1

EPIDEMIOLOGY & ETIOLOGY OF CANCER IN INDIA

INTRODUCTION
1.
Recent times have seen an increase in the incidence of cancer. This is mainly
attributed to urbanization, industrialization, lifestyle changes, population growth and
increased life span (in turn leading to an increase in the elderly population). In India,
the life expectancy at birth has steadily risen from 45 years in 1971 to 62 years in
1991, indicating a shift in the demographic profile. It is estimated that life expectancy
of the Indian population will increase to 70 years by 202125. This has caused a
paradigm shift in the disease pattern from communicable diseases to noncommunicable diseases like cancer, diabetes and hypertension.
2.
The epidemiology of cancer is the study of the factors affecting cancer, as a
way to infer possible trends and causes. The study of cancer epidemiology uses
epidemiological methods to find the cause of cancer and to identify and develop
improved treatments.
3.
This area of study must contend with problems of lead time bias and length
time bias. Lead time bias is the concept that early diagnosis may artificially inflate the
survival statistics of a cancer, without really improving the natural history of the
disease. Length bias is the concept that slower growing, more indolent tumors are
more likely to be diagnosed by screening tests, but improvements in diagnosing
more cases of indolent cancer may not translate into better patient outcomes after
the implementation of screening programs. A similar epidemiological concern is
overdiagnosis, the tendency of screening tests to diagnose diseases that may not
actually impact the patient's longevity. This problem especially applies to prostate
cancer and PSA screening.
4.
Some cancer researchers have argued that negative cancer clinical trials lack
sufficient statistical power to discover a benefit to treatment. This may be due to
fewer patients enrolled in the study than originally planned.
5.
Etiology is the study of causes or
origins of a disease or a matter of study.
It can also be classified as the branch of
medicine that deals with the causes or origins
of disease.
6.
Assignment of a cause, an origin,
or a reason for something. The cause or origin
of a disease or disorder as determined by
medical diagnosis.

UNDERSTANDING CANCER
Defining Cancer & What Causes Cancer
7.
Cancer begins when cells in a part of the body start to grow out of control.
There are many kinds of cancer, but they all start because of out-of-control growth of
abnormal cells. Today, millions of people are living with cancer or have had cancer.
8.
All forms of cancer spread with the help of the
tissue-dissolving mechanism. This illustration shows
an example of the development of liver cancer. The
liver is the bodys central metabolic organ, and it is
responsible for neutralizing and removing toxins from
the body. The toxins entering the body from the diet,
such as pesticides and preservatives, are the most
common cause of liver cancer. Also, all
pharmaceutical drugs have to be detoxified in the
liver. Liver cells that are exposed to these poisonous
substances can either be destroyed or permanently
damaged. This damage often involves an error in the
genetic program of the cells (cells software), similar
to what we have seen in virus infections. This
damage can trigger two processes that facilitate the
development of cancer:
9.
Uncontrolled Cell Multiplication. The
software of a cancer cell is reprogrammed in such a
way that it causes constant reproduction and
multiplication of the cell. This uncontrolled cellular
multiplication is the first precondition for cancer to
develop.
10.
Mass Production of Collagen-Digesting
Enzymes. The second precondition is the production
of enzymes that destroy the surrounding connective
tissue that would otherwise keep the cancer cells
confined. Research has established that the more
enzymes a cancer cell produces, the more
aggressively the cancer develops. The faster the
cancer can spread through a body, the shorter the life
expectancy of the patient if the mechanism is not
stopped.
11.
Oldest Descriptions of Cancer.
Human beings and other animals
have had cancer throughout recorded history. So its no surprise that from the dawn
of history people have written about cancer. Some of the earliest evidence of cancer
is found among fossilized bone tumors, human mummies in ancient Egypt, and
ancient manuscripts. Growths suggestive of the bone cancer called osteosarcoma
have been seen in mummies. Bony skull destruction as seen in cancer of the head
and neck has been found, too. Our oldest description of cancer (although the word

cancer was not used) was discovered in Egypt and dates back to about 3000 BC. It
is called the Edwin Smith Papyrus and is a copy of part of an ancient Egyptian
textbook on trauma surgery. It describes 8 cases of tumors or ulcers of the breast
that were treated by cauterization with a tool called the fire drill. The writing says
about the disease, There is no treatment.
12.
Origin of the Word Cancer.
The origin of the word cancer is credited to
the Greek physician Hippocrates (460-370 BC), who is considered the Father of
Medicine. Hippocrates used the terms carcinos and carcinoma to describe non-ulcer
forming and ulcer-forming tumors. In Greek, these words refer to a crab, most likely
applied to the disease because the finger-like spreading projections from a cancer
called to mind the shape of a crab. The Roman physician, Celsus (28-50 BC), later
translated the Greek term into cancer, the Latin word for crab. Galen (130-200 AD),
another Roman physician, used the word oncos (Greek for swelling) to describe
tumors. Although the crab analogy of Hippocrates and Celsus is still used to describe
malignant tumors, Galens term is now used as a part of the name for cancer
specialists oncologists.

