8 minute read
HEALTH
health SURGING CANCER RATE IN KERALA
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Dr Chandramohan K
On September 15th famous medical journal published a shocking article about, cancer incidence in India. This article, which was published by Prof Lalit Dandona, Public Health Foundation of India, carried a lots of bad news for India in general and Kerala in particular. The study was funded by Bill & Melinda Gates Foundation and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India. The researchers collected data from multiple sources, including 42 population-based cancer registries and the nationwide Sample Registration System. They found out that 8.3% of total deaths and 5% of disability in India are due to cancer, and it was double in 2016, compared to 1990. There was an increase in age adjusted incidence rates of 40.7% for breast cancers between these two time periods. But there is more alarming information in store for Kerala. In 2016, Kerala has the maximum crude cancer rate in the country apart from Mizoram and Delhi. In these regions the cancer incidence is more than 105 per 1 lakh, which is highest in the country (see figure).
This Kerala is supposed to be best among Indian states in health care. The maternal mortality rate which is an important index of the strength of health care services of a particular country or region is very low in Kerala is similar to the rate which you see in the most developed nations like Sweden or UK. But unfortunately this is no longer the scenario in many other branches of
Medicine. For example, if you look into the survival of a cancer patient, you will see the figures are frustratingly low in Kerala. In most developed nations, the cancer treatment is so advanced that the cure rate has touched 90% marks in many cancers. For example the SEER data base in US shows that the breast cancer survival for all stages in US is something like 90%. But a study which came from India showed that only 50% patients are surviving breast cancer in India. Apart from those patients who
receiving treatment in reputed institutes like RCC (Regional Cancer Centre, Trivandrum), a large number of patients are getting treated elsewhere in not so scientific manner. So the survival of those patients is miserably low compared to the international or these national standards. Why this is happening in India and Kerala in particular?
The reason is that even though Kerala is having half million new cancers diagnosed every year and huge population of 35 million. Dedicated cancer hospitals are less than ten in the
state of Kerala. So if each cancer hospital can take 500 cancer patients, the total number of patients can be treated as in-house patient are something like 5000 which is much less. So the majority of the patients are treated elsewhere in Kerala. Now, let us see what the difference between a modern cancer hospital/unit and the conventional old treatment of cancer is. In any of the modern cancer hospitals, for example like RCC, the treatment is decided by a multi disciplinary team which includes all specialists in cancer. The MDT (Multi Disciplinary Team) is the part and parcel of cancer treatment in the modern era. This group thinking will eliminate individual bias, achieve best results and may avoid many complications. So if we have a significant number of patients whose treatment are decided by MDT, of course with the support of the latest developments and technology and trained manpower, the cancer becomes a curable disease.
If you compare the number of cancer hospitals in the district of Trivandrum with districts in other states, we will find that other than RCC there is only one hospital which can give the comprehensive cancer care including radio therapy. This is not the scenario even in most of the semi urban or rural towns in India. So because of this sheer work load, hospitals like RCC are unable to implement the latest facilities in cancer for each individual cancer victims. For example if you think about breast cancer, the part of the treatment include removal of the lymph nodes in axilla which may results in swelling of the arms and many other complications in long term. Similarly the breast cancer treatment option includes removal of the entire breast which creates a huge dent in the personal and social quality of life. To circumvent these two issues, there are procedures called Sentinel Node Biopsy in which instead of removing the entire lymph node, with the help of a
radioisotope dye selected only selected nodes are removed from axilla, which won’t create the complications like axillary dissection. Similarly in case of difficult tumour locations of breast instead of doing a mastectomy, a combined use of chemotherapy radiation and surgery with the help of latest developments in plastic surgery techniques like mammoplasty or mastopexy, the breasts can be salvaged. Even a negligible percentage of patients with early breast cancer in Kerala are fortunate enough to get these procedures. In case of Abdominal and thoracic
