Cancer Epidemiology In India

Cancer Epidemiology In India

Ramesh PawarModerated by: Prof. Deshmukh Sir

FrameworkDefinition IntroductionMagnitudeRisk factorsNational programmeCancer registry and AtlasCancer registry at MGIMS, SevagramReferences

CancerCancer refers to a class of diseases in which

a cell or group of cells divide and replicate uncontrollably, intrude into adjacent cells and tissues( invasion) and ultimately spread to other parts of the body than the location at which they rose ( metastasis) ( national cancer Institute)

Introduction India is experiencing a rapid health transition with rising

burden of Non Communicable diseases (NCDs).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).

According to national commission on macroeconomics and Health (NCMH) report (2005), the crude incidence rate for Cervix cancer, beast cancer and oral cancer is 21.3, 17.1 and 11.8 (among both men and women) per 100,000 population respectively.

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

Burden of Cancer:

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

Source: http://globocan.iarc.fr/factsheet.asp

MEN

WOMEN

Global Estimated age-standardised incidence and mortality rates: Men


Global Estimated age-standardised incidence and mortality rates: Women


Global Estimated age-standardised incidence and mortality rates: both men and women


INDIA

Men Women

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

http://globocan.iarc.fr/factsheet.asp

India Estimated age-standardised incidence and mortality rates: Men


India Estimated age-standardised incidence and mortality rates: Women


Cancer Burden: IndiaCaner 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 and 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 (Farlay et al 2004)

Risk factors for cancers:

o Genetic factorso Retinoblastoma (RB1)

o Interaction of gene and environmento Mutation in some p53 codons are more

prevalent in cancer of a particular organ.

http://p53.free.fr/Database/p53_cancer/all_cancer.html

Risk factors o Infection

o approximately 20% of the cancers among men and women in developing countries is attributed for infectious agents as opposed to 9% in developed countries.(Pisanil 1997)

o Hep B & C, HPV.

o Tobaccoo Responsible for about 40 to 50% of cancers in men

and about 20% of cancers in women

Tobacco use among men and women-NFHS3

7

50

13

61

11

57

Urban Rural Total

Women Men

NFHS-3, 2005-06

(Percentage)

NFHS-3, 2005-06

Alcohol use by men and women-NFHS-3

1

31

3

33

2

32

Urban Rural Total

Women Men

NFHS-3, 2005-06

(Percentage)

Alcohol use by women is rare.

NFHS-3, 2005-06

Risk factorso Diet

o In India dietary habits responsible for about 10-20% of cancers.

o The changing dietary patterns particularly involving animal proteins.

o Consumption of large amount of red chillies, food at very high temperatures and alcohol consumption are the main risk factors for stomach cancer in India

o Tuibur –Mizorum

Source: WHO (2003) RTS 916. Diet, Nutrition and prevention of chronic diseases.

Risk factors PesticidesMalwa region of Punjab- a cotton belt“Cancer train” ( sengupta N.A. train ride to cancer

care. Times of India 2011)

Breast cancer: late age at 1st pregnancy, single child, late menopause, high fat diet.

Cancer cervix: early marriage, multiple sexual partner, multiple pregnancy ,poor sexual hygiene.

Education and socio-economic status. Physical inactivity and life style

Life style factors and risk of developing cancer

Source: WHO TRS 916. Diet, nutrition and prevention of chronic diseases.

Disease should be an important public health problem

Must have a latent asymptomatic stageAdequate treatment should be availableThe test should be safe and relatively in-

expansiveCapable of rapid applicationShould be accurate and reproducibleTest should be acceptable to people The test should be reasonably inexpensiveAdequate follow up of the positives should be

ensuredUndesired harm due to screening should be

avoided

Criteria for Screening

Early warning signals

If someone notice following symptoms she/he should contact to health centre immediately:

A sore that doesn’t healRecent changes in wart or moleUnusual bleeding/discharge/per vagina/rectumPersistent cough or hoarseness of voice Persistent change in bladder/bowel habitsDifficulty in swallowing Painless lump or swallowing.

National programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke

Pilot programme was launched on 4th January 2008 in 7 states covering one district each

Objectives Prevent and control common NCDs through behaviour and

life style changes.Provide early diagnosis and management of common NCDsBuilt capacity at various levels of health care for

prevention, diagnosis and treatment of NCDs.Train human resource within the public health setup viz

doctors, paramedics and nursing staff to cope with the increasing burden of NCDs

Establish and develop capacity for palliative and rehabilitative care.

