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ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 1  |  Page : 133-138
 

Increasing cancer incidence in a tertiary care hospital in a developing country, India


Department of Pathology, Lakeshore Hospital, Nettoor, Kochi, Kerala, India

Date of Web Publication3-Feb-2016

Correspondence Address:
T Cherian
Department of Pathology, Lakeshore Hospital, Nettoor, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175596

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 » Abstract 

Objective: Cancer is a major health problem in many countries including India. Since Cancer Registries are incomplete in India, only a few epidemiological studies have been done so far. The objective was to determine the leading causes of cancer in a tertiary care hospital and compare the incidences of different types of cancer with the incidences in India and developed countries.Materials And Methods: An epidemiological study was done to collect data from pathology records of 1003 cancer cases during 6-month period in the year 2010. The data was collected in a computer and the data was utilized to make tables and histograms.Results: Of the 1003 cases, the leading cancer site was breast, followed by colon and rectum, lymph node and stomach. The leading cancer site for men was colon and rectum and for women was breast. Conclusion: Cancer incidence is now low in India, a developing country, compared to developed Western countries. However, some cancers, like breast and colon and rectum cancers are increasing every year.IMPACT: The findings of this study support that cancer incidence is increasing in India and more epidemiological studies are needed.


Keywords: Breast, cancer, colorectum, lymphoma, stomach


How to cite this article:
Cherian T, Mahadevan P, Chandramathi S, Govindan J, Mathew I L. Increasing cancer incidence in a tertiary care hospital in a developing country, India. Indian J Cancer 2015;52:133-8

How to cite this URL:
Cherian T, Mahadevan P, Chandramathi S, Govindan J, Mathew I L. Increasing cancer incidence in a tertiary care hospital in a developing country, India. Indian J Cancer [serial online] 2015 [cited 2020 Apr 9];52:133-8. Available from: http://www.indianjcancer.com/text.asp?2015/52/1/133/175596



 » Introduction Top


Cancer is a major health problem in developed countries. Cancer is the leading cause of death in Canada (29%) and is the second leading cause of death in United States of America (USA), United Kingdom (UK) and Australia.[1],[2],[3],[4] In USA, the leading types of cancer are in prostate, lung, colorectum and urinary bladder in men and breast, lung, colorectum and uterus in women. The leading causes of cancer deaths among men are lung, prostate and colorectal cancer and among women lung, breast and colorectal cancer. In UK, Canada, Australia, the most leading types of cancer were in prostate, breast, lung and bowel. In Canada in 2007, lung cancer is the most commonly diagnosed type among all cancer deaths (27%) and prostate cancer is the leading one among men (27%) and breast cancer among women (28%). In Australia in 2007, the leading cancer in men was prostate cancer and in women breast cancer. In UK in 2009, prostate cancer was most common among males (25%) and breast cancer among women (30%).

Cancer incidence is low in developing countries compared with high incidence in developed countries. The cancer incidence rate is 361/100,000 population in USA and about 300/100,000 in Europe compared with 100/100,000 in India.[5] In some developing countries, cancer is also becoming a major health hazard. In China, cancer is the leading cause of death.[6] The common cancers are in the lung, stomach, liver, esophagus and colorectum. Lung, liver and stomach cancer are the leading types in men and breast, lung and stomach cancer are the leading types in women.[7]

In India in 2008, 948,000 new cancer cases were diagnosed according to projected estimation. About 550,000 cancer deaths were estimated to occur.[8] The leading cancer types in men were the oral and pharyngeal, stomach, lung and esophageal cancer and in women cervix, breast, stomach and esophagus. Tobacco related cancers contributed to about 50% of all cancers. The estimated cancer mortality in India for the year 2000 was 157,168. According to World Health Organization, the estimated cancer deaths in India are projected to increase to 700,000 by year 2015. The estimated cancer incidence in Kerala state in 1990 was about 15,000 and increased to 35,000 in 2009 where the total population was about 30 million.[9]


 » Materials and Methods Top


This tertiary care private hospital is situated in central Kerala (known as “GOD's own country”) and the patients come to this hospital from Ernakulam district and other surrounding districts. Many cancer surgeons and medical Oncologists are available in this hospital for treating patients. Patients coming to this hospital are mostly educated and belong to the middle or upper socio-economic classes. The people of Kerala state are highly educated compared with other parts of India and will consult a medical doctor at least during the late clinical stages of cancer. Hence, the cancer estimates and reporting can be considered as very reliable in Kerala.

