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ORIGINAL ARTICLE
Year : 2014  |  Volume : 58  |  Issue : 1  |  Page : 5-10  

Breast and cervical cancer risk in India: An update


1 Scientist C, Division of Epidemiology and Biostatistics, Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, Department of Health Research, Noida, Uttar Pradesh, India
2 Assitant Statistician (Project), Division of Epidemiology and Biostatistics, Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, Department of Health Research, Noida, Uttar Pradesh, India
3 Scientist F, Division of Epidemiology and Biostatistics, Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, Department of Health Research, Noida, Uttar Pradesh, India

Date of Web Publication5-Mar-2014

Correspondence Address:
Satyanarayana Labani
Scientist F, Division of Epidemiology and Biostatistics, Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, Departmant of Health Research, I-7, Sector-39, Noida - 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.128150

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   Abstract 

Background: Breast and cervical cancers are two major cancers among Indian women. Analysis of trends would help in planning and organization of programs for control of these cancers. Objective: The objective of the following study is to compute risk of breast and cervical cancers using updated data from different cancer registries of India and study of its trends. Materials and Methods: Data on incidence rates of breast and cervical cancers were obtained from six major cancer registries of India for the years 1982-2008 and from the recently initiated cancer registries, North Eastern Registries of India with a total of 21 registries. Annual percent change in incidence and risk in terms of one in number of women likely to develop cancer was estimated for both the cancers in various registries. Results: The annual percentage change in incidence ranged from 0.46 to 2.56 and −1.14 to −3.4 for breast and cervical cancers respectively. Trends were significant for both cancers in the registries of Chennai, Bangalore, Mumbai and Delhi except Barshi and Bhopal. North East region showed decrease in risk for breast and cervical cancers whereas increasing trend was observed in Imphal (West) and for cervical cancer in Silchar. Conclusion: North Eastern region recorded decline in the incidence of breast cancer which is contrary to the observation in other registries, which showed increase in breast cancer and decline in cervical cancer incidences.

Keywords: Breast cancer, Cancer in India, Cancer incidence, Cervical cancer


How to cite this article:
Asthana S, Chauhan S, Labani S. Breast and cervical cancer risk in India: An update. Indian J Public Health 2014;58:5-10

How to cite this URL:
Asthana S, Chauhan S, Labani S. Breast and cervical cancer risk in India: An update. Indian J Public Health [serial online] 2014 [cited 2017 Jul 20];58:5-10. Available from: http://www.ijph.in/text.asp?2014/58/1/5/128150


   Introduction Top


Breast cancer is by far the most common cancer diagnosed in women in the world. Breast cancer ranks second and cervical cancer ranks seventh according to incidence of cancers in the world. [1] There was a definite decline in cervical cancer in developed countries while this is still a major cancer in developing countries. Cancers of uterine cervix and breast are the two leading cancers sites among Indian women with 13,4420 incident cases, 338,010 five yearly prevalence and 115,251 incident cases, 315,679 five yearly prevalence respectively. [2] According to National Cancer Registry Program (NCRP) recent report for the 2008, the load of breast and cervical cancers together was 23.6-38.7% of total cancers in North Eastern states while in all the other states these two cancers contributed 35.2-57.7% of the total cancers. [3] Published reports from different cancer registries in India indicate rising trends in breast cancer incidence and declining trends in cervical cancer. [4],[5],[6],[7],[8] One study [6] reported trends for 16-22 year period up to the year 2003 on cancer incidence on breast, cervix uteri, corpus uteri and ovary in India. Another study [7] reported trends in incidence of breast and cervical cancer for the period 1990-2003 for 14 year period. A recent study [8] reported trends in breast, ovarian and cervical cancer incidence for Mumbai city for a 30 year period from 1976 to 2005. NCRP periodically brings out comprehensive annual reports containing updated and revised incident data of the registries following rigorous checks. Overview of update on trends in risks of leading cancers is important for planning cancer control activities and policy decisions. The present communication presents an update on trends in risks of breast and cervical cancers among Indian women.


