|Year : 2021 | Volume
| Issue : 1 | Page : 1-4
Contribution of public health in prevention and control of cancers in India: A time to redeem ourselves
Atul Kotwal1, Arun K Yadav2
1 Editorial Board Member, IJPH, Professor, Armed Forces Medical Services, Pune, Maharashtra, India
2 Professor, AFMC, Pune, Maharashtra, India
|Date of Submission||09-Dec-2020|
|Date of Acceptance||10-Dec-2020|
|Date of Web Publication||20-Mar-2021|
Editorial Board Member, IJPH, Professor, Armed Forces Medical Services, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kotwal A, Yadav AK. Contribution of public health in prevention and control of cancers in India: A time to redeem ourselves. Indian J Public Health 2021;65:1-4
|How to cite this URL:|
Kotwal A, Yadav AK. Contribution of public health in prevention and control of cancers in India: A time to redeem ourselves. Indian J Public Health [serial online] 2021 [cited 2021 Apr 17];65:1-4. Available from: https://www.ijph.in/text.asp?2021/65/1/1/311515
| Introduction|| |
The total number of new cancer cases in the world in 2018 was 18,078,957 with a cumulative risk of 20.20% (0–74 years). Globally, cancer is second only to cardiovascular diseases in the leading causes of death, with an estimated 9.6 million (1 in 6) deaths in 2018 and 70% of these contributed by low- and middle-income countries (LMICs). In 2018, India contributed 13.2% (1,157,294) of total cancer cases of the Asian continent (8,750,9321 cases, 48.4% of world total), with more than one-third being oral, breast, and cervical cancer cases. India has the highest estimated lip and oral cavity cancer cases worldwide (119,992, 33.8%) and the second-highest number of breast (162,468, 17.8%) and cervix uteri (96,922, 30.7%) cancers in Asian sub-continent. In India, noncommunicable diseases (NCDs) were estimated to account for 63% of all deaths, with cancer as one of the leading causes (9%).
An increasing time trend of incidence at all registry sites in India, among both sexes and a high region-specific variation with risk of developing cancer during lifetime (0–74 years) as 1 in 68 males (lung cancer), 1 in 29 females (breast cancer), and 1 in 9 Indians overall, has been shown recently. The study projected 1,392,179 cancer cases in India for 2020 with cancers of the breast, lung, mouth, cervix uteri, and tongue being five most common.
Coupled with the high magnitude, most (75%–80%) of the cancer cases in India are diagnosed with an advanced disease (Stage 3–4). Locally advanced stages were seen for breast (57.0%), cervix uteri (60.0%), head and neck (66.6%), and stomach (50.8%) cancer, whereas distant metastasis was predominant among males (44.0%) and females (47.6%) for lung cancer., Low cancer awareness, late detection and diagnosis, lack of equitable, and affordable access to health-care services in LMICs, including India, lead to poorer prognosis and survival. In India, 5-year relative survival rate for oral cavity, breast, and cervical cancer cases is as low as 37.0%, 51.4%, and 46.1%, respectively., India's rural areas lack facilities to screen, diagnose, and treat and are far off from secondary and tertiary care centers and thus fare worse than their urban counterparts.
| Cancer Prevention and Control|| |
A significant number of preventable cancers are epidemiologically linked with infections, alcohol use, dietary factors, physical activity and body composition, asbestos exposure, air pollution (outdoor and indoor), and several occupational exposures., High body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use (22% deaths), and alcohol use are the five leading behavioral and dietary risk factors responsible for almost one-third of deaths from cancer., Infections such as hepatitis and human papilloma virus are responsible for up to 25% of cancer cases in LMICs.
As per current evidence, 30%–50% of cancers could be prevented by avoiding known risk factors and implementing existing evidence-based preventive strategies. In addition, early detection and appropriate management will further reduce the cancer burden, associated morbidity, mortality, and financial burden as many cancers have a high probability of cure when diagnosed early and treated adequately.
