All lndia lnstitute Sffiedical Sciences

To Shri Shambhu Kumar Under Secretary to the Govt. of lndia Ministry of Health and Family Welfare PMSSY-lV Section 3'd Floor, IRCS Building, New Delhi

Sub: Matter raised by Shri Suresh Pujari, Hon'ble M.P. under rute 377 in regarding abnormal rise of cancer cases in Bargarh District of .

Ref: Ministry of Health and Family Welfare (PMSSYJV Section), Government of lndia, New Delhi letter No. H-l1014t1t201g-NCD-tl dated 21.05.20:i0 received vide e-mait dated 21.05.2020.

Sir,

I am directed to rgfer.to your tetter under reference on the above subject and to enclose the information alongwith its enclosures submitted by the Community Medicine & Family Medicine Department of AllMS, Bhubaneswar for further course of action at your end.

sffi€fq /you rs fa ithfu I !y, ,a_' eT.fi. qIfr/ (S. K. pani) Eft'Ed Inngft+. 3rfrrlt / Senior Administrative Officer w, areeefi /AllMS, Bhubaneswar Enclosures : As above Copv to:

1. PS to Director for kind information of the Director. 2. PS to MS, DD (A) & HoD CM & FM for kind Information. 3. Shri S. M. Routray,-Deputy Secretary, Ministry of Health & Family Welfare, pMSSy Division,3rd Floor, IRCS Building, Red Cross Road, New Delhi, 11d001 forinformation and necessary action. 4. Shri Jitendr3 Kumar Jangid,section Officer (PMSSY-lV)'Govt. of lndia,Ministry of Health - ?nd Family Welfare,lRCS Building,New Delhi for information and necessary action. 6' Shri Shubham Goel, Assistant Section Officer (PMSSY Division), Ministry of Health and Family Welfare, Government of lndia, Red Cross Building, Near parliament, New Delhi for information and necessary action w.r.t. e.mail dated zl.os.zozo. All lndia lnstitute of Medical Sciences, Bhubaneswar -19

Department of Community Medicine & Family Medicine

Regarding abnormal rise of cancer cases in Bargarh district of Odisha

The statement that cancer cases are occurring in excessive numbers in Bargah district of Odisha is found in the newspapers and some websites. However, the data published in scientific journals that are more reliable do not echo such gross excess of cases in the said district; An article published in International Journal of Cancer and Clinical Research on 'Cancer patterns in Odisha- An important mining state in ' in October 2019 (Page nos294-300;page297 has graph) shows that prevalence of cancer in Bargarh is on the lower side compared to other districts of the state. Bargarh has 6.2 cancer cases per lakh population and is on 23'd position in terms of prevalence. This data is from Acharya Harihara Regional Cnacer Centre (AHRCC), Cuttack which is the largest cancer hospital in Odisha.

This fact is also reflected in our own AIIMS Bhubaneswar hospital data of the past three years, which shows that cancer cases coming from Bargarh is only 50 since 2018 which is much lower than rest of the districts and is on 15th position in our list of districts.(Page no 293)

Hence, the claim that Bargarh is excessively affeeted by cancer cases is unfounded by scientific evidence available thus far. Further information may be obtained from Regional Medical Research Centre, Bhubaneswar as there were newspaper reports (if true) that ICMR had sent a team to Bargarh district to study the cancer situation there in February 2020. However, we neither have access to the report nor the data.

Dr. SortfHangma Subba Professor & Head Department of Community Medicine & Family Medicine AIIMS Bhubaneswar Odisha gm

Chatterjee et al. lnt J Cancer Clin Res 2019, 6:126 DOI: .. : Volume6llssue5 Y r*€ x r xa at** xa*$ $ <> *Nr rx a2. * { Open Access {mxxx*w ew& {Kzwb*,w,K Wg*swew{.Xz

:.: t:t I it I lV & L ft b. 5 t i.1 11 {: ?} Cancer Patterns in Odisha - An lmportant Mining State in lndia

Shormila Chotterjee, MBB$ MPH, CPHI, Poul H Levine, MA\ Surendra Nath Senopoti, MDa, Dipti R^oniSqmonta, MDs and Pinoki Panigrahi, MD, PhD6- lCenter for Global Health and Development, lJniversity of Nebrosko Medicol Center College of pubtic Heolth, Omaho, NE, USA 2Deportment of Epidemiology, lJniversity of Nebrasko Medical Center Cotlege of Public Health, Omoho, NE, USA 3Asion lnstitute of Public Heolth Bhubaneswor, Odisho, lndio 4Deportment of Rodiotion Oncology, Achoryo Horihar Regionol Concer Centre, Cuxack, Odisha, lndio sDeportment of Medical Oncology, Acharya Harihor Regionol Concer Centre, Cuttock, Odisho, tndia 6Center for Globol Health and Development, LJniversity of Nebrasko Medical Center, Coltege of public Heotth, Omoho, NE, USA *Corresponding author: Pinoki Ponigrohi, MD, PhD, Center for Gtobol Heotth and Development, College of public Health, 984385 Nebroska Medicol center omaho, NE 68198-438s, t)sA, Tet: +1402-552-6692

