Post on 24-Dec-2015
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
Prabhat.jha@utoronto.ca
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
CGHR.ORG/CANCERTwitter: CGHR_org
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
CGHR.ORG/CANCERTwitter: CGHR_org
CGHR.ORG/CANCERTwitter: CGHR_org
• 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?
CGHR.ORG/CANCERTwitter: CGHR_org
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.)
CGHR.ORG/CANCERTwitter: CGHR_org
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
CGHR.ORG/CANCERTwitter: CGHR_org
• 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
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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:
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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
CGHR.ORG/CANCERTwitter: CGHR_org
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
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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)
112 of 1000 men will die of cancer
60 of 1000 women will die of cancer
Bihar(lower risk)
25 of 1000 men will die of cancer
29 of 1000 women will die of cancer
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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
/
/
/
/
/
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/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
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
/
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CGHR.ORG/CANCERTwitter: CGHR_org
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
Age standardisedcancer mortality
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)
/
/
/
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/ /
2 4 6 8 10
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/
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
CGHR.ORG/CANCERTwitter: CGHR_org
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
Age standardisedcancer mortality
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
CGHR.ORG/CANCERTwitter: CGHR_org
Cancer death rates by education, men and women
aged 30-69
Source: Dikshit et al, Lancet 2012
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
CGHR.ORG/CANCERTwitter: CGHR_org
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)
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
• 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
Source: Dikshit et al, Lancet 2012
CGHR.ORG/CANCERTwitter: CGHR_org
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
CGHR.ORG/CANCERTwitter: CGHR_org
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