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My fight with Breast Cancer
R. Anuradha
Editor, Publication Division,
Ministry of I & B,
Government of India

Good evening dignitaries, medical experts, care givers, fellow patients and survivors.

At the outset, I thank the Indian Cancer Congress for giving me this opportunity to share my story about my fight with breast cancer.

I am a bilateral breast cancer survivor fighting for the last 15 years. When first detected I was 31, absolutely and happily ignorant about cancer of any kind.

But after the diagnosis, I greedily gathered as much information as possible about the disease. Being a media professional, made it easy for me and I accessed various authentic and most modern sources of information. I educated myself on the latest research, the trials taking place the world over and the best treatment options available. I also took special care to know about the side effects of my ongoing treatments and picked up tips to manage them to make my day-to-day life easier. You should know; I am also a mother of a school-going child.

The information galvanized me, shored up my courage to fight the disease with all my physical and mental strength and helped keep my spirit up during the difficult periods of the treatment. It helped conclude that my latest problem was just another disease with a longer and harsher treatment before I got well and hearty.

In the Breast Cancer Clinic of All India Institute of Medical Sciences, where I would be waiting for my turn, I met more women like me, younger and older. Often these were from far different backgrounds, from modest lower middle class housewives and workers to elite professionals like architects and interior designers. There I started sharing the small tips and simple tricks of personal hygiene, cleanliness, nutritious food habits and emotional issues at the family level.

Regular interactions with them for more than 3 years, way past my time in that waiting room, gave me the satisfaction of sharing beneficial information with them. But I also gained a deep insight into the social, financial and health issues of the common people of the country.

I’ll share one of those tales.

This is the story of Sarita Chugh, a 40 plus, good-looking primary school teacher, married to an engineer. After her mastectomy her husband found her physically repulsive. Sarita told me that her husband told her he is not used to playing with “broken toys”. A heart-broken Sarita found that even her parents would not want her over and, eventually, decided to stay with an abusive husband for material support.

In our country, breasts are seen primarily as sexual organs and talking about sex is taboo. Most men forget that their mother’s breast was their first font of nutrition.

Women’s health and happiness is the last priority of the regular, average Indian family. This has spawned a generation of women who generally don’t talk about their illness unless it interferes in their daily chores, especially if it involved sexual organs.

After my first battle with cancer, I wanted to spread whatever experience and knowledge I gained about breast cancer. For me, the easy and long-lasting way was to write it all out. My experiences with the diagnosis and treatments mixed with the rich and varied experiences of other patients’ stories formed the core of a book in Hindi I wrote. It is called – इंद्रधनुष के पीछे-पीछे: एक कैंसर विजेता की डायरी , published in 2005. It translates as- Following The Rainbow: Diary of a cancer Survivor. The book has seen several editions. It has been published in Gujarati and I am working on its English translation.

All these years, I have also been writing about the scientific and social aspects of cancer in leading Hindi publications and speaking on TV and radio. I also participate as a survivor speaker in public awareness camps and lectures on cancer.

I also run the first Hindi blog on cancer. It is called INDRADHANUSH, the Hindi word for rainbow. While still busily occupied with all these activities, about 19 months ago, I was diagnosed as a Stage 4 breast cancer patient. Once merrily happy that I was free of the disease, I was told Cancer was living in me and growing. I am now LIVING WITH CANCER. From the bones, the disease has now spread to the lungs and skin.

ODDLY ENOUGH, more than 70 per cent of INDIAN breast cancer patients reach the hospital at advanced stage when the chances of getting rid of the disease for long periods are very slim. I think there is so much to do for metastatic cancer patients.

Some-how struggling to lead a regular life, they may not be as productive as they were, but as human beings they need extra care... More targeted therapies, affordable treatment options, information about new trials, better pain-management and more compassionate hospital care.

I wish to re-iterate that a systematic, well planned introduction of pain-management regimen is very critical in metastatic cancer patients’ treatment.

Now, I am someone who will always be in-treatment, because I am on the wrong side of the disease. But I remain a self-willed individual, as I always was. I look for more understanding from my oncologists, seeking for treatments that keep the quality of my life as high as possible with minimum side effects.

While my live-in relationship with cancer goes on, I want to use this rare and grand opportunity when I am being heard by the who’s-who of oncology and cancer care at ICC. I request you to use your good offices to collectively impress upon policy makers to introduce cancer as a topic for students at the high school level.

Children should be systematically introduced to the basics of cancer, HPV, cervical cancer, breast self examination, oral cancer, tobacco, pan masala, environment and other related aspects.

I want my own 17-year-old child to learn it in time, along with his classmates, from school, not ONLY from home.

Thank you all for listening to me.

Anuradha

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My regained identity

What can breast cancer do to your life?? I could never have guessed until I got it myself. My first cousin had gone through it but at that time I didn’t realize how bad it could be. Then, after a year I found myself in her shoes. Angela was really concerned and discussed lots of issues with me. When she came to India next, she accompanied me for my chemo, got prosthesis for me and also brought nice bras. Surprisingly use of prostheses and possibility of reconstruction had not been discussed by my doctors. So with my knowledge and the hard time I was having coping with mastectomy - voila! For the first time I was able to wear bras with pocket for prosthesis. I had started feeling complete to some extent. Now I didn’t mind the loss of a breast that much. Sometimes I even liked the touch of my flat breast as it felt so new, so soft and different. I could feel the touch deep inside me. I was in the process of re-discovering my own body.

After discussions with Angela I realized that since my surgery, I had hardly shared my thoughts with anyone. I had never spoken about my loss, grief and the hatred born in my mind for my body with anyone. I would only shed tears of frustration in the privacy of my room. How did my teen age daughter feel about her mom having just one breast? How did my mother cope with the trauma of her daughter going through such a rough phase? Hundreds of questions haunted me day and night, while I did not have answer to any. We, in India, are not that frank with each other to speak about such matters openly. Sometimes I couldn’t believe my breast had actually been removed and I would never get it back. Terrible thoughts crossed my mind one after the other. I found it very difficult to sit alone in a room. I passed many sleepless nights. Many a times I would wake up startled. But when I closed my eyes, I would see cancer cells mocking me. I grieved more and more. I hated the sight of lingeree stores. Would I never be able to wear good bras? Was I turning insane? Though I put a brave front in front of others I could no longer be my normal self. That was when I decide to go for reconstruction.

When I discussed this with my sister and mom, they were dead against another surgery because there were many social issues involved. Moreover, they didn’t want me to suffer the after effects of another surgery. We simply could not come to the same frequency of thoughts. I was ‘supposed to’ listen to them and agree with what they thought was right. My heart gave in while my mind did not. To this date I cannot understand why women in India are so backward when it comes to taking decision for their own bodies? I started feeling guilty for not being able to adjust or agree with them. At 47 years of age, was I not old enough to make my own decision?

Again Angela was the one I could relate to and discuss my options with. She had already completed a reconstruction and was very happy about it. But hers was done in UK so it was flawless, without any remains of scars. Finally, when I had made my decision I was advised to wait for two years from the date of surgery. This seemed a really long time as I was in a hurry to get done with reconstruction, anyways I started reading and preparing myself for the same.

There are mainly two types of reconstruction: Implant Procedures and Tissue Flap Procedures. My cosmetic surgeon, Dr Vipul Sud, advised me to go for Lattisimus Dorsi Flap, in which muscles from the back are pulled in front to form the breast mound. The pain after surgery was unbearable. When the bandages were opened I could not get used to the new breast. I felt heavy on the left side and sagging on the right. I felt uneasy and could not balance my body. The stitches took long to heal so I had to wear loose clothes. It took nearly one year to reach a stage of harmony between the two boobs.

International Conferences have changed me entirely. I am amazed and thrilled with the openness of thoughts and words of women from western Countries. These conferences have given me new confidence and have taught me a lot about breast cancer survivors. I have seen that we all undergo similar emotional downfalls, no matter which Nation we belong to. Now I also know that I was never wrong in my thoughts and sorrows.

After 3 years of reconstruction, I am glad and proud of my decision taken against all odds. I can now wear nice swimwear, sexy bras and even look younger than my actual age. I am relieved of all nightmares as well as lopsidedness. I can now step into a lingaree shop without a sigh of self pity. I must admit, I now have more lingeree than ever, neither do I hesitate to buy one when I feel like it. My new boob definitely deserves an extra bra once in a while for giving me this new identity.

In June 2011 I met Pam at the 6th WCBCF, Hamilton, Ontario. I attended her session on breast massage and was amazed to see the ease of her strokes. I learnt the right way of breast massage. Since that day I have been massaging regularly once or twice a day. I suppose the itching and pain inside the breast and on the stitches come as a ‘free gift’ after reconstruction. I must admit that breast massage technique learnt from Pam has helped me a lot. The right oil / cream and the right method of breast massage regulate the lymph in the right direction, and are highly soothing for muscles and nerves. Though I am always in a hurry and never seem to find enough time for self massage, I guess even a few minutes of self touch can do wonders to your body and soul! Hats off to Pam for her good work !!!

By: Dr Rita Banik
Coordinator for Development and Welfare of Girls and Counselor Women's Cell,
Pd Deendayal Petroleum University Raisan, Gandhinagar Gujarat
Phone: 079 23275066 079 23245001

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Role Of Cancer Markers In Cancer Detection

Pathology Investigations are playing increasingly important role in detection and monitoring of various cancers such as Colonic cancer, Breast Cancer, Ovarian cancer, Liver cancer, Prostate cancer and Pancreatic cancer. These tests have to be performed only on clinician's advice and their interpretation is always done in conjunction with the overall clinical picture of the patient. They are simple noninvasive blood tests, which give extremely useful information about progression of cancer as well as early detection. Tumour Markers are used to monitor effect of therapy or recurrence of lesion, to follow the clinical course, or to pinpoint the tissue of origin. They are also useful to assess the extent of tumour and to estimate prognosis.

CEA:(Carcinoembryonlc Antigen)-For Intestinal Cancer

CEA is primarily used to monitor persistent, metastatic, or recurrent cancer of colon after surgery. CEA is the glycoprotein. CEA has significant value in monitoring of patients with diagnosed malignancies. Persistently elevated levels that are 5 to 10 times the upper limit strongly suggest presence of colon cancer. After successful therapy the levels decline. CEA should decrease to normal in 6-12 weeks after complete resection of colon. Declining CEA values have favorable prognosis. Determining prognosis in patients with colon carcinoma. Rising levels indicate recurrence of disease. CEA levels are .not recommended for screening procedure to detect cancer in general population.

CA 125: For Ovarian Cancer

CA 125 is a tumour marker for ovarian and endometrial carcinomas. It also increases in non-malignant conditions like endometriosis and pregnancy. It is a glycoprotein derived from coelomic epithelium; increased in benign or malignant conditions that stimulate peritoneal synthesis. It is used to monitor persistent or recurrent serous carcinoma of ovary in postoperative period or during chemotherapy. CA 125 level can decrease after the therapy and increase in relapse, residual disease and in metastasis. Interpretation of CA 125 result should be made taking into consideration the patient history and any other test result.

CA-19-9: For Pancreatic Cancer

CA 19.9 is the marker for both colorectal and pancreatic carcinoma. It is also increased in Hepatobiliary cancer. Very high concentrations predict surgically unresectable cancer. Elevated levels may indicate development of cholangiocarcinoma in patients with primary sclerosing cholangitis. Constant elevation of CA 19.9 reflects evolution of tumour and a poor response to therapy. A decrease in CA 19.9 assay value indicates positive response.

CA 15-3:For Breast Cancer

CA 15-3 is an aid in monitoring the disease status and disease progression of breast cancer. CA 15-3 should always be used in conjunction with other clinical methods for diagnosis and monitoring of breast conditions. It is a glycoprotein expressed on various adenocarcinomas, especially breast. It is also useful to detect breast tumour recurrence before symptoms appear and to monitor response to treatment. Elevated CA 15-3 values are also encountered in nonmalignant conditions like cirrhosis, hepatitis, benign diseases of ovary and breast. CA 15-3 values are not elevated in normal individuals.

AFP: For Liver Cancer and Germ cell Tumours of Testis and l Ovaries

AFP is oncofetal protein (glycoprotein), which is synthesized in fetal liver, yolk sac, which disappears in weeks following birth.    AFP elevation is typically found in individuals in several malignant conditions most notably in testicular carcinomas, primary hepatocellular carcinomas. It is a tumour marker for hepatoma, germ cell tumour of ovary and testis, teratoblastoma and yolk sac tumour. It is used for screening fetal defects during pregnancy. Changes in concentration can indicate effects of chemotherapy. In patients with clinical remission the AFP levels gradually decrease. AFP testing is not recommended as a screening procedure to detect cancer in general population.      

PSA:(Prostate specific antigen): For Prostate Cancer

Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland into seminal fluid: The PSA test measures the level of PSA in the blood. PSA is simple, safe and noninvasive test for early detection. It is normal for men to have low levels of PSA in their blood; however, prostate cancer or benign conditions can increase PSA levels. Clinical significance of PSA Levels: Increased levels of PSA may suggest the presence of prostate cancer. However, prostate cancer can also be present in the complete absence of an elevated PSA level, in which case the test result would be a false negative. PSA levels can be also elevated due to prostate infection, irritation, benign prostatic hypertrophy (enlargement) or hyperplasia (BPH) or recent ejaculation.

PSA also has a significant value in detecting metastatic or pre-existent disease in patients following surgical or medical treatment of prostate cancer. PSA test is widely accepted as an adjunct in the management of prostate cancer. A small amount of PSA is not protein bound and is called free PSA. Percentage of free PSA is lower in patients having prostate cancer than benign disease. In men with prostate cancer the ratio of free PSA to total PSA is decreased. The risk of cancer increases if the free to total ratio is less than 25%. The lower the ratio the greater the probability of prostate cancer. Measuring the ratio of free to total PSA appears to be particularly promising for eliminating unnecessary biopsies in men with PSA levels between 4 and 10 ng/mL.

By:Dr.Avinash A Phadke
Director of Wellspring Path labs,
Udyam, Ranade Rd, Shivaji Park, Dadar, Mumbal-28
Ph:24469250,24450283

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My Fight Against Cancer (The story of my father Pragji Dossa who had Cancer twice)- by Madhavsinh Dossa (Click to view detailed bio-data)

CANCER DOES NOT MEAN CANCEL. Certainly not today when there are so many medical advances and discoveries, miraculous remedies to achieve victory over this dreadful disease and prolong the life of a person afflicted with it. 

I am writing this article about my respected father, late Shri PRAGJI DOSSA, (Born: 07-10-1907) an author, journalist, playwright, film writer, TV writer; radio plays writer, musician, singer and also sports-man, who suffered cancer twice: first in 1976-77, at the age of 70 and again at the old age of 83. Both times, he faced this disease bravely with undaunted spirit and courage. His larynx (voice box) was removed in 1977 following major surgery in Tata Memorial Hospital to remove a cancerous growth in his throat. In spite of this handicap, he continued to make his voice heard by millions all over the world through his   prolific pen. At the time of his laryngectomy operation in April 1977, he was a lecturer in I.N.T.’s   Children’s Wing and also in two other institutions. Being a singer himself, he had also studied Indian Classical Music as a pupil of Sangeet Samrat Pandit Omkarnathji Thakur. At that time he was writing a history of the Gujarati stage from the year 1852, besides writing stories, dialogues and screenplays of  feature films. On the third day after his operation, with the permission of his doctor, he started writing again. 

He also underwent plastic surgery twice on his neck as the skin had become dead due to the after effects of Cobalt Radiation. For this purpose, a piece of skin 6” x 2” in size was removed from his arm to be grafted on his neck as required. 

Two months later, he was awarded A.I.R. Akashwani Golden Jubilee Memento presented by then Prime Minister of India, Shri Morarji Desai. My father Shri PRAGJIBHAI was personally present in Akashwani Auditorium with bandage to receive this award on stage from Shri Morarji Desai. This was followed by five more awards and honours in the years 1978, 1979 and 1980; Gujarat Rajya Sangeet Nritya Natak Akedemy Award, Gold Medal and Tamrapatra presented by then Chief Minister of Gujarat, Shri Babubhai J. Patel in 1980 and his appointment as Special Executive Magistrate, Maharashtra State for 1980-1983. 

The death of my mother in July, 1982 was a severe blow which he had to accept as God’s will. 

My father continued with his writings from 3.45 in the morning, leading a disciplined life regularly practicing meditation and yoga. 

On his 75th birthday, in recognition of his great services and contributions in the field of Drama, Literature, Children’s Theatre, Films, Music and Radio, he received messages of goodwill and felicitations from then Chief Minister of Gujarat, Shri Madhavsinh Solanki and also from France, Germany, London, Czechoslovakia and East Africa. He also received a letter from Washington, DC informing him that on this special occasion, a flag of the United States was flown over the capitol in his honour. This flag was subsequently sent to him with a certificate and picture of it flying over the capitol.  In November 1982, immediately after his 75th birthday, my father was also felicitated and honoured on the occasion of release of his book "Takhto bole Chhe - part 2" by the Chief Guest reputed classical Bharat Natyam dancer Smt. Mrinalini Sarabhai along with other dignitaries, chief among whom were Film Producer & Director Shri. Vijay Bhatt, famous Test Cricketer Shri. Vijay Merchant, PujyaPad Shri. Mukundraiji Goswami, Managing Editors of leading Gujarati Newspapers & many other artistes

 

This was immediately followed by the Soviet Land Nehru Award and Gold Medal presented to him by Shri Rajiv Gandhi in 1983. It is ironic that he had received this prestigious award earlier in 1966 from then Prime Minister, Smt. Indira Gandhi.

 

 

He was given four more Awards and Honours from 1985 to 1989 by Chief Ministers of Maharashtra, namely, Shri Shivajirao Patil Nilangekar in 1985 and Shri Shankarrao B. Chavan in 1987 during the release of writer Pragji Dossa's book 'Nayika Bhed' by him (5th June, 1987). (Photograph of Shri S. B. Chavan honouring Pragji Dossa to be shown here).

Fate plays a prominent and unpredictable part in one’s life. In February 1990, during an investigation for enlargement of prostate, his biopsy revealed Adenocarcinoma. The cancer had struck him again. After a month, he was operated upon for the removal of the prostate. Though physically he was not strong and stout, mentally he was made of sterner stuff. Fate tested his strength very often but he was not to be cowed down. He possessed tremendous stamina and will power. In spite of having suffered cancer twice, a physically handicapped old and infirm person who had earlier lost his voice, fighting against all odds, trying to maintain himself, he continued to write and received five more awards and honours. 

