Nasopharyngeal carcinoma is one cancer that is curable if detected early. SOO EWE JIN talks to patients, caregivers and doctors – including an internationally acknowledged Malaysian doctor – on how the battle
IN the small, nondescript office on the second floor of the Medical Faculty at Universiti Malaya, Professor Umapati Prasad hardly projects an image of a medical giant.
Yet his research over the past 30 years into nasopharyngeal carcinoma (NPC), commonly referred to as nose cancer, has been remarkable and internationally acknowledged.
Prasad, almost 70 years old, shows no sign of slowing down. He is deep into research and attends many conferences overseas to share his findings and learn from others. He continues to teach the university’s medical students and also acts as an external examiner and assessor for other local public universities.
And the teacher in him also permeates much of his private life where, as a spiritual mentor, he teaches the sacred Bhagavad Geeta text to many at the Geeta Ashram Malaysia in Petaling Jaya.
But what brings him great joy is when he becomes a doctor again at the NPC clinic every Monday. “I am so happy to see so many smiley faces at the clinic. Instead of me asking my patients how they are, most of them would ask me how I was. Some of them even bring me home delicacies, like Ipoh kaya,” he tells The Star.
There is a strong reason why Prasad attaches so much value to the demeanour of his patients. “Thirty years ago, when I first entered into the realm of NPC, the sight was always very depressing. Nurses cried. Patients, by the time they were referred to us, invariably were in their final stages of life. It all seemed so senseless and helpless.
“Now we have made so much progress. When patients know what it is they are facing and their chances of survival, they are no longer scared. If there is one cancer that can be licked, this is the one.”
It is Monday afternoon at the NPC clinic. Some 20 patients are in the waiting hall. Almost all would have a bottle of water handy.
“This is like our mark of life,” says a patient now into his fourth year of remission. “After radiotherapy, our salivary glands are affected and we have to constantly moisten our mouths. But when you consider that we are ‘cured’, this is really a small price to pay.”
Prasad steps into Room 4 at 2pm sharp. He does not like to keep the patients waiting too long, some of whom travel from as far as Sabah and Sarawak. The ENT (ear, nose and throat) clinic is open every day but the NPC clinic run by Prasad is only available on Monday afternoons. He sees an average of 30 patients each week.
Prasad recalls that 30 years ago, when he first took an interest in NPC, more than 75% of patients ended up in wards other than ENT, which led to further delays in diagnosis and treatment. “The fatality rate was very high because most of these patients were already in their advanced stage,” he says.
In a paper published in 1970 entitled Problems in the early diagnosis of nasopharyngeal carcinoma, Prasad pointed out that the patients were referred to other wards because of the bizarre presentation of symptoms.
Today, all NPC patients can be properly diagnosed if they are sensitive to the early warning signs and are immediately referred to ENT specialists.
A patient relates how he felt an unequal pressure in his right ear for about a week but did not bother too much about it. “Then one day, while clearing my throat, I noticed blood-stained phlegm. I went to my family doctor and he confirmed that I was in the pink of health,” he recalls. “But because I was not suffering any flu or other minor ailments at that time, which might have caused some problems around the ear, nose or throat, he immediately wrote out a letter referring me to the NPC clinic at Universiti Hospital (now known as the Universiti Malaya Medical Centre).
“As it turned out, I had NPC in the very early stage and the early detection saved my life.”
This doctor, a former student of Prasad in the 80s, recalls how the professor would drum into them the need to be alert to the early symptoms, especially uneven ear pressure problems and the hawking out of blood-stained phlegm when the patient is otherwise healthy. “All the research done locally had already established the ethnic groups and age range where NPC is most prevalent. In this case, my patient was just turning 40, a Chinese male, so I did not want to take any chances.”
Prasad has also written extensively about how doctors in general practice tend to miss the early warning signs. “When I lecture our students, I tell them that if they clinically observe these symptoms and do not take the necessary measures to exclude NPC, then they are committing a great crime,” Prasad say.
Getting to the professionals is one aspect. The general public, especially the high-risk groups, need to be educated as well. Prasad recalls his early research activities which concentrated on towns throughout the country where there were high Chinese populations from the lower-income group. At that time, he was looking for the link between NPC and the Epstein-Barr virus (the virus that causes glandular fever).
“The virus is present in all of us. In the Asian context, we have learnt that it is present six months after birth. But this is a very benign situation. But somehow at the later stage of life, we find that the virus becomes highly agitated in NPC cases, probably caused by food factors, specifically salt-cured food like salted fish.
“A vaccine is now available but it is not commercially viable to produce it since there is no market in the West where NPC incidences are very low.”
Prasad was awarded the Tun Razak International Award in 1989 for his pioneering work that has put Malaysia ahead of other countries in the quest to eliminate NPC.
