1. Cancer Epidemiology in India
By: Dr Snehal
Moderator: Dr Abhay Ambilkar

2. Framework 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

3. 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.

4. 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
source: National commission on health economics and health(NCMH)Report,2005
crude incidence rate per population
Cancer cervix
21.3
Cancer Breast
17.1
Cancer Oral cavity
11.8

5. Global Estimated age-standardised incidence and mortality rates: men and women
Source:

6. India: Estimated age-standardised incidence and mortality rates: men and women

7. Cancer Burden: India
Caner has become one of the ten leading causes of death in India.
It is estimated that there are nearly 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 .

8. Year wise total cancer prevalence in India .
Source:[ICMR, 2006; ICMR, 2009]

9. Demographic shift
Urbanization, industrialization, changes in lifestyles, population growth and ageing all have contributed for epidemiological transition in the country.
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.

10. Cancer Causes in India Tobbaco Alcohol Dietary habits Radiation
Miscellaneous pollutants
Infections
Sexual and Reproductive factors

11. 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

12. Source: GATS factsheet India; 2009-2010

13. NFHS-3,

14. 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

15. Alcohol use by men and women-NFHS-3
(Percentage)
NFHS-3,

16. 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.

17. 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.
High consumption of fruits and vegetables associated with reduced risk of several cancers including lung, oral, pancreas, larynx, oesophagus, bladder, stomach and cervical cancers.

18. 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.

19. 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.
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.

20. 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.
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.

21. Approaches to Cancer Control
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.

22. 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 pre-cancerous lesions of the oral cavity e.g. Leukoplakia, erythroplakia, non-healing ulcers and oral sub-mucous fibrosis.

23. 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.

24. Evolution of NCCP
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.
The strategy was revised and stress was laid on primary prevention and early detection of cancer cases.
District Cancer Control Programme was started in selected districts (near the medical college hospitals).
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.

25. 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 one-time 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 crores for the development of Oncology Wing.

26. 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.

27. Activities/Interventions adopted Prevention through behavior change
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
Activities/Interventions adopted
Prevention through behavior change
Early diagnosis
Treatment
Health promotion, awareness generation and promotion of healthy lifestyle
• Screening and early detection
• Timely, affordable and accurate diagnosis
• Access to affordable treatment,
• Rehabilitation

28. 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.

29. 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 )
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

30. National cancer registry Programme
National cancer registry programme was launched in
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

32. 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.

33. 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.

34. Population-based cancer registries play an important role in epidemiology by quantifying the incidence and prevalence of the disease in the community and as a source of ascertainment of cancer cases in intervention, cohort and case–control studies.
Their data are also important in planning and evaluating cancer control programmes by helping to establish priorities and forecast future needs; by monitoring cancer occurrence in relation to the prevalence of important risk factors; by helping to assess and monitor the effectiveness of screening programmes; and by evaluating cancer care through survival statistics.
The data items to be collected by a population-based cancer registry are determined by their aims, the data collection methods to be used, and the resources available. The emphasis should be on the quality of the data rather than their quantity. The completeness and validity of the data should be monitored regularly.
Population-based cancer registries are particularly useful in developing countries where reliable cause-specific mortality data are rarely available

35. Cancer registry at MGIMS Sewagram

36. Cancer registry at MGIMS-Sewagram`
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

37. Main source of registration of incident cases
MGIMS Sewagram
JNMC Sawangi
Dental college Sawangi
RST Cancer hospital Nagpur
GMC Nagpur
Jajoo hospital wardha
Amay patho lab wardha

38. References
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:
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] [cited on] Available from: URL:

39. The Gambia Hepatitis Intervention Study is a large-scale vaccination trial in The Gambia, initiated in July 1986, in which about 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).