Improving Cancer Care in India: Prospects and Challenges

The World Cancer Report, a 351 - page global report issued by International Agency for Research on Cancer ‍(IARC) tells us that cancer rates are set to increase at an alarming rate globally (Stewart and Kleiues 2003). Cancer ‍rates could increase by 50 % to 15 million new cases in the year 2020. This will be mainly due to steadily aging ‍populations in both developed and developing countries and also to current trends in smoking prevalence and the ‍growing adoption of unhealthy lifestyles. The report also reveals that cancer has emerged as a major public health ‍problem in developing countries, matching its effect in industrialized nations. Healthy lifestyles and public health ‍action by governments and health practitioners could stem this trend, and prevent as many as one third of cancers ‍worldwide. ‍In a developing country such as India there has been a steady increase in the Crude Incidence Rate (CIR) of all ‍cancers affecting both men and women over the last 15 years. The increase reported by the cancer registries is nearly ‍12 per cent from 1985 to 2001, representing a 57 per cent rise in India's cancer burden. The total number of new ‍cases, which stood at 5.3 lakhs Care lakh is 100,000 in 1985 has risen to over 8.3 lakhs today. The pattern of cancers ‍has changed over the years, with a disturbing increase in cases that are linked to the use of tobacco. In 2003, there ‍were 3.85 lakhs of cases coming under this category in comparison with 1.94 lakhs cases two decades ago. Lung ‍cancer is now the second most common cancer among men. Earlier, it was in fifth place. Among women in urban ‍areas, cancer of the uterine cervix had the highest incidence 15 years ago, but it has now been overtaken by breast ‍cancer. In rural areas, cervical cancer remains the most common form of the disease (The Hindu 2004).     

Screening and Management of PreCancerous Lesions To Prevent Cervical Cancer in Low-Resource Settings

Cervical cancer is a leading cause of cancer death among women in low-resource settings, but it is completely ‍preventable by screening for and treating precancerous lesions. In this article, the current approaches to screening, ‍confirmation, and treatment of precancerous lesions of the cervix are reviewed from the perspective of low-resource ‍settings. Cervical cytology is compared to visual inspection with acetic acid (VIA) for screening women to detect ‍precancerous lesions. The use of colposcopy to confirm findings in women with positive screening test results and ‍various treatment methods are discussed. With one examination, cytology appears to detect fewer precancerous ‍lesions than VIA, but VIA has a lower specificity and labels proportionately more women falsely positive. When ‍available, colposcopy may be used to obtain directed biopsies from abnormal areas of the cervix to pathologically ‍confirm the findings in women with positive screening tests. Treatment with cryotherapy appears to be a safe, ‍acceptable, and effective procedure for the majority of precancerous lesions. Lesions that are not suitable for ‍cryotherapy because of endocervical canal involvement or large size are amenable to outpatient treatment by loop ‍electrical excision procedure (LEEP). HIV/AIDS and immune system suppression are associated with more rapid ‍CIN progression and HIV-positive women generally have high recurrence rates of CIN after treatment. Women ‍tempora may more readily transmit the virus after cryotherapy and, therefore, they require counseling regarding ‍abstinence and condom use. Highly active antiretroviral therapy (HAART) may cause CIN to regress and may ‍decrease the risk of cervical cancer in HIV-infected women. Cost-effectiveness modeling using South African data ‍shows that use of a single lifetime VIA test and immediate cryotherapy saves costs compared to cytology or to no ‍screening. VIA and cryotherapy are appropriate services for low-resource settings. Colposcopy and LEEP services ‍should be available on a referral basis. ‍     

Cancer Screening,Reproductive History,Socioeconomic Status,and Anticipated Cancer-related Behavior among Hmong Adults

In the United States, breast, cervical, colorectal and prostate cancer screening rates are low or non-existent in the ‍Hmong population compared to non-Hispanic Whites. No Hmong adults report ever participating in prostate (male ‍only) and colorectal cancer screening. US-born Hmong women, those living in the US ≥20 years, and those ≤39 years ‍old are more likely to be screened for breast and cervical cancer than other women. The Hmong, in general, are a ‍young population (median age = 34 years) with low socioeconomic status. As a function of these characteristics, 52% ‍of Hmong women reported having their first child at 15-19 years old and continued to bear children until 40-54 ‍years old. The combination of young age at first pregnancy and multiparity probably protects Hmong women from ‍breast cancer but elevates cervical cancer risk.     

