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Cancer Therapy Vol 8, page 62
62
higher risks of stomach, mouth, pharyngeal, esophageal,
lung, pancreas, and cervical cancers (Chandalia et al,
2003). Recently, the case control studies carried out in
Asian Indian immigrants to U.K. and U.S.A. found high
levels of homocysteine as a risk factor for the breast,
ovarian and pancreatic cancers (Wu et al, 2002).
Vegetarianism; practiced by a large population of
Indians (particularly Hindus); has been associated with
lower risks of prostate cancer (Rajaram et al, 2000). A
comparison of non-vegetarian and vegetarian diets and
alcohol and tobacco uses in India was carried out
through case control studies. It was observed that
vegetarians have a lower risk of esophageal (Roa, 1997),
oral (Roa et al, 1994) and breast cancers (Jain et al,
1999). Beans, chickpeas and lentils are the principal
components of vegetarian diet- a rich source of proteins;
and pulses have been significantly associated with
reductions in cancer (Jain et al, 1999; Mills et al, 1989).
An increased risk of cancer has been observed with diets
with high saturated fats. Middle class people in India and
some of the rural areas have a high intake of ghee, which
may create an increased cancer risk (Ghafoornissa, 1998;
Law, 2000). The Indian diet containing adequate
quantities of vegetables, fruits, and fibre rich grains
provides protection against the increased risk of colon
and breast cancers (World cancer research fund, 1997).
Furthermore, Figure 4 depicts that improper life style
and poor dietary habits, which are the key factors for the
prevalence of breast and cervical cancers in the female
population of Goa. High incidences of throat and food
pipe cancers in Andhra Pradesh and Assam were
attributed to improper diets (Lammers et al, 1998).
B. Tobacco
The consumption of tobacco is the leading cause of
cancers in India. Figure 4 shows the regular use of
tobacco via smoking, chewing, snuffing etc. in some
areas of the country, which is responsible for 65 to 85%
cancer incidences in men and women, respectively. The
various cancers produced by the use of tobacco are of
oral cavity, pharynx, esophagus, larynx, lungs and
urinary bladder. It has been observed that women in
Bangalore are known to have the highest rates of cancers
of esophagus in the world (around eight per 100,000).
Contrarily, men in Bhopal have the highest rate of
tongue cancer in the world (nine per 100,000) (Bobba et
al. 2003). Smoking is the most notorious factor for the
causation of lung cancer (Hammond et al, 1958).
Approximately, 87 and 85% males and females have
been found to have lung cancer due to tobacco smoking
in the form of bidi (a thin South Asian cigarette type
structure filled with tobacco flake and wrapped in a
tendu leaf, tied with a string at one end) (Behera et al,
2004) and cigarette in India (Notani et al, 1974). The
severe carcinogenic nature of bidi has been proved by
the studies of Jussawalla and Jain (Jussawalla et al,
1979) and (Pakhale et al, 1985). They observed that the
unrefined form of tobacco used in bidis (WHO, 1999)
and the frequency with which a bidi needs to be puffed
per minute may be responsible for its relatively higher
carcinogenic effects as compared to cigarettes (Bano et
al, 2009). Bidi smoking at two puffs per minute produces
about equal amounts of carcinogens (steam volatile
phenols, hydrogen cyanide and benzopyrene) as
produced by one puff per minute of unfiltered cigarette
(Pakhale et al, 1990). Hookah (a special cigar used in
India using raw tobacco) smoking causes lung cancer; as
reported by Nafae et al. (Nafae et al, 1973). Recently,
Gupta et al. (Gupta et al, 2001) reported 80 and 33%
lung cancers in men and women chain smokers,
respectively, as compared to controlled subjects where
these numbers were 60 and 20%. Besides, Figure 4
shows that cigarette smoking and Hookah are the main
causes of lung cancer in Indian states; especially in
Jammu and Kashmir, Himachal Pradesh, Uttarakhand,
Manipur, Tripura and some parts of Sikkim. Similarly,
bidi and hookah smoking are responsible of
oropharyngeal cancers in male population of Haryana.
Bidi and cigarette smoking are thought to be etiological
factors for the causation of cancers in Andhra Pradesh.
In some north-eastern states of India such as Arunanchal
Pradesh, Nagaland and Sikkim, high incidences of
stomach cancer are attributed to the consumption of
smoked meat and chewing of tobacco. High incidences
of stomach cancer in Mizoram are the result of the
excessive use of tuibur (water filterate of tobacco).
