Ifeoma Okoye is a Professor of Radiology, College of Medicine, University of Nigeria, Nsukka/University of Nigeria Teaching Hospital Enugu (UNTH), Enugu State. Fondly called ‘Pink Professor’, Okoye is also the Director, University of Nigeria Centre for Clinical Trials (UNNCECT), and Founder /Co-Chair African Clinical Trial Consortium. Okoye, who is also the founder, Breast Without Spot (BWS), a non-governmental organisation (NGO), in this interview with The Guardian, ahead of World Cancer Day, February 4, said pollution has become a major contributor to cancer cases and deaths in Nigeria. She provided reasons the country has one of the highest cancer cases and deaths globally. The radiation oncologist, however, made recommendations on how to reduce the rising cancer cases and deaths in the country. CHUKWUMA MUANYA writes.

•Radiation oncologist says situation deserves institution of emergency response, proffers solutions

In recent times, cancer has become very common with over 90 per cent fatality in Nigeria. Why the rise?
Cancer has remained top of the list of diseases that are indiscriminately reducing the welfare and wellness of persons across the world, particularly, in developing countries like Nigeria.

In the views of Nzelu, 70 per cent of cancer deaths occur in developing nations like Nigeria due to lack of access to optimal care. Nigeria is currently estimated to have 233,911 cancer cases, with 124,815 new cases and 78,899 cancer deaths, yearly!

Tobacco use is the most important risk factor for cancer and it is responsible for approximately 22 per cent of cancer deaths. Other important lifestyle risk factors include; alcohol consumption, unhealthy diet, physical inactivity, Obesity and air pollution. They are also risk factors for other non-communicable diseases.

Some chronic infections are risk factors for cancer and referred to as ‘Cancer causing infections’ … this is a particular issue in low- and middle-income countries.

These ‘Cancer causing infections’ include: hepatitis and human papilloma virus (HPV), and are responsible for up to 25 per cent of cancer cases in low- and middle-income countries!

Tobacco and alcohol abuse, are amongst the commonest substance abuse, amongst young adults in Nigeria! E-cigarette and Sisha are becoming very popular amongst the ‘upwardly mobile’ middle/high income population.

Forced nutrition transition with embracement of western diet has resulted in unhealthy diet being rife, mostly made up of highly processed, energy dense/nutrient poor carbohydrates, sugar-laden drinks, and Monosodium Glutamate (MSG) laden food enhancers. MSG is a flavour enhancer often added to restaurant foods, canned vegetables, soups, deli meats and other foods.

Culture of reducing physical inactivity, has become better in the past five years. A significant population of middle income Nigerians have become healthy living conscious and now engage in intentional regular exercise.

Air pollution is one of the risk factors with significant contribution of 80 per cent to cancer risk that barely any attention is paid to, in Nigeria! The situation deserves institution of an emergency response.

Various factors predispose humans to cancer and they include genetic and lifestyle factors.

Environmental factors which include: putrefying fumes released from dangerous bio-wastes and fumes from fuels used in generators, vehicles, burning wastes, cooking, etc.

Environmental pollution contributes up to 80 per cent to risk factors for cancer. Poor handling of refuse disposal, such that both biodegradable and non bio-degradable are left to cause a lot of putrefaction fumes, and release of dangerous bio-wastes that can pollute also our drinking water sources, available to both humans and livestock!

Vehicular fumes and Industrial fumes contribute seriously to environmental air pollution in Nigeria. Last year, the World Bank reported that 94 per cent of the population in Nigeria is exposed to air pollution levels that exceed WHO guidelines (compared to 72 per cent on average in Sub-Saharan Africa in general) and air pollution damage costs about one per cent post of Gross National Income (2015).

At a CNN interview, Dr. Maria Neira, WHO Director, Department of Public Health, Environmental and Social Determinants of Health, said: “The contributing factors to pollution are a reliance on using solid fuels for cooking, burning waste and traffic pollution from very old cars.”

At home, due to unreliable electricity supplies, many Nigerians rely on generators, which spew out noxious fumes, often in unventilated areas. On the street, car emissions go unregulated. There is no serious roadworthiness oversight of vehicles in Nigeria, and with the little there is, owners bribe their way across regulators.

Neira added: “In Africa, unfortunately, the levels of pollution are increasing because of rapid economic development and industry without the right technology.”

Indeed, Nigeria’s economy has raced forward in the past decade, overtaking South Africa as the continent’s largest economy in 2014, following a recalculation of its Gross Domestic Product (GDP).

