Ladakh is the abode of nature’s raw and untouched beauty with Rough Terrains, Snow-capped peaks, and winding roads. The region might be a heaven for adventure travelers, but all is not well for the local residents.

In recent studies conducted by Dr Sajjad Hussain, Consultant Surgeon, District Hospital Kargil, there was an alarming rise of Cancers and Cancer-related deaths in this region, having not even a population of 3 lacs, with various risk factors prevalent and peculiar to U.T Ladakh.

 His Study “Cancer Burden in High Altitude Kargil Ladakh: Ten Year Single Centre Descriptive Study” was recently published in a reputed International Journal of Cambridge, Britain, the – “International Journal of Cancer and Treatment”. The study was undertaken for the first time in the high altitude, mountainous Ladakh region to analyze the incidence of different cancers and the risk factors involved for causing these cancers.

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According to his research, Stomach Cancer was the most common cancer in the region (42.12%). In males, it was followed by Lung cancer and Liver cancer. In females, Stomach cancer was followed by cancer of the Gall-Bladder and Breast. Gastro-intestinal malignancies were the commonest malignancies including cancer of Oesophagus, Colon and Rectum and together accounted for half (51.35%) of all the cancers of Kargil Ladakh region.

Dr Sajjad Hussain examined 444 cases of cancers over a period of 10 years in Kargil Ladakh and studied in detail unique food habits of the region, Smoking habits, peculiar cultural and life style changes of the region and other associated risk factors of the region including high UV rays, high prevalence of hepatitis B infection and high altitude with hypoxic conditions and their association with cancer in these patients.

In the study population, 31.08% patients were Smokers, 15.99%  were Ex-smokers and rest were non-smokers, but all of them were exposed to Smoke due to wood – domestic Cooking practices at home due to traditional woody- smoky traditional Chullahs for most of the year. 65% patients used to have >4 cups of traditional Salty “Noon”-Butter tea and out of which 57(12.84%) patients had the habit of taking >10 cups of Noon tea per day. All the patients in the study group were non-Vegetarian having dietary habit of intake of Red- meat with fat intake of 1-3 /month in 16.45% patients, 1-2/week in 37.38% patients and 2-4/week in 31.08% patients. . Another important risk factor seen in this research study was the less intake of fresh fruits and vegetables, with 58.78% patients taking <1/week, 24.55% taking <4/week, and only 16.67% taking fresh fruits and vegetables >4/week. This was due to loss of air and road connectivity with other parts of the state and country, for 6 months (November-April) in harsh winter, forcing the population to eat excess of dry, raw food stuffs, stored meats, stored tinned food items, besides traditional spicy foods and pickles.

The high rates of gastro-esophageal cancer in Ladakh region is alarming and may be due to the fact that majority of the risk factors are prevalent in this region. Dietary habits, Smoking, H.Pylori infection, Genetic susceptibility etc. are widely studied. In Ladakh, the most important specific food habit is the consumption of large quantities of hot, salted, butter tea; locally known as “noon” tea or “ Gurgur” tea; which is made of local butter added to boiling water mixed with common salt(Nacl), Sodium bicarbonate(soda), milk and green tea leave extracts. The sodium bicarbonate (soda) and common salt (Nacl) are well-known irritants of gastric epithelium and have been considered as risk factor for gastric cancer. Salt-tea showed the formation of high amount of N-nitrosopipe-colic acid with several unidentified non-volatile N-nitroso compounds on nitrosation of green tea extracts, which all are irritants to the gastric mucosa. Ingestion of salt has been shown to increase gastritis and the carcinogenic effects of known gastric carcinogens such as N-methyl-N-nitro-N-nitrosoguanidine (MNNG). Salt is known to erode the mucosal barrier of the stomach, thereby leading to inflammation. Cultures whose diets are rich in salt and pickled foods, such as the Koreans and Japanese, exhibit higher rates of gastric cancer. Japanese immigrants to the United States who assimilated and adopted Western foods exhibited a substantially lower rate of gastric cancer relative to those who did not assimilate their diet.

