INCTR India Annual Report 2017

Branch: India
President: Shivraj Singh
Board Members: Hemant Malhotra
Collaborators: Biyani Girls Nursing Colleges
Country(s): India
Year Established:
Annual Report: Cancer Prevention through Education and Screening in Rajasthan, India


Cancer is a major health problem in India and is placing an enormous burden on its health care systems. The country’s statistics are sobering. The risk of cancer is constantly increasing - 1.5 million people diagnosed with cancer each year – equivalent to a cancer-related death occur every 50 seconds. In India, breast and oral cancer have become the commonest cancers, with a five-year survival rate of only 52%. The frequency of oral cancer is very high due to the cultural, ethnic, geographic factors, along with the popularity of addictive habits such as chewing betel nut and tobacco. It ranks number one in terms of incidence among men and third among women. Several factors such as tobacco and tobacco-related products, alcohol, genetic predisposition, and hormonal factors in the age of menarche and menopause are suspected to be the most important predisposing factors to breast cancer. Breast cancer is constantly increasing, with 0.15 million new cases having been diagnosed in 2016. Cervical cancer kills more than 0.27 million women every year. The Indian Council of Medical Research has estimated that India is likely to have over 1.73 million new cases of cancer and over 0.88 million deaths by 2020 due to breast, cervical and oral cancer combined. The high incidence and mortality rate of cancer is projected to cause economic losses of around 20 billion US dollars in India by the year 2030. The impact of this enormous burden on the economy dictates the need for prioritization of control measures, and studies of the cost-effectiveness of prevention and treatment.

INCTR India is located in Rajasthan, the largest state which is home to approximately 70 million people – approximately 10% of the population of India. It is also the poorest state – the majority of people (approximately 75%) live in rural and tribal regions (55, 334,062 million) and only 13,214,375 in urban areas. Since cancer prevention is almost non-existent in Rajasthan, the state government has established a public-private partnership (PPP) with INCTR India to address this unmet need.

Cancer Prevention Program in Rajasthan

The goal of this program is to develop a Cancer Prevention Program (CPP) in Rajasthan, India. Prevention, if successful, reduces the incidence of cancer, thereby reducing the need for tertiary cancer care and the morbidity and mortality associated with it. This pilot program will initially focus on education of the population regarding vaccinations against Hepatitis B and HPV; descriptions of the lifestyles and habits associated with an increased risk of cancer (e.g., tobacco use and alcohol consumption) and advice on how to live a healthier life; sensitization of the public and primary care providers to symptoms and signs that require further tests to exclude or confirm the presence of a cancer; information on where to go for such testing, and if positive, referrals made for cancer treatment. The feasibility of detecting some potential cancers (e.g., uterine cervical cancer and oral cancer) at a premalignant stage by screening individuals who are considered to be “high risk”(based on age) will be explored, in part by initiating pilot studies in order to identify problems that may arise – e.g., whether to focus more on screening camps, after appropriate education has been given to the population, or on the Primary Health Care units which might set aside a day or half day per week for cancer screening. Only high risk individuals (according to age or habits, such as tobacco use in the case of oral cancer) will be screened. In addition to identifying high risk individuals, the costs of various approaches to screening will be explored for efficacy and cost.

Prevention, unlike cancer treatment, requires no special facilities and its success is assessed by the reduction of cancer mortality in the defined population. To have an impact on populations, however, communities will require education regarding why screening is recommended and how it is done. Thus, although it causes minimal disruption of family life, successful CPPs require a large number of “educators” and persons competent to administer a vaccine or perform screening. The Rajasthan government has established 213 Primary Health Centers (PHCs) in recent years for which the government provides all infrastructure, including facilities, equipment, surgical supplies and medicines, as well as funding for 5 years. Forty-one are privately managed through a public-private partnership (PPP). Selected PHCs have committed to provide space for training educators and screeners in sufficient numbers to implement the CPP. The government has agreed to allow the active involvement of the staff of these selected PHCs to participate in this program. The staff will be trained by INCTR India and INCTR Brussels to provide relevant education and services at the time of implementation and as the program expands. Priority will be given to communities located in urban slums, rural and tribal regions, where cancer prevention, diagnosis and care are essentially non-existent.

