The number of overweight and obese people in the world is increasing at an alarming rate. This problem is not only confined to developed and rich countries, it is affecting people living in developing countries too. Obesity is known to cause type 2 diabetes mellitus, hypertension (high blood pressure) and elevated cholesterol / triglyceride levels. Excess body fat accelerates the development of atheroma (furring of the artery) and increases the risk for coronary heart disease, stroke and early death. Unfortunately, the association of obesity with ill health does not stop there.

Researchers from the University of Oxford recently reported the findings of the Million Women Study in the United Kingdom (BMJ, 2007 Nov 6; epub). During the period 1996 – 2001, 1.2 million UK women, aged 50 – 64, were recruited into the study. The aim of the study was to examine the relationship between BMI and cancer incidence and mortality. Currently, 23% of all UK women are obese and 34% are overweight. These 1.2 million women were followed up on average for 5.4 years for cancer incidence and 7.0 years for cancer mortality. The study found that women with a higher BMI tended to come from a lower socioeconomic class, had more children than those with a lower BMI, were less likely to smoke, drink and use hormone replacement therapy. After adjusting for all the possible confounding factors, the study showed that increasing BMI was associated with an increased incidence of endometrial cancer (cancer of the womb), adenocarcinoma of the oesophagus, kidney cancer, leukaemia, multiple myeloma, pancreatic cancer, non-Hodgkin’s lymphoma, ovarian cancer and breast cancer in postmenopausal women and colorectal cancer in premenopausal women. To put it in another way, if you have a high BMI, your chance of getting endometrial cancer is increased by 189%, 138% for adenocarcinoma of the oesophagus, 53% for kidney cancer, 50% for leukaemia, 31% for multiple myeloma, 24% for pancreatic cancer, 17% for non-Hodgkin’s lymphoma, 14% for ovarian cancer, 40% for breast cancer in postmenopausal women and 61 % for colorectal cancer in premenopausal women. It is estimated that 5% of all cancers in postmenopausal women in UK are attributable to being overweight or obese.

The desire to reduce one’s chance of developing cancer is a good enough reason to want to lose weight. Apart from the above reason, there are a multitude of reasons to want to lose weight. However, using hearsay methods can sometimes land you in big trouble. This week a lady consulted me for becoming jaundiced (turning yellow in colour). Except for a recent short history of taking some slimming pills from China, I could find no medical reasons for the jaundice. Apparently, a house mate had taken the slimming pills and managed to lose a significant amount of weight and looked much better. After a series of investigations, the only reason that could account for the jaundice was drug-induced acute hepatitis. The lady’s liver function continued to deteriorate despite stopping the medication. Now she is likely to need a liver transplant in order to save her life.

If there was such a wonder drug that makes you lose weight quickly and safely, don’t you think it would have been marketed worldwide? The owner of the company that invented this slimming pill would become richer than Bill Gates and Warren Buffet put together. Losing weight requires hard work. There is no short cut, at least not yet! Next time you want to self medicate for losing weight, think thrice!

Every year, approximately 500,000 women are affected by cervical cancer worldwide. Of these, 80% are women living in developing countries, thus making cervical cancer the most common cancer affecting women in developing countries. It is now well established that virtually all cervical cancer results from genital infection with the human papillomavirus (HPV). Human papillomaviruses are DNA viruses that infect basal epithelial (skin and mucous membrane) cells. There are many genotypes of HPV but the ‘high-risk’ genotypes are genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 66. These high-risk genotypes can lead to cervical cancer and are associated with other mucosal anogenital and head and neck cancers. Other genotypes are ‘low-risk’ but can cause genital warts on the cervix, vagina, vulva and anus in women and the penis, scrotum and anus in men. They also cause growths over the vocal cords of children and adults (juvenile and recurrent respiratory papillomatosis) that require surgical intervention.

The main burden of HPV-related disease is due to cervical cancer. In 2005, HPV was estimated to have caused all of the almost 260,000 cervical cancer deaths worldwide. In 2002, there were 492,800 cases of cervical cancer worldwide. Of these, 409,400 cases (83.07%) were in developing countries. HPV infection of the epithelium leads to changes within the cells which look and behave abnormally. The appearance of these abnormal cells in the cervix is termed cervical intraepithelial neoplasia (CIN). With time and no treatment, the abnormality increases and progresses to cancer in situ (meaning localized cancer) and if left untreated it will progress to frank cancer. Regular cervical screening in sexually active women is an effective manoeuvre to detect CIN early before they turn into frank cancers. Cervical screening is widely practiced in developed countries but still lags behind in the developing world.

