One of the most distressing and anguishing moments in a parent’s life is when he/she discovers that the child on whom they have showered so much love and sought to protect from all harm, has been diagnosed with cancer. Their first reaction is to go into a state of denial. The majority come to terms with the diagnosis and follow prescribed treatment regimens resulting in good outcomes. A few turn to the so called “witchcraft doctors’’ resulting in dire consequences. In this day and age this could be due to some deep rooted misconceptions in society.
Sri Lanka has some of the best trained doctors, with excellent support services to care for young children with cancer. The backing of the Health Ministry with its current focus on minimizing Non Communicable Diseases ( NCD) of which cancer is among the highest on the list is also a positive factor.
The Sunday Observer posed these questions to well known Paediatiric Oncologist at the National Cancer Institute, Maharagama (now known as the Apeksha Hospital) Dr Sanjeeva Gunasekera for his views for more light on the subject.
Excerpts…
Q. Paediatric cancer is a condition not very well understood. As a specialist in the field, could you explain what it is in laymen’s language for the benefit of our readers?
A. Any uncontrolled growth occurring in a solid organ (brain, liver, kidneys, etc) or in the blood stream can be defined as a cancer. In Sri Lanka we generally consider anyone 18 years or less as a child. Therefore, any cancer occurring in this age group would be considered as a paediatric cancer.
Q. Has there been a surge in childhood cancer in recent years in Sri Lanka compared to the rest of the world?
A. Childhood cancers increase in incidence by about 1% worldwide. The rate of increase in Sri Lanka is higher than this. This could be because of the actual increase of cancers and better detection now. Due to advancements we have means to diagnose cancers which would have gone undiagnosed previously. Although I wouldn’t call it a surge there is an increase of cancer incidence in Sri Lanka.
Q. Are these figures evidence based ? When was the last national survey done? Did it cover all districts and populations?
A. Sri Lanka has a robust cancer data collection system lead by the National Cancer Control Program. They maintain the National Cancer Registry and periodically publish relevant reports. It is mainly a hospital based cancer registry and they collect data annually and cover all cancer treatment centres in the island. The latest data available is from 2014 and in that year there had been over 23,000 newly diagnosed patients, of which around 750 were children.
Q. From studies done so far, what are the most common cancers in Sri Lanka?
A. Similar to the rest of the world, the most common childhood cancer in Sri Lanka is Acute Lymphocytic Leukaemia. In simple terms this is a cancer occurring in the blood. More than 50% of children diagnosed with a cancer will have this disease. The commonest cancer in a solid organ are brain tumours. This pattern has not changed anywhere in the world for decades now.
Q. What is the most common type of leukamia found in Sri Lanka?
A. Leukaemias can develop suddenly (Acute Leukaemia) or slowly, over a period of time (Chronic Leukaemia). Depending on the type of blood cell involved they can be further classified as lymphoid malignancies or myeloid malignancies. In children, almost always you see only acute leukaemia and nearly 70% of them would be Acute Lymphocytic Leukaemia.
Q. Do cancers fall into specific types? How different are cancers in adults and in children?
A. There are many different types of cancers in children. They are grouped according to the site of origin, cells involved, genetic changes seen, patterns of spread, treatment methods used, etc. There is a vast difference between paediatric and adult cancers. Hence, the development of Paediatric oncology is a different specialty. Some important differences are, commonly involved organs, biology of the cancer, better outcomes, causes and treatment modalities used.
Q. Children most at risk of getting cancer?
A. Compared to adults there are not many preventable risk factors identified in children with regard to cancer. Historical reports clearly show if children or pregnant mothers were exposed to radiation as seen in nuclear accidents, they are at a far higher risk of developing a cancer. Also, we have now identified some cancers in children which are due to inherited genes from parents. Therefore, in some cases if a family has a high incidence of cancers, their children are at a far higher risk even during the early years of their lives. Sometimes, children might not have a family history of cancer but have a genetic syndrome such as, Down Syndrome. Patients with some of these syndromes are also at risk of developing cancers and need close vigilance.
Q. In the West as in US and UK it is the Primary Care professionals who first detect the symptoms of cancer in children and advise parents to see a paediatric oncologist . What is the procedure here?
A. It is more or less the same in Sri Lanka. However, usually they would first be referred to a general paediatric ward where they would do the initial investigations or contact us for advice regarding further management.
Q. Can children inherit cancer if their parents or a close relative has the disease?
A .As mentioned above some of these cancers can be inherited from parents. However, no one should worry unnecessarily if a relative develops a cancer. The chance of it getting transferred to a child would depend on the type of cancer, exact relationship to the child, number of other family members affected, exact genetic change seen, etc. Therefore, it would be best to seek medical advice if there is any doubt.
Q. Could toxic environments lead to cancer in both children and adults alike?
A. It is clearly proven that pollution is a factor in the increased incidence of cancer worldwide. However, the impact of environmental changes in paediatric cancers is less clear. For environmental factors to cause cancer one needs to be exposed to an agent for a considerable length of time. However, avoiding toxic environment is highly advisable for the overall well being of the child.
Q. Can early detection reverse the condition or delay the onset of cancer if it is in its initial stage?
A. Early detection will identify the cancer in its initial stages before it has spread. This would provide a better chance to completely cure the cancer. Also, treatment needed to cure an early cancer as opposed to an advanced cancer is far less intense. Therefore, we can minimize treatment related side effects.
Q. What is the treatment given to cancer patients? Is it the same as for children?
A. There are three main types of treatment used in cancer. They are surgery, chemotherapy and radiotherapy. Which modality is used and at what intensity would depend on the type, stage of the cancer, and age of the patient. All of these treatment modalities are used in treating children as well. Some of the cancer treatment options have side effects, but what needs to be emphasised is that the benefits of these treatment modalities far outweigh the risks of side effects.
Q. What are the outcomes of such treatment?
A. Generally, the outcomes of childhood cancers are much better, because the biology of paediatric cancers make them more susceptible to current treatment options. In some advanced countries cure rates for Acute Lymphocytic Leukaemia can be around 90%. It is believed, this is as high as we can go in this disease. Therefore, the focus now is to minimize treatment related side effects.
Q. Do you think there is room for improvement in the treatment of childhood cancers in our health system?
A. Treating children with cancer is a team effort. There is a significant role to play for all health care workers, social workers, parents, charity organizations, etc. The goal is not only cure, but to minimize the short and long term impacts it would have on the child and the immediate family. At present we have achieved high success rates in medical aspects of treatment compared to other economically similar countries. However, we need to focus more on the non medical aspects of cancer care. Another area which can improve is research into cancer. It is best to plan quality improvement projects using local data. Therefore, we need to generate quality data through well conducted research projects. These areas have been recognized as areas in need of improvement and a number of interventions are underway to rectify the situation.
Q. What do you see as the future of cancer patients in Sri Lanka especially, children, given the fact that many of them now have access to more services, newer drugs and technologies to identify their problems early?
A. I have a very positive outlook for treatment of childhood cancers in Sri Lanka. We already have a competent health care staff. The Ministry of Health has placed great emphasis on tackling NCDs. The World Health Organization (WHO) recently launched the “Global initiative for Childhood Cancer” to improve outcomes worldwide. We have linked up with well recognized international partners to obtain technical assistance. Everything coming together will further improve our services.
Q.Tell us more about how the public can help cancer patents in Sri Lanka?
A. Cancer patients and their families undergo a challenging period. They need the highest level of support from relatives, friends and the public at large.
There are several charity organizations working with the Apeksha Hospital as well as regional cancer units. The public can volunteer their services by contacting the Hospital directly.