Community-based Screening of Oral Cancer in Selected Districts of Nepal: A Cross-Sectional Study.

OBJECTIVE: Oral cancer screening plays a vital role in the prevention and control of oral cancer. This study aimed to determine the prevalence of oral potentially malignant disorders (OPMDs) in the Nepalese community. METHODS: A cross-sectional study was conducted in six purposively selected districts in Nepal from May to December 2019. It utilized a camp-based approach, where a standardized questionnaire was administered through face-to-face interviews. Screening of oral cancer was performed by direct visualization and palpation. The study included adults aged 18 years and above, while those already diagnosed with oral cancer were excluded. Logistic regression was used to find out the association between OPMDs and the related variables. RESULTS: A total of 1930 participants with a mean age of 44.3 years (SD=15.1) underwent oral cancer screening. Among them, 32% were current tobacco users, 2% were ex-users, and 11% were alcohol consumers. OPMDs, including suspected cancer, were identified in 139 (7.2%, 95% CI=6.1-8.4) participants. The most common lesion detected was leukoplakia (4.2%), followed by submucous fibrosis (1.5%), erythroplakia (0.9%), and palatal changes due to reverse smoking (0.1%). Additionally, 10 participants were suspected of having oral cancer. Older age group (AOR=7.00; 95% CI=2.76-17.77), male gender (AOR=2.52; 95% CI=1.58-4.02), tobacco chewers (AOR = 14.30; 95% CI=8.82-23.19), and smokers (AOR=4.67; 95% CI=2.88-7.57)) were identified as predictors of OPMDs. CONCLUSION: This study revealed a high prevalence of OPMDs in Nepal, highlighting the need for oral cancer screening. The findings emphasize the importance of developing strategies to reduce tobacco use and implementing tobacco cessation intervention programs in Nepal to alleviate the burden of oral cancer.

Differences in risk factors for head and neck cancer among men and women in Nepal: A case-control study.

BACKGROUND: Head and neck cancer (HNC) is a major cause of cancer morbidity and mortality in Nepal. The study aims to investigate differences in risk factors for head and neck cancer by sex in Nepal. METHODS: A hospital-based case-control study was conducted at the B.P. Koirala Memorial Cancer Hospital in Nepal from 2016 to 2018. A semi-structured questionnaire consisting of socio-demographic characteristics, dietary habits, reproductive factors, household air pollution, tobacco use (smoking and chewing), alcohol consumption, and second-hand smoking was used to collect the data. Odds ratios (OR) and 95 % confidence intervals (CI) were estimated using unconditional logistic regression adjusting for potential confounders. RESULTS: A total of 549 HNC cases (438 men and 111 women) and 601 age-matched healthy controls (479 men and 122 women) were recruited in this study. An increased risk of HNC for low education level and family income were observed among men (adjusted odds ratio (AOR) for 3rd grade and less= 1.58, 95 % CI= 1.14-2.18; AOR for family monthly income < 5000 Rupees = 1.64, 95 % CI 1.20-2.24). The AORs among women were higher than the men for known risk factors (AOR for smoking 1.34 (95 % CI 0.96-1.86) for men, 2.94 (95 % CI 1.31-6.69) for women; AOR for tobacco chewing 1.76 (95 % CI 1.27-2.46) for men, 10.22 (95 % CI 4.53-23.03) for women). CONCLUSION: Our results point to an effect modification by sex for HNC risk factors with high AORs observed among women.

Community-Based Cervical Cancer Screening using Visual Inspection with Acetic Acid.

