CANCER

CANCER SCENARIO-INDIAN PERSPECTIVE WITH RESPECT TO WORLDINDRANIL KHAN AND RAJIV LOCHAN JENA,1ST Yr PGTs,Dept. of RADIOTHERAPY,MEDICAL COLLEGE,KOLKATA.

RAJIV LOCHAN JENA,1ST YR PGT ,Dept. of RADIOTHERAPY,MEDICAL COLLEGE,KOLKATA. CANCER CANCER SCENARIO-WORLDWIDEHistoryEarliest evidence of cancer-found among fossilized bone tumors, human mummies in ancient Egypt, and ancient manuscripts. Earliest known descriptions of cancer -appear in 7 papyri from Egypt.Two of them, the "Edwin Smith" and "George Ebers" papyri, were written around 1600 B.C., and are believed to date from sources as early as 2500 B.C. Hippocrates(ca. 460 BC ca. 370 BC) described several kinds of cancer, referring to them with the Greek word carcinos (crab or crayfish).Celsus(ca. 25 BC - 50 AD) translated carcinos into the Latin cancer, also meaning crab. Galen(2nd century AD) called benign tumours oncos, Greek for swelling, reserving Hippocrates' carcinos for malignant tumours. He later added the suffix -oma, Greek for swelling, giving the name carcinoma.

PAPYRUSCancer in the sixteenth to eighteenth centuries1761- Giovanni Morgagni of Padua-first to do autopsies to relate the patients illness to pathologic findings after death.Foundation for scientific oncology.

Famous Scottish surgeon John Hunter (1728-1793) suggested surgery as a treatment of cancer and described how the surgeon might decide which cancers to operate on.

A century later the development of anesthesia allowed surgery to flourish and classic cancer operations such as the radical mastectomy were developed.

Cancer in the nineteenth century

The 19th century saw the birth of scientific oncology with use of the modern microscope in studying diseased tissues. Rudolf Virchow correlated microscopic pathology to illness.

Body tissues removed by the surgeon could now be examined and a precise diagnosis could be made.

The pathologist could also tell the surgeon whether the operation had completely removed the cancer.

History of cancer epidemiology

During the 18th century, 3 important observations launched the field of cancer epidemiology :1.In 1713, Bernardino Ramazzini, an Italian doctor, reported the virtual absence of cervical cancer and relatively high incidence of breast cancer in nuns. Was an important step toward identifying and understanding the importance of hormones and sexually-transmitted infections and cancer risk.2.In 1775, Percival Pott of Saint Bartholomews Hospital in London described an occupational cancer in chimney sweeps, cancer of the scrotum, which was caused by soot collecting in the skin folds of the scrotum. Led to understanding of occupational carcinogenic exposures.

3.Thomas Venner of London-one of the first to warn about tobacco dangers in his Via Recta, published in London in 1620.In 1761, only a few decades after recreational tobacco became popular in London, John Hill wrote a book entitled Cautions Against the Immoderate Use of Snuff. These first observations linking tobacco and cancer led to epidemiologic research many years later (in the 1950s and early 1960s) which showed that smoking causes lung cancer and led to the US Surgeon Generals 1964 report Smoking and Health.

Present Scenario(In 2012) About 14.1 million new cases of cancer occurred globally.Has increased by 11% over 4 yrs. About 8.2 million deaths or 14.6% of all human deaths. 32.6 million people living with cancer (within 5 years of diagnosis) 57% (8 million) of new cancer cases, 65% (5.3 million) of the cancer deaths and 48% (15.6 million) of the 5-year prevalent cancer cases occurred in the less developed regions(Africa,Asia and Central and South America).Over 20,000 people die of cancer every day.Skin cancer is not included in these statistics and if it were it would account for at least 40% of cases.In children acute lymphoblastic leukaemia and brain tumors are most common except in Africa where non-Hodgkin lymphoma occurs more often.About 165,000 children less than 15 years of age were diagnosed with cancer.

1 in 8 deaths in the world are due to cancer(more than AIDS,TB and Malaria combined).30% of cancers could be prevented,mainly by not using tobacco,having a healthy diet,being physically active and moderating the use of alcohol.Tobacco use is the single largest preventable cause of cancer in the world causing 22% of cancer deaths.In developing countries upto 20% of cancer deaths could be prevented by immunization against the infection of HBV and HPV.1/5th of all cancers worldwide are caused by a chronic infection,eg HBV-Liver cancer,HPV-Cervical cancer.

