Indian J. Prev. Soc. Med. Vol. 41 No.1& 2, 2010

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1 Indian J. Prev. Soc. Med. Vol. 41 No.1& 2, 2010 CANCER REGISTRATION: ITS RELEVANCE FOR HEALTH CARE PLANNING IN INDIA NS Murthy 1, BS Nandakumar 1, NS Shivaraj 1, S Pruthvish 1, CN Shalini 1, K Chaudhry 2 &, A Mathew 3 ABSTRACT Cancer registration is the process of continuing, systematic collection of data on the cancer occurrence and charac teristics of reported neoplasms with the purpose of helping to assess and control the impact of malignancies on the community. Broadly, there are two types of cancer registries viz. Population based and Hospital based cancer registries. The population-based cancer registries (PBCR) records all newly diagnosed cases of cancer occurring in a population of well defined composition and size. Such information is the primary resource for planning, evaluating health services for the prevention, diagnosis, treatment and epidemiologic research. On the other hand the hospital-based cancer registry (HBCR) records all cases in a given hospital without knowledge of the background population and emphasis is on clinical care and hospital administration. The present paper addresses issues relating to (i) cancer registration principles and methods, establishment, collection and quality measures being adopted by the Indian PBCRs and (ii) its relevance to health care planning in India through estimation of certain statistical information needed for development of cancer control measures. Presently, a network of twenty three population based cancer registries is functioning in the country under the National Cancer Registry Programme (NCRP) of Indian Council of Medical Research (ICMR). Based on cancer incidence data obtained from various PBCRS, an attempt was made to provide scenario of cancer in India during the year 2001 and its projections for 2016 for all sites of cancer as well for selected leading sites of cancer. Similarly, attempts have been made to study time trends, disability adjusted years of life lost (DALYs), risk for development of cancer and shortfalls in radiotherapy facilities. During the year 2001, nearly 0.80 million new cancer cases were estimated and this would get increased to 1.22 million by 2016 as a result of change in size and composition of population. Lung, esophagus, stomach, oral and pharyngeal cancers are much higher in men while in women, cancers of cervix and breast are predominant forms followed by those of oral cancers, stomach and esophagus. Tobacco related cancers account for almost one-third of all cancers in India-predominantly oral and pharyngeal, lung and esophageal cancers. Trend analysis by modeling approach revealed statistically significant increase in Age adjusted Rates (AAR) for all sites of cancer and for various other sites over time period. Further it was estimated that DALYs due to cancer in India combined for both sexes would increase from 46.0 lakhs in 2001 to lakhs in The above computations revealed huge burden of cancer and the urgent need for initiating primary and secondary prevention measures for control of cancers. INTRODUCTION Cancer is regarded universally as a dreaded disease and as an important health problem. Cancer registries have been established in many developed and developing countries throughout the world. The main objective of such registries is to improve efforts towards cancer control by providing information not only on magnitude of cancer problem and patterns of cancer in various segments of population, to study the various epidemiological and aetiological factors related thereon but also for planning and evaluation of health services. 1 Dept. of Community Medicine, MS Ramaiah Medical College, MSR Nagar, Bangalore, Division of Non- Communicable Diseases, ICMR, New Delhi, Regional Cancer Centre, Trivandrum, Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB & Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

2 The present paper addresses issues relating to (i) cancer registration principles and methods, establishment, collection and quality measures being adopted by the Indian PBCRs (ii) magnitude and patterns of cancer, and (iii) results of estimation of certain statistical information needed for development of cancer control measures in terms of incident number of cases & its projection till 2016, trends in incidence of sites of all sites, DALYs, Probability for development of cancer and shortfalls in radiotherapy facilities. A. Cancer registration principles and methods, establishment, collection and quality measures being adopted by the Indian PBCRs Definition of Cancer Registry Cancer registration is the process of continuing, systematic collection of data on the cancer, occurrence and characteristics of reported neoplasm s with the purpose of helping to assess and control the impact of malignancies on the community 1. Cancer registry has been defined as an organization for collection, storage, analysis and interpretation of data on persons with cancers. Cancer registry is an essential part of any rationale programme of cancer control activity 2. Types of registry: Broadly, there are two types of cancer registries viz. Hospital based cancer Registry (HBCR) and the Population Based Cancer Registry (PBCR). The hospital-based cancer registry (HBCR) records all cases in a given