My father who being appointed on the Western Regional Advisory Board of Soviet Land Nehru awards committee for Gujarati language from the year 1970 continued to serve even after cancer till the year 1982.

He was also selected :
As member of script panel of National Film Development Corporation since 1990.
On the panel of jury for Kabir Samman award for 1991-92.
On the panel of jury for Lata Mangeshkar Purashkar for 1992-93.

He was appointed as one of the judges for Filmfare awards for best story in 1989 and for best screenplay in 1992, along with well known film maker, Shri B.R.Chopra. When he read my father’s bio-data, he was impressed by my father’s multi-faceted literary adventures and his achievements in so many fields. He wrote a wonderful letter to my father, which is treasured by our family today.

My father wrote 26 episodes of the T.V. serial “Savitri” in 1990-1991 for Smt. Hema Malini. He also wrote for T.V. serial “MAA (Adyashakti Bhuvaneshwari)” which was telecast on Zee T.V. in 1995. Many a times he had been interviewed on television when he spoke with the help of electronic larynx machine. As he had been interviewed for Akashwani for one-hour audio recording for Bombay Archives, so also even after his cancer operation, he was interviewed by the N.C.P.A. for one hour video recording for National Archives in March 1992. 

Only the patient knows how much a laryngeal cancer victim has to suffer even after a successful laryngectomy operation. On several occasions, my father had accumulation of phlegm in his wind-pipe and could not breathe properly. We had to rush him to Jaslok Hospital to alleviate the suffocation with the aid of suction machine. Dr. R.S.Rao who operated my father for Larynx Cancer in Tata Memorial Hospital in 1977 always took great personal care during his post-operative quarterly, half-yearly and later, yearly check-ups and also during emergencies. In spite of all these physical sufferings, he was active with new literary creations in various fields till his very last, whether it be Dramas, Plays, Radio Plays, Children’s Theatre & Plays for Children, Journalism, Novels, Films, T.V.Serials, Music, taking Interviews of Eminent Great Personalities or being interviewed by others. This, he always said, kept his mind and soul very active and energetic. 

In February 1996, his oesophagus (food-pipe) became constricted with the result that the food he ate was not able to pass through it. Even liquids like milk, tea and soups could only pass through drop by drop, resulting in it coming out by way of mouth or even nose. Ultimately in June 1996, he underwent endoscopic oesophageal dilatation operation. The food-pipe was widened a bit, since on account of his old age, the risk of fully widening it could not be undertaken. But within three months, the same problem started again, hence in October 1996 the same operation was performed. The surgeon informed my father that in case the trouble persisted, this operation could not be carried out again as there was a risk of the food-pipe rupturing. Thereafter, eating even half a chapati took him one to one and a half hours. His weight was reduced from 55 kg to 39 kg.   

In spite of this, his writings continued as usual much before sunrise. On 18th December, 1996, he was honoured with the prestigious Sangeet Natak Akademi Award for playwriting for 1995, presented to him by then President of India, Dr. Shankar Dayal Sharma at Rashtrapati Bhavan, in New Delhi. Even with his frail and weak body, at the very old age of 89 he showed great stamina and will power, travelling to New Delhi in cold and wintry weather to receive the award. It was a moving sight to see him slowly walking with the support of a stick in the Durbar Hall of Rashtrapati Bhavan. Thereafter, several associations paid tribute to  him on his receipt of this very prestigious award and honour.   

As fate would have it, on 15th August, 1997, while walking at home in the early morning, he lost his balance and fell down and fractured his right hip-bone. He was admitted to Bhatia General Hospital, where in spite of his pain, he insisted on carrying all his writing material. Through all the tests and intense pain he always mainatained a smiling face. He was operated on 19th August, but his heart gave way on the morning of 20th and he collapsed in the Intensive Care Unit. All efforts by the doctors and nurses to resuscitate and revive his heart were of no avail. 

At this time, he was working on “Bal-Pratibha”, on the lives of great men and women during their childhood. He had earlier written such stories for Mumbai Samachar. He told me that he wanted to write on this subject as he knew of many leaders whose childhood had been equally brilliant and noteworthy. 

Subsequently, V-Care Foundation gave him the “Victor Award” for deserving cancer patients who have faced the hardships and hazards of life after being afflicted with cancer bravely, posthumously on 14th February, 1998 for being “a source of inspiration and hope to cancer victims during a span of 20 years after suffering cancer through his immense courage, resilience and strength in his victory over cancer.” 

Pragji Dossa’s Creations after Suffering from Cancer:

138 Children’s Plays,   78   Full Length Plays,  14   Films - Story, Screenplay, Dialogues,  140 Radio Programmes, 130 T.V. Programmes, more than 1500 Articles in various Magazines and Newspapers,    26 Books more published.

Wrote Story, Screenplay, and/or Dialogues for Mythological Subjects - Maa Adyashakti Bhuvaneshwari, Durga, Savitri, Shiv Mahapuran, Narad etc. for Film and T.V. Producers.

9.      Interviews  of  several  eminent  famous  personalities  in  different  fields  taken and Published.

Operated on for larynx cancer on 01 – 04 – 1977:

Photographs in this article:

  1. Pragji Dossa speaking with help of electronic larynx machine.

  2. Pragji Dossa receiving Soviet Land Nehru award and gold medal presented to him by Shri Rajiv Gandhi, at Mavlankar Hall, New Delhi on 14 – 11 –1983.

  3. Film actresses Hema Malini and Dina Pathak with producer Jayesh Gokani, set-designer Paresh Daru and writer Pragji Dossa on the sets of his two children’s plays, “Choti Chatur” and “Dadano Dangoro” on 15 – 07 –1990.

  4. Film actress Asha Parekh with Pragji Dossa on the sets of his children’s play “Tagad-Dhinna” on 02 – 07 – 1988.

  5. Pragji Dossa receiving Sangeet Natak Akademy award and tamrapatra for playwriting for the year 1995 presented to him by the President of India, Dr. Shankar Dayal Sharma at Rashtrapati Bhavan, New Delhi on 18 – 12 – 1996.

  6. Pragji Dossa being felicititated & honoured by the Chief Guest, reputed classical Bharat Natyam dancer Smt. Mrinalini Sarabhai on the occasion of release of his book "Takhto Bole Chhe - 2" by her. November, 1982.
  7. Pragji Dossa being felicititated & honoured by Shri Shankarrao B. Chavan, Chief Minister Of Maharashtra during the release of Pragji Dossa's book 'Nayika Bhed' by him on 05-06-1987.
  8. Pragji Dossa lighting a lamp at The Film Writers Association's Annual General Meeting 1996-97.

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Colorectal Cancer Research from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, or PLCO, is a large-scale clinical trial to determine whether certain cancer screening tests reduce death from cancer. In the PLCO Trial, researchers are testing flexible sigmoidoscopy. During a sigmoidoscopy, a thin, lighted viewing instrument is inserted into the rectum to examine the left, or distal, portion of the colorectum.
The detection rate of colorectal cancer in subjects undergoing screening in one study was 1.8 per 1,000 in women and 3.8 per 1,000 in men, while the detection rate for advanced adenomas (pre-cancerous polyps) was 23 per 1,000 in women and 43 per 1,000 in men.

The PLCO is testing the effectiveness of early prostate, lung, colorectal, and ovarian cancer detection using the following tests: digital rectal examination and blood prostate-specific antigen (PSA) testing for prostate cancer; chest X-ray for lung cancer; flexible sigmoidoscopy for colorectal cancer; and transvaginal ultrasound and the blood cancer antigen, CA-125, for ovarian cancer. Screening for cancer may enable doctors to discover and successfully treat the disease earlier, thus preventing deaths. Numerous epidemiologic and other studies are also part of this research.

Sponsored and run by the National Cancer Institute's (NCI) Division of Cancer Prevention, the PLCO trial is taking place at 10 screening centers across the United States: Birmingham, Ala.; Denver, Colo.; Washington, D.C.; Honolulu, Hawaii; Detroit, Mich.; Minneapolis, Minn.; St. Louis, Mo.; Pittsburgh, Pa.; Salt Lake City, Utah; and Marshfield, Wis. Between 1993, when the trial opened, and 2001, when enrollment completed, a total of 154,942 women and men between the ages of 55 and 74 joined PLCO. Screening of participants will continue until 2006. Additional follow-up will continue for at least 10 more years to determine the benefits or harms of the cancer screening exams being studied.

The PLCO trial also includes research on the genetic and environmental causes of cancer (prostate, lung, colorectal, ovarian and other types of cancer) and studies of new methods for the early detection of cancer, in collaboration with the NCI's Division of Cancer Epidemiology and Genetics. Together, prostate, lung, colorectal, and ovarian cancers account for 42 percent of all diagnosed cancers in the United States and nearly half of all cancer deaths (47 percent). An estimated 266,360 people will die of prostate, lung, colorectal and ovarian cancer in this country in 2005.

Colorectal cancer is the third most commonly diagnosed cancer among both men and women in the United States. Family history of the disease and a personal history of inflammatory bowel disease or polyps are factors known to increase a person's risk of colorectal cancer. A diet high in fat and low in dietary fiber also may increase a person's risk. The colon and rectum are the lowest portion of the digestive system. The colon is the last five or six feet of the intestine and the rectum is the last eight to ten inches of the colon. Because the areas are connected, cancer researchers often report this as a single type of cancer. In the PLCO trial, researchers are testing flexible sigmoidoscopy. During a sigmoidoscopy, a thin, lighted viewing instrument is inserted into the rectum to examine the left, or distal, portion of the colorectum. PLCO Subjects with a polyp or mass noted on sigmoidoscopy are often referred for further examination with colonoscopy, a procedure that examines the entire colorectum.

Patient Population, Trial Design, and Data Collection
The PLCO is a randomized, controlled trial in which 154,942 persons ages 55 to 74 at entry are randomly assigned to two study arms: half to undergo cancer screening (intervention group) and half to continue their normal health care routine (control group). Both groups answer yearly questionnaires about their health and give biologic samples (blood and tissue) for studies of cancer causes and of early markers for cancer (biomarkers). The sigmoidoscopy exam is offered twice--at the initial visit and at either the third or fifth annual visit, depending when the participant enrolled in PLCO. With the completion of enrollment and screening, researchers continue to follow participants in both groups for at least 13 years from the time they enrolled.

Results/Publications
The following PLCO analyses regarding colorectal cancer have been published, with the most recent studies listed first:

Screening and Related Clinical Studies
The PLCO trial offers a unique opportunity to examine the effectiveness of screening flexible sigmoidoscopy in a large, diverse population. Results from the initial screening and 12 months of follow-up were comparable to other studies.

Of 77,465 subjects randomized to the screening arm, 64,658 (83 percent) received the baseline flexible sigmoidoscopy exam. A total of 18 percent of women and 28 percent of men were found to have a positive screen (i.e., a lesion or mass reported). The detection rate of colorectal cancer in subjects undergoing screening was 1.8 per 1,000 in women and 3.8 per 1,000 in men, while the detection rate for advanced adenomas (pre-cancerous polyps) was 23 per 1,000 in women and 43 per 1,000 in men. Because of the large size of the study population, the broad geographic representation, and the follow-up criteria, the results of the PLCO trial will offer a benchmark for screening flexible sigmoidoscopy in the United States. Repeat screening flexible sigmoidoscopy three years after a negative exam will detect abnormalities or masses in the lower portion of the colon.

The PLCO trial is evaluating the effect of flexible sigmoidoscopy (FSG) on colorectal cancer mortality. The trial screened the intervention group upon entry to the study and then in three years. Individuals included in this analysis had an initial FSG that showed no abnormalities or masses and then underwent a screening FSG three years later. Of the 11,583 individuals without an abnormality or mass on initial FSG, 9,317 (80.4 percent) returned for repeat screening after three years. Of the people who returned, 1,292 (13.9 percetn) had a polyp or mass detected. Of those with a polyp or mass, 951 (73.6 percent) went on to have follow-up screening, colonoscopy or repeat FSG. In the distal colon, 292 (3.1 percent) were found to have an adenoma (a pre-cancerous polyp) and 78 (0.8 percent) were found to have either an advanced adenoma or cancer.

Data from the second screening for participants in the PLCO trial determined that excellent adherence to repeat screening with flexible sigmoidoscopy could be achieved. However, gender may impact adherence to repeat screening, with women less likely to return for follow-up screening. This study was comprised of 10,164 patients from the PLCO screening trial who had a negative/normal initial screen. These patients were scheduled for repeat flexible sigmoidoscopy three years after the initial screening. Almost 87 percent of eligible patients returned for repeat screening.

Measures of nonadherence with repeat sigmoidoscopy varied significantly according to gender. Compared with men, women missed the year-three clinic almost two times more often than men, and women who attended the year-three clinic refused repeat sigmoidoscopy more than two times more often than men.

Overall, patients' thoughts are similar and positive for both CT colonography (virtual colonoscopy) and traditional colonoscopy, with less favorable thoughts about bowel preparation. Most patients state that they would prefer virtual colonoscopy for future evaluation. A newer examination for detection of colorectal abnormalities is CT colonography, or "virtual colonoscopy." Computer-simulated three-dimensional images are used to examine the mucosal surface of the colon and a two-dimensional view is used to visualize the structure of the colon. This non-invasive alternative offers several advantages to the patient over colonoscopy: no need for sedation or monitoring of vital signs and no recovery period. Disadvantages are that the conventional bowel preparation program is still needed and that the insufflation (blowing gas into the colon to enlarge the area) is uncomfortable.

A total of 120 patients were recruited for this study. The patients who were included had an increased risk of colorectal abnormalities, due to; suspected polyps, rectal bleeding, blood in the stool, history of prior polyps, or a family or personal history of colorectal cancer. These patients received virtual colonoscopy followed by a traditional colonoscopy on the same day.
The study showed that for both virtual colonoscopy and traditional colonoscopy, patients' thoughts after the procedure were more favorable than what was expected. Patients expressed more favorable thoughts about colonoscopy for pain and embarrassment with most responses being "none" to "a little" for both exams. Overall appraisals of the tests were favorable and similar between colonoscopy and virtual colonoscopy. Patients mainly expressed "not unpleasant" to "a little unpleasant." Overall appraisal of the bowel preparation was the most negative.

Subjects who have undergone screening flexible sigmoidoscopy (FSG) and were found to have non-advanced adenomas (pre-cancerous polyps) in the lower portion of the colon have a similar risk for advanced abnormalities in the upper portion of the colon as subjects with no adenomas in the lower colon. Subjects with advanced adenomas in the lower colon, however, are at an increased risk. Patients found to have these abnormalities were referred for a colonoscopy to examine the upper portion of the colon.

Sigmoidoscopy is used to view the lower (distal) portion of the colon. When physicians find an abnormality in this area, studies have suggested that it is predictive of abnormalities in the upper (proximal) portion of the colon. Therefore, these patients are referred for a colonoscopy which is able to view the entire colon. A total of 8,802 patients underwent a full colonoscopy within one year of an abnormal baseline flexible sigmoidoscopy in PLCO, with two-thirds of those patients having a follow-up colonoscopy within three months. Subjects with advanced adenomas in the distal colon were found to be at increased risk for having advanced adenomas in the proximal colon; however, subjects with only non-advanced distal adenomas were not at increased risk for advanced proximal adenomas. Specifically, 12 percent of subjects with advanced distal adenomas, 4 percent of subjects with (only) non-advanced distal adenomas, and 4 percent of subjects with no distal adenomas were found to have advanced proximal adenomas.

In a group of patients who were found to have many polyps, radiologists were in agreement that virtual colonoscopy and traditional colonoscopy identified the same problems. The evaluation of computed virtual colonoscopy as a non-invasive examination of the colon continues to face new challenges. Early estimates of the diagnostic performance of virtual colonoscopy have been promising but variable.

The purpose of this study was to evaluate reader agreement by a radiologist for colorectal polyp detection in a group of patients who had many polyps. This group of patients, who were suspected of having polyps, was first examined with virtual colonoscopy and then traditional colonoscopy the same day. The images were analyzed independently by four experienced radiologists.
A total of 157 colorectal lesions ranging from 4 millimeters to 30 millimeters were found at colonoscopy and correlated with virtual colonoscopy findings. Overall analysis demonstrated a 75 percent agreement among the four readers.

Approximately 70 percent of individuals who undergo screening sigmoidoscopy are satisfied and find the procedure more comfortable than expected, and only 15 percent to 25 percent find the procedure unpleasant. Physicians should not project discomfort to patients as a reason for not requesting screening sigmoidoscopy. Physicians often cite patient discomfort as a reason for not requesting sigmoidoscopy, but patient experiences have not been well-studied. The researchers for this study adapted a survey which was designed to measure satisfaction with screening mammography. Questions about screening using flexible sigmoidoscopy centered on convenience, accessibility, staff interpersonal skills, physical surroundings, perceived technical competence, pain and discomfort, expectations and beliefs, and general satisfaction.

A total of 1,221 patients were surveyed after sigmoidoscopy. The results show that over 93 percent of the participants strongly agreed or agreed that they would be willing to undergo another examination, and 74.9 percent would strongly recommend the procedure to their friends. Regarding pain and discomfort, 76.2 percent strongly agreed or agreed that the examination did not cause a lot of pain, 78.1 percent stated that it did not cause a lot of discomfort, and 68.5 percent thought that it was more comfortable than expected. Fifteen percent to 25 percent of the patients indicated they had a lot of pain, great discomfort, or more discomfort than expected. Women were more likely to have significant pain or discomfort than men.

Among experienced abdominal radiologists using virtual colonoscopy, the ability to find polyps was similar with 2-D and 3-D (two dimensional and three dimensional) display techniques, although individual cases showed improved results with 3-D display techniques. Evaluation of reader agreement (independent radiologists detecting the same abnormalities) demonstrated good agreement for 3-D display, but not as good for 2-D display. Virtual colonoscopy is a rapidly growing and evolving technology for the detection of colorectal polyps and permits viewing with 2-D and 3-D display techniques. This method is being used as a potential noninvasive alternative for the detection of colorectal polyps.

Virtual colonoscopy was performed on 16 patients who were suspected of having polyps at a prior flexible sigmoidoscopy examination or barium enema examination. Three specific 2-D and 3-D display techniques were tested. Three experienced abdominal radiologists independently analyzed each test case and each patient was retested six weeks later. The results of readings 1 and 2 were similar for both 2-D and 3-D techniques among the readers. Overall observer agreement was good for the 3-D display techniques; however, observer agreement for 2-D techniques was lower.

