Cancer has been the leading cause of death in Taiwan since 1982, holding that dubious honor for 17 consecutive years.

The latest statistics show that cancer takes more than 30,000 lives in Taiwan per year, accounting for 21% of all deaths. Each year, medical expenses for cancer treatment exceed NT$10 billion.

The incidence of cancer among people in Taiwan has doubled in the last decade or so. It is estimated that one out of every five persons will get cancer at some time in their lives. Cancer has become an enemy that every family very well may face.

Recently the Formosa Cancer Foundation issued its 1999 Cancer Prevention White Paper, and declared 2000 to be "National Cancer Prevention Year." They are telling everyone that the era of total mobilization against cancer is here!

The word cancer derives from a word that means "crab." Like a crab, the disease spreads out in all directions. Major efforts to defeat cancer began back in the 1960s. Although it is too early to say that complete victory has been achieved, some battles have been won.

After the invention of refrigeration, given the availability of fresher foods, the incidence of stomach cancer fell sharply in the developed countries. Chen Chien-jen, a professor of epidemiology at National Taiwan University, says that a similar trend has been observed in Taiwan since the 1960s.

In addition, pap smear tests have made it possible to detect cervical cancer very early on, and the death rate has dropped. Twenty years ago gynecologists saw this as "mission impossible," but today, when the slogan "six minutes to save your life" rolls off everyone's lips, the death rate from cervical cancer has fallen from being the highest among all forms of cancer in women in 1991 to being fifth highest in 1997.

The over two million chewers of betelnut （an NT$13 billion industry in Taiwan） are at high risk for oral cancer.

Moreover, since the widespread application of hepatitis B inoculations in 1984, liver cancer in children has dropped. Chen Chien-jen estimates that in the future the incidence of liver cancer in Taiwan could fall to as little as one-fourth that of the present level. Taiwan's cancer map

Regrettably, while the incidence and death rate for some forms of cancer have fallen, the incidence of most types of cancer has been on the rise.

Looking at the overall picture, the incidence of cancer has doubled in Taiwan in 14 years. The main reasons have been the aging of the population and the increase in risk factors in the environment.

The elderly have always been the highest-risk group for cancer. The death rate for most forms of cancer rises with the age cohort. For example, the death rate from lung and colon cancer rises for people in their 60s and peaks for people over 80.

Most cancer is caused by external factors, including air, water, and soil pollution.

However, it should not be overlooked that the death rate for some forms of cancer shows a dual-peak phenomenon. Besides the peak period among the elderly, there is another peak among middle-aged people. For example, the death rate from oral cancer is very high for men aged 55-59, while that for breast cancer is high among women aged 45-49. This phenomenon is related to the increase in risk factors at these ages. Domestic and imported

For various reasons, including lifestyle, diet, and genetic inheritance, people of Chinese ancestry are more susceptible to some forms of cancer, including nasopharyngeal, liver, and cervical, than people of other ethnic groups. Liver cancer has had the highest death rate for men in Taiwan since 1982. Up to 1991, cervical cancer had the highest death rate for women.

In addition to these "domestic" types of cancer, the internationalization of lifestyles in Taiwan since the 1970s has led to an increase in "imported" forms, such as lung, breast, prostate, and intestinal cancer.

Since 1991 lung cancer has been the form of cancer with the highest death rate for women in Taiwan, while among men it now stands second only to liver cancer. Meanwhile, breast cancer is now the second most common form in women, and number four or five in terms of death rate. The incidence of intestinal and prostate cancer is also on the rise. that several forms of cancer will become increasingly widespread. Breast cancer, for example, is likely to increase because of several risk factors: modern women start menstruation earlier, get married

Based on risk factors in the environment, Chen Chien-jen estimates later, and are less likely to breast feed; intake of animal fat is increasing; and modern lifestyles are more stressful and erratic.

As Western fast foods like hamburgers, fried chicken, and french fries have become more popular in Taiwan, breast, intestinal, prostate, and pancreatic cancer （to which fat is a contributory factor） have also been on the rise. （photo by Pu Hua-chih）

The rising intake of fat also will cause colon cancer to increase, while worsening air pollution and a surge in the number of smokers will the cause the incidence of lung cancer to rise. Chronic disease

Because of progress in medical technology, in comparing the rate of incidence with the rate the death, you can see that the "fatality rate" for cancer in Taiwan has been declining. Take for example the top five forms of cancer in terms of incidence in women: lung, liver, colon, breast, and cervical. The fatality rate has fallen from 78% in 1982 to 58% in 1995.

