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  Table of Contents  
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 164-168

Lung cancer: Presentation and pattern of care in a cancer center in South India

1 Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
2 Department of Cancer Epidemiology and Biostatistics, Regional Cancer Centre, Trivandrum, Kerala, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. C Krishnan Nair
Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_56_17

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 » Abstract 

BACKGROUND: In India lung cancer is the most commonly diagnosed malignancy in males and an increasing trend in the incidence is reported from the National Cancer Registry programme. AIMS: The aim of this study is to find out the recent trends in presentation and management of lung cancer at Regional Cancer Centre, Trivandrum. METHODS: Published reports of hospital based cancer registries (HBCR) and population based cancer registries (PBCR) of Trivandrum were compared with reported statistics from other parts of India and global data. RESULTS: Lung is the leading site of cancer in males (15%) getting treatment at Regional Cancer Centre , Trivandrum in 2013 as per the HBCR. There is an increase in the age adjusted incidence rate of lung cancer among males in the Trivandrum PBCR from 14.6 to 18.5 during 2012 -2014. Among the patients who were treated at the Center majority (55.2%) presented with distant metastases with adenocarcinoma as the most common histological type (28.5%) and only 15.7% had undergone treatment with curative intent. CONCLUSIONS: Lung cancer is the major cancer affecting males in India with a high incidence in Trivandrum and a very low percentage of patients receiving curative treatment which could be due to the high prevalence of tuberculosis and scarce availability of facilities and trained manpower for thoracic oncology.

Keywords: Lung cancer, pattern of care, South India

How to cite this article:
Nair C K, Mathew A P, George P S. Lung cancer: Presentation and pattern of care in a cancer center in South India. Indian J Cancer 2017;54:164-8

How to cite this URL:
Nair C K, Mathew A P, George P S. Lung cancer: Presentation and pattern of care in a cancer center in South India. Indian J Cancer [serial online] 2017 [cited 2020 Jul 9];54:164-8. Available from:

 » Introduction Top

Lung cancer is the most common cancer and the most common cause of cancer-related mortality in the world. Annually 1.8 million new lung cancers (13% of all new cancers) and 1.59 million lung cancer deaths (19.4% of cancer deaths) occur globally. Lung cancer used to be one of the most common killer cancers for a long time. Unfortunately, 58% of lung cancers occur in under developed nations, where expertise and resources for diagnosis and treatment of lung cancer are pretty scarce. Lung cancer incidence shows a strong gender difference, and it is the most common cancer in men globally (1.2 million, 16.7% of the all).[1] In 2012, there were 1,824,701 new cancers in the world, which is likely to increase to 2,269,124 by 2020, which is 24.4% increase. In India also, lung cancer is a major public health problem. According to the published results, 70,275 new cases were diagnosed in the year 2012, and by the year 2020, the projected incidence rates may rise up to 88,831 per year [Table 1].[2]
Table 1: Estimated number of lung cancers in world (all ages) in 2020

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Among various geographical locations, the highest age-standardized incidence rates (ASRs) in males are seen in Central and Eastern Europe (53.5 per 100,000) and Eastern Asia (50.4 per 100,000). At the same time, very low ASRs are seen in certain countries like Middle and Western Africa (2.0 and 1.7 per 100,000, respectively). Among women, the geographical distribution is little different. The highest lung cancer incidence rates are seen in Northern America (33.8) and Northern Europe (23.7). At the same time, the incidence rate is less in Eastern Asia (19.2) and the lowest in Western and Middle Africa (1.1 and 0.8, respectively).[1] Lung cancer has a very high fatality rate (the overall ratio of mortality to incidence is 87%), and this paints a gloomy picture on the outlook of lung cancer scenario in the world.

 » Materials and Methods Top

Published reports of population-based cancer registry (PBCR) and hospital-based cancer registries (HBCRs) of Trivandrum were compared with reported statistics from other parts of India and the global data. For Indian data, the published articles and data from the National Cancer Registry Programme were used. For global data, GLOBOCAN reports and published reports were referred.

