Catching Them Young
- 55,000 children diagnosed with cancer every year in India
- Worldwide, the annual figure is 2 lakh; in the US, 12,500
- Studies show a direct link between increased urbanisation and childhood cancer worldwide
- Only 5 per cent of childhood cancer is hereditary; 95 per cent of the causes are external factors: viruses, pollution, radiation etc
- In 2009, India had only 55 paediatric oncologists, 15 of them in Mumbai; even the rest are available only in cities.
- Paediatric oncology not recognised as a speciality in over 250 medical colleges across the country
- The commonest childhood cancer is leukaemia; lymphomas, brain tumours, tumours of bone and soft tissue rank next
- Childhood cancer constitutes just four per cent of total cancer in India—the rising figures are a cause of concern, not excess alarm
Nitish loves a red toy car and thinks eating Maggi noodles is a treat. He smiles through heavy sedation to get his photograph taken. The 12-year-old has been battling bone cancer for over six years now. Last month, his father, a farmer from Bihar, was told by doctors at the All India Institute of Medical Sciences (AIIMS) that he should take his son home as the cancer had reached an incurable stage. Now, Nitish’s skeletal body must fight the last and most painful stage of the disease with four rounds of morphine injections every day. All his parents want is for him to die without pain. In his child’s mind, Nitish believes he will be fine, there will be a tomorrow.
During the Christmas season last year, Risa Garg, 7, was diagnosed with leukaemia. No one in her family had had cancer, so her parents were shocked when the body aches and fever she had for a few days turned out to be cancer. Risa wasn’t sick for months: she wanted to skip school only on one day. Her mother thought, at worst, it was rheumatoid fever, which was in the air around that time. A blood test showed Risa had acute lymphoblastic leukaemia, the commonest juvenile cancer—fatal if not treated quickly, but with very high chances of a cure if diagnosed within three weeks. Risa spent the next few months in and out of hospital for radiation, chemotherapy and injections. Big changes had to be made: no school, limited visitors, the family dog was given away to avoid secondary infections. “The biggest challenge for us was at an emotional level,” says Rabani, her mother. “She’d cry and tell us to take her home.”
Like Risa and Nitish, there are 55,000 children being diagnosed with cancers of various kinds in India every year. An unknown number die every year, too. True, India loses more children to malnutrition and other diseases, but the rate at which the number of cancer cases in kids is going up is causing some alarm. (The caveat is that, despite the numbers, childhood cancer still accounts for only 4 per cent of the cancer cases detected in India.) Dr Vinod K. Paul, head of paediatrics at AIIMS, puts it in perspective: “There’s definitely an increased recognition of childhood cancer, a willingness of people to come forward for diagnosis—this could well have translated into more cases. But there’s an overall trend of an increase in cancer with urbanisation. Given that we have a large population, we may well have the largest pool of cancer patients.”
It might be said, without empirical backing, that a global pattern seems to be manifesting in India: no one knows exactly why, but worldwide there seems a direct link between urbanisation and cancer in general and in children too. Cancer is the number one cause of death in children in the US and Canada. Twenty-three per cent of the afflicted children are less than a year old, 20 per cent 1-4 years. In the UK, doctors tell 10 children every day that they have cancer; 7 per cent of children’s deaths there are caused by cancer. In Japan, it’s 6.6 per cent.
|“Treatment of cancer, especially in kids, needs a lot more in terms of financial and emotional support. NGOs can play a vital role.” Prof Vinod K. Paul, Head of paediatrics, AIIMS, Delhi||“I can say with conviction that cancer in children is on the rise. Environmental factors are major contributors in this.” Dr Navin Dang, Leading pathologist, Delhi|
|“Of the 85 cancer patients in my hospital, 40 are kids—indication enough of the sheer numbers of children afflicted with the disease.” Dr R.N. Ghosh, Paediatric oncologist, Calcutta||“Industrialisation, development have led to an increase in childhood cancers. Improved diagnostics has also added to the numbers.” Dr Amita Mahajan, Leading paediatric oncologist|
|“80 per cent of poor children who suffer from cancer do not survive, for want of money to get the required surgery done.” Gitanjali Bhalla, Pall Can Care, an NGO||“There’s no research on childhood cancer in India and hardly any trained staff in hospitals. There are few support groups for families.” Rabani Garg, Mother of a child with cancer|
Even so, the US has only 12,500 new cases of childhood cancer every year, much lower than India’s 55,000 yearly, with several more going undetected. Dr Amita Mahajan of Apollo Hospital, a leading paediatric oncologist, says, “There’s an increase in childhood cancer with the rise in industrialisation and development. But improved diagnostics has also played a role in more cases being detected early.” Leukaemia is the commonest, followed by lymphoma, brain tumours and tumours of the bone, soft tissues and kidneys. Since only five per cent of childhood cancer is known to have hereditary causes, external factors—food, water, pollution, radiation—are being suspected.
The trouble is, we are hardly equipped to deal with this heart-rending problem. In 2009, India only had 55 paediatric oncologists, and 15 of them were in Mumbai. “It’s a shame some of our top hospitals don’t have paediatric oncologists: regular oncologists attend on children,” says a doctor. The India Paediatric Oncology Initiative of the Jiv Daya Foundation, Dallas, US, found India had just 26 regional cancer centres and 172 oncology departments. In 265 Indian medical colleges, paediatric oncology isn’t recognised as a speciality.
