India’s top cancer specialist says: Be afraid, very afraid, of diabetes, hypertension and high blood pressure
Dr. Rajendra Badwe
Diabetes, hypertension and high blood pressure are some of the greatest threats to life, yet most people are terrified by cancer, even though nobody can say with any degree of certainty that it will lead to death.
On the contrary, if people are careful about just three things infection, obesity and the use of tobacco they will double their chances of surviving cancer in a few years (which is not the case with diabetes, hypertension and high blood pressure which take a big toll but in the distant future).
This revealing information was made at the last meeting by Dr. Rajendra A. Badwe, Director of the Tata Memorial Centre. Decorated with the Padma Shri by the President of India earlier this year, he was speaking on “Prevention of cancer.” He was introduced by Zinia Lawyer.
Dr. Badwe stated that the fear associated with cancer was a myth. Out of 100 persons diagnosed with the cancers common in India, the chances of their survival at the end of 10 or 5 years were quite high about 65 to 70%. This was in the case of patients detected with cancer after routine diagnosis. In the case of early diagnosis, the number of survivors would be as high as 85%.
In the case of hypertension and blood pressure, on the other hand, the chances of a person surviving were lower. A person diagnosed with hypertension at the age of 45 or with high blood pressure at 50 had a less than 50% chance of surviving 10 or 15 years. Besides, he would have to take treatment for the rest of his life.
And yet, when it came to seeking a diagnosis, there was a morbid fear associated with cancer and a laissez faire attitude in the case of diabetes, blood pressure and hypertension.
“The reason for this is human nature if the event (cancer) and its effect (death) are close to each other, then the memory of correlating the two, (seeing them) together remains very strong. But if the event and the effect are at a distance, then the thought that one day this will create a fatal problem doesn’t remain with us.
“In somebody diagnosed with cancer, the risk may be 30 to 40%, but 85% of that risk is within the first four years and 65% of the risk is within the next three years. As against this, with diabetes and blood pressure the risk rises only between years 8 and 15. Therefore, since the interval is longer, we don’t experience the same kind of fear as we do with cancer.”
Taking up the causes, prevalence and effects of cancer in India vis-a-vis the rest of the world, Dr. Badwe said it would be best to first see whether the occurrence of cancer was uniform across the country.
In rural India, the incidence of cancer (all cancers) was 47 per 100,000 population.This figure doubled in urban, metropolitan areas and became 100 per 100,000. Juxtaposed against this was the fact that the incidence of all cancers in the US was 300 per 100,000 population ? three times more than the urban Indian figure.
To those who suspected that many cancer patients might have been missed because of incomplete coverage in rural India, Dr. Badwe said there were two cancer registries covering more than a million individuals in India. These had been running for more than 25 years, with a house-to-house survey conducted annually to assess those million people.
These surveys showed that the incidence of breast cancer in rural areas had remained static at 8 per 100,000.For Bombay the figure for breast cancer was 12 per 100,000 in the early
1970s but had more than doubled to 30 per 100,000. Although the latter figure was about three years old, in rural India the incidence had remained constant at 8 even after 25 years. The incidence of lung cancer in urban India was 6 per 100,000 and 70 in the US.
Was cancer responsible for the lower life expectancy in India compared to the West Dr. Badwe said the statistics for longevity that appeared periodically in the general media were wide of the mark. “As a doctor, what I sell is immortality. I don’t want my patients to die, that’s why I want as much longevity as possible, provided the quality of life is good.”
While the life expectancy for women in India was 68 years, it was 78 in the UK and the US and 82 in Japan. On seeing these figures, people felt that Indians were dying at a younger age. But this was not true. The final figure was actually an average and in India the average was pulled down by the high incidence of infant mortality (before the age of five).
But if one studied the figures for those who had crossed the five-year or the ten-year mark, then the life expectancy in India was 76 or 78 not vastly different from the figures for the US, the UK and Japan.
“I don’t think that increasing life expectancy from 78 to 82 at a phenomenal cost (the US spends 50 times more on health than India) is a goal… I am not saying people should die early, please don’t misunderstand, but there is a limit to which government money or tax-payers. money can be spent.”
