An Untalked About Menace: Cancer Of The Head And Neck

Originally published in The Bangladesh Observer; Dhaka, Bangladesh

THE patient, a young man of 28 years, is sitting before me, in the ENT Department of Mitford Hospital. He is complaining of hoarseness, difficult of breathing and pain while swallowing. Other than this he seems quite fit, even muscular and well nourished. He is a farmer and until recently had worked long, hard, full days. His sudden incapacitation and the sad faces of loved ones dependent on him compelled him finally to seek help.

The patient opens his mouth and I begin my examination. In a few moments, after adjusting my light and mirror. I have my answer: the patient has a large cancer (or tumor) growing deep in his throat and voice-box. After feeling his neck, I quickly discern that the tumor has grown outside the throat and into the lymph nodes of his neck. It has even invaded the skin of the neck already. This young man will need to have his entire throat, viocebox and the lymph nodes of both sides of his neck removed if he is to be saved. After surgery, he unfortunately, will no longer have a voice. He agree to the surgery.

Another day: I am making rounds with the residents of the ENT Department at Dhaka Medical College. The wards here are crowded with patients and their families, the austere rooms are poorly lit. Dhaka Medical College is the oldest hospital in Bangladesh and the facilities slightly antiquated. One of the residents gestures towards a patient he'd like me to see. Lying curled up like a fetus, barely stirring, almost oblivious to the clamor around her, is a woman of 45 years, quite consumed by her own private torment. She sits up for me, grimacing, obviously in great discomfort. A large gauze pad is wrapped around the lower left side of her face an attempt to conceal something perhaps more than to protect whatever it is that is covered. After removing the bandage and blinking once or twice, I understand instantly the nature of this woman's suffering. Open now, for all to see, even in the dim light, is an angry, cancerous mound of ground beef growing from her salivary gland. The tumor is so large it has utterly chewed up and destroyed the lower left side of her face, including the skin; a medical version of a direct hit on this poor woman's left cheek. She is unable to move her face or even close her eye as the tumor has already eaten away the nerve responsible for facial movement. To save this lady and remove this grotesque intruder a major operation will be needed including removal of the tumor and about half the skin of the left side of her face and neck. A second procedure will then be required to reconstruct the lost skin.

Another day: I am sitting in an office at P.G. Hospital. Before me is a man in his thirties who complains of difficulty of speaking and swallowing and a great deal of pain. I look into his mouth. With no effort at all, as the large cancer mass on his tongue almost jumps out at me, I see an amorphous, surly. cauliflower-like tumor that has destroyed about 75% of the patient's tongue and has already begun its deadly advance on the man's lower jaw. There is no need to guess at the reason for his pain and difficulty swallowing. What is hard to fathom is how he could have waited so long. He is already emaciated for lack of nourishment and in obvious discomfort. He will require a major operation to remove almost his entire tongue and one half of his lower jaw. A second procedure will be needed to put every-thing back together again.

An Overwhelming Problem

These short anecdotes only just begun to scratch the surface of what is truly a vast, even overwhelming problem in Bangladesh, and one that, for various reasons, receives relatively little attention in public discourse: the rampant. even epidemic occurrence of cancer in the head and neck. By "head and neck" I refer to the upper aerodigestive tract, mainly the oral cavity (tongue. palate, lips, cheek), throat and voicebox (larynx); the frequency with which patients are being seen with these life-threatening and disfiguring cancers at the various medical centers in Dhaka, can be likened to a serious torrent in the heart of the Monsoons.

The cause of this disease is not known but various factors seem to encourage their incipient growth. Smoking and chewing tobacco, alcohol consumption and chewing betel nut appear closely related to their genesis. Other possible though unproven factors include poor oral hygiene, diet and malnutrition. Mal-nutrition weakens the body's immune system in general thereby pre-disposing the patient to developing these growths. The most common signs and symptoms are difficulty of swallowing often associated with pain, hoarseness and, if the tumor grows large enough. difficulty of breathing. Sometimes, the first sign of a head and neck tumor will be a lump in the neck. Other warning signals that should alert the primary care physician are otalgia (ear pain) or serious otitis media (fluid behind the eardrum) in an adult, which may suggest the possibility of a cancer in the nasopharynx. Serious otitis media in children is another story. This is rarely associated with cancer.

The doctors that are best equipped to take care of these patients are Ear. Nose and Throat surgeons (also known as ENT or Otolaryngologists) who have special training in the management of head and neck cancer. Other surgical specialists (such as general surgeons or plastic surgeons) also take care of these patients but as medicine in all countries moves towards greater and greater sub-specialisation, the treatment of head and neck cancer is falling most commonly into the do-main of the ENT Head and Neck specialist.

I am an American trained ENT --Head and Neck specialist and have been privileged to have the opportunity to visit and work in four countries in Asia, including Thai-land, Nepal, India and, most recently, Bangladesh. This experience has given me an unusual perspective regarding the relative incidence of head and neck cancer from country to country and the way it is being treated.

More Prevalent In Asia

To begin, I can unequivocally state that head and neck cancer is much more prevalent in Asia than in the United States. In Thailand. for example about 33% of all cancer occurs in the head and neck. This places head and neck cancer just behind cancer of the cervix as the leading malignancy in Thailand. This is in contrast with a figure of 5% in the US, very far behind the leading cancers of the lung, colon and breast. Within Asia there are region-al differences but overall this glaring discrepancy between Thailand and the US is true of the other 3 nations I have worked in as well.

In India, there is a predominance of head and neck cancer in the oral cavity (roughly 25% of all cancer in India occurs in the oral cavity alone) which can probably be accounted for by the very popular Indian pastime. along with cricket, of chewing betel nut (There are small stalls on every corner in every city throughout India, making interesting and, no doubt for the locals, tempting betel nut concoctions .with assorted flavours, syrups and spices. The same is true, though slightly less prevalent. for Bangladesh). ( To be continued.)