Agriculture, telecoms and oil are all driving this growth at a certain environmental cost. All these leave our lungs in a permanent state of inflammation and could possibly increase risk of coming down with serious complications of COVID-19.

Some mining areas like Jos, Tin, Lead and Iron Ore, Coal in Enugu, etc. are all emitters that have implicated carcinogenic effects, often by direct exposure or contaminants of drinking water.

Some authorities also blame the low-level or absent funding, bad policy implementation and lack of political will and commitment for the persistence of the clogs in the wheel of progress of the fight against the menace of cancer.

How about the issue of dearth of diagnostic and treatment facilities?
For decades, Nigeria has lacked comprehensive cancer centres covering the six geo-political zones of the country where all cancers and care around the disease can be taken care of.

This is gradually changing with the Federal Government successfully making significant investment into developing Functional Oncology Centers in Maiduguri, Abuja, Lagos, Ibadan, Enugu, and to small extent in three-four other hospitals. What is interesting and which has raised hopes, are privately funded Cancer Centers, in Abuja, Owerri, Calabar, Lagos, etc.

Some significant inroads being made to abate and ameliorate out of pocket payment for cancer care include: Cancer Health Fund (CHF), Drug Access Initiative, Chemo-Safe, National Health Insurance Act (NHIA) treatment packages for cancer patients.

Very interesting and significant news is the recent creation of the National Cancer Research and Treatment Institute, and appointment of the ‘pioneer Director General (DG)’ by President Muhammadu Buhari. It is expected to yield great outcomes and huge impact in cancer control.

Why the high fatality rate of cancers in Nigeria? What is the burden of cancer in Nigeria in terms of numbers?
Nigeria has one of the highest cancer mortality rates in the world, with approximately four out of five cases resulting in death, according to the Global Cancer Observatory. 10,000 cancer deaths are recorded yearly with 250,000 new cases. Currently in Sub-Saharan Africa (SSA) about 95 per cent of cancer cases are diagnosed too late, leading to higher management costs with poor outcomes (high mortality and morbidity).

Personally, I attribute this appalling high death rates to; poor health seeking behaviour, denial (it is not my portion syndrome), superstition, conviction that it is not a disease but diabolical, evil arrow, punishment of the gods, something to be ashamed of because it involves the sexual/genital areas … breast, cervix, prostate … fear of stigmatisation, brutal withdrawal of support by male spouses, fear of out of pocket payment of bills, poverty of pocket and poverty of health information, prolonged appointments ( paucity of treatment centre’s, low ratio of oncology experts/demand, epileptic function of needed radiotherapy due to frequent breakdown of equipment, high cost of care , among other treatment challenges. The current Cancer Health Fund operates only in six institutions and so sparse, it cannot serve all that need the support.

There is in-efficient roll out/implementation of the carefully produced National Cancer Control Plans (NCCP), which directs the public policy on cancer issues in Nigeria.

In conclusion, In Nigeria, the most common type of cancer in women are breast and cervical cancer, accounting for up to, 57 per cent of all cancer cases in women. Prostate cancer accounts for 45.6 per cent of all cancer cases in males between 2012 and 2016, according to Nigerian cancer registry report.

These abysmal outcomes are driven mostly by ‘Late Presentation’, which itself, is tied to the people’s fearful perception that cancer is a death sentence, due to the poor survival statistics. Drivers of these appalling statistics may include factors like: limited availability of screening units, poverty, lack of proper education/awareness, poor lifestyle choices, etc., that affect health seeking behaviour, resulting in late presentation.

Additionally,’ Out of Pocket’ payment and unaffordable medical bills accentuate poor outcomes. Thus, cancer patients in Nigeria are faced with many challenges that may negatively impact on their survival and ability to live a normal life afterwards.

Food additives/ sharp practices in food production and manufacture & handling! Examples are ripening agents like carbide used by sellers of fruits to ripen fruits such as banana, pawpaw, mangoes, etc., food colouring to redden stews, palm oil, food enhancers with bleaching and carcinogenic properties, containing Monosodium Glutamate (MSG), cubed and powdered enhancers, sweeteners with aspartame, uncontrolled use of insecticides/pesticides to de-weevil grains and antibiotics, hormones in poultry and fish farming, de-furring of cattle, sheep and goats with kerosene and tires (and so many others).

Recent study has associated ultra-processed foods with increased risk of cancer. How true is this?
Higher consumption of ultra-processed foods may be linked to an increased risk of developing and dying from cancer, an Imperial College London-led observational study suggests.

