Cancer survival in Barshi, India, 1993-2000.

The rural cancer registry of Barshi, Paranda and Bhum, was the first of its kind in India and was established in 1987. Registration of cases is carried out entirely by active methods. Data on survival from 15 cancer sites or types registered during 1993-2000 are reported in this study. Follow-up has been carried out predominantly by active methods, with median follow-up time ranging between 2-49 months for different cancers. The proportion of histologically verified diagnosis for various cancers ranged between 73-98%; death certificates only (DCOs) comprised 0-2%; 98-100% of total registered cases were included for survival analysis. Complete follow-up at five years ranged between 96-100% for different cancers. The 5-year age-standardized relative survival rates for selected cancers were non-melanoma skin (86%), penis (63%), breast (61%), cervix (32%), mouth (23%), hypopharynx (11%) and oesophagus (4%). The 5-year relative survival by age group did not display any particular pattern. Five-year relative survival trend between 1988-1992 and 1993-2000 showed a marked decrease for cancers of the tongue, hypopharynx, stomach, rectum, larynx, lung and penis; but a notable increase for breast and non-Hodgkin lymphoma.

Experience with telepathology at a tertiary cancer centre and a rural cancer hospital.

BACKGROUND: Telepathology allows quick and timely access to an expert opinion, no matter where the patient is located. We analysed the experience with the use of telepathology between a tertiary cancer centre and a rural cancer hospital. METHODS: Ninety-three cases were analysed in which static telepathology was used to obtain a consultation between Tata Memorial Centre and Nargis Dutt Memorial Cancer Hospital at Barshi, a rural area. RESULTS: Successful teleconsultation was achieved in all cases. A diagnosis was offered in 92 cases (98.9%) and was deferred in 1 case (1.1%). Complete concordance, clinically unimportant minor discrepancy and hedged diagnosis were obtained in 83 cases (90.2%). Major discrepancies were encountered in 9 cases (9.7%). The number of images per case ranged from 3 to 27 (average: 7 images). Images were of diagnosable quality in 89.2% of cases. Most of the cases (77.4%) were reported within 3 days; 32.2% were reported within 8 hours (a single working day) and 45.1% within 1-3 days. CONCLUSION: Telemedicine can be effectively used to bridge the gap between medically underprivileged, geographically distant rural areas and advanced centres using the static store and forward methodology.

Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India.

India is a high-risk country for cervical cancer which accounts a quarter (126,000 new cases, 71,000 deaths around 2,000) of the world burden. The age-standardized incidence rates range from 16-55 per 100,000 women in different regions with particularly high rates in rural areas. Control of cervical cancer by early detection and treatment is a priority of the National Cancer Control Programme of India. There are no organized cytology screening programmes in the country. The technical and financial constraints to organize cytology screening have encouraged the evaluation of visual inspection approaches as potential alternatives to cervical cytology in India. Four types of visual detection approaches for cervical neoplasia are investigated in India: a) naked eye inspection without acetic acid application, widely known as 'downstaging'; b) naked eye inspection after application of 3-5% acetic acid (VIA); c) VIA using magnification devices (VIAM); d) visual inspection after the application of Lugol's iodine (VILI). Downstaging has been shown to be poorly sensitive and specific to detect cervical neoplasia and is no longer considered as a suitable screening test for cervical cancer. VIA, VIAM and VILI are currently being investigated in multicentre cross-sectional studies (without verification bias), in which cytology and HPV testing are also simultaneously evaluated, and the results of these investigations will be available in 2003. These studies will provide valuable information on the average, comparative test performances in detecting high-grade cervical cancer precursors and cancer. Results from pooled analysis of data from two completed studies indicated an approximate sensitivity of 93.4% and specificity of 85.1% for VIA to detect CIN 2 or worse lesions; the corresponding figures for cytology were 72.1% and 91.6%. The efficacy of VIA in reducing incidence of an mortality from cervical cancer and its cost-effectiveness is currently being investigated in two cluster randomized controlled intervention trials in India. One of these studies is a 4-arm trial addressing the comparative efficacy of VIA, cytology and primary screening with HPV DNA testing. This trial will provide valuable information on comparative detection rates of CIN 2-3 lesions by the middle of 2003. The expected outcomes from the Indian studies will contribute valuable information for guiding the development of public health policies on cervical cancer prevention in countries with different levels of socio-economic and health services development and open up new avenues of research. This paper is available too at: http//www.insp.mx/salud/index.html.

Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India

La India es un país de alto riesgo de cáncer cervical, donde se presentan cerca de la cuarta parte de los casos del total mundial (126 000 casos incidentes y 71 000 muertes durante 2000). La tasa de incidencia estandarizada por edad se encuentra en el rango de 16 a 55 por 100 000 mujeres en diferentes regiones con tasas particularmente altas en áreas rurales. El control del cáncer cervical por detección temprana y tratamiento es una prioridad del Programa Nacional de Control de Cáncer y, desafortunadamente, no hay programas organizados de tamizaje citológico en este país. La infraestructura técnica y financiera para organizar tamizaje en este tipo de cáncer, ha promovido la inspección visual como una potencial alternativa de la citología cervical en la India. Se investigan cuatro tipos de opciones de detección visual de neoplasia cervical: a) inspección a ojo desnudo sin la aplicación de ácido acético, opción ampliamente conocida como downstaging; b) inspección de ojo desnudo después de la aplicación de ácido acético de 3 a 5 por ciento (VIA); c) VIA usando un dispositivo de aumento (VIAM); d) inspección visual después de la aplicación de yodo-lugol (VILI). Se ha mostrado que el Downstaging ha sido pobremente sensible y específico para detectar neoplasia cervical y no es considerado ampliamente como una prueba de tamizaje conveniente para cáncer cervical. VIA, VIAM y VILI son frecuentemente investigados en estudios de corte transversal multicéntricos (sin verificación de sesgo), en los que se evalúan simultáneamente la citología y las pruebas del VPH; los resultados de esas investigaciones estarán disponibles próximamente. Estos estudios proveerán información valiosa sobre el desarrollo de pruebas comparativas para detectar lesiones de alto grado precursoras de neoplasia cervical, y cáncer invasor. Los resultados de los análisis de los datos de dos estudios previos indicaron una sensibilidad aproximada de 93.4 por ciento y una especificidad de 85.1 por ciento para VIA en la detección de CIN 2-3 o lesiones invasoras, comparadas con las de citología con 72.1 por ciento y 91.6 por ciento de sensibilidad y especificidad, respectivamente. La eficacia de VIA para la reducción de la incidencia y la mortalidad de cáncer cervical y su costo-efectividad están siendo actualmente investigadas en dos ensayos de intervención aleatorizados controlados en población de la India. Uno de esos estudios es un ensayo con cuatro brazos que establece la eficacia...

Radio-contrast imaging of the rectum prior to colostomy closure for rectal trauma--is routine use still justified?

This retrospective study was undertaken to assess the yield of radio-contrast imaging of the rectum before closure of colostomy following extraperitoneal rectal trauma. Sixty-nine patients (63 males) underwent colostomy closure in 36 months. All radio-contrast studies (colograms) performed before closure of colostomy were normal, and there were no deaths following closure. This study demonstrated that the yield from pre-closure radio-contrast imaging of the rectum after rectal trauma was negligible and did not influence colostomy closure. We conclude that while it may be appealing to suggest abandonment of its routine use, this investigation needs to be further evaluated prospectively with special attention given to injury to associated structures such as bone, bladder and vagina.

Early detection of cervical cancer by visual inspection: a population-based study in rural India.

