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Gastrointestinal (GI) cancer accounts for 1/3rdof cancer deaths in developing countries like india. Stomach, liver and colorectal (large intestine) cancers are the three most common. In addition pancreatic , gallbladder , oesophageal and small bowel cancer are less common but aggressive cancers which have comparatively poorer outcomes even when they are detected at an operable stage. It is imperative to prevent these cancers by lifestyle changes and detect them at an early stage by cancer screening to prevent advanced disease.

The main Strategies to prevent cancer deaths include

• Diet changes &Life style changes.
• Identifying cancer families.
• Preventive screening of at risk induviduals

1.Health and life style

Smoking predisposes to most GI Cancers. Quitting smoking is probably the best decision you can make for your health as it reduces your risk for not just gastric cancer but also many other medical problems like heart disease and stroke. Tobacco chewing can also predispose to throat and esophagus cancer

Alcohol can contribute to gastric, esophageal and colon cancer . Chronic alcoholic intake also leads to chronic liver disease and chronic pancreatitis (scarring of pancreas) predisposing them to liver cancer and pancreatic cancer respectively.

Diet plays an important role. Eating preserved foods such pickled foods and salted meats predisposes to gastric cancer. Food rich in fat intake predisposes to colon and pancreatic cancer. A diet high in fresh fruits and vegtables with plenty of fiber, vitamin A Vitamin C and antioxidants prevents cancer. Likewise people in cold climates used to drinking extremely hot liquids may predispose you to esophageal cancer.A high carbohydrate diet also predisposes to obestity and cancer.

Obesity is a risk factor for gastrointestinal cancer especially for colon and pancreatic cancers. It is also a risk factor for non GI cancers like breast cancer. Obesity can lead to fatty liver disease that predisposes to hepatocellular (liver cancer).An active lifestyle mainitaing BMI less than 25 reduces risk of GI as well as non GI cancers such as breast and ovary.

Acid reflux Long standing acid reflux can predispose you to esophageal cancer and proximal gastric cancer. Patients with persistantrefluxs symptoms for more than 2 years should consult a gastroenterologist for a diagnostic endoscopy to detect barretsesophagus.

Others factors : long term use certain medication , industrial toxins Helicobacter pylori infection, history of radiation therapy can also predispose to GI cancer

2.Identifying at risk families

The following features (if more than 2) if present should make you consider going to doctor for genetic testing and early screening

• Cancer diagnosed at an unusually young age (less than 50)
• Cancer in two generations of family
• Cancer in 2 or more first /second degree relatives
• Developing more than 1 type of cancer (sametime / separately)in life time
• Cancer in index patient / first degree relative with proven genetic mutation.

3.Screening

Unlike breast and cervical cancer routine screening is not mandatory for gastrointestinal cancers .Only selected groups of at risk induviduals for some GI cancers need screening for that particular cancer. The screening frequency and modalities vary for individual cancers and are best decided by the gastroenterologist. In the developed world the entire population is screened for colon cancer starting from 50 years of age every 5 years but clear cut recommendations are lacking in India due to lack of data.The at risk patients who need screening include-

Oesophageal cancer : Patients with longstanding reflux disease and new onset dysphagia (difficulty in swallowing), patients with esophageal disease like esophgeal stricture, esophageal motility disoders need screening for esophgeal

Gastric cancer : Patients with family history, Hpylori associated atrophic gastritis, prolonged reflux disease, elderly individuals with low haemoglobin, weightloss , gastrointestinal bleeding and persistant upper abdominal pain Pancreatic cancer :Patients with family history Patients with chronic pancreatitis especially alcoholic and hereditary chronic pancreatitis, Lynch syndrome. Patients with Jaudice and itching .

Intestinal cancer: Family history of intestinal cancer, patients with inflammatory bowel disease like ulcerative colitis/ crohns diseae, Patients with gastrointestinal polyps. Patients with past history of radiation need screening. Patients with history of treated colon cancer are at risk of developing cancer at a new location

Liver cancer : Patients with chronic liver disease secondary to hepatitis B, Hepatitis C, Alcohol , hemochromatosis are highly prone to developing liver cancer. Liver cirrhosis leads to cancer . Likewise Non alcoholic fatty liver disease (NAFLD ) predisposes to cancer . All these patients need ultrasound and blood tests at 6 monthly intervals for early detection.

Gallbladder and biliary cancer : some parts of Northern india like the cow belt region are endemic for Gallbladder cancer. Gallstones are assoaciated with gall bladder cancer but a causative relation is not established. Patients with Liver stones ( hepatolithiasis), repeated attacks of bile infection (cholangitis), bile duct anamolies such as bileduct cysts, narrowing (strictures ) and choedochal cyst are at risk for bilary cancer and should get treated with liver specialist.

Dr R Phani Krishna MS (JIPMER), MCh (SGPGIMS), MRCS (Edin) HPB oncologyfellowship (Japan), Transplant fellowship (Leeds UK)Director: Dept. of Surgical Gastroenterology & HPB surgery, Pace Hospitals, Hyderabad. Founder: Hyderabad HPB Oncology Foundation Miyapur: Beside South India Shopping Mall, Mythri Nagar, Madinaguda, Hyderabad, Telangana - 500050. T: 040 48486767