Cancer PDF (social preventive pharmacy)

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surveillance for streptococcal pharyngitis. Ideally a sore 3. Medscape (2012), Thomas K Chin, Paediatric Rheumatic Heart

Disease Overview Epidemiology, May 30th, 2 0 1 2 .
throat should be swabbed and cultured. If streptococci are
4. WHO ( 1 9 8 6 ) . Techn Rep. Ser. No. 732.
present, the child should be put on penicillin. Since facilities
5. Strasser, T. and Rotta J. ( 1 9 7 3 ) WHO Chronicle, 27 (2) 49-54.
for throat swab culture are not easily available, it is justified
6. Govt. of India (2006). Health Information of India, 2005, Min. of
to treat a sore throat with penicillin even without having the
Health and Family Welfare New Delhi.
culture. For this purpose, a single intramuscular injection of
7. Govt of India (2004), A n n u a l Report 2003-2004, Ministry of Health
1.2 million units of benzathine benzyl penicillin for adults and Family Welfare, New Delhi.

and 600,000 units for children is adequate, or oral penicillin 8. Kaplan, E.L. ( 1 9 8 5 ) Int. J. Epi, 14 (4) 499.

(Penicillin V or Penicillin G) should be given for 1 0 days. 9. Strasser, T. ( 1 9 7 8 ) WHO Chronicle, 32 ( 1 ) 18-25.

This is the least expensive method of giving penicillin for 10. Wahi, P.L. (1984) Ann Acad. Med. Sci. (India) 20 (4) 199-215.

eradication of streptococci from the throat. For patients with 11. El Kholy, A. et al ( 1 9 7 8 ) . Bull WHO 5 6 : 8 8 7 .

allergy to penicillin, erythromycin is the drug of choice. The 12. WHO (2004), Tech. Rep. Ser. No. 923.

MCH and school health services should be utilized for this 13. Strasser, T. et al ( 1 9 8 1 ) Bull WHO 5 9 : 285-294.


In short, the impossible logistics of primary prevention
coupled with enormous financial constraints force us to

concentrate on secondary prevention ( 1 0 ) . Cancer may be regarded as a group of diseases

characterized by an (i) abnormal growth of cells (ii) ability to
invade adjacent tissues and even distant organs, and ( i i i ) the

Secondary prevention ( i . e . , the prevention of recurrences eventual death of the affected patient if the tumour has

of RF) is a more practicable approach, especially in progressed beyond that stage when it can be successfully

developing countries. It consists in identifying those who removed. Cancer can occur at any site or tissue of the body

have had RF and giving them one intramuscular injection of and may involve any type of cells.

benzathine benzyl penicillin ( 1 . 2 million units in adults and
The major categories of cancer are : (a) Carcinomas,
600,000 units in children) at intervals of 3 weeks ( 1 2 ) . This
which arise from epithelial cells lining the internal surfaces
must be continued for at least 5 years or until the child
of the various organs ( e . g . mouth, oesophagus, intestines,
reaches 18 years whichever is later. For patients with carditis
uterus) and from the skin epithelium; (b) Sarcomas, which
(mild mitral regurgitation or healed carditis) the treatment
arise from mesodermal cells constituting the various
should continue for 10 years after the last attack, or at least
connective tissues (e.g. fibrous tissue, fat and bone); and
until 25 years of age, which ever is longer. More severe
(c) Lymphomas, myeloma and leukaemias arising from the
valvular disease or post-valve surgery cases need life-long
cells of bone marrow and immune systems.
treatment ( 1 2 ) . This prevents streptococcal sore throat and
The term “primary tumour” is used to denote cancer in
therefore recurrence of RF and RHD.
the organ of origin, while “secondary tumour” denotes
However, the crucial problem is one of patient
cancer that has spread to regional lymph nodes and distant
compliance as penicillin prophylaxis is a long-term affair.
organs. When cancer cells multiply and reach a critical size,
Studies have shown that secondary prevention is feasible,
the cancer is clinically evident as a lump or ulcer localized to
inexpensive and cost-effective, when implemented through
the organ of origin in early stages. As the disease advances,
primary health care systems (13).
symptoms and signs of invasion and distant metastases

become clinically evident ( 1 ) .

Non-medical measures for the prevention/control of RF Problem statement
are related to improving living conditions, and breaking the

poverty-disease-poverty cycle. Improvements in socio­ WORLD
economic conditions (particularly better housing) will in the
In 2012, the worldwide burden of cancer rose to an
long term reduce the incidence of RF.
estimated 14 million new cases per year, a figure expected to

Objective evaluation of available data indicates that rise to 22 million annually within the next two decades. Over
penicillin alone will not lead to effective control. Predictions the same period, cancer deaths are predicted to rise from an
suggest that many of the countries which suffer severe estimated 8.2 million annually to 13 million per year.
economic constraints will not be likely to be able to raise Globally, during 2 0 1 2 , the most common cancers diagnosed
their standards of living in the foreseeable future to were those of the lung ( 1 . 8 m i l l i o n ) , breast ( 1 . 7 million) and
significantly alter the incidence of this disease (9). colorectal ( 1 . 4 m i l l i o n ) . The most common causes of cancer

deaths were cancer of lung ( 1 . 6 million), liver ( 0 . 8 million)
and stomach (0. 7 m i l l i o n ) .
In the evaluation of the programme, the prevalence of
As a consequence of growing and ageing populations,
RHD in school children from periodic surveys of random
developing countries are disproportionately affected by the
samples is probably the best indicator. It is suggested that
increasing numbers of cancers. More than 60 per cent of the
surveys should be carried out on samples of schools (not
worlds total cases occur in Africa, Asia, and Central and
individuals) in the 6-14 years age group at 5-year intervals.
South America, and these regions account for about 70 per
The recommended sample size is 20,000 to 30,000 children
cent of the world’s cancer deaths. Situation is made worse
depending upon the expected prevalence (13).
by the lack of early detection and access to treatment (2).

References The “Westernization” trends : As low human-development

index (HD!) countries become more developed through
1. W H O ( 1 9 6 9 ) . WHO Chronicle, 28:345.
rapid societal and economic changes, they are likely to
2. WHO ( 2 0 1 1 ) , Disease and Injuries, Regional Estimates, Cause Specific

mortality, Estimates for 2008. become “westernized”. As such, the pattern of cancer
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incidence is likely to follow, that seen in high HDI settings, cancer in different regions of the world for men and w o m e n .

with likely decline in cancer incidence rate of cervix uteri Table 1 and 2 show the age standardized incidence and

and stomach, and increasing incidence rates . of breast, mortality of most common cancers in men and women

prostate and colorectal cancers. This westernization effect is worldwide.

a result of reduction in infection-related cancers and increase
For any disease, the relationship of incidence to mortality
in cancers associated with reproductive, dietary and
is an indication of prognosis. Similar incidence and mortality
hormonal risk factors (3).
rates being indicative of an essentially fatal condition. Thus,

Large variations in both cancer frequency and case lung cancer accounts for most deaths from cancer in the

fatality are observed, even in relation to the major forms of world ·(1.6 million) annually, since it is most invariably



