A review on cancer incidence in India from 25 ...

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Original Article

A review on cancer incidence in India from 25 population-based cancer registries Smita Asthana, Preeti S. Labani1, L Satyanarayana Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, Noida, Uttar Pradesh, 1 Department of Pediatrics, Lok Nayak Hospital, New Delhi, India

ABSTRACT Background and Objective: An overview of the update of cancer incidence summary findings will be of help to researchers and clinicians for quick reference of facts in cancer control. To present an overview of cancer incidence available from the recent population-based cancer registries (PBCRs) in India from 2009 to 2011. Materials and Methods: Data on age-adjusted incidence rates and cumulative risks of cancer at various sites were collected for both sexes for six major cancer sites from the first report of the National Cancer Registry Programme (NCRP) on 25 PBCRs in India for the years 2009-2011. Site-specific risks in terms of one out of the total number of persons who develop cancer were computed. The summaries, in the form of ranges, are presented in six regions of the country in which the 20 PBCRs are located. The range of age-adjusted rates (AARs) and one out of the number of persons who develop cancer as a lifetime risk in the age of 0-64 years is presented. Results: In different regions, the highest risks for males for developing cancer in the various major sites studied were as follows: One out of 67 for cancer in the lungs in the Northeast, one out of 27 for cancer in the esophagus in the Northeast, one out of 71 for cancer in the mouth in the western region, one out of 100 cancer in the tongue in the rural western region, one out of 333 for cancer in the prostate in the northern region, and one out of 33 for cancer in the stomach in the northeastern region. The highest risks for the various sites studied were as follows: one out of 36 for cancer in the breast in the south, one out of 59 for cancer in the cervix in the western region, one out of 125 for cancer in the ovary in the northern region, one out of 63 for cancer in the esophagus in the northeastern region, one out of 250 for cancer in the mouth in three regions, and one out of 125 for cancer in the gall bladder in the western and central regions. Overall, for all cancers there is a risk of one out of 8-27 persons and one out of 10-25 persons among males and females, respectively, in the Indian population who are likely to develop cancer of any site in their lifetime during the age of 0-64 years. Conclusion: Female breast cancer in the southern region and esophagus and stomach cancers among males in the northeast region were of the highest magnitudes. Key words: Age-adjusted rate (AAR), age-adjusted incidence rate, cancer incidence, cancer registry, cancer risk, cancer statistics, cumulative risk

Address for correspondence: Dr. Smita Asthana, Division of Epidemiology and Biostatistics, Institute of Cytology and Preventive Oncology, Indian Council of Medical Research, I-7, Sector-39, Noida, Uttar Pradesh, India. E-mail: [email protected] Access this article online Quick Response Code: Website: www.jdrntruhs.org

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INTRODUCTION Population-based cancer registries (PBCRs) collect a complete summary of the patient’s history, diagnosis, treatment, and status for every cancer patient in the defined geographical area such as district, state, or country. These are useful for knowledge on cancer burden, etiological studies, and effectiveness of cancer control activities. An estimated 12.7 million new cancer cases and 7.6 million cancer deaths were reported as estimates of worldwide cancer statistics in terms of incidence and mortality in the year 2008 by GLOBOCAN 2008. Of the total global load, 56% of new cancer cases and 63% of cancer deaths occur in the less developed regions of the world. The incidence data for GLOBOCAN were derived from the PBCRs.[1,2] For the developed countries, these incidence data may cover entire national populations but in developing countries, they cover smaller areas such as only major cities. The National Cancer Registry Programme (NCRP) periodically publishes cancer statistics from registries and currently, the reports are available in the website of NCRP. The report[3] for the year 2009-2011 is available too. This report is of 25 PBCRs reporting information on cancer incidence and mortality in the community covering 7% of the country’s population. Though the coverage is still low, it gives a fair idea of the pattern of cancer incidence emerging in various regions or parts of the country. Full cancer statistics from regionwise registry on all cancer sites in a uniform pattern is available in the NCRP website. There are studies that assessed the reliability and completeness of cancer registration in India.[4,5] A summary of such recent detailed cancer statistics on major cancer sites is helpful for researchers and clinicians as quick reference for cancer load in the country. In order to have a quick summary on cancer statistics, this study attempts to report an overview of the incidence from the recent NCRP 2009-11 report by highlighting the cancer load for six major sites from 25 cancer registries in treating them as located in five regions of the country.

