5 decades of cancer control in india - v. shanta part i

8/11/2019 5 Decades of Cancer Control in India - V. Shanta Part I

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5 DECADES OF

CANCER CONTROL

19552005

Dr.(Mrs.) S. Muthulakshmi Reddy

1886-1968

Cancer Institute (WIA),

Chennai, India


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CANCER IN INDIA

Historical

1895 Balram Jaker : Trivandrum

1905 Niblock : Govt. General Hospital, Madras

Related association of Tobacco habit & Oral cancer

1933-37 Viswanath & Grewal

Edward Medical College, Lahore

First field study of Cancer in India

Documented common cancers then,

as of now, Mouth, GI Tract, Cervix, Penis


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CANCER TREATMENT FACILITIES

1941 Tata Memorial Hospital at Mumbai

1950s Chittaranjan Cancer Hospital, Calcutta

1954 Cancer Institute(WIA), Chennai

All non governmental efforts

Radiotherapy departments of General Hospitals

with only High Voltage units


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Cancer Control: a complex

multidisciplinary effort

Has to co-ordinate advances in early

diagnosis, prevention, therapy and

palliative care

Develop them synchronously

Object: Reduce morbidity and mortality

due to cancer.


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Data from the Demographic Registries

Common cancers in womenCervix, breastand oral cavity (52%)

Common cancers in menTobacco related

(45%) (Oral, lung, pharynx and oesophagus)

Breast and cervix 47% of all cancers in

women

Over 75% of patients seek treatment at a late

stage.


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Prevention of Cancer

Primary preventionelimination of the causativeagent most cost effective

Priority to Tobacco controlmore easily said than

done

Comprehensive strategy needed

Education of youth and adults

on healthy life styleCessation programmes

Legislative action

Implementation: Needs motivated groups

OBJECTIVE 1 of NCCP:


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ANTI TOBACCO PROGRAMME

ICMR Sponsored : Anti tobacco health education andoral screening

Trivandrum : Unemployed youth trained

Tobacco as health hazard

Various aspects of oral cancer

Clinical appearance of normal and

abnormal oral mucosa

pre-cancer and cancer

Karnataka : Recorded 37.8% reduction in tobacco

habit in study area


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Tobacco Cessation Clinics

Initiated by SEARO of WHO : 12 centres in India

TCC at Cancer Institute, Chennai

Objectives:

- aims at treatment of tobacco dependence

- provides pharmaceutical aids to reduce withdrawalsymptoms

- Smokeless Tobacco Cessationa special feature

Activities:

Sub centres established - 9

Educational & awareness programmes

Training programmes - 112

Exhibitions etc.


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Screening of asymptomatic populationComponents: Continuing public education campaigns

Training of public health workers

Population Screening:Successful in reducing morbidity and

mortality in countries with high level

resources, at certain sites viz. cervix,

breast, colo rectum.

In a large country with limited resources, it is not

practicable.

Screening of high risk group possible

Early detection & Screening:

OBJECTIVE 2: Crux of the Problem


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FEASIBILITY TO TRAIN

THE VILLAGE HEALTH NURSE 1989

Number Trained - 101

To detect an abnormal cervix

To take an adequate pap smear

Clinical concordance 90%

Pap smear adequacy 80%

Motivation Low


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Problems in the South Arcot Programme

1. Dual Govt. control

Unacceptable delays in communication andrelease of grants.

2. Dual responsibilities in the conduct of project

3. Transfer of trained personnel

Without information to implementing agency


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Early Detection & Screening ProjectsRest of India

Many projects completed and many ongoing.

Screening and early detection of accessible cancers.

Cervix, Breast and Oral

Objectives:

Evaluation of Screening Tests - Project Oriented

Evaluation of Screening methods

Performance of cytology, VIA, VILI Research Oriented

HPV TestingInterventional trials

Our focus was on how to integrate early detection with routine

health delivery system


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Cost modelling project for Cervical Cancer in Osmanabad

Cost of screening/eligible woman [Dr.Sankaranarayanan]

Cost of one time screening

Test Cost in USD (VIA) of eligible women

covering entire country

(in million Rs.)

VIA 9.5 76,166

Cytology 11.8

HPV 16.4

Conclusion of the Model Programme in Ratnagiri and

Sindhudurg Awaited

Cost effectiveness and whether replicable needs to bestudied


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Our Recommendations

For Cervix & Breast only women

should be involved

Include local rural women- Self help groups

- Survivors

Ideally implemented by NGOs

Motivated TeamProject considered a

Mission

Adequate financial support

Separate Cancer Network

Health Projects


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OBJECTIVE : 3

Enhancement of cancer treatment and control

services through Regional Cancer Centres,

Medical and Dental colleges.

Treatment Centres 210 RCCs 24

RT facilities 186Teletherapy units 345


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Enhanced Imaging

Gamma Camera (1958)

CT (1971)

USG (1968-69)PET CT (2002) ?


