A CANCER OVERLOOKED AND HISTORY’S GREATEST HEALTH EPIDEMIC: Prostate Cancer & HIV/AIDS
Statistics show that 12% of women, one in eight, will develop invasive breast cancer. Taking the seriousness of the matter into consideration, there are an abundance of campaigns and fundraising towards raising awareness and treating breast cancer. Similar statistics show that 14%, 1 man in 7 will be diagnosed with prostate cancer in his life time, 6 out of 10 cases of these are diagnosed in men over the age of 65. This makes it one of the most common forms of cancer in men, yet it is the least talked about.
These statistics tell a depressing story, but on the brighter side, this is normal- ly a slow growing disease and of the many men who develop the cancer, few die because of it. Nevertheless, the c-word definitely rings an alarming bell. Negligence, on behalf of the men, does not help the issue.
If there was an equivalent for breast cancer in men, this is it. However, men do tend to overlook any early signs or symptoms of the disease. A little precaution today can go a long way tomorrow, and may even save your life.
The prostate gland is a walnut sized gland located at the front of a man’s rectum, below the bladder. Its job is to produce the fluid that nourishes and protects sperm cells. Pros- tate cancer begins with the growth of a malignant tumor within the prostate gland and spreads by extending into the seminal vesicles, bladder and peritoneal cavity. It eventual- ly metastasizes to the lymph nodes, bones, lungs, liver, and kidneys.
The cancer is classified based on the tumor’s aggressiveness and the degree of its differ- ence from the surrounding tissue. Most prostate cancers are staged using the Whit- more-Jewett system (A B C D system). The system catego- rizes the tumors using the following scale:
• A: Tumor that cannot be detected by touch but only through microscopic biopsy (tissue sampling).
• B: Tumor that can be detect- ed through touch and is still confined to the prostate.
• C: Spreading of the tumor beyond the prostate.
• D: The cancer has spread to regional lymph nodes.
ARE YOU AT RISK?
Yes, if you are going solely by the numbers, no one is com- pletely immune to the cancer which exhibits tremendous differences in incidence among population worldwide. Howev- er, statistics have also shown that Asian men typically have a very low incidence of pros- tate cancer, with age-adjusted incidence rates ranging from 2 to 10 cases per 100,000 men.
The three most recognized risk factors for prostate cancer are:
1) Age: Age is an important risk factor for prostate cancer. This cancer is rarely seen in men younger than 40 years; the incidence rises rapidly with each decade thereafter.
2) Race: The risk of develop- ing and dying from prostate cancer is dramatically higher among blacks, if of intermedi- ate levels among whites, and is lowest among native Japanese.
3) Family history of prostate cancer: 5 to 10 percent of prostate cancer cases are be- lieved to be primarily caused by high-risk inherited genetic factors or prostate cancer sus- ceptible genes.
4) Diet: The main component associated with prostate cancer is fat. One can actually reduce his chances of develop- ing the cancer by modifying their diet.
Dietary Factors: While some dietary factors have been as- sociated with prostate cancer the evidence is still tentative. However, it does support lack of role for dietary fruits and vegetables for the occurrence of prostate cancer. Red meat and processed meat also appear to have little effect in human studies. Higher meat consumption has been associ- ated with a higher risk in some studies. Lower blood levels of vitamin D may increase the risk of developing prostate cancer. Conversely, Folic acid supplements have no effect on the risk of developing prostate cancer.
Sexual factors: Several case-control studies have shown that having many lifetime sexual partners or starting sexual activity early in life substantially increases the risk of prostate cancer. This correlation suggests a sexu- ally transmissible infection (STI) may cause some prostate
cancer cases; however, many studies have unsuccessfully attempted to find such a link, especially when testing for STIs shortly before or after prostate cancer diagnosis.
IS IT IN YOUR GENES?
It isn’t uncommon to wonder how closely genetics and heredity are related with pros- tate cancer. In fact, 42 percent of prostate cancer risk may be accounted for by heritable factors. All cancers are caused by changes to materials in
our bodies called “genes” and genetics is the study of genes, heredity, and variation in living organisms.
Everyone has two copies of each gene, one from each par- ent. Hereditary cancer occurs when a person is born with changes or mutations in one copy of a damage-controlling gene which normally protects against cancer.