India’s youthful population is the reason why the incidence of cancer is low here, says Dr. Rajendra Badwe
However, if concerted efforts were made in other fields it would help prevent premature deaths. The most important of these were infection, obesity and tobacco, three parameters that could be easily corrected.
India was a young, vibrant and colourful country. Only 18% of the population was above the age of 50.This meant that 82% of the population was below 50. In the West, the situation was the reverse.
In the UK and the US, people aged above 50 comprised 45% to 50% of the population. So while the West had huge numbers of aged individuals, in India the percentage of those above 50 was very small and this was one of the reasons why the cancer figures were low.
Making what he called a statistical correction, Dr. Badwe said that even if one were to look at age-matched survival or age-matched figures for the incidence of cancer, India was still at about a third of the West. In those aged between 60 and 70 the incidence of cancer was about a third of that in the US. In rural India, in fact, it was about a fourth, or even one-eighth of that in the US.
The Bill & Melinda Gates Foundation had invested about $6 million in aborough called Barshi in central Maharashtra where the incidence of cancer was low; prostate cancer was just 1 per 00,000 while in the US the number was 102 per 100,000.
What did this mean? That Barshi was like heaven on earth with no cancer’ The Foundation was looking closely at various factors and the Tata Memorial Centre was helping it in collecting data to understand what it was that kept cancer so low.
Taking up infections, the first of the three “easily corrected factors”, Dr. Badwe pointed out that these were now well controlled. There were viral and HPV (human papilloma virus) infections, but the HPV vaccine had helped reduce some of the pre-cancers such as pre- cervical cancers.
Uterine cancer in women and penile cancer in men, plus retinoblastoma in children, were now under control thanks to HPV vaccine. (As an aside, he explained that women affected by HPV in the cervical region transmitted it to the child at the time of delivery, thus resulting in non-inherited retinoblastoma.) All these cancers were now on the wane.
The reduction was an entirely urban phenomenon. There was no screening, no vaccine and yet the reduction was approximately 25% per year. The incidence in Bombay in 1984 was 32 per 100,000. But today it was just 10 per 100,000 even though nobody had done anything about controlling it. A similar situation prevailed in other metros such as Delhi, Bangalore, Calcutta and Chennai.
Obviously, said Dr. Badwe, “there is something happening is it having running water in houses and bathrooms” It was obvious that personal hygiene had contributed to reducing these cancers to a great extent.
“In India, the moment there is a municipal corporation and it provides running water in homes, the incidence of cervical cancer goes down in three years. This is such a simple measure; it can be implemented anywhere. Thus there is a ‘cafeteria choice’ in dealing with these cancers, uterine, penile and retinoblastoma in children. All three can be avoided if HPV infection is prevented. And at the top of the list is personal hygiene.”
Another aspect that the speaker dealt with was the very low incidence of cervical cancer in certain pockets of India. This had been emphasised in an article “Million death study” which appeared in the reputed medical journal Lancet in 2011. The paper was accepted for publication because it was the first documentation of the various causes of death in India and the contribution of cancer therein .
Dr. Badwe said that the incidence of cervical cancer, which was the commonest cancer and the biggest reasonfor death in women in India, was lowest in States where the Muslim population was high.
“We wrote to the authorities in the Middle East to know the situation in their countries. Did they have this problem And pat came the reply, we don’t have this cancer. (We were surprised that) they don’t have cervical cancer! ”
“So it can be said that circumcision at a young age offers complete protection against HPV transmission. If I were to say this in Parliament, I would be stoned… There are so many connotations to religion. But if there is something good in some religion, what’s wrong in implementing it?
“We have a choice we can go for personal hygiene, circumcision at birth or early in life, or HPV vaccination.But the difficulty with HPV vaccination is that if one takes it today, it will be effective approximately 20 years later. So we have to do something as a preventive measure for those 20 years; without that, cervical cancer will not come down.”
