The National Cancer Registry Programme (NCRP) of India released its latest data on cancer. They represent a massive and impressive effort to gather the best data on new cases of cancer, and their survival and death rates. The authors have reported the results in detail. I briefly touch on an issue not covered in the report i.e. the implications of the report on prevention.

There are many ways to define prevention. Here, I refer to primary prevention as actions taken by health authorities and individuals to address behaviors and actions known to cause cancer. Tobacco use is a leading cause of cancer globally and in India.

In India, rates of lung and oral cancers – including mouth, tongue, and esophageal cancer – are particularly high with the NCRP data finding that among men, the lungs, mouth, and esophagus ranked in the top three in terms of new cases detected each year.

Secondary prevention is particularly important for cancers that can be detected and treated early in the stage of their development. Of note, clear examples include breast and cervical cancers. Among women, rates of breast, cervical, and ovarian cancer are also relatively high with the NCRP data finding them rounding out the top three – just ahead of lung cancer– in terms of new cases detected each year.

The cancer statistics are a mirror that reflect weak tobacco control and poor access to primary healthcare, especially for women.

Our recent report on tobacco use in India shows that smokeless tobacco use among women is particularly high with nearly 60 million report using smokeless tobacco with few having access to robust tobacco cessation support. More broadly, our report also shows that India has some of the highest rates of tobacco use in the world with India being home to a majority of all oral cancers globally. Various forms of tobacco use are responsible for an estimated 27% of all cancers in India in 2020.

The NCRP data confirm the importance of tobacco use but do not provide needed guidance to policy makers about the types of tobacco used across India and their specific impacts on cancers. Researchers have identified the relationship between many forms of toxic smokeless tobacco products used in India and the exceptionally high rates of oral cancer for well over a century (see textbox below). Further, the authors do not mention beedis at any point despite their impact on many forms of cancer and other diseases. Nearly 72 million adults report using beedis.

The prevalence of oral cancer in India is exceptionally high and has been so for well over a century. In the late 1890s, Dr. Charles Bentall studied over 1,700 malignant cases across fifteen hospitals of the London Missionary Society centered around Travancore (present-day Kerala). He found that over a third of all oral cancers were on the lining of the cheek and most of the remainder were of the lips, tongue and jaw. Those numbers far exceeded the prevalence of such cancers in Britain. Dr. Bentall immediately suspected that the popularity of the betel quid – a combination of areca nut, betel leaf, slaked lime and tobacco leaf, usually soaked in jaggery syrup – as a potential cause. He reported the use of betel quid as being “almost universal” in Southern India and used to help users “work hard all day without food.” Sadly, many of the same problems persist till today.

More effective tobacco control well adapted to the reality of products used and the socio, cultural and gender dimensions of their use are needed if the extremely high toll of death and disease is to be tackled.

The high incidence and mortality caused by cancer of cervix should motivate policy makers to accelerate access to effective vaccines. The HPV vaccine is being introduced into national vaccine programs globally with a focus on reaching young girls. WHO recommends HPV be administered to all girls between the ages of 9 and 13. However implementation through the public health service in India has been limited. It could well cut future deaths and disease from cervical and several other cancers among women, especially the poorest.

For several types of cancers, early screening makes a big difference to survival. The NCRP show that a third of the new cases of breast and cervical cancer are detected when they are still local. At that stage, 5-year survival (based on US data) is greater than 95% at 5 years follow-up. In the USA, two thirds of the women with these cancers are detected early. It would be valuable for NCRP to indicate how women’s access to screening and their general access to primary healthcare are related. It is likely that this data reflects gaps in access to both across the country.

For lung cancer, 85% of new cases are detected after they have spread locally or metastasized widely, and for oral cancer, the figure is 70%. Both figures are not significantly different from those seen in the USA. Survival at this stage is extremely poor with current diagnostic methods. The implications of this are that if we are to address these very large groups of cancer, we need to double down on primary prevention – ending smoking and toxic smokeless tobacco use, and invest in far better ways to diagnose lung and oral cancer at a stage when treatment can improve survival and quality of life.

The NCRP data is a call to urgent action for better tobacco control adapted to India’s needs; enhanced access to healthcare and screening for women; provision of HPV vaccine to girls; and research to get more effective diagnostics with a focus on oral cancer being some pragmatic ways to naturally build on this report.

Derek Yach is President, Foundation For A Smoke Free World, USA.