5 DECADES OF CANCER CONTROL 1955 – 2005

1. 5 DECADES OF CANCER CONTROL 1955 – 2005 Cancer Institute (WIA), Chennai, India Dr.(Mrs.) S. Muthulakshmi Reddy 1886-1968

2. 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

3. 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

4. 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.

5. 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.

6. OBJECTIVE 1 of NCCP: 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

7. 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

8. 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. ≥

9. OBJECTIVE 2: Crux of the Problem Early detection & Screening: 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

10. 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

11. Problems in the South Arcot Programme • Dual Govt. control • Unacceptable delays in communication and • release of grants. • Dual responsibilities in the conduct of project • Transfer of trained personnel • Without information to implementing agency

12. 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

13. 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

14. Our Recommendations • Separate Cancer Network • Health Projects • 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

15. 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

16. Enhanced Imaging Gamma Camera (1958) CT (1971) USG (1968-69) PET CT (2002) ?

17. 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

18. 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)

19. 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

20. 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

21. Demographic & Hospital Registries A vital component of cancer control

22. Documented changes in cancer scenario

23. Trend in Incident cancer burden, India, 1983 - 2005 Alarming ↑ due to Demographic effect

24. Trend of TRC, India, 1983-2002 Minimal ↑ in males No change in females Trend of TRC, Chennai, 1983-2002 Minimal ↑ in females Pronounced ↑ in males TRC includes oral cavity, pharynx, larynx, lung, oesophagus, pancreas and urinary bladder

25. Trend of stage distribution (%), Chennai, 1984-2003

26. TIME TREND SURVIVAL

27. 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%

28. Time Trend Survival - 5 years Hodgkin’s Disease (C.I.) Prior to 1970 < 50%

29. Non Metastatic Osteosarcoma Survival Trend: 1970-99 Cancer Institute(WIA), Chennai

30. Health care in India 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

31. 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

32. 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

33. Strategies for future Thrust on Prevention, Education Early detection