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Enhancements in Tissue DiagnosisTill 2 decades ago

Gross Examination, Light microscopyand clinical information only for

diagnosis and treatment plan

Today pathologic diagnosis in multimodal

Histochemistry, electron microscopy

Cytogenetics, molecular genetics have

added new dimension to diagnosis

Plays an important role in improved

survival and

Tailor treatment to specific tumour type


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Advances in Radiation Oncology

Introduction of

the First

Linear Accelerator - 1976

Cancer Institute(WIA),

Chennai

Virtual simulation 3-D planning

Conformational therapy IMRT

Modifiers of radiation response

(Chemopotentiation)


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Changing concepts and advances

in Surgical Oncology

Conceptual change from widestremoval possible

Avoid mutilation

Stress on conservationand functional

rehabilitation without compromise on

disease eradication

Minimally invasive surgery

f


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Training of Personnel Changing scenario of cancer treatment

Impact of multidisciplinary management in

cancer survival & quality of life

Misconception that radiotherapy and

cancer care were synonymous

No concept of oncology

Militated against interdisciplinary management

Need for specialized trained oncologic

personnel for total oncologic care

INTRODUCTION OF SUPER SPECIALTY

COURSES AT Cancer Institute, Chennai - 1984


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Demographic & Hospital Registries

A vital component of cancer control


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Documented changes in

cancer scenario

Trend in Incident cancer burden India 1983 2005


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443,000

229,660

469,000

263,480

0

100

200

300

400

500

1985 1990 1995 2000 2005

Male Female(inthousa

nds)

PeriodNo. of new cancer cases

M:F RatioMale Female

1985 229,660 263,480 1:1.15

1990 293,475 314,655 1:1.07

1995 328,115 348,660 1:1.06

2000 379,625 411,775 1:1.08

Annual % increase 4.4% 3.8%

Estimated for 2005 443,000 469,000 1:1.06

Trend in Incident cancer burden, India, 1983 - 2005

Alarming due toDemographic

effect

Trend of TRC India 1983 2002


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Trend of TRC, India, 1983-2002

31.631.430.529.5

14.514.715.514.7

0

10

20

30

40

1983-87 1988-92 1993-97 1998-2002

Male

Female

CIR/

105

39.737.3

35.430.4

16.716.416.115.4

0

10

20

30

40

50

1983-87 1988-92 1993-97 1998-2002

Male

Female

CIR

/105

Trend of TRC, Chennai, 1983-2002

Minimal in females

Pronounced in males

Minimal in males

No change in

females

TRC inclu des oral cavi ty, pharyn x, laryn x, lung, oesophagus, pancreasand ur inary bladder

Trend of stage distribution (%) Chennai 1984 2003


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Trend of stage distribution (%), Chennai, 1984-2003

Stage 1984-88 1989-93 1994-98 1999-2003 Trend

Breast

Un-changed

1 1.2 2.1 0.9 1.3

2 22.4 24.1 22.4 25.83 53.3 48.1 44.9 46.4

4 16.0 20.7 22.9 19.3

UNK 7.1 5.1 9.0 7.1

Cervix

Un-

changed

1 4.9 6.9 4.6 8.52 30.9 35.4 26.6 36.1

3 45.7 50.8 49.9 42.2

4 18.3 6.5 16.9 8.1

UNK 0.1 0.5 2.0 5.0

Oral Cancer

Un-

changed

1 4.4 6.0 5.9 4.2

2 10.4 11.4 11.8 10.5

3 36.9 31.4 20.3 14.7

4 40.8 43.9 50.4 48.5

UNK 7.5 7.3 11.5 22.2


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TIME TREND

SURVIVAL


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Period No.

Overall survival

(%)

Disease free survival

(%)

5 yr 10 yr 5 yr 10 yr

1960-79 5225 42.1 33.4 39.5 31.3

1980-89 5310 55.0 46.2 51.6 43.4

1990-94 2608 59.8 49.1 52.7 41.5

p-value 13143


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Survival

(%)

Paediatric Adult

1970-88 1989-98 1981-87 1988-94

(135) (132) (132) (147)

Disease Free 73.5 85.3 55.9 67.7

Overall 80.3 90.2 64.7 78.7

Time Trend Survival - 5 years

Hodgkins Disease (C.I.)

Prior to 1970 < 50%

N M i O


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Non Metastatic Osteosarcoma

Survival Trend: 1970-99Cancer Institute(WIA), Chennai

1970-84 (n=70) RFS % 1985-99 (n=198) RFS %

No. 3 yrs. 5 yrs. No. 3 yrs. 5 yrs.

Amputation/

Disarticulation+Adj. CT

42 42 34.7 121 34.2 24.6

Neo Adj. CT

Limb Conservation - - - 43 64.0 55.2

Declined CT/

Prog. Disease

Under treatment

28 - 10.0 34 - 11.1


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Current Infrastructure Inadequate1.5 Beds/1000 Bench mark 4.3

0.5 allopathic doctors/1000 Bench mark 1.8

Large dependence on unregistered and alternative

medicine practitioners

(WHO managerial guide lines)

Cancer Beds No reliable information

Health care in India

Infrastr ct re for Cancer (India)


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Infrastructure for Cancer (India)

Treatment Centres 210 RCC 24

RT facilities 186

Teletherapy units 345

(Co-60 & LA)

Brachytherapy units 276 Manual 163

Remote 113

(DGHS, Government of India publication)

IAEA Recommendation (Website)RT Units 1 / million population

Required for India 1100

Available 345

Cancer Control in India


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Cancer Control in India

Where are we?

Public awareness and education

(Stage of disease unchanged)

Tobacco Control

Tobacco habit LONG WAY

Tobacco related cancer TO GO

Early detection and prevention

(All programs are project or researchoriented. No effort to integrate it with

the routine health delivery system)

Treatment facilities inadequate


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Strategies for future

Thrust on

Prevention, Education

Early detection

5 decades of cancer control in india - v. shanta part i

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