‘Declare it a notifiable disease’
It was way back in 1982 at a WHO seminar, with the Union Health Minister in the chair, that a plea was made by the Cancer Institute (WIA), Madras, and recommended by the seminar committee on cancer control that in order to get quality data on cancer incidence, cancer should be declared a “Notifiable Disease.” The request was straight away rejected (The Hindu Editorial dated December 25, 1982) on the ground that “cancer had not assumed epidemic proportion”! Fantastic statement! If cancer becomes an epidemic — God forbid — we can only see a deluge of unimaginable human suffering.
The Government of India constituted the “Rao Committee” in 1965 and the “Wahi Committee” in 1971, which laid out a broad framework for cancer treatment and research. The Cancer Assessment Committee strongly recommended commencement of cancer registries in 1972. It was, however, only in 1982, as part of the National Cancer Control Programme (NCCP), that the Indian Council of Medical Research (ICMR) initiated the National Cancer Registry Project (NCRP).
Cancer registration was mandatory and pivotal for cancer control planning. It started with the establishment of three ICMR-sponsored demographic registries, in Bombay, Bangalore and Madras, in 1982. The data from these registries in 1984 provided the basis for the National Cancer Control Project in 1986. As of now, there are 28 demographic registries (21 urban, 4 rural and 3 covering small state population) collecting information about new cancer cases arising from about an 80-million population and 7 hospital registries throughout India. Development of a cancer atlas in a few States is on the anvil. Through cancer registries, unlike as in the case of tuberculosis, a nationwide systematic data collection by active methods was initiated and expanded over time, but at a prohibitive cost.
Their being largely urban-based registries, the urban-rural differential pattern could not be adequately studied. The Dindigul (covering the entire district since 2003) and Chennai (covering the metropolitan area since 1982) registries documented a significant difference. The significant change in cancer pattern in Chennai is already well-documented, while time has not matured to study this in Dindigul. Such different and changing cancer patterns in different districts in Tamil Nadu led to the origin of the State cancer registry (Tamil Nadu Cancer Registry Project) initiated by the Cancer Institute (WIA) in collaboration and co-operation with the Government of Tamil Nadu and it will address these issues.
In health planning, the focus naturally has been on communicable diseases. This prevented any major attention to NCDs till recently.
My focus is on cancer, the magnitude of the problem, the changing pattern of cancer in India, the changing socio-economic scenario, the rising gap in the socio economic level, increasing urbanisation, changes in lifestyle, increase in life expectancy and related factors.
Lifestyle changes are basically related to improved socio-economic condition, urbanisation and industrialisation. However, it has been documented by the WHO that “although NCD epidemics originate in the upper socio-economic strata, they diffuse across the social spectrum and social gradient reversing and the poor becoming predominantly afflicted in the more mature stages of the epidemics, the poor are the worst afflicted in terms of the disease and usually more marginalised.”
The major issue that needs to be highlighted is that although cancer is one of the NCDs, it cannot be clubbed with the others for the simple reason“cancer is an extremely complex biologic phenomenon.” It is NOT A SINGLE DISEASE. It is a generic name for a wide spectrum of conditions, biologically different, even carcinogenesis is different.
In the early years of my association with cancer, it was a Herculean task to make the health planner understand that cancer and radiotherapy were not synonymous. Today, it has become necessary to clarify the nuances associated with cancer care, cure and control.
The publication in The National Medical Journal of India Vol.24, (No. 2) in 2011 has carefully analysed the trend in cancer incidence in Chennai City (1982 – 2006) and made a Statewide prediction of the future burden of cancer in Tamil Nadu (2007-16). The cancer burden in Chennai is predicted to increase by 32% by 2012–16 compared to 2002–06. The average annual cancer burden for Chennai predicted for 2012-16 is 6,100 translating to 55,000 new cancers per year Statewide (Tamil Nadu).
There is also an ominous change in the pattern of cancer with an increase in lung, stomach and large bowel cancers. Breast cancer will replace cervix cancer in urban areas but the cervix cancer burden will continue in the rural areas of Tamil Nadu. Thus we will have the burden of both breast and cervix cancers. Tobacco-related cancers are also showing an increasing trend and constitute 40% of cancers in men.
With a potential possibility of increase in the burden of cancer, concerted efforts must be made at the national level or maybe at least State-wide and without any further delay. The priority will be strengthening cancer information system and surveillance. The existing attempts by various NGOs in public education, creating cancer awareness, screening programme will continue and have to be enhanced with adequate financial support.
Let us not drag our feet as we did in the case of tuberculosis. We have waited over three decades. It is time “to declare cancer a Notifiable Disease” if we have to prevent the epidemics of tobacco-related cancers and not lose the opportunity to prevent common cancers and face the challenge of more ominous cancers like lung and stomach cancers. This act of cancer notification will also ensure a continuous and systematic Statewide collection of cancer information at a considerably lesser cost than by doing the same by active methods.
This does not address the issues of comprehensive scientific cancer care, locally advanced disease, palliative care and many others and how to make them accessible, affordable and equitable.
(The writer is Chairman, Cancer Institute (WIA), Chennai. Email: chairman @cancerinstitutewia.org)