Estimated incidence, mortality and 5-ye ar prevalence of top 1 0 cancers worldwide, 2012


Incidence Mortality 5-year prevalence
. Proportion per •.•..
% of total ASR (W) % of total ASR (W) % of total
100,000 population


Lung 16.7 34.2 23.6 30.0 8.2 48.8

Prostate 15.0 31.1 6.6 7.8 25.5 151.2

Colorectum 10.0 20.6 8.0 10.0 12.7 75.3

Stomach 8.5 17.4 10.1 12.8 6.7 39.7

Liver 7.5 .15.3 11.2 14.3 3.0 17.5

Oesophagus 4.3 9.0 6.0 7.7 2.2 13.0

Bladder 4.4 9.0 2.6 3.2 6.6 39.3

Non-Hodgkin 2.9 6.0 2.5 3.2 3.0 17.9


Kidney 2.9 6�0 2.0 2.5 3.8 22.4

Leukaemia 2.7 5.6 3.3 4.2 1.9 11.0

All cancers excluding 100.0 205.4 100.0 126.3 100.0 592.0


skin cancer




Breast 25.2 43.3 14.7 12.9 . 36.4 240.8

Colo rectum 9.2 14.3 9.0 6.9 9.3 61.2

Cervix uteri 7.9 14.0 7.5 6.8 9.0 59.6

Lung 8.8 13.6 13.8 11.1 3.6 24:1

Corpus uteri 4.8 8.3 2.1 1.8 . 7.1 46.8

Stomach 4.8 7.5 7.2 5.7 3.0 19.5

Ovary 3.6 6.1 4.3 3.8 3.4 22.6

Thyroid 3.5 6.1 0.8 0.6 5.4 36.0

Liver 3.4 5.3 6.3 5.1 1.0 6.9

Non-Hodgkin 2.5 4.1 2.4 2.0 2.2 14.2


All cancers excluding 100.0 165.3 100.0 82.9 100.0 661.4


skin cancer



Breast 11 . 9 43.3 6.4 12.9 19.2 240.8

Prostate 7.9 31.1 3.7 7.8 12.1 151.2

Lung 13.0 23.1 19.4 19.7 5.8 36.5

Colorectum 9.7 17.2 8.5 8.4 10.9 68.2

Cervix uteri 3.7 14.0 3.2 6.8 4.8 59.6

Stomach 6.8 12 .. 1 8.8 8.9 4.7 29.6

Liver 5.6 10.1 9.1 9.5 1.9 12.2

Corpus uteri 2.3 8.3 0.9 1.8 3.7 46.8

Ovary 1.7 6.1 1.9 3.8 1.8 22.6

Oesophagus 3.2 5.9 4.9 5.0 1.4 8.9

All cancers excluding 100.0 182.3 100.0 102.4 100.0 626.7


skin cancer

* Incidence and mortality data for all ages. 5-year prevalence for adult population only.

* ASR (W) Age-standardized rate and proportions per 100,000.

S o u r c e : (4)



Summary Statistics, World – 2 0 1 2


. _ · . . . . . . • ··.· ·>>World · : ·
. . – .


Population (thousands) 3557717 3496728 7054446

Number of new cancer cases (thousands) 7427.1 6663.0 14090.1

Age-standardized rate (W)* 205.4 165.3 182.3

Risk of getting cancer before age 75 (%) 21.0 16.4 . . 18.5

Number of cancer deaths (thousands) 4653.1 3547.9 · 8201.0

Age-standardized rate (W)* 126.3 82.9 102.4

Risk of dying from cancer before age 75 ( % ) 12.7 8.4 10.4

5-year prevalent cases, adult population 15362.3 17182.3 32544.6


Proportion (per 100;000) 592.0 661.4 626.7

* Age-standardized rate (W): A rate is the number of new cases or deaths per 100 000 persons per year. An age-standardized rate is the rate that

a population would have if it had a standard age structure. Standardization is necessary when comparing several populations that differ with

respect to age because age has a powerful influence on the risk of cancer.

Risk of getting or dying from the disease before age 75 (%) : The probability or risk of individuals getting/dying from cancer. It is expressed as

the number of new born children (out of 100) who would be expected to develop/die from cancer before the age of 75, if they had cancer.tin the

absence of other causes of death).

Source : (4)


associated with poor prognosis. On the .other hand, The five most frequent cancers in men were cancer lung,

appropriate intervention is often effective in avoiding fatal lip and oral cavity, stomach, colorectum and other pharynx,

outcome following diagnosis of breast cancer. Hence this and in women, cancer breast, cervix uteri, colorectum,

particular cancer, which rank second in terms of incidence, ovary, lip and oral cavity. Cancer in males were mostly

is not among the top three causes of death from cancer, tobacco related. In women, cervical cancer is closely

which are respectively cancers of the lung, stomach, and associated with poor genital hygiene, early consummation of

liver. marriage, multiple pregnancies, and contact with multiple

sexual partners. It is also reported that breast cancer is
The most conspicuous feature of the distribution of
proportionately on the increase in a few metropolitan areas
cancers between the sexes is the male predominance of lung
of India. This appears to be related to late marriage, birth of
cancer. Prostate, colorectal, stomach and liver cancer are
the first child at a late age, fewer children, and shorter
also much more common in males (Table 1). Cancer of
periods of breast-feeding, which are increasingly common
breast, colorectum, cervix, uteri, lung and stomach are
practice among the educated urban women (7).
common in females (4). For the most part, differences in

distribution between the sexes are attributable to differences Facilities for screening and proper management of cancer

in exposure to causative agents rather than to variation in patients are grossly limited in India. More than two-thirds of

the susceptibility. For other tumour types, including cancers cancer patients are already in an advanced and incurable

stage at the time of diagnosis. Appropriate strategies are
of pancreas and colorectum, there is little difference in the
being developed, including creating public awareness about
sex distribution. Generally speaking, the relationship of
cancer, tobacco control and application of self or assisted
incidence to mortality is not affected by sex. Thus for
screening technique for oral, cervical, and breast cancers.
example, the prognosis following diagnosis of liver or

pancreatic cancer is dismal for both males and females.
Time trends
Many other tumour types are more responsive to therapy, so

that cancers of breast, prostate and uterine cervix are the Few decades ago, cancer was the sixth leading cause of

cause of death in only a minority of patients diagnosed (5). death in industrialized countries; today, it is the second

leading cause of death. There are a number of reasons for
The burden of cancer is distributed unequally between
this increase, the three main ones being a longer life
developed and developing countries, with particular cancer
expectancy, more accurate diagnosis and the rise in cigarette
types exhibiting different patterns of distribution.
smoking, especially among males. The overall rates do not

reflect the different trends according to the type of cancer.
For example, there has been a large increase in lung cancer
In India, the National Cancer Registry Programme of the
incidence and the stomach cancer has shown a declining
ICMR provides data on incidence, mortality and distribution
trend in most developed countries for reasons not
of cancer from 25 population-based registries and 5 hospital
based registries.

