Notes From The Head And Neck Cancer Wards I

Originally published in The Bangladesh Observer; Dhaka, Bangladesh

THE patient sitting before me is an urbane and educated man in his mid-fifties. He is an accountant by trade and fluent in English. Amongst; his relatives are a few in the medical, profession. employed either here at, one of the various medical centers in! Dhaka or, even some who have made it over to that mythical and remote land across the seas. the United States. The soft-spoken gentleman had been semi-retired the past two years, but unfortunately his retirement has been spoiled by a problem that simply refuses to go away.

The patient wears a bandage wrapped around his neck. with additional padding over the left side. Despite the thick dressing there is a green and reddish stain that has penetrated to, the outermost layers of gauze. I notice that the patient is unable to move his neck. When I ask him to turn his head, as I begin to remove his bandage, he must move his entire upper torso to effect movement, as if the neck were fixed rigidly to his upper chest, with each unfurled layer of gauze the green blood tinged stain increases in size, even begins to give off a foul odor. After the final swath is removed I am confronted by what is unquestionably the most grotesque manifestation of a head and neck cancer completely out of control that I have ever encountered. I dispose of the dirty dressing and look at what I have unearthed.

The entire left side of the patients. neck and lower face appears to have had a small but powerful explosive just detonated underneath his skin tearing open his whole neck in a glistening moist, pink display of blood vessel. sinew nerve and tendon. The explosive in this case-a massive industrial age cancer chewing with industrial vengeance into the deepest layers of this poor man's flesh. The wound weeps an infected and putrid green ooze from the thickened edges of tumor onto his shoulder below. Where skin and tumor meet along the broad, outer frontier of this vast wound. there are turbulent waves and ridges as the tumor invades and advances its border into the surrounding skin. In the depths of this unforgiving crater, at the very centre of its malcontent heart, lies, vulnerable and exposed the great artery... The carotid artery. the precious conduit that carries blood to the brain. And with this loaded gun sitting in his neck the ever present anxiety that at any point at any time of the day or night. this great vessel. having been pressed and prodded too long by the encroaching cancer will simply blow... Rupture. Explode in a paroxysm of crimson spurt and spray and cause the patient to exsanguinate within minutes.

The record of treatment for this patient is so murky it is almost unfathomable. There is some mention of a cancer arising from a salivary gland of limited extent when first seen a year ago. here in Dhaka. This type of cancer is usually best treated by surgery but for some reason he wit. sent to Calcutta for radiation therapy instead. It is well known by most specialists in the field that radiatior alone is not very effective in controlling this kind of tumor. As expected the radiation had little or no effect but no further treatment was offered. The tumor continued to grow. Despite his obvious sophistication and intelligence the presence of doctors in his family and his interaction with the doctors treating him both in Dhaka and Calcutta his disease had not been properly treated nor had the seriousness of his condition ever been fully explained to him.

Second case I receive a phone-call from a man in Dhaka. He informs me that a relative of his has a problem that he'd like me to look at. The next day I' meet the patient. He is an educated man, influential in the business and political community. He tells me he has difficulty swallowing and pain I see he is very worried about his condition. even despondent: already suspecting the likely diagnosis. In his face can he read the long review of urgent concerns agitating inside him.

What will I do? who will look after my wife and children? The business? What will become of Me?

The whole litany of fears anxieties and practical questions that are likely to invade some one's thoughts when confronted with the possibility of having cancer seem to he percolating wildly through his mind.

"How could this have happened to me? Yes I smoke but.... A big but! still I'm a good man, follow closely the precepts of my religion, care for my family I have led a decent life. And now this How ?!.

I sit before the patient and begin my examination. After opening his mouth I notice a firm. round tumor in his tongue. It has already spread perilously close to his lower jaw hone. After the exam I talk with the patient. Curiously he seems almost buoyant now. As if the guessing and uncertainty of his condition have been lifted allowing him to now face his problem squarely. He knows his diagnosis. He has cancer But maybe I still have a chance.

I inform him that he will need major surgery involving removal of most of his tongue and lower jaw. His chances of cure I place at 50%. He accepts the plan.

