India faces a massive and rapidly growing cancer crisis. Projections indicate India’s cancer cases will reach nearly 1.6 million annually, with one in nine Indians developing cancer in their lifetime.

When cancer data was collected worldwide, it was discovered that more women than men were affected by this dreadful disease. Also, more women than men died because of the disease. However, the strike rate of cancer in India is puzzlingly different. More women than men are affected, but more men die because of cancer.

Cancer is one of the most feared diseases. A confirmed cancer diagnosis gives a mental shock to the affected person. Cancer affects the middle-aged (45-69 years) and the elderly (above 70 years) more than the children (below 15 years) and those in the reproductive period (15-45 years) of their life. However, the trend is undergoing a slow change, and those in their 30s and 40s are also being affected.

How Big is the Problem?

India operates 350 cancer registries, with 48 of them actively tracking the number of cases in all geographical regions. The last large sampling was done in 2022. Yearly estimates stagewise are also made available. Due to underreporting, actual figures may be higher.

• In 2022, for every 1 lakh people of the world, 197 were diagnosed with cancer. Men outnumbered women – for every 212 cases in men, 186 cases were reported in women.
• India ranks 3^rd in absolute number of cancer cases after China and the US. In India, 0.7 million new cases of cancer are reported every year. As per estimates, 2.5 million cancer patients are present at any point of time. Worldwide, more men than women suffer from cancer. And more men than women die from cancer.
• It ranks 2^nd for cancer-related deaths after China. 0.7 to 0.8 million Indians die every year due to this scourge, forming over 10% of deaths worldwide.
• 70% of all cancer deaths occur in people above 30 years of age.
• In the year 2022, 104 per lakh women suffered from cancer as compared to 95.1 per lakh men.
• Annually, men accounted for 55% of total cancer deaths as compared to women who accounted for 45%.
• Hence the paradox- in India, more women are affected by cancer, but more men die because of it.

Five Common Cancers in Indian Men

• Oral cancer and Throat cancer. Chewing tobacco in the form of gutka, khaini, naswar, advertised as flavoured elaychi or pan masala, is the Number 1 cause. Other causes are excessive alcohol consumption, poor oral hygiene, ill-fitting dentures and HPV. Forms 15% to 16% of all cancer cases in men.
• Lung cancer. This is primarily due to smoking. Other causes are high air pollution, exposure to industrial toxins at work like asbestos, radon and some rarer ones. Persons suffering from chronic lung diseases like COPD (chronic obstructive pulmonary disease) may also develop this malady. Contributes to 10% of cases.
• Stomach cancer. Apart from alcohol and tobacco, diet also plays a role in stomach cancer. A high-salt diet, especially with processed and smoked foods, is another cause. Bacterial infection by H.Pylori and acid reflux leading to gastritis are other causes. Contribute to 10% of cancer cases in men.
• Colorectal cancer. This cancer is being seen much more commonly in the last 2 decades. Unfortunately, it is being seen in the younger population of the reproductive age group when sufferers are prime breadwinners, often having family responsibility. Poor diet with low fibre, high saturated fats, and ultra-processed foods, especially processed red meat, is one cause. Sedentary lifestyle, chronic diseases of the gut and those with a genetic predisposition are also candidates for this cancer. Contribute to 8% of cancer cases in men.
• Oesophageal cancer. The food tube leading from the throat to the stomach becomes cancerous in those drinking very hot beverages, drinking excess alcohol or tobacco or having some deficiency in diet.

Prostate cancer is added as this is the 2^nd most common cancer in men who cross the age of 50. Fortunately, deaths due to prostate cancers are not huge as compared to other cancers noted above, especially if diagnosed earlier. Screening with a yearly blood test (PSA) after 50 years of age can help detect the disease.

