Time is of the essence in treating Nasopharyngeal Cancer

Diagram shows a nasopharyngeal tumour. Source: International Medical University.

NASOPHARYNGEAL cancer (NPC) is a rare type of cancer that occurs in the nasopharynx — an area behind our nose and above our mouth — and worldwide, its rate of incidence is less than one per 100,000 in many western countries like the US and most of Europe.

Locally, however, Sarawak has one of the highest rates of NPC in the world with 13.5 and 6.2 per 100,000 for all Sarawakian males and females. There are an estimated 180 new cases of NPC each year at the Sarawak General Hospital’s (SGH) Radiotherapy and Oncology Unit (RTU), making the disease our second most commonly seen cancer type for males.

And with a disturbingly high figure of an estimated 50 to 60 per cent of all new NPC cases at SGH’s RTU presenting in the late Stages 3 and 4, raising awareness of this frightening disease is now more imperative than ever.

And for a start, we should understand why our state is such a hotspot for NPC.

Causation factors

According to Dr Yu Kong Leong, a committee member of the Malaysian Oncological Society (MOS) and head of the RTU, NPC is caused by a combination of factors such as genetics, viral infections and environmental influences.

Genetics, especially, seems to play huge part in the causation of NPC as Dr Yu explains that the disease is more common in Bidayuh males and females than any other ethnic group worldwide.

“In a study conducted a few years ago, it was found that the Bidayuh community showed the highest rate of NPC in the world, followed by Chinese from Hong Kong and Singapore, and all other Dayak races and Chinese in Sarawak,” he shared.

Published in 2004 and written by a team of researchers at SGH, the study indicated that the risk in the Bidayuh was 2.3 and 1.9 times higher for males and females compared to the Sarawak average.

“This correlates with our department’s own data as we have noted a higher proportion of Bidayuh patients with NPC, and found that our NPC cases are saturated in Serian where there is larger Bidayuh population,” he added.

Besides genetics, Dr Yu said recent studies and research have found an association between the Epstein-Barr Virus (EBV) and NPC rates.

Commonly known as the ‘kissing disease’ or mononucleosis, EBV is a common virus found in our bodily fluids that can spread as easily from one person to another from just sharing drinking glasses or utensils.

An important feature of this virus is its ability to persist in the host and it is estimated that more than 95 per cent of adults are carriers of the virus.

EBV can transform latently infected primary cells from healthy individuals into cancerous ones, thereby causing important human cancers such as B-cell neoplasms (eg Burkitt’s lymphoma), and some epithelial cancers (eg nasopharyngeal and gastric carcinomas).

Understanding viral latency, what triggers viral reactivation and the mechanism of transformation of normal host cells into malignant cells are critical for the development of strategies for the prevention and control of this intriguing virus and related cancers.

Unfortunately, without an EBV vaccine, there is no realistic way to limit and reduce our exposure to this common virus, making it a factor that we cannot control just like our genetics.

Factors that we can control instead are environmental factors, involving our diets, health and exposure to cancer-causing substances.

“In general, to lower our overall risk of developing most types of cancers, including NPC, it’s recommended that we practise a healthy balanced diet, plenty of exercise and avoid cancer-causing substances like smoking,” Dr Yu advised.

Chart shows the incidence rate of NPC in several ethnic groups around the world.

Symptoms of NPC

But even if we practise a healthy lifestyle, the risk of developing NPC for Sarawakians is still higher than the general population in the world, and the only thing we can do to address this at this time is to educate ourselves on the early symptoms to help us catch it.

Some of the most common symptoms unique to NPC include reduced hearing on one side, epistaxis or nose bleeds, neck swelling from swollen lymph nodes, nasal blockages, persistent headaches and double vision.

“Early symptoms for NCP are reduced hearing and nose bleeds, everything else occurs in the later stages, so it’s imperative that early symptoms are not ignored,” Dr Yu said.

But as nose bleeds are a common symptom for many conditions, ranging from hypertension to allergies, it’s often hard for people to discern whether or not a nose bleed is abnormal.

