NATIONAL CANCER CONTROL PROGRAMME IN INDIA keralamonitor.com Cancer in all forms causes about 12 per cent of deaths throughout the world. In the developed countries cancer is the second leading cause of death accounting for 21 per cent (2.5 million) of all mortality. In the developing countries cancer ranks third as a cause of death and accounts for 9.5 per cent (3.8 million) of all deaths.
Cancer has become one of the ten leading causes of death in India. According to an estimate there are nearly 1.5-2 million cancer cases at any given point of time. Over 7 lakh new cases of cancer and 3 lakh deaths occur annually due to cancer. Nearly 15 lakh patients require facilities for diagnosis, treatment and follow up at a given time. Data from population-based registries under National Cancer Registry Programme indicate that the leading sites of cancer are oral cavity, lungs, oesophagus and stomach amongst men and cervix, breast and oral cavity amongst women. Cancers of mouth and lungs in males, and cervix and breast in females account for over 50 per cent of all cancer deaths in India.
The WHO has estimated that 91 per cent of oral cancers in South-East Asia are directly attributable to the use of tobacco and this is the leading cause of oral cavity and lung cancer in India.
Cancer usually occurs in the later years of life and with increase in life expectancy to more than 60 years. An estimate shows that the total cancer burden in India for all sites will increase from 7 lakh new cases per year to 14 lakh by 2026.
Control Measures
Started in 1975-76, the main objectives of the National Cancer Control Programme (NCCP) included primary prevention of cancers by health education regarding hazards of tobacco consumption and necessity of genital hygiene for prevention of cervical cancer. The programme covered secondary prevention, i.e. early detection and diagnosis of cancers of cervix, breast and of the oro-pharyngeal cancer by screening methods and patients’ education on self - examination methods. Strengthening of existing cancer treatment facilities, which were inadequate and palliative care in terminal stage cancer were also envisaged.
The scheme of financial assistance to voluntary organisations is meant for early detection of cancer. Under the scheme financial assistance upto Rs. 5 lakh is provided to the registered voluntary organisations recommended by the State government for undertaking health education and early detection activities in cancer.
As a large number of cancer cases can be prevented with suitable health education and early case detection, the scheme for district projects regarding prevention, health education and pain relief measures was started in 1990-91. Under this scheme a one time-financial assistance of Rs. 15 lakh is provided to the concerned State government for each district project selected under the scheme with a provision of Rs. 10 lakh every year for the remaining four years of the project period. The project is linked with a Regional Cancer Centre or an institution having good facilities for treatment of cancer patients. The patients are provided treatment at the concerned Regional Cancer Centre or the nodal institution.
To strengthen cancer treatment facilities, financial assistance of Rs. 1 crore per unit, for cobalt therapy installation in charitable organisations and 1.5 crore for government institutions is provided.
The scheme relating to development of oncology wings in Government Medical College Hospitals had been initiated to fill up the geographical gaps in the availability of cancer treatment facilities in the country. Central assistance is provided for purchase of equipment which include a cobalt unit beside other equipments. The civil works and manpower are to be provided by the concerned State Government/institution. The quantum of central assistance is Rs. 2 crore per institution under the scheme.
There are 17 Regional Cancer Research and Treatment Centres recognised by the Government of India and a recurring grant of Rs. 75 lakh is being given to these Regional Cancer Centres (RCC).
New Initiatives
There are some activities, which are carried out under the NCCP out of WHO funding under the biennium pattern. In the last biennium i.e. 1998-1999, 16 workshop/training programmes were held throughout India. The Pap Smear Kits and Can scan software were supplied to 12 RCCs. Morphine tablets were also supplied to them. In the current biennium 2000-2001 the outreach activities are being conducted by medical colleges for early detection and awareness of cancer. Personnel are being trained in early detection and awareness of cancer.
The Disease
Cancer is an abnormal growth of a cell or an organ due to a specific stimulus (carcinogen). This growth is an uncoordinated, purposeless one which continues to grow even after the cessation or withdrawal of the stimulus. Cancer can originate from any organ or part of the body. The natural behaviour of a particular cancer depends upon the site of involvement and the histopathological type of the cancer. Some of the cancers are very mild and can be controlled very easily while some are very aggressive and results of treatment are very poor. As cancer grows,it invades the surrounding structures and interferes with the local function. It spreads to the draining lymph nodes through the lymphatic. Through the blood streams it spreads to the other parts of the body. The common organs of distant metastasis are lung, liver, bones and brain. The exact cause of cancer is not yet known. However, there are certain risk factors, which may cause this disease in individuals prone to develop cancer. Among the common factors, chemicals are one of the important causes. These chemicals may be in the form of tobacco or chemicals present in food, air and water. These chemicals are known as carcinogens. Till now about 60 agents have been identified.
Some common causes of cancer are tobacco smoking in the form of cigarettes, bidis, cigar and hukka. Chewing and inhailing tobacco can also cause cancer. Electromagnetic radiation and polluted food, water and air can be the other causes.
Prevention
In a majority of Indian patients, cancer can definitely by prevented. About 50 per cent cancer are tobacco-related e.g. lung cancer, oral cancer, laryngeal cancer (voice box), oesophageal cancer (food pipe). They can be prevented to a large extent by abvoiding the intake of tobacco. Certain other cancers like the bowel cancer can also be prevented by diet control.
The signs and symptoms of cancer depend upon the body part affected by the disease. The primary tumour or the spread of tumour to lymph nodes or distant parts of the body may cause symptoms. In general, cancer has a tendency to start as a nodule or mass of tissue which keeps on growing. The growth rate of cancers is variable with some cancers growing very rapidly and others growing slowly. With further growth, cancers, which affect the external or internal body surfaces, can form wounds or ulcers leading to dirty discharge and bleeding. The common symptoms of cancer can be described as follows: a lump or swelling, a sore that does not heal, unusual bleeding or discharge, changes in bladder or bowel habits, nagging cough or hoarseness and difficulty in swallowing.
