Cancer – getting the story right: Harmala Gupta

Guest post by HARMALA GUPTA

Despite the almost daily dose of information on some aspect of cancer or the other in the national and international media these days, the confusion around cancer persists. The reports and their headers are calculated to catch the public eye rather than inform: “tetanus shot may boost brain cancer survival”; “extra oxygen could help you fight cancer”, etc. The reality on the ground is far removed and infinitely more complex.

To begin with, cancer is one word used to describe a number of different diseases. Furthermore, despite the progress made, we are still far from curing a majority of cancers, from preventing them or finding them early enough to ensure long term survival. The progress that has been made is largely in the West and can be attributed to screening techniques which are able to detect cancers earlier than they did before. In fact, some would argue, too early.

The question being asked is: should we be meddling with pre- cancerous or early stage tumours that are unlikely to ever become life threatening?  Studies show that in some people, for no clear reason, these tumours do not progress. Once again, the baffling question is: Are these tumours best left alone? And if so, at what stage should we begin to engage with them? Only now are we learning that the mammogram touted as the gold standard for detecting breast cancer works best for women over 50 years of age. Before that age there are too may false positives with their attendant consequences to ethically warrant its regular use as a diagnostic tool. Shame that it took medical science so long to work this out. In the meantime, thousands of women have had surgeries and gone through emotional trauma they could have avoided.

The changing contours of the cancer discourse, so evocatively charted by Siddhartha Mukherjee in his bestselling book, The Emperor of All Maladies, gives us an insight into the role that multiple actors as well as sheer coincidence have played in taking the fight against cancer forward in the West. One wonders a bit about this, as this so called progress has come with a sting in its tail. For the ordinary person; the crab looks more and more like a scorpion.

Cancer has become a lucrative multi-billion dollar business from start to finish, with the promise of more money to come. The main battlefield of the “war against cancer”, begun in the last century in the West, has now shifted to our part of the world as cancer rates there are tapering off. India and China are already seeing a surge in the incidence of many types of cancers and established pharmaceutical companies are fighting to maintain their dominance and secure their profits in our markets. Court cases are being fought to extend patents on the flimsiest of grounds and stop generic drugs from being made. The medical establishment has unfortunately become a willing partner. Part of the strategy is to use the media to keep us confused and misinformed.

We are told that the rise in the number of cancer cases is because of the following reasons: we are living longer, our lifestyles have changed and we have the wrong habits. In other words, we are to blame. No one talks about the fact that the policies followed by our self-serving leaders in the name of growth and development have left us with no choice. To cite an example, it is now well known that the “green revolution” was responsible for introducing toxic carcinogens into the air, ground and water of vast swathes of the Punjab, so that today we talk about a cancer belt in the Malwa region. Instead of trying to fix the root of the problem, our political leaders sensing an opportunity, have joined forces with private interests and handed publicly funded cancer facilities over to them. The poor farmers now take a train called the “cancer express” to be treated in the adjoining state of Rajasthan where care is more affordable.

It is no different in our towns and cities where our current model of urbanisation ensures that we have no place to walk or cycle but must perforce  breathe lethal carcinogens day in and day out as private vehicles are given primacy of place on our roads. The rising incidence of diabetes as well as of certain types of cancers can be attributed largely to this. It begins at a young age as even children no longer have places near their homes where they can run and play.

Rather than turning the spotlight on themselves for this sorry state of affairs, those who benefit would rather accept the cancer story put out by the West. So, women are told that they are getting breast cancer because they marry late, do not have enough children and do not breast feed. The statistics in India for breast cancer give a lie to this as we are witnessing a rise in breast cancer among women who marry early, have children and breast feed.

Moreover, people in this country, except for the affluent and westernised elite, do not eat processed foods, smoked meats, animal fats, etc, as a matter of course. Their diets by and large include lentils (when they can afford them) and grains, while vegetables and fruits make a seasonal appearance – a diet that is not necessarily a balanced one but which by and large is rich in fibre, besides being primarily vegetarian. Also, people living in rural areas get plenty of exercise as not only do the majority not own private vehicles but they have to exert themselves physically to earn a living. This is reflected in the types of cancers that predominate in India which are not related to life style choices but rather to low socio-economic status and lack of education.

The number one cancer among the majority of women in this country is cancer of the uterine cervix. The rural registry in Barshi, Maharashtra reveals that it accounts for one-half of the cancers that women get.  Even in a city such as Delhi, the figure stands at one-quarter of the total female cancers recorded. The causes can be attributed to early marriage, multiple pregnancies, the sexual behaviour of partners who infect them with the papilloma virus, and lack of personal hygiene (due to inability to access clean water).

