Lecture Note: “Concepts of Malignancy in Ayurveda” (Part-2) by- Prof. Muralidhar Sharma

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Concepts of Malignancy in Ayurveda
(Part-2)

Prof. Muralidhar Sharma

Transcript by-
Dr. Mrityunjay Dwivedi,
JR-3, Department of Shalya Tantra,
Faculty of Ayurveda,
Institute of Medical Sciences,
Banaras Hindu University, Varanasi

Based on the lecture available at–Concepts of malignancy in Ayurveda

About the theories existing about carcinogenesis and how the tumor occurs. Initially, tumors were considered to be from an unknown origin. Real reasons were not known and then the real reasons are not known. Of course, lots of reasons are attributed. Naturally, the theories about the carcinogenesis also are quite varying.

Theories of Carcinogenesis:

  • Genetic
  • Epigenetic
  • Inflammation
  • Virus
  • Hormonal origin
  • Carcinogenesis
  • Immune surveillance
  • Somatic evolution(Monoclonal)

So, it starts with the genetic epigenetic where the gene has been modified in the later part of life, inflammation, virus, hormonal, carcinogens, and chemicals are the other factors which produce the malignancies and immune factors of the body. These were considered as the different causes and all these theories are still valid. None of the theories has become invalid but the latest theory and which seems to have more validity and is considered to be one of the major approaches to  malignancy and which has changed a lot of output about the management pathology is the somatic evolution theory or monoclonal theory. So, for the sake of clarification, I would like to brief v about what is that somatic evolution theory.  Because it has something relevant to the approach to the malignancy approach to the management of the malignancy process and changing trends.

 So I will not touch about the other theories. The somatic evolution theory which was profounded by Nowell in 1976. This theory is younger than many of us. And so that’s how important and the theory is based upon the basic issue, when the cells divide during the normal growth. during that normal growth of the cells, there is always a possibility that some of the cells may become aberrant.  So, when you have a large number of divisions, one cell dividing into 2, 2 into 4, 4 into eight and so on. When such a division occurs, sequence of the division occurs.  At least some of those sequential cells would have some abnormality. It’s not as in the case of any big plane production in any industry, in an industry when there is a big plane production, a large number of those materials are produced, then there will be some amount of errors produced. Some erroneous products would be produced. In a sophisticated factory, well quality-maintained factory, there will be some inbuilt system where these products which do not contain the normal standards or erroneous products are identified, picked up then separated, and segregated. Similarly, our physiology has a segregation mechanism. So many of the mutated cells would have to be picked up and then distract only the normal cells are allowed to progress. This is basic physiology. So, there is a normal process of natural selection. Abnormalities tend to occur also normal. That’s all the important thing. The basic theory is that there is a physiological normal tendency for the abnormality to occur and there is an in-built system to correct that abnormality asset and as long as there is a balance between the two, like the abnormal cells are not produced in large number and wherever they are produced they are described by the mechanisms. so, something like a combination of a brake and accelerator. The whole process will be normal and the theory is if there is more of cell division then there has to be a higher chance of producing these abnormal cells. And the chance of malignancy would be more so if during the division if one of the cells becomes abnormal and before it becomes multiplied like in a larger number. If it is justified, the whole process may end up directly. But somehow if it is not possible then one abnormal cell may multiply. It may continue to produce it soon clone and then it may produce a tumor pathologies. So, when we say malignant pathology, it means that some of the aberrant cells itself something which has lost the normal pattern and has gone out of the way. Cells who  has lost the guidance and it results in an abberent area and the group of that different tissues it will continue and that growth will continue and this growth doesn’t follow all the normal rules of the normal growth to become malignant.

