Kerala Cancer Crusade and Cancer Literacy Mission and IRIA Preventive Radiology National Program conducted a Webinar Series on “Kerala Cancer Crusade and Cancer Literacy Mission” in association with IRIA Kerala, Swasthi Foundation and Community Oncology, Regional Cancer Centre, Journo Med. The seventh-day webinar discussed “Early Cancer Detection and Scientific Evidence for Cancer Concept.” The event was held on 21st October 2022.
Dr Rijo Mathew, President of IRIA Kerala spoke about the “Early Cancer Detection and interpreting scientific evidence for cancer control.”
Dr Krishnanda Pai, Founder of Malabar Cancer Society spoke about this program which is vigorously spread among the 13 million population. Nearly 1,20,000 volunteers have been trained across Kerala and globally. As a result, nearly 5,300 cancer cases were detected at very stages. The early detection activities when performed in rural areas gave rise to several issues initially. There was a program where high incidents of breast cancer were detected among the population. This project was enforced with nearly 7 lakh women population. The early detection camps were conducted in villages, involving women in screening. 1054 abnormalities were detected among women for whom a regular follow-up is been suggested. Comprehensive management of cancer packages has been introduced right from early detection to the rehabilitation of cancer survivors. Gross routing the awareness, a follow-up is done for early detection camps, and the treatment RCC support was given. All cancer survivors have higher follow-up and regular longevity, yoga training and necessary financial support are provided to them regularly with yearly executive health checks freely suggested for them. So, the longevity is being extended to 32 years. There are cancer survivors who die at the age of 90/91 years. Cancer survivors can have longevity of life. All these activities could be taken forward and it is very difficult to detect cancer at a very early stage. There are various reasons behind this. There can be stigma, and fear of cancer, even with excellent radiodiagnosis and committed personalities. The person need not approach the centre for the facility or take full advantage. There comes the role of the Swasthi foundation cancer literacy mission. Cancer literacy is very crucial, and the Malabar Cancer Society is fully confident that cancer literacy can cause a revolution in early detection. For the year 2019-2021, the main motto of “World Cancer Day” was “I am, and I will,” which implies community empowerment. The standard declaration of the World Health Assembly of 2018 aims for the same slogan i.e., community empowerment. The community empowerment for universal primary healthcare. For that also, empathy is given for community empowerment. So, community empowerment coupled with radio diagnostic services excellently and it definitely can lead to excellent early cancer detection. If early cancer detection is done at early stages, the treatment facilities can be augmented. In Kerala, for so many years, the incidents of cancer cases is very high, because of the role played by RCC and Malabar Cancer Society (MCI). Early cancer detection has drastically increased. Compared to other states, the incidents of cancer are very high. The facilities must be available in vast to reduce the mortality rate of cancer. Need cancer, the facilities should be augmented for mortality rate. From that perspective too, the role of early detection also remains crucial. Community empowerment and the role of radiodiagnosis have already been highlighted. The second point is the modification of the risk factors that longevity is going up, the cases are going to be increased. The modification of the risk factors delays the onset of cancers. More attention needs to be paid to the modification of risk factors and transforming the modifiable risk factors into something positive. The terms of exercise, diet control or weight reduction, will also alter the incidents of the prevalence of cancer in the state.
Dr Jayakrishnan, Additional Professor, Community Oncology, RCC, Trivandrum spoke about the marvellous work related to cancer control is concerned. It is condition par excellence. He implements cancer control programs There are more than 3 decades of experience in cancer crusade control. It is a condition par excellence. His passion to conduct public health initiatives is just marvellous. He is a hard-working person, a teacher, and as well a mentor.
Dr K Ramadas, Former Additional Director of RCC and Director of Clinical Operations and Allied Services, Karkinos spoke about the “Early Cancer Detection and Interpreting Scientific Evidence for Cancer Control. The incidence of cancer is in increase, and it is there in almost all countries. But in countries like India, most of the cases are in advanced stages. Most of the cancers were located mainly in major cities. The non-availability of the cancer centre is the main reason why people roam around. There is no culture for early detection yet. These are some of the important things that one needs to address and discuss regarding cancer control as a whole.
Top 5 Cancers in India
The Top 5 Common Cancers in India especially in Kerala. Among males, lung and oral tobacco cancers, are related to males. The cancers are oral cavity, prostate and colorectal cancers. Among females, breast cancer is leading cancer, followed by the thyroid, corpus uteri, cervix uteri and ovarian cancers. These are common cancers which are observed in our control. Observing the statistical data, breast cancer cases are the leading cases of cancer and lung cancer comes under 6th place when the incidence and the mortality rates of the cancer are taken into consideration. There are a few cancers which can be prevented and detected in the early stages. But most of them are not detected in advance at very early stages. One should approach diagnosis during stage 1 and stage 2, then only diagnosis can be performed at an early stage.
