Personal Blog of a Simple Doctor from India

Breast cancers have strong familial predisposition and runs in families. Many studies have been done in this regard. About 10% of human breast cancers can be linked directly to germline mutations. Several genes have been implicated to cause breast cancer.

Li-Fraumeni syndrome is characterized by inherited mutations in the p53 tumor-suppressor gene, that lead to an increased incidence of breast cancer, osteogenic sarcomas, and other type of cancers. Inherited mutations in PTEN have been reported to increase breast cancer.

BRCA-1, a tumor suppressor gene, has been identified at the chromosomal locus 17q21. The gene seems to be involved in gene repair. Women who inherit a mutated gene from either parent have at least a 60% to 80% lifetime chance of developing breast cancer and about a 33% chance of developing ovarian cancer. Men who inherit the gene have an increased incidence of prostate and breast cancer.

Another gene, BRCA-2, which has been identified at the chromosomal locus 13q12, is also associated with an increased incidence of breast cancer in men and women.

Mutations in BRCA-1 and BRCA-2 can be easily detected and patients should be given genetic counseling. All women with strong family histories for breast cancer are ideally sent to genetic screening programs, particularly women of Ashkenazi Jewish origin, because they have a high incidence of a specific BRCA-1 mutation. This mutation is due to deletion of adenine and guanine at position 185.

The role of these genes is more important in sporadic form of breast cancer than inherited form of breast cancer. p53 mutation is present in about 40% of human breast cancers as an acquired defect and PTEN occur in about 10%. But BRCA-1 mutation in sporadic primary breast cancer has not been reported yet.

Lots of research is still required to determine exact risk of familial predisposition of breast cancer and diseased (mutated) genes before we can say conclusively.

Few days back the big boss (the main partner of the institute where I work; the other partner is the local govt.) came here to find out the ground situation of the institute. He came here with the mission to solve the problems the college is facing as he is the best and only person who can solve the problems.

Here, I would like to mention that the local govt. is not doing the duty which it is supposed to do in trying to solve the difficulties. Govt. knows (at least everybody believes so) every thing but not taking any positive action in solving the problems. After all a democratically elected govt. has a moral duty to look after its people and their aspirations.

The big boss came and had a meeting with the faculty members first. Many of the faculty members raised many questions from the welfare of the college to the welfare of the faculty and other employees and the big boss tried to answer to them in most convincing ways. But, I think many of the faculty members were not convinced by the answers which they got. After meeting with faculty he met other employees of the institute and they had much more complains than the faculty staffs. There he reassured them but I don’t know how much they were convinced by his reassurance.

The big boss reassured every body that very soon (we hope) the problems will be solved and the Medical Council of India (MCI) will give the green signal for the admission to the new batch this academic year (though it is already late by more than 3 months). If admission for the new batch is granted it will solve the major problems, and every body is hoping and praying for that.

In the mean time during the agitation in the college for the problems many unexpected things also came to limelight. We all hope that the big boss will take concrete action to sort out all the problems the institute is facing right now. Because he is the only person who can solve the problem and he will be the largest beneficiary of that, being the main partner of the institute.

We all are eagerly waiting for the good news of Medical Council of India permission for the new admission to come. We can only wait and watch. So let’s wait and watch.

We have been waiting for quite long time now about the future course of the college. But unfortunately nobody can tell anything about the outcome. Not even the management side is uttering a word about the subject.

Only last week the combined Central govt. health ministry team with MCI (medical council of India) team visited the college once again to ascertain the feasibility of the infrastructure of the college if it can take up another batch of students for the current academic year. The combined team has gone back to national capital reported back to the concerned. But we are still in darkness regarding the fate of the college. Along with the college the fate of the employees as well as the faculty members are hanging in the balance. All of the faculty as well as non faculty employees are still positive about the outcome of the visit except a few exceptions. But the fact is only positive thinking is not enough to get the permission to admit students in a professional college like the medical profession. It has far reaching consequences to the society and to the nation.