To this, Dr Yu advised that nose bleeds caused by NPC will definitely not be a one-time occurrence and will normally be accompanied by other general symptoms of cancer such as reduced appetite, nasal blockages and neck swellings.

“However for me, I would actually recommend that all Sarawakian men who have experienced any of the early symptoms of NPC to just go to their nearest ear, nose and throat (ENT) doctor for a check-up,” he said.

“I think for this region, it’s better to be extra cautious and screen for it earlier rather than waiting a few weeks for another symptom or episode of nose bleeding to occur. That way, we can catch and treat it earlier, allowing a better chance of successful treatment.”

The Epstein-Barr Virus DNA may incorporate into our own cell’s DNA and instruct them to divide uncontrollably, causing cancer.

Treatments and alternative competition

Dr Yu said five-year survival rates of NPC in early Stages 1 and 2 are around 70 to 80 per cent, but in later stages, the survival rates are not nearly as optimistic as it becomes increasingly difficult to treat when it has spread to other parts of the body.

Because of this, Dr Yu urged patients to be aware of any early symptoms and encouraged them to seek medical attention as soon as possible.

Currently, there are only two treatment options available for NPC — radiotherapy (high-energy rays used to kill cancer cells) and chemotherapy (cancer-killing drugs).

These treatments are usually tailored to what stage the cancer is presented in. Patients diagnosed at Stages 1 to 3 will receive both radiotherapy and chemotherapy but Stage 4 patients may only receive chemotherapy as palliative care due to the severity.

While it is clear that time is of the essence in successfully treating NPC, Dr Yu lamented there are still many patients who actively

delay their recommended treatments because they are too fearful of the side effects and may get roped into first attempting alternative treatments that capitalise on this fear, contributing to higher mortality rates.

“Yes, we do know that radiotherapy gives a lot of negative effects in that part of the body (nasopharynx), such as skin rashes, mouth ulcers, painful swallowing, skin fibrosis, reduced hearing and dry mouth.

“However, most of these side effects are short term and resolved within three months of treatment completion.

“And with our newer intensity modulated radiotherapy (IMRT) treatment, these side effects are reduced even more, so treatment really shouldn’t be too much of a fear,” he said.

Dr Yu said the fear of treatment isn’t the biggest issue but rather the trust that people would place on alternative treatments such as so-called ‘cancer curing’ supplements that some direct sellers are peddling.

“In recent years, we have seen more and more cases of NPC being diagnosed in the early stages, but these patients have been told over and over by those marketing alternative treatments that radiotherapy and chemotherapy have a lot of side effects and are instead encouraging them to consider alternative treatments first.

“This causes patients to allow their cancer to progress to an advanced stage before seeing us, and for advanced stages, especially for NPC, we really cannot do much other than offer palliative care to ease some of the symptoms.

“Eventually, the patient will succumb to the disease and these alternative treatment sellers will twist these numbers against us to show that radiotherapy and chemotherapy are not effective and have caused the patient to die,” Dr Yu said.

While it is a sad situation, Dr Yu is hopeful the things will improve as more awareness is brought into the subject of cancer, allowing more patients to choose medically approved treatments over the alternative treatments that have not been recognised to be effective and safe cancer treatments.

“If the manufacturers of such treatments are able to produce enough data to prove that their products do indeed work, they can register their product as an approved drug with our Ministry of Health or US Food and Drug Administration (FDA).

“They can sell in bulk to all hospitals and pharmacies and we will be the promoters for you, so please reconsider if are you faced with such a situation,” added Dr Yu.

Dr Yu Kong Leong

Dr Yu Kong Leong

After graduating from medical school in 2001, Dr Yu was already interested in the field of oncology due to a strong family background in cancer.

His ambition to become an oncologist was later solidified when he was posted to SGH’s RTU in 2002 where he developed a passion in oncology care and sought to help cancer patients as much as he could.

Since finishing his specialist training in 2010, he returned to Sarawak where he became head of the RTU in 2013.

During his free time, Dr Yu is an active member of the MOS and regularly participates in cancer awareness programmes around the state as he believes that early detection and treatment are vital in treating cancer.

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