Slide 1 Mutation

There is a possibility that this process may be affected somewhere in the beginning. In the initial stages it would be easy, it may be destroyed. If it has failed to destroy and then it has reached a critical level then the body’s defense mechanisms will not be able to suppress that and it may become a progressive human pathology. This is the latest theory of the clonal theory. When we see this clonal theory, the basic law is if there is a larger number of cell division, there is a larger chance of the tumor pathology. And hence naturally you will be feeling better. A body which has a bigger size and where the cell divisions are to be more would have larger tumor, larger incidents of the tumor. But this is not true. And this is mentioned as a Peto’s paradox, Peto’s Paradox is one of the very popular theory which is now I would be considering is a game changing approach in the pathology as such.

Slide 2Peto’s Paradox

The basic issue is very simple. I would like to make it as simple as possible. If the number of cell divisions are more and if the production of the malignancy or presentation of the malignancy would be more depending upon the number of divisions, elephants or maybe the other animals which have a bigger mass size than that of the human body, would have a very high incidence of tumor pathology. The animals which are having a smaller size of the body or number of cell divisions are lesser than the human being, would have a lesser chance of the malignancy. So presentation of the maliganancy should have followed lying. But this is not true. The issue is, the animals which are present in the natural environment which live in a natural lifestyle, their mechanism of suppression of the tumor are efficient and they have a lesser chance of developing the tumor pathology. Among all the species of animals studied, it is the human beings who are considered to have the maximum ratio or maximum chance of the neoplastic lesion. So naturally the and then of course the another is also observed that domesticated animals, domesticated animals and animals which are brought up by the human being in an artificial condition. They have a higher chance of developing the malignant lesion than the naturally developed. This is what we call as this observation is Peto’s paradox observation. So this led to the theory like the lifestyle factors. The factors where a person live would be the triggering factors or factors which produce the aggravated malignant lesion.

Slide 3Cancer process

So, the theory has been now like during this normal growth, the factors like host factors it could be the genetic or maybe the other pathologies like inflammatory lesions, virus infections, etc or environmental factors like food. This important thing or the other chemicals present over the area which we call as the carcinogens. Now we identified as the carcinogens or the lifestyle and the diet. These are the factors which increase the susceptibility of a human being to the tumor pathology. Because of these factors, either the mechanism of suppression of the tumor is either inefficient or the mechanism of producing an abnormal cell has become more so in both ways. Either the number of such apparent neoplastic cells, the cells which are having an aberrant pathway, they are either produced in large number or the body’s mechanism of suppression has become reduced and that’s how the whole approach now has changed. Like the tumor now is considered as a disease produced due to acquired factors like the factors related to lifestyle and diet. Value of lifestyle and the diet has become very important now in prevention of the tumor. And the importance is given a large quantity and come to that part so much more detail.

Slide no 4  Tumor suppression factor

Now, those mechanisms which will suppress the tumor as they are identified and those factors are when it’s lower somatic mutation rates. That’s why I said, the number of divisions being lesser. So number of divisions being lesser. In the sense in older age, the number of divisions will be lesser. Younger age- The number of divisions will be more. The body size- bigger the body says, a person who is obese would have a higher mutation rate, whereas a relatively built body will have a lesser mutation rate. And if the tumor suppressor genes that our inner mechanism of tumor suppression, they have become redundant, then to there could be a tumor development. The most important two factors which can be easily modified by the external agents like medicine and the lifestyle management would be the immune system in the body and the oxygen species, lesser reactive oxygen species in the metabolic rate which is very new concept of antioxidants and oxidant damage, which is now considered to be the cause for many other diseases.  The oxidation and residuals of that oxidation molecules and the method of dealing with them with antioxidants. These are now one of the rather upcoming the approaches in the medical management of all the diseases. And they’re usually claims as something where we have some more issues. So, these are the two very major important intervenable factors.  then the other efficient apoptotic process. Apoptosis is a natural process of cell death. if there is any cell which doesn’t deserve to win, it will be dying. That’s physiologically. It’s true in the normal environment. The nature if there is any creature or any animal which doesn’t deserve to be capable and if is not really viable, it should be giving scope for the new growth or new person to develop or a new person to occupy that area or new animal to occupy that area. But it’s only the human beings where people over live in ICUs or maybe with all that external support agencies. Only the statistics will say that the person will be surviving. But virtually there would be no use of survival. This is a controversial statement, but one of the important issues, the nature, the rules of the nature and what we do as such. Then there is a possibility for hyper tumors that humor growth can destroy another tumor. This is another possible hypothesis. Of course, this doesn’t have lots of support now. But one of the suppression mechanism.