Turning to stomach cancer, Dr. Badwe said it was also coming down, mainly because of correct preservation of food. Food cooked on a given day was best consumed on that day or preserved well for the next day. In the past, when preservation methods were neither proper nor appropriate, the organisms that grew on food led to stomach cancer.
What about cancer of the gall bladder? This was a unique cancer affecting people living in the belt along the Ganges and the Brahmaputra. Apart from these two places, gall bladder cancer was seen only in Chile.
It had been observed that it was related to a parasite. Scientific studies were going on to obtain confirmatory evidence, but early results showed that the parasite had an intermediate presence in fresh-water fish. Consumption of improperly cooked fresh-water fish resulted in the parasite surviving and going straight to the gall bladder and producing cancer there.
“Again, this (cause of cancer) is easily preventable. Don’t stop eating fresh-water fish, it’s excellent, but cook it well and eat it.”
Dr. Badwe then turned to the last two points, obesity and tobacco which, he said, had the same bottom line. If someone was told to stop smoking or to reduce weight… it was easier said than done! But it was not impossible.
Several kinds of cancerous afflictions were correlated with obesity, for example, breast cancer, uterine cancer, food-pipe cancer, colon cancer, kidney cancer and so on. While the first two were very strongly correlated with obesity, the other three were weakly correlated, but definitely correlated with obesity.
The average individual in rural India put in a huge amount of physical effort. City dwellers did not do so, hence obesity was quite rampant in urban India. It was now a major problem in most of the developing world. It could be seen on the streets in the US, in Europe and so on. But the moment one left the city limits and ventured into the hinterland, obesity was not so marked. Obviously, some amount of physical activity took place routinely.
“Not just cancer, obesity is related to diabetes, to hypertension, stroke, cardiac events, arthritis…Name the disease that we commonly fear, and obesity is one of the root causes.”
Dr. Badwe said there were many ways in which people could be helped to combat obesity. One of these was to request restaurants to print the calorific value of their dishes in the menu card. Another was to create “travellators” (flat escalators) which could move at varying speeds and allow those using them to walk to work.
“If you’re walking on a footpath, you’re walking at 4 to 5 kmph. If you step on the “travellator” belt, you will walk at 10 kmph. Or at 15 kmph. You can go from Versova to the Gateway of India in one hour, walking and breathing fresh air blowing from the sea. Imagine a city with people walking like this; it would be healthier and I would be out of business!
He then referred to some “frightening numbers”; whatever one’s weight at 25, if a person gained one-third of that weight by the time he or she was 50, that meant a three-year reduction in life expectancy. If the weight gained was 50%, then the person would lose 9 years of life.
“I was about 72 kg. in 1972, I am now 100 kg. It’s a huge gain, whether I like it or not. And this gain is going to reduce my life expectancy. I need to walk!”
What about preventive measures? Dr. Badwe said that in the case of breast cancer the suggestion that a woman should have her first child before 25 now sounded absurd. The second, breast-feeding her child for a year, was easily implementable and a great preventive measure.
‘DIET PLAYS A KEY ROLE IN THE OCCURRENCE OF CERTAIN CANCERS’
A third measure was avoiding hormone replacement therapy. It had dawned on the West quite late in the day that hormone replacement therapy beyond one year was a serious risk factor for breast and ovarian cancer.
Coming to early detection, including physical examination and mammography, he said that mammography was generally not effective before the age of 50. The problem was that false negativity was as high as 45% in those below the age of 50.
If a woman was menstruating regularly and if a mammography was done on her, there was a 45% chance that even if she had cancer it would not be detected. Therefore, nowhere in the world was this test offered as a screening modality before the age of 50.
Dr. Badwe revealed that the “Million death study” had shown that in 2010 far more than a million deaths all over India had occurred because of tobacco. Even more startling was the fact that almost 75% of the deaths occurred in the age group of 35 to 55 years which was not the right age for people to lose their lives.
But while it was a truism that prolonged tobacco use killed, it was also true that sustained stopping worked, irrespective of the time at which the use of tobacco was stopped.
