The two H's that cause the most common cancers in China

Pre-cancerous cirrhotic liver

by Michael Woodhead
In western countries we are quite rightly focused on the high profile cancers and how to prevent them. Lung cancer is now in decline due to the very successful campaigns to stop smoking. Likewise in sunny Australia we are starting to see declines in skin cancer thanks to the campaigns that encourage people to cover-up and avoid carcinogenic UV rays. Other common cancers that are the focus of public attention are of course breast cancer, prostate cancer and to a lesser extent cervical and bowel cancer. All of these are the focus of major screening activities - some with official blessing, others (hello prostate cancer) despite a lack of evidence that they reduce cancer deaths.
In China it's a very different story. As you'd expect given the high rates of smoking, lung cancer is the most common malignancy seen in the country, but the other common cancers are those of the liver and digestive tract - hepatic cancer, gastric cancer and oesophageal cancer, in that order. A new review finds that the incidence of these cancers has increased dramatically since the 1980s. Perhaps because Chinese people now live longer or have better access to diagnostic services, but the gastric and liver cancers are now more common than ever. And the causes? It's the "H''s  - hepatitis and H. pylori. The high rates of hepatitis B in China are the reason for the country's huge rates of liver cancer. China has some of the highest rates of hepatitis B in the world (almost one in ten people have been infected) and new infections are still a major problem. The good news is that most children are now being immunised against hepatitis B, and the government believes that there will be far fewer hepatitis cases by 2050, when the current generation of immunised kids are adults.
Gastric cancer is the third most common cancer in China, and much of this may attributable to diet and chronic infection with the carcinogenic H. pylori pathogen. It has been estimated that the number of people in China infected with H. pylori infection rate is still above 50%, and as high as 80% in rural areas. Some hospitals are now implementing a 'test and treat' H. pylori screening approach and providing antibiotic-based eradication therapy to those found to be positive. There have also been some attempts to screen patients with endcoscopy - but is going to be a resource-intensive and logistically impossible approach to adopt nationally. Oesophageal cancer is another common cancer in China. To try prevent more cases, the government is focusing on diet in rural areas, and urging pubic health services to improve nutritional campaigns and avoid agents such as nitrosamines and harmful water contamination.
For the time being, however, China will continue to have high rates of liver and gastric cancers. Eradicating hepatitis and H. pylori will help in the long run, but Chinese people should be aware of the cancers that currently pose the greatest risk to themselves and their families.
[Based on an article by Dr Wang Rui and colleagaes at the Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, published in Clinics and Research in Hepatology and Gastroenterology)

Dysentery in China - the good news and the bad news

by Michael Woodhead
Dysentery is one of those disease most westerners associate with 'the olden days' - or the Third World. 
Bacillary dysentery, also known as Shigellosis, is the severe gastro disease of poor hygiene, spread by faecal contamination. Ten years ago dysentery was still relatively common in Guangzhou, but a new report shows the city has brought rates of the disease down with a co-ordinated campaign to detect and manage cases and prevent further outbreaks. In 2006 the city had about 12 cases of dysentery per 100,000 population - so for a city of 8.5 million people that's more than a thousand cases a year. To tackle the infection, the city health department implemented the "Intestinal Infectious Disease Surveillance, Prevention and Control Program" (IIDSPCP). This means that once a patient is suspected as having Bacillary dysentery, public health workers target their household with preventive measures such as quarantine, disinfection, and good personal hygiene practices mandatorily implemented by local government. This program has seen the rate of dysentery cut to around 2 per 100,000. Good news so far. However, public health staff say dysentery still remains a problem in the poorest families - as judged by the high rates among children who do not attend school. They now account for the largest group of patients with dysentery.
This social group - usually migrant workers from the poor inland provinces - is China's new underclass. As the report notes: "They are usually lacking in adequate sanitation, with low health risk awareness, and more likely to have exposure to contaminated food or water. It has been reported that compared to the other group, the school-age children not attending school have higher incidence in many infectious diseases such as hand-food-mouth disease, infectious diarrhea, and hepatitis A."
Interestingly, the other high risk group for dysentery is young people aged the people aged 20-44 years - perhaps because they take part in more social activities, have more chance to contact with Shigella patients or carriers, and have more leisure time, and finance to travel and thus more likely to have exposure to Shigellosis.
As the report authors conclude: "more effort should be made to enhance health education about dysentery and monitoring/targeting at school-age children not attending school ... .as well as establish strategies for prevention of the disease in China."

