Without prevention, we will lose the fight against cancer in India.

The increase in the number of patients getting diagnosed with cancer in India is surpassing all projections and the numbers are alarming. According to GLOBOCAN data that considered only 16 population-based cancer registries data and extrapolated it to entire country, the estimated cancer incidence in India in 2018 was 11.57 lac cases but this number appears less than other rough estimates that put the incidence at 15 lac (1.5 million) as a lot of cases go unreported at the registries. Additionally, 8 lac people lost their lives due to cancer in India which means that every day more than 2100 people are losing life due to cancer. This number is going to double in the next 15 years if corrective actions are not taken to reduce the incidence of cancer. An alarming rise in cancer cases would have catastrophic consequences in India given our huge population base, limited diagnostic & treatment infrastructure, very high treatment costs and poor survival prospects due to delayed diagnosis.

The economic burden of cancer on society is tremendous as this disease drags more than 40% of affected families to below poverty line and the remaining ones many times lose the sole breadwinner for the family. According to rough estimates, the financial burden of cancer treatment in India ranges around $18 billion (from E&Y report 2015) and this number (overall cancer burden) will cross $100 billion with addition of loss of productivity in terms of productivity of lost lives, DALYs (disability-adjusted life years), lost education of kids and careers, lost sources of household income and lost quality of life. Given poor public spending in healthcare and lack of social support, the families bear the burden of these losses which is never reported.

Epidemiological Advantage: Case for Cancer Prevention

Worldwide 35%-50% of cancers happen due to potentially modifiable risk factors, which essentially means these are preventable by a change in habits and lifestyles. An interesting fact about cancers we see in India is that more than 70% of cancers are preventable which means these happen due to potentially modifiable risk factors. This essentially means that we can reduce the incidence of cancer by up to 70% by controlling modifiable risk factors. Let's understand these factors and how we can mitigate them:

1. Tobacco: Tobacco consumption is a well-known cause for cancer and up to 40% of cancers are caused due to Tobacco consumption in India. Up to 48% of men and up to 30% of women consume Tobacco in smoking or smokeless forms. In fact, chewable tobacco consumption is highest in India globally. Tobacco has been found to have a direct correlation with oral and oropharyngeal cancers, lung cancers and bladder cancers among common ones. This reflects in the form of oral and head and neck being commonest cancers in India which is unique if we compare with global numbers. Lung cancer is the second most common cancer among men in India and 3rd most common among women. This also is largely related to smoking tobacco consumption in the form of cigarettes and bidi smoking. Spreading awareness from childhood age group and tighter regulations on the tobacco industry with the government changing their focus and ignoring the loss of tax revenue from tobacco can help drastically reduce tobacco consumption and result in a reduction in the incidence of tobacco-related cancers in India.
2. Betel: Betel nut and leaf are themselves cancer-causing agents and in practice, they are often combined with tobacco especially in north India and this enhances the risk of oral cancers among the population.
3. HPV Infections: Human Papilloma Virus (HPV) infections have been directly related to cervical cancer among women. Cervical cancer is the second most common cancer among women in India and it affects more than 100,000 women in our country and most of them come from low socioeconomic population. Two common factors responsible for HPV transmission are sexual intercourse and poor menstrual hygiene. Fortunately, we have an effective vaccine against HPV and we can prevent cervical cancer by administering cervical cancer vaccines in girls before the age of first sexual intercourse mostly before 13 years of age but it can be administered in older girls until before first sexual intercourse. Countries like Australia have mad this vaccine part of their national immunization schedule and have been able to drastically reduce the incidence of cervical cancer to negligible numbers. Unfortunately in spite of the fact that cervical cancer is a second most common cancer among women in our country, the Indian government has failed to include cervical cancer vaccine in national immunization program and we continue to allow more than 1 lac mostly poor women and families to bear the burden of this disease. Surprisingly, it's not the economic cost but opposition from some influential social groups who are opposing it on the presumed fear that this vaccination would promote early age sexual activity among girls is the reason for the reluctance to introduce mass cervical cancer immunization in India. The government needs to be objective about this and focus on immunization of girls especially in rural and poor urban population to make effective progress against cervical cancer. Other infections like HIV, EBV etc. have been found to be causing cancer. Overall up to 10%-15% of cancer incidence in India may be attributed to infections.
4. Diet: Dietary intake has been found to be an important factor in the causation of cancer. High dietary fat and less of fibers, red chilies, red meat and increasing consumption of preserved food are linked to a higher risk of cancer of stomach and colon. It is need of the hour to spread awareness about these facts to modify lifestyles and food habits and focus on switching to a majority vegetarian diet and consumption of fresh fruits and vegetables and avoidance of preserved food.
5. Physical Activity: An active lifestyle has been found to reduce the risk of cancer especially breast and colon cancers. In several published studies it has been reported that regular exercise and a healthy weight can help us reduce the risk of common cancers like breast and colon. So it has added advantage in addition to the prevention of cardiovascular disorders.

We need a national movement on cancer prevention to realize this epidemiological advantage and substantially reduce our cancer burden. It cannot be done by government alone and we need to formulate a social strategy to bring mass change in our lifestyle as a country bringing in a culture of health awareness, safety, active lifestyle, dietary modifications and abolition of social myths to get to a cancer-free society. More epidemiological research is needed to identify modifiable risk factors in different regions as different cultures and habits have been linked to different patterns of cancer incidence. The government needs to abandon tax revenues from tobacco and add cervical cancer vaccine to the national immunization program, in addition, to add cancer prevention awareness in the school curriculum for our future generations to have a cancer risk-free lifestyle.

'Together' we can and together we will win the war over cancer and 'prevention' is our best weapon!