The immune mechanism is considered to be very capable or very potent where if there is any such abnormal cell produced, immediately some chemicals are produced between either identified as tumor markers or Tumor Necrotizing factors (TNF). Multiple factors which can produce the tumor necrosis. They are produced and they will destroy the cell and that’s how normally we don’t have develop the tumor. Now this theory is exactly the basic theory of Ayurveda that there is a possibility of for the variation of doshas- abnormal pathological processes tend to other as a normal process in every day. Day to day, you will have the Doshas temporary imbalance is a natural process. That’s what Vagbhata had said

Shloka  side 5

विकृताविकृता देहं घ्नन्ति ते वर्तयन्ति च|

वयोहोरात्रिभुक्तानां तेऽन्तमध्यादिगाः क्रमात्| A.H  1/7,8

The Doshas tend to have a fluctuation. They may not remain in a balanced condition based upon the age, daytime or night also on and relationship to food and so on. But these do not produce a disease. These do not produce a disease because you have to follow a swasthavritta or you have to follow the rutucarya or dinacarya. Dinacarya and rutucarya are mentioned as one of the effective measures by which these dosha imbalances, which can occur every day or not resulting in a disease presentation. So, prevention is based upon the lifestyle and then of course one of the major lifestyles which is suggested to prevent the diseases are the rutucarya where-

शीतोद्भवं दोषचयं वसन्ते

विशोधनं ग्रीष्मजमभ्रकाले|

घनात्यये वार्षिकमाशु सम्यक्

प्राप्नोति रोगानृतुजान्न जातु||A.H 4/35

So the shodhana according to the season which are the subjects which have studied as or taking care of the food.

 नित्यं हिताहारविहारसेवी

समीक्ष्यकारी विषयेष्वसक्तः|

दाता समः सत्यपरः क्षमावा-

नाप्तोपसेवी च भवत्यरोगः|| A.H 4/36

So,lifestle you have a balance of food and you have a balanced activity and a social concern and giving us a social animal where you will be considering the health of all that’s considered as one of the important matters. So, the one of the basic changes which have occurred in the last few years related to the malignancy is that malignancy is considered as an environmental related,lifestyle related disease than the other way .At one stage earlier, cancer was considered incurable and once you have a cancer, it is certainly or it was felt like every person will die. But the changes are now seen – approach, at least the primary approach to cancer. This has been changed because of this clonal theory and because of that reason, I have spent some time to explain and that’s exactly the basis of Ayurvedic approach to any disease. It’s not only about the tumor as such.

Slide  no6

Now to summarize, what the present situation about that cancer have selected a few sentences from WHO statement on cancer and I have selected only a few which have some significance. One is, Cancer is the second leading cause of death globally and it’s responsible for an estimated 9.5 million deaths in 2018. So, it’s one of the diseases which is very prevalent and one of the burning problems of the present day and the approximately 70% of the deaths occur in low and middle-income countries. So, it’s one of the burning problems related to the low-income countries and developing countries, non-developed and developing countries and one third of the deaths of cancer are due to the 5 leading behavioral and dietary risks. This is the important part. At least 20% of the malignancy diseases, they are related to the dietary risk, high body mass index, low protein, vegetable intakes and lack of physical activity, tobacco use and alcohol use. So at least 20% of the malignant diseases are preventable. If you have a sufficient healthy lifestyle. This is established. So, I have highlighted those issues from internationally to stress upon those facts. And tobacco is considered to be the most important risk factor for cancer and it’s responsible for about 22% of the cancer deaths. And cancer-causing infections such as hepatitis and human papilloma viruses (HPV) are responsible for about 25% of the cancer. So whether the infections like hepatitis B, they are considered to be the pre-cancerous condition. That’s another important issue. So early management of those is another factor which can reduce the incidence of cancer. Then another factor is, the diagnosis of the disease. This is what WHO says like if you have diagnosed the disease quite early then the outcome will be better. If there is a late diagnosis, the outcome would be poorer and the whole diagnostic setup in low-income countries are not that efficient, this is what a bit controversy. I’ll deal with that controversy in a different manner, later. Then the economic impact of the cancer is very significant and is increasing. The total cost is very huge as such and particularly this is true in the western developed countries and only one in 5 low- and middle-income countries have necessary data to drive their cancer policies. So, cancer policies are now established in western countries. In America, there is a specific policy about managing the cancer and identification of the cancer. Whereas the same is not true in our country and that’s about what the WHO says.