Studies of Cancer Causes
Cigarette use is a risk factor for developing colorectal adenomas. Inherited variation in two genes (NQO1 and CYP1A1), which influence the activation of the cancer-causing substances in tobacco smoke, were found to increase risk for developing colorectal adenomas. In this study, researchers investigated the roles of variations in the CYP1A1 and NQ01 genes, combined with tobacco use, on the development of colorectal adenomas. These genes play a role in activating the cancer-causing substances in tobacco smoke. While tobacco use has been found to be a risk factor for developing colorectal adenomas, the role of these two genes is unclear. For this study, 772 people with at least one advanced adenoma and 777 people with no adenomas completed questionnaires about their lifestyles and had genetic tests done on their blood to determine if they had changes in these two genes.

The researchers found that the risk of having advanced colorectal adenomas was increased in smokers who had a variation in either the CYP1A1 gene or the NQO1 gene, and greatest in those with variations in both genes. In people who did not smoke, these gene variations did not affect their risk for developing colorectal adenomas.

Microsomal epoxide hydrolase (EPHX1) is responsible for breaking down carcinogens in cigarette smoke. Variations in this gene that increase EPHX1 protein activity appeared to increase risk for colorectal adenoma, particularly among recent and current smokers.It is is a protein that breaks down polycyclic aromatic hydrocarbons found in cigarette smoke, which are known to cause cancer. However, in the process of breaking down these carcinogens, EPHX1 creates another carcinogen, benzo(a)pyrene 7,8 dihydrodiol 9,10 epoxide (BPDE).

Researchers looked at two variations in the EPHX1 gene that are thought to affect the level of activity of the EPHX1 protein. They compared 772 people with advanced colorectal adenoma to 777 people without the disease. Detailed information on smoking history was collected from a risk factor questionnaire that participants filled out when they enrolled in the PLCO study. Non-smokers were considered those who did not smoke cigarettes for more than six months or who did not smoke pipes or cigars for more than one year. Current or recent smokers were those who quit less than 10 years before enrollment in the study.

Researchers found that those participants with variations in the EPHX1 gene, which led to higher protein activity, had an increased risk of colorectal adenoma. This was especially true among recent and current smokers.

Even though iron has been suggested as a risk factor for colorectal cancer, there was no relationship found between dietary intake of iron and risk of colorectal adenomas, the precursor condition to colorectal cancer. In addition, genetic variations that increase levels of iron in the blood were not found to be related to adenoma risk. Both iron intake and measures of iron in the blood have been suggested to be related to increases in the risk of colorectal cancer and adenoma. Researchers looked at iron intake and genetic variation in 679 people with advanced colorectal adenoma and 697 controls. Iron intake information was taken from participant responses to a food frequency questionnaire. Researchers found no relationship between iron intake and risk of adenoma.

Variations in the hemochromatosis gene (HFE) affects levels of iron in the blood. Researchers who looked at three different polymorphisms, or variations in this gene, did not find any relationship between the polymorphisms and risk of adenoma.

People who had a high calcium intake, greater than 1200 mg/d (milligrams per day), had reduced risk of colorectal adenoma, a pre-cursor condition to cancer.
Calcium can reduce the risk of colorectal tumors by reducing exposure to harmful compounds in the bowel, or by influencing various cellular activities in the colon, such as cell growth and death. This study compared supplemental and dietary calcium intake of 3,696 people with adenoma to 34,817 controls. Calcium intake information was derived from individual responses on a food frequency questionnaire. Researchers found that people with the highest intakes of calcium had the lowest risk of colorectal adenoma. The association between intake and risk was stronger for calcium from nondairy foods and supplements, and for adenoma of the distal colon, the part of the colon farthest from the stomach.

Variations in the calcium-sensing receptor gene were associated with advanced colorectal adenoma, a precursor condition to cancer. Also, a protective association was found between total calcium intake and advanced colorectal adenoma risk. The calcium-sensing receptor (CASR) is thought to mediate calcium's role in preventing cancer. Researchers looked at three common polymorphisms, or variations, in this gene in 772 people with advanced colorectal adenoma and 777 people without the disease. They found an association between advanced colorectal adenoma and these polymorphisms. This is the first study to evaluate variations in this gene in relation to risk of colorectal adenoma. Therefore, this study contributes new data that show a mediating role of CASR in preventing cancer.

This study also looked at calcium intake by reviewing participants' answers to a food frequency questionnaire which contained questions about dietary calcium intake and supplement use. A protective association was found for total calcium intake. For each additional 1,000 mg of calcium they took, participants had a 21 percent reduction in risk of advanced colorectal adenoma.

The VDR TaqI variation in the vitamin D receptor gene was not associated with risk of advanced colorectal adenoma, a pre-cursor condition to cancer. One vitamin D metabolite, 1,25(OH)2D, was not associated with advanced adenoma risk. Another vitamin D metabolite, 25(OH)D, was inversely associated with advanced adenoma risk in women but not in men. Vitamin D may be involved in the prevention of colorectal cancer, and this action may be mediated by the vitamin D receptor (VDR). Researchers analyzed a polymorphism, or variation in the VDR gene, called VDR TaqI, in 763 people with advanced colorectal adenoma and 774 people without the disease. They found no association between this polymorphism and adenoma.

Researchers also measured blood serum levels of two vitamin D metabolites, 1,25(OH)2D and 25(OH)D, in a subset of 394 cases and 397 controls. They found that serum levels of 1,25(OH)2D were not associated with adenoma risk. However, for the second metabolite, 25(OH)D, researchers found that higher levels were associated with a decreased adenoma risk in women, but not in men. In women, when comparing those in the highest quintile with those in the lowest quintile, the risk of advanced adenoma decreased by 73 percent.

People who had a high level of fiber in their diet were at lower risk of colorectal adenoma, a pre-cursor condition to cancer. The potential impact of dietary fiber on colorectal cancer risk is controversial. Researchers examined fiber intake from food and supplements in 3,591 people with adenoma, and 33,971 people without the disease. They found that risk of adenoma decreased with increasing intake of dietary fiber in both men and women. People in the highest quintile of fiber intake, who consumed approximately 24 more grams of fiber per day than those people in the lowest quintile, had a 27 percent decrease in adenoma risk compared with those in the lowest quintile.

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A Breast Cancer With a Built-In Quandary

Of all the debates surrounding the diagnosis and treatment of breast cancer in recent decades, the most persistent and perplexing one involves a very early cancer called D.C.I.S., or ductal carcinoma in situ. This cancer is noninvasive, confined to the milk duct where it arose. Some of these cancers will eventually become invasive, others never will. In autopsies, about 10 percent of women are found to have a ductal carcinoma that never became evident. Diagnoses of these early cancers have skyrocketed with the growth of screening mammography, breast X-rays done every year or two on presumably healthy women. This year, the American Cancer Society estimates, more than 50,000 women in the United States will be told they have the carcinoma.

About 80 percent of carcinomas in situ are found only on mammograms. They account for 20 to 30 percent of the breast cancers detected by mammography. A D.C.I.S. is usually too small to be felt in an examination by a woman or her doctor. When a mammogram reveals one of these carcinomas, it must be biopsied and the suspicious cells examined microscopically. Biopsy choices include fine-needle aspiration, which removes fluid and tiny bits of breast tissue; core-needle biopsy, which uses a larger needle to remove a cylinder of breast tissue; or surgical biopsy, in which the suspicious area is removed, including, perhaps, some surrounding normal looking tissue.

Then it is up to the pathologist to determine whether cancer is present, and if so, what type of D.C.I.S. it is. There are two main categories, a more aggressive type called comedo, which resembles a blackhead because it contains a core of dead cancer cells, and noncomedo. The comedo type may become an invasive cancer and, thus, less curable in three to five years; the noncomedo type may not progress to invasive cancer for a decade.

After the diagnosis comes the question, ''So what should I do?'' Should a woman have a mastectomy, a lumpectomy with or without radiation therapy, followed perhaps by a cancer-blocking drug like tamoxifen? Should she skip surgery and just take tamoxifen? Or should she do nothing, what doctors call ''watchful waiting,'' because the cancer may never become invasive before she dies of something else?

Until recently, the customary treatment was mastectomy, and there were good reasons for this approach. About 30 percent of women had more than one area of ductal carcinoma in situ in a breast, and in a significant percentage of cases treated with lesser surgery, the cancer recurred in the same breast. After a mastectomy, the recurrence rate is 1 to 2 percent.

Now, however, with improved therapies for early invasive breast cancer that do not involve removal of the entire breast, treatment choices are being debated. So how is a woman to decide? The quandary is similar to that faced by some men found through P.S.A. screening to have an early prostate cancer because it, too, may never become clinically significant. To arrive at a sensible and effective treatment decision, a woman should first know about the varying nature of the carcinomas and where her particular cancer fits along the spectrum from indolent to aggressive. She should take into account factors like her family history, her age and health status, her projected life expectancy and her ability to tolerate various treatment options. There is no emergency in deciding what to do after receiving a diagnosis of the ductal carcinoma. A woman has time to do research, ask questions of one or more physicians and discuss it with family members and with other women who have chosen various courses of treatment.

For example, Margaret in Minneapolis was 70 when a mammogram showed the cancer in one breast. After doing her homework, she decided that a simple mastectomy was her best chance for a lasting cure. She was not keen on undergoing radiation for five days a week over six weeks, which would have been necessary if she had chosen a lumpectomy. Her doctor thought there might be other suspicious areas in her breast that could become cancer if only the one known area was removed. Her husband said he would not find her any less attractive and lovable with one breast. And, given that her mother was still alive in her 90's, Margaret could expect to live decades longer and did not want to have to worry about a recurrence.

Debates abound as to whether some women with the ailment are being treated too aggressively and others not aggressively enough. In 1987, Nancy Reagan learned she had ductal carcinoma in situ. She chose a simple mastectomy. Some advocates for lesser surgery said she set back the movement to make removal of a breast a thing of the past for early cancers. Yet, she, like Margaret, may have had good reasons for her decision. It is not a matter for others to decide, especially when they do not have all the facts.

The final treatment decision depends largely on the the mammogram and the biopsy. A treatment guide from the cancer society states that ''in most cases, a woman can choose between breast-conserving therapy'' (lumpectomy, usually followed by radiation therapy) and simple mastectomy (removal of the entire breast). It is usually not necessary to remove lymph nodes, though the surgeon may choose to do a sentinel node biopsy, removing a few nodes to check for cancer spread.

The guide continues, ''Lumpectomy without radiation therapy is usually considered an option only for women with small areas of low-grade D.C.I.S.'' An eight-year study of 814 women found that radiation after lumpectomy significantly reduced the risk of recurrence. Radiation also greatly reduced the risk of a later invasive cancer.

The guide emphasizes that ''mastectomy may be necessary if the area of D.C.I.S. is very large, if the breast has several areas of D.C.I.S. or if lumpectomy cannot completely remove'' it. Mastectomy may also be the only choice for pregnant women, those with connective tissue disease and those who were previously irradiated in the breast area.

Another fact to consider is that not all carcinomas turn out to be noninvasive once removed. Dr. Monica Morrow of the Lynn Sage Breast Center at Northwestern University reports that 11 to 20 percent of the cases diagnosed with mammography will contain invasive cancer and warrant more definitive treatment, perhaps with a cancer-inhibiting drug taken for several years after surgery and radiation.

The good news is that few women with the ductal carcinoma die of breast cancer, even when it is conservatively treated. In the study that followed women for an average of eight years after lumpectomy with or without radiation, 1.6 percent (14 women out of 814) died of breast cancer. But recurrence rates vary, depending on the treatment, ranging from 1 to 2 percent at 10 years after a mastectomy to 32 percent at 12 years after a lumpectomy alone.

In a recent commentary in Cancer, experts at Rhode Island Hospital in Providence called the definitive treatment for the carcinoma an invasive-cancer preventive, similar to that used to treat polyps in the colon and precancer of the cervix.

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How Breast Cancer Affects Fertility

What there is to know about having a baby when you have breast cancer

More than 11,000 women under 40 are diagnosed with breast cancer in the U.S. each year. Breast cancer can be scary enough without wondering if it will also prevent you from having children. More and more American women are diagnosed with breast cancer in their childbearing years, and many want to know how the disease will affect their fertility. While there's no one-size-fits-all answer to this complex question, this article attempts to answer some tough questions including: What are the risks posed by cancer treatment, methods of preserving fertility, and ways cancer might affect future offspring.

How breast cancer treatment affects fertility depends largely on three factors: the type of treatment used, type and stage of the cancer at diagnosis, and the age of the patient.

Type of treatment

Not all breast cancer treatments affect fertility.

"If a patient needs only surgery and radiation and no chemotherapy, the treatment will have no impact on future fertility," Robert Barbierri, MD, chief of obstetrics and gynecology at Brigham and Women's Hospital in Boston, tells WebMD. The same, however, cannot be said for chemotherapy. Breast cancer patients treated with chemotherapy run the risk of developing premature ovarian failure or very early menopause. Almost four out of five women treated with cyclophosphamide -- an often-prescribed chemotherapy drug for treating breast cancer -- develop ovarian failure, according to Kutluk Oktay, MD, assistant professor of reproductive medicine and obstetrics and gynecology at Cornell's Center for Reproductive Medicine and Infertility. FertileHope, a nonprofit organization dedicated to disseminating education on infertility associated with breast cancer treatment, places the risk at 40% to 80%.

Type and Stage of Cancer

How advanced a cancer is upon detection, as well as what type it is, dictate whether chemotherapy will be required, thereby affecting the risk of side effects to the ovaries.

The more advanced the cancer upon detection, the greater likelihood that chemotherapy, which affects the whole body, will be used to treat it. For instance, invasive breast cancer typically requires systemic chemotherapy, whereas a small tumor with small nodes that is localized and contains a minimal threat of spreading may not. The type of tumor also impacts a patient's treatment options. Some breast cancers can be treated with the use of hormone-containing drugs. But a small percentage of breast cancer tumors are "hormonally insensitive," explains Susan Domcheck, MD, assistant professor of medicine at the University of Pennsylvania. What does this mean? "You can't use hormones to treat them. You're left with chemotherapy as your only option."

Age of Patient

Age plays a big role in patients' future fertility. "The age of the woman at the start of systemic chemotherapy is the biggest predictor of infertility," Barbierri tells WebMD. But why? "If you're 30, your fertility is already declining. Add to that chemotherapy, and you tack on a few more years. We know that chemotherapy induces menopause, particularly with women over 40," Domcheck says.

Preserving Fertility

Despite the fertility risks associated with breast cancer treatment (chemotherapy in particular), methods to preserve fertility prior to treatment offer hope to many patients.

To date, freezing embryos (fertilized eggs) created by in vitro fertilization (IVF) is the most widely used and effective method of preserving fertility. But there are potential downsides. IVF takes three to four weeks, a delay in cancer treatment that, depending on the stage and type of cancer, patients may or may not be able to afford. Sperm -- either from a partner or donor -- must be made available immediately to fertilize the eggs. And IVF is expensive -- anywhere from $10,000 to $14,000 per cycle.

Other methods of fertility preservation, albeit experimental, show promise. Egg freezing, which applies the same concept as embryo freezing, has proven less effective -- most likely because eggs are smaller, and less hardy, than embryos. There's also ovarian suppression during treatment, which "protects ovaries to some degree from chemical onslaught of chemotherapy," Barbierri tells WebMD. Freezing entire strips of ovarian tissue is a third technique under investigation; it involves surgically removing, storing, and later replacing the tissue in another part of the body.

Tamoxifen, a drug traditionally used to prevent breast cancer reoccurrence, was recently found to stimulate ovaries in breast cancer survivors during an IVF cycle, enhancing both egg and embryo production. This extra boost can combat infertility barriers such as age and the diminishing ovarian reserves, which occurs naturally with aging, notes Oktay.

Although males rarely develop breast cancer, it does happen. For male breast cancer patients who must undergo chemotherapy and want to preserve their fertility, freezing sperm is an effective option. "Since there are millions of sperm, even if you kill half in the freezing process, you still have a lot left," Barbierri explains.

Researchers' focus on fine-tuning methods of fertility preservation fuel optimism about its increasing viability. "A decade ago, there was practically no emphasis on fertility preservation. Today, there are several methods and thus a much greater potential," said Oktay.

Conception Concerns: Relapse, Harm to Offspring

For survivors who remain fertile, questions about conception remain. Relapse is one of them.

"A common clinical recommendation is that a survivor wait two years before attempting to become pregnant, since most serious relapses will occur within the first two years after treatment," said Barbierri. "If you wait two years, there's no strong evidence that pregnancy will influence the course of disease."

Survivors also worry that their offspring will be at risk for cancer. According to experts, that risk is small. "Only 5% of breast cancers are truly inherited via a specific genetic mutation. If you have an inherited genetic mutation, you have a 50-50 chance of passing it on to your children." To date, researchers have identified a few genetic mutations that contribute to breast cancer; these include BCRA-1 and BCRA-2.

What is the prognosis for offspring who do inherit one of these genetic mutations? "There does not appear to be an increased risk of childhood cancers. However, these children are at a slightly higher risk for developing ovarian and breast cancers," Domcheck says.

But genetics are only part of the picture.

"It's likely that an interplay between a collection of genes, when added to certain environmental factors, results in breast cancer," Domcheck says. Known environmental risk factors include moderate or heavy drinking (for women, two or more drinks per day), having children later in life, and obesity.

Survivors also question the impact of cancer treatment on future offspring. The news on this front is very encouraging. "There does not seem to be any increased risk of birth defects if the woman who's gone through breast cancer treatment gets pregnant. Even if the woman gets chemotherapy during pregnancy, fetuses do surprisingly well," said Domcheck.

Addressing Fertility With Your Doctor

Absorbing news of a breast cancer diagnosis as well as focusing on how it might affect future fertility can be overwhelming. But because oncologists are trained to provide the best cancer treatment available -- not necessarily in light of fertility options -- patients interested in seeking information on fertility need to be proactive. "A patient needs to say to herself, 'What do I want in the future' and ask the doctor, 'What's this [treatment] going to do with my future plans for fertility?'" says Ann Partridge, MD, MPH, breast oncologist and instructor at Harvard School of Medicine in Boston.

Others agree. "You need to have as much information as possible," says Karen Dow, PhD, RN, professor at University of Central Florida's School of Nursing. She suggests getting a third or even fourth opinion, ideally from doctors in different specialties -- oncology, reproductive endocrinology, gynecology -- since each will bring a unique perspective unique to the table.

"It would be wonderful if, in the future, doctors would all come together to say, 'Hey, here's what's out there, here's what it means to you,'" Dow says. But for now, it's up to the patient to seek information on her options, as early as possible.

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The Breast Cancer Gene: What Should You Do?

Is preventative mastectomy for women with breast cancer mutations a good idea?

