|Year : 2014 | Volume
| Issue : 2 | Page : 133-137
Cancer trends in Kashmir; common types, site incidence and demographic profiles: National Cancer Registry 2000-2012
MA Wani1, FA Jan1, NA Khan2, KK Pandita1, R Khurshid1, SH Khan1
1 Department of Hospital Administration, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Radiation Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||7-Aug-2014|
M A Wani
Department of Hospital Administration, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: An assessment of cancer incidence in population is required for prevention, early diagnosis, treatment and resource allocation. This will also guide in the formation of facilities for diagnosis, treatment, rehabilitation and follow-up for these patients. The demographic trend of cancer will help to identify common types and etiological factors. Efforts at clinical, research and administrative levels are needed to overcome this problem. Settings and Design: Present retro prospective study was conducted in regional cancer center of a tertiary care hospital. Materials and Methods: After permission from ethics committee, a retro prospective study of 1 year duration was undertaken to study the profile of cancer patients and to compare it with other cancer registries in India. Statistical Analysis: Pearson's Chi-square test and simple linear regression were used. Statistical Package for the Social Sciences version-16 (University of Bristol information services (www.bristol.ac.uk/is/learning/resources) was used. RESULTS: The overall incidence of cancer in Kashmir is on the increase and common sites of cancer are esophagus and gastroesophageal (GE) junction, lung, stomach, colorectal, lymphomas, skin, laryngopharynx, acute leukemias, prostate and brain in males.In females common sites are breast, esophagus and GE junction, ovary, colorectal, stomach, lung, gallbladder, lymphomas, acute leukemias and brain. Conclusion: Cancers of esophagus, stomach and lungs have a high incidence both in men and women in Kashmir. Future studies on sources and types of environmental pollution and exposures in relation to these cancers may improve our understanding of risk factors held responsible for causation of these malignancies in this region. This will help in the allocation of available resources for prevention and treatment strategies.
Keywords: Cancer incidence, epidemiology, hospital cancer registry, leading sites, regional cancer center
|How to cite this article:|
Wani M A, Jan F A, Khan N A, Pandita K K, Khurshid R, Khan S H. Cancer trends in Kashmir; common types, site incidence and demographic profiles: National Cancer Registry 2000-2012. Indian J Cancer 2014;51:133-7
|How to cite this URL:|
Wani M A, Jan F A, Khan N A, Pandita K K, Khurshid R, Khan S H. Cancer trends in Kashmir; common types, site incidence and demographic profiles: National Cancer Registry 2000-2012. Indian J Cancer [serial online] 2014 [cited 2019 Aug 22];51:133-7. Available from: http://www.indianjcancer.com/text.asp?2014/51/2/133/138188
| » Introduction|| |
Data regarding cancer incidence are important for several reasons. Cancer affects all nations and therefore it is an endemic disease with considerable variation in frequency according to the site incidence. The geographical differences in total and site incidences have provided clues of causative factors and especially in separating environmental and ethnic factors from intrinsic factors. The total world incidence shows the enormous health problem caused by cancer, which is recognized as the second killer disease in humans.  In Japan cancer of the stomach is the most common malignant tumor in both men and women in marked contrast to other countries.  The high incidence of cancer of the mouth in India is well-known and has led to the identification of habit of chewing tobacco with betel nut as a risk factor. 
Clarke et al. used incidence and mortality data from the California Cancer Registry and examined rates and trends for 1990-1999 for invasive breast cancer among non-Hispanic, white women in California. They concluded that the incidence of invasive breast cancer has increased significantly in the affluent population of California, between 1990 and 1999. They associated this increase in breast cancer with higher socio-economic status of people in the region. 
In a study in Ireland it was concluded that the number of cancers diagnosed in Ireland is expected to almost double between the period 1998-2002 and 2020. An increase will occur in almost all cancer types, mostly as a result of population ageing, but also as a result of an increase in underlying incidence rates for most cancers. 
Cancer is occurring in every country, though the magnitude of the problem and common sites differ. Accurate statistics on the occurrence of cancer are not available for the developing countries. 
The global increase in the cancer burden and its shift from high to low and medium-resource countries is being propelled by both demographic changes and by temporal and geographic shifts in the distribution of the major risk factors. The three most important factors that contribute to these trends are growth and aging of populations, the entrenchment of modifiable risk factors particularly cigarette smoking, western diet and physical inactivity in developing countries and the slower decline in cancers related to infectious etiologies in low versus high resource countries. 
It is estimated that there are approximately 2-2.5 million cases of cancer in India at any given point of time, with around 7-9 lack new cases being detected each year. Nearly half of these cases die each year.  This burden is going to be double in 2026.  By 2020, up to 70% of the 20 million new cases annually are predicted to occur in the developing countries.  On the optimistic side, the 5 year survival rate of cancer patients has increased world over. Better outcomes are due to advances in research and education. Progress will require ongoing advances in cancer prevention, early detection and treatment. 