hospital without knowledge of the background population and emphasis is on clinical care of cancer patients by assisting clinicians in the follow-up of their cases, by providing statistical data on the results of therapy and the hospital s cancer programme. They contribute to the PBCR in the given area and help to undertake epidemiologic research. In contrast to Hospital based cancer registry, Population-based cancer registries (PBCRs) collect and classify information on all cancer cases and produce statistics on the cancer incidence and mortality in a population of well defined composition and size. The hospital based registry may form as a nucleus for a population based cancer registration scheme. Requirements for establishment of PBCR: It is essential that the purpose of cancer registration be clearly defined before a registry is established. The way in which a registry operates depends, inevitably, on local conditions and on the material resources available. The plans for a cancer registry should be discussed with members of the medical profession, medical agencies and health care officials. In the planning of a population based cancer registry, the availability of accurate and regular published population data by sex and five year age groups are required. Optimal size of the population covered by PBCRs are generally between one and five millions. For operation of a registry there must be sufficient funds and personnel. The registries are established in a variety of locations such as research organizations, associated hospitals, cancer hospitals and institutes of pathology 2. Tasks of registry : The Cancer registry has several tasks to perform (a) individual follow-up of cancer patients, (b) to provide reliable morbidity & mortality statistics with a view to accurate estimate of therapeutic results, (c) accurate evaluation of variation in incidence of malignant neoplasms, by secular, geographical, occupational and establishing a sound basis for research 2. Cancer registration in India: India has a long tradition of research in the field of cancer epidemiology. It has one of the oldest cancer registries in this part of the world dating back to 1964 when the Indian cancer society established one at Bombay. The information generated through this registry has provided the scenes as it existed in Bombay till 1982, there was no data from other parts of the country excepting for data from Aurangabad, Nagpur and Pune. Realising this, the Indian Council of Medical Research (ICMR) initiated a net work of cancer registration through the national cancer registry project (NCRP) during 1981 Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 76

3 with the definitive aim of assessing incidence and distribution of cancer in the country. The objectives of NCRP were three fold, (i) to generate data on the magnitude of cancer problem (ii) undertake epidemiological investigations and provide control measures and (iii) undertake human resource development. The NCRP augmented/ established three population-based registries at Bombay, Bangalore and Madras and three hospital-based registries at Dibrugarh, Chandigarh and Trivandrum in Over the years the registry network has expanded so as to have twenty three PBCRs under NCRP network, which are located at Bangalore, Barshi (rural registry, Maharastra), Bhopal, Chennai, Delhi, Mumbai, Ahmedabad District (other than Ahmedabad urban), Kolkata (West Bengal) and, eight under North Eastern region of the country, recently augmented registries of Poona, Nagpur and Aurangabad, urban registry of Ahmedabad in Gujarat, Kollam district in Kerala, urban registry of Trivandrum located at the Regional Cancer Centre. Besides this, there is one population based cancer registry at Ambillikai is under the Cancer Institute, Chennai. However, the coverage of NCRP in India is less than 15%. Methods of data collection: Traditionally, reporting methods in cancer registry have been classified as active or passive. Active reporting involves registry personnel actually visiting various sources for data collection and abstracting the required information onto special forms or obtaining copies of necessary documents. Passive (self) reporting relies upon other health care workers to complete notification forms and forward them to registry or send copies of discharge abstracts etc. from which necessary data can be obtained 2. Cancer is not as yet reportable disease in India. In the Indian registries this 'active-system' is being followed since there is no centralized reporting system in India and also there is no legislation in the country concerning registration and notification of cancer either at the centre or at state level. To initiate, establish and sustain population based cancer registries as per international norms requires meticulous planning, cooperation of medical institutions in the area, dedicated and committed personnel and adequate funding. Sources of data collection in PBCRs: The main sources of data collection for cancer registry are through hospitals or cancer centres. Population based registry involve private clinics, general practitioners, laboratories, hospices, health insurance systems, death certificates, screening programmes and central registries. In Indian PBCRs, the data collection in each of the registries is being carried out by the social workers who