MATERIALS AND METHODS Secondary data from NCRP, India’s report on 25 PBCRs were used in this study.[3] Under the banner of Indian Council of Medical Research (ICMR), NCRP brings out comprehensive annual reports 2

containing various data at the population level such 1 as incidence rates and mortality rates. The availability 2 of data in different cities of the country depends 3 on the year a particular registry came under the 4 5 network of NCRP and or initiation of the registry in 6 a particular area. The main resources for registration 7 of the incidence cases and the type of population 8 covered in various registries were described in 9 the NCRP reports. [3,6-10] Incidence data on cancers 10 at six major sites among males and females were 11 considered for the summarization of age-adjusted 12 rates (AARs) and cumulative risks in the computation 13 of lifetime risk as the probability of one out of the AQ4 14 total number of persons who developed cancer in 15 the lifetime. The ranges of these three summary 16 measures were presented as minimum and maximum 17 for various regions of the country as per the location 18 the registry. The regions are formed and presented 19 by the authors and not by the original NCRP report. 20 We used ranking of cancer incidence rates of the 21 years 2006-2008, as given in the NCRP report,[9] for 22 23 the selection of the six sites from different registries. 24 The six sites for females were the breast (C50), 25 cervix (C53), mouth (C03-06), esophagus (C15), gall 26 bladder (C23-24), and ovary (C56); for males, the 27 six sites were the lungs (C33-34), tongue (01-02), 28 mouth (C03-06), esophagus (C15), stomach (C-16), 29 and prostate (C61). 30 One out of the total number of persons who develop cancer was calculated as 100/cumulative risk, where cumulative risk = 100 × [1-exp (-cum.rate/100)] and cumulative rate = [5 × Σ(ASpR) × 100]/100,000; ASpR was the age-specific incidence rate. The age-specific incidence rates of cancer of various sites and the AARs are available in the NCRP reports for every site and registry. The site-specific cumulative rates and cumulative risks are also available from the NCRP reports. The site-specific statistics of one out of the total number of persons developing cancer were computed by us for every registry and presented as ranges in each region. One out of the total number of persons who develop cancer is an easily understandable statistics and used for public health messages. Cumulative risk is the probability that an individual will be diagnosed with cancer during a certain period in the absence of any competing cause of death and the assumption that the current trends will prevail over the time period.[9] The present analysis is part of an intramural ongoing study entitled “Exploration of National Cancer Registry Journal of Dr. NTR University of Health Sciences 2015;?(?)

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Program (NCRP) data and its statistical modeling” of the Institute of Cytology and Preventive Oncology (ICPO), ICMR. There was, as such, no requirement of ethical approval from the ICPO in the overview of the data sets of ICMR from the public domain.

RESULTS Age-adjusted incidence rates and one out of the total number of persons who develop cancer at any site during the lifetime of 0-64 years of age are presented for the different regions in Table 1. The overall risk TABLE 1: CANCER INCIDENCE (ALL SITES) IN BOTH THE SEXES FROM 25 PBCRS IN INDIA ACCORDING TO THE REGION OF LOCATION OF THE VARIOUS REGISTRIES Registry location

North South Central East/ North East West Rural West All regions

AARs of incidence

One out of the total number of persons who developed cancer

Male

Female

Male

Female

125.2 113.7-132.6 105.9 69.5-273.4

120.6 91.6-137.2 105.6 56.1-227.8

13 13-17 15 8-24

11 11-15 13 10-23

43.7-117.5 51.8-74.2 43.7-273.4

56.6-103.0 51.6-62.6 51.6-227.8

14-29 19-27 8-27

13-21 21-25 10-25

North = Delhi, South = Bangalore, Chennai, Kollam, Thiruvananthapuram, Central = Bhopal, East = Kolkata, Northeast = Cachar, Dibrugarh, Kamrup, Manipur, Mizoram, Sikkim, Meghalaya, Tripura, Nagaland, West = Mumbai, Nagpur, Pune, Ahmadabad (U), extended Barshi, Aurangabad, Wardha, Rural West = rural Barshi, Ahmedabad (R), PBCR = Population based cancer registry, Data Source = NCRP Report 2009-11 (3)

of cancer for all the regions ranged 1-8 to 1-27 and one in 10 to one in 25 for males and females, respectively, for all the sites in the lifetime. The highest incidence of cancer at all sites for males was 273 per 100,000 persons and for females, it as 227 per 100000 persons as observed in the northeastern region. The cancer incidence at six major sites for the male population, namely, the lungs, esophagus, mouth, tongue, stomach, and prostate is presented in Table 2. Maximum risks for the development of cancer is one out of 27 persons for cancer in the esophagus and one out of 33 persons for cancer in the stomach followed by one out of 67 persons for cancer in the lungs in the eastern region of the country. In different regions, the highest risks among males for developing cancer at the various major sites studied were as follows: 27 for cancer in the esophagus and 67 for cancer in the lungs in the Northeast, 71 for cancer in the mouth in the western region, 100 for cancer in the tongue in the western region, 333 for cancer in the prostate in the southern, northeast, and northern regions and 33 for cancer in the stomach in the northeastern region. Table 3 shows the regionwise risks for six major cancers among females. The highest risk was observed for breast cancer followed by cervical cancer and gall bladder cancer with one out of 35 persons, one out of 61 persons, and one out of 123 persons,

