Outcome of early detection approach in control of breast, cervical, and oral cancer: Experience from a rural cancer center in India.

In low- and middle-income countries most of the cancer patients attend the hospital at a late stage and treatment completion of these cases is challenging. The early detection program (EDP), in rural areas of Punjab state, India was initiated to identify breast, cervical, and oral cancer at an early stage by raising awareness and providing easy access to diagnosis and treatment. A total of 361 health education programs and 99 early detection clinics were organized. The symptomatic and self-interested (non-symptomatic individuals who opted for screening) cases visited the detection clinic. They were screened for breast, cervical, and/or oral cancer. Further diagnosis and treatment of screen-positive cases were carried out at Homi Bhabha Cancer Hospital (HBCH), Sangrur. Community leaders and healthcare workers were involved in all the activities. The EDP, Sangrur removed barriers between cancer diagnosis and treatment with the help of project staff. From 2019 to 2023, a total of 221,317 populations were covered. Symptomatic and self-interested individuals attended the breast (1627), cervical (1601), and oral (1111) examinations. 46 breast (in situ-4.3%; localized-52.2%), 9 cervical (localized-77.8%), and 12 oral (localized-66.7%) cancer cases were detected, and treatment completion was 82.6%, 77.8%, and 50.0%, respectively. We compared cancer staging and treatment completion of cases detected through EDP with the cases attended HBCH from Sangrur district in 2018; the difference between two groups is statistically significant. Due to the early detection approach, there is disease down-staging and improvement in treatment completion. This approach is feasible and can be implemented to control these cancers in low- and middle-income countries.

Rural-urban disparity in cancer burden and care: findings from an Indian cancer registry.

BACKGROUND: Cancer incidence and mortality vary across the globe, with nearly two-thirds of cancer-related deaths occurring in low- and middle-income countries. The rural-urban disparity in socio-demographic, behavioural, and lifestyle-related factors, as well as in access to cancer care, is one of the contributing factors. Population-based cancer registries serve as a measure for understanding the burden of cancer. We aimed to evaluate the rural-urban disparity in cancer burden and care of patients registered by an Indian population-based cancer registry. METHODS: This study collected data from Varanasi, Uttar Pradesh, India, between 2017 and 2019. Sex and site-specific age-standardised rates for incidence and mortality per 100,000 population were calculated. Rural-urban disparities in cancer incidence and mortality were estimated through rate differences and standardised rate ratios (with 95% confidence intervals). Univariable and multivariable regressions were applied to determine any significant differences in socio-demographic and cancer-related variables according to place of residence (rural/urban). Crude and adjusted odds ratios with 95% confidence intervals were calculated. RESULTS: 6721 cancer patients were registered during the study duration. Urban patients were older and had better literacy and socioeconomic levels, while rural patients had higher odds of having unskilled or semi-skilled professions. Diagnostic and clinical confirmation for cancer was significantly higher in urban patients, while verbal autopsy-based confirmation was higher in rural patients. Rural patients were more likely to receive palliative or alternative systems of medicine, and urban patients had higher chances of treatment completion. Significantly higher incidence and mortality were observed for oral cancer among urban men and for cervical cancer among rural women. Despite the higher incidence of breast cancer in urban women, significantly higher mortality was observed in rural women. CONCLUSIONS: Low- and middle-income countries are facing dual challenges for cancer control and prevention. Their urban populations experience unhealthy lifestyles, while their rural populations lack healthcare accessibility. The distinctness in cancer burden and pattern calls for a re-evaluation of cancer control strategies that are tailor-made with an understanding of urban-rural disparities. Context-specific interventional programmes targeting risk-factor modifications, cancer awareness, early detection, and accessibility to diagnosis and care are essential.

Head and neck cancer burden in India: an analysis from published data of 37 population-based cancer registries.