CAUSES & CURE

What causes cancer?

13.
Cancer is ultimately the result of cells that uncontrollably grow and do not die.
Normal cells in the body follow an orderly path of growth, division, and death.
Programmed cell death is called apoptosis, and when this process breaks down,
cancer begins to form. Unlike regular cells, cancer cells do not experience
programmatic death and instead continue to grow and divide. This leads to a mass
of abnormal cells that grows out of control.

14.
Genes - the DNA type.
Cells can experience uncontrolled growth if there
are damages or mutations to DNA, and therefore, damage to the genes involved in
cell division. Four key types of gene are responsible for the cell division process:
oncogenes tell cells when to divide, tumor suppressor genes tell cells when not to
divide, suicide genes control apoptosis and tell the cell to kill itself if something goes
wrong, and DNA-repair genes instruct a cell to repair damaged DNA.

15.
Cancer occurs when a cell's gene mutations make the cell unable to correct
DNA damage and unable to commit suicide. Similarly, cancer is a result of mutations
that inhibit oncogene and tumor suppressor gene function, leading to uncontrollable
cell growth.
16.
Carcinogens.
Carcinogens are a class of substances that are directly
responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos,
arsenic, radiation such as gamma and x-rays, the sun, and compounds in car
exhaust fumes are all examples of carcinogens. When our bodies are exposed to
carcinogens, free radicals are formed that try to steal electrons from other molecules
in the body. Theses free radicals damage cells and affect their ability to function
normally.
17.
Genes - the Family Type.
Cancer can be the result of a genetic
predisposition that is inherited from family members. It is possible to be born with
certain genetic mutations or a fault in a gene that makes one statistically more likely
to develop cancer later in life.
18.

Environmental Risk Factors.

(a)
Radiation. High levels of radiation like those from radiation therapies
and x-rays (repeated exposure) can damage normal cells and increase the
risk of developing leukemia, as well as cancers of the breast, thyroid, lung,
stomach and other organs.

19.
Ultraviolet (UV) Radiation.
UV radiation from the sun are directly linked
to melanoma and other forms of skin cancer. These harmful rays of the sun cause
premature aging and damage the skin. Artificial sources of UV radiation, such as sun
lamps and tanning booths, also increase the risk of skin cancer. By wearing
protective clothing and sunscreens and by avoiding prolonged exposure to the sun,
one may reduce the risk of skin cancer. Many of the 1.3 million skin cancers
diagnosed in the year 2000 could have been prevented by protection from the sun`s
rays.
20.
Viruses.
Some viruses, including hepatitis B and C, human
papillomaviruses(HPV), and the Epstein Barr virus, which causes infectious
mononucleosis, have been associated with increased cancer risk. Immune system
diseases, such as AIDS, can make one more susceptible to some cancers.
21.
Chemicals.
Long term exposure to chemicals such as pesticides, uranium,
nickel, asbestos, radon and benzene can increase the risk of cancer. Such
carcinogens may act alone or in combination with another carcinogen, such as
cigarette smoke, to increase the risk of cancer and other lung diseases.
22.
Tobacco.
Cigarette smoking and regular exposure to tobacco smoke
greatly increase lung cancer. Cigarette smokers are more likely to develop several
other types of cancer like those of the mouth, larynx, oesophagus, pancreas,
bladder, kidney and cervix. Smoking may also increase the likelihood of developing
cancers of the stomach, liver, prostate, colon and rectum. The use of other tobacco
products, such as chewing tobacco, are linked to cancers of the mouth, tongue and

throat. The risk of cancer decreases soon after a smoker quits, while precancerous
conditions often diminish after a person stops using smokeless tobacco.

23.
Alcohol.
Heavy drinkers face an increased risk of cancers of the mouth,
throat, esophagus, larynx and liver. Some studies suggest that even moderate
drinking may slightly increase the risk of breast cancer. All cancers caused by
cigarette smoking and heavy use of alcohol could be prevented completely.
24.
Diet. High-fat, high cholesterol diets are proven risk factors for several
types of cancer such as those of the colon, uterus and prostate. Obesity may be
linked to breast cancer among older women as well as to cancers of the prostate,
pancreas, uterus, colon and ovary. Many cancers that are related to dietary factors
could be prevented. Healthy food choices and a well balanced diet including fiber,
vitamins, minerals and low fat items may help to reduce cancer risk. Scientific
evidence suggests that up to one-third of the cancer deaths expected to occur in
future are related to nutrition and other lifestyle factors. Certain cancers are related
to viral infections-for example, hepatitis B virus (HBV), human papillomavirus (HPV),
human immunodeficiency virus (HIV), human T-cell leukemia/lymphoma virus-I
(HTLV-I), and others-that can be prevented through behavioral changes.
25.
Other Medical Factors. As we age, there is an increase in the number of
possible cancer-causing mutations in our DNA. This makes age an important risk
factor for cancer. Several viruses have also been linked to cancer such as: human
papillomavirus (a cause of cervical cancer), hepatitis B and C (causes of liver
cancer), and Epstein-Barr virus (a cause of some childhood cancers). Human
immunodeficiency virus (HIV) - and anything else that suppresses or weakens the
immune system - inhibits the body's ability to fight infections and increases the
chance of developing cancer.
What are the symptoms of cancer?
26.
Cancer symptoms are quite varied and depend on where the cancer is
located, where it has spread, and how big the tumor is. Some cancers can be felt or
seen through the skin - a lump on the breast or testicle can be an indicator of cancer
in those locations. Skin cancer (melanoma) is often noted by a change in a wart or
mole on the skin. Some oral cancers present white patches inside the mouth or white
spots on the tongue.