Now, because of the importance of the diet and lifestyle in the onset of the cancer, WHO has taken a huge project to identify the diet and the practice which can trigger the cancer or which can suppress the cancer.And this study was done with a huge budget and multi-level studies and it has presented three reports now one is in 1997. Then the 2007 report is quite new second report and it contains around 3600 pages. And the third report has come just last year 2019. And this is totally online report. The second of the important issues now that the second until 2007 report, It has certain paragraphs, I copied one paragraph from page no. 360 which relates to the diet in India and the dietary factors.

Slide8

 So, I just picked up one page just to show the prejudices and perceptions about the India in the global situation. One of the statements that is, India doesn’t have identifiable national diet. So there is no such national diet this is one of the statements that are mentioned in the previous page. Very unfortunate- India is the country where the science of preparing the food ‘Soop  Shastra’ is mentioned and as we know, a very scientific and methodical approach to the diet and the practices are followed. Somehow it doesn’t get mentioned in that the global registry which is studied in such a huge entity. And unfortunately, there are representations from India also in that group which has read that report but somehow, it’s not seen. That’s very bad as such. Then there’s another comment about the status of the diet in India. I would just like to read the sentence as such without any addition. This is since 1975. There has been a reduction in cereal consumption, particularly those grains, although this has not affected overall energy consumption. This is probably due to large increases intake of fat and animal protein and also of milk and milk products in lower income households. Fat comes mainly from vegetable foods with very little conventional animal fats whereas in the highest income households, the majority of fat is from animal sources and India is a major producer of vegetable and fruits but much of which is exported. So, India is one of the countries where the dietary factors are one of the major causes for the triggering of the diseases including management.

तत्रखल्विमान्यष्टावाहारविधिविशेषायतनानिभवन्ति;तद्यथा- प्रकृतिकरणसंयोगराशिदेशकालोपयोगसंस्थोपयोक्त्रष्टमानि (भवन्ति)||Ch.Vi 1/21

तत्रेदमाहारविधिविधानमरोगाणामातुराणां चापि केषाञ्चित् काले प्रकृत्यैव हिततमं भुञ्जानानां भवति- उष्णं, स्निग्धं, मात्रावत्, जीर्णे वीर्याविरुद्धम्, इष्टे देशे, इष्टसर्वोपकरणं, नातिद्रुतं, नातिविलम्बितम्, अजल्पन्, अहसन्, तन्मना भुञ्जीत, आत्मानमभिसमीक्ष्य सम्यक्|| Ch.Vi 1/24

 I have read the whole book thoroughly. If all that book contains, I think I can summarize with simple 3-4shlokas of the text. That’s all the summary. If I have to summarize all that huge volume which is mentioned that it’s only about the diet factors- details of the diet. Prakriti, Karana, Samyoga, Rashi, etc. these descriptions are mentioned in text, and the same are studied in different contexts in different 169 countries all over and there are studied in that book and the whole summary of advice is I will have to summarize what Ayurveda has mentioned. It’s exactly the same. The language is different.