The pathology reports of 2,970 surgical pathology cases and 1,490 cytology cases of this hospital during the period from 1st of January to 30th of June, 2010 (6 months period) were reviewed and 1003 new cancer patients having different types of cancers were included in this study. The old cases with recurrence were not included in this study. Many of these cases had biopsies or resection surgeries in this hospital, but cases from two peripheral hospitals were also diagnosed in this hospital laboratory. Some of the cases were referred to this hospital for a second opinion. The biopsy, cytology and resection specimen details were collected together for one patient without any duplication. After the initial biopsies, some patients preferred to go back to their local hospital, to the government hospital or to the Regional Cancer Center at Thiruvananthapuram, Kerala for further management. The data were collected from the laboratory reports only, without reviewing the patients' charts. Available information was collected on all cases on name, age, sex, religion, site, diagnosis, metastases and immunohistochemistry (IHC). The IHC studies included mostly estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (Her-2-neu) status for breast carcinoma and also other tumor markers. About 70 antibodies including the ones for lymphomas are available in this laboratory for IHC studies. These antibodies are supplied by either Dako company Denmark or Biogenex laboratories, USA and distributed through Indian agencies to this hospital.


 » Results Top


Cancers in general (all cancer cases)

During the study period of 6 months, 1,113 cancer cases were evaluated at this hospital, of which 110 cases were old cases with recurrence of the disease and the rest 1,003 were new cancer cases.

About 2000 cancer cases were seen in this hospital in 2010. This hospital registered 887 new cancer cases in 2003 and 1094 cases in 2005. The majority of the cancer cases were involving the breast, colon and rectum, lymph nodes, stomach etc., as given in [Table 1], breast being the leading cancer site.
Table 1: Distribution of cancer cases

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Age and sex

The distribution of 1003 cancer cases according to the age and sex is given in [Figure 1]. Most of the patients were between the ages of 41 and 80. The peak incidence was between 41 and 60 (45%). The increased incidence of cancer in female patients between the ages of 41 and 60 is due to the increased cases of breast carcinoma. Among the 1,003 cancer cases, 52% were in females and 48% in males. If the gender specific cancers such as breast, ovary, uterus and prostate were excluded, the male:female ratio is approximately 2:1 in other types of cancers.
Figure 1: Distribution of cancer cases according to age and sex

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The leading sites of cancer among males are given in [Table 2] and among females are given in [Table 3]. The top ranking cancer site among males is colon and rectum and among females is the breast. The colon and rectum cancers constitute 13.5%, the lymph node cancers 10%, the stomach 7.5%, the lung 7% and the prostate 6.6% of all the male cancers. The breast cancers constitute 40%, the ovary 9.5%, the uterus 7%, the colon and rectum 6% and the lymph nodes 6% of all the female cancers.
Table 2: Leading cancer sites among males (n=482)

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Table 3: Leading cancer sites among females (n=521)

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Religion

Among the 1003 cancer cases, the Christian patients were 40%, the Hindu 38% and the Muslim 22%, more or less similar to the percentage of religious divisions among the general population in the region around this hospital. In most of the cancer types according to the sites, the religious distribution of cancer patients are proportional to the religious divisions of the general population. However, the Muslim women showed low incidence of cancer of certain sites, namely myeloma (none), uterine cervix (none), esophagus (none), kidney (one case), thyroid (one case), urinary bladder (one case) and lung (two cases).

The leading cancers are described below.

