IN Narthua village of Bihar, Vimlesh Yadav, 47, does not know he may have just a little over a year to live. The labourer’s eyes have turned yellow with jaundice — indicative of an advanced stage of gall bladder cancer. He remembers having seen the same colour, 4 kilometres away, in the neighbouring village head’s eyes. The latter died after getting diagnosed with the same disease a year ago. Yadav, just like the village head did, has lived all along in Madhepura district, 40 km from Ganga’s course, little knowing the river, along with Brahmaputra, is somehow responsible for the high incidence of gall bladder cancer in North and North-East India. The rivers are known to cause death in 70 per cent of such cases.
“Such an epidemic is found only in Chile, also along the banks of a river,” points Dr Rajan Badwe, director at Mumbai’s Tata Memorial Center (TMC), India’s largest cancer research institute. These rivers, Badwe says, have kept oncologists on their tail. While plans of joint study had been formulated between the University of Chile and the TMC previously, the research never took off.
According to a Globocan report, India has an incidence of 7,615 cases per lakh population in gall bladder cancer, with 6,416 deaths per lakh annually. In north and north-eastern parts, incidence is double in women than men.
The Indian Council of Medical Research (ICMR) report of 2009-2011 showed an incidence of 14 per lakh population in women, contrary to 7.4 per lakh in men, in Assam’s Kamrup from where Brahmaputra passes. The incidences remained more or less constant in parts of UP, Bihar, West Bengal and Bangladesh, all basins for Ganga and Brahmaputra. Such an incidence is close to negligible in other parts of the country. For instance, in South India, say Thiruvananthapuram, the incidence is merely 0.7 per lakh population. “We see high incidence in Imphal, Aizawl, Kachad and almost zero in Thiruvananthapuram, Bengaluru or Maharashtra,” says Dr Rajesh Dikshit, who heads the epidemiology department at TMC and has been studying the disease for the last five years.
Says Dr Mahesh Goel, surgical oncologist at Tata Memorial Hospital, which receives close to 700 patients of gall bladder cancer, “Interestingly, this cancer does not exist in upper reaches of the Ganga and Brahmaputra where they originate from. Something changes in the river in its middle course that spurs the cancer.”
In UP’s Gorakhpur, Shanti Dubey (46) has been suffering with acute abdominal pain for four months. A month ago, she was diagnosed with gall bladder cancer. “I have lived all my life in Gorakhpur. How can river cause cancer? No one in my family has it,” she says when told about the findings. Husband Omprakash Dubey, after borrowing money from relatives, has been taking her for various tests, CT scan, blood test, biopsy, for a month now. “Treatment has still not begun,” he worries. Both Dubey and Yadav claim stomach pain gives them sleepless nights. Yadav has spent Rs 500 on tests back in Bihar, at a peripheral centre in Purnia, and later Rs 15,000 in Patna after mortgaging his land. “I have no money left for treatment,” he says. Yadav used to visit the Ganga every year for a bath.
Dr C S Pramesh, attached with the National Cancer Grid, says the formation of a national registry has helped throw systematic light on regions showing high gall bladder cancer incidence. “But we are as far from treating it, as we are in finding its cause,” he says. Different studies have floated vastly differing speculations. A Jama Oncology study, based on 125 patients, has claimed the cancer is spurred by traces of aflatoxin (metal) in rivers. Another study points at salmonella, a bacteria that also thrives in river water. “Small studies have also pointed towards presence of other bacteria called helicobacter bilis or helicobactor pylori as responsible factors too,” says Dikshit. He suspects heavy pollution in river and hormonal reactivity with water in women as a likely factor for the disease’s high presence in females, though no research has been done in that regard.
“River pollution cannot be ruled out. But it is just a speculation. There could be other contributing factors,” adds Dr Mahesh Goel, a surgical oncologist treating the disease. What worries researchers and oncologists alike is the “aggressive nature” of this cancer. In advanced stage, at which 70 per cent patients are diagnosed, the survival chances are nil, with life span often capsuled between three and five years.
“Initial symptoms of gall bladder cancer are mild, such as gas formation, mild pain and an upset stomach. It makes the diagnosis difficult. By advanced stage, jaundice occurs or lumps may be visible,” explains Goel, adding that surgical removal of bladder in advanced stage is not possible. Only patients who have been lucky to have a diagnosis well in advance have a shot at survival, which forms a mere 30 per cent of total cases.
Afroz Jafri, 62, from Lucknow, Uttar Pradesh, found out about her disease two months ago. “We consulted two doctors in Lucknow and then came to Mumbai. No treatment has been outlined to us and her symptoms are aggravating by each day,” says her husband Ejaaz Jafri (64). He manufactures aluminum doors. His business is suffering as he is camping in Mumbai to look after his wife. “I have swelling in right side of stomach,” Afroz complains, not understanding the complications of entering an advance stage.
Oncologist Pavan Sugoor explains that treatment in advanced gall bladder cancer is often limited to chemotherapy for six months. “We try to extend their life from a few months to over a year,” he says.
Most patients are given palliative care to lessen their pain. Jafri will undergo a similar procedure.
Research in India
As the mysterious cancer plagues the upper reaches of India, a 3,000-patient study, the largest ever for this cancer in India, has been under way since 2010. The research is focused on two aspects — whether gall bladder cancer is hereditary and what factors in Ganga and Brahmaputra are leading to the cancer.
Currently, a clinical team is studying the genome makeup of 7 lakh single nucleotide polymers (SNPs) in all patients. The body has 3 lakh SNPs. “By analysing the SNPs, we are checking if the same gene in each patient has mutated,” says Dr Rajesh Dikshit.
In its next phase, the team will test each possible risk factor in the 3,000 patients. Salmonella bacteria, Helicobacter bilis or pylori, and heavy metals’ quantity will be assessed in each patient to understand what is spurring this cancer. “Inflammation in bladder walls causes this cancer. There is something causing that inflammation,” says Dr Mahesh Goel.