Annual Burden of Cancer

2001 2005806,300 912,000

With control of communicable diseases

Increase in life expectancy

Trends in smoking

Changing life style

Cancer incidence and burden

Cumulative Risk

Male Female1 in 9 1 in 8

ANTI-CANCER ACTIVITIES

1936First effort to set up a cancer hospital – appeal to King George V Memorial Fund by Dr.Muthulakshmi Reddy

No Major national effort for 30 years after this

Dr. Reddy also responsible for including cancer in the National Health Programme in the First 5-year Plan of Govt. Of India.

1965-71 Govt. of India committeeConcept of Regional Cancer Centre

1982 Demographic registries

1985 NCCP

Perception of Cancer Then

1949 Dr.Reddy had to justify the needfor a Cancer Hospital

Cancer perceived as a disease of the Aged a fatal / incurable disease Needed only Morphine to help

their way to Eternity

Cancer a major component of the National Health Plan

Most states have a Cancer Centre

Today’s Slogan

Cancer is preventable, curableStress on cancer survivors &Children of survivors

Perception of Cancer now – 50 years later

National Cancer Registry Project (ICMR), 1981 &Other voluntary efforts

• Setting up of 3 Demographic Registries Bombay, Madras and Bangalore

• A total of 14 Demographic Registries and 5 Hospital Cancer Registries (HCR) at present under NCRP

• Only 3 are rural demographic registries

• Six Demographic Registries outside NCRP network

• ICMR Atlas Project – Data on cancer pattern in 82 districts from 105 centres in India.

• Coverage: 6.9% of the population

Objectives based on the data from the Demographic registries

• Primary prevention of Tobacco Related Cancers

• Early detection and treatment of cancer of the cervix (extended to cover cancer at accessible sites cervix, breast and oral)

• Enhancement of cancer treatment and control services through Regional Cancer Centres, Medical and Dental colleges.

• Palliative care [added in – 1989]

Objectives of the National Cancer Control Programme, 1985

Tobacco Research Activities in India

Chennai cohort study (300,000 men, aged ≥ 25 years)• 31% of total deaths due to any cancer was attributable to tobacco

smoking ranging from 39% for stomach/oesophagus to 56% for lung/larynx cancers

• Prevalence of tobacco smoking among men aged 35 and above is estimated to be 40%

Mumbai Cohort Study• 150,000 persons; Tobacco habit – 57.6% women; 69.3% men,

smokeless tobacco use more common than smoking

• Mortality rates higher for tobacco user than non-user

Global Youth Tobacco Survey (GYTS) among 13-15 yrs students• Prevalence ranged between 59% in Bihar, 4% in Goa;• 7% in Tamil Nadu and • Survey not carried out in Kerala.

MDCCP DATA FROM TAMIL NADU STATE (Women)

21.1

32.1

8.3

13.4

0

5

10

15

20

25

30

35

%

18-24 25-34

35-44 >44

Prevalence: Tobacco smoking: 3%; Tobacco chewing: 21%

10.5 10.9

24.8

15.3

0

5

10

15

20

25

30

%

Nil <5 yrs

5-10 yrs >10 yrs

Age group Education

Tobacco habit: with increasing age; with increasing education

Frequency of women with awareness ofCancer as a term 79.2%Curability of cancer 45.0%Cancer Trt centres 32.4%Tobacco as a hazard 56.0%

Legislative Action

1. Anti-tobacco measures Ban on tobacco advertisement Ban on sale of tobacco near schools and colleges Ban on smoking in public places Ban on smoking in buses, airports. etc Ban on sports promotion by tobacco companies• Hazards of tobacco in school books (hygiene,

preventive medicine)• Monitoring of industries

Our recommendationsPreference to non-smokers as teachers in schools and colleges

Declare cancer a “Notifiable Disease”

CHINGLEPUT SURVEY OF CANCER 1961-63

% Stage Distribution of Carcinoma Cervix 1961 – 63Stage Survey C.I.