Carcinoma of the breast

The carcinomas and other malignant tumors of the breast constituted the largest number of cancer cases in this hospital. During the study period of 6 months, 211 cases of carcinoma or other malignant tumors of the breast were diagnosed, amounting to about 21% of the total cancer cases. The majority of these tumors were invasive ductal carcinoma (IDC), (88%) and other tumors included metaplastic, papillary, mucinous, lobular, mixed and intraductal carcinomas. Occasional cases of malignant phyllodes tumor and carcinoma of male breast were encountered, but none of these cases were seen during this study period. The details of invasive ductal carcinoma (IDC) are given below.

The distribution of 190 cases of IDC according to the age is given in [Figure 2]. Nearly, 91% of patients were between the ages of 31 and 70. The highest number of cases, 58 (30.5%) was between 41 and 50 years of age. The Christians were 43%, the Hindus 40% and the Muslims 17%, more or less reflecting the same pattern of religious distribution among the general population in the region surrounding this hospital. About 27% of cases were referred to this hospital for a second opinion of the histologic diagnosis and for further management.
Figure 2: Distribution of patients with IDC by age in years

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Of the 190 IDC cases, 46% occurred in the right breast and 34% in the left breast and 19.5% had no mention of the side of the breast. One case had carcinoma in both breasts at the time of diagnosis. About 31.5% had lumpectomy or wide excision and 38.5% had mastectomy, simple or radical and 30% were referred to the government or local hospitals. The grading of IDC cases were available in 111 cases, 73% being in Grade 3 and 27% in Grade 2. Lymph nodes were examined in 113 cases with an average of 13.6 nodes per case. The metastases in the lymph nodes were present in 62% of the cases. Seven cases had metastases at sites other than lymph nodes at the time of diagnosis.

IHC

The ER and the PR status were evaluated in IDC cases. Of the 85 positive cases, 62% of cases were positive for both ER and PR, 31% were for ER only and 7% for PR only. Of the 95 cases, 68% of cases were negative for both ER and PR, 4% were ER only and 27% were PR only. The Her-2-neu status was evaluated in 135 cases with 26% being positive (score 2+ and 3+) and 74% being negative.

Carcinoma of colon and rectum

During the study period of 6 months, 98 cases of malignant tumors of the colon and rectum were diagnosed of which 94 adenocarcinomas constituted 9.8% of all cancer cases. Other tumors were two cases of lymphoma, one neuroendocrine carcinoma and one sarcoma. The distribution of 94 cases of adenocarcinoma according to age and sex is given in [Figure 3]. Most of the patients (79%) were above the ages of 50. The male:female ratio was about 2:1. The Christians were 40%, the Hindus 39% and the Muslims 21%, more or less similar to the religious divisions in this region. Of the 94 cases, 75% were in the left colon or rectum and 25% were in the right colon or transverse colon. 62 cases had resection operations carried out in this hospital.
Figure 3: Distribution of patients with carcinoma of colon and rectum according to age and sex

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Some others were referred to other private or government hospitals, some had chemotherapy and some declined further treatment because of high end disease. Of the 62 cases, 84% had a pathological staging of T3 or above and 16% had a pathological staging of less than T3 according to the tumor-node-metastasis classification. Distal metastases or local extension to adjacent organs were present in eight cases at the time of diagnosis. Lymph node metastases were diagnosed in 34 of 62 cases and the average lymph node collection per specimen was 15. Three cases had a previous history of ulcerative colitis, one had Cohn's disease and three had a history of familial adenomatous polyposis.

Non-Hodgkin lymphoma

Between January and June of 2010, 97 cases were diagnosed as lymphoma, of which 13 cases were Hodgkin lymphoma. Of the 84 NHL, 52 were diagnosed in the lymph nodes and 32 at extranodal sites. The male patients were 73% and the female patients were 27% (ratio 2.8:1). The distribution of NHL patients according to age and sex is given in [Figure 4].
Figure 4: Distribution of NHL patients according to age and sex