TABLE 2: CANCER INCIDENCE AMONG MALES (SIX MAJOR SITES) FROM 25 PBCRS IN INDIA ACCORDING TO THE REGION OF LOCATION OF THE VARIOUS REGISTRIES Registry location according to region

North South Central East/Northeast West Rural West All regions

Lung:C33-34 AAR [one out of the total number of persons who develop cancer]

Esophagus: C 15 AAR [one out of the total number of persons who develop cancer]

Mouth: C3-6 AAR [one out of the total number of persons who develop cancer]

Tongue: C 1-2 AAR [one out of the total number of persons who develop cancer]

Prostate: C-61 AAR [one out the total number of persons who develop cancer]

Stomach: C 16 AAR [one out of the total number of persons who develop cancer]

13.9 [111] 10.8-19.5 [83-200] 12.4 [143] 3.2-28.3 [67-500] 2.2-10.8 [167-500] 2.4-8.3 [167-500] 2.2-28.3 [67-500]

5.0 [250] 4.2-7.5 [250-333] 5.1 [333] 2.9-46.2 [27-500] 3.1-7.2 [250-500] 4.5-3.8 [333] 2.9-46.2 [27-500]

6.8 [200] 4.3-7.0 [250-333] 12.5 [111] 1.7-9.2 [143-1000] 3.5-17.1 [71-333] 6.5-9.5 [143-167] 1.62-12.91 [71-1000]

8.0 [167] 4.7-7.2 [200-333] 9.0 [143] 1.8-9.4 [143-1000] 2.7-12.2 [100-500] 2.0-9.3 [143-500] 1.8-12.2 [100-1000]

11.2 [333] 5.7-8.9 [333-500] 6.6 [500] 0.5-11.2 [333-1000] 1.5-7.7 [500-1000] 1.9-2.6 [1000] 0.5-11.2 [333-1000]

3.5 [500] 4.8-12.2 [125-333] 2.7 [500] 3.8-47.6 [33-500] 1.3-4.2 [333-1000] 1.1-2.7 [500-1000] 1.1-47.7 [33-1000]

North = Delhi, South = Bangalore, Chennai, Kollam, Thiruvananthapuram, Central = Bhopal, East = Kolkata, Northeast = Cachar, Dibrugarh, Kamrup, Manipur, Mizoram, Sikkim, Meghalaya, Tripura, Nagaland, West = Mumbai, Nagpur, Pune, Ahmedabad (U), extended Barshi, Aurangabad, Wardha, Rural West = rural Barshi Ahmedabad (R), PBCR = Population-based cancer registry, AAR = Age-adjusted rates of incidence, Cu R = Cumulative risk, Cancer site C code = ICD 10 code, Data Source = NCRP Report 2009-11 (3)

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TABLE 3: CANCER INCIDENCE AMONG FEMALES (SIX MAJOR SITES) FROM 25 PBCRS IN INDIA ACCORDING TO THE REGION OF LOCATION OF THE VARIOUS REGISTRIES Registry location

Breast: C-50 AAR Cervix: C 53 AAR Ovary: C56 AAR Esophagus: C15 Mouth: C 3-6 [one out of the [one out of the [one out of the AAR [one out of AAR [one out of total number total number total number the total number the total number of persons who of persons who of persons who of persons who of persons who develop cancer] develop cancer] develop cancer] develop cancer] develop cancer]

North South Central East/Northeast West Rural West All regions

32.25 [40] 23.15-36.07 [36-48] 25.36 [45] 7.17-25.5 [55-167] 13.32-32.3 [38-77] 8.76-10.46 [100-111] 7.17-36.06 [36-167]

17.87 [77] 8.34-21.13) [71-100] 18.94 [77] 6.09-17.65 [67-200] 9.05-18.93 [59-143] 8.45-18.59 [67-125] 6.09-21.13 [59-200]

8.88 [167] 4.21-7.41 [167-250] 7.7 [167] 3.0-7.81 [125-1000] 3.23-7.11 [200-500] 1.94-2.41 [333-500] 1.94-8.88 [125-1000]

2.78 [500] 0.94-6.44 [250-1000] 5.41 [333] 1.7-14.81 [63-1000] 1.31-4.19 [250-1000] 2.06-2.17 [333-1000] 0.94-14.81 [63-1000]

