Bhawna Gupta

Oral cancer in India continues in epidemic proportions: evidence base and policy initiatives.

OBJECTIVES India has the highest number of cases of oral cancer in the world and this is increasing. This burden is not fully appreciated even within India, despite the high incidence and poor survival associated with this disease. Because the aetiology of oral cancer is predominantly tobacco-related, the immense public health challenge can be ameliorated through habit intervention. METHODS We reviewed current rates of incidence, mortality and survival, and investigated the determinants of disease and current prevention strategies. RESULTS In addition to tobacco smoking and the myriad other forms of tobacco use prevalent in India, risk factors include areca nut consumption, alcohol consumption, human papillomavirus, increasing age, male gender and socioeconomic factors. Although India has world-leading cancer treatment centres, access to these is limited. Further, the focus of health care services remains clinical and is either curative or palliative. CONCLUSIONS Although the efforts of agencies such as the Ministry of Health and Family Welfare and the Indian Dental Association are laudable, enhanced strategies should be based on common risk factors, focusing on primary prevention, health education, early detection and the earliest possible therapeutic intervention. A multi-agency approach is required.

Global Epidemiology of Head and Neck Cancers: A Continuing Challenge.

Background: Head and neck cancers (HNCs) continue to remain a significant public health burden worldwide, causing significant mortality and morbidity despite significant clinical advances enabling their early diagnosis and treatment. Methods: We used data from the GLOBOCAN 2012, Cancer Incidence in Five Continents, World Health Organization Mortality Database and Surveillance, Epidemiology, and End Results programmes to describe the current epidemiology of HNCs. Results: Estimated age-standardised incidence/mortality rates for cancers of the lip and oral cavity among males and females (7.0/2.3 and 2.6/0.6 per 100,000 per annum) in more developed regions are higher compared to those in less developed regions (5.0/2.8 and 2.5/1.4 per 100,000 per annum). Similarly, the estimated rates for cancers of the tonsils and pharynx among males (7.5/2.5 per 100,000 per annum) and females (2.7/0.5 per 100,000 per annum) are reported to be the highest in Western Europe, whereas these rates for cancer of the larynx among males (7.9/4.0 per 100,000 per annum) and females (0.9/0.5 per 100,000 per annum) are reported to be the highest in the Caribbean. Cancer of the nasopharynx represents a significant HNC burden in the Asia-Pacific region and Northern Africa. Conclusion: The current and future estimated burden of HNCs is shifting to less developed regions which may be ill equipped to deal with this increasing burden. This needs urgent attention of policy makers through effective cancer control policy implementation with population-based interventions.

Worldwide incidence, mortality and time trends for cancer of the oesophagus.

The incidence and mortality trends of oesophageal cancer are changing significantly across the world with considerable heterogeneity between sex, histological types, ethnic patterns and geographical distribution. Recent oesophageal cancer incidence and mortality trends have been analysed using data available from the WHO mortality database, the GLOBOCAN 2012 database and the Cancer Incidence in Five Continents database managed by the International Agency for Research on Cancer. Huge geographical variation is an epidemiological characteristic of oesophageal cancer, with the highest incidence rates observed in Eastern Asia and in Eastern and Southern Africa and the lowest rates observed in Western Africa. The variation is to the order of more than 21 times between the lowest-incidence and the highest-incidence countries. Although the incidence of squamous cell carcinoma is increasing globally, its incidence rates are decreasing in the USA and a few European countries. However, the decrease in the incidence of squamous cell carcinomas in these countries has been accompanied by a marked increase in adenocarcinoma incidence rates. There is a significant sex variation as well, with men being affected three to four times more commonly than women worldwide. The observed trends reflect significant global variations in the incidence and mortality of oesophageal cancers on the basis of sex, geographical distribution, ethnicity and histology. These epidemiological factors related to oesophageal cancers point out a possibly significant role of molecular epidemiological factors (genetic susceptibility and response to treatment) with major differences likely between the characteristics of Asian and Western populations.

A cross-country comparison of knowledge, attitudes and practices about tobacco use: findings from the global adult tobacco survey.