   Materials and Methods Top


Data on incidence rates of cervical cancer and breast cancer were obtained from NCRP reports [3] from six population based cancer registries for the years 1982-2008. NCRP brings out a comprehensive annual report containing various data summaries, such as incidence rates and mortality rates. The availability of data in different cities of the country depends on the year a particular registry came into network of NCRP and or initiation of the registry in a particular area. Data for the years 1982-2008 were available for Mumbai, Chennai and Bangalore; whereas data for Bhopal, Delhi and Barshi (rural registry) were available from the year 1988. Though Mumbai cancer registry was established in 1963, it came into NCRP network in 1982 only. For the new and recently initiated registries such as Ahmadabad, Kolkata, Aurangabad, Kollan, Nagpur, Pune, Thiruvananthapuram and North Eastern states of India the data was available for the years 2003-2008. International classification of diseases (ICD) coding used was as per ICD 10. Age-specific annual cancer incidence rates for either sex in different registries for breast and cervical cancer sites for ages in the range of 0-64 years were used for computations. The ICD codes for two sites of female breast and cervix are C50 and C53 respectively. The data from 1982 to 2008 were used for trend analysis. For assessing trends, exponential regression analysis was performed on age adjusted rates (AAR) of incidence for both breast and cervical cancer sites in various registries. Annual percent change (APC) in incidence was estimated. Cumulative risks as lifetime risk for the development of specific cancer were computed for all registries data using the following formulae. Cumulative risk = 100 × (1- exp [-cum.rate/100]) where cumulative rate = (5 × ∑ (ASpIR) × 100)/100,000 and ASpIR is age specific incidence rate. One in number of persons develop cancer is 100/cumulative risk. The cumulative risk is the probability that an individual will be diagnosed with cancer during a certain age period in the absence of any competing cause of death, assuming that the current trends prevail over the time period. [3] It is well-known that incidence rates are informative. Nevertheless, APC in incidence would give a better picture. The risk statistics based on incidence is not a replacement of incidence rate itself. The cumulative risk as one in number of persons developing cancer is an easily understandable statistics for public health messages for the respective governments and for the use by policy maker. [9]

All cancer registries from which data were obtained followed uniform data collection procedures and reliability measures. There may be variability in terms of indices of reliability since mortality incidence ratio, an important index of reliability, for the years 2001-2003 in these six registries for males ranged from 12.0% in Delhi to 78.5% in Barshi; and for females, it ranged from 9.3% in Delhi to 73.0% in Barshi. There may be variability in terms indices. Case registration based only death certificate was fewer than 10% in different registries.


   Results Top


[Table 1] shows AAR of incidences along with risk of developing breast and cervical cancers for the years 1982 or 1988 and for 2007 or 2008 for six major registries. For all the six registries in India, APCs for the breast and cervical cancers and risks as lifetime risk (0-64 years) for development of breast and cervical cancers are also presented in [Table 1]. For example, breast cancer risk in the year 1988 was minimum with one out of every 133 women in Barshi and maximum with one out of every 46 women in Delhi. Observed APCs in incidence were positive for breast cancer and negative for the cervical cancer indicating increasing and decreasing trends for the two cancers respectively. The annual percentage change in incidence for breast cancer ranged from 0.46 to 2.56 and for cervical -1.14 to -3.4. Trends were significant for both cancers in all registries except Barshi. [Table 2] shows cumulative risk and one in number of persons developing cancer in North Eastern states of India. Decrease in risk was observed for both the breast and cervical cancers. [Table 3] shows risk for breast and cervical cancer for the other new registries in the country.
Table 1: Incidence (AAR) and APC of breast and cervical cancers in old registries of India during 1982-2007/08

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Table 2: CR and possibility of one in number of persons developed cancer along with incidence rates in the age group (0-64) in North Eastern States

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Table 3: CR and possibility of one in number of persons developed cancer along with incidence rates in the age group (0-64) in other new registries of India

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   Discussion Top


The study presents updated trends of breast and cervical cancers up to the recent year of 2008 on which data is available with NCRP. The risks as one in number of women develop breast and cervical cancers are summarized for North Eastern states of India and newly initiated registries in 2004 and 2007. Cancer registries suggest that the North Eastern Region of India observed a declining risk for breast cancer, whereas the other and older registries observed upward trend in breast cancer incidence and a declining trend in cervical cancer, whereas the other recently established cancer registries Ahmadabad and Kolkata are in comparison with other major cancer registries.