 The Usnam, Snigdham, Matravad, Jirne, Viryaviruddham, Iste Deshe- these kinds of the detailed description, you cannot find in any other global situation. Even in that detail studied sponsored by WHO, you don’t find any such definite mention. And interestingly, 5000 years earlier Ayurveda mentioned all these details as such and the typical ‘Annakala’- the time for the consumption of the food.

प्रसृष्टे विण्मूत्रे हृदि सुविमले दोषे स्वपथगे

विशुद्धे चोद्गारे क्षुदुपगमने वातेऽनुसरति|

तथाऽग्नावुद्रिक्ते विशदकरणे देहे च सुलघौ

प्रयुञ्जीताहारं विधिनियमितं, कालः स हि मतः||A.H.Su 8/55

This kind of standard description can never be seen anywhere in the world. But unfortunately, the report and someone appear up next to the fact also is that in the current situation we are categorized in a situation where food is considered to be a cause of diseases. Now based on that observations the American Institute of Cancer Research and World Cancer Research Fund. These are the two organizations – they that summarized the methods of prevention of cancer. So recommendations for the prevention of cancer. I have just copied it from their side.

 One is you maintain a healthy weight. There is a world, that is physically active, does regular exercises, and try to reduce dependency on machines. Then have from vegetables and fruits should have been a major content of the diet and limit consumption of fast food and other processes. I think every time when I talk I always have some criticism over the fast food and so on. The reason is simple it is well-studied that fast food is the source of the majority of the diseases and unfortunately our present lifestyle it is the same. It has become the major diet. And most of the times people would not like the food prepared at home in a convenient manner. And this has become the primary food. Then limit the consumption of red and processed meat as such to reduce the possibility of cancer, limit the consumption of sugar and sweetened drinks, aerated drinks like coca cola, sprite and so on and limit alcohol consumption. It’s not limit I would say stop alcohol consumption and do not use supplements. Another very important is the supplements – calcium, zinc and so on all that which are considerable tonics. They are not to be taken if you have to have cancer. This is and it is not said by me is by the renowned institutions based upon the research studies and that conclusions are drawn by elaborate study which has continued for about 30 years throughout the globe. So I have picked up from that point of view and I think every time when I speak about this the supplements and their harmful effects. It’s not only what I say from my own side  it’s from with all that background and then the other is -you have to for the mother breastfeed the child of course it’s from civilization known thing and then the after the cancer diagnoses follow the recommendations. Do not neglect these are the recommendations by the world cancer association. But most important factors are these.  The majority of the cancers are preventable and these are related to lifestyle and all that lifestyle recommendation mentioned is what’s mentioned in Ayurvedic textbooks as such. So they made the ultimate remedy. Of course it’s well known. The cancer may not be curable in all conditions though to a certain extent we may be able to cure certain conditions now but basically cancer is considered incurable but it is preventable and that means of prevention is in Ayurveda.  That’s the summary.

Another issue I wish to drive their attention is in the same report which I have referred to earlier. There is a list of countries where physical inactivity would be lesser and the projected physical in activity by 2020 in different regions. So, I have copied exactly from the same source. I have not added anything of mine but only the thing which I added is this arrow which shows the position of India and Bangladesh.

The physical activity is lesser in 42% and in 14 to 25% of the total population. The people are categorized as inactive so insufficient. Forget about other countries. The rank of India is 6th that the physical activity, the rank of India is 6th as such. So another point of issue which I usually always report in every context like mechanization, globalization are causes of disease

.                                                                                                                                                                                                                                                              . Now the histological studies like newer technologies are added now and it could be even it works even immunohistochemistry. It’s not simply the histological studies, where the immunological contents of the tissue also are studied so that the creation of the cancer and prediction of the malignancy is possible. And that part is a very detailed part. I would not go into that part as such. Then molecular biology where the genes also are studied.

