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Rapid Responses: Rapid Responses published:
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First Oncological Terrain and then environmental factors in oncogenesis.
- Sergio Stagnaro (5 April 2002)
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Causes of buccal mucosa cancer
- Peter Reay-Young (6 April 2002)
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Carcinogenicity of betel nut use
- Jonathan M. Birns (19 April 2002)
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Areca nut in Alternative Medicine.
- Thomas M. Walter (20 April 2002)
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Areca nut use is not an issue in first generation east London Bangladeshis
- Jim N Hardy (10 May 2002)
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"gutka."
- dr.manan vasenwala (25 July 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal and Metabolic Diseases Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy
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Sirs, S. Warnakularuriya,C. Trivedy and T.J.Peters (BMJ 2002;324:799-800, 6 April) discuss fascinatingly an “health problem under-recognised”, i.e., Areca nut use, as independent risk factor for oral cancer. Interestingly, the seed of “Areca catechu” is used by an estimated 200-400 million people, both men and women, mainly IndoAsians and Chinese, in all age group and social classes. Moreover, the most important consideration is the relation between areca nut use and the development of mouth cancer, oral squamous cell carcinoma, as well as leukoplakia and submucous fibrosis. From these briefly above-referred remarks, it "appears" that a serious risk factor for oral cancer is overlooked by physicians around the world. However, there is something more to be carefully considered, which doctors have ignored or overlooked until now, although its primary role is possibly in cancer primary prevention. In fact, because a congenital functional mitochondrial cytopathology is overlooked--a "conditio sine qua non" of the most frequent and dangerous human disorders, including malignancies--all current clinical research and statements are fundamentally biased. That is, doctors continue to think inaccurately about the existence or location of Congenital Acidosic Enzyme-Metabolic Histangiopathy (1, 2, 4). In fact, both environmental risk factors and every drug or substance, like the Areca nut, suggested as a risk factor for oral cancer, "could" surely influence some human biological functions and/or bring about different disorders, such as cancers, but exclusively in relation to both the presence, location, and intensity of CAEMH in a well-defined biological system. As a matter of fact, “Oncological Terrain” (See the site HONCode ID, N° 233736, http://digilander.iol.it/semeioticabiofisica and the Page “Semeiotica Biofisica”, I held in the italian site www.katamed.it), based on CAEMH, characterized by abnormalities of psycho-neuro-endocrino immunological system, evaluated "clinically", that is at the bed-side, in “quantitative” manner, represents the “genetic” factor (conditio sine qua non) of malignancies. CAEM-alfa, conditio sine qua non also of oncological terrain, is actually a severe alteration of mitochondrial oxidative phosphorilation processes, i.e. ATP synthesis, as well as nucleophyl substitution, variable in intensity from individual to individual, from tissue to tissue and within the same tissue (1-4). Sergio Stagnaro MD., Active Member NYAS. 1) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica condizione necessaria non sufficiente della oncogenesi. XI Congr. Naz. Soc. It. di Microangiologia e Microcircolaz. Abstracts, pg 38, 28 Settembre-1 Ottobre, Bellagio 2) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica. X Congr. Naz. Soc. It. di Microangiologia e Microcircolazione. Atti, 61. 6 -7 Novembre, Siena 3) Stagnaro S., Stagnaro-Neri M. Una patologia mitocondriale ignorata: la Istangiopatia Congenita Acidosica Enzimo-Metabolica. Gazz. Med. It. - Arch. Sci. Med. 149, 67 1990. 4) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447 1993 |
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Peter Reay-Young, Retired Oncologist
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I spent 8 years as a surgeon and then an oncologist in Papua New Guinea where the commonest cancer in males was buccal mucosa cancer. Betel nut chewing starts in the young and is chewed alike by males and females. There is an article in the Lancet (I do not now have access to its files), where a woman (not Asian) to improve her looks put cotton wool pads in both cheek pouches, daily for many years. She developed buccal mucosa cancer. Continued trauma may well be an initiating cause. As well we found the addition of lime to the chew was significant. There were many cases of cancer of the angle of the mouth where the stick which is dipped in lime in a pot is then drawn through into the mouth. |
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Jonathan M. Birns, Specialist Registrar in Geriatrics and General Internal Medicine Northwick Park Hospital, Watford Road, Harrow, Middlesex. HA1 3UJ
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As a doctor who has worked in a number of hospitals in areas of inner city London with large populations of Asian immigrants I was interested to read the article by Warnakulasuriya et al. outlining the health problem of areca nut use1. As a physician, I saw betel nut users with cancer of the oesophagus rather than of the oral cavity. I was surprised by the authors’ omission of its use being an important risk factor for developing squamous cell carcinoma of the oesophagus as well as their limited discussion of the mechanisms of betel induced carcinogenesis. In some areas of north- eastern India, oesophageal carcinoma is the most commonly diagnosed cancer, with betel nut use being highly significant both in terms of its duration of use and frequency of daily chewing2. In a Taiwanese series of squamous cell oesophageal carcinomas, after adjusting for cigarette smoking, alcohol consumption, and other confounders, subjects who chewed from 1 to 495 betel-year and more than 495 betel-years (about 20 betel quid per day for 20 years) had 3.6-fold (95% Cl = 1.3-10.1) and 9.2-fold risk (95% Cl = 1.8-46.7), respectively, of developing oesophageal cancer, compared to those who did not chew betel3. Both areca nut extract and arecoline induce c-jun proto-oncogene expression in human mucosal fibroblasts4. In addition, the mixture of the nut with slaked lime