visit each of the hospital/ nursing homes/laboratories/specialists/ routinely to enumerate the cancer cases. Staff scrutinize the records in various departments of the hospital that include pathology, radiology, radiotherapy, in-patient wards and out-patient clinics to elicit the desired information on reported cancer cases in a common core proforma that has been standardized for all cancer registries in India. Besides the above sources, pathology laboratories that routinely report cancer cases are also visited. In addition, the information on deaths is also being collected from the departments of vital statistics of the respective municipal corporations to have complete information on number of cancer cases. Every attempt is made by the registries to register all cancer patients. The use of multiple sources for data collection helps to prevent for the cases being missed and ensure that only a few cases may escape from the registry. The detailed methodology adopted by the PBCR's for validating the data has been reported in the annual reports of registries 3. a. Diagnostic criteria: Coding of the disease in the registries is being done according to International Classification of Diseases (WHO, ICD-10). This facilitates comparison of the data with that from registries across the world. In addition, to facilitate the detailed histological studies, coding is also done according to International Classification of Diseases for Oncology (WHO, 3 rd edition 2002) 4,5. b. Data quality and indices of reliability of diagnosis: The registries routinely undertake various exercises to ensure that the data they gather and process is of high quality 6. The three commonly used indices for comparing the registered data on incident cases are (i) microscopic verification of diagnosis (MV) (ii) the proportion of cases registered for which no Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 77

4 information was available other than death certificate only (DCO) that the deceased with cancer and (iii) mortality by incidence ratio (M/I). Of the several criteria of reliability of diagnosis, microscopic verification can be considered as most valid. Microscopic verification of diagnosis has been generally good in all the Indian PBCRs registries. As per the recently published reports of PBCR, the proportion of cancer cases based on clinical diagnosis ranged from 0.0% to 12.2% in the eight PBCRs viz. Bangalore, Barshi, Bhopal, Chennai, Delhi, Kolkotta, Mumbai working under the net work of NCRP for the year (Table 1A &B). While the diagnosis based x-ray examination varied from 0.7% to 12.5% in different registries. The proportion in the category of death only is around 0.7% to 9.0% in all the above PBCR's. In males, Kolkata registry (83.3%), Mumbai (83.7%), Barshi (80.6%), Chennai (79.6%) and Ahmedabad district (other than Ahmedabad urban) (79.1%). In females, Kolkata (91.6%), had the highest proportion of cancer cases confirmed microscopically followed by Bhopal (91.1%), Barshi (83.3%), Bangalore (86.9%), Chennai (85.7%), Mumbai (84.0) and Ahmedabad (other than Ahmedabad urban). Similarly, The portion of microscopic diagnosis in the eight registries areas covered under NERPBCRs varied from 60.5% in males in Silchar Town to 95.6% in females in Imphal West District. Table-1: Relative Proportion of cancers (%) based on different method of diagnosis in Indian registries-males Registries Male Female Microscopic X- Ray Clinical Others DCO Total Microscopic X- Ray URBAN Bangalore a Mumbai (Bombay) a Bhopal a Delhi a Chennai (Madras) a Kolkata a Trivandrum RURAL Barshi a Ahmedabad NER PBCR Barshi a Ahmedabad NER PBCR Dibrugarh b Kamrup Urban Dist b. Silchar Town b Imphal West Dist b. Mizoram state b Sikkim State b Source: a National cancer Registry Programme (2008). b National cancer Registry Programme (2008). Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 78

5 Table -2 : Percentage by mortality incidence percent The mortality by incidence ratio (M/I) is an important indicator of completeness of registration. In general, in cancers with very poor survival such as cancer of liver, the M/I will be close to 1 (or 100). Cancers with better survival like breast cancer would have figures less than one. If the number of deaths as obtained by DCO exceeds the number registered, then the registration can be taken as incomplete, unless the incidence of that cancer is declining at a very rapid rate. The indices of reliability for all sites and all ages during the year and are presented in Table 2. A uniform pattern of recording is being followed by all the registries. The information is collected on a standard proformae at each of the registries. The same is being sent to technical unit for computerization. Duplications are checked at each level of the registries and also at the technical wing and as mentioned earlier morphology ICD- 10 and ICD-O are being employed. Registry Male M/I URBAN Bangalore a Mumbai (Bombay) a Bhopal c Delhi a Chennai (Madras) a Kolkata e Trivandrum a RURAL Barshi c Ahmedabad a Dibrugarh Kamrup Urban Dist Silchar Town Imphal West Dist Mizoram state Sikkim State Female M/I Source: a National cancer Registry Programme (2008). b National cancer Registry Programme (2008). The other areas of consideration of quality in PBCRs are (a) completeness of coverage (to obtain information on all cancers diagnosed