Abstract

Introduction?Cancer continues to grow in number. Knowing the epidemiology helps in prevention and treatment. Existing hospital-based cancer registries (HBCRs) provide little data of private sector including patients for medical tourism.

Objectives?The aim of this study was to describe the distribution of cancer at a tertiary center in the private sector in North India for all cancer patients.

Materials and Methods?Cases were ascertained from the Oncology Outpatient Department of Max Super Specialty Hospital, Saket, between January 1, 2013, and December 31, 2017, and from pathology database since July 2015. They were abstracted into National Cancer Registry Program (NCRP) core pro forma. We conducted a descriptive analysis of distribution by age, gender, nationality, site, stage, and treatment.

Results?Among the 15,850 confirmed cases, 8,034 (51%) were males. Nearly 1.8% of patients were pediatric (<15>65 years). A high proportion of patients (13%) came from outside India and 27% from outside Delhi-National Capital Region. The most common cancers in males were prostate (10.9%), lung (10%), and mouth (7.6%). Stomach was the most common site of cancer in international male patients. Four of the top ten cancers in males were of the gastrointestinal tract (esophagus, stomach, colon, and rectum). The most common cancers in females were breast (37.4%), ovary (7.1%), and corpus uteri (5.6%). Tobacco-related cancers accounted for 36.9% of cancers in males and 11.3% in females. The composite stage in males was IV in 54%, followed by stage III (21%), stage II (15%), and stage I (10%). In females, stage IV was 33%, stage III was 23%, stage II was 28%, and stage I was 16%. As registry included outpatient record visits and pathology records, not all registered patients received treatment at Max Super Specialty Hospital. Overall, 49.8% of male patients and 49.7% of female patients received treatment at Max Super Specialty Hospital. Data quality metrics matched other national HBCRs.

Conclusion?We highlight the differences from other NCRP HBCRs, with prostate cancer being the top cancer in males and gastrointestinal cancers forming major proportion among all. Socioeconomic status of our patients, referral bias, and international medical tourism could be responsible.

Keywords

cancer - epidemiology - hospital-based cancer registry - India - medical tourism

Introduction

As the population grows and our lifestyle is changing, cancer continues to increase in incidence. As per the International Agency for Research on Cancer, it is estimated that one in five men and one in six women worldwide will develop cancer over the course of their lifetime and that one in eight men and one in 11 women will die from this disease.[1] Cancer incidence continues to rise in all countries, but as per GLOBOCAN 2018, Asian countries share the burden of nearly half of the new cancer cases and more than half of cancer deaths. The excess burden of deaths is thought to be because of poorer health facilities along with a higher prevalence of cancer types associated with poorer prognosis. By 2025, it is predicted that, worldwide, there will be 20 million new cancer cases, and low- and middle-income countries will share 80% of the disease burden.[2]

A national health program directed toward cancer screening, prevention, and treatment is increasingly becoming the need of the hour and cancer registries form the very basic foundation for any such endeavor. It was in June 1963 that the first cancer registry program was established in India in Mumbai,[3] but the program got the requisite boost only in 1982 when the National Cancer Registry Program (NCRP) was established. At present, there are 20 population-based cancer registries (PBCRs) along with 29 hospital-based cancer registries (HBCRs).[4] While PBCRs provide data on the magnitude, patterns, and trends of disease over time, HBCRs give a better insight regarding the diagnosis and treatment of cancer in patients along with their compliance and long-term follow-up.

Of the 17 HBCRs that were included in the most recent consolidated report of NCRP (2012?2014),[5] there were only three from North India and only one from the capital city of Delhi. This was from the Dr. B R Ambedkar Institute Rotary Cancer Hospital (BRAIRCH), New Delhi, which is representative of government sector. Private sector has been under represented in the registry data with only 4 out of 17 registries from private institutes, all of which are from southern India. Hence, there are no data on the epidemiology of patients with cancer who seek care in the private sector in North India including patients traveling from other states as well as from outside India to Delhi for medical tourism.

We hereby report the data collected at our tertiary cancer center for all cancer patients registered between 2013 and 2017.

Materials and Methods

Setting

Max Healthcare, established in 2000, is a provider of health care to Delhi-National Capital Region (NCR) and North India including cancer care. The oncology division of Max Super Specialty Hospital, Saket, located in South Delhi is one of the hospitals in this network and registers ~3,000 cancer patients per year.

Case Ascertainment and Registration

All patients visiting the Oncology Outpatient Record (OPD) of Max Cancer Centre (MCC), Saket, between January 1, 2013, and December 31, 2017, were potentially eligible, and those with cancer were included. The patients were identified using their unique patient identity number. Data were extracted prospectively from the medical record files along with OPD notes, investigation reports, treatment procedures, and discharge summaries. Since July 1, 2015, we have also ascertained cases from the pathology records to enhance the completeness of our registration. This is done by monthly review of all patients with cancer diagnosis in the pathology database, and these are then matched with those which have already been identified through the primary route of MCC OPD. Any new patients identified through this mechanism are then added to the registry database. The data so extracted were abstracted into the NCRP core pro forma. The cancer registry used the International Classification of Diseases, Tenth Revision (ICD-10) version for site classification and ICD-O-3 for histological classification to code the data. The HBCR DM software developed by the NCRP is used for online data entry.

