6
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Cancer research in India: Challenges & opportunities

      editorial

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          With changing lifestyle, improved longevity and better control of infectious diseases, non-communicable diseases have emerged as major health problems worldwide, more so in developing countries. After cardiac diseases, cancer has emerged as an important cause of morbidity and mortality in India. According to The National Centre for Disease Informatics and Research of the Indian Council of Medical Research (ICMR) at Bengaluru, India, 1.45 million cases of cancer were estimated to be diagnosed in 2016. This burden is likely to become double in the next 20 years1 2. Magnitude & pattern of various cancers in India The National Cancer Registry Programme was commenced by the ICMR in December 1981 and is a major source of information on cancer incidence and pattern in the country. Currently, there are 29 population-based cancer registries (PBCRs) and 29 hospital-based cancer registries. These cover about 10 per cent of India's population. Of these, 11 PBCRs are located in the North-East (NE) region. Age-adjusted incidence (per 100,000) rate for males is higher in the West - 631.9 in Brazil, 493.9 in USA - Michigan, compared to India 270.0 in Aizawl district and 149.4 in Delhi. Corresponding figures in females are 474.6 in Brazil, 363.3 in USA, 207.7 in Aizawl and 144.8 in Delhi (India) per 100,000, respectively3. The top five cancers among men are lung, head and neck region (mouth, tongue and larynx), prostate and oesophagus. While among women - breast, cervix, ovary, oral cavity and uterine cancer are most common3. The incidence of cervical cancer is declining over the past three decades in Delhi, Chennai, Bengaluru, Bhopal, Mumbai and Barshi PBCRs. The incidence of colon/rectum, lung, breast and prostate cancer is gradually rising in these registries3. There is significant geographical variation in the incidence of cancer in India. For example, in the NE region, the incidence of cancer is highest in India, for both sexes. In males, Aizawal district (located in Mizoram) reported highest cases while Papumpare district in Arunachal Pradesh had the highest number in females. Higher incidence of gallbladder cancer in north India and NE region compared to other parts, higher incidence of stomach cancer in Chennai and Bengaluru PBCRs, oesophagus cancer in Kashmir and NE region would indicate different aetiological factors operating, for example, environmental, diet, lifestyle and genetic factors4. Nearly 50 per cent of cancers in males and 15 per cent in females are related to the use of tobacco in different forms. These include cancers of aerodigestive tract (head and neck, lung and oesophagus), pancreas and renal and urinary bladder4. It is clear that the biggest measure to reduce the incidence of these cancers would be to reduce the consumption of tobacco. Specific cancer research programmes to focus on biology of population present in various States with PBCRs will help determine risk factors responsible and suggest strategies for prevention. Delay in diagnosis Almost 75-80 per cent of patients have advanced disease (Stage 3-4) at the time of diagnosis5. This has been attributed to the late presentation which in turn is due to low level of awareness in the population and among community physicians, lack of screening programmes, lack of diagnostic facilities locally and vast distances to travel to reach a major tertiary cancer centre, financial constraints and stigma associated with the diagnosis. The situation is even worse in rural areas (69% of total population) where patients and families have to travel a long distance to reach a tertiary care oncology centre. Lack of place to stay, long time taken for investigations, limited finances, language and cultural differences are also some of the limitations4. As per data from rural-based PBCRs, the incidence of cancer is low in rural India compared to urban PBCRs2. Even the pattern of cancers in rural PBCRs is different compared to those in urban PBCRs, suggesting a different policy/approach to adopt in rural areas. Infrastructure One of the major reasons for not being able to implement screening programme in India has been lack of workforce - physicians, health workers, technical staff and pathologist to review pathological material. The preference of healthcare personnel to work in urban settings has also resulted in unequal distribution of healthcare centres and practitioners. Many tertiary care centres (not all) have a comprehensive team of professionals comprising medical, radiation and surgical oncologists, pain and palliative care experts and auxiliary services, for example, diagnostics and pathological tests. A complex team like this is yet to be a reality in rural India6. Available data from randomized trials done in south India suggest that simple innovative methods such as visual inspection-based screening (for oral cavity)7, visual inspection with acetic acid application for cervical cancer8 may be useful and cost-effective methods of screening for these two common cancers. Similarly, for breast cancer self-examination or examination by a physician may be alternative methods to screening mammography9 which are doable for early detection of breast cancer, as detection in early stages is amenable for treatment with curative option with less morbidity. Ultimately, the screening programmes can bring down the incidence of some of the common cancers in India. There has been effort by the Government of India (GOI) to establish regional cancer centres in rural areas, and upgrade medical colleges with oncology department. Under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke, the GOI has allocated ₹ 120 crores each for the establishment of 20 State-level cancer centres10. The GOI has also allocated 20 million USD to develop 23 new tertiary care centres and to strengthen 27 regional cancer centres10. Under the ‘Pradhan Mantri Swasthya Yojna’, eight new cancer centres would be set up in various parts of country and 58 existing medical colleges would be upgraded in a phased manner. This is a mammoth task and will take some years before this translates into standard care and survival benefit. One solution to this problem might be setting up and improving primary care services in rural areas and educating people about cancer, environmental pollution, clean drinking water, healthy diet and avoid tobacco use11. Experienced health practitioner, researchers and physicians should concentrate on early detection of cancer, as cure rates are high, if cancer is detected in early stage. Several non-government organizations are engaged in increasing public awareness, supporting screening, early detection, patient and family support services and palliative care by providing home care4 12. There is a need to consolidate and strengthen their role in national cancer control programme. Further, the ICMR has taken initiative to publish consensus documents on common cancers in India to improve quality and standardized cancer care. These are expert and evidence-based guidelines to promote uniformity and to ensure the quality of treatment across cancer centres in India13. In recent years, the government has tried to address these issues by establishment of the National Health Mission and insurance schemes such as Rashtriya Swasthya Bima Yojna (a central government initiative); Rajiv Aarogyasri Scheme (an Andhra Pradesh government initiative); Vajpayee Arogyashree Scheme (a Karnataka government initiative)12, and also Gujarat health scheme model13. The emphasis is now to educate people about these programmes. Clinical research Although a notable progress in this field has been made in the recent years, there is a need to develop proper clinical research environment. This includes exposing graduate and postgraduate medical students, community physicians and medical college teachers about translation clinical research, and developing adequate infrastructure. Indian pharmaceutical industry has made phenomenal growth in the field of generic molecules; they need to invest in the development of new molecules and India centric cancer research14 15. India has a large pool of individuals with genetic diversity (4000 anthropologically distinct groups and 22 languages)14. This provides an opportunity to study environmental influences on drug metabolism (such as smoking, alcohol and use of herbal medicine), variation in drug targets (for example, higher incidence of activating mutations of epidermal growth factor receptor in lung cancer in patients from Asia), and genetic polymorphism in drug-related genes. Indian population is unique in terms of genetics, culture, languages and food habits. Well-planned genome-wide association studies may yield insights into disease aetiology and potential responses to therapy14. In the era of precision medicine, it will be important to define risks or susceptibility of certain population or ethnic subgroups for high incidence of cancer seen in these areas16 and also from treatment point of view if these subgroups need dose modification or special precaution during the treatment. Translational studies involving imaging, pathology, gene expression profiling, sequencing, bioinformatics and detection of circulating tumour cells can be done in few centres, and then data generated can be evaluated for its translation at other centres14 15. Key priority areas for research One of the important tasks would be to develop consensus on key priorities for cancer research in Indian context based on common cancers in males and females in a particular region. There is a need to focus research on prevention of some cancers with high incidence in certain areas, for example, gallbladder cancer in Gangetic belt, penile cancer in rural population, oesophageal cancer in NE region, colon cancer in Goa, stomach cancer in southern and northeast India4. Whether these regional differences in epidemiology are due to a difference in genomics and biology or due to differences in the prevalence of cancer risk factors or both are not yet known and would be an important area of research14. These cancers are rare in West and therefore, not a focus for large research programmes. Similarly, directing research for upcoming problems like lifestyle and obesity-related cancers would be timely. Since most patients have advanced disease and poor performance status at presentation, research efforts to develop cost-effective protocols for palliative care would be meaningful. Developing protocols to less toxic regimens (e.g. metronomic therapy with minimal visits to a busy cancer centre)17 and minimizing need for imaging (e.g. computed tomography scan)18 in the follow up would be simple, yet important solutions. An active collaboration between investigators, funding agencies, industry and regulatory bodies would be important to understand needs of each other. Way forward Cancer in India is emerging as a major cause of morbidity and mortality. Some of the key features include young age (generally one decade younger compared to the western population), advanced disease, poor performance status and possibly more aggressive phenotype. While many tertiary cancer centres have state of the art diagnostic workup and treatment protocols, this is yet to reach to a standard level in many other regional cancer centres and hospital in smaller towns. Focussing on epidemiological research, screening for certain cancers and clinical trials India-centric common cancers may provide solutions for improvement in outcome. A planned and teamwork approach at the institution level and collaboration with different research teams are likely the key to success.