The moment tobacco use stops, there is a precipitous reduction within the first two years; this means that the ill-effects do continue but smoke-related deaths reduce by almost half at the end of two years if there is a sustained stoppage of tobacco use.
Smoking in women was fortunately not very common in India. But chewing tobacco in women was a common sight in rural India. Tobacco use in any form was bad. There was invariably an increase in use depending on the dose response;the greater the dose, the greater the effect.
The risk in men was slightly lower for the number of cigarettes smoked. In women the effect of cigarettes was almost one and a half times higher. It was not right for anybody to smoke, but for women it was even worse. But stopping, even in women, produced a precipitous reduction in risk related to death in general.
“The risk (from smoking) is big because half the individuals who are smokers are dead in 25 years of starting to smoke. Many are killed in middle age, from 35 to 69 years of age, losing more than 20 years of life. But stopping tobacco use works.”
Dr. Badwe said that when this information was conveyed to the Maharashtra Chief Minister, it had an immediate, precipitous effect the sale of gutkha was banned in the State. It was suggested that either the sale be banned or the tax on gutkha be tripled. If this was done, then the consumption would be halved and the revenue doubled. The State decided to ban gutkha.
Referring to the suggestions for regular annual checks for cancer, he said that although this appeared to be a logical idea, it did not work in practice. It was said that someone diagnosed with a very small tumour had a 90% chance of cure, but one diagnosed later had a poor chance, so why not conduct tests on an annual basis?
Although this appeared to be simple logic on the face of it, it did not work in all cancers. In the case of oral cancers, it worked for tobacco users; in the case of breast cancer, it only worked for those above the age of 50, whereas in those below 50 it worked in the opposite direction and the number of deaths increased if screening was started before the age of 50.
The number of deaths increased in cases of lung and prostate cancers the moment screening was started. No national government organisation in any part of the world offered lung or prostate cancer screening. In the case of the cervix, screening worked at any age. A pap-smear and visual inspection of the cervix on an annual basis worked very well.
But, in general, God had been kinder to women. In women, remission from cancer was fantastic but in men it was extremely dismal.
Dr. Badwe said that colonic cancer was extremely uncommon in India, though it was seen in certain populations, such as Parsis, because of dietary factors. Basically, the Indian diet was vegetarian and excellent. Even in the case of those who were non-vegetarians, their platter would have only one non-vegetarian dish, the rest would be vegetables which were good for health.
In European countries, the focus was totally on non-vegetarian items, whether fish, fowl or steak, with the occasional vegetable (such as a tiny potato) remaining uneaten.
Another excellent component of the Indian diet was the use of spices. Spices increased the speed of transit within the intestines and the duration of exposure of DNA material to the mucosa was reduced remarkably. In other words, the meat consumed did not remain in contact with the intestine for too long and just passed off on account of irritation.
Dr. Badwe recalled eating non-vegetarian food in the interiors of Maharashtra and Karnataka where diners were also served three or four green chillies. He usually kept these aside, but the locals happily bit into a chilli with every morsel of meat that they consumed.
“But the incidence of cancer in those individuals is extremely low! I’m not asking you to bite into chillies, but they are extremely protective.
“In conclusion, these are the three preventable causes, infection, tobacco and obesity, and there are many ways of preventing cancer. In general, death in old age is inevitable, but death before old age is not,” Dr. Badwe added.
Answering questions, he told Vijay Meghani that there was no evidence to show that the use of cell phones increased the incidence of brain tumours.Nor could it be proved that radiation from mobile towers had a malevolent effect.
“It’s a very good question, but I don’t have an answer. The data are not enough. There isn’t any good, sound evidence to say that cancer is directly related to these… We have approximately brain tumours in 1 million people (not in100,000). That’s the normal incidence. This increases to about 6 per million if all these million individuals are exposed to such radiation. So the number gets doubled, but there are 1 million minus 6 who will not get it at all in their lifetime.”
