cghr.org/cancer twitter: cghr_org cancer mortality in india on behalf of the million death study...

CGHR.ORG/CANCERTwitter: CGHR_orgCGHR.ORG/CANCERTwitter: CGHR_org

CANCER MORTALITY IN INDIA

On behalf of the Million Death Study Collaborators, and in partnership with

Tata Memorial Hospital (Mumbai, India), St. John’s Research Institute (Bangalore, India), IARC (Lyon, France)

and SEARO (Delhi, India) of WHO and the Centre for Global Health Research (Toronto, Canada)

LANCET PRESS RELEASE: WEDNESDAY, MARCH 28, 2012

[email protected]

CGHR.ORG/CANCERTwitter: CGHR_org

Key findings• About 0.6 Million (M) or 6 Lakh cancer deaths in 2010• Over 70% of cancer deaths occurred during ages 30-69

years (200,000 men and 195,000 women) • At ages 30-69 years, the three commonest fatal cancers

– Men: oral, stomach, and lung– Women: cervical, breast and stomach

• Tobacco-related cancers are over 40% of male and nearly 20% of female cancers

• Cancer death rates are similar in rural and urban areas• Huge variation in cancer death rates across states- partly

due to tobacco, and partly for reasons awaiting further discovery

• Cancer death rates 2-fold higher in the least educated compared to the most educated adults

• Cervical cancer death rates far less in Muslim women than among Hindu women

Source: Dikshit et al, Lancet 2012


What’s new about this research?

• First large, nationally-representative study of cancer mortality in India, reflecting both urban and rural areas

• Previous cancer estimates have relied mostly on cancer registries in cities, but 70% of Indians live in rural areas

• Provides distribution of cancer deaths by area, educational level, and religion



• Nationally representative sample (Sample Registration System)

• 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area)

How was the study done?


How was the study done?800 Registrar General of India field workers

interviewed 122 thousand families of people who had died in 2001-2003

Written reports each coded independently by at least two physicians to attribute a probable cause of

death (i.e., cancer)

Cancer deaths grouped into broadly similar categories (i.e., oral, lip and pharynx; lung and

trachea, etc.)


How was the study done?

Calculated proportion of all cancer deaths by age, gender, and cancer type within the

study

Combined with national 2010 UN totals of deaths, and 2007-2009 state-specific SRS

death rates

Produced national and state estimates of rates and number of cancer deaths for 2010


• 7137 of 122 429 study deaths were due to cancer, meaning about 600,000 cancer deaths across the whole of India in 2010. • Some 71% (395,000) of cancer deaths occurred in people aged 30-69 years (200,100 men and 195,300 women). •At ages 30-69, cancer deaths are: 8% of the 2.5 million total male deaths 12% of the 1.6 million total female deaths

Key results



MEN• Oral 45,800 or 23%• Stomach 25,200 or 13%• Lung 22,900 or 11%

WOMEN• Cervical 33,400 or 17%• Stomach 27,500 or 14%• Breast 19,900 or 10%

Leading cancers in men and women, age 30-69 years



47 of 1000 men will die of cancer

44 of 1000 women will die of cancer

Risk of death from cancer

For middle-aged Indians, the risk of dying before age 70 in the absence of other diseases:



MEN WOMEN

INDIA 47 44

Rural 46 45

Urban 49 42

Richer states

51 46

Poorerstates

39 39Source: Dikshit et al, Lancet 2012

Deaths among 1000 30 year olds before age 70 from cancer,

at 2010 death rates


MEN: 84,000 or 42% of all cancers WOMEN: 35,700 or 18% of all cancers

Together: over 120,000 tobacco cancers

Twice as many oral cancers as lung cancers

Tobacco cancers in men and women, age 30-69 years



Risk of cancer death*, by state

*For Indians aged 30, the risk of dying before age 70 from cancer in the absence of other diseases

Men WomenNortheast States(highest risk)



Bihar(lower risk)