Theraputic options

  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Target therapy
  • Hormone therapy
  • Stemcell transplant
  • Precision medicine

To summarize therapeutic options which are available for the malignancy now, either it could be surgery which is considered to be the oldest of the method. And earlier it was believed when we were studying it was said that if you can remove the tumor tissue completely by surgery, that would be the wounded cure. But now of course the approach has been changed. It’s not necessary that you have to remove every cell you have the other means of destroying the cells as such. So surgery being the sole solution for the malignancy, that concept has slightly altered. I don’t say it has been completely replaced but it’s slightly altered. So importance of surgery is comparatively reduced. Radiation, chemotherapy, targeted therapy, hormone therapy, stem cell transplantation and the ultimately the latest is the precision medicine where you can target the cancer cells specifically. These are all the technological advances. The development of the medicine and the approaches is very rapid. And as I told you is based upon again the statistics like the last  five years, more than 57 new drugs are introduced with the different indications globally for the malignancy. To follow all that, to practice, that is virtually not possible. So my purpose is not to go into that detail. My purpose is to show like how the progress has occurred globally about the cancer and the perception of the cancer is changing. For a practitioner, we need to know about the changes though we may not be able to implement them now, some more of the statistics about the cancer. These are all the issues which we have to be aware. The incidence of the tumor throughout the globe is gradually increasing. With certain varieties, it’s releasing but it’s increasing. This is again from the Western data in India, this may not be totally true.

Currently the maximum incident disease in the western country is among the males is the prostatic cancer and lung cancer. Whereas in the females it is a breast cancer. Of course, in India also breast cancer is the number leading in females. But in the men, it’s the oral cancer which is the common in India. Distribution of the cancer also is not uniform throughout. Maximum incidents of malignancy are reported in American continent and certain extent, europe and Australia which are considered to be developed and forward. Whereas comparatively India is in that area where the incidents comparatively is lesser. Reason could be the other way it could be under diagnosis or maybe still the lifestyle has not gone to the same level as it is seen in western. As India is westernizing the incidence of the tumor is increasing.

The incidence of tumor in India. This is the data from India, from the WHO. It’s increasing gradually and the graph it was somewhat horizontal. The line is horizontal up to around 2005. From 2005 onwards that’s where the globalization has become now very prominent. It’s ascending and by 2017, the angle has become changed. Then the there is a difference in the trend in the cancer mortality. The results of cancer treatment. Now, I’m not going to the which cancer and so on. But in the present-day situation, the outcome about the cancer has been changed globally based upon the current developments and the mortality related to the cancer has been reduced. This is from the global trend that the mortality has reduced. But the graph of mortality that death has become more flattened and in the past 20 years after 1960 or so on, there is a gradual reduction. The newer technologies have definitely reduced the mortality rate. I’m not saying that this is all the result of Ayurveda so on. It’s not that ayurvedic treatment will produce the same change. But for a successful Ayurvedic practitioner we have to be aware of that.

The trends in the cancer, mortality also is gradually changing, but it’s not that every cancer has changed. Certain cancers, varieties of the cancers still are having a high mortality rate rather the mortality rate is higher than earlier in some of the cancers like the cancer of lung whereas cancer, breast and ovary, the death of the diseased has remarkably reduced.It has been done, reduced remarkably. So this is about the global rate as such. So for a practitioner to be successfully dealing with cancer, you have to be aware of this issue like which of the disease has now a better prognosis and which of the conditions would have a poorer prognosis. Why and how? I will come to that when I go into my strategies the next part.

