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ORIGINAL ARTICLE
Year : 2012  |  Volume : 8  |  Issue : 2  |  Page : 243-246

Cancer in Kashmir, India: Burden and pattern of disease


1 Department of Radiation Oncology, Regional Cancer Center, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
2 Department of Cardiovascular and Thoracic Surgery, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
3 Department of Radiological Physics, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, India

Date of Web Publication26-Jul-2012

Correspondence Address:
Malik Tariq Rasool
Room 229, Radiation Oncology, Regional Cancer Center, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar
India
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DOI: 10.4103/0973-1482.98978

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 > Abstract 

Background: Incidence and prevalence of cancers differ in different regions of the world. To study the profile of different cancers in a particular cancer belt helps to know the exact incidence of different cancers in that region and their likely etiology. The aim of this study was to analyze the incidence of different cancers in Kashmir valley.
Materials and Methods: Retrospective study of patients registered at our Regional Cancer Centre (RCC) from Jan. 2009 to Dec. 2011 was carried out. All patients were histologically proven malignancies and were referred to the RCC for proper staging and treatment. All patients were properly evaluated and treated.
Results: A total of 8648 patients were registered during this period. Esophageal cancer was the most common cancer followed by cancers of Lung, Stomach, Colorectal, Breast, Non-Hodgkin's Lymphoma, Gastro esophageal junction, Ovary, Skin, Gallbladder, Multiple Myeloma, Acute Lymphoid Leukemia, Urinary Bladder, Prostate and Hodgkin's lymphoma.
Conclusion: Pattern of malignancies in valley is different from rest of the India. Gastrointestinal malignancies are the commonest malignancies in Kashmir valley followed by lung cancer in males and breast cancer in females.

Keywords: Breast cancer, cancer epidemiology, esophageal cancer, Kashmir valley, lung cancer, risk factor


How to cite this article:
Rasool MT, Lone MM, Wani ML, Afroz F, Zaffar S, Mohib-ul Haq M. Cancer in Kashmir, India: Burden and pattern of disease. J Can Res Ther 2012;8:243-6

How to cite this URL:
Rasool MT, Lone MM, Wani ML, Afroz F, Zaffar S, Mohib-ul Haq M. Cancer in Kashmir, India: Burden and pattern of disease. J Can Res Ther [serial online] 2012 [cited 2014 Oct 31];8:243-6. Available from: http://www.cancerjournal.net/text.asp?2012/8/2/243/98978


 > Introduction Top


Cancer is one of the most dreaded diseases in the world. Of the ten million new cases diagnosed every year, more than half are from developing countries. According to the latest statistics, over 10 million people will die annuallyby the year 2020 due to cancer, and 70% of them from the developing world. The incidence of cancer is risingevery year, and thisis attributed to the changes in lifestyle and increase in life expectancy. [1],[2],[3] Cancer profile varies in different parts of the world, and an epidemiological study will help us to know about the common cancer types prevalent in particular segments of a population, and the risk factors involved. [2],[3] As per the National Cancer Registry Programme (NCRP) report, the incidence of stomach cancer is leading in Bangalore and Chennai in India, and is less common in Bhopal, Mumbai and Delhi. Similarly, cancer of the gall bladder is the leading cancer in women in Bhopal and Delhi, and is hardly seen in Chennai and Bangalore. [4] Kashmir valley is distinct from rest of India with respect to its geography, climate, dietary habits and social culture. More than 90% of the population follows theMuslim religion. As theRegional Cancer Centre (RCC) in Kashmir is the only center maintaining the cancer registry in this area for the last few years, it is worthwhile to analyze the incidence of the different types of cancers in this part of the world, which is socially and culturally different from the rest of the world.


 > Materials and Methods Top


A cross sectional study was conducted between January 1, 2009 and December 31, 2011 at our institute, which is a cancer referral center for the entire Kashmir valley,and has recently acquired the status of a regional cancer center through the National Cancer Control Program (NCCP). Also, presently it is thelargest hospital based cancer registry in Jammu and Kashmir, with a catchment of all the districts of Kashmir valley comprising of a population of around 7 million people. Only the cases histologically confirmed as cancer were included in ourstudy. Descriptive statistics was obtained from well-maintained files of patients from the Hospital Based Cancer Registry, Kashmir. Medical records of all these patients were analyzed. All patients were assigned a Regional Cancer Centre number. The history, results of physical examination and investigations were recorded for these patients. Baseline investigations like hemogram, kidney function tests, liver function tests, and radiograph chest was done in every patient. In all the patients, relevant investigations for cancer staging were performed. After proper staging, the patients were either subjected to surgery, chemotherapy and/or radiation therapy, or were put on palliative treatment depending on the individual case. In most of the cases, a combination of these modalities was used. All such patients were enrolled for this study.