Abstract ant areas of research for risk factors and cancer control in Odisha. Backgrourrd: Odisha, a populous state and a major mining belt in lndia has high levels of environmental carcinogens. Keywords There is no population-based cancer registry in Odisha, Cancer registry, thus giving no opportunity to develop systematic studies on Environmental carcinogens, lndia, Risk factors, Prevalence important regional carcinogens. This paper highlights cur- rent patterns of cancer as seen at Acharya Harihar Region- Abbreviations al Cancer Centre (AHRCC), and provides the first oppor- tunity to determine the most important research questions AHRCC, Acharya Harihara Regional Cancer Centre; AlpH: that could drive cancer control programs in Odisha, Asian lnstitute of Public Health; CDC: Centers for Disease Control & Prevention; HBCR: Hospital based cancer regis- Methorls: The analysis included all patients diagnosed and lry; H. pylori: Helicobacter pylori; HPV: Human papilloma admitted with cancer at AHRCC, Cuttack, Odisha between virus; IARC: lnternational Agency for Research on Cancer; January, 1.t and December, 31"t,2012. patient data were ICD 10: International Classification of Diseases and Related extracted from inpatient records, investigation reports and Health Problems 10; ICMR: lndian Council of Medical Re- from in-patient registers and admission registers main- search; NCRP: National Cancer Registry Program; pBCR: tained by the Medical Records Department. Relevant in- Population based cancer registry; VIA: Visual inspection formation on diagnosis; primary site and demographic data with acetic acid were retrieved. Results: There were a total of 4811 patients, with a mean ,,,tr,dUell*nr rr vq age of 47.5 ! 15.5 years, 44o/o males. The most common " cancers among males were oral (14%), gastric (13%) and Cancer is the second most common fatal disease in H:: il:J3,Ji[?3'i;#ir!"Srljll;iil:l?r$:"ffi'(;ifi rnoia accounting ror about 7% or annuar deaths r1]. rhe prevalent gastric (5%)and gatt btadder (il%). Seuen fercult tf oui number of cancer cases in lndia over 5 years cancer patients were aged < 20 years. Acute lymphoblastic is estimated to be around 2.3 millions with about 1.2 leukemia, Non-Hodgkin's lymphoma, Hodgkin's lymphoma milllon new cases and 785 thousand deaths [:]. The and brairr tumors were most common in this age group' total cancer burden in lndia is projected to increase Conclusion: Findings from this study suggest that particu- substantially from about 1.2 million new cases in 2018 lar attention be given to high prevalence cancers as import to more than 1.9 million by 2O4O [3]. Recognizing the