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Most of the patients were between 41 and 70 years of age. The Christians were 44%, the Hindus 33% and the Muslims 23%. The incidence of NHL among the Muslim women was low (3.5%). The Christians showed slightly increased incidence of NHL than the Hindus. The diagnosis of NHL was initially made and later reclassified according to the IHC studies. Multiple lymphoma panel antibodies were appropriately used. The commonly used antibodies were leukocyte common antigen, CD 20, CD 3, Bcl2, CD 10, CD 30, CD 15, CD 5, cyclin D1, CD 23, terminal deoxynucleotidyl transferase, anaplastic lymphoma kinase, and Ki67 (MIB1). Of the 84 cases, IHC was performed only in 65 cases, of which 54% were diffuse large B cell lymphomas, 32% were other high grade lymphomas and 14% low grade lymphomas. The other high grade lymphomas were T cell, anaplastic large cell, T lymphoblastic and Burkitt's lymphomas. The low grade lymphomas included follicular, small lymphocytic and marginal zone lymphomas.

Carcinoma stomach

During the study period, 54 malignant tumors of the stomach were diagnosed, of which 48 cases were adenocarcinoma. Other tumors were gastrointestinal stromal tumor and lymphoma. The distribution of 48 cases of adenocarcinoma of stomach according to the age and sex is given in [Figure 5]. Nearly, 71% of the patients were between the ages of 51 and 70. The youngest patient was 35 years old. The male:female ratio was approximately 2:1. The Christian patients were 40%, the Hindus 37% and the Muslim 23% similar to the religious divisions in this region. About 37% of cases were referred to this hospital for a second opinion. All the cases were adenocarcinomas including one mucinous and one signet ring cell carcinoma. Lymph node metastases were present in 30% cases and distant metastases were present in 21% cases at the time of diagnosis.
Figure 5: Distribution of patients with adenocarcinoma of stomach by age and sex

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 » Comment Top


The developed countries have increased incidence of cancer every year. In India, a developing country, the cancer incidence is low, about 100/100,000 population compared with about 361/100,000 in USA. This may be because the life expectancy in India is shorter than developed world, due to increased deaths related to infections or other causes. The more a person lives in this planet, the chances are that he or she can get cancer in the future.

In the developed world, the leading types of cancers were in the prostate, lung, breast and colorectum. In India, the leading type of cancer was tobacco related (oral, pharynx, larynx, lung etc.) along with stomach, esophagus, breast and uterine cervix.[10],[11] The tobacco related cancers are due to smoking and pan chewing and are more common among the less educated patients. In this hospital, tobacco related cancers were less because patients were more educated. Similarly, only 11 cases (1%) of carcinoma of the uterine cervix were diagnosed in this hospital because most of patients with cervical carcinoma were less educated and they would go to the government hospitals.

Increasing incidence of breast cancer is becoming a world phenomenon. Even the Muslim countries show increased breast cancer incidence. The incidence of breast carcinoma among all the cancers is high (21%) in this hospital and also in the Regional Cancer Center, Thiruvananthapuram.[9] The overall survival from breast cancer in Kerala was 40% in 1984.[12] The overall 5-year survival for breast cancer patients in Mumbai, India, treated between 2005 and 2010 was 75%.[13] The Etiology of breast cancer is related to diet, pesticides, reproductive factors, body weight, exogenous or endogenous hormones. The prevalence of smoking and usage of alcohol are very minimal among the female population in Kerala state. If detected early, the prognosis of breast cancer is very good and the mortality can be reduced similar to the improvement in Western countries where early diagnosis has leveled off or declined the mortality trend.[14]

The annual incidence of colorectal cancer in USA and other developed Western countries is about 35/100,000 and is about 27/100,000 in Eastern and Central Europe.[15] The annual incidence in India is about 4/100,000 while the developed Asian countries like Japan, Korea and Singapore who have adopted a Western life-style, have incidence of about 40/100,000.[16] The annual incidence of colorectal cancer in Kerala state is about 5.5/100,000 because the Kerala population eat more meat than the rest of the Indian population [11]. Studies have indicated that meat consumption, smoking and alcohol consumption are risk factors of colorectal cancer, whereas vegetable consumption, non-steroidal anti-inflammatory drugs and physical activity are inversely associated.

