An Alternative Approach to Study the Changes in the Cancer Pattern of Women in India (1988-2005)

Background: The changes in the cancer pattern are often studied with the help of changes in the rank ofleading sites, changes in the Age Adjusted Rates of the sites over the time or with the help of time trends. However,these methods do not quantify the changes in relation to overall changes that occurred in the total cancer casesover the period of time. An alternative approach was therefore used to assess the changes in cancer pattern inrelation to overall changes in time and also an attempt was made to identify the most emerging new cancers inIndia. Methods: The cancer incidence data of various sites for women, over the periods 1988-90 and 2003-05 inIndia, for five urban registries namely Bangalore, Bhopal, Chennai, Delhi and Mumbai, functioning under thenetwork of National Cancer Registry Programme (ICMR), formed the sources of data for the present analysis.The changes in incidence cases by various cancer sites for women were assessed by calculating the differences inincidence cases over the two period of time. Based on the contribution of each site to total change, the ten mostleading sites were identified separately for each registry. The relative changes in the sites with time were takento identify the most emerging new cancer cases over the period of time. Results: The pooled cancer cases forwomen among five urban registries increased from 29447 cases in 1988-90 to 48472 cases in 2003-05 registeringan increased of about 63.3%. The lowest percentage of increase was observed in the registry of Chennai (41.5%)and the maximum in Bhopal (102.0%). Based on the pooled figures, the breast cancer contributed to the maximum% change (38%), followed by ovarian (8.0%), gallbladder (5.1%), corpus uteri (4.9%) and cervix uteri (4.1%).Based on the pooled data and relative changes, the emerging new cancers were corpus uteri (187%), gallbladder(162.1%) and lung cancer (136.1%). The % change by sites and the emerging new cancers varied between theregistries.     

Pattern of Reproductive Cancers in India

Background: Reproductive cancers are those that affect the human organs that are involved in producingoffspring. An attempt is made in the present communication to assess the magnitude and pattern of reproductivecancers, including their treatment modalities, in India. The cancer incidence data related to reproductive cancerscollected by five population-based urban registries, namely Bangalore, Bhopal, Chennai, Delhi and Mumbai, forthe years 2006-08 were utilized. The reproductive cancers among females constituted around 25% of the totaland around 9% among males. Among females, the three major contributors were cervix (55.5%), ovary (26.1%)and corpus uteri (12.4%). Similarly among males, the three major contributors were prostate (77.6%), penis(11.6%) and testis (10.5%). For females, the AAR of reproductive cancers varied between 30.5 in the registryof Mumbai to 37.3 in the registry of Delhi. In males, it ranged between 6.5 in the registry of Bhopal to 14.7 inthe registry of Delhi. For both males and females, the individual reproductive cancer sites showed increasingtrends with age. The leading treatment provided was: radio-therapy in combination with chemo-therapy forcancers of cervix (48.3%) and vagina (43.9%); surgery in combination with chemo-therapy (54.9%) for ovariancancer; and surgery in combination with radio-therapy for the cancers of the corpus uteri (39.8%). In males,the leading treatment provided was hormone-therapy for prostate cancer (39.6%), surgery for penile cancer(81.3%) and surgery in combination with chemo-therapy for cancer of the testis (57.6%)     

Trends in incidence of head and neck cancers in India

Information relating to cancer incidence trends forms the scientific basis for the planning and organization of prevention, diagnosis and treatment of cancer in a community. An attempt was here made to study the trends in the age adjusted incidence rates for the sites of head and neck cancers in Mumbai, Bangalore, Chennai, Delhi, Bhopal, and Barshi registry's populations. For carrying out trend analysis the gum, the floor of mouth, the mucosa of cheek, the hard and soft palate and the uvula were grouped together and assigned as cancers of mouth. The trend analysis was carried out for all sites together, tongue, mouth, hypopharynx and larynx in males and all sites together and mouth in females. Sites such as lip, hypopharynx and nasopharynx were not considered. In males, for all sites together linear regression showed no increase or decrease in age adjusted rates overall for Bangalore and Delhi registries, a significant decrease for Mumbai and Delhi registries, but a rising trend for Chennai and Bhopal registries over a period of time. In females, for all sites together no change was observed in age adjusted incidence rates for Mumbai, Chennai, Bhopal, Bangalore and Barshi registries while a decreasing trend was noted for Delhi registries over a period of time. For the specific sites, variation among registries was also apparent. The results point to local differences in sub-site specific risk factors which might be elucidated by analytical epidemiological assessment.     