Statistical Analysis

Data from the HBCR DM software were extracted into Microsoft Excel. We conducted a descriptive analysis of cancer distribution by age, gender, nationality, and stage. Methods of diagnosis were noted for all patients. We studied the distribution of cancer across various sites as classified in ICD-10 classification. Site of cancer as per the NCRP nomenclature was further analyzed for individual subgroups, namely, sex (male/female) and geography (native population/foreign patients). Cancers of the lip, tongue, mouth, pharynx (excluding nasopharynx), esophagus, larynx, lung, and urinary bladder were considered as sites of cancer related to tobacco use. We looked into the clinical stage and the extent of disease for all patients and the treatment modalities received.

Ethical Statements

The institutional ethics committee approved the study with reference number CRP001: NCRP Max Healthcare CT/MSSH/SKT-2/ONCO/12?10. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional) and with the Helsinki Declaration of 1964, as revised in 2013. Written informed consents of patients were taken.

Results

The total number of patients identified was 24,680 (24,069 through OPD records and additional 611 through pathology records) for the time period 2013 to 2017. Among the registered patients, 15,850 (64.2%) had cancer and 5,332 (21.6%) did not have cancer. It was not possible to be certain if the diagnosis was cancer in 3,498 (14.2%) patients due to inadequate workup or absence of documentation. This category of patients with uncertain diagnosis decreased steadily with time from 43.02% in January 2013 to 11.30% in December 2017 as our procedures of patient identification, documentation, and data quality improved. Of the 15,850 patients with confirmed cancer diagnosis, microscopic verification was done in 98.1% of male patients and 98.4% of females. The remaining patients were diagnosed mainly on radiology. The flowchart of cancer registry is depicted in [Fig. 1].

|?Fig. 1?Flowchart of cancer registry. MCC, Max Cancer Centre; NCRP, National Cancer Registry Program.|

Distribution by Sex, Age, and Geography

Of the 15,850 cases, 8,034 (51%) were males and 7,816 (49%) were females, with a male-to-female ratio of 1:0.97. The age distribution of cancers is seen in [Fig. 2]. Data analyzed by 5-year age groups showed that, among males and females, the peak incidence was seen in the age group of 60 to 64 years. Nearly 1.8% of cancer patients were pediatric (<15>65 years of age). Sixty percent of patients were from Delhi-NCR (South Delhi 38%, Southwest Delhi 14%, Gurgaon 8%, West Delhi 7%, Northwest Delhi 7%, East Delhi 5%, and others 21%), 27% from other parts of India, and 13% from outside India.

|?Fig. 2?Distribution of cancer by gender in broad age groups.|

Distribution by Site and Variation by Gender and Geography

The most common sites (organ systems) of cancer in decreasing order were digestive organs (20.7%); breast (18.9%); lip, oral cavity, and pharynx (11.8%); female genital organs (9.5%); respiratory and intrathoracic organs (9.2%); lymph, hematological, and related tissues (6.5%); male genital organs (6.2%); eye, brain, and central nervous system (4.7%); urinary tract (3.8%); melanoma of skin (2.7%); thyroid and other endocrine glands (1.9%); ill-defined, secondary, and unspecified sites (1.4%); bone and articular cartilage (1.4%); and mesothelial and soft tissue (1.3%). The breakdown of hematolymphoid malignancies consisted of non-Hodgkin lymphoma (3.1% of entire population), Hodgkin lymphoma (1.0% of entire population), leukemia (1.6% of entire population), and multiple myeloma (0.9% of entire population).

The distribution of cancer by site (organs) for males and females is displayed in [Tables 1] and [2], respectively. The most common organs for cancer in males by site were prostate (10.9%), lung (10%), and mouth (7.6%). The number of male patients with other and unspecified sites was 1.5%.

The pattern was slightly different in male patients from outside Delhi where prostate cancer ranked lower than lung cancer and mouth cancer. In male patients visiting from outside India, distribution was quite different with cancers of the stomach most commonly followed by brain and nervous system and prostate ([Table 1]). Cancers of the mouth and tongue did not rank in the top ten cancers in this subset.

The most common organs for cancer in females were breast (37.4%), ovary (7.1%), and corpus uteri (5.6%). The number of female patients with other and unspecified sites was 25 (1.9%).

Breast cancer was the most common cancer among all females irrespective of the geography. This was followed by ovary and cervix/uterus in Indian females in contrast to brain and nervous system and cervix in females visiting from outside India ([Table 2]).

The top ten cancers in males and females among the four age groups are shown in [Tables 3] and [4], respectively.

Tobacco-Related Cancers

In males, 2,964 tobacco-related cancers (TRCs) were detected, accounting for 36.9% of all cancer cases. In females, 884 TRCs were detected, accounting for 11.3% of all cancer cases. Among these cases, lung, esophagus, mouth, tongue, and urinary bladder were the top five sites, in that order ([Table 5]).

|?Fig. 1?Flowchart of cancer registry. MCC, Max Cancer Centre; NCRP, National Cancer Registry Program.|

|?Fig. 2?Distribution of cancer by gender in broad age groups.|

References

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