The Foundation Day Lecture on “Cancer” at the inauguration of WHO-FCTC Global Hub for information on smokeless tobacco at the Institute of Cytology & Preventive Oncology (ICPO)
by Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region
13 January, 2016
Dr. Soumya Swaminathan, Director General of ICMR, Distinguished Participants, Ladies and Gentlemen,
It is a great pleasure for to be here at the Institute of Cytology & Preventive Oncology (ICPO) and I am honoured to be invited to give the Foundation Lecture on Cancer on the occasion of the launch of the WHO-Framework Convention for Tobacco Control Global Hub. I would like to thank the ICMR and the ICPO for giving me the opportunity to be here.
The word cancer is a dreaded one. But the fear becomes real only when cancer touches oneself or those close to you.
Cancer is a major cause of mortality and morbidity. Indeed it is becoming truly the “Emperor of Maladies” as aptly named by Dr Siddhartha Mukherjee in his now famous book on cancers. A recent study indicates annual burden of 14 million new cancer cases, and 8.2 million deaths every year, accounting for nearly one-sixth of the total deaths worldwide. And what is worrisome is the increasing trend of the cancer epidemic. The world is expected to see 50% increase in morbidity and 60% increase in mortality from cancers in the next 18 years. It is projected that by 2030, over 21 million people will be diagnosed with cancers annually and, of those, 13 million will die from them.
The devastating impact of cancer is felt not only by the patient, but also by the family members, co-workers and the very society in which the afflicted live. Opportunity cost on the patient and people around him, the mental stress, the high cost of care, and the overall economic loss to society are some of the collateral maladies that accompany the “emperor of maladies.”
Once cancer is diagnosed the cost of treatment often is often prohibitive. Even after that a favourable outcome is not often guaranteed. The overall economic burden from cancer to Indian society for the period between 2012 and 2030 is estimated to be in excess of US $ 250 billion, a truly significant economic burden to the country.
There are three common myths around cancers.
First, cancer is a disease of the rich. In the past, it may have been more common to see cancer patients often among the better off people, either because of their better access to diagnosis and treatment or their better knowledge about cancers. But that phenomenon is long gone. Available evidence shows that rates of cancer deaths are twice as high in the least educated as compared to the most educated in both men and women. Furthermore, evidence indicates that 60% of all new cases and 70% of cancer-related deaths will occur in low and middle income countries.
The Southeast Asia Region is going through a demographic and epidemiological transition, as well as rapid urbanisation and accelerated lifestyle changes, all of which are contributing to the growing burden of noncommunicable diseases, including cancers.
Cancer is a major cause of mortality in the SEA Region, accounting for 1 in 10 deaths. Recent studies indicate an estimated 1.7 million new cases and 1.2 million deaths a year from cancers in the SEA Region. And India alone sees more than a million new cancer cases and an estimated 680,000 deaths due to cancers. The second myth is that cancer is a disease of the elderly. Data indicate that 72% of cancer deaths occur in those aged below 70 years, the age when most are still active and economically productive. Furthermore, the trend of cancer-at-younger-age is becoming more and more common. Therefore, the premature deaths of many breadwinners will have profound economic impact on their dependents.
And the third myth is that cancer afflicts only the unlucky people whose destiny chose for them an early exit from life. And thus people have a resigned attitude towards cancer, perceiving it to be inevitable. The reality is otherwise - most cancers are preventable, detectable and treatable.
The high morbidity and mortality from cancer in our Region reflect the high exposure to many well-known risk factors. Two most common sites for cancer among men are lungs and oral cavity, while breast, cervical and colorectal cancers are the leading cancers in women. All of these cancers are closely associated with known risk factors and, in particular, to tobacco use.
Our Region carries the highest burden of oral cancer with over 95 000 oral cancer cases reported each year. Over half of these cases are attributable to tobacco use, according to the International Agency for Research on Cancer (IARC).
Tobacco use, both smoking and smokeless products, is the single most preventable cause of cancer worldwide. Nearly 35 % adults in the Region use tobacco in one form or another. Nearly 1 in 5 adults in the Region smoke. In addition, exposure to second hand smoke is alarmingly high; over 45% of adults in the Region are exposed to second hand smoke at home, and 35% at the work place.