However, in comparison with advanced countries, Taiwan's rate of cancer cures (defined as survival for more than five years) is still low. It is, for example, only about half that of the United States (where the survival rate is about 50%).

Why is this? Most doctors agree on two reasons. One is that people in Taiwan do not give much though to routine health check-ups, so that cancer is often discovered too late. In addition, many people diagnosed with cancer abandon orthodox medicine in favor of alternative treatments.

The 1999 Cancer Prevention White Paper points out that, according to figures from 1991, 41% of cancer sufferers were not undergoing orthodox treatment. This phenomenon was especially pronounced in victims of liver and lung cancer, two forms with a generally poor prognosis. The percentage of liver cancer victims not under orthodox treatment was 76%, while the figure for lung cancer victims was 64%.

Chen Chien-jen says that, while cancer is by no means always fatal, nevertheless, when many people find out they have cancer, they throw away the "life preserver" that could save them and instead grasp at straws.

The Formosa Cancer Foundation has produced a booklet on how to reduce fat intake, offering ideas for reducing fat consumption plus delicious low-fat recipes.

Lai Gi-ming, director of the Division of Cancer Research of the Taiwan Cooperative Oncology Group, says that in many individual cases in which alternative treatment is said to be effective, in fact the patient had already been through orthodox treatment, and in other cases the illness concerned was not even cancer at all. Lacking the right to know

There is no clear outcome in the debate over alternative cancer treatments (an issue explored in the accompanying article, "Alternative Treatment: Cure or Illusion?"). But there are ideas about why so many people in Taiwan throw away their life preserver and grasp at straws. One is that they don't enjoy as much knowledge of their illness as they deserve.

Su Lien-ying, who was an oncology nurse for many years and now is assistant executive director of the Der Tao Cancer Caring Foundation, says that nine out of ten cancer patients who make inquiries at the foundation are unclear about their own treatment. Most are completely ignorant about the possible side effects of their treatments, while others have been misinformed (and intimidated) by the frightening tales they have heard. For example, chemotherapy sometimes causes vomiting, and some treatments can lead to infection or fever. The resulting frequent trips to the emergency room can be exhausting. Patients may abandon orthodox treatments altogether out of fear, and seek alternative treatments which promise fewer side effects.

Another factor, say some doctors, is that many doctors are deliberately pessimistic in cases where there are no objective indicators of the patient's prognosis. In the event that there's a turn for the better, patients are thankful to their doctor for treatment. But, unexpectedly, such pessimism may cause many patients to lose faith in orthodox treatments.

A third factor underlying the reluctance of people in Taiwan to seek orthodox cancer treatment is "white lies" on the part of family members.

"Save your life in six minutes." Since the general promotion of cervical cancer testing, the death rate from cervical cancer in Taiwan has fallen from the highest rate among cancers for women to fifth highest.

Chang Jang-yang, a staff physician at National Taiwan University Hospital's Cancer Cooperative Ward and secretary-general of the Chinese Oncology Society, says that many family members, fearing that relatives could not stand the shock, ask doctors to hide from patients the true severity of their illness. Ignorant of their condition, such patients often feel that orthodox treatments, with their side-effects, not only aren't making them better, but in fact make them feel even worse. Naturally this makes them less willing to continue such treatments. It can't happen to me!

Another factor affecting the cancer cure rate in Taiwan is the "malignancy" of various forms of cancer.

Take for example nasopharyngeal cancer, to which Chinese are specially susceptible. Nasopharyngeal cancer originates near the base of the skull, close to vital organs, so there's little room for safety to make surgery more practicable. In addition, nasopharyngeal cancer is extremely likely to spread to the lymph nodes in the neck or other more remote areas of the body, so it is difficult to get all of the cancer with surgery. Usually the prognosis is poor.

Liver cancer, which has the highest death rate among forms of cancer for men in Taiwan, is another type with poor prognosis. It is difficult to discover liver cancer early. Statistics show that more than 70% of liver cancer victims are suffering only mild discomfort or swelling in the abdomen when the cancer is discovered. Only a small number of victims have pronounced weight loss, bleeding in the digestive tract, or jaundice. The lack of pronounced symptoms means that by the time liver cancer is discovered, it is often already at an advanced stage.