Among Indian males, the cancers that predominate are those of the oral cavity and of the oesophagus. If one takes into account the figures from Barshi, our rural registry, cancer of the penis may be added to the list. These too can be related to the conditions in which people live and work. Not only is there overcrowding and lack of hygiene but people drink liquor, chew tobacco and smoke biris. What one needs to understand is that the reasons why people do this are very different from those of cigarette smokers. While the latter may be aspiring to a more sophisticated lifestyle, the former are reacting to the tough circumstances in which they find themselves. The sad fact is that tobacco quells hunger while liquor helps one forget. Banning advertising by cigarette companies is not going to solve the problem. The majority of tobacco users in this country chew tobacco and smoke biris. One will have to address the reasons why they do this which are more related to poverty and rapacious tobacco manufacturers  rather than to an affluent lifestyle.

One also needs to realise that people are at high risk from cancer in this country due to the degradation of the environment and their exposure to carcinogens at home and in the workplace. Here again lack of awareness and economic disparities play a role. Thus workers in high risk industries such as in the paint and dye industries wear no protective gear and neither are they in a position to demand this from their employers. This is true for farmers in the rural areas as well who use pesticides and insecticides without taking any precautions. Asbestos cement pipes are still widely used for supplying water and sewage disposal in our country, while asbestos sheets provide many a home overhead cover. A few years ago a study revealed that Indians had the highest levels of DDT in their bodies – a substance which like asbestos is a recognised carcinogen and is banned in the West.

In other words, if India is to make any progress in stemming the rise of the cancer mortality rate it is time for those who talk about cancer prevention to press for poverty alleviation, better hygiene and living conditions and education. Making appeals for changes in a lifestyle associated with the west will not alter the ground realities that are associated with the predominant cancers in our country.

Never at a loss for an explanation and adapting to shifting sands what we are being told now is that the answer lies in our genes and may even be plain bad luck. It is forcing women to panic and undergo radical surgeries prophylactically. It also has companies that monopolise these genetic tests, laughing all the way to the bank. But in fact, it is well near impossible to say with any certainty why certain genetic mutations take place in cells and whether they will in fact lead to full blown cancer. As any scientist worth her salt will tell you, biology is not your destiny. There are so many other factors that weigh in.

In short, the real story of what causes cancer is yet to be told. It will certainly not win a Pulitzer.

Harmala Gupta is Founder-President, CanSupport

17 thoughts on “Cancer – getting the story right: Harmala Gupta

  1. Shibu jacob

    It’s obvious that the Cancer industry spends an obnoxious amount of money on culling cures and awareness. There are heaps of stories on the net itself about people who got cures for cancer and were beaten into submission or extinction. Their works were ridiculed and dismissed. There’s more money in treating rather than curing cancer. Nature in itself has cures for all ailments,the thing is to find what’s right for each individual! It’s also proven that chemo patients have 2% or less chance of survival,apart from the complications it causes. Lifestyle and food choices may lead to cancer,but then so can personalities. A person stressing over everything also can get cancer. Anything that can cause gene alteration,paves the way for a cancerous growth.

    1. Shibu Jacob, Curing cancer?? Seriously??….. Cancer cannot be cured under any presently known treatment modality. I wish you wouldn’t post such utter nonsense. There are some cancer that have a very low recurrence rate, some cancers like uterine cancer that can be treated by surgically removing the cancer affected organ. No one has cured cancer, in the way doctors cure malaria or leptospirosis. If someone actually cured cancer, they would get a Nobel prize.

  2. Unadulterated rubbish…. Far from unnecessary surgeries, cancers in India, especially among the poor are never detected early. Check any government hospital, ask what the stage of cancer the patients are suffering from. Nearly all the cancers are stage 3 or stage 4 cancers. Surgically incurable and often metastasised. The kind of misuse where patients are forced to surgically remove pre cancerous lesions rarely occurs and only among the upper crust of society and I mean, the top 1 percent. Breast cancers are rare among women who have multiple children and breast feed. This is medical fact. Check any standard textbook of repute.

  3. Finally, smoking reduces hunger??? Alcohol reduces regret?? Smokers smoke and alcoholics drink because they are ADDICTS, not because they are sad or hungry. Women in rural poor families are often both hungrier and live in far more abusive conditions than the men, but incidence of both smoking and drinking is lesser in women, proving that hunger is a social issue independent of hunger or regret. Drinking and smoking are common because awareness is low, it is considered socially acceptable for men and it is considered ‘cool’ and ‘manly’.

  4. Aditya G

    A well intentioned but mainly a disappointing article.
    I have a few questions :
    ‘One also needs to realise that people are at high risk from cancer in this country due to the degradation of the environment and their exposure to carcinogens at home and in the workplace.’
    Can the author name some carcinogens that are supposedly all around us? It is true that certain occupations are associated with specific cancers. But the role of environmental factors is often overstated. Endogenous factors ie genetic factors are just as important.