CPP Development Process

The development of the CPP initially began by working with accredited social health activists (ASHAs) and PHCs. The ASHAs were trained in the early detection of breast, cervical and oral cancers by the Swai Man Singh (SMS) Government Hospital and Medical College in Jaipur. PHCs were selected as sites where the screening could be conducted. It soon became apparent that only a limited number of ASHAs were available and that the doctors at the selected PHCs had insufficient time to contribute to the CPP. Therefore, INCTR India began to explore alternative ways in which it could develop a CPP.

In 2016, INCTR India decided to identify nursing colleges that offered B.Sc. and M. Sc. degrees in Nursing. The Biyani Girls Nursing Colleges (BGNCs) were contacted and they agreed to allow nursing students in their final year of the B.Sc. program to spend at least one month to work on the CPP as part of their core nursing curriculum. These students were trained in the early detection of cervical, breast and oral cancers and in cancer awareness at SMS Government Hospital and Medical College in Jaipur. The students were joined by Women’s Self-Help Groups (WSHGs). In 30 days, 1,674 women were screened. The students found that among the women examined, 475 were using tobacco or tobacco-related products. Of these women, 65 showed some signs or reported symptoms suggestive of oral cancers and were referred to a PHC. Others with signs and symptoms of cervical or breast cancer were also referred to a PHC. It was considered a successful start to the CPP because large numbers of men and women in the villages participated in the overall cancer awareness program. Based upon this initial study, it was decided to expand the program to cover a much larger area of four villages in the Jaipur district.

In order to further expand the CPP, another method was tested. In early March 2018, a health camp was organized in a village near Shahpora in the Jaipur District. The Health Camp was conducted in partnership with a hospital and the Rani Ratna Kumari Foundation (RRKF), in collaboration with the Village Heads (Surpanchs) who announced the date and place where the camp would be held. The activities in this test camp focused on cancer awareness and early detection of oral, breast and cervical cancer. Six physicians from the hospital including oncologists and gynecologists examined men and women – providing them with a general “check-up” as well as a screening for specific cancers such as cervix and oral cancer and asymptomatic individuals who fulfilled the entry criteria for screening. About 700 men and women came for the health camp. It lasted longer than was scheduled and women did consent to undergo cervical cancer screening. The attendees were extremely grateful and it demonstrated that the people need help and want help. Data about the participants was not collected at this time. Subsequent to this camp, the Dana Shivam Heart & Super Specialty Hospital (DSHSSH) was selected to be a part of the CPP. A Memorandum of Understanding (MOU) has been signed by INCTR India, RRKF and DSHSSH to hold regular Health Camps in the rural regions in Rajasthan. The next Health Camp has been organized for April 15th 2018. WHSGs and Village Heads will again be involved in this and other upcoming Health Camps. The senior nursing college students will make home visits to those unable to attend the Health Camps. Standardized data collection will be collected at all future camps. An important consideration will be the amount of time hospital staff can be available to take part in these camps.

It should be born in mind, however, that a successful screening program will eventually obviate the need for the much more expensive and time-consuming treatment, particularly when the screening activities take place not far from where the people live and are provided at no cost, and if symptomatic, patients can be referred to a PHC or specialty hospital closer to home for the prompt initiation of treatment, if needed. INCTR is implementing WHO guidelines for cancer control according to WHO’s “New Guidance for Cancer Control” which emphasized early diagnosis and prompt treatment, especially for breast, cervical, colorectal and oral cancers.

CPP Objectives

The objectives of the more formal project are:
1. To reduce cancer mortality in rural populations by addressing cancers that are preventable or treated with appropriate methods if detected early (e.g., breast, cervical and oral cancers).
2. To demonstrate how cancer awareness and early detection can reduce mortality due to cancer.
3. To introduce cancer awareness in rural communities.
4. To reduce tobacco consumption in rural populations (where locally made cigarettes are predominately made and used).
5. To integrate control of women’s cancers into the existing national health system on a cost-effective and long-term sustainable basis and to provide education about healthier lifestyles for rural men and women.
6. To develop and/or utilize Women’s Self-help Groups to combat cancer and to empower women to fight against cancer.