BACKGROUND Knowledge and individual perceptions about adverse effects of all forms of tobacco exert direct influence on the level of tobacco consumption in various socio-demographic groups. The objective of this study was to determine the nature, extent and demographic correlates of knowledge, attitudes and perceptions of use of tobacco among adults in low and middle income countries. MATERIALS AND METHODS The Global Adult Tobacco Survey, conducted in fourteen different countries from 2008-2010, was sourced for the data analyzed in this study. Descriptive statistical analyses were conducted to determine the prevalent knowledge and individual perceptions amongst adults about all forms of tobacco consumption. RESULTS There was relatively high awareness about the harmful effects of smoking tobacco with main awareness being about its relationship with lung cancer (>90% in most countries). In contrast, there was relatively low awareness about harmful effects of smokeless tobacco (< 90% in all countries except India and Bangladesh), and observed correlations of smoking tobacco with heart attacks (40.6% in China, 65.1% in India) and stroke (28.2% in China, 50.5% in India). CONCLUSIONS A large proportion of adults living in low and middle income countries possess adequate knowledge about smoking tobacco but have inadequate awareness as well as false perceptions about smokeless forms of tobacco. Popular beliefs of inverse relationships of tobacco consumption with knowledge, attitudes and perception of populations towards tobacco are challenged by the findings of this study.

A risk factor-based model for upper aerodigestive tract cancers in India: predicting and validating the receiver operating characteristic curve.

BACKGROUND A study was conducted to develop and validate a screening model using risk scores to identify individuals at high risk for developing upper aerodigestive tract (UADT) cancers in an Indian population. METHODS A hospital-based case-control study (n = 480) was conducted in Pune, India. We assessed risk factors for UADT cancers by administering a questionnaire through face-to-face interviews. We developed a risk factor model based on the statistically significant risk factors in multiple logistic regression. A total, single risk score was calculated per individual based on the adjusted odds ratio for each of their risk factors. Standard receiver operator characteristic curve was plotted for the total score and the presence of UADT cancers. The stratification ability of the model was determined using the c-statistic. The optimal criterion value was determined at the point on curve at which the Youdens index was maximal. Confidence intervals were calculated by bootstrapping. RESULTS Total risk score for each individual ranged from 0 to 26. Area under the receiver operating characteristic curve (95.8; P < 0.001) suggests strong predictive ability. A risk score criterion value of ≤10 produced optimal sensitivity (93.5%), specificity (71.1%), false-positive rate (28.8%), false-negative rate (6.4%), positive predictive value (74.8%), and negative predictive value (96.6%). CONCLUSION This risk factor-based model has the potential of satisfactorily screening and detection of UADT cancers at its early stage in a high-risk population like India. The identified at-risk individuals can then be targeted for clinical examination and for focused preventive/treatment measures at the hospital.

Relationship of Lifetime Exposure to Tobacco, Alcohol and Second Hand Tobacco Smoke with Upper aero-digestive tract cancers in India: a Case-Control Study with a Life-Course Perspective

Background: Squamous cell carcinomas of the upper aero-digestive tract (UADTSCC) are a multifaceted public health problem. Effects of lifestyle risk factors, including tobacco (chewing and smoking), alcohol drinking and exposure to second hand tobacco smoke (SHS) at home and their association with UADT cancers was assessed in a case-control study with a life-course perspective. The study was conducted at two different hospitals in Pune, India. Material and methods: The total sample size (N=480) included 240 histopathologically confirmed cases of UADT cancers and an equal number of controls frequency matched with cases by gender and age distribution (+5 years). All the patients were interviewed face-face using structured questionnaires. Self-reported information on socio-demographic and lifestyle risk factors from childhood to the date of diagnosis of disease/cancer was obtained. Frequency, duration and age of initiation of habits were also recorded to study dose-response relationships. Odds ratios and their 95% confidence intervals were calculated through unconditional logistic regression, adjusting for relevant potential confounders. Results: Chewing tobacco emerged as the strongest predictor for UADT cancers (OR=7.61; 95% CI 4.65-12.45) in comparison to smoking and drinking alcohol. Exposure to SHS during childhood (<16 years) rather than ≥16 years increased the risk (OR=4.05; 95% CI 2.06-7.95). Combined effects of tobacco and alcohol consumption habits elevated the risk by twelve fold (OR=12.05; 95% 4.61-31.49) in comparison to never users of these habits. Furthermore, the combination of these lifestyle risk factors accounted for 86.8% of population attributable risk. Conclusions: Early exposure to various modifiable lifestyle risk factors has a strong positive association with UADT cancer incidence. Effective future public health interventions with focus on vital time points in life targeting these risk factors could possibly be a major step in primary prevention and control of this cancer at the population level.