Cancer patterns
It is estimated that during the year 2 0 1 2 , 1 0 . 1 5 lac new

cancer cases occurred in the country, of these 4.77 lac were There are wide variations in the distribution of cancer

males and 5.37 lac females. It gives an incidence rate of throughout the world. That cancer of the stomach is very

92.4 per lac population. Same year about 6 . 8 3 lac persons common in Japan, and has a low incidence in United States.

died of cancer, (3.57 lac males and 3.26 lac females), a The cervical cancer is high in Columbia and has a low

mortality rate of 69.7 per lac population. Table 3 and 4 show incidence in Japan. In the South-East Asia Region of WHO,

the age standardized incidence and mortality due to cancer the great majority are cancers of the oral cavity and uterine

in India. cervix. These and other international variations in the
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Estimated i n c i d e n c e ; mortality and 5-year prevalence of top 10 cancers in I n d i a , 2 0 1 2

Incidence Mortality 5-year prevalence
·. · Proportion per .
% of total · ASR(W) % of total ASR(W) % of total
100,000 population


Lung 11.3 11.0 13.7 9.9 3.7 5.4

Lip and oral cavity 11.3 10.1 10.2 6.7 12.6 18.5 ·

Stomach 9.1 8.6 11.4 8.0 4.7 6.8

Colorectum 7.7 7.2 7.8 5.4 7.5 11.0

Other pharynx 6.6 6.3 7.6 5.3 7.0 10.3

Oesophagus 5.7 5.4 7.1 5.0 2.1 3.1

Larynx 4.8 4.6 4.4 3.2 6.8 10.0

Prostate 4.0 4.2 3.4 2.7 9.6 14.1

Liver 3.6 3.5 4.7 3.3 1.2 1.8

Leukaemia 4.1 3.3 4.5 2.7 2.1 3.1


All cancers excluding 100.0 92.4 100.0 69.7 100.0 146.6


skin cancer




Breast 27.0 25.8 21.5 12.7 35.3 92.6

Cervix uteri 22.9 22.0 20.7 12.4 27.4 72.0

Colorectum 5.1 5.1 6.4 3.8 3.3 8.6

Ovary 5.0 4.9 6.0 3.6 4.9 12.9

Lip, oral cavity 4.3 4.3 4.8 3.0 3.1 8.2

Stomach 3.7 3.7 5.6 3.4 1.3 3.3

Lung 3.1 3.1 4.6 2.8 0.7 1.9

Oesophagus 2.7 2.8 4.1 2.6 0.7 1.9

Corpus uteri 2.3 2.3 1.5 0.9 4.0 10.5

Leukaemia 2.4 2.3 3.3 1.9 0.9 2.3


All cancers excluding 100.0 97.4 100.0 60.2 100.0 262.5


skin cancer



Breast 14.3 25.8 10.3 12.7 22.2 92.6

Cervix uteri 12.1 22.0 9.9 12.4 17.3 72.0

Lip, oral cavity 7.6 7.2 7.6 4.9 6.6 13.5

Lung 6.9 6.9 9.3 6.3 1.8 3.7

Colorectum 6.3 6.1 7.1 4.6 4.8 9.8

Stomach 6.2 6.1 8.6 5.7 2.8 5.1

Ovary 2.6 4.9 2.9 3.6 3.1 12.9

Prostate 1.9 4.2 1.8 2.7 3.6 14.l

Oesophagus 4.1 4.1 5.7 3.8 1.2 2.5

Other pharynx 3.8 3.7 4.8 3.1 3.2 6.4


All cancers excluding 100.0 94.0 100.0 64.5 100.0 202.9


skin cancer

S o u r c e : (6)



Summary Statistics, I n d i a – 2 0 1 2

India Male Female Both sexes

Population (thousands) 649474 608876 1258350

Number of new cancer cases (thousands) 477.5 537.5 1014.9

Age-standardized rate (W) 92.4 97.4 94.0

Risk of getting cancer before age 75 (%) 10.2 10.1 10.1

Number of cancer deaths (thousands) 356.7 326.1 682.8

Age-standardized rate (W) 69.7 60.2 64.5

Risk of dying from cancer before age 75 (%) 7.8 6.5 7.1

5–‘year prevalent cases, adult population 664.5 1126.0 1790.5


Proportion (per 100,000) 146.6 262.5 202,9

Source: (5)


pattern of cancer are attributed to multiple factors such as origin. The human T-cell leukaemia virus is associated with

environmental factors, food habits, lifestyle, genetic factors adult T-cell leukaemia/lymphoma in the United States and

or even inadequacy in detection and reporting of cases. southern parts of Japan (5, 12). (f) PARASITES : Parasitic

infections may also increase the risk of cancer, as for
Hospital data clearly indicates that the two organ sites
example, schistosomiasis in Middle East producing
most commonly involved are: (i) the uterine cervix in
carcinoma of the bladder. (g) CUSTOMS, HABITS AND
women, and (ii) the oropharynx in both sexes. These two
LIFESTYLES : To the above causes must be added customs,
sites represent approximately 50 per cent of all cancer cases.
habits and lifestyles of people which may be associated with
Both these cancers are predominantly environment related
an increased risk for certain cancers. The familiar examples
and have a strong socio-cultural relationship. It is also
are the demonstrated association between smoking and lung
important to note that these two kinds of cancer are easily
cancer, tobacco and betel chewing and oral cancer, etc ( 1 3 ) .
accessible for physical examination and amenable to early
(h) OTHERS : There are numerous other environmental
diagnosis by knowledge already available. i . e . , good clinical
factors such as sunlight, radiation, air and water pollution,
examination and exfoliative cytology. The cure rate for these
medications (e.g., oestrogen) and pesticides which are
neoplasma is also very high if they are treated surgically at

stages I and II. But unfortunately, in most cases, the patients related to cancer.

present themselves to a medical facility when the disease is
far advanced and is not amenable to treatment. This is the

crux of the problem. Genetic influences have long been suspected. For

example, retinoblastoma occurs in children of the same

Causes of cancer parent. Mongols are more likely to develop cancer

(leukaemia) than normal children. However, genetic factors
As with other chronic diseases, cancer has a multifactorial
are less conspicuous and more difficult to identify. There is
probably a complex interrelationship between hereditary

susceptibility and environmental carcinogenic stimuli in the
causation of a number of cancers.
Environmental factors are generally held responsible for

80 to 90 per cent of all human cancers. The major Cancer control
environmental factors identified so far include
Cancer control consists of a series of measures based on
(a) T O B A C C O : Tobacco in various forms of its usage ( e . g . ,
present medical knowledge in the fields of prevention,
smoking, chewing) is the major environmental cause of
detection, diagnosis, treatment, after care and rehabilitation,
cancers of the lung, larynx, mouth, pharynx, oesophagus,
aimed at reducing significantly the number of new cases,
bladder, pancreas and probably kidney. It has been estimated
increasing the number of cures and reducing the invalidism
that, in the world as a whole, cigarette smoking is now
due to cancer.
responsible for more than one million premature deaths each
The basic approach to the control of cancer is through
year (8). (b) ALCOHOL : Excessive intake of alcoholic
primary and secondary prevention. It is estimated that at
beverages is associated with oesophageal and liver cancer.
least one-third of all cancers are preventable (14).
Some recent studies have suggested that beer consumption

may be associated with rectal cancer (9). It is estimated that
alcohol contributed to about 3 per cent of all cancer

deaths (10). (c) DIETARY FACTORS: Dietary factors are also Cancer prevention· until recently was mainly concerned

related to cancer. Smoked fish is related to stomach cancer, with the early diagnosis of the disease (secondary

dietary fibre to intestinal cancer, beef consumption to bowel prevention), preferably at a precancerous stage. Advancing

knowledge has increased our understanding of causative
cancer and a high fat diet to breast cancer. A variety of other
factors of some cancers and it is now possible to control
dietary factors such as food additives and contaminants have
these factors in the general population as well as in
fallen under suspicion as causative agents. (Refer to chapter
particular occupational groups. They include the following :
10 for further details.) (d) OCCUPATIONAL EXPOSURES :

