Cancer Is Preventable In India

World cancer day 2013 (04.02.2013)

Cancer Is Preventable In India

Dr. M.A. Aleem M.D., D.M., (Neuro)

Professsor of Neurology

KAPV Govt. Medical Collage & MGM Govt. Hospital

Trichy Tamilnadu India.

Cancer is a generic term for a large group of diseases that can affect any part of the body. Other terms used are malignant tumours and neoplasms. One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs. This process is referred to as metastasis. Metastases are the major cause of death from cancer.

Cancer is the uncontrolled growth and spread of cells. It can affect almost any part of the body. The growths often invade surrounding tissue and can metastasize to distant sites. Many cancers can be prevented by avoiding exposure to common risk factors, such as tobacco smoke. In addition, a significant proportion of cancers can be cured, by surgery, radiotherapy or chemotherapy, especially if they are detected early.

Each year on 4 February, WHO supports International Union Against Cancer to promote ways to ease the global burden of cancer.

World Cancer Day 2013 (4 February 2013) will focus on Target 5 of the World Cancer Declaration: Dispel damaging myths and misconceptions about cancer, under the tagline “Cancer - Did you know?”. World Cancer Day is a chance to raise our collective voices in the name of improving general knowledge around cancer and dismissing misconceptions about the disease. From a global level, we will be focusing our messaging on the four myths above. In addition to being in-line with our global advocacy goals, we believe these overarching myths leave a lot of flexibility for members, partners and supporters to adapt and expand on for their own needs.

Magnitude of problem

About 70% of all cancer deaths occurred in low- and middle-income countries. Deaths from cancer worldwide are projected to continue to rise to over 13.1 million in 2030.

• Cancer is a leading cause of death worldwide, accounting for 7.6 million deaths (around 13% of all deaths)
• Lung, stomach, liver, colon and breast cancer cause the most cancer deaths each year.
• The most frequent types of cancer differ between men and women.
• About 30% of cancer deaths are due to the five leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use.
• Tobacco use is the most important risk factor for cancer causing 22% of global cancer deaths and 71% of global lung cancer deaths.
• Cancer causing viral infections such as HBV/HCV and HPV are responsible for up to 20% of cancer deaths in low- and middle-income countries.
• About 70% of all cancer deaths in 2008 occurred in low- and middle-income countries.
• Deaths from cancer worldwide are projected to continue rising, with an estimated 13.1 million deaths in 2030
  In India

• Cancer is the second biggest cause of death in India, growing at 11 per cent annually. There are 2.5 million cancer cases and four lakh deaths a  year in India. In 1991, six lakh new cancer cases were diagnosed; that figure has now risen to eight lakh. Smoking one to seven cigarettes daily doubles the cancer risk. One in five Indian men dies between age 30 and 69 due to tobacco-related cancers.

• Cancer is one of the leading causes of adult deaths worldwide. In India, the International Agency for Research on Cancer estimated indirectly that about 63,5 000 people died from cancer in 2008, representing about 8% of all estimated global cancer deaths and about 6 % o f all deaths in India.
  
• In India, with more than 70 % of fatal cancers occurring during the productive ages of 30 – 6 9 years

• In our country cancer deaths were generally similar between rural and urban

areas and about twice as high in the least versus the most educated.

• One in 22 men or women aged 30 years alive today in rural India is likely to die of cancer before 70 years of age based on the rates of actual deaths and in the absence of other disorders; in urban areas, the risks are one in 20 for men and one in 24 for women.

• Cervical cancer is the leading cause of cancer death in women in both rural and urban areas. The cervical cancer death rate of 16 per 100 000 reported which suggests that a 30-year old Indian woman has about 0·7 % risk of dying from cervical cancer before 70 years of age in the absence of other diseases.
  
• Cervical cancer risks were much lower in Muslim women and in states where the proportion of Muslims was larger, as noted internationally. Circumcision Among Muslim m en, which reduces the sexual transmission of human papillomavirus, is a likely explanation
  
• In women, breast cancer mortality was similar in rural and urban India. Breast cancer is likely to be diagnosed at earlier stages in urban women than in rural women and is therefore more treatable.
  
• Stomach cancer was about twice as common in our country
  
• Rates of cancer deaths in India are about 40% lower in adult men and 30 % lower in women than in men and women in the USA or UK
  
• In India cancer death rates are expected to rise, particularly with increases in age-specific exposure to tobacco smoking. Many cancer deaths before 70 years of age are avoidable, most not ably through prevention of cervical, liver, and tobacco-related cancers, and with early diagnosis of oral, cervical, and breast cancers that enables effective treatment in India.