Shortly after her mother died of ovarian cancer in 1999, Karen (who asked that her full name not be used) got a call from her first cousin, Joanne. Joanne, a cancer survivor, was in the process of researching their family's cancer history and had discovered that numerous female relatives had died from breast or ovarian cancer. She suggested that Karen consider getting tested for one of the inherited mutations -- called BRCA1 and BRCA2 --, which greatly increases the risk of breast cancer and can also increase the risk of ovarian cancer. If Karen had this genetic mutation, it would mean that she was also at high risk of developing breast cancer.

Karen, now 48, was tested at Memorial Sloan-Kettering Cancer Center in New York City and learned that in fact she did have a mutation on the BRCA1 gene, which means that her lifetime risk of ever developing breast cancer is as high as 80%. Depending on the age of a woman, the risk in the general female population is about 7%-8%. Because the lifetime risk of ovarian cancer is also high (15%-60%) in these women, this, too, was a concern. "Even with my family history, I was shocked to learn that I had the gene mutation, but at the same time I felt lucky because I was the first person in my family who had the chance to do something about it," says Karen. These inherited mutations are responsible for only about 5%-10% of breast cancers.

What to Do?

The question was, what exactly would she do?

Current recommendations for women with this inherited risk include:

  • Being closely monitored by monthly self-breast exams

  • Semiannual breast exams by a health care professional and annual screening mammograms

  • Having ovaries and/or having both breasts removed (these surgeries remove healthy organs to prevent cancer from developing)

While detection methods have come a long way, breast MRIs have been shown in studies to be better at detecting early-stage cancer in high-risk women. Screening tests, such as mammograms, when done regularly, can find cancers at an early stage and lower the risk of dying from breast cancer. But detection of a cancer is not the same as prevention of a cancer.

Bilateral prophylactic mastectomy is preventive surgery and is the only way to dramatically reduce the risk of developing breast cancer. Studies have shown that the procedure cuts the risk by nearly 90%.

In women with the BRCA mutation, preventive surgery to remove the ovaries (prophylactic oophorectomy) is most often done to reduce the risk of ovarian cancer, but it also cuts the risk of breast cancer. By removing the ovaries there are reduced amounts of hormones, such as estrogen, which stimulate breast cancer cells to grow.

Still, removing healthy organs is not a decision women should take lightly.

Instead, they should approach their options in a very practical and rational manner, says Mark E. Robson, MD, director of the Clinical Genetics Service at Memorial Sloan-Kettering. "They weigh the physical and psychological costs of having surgery against the cost of choosing screening and having it fail." A diagnosis of breast cancer is not the only thing women hope to escape; they also want to avoid potentially grueling cancer treatments.

Assuming they're done having children, women generally have an easier time accepting the idea of losing their ovaries than they do their breasts. "Unlike breasts, the ovaries are internal organs, so the psychological impact is less and there is less stigma involved," says Carolyn Kaelin, MD, MPH. Since menopause is inevitable anyway, many women can handle the prospect of it occurring a little sooner. Kaelin is a breast surgeon at the Dana-Farber Cancer Institute and director of The Comprehensive Breast Center at Brigham and Women's Hospital in Boston.

But oophorectomy only reduces the risk of breast cancer by 50%, which isn't all that meaningful if your risk was 80% to begin with -- making prophylactic bilateral mastectomy the surest route to real peace of mind (having both surgical procedures done cuts breast cancer risk by 95% or more).

Making the Surgery Decision

Robson says he's seen a wide variety of motivations among women who opt for this radical approach. Some have watched their mothers or other relatives die from breast cancer and will do anything to escape that experience. Others, particularly younger women, are primarily thinking of their children and wanting to be around for them. For women well past menopause, losing their breasts feels less traumatic than it might have at a younger age.

For Karen, it was a divorce and a new job that forced her hand. In January 2001, shortly after learning her genetic status, she had her ovaries removed, but wasn't able to face also losing her breasts at that time. She was living near Sloan-Kettering Cancer Center, going there every three months for screening, and felt in control of her situation. But when her husband asked for a divorce, it required her to find a new job; she ended up landing one in North Carolina, where getting top-notch cancer care would require a several-hour drive.

"I started seriously considering having the procedure at Sloan-Kettering before I left," said Karen. "I read all kinds of books and studies, talked to doctors and plastic surgeons and other women." In December, she will have both breasts removed, followed by breast reconstruction. "I feel very good about my decision," says Karen, noting that her friends and family have been supportive of her choice -- something that is not always the case.

"A lot of women who consider prophylactic mastectomy are doing so in a very measured, rational way and yet, at least in the U.S., they seem to be swimming upstream against people who are saying, 'What, are you crazy?'" explains Robson. "Those people don't understand the journeys, which have led these women to their decisions." What's most important, say Robson and Kaelin, is for a patient to be given all the information she needs to make a decision on her own, without any pressure from doctors. She should consult with a breast surgeon, a reconstructive surgeon, and most importantly, other women who have gone through it already. "One patient told me that the most helpful thing she was told was that it was perfectly reasonable to have the surgery and it was perfectly reasonable not to have it," recalls Robson. "It's just a personal choice and a woman should be supported no matter which way she goes."

Like Karen, the vast majority of women who choose prophylactic mastectomy opt for reconstructive surgery immediately afterward. During a bilateral mastectomy, a surgeon removes all breast tissue that is visible to the naked eye, including the nipple. The risk of cancer can never be 100% eliminated, says Kaelin, because there might be a wisp of a breast tissue cell that has dived down into the chest wall or beyond the normal boundaries.

Options for Breast Reconstruction

Options for breast reconstruction depend largely on a woman's individual physique. The most common procedure for women who've had both breasts removed involves saline or silicone breast implants. In alternative procedures, breasts are recreated using muscle and fat from other areas of the body. These tissues are used to create a sling-like structure on the chest wall; afterwards implants are placed in the position of the breast. With a TRAM flap (transverse rectus abdominal muscle), abdominal muscle and fat are used. A similar procedure, called a DIEP flap (deep inferior epigastric perforator), leaves the abdominal muscle in place and uses only fat and skin from that area. A different procedure uses back muscle.

Because two breasts must be recreated, a woman needs to have a large amount of appropriate tissue to spare for these procedures. Also, removing major muscles can cause weakness and pain in specific body regions. Nipple reconstruction usually involves a skin graft that's formed into a nipple shape and then tattooed to resemble a natural nipple in color. While reconstructed breasts have scars and no nipple sensation, Kaelin says that some women are genuinely "delighted" with their reconstruction.

But the real delight comes from the immense relief in no longer feeling like a ticking time bomb --something that Karen looks forward to. "My risk will be below that of the normal population; I won't need the surveillance anymore and getting health insurance won't be an issue," she says, pausing and then admitting that she is also pleased about a more superficial benefit of the surgery: "My new breasts will be perky for life!"

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Breast Cancer Survivors: Life After the Treatments End

The breast cancer treatments are over. Now what? Here's how to return to your "new normal."

The song says "It ain't over 'til it's over," but when you've had breast cancer, you discover that it's not even over when it's over. After a marathon of breast cancer diagnosis and treatment that may last six months to a year, you can hardly wait to get back to a normal life again. But the day of your last radiation treatment or chemotherapy infusion doesn't mark the end of your journey with breast cancer. Instead, you're about to embark on another leg of the trip. This one is all about adjusting to life as a breast cancer survivor. In many ways, it will be a lot like the life you had before, but in other ways, it will be very different. Call it your "new normal."

From your relationships with your family and your spouse to eating habits and exercise, breast cancer will change your life in ways that last well after treatment ends. How do you fight lingering fatigue? What should you eat to help prevent a breast cancer recurrence? Will you ever have a regular sex life again? These are just a few of the questions that may nag at you as you make the transition from breast cancer treatment to breast cancer survival.

"Chemobrain" and Other After-Effects

You watched the last dose of chemotherapy drip from the IV into your veins six months ago. Your hair has really started to grow back. Maybe it's curly where it once was straight, or a lot grayer than before, but it's hair. You have eyebrows again. So why are you still so tired? When are you going to feel like you again? "Your body has just been through an enormous assault, and recovery is a huge thing. You're not going to just bounce back right away," says oncologist Marisa Weiss, MD, founder of Breastcancer.org and the author of Living Beyond Breast Cancer. "You've been hit while you're down so many times: with surgery and anesthesia, perhaps with multiple cycles of chemotherapy, perhaps with radiation."

Two of the biggest hurdles women with breast cancer face post-treatment are fatigue resulting from chemotherapy and/or the accumulated effects of other treatments, and a phenomenon some women have dubbed "chemobrain" -- mental changes such as memory deficits and the inability to focus. If you tried, you probably couldn't pick two more frustrating and troubling side effects for women handling busy lives, managing careers, and caring for families. "You expect them to go away as soon as treatment ends, and they don't," says Mary McCabe, RN, director of the Cancer Survivorship program at Memorial Sloan-Kettering Cancer Center in New York.

That such a program as McCabe's exists is a testament to the changing nature of what it means to have cancer. Women with breast cancer, like other people with a cancer diagnosis, are now surviving for so much longer, and in such large numbers, that some hospitals are opening entire departments devoted to survivorship. The National Cancer Institute has also launched a special research area dedicated to studying what it means to survive cancer.

How long after breast cancer treatment ends can you expect fatigue, "chemobrain," and other post-treatment side effects to persist? Everyone's different, of course, but as a general rule of thumb, Weiss tells her patients to expect a recovery period about the same time from your first "cancer scare" moment to the date of your last treatment. So if you found a lump or had a suspicious mammogram in April, and had your last radiation treatment in December, it may be August or September of the following year before you reach your "new normal."

"Even then, that doesn't mean that you're fully back to yourself again, but by then you should have a sense of where you're going to be, what your energy level will be, and so on," says Weiss. Ongoing treatments, like tamoxifen or other hormonal therapies such as arimidex, aromasin or femara, or reconstructive surgery, can affect the process. "I have a lot of patients who are in their second year of dealing with this. Yes, their main anti-cancer treatment may be over, but they're still figuring out how to manage the side effects of hormonal therapies and so on. It can feel like an endless process."

Breast cancer survivorship, Weiss observes, is a marathon, not a sprint. That means learning to handle the symptoms that stick around after treatment ends, says Sloan-Kettering's McCabe, by using those adaptive strategies you learned while on chemotherapy or recovering from surgery. "You need to continue to have planned periods of rest, and think about what times in the day and after what activities you tend to find yourself most tired," she says. "If chemobrain is still bothering you, continue using tricks like writing things down, posting reminders to yourself, and asking people to repeat information." Some women find it helps to keep a daily diary, noting down the times when fatigue or mental fogginess hit hardest, to help them plan around it.

A Chance to Make Some Life Choices

Make sure your family and your officemates understand that just because treatment is over, that doesn't mean that you're going to be able to jump right back into running the carpool, coaching soccer, and traveling to conferences a week out of every month. "Everyone's ready for treatment to be over, not just you, and although they've been supportive, your friends and family may be expecting you to spring back right away," says McCabe. "It's an education process. They need to understand that when the therapy stops, that doesn't mean that the effects of the therapy stop immediately." Manage your expectations, urges Weiss. "Decrease the stress and the pressure on you in whatever ways you can. There are a lot of decisions you can make to take charge of how your life goes while you're in this recovery process."

For example, you may have certain ideas about how your house should look, how much income you're going to have, and what your commitments to your community need to be. Decide which of those things are really important to you and which ones don't matter quite as much. Let the less-important ones slide or find someone else to do them.

Gina Shaw is a medical writer who was treated for breast cancer in 2004, and now calls herself a "joyful breast cancer survivor."

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Social Disparities in Tobacco Use in Mumbai, India: The Roles of Occupation, Education, and Gender-(Glorian Sorensen, Prakash C. Gupta and Mangesh S. Pednekar, 09/07/2005)

Objectives. We assessed social disparities in the prevalence of overall tobacco use, smoking, and smokeless tobacco use in Mumbai, India, by examining occupation-, education-, and gender-specific patterns.

Methods. Data were derived from a cross-sectional survey conducted between 1992 and 1994 as the baseline for the Mumbai Cohort Study (n=81 837).

Results. Odds ratios (ORs) for overall tobacco use according to education level (after adjustment for age and occupation) showed a strong gradient; risks were higher among illiterate participants (male OR=7.38, female OR=20.95) than among college educated participants. After age and education had been controlled, odds of tobacco use were also significant according to occupation; unskilled male workers (OR=1.66), male service workers (OR=1.32), and unemployed individuals (male OR=1.84, female OR=1.95) were more at risk than professionals. The steepest education- and occupation- specific gradients were observed among male bidi smokers and female smokeless tobacco users.

Conclusions. The results of this study indicate that education and occupation have important simultaneous and independent relationships with tobacco use that require attention from policymakers and researchers alike. (Am J Public Health. 2005;95:1003-1008. doi:10.2105/AJPH.2004.045039)

Tobacco use in low-income and middle-income countries is predicted to contribute to an increasing share of the global burden of disease in future decades.1 Eighty-two percent of the world's 1.1 billion smokers now reside in low- and middle-income countries, where, in contrast to declining consumption in high-income countries, tobacco consumption is on the rise.1 Indeed, the World Health Organization's Framework Convention on Tobacco Control underscores the importance of tobacco control efforts within developing countries as part of a worldwide strategy to reduce the health, economic, and social consequences of tobacco use.2 Addressing this growing public health problem requires attention to increasing social disparities in patterns of tobacco use. Across high-, middle-, and low-income countries, smoking rates are highest among individuals of low socioeconomic position.3

Indicators of socioeconomic position vary across studies; often education, occupation, and income level are used interchangeably to measure socioeconomic position.4 It is important, however, to examine multiple indicators of socioeconomic position simultaneously if one is to understand their combined impact and thereby provide more complete descriptions of social inequalities in tobacco use. In particular, insufficient attention has been focused on occupational disparities in tobacco use, given the role of occupation in linking education and income as well as its role as a determinant of health in its own right, through hazardous workplace exposures. Indeed, recent analyses of US data indicate that education does not represent a "stand-in" surrogate for occupation, or vice versa; rather, they reflect distinct social constructs making overlapping as well as independent contributions to patterns of tobacco use.5

In this study, we examined social disparities in tobacco use in India, where multiple forms of tobacco consumption complicate attempts to reduce its overall impact on public health. It has been estimated that 65% of men use some form of tobacco, including 35% who smoke, 22% who use smokeless tobacco, and 8% who engage in both forms of tobacco use.6,7 About one third of women use at least one form of tobacco, although rates among women vary considerably by region (from approximately 15% to approximately 65%).6,7 In general, cigarettes account for an estimated 20% of tobacco consumption; about 50% of tobacco is consumed in the form of bidis, that is, traditional, leaf-wrapped unfiltered cigarettes.8,9

In previous studies, different patterns have been observed in the educational gradient in tobacco use depending on the type of tobacco used. Whereas overall tobacco use has been shown to be highest among those with the least education, cigarette smoking rates have been shown to increase with increasing education.10 In India, because of their low cost, bidis are more commonly smoked than cigarettes by individuals of lower socioeconomic position; in turn, cigarettes are more commonly consumed among those with greater financial resources.10,11 (Bidi smoking has been shown to pose significant health hazards.12-14) A similar socioeconomic gradient has been observed for the use of smokeless tobacco, including chewing tobacco, snuff, burnt tobacco, powder, and paste.7,15

In general, men in India smoke as well as chew or apply tobacco, whereas women generally chew or apply tobacco, with the exception of the few areas where prevalence rates of smoking among women are high.7,16 It is estimated that more than 150 million men and 44 million women in India use tobacco in various forms,14 and approximately 635000 deaths in India are attributed to tobacco each year. Tobacco-related cancers constitute about half of the total cancer incidence among men and about 20% among women.8

The purpose of this study was to assess educational and occupational differences in the prevalence of tobacco use, including total tobacco use, bidi and cigarette smoking, and smokeless tobacco use, in a large sample of residents of Mumbai, India. In addition, we sought to assess the joint effects of occupation and education level on tobacco use after controlling for other key determinants of use (i.e., gender and age).

METHODS

Baseline data for the Mumbai Cohort Study were collected between 1992 and 1994 in Mumbai (Bombay), India.17 The overall purpose of this prospective cohort study was to assess mortality associated with tobacco use in Mumbai.

Study Population

Mumbai is a large, densely populated city whose population was approximately 12 million people in 2001.18 The city is divided into 3 sectors: the main city, the suburbs, and the extended suburbs. This study exclusively focused on the main city. The sampling frame comprised the city's electoral rolls, which are updated via house- to-house visits before each major election. From these rolls, assumed to be relatively complete given that almost all adult residents are entitled to vote, data were derived on the name, age, gender, and address of all individuals older than 18 years. The electoral rolls were organized by geographical areas; sampling was based on the smallest unit, the "polling station," which included 1000 to 1500 eligible voters. Selection of polling stations excluded those involving a large proportion of apartment complexes with high levels of security; results of the pilot data collection indicated the need for this exclusion owing to the difficulty of gaining access to such buildings.

At the selected polling stations, all individuals 35 years or older who were listed on the electoral rolls were eligible to be interviewed. The age cutoff of 35 years was selected as a result of the study's overall goal of studying tobacco-attributed mortality. In selected geographical areas, lists were supplemented to include individuals who were not listed on the electoral rolls but whose residence status was confirmed by a "ration card." These cards, issued by the Bombay Municipal Corporation, serve as a proxy for residence cards and permit access to all city and state governmental services; individuals identified in this manner represented approximately 5% of the overall sample.

Of the individuals approached and invited to participate in the study, the nonresponse rate was less than 1%. It was not possible to contact approximately 50% of the individuals included on the lists as a result of incomplete addresses, houses being demolished, changes of residence, and inaccessibility of residences (often owing to security considerations). A total of 99 598 adults (40 071 men and 59 527 women) were recruited and surveyed. In the analyses presented here, we excluded respondents who reported that they were retired (n=15 223) or had missing data for occupation (n=2538). The final sample comprised 81 837 respondents.

Data Collection

The survey was conducted by trained interviewers within participants' households. Hand-held computers were used to record data at the time of the interview. Interviews were conducted in the local languages, including Hindi and Marathi. No surrogate responses were permitted.

Measures

The primary outcome in the present analyses was tobacco use, categorized as follows: (1) having no habit in either the past or present ("never user"), (2) former user (including smoking and use of smokeless tobacco), (3) current smokeless tobacco user (including betel quid, mishri, and creamy snuff), (4) current cigarette smoker, and (5) current bidi smoker (including other forms of smoked tobacco as well, e.g., chilum and hooka). Smokers who also used smokeless tobacco were classified as smokers in these analyses.

