M Krishnan Nair
Regional Cancer Centre, Thiruvananthapuram
India was one of the first few counties in the world to initiate a Cancer Control Programme in 1984 with laudable objectives such as prevention of tobacco related Cancer, early detection of cancers in accessible sites and expansion of treatment facilities and palliative care.
It is simply because we totally neglected the principles and components of cancer control such as prevention, early detection, diagnosis and treatment and palliative care which are essential for comprehensive control of this disease.
the lack of awareness about the warning signals of early cancer make patients complacent about the serious nature of their illness. Simple messages like the importance of long standing cough, white patches in the mouth, hoarseness and loss of voice, bloated abdomen, blood and mucous in the stools or bloody urine, post coital bleeding and lumps in the breast if impressed as warning signs for cancer, the population would be motivated to seek medical assistance.
There is a long delay between development of symptoms and seeking of medical advice.
India was one of the first few counties in the world to initiate a Cancer Control Programme in 1984 with laudable objectives such as prevention of tobacco related Cancer, early detection of cancers in accessible sites and expansion of treatment facilities and palliative care.1,2 To meet these objectives we did not require any high technology or massive resources.
Unfortunately when we look back after quarter of a century, our achievements simply stand out as just a few high tech cancer centres public and corporate mostly utilized by the affluent sections in the metro cities and larger towns. It is evident from the cancer statistics available from the National Cancer Registry Programme of India (NCRP) and the IARC Cancer compendium that there is nothing rosy in Cancer Control in spite of our early start in this field.
India has one of the highest cancer mortalities next only to African countries in sub-Saharan regions (IARC). In the case of all common cancers, still 80% of the patients report to hospitals with advanced incurable disease in all the states (NCRP). In the cure of common cancer we are far behind Thailand and China. But we have imported and installed radiotherapy equipment worth more than Rs.1000 crores and are using anticancer drugs worth Rs.1000 crores annually.
Where did we go wrong? It is simply because we totally neglected the principles and components of cancer control such as prevention, early detection, diagnosis and treatment and palliative care which are essential for comprehensive control of this disease. The equipment’s and medicines worth crores of rupees did not help our population to escape from this scourge. If one examines the pattern of cancer and its stage of presentation it will be become obvious that we had been off target in our cancer control programme. Otherwise our cancer control programme could not have failed so miserably. Certainly it has helped corporate hospitals, physicians, equipment manufactures and drug manufactures but not the patients.
If one recalls the objectives of the Cancer Control Programme we would see that the first objective was to prevent tobacco related cancers which are least amenable to various forms of cancer therapy. What have we done to reduce active consumption of tobacco or its passive ill effects. True that India is a signatory of FCTC which is the international agreement for control of tobacco consumption. Have we tried to implement the recommendation contained in that document. Not at all. I had been watching from close quarters the unsuccessful efforts of an enthusiastic former Minister of Health (Sri Ramdoss) and his frustrations. At least he succeeded in getting a message “TOBACCO CAUSES CANCER” printed on cigarette packs. But the fact is tobacco related cancers are the most hard nuts to crack. Most of the tobacco related cancers cannot be cured in spite of high energy machines latest computer software and most expensive drugs. It is now well-known that passive smoking forced up on the population through smoking in public places and at home by the elder male members of the family, too many innocent people contract heart disease and some of the worst forms of cancer with no cure such as stomach cancer, pancreatic cancer, lung and esophageal cancer. When a pancreatic cancer patient comes with intense pain to a doctor one should realize that all his misery had been inflicted on him by smokers through their irresponsible behaviour. Ban of smoking in public place and its strict implementation in some of the western countries have saved a lot more lives than all the drugs and machines together and such other off target therapies.
While smoking passive and active present us with a lot of new cancer cases mostly incurable, the lack of awareness about the warning signals of early cancer make patients complacent about the serious nature of their illness. Simple messages like the importance of long standing cough, white patches in the mouth, hoarseness and loss of voice, bloated abdomen, blood and mucous in the stools or bloody urine, post coital bleeding and lumps in the breast if impressed as warning signs for cancer, the population would be motivated to seek medical assistance.
But our population in general, including most of the doctors is unable to provide appropriate guidance to aid patients in their diagnosis except for those in metros and larger towns. Surely none would take the trouble to go to a big hospital in a big town to clear doubts about a symptoms like the one described above, clearly when he is marginalized. Even in a literate state like Kerala the average delay between the first symptoms and hospital presentation is 4 -6 months which is enough time for the cancer to get advanced and become incurable. It is quite possible that we may get early treatable cancer only when there is a mechanism to make the population aware of the harmful effects of tobacco, the early warning sings of cancer with provision to guide them to diagnostic facilities in the community and provide and financial / insurance support for at least the BPL groups. The NRHM and their workers would appear to have all these elements. The Asha workers who are involved currently in all disease control activities have the capacity to teach the people on cancer risk factors and early warning signals. They could also provide the guidance for diagnosis with the help of doctors in the locality. Since the work is done on the basis of remuneration, the Asha workers will be enthusiastic if reasonable compensations are made for detecting early cancer in the population As the numbers to be examined are limited one can expect reasonable returns in terms of early detection and diagnosis from NRHM workers. The capacity building of cancer literate Asha workers could be done at the local level by making use of locally available medical manpower.
I am not going to dwell on treatment diagnosis and rehabilitation which are also priorities in Cancer Control as much as prevention and early detection. With a ground level organization such as the NRHM the first two components of comprehensive cancer control can be successfully implemented as it will ensure penetration and reach of National Cancer Control Programme (NCCP) in the community finally enhancing cancer cure in the country.
Dr. M Krishnan Nair, MD, FRCR, FRCP,
Founder Director, Regional Cancer Centre,
Conflict of Interest: None declared