in the population so as to ensure a high degree of case ascertainment), (b) adequacy of data (to have certain core and critical items of patient information on all cases), (c) accuracy of data ( to ensure that data are from erroneous abstraction, coding, data entry, etc), comparability of data and reliability of data. The details on these aspects as adopted by registries have been published by the registries elsewhere 7,8. c. Problem in cancer registration : Cancer registration is quite a complex undertaking, and careful quality control is essential to ensure that the resulting data on incidence are valid and reliable. The major problem, however, is ensuring that every new case of cancer is identified. The ease with which this can be done depends on the extent of the medical facilities available and the quality of the statistical and recording systems already in place (e.g. pathology request forms, hospital discharge abstracts, treatment records). A further difficulty is identifying individuals and ascertaining that they do in fact come from the population under study. These problems are difficult to surmount in developing countries. Incidence statistics from cancer registries around the world are published in the series of compilations entitled cancer incidence in five continents [15-19] which also contain a description of the methods used to measure the validity of registry data. Changing standards of diagnosis have been mentioned as a possible source of confusion in interpreting trends in mortality and this will apply also to registry data. However, a further problem with the registration of new cases of cancer is a precise definition of incidence. For example, sub-clinical cancer is very common in the elderly, and may be brought to light by autopsy. Breslow et al 21 found cancer in 25% of prostate glands of males aged 70 in the USA; if such cases are registered, incidence rates will vary greatly depending on autopsy rates. Similarly, the introduction of widespread screening programmes e.g. for cancer of the breast will result in the detection of many lesions with histological features of malignancy -many of which may never have become clinically manifest. Registration of such lesions as incident cancer will result in apparent increase in incidence rates (usually with no corresponding change in mortality). Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 79

6 d. Utility of data being generated by the PBCRs : Population based cancer registry data helps to know the distribution of cancers in human population and to search for the determinants of the disease. The population based cancer registries provides the following types of statistical information needed for health care planning and monitoring in terms of : (a) incidence, prevalence & mortality rates and distribution of cancers occurring in a defined area, (b) cases by diagnostic entities by topography of tumour, (c) geographical differences in cancer occurrence and mortality, ( d) need for treatment facilities, (e) patients survival rate with various treatment modalities, (h) understanding the effect of various screening programmes being initiated for the control of cancer, (i) studying of time-trends in the incidence/mortality rates of cancer employing modelling procedures, (j) estimation of burden of disease in terms of disability adjusted life years (DALYs), (k) estimation of risk for development of cancer and,(l) economic implications. e. Impact of registry operations i. PBCRs in cancer control : The data generated by NCRP has been of great help in formulating and monitoring of the national cancer control programme and preparing strategies for cancer control. The net work of cancer registries in India has provided initial estimates of the magnitude of the cancer problem in the country, and has given an idea of the common cancers in men and women. It has revealed that almost half of the cancers in men and about a quarter in women are related to tobacco habits and are therefore amenable to primary prevention. In women, bulk of the cancers are of the uterine cervix, and their early detection by cervical cytology can have a major impact in initially shifting the stages of disease at diagnosis to the left, and later on in reducing incidence and mortality due to uterine cervix cancer and oral cancers. The data generated by the NCRP especially on tobacco related cancers, cervical and breast cancers have been of value in determining the priorities for the national cancer control programme for India. The data has specifically shown the importance of tobacco control and of early screening for specific cancer sites such as oral cervical and breast cancer to create a maximum cancer control impact. In the recent five year plans under National Cancer Control Programme (NCCP) due importance has been paid for control and prevention of these cancers through primary and secondary prevention measures. The NCRP has also given a major thrust to research in cancer epidemiology in India, apart from generating public awareness and attracting the attention of health policy planners. ii. Epidemiological investigations carried out by NCRP: The magnitude and patterns of cancer obtained from the various PBCRs in India helped in determining clues to the cause of cancer. A number of research investigations mainly epidemiologic studies have