Assessment of spatial variation in lung cancer incidence and air pollutants: spatial regression modeling approach.

A notable finding is that Kerala's capital Thiruvananthapuram has shown an increasing trend in lung cancer (LC) incidence. Long-term exposure to air pollution is a significant environmental risk factor for LC. This study investigated the spatial association between LC and exposure to air pollutants in Thiruvananthapuram, using Spatial Lag Model (SLM), Spatial Error Model (SEM), and Geographically Weighted Regression (GWR). The results showed that overall LC incidence rate was 111 per 105 males (age >60 years), whereas spatial distribution map revealed that 48% of the area had an incidence rate greater than 150. The results revealed a significant association between PM2.5 and LC. SLM was identified as the best model that predicted 62% variation in LC. GWR model improved model performance and made better local predictions in the southeastern parts of the study area. This study explores the effectiveness of spatial regression techniques for dealing spatial effects and pinpointing high-risk areas.

Educational Status, Cancer Stage, and Survival in South India: A Population-Based Study.

PURPOSE: Lower socioeconomic status is associated with more advanced cancer at the time of cancer diagnosis. It is unknown whether this leads to inferior survival in low- and middle-income countries. Here, we explore the association between educational level and survival in South India. METHODS: The Trivandrum Cancer Registry (3.3 million population) was used to identify all cases of breast and cervical cancer (women) and oral cavity (OC) and lung cancer (men) diagnosed during 2012-2014. Educational level was classified as illiterate/primary school, middle school, and secondary school and above. Survival was measured from date of diagnosis using the Kaplan-Meier method. Cox proportional hazards regression modeling was used to describe the associations among education, stage of cancer at diagnosis, and survival. RESULTS: The study population included 3,640 patients with breast (n = 1,727), cervical (n = 425), OC (n = 702), and lung (n = 786) cancer. Educational level was 27%, 23%, and 32% for illiterate/primary, middle, and secondary school and above, respectively. The 5-year survival rate for breast cancer was 59%, 68%, and 73% (P = .001); for cervical cancer, 51%, 52%, and 60% (P = .146); and for OC cancer, 42%, 35%, and 48% (P = .012) for illiterate/primary, middle school, and secondary school and above, respectively. The survival gradient across social groups was substantially attenuated when stage was added to the multivariable model. There was no observed difference in survival across educational groups for lung cancer (2%, 4%, and 3%; P = .224). CONCLUSION: Data from this population-based study in South India demonstrate that patients from a lower educational background have inferior survival and that this is at least partially explained by having more advanced disease at the time of diagnosis. Public health efforts are needed to facilitate timely diagnosis and reduce disparities in cancer outcomes.

Development of a field-friendly automated dietary assessment tool and nutrient database for India.

Studies of diet and disease risk in India and among other Asian-Indian populations are hindered by the need for a comprehensive dietary assessment tool to capture data on the wide variety of food and nutrient intakes across different regions and ethnic groups. The nutritional component of the India Health Study, a multicentre pilot cohort study, included 3908 men and women, aged 35-69 years, residing in three regions of India (New Delhi in the north, Mumbai in the west and Trivandrum in the south). We developed a computer-based, interviewer-administered dietary assessment software known as the 'NINA-DISH (New Interactive Nutrition Assistant - Diet in India Study of Health)', which consisted of four sections: (1) a diet history questionnaire with defined questions on frequency and portion size; (2) an open-ended section for each mealtime; (3) a food-preparer questionnaire; (4) a 24 h dietary recall. Using the preferred meal-based approach, frequency of intake and portion size were recorded and linked to a nutrient database that we developed and modified from a set of existing international databases containing data on Indian foods and recipes. The NINA-DISH software was designed to be easily adaptable and was well accepted by the interviewers and participants in the field. A predominant three-meal eating pattern emerged; however, patterns in the number of foods reported and the primary contributors to macro- and micronutrient intakes differed by region and demographic factors. The newly developed NINA-DISH software provides a much-needed tool for measuring diet and nutrient profiles across the diverse populations of India with the potential for application in other South Asian populations living throughout the world.

Smoking cessation intervention in rural kerala, India: findings of a randomised controlled trial.