India Map showing the states to implement NPCDCS

Operational guidelines. (NPCDCS).Director General of Health services Ministry of health and family welfare Government of India.

Strategies

Prevention through behaviour change Early diagnosis TreatmentCapacity building of human resourceSurveillance, monitoring and evaluation

1. Prevention through behaviour change

Creating general awareness Promotion of healthy life style habits The various approaches such as mass media,

community education and interpersonal communication Increase intake of healthy foodIncreased physical activity through sports,

exercise etc.Avoidance of tobacco and alcoholStress management Warning signs of cancer etc.

2.A Early diagnosis

Strategy for early diagnosis of chronic non communicable diseases will consist of opportunistic screening of person above the age of 30 yrs at the point of primary contact with any health care facility, be it the village, CHC, district hospital, tertiary care hospital.

Opportunistic screening will have in built component of mass awareness creation, self screening and trained health care providers.

Involves simple clinical examination comprising of relevant questions and easily conducted physical examination (such as h/o tobacco consumption and measurement of blood pressure etc.)

2.B TreatmentScreening, diagnosis and management

(including diet counselling, lifestyle management ) and home based care will be the key functions.

One of the nurse-home visit for bedridden cases.

Supervise work of health worker and attend monthly clinic held in villages on a random basis.

Advice patient about careRefer if required.

2.C Home based care

2.C Referral

3.Palliative careAffirms life and dying as a natural processNeither hastens nor postpones deathActive total care of patients and families by

multi-professional team.

Services available under NPCDCS at different levels

Packages of services to be made available at different levels under NPCDCS

Management structure:

National NCD CellNCD Cell will be responsible for overall

planning, implementation, monitoring, and evaluation of different activities and achievement of physical and financial target planned under the programme.

Organization structure of National NCD cell

Technical wing Administrative wing

Deputy Director General Additional secretary/Joint secretary

CMO( Cancer) Director(NCD)

CMO(Dibetes andCVD) Under secretary (NCD)

CMO (Geriatric care) Under secretary(NCD)

Consultant Section officer

The national NCD cell is supported by following staff

Sr.No. Name of post No. of post

1 National programme officer(NCD) 12 National programme officer(training and coordination) 1

3 National program officer ( M & E and surveillance) 14 National epidemiologist 15 Functional consultant 16 Technical officer (health management) 17 Technical officer( Nutrition) 18 Technical officer (Physiotherapy) 19 Technical officer (IEC) 110 Logistic co coordinator 111 M & E officer 112 Data manager 113 Computer assistant 214 Technical assistant 2

Total 16

Role and responsibilities of National NCD Cell is as underPlan, Coordinate, and Monitor all the activities at National and

State level.Develop operational guidelines, Standard Operating

Procedures (SOP), Training modules, Quality benchmarks, Monitoring and reporting systems and tools.

Monitoring and evaluation of the programme through HMIS, Review meetings, Field observations, surveillance, operational research and evaluation studies.

Prepare National Training Plan: Curriculum, Training resource centres, training modules and organize national level training programmes

Procurement of equipment and supplies for items to be provided as commodity assistance;

Release of funds and monitoring of expenditure

State NCD cellThe Cell shall function under the guidance of

State programme Officer (SPO NCD) and will be supported by the identified officers/officials from the Directorate /Director General of Health Services. SPO (NCD) will be a State level health official identified by the State government.

1. State Programme Officer2. Programme Assistant3. Finance cum Logistics Officer4. Data Entry Operators (2)

A. Health promotion:

Behaviour and life style changes Sub centre level Carried out by the front line health workers- ANM and

(or) Male Health Worker.Camp, interpersonal communication (IPC), posters,

banners Educate people at community/school/workplace

settings.Increased intake of healthy foodsIncreased physical activity through sports, exercise, etc.; Avoidance of tobacco and alcohol;Stress managementWarning signs of cancer etc.

B Opportunistic ScreeningDuring the camps/ designated day ANM and (or) Male Health Worker

also examine persons at and above the age of 30 years for alcohol and tobacco intake, physical activity, blood sugar and blood pressure.

During the examination, health worker shall also carry out the measurement of weight, height, and Body Mass Index (BMI) etc.