High consumption of Red-Meat and fatty meal are another worrisome risk factors of the area, with all the cancer patients in this study taking the red-meat frequently and mostly taking >4/week, especially in the winter 6 months. Habit of taking barbecued meat was found to be prevalent in the Zanskar sub-region. Another important risk factor seen in this research was the less intake of fresh fruits and vegetables, with 58.78% patients taking <1/week, 24.55% taking <4/week, and only 16.67% taking fresh fruits and vegetables >4/week. All these traditional food habbits are the risk factors for Gastro-Esophageal and many other varieties of cancer. Preserved meats are rich in N-nitroso compounds, which can illicit similar effects in the body as already mentioned above. Grain-fed red meat is specially rich in saturated fats and low in protective fats such as omega-3 which contributes to its inflammatory processes and thus increases gastric cancer risk. Fruits and vegetables are rich in carotenoids, folate, phytochemicals and vitamin C, which help modulate xenobiotic metabolizing enzymes during digestion. They contain numerous antioxidants that prevent against metabolic damage. Case- control studies found that a higher intake of fruits and vegetables was associated with a 37% lower risk of gastric cancer. Fresh vegetables and fruits are considered to be probable protective factors and other food habbits like high rice intake, pickled food, spicy food, smoked, dried, salted meat, use of soda etc. are the significant dietary risk factors of cancer. Another risk-factor in Ladakh is the high colonization of H.Pylori in this population. H.Pylori is carcinogenic to humans based on epidemiological evidence. There is 2-3 fold increase in gastric cancer among individuals exposed compared to non-exposed ones. The Cag A gene of H.Pylori is the main virulence factor which is responsible for the development of gastric cancer through derangement of cellular architecture and signaling pathway. The prevalence of H.Pylori is high in India due to low socio-economic condition and poor hygiene. There might be complex interaction between dietary and life-style related factors, H.Pylori infection with certain strain types, in presence of genetic polymorphism, along with heightened inflammatory response that may produce a cascade of changes at molecular level and ultimately cancer cells of the stomach, and needs an in-depth research in future. H.Pylori strains from Ladakh are genetically distinct and possibly less virulent than the isolates from East-Asian countries, such as china and Japan where the prevalence of gastric cancer are very high.

The risk factors involved in the rise of Colo-Rectal cancer in this region may be due to vanishing habit of high fiber ancestral diets like” Khulak” and “Pappa”, and increased westernization such as Obesity, Physical inactivity including less of agrico-farming activities in modern generation, heavy metal contamination of soil, food and water, use of pesticides, dyes and artificial coloring agents (like Tartazine), food adulteration, reuse of frying oils, increased intake of Killer foods (junk food, snacks, cold-drinks etc.) that are added with dangerous activities and adulterants. Even the milk and milk products in the market contain chemicals such as detergents (caustic soda). Artificial coloring agent or dyes like Tartazine has been found in many edibles, spices and condiments in the area. Tartazine metabolizes to Benzidine and 4-amino bi phenyl, listed under ‘known- carcinogenic’ category in 13^th report on carcinogens by U.S Department of Health and Human Services. Many international studies have linked presence of Heavy Metals (potential carcinogen) in soils, vegetables, fruits and drinking water, to gastrointestinal cancers. All such trends are leading to a health catastrophe especially cancer in Ladakh.

This study observed Liver cancer as the third most common cancer in the region (9.24%).The high incidence of Liver cancer in the region is due to the fact that the prevalence of Hepatitis B virus is very high in Ladakh region. In Kargil district, the prevalence of Hepatitis B infection is 7.86%-8.3%, where as its prevalence is 3.3-5.75 % in Leh, 1.2% in Srinagar and 2.4% in Jammu region of Jammu and Kashmir. In another research study by Dr Sajjad Hussain; “Hepato Cellular Carcinoma in High Altitude Kargil Ladakh: A Hepatitis B Virus High Endemic Zone”, published in renowned Clinical Surgery Journal; Chronic Hepatitis B infection was found to be one of the most important causes of Hepato-Cellular carcinoma (HCC) in Kargil Ladakh.