Head and neck cancer (HNC) is a major public health problem in India. This article presents the HNC burden in different regions of India. The published population-based cancer registries (PBCRs) data from the National Cancer Registry Programme, Bengaluru, and the Tata Memorial Centre, Mumbai, India, were utilised. The 37 PBCRs were divided into six regions including central, east, north, northeast, west and south. The age-standardised incidence rate of HNC was 25.9 (95% CI 25.7-26.1) and 8.0 (95% CI 7.9-8.1) per 100,000 population, respectively, in males and females. HNC accounted for about 26% of all cancer cases in males and 8% in females. The risk of developing HNC was 1 in 33 for males and 1 in 107 for females. The northeastern registries reported the highest incidence rate 31.7 per 100,000 population in males followed by northern (28.5), central (28.3), western (24.4), southern (23.9) and eastern (18.3). In females, the incidence was in the range of 6.2-10.1 per 100,000 population. For all PBCRs together, the HNC burden was two to three times higher in the age group 60+ as compared to 20-39 years. The HNC burden in India is higher than in the USA, UK, Australia, Africa and Brazil. The PBCRs from the south-east Asia region such as the Colombo district, Sri Lanka, as well as Siraha, Saptari, Dhanusha and Mohattari - Nepal have also reported a high burden of HNC. All regions reported mouth as a leading cancer site followed by tongue, larynx, hypopharynx and tonsil except the northeastern region registries where hypopharynx was the top leading cancer. The burden of other sites of HNC is low. Raising awareness of the disease and associated risk factors, providing early detection services, as well as easy access to diagnosis and treatment are required. The government should focus on building the infrastructure and capacity building to control this disease.

Role of verbal autopsy in cancer registration: A mixed-methods study from the population-based cancer registry of Northern India.

OBJECTIVES: To describe utilisation of verbal autopsy as one of the data collection approaches in cancer registration in an Indian setting. We aimed to estimate the proportion and epidemiological characteristics of malignancies identified by the Varanasi population-based cancer registry (PBCR) using verbal autopsy between 2017 and 2019 and to develop a thematic network for implementing verbal autopsy. METHODS: This was a cross-sectional mixed-methods study. Quantitative methods were applied to analyse information from PBCR proforma of the verbal autopsy-confirmed cancers; qualitative methods were applied to evaluate verbal autopsy conducted by field staff from key informants. In-depth interviews of field staff for the challenges and potential solutions during verbal autopsy were assessed. RESULTS: Of 6466 registered cancers, 1103 (17.1%) were verbal autopsy-confirmed cancers, which had no other source of information. The majority of verbal autopsy cases were from vulnerable populations who were aged >50 years (721, 65.4%), female (607, 55.1%), from rural backgrounds (853, 77.3%), illiterate or just able to read and write (636, 57.7%), and from lower and middle-income groups (823, 74.6%). Verbal autopsy helped provide information about symptoms and site of disease, diagnostic and treatment details, and disease status. Major challenges during verbal autopsy described by field staff were incomplete cancer treatment, destruction of medical records and non-cooperation by the community and lack of support from the local workforce as cancer is not notifiable. CONCLUSION: Verbal autopsy helped identify cancers that would have been missed during active case finding from available resources. The majority of verbal autopsy-confirmed patients belonged to vulnerable populations. Non-cooperation from community and local health systems was major challenge during verbal autopsy. Developing robust cancer awareness, patient navigation, and social support programmes will strengthen verbal autopsy. Integration of standardised and reproducible methods of verbal autopsy in cancer registry and digitalization of health information, especially in limited-resource settings with weak vital registration, will facilitate completeness in cancer registration.

Epidemiology of rare cancers in India and South Asian countries - remembering the forgotten.