Early 69.57 5.76

Late 30.43 94.24

Number surveyed : 10,775Male : 3,239Female : 4,842Children : 2,092

Cancers detected : 67Oral : 24Cervix : 27Breast : 16

Foundation for the first ever pilot cancer controlProgramme – Kanchipuram 1967, WHO

1st INTERNATIONAL WHO CANCER CONTROL PROJECT

KANCHIPURAM 1967

Opportunistic Screening!

Objective To integrate the screening & educationprogramme with the states’ permanenthealth infrastructure and delivery system

This would significantly reduce cost

Trained 258 Medical officers672 VHNs30 Block health educators2 cytotechnicians

Setup 2 Cytology laboratoriesin Cuddalore and Villupuram

Total women examined 59314Cancers detected 310

Early 12.3%

Late 87.7% MOTIVATION POOR

South Arcot District LevelCervical cancer early detection project: 1992-99

Problems in the South Arcot Programme

4. VHN had multiple duties and received incentives for the FPP & immunization

drive

No incentives in cancer detection programme

5. Fresh young women medical graduates – not confident

6. Compliance of women to be screened – Dependant on men folk!

Information, Education and Health Care InterventionIARC in collaboration with Nargis Dutt MemorialCancer Hospital, Barshi

Int. Area Non Int. Area

Ca Cervix 66% 25%Stage I & II

Major conclusions from various Indian studies

• Population screening not practicable

• For Cervical cancer VIA recommended at present

• High priority and focus on

Educational Programmes

• Serious effort to integrate screening with

routine health delivery system

• Introduction of opportunistic screening can be

considered

• Enhanced Imaging

• Enhancement in Tissue diagnosis

• Molecular Diagnostics

Technologic Advances

Enhanced Imaging

For evaluation of extent of disease / tumour size and tumour spread and monitor response to therapy

Ultrasound

CT Scan, Spiral CT

MRI, PET

Implications of sophisticated Imaging

Expertise in interpretation

Knowledge of relative merits of diff. available techniques

Increase in cost of diagnosis

Molecular Markers

• Molecular diagnostics

• Prognostic & Predictive Markers

• Minimal Residual Disease

Conceptual influences in Therapeutic Oncology

1. Preventive Oncology : Based on natural history of evolution of disease

2. Definition of early disease

3. Concept of Micrometastasis

4. Evaluation of extent of disease

5. Introduction of multi disciplinary approach

Multidisciplinary approach in Oncologic care

• Appreciates limitation inherent in different modalities of treatment

• Sequencing of different modalities

• Surgery, radiation and chemotherapy based on biologic needs

• Different in early disease and locally advanced disease

RESEARCH

Synthesis of clinical practice studies &

laboratory and research data

Essential for progress

Hereditary Cancer Cliniconly one of its kind in India - 2002

Palliative Care: Palliative care medicine – a specialityA major component in cancer control

Facilities in IndiaPalliative care centres, hospices, hospital based centresDomiciliary services

Andhra Pradesh 1 Tamil Nadu 5 Kerala 4

Assam 1 Uttar Pradesh 1 with 50 satellite

Chandigarh 1 Rajasthan 1 centers

Karnataka 4 Goa 1 55% of cancers

Madhya Pradesh 2 have access to

Maharashtra 3 Palliative Care

New Delhi 2

Orissa 2

Calicut CentreWHO Demo Project

PAIN CONTROL

INCIDENCE AND BURDEN OF CANCER$

INDIA, 2001 & 2005

Male Female M+F

2001

CIR/105

Population

(In millions)

New Cancer cases

72.3

534.7

386,600

84.1

499.0

419,700

78.0

1033.7

806,300

2005Population

(In millions)

New Cancer cases

576.9

443,000

539.9

469,000

1116.8

912,000

$ Estimates based on urban & rural registriesSource: NCRP, ICMR Report (2004) & Individual Cancer Registry Reports

Registry (Period) Breast Cervix

Tamil Nadu

Chennai (1999-02) Urban 24.5 24.3

Dindigul (2003) Rural 13.1 27.8

Kerala

Trivandrum (2000) Urban 26.5 8.7

Karunagapally Rural 14.4 11.2

(93-01)