          Related collections

          Most cited references16

          • Record: found
          • Abstract: found
          • Article: not found

          Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial.

          Oral cancer is common in men from developing countries, and is increased by tobacco and alcohol use. We aimed to assess the effect of visual screening on oral cancer mortality in a cluster-randomised controlled trial in India. Of the 13 clusters chosen for the study, seven were randomised to three rounds of oral visual inspection by trained health workers at 3-year intervals and six to a control group during 1996-2004, in Trivandrum district, Kerala, India. Healthy participants aged 35 years and older were eligible for the study. Screen-positive people were referred for clinical examination by doctors, biopsy, and treatment. Outcome measures were survival, case fatality, and oral cancer mortality. Oral cancer mortality in the study groups was analysed and compared by use of cluster analysis. Analysis was by intention to treat. Of the 96,517 eligible participants in the intervention group, 87,655 (91%) were screened at least once, 53,312 (55%) twice, and 29,102 (30%) three times. Of the 5145 individuals who screened positive, 3218 (63%) complied with referral. 95,356 eligible participants in the control group received standard care. 205 oral cancer cases and 77 oral cancer deaths were recorded in the intervention group compared with 158 cases and 87 deaths in the control group (mortality rate ratio 0.79 [95% CI 0.51-1.22]). 70 oral cancer deaths took place in users of tobacco or alcohol, or both, in the intervention group, compared with 85 in controls (0.66 [0.45-0.95]). The mortality rate ratio was 0.57 (0.35-0.93) in male tobacco or alcohol users and 0.78 (0.43-1.42) in female users. : Oral visual screening can reduce mortality in high-risk individuals and has the potential of preventing at least 37,000 oral cancer deaths worldwide.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial.