Increase in risk was observed in the year 2008 with one out of 86 in Barshi to one out of 39 in Delhi. Similarly, the risk for cervical cancer for the year 1982 was one out of every 61 in Mumbai and one out of every 25 in Chennai. In the year 2008, the decrease in risk for cervical cancer was observed with one out of every 91 in Mumbai to one out of every 68 in Chennai [Table 1]. Among North Eastern states, Aizawl showed high risk for developing both the cancers with one out of every 43-58 women at the risk of developing breast cancer and one out of every 41-49 women cervical cancer. Contrary to the trends observed in general, risks of developing breast cancer was declined in Imphal West between 2003 and 2008 [Table 2]. There are differences in magnitude of cancer between Western and Eastern region of the country. For example, Ahmadabad data suggests that the women in the state were at low risk for developing cervical and breast cancers with one out of every 164 and 139 women developing the cancers respectively. In Kolkata, risk of developing breast cancer was high [Table 3] i.e., one out of every 62 women. In the registries of Ahmadabad and Kolkata incidence rates both the cancers were low when compared to rest of the registries while high incidence rate (AAR: 20.6) for breast cancer was observed in Kolkata. [3]

The study of the trends in age adjusted incidence only "period" component was taken into consideration. Study of age-specific incidence trend was not attempted in this communication. Even if age specific is considered for the trend evaluation, the cohort effects may still not be controlled. This is the limitation of this study.

Over the 30-year study period for Mumbai from 1976 to 2005, [8] the age-standardized rates significantly increased for breast cancer (APC: 1.1%), significantly decreased for cervical cancer (APC -1.8%) whereas in the present study up to the year 2008 in Mumbai, the APC for breast cancer was 1.62 and APC for cervical cancer was -1.37. This indicates further up in breast and low in cervix observed in present update. In general the trends observed from previous reports [6],[7],[8] for different duration are in agreement with present study observations.

In the initial years different registries might have suffered from quality assurance, which might have influenced the trends during the study period. This is another limitation in the present study, for possible bias in trend assessment. In spite of declining trend in cervical cancer, in terms of magnitude, it still stands as second to breast cancer in most Indian cancer registries. Various feasible screening tests are available for this cancer to detect early and prevent it. [10] Pooled analysis of the accuracy of five cervical screening tests assessed in eleven studies in Africa and India [11] showed lowest sensitivity of 57% for Pap test and higher sensitivity of 79% for visual inspection with acetic acid (VIA) for the outcomes of cervical intra-epithelial neoplasia (CIN) 2+ or CIN 3+. Visual inspection with Lugol's iodine (VILI) was found to be on average 10% more sensitive than VIA. The human papillomavirus (HPV) test by hybrid capture II assay showed sensitivity of CINII + as 62%. The current screening modalities including HPV deoxyribonucleic acid (DNA) test shows a great promise for the control of cervical cancer. Though recent information supports the use of HPV DNA technology however, until low cost HPV-DNA testing becomes more widely available for low and middle income countries, visual inspection methods, especially VIA will continue to provide a reliable and effective means for reducing the burden of cervical cancer. [12] The feasibility of HPV screening is yet to be established in low resource setting as it is likely to give rise the similar challenges related manpower as that of Pap test in implementation in low resource settings. A large sample population based randomized controlled trial conducted by World Health Organization/International Agency for Research on Cancer in India proved that with the pre-requisites of short-term training and effective quality control VIA/VILI can be used as an effective cervical cancer screening method in developing countries. [12]

On the other hand, the status of breast cancer screening is very different. The incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is increasing, the mortality rate is definitely decreasing. [13]

Though the magnitude of the breast cancer is lower in India as compared to developed countries, a significant rise was observed in the last two decades in most of the Indian registries [Table 1]. It is believed that socio-economic and life-style changes such as later childbearing and dietary changes and associated changes in menstrual patterns are responsible for rising risk of breast cancer in developing countries. [14],[15]

The absence of screening programs, which are unanimously cost-effective present further challenge in control program for these cancers. Earlier reports suggested that screening by mammography can substantially reduce breast cancer mortality in the women 50 years above. The screening approach for breast cancer is clinical breast examination (CBE), breast self-examination and mammography. The CBE has a sensitivity of 54% and specificity of 94% while mammography has a sensitivity of 83-95%. [16] A large scale mammography trial conducted in Canada showed that the CBE alone was effective in reducing morbidity when compared to combination of CBE and mammography. [17]

However, a recent Cochrane review [18] suggests more modest benefits. On assessing the effect of screening for breast cancer with mammography on mortality and morbidity by including eight eligible randomized trials with 600,000 women in the age range 39-74 years for comparing mammographic screening with no mammographic screening. Trials that had failed in randomization to produce comparable groups were excluded. The review concluded that screening reduced breast cancer mortality by 15% and that over diagnosis and over treatment was at 30% and also stated that recent observational studies showed more over diagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening. This raises doubts on efficacy of mammographic screening for the control of the disease.