Smoking deprivation | Suicidal ideation in school students | Obesity surgery | Oestrogen in the environment

About 7% of Chinese people smoke so much their spending on cigarettes deprives the household of essential items like food, a study from Beijing has found. Low-income smokers were more likely to have smoking-induced deprivation.

Suicidal ideation occurs in one in three Chinese high school girls and 20% of boys, a study of 5249 students in Anhui Province of China has found.

Laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy are safe and effective for the treatment of morbid obesity, resulting in 63% and 76% loss of excess weight, a study from Nankai Hospital of Tianjin Medical University has shown.

The waist circumference cut off for high risk of central obesity and metabolic syndrome is 85 cm for women and 90 cm for men, researchers from Shandong have shown.

In Shanghai, almost one-in-five boys are obese and 8% of girls are obese. The prevalence of combined overweight and obesity is 49% for boys and 31% for girls aged 8-15-years, according to a study that found rates of obesity started to increase from age 10 years.

Oestrogen hormones are widely used in animal rearing in China and this leads to high levels of the hormones in excreted manure which is then used on crops, perpetuating the environmental contamination and human exposure, researchers from the State Key Laboratory of Water Environment Simulation, Beijing have shown.

The highly pathogenic strain of H7N9 avian influenza is quite different from other H7N9 strains seen in China and appears to have come about by re-assortment with the H9N2 strain, according to researchers from the Guangdong Provincial Center for Disease Control and Prevention.

Infliximab is safe and effective in Chinese patients with ulcerative colitis, resulting in 85% response rates and 62% remission rates after 30 weeks of treatment. However, relapse rates are high, say researchers from the Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou.

Today's Top 10 China medical news stories

1. China is to launch a national cervical cancer screening program to test 10 million Chinese women annually, the National Health and Family Planning Commission says. The move follows concerns about increasing rates of cervical cancer, especially in women under 35. China has 130,000 new cervical cancer cases a year and up to 30,000 deaths a year due to the disease.

2. Vaccination rates have fallen as much as 30% since the hepatitis B vaccine safety scare over the deaths of 17 infants, immunisation experts say. They said the drop in vaccination rates could put up to 500,000 infants at risk of serious vaccine-preventable diseases.

3. In a landmark study, Shanghai clinicians have shown that pulse oximetry is a simple and accurate method for detecting major congenital heart disease in newborn babies in China. Writing in the Lancet, they say the method should be used in all maternity hospitals.

4. Salmonella in China is becoming resistant to most antibiotics including ciprofloxacin, ceftriaxone and azithromycin, "posing huge threat to public health and infection control" say clinicians in the journal Antimicrobial Agents and Chemotherapy.

5. A Beijing doctor was punched by the husband of a pregnant woman who said the doctor had pinched her stomach and threatened to kill her. The woman admitted she had first cursed the doctor when she believed she had been ignored by him.

6. Seven leading hospitals in China have signed an alliance agreement to for a National Team to tackle difficult diseases.

7. Kindergartens in Beijing have been struck by the norovirus gastro bug and dozens of children are showing symptoms such as diarrhoea and vomiting.

8. Young Chinese people do not wish to pursue a career in the medical sector, as jobs in medical services were ranked lowest in a survey of desirable careers by recruitment site zhaopin.

9. Complaints about fake drugs and medical devices being sold online are the most frequent calls to the China Food and Drug Administration hotline.

10. Hospital clinics in Shanghai are overflowing with three-four hour waiting times and yet community clinics are sitting almost empty and 'general practitioners see few patients because the public has little confidence in the level of services provided, according to an article in China Daily.

Clinical Friday - news briefs from the medical journals

An outbreak of Hand, Foot, and Mouth Disease in Changchun in 2013 affected more than 1125 children and was caused by Coxsackievirus A6 researchers report. They say the finding of a different causative strain means that vaccination against enterovirus EV71 will not solve the millions of cases of the disease in China every year.

