India’s Nutty Problem

In India, cancer presentation and care are markedly different than in the United States. It can be attributed to a variety of factors, including poverty, tobacco, alcoholism, and diet. For one, rare in the United States but relatively prevalent in India, are extreme cases of head and neck cancers due to the popular usage of smokeless tobacco. It has been linked to a variety of premalignant oral cavity lesions such as oral leukoplakia, erythroplakia, and tobacco-associated keratosis, which can all result in carcinoma in situ, invasive squamous cell carcinoma (SCC), and verrucous carcinoma. Additional risk factors for oropharyngeal and mucosal cancers include HPV 16 & 18 and poor oral hygiene.

Tobacco is often wrapped in betel leaf and situated in the oral vestibule, the area between the gum and cheeks. They are cheap and highly addictive. Sad to also say the cancers progressive rapidly, first forming precancerous lesions then becoming malignant. Other forms of tobacco use include beedies (rolled up cigarettes in tendu leaf, also known as the “poor man’s cigarette”) and reverse smoking, that is, smoking a cigarette from the lit end.

Bidis Cigarettes

Betel Leaf Wrap

Betel Quid

In Southeast Asia, oral submucous fibrosis is a common premalignancy associated with betel leaf chewing. Areca nut is the potent ingredient in betel quid, often in combination with betel leaf, tobacco, alkaline slaked lime, and catechu (extract of Acacia catechu tree). The quid, or chew, is placed in the mouth, allowing for sublingual absorption. The compound found in areca nut is arecoline, an alkaloid that stimulates salivation and pleasure. Variations of betel quid include pan (fresh quid), gutka, pan masala (powdered quid w/o tobacco), pan parag, mawa (crude mix of areca, tobacco, lime), and mainpuri tobacco (with additional sweeteners or spices such as cardamom, saffron, clove, anise seed, tumeric, mustard).

In the case of oral SMF, the clinical manifestations include restricted mouth movements, oral pain and dryness, glossy tongue and de-papillation, growing intolerance of spicy foods, increased salivation, and hearing loss from stenosis of eustachian tube.

During my surgery OR hopping, I saw a ridiculous number of oral cancers: buccal (cheeks), tongue, gingival, lower alveolar (jaw), floor of the mouth (FOM), larynx, and thyroid. Following removal of the tumor and nearby tissue, a meticulous neck dissection was performed to ensure lymphatic clearance. The sickest and goriest surgery I witnessed involved the lower alveolar carcinoma, cancer of the jaw. Teeth were mercilessly pulled out using pliers. A special metal saw in the form of a thin wire was employed to cut off the mandible. The vigorous oscillating movements looked strangely similar to flossing, except it was obnoxiously, painfully loud and misty dusts of blood and bone hovered in the area between doctor and patient. Another brutal, but less common cancer, was floor of the mouth. What on earth?! I did not know it could happen, but it certainly did in India. Just picture how the surgery would happen, let alone how the doctor would get his hands in the mouth! FOM carcinoma would be a terrible disease because it is located right at the midline, so for the lymphatic clearance, jugular, cervical and other regional lymph nodes from both sides have to be removed.

It’s interesting how cancer surgery is performed in India; it is a blend of general surgery, surgical oncology, and reconstruction. After the tumor excisions in cases of buccal, lower alveolar, and FOM, there will obviously be something missing. Without the jaw bone, it’s just flubbery there. Without a floor to the mouth, there’s no foundation to the oral cavity. And without your cheeks, well, there’s just a gaping hole. What they do in India is a flap, such as a pectoralis major flap. An island of a skin flap is carved out over the pectoralis muscle. The piece of muscle is carefully cut out, like a raw and red beef brisket, and subsequently flipped up and through the neck to its final destination. The flap is sutured in the designated area, whether its the cheek, the FOM, or the lower jaw. Cosmetically it may not be very aesthetically pleasing, but functionally, it works.

On one occasion, the head surgeon was chatting with his assistants and residents, “You know, I would promote tobacco use. Otherwise, I won’t have a job.” A terrible thing to say indeed, but if you think about it, doctors have a job because there are diseases to fight. If talks of prevention are to succeed and more people become healthy, then what will doctors do?! If India is to address and fix the nation’s issue with tobacco use, alcohol, and poverty, then the RCC would run out of business… Doctors would not be running on their feet or cutting out tumors all day. It’s unbelievable to realize that nowadays, chronic illnesses are keeping doctors on their feet and perpetuating the lucrative profession in specialized medicine.

 

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