 » Results Top

According to various main PBCRs in India, there is a variation in ASR for lung cancer from 14.2 in Tripura state to 37.9 in Aizawl district among men. Among females, the ASR varied from 5.6 in Naharlagun to 40.8 in Aizawl district [Figure 1]. Similarly, when ASRs in cancer registries in 10 main cities were analyzed, the lowest was in Pune, Maharashtra (6.9), and the highest was in Kollam, Kerala (21.5) [Figure 2]. Similarly, in women, the lowest ASR was recorded in Ahmedabad (2.7) and the highest in Kolkata (7.4).[3] Lung cancer is the most common cancer in Trivandrum among men, and the incidence rates are still increasing. Analyzing the PBCR, we could see an increase in the incidence of lung cancer from 14.6 to 18.5 during 2012–2014 among men in Trivandrum. On the contrary, among women, there is a slight reduction in cancer incidence from 4.5 to 4.4 during the same period [Figure 3].[3]
Figure 1: Comparison of lung cancer age-adjusted incidence rates of first 12 cancer registries in India

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Figure 2: Comparison of lung cancer age-adjusted incidence rates of first 10 cancer registries of main cities in India

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Figure 3: Lung cancer incidence rates per 100,000 persons in district cancer registry, Thiruvananthapuram (2012–2014). CR: Crude incidence rate, AAR: Age-adjusted rate, TR: Truncated rate (35–64 years)

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Lung cancer is the most commonly diagnosed cancer among males getting treatment at the Regional Cancer Centre (RCC), Trivandrum. In the year 2013, according to the HBCR of RCC Trivandrum, lung cancer (15%) was the leading site among males followed by cancer of the oral cavity (13.4%).[4]

Among 6482 new cancers registered in our hospital in 2013, 1178 were lung cancers. Even though tobacco smoking has reduced significantly in the district, the incidence of lung cancer in men is rising in Trivandrum. In women, lung cancer is not among the ten most common cancers. When incidence of lung cancer was analyzed, lung cancer is the most common cancer in males more than 35 years while leukemia is the most common malignancy in men <35 years. The peak age of lung cancer incidence happens after 60–64 years.

When HBCR data were analyzed at two different time periods, i.e., 1982 and 2011, proportion of lung cancer has increased from 11.9% to 13.7% in males and from 1.2% to 2.5% in females.[4]

In the year 2013, 1178 patients presented to our institute with lung cancer. Among these, 1086 patients received the first treatment at the institute while 92 patients received the initial treatment elsewhere. Among 1086 patients who were treatment naïve, 44 (4.1%) presented with localized disease while 443 (40.8%) had locoregional disease, and majority, i.e., 559 (55.2%) patients presented with distant metastases. The most common histology was adenocarcinoma (336, 28.5%) followed by squamous cell carcinoma (152, 12.9%) and small cell carcinoma (57, 4.9%). There were also 151 (12.8%) cases which were not subtyped and mentioned as broad group, nonsmall cell carcinoma.[5]

When treatment methods were analyzed, of 1086 patients treated at RCC, it was found that the majority (916, 84.3%) of patients had undergone noncurative treatment while only 170 (15.7%) had undergone radical treatment with curative aim. Among various treatment regimens, a majority of (570, 52.5%) patients received chemotherapy. While 329 (30.3%) patients received chemotherapy alone, 241 (22.19%) patients received chemotherapy along with some other treatments. Similarly, among 408 (37.57%) patients who received radiotherapy, 178 (16.4%) patients received radiotherapy alone while 230 (21.18%) patients received radiotherapy along with other modalities. Similarly, 21 patients had undergone surgery either alone or with other modalities.[5]

 » Discussion Top

Lung cancer is the most common cancer among males, and it is a major public health challenge in India. Males are affected more compared to females. The probable reasons may be more exposure to tobacco smoke, air pollution, and other hazards that men face more compared to women. According to HBCR reports of the RCC Trivandrum, the male-to-female ratio in the occurrence of lung cancer is 4.7: 1.[5] A similar ratio (6:1) is also reported from the Malabar Cancer Centre, which is the other major cancer center in our state.[6] Very few patients present early enough to be eligible for curative therapy. This is the same across many Indian centers, and the reasons for this delay are many. One of the important reasons is that the prevalence of tuberculosis is very high in India. According to the latest figures, 2, 700,000 prevalent TB patients were there in India in 2013.[7] In 2012, 3706 cases are newly diagnosed in India whereas 5-year prevalence is 24,473.[1] Hence, it is very likely that in a resource-poor country like India, many patients with lung cancer may likely be misdiagnosed as having sputum-negative tuberculosis. In fact, most lung cancers in India are diagnosed late because of many reasons varying from delay from the part of patient in seeking expert medical care and delayed referrals to the insufficiency of health-care delivery systems. According to one study, 14 of 70 (20%) patients received wrong treatment because of misdiagnosis.[8] In a study done on 96 cases of lung cancers reported to a tertiary care institute in India, 18% of physicians made a wrong diagnosis of cancer as tuberculosis, and 86.6% of these patients received antituberculosis treatment. Only 27% of doctors referred patients to appropriate centers for further evaluation and treatment.[9] There were also differences in diagnostic accuracy across various specialists seeing the patient. Pulmonologists identified the lung cancers correctly while the diagnostic accuracy was less in general practitioners followed by general medicine physicians. India is a country where tuberculosis is highly prevalent, so there may be many patients with lung cancer who will have coexisting tuberculosis. In a study from northern India, history of tuberculosis was present in 16% of lung cancer patients.[10] If this reflects a national trend, many patients with lung cancer may also have coexisting tuberculosis, and in many patients, lung cancer may be missed because tuberculosis is endemic in several areas. To complicate things further, tuberculosis is one of the etiologic factors for lung cancer and lung cancer-related mortality.[11] There are also some reports suggesting that risk of tuberculosis is nine times more in patients with lung cancer.[12] In fact, tuberculosis is a comorbidity of lung cancer even in countries with a moderate prevalence of tuberculosis.[13]