been undertaken based on the cancer registry data and many of the results have been published in national and international journals. Studies in cancer epidemiology in India till the late 1960's essentially concentrated upon descriptive and analytical studies of malignancy of oral cavity and uterine cervix. The NCRP, apart from generating data on the incidence of cancer as a whole, has also brought forth certain interesting aspects such as predominance of stomach cancer in Madras and Bangalore, the high frequency of oesophageal cancer in almost all parts of the country, and a very high proportion of pharyngeal cancer in the north-eastern part of the country. In view of the above, epidemiological studies related to stomach cancer at Bombay, Madras and Trivandrum, oesophagus at Bombay, Bangalore and Chandigarh, pharynx at Dibrugarh and cervix with special reference to factors related to primary prevention at Delhi and Bombay [9-14] were undertaken using case-control approach. In Trivandrum, other than the studies carried out by the NCRP a number of epidemiologic studies on cancers of the breast, lung, colon, oral cavity and leukemia were conducted in collaboration with international agencies. Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 80

7 Table- 3: Crude and Age adjusted incidence rate per 100,000 person years (AAR) of cancer all sites in Indian registries Male Female Registry Period CR AAR CR AAR Aurangabad b Bangalore a Mumbai (Bombay) a Bhopal c Delhi a Chennai (Madras) a Kolkata e Nagpur a Trivandrum a Pune a Barshi c Ahmedabad a Dibrugarh Kamrup Urban Dist Silchar Town Imphal West Dist Mizoram state Sikkim State Source: a National cancer Registry Programme (2008). b National cancer Registry Programme (2008); PBCR, Regional Cancer Centre, Trivandrum, 2005.; Cancer Incidence and patterns in Urban Maharastra-2008, Mumbai, India [B] Magnitude & Patterns of cancers: a. Cancer incidence and mortality rates in India: The cancer registries are rich source for yielding information on the magnitude on cancer in different population groups i.e. incidence rates and mortality rates of cancer at various sites for the geographical areas being covered by the NCRP. The crude incidence rate for the year from the eight PBCR's ranged from 45.3 to 74.5 and 37.5 to per 100,000 males and females respectively. The age adjusted incidence rates of all cancers vary from 67.5 to for males and 59.9 to for females respectively 7,8,22,23 (Table 3). The incidence rates in rural populations were quite low in comparison to their urban counterparts. Cancer mortality rates in India are often under reported due to poor recording of the cause of death. The crude mortality rate in the six PBCRs (crude mortality rates) have been reported to be 23.7, 31.9, 18.1, 38.6, 9.0, 34.4, and 22.4, 36.1, 16.4, 32.4, 7.6, 34.4 amongst males & females respectively in Bangalore, Barshi, Bhopal, Chennai, Delhi, Mumbai respectively. The pooled rates for all registries were observed to be 23.4 and 23.0 amongst males and females respectively. b. Pattern of Cancers in the country : Lung, esophagus, stomach, oral and pharyngeal cancers are the predominant cancers in men. In women, cancers of the cervix and breast (these two cancers together account for nearly 40% of all female cancers) are the predominant sites followed by stomach and esophagus (Table 4) 24. Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 81

8 However, variations occur in the site-wise distribution within various population groups. Esophageal cancers are often found in the southern states of India such as in Bangalore and Chennai and also in Mumbai and Ahmedabad. Stomach cancers are more common in Southern India with the highest incidence in Chennai. Cancers of oral cavity are high in Kerala (southern India) and pharyngeal cancers in Mumbai (western India) and in the north-eastern part of the country. Thyroid cancers among women are more common in Kerala. Gall bladder cancer is high in northern India, particularly in Delhi and Kolkata 24. c. Cancer sites associated with use of tobacco : The proportion of tobacco related cancers (TRC) (oral cavity, pharynx, esophagus, larynx, lung and urinary bladder) in males vary from 35.6% in Bangalore to 50% in Bhopal, whereas in females Bangalore has the highest proportion of TRCs (17.3%). Table- 4: India & States Projected annual number of new cancer cases by sex during quinquennial years Both sexes Sites India Andhra Pradesh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Source: Murthy et al., APJ C P, 9, , 2009 Cancer of the lung is the leading site in Delhi, Mumbai, Bhopal, Trivandrum and Karunagappally. It is the second and third leading site among males in Bangalore and Chennai respectively. In females also, cancer of the lung is one of the ten leading sites in Bhopal, Chennai, Delhi and Mumbai. Cancer of the oral cavity and pharynx in both males and females are high in all the registries particularly in Kerala. Cancer of the esophagus is one of the three leading site in both males and females in Bangalore, Chennai, Mumbai, Bhopal and Barshi 24. [c] Results of estimation of incident number of cases & its projection till 2016, trends in incidence of cancer, DALYs, Probability for development of cancer and shortfalls in radio-therapy facilities. a) Projections of incident number cancer cases: Plausible