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Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 299-303 Brief Communication Cancer care in the rural areas of India: A firsthand experience of a clinical oncologist and review of literatures S Das1, KC Patro2 1 Department of H& FW, Government of Orissa, India Correspondence Address:S Das, Plot No 1083, Jagamara, Jagamohan Nagar, Khandagiri, Bhubaneswar 751030, Orissa, India, drsumandas@gmail.com Code Number: cr10067 PMID: 21119257 DOI: 10.4103/0973-1482.73369 Abstract Over 8,00,000 new cases are diagnosed and 5,50,000 deaths occur annually due to cancer in India. The dramatic increase in morbidity and mortality due to cancer is a matter of concern for the society. Though the burden of cancer involves the entire nation, but the rural and underprivileged population represents majority of patients. Despite an already overwhelming burden of health problems, it is high time we must address the cancer pandemic and its alarming share of morbidity and mortality. Many large scale and innovative initiatives have been launched to counter the deadly disease. This includes efforts to expand the resources for health education and increase awareness of cancer prevention to the people and health care providers. These initiatives call for an unprecedented level of cooperation among international agencies, government and nongovernmental organizations, international foundations, healthcare system and local institutions. This review signifies the need for special attention to cancer prevention and early diagnosis with emphasis to rural and remote places of India.Keywords: Cancer Prevention, Cancer Control, Cancer Control Program Introduction At any given point of time, nearly 2.5 million cancer cases are estimated to be present in India. Over 8,00,000 new cases are diagnosed and 5,50,000 deaths occur annually due to cancer. Nearly 15 lakh patients require facilities for diagnosis, treatment and follow up at a given time. National cancer registry program reveals the leading sites of cancer being in the oral cavity, lungs, esophagus and stomach among men and cervix, breast and oral cavity among women. Cancers, namely those of oral and lungs in males and cervix and breast in females, account for over 50% of all cancer deaths in India. [1] It is important that the cancer pandemic be appreciated now and priorities for appropriate responses be formulated. To this end, many large-scale educational, research, prevention, and treatment programs have been gaining momentum in the fight against cancer. While they vary in their specific objectives, the ultimate goal of all these programs is to decrease the incidence of disease and improve the effectiveness of treatment. Government of India first developed its statement on cancer control as early as in 1971. The cancer control program was revised in the year 1984 with the aim to have primary prevention of tobacco-related cancers, early detection of cancers of easily accessible sites, augmentation of treatment facilities and providing pain and palliative care. Twenty-one Regional Cancer Centers (RCC) have been established but the main contribution has been lacking in the direction of prevention and early detection. Studies have documented lack of awareness and screening for cervical carcinoma in India. [2] There is no organized screening and awareness program for any of the common cancers in the country. Most cancer centers provide only opportunistic screening services. [3] In this article, we here with discuss the problems that are responsible for the poor facilities of cancer control especially in rural areas of India as a firsthand experience and review of literatures discussing various possible initiatives that can be implemented to improve the cancer control program with emphasis on rural and remote places of India. Cancer Burden The incidence of cervical cancer is in its declining trend in the urban areas. However, as more than 70% of Indian population reside in rural areas, this constitutes the number one cancer in either sex. [1] Though breast cancer incidence is rising in the urban areas, but still 50% to 70% patients present in advanced stage due to lack of awareness regarding the disease coupled with non affordability and non availability of facilities for early detection and treatment. [4] High incidence of oral cancer in India is due to high prevalence of betel quid (with or without tobacco) chewing, smoking and alcohol. [5] The causes of this high prevalence of cancer in rural India being the combination of lack of awareness among people, self neglect and late presentation, Lack of awareness of the doctors and lack of infrastructure at rural areas regarding early diagnosis, prevalence of alternative systems and quacks who do not have any knowledge of cancer and its management, prevalent tobacco and alcohol use, poverty and resource crunch. In the rural areas, many people consider cancer as communicable infectious disease and consider it as a taboo for the family which leads to isolation. [3] The distance of the residence from the cancer center is also responsible for the late presentation and poor survival in cancer patients. [6] Patients from outlying rural areas of many countries have been found to have more advanced stage at diagnosis and poor survival. [7] The addiction of tobacco among youth in the rural areas adds fuel to fire being responsible for the major cause of oral malignancy in Indian population. As stated by Sharma et al., the cancer control in India has a sorry figure. [5] Strategies for Cancer Prevention Increasing awareness about cancer and screening camps of common cancers