Cancer - A Community Medicine Case Study (10 Marks)

a) National Programme for Cancer Control in India

• Launched in 1975-76 with objectives of prevention, early diagnosis, and treatment
• Revised in 1984-85 and again in December 2004 in view of gaps in cancer treatment facilities
• In 2010, integrated with the National Programme on Prevention and Control of Diabetes, CVD, and Stroke to form NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke)
• During the 12th Five Year Plan, the programme was extended to all districts of India

1. Primary prevention of cancers by health education
2. Secondary prevention - early detection and diagnosis of common cancers (cervix, mouth, breast, tobacco-related) by screening/self-examination
3. Tertiary prevention - strengthening institutions for comprehensive therapy including palliative care

• Common diagnostic services, basic surgery, chemotherapy, and palliative care at 100 district hospitals
• Each district supported with Rs. 1.66 crores per annum
• Chemotherapy drugs provided for 100 patients per district hospital
• Day care chemotherapy facilities at 100 district hospitals
• Screening for cervical, breast, and oral cancers
• Education about breast self-examination and oral self-examination

• 25% relative reduction in premature mortality from NCDs by 2025
• 30% relative reduction in tobacco use by 2025

b) Screening for Cancer

1. Oral Cancer Screening

• Visual inspection of oral cavity by primary health care workers (village health guides, multi-purpose workers) during home visits
• Detection of precancerous lesions (leukoplakia) - can be detected up to 15 years before turning invasive
• Leukoplakia resolves with cessation of tobacco use
• Over 50% of oral cancers in developing countries are detected only at an advanced stage - early detection is the key challenge

2. Cervical Cancer Screening

• Pap smear (Papanicolaou test) - exfoliative cytology; mainstay of cervical cancer screening
• VIA (Visual Inspection with Acetic Acid) and VILI (Visual Inspection with Lugol's Iodine) - low-cost alternatives in low-resource settings
• HPV DNA testing - highly sensitive for high-risk HPV types
• Target: sexually active women; screening recommended every 3-5 years
• Recommended for women aged 21-65 years; once-in-a-lifetime screening can reduce cervical cancer mortality by 25-36%
• Colposcopy and biopsy for follow-up of positive screens

3. Breast Cancer Screening

• Breast Self-Examination (BSE) - taught to all women; monthly self-examination
• Clinical Breast Examination (CBE) by health workers
• Mammography - gold standard screening tool; recommended for women aged 40-74 years (annual or biennial)
• Mammography can reduce breast cancer mortality by 15-20%

Criteria for a Good Screening Test (Wilson & Jungner):

• Disease must be an important health problem
• Natural history well understood
• Recognizable early/latent stage
• Treatment at early stage more beneficial than late
• Suitable test available (sensitive, specific, acceptable)
• Test should be repeatable and cost-effective

c) Risk Factors for Cancer

1. Environmental Factors

• Smoking: cancer of lung, larynx, mouth, pharynx, oesophagus, bladder, pancreas
• Chewing: betel quid (betel leaf + arecanut + lime + tobacco), khaini - strongly associated with oral cancer
• Indigenous forms: bidi, chutta, chilum, hookah
• Reverse smoking (chutta) with burning end inside mouth - associated with carcinoma of the hard palate in Andhra Pradesh

• High fat diet - associated with colorectal, breast, prostate cancer
• Salted/smoked/preserved foods - stomach cancer
• Aflatoxin in stored grains - hepatocellular carcinoma
• Low fibre intake - colorectal cancer
• Protective: fruits, vegetables (antioxidants), cruciferous vegetables

• Asbestos - mesothelioma, lung cancer
• Benzene - leukaemia
• Aniline dyes - bladder cancer
• Coal tar, soot - skin cancer (scrotal cancer in chimney sweeps - Pott's cancer, first occupational cancer described)
• Radiation - radiation workers, radiologists

• HPV (Human Papillomavirus) - cervical cancer (HPV 16, 18); also oropharyngeal cancer
• Hepatitis B & C - hepatocellular carcinoma
• H. pylori - gastric cancer
• EBV (Epstein-Barr Virus) - Burkitt's lymphoma, nasopharyngeal carcinoma
• HIV - Kaposi's sarcoma, lymphoma

• Ionizing radiation - leukaemia, thyroid cancer, bone cancer
• UV radiation (sunlight) - skin cancer, especially in fair-skinned individuals

• Cervical cancer: early marriage, multiple sexual partners, poor genital hygiene, multiple pregnancies
• Breast cancer: late marriage, first child at late age, fewer children, shorter breastfeeding - common in educated urban women

2. Host Factors

• Age - Incidence increases with age (multistep carcinogenesis takes years)
• Sex - Some cancers specific to sex (cervical, prostate)
• Genetic predisposition - BRCA1/2 in breast/ovarian cancer; familial adenomatous polyposis; retinoblastoma
• Immune status - Immunosuppression increases cancer risk
• Hormonal factors - Oestrogen and breast/endometrial cancer

d) Prevention and Control of Cancer

Primary Prevention (Reducing Incidence)

1. Tobacco Control - Most impactful single intervention:
   • The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, COTPA 2003
   • Ban on smoking in public places; health warnings on tobacco products
   • Tobacco cessation clinics
   • Taxation, price increase, and restriction of advertising
2. Dietary Modification:
   • Increase fruits, vegetables, fibre
   • Reduce red/processed meat, high-fat and salt-preserved foods
   • Avoid aflatoxin-contaminated foods
3. Vaccination:
   • HPV vaccine (Gardasil/Cervarix) - prevents HPV 16, 18 associated cervical cancer; given to girls 9-14 years
   • Hepatitis B vaccine - prevents hepatocellular carcinoma; part of Universal Immunization Programme (UIP) in India
4. Occupational Safety: Regulation of carcinogen exposure in workplaces (asbestos, benzene, radiation)
5. Radiation Protection: Limiting unnecessary X-ray exposure; protection for radiation workers
6. Reduce alcohol consumption
7. Physical activity and healthy weight maintenance
8. Health Education and IEC - Community awareness about cancer warning signs (CAUTION mnemonic):
   • C - Change in bowel/bladder habits
   • A - A sore that does not heal
   • U - Unusual bleeding or discharge
   • T - Thickening or lump in breast or elsewhere
   • I - Indigestion or difficulty swallowing
   • O - Obvious change in wart or mole
   • N - Nagging cough or hoarseness

Secondary Prevention (Early Detection and Treatment)

1. Screening programmes for oral, cervical, and breast cancer (see Section b)
2. Training primary health workers for early detection during home visits
3. Referral systems from PHC to CHC to District Hospital to Regional Cancer Centre
4. Cancer registers (population-based and hospital-based) for surveillance

Tertiary Prevention (Reducing Disability and Death)

1. Comprehensive treatment - surgery, chemotherapy, radiotherapy
2. Regional Cancer Centres (RCCs) - 27 RCCs across India
3. Palliative care - pain relief, quality of life improvement; oral morphine availability
4. Rehabilitation - physical, psychological, social rehabilitation of cancer patients

Role of Primary Health Care System in Cancer Control:

• ANMs and health workers conduct home visits and visual screening
• Medical Officers at PHC run cancer detection camps
• District hospitals provide chemotherapy and surgery
• NPCDCS funds district-level cancer services