Cancer incidence estimates for 2022 & projection for 2025: Result from National Cancer Registry Programme, India

Background & objectives: Information on recent cancer statistics is important for planning, monitoring and evaluating cancer control activities. This article aims to provide an update on the cancer incidence estimates in India by sex, age groups and anatomical sites for the year 2022. Methods: The National Cancer Registry Programme Report 2020, reported the cancer incidence from 28 Population-Based Cancer Registries (PBCRs) for the years 2012-2016. This was used as the basis to calculate cancer estimates in India. Information pertaining to the population at risk was extracted from the Census of India (2001 and 2011) for the estimation of age–sex stratified population. PBCRs were categorised into the respective State and regions of the country to understand the epidemiology of cancer. The age-specific incidence rate for each specific anatomical site of cancer was applied to the estimated population to derive the number of cancer cases in India for 2022. Results: The estimated number of incident cases of cancer in India for the year 2022 was found to be 14,61,427 (crude rate:100.4 per 100,000). In India, one in nine people are likely to develop cancer in his/her lifetime. Lung and breast cancers were the leading sites of cancer in males and females, respectively. Among the childhood (0-14 yr) cancers, lymphoid leukaemia (boys: 29.2% and girls: 24.2%) was the leading site. The incidence of cancer cases is estimated to increase by 12.8 per cent in 2025 as compared to 2020. Interpretation & conclusions: The cancer incidence is continuing to increase in India. The new estimates will be helpful in planning cancer prevention and control activities through the intervention of early detection, risk reduction and management.

Preparedness of primary & secondary care health facilities for the management of non-communicable diseases in tribal population across 12 districts in India

Background and objectives: Non-communicable diseases (NCDs) are highly prevalent in the tribal populations; however, there are limited data regarding health system preparedness to tackle NCDs among these populations. We estimated the availability of human resources, equipment, drugs, services and knowledge of doctors for NCD management in the selected tribal districts in India. Methods: A cross-sectional survey was conducted in 12 districts (one from each State) with at least 50 per cent tribal population in Andaman and Nicobar Islands, Himachal Pradesh, Madhya Pradesh, Odisha and eight northeastern States. Primary health centres (PHCs), community health centres (CHCs) and district/sub-district hospitals (DHs) were surveyed and data on screening and treatment services, human resources, equipment, drugs and information systems indicators were collected and analysed. The data were presented as proportions.Results: In the present study 177 facilities were surveyed, including 156 PHCs/CHCs and 21 DHs. DHs and the majority (82-96%) of the PHCs/CHCs provided outpatient treatment for diabetes and hypertension. Overall, 97 per cent of PHCs/CHCs had doctors, and 78 per cent had staff nurses. The availability of digital blood pressure monitors ranged from 35 to 43 per cent, and drugs were either not available or inadequate. Among 213 doctors, three-fourths knew the correct criteria for hypertension diagnosis, and a few correctly reported diabetes diagnosis criteria. Interpretation & conclusions: The results of this study suggest that the health system of the studied tribal districts was not adequately prepared to manage NCDs. The key challenges included inadequately trained workforce and a lack of equipment and drugs. It is suggested that capacity building and, procurement and distribution of equipment, drugs and information systems to track NCD patients should be the key focus areas of national programmes

Non-communicable diseases as a major contributor to deaths in 12 tribal districts in India

Background & objectives: Non-communicable diseases (NCDs) are the leading cause of death in India. Although studies have reported a high prevalence of NCD in tribal populations, there are limited data pertaining mortality due to NCDs. Therefore, in this study we estimated the proportion of deaths due to NCDs among 15 yr and older age group in tribal districts in India. Methods: We conducted a community-based survey in 12 districts (one per State) with more than 50 per cent tribal population. Data were collected using a verbal autopsy tool from the family member of the deceased. The estimated sample size was 452 deaths per district. We obtained the list of deaths for the reference period of one year and updated it during the survey. The cause of death was assigned using the International Classification of Diseases-10 classification and analyzed the proportions of causes of death. The age-standardized death rate (ASRD) was also estimated. Results: We surveyed 5292 deaths among those above 15 years of age. Overall, NCDs accounted for 66 per cent of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. ASRD due to NCD ranged from 426 in Kinnaur to 756 per 100,000 in East Garo Hills. Interpretation & conclusions: The findings of this community-based survey suggested that NCDs were the leading cause of death among the tribal populations in India. It is hence suggested that control of NCDs should be one of the public health priorities for tribal districts in India.