Cancer: MEN aged 30-69 years

State or Region

Northeast states

Assam

Kerala

Jammu & Kashmir

Gujarat

Himachal Pradesh

Other states

Delhi

Karnataka

Haryana

West Bengal

Uttarakhand

Rajasthan

Madhya Pradesh

Uttar Pradesh

Andhra Pradesh

Maharashtra

Punjab

Tamil Nadu

Odissa

Bihar

Chhattisgarh

Jharkhand

Rural

Urban

Poorer states

Richer states

Total

157

129

278

80

162

52

88

38

182

89

225

11

120

102

212

124

121

56

128

89

88

23

19

1969

604

793

1780

2573

Tobaccorelated †

2·8

5·2

3·9

0·8

8·9

0·7

0·5

2·0

5·3

2·2

5·7

1·0

4·4

4·4

11·0

4·7

9·5

1·9

3·8

1·5

2·3

1·0

0·7

57·1

26·9

31·4

52·6

84·0

All

237·4

177·1

158·5

145·0

142·6

130·4

102·9

120·2

120·7

120·3

106·1

99·2

95·5

94·0

91·1

91·1

87·0

80·6

77·5

59·3

54·2

48·5

46·5

95·6

102·4

83·3

108·5

97·6

Tobacco related †

115·0

114·0

53·9

46·0

86·3

58·4

49·0

70·6

49·3

55·7

33·4

57·7

44·0

40·1

36·0

29·0

46·4

36·5

25·7

21·0

15·5

27·4

12·4

39·9

45·0

36·4

46·1

41·4

Cumulative riskfor all cancers

11·2

8·5

7·6

7·4

6·7

6·5

5·0

6·0

5·7

5·5

5·0

4·7

4·6

4·5

4·2

4·2

4·2

4·0

3·6

2·8

2·5

2·3

2·1

4·6

4·9

3·9

5·1

4·7

(99%CI)

(8·9−13·5)

(6·5−10·4)

(6·4−8·7)

(5·3−9·6)

(5·3−8·1)

(4·2−8·8)

(3·6−6·4)

(3·5−8·4)

(4·6−6·7)

(4·0−7·0)

(4·1−5·8)

(1·0−8·3)

(3·5−5·7)

(3·4−5·7)

(3·5−5·0)

(3·2−5·1)

(3·2−5·1)

(2·6−5·4)

(2·8−4·4)

(2·0−3·6)

(1·8−3·2)

(1·0−3·5)

(0·9−3·3)

(4·4−4·9)

(4·4−5·5)

(3·6−4·3)

(4·8−5·5)

(4·5−5·0)

AllStudy cancer

deaths /

Estimated cancerdeaths (000s) in 2010

Age standardisedcancer mortality

rate per100 000 (99% CI)

(35·9 - 43·9)

(38·5 - 51·5)

(30·8 - 40·2)

(41·1 - 50·7)

(38·0 - 44·8)

(77·3 - 107·8)

(87·8 - 108·8)

(76·2 - 90·5)

(101·3 - 115·8)

(80·4 - 108·1)

2 4 6 8 10 12 14

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

5·6

8·5

11·3

2·7

15·3

1·6

1·1

3·6

13·2

4·9

18·2

1·6

9·6

10·2

27·5

14·6

18·0

4·1

11·5

4·5

8·3

1·8

2·7

138·3

61·8

74·6

125·5

200·1

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/


Cancer: WOMEN aged 30-69 years

Northeast states

Himachal Pradesh

Assam

Punjab

Jammu & Kashmir

Karnataka

West Bengal

Uttar Pradesh

Other states

Andhra Pradesh

Uttarakhand

Tamil Nadu

Kerala

Gujarat

Delhi

Madhya Pradesh

Maharashtra

Chhattisgarh

Rajasthan

Haryana

Bihar

Odissa

Jharkhand

Rural

Urban

Poorer states

Richer states

Total

118

63

73

80

60

173

212

260

66

137

10

175

184

118

34

98

134

31

103

63

119

85

19

1907

508

798

1617

2415

0·4

0·3

0·2

0·8

0·04

1·8

2·7

4·0

0·2

3·0

−−

5·4

0·9

2·0

0·3

1·2

3·8

0·9

1·0

0·4

2·0

0·9

1·1

25·4

8·0

11·4

22·0

33·4

138·0

127·5

116·0

113·2

113·7

114·8

110·5

108·2

83·7

104·2

91·9

102·5

90·3

92·1

90·9

87·4

88·6

80·4

77·3

73·8

68·2

63·5

53·0

96·6

91·2

87·1

101·2

95·1

21·0

27·9

37·5

25·8

17·2

34·1

17·5

14·6

15·7

20·3

27·2

12·3

16·8

22·5

9·1

21·2

20·3

9·7

13·7

18·3

7·1

9·6

2·8

17·5

17·6

14·2

20·1

17·6

15·2

19·7

3·5

16·7

2·3

16·5

15·5

13·6

17·5

17·6

−−

35·7

11·1

16·8

9·4

10·1

19·0

24·6

10·3

11·4

12·9

10·9

19·5

16·6

14·7

12·5

18·7

16·0

6·0

5·9

5·5

5·3

5·3

5·3

5·0

4·8

3·9

4·7

4·6

4·5

4·3

4·3

4·0

4·0

3·9

3·8

3·4

3·3

2·9

2·8

2·1

4·5

4·2

3·9

4·6

4·4

(4·6−7·4)

(4·0−7·8)

(3·8−7·1)

(3·8−6·9)

(3·6−7·1)

(4·2−6·3)

(4·1−5·9)

(4·1−5·6)

(2·7−5·1)

(3·7−5·8)