More than 80% of elderly people in Beijing are infected with the stomach bug Helicobacter pylori that predisposes to ulcers and gastric cancer, a study has found. The infection rate with the more pathogenic type 1 H. pylori strain was 56%, researchers found.

Patients with H7N9 influenza living in rural areas were more likely to be female and caught the infection from backyard poultry breeding, a study from Zhejiang has shown.

Heart failure has a poor prognosis in China with 40% patients dying within four years if they have chronic heart failure with reduced ejection fraction, a study from the National Center for Cardiovascular Diseases and Peking Union Medical College shows.

More than one in ten patients attending China's overcrowded hospitals leave without being seen, a study has found. Patients who left without waiting for treatment tended to have less serious illness and have arrived on foot, according to researchers from the Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu.

Uric acid may have a role in hypertension, according to researchers from Xinjiang. In a study of 3778 children and adolescents they found that increasing levels of serum uric acid were associated with high blood pressure.

The most common forms of cancer in China are lung cancer (20.5%), stomach (11%), colorectal (10%) and liver cancer (10%) according to new figures from the National Central Cancer Registry.

My top10 medical stories from China for Saturday 22 February

1. Smoking with a water pipe confers a 'profound' risk of chronic obstructive pulmonary disease (COPD) among people in south west China and also carries a high risk from passive smoking, researchers have shown.

2. Patients with pneumonia of unexplained origin should be promptly investigated for H7N9 risk factors such as exposure to poultry and they should also be given pre-emptive antiviral treatment such as Tamiflu, the Beijing health department has ordered.

3. About 85% of Chinese doctors experience burnout, with those who are younger, unmarried and working in emergcncy medicine having the highest risk of serious burnout, a study shows.

4. Fertility clinics in China need to become more patient-friendly as they are perceived as too impersonal and lacking in transparency and respect for patient informed consent, researchers say.

5. The stigma of mental illness in Chinese culture means that patients with schizophrenia often do not understand their medication and are unwilling to take any anti-psychotic medication, according to a study from the Guangzhou Psychiatric Hospital.

6. H. Pylori infection rates are over 90% among people in their thirties in Jiangsu, which may explain high rates of gastric cancer in the region, say researchers from Nanjing.

7. Babies in Shenyang have increased rates of neurodevelopmental deficits because their mothers were exposed to high levels of organophosphorous pesticides during pregnancy, according to a study in PLOS One.

8. Adenovirus has emerged as a significant cause of serious pneumonia in China, with a study showing that 5% of cases are attributable to the virus.

9.  People with tuberculosis are also at high risk of HIV, with rates of around 3% in groups tested in TB patients from Guangxi, Henan and Sichuan, say Chinese researchers.

10. A mediation service for patients involved in medical disputes with hospitals is to be launched in Shanghai and it will be open to patients where compensation claims exceed 30,000 yuan ($2900) regardless of whether the hospital refers them.

Clinical news in brief - from the journals

In 'grassroots' hospitals, knowledge about Parkinson's disease - its diagnosis and management - is very limited for both neurologists and patients, a study from the West China Hospital in Chengdu has shown. Neurologists lacked knowledge of non-motor symptoms, differential diagnosis, therapeutic strategy and appropriate indications of surgical treatment, although they were familiar with the motor symptoms of the disease.

Adenoviruses cause 10% of cases where children are hospitalised for severe diarrhoea in China, according to a study from the Capital Institute of Pediatrics, Beijing.

More than 95% of people in Jiangsu have inadequate levels of riboflavin in their diet, putting them at risk of anaemia, a study has shown.

High levels of arsenic in seafood - and especially shellfish - pose a risk to human health, researchers from Shandong have warned.

People with epilepsy who have been seizure free for at least two years may be able to come off their anti-epilepsy medication, neurologists in Chengdu has shown. In a study of 162 patents with epilepsy who slowly tapered off their medication, 23% had a recurrent seizure and had to re-commence medication.

Ovarian cancer is relatively uncommon in China and rates are in decline, a review by the Henan Cancer Research and Control Office has concluded.