27.
Other cancers have symptoms that are less physically apparent. Some brain
tumors tend to present symptoms early in the disease as they affect important
cognitive functions. Pancreas cancers are usually too small to cause symptoms until
they cause pain by pushing against nearby nerves or interfere with liver function to
cause a yellowing of the skin and eyes called jaundice. Symptoms also can be
created as a tumor grows and pushes against organs and blood vessels. For
example, colon cancers lead to symptoms such as constipation, diarrhea, and
changes in stool size. Bladder or prostate cancers cause changes in bladder function
such as more frequent or infrequent urination.
28.
As cancer cells use the body's energy and interfere with normal hormone
function, it is possible to present symptoms such as fever, fatigue, excessive
sweating, anemia, and unexplained weight loss. However, these symptoms are
common in several other maladies as well. For example, coughing and hoarseness
can point to lung or throat cancer as well as several other conditions.
29.
When cancer spreads, or metastasizes, additional symptoms can present
themselves in the newly affected area. Swollen or enlarged lymph nodes are
common and likely to be present early. If cancer spreads to the brain, patients may
experience vertigo, headaches, or seizures. Spreading to the lungs may cause
coughing and shortness of breath. In addition, the liver may become enlarged and
cause jaundice and bones can become painful, brittle, and break easily. Symptoms
of metastasis ultimately depend on the location to which the cancer has spread.
How is cancer classified?
30.

There are five broad groups that are used to classify cancer.
(a)
Carcinomas are characterized by cells that cover internal and external
parts of the body such as lung, breast, and colon cancer.
(b)
Sarcomas are characterized by cells that are located in bone, cartilage,
fat, connective tissue, muscle, and other supportive tissues.
(c)
Lymphomas are cancers that begin in the lymph nodes and immune
system tissues.
(d)
Leukemias are cancers that begin in the bone marrow and often
accumulate in the bloodstream.
(e)
Adenomas are cancers that arise in the thyroid, the pituitary gland, the
adrenal gland, and other glandular tissues.

31.
Cancers are often referred to by terms that contain a prefix related to the cell
type in which the cancer originated and a suffix such as -sarcoma, -carcinoma, or
just -oma. Common prefixes include:

(a)

Adeno- = gland.

(b)

Chondro- = cartilage.

(c)

Erythro- = red blood cell.

(d)

Hemangio- = blood vessels.

(e)

Hepato- = liver.

(f)

Lipo- = fat.

(g)

Lympho- = white blood cell.

(h)

Melano- = pigment cell.

(j)

Myelo- = bone marrow.

(k)

Myo- = muscle.

(l)

Osteo- = bone.

(m)

Uro- = bladder.

(n)

Retino- = eye.

(o)

Neuro- = brain.

How is cancer diagnosed and staged?

32.
Early detection of cancer can greatly improve the odds of successful
treatment and survival. Physicians use information from symptoms and several other
procedures to diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI
scans, PET scans, and ultrasound scans are used regularly in order to detect where
a tumor is located and what organs may be affected by it. Doctors may also conduct
an endoscopy, which is a procedure that uses a thin tube with a camera and light at
one end, to look for abnormalities inside the body.
33.
Extracting cancer cells and looking at them under a microscope is the only
absolute way to diagnose cancer. This procedure is called a biopsy. Other types of
molecular diagnostic tests are frequently employed as well. Physicians will analyze
your body's sugars, fats, proteins, and DNA at the molecular level. For example,
cancerous prostate cells release a higher level of a chemical called PSA (prostatespecific antigen) into the bloodstream that can be detected by a blood test. Molecular
diagnostics, biopsies, and imaging techniques are all used together to diagnose
cancer.

How is cancer treated?