In fact, late detection is one of the major shortcomings of cancer treatment in Taiwan.

"Many patients only come to seek treatment when they are in stage four. They want the most expensive medications and every kind of treatment available, but by then it is too late," says Andrew Huang, director of the Koo Foundation Sun Yat-sen Cancer Center. People in Taiwan do not give much thought to routine health maintenance, and they often only go to the doctor when it is too late. Huang takes cervical cancer as an example: in the US cervical cancer is discovered in the "preinvasive carcinoma" stage in four out of five cases; in Taiwan the figure is only one out of five.

"Early discovery, early treatment" is a principle for the successful treatment of any illness. Why is it that Taiwan patients only go for examination or treatment when it is "too late"?

Jacqueline Whang-Peng, director of the Division of Cancer Research at the National Health Research Institutes (NHRI), suggests that most people feel they are not likely to be so unlucky; they think, "It can't happen to me!" And even when it finally becomes obvious that something is very wrong, they are still afraid to face up to reality.

Early detection of cancer relies on tests. Unfortunately, there are as yet no reliable tests for most forms of cancer.

Lin Jaung-geng, director of the Acupuncture Research Center at China Medical College, on the other hand, blames the problem of late detection of cancer in Taiwan mainly on inadequate efforts at public health information work by relevant government agencies.A lottery?

Whatever the case may be, it is undeniable that the low cancer cure rate in Taiwan is also related to inconsistency of treatment. In Taiwan, cancer patients going to different doctors do not necessarily get the same kind of treatment. Some say that cancer treatment is like a lottery: you just have to get lucky.

Currently, one of the major problems in cancer treatment is a shortage of onco-logists.

Andrew Huang points out that in the US, when a cancer patient goes in for a preliminary diagnosis, the doctor spends at least an hour with him or her, and does biopsies and various kinds of tests to determine the stage the cancer is at. Taiwan doctors, on the other hand, often dispense with their patients in just a few minutes.

Chang Jang-yang notes that oncology has only been recognized as a specialty in Taiwan for about 11 or 12 years. Currently Taiwan only has a hundred or so cancer specialists. Of these, half focus on blood-related oncology, so that the number of specialists for each of the various other kinds of cancer is very small indeed.

Taiwan has a relatively low cancer cure rate. This is related to factors such as the forms of cancer prevalent here, inadequate health education, doctor-patient relations, and the medical care environment. The problem must be tackled through all these channels to raise the quality of care.

Chang explains that oncology is a difficult and unrewarding specialty. Many of the patients a doctor deals with are terminal, so it is a very frustrating field. Besides that, National Health Insurance payments are low. "You get the same amount for seeing a cancer patient as for seeing someone with a cold, NT$200," he points out. National health insurance payments are based on the service rendered, not on the knowledge required or the time spent. Thus the specialty attracts very few people. Hang together or....

Another obstacle to raising the overall quality of cancer treatment in Taiwan is the narrow-minded attitude of some doctors.

Andrew Huang says that very few hospitals have formed any multi-disciplinary cooperation system, and "team treatment" is rare.

At present, surgery is the first line of defense against many forms of cancer. Radiotherapy is applied to those tumors that cannot be surgically excised. When surgery or radiotherapy is completed, chemotherapy is undertaken to eradicate remaining cancer cells. Thus the full course of cancer treatment includes the departments of surgery, oncology, radiology, and reconstructive surgery.

Not only do few hospitals offer team treatment, it is even common to see surgery, radiology, and oncology separated from each other, with few contacts at all. Su Lien-ying points out that in the past it was usually a surgeon who was responsible for the entire process of cancer treatment. Now that there are oncologists, some surgeons feel that their "turf" is being "invaded," and they are unwilling to turn over chemotherapy to the oncologists. It is not uncommon to see surgeons "crossing departmental boundaries" to take charge of chemotherapy for their patients.

There are also some doctors who make National Health Insurance payments a more important concern than the patient's well-being. Because payments for surgery are high, some doctors engage in rampant unnecessary surgery. Take liver cancer for example. Lai Gi-ming says that when a liver tumor grows to a certain size, embolization is better than surgery, because if the surgery is not done precisely and the tumor is not cleanly removed, the cancer could spread even more quickly through the circulatory system.