The Coverage of Cervical Cancer Screening in Khon Kaen,Northeast

Cervical cancer is a common cancer in Thai women and one of the only cancers that can be readily cured if early ‍detection is successful. The Pap smear is an accepted as an appropriate means for cervical cancer screening at ‍present. However, there are still some management problems with early detection programmes. Since data showing ‍how many women have been screened by Pap smear are limited in Thailand, the present study was conducted with ‍the aim of determining coverage in a defined population in the sample area, Thakaserm sub- district in Nampong ‍district, Khon Kaen province, Thailand. The investigation was carried out during June-August 2000 to collect ‍information on history of screening for cervical cancer using questionnaires. All women aged 20 and above were ‍asked to answer the set of questionnaires a total of 1,199 women responded. There were 66.9% that reported having ‍received a Pap smear test for screening for cervical cancer at least once. However, there were 33.1 % that had never ‍undergone a Pap smear in their life. It is important to find a strategy to increase the coverage of cervical cancer ‍screening programme for this population. ‍     

Cancer in Women in Kerala - a Transition from a Less-developed State

An epidemiologic assessment of the problem of cancer in women in Kerala based on 3 Population Cancer Registry ‍data and a Hospital Based data is presented. Kerala’s Socio-economic and demography presents an intermediate ‍development from a less developed to a better-developed state. As yet, the women follow a tradition-based life style. ‍Cancer incidence rate in Kerala was only 80% of urban rates than seen in Urban Metropolis in India. The pattern of ‍site distribution has shown that GI, Breast & Cervix cancers are the predominant cancers. Oral cavity cancers also ‍show a high frequency. Thyroid cancer has a higher incidence rate in Kerala compared to other areas. Lung cancer ‍among women has higher incidence rate in Karunagappally women. A high prevalence of tobacco use is reported ‍among the men in the above area. Breast cancer incidence rate in the rural areas was only 60% of the rate seen in ‍Urban Trivandrum. Unlike in other rural and urban areas of India Cervix cancer has a low incidence rate in Kerala ‍women. This may be due to better education and also due to the changes in marital and other life style practices. ‍Only 15% of cancer patients attend for medical assistance in localized stage of disease. The need for public education ‍is highlighted and focusing on tobacco use control, self-examination and screening.     

A Comparison of Cytology with Pap Smears Taken by a Gynecologist and with a Self-sampling Device

Cervical cancer is the most common cancer in Thai women and as yet screening programmes are minimally ‍effective. The Pap smear is the test accepted to be most appropriate for cervical cancer screening so far. One of the ‍main reasons why women do not come to have Pap smear done is “shyness”, which weakens compliance with ‍recommendations to undergo Pap smear with pelvic examination. The self-administered device by the Kato method ‍was established to overcome this problem and the present study was carried out to confirm the adequacy of the ‍specimens obtained with this technique in comparison with specimens collected by gynecologists. Two hundred ‍women were invited to participate in the study voluntarily. Each was allocated to have a Pap smear conducted by a ‍gynecologist and then instructed to produce a self-obtained smear using Kato’s device. The cytology results of Pap ‍smears from both methods were compared to test for agreement using Kappa statistics. ‍There was agreement between the adequacy of smears collected by gynecologists and those self-sampled with the ‍percentage agreement of 96.5% and a Kappa score of 0.43 (95% CI 0.33-0.54, P<0.001). There were 8 cases detected ‍as epithelial cell abnormalities from the cervical cells collected by gynecologists and also with the self-administered ‍technique. Good agreement for detection of cellular changes was found with a percentage of 78.0% and the Kappa’s ‍score was 0.61 (95% CI 0.46-0.76, P<0.001). The results from this study provide convincing evidence that the selfadministered ‍device can be an alternative choice for women who are too shy to undergo pelvic examination or even ‍for those who have limited time to visit health care centers or doctors to have a Pap smear test.     