Trends in cancer incidence in esophagus, stomach, colon, rectum and liver in males in India.

Time trends in cancers of the esophagus, stomach, colon, rectum and liver cancers among the male population in five Indian urban population based cancer registries (Mumbai, Bangalore, Chennai, Delhi, and Bhopal) were examined over the period of the last two decades. The model applied fits data to the logarithm of Y=ABx. This Linear Regression method showed decreasing trends in age-adjusted incidence rates for cancers of the stomach and esophagus, especially in Bjopal, and increasing trends for colon and rectum and liver, throughout the entire period of observation in most of the registries. The five cancers together constitute more than 80% of the total gastro intestinal cancers and are serious diseases in both sexes. To understand the etiology of these cancers in depth, analytic epidemiological studies should be planned in the near future on a priority basis.     

Trends in the brain cancer incidence in India

Trends in cancers of the central nervous system in both sexes in five Indian population based cancer registries (Mumbai, Chennai, Bangalore, Delhi and Bhopal) were evaluated over a period of the last two decades. For this purpose we applied a model that fits the data to a Linear Regression model. This approach revealed an increasing trend in cancers of nervous system in both sexes throughout the entire period of observation in almost all registries. As CNS cancers are increasing, analytic epidemiological studies should be planned in a near future on a priority basis to understand the etiology of these cancers in depth.     

Time Trend in Breast and Cervix Cancer of Women in India, (1990-2003)

The Indian Council of Medical Research (ICMR) started a National Cancer Registry Programme (NCRP)in the year 1982 with the main objective of generating reliable data on the magnitude and pattern of cancer inIndia. There are about 20 Population Based Cancer Registries (PBCR) which are currently functioning underthe network of NCRP. The present paper aims to provide the time trends in the incidence of breast and cervixcancer among females of India. The incidence data collected by Bangalore, Barshi, Bhopal, Chennai, Delhi andMumbai over the period 1990 to 2003 formed the sources of data. In the year 1990, cervix was the leading site ofcancer followed by breast cancer in the registries of Bangalore (23.0% vs. 15.9%), Bhopal (23.2% vs. 21.4%),Chennai (28.9% vs. 17.7%) and Delhi (21.6% vs. 20.3%), while in Mumbai breast was the leading site of cancer(24.1% vs. 16.0%). By the years 2000-3, the scenario had changed and breast had overtaken as the leading siteof cancer in all the registries except in Barshi (16.9% vs. 36.8%). The time trend analysis for these sites suggesteda significant decreasing trend in the case of cervix in Bangalore and Delhi registries, while the registries ofBhopal, Chennai and Mumbai did not show any significant changes. However, in the case of breast cancer, asignificant increasing trend was observed in Bhopal, Chennai and Delhi registries with Bangalore and Mumbairegistries demonstrating no such significant changes. Histopathologic confirmation for both malignancies wasfound to be more than 80% in these registries. It is concluded that in India the cervix cancer rates are decreasingwhile breast cancer is on the increase.     

Trends in the prostate cancer incidence in India.

Trends in prostate cancer in five population-based cancer Registries (Mumbai, Chennai, Bangalore, Delhi & Bhopal) in India were studied over a period of two decades using a model that fitting the data as the logarithm of Y=ABx which represents a Linear Regression model. This approach showed increasing trends in the age adjusted incidence rates throughout the entire period of observation for most of the registries, especially in Chennai and Bhopal and to the least extent in Mumbai. Particularly in Asia we face a future major increase in the rates of prostate cancer. Collaborative action now is a high priority to allow the preparations necessary for effective control of prostate cancer.     

