Cervical cancer burden in India

The incidence reported by different rural and urban cancer registries in India varied according to population and region (Globocan 2008). In India, cervical cancer is currently the second most common female cancer after breast cancer with an age-adjusted incidence rate of 22 per 100,000 and mortality rate of 12.4, respectively (Globocan 2012).

Estimated numbers of cervical cancer cases and deaths were 123,000 and 67,500 respectively in 2012 and represented one quarter of global burden (Globocan 2012).

Age-specific data from Globocan 2012 showed peak incidence of cervical cancer in 55-59 year old women with an increasing trend from 40 to 59 years and then a decline after 60 years. However mortality was increasing with increasing age. Also it is noted that the age-specific incidence and mortality estimates of India are much higher than the overall estimates in less developed region (Figure 6).

Source: (Globocan 2012)

Figure 6. Age-specific cervical cancer incidence and mortality rates in India 0

10 20 30 40 50 60 70 80 90

15-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Incidence per 100,000 PYRS

age group

Age-specific incidence and mortality rates in India

Incidence mortality

The peak incidence in 50-59 year old women can be connected with lack of screening and late-stage diagnosis of cervical cancer. The increasing mortality by age is again a reflection of late-stage diagnosis which shows health system inefficiency to detect and treat cervical cancer on time.

Globocan 2012 estimated the age-specific incidence and mortality rates using the data from 12 regional registries such as Bangalore (IR=20.6 per 100,000 PYRS) in Kartanataka state; Mumbai (IR=13.5), Barshi (IR=18.7) and Poona (IR=13.4) in Maharashtra state; Bhopal (IR=19.5) in Madhya Pradesh state; Chennai (IR=21.4) and Dindigul-Ambillikai (24.5) in Tamil Nadu state; Karunagapalli/Kollam (IR=8.9) and Trivandrum(IR=10.1) in Kerala state; Mizoram (IR=19.7) ; Sikkim (10.2) ; and New Delhi(17.7), in which Barshi and Dindigul-Ambillikai are covering predominantly rural areas (Forman et al. 2014). Total coverage of all these registries is only less than 10% of the whole population in India (Globocan 2012).

Cervical cancer incidence was comparatively low in areas where women have better socioeconomic position, for example the lowest incidence reported in the country in 2009 was 7 per 100,000 in Trivandrum, one of the places having high proportion of educated women in South India (Mathew, George 2009). In 2002, highest age-adjusted incidence rates for cervical cancer were reported from Pondichery (39.2) which is a union territory near Tamil Nadu state, and other north-eastern districts of Tamil Nadu state (Canceratlasindia.org).

Even though Kerala and Tamil Nadu are geographically close to each other, civilization is entirely different. Socioeconomic position of women in rural areas of Tamil Nadu state is not as good as women from Kerala state. Also in rural areas of Tamil Nadu, living conditions and sanitation facilities are very poor. So cervical cancer burden is high among areas where socioeconomically disadvantaged women are predominant. It was reported that cervical cancer incidence is inversely associated with educational status of women in Tamil Nadu (Swaminathan et al. 2009).

Socioeconomic inequality in accessing health care is one of the major factors associated with the huge burden of cervical cancer in India (Mallath et al. 2014).

Well-organized screening programmes and changes in socioeconomic profile decreased incidence and mortality of cervical cancer in developed

countries (Mathew, George 2009). Many of developing countries also showed a declining trend even though the proportion of decline is lower compared to western countries (Mathew, George 2009). Reports from Indian cancer registries have also showed a declining trend of cervical cancer incidence in India (Yeole 2008, Nandakumar, Ramnath &

Chaturvedi 2009, Asthana, Chauhan & Labani 2014).

In a recent study by Badwe et al (2014), cancer incidence trends were analysed using published data since 1988 to 2005 from six population-based cancer registries. Registries included in the study were Bangalore, Bhopal, Chennai, Delhi, Mumbai and Barshi (rural). Cervical cancer incidence was significantly decreasing in all registries during 1988 to 2005 except for rural registry in Barshi. Time trends clearly illustrate that even though cervical cancer incidence is decreasing in urban settings, it remains the leading cancer in rural settings. The decrease of cervical cancer incidence in urban settings may partly be attributed to improved living conditions, awareness for genital hygiene and better healthcare facilities for early detection, which further emphasised the role of socioeconomic status in cervical cancer incidence (Badwe et al.

2014).

Cervical cancer survival largely varies between regions and populations within India. For the year 2010, the median five-year ASRS for cervical cancer was 46% with a range of survival from 34% to 60%

(Sankaranarayanan et al. 2010). The ASRS for cases registered during 1993- 2000 and followed up until 2003 in Barshi was 32.1%, and for cases registered during 1991 - 1995 and followed up until 2000 in Bhopal was 30.8%. In Mumbai (Bombay) the ASRS was 43.8% (for cases registered during 1992-1994 and followed until 1999; cases registered during 1995-1999 and followed until 2003), and in Karunagapalli 54.8%

(for cases registered during 1991-97 and followed until 1999). The highest survival rate was observed in Chennai registry where the ASRS for cases registered during 1990-1999 and followed up until 2001 was 60.2% (Sankaranarayanan 2011).

The reported five-year observed survival of cervical cancer in 1995 for patients diagnosed during 1982-1989 was 34.4% with a relative survival of 38.3% in Bangalore, where the five-year observed survival for patients with stage 1 disease was 63.3% and for stage 4 disease 5.7%

(Nandakumar, Anantha & Venugopal 1995). Survival rates were

decreasing with increasing age and stage of disease, and observed survival was 37.2% among literate and 33.8% among illiterate (Nandakumar, Anantha & Venugopal 1995).

A hospital registry-based study among patients registered during 1984 in Trivandrum showed an observed 5- year survival of 47.4%, where low socioeconomic status, poor performance status (not active or bedridden vs. active) and advanced stage of disease were predictors of survival (Sankaranarayanan et al. 1995).Women with poor socioeconomic status had an observed survival of 44.8%, whereas women with high socioeconomic status had an observed survival of 85.6%. Stage1 disease had a 69% survival whereas stage 4A had a survival of 29%

(Sankaranarayanan et al. 1995).

The five-year relative survival for cases registered during 1992-1994 in the population-based cancer registry in Mumbai was 47.7% with age and extent of disease being independent predictors of survival (Yeole et al.

2004). The five-year observed survival reported by the Dindigul-Ambillikai Cancer Registry (DACR) in rural Tamil Nadu was 35% for cervical cancer cases diagnosed in 2003 (Swaminathan et al. 2009).

Whereas, the five-year observed survival for cervical cancer cases registered in Chennai urban PBCR during a period of 1990-99 was 54%, and the one of treated cases during 2000 to 2001 from hospital-based cancer registry (HBCR) was 62%. However, incidence rates in Chennai urban and Dindigul-Ambillikai rural registries were almost similar (Swaminathan et al. 2009).

The above-mentioned studies show that there is not much variation in overall survival over a long period, and late stage diagnosis is the major determinant of poor survival.