Background: Rare cancers (RCs) are challenging to manage and are "forgotten cancers" though they collectively constitute a significant proportion of all cancers (∼20%). As a first step towards streamlining care, there is an unmet need to map the epidemiology of RCs in South Asian Association for Regional Collaboration (SAARC) countries. Methods: The authors collected data from 30 Population-Based Cancer Registries (PBCR) of India and the published national registries of Nepal, Bhutan and Sri Lanka (SL) and compared them with the standard RARECAREnet RC list. Findings: With the standard definition of crude incidence rates (CR) ≤6/100,0000 per population, 67.5%, 68.3%, 62.3% and 37% of all incident cancers qualify as RCs in India, Bhutan, Nepal and SL, respectively. An arbitrary cut-off CR ≤3 appears more appropriate with 43%, 39.5%, 51.8% and 17.2% of cancers identified as RCs, respectively, due to the lower cancer incidence.There are similarities and notable differences between the RC lists of the SAARC region with that of the European RC list. Oral cavity cancers are rare in Europe, while pancreas, rectum, urinary bladder and melanomas are common. In addition, uterine, colon and prostatic cancers are rare in India, Nepal and Bhutan. In SL, thyroid cancer is common. There are gender-related and regional differences in RC trends in the SAARC countries. Interpretation: There is an unmet need in SAARC nations to capture epidemiological nuances in rare cancers. Understanding the unique issues in the developing world may guide policymakers to adopt appropriate measures to improve RC care and tailor public health interventions. Funding: None.

Overall survival of prostate cancer from Sangrur and Mansa cancer registries of Punjab state, India.

Introduction: There is a scarcity of population-based prostate cancer survival data in India. We assessed the population-based, overall survival of patients with prostate cancer from the Sangrur and Mansa cancer registries of the Punjab state, India. Methods: In the year 2013-2016, a total of 171 prostate cancer cases were registered in these two registries. Based on these registries, survival analysis was performed using the date of diagnosis as the starting date and the last follow-up date being December 31, 2021 or the date of death. Survival was calculated using STATA software. Relative survival was calculated using the Pohar Perme method. Results: Follow up was available for all the registered cases. Of the 171 cases, 41 (24%) were alive and 130 (76.0%) were dead. Of the prescribed treatments, 106 (62.7%) cases completed the treatment and 63 (37.3%) cases did not complete the treatment. Overall, 5-year age-standardized prostate cancer relative survival was 30.3%. Patients who completed the treatment had a 7.8 times higher 5-year relative survival (45.5%) compared to those who did not (5.8%). The difference between the two groups is statistically significant (hazard ratio 0.16, 95% confidence interval [0.10-0.27]). Conclusion: To improve survival, we need to raise awareness in the community and among primary physicians so that prostate cancer cases can reach the hospital early and should be treated effectively. The cancer center should develop the systems in their hospital so that there will be no hurdles to the patients in treatment completion. We found a low overall relative survival among patients of prostate cancer in these two registries. Patients who received treatment had a significantly higher survival.

Pediatric Cancer Burden in Different Regions of India: Analysis of Published Data From 33 Population-Based Cancer Registries.

OBJECTIVE: To provide the regional pediatric cancer (age-group 0-14 years) burden and pattern in India utilizing published data of population-based cancer registries established under the National Cancer Registry Programme and Tata Memorial Centre, Mumbai. METHODS: Based on the geographic locations, the population-based cancer registries were categorized into six regions. The age-specific incidence rate was calculated using the number of pediatric cancer cases and population in the respective age-group. Age-standardized incidence rate per million and 95% CI were calculated. RESULTS: In India, 2% of all cases were pediatric cancer. The age-standardized incidence rate (95% CI) for boys and girls is 95.1 (94.3-95.9) and 65.5 (64.8-66.2) per million population, respectively. Registries from northern India reported the highest rate; while the lowest rate was in northeastern India. CONCLUSIONS: There is a need to establish pediatric cancer registries in different regions of India to know the accurate pediatric cancer burden.

Cancer pattern in Varanasi district from Uttar Pradesh state of India, a foundation for cancer control based on the first report of the population-based cancer registry.