Cancer prevention and control are the complex issues requiring the effective implementation of preventive, promotive, management, and rehabilitation approaches with emphasis on early diagnosis. The activities enhancing early diagnosis include awareness and access to care, clinical evaluation, diagnosis and staging, and equitable access to affordable management. In LMICs such as India, appropriate planning, strategies, and their effective implementation can lead to remarkable results in the prevention, early diagnosis, and management with considerable benefits in terms of disease burden, mortality, and finances.
In India, the National Cancer Control Program was started in 1975–1976 and was later merged with National Program of Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke (NPCDCS) in 2008. Although the programs have achieved remarkable success in diagnostics, therapeutics, palliative care, and rehabilitation while strengthening the information management system through the cancer registries, yet they lacked any systematic, nationwide approach toward preventive, promotive, and early diagnosis/screening activities.,
Consequently, misconceptions about the risk factors, signs and symptoms, diagnosis, and treatment have always been rampant among community members as well as a large proportion of healthcare workers (HCWs)., The evaluations in two well-performing states have clearly shown vacant staff positions, inadequate staff training, low awareness generation regarding prevention, early diagnosis, and self-care and low uptake of screening., Importantly, the available literature in this area shows positive attitude toward involvement in cancer-related activities including screening if provided.,
Unlike other NCDs, there is a paucity of well-designed, large-scale community-based interventions as literature search showed only one large-scale community-based educational intervention from India and few from other countries.,, An Indian study has helped in understanding the determinants of perceptions, attitude, and practices regarding cancer in the community, which in turn helped in formulating the need-based intervention strategies. Testing the short-term outcome of community-based interventions to increase the knowledge and influence the attitudes and practices has shown to be effective.
In view of commonality among the risk factors of major NCDs, cost-effective–integrated primary prevention strategies to reduce the incidence of cancer by risk factor modification are required. India has rightfully integrated cancer prevention as part of the NCD prevention program. It will make community-based preventive strategies utilizing community based workers and health workers like Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), Community Based Organizations (CBOs) and Non Governmental Organizations (NGOs), etc., more effective and feasible.
Another important strategy linked with enhanced early diagnosis is screening, which aims to identify individuals with abnormalities, suggestive of a specific cancer or precancer who have not developed any symptoms and refer them promptly for the diagnosis and treatment. Screening programs can be effective for select cancer types when appropriate tests are used, implemented effectively, linked to other steps in the screening process and when quality is assured. In general, a screening program is a far more complex public health intervention compared to early diagnosis. Combining the program with NCDs provide the opportunity to screen cancer while screening for other risk factors such as hypertension.
Several nations such as the UK, China, and many EU nations have shown evidence supporting reduction in the burden of cancer, mainly by systematic programs, which have provided their populations with access to screening and early detection of cancer and different approaches and models of screening are available. Evidence-based–targeted interventions, including reminders to the community members and HCWs to ensure on-time screening coupled with improved follow-up, have been shown to increase cancer screening rates.,
Earlier, major reasons for nonimplementation of early diagnosis and screening component in India had been lack of and unequitable distribution of trained HCWs, nonavailability of cheap, point-of-care options, and low awareness generation. Available evidence from randomized trials in India has shown simple innovative methods such as visual inspection-based screening (for oral cavity), visual inspection with acetic acid application for cervical cancer, self-breast examination or examination by a trained HCW, as useful and cost-effective for screening these three common cancers.,, Thus, the screening programs can bring down the incidence of some of the common cancers in India.
In India, the NFHS-4 (2015–2016) collected evidence pertaining to screening for cancers at the national level for the first time and revealed extremely low rates of ever examination among women aged 15–49 years for cervix (22.3%), breast (9.8%), and oral cavity (12.4%). A detailed analysis has shown that increased uptake of cervical and breast screening is associated with higher socioeconomic status, general caste, rural area, and currently married women.
| Renewed Efforts|| |
The weak components of preventive, promotive, screening and early diagnosis, equitable access to affordable treatment activities under the NPCDCS have now been bolstered by the Ayushman Bharat, which was launched as per the recommendations of the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet sustainable development goals (SDGs 3.4; to reduce premature mortality from NCDs, including cancer by one-third by 2030) and its underlining commitment, which is to “leave no one behind.”
Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components: Health and Wellness Centers (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY). In February 2018, the Government of India (GoI) announced the creation of 150,000 HWCs by transforming the existing subcenters and primary health centers. These centers are to deliver comprehensive primary health care (CPHC) bringing healthcare closer to the homes of people. HWCs are envisaged to deliver an expanded range of services ensuring access, universality, and equity close to the community. The emphasis of health promotion and prevention will engage and empower individuals and communities to choose healthy behaviors and make changes that reduce the risk of developing NCDs. As a first step in the expanded range of services, screening, prevention, control, and management of NCDs and chronic communicable diseases such as tuberculosis and leprosy have been introduced at HWCs. This will provide a renewed opportunity for early identification and screening of common cancers with enhanced accessibility, acceptability, and affordability (including opportunity cost) for the community. An addition of new cadre of nonphysician as community health officer at subcenter would augment the public health services and improve coordination and implementation of extended services at ground level.
The other component, PM-JAY is the world's largest health insurance/assurance scheme fully financed by the government to provide a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals in India. Thus, AB has taken firm and significant steps toward UHC.
| Enhanced Role of Public Health|| |
However, even with the sincere efforts by the GoI and all states to make the HWCs fully operational in a time-bound manner, many individuals and communities might face barriers to utilizing these services or prefer private health services. In addition, shortage of trained human resource for health at different levels may adversely affect the implementation. This is where the public health specialty and teams can make a difference. Through the active involvement of the departments of Community Medicine/Preventive and Social Medicine (CM/PSM), opportunities exist to improve the services, follow-up and overall impact by capacity building, support, and linkages. Substantial improvement in control of cancer and all NCDs can be achieved through population-based approaches to enhancing the health literacy, use of screening, and referral linkages and pathways for populations with higher NCDs including cancer prevalence.
The public health specialist can get involved in any/all aspects of CPHC. In particular, PSM/CM departments of the medical colleges will have a tremendous opportunity to work collaboratively with the state/district health agencies to increase NCDs including cancer screening as more and more beneficiaries get enumerated and enrolled in HWCs. The faculty, residents, and UG students could get involved in providing a partnership role involving functional/supportive/collaborative/oversight depending upon the experience. The medical colleges could also help in data linkages and clinical registries to monitor participation, follow-up, treatment initiation, and long-term outcomes. India has undertaken a concrete step toward UHC by implementing the AB-PM-JAY and we all have an opportunity to ensure that preventive and promotive activities of NCDs including screening are widespread and equitable. An initial involvement in NCDs screening and prevention could ultimately be expanded to other initiatives and programs as the urgency has never been greater to implement better screening and treatment programs in India. Existing health cadre at subdistrict or district level may be trained in public health activities so as to give equal importance to preventive and promotive services and curative services. A dedicated public health cadre at district and subdistrict level with responsibility and accountability toward health of the community may further augment the activities for reduction of NCDs including cancers.
These are exciting times for the health sector in India, with a sincere effort by the GoI toward CPHC, referral linkages, and provision of efficient, affordable, equitable care at all levels with incremental and eventual transition to UHC. The public health specialty has a duty to ensure that our hubris and current approach get the much-needed tectonic shift toward committed and active participation at all levels, including ground level of implementation beyond research, planning, monitoring, evaluation, and leadership.
| References|| |
Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al
(on behalf of ICMR-NCDIR-NCRP Investigator Group). Cancer Statistics, 2020: Report from National Cancer Registry Programme, India. JCO Global Oncol 2020;6:1063-75.
Singh M, Prasad CP, Singh TD, Kumar L. Cancer research in India: Challenges & opportunities. Indian J Med Res 2018;148:362-5.
] [Full text]
Lucas E. In: Sankaranarayanan R, Swaminathan R, editors. Cancer Survival in Africa, Asia, the Caribbean and Central America. Lyon, France: International Agency for Research on Cancer; 2011.