projections of future burden of cancer in terms of incident cases at the national and state level are useful aid in decisions for planning of cancer control activities. Based on the data of pooled incidence rate of 12 population based registries established in the country and Population of the country according to age and sex the estimates of incident number of cases for different calendar years viz. 2001, 2006, 2011 and 2016 were made. Detailed methodologies of estimations have been reported elsewhere 25. In India, during the year 2001, nearly 0.80 million new cancer cases were estimated and this would get increased to 1.22 million by 2016 as a result of change in size and composition of population. The estimated cases were more for females (0.406 millions, 2001) than males (0.392 millions, 2001) (Table 5). When adjustments for increasing tobacco habits and increasing trends in many cancers are made, these estimates may further get increased 25. b) Time trends through modelling approaches: The information behind cancer incidence and trends forms the scientific basis for planning and organization of prevention, diagnosis and treatment of cancer in the community. The trends also may give rise to hypothesis concerning the etiology and biology of cancer, and they are applicable for the Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 82

9 testing of various hypothesis presented in clinical and experimental oncology. A trend, however, always represents a summary curve of changes that have occurred with different groups of people living under divergent conditions [26]. Trends in the incidence rate of cancer, was carried-out for 7 PBCRs of the country, viz: Ahmedabad, Bangalore, Chennai, Delhi, Mumbai, Nagpur & Poona based on published literature Detailed methodologies of trend estimations based on relative difference method have been reported elsewhere [26]. In brief, trends in cancer incidence were calculated by considering (i) period of diagnosis alone (ii) age at diagnosis in broad intervals and five year intervals (iii) considering all the factors such as period, age at diagnosis and age at birth. Table- 5: Incident number of cancer cases by pattern and sex in 2001 and 2016-National level Pattern of Cancer Male Female Oral Cavity Pharynx & Larynx Oesophagus Stomach Lung Breast Cervix Uteri Others Total Source: Murthy et al., APJ C P, 9, , 2009 c) Trends in crude and age adjusted incidence rates (Tables Nos. 6a & 6b): The trend analysis showed that in males, when all sites of cancer were considered together, in Chennai registry, the crude incidence rate showed an increasing trend from 64.8 in to 89.6 in and similarly age-standardized incidence rates adjusted to the world standard population increased from 95.3 to showing an increase of nearly 1.9% per year in CR and 0.6% in AAR, while in females, such increasing trends were noticed in CRs amongst Mumbai (0.77 percent per year) and Nagpur (1.1 percent per year) registries (Table 6a & 6b). The AAR also revealed an increase in the rates however, the mean percentage change per year was small. Table- 6a: Trends in crude rates (CR) and age adjusted rates (AAR) per 100,000 person years in various registries by calendar year and mean annual percent change (MAPC) between the earliest and last period: All Sites of Cancer, Males. Period Ahmedabad Bangalore Chennai Mumbai Nagpur Poona Delhi CR AAR CR AAR CR AAR CR AAR CR AAR CR AAR CR AAR! N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A * N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A. N.A. N.A NA NA Mean % N.A. = Not available; * = in case of Nagpur. Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 83

10 Table-6 b: Trends in crude rates (CR) and age adjusted rates (AAR) per 100,000 person years in various registries by calendar year and mean annual per-cent change (MAPC) between the earliest and last period: All Sites of Cancer, Females. Period Ahmedabad Bangalore Chennai Mumbai Nagpur Poona Delhi CR AAR CR AAR CR AAR CR AAR CR AAR CR AAR CR AAR! N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A * N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A. N.A. N.A. N.A. N.A N.A. N.A N.A. N.A. N.A. N.A NA NA Mean % Similar analysis carried out for other leading sites revealed that cancer of liver, gallbladder, lung, prostrate, urinary bladder, brain, thyroid gland, female breast, endometrium, ovary and non-hodgkin s diseases, myeloid leukemia showed increasing trends in incidence in majority of registries over period. During the same period, cancers of the tongue, mouth, hypopharynx, oesophagus, stomach, larynx, and uterine cervix have registered a decline in incidence over a period of observation in most of the registries. e. Estimation of burden of disease in-terms disability adjusted life years (DALYs): In the present study YLD and YLL and DALYs were estimated by the methodology suggested by under Global Burden of Disease (GBD). Further, disease model (DISMOD II) was employed for carrying out computations. The estimates of burden of disease due to cancer have been based on the pooled data of six PBCRs-Bangalore, Barshi, Bhopal, Chennai, Delhi and Mumbai for the year The DISMOD disease model assumes that there are two causes of death: from the disease under study and from all other causes, which are assumed to be independent. Under this assumption the disease model