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| Cancer - To be nailed to the Cross | | | Dr.Vikas Roshan | 11/3/2016 9:06:01 PM |
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Cancer prevalence in India is estimated to be 3.9
million with reported incidence of 1.1 million in 2015. This estimate is however conservative as the real incidence is at least 1.5 to 2 times higher than noted in literature. The reason behind this is lack of hospital based and population based cancer registries in India. India's age-standardized cancer incidence estimated at 150-200 per 100,000 population is higher than Africa and on par with China.
Breast and cervical cancers among women, and head and neck, lung and gastrointestinal cancers among men, represent >60% of the incidence burden. Now India has nearly touched three times the incidence of US and China for head and neck and cervical cancers.
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 papillomavirus 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 showing an increasing trend.
Cancer Detection rates in India are poor around 20-30% which is about half of US, China.Only 20% of cancer is diagnosed in stage I/II in India and rest 80% in Stage III/IV and this is contrary to USA/UK.
Risk Factors
The key risk factors involved in cancer are Tobacco use, Alcohol consumption, Obesity, Dietary, Lifestyle changes, Poor hygiene. One third of obese population of world in India. More than 17% of the population of India uses different forms of tobacco and currently the trend is still rising. 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 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 at 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 played key part as obesity, nitrosamines in packaged food, pickles contaminated with fungus leads to malignancy. A case-control study, conducted in Mumbai, in stomach cancer patients revealed a 40% higher risk of malignancy with consumption of poultry at least once a week. In recent times it has been seen that Per capita consumption of poultry in India is increased and India is fourth in line for poultry consumption.
In case of breast cancer patient'saetiology is 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 v. 9% in 2001) is a driving factor for delayed child birth. Moreover familial causes are also involved for example if one female in family have breast cancer, the risk to first degree relative female is around 2 times and this risk can increase upto five 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 can enable improved staging, assessment and treatment planning. The Cost factor of different investigation also playing a key role. Patients from poor socioeconomic 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 results in poor detection rates. Patients present vey late in stomach cancer and oesophagus cancer because there is lot of empty space for tumour to grow. 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.
Now a days 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 unaffordable for a large section of society due to poverty, low population coverage of public and private insurance programs (only 30% of population covered) .
Another issue is access to physical infrastructure (diagnostic and treatment facilities) and human infrastructure (oncologists) 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).people from pan India are forced to travel to metro cities.The treatment duration for cancer ranges from months to years and staying in metros for months together also adds cost to treatment.
Awareness regarding disease, symptoms and screening practices is low 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.
Early diagnosis and screening is imperative in India as less than 30% of cancers are diagnosed in stage I and II, as a result of which survival rates are significantly lower when compared with its global peers. India does not have any organised national screening programs, as infrastructure and resource constraints make large-scale screening cost ineffective. We need concerted to leverage 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 center 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 centers, 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. 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, and it require regular audits of clinical outcomes.
Multidisciplinary (MDT) approach to treatment should be adopted. Hospitals should constitute tumor boards consisting of a multidisciplinary panel of medical, surgical and radiation oncologist along with other specialities like radiology, pathology, oncology nurse, PMR and palliative care physician 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 centers and cancer institutes. We have to provide training to district level doctors in palliative care, in conjunction with local NGOs, is also essential 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 center should maintain a database of all registrations with detailed information including 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. This should be provided to policy makers periodically for review and decision making. |
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