These include exposure to benzene, arsenic, cadmium, (a) CONTROL OF TOBACCO AND ALCOHOL

chromium, vinyl chloride, asbestos, polycyclic hydrocarbons, CONSUMPTION : Primary prevention offers the greatest

etc. Many others remain to be identified. The risk of hope for reducing the number of tobacco-induced and

occupational exposure is considerably increased if the alcohol related cancer deaths. It has been estimated that

individuals also smoke cigarettes. Occupational exposures control of tobacco smoking alone would reduce the total

are usually reported to account for 1 to 5 per cent of all burden of cancer by over a million cancers each year ( 1 5 ) .

human cancers ( 1 1 ) . (e) VIRUSES: An intensive search for a (b) PERSONAL HYGIENE: Improvements in personal

viral origin of human cancers revealed that hepatitis B and C hygiene may lead to declines in the incidence of certain types

virus is causally related to hepatocellular carcinoma. The of cancer, e . g . , cancer cervix. (c) RADIATION: Special efforts

relative risk of Kaposi’s sarcoma occurring in patients with should be made to reduce the amount of radiation (including

HIV infection is so high that it was the first manifestation of medical radiation) received by each individual to a minimum

the AIDS epidemic to be recognized. Non-Hodgkin’s without reducing the benefits. (d) OCCUPATIONAL

lymphoma, a cancer of the lymph nodes and spleen is a late EXPOSURES : The occupational aspects of cancer are

complication of AIDS. The Epstein-Barr virus (EBV) is frequently neglected. Measures to protect workers from

associated with 2 human malignancies, viz. Burkitt’s exposure to industrial carcinogens should be enforced in

lymphoma and nasopharyngeal carcinoma. Cytomegalovirus industries. (e) IMMUNIZATION: In the case of primary liver

(CMV) is a suspected oncogenic agent and classical Kaposi’s cancer, immunization against hepatitis B virus and for

sarcoma is associated with a higher prevalence of antibodies prevention of cancer cervix immunization against HPV

to CMV. Human papilloma virus (HPV) is a chief suspect in presents an exciting prospect. (/) FOODS, DRUGS

cancer cervix. Hodgkin’s disease is also believed to be of viral AND COSMETICS: These should be tested for carcinogens.
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{g) AIR POLLUTION : Control of air pollution is another of time trends, and planning and evaluation of operational

preventive measure. (h) TREATMENT OF PRECANCEROUS activities in all main areas of cancer control.

LESIONS : Early detection and prompt treatment of
precancerous lesions such as cervical tears, intestinal

polyposis, warts, chronic gastritis, chronic cervicitis, and Cancer screening is the main weapon for early detection
adenomata is one of the cornerstones of cancer prevention. of cancer at a pre-invasive (in situ) or pre-malignant stage.
{i) LEGISLATION : Legislation has also a role in primary Effective screening programmes have been developed for
prevention. For example, legislation to control known cervical· cancer, breast cancer and oral cancer. Like primary
environmental carcinogens (e.g., tobacco, alcohol, air prevention, early diagnosis has to be conducted on a large
pollution). {j) CANCER EDUCATION : An important area of scale; however, it may be possible to increase the efficiency
primary prevention is cancer education. It should be directed of screening programmes by focussing on high-risk groups.
at “high-risk” groups. The aim of cancer education is to Clearly, there is no point in detecting cancer at an early
motivate people to seek early diagnosis and early treatment. stage unless facilities for treatment and after-care are
Cancer organizations in many countries remind the public of available. Early detection programmes will require
the early warning signs (“danger s i g n a l s ” ) of cancer. These
mobilization of all available resources and development of a
are: cancer infrastructure starting at the level of primary health

a. a lump or hard area in the breast care, ending with complex cancer centres or institutions at

the state or national levels.
b. a change in a wart or mole

c. a persistent change in digestive and bowel habits
d. a persistent cough or hoarseness
Treatment facilities should be available to all cancer
e. excessive loss of blood at the monthly period or loss of
patients. Certain forms of cancer are amenable to surgical
blood outside the usual dates
removal, while some others respond favourably to radiation

f. blood loss from any natural orifice or chemotherapy or both. Since most of the known methods

of treatment have complementary effect on the ultimate
g. a swelling or sore that does not get better
outcome of the patient, multi-modality approach to cancer
h. unexplained loss of weight.
control has become a standard practice in cancer centres all

There is no doubt that the possibilities for primary over the world. In the developed countries today, cancer

prevention are many. Since primary prevention is directed at treatment is geared to high technology. For those who are

large population groups (e.g., high risk groups, school beyond the curable stage, the goal must be to provide pain

children, occupational groups, youth clubs), the cost can be relief. A largely neglected problem in cancer care is the

high and programmes difficult to conduct. Primary management of pain. The WHO has developed guidelines

prevention, although a hopeful approach, is still in its early on relief of cancer pain (18). “Freedom from cancer pain” is

stages. Major risk factors have been identified for a small now considered a right of cancer patients.

number of cancers only and far more research is needed in

that direction. CANCER SCREENING

2 . SECONDARY PREVENTION In the light of present knowledge, early detection and

prompt treatment of early cancer and precancerous
Secondary prevention comprises the following measures :
conditions provide the best possible protection against

cancer for the individual and the community. Now a good
deal of attention is being paid to screening for early
Cancer registration is a sine qua non for any cancer
detection of cancer. This approach, that is, cancer screening
control programme. It provides a base for assessing the
may be defined as the “search for unrecognized malignancy
magnitude of the problem and for planning the necessary
by means of rapidly applied tests”.
services. Cancer registries are basically of two types :
Cancer screening is possible because : (a) in many
hospital-based and population based. (a) HOSPITAL­
instances, malignant disease is preceded for a period of
BASED REGISTRIES: The hospital-based registry includes
months or years by a premalignant lesion, removal of which
all patients treated by a particular institution, whether in­
prevents subsequent development of cancer; (b) most
patients or out-patients. Registries should collect the
cancers begin as localized lesions and if found at this stage a
uniform minimum set of data recommended in the “WHO
high rate of cure is obtainable; and (c) as much as 75 per
Handbook for Standardized Cancer Registers” (16). If there
cent of all cancers occur in body sites that are accessible.
is a long-term follow-up of patients, hospital-based registries

can be of considerable value in the evaluation of
diagnostic and treatment programmes. Since hospital

population will always be a selected population, the use of (a) Mass screening by comprehensive cancer detection

these registries for epidemiological purposes is thus limited. examination: A rapid clinical examination, and examination

(b) POPULATION-BASED REGISTRIES : A right step is to of one or more body sites by the physician is one of the

set up a “hospital-based cancer registry” and extend the important approaches for screening for cancer. (b) Mass

same to a “population-based cancer registry”. The aim is to screening at single sites : This comprises examination of

cover the complete cancer situation in a given geographic single sites such as uterine cervix, breast or lung.

area. The optimum size of base population for a population {c) Selective s c r e e n i n g : This refers to examination of those

based cancer registry is in the range of 2-7 million ( 1 7 ) . The people thought to be at special risk, for example, parous

data from such registries alone can provide the incidence women of lower socio-economic strata upwards of 35 years

rate of cancer and serve as a useful tool for initiating of age for detection of cancer cervix, chronic smokers for

epidemiological enquiries into causes of cancer, surveillance lung cancer, etc.