Effect of Spinal Cord Injury on Quality of Life of Affected Soldiers in India: A Cross-Sectional Study

Study Design A prospective cross-sectional study with convenience sampling approach was done to assess quality of life (QoL) in 100 soldiers and veterans affected by spinal cord injury (SCI). Purpose SCI affects almost every aspect of the life of an affected individual. This study was done to measure the impact of SCI on QoL of affected soldiers and veterans using the WHOQOL-BREF questionnaire. Overview of Literature The devastating effect of SCI on QoL is well known. However, this study is unique in that it includes soldiers and veterans, who constitute a large, but excluded, cohort in most demographic studies. Methods A cross-sectional study was done at two SCI rehabilitation centres of the Indian armed forces. Data was collected by face-to-face interviews from 100 patients, which included both sociodemographic data as well as all the questions included in WHOQOL-BREF questionnaire. Statistical analysis was performed using SPSS software. Results Age and marital status did not have any influence on QoL. Level of injury (paraplegic or quadriplegic), level of education and presence of other medical co-morbidities had the most significant influence on QoL. Presence of other medical co-morbidities had a negative influence on QoL. Conclusions Identification of factors having a positive and negative influence on QoL help in formulating measures and policies that positively influence the QoL following SCI in soldiers. Future longitudinal studies with larger sample sizes and assessment of additional variables in addition to WHOQOL-BREF, like presence/absence of secondary complications, are required to bring about policy changes to provide SCI patients with additional support and increased access to equipment or lifestyle interventions.

Life course models for upper aero-digestive tract cancer

Upper aero-digestive tract (UADT) cancers are collectively cancers of various human body sites, such as the oral cavity, pharynx, oesophagus and larynx. Worldwide, they are the fourth most frequent cancer type and the fourth most common cause of mortality from cancer. Many studies have shown that several chronic diseases, such as cancer, which occur more commonly in later adulthood, are influenced by social and psychological circumstances during birth, childhood, adolescence and early adult life. It is suggested that the build up of problematic circumstances throughout life is the cause of disease, rather than circumstances that happen at one point in time. UADT cancer is a chronic disease of complex multifactorial origin and most of the underlying exposures/risks cannot be considered as individual factors or in isolation, as they act at different levels, which differ from time to time. Thus, life-course epidemiology, rather than drawing false dichotomies between different risk factors of the underlying disease, attempts to integrate biological and social risk processes that cause the chronic disease. It studies how socially patterned exposures during all stages of life--childhood, adolescence and early adult--influence disease risk in adulthood and socio-economic position and hence may account for social inequalities in adult health and mortality. Furthermore, varying health effects, according to the timing or duration of exposure to socio-economic circumstances, may indicate important traces to the causes of cancer. In this paper, we have attempted to draw a conceptual framework on the relationships between socio-economic inequalities, oral health risk factors along the life-course of an individual and incidence of UADT cancer.

The epidemic of oral cancer in India continues unabated: Need for new policy initiatives

[Extract] The Indian sub-continent remains the global epicentre of oral cancer, first described in Sushruta Samhita, a Sanskrit treatise of ~600 B.C. The burden: incidence, mortality, survival; disease determinants and stretched healthcare resources are under-appreciated. Approximately 70,000 cases and >48,000 oral cancer-related deaths occur yearly. Cases [ICD10, C00–08] are predicted to be ~103,000 pa by 2020. This is the second-most common malignancy in men: fourth in women; many go unrecorded and/or are lost to follow-up.

Associations between oral hygiene habits, diet, tobacco and alcohol and risk of oral cancer: A case–control study from India

OBJECTIVE This study examines the association between the incidence of oral cancer in India and oral hygiene habits, diet, chewing and smoking tobacco, and drinking alcohol. We also assessed the effects of oral hygiene habits with oral cancer risk among chewers versus never chewers. METHODS A hospital-based case-control study was conducted in Pune, India, based on face-to-face interviews, anthropometry, and intra-oral examinations conducted for 187 oral cancer cases and 240 controls. RESULTS Poor oral hygiene score was associated with a significant risk of oral cancer (adjusted OR=6.98; 95%CI 3.72-13.05). When stratified by tobacco-chewing habit, the poor oral hygiene score was a significant risk factor only among ever tobacco chewers (adjusted OR=14.74; 95%CI 6.49-33.46) compared with never chewers (adjusted OR=0.71; 95%CI 0.14-3.63). Dental check-ups only at the time of pain by ever-chewers with poor oral hygiene was associated with an elevated risk (adjusted OR=4.22; 95%CI 2.44-7.29), while consumption of green, yellow, and cruciferous vegetables and citrus fruits was protective. A linear dose-response association was observed between oral cancer and chewing tobacco in terms of age at initiation, duration, and frequency of chewing per day (P<0.001). Smoking more than 10 bidis/cigarettes per day (adjusted OR=2.74; 95%CI 1.28-5.89) and for a duration >25 years (adjusted OR=2.31; 95%CI 1.14-4.71) elevated the risk of oral cancer. CONCLUSION Good oral hygiene habits - as characterized by healthy gums, brushing more than once daily, use of toothpaste, annual dental check-ups, and a minimal number of missing teeth - can reduce the risk of oral cancer significantly. In addition to refraining from chewing/smoking tobacco, a diet adequate in fruits and vegetables may protect against the disease.