Men with cancer are twice as likely as women to have a modifiable risk factor for their disease.Currently,most cancer deaths caused by occupational risk factors occur in developed world.Chernobyl Nuclear disaster produced the largest group of cancers in history from a single incident.The financial costs of cancer have been estimated at $1.16 trillion US dollars per year as of 2010.Cancer cases worldwide are forecast to rise by 75% and reach close to 25 million over the next two decades.

Estimated age-standardised rates (World) per 100,000Estimated cancer incidence worldwide in-Men and Women(2012)

MEN WOMEN

Trends in incidence of cancer in selected countries- age-standardised rate (W) per 100,000, menTrends in incidence of cancer in selected countries age-standardised rate (W) per 100,000, womenAt a glance The overall age standardized cancer incidence rate is almost 25% higher in men than in women, with rates of 205 and 165 per 100,000, respectively.

Male incidence rates vary almost five-fold across the different regions of the world, with rates ranging from 79 per 100,000 in Western Africa to 365 per 100,000 in Australia/New Zealand (with high rates of prostate cancer representing a significant driver of the latter).

There is less variation in female incidence rates (almost three-fold) with rates ranging from 103 per 100,000 in South-Central Asia to 295 per 100,000 in Northern America.

Estimated age-standardised rates (World) per 100,000Estimated Cancer Mortality Worldwide in Men and Women(2012)

MEN WOMEN

Trends in mortality from cancer in selected countries age-standardised rate (W) per 100,000, menTrends in mortality from cancer in selected countries age-standardised rate (W) per 100,000, womenAt a glanceIn terms of mortality, there is less regional variability than for incidence, the rates being 15% higher in more developed than in less developed regions in men, and 8% higher in women.In men, the rates is highest in Central and Eastern Europe (173 per 100,000) and lowest in Western Africa (69). In contrast, the highest rates in women are in Melanesia (119) and Eastern Africa (111), and the lowest in Central America (72) and South-Central Asia (65).

Estimated age-standardised rates (World) per 100,000

Estimated age-standardised incidence and mortality rates menEstimated age-standardised incidence and mortality rates womenEstimated age-standardised incidence and mortality rates both sexes

MEN

WOMEN

BOTH SEXESWORLDMALEFEMALEBOTH SEXESPopulation(thousands)355771734967287054446No.ofnewcancercases(1000 s) 7427.16663.014090.1Age-standardisedrate(W)205.4165.3182.3Riskofgettingcancerbefore age 75(%)21.016.418.5No.ofcancerdeaths(1000 s)4653.13547.98201.0 Age-standardisedrate(W)126.382.9102.4Riskofdyingfromcancer beforeage75(%)12.78.410.45-yearprevalentcases,adult population(1000 s)15362.317182.332544.6Proportion(per 100,000)592.0661.4626.75mostfrequentcancersLUNGBREASTLUNGPROSTATECOLORECTUMBREASTCOLORECTUMLUNGCOLORECTUMSTOMACHCERVIX UTERIPROSTATELIVERSTOMACHSTOMACHDistribution of types of cancer

HepatocellularAge PredelictionCancers in children-leukemia,brain and CNS tumors,neuroblastoma,wilms tumor,lymphoma,rhabdomyasarcoma,retinoblastoma,bone cancers.Cancers in adults-lymphoma,melanoma,testis cancer,female genital tract malignancies,thyroid cancer,soft-tissue sarcomas,leukemia,brain and spinal cord tumors,breast cancer,bone sarcomas,liver,colon and rectal cancer,nongonadal germ cell tumors-account for 95% of cancers.Cancers in old ageprostate,lung,bowel,bladder,stomach etc.Cancers occuring between 15-30 yrs is 2.7 times more common than cancer occuring in 1st 15 yrs of life,yet much less than in older age groups.

The Growth in Cancer Incidence and Mortality is due to:

The increasing size and the lifespans of the population. Robert A.Weinberg-if we lived long enough,sooner or later we all would get cancerIndustrialization and adaptation of Western habits (smoking, diet, etc.) This is especially a problem in South America, Africa and AsiaGrowing biotechnology and development of diagnostic tests and screening technologies.