    2. It must be said that late marriage, not breastfeeding, having no children are RISK FACTORS of breast cancer, not causes. They make breast cancer more likely. It can and does occur without them.

    3. You also dismiss links between longer life spans and cancer incidence. Our genes are more likely to mutate as we age and that is why we see increased incidence with increasing life spans. In the past most Indians succumbed to infectious diseases and cancer incidence was relatively low. It must be said though that the incidence of infectious diseases has not decreased (in India) as expected and people only live longer due to better treatment strategies.

    4. The author makes a good point about the broad diagnostic criteria. But we have to understand that they are that wide so as to diagnose maximum number of people who have cancer, that is, to reduce ‘false negative ‘ results. As cancer is such a deadly disease but can be treated fully if detected early such broad criteria are justified. We would rather treat 10 patients with doubtful diagnosis than miss one who will go on to develop advanced cancer.

    It is true that such liberal definitions of a disease allows for scaremongering by profit seeking agents but that is their fault. The science is sound.

    As you say majority of cancer in India can be linked to socioeconomic conditions. Woefully low investment in health services and lack of enthusiasm in health promotion is to blame.
    I see such patients everyday and it makes me sad. It also makes me angry. Many cancers can be prevented, many cannot be. In such cases the best treatment is required which our public health service cannot provide. We fail our fellow citizens when we say that we have no money for their treatment.

    It is absolutely shameful.

  5. Nivedita Menon

    Shibu Jacob once more places responsibility for cancer on the victim, while Aditya G and reformtheworld3497 have basically simply restated the dominant “wisdom” on cancer, “addiction” etc that Harmala is questioning. Without any additional evidence or even argument – it’s in the mode of “I dont agree, I prefer to believe what we have been told so far.”
    The most revealing challenge is – “This is medical fact. Check any standard textbook of repute.”
    Medical textbooks are notorious for reflecting every possible social prejudice of the era (for example, on homosexuality), and are periodically reformed for this reason.
    To reflect seriously on Harmala’s radically different perspective on cancer would entail an uncomfortable re-thinking of the dogma of “development” and “progress”, I guess it’s not surprising that the responses are so immediate and so defensive.

    1. Ramray Bhat

      There was once a friend of mine in medical school who upon reading a particular clinical sign called Dalrymple’s sign (but misspelled in the text book as Dalrympte’s sign) kept pronouncing it incorrectly. The logic was the textbook cannot be questioned. That logic can and should never be applied to anything in science, especially when empirical evidence points to the contrary. This is a brilliantly and bravely written article every line of which needs to be pondered upon. Congratulations, Harmala!

  6. Nivedita Menon

    Re medical textbooks as collections of undisputed facts, here is a letter to Indian Journal of Medical Ethics published in 2013:

    Homosexuality is not a new issue in western medical literature; but an empathetic approach to it in the medical literature in India is a recent phenomenon (1, 2, 3). Equality in providing healthcare is not being practised, as evidenced by homophobia among doctors (4, 5), more so in the Indian sub-continent where religious and social biases contribute to denying proper healthcare to the homosexual – as well as the lesbian, bisexual and transgender – community. The attitudes of young medical students are more amenable to change, and can be better oriented towards providing equitable healthcare, irrespective of the sexual orientation of patients (6). Here the question arises: “What does our curriculum teach about sexuality issues?”

    We highlight the misleading information given in the textbooks widely followed by the students of the West Bengal University of Health Sciences. The most affected subjects are physiology, psychiatry and forensic medicine. According to the physiology textbook, in puberty “there develops attraction to opposite sex.” (8). This clearly promotes heterosexuality as the only norm. Some forensic science textbooks state that homosexuality is an “offence”, homosexuals “may be psychologically imbalanced”, and they are “egoists”, who “disregard society” and pose a “social, moral and psychological problem”. (9) The term “crime of homosexuality” has been used and “treatment of homosexuality” has been suggested (9). Some books say “AIDS infection is commonly transmitted by unnatural sex acts with the homosexuals” (9) and call sodomy “a sexual offence” which is most popular and widely practised among homosexuals (10). This portrays same sex behaviour as an inferior form of sexuality. In spite of a long debate on the controversial term ‘gay bowel syndrome’ as it indicates a link between homosexual activity and gastro-intestinal disease, it is still referred to in a standard microbiology textbook (11). A widely followed textbook of psychiatry uses terms like “crossgender homosexuality” and “ego-dystonic homosexuality” (12).

