How attitudes play a role in India's cancer rate
By the time Archana Lal, a government midwife in Chandigarh, India, consulted a doctor in August, she had been experiencing constant pain and discharge in her left breast for some months. It was only when it became unbearable that her husband dragged her to see a doctor.
She had thought of seeing a doctor, but the idea of removing her clothes to be examined was unthinkable. Like millions of Indian women, Lal has been culturally conditioned always to be modest.
There are millions of women in rural areas who don't remove their clothes even while making love with their husbands. So powerful is the cultural conditioning against nudity, or 'wantonness', that they have sex still wearing their sari blouses and petticoats under the saris.
Even many educated women in the cities put off having mammograms or ultrasound scans because of acute embarrassment over taking off their clothes and being examined by a male doctor or technician.
'By the time I saw her, the cancer had spread to her lymph nodes,' said Chandigarh oncologist Dr Rajeev Bedi. 'Patients generally present in advanced stages when it's too late to help them.'
Cultural attitudes such as 'shyness' that can play a part in determining the incidence of cancer in a country are some of the factors that will be studied as part of the largest cancer study ever to be undertaken in India. Nine leading cancer centres in the country will collaborate with Oxford University on the study, called Indox.
Previous studies of this type have been limited to a few hundred people, but this new study will involve more than 20,000 people. It will examine whether cultural imperatives and lifestyles found only in India are important in influencing the risk of cancer.
For example, can lifelong vegetarianism - widespread in India - have a beneficial effect in lowering the risk of cancer? Does it explain why the incidence of bowel cancer in India is far lower than in Western countries? Do certain spices such as turmeric have a similar effect? Does the practice of burning wood inside tiny kitchens - the norm in villages - heighten the risk of cancer? Is the lack of information about prevention - given the high illiteracy levels in the countryside - one reason breast cancer rates are high?
Cancer and health care experts hope the insights that will emerge will help to shape policy in the future, both to help treat victims and reduce the financial burden of the disease. As it is, the incidence of cancer in India is rising, despite the common perception of it as a disease of rich countries.
Indox researchers say that cancer is now the second leading cause of death (after heart disease) in many low and middle-income countries in the world, including India. By 2020, they estimate that 70 per cent of all cancer cases will be in these lower income countries, and approximately one-fifth of these will be in India.
Last year, the Indian Council of Medical Research predicted there will be about 1.5 million new cancer patients in India by 2015. The figures available in India are highly variable, owing to the fact that many cancer cases in remote areas are not even reported.
Some doctors estimate there are already two million to 2.5 million cancer cases at any given time in India. Mortality rates are much higher than in the West because of the cost of treatment, social stigmas, lack of awareness of the signs of cancer, and cultural attitudes such as those that stopped Lal from seeking advice. But even an educated and affluent woman such as New Delhi-based garments exporter Rita Sharma was just as reluctant to be tested.
Last year, Sharma accompanied a close friend who was having a check-up, including a mammogram. The friend suggested that Sharma have a mammogram, too, her first at the age of 56. When the doctor detected lumps in both breasts, Sharma collapsed, crying out loud about what would happen to her young twin sons. Her husband had to be called from the office to calm her.
Her treatment appears to have been effective but, as her doctor, Alok Zutschi, said: 'Women in India read the papers, they read the net, but somehow they just can't get over this phobia of being examined by a male doctor and keep putting off the mammogram.'
Breast cancer is now the second most common cancer in women after cervical cancer, and in urban areas, it has overtaken cervical cancer to be the most frequently diagnosed cancer in women.
According to the Indian Council of Medical Research's figures, a decade ago the breast cancer figure for women in the southern city or Bangalore was 16 per cent. Now it is over 34 per cent.
Experts say lifestyle changes are responsible for the higher breast cancer figures. 'Women are having babies later and either not breast-feeding at all or not for very long,' said Dr Rajan Badwe, director of the Tata Memorial Centre in Mumbai.
In a recent survey of 1,000 women, the Breast Cancer Foundation of India found that poor women working as nannies for rich women were copying their employers' behaviour. The rich women would hurry to get back to their jobs after breastfeeding for only two months.
The nannies mimicked their employers, leaving their babies back in the slums to be fed on packaged milk by relatives while they returned to work.
India will account for this percentage of the cancer cases in lower income countries worldwide by 2020, Indox estimates