Treatment
Cancer is curable if detected early. The results of treatment in stage I and stage II (early stage cancer) are about 80 per cent. In late stage diseases (stage III & IV) the results are very poor. In India, about 70 per cent patients at present are in advanced stages of the disease and hence difficult to treat. Basically, there are three main modalities of cancer treatment-surgery, radiotherapy and chemotherapy. To decide the best treatment for a given patient, initial testing is done to make the diagnosis and decide the stage of disease.
The progress of treatment and response of disease is assessed from time to time. A review of the progress is made subsequently in meetings to decide whether any change in the treatment plan is required or not. Once the treatment is completed, cancer patients need regular follow-up. The purpose of follow-up is to examine the patient and carry out necessary investigations to detect recurrence of the disease or development of new cancers so that appropriate and timely treatment can be done.
ANTI-TOBACCO CAMPAIGN GETS A BOOST
Dinesh C Sharma*
Anti-smoking campaign is gaining momentum in India. Earlier this year, the central government tabled a comprehensive anti-smoking law in Parliament. While this law is yet to be passed, the Supreme Court (SC) has directed all states to ban smoking at public places and to ensure compliance of existing provisions on tobacco advertising. This is perhaps the most significant anti-tobacco measure in recent years.
Public places where smoking has been banned include hospitals, health institutes, public offices, public transport, court buildings, educational institutions, libraries and auditoria. However, hotels and amusement parks have been excluded from the ban. This is not the first time that smoking at public places has been banned. Three state governments - Delhi, Goa and Rajasthan - have enacted local laws banning smoking at public places. In Kerala the High Court has ordered a ban. The central legislation – now with the Parliament’s Select Committee – also proposes a ban on smoking at public places. But this is the first time a nationwide ban has been ordered. The order will act as a stop-gap arrangement till the central legislation in enacted and implemented.
Critics of the order say that the ban may not be enforceable. They are wrong. The SC order removes the ambiguity that has been there with regard to what constitutes a public place. A clear definition has been provided. All covered premises have been included where "no smoking" ban can be effectively enforced. After all, smoking has been banned in public transport buses for decades and has proved to be effective without much policing. In Goa, where the state government has banned smoking at public places, cigarette sales are reported to have dropped by 30 per cent. The Goa Act even empowers voluntary bodies to implement the law.Legislations and ban orders can only act as deterrents. A case in point is the proposed Tobacco Products (Prohibition of Advertisement and Regulation) Bill 2001 which seeks to impose a total ban on sponsoring of sports and cultural events by cigarette and other tobacco companies. Although this Bill has not yet become a law, a leading cigarette manufacturer which was the official sponsor of India’s national cricket team, has withdrawn its sponsorship voluntarily. The proposed Bill would replace the existing Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975.
Yet another issue that has been highlighted by the SC order relates to violation of rules on advertising of cigarettes in the print medium and outdoor hoardings. Despite the existing law of 1975, many tobacco companies are not showing the statutory warning as per specifications. Not only this, internationally there is a move to make this statutory warning more explicit to say that "smoking causes cancer and heart diseases".
India has some 200 million active tobacco users. Recent studies show that tobacco is emerging as a giant killer in India. It is a major cause of all cancers in India according to the latest cancer registry data compiled by the Indian Council of Medical Research (ICMR). The ICMR operates the National Cancer Registry Programme (NCRP) network which has seven population-based registries and five hospital-based registries across the country. The data from these population-based registries shows that the most common site of cancer in men in all but one cities is related to tobacco consumption – lung or oesophagus. About half of the cases among men and one fifth of cases among women pertain to sites mainly attributable to tobacco use. And overall, about one-third of cancers in India pertain to tobacco-related sites.
This is putting an unbearable burden on the national resources and the economy. Supporters of tobacco often say that the tobacco industry provides employment to millions of farmers and workers and also contributes to the national exchequer by way of various taxes. But they often overlook the health costs of tobacco. For the first time, a study has been conducted to calculate the economic costs of tobacco-related health burden. A study by ICMR has shown that three tobacco-related disease groups - cancers, coronary artery disease, and chronic obstructive lung disease - cost the country Rs 27700 crore in 1999, far more than the so-called benefits from the tobacco industry.
The patterns of tobacco consumption in India are totally different from other parts of the world. Here just about 20 per cent tobacco-users consume cigarettes, while nearly 40 per cent smoke bidis, which deliver more nicotine than cigarettes. The remaining 40 per cent chew tobacco and tobacco-containing products such as Paan Masala and Gutkha. The absolute number of people consuming Pan Masala and Gutkha is growing everyday with its consumption gaining social acceptance.
Due to availability in convenient sachets and high profile advertising, the use of Pan Masala and Gutkha is growing among population segments like young men and women who otherwise do not smoke or chew tobacco. Young children are getting addicted to Gutkha. Recent studies in India have shown that long-term use of Pan Masala may cause tumours in several parts of the body and not just oral cavity as proved so far. Chemical and toxicological evaluation of Pan Masala has revealed the presence of harmful substances including toxic metals such as lead, cadmium and nickel and residual pesticides such as DDT and BHC and their isomers which are known to be carcinogenic.
In the fight against tobacco, equal emphasis must be placed on smokeless tobacco products like Pan Masala and advertising and public places bans must be expanded to cover these products as well.
*Columnist and commentator on science and health policy matters.