Co-Risk Factors for HPV Infection in Northeastern Thai Women with Cervical Carcinoma

HPV infection is the main cause of cervical cancer; however, factors that promote and maintain HPV infection ‍are still unclear. This study was designed to search for factors responsible for the HPV infection in Northeastern ‍Thai women. A total of 190 volunteers with a normal histopathologic appearance of cervix as controls (n=100) and ‍with squamous cell cervical carcinoma (SCCA) (n=90) were the subjects. Variables of risk factors including sexual ‍behaviors, history of reproduction, history of sexually transmitted diseases and smoking were conducted with selfreport ‍and direct interview. Number of sexual partners and smoking history increased the likelihood of high-risk ‍HPV infection. Multiple sexual partners showed significantly higher 3.94-fold risk for HPV infection (95% CI = ‍1.82-8.82, p-value<0.001). Smoking history of partner increased the risk for HPV infection 3.03-fold (95%CI=1.42- ‍6.58, p-value< 0.002). After OR were adjusted, significant difference was still observed in the number of sexual ‍partners (p-value <0.0001) and smoking history of the partner (p-value<0.005). To decrease the incidence of cervical ‍cancer, we should prevent HPV dissemination and be on the alert for having multiple sexual partners and a partner’ ‍s smoking habit, which must be included in our public health planning.     

Evaluation of Efficacy of Self Breast Examination for Breast Cancer Prevention: a Cost Effective Screening Tool

Breast cancer is the most prevalent neoplasm among females and every year the number of associated deaths ‍increases so that there is a dire need for implementation of cancer screening and early detection. A survey conducted ‍by various locally organised cancer registries indicated breast cancer to be the most prevalent cancer among females ‍and the second most common cause of cancer deaths among Pakistani women. Since Pakistani females do not generally ‍engage in screening practices we argue that nurses and lady health workers should team up to educate women for ‍the possible early detection of cancer using Self Breast Examination as a screening tool. In this paper, we attempt to ‍evaluate the primary efficacy of self breast examination as an early and cost effective cancer screening measure, and ‍to discuss the relation of community health nurses as well as the lady health workers to education of females of low ‍income countries such as Pakistan to possibly lower the cancer burden.     

Cancer Burden and Trends in the Asian Pacific Rim Region

This paper describes the current cancer burden and time trends, discusses dominant risk factors and prevention ‍and control strategies, and makes future projections for the top eight cancers (stomach, lung, liver, colon/rectum, ‍esophagus, breast, cervix, and leukemia) in the Asian Pacific Rim region. The future cancer trends through to the ‍year 2050 are projected based on population dynamics, including population growth and ageing. In 2000, the Asian ‍Pacific Rim had over 3 million new cancer cases, over 2 million cancer deaths, and 5.4 million people living with ‍cancer. In 2050, 7.8 million new cancer cases and 5.7 million deaths from cancer are projected. The current cancer ‍burden and the future projection provide facts that cancer is and will be a very serious public health problem in the ‍Asian Pacific Rim region and will assist public health officers and cancer researchers in the design and establishment ‍of public health policies, prioritization of future research, and application of current knowledge in the prevention ‍and control of cancer. ‍     

Accuracy of Visual Inspection with Acetic Acid (VIA) for Early Detection of Cervical Dysplasia in Tehran,Iran