Researchers from Imperial’s School of Public Health have produced the most comprehensive assessment to date of the association between ultra-processed foods and the risk of developing cancers. Ultra-processed foods are food items, which have been heavily processed during their production, such as fizzy drinks, mass-produced packaged breads, many ready meals and most breakfast cereals.

Ultra-processed foods are often relatively cheap, convenient, and heavily marketed, often as healthy options. But these foods are also generally higher in salt, fat, sugar, and contain artificial additives. It is now well documented that they are linked with a range of poor health outcomes including obesity, type 2 diabetes and cardiovascular disease.

The first UK study of its kind used UK Biobank records to collect information on the diets of 200,000 middle-aged adult participants. Researchers monitored participants’ health over a 10-year period, looking at the risk of developing any cancer overall as well as the specific risk of developing 34 types of cancer. They also looked at the risk of people dying from cancer.

The study found that higher consumption of ultra-processed foods was associated with a greater risk of developing cancer, and specifically with ovarian and brain cancers. It was also associated with an increased risk of dying from cancer, most notably with ovarian and breast cancers.

For every 10 per cent increase in ultra-processed food in a person’s diet, there was an increased incidence of two per cent for cancer overall, and a 19 per cent increase for ovarian cancer specifically.

Each 10 per cent increase in ultra-processed food consumption was also associated with increased mortality for cancer overall by 6 per cent, alongside a 16 per cent increase for breast cancer and a 30 per cent increase for ovarian cancer.

These links remained after adjusting for a range of socio-economic, behavioural and dietary factors, such as smoking status, physical activity and body mass index (BMI).

The Imperial team carried out the study, which is published in eClinicalMedicine, in collaboration with researchers from the International Agency for Research on Cancer (IARC), University of São Paulo, and NOVA University Lisbon.

Previous research from the team reported the levels of consumption of ultra-processed foods in the UK, which are the highest in Europe for both adults and children. The team also found that higher consumption of ultra-processed foods was associated with a greater risk of developing obesity and type 2 diabetes in UK adults, and a greater weight gain in UK children extending from childhood to young adulthood.

Lead senior author for the study, from Imperial College London’s School of Public Health, Dr. Eszter Vamos, said: “This study adds to the growing evidence that ultra-processed foods are likely to negatively impact our health including our risk for cancer. Given the high levels of consumption in UK adults and children, this has important implications for future health outcomes.”

“Although our study cannot prove causation, other available evidence shows that reducing ultra-processed foods in our diet could provide important health benefits. Further research is needed to confirm these findings and understand the best public health strategies to reduce the widespread presence and harms of ultra-processed foods in our diet.”

First author for the study, from Imperial College London’s School of Public Health, Dr. Kiara Chang, said: “The average person in the UK consumes more than half of their daily energy intake from ultra-processed foods. This is exceptionally high and concerning as ultra-processed foods are produced with industrially derived ingredients and often use food additives to adjust colour, flavour, consistency, texture, or extend shelf life.

“Our bodies may not react the same way to these ultra-processed ingredients and additives as they do to fresh and nutritious minimally processed foods. However, ultra-processed foods are everywhere and highly marketed with cheap price and attractive packaging to promote consumption. This shows our food environment needs urgent reform to protect the population from ultra-processed foods.”

The World Health Organisation and the United Nations’ Food and Agriculture Organisation has previously recommended restricting ultra-processed foods as part of a healthy sustainable diet.

There are ongoing efforts to reduce ultra-processed food consumption around the world, with countries such as Brazil, France and Canada updating their national dietary guidelines with recommendations to limit such foods. Brazil has also banned the marketing of ultra-processed foods in schools. There are currently no similar measures to tackle ultra-processed foods in the UK.

Chang added: “We need clear front of pack warning labels for ultra-processed foods to aid consumer choices, and our sugar tax should be extended to cover ultra-processed fizzy drinks, fruit-based and milk-based drinks, as well as other ultra-processed products.

“Lower income households are particularly vulnerable to these cheap and unhealthy ultra-processed foods. Minimally processed and freshly prepared meals should be subsidised to ensure everyone has access to healthy, nutritious and affordable options.”

The researchers noted that their study is observational, so does not show a causal link between ultra-processed foods and cancer due to the observational nature of the research. More work is needed in this area to establish a causal link. Cancer Research UK and World Cancer Research Fund funded this study.