Sheri Kashmir institute of medical sciences (SKIMS), Srinagar is a 700 bedded tertiary care teaching hospital of Jammu and Kashmir. Projected population of Jammu and Kashmir is 12.5 million. There is no any independent cancer hospital in J and K and regional cancer center (RCC) SKIMS is the only center in Kashmir which is an integral part of this tertiary care institute.RCC (SKIMS) was established under national cancer control program with the objective to provide cancer treatment facilities in addition to prevention activities across the state. 
A hospital cancer registry (HCR) under national cancer registry program is well maintained by the department of medical records which provides statistical and surveillance support to researchers.
| » Materials and Methods|| |
After permission from ethics committee, a retro-prospective study of 1 year duration was undertaken from January, 2012 to December, 2012 in RCC (SKIMS). A pro forma was developed for this purpose which included Demographic information like age, sex, occupation, geographical distribution, smoking history, educational background and profession besides diagnosis of the case. Malignant tumors were included and benign tumors were excluded from the study. A HCR is maintained in RCC where all cancer patients who come to hospital are registered initially irrespective of admission to hospital including early stage cases and their individual case records are maintained by medical record department, which are computerized. These case records were studied retrospectively for 2000-2011 using data from cancer registry. Prospective study was conducted on patients who reported to RCC during 2012. This data was compared with other cancer registries in India which is available in different Indian Council of Medical Research annual reports, to 2 investigate the demographic and epidemiological trend of cancer in Kashmir.
A Pearson's Chi-square statistical test was used while looking at age and gender differences of incidence of disease. An analysis of variance was used in order to determine what differences, if any, existed between incidence of disease among young and elderly and similarly in male and female populations. Simple linear regression was used for trend analysis. Statistical Package for the Social Sciences version-16 (University of Bristol information services (www.bristol.ac.uk/is/learning/resources) was used for statistical analysis.
| » Results|| |
A total of 24768 patients with malignancy reported to RCC (SKIMS) from 2000 to 2012. The highest number of patients fall in the age group 65-69 (3245), followed by 55-59 age group (2925) [Table 1]. The mean age is being 53 years and median age of 56 years. This shows an increase in occurrence of disease with increasing age. This also suggests likely increase in number of cancer patients given the expected aging of our population. There is statistically significant difference based on age (P = 0.01).
There is overall male predominance (3:2 male/female) of cancer in Kashmir valley [Table 2]. However, there was no statistically significant difference based on gender (P = 0.846). 70% of cancer patients fall in the rural category. The majority of patients were farmers from a rural background followed by house wives who also had rural back ground with farming as main occupation. 70% males had a positive tobacco smoking history and 49% of them had rural background with farming as main profession. Only small percentage (7%) of women had a positive smoking history. No patient had tobacco chewing history positive. 13% patients had reimbursement plan by their employer (mainly government) and lesser than 1% had some sort of health insurance.
Over all Incidence of cancer in Kashmir showed a distinctly increasing trend over the past decade [Figure 1] and [Figure 2]. Simple linear regression showed that all site incidence increased by 11.27% between 2000 and 2012 and statistical projection showed that over all incidence will double between 2012 and 2027. However, during the same period cancer esophagus showed a slightly declining trend (1.50%) and cancer stomach showed a significantly increasing trend (7.84%) [Figure 3] and [Figure 4].
|Figure 1: Year - wise number of cancer patients registered in cancer registry showing all site incidence and trends of cancer 2000-2012|
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The leading sites of cancer for each gender were decided on the basis of proportion relative to all sites of cancer registered in the cancer registry.
The leading sites of cancer in Kashmir during the study period were esophagus and gastroesophageal (GE) junction (19.95%), lung (16.54%), stomach (11.60%), colorectal (7.36%), lymphomas (5.40%), skin (3.46%), laryngopharynx (3.0%), acute leukemias (2.62%), prostate (1.7%) and brain (1.54%) [Table 3].
|Table 3: Leading sites of cancer - (…) (hospital cancer registry: 2000 - 2012) male/female|
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The leading sites among females were breast (16.83%), esophagus and GE junction (12.85%), ovary (7.45%), colorectal (6.68%), stomach (6.60%), lungs (4.56%), gall bladder (3.9%) lymphomas (3.30%), acute leukemias (2.45%) and brain (1.95%) [Table 3].
Cancer esophagus has a high incidence in both males and females in Kashmir with a sex ratio of approximately 2:1 followed by cancer lung and stomach in males and cancer breast and ovary in females. The overall male:female ratio of top ten cancers was also approximately 2:1. There is just a significant difference based on gender distribution of the top ten cancers (P = 0.05). The two leading sites esophagus and stomach constituted over 27% of the total cancers.
| » Discussion|| |
Our study showed an increase in occurrence of cancer with increasing age. This suggests likely increase in number of cancer patients given the expected aging of our population. Seventy percent of the population in Jammu and Kashmir lives in rural areas whose major occupation is farming. Smoking is a common habit in these farmers, especially in males. Females rarely smoke in our society being a closed society. There is overall male predominance (3:2 male/female) of cancers in Kashmir province. This suggests that smoking is a major risk factor in males, which is amenable to prevention strategies. Health insurance is yet a rare entity in our society and only 13% patients had reimbursement plan by their employer (mainly government).