further contributes to carcinogenicity. Powdered slaked lime applied to the chewed areca nut with piper betel inflorescence at the corner of the mouth causes the mean pH to rise to 10, at which reactive oxygen species are generated from betel quid ingredients and these may cause oxidative DNA damage to the surrounding tissues. Lime also causes ulceration at its site of application, exposing basal stem cells to mutagens. Thomas et al. showed that oral cancer in betel nut users is concentrated at the corner of the mouth and cheek, by striking contrast with western populations, and corresponds precisely with the site of application of lime in 77% of 169 cases5. Piper betel inflorescence contains 15 mg/g safrole which is a known rodent carcinogen and following betel quid chewing, safrole forms stable safrole-DNA adducts in human oral tissue which may further contribute to oral carcinogenesis. References: 1. Warnakulasuriya S, Trivedy C, Peters TJ. Areca nut use: an independent risk factor for oral cancer. BMJ 2002; 324: 799-800 2. Phukan RK, Ali MS, Chetia CK, Mahanta J. Betel nut and tobacco chewing; potential risk factors of cancer of oesophagus in Assam, India. Br J Cancer 2001; 85(5):661-7 3. Wu MT, Lee YC, Chen CJ, Yang PW, Lee CJ, Wu DC, Hsu HK, Ho CK, Kao EL, Lee JM. Risk of betel chewing for oesophageal cancer in Taiwan. Br J Cancer 2001;85(5):658-60 4. Ho TJ, Chiang CP, Hong CY, Kok SH, Kuo YS, Yen-Ping Kuo M. Induction of the c-jun protooncogene expression by areca nut extract and arecoline on oral mucosal fibroblasts. Oral Oncol 2000 ;36(5):432-6 5. Thomas SJ, MacLennan R. Slaked lime and betel nut cancer in Papua New Guinea. Lancet 1992 ;340(8819):577-8 |
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Thomas M. Walter, Asst. Lecturer, Dept. of Medicine, Government Siddha Medical College, Palayamkottai, T.N., India. 627 002.
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Sir, I read the article, 'Areca nut use: an independent risk factor for oral cancer' with great interest since I come across a number of patients with oral carcinoma in our Medical College Hospital (a 250 bedded Government Medical College Hospital for Alternative Medicine). History of such patients reveal the regular use of paan - in which areca nut is an major ingredient. It is a fact that all those who use areca don't get complications. As the author has correctly stated," Areca nut usage is culturally bound and is an integral aspect of several IndoAsian customs and thus part of their identity. Casual use of small quantities of areca nut on a non- regular basis is widely prevalent in Asian communities. Although this practice is unlikely to have long term ill effects with time, some individuals may develop a dependency syndrome"#. Most of the men and women in the rural areas of India use areca nut extensively along with betel leaf. This combination is a regular part of their daily activities such as honouring their guests, rituals offered to the God and Teachers (Guru) etc. The seed or kernel and the extract; root and tender leaves; catechu are the parts used. The main constituents are: Kernels (seeds) contain catechu, tannin 15%; gallic acid, oily matter (fat 14 p.c), gum and alkaloids, viz. arecoline 0.07%, arecaine 1%, arecaidine, and guvacoline, guvacine and choline occur in traces only. Arecoline is the most important alkaloid and an anthelmintic principle forms white crystalline salts with acids, i.e., hydro-bromide which is official in several pharmacopoeias in Europe. It is soluble in water, alcohol and ether.* The actions of Areca are: Fresh nut is somewhat intoxicating and produces giddiness in some persons. Dried nut is stimulant, astringent and taenifuge. It increases the flow of saliva; lessens perspiration, sweetens the breath, strengthens the gum and produces mild exhilaration. Pharmacological action of arecoline resembles that of muscarine, palletierine and pilocarpene. It violently stimulates the peristaltic movements of the intestines and bowels, acts on entozoa; and produces a marked constriction of the bronchial muscles which can be overcome by adrenaline or atropine.+ The main uses of seeds are: Kernel (seed) of the fruit is one of the constituents chewed together with lime, black catechu and the leaves of betel and sometimes also with such articles as turmeric and tobacco leaf. The popular belief is that decay of teeth is prevented, but owing to constant irritation the mucous membrane of the mouth and gum is inflamed causing loosening and loss of teeth, and some times oral carcinoma. Juice of tender leaves mixed with oil is applied as an embrocation in cases of lumbago and a decoction of the root is a reputed cure for sore lips.* Thanks, Walter. # Areca nut use: an independent risk factor for oral cancer Saman Warnakulasuriya, Chetan Trivedy, and Timothy J Peters BMJ 2002; 324: 799-800 * Dr. K.M. Nadkarni's Indian Materia Medica - Volume I, Third revised edition pp 130 - 133. + Dr. Chopra's Indigenous Drugs - pp. 284 to 286. |
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Jim N Hardy, GP principle Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Editor, Warnakulasuriya and colleagues right draw attention to the use of areca nut in the world population (1). I have worked for over 15 years in London's east end where there is a large resident Bangladeshi population. My observation is that while immigrants remain dependent users of the nut, the first and second generations have eschewed the habit, reserving it instead for occasional recreational use. I do not feel it poses a longterm health risk and suggest health promotional messages should continue to be focussed on more ubiquitous habits like cigarette smoking. Dr Jim Hardy. (1)S Warnakulasuriya, Chetan Trivedy, Timothy J Peters. Areca nut use: an independent risk factor for oral cancer. BMJ 324:799-858 No 7341 6th April 2002 |
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dr.manan vasenwala, consultant-cardiologist k.k.heart center, aligarh-202002.india.
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the contents of betel nut chewing are now available in small pouches called "gutka". the contents are put directly in the mouth without using a betel leaf.many of these products, rather most of them also contain tobacco. the practice is catching on and in a day a young man can easily take in 10-15 pouches. apart from oral cancer, it may be a factor for the epidemic of coronary heart disease in young people in the indian sub- continent. Competing interests: None declared |
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