Doctors involved in NPC cases credit Prasad and his team for laying very strong foundations in the way they handle their patients. Dr Gurcharan Singh, a clinical oncologist in private practice, agrees that early diagnosis is the key and more public awareness programmes must be carried out to help contain NPC.
“Unlike breast cancer, for example, where one can perform breast self examination on a regular basis, we need to tell the public to be alert to the early warning signs,” he says. “However, I must also stress that while the ethnic factor with regards to the Chinese being in the most vulnerable group is convincing, anyone who has the symptoms must also check to exclude NPC.”
Another doctor who handles NPC patients is Dr Awal Hassan, a private ENT surgeon. Awal saw more than 100 NPC cases while he was in public service and the prognosis was often very depressing. “In those instances, most of the patients tended to come in late. They were also mainly from the lower-income group,” he says.
His advice: If you do not have the flu but hawk out blood-stained phlegm, have a blocked ear, or can feel the fluid in the ear, then you should check. Also, if you can feel a lump around your neck area that does not give you any pain or discomfort, then you should also check.
Awal relates the case of a lorry driver from Seremban, in his 40s, who first saw him with such early symptoms seven years ago. “He is still fine and we are happy when we know that the patient has taken the initiative to check out such symptoms early so that we are able to treat him.”
Somewhere in Kuantan, construction supervisor Chong (not his real name), 50, is carrying on his life as normal.
Diagnosed with NPC five years ago, Chong underwent the requisite 35-course radiotherapy treatment and is now in complete remission. He undergoes regular six-month checks at the Kuantan General Hospital with doctors who come in from Kuala Lumpur. “We live a fairly normal life and unless we tell people about the cancer, no one really notices,” says Chong.
The NPC was discovered when he first noticed a lump around his neck. “There was no pain but I was troubled by it. However, when I went to visit the doctors, they also did not think it was anything serious. It was only when doctors from Kuala Lumpur came to the Kuantan GH that the NPC was discovered. I subsequently went for radiotherapy in Kuala Lumpur as there was no such facility in Kuantan.”
Madam Lai Mui, 68, had the symptoms of occasional blood in the nose and phlegm and also an ear pressure problem. She felt very tired most of the time. She mentioned her problems to her regular GP. Although the doctor told her it would be good to go for further checks at the Hospital Universiti (now UMMC), there was no follow-through.
“The doctor did not mention any possibilities of complications or offer any recommendation letter to the hospital. He did not even ask her about the nose problem during the numerous occasions when she visited the clinic thereafter. So it was left as a non-serious problem,” her daughter Mee Ling recalls.
All this changed four years ago when a friend of Mee Ling was diagnosed with NPC. After he related the symptoms, they decided to take her mother for a more thorough check.
As it turned out, she too had NPC, but of a later stage than her friend. “But with the information available to us, we were more prepared to deal with my mother’s treatment,” says Mee Ling. “She is in good health now. We are fortunate because we learnt through our friend’s experience. He was such a normal healthy person and when he got the cancer, we were all shocked.
“But his positive attitude and the willingness to share his knowledge about NPC helped us to be alert to our own situation.
Nicole Teh Pek Ooi, 29, discovered she had NPC in late December 2000. One day, she started to bleed from her nose and throat area. She immediately went to her GP but he assured her that there was nothing wrong.
"He just gave me some antibiotics. But I was still concerned about the matter and although the bleeding did not come back, I went for another check. Again I was told it was nothing. A third check followed but the GP still did not want to give me a referral letter to a specialist.
"Fortunately, I met a church member who is a doctor and he immediately referred me to the ENT surgeon in a hospital in Kuala Lumpur. I was diagnosed with NPC but it was in the early stage so I underwent only radiotherapy at a private hospital in Damansara.
"I am now very well. My husband and all the family members were such a great support to me."
Another patient in remission puts it this way: “Whenever a colleague or a friend tells me he is having some ear pressure problem, I immediately give him or her the number of my ENT surgeon. Never mind that it turns out to be a sinus problem or something else, but I have learnt from my own experience that one cannot be too careful.”
From all the available statistics, and the examples above, it is clear that the quality of life of NPC patients once the treatment is completed is not affected. “This is what we want to stress. If you are diagnosed early, and you undergo the proper treatment, you can carry on with your life as normal as possible,” says Prasad.
Even in the more advanced cases, the fatality rate has been remarkably reduced because of improved treatment techniques. Nevertheless, Prasad remains committed to ensuring that there will come a day when it will be possible to wipe out NPC.
There is currently a major research involving a team of scientists headed by Prasad with funds provided by the Ministry of Science and Technology that will pave the way for even more effective diagnosis and control of NPC. “It is my lifelong mission to live to the day when the world will be free from NPC,” says Prasad.
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