Maharashtra

Mumbai (2000) Urban 21.3 11.8

Barshi (1999-00) Rural 5.6 19.8

CIRs of Cervical & Breast cancers in India(Urban vs Rural registries)

Source: NCRP, ICMR Report (2005) & Individual Cancer Registry Reports

Period Cervix Breast Cx :Brt

1983-87 16.6 10.4 1:0.63

1988-92 19.3 16.7 1:0.87

1993-97 17.4 18.2 1:1.05

1998-02 15.9 21.9 1:1.38

Trend Reversed now

Trend of CIR of Cervical & Breast Cancers

Urban India:1983-2002

 

Trend of stage distribution (%), Trivandrum, 1984-1999Stage 1984 1989 1994 1999

Breast

1 4.8 1.3 3.3 3.2

2 43.3 47.5 43.3 33.3

3 34.6 41.9 37.4 42.5

4 17.3 9.4 16.1 21.0

Cervix

1 6.3 11.1 14.4 12.7

2 27.4 34.6 29.6 32.1

3 59.4 44.5 49.5 50.9

4 6.9 9.9 6.5 4.2

Oral Cancer

1 5.7 8.7 15.6 10.6

2 17.8 15.8 22.4 21.1

3 39.7 53.3 25.6 47.2

4 36.8 22.2 36.3 21.1

Trend in survival(%) at 5 yearsALL: 0-25 Years : 1970-99 : (C.I)

Age Group 1970-82 (%) 1983-89 (%) 1990-99 (%)

OS

0-14 Yrs. 25.1(42)

43.0(114)

56.8(197)

15-25 Yrs. 16.7(6)

30.7 (57)

46.6(73)

0-25 Yrs. 24.0(48)

38.9 (171)

54.0(270)

RFS

0-14 Yrs. 35.3(30)

55.1(89)

62.6(176)

15-25 Yrs. 35.3(3)

42.3(39)

59.6(57)

0-25 Yrs. 35.1(33)

52.0(128)

62.6(233)

Period No.

Overall survival (%)

Disease free survival (%)

5 yr 10 yr 5 yr 10 yr

1960-74 776 35.0 24.3 29.3 21.5

1975-89 2503 49.3 35.7 44.5 31.8

1990-95 1767 60.6 46.8 47.8 36.8

1996-99 1558 66.3 57.3* 55.7 46.3*

p-value 6604 <0.001 <0.001

Carcinoma Breast : Survival : HBCRAll cases accepted for Treatment (All stages)

Cancer Institute(WIA), Chennai

* 9 year survival

Testicular Germ Cell TumourCancer Institute, Chennai

Treatment

Stage I : High Inguinal Orchidectomy - ObservationStage II-III : High Inguinal Orchidectomy - CT

• Role of Retroperitoneal lymphadenopathy is controversial

Institution Period / Regimen No. 5 Yr. OS %

Cancer Institute

1970-84 (All Stages) 34 30.2

1985-89 (All Stages) 165 60.0

World Survival

PVB (Testicular)Proc Am Soc Cli Onc 1998; 17: 525

34 97.0

Disease profile in India

Shift from communicable to Non communicable diseases

Health Budget and Cancer Budget (Government of India)

% of Total outlay

Health and Family Welfare 8.6% (Rs.6,283 crores)

Health 2.0% (includes cancerAnnual Rs.55 crores)

Family Welfare 6.45%

Indigenous medicine 0.18%

Change in cancer scenario : 1955-2005

• Improved Survival

• Organ conservation

• Concept of cancer prevention & stress on early detection

Result of advances in Technology & conceptual

influences

• High technology involves heavy financial investment

• Increases cost and treatment

• Reduces affordability

Future Directions

1. Identify individuals who have inherited or acquired defective suppressor gene

2. Identify precursor lesions & chemoprevention

3. Vaccine Based Strategies

4. Predictive Medicine – Pharmacogenomics

5. Array based methods for diagnosis, prognosis and choice of drugs for treatment