7 million Deaths11 million New Cases 25 million Living with CancerCANCER WORLDWIDE BURDEN (2005)31

17 million Deaths27 million New Cases75 million Living with CancerCANCER WORLDWIDE BURDEN (2030)32

Global cancer transitions according to the Human Development Index (20082030): a population-based study

4 levels (low, medium, high, and very high) of the Human Development Index (HDI), a composite indicator of life expectancy, education, and gross domestic product per head-were used.Highest HDI regions-cancers of female breast, lung, colorectum, and prostate50% of the cancers.Medium HDI regions-cancers of HDI-cancers of female breast, lung, colorectum, prostate,oesophagus, stomach, and liver-62% of the cancers. Low HDI regions-cervical cancer more common than both breast cancer and liver cancer. In medium and high HDI settings-decrease in cervical and stomach cancers incidence seem to be offset by increases in the incidence of cancers of the female breast, prostate, and colorectum.Interpretation

Findings suggest that rapid societal and economic transition in many countries means that any reductions in infection-related cancers are offset by an increasing number of new cases that are more associated with reproductive, dietary, and hormonal factors.

CANCERAn Indian Perspective

Dr. Indranil KhanCANCER is not a disease of modern times.While the earliest incidence of cancer is recorded in the ancient Egyptian inscriptions on the papyrus dating back to 2500 BC ..Ancient India isnt lagging behind..

The first Radiotherapy Department in India or rather Asia was established in Calcutta Medical College, India as early as January 25, 1910- just 15 years after the discovery of X-rays by Wilhelm Roentgen in 1895.

ADVENT OF MODERN CANCER TREATMENTCancer: the Indian Scenario

1,014,900 Indians are diagnosed with cancer every year.1,790,500 Indians are living with cancer .682,800 deaths in India reported annually due to cancer.10.1% Indians carry the risk of getting cancer before the age of 75.Cancers of the lip and oral cavity account for the maximum number of cancer cases in Indian males, while breast cancer accounts for the maximum number of cases among females.33

Top 10 Leading Sites of Cancer

Age-standardised rate (W):A rate is the number of new cases or deaths per 100 000 persons per year. An age-standardised rate is the rate that a population would have if it had a standard age structure. Standardization is necessary when comparing several populations that differ with respect to age because age has a powerful influence on the risk of cancer.Top 10 Leading Sites of Cancer

Age-standardised rate (W):A rate is the number of new cases or deaths per 100 000 persons per year. An age-standardised rate is the rate that a population would have if it had a standard age structure. Standardization is necessary when comparing several populations that differ with respect to age because age has a powerful influence on the risk of cancer.Most Common Cancer in Children

Leukemias LymphomasCNS TumorsSNS TumorsRetinoblastomasRenal TumorsHepatic TumorsBone TumorsSoft Tissue sarcomasGerm Cell Tumors

Variations in AAR among Different PBCRs of IndiaREGIONAL VARIATIONMALES:Highest AARs noted in North East.Aizawl PBCR: 273.4 per 100,000Thiruvananthapuram leads in rest of India at 132.6

FEMALES:Highest AARs noted in North East.Aizawl PBCR: 227.8 per 100,000Bangalore leads in rest of India at 137.2

Specific sites of cancer are reported in higher incidence in certain regions of India:

North-East: Oesophagus

Punjab: Kidney, Urinary Bladder

Madhya Pradesh: Oral Cavity

Rajasthan: Head and Neck

Goa: ColonMALE VS FEMALE RATIO:As per data of various PBCRs (2007-11) under NCRP,Male:Female Ratio in AAR for all cancer sites varies from 0.77 in Barshi to 1.88 in Meghalaya.Thyroid and Gall Bladder (Thyroid>Gall Bladder) have higher incidence in females across all PBCRs.Rest all sites in most PBCRs have higher incidence in males.As per GLOBOCAN 2012,Risk of getting cancer before age 75 is 10.2% in Indian males vs 10.1% in Indian females.CHANDIGARH:MALEFEMALELUNG (9.2%)BRAIN & NS TUMORS (7.6%)TONGUE (7.3%)OESOPHAGUS (5.7%)LEUKEMIA (5.9%)CERVIX (18.4%)BREAST (16.3%)OVARY (7.9%)GALL BLADDER (6.6%)OESOPHAGUS (5.1%)MUMBAI: MALEFEMALEMOUTH (12.3%) LUNG (8%)TONGUE (7.1%)NHL (6.1%)OESOPHAGUS (4.6%)BREAST (30.3%)CERVIX (13.4%)OVARY (5.1%)MOUTH (4.4%)GALL BLADDER(3.9%)CHENNAI:MALEFEMALESTOMACH (9.2%)LUNG (8.9%)MOUTH (8.6%)TONGUE (6.7%)OESOPHAGUS (5.7%)

