India has a population of 1.3 billion and has more than 2000 ethnic groups with genetically distinct ancestry and diverse lifestyles. India has seen heterogeneous economic growth over the past few decades, and because of diversity in religion, culture, diet, and socioeconomics, there are wide variations in health and disease distribution in different parts of the country. Over the past two decades, epidemiological changes have caused a decrease in communicable, maternal, neonatal, and nutritional diseases and an increase in noncommunicable diseases (NCDs).
Cancers constitute a major chunk of the NCD baggage, with an ever-increasing detection, a vastly heterogeneous population, an increasingly polluted environment, and a generally “toxic” lifestyle, posing veritable challenges. New challenges need new solutions. The advent of artificial intelligence (AI) and the recent boost to telemedicine during the COVID pandemic, promises to offer novel diagnostics, therapeutics, and surveillance means. With its strong information technology backbone, India is poised to take that leap forward into a better future, pursue national goals, and surpass global expectations with renewed vigor. Our vast populace is a treasure trove of information, and reliable data collection, through easily accessible and universally implemented cancer registries, can enable us to make informed and focused choices in our fight against cancer.
BURDEN OF CANCERS
Globally cancer and cancer deaths are rising. Cancer ranks either first or second among the leading causes of death before the age of 70 years across 91 out of the 172 countries worldwide. We are living in an aging world, and so the population living with cancers is on a steep rise.
The GLOBOCAN (Global Cancer Observatory) 2018, reported 18.1 million new cancer cases and 9.6 million deaths in the world, and by 2040, cancer incidence and mortality are expected to rise to 29.5 million and 16.3 million, respectively.
The International Agency for Research on Cancer (IARC [link is external]) estimates that globally, 1 in 5 people develop cancer during their lifetime, and 1 in 8 men and 1 in 11 women die from cancer. These new estimates suggest that more than 50 million people are living within 5 years of a past cancer diagnosis.
Breast and lung cancers are the most common cancers worldwide, contributing 12.5% and 12.2% of the total number of new cases diagnosed in 2020. Colorectal cancer is the third-most common cancer with 1.9 million new cases in 2020, contributing 10.7% of new cases.
As per the National Health Policy 2017 of India, the estimation of disability-adjusted life years (DALYs) is recommended as a key epidemiological tool to assess epidemiological transitions and study macro-level policies on the expected health-care use, evaluate the impact of prevention and control programs, allocate resources, and benchmark the progress being made in the country (DALYs for a disease or health condition are the sum of the years of life lost (YLL) to due to premature mortality YLLs and the years lived with disability (YLD) due to prevalent cases of the disease or health condition in a population). The burden of cancer can be quantified at national and subnational levels as crude incidence, mortality, YLL, YLD, and DALYs.
Among females, the five-most common contributors to cancers which are causes of cancer DALYs are the breast (232.7 per 100,000), cervix uteri (98.6 per 100,000), ovary (78.9 per 100,000), lung (74.1 per 100,000), and gallbladder (58.3 per 100,000) cancers.
There continue to be significant gaps between higher- and lower-income countries, with GLOBOCAN 2020 predicting that countries classified with “low or medium Human Development Index” will have the greatest relative increases in cancer incidence by 2040.
There is a rise of more than three times in cancer DALYs since 2004, primarily due to the growing and aging population. Further, in the study by Kulothungan et al., “Burden of cancers in India”, projections reveal an 11.4% rise in cancer DALYs from 2021 to 2025.
RISK FACTORS FOR CANCERS
Epidemiological changes such as rapid urbanization, population aging, inactive and unhealthy lifestyles, indoor and outdoor air pollution, smoking, alcohol, and physical inactivity are responsible for the emerging cancer burden across the globe but are mainly impacting the middle-to-low socioeconomic countries including India. Policies need to be designed to ensure the availability of affordable healthy food and space for physical activities, to promote healthy eating and living.