Objectives of Screening
- To detect cancer early.
- To improve treatment outcomes.
- Administer less intensive treatment.
- Decrease morbidity.
- Having a good quality of life.
- Reduce cost.
Limitations of Screening
There are Limitations to Screening.
- Implementation Cost
- Barriers to access
- Poor compliance with screening
Cancer Prevention can be divided into primary, secondary and tertiary prevention.
The risks need to be removed. For eg: Tobacco cessation, vaccination etc. which removes the risk factors.
Secondary Prevention can be done i.e., either the screening or early clinical diagnosis and ⅓ rd of cancer can be prevented and another ⅓ rd of cancer can be detected in its early stages.
Tertiary prevention discusses the actual treatment.
Early Detection Approaches
Screening: It is a systemic application of an early detection test in a systematically invited asymptomatic population to detect preclinical disease.
Early Clinical Diagnosis: Searching for early invasive cancer in symptomatic individuals in opportunistic settings. Improved awareness and access to health services promote early clinical diagnosis.
In a normal individual, application of the screening test either in the precancerous stage or in the cancerous stage or performing the early clinical diagnosis among people who are having some form of symptoms, before it reaches the advanced stages. These are the two stages where cancer can be detected at very early stages.
Principles of Population Screening
(Wilson and Jungner 1968)
Screening is performed in cases where the diseases are quite common. The screening can’t be performed for a rare disease.
- The condition should be a significant health problem.
- It should have a recognizable latent or early symptomatic stage with a long detectable preclinical phase.
- Natural history should be well understood.
- A suitable and acceptable screening test which is non-invasive is available. It is in the early stages and can be applied in the community.
- Diagnosis and treatment should reduce morbidity and mortality.
- Benefits should exceed harms.
- It should be affordable.
Cancers amenable to Screening
There are six cancers which are amenable to screening and early detection.
- Oral cancer
- Breast cancer
- Cervical cancer
- Colorectal cancer
- Prostate cancer
- Lung cancer
The screening programs can be extended to colorectal and prostate cancers.
Early Detection Tests for Oral Neoplasia
The physical (visual) examination of the oral cavity and the mouth self-examination (MSE) are the early detection tests by a health provider. These are the two easiest ways to identify the lesions. There are several other examinations like a light-based study.
- Oral exfoliative cytology
- Toluidine blue intravital staining
- Oral brush biopsy (oral CDX Brush Test)
- Chemiluminescence (Vizi Lite system)
- Tissue Fluorescence Imaging
- Tissue Fluorescence Spectroscopy
- Saliva Estimation
There are 8 steps in oral cancer screening. These eight steps examine each part of the mouth under bright light, so any change in the mouth can be detected if there is any white or red patch. If there is any ulcer, growth is moist. The ulcers may not be painful and there might be just a growth. The mouth self-examination is done by standing in front of the mirror.
Visual (physical) Examination of the Oral Cavity
It is the most widely evaluated early detection test. The examination of the oral cavity is an integral part of any physical examination i.e., whoever approaches a doctor’s examination of the oral cavity is an integral part of the clinical examination. It has got acceptable, specificity sensitivity and positivity. It is simple and affordable. The providers can be easily trained. The acceptable sensitivity is (58-94%) and the specificity is (94-99%). The positive predictive value is 10-30%. There is evidence from descriptive, observational and experimental studies. It misses cancer in apparently healthy-looking areas. The positive predictive value is 10-30%.
Lessons from Trivandrum Oral Cancer Screening Trial
It started in 1996 and continued till 2013.
Trivandrum Oral Cancer Screening Study (TOCS)
13 Panchayats are being randomized. The randomized controlled trial evaluates the efficacy of oral visual screening in reducing oral cancer mortality. (Trivandrum District, India).
The controlled panchayats are 6 and 95,358 participants participating in the panchayat. There are 7 intervention panchayats, and 96,516 participants are there. There is door-to-door identification and interview of eligible students (> 34 years, no debilitating disease). A consent form, Individual questionnaire, and Education on tobacco and alcohol health effects follow-up care are required for oral cancer, incidence and mortality. In controlled panchayats, the care is usual and when it comes to intervention panchayats, there is an inspection by a trained health worker, where the screen-positive cases are referred by inference investigations. The specific treatment is given for precancerous and cancerous cases. Three rounds of screening are done and each lasting for 3 years.