BACKGROUND: Prevalence of tobacco use is higher in the rural than urban areas of India. Unlike tobacco cessation clinics located in urban areas, community-based smoking cessation intervention has the potential to reach a wider section of the community to assist in smoking cessation in the rural setting. The present study aimed to assess the effectiveness of a cessation intervention in rural Kerala state, India. MATERIALS AND METHODS: Current daily smoking resident males in the age group 18-60 years from four community development blocks in rural Kerala were randomly allocated to intervention and control groups. The intervention group received multiple approaches in which priority was given to face-to-face interviews and telephone counselling. Initially educational materials on tobacco hazards were distributed. Further, four rounds of counselling sessions were conducted which included a group counselling with a medical camp as well as individual counselling by trained medical social workers. The control group received general awareness training on tobacco hazards along with an anti-tobacco leaflet. Self-reported smoking status was assessed after 6 and 12 months. Factors associated with tobacco cessation were estimated using binomial regression method. RESULTS: Overall prevalence of smoking abstinence was 14.7% in the intervention and 6.8% in the control group (Relative risk: 1.85, 95% CI: 1.05, 3.25). A total of 41.3% subjects in the intervention area and 13.6% in the control area had reduced smoking by 50% or more at the end of 12 months. Lower number of cigarettes/ bidi used, low nicotine dependence and consultation with a doctor for a medical ailment were the statistically significant predictors for smoking cessation. CONCLUSIONS: Rigorous approaches for smoking cessation programmes can enhance quit rates in smoking in rural areas of India.

Assessment of nicotine dependence among smokers in a selected rural population in Kerala, India.

OBJECTIVES: An attempt was made to understand the nicotine dependence of smokers selected for an ongoing smoking cessation intervention programme in rural Kerala, India. METHODS: Data were collected from resident males in the age group of 18 to 60 years from 4 randomly allocated community development blocks of rural Thiruvananthapuram district (2 intervention and 2 control groups). Trained accredited social health activist workers were utilised to collect data from all groups through face to face interview. Nicotine dependence among participants was assessed by means of the six-item Fagerstrom Test for Nicotine Dependence (FTND) translated into the local language. The internal consistency of FTND was computed using Cronbach's alpha coefficient. Criterion validity (concurrent) was assessed by correlations of nicotine dependence scores with age at initiation of smoking and cumulative smoking volume in pack-years. RESULTS: Among the 928 smokers identified, 474 subjects were in the intervention area (mean age =44.6 years, SD =9.66 years) and 454 in the control area (mean age= 44.5 years, SD =10.30 years). The overall FTND score among current daily smokers was 5.04 (SD: 5.05). FTND scores in the control and intervention areas were 4.75 (SD: 2.57) and 4.92 (SD: 2.51) respectively. The FTND scores increased with age and decreased with higher literacy and socioeconomic status. The average FTND score was high among smokers using both bidi and cigarettes (mean 6.10, SD 2.17). Internal consistency analysis yielded a Cronbach's alpha coefficient of 0.70 in a subsample of 150 subjects, a moderate result. The association of the scale was strongest, with the number of pack-years smoked (rho = 0.677, p < 0.001). CONCLUSION: A moderate level of nicotine dependence was observed among smokers in the current study. Tobacco cessation strategies could be made more cost effective and productive if a baseline assessment of nicotine dependence is completed before any intervention.

Assessment of follow-up, and the completeness and accuracy of cancer case ascertainment in three areas of India.