CERVIX (25.5%)BREAST (22.4%)OVARY (5.3%)MOUTH (5.2%)STOMACH (3.7%)KOLKATAMALEFEMALELUNG (17.22%)MOUTH (7.48%)PROSTATE (7.42%)LARYNX (6.4%)BLADDER (4.99%)BREAST (17.22%)CERVIX (14.91%)OVARY (8.04%)GALL BLADDER (5.99%)LUNG (4.18%)International Comparison of Indian AARs

MalesInternational Comparison of Indian AARs

FEMALESComparison of Cancer Cases of India vs US

Today, Cancer treatment in India is at par with the rest of the world.Metro cities like Mumbai, Delhi, Chennai today boast of state-of-the-art radiotherapy equipments like Gamma Knife, Cyber Knife, RapidArc in private as well as government facilities.Nowadays, when newer drugs are introduced abroad they are almost simultaneously launched here and are easily available here.Cancer: A Treatable Disease In India

In fact, cancer patients from abroad are today coming to India for effective yet economical treatment. Medical tourism is picking up.

Cancer Screening in IndiaEarly Detection and Treatment is perhaps the most important fundamental of cancer therapy- to follow which cancer screening awareness must percolate down to the lowest strata of society.Though only few cancers like cervix or breast or some colonic carcinomas maybe detected early by screening, considering their overall incidence and favorable prognosis if detected early, cancer screening should be given more importance and people to be educated more about its benefits.

Cancer screening isnt even in nascent stage in India!

Voluntary screening abysmally low in India even among the educated.Govt yet to make a big enough dent in early diagnosis/prevention through public screening.Less than 25% of target population attends screening camps conducted by govt. agencies/NGOs. And even when they attend camps, patients are often lost to follow-up.All these directly impacts survival post-diagnosis. [As per a study conducted under University of Michigan, women in United States survive roughly a decade longer than than those in India after a breast cancer diagnosis.]

Public Perception About CancerA major cause of cancer-related mortality in India is the general perception that cancer has no answer.Despite so many recent advances and lots of success stories clinicians create and witness, public perception hasnt altered much.Many patients never even attend an oncologist because his/her family members feel death is inevitable now and medical attention is futile- just a waste of time and money. The result: A cervical cancer patient who would otherwise have been diagnosed and treated as stage IIA (favorable prognosis) is lost to false perception of her family members.Cancer Economics-An Indian PerspectiveAs per an ISI study (2011), average cost of treatment in a govt hospital is Rs 36,812 per cancer patient.In a private hospital, it may take between 2-20 lakhs per patient.

Newer molecules introduced in cancer therapy, but too few people to afford them regularly.

Low awareness and late detection further augments cost of treatmentHouseholds across the Socio-Economic Status (SES) spectrum face a large economic risk from cancer, with highly increased borrowing and asset sales to finance their healthcare. [PLOS Study 2013]Health insurance covers less than 25% of Indians.Although the RSBY scheme now covers more than one hundred million people in India, the financial cover it provides is relatively small (INR 30,000) for a family of four and is inadequate given the financial costs of cancer treatment The Tobacco Menace

Cancers Related To Smoking:Tobacco Legislation in IndiaThe Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 on 18 May, 2003.India became a Party to the WHO Framework Convention on Tobacco Control on February 5, 2004.

Total ban on direct and indirect advertisements of all tobacco products.Prohibition on sponsorship of sports and cultural events which encourage tobacco use; ban on smoking in public places.Ban on sale of tobacco products to minors. Mandatory pictorial depiction of specified health warnings and clear indication of nicotine and tar contents on packets and cartons of all tobacco products.Ban on smoking in public place India sells around 102 billion cigarettes a year, second only to China. One million deaths per year in India are attributed to smoking.Shamefully, India is one of the few countries where tobacco sales are still rising.Despite ban on smoking in public places, smokers in most parts of India openly flout law and blatantly smoke in railway stations, roads, and even in hospital premises- making themselves and those around them vulnerable to cancer as explained now.

SMOKINGININDIA

Tobacco smoking in public places or chewing of gutkha, khaini and other tobacco related products is rampant in almost every nook and corner of the country. Despite numerous legislations and public education through infomercials and never-ending statutory warnings, deaddiction from tobacco smoking and related products has never quite picked up in India.

INFERENCE:India, as of today, has lower incidence of cancer than the developed countries. North Eastern states, followed by South India share the highest incidence rates.Lung is still the most common cancer site among males and breast among females.Tobacco abuse needs to be curbed.Cancer incidence projected to rise as a result of greater industrialisation, urbanisation, changing lifestyles, and an increase in average life expectancy.Economic challenges need to be addressed.