would provide the most cost effective approach and lead to high public health potential. As tobacco is the single leading cause of cancer worldwide, highest priority has to be given to tobacco control. [8] It calls for complete evaluation of National Cancer Control Program (NCCP) with strong emphasis on educating the public about the common symptoms and signs and the importance of early diagnosis and treatment. This can be achieved through educating the individuals involved in health care i.e. doctors at primary health center, pharmacists, health workers (male and female), anganwadi workers etc. The next level includes the educated and respectable persons in the villages i.e. school teachers, sarpanch, ward members and active youths. A variety of methods that can be employed for educating people e.g. conducting drawing and essay competitions for school children, debates, discussions, seminars and street play competitions by the youth and college students. Participatory workshops and training sessions by the non government organizations(NGO), municipal, district and state health administration, structured training and field activities by medical colleges and regional cancer centers, participatory programs on radio and television i.e. mass media, descriptive articles in newspapers and magazines, exhibitions and public lectures etc. Well-illustrated audiovisual educational materials are extremely useful for literate as well as illiterate populations. The other programs like reproductive and child health programs can be utilized as opportunities to educate the public about the presentation and early detection of cancer. Community-based educational intervention can increase community awareness about cancer and can yield a positive change in the practice of strategy for early detection of cancer. [9] Cervical cancer is the most common cancer in Indian women. The incidence has decreased in states like Kerala but still it is the leading cancer in females. Cytologic screening is the most effective method for detecting and treating precancerous lesions. Papanicolaou smears and treatment of precancerous lesion can lead to 90% reduction of incidence of invasive cervical cancer. [10] In the rural areas, this approach would have limited success as cytological screening requires highly trained cytologists but the visual inspection with acetic acid (VIA) or Lugol′s iodine (VILI) by trained personnel can provide a sound basis for this program. The Alliance for Cervical Cancer Prevention (ACCP) is an alliance of five international groups. The International Agency for Cancer Research (IARC), Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), The Pan American Health Organization (PAHO) and The Program for Appropriate Technology in Health (PATH). The ACCP has instituted a five-year plan to assess technologies and approaches to screening and treating precancerous cervical lesions and to improve awareness and encourage community involvement in cervical cancer prevention. The ACCP consortium recommends non cytologic methods of screening with community participation. [11] A vaccine against the human papilloma virus (HPV) is the most promising intervention to prevent cervical cancer. Clinical trials suggest that a vaccine can offer effective protection from incidence of cervical lesions. [12] Regular cervical cytology examination of at risk patients can help in decreasing the incidence, but it needs proper training to health care professionals to risk stratify the females and guide them with proper counselling and referral to centers with availability of screening procedures. In India, the rural areas are not equipped with the infrastructure to provide any screening procedure. Though the National Cancer Control Program aims at providing the facilities at least at the district level, still it is on the paper only in many states of the country. The education of the female health workers, lady health visitors (LHV) etc about the signs and symptoms of cervical cancer and the presence of adequate facility for screening at the community health center level is essential to curb the leading cause of cancer in females of India. Breast cancer among Indian women account for the second most common cause of cancer though the incidence in urban areas are increasing, but the rural India is notorious in presenting at an advanced stage which accounts for 50-70% of the cases. [13] Rao et al. emphasized on community-based educational intervention which they suggest to be very productive. [4] Clinical breast examination by trained personnel in the rural areas like female health workers has been suggested to be a viable screening option considering the socio-economic condition and the unavailability of facilities at the remote places. In the present scenario where a number of programs are being conducted on the national basis under National Rural Health Mission (NRHM), organizing training and education for the health workers regarding clinical breast examination can be achieved. Proper screening at the root level can definitely improve the present scenario of presentation at an advanced stage in breast carcinomas. The availability of treatment option at least at the district level is also essential as the economically poor people differ to go for treatment to a far off place which is the major cause for late presentation. A breast cancer pilot project can be initiated with establishment of diagnostic facilities with trained staff for early diagnosis and treatment of breast cancer patients at an early stage. Oral cancer is the leading cause of cancer among males in India. The prevalence of chewing betel quid (with