A clinicoepidemiological profile of lung cancers in India – Results from the National Cancer Registry Programme

Background & objectives: Lung cancer is a significant public health concern in low- and middle-income countries such as India. The present article describes the epidemiology, and clinical profile of lung cancer in India, based on recent data from the National Cancer Registry Programme (NCRP). Methods: The latest data on lung cancer from the NCRP were collated from 28 population-based cancer registries and 58 hospital-based cancer registries across a five-year (2012-2016) reporting period. Results: The highest age-adjusted incidence rate and mortality (AAMR) was found amongst males and females in the Aizawl district of Mizoram. A significant increase in the annual per cent change of lung cancer incidence was observed in metropolitan cities from 1982 to 2016. About one-third of the cases (36.5%) in males and females (31.7%) were recorded in the age group of 55-64 yr. Adenocarcinoma accounted for about a third (34.3%) of the morphological type in males and half (52.7% ) amongst females. Out of 22,645 recorded lung cancer cases, close to half (44.8%) of the patients presented with distant spread, while over one-third (35.3%) had loco-regional spread of disease at the time of diagnosis. Interpretation & conclusions: Our estimates suggest that the number of cases is expected to rise sharply to 81,219 cases amongst males and 30,109 in females in 2025. The rising incidence and delayed diagnosis of lung cancer in India are grave concerns. The findings of the present study call for scaling up and intensification of lung cancer-specific preventive, early diagnosis and control measures.

Performance of equations for estimation of 24-hour urinary sodium from morning fasting urine samples in a multisite study in India

BACKGROUND Dietary salt intake is an important modifiable risk factor for cardiovascular diseases. Estimation of 24-hour salt intake using morning urine samples needs to be validated in the Indian context. We examined the performance of INTERSALT, Tanaka and Kawasaki equations for the estimation of 24-hour urinary sodium from morning fasting urine (MFU) samples. METHODS We enrolled 486 adults aged 18–69 years from four regions of India with equal rural/urban and sex representation to provide 24-hour urine samples. The next day, a MFU sample was obtained. Based on the volume and sodium content of the 24-hour urine sample, 24-hour sodium excretion (reference method) was calculated. Sodium levels in the MFU samples were measured along with other parameters required, and the above equations were used to estimate 24-hour urinary sodium levels. Intraclass correlation coefficient (ICC) was used to assess the degree of agreement between the estimates from the reference method and the three equations. Bland–Altman (BA) plots were used to identify systematic bias and limits of agreement. A difference of 1 g of salt (0.39 g of sodium) between the mean salt intake by 24-hour urine and as estimated by equations was considered acceptable. RESULTS A total of 346 participants provided both the samples. The mean (SD) daily salt intake estimated by the 24-hour urine sample method was 9.9 (5.8) g. ICC was low for all the three equations: highest for Kawasaki (0.16; 95% CI 0.05–0.26) and least for Tanaka (0.12; 0.02–0.22). Only Tanaka equation provided estimates within 1 g of measured 24-hour salt intake (–0.36 g). BA plots showed that as the mean values increased, all the three equations provided lower estimates of salt intake. CONCLUSION Tanaka equation provided acceptable values of 24-hour salt intake at the population level. However, poor performance of all the equations highlights the need to understand the reasons and develop better methods for the measurement of sodium intake at the population level.

Health systems challenges and opportunities in tackling non-communicable diseases in rural areas of India

The increasing burden of non-communicable diseases in rural areas poses new challenges to an already overburdened health systems. We detail these challenges and identify opportunities to address them. The major challenges in service delivery in rural areas include poor accessibility, shortage of adequate manpower especially specialists in rural areas, irregular supply of medicines and lack of adequate diagnostic facilities. This has led to an increased dependency on the private sector resulting in high out-of-pocket and catastrophic health expenditure. The challenges are amplified by lower health literacy, large pool of informal or untrained healthcare practitioners, and lack of proper referral and follow up. The health system opportunities identified include task-shifting by training of mid-level healthcare providers and practitioners from Indian systems of medicine, widening use of e-health and m-health, community engagement and public–private partnerships. Participatory health governance through community engagement has been shown to improve accountability and quality in health systems. Civil society organizations (CSO) can also improve awareness and health-seeking behaviour. New and evidence-based strategies need to be implemented to address health system challenges for tackling non-communicable diseases in rural areas.

Effect of Pioglitazone on Body Composition in Asian Indian Diabetics Suggest Role of Limb Fat in their High Insulin Resistance.

