Cancer mortality in India: a nationally representative survey

doi:10.1016/S0140-6736(12)60358-4

The Lancet

Volume 379, Issue 9828, 12–18 May 2012, Pages 1807-1816

https://doi.org/10.1016/S0140-6736(12)60358-4 Get rights and content

Summary

Background

The age-specific mortality rates and total deaths from specific cancers have not been documented for the various regions and subpopulations of India. We therefore assessed the cause of death in 2001–03 in homes in small areas that were chosen to be representative of all the parts of India.

Methods

At least 130 trained physicians independently assigned causes to 122 429 deaths, which occurred in 1·1 million homes in 6671 small areas that were randomly selected to be representative of all of India, based on a structured non-medical surveyor's field report.

Findings

7137 of 122 429 study deaths were due to cancer, corresponding to 556 400 national cancer deaths in India in 2010. 395 400 (71%) cancer deaths occurred in people aged 30–69 years (200 100 men and 195 300 women). At 30–69 years, the three most common fatal cancers were oral (including lip and pharynx, 45 800 [22·9%]), stomach (25 200 [12·6%]), and lung (including trachea and larynx, 22 900 [11·4%]) in men, and cervical (33 400 [17·1%]), stomach (27 500 [14·1%]), and breast (19 900 [10·2%]) in women. Tobacco-related cancers represented 42·0% (84 000) of male and 18·3% (35 700) of female cancer deaths and there were twice as many deaths from oral cancers as lung cancers. Age-standardised cancer mortality rates per 100 000 were similar in rural (men 95·6 [99% CI 89·6–101·7] and women 96·6 [90·7–102·6]) and urban areas (men 102·4 [92·7–112·1] and women 91·2 [81·9–100·5]), but varied greatly between the states, and were two times higher in the least educated than in the most educated adults (men, illiterate 106·6 [97·4–115·7] vs most educated 45·7 [37·8–53·6]; women, illiterate 106·7 [99·9–113·6] vs most educated 43·4 [30·7–56·1]). Cervical cancer was far less common in Muslim than in Hindu women (study deaths 24, age-standardised mortality ratio 0·68 [0·64–0·71] vs 340, 1·06 [1·05–1·08]).

Interpretation

Prevention of tobacco-related and cervical cancers and earlier detection of treatable cancers would reduce cancer deaths in India, particularly in the rural areas that are underserved by cancer services. The substantial variation in cancer rates in India suggests other risk factors or causative agents that remain to be discovered.

Funding

Bill & Melinda Gates Foundation and US National Institutes of Health.

Introduction

Cancer is one of the leading causes of adult deaths worldwide. In India, the International Agency for Research on Cancer estimated indirectly that about 635 000 people died from cancer in 2008, representing about 8% of all estimated global cancer deaths and about 6% of all deaths in India.¹ The absolute number of cancer deaths in India is projected to increase because of population growth and increasing life expectancy. Rates of cancer deaths are expected to rise, particularly, from increases in the age-specific cancer risks of tobacco smoking, which increase the incidence of several types of cancer.² India is a culturally diverse country, with huge regional and rural-to-urban variation in lifestyles and in age-specific adult death rates.³ Thus, understanding the geographical and social distribution of specific cancers is essential to target cancer control programmes and spur further research into the causes of cancer.

About three-quarters of Indians live in rural areas. Yet, mortality for specific cancers is estimated mostly with data from India's 24 urban population-based cancer registries, with only two registries representing rural areas.⁴ Most deaths in India (and in most low-income or middle-income countries) occur at home and without medical attention.³ Thus, alternative methods to obtain information about cancer and other deaths are necessary. Here, we assess cancer mortality in the Million Death Study (MDS), which is in progress in India and is one of the few, large, nationally representative studies of the causes of death in any low-income or middle-income country.3, 5, 6, 7 We focus on the geographical and social variation in specific cancers, and the degree to which these cancers might be avoidable by controlling their risk factors or causative agents.

Section snippets

Study design

Details of the MDS design,3, 5 assignment of the underlying causes of death, statistical methods, and preliminary results for various diseases and risk factors have been reported elsewhere.6, 7 Briefly, the Registrar General of India (RGI) divides India into 1 million small areas after each 10-year census. The RGI's Sample Registration System (SRS) randomly selected 6671 of these small areas (with about 1000 individuals per area) from the 1991 census and monitored all births and deaths in 1·1

Results

For both sexes at all ages, 122 429 deaths occurred in 2001–03 and 7137 of these were attributable to cancer (table 1). In 2010, more than 556 000 cancer deaths were estimated in India for people of all ages, and 71·1% occurred in people aged 30–69 years (table 1). Cancer deaths accounted for 8·0% of the 2·5 million total male deaths and 12·3% of the 1·6 million total female deaths at age 30–69 years (table 1). In 2010, at all ages, the rates of cancer deaths were about 59 per 100 000 for men

Discussion

The results of our nationally representative mortality survey confirm that cancer is an important cause of adult deaths in India, with more than 70% of fatal cancers occurring during the productive ages of 30–69 years. Contrary to the common perception that cancer kills urban and educated people, we noted that rates of cancer deaths were generally similar between rural and urban areas and about twice as high in the least versus the most educated. One in 22 men or women aged 30 years alive today

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^‡: Full list of the Million Death Study Collaborators is provided in the appendix p 9

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ArticlesCancer mortality in India: a nationally representative survey

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study design

Results

Discussion

Lancet

Lancet Oncol

Lancet

Lancet

Lancet

Lancet

Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008

Int J Cancer

Avoidable global cancer deaths and total deaths from smoking

Nat Rev Cancer

Causes of death in India, 2001–2003: Sample Registration System

Three-Year Report of Population Based Cancer Registries 2006–2008: Incidence and Distribution of Cancer

Prospective study of one million deaths in India: rationale, design, and validation results

PLoS Med

A nationally representative case-control study of smoking and death in India

NEJM

Technical document VII: health care professional's manual for assigning causes of death based on RHIME household reports

The ICD-10 Classification of Mental and Behavioural Disorders

Validity of verbal autopsy in determining causes of adult deaths

Indian J Public Health

Verbal autopsy of 80,000 adult deaths in Tamil Nadu, South India

BMC Public Health

World population prospects (2010 revision)

Completeness of India's sample registration system: an assessment using the general growth balance method

Popul Stud

An assessment of the completeness of death registration in India over the periods 1975–1978 and 1996–1999 under the generalized population model: an analysis based on SRS data Mumbai, India

Sample registration system statistical report 2009

Articles
Cancer mortality in India: a nationally representative survey