Download What is Cancer?

Cancer Epidemiology in India
By: Dr Snehal
Moderator: Dr Abhay Ambilkar
Framework
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What is Cancer?
Introduction
Global Scenario
Indian Scenario
Time trends and cancer patterns
Causes of Cancer
Cancer Screening
Cancer Control and Prevention
National programmes
Cancer Registry
What is Cancer?
Cancer is a group of diseases characterised by
(i) abnormal growth of cells
(ii) ability to invade adjacent tissues and even distant organs,
(iii) the eventual death of the affected patient if the tumour has progressed beyond
that stage when it can be successfully removed.
Major categories of cancer
Origin
Carcinomas
Arise from epithelial cells lining the internal surfaces of
the various organs and from the skin epithelium; e.g.
mouth, oesophagus, intestines, uterus
Sorcomas,
Arise from mesodermal cells constituting the various
connective tissues, e.g. fibrous tissue, fat and bone)
Lymphomas,myeloma and
leukaemias
Arising from the cells of bone marrow and immune
systems.
Introduction
• The burden of NCDs is still increasing worldwide despite advances for diagnosis and
treatment.
• Cancer is currently the cause of 12% of all deaths worldwide.
• Overall NCDs are emerging as the leading cause of death and disability in India
accounting for over 42% of all deaths (Registrar General of India)
• Cancer registry data reveals that 48% of cancer in males and 20% in females are
tobacco related and are totally avoidable.
• 75-80% patients are in advanced stage of disease at the time of first attendance
crude incidence rate per
100000 population
Cancer cervix
21.3
Cancer Breast
17.1
Cancer Oral cavity
11.8
source: National commission on health economics and health(NCMH)Report,2005
Global Estimated age-standardised incidence and
mortality rates: men and women
MEN
WOMEN
Source: http://globocan.iarc.fr/factsheet.asp
India: Estimated age-standardised incidence and
mortality rates: men and women
Men
Women
http://globocan.iarc.fr/factsheet.asp
Cancer Burden: India
• Caner has become one of the ten leading causes of death in
India.
• It is estimated that there are nearly 2-2.5 million cancer cases at
any given point of time.
• 8-9 lakh new cases and 4 lakh deaths occur annually due to
cancer.
• Cancer of oral cavity and lungs in males and cervix and breast in
females account for 50% of all cancer deaths in India
• WHO has estimated that 91% of oral cancers in SEAR directly
attributable to the use of tobacco and this is the leading cause of
oral cavity and lung cancer in India.
• By 2050, there will be 17 million new cases in the developing
world .
Year wise total cancer prevalence in India .
Source:[ICMR, 2006; ICMR, 2009]
• Demographic shift
• Urbanization, industrialization, changes in lifestyles, population
growth and ageing all have contributed for epidemiological
transition in the country.
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The absolute number of new cancer cases is increasing rapidly
and increase in the proportion of elderly persons as a result of
improved life expectancy following control of communicable
diseases.
• In India, the life expectancy at birth has steadily risen from 45
years in 1971 to 62 years in 1991, presently 67.3 for males and
69.6 for females indicating a shift in demographic profile.
Cancer Causes in India
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Tobbaco
Alcohol
Dietary habits
Radiation
Miscellaneous pollutants
Infections
Sexual and Reproductive factors
Causes of Cancer
• TOBACCO
 Tobacco consumption remains the most important avoidable
cancer risk.
 Between 25 and 30% of all cancers in developed countries are
tobacco-related.
 The principle impact of tobacco smoking is seen in higher
incidence of cancers of the lung, larynx, oesophagus, pancreas
and bladder.
 Bidi smoking is associated with cancer of oropharynx as well as
larynx.
 India is the third largest producer and consumer of tobacco.
• The unrefined form of tobacco used in bidis (WHO, 1999) and
the frequency with which a bidi needs to be puffed per minute
may be responsible for its relatively higher carcinogenic effects
as compared to cigarettes
Source: GATS factsheet India; 2009-2010
NFHS-3, 2005-06
Alcohol
• Increased alcohol consumption is causally associated with cancers at
various sites, mainly oral cavity, pharynx, larynx, and oesophagus and is also
responsible for the incidence of primary liver cancer.
• Globally about 9.4% new colorectal cancer cases are attributed to the
consumption of alcohol.
• It is thought that ethanol being a co-carcinogen might play a crucial role in
the carcinogenesis .