34.
Cancer treatment depends on the type of cancer, the stage of the cancer (how
much it has spread), age, health status, and additional personal characteristics.
There is no single treatment for cancer, and patients often receive a combination of
therapies and palliative care. Treatments usually fall into one of the following
categories: surgery, radiation, chemotherapy, immunotherapy, hormone therapy, or
gene therapy.
35.
Surgery.
Surgery is the oldest known treatment for cancer. If a cancer has
not metastasized, it is possible to completely cure a patient by surgically removing
the cancer from the body. This is often seen in the removal of the prostate or a

breast or testicle. After the disease has spread, however, it is nearly impossible to
remove all of the cancer cells. Surgery may also be instrumental in helping to control
symptoms such as bowel obstruction or spinal cord compression.
36.
Radiation. Radiation treatment, also known as radiotherapy, destroys
cancer by focusing high-energy rays on the cancer cells. This causes damage to the
molecules that make up the cancer cells and leads them to commit suicide.
Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as
radium or high-energy x-rays that are created in a special machine. Early radiation
treatments caused severe side-effects because the energy beams would damage
normal, healthy tissue, but technologies have improved so that beams can be more
accurately targeted. Radiotherapy is used as a standalone treatment to shrink a
tumor or destroy cancer cells (including those associated with leukemia and
lymphoma), and it is also used in combination with other cancer treatments.
37.
Chemotherapy.
Chemotherapy utilizes chemicals that interfere with the
cell division process - damaging proteins or DNA - so that cancer cells will commit
suicide. These treatments target any rapidly dividing cells (not necessarily just
cancer cells), but normal cells usually can recover from any chemical-induced
damage while cancer cells cannot. Chemotherapy is generally used to treat cancer
that has spread or metastasized because the medicines travel throughout the entire
body. It is a necessary treatment for some forms of leukemia and lymphoma.
Chemotherapy treatment occurs in cycles so the body has time to heal between
doses. However, there are still common side effects such as hair loss, nausea,
fatigue, and vomiting. Combination therapies often include multiple types of
chemotherapy or chemotherapy combined with other treatment options.
37.
Immunotherapy. Immunotherapy aims to get the body's immune system to
fight the tumor. Local immunotherapy injects a treatment into an affected area, for
example, to cause inflammation that causes a tumor to shrink. Systemic
immunotherapy treats the whole body by administering an agent such as the protein
interferon alpha that can shrink tumors. Immunotherapy can also be considered nonspecific if it improves cancer-fighting abilities by stimulating the entire immune
system, and it can be considered targeted if the treatment specifically tells the
immune system to destroy cancer cells. These therapies are relatively young, but
researchers have had success with treatments that introduce antibodies to the body
that inhibit the growth of breast cancer cells. Bone marrow transplantation
(hematopoetic stem cell transplantation) can also be considered immunotherapy
because the donor's immune cells will often attack the tumor or cancer cells that are
present in the host.
38.
Hormone therapy.
Several cancers have been linked to some types of
hormones, most notably breast and prostate cancer. Hormone therapy is designed to
alter hormone production in the body so that cancer cells stop growing or are killed
completely. Breast cancer hormone therapies often focus on reducing estrogen
levels (a common drug for this is tamoxifen) and prostate cancer hormone therapies
often focus on reducing testosterone levels. In addition, some leukemia and
lymphoma cases can be treated with the hormone cortisone.
39.
Gene therapy.
The goal of gene therapy is to replace damaged genes
with ones that work to address a root cause of cancer: damage to DNA. For
example, researchers are trying to replace the damaged gene that signals cells to
stop dividing (the p53 gene) with a copy of a working gene. Other gene-based
therapies focus on further damaging cancer cell DNA to the point where the cell

commits suicide. Gene therapy is a very young field and has not yet resulted in any
successful treatments.

Burden caused by Cancer:India

40.
Cancer is a group of diseases with similar characteristics, which can occur in
all living cells in the body and different cancer types have different natural history.
The myth that cancer affects people mostly in the developed countries is being
broken by the fact that, of the 10 million new cancer cases seen each year
worldwide, nearly 5.5 million are in the less developed countries. Cancer is the
second most common cause of death in the developed world and a similar trend has
emerged in the developing countries too.
41.
Cancer prevalence in India is estimated to be around 2.5 million, with over
8,00,000 new cases and 5,50,000 deaths occurring each year due to this disease.
More than 70% of the cases report for diagnostic and treatment services in the
advanced stages of the disease, which has lead to a poor survival and high mortality
rate.The impact of cancer is far greater than mere numbers. Its diagnosis causes
immense emotional trauma and its treatment, a major economical burden, especially
in a developing country like India.
42.
The initial diagnosis of cancer is perceived by many patients as a grave
event, with more than one-third of them suffering from anxiety and depression.
Cancer is equally distressing for the family as well. It could greatly affect both the
familys daily functioning and economic situation. The economic shock often includes
both the loss of income and the increase of expenses because of the treatment and
health care. This disease is associated with a lot of fear and despair in the country.
Distribution of Various types Cancers across the Subcontinent
43.
Among men:- lung, esophagus, stomach, oral and pharyngeal cancers are
more prevalent.
44. In women:- cancers of cervix and breast are most common, followed by those
of stomach and esophagus.
45.

Different cancers occur in different states of our country

Esophageal cancers: Southern states of India like Karnataka and Tamil Nadu
and also in Maharashtra and Gujarat.

Stomach cancers: Southern India with the highest incidence in Chennai.

Oral cancers: Kerala (South India)

Pharyngeal cancers: Mumbai (Western India)

Thyroid cancers among women: Kerala

10

Gall bladder cancer: Northern India, particularly in Delhi and West Bengal.