Objective: To evaluate the accuracy of visual inspection with 5% acetic acid (VIA) when used to detect cervical ‍cancer and its precursors. ‍Methods: The study population included women attended Family Planning and Gynecological Clinic in Bagher ‍Abad Health Center and Mirza Koochak Khan Hospital for regular cervical screening tests. After obtaining informed ‍consent from each woman, VIA was performed. One hundred with a positive VIA test and 100 women with a ‍negative VIA test were randomly selected for this study. Cytology and colposcopy examination were performed for ‍all 200 cases and cervical biopsies were conducted for those individuals showing abnormal colposcopic findings. ‍Results: Nine cases in VIA-positive group and two cases in VIA-negative group had an abnormal cytology. Ninety ‍five women in the VIA-positive group and 25 in the VIA-negative group had abnormal colposcopic findings. From ‍biopsy examination, 67 (71%) of cases in the VIA-positive group and 3 (12%) cases in the VIA-negative group had ‍a final diagnosis of dysplasia. Among biopsied samples, only 7 cases of VIA-positive group showed abnormal result ‍and the remaining were normal. Based on these results, VIA test sensitivity and specificity were 95.7% and 44.0% ‍respectively, while they were 10% and 92% for cytology tests. ‍Conclusions: The results of this study indicate that although VIA is a sensitive screening test for detection of ‍cervical dysplasia, it can not be used by itself. Applying VIA along with Pap smears helps to detect a higher number ‍of cases with cancer precursor lesions.     

Awareness of Cervical Cancer Among Female Students of Premier Colleges in Kolkata,India

In the absence of any nationwide cervical screening program, cancer of cervix remains a major public health problem for India. We here assessed knowledge levels of female college students about cervical cancer, its risk factors, the human papillomavirus (HPV) etiologic agent and Pap (Papanicolaou) smear testing for screening. We conducted a questionnaire survey of the students (N=630), aged 17 to 24 years, in Kolkata, India. Only 20% correctly identified cervix cancer as the most prevalent female cancer in India, while 43% were aware of the ages of occurrence. Though 41% thought sexual activity to be associated with cervical cancer, its risk factors, like, ‘smoking’, ‘having multiple sex partners’, ‘cervical infections’, ‘early onset of sexual intercourse’, ‘multiple parity’ were recognized by 29%, 3%, 4%, 13% and 15%, respectively. The terms ‘Pap test’ and HPV had been heard by 11% and 15 % of the students, respectively, and 75% of the students desired to have protective vaccination. Bivariate analysis revealed that educational stream, standard of the college and family size were significantly associated with knowledge levels. Additionally, multivariate regression analysis indicated city students were more knowledgeable than those from outside the city. It is imperative that women gather adequate knowledge on cervical cancer for the success of any program to control the disease. Wide and effective spreading of awareness about the disease among women must form an integral part of public health policy of government.     

Cervical Cancer: Etiology,Pathogenesis, Treatment,and Future Vaccines

Cervical cancer is a sexually transmitted disease caused by the human papillomavirus (HPV), especially HPV-16 ‍and -18. Of the half million new cases of cervical cancer reported yearly, 20% occur in India. Mass cancer screening ‍programs to detect and treat cervical cancer and its precursor lesions are not available in India and most other ‍developing countries because of the lack of resources. Curative and palliative treatments are not the same for all ‍patients with cervical cancer because the result depends on the immunological response of the patient. This article ‍describes the natural history of cervical carcinogenesis and the rational behind various modalities of prevention and ‍treatment for the practising gynecological oncologist. Prophylactic vaccines against HPV-16 and -18 and therapeutic ‍vaccines against cervical cancers should be able to overcome the logistical problems that now exist to screen, diagnose ‍and treat cervical cancer and its precursor lesions. ‍     

Cancer Screening Literature in the Period 2000-2002 : Pointers to Future Research Avenues