SEA Region is the global hub of smokeless tobacco. 90% of the 300 million global smokeless tobacco users reside in this Region which is nearly 1 in 5 adults in the. And in India 33% of males and 18% of females use smokeless tobacco. Not only the high prevalence of smokeless tobacco use but the increasing trend of use by the youth is a serious concern; the future burden of cancers will rise as this population group begins to age. Already, research shows the increasing trend of oral cancers among the younger age groups. Unlike the male predominance for smoking tobacco products, chewing tobacco among women and men in our Region is not only a big problem but of equal proportion among the sexes.
Smokeless tobacco products come in many forms and there are a variety of consumption patterns. Apart from tobacco itself, there is strong association of use of betel quid with cancer of oral cavity or oropharynx, not to mention its association with hypertension, another major public health problem. We must find good public policy and adopt appropriate regulatory measures to discourage the use of betel quid, in particular, co-use with tobacco which can multiply harmful effects of each individual product.
Ladies and gentlemen,
Besides tobacco, our population in the Region are also exposed to many other carcinogens and risks.
Alcohol consumption increases risks of cancers of mouth, nasopharynx, oropharynx, larynx, oesophagus, liver, colon, rectum and female breast. Consumption of unprocessed red meat and a diet low in fibre have been associated with cancers. Similarly, links between physical inactivity and elevated risk for cancers of breast and colon is well established. Obesity, a result of poor dietary practices and physical inactivity, is a risk factor for breast and colorectal cancers. The increasing trend of obesity seems inevitable and this will, in turn, drive up the cancer rates.
Occupational carcinogens such as asbestos, aromatic amines, benzene, benzidine are serious chemical risk factors as high exposure to these in the communities are common. Similarly, exposure to carcinogens such as arsenic, air pollution, aflatoxin, polychlorinated biphenyls, radon, and heavy metals pose significant threat to population health in our Region.
Infectious agents such as helicobacter pylori, hepatitis B and C viruses, and human papilloma viruses (HPV) are causes for the major proportion of stomach, liver and cervical cancers. Human papillomavirus (HPV) infection is a well-established cause of cervical cancer and there is growing evidence of HPV also being a risk factor for other ano-genital cancers and cancers of head and neck.
The majority of cancers can be prevented by reducing exposure to risk factors. But to tackle the risks in isolation is not the proper solution. WHO calls for the ‘total risk approach’ which has been proven to be more efficient in controlling cancers and other NCDs. Risk factor reduction requires not only promotion of healthy behaviours at the individual level; even more important is the making of our physical, mental and social environment less cancer-friendly. There are many examples showing that structural changes such as fiscal policies, urban design and supportive legal environment can effectively reduce cancer risk-exposure at a collective level.
Equally crucial is investing in health systems to enable early detection and adequate continuum of care for those with the disease. Cervical cancer screening and hepatitis B vaccination are among the most cost effective cancer control interventions. However, we need a robust health system to deliver these services.
Ladies and Gentlemen,
Let me say few words on the global movement for cancer prevention and control, and what’s being done in the South-East Asia Region for the same.
In September 2011, global leaders and head of States adopted the UN Political Declaration on NCD Prevention and Control. Two years later, the World Health Assembly and UN General Assembly, in 2013, adopted the 9 global targets for NCDs to be achieved by 2025. The key global target is a 25% relative reduction in the overall premature mortality from NCDs by 2025. The Sustainable Development Goals adopted by the UN Member States last September further mainstreams NCDs in global agenda aiming for a one-third reduction of premature mortality from NCDs by the year 2030. In consonance with global efforts, the Member States of the SEA Region are also taking important steps to reduce the burden of NCDs, including cancers, and their associated risk factors.
Last year, the Sixty-eighth session of WHO Regional Committee Meeting in Dili, Timor-Leste, attended by the Health Ministers from the Member States passed two important resolutions. First, the cancer prevention and control resolution reaffirmed the commitment by Member States to increase access to early detection and treatment services, and to ensure the availability of essential medicines and related technologies. Second, the Regional Committee adopted the Dili Declaration on Tobacco Control which provides fresh impetus to the implementation of the provisions of WHO’s FCTC.