Earlier smoking is thought to be one of the important etiologic factors for lung cancer. There are published reports that the incidence of lung cancer in nonsmokers is increasing now.[14]

According to our hospital data, the percentage of lung cancers which presented with localized disease reduced from 13.4% (1994–1998) to 3.1% (2010–2014). This reduction is alarming even though this may be partly due to the increased sensitivity of cross-sectional imaging resulting in an added detection of lymph nodes. The cases presenting with lymph node metastasis have increased from 29.5% (1994–1998) to 41% (2010–2014) while those presenting with distant metastases remained essentially the same [Table 2] (unpublished reports).
Table 2: Comparison of presentation of lung cancer and treatment modality in the Regional Cancer Centre, Trivandrum during 1994-1998 versus 2010-2014

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According to our hospital data, the most common histology was adenocarcinoma (28.5%) followed by squamous cell carcinoma (12.9%). According to a study done in a center in Northeast India, 49.1% of lung cancers presented to them were squamous cell carcinoma,[10] while in another two centers located in the northern and western India, the predominant cases were adenocarcinoma, which constituted 39% and 43.8% of lung cancers, respectively.[14],[15] Now, worldwide, there is an epidemiologic shift in lung cancer with adenocarcinoma incidence surpassing that of squamous cell carcinoma.[16] Reports from the USA showed that 80% of lung cancers are nonsmall cell type and 20% are small cell type. Among nonsmall cell types, 60% are adenocarcinoma while 20% are squamous cell type.[17]

Regarding treatment methods, the percentage of patients undergoing surgery remained dismally low and changed very little in the two time periods (1.6% and 1.7%, respectively) (unpublished reports). Some of the reasons are poor general conditions of the patient and the lack of fitness for a major thoracic procedure because of pulmonary and other morbidities. Underutilization of curative resection is a serious problem worldwide. In a major center in North India, only 14 of 104 potentially curable patients have undergone curative resection.[18] Even in the USA, there is significant underutilization of surgery in a certain underprivileged group of people and resultant increased mortality.[19] In our center, there was a reduction in the percentage of patients who received radiotherapy, i.e., (from 69.2% to 48.4%) and a significant increase in the percentage of patients receiving chemotherapy (from 16.8% to 49.6%) owing to latest developments in systemic therapy for lung cancers.

Even after the lung cancer being referred to a tertiary cancer center, there are issues such as lack of expert help in thoracic oncology and the upstaging of lung cancers due to lack of metabolic imaging and surgical staging. Whenever cross-sectional imaging is done, it may show many lymph nodes in mediastinum, which may be considered metastatic, and this has resulted in upstaging cancer and patient getting palliative chemotherapy. Many disease processes such as tuberculosis and sarcoidosis have high standardized uptake values making it not much useful in countries where such diseases are highly prevalent.[20] Even if metabolic imaging is positive, the mediastinal lymph nodes should be evaluated by surgical staging (mediastinoscopy). Invasive staging of mediastinal adenopathy was traditionally done by mediastinoscopy, but recent developments in this area are endobronchial and esophageal endoscopic ultrasound. Now, there is evidence to show that these two modalities are equivocal in diagnostic accuracy.[21],[22] Very few centers in India have dedicated thoracic oncology facilities and such accessories in place to deal with doubtful mediastinal adenopathy.

A significant number of lung cancers, even if they present early, may not receive curative surgical treatment owing to poor patient factors. The reasons are mainly two: many of the etiologic factors of lung cancer such as smoking also cause significant damage to lung parenchyma, which itself will make a patient an unsuitable candidate for undergoing a major parenchymal resection, and postoperative lung function is an important factor in deciding the morbidity and survival of patients.

