Comment
Art Wolfe, Mint Images/SPL
Cancer prevention and care in India: an unfinished agenda
Published Online April 11, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70140-8 See Series page e205, e213, and e223 For GLOBOCAN see http:// globocan.iarc.fr
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With 1 million new cases and 683 000 deaths estimated in 2012 by GLOBOCAN, and 1·7 million new cases and 1·2 million deaths projected to occur in 2035, cancer is a major public health challenge in India. Breast cancer (145 000 cases per year), tobacco-related head and neck cancers (141 000), cervical cancer (123 000), lung cancer (70 000), large bowel cancer (64 000), and stomach cancer (63 000) account for more than half of the burden, implying that prevention, along with early detection and treatment, are important interventions for cancer control. The socioeconomic, service delivery, and cost and resource implications from this enormous burden require urgent attention from central and state governments, cancer communities, and public health communities to reduce their effect in a sustainable and cost-effective manner. In The Lancet Oncology, recognised leaders in cancer research in India and world experts have addressed the implications of the growing burden and changing pattern of cancer, as well as how the role of research can further clinical advances and what challenges lie ahead to deliver cost-effective cancer care. This Series1–3 provides an explicit appraisal of cancer control in India and are a valuable addition to the published work for cancer control in low-income and middle-income countries. In India, a large network of population-based cancer registries—unique in the developing world, although deficient in central and northern regions— provide valuable data to assess cancer patterns, burden, incidence trends, and population-based outcomes for cancer survival.1,4,5 The National Cancer Control Programme (1975) and subsequent National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (2010) and National Rural Health Mission (2005) have improved cancer health-care services and human resources, albeit neither are sufficient to meet the increasing burden nor are uniform across the country. Unfortunately, their overall effect on cancer awareness, clinical stage at diagnosis, and cancer survival outcomes has been poor. The substantial inequity across the country is further aggravated by the difference in response to healthcare needs by state governments, as evidenced by the disparities between northern and southern regions as discussed by Mallath and colleagues.1 At the same time the socioeconomic and geographic diversity of India
presents the cancer research community with major opportunities to investigate the causes, prevention, and treatment of the disease. Cancer diagnosis and treatment are becoming increasingly unaffordable for health-care systems in India and in many low-income and middle-income countries since it has centred on expensive diagnostic and staging investigations such as imaging, and on specialised treatments and costly drugs. Despite the improving public health-care financing that is targeted at vulnerable sections of society, out-of-pocket healthcare expenditure is still substantial and most patients do not have the means or access to basic cancer treatment, although schemes are being implemented to help.3 In this context, much importance is placed on primary prevention of tobacco-related cancers, cervical cancer induced by human papillomavirus (HPV) infection, and lifestyle-related cancers. Efforts to curtail the range of smoked and smokeless tobacco products (used by almost 275 million people in India) are crucial, although enforcement of policies on sales restriction and tobaccofree environments is weak. Ill-informed anti-HPV-vaccine campaigns and media and political frenzies have substantially undermined the prospects of introduction of HPV vaccination, which could substantially reduce morbidity, mortality, and healthcare costs in the country in which a fifth of the global cases of cervical cancer occur. In view of the challenges to introduce cervical screening programmes and given the level of development of health services in several states, introduction of HPV vaccination for girls aged 9–13 years in the national immunisation programme should be a high priority, since the individuals who cannot afford vaccination need it the most. Investment in pedestrian walkways, cycling paths, and recreational grounds in town planning to increase physical activity, and development of locally relevant dietary campaigns and consideration of appropriate legislation on foods to prevent overweight and obesity, are crucial to counter the increasing burden of breast and colorectal cancers in India. Indeed, India has opportunity to pre-empt the effect of transition to a more industrialised dietary pattern if it places priority on this area now. Population-based survival comparisons for cancer between nine Asian countries showed that India has www.thelancet.com/oncology Vol 15 May 2014
Comment