BACKGROUND: Cervical cancer is the most common cancer among Nepalese women. Cervical cancer screening plays a vital role in reducing the morbidity and mortality of the disease. In this study, we assessed the prevalence of precancerous lesions of cervical cancer from community-based screening programs in Nepal. METHODS: In this cross-sectional study involving record review, data were drawn from community-based screening programs in 14 districts by B.P. Koirala Memorial Cancer Hospital in Nepal. All women who underwent cervical cancer screening using visual inspection with acetic acid between June 2017 to December 2018 were included. RESULTS: A total of 7,270 women were screened during the study period with the prevalence of cervical precancerous lesions among 153 (2.1%; 95% Confidence Interval 1.8-2.5) participants. Of which, the highest positivity rate was observed in the age group 30 years and below (46, 3%). The majority (4453, 61%) of the total women screened, were married at age below 20 years and 188 (3%) reported a history of cancer in their families. The most common presenting complaints were low abdominal pain (1236, 17%), low back pain (1152, 16%), itching in the anogenital region (828, 11%), and per vaginal discharge (818, 11%). Cervical cancer was suspected in 25 (0.3%) women. CONCLUSIONS: The prevalence of precancerous lesions of cervical cancer is low but with high existing risk factors among Nepalese women of selected districts. The government should implement effective and sustained cervical cancer awareness and population-based screening programs along with a continuum of care. The national criteria for screening should also include young women with known risk factors.

Bacterial Profile and Antibiotic Resistance among Cancer Patients with Urinary Tract Infection in a National Tertiary Cancer Hospital of Nepal.

Cancer patients are at high risk of antibiotic resistant bacterial urinary tract infections (UTIs). In this study, we assessed the bacterial profile and antibiotic resistance among cancer patients suspected of UTI in B.P. Koirala Memorial Cancer Hospital in Nepal through a cross-sectional study with routinely collected data. All cancer patients who had a recorded urine culture between July 2018-June 2019 were included in the study. Out of 308 patients who had undergone culture, 73 (24%) of samples had bacterial growth. The most common organisms isolated were E. coli (58%), Staphylococcus (11%) and Klebsiella (10%). These bacteria had undergone susceptibility testing to 27 different antibiotics in various proportions. Of the limited antibiotic testing levels, nitrofurantoin (54/66, 82%) and amikacin (30/51, 59%) were the most common. Among those tested, there were high levels of resistance to antibiotics in the "Access" and "Watch" groups of antibiotics (2019 WHO classification). In the "Reserve" group, both antibiotics showed resistance (polymyxin 15%, tigecycline 8%). Multidrug resistance was seen among 89% of the positive culture samples. This calls for urgent measures to optimize the use of antibiotics in UTI care at policy and health facility levels through stewardship to prevent further augmentation of antibiotic resistance among cancer patients.

Trend of Head and Neck Cancers in a National Tertiary Cancer Hospital of Nepal from 2012 to 2017.

Introduction Head and neck cancers (HNCs) are increasing in Nepal and have become a major public health issue. This study aims to describe the trend of HNCs in a national tertiary cancer hospital in Nepal. Methods This was a cross-sectional study with secondary data analysis conducted at B.P Koirala Memorial Hospital, Chitwan, Nepal. The data were obtained from the medical record section and included all new HNC cases registered from 2012 to 2017. Analysis was done using Statistical Package for Social Sciences version 17. Subgroup analysis was done according to age, gender, site, and year. Results A total of 4,582 new HNCs were registered, of which 3,097 (67.6%) were males and 1,482 (32.4%) were females. Lip and oral cavity cancers (46.5%) were the most common HNCs followed by tonsil and pharynx (18.0%) and larynx (15.8%). The trend of HNCs shows a steady rise in incidence with difference according to the sites. HNCs were more common among males than females except for thyroid cancer. The most common age group was 60 to 74 years. Conclusions The trend of HNCs is increasing in Nepal especially oral cancers. Awareness of risk factors, effective screening programs, and comprehensive treatment should be focused to decrease the burden of HNCs.

Experiences of cervical cancer survivors in Chitwan, Nepal: A qualitative study.