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In India Cervical, stomach and breast cancers accounted for 41% of cancer deaths in women in rural and urban areas. Thus, interventions such as tobacco control, human papillomavirus (HPV) vaccination, cervical cancer screening alongside early detection and treatment of oral and breast cancer can have a substantial impact in India in averting future cancer deaths.

In Tamil Nadu

In Tamil Nadu, the total cancer burden is predicted to increase by 32% by 2012-16 compared with 2002-06, with 19% due to changes in cancer risk and a further 13% due to the impact of demographic changes. The incidence of cervical cancer is projected to drop by 46% in 2015 compared with current levels, while a 100% increase in future thyroid cancer incidence is predicted. Among men, a 21% decline in the incidence of oesophageal cancer by 2016 contrasts with the 42% predicted increase in prostate cancer. The annual cancer burden predicted for 2012-16 is translating to 55,000 new cases per year in Tamil Nadu. Breast cancer would dislodge cervical cancer as the top-ranking cancer in the state, while lung, stomach and large bowel cancers would surpass cervical cancer in ranking in Metros by 2016.

In order to tackle the predicted increases in cancer burden in Tamil Nadu our chief minister Jayalalithaa has created various investigation and treatment facilities across the state including management facilities for cancer patients, under the Tamil Nadu chief minster comprehensive health insurance scheme in the state.

What causes cancer?

Cancer arises from one single cell. The transformation from a normal cell into a tumour cell is a multistage process, typically a progression from a pre-cancerous lesion to malignant tumours. These changes are the result of the interaction between a person's genetic factors and three categories of external agents, including:

• physical carcinogens, such as ultraviolet and ionizing radiation;
• chemical carcinogens, such as asbestos, components of tobacco smoke, aflatoxin (a food contaminant) and arsenic (a drinking water contaminant); and
• biological carcinogens, such as infections from certain viruses, bacteria or parasites.

WHO, through its cancer research agency, International Agency for Research on Cancer (IARC), maintains a classification of cancer causing agents.

Ageing is another fundamental factor for the development of cancer. The incidence of cancer rises dramatically with age, most likely due to a build up of risks for specific cancers that increase with age. The overall risk accumulation is combined with the tendency for cellular repair mechanisms to be less effective as a person grows older.

Risk factors for cancers

Tobacco use, alcohol use, unhealthy diet and physical inactivity are the main cancer risk factors worldwide. Chronic infections from hepatitis B (HBV), hepatitis C virus (HCV) and some types of Human Papilloma Virus (HPV) are leading risk factors for cancer in low- and middle-income countries. Cervical cancer, which is caused by HPV, is a leading cause of cancer death among women in low-income countries.

How can the burden of cancer be reduced?

Knowledge about the causes of cancer, and interventions to prevent and manage the disease is extensive. Cancer can be reduced and controlled by implementing evidence-based strategies for cancer prevention, early detection of cancer and management of patients with cancer. Many cancers have a high chance of cure if detected early and treated adequately.

Modifying and avoiding risk factors

More than 30% of cancer deaths could be prevented by modifying or avoiding key risk factors, including:

• tobacco use
• being overweight or obese
• unhealthy diet with low fruit and vegetable intake
• lack of physical activity
• alcohol use
• sexually transmitted HPV-infection
• urban air pollution
• indoor smoke from household use of solid fuels.

Tobacco use is the single most important risk factor for cancer causing 22% of global cancer deaths and 71% of global lung cancer deaths. In many low-income countries, up to 20% of cancer deaths are due to infection by HBV and HPV.

Prevention strategies

• Increase avoidance of the risk factors listed above.
• Vaccinate against human papilloma virus (HPV) and hepatitis B virus (HBV).
• Control occupational hazards.
• Reduce exposure to sunlight.

Early detection

Cancer mortality can be reduced if cases are detected and treated early. There are two components of early detection efforts:

Early diagnosis

The awareness of early signs and symptoms (for cancer types such as cervical, breast colorectal and oral) in order to get them diagnosed and treated early before the disease becomes advanced. Early diagnosis programmes are particularly relevant in low-resource settings where the majority of patients are diagnosed in very late stages and where there is no screening.

Screening

Screening is defined as the systematic application of a test in an asymptomatic population. It aims to identify individuals with abnormalities suggestive of a specific cancer or pre-cancer and refer them promptly for diagnosis and treatment. Screening programmes are especially effective for frequent cancer types for which a cost-effective, affordable, acceptable and accessible screening test is available to the majority of the population at risk.

