Magnitude of Problem
Cancer prevalence in India is estimated to be at 3.9 million with reported incidences of 1.1 million in 2015. This estimate is however conservative as the real incidences are at least 1.5 to 2 times higher than noted in literature. The reason behind this is the lack of hospital and population-based cancer registries in India. India’s age-standardized cancer incidences, estimated at 150-200 per 100,000 population is higher than Africa and at par with China.
Breast and cervical cancers among women, and head, neck, lung and gastrointestinal cancers among men, represent > 60% of the incidence burden. Now, India has nearly touched three times the incidences of US and China for head, neck and cervical cancers already.
However, the outline of cancer in India is also changing, and is paralleling trends seen in more urbanized nations. In 2000, the most prevalent cancers in India were head and neck cancers in men (associated with all forms of tobacco use) and cervical cancer in women (associated with human papilloma virus infection, sexual hygiene and habits). Breast cancer has now surpassed cervical cancer as the most prevalent female cancer, and incidence rates of gastrointestinal cancers, which have traditionally been low in India have also been on the rise.
Cancer detection rates in India are poor, and estimated to be around 20-30 % which is about half of US and China. Only 20% of cancer is diagnosed in stage I/II in India and the rest 80 % in Stage III/IV, contrary to the trends observed in the USA/UK.
The key risk factors involved in cancer are tobacco use, alcohol consumption, obesity, dietary and lifestyle changes and poor Hygiene. One third of the obese population of the world is in India. More than 17 % of the Indian population uses different forms of tobacco and the trend is still continuing. Similarly, alcohol consumption per capita increased by 50% in age more than 15 years. Infection itself leads to 16% of malignancies and these infections are mostly viral in nature like HBV, HPV and EBV.
Barshi rural registry, for instance, had the highest incidence of cervical cancer (30% of the total new cases among female versus 9% in Mumbai, 12% in Delhi, 13% in Chennai) and its root causes are poor sexual hygiene, lower age during marriage and first intercourse, higher parity, and low condom usage . While reported prevalence of multiple sexual partners and high risk sexual behaviour is low in India (0.1% among women and 2% among men), the prevalence is higher among selected population sub-groups such as unmarried/widowed/deserted populations (4% among women and 12% among men).
Dietary factors have also been found to play key part as obesity, nitrosamines in packaged food, pickles contaminated with fungus lead to malignancy. A case-control study in stomach cancer patients, conducted in Mumbai, revealed a 40% higher risk of malignancy with consumption of poultry at least once a week. In recent times it has been seen that the per capita consumption of poultry in India has increased, and that it is the fourth in line for poultry consumption.
For breast cancer patients, the increase in the mean age of first childbirth and the reducing trend in breast feeding practices are also considered as risk factors, especially in urban areas. An increasing number of working women in urban areas (12% in 2011 vs. 9% in 2001) is a driving factor for delayed child birth. Moreover familial causes are also involved. For example, if one female in the family has breast cancer, the risk it poses to the first degree female relative is around 2 times and it could increase to up to 5 times, if two cancers are detected in two individuals (first degree relatives).
Problems in our country
Higher mortality rates in head and neck cancer are attributable to poor awareness levels resulting in ulcers being ignored by many patients, consequently delaying diagnosis. Limited inclusion of advanced diagnostic tools in treatment protocols, such as PET CT that enable improved staging, assessment and treatment planning is also a factor. The Cost factor of different investigations also play a key role. Patients from poor socio-economic background are not able to afford these investigations.
In case of stomach cancer, there is lack of overt presentation of symptoms and standard screening tests result in poor detection rates. In addition, general physicians and gastroenterologists, who are the first point of contact for such patients, may not be adequately aware or trained to detect and refer, or treat these patients.
Lately we are treating lots of cancer patients from foreign countries as the cost of cancer treatment in India is 5-6 times lower than that in the US, but for Indian patients, treatment is still unaffordable due to poverty and lower coverage of public and private insurance programs (only 30% of population covered).
Another issue is the access to physical infrastructure (diagnostic and treatment facilities) and human infrastructure (oncologists), which is low on account of low density and significant geographical skew (40-60% of the facilities and oncologists are present in the top metros of India only). People from other parts of the country are forced to travel to metro cities for treatment. The duration for cancer, for example, ranges from months to years and staying in metros for months together adds costs to treatment.