or without tobacco) and smoking are the foremost cause for this notorious disease. Though the government of India has taken many steps including pasting photographs of cancer related conditions on the cigarette covers, imposing ban on smoking at public places, high tax imposition on cigarettes and chewable tobacco etc., but that does not solve the problem entirely as the people in the rural areas are still ignorant of the fact that these habits can cause cancer. As clinical examination of the oral cavity is the best and cheapest method for diagnosing the premalignant and malignant lesions, the education of the health workers can be the most helpful step along with educating the common man about the harmful effects of these habits. This can be achieved by conducting educational programs involving the village folks and in schools. Strategies of cancer prevention and control in China include controlling smokingand HBV infection, early detection and treatment at countryside for digestive/cervical cancer and at urban for breast/colon cancer, and better diet and physical activities. The early detection and treatment demonstration program of cancer started in 2005 that covered the cancers of esophagus, stomach, liver, colon-rectum, nasopharynx, breast and cervix. By the health care reform, the government-sponsored cervical and breast cancer screening program expanded to whole nation including rural women. [14] In Singapore, the strategies for cancer control includes hepatitis vaccination, antismoking campaign, health campaigns on nation wide basis, healthy lifestyle promotion, awareness programs etc. [15] Cancer Control Initiatives Cancer control unlike other disease control programs is definitely complicated as there are different cancers involved which require different strategies for individual cancers. As every different cancer differs in its etiology, presentation, screening strategies, diagnosis and treatment, it is essential to have a multidisciplinary approach. Most cancer control procedures need high technology, expertise, and experience. In the developing countries like India if the methodologies are imposed they are bound to fail due to inadequate resources, technical support, and inability of the public and professionals to cooperate because of their ignorance. The priorities of government health policy continue to focus on eradication of communicable and parasitic diseases, population control etc. There are no programs or agencies planned or executed at community level for cancer control. No coordinating or committed agency now functions in the governmental health sector for cancer control. Here the political will to curb one of the leading causes of mortality is lacking and the administrative skills are not being utilized. National cancer control programs are comprehensive public health approaches designed to reduce the incidence and mortality of cancer and to improve the quality of life in cancer patients through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, treatment, and palliation, by optimal use of available resources. These programs are designed to implement a systemic and comprehensive approach, with health agendas that are fully integrated into the social context of prevention and cancer care delivery. In the National Cancer Control Program, the government of India has set up Regional Cancer Centers (RCC). Apart from delivery of stateoftheart therapy, these centers were also envisaged to undertake cancer control activities in the community cancer registration, cancer research, rehabilitation, palliative care and cancer pain relief. In most of the regional cancer centers, year after year the cancer control program continues to be limited to treatment of advanced cancers only. Majority of professional medical societies and non government organizations have not been involved in anticancer activities and very few attempts have been made in this aspect. The general practitioners and family physicians can be a very useful source for health education on cancer. Primarily such personnel are busy with the ailments presented by the patient and hardly any health education is imparted. The basic attitude of the population is sickness management rather than regular health check up. If the cancer warning signals are properly discussed and self awareness is increased regarding danger signals then the population can get the benefit. Hence, there should be consistent and continuous effort for propagation of knowledge regarding cancer warning signals and self examination techniques. National Cancer Control Program (NCCP) launched in the year 1975-76 has seen three major revisions. In the first revision (1984-85) the primary objectives were (i) primary prevention of tobacco related cancer, (ii) early detection of cancer at accessible sites, (iii) augmentation of treatment facilities, (iv) establishment of equitable, pain control and palliative care network throughout the country. Only few states like Kerala have successfully implemented the cancer control program. Launch of District Cancer Control Program was fundamental theme of the second revision (1990-91). The current NCCP implementation identified layered cancer care delivery system with Community Health Centers (CHC); Level-0; for early detection and referral), Cancer care Services at District Hospitals (Level I,II), Oncology Wing at Medical Colleges (Tertiary level care; Level III,IV) and comprehensive cancer care through Regional Cancer Centers. Translational research on aspects of etiology, early diagnosis, treatment selection, monitoring including prognostication in Indian context is the need of the day. This