A total of 3784 women aged 35 and above living in 26 villages in rural Maharashtra state, India, were invited to undergo a pelvic examination, to evaluate the performance of unaided visual inspection by trained paramedical workers in detecting cervical cancer. Of this number, 2135 (56.4%) women complied with the invitation. Paramedical workers scored 1120 (57.3%) and 118 (6%) women as having abnormal cervices using the low- and high-threshold criteria respectively. There was good agreement between the visual findings of the paramedical workers and those of a gynaecologist. All subjects had a cervical smear. A total of 10 cervical cancers were detected by cytology/histology. The sensitivity of visual inspection by paramedical workers to detect cervical cancer was 90.0% using the low threshold and 60.0% with the high threshold to define a positive test. The values for specificity were 42.8% and 94.5% respectively. The results obtained by the gynaecologist were very similar. Cost savings implied by limiting cytology/other investigations to approximately half of the population pre-selected on the basis of visual inspection are likely to be offset by the necessity to repeat the test at frequent intervals, repeated follow-up visits and other investigations.

Improved survival in cervical cancer cases in a rural Indian population.

In the first Rural Cancer Registry in India, 194 cervical cancer cases were registered during 1988-91. The 3 year survival was significantly higher in cases registered in 1990-91 (40.0%), than in those registered in the earlier years (26.6%). This improvement was due to the cancer education activities undertaken by the Registry.

Improved stage at diagnosis of cervical cancer with increased cancer awareness in a rural Indian population.

As part of its strategy to identify cancer cases in a rural population, the cancer registry of Barshi, India, has developed a methodology which includes education of the population about likely symptoms of cancer, and motivation of symptomatic individuals to undergo medical investigation. Patients with cervical cancer from the registry area who attended Barshi Cancer Hospital (84% of the total) showed a significant improvement in stage at diagnosis between 1988-1989 (38% in stages I and II) and 1990-1992 (51% in stages I and II). No change was observed in those attending the same hospital from a control area (38% vs. 34%). Among a random sample of the population of the registry area, 76% of women were aware of the symptoms of cervical cancer, compared with 25% of the population of control areas. It is suggested that action to raise awareness of symptoms of cancer, and to encourage medical consultation, should form an important initial component of cervical-cancer control programmes.

Early diagnosis of cervical cancers. Our experience at the Rural Cancer Registry, Barshi, India.

In the cervical cancer cases registered at the Cancer Hospital at Barshi, India during 1988-90, 99 of the 105 cases were clinically staged (Total number of cases registered: 136). The annual number of cases were too few for a comparison of stage distribution between the registry years. However, comparison of the proportions of early cases (FIGO Ib, IIa & IIb) in each year, with the corresponding proportion in a large series at the Tata Memorial Hospital (TMH) in Bombay in 1988, showed that the proportions of early cases in 1988 & 1989 (0.31 and 0.35 respectively) were similar to that (0.30) in TMH but in 1990, it (0.50) was significantly higher (P < 0.01). The shift to early stages observed three years after the inception of the Registry is most likely due to the registry activity which involved inter-personal contact with the community and motivation of the symptomatics to undergo a medical investigation. These activities were designed to overcome the adverse conditions for cancer registration prevailing in the rural population. It is suggested that to achieve early diagnosis similar activities be incorporated in the initial phase of a cervical cancer control programme in the country, where cervical cancer is not only the predominant cancer in women but also the cases generally present themselves in advanced stages.

Experience in screening for cervical cancer in rural areas of Barsi Tehsil (Maharashtra).

The organization of cancer detection camps is gaining popularity in our country and it is therefore necessary to evaluate the effectiveness of this approach in the early diagnosis and treatment of cancer. This to our knowledge has not been done. This report analyses an experience in screening for cervical cancer in rural areas of Barsi Tehsil (Maharashtra). The Barsi Tehsil consists of 134 villages with a population of 34,080 women above the age of 30 years (1982-1987). Of these 2,846 were screened through a series of cancer detection camps between 1982 and 1987. The results of the cytological screening in these women have been presented. An evaluation of the camp approach was carried out by the Population based Cancer Registry set up under the National Cancer Registry Programme (Indian Council of Medical Research) in Barsi, Paranda and Bhum tehsils. It was shown that acceptance of cytological screening was poor, thereby indicating that the mere holding of camps was not in itself sufficient to motivate the people, to subject themselves to the Pap smear. Certain suggestions which would appreciably increase the acceptance of cytological screening have been put forward.