The quietness of the management side is deafening in the situation like the one we are facing. The quietness may be some thing like the quietness we see before an impending storm, who knows? God forbid this should not happen. If unfortunately this happen the institute may not survive unless it gets a fresh fund supply from some other source. But I think the management can manage the fresh fund to make it survive.

There is hardly any time left for the permission to admit fresh students. This is the main negative point for the college. And may be a few negative points are sufficient to counter lots of positive points. Let hope no such things happens here and hope for the best outcome.  If some body give up hope than he/she is as good as dead, so lets not die before dying.  

Breast cancer is a malignant (cancerous) proliferation of epithelial cells lining the ducts or lobules of the breast. Malignancies arising out of epithelial lining of the breast are the commonest cause of cancer in women and account for about one-third of all cancer in women.

Human breast cancer is a clonal disease; that is, a single transformed cell can produce a series of somatic (acquired) or germline mutations and is able to express full malignant potential. So, breast cancer may exist for a long period as a noninvasive disease or an invasive but nonmetastatic disease. These facts have significant clinical ramifications.

Breast cancer is the commonest cancer in women in terms of yearly incidence, which accounted to 178,480 cases of breast cancers in United States in the year 2007. In terms of deaths it comes second just behind lung cancer (40,460 deaths due to breast cancer in 2007 in USA against 70,880 deaths due to lung cancer). The reason behind is success of treatment of breast cancer in the form of surgery, chemotherapy and radiotherapy. But lung cancer therapy is not as success as breast cancer therapy and consequently larger number of deaths with lesser number of incidences. 

As a result of improved treatment and earlier detection, mortality from breast cancer has begun to decrease substantially in the United States and other developed countries as well as throughout the world.

The three dates in a woman’s life that has a major impact on breast cancer incidence. They are age at menarche (first menstruation), age at first full-term pregnancy, and age at menopause. Women who start menstruation at age 16 years have only 50–60% of the breast cancer risk of a woman having menarche at age of 12 and the lower risk persists throughout life. Same way, menopause occurring 10 years before the average age of menopause (52 years), natural or surgically induced, reduces lifetime breast cancer risk by 35%. Women who have a first full-term pregnancy by age 18 have a 30–40% lower risk of breast cancer compared with women who has only one child and at older age.

Studies of molecular genetics have shown that lung cancer cells acquire many properties before turning to malignant form. These include activation of dominant oncogenes (which try to tilt the balance toward cancer formation) and inactivation of tumor-suppressor or recessive oncogenes (which try to suppress cancer) in genetic lesions. Lung cancer cells accumulate in these genetic lesions which may be more than 20 in number. A small portion of cells (less than 1%) in a tumor are responsible for the full malignant behavior and these cells are called cancer stem cells. A large bulk of the cells in cancer is formed from these cancer stem cells. They are clonally related to the cancer stem cell but themselves cannot regenerate the full malignant phenotype for metastatic disease and unlimited replicative potential. These cancer stem cells are very important in the treatment because unless they are identified and removed cancer can not be treated successfully. These cancer stem cells are more resistant to chemotherapy than the bulk.    

Changes in dominant oncogenes include point mutations in the coding regions of oncogenes, mutations in the tyrosine kinase domain and amplification, rearrangement, and/or loss of transcriptional control of oncogenes.

A large number of tumor suppressor genes (recessive oncogenes) at the time of pathogenesis of lung cancer. This inactivation is also result of mutation. Due to the mutation the tumor suppressor genes are left with functionally inactive alleles which lead to loss of function of tumor suppressor genes and single dominance of dominant oncogenes.

Lung cancer, like many other epithelial cancers, arises by a multi step process that involves both carcinogens causing mutation known as “initiation” and tumor promoters. Preventive measures of lung cancer as well as other cancer can be directed towards these factors to be successful.