Dr. Aashish Contractor said Dr. Badwe had stated that there was no routine test for prostate cancer; but would he recommend regular screening to detect cancer in those in the 40 to 50 age group
Dr. Badwe pointed out that if he ran a test, he would pick up cancer, but what he wanted to pick up was something that threatened life. For example, the incidence of prostate cancer in the US was close to 100 per 100,000. If additional screenings were added, it could increase the diagnosis and the number 100 would go up to about 150 within two years of conducting the tests. But the number of individuals dying would not change.
“So I’m adding some numbers and these numbers are not supposed to die, yet I am diagnosing them under a microscope as cancer.
“Increasing (the number of) procedures give us more (figures for) cancers, but we need solid evidence to say that that kind of increased yield reduces the death rate. And that doesn’?t happen for prostate cancer or for lung cancer or for breast cancer below the age of 50, so we need not do it.
To give you a simile, if I put up a CCTV at a traffic signal, I’m sure I will pick up plenty of those who cross the white line, those who break the signal and get away, but they are not individuals who will pick up an AK-47 and fire it. I’m looking for that.”
Dr. Rohini Chowgule pointed out that more people were dying because of tobacco yet no mass campaign had been initiated as had been done for HIV. Why this discrimination?
“Revenue… Business… Plain and simple,”Dr. Badwe replied.
Kamal Bulchandani regretted that medical science had made tremendous advances, yet there was no absolute cure for cancer at any stage.
Dr. Badwe replied that there was nothing absolute. If there was a 90% cure rate for a disease that he was treating,then it was a very fair achievement. He could make efforts to increase the cure rate to 95%, but there was no 100%.
If I were to say at the time of boarding a flight that the fail-safe ratio of an engineer who has looked at the correctness of the engineering in the plane is 1 out of 10,000 and if the pilot has a ratio of 1 out of 50,000 miles and so on, if I were to rattle out all that, then life would not be worth living or getting on to the flight!
Routine annual screenings for cancer do more harm than good: Dr. Badwe
“We need to look at the rate at which we can take uncertainty and accept it; we need to improve our cure rates not to 50 or 60% but to above 80% or more, then we will be able to say that we have conquered it. We have done it at least for breast, uterine and cervical cancer, especially the last two. We are still a long way for the others, but we are making an effort.
“The problem is that the newer modalities that give a 5% or 10% increment are phenomenally expensive.You have to have a bag full of money to get that kind of result.”
Dr. Percy Chibber wondered whether it was right to take a page out of the West and to decide against screening for prostate cancer. The West had adopted a procedure called PSA screening for prostate cancers in the 1990s when the incidence of invasive prostate cancers as high; but today just 10% of prostate cancers were metastatic (or invasive, and therefore harmful) in the West. This was not the case in India
Posing a counter-question, Dr. Badwe asked:
“Early diagnosis by what methodology? If I were to run a PSA in an asymptomatic patient, I am actually screening. But screening in general should have robust evidence that deaths are reduced. If I were to say that in a randomised study of 50,000 individuals who would have PSA and 50,000 who would not have PSA, and then in somebody who is PSA positive if I do some additional tests, diagnose, treat and then look back at him at the end of 10 or 15 years, what?s the number of deaths in the 50,000 who had PSA screening versus the other 50,000? There should be a clear reduction in the number of individuals dying of prostate cancer on the PSA side.
But that has not happened.
“In all the studies that have been reported from the US and Europe, except in a recent study in the US, the number of individuals who lost their lives because of prostate cancer was higher in the screening mode. So, you are treating more and you are killing more. That is just not acceptable. That cannot be offered as early detection; that means we are producing a problem in an individual who has no symptoms at all.
“As for late diagnosis, the absolute number of metastatic prostate cancer patients per 100,000 population has not changed in the last 20 years (I am not talking about those diagnosed with prostate cancer; in them, the percentage has reduced)… that is the reason why people are now talking against it; they are saying that we are unable to make a dent on those who are supposed to manifest themselves as metastatic prostate cancer. That’s exactly the same for breast cancer, that’s exactly the same for lung cancer, we’re just not able to do it,? Dr. Badwe concluded.