cavity cancers minimally invasive surgery is the new accepted standard of care. The advantage of minimal invasive surgery is that it won’t be having big incisions. So patient will have less discomfort, less pain and less complication related to the wound after surgery. Moreover the long term complications like incisional hernia and weakness of abdominal wall are much less in the minimally invasive surgery. But the majority, I will say that more than 90% of patients getting cancer treatment for abdominal and thoracic malignancy are not offered minimally invasive surgery in our part of the world. This also shows the inadequacy of cancer care. Similarly robotic surgery is important new modality which has lots of advantages and the number of robots in Kerala is much less, compared to other states. None of the cancer hospitals in Kerala is having robot which is a striking contrast compared to any big cancer hospitals like Tata Memorial Hospital Mumbai, Kidwai Hospital Bengaluru and all major National Cancer Institutes. So, may be because of this many of the patients who needs robotic surgery are
INFO
Comparitive study of cancer incidents in various states during 1990 and 2016. CANCER IN INDIA 2016 1990
Haryana 71.0/103.3 Punjab 58.0/85.5
Rajasthan 58.8/72.6
Madhya Pradesh 69.4/83.1
Gujarat 55.5/75.8
Maharashtra 62.0/80.2
Goa 52.5/97.0 Karnataka 76.2/101.6
Kerala 74.1/135.3
Jammu and Kashmir 69.1/79.2
Assam 68.7/90.2 Bihar 44.9/53.9 Himachal Pradesh 69.8/91.6
Meghalaya 69.0/81.4
Nagaland 63.1/70.3 Arunachal Pradesh 75.9/78.5 Sikkim 67.8/74.4 Uttar Pradesh 72.0/79.0 Uttarakhand 69.3/91.0 Delhi 64.6/102.9
Andhra Pradesh 58.1/76.6 Chhattisgarh 58.8/82.0 Jharkhand 58.0/64.3 Odisha 68.6/83.6 Telangana 54.9/72.6 Tripura 52.9/69.0 West Bengal 63.9/85.4
Tamil Nadu 58.9/82.9
Manipur 48.1/64.3
Mizoram 89.1/121.7
forced to go to other states and other countries to get the treatment done. So those who can’t afford the treatment elsewhere will have to be contended with the open surgery which is getting obsolete day by day.
Another index so far the betterment of cancer care is the ratio of the cancer patient to the oncologist. In most developed nations it is 100:1 that means one cancer specialist of each specialty will available for hundred cancer patients. But this figure is something like one in two thousand in Kerala. So nailing cancer menace in Kerala need huge manpower and the specialized cancer training is an important aspect for improvements in cancer care. The trained man power is lacking in Kerala. The main reason is that we never had training institutes in Kerala to train doctors in various disciples of oncology till recent past.
In order to care the increasing burden of cancer patients in Kerala in a proper way, we should prepare ourselves by creating enough manpower and enough cancer hospitals with multi disciplinary care where this manpower can be deployed.
Patients undergoing treatment in major cancer centers need to be followed regularly for recurrence of symptoms
and treatment related side effects for long period and some of them also need to have medications continued for more than 10 years. So such patients need not crowd again in cancer hospitals. They can have their consultation arranged at their own places of residence, provided an NGO or a local authority can set up a cancer care follow up clinics at their locality. For patients getting treatment at RCC, such clinics are regularly taking place in places like Kannur, Kozhencheri as well as Neendakara on a regular basis. Another thing needed is improvement of the cancer registry programme. Unless we know the incidence and prevalence of cancer we may not be able to shape up measures to tackle it. Unfortunately RCC, Trivandrum and Malabar Cancer Centre are the only two institutions actively involved in the cancer registry programme. So some of the southern as well as some of the northern districts are only covered. This has to be extended to all districts so that the precise number of cancer patients can be recorded. Today there is no way we can calculate the survival of a cancer patient in Kerala. We should collect more data, including treatment and survival and should devise a data bank, so we will know what the survival of each cancer in Kerala is.
In nutshell, cancer control programme in Kerala needs lots of improvement. First of all we need to have more cancer hospitals which provide multi disciplinary cancer care. We also need to have many of supporting hospitals who will be able to help in diagnosis of cancer, follow up of cancer patients and to support the palliative care programmes. We also need to strengthen our cancer prevention strategies with the involvement of local groups, NGO’s and other associations Last but not least we should strengthen the cancer registry programme so that the entire cancer statistics in Kerala can be captured and the information can be used for planning further strategies for cancer control.
Writer is Additional Professor, Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram.