Citation: Chatterjee S, Levine PH, Senapati 5N, Samanta DR, Panigrahi P (2019)Cancer patterns rn OcJislra ffi) - An Important Mining State in lndia. lnl i Cancer Clin Res 6:126. doi.org/IA.2.3931 j6 1237g.3419/141U:1 q,YF" Accepted: Oi:tober 1.?, 201,9; Published: Ortoirer 74, 20irg Copyright: O 2019 Chatteriee 5, et al. This is an open-access artrclc distributed uncJer the tornrs of ihr, {.u$ N,\& x.* Crealrve Commons Attribuiion License. rr.rhrch permrts unrestricted use. distribulon, and reproductron N ; ttt NA.i tt")r\iAL i"I {ttlA ir.Y in any medium, provided the original author and source are credited. DOI: 1 i).i?3937 i?-37 8 "341. 51 1 4 101 ?6 ...,,,i.|. need for active cancer surveillance and cancer control reported among gall bladder cancer patients In ln- activities in lndia, the lndian Council of Medical Re- dia [9] and this is probably due to the presence of s€-^h (ICMR) initiated the National Cancer Registry dangerously high concentrations of such metals in Programme (NCRP) with a network of cancer registries drinking water. Hence, it is extremely important to in 1981. The NCRP now comprises twenty seven Popu- understand cancer patterns in Odisha, and focus on lation-Based Cancer Registries (PBCRs) and seven Hospi- etiological factors for some of the most important tal-Based Cancer Registries (HBCRs). Published reports cancers in the region, which will help formulate prac- from these PBCRs and HBCRs have provided valuable in- tical cancer control methods. priorities for cancer research and formation for setling The Asian lnstitute of Public Health (AIPH) [1"$], situ- identified target sites - both anatomic and geographic ated in Odisha, has partnered with the Acharya Hariha- - for cancer control measures [4]. ra Regional Cancer Centre (AHRCC) [1"1], a tertiary care Cancer patterns in lndia vary widely across regions center established to provide care of cancer cases in the and have been well documented in the registries un- state, thus allowing an opportunity to begin accumulat- cancers in the region, der the NCRP [5]. Odisha, with a large population of ing data on the most important 41,947,358 has only recently been included under the The data collected may thus foster further research ef- NCRP'with a Hospital-Based Registry (HBCR) (figure 1) forts leading to improved cancer control in the state. [b]. There is no existing published report on the status This paper provides a description of the data collect- of cancer in the region, The state is in one of the largest ed in the first year of this initiative and highlights obvi- mining belts in lndia, and its population is exposed to ous opportunities for cancer control in Odisha. several mining products (asbestos, coal, cadmium, chro- Materials and lVletheds mium, iron ore, nickel, quartz) [7]. Asbestos, cadmium, chromium and nickel have been designated as class 1 Study setting carcinogens to humans by the lnternational Agency for The study was initiated at AHRCC, Cuttack in Odisha Research on Cancer [S]. Higher concentrations of heavy metals (cadmium, chromium, and lead) have been state, lndia. AHRCC established in 1983 has a total of

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I Populatiou based registry Barglorc A Hospi(xl based regislry - i- t- .ra '''.t, Y HBCR in regional crncer Al, Chennai :. ccntcrs ,. .,i!. KmohccPror -': Kollam I I.. + Purlucherry 'I$ thiruvanthapuam

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Figure 1: Showing the distribution of population based and hospital based cancer registries in lndia; HBCR at AHRCC Cuttack was set up in 2016. : I ) DO | : ll l:l):3 7 i i: :j'1 lz, -:i4 1 E I 1 4 1 * 1 il A ISSN:237&-34rr@

260 beds. Being the only regional cancer center in the 5AS program (V9.2, SAS lnstitute, Cary, NC). statp. AHRCC covers all 30 districts of Odisha state and Ethicalapproval alscTarts of neighboring states of West Bengal, Bihar, Jharkhand, Chhattisgarh and Andhra Pradesh. AHRCC is This study was approved by the Ethical Review also the seat for the HBCR which was recently set up in Boards of the AIPH and AHRCC. Odisha, Results Study population and data source There were a total of 4811 patients (2108 males This analysis included all patients' histopathology and 2703 females) admitted at AHRCC during the proven cancer diagnosis and admitted at AHRCC be- study period. The mean age of the population was tween January 1't and December, 3t't 2012. AHRCC 47.5 ! 15.5 years. At AHRCC, 6.8% {n = 325) of the 2012 data was used to enable us to compare with the population constituted patients aged s 20 years. latest published 2012-2014 NCRP consolidated reports. Demographic characteristics of the studied popula- Data were abstracted from medical records according tion are described in Table 1. to a protocol which identified 25 items deemed import- ant for epidemiological studies, ln-patient registers and admission registers, maintained by the medical records Tabte 1: Shows the demographic characteristics of the studied department of AHRCC, were used to identify cancer population. patients admitted to the hospital during the period. Pa- ot Characteristics l /o tient data were extracted from inpatient records and Total no. i nvestigation reports. )4911 Gender Physicians-in-charge of patients were also inter- Male 2108 43.8 viewed to ensure consistency of data. For oral can- Female 2703 cer, we included all cancers involving buccal mucosa, 56.2 tongue, gum and palate, 6.8 Data collection and variable information 21-40 '23.3 Two well trained data entry operators systemati- 41 -60 53.4 cally. reviewed medical records of identified cases and 61 -80 17 collected information on socio-demographic status, >80 0.6 district of residence, diagnosis and primary tumor site and tumor characteristics (coded according to the 10th 0.2 Revision of the lnternational Classification of Diseases and Related Health Problems (lCD10) with the codes 4708 97.7 C00-C97) (lCD 10, 20L0) lt2l. All data were entered in 101 2.1 an electronic database created on an epi-info platform z 0.2 (Epi lnfo'" CDC, 2018) [13]. Any data discrepancy was cross-checked with patient records for errors during en- try. All patient personal identifiers were removed from Farmer 734 data files to maintain patient confidentiality. Quality of 34.8 data was assessed by screening one hundred random- Business 146 6.9 ly selected records every month. Duplicate cases were Student 208 9.9 eliminated by cross-checking the in-patient lD number Daily wage laborer zoo I Z.O of each patient. Service 221 10.5 Statistical analysis rOthers : 533 Female The overall 2012 yearly prevalence of cancer and House-wife site specific cancers were determined for each dis- 2457 90.9 trict in Odisha and were categorized according to Service 35 1.3 demographic characteristics (age, sex, religion, dis- Others 211 7.8 trict of residence and income). 2011 Odisha Census Missing data 1 639 34 population data [14] were used as the denominator lncome ,3501 72.8 population. Statistical reports in this study include Low 3502 72.7 absolute number of site-specific cancer cases, crude Average '1308 27.2 proportions, Odisha district specific prevalence rates, commonest cancers and the overall demographic High 1 0.01 profile. All statistical analysis was done using the pC- Missing data 1310 27.2 -.3r1 "t D O | : I i :,,i 3!:3 ? t'i :j 7 i3 .Li i 1 4 1 0 1 ? 0 ISSN: 2378-34'1li