• The metabolic products of ethanol are acetaldehyde and free radicals. The
free radicals are responsible for alcohol assisted carcinogenesis through
their binding to DNA and proteins, which destroy foliate leading to
secondary hyper proliferation
(Percentage)
33
31
1
Urban
3
2
Rural
Women
32
Total
Men
NFHS-3, 2005-06
Infections
• There is strong evidence that majority of cervical neoplasia is caused
by certain sub types of human papilloma virus (HPV), a sexually
transmitted infections.
• Besides cervical cancer, evidence indicates that sexually transmitted
virus is associated with a variety of other malignancies such as
oesophageal carcinoma, anal cancer, penile cancer and oral cancer.
• Other virus–cancer relationships are between Epstein–Barr virus and
nasopharyngeal cancer; chronic active infection and hepatitis B virus
and primary liver cancer; Helicobacter pylori and stomach cancer; HIV
and Kaposi’s sarcoma and some forms of lymphoma.
DIET
• The heavy consumption of red meat is the main cause of several
cancers including gastrointestinal tract and colorectal, breast, oral ca.
• Most probably, it is due to the production of heterocyclic
amines(most potential carcinogens) during cooking of red meat.
• Food kept in plastic containers turns out to be carcinogenic because
bios-phenol from the plastic containers gets dissolved and migrates
into the food; resulting into the risk of breast and prostate.
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High consumption of fruits and vegetables associated with reduced
risk of several cancers including lung, oral, pancreas, larynx,
oesophagus, bladder, stomach and cervical cancers.
• Sexual and reproductive factors
• Role of sexual and reproductive factors affecting the incidence of
breast and cervical cancers has been well documented.
• Epidemiological data strongly implicate sexually transmitted agents in
the etiology of cervical cancer.
• Studies carried out have been shown that early onset of menarche,
late age at first child birth, nulli-parity and late natural menopause
increase the risk of breast cancer.
• Early age at first sexual intercourse and multiple sexual partners add
to the risk of cancer of the cervix.
Radiatios
• In the developed and developing countries, the radiations are also
notorious carcinogens. About 10% cancer occurrence is due to
radiation effect, both ionizing and non-ionizing.
• The major sources of radiations are radioactive compounds,
ultraviolet (UV) and pulsed electromagnetic fields.
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Exposure leads to thyroid, skin, leukemia, lymphoma, lung and
breast carcinomas.
• High risk of breast cancer among girls at puberty is due to chest
irradiation of X-rays (used for diagnostic and therapeutic purposes).
• The underground testing of nuclear weapons may be the major cause
of digestive system, liver and kidney cancers, as radiations have been
reported in ground water of the nuclear weapon testing area.
Miscellaneous Pollutants
• Various types of cancers are believed to be due to ill effects of the
polluted environment.
• The risk of lung cancers is increased by a number of outdoor
pollutants such as poly aromatic hydrocarbons.
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Long term exposure to PAHs (polyaromatic hydrocarbons) in air was
found to increase the risk of deaths associated with lung cancer.
• Indoor environmental pollutants such as volatile organic compounds
and pesticides increase the risk of leukemia and lymphoma, brain
tumors, Wilm’s tumors, Ewing’s sarcoma and germ cell tumors.
Approaches to Cancer Control
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There are four principal approaches to cancer control:
1. Prevention
2. Early Detection
3. Diagnosis and Treatment
4. Palliative Care
Strategies for Early Detection of Common Cancers in India:
Screening for Cervix Cancer
• In many developed countries a decline in the incidence of and
mortality due to cervix cancer has been observed in the past 30 years
due to cytology screening (PAP Smear)
• Visual inspection of the cervix after application of 4-5% acetic acid
(VIA) is a simple, inexpensive test that can be provided by trained
health workers.
Screening for Breast Cancer
• Though Mammography can substantially reduce
mortality from breast cancer,imaging techniques are
expensive and for this reason cannot be adopted in
developing countries as a routine public heath
measure.
• Clinical Breast Examination (CBE) performed by trained
paramedical personnel such as female health workers.
• Breast Self Examinaion (BSE) .
Screening for Oral Cancer
• Simple oral examination with adequate light is a fairly
good screening method for the early detection of precancerous lesions of the oral cavity e.g. Leukoplakia,
erythroplakia, non-healing ulcers and oral sub-mucous
fibrosis.
• National Cancer Control Programme was started
in 1975-76.