Coeliac disease widespread in China

Coeliac disease is more common than has been reported in China, according to a new study by researchers from Nanchang University.
Coeliac disease is an autoimmune disorder caused by genetically susceptible individuals consuming food and drinks made from wheat, barley or rye and therefore containing gluten. Gluten proteins can induce inflammation in the small intestine, hindering the uptake of nutrients, and can also disturb the normal functioning of other organs. In the Western world, prevalence of the disease is between 0.5 and 2 percent of the population. Despite the fact that China is the world’s largest wheat producer and has a high and rapidly increasing consumption of wheat and gluten-containing products, coeliac disease was considered to be rare in China and had not been studied thoroughly.

Guangzhou oncologists develop better staging method for colon cancer

Guangzhou oncologists have developed an improved staging method for colon cancer that accurately predicts the risk of disease recurrence and benefit of adjuvant chemotherapy for patients who have had surgery for stage II colon cancer.
Researchers from the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, used expression patterns of multiple microRNAs (miRNAs) combined into a single model to improve postoperative risk stratification and prediction of chemotherapy benefit for these patients.
Using this tool, they were able to classify patients as at high risk or low risk of disease progression. Five year disease-free survival was was 85% for the low-risk group, and 57% for the high-risk group. The six-miRNA-based classifier was an independent prognostic factor for, and had better prognostic value than, clinicopathological risk factors and mismatch repair status.
Patients in the high-risk group were found to have a favourable response to adjuvant chemotherapy The clinicians developed two nomograms which combined the smiRNA-based classifiers and clinicopathological risk factors to predict which patients might benefit from adjuvant chemotherapy after surgery for stage II colon cancer.
“Our six-miRNA-based classifier is a reliable prognostic and predictive tool for disease recurrence in patients with stage II colon cancer, and might be able to predict which patients benefit from adjuvant chemotherapy. It might facilitate patient counselling and individualise management of patients with this disease,” they concluded.
Full study: Lancet Oncology

Xinjiang study links oesophageal cancer to fibre intake

People in China's north-west have been the focus of research which investigated risk factors for oesophageal cancer. 
The research  found high dietary fibre intake can help reduce the incidence of oesophageal cancer, which has a low survival rate.

Shihezi University conducted the hospital based case-control study in remote north-west China (Xinjiang region), where the rates of oesophageal cancer are far greater than anywhere else in the world.

Oesophageal cancer is the sixth leading cause of cancer-related deaths worldwide.

The Chinese participants included 359 oesophageal cancer sufferers and 380 healthy controls. Participants were both male and female; and they came from the same area and were of similar age (average age 61 years).

With the information discovered the researchers advise that new dietary guidelines for China include a recommendation to increase fibre intake to prevent oesophageal  cancer.

Source: Medical Xpress

Bowel cancer to increase by a million cases in next decade - report

Significant population growth combined with lifestyle changes and increased awareness of the disease will result in a dramatic increase in prevalent cases of colorectal cancer in China over the next decade, according to a new report.
The company’s latest epidemiology report forecasts prevalent CRC cases in China to jump from just under 2 million cases in 2012 to 3.3 million cases by 2022 – an increase of 65% in only 10 years.
China’s above-average population growth will be the primary driver for this worrying increase in CRC prevalence, but shifting living standards and improving healthcare awareness are also important contributors, as this increases the likelihood of sufferers being correctly diagnosed with the disease. According to the report, the incidence of CRC in China increased from about 30 cases per 100,000 people per year in 1988 to about 50 cases per 100,000 people in 2002.
Source: GlobalData

Chinese doctors prescribe antibiotics instead of rehydration treatments for diarrhoea