Most of the countries have completed or are at the final stages of developing multisectoral NCD Action Plans in which cancer control is an integral component. Majority of countries of the SEA Region already have national cancer control programmes in place. Cancer Registries are in place in most countries, either as hospital-based or more desirably as population-based registries. Global Adult Tobacco Surveys, Global Youth Tobacco Surveys, and comprehensive NCD Risk factors survey, like the WHO STEPS survey, have been carried out in most Member States. The local data generated by these facilitate evidence-based policy formulation and strategic planning for the implementation of measures to control and prevent cancer, and to measure the impact of interventions.
Member States are making steady progress in the strengthening of tobacco control measures within the provisions of the WHO Framework Convention on Tobacco Control (FCTC. Ten out of 11 SEA countries, have signed and ratified the WHO FCTC, and all countries have tobacco control legislations in place. Many countries have established smoke-free public places and banned tobacco product advertisements. SEA Member States are among the global front-liners in pictorial health warnings on tobacco product packages; Nepal is the world champion with 90% of package surface covered, followed by Thailand with 85%. Several Member countries have recently increased taxes on tobacco products as there is well established evidence that high taxes reduce demand.
Ladies and Gentlemen,
While Member States have made significant progress in cancer control, much more remains to be done.
Effective cancer control requires comprehensive national policies and programmes with adequate resource allocation for universal access to the whole continuum of services and care - from prevention, diagnosis, treatment to palliative care. I would like to highlight three major challenges in cancer prevention and control in the Region.
First, cancer control is hindered by the lack of effective policy and programmes to address carcinogens at the population level and further hampered by poor enforcement of tobacco, alcohol, and food legislations.
Second, we need to invest more to build a robust health system. At the moment, the availability of screening and diagnostic services for cancer, and competent human resources, particularly at primary health care level, is generally limited in our Region. The lack of effective preventive, early detection and treatment services result in the majority of patients unnecessarily presenting at a late stage of the disease and usually with complications. This results in enormous suffering for the patients and their families, high cancer fatality and high financial.
Third, hospital facilities cannot match with the increase in cancer patients. Therefore, community-based and home-based care for cancer patients are important in the long run, including availability of potent pain killers for end-stage palliative care.
Given the above challenges, tackling cancer comprehensively requires addressing the underlying social determinants, risk factors and health system strengthening. Above all, continuing political commitment and multisectoral collaboration for cancer prevention and control is vital for success.
We at WHO stand ready to provide technical and other support to our Member States for the control and prevention of cancer.
WHO is playing a leadership role in fostering partnerships, coordinating intersectoral collaboration and carrying out advocacy at the highest level. Technical support of WHO at the national level is executed in close collaboration with the ministries of health through the framework of the WHO country cooperation strategies. SEARO, with assistance of WHO collaborating Centres, provides technical support in the development of national cancer policies and strategy; setting up of cancer registries and cancer surveillance, developing training manuals; capacity building of health personnel; and monitoring and evaluation of cancer control programmes.
As we look to the future, I want to underscore the need to strengthen evidence-based prevention and control of cancer and the continuum of care while implementing programmes within the resource constraints of each country. It is important to perform locally relevant research that will assess how to scale-up and evaluate proven cost-effective interventions in resource-limited settings. It is equally important to ensure that available knowledge on cancer control is applied to the underprivileged groups as well.
Building research capacity in the Region and in countries is an important way forward for cancer control. In this context, I would like to place on record our appreciation for the excellent work of the ICPO, particularly in HPV and cervical cancer surveillance and early detection. We hope to see similar successes in the areas of smokeless tobacco as well. WHO is pleased to collaborate with ICPO in order to present a united fight against cancers and noncommunicable diseases in general. With the launch of the regional hub, ICPO is achieving an important milestone towards prevention and control of cancer, especially tobacco related cancers. I’d like to take this opportunity to wish the ICPO regional hub for information on smokeless tobacco all success.