Trends in Incidence of Cancer in India:

46. A trend analysis of the data on cancer incidence for the period 196496 has
demonstrated that the overall occurrence of cancer is increasing with among
females. The greatest increase among females was for cancer of the breast and
among males for cancer of the prostate. There was an increasing trend for
lymphoma, urinary bladder, gall bladder and brain tumors in both sexes. Cancer of
the colon was increasing in females and that of the kidney in males. Esophageal and
stomach cancers were decreasing in both sexes. Cervical cancer showed a
decreasing trend.

PREVENTION & CURE

Major Preventable Risk Factors For Cancers In India
47.
According to epidemiological studies, 80-90% of all cancers are due to
environmental factors of which, lifestyle related factors are the most important and
preventable. The major risk factors for cancer are tobacco, alcohol consumption,
infections, dietary habits and behavioral factors. Tobacco consumption, either by way
of chewing or smoking accounts for 50% of all cancers in men. Dietary practices,
reproductive and sexual practices account for 20-30% of cancers. Studies have
shown that appropriate changes in lifestyle will reduce the mortality and morbidity
caused to cancer. This offers the prospect for initiating primary and secondary
prevention measures for control and prevention of cancers.
48.
Tobacco.
Tobacco consumption remains the most important avoidable
cancer risk. Between 25 and 30% of all cancers in developed countries are tobaccorelated. India is the third largest producer and consumer of tobacco. The country has
a long history of tobacco use in a variety of ways of chewing and smoking. The
habits of chewing (1570%) and smoking (2377%) vary considerably from area to.
It has been estimated that in 1996, 184 million persons used tobacco in the country
in one or other. The cancer risk of tobacco use has been extensively investigated.
The principle impact of tobacco smoking is seen in higher incidence of cancers of the
lung, larynx, oesophagus, pancreas and bladder. Bidi smoking is associated with
cancer of oropharynx as well as. Tobacco-related cancers account for nearly 50% of
all cancers among men and 25% of all cancers among women. The burden of
tobacco-related cancers in India by 2001 has been estimated to be nearly 0.33
million cases annually. These estimates are based on occurrence of cancer of
mouth, pharynx, larynx, oesophagus, lung, bladder and pancreas. There are
predictions of incidence of 7-fold increase in tobacco-related cancer morbidity
between 1995 and 2025. Further there will be an overall increase by 220% of cancer
deaths simply related to tobacco use by the year 2025. Information on mortality rates
associated with tobacco use in India is available from the cohort studies which have
been carried out in the country. Applying the median risks of tobacco as obtained
from the above cohort studies and the prevalence of tobacco habit as obtained from
the first national sample survey showed that about 800,000 persons in India died due

11

to their tobacco habit in 1996. Smokeless tobacco users also have a higher risk of
mortality. In India, tobacco consumption, which is widespread, is one of the major
risk factors for cancer and assumes a very important aspect in all primary prevention
of cancer control measures. WHO has estimated the excess premature mortality
attributable to tobacco use amounting to 4 million deaths per year. According to
WHO estimates, the annual cigarette consumption per adult in developing countries
is on the rise. The WHO has estimated that 91% of oral cancer in this part is directly
attributable to tobacco usage. Even for coronary artery disease, cigarette smokers
have 70% greater mortality than non-smokers do.
49.
Alcohol.
Epidemiological studies carried out in India and abroad have
shown that increased alcohol consumption is causally associated with cancers at
various sites, mainly oral cavity, pharynx, larynx, and oesophagus. Heavy alcohol
drinkers are frequently heavy smokers as well. A synergistic effect with cigarette
smoking has been suggested. Global results from several case-control and cohort
studies indicate that excessive alcohol consumption is responsible for the incidence
of primary liver cancer. Several studies have shown an association between alcohol
consumption and an increased risk of cancers of colon, rectum and breast.

50.
Infections. There is strong evidence that majority of cervical neoplasia is
caused by certain sub types of human papillomavirus (HPV), a sexually transmitted
infection. Studies carried out in India have also confirmed the role of HPV and
cervical cancer. Besides cervical cancer, evidence indicates that sexually transmitted
virus is associated with a variety of other malignancies such as oesophageal
carcinoma, anal cancer, penile cancer and oral cancer. Other viruscancer
relationships are between EpsteinBarr virus and nasopharyngeal cancer; chronic
active infection and hepatitis B virus and primary liver cancer; Helicobacter pylori and
stomach cancer; HIV and Kaposis sarcoma and some forms of lymphoma.
51.
Diet and Cancer. Mounting scientific evidences from epidemiological,
experimental, clinical/metabolic and intervention studies in the past two decades
provide valuable information, which positively suggest role of diet in human cancers.
These studies indicate an increased intake of fat and red meat associated with a
higher risk of colorectal cancer and probably prostate cancer. High consumption of
fruits and vegetables is associated with reduced risk of several cancers including
lung, oral, pancreas, larynx, oesophagus, bladder, stomach and cervical cancers. In
recent decades, increasing attention has been paid to various foods and their
nutrients as modifiers of cancer risk. Doll and Peto have shown the percentage of
cancers directly attributable to diet to be approximately 35%. Both laboratory and
epidemiological studies support the hypothesis that some dietary components (e.g.
high fat intake) can increase the risk of cancer and that others (e.g. high dietary fibre,
vitamins C, E and A, and selenium) offer protection against cancer. Persons eating
diets high in various micronutrients have been shown to have a lower incidence of
certain cancers, especially those of breast, colon and uterus40. Dietary and
nutritional profile in India In India, the National Nutrition Monitoring Bureau (NNMB)
has been conducting diet and nutrition surveys from 10 states of India since 1972.
The nutrition scenario
Cancer Prevention Strategies