Occupation was assessed according to respondents' self-reports. Following the standard Indian classification system, occupations were coded as follows: skilled workers, unskilled workers, traders, service workers, and professionals.19 Additional categories \included unemployed and housewife. Women were considered as housewives unless they were currently employed or looking for employment. Retirees were excluded from the analyses. Education level was classified as illiterate, primary school (up to 5 years of education), middle school (6-8 years of education), secondary school (9-12 years of education), and college (including both some college and attainment of college degree). Gender and age data were also collected.

Data Analysis

Descriptive statistics were calculated for the overall population as well as for men and women separately. Logistic regression was used in conducting multivariate analyses. The response variable, tobacco use, was converted into a dichotomous variable in which current tobacco users (including users of any form of tobacco) were compared with current nonusers. Multivariate analyses of cigarette and bidi smoking were conducted only among men because of the extremely low prevalence (less than 0.5%) of smoking among women. SPSS statistical software (SPSS Inc, Chicago, Ill) was used in analyzing the data.

RESULTS

Sample Characteristics

Men represented about one third of the sample (Table 1). More than 40% of men were employed in service positions, and one third were unskilled workers, whereas a large majority (88%) of women were classified as housewives. Women were generally less educated than men; 45% of women were illiterate, as compared with 11% of men. In addition, only 5% of women had completed secondary school or college, whereas 16% of men had done so. Overall, about a quarter of the participants were between the ages of 35 and 39 years; more than a third were between 40 and 49 years of age.

Tobacco Use Prevalence: Bivariate Analyses

Patterns of tobacco use differed dramatically according to gender (Table 1). While women were less likely than men to have ever used tobacco (26% vs 41%), they were more likely to currently use smokeless tobacco (57% vs 44%). Smoking prevalence rates were 27% among men and, as mentioned, less than 0.5% among women (thus, data on female smokers are not shown separately in Table 1 or described in subsequent analyses). Among male smokers, 12% were cigarette smokers and 15% were bidi smokers. Overall, 2% of the sample members were former tobacco users, an indicator of cessation rates.

TABLE 1-Tobacco Use, by Gender, Occupation, Education, and Age: Mumbai Cohort Study

Among men as well as women, professionals were least likely to have ever used tobacco, whereas unskilled workers and unemployed individuals were most likely to have done so. Use of smokeless tobacco was more common than smoking across all occupational categories. Rates of smokeless tobacco use among women were highest among unskilled workers, those who were unemployed, and housewives. Among men, smokeless tobacco use was especially prevalent among service and unskilled workers and unemployed individuals. Bidi smoking among men followed a similar pattern, with high prevalence rates among unemployed individuals and unskilled workers. In contrast, cigarette smoking was most common among professionals and traders. Self-reported rates of former tobacco use ranged from less than 2% to 6%.

There was a strong gradient in tobacco use according to education level. Among both men and women, the rate of smokeless tobacco was highest among the illiterate and lowest among those with a college education. Among men, the prevalence of bidi smoking was highest among those at low levels of education, but the prevalence of cigarette smoking was highest among those at the highest education levels.

Multivariate Analyses

Table 2 presents gender-specific tobacco use odds ratios comparing current tobacco users, current cigarette smokers, current bidi smokers, and current smokeless tobacco users with individuals reporting no current use of any type of tobacco. Odds ratios according to occupation and education were adjusted for age and the other relevant model variable (i.e., either occupation or education). The reference category for occupation was professional, and the reference category for education was college.

Tobacco use was inversely related to education level across all types of tobacco use. The magnitudes of the odds ratios were especially large among those with no more than a primary school education; in addition, in this subgroup, odds ratios were particularly pronounced among women who used smokeless tobacco and men who were bidi smokers. Relative to participants in the reference educational category (college), odds ratios for all forms of tobacco use were significantly higher among those in the other educational categories. After adjusting for age and education, we also observed an inverse relationship between cigarette smoking and education (see Table 2).

TABLE 2-Adjusted Odds Ratios (and 95% Confidence Intervals) for Various Forms of Tobacco Use (vs No Current Habit), by Education, Occupation, and Gender: Mumbai Cohort Study

Although the magnitudes of the relationships were not as large, occupation continued to play an important role in patterns of tobacco use when education and age were controlled. In the case of men, odds ratios for smokeless tobacco use remained statistically significant among unskilled workers, service workers, and unemployed individuals, and the odds ratios for bidi smoking remained significant among unemployed individuals and both skilled and unskilled workers. None of the odds ratios for cigarette smoking were significant. After education level had been controlled, male traders were actually less likely to use smokeless tobacco than were professionals, suggesting an interesting interaction between education and occupation. Among women, after control for education level and age, only the odds ratios for those who were unemployed remained statistically significant.

DISCUSSION

The present results demonstrate the important roles of education and occupation in tobacco use patterns in India. Research in the West has consistently documented a strong socioeconomic gradient in tobacco use, with higher rates of use among those of greater social disadvantage.4,5,20-22 Indeed, Jarvis and Wardle23 concluded that, in Western countries, "any marker of disadvantage that can be envisaged and measured, whether personal, material or cultural, is likely to have an independent association with cigarette smoking." Recent evidence documents the same socioeconomic tobacco use gradient in India; tobacco use has been found to be higher among individuals at lower levels of education,10,11,15,24-27 of lower castes,15,27 and with lower standards of living.27,28 (Other research, however, has failed to reveal an association between tobacco use and socioeconomic position.29)

Education is a powerful correlate of tobacco use patterns.10 In this study, after adjustment for occupation and age, all forms of tobacco use followed an inverse linear pattern in terms of educational level; similar results have been reported by others.11,15,27 Odds ratios were alarmingly high among individuals with no more than a primary school education, particularly, as described earlier, women using smokeless tobacco and men smoking bidis. Of note, when we adjusted only for age (data not shown), the direction of the relationship between education and cigarette smoking among men was reversed relative to the bivariate relationships presented in Table 1. Unlike the use of other forms of tobacco, cigarette smoking was most prevalent among the younger groups within this sample; among male participants, age contributed significantly to both education- and occupationspecific odds of cigarette smoking. These findings underscore the importance of adjusting for age in analyses such as those described here.

Our analyses also offer evidence of the independent effects of occupation and education on tobacco use among men; even after control for education, odds ratios for occupation were statistically significant among the most disadvantaged workers in regard to bidi smoking and use of smokeless tobacco. One interesting exception in these occupationspecific results involved the odds of using smokeless tobacco among male traders; although the overall prevalence of smokeless tobacco use was somewhat higher among traders than among professionals, a lower proportion of traders than professionals in each of the various educational groups used smokeless tobacco (data not shown).

Occupation appeared to carry more weight in regard to men's tobacco use than that of women. Because a large proportion of the women in this sample were housewives and 45% were illiterate, it is not surprising that education was a more important indicator of socioeconomic position than current occupation. The "housewife" category provided insufficient information to adequately describe socioeconomic position because it included women living in a range of social and economic circumstances. In addition, education appeared to swamp any influence of occupation among women; for example, the odds of smokeless tobacco use were more than 20 times greater among women who were illiterate than among women with a college education.

Unemployment was a particularly powerful predictor of tobacco use. In the case of all comparisons, even those taking education into account, unemployed individuals were at the highest risk of using tobacco, a relationship that has been reported in other populations as well.30-34 In addition, unemployment was most strongly associated with bidi use among men (OR=3.5). Unemployment is an indicator of increased economic disadvantage and associated stressors such as poor housing conditions, unmet needs for food, and potential lack of social connectedness.23,35 Expenditures on tobacco products have been found to represent a significant portion of the daily incomes of Indian residents in low income categories, including unemployed individuals.36

The present findings demonstrate the need, instudies assessing social disparities in tobacco use, to examine occupation and education separately as well as simultaneously. This will allow researchers to gain a more complete understanding of such disparities than might be the case when considering either indicator alone.5 Others have noted the importance of considering multiple indicators of socioeconomic position in understanding patterns of tobacco use.5,23,37 Education and occupation are likely to operate through differing pathways. Education is one of the most widely used indicators of socioeconomic position, given that it is easy to measure, applicable to individuals both inside and outside the labor force, and stable across the life course. It has consistently been shown to be a strong correlate of tobacco use, both in India and elsewhere.5,10,11,15,22,24-26 Nonetheless, it may fail to capture some of the elements of socioeconomic position expressed by occupation; occupation may further indicate one's standing in the community, reveal aspects of the normative environment prevalent within one's occupational "culture," and serve as a marker for the general conditions present at one's workplace.5,37

Several caveats must be noted in interpreting our results. For example, our education and occupation data were based on self- reports. In addition, the complexities of obtaining, recording, and coding occupational data can lead to misclassification.37-40 Furthermore, our occupational categories were combined into broad groupings, which could have contributed to biased estimates in terms of the gradients observed. Nonetheless, these groupings provided greater precision than those used in earlier tobacco use research in India; in these studies, occupation was grouped into even more general categories.41 We collected data at the individual level, not the household level, and thus our data on socioeconomic position may have been incomplete, particularly in the case of women.37 Future studies could include other indicators of socioeconomic position, such as caste or different standard of living measures.

In addition, as described earlier, the present data were collected as part of the initial data collection effort in a prospective cohort study; they were not part of a surveillance study designed to assess population prevalence rates of tobacco use. The sample was not a random or representative sample of the population. In particular, we excluded individuals who resided in upper-middle- class and upper-class housing complexes that were not accessible as a result of security issues. Thus, the proportions of individuals in different occupational categories might not have been comparable to the proportions in other cities or in India as a whole. Nonetheless, our findings provide important insight into the interrelationships between education, occupation, and tobacco use. Moreover, although the proportions of different occupation types and the prevalence rates of tobacco use may not have been representative of the general population, it is highly unlikely that the interrelationships observed would have been seriously affected by our sampling methods.

Identifying occupation- and educationspecific disparities in tobacco use can provide a useful "signpost" indicating inequities that need to be addressed by policymakers and the broader community through allocation of resources.42 Our results indicate that tobacco use in India follows a social gradient mirroring that reported for Western countries. If one is to shed light on patterns of disparities, it is important to consider multiple indicators of socioeconomic position, including both education and occupation, as well as gender. Additional research elucidating the differing pathways by which occupation and education may influence tobacco use can inform future policies and other interventions.

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31. Bennett N, Jarvis L, Rowlands O, Singleton N, Haselden L. Living in Britain: Results From the 1994 General Household Survey. London, England: Her Majesty's Stationery Office; 1996.

32. Novo M, Hammarstrom A, Janlert U. Smoking habits: a question of trend or unemployment? A comparison of young men and women between boom and recession. Public Health. 2000;114:460-463.

33. Morrell SL, Taylor RJ, Kerr CB. Jobless: unemployment and young people's health. Med J Aust. 1998; 168:236-240.

34. Hammarstrom A. Health consequences of youth unemployment: review from a gender perspective. Soc Sci Med. 1994;38:699-709.

35. Kaplan GA. Where do shared pathways lead? Some reflections on a research agenda. Psychosom Med. 1995;57:208-212.

36. Efroymson D, FitzGerald S, eds. Tobacco and Poverty: Observations From India and Bangladesh. Mumbai, India: PATH Canda; 2003.

37. Krieger N, Williams DR, Moss NE. Measuring social class in U.S. public health research: concepts, methodologies, and guidelines. Annu Rev Public Health. 1997;18:341-378.

38. Levy BS, Wegman DH. Occupational Health: Recognizing and Preventing Work-Related Disease and Injury. Philadelphia, Pa: Williams & Wilkins; 2000.

39. History, Origins, and Conceptual Basis: National Statistics Socio-Economic Classification. London, England: Office for National Statistics; 2002.

40. Standard Occupational Classification (SOC) U\ser Guide. Washington, DC: Bureau of Labor Statistics; 2003.

41. Gupta PC, Ray CS. The epidemic in India. In: Boyle P, Gray N, Henningford J, Seffrin J, Zatonski W, eds. Tobacco and Public Health: Science and Policy. Oxford, England: Oxford University Press Inc; in press.

42. Carter-Pokras O, Baquet C. What is a health disparity? Public Health Rep. 2002;17:426-436.

Glorian Sorensen, PhD, MPH, Prakash C. Gupta, DSc, FACE, and Mangesh S. Pednekar, MSc

About the Authors

Glorian Sorensen is with the Center for Community-Based Research, Dana-Farber Cancer Institute, the Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Mass. At the time of this study, Prakash C. Gupta was with the Tata Institute of Fundamental Research, Mumbai, India; Mangesh S. Pednekar was with the Tata Memorial Centre, Mumbai, India.

Requests for reprints should be sent to Glorian Sorensen, Dana- Farber Cancer Institute, 44 Binney St, Boston, MA 02115 (e-mail: glorian_sorensen@dfci.harvard.edu).

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Ode-By Zahir

This email was sent to CPAA's Zakia Topiwala by a friend. 

Dear Zakia,

This Ode written by me has been displayed in London's Royal College of Arts and has been appreciated by Oncologist, doctors and hospital staff in general.

WHY ME?

Why Me? I asked, but got no answer
Oh! the anguish, the Pear, the dreadful Cancer
Why Me? I asked, but got no answer.

The hopeful doctor and friendly nurse 
assured me that it was no curse
but treatment, would be heavy on my purse.

Nausea, weakness, hair loss and pain
was a part and parcel of my domain
dear ones comforted, it won’t be in vain.

Pain vanished, strength returned and I felt better 
each new strand of hair made me fitter
people were joyous, as I was no quitter.

Doctor and nurse elated with my test sample 
said courage and grit you have in ample
as you're the one who’s set an example.

Being reborn, I say to you, conquer Cancer
Why Me? don't ask, you won't get an answer
just fight the fight and beat the Cancer

by Zahir Jabalpurwala

Why Me - an Ode dedicated to the 'Triumph of the Human Spirit', and to my late wife Rashida who was an embodiment of that fighting spirit and positive attitude.

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A Day Without Cancer

In December 2003, I received this email. It reiterated to me the fact that the problem of the fight against cancer must be met on many levels. While one child is being given treatment, a sibling is also affected. A few years ago, CPAA provided support for a 8 year-old boy who had moved along with his family from Kolkatta to Mumbai for his treatment. On going into details, we realised that along with the financial burden the family was facing, an additional problem was that the child's elder sister was becoming uncharacteristically aggressive and unruly. When counseled she revealed that she had been forced to leave her school in Kolkatta and since her father was busy with her brother's treatment, she was yet to start school in Mumbai. Her father was helpless and told us, "What can I do? Here is a matter of life and death. Should I be wasting time and money trying to get admission to a school for my daughter?" At this stage CPAA stepped in and got the child prized admission to a convent school in her locality. We got her uniform and bus fees sponsored by different persons. Hard working as she is, she soon shone, even at Marathi, a subject which was completely new to her.

Here is another story, one about how a loving sister can be affected by the pain her brother has had to bear during his treatment for leukemia. I received this mail in December 2003 from the mother of a cured cancer patient ho shared this essay her daughter had written in school. I requested and received her permission to share the message with our readers.

My son was diagnosed with cancer in 1997 he was almost three and my daughter was five. It was very hard for all of us, but I think it was hardest on my daughter, being a child and not understanding. My son has been in remission for six years. Recently I was looking in my computer and found this essay that my daughter wrote for school. This essay let me see things through a child's eyes and I see that after all these years my daughter still remembers. We always do everything to make the sick child comfortable but sometimes we forget that there is a sibling, another child watching from the side and as the essay shows listening and noticing every detail. I hope that this essay touches your heart like it touched mine. Sincerely, Olga Gardo

A Day Without Cancer By Camille Gardo

A Day Without Cancer By Camille Gardo Have you ever had an important day in your childhood? To begin with, it was a cold day, full of happiness and sadness. Dead bodies crossing the halls and people crying because of an illness. The illness that has different types, still, I say there all the same most people die from it. But, that day things were going to change. Today was the day my brother was leaving the hospital after all these months with cancer. After all the friends he had lost because of cancer, it must have been hard for him. However, it was his last day in the hospital, he finally got to go home with me. He left the hospital one day after they told us he no longer had cancer. My brother didn't have to eat the gross hospital food. He would get to eat homemade food that my mother and grandmother cooked. He got to eat whatever he wanted. He got to eat junk food and my mother baked almost everyday. She baked cookies, brownies, cakes and muffins. But, the best part of leaving the hospital was that he didn't have to go through pain. He didn't have to get shots on his back and scream. He didn't have to have IVs inside his arms. He didn't have to get blood from someone we didn't know. In conclusion, this was the important day of my childhood. Now I'm happy but at the same time sad because my brother doesn't get to see his friends. But, it has been 6 years already since he had cancer. I thank god for that.

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Brain Tumors (KidsHealth.org-Apr 24, 2003)

After leukemias, brain tumors are the second most common type of childhood cancer. Because the brain controls everything from breathing and movement to speech and coordination, the diagnosis is often frightening and emotional for parents and children alike.

Brain tumors in children vary in location, type, rate of growth, and how they affect a child. Cancer specialists, however, have developed nationwide standards called protocols that help determine how a child will be treated once a diagnosis is made. These protocols are based on years of tracking children with brain tumors, and they ensure that medical treatment is constantly being refined and improved. "No matter where a family lives, they do not have to feel isolated when it comes to getting the best treatment for their child," says Richard A. Fischer, MD, a pediatric neurologist. "The national protocols for treating brain tumors in children ensure that there is communication between all of the leading medical centers and that your child will benefit from research and medical advances regardless of where you live."

What Are Brain Tumors?

Brain tumors are abnormal masses in or on the brain. They develop when cells grow and divide in an uncontrolled manner and can be either primary or secondary tumors.

Primary tumors are composed of cells just like those that belong to the organ or tissue where they start. A primary brain tumor starts from cells in the brain. Most brain tumors in children are primary, and at least half of all primary tumors originate from cells of the brain that support the body's nervous system. Tumors related to the nervous system are called gliomas, and they originate in the brain's glia cells.

Secondary tumors are made up of cells from another part of the body that have spread to one or more areas. Secondary brain tumors are actually composed of cancer cells from somewhere else in the body that have metastasized, or spread, to the brain, such as osteosarcoma (a primary bone tumor) or rhabdomyosarcoma (a primary tumor of muscle).

Brain tumors can also be benign or malignant. Benign tumors grow slowly and do not spread. However, benign tumors are serious and can be life threatening; growing in a limited space, a benign tumor can put pressure on the brain and compromise its function. Malignant tumors grow quickly and can spread to surrounding tissues. "Malignancy" or "malignant" almost always refers to cancer.