Similarly, high incidences of oral cancers in Orissa and
Madhya Pradesh are owing to the consumption of beetle
leaves and tobacco in different forms. The relatively
high incidences of oesophageal cancers in certain parts
of Karnataka are because of heavy consumption of
tobacco in various forms.
Figure 4 also depicts that the exceptionally
high incidences of oral cancer in some parts of Uttar
Pradesh and Gujarat are due to the consumption of Pan
Masala, Dohra and Zarda. Similarly, the consumption of
Beetal, Nut, Pan Masala, Opium and Bhang (leave and
flower powder of female cannabis plant) has been
recognized as the major cause of mouth cancer in
Rajasthan. Oral cancer being the common malignancy in
Allahabad is attributed to the chewing of Dohra; an
indigenous preparation of tobacco and slaked lime. The
daily consumption of the number of beetle leaves by an
individual is about 15-25 in Allahabad and Varanasi
districts, which continuously acts as an irritant to the
buccal mucosa (Mehrotra et al, 2003). One of the most
important factors responsible for the oropharyngeal
malignancy in Agra and Mainpuri belt of Uttar Pradesh
is the chewing of beetle nut (Wahi et al, 1965). Among
various risk factors for the occurrence of esophageal
cancer in India, betel quid chewing carries a relative risk
of 1.5 to 3.5%. The salted tea made by adding sodium
bicarbonate has shown to possess a high methylation
activity and may lead to the endogenous formation of
nitrosamine (Malkan et al, 1997).
C. Alcohol
Alcohol consumption has been considered as one of the
major causes of colorectal cancer as per a recent
monograph of WHO (Baan et al, 2007).
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Cancer Scenario in India with Future Perspectives
63
Annually, about 9.4% new colorectal cancer cases are
attributed to the consumption of alcohol, globally
(Parkin et al, 2002). An increased risk of 10% was
observed with consumption of more than two drinks per
day, which suggests a causative role of alcohol
consumption in colorectal cancer (Toriola et al, 2008).
Recently, a study revealed that an increased risk of
colorectal cancer was limited to consumption of more
than 30.0 g of alcohol per day (Longnecker et al, 1990).
Relationship between alcohol consumption and high risk
of oesophageal cancer was first known in 1910 (Tuyns,
1979). However, chronic alcohol consumption has been
found to be a risk factor for the cancers of the upper
respiratory and digestive tracts, including oral cavity,
hypopharynx, larynx and esophagus as well as liver,
pancreas, mouth and breast cancers (Tuyns, 1979; Maier
et al, 1994; Seitz et al, 2004; Doll et al, 1981). A 10.0
g/day intake of alcohol by a woman increases its relative
risk of breast cancer by 7.1% (Doll et al, 1981). The
mechanism of carcinogenesis due to alcohol
consumption is not exactly known, however, it is
thought that ethanol being a co-carcinogen might play a
crucial role in the carcinogenesis (Poschl et al, 2004).
The metabolic products of ethanol are acetaldehyde and
free radicals. The free radicals are responsible for
alcohol assisted carcinogenesis through their binding to
DNA and proteins, which destroy foliate leading to
secondary hyper proliferation (Anand et al, 2000).
D. Radiation
In the developed and developing countries, the radiations
are also notorious carcinogens. About 10% cancer
occurrence is due to radiation effect, both ionizing and
non-ionizing (Belpomme et al. 2007). The major sources
of radiations are radioactive compounds, ultraviolet
(UV) and pulsed electromagnetic fields. The main series
of cancers induced by exposure to the adequate doses of
the carcinogenic radiations include thyroid, skin,
leukemia, lymphoma, lung and breast carcinomas. The
most common source of ionizing radiation exposure is
Radon, which is a radioactive element. Radioactive
nuclei of radon, radium and uranium are found to be
associated with an increased risk of gastric cancer in
rats. High risk of breast cancer among girls at puberty is
due to chest irradiation of X-rays (used for diagnostic
and therapeutic purposes). The major risk factor for
various types of skin cancers viz. basal cell carcinoma,
squamous cell carcinoma and melanoma is the exposure
to ultraviolet light, which is a non- ionizing radiation
(Anand et al, 2000). The underground testing of nuclear
weapons may be the major cause of digestive system,
liver and kidney cancers, as radiations have been
reported in ground water of the nuclear weapon testing
area. Moreover, Figure 4 clearly shows that nuclear
pollution is the main cause of lung cancer in Jharkhand.