 > Results Top


Out of 8648 patients who were diagnosed with cancer, 5174 (59.82%) were males and 3474 (40.17%) were females [Table 1], with a male to female ratio of 1.5:1. In both the sexes combined, cancer of esophagus was the most the common cancer, and was found in 1221 (14.11%) patients (699 males and 522 females) with a median age of 63 years for males and 60 for females [Table 2]. When analyzed separately for both the sexes, it was the most common cancer in females, and second most common cancer in men, and was only superseded by lung carcinoma in the latter. Lung cancer was observed in 903 (17.4%) male patients,with a median age of 60 years. In females, this cancer was fifth in order. Stomach cancer was recorded in 776 (9%) patients (590 males and 186 females) with a median age of 55 years for males and 60 years for females [Table 2]. Also, this was the third most common cancer in men and sixth most common in women. Colorectal carcinoma was fourth most common cancer in males, and held a third rank amongst the female population.It was found overall in 616 (7%) patients, (342 males and 274 females) with a median age of 53 years in males, and 50 years for females.
Table 1: Top 10 Cancers in Males and Females (n=8648)

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Table 2: Age Parameters of Studied Patients

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Carcinoma of the breast was second most common cancer in women and comprised of 14.6% [Table 1] of all female malignancies with a median age of 45 years [Table 2]. Non-Hodgkin's Lymphoma (NHL) was sixth and eighth most common malignancy in males and females, respectively, and was found in 397 (4.6%) patients, with a median age of 50 years for males, and 45 years in females. Carcinoma of the gastro-esophageal junction was found in 334 (4%) patients, and was the fifth common cancer in men, and was not a common cancer in women. Median age for this cancer was 60 years for males, and 61 years for females. Carcinoma of the ovary was fourth common cancer in females andwas recorded in 250 patients, and comprised of 7.2% all female cancers with a median age of 48 years. Non-melanoma skin cancer was a common cancer recorded in both the sexes, and comprised of 2.7% and 2.8% of all cancers in males and females, respectively, and was predominantly "Kangri" cancer, a peculiar cancer found in the population of the Kashmir valley. Median age for this cancer was 65 years in both the sexes. Carcinoma of the gall bladder was found in 195 (2.2%) patients with a female preponderance, and with a median age of 58 years for males, and 55 years for females. Multiple myeloma was confirmed in 182 (2%) patients, acute lymphoblastic lymphoma (ALL) in 144 (1.7%) patients, and urinary bladder carcinoma in 102 (1.2%) patients. Carcinoma prostate was found in only 99 patients, and comprised of 2% of all the male cancers; and, Hodgkin's lymphoma was seen in 88 (1%) patients with a median age of 25 for males and 55 for females.


 > Discussion Top


The incidence and pattern of cancer varies from country to country. Developed countries have a high incidence of cancer because of their diet patterns, lifestyle and affluent living conditions. Increase in the life expectancy is one of the major factors for an increased incidence of cancer. Cancer is predominantly a disease of middle and old age, although no age is immune. Genetic factors may significantly alter the cancer risk caused due to environmental exposure to genotoxins. Infection with viruses and bacteria contributes to the increased risk of cancer, especially in developing countries. Twenty five percent of cancers in the developing countries are associated with chronic infection. We observed that esophageal cancer was the most common cancer in both sexes combined, with a male to female ratio of 1.33:1, and remained the most common cancer in females and second most common in males. This cancer has a very high incidence in Kashmir valley, which is comparable to the Iranian cancer belt. [5] This is probably because of the peculiar food habits of the people of Kashmir. Most Kashmiris take hot tea called "Noon-Chai" (hot beverage boiled in samovar) both in the morning and at supper, and this has been proposed as responsible for the high incidence of thiscarcinoma in the valley. [5] Besides, hukka smoking may also be a causative factor, and is practiced commonly by both, the males and females in rural Kashmir.

This is the first study indicating that lung cancer is the most common cancer type the male population of the valley. The National Cancer Registry Programme (NCRP) of the Indian Council of Medical Research (ICMR), collected data from six different parts of the country, and reported that cancer of the trachea, bronchus and lungs was the most common type of malignancy in males in 1989 from Bombay, Delhi and Bhopal. It was the second most common cancer in Madras (Chennai) and third mostin Bangalore, and was most unusual in Barshi, a rural area. [6] Lung cancer was reported as the second most common malignancy in an earlier hospital-based study from the Kashmir Valley of the Indian subcontinent. [7] However, a recent study by Koulet al.[8] reported that Srinagar, the summer capital of Jammu and Kashmir, has the highest incidence of lung cancer among males in India.

