5 DECADES OF

CANCER CONTROL
1955 2005
Dr.(Mrs.) S. Muthulakshmi Reddy
1886-1968
Cancer Institute (WIA),
Chennai, India
CANCER IN INDIA

Historical

1895 Balram Jaker : Trivandrum
1905 Niblock : Govt. General Hospital, Madras

Related association of Tobacco habit & Oral cancer

1933-37 Viswanath & Grewal
Edward Medical College, Lahore

First field study of Cancer in India

Documented common cancers then,
as of now, Mouth, GI Tract, Cervix, Penis
CANCER TREATMENT FACILITIES
1941 Tata Memorial Hospital at Mumbai

1950s Chittaranjan Cancer Hospital, Calcutta

1954 Cancer Institute(WIA), Chennai

All non governmental efforts

Radiotherapy departments of General Hospitals
with only High Voltage units
Cancer Control: a complex
multidisciplinary effort
Has to co-ordinate advances in early
diagnosis, prevention, therapy and
palliative care

Develop them synchronously

Object: Reduce morbidity and mortality
due to cancer.
Data from the Demographic Registries

Common cancers in women Cervix, breast
and oral cavity (52%)

Common cancers in men Tobacco related
(45%) (Oral, lung, pharynx and oesophagus)

Breast and cervix 47% of all cancers in
women

Over 75% of patients seek treatment at a late
stage.

Prevention of Cancer

Primary prevention elimination of the causative
agent most cost effective

Priority to Tobacco control more easily said than
done

Comprehensive strategy needed
Education of youth and adults
on healthy life style
Cessation programmes
Legislative action

Implementation: Needs motivated groups
OBJECTIVE 1 of NCCP:
ANTI TOBACCO PROGRAMME
ICMR Sponsored : Anti tobacco health education and
oral screening

Trivandrum : Unemployed youth trained
Tobacco as health hazard
Various aspects of oral cancer
Clinical appearance of normal and
abnormal oral mucosa
pre-cancer and cancer

Karnataka : Recorded 37.8% reduction in tobacco
habit in study area

Tobacco Cessation Clinics
Initiated by SEARO of WHO : 12 centres in India

TCC at Cancer Institute, Chennai

Objectives:
- aims at treatment of tobacco dependence
- provides pharmaceutical aids to reduce withdrawal
symptoms
- Smokeless Tobacco Cessation a special feature

Activities:
Sub centres established - 9
Educational & awareness programmes
Training programmes - 112
Exhibitions etc.
Screening of asymptomatic population

Components: Continuing public education campaigns
Training of public health workers

Population Screening:
Successful in reducing morbidity and
mortality in countries with high level
resources, at certain sites viz. cervix,
breast, colo rectum.
In a large country with limited resources, it is not
practicable.

Screening of high risk group possible
Early detection & Screening:
OBJECTIVE 2: Crux of the Problem
FEASIBILITY TO TRAIN
THE VILLAGE HEALTH NURSE 1989
Number Trained - 101

To detect an abnormal cervix

To take an adequate pap smear

Clinical concordance 90%
Pap smear adequacy 80%

Motivation Low
Problems in the South Arcot Programme
1. Dual Govt. control
Unacceptable delays in communication and
release of grants.


2. Dual responsibilities in the conduct of project


3. Transfer of trained personnel
Without information to implementing agency
Early Detection & Screening Projects Rest of India
Many projects completed and many ongoing.

Screening and early detection of accessible cancers.
Cervix, Breast and Oral
Objectives:
Evaluation of Screening Tests - Project Oriented
Evaluation of Screening methods
Performance of cytology, VIA, VILI Research Oriented
HPV Testing
Interventional trials

Our focus was on how to integrate early detection with routine
health delivery system
Cost modelling project for Cervical Cancer in Osmanabad
Cost of screening/eligible woman [Dr.Sankaranarayanan]

Cost of one time screening
Test Cost in USD (VIA) of eligible women
covering entire country
(in million Rs.)
VIA 9.5 76,166
Cytology 11.8
HPV 16.4
Conclusion of the Model Programme in Ratnagiri and
Sindhudurg Awaited

Cost effectiveness and whether replicable needs to be
studied
Our Recommendations
For Cervix & Breast only women
should be involved
Include local rural women
- Self help groups
- Survivors
Ideally implemented by NGOs
Motivated Team Project considered a
Mission
Adequate financial support
Separate Cancer Network
Health Projects
OBJECTIVE : 3
Enhancement of cancer treatment and control
services through Regional Cancer Centres,
Medical and Dental colleges.

Treatment Centres 210 RCCs 24
RT facilities 186
Teletherapy units 345

Enhanced Imaging
Gamma Camera (1958)
CT (1971)
USG (1968-69)
PET CT (2002) ?
Enhancements in Tissue Diagnosis
Till 2 decades ago

Gross Examination, Light microscopy
and clinical information only for
diagnosis and treatment plan

Today pathologic diagnosis in multimodal

Histochemistry, electron microscopy

Cytogenetics, molecular genetics have
added new dimension to diagnosis

Plays an important role in improved
survival and

Tailor treatment to specific tumour type
Advances in Radiation Oncology
Introduction of
the First
Linear Accelerator - 1976
Cancer Institute(WIA),
Chennai
Virtual simulation 3-D planning

Conformational therapy IMRT

Modifiers of radiation response
(Chemopotentiation)
Changing concepts and advances
in Surgical Oncology
Conceptual change from widest
removal possible