multi-factorial functionality of NCCP would obviously lead to an increase in budget allocation by the Government in the forth coming five year plan. The Regional Cancer Centres are involved actively in early detection programs in few states of the country. The emphasis is on education followed by screening of cancers. Awareness cum screening camps can be organized in periodical interval with the support of the governmental and non governmental voluntary organizations. Self examination of oral cavity and breast by the common man and clinical examination by physicians and health workers needs to be emphasized. Village level volunteers need to be actively trained to create awareness on cancer, early signs, in advocating and motivating people to undergo diagnostic screening test and if required treatment at the regional cancer center. Early Cancer Detection Centers (ECDC) can be initiated by the government or non government organizations with technical support from Regional Cancer Center. They can provide easily accessible diagnostic facility for people in a district and also function as a coordinating agency for cancer related activities like prevention, palliative care, and follow up. They can be located at the remote places at the level of community health centers which is easily accessible to the poor people from villages. Early Cancer Detection Centers (ECDC) can also be handy in screening of common cancers with the help of trained personnel. The District Cancer Control Program was perceived by the Government of India as the demonstration module for universalizing cancer control program. The District Cancer Control Program is not well established in many states of India may be due to lack of political will, lack of human resource, and lack of established Early Cancer Detection Centers in the districts. In Kerala, the District Cancer Control Program is well established. In this program, the trained personnel can go to the peripheral level and systematically search for early cancer cases. They can be helpful in educating the common man about cancer, its causes, prevention and its treatment. The screening camps can be done at the primary health centers with the Chief District Medical Officer as the chief program officer. The medical officers, multipurpose health workers can be trained in the program. Ernakulam in Kerala has a well established District Cancer Control Programme and it can be very much used as a model for the rest of the country. No program can be successful without a proper registry. Population based cancer registry (PBCR) is the source of data in estimating the incidence and mortality as it records all cancer cases occurring in a defined region. The Indian Cancer Society started cancer registration in India by initiating PBCR in the city of Mumbai during the year 1963. Keeping in view the paucity of reliable data in a country with wide socio-cultural diversity, the Indian Council of Medical Research (ICMR) initiated a network of cancer registration through the National Cancer Registry Programme (NCRP) in 1982 to set up cancer registries in different regions of the country. The Indian Council of Medical Research network of registries now consists of six PBCRs located at Bangalore, Bhopal, Chennai, Delhi and Mumbai (five urban) and Barshi (rural). There are some other PBCRs in Kerala (Thiruvananthapuram and Karunagapally), West Bengal (Kolkata), Gujarat (Ahmedabad), and Maharashtra (Pune, Nagpur and Aurangabad), which are not under Indian Council of Medical Research. The population covered by cancer registry covers only 5%. [16] The proper registration of data is very essential for proper implementation of the proposed programs. All common methods of case ascertainment and registration must be used throughout India irrespective of the remote residence similar to registration of birth and death. Then they can be transmitted to a central store which is easily accessible. With the availability of proper registry, we can find out the problems responsible for poor cancer care at the remote places and corresponding plan can be implemented with emphasis on those problems. Construction of National cancer information service can form a pivotal role in the cancer control program. The suggested National cancer information service includes collection of cancer information and forming a database which can be standardized and used for research and application. Conclusion The comprehensive cancer control programs emphasizing on the rural and remote places is the need of the hour. This can definitely decrease the incidence and also can help in presentation of cancer at an early stage at which they can be curable. Strong political will, financial support and most importantly the support from Regional Cancer Centers, private practitioners, health workers of the villages, non government organizations are very essential. More clinical and interventional research is needed to better understand intervention capabilities and requirements. While research is necessary to inform effective programs, it is also time to move beyond research to act, by implementing programs in cancer prevention and treatment. To the extent possible, these efforts should join forces with other public health interventions at a grassroots level. Novel programs should strive to expand the existing infrastructure of culturally relevant programs that have already been successful in the fight against problems such as infectious diseases, and expand them to include cancer prevention and screening. References
Copyright 2010 - Journal of Cancer Research and Therapeutics |
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