Background: The cancer registry provides reliable data from the population. In this article, we provide cancer burden and its patterns from the Varanasi district. Methods: The method adopted by the Varanasi cancer registry is community interaction along with regular visits to more than 60 sources to collect data on cancer patients. The cancer registry was established by the Tata Memorial Centre, Mumbai, in 2017 covering 4 million population (57% rural and 43% urban population). Results: The registry has recorded 1,907 incidence cases (1,058 male and 849 female). The age-adjusted incidence rate per 100,000 population in male and female of Varanasi district is 59.2 and 52.1, respectively. One in 15 male and one in 17 female are at risk of developing the disease. Mouth and tongue cancers are the predominant cancers in male, whereas breast, cervix uteri, and gallbladder are the leading cancer sites among the female. In female, cervix uteri cancer is significantly higher (double) in rural areas when compared with urban areas (rate ratio [RR] 0.5, 95% confidence interval [CI; 0.36, 0.72]), whereas in male, mouth cancer is higher in urban areas when compared with rural areas (RR 1.4, 95% CI [1.11, 1.72]). More than 50% of cancer cases in male are due to tobacco consumption. There may be underreporting of the cases. Conclusion: The results of the registry warrant policies and activities related to early detection services for the mouth, cervix uteri, and breast cancers. The Varanasi cancer registry is the foundation for cancer control and will play an important role in the evaluation of the interventions.

Diagnostic accuracy of menstrual blood for human papillomavirus detection in cervical cancer screening: a systematic review.

Globally, cervical cancer is the fourth most common cancer among females and a major public health problem in low- and middle-income countries (LMICs). There are several screening tests available for cervical cancer screening; however, due to a lack of organised screening facilities as well as factors such as low participation rates in screening programmes, many women die due to cervical cancer. To reach out to a large number of women, an easy, non-invasive and time-saving screening method is required. Evidence supports that cervical cancer screening with human papillomavirus deoxyribonucleic acid (HPV DNA) testing is the most effective technique for lowering the incidence and mortality associated with cervical cancer when compared to other screening methods. Furthermore, a small number of studies have reported that menstrual blood can be used as an alternative sample for HPV detection for cervical cancer screening. We have done a systematic review of the studies that have reported the diagnostic accuracy of menstrual blood to detect HPV. We found five studies in our literature search. The studies showed the diagnostic accuracy of menstrual blood in terms of sensitivity ranging from 82.8% to 97.7% and specificity ranging from 50.0% to 98.0% in cervical intraepithelial neoplasia or HPV infection detection. This review supports the use of menstrual blood as a screening tool for cervical cancer especially in LMICs where women are reluctant to participate in cervical cancer screening due to issues such as embarrassment and discomfort to test procedures as well as busy schedules. However, further studies are required to compare the diagnostic accuracy of menstrual blood in detecting HPV compared to other self-sampled HPV detection methods. This is one of the methods that can be explored further for use as a cervical cancer screening test.

Factors influencing women to participate in cervical cancer screening by providing menstrual pads: A population-based study from rural areas of Maharashtra state, India.

Background: India accounts for a quarter of the world cervical cancer burden. Cervical cancer is highly preventable. However, low level of participating women in screening is one of the major issues. The aim of this work was to study the factors that influence women to participate in cervical cancer screening by providing menstrual pads for human papillomavirus (HPV) testing. Methods: Menstrual clothes were collected from two different populations from the rural areas of Maharashtra state for HPV testing to screen for cervical cancer. For this study, out of 945 participated women, 557 (58.9%) provided their menstrual pads. Multivariate logistic regression was applied to calculate the odds ratio (OR) and 95% confidence interval (95% CI). Results: The probability of providing the menstrual pads was high among the women who were highly educated compared to those with less education (OR: 1.4; 95% CI: 1.0-1.9), having mobile phone facilities as compared to those with no mobile phones (OR: 1.4; 95% CI: 1.0-2.0), who were using new cloths as menstrual pads compared to those who did not use the same (OR: 8.5; 95% CI: 5.0-14.3), who did not have tobacco habit as compared to those who had tobacco habit (OR: 1.4; 95% CI: 1.1-1.9) and in the village where health worker was stationed as compared to the village where health worker was not stationed (OR: 1.8; 95% CI: 1.4-2.5). Conclusion: Factors including health worker availability, using mobile phones for communication and high education level facilitate women's participation. To improve the participation, there is need to apply special strategies for older age group, less educated women and women having tobacco habit.