the lowest 5-year survival for most cancer sites; 5-year survival for breast cancer was 52% and for colorectal cancer was 28%, compared with 82% and 44% in China.5 The poor prospects for cancer survival indicate an underdeveloped and fragmented public healthcare system for cancer that has inadequate health-care financing and human resources and poor accessibility and quality of care.6 This fact is not surprising because public expenditure on health was 1·1% of the share of the gross domestic product in 2008–09.3 Although screening is an important intervention for cancer control, the level of development of health services and human resources in many Indian states cannot support the inputs needed and demands that arise from organised programmes of frequently repeated screening for cancers, such as those of the breast, cervix, and oral cavity. However, some states, such as those in south India that have more developed health services, have the potential to introduce visual inspection-based screening for both cervical cancer and oral cancer based on results from large randomised trials.7–9 The Government of Tamil Nadu has scaled-up cervical screening using visual inspection, covering the entire state in a phased manner since 2007 after a 25% reduction in cervical cancer incidence and 35% reduction in mortality was reported in a randomised trial done in the Dindigul district.8,10 Sikkim also introduced state-wide visual screening for cervical cancer in 2010. Building up an operational research component to monitor and evaluate these programmes will provide valuable leads to improve inputs and outcomes.2 The final results from the two ongoing trials for clinical breast examination should provide valuable insights into the appropriate population-based strategy for early detection of breast cancer in the country.11,12 A close look at the role and effect of delivery models for cancer care indicate that states with adequately developed and well-functioning regional cancer centres are much more advanced for cancer control. This fact shows the high quality of technical support provided by these centres as compared with states with no or inadequately developed centres. Investment for resources in a network of adequately developed comprehensive regional cancer centres catering to a population of 10–20 million people throughout the country is valuable to provide quality assured and optimum cancer care in India. www.thelancet.com/oncology Vol 15 May 2014
An urgent need exists to rationalise regulatory requirements to sustain and promote essential and genuine cancer research.2 Clinical and implementation research to guide the scaling-up of successful measures for cancer control should be done. The pilot programme of colorectal cancer screening in Lampang province in Thailand is a good example.13 Although important initiatives for cancer control, especially those for primary prevention, will come through the integrated programme for control of non-communicable diseases, requirements for comprehensive cancer control that are in tune with national situations and priorities (especially in the domain of early detection, treatment, and palliative care) demand more focused inputs than do those within the scope of the WHO non-communicable diseases agenda. Rengaswamy Sankaranarayanan Section of Early Detection and Prevention, International Agency for Research on Cancer, Lyon, France [email protected] I declare that I have no competing interests. 1
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Mallath MK, Taylor DG, Badwe RA, et al. The growing burden of cancer in India: epidemiology and social context. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70115-9. Sullivan R, Badwe RA, Rath GK, et al. Cancer research in India: national priorities, global results. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70109-3. Pramesh CS, Badwe RA, Borthakur BB, et al. Delivery of affordable and equitable cancer care in India. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70117-2. National Cancer Registry Programme. Time trends in cancer incidence rates 1982–2010. Bangalore: National Cancer Registry Programme, 2013. Sankaranarayanan R, Swaminathan R, Brenner H, et al. Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol 2010; 11: 165–73. Sankaranarayanan R, Ramadas K, Qiao YL. Managing the changing burden of cancer in Asia. BMC Med 2014; 12: 3. Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005; 365: 1927–33. Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a clusterrandomised trial. Lancet 2007; 370: 398–406. Shastri SS, Mittra I, Mishra GA, et al. Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India. J Natl Cancer Inst 2014; published online Feb 22. DOI:10.1093/jnci/dju009. Krishnan S, Madsen E, Porterfield D, et al. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2013; 18: 1285–97. Mittra I, Mishra GA, Singh S, et al. A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening. Int J Cancer 2010; 126: 976–84. Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast examination: preliminary results from a cluster randomized controlled trial in India. J Natl Cancer Inst 2011; 103: 1476–80. Khuhaprema T, Sangrajrang S, Lalitwongsa S, et al. Organised colorectal cancer screening in Lampang Province, Thailand: preliminary results from a pilot implementation programme. BMJ Open 2014; 4: e003671.