C. ReferralANM and (or) Male Health Worker refer the suspected case of

Diabetes and Hypertension to the CHC or higher Health Facility for further diagnosis and management

D. Data recording and reportingANM and (or) Male Health Worker at Sub Centre maintain in

prescribed format to related CHC under the programme and submit the report monthly to CHC.

Activities at Community Health Centre

A. ScreeningB. Prevention and health promotionC. Laboratory investigationsD. Diagnosis and Management E. Home based careF. ReferralHuman Resources for CHC NCD services

a. Doctor (1)b. Nurses (2)c. Counsellor (1)d. Data Entry Operator (1)

Activities at District Level

The selected districts provide the full complement of preventive, supportive and curative services for NCD

‘NCD clinic’A. Opportunistic screeningB. Detailed investigationC. Outsourcing of certain laboratory investigationsD. Out-patient and In-patient CareE. Day Care Chemotherapy FacilityF. Home Based Palliative CareG. Referral & Transport facility to serious patientsH. Health promotionI. TrainingJ. Data recording and reporting

K. Human Resources at District Hospital

a. Doctor (specialist in Diabetology/Cardiology/M.D Physician)

b. Medical Oncologistc. Cyto-pathologistd. Cytopathology Techniciane. Nurses (4): 2 for Day Care, one for Cardiac

Care Unit, one for O.P.Df. Physiotherapistg. Counsellorh. Data Entry Operatori. Care coordinator

NPCDCS District covered during 2010-11

National cancer registry Programme:

Cancer registration is the process of systemically and continuously collecting information on malignant neoplasm.

National cancer registry programme was launched in 1982 by ICMR to provide true information on cancer prevalence and incidence

Objectives: To generate authentic data on the magnitude of cancer

problem in India To undertake epidemiological investigations and advice

control measures and Promote human resource development in cancer

epidemiology.


Population based cancer registries: there are 23 PBCR. Initially 5 in urban areas ( Delhi, Bhopal, Mumbai, Bangalore, Chennai ) and one in rural area ( Barshi In Maharashtra)

Hospital Based Cancer registries: at Chandigarh, Dibrugarh, Thiruvananthapuram, Bangalore, Mumbai and Chennai, six hospital based registries are maintained.

A total of 3.3% population is covered by these registries (12.8% Urban and 0.06% rural population).


These registries generate annual report From these registries, trends are indicating

to put more emphasis on cancer prevention.

Incidence of cancer In males, the age adjusted incidence rate (AAR) varied

from 53.0 per 100,000 in the rural PBCR at Barshi to 239.2 per 100,000 in Aizawl district of Mizoram state.

Among females, the AAR varied from 49.9 per 100,000 in Ahmedabad rural district to 197.4 per 100,000 in Aizawl district.

The proportion of tobacco related cancers (TRCs) among males varied from 33.24% in Barshi to 59.2% in Dibrugarh.

Among females, the relative proportion varies from 9.8% in Thiruvananthapuram to 26.3% in Dibrugarh district. http://www.icmr.nic.in/annual/2009-10/english/ncd.pdf

Development of Atlas of cancer in IndiaObjectives:

(i) To obtain an overview of patterns of cancer in different parts of the country (ii) To calculate estimates of cancer incidence wherever feasibleThe response from pathologists across the country has been overwhelming and over 96 centres out of the 212 letters sent have responded so far and over 50% of these centres have already started collation of information on malignant neoplasms reported from 1 January 2001

THE INDIAN CANCER ATLASUsing pathology-based data to obtain clues about geography of cancer

Report of national cancer registries and atlas of cancer in India:

One in about 15 men and one in about 12 women in the urban areas could develop cancer in their lifetime.

Age adjusted incidence rate of oesophageal cancer in women of Bangalore is one of the highest (8.8 per 1, 00,000) in the world.

Cancer of tongue in males in Bhopal (8.8 per 1, 00,000) is the highest in the world.

Cancer of stomach is one of the main cancers in males in southern registries.

Gall bladder cancer in Delhi women is one of the highest (8.9 per 1, 00,000) in the world.

75-80% patients are in advanced stage of disease at the time of first attendance

Report of national cancer registries and atlas of cancer in India:

The present load of cancer cases is going to increase almost 1/3rd in each of the next few decades.

Current projection suggest that the total cancer burden in India for all sites will double by 2026 because of increasing longetivity, greater exposure to environmental carcinogens due to wide variety of chemical agents in industry and agriculture, and continued use of tobacco.