A person who inherited gene change has a 50 percent chance of passing the mutation to each of their children. The medical community uses the term “genetic susceptibility” to describe the high risk for cancer in people with an inherited mutation. Results from several large case control studies and cohort studies representing var- ious populations suggest that family history is a major risk factor in case of prostate cancer. A family history of a brother or a father with the said cancer increases the risk while the risk is inversely related to the age of the affected relative. Although the reason for this difference in risk is unknown, possible hy- potheses have included X-linked or recessive inheritance. If two parents are both car- riers of a genetic condition with a recessive inheritance pattern, there is a one-in-four chance that each child will be affected. There is also a one- in-two chance that each child will be an unaffected carrier, like the parents.
Also risk increases with the of affected close relatives. Risk also increases when a first-de- gree relative (FDR) is diag- nosed with prostate cancer before the age of 65.
The risk of prostate cancer may also increase in men having a family history of breast cancer while men with a history of both prostate and breast/ovarian cancer are at an increased risk.
The best bet is to detect it early, best before stage B. In order to do so, it is important to listen to the signs your body is giving you. Because of the location of the prostate gland in men’s body, prostate cancer often shows a unique number of signs.
• Delayed or slow start of urinary stream (urinary hesi- tancy)
• Pain with urination
• Urinary dribbling
• Urinary retention
• Lower back pain
• Pain with ejaculation
• Pain with bowel movement • Excessive urination during the night
• Excessive sweating
• Frequent and urgent urina- tion
• Abnormal urine color
• Weight loss
• Bone pain
• Abdominal pain
Due to the rise in number
of men afflicted with this disease, annual screening tests have been put into place to hopefully catch prostate cancer in its early stages. A number of tests also exist to confirm its presence after an abnormality is found through screening.
DIGITAL RECTAL EXAM (DRE)
During this exam, the phy- sician inserts a lubricated, gloved finger (digit) into
the rectum. Because of the prostate’s location just in front of the rectum, the physician
is able to feel the edge of the prostate where the majority of cancers begin. Abnormalities such as bumps or hardness of the prostate can be detected in this way. This test takes only
5 to 10 seconds to complete. Most men have complained of little discomfort during the test.
PROSTATE SPECIFIC ANTI- GEN (PSA) BLOOD TEST
A small sample of blood is taken and then sent to a lab for analysis. PSA is a protein that is only produced by prostate cells. As the prostate enlarg- es, whether due to cancer or other causes, the amount of PSA produced increases. High levels of PSA or rapid increases in the PSA level can alert the physician to a possible under- lying cancer.
If an abnormality is found on the DRE or the PSA test, the physician will typically order a biopsy of the prostate.
A biopsy involves taking a very small sample of tissue from the prostate. This is done using a thin needle that is placed into the prostate. A tiny amount of tissue is trapped in the needle while it is in the prostate and then the needle is pulled out. This is repeated in a number of locations throughout the prostate so as to minimize the chance of missing an area where cancer may is present. The tissue samples are then sent to a pathologist who makes the final diagnosis of prostate cancer.
At this time, the pathologist can also look at the cancer cells to determine how abnor- mal they are. This is called
the cancer’s “grade”. A high grade means that the cells are very abnormal and that the cancer is more likely to spread. Depending on your grade, your physician will suggest a treatment.
After the diagnosis is made, a treatment is discussed and action is taken.
Watchful waiting: This option is best suited for older men with a ten-year life expectan- cy or less and whose tumor has not spread beyond the prostate. If the cancer is growing slowly, chances are, the patients will probably die from natural causes before the tumor spreads. Other radical treatments, such as surgery, might be more dangerous than simply waiting.
Radical Prostatectomy (RP): A treatment where the prostate is completely removed. If performed when cancer is con- fined to the gland, the patient should be cured since, in the- ory, it removes all the cancer. RP is a serious operation that requires weeks of recuperation. This treatment can have lasting side effects, including impotence and incontinence.
Radiation: An option that is less traumatic than RP and appears to have similar results when used in the early stages. Radiation treatment, however, also has side effects. Half the patients treated have reported various types of impotence. The treatment is applied through an external beam that directs the radiation dose directly within the prostate to kill cancer cells.
Cryotherapy: An experimental treatment with unknown long- term effectiveness due to in- adequate data. The treatment involves killing the tumor’s cells by freezing them. Early results are very encouraging.