Examples of screening methods are:

• visual inspection with acetic acid (VIA) for cervical cancer in low-resource settings;
• PAP test for cervical cancer in middle- and high-income settings;
• mammography screening for breast cancer in high-income settings.

Treatment

Cancer treatment requires a careful selection of one or more intervention, such as surgery, radiotherapy, and chemotherapy. The goal is to cure the disease or considerably prolong life while improving the patient's quality of life. Cancer diagnosis and treatment is complemented by psychological support.

Treatment of early detectable cancers

Some of the most common cancer types, such as breast cancer, cervical cancer, oral cancer and colorectal cancer have higher cure rates when detected early and treated according to best practices.

Treatment of other cancers with potential for cure

Some cancer types, even though disseminated, such as leukemias and lymphomas in children, and testicular seminoma, have high cure rates if appropriate treatment is provided.

Palliative care

Palliative care is treatment to relieve, rather than cure, symptoms caused by cancer. Palliative care can help people live more comfortably; it is an urgent humanitarian need for people worldwide with cancer and other chronic fatal diseases. It is particularly needed in places with a high proportion of patients in advanced stages where there is little chance of cure.

Relief from physical, psychosocial and spiritual problems can be achieved in over 90% of advanced cancer patients through palliative care.

Palliative care strategies

Effective public health strategies, comprising of community- and home-based care are essential to provide pain relief and palliative care for patients and their families in low-resource settings.

Improved access to oral morphine is mandatory for the treatment of moderate to severe cancer pain, suffered by over 80% of cancer patients in terminal phase.

Cancer Myths

World Cancer Day is a chance to raise our collective voices in the name of improving general knowledge around cancer and dismissing misconceptions about the disease. From a global level, we will be focusing our messaging on four myths.

Myth 1 - Cancer is just a health issue

Truth: Cancer is not just a health issue. It has wide-reaching social, economic, development, and human rights implications.

CANCER AND DEVELOPMENT

Cancer constitutes a major challenge to development, undermining social and economic advances throughout the world.

Evidence

• Approximately 47% of cancer cases and 55% of cancer deaths occur in less developed regions of the world. 
• The situation is predicted to get worse: by 2030, if current trends continue, cancer cases will increase by 81% in developing countries. 
• Today, the impact of cancer on individuals, communities and populations threatens to prevent the achievement of the Millennium Development Goals (MDGs) by 2015. 
• Cancer is both a cause and an outcome of poverty. Cancer negatively impacts families’ ability to earn an income, with high treatment costs pushing them further into poverty. At the same time, poverty, lack of access to education and healthcare increases a person’s risk of getting cancer and dying from the disease. 
• Cancer is threatening further improvements in women’s health and gender equality. Just two cancers, cervical and breast, together account for over 750,000 deaths each year with the large majority of deaths occurring in developing countries.

Cancer prevention and control interventions must be included in the newset of global development goals for the post-2015 agenda.

Broadening the future global development goals to include proven, economically sound interventions that span the entire cancer control and care continuumcan strengthen health systems, and increase capacity to respond to all health challenges faced by individuals, families and communities.

CANCER AND HEALTH POLICY

An approach including all areas of government (not just health ministries) is necessary for the effective prevention and control of cancer.

Evidence

• Most premature deaths from cancer are preventable by making policy changes in sectors in and beyond health such as education, finance, development, transport, agriculture, etc.
• A ‘whole-of-society’ approach that includes civil society (e.g. NGOs), academia, private sector, people living with and affected by cancer, and others, is just as important to support cancer prevention and control.

INVESTING IN CANCER

Investing in prevention and early detection of cancer is cheaper than dealing with the consequences.

Evidence

• The cost of cancer is estimated to reach USD 458 billion per year in 2030, yet cost effective strategies to address the common cancer risk factors (such as tobacco use, alcohol abuse, unhealthy diet and physical inactivity) would cost only USD 2 billion per year.
• Whilst non-communicable diseases (NCDs) account for 65% of annual deaths globally, less than 3% (USD 503 million out of USD 22 billion) of overall development assistance for health was allocated to the issue in 2007, compared to approximately 40% allocated to HIV/AIDS.

Myth 2 - Cancer is a disease of the wealthy, elderly and developed countries

Truth: Cancer is a global epidemic. It affects all ages and socio-economic groups, with developing countries bearing a disproportionate burden.

CANCER IN DEVELOPING COUNTRIES

Cancer is a global issue and becoming an increasing public health problem in poorer countries.