Representatives of CPP and Roles in the Development of the CPP

Dr. Shivraj Singh
President, INCTR India
Swasthya Kalyan Bhawan
Narain Singh Road
Jaipur -302004
Rajasthan, India
Role: Facilitator for the Organization of Health Camps; Contact Person for Biyani Nursing Colleges, NGOs involved in empowering women; Specialty Hospitals and Village Heads

Dr. Hemant Malhotra
Consultant Medical Oncology and Hematology
Professor of Medicine & Head Division of Medical Oncology
SMS Govt. Medical College and Hospital
Jaipur 302004, Rajasthan, India
Role: Training of senior nursing college students in techniques for raising public awareness about cancer and early detection of selected cancers

Mr. Hemant Jha
Monitoring & Evaluation Specialist
Swasthya Kalyan Bhawan, Narain Singh Road
Jaipur, Rajasthan, India
Role: Project Director; Data Collection

Biyani Girls Nursing College
Vidhyadhar Nagar
Jaipur, Rajasthan, India

Dr Manesh Biyani
Res Director, Biyani Group of Colleges, India
Biyani Girls College (affiliated with the University of Rajasthan)

Mr Satish Gupta
Principal, Biyani School of Nursing and Paramedical Science
Jaipur, Rajasthan, India
Roles of Dr. Gupta: Project Advisor; identifying eligible nursing students to assist with the CPP.

Dana Shivam Heart and Super Specialty Hospital (Jaipur District)
Role: Provisions of expertise: highly trained physicians in a variety of disciplines, non-clinical staff, provision of care to those in need within the community; liaison for suspected cancer cases to cancer specialty hospitals.
Dr. Sunil Kumar
Director & in-charge of the hospital

Dr. Mrs. Shalini Tomar
Associate Director

Dr. Mrs. Sunita Choudhary

Dr. C. P. Suthar
Sr. Physician

Dr. Subhash Doot

Rani Ratna Kumari Foundation
Founder Trustee
Shahpura, Jaipur District
Role: to work with hospitals and village heads to arrange health camps and to assist the local communities in skill development and empowerment of women.

WHO Regional Office for South-East Asia, New Delhi, India
Dr. Gampo Dorji, Technical Officer, Non-Communicable-Diseases was nominated by the Director WHO Regional office to participate in a palliative care conference held in February, in Delhi jointly organized by INCTR India. He has indicated interest in the concept of the health camps to reach the rural and urban poor in the state of Rajasthan and plans to participate in the upcoming health camps.
Future Plans: Measuring Cx Cancer Death and Survival Rates in Assessing the Impact of the Preventive measures

While in Rajasthan, the cancer prevention program is still in its implementation phase, INCTR India has begun to collect the necessary information that will indicate how successful its programs have been in terms of increasing the survival rate. This can be measured directly, once a cancer registry has achieved sufficient size to be able to provide accurate information on mortality from Cx cancer or death from any cause. The all-cause mortality rate, which is the ratio between the mortality rate in Cx cancer and that in all women, with both measurements being made in the same geographical region, gives a measure of the fraction of deaths accounted for by Cx cancer. The size of the region may change, but so will the expected fraction of Cx cancer deaths, such that there will be a constantly increasing number of Cx cancer deaths which, if expressed as a rate, should show a trend either upwards (more deaths) or downwards (fewer deaths), although this may require large numbers of people to be included in the study. A graphic depiction will demonstrate this more clearly, as well as showing the relative importance of Cx cancer as a cause of death. If one looks, instead at mortality rates of Cx cancer alone, changes in mortality rate occurring over time will be more apparent and it can be calculated what fraction of deaths in the female population differences in through an environment in which it will eventually be able to measure the impact of its programs on cancer survival, as well as make comparison with Cx cancer deaths, in terms of the rates discussed above.
Month: 01
Year: 2017
Date of Last Report: 12/2016
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