Hormonal therapy: Used in all phases of prostate cancer treat- ment. It helps block production or action of male hormones that have been shown to fuel prostate cancer. In some cases, the testicles are removed be- cause they produce hormones.
PROSTATE CANCER IN NEPAL
Nepal is still struggling to step up its game in improving and managing even conventional modalities for cancer manage- ment. But cancer management including treatment, preven- tion and control is slowly improving in Nepal. Steady progress has been achieved to some extent in past two decades. Although cancer services have been started in 7 major hospitals of the country, only 5 of them have radiother- apy facilities, which might actually be helpful in terms of prostate cancer.
Four centers are located in the Central region. Out of them three are located in Kathmandu valley and 4th one in Bharatpur, Chitwan. The 5th center is located in the Teaching Hospital, Manipal college of Medical Sciences, Pokhara in Western region. Recently, some private hospitals have also started radiotherapy and some are planning to start with one or more treatment modalities.
Presently, B. P. Koirala Memorial Cancer Hospital, Bharatpur, contributes to the treatment of most cancer patients. In 1999,
with the cooperation of Chinese Government, it was established as the first national cancer center of its kind to fight against cancer in Nepal.
Hospital records show that more than 50 cancer patients are treated every day with radiotherapy in these cancer centers. Cancer centers are unable to treat all patients visiting these centers because the existing hospitals lack sufficiently qualified technical man power, advanced technology and other facilities to provide a full-ranged multi- disciplinary quality treatment.
According to the records (Feb, 2012) of major hospitals, there are only 20 radiation oncologists and 8 radiation physicists available in the country. Most of them are working in Kathmandu Valley. The National Academy of Medical Sciences (NAMS) has adopted Bir hospital and B.
P. Koirala Memorial Cancer Hospital, Bharatpur for a post graduate degree (M.D. in radiation oncology).
A study conducted for Prostate Cancer Screening in a Healthy Population Cohort in Eastern Nepal enrolled 1510 for an
analysis with ages ranging from 50 to 100 years with the average age of 64 years showed the overall cancer detection rate in this study was 0.73%.
DON’T JUMP TO CONCLUSIONS
Below the age of 50? These symptoms might not translate to cancer because prostate cancer is not the only disease that can cause the prostate to swell, however. In fact, BPH (benign prostatic hyperplasia) is a much more common cause of an enlarged prostate and, thus, of urinary symptoms. BPH is not cancer, but is
still an important condition that should be treated by a physician. When sufficiently large, the nodules impinge
on the urethra and increase resistance to flow of urine from the bladder. Always consult with a physician before worrying yourself.
YOUR LOVED ONE IS DIAGNOSED WITH PROSTATE CANCER
Life isn’t always fair, and things can go wrong. But your attitude in tackling the situation is what determines how everything else falls into place. It is very important to provide a person with prostate cancer with the right support.
TALKING ABOUT IT
Many men with prostate cancer value being able to talk to those close to them about how they are feeling. Of course, some men won’t want to talk.
JUST BEING THERE
Some say that just having family and friends around is enough. Chatting about normal things and doing some everyday activities together might help. Encourage your loved one to see family and friends and to keep up with social activities and hobbies if he feels up to it.
Many men with prostate cancer say that they want to be able to manage their side effects, themselves. This could involve, for example, changing their diet or being more phys- ically active. Some partners and family members find that supporting their loved one to make lifestyle changes gives them a sense that they are doing something to help.
HELP AT HOME
Some men with prostate cancer have difficulty carrying out their usual activities. This could be because of side effects or because they are recover- ing from treatment. Try not
to take on too much yourself. This will help make sure that you don’t tire yourself out and will help your loved one main- tain his independence.
Despite being one of the biggest threats to the global public health, HIV and AIDS are often overlooked upon until the month of December which kicks off with AIDS day. One thing that needs to be put into perspective is the fact that despite the numbers have shrunk; HIV/AIDS is still here.
There have been few other diseases that have made as big of an impact as HIV/AIDS did in the last 30 years however, It became a worldwide crisis and in the process, carried along a lot of stigmas, misconceptions and myths along with it.Progress in the field has been commendable, no doubt, but the fact of the matter is, complete eradication is still
a distant goal. After the first identification of HIV in Nepal was made in 1988, there has been notable improvements in Nepal making significant achievement in the reduction of new HIV infection from 8,039 annually in 2000 to 1,408 in 2013. The prevalence of HIV is concentrated on certain groups which has categorized as a concentrated epidemic. The groups affected consists of sex workers, injecting drug users (IDUs), men who have sex with men (MSM), and some migrants.