Aim: To study (1) effect of pioglitazone mono-therapy on body composition in treatment naive type-2 diabetes mellitus patients and (2) relationship between changes in body composition and insulin resistance induced by pioglitazone. Methods: Subjects: 49 newly diagnosed non-obese T2DM patients were recruited. Design: Open label observational study. Drug and Dose: pioglitazone 30 mg orally once daily for at least 6 months. Exclusion: Primary un-responsiveness at 3 months (10 subjects) and adverse effect (2 subjects). Final analysis done on 37 subjects (Mean age 47.9 years, male:female ratio 20:10) Controls: 37 healthy control subjects (Mean age 47 years M:F ratio 27:10) with normal glucose as per American Diabetes Association criteria. Study parameters were: Plasma glucose, Lipid profile, body mass index, HOMA-R, HOMA-B and body composition measured by dual-energy X-ray absorptiometry (DEXA) at start and after at least 6 months of follow up. Results: Treatment with pioglitazone was associated with significantly decreased glycated hemoglobin (HbA1c), fasting and post-prandial plasma glucose, insulin resistance and triglycerides HDL ratio.Significant increase in total body, limb and head fat mass was observed. The trunk composition did not show significant change. The DEXA Parameters of body composition of diabetics became comparable with controls. Significant correlation was seen between decrease in FPG, PPG, insulin resistance and increase in limb fat mass. Conclusions: Pioglitazone alters body composition by increasing limb and head fat content, without altering trunk fat. Decrease in insulin resistance by it is related to increase in limb fat mass.

Lessons for addressing noncommunicable diseases within a primary health-care system from the Ballabgarh project, India.

Background: Most patients with noncommunicable diseases (NCDs) can be managed appropriately at the primary care level, using a simplified standard protocol supported by low-cost drugs. The primary care response to common NCDs is often unstructured and inadequate in low- and middle-income countries. This study assessed the feasibility of integration of NCD prevention and control within the primary health-care system of India. Methods: This study was done among 12 subcentres, 2 primary health centres (PHCs) and one subdistrict hospital in a block in north India. All 28 multipurpose health workers of these subcentres underwent 3-day training for delivering the package of NCD interventions as a part of their routine functioning. A time–motion study was conducted before and after this, to assess the workload on a sample of the workers with and without the NCD work. Screening for risk assessment was done at domiciliary level as well as at health-facility level (opportunistic screening), and the cost was estimated based on standard costing procedures. Individuals who screened positive were investigated with electrocardiography and fasting blood sugar. PHCs were strengthened with provision of essential medicines and technologies. Results: After training, 6% of the time of workers (n = 7) was spent in the NCDrelated activities, and introduction of NCD activities did not impact the coverage of other major national health programmes. Loss during referral of “at-risk” subjects (37.5% from home to subcentre and 33% from subcentre to PHC) resulted in screening efficiency being lowest at domiciliary level (1.3 cases of NCDs identified per 1000 screened). In comparison to domiciliary screening (`21 830.6; US$ 363.8 per case identified), opportunistic screening at subdistrict level (`794.6; US$ 13.2) was 27.5 times and opportunistic screening at PHC (`1457.5; US$ 24.3) was 15.0 times lower. There was significant utilization of NCD services provided at PHCs, including counselling. Conclusion: Opportunistic screening appears to be feasible and a cost-effective strategy for risk screening. It is possible to integrate NCD prevention and control into primary health care in India.

Evidence building for policy: Tobacco surveillance/surveys and research in India.

India is at a crucial juncture relating to tobacco control and implementing the recommendations of the WHO FCTC. Tobacco consumption in the country remains alarmingly high in urban as well as rural areas. Smokeless tobacco consumption is very popular among larger masses, including the youth. Cigarette smoking has declined, but bidi use has increased concomitantly. Youth continue to be lured to initiate tobacco consumption through efficient marketing strategies of tobacco companies. The epidemiology of tobacco consumption is markedly varied across the country, with high rates in 15 States. Progress has been made towards tobacco control by the enactment of laws and regulations and the National Tobacco Control Program. Strengthening their implementation and enforcement is the biggest challenge and requires resource inputs. Evidence generation and its translation and utilisation for policy interventions would be useful.

Alpha 1 Antitrypsin Deficiency in Children with Chronic Liver Disease in North India.

Objective: We attempted to determine the role of alpha-1- antitrypsin (AAT) deficient variants as an etiologic factor for chronic liver disease in North Indian children. Design: This study investigated 1700 children (682 retrospectively and 1018 prospectively) (840 CLD, 410 neonatal cholestasis and 450 without liver disease) for AAT deficiency. Setting: Tertiary referral center, All India Institute of Medical Sciences, New Delhi. Patients: Of 1250 liver disease patients, 98 (7.8%) were suspected to be AAT deficient on the basis of screening tests (low serum AAT levels and/or absent/faint alpha-1- globulin band on serum agarose electrophoresis and/or diastase resistant PAS positive granules on liver biopsy). Main outcome measures: AAT deficient Z or S allele in suspected patients. Results: Z or S allele was not observed on phenotyping (1700 subjects), or with PCR-RFLP, SSCP and sequencing done in 50 of 98 suspected AAT deficient patients. A novel mutation G-to-A at position 333 in exon V was found in two siblings having positive immunohistochemistry for AAT on liver biopsy, both of whom had significant liver disease with portal hypertension. Conclusion: In conclusion, AAT deficiency as an etiologic factor for chronic liver disease in childhood appeared to be uncommon in North India.