12

56.
India is one of the first few developing countries where a nation-wide cancer
control programs were launched. Government of India took its first initiative in 1971.
The National Cancer Control Program for India was formulated in 1984 with four
major goals.
1. Primary prevention of tobacco related cancer
2. Early detection of the cancers of easily accessible sites
3. Augmentation of treatment facilities
4. Establishment of equitable, pain control and palliative care network
throughout the country

National Cancer Control Programme (from 1975)INDIA

57. The Government of India launched the National Cancer Control Programme
(NCCP) in 197576 to tackle the increasing incidence of cancers in the country. This
was later revised in 198485 stressing on primary prevention and early detection of
cancers. The primary prevention focused on health education regarding hazards of
tobacco consumption, genital hygiene, and sexual and reproductive health.
Secondary prevention aims at early diagnosis of cancers of uterine cervix, breast
and oro-pharyngeal cancers by screening methods. For the purpose of detecting
cancer of cervix at an early stage, early cancer detection centres in different medical
colleges and postpartum smear testing units in medical colleges in the country
have been established. A National Cancer Control Board was constituted at the
Centre to operationalize the programme.Similar boards were suggested at the state
levels called as State Cancer Control Board (SCCB) for the proper co-ordination of
activities. Several states have formulated SCCB.
During the period 199091, a demonstration project named district cancer control
programme (DCCP) was initiated in selected districts of the country for early
detection of cervical, oral and breast cancers at the door steps of rural community.
The programme created awareness amongst people regarding early symptoms of
cancer, importance of observation of personal hygiene and healthy lifestyle, ill effects
of tobacco consumption, etc. The project has five components, viz. health education,
early detection,training of medical and para-medical personnel,palliative treatment
and pain relief and co-ordination and monitoring. The district projects are linked with
Regional Cancer Centres (RCC), medical college hospitals having infrastructure for
treatment of cancer and the appropriate institutions that supervise and monitor the
programme in collaboration with the concerned state governments.
The DCCP scheme has been further reoriented on a pilot basis as Modified District
Cancer Control Programme.The project has been implemented in the states of Bihar,
Tamil Nadu, Uttar Pradesh and West Bengal under thesupervision of the state
regional Cancer Centres. Twenty/ten rural blocks from each of the above states have
beenselected. For each block, 20 female non-communicable workers have been
appointed to advice women about healthy lifestyles, ill effects of tobacco and to
detect the early symptoms of cancers.

13

NCCP was revised in December 2004.The primary focus of the same is on

correcting the geographic imbalance in the availability of cancer care facilities across
the country. The scope of the programme and the quantum of assistance under the
various schemes have been increased in the revision.

58 Highlights of the same are

(a) 25 Regional Cancer centres : comprising 217 institutions possessing
radiotherapy installations (2004).
(b) National Strategic Task Force National Cancer Control Programme for the
Eleventh Five- Year Plan.
(c) Training: increase the capacity of the health staff at all levels of health care.
Training manuals have been developed in cancer control, tobacco cessation,
cytology and palliative care.
(d) Onconet-India: 25 RCCs are linked with each other and also each RCC is in turn
be linked to 5 peripheral centres.
(e) A proton therapy unit would be assembled and installed in the Advanced Centre
for Treatment, Research and Education in Cancer, Navi Mumbai, for clinical
application in treatment of cancer. Medical cyclotron, which is under construction,
would also be available during the Eleventh Five Year Plan period.
(f) Inter-agency projects: new insights in cancer biology identification of novel
targets and development of target based molecular medicine; Under the 11th 5year plan
59.
Though cancer per se does not feature in the United Nations 'Millennium
Development Goal' health agenda, WHO predicts that by the year 2020, almost
70% of the world's 20 million cancers patients will be in the developing nations
Approximate budget allocation under the 5 schemes of the Revised Programme:
(a)

Recognition of new Regional Cancer Centres (RCCs) by providing a onetime

grant of Rs. 5.00 crore ( existing 25).
(b) Strengthening of existing RCCs by providing a one-time grant of Rs. 3.00
crore.
(c) Development of Oncology Wing by providing enhanced grant of Rs. 3.00
crore to the Government institutions (Medical Colleges as well as government
hospitals).
(d) Development of District Cancer Control Programme by providing the grantin-aid
of Rs. 90.00 lakh spread over a period of 5 years.