Avoid mutilation

Stress on conservation and functional
rehabilitation without compromise on
disease eradication

Minimally invasive surgery
Training of Personnel
Changing scenario of cancer treatment

Impact of multidisciplinary management in
cancer survival & quality of life

Misconception that radiotherapy and
cancer care were synonymous

No concept of oncology

Militated against interdisciplinary management

Need for specialized trained oncologic
personnel for total oncologic care

INTRODUCTION OF SUPER SPECIALTY
COURSES AT Cancer Institute, Chennai - 1984
Demographic & Hospital Registries

A vital component of cancer control

Documented changes in
cancer scenario

443,000
229,660
469,000
263,480
0
100
200
300
400
500
1985 1990 1995 2000 2005
Male Female
(
i
n

t
h
o
u
s
a
n
d
s
)
Period
No. of new cancer cases
M:F Ratio
Male Female
1985 229,660 263,480 1:1.15
1990 293,475 314,655 1:1.07
1995 328,115 348,660 1:1.06
2000 379,625 411,775 1:1.08
Annual % increase 4.4% 3.8%
Estimated for 2005 443,000 469,000 1:1.06
Trend in Incident cancer burden, India, 1983 - 2005
Alarming due to
Demographic
effect
Trend of TRC, India, 1983-2002
31.6 31.4
30.5
29.5
14.5
14.7
15.5
14.7
0
10
20
30
40
1983-87 1988-92 1993-97 1998-2002
Male
Female
C
I
R

/

1
0
5
39.7
37.3
35.4
30.4
16.7 16.4
16.1
15.4
0
10
20
30
40
50
1983-87 1988-92 1993-97 1998-2002
Male
Female
C
I
R

/

1
0
5
Trend of TRC, Chennai, 1983-2002
Minimal in females

Pronounced in males
Minimal in males

No change in
females
TRC includes oral cavity, pharynx, larynx, lung, oesophagus, pancreas
and urinary bladder


Trend of stage distribution (%), Chennai, 1984-2003
Stage 1984-88 1989-93 1994-98 1999-2003 Trend
Breast

Un-
changed
1 1.2 2.1 0.9 1.3
2 22.4 24.1 22.4 25.8
3 53.3 48.1 44.9 46.4
4 16.0 20.7 22.9 19.3
UNK 7.1 5.1 9.0 7.1
Cervix

Un-
changed

1 4.9 6.9 4.6 8.5
2 30.9 35.4 26.6 36.1
3 45.7 50.8 49.9 42.2
4 18.3 6.5 16.9 8.1
UNK 0.1 0.5 2.0 5.0
Oral Cancer

Un-
changed

1 4.4 6.0 5.9 4.2
2 10.4 11.4 11.8 10.5
3 36.9 31.4 20.3 14.7
4 40.8 43.9 50.4 48.5
UNK 7.5 7.3 11.5 22.2

TIME TREND
SURVIVAL

Period No.
Overall survival
(%)
Disease free survival
(%)
5 yr 10 yr 5 yr 10 yr
1960-79 5225 42.1 33.4 39.5 31.3
1980-89 5310 55.0 46.2 51.6 43.4
1990-94 2608 59.8 49.1 52.7 41.5
p-value 13143 <0.001 <0.001
Carcinoma Cervix : Survival : HBCR
All cases accepted for Treatment (All stages)
Cancer Institute(WIA), Chennai
Stage II b, III & IV
(Locally advanced cancers): 81.7%

Survival
(%)
Paediatric Adult
1970-88 1989-98 1981-87 1988-94
(135) (132) (132) (147)
Disease Free 73.5 85.3 55.9 67.7
Overall 80.3 90.2 64.7 78.7
Time Trend Survival - 5 years
Hodgkins Disease (C.I.)
Prior to 1970 < 50%
Non Metastatic Osteosarcoma
Survival Trend: 1970-99
Cancer Institute(WIA), Chennai
1970-84 (n=70) RFS % 1985-99 (n=198) RFS %
No. 3 yrs. 5 yrs. No. 3 yrs. 5 yrs.
Amputation/
Disarticulation+
Adj. CT

42

42

34.7

121

34.2

24.6
Neo Adj. CT
Limb Conservation

-

-

-

43

64.0

55.2
Declined CT/
Prog. Disease
Under treatment

28

-

10.0

34

-

11.1
Current Infrastructure Inadequate
1.5 Beds/1000 Bench mark 4.3
0.5 allopathic doctors/1000 Bench mark 1.8

Large dependence on unregistered and alternative
medicine practitioners
(WHO managerial guide lines)

Cancer Beds No reliable information
Health care in India
Infrastructure for Cancer (India)
Treatment Centres 210 RCC 24
RT facilities 186

Teletherapy units 345
(Co-60 & LA)

Brachytherapy units 276 Manual 163
Remote 113

(DGHS, Government of India publication)

IAEA Recommendation (Website)
RT Units 1 / million population
Required for India 1100
Available 345
Cancer Control in India
Where are we?
Public awareness and education
(Stage of disease unchanged)

Tobacco Control
Tobacco habit LONG WAY
Tobacco related cancer TO GO

Early detection and prevention
(All programs are project or research
oriented. No effort to integrate it with
the routine health delivery system)

Treatment facilities inadequate
Strategies for future
Thrust on

Prevention, Education

Early detection