By Dr Lemma

Cancer is an expensive disease to treat. This is true anywhere in the world although most challenging when resources are limited. Although there are childhood cancers, most cancers are common in older ages. The commonest cancers worldwide are lung, breast and colon cancer. In men the commonest cancer is lung where as in women the commonest cancer is breast. However lung cancer is the commonest cause of cancer death in both men and women worldwide.
Although data is limited and based mainly on hospital reports, the commonest cancers reported for sub-Saharan African countries are breast and cervical cancer. This could be because:
-patients are more likely to seek care for more symptomatic cancers like advanced cervical cancer (bleeding, pain) or lump in the breast
-shorter life expectancy (cancers that present at older age may not be accounted for)
-other factors which are not well understood at this time

What causes cancer?
It is usually difficult to pin point a specific cause for cancer as it could be a result of multiple factors. Eventually everything comes to abnormal and uncontrolled cell division that will spread both locally and distant sites in the body.
Below are few conditions known to be associated with the development of cancer:
Smoking: associated with several types of cancers but most strongly with lung cancer. It is one of the commonest preventable causes of cancer death worldwide!

Excessive alcohol intake: strongly associated with liver cancer, cancer of the esophagus and stomach.
Infections: It could take several years from the time of infection to the development of cancer.
•Hepatitis B and C associated with liver cancer
•Human Pailloma Virus (HPV) is the initiating infection for almost all cases of cervical cancer. Also associated with head and neck cancers. It is important to note that HPV is sexually transmitted infection.
•HIV(particularly untreated HIV is associated with Kaposi sarcoma and some lymphomas)
•Helicobacter pylori (bacteria in the gut that also predisposes to peptic ulcer disease is associated with some forms of gastric/stomach cancer)
•Schistosomiasis(Bilharzia) in bladder cancer.

Hereditary: passing of genes in family that predispose to the development of cancer. This type of cancer tends to be seen at younger age and also in multiple family members/generations.
Familial cancers are responsible for minority of cancers.
•Familial Breast cancer: familial breast cancer is responsible only for minority of breast cancer cases. However, history of breast cancer in one’s immediate family also increases the risk of developing breast cancer.
•Ovarian cancer: the same gene abnormality that causes familial breast cancer also causes familial ovarian cancer. Again this is responsible for minority of ovarian cancers.
•Colon cancer: can be part of other familial cancers. Again only minority of colon cancer cases run in family.

Obesity (excessive weight):
Linked to several cancers (uterine,cancer,colon,breast…).Difficult to establish direct cause and effect relationship. Obesity is also a strong risk factor for diabetes, hypertension and heart disease.
Previous chemotherapy and radiation therapy or exposure to harmful radiation: could take few to several years before cancer development.

Symptoms of cancer:
Cancer can present in variety of ways depending on the location and extent of spread. Some of the ways cancer can present include swelling/lump in the body, pain, bleeding (especially for uterine and cervical cancer). Sometimes cancer can also be discovered on routine blood test or x-ray/CAT scan done for other reasons.
Advanced cancer is usually associated with significant and unintentional weight loss, decreased appetite, as well as decreased energy. As there are several other diseases that can present the same way, it will be wrong to assume that these symptoms are always from cancer. However one needs to be evaluated by a health professional before reaching into any conclusion.

Stages:
Early to locally advanced (in most cases stages I-III)
Advanced /spread (stage IV)

Treatment:
In general cancer treatment involves any of the following alone or in combination: surgery, chemotherapy, radiation therapy, hormonal and biologic therapy. Occasionally watchful waiting without initiating any treatment could be appropriate.

In most cases, the goal of treatment for early stage cancer is cure or long term cancer free status. However, most of the advanced stage cancers are incurable with current therapy and the goal of treatment is mainly to prolong life and to alleviate symptoms that cause pain and discomfort to patients. It is very important for the patient and health professional to have honest communication on the goals of treatment and expected outcome. This is very important as treatment can be associated with significant side effects.
An important component of care for advanced incurable cancer is to control symptoms particularly pain and help patients to be as comfortable as possible. In this situation, trying to treat the cancer will cause more harm than benefit and should be stopped.

What can I do?
This is a difficult question however the following are helpful to prevent some types of cancer or to diagnose it at early stages.
•Stop smoking
•Avoid excessive alcohol consumption
•Vaccines (Hepatitis B vaccine can help prevent liver cancer, HPV vaccine is relatively new vaccine and prevents the virus that causes cervical cancer)
•Undergo age appropriate screening that can detect early stage cancer or precancerous abnormalities that can be treated successfully:
oBreast: mammogram for women aged 50-74
oColon: colonoscopy starting at age 50
oCervix: Pap smear usually starting from age 21

Screening recommendations may vary depending on risk/family history. Screening services are not available in most low income countries making early diagnosis and treatment impossible. A recent study from India that showed successful cervical cancer screening using simple test with vinegar (the test reduced deaths related to cervical cancer in the community by around one third!). The test requires minimal expertise and is cheap to perform. This is encouraging news that could potentially be adopted in most developing countries. However, one needs to have the set up to evaluate and provide treatment for those who test positive. (http://www.medicalnewstoday.com/articles/261381.php)

Additionally healthy life styling including maintaining appropriate weight, exercise and healthy diet could help.

In conclusion, although infectious and communicable diseases still deserve priority in developing countries, the impact of cancer related illness and death is growing and should not be totally neglected.

Dr Lemma is a cancer specialist.