Genetic Predisposition: Though lung cancer is not a familial disease there are certain factors which indicates some relation of lung cancer with familial predisposition. For example patients living till adulthood with retinoblastoma (tumor of eye) and Li-Fraumeni syndrome can develop lung cancer more commonly than can be explained by simple coincidence. Another factor is the first degree relative of lung cancer patients have 2 to 3 fold increase incidence of lung cancer than general population, many of which are not related to smoking.

Back to work place after almost a week of holiday. But not much work without the students. Students are still enjoying their vacation because they get longer vacation than the faculty members. So I will not have much work till students return. Today I am having solitary presence myself in the department. Other staffs are yet to join duty (they may join the coming Monday).

I thought I should give you news about my city, that only this week the capital city was connected by rail. The state being hilly and land locked had no rail connection though it is very well connected by air since very long time. Locals were very enthusiastically waiting for the rail connectivity and they were visibly happy the day rail connectivity was established. I only hope the service is up to the mark of acceptability. The Indian Railway is notorious for its punctuality, though after the present railway minister took over the situation has improved dramatically. But still lots need to be done.

Another information I would like to share with all of you, that my college did not get permission (till date) to admit students in the college from MCI (medical council of India) nor from Central health ministry. It is very sad and bad news for all of us who are related to this college including students, faculty members and other supporting staffs. Nobody is clear about the future of the students as well as faculty members. If admission is not permitted for one year what will happen to the students. The institute being self financing will have tough time managing its finances.

But the motto of life should be never ever to give up in any failure, and I hope the management also believes in the above mantra of life. If a door closes than more than one door will open.  

We have been waiting for quite long time now for the permission of admission of new students in the college where I work. But now wait has been too long and hopes of new admissions are fading as time is passing. From management side they are still reassuring us that the job will be done. But nobody can tell for sure when and how the job will be done. The management seems to be playing hide and seek game with everybody.

The last date according to the guidelines has already passed and the management is trying to extend the deadline. But I have my doubt. If new admissions are not there every thing can go wrong. We are just hoping for the best and preparing for the worst.

As I wrote before the Central health ministry team visited the last week and supposed to report, but we still don’t know what report they have submitted to the govt.

We are supposed to a pay hike around this time but it seems unlikely, even our pay slips may get delayed (we don’t know for how long if this present situation continues). Lots of things are happening in the college and in the hospital where the college is affiliated, which should not happen in the best interest of all of us.

In a situation like this one can only hope for the best, but can’t do anything until he/she has an alternative source of income which is ideally at least the same as salary. At this time I hope I had an alternative source of income. I am at present working to get an alternative income source.

By the way today I got an invitation from one of my doctor friend who works here in another department on the occasion of her marriage with another doctor, who is doing post graduation at present. I can’t attend her marriage but can wish her a happy and prosperous life ahead.     

On evening of 1^st October 2008 terrorists had struck the city where I live. It was around 7.30 PM on 1^st October and I was surfing the internet like any other day when I heard a loud sound. I did not bother much because it was a festive season and also wedding season, when lots of fire crackers are used to celebrate weddings. But it was a bomb blast planted by terrorists to create panic; the next day was holy festival of Muslims (Id) and also birth day of our father of nation the Mahatma Gandhi.

Unconfirmed reports say the number of death at three and injured people at 120. but the official reports say that there was no death and injured persons were about 100.

I had no idea what has happened till my sister in law rang me up to enquire about our well being and if we were out of house. The place where the bomb exploded was only half kilometer from my house. There were few more (about three) explosions in the other parts of the city. After the explosions the administration jammed all the mobile line it seems to stop spread of panic.

The explosion near my house was in a busy market area near a temple in a laundry shop run by a lady. The rumor is that, two young people came to that laundry shop and left a shopping bag telling the lady that they will come and take that shopping bag after finishing their shopping. The lady kept the bag in good faith and it exploded after some time injuring the lady seriously. The lady lost both her legs and is at present in ICU (intensive care unit) battling for life. She is now in coma and may not come back from coma.

The police are still clueless about the blasts. Central Govt. also sent team of forensic experts with a team of nation security guards. They are slowly trying to join a few threads together to find out the culprits.

