|Year : 2016 | Volume
| Issue : 2 | Page : 61-62
National prevention and cancer screening programs in India: Why bother?
Professor of Oncology, Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, 200 First St. SW Rochester, MN 55905, USA
|Date of Web Publication||19-May-2016|
Professor of Oncology, Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, 200 First St. SW Rochester, MN 55905
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kohli M. National prevention and cancer screening programs in India: Why bother?. MAMC J Med Sci 2016;2:61-2
A global epidemic of cancer is projected in the next decade with a rise in cancer incidence from 12.9 million new cased in 2009 to 16.6 million in 2020. Worldwide, the most common tumor types observed include lung (12.6%), breast (10.5%), colorectal cancer (9.4%), stomach cancer (8.7%), and prostate cancer (6.4%), although there is considerable area specific heterogeneity in distribution patterns for tumor types. In developed countries, prostate, breast, lung, and colorectal cancers predominate, whereas in developing countries, cervical and liver cancers are the top two tumor types by incidence. In 2009, of the estimated 12.9 million global cancer incidence 821,892 were projected from prostate cancer of which 21,150 occurred in low-income countries (translating to a 2.4% incidence of all cancers in low-income countries) compared to 573,008 in high-income countries (11.6% of all cancers among high-income countries). Despite these economic region-based differences in incidence, prostate cancer in low to middle-income countries is estimated to have age-standardized cancer mortality rates (ASMR) that are beginning to approach the traditionally observed ASMRs in high-income countries  and thus is increasingly relevant as a public health burden. In general, the cancer public health burden is shifting to low to middle-income countries which at present account for 57% of global cancer cases and 65% of cancer-related deaths. Several well-known risk factors associated with cancer occurrence including aging of the population, increasing prevalence of smoking, obesity, physical inactivity, and changing reproductive patterns associated with urbanization and economic development in low to middle-income nations have contributed to this growing shift. By all estimates it appears that cancer-related morbidity and mortality in the low to middle income and industrialized world is destined to grow and cause a significant increase in the public health burden. In parallel, the high price of oncology drugs which is already affecting the ability to take care of cancer patients even in resource-rich countries  is likely to add to the challenge of managing cancer as a public health burden in low to middle-income countries. In one study performed in the United States (US) on the increased costs of cancer care, Howard et al. documented an escalation in cancer drug prices by an average of US$8,500 a year over the past 15 years. The lack of existing and adequate infrastructure and support for cancer care, competing social, political demands for limited resources, management of acute infectious, and other publically relevant chronic noncommunicable disease (NCDs) (chronic respiratory diseases, diabetes, and cardiovascular heart disease) makes it difficult to imagine how an efficient and practical planning in resource allocation for cancer care will emerge and look like in low to middle-income group countries. Cancer preventive strategies and early detection of cancer will have an increasing and important cost-effective role to offer in the formulation of any game plan in the future since treatments with increasingly costly drugs in managing cancer is unlikely to offer an effective and meaningful control of cancer mortality and morbidity.
In the context of India where the population continues to expand, it is estimated that NCDs will rapidly pose a major threat to human, health, economic growth, and national development. In a report prepared by the Harvard School of Public Health on the impact of NCDs in India, and presented in November 2014 at the World Economic Forum (http://www.weforum.org/issues/healthy-living), India stands to incur a cost of US$4.58 trillion between 2012 and 2030 due to NCDs and mental health conditions of which US$250 billion is estimated to be as a result of cancer-related causes. To meet this emerging challenge, the Government of India formulated a “Category “A” intervention national level programmatic intervention strategy in 2008 that focuses on screening, vaccination (in the case of human papillomavirus [HPV]), and reduced tobacco use. Of the 12 programs in this national level initiative for combating the threat of NCDs as a whole, six programmatic interventions relate directly or indirectly to tackling cancer prevention and screening. These include the (i) National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke; (ii) Health systems strengthening project: State-level experience in Tamil Nadu; (iii) HPV vaccination: Public policy for prevention of cervical cancer; (iv) Tobacco taxation: Public policy Response to prevent tobacco use; (v) Tobacco regulation: Enforcement of a complete smoking ban in public places; and (vi) Mobilizing Youth for Tobacco-Related Initiatives: School-based program to prevent tobacco use. In addition, National Cancer Institutes (NCIs) modeled on the NCI (US) are being planned, and a National Cancer Registry Program has been commenced by the Indian Council of Medical Research. However a nationwide impact of national programs that plan for population-based screening and cancer prevention have so far not been included in these interventions but are more than likely to add value if and when included. In high-income group countries population screening for breast (with mammography), prostate cancer (using prostate cancer antigen), colon (using colonoscopy after the age of 50 years), and lung (with low resolution computerized tomography scans) have been systematically evaluated. The US Preventive Task Force in the US, based on evidence collected from randomized clinical trials grades population screening tests (http://www.uspreventiveservicestaskforce.org/Page/Name/home) for use or not. A high grade for offering a service is graded as “A” (high certainty that a net benefit is substantia), whereas a “D” grade represents a discouragement for the use of a service. Population-based mass screening for lung cancer receives a “B” grade (high certainty that the net benefit is moderate) and prostate screening receives a “D” grade in the US at present. The nature of these recommendations takes into account the societal needs of a nation and the subsequent net benefit-risk ratio to offer a service to society. Such nationwide programs with the intent of controlling cancer and lowering cancer incidence are missing in India's strategy for screening and preventing common cancers in the population. This will require a concerted and integrated input from the government, national administration, medical experts, and not for profit organizations such as Public Health Foundation of India (PHFI), which is celebrating its 10th year since inception in 2006 (http://www.phfi.org). The PHFI has evolved since inception into a multidisciplinary institution focusing on alleviating public health through national strategies, research, and education including emerging NCDs in particular. Apart from running Indian Institutes of Public Health in Delhi, Gandhinagar, Hyderabad, and Bhubaneshwar, it has also setup Centers of Excellence pertaining to research training and education in NCDs. However, a systematic and widespread integration of such public health institutes with national cancer control programs and medical colleges has not yet taken place.
Cancer management strategies in India can no longer be ignored in an era where both, the incidence and prevalence of disease is set to grow. With an increasing use of effective, but cost prohibitory genome and high technology-based interventions in the management of advanced stage disease and an absence of nation-wide identifiable preventive and screening strategies, a priority focus for preventing the individual patient's suffering and the mitigation of loss in national productivity as a result of cancer is expeditiously needed in India's public health advocacy programs in the near future.
| References|| |
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108.
Hashim D, Boffetta P, La Vecchia C, Rota M, Bertuccio P, Malvezzi M, et al.
The global decrease in cancer mortality: Trends and disparities. Ann Oncol 2016. pii: Mdw027.
Tefferi A, Kantarjian H, Rajkumar SV, Baker LH, Abkowitz JL, Adamson JW, et al.
In support of a patient-driven initiative and petition to lower the high price of cancer drugs. Mayo Clin Proc 2015;90:996-1000.
Howard DH, Bach PB, Berndt ER, Conti RM. Pricing in the Market for Anticancer Drugs. J Economic Perspect 2015;29:139-62.