Awareness regarding disease, symptoms and screening practices is quite low too. For instance, breast cancer studies in South India have revealed 55% of women have never heard about breast cancer, 80-90% were not aware of symptoms and 65% did not practice self-examination at all.
Early diagnosis and screening is imperative in India since less than 30% of cancers are diagnosed in stage I and II, as a result of which survival rates are significantly lower when compared globally. India does not have any organised national screening programs, as infrastructure and resource constraints make large-scale screening cost ineffective. We need to come up with more cost effective methods for diagnosis and screening.
We have to focus on cancers with high incidence, and have to make screening efforts to detect cancers such as breast and cervical cancers in women, and oral cancers in both sexes. Implementation of such measures would necessitate large scale training of public health workers, contribution by local NGOs/ self-help groups for outreach, standard screening protocols and effective gatekeeping mechanisms.
Simple techniques like cervical screening by visual inspection with acetic acid is a highly cost-effective alternative to pap-smear based screening (less than one-tenth of the cost) and has been shown to reduce cervical cancer mortality by 30% as per recent literature. Moreover, this can be administered by health workers/sisters with minimal training, and is particularly useful in the southern and eastern states which have high rates of cervical Cancer.
Oral cancer screening by visual inspection in high-risk populations is a cost-effective procedure that should be administered by trained para-medical staff of the primary health centre for early detection and for providing health education.
Faecal occult blood testing (FOBT) in stool samples is a simple cost-effective screening tool for GIT malignancies, which can be performed at the district cancer centres, particularly in the north-eastern states and a few of the southern states which have a higher incidence of these cancers.
Focus on training the public health workers/Hospital employees/Nurses for providing effective counselling services to direct the suspected cases to the right practitioners for evaluation.
Cancer is a complex disease that requires a multimodal approach to treatment with the involvement of several specialists and technology for accurate staging and treatment to ensure management of the disease and prevent recurrence.
Areas to Improve
In order to achieve right treatment in first attempt and improved patient survival, the following measures should be adopted.
To establish Institute-based national standard guidelines and protocols, periodical review of management protocols by a high-level board is needed. We should include new innovations in molecular diagnosis, targeted drugs, and radiological procedures in standard treatment guidelines. Institutional review boards should be set up to ensure implementation of these protocols with regular audits of clinical outcomes.
Multidisciplinary (MDT) approach to treatment should be adopted. Hospitals should constitute tumour boards consisting of a multidisciplinary panel of medical, surgical and radiation oncologists, along with other specialities like radiology, pathology, oncology nurse, PMR and palliative care physicians for effective diagnosis, treatment planning and execution. Where feasible, molecular diagnosis (IHC), neoadjuvant radio-/chemotherapy and targeted modalities of treatment must be incorporated in patient management.
Training and education of nurses and providers of palliative care, who play a pivotal role in provision of comprehensive cancer care, should be a key imperative for tertiary cancer centres and cancer institutes. We have to provide training to district level doctors in palliative care, in conjunction with local NGOs to ensure adequate service delivery.
Indian cancer registries are unevenly distributed within the population (total 27 in no), and suffer from low coverage and under-reporting in the absence of mandates for reporting of cancer statistics. As per Globocan 2012, for Jammu and Kashmir, there is no cancer data available. As national cancer control programs rely on the data provided by cancer registries, the following measures are proposed to improve the availability and quality of data in cancer registries.
The National Cancer Registry program including both hospital-based and population-based registries should ensure mandatory submission of cancer statistics by all government and private institutes that treat cancer patients. We have to strengthen the network between hospital-based registries with ICMR. This will ensure adequate population coverage of cancer-specific data and provide detailed information on the trends of specific cancers.
Each cancer centre should maintain a database of all registrations with detailed information including the stage at diagnosis, decisions of MDT, treatment offered and response rates, mortality and morbidity statistics, and survival statistics. There should be provision for data mining from the cancer data saved in hospital records. This should be provided to policy makers periodically for review and decision making.
Take Home Message
Policy decisions should always be data-driven. Cancer registry data should be periodically reviewed and trends of disease burden, geographical distribution of site-specific cancers must be identified for determining resource allocation and cancer control measure.
Dr.Vikas Roshan & Team
Associate Consultant, Department of Radiation Oncology
Shri Mata Vaishnodevi Narayana Superspeciality Hospital, Jammu