The age adjusted incidence rate for NHL in USA was 19.6/100,000 population.[17] The estimated crude incidence of NHL in India is about 3.3/100,000 population, which may be due to under reporting.[18] The estimated crude incidence rate for NHL in Kerala is about 4.4/100,000.[9] The NHL appears to be cancer of the old age, the median age being 66 years in USA and the median age of NHL patients in this hospital is 53 years.

The annual incidence of stomach cancer is decreasing every year in USA and other developed countries and is about 4-6/100,000.[15] The incidence is very high in East Asian countries like Japan reaching about 30/100,000. The annual incidence is about 5.4/100,000 in India and about 4/100,000 in Kerala state. The risk factors of carcinoma of stomach include diet, bile reflex and Helicobacterpylori infection. The mortality can be reduced by early diagnosis and treatment.

Prostate cancer is the leading type of cancer in men and the second leading cause of death in the developed world. The prostate cancer is 4-8/100,000 in East and South Asia, increases to 18/100,000 in the Middle East, then increase to about 28/100,000 in Eastern Europe and then hit the climax of 90/100,000 in Western Europe and 85/100,000 in North America.[15] The incidence of prostate cancer in Italy and Spain is about 16/100,000.[19] The crude incidence rate of prostate carcinoma in Kerala is about 2/100,000. The etiological factors appear to be red meat and pesticides. The increased incidence of prostate cancer in the Western countries is a mystery.

Limitations of this study

Since we were dealing with all the different types of cancer in this study, it was not possible to include all the 60 specialists of this hospital in this study and hence, we decided to do a study based on referring only the pathology records. Therefore, we could not include the effects of predisposing factors such as smoking, chemical exposures, viruses etc., for the development of cancer. The state government has not so far started a statewide cancer registry, which will represent the whole population of Kerala state. This private tertiary care hospital treats patients from different parts of the state and hence it is not a truly representative population. According to the director of Regional Cancer Centre, about 35,000 (estimated) new cancer cases occur in this state every year. We have about 2000 new cancer cases coming to this hospital annually, a remarkable percentage for an individual hospital.

Hospital based survival studies are possible only in individual cancer types with the cooperation of the clinicians. Even though, the survival information is just a click away on the mobile phone (cellphone), some clinicians are reluctant to contact their “lost to follow-up” patients. (Most of the patients or their relatives have mobile phones in Kerala now). A wider research will need research fund, which was not available for this study.

Population measures for prevention of cancer

For the last 50 years, government health department and media has promoted awareness and information about the consequences of cancer among the people. Many educated persons refrain from smoking and pan chewing now a days. Public places, hospitals and offices are now smoking free areas due to government orders. Regional Cancer Center conducts screening camps especially for oral cancers and awareness seminars to the public. Recently, government is going to start additional public laboratories to find the amount of pesticides in vegetables and other food materials as a campaign to reduce cancer induced by pesticides.

Private hospitals also conduct seminars open to the public regarding cancer awareness and the need for early diagnosis. Major hospitals in Kerala have ultrasound scans, computed tomography scans, magnetic resonance imaging scans, Pap smear and biopsy facilities and laboratory tests to detect cancer early.

Spices and cancer prevention

Kerala is the Land of Spices and search for Kerala spices by Europeans changed the world history. Several spices have antioxidants, which may fight against cancer. Prof. Will Stewart of University of Leicester, UK is doing research with Curcumin, an ingredient of the spice, turmeric, in cancer therapy.[20] Curcumin will fight cancer cells by inducing apoptosis. Other spices such as oregano, garlic, black pepper, ginger and fennel may also help in cancer therapy.


 » Conclusion Top


In India, the Cancer Registries are in a primitive stage. A few Cancer Registries are functioning mainly in the government sponsored Regional Cancer Centers in the big cities. A new Cancer Control Agency in Kerala state may very well promote preventive measures against cancer among the population and install a Kerala Cancer Registry to co-ordinate the data and records of cancer patients in the private and government hospitals, which is a must for progress in the health sector.

Sometime in the near future, all cancers will be cured or prevented. Until then, “early to diagnose, early to treat, that is the way to get rid of cancer.”


