Demographic and Epidemiological Transition and Cancer in India

Demographic and Epidemiological Transition and Cancer in India ALEYAMMA MATHEW PROFESSOR TRIVANDRUM CANCER REGISTRY Regional Cancer Centre, Thiruvananthapuram 2019 NAACCR-IACR, Vancouver, BC, Canada, June 9 -13, 2019

Transition of Cancer Demographic 1. Population ↑ 2. Life Expectancy ↑ Epidemiological 1. Risk factors ↑ Tobacco Alcohol consumption Dietary habits Obesity Infection 2. Protective factors ↓ Physical activity Fruits and vegetables Access to Care 1. Diagnostic facilities ↑ 2. Screening programmes ↑ 3. Treatment facilities ↑

Objectives • To asses the transition of cancer in India according to i. Transition in Demographic factors ii. Transition in Epidemiologic risk and protective factors iii. Transition in Detection practices during the past 30 years

MATERIALS: REPORTES OF NATIONAL CANCER REGISTRY PROGRAMME, GOVT. OF INDIA 1986 2016 • • • Mumbai Bangalore Chennai Bhopal Delhi Rural Barshi 1982 1985 1986 Currently 29 PBCRs under NCRP network South: Trivandrum, Kollam, Bangalore, Chennai West: Ahmedabad, Aurganbad, Mumbai, Pune Central: Barshi, Bhopal, Nagpur, Wardha North: Delhi, Patiala North East: Cachar, Dibrugargh, Kamrup, Kolkata, Manipur, Meghalaya, Mizoram, Nagaland, Pasighat, Sikkim, Tripura

Cancer Registry: Case-ascertainments methods Private hospitals RCCs Radiotherapy centres Pathology departments Govt. hospitals Medical college hospitals Cancer Registry Vital statistics office Publish Report National Cancer registry (NCRP) State/central Government IARC Research Some Registries have Administrative orders

Statistical Methods • The various measures used are i) crude cancer incidence rate (CR) ii) age-standardized incidence rate (world population) (ASR) iii) annual percent change (APC) using Joint. Point linear regression.

Demographic Transition vs. Transition of Cancer Burden in Men Population growth 42 % 800 Cancer Burden Million 600 400 12. 8 % 200 0 1990 2012 480000 470000 460000 450000 Life expectancy (years) 440000 430000 8. 7 years 420000 63 410000 61 400000 59 1990 57 1990 2012

Demographic Transition vs. Transition of Cancer Burden in Women Population growth 600 44. 0 % Million 500 Cancer Burden 400 300 49. 7 % 200 100 600000 0 1990 2012 500000 Life expectancy (years) 10. 1 years 400000 65 63 300000 61 1990 59 57 1990 2012

Transition in rank ordering and proportion of leading cancer sites (1990 vs. 2014) MALE 1990 RANK 2014 Lung (10. 6%) 1 1 Lung( 11. 3%) Pharynx (9. 1%) 2 2 Stomach (9. 1%) Oesophagus (6. 7%) 3 3 Colo-Rectum (7. 7%) Tongue(6. 6%) 4 4 Prostate (7. 7%) Stomach (5. 7%) 5 5 Tongue (7. 6%) Prostate (4. 5%) 6 6 Pharynx (6. 7%) Mouth(4. 2%) 7 7 Oesophagus (5. 7%) Colo - Rectum (2. 9%) 8 8 Leukemia (2. 7%) 9 9 10 10 NHL (1. 9%) Total 10 sites (76. 6%) Larynx (4. 8%) Mouth (4. 0%) Leukemia (4. 0%) Total 10 sites (75. 8%)

Transition in rank ordering and proportion of leading cancer sites (1990 vs. 2014) Female 1990 RANK 2014 Cervix uteri (23. 5%) 1 1 Breast (27. 0%) Breast (19. 3%) 2 2 Cervix-uteri (22. 9%) Ovary (5. 5%) 3 3 Colo-Rectum (5. 1%) Oesophagus (4. 4%) 4 Mouth (3. 9%) 4 Ovary (5. 0%) 5 5 Corpus uteri (4. 0%) Stomach (3. 0%) 6 6 Stomach 3. 7%) Colo-rectum (2. 0%) 7 7 Lung (3. 1%) Corpus uteri (2. 0%) 8 8 Oesophagus (2. 7%) Lung (2. 0%) 9 9 Tongue (2. 0%) Tongue (1. 9%) 10 10 Total 10 sites (76. 6%) Mouth (2. 0%) Total 10 sites (75. 8%)