Epidemiology of breast cancer in Indian women

Breast cancer has ranked number one cancer among Indian females with age adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women. Data reports from various latest national cancer registries were compared for incidence, mortality rates. The age adjusted incidence rate of carcinoma of the breast was found as high as 41 per 100,000 women for Delhi, followed by Chennai (37.9), Bangalore (34.4) and Thiruvananthapuram District (33.7). A statistically significant increase in age adjusted rate over time (1982–2014) in all the PBCRs namely Bangalore (annual percentage change: 2.84%), Barshi (1.87%), Bhopal (2.00%), Chennai (2.44%), Delhi (1.44%) and Mumbai (1.42%) was observed. Mortality‐to‐incidence ratio was found to be as high as 66 in rural registries whereas as low as 8 in urban registries. Besides this young age has been found as a major risk factor for breast cancer in Indian women. Breast cancer projection for India during time periods 2020 suggests the number to go as high as 1797900. Better health awareness and availability of breast cancer screening programmes and treatment facilities would cause a favorable and positive clinical picture in the country.     

Trends in cancer incidence in female breast, cervix uteri, corpus uteri, and ovary in India.

Trends in breast, cervix uteri, corpus uteri and ovarian cancers in six population based cancer registries (Mumbai, Bangalore, Chennai, Delhi, Bhopal, and Barshi) were evaluated over a period of the last two decades. For studying trends we used a model that fits this data is the logarithm of Y=ABx which represents a Linear Regression model. This approach showed a decreasing trend for cancer of the cervix and increasing trends for cancers of breast, ovary and corpus uteri throughout the entire period of observation in most of the registries. The four cancers, breast, cervix, corpus uteri and ovary, constitute more than 50% of total cancers in women. As all these cancers are increasing, to understand their etiology in depth, analytic epidemiology studies should be planned in a near future on a priority basis.     

A Model Approach to Calculate Cancer Prevalence From 5 Year Survival Data for Selected Cancer Sites in India

Background: Prevalence is a statistic of primary interest in public health. In the absence of good followupfacilities, it is difficult to assess the complete prevalence of cancer for a given registry area. Objective: Anattempt was here made to arrive at complete prevalence including limited duration prevalence with respect toselected sites of cancer for India by fitting appropriate models to 1, 3 and 5 years cancer survival data availablefor selected population-based registries. Materials and Methods: Survival data, available for the registries ofBhopal, Chennai, Karunagappally, and Mumbai was pooled to generate survival for breast, cervix, ovary, lung,stomach and mouth cancers. With the available data on survival for 1, 3 and 5 years, a model was fitted andthe survival curve was extended beyond 5 years (up to 35 years) for each of the selected sites. This helped ingeneration of survival proportions by single year and thereby survival of cancer cases. With the help of survivalproportions available year-wise and the incidence, prevalence figures were arrived for selected cancer sites andfor selected periods. Results: The prevalence to incidence ratio (PI ratio) stabilized after a certain duration for allthe cancer sites showing that from the knowledge of incidence, the prevalence can be calculated. The stabilizedP/I ratios for the cancer sites of breast, cervix, ovary, stomach, lung, mouth and for life time was observed tobe 4.90, 5.33, 2.75, 1.40, 1.37, 4.04 and 3.42 respectively. Conclusions: The validity of the model approach tocalculate prevalence could be demonstrated with the help of survival data of Barshi registry for cervix cancer,available for the period 1988-2006.     

Cancer survival in Bhopal, India, 1991-1995

The Bhopal population-based cancer registry was established in 1986 under the national cancer registry programme to investigate the after-effect of a gas leak in 1984. Cancer registration is done entirely by active methods. The registry is contributing data on survival for 16 cancer sites or types registered during 1991-1995. Follow-up of cases was done by active methods with median follow-up time ranging between 8-44 months for different cancers. The proportion with histologically verified diagnosis for various cancers ranged between 61-100%; death certificates only (DCOs) comprised 0-2%; 50-92% of total registered cases were included for survival analysis. The 5-year age-standardized relative survival rates for common cancers were mouth (34%), cervix (31%), breast (25%), tongue (12%), oesophagus (3%) and lung (1%). The 5-year relative survival by age group showed that survival was the highest in the youngest age group (45 years and below) for a majority of cancers. A decreasing survival with increasing clinical extent of disease was noted for most cancers studied.     