INTRODUCTION: Cervical cancer is a global leading cause of morbidity and mortality. The majority of cervical cancer deaths occur in developing countries including Nepal. Though knowledge of cervical cancer is an important determinant of women's participation in prevention and screening for cervical cancer, little is known about this topic in Nepal. This study explores the experiences of cervical cancer survivors and assesses the attitude of family and community towards it and stigma related to this disease in Bharatpur, Nepal. METHODS: The study design was qualitative methods involving two focus-group discussions. A total of 17 cervical cancer survivors, who have completed two years of cancer treatment were selected purposively from Chitwan. All qualitative data were transcribed and translated into English and were thematically analyzed. RESULTS: The majority of the participants had scant knowledge about cervical cancer, its causative agent, showed less cervical cancer screening, delayed healthcare-seeking behavior despite having persistent symptoms before the diagnosis. The main reasons identified for not uptaking the cervical screening methods were an embarrassment and having no symptoms at all. Most of them endured social stigma related to cervical cancer in the form of physical isolation and verbal abuse. CONCLUSIONS: There is an urgent need for interventions to make women and the public aware of cervical cancer and launch effective health education campaigns, policies for cervical cancer prevention programs. This implementation can save the lives of hundreds of women and help them avoid going through all the negative experiences related to cervical cancer. More studies are required to gain the perspectives, knowledge, experiences, and attitudes of cervical cancer survivors to add to the research.

Tobacco smoking, chewing habits, alcohol drinking and the risk of head and neck cancer in Nepal.

Although tobacco smoking, pan chewing and alcohol drinking are important risk factors for head and neck cancer (HNC), the HNC risks conferred by products available in Nepal for these habits are unknown. We assessed the associations of tobacco smoking, chewing habits, and alcohol drinking with HNC risk in Nepal. A case-control study was conducted in Nepal with 549 incident HNC cases and 601 controls. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using unconditional logistic regression adjusting for potential confounders. We observed increased HNC risk for tobacco smoking (OR: 1.54; 95% CI: 1.14, 2.06), chewing habits (OR: 2.39; 95% CI: 1.77, 3.23), and alcohol drinking (OR: 1.57; 95% CI: 1.14, 2.18). The population attributable fraction (PAF) was 24.3% for tobacco smoking, 39.9% for chewing habits and 23.0% for alcohol drinking. Tobacco smoking, chewing habits, and alcohol drinking might be responsible for 85.3% of HNC cases. Individuals who smoked tobacco, chewed products and drank alcohol had a 13-fold increase in HNC risk (OR: 12.83; 95% CI: 6.91, 23.81) compared to individuals who did not have any of these habits. Both high frequency and long duration of these habits were strong risk factors for HNC among the Nepalese with clear dose-response trends. Preventive strategies against starting these habits and support for quitting these habits are necessary to decrease the incidence of HNC in Nepal.

Cancer Registration in Nepal: Current Status and Way Forward.

Cancer registration is an organization for the systematic collection, storage, analysis, interpretation and reporting of data on subjects with cancer. Cancer Registry was initiated in 1995 and expanded as National Cancer Registry Program since 2003 by B.P. Koirala Memorial Cancer Hospital with the support of World Health Organization. National cancer registry program currently includes 12 hospital-based registries. First time in Nepal, B.P. Koirala Memorial Cancer Hospital piloted population-based cancer registry in 2013, which included 15 districts covering 25.8% of total population of Nepal. National cancer registry program is important to assure the quality of data from all the registries to ensure the availability of reliable and valid data of cancer cases. This will further help policymakers to develop preventive and control strategies against cancer. This paper reviews the current status of cancer registries in Nepal and discusses challenges and future perspectives related to national cancer registry program. National cancer registry should further include major hospitals in Nepal to give scientific information on cancer trends by community, provinces and regions and to analyze on survival of cancer cases. Keywords: cancer; national cancer registry program; Nepal.

Reproductive and Hormonal Factors in Relation to Lung Cancer Among Nepali Women.