Types of Tumors in Childhood Brain tumors in children can be broken down into two major categories: tumors in the lower portion of the brain, called the posterior fossa, or tumors in the upper portion of the brain, called the cerebral hemispheres. More than half of all childhood brain tumors are located in the lower region of the brain. The four most common types of posterior fossa tumors are:

·Cerebellar astrocytoma: This benign tumor of the cerebellum can occur throughout childhood and adolescence. It is the most common tumor of the posterior fossa, and it carries the best prognosis.

·Medulloblastoma: This type of tumor can spread to other parts of the brain through brain and spinal (cerebrospinal) fluid. The most common brain tumor in children younger than 7, medulloblastomas typically occur between the ages of 4 and 10 and are more common in boys than girls.

·Brain stem glioma: These tumors are located in or near the brain stem and tend to affect children between the ages of 5 and 10.

·Ependymoma: Another type of glioma tumor involving cells that line the cerebral ventricles, ependymomas can occur throughout childhood. Tumors in the upper portion of the brain, or the cerebral hemispheres, include:

·Astrocytoma: Due to their location in the cerebral hemisphere, these tumors often cause seizures; they can occur throughout childhood.

·Optic nerve glioma: Located near the optic nerve (and hypothalamus), these tumors can affect vision and result in hormone problems.

·Craniopharyngioma: Found near the pituitary gland, these tumors can affect vision and growth.

·Choroid plexus papilloma: Rare tumors that occur where the brain produces cerebrospinal fluid, choroid plexus papillomas develop most often in infants and can cause hydrocephalus.

Signs and Symptoms

According to Dr. Fischer, most parents think that a persistent headache is a common sign of a brain tumor. "But in fact," he explains, "it's a rare sign, particularly when it occurs without other symptoms." Instead, the following signs and symptoms are better indicators of a possible brain tumor:

· seizures
· poor coordination
· weakness on one side of the body
· headaches, particularly in the early morning, combined with vomiting or nausea
· slurred speech
· dizziness
· a sudden change in vision or sense of smell
· in infants, increased head size

These signs and symptoms may vary depending on the age of a child and the location of the tumor.

When to Call Your Child's Doctor

Any of the signs mentioned above warrants a call to your child's doctor. Typically, parents will first call the doctor about just a symptom, not because they think their child has a brain tumor. For example, "a small child will, over a period of days or weeks, begin to stumble or fall more easily. Or there may be a report of double vision or early morning vomiting," Dr. Fischer explains. Upon examination, a doctor may find that the symptoms are the result of a recent but less threatening condition - the flu, a sports injury, or vision difficulties that need correction. Or the doctor might feel uncomfortable with the set of symptoms and call a pediatric neurologist, a doctor who specializes in brain disorders in children, for a second opinion.

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Fighting Bladder Cancer

In August 2002, I received an email from my friend in the US. Her father had been diagnosed with bladder cancer. She wanted to know what to do. Her father is a dear friend of mine, too, and I was as shocked perhaps as she was. I sent her some material from the web regarding treatment for bladder cancer-and waited to hear more. In December, I heard that her father, after treatment, had gone for a check up where he had been told that there were no mailgnant cells left. Seemingly, it was a miracle! I asked him to share what he had gone through for the benefit of other bladder cancer patients. His experience is one we can all learn from. Trust your doctor, but also try to learn more about your disease from the internet, books, other doctors and discuss your treatment in details. It may just make a difference...

I really don't know what emotions I had from the start except to say that I was aware of the doctor saying "You have bladder cancer". However, I don't know if that ever sunk in, to tell you the truth. I realized that I had cancer but I experienced no pain and only a couple times at the very beginning did I ever have any bleeding. I felt normal except for an increased urgency which was somewhat embarrasing.

However, my first symptoms were the first of August 2002, a short spell of bleeding when I urinated. I went to my family doctor who in turn recommended a urologist. I saw him during the latter part of August and he set up an appointment for a cystoscope. He verified that I had cancer, two types, CIS and Papillary. He talked to me about the various types of treatments and finally said that he thought that I should have an immunobiological treatment called BCG, which stands for Bacillus-Calmette-Guerin (Spelling?) named for a Frenchman who did the original work in the '80s, I believe. After that interview I was scheduled for 6 bladder infusions, each a week apart, the first to begin Oct. 3, 2002.

I went home and thought over what the doctor had said. First, I would have the series as above outlined. Then after a few weeks, I would have another biopsy to determine whether I had any improvement. Depending on the outcome of the biopsy, I would perhaps have another set of six BCG treatments or I might be put on a maintenance check every 3 months. If there was no improvement after the second set of BCG treatments, I could have my bladder removed and a "bag" placed or I could possibly have a portion of my large intestine removed and made into a bladder and everything reconnected. I really didn't like all I heard about this program!!!

I immediately got on the computer and searched for any info on bladder cancer and BCG. To my amazement there is a world of info available and I copied many reprints on the subject. One of the reprints was from The Journal of Urology about the work of one Dr. Michael O'Donnell at The University of Iowa. He had studied BCG alone and in combination with Interferon. He made the statement that " The combined treatment of BCG/Interferon is up to 40 times more effective in stimulating the immune system than the use of either interferon or BCG alone".

After reading that article, I contacted my doctor and we talked about the combination treatment. He was somewhat hesitant to go that route but after voicing several objections, he finally agreed to add the interferon to the treatment.

I have had 6 treatments starting on October 3 at 7 day intervals. Then on December 19th, after a 6 week hiatus waiting for the bladder to get the best response, I had another biopsy. I was given the report on Dec. 30th that the tests for cancer showed only benign cells.

My doctor was as pleased as I was and decided to give me 3 more "Insurance" treatments and then put me on a 6 month maintenance check.

This is where I stand at present and I am very thankful for the very good treatment and particularly for the many prayers that have been said on my behalf. I would almost have to say that it is like a miracle to have been diagnosed with bladder cancer on September 11th 2002 -that infamous day- and on the 30th of December 2002 to be told that the cancer was no longer evident.

However this is not to say that it is gone or that it won't return. At this time I no longer have any bleeding and have gotten over most of the urgency. I feel most blessed. I will begin my 3 "insurance" treatments on 3rd February 2003 and at some post treatment time they will set up my maintenance schedule.. I would urge any of your patients who are experiencing anything similar to educate themselves through any means but particularly through the available information on the "net".

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Fighting Colon Cancer

In December 2001 Vijay was told, during the course of a routine medical examination, that he had cancer of the colon. The diagnosis threw his ordered life into turmoil. The next few months, while he underwent treatment, were spent readdressing many truths he had never questioned before.

Each cancer patient faces the challenges of his situation in a different way - with hope, fear, anger, disbelief, despair. A crucial contributor to his healing process was that Vijay (and his wife Nilima) reached out, shared their journey and found succor in correspondence with their friends and relatives. They sent regular email updates regarding his condition during the difficult six months of his surgery and recuperation. And received an overwhelming response from all around the world - of love and support and prayer.

Today Vijay is well on his way to conquering the disease in a manner that has left him stronger than ever before. He equates the struggle with climbing a mountain and today he finds himself "A Short way up the Peak"

Vijay is very happy to share his email updates (reproduced below) with any one who may benefit from them in any way. He says it is his way of "honoring his cancer so he can transcend it".

Read on....

14/12/2001: A New Mountain To Climb

Hi all,

This is Vijay.

I have to convey some very bad news and (within that context) some relatively good news.

The bad news first. What started as a routine investigation into an innocuous anaemic condition has turned deadly serious. On 12th Dec, the doctors discovered two polypoid carcinomas in my lower gastro-intestinal tract. In simple English, it means I have colon cancer. That's right ... cancer.

And that one word, my/ our life has changed forever.

The good news is

- Of the two tumours, only one is quite big, with somewhat advanced malignancy. The other is small and does not seem to be that advanced
- A CT scan was carried out immediately, which showed the tumours are localised to the colon and that there is no distant spread to any of the vital organs - liver, lungs etc
- The location of the tumours is such that they can be surgically removed in a way that my bowel functions can be reasonably and normally retained.
- I am in very good hands. Investigations, surgery and post-operative care/ treatment will all be carried out by some of the best doctors in some of the very best facilities in the world.
- Specifically, Nilima and I spent a long time with the surgeon (Dr. Sina Dorudi) yesterday and we found him to be very straightforward, but very human and with fine credentials indeed. This has been confirmed by a couple of other doctors we have spoken to. I feel safe in his hands.
- Most importantly, there have been significant medical advances in the field of cancer treatment and particularly in the case of colon cancer. The statistics in circumstances similar to mine - of surgical success and of subsequent recovery are extremely high. Dr. Dorudi pointed out that "We are not dealing with a terminal illness ... we are not even talking about controlling or suppressing it ... we are talking about removing the source and curing it completely, so you can get back to a reasonably normal and active life"

The next steps are to carry out the surgery as soon as possible (likely date: next Friday, 21st Dec). This, plus lab tests on the tissues that are removed will determine what further treatment/ monitoring is required. My sister (who is a doctor in America) plans to be with us for a few days and Nilima's mum will also be here, for a longer period. With their physical presence (and others providing support) we hope to see the immediate - surgery and post-operative - period through. We have to focus on this above all else and as a result, we have cancelled all our holiday plans.

As you can imagine, the enormity of this news has not been at all easy to take in. The last few days have seen a roller-coaster of tumultous emotions and we know there is much more to come. Without alarming them in any way, we have been open and honest with the children ... they are probably still too young to understand fully what is going on and what the implications are. Who can blame them ... we ourselves are quite dazed and confused!

We have of course, told our immediate families in person, but we thought we should also keep you posted - our friends, relatives, colleagues and well wishers - as soon as possible, even if it is only by email. Bringing you into the picture is important for two reasons. One, that you deserve to know it exactly as is, directly from us. Two (and more selfishly!) because we need and are counting on your prayers, good wishes and support, at this difficult time and turning point in our lives.

(If you have the opportunity, please also help us by offering your comfort and support to our parents and siblings; hearing and dealing with this news long-distance, as they have, is always harder.)

We will keep you posted by phone or email as we approach/ overcome important milestones, but for the moment, our focus is on the surgery and its immediate aftermath. Getting through it all will require a combination of the best medical expertise, my own strength (of body and of character and of faith), the love and support of our near and dear ones. But most crucially, the infinite Grace of God.

What is wonderful is that we genuinely believe we have been blessed with all of these in abundance. Having said that, please do pray with all your heart .... this is really very important for me to climb this new mountain and to better understand/ accept His larger purpose and vision for us.

Love, Vijay

23/12/2001: So far so good ....

Friends,

Since it may be a while before Vijay can write to you personally, I thought I should let you know that Vijay's operation yesterday went off very well.

The surgeon, Mr Dorudi, had a reassuring smile when he came out of the operation theatre and announced that the whole thing went to plan. (With some extra bits of good news like the fact that the more advanced of the two cancers turned out not to be as spread as it seemed in the CT scan. That despite his anaemia, Vijay lost very little blood and didn't need any transfusion. Also, best of all, reconfirmation upon surgery that the cancer hadn't spread to the liver or anywhere else.)

We now have to wait for the pathology reports of the removed tissue. With extreme good fortune, the lymph nodes may not show any signs of invasion and this can effectively be the end of the treatment. But, there is every chance of course that some cancerous cells may have got into the lymph nodes and so he will need some chemotherapy. Should that happen, Mr Dorudi has assured us that he has two internationally known oncologists he will refer us to...

While it feels like a huge hurdle has been crossed, the euphoria will probably not last as we enter the slow post-operative recovery period. Keeping cheerful and positive is going to take effort. So, keep in touch as I know how good reaching out to you has been for us. We have been overwhelmed by the support and good wishes that have poured in from around the world. Thank you for every prayer in every faith that has been said for us with such heartfelt love and sincerity. Let's swing the prayer wheel around one more time to keep our spirits from sagging and our faith in God's plan for us ever strong.

May God bless you this Christmas and the coming New Year. We know we are blessed to have you.

Nilima

PS: The pathology report on the tissue should be ready in a week and all going well, Vijay hopes to be home from hospital in time to usher in the New Year. I will keep you posted.

5/01/2002: The 'path' has cleared!

Dear all,

Excellent news to convey ....

1. I got back home last night from the hospital and have been resting today. There were a couple of small hiccups (low fever etc) which delayed the return home but overall, the post op recovery has been very good. I am back to a reasonably normal diet and quite mobile... able to climb up and down steps, go to the bathroom on my own etc. It feels fantastic to be back with the kids, enjoy home food, etc.

2. The best news of all is the pathology report on the tumours/ lymph nodes. By the grace of God, the lymph nodes are completely clear. Some 30 of them were individually checked and none of them show any cancerous cells. So the malignancy was caught and surgically removed before spreading through the walls of the colon into the lymph system. Effectively, it means I don't need any further treatment such as chemotherapy, but I may choose to participate in an ongoing trial programme. This is to be confirmed after a discussion with the oncologist in a couple of weeks.

According to the doctors, the healing/ settling process will take another six weeks, during which I have to stay at home, not drive, not lift any heavy items, not subject myself to stress, etc. However, I am encouraged to eat well, slowly build up my capacity for exercise/ muscle tone, keep myself constructively occupied etc. Sounds good ... yes?!

As you can imagine, the relief is immense and we are now beginning to look ahead to the future with a sense of optimism that seemed out of reach only a few weeks ago. What an experience ... and how rich the learnings! But from all the learnings, the single most important one to me has been the realisation of what 'HUMAN-ITY' really means and how powerful a force it can be, particularly if one thinks of it as a verb, not a noun.

Nilima and I are absolutely convinced that all your prayers, your positive energies, your 'HUMAN-ITY' have helped enormously in clearing this difficult path for us. We felt the divine Grace of God pulling us from above and the surge of a 'wind beneath our wings', carrying us along.

We are eternally grateful for both.

Love, Vijay

3/02/2002:

Still A Long Way To Go Up The Mountain, But The View Ain't Bad ...

Hello all,

It is almost month since I got back home from the hospital, and we owe you an update on what's going on. (Be warned, it is a long letter!) But here goes ....

Physically, my post-op recovery has been very good. Mr. Dorudi is pleased ... and so are we. The surgical incision has healed well and there is no pain, though a 12-inch scar takes getting used to! I am eating well, almost fully back to a normal diet, though the challenge is to regain my strength/ stamina, without putting on weight (not easy, in my case). My digestive system has not fully settled yet but I am told this is quite normal. I am totally mobile, active around the house and have started going out for walks/ getting some exercise, but without straining the abdominal muscles. I spend my time reading (current books: "World Mythology" by Joseph Campbell, "Healing Foods" by Dr. Rosy Daniels of the Bristol Cancer Centre and "The Far Side" by Gary Larson), listening to music, watching One-Day cricket on TV ... and learning to meditate ... not all simultaneously, I hasten to add!

Emotionally, I am in good spirits most of the time. The occasional bout of brooding does occur but is to be expected. I am trying to contain/ learn from it, rather than to deny or ignore it. It has helped hugely that so many of you have visited, written or called to give me strength and to lift my spirits. Each contact has given us a different perspective and something new to think about/ act on. Thank you, all.

Life-changing events are said to bring the family closer to one another and closer to God. This is certainly true for us. And particularly important in the rapidly fragmenting world we see all around us. With our kids growing up so fast, we never want to let this closeness go. I sense we have taken a BIG step forward spiritually and this is both liberating and fulfilling. More on this later.

From a medical/ treatment standpoint, we have had two meetings with a leading oncologist. While a couple of tests are still awaited, I have, as of now, chosen not to undergo chemotherapy. The benefits are marginal vis-a-vis the risks in my case (with a T3-N0-M0 classification i.e. lymph nodes being free of any cancerous involvement). The next 2-3 years are crucial ... if there is no recurrence during that period, then subsequent risks fall away exponentially. So rather than chemotherapy, I am inclined to put my faith in positive thinking, holistic/ complementary therapies (as a first step, we met a leading practitioner of Chinese Medicine yesterday, who has had great success with cancer patients), a planned diet/exercise program and a few carefully chosen lifestyle changes. Of course, I continue to count on your prayers and the grace of the Great Sherpa In The Sky!

We have also started picking up the threads of 'normal' life ... both Nilima and I have started thinking about 'work' again. The doctors have cleared me to get back to work in the last week of Feb. The plan is to start with 3 days a week working from home and go in twice a week to the office. And to slowly build up to full capacity thereafter. They have asked me to keep travel/ stress to a minimum during the early days ... and I will have to re-calibrate my approach to work accordingly. All going well, my target is to be fully back to a normal work schedule by April.

Thinking back, these last few weeks have been quite disorienting, to say the least. I feel like I've fallen off a cliff, seen my life flash before my eyes while in free-fall, then land miraculously on my feet, and be able to brush myself off / walk away, albeit a bit unsteadily!

Interestingly, it also coincides with two important (and possibly related?) developments. One, I turned 40 in Nov 2001. For some reason this was a more important milestone than usual, psychologically and maturity-wise. The questions are very different ... and so are the answers. Two, as you may have gathered already, Nilima and I have been on a path of self/ spiritual discovery for some time now (both individually and jointly); again, this has been a marvellous prism to look through to understand ourselves and life around us.

In a strange sort of way, I feel my cancer experience - short, intense and turbulent - has been God's way of actually granting me a 'Third Eye' ... a totally new perspective, with much greater clarity and much sharper focus. I am grateful to Him for this blessing and it is now my duty and responsibility to use it well .... to make some genuine good come of it.

As we now start to look ahead, there are no doubt BIG lessons to be learnt but the question we ask ourselves most often is this, "Is this experience a bump or a fork in the road?" On reflection, the answer is easy (probably it is both!) but the implications are not (what changes should we make - big and small - in our lives, from here on?) We need to make some changes, recognising the simple reality that I have a wife and two young children to provide for; that my responsibilities to them do not end because of what has happened. To the contrary, the stakes have now been raised even more! It will take some time to work this out, sensibly and constructively.

To deal with this journey ahead, our relatives, friends and well-wishers are trying to open new doors for us through their experiences, ideas and inputs, all with my best interests at heart. Please keep them coming, because they are of great value. But the options, theories, therapies, advice (and combinations thereof) can also be somewhat bewildering. So for the moment, I am simply keeping an open mind (and heart), soaking in all the signals/ messages and praying that in time, the right path will reveal itself. Then, as Nilima keeps reminding me, I need to dig deep in one spot to find sweet water, rather than to flit from one spot to another, digging shallow pits everywhere.

In summary, I am doing well and I am determined to come out stronger - in every way. This period of enforced R&R is actually turning out to be an opportunity to reflect, get in touch with ourselves, think through/ discuss issues like these and therefore is extremely rich in self-discovery and in potential. Exciting ... isn't it?