Most patients with diarrhoea were given inappropriate antibiotics when they should have received oral rehydration solution

by Michael Woodhead
In Chinese hospitals, patients presenting with diarrhoea are given inappropriate antibiotics and IV infusions rather than the simple oral rehydration therapies recommended in 'best practice' guidelines, and mismanagement  is much worse in rural areas, a study has found.
Researchers from the Department of Infectious Diseases at Peking University First Hospital assessed adherence by tertiary hospital physicians to national guidelines and World Gastroenterology Organization guidelines for the management of acute diarrhea in adults. The findings suggest nationwide education and effective health policies are needed to improve medical practice and reduce the unnecessary burden on the healthcare system.
Their survey was carried out among physicians and 800 patients in 20 hospitals in Beijing and Shaanxi. Data were collected for 800 patients.
The researchers found that 31% of patients with diarrhoea self-medicated before visiting the clinic, most commonly with antibiotics. The mean interval between the onset of acute
diarrhoea and going to a specialist hospital diarrhea clinic was 2.4 days.
In hospital, routine stool examinations were ordered for 70% of patients, vibrio cholera stool culture for 57%, and non-vibrio bacteria stool culture for only 11%.
Only 62% of patients received the recommended fluid and electrolyte therapy and only 28% received oral rehydration solution. In contrast, 33% of patients were given IV fluids even though only 14% needed it.
Antibiotics were the most common drugs (61%) used and the most common antibiotics were fluoroquinolones, followed by aminoglycosides. In total 51% of patients received irrational antibiotic treatment (unnecessary for 48%; indicated but not prescribed for 3%).
Poor adherence to best practice guidelines was more common in Shaanxi compared with Beijing -  fewer individuals received oral rehydration (8% vs 49% respectively) and more received intravenous fluids (46% vs 21%, respectively). More of the patients in Shaanxi province were given antibiotics (65% vs 57%, respectively), and more received IV antibiotics than Beijing (49% vs 27%).
The researchers conclude: "tertiary hospital physicians in China do not adhere well to [international] guidelines or to national guidelines for the management of acute diarrhea. These findings suggest that nationwide education and effective health policies are needed to improve medical practice and reduce the unnecessary burden on the healthcare system.
Source: BMC Public Health

Eradication regimens have poor efficacy against H. pylori in China

Most of the first and second line eradication drug regimens have poor efficacy against H. pylori infection in Chinese patients, a study from Nanjing has shown.
Researchers from the Department of Gastroenterology at the First Affiliated Hospital of Nanjing Medical University assessed the efficacy of standard sequential therapy for H pylori (five days of treatment with a proton pump inhibitor [PPI] and an antibiotic such as amoxicillin followed by five days of treatment with the PPI and two other antibiotics such as clarithromycin and tinidazole) and the efficacy of levofloxacin-containing triple therapy and levofloxacin-containing sequential therapy.
Their study showed that the H pylori eradication rate was 83% for the standard sequential therapy compared to 81% for levofloxacin-containing triple therapy and 87% for levofloxacin-containing sequential therapy.
The researchers conclude that : "standard sequential therapy and seven-day levofloxacin triple therapy produce unacceptably [low] therapeutic efficacy in China. Only levofloxacin-containing sequential therapy achieved borderline acceptable result. None of the regimens tested reliably achieved 90% or greater therapeutic efficacy in China."
Read more: Helicobacter

Traditional Chinese surgery proves superior and less invasive than fistulotomy

A traditional Chinese surgical treatment known as suture dragging combined with pad compression for anal fistulae with secondary tracks and abscess is safe, effective and less invasive.
Surgery is one of the most effective therapies for anal fistulae. More and more surgeons begin to seek less invasive therapies. However, classical procedures such as fistulotomy and fistulectomy, may produce complications such as longer healing time, larger defects, and higher risk of incontinence when dealing with fistulae with secondary tracts or abscess. In China, traditional Chinese surgical method suture dragging combined with pad compression (SDPC) has been used to treat anal fistulae and achieved good results.
In a new  study researchers from the Department of Anorectal Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine,
 have shown that the traditional Chinese surgical method SDPC is safe, effective and less invasive, and they suggest that it could be used as an alternative to the treatment of complex anal fistulae.
In the study, 60 patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression] and control group [fistulotomy].
The time of healing was significantly shorter (24 days vs 31 days) and the patient satisfaction score at one month postoperative follow-up was significantly higher in the SDPC group.
Maximum postoperative pain scores were 5.83 in SDPC vs 6.37  with fistulotomy and the recurrence rates were 3.33 in SDPC vs 0 in fistulotomy patients.

Read more: World Journal of Gastroenterology