ALL BECAUSE OF SOME MONKEY BUSINESS
The modern HIV virus comes from two strains called HIV-1, which stems from chimpanzees, and HIV-2, which stems from a small African monkey. How it transmitted to humans is still debated, somewhat, but it’s believed to have happened early in the 20th century. Introduction to humans was probably the result of tribes consuming bushmeat, probably not because of interspecies fornication, hopefully.
WHAT ARE HIV AND AIDS?
HIV causes AIDS. HIV stands for human immunodeficiency virus. It breaks down the immune system — our body’s protection mechanism against diseases. HIV causes people to become sick with infections that normally wouldn’t affect them. AIDS is short for Acquired Immune Deficiency Syndrome. AIDS is the most advanced stage of HIV disease.
There are several stages of HIV disease. The first HIV symptoms may include swollen glands in the throat, armpit,or groin. Other early HIV symptoms include slight fever, headaches, fatigue, and muscle aches. These symptoms may last for only a few weeks. However, HIV symptoms are also hard to diagnose because there are usually no symptoms for many years. This is the reason why many people are unaware of the fact that they are carrying the HIV virus.
AIDS symptoms appear in the most advanced stage of HIV disease. In addition to a badly damaged immune system, a person with AIDS may also have:
- Thrush — a thick, whitish coating of the tongue or mouth that is caused by a yeast infec- tion and sometimes accompa- nied by a sore throat
- Severe or recurring vaginal yeast infections
- Chronic pelvic inflammatory disease
- Severe and frequent infec- tions
- Periods of extreme and un- explained tiredness that may be combined with headaches, light-headedness, and/or dizziness
- Rapid weight loss (more than 10 pounds) that is not due to increased physical exercise or dieting
- Long periods of frequent diarrhoea
- Frequent fevers and/or night sweats
- Swelling or hardening of glands located in the throat, armpit, or groin
- Periods of persistent, deep, dry coughing
- Difficulty in breathing
- Discoloured or purplish growths on the skin or inside the mouth
- Unexplained bleeding from growths on the skin, from the mouth, nose, anus, or vagina, or from any opening in the body
- Frequent or unusual skin rashes
- Severe numbness or pain in the hands or feet, the loss of muscle
- Control and reflex, paralysis, or loss of muscular strength confusion, personality change, or decreased mental abilities
THERE HAVE BEEN FEW OTHER DISEASES THAT HAVE MADE AS BIG OF AN IMPACT AS HIV/AIDS DID IN THE LAST 30 YEARS.
There is no vaccine to prevent HIV infection and AIDS, but
it is easy to protect yourself
and others from infection with different preventive measures. It is spread when infected fluids — blood, semen, vaginal secretions and breast milk — comes in contact inside your body. Here are a few ways to prevent the spread
• Avoid injecting illicit drugs.
If you use injected drugs, avoid sharing needles or syringes. Always use new needles. (Boiling or cleaning them with alcohol or cleansing liquid does not guarantee that they’re sterile and safe.)
• Avoid oral, vaginal, or anal contact with semen from HIV- infected people.
• Avoid unprotected anal intercourse, since it causes small tears in the rectal tissues, through which HIV in an infected partner’s semen may enter directly into the other partner’s blood.
• USE A CONDOM when you have sex.
• People with AIDS or who have had positive HIV antibody tests should not donate blood, plasma, body organs, or sperm. They should not exchange genital fluids during sexual activity.
• Safe sex behaviours may reduce the risk of getting the infection. There is still a slight risk of getting the infection even if you practice ‘safe sex’ by using condoms. Abstinence is the only sure way to prevent sexual transmission of the virus.
• Use protection when having sexual contact with people
you know or suspect of being infected with HIV.
Contracting AIDS is not the end of the world. Although there is no cure for AIDS at this time, treatments are available to manage symptoms. These treatments also improve the quality and longevity of life of affected individuals.