The city is very peaceful and nobody expected it to be target of terrorists. But now one can say for sure that no place in the world is safe from terrorists. The life of the people of this has changed forever.    

The most important cause of lung cancer is cigarette smoking. Most of the lung cancers are caused by carcinogens and tumor promoters inhaled via cigarette smoking. The relative risk of developing lung cancer is increased about thirteen fold (1300%) by active smoking and about 1.5-fold by long-term passive exposure to cigarette smoke than non smokers.

The lung cancer death rate is related to the total amount of cigarettes smoked expressed in “cigarette packs per year” such that the risk is increased 60 to 70 fold for a man smoking two packs a day for 20 years as compared with a nonsmoker. The chance of developing lung cancer decreases with cessation of smoking, but it may never return to the nonsmoker level.

Women have a higher relative risk per given exposure than men (approximately1.5-fold higher), this means if a man and a woman smokes two packs of cigarettes a day the woman has 1.5 times more chance of developing lung cancer than man. This difference may be due to a greater susceptibility to tobacco carcinogens in women, but there is controversy.

Chronic obstructive pulmonary disease (COPD), a lung disease which is also smoking-related, also increases the risk of developing lung cancer.

About 15% of lung cancers occur in individuals who have never smoked (pure non smoker) and the majority of these are found in women. The reason for this sex difference may be due to hormonal factors, but it is not clear.

Radiation is an environmental cause of lung cancer. People exposed to high levels of radon or receiving thoracic radiation therapy have a higher than normal incidence of lung cancer, particularly if they smoke.

Prevention: Prevention is by efforts to get people to stop smoking. smoking cessation is extremely difficult, because the smoking habit represents a powerful addiction to nicotine along with it psychological addiction. In one study in Australia it was fond to be more difficult to stop smoking than stop alcohol. It is because smoking becomes a habit, a part of personality.

Counseling, behavioral therapy, nicotine replacement (gum, patch, sublingual spray, inhaler), and antidepressants (such as bupropion) are available to motivate smokers to give up the habit. But the methods are successful in only 20–25% of individuals. So the best is to prevent people from starting to smoke. In the United States prevalence of smoking is 28% for males and 25% for females, age 18 years or older and 38% of high school seniors smoke.

Lung cancer is the commonest type of cancer in terms of incidences (cases) and also in terms of death. It causes more deaths in females than breast cancer. In USA in 2007 lung cancer affected more than 114,760 males and about 98,620 females. 86% die within 5 years of diagnosis of lung cancer and makes it the leading cause of cancer death in both men and women. In 2007 in USA number of death from lung cancer were approximately 89,510 for men and approximately 70,880 in women, whereas breast cancer deaths in women were 40,460 in 2007 in USA in 2007.

Globally at present lung cancer incidence is more than 1.2 million (1,200,000) in men and about 400,000 cases in women. Number of deaths due to lung cancer globally at present is about 900,000 for men and 300,000 for women, a total of approximately 1.2 million. The total number of death due to lung cancer is going to be about 10 million by the year 2030, according to The International Agency for Research on Cancer. This roughly calculates to one lung cancer case for every 3 million cigarettes smoked.

The incidence of lung cancer is highest between ages 55 and 65 years. Lung cancer is responsible for more deaths in the United States every year than breast cancer, prostate cancer and colon cancer, combined. The incidence and age-adjusted death rate in males is decreasing, but in females it is stable or still increasing. These death rates are related to smoking; smoking cessation efforts begun 40 years ago in most developed countries in men and are responsible for the decrease in incidence and death rates in men. But women started smoking in large numbers about 10–15 years later than men and smoking cessation efforts are not particularly aimed at women. This is the main reason of increase of lung cancer incidences in women. Smoking cessation efforts need to increase for women. 

In the past 30 years, 5-year overall lung cancer survival rate has nearly doubled to about 15%. The improvement is due to advances in combined-modality of treatment with surgery, radiotherapy, and chemotherapy.