Cancer Epidemiology In India
Ramesh Pawar
Moderated by: Prof. Deshmukh Sir
Framework
 Definition
 Introduction
 Magnitude
 Risk factors
 National programme
 Cancer registry and Atlas
 Cancer registry at MGIMS, Sevagram
 References
Cancer
 Cancer 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
MEN
WOMEN
Source: http://globocan.iarc.fr/factsheet.asp
Global Estimated age-standardised incidence and
mortality rates: Men
Source: http://globocan.iarc.fr/factsheet.asp
Global Estimated age-standardised incidence and
mortality rates: Women
Source: http://globocan.iarc.fr/factsheet.asp
Global Estimated age-standardised incidence and mortality rates:
both men and women
Source: http://globocan.iarc.fr/factsheet.asp
INDIA
India: Estimated age-standardised incidence and mortality rates: men and
women
Men
Women
http://globocan.iarc.fr/factsheet.asp
India Estimated age-standardised incidence and
mortality rates: Men
http://globocan.iarc.fr/factsheet.asp
India Estimated age-standardised incidence and
mortality rates: Women
http://globocan.iarc.fr/factsheet.asp
Cancer Burden: India
 Caner has become one of the ten leading causes of death in
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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 factors
o Retinoblastoma (RB1)
o Interaction of gene and environment
o 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 Tobacco
o
Responsible for about 40 to 50% of cancers in men and about
20% of cancers in women
(Percentage)
61
57
50
13
11
7
Urban
Rural
Women
Total
Men
NFHS-3, 2005-06
NFHS-3, 2005-06
(Percentage)
33
31
1
Urban
3
Alcohol use by women is rare.
2
Rural
Women
32
Total
Men
NFHS-3, 2005-06
NFHS-3, 2005-06
Risk factors
o Diet
o
o
o
o
In India dietary habits responsible for about 10-20% of
cancers.
The changing dietary patterns particularly involving animal
proteins.
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
Tuibur –Mizorum
Source: WHO (2003) RTS 916. Diet, Nutrition and prevention of chronic
diseases.
Risk factors
Pesticides
Malwa 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.
Criteria for Screening
 Disease should be an important public health
problem
 Must have a latent asymptomatic stage
 Adequate treatment should be available
 The test should be safe and relatively in-expansive
 Capable of rapid application
 Should be accurate and reproducible
 Test should be acceptable to people
 The test should be reasonably inexpensive
 Adequate follow up of the positives should be
ensured
Undesired harm due to screening should be avoided
Early warning signals
 If someone notice following symptoms she/he should
contact to health centre immediately:
 A sore that doesn’t heal
 Recent changes in wart or mole
 Unusual bleeding/discharge/per vagina/rectum
 Persistent cough or hoarseness of voice
 Persistent change in bladder/bowel habits
 Difficulty 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
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style changes.
Provide early diagnosis and management of common NCDs
Built 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
 Treatment
 Capacity building of human resource
 Surveillance, monitoring and evaluation
1. Prevention through behaviour change
 Creating general awareness
 Promotion of healthy life style habits
 The various approaches such as
community
education
communication
and
mass media,
interpersonal
 Increase intake of healthy food
 Increased physical activity through sports, exercise etc.
 Avoidance of tobacco and alcohol
 Stress 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 Treatment
 Screening, diagnosis and management (including diet
counselling, lifestyle management ) and home based
care will be the key functions.
2.C Home based care
 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 care
 Refer if required.
2.C Referral
3.Palliative care
 Affirms life and dying as a natural process
 Neither hastens nor postpones death
 Active 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 Cell
 NCD 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
2
National programme officer(NCD)
National programme officer(training and coordination)
1
1
3
4
5
6
7
8
9
10
11
12
13
14
National program officer ( M & E and surveillance)
National epidemiologist
Functional consultant
Technical officer (health management)
Technical officer( Nutrition)
Technical officer (Physiotherapy)
Technical officer (IEC)
Logistic co coordinator
M & E officer
Data manager
Computer assistant
Technical assistant
Total
1
1
1
1
1
1
1
1
1
1
2
2
16
Role and responsibilities of National NCD Cell is
as under
 Plan, Coordinate, and Monitor all the activities at National and
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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 cell
 The Cell shall function under the guidance of State
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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 Officer
2. Programme Assistant
3. Finance cum Logistics Officer
4. 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 foods
Increased physical activity through sports, exercise, etc.;
Avoidance of tobacco and alcohol;
Stress management
Warning signs of cancer etc.
B Opportunistic Screening
 During 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. Referral
 ANM 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 reporting
 ANM 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.
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Activities at Community Health Centre
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A. Screening
B. Prevention and health promotion
C. Laboratory investigations
D. Diagnosis and Management
E. Home based care
F. Referral
Human 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,
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supportive and curative services for NCD
‘NCD clinic’
A. Opportunistic screening
B. Detailed investigation
C. Outsourcing of certain laboratory investigations
D. Out-patient and In-patient Care
E. Day Care Chemotherapy Facility
F. Home Based Palliative Care
G. Referral & Transport facility to serious patients
H. Health promotion
I. Training
J. Data recording and reporting
K. Human Resources at District Hospital
 a. Doctor (specialist in Diabetology/Cardiology/M.D
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Physician)
b. Medical Oncologist
c. Cyto-pathologist
d. Cytopathology Technician
e. Nurses (4): 2 for Day Care, one for Cardiac Care Unit,
one for O.P.D
f. Physiotherapist
g. Counsellor
h. Data Entry Operator
i. 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.
National cancer registry Programme:
 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).
National cancer registry Programme:
 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 India
Objectives:
(i) To obtain an overview of patterns of cancer in
different
parts
of
the
country
(ii) To calculate estimates of cancer incidence
wherever feasible
The 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 ATLAS
Using 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
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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
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Population based cancer registry (PBCR)
Started since Feb 2010 to 31st Jan 2014
Principle investigator: Dr Gangane
Staff
 1 MO (cancer Mgnt) Dr. Priti Shende
 1 Statistician
 4 Investigator
 1 Computer operator
 MGIMS-HIS, Sawangi and Pvt hospitals and Nagpur Pvt. And
Govt Hospitals.
 NCR Bangalore
References
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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.
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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.
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National cancer control programme
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Launched 1975-76
Revised 1984-85 and subsequently 2004
Objective-prim. Prevention by health education
Sec- early diagnosis and t/t
Tertiary prevention- strengthening existing institution and
palliative care
Regional cancer center scheme
Oncology wing development scheme
Decentralization NGO scheme
IEC activities at central level
Research and training
Cancer 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 vacine
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Cancer vaccine
Preventive
Therapeutic
Given to cancer patients- strengthens body’s natural defenses against
cancer.
Antitumoral lumphocytes
E.g Resan
Tumor not developed but tumor marker level high
Preventing replase
Antimetastatic drug
Immunotherapy of benign tumor
Mastopathy, BPH, autoimmune thyroiditis, diffuse goitre
Gardasil Vaccine-HPV.
Provenge- Prostate cancer.