Menstrual pad, a cervical cancer screening tool, a population-based study in rural India.

In the rural areas of India, women generally use a piece of old cloth as a menstrual device. The aim of this study was to detect human papilloma virus (HPV) from menstrual blood on the menstrual pad and assess whether this could be a useful screening tool for cervical cancer. In Jamkhed area of rural Maharashtra, (population A), we collected menstrual pads from women who provided consent in the 30-50 year age group. The women who had provided menstrual pads underwent HC2 testing. We standardized the method for extracting DNA by PCR from the menstrual pad. The women who tested HPV positive, on the basis of HC2/PCR testing, underwent colposcopy. In the rural population of Pune area of Maharashtra state (population B), menstrual pads were collected. HPV was tested using the PCR method. HPV-positive women and a few HPV-negative women, selected randomly, underwent colposcopy and HC2 testing. In population A, 164 women provided their used menstrual pads and also underwent an HC2 screening test. Of these, six (3.2%) cases were reported as HPV positive. In population B, 365 women provided their used menstrual pads for HPV testing, of which 18 (4.9%) cases were diagnosed as HPV positive. The women who tested HPV positive, on the basis of PCR testing, and 10% randomly selected HPV-negative cases (37) and 18 women who voluntary requested testing underwent colposcopy and HC2 testing. The sensitivity of menstrual pad HPV testing compared with gold standard HC2 testing was 83% [95% confidence interval (CI): 0.47-0.97], 67% (95% CI: 0.30-0.91) and specificity was 99% (95% CI: 0.96-0.99), 88% (95% CI: 0.77-0.94) in population A and population B, respectively. The sensitivity of diagnosing CIN lesion was 83% (95% CI: 0.44-0.97) and specificity was 95% (95% CI: 0.91-0.97). On the basis of the sensitivity and specificity results, and the completely noninvasive, simple and convenient method of detecting HPV, menstrual pad might be considered a cervical cancer screening tool in rural Indian women.

Prevalence and nonsexual transmission of human papilloma virus (HPV) in the adolescence girls from rural area of Maharashtra state, India.

OBJECTIVE: To find out the prevalence of human papilloma virus (HPV) in adolescent girls and to access the nonsexual transmission of HPV from their mother by using the same old cloth used by their mother. METHOD: Menstrual pads were collected from the women of age group years to find out the presence of HPV and whether it can be used as a cervical cancer screening tool. The results of the said study have been published in the European Journal of Cancer Prevention. During this study, menstrual pads of the daughters of participating women were collected to see the nonsexual transmission of HPV. After conducting the health education and obtaining the informed consent, we interviewed 57 mothers (age group 30-50, married, sexually active) and daughters [age group 12-18, unmarried (not exposed to sex)] from the rural area of Pune district of Maharashtra state, India. The menstrual pads were collected and transported to Mumbai for polymerase chain reaction (PCR) testing. HPV testing was carried out by PCR. RESULTS: Out of 57, 28 (49%) daughters and 23 (40.4%) mothers provided menstrual pad. Out of 23 mothers, one was HPV positive [4.3%: 95% confidence interval (CI) 0.2-23.0] and out of 28 girls, 3 (10.7%: 95% CI 2.0-33.0) were HPV positive. The daughter, whose mother was HPV positive, had negative result for HPV. CONCLUSION: The HPV prevalence in adolescence girls was 10.7%. There may be other nonsexual medium that might have caused HPV in adolescence girls, which needs further research.