Today's Editorial

Today's Editorial - 04 February 2023

Cancer in India: A status report

Source: By Anonna Dutt: The Indian Express

Deaths due to cancer have declined by 33% in the United States since 1991, according to a report by the American Cancer Society released in the first week of January 2023. This has translated into 3.8 million fewer deaths, the report said, and attributed the success to early detectionlower rates of smoking, and improvements in cancer treatment.

This trend is yet to be reflected in India. Even with improvements in treatment, both the incidence of cancer and mortality continue to rise in the country.

The findings in the US, published in CA: A Cancer Journal for Clinicians, record a steep reduction of 65% in the rates of cervical cancer in women in their early 20s between 2012 and 2019, the first cohort to receive the human papillomavirus vaccine (HPV) vaccine. Doctors confirmed that the rates of cervical and smoking-related cancers have gone down in India as well; however, the incidence of lung and breast cancers has increased.

Better screening and treatment centres, and more comprehensive linkages between screening centres and hospitals are essential to reduce cancer mortality in the country, experts said.

What is the incidence of cancer and mortality in India currently?

An estimated 14.6 lakh new cancer cases were detected in 2022, up from 14.2 lakh in 2021 and 13.9 lakh in 2020, as per data from the National Cancer Registry of the Indian Council of Medical Research (ICMR) presented in Parliament. Deaths due to cancer increased to an estimated 8.08 lakh in 2022 from 7.9 lakh in 2021 and 7.7 lakh in 2020. The incidence of all cancers is estimated to increase to 15.7 lakh by 2025, according to the data.

One in nine Indians will develop cancer during their lifetime, according to an ICMR study using data from population-based cancer registriesOne in 68 men will develop lung cancer and one in 29 women will develop breast cancer, according to the study.

The incidence of cancer is higher among women — 103.6 per 100,000 in 2020 compared to 94.1 among men. Among men, the most common cancers were of the lungmouth, prostate, tongue, and stomach; for women, they were breast, cervix, ovary, uterus, lung.

Why are some cancers on the decline and others continue to rise?

The incidence of cervical cancer has dropped in India over the last 50 years from 45 to 10 per 100,000 populations, Prof G K Rath, adviser to the oncology platform Karkinos Healthcare and a former head of the AIIMS National Cancer Institute in Jhajjar, said.

“At the same time, there is an increase in rates of breast cancer, especially in urban centresRates of cervical cancer have declined because of later marriages, fewer children, better hygiene, and vaccination. And the incidence of breast cancer has gone up because of the same reasons — later age of marriage, having the first child at a later age, not breastfeeding, and a high protein diet,” Dr Rath said.

The incidence of breast cancer is 9 per 100,000 in Barshi, Maharashtra, and 45 per 100,000 in Hyderabad, Dr Rath, who also headed the scientific steering committee for the National Cancer Registry, said. The incidence of breast cancer is 110 cases per 100,000 population in the US, he said.

Unlike cervical cancer, which can be prevented with HPV vaccination — with vaccines becoming cheaper, the government plans a campaign soon — there is no specific intervention for breast cancers other than screening because what causes it is unknown.

“The rates of tobacco-related cancers — oral, oesophageal — cancers are also coming down. This is largely due to tobacco laws that have brought down smoking in public places,” Dr Rath said.

Lung cancers, however, remain a cause for concern. “Lung cancer is caused not only by smoking. For example, lung cancer rates are high in Arunachal Pradesh because they light fires indoors in winter. We see lung cancers in women in Bihar because they have spent years cooking on chullahs. And with the kind of air we are breathing in Delhi, we will see the impact in the next 10 years,” Dr Abhishek Shankar of Dr B R Ambedkar Institute-Rotary Cancer Hospital at AIIMS, said.

“Unfortunately, the survival rate for lung cancer is not very high and it is mostly diagnosed in the late stages,” Dr Shankar said.

Have there been improvements in cancer treatments?

Yes, Dr Rath said.

“The cure rate for various cancers is rising. And we do see individuals who have completely beaten cancer. The cure rate for pancreatic cancer has doubled from 3% 50 years ago to 6%. For prostate cancer, it has gone up from 60% to 100%. And for breast cancer it has improved from 50% to 90% with newer treatments. But in order to reduce mortality, we have to ensure people get diagnosed early on and receive timely treatment,” he said.

Dr Sushma Bhatnagar, the current head of the Jhajjar cancer institute, said: “Certainly cancer is no longer synonymous to death, but there is much that remains to be done.”

What must be done to bring down overall mortality like in the US?

The first intervention has to be screening.

Screening for the three most common types of cancer — breast, cervical, and oral — has already started through the government’s upgraded health and wellness centres. This, coupled with other government programmes, has meant people are reaching hospitals sooner.

“I used to have a 80/20 rule — 80% of patients present to the hospital late, of whom 20% are curable, and 20% of patients present early, of whom 80% are curable. Over the last 10 years, this has become 70/30 — now 30% of patients are presenting early to hospitals,” Dr Rath said.

Cervical, breast, and oral cancers account for 34% of cancers in India, so screening for them is good; however, it has to be more focused in order to achieve mortality gains, Dr Shankar said. “Dual stain testing is the best tool for screening for cervical cancer, while a low-dose CT in those with a history of smoking is the best for lung cancer. Breast self-examination cannot be standard screening for breast cancer. We have to improve and better target screening methods to start showing mortality benefits,” he said.

Also, “screening should lead to treatment”, Dr Shankar said. “You tell someone they are likely to have cancer but if they do not have the means to go to a hospital, get tested, and seek treatment, it will be of no use. The treatment has to be accessible and affordable,” he said.

Dr Bhatnagar pointed to the need to coordinate existing efforts.

“There are several programmes of the government that are working independently and in silos. They need to be coordinated so that once a person is screened, they do reach a hospital. We have adopted districts where we screen patients and then bring them in for treatment, but this has to happen everywhere,” she said.

There must be many more cancer care facilities.

“We have one comprehensive cancer care centre for every 5 crore population. There are seven pillars of cancer care — prevention, surgery, chemotherapy, radiotherapy, imaging, laboratory diagnostics, and palliation — but I will talk of only one,” Dr Rath said. “The WHO says there should be 1 radiotherapy machine per million population in developing countries, so for our 1.4 billion people we need 1,400 machines, and we have only 700,” he said.

India needs to prepare better, Dr Rath said. “Cancer has overtaken cardiac issues as the leading cause of deaths in the US. In India, cardiac issues are still the leading cause but cancer is number 2. Sixty years ago when I was studying medicine people were dying of cholera, cancer was not even in the top 10 causes of death,” he said.

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