Evolution of Cancer Programmes in India The cancer programme started with the evolution of NCRP Programme in India

Evolution of Cancer Programmes in India
The cancer programme started with the evolution of NCRP Programme in India, and has now grown to include a big network of Population Based Cancer Registries and Hospital based Cancer registries.

Review of Literature
The journal titled, “Geographic pathology revisited: Development of an atlas of cancer” in India written by Nandakumar et al. talks about the usefulness of the cancer atlas in determining the risk of different cancers at various places. It also highlights the need for comparison of the cancer atlas data which was collected with the PBCR data to find the validity of the data.

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The NCRP report titled, “Three year report of Population Based Cancer Registries: 2012-14”, published by the Indian Council of Medical Research talks about the population served by the respected registries and the cancer incidence. It also talks about the leading sites of cancer and especially those which are associated directly with the usage of tobacco. Lastly, it also projects the burden of cancer.

The NCRP report titled, “Consolidated Report of Population Based Cancer Registries: 2012-14”, published by the Indian Council of Medical Research talks about the efficiency of various hospitals in dealing with cancer patients. It stresses on development of online modules which are linked to HBCR-DM software to capture real time data, which is accurate.

The journal titled, “Cancer Registration in India – Current Scenario and Future Perspectives” written by Chatterjee et al. talks about the registration of cancer cases in India for better surveillance, earlier access to treatment, and to reduce the incidence and mortality rates.

An article titled, “The burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016” written by D.Prabhakaran et al. talks about burden of cancer in India. This study takes into account the Sample Registration System in India, the data from the existing Population Based Cancer Registries, to present the Disability adjusted Life Years, Incidence and Death rates for all 28 types of cancer.

NCRP
In India, initiation of population based cancer registries at Bombay in 1964, Pune in 1973 and Aurangabad in 1978, Ahmedabad and Nagpur in 1980 paved the way for the National Cancer Registry Programme by providing data on cancer incidence on a regular basis. However, cancer registration started full-fledged with the National Cancer Registry Programme (NCRP) by Indian Council of Medical Research in 1982. It started off with three population based registries (existing Bombay registry and new registries at Bangalore and Madras), and three hospital based registries (at Chandigarh, Dibrugarh & Trivandrum).

Cancer Burden
According to the article, “The burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016″, 8.3% of the total deaths and 5% of total DALYs in India were due to Cancer. This study had used the existing data available from the Population Based Cancer Registries and the Sample Registration System for estimation purposes. In the Indian context, the Sample Registration System, is an indicator of births and deaths.
Mainly, the data from the Cancer Registries were compared with data from the Sample Registration System, and in case of any variations, especially in death data, registry data was taken into account , as in most of the cases registered under the Sample Registration System, the cause of death were not filled.
DALYs was calculated using the following formulae
DALY = YLL + YLD
Where DALY – Disability Adjusted Life Years
YLL – Years of Life Lost (Premature mortality)
YLD – Years of Life lost due to Disability (Incident Cases)
This study has highlighted a negative correlation between Epidemiological Transition Levels and the Socio-Demographic Index(which is calculated based on Income/Education/Fertility levels), which means that as Epidemiological transition levels decreases, Socio-Demographic Index increases and vice versa.

PBCR Reports
The PBCR reports give the reports of 27 Population Based Cancer Registries which are functional in India. Population Based Cancer Registries are set up to mainly calculate the incidence rates, and to systematically collect information from a specified population for a period of time.
The main concentration is on development of a framework to assess and control the impact of cancer in a defined population. The existing PBCRs have been concentrated mainly on the urban population except for a few rural population like Wardha and Barshi in Maharashtra, but some states and union territories do not have population based registries like Uttar Pradesh, Chandigarh, etc.
The PBCR report has used the Census data of years 2001 and 2011 for comparison of mid-year population except for Kamrup Urban and Nagaland PBCRs, as the 2011 census has been rejected by the Government of Nagaland.
This report had compared the cancer incidence and patterns of all Population based cancer registries, and has reported that North East Registries occupy the top positions, followed by Delhi, among both males and females. Except for a few cancers like Breast, Cervix Uteri, Prostate, Kidney, Urinary Bladder, Brain, Nervous System, all the others were high in the north eastern registries, which is an alarming indicator that tobacco related cancers are at the highest in the north-east.