E. Miscellaneous pollutants
It is estimated that about 90% cancer is owing to the
environmental contaminants (Anand et al, 2000).
Various types of cancers are believed to be due to ill
effects of the polluted environment. The risk of lung
cancers is increased by a number of outdoor pollutants
such as poly aromatic hydrocarbons. Long term
exposure to PAHs (polyaromatic hydrocarbons) in air
was found to increase the risk of deaths associated with
lung cancer. Indoor environmental pollutants such as
volatile organic compounds and pesticides increase the
risk of leukemia and lymphoma, brain tumors, Wilm’s
tumors, Ewing’s sarcoma and germ cell tumors. An
increased risk of cancer has been observed in people
using chlorinated water for drinking purposes for a long
time. N-Nitroso compounds (mutagenic in nature) are
formed from nitrates present in drinking water and
increase the risk of lymphoma, leukemia, and colorectal
cancer and bladder cancers (Belpomme et al, 2007).
Figure 4, also shows that high level of air pollution is
responsible for the prevalence of lung cancers in Delhi
and some other parts of West Bengal including Calcutta.
The low socio-economic conditions related to poor
hygiene, poor diet or infections of viral origin are also
responsible for various types of cancers (Mehrotra et al,
2003).
V. Preventive measures of cancer in
India
As per the proverb, “prevention is better than cure” the
prevention strategies are crucial in cancer eradication.
This approach offers a great public health concern and
inexpensive long term method of cancer control.
National Cancer Control Programme (started in 1975-
1976 in India) led to the development of Regional
Cancer Centers (RCCs), a number of oncology wings in
Medical Colleges; supported the purchase of teletherapy
machines. District Cancer Control Programme was also
initiated but could not result into sustainable and
productive activity (National Cancer Control
Programme). The education should focus on harmful
effects of tobacco and discourage its use. Besides, we
should create awareness among public about physical
activities, avoiding obesities, healthy dietary practices,
reducing occupational and environmental exposures,
reducing alcohol uses, immunization against hepatitis B
virus and safe sexual practices for avoiding cancer
genesis (Dinshaw et al). The same approach should be
included in adult education programme. Several state
wise programmes like Kerala (Ten year action plan),
Tamil Nadu (Kancheepuram Cancer Screening
Programme) and opportunistic programmes in social
regions have been implemented by some State
Governments and Regional Cancer Centers (RCCs) for
an early detection of different cancers in India. The
predicted results were not materialized in most of the
programmes except RCC programme in Trivandrum as
the health service system could not support such
activities due to deficiencies in health system
management and non-availability of human resources
(Cytologists /Pathologists) and absence of integration
with multi-sectoral groups. Unfortunately, a little
population got aware of cancer havoc, which might be
spread to the population of the whole country (National
Cancer Control Programme).
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As discussed above tobacco is the most notorious agent
for cancers, which must be banned to eradicate the
prevalence of tobacco related cancers. India should give
the highest priority to tobacco control programme due to
its acute carcinogenic nature (WHO, 2002). It has been
predicted that a ban on tobacco use can prevent up to
30% cancers in India (Central Statistical Organization,
2003-04). Alcohol consumption is responsible for the
occurrence of colorectal cancer. About 25% population
is consuming alcohol in India, which must be minimized
or avoided to eradicate this havoc. Government needs to
impose a ban on the public sale of alcohol. Seminars and
public health camps should be conducted to create
awareness of alcoholic harmful effects among Indians.
Radiations are silent and serious carcinogens that cause a
number of cancers and, hence, the strategies that reduce
the exposure of people to these notorious radiations
should be fully practiced to reduce the incidence of
cancers. India being one of the nuclear power nations
needs to build safe equipped nuclear plants with greater
protection from the hazardous nuclear radiations.
Nuclear reactors should be well constructed with good
quality shields to provide more protection to the people
at work. Nuclear tests should be carried out at safe
places away from human populations to avoid exposure
to these radiations.
