Ambakumar Nandakumar

Oral cancer in southern India: The influence of smoking, drinking, paan‐chewing and oral hygiene

Between 1996 and 1999 we carried out a case‐control study in 3 areas in Southern India (Bangalore, Madras and Trivandrum) including 591 incident cases of cancer of the oral cavity (282 women) and 582 hospital controls (290 women), frequency‐matched with cases by age and gender. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from unconditional multiple logistic regressions and adjusted for age, gender, center, education, chewing habit and (men only) smoking and drinking habits. Low educational attainment, occupation as a farmer or manual worker and various indicators of poor oral hygiene were associated with significantly increased risk. An OR of 2.5 (95% CI 1.4–4.4) was found in men for smoking ≥ 20 bidi or equivalents versus 0/day. The OR for alcohol drinking was 2.2 (95% CI 1.4–3.3). The OR for paan chewing was more elevated among women (OR 42; 95% CI 24–76) than among men (OR 5.1; 95% CI 3.4–7.8). A similar OR was found among chewers of paan with (OR 6.1 in men and 46 in women) and without tobacco (OR 4.2 in men and 16.4 in women). Among men, 35% of oral cancer is attributable to the combination of smoking and alcohol drinking and 49% to pan‐tobacco chewing. Among women, chewing and poor oral hygiene explained 95% of oral cancer.

Geographic pathology revisited: Development of an atlas of cancer in India

Information on 217,174 microscopically diagnosed cancers diagnosed in 2001–2002 was collected from pathology laboratories in 68 districts across India. Data collection took place primarily via the Internet. Average annual age‐adjusted incidence rates for microscopically diagnosed cases (MAAR) by gender and site were calculated for each of the 593 districts in the country. The rates were compared to those from established population based cancer registries (PBCR). In 82 districts, the MAAR for ‘all cancer sites’ was above a “completeness” threshold of 36.2/100,000 (based on results of a rural PBCR). The results confirmed some known features of the geography of cancer in India, and brought to light new ones. Cancers of the mouth and tongue are particularly frequent in both genders in the southern states. Very high rates of nasopharynx cancer were found in the northeastern states (Nagaland, Manipur). There was clear geographic correlation between the rates of cervical and penile cancer, and a high rate of stomach and lung cancer (in both genders) in many districts of Mizoram State. The area of high risk for gallbladder cancer seems larger than suspected previously, involving a wide band of northern India. There is a belt of high incidence of thyroid cancer in females in southwest coastal districts. Other than identifying possible existence of high‐risk areas of specific cancers, our study has recognized places where PBCR could be established. The study was remarkably cost‐effective and the electronic data‐capture methodology provides a model for health informatics in the setting of a developing country.

Oral cancer in Southern India: the influence of body size, diet, infections and sexual practices

Between 1996 and 1999, we carried out a study in Southern India on risk factors for oral cancer. The study included 591 incident cases of cancer of the oral cavity (282 women) and 582 hospital controls (290 women). Height was unrelated to oral cancer risk. Body mass index (weight in kilograms/height in metres squared) was inversely associated with risk (P for trend<0.001). Paan chewers with low BMI were at particularly high risk. Risk was increased among subjects consuming meat (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.00–2.37), ham and salami (OR 4.40, 95% CI 2.88–6.71) two or more times per week. Frequent consumption of fish, eggs, raw green vegetables, cruciferous vegetables, carrots, pulses, apples or pears, citrus fruit, and overall consumption of vegetables and fruit decreased oral cancer risk (P for trend for each of these items less than or equal to 0.001). The risk associated with low consumption of vegetables was higher among smokers than among non-smokers. Men, but not women, who practised oral sex had an increased oral cancer risk (OR 3.14, 95% CI 1.15–8.63). Women with more than one sexual partner during life were at increased oral cancer risk (OR 9.93, 95% CI 1.57–62.9).

A population-based case-control investigation on cancers of the oral cavity in Bangalore, India.