It suppresses the replication of the HIV virus in the body. A combination of antiretroviral drugs, called antiretroviral therapy (ART), also known as highly active antiretroviral therapy (HAART), is very effective in reducing the amount of HIV in the bloodstream. This is measured by the viral load (how much free virus is found in the blood). Preventing the virus from reproducing (replicating) can improve T-cell counts and help the immune system recover from HIV infection.
People on ART with suppressed levels of HIV can still transmit the virus to others through
sex or by sharing needles. When HIV becomes resistant
to HAART, other drug combinations must be used to try to suppress the resistant HIV strain of HIV. There are a variety of new drugs on the market for treating drug- resistant HIV.
However, treatment with
ART has complications. Each drug has its own side effects. Common side effects are:
• Collection of fat on the back (buffalo hump) and abdomen
• General sick feeling (malaise) • Headache
When used for a long time, these drugs increase the risk of heart attack, perhaps by increasing the levels of cholesterol and glucose (sugar) in the blood. Medicines may be prescribed to treat problems related to AIDS such as anemia, low white cell count, and to prevent opportunistic infections.
Letting the cat out of the bag
Letting people know you have HIV can be extremely daunting; the stigma and perception of society isn’t as welcoming as it could be. Usually, no two people react in the same way to the news. Responses can range from involvement, caring and support on the one hand, to abandonment, indifference, and antagonism on the other. Whether or not to disclose your HIV-positive status is a difficult decision to make because disclosure (or non-disclosure) is often followed by major and life-changing consequences.
However confessing to your closed ones such as your sexual partners or your family members is vital for yourself and well as them because HIV+ status disclosure helps prevent HIV transmission and increases social support for HIV+ individuals.
These tips can help you get about the situation.
• Think things through. Disclosure is a process, not
an event. Try to think of the implications of disclosure. Consider the reaction of family, friends, colleagues and others might be. Make sure it is what you want to do. Plan how you are going to do it.
• Be practical. Develop a “plan” before disclosure – who you will inform first, how and where the disclosure will take place, and what the level of disclosure will be.
• It may be a better idea to disclose gradually rather than to everyone at once.
• Choose the person/people you want to disclose to carefully: It must be someone who is accepting, mature, empathic and supportive. Make sure that the time and place are right for disclosure
• Identify sources of support, such as support groups for people living with HIV and counselling organisations. Counsellors can help you to role play to help you prepare for disclosure.
• Be prepared for a shocked and even hostile reaction from some people. The people close to you will probably learn
to accept your HIV status over a period of time – if not immediately.
• Once the decision to disclose has been made, it may be easier to begin with those nearest to you: relatives, family, friends, or someone to whom you are very close and whom you trust.
• Be strong enough to allow others to express their feelings and concerns after your disclosure.
• Ask a counsellor’s help if you need him or her to mediate the disclosure process if the need arises (e.g. to be present when you disclose your HIV-positive status to a partner).
NON-GOVERNMENTAL AND COMMUNITY BASED ORGANIZATIONS (NGOS & CBOS)
There are currently almost 100 NGOs working in the area of HIV/AIDS in Nepal and numerous private and voluntary organizations implement activities funded by donors. As a result, the relationship and communications between the government and the NGO community, as well as among NGOs themselves, are not coherent. Donors: A number of multi-lateral and bilateral organizations support HIV/ AIDS prevention, care and support and treatment initiatives in Nepal, including interventions for vulnerable groups; behavioral change communications; condom promotion; STD control; testing and counseling; surveillance; and operational research. Financing for HIV/ AIDS services has been provided by, among others, Family Health International (FHI), USAID and the Global Fund, and has been mostly managed by UNDP and FHI. Presently, the pooled funders in the SWAP have financed for preventive services for the targeted populations.
The World Bank has provided the Government of Nepal with technical assistance in a variety of areas pertaining to HIV and AIDS. This includes updating the National Strategy, and integrating HIV prevention into the country’s National Health Sector Program. It also covers issues related to STI treatment, blood safety, HIV surveillance, voluntary counseling and testing for HIV, and care and support of people living with HIV and AIDS.
The National Center for AIDS and STD Control (NCASC) is responsible for the implementation of the response to the HIV epidemic through MOHP’s network of health facilities and health workers, and for the contracting out of NGO‐delivered services to reach MARPs with effective prevention, diagnosis and treatment services in their own communities. The HIV/ AIDS and STI Control Board (HSCB) is responsible for the coordination of the overall national multi‐sector response, policy formulation, and strategic planning.