Recently 2 types of vaccine against HPV have been approved for general use. The quadrivalent vaccine protects against the high-risk genotypes 16 and 18 and also against the low-risk genotypes 6 and 11. The bivalent vaccine protects against genotypes 16 and 18 only. Clinical trials have shown that one month after the 3rd dose of the HPV vaccine, nearly 100% of women aged 15 – 26 years in trials of either vaccine have detectable antibody to each genotype. The levels detected were 10 -104 times higher than those in normal infections. A study from the University of Helsinki recently reported on the efficacy of HPV vaccination against genotype 16 and 18 in young women (Lancet 2007; 369: 2161 - 2170). Nine thousand three hundred and nineteen women aged 15 -25 years were given the HPV vaccine while the placebo group of 9325 women received Hepatitis A vaccine. At the end of a mean follow-up period of 14.8 months, there were 23 women with CIN grade 2+ changes detected on cervical cytology. Of these only 2 were in the vaccinated group. The vaccine efficacy against CIN 2+ containing HPV 16 / 18 DNA was 90.4%.

HPV vaccination is only efficacious in women who have never been infected with HPV. Thus the vaccination is most suitable for those who have not embarked on any sexual activities yet. Since 83.07% of the cervical cancer cases occur in the developing countries, HPV vaccination for adolescent girls may well be an effective public health manoeuvre in order to reduce the societal burden in caring for women with cervical cancer in time to come. As each vaccine costs more than $100, the present discussion in developing countries revolves around the cost of mounting such a vaccination programme. While the cost of vaccination may seem huge now, when a woman is stricken with cervical cancer, the eventual cost to the community and the health care system in looking after the cervical cancer patient may be many times greater. For the benefit of mankind, both the pharmaceutical company and the health authorities need to find ways to make the vaccine more affordable in order to save future lives.

“I am feeling tired” or “I am too tired to carry on with the therapy” are two statements you commonly hear from patients with advanced cancer or patients who are undergoing chemotherapy or radiotherapy. Cancer-related fatigue is one of the most frequent complaints from cancer patients. Cancer-related fatigue has been described as “a persistent subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning” by Mock and colleagues in the National Comprehensive Cancer Network (NCCN) Practice Guidelines for cancer-related fatigue and it often affects one’s quality of life and ability to function well before, during and after cancer treatment.

It is recognized that there are 5 primary factors known to be associated with fatigue – pain, emotional distress, sleep disturbance, anaemia and hypothyroidism. When specific causes for fatigue such as infection, cardiac dysfunction, fluid and electrolyte imbalances can be identified, treating with the appropriate medication will greatly alleviate the fatigue state. When specific causes cannot be identified, pharmacologic and non-pharmacologic treatments may become necessary. Researchers from the University of Toronto, Canada, reported a double-blind study on the effects of d-methylphenidate (d-MPH) on fatigue and cognitive dysfunction in women undergoing adjuvant chemotherapy for breast cancer (Support Care Cancer 2007; Oct 31 epub). Methyphenidate has been reported to improve fatigue and to decrease cognitive impairment in other populations. d-MPH, a form of methyphenidate, was given to women receiving adjuvant chemotherapy for breast cancer who complained of fatigue and cognitive impairment. Twenty nine women had d-MPH and 28 were given placebo. Neither treatment made any difference to the symptoms. Interestingly, the researchers found it difficult to recruit enough patients to participate in the study because most patients were reluctant to take additional medication. Thus, pharmacological interventions may not be helpful and patient acceptance of such interventions may also be low.

Non-pharmacological interventions such as exercise and psychological counseling may help cancer-related fatigue. Researchers from the H. Lee Moffitt Cancer Centre in Tampa, Florida reviewed and analysed the results of 41 randomised studies [Health Psychology 2007; 26 (6)] on the efficacy of psychological therapy and exercise in reducing fatigue among patients with cancer. They found that 50% of the psychological intervention trials and 44% of the activity intervention trials showed that patients who had psychological interventions (such as mind-body and relaxation techniques and psychotherapy) or exercise activities programmes demonstrated less fatigue.

While it is common for doctors to prescribe vitamin supplements and other medications to help patients with cancer-related fatigue, pharmacological interventions cannot be the only answer to such problems in some patients. Much research effort is being expended on solving the cause(s) of cancer-related fatigue worldwide. Until we have a better handle on how to help our patients with this problem, I normally remind my patients not to forget that they can contribute too. A routine of regular exercise, maintenance of a balanced, nutritious diet and getting out of the house daily will naturally help their fight against cancer-related fatigue.