With the burden growing in almost every country, preventing cancer is a significant public health challenge. Around 40%–70% of cancer cases could be prevented by tackling risk factors relating to diet, nutrition, and physical activity. Reducing the cancer burden requires concerted and integrated action across society, including civil society, private sector, and health and other professions.
Policy changes must focus on changing the environments where people live and tackle social and health inequalities. Social determinants of health have a significant impact on who is more likely to be aware of the risk factors associated with cancer and undertake behaviors that impact cancer risk and take part in cancer screening.
India is best described as “The nations within a nation” due to heterogeneities in the epidemiological transition levels within its states.
Most of the rise in cancer incidence in India can be attributed to its epidemiologic transition and the commitment of the Government of India (GOI) to improving the use of cancer diagnostics in the country, but also as a result of the continuing pace of cancer risk factors and its determinants. Most affected would be the most populous and least affluent states where the current cancer diagnostic and treatment facilities are inadequate.
For making policies and plans at the state and national level, we need national data about cancers, and IARC (International Association of Research in Cancer) draws attention to the same fact that we need more cancer data for better planning, and that best data comes from population-based cancer registries (PBCRs) and not hospital-based cancer registries (HBCRs).
In countries with larger populations and limited resources, where we cannot have large registries we can start with smaller units, and then it is feasible and appropriate to gradually scale up high-quality subnational PBCRs to provide an increasingly representative profile of the cancer burden nationally.
Although HBCRs are of enormous value in assessing health-care services among the institution (s) they serve, the collected data are not an accurate reflection of cancer in the community. This is because HBCR data are based on patient attendance at one or more hospitals, and so the cancer profile is determined by referrals, which are based on the facilities and expertise within the institution(s).
Only one in three countries in the world provides these registries and there are 70 of these countries providing these registries and India is one of those which have PBCR and HBCR.
Cancer registration was initiated in 1961 and PBCR and HBCR expanded in 1982, through the initiation of the National Cancer Registry Program (NCRP) by the Indian Council of Medical Research. The population and HBCRs have gradually grown and now there are 38 PBCRs and 189 HBCRs in the NCRP network. As more and more hospitals go on joining these registries so this number would go on changing. https://ncdirindia.org.
PBCR collects data on all cases of cancer occurring in a well-defined population. The population is that which is resident in a particular geographical region for 1 year or more.
The main objectives of Population based cancer regisries are to produce statistics on the occurnece of cancer in a geographically defined population by collecting data about incidence, survival, mortality, and risk factors from population surveys, and mortality from vital statistics offices. Incidence and survival are critical indicators to design and measure the impact of primary prevention, early detection, screening, and cancer management.
Our challenges are our huge population and despite there being a large number of registries in India under PBCR, we are still covering a meager 10% of the population. Furthermore, there is inhomogeneity in the areas which are being covered.
However, whatever projections are made would be influenced by the future investment decisions of GOI in health care, cancer research, and public awareness of cancer risk factor reduction, other social and economic changes, and cancer notification.
ELECTRONIC HEALTH RECORD
Enhanced cancer research collaboration may yield results using electronic health records (EHRs) which may provide added advantage over the use of cancer registries alone.
EHRs collect longitudinal data related to health behaviors (e.g., body mass index and current smoking status), and preventive care services. Appropriate use of EHRs for research can facilitate the development of longitudinal studies of environmental or behavioral risk factors, or cancer outcomes after routine screening.
Registries provide detailed diagnoses, tumor characteristics, and treatment summaries, whereas EHRs contain rich clinical detail. A carefully conducted cancer registry linkage may also be used to improve the internal and external validity of inferences made from EHR-based studies. PBCRs play a vital role in formulating cancer control plans as well as in monitoring their success.
Digitalization of health care is one of the ambitious plans of GOI and is being taken care of by MOHFEW through the National Digital Health Blueprint and the National Institution for Transforming India (NITI) Aayog, and creating EHRs is one of the main agendas. Aims are to create affordable, accessible, and equitable solutions. Obstacles are funding, security of data, minimum quality of health care and data collection, minimum standards, and streamlining infrastructure barriers.