1 . Screening for cancer cervix has been concern about exposure to radiation from repeated

mammographies and the risk of breast cancer developing as
Screening for cervical cancer has ·become an accepted
a result (ii) mammography requires technical equipment of a
clinical practice. The prolonged early phase of cancer in situ
high standard and radiologists with very considerable
can be detected by the Pap smear. Current policy suggests
experience – these two factors limit its more widespread use
that all women should have a Pap test (cervical smear) at the
for mass screening purposes, and (iii) biopsy from a
beginning of sexual activity, and then every 3 years
suspicious lesion may end up in a false-positive in as many
thereafter (19). A periodic pelvic examination is also
as 5-10 cases for each case of cancer detected.
recommended. Organized population based screening

programmes have reduced the incidence and mortality from Although recent evidence points to the superiority of

cervical cancer in many developed countries. mammography over clinical examination in terms of

sensitivity and specificity (21), medical opinion is against
However, screening for cancer cervix using Pap smear
routine mammography on the very young. Women under 35
requires excessive resources in terms of laboratories,
years of age should not have X-rays unless they are
equipments and trained personnels. This has led to search
symptomatic or a family history of early onset of breast
for an alternative screening method that can be more cost­
cancer (22). ·
effective. Visual inspection based screening tests such as

visual inspection with 5 per cent acetic acid (VIA), VIA with
3 . Screening for lung cancer
magnification (VIAM), and visual inspection post application
At present there are only two techniques for screening for
of Lugol’s iodine (VIL!) are some of the alternative screening
lung cancer, viz. chest radiograph and sputum cytology.
tests, which have been studied for their effectiveness in
Mass radiography has been suggested for early diagnosis at
India. Sensitivity of VIA tends to be similar to cytology based
six monthly intervals, but the evidence in support of this is
screening. It is easy to carry out and easy to train
not convincing. So it is not recommended. It is doubtful
appropriate health workers (20).
whether the disease satisfies the criteria of suitability for
The present strategy is to screen women using visual
screening (see chapter 4 ) .
inspection after application of freshly prepared 5 per cent

acetic acid solution (5 ml of glacial acetic acid mixed with
95 ml distilled water). Detection of well-defined opaque

acetowhite lesions close to the squamo-columnar junction,
1 . Oral cancer
well defined circum-orificial acetowhite lesion or dense

acetowhitening of ulceroproliferative growth on the cervix Oral cancer is one of the ten most common cancers in the

constiute a positive VIA or VIAM. The test is followed by a world. Its high frequency in Central and South East Asian

single visit approach for further investigation and countries (e.g., India, Bangladesh, Sri Lanka, Thailand,

management at district hospital. The management at district Indonesia, Pakistan) has been well documented. It is

hospital is planned in such a way that the treatment based estimated that during the year 2012, about 1.98 lac new

on colposcopy is offered in the same visit. Pap smear and cases and 98,000 deaths occurred worldwide, with a

biopsy are the investigations that are done to ensure that mortality rate of 2 . 1 per lac population (4).

there are cytological and histopathological back-up for the

interventions (20). PROBLEM IN INDIA

Intensive information, education and communication For the year 2 0 1 2 , with estimated incidence of 1 0 . 1 cases

activities are required to sensitize the community about the per 100,000 population for males and 4.3 per 100,000

significance of the disease and its early detection through population in females, oral cancer is a major problem in

screening. India. The estimated mortality is about 6. 7 per 1 0 0 , 0 0 0 in

males and 3.0 per 100,000 in females. During the year,

2 . Screening for breast cancer 77,003 new cases occurred in the country with 52,067

deaths due to oral cancer (4).
There is evidence that screening for breast cancer has a

favourable effect on mortality from breast cancer. The basic
techniques for early detection of breast cancer are :

(a) breast self-examination (BSE) by the patient (b) palpation (a) Tobacco : Approximately 90 per cent of oral cancers in

by a physician (c) thermography, and (d) mammography. South East Asia are linked to tobacco chewing and tobacco

smoking. During 1 9 6 6 – 1 9 7 7 , a large epidemiological survey
All women should be encouraged to perform breast self­
was carried out in different parts of the country. In this
examination. Breast cancers are more frequently found by
10-year follow-up study of 30,000 individuals in the three
women themselves than by a physician during a routine
districts of Ernakulam (Kerala), Srikakulam (Andhra), and
examination. Although the effectiveness of BSE has not
Bhavnagar (Gujarat), the results indicated that ( i ) oral cancer
been adequately quantified, it is a useful adjuvant to early
and precancerous lesions occurred almost solely among
case detection. In many countries, BSE will probably be the
those who smoked or chewed tobacco, and (ii) oral cancer
only feasible approach to wide population coverage for a
was almost always preceded by some type of precancerous
long time to come. Palpation is unreliable for large fatty
lesion (24, 25). The case about tobacco is further
breasts. Thermography has the advantage that the patient is
strengthened by the findings that the cancer almost always
not exposed to radiation. Unfortunately, it is not a sensitive
occurred on the side of the mouth where the tobacco quid
tool. Mammography is most sensitive and specific in
was kept (23), and the risk was 36 times higher than for non­
detecting small tumours that are sometimes missed on
chewers if the quid was kept in the mouth during sleep (26).
palpation. The use of mammography has three potential

drawbacks: ( i ) exposure to radiation. This may amount to a (b) Alcohol : Data indicates that oral cancer can also be

dose of 500 milliroentgen compared to a 30-40 caused by high concentrations of alcohol, and that alcohol

milliroentgen dose received in chest X-ray. Therefore, there appears to have a synergistic effect in tobacco users (23).
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(c) Pre-cancerous stage : The natural history of oral 2 . Cancer of the cervix
cancer shows that often a precancerous stage precedes the
This is the second most common cancer among women
development of cancer. The pre-cancerous lesions
worldwide, with an estimated 527,624 new cases and
(leukoplakia, erythroplakia) can be detected for upto
265,653 deaths with overall incidence: mortality ratio of
15 years prior to their change to an invasive carcinoma (23).
52 per cent (4). Developing countries, where it is often the
Intervention at this stage may result in regression of the
most common cancer among women, account for 88 per
cent of cases. Wide variations in incidence and mortality

