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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