Cancer is by no means incurable. Many advances have been made in terms of technology and medications in recent years. The photo shows the new anticancer medication Taxol.

Chang Jang-yang says that there is still no final word on many forms of cancer treatment, and in the past each hospital had its own specialty. Without consensus, it has proved impossible to improve the overall quality of cancer treatment. All the fault of fat

Clearly the reasons for the relatively low cancer cure rate in Taiwan are complex. But at a more fundamental level, the only real solution is cancer prevention.

"Prevention is more important than early detection," says Lai Gi-ming. It may take 20 or 30 years for normal cells to mutate into cancer cells. It may take several more years before these cancer cells divide and can be discovered. This is the period that is most important for cancer prevention. "Everyone has cancer cells in their body, so our goal must be to postpone the point at which cancer cells grow into tumors," he says.

How can cancer be prevented? Pesus Chou, a professor of epidemiology at Yang Ming Medical College, says that there are three lines of defense against disease.

The so-called primary line is the eradication of risk factors.

Research shows that in 70 to 90% of cancer cases, the cause is external. Causal factors include bacteria, viruses, radiation, chemicals, pollution, diet, cigarettes, and betelnut.

In terms of diet, the main problem is an excessive intake of fat.

According to Taiwan's national nutrition and health survey, fat accounts for 34% of the total number of calories consumed by Taiwanese. The incidence of cancer tends to rise whenever this figure exceeds 30%. Cancers related to high fat intake include those of the lungs, breast, ovaries, colon, rectum, prostate, gallbladder, endometrium, and pancreas.

The first duty in cancer prevention is to educate the public and raise their awareness of how to fight cancer.

In April of this year, the Formosa Cancer Foundation produced the first volume in their series of guides to "Eating to Prevent Cancer." This first guide sets out to teach people how to reduce the fat intake in their diet. People can, for example, eat more rice and less meat; skim fat off the top of soup before eating; eat vegetables before meat; and eat less rich soups and nuts. Cigarettes + betelnut = lung cancer

The rising incidence of lung cancer in Taiwan is closely connected to cigarette smoking and betelnut chewing. According to statistics, a person who both smokes and chews betelnut is 123 times as likely as an ordinary person to get lung cancer.

Reducing the number of smokers and betelnut consumers is a major target of primary stage cancer prevention in Taiwan. However, says Koong Shin-lan, director of the Bureau of Health Promotion and Protection at the Department of Health (DOH), there many factors which lead to smoking, and smokers are in any case generally aware of the dangers involved, so it is difficult to change their individual behavior. The best thing that can be done is to reduce the dangers of second-hand smoke. In 1997, a law was passed to do just this. As the ban on smoking in public places goes into effect, it is expected that the exposure to second-hand smoke will be greatly reduced.

However, changing personal lifestyles and behavior is not enough to secure the first line of cancer defense (i.e. reducing risk factors). It is also up to the government to undertake matching public policies. For example, while health agencies have been continually trying to persuade citizens not to consume betelnut, at the same time the area cultivated for betelnut in Taiwan has been continuously expanding. Obviously there's a contradiction here.

In addition, Taiwan spends very little money on cancer research. As a result, there's a sore lack of research on the sociology, epidemiology, and ethnology of cancer here. And this means that there's a lack of reliable information on which to base primary prevention activity.

Mother is often the main protector of the family's health. At the end of April, the Formosa Cancer Foundation brought together more than 1000 "cancer fighting moms" and held a series of seminars to teach them about cancer prevention.

The 1999 Cancer Prevention White Paper points out that in 1998 the amount of money spent on cancer research in Taiwan by government bodies (including the National Science Council, DOH, NHRI, and Academia Sinica) and various hospitals totaled only NT$370 million. This is a world away from the figure spent in the US-the equivalent of NT$800 billion. Save a life in six minutes

The second line of cancer prevention is early detection.

Besides strengthening public education about cancer in order to raise awareness, early detection relies on testing.

Unfortunately, there are still no reliable tests for early detection of most forms of cancer. To take just two examples, says Pesus Chou, for liver and intestinal cancer, existing tests are expensive and inaccurate, so they are not very cost-effective. The exception is testing for cervical cancer.