Evidence

• Cancer now accounts for more deaths worldwide than HIV/AIDS, tuberculosis and malaria combined. Of the 7.6 million global deaths from cancer in 2008, more than 55% occurred in less developed regions of the world. By 2030, 60-70% of the estimated 21.4 million new cancer cases per year are predicted to occur in developing countries.
• Cervical cancer is just one example of the disproportionate burden borne in the developing world. Over 85% of the 275,000 women who die every year from cervical cancer are from developing countries. If left unchecked, by 2030 cervical cancer will kill as many as 430,000 women per year, virtually all in these countries.
• There are massive inequities in access to pain relief with more than 99%of untreated and painful deaths occurring in developing countries. In 2009, more than 90% of the global consumption of opioid analgesics was in Australia, Canada, New Zealand, the US and some European countries; with less than 10% of global quantities used by the other 80% of the world’s population.
  CANCER VS INFECTIOUS DISEASES

Many developing countries are now facing a growing double burden of infectious diseases and non-communicable diseases (NCDs), including cancer.

Evidence

• Whilst some question the appropriateness and necessity of cancer interventions in countries facing high burdens of infectious diseases including HIV/AIDS, the distinction between infectious diseases and NCDs is in fact narrowing with HIV/AIDS moving in many cases from an acute, fatal disease to a chronic illness, and many cancers of high incidence in developing countries having been caused by chronic infections.
• NCDs including cancer, and infectious diseases, should not be seenas competing priorities but instead as global health issues that disproportionately affect developing countries. They require an integrated approach that builds capacity in national health systems to protect individuals across the spectrum of diseases.

CANCER AND AGEING POPULATIONS

Cancer not only affects the elderly, but young men and women, often in their prime working years, particularly in the developing world.

Evidence

• Approximately 50% of cancer in developing countries occurs in individuals less than 65 years of age. This is a tragedy for families and for populations, and has the potential to have a long-term impact on economic development.
• Most of the 750,000 cervical and breast cancer deaths per year occur during a woman’s reproductive years.
• Cancer is also a disease of young people. For children aged 5-14, cancer is a leading cause of death in many countries. However, mortality is only part of the picture, with cancer-related illness and disability limiting opportunities for education, and ultimately impeding full participation in the workforce. Parents and caregivers of children may also be severely impacted by the significant costs of treatment, pushing families further into poverty.

CANCER AND WEALTH

The impact of cancer on all populations is devastating but especially so for poor, vulnerable and socially disadvantaged people who get sicker and die sooner as a result of cancer.

Evidence

• Demographic differences correlate highly with common cancer risk factors e.g. poor nutrition, tobacco use, physical inactivity and alcohol.
• Inequities in access to cancer services are also associated with socioeconomic status, with poor and vulnerable populations unable to afford expensive cancer medicines and treatments which must often be paid by patients out-of-pocket, as well as experiencing other obstacles to access such as distance to quality treatment facilities.
  Myth 3 - Cancer is a death sentence

Truth: Many cancers that were once considered a death sentence can now be cured and for many more people, their cancer can be treated effectively. 

ADVANCES IN CANCER PREVENTION AND TREATMENT

Advances in understanding risk and prevention, early detection and treatment have revolutionised the management of cancer leading to improved outcomes for patients.

Evidence

• With few exceptions, early stage cancers are less lethal and more treatable than late stage cancers.
• In the United States alone, there are 12 million Americans living with cancer today.
• In countries with more than a decade of experience with organised breast cancer screening programmes, the reduction in mortality from breast cancer is significant, with for example, Australia’s mammographic screening programme established in 1991, integral to achieving an almost 30% reduction in mortality from breast cancer over the last two decades.
• Cervical cancer rates in wealthier nations plummeted once Pap testing was introduced broadly - and rates continue to lower, with recent figures showing that in some countries such as the UK, mortality has halved between 1990 and 2010.

ACCESS TO CANCER SERVICES

Sadly, access to comprehensive cancer services, including access to essential medicines, is largely restricted to wealthy countries and individuals.

Evidence

• Globally, closing the gap in cancer outcomes between rich and poor countries is an equity imperative.
• We know it is possible; there are proven examples of low resource settings providing effective cancer services that span the spectrum of cancer control and care from prevention through to palliation, dispelling the myth that this approach is only feasible in high resource settings.

DELIVERY OF CANCER SERVICES IN ALL RESOURCE SETTINGS

Increasing public and political awareness that solutions exist and can be implemented and integrated in all resource settings is essential to achieving equity in cancer prevention and care.