A case-control study on cancers of the oral cavity was conducted by utilising data from the population based cancer registry. Bangalore, India. Three hundred and forty-eight cases of cancers of the oral cavity (excluding base tongue) were age and sex matched with controls from the same residential area but with no evidence of cancer. The relative risk due to pan tobacco chewing was elevated in both males and females, being appreciably higher in the latter (relative risk 25.3%; 95% confidence interval 11.2-57.3). A statistically significant (linear test for trend P less than 0.001) dose response based on years, times per day and period of time chewed was seen. Any smoking (cigarette or bidi or both) had only slightly elevated risk of developing oral cancer, whereas a history of alcohol drinking or inhalation of snuff did not influence the risk. A new finding of our study was the markedly elevated risk of oral cancer in persons consuming ragi (Eleusine coracana, family graminae) in comparison to those not consuming ragi as staple cereal in their diet. There also appeared to be some interaction between ragi consumption and tobacco chewing with substantially higher relative risks in those who pursued both habits compared to those who gave a history of either.

Importance of anatomical subsite in correlating risk factors in cancer of the oesophagus--report of a case--control study.

In Bangalore, cancer of the oesophagus is the third most common cancer in males and fourth most common in females with average annual age-adjusted incidence rates of 8.2 and 8.9 per 100,000 respectively. A case-control investigation of cancer of the oesophagus was conducted based on the Population-based cancer registry, Bangalore, India. Three hundred and forty-three cases of cancer of the oesophagus were age and sex matched with twice the number of controls from the same area, but with no evidence of cancer. Chewing with or without tobacco was a significant risk factor. In both sexes chewing was not a risk factor for cancer of the upper third of the oesophagus. Among males, non-tobacco chewing was a significant risk factor for the middle third but not for the other two segments and tobacco chewing was a significant risk factor for the lower third of the oesophagus, but not for the other two segments. Bidi smoking in males was a significant risk factor for all three segments being highest for the upper third, less for the middle third and still less for the lower third. The risk of oesophageal cancer associated with alcohol drinking was significant only for the middle third.

Descriptive epidemiology of childhood cancers in Bangalore, India

While fairly complete and reliable incident data on childhood cancers are available from the registries in India, mortality and survival information is not. Information concerning the latter was obtained by the Bangalore cancer registry through active follow-up involving visits to homes of patients. Between 1982 and 1989, 617 cases of cancers in childhood were registered, giving an age-standardized incidence rate of 84.8 and 48.4 per million in male and female children, respectively. Active follow-up provided mortality/survival information in 532 or 86.2 percent of these cases. Overall, observed five-year survival was 36.8 percent (both genders combined) with a relative survival of 37.5 percent when childhood mortality in the general population was taken into account. The five-year relative survival was best for thyroid carcinoma (100 percent) followed by Hodgkins disease (73 percent) and retinoblastoma (72.9 percent). Survival was comparatively low, being 9.9 percent in acute nonlymphatic leukemia and less than 20 percent in rhabdomyosarcoma and the category grouped as ‘other malignant neoplasms.’ Survival in Hodgkins disease was influenced by clinical stage at presentation, but was not statistically significant possibly due to small numbers.

Incidence, mortality and survival in cancer of the cervix in Bangalore, India.

Cancer of the cervix is the most common cancer among women in India, constituting between one-sixth to one-half of all female cancers with an age-adjusted incidence rate ranging from 19.4 to 43.5 per 100,000 in the registries under the National Cancer Registry Programme (NCRP) (Annual Reports, NCRP, ICMR). It has been estimated that 100,000 new cases of cancer of the cervix occur in India every year, and 70% or more of these are Stage III or higher at diagnosis. However, the incidence of cancer of the cervix as suggested in this report appears to be on the decline in Bangalore. Besides incidence and clinical stage at presentation knowledge of survival is essential to complete the picture of establishing baseline indicators to monitor and evaluate cancer control programmes. Survival analysis was carried out in 2121 patients diagnosed during 1982-89 in the population of Bangalore, India. The observed 5 year survival was 34.4% and the relative survival 38.3%. Clinical stage at presentation was the single most important variable in predicting survival. The 5 year observed survival for stage I disease was 63.3%, for stage II 44.0%, for stage III 30.3% and for stage IV 5.7%.