14

(e) Decentralised NGO Scheme by providing a grant of Rs. 8000 per camp to
the NGOs for IEC activities.
.
60.
Primary Prevention.
The data from the National Cancer Registry
Programme showed that one third of the cancers occurring in Indian population are
related to tobacco usage and thus are preventable. The main strategy for control of
tobacco related cancers would be through primary prevention. Tobacco-related
cancers such as oral, pharyngeal and lung are mainly amenable to primary
prevention programmes. Extensive persuasive health education needs to be directed
to control/reduce the tobacco habit. Teen-aged students need to be targeted as most
of them pick up habits at this time. The school curricula should involve messages for
a healthy lifestyle and warn about the harmful effects of tobacco and alcohol.
Appropriate legislative measures need to be taken up for prohibiting sale of tobacco
to youngsters, to help in protection of the nonusers of tobacco passive smokers
and for stopping advertisements on tobacco. Though there is a ban on
advertisement of cigarettes, cigarette smoking is glamorized in various ways.
Existing rules and regulations concerning smoking in public places of entertainment
and public transport need to be rigidly enforced. In addition to the above, more
strategies are needed for control of tobacco related cancers.
(a)
There are several core strategies for a comprehensive tobacco-control
programme that have the support of the International Agency for Research on
Cancer (IARC), the WHO, and the Bureau Against Smoking Prevention and
several other international organizations interested in tobacco control. Top
priority should be given to control of tobacco; this is likely to have the greatest
impact on reducing cancer incidence and cancer mortality compared with any
other strategy currently known. Based on the recommendations for Indian
situation, the strategies which have been suggested are:
(i)

Education of public.

(ii)

Practice of tobacco control and.

(iii)

Advocacy for tobacco control.

Results of an eight-year primary prevention follow-up study of oral

cancer among Indian villagers have shown that through extensive and
persuasive health education programme, it is possible to
control/reduce the tobacco habits in the community. The tobacco
control could be achieved by government (including through
legislation) and societal actions. It has also been suggested that
in terms of tobacco control policies, appropriate health warning labels
on cigarette and bidi packets and on all tobacco products,
advertisements, warning on smokeless tobacco products, prohibition
for smoking in public places, ban on sale of tobacco products to
minors, higher taxation on bidis similar to that on cigarettes needs to
be adopted. Public education on tobacco and its health hazards, price
increase and legislative measures form the main features of primary
prevention of tobacco-related cancers. Heavy consumers of
alcohol should be advised to moderate their consumption and to stop
smoking. The impact of this advice could be in the control of cancers
of upper respiratory tract.

15

(b)
Nutrition education is important for increasing the public awareness,
promoting good health and for control of cancers. The recommended dietary
guidelines need to be propagated. Dietary intervention for cancer prevention
in terms of lowering dietary fat content, increasing intake of fibre, fruits and
vegetables is needed to control cancer and other diseases, besides avoiding
risk factors such as smoking and alcoholism and exposure to geno toxicants.
Public education and awareness about the beneficial effects of consuming
plenty of fresh vegetables and fruits with species such as turmeric in
adequate amounts to prevent cancer are required. There is a need to
popularize the following dietary guidelines for prevention of cancer.
61.

Dietary Guidelines.
(a)
It is essential to maintain appropriate weight for height, thus avoiding
both under and over-nutrition.
(b)
Physical activity needs to be promoted to avoid obesity and
accumulation of fat.
(c)
Intake of protective foods such as vegetables and fruits, preferably
fresh, need to be increased to avoid deficiency and protection against
environmental insults.
(d)
Plant foods such as cereals, pulses, roots and tubers, green leafy and
yellow vegetables, other vegetables/ fruits and spices providing nutrients, as
well as fibre and protective phytochemicals, should be preferable items in the
diet.
(e)
Animal foods (meat and fat) except fish should be curtailed. It is
necessary to avoid salted, pickled, smoked and charred food substances.
(f)

Mouldy and damaged foods should be totally eliminated from the diet.

(g)
Prospects for the primary prevention of cervical cancer are good as it is
related to certain defined risk factors involving lifestyles and behaviour
modifications. The development of invasive cervical cancer (ICC) has been
strongly linked with early onset of sexual activity and multiple sexual partners.
Epidemiological data strongly implicate sexually transmitted agents in the
aetiology of invasive cervical cancer. Raising the age at marriage beyond 18
years, observing small family size, adopting safe sexual practices, attention to
personal hygiene of both males and females and use of obstructive methods
of contraception could help towards primary prevention of ICC. In India, due to
absence of any organized mass-screening programme, primary prevention
measures assume more importance for prevention of uterine cervical cancer.
Prevention of exposure to high-risk Human Papilloma Virus (HPV) types by
prophylactic vaccination may prove to be most efficient and feasible option for
the prevention of pre-cancerous and cancerous lesions of cervix. Introduction
of vaccination against hepatitis B virus into vaccination programme of infants
would help in the control of liver cancer.
(h)
Continuing increased incidence of breast cancer has added urgency to
investigations of prevention. It is only recently that primary prevention of
human breast cancer has been discussed as a practical possibility. The

