Dr. Dharmakanta Kumbhakar (The writer can be reached at drkdharmakanta@yahoo.com)
According to a latest report of the Indian Council of Medical Research (ICMR), the north-eastern part of India is witnessing an alarming rise in the number of cancer patients in recent years. As per that report, the Northeast India has the highest incidence of cancer in the country. While the national average of reported cancer incidences is 80-110 cases per lakh population, this number varies between 150 and 200 cases per lakh in the Northeast (NE). With cancer incidence rates at double the national average, calling Northeast India 'the cancer capital' is no longer an exaggeration. The Northeast India is emerging as the cancer hub. The lifestyle-related cancers top the chart in the NE region which has an overall high incidence of cancer in India. Data from different population based cancer registries in the country show that the most common cancers in men are that of the lung, mouth, oesophagus, stomach and nasopharynx, while the most common cancers in women are that of breast, cervix, uterus, oesophagus and lung within this regional belt. All these cancers are linked to extremely high lifestyle-related risk factors. As per a recent report compiled by the National Centre for Disease Informatics and Research under the ICMR, oesophageal cancer is the highest in men followed by cancers of lung and stomach in Northeast India. Together, they form 33.5% of all cancers in the NE among men. In women, breast cancer is the highest followed by cervix and oesophageal cancer. Together, they form 33.8% of all cancers in the NE among women.
Within the north-eastern part of India, the highest rate of cancer affected people has been seen in Mizoram comprising 168.2 men and 149.5 women per 100,000 populations. Within NE regional belt, the cancer incidence rate in men is the highest in Aizawl district of Mizoram (270.7 per 100,000 populations) followed by East Khasi Hills of Meghalaya (218.3 per 100,000 populations) and in women is the highest in Papaumpare district of Arunachal Pradesh (230.4 per 100,000 populations). Assam is also witnessing an alarming rise in the number of lifestyle-related cancers patients in recent years. Over 20,000 new cancer patients are being diagnosed every year in Assam. As per the State Government, over 90,000 cancer patients were detected during the last five years in Assam. Out of these, 86,405 cancer patients were registered with the Dr. B. Barooah Cancer Institute alone. As per a report, the estimated cancer patients in all anatomical sites and both sexes in Assam were 24846 (2011), 25119 (2012), 30775 (2013), 31124 (2014), 31474 (2015), 31124 (2016), 31474 (2017) and 31124 (2018). The report recorded 10932 (2011), 11052 (2012), 15677 (2013), 15853 (2014), 31124 (2015), 31474 (2016), 31124 (2017) and 16029 (2018) deaths in Assam due to cancer. As per the latest report by the ICMR, Assam's Kamrup (Metro) district has the fourth highest incidence of cancer in the country (206 per 100,000 people) in men and the third highest in women (165/100,000).
There are certain lifestyle choices including local addictive habits and dietary habits that definitely play a role in the increased incidence of cancer in Northeast India. Excessive tobacco consumption either in smoking (cigarette, bidi, hookah, etc) and/or smokeless forms (guthka, khaini, panmasala, etc.), the later being more common, stands out as a common lifestyle trait in NE states. Six NE states – Mizoram, Meghalaya, Manipur, Nagaland, Tripura and Assam – are among the top states for the consumption of tobacco in any form in India. According to the National Family Health Survey, about 70 per cent of people in NE consume tobacco which is 26 per cent higher than the national average. The highest tobacco-consuming state is Mizoram. Global Adult Tobacco Survey 2017 also shows a rise in tobacco use in Assam, Tripura, and Manipur. Smoking tobacco is responsible for cancer of lung, upper respiratory tract, gastro-intestinal tract, pancreas, urinary bladder and kidney. Smokeless tobacco is an etiological factor in cancers of the mouth, lip, tongue and pharynx. In Northeast India, people mainly suffer from cancer due to tobacco. As per report, about 57 per cent of all cancers in north-eastern males and 28% of all cancers in north-eastern females are directly linked to tobacco consumption. Assam has one of the highest incidence rates of tobacco-related cancers in the country. The high incidence of oral cancer in Assam is linked to chewing tobacco. As per the Cancer Registry report, the incidence of tobacco-related cancers out of total cancer cases in male and female in selected places of Assam are: Kamrup Metro district (49.7% and 24.1%), Dibrugarh district (51.6% and 22.8%), Cachar district (46.2% and 20.6%), B Barooah Cancer Institute (56% and 25.5%).