Five Common Cancers in Indian Women

• Breast cancer. The number one cancer in women affects more women living in urban areas as compared to rural women. This is because of numerous risk factors like delayed pregnancy, shorter period of breastfeeding, late menopause, obesity and alcohol consumption. Some women in both urban and rural areas have a genetic predisposition to develop breast cancer.
• Cervical cancer. Another common cancer among women. This occurs mostly in women of lower socioeconomic strata; some have low genital hygiene and get married early. Multiple pregnancies are another reason. Untreated infection with Human Papillomavirus (HPV) is a common causative factor in most. Mass immunisation with HPV vaccine may, hopefully, reduce the incidence of this cancer.
• Ovarian cancer. The two ovaries of women, which lie deep in the lower abdomen, may get cancerous. The high death rate is the absence of noticeable symptoms till it is too late. It affects those women who never become pregnant and those with a family history. Tobacco, alcohol and hormone replacement therapy are also implicated.
• Oral cavity cancer. Causative factors are similar to those noted above for males.
• Lung and Stomach cancer are jointly at number five. The causative factors are the same in these two cancers as in men. Women working in kitchens with wood/ coal-based fires are at high risk of lung cancer due to the smoke.

Regional Disparities of Cancer

India is a country with the largest population in the world. Geographically, it has people living in regions with plains, mountains, deserts, forests and seacoasts. People have different languages, cultures, religions, and traditional food and other habits. People living in cities may have evolved differently over a period of time, but the 70% rural population of India has its own identity in each region/ state. This is the reason why certain states have higher cancer rates of certain organs than others. The total number of cancer cases may be more in larger states, but cancer rates may be higher in smaller states as well. Care will also be taken to exclude places like Delhi where people from other states come for treatment and may be registered here.

Why More Women Have High Cancer Rates than Men

Most of the cancers occur in the elderly, followed by the middle-aged group. With better medical facilities, maternal deaths during childbirth have declined considerably. Further, better facilities for the elderly have increased life expectancy of both sexes. With more people in these age groups, more cancers are being reported. Below are the reasons why more women suffer from cancer than men:

• Female anatomy and hormones. As compared to males, females have ovaries, cervix and breasts, all of which fall prey to cancer. Similarly, they have additional hormones which fluctuate when they start menstruation, are pregnant, during delivery, as well as when they are in menopause. Those not having children or those who do not breastfeed are more prone to cancers.
• Lifestyle changes. Like men, some women indulge in tobacco abuse. A diet high in simple carbohydrates, saturated fats, and ultra-processed foods causes obesity and cancers.
• Indoor pollution. Smoke-filled kitchens, especially in rural areas and urban slums is a common sight. This is an important reason why Indian women have such high cancer rates.
• Poor genital hygiene. Till a few years ago, sanitary pads were considered a luxury in poor households. Add to it a common community toilet, and genital hygiene was quite poor, leading to a high rate of cervical cancer.

Reasons Why More Men Die from Cancer than Women

World over, except in India, more women die than men due to cancers. But it is the opposite in India, where more men die than women. Let’s see why.

• Masculinity. Men in India are expected to be masculine. They usually do not like to show themselves as being weak. Hence, they hide their sickness and do not seek medical attention.
• Fear of loss of job. Men don’t take sick leave often (for diagnoses/ treatment), nor do they report their illness.
• Poor lifestyle-related cancers. Tobacco and alcohol are the cause of 46% of cancers in men. To avoid feeling guilty, men delay seeking treatment till it is too late.
• Most cancers in men pertain to oral cavity, throat, oesophagus and lungs. These cancers are aggressive (fast-growing) and diagnosed late. Hence, lower survival rate.
• Almost no free screening facility for cancers for men (especially in rural areas/ slums) as compared to women who have screening camps for breast as well as cervical cancers.

Despite the above, cancer deaths in Indian women are rising faster than in men and may soon catch up.

States with More Cancers View Traditional and Environmental Conditions

In the write-up below, states of Karnataka, Tamil Nadu and Union territories like Delhi and Chandigarh are excluded because of higher literacy, public awareness, cancer screening or patients coming for better treatment from other states. Kerala, however, has been retained.

1. Mizoram. The state with the highest per capita cancer disease as well as death rate, more than twice the average. Why? Mizoram has a liquor ban, so one important risk factor is missing. See below for some unusual risk factors:

• Diet. Their traditional diet includes excessive eating of pork, for which the pork fat and meat is smoked during cooking. Eating food prepared by smoking/ burning over charcoal regularly has a strong link to cancers of the stomach and oesophagus.
• Tobacco and raw betel nut. Tobacco is used for smoking as well as chewing with betel nut- kwai by both men and women in Mizoram. Thus, Mizos have high rates of cancers of head and neck (including oral), stomach, oesophagus and lungs.
• Genetic predisposition. Mizoram is a state with a small population. A distinct social feature is not getting married outside of Mizo family lines. This inter-community marriage creates a smaller genetic pool with higher hereditary risk of passing defective genes.

