Most cancers caused by industrial products: Pankaj Chaturvedi

The World Cancer Day is celebrated on February 4 to raise awareness and encourage prevention, detection and management of cancer. The day was decided upon by the Union for International Cancer Control (UICC) to support the goals of the World Cancer Declaration, 2008. The primary aim of the World Cancer Day is to reduce death and disability caused by cancer by 2020.

Cancer is an ever-increasing public health challenge in India. It is one of the 10 leading causes of deaths. With a prevalence of 3 million and an annual incidence of 1 million, it is indeed a serious issue. It kills around 5 lakh people annually, owing to their advanced stage of presentation. As per the World Health organisation (WHO) report 2005, the estimated cancer deaths in India is projected to increase to 7 lakh by 2015. The situation is expected to worsen due to an increase in the life expectancy, demographic transitions and the effects of tobacco, alcohol and other risk factors.

The leading sites for cancer are the oral cavity, lungs, oesophagus and stomach among men, and cervix, breast and oral cavity among women. Cancer accounts for more deaths worldwide than Aids, malaria and tuberculosis combined. According to the World Economic Forum (WEF), "Cancer is among one of the three greatest risks to the global economy, due to escalating cost of care, threat to productivity from death and disability, and the effects of costs on household impoverishment."

On September 19, 2011, heads of states and governments of 117 countries converged at the United Nations (UN) in New York to address the prevention and control of cancer and non-communicable diseases worldwide, with a particular focus on developmental and other challenges, and social and economic impact, particularly for the developing countries. The UN resolution declared four key strategies to curb the rising burden of cancer – control of tobacco, unsafe use of alcohol, obesity, and better nutrition.

It is a mammoth task to improve the nutritional status of a nation of one billion people. Control on tobacco, areca nut, alcohol and junk food, however, is well within the reach of our policy makers. A lot is known about the cancer causing properties of tobacco, but still most are unaware of the harmful effects of alcohol, areca nut and obesity. In this article, I have tried to cover these three lesser known issues as well.

Tobacco
As per the Global Adult Tobacco Survey (GATS) released in 2010 by the Ministry of Health and Family Welfare, India has 27.5 crore people consuming tobacco in some or the other form. It is estimated that nearly one third of them will die prematurely due to serious illnesses such as cancers, heart diseases and so on. According to a recent WHO Global Report 'Mortality Attributable to Tobacco', almost two in five deaths among adults aged 30 years and above are caused due to smokeless tobacco. It is important to note that nearly 22 crore are using tobacco in the smokeless form.

This is responsible for an epidemic proportion of oral cancer, especially among youths. Though gutka is banned, it can be easily accessed anywhere with little restriction. The Ministry of Health and Family Welfare have agreed that flavoured smokeless tobacco (SLT) products are unsafe food. Even then, only 11 states have banned flavoured chewing tobacco in addition to gutka.

There is no law prohibiting smoking products such as cigarettes and bidi. The only way to discourage their usage is to strictly implement the Cigarette and Tobacco Products Act that aims to prohibit smoking in public places, prohibit sale to minors, and stop direct and indirect advertising. Taxation is a very powerful tool that is known to decrease consumption world over. Unfortunately, India has low taxation on tobacco and poor implementation of the Act.

Alcohol
Alcohol is a confirmed cancer causing substance as per the International Agency for Research on Cancer, WHO. Alcohol is causally related to cancers of the mouth, oropharynx, liver, oesophagus and breast. Alcohol consumption increases the risk of larynx cancer by 17-fold and mouth cancer by 10-fold. The risk becomes much higher when tobacco is consumed along with alcohol.

Apart from cancer, it causes dependence syndrome, cirrhosis, pancreatitis (acute and chronic), gastritis, polyneuropathy, hemorrhagic stroke, psychoses, epileptic seizures and other mental conditions. There are about 2 billion people worldwide who consume alcohol and 76.3 million suffer from nearly 60 types of alcohol-related diseases and injury. Alcohol causes 1.8 million deaths (3.2 per cent of total). Akin to tobacco in 80s, alcohol has a great social acceptability because of several decades of shrewd marketing. Both continue as profit-making industries, despite a plethora of evidence against them.

Alcohol is one of the leading risk factors for disease burden in low-mortality developing countries and the third largest risk factor in developed countries. Its consumption leads to actions that result in unintentional injury and deaths, such as traffic accidents, fall and occupational injury. This alone account for about one-third of the 1.8 million deaths. Interestingly, alcohol usage is associated with many negative consequences both for the drinker's family and community. Just like tobacco, these negative economic consequences are more pronounced in impoverished nations.

Unfortunately, rather than discouraging people to pick up drinking, alcohol is being heavily advertised in all forms of media. The positive portrayal of alcohol in cinemas has dramatically increased in the last decade and censor board finds nothing abnormal in it. Newspapers, television and hoardings carry surrogate advertisements of alcohol and Advertising Standard Council of India seems to have done nothing about that.

Areca nut
India has one of the highest incidence of oral cancer in the world. The cause of this high incidence is the chewing of smokeless tobacco and areca nut in varying combinations, such as zarda, khaini, betel quid, gutka, pan masala and so on. While smokeless tobacco is a well accepted carcinogen and regulated under the Cigarette and Other Tobacco Products Act 2003 (COTPA), areca nut is considered to be safe by most. Just like tobacco, areca nut or betel nut is a psycho-stimulant, an addictive substance and a well-known carcinogen.

The cancer-causing properties of areca nut have been well reported in animal, human and epidemiologic studies. WHO and the International Agency for Research on Cancer have classified areca nut as a Group 1 human carcinogen with sufficient evidence. There are several other reports that have linked areca nut chewing, with or without tobacco, with hepatocellular carcinoma, cholangiocarcinoma, cancers of the larynx, stomach, lung and cervix in humans.

Pan masala or supari mix, a combination of areca nut, spices, sugar, flavouring agents and perfumes, glamorises this inherently harmful food. As per the Food Standards Authority of the Government of India, such areca nut products are permitted to be sold with a health warning printed on the packets. Pan masala is sold as a mouth freshener with a miniscule warning on the packet. It is advertised aggressively on all popular media with celebrity endorsements. While section 2.3.4 of Food Safety Standards Act of India Regulation 2011 (FSSAI) warrants prohibition on gutka, there is no such legal provision to ban pan masala or areca nut products.

Obesity
Obesity is a condition where an individual has an abnormally high proportion of body fat. It is associated with increased risks of cancers of esophagus, pancreas, colon, rectum, breast, endometrium and so on. One study, using NCI Surveillance, Epidemiology, and End Results (SEER) data, estimated that in 2007 in the United States, about 34,000 new cases of cancer in men (4 per cent) and 50,500 in women (7 per cent) were due to obesity.

The proportion of cases attributed to obesity varied widely, but was as high as 40 per cent for some cancers, especially endometrial cancer and esophageal adenocarcinoma. This analysis also reported, "If every adult reduced their BMI by 1 per cent (approximately 1 kg for an average adult), it would prevent about 100,000 new cases of cancer."

The fast food industry has mushroomed all over India and their powerful advertising has influenced the eating habit of most urban kids. The advertisement of burger, pizza, chocolates, soft drinks, noodles and biscuits have misled the vulnerable young to accept them as safe food. It is not surprising that fast food, coupled with a lack of exercise, has led to a sharp increase in obesity among the urban population.

Prof Pankaj Chaturvedi, oral cancer surgeon, Tata Memorial hospital