Table 2: Shows the commonest cancer sites among males and females at AHRCC..

0ral 13.9 Gastric 12.7 Cervix 560 Lung 210 10 Ovary 289 10.7 NHL 139 6.6 Gastric 138 5.1 Rectum 133 6.3 Uterus 124 4.4 o7 Gall bladder 58 2.6 Gall bladder 100 J.l

'AHRCC: Acharya Harihara Regional Cancer Centre.

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ricts- districts closest to AHRCC, Cuttack has a higher prevalence compared to districts away from AHRCC.

The most common cancers among males were oral Angul (n = 1,221districts, Ytgur* 2 shows prevalence of (C01-C06 and C09), gastric (C16) and lung (C33-C34). all cancers in Odisha districts per L00,000 populations Buccal mucosa (C03-C04) and the tongue (C01-C02) and the districts with higher proportion of cancer cases were the most common oral cancers constituting 45% in proximity to AHRCC. and 38% of all oral cancers respectively. For females, Discussion among the most common locations of primary cancers were breast (C50), cervix (C53), ovary (C56), gastric This study represents the first attempt to systemat- (C16) and gall bladder (C23-C241(-lable 2). ically collect data from mixed rural, urban, and minlng areas of Odisha with environmental factors notably dif- Hematological malignancies (acute lymphoblastic ferent from those where the NCRP PBCRs and HBCRs and myeloblastic leukaemia, chronic myelocytic and are currently based. Oral cancers were the commonest lymphocytic leukaemia (C91-C92), multiple myeloma cancer among males in Odisha, the most prevalent sites (C90), Non-Hodgkin's lymphoma (C82-C85 and C96)and being buccal mucosa and tongue. This is a likely finding, Hodgkin's lymphoma (C81) constituted 8.4% (n = 402) with oral cancers being consistently reported as one of of cases. Non Hodgkin's lymphoma was the commonest the commonest male cancers allover lndia []]. The high haematological malignancy. The commonest cancers prevalence of oral cancer in lndia has been attributed in the ( 20 year age group included acute lymphoblas- to use of tobacco smoking or chewing) [15,]"51. Tobac- tic leukaemia (n 60), Non-Hodgkin's lymphoma (n = = co chewing in the form of betel quid referred to as pan 31), Hodgkin's lymphoma (n 28) and brain tumours = and consisting of pieces of areca nut, processed or un- (c70-c72\ (n = 23). processed tobacco, aqueous calcium hydroxide (slaked Most cancer cases at AHRCC were reported from lime), and spices wrapped in the leaf of piper betel vine Cuttack (n = 644), Baleswar (n = 330), Bhadrak (n = 281), leaf, khaini and gutka is a common practice among Dhenkanal (n =181), Jagatsinghpur (n = 266), Jajapur (n males in Odisha. The general understanding about = 3771, Kendrapara (n = 347\, Khordha (n = 387), Nay- health threats associated with chewing and smoking is agarh (n = 153), Puri (n =33711, Kendujhar (n = 187) and sparse among the younger population in Odisha, who DOI: 't t.' ii.j':.i77 /? :7l1" ,-tt|': iJI141t:1?.{) ,r"*,r.rJ*.% do not hesitate to pick up the habit [17]. Thus the state decreases in vaccine-type HPV infection prevalence government should strictly implement legislative mea- and associated disease incidence after implernentation sure, for tobacco control in