This study showed cancer of Gall bladder as the fifth most common finding in Kargil Ladakh and it was second most common cancer in females. It may be due to the fact that the prevalence of gall-stone disease, gastritis and gastro-esophageal reflux disease  are again very high in Ladakh Region due to inherited low transit time of intestine in the region, habit of high intake of fatty meal, spicy food and excess of  red meat at parties and at home.

This study observed Lung cancer as the second most common cancer in males in the region but eighth most common cancers in females, with M: F ratio of 7.6:1. This striking difference may be because of smoking pattern which was not seen even in a single female patient in our study. Use of Tobacco in the form of cigarette smoking, hukka and chewing were seen in 31.08% patients. Tobacco is an independent risk factor for Lung cancer, Stomach cancer and many other cancers while Alcohol may be carcinogenic to Esophagus, Cardia and Liver. International Agency for Research on Cancer (IARC) has reported that there is association between Tobacco use and smoke with cancer of Lung, oral-cavity, Pharynx, Esophagus, Larynx, Urinary Bladder, Ovary, Colon and Rectum. Tobacco related cancers contribute to two-thirds of all cancers, with three-fourths of cancers among men and more than half of cancers among women.

Alcohol use has been shown to increase the risk of gastric cancer, moderate alcohol consumption was shown to increase the gastric cancer risk by 39%, while heavy consumption further worsen the odds. Alcohol is known to irritate and erode the stomach lining, resulting in gastritis, a precursor for stomach cancer.

In his another research study, “ High Incidence of Gastric Cancer in Kargil Ladakh”, which has been published in International Journal of Science and Research, Dr Sajjad Hussain mentions other  worrisome factor in Ladakh region which are high prevalence of gastritis and gastroesophageal reflux disease, again because of the above mentioned peculiar food habits of the region and life style. According to him, the risk of gastric cancer is almost twice the expected rate among patients with gastric ulcers. Cardia gastric cancer is seen to be positively associated with both severe gastric atrophy and with frequent GERD symptoms. Multiple distinct pathways of tumorigenesis exist at esophagogastric junction , including one in which tumors arise from dysplastic intestinal metaplasia, and one potentially involving dysplasia of the cardiac-type mucosa. Incidence rate trends in reflux-related cardia cancer and esophageal adenocarcinoma are very similar, suggesting that these two cancers share a similar etiology and pathophysiological process.

According to him, Obesity is also considered to be a risk factor in the occurrence of cancer especially gastric cancer. A statistical meta-analysis from around the world found that those with an excess body mass index (over 25kg/m2) have a 1.13 odds ratio of developing cancer. The strength of the association increased with increasing BMI. Obesity was an especially strong predisposing factor for cancer. Obesity may induce inflammation of the stomach lining via tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and monocyte chemoattractant protein-1 (MCP-1). Those with a diet of heavily inflammatory foods, such as a diet high in meat and low in fruits and vegetables, also have a higher risk of being obese.

The message is loud and clear. With this research, Dr Sajjad Hussain has emphasized upon the people of Ladakh, especially young population of the region, to focus more on the healthy dietary habits including high fiber traditional diets, more of fruits and vegetables, less of salted tea, soda, spicy foods, pickled food, junk foods, cold drinks, less consumption of fats and meats, stored meats  over long period, less consumption of too many hot beverages, regular exercise, increased physical activities, avoiding high ultraviolet rays with skin barriers in high altitudes especially Zanskar region, avoiding excessive exposure to mobile radiations, vaccination against hepatitis B and last but not the least, avoiding high risk factors like  smoking and alcohol.

The world cancer burden has risen to 18.1 million cases and 9.6 million cancer deaths. Globally 1 in 6 deaths is due to cancer. There is a constant rise in cancer cases, but the trend and pattern vary according to the geographical region, as seen in Ladakh. According to DR Sajjad Hussain, the study findings are in direct contrast to global findings, as globally, Lung cancer and Breast cancer are the most common diagnosed cancer and the leading cause of cancer death in males and females respectively.

The studies were the need of the hour as the cancer rate was spiraling in Ladakh and it was very disheartening to see people die of cancer as young as 40 years. According to him, Cancer awareness programme, establishment of a proper cancer registry, establishment of active cancer society and establishment of a Regional Cancer Centre are the need of the hour to bring a wind of change in Ladakh.