Remotely located, it also underwent a period of militancy; hence, the health infrastructure was limited. A cancer research centre and hospital by the government is likely to be set up in the near future.

2. Kashmir. The per capita rate of stomach & oesophagus cancer in Kashmir is 3 to 6 times higher than the national average. Let’s see the unique risk factors:

• Food and beverage. Kashmiris are fond of traditional noon chai, a specially brewed tea with high salt content. Fresh fruits and vegetables are practically absent in long winters. Their meals contain more red meat and less dietary fibre. Most meals are cooked with excess salt. Smoked and dried foods, Hokh Syun, are consumed in winters when fresh foods/ vegetables are not available. High salt content, fungal contamination during long months of preservation and use give rise to chemical intake in the body. All the above reasons contribute to a high incidence of cancers of the stomach, head and neck and oesophagus.
• Smoke. Tobacco smoke is inhaled from Hookah and cigarettes. Indoor smoke due to burning firewood or charcoal for warming house in winters also exposes the inhabitants to chemical gases. Both factors combined increase the risk of lung cancer in both sexes.
• Genetic susceptibility. Like the Mizos, Kashmiris also have a close social community for marriages, and this also increases the risk of certain cancers.

Not listing here other risk factors, especially for women, which are seen commonly in other parts of the country.

Kashmir also had a high incidence of Kangri cancer. Kashmiris stayed warm with an earthen pot containing fire, next to their lower abdomen and thighs. Over a period of time, this caused a skin cancer called Kangri cancer. With health education and the use of indoor electrical heating appliances, this cancer is on the decline. A study revealed that Kangri cancer patients had a history of using a kangri for 5-6 hours a day, 3-4 months a year.

3. States with high cancer rates linked to pesticides. 

The following states (or regions in these states) have been linked to high cancer rates:

• Punjab. The Malwa region of Punjab produces cotton. This small region accounts for 70% of pesticide usage. The runoff water from the fields has contaminated the groundwater, which is also used for drinking. High incidence of cancers of ovary, breast and lymphoid tissues has been reported. A train carrying cancer patients to the nearest hospitals is notoriously called the Cancer Express.
• Haryana. The harit or green state produces large quantities of basmati rice for export, vegetables for self and NCR and cotton. For all these crops, farmers use massive amounts of chemicals/ pesticides. No wonder the state has high cancer rates of the breast and reproductive system.
• Himachal Pradesh. Earlier famous only for apples, Himachal is now growing and selling/ exporting large amounts of other fruits too. These are plums, cherries, apricots, peaches and mangoes. In the past decade, exotic fruits have also been grown and sold in other states. These are pears, kiwis and persimmon. Spraying of hazardous pesticides has resulted in the highest growth rate of cancers amongst the states (2.2%).           
• Kerala has the highest cancer rates, and Maharashtra has the greatest number of cancer cases in India. Even if their population and better reporting are considered, high cancer cases have been reported. Many cases of neurotoxicity are also detected in high numbers in both states. Most cases of cancer and neurotoxicity are linked to pesticides as well as chemicals used for crops like cotton and sugarcane in Maharashtra and plantation crops/ spices and paddy.
• People of the Saurashtra region of Gujarat have high cancer rates of the gall bladder and gastrointestinal tract. The habit of eating very spicy food cooked with a liberal dose of oil is implicated in the causation of these cancers.

Most polluted metros like Delhi NCR and Greater Mumbai and many industrial towns have high air pollution. Lung cancer rates are rising in these states besides other respiratory diseases. Catechu or katha consumed in excess with tobacco in paan acts as a catalyst in producing cancer-causing chemicals. Used without tobacco, catechu is used as a medicine in Ayurveda.

India requires a comprehensive approach that combines multi-disciplinary medical treatment with government financial assistance and holistic post-cancer rehabilitation.

Title Image Courtesy: Mint

Disclaimer: The views and opinions expressed by the author do not necessarily reflect those of the Government of India or the Defence Research and Studies.