BACKGROUND: A prospective study of diet and cancer has not been conducted in India; consequently, little is known regarding follow-up rates or the completeness and accuracy of cancer case ascertainment. METHODS: We assessed follow-up in the India Health Study (IHS; 4671 participants aged 35-69 residing in New Delhi, Mumbai, or Trivandrum). We evaluated the impact of medical care access and relocation, re-contacted the IHS participants to estimate follow-up rates, and conducted separate studies of cancer cases to evaluate registry coverage (604 cases in Trivandrum) and the accuracy of self- and proxy-reporting (1600 cases in New Delhi and Trivandrum). RESULTS: Over 97% of people reported seeing a doctor and 85% had lived in their current residence for over six years. The 2-year follow-up rate was 91% for Trivandrum and 53% for New Delhi. No cancer cases were missed among public institutions participating in the surveillance program in Trivandrum during 2003-2004; but there are likely to be unmatched cases (ranging from 5 to 13% of total cases) from private hospitals in the Trivandrum registry, as there are no mandatory reporting requirements. Vital status was obtained for 36% of cancer cases in New Delhi as compared to 78% in Trivandrum after a period of 4 years. CONCLUSIONS: A prospective cohort study of cancer may be feasible in some centers in India with active follow-up to supplement registry data. Inclusion of cancers diagnosed at private institutions, unique identifiers for individuals, and computerized medical information would likely improve cancer registries.

Comparison of quality of life between voice rehabilitated and nonrehabilitated laryngectomies in a developing world community.

CONCLUSIONS: Quality of life (QOL) scores were significantly higher among voice rehabilitated patients although this was accompanied by significant immediate and long-term morbidity and a cost implication for the patient. OBJECTIVE: We present a prospective and cross-over study of overall QOL and morbidity related to voice restoration in laryngectomees. METHODS: The EORTC QOL questionnaire (QLQ-C30 and QLQ-H&N-35) was distributed among all the consenting patients alive after laryngectomy from January 2008 to October 2009. In patients who had secondary voice rehabilitation, post-rehabilitation QOL scores were collected separately. Comparison of QOL between the non-rehabilitated and rehabilitated cohorts was done and a cross-over study of pre-rehabilitation and post-rehabilitation scores were done in the second cohort. RESULTS: A total of 113 patients were studied. QOL scores were significantly higher among voice rehabilitated patients.

A community based smoking cessation intervention trial for rural Kerala, India.

OBJECTIVES: An attempt was made to compare tobacco prevalence and socioeconomic factors of two groups (intervention and control) from a selected rural community in Thiruvananthapuram, Kerala, India. METHODS: Data were collected from resident males in the age group of 18.0 to 60.0 years from 4 randomly allocated Community Development Blocks of rural Thiruvananthapuram district (2 intervention and control groups). Trained Accredited Social Health Activists workers were utilised to collect data from both the groups through a face to face interview. RESULTS: Among 3304 subjects were interviewed, the overall prevalence of smokers was 28% (n=928) (mean age=44.4 years, SD=9.2 years). Socio-economic status (SES) score points indicated that majority of smokers belonged to the upper lower SES category (61%) (mean SES score =10, SD= 3) and among non-smokers, the participants mainly belonged to the lower middle SES score (45%) (mean SES score =12, SD= 3) (p-value=0.0001). Among the 928 smokers, 474 subjects were in the intervention area (mean age =44.56 years, SD =9.66 years) and 454 in the control area (mean age= 44.47 years, SD =10.30 years). No significant difference was found between the intervention and control groups according to age (p=0.89) and SES (p=0.11). Majority of smokers in the intervention and control areas were from the upper lower SES group (64.14% and 57.17%). CONCLUSION: Smoking continues to be a predominant public health problem among males in rural Kerala particularly among lower socio-economic population. Apart from strengthening legislation, multiple cost effective intervention approaches are required to reduce tobacco consumption in the community.

Trends in rectal cancer incidence--Indian scenario.

The objective was to analyse time trends of rectal cancer for the Indian population by gender, year of diagnosis, and age. Published data for Indian registries were obtained from "Cancer Incidence in Five Continents" and /or individual Indian registries for different time periods. Mean annual percentage change (MAPC) in incidence rates for seven Indian registries was computed using relative difference between two time periods (earliest and latest) and estimation of annual percentage change (EAPC) was computed for three registries by log-linear regression model using SAS version 8.1. The age standardized incidence rate (ASR) of rectal cancer during 2004-2006 ranged from 0.0 to 5.0 per 100,000 population with a male preponderance in most Indian registries. Among males, excepting for the Southern cities, all other registries revealed a decreasing trend/no change in the MAPC both in crude incidence rate (CR) and ASR. However, in females, an increase in MAPC in CR was noted in several registries. Statistically significant increase in EAPC in CR was observed in all the three registries ranging from 1.45% to 3.99% in males while in females the increase was 1.13% in Mumbai and 1.76% in Bangalore. Further studies are required to understand these changing trends and factors that operate in the aetiology of rectal cancer in the Indian scenario. Higher incidence in males indicates the need for greater attention to understand the causes of gender disparities.