We will keep you posted as we face and cross major milestones up the Mountain.

Thanks once again for your love and support ...

Love, Vijay

17/03/2002: Report from Base Camp

Hello all,

It is time for my next update, so here goes ....

1. On the whole, the last few weeks have been very positive. In physical terms, daily life is more or less back to normal. I am feeling well; my haemoglobin count is back up and I no longer need to take iron supplements. My energy level is good; I am eating sensibly and getting regular exercise. My digestive system has not fully stabilised yet, but with the kind of surgery I have had, it takes time. Being at home with the family has been very fulfilling indeed.

Since 1st March, I have slowly started getting back to work. I go in to office once a week and on other days, I work half-days from home. But I have to admit the commute is still quite tiring .... and I have to take it one step at a time.

2. More important than physical normalcy is our broader learning about 'HEALING'. From all the inputs we have received - books, personal experience, advice - we have distilled 5 key principles:

- Healing is a life-long process that each of us needs to take personal responsibility for.
- Its 4 inter-related levels - physical, psychological, energetic, spiritual - need to be addressed together
- 'Feeling' better (quality of life) and 'getting' better (quantity of life) are like chicken and egg; each leads to the other
- To release one's personal potential fully, we need to transcend three life-traps: power, money, self-indulgence
- The only way to overcome fear - even of early death - is to open ourselves completely to it (Re-reading these, it strikes me that 'Healing' or even 'Well-being' may not be relevant to everyone ... but even if we were to replace them with the word 'Happiness', the principles still stand!)

3. We are now starting to put these principles into practice. At the physical level, I have changed my diet significantly. I am taking Chinese herbal medicines to aid my digestion, enrich my blood and boost my immune system. At the psychological level, I am learning to manage my mood swings better ... and trying to keep my 'Third Eye' open all the time. At the energetic level, I am taking Acupuncture and I am also learning to meditate. And at the spiritual level, I have taken the first steps in reaching out for Divine guidance ... and I am keeping myself completely open to receiving the signs that must eventually come my way. As a result of addressing all 4 levels of Healing, I am certainly 'feeling better' and we are very confident the 'getting better' will follow.

4. The change in approach has also meant a change in priorities. It has forced us to consider our 'life goals' as being different from 'professional goals' ... until now, I couldn't really tell the difference! This is bound to have far-reaching implications, both personally and professionally. More on this as things evolve. In tangible terms, the new priorities have led to a total review of our financial situation and I am getting professional help in developing a more coherent financial plan for the family's future ... again, something I had been procrastinating on so far.

From all that I have written, I think you will get a sense of why I describe the current position as 'Base Camp'. We have reached the snow line already, in a relatively short time. We don't have much training for the climb but we do have the desire, the tools and everyone's support in abundance. The journey ahead is going to be tricky but the views are going to get better and better. We can't yet see the path but on a clear day, we can at least see the summit.

To quote Maurice Herzog (the first man to climb Mt. Annapurna) "You don't conquer the mountain. The mountain changes you, so you can conquer yourself".

As ever, heartfelt thanks for your love, prayers and support. And keep the emails coming!

Vijay

14/06/2002: Onwards ... and upwards!

Hello all,

It has been almost 3 months since I wrote an update, so here goes ... you will be happy to hear that it is good news all around!

1. The results of my first big 6-monthly check up are just in. All tests - physical examination, sigmoidoscopy and CEA count - are entirely normal. Mr Dorudi (the surgeon) is delighted and so are we. I will be monitored like this every 6 months for the next 5 years, so it is 1 down and 9 to go. Most crucially, I am feeling very confident and great within myself.

2. In parallel, I am also taking Traditional Chinese Medicine: a combination of diet, herbal medicine and acupuncture. Again, Dr Song Ke is pleased with my progress but feels there is still some way to go. Being more holistic, this kind of treatment is relatively longer term and one needs to be patient. I am happy to follow his lead and keep at it.

3. So physically, life is almost fully back to normal, and that's great. But beyond this, the progress on the emotional/ psychological path is even more exciting and fulfilling. In fact, the last 2 months have seen intense introspection and rewarding discussion which, I can safely say, have led to a much expanded self-awareness and a sense of being "whole" that is unlike anything I have ever felt before. Many factors have contributed and I am grateful to them all. First of course is Nilima, bless her, who continues to inspire and challenge and hold firm and let go when necessary. Then Fr. Lancy Pereira - priest, scientist, musicologist, counseller - and in our case, also friend, mentor and guide, who spent 10 wonderfully stimulating and empowering days with us. Dr. Bill Mitchell - clinical psychologist - with his valuable and practical input on how to manage the transition back into the work environment. Lots of insightful wisdom from books (too many to list here) ranging from the most scientific to the most esoteric. And of course ideas and perspectives and tips and support from so many of you. We are so, so blessed!

4. Not only is this feeling of being "whole" or "better integrated in mind, body and spirit" a new and powerful one at a personal level, but there are some parallels on the professional/ work front too. The "wholeness" of approach to brand communications - we call it 360 degree branding - is absolutely central to what we believe and how we behave as a company. I am beginning to see an even deeper connection between my personal and professional journeys, and it will be interesting to see how this plays out.

5. Speaking of professional journeys .... two big milestones. One, I completed 19 years last week with my company; on 6th June I entered my 20th. I feel so proud and such a sense of belonging! Two, as some of you already know, I have recently accepted a new assignment, in a different and larger role. It is an exciting opportunity; the challenge is to do the job brilliantly but not compromise my health and well-being in any way.

6. All of us are looking forward to the move. Timing is, as ever, short. We are in the throes of winding down already. We will leave on 1st July, spend until 3rd week Aug in India and start work/school on 2nd Sept. A time for checklists and farewells and clearing out assorted possessions accumulated over the years, but also a time of transition and new beginnings. Another fork in the road ... and we are taking it!

Looking back over the last 6 months, it strikes me that the pendulum has been swinging somewhat wildly and in different directions. Thankfully, everyone - family, friends, employer, colleagues - has been wonderful in their understanding and in helping me deal with it. The swing was partly due to the circumstances - discovery of cancer, surgery and recovery, the slow transition back to normalcy. But also due to my own nature - wanting to explore every dimension of these difficult circumstances, leaving no stone unturned, using both my rational and my intuitive self.

Now I feel the pendulum is much closer to equilibrium; its movement steadier and more rhythmic. More importantly, it seems to be coming to rest in a different - and higher - place from the past.

Looking to the future, I have a strong and renewed purpose and I am committing myself to re-engaging with Life fully on every front - work, family and personal - while holding this expanded awareness, wholeness and equilibrium. Is it too early to say that instead of threatening my life, cancer may actually have saved it? It may well be .... but that is how I am starting to feel.

Onwards ... and upwards!

Love, Vijay

14/10/02: From Garden Road ... a short way up the Peak!

Greetings all,

The title of this email is both literal and figurative. Literal because Garden Road is where we stay and it is a short way up the Peak. Figurative in that it captures pretty much how I feel these days ... happy and optimistic in new and pleasant surroundings, but very conscious that the journey is far from over.

Since I last wrote to you in June, so much has happened that it is hard to figure out whether time has stood still or has flown by; it is quite disorienting actually.

June was all about winding down. A whirl of fond farewells and packing up followed. Looking back, we are surprised how attached we became in only 3 years - to our home, our friends, our daily routines, our work.

July and most of August was spent basking in the warm and loving embrace of family, friends and well-wishers in India. We usually go home to India every year but this visit was much more intense than any previous ones. It wasn't only that we met more people than usual (which we did) or that we travelled to more places than usual (we did this too ... particularly a big family reunion trip which was all about reconnecting with our roots - ancestral villages, family temples, the blessings of our 'gurus', glorious countryside, fabulous food.) The real difference was that our recent journey - from the time my cancer was diagnosed till now - has resulted in connections with all of you that are deeper, richer, more personal - and which we celebrated with so much joy when we met. Showered with love and smothered with hospitality. Can there ever be better medicine?

September onwards was about diving in and settling down. We have been fortunate in every respect .... we found a well-located, lovely, large apartment, the kids have joined excellent schools, Nilima has quickly formed a close social circle and I have been eagerly and warmly received at work. Good signs that we are grateful for ... long may they continue!

All sugar and spice and all things nice? No, alongside the good things I have described, the last four months have also been very hectic and turbulent. But we are quite pleased that on the whole, we stayed on top of things; we seem to have managed a complex and difficult transition with increased focus and equanimity. And in this process, we have taken many big steps in clarifying our long-term plans for ourselves. Hopeful indications that our outlook and approach have changed (and have changed us) for the better.

On the health front, no news is good news. I am doing well and feeling well. Those of you who have seen me recently also say I am looking well. Thank you. My ongoing challenge is to engage with and enjoy life fully while staying within a very small margin of error when it comes to life-style. (In ad-speak, we call it "the freedom of a tightly-defined brief"!) We are in the process of finding a good doctor/ cancer clinic and my next big check up is in December. I am confident it will only be a formality ... but the fingers remain crossed and prayer wheels continue to spin!

Two unexpected (and parallel) developments that are becoming factors in shaping our future.

The first causes me utter despair. Since July, as many as 6 (yes, six!) people we know well have been diagnosed with some form of cancer. 3 with breast cancer, 1 with brain cancer, 1 leukemia and 1 colon cancer. What is going on here ... is it just that I am now more aware of others facing similar situations ... are we just paying less attention to ourselves: physically, emotionally, psychologically, spiritually ... or is there some other deeper, subtler pattern that remains to be discerned and dealt with?

The second development is that I am being increasingly drawn into sharing my own experiences more widely and in actively helping/ counseling others. This started loosely (with some of the people described above) but is slowly gaining both momentum and form. Again, thanks to my cancer, new spaces are opening up ... and I need to figure out how to explore them. Put another way, I feel brave enough to face cancer; the real question is whether I am brave enough to honour it?

In summary then, I find myself in an intriguing 'threshold' position ... a spot of stillness yet full of possibilities ... or if you prefer, on Garden Road, a short way up the Peak!

I look forward to hearing from you soon and to keeping the connections strong!

Love, Vijay

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Caregivers Bible

Caring for a cancer patient is no bed of roses. It can be challenging, and, at times, depressing and isolating. The Caregivers Bible provides tips for improving the quality of life for both caregivers and the people they are taking care of.

  • Maintain social contacts and as many activities as possible
  • Formally, and in writing, schedule respite time for yourself on a daily or weekly basis. Even a few minutes a day can make a difference in your outlook. Stick to that schedule.
  • Involve other relatives in care of the care recipient early on, including multiple-day care over weekends and holidays.
  • Do not martyr yourself. No one should expect to provide all care every day without help. If you can, get a job or activity away from home for periods of time.
  • Make sure that children and siblings understand the disease. Let them assume caregiving duties for short periods, so they experience first-hand the stress you experience as a caregiver. They too will suffer doubt, denial, guilt and anger, and the fury may be directed at you.
  • Guilt and anger are normal emotions. Recognize them for what they are, and avoid acting on them. Anger usually accompanies a sense of guilt.
  • The incidence of headache, insomnia, backache or other physical symptoms during caregiving can be stress-related, stemming from unresolved anger, guilt and/or depression. Nearly all caregivers are physically affected by the care recipient's illness. Face that fact and accept it. To remain an effective caregiver, you must take time out for yourself.

*Source unknown*

Caregiver's Bill Of Rights

I have the right...

  • To take care of myself. This is not an act of selfishness. It will give me the capability of taking better care of my relative.
  • To seek help from others even though my relatives may object. I recognize the limits of my own endurance and strength.
  • To maintain facets of my own life that do not include the person I care for, just as I would if he or she were healthy. I know that I do everything that I reasonably can for this person, and I have the right to do some things just for myself.
  • To get angry, be depressed, and express other difficult feelings occasionally.
  • To reject any attempts by my relative (either conscious or unconscious) to manipulate me through guilt, and or depression.
  • To receive consideration, affection, forgiveness, and acceptance for what I do from my loved one for as long as I offer these qualities in return.
  • To take pride in what I am accomplishing and to applaud the courage it has sometimes taken to meet the needs of my relative.
  • To protect my individuality and my right to make a life for myself that will sustain me in the time when my relative no longer needs my full-time help.
  • To expect and demand that as new strides are made in finding resources to aid physically and mentally impaired persons in our country, similar strides will be made towards aiding and supporting caregivers.

*Author Unknown*

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Quitting Smoking

Are you one of those people who are going to quit smoking-tomorrow? I am sure that you know that smoking is harming your health and that of those near you who are forced to inhale the smoke. Have you tried to quit over and over again? If you are struggling to quit, read on....

As any smoker will testify, quitting smoking is tough. Why so? Well, first understand why cigarettes are so addictive. Cigarettes contain nicotine, an alkaloid. Alkaloids are one of a large group of substances found in plants. They are usually bitter and often have druglike effects. Caffeine, found in coffee, is an alkaloid, as is cocaine, obtained from the leaves of the coca plant. Now, inhaled nicotine bonds with receptors that provoke pharmacological effects which are perceived as positive and pleasant. When the effects dissipate, the receptors send signals that they want renewed stimulation. This manifests itself in an unpleasant way, ie the desperate need to smoke, called craving. To compound the effect, smoking is accompanied by certain emotions and desires and these can be as compelling as the physical effects. Gradually the urge to smoke is triggered whenever the level of nicotine falls below a certain level or when a situation, setting, emotion or desire cues the ‘need’ to smoke.

What makes quitting smoking so hard is that while nicotine withdrawal produces measurable physical effects that last anywhere from 7 to 30 days, craving can continue for many months. This is because while the deprived nicotine receptors wither rapidly, the environmental cues continue and these are the associations that are difficult to erase.

So, how does one quit smoking?

The most important thing is for you to decide that you want to stop. This may happen due to a build-up of worry, symptoms of ill health that create a feeling of vulnerability, or an event that generates a feeling of dislike of the habit.

At this stage you can take the following steps to resist craving:

  • Analyse your smoking patterns and recognize which settings, situations, emotions and desires trigger smoking. Avoid them if possible, or find alternative responses (chewing bubble gum, for instance).
  • Avoid alcohol, since alcohol reduces vigilance and resistance.
  • Practice thinking of yourself as a non-smoker. Keep telling yourself that no problem can be solved and no pleasure enhanced by smoking.
  • Until you can resist the urge, try to delay it. Keep busy, make yourself wait and the craving will go away.
  • Exercise. This will keep any weight gain to a minimum and generally make you feel better.

Today there are also medical interventions available, in the form of nicotine replacement therapy, for those who wish to stop smoking.

Are you trying to help someone else quit smoking? Here are some tips:

  • Create non-smoking zones where, cordially and with great understanding, the smoker is made to feel that it is unreasonable to bother others with tobacco smoke. This establishes mutual respect between a smoker and non-smoker.
  • Gather information about tobacco and supportively, never judgementally, tell the person about it.
  • Always be supportive of the efforts made to break away from tobacco. Research has shown that smokers have more success when they live in a supportive environment.

What are the benefits of cessation?

  • In 20 minutes, blood pressure and pulse rate return to normal, and circulation improves to hands and feet, making them warmer.
  • In 8 hours, oxygen levels in the blood return to normal and chances of a heart attack start receeding.
  • In 24 hours, carbon monoxide is eliminated from the body and the ability to taste and smell is improved.
  • In 48 hours, nicotine is no longer detectable in the body.
  • In 72 hours, breathing becomes easier as bronchial tubes relax and energy levels increase.
  • In 2-12 weeks, circulation improves, making walking perceptibly easier.
  • In 3-9 months, breathing problems, such as shortness of breath, coughing and wheezing, reduce. Overall lung function increases by 5-10%.
  • In 5 years, the risk of heart attack falls to about half that of a smoker.
  • In 10 years, the risk of lung cancer falls to about half that found in a smoker. The risk of a heart attack falls to about the same as someone who has never smoked.

Are you a smoker who would like to quit? Are you trying to help someone else to quit smoking? Would you like more information on how to quit? At CPAA we have a dedicated team who can help you. Our experience with people from different socio-economic backgrounds and age groups has enabled us to help countless people in the past. We can do the same for you. Contact us.

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Alternative Therapies

Introduction

No unqualified cure for cancer exists, either in conventional or non-conventional medical systems, hence the need to broaden our horizon of knowledge and explore the realm of alternative healing techniques. These refer to mind-body techniques that the practitioner hopes will help the body cope with side effects of medical treatment and help prolong life. However, there are no studies documenting the validity of these therapies; information comes primarily through anecdotal references.

Fighting Cancer through alternative healing therapies involves viewing the illness in an alternative manner. You need to see it as a total body disease right from the beginning rather than only after the disease has spread through the entire body. Cancer represents an imbalance in the body’s ability to adapt to adverse external or internal conditions. The best in cancer care comes through an amalgam of both conventional and alternative medicine. Curing cancer requires an integration of the two in such a way that an alternative therapy scrutinizes its treatments via the language of conventional medicine. Alternative therapies do not replace or intend to compete with the conventional cancer treatment of chemotherapy and radiation. Instead they complement conventional treatments by making the process smoother, and providing relief from pain, trauma, nausea and other ill effects of the disease.

What do Alternative Therapies do?

Alternative Therapies help to extract the wisdom of age-old traditional healing systems, merge this knowledge into mainstream medicine and treat the patient as a "whole" (body-mind-spirit) and not merely a disease. It achieves this by energizing the individual’s own inherent healing power.

They are broad-spectrum programmes, assisting in locating the root cause (source) of the disease, and assessing whether it is located within the body or outside of it.

They strive towards restoring the immune system by utilizing treatments, which depend upon bio–pharmaceuticals, immune enhancement, metabolic, nutritional and herbal medicine that can ultimately cure the whole body.

However, anyone considering Alternative Therapies needs to remember this:

"Alternative Healing is a lifestyle---it is not just a herb or a pill or a treatment for fighting disease. You must remember the fact that people who have had some success in treating cancer in a "progressive" manner are typically humanitarian healers and not researchers."

Only the patient’s own natural life force can create healing and this healing can be facilitated only through increasing awareness, vitality and energy flow. The issue of disease is really a spiritual issue since the root cause of all of a person’s diseases is the person themself. Individual beliefs and attitudes block the energy system causing imbalance and disease. Working on oneself emotionally and spiritually is ultimately the only way to cure the roots of disease. Alternative healing helps in working with each individual’s energy systems by removing all blocks and stresses and achieving the much-needed balance.

The ultimate objective of Alternative Healing is Total Treatment and Rehabilitation.