(0·9−8·4)

(3·6−5·4)

(3·5−5·1)

(3·3−5·3)

(2·3−5·8)

(2·9−5·0)

(3·1−4·8)

(2·0−5·5)

(2·6−4·3)

(2·3−4·4)

(2·2−3·6)

(2·0−3·6)

(0·9−3·4)

(4·2−4·7)

(3·7−4·7)

(3·5−4·3)

(4·3−4·9)

(4·2−4·6)

State or RegionTobaccorelated † All

Tobacco related †

Cumulative riskfor all cancers (99%CI)All

Study cancerdeaths /

Estimated cancerdeaths (000s) in 2010


rate per100 000 (99% CI)

/ Cervical ‡ Cervical ‡

(15·0 - 20·1) (14·2 - 19·1)

(13·6 - 21·5) (10·7 - 18·7)

(11·2 - 17·1) (9·7 - 15·2)

(17·1 - 23·2) (15·7 - 21·7)

(15·4 - 19·7) (13·9 - 18·1)

(79·2 - 103·2)

(75·3 - 97·1)

(79·8 - 94·3)

(94·3 - 108·1)

(78·1 - 101·5)

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/ /

2 4 6 8 10

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

3·2

1·7

5·3

5·5

2·0

13·2

18·0

31·2

0·9

17·6

1·5

15·7

7·5

9·6

2·6

9·8

18·1

3·0

8·1

3·0

10·4

5·0

2·9

143·8

51·6

77·0

118·4

195·4

0·4

0·4

1·7

1·3

0·3

4·0

2·7

4·1

0·2

3·3

0·4

1·9

1·4

2·3

0·3

2·3

4·2

0·4

1·5

0·8

1·0

0·7

0·2

25·7

10·0

12·2

23·4

35·7


Cancer (non tobacco/non infection):BOTH GENDERS aged 30-69 years

Northeast states

Jammu & Kashmir

Kerala

West Bengal

Himachal Pradesh

Assam

Karnataka

Uttar Pradesh

Uttarakhand

Andhra Pradesh

Delhi

Punjab

Gujarat

Madhya Pradesh

Rajasthan

Haryana

Tamil Nadu

Other states

Maharashtra

Bihar

Odissa

Chhattisgarh

Jharkhand

Rural

Urban

Poor

Rich

Total

165 / 89 / 76

96 / 50 / 46

273 / 183 / 90

280 / 152 / 128

65 / 29 / 36

91 / 50 / 41

195 / 111 / 84

291 / 126 / 165

12 / 5 / 7

159 / 82 / 77

37 / 16 / 21

69 / 29 / 40

114 / 63 / 51

107 / 56 / 51

125 / 64 / 61

72 / 42 / 30

156 / 86 / 70

75 / 50 / 25

106 / 56 / 50

125 / 59 / 66

106 / 56 / 50

21 / 9 / 12

23 / 14 / 9

2157 / 1136 / 1021

606 / 341 / 265

901 / 439 / 462

1862 / 1038 / 824

2763 / 1477 / 1286

4·6

3·3

10·9

23·1

1·7

6·2

14·3

35·2

1·7

19·3

3·2

4·8

10·7

10·5

9·6

3·9

14·1

1·0

15·9

11·5

5·8

2·0

3·3

155·4

61·0

85·7

130·7

216·4

103·1

89·3

71·2

69·2

65·8

63·6

62·9

60·1

53·5

58·4

53·8

49·0

50·4

48·2

47·4

47·0

46·9

45·3

38·2

37·3

37·0

27·9

30·5

53·2

50·0

48·2

56·0

52·7

5·0

4·6

3·5

3·3

3·3

3·1

3·0

2·8

2·8

2·7

2·6

2·5

2·4

2·4

2·3

2·2

2·2

2·1

1·8

1·7

1·7

1·4

1·3

2·5

2·4

2·3

2·6

2·5

(3·9 − 5·8)

(3·3 − 5·6)

(2·9 − 4·0)

(2·2 − 4·3)

(2·7 − 3·7)

(2·2 − 3·9)

(2·4 − 3·5)

(0·7 − 4·8)

(2·4 − 3·2)

(2·1 − 3·2)

(1·5 − 3·6)

(1·7 − 3·2)

(1·8 − 2·9)

(1·8 − 2·9)

(1·7 − 2·7)

(1·5 − 2·8)

(1·7 − 2·6)

(1·5 − 2·7)

(1·3 − 2·2)

(1·3 − 2·1)

(1·2 − 2·0)

(0·6 − 2·1)

(0·6 − 2·0)

(2·4 − 2·6)

(2·1 − 2·6)

(2·1 − 2·4)

(2·5 − 2·8)

(2·3 − 2·6)

0 1 2 3 4 5 6

State or Region Total Cumulative risk (99%CI)

