Categories: Oncology

The fight against Cancer – then and now

Cancer Prevalence:

An estimated 3.9 million people in India are reported to be suffering from cancer, alarmingly up from 1.1 million in 2015. Remember that these are only detected cases of cancer and the actual figure could be 1.5 to twice the reported number.

India lacks a sufficient number of hospitals and population-based cancer registries for an accurate estimate of cancer victims in the country. India’s age-standardized cancer incidences are 150-200 per 100,000 population, higher than Africa and at par with China. India has nearly three times the number of head, neck and cervical cancers than in the US and China. Cancer detection rates in India estimated to be at a low 20-30 %, about half of the US and China.

Breast cancer has overtaken cervical cancer as the most common form of cancer among women. Gastrointestinal cancers, which have traditionally been low in India, have also been on the rise.

Only 20% of cancer is diagnosed at Stage I and Stage II in India; the rest 80% is detected only in Stage III/IV, contrary to the USA and UK.

Risk Factors:

  1. Tobacco use – more than 17% of India’s population consume different forms of tobacco
  2. Alcohol consumption – alcohol consumption per capita increased by a shocking 50% in people older than age 15
  3. Obesity – India has one-third of the world’s obese population
  4. Unhealthy dietary and lifestyle – nitrosamines in packaged food, pickles contaminated with the fungus can lead to cancer
  5. Poor hygiene
  6. High-risk sexual behaviour
  7. Delayed pregnancies – a cause for increasing breast cancer among urban women

Cancer challenges in India:

  1. Higher mortality rates in the head and neck cancer due to lack of awareness; ulcers being ignored by many patients and thereby delaying cancer diagnosis.
  2. Limited availability of advanced diagnostic tools such as PET/CT in the treatment.
  3. The high cost of tests and treatment makes cancer detection difficult among economically weaker sections of the country.
  4. General physicians and gastroenterologists, the first point of contact for many patients are not adequately aware or sufficiently trained to detect, refer or treat patients suffering from cancer such as stomach cancer.
  5. Limited availability of cancer treatment resources in the country going towards treatment of many cancer patients from foreign countries (cost of cancer treatment in India is 5-6 times lower than in the US), while treatment is still unaffordable for many Indian patients due to: a) poverty and b) lower coverage of public and private insurance programs (only 30% of population covered).
  6. A limited number of oncologists in the country. Many people are forced to travel to big cities for treatment. Since treatment can last from months to years, the costs of treatment become prohibitive. Many middle-class families have been financially ruined due to the costs of cancer treatment for a member of the family.
  7. Low awareness about cancer, symptoms and screening practices. Studies in South India have revealed the stunning fact that 55% of women have never heard about breast cancer, 80-90% were not aware of symptoms and 65% did not practice self-examination at all.

Solutions:

  1. Early diagnosis and screening are imperative in India since less than 30% of cancers are diagnosed in stage I and II. This results in significantly lower survival rates compared to the rest of the world. The country needs more cost-effective methods for diagnosis and screening.
  2. Focus on cancers with high incidence. Increase the screening efforts to detect cancers such as breast and cervical cancers in women, and oral cancers in both sexes. For this, undertake large scale training of public health workers, involve local NGOs and self-help groups for spreading awareness and ensuring standard screening protocols.
  3. Simple techniques like cervical screening through visual inspection with acetic acid is a very cost-effective alternative to pap-smear based screening (less than one-tenth of the cost). This reduces cervical cancer mortality by 30%. As this can even be administered by health workers/sisters with minimal training, these cost-effective measures can be implemented in southern and eastern states that have high rates of cervical cancer.
  4. Use trained para-medical staff of the primary health centre for early detection of oral cancer.
  5. Faecal occult blood testing (FOBT) in stool samples is a simple cost-effective screening tool for GIT malignancies. This can be done through district cancer centres in the north-eastern states and southern states with a higher incidence of these cancers.
  6. Focus on training the public health worker, hospital employees, and nurses as cancer counsellors who can refer suspected cases to the oncologists for accurate and early evaluation.

Cancer is a complex disease needing a multi-dimensional approach for treatment. It needs the involvement of many specialists and the latest technology for accurate detection, treatment, management and to prevent recurrence of cancer.

Measures to improve detection and treatment:

  • Establish institute-based national standard guidelines and protocols, with a periodical review of management protocols by a high-level board. Include innovations in molecular diagnosis, targeted drugs, and radiological procedures in the standard treatment guidelines. Set up institutional review boards to ensure the implementation of the above protocols. Have regular audits of clinical outcomes.
  • Adopt a Multidisciplinary (MDT) approach to treatment. Institute tumour boards in hospitals that have a multidisciplinary panel of medical, surgical and radiation oncologists, along with other specialities like radiology, pathology, oncology nurse, PMR, and palliative care physicians for effective diagnosis, treatment planning, and execution. Where possible, neoadjuvant radiotherapy/chemotherapy, molecular diagnosis (IHC) and targeted modalities of treatment can be used in patient management.
  • Train nurses, district level doctors and providers of palliative care. They have a vital role in comprehensive cancer care.
  • Increase the number of cancer registries in India which are currently too low. The National Cancer Registry program with hospital-based and population-based registries must ensure mandatory submission of cancer statistics by all government and private institutes that treat cancer patients.

Each cancer centre should maintain a database of all registrations, including a detailed information every stage of diagnosis, decisions of MDT, the treatment offered and response rates, mortality and morbidity statistics, and survival statistics. Provide for data mining from the cancer data saved in hospital records and can be made available to cancer policy planners.

Take-Home Message:

Policy decisions should be data-driven and the data should be accurate.

Periodically review Cancer registry data, to identify trends of disease burden, the geographical distribution of site-specific cancers and for more effective resource allocation and cancer-control measures.

Dr. Vikas Roshan, Associate Consultant – Radiation Oncology, Shri Mata Vaishnodevi Narayana Superspeciality Hospital, Jammu

Narayana Health

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