Sivaram S, Majumdar G, Perin D, Nessa A, Broeders M, Lynge E, et al
. Population-based cancer screening programmes in low-income and middle-income countries: Regional consultation of the International Cancer Screening Network in India. Lancet Oncol 2018;19:e113-e122.
Ott JJ, Ullrich A, Mascarenhas M, Stevens GA. Global cancer incidence and mortality caused by behavior and infection. J Public Health (Oxf) 2011;33:223-33.
Parkin DM, Boyd L, Walker LC. 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011;105 Suppl 2:S77-81.
GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1659-724.
Plummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S. Global burden of cancers attributable to infections in 2012: A synthetic analysis. Lancet Glob Health 2016;4:e609-16.
Kotwal A, Seth T, Thakur R, Rath GK, Sharma DN, Nagpal J. Outcome of community based planned intervention targeting perceptions, attitudes and health seeking behaviour regarding cancers in New Delhi, India. Int J Community Med Public Health 2020;7:711-6.
Ministry of Health and Family Welfare. National Cancer Control Programme Guidelines. Government of India, New Delhi: Ministry of Health and Family Welfare; 2005.
National Institute of Health & Family Welfare. Report on Evaluation of Implementation Status of National Cancer Control Programme in India. New Delhi: National Institute of Health & Family Welfare; 2002.
Seth T, Kotwal A, Thakur RK, Ganguly KK. A study on community perceptions of common cancers, determinants of community behaviour and program implementation in New Delhi, India. Asian Pac J Cancer Prev 2012;13:1-4.
Seth T, Kotwal A, Thakur R, Singh P, Kochupillai V. Common cancers in India: Knowledge, attitudes and behaviours of urban slum dwellers in New Delhi. Public Health 2005;119:87-96.
Ainapure K, Sumit K, Pattanshetty SM. A study on implementation of national programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke in Udupi district, Karnataka. Int J Community Med Public Health 2018;5:2384-87.
Modi B, Jadav P, Vasoya N. Evaluation of national programme for prevention and Gandhinagar district, Gujarat. Healthline J 2019;10:33-8.
Narayana G, Suchitra MJ, Sunanda G, Ramaiah JD, Kumar BP, Veerbhadrappa KV. Knowledge, attitude and practice towards cervical cancer among women attending Obstetrics and Gynaecology department: A cross sectional hospital based study. Indian J Cancer 2017;54:481-7.
] [Full text]
Rabbania SA, Al Marzooqi AM, Srouji AE, Hamad EA, Mahtab A. Impact of community-based educational intervention on breast cancer and its screening awareness among Arab women in the United Arab Emirates. Clin Epidemiol Glob Health 2019;7:600-5.
Ali AN, Yuan FJ, Ying CH, Ahmed NZ. Effectiveness of intervention on awareness and knowledge of breast self-examination among the potentially at risk population for breast cancer. Asian Oncol Res J 2019;2:1-13.
Thomas CC, Richards TB, Plescia M, Wong FL, Ballard R, Levin TR, et al
. CDC Grand Rounds: The future of cancer screening. MMWR Morb Mortal Wkly Rep 2015;64:324-7.
Richardson LC, Royalty J, Howe W, Helsel W, Kammerer W, Benard VB. Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005. Am J Public Health 2010;100:1769-76.
Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al
. Effect of screening on oral cancer mortality in Kerala, India: A cluster-randomised controlled trial. Lancet 2005;365:1927-33.
Sankaranarayanan R, Esmy PO, Rajkumar R, 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.
Sankaranarayanan R, Ramadas K, Thara S, Muwonge R, Prabhakar J, Augustine P, et al
. Clinical breast examination: Preliminary results from a cluster randomized controlled trial in India. J Natl Cancer Inst 2011;103:1476-80.
Monica , Mishra R. An epidemiological study of cervical and breast screening in India: District-level analysis. BMC Womens Health 2020;20:225.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). Available from: https://pmjay.gov.in/
. [Last accessed on 2020 Dec 04].
Kumar S, Bothra V, Mairembam DS. A dedicated public health cadre: Urgent and critical to improve health in India. Indian J Community Med 2016;41:253-5.
] [Full text]