cultural barriers. It also involves resources. Affordability and accessibility play a big role. As a result of these factors, the chances of treatment with an intention to cure comes down drastically, which translates into decreased number of years of survival after diagnosis.
Data on populationData on the Indian population show that the survival rate at the end of the first year is 34.3-35.7 per cent, which drops to 13.2-14.6 per cent in the third year and 8.6-10.1 per cent at the end of five. In contrast, in Korea, the five-year rate of survival in 2000 was 46.6 per cent, which improved to 67 per cent in 2010. This positive change is due to a unique screening programme where endoscopy is done routinely for anybody above 40. This helps in very early stage diagnosis.
A nationwide survey done by us, which included 495 surgeons managing gastric cancer in India, and using a 43-point questionnaire, revealed: the common age group was between 41 and 50 years, with a male preponderance of 70:30. In 47.17 per cent of situations, patients experienced vomiting and 40.28 per cent had dyspeptic symptoms such as indigestion and a loss of appetite. Those with vomiting had a relatively advanced stage of the disease when compared to those who had consulted a doctor and undergone early endoscopy. The next major contributing factor was the availability of resources for management of the condition. For a rural population, many will get the basic and limited level, a few, the enhanced level, and fewer still, the maximum level. The factors analysed in deciding the level — the findings were published in Lancet — are endoscopy and its advances, ultrasound and its advances, CT scan, MRI, PET scan, laparoscopy, molecular targeting, endo-interventions, surgical interventions, availability of latest and targeted chemotherapeutic agents and structured follow-up. The States with the highest health standards are considered to be Tamil Nadu and Kerala but they provide care to only 9.1 per cent of the Indian population, whereas States with the lowest health standards according to Indian public health standards are Assam, Bihar and Jharkhand and are responsible for care to 13.1 per cent of the population.
Another important factor is the availability of trained personnel and experts. Health-care resources are found to be unequal between rural and urban regions within each geographical region. Urban areas have a greater proportion of trained physicians (60 per cent) than rural areas (40 per cent). Tamil Nadu, for instance, has focussed efforts on rural recruitment and placement in trying to reach health care to rural areas.
The Union for International Cancer Control has undertaken an initiative for a three-year campaign against cancer, with the theme being “We Can — I Can”. This explores how everyone can play his/her part in reducing the global burden of cancer.
Major changes can be initiated at the individual level by observing a healthy lifestyle. As a society, we have to break socio-cultural barriers obstructing cancer care such as a low regard for health care, social taboos, nihilistic approach to cancer diagnosis (that is, cancer fatalism), blind faith in traditional methods of healing, religious dynamics and superstitions.
(Prof. S.M. Chandramohan is former director of surgical gastroenterology, Madras Medical College. The article is based on the lecture delivered by the writer at the 11th International Gastric Cancer Congress, Sao Paolo, Brazil, in June 2015, on the theme ‘Sustainability of Gastric Cancer Treatment in High Volume Poor areas’.)