Cancer control-planning and monitoring population-based systems

Cancer is a growing global health issue, and many countries are ill-prepared to deal with their current cancer burden let alone the increased burden looming on the horizon. Growing and aging populations are projected to result in dramatic increases in cancer cases and cancer deaths particularly in low- and middle-income countries. It is imperative that planning begin now to deal not only with those cancers already occurring but also with the larger numbers expected in the future. Unfortunately, such planning is hampered, because the magnitude of the burden of cancer in many countries is poorly understood owing to lack of surveillance and monitoring systems for cancer risk factors and for the documentation of cancer incidence, survival and mortality. Moreover, the human resources needed to fight cancer effectively are often limited or lacking. Cancer diagnosis and cancer care services are also inadequate in low-and middle-income countries. Late-stage presentation of cancers is very common in these settings resulting in less potential for cure and more need for symptom management. Palliative care services are grossly inadequate in low- and middle-income countries, and many cancer patients die unnecessarily painful deaths. Many of the challenges faced by low- and middle-income countries have been at least partially addressed by higher income countries. Experiences from around the world are reviewed to highlight the issues and showcase some possible solutions.

The magnitude of cancer breast in India: a summary

Cancer of breast has emerged as the leading site of cancer in most urban populations of India. For the year 2007, there have been an estimated 82,000 new cases of cancer Breast in India. It is rapidly replacing cancer of cervix as the most important leading site of cancer among women. The data collected over the years from five urban population based cancer registries namely Bangalore, Bhopal, Chennai, Delhi and Mumbai, under the network of National Cancer Registry Programme (NCRP) have shown a statistical rising trend in the incidence rate of breast cancer. In hospital-based cancer registries, cancer of the breast is the leading site of cancer in Mumbai and Thiruvananthapuram, second leading site in Bangalore, Dibrugarh and Chennai. Cancer of breast constitutes 14.3 to 30.0% of all cancers in women in these HBCRs. The report on ‘Development of an Atlas of Cancer in India’ showed that Chandigarh (39.5), North Goa (36.8), Aizawl (36.2) and Panchkula (34.6) had the higher microscopic incidence rates of breast cancer compared to that seen in Delhi PBCR that had the highest rate among all PBCRs.

Concurrent Chemoradiation for Cancer of the Cervix: Results of a Multi-Institutional Study From the Setting of a Developing Country (India)

Purpose The primary output of hospital-based cancer registries is data on cancer stage and treatment-based survival that can be used to evaluate patient care, but because there are many challenges in obtaining follow-up details, a separate study on patterns of care and patterns of survival for patients at selected sites was initiated under the National Cancer Registry Programme of India. This article presents the results for cervical cancer. Patients and Methods A standardized patient information form was used to record patient information, and data were entered into a central repository—the National Centre for Disease Informatics and Research. The study patients were from 12 institutions and were diagnosed between January 1, 2006, and December 31, 2008. Patterns of treatment were assessed for 7,336 patients, and patterns of survival were determined for 2,669 patients from six institutions, at least 70% of whom had data regarding follow-up as of December 31, 2012. Results Of 7,336 patients, 55.5% received optimal radiotherapy (RT). In all, 80.9% of patients had locally advanced cancers (stage IIB to IVA), 51.1% received RT alone, and 44.4% received concurrent chemoradiation (RTCT). In 1,753 patients with locally advanced cancers, significantly better survival was observed with RTCT than with RT alone (5-year cumulative survival, 70.2% v 47.3%; hazard ratio, 0.48; 95% CI, 0.41 to 0.56). Conclusion A conservative estimate indicates that, on an annual basis, 38,771 patients with cervical cancers in India alone do not get the benefit of RTCT and thus they have poorer survival. There is a need to reiterate the National Cancer Institutes alert that advised supplementing chemotherapy to radiation for locally advanced cancer of the cervix in the context of the developing world, where 84.3% of cancers of the cervix occur.