(d) High-risk g r o u p s : These include tobacco chewers and from the disease exist between countries. Cases and deaths

smokers, bidi smokers, people using tobacco in other forms have declined markedly in the last 40 years in most

such as betel quid; people who sleep with the tobacco quid industrialized countries, partly owing to a reduction in risk

in the mouth (27). factors, but mainly as a result of extensive screening

programmes. More limited improvements have been
(e) Cultural patterns : In studying the tobacco habits in
observed in developing countries, where persistently high
developing countries, indigenous forms of smoking, as well
rates tend to be the rule ( 1 ) .
as chewing, which are characteristic of certain regions have

to be taken into account (8). Tobacco is smoked in the form In India, cancer of the cervix is the second most common

of manufactured cigarettes. The indigenous forms of number one killer cancer among women. It is estimated that

smoking are : bidi, chutta (cigar), c h i / u m , hookah (hubble-­ during 2 0 1 2 , 122,644 new cases of cancer cervix occurred

bubble). Tobacco in powdered form is inhaled as snuff. in the country (incidence rate of 22 per lac population) and

about 6 7 , 4 7 7 women died of the disease (mortality rate of
The most common form of tobacco chewing in India is
1 2 . 4 per lac population). It comes to 20. 7 per cent of all
the betel quid which usually consists – of the betel leaf,
cancer deaths in women and about 9. 9 per cent of total
arecanut, lime and tobacco. It is common for the poorer
cancer deaths in the country (6).
people to rub with the thumb flakes of sun-dried tobacco

and slaked lime in the palm of their left hand until the
desired mixture is obtained. The mixture (khaini) is then put
(a) The disease: Cancer cervix seems to follow a
into the mouth in small amounts and at frequent intervals
progressive course from epithelial dysplasia to carcinoma in
during the day and slowly sucked and swallowed after
situ to invasive carcinoma (Fig. 1 ) . There is good evidence
dilution with saliva.
that carcinoma in situ persists for a long time, more than
Cancer of the oral cavity is also very prevalent -in
8 years on an average (19). The proportion of cases
Central Asian districts of USSR, where people chew “nass” progressing to invasive carcinoma from preinvasive stage is
or “nasswar” – a mixture of tobacco, ashes, lime and cotton­ not known – it may average 15 to 20 years or longer ( 3 1 ) .
seed oil. The duration of the preinvasive stage is also not known.

Another type of cancer common in the eastern coastal There is evidence that some in situ cases will spontaneously

regions of Andhra Pradesh state in India is the epidermoid regress without treatment. Once the invasive stage is

carcinoma of the hard palate. It is associated with the habit reached, the disease spreads by direct extension into the

of reverse smoking of cigar (ch utta), i . e . , smoking with the lymph nodes and pelvic organs.

burning end inside the mouth (28).
Normal Dysplasia Cancer � Invasive

PREVENTION epithelium in situ cancer

FIG. 1
Hypothetical model of the natural history of cancer cervix

Oral cancer is amenable to primary prevention. If the
(b) Causative agent : There is evidence pointing to
tobacco habits are eliminated from the community, a great
Human papilloma virus (HPV) – sexually transmitted – as
deal of reduction in the incidence of oral cancer can be
the cause of cervical cancer (32). This virus was once
achieved. This requires intensive public education and
supposed to produce only vegetant warts, but now
motivation for changing lifestyles supported by legislative
acknowledged as responsible for a much wider clinical and
measures like banning or restricting the sale of tobacco.
subclinical lesions. The virus is found in .more than 95% of

the cancers. Current evidence suggests that the virus is a
necessary but not sufficient cause of the disease and
Oral cancers are easily accessible for inspection allowing
researchers are now trying to define other co-factors.
early detection. If detected early, possibly at the

precancerous stage, they can be treated or cured. The
precancerous lesions can be detected for up to 15 years,
(a) AGE : Cancer cervix affects relatively young women
prior to their change to an invasive carcinoma. Leukoplakia
with incidence increasing rapidly from the age of 25 to 45,
can be cured by cessation of tobacco use. The main
then levelling off, and finally falling again. (b) GENITAL
treatment modalities that offer hope are surgery and
WARTS : Past and/or present occurrence of clinical genital
radiotherapy (29). In developing countries over 50 per cent
warts has been found to be an important risk factor (32).
of oral cancers are detected only after they have reached an
(c) MARITAL STATUS : Cases are less likely to be single,
advanced stage ( 1 4 ) .
more likely to be widowed, divorced or separated and
The primary health care workers (village health guides, having multiple sexual partners. The fact that cancer of the
and multi-purpose workers) are in a strategic position to cervix is very common in prostitutes and practically
detect oral cancers at an early stage during home visits. unknown among virgins suggests that the disease could be
They can prove to be a vital link and a key instrument in the linked with sexual intercourse. (d) EARLY MARRIAGE: Early

control of oral cancer in developing countries (30). marriage, early coitus, early childbearing and repeated
_ _
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_ R__ Y·s:s�::
childbirth have been associated with increasing risk. Breast cancer is not only infrequent in Indian women, but

(e) ORAL CONTRACEPTIVE PILLS : There is renewed also it occurs in them a decade earlier than in Western

concern about the possible relationship between pill use and women – the mean age of occurrence is about 42 in I n d i a ,

the development of invasive cervical cancer (33). A recent as compared to 53 in the white women.

WHO study finds an increased risk with increased duration
(b) FAMILY HISTORY : The risk is high in those with a
of pill use and with the use of oral contraceptives high in
positive family history of breast cancer, especially if a
oestrogen (34). (f) SOCIO-ECONOMIC CLASS : Cancer
mother or sister developed breast cancer when
cervix is more common in the lower socio-economic groups
reflecting probably poor genital hygiene.
(c) PARITY : MacMahon, et al (40) in their international

case-control study found that the risk of breast cancer is
directly related to the age at which women bear the first
( a) PRIMARY PREVENTION : Until the causative factors
child. An early first, full-term pregnancy seems to have a
are more clearly understood, there is no prospect of primary
protective effect. Those whose first pregnancy is delayed to
prevention of the disease ( 3 1 ) . It may be that with improved
their late thirties are at a higher risk than multiparous
personal hygiene and birth control, cancer of the cervix uteri
women. Unmarried women tend to have more breast
will show the same decline in developing countries tumours than married single women, and nulliparous
as already experienced in most of Europe and North women had the same risk.
America (35).
(b) SECONDARY PREVENTION : This rests on early menarche and late menopause are established risk factors
detection of cases through screening and treatment by (41). The risk is reduced for those with a surgically induced
radical surgery and radiotherapy. The 5-year survival rate is menopause. Forty or more years of menstruation doubles

virtually 100 per cent for carcinoma in situ, 79 per cent for the risk of breast cancer as compared with 30 years (42).

local invasive disease and 45 per cent for regional invasive
(e) HORMONAL FACTORS : The association of breast
disease (19). Cancer cervix is difficult to cure once
cancer with early menarche and late menopause suggests
symptoms develop and is fatal if left untreated. Prognosis is
that ovary appears to play a crucial role in the development
strongly dependent upon the stage of disease at detection
of breast cancer. Evidence suggests that both elevated
and treatment. oestrogen as well as progesterone are important factors in

increasing breast cancer risk (43). In short, hormones
3 . Breast cancer
appear to hold the key to the understanding of breast

