The killer of Azam Khan

Azam Khan, the pop legend breathed his last a few days ago. Azam Khan contributed more than his fair share to the country he helped create and to the people he lived to entertain. Unlike most, he will live in our collective memories and his songs will remain beyond the longevity of many generations.

As he did throughout his life, let Azam Khan's death be an opportunity to contribute more to the people he loved so much. This would be possible if the nation understands the cause of his death and the manner he lived the last few days of his life.

Only 61, Azam Khan definitely was not supposed to leave so early. But a killer cancer involving his oral cavity cut his life short. As per the reports published in Bangladesh media, last year Azam Khan was diagnosed with the cancer. From media reports about treatments planned for him in Singapore, it can be assumed that by the time the pop legend presented to doctors in Singapore, the disease was relatively advanced. And like many other types of cancers, in case of oral cavity cancer, the stage of the cancer makes a big difference in terms of outcome. In most advanced countries, while over 80 percent people survive early stage oral cavity cancer, only 50 percent live beyond five years if the cancer is locally advanced at the time of diagnosis.

So when Azam Khan started his treatment with a major mouth surgery followed by dozens of repeat cycles of unbearably difficult chemotherapy and radiation therapy, he had only 50 percent chance of winning the battle even if he could complete the ordeal of all intended chemotherapy cycles.

Now, one needs to understand that undergoing repeat cycles of chemotherapy is not like taking a pill or finishing an injection antibiotic course or taking any other medicine. Despite development of better chemotherapeutic agents over the past decades, with its side effects and dangerous toxicities, being on chemotherapy is like suffering from an additional disease by itself. No one, except who has been through chemotherapy, will ever understand what it means physically and mentally to go through the cycles of chemotherapy.

Not to his fault, Azam Khan could not tolerate completion of chemotherapy cycles. We can assume that either he did not find it worth suffering that much or his physical aspects like his blood count could not handle further chemotherapy. And while he was off chemotherapy, the inevitable had happened. The cancer kept progressing at a rapid aggressive pace and at some point spread all over his body. That was a point of no return –facing inevitable death, treatments are only aimed at reducing the sufferings and prolonging life for a few weeks.

It may not be widely appreciated, but there are not many direct ways for cancer to cause death. Typically, cancer causes death by facilitating other illnesses. Azam Khan went into respiratory failure. From media reports, it is not clear what caused the sudden deterioration into respiratory failure. Most likely cause of this deterioration could be a combination of heart problem, pneumonia, cancer spread in lung etc. Even his physicians might not be very sure why this happened. This sort of uncertainty is very commonplace scenario in clinical practice. And at the end, his death could have been immediately attributed to acute respiratory failure.

How the outcome could have been different for Azam Khan or anyone else with similar problems?

First and foremost, the most significant difference could have been achieved if the diagnosis was made early in the disease process, when the disease has not yet advanced. Recognising a disease early needs multiple favourable conditions. First there must be a general awareness of the risk factors causing the disease, the initial presentation of the symptoms and its potential to cause life-threatening implications. Then there must be an established screening programme of the population to catch the disease early and intervene. Then other factors include availability of skilled physicians, chemotherapeutic drugs and infrastructure.

According to the WHO data, cancer of oral cavity and lip is second most common cancer among Bangladeshi male and third most common cancer among Bangladeshi female. Only other cancers that are more common are lung cancer for men and breast and cervical cancer for women.

Unfortunately, there is an absolute lack of awareness about oral cavity/lip cancer in Bangladesh. Even if we forget about the illiterate majority and understand the lack of awareness among the educated class, even the general physician class (other than handful of cancer practitioners) is blissfully ignorant about the public health importance of lip and oral cavity cancer in Bangladesh. This is not their fault. In medical college curriculum, there has not been any weighted emphasis on cancers occurring in higher frequencies in Bangladesh.

After awareness, the most important factor in early detection of cancer is an effective national screening program. National screening program means establishment of a standard of care that every physician is required to advise his/her patient of certain screening tests for certain disease at certain age. For example, in the USA and many other Western countries there are screening program for colon cancer, breast cancer, cervical cancer etc. Every patient goes through specific tests annually or every few years to detect breast or colon or cervix cancer in an early stage.

An essential prerequisite of national screening recommendation is good population based epidemiological data on the frequency of a disease and its likelihood to cause death or other disabilities. Then there has to be epidemiologic research proving that screening of a specific disease would eventually reduce the frequency and ease the effect of that specific disease.

For Bangladesh, forget about national screening program or screening recommendation – the problem is that, we don't even have any good epidemiological study on the incidence and prevalence of common diseases and their mortality. Most data we get from the WHO or other organisations are usually derived from information gathered from neighbouring states like India, Sri Lanka etc.

How many of us remember Jahanara Imam? The frail looking gracious lady with the strongest mind is the pioneer of war crimes trial movement in Bangladesh. She also died of oral cavity lip cancer. Let's take this opportunity to reiterate that lip and oral cavity cancer is the second leading cancer in male and third leading cancer in female in Bangladesh. Let's use this sad occasion to educate the nation not to ignore small non-healing sores or white patches anywhere inside the mouth.

Let's also remind the informed authorities to rise to this occasion to take steps to prepare the nation to fight oral cavity cancer. The steps may include designing of epidemiological study, changing the curriculum in medical and dental schools to educate the new graduates about basic oral cancer screening practices.

Let's also send a public health message to all that cigarette smoking or chewing tobacco, betel nut, and possibly other components of pan-shupari or even arsenic may put people at higher risk of oral cavity cancer.

Our pop idol Azam Khan left us forever. But let his departure be an opportunity to educate the nation of oral cavity cancer.

Azam Khan, when alive, single-handedly brought a new dimension to our culture and music. Let his untimely departure be the driving force to push our public health practices from 18th century stagnation to 21st century dynamism.

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Rumi Ahmed is a specialist physician and an associate professor at a major medical school in the USA.