Although the death rate from cervical cancer in Taiwan has been declining, there is still plenty of room for expanding pap smear testing. In the Three-Year National Health Plan adopted by the Department of Health, it is hoped that, after three years, the percentage of women who have been tested for cervical cancer will have increased from the 23% of last year to 40%.

Andrew Huang notes that breast cancer is another form that is amenable to early detection. If breast cancer is caught between Stage 0 and Stage 1, the cure rate is as high as 95%. Although government health agencies have long extolled breast self-examinations, it is almost impossible to detect a tumor of less than one centimeter. This requires a mammogram.

Koong Shin-lan points out that in the US, where the incidence of breast cancer is very high (one in nine women will get breast cancer at some time in their lives), women over 40 years of age are supposed to get tested once every two years, while women over 50 are to be tested each year. With the incidence of breast cancer in Taiwan also on the rise, the DOH intends to implement mammograms for people who have a family history of breast cancer. Cut off dangerous relationships

Given the absence of reliable tests for other forms of cancer, early detection is very difficult at this time.

Lai Gi-ming says that a tumor can only be discovered by ultrasound if it is larger than one centimeter. However, by this point, the cancer cells have already divided for 30 generations, and the number of cancer cells has reached a billion. Since cancer cells begin to enter the bloodstream when the tumor is a mere 0.22 cm large, and the number of cells is only about 10 million, this means that by the time the tumor is large enough to be detected, the cancer has already begun to spread.

Take lung cancer for example. It takes 8-10 years for a single cancer cell to grow into a tumor about the size of an NT$5 coin. But it only takes a few years for it to grow from NT$5-size to being fatal. In other words, by the time a lung tumor is discovered, it is already three-fourths of the way through its life-cycle, and the cancer is into the terminal stage.

This is why some people overseas are going so far as to surgically remove high-risk body parts even before any cancer sets in.

In the US, where the incidence of breast cancer is very high and where reconstructive surgery is advanced, some women from families with a history of breast cancer opt to have mastectomies even before any cancer is detected. Research has discovered that a preemptive mastectomy can reduce the risk of breast cancer by 91%. In addition, the preemptive removal of polyps in the intestines can lower the incidence of intestinal cancer.

Lai Gi-ming acknowledges that this type of preemptive surgery is feasible in Taiwan. But there's still no reliable method here for determining who the individuals at the highest risk may be. Moreover, Taiwanese are not likely accept the preemptive removal of organs. Building a consensus

The third line of defense in the fight against cancer is increasing the quality of care for cancer victims. The NHRI has established the Taiwan Cooperative Oncology Group, bringing together 20 major hospitals in Taiwan. There are separate committees for each form of cancer, and they hold regular conferences in order to build up a consensus on the diagnosis and treatment of each form.

The NHRI has completed "diagnostic and treatment consensus handbooks" for cervical, breast, lung, intestinal, and oral cancer. Next will come books on stomach and prostate cancer.

Lai Gi-ming notes that these handbooks not only are reference works for doctors, they also give patients a standard by which to judge whether or not the treatment they are receiving is appropriate.

On another point, in the past Taiwan lacked clinical studies on cancer. Doctors relied entirely on reports and data from overseas. Thus there has been a lack of accurate statistics and case studies on locally prevalent forms of cancer. To remedy this, the Taiwan Oncology Clinical Studies Organization has set up cancer research wards in both Veterans General Hospital and National Taiwan University Hospital. It has begun by conducting clinical studies on some of the more prevalent forms in Taiwan, including liver, nasopharyngeal, stomach, cervical, and lung cancer. It is seeking to finding the most effective treatments in order to raise the cancer survival rate in Taiwan. Everyone's war

Cancer is by no means incurable in all cases. Andrew Huang says hopefully that when the human genome project is completed in 2003, gene diagnosis will make possible better early detection of cancer and identification of high-risk groups. This will mark a major step forward in cancer treatment. He estimates that within a decade or two, the death rate from cancer in advanced countries will be cut in half.

Nevertheless, however medical technology may improve, what is needed right now to face up to this leading killer of Taiwanese is individual efforts to change eating habits and lifestyles along with coordinated public health and environmental policies.

In this era of national cancer prevention, the fight against cancer is everyone's fight.