Epidemiological Transition in Tobacco prevalence and Transition in related cancers Tobacco Prevalence in 35, 9 men - India 29, 5 40 30 24, 4 22, 8 20, 4 20 10 0 2005 2010 2012 2015 Year is mainly tobacco chewing • Tobacco-related cancers mainly include: Lung, Mouth, Tongue, Pharynx (excluding nasopharynx), Oesophagus, Larynx, Urinary bladder • Population attributable fraction (PAF) due to tobacco Lung: 60% Oral cavity: 37% Other pharynx : 37% Oesophagus : 37% Urinary bladder : 21% Mouth and other Pharyngeal cancers

Transition in Tobacco prevalence vs. transition in the burden of related cancers in Women 7, 3 Tobacco Prevalence among women - India 6 8 6 2, 9 5 2, 4 4 1, 9 3 2 1 0 2005 2010 2012 Year Mouth and other Pharyngeal cancers Aar per 100, 000 persons 5 4, 6 7 Lung cancer 4 3 2 2015 1 Bangalore Chennai Delhi Mumbai 0 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015

Epidemiological Transition in Prostate Transition and Breast of Cancer cancers in Men in India – Obesity (1982 -2014) Breast cancer 14 40 Prostate cancer 12 35 Aar per 100, 000 persons 45 2012 2009 0 2006 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015 2 2003 0 Mumbai 4 2000 5 Delhi 1997 10 Chennai 6 1994 15 Bangalore Barshi Bhopal Chennai Delhi Mumbai Bhopal 1991 20 8 1988 25 Bangalore 1985 30 1982 Aar per 100, 000 persons 10

Transition in Alcohol prevalence vs. transition in the burden of related cancers in men 6 5 Alcohol prevalence: men in India Colon cancer 4 35 3 30 2 Bangalore Chennai Delhi Mumbai 1 25 0 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015 20 5, 0 15 10 4, 0 5 3, 0 0 200020012002200320042005200620072008200920102011201220132014 PAF due to alcohol for colo-rectal cancers < 5% 2, 0 1, 0 0, 0 Rectal cancer Bangalore Chennai Delhi Mumbai 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015

Transition in Economic status vs. Transition in infection-related cancer in India 60 GDP and Poverty 50 50 GDP Poverty 45 2000 40 35 1500 30 25 1000 20 Aar per 100, 000 persons 2500 40 30 20 Population attributable fraction of cancers infection : 23% Cervix uteri (1982 -2014 Bangalore Barshi Bhopal Chennai Delhi Mumbai 15 500 10 10 5 0 0 1995 2000 2005 2010 2015 0 198219851988199119941997200020032006200920122015

Transition in prevalence of Obesity vs. Transition in Corpus uteri and Ovarian cancers (1982 -2014) Aar per 100, 000 persons 7 Prevalence of obesity among women in India 6 5 4 3 2 Bangalore Chennai Delhi 1 0 3 Corpus uteri cancer 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015 12 1 2016 2014 2012 2010 2008 2006 2004 Year 2002 2000 1996 1998 1994 1992 1990 1988 1986 1984 1982 0 Aar per 100, 000 persons 2 Ovarian cancer 9 6 3 Bangalore Bhopal Chennai Delhi 0 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015

Male 4, 2 0 -2 02 8 19 01 -2 15 20 Year 01 6 4 01 -2 13 20 1 - 01 20 1 -2 09 12 0 8 00 -2 07 20 05 -2 00 6 0 20 34 24 61 49 41 20 20 96 84 72 20 2, 1 40 -2 3, 6 3, 0 5, 6 17 60 6, 5 5, 2 Observed 80 20 Number 100 Predicted 7, 4 M-CR 20 120 8, 0 7, 0 6, 0 5, 0 4, 0 3, 0 2, 0 1, 0 0, 0 Rate per 100, 000 Transition in Access to care vs. Transition in Thyroid cancer incidence

Summary • Burden of cancer has been increasing in India. • Transition in economic status and life-style modification happened in many parts of the country reflect increased incidence of breast cancer and reduction in infection-related cervix uteri cancer. • Decline in tobacco prevalence reflected slight decline in some related cancers in many parts of the country. • The future burden of cancer in India will already expect to be large due to demographic effects. • The increase in alcohol consumption, increased prevalence in overweight, obesity and physical inactivity and with the tobacco epidemic, the burden of related cancers in India will be very heavy.

Conclusion • To assess the burden of cancer in terms of both incidence and mortality more accurately, cancer should be included as a notifiable disease in India. • Public health efforts for the increasing prevalence in overweight, obesity, physical inactivity and alcohol consumption in addition to the tobacco prevention and control are needed especially among females to reduce the cancer burden.