Cancer of the stomach is also amongstthe first five cancers in the valley, with a male preponderance (Male: Female - 3.17:1). Also, the dietary factors are probably the main reason for thehigh incidence of this cancer. [5] Consumption of high salt content (including salted tea), and infection with Helicobacter pylori bacteria, may be the possible reasons for thehigh incidence of this cancer in the Kashmiri population. Carcinoma of the colo-rectum (CRC) was among the most common cancers in our series. The high incidence rate of CRC hasbeen associated with food habits and life style patterns. Further, the highest incidence rate of CRC wasobserved in the period from 1998 to 2002, in the registries from North America, Oceania, and Europe, including Eastern European countries, and the lowest incidence rates were reported from the registries of Asia, Africa and South America. These high rates in the former regions are most likely due to the increased "westernization" andobesity and physical inactivity. [9] The increasing prevalence of obesity and decreasing physical activity in many parts of the world is likely to further increase the incidence of CRC if these behaviors are not modified. It is believed that these risk factors may also have increased the incidence of adenocarcinoma of the lower esophageal tract, and the gastro-esophageal junction cancers. Moreover, there was a significant difference in the sex ratio in the gastro-esophageal junction cancers, and the male to female ratio was 5.54:1, which was significantly different from those observed for the esophageal, stomach and colorectal cancers. The cause of this difference is unknown. Thus, within the limitations of our study, we can conclude that, the malignancies of gastrointestinal tract werethe most common in the Kashmiri population. This finding is consistent with an earlier similar study by Durrani and Shah.

Carcinoma of the breast was the second most common cancer in adult females in this study. Similar incidence has been found in other cities of the country, like Delhi and Mumbai. Breast cancer is common in affluent societies having a western lifestyle. [10],[11] Male breast cancer is 100 times less frequent than the female breast cancer. [2] However, of all breast cancers, only 4% cases were seen in males. Non-Hodgkin's lymphoma was also a common cancer in our series. The high incidence of this malignancy warrants immunohistochemical analysis, and virological and genetic studies. High incidence of thistumor was also found in other metropolitan cities like Delhi, Bangalore and Chennai. [4] There is a high incidence of these tumors in the middle-east regions as well, though, the exact cause still needs to be evaluated. [12],[13] Carcinoma of the ovary was the fourth common cancer among females. However, we encountered only a small number of carcinoma cervix patients, which is the most common cancer country-wise in the Indian females. Similarly, other genital cancers, such as uterine cancer, have also shown a low incidence in ourseries. Cancer of the penis is almost non-existent in the Kashmir valley. The main reason for this is probably the fact that the majority of the population in this part of the world is Muslim, and they practice the ritual of early circumcision. [14]

Carcinoma of the skin in the form of "Kangri" cancer was a common cancer in our series. Nearly 50% of the cancers of skin were of this type. Kangri cancer is a highly aggressive tumor with a propensity for nodal metastasis. This malignancy is virtually non-existent in the rest of world. High incidence of this carcinoma is because of the chronic irritation of the skin due to the use of afire pot (Kangri), by the Kashmiri people the during winter season, [15] thus producing a premalignant lesion called erythema-ab-ignae. Cancer of the gallbladder was also found to be in high incidence in this study, especially in females. Similar incidence rates have been found in other cities of the India like Delhi. High incidence of gallbladder cancer is probably because of the high incidence of gall stones in this region. [4] Multiple myeloma, Acute Lymphoblastic Leukemia and Hodgkin's lymphoma were also commonly reported in this study. Incidence of prostatic cancer is low in our population, probably because of low the average age ofthe male population, and consistent with the data obtained from other parts of Asia.

In conclusion, the differences in the pattern of various cancers in the Kashmir valley have not been well researched, andno large population based epidemiological study has been done so far. Few studies have however suggested that the pattern of high esophageal and low cervical cancers are seen in this area due to the differences in the lifestyle and characteristic socio-cultural and religious practices of this region. Further, smoking related tumors have a high incidence in the valley, such as lung cancers. Due to increasing smoking rates in children and young adults, the incidence of such cancers may further rise in near future. Furthermore, site-specific epidemiological studies will throw a light upon the differences in the epidemiological profile, and may also suggest preventive measures in tackling such cancers.

 
 > References Top

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2.Stewart BW, Kleihues P. World cancer report. Lyon: WHO International Agency for Research on Cancer; 2003.  Back to cited text no. 2
    
3.Gaur DS, Kishore S, Harsh M, Kusum A, Bansal R. Pattern of cancers amongst patients attending Himalayan Institute of Medical Sciences, Dehradun. Indian J Pathol Microbiol 2006;49:193-8.  Back to cited text no. 3
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5.Khuroo MS, Zargar SA, Mahajan R, Banday MA. High Incidence of esophageal and gastric cancer in Kashmir in a population with special personal and dietary habits. Gut 1992;33:11-5.  Back to cited text no. 5
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6.National Cancer Registration Programme Biennial report 1988-89. An epidemiological study, Cancer Incidence. New Delhi: ICMR; 1988-1989. p. 3-42.  Back to cited text no. 6
    
7.Dhar GM, Shah GN, Nahseed B, Hafiza. Epidemiological trend in the distribution of cancer in Kashmir Valley. J Epidemiol Community Health 1993;47:290-2.  Back to cited text no. 7
    
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