Assessment of confounding and interaction using the mantel-haenszel risk estimation method.

The association between an exposure of interest (risk factor) and a disease may be confounded by the action of other separate factors as well as by interactions between risk factors exerting an impact. Crude measures of effect may be misleading in such situations. Levels of the potential confounding factor could be estimated using stratified analysis. Uniformity of the stratum-specific effect estimates can be assessed by performing chi-square tests for heterogeneity. If the effect is uniform across strata, we can calculate a pooled adjusted summary estimate of the effect using the Mantel-Haenzel (M-H) method. Confidence intervals for the adjusted estimate and the M-H chi-square test are calculated to assess the significance. If the effect is not uniform (presence of interaction), we report stratum-specific estimates, confidence intervals and chi-square for each estimate. In the present paper, assessment of the level of confounding and interaction between risk factors are illustrated using a case-control study of lung cancer conducted at the Regional Cancer Centre, Trivandrum.

Effects of socio-economic and demographic factors in delayed reporting and late-stage presentation among patients with breast cancer in a major cancer hospital in South India.

OBJECTIVE: We analyzed the distribution of socio-economic and demographic (SEDs) factors among breast cancer patients and assessed their impact on the stage at diagnosis of the disease and symptom duration. METHODS: Data for the year 2006 was collected from the Hospital Based Cancer Registry, Regional Cancer Centre (RCC), Trivandrum, Kerala, India. Patients (n=522) were included if they were from native Kerala state or adjoining Tamil Nadu. SEDS factors included age, residing district, religion, marital status, income, education and occupation. Other study variables were menopausal status, parity, listed symptoms with duration and stage at diagnosis. Association between SEDs factors by stage at diagnosis and duration of symptoms was tested using chi-square statistics, with odds ratios (OR) estimated through logistic regression modeling. RESULTS: Forty-five percent were reported at early stages and 53% at late stages. Elevated risks for late stage reporting among breast cancer patients were observed for women who were unmarried (OR=3.31; 95%CI: 1.10-9.96), widowed/divorced (OR=1.46; 95%CI: 0.89-2.37), with lower education (OR=2.72; 95%CI: 1.06-7.03 for illiterate women and OR=2.32; 95%CI: 1.05-5.13 for women with primary school education and OR=2.07; 95%CI: 1.02-4.21 for women with middle school education) and post-menopausal women (OR=1.45; 95%CI: 0.97-2.19). CONCLUSIONS: This analysis helped to identify the target population group for receiving health education for early detection of breast cancer.

Impact of socio-economic factors in delayed reporting and late-stage presentation among patients with cervix cancer in a major cancer hospital in South India.

The impact of socio- economic and demographic status (SEDS) factors on the stage of cervical cancer rat diagnosis, symptom duration and delay-time from diagnosis to registration was determined by analysing data for the year 2006 from the Regional Cancer Centre (RCC), Trivandrum, Kerala, India. Patients (n=349) were included if they were from the states of Kerala or Tamil Nadu. SEDS factors included age, residing district, religion, marital status, income, education and occupation. Associations between SEDS factors by stage at diagnosis and symptom duration were tested using chi-square statistics with odds ratios (OR) estimated through logistic regression modeling. Elevated risks for late stage reporting among cervical cancer patients were observed for women who were widowed/divorced (OR=2.08; 95%CI: 1.24-3.50) and had a lower education (OR=2.62; 95%CI:1.29-5.31 for women with primary school education only). Patients who had symptoms of bleeding/bleeding with other symptoms (77%) were more likely to seek treatment within one month, compared to patients with other symptoms only (23%) (p=0.016). This analysis helped to identify populations at increased risk of diagnosis at later stages of cancer with the ultimate intent of providing health education and detecting cancer at earlier stages.