Cancer of the gallbladder is relatively rare in India; however, it still contributes to about 10% of the global GBC burden. A vast majority of the gallbladder cancer cases are diagnosed in the advanced stages of disease (stage III and above) resulting in poor clinical outcomes. The prevalence of biliary malignancy shows geographical and racial variations within India. Following risk factors act in tandem in an additive manner resulting in a higher incidence of GBC as well as hasten the development of GBC.
The gallbladder is a pear-shaped organ located within the abdomen of the human body, whose primary function is to store and concentrate the bile fluid produced by the liver.
Bile fluid plays an integral role in the digestion and absorption of fats from the human gut. Due to its integral function as a bile concentrating organ, the gallbladder is prone to develop gallstones. Large and long-standing gall stones are associated with a higher risk of GBC. A combination of multiple repeated insults of varying nature may overwhelm the tissue repair mechanism giving way to chronic inflammation, mutagenesis, and carcinogenesis. An epidemiological study reported that gallstones are present in 80% of the Indian patients with GBC and its presence increases the vulnerability of the GB to mucosal injury. The incidence of GBC is out of proportion to the prevalence of gallstones in the country.
The incidence of GBC is 10 times higher in North India compared to the Southern Indian states. The marked geographical variations in the incidence of this malignancy suggest ethnic predisposition or presence of local environment risk factors. One of the putative factors is the influence of densely populated human civilization on major river banks (namely the Ganges, the Yamuna, and the Brahmaputra). North Indian states are established agricultural driven communities, who subsist on these rivers for their daily needs. As these rivers arise from the glaciers and flow from the Northern Himalayas towards West and East, the pollutant concentration, as well as bacterial contamination, steadily rises which may account partially for the high incidence of GBC in this region of the country. Unfortunately, even untreated sewage gets added to the river water along its course which might cause chronic S. Typhi infection, H. pylori infection in patients with gallstones promoting carcinogenesis.
Mustard oil has irritant properties on the gut and is often adulterated with butter yellow which is a known carcinogen. Also, mustard oil itself has pro-inflammatory properties and induces tumors. In North, North East and Eastern India mustard oil is the staple cooking oil in contrast to coconut oil, sesame or groundnut oil in South and West India. Poverty-stricken individuals are unable to afford branded safe oils and thus consume loose mustard oils which may be contaminated/adulterated. Higher levels of carcinogenic adulterants of mustard oil (sanguinarine, diethylnitrosamine) have been found in the blood and tissue of GBC patients as compared to patients with cholelithiasis.
Studies shows that healthy dietary pattern inclusive of vegetables, fruits, low-fat dairy products, whole grains, nuts, legumes, fish oil, and ω-3 PUFA appeared to be associated with prevalence of decreased gallstone disease while unhealthy dietary pattern inclusive of processed meat, soft drinks, refined grains, red meats, high-fat dairy products was associated with increased risk. Researchers have proposed that tea might protect against cancer because of its antioxidant content.
A retrospective study for a period of more than 4 decades found that women are at 2-6 times higher risk for developing GBC. The GB mucosa has been found to have estrogen and progesterone receptors which may promote GB stasis, the stone formation which in turn exposes GB mucosa to bacterial and chemical toxins for an extended period of time. Women are exposed to higher levels of estrogen and progesterone during their lifetime more so during pregnancies. Females in India are much younger in age at the time of marriage and 1st pregnancy. Likewise, Indian women have a higher number of pregnancies than their western counterparts. Women are socio-economically marginalized which renders them with inadequate nutrition and substandard medical caregiving rise to a compromised immune system and micronutrient deficiencies both of which promote carcinogenesis.
The GBC occurrence rate is on the rise in our country. Thus it is important to step up cancer awareness amongst high-risk factor groups. Management and treatment of GBC can be life-saving if GBC is detected early. Necessary lifestyle modifications can prevent GBC in Indians.
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-By Fatma Islahi