Estimatedcancer deaths(000s) in2010


rate per 100 000(99% CI)/ Male Female/

Study deaths ofnon-tobacco related cancers

common to both genders

(50·0 - 56·3)

(45·3 - 54·7)

(44·4 - 52·1)

(52·4 - 59·6)

(50·0


Cancer death rates by education, men and women

aged 30-69


0

20

40

60

80

100

120

Illiterate Primary Above secondary

Educational level

Ag

e-st

and

ard

ised

dea

th r

ate

(per

10

0,00

0)

Men

Women


Selected cancer rates by religion, women 30-69 years

Type

Standardised mortality ratio(and study deaths)

Hindu Muslim

Cervical1.06(340)

0.68(24)

Oral1.01(190)

0.80(24)

Breast 0.92(178)

1.43(32)



Cervical cancer rates by state, women 30-69 years

Age-standardised mortality rates per 100,000

Jammu & Kashmir Assam India

2.3 3.5 16.0



• Most cancer deaths in India are avoidable as they occur at younger ages and present late after cancer starts • Most importantly, higher tobacco taxes reduce cancer• Strategies to vaccinate, screen, and treat women with cervical cancer also work.• Early detection of cancer dramatically improves the prospect of cure• Big differences suggest more research on why common cancers are rare in parts of India

Implications



www.cghr.org/cancer

Follow us on Twitter: @CGHR_org

• The Lancet Paper and Web appendix• Press release (English, Hindi, and main

regional languages)• Video release (English, Hindi, and

main regional languages• FAQs• PowerPoint slides


Million Death Study CollaboratorsIndian Academic Partners (in alphabetical order):Clinical Epidemiology Resource and Training Centre Trivandarum: KB Leena, KT Shenoy (until 2005) Department of Community Medicine Gujarat Medical College Ahmedabad: DV Bala, P Seth KN TrivediDepartment of Community Medicine Kolkatta Medical College Kolkatta: SK RoyDepartment of Community Medicine Regional Institute of Medical Sciences Imphal: L UsharaniDepartment of Community Medicine S.C.B. Medical College Cuttack Orissa: Dr. B MohapatraDepartment of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R GuptaEpidemiological Research Center Chennai: V Gajalakshmi, CV Kanimozhi Gandhi Medical College Bhopal: RP Dikshit, S SorangiHealis-Seskarhia Institute of Public Health Mumbai: PC Gupta, MS Pednekar, S SreevidyaIndian Institute of Health & Family Welfare, Hyderabad: P BhatiaInstitute of Health Systems Research Hyderabad: P Mahapatra (until 2004)St. John’s Research Institute St. John’s Academy of Health Sciences Bangalore: A Kurpad, P Mony, M Vaz, R Jotkar, S Rao-Seshadri, S Shrihari, S

SrinivasanKing George Medical College Lucknow: S AwasthiNajafgarh Rural Health Training Centre Ministry of Health Government of India New Delhi: N Dhingra, J Sudhir, I Rawat (until 2007)National Institute of Mental Health and Neurosciences Bangalore: G Gururaj (until 2004)North Eastern Indira Gandhi Institute of Regional Medical Sciences Shillong Meghalaya: FU Ahmed (until 2005), DK ParidaRegional Medical Research Center ICMR Institute Bhubaneshwar: AS Karketta, SK Dar School of Preventative Oncology Patna: DN SinhaSchool of Public Health Post Graduate Institute of Medical Education and Research Chandigarh: N Kaur, R Kumar, JS Thakur Tata Memorial Hospital Mumbai: RA Badwe, RP Dikshit, K Mohandas

Lead Partners: Office of the Registrar-General India RK Puram New Delhi India: C Chandramouli (Registrar General of India [RGI]), RC Sethi, B Mishra, S Jain (until

2008), DK Dey (until 2009), AK Saxena, MS Thapa, N Kumar, JK Banthia and DK Sikri (former RGIs) Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute Keenan Research Centre St. Michael’s

Hospital Dalla Lana School of Public Health University of Toronto Canada: DG Bassani, P Jha (Principal Investigator), R Jotkar, R Kamadod, B Pezzack, S Rao-Seshadri, P Rodriguez, J Sudhir, C Ramasundarahettige, W Suraweera

Affiliated Partners:Indian Council of Medical Research New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly (DG to 2008), L Kant, B BhattacharyaSchool of Population Health The University of Queensland Australia: AD Lopez, C RaoWorld Health Organisation Geneva and SEARO Office New Delhi: T Boerma, T Evans, A Fric, S Habayeb (former WHO Representative-India), S Khanum,

C Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director)Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU) University of Oxford England: N Bhala, J Boreham, Z Chen, R Collins, R Peto, G

Whitlock

cghr.org/cancer twitter: cghr_org cancer mortality in india on behalf of the million death study...

Documents