• Goals & Objectives
1. Primary prevention of cancers by health education
regarding hazards of tobacco consumption and necessity
of genital hygiene for prevention of cervical cancer.
2. Secondary prevention by early detection and diagnosis of
cancers, for example, cancer of cervix, breast cancer and
the oro-pharyngeal cancer by screening methods and
patients’ education on self examination methods.
3. Strengthening of existing cancer treatment facilities,
which were inadequate.
4. Palliative care in terminal stage cancer.
• Evolution of NCCP
• 1975-76 National Cancer Control Programme was launched with
priorities given for equipping the premier cancer hospital/institutions.
Central assistance at the rate of Rs.2.50 lakhs was given to each
institution for purchase of cobalt machines.
• 1984-85 The strategy was revised and stress was laid on primary
prevention and early detection of cancer cases.
• 1990-91 District Cancer Control Programme was started in selected
districts (near the medical college hospitals).
• 2000-01 Modified District Cancer Control programme initiated.
• 2004 Evaluation of NCCP was done by National Institute of Health &
Family Welfare, New Delhi.
• 2005 The programme was further revised after evaluation.
• Existing Schemes under National Cancer Control Programme
(NCCP)
• 1. Recognition of New Regional Cancer Centres (RCCs): to
enhance the cancer treatment facilities across the country and
reduce the geographical gap in the country in the availability of
cancer care facilities.
• 2. Strengthening of existing Regional Cancer Centres: A onetime grant of Rs.3.00 crores is provided to the existing Regional
Cancer Centres to further strengthen the cancer care services.
• 3. Development of Oncology Wing: Government Hospitals &
Government Medical Colleges are provided with a grant of Rs.
3.00 crores for the development of Oncology Wing.
• 4. District Cancer Control Programme: The DCCP implemented by
a nodal agency, which may be a Regional Cancer Centre or
Government Medical College or Government Hospital with
radiotherapy facility. A cluster of 2-3 districts are taken up for
prevention, early detection, minimal treatment and provision of
supportive cancer care at district levels.
• 5. Decentralized NGO Scheme: A grant of Rs. 8000/- per camp
provided to the NGOs for IEC activities.The funds are released
through a Nodal agency which could be a Regional Cancer Centre
or Government Medical College or Government hospital with
radiotherapy facilities.
NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER,
DIABETES, CARDIOVASCULAR DISEASES & STROKE (NPCDCS)
• The programme was initiated in the second half of 2010 with focus on
strengthening of infrastructure, human resource development, health
promotion, early diagnosis, treatment and referral.
• It was implemented in 100 backward and inaccessible districts across 21
States during 2010-12.
• Activities/Interventions adopted
I.
Prevention through behavior change
II. Early diagnosis
III. Treatment
• Health promotion, awareness generation and promotion of healthy
lifestyle
• Screening and early detection
• Timely, affordable and accurate diagnosis
• Access to affordable treatment,
• Rehabilitation
• Screening, diagnosis and treatment
• Opportunistic screening for common cancers (breast,
cervical and oral) among the population 30 years at
different level of health facilities is carried out.
• The ANMs are trained for conducting screening so that
the same can be also conducted at sub centre level.
• Each district are linked to nearby tertiary cancer care
(TCC) facilities to provide referral and outreach services.
• The suspected cases are referred to District Hospital and
tertiary cancer care (TCC) facilities.
Health
facility
Provided Service package
Sub
center
& PHC
•Identification of early warning signals and Referral of suspected cases
CHC
•‘Opportunistic’ Screening of common cancers (Oral, Breast, Cervix )
•Referral of difficult cases to District Hospital
DH
•Early diagnosis of diabetes, CVDs and Cancer
•Medical management of cases (outpatient , inpatient and intensive Care )
•‘Opportunistic’ Screening of common cancers (Oral, Breast, Cervix )
• Referral of difficult cases to higher health care facility
• Health promotion for behavior change and counseling
•Follow up chemotherapy in cancer cases
•Rehabilitation and physiotherapy services
Medical
college
•Mentoring of District Hospital
• Early diagnosis and management
•Training of health personnel
Tertiary
Cancer
Center
•Mentoring of District Hospital and outreach activities Comprehensive cancer care,
•diagnosis, treatment, minimal access surgery, after care, palliative care and
rehabilitation
•Training of health personnel
National cancer registry Programme
• National cancer registry programme was launched in 1982 .