THIRD CASE: A friend from a Dhaka based N.G.O. asks me to see a former employee of his. The next day I meet the patient and her husband. a retired couple in their 60's. She was diagnosed with having tongue cancer (despite never having smoked) a year ago. Surgery was ruled out then because the tumor was felt to he toe large. Instead she was offered radiation and chemotherapy to reduce the size of the tumor. The tumor, though has persisted and grown and the wife is in great pain. She is unable to swallow. Simply speaking is a major ordeal. At night she cannot sleep. Pain medicine is of no use. Her entire life has become utter torture because of the unrelenting pain of her tongue cancer. "Is there anything you can do?" The husband wants to know.

In fact. though. considering the husband's comments. the patient appears quite calm. even complacent. It is hard to imagine that she is in such agony. I believe that perhaps the tumor is not quite so large. or that the husband may he exaggerating or projecting his own concerns... I look into her mouth.

I instantly realize I am dealing with someone possessed of great self- restraint and composure. Even stoicity... An enormous tumor completely uncontrolled. has consumed her entire tongue. The tumor has grown in so large and irregular a manner it appears almost volcanic: a primeval eruption from another aeon that has converted her mouth to a geologic ruin of cliffs and gullies. As she moves her tongue hack and-forth. the cancer almost leaps out at me in dramatic seismic shifts. Her throat and mouth are a burning red from the prior radiation....

Other patients I have seen with tumors of this size were usually curled up in pain, drooling, barely able to open their mouths. utterly consumed by the torment of cancer out of control in their own bodies. This brave lady though was sitting as serenely as an azalea in spring. I completed my exam without any difficulty.

I discussed with her husband her condition. I mentioned her age. her ether medical problems (diabetes and

prior stroke). the extent of tumor and the low likelihood of curing her. I expressed my concern about her ability to even survive so major an operation. Perhaps she could not tolerate it. Technically it was feasible but I could offer no guarantees.

While speaking with the husband 1 soon noticed that he was crying. His eyes remained fixed on me. He did not move his head away, nor did he a tempt to wipe away the tears. He was as silent and attentive to everything I was saying: only that he was 'so deeply saddened by it all. He had heard it before but perhaps he was still hoping for a miracle: a way out of t! : suffering... My words gave little consolation.

His wife though remained tranquil. She seemed almost to be elsewhere, far removed from the urgings and agonies of this mortal body and capable of shifting her energies and attention beyond her own suffering. She was filled with compassion for her husband. Her duty to him remained paramount. Her instinct for helping him, built over the past 40 year, would not be shaken, even by life-threatening cancer. With her calm, presence she consoled him: provided him the comfort that I could not offer.

They both stood and walked slowly! down the hospital corridor. each leaning on the other. He will call me he says, after thinking, about it. He never does.

These three patients have one thing in common besides the misfortune of having head and neck cancer; each patient comes from a middle class, educated background. This is to say that head and neck cancer is not a disease limited to the poor, uneducated villager. In fact it is a terrifying disease that penetrates into all sectors of society, with no regard for age, income or education level, and in alarmingly high numbers. Although it is more commonly associated with the poor villager, as these three cases (all seen in Dhaka within the space of a single week) amply demonstrate, it does not stop there. It can affect anyone. Head and neck cancer is a major national health problem, a human tragedy on a grand scale occurring in this country every day.

The number of total new cancer cases per year in Bangladesh: 2000. Total cancer deaths per year: 150,000. The overall incidence of head and neck cancer relative to other regions of the body: almost 50%. This is in comparison. as mentioned in a previous article, with 45% the United States and 33% in Thailand. Of 200,000 new cancer cases per year in Bangladesh. 50% or 100,000 occur in the head and neck... One Hundred Thousand new cancer cases per year- and precious few head and neck specialists able to take care of them and those few only in Dhaka. skin males. the two leading cancers occur in the throat (25% ).and oral cavity (20%). In females, cancer of the oral Cavity (20%) is the second leading cancer just behind cancer of the cervix (26%). These numbers send an important message: head and neck cancer is a serious health hazard in Bangladesh. (The statistics are from the Bangladesh cancer society).

How to improve current treatment for head and neck canter patients? The single most important step is to train more junior doctors to become ENT- Head and Neck cancer surgeons. There is a dearth of Head and Neck specialists in proportion to the overwhelming deluge of head and neck cancer patients in this country. In. Dhaka though there are at least some centers for treating head and neck cancer patients.

(To be Continued)