Dr. Sajjad Hussain, Consultant Surgeon, District Hospital Kargil, Ladakh: Cancer and cancer-related deaths in Ladakh is alarmingly on the rise because majority of the risk factors are prevalent in this region. Cancer of Stomach (42.12%) is the most common cancer cases in both males and females. Two-year cancer registry record of Leh district shows 19 cases of stomach cancer in 2017-18 and 22 cases in 2018-19, almost similar in comparison to Kargil district with 21 cases in 2017-18 and 19 cases in 2018-19.

In Kargil, stomach cancer is followed by lung cancer and liver cancer in males. In females, it is followed by Gall-Bladder and Breast cancer. Gastrointestinal malignancies are the commonest malignancies including cancer of esophagus, Colon and Rectum and together accounted for half (51.35%) of all the cancers. 

Common cancer cases:

The top ten most common cancers in descending order in Kargil Ladakh are stomach, lung, liver, oesophagus, rectum, urinary bladder, gall-bladder, brain, colon, and testicular cancers in males. Whereas in females, stomach, gall-bladder, breast, esophagus, ovary, liver, pancreas, lung, cervix and thyroid cancer are found. More cases of various organ cancer are being diagnosed during the last 3 decades in Ladakh due to improved health care delivery system in the region.

Risk Factors and Reasons:

Rough terrain, high altitude with hypoxic conditions, exposure to high UV rays, unique food habits of the region, peculiar culture and life-styles and high prevalence of Hepatitis B infections. (8.3%) in the region are the various prevalent risk factors. In Ladakh, the most important specific food habit is the excessive consumption of large quantities (>5-10 cups/day) of butter tea or Gurgur tea. The sodium bicarbonate (soda) and common salt (Nacl) in it are well-known irritants of gastric epithelium and have been considered as a risk factor for gastric cancer. High consumption of red meat and fatty meal, fewer intakes of fresh fruits and vegetables for almost 6 months (November-April), excess intake of dry, raw foodstuffs, stored meats, stored tinned food items, besides traditional spicy foods and pickles; especially in winter; are the other worrisome risk factors of the area. Tobacco is an independent risk factor for Lung, Stomach and many other cancers like oral-cavity, Pharynx, Esophagus, Larynx, Urinary Bladder, Ovary, Colon and Rectum. The high incidence of liver cancer in our region is because of the high prevalence of Hepatitis B virus. In Kargil district, the prevalence of Hepatitis B infection is 7.86%-8.3%, whereas its prevalence is 3.3-5.75 % in Leh. Chronic Hepatitis B infection is one of the causes of liver cancer in Kargil Ladakh. 

Alcohol may be carcinogenic to Esophagus, Cardia, and Liver. Alcohol intake increases 3-fold the risk of cirrhosis and liver cancer. The risk for HCC increased significantly among subjects with an alcohol intake of 50 g/day or more, with a relative risk of 1.2 for 50-99 g/day and 1.5 for > 100 g/day.

The risk factors involved in the rise of Colo-Rectal cancer in this region may be due to the declining habit of taking high fibre ancestral diets like” Khulak” and “Pappa”. Changing lifestyles such as less physical activities, heavy metal contamination of soil, food and water, use of pesticides, dyes and artificial coloring agents (like Tartazine), food adulteration, reuse of frying oils, increased intake of junk foods is leading to a health catastrophe especially cancer in Ladakh.

Sedentary lifestyle, physical inactivity including less of agrico-farming activities in the modern generation, spending more time on mobiles, computers and have increased the risk of obesity which is also considered to be a cancer risk factor. 

Challenges

Due to the non-existence of population or hospital-based cancer registry or any other previous cancer-related study, no data of magnitude of this dreaded disease was available before my studies. It was also very disheartening to see people die of cancers as young as 30 years, in Ladakh. Lack of awareness among the people about the disease is a cause of concern.

Precautionary measures 

Focus more on the healthy dietary habits including high fibre traditional diets, more of fruits and vegetables, less of salted tea, unhealthy foods, fats and meats, stored meats over long period, do regular exercise and physical activities, avoid high ultraviolet rays and excessive exposure to mobile radiations, vaccination against hepatitis B and last but not the least, avoid high-risk factors like smoking and alcohol.  

A significant percentage of newly diagnosed cancers can be cured. Cancer is more treatable when detected early. Some common sign and symptoms that may occur with cancer and may need further investigation are Persistent cough or blood-tinged saliva, significant change in bowel habits, blood in the stool or urine, unexplained anemia, breast lump or breast discharge, lumps in the testicles/Undescended testis presenting late, change in urinary symptoms, hoarseness of voice, persistent lumps or swollen glands, obvious change in a wart or a mole/swelling, indigestion or difficulty swallowing, unusual vaginal bleeding or discharge, non-specific symptoms like unexpected weight loss, night sweats, loss of appetite, headache, back pain, pelvic pain, bloating, or indigestion and non-healing sores/ ulcers.

Solutions 

• Need for cancer- related infrastructure 
• Mass awareness among the people about the disease
• Need for urgent screening protocol to identify patients at earlier stages
• Establishment of a proper cancer registry and active cancer society 

Dr. Tashi Thinles, Consultant Physician, SNM Hospital, Leh: Cancer is becoming one of the most alarming diseases in Ladakh. The common cases are stomach, colon, esophagus, liver pancreas, lung, and cervical cancer. To determine the exact reasons behind the actual causes of the disease requires scientific studies. In Ladakh, the incidence of stomach cancers is very high as compared to rest other parts of India. 

Most of the cases, when patients are diagnosed with cancer they are in the age group of 40-60 years which is a matter of concern. The geographical condition of the region such as high altitude with the hypoxic condition itself is a risk factor. According to the study done earlier, it shows that the food habit of people like high intake of salt in local butter tea is a risk factor. Apart from that, other reasons are the consumption of leftover food which is very common due to cold climatic conditions, unavailability of fresh foods and vegetables in winter almost for 6 months, cigarette smoking, alcohol, red meat specially barbecued are also contributors of the disease. 

Hepatitis-B virus is another risk factor of causing cancer in certain cases such as the liver. Hepatitis B is very common in Ladakh and an average of around 7% of the population carries the virus and is spreading at the same time. In Leh, we are also observing an increasing number of non-communicable diseases such as hypertension, obesity, diabetes, blood pressure which mainly results from a sedentary lifestyle. Obesity is also a risk factor for cancer. A preventive strategy of cancer must essentially include these factors.

Different cancers have different staging systems, but in general, there are four stages which include the first and second stage which are early cancer stage, third and fourth are widespread cancer stage. Early-stage cancers are generally, curable. Around 50% of the cancer is curable if detected at the right time. Detection of cancer depends on its types, for e.g screening of early cervical cancer which is done easily by the gynaecologist whereas; the screening of stomach cancer is a bit difficult. Late diagnosis is one of the major concerns, as the treatment doesn't cure the disease. At that stage, the treatment is aimed at palliation, trying to maintain quality of life while prolonging life with cancer, as much as possible. In most of the cases, people ignore symptoms and mild illness; they tend to visit the doctor only after prolonged illness or severe pain. By that time, we see that the disease has already spread to several organs of the body. Thus, early screening is very much important to detect cancer, which needs awareness and most importantly sophisticated hi-tech diagnostic facilities in hospitals. 

Treatment varies according to the type and stage of cancer. However, most treatments include at least one of the following and may include all: surgery, chemotherapy, and radiation therapy.

Solution

• We need proper data collection system and more research 
• Awareness at a mass level about the disease
• Proper diagnostic facilities and sophisticated equipment is very important