Background: Of the 1.8 million global incident lung cancer cases estimated in 2012, approximately 60% occurred in less developed regions. Prior studies suggest sex differences in lung cancer risk and a potential role for reproductive and hormonal factors in lung cancer among women. However, the majority of these studies were conducted in developed regions. No prior study has assessed these relationships among Nepali women. Methods: Using data from a hospital-based case-control study conducted in B. P. Koirala Memorial Cancer Hospital (Nepal, 2009-2012), relationships between reproductive and hormonal factors and lung cancer were examined among women aged 23-85 years. Lung cancer cases (n = 268) were frequency-matched to controls (n = 226) based on age (±5 years), ethnicity and residential area. The main exposures in this analysis included menopausal status, age at menarche, age at menopause, menstrual duration, gravidity, and age at first live-birth. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression. Results: Among postmenopausal women, those with a younger age at menopause (<45 years; 45-49 years) had an increased odds of lung cancer compared to those with an older (≥50 years) age at menopause [OR (95%CI): 2.14 (1.09, 4.17); OR (95% CI): 1.93 (1.07, 3.51)], after adjusting for age and cumulative active smoking years. No statistically significant associations were observed with the other reproductive and hormonal factors examined. Conclusion: These results suggest that Nepali women with prolonged exposure to endogenous ovarian hormones, via later age at menopause, may have a lower odds of lung cancer.

Evolutionary selected Tibetan variants of HIF pathway and risk of lung cancer.

Tibetans existed in high altitude for ~25 thousand years and have evolutionary selected unique haplotypes assumed to be beneficial to hypoxic adaptation. EGLN1/PHD2 and EPAS1/HIF-2α, both crucial components of hypoxia sensing, are the two best-established loci contributing to high altitude adaptation. The co-adapted Tibetan-specific haplotype encoding for PHD2:p.[D4E/C127S] promotes increased HIF degradation under hypoxic conditions. The Tibetan-specific 200 kb EPAS1 haplotype introgressed from an archaic human population related to Denisovans which underwent evolutionary decay; however, the functional variant(s) responsible for high-altitude adaptation at EPAS1/HIF-2α have not yet been identified. Since HIF modulates the behavior of cancer cells, we hypothesized that these Tibetan selected genomic variants may modify cancer risk predisposition. Here, we ascertained the frequencies of EGLN1D4E/C127S and EGLN1C127S variants and ten EPAS1/HIF-2α variants in lung cancer patients and controls in Nepal, whose population consists of people with Indo-Aryan origin and Tibetan-related Mongoloid origin. We observed a significant association between the selected Tibetan EGLN1/PHD2 haplotype and lung cancer (p=0.0012 for D4E, p=0.0002 for C127S), corresponding to a two-fold increase in lung cancer risk. We also observed a two-fold or greater increased risk for two of the ten EPAS1/HIF-2α variants, although the association was not significant after correcting for multiple comparisons (p=0.12). Although these data cannot address the role of these genetic variants on lung cancer initiation or progression, we conclude that some selected Tibetan variants are strongly associated with a modified risk of lung cancer.

Household air pollution and lung cancer risk among never-smokers in Nepal.

More than half of the global population relies on biomass fuels (wood, charcoal, crop residue, dung) for cooking and/or heating purposes. Household air pollution (HAP) resulting from the use of these solid fuels is of particular concern, given the overall prevalence as well as the intensity of exposure and the range of potential adverse health outcomes. Long term exposure to HAP is a major public health concern, particularly among women and children in low and middle income countries. In this study, we investigated the association between exposure to HAP resulting from combustion of biomass and lung cancer risk among Nepalese population. Using a hospital-based case-control study (2009-2012), we recruited 606 lung cancer cases and 606 healthy controls matched on age (±5 years), gender, and geographical residence. We used unconditional logistic regression to compute odds ratios (ORs) and 95% Confidence Intervals (95% CI) for lung cancer risk associated with HAP exposures, adjusting for potential confounders (tobacco use, TB status, SES, age, gender, ethnicity, and exposure to second hand smoke. In our overall analysis, we observed increased risk of lung cancer among those who were exposed to HAPs (OR: 1.77, 95% CI: 1.00-3.14). A more detailed analysis stratified by smoking status showed considerably higher risk of lung cancer associated with increasing duration of exposure to HAP from biomass combustion, with evidence of a borderline exposure-response relationship (Ptrend=0.05) that was more pronounced among never-smokers (Ptrend=0.01). Our results suggest that chronic exposure to HAP resulting from biomass combustion is associated with increased lung cancer risk, particularly among never-smokers in Nepal.