Besides, in developing countries such as India, economic reasons may preclude use of mammography as a screening procedure. In May 1998, the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and CBE in the screening arm and only health education in the control arm. [19] The final results of this trial when available may provide some leads in early detection of the disease and on likely impact on cancer mortality. In the meantime educating women about the importance of Breast changes and life-style modifications through mass communication and implementation of feasible screening programs at community level for these two cancers is the immediate need.


   Conclusion Top


North Eastern region recorded decline in the incidence of breast cancer which is against the observation in other registries which showed increase in breast cancer and decline in cervical cancer incidences.

 
   References Top

1.Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://www.globocan.iarc.fr. [Last accessed on 2013 Jun 10].  Back to cited text no. 1
    
2.IARC Fact sheet. Available from: http://www.globocan.iarc.fr/factsheet.asp. [Last accessed on 2013 Jun 10].  Back to cited text no. 2
    
3.Annual Reports. 1982-2008. National Cancer Registry. New Delhi: Indian Council of Medical Research; 1985-2010. Available from: http://www.ncrpindia.org. [Last accessed on 2013 Jun 11].  Back to cited text no. 3
    
4.Murthy NS, Agarwal UK, Chaudhry K, Saxena S. A study on time trends in incidence of breast cancer - Indian scenario. Eur J Cancer Care (Engl) 2007;16:185-6.  Back to cited text no. 4
    
5.Murthy NS, Chaudhry K, Saxena S. Trends in cervical cancer incidence - Indian scenario. Eur J Cancer Prev 2005;14:513-8.  Back to cited text no. 5
    
6.Yeole BB. Trends in cancer incidence in female breast, cervix uteri, corpus uteri, and ovary in India. Asian Pac J Cancer Prev 2008;9:119-22.  Back to cited text no. 6
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7.Takiar R, Srivastav A. Time trend in breast and cervix cancer of women in India - (1990-2003). Asian Pac J Cancer Prev 2008;9:777-80.  Back to cited text no. 7
    
8.Dhillon PK, Yeole BB, Dikshit R, Kurkure AP, Bray F. Trends in breast, ovarian and cervical cancer incidence in Mumbai, India over a 30-year period, 1976-2005: An age-period-cohort analysis. Br J Cancer 2011;105:723-30.  Back to cited text no. 8
    
9.Satyanarayana L, Asthana S. Life time risk for development of ten major cancers in India and its trends over the years 1982 to 2000. Indian J Med Sci 2008;62:35-44.  Back to cited text no. 9
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10.Satyanarayana L, Asthana S. Uterine cervical cancer - Prevention and control. Curr Sci 2007;93:447.  Back to cited text no. 10
    
11.Arbyn M, Sankaranarayanan R, Muwonge R, Keita N, Dolo A, Mbalawa CG, et al. Pooled analysis of the accuracy of five cervical cancer screening tests assessed in eleven studies in Africa and India. Int J Cancer 2008;123:153-60.  Back to cited text no. 11
    
12.Sankaranarayanan R, Esmy PO, Rajkumar R, Muwonge R, Swaminathan R, Shanthakumari S, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: A cluster-randomised trial. Lancet 2007;370:398-406.  Back to cited text no. 12
    
13.Leong SP, Shen ZZ, Liu TJ, Agarwal G, Tajima T, Paik NS, et al. Is breast cancer the same disease in Asian and Western countries? World J Surg 2010;34:2308-24.  Back to cited text no. 13
    
14.Forbes JF. The incidence of breast cancer: The global burden, public health considerations. Semin Oncol 1997;24 1 Suppl 1:S1-20-S1-35.  Back to cited text no. 14
    
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16.Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? JAMA 1999;282:1270-80.  Back to cited text no. 16
    
17.Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2:13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst 2000;92:1490-9.  Back to cited text no. 17
    
18.Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013;6:CD001877.   Back to cited text no. 18
    
19.Mittra I, Mishra GA, Singh S, Aranke S, Notani P, Badwe R, 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.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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