Cancer survival in China, 2003–2005: A population‐based study

Limited population‐based cancer registry data available in China until now has hampered efforts to inform cancer control policy. Following extensive efforts to improve the systematic cancer surveillance in this country, we report on the largest pooled analysis of cancer survival data in China to date. Of 21 population‐based cancer registries, data from 17 registries (n = 138,852 cancer records) were included in the final analysis. Cases were diagnosed in 2003–2005 and followed until the end of 2010. Age‐standardized relative survival was calculated using region‐specific life tables for all cancers combined and 26 individual cancers. Estimates were further stratified by sex and geographical area. The age‐standardized 5‐year relative survival for all cancers was 30.9% (95% confidence intervals : 30.6%‐31.2%). Female breast cancer had high survival (73.0%) followed by cancers of the colorectum (47.2%), stomach (27.4%), esophagus (20.9%), with lung and liver cancer having poor survival (16.1% and 10.1%), respectively. Survival for women was generally higher than for men. Survival for rural patients was about half that of their urban counterparts for all cancers combined (21.8% vs. 39.5%); the pattern was similar for individual major cancers except esophageal cancer. The poor population survival rates in China emphasize the urgent need for government policy changes and investment to improve health services. While the causes for the striking urban‐rural disparities observed are not fully understood, increasing access of health service in rural areas and providing basic health‐care to the disadvantaged populations will be essential for reducing this disparity in the future.     

A Model Approach to Calculate Cancer Prevalence from 5 Years Survival Data for Selected Cancer Sites in India – Part II

Objective: Prevalence is a statistic of primary interest in public health. In the absence of good follow-upfacilities, it is often difficult to assess the complete prevalence of cancer for a given registry area. An attemptis made to arrive at the complete prevalence including limited duration prevalence with respect of selectedsites of cancer for India by fitting appropriate models to 1, 3 and 5 year cancer survival data available forselected registries of India. Methodology: Cancer survival data, available for the registries of Bhopal, Chennai,Karunagappally, and Mumbai was pooled to generate survival for the selected cancer sites. With the availabledata on survival for 1, 3 and 5 years, a model was fitted and the survival curve was extended beyond 5 years (upto 30 years) for each of the selected sites. This helped in generation of survival proportions by single year andthereby survival of cancer cases. With the help of estimated survived cases available year wise and the incidence,the prevalence figures were arrived for selected cancer sites and for selected periods. In our previous paper, wehave dealt with the cancer sites of breast, cervix, ovary, lung, stomach and mouth (Takiar and Jayant, 2013).Results: The prevalence to incidence ratio (PI ratio) was calculated for 30 years duration for all the selectedcancer sites using the model approach showing that from the knowledge of incidence and P/I ratio, the prevalencecan be calculated. The validity of the approach was shown in our previous paper (Takiar and Jayant, 2013). TheP/I ratios for the cancer sites of lip, tongue, oral cavity, hypopharynx, oesophagus, larynx, nhl, colon, prostate,lymphoid leukemia, myeloid leukemia were observed to be 10.26, 4.15, 5.89, 2.81, 1.87, 5.43, 5.48, 5.24, 4.61,3.42 and 2.65, respectively. Conclusion: Cancer prevalence can be readily estimated with use of survival andincidence data.     

Multiple tumours in survival estimates

In international comparisons of cancer registry based survival it is common practice to restrict the analysis to first primary tumours and exclude multiple cancers. The probability of correctly detecting subsequent cancers depends on the registry’s running time, which results in different proportions of excluded patients and may lead to biased comparisons. We evaluated the impact on the age-standardised relative survival estimates of also including multiple primary tumours.Data from 2,919,023 malignant cancers from 69 European cancer registries participating in the EUROCARE-4 collaborative study were used. A total of 183,683 multiple primary tumours were found, with an overall proportion of 6.3% over all the considered cancers, ranging from 0.4% (Naples, Italy) to 12.9% (Iceland). The proportion of multiple tumours varied greatly by type of tumour, being higher for those with high incidence and long survival (breast, prostate and colon-rectum). Five-year relative survival was lower when including patients with multiple cancers. For all cancers combined the average difference was –0.4 percentage points in women and –0.7 percentage points in men, and was greater for older registries. Inclusion of multiple tumours led to lower survival in 44 out of 45 cancer sites analysed, with the greatest differences found for larynx (–1.9%), oropharynx (–1.5%), and penis (–1.3%).Including multiple primary tumours in survival estimates for international comparison is advisable because it reduces the bias due to different observation periods, age, registration quality and completeness of registration. The general effect of inclusion is to reduce survival estimates by a variable amount depending on the proportion of multiple primaries and cancer site.     