The programme was commenced with the following objectives:
1. To generate reliable data on the magnitude and patterns of cancer
2. To undertake epidemiologic studies in the form of case control or cohort
studies based on observations of registry data
3. Provide research base for developing appropriate strategies to help in NCCP.
4.Develop human resource in cancer registration and epidemiology
Presently in India 25 PBCR and 6HBCR
Cancer Registry
• The cancer registry is an organization for th systematic
collection, storage, analysis, interpretation and reporting of
data on subjects with cancer.
There are two main types of cancer registry:
 Hospital-based cancer registries
• Concerned with the recording of information on the cancer
patients seen in a particular hospital.
• It helps to contribute to patient care by providing readily
accessible information on the subjects with cancer, the
treatment the received and its result.
• For administrative purposes and for reviewing clinical
performance.
 Population-based cancer registries
• Collect data on all new cases of cancer occurring in a well defined
population.
• The population is that which is resident in a particular
geographical region.
• The main objective of this type of cancer registry is to produce
statistics on the occurrence of cancer in a defined population and
to provide a framework for assessing and controlling the impact
of cancer in the community.
• The uses of PBCR:
(1) They describe the extent and nature of the cancer burden in the
community and assist in the establishment of public health
priorities.
(2) They may be used as a source of material for etiological studies.
(3) They help in monitoring and assessing the effectiveness of
cancer control activities.
Cancer registry at MGIMS-Sewagram
• Population based cancer registry (PBCR) in Dept of
Pathology MGIMS Sewagram.
• Started since Feb 2010
• Principle investigator: Dr Nitin Gangane
• Staff
– 1 MO Dr. Swapna Maliye
– 1 Statistician: Mrs. Rupali Raut
– 1 Computer operator: Mr. Maroti Zade
– 4 Social worker 1. Mrs.Usha Jambulkar
2. Mrs.Mamta Junghare
3. Mrs.Seema Sakhare
4. Mr.Narendra Devtale
• Main source of registration of incident cases
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MGIMS Sewagram
JNMC Sawangi
Dental college Sawangi
RST Cancer hospital Nagpur
GMC Nagpur
Jajoo hospital wardha
Amay patho lab wardha
References
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Imran Ali, Waseem A. Wani and Kishwar Saleem; Cancer Scenario in India with Future
Perspectives, Cancer Therapy Vol 8, 56-70, 2011
N. S. Murthy* and Aleyamma Mathew; Cancer epidemiology, prevention and control
National Cancer Registry Programme, Indian Council of Medical Research, Consolidated
report of the population based cancer registries, New Delhi, India: 1990-96.
National Cancer Control Programmes; Policies and Managerial Guidelines; 2nd Edition;
World Health Organization, Geneva, 2002.
Globocan 2008 database,international agency for research of cancer, world health
Organisation. htpp://globocan.iarc.fr/
NCMH. National commission on health and economics, ministry health and family
welfare,GOI2005
Sudhir Gupta, Y. N. Rao and S. P. Agarwal; EMERGING STRATEGIES FOR CANCER
CONTROL IN WOMEN OF INDIA; 50 Years of Cancer Control in India
National programme for control and prevention of cancer, Diabetes, CVD and
Stroke(NPCDCS);Director General Health Services, ministry of health and family welfare,
GOI
National Family Health Survey India (NFHS-3). Maharashtra [Online] 2005-06.[cited on]
Available from: URL:http://www.nfhsindia.org/
• The Gambia Hepatitis Intervention Study is a large-scale
vaccination trial in The Gambia, initiated in July 1986, in which
about 60 000 infants received a course of hepatitis B vaccine and a
similar number did not. New cases of liver cancer will be
ascertained through the nationwide cancer registration scheme
(Gambia Hepatitis Study Group, 1987).
• The importance of some selected risk factors in the etiology of
oesophageal cancer in Bulawayo, Zimbabwe, was assessed using
data collected by the local cancer registry during the years 1963–
77, when an attempt was made to interview all cancer patients
using a standard questionnaire. Risk factors for oesophageal
cancer were estimated by case–control analysis in which other
non-tobacco- and non-alcohol-related cancers were taken as the
‘control’ group .There was a strong association with tobacco use,
with an apparent dose–response effect. In contrast, alcohol intake
appeared to have little effect on the risk of oesophageal cancer in
this population (Vizcaino et al., 1995).