16

following are some of the possible associated actions to prevent invasive

breast cancer:
(i)

Avoidance of breast irradiation particularly in young women,

(ii)
Avoidance of cigarette smoking, active or passive, particularly in
adolescence,
(iii)

To have early first full term pregnancy,

(iv)
Delay in onset of menarche by avoiding over nutrition and by
increased physical activity in adolescence,
(v)

Prolonging the duration of lactation,

(vi)

Avoiding obesity especially in postmenopausal women,

(vii) Prophylactic mastectomy in women with history of breast cancer

in first degree relatives.
62.
Secondary Prevention. Under the secondary prevention of NCCP Cancer
Registration, early detection of cases and Treatment was focused upon.
Cancer registration was done in two parts:
(a) Hospital based registration &
(b) Population based registration

63. Population Based Cancer Registry of India: National Cancer Registry

Programme : commenced in 1981,Three Hospital based cancer registeries (HBCRs)
and three Population Based Cancer Registry (PBCRs) commenced data collection in
1982
the ICMR commenced PBCRs in four of the eight North Eastern states in 2003, and
from January 2009 in three additional states of the North East.Now 23 PBCRs as
follows are actively involved under the NCRP:Ahmedabad,Bangalore,Barshi(rural),Bhopal,Chennai,Delhi,Kolkata,Mumbai,Aizwal
Dibrugarh,Imphal,Kamrup dst, Mizoram, Mizoram(exc Aizwal distt),Sikkim and
Silchar

Primary budget allocation in NCCP

64.

Screening
(a)
Cervical Cancer Screening.
Though cytological examination has
been the mainstay for early detection of cervical cancer, its widespread use is
not possible in our country due to paucity of resources, manpower and other
facilities. Alternative strategies such as naked eye visual inspection of cervix
(down staging), visual inspection with acetic acid (VIA), magnified VIA (VIAM),
visual inspection with logos iodine (VIAL), cervicography and HPV DNA
testing in detecting cervical cancer and its precursors have to be adopted.
The findings from various research studies support the possibility of reducing

17

mortality by earlier clinical detection, followed by basic treatment. This offers a

hope for countries with limited resources.
(i)
In India, under district cancer control programme project, in
selected districts medical and paramedical staff of the district hospital
and anganwadi workers have been trained on the visual examination of
the cervix, collection of Pap smears and referring the suspected cases
to the district hospital for further evaluation. However, modified
district cancer control programme need to be extended to more states
and peripheral areas of the country.

(b)
Oral Cancer Screening. Oral cancer satisfies the criteria for
screening and oral visual inspection is a suitable test for oral cancer
screening. Several studies carried out have indicated that it is possible to train
para medical staff to perform the oral cancer-screening test as accurately as
doctors. Under the district cancer control programme the para-medical staff of
the primary health centre have been trained to conduct oral examination for
early detection and for providing health education.
(c)
Breast Cancer Screening.
The model proposed for the
control of breast cancer in the country relies mainly on physical examination
of the breast by trained female health workers in a primary health care set up
and referring the palpable lesions to district hospital/medical colleges/RCT
and TC for further evaluation. The use of fine needle aspiration cytology
would cut down the cost and disadvantage of unnecessary biopsies. Breast
self-examination could be another effort towards picking up early lesions.
Training of existing human resources and health education could be
undertaken towards this objective, which would involve minimal funds. In our
country, mammography is unlikely to be a cost effective approach to early
detection of breast cancer. It is also noted that most of the breast cancer
cases in developing countries occur in women below the age of 50 years
while the mammography has been found to be effective in postmenopausal
women. As research advances, leading to proven intervention strategies, it is
critical that knowledge about these strategies should be disseminated to the
public for improving awareness about the prevention and control measures.
CONCLUSION

18

49.
Non-communicable diseases including cancer are emerging as important
public health problems in India. The major risk factors for these diseases are
tobacco, dietary habits, inadequate physical activity, alcohol consumption and
infections due to viruses. The greatest impact to reduce the burden of cancer comes
from primary prevention. Extensive persuasive health education is needed to be
directed to control/reduce the tobacco habit. Nutrition education, safe sexual
practices, attention to personal and genital hygiene needs to be imported for
increasing public awareness. Prophylactic vaccinations against HPV infection and
hepatitis B virus are useful strategies for the prevention of cancerous lesions of
cervix and in the control of liver cancer. Further, screening for uterine cervix, oral and
breast cancers could have a significant effect on reducing mortality from cancer.

END NOTES : REFERENCES

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19

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Masters of Social Work(Sem III)

B-01: Health care social work practice
Assignment : Cancer:Epeidemology

Submitted
Submitted by
Dr.
Pragya
Maj (retd) Suman Dhaka

to
Sharma