1.98) [500] 2.67-6.46 [250-1000] 5.47 [250] 0.74-5.76 [250-1000] 0.87-4.2 [250-1000] 0.99-1.64 [500-1000] 0.74-6.46 [250-1000]

Gall bladder: C23-24 AAR [one out of the total number of persons who develop cancer] 8.78 [143] 0.58-1.44 [1000-2500] 4.01 [333] 0.8-8.24 [125-1000] 0.18-8.78 [500-1000] 0.66-0.8 [1000] 0.3-8.78 [125-1000]

North = Delhi, South = Bangalore, Chennai, Kollam, Thiruvananthapuram, Central = Bhopal, East = Kolkata, North East = Cachar, Dibrugarh, Kamrup, Manipur, Mizoram, Sikkim, Meghalaya, Tripura, Nagaland, West = Mumbai, Nagpur, Pune, Ahmedabad (U), extended Barshi, Aurangabad, Wardha, Rural West = rural Barshi, Ahmedabad (R), PBCR = Population-based cancer registry, AAR = Age-adjusted rates of incidence, Cu R = Cumulative risk, Cancer site C code = ICD 10 code, Data Source = NCRP Report 2006-08 (3)

respectively. The highest risks among females for developing cancer at the various sites studied were as follows: 35 for cancer in the breast in the south, 61 for cancer in the cervix in the western region, 141 for cancer in the ovary in the northern region, 100 for cancer in the esophagus in the northeastern region, 233 for cancer in the mouth in the southern region, and 123 for cancer in the gall bladder in the northeastern region.

DISCUSSION A review of the data of 25 PBCRs on six major sites for males and females separately from different regions of the country has been presented by us. The regions are arbitrary in nature. Though this was a limitation, our aim of regional distribution was not to make a representation of the country. The aim was only to simplify for the purpose of review by avoiding the individual presentation of data of the 25 registries and provide a summary of cancer incidence in India. Delhi is a single registry in the northern region while the northeastern region has a sufficient number of registries. The western region now has seven registries while the southern region has four. The representation of the rural region is still low with two rural registries, one in Barshi and the other in Ahmedabad. As a whole, all the 25 registries have a coverage of only 7.45% of the total country’s population. It is practically not possible to have a full 4

coverage for a large country such as India. Efforts of the NCRP to expand the registries further in various parts of the country are in full swing. The current registries present a reasonably fair account of the pattern of cancer in the country. For obtaining the incidence rates for individual sites for any particular registry, the researcher should consult the original source of NCRP report.[3] NCRP (ICMR) follows uniform data collection procedures. However, there are still reliability issues on the data collected across the registries in different regions through cancer registries under the network. A study from Mumbai, Maharashtra, India[4] stated that for studying the completeness of the data, the indicators “proportion of deaths in period” and “proportion of death certificates only” and the stability of age incidence rates have been utilized. The indicators “proportion of cases registered on histological verification,” “proportion of cases where age is not known,” “flattening of age incidence curve,” and “proportion of other and unspecified neoplasms” can throw some light on the quality of data collected by the registry. There has been a notable improvement in the percentages of histological verification cases and a substantial decrease in the proportion of death certificate alone cases in both the sexes over a period of time. Mortality incidence ratio remained stable over a period of time in both the sexes. On examining the various indices of reliability Journal of Dr. NTR University of Health Sciences 2015;?(?)

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and completeness of Mumbai cancer registry data,[4] it was concluded that the data collected by this registry were quite complete and reliable. In the present NCRP report,[3] mortality incidence ratio that is an important index of reliability for males and females ranged 11.8-82% and 7.1-73.1% for males and females, respectively. The other measure is that of a good proportion of microscopically verified cases. This for the present report is 61.5-93.9% and 56.4-94.4% for males and females, respectively. This shows a good proportion of microscopically verified cases as compared to the highest 89% in a previous report of NCRP.[9] In an independent survey in Chennai, Tamil Nadu, India, the completeness of Chennai PBCR was assessed during 1982-1995. It was found that the completeness of cancer registration is 96% and is comparable to that of the other registries in the world. This review aimed at only the incidence data though the report provided data on mortality too. It is concluded from the present overview that the overall risk of developing cancer in either sex is almost equal. Female breast cancer in the southern region and esophagus and stomach cancers among males in the northeast region were of the highest magnitude. Financial support and sponsorship Nil.

Author Queries??? AQ1: Kindly confirm single article title. A review on cancer incidence in India from 25 population-based cancer registries Or Cancer incidence in India based on 25 population-based cancer registries: An overview AQ2: Kindly provide department for author Smita Asthana and L Satyanarayana and also provide complete first name of author L Satyanarayana.

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Conflicts of interest There are no conflicts of interest.

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