Cost Effectiveness of Visual Screening for Oral Cancer in India
In around 9 years of screening, there is a 34% reduction in the number of people who uses tobacco and alcohol. No study has shown this kind of result in the World. A positive analysis was found, spending 156 $ can save a life, which is very cost-effective in a country like India. Screening is being continued after having checked the benefit of the intervention. Also, provided the screening in the controlled group, the benefit still prevailed at 21%. So, simply examining the mouth and identifying the lesions and treating them can bring down the death rate for cancer. The benefit also increases as one increases the number of screens from 1-4.
Oral Cancer Screening
- Oral Visual Screening is a suitable screening test.
- The users of tobacco or alcohol or both are the suitable target populations for screening.
- Oral Cancers rare among non- habituees (3/100000, vs 63/ 100000 in habituees)
- Oral visual screening leads to early detection of oral cancers and reduced oral cancer mortality.
- Oral cancer screening is a cost-effective intervention.
- It is a feasible intervention that can be readily integrated into health services, but needs proper implementation with trained providers, monitoring and evaluation.
Modalities of Early Detection of Breast Cancer
To detect breast cancer lesions in early stages.
- Clinical Breast Examination (CBE)
- Magnetic Resonance Imaging (MRI)
- Fine Needle Aspiration Cytology (FNAC)
- Core Biopsy
- Triple Diagnosis
Pooled Analysis: Efficacy of Mammographic Screening
It is a pooled analysis which showed 98% mortality among the ladies between the age of 40-49 years and when the annual mammographic screening was performed before the age of 50 years. One can observe a 25% reduction in mortality. This may not be feasible right now in India. So, one has to identify it as a major issue by doing a study at Trivandrum again with the help of WHO.
Trivandrum Breast Screening Study (TBCS)
A package is provided for interventions creating breast awareness teaching them how it would be breast self-examination, offering breast clinical examination through health workers who are trained to examine the breast and if there is an issue in positive findings, it is confirmed by a doctor and later it is subjected to mammography, ultrasound and then a biopsy. So, mammography in these situations is used for diagnostic purposes. Not for primary screening and mammography were done for about 11% of the total individuals in the individual screening group. So, there is a restriction on resources. There is a difference in the survival rate. 66% in the control group and 72.9% in the intervention group. But one could not observe a reduction in mortality.
Approaches to Cervical Cancer Prevention
- Awareness, Socio-economic Development
- HPV Vaccination
- Early Clinical Diagnosis
Cervical Cancer Screening Methods
Conventional Cytology/ Liquid-based Cytology
Alternatives to Cytology
- HPV Testing
- Naked eye visual inspection with 3-5% acetic acid (VIA)
- VIA with low level (2-4x) magnification (VIAM)
- Visual inspection with Lugol’s iodine (VILI)
High sensitivity is an important requirement for early detection in low-resource settings.
- Cytology is the most widely used cervical screening test.
- It is frequently repeated. It has resulted in a considerable reduction in disease burden in developed countries.
- Implementation is challenging in low and medium-resource settings.
HPV Testing is recommended by WHO.
- It is highly objective, robust, reproducible, accurate and effective. It is the most preferred screening test, especially in the post-HPV vaccination era.
- It is recommended for women above 25 years of age and up to the age of 65 years i.e., once in 5 years.
- HPV Testing has identified lesser advanced-stage diseases and showcased a 48% of reduction in mortality using Telecommuters as a control group. The benefit was less than the other tests.
- Similar tests were performed from the same areas comparing the cytology and HPV Testing and it has been found that HPV Testing is much superior to cytology testing. The low-cost study from the Tamil Nādu, Dindigul District and the Intervention group (VIA) is found not to be as good as HPV Testing.
IARC Working Group- Findings
- Higher protection for women with two or more negative smears.
- Little difference in protection by annual screen compared to 3 yearly screens.
- Screening every 3 years could prevent 91% of incident cases.
- Screening once in 5 years could prevent 84% of incident cases.
- Risk reduction persists for 6-9 years.
- Relative protection did not appear to depend on women’s age.
- Even a single lifetime screening can reduce mortality by 33%.
- Optimum frequency controversial.
Global Elimination Targets on Cervical Cancer
Vision: A world without cervical cancer and to eliminate cervical cancer from the World at least by 2030.
Threshold: All countries to reach less than 4 cases 1,00,000 women years.
The strategy is 90-70-90. 90% of girls fully vaccinated with the HPV vaccine are by 15 years of age. 70% of women screened with a high precision test at 35 and 45 years of age and 90% of women identified with cervical disease receive treatment and care.