The reports from various PBCRs and HBCRs show an increase in the rate of lung cancer. On the contrary, in the USA, according to SEER data, the lung cancer incidence is decreasing by 1.8%, and the mortality is decreasing by 2.2% per year.[23] Conversely, Indian lung cancer patients have lower survival. According to one study from South India, 30-month survival for patients with lung cancer was 41.2%.[24]

 » Conclusion Top

Lung cancer is the major cancer affecting males in India. The incidence is very high in the South Indian state, Kerala. Because of the high prevalence of tuberculosis, the disease presents very late for treatment. The percentage of patients receiving curative treatment is dismally low. The reasons are delayed diagnosis, comorbidities of patients, and lack of thoracic oncology facilities in the state. It is of utmost importance that we should give more thrust for evaluating patients with chest symptoms for ruling out lung cancer and improve thoracic oncology facilities.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer; 2013.  Back to cited text no. 1
Takiar R, Nadayil D, Nandakumar A. Projections of number of cancer cases in India (2010-2020) by cancer groups. Asian Pac J Cancer Prev 2010;11:1045-9.  Back to cited text no. 2
NCRP (National Cancer Registry Programme). Three Year Report of the Population Based Cancer Registries 2012-2014: Report of 27 PBCRs. Bangalore, India: Indian Council Medical Research; 2016.  Back to cited text no. 3
HBCR. 30 Year Consolidated Hospital Based Cancer Registry Report (1981-2011). Regional Cancer Centre, Thiruvananthapuram, Kerala, India; 2012.  Back to cited text no. 4
Annual Report HBCR. Hospital Based Cancer Registry Report (2013). Regional Cancer Centre, Thiruvananthapuram, Kerala, India; 2015.  Back to cited text no. 5
Bhaskarapillai B, Kumar SS, Balasubramanian S. Lung cancer in Malabar cancer center in Kerala – A descriptive analysis. Asian Pac J Cancer Prev 2012;13:4639-43.  Back to cited text no. 6
Subbaraman R, Nathavitharana RR, Satyanarayana S, Pai M, Thomas BE, Chadha VK, et al. The tuberculosis cascade of care in India's public sector: A systematic review and meta-analysis. PLoS Med 2016;13:e1002149.  Back to cited text no. 7
Singh VK, Chandra S, Kumar S, Pangtey G, Mohan A, Guleria R. A common medical error: Lung cancer misdiagnosed as sputum negative tuberculosis. Asian Pac J Cancer Prev 2009;10:335-8.  Back to cited text no. 8
Ramachandran K, Thankagunam B, Karuppusami R, Christopher DJ. Physician related delays in the diagnosis of lung cancer in India. J Clin Diagn Res 2016;10:OC05-8.  Back to cited text no. 9
Mandal SK, Singh TT, Sharma TD, Amrithalingam V. Clinico-pathology of lung cancer in a regional cancer center in Northeastern India. Asian Pac J Cancer Prev 2013;14:7277-81.  Back to cited text no. 10
Hong S, Mok Y, Jeon C, Jee SH, Samet JM. Tuberculosis, smoking and risk for lung cancer incidence and mortality. Int J Cancer 2016;139:2447-55.  Back to cited text no. 11
Cheng MP, Abou Chakra CN, Yansouni CP, Cnossen S, Shrier I, Menzies D, et al. Risk of active tuberculosis in patients with cancer: A systematic review and meta-analysis. Clin Infect Dis 2016. pii: Ciw838.  Back to cited text no. 12
Seo GH, Kim MJ, Seo S, Hwang B, Lee E, Yun Y, et al. Cancer-specific incidence rates of tuberculosis: A 5-year nationwide population-based study in a country with an intermediate tuberculosis burden. Medicine (Baltimore) 2016;95:e4919.  Back to cited text no. 13
Noronha V, Dikshit R, Raut N, Joshi A, Pramesh CS, George K, et al. Epidemiology of lung cancer in India: Focus on the differences between non-smokers and smokers: A single-centre experience. Indian J Cancer 2012;49:74-81.  Back to cited text no. 14
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Malik PS, Sharma MC, Mohanti BK, Shukla NK, Deo S, Mohan A, et al. Clinico-pathological profile of lung cancer at AIIMS: A changing paradigm in India. Asian Pac J Cancer Prev 2013;14:489-94.  Back to cited text no. 15
Devesa SS, Bray F, Vizcaino AP, Parkin DM. International lung cancer trends by histologic type: Male: Female differences diminishing and adenocarcinoma rates rising. Int J Cancer 2005;117:294-9.  Back to cited text no. 16
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Esnaola NF, Gebregziabher M, Knott K, Finney C, Silvestri GA, Reed CE, et al. Underuse of surgical resection for localized, non-small cell lung cancer among whites and African Americans in South Carolina. Ann Thorac Surg 2008;86:220-6.  Back to cited text no. 19
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