is completely determined by the three- transition hazards incidence, remission and case fatality. However, for cancer disease, information on remission is difficult to obtain. DISMOD II is useful in situations when an input variable like prevalence is known. When values for the three hazards are entered in DISMOD II, the programme inserts these values in the equations, and calculates the epidemiologic variables and compares them with the input variables. The DISMOD II needs total mortality rates and population number under study. All the variables are by age, and calculations are done separately for men and women. WHO Template of DALY was employed for estimations. The pooled estimates of incidence & mortality data of all the six registries were 70.8, 84.2 and 23.4 & 23.0 (per 100,000 populations) for males and females respectively. The DISMOD analysis of DALYs for various sites of cancer is given in table 8. The total number of DALYs due to cancer in India in the year 2006 is estimated to be lakhs (Table 7). The projection of DALYs due to cancer in the country by various leading sites from 2001 to 2016 is given in table 8. The estimated burdens of total number of DALYs attributable to cancer in the present investigation are lakhs in 2001 and would get increased to lakhs for f. Risk for development of cancer: Based on the incidence rates of 12 population based cancer registries, current probability for development of cancer is found to be 1 in 10 amongst men and 1 in 8 amongst women. The current probability (per-cent) for development of malignancy of all sites of cancer from years was found to be 4.67%in males and 6.55% in females. The increased risk in females was mainly due to the high risk of development of cancer Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 84

11 of uterine cervix and breast. When 35 to 70+ years were considered, the probability percentage was found to be 9.94% and 11.62%. According to these estimates that, 1 in 10 men and 1 in 8 women would develop cancer of any form some time after the age 35 years. The probability of developing of tobacco related cancers from 35 years to 70+ years was found to be 4.75% and 2.16% amongst males and females respectively 29. Table-7: Site- specific burden of cancer for males and females by various periods TOTAL DALYS Sites of Cancer Male Female Oesophagus 106, , , ,593 76,805 90, , ,404 Stomach 94, , , ,528 62,218 71,993 83,503 96,572 Liver 75,315 86, , ,635 39,423 46,235 53,846 62,271 Pancreas 37,046 42,778 50,181 58,282 24,026 28,473 33,333 38,740 Breast 5,720 6,444 7,478 8, , ,689 1,088,642 1,244,773 Cervix uteri , , , ,279 Corpus Uteri ,242 45,473 53,055 61,910 Ovary , , , ,909 Prostate 43,033 53,682 64,263 76, Bladder 38,273 44,138 51,463 59,826 10,400 12,447 14,788 17,456 Oral cavity 549, , , , , , , ,460 Colon & Rectum 79,065 91, , ,043 69,857 82,491 96, ,851 Trachea & Bronch & Lung Melanoma & Oth. Skin Lymphoma &. Mul Myeloma 169, , , ,468 65,434 76,726 89, ,791 26,025 29,661 34,161 38,767 14,380 17,080 20,010 23, , , , ,969 76,131 87,073 98, ,678 Leukaemia 219, , , , , , , ,925 Other Cancers 464, , , , , , , ,508 Total Murthy, (2009): ICMR, New Delhi g. Radio therapy requirement and short falls: The existing radiotherapy facilities available in the country for cancer treatment during the year 2007 was obtained from published reports and updated through personal communication from the Ministry of Health of Govt. of India. Considering all the sources, it is noted that there were 347 Teletherapy units (Telecobalt 258 units, Telecesium 4 units, Accelerator 85 units) and 240 Brachytherapy installations (Remote Brachytherapy 137; Manual Brachytherpy 103) in 237 centres across the country during the year Keeping in view of magnitude of cases of cancer, the actual requirement of radio-therapy installations has been worked out for the country level from 2006 till 2016 based on the WHO recommendations that one cobalt unit is required for one million populations. The calculations revealed that 1059, 1100 and 1142 installations are required for the years Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 85

12 2006, 2011 and During the year 2007 as against the actual requirement of 1059 only 347 installations were present indicating short-fall of more than 700 teletherapy units in the country (Table 8). Table -8: Projected all India & in the major 15 states requirement of Teletherapy Units and short falls in each of the state. CONCLUSION In this context, cancer registries provide a range of important information pertaining to distribution and determinants of cancer which have a pivotal role in planning and implementation of prevention, control and management of various malignancies in defined populations. Thus for the establishment and proper utilization of cancer registries it is imperative that necessary quality assurance measures are undertaken at each juncture to ensure reliable and valid information for decision making. The cancer registries in India are mainly in urban areas except a few registries, but 70-80% of India s population live in rural areas. Thus there is a limitation to the information on cancer in India obtained from the present registries and the need for more information on cancer in the rural population is apparent. Requirement of Radiotherapy installations@ Short fall in Radiotherapy installations