Breast cancer is by far the most frequent cancer among cancer.

women, with an estimated 1 . 6 7 million new cases diagnosed (f) PRIOR BREAST BIOPSY : Prior breast biopsy for
in 2 0 1 2 (about 25 per cent of all cancers). It is now the most benign breast disease is associated with an increased risk of
common cancer both in developed (794,000 cases) and breast cancer.
developing regions (883,000 cases). Incidence rates vary
(g) DIET : Current aetiological hypotheses suggest that
from 27 per lac women in Eastern Africa to 98 per lac
cancer of the breast is linked with a high fat diet and obesity.
women in Western Europe. The range of mortality rate is
It is not known how dietary fat influences breast cancer risk
similar, approximately 6-20 per lac, because of the more
at a cellular level (43).
favourable survival of breast cancer cases in developed
(h) SOCIO-ECONOMIC STATUS : Breast cancer is
countries. As a result, breast cancer ranks as the fifth cause
common in higher socio-economic groups. This is explained
of death from cancer, but it is still the most frequent cause of
by the risk factor of higher age at first birth.
cancer death in women in developing regions (36).
(i) OTHERS : (i) Radiation : An increased incidence of
It is estimated that during the year 2 0 1 2 , about 1 4 4 , 9 3 7
breast cancer has been observed in women exposed to
new cases of breast cancer in women occurred in India,
radiation. (ii) Oral contraceptives : Oral contraceptive
which accounts for 27 .0 per cent of all malignant cases (an
appears to have little overall effect on breast cancer,
incidence rate of 2 5 . 8 per lac population). About 70,218
although prolonged use of oral pills before the first
women died of this cancer (mortality of 2 1 . 5 per cent of all
pregnancy or before the age of 25 may increase the risk in
cancer cases), mortality rate being 1 2 . 7 per lac population,
younger women (44).
ranking number one killer in women (6).


The established risk factors of breast cancer include the a. PRIMARY PREVENTION

Current knowledge of the aetiology of breast cancer (35)

(a) AGE : Breast cancer is uncommon below the age of offers little prospect of primary prevention. However, the

35, the incidence increasing rapidly between the ages of 35 aim should be towards elimination of risk factors discussed

and 50. A slight bimodal trend in the age distribution has above and promotion of cancer education. The average age

been observed (37) with a dip in incidence at the time of at menarche can be increased through a reduction in

menopause. A secondary rise in frequency often occurs after childhood obesity, and an increase in strenuous physical

activity; and the frequency of ovulation (after menarche)
the age of 65. Women who developed their first breast
decreased by an increase in strenuous physical activity (45).
cancer under the age of 40, had three times the risk of
There is also good reason for reducing fat intake in the diet.
developing a second breast cancer than did those who

developed their first cancer after the age of 40 (38). Indeed
the aetiologies of pre-menopausal and post-menopausal

breast cancer appears to be different (39). Breast screening leads to early diagnosis of breast cancer,
t.· – N_O_N_-c
_ _o_M_M_U_N_IC
_ _A_BL_E_D_I_
S E_A_SE_s _


which in turn influences treatment and, hopefully, mortality. lung cancer is at present increasing more in females than in

An important component of secondary prevention is follow­ males (49).

up, i . e . , to detect recurrence as early as possible; to detect

cancer in the opposite breast at an early stage; and to b . RISK FACTORS
generate research data that might be useful (39).
(i) Smoking : Tobacco smoking was first suggested as a

No major improvement in survival rates has yet been cause of lung cancer in the 1920s. Subsequent studies

shown by current treatment modalities. Some cases progress proved the causal relationship between cigarette smoking

rapidly even if diagnosed at an apparently early stage, and lung cancer. Two studies in India showed that the lung

others surviving for 20 years even after metastatic spread. cancer risk for cigarette smokers is 8 . 6 times the risk for non­

However, in general, the removal of the tumour early is smokers (50, 5 1 ) . The risk is strongly related to the number
more likely to be curative than removal at a later stage (29). of cigarettes smoked, the age of starting to smoke and

smoking habits, such as inhalation and the number of puffs
4. Lung cancer and the nicotine, the tar content and the length of cigarettes.

Those who are highly exposed to “passive smoking”
(somebody else’s smoke) are at an increased risk of

Lung cancer has been known in industrial workers from developing lung cancer. It has been calculated that in

the late 19th century. It came into prominence as a public countries where smoking has been a widespread habit, it is

health problem in the Western world in 1930s – at first in responsible for 90 per cent of lung cancer deaths (52). The

men, and later (in 1960s) among women (46), and has strongest evidence that cigarette smoking is responsible for

followed the increasing adoption of cigarette smoking first lung cancer is the incidence reduction that occurs after

by men and later by women. According to WHO reports, cessation of smoking. This has been convincingly

between 1960 and 1 9 8 0 , t h e death rate due to lung cancer demonstrated in a 20-year prospective study on male
increased by 76 per cent in men and by 135 per cent in British doctors (53).
women (47, 27). In countries where cigarette smoking has
The most noxious components of tobacco smoke are tar,
only recently begun to be widely adopted, lung cancer
carbon monoxide and nicotine. The carcinogenic role of tar
deaths still remain low, but it may be expected that they will
is well established. Nicotine and carbon monoxide,
rise soon. In others, such as Poland, where the use of
particularly, contribute to increased risk of cardiovascular
cigarettes began earlier, the rise is already occurring. The
diseases through enhancement of blood coagulation in the
total burden of lung cancer in any country is directly related
vessels, interference with myocardial oxygen delivery, and
to the amount and duration of cigarette smoking.
reduction of the threshold for ventricular fibrillation (8).
Lung cancer has been the most common cancer in the
A study in India has shown that there is no difference
world for several decades, and by 2012, there were an
between the tar and nicotine delivery of the filter and
estimated 1 . 8 2 million new cases, representing 1 3 . 0 % of all
non-filter cigarettes smoked in India, so that a filter gives no
new cancers. It was also the most common cause of death
protection to Indian smokers. The “king-size” filter cigarettes
from cancer, with 1 . 5 8 million deaths ( 1 9 . 4 % of the total).
deliver more tar and nicotine than ordinary cigarettes.
A majority of the cases now occur in the developing
Bidi smoking appears to carry a higher lung cancer risk than
countries (55%). Lung cancer is still the most common
cigarette smoking owing to the higher concentration of
cancer in men worldwide ( 1 6 . 5 % of the total). In females,
carcinogenic hydrocarbons in the smoke (8).
incidence rates are generally lower, but worldwide, lung

cancer is now the fourth most frequent cancer of women (ii) Other factors : Besides cigarette smoking, there are

( 8 . 5 % of all cancers) and the second most common cause of other factors which are implicated in the aetiology of lung

death from cancer (12.8% of the total). The highest cancer. These include air pollution, radioactivity, and

incidence rate is observed in Northern America (where lung occupational exposure to asbestos, arsenic and its

cancer is now the second most frequent cancer in women), compounds, chromates, particles containing polycyclic

and the lowest in Middle Africa (15th most frequent cancer). aromatic hydrocarbons and certain nickel-bearing dusts.