            Cervical cancer is the most common cancer among women in developing countries. We assessed the effect of screening using visual inspection with 4% acetic acid (VIA) on cervical cancer incidence and mortality in a cluster randomised controlled trial in India. Of the 114 study clusters in Dindigul district, India, 57 were randomised to one round of VIA by trained nurses, and 57 to a control group. Healthy women aged 30 to 59 years were eligible for the study. Screen-positive women had colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Those with larger precancerous lesions or invasive cancers were referred for appropriate investigations and treatment. Cervical cancer incidence and mortality in the study groups were analysed and compared using Cox regression taking the cluster design into account, and analysis was by intention to treat. The primary outcome measures were cervical cancer incidence and mortality. Of the 49,311 eligible women in the intervention group, 31,343 (63.6%) were screened during 2000-03; 30,958 control women received the standard care. Of the 3088 (9.9%) screened positive, 3052 had colposcopy, and 2539 directed biopsy. Of the 1874 women with precancerous lesions in the intervention group, 72% received treatment. In the intervention group, 274,430 person years, 167 cervical cancer cases, and 83 cervical cancer deaths were accrued compared with 178,781 person-years, 158 cases, and 92 deaths and in the control group during 2000-06 (incidence hazard ratio 0.75 [95% CI 0.55-0.95] and mortality hazard ratio 0.65 [0.47-0.89]). VIA screening, in the presence of good training and sustained quality assurance, is an effective method to prevent cervical cancer in developing countries.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Cancer mortality in India: a nationally representative survey.

              The age-specific mortality rates and total deaths from specific cancers have not been documented for the various regions and subpopulations of India. We therefore assessed the cause of death in 2001-03 in homes in small areas that were chosen to be representative of all the parts of India. At least 130 trained physicians independently assigned causes to 122,429 deaths, which occurred in 1·1 million homes in 6671 small areas that were randomly selected to be representative of all of India, based on a structured non-medical surveyor's field report. 7137 of 122,429 study deaths were due to cancer, corresponding to 556,400 national cancer deaths in India in 2010. 395,400 (71%) cancer deaths occurred in people aged 30-69 years (200,100 men and 195,300 women). At 30-69 years, the three most common fatal cancers were oral (including lip and pharynx, 45,800 [22·9%]), stomach (25,200 [12·6%]), and lung (including trachea and larynx, 22,900 [11·4%]) in men, and cervical (33,400 [17·1%]), stomach (27,500 [14·1%]), and breast (19,900 [10·2%]) in women. Tobacco-related cancers represented 42·0% (84,000) of male and 18·3% (35,700) of female cancer deaths and there were twice as many deaths from oral cancers as lung cancers. Age-standardised cancer mortality rates per 100,000 were similar in rural (men 95·6 [99% CI 89·6-101·7] and women 96·6 [90·7-102·6]) and urban areas (men 102·4 [92·7-112·1] and women 91·2 [81·9-100·5]), but varied greatly between the states, and were two times higher in the least educated than in the most educated adults (men, illiterate 106·6 [97·4-115·7] vs most educated 45·7 [37·8-53·6]; women, illiterate 106·7 [99·9-113·6] vs most educated 43·4 [30·7-56·1]). Cervical cancer was far less common in Muslim than in Hindu women (study deaths 24, age-standardised mortality ratio 0·68 [0·64-0·71] vs 340, 1·06 [1·05-1·08]). Prevention of tobacco-related and cervical cancers and earlier detection of treatable cancers would reduce cancer deaths in India, particularly in the rural areas that are underserved by cancer services. The substantial variation in cancer rates in India suggests other risk factors or causative agents that remain to be discovered. Bill & Melinda Gates Foundation and US National Institutes of Health. Copyright © 2012 Elsevier Ltd. All rights reserved.
                Bookmark

                Author and article information

                Journal
                Indian J Med Res
                Indian J. Med. Res
                IJMR
                The Indian Journal of Medical Research
                Medknow Publications & Media Pvt Ltd (India )
                0971-5916
                October 2018
                : 148
                : 4
                : 362-365
                Affiliations
                [1]Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110 029, India
                Author notes
                [* ] For correspondence: lalitaiims@ 123456yahoo.com
                Article
                IJMR-148-362
                10.4103/ijmr.IJMR_1711_18
                6362726
                30665997
                41909b92-106a-47a2-9eea-daacb1df5858
                Copyright: © 2018 Indian Journal of Medical Research

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 12 September 2018
                Categories
                Editorial

                Medicine
                Medicine

                Comments

                Comment on this article