Cancer survival in Kampala, Uganda, 1993-1997

The Kampala cancer registry was established in 1954 as a population-based cancer registry, and registration of cases is done by active methods. The registry contributed data on survival for 15 cancer sites or types registered in 1993-1997. For Kaposi sarcoma, only a random sample of the total incident cases was provided for survival study. Follow-up has been carried out predominantly by active methods, with median follow-up ranging from 4-26 months. The proportion with histologically verified diagnosis for various cancers ranged between 36-83%; death certificate only (DCO) cases were negligible; 58-92% of total registered cases were included for survival analysis. Complete follow-up at five years ranged between 47-87% for different cancers. Five-year age-standardized relative survival rates for selected cancers were Kaposi sarcoma (22%), cervix (19%), oesophagus (5%), non-Hodgkin lymphoma (26%), breast (36%) and prostate (46%). None survived beyond 5 years for cancers of the stomach and lung. Five-year relative survival by age group was fluctuating with no definite pattern or trend emerging and no survivors in many age intervals.     

The burden of cervical cancer in China: synthesis of the evidence

The burden of cervical cancer in China has not been characterized in detail. We reviewed cervical cancer data from national mortality surveys and registries, and conducted a meta-analysis to estimate the prevalence of high-grade lesions (HSIL) and high-risk human papillomavirus (HR-HPV) infections in rural Shanxi Province. We found that a national survey in the 1970s estimated age-standardized cervical cancer mortality rates as ~15 and ~83/100,000 women nationally and in Xiangyuan, Shanxi; but the latest survey (2004-2005) found much lower rates of ~3 and ~7/100,000, respectively. IARC registries record age-standardized cervical cancer incidence in China as <5/100,000 (1998-2002); but the five registry sites cover <2% of the population, and the gross domestic product per capita at each of the registry sites is higher than China's average (by a factor ranging from 1.3 to 3.9). The pooled estimate of the prevalence of HSIL and HR-HPV in women aged 30-54 years in Shanxi was 3.7%(95%CI:2.7-4.8%) and 17.2%(95%CI:13.1-21.3%), respectively. Based on a feasible range informed by the incidence data for China and other unscreened populations, the predicted indicative annual number of new cervical cancer cases nationally, in the absence of any intervention, ranges from ~27,000 to 130,000 (2010) to 42,000 to 187,000 (2050). In conclusion, recent data suggest comparatively low rates of cervical cancer incidence in China, which may be partly explained by the location of registry sites in higher socioeconomic status areas. However, the evidence is consistent with considerable heterogeneity within China, with a higher disease burden in some rural areas such as Shanxi. Therefore, the lower reported rates of cervical cancer in China should be interpreted cautiously.     

Cancer Incidence Rates in Turkey in 2006: A Detailed Registry Based Estimation

Purpose: The purpose of this study is to provide a detailed report on cancer incidence in Turkey, a relativelylarge country with a population of 72 million. We present the estimates of the cancer burden in Turkey for2006, calculated using data from the eight population based cancer registries which have been set up in selectedprovinces representative of sociodemographic patterns in their regions. Methods: We calculated age specificand age adjusted incidence rates (AAIR–world standard population) for each of registries separately. Weassigned a weighting coefficient for each registry proportional to the population size of the region which theregistry represents. Results: We pooled a total of 24,428 cancers (14,581 males, 9,847 females). AAIRs per 100000 were: 210.1 in men and 129.4 in women for all cancer sites excluding non-melanoma skin cancer. The AAIRper 100 000 men was highest for lung cancer (60.3) followed by prostate (22.8), bladder (19.6), stomach (16.3)and colo-rectal (15.4) cancers. Among women the rate per 100 000 was highest for breast cancer (33.7) followedby colorectal (11.5), stomach (8.8), thyroid (8.8) and lung (7.7). The most striking findings about the cancerincidence in the provinces were the high incidence rates for stomach and esophageal cancers in Erzurum andhigh stomach cancer incidence rates in Trabzon for both sexes. Conclusions: We are thus able to present themost accurate and realistic estimations for cancer incidence in Turkey so far. Lung, prostate, bladder, stomach,colorectal, larynx cancers in men and breast, colorectal, stomach, thyroid, lung, corpus uteri cancers in womenare the leading cancers respectively. This figure shows us tobacco related cancers, lung, bladder and larynx,predominate in men. Concurrently, we analyzed the data for each province separately, giving us the opportunityto present the differences in cancer patterns among provinces. The high incidences of stomach and esophagealcancers in East and high incidence of stomach cancer in Northeast regions are remarkable.     