The cancer incidents, I said that incidents in India is lesser compared to the USA. This is about the comparison to India and the USA. The varieties of the cancer. So in all varieties the incidents in India this green and violet color, those columns suggest about the incidents in India.  Blue and red color- This is the incidents in the US and these are the locations. The maximum incidence of female malignancy is the breast they have as such in USA of course the prostate cancer is the maximum incidence and the gap between India and USA is quite sure.  Now point is when I have presented these case, unfortunately we have very major data about what’s seen in India. All that approaches which are practiced in the contemporary situation sophisticated oncological practice. They are dictated by the policies which are mentioned in the USA. And the situation in the USA is totally different from what we see in India. And I will only say our contemporary medical system including ICMR doesn’t have any specific policies which are related to the India except for tobacco consumption and oral cancer, otherwise there are no special policies. So there is a need to relearn the whole thing and maybe establish the factors which could be relevant to the Indian situation. Now certain of the facts about the cancer status in India based upon national profile of 2019. These are all the important thing, 80% of the Indian counsel doctor only when the recovery is difficult. There is a criticism like cancer patients are not diagnosed at an early state. They are diagnosed later state. Either the patients do not report to the doctor or the doctor fails to make the diagnosis, 71% of the deaths between the younger age.

Now, this is another important thing, mortality age of cancer in India is much lesser. It’s 39 to 59 years. Whereas in the USA the mortality is higher in the year 70 to 80. So 50% of the USA is about 70 years. Whereas in India the situation is different. So the incidence of cancer in India is lesser. The impact of the mortality in India could be more severe when the younger person dies, the impact will be more compared to a person who is an old aged. We have to consider from that point of view and then 70% of the patients die in the first year in India because of the late diagnosis, this is another of the fact which is mentioned and this is too is 70%.

Now, late diagnosis and early diagnosis. Another controversy shall come to that part. I look at that issue in a different manner. But this is what the general perception is that the diagnosis of cancer in India is always late and because of the late diagnosis, the survival period is lesser. 50% of the cancer is related to lifestyle factors like obesity and tobacco, 50% – half of the cancer is preventable. That’s all the important thing. And if we have a specific policy related to lifestyle, diet and so on, the end it can be prevented. The disease can be prevented. Probably India would be in a situation where cancer may not be a serious problem at all. That’s all the point. And unfortunately we are moving in the opposite direction. We are following the Western lifestyle and we are trying to follow the graph of the USA about the incidents of the cancer. So that’s all the point that we have to be very much aware of and as far as possible convey this to the common man. Of course, I don’t appreciate that the common man would easily accept whatever they say. But we will try to blow our trumpet and at least within our community, we have to be aware of this issue. Then 15% of the cancer is in minors in India whereas the global average is only 0.5%. This also is another point of concern. The incidents of tumor malignancies in younger age. Its maximum in India compared to any other countries. But as the global average is just 0.3%. The exact reasons are not known. And again the basic issue is the data and the collection of the data and analysis, it’s not as efficient as in Western countries. And hence we cannot attribute any specific reason for that. Then certain of the odd factors about the cancer in India. These are very interesting issues. Aizawl has the world’s highest; it has become topper throughout the globe, incidents of global pharyngeal and tongue cancer in men. Again, these are all the things which need to be studied, lifestyle factors which are needed to be studied, which can give you exact cause. New Delhi is considered to be having the highest incidence of gallbladder cancer in women. In Maharashtra has the world’s highest incidence of mouth cancer, Pondicherry has among the world’s highest incidence of the mouth and tongue cancer in men. Kohima has one of the world’s highest incidents rates of nasopharyngeal cancer. These are all certain of the facts, which of course if there is an efficient system of collecting the data, there could be more of these kinds of information. And if these kinds of information are analyzed properly, certain specific causes could be identified and prevention of cancer could be more efficient than what we generally perceive. That’s one aspect of the cancer management. The other aspect of the cancer management which we have to be aware of and which have to be sensitive is the whole approach to the cancer diagnosis and management is a very costly affair. The spending of two of the globe. This is important, globe would be issue some dollars, 240 billion per year. And that cost is increasing throughout the world including in India.  And in India, the cost of the treatment is raising enormously compared to what we see in 2000 and 2015.

 In this data collected from the source in four years. The average cost of the treatment of different cancers in India this data is very specific to India has increased from 1.72 lakhs to 4.6 lakhs in case of the cancer of lung or it could 1.5-6 lakhs in case of the cancer of the breast and so on. So the cost in general has increased or is increasing many fold as such  and that’s one of the factor by which patients would have inhibition to go for treatment.