A number of studies have shown an interaction between
Because of its high fatality · (the ratio of mortality to
smoking and asbestos exposure.
incidence is 0 . 8 6 ) and the lack of variability in survival in

developed and developing countries, the highest and lowest
mortality rates are estimated in the same regions, both in

men and women (48).
The estimates for the year 2012 for India are about

7 0 , 2 7 6 new lung cancer cases of which 5 3 , 7 2 8 were men In lung cancer control, primary prevention is of greatest

and 16,547 women (incidence rate of 6.9 per lac importance. The most promising approach is to control the
population). About 63, 759 persons died of lung cancer “smoking epidemic”, because 80 to 90 per cent of all cases
during the same year, of which 48,697 were men and of lung cancer in developed countries are due to smoking of
15,062 women (a mortality rate of 6.3 per lac population). It cigarettes (50). Methods of controlling the smoking epidemic
accounts for 6 . 9 per cent of all malignancies and 9.3 per have been described by the WHO expert committees in their
cent of all deaths due to cancer in the country (6). reports (49, 53). Broadly these methods include :

EPIDEMIOLOGICAL FEATURES a. Public information and education

b. Legislative and restrictive measures
c. Smoking cessation activities
About a third of all lung cancer deaths occur below the

age of 6 5 . In many industrialized countries, the incidence of d. National and international coordination


a. Public information and education met with only limited success. For untreated patients, the

median survival is 2 to 3 months, compared to 10-14
The need of the hour is to create public awareness about
months for patients receiving combined chemotherapy. In
the hazards of smoking through mass media. The target
view of these limitations, primary prevention merits greater
population should be the entire population with greater
attention. An important part of treatment is relief of pain so
emphasis laid on young people and school children. Nothing
that each dying patient has the right to spend his last days as
less than a national anti-smoking campaign will be needed
pain-free as possible.
to change human behaviour or life styles associated with

smoking. Curtailment of smoking must be an essential part
· 5 . Stomach cancer

of national health policy.
About one million new cases of stomach cancer were

b . Legislative and restrictive measures estimated to have occurred in 2012 (6.8% of the total),

making it currently the fifth most common malignancy in the
Legislation and restrictive measures have been suggested
world, behind cancers of the lung, breast, colorectum and
in the following areas : control of sales promotion; health
prostate. More than 70% (677,000) of cases occur in
warnings on cigarette packets and advertisements; product
developing countries·(456,000 in men, 2 2 1 , 0 0 0 in w o m e n ) ,
description showing yield of harmful substances; imposition
and half the world total occurs in Eastern Asia (mainly in
of upper limits for harmful substances in smoking materials;
taxation; sales restrictions; restriction on smoking in public

places; restriction on smoking in places of work, etc. (52). Stomach cancer is the third leading cause of cancer death

in both sexes worldwide (8.8% of the total). The highest
The Government of India have provided legislative
mortality rates are estimated in Eastern Asia (24 per
support to the anti-smoking campaign. “The Cigarettes
1 0 0 , 0 0 0 in men, 9 . 8 per 1 0 0 , 0 0 0 in w o m e n ) , the lowest in
(Regulation of production, supply and distribution) Act of
Northern America ( 2 . 8 and 1 . 5 respectively) (54).
1975″ which came into force from 1 April 1976, requires all

manufacturers or persons trading in cigarettes to display About 63,097 new cases of stomach cancer were

prominently the statutory warning “Cigarette Smoking is estimated to have occurred in India during 2012 (an

Injurious to Health” on all cartons or packets of cigarettes incidence rate of 6.2 cases per lac population)· of these

that are put on sale. Most of the State Governments in India 43,386 were in men and 19,711 in women. About 5 9 , 0 4 1

have promulgated laws prohibiting smoking in closed areas, persons died of stomach cancer (mortality rate of 5. 7 per lac

e . g . , cinemas, buses, educational institutions, and hospitals. population) of which 40,721 were men and 18,320

Again in the year 2003, a comprehensive tobacco control women (6).

legislation titled “The Cigarettes And Other Tobacco
The constant decline of stomach cancer in industrialized
Products (Prohibition of Advertisement and Regulation of
countries is linked to improved food preservation practices;
Trade and Commerce, Production, Supply and Distribution)
better nutrition more rich in vitamins from fresh vegetables
Act 2003 was passed by the Govt of India. Refer to chapter 7
and fruits; and less consumption of preserved, cured and
“National cancer control programme” for the details.
salted foods. Infection with the bacterium Helicobacter

pylori contributes to the risk, probably by interacting with
c. Smoking cessation activities
the other factors.

Research continues on different methods of smoking
Symptoms are non-specific, which explains why most of
cessation. In all countries well over 90 per cent of those who
the cases are diagnosed when the disease is at an advanced
give up smoking do so of their own volition, i . e . , without use
stage. Patients may complain of weight loss, fatigue or
of any specific therapy. The basic role of most treatments for
gastric discomfort. Diagnosis is performed by barium X-rays
smoking cessation would be to relieve the smoker of
and with biopsy.
“abstinence symptoms” (e.g., sleeplessness, craving for
This cancer is treated by surgical removal of the tumour,
smoking, dizziness, constipation, etc). The report of the
with or without adjuvant chemotherapy.
WHO expert committee (52) on smoking control contains

information on specific smoking cessation methods such as Stomach cancer cases have a generally poor survival

smoking cessation clinics, nicotine substitutes, hypnosis, etc. prognosis, averaging no more than 20% survival after five

years. If the tumour is localized to the stomach, 60% of
d . National and International coordination patients survive five years or more. However, only 1 8 % of

all cases are diagnosed at this early stage. Screening by
Since smoking is a worldwide epidemic, it requires
photofluoroscopy has been widespread in Japan since the
coordinated political and non-political approaches at local,
late 1960s and mortality rates are declining. It is unclear
national and international levels to contain the smoking
whether this trend can be attributed to mass screening alone.


1. WHO ( 1 9 9 7 ) . The World Health Report 1997, Report of the Director
This rests on early detection of cases and their treatment.
General WHO.
At present, there are only two procedures capable of
2. WHO (2013), Press Release No. 223, 12 Dec. 2 0 1 3 , Latest World
detecting presymptomatic, early-stage lung cancer. These
Cancer Statistics.
are the chest X-ray and sputum cytology. But screening for 3. WHO ( 2 0 1 4 ) , World Cancer Fact Sheet, Cancer Research UK, January

early-stage lung cancer is less attractive, more expensive 2014.

and appears to have less potential for reducing mortality 4. GLOBOCAN 2013, World Fact Sheet, (2013), Section of Cancer

Information, International Agency for Research on Cancer, Lyon,
than primary prevention. Therefore, mass screening for
lung cancer is not recommended as a routine public health
5. WHO (2003), World Cancer Report, Ed. by Bernard W. Stewart and
policy (49).
Paul Kleihues.

Efforts to find effective treatment for lung cancer have 6. GLOBOCAN 2013, India Fact Sheet, 2013, Section of Cancer