This makes diagnosis of childhood cancer difficult, for the disease can take a curious journey. It was a limp that Shaila Raj’s (name changed) pre-nursery teacher in Mumbai noticed in 2009 (she was three then) that led her to being diagnosed with a brain tumour. Again, no family history, no symptoms. “We questioned everything. The food, the water, the lead in the house paint, the pollution,” says her mother Shruti Raj. “We haven’t been able to come to terms with it.” Now six, Shaila has had four surgeries as the tumour keeps growing back.
Doctors loosely explain that viruses (contracted through food, water or air) and a low immunity can cause gene mutations leading to cancer. But there’s no detailed study yet. Dr Navin Dang, who runs one of the oldest pathology labs in Delhi and has had to test an increasing number of children, has his own way of putting it: a conglomeration of factors. “Food, water, what kids are inhaling, or exposed to—these can all contribute to cancer. Three years ago, one saw the occasional child come for cancer screening; now, we have many being tested daily.”
Dr R.N. Ghosh, head of the paediatric oncology department at the Saroj Gupta Cancer Centre & Research Institute, Calcutta, says that at any time he has 40-50 child patients. West Bengal’s unique problem, he says, is the presence of arsenic, a carcinogen, in water in some parts of the state, which people are forced to consume. “Of the 85 cancer patients in my hospital, 40 are children—an indication of the sheer numbers of children afflicted with the disease,” he says.
That external factors have a strong correlation with cancer—even across generations—is borne out in Bhopal. According to a study, says Dr Shyam Agarwal, an oncologist based there, people exposed to the MIC gas leak in 1984, and children born to parents who were exposed, had a higher incidence of cancer. Scientifically, it takes more than just correlation to establish a causative relationship, so Dr Agarwal steers clear of doing that.
Part of the trouble in diagnosis is in the vagueness of symptoms—prolonged fever, black spots, marks on the body, bleeding gums or blood in the urine, paleness or yellowness of skin, swollen lymph nodes, shortness of breath—any number of diseases could be the cause. “Some of these could also be associated with other, much more common, childhood infections,” says Dr Agarwal. “So doctors often suspect other diseases.”
One factor being blamed for cancers now is radiation from mobile towers, though research on this is still inadequate. Neha Kumar of NESA, a company which has made a handheld device to measure radiation levels, claims she has found areas that can be called as a “cluster of cancer”—say a particular floor in a building. But is such panic-mongering aimed at selling a product? Parents may go without it, but would definitely want to save their children from exposure (see photo and box). In fact, after the diagnosis, Risa’s parents worried about the three mobile towers within 20 ft of their Jor Bagh house in Delhi.
Despite the poor facilities for diagnosis and collation of cases, some initiatives seem encouraging. Chennai will be the first to get a paediatric cancer registry, in about two years. Work began last year, says Dr Rejiv Rajendranath of the Cancer Institute. The city has only eight paediatric oncologists—so most children get treated by the 600 general oncologists in the city. At the Cancer Institute, where treatment is free, there are 60-70 child patients, many from rural areas. The big task, though, is quantifying the burden of the disease, as Prof B. Arora of the Tata Memorial Hospital, Mumbai, pointed out in a 2009 paper, ‘Childhood Cancers in India: Burden, Barriers and Breakthrough’. Much of India’s childhood cases are invisible, he says, for there is no registry for the poor: only when the burden is quantified can we focus on better cure rates. Worldwide, as Prof Tim Eden, former president of the International Society of Paediatric Oncology, pointed out in a 2011 report, “childhood cancer is becoming an increasingly important cause of morbidity and mortality as parasitic and infectious diseases are conquered”. All the more reason for India to wake up.
The rich can pay for the treatment of their child’s cancer. What happens to a poor child? Nitish was aided by CanKids, an NGO near AIIMS. But this premier government hospital has only six beds for palliative and pain care—children with painful cancers have little chance of getting there. The pain is terrible: Gitanjali Bhalla of Pall Can Care, an NGO, knows of a child who attempted suicide. Thankfully, the government recently eased the law for use of morphine for pain relief.
Perhaps the only good news about childhood cancer is that, unlike adult cancers, the cure rate is high: 75 per cent of childhood cancers are completely curable. But the severe pain will have to be borne—by those who should have to deal with no more than knees and elbows scraped at play.
The debate over the harm that radiation causes is far from over. However, the fact remains that there are currently 7 lakh towers across the country, emitting radiation beyond permissible limits. On September 1, the government ordered that the minimum distance of a tower from a residential building should be 35 metres. “Public health comes first. Technology must be embraced, but ultimately it must be subject to public health,” says Union telecom minister Kapil Sibal. The department of telecom (DoT) will ensure the exposure limits (for radio frequency fields for 1,800 Mhz) are brought down to 0.92 watt per square metre from 9.2 watts per square metre currently, he adds. Many feel this is a complete eyewash, given the strong lobbying the telecom sector is capable of. The bottomline is that in India monitoring of radiation of towers will be unreliable unless civil society gets active.
By Amba Batra Bakshi with Pushpa Iyengar in Chennai, Dola Mitra in Calcutta, K.S. Shaini in Bhopal