555
Art Wolfe, Mint Images/SPL
Cancer prevention and care in India: an unfinished agenda
Published Online April 11, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70140-8 See Series page e205, e213, and e223 For GLOBOCAN see http:// globocan.iarc.fr
554
With 1 million new cases and 683 000 deaths estimated in 2012 by GLOBOCAN, and 1·7 million new cases and 1·2 million deaths projected to occur in 2035, cancer is a major public health challenge in India. Breast cancer (145 000 cases per year), tobacco-related head and neck cancers (141 000), cervical cancer (123 000), lung cancer (70 000), large bowel cancer (64 000), and stomach cancer (63 000) account for more than half of the burden, implying that prevention, along with early detection and treatment, are important interventions for cancer control. The socioeconomic, service delivery, and cost and resource implications from this enormous burden require urgent attention from central and state governments, cancer communities, and public health communities to reduce their effect in a sustainable and cost-effective manner. In The Lancet Oncology, recognised leaders in cancer research in India and world experts have addressed the implications of the growing burden and changing pattern of cancer, as well as how the role of research can further clinical advances and what challenges lie ahead to deliver cost-effective cancer care. This Series1–3 provides an explicit appraisal of cancer control in India and are a valuable addition to the published work for cancer control in low-income and middle-income countries. In India, a large network of population-based cancer registries—unique in the developing world, although deficient in central and northern regions— provide valuable data to assess cancer patterns, burden, incidence trends, and population-based outcomes for cancer survival.1,4,5 The National Cancer Control Programme (1975) and subsequent National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (2010) and National Rural Health Mission (2005) have improved cancer health-care services and human resources, albeit neither are sufficient to meet the increasing burden nor are uniform across the country. Unfortunately, their overall effect on cancer awareness, clinical stage at diagnosis, and cancer survival outcomes has been poor. The substantial inequity across the country is further aggravated by the difference in response to healthcare needs by state governments, as evidenced by the disparities between northern and southern regions as discussed by Mallath and colleagues.1 At the same time the socioeconomic and geographic diversity of India
presents the cancer research community with major opportunities to investigate the causes, prevention, and treatment of the disease. Cancer diagnosis and treatment are becoming increasingly unaffordable for health-care systems in India and in many low-income and middle-income countries since it has centred on expensive diagnostic and staging investigations such as imaging, and on specialised treatments and costly drugs. Despite the improving public health-care financing that is targeted at vulnerable sections of society, out-of-pocket healthcare expenditure is still substantial and most patients do not have the means or access to basic cancer treatment, although schemes are being implemented to help.3 In this context, much importance is placed on primary prevention of tobacco-related cancers, cervical cancer induced by human papillomavirus (HPV) infection, and lifestyle-related cancers. Efforts to curtail the range of smoked and smokeless tobacco products (used by almost 275 million people in India) are crucial, although enforcement of policies on sales restriction and tobaccofree environments is weak. Ill-informed anti-HPV-vaccine campaigns and media and political frenzies have substantially undermined the prospects of introduction of HPV vaccination, which could substantially reduce morbidity, mortality, and healthcare costs in the country in which a fifth of the global cases of cervical cancer occur. In view of the challenges to introduce cervical screening programmes and given the level of development of health services in several states, introduction of HPV vaccination for girls aged 9–13 years in the national immunisation programme should be a high priority, since the individuals who cannot afford vaccination need it the most. Investment in pedestrian walkways, cycling paths, and recreational grounds in town planning to increase physical activity, and development of locally relevant dietary campaigns and consideration of appropriate legislation on foods to prevent overweight and obesity, are crucial to counter the increasing burden of breast and colorectal cancers in India. Indeed, India has opportunity to pre-empt the effect of transition to a more industrialised dietary pattern if it places priority on this area now. Population-based survival comparisons for cancer between nine Asian countries showed that India has www.thelancet.com/oncology Vol 15 May 2014
Comment