Cancer registry

at MGIMS

Sevagram

Cancer registry at MGIMS-Sevagram

Population based cancer registry (PBCR)Started since Feb 2010 to 31st Jan 2014Principle investigator: Dr GanganeStaff

1 MO (cancer Mgnt) Dr. Priti Shende1 Statistician4 Investigator1 Computer operatorMGIMS-HIS, Sawangi and Pvt hospitals and

Nagpur Pvt. And Govt Hospitals.NCR Bangalore

Cancer registry at MGIMS-Sevagram

Thank you

References Operational guidelines. National programme for prevention and control of Cancer, Diabetes, CVD and Stroke

(NPCDCS).Director General of Health services Ministry of health and family welfare Government of India. WHO (2003) Technical report series 916. Diet, Nutrition and prevention of chronic diseases. NCMH. National commission on health economics and health report. Ministry of health and family welfare, Govt.

Of India 2005. ICMR. Cancer research in ICMR. http://www.ncrpindia.org/Cancer_Atlas_India/about.aspx GLOBOCAN 2008 database, international agency for research on cancer, World health organization.

http://globocan.iarc.fr/ Kishore J. National Health Programme of India 10th ed. National policies and legislations related to health.2012 Park K textbook of preventive and social medicine 21st ed. 2011. Willet MC. Diet, nutrition, and avoidable cancer. Environmental Health Perspectives, 1995, 103(Suppl. 8):S165--

S170. Weight control and physical activity. Lyon, International Agency for Research on Cancer, 2002 (IARC Handbooks of

Cancer Prevention, Vol. 6). Cancer: causes, occurrence and control. Lyon, International Agency for Research on Cancer, 1990 (IARC Scientific

Publications, No. 100). Brown LM et al. Adenocarcinoma of the esophagus: role of obesity and diet. Journal of the National Cancer

Institute, 1995, 87:104--109. Overweight and lack of exercise linked to increased cancer risk. In: Weight control and physical activity. Lyon,

International Agency for Research on Cancer, 2002 (IARC Handbooks of Cancer Prevention, Vol. 6). Food, nutrition and the prevention of cancer: a global perspective. Washington, DC, World Cancer Research

Fund/American Institute for Cancer Research, 1997. Palli D. Epidemiology of gastric cancer: an evaluation of available evidence. Journal of Gastroenterology, 2000,

35(Suppl. 12):S84--S89. Armstrong B, Doll R. Environmental factors and cancer incidence and mortality in different countries, with special

reference to dietary practices. International Journal of Cancer, 1975, 15:617--631. Hardman AE. Physical activity and cancer risk. Proceedings of the Nutrition Society, 2001, 60:107--113. Howe GR et al. The relationship between dietary fat intake and risk of colorectal cancer: evidence from the

combined analysis of 13 case--control studies. Cancer Causes and Control, 1997, 8:215--228. Michels KB et al. Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers.

Journal of the National Cancer Institute, 2000, 92:1740--1752. Schatzkin A et al. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp

Prevention Trial Study Group. New England Journal of Medicine, 2000, 342:1149--1155. AlbertsDSet al. Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas.

Phoenix Colon Cancer Prevention Physicians’ Network. New England Journal of Medicine, 2000, 342:1156--1162.

http://www.ncrpindia.org/Cancer_Atlas_India/about.aspx

National cancer control programmeLaunched 1975-76Revised 1984-85 and subsequently 2004Objective-prim. Prevention by health educationSec- early diagnosis and t/tTertiary prevention- strengthening existing institution and

palliative careRegional cancer center schemeOncology wing development schemeDecentralization NGO schemeIEC activities at central levelResearch and trainingCancer atlas

Therapy facilities available in India 31st March 2004

Total number of centres 217

No. of Brachytherapy centers 136

No. of Telecobalt units 262

No. of Telecobalt Cs-137 units 9

No. of Linacs 77

No. of Remote HRD units 83

No. of Remote LRD units 36

Manual Intracavitary 75

Manual Intrastitial 29

Cancer vacineCancer vaccinePreventiveTherapeuticGiven to cancer patients- strengthens body’s natural defenses

against cancer.Antitumoral lumphocytesE.g ResanTumor not developed but tumor marker level highPreventing replaseAntimetastatic drug Immunotherapy of benign tumorMastopathy, BPH, autoimmune thyroiditis, diffuse goitreGardasil Vaccine-HPV.Provenge- Prostate cancer.

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Cancer Epidemiology In India