The age group of 9-14 must be vaccinated. With this strategy, WHS is aiming to eradicate cervical cancer. SDG 2030: Target 3.4- 30% reduction in mortality from cervical cancer.
Currently Licensed HPV Vaccines
There are four vaccines available.
- Cervarix (targets HPV 16,18)
- Gardasil (targets HPV 16,18, 6,11)
- Gardasil 9 (targets HPV 6,11, 16,18)- recently introduced in the market and it is 10,000 per dose.
- Cecolin (targets HPV 16,18)
Luckily Serum Institute has come up with an Indian Vaccine where all the testing has been done. So, it is available in the market, which is considered less expensive. WHO has prequalified.
The application submitted for WHO prequalification is currently licensed in China only. It is available in India.
So, cancer awareness screening programs can be started, and they are sent for survival.
- Lung Cancer is the most common cancer related to death worldwide.
- Lung cancer screening programs using chest radiographs (CXR) and sputum cytology began in the late 1940s.
- Low-dose computerized tomography (LDCT) is an appealing technology for lung cancer screening. It uses an average of 1.5 mSv of radiation to perform a lung scan in 15 seconds.
Low Dose CT
- Low dose CT is focused after the age of 55-74 years.
- At least a 30-pack years of smoking history.
- Currently smoke or have quit within the past 15 years.
- Relatively good health.
Should discuss include the benefits, uncertainties and harms associated with screening for lung cancer with LDCT.
Screening program at an institution with expertise in LDCT screening, with access to a multidisciplinary team skilled in the evaluation, diagnosis and treatment of abnormal lung lesions. If such a program is not available, the risks of harm due to screening may be greater than the benefits.
The incidents of colorectal cancer are going very fast. It also changes dietary habits. Because of more and more animal fat usage, colorectal cancer is on increase. It can be identified with faecal occult blood testing (FOBT) and stool DNA testing. There are flexible sigmoidoscopies and colonoscopies which can be used to detect colon cancers at an early stage. The advantage of performing the sigmoidoscopy and colonoscopy is, the polyp if removed earlier can decrease the cancerous phase.
FOBT was the first colorectal screening test studied in a prospective randomized clinical trial. It shows a 20% reduction in colon cancer incidence. The Minnesota Colon Cancer Control Study and the Faecal Immunochemical tests (FIT) are stool tests that do not react to haemoglobin in dietary products. They appear to have higher sensitivity and specificity for colorectal cancer.
- Once only flexible sigmoidoscopies-23 % reduction in colorectal cancer incidence and a 31% reduction in colorectal cancer mortality after a median of 11.2 years of follow-up.
- In the NCIS prostate, lung, colorectal and ovarian cancer screening trial (PLCO)- a 21% reduction in colorectal cancer incidence and a 26% reduction in colorectal cancer mortality with two sigmoidoscopies done 3 to 5 years apart compared to with the usual care group after a median follow-up of 11.9 years.
- In both studies, there was no effect on proximal lesions (i.e., right and transverse colon) due to the limited reach of the scope. A colonoscopy is recommended once in 10 years.
The ACS, the American College of Gastroenterology
Screening modalities be chosen based on personal preference and access. Average-risk adults should begin colorectal cancer screening at age 50 years with one of the following options.
- Annual high sensitivity FOBT or FIT.
- A flexible sigmoidoscopy every 5 years.
- A colonoscopy every 10 years.
Warning Signals of Cancer
- Abnormal bleeding
- Foul-smelling discharge per vagina
- Breast lump which increases in size
- Difficulty in eating food
- Foreign body sensation in the throat
- Painless ulceration or growth in the mouth
- Persistent cough or change in voice
- Rapidly increasing swelling in the body
- Altered bowel or bladder movements
- Changes in the pre-existing wart or mole
- Unexplained weight loss
Common Cancers and Early Detection
Types of Cancers – Screening Tests Performed for Early Cancer Detection
Breast Cancer – Clinical Breast Examination, Mammography
Cervical Cancer- HPV Test, Pap smear, Liquid-based cytology, Visual Inspection
Oral Cancer- Oral-based examination
Colorectal Cancer- Fecal Occult Blood Test, Sigmoidoscopy, Colonoscopy
Prostate Cancer- PSA (High risk only)
Lung Cancer- Low dose CT
Karkinos is the latest technology-led purpose-driven oncology platform. There’s no point in choosing new cancerous platforms. With the early cancer detection screening methodologies performed, one can detect cancer at precancerous and even at the cancerous stage and this also helps in eradicating cancer to a greater extent. Also, Kerala Cancer Crusade Literacy Mission motivates cancer screening, prevention and eradication to a major extent.