 » Acknowledgments Top


We gratefully acknowledge Mr. A. R. Rakesh and Ms. Shymol Abraham for their computer data management and Ms. K. A. Staphana, Ms. K. R. Mini and their team of laboratory technicians for processing excellent microscopic slides for diagnosis.

 
 » References Top

1.
Canadian Cancer Society. Available from: http://www.cancer.ca/canadawide/Aboutcancer/Cancerstatistics/stats2012. [accessed Jan 2013].  Back to cited text no. 1
    
2.
National vital statistics reports USA, 2009. Available from: http://www.cdc.gov/nchs/data/vol 59-04. [accessed Jan 2013].  Back to cited text no. 2
    
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Office of national statistics, 2011. [accessed Jan 2013] Available from: http://www.ons.gov.uk/ons/rel/Nsob1/cancer-statistics-registration. [accessed Jan 2013].  Back to cited text no. 3
    
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Australian Institute of Health and Welfare and Australasian Association of Cancer Registries. Cancer in Australia: An Overview, 2010. Cancer Series No. 60. Canberra: AIHW; 2010.  Back to cited text no. 4
    
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www.globocan.iarc.fr. 2008. [accessed Jan 2013].  Back to cited text no. 5
    
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He J, Gu D, Wu X, Reynolds K, Duan X, Yao C, et al. Major causes of death among men and women in China. N Engl J Med 2005;353:1124-34.  Back to cited text no. 6
    
7.
Zhao P, Dai M, Chen W and Li N. Cancer trends in China. Jpn J Clin Oncol 2010; 40: 281-5.  Back to cited text no. 7
    
8.
Dikshit R, Gupta PC, Ramasundarahettige C, Gajalakshmi V, Aleksandrowicz L, Badwe R, et al. Cancer mortality in India: A nationally representative survey. Lancet 2012;379:1807-16.  Back to cited text no. 8
    
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Annual Report 2009-10. Thiruvananthapuram, Kerala: Regional Cancer Center. p. 28-9, 40-3.  Back to cited text no. 9
    
10.
National Cancer Registry Program. Development of An Atlas of Cancer in India. First All India Report 2001-2002. Vol. I.p. 193-270.  Back to cited text no. 10
    
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Maiti PK, Jana U, Ray A, Karmakar R, Mitra TN, Ganguly S. Patterns of cancer occurrence in different regions of West Bengal – A hospital based study. J Indian Med Assoc 2012;110:445-8.  Back to cited text no. 11
    
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Nair MK, Sankaranarayanan R, Nair KS, Amma NS, Varghese C, Padmakumari G, et al. Overall survival from breast cancer in Kerala, India, in relation to menstrual, reproductive, and clinical factors. Cancer 1993;71:1791-6.  Back to cited text no. 12
    
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Gadgil A, Roy N, Sankaranarayanan R, Muwonge R, Sauvaget C. Effect of comprehensive breast care on breast cancer outcomes: A community hospital based study from Mumbai, India. Asian Pac J Cancer Prev 2012;13:1105-9.  Back to cited text no. 13
    
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World Health Organization. World Health Organization 1997-1999. World Health Statistics Annual, 2000. Available from: http://www.who.int/whosis. [accessed Jan 2013].  Back to cited text no. 14
    
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Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917.  Back to cited text no. 15
    
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Mohandas KM. Colorectal cancer in India: Controversies, enigmas and primary prevention. Indian J Gastroenterol 2011;30:3-6.  Back to cited text no. 16
[PUBMED]    
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Available from: http://www.SEER.cancer.gov/statfacts/html.nhl.html. [accessed Jan 2013].  Back to cited text no. 17
    
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Yeole BB. Trends in the incidence of non-Hodgkin's lymphoma in India. Asian Pac J Cancer Prev 2008;9:433-6.  Back to cited text no. 18
    
19.
Verdecchia A, Micheli A, Colonna M, Moreno V, Izarzugaza MI, Paci E, et al. A comparative analysis of cancer prevalence in cancer registry areas of France, Italy and Spain. Ann Oncol 2002;13:1128-39.  Back to cited text no. 19
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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