the lowest 5-year survival for most cancer sites; 5-year survival for breast cancer was 52% and for colorectal cancer was 28%, compared with 82% and 44% in China.5 The poor prospects for cancer survival indicate an underdeveloped and fragmented public healthcare system for cancer that has inadequate health-care financing and human resources and poor accessibility and quality of care.6 This fact is not surprising because public expenditure on health was 1·1% of the share of the gross domestic product in 2008–09.3 Although screening is an important intervention for cancer control, the level of development of health services and human resources in many Indian states cannot support the inputs needed and demands that arise from organised programmes of frequently repeated screening for cancers, such as those of the breast, cervix, and oral cavity. However, some states, such as those in south India that have more developed health services, have the potential to introduce visual inspection-based screening for both cervical cancer and oral cancer based on results from large randomised trials.7–9 The Government of Tamil Nadu has scaled-up cervical screening using visual inspection, covering the entire state in a phased manner since 2007 after a 25% reduction in cervical cancer incidence and 35% reduction in mortality was reported in a randomised trial done in the Dindigul district.8,10 Sikkim also introduced state-wide visual screening for cervical cancer in 2010. Building up an operational research component to monitor and evaluate these programmes will provide valuable leads to improve inputs and outcomes.2 The final results from the two ongoing trials for clinical breast examination should provide valuable insights into the appropriate population-based strategy for early detection of breast cancer in the country.11,12 A close look at the role and effect of delivery models for cancer care indicate that states with adequately developed and well-functioning regional cancer centres are much more advanced for cancer control. This fact shows the high quality of technical support provided by these centres as compared with states with no or inadequately developed centres. Investment for resources in a network of adequately developed comprehensive regional cancer centres catering to a population of 10–20 million people throughout the country is valuable to provide quality assured and optimum cancer care in India. www.thelancet.com/oncology Vol 15 May 2014
An urgent need exists to rationalise regulatory requirements to sustain and promote essential and genuine cancer research.2 Clinical and implementation research to guide the scaling-up of successful measures for cancer control should be done. The pilot programme of colorectal cancer screening in Lampang province in Thailand is a good example.13 Although important initiatives for cancer control, especially those for primary prevention, will come through the integrated programme for control of non-communicable diseases, requirements for comprehensive cancer control that are in tune with national situations and priorities (especially in the domain of early detection, treatment, and palliative care) demand more focused inputs than do those within the scope of the WHO non-communicable diseases agenda. Rengaswamy Sankaranarayanan Section of Early Detection and Prevention, International Agency for Research on Cancer, Lyon, France [email protected] I declare that I have no competing interests. 1
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6 7
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Mallath MK, Taylor DG, Badwe RA, et al. The growing burden of cancer in India: epidemiology and social context. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70115-9. Sullivan R, Badwe RA, Rath GK, et al. Cancer research in India: national priorities, global results. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70109-3. Pramesh CS, Badwe RA, Borthakur BB, et al. Delivery of affordable and equitable cancer care in India. Lancet Oncol 2014; published online April 11. http://dx.doi.org/10.1016/S1470-2045(14)70117-2. National Cancer Registry Programme. Time trends in cancer incidence rates 1982–2010. Bangalore: National Cancer Registry Programme, 2013. Sankaranarayanan R, Swaminathan R, Brenner H, et al. Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol 2010; 11: 165–73. Sankaranarayanan R, Ramadas K, Qiao YL. Managing the changing burden of cancer in Asia. BMC Med 2014; 12: 3. Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005; 365: 1927–33. Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a clusterrandomised trial. Lancet 2007; 370: 398–406. Shastri SS, Mittra I, Mishra GA, et al. Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India. J Natl Cancer Inst 2014; published online Feb 22. DOI:10.1093/jnci/dju009. Krishnan S, Madsen E, Porterfield D, et al. Advancing cervical cancer prevention in India: implementation science priorities. Oncologist 2013; 18: 1285–97. Mittra I, Mishra GA, Singh S, et al. A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening. Int J Cancer 2010; 126: 976–84. Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast examination: preliminary results from a cluster randomized controlled trial in India. J Natl Cancer Inst 2011; 103: 1476–80. Khuhaprema T, Sangrajrang S, Lalitwongsa S, et al. Organised colorectal cancer screening in Lampang Province, Thailand: preliminary results from a pilot implementation programme. BMJ Open 2014; 4: e003671.
555