Ethnic Variation in Consumption of Traditional Tobacco Products and Lung Cancer Risk in Nepal.

Lung cancer is the leading contributor to cancer deaths in the developing world. Within countries, significant variability exists in the prevalence of lung cancer risk, yet limited information is available whether some of the observed variability is associated with differences in the consumption pattern of local tobacco products with differing potency. We recruited 606 lung cancer cases and 606 controls from the B.P. Koirala Memorial Cancer Hospital in Nepal from 2009-2012. We estimated odds ratios (ORs) and 95% confidence intervals (CI) for lung cancer risk associated with different tobacco products, using unconditional logistic regression. Unfiltered cigarettes tended to be the most frequently used products across ethnic subgroup with about 53.7% of Brahmins, 60.1% of Chettris, and 52.3% of Rai/Limbu/Magar/others. In contrast, about 39.9% of Madishe/Tharu smokers reported using bidi compared with only 27.7% who smoked unfiltered cigarettes. Among those who only smoked one type of product, choor/kankat smokers had the highest lung cancer risk (OR 10.2; 95% CI 6.2-16.6), followed by bidi smokers (OR 5.6; 95% CI 3.6-8.7), unfiltered cigarettes (OR 4.9; 95% CI 3.4-7.2), and filtered cigarettes (OR 3.4; 95% CI 2.2-5.3). A clear dose-response relationship was observed between increased frequency of smoking and lung cancer risk across all ethnic subgroups. These results highlight the important role of traditional tobacco products on lung cancer risk in the low income countries.

Malignant Neoplasm Burden in Nepal - Data from the Seven Major Cancer Service Hospitals for 2012.

In Nepal, while no population based cancer registry program exists to assess the incidence, prevalence, morbidity and mortality of cancer, at the national level a number of hospital based cancer registries are cooperating to provide relevant data. Seven major cancer diagnosis and treatment hospitals are involved, including the BP Koirala Memorial Cancer hospital, supported by WHO-Nepal since 2003. The present retrospective analysis of cancer patients of all age groups was conducted to assess the frequencies of different types of cancer presenting from January 1st to December 31st 2012. A total of 7,212 cancer cases were registered, the mean age of the patients being 51.9 years. The most prevalent age group in males was 60-64 yrs (13.6%), while in females it was 50-54 yrs (12.8%). The commonest forms of cancer in males were bronchus and lung (17.6%) followed by stomach (7.3%), larynx (5.2%) and non Hodgkins lymphoma (4.5%). In females, cervix uteri (19.1%) and breast (16.3%), were the top ranking cancer sites followed by bronchus and lung (10.2%), ovary (6.1%) and stomach (3.8%). The present data provide an update of the cancer burden in Nepal and highlight the relatively young age of breast and cervical cancer patients.

Socioeconomic status and lung cancer risk in Nepal.

BACKGROUND: Lung cancer is the most common cancer among men and the third most common cancer among women in Nepal. Socioeconomic disparities in lung cancer have not been studied in the Nepalese population. METHODS: We conducted a lung cancer case-control study, including 209 cases and 313 controls at the main cancer hospital in Nepal, the B.P. Koirala Memorial Cancer Hospital (BPKMCH). RESULTS: We observed differences in lung cancer risk by ethnicity; the Rai, Limbu and Magar groups had a higher risk of lung cancer than Brahmin (OR=3.11, 95%CI=1.55-6.23). An inverse association was observed between education and lung cancer risk (p for trend=0.0008). We also observed greater lung cancer risk among unmarried individuals (OR=2.25, 95%CI=1.12-4.53), and lower risk in individuals who lived in the Central region compared to the West (OR=0.47, 95%CI=0.26-0.85). There were greater proportions of late stage cancers among women compared to men, in the Rai/Limbu/Magar ethnic groups, in individuals with lower education and in older age groups. CONCLUSIONS: Disparities in lung cancer risk were observed by race/ethnicity, education, marital status, and by region of residence. Further research on socioeconomic influence on lung cancer in Nepal is warranted to develop better prevention efforts against the disease.