As there is only one functional RCC in Kashmir valley with a HCR and as a matter of fact most cancer patients will require hospitalization at some point during the course of their disease either for surgery, chemotherapy or palliative therapy.  The number of patients registered in RCC depicts the overall incidence of cancer in Kashmir.
Over all Incidence of cancer in Kashmir showed a distinctly increasing trend over the past decade and the number of cancers diagnosed is expected to double between the period 2012 and 2027. However, during the same period cancer esophagus showed a slightly declining trend and cancer stomach showed significantly increasing trend. He YT et al. from China reported similar trends in the incidence rates of esophageal and gastric cardia cancer.  Further investigation is needed in both these regions to know the exact epidemiological determinants that are responsible for these newer trends.
The overall increase in number of cases may be explained on the basis (1) improvement in diagnostic and treatment facilities since the last decade in oncology center at SKIMS (2) increase in the aged population and (3) increase in incidence of almost all cancers especially tobacco related cancers, e.g. gastric, esopagheal and lung cancers. Kashmir is the geographical region where cancers of esophagus, stomach and lungs have a high incidence both in men and women. Two important risk factors, salted tea and hukka tobacco smoking (which are yet to be established), which are commonly used by Kashmiri farmers and laborers needed to be studied scientifically. Besides, prevalence of Helicobacter pylori in Kashmiri population needs to be investigated. Epidemiological studies could lead to recognition of unique risk factors for the disease and could point to ways to reduce exposures to those factors, thereby preventing some cancers.  The major risk factors for cancer are tobacco, alcohol consumption, infections, dietary habits and behavioral factors. Tobacco use accounts for 50% of all cancers in men. Dietary practices, reproductive and sexual practices account for 20-30% of cancers. Studies have shown that appropriate changes in life-style will reduce the mortality and morbidity caused by cancer. 
According to epidemiological studies, 80-90% of cancers are due to environmental factors of which, life-style related factors are the most important and preventable.  This offers the prospect for initiating primary and secondary prevention measures for control and prevention of cancers. 
The ten leading sites of cancer are esophagus and GE Junction, lung, stomach, colorectal, lymphomas, skin, laryngopharynx, acute leukemias, prostate and brain in males. In females the leading sites are breast, esophagus and GE Junction, ovary, colorectal, stomach, lung, gallbladder, lymphomas, acute leukemias and brain. Esophagus and stomach alone constituted over 27% of the total cancers.
The knowledge of leading sites of cancer in population not only provides a clue about causation, but should also give the useful insight into the early detection and treatment of these leading cancers, besides initiating prevention measures for the general population. This will also help in resource allocation for treatment and prevention of these cancers.
When we compare our data with the other cancer registries in India, sites like esophagus, stomach and lungs happen to be among the ten leading sites in all the registries in males and esophagus, breast and ovary in females. However, oral cancer is very common in India due to habit of tobacco chewing, which is not prevalent in Kashmir [Table 4],[Table 5],[Table 6] and [Table 7]. 
|Table 4: Ten leading sites of cancer - Bangalore (consolidated report of PBCRs: 2001 - 2004)|
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|Table 5: Ten leading sites of cancer - Chennai (consolidated report of PBCRs: 2001 - 2004)|
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|Table 6: Ten leading sites of cancer - Delhi (consolidated report of PBCRs: 2001 - 2004)|
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|Table 7: Ten leading sites of cancer - Mumbai (consolidated report of PBCRs: 2001 - 2004)|
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limitation of this study is that trend analysis will require a high level of detail, e.g., incidence data alone will not be a sufficient guide, as cancer prevalence particularly acute cases will have a significant impact on the trend.
| » Conclusion|| |
The overall incidence of cancer in Kashmir shows an increasing trend and the number of cancers diagnosed is expected to double between the period 2012 and 2027. The cancers of esophagus, stomach and lungs have a high incidence in Kashmir both in men and women. Future studies on sources and types of environmental pollution and exposures in relation to gastro-esophageal cancer may improve our understanding of risk factors for these malignancies in this region. This will also help in the allocation of available resources for prevention and treatment of these cancers.
| » Acknowledgments|| |
The authors express their gratitude to Firdous Ahmad Wani and Mudasir Ahmad Wani for their work in compiling and processing the data; to Bashir Ahmad for his efforts in gathering data for this work; to Mr. Rayees Ahmad for statistical analysis and to Jawahira Akhter for the valuable comments during the final touch of this work.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]