An Untalked About Menace: Cancer Of The Head And Neck II

Originally published in The Bangladesh Observer; Dhaka, Bangladesh

IN Nepal there again is an abundance of head and cancer but accurate numbers are hard to come by, given the inaccessibility of many regions in that mountainous country. In Bangladesh by some accounts, head and neck cancer comprises 40-50% of all cancer seen. This is an amazingly high figure even in comparison with other Asian countries and certainly with the US. and marks this terrible disease as one of the major causes of death and disability in the nation. No doubt all the usual etiologic factors can be called to task for this remarkably high figure including smoking and chewing tobacco and the use of betel nut. In addition, I believe poor nutrition to be a significant factor in this country as well. I feel this way because of the frequent cases of head and neck cancer afflicting patients only in their 20's and 30's I have already encountered in my short 5 week stay in Bangladesh. In the US, head and neck cancer usually strikes patients in their 50's and 60's and there is commonly a close relationship between length of time of tobacco use and the development of head and neck cancer. No such relationship however can be cited for patients only in their 20's and 30's. Other explanations must be sought and malnutrition, which can depress immune function and thereby inhibit the bodies ability to guard against tumor growth is a possibility.

Loss of time

In addition to the prevalence of head and neck cancer in Bangladesh, of equally devastating importance is the length of time patients will delay before seeking treatment. Patients will often wait until they are driven to see a doctor by the ravaging effects of a cancer ignored far too long. Frequently, the cancer is so extensive the patient has no chance for cure. Other times, cure is possible but only through the unpleasant expedients of major surgery, sophisticated reconstructive procedures and radiation treatment. Because of the extent of surgery_ even with the best surgeons, complications can arise, particularly in patients who have failed radiation treatment. The net result of all this is often a prolonged hospital stay, increased morbidity, even mortality and a greatly reduced long term cure rate for these patients. There is also a considerable financial burden for the patient, family and the state.

Reasons for this delay are not difficult to imagine: lack of education, low literacy rates, general ignorance regarding health, little or no access to adequate health care facilities for many villagers, the cost of treatment, reluctance to take time out from work, superstitions, misconceptions, fear, use of "home remedies," anxiety over losing one's voice (for cancer of the voicebox) are all possible explanations.

What can be done to reduce the incidence of this terrible disease and increase the cure rate for those unfortunate enough to become stricken with it? Most importantly, people need to be educated about the hazards of tobacco and betel nut use. Improvement in the general level of health and nourishment will be of benefit as well. Physicians and the lay public need to be alerted to the signs and symptoms, of the disease, such as difficulty of speaking and swallowing, pain associated with swallowing, hoarseness, respiratory obstruction or a lump in the neck.

Serous otitis media in an adult is a warning signal of a growth in the nasopharynx. Once the primary physician has either become suspicious or made the diagnosis of a head and neck cancer the patient should be sent to a specialist trained in the management of these patients. Primary physicians should resist the urge to immediately take a biopsy of a neck mass before a complete evaluation of the patient has been per-formed (best accomplished by an ENT specialist). Such an ill-advised biopsy can reduce the patient's chance for survival. In all cases, the earlier the diagnosis, the sooner effective treatment can be instituted, the better the chance for cure.

Rural Camps

A program of rural ENT camps can be very useful. This essentially brings a team of medical centre specialists to the people, particularly those living in remote areas who rarely if ever have the opportunity of visiting a high level health care facility. Seminars at provincial hospitals can acquaint local physicians with diseases of the ear, nose and throat and, in particular, early signs and symptoms of head and neck cancer. In Thailand, the ENT camp program has had tremendous success in eradicating ear diseases throughout the country. It has be-come a model for developing countries. Until the day comes when Bangladesh can better afford to build more provincial hospitals and regional medical centers, rural camps represent an effective and relatively inexpensive alternative.

Of course at some future point, hopefully it will be possible to expand the health care network in Bangladesh, by building more hospitals and Medical Schools and training more specialists; but all this will require time and money. Inviting specialists from abroad to help train the local doctors in the surgery and management of he and neck cancer could be effective however most senior specialists from other nations are usually quite busy in their own practice and institution. They can rarely stay for more than a few days to teach a lecture or two. Practical benefit for the developing country is minimal, unless a prolonged visit with active "hands on" demonstration can be offered.

I would also like to mention, in closing, that the open-mindedness, determination and ability of many of the ENT surgeons I have been privileged to work with here in Dhaka has been both an inspiration and a joy. If their skill and devotion is any indication I believe that in time Bangladesh will come a long way in overcoming the scourge of head and neck cancer.

[Dr. Richard M. Moss, formerly an Assistant Professor at the University of California in San Francisco, is currently engaged in training the local ENT-Head and Neck surgeons in the surgery and management of head and neck cancer at major medical centers in Dhaka.]