TRACKING CANCERS FROM ROOT LEVELS
It is time for strengthening primary health-care services starting from the rural primary health services and going through clinicians and various collaboration of public and private partnerships. In our country, the scope and coverage of cancer prevention and treatment services have remained in hospitals and urban settings but changed scenarios and demand is for India to build upon the ongoing approach which should be focused on “tracking the cancer, teaching the future and helping the masses” by implementing primary health-care cancer prevention and control approach.
India is poised to execute universal health care at the national level. It is imperative that cancer prevention is made an integral part of health interventions, rapidly extended to primary health-care services and facilities and linked with specialized treatment facilities. The opportunity provided by the Ayushman Bharat Programme launched in 2018 should be leveraged for rapid expansion and effective coverage of cancer prevention and treatment interventions in India.
We have a robust system of three-tiered health system consisting of primary health centers, district hospitals, and tertiary care institutions [Figure 1].
Accredited Social Health Activist (ASHA) and auxiliary nurse midwives give door-to-door services in rural areas. These can be used for education about cancers and awareness and data collection for cervical cancer and breast cancer and vaccination drive.
But preexisting programs have to be scaled up as, although cervical cancer screening pathways were introduced in the operational framework by the National Cancer Control Programme in 2005 and later modified in 2016, the fifth National Family Health survey-5 pan-India data reveals that only 1.9% of women have ever undergone cervical cancer screening.
Cervavac, the quadrivalent human papillomavirus vaccine developed by the Serum Institute of India in coordination with the Department of Biotechnology, GOI was approved for marketing in September 2022 and its lower cost would make it feasible to be included in the universal immunization program from 9 to 26 years of age.
The time is ripe to establish a well-functioning health system which focuses on cancer prevention, screening, and early detection, and it requires attention to three specific pillars which must be strengthened: cancer registries, medical and health education, and community-based screening and prevention interventions.
Behavioral and modifiable factors such as smoking, alcohol, and alterations in the diet pattern are risk factors for cancer and should be tackled on warfront.
Community-based preventive measures should be taken in all states to reduce the complications and burden of cancers. The cancer health system needs to establish better coordination mechanisms between national stakeholders, state-level stakeholders, and the public and private sectors to specifically focus on cancer prevention. Undergraduates and postgraduates should be taught cancer prevention and medical colleges should introduce courses for preventive oncology but most important is involving health workers in the education and dissemination about various cancers and risk factors.
ROLE OF ARTIFICIAL INTELLIGENCE IN CANCER SCREENING
With 1 million new cancer diagnosed every year, India has barely 2000 pathologists experienced in oncology, and <500 pathologists who could be considered expert onco-pathologists. New vistas of AI and machine learning solutions are the solution for these gaps of the availability of human resources and are a prerequisite in the successful implementation of any large-scale cancer intervention. We have AI-empowered colposcopes to help in diagnosis at the health center levels by transmission of images NITI Aayog, and the government finds an immense scope in AI to improve cancer care in India. We would be scaling up our competence and overcoming the problem of deficient trained workforce. Technology and medicine are joining hands to develop application programming interface, so that, to diagnose cervical cancer, cytological, and pathological samples can be tested with precision and speed, to reach out to masses with screening technology, help in research and teaching, and develop surgical skills.
India is well equipped to fight the menace of cancers in our women starting from prevention of modifiable risk factors, to vaccinations, making new policies for diagnostics and research, and therapeutic frameworks from basic root level to tertiary care hospitals. Technology and medicine are going to join hands together to get the best results.
Let us all be prepared for International Cancer Awareness Day.
World Cancer Day 2022–2024 – Feb 4 – Theme “Close the Care Gap.”
We have to recognize the power of working together and that every single one of us has the ability to make a difference, large or small, and that together we can make real progress in reducing the global impact of cancer.
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