The people in the NE region also show addictive behaviour for raw betel nuts and fermented variety of betel nuts. It is still very customary here to chew tobacco, betel nuts, and arecanuts. These contain confirmed carcinogenic substances, and contribute hugely towards the high cancer occurrence. Another risk factor for high incidence of cancer in NE region is alcohol. Most of the tribal people of NE consume alcohol regularly.
The high incidence of oesophageal cancer among north-eastern people is linked to the region's dietary habits. The north-eastern palate comprises foods high on spices and chillies (the region is famous for being a spot of origin for home grown varieties of chillies, such as bhut jolokia). People are also prone to consuming large quantities of hot beverages such as tea and coffee. These habits have been linked to high incidence rates of oesophagus cancer. A study by the Tata Memorial Hospital in Mumbai in 2009 showed that people who gulped down very hot tea (simmering temperature) were four times more prone to oesophageal cancer. Another unhealthy practice in NE is the consumption of shidol, shutki, fermented and salted dry fish. These contain high amounts of nitrosamines which cause DNA damage leading to cancer.
There is an extensive use of pesticides in tea gardens in Northeast which can lead to widespread occupational and environmental exposures. Moreover, nowadays most of the people of NE eat fruits and vegetables that are produced by extensive use of pesticides. Fifty per cent of these pesticides are found to possess carcinogenic potential.
Aside from dietary habits, high-incidences of sexually transmitted cancer types in the north-eastern region have also been linked to general lifestyle practices within the native populations. Breast cancer incidences in the region have been linked to late pregnancies and obesity. Cervical cancer incidence rates have been attributed to a lack of sexual hygiene.
Despite the heavy burden of cancer in Northeast India, the available infrastructure for cancer care is inadequate; hence, people are compelled to seek treatment outside NE. A good proportion of people from NE visit Mumbai's Tata Memorial Hospital (TMH) every year for diagnosis and treatment of cancer. Nearly 4 per cent of the cancer cases detected in TMH are in patients from the Northeast. In 2016, 1,254 out of the total 32,913 cancer cases detected in TMH were of Northeast patients. In 2015, 1,147 out of the 30,107 cancer cases were from this region. There is still an acute lack of expert oncologists and adequate treatment infrastructure – hospitals, diagnostic centres, etc. for the cancer affected people of Northeast India.
There is an urgent need to develop comprehensive cancer control program in NE region. Extensive research is needed that is focused on NE to highlight the different aspects for reducing the incidence of cancer. The State Governments and Central Government should make efforts to offer the best treatment possible to all the cancer patients of NE for free, irrespective of their socio-economic status. The data on specialized workforce should be collected and collated for the entire NE. There is an urgent need of trained personnel at the primary- and secondary-level health-care facilities who could identify risk factors, screen the patients, and guide them to the relevant facilities. Cancer treatment facilities for palliative care, radiotherapy, etc., need to be established and strengthened. Remote expert consultations are essential to facilitate the right treatment planning and delivery. There should be satellite clinics in the remote areas of NE for cancer patients who are unable to travel long distances to visit the hospital. The oncologists of NE should start going to the villages to provide treatment to cancer patients. They should provide phone or internet consultations and stay in touch with cancer patients who have returned home with prescriptions. Home Care Services as well as facilities to train the family members for taking care of terminally ill cancer patients should be launched. The NGOs should also come forward to help the cancer patients of NE region in their treatment, and by providing information and support for getting financial aids from different schemes.
Efforts toward cancer prevention will be immensely helpful to lower the burden of the disease in this part of the India. Apart from Government initiation it requires the cumulative efforts of hospitals, administrative bodies, medical organizations, NGOs and more – to impart the right awareness and lifestyle guidance. Since the problem of tobacco consumption is so deeply rooted in the NE region, tobacco control programmes need to be more aggressive. The onus on treating cancer more effectively also lies with the native population. People in NE need to adopt healthier lifestyle habits. At an individual level, people need to quit habits (smoking, chewing tobacco, consumption of betel nut and alcohol, etc), changing the food habit (reduce the consumption of extremely spicy foods and piping hot beverages and lifestyle.