Evidence

• It is a common misconception that cancer solutions are too complex and expensive for developing countries.
• The cost of interventions does not have to be prohibitively expensive. A recent report estimates that most of the off-patent generic cancer medicines required for developing countries are available for less than $US 100 per course of treatment, and nearly all for under $US 1000. For life-saving vaccines, such as the human papillomavirus (HPV) vaccine, progress towards affordable pricing is being driven by the GAVI Alliance, with GAVI recently opening a window of support for eligible countries for the introduction of the HPV vaccine at either the national level or as a demonstration project.

Myth 4 - Cancer is my fate

Truth: With the right strategies, a third of the most common cancers can be prevented.

CANCER PREVENTION

Prevention is the most cost-effective and sustainable way of reducing the global cancer burden in the long-term.

Evidence

• Global, regional and national policies and programmes that promote healthy lifestyles can substantially reduce cancers that are caused by risk factors such as alcohol, unhealthy diet and physical inactivity. Improving diet, physical activity and maintaining a healthy body weight could prevent around a third of the most common cancers.
• Based on current trends, tobacco use is estimated to kill one billion people in the 21st century. Addressing tobacco use, which is linked to 71% of all lung cancer deaths, and accounts for at least 22% of all cancer deaths is therefore critical.
• For developing countries, the situation often goes beyond addressing behavioural change, with many countries facing a ‘double burden’ of exposures, the most common of which is cancer-causing infections. Chronic infections are estimated to cause approximately 16% of all cancers globally, with this figure rising to almost 23% in developing countries. Several of the most common cancers in developing countries such as liver, cervical and stomach cancers are associated with infections with hepatitis B virus (HBV), the human papillomavirus (HPV), and the bacterium Helicobacter pylori (H. pylori), respectively. As a consequence, the introduction of safe, effective and affordable vaccines should be implemented as part of national cancer control plans.
• Exposure to a wide range of environmental causes of cancer in our personal and professional lives, including exposure to indoor air pollution, radiation and excessive sunlight are also major preventable causes of cancer

CANCER KNOWLEDGE

Lack of information and awareness about cancer is a critical obstacle to effective cancer control and care in developing countries, especially for the detection of cancers at earlier and more treatable stages.

Evidence

• In many developing countries, misconceptions about diagnosis and treatment and stigma associated with cancer can lead individuals to seek alternative care in place of standard treatment or to avoid care altogether. Understanding and responding to cultural beliefs and practices is essential.
• Although general cancer awareness in developing countries remains low, even among health professionals, levels of concern about cancer are high, and the public pays attention to messaging about the disease.
• Individuals, policy makers and healthcare professionals need to understand that many cancers can be prevented through appropriate lifestyle change, that cancer can often be cured, and that effective treatments are available, regardless of the resource setting.
• Recent experience with screening and vaccination programmes in developing countries suggests that once people understand basic information about cancer and know how to access services they tend to come for the services. Equally important is the development of strategies to encourage help seeking behaviour, including awareness and education of ways to recognise the signs and symptoms, and understanding that timely evaluation will increase the opportunities for cure.

CANCER OUTCOMES

Disparities in cancer outcomes exist between the developed and developing world for most cancers.

Evidence

• Patients whose cancers are curable in the developed world unnecessarily suffer and die due to a lack of awareness, resources and access to affordable, effective and quality cancer services that enable early diagnosis and appropriate treatment and care.
• The reality of cancer cure rates in children is reflective of the inexcusable inequities in global access to treatment and care. There are an estimated 160,000 newly diagnosed cases of childhood cancer worldwide each year with more than 70% of the world’s children with cancer lacking access to effective treatment. The result is an unacceptably low survival rate of ~10% in developing countries compared to ~90% in high-income countries.
• In many cases the largest and most unacceptable gap in cancer care is the lack of adequate palliative care and access to pain relief for much of the world’s population. A short list of medications can control pain for almost 90% of all people with cancer pain including children, yet millions of cancer patients have little to no access to adequate pain treatment.

World Cancer Declaration

Through the targets outline in the World Cancer Declaration our aim by 2020 is to have:

• effective cancer control programmes
• reduced risk factors such as tobacco use, alcohol consumption and obestity 
• universal vaccination programmes
• a better informed public
• improved diagnosis methods
• universally available pain control
• improved training for medical staff
• better survival rates for cancer patients

To reach these targets we will take action to:

• place cancer on the political agenda
• improve cancer prevention and early detection
• enhance access to and treatment for cancer patients