Choices: a guide to help you fight cancer naturally

There are many alternative therapies, which are of use in fighting cancer.

Acupressure:

This is a simple method of applying pressure to certain areas or nerves. It is a safe and effective method to relieve pain associated with any chronic disease like cancer. Any disturbances in the body organs are reflected on the palms and soles. Certain points on the palm and soles may feel tender or painful which is an indication that certain organs are unhealthy.

In the treatment of cancer, it is not enough to focus on just the diseased organ, the entire body has to be treated as a whole, especially the main organs of regeneration such as the liver, spleen, kidneys, and gall bladder. These need to be reactivated.

Acupressure helps in the process of recovery by accelerating the reactivation and bringing the metabolism of the body in order.

Acupuncture

This is an ancient Chinese art of healing which consists of putting acupuncture needles at certain points in the body. It is a painless procedure, recommended for several conditions - relief from pain, nausea and vomiting are the ones of great interest for cancer patients.

Studies have revealed that acupuncture can help patients undergoing chemotherapy experience relief from nausea, and reduce the need for pain medications.

Aroma Therapy

This ancient healing art is a natural way to relieve stress, energize the body and create a sense of well-being.

Although not proven to cure a disease like cancer, aromatherapy when used along with other forms of alternative therapies can help alleviate the pain, stress, and discomfort of the disease.

Ayurveda

As the world’s oldest existing medical system, Ayurveda has been in existence since Vedic times. It teaches a very systematic and scientific way of life. Its’ fundamental principles are the use of various herbs, minerals, Panch-Karma therapy and knowledge of the constitution of our bodies. Other approaches to the treatment include detoxification, massage, and breathing exercises. The most important aspect of Ayurvedic treatment is that it treats the whole person in the belief that one cannot split a person into parts. It can be taken alongside other forms of treatment.

Many new Ayurvedic herbal compounds like MAK-4 and MAK-5 have proved suitable for cancer treatment.

Color Therapy

Our body has 7 main energy centres or Chakras and each of them vibrate to a certain color. Each color - red, orange, yellow, lemon, green, turquoise, blue, indigo, violet, purple, magenta, scarlet has a different effect on the body, since their energy vibrates at varied frequencies. Colour Therapy applies the correct colors for healing in a more concentrated form than sunlight. It can be used as a supplement to other alternative healing techniques to treat any disease.

Like color, light and sound (music) also exude vibratory energy and can affect the way we feel. Light gentle music always has a therapeutic effect as compared to loud irritating noises.

Crystal Therapy

A crystal is a geometrically formed fused mineral/sugar or substance whose molecules or atoms are arranged in a repetitive manner, giving its external shape a symmetrical appearance. Quartz crystals have become very popular as a tool to amplify and direct natural energies.

If cancer exists in your physical system, the positive changes that crystals help to make on the etheric level will eventually affect the connection on the physical level. They help in removing energy blocks and negative thought forms on the subtle energetic level. They provide healers with a permanent tool to amplify and direct healing energy. They can be used with, say, Reiki to promote further healing.

Crystals can be programmed for specific health problems.

Diet – Herb Therapy

Diet therapy stresses on foods and supplements, which are high in potassium. Patient- specific dietary programmes are established, with stress being laid on detoxification and neurological stimulation through chiropractic adjustment and supplements of vitamins, minerals and enzymes.

Herbs: Plants extracts are man’s oldest medicines. Many plants contain naturally-occurring anti-cancer agents. The botanicals that fight cancer are many and varied, and include:

  • Ginseng
  • Green tea
  • Mistletoe
  • Bioflavonoids
  • Carotenoids
  • Garlic

Homeopathy

Cancer as a disease has always presented a formidable challenge to the medical profession. Homeopathy, which is based on the principle of ‘like cures like’, helps stimulate the body’s immune system, thus strengthening the system from within.

Although it may not cure terminally ill patients, it has been shown to be effective in providing pain relief, and helps in relaxing the patient.

Magneto Therapy

The use of magnets for healing has several advantages. It slows down the degenerative process of the body and encourages quick healing post surgery. It also normalizes blood pressure and increases oxygen absorption via the lungs. There are no side effects as no foreign toxins are injected into the body.

Meditation and chanting of mantras

Just as Prayer is talking to God, Meditation is listening to the answers or the guidance of your inner self. The sources of guidance are several but you must ‘listen.’

Chanting of mantras has always existed within the Hindu religious tradition. "Om" is regarded as the creative principle of sound from which the universe has evolved, and chanting this on a regular basis actually alters the patterns of your brain and body. This is due to the fact that the mantra is a symbol of boundless energy, and chanting of the mantra is a reminder of the various degrees of purification, of self-refinement necessary for growth.

Chanting should continue despite the disease. For chanting, you can choose any word that you are comfortable with and repeat them over and over again until they become a part of you. Some of the single words commonly used are Om, Amen, and Alleluia.

Having the right mental attitude is of absolute importance: What you think is what shall be. Your body is a reflection of the mind and its tissues will adjust in size and texture according to the quality of emotions and thoughts passing through your mind. Positive energy will keep your body flexible and supple whereas negative energies work in the reverse manner.

Developing the right attitude towards illness imparts the strength to face its existence and overcome it

Reiki

Every human being is alive because a life force flows through him or her. This life force nourishes our organs and cells and is responsive to thoughts and feelings. When there is a disruption in the life force flow due to negative thought patterns, the vital functions of the physical body diminish and disease results.

Reiki is a simple hands-on treatment, which heals by clearing and straightening the energy path allowing the life force to flow healthily and naturally. It is spiritual in nature but is not a religion, nor does it have a dogma. Reiki complements conventional medical treatment by reducing pain and stress and shortening the healing time.

Reiki treatment helps in cancer by:

  • Balancing energy
  • Releasing emotions and stress
  • Increasing awareness
  • Working on a causal level in a holistic manner
  • Reversing the aging process

Reflexology

This gentle non-intrusive touch therapy is applied to the feet and hands to assist the body’s own healing process and abilities. It is a powerful, unique and effective form of therapeutic bodywork.

Tai Chi

Although Tai Chi is often spoken of as a martial art, it is far more than that. It helps us to achieve our potential in areas of preventive health and personal development.

Physically, it helps improve blood circulation, strengthen the immune system and balance regulatory functions. It strengthens the organs, tissues, joints, muscles, and bones and as a therapy, promotes calmness, mind-body integration, balance and self-discipline.

Yoga

Yoga is both a spiritual path and a way of life. It is a holistic healing technique that helps a person to grow spiritually and gives them the inner resilience to accept the disease and cope with it. Yoga helps you to go back to nature by learning the proper breathing techniques and postures, which can reduce and eliminate pain.

Yoga centres on "Asanas", "Pranayama" and "Kriya".

Relaxation is a form of yoga therapy, which rejuvenates depleted energies. Relaxation performs the function of a tranquilizer and is far more effective than medication. The 2 most important methods often suggested for relaxation are:

  • Shavasana: a corpse-like posture where the person lies supine on the floor in a calm environment. The body is relaxed by loosening the muscles. The focus is on letting one’s tensions/anxieties just wash away
  • Long Swing: the person stands with legs apart, hands loose by the side and turns left to right and right to left, hands moving freely

Pranic Healing

Pranic Healing is based on the principle that body has the ability to heal itself. It utilizes life force as fuel to initiate the necessary biochemical changes to make this happen. Using a scientific "no-touch" methodology, Pranic Healing can prevent and heal a whole spectrum of physical, emotional and mental ailments. Because the methods are simple and easy to understand, anyone can learn and apply Pranic healing in a short amount of time. In Pranic Healing, healing is accomplished by removing negative or disease energy from the patient's energy body and transferring fresh Prana to the affected areas.

(Contributed by Jyotsna Kumar).

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Cancer Prevention and the Importance of Diet

We are what we eat-even more so where cancer is concerned than in any other disease. What can you do to reduce your cancer risk? Read on...

In 1994, the American Institute for Cancer Research, in collaboration with its international affiliate, the World Cancer Research Fund, began the Diet & Cancer Project, an effort which brought together 15 of the world's leading researchers to produce a comprehensive new report on the correlation between diet and cancer prevention. This project was an outgrowth of the landmark 1982 report of the U.S. National Academy of Sciences, Diet, Nutrition and Cancer. In the years since the publication of that report, thousands of research studies in diet and cancer have been produced.

The 660-page report which resulted from these efforts provides an analysis based on thousands of research studies, examines the relationship between dietary factors and 18 specific cancers, provides new dietary guidelines for cancer prevention and offers public policy recommendations to help make cancer prevention an achievable goal. This report also, for the first time, examines diet and cancer prevention from an international perspective, which is vital in the light of growing cancer incidence rates in developing nations.

The full report, Food, Nutrition and the Prevention of Cancer: a global perspective, was published in September 1997 and launched with major conferences in the U.K. and U.S., as well as events in India, Tanzania and other countries. Since its publication the report has been hailed by scientists around the world and has helped set a new foundation for research and education efforts related to cancer prevention. Based on an analysis of more than 4,500 research studies, these guidelines present the best currently available advice on actions to take for lower cancer risk. Some of the recommendations of that report are given below:

Recommendation 1 Adopt predominantly plant-based diets rich in a variety of vegetables and fruits, pulses (legumes) and minimally processed starchy staple foods.
Recommendation 2 Avoid being underweight or overweight. Limit weight gain during adulthood to less than 5kg (11 pounds).
Recommendation 3

If occupational activity is low or moderate, take an hour's brisk walk or similar exercise daily. Exercise vigorously for a total of at least one hour in a week.

Recommendation 4 Eat 400-800 grams (15-30 ounces) or five or more portions (servings) a day of a variety of vegetables and fruits, all year round.
Recommendation 5 Eat 600-800 grams or more than seven portions (servings) a day of a variety of cereals (grains), pulses (legumes), roots, tubers and plantains. Give preference to minimally processed foods. Limit consumption of refined sugar.
Recommendation 6 Alcohol consumption is not recommended. Limit alcoholic drinks to less than two drinks a day for men and one for women.
Recommendation 7 Drop red meat from the diet or limit intake to less than 80 grams daily. Eat fish, poultry and meat from non-domesticated animals instead of red meat.
Recommendation 8

Limit consumption of fatty foods, particularly those of animal origin. Use modest amounts of appropriate vegetable oils.

Recommendation 9 Limit consumption of salted foods and use of cooking and table salt. Use herbs and spices to season foods.
Recommendation 10 Do not eat food, which, as a result of prolonged storage at ambient temperatures, is liable to contamination with mycotoxins.
Recommendation 11 Use refrigeration and other appropriate methods to preserve perishable foods.
Recommendation 12

Moderate levels of additives, contaminants and other residues in food and drink are not harmful. However, their unregulated or improper use can be a health hazard, especially in economically developing countries.

Recommendation 13 Do not eat charred food. For meat and fish eaters, avoid burning of meat juices. Consume the following only occasionally: meat and fish grilled (broiled) in direct flame; cured and smoked meats.
Recommendation 14 For those who follow the recommendations presented here, dietary supplements are probably unnecessary, and possibly unhelpful, for reducing cancer risk.
Recommendation 15

Do not smoke or chew tobacco.

The Benefits

  • A simple change, such as eating the recommended five servings of fruits and vegetables each day, could, by itself, reduce cancer rates more than 20%.
  • Eating right, staying physically active and maintaining a healthy weight can reduce cancer risk by 30% to 40%.
  • Recommended dietary choices coupled with not smoking have the potential to reduce cancer risk by 60% to 70%.

Why are people on fat rich diets at such risk?

What is there about a diet high in saturated fat vs. a diet rich in fruits and vegetables that could have such a dramatic effect? The ingestion of certain vegetables or the active ingredients they contain, in the form of dietary supplements, can act to neutralize carcinogenic substances, especially free radicals. Vegetables provide antioxidants, which react with and neutralize the free radicals that can cause tumours. There is still another reason why people should lower their caloric intake of fat to 20-25% from the 40-70% range that so many of them are in. Fat molecules can form "lipid peroxides", which can destroy the beneficial antioxidants that we ingest in fruits and vegetables. Also, fats have toxic breakdown products that can enter the bloodstream from the gastrointestinal tract if they remain there too long.

Of course, the more fat a person consumes, the less desire they have to eat fruits and vegetables, but this is only the beginning of a very interesting story. Researchers have shown that differences in exercise and childbearing patterns do impact the incidence of cancer. Studies of Asian and Slavic peoples who migrate and adopt Western eating habits (with 40% or more of their caloric intake high in saturated fats) show an increase in steroid-involved cancers that directly correlates with their dietary change.

What Substances Exist In Vegetables That Can Reduce Cancer Risk?

In the 1970's, it was reported by Dr Lee Wattenberg at the University of Minnesota that feeding experimental animals a chemical substance called indole-3-carbinol (I-3-C) had the same anticancer effect as feeding them vegetables such as cabbage, broccoli, Brussels sprouts, and cauliflower. He knew that these vegetables were particularly abundant in I-3-C. In 1990 Dr. Jon Michnovicz reported that women who take I-3-C each day doubled their blood level of C-2 estrogen (the good estrogen) and reduced their blood level of C-16 (the bad estrogen) in an equally impressive way, which led to the conclusion that I-3-C was really the substance that stimulated C-2 estrogen production and increased the rate of removal of the dangerous C-16 estrogen.

Other substances are also known to slow or limit cell division in the prostate gland. One of them is a substance known as "serenoa reopens B". This is found in "pho inta" berries (traditionally consumed by Seminole Indians of North America). The important thing to remember is that anything that will lower the estrogen/testosterone ratio in aging men by lowering the rate at which 17 beta estradiol is formed (by the aromatization of testosterone) will be beneficial. Men should be motivated to lower their risk of cancer in any steroid sensitive tissue. This includes not only tissue of the prostate gland, but also tissue in other areas such as fat-laden breast tissue.

Sulforaphane, found in vegetables such as broccoli stimulates enzymes in the liver to break down such dangerous carcinogens as aflatoxin and polybrominated biphenyls. Limonene, found in citrus fruits, and lignan, found in whole grains, have also been observed to slow, stop, or even reverse the growth of steroid-involved malignant tumors.

How Can Fibre Help?

There are two kinds of fibre. Soluble fibre is digested by bacteria normally present in the gastrointestinal tract. But insoluble fibre such as cellulose, present in many types of fruits and vegetables, is not digested. It plays a very beneficial role in that it can bind to any estrogen that passes from the liver to the intestine. A lack of fibre in the diet, therefore, can result in carcinogenic forms of estrogen being reabsorbed back into the bloodstream from the gastrointestinal tract. Glucarates are another group of substances, present in fruits and vegetables that can bind and prevent the reabsorption of estrogen.

Fruits and Vegetables(The following is from the Times of India dated 19/7/99)

  • Plant foods are full of antioxidants and phytochemicals that help combat degenerative diseases. Even though it is unclear how most phytochemicals work, their beneficial effects are apparent. Researchers have identified health benefits with the following fruits and vegetables:
  • Apples/Grapes/Cherries/Strawberries: These fruits contain ellagic acid thought to fight cancer by blocking an enzyme used by cancer cells.
  • Cabbage family: The beta-carotene, indoles, glucoinolates and isothiocyanates (found particularly in broccoli) in these vegetables may prevent certain cancers.
  • Chilies /Peppers: Capsaicin, the stuff that gives chilies their fire, is an antioxidant, which can neutralise free radicals. Also a good source of vitamin C and Beta-carotene.
  • Citrus Fruits: Orange, sweet lime, grapefruit, lemon, etc. are packed with vitamin C, bioflavonoids and limonene being studied for its effects on breaking down carcinogens and stimulating cancer fighting cells.
  • Garlic and Onion Family: The allicin in garlic lowers bad LDL cholesterol and triglycerides and raises the good HDL cholesterol in blood. Garlic drops blood pressure levels, boosts immunity and has antibiotic properties. The evidence for combating cancer is still inconclusive. (An article, "Diet can prevent cancer" which appeared in the Times of India on 12/8/99 recommended consuming 2 cloves of chopped raw garlic and half a raw onion with both meals every day. More than thirty different anti-cancer compounds have been identified in them, the article says.)
  • Green Tea: Research indicates that green tea which contains polyphenols (a class of antioxidant) and in particular, catechins may have an anti-cancer effect.
  • Guava/Amla: These fruits contain more vitamin C per gram than oranges.
  • Leafy Greens: Leafy greens like spinach, fenugreek, amarnath, lettuce, parsley, celery are an excellent source of beta-carotene, calcium, iron, folic acid, vitamin C and nutrients. Glutathione, active ingredient in spinach safeguards against cancer.
  • Oily Fish: Mackerel, salmon, tuna, sardines, herring, lake trout contain omega-3-fatty acids, which protect against diabetes, cancers, inflammatory and autoimmune diseases.
  • Soya: Soya products rich in genistein have been linked to lower rates of certain cancers.
  • Tomatoes: Tomatoes contains lycopene, a carotenoid which has cancer-resistant effects, and coumaric acid and chlorogenic acid which flush out carcinogens.

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Details of the Various Types of Larynx Prosthesis Available in Mumbai

Patients of head and neck cancers sometimes dread losing their voices more than the cancer itself. This need not happen. Here is a list and description of some of the prostheses that do the job of your voice box...

Duckbill prosthesis :

This is a temporary voice box prosthesis, which can be used for a maximum period of 2-3 months. It has to be fitted into the TEP (Trachea -Oesophagal Puncture) and must be taken out every 3 - 4 days for cleaning.

It costs Rs.1600/-.

Ultra low resistant voice prosthesis :

This too is a temporary voice box prosthesis, which can be used for 2-3 months. It is superior in quality compare to the Duckbill prosthesis - it has better clarity of sound. This too has to be fitted into the TEP and has to be clean every 3-4 days.

It costs Rs.2800/-.

Provox prosthesis :

This is a permanent voice prosthesis and can be used for 4 to 5 years. This too has to be fitted into the TEP. It comes along with a cleaning brush and the patient can clean it periodically without removing it.

It costs Rs.12000/-.

Electro Larynx :

This is a permanent prosthesis. Here the TEP is not essential. This prosthesis has to be worn around the neck. It has a vibrator, batteries and a switch. The switch can be carried in the patient’s pocket. When switched on, the vibrator acts and a resultant metallic sound is created. It needs a lot of timing. There is only one pitch with this prosthesis while all the earlier mentioned prosthesis have pitch control facility.

It cost Rs.8000/- and is manufactured in Delhi.

Servox speech aid :

This is manufactured in Germany and costs Rs.33,000/-. It is similar to the above-mentioned Electro Larynx.

For details and information on how to order these prosthesis contact us.

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