Surveillance of cardiovascular disease risk factors in India: The need & scope.

There is a rise of non-communicable diseases (NCDs) burden, which is causing increasing morbidity and premature mortality in developing countries. In 1990, cardiovascular diseases (CVD) accounted for 63 per cent of all deaths and India contributed to 17 per cent to the worldwide mortality. Several surveys conducted across the country over the past two decades have shown a rising prevalence of major risk factors for CVD in urban and rural populations. These surveys are limited by their generalisability to other parts of the country, and more was required to roll out of an action plan. There was lack of an organized national system for monitoring these risk factors over time so as to inform policy and programme for appropriate interventions. The Indian Council of Medical Research (ICMR) leveraged its research on NCD risk factor surveillance to the development of the national plan under the Integrated Disease Surveillance Project (IDSP) which will obtain State-based prevalence of selected risk factors. This review provides the scenario of CVD in India and the need for a surveillance system. By examining similar experiences globally, it outlines the scope of CVD surveillance in India.

Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India.

Background & objectives: Kerala State is a harbinger of what will happen in future to the rest of India in chronic non-communicable diseases (NCD). We assessed: (i) the burden of NCD risk factors; (ii) estimated the relations of behavioural risk factors to socio-demographic correlates, anthropometric risk factors with behavioural risk factors; (iii) evaluated if socio-demographic, behavioural and anthropometric risk factors predicted biochemical risk factors; and (iv) estimated awareness, treatment and adequacy of control of hypertension and diabetes, in Kerala state. Methods: A total of 7449 individuals (51% women) stratified by age group, sex and place of residence were selected and information on behavioural risk factors; tobacco use, diet, physical activity, alcohol use, measured anthropometry, blood pressure was collected. Fasting blood samples were analysed for blood glucose, total cholesterol, high density lipoprotein cholesterol and triglycerides in a sample subset. Using multiple logistic regression models the associations between socio-demographic and anthropometric variables with biochemical risk factors were estimated. Results: The burden of NCD risk factors was high in our sample. Prevalence of behavioural and each of the biochemical risk factors increased with age, adjusting for other factors including sex and the place of residence. The odds ratios relating anthropometric variables to biochemical variables were modest, suggesting that anthropometric variables may not be useful surrogates for biochemical risk factors for population screening purposes. Interpretation & conclusions: In this large study of community-based sample in Kerala, high burden of NCD risk factors was observed, comparable to that in the United States. These data may serve to propel multisectoral efforts to lower the community burden of NCD risk factors in India in general, and in Kerala, in particular.

Primary pioglitazone failure in Asian Indian diabetics is not related to common Pro12Ala polymorph of ppar- γ gene.

To determine the various factors influencing glycemic response to pioglitazone mono therapy in newly diagnosed Asian Indian T2DM patients. Thirty T2DM patients (age 53.23±8.067 yrs, M : F ratio 14:16) were treated with pioglitazone for at least 14 weeks. Relationship between its glucose lowering effect and following patient parameters was studied: BMI, W:H ratio, HOMA-R, HOMA-β and Pro12Ala polymorph of PPAR-γ gene. Glycemic targets could be achieved in 20 (66.67%) subjects. All the parameters were comparable among responders and non-responders at the start of therapy. All the participants were homozygous for Pro allele of Pro12Ala polymorph of PPAR-γ gene. There was a significant positive association between glycemic response to pioglitazone and W: H ratio (beta = 0.426, P = 0.034) and HOMA-R (beta = 0.563, P = 0.008). Primary pioglitazone failure cannot be explained on the basis of body fat and its distribution, insulin resistance and secretory function and Pro12Ala polymorph of PPAR-γ gene. Among responders central obesity and high insulin resistance were associated with better glycemic response.

Are the urban poor vulnerable to non-communicable diseases? A survey of risk factors for non-communicable diseases in urban slums of Faridabad.