In order to determine which areas of cancer screening are currently receiving greatest emphasis in different ‍parts of the world a Medline search of the literature for the period 2000-2002 was performed, concentrating ‍attention on research into all aspects of efforts for early detection of tumours, with especial attention to ‍methodology, motivation (including awareness of utility in the general populace and in minority groups), and ‍intervention (professional training and general education). Focus on the skin, lung, cervix, breast, ovary + ‍endometrium, oral cavity-oesophagus, gastric, colorectal, kidney + urinary tract and prostate, demonstrated ‍large numbers of journals to be publishing papers in the field, with 10, 33, 130, 53, 24, 21, 6, 81, 12 and 58, ‍respectively, in the period investigated, the grand total being 259. The average numbers of papers/journal ‍ranged from 1.0-2.4 with only 15-35% appearing in journals with wide coverage. With the exception of oral, ‍oesophageal and gastric cancer screening, an approximately 50% contribution in all areas was made by scientists ‍in the US, followed by Europe (31% overall,) Asia (11%) then Australasia, Central and South America and ‍Africa (3%, 2% and 1%, respectively). Clear differences were evident with the organ regarding specific topics ‍receiving attention, most publications concerning the lung, ovary and urological tract dealing with detection ‍methods. With the cervix and colorectum this topic accounted for half of the papers with especial attention to ‍the relative advantages of the PAP smear, HPV testing and direct visual acetic acid (DVA) in the one, and FOBT ‍and endoscopy in the other. Another major focus was found to be minority attitudes to breast, prostate and ‍cervical screening in the US, whereas only few papers were found dealing with practical intervention, targeting ‍professionals or screenees to increase participation in screening programs. The present approach suggested a ‍number of areas requiring more attention, not least being the need for more comprehensive reviews across ‍organs to allow the general reader a better undertanding of the overall picture, and which avenues might best ‍reward exploration in the future. ‍     

Ethical Issues for Cancer Screening

In recent years medical ethics has become an undisputed part of medical studies. Many people believe that ‍modern advances in medical technology - such as the development of dialysis machines, respirators, magnetic ‍resonance imaging and genetic testing and types of cancer screenings - have created bioethical dilemmas that confront ‍physicians in the 21st century. Debates over research and screening ethics have until recently revolved around two ‍related questions: the voluntary, informed consent of subjects, and the appropriate relationship between risk and ‍benefit to subjects. ‍Every patient has a right to full and accurate information about his or her medical condition. This legal principle ‍arose primarily through court decisions concerning informed consent, but over time physicians recognized that ‍most patients prefer to learn the truth about their condition and use the information well. To screen is to search for ‍disease in the absence of symptoms or, in other words, to attempt to find disease in someone not thought to have a ‍disease. Examples of screening include routine mammography to detect breast cancer, routine pap smears to detect ‍cervical cancer, and routine Prostate Specific Antigen (PSA) testing to detect prostate cancer. Ethical principles to be ‍followed in cancer screening programmes are intended mainly to minimize unnecessary harm for the participating ‍individuals. Numerous ethical questions can be raised about the practice of screening for disease. ‍Here, we examine four leading cancer killers worldwide and we review the screening of protocols of these cancer ‍types and their possible ethics. ‍     

Prevention and Health Education : How Recent Advances in the Science and Art of Health Education have been Applied in Practical Ways within Medical and other Settings for Prevention and Public Health

The terms health education, patient education, self-care education, school health education, and health promotion ‍are distinguished from each other as follows. Health education is a subset or strategy within each of these but is the ‍primary and dominant strategy in health promotion. Health education occurs through the health care providers in ‍various settings: worksites, medical, community agencies and schools. Nurses and midwives are the most important ‍health care providers to train people for health promotion and cancer prevention. We appreciate the importance of ‍the “Fight against Cancer” movement in the primary health care centre and its health care providers who inform ‍people about cancer and its symptoms, how to find lesions and early stages, and how to avoid hazardous factors. ‍This is as process of continuous information transfer by in-service education. Primary prevention should encompass ‍all actions aimed to reducing the occurrence of cancer. In reviewing recent advances in science and how the art of ‍health education has been applied in practical ways within medical and other settings for prevention and public ‍health, we can point ot the necessity for facilities like an APOCP Training Centre as a venue for scientific courses.     

Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.     

Social and Geographic Predictors of Cancer Survival: Role of the Population-based Cancer Registry in Cancer Control

One of the objectives of a cancer registry is to provide survival information on subsections of the population that ‍have unfavorable outcomes. A cancer control strategy can be planned on the basis of such information. In the present ‍study, the data of the Songkhla Cancer Registry were analyzed to determine if social and geographic parameters ‍can be used to predict cancer survival. A total of 3423 cases identified in the population-based cancer registry of ‍Songkhla Province registered during 1990-1994, were the subjects of this study. The rest were excluded because of ‍unknown primary cancer sites. Eight leading primary cancer sites were focused on: oral cavity, pharynx, esophagus, ‍colorectum, lung, liver, breast, and cervix uteri. Predictors of survival were derived from items recorded in the ‍registry. Age, gender, extent of disease, cultural belief, life-style, and access to medical care were the predictors of ‍interest. Religion, urban environment, and distance to tertiary care centers were proxies for the last three parameters. ‍Kaplan-Meier plots, Cox regression, and log-rank tests were used for analysis of the hazard ratios. The results ‍revealed a significance of disease extent for survival from oral, colorectal, breast, and cervical cancers. Muslim ‍people had poorer survival rates than those of Buddhists for oral, breast, and cervical cancers. Women with breast ‍cancer living in distant from tertiary medical care centers had a poorer prognosis. For the non-aggressive cancers, ‍early detection and pretreatment counseling for the prevention of unnecessary incomplete treatment is recommended ‍for prolonged survival. With aggressive cancers such as lung, liver, and pharyngeal cancers, there were no significant ‍differences with these parameters investigated. Good quality of life provided by palliative care, not prolongation of ‍survival, is the ultimate goal of medical care services to such patients.     

Burden of cervical cancer in Europe: estimates for 2004.

The European Council recommends that organised cervical cancer screening be offered in all member states. In order to evaluate the impact of existing and new prevention methods, regularly updated information on the burden of cervical cancer is needed. The best estimates of mortality and incidence rates were applied to the 2004 projected population of 40 European countries using methods developed by the International Agency for Research on Cancer. Using the absolute number of cases and deaths, the standardised and cumulative rates (up to age of 74 years) were computed for individual countries, and aggregated for the 15 old (EU15) and the 10 new member states (EU10) of the European Union (EU25). For the 28 countries (25 belonging to the EU25 and three others), deaths from not otherwise specified uterine cancer were reallocated to cervix or corpus uteri cancer using age-specific rules described in GLOBOCAN 2002. The burden of cervical cancer deaths in the whole of Europe was assessed by analysing uterus cancer mortality in women aged <45 years. In 2004, approximately 31,000 women in the EU25 developed cervical cancer and almost 14,000 died from the disease. A striking contrast is noted between the 15 old and 10 new EU member states: world age-standardised incidence rates (per 10(5) women-years) of 9.5 versus 16.7; standardised mortality rates of 4.9 versus 10.7; cumulative mortality rate of 0.27% versus 0.71%. The burden was lowest in Finland (cumulative incidence and mortality rate of 0.38% and 0.12%, respectively) and highest in Lithuania (cumulative incidence and mortality of 1.64% and 0.94%, respectively). The mapping of uterine cancer mortality among women aged <45 years indicates that the burden of cervical cancer is particularly high across the whole of Eastern Europe. Cervical cancer still constitutes a considerable public health problem in Europe. The dramatic contrast between West and East European states merits particular attention from the health authorities of the countries concerned and the EU as a whole. The European Commission should maintain cervical cancer control in future action plans and increase support to the most affected member states.