during India Andhra Pradesh Assam Bihar Gujarat Harayana Karnataka Kerala Madhy Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal REFERENCES Source: Murthy et al., APJ C P, 9, , Jenson O. M., and Whelan S, Planning a cancer registry, In: Cancer Registration Principles and Methods, IARC Scientific Publication, Eds. Jenson OM, Parkin DM, Macclennan R, Muir CS and Skeet R.G.,Lyon, 1991; 95, Jenson OM and Storm HH, Purposes and uses of cancer registration: In: Cancer Registration Principles and Methods, IARC Scientific Publication, Eds. Jenson OM, Parkin DM, Macclennan R, Muir CS & Skeet RG., Lyon, 1991;95, Powell J, Data sources and reporting, In: Cancer Registration Principles and Methods, IARC Scientific Publication, Eds. Jenson OM, Parkin DM, Macclennan R, Muir CS and Skeet RG.Lyon, 1991; 95, WHO International Statistical Classification of Diseases and Related Health Problems-10 th revision, World Health Organization, Geneva, WHO International Classification of Diseases for Oncology (ICD-O). Third Edition, Eds. Fritz, A., Percy, C., Jack, A., Shanmugaratnam, K., Sobin, L, Parkin DM and Whelan S, World Health Organization, Geneva, Skeet R. G., Quality and quality control., In: Cancer Registration Principles and Methods, IARC Scientific Publication, Eds. Jenson OM, Parkin DM, Macclennan R, Muir CS and Skeet R. G. Lyon, 1991; 95, National Cancer Registry Programme (NCRP). Two-year report of the population based registries , Incidence and distribution of cancer, Indian Council of Medical Research, New Delhi, 2008 a. Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 86

13 8. National Cancer Registry Programme (NCRP). North East population based registries, Second report: , Incidence and distribution of cancer, Indian Council of Medical Research, New Delhi, 2008 b. 9. Gajalakshmi CK and Shantha V. Lifestyle and risk of stomach cancer: A hospital-based case-control study, International Journal of Epidemiology 1996; 25, 1146, 10. Mathew A, Gangadharan P, Varghese C, Nair MK. Diet and stomach cancer: A case-control study in South India. Eur J Canc Prev, 2000; 9, Nandakumar A, Anantha N, Dhar M, Ahuja V, Kumar R, Reddy NMS, Venugopal TC, Rajanna, Vinutha AT and Srinivas. A case-control investigation on cancer of the ovary in Bangalore, India. Br J cancer, 63, , Nandakumar A, Anantha N, Pattabhiraman V, Prabhakaran PS, Dhar M, Puttaswamy K, Venugopal TC, Reddy NMS, Rajanna, Vinutha AT and Srinivas. Importance of anatomical sub-site in correlating risk factors in cancer of the esophagus report of a case-control study. Br J Cancer, 1996; 73, Jussawalla DJ, Yeole BB, Natekar MV.Cancer in Indian Moslems.Cancer, 1985; 55(5), Yeole BB, Advani SH, Kukure AP and Sunny L. An assessment of cancer incidence patterns in Parsi and non-parsi populations in greater Mumbai, Asian Pacific J of Cancer Prevention, 2001; 2, Waterhouse JAH, Muir CS, Correa P. Cancer incidence in Five Continents, International Agency for research on Cancer, Lyon, Vol III, IARC Scientific Publication, 1976; Waterhouse JAH, Muir CS, Shanmugarathanam K. Cancer incidence in Five Continents, International Agency for research on Cancer, Lyon, Vol IV, IARC Scientific Publication, 1976; Muir CS, Waterhouse JAH, Mack T. Cancer incidence in Five Continents, International Agency for research on Cancer, Lyon, Vol. V, IARC Scientific Publication, 1987; 5 (88). 18. Parkin DM, Muir CS, Whelan Sl. Cancer Incidence in Five Continents. VI. International Agency for research on Cancer, Lyon, France, IARC Scientific Publication, 1992; Parkin DM, Whelan SL, Ferlay J. Cancer Incidence in Five Continents. VII. International Agency for research on Cancer, Lyon, France, IARC Scientific Publication, 1997; Parkin DM, Whelan SL, Ferlay J. Cancer Incidence in Five Continents Vol. VIII. International Agency for research on Cancer, Lyon, France, IARC Scientific Publication 2002; Breslow, C.W. Chan, G. Dhom et al., Latent carcinoma of prostate at autopsy in seven areas of USA, Int J Cancer, 1977, 20, PBCR (Population Based Cancer Registry), Two Year Repot Report ; Regional Cancer Centre, Trivandrum, Cancer Incidence and patterns in Urban Maharastra-2001, Report to the State of Maharastra on Status of Cancer, Indian Cancer Society, Cancer Registry Division Division, Mumbai, India, Murthy NS and Mathew A Cancer Epidemiology, Prevention & Control-Indian Scenario. Current Science, 2004; 86, Murthy NS, Chaudhry K, Rath GK. Burden of cancer & projection for 2016, Indian Scenario: Gaps in the availability of radiotherapy treatment facilities, Asian Pacific Journal of Cancer Prevention, 2009; 9, Murthy NS. Trends and patterns of cancer load in India: An Epidemiological estimation and analysis, Submitted to the Indian Council of Medical Research, New-Delhi, (Mimeographed), Murthy, NS Usha K Agarwal, K Chaudhry, and S Saxena. A study on Time Trends in incidence of breast cancer-indian Scenario, European J Cancer Care, 2007; Murthy NS, Nandakumar BS, Shivaraj NS and Pruthvish S. Estimation of burden of cancer in-terms of DALYs, Proceedings of the Karnataka association for community health, 9 th & 10 th, JSS Medical College, Mysore, Shivaraj NS, Murthy NS, Nandakumar BS and Pruthvish S. Risk for development of cancer, Proceedings of the Karnataka association for community health, 9 th & 10 th, JSS Medical College, Mysore, Indian J. Prev. Soc. Med Vol. 41 No.1 & 2 87