Cost-effectiveness of oral cancer screening: results from a cluster randomized controlled trial in India.

OBJECTIVE: To evaluate oral cancer screening by visual inspection. METHODS: A cluster randomized controlled trial was initiated in Trivandrum district, Kerala, India. Of 13 population clusters, seven were randomly allocated to three rounds of screening between 1996 and 2004, while standard care was provided in six (control arm). An activity-based approach was employed to calculate costs associated with various components of the screening trial. Information on the resources used and on clinical events in each trial arm was derived from trial databases. Total costs for each cluster were estimated in 2004 United States dollars (US$). The incremental cost per life-year saved was calculated for all eligible individuals and for high-risk individuals (i.e. tobacco or alcohol users). FINDINGS: The proportion of oral cancers detected at an early stage (i.e. stage I or II) was higher in the intervention arm than the control arm (42% versus 24%, respectively). The incremental cost per life-year saved was US$ 835 for all individuals eligible for screening and US$ 156 for high-risk individuals. Oral cancer screening by visual inspection was performed for under US$ 6 per person. CONCLUSION: The most cost-effective approach to oral cancer screening by visual inspection is to offer it to the high-risk population. Targeted screening of this group will ensure that screening can be offered at a reasonable cost in a limited-resource setting.

Body mass index, weight change and mortality risk in a prospective study in India.

BACKGROUND: Although the detrimental effect of overweight and obesity has been extensively reported in Western populations, little is known on the association between body weight, weight change and mortality in Asian populations whose weight distribution and mortality differ considerably from the West. METHODS: A cohort of 75 868 subjects aged 35 years and above, participants of the Trivandrum Oral Cancer Study-a cluster-randomized controlled trial originally implemented to evaluate the efficacy of visual inspection on oral cancer, in Kerala State, South India-were followed up from 1995 to 2004. Weight and height were measured both at baseline and in 3.5-year follow-up surveys. Early years of follow-up were excluded from the analyses. Relative risks of overall death and cause-specific death were estimated according to the body mass index (BMI) category of the WHO Asian population definitions, and to weight changes between two surveys. RESULTS: Low BMI was a predictor of mortality, while high BMI was not. Mortality risks in men adjusted for age, smoking habits and other potential confounders, as compared with a BMI 18.5-22.9 kg/m(2), were 1.26 (95% CI 1.03-1.55) for BMI < 16 kg/m(2); 1.16 (1.03-1.32) for BMI = 16-18.4 kg/m(2); 0.95 (0.81-1.12) for BMI = 23-24.9 kg/m(2); 0.85 (0.69-1.05) for BMI = 25-27.4 kg/m(2); and 0.89 (0.65-1.21) for BMI >/= 27.5 kg/m(2). Similar findings were observed in women. BMI was not associated with deaths from cancer, cardiovascular and cerebrovascular diseases, and diabetes. A low BMI (<16 kg/m(2)) was associated with increased deaths from chronic respiratory diseases. Smoking and socio-economical status did modify the association. A moderate weight gain of 4-10% between the two surveys was associated with decreased risk of death, while moderate and severe weight loss were predictive factors of death. Similar results were observed in both men and women. CONCLUSIONS: Among this Indian rural population, mild to severe leanness (BMI < 16 kg/m(2)) and weight loss were important determinants of mortality, especially from chronic respiratory diseases, while overweight and above (BMI > 23 kg/m(2)) did not show any detrimental effect.

Role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer in Trivandrum, India: a nested case-control design using incident cancer cases.

Oral cancer is one of the most common cancers in the world, with two-thirds of the cases occurring in developing countries. While cohort and nested case-control study designs offer various methodological strengths, the role of tobacco and alcohol consumption in the etiology of oral cancer has been assessed mainly in case-control studies. The role of tobacco chewing, smoking and alcohol drinking patterns on the risk of cancer of the oral cavity was evaluated using a nested case-control design on data from a randomized control trial conducted between 1996 and 2004 in Trivandrum, India. Data from 282 incident oral cancer cases and 1410 matched controls were analyzed using multivariate conditional logistic regression models. Tobacco chewing was the strongest risk factor associated with oral cancer. The adjusted odds ratios (ORs) for chewers were 3.1 (95% confidence interval (CI)=2.1-4.6) for men and 11.0 (95%CI=5.8-20.7) for women. Effects of chewing pan with or without tobacco on oral cancer risk were elevated for both sexes. Bidi smoking increased the risk of oral cancer in men (OR=1.9, 95%CI=1.1-3.2). Dose-response relations were observed for the frequency and duration of chewing and alcohol drinking, as well as in duration of bidi smoking. Given the relatively poor survival rates of oral cancer patients, cessation of tobacco and moderation of alcohol use remain the key elements in oral cancer prevention and control.