If you combine all types of cancer together, the survival period of the cancer has moderately increased from 40 years in 75 to maybe something around 60 by 2015. So with all that expenditure throughout the globe,the total net advantage is something around 20 years of life and virtually how far this is useful. And these are all the questions. The other way we can debate on that point, like whether it’s useful or not. But in general the survival period of the cancer has been increased according to the data.

How that survival period is calculated there’s another part of it. One of the measures which are now claimed to be a very efficient method of changing that outcome of the cancer is considered early detection. The screening early detection by screening is considered to be one of the efficient methods. But early detection the word early detection may not have a strong basis because the basic issues as we have discussed earlier about the pathology of the cancer, cancer starts with the first division of the cell and at that time the first division of the cell, nobody knows and this occurs almost every day. We don’t know which of that will result in a clone of malignancy for a tumor to be identified. The minimum size by which we can identify would be two millimeters and until the attains a size of two millimeters, none of the currently available investigations including PET scan can identify the smaller size to achieve that of two millimeters. It is calculated like the sense will have to go undergo 13×1016 that’s 13 followed by 16 zeros. That much of the number of division have occurred. And then only with all the newer technologies. The latest of the technologies you can identify a tumor. If you are depending only on the clinical assessment, when a size will be palpable by your finger. The size would be the number of divisions would have occurred and would be quite enormous another a few more zeros. It meant we don’t know except for 69 maybe it could be 10 to the 100 or so on. So it’s all been a huge number of divisions. And so what we now identify as early detection between claim as an early detection is not really early. Really early detection would have been at that first division where the aberrant growth has been identified, which is not possible. Of course lots of efforts are going and to reach that level. But with the current methods of investigations we claim that whatever that early detection would be maybe comparatively earlier in the line of growth of the tumor. But you may be diagnosing the patient’s early but already the tumor might have been established Now a fact which is presented by a review article references over here. I can refer that and it’s a copyrighted article from W. B. Saunders. I have selected a graph from that article,very important and useful article.

Lung cancer screening with CT Clinics in chest medicine add slide(46.11)

It’s has already studied large number of cancer of the lungs throughout the globe. In middle and large number of efficiencies of lung cancer screening with the CT findings. Resident in chest medicine and this is presented in 2008 . The point is I’d like to highlight like the basic issues , earlier days before the technology was developed, like the CT technology was developed, lung cancer would not be diagnosed at an early stage, lung cancer will be diagnosed at a late stage and the person would be surviving lung cancer for the survival period and then die. The next survival period of the human being has not changed. If you have made a diagnosis early still while treating the patient, the expected life period remains the same.  It has proved that it hasn’t changed. The only advantage of the early diagnosis is now that person has to survive for a longer period with stigma of cancer.

  Now, because we have diagnosed early before the patient has any clinical symptoms. Now, if you consider this as a mark of that region of the clinical symptoms. So before the patient had any clinical symptoms, you might have been diagnosed, that patient as cancer, you might have treated that patient with some specific treatment for cancer. The size of the cancer tumor might be reduced at that period. But at the end, when the total life is considered, it will be the same. So naturally, the question comes in like this, whether this much of the period will be statistically adding to the survival period. So now we claim that the survival period will be longer after diagnosing the cancer. Whereas we say that survival period is shorter if you have a great diagnosis. But if the end is almost the same, is there really advantage of these early diagnosis? This question is a valid question. Of course when I say this, I’m not undermining the value of that methods of early diagnosis. They are valid for a great extent. But it’s not that early diagnosis alone, which makes the whole change. Rather it should be the possibility of the prevention. Now this is done in a large number of population with different methods. So chemotherapies and with the CT diagnosis, it’s done much early. But then that would be almost same. So virtually there is not much of a change in the total outcome. That’s about the current situation.

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