Projection of cancer incidence in five cities and cancer mortality in India

Background: Cancer is second largest non-communicable disease and it has a sizable contribution in the total number of deaths. It is important for the public health professionals to understand the dynamics of cancer incidence for future strategies. Therefore, this paper is attempted with the objective of projecting number of cancer incidence for five cities namely, Bangalore, Chennai, Delhi, Bhopal and Mumbai and to estimate the cancer mortality rate for all India for the year 2008. Materials and Methods: The data were used from the Indian Council of Medical Research's publication of Population-Based Cancer Registry for the year 1999-2000. The population was calculated from the Census reports of 1991 and 2001. Causes-specific mortality report by the Central Bureau of Health Intelligence was used for estimating cancer mortality for all India. The age-specific rate method is utilized to project number of cancer incidence for the cities of Bangalore, Chennai, Delhi, Bhopal and Mumbai and to estimate cancer mortality in 2000 for all India. Results and Conclusion: About 26.6% increase is expected in the registered number of cancer cases in these five cities and 52.68% increase is projected for Delhi which would mean highest number of cases in Delhi among these five cities within a span of eight years. And in Mumbai it is expected to have a marginal decline in the number of cases for the year 2008 (around -3.25%). The age adjusted analysis indicates that Mumbai is experiencing the higher incidence rate among the five cities studied herein. It is estimated about 50% cancer mortality is reported from the age group 55 and above years.     

Projection of Cancer Incident Cases for India -Till 2026

Projection of cancer incidence is essential for planning cancer control actions, health care and allocationof resources. Here we project the cancer burden at the National and State level to understand the magnitudeof cancer problem for the various calendar years from 2011 to 2026 at 5-yearly intervals. The age, sex andsite-wise cancer incidence data along with populations covered by the registries were obtained from the reportof National Cancer Registry Programme published by Indian Council of Medical Research for the period2001-2004. Pooled age sex specific cancer incidence rates were obtained by taking weighted averages of theseseventeen registries with respective registry populations as weights. The pooled incidence rates were assumedto represent the country’s incidence rates. Populations of the country according to age and sex exposed to therisk of development of cancer in different calendar years were obtained from the report of Registrar Generalof India providing population projections for the country for the years from 2001 to 2026. Population forecastswere combined with the pooled incidence rates to estimate the projected number of cancer cases by age, sexand site of cancer at various 5-yearly periods Viz. 2011, 2016, 2021 and 2026. The projections were carried outfor the various leading sites as well as for ‘all sites’ of cancer. In India, in 2011, nearly 1,193,000 new cancercases were estimated; a higher load among females (603,500) than males (589,800) was noted. It is estimatedthat the total number of new cases in males will increased from 0.589 million in 2011 to 0.934 million by theyear 2026. In females the new cases of cancer increased from 0.603 to 0.935 million. Three top most occurringcancers namely those of tobacco related cancers in both sexes, breast and cervical cancers in women accountfor over 50 to 60 percent of all cancers. When adjustments for increasing tobacco habits and increasing trendsin many cancers are made, the estimates may further increase. The leading sites of cancers in males are lung,oesophagus, larynx, mouth, tongue and in females breast and cervix uteri. The main factors contributing to highburden of cancer over the years are increase in the population size as well as increase in proportion of elderlypopulation, urbanization, and globalization. The cancer incidence results show an urgent need for strengtheningand augmenting the existing diagnostic/tr eatment facilities, which are inadequate even to tackle the present load.