HBCR Reports
According to Isabel et al. (1999), Hospital based cancer registries are concerned with recording of information on the cancer patients seen in a particular hospital.
HBCRs in India were established to provide real time accurate data to evaluate the quality of patient care and the services provided.
The Consolidated Reports of HBCR: 2012-14 has identified the leading sites of cancer in various hospital settings. It was found that in males, most of the hospitals had leading cases of lung cancer followed by mouth cancer. Whereas in females, the leading cause was breast cancer followed by cervix uteri.
HBCR Trivandrum had highest number of thyroid cancer in the 15-34 age group in females, whereas in males in the same age group, HBCR Chandigarh had highest cases of brain cancer.
In the 35-64 age group, in females, the highest were reported in HBCR Thiruvananthapuram with breast cancer, and HBCR Chandigarh reported the highest number of lung cancer in males.
In the 65 years and above age group, Bangalore reported the highest number of cases in cervix uteri in females, and Dibrugarh reported the highest number of cases in hypopharynx.
In childhood cancers, Chandigarh reported the highest number of cancer cases, closely followed by Mumbai and Trivandrum.
The report has also highlighted on a very important aspect, named no Cancer Directed Treatment (CDT), which indicates that this group of patients have neither received nor accepted any treatment and the status cannot be ascertained. The percentage of no CDT was highest in Chennai with 60%, which is actually a sign of alarm.

State Based Registries
The journal titled,” Cancer Registration in India – Current Scenario and Future Perspectives” talks about the existence and number of Population Based Cancer Registries and Hospital Based Cancer Registries in each state and union territory. But this report has estimated the population on the basis of the 2011 census, which differs in the report for the following states and union territories:-Chandigarh, Delhi, Meghalaya, Nagaland, Daman & Diu, Lakshadweep, Goa, Pondicherry , Andaman & Nicobar Islands and Dadra and Nagar Haveli. And it is also surprising to see that the state of Andhra Pradesh, which then included the recently formed state of Telangana in 2014, does not have a population based cancer registry. Apart from Andhra Pradesh, Odisha, Puducherry, Uttarakhand, Uttar Pradesh do not have registries.

Recommendations
• Setting up of PBCR in all states and Union Territories
The National Cancer Registry Programme should set up Population Based Cancer Registries especially in heavily populated states, so as to serve the population and to ascertain the trends and patterns of cancer. It should also be set up in Union territories, except New Delhi and Chandigarh, where it is already existent.
• Prioritize setting up of PBCR in EAG States
EAG means Empowered Action Group (EAG) States are those which lack in socio-demographic development. The States are Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Orissa and Rajasthan.
• Concentration on rural areas
After setting up Population Based Cancer Registries, the focus should shift to setting up of registries in rural areas to concentrate on the trends as people from rural areas move to urban areas to get treated. So, setting up of a registry could give an insight into the trends and patterns of cancer in rural areas.
• Increase coverage area under registries
Population coverage has to be increased to get more accurate data, as currently only 10% of the population are being covered under Population Based Cancer Registries,

References
1. Nandakumar A, Gupta PC, Gangadharan P, Visweswara RN, Parkin DM. Geographic pathology revisited: Development of an atlas of cancer in India. Int J Cancer. 2005;116(5):740–54.
2. Prabhakaran D, Jeemon P, Sharma M, Roth GA, Johnson C, Harikrishnan S, et al. The burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016. Lancet Glob Heal Internet. 2018;2045(18):5–20.
3. Chatterjee S, Chattopadhyay A, Senapati SN, Samanta DR, Elliott L, Loomis D, et al. Cancer registration in India – Current scenario and future perspectives. Asian Pacific J Cancer Prev. 2016;17(8):3687–96.
4. NCRP: – Consolidated Report of Hospital Based Cancer Registries 2012-2014
5. NCRP: – Three-Year Report of Population Based Cancer Registries 2012-2014

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