BACKGROUND: Non-communicable diseases have modifiable risk factors, which are easy to measure and can help in planning effective interventions. We established a community-based sentinel surveillance to estimate the prevalence and level of common risk factors for major non-communicable diseases as part of a joint Indian Council of Medical Research/WHO initiative. METHODS: This survey was done from February 2003 to June 2004 and included 1260 men and 1 304 women 15-64 years of age living in urban slum areas of Ballabgarh block, Faridabad district, Haryana. A list of all slums in Ballabgarh block was obtained from the Municipal Corporation of Faridabad. Slums were selected by stratified cluster sampling. All households in the selected slums were visited and men and women interviewed in alternate households. The study instrument was based on the STEPS approach of WHO. It included questions related to tobacco use, alcohol intake, diet, physical activity, and history of treatment for hypertension and diabetes mellitus. Height, weight, waist circumference and blood pressure were measured. To estimate prevalence at the population level, age adjustment was done using the urban Faridabad population structure from the 2001 Census of India. RESULTS: The age-adjusted prevalence of smoking among men was 36.5% compared with 7% in women. Bidi was the predominant form of smoked tobacco used. The use of smokeless tobacco was reported by 10.2% of men and 2.9% of women. While 26% of men reported consuming alcohol in the past 1 year, none of the women did. The mean number of servings per day of fruits and vegetables was 2.7 for men compared with 2.2 for women. Overall, only 7.9% and 5.4% of men and women, respectively took > or = 5 servings per day of fruits and vegetables. Women were more likely to be physically inactive compared with men (14.8% v. 55%); 67% of men and 22.8% of women reported mean physical activity > 150 minutes per week. The mean body mass index (BMI) was lower in men than in women (20.9 v. 21.9 kg/m2). The prevalence of overweight (BMI > or = 25 kg/m2)) was 16% among men and 21.9% among women. The prevalence of hypertension (blood pressure > or = 1 40/> or = 90 mmHg or on an antihypertensive drug) was 17.2% in men and 15.8% in women. CONCLUSION: The high prevalence of risk factors for noncommunicable diseases across all age groups in this urban slum community indicates the likelihood of a high future burden of illness. Immediate action for prevention and control is required to prevent the situation from worsening.

Non-alcoholic fatty liver disease and childhood obesity.

Obesity has emerged as a significant global health problem in the pediatric population. Pediatric liver disease is a serious complication of childhood obesity. Non-alcoholic steatohepatitis (NASH) is an entity in the spectrum of non-alcoholic fatty liver disease (NAFLD) ranges from fat in the liver--simple steatosis, NASH/ steatohepatitis--fat with in.ammation and/or fibrosis to advanced fibrosis and cirrhosis when fat may no longer be present. NASH is associated with obesity, diabetes, insulin resistance (IR), and hypertriglyceridemia. Children get NAFLD, and the incidence of this pediatric liver disease is rising as childhood obesity becomes increasingly prevalent. Although much remains to be learned about pediatric NAFLD, it is already evident that children with NASH risk progressive liver damage, including cirrhosis. Liver biopsy is required for definitive diagnosis, and other causes of fatty liver in childhood must be excluded. Gradual weight loss through increased regular exercise and a low-fat, low-refined carbohydrate diet appears to be effective. Drug treatments are being developed. The important message is that childhood obesity poses important health problems, including but not limited to potentially severe chronic liver disease. Early diagnosis of children who are only overweight is a worthy goal so that strategies to limit obesity can be instituted as early as possible. Identification of genetic risks is important, but management will invariably require changes in environmental factors. In addition to individual treatment, a multifaceted, societal initiative is required for solving the childhood obesity epidemic.

Pancreatic diseases in children in a north Indian referral hospital.

This was a cross-sectional study to determine the profile of pancreatic disorders in 54 children (age <15 years) presenting to a tertiary care center in India. Acute pancreatitis was the most common pancreatic disorder (28/54, 52%). Twenty-three children (43%) were diagnosed to have either chronic calcific (n = 15, 28%) or chronic non-calcific (n = 8, 15%) pancreatitis. Specific etiologic factors could be identified in 64.3% (18/28) of acute pancreatitis and 43.5% (10/23) of chronic pancreatitis patients. At least some of the 13 children with idiopathic chronic pancreatitis had features suggestive of tropical pancreatitis.

Erythema annulare centrifugum with autoimmune hepatitis.

Erythema annulare centrifugum (EAC) is a rare disease entity characterized by dense perivascular lymphocytic infiltrates in dermis. It has been associated with a few conditions, though its etiology is largely unknown. To our knowledge there has been no reported association with autoimmune hepatitis described earlier. This child also was positive for hepatitis C virus antibodies, though HCV RNA was negative. We should keep in mind the false positivity of hepatitis C antibodies before deciding on its therapy.