Indian Journal of Public Health

: 2021  |  Volume : 65  |  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

Correspondence Address:
Atul Kotwal
Editorial Board Member, IJPH, Professor, Armed Forces Medical Services, Pune, Maharashtra

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 10 ];65:1-4
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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).[1] 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.[1] In India, noncommunicable diseases (NCDs) were estimated to account for 63% of all deaths, with cancer as one of the leading causes (9%).[2]

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.[3]

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.[3],[4] 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.[5],[6] 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.[4]

 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.[7],[8] 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.[9],[10] Infections such as hepatitis and human papilloma virus are responsible for up to 25% of cancer cases in LMICs.[11]

As per current evidence, 30%–50% of cancers could be prevented by avoiding known risk factors and implementing existing evidence-based preventive strategies.[10] 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.[9]

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.[12]

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.[13],[14]

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).[15],[16] 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.[17],[18] Importantly, the available literature in this area shows positive attitude toward involvement in cancer-related activities including screening if provided.[15],[19]

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.[12],[20],[21] 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.[12]

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.[22] 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.[22],[23]

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.[24],[25],[26] Thus, the screening programs can bring down the incidence of some of the common cancers in India.[27]

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%).[28] 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.[29]

 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.”[30]

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.[31]

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.


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