    We suggest substantial revision in the undergraduate medical syllabus and textbooks as these are the main sources of knowledge for doctors. If distorted information is provided from the start of their medical education, any seminars or discussions will be in vain. An unbiased discussion of concepts like sexual behaviour, orientation, identity, sex and gender are much needed. Specific diseases which affect homosexuals must be highlighted rather than providing the “treatment guidelines of homosexuality” (13). Policy makers, educationalists, authors and thoughtful readers must come forward to fill this void in the sphere of wisdom and forge a better patient-doctor relationship.

    Subhankar Chatterjee, Fifth Semester Student, MBBS, R.G.Kar Medical College & Hospital, Kolkata, INDIA,

    1. I agree completely on the issue of presentation of homosexuality in Indian medical textbooks. It is presented improperly and often wrongly. But we were talking about cancer. Similar biases do not exist with reference to cancer in most standard textbooks.

      1. Nivedita Menon

        Harmala’s point is that when medical textbooks claim that breast cancers are rare among women who have multiple children and breast feed, it derives from the dominant understanding that if women do not fulfill their deep biological destiny, they are punished with cancer. My point in bringing in homosexuality is to show that medical textbooks are as much dyed in popular prejudice as is any other kind of discourse, whether about homosexuality or cancer.

        1. Actually, in this case you are wrong. The reason here is hormonal, and it has nothing to do with biological ‘destinies’. Ladies are amennorheic during lactation. The menstrual cycles do not occur during lactation, and it is medically known estrogen and progesterone promote breast tissue growth and breast cancer as well. Estrogen and progesterone are the reason why breast cancer is 100 times more common in women than men. If the cycles do not occur, there is less exposure to hormonal variations that cause breast cancer. This is also the reason why late menarche and early menopause are protective against breast cancer. Fewer cycles mean less hormonal variations mean lower probability of breast cancer.

      2. Ramray Bhat

        This may or may not be the right forum to get very technical with empirical findings on breast cancer. But it does take a long time for contemporaneous findings and breakthroughs as well as conceptual overhauls to seep into medical textbooks. A simple instance, the concept of microenvironment which challenges a gene-centred theory of cancer, and allows for a dialectic between genes and environment to contribute to health and disease, has become mainstream since a decade . To my knowledge it is yet to find any place in medical textbooks. The implications in terms of treatment cannot be overemphasized.

        We have been a bit too hasty, a bit too clever, and a bit too ruthless when it comes to the reproductive health and disease of women. Too many sad sad instances….

  7. Harmala Gupta

    I thank all those who have reacted positively or negatively to my article. It was meant to challenge and provoke which I think it has. The main point I wish to make is that the last word has not yet been written on cancer. It is complex and can not be reduced to any one characteristic, habit or physical trait. The death rates for most cancers have not declined, we just pick them up earlier. The biography of a person is as important as their biology as mind, body and emotions are all inter connected. For example, we know that the chances of some one getting cancer after losing a spouse are higher than the normal population. Why is this so? And is chemotherapy alone the way to treat it? Thank you again for taking the trouble to respond.

  8. Nivedita Menon

    reformtheworld3497, once again, you’re simply repeating what is commonly purveyed. It is now being argued that estrogen does not cause breast cancer, this is a myth. See
    Estrogen Does NOT Cause Breast Cancer: Debunking Common Myths About The Hormone.
    As Harmala says, we know far less about cancer than we have been led to believe.
    There is no harm in taking a deep breath and thinking about the implications of her argument than coming back without a moment’s pause to just unthinkingly reiterate what you have always believed.

    1. The word I used here is ‘promote’, not cause. Estrogen promotes breast cancer like fertiliser causes weeds. The ’cause’ of cancer according to present medical knowledge is abnormal genetic mutations which prevent natural death cycle of cell, literally creating immortal cells. The cause of cancer is therefore the result of a mix of inherited susceptibility to cancer, exposure to carcinogens and unlucky genetic mutations. To get the idea, consider life to be a dice game. You get cancer if the dice is showing six thrice consecutively. Each throw of the dice represents a menstrual cycle. It should then be obvious that someone who has thrown the dice 100 times is more likely to get consecutive three sixes than someone who’s thrown the dice ninety times. Cancer is a probabilitarian disease. You can get cancer due to literal bad luck without ever having been exposed to any carcinogen at all. I agree completely with the article you quoted. You are, however, interpreting it wrongly. Estrogen is an unbiased fertiliser which promotes breast tissue growth, irrespective of whether that tissue is healthy or cancerous.

  9. Harmala Gupta

    References for household carcinogens:

    Reference for cancer incidence in India:

    (It may be noted that the maximum number of cancers occur in our country in the age group between 35 and 64 ; unlike the West where the numbers increase after the age of 65 onwards. Most Indians get cancer 10 years before their counterparts in the West).

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