In a recent paper in Jama Oncology, Institute of Health Metrics and Evaluation (IHME) researchers analysed new cancer cases in 195 countries in 2016. At 106.6 new cancer cases per 100,000 people, India ranked 10th among countries with the lowest cancer incidence. The paper, according to members of the research team in India, is just the tip of the iceberg and a more detailed analysis looking at cancer at the level of the states is under way in six weeks.
While India’s ranking by the Global Burden of Disease team in IHME may appear counter-intuitive, the truth is that incidence alone does not tell India’s full cancer story. There are other details to look at; for example, India’s cancer incidence may be far lower than in Australia, New Zealand and the United States, but its mortality rate is at par.
In a 2014 article in The Lancet Oncology, researchers from Indian cancer centres wrote: “Reported age-adjusted incidence rates for cancer are still quite low in the demographically young country. Slightly more than 1 million new cases of cancer are diagnosed every year in a population of 1.2 billion. In age-adjusted terms this represents a combined male and female incidence of about a quarter of that recorded in western Europe. However, an estimated 600,000-700,000 deaths in India were caused by cancer in 2012. In age-standardised terms, this figure is close to the mortality burden seen in high-income countries. Such figures are partly indicative of low rates of early-stage detection and poor treatment outcomes.”
Screening in the country, too, is poor. The pilot phase of the National Programme For Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) was launched in 2008 and one of the items on the agenda was cancer screening. In 2017, the Health Ministry was still talking about a rollout of universal cancer screening in 100 districts and training of personnel.
A case in contrast is the Fred Hutchinson Cancer Research Center in Seattle — incidentally also the home of IHME that has done the cancer incidence analysis — where 60% of women detected with breast cancer are asymptomatic individuals who have walked in for a screening, most of them in the early stages and therefore with a far better prognosis.
A 2015 policy paper on cancer by Ernst and Young said: “The gap between reported and real incidence can be primarily attributed to under-diagnosis of cancer in India, which is manifested in the relatively late stage of presentation of the disease. Data collected between 2009 and 2011 show that only 43% of breast cancer cases were diagnosed at an early stage (i.e. stage I or stage II) of the disease in India whereas 62%, 81% and 72% of breast cancers were diagnosed at an early stage in the US, UK and China respectively. Although this varies with the type of cancer, the stage of diagnosis in India is generally more delayed compared to other countries with only 20-30% of cancers being diagnosed in Stages I and II, which is less than half of that in the US, UK and China.”
India stands out also because it bucks the global trend of men having more cancers than women. Earlier this year, researchers from the National Institute of Cancer Prevention and Research wrote in a paper in The Lancet Oncology: “The proportion of cancer diagnoses in India is higher in women than in men, which is in marked contrast to the worldwide age-standardised cancer incidence of a 25% higher incidence in men than in women. Cumulatively, breast, cervical, ovarian, and uterine cancer account for more than 70% of cancers in women in India.”
Matters are further complicated by the lack of access to cancer care and a lack of trained professionals equipped to deal with the disease. India has only 200-250 comprehensive cancer care centers (0.2 per million population in India vs 4.4 per million population in US), 40% of which are present in eight metropolitan cities and fewer than 15% are government operated. The country has only one oncologist per 1,600 new cancer patients in India, as against one per 100 and 400 new cancer patients in the US and UK respectively, the EY report noted.