Environmental pollution is a serious issue and has
become a challenge for all of us as it is responsible for
the genesis of various types of cancers. Air pollution is
the most notable cause of lung cancer in the metropolitan
cities of India. The harmful gases such as carbon
monoxide (CO) and sulphur dioxide (SO
2
) produced by
combustion of fuels in automobiles and several industrial
processes, respectively, cause lung cancer, respiratory,
digestive, ocular and skin carcinomas. Automobiles that
run on compressed natural gas (CNG) should be
encouraged; at least in the metropolitan cities of the
country to avoid air pollution. The use of
chlorofluorocarbons (CFCs), methyl halides, carbon
tetrachloride and carbon tetra fluoride is the main cause
of the depletion of ozone layer, which protects us from
the harmful UV-rays. The use of such chemicals should
be minimized in order to reduce the incidence of skin
cancer caused by the harmful effects of UV-rays. The
sewage discharged by several industries and
municipalities is polluting Indian water resources due to
insufficient water treatment plants; leading to various
types of cancers. Therefore, these wastes should be
treated prior to their discharge to land or river.
Due to over growth of Indian population, farmers are
compelled to produce more cereals and vegetables to
meet out public requirements. This pressure forces
farmers to use excessive fertilizers and pesticides, which
are being transported into our body via food and water
causing various sorts of cancers. Farmers should be
encouraged to use eco-friendly organic manures and
biocides to reduce cancer incidences. India is a
developing country and gradually adopting modern life
styles involving the use of various kinds of chemicals in
terms of medicines, cosmetics, cloths, utensils, mobile
phones and other luxurious items. The use of such items
may cause different sorts of cancers. That is why during
past few decades the incidences of cancers have
increased. It is urgent to emphasize that Indians should
be aware about their life styles particularly the use of
synthetic products, fabric dressing, and mode of sex,
abuse of drugs and excessive use of mobile phones.
Besides, an increased fashion of fast food in this country
is also responsible for this havoc. Indians should adopt a
healthy food habit having sufficient quantities of
vitamins, minerals, proteins, fibers, carbohydrates etc.
The healthy and proper foods are important aspects to
control different cancers. The consumption of whole
grains, vegetables and fruits antagonize the development
of some cancers. The effects of various foods on the
prevention and eradication of different cancers are given
in Table 1. Briefly, there are no uniform standardized
information programs, education and communication
(IEC) strategies for cancer prevention in this nation.
Besides, limited diagnostic and treatment infrastructures
in the country are the serious issues, which must be
increased on urgent basis. The government and other
NGOs should come forward to initiate the above
programs for controlling this havoc so that the present
and coming generation of the country may lead healthy
life.
VI. Effect of cancer on Indian
economy
As per nominal Gross Domestic Product (GDP),
the economy of India stands on eleventh position in the
world, while it is fourth largest by Purchasing Power
Parity (PPP) (CIA-The World Factbook, 2009). Indians
are at high risk of acquiring cancers due to high rates of
smoking, tobacco use, occupational risks, and
unhygienic residential living conditions. The prevalence
of cancer in India is affecting the economy of the
country. The data on the effect of cancer on Indian
economy is not available; however, Popkin et al. (2001)
assessed the impact of cancer of diet related health
conditions in terms of health spending and on income
losses experienced by households (Popkin et al, 2001).
The estimation of expenditures of cancer patients
includes both direct medical and non-medical costs. The
direct costs include buying medicine, hospitalization,
pathological tests, medical practitioner consultancy,
travel, lodging while the indirect costs are loss of income
during treatment, premature death and affect on the
income of other family members etc. In 2007,
Abegunde et al. calculated the effect of cancer deaths on
Indian economy. Furthermore, they assessed the
economic impact of mortality from chronic diseases on
Gross domestic product (GDP) (Abegunde et al, 2007).
Briefly, Indian economy has been affected by the
alarming rise of cancers in the last decade. It is still
being affected due to continuous increase of cancer
patients. An estimation of the effect of cancer on the
Indian economy has been carried out and the data is
given in Table 2. The economical loss was calculated by
considering all the factors viz. both direct medical and
non-medical costs. It is clear from Table 2 that there is a
steady rise in the number of cancer cases in India. This
17
Cancer Scenario in India with Future Perspectives
65
Table also shows that the total number of cancer patients
in 2004 was 819354 with a total loss of 215.16 million
US $. The number of cancer patients and economic loss
are continuously increasing, which have become 962832
and 274.10 million US $ by the end of 2009,
respectively. Similarly, the total cancer patients in 2010
were 979786 with total economic loss of 270.06 million
US $. Clearly a direct relationship between the number
of cancer patients and the economic loss may be seen
from this Table. It is interesting to mention if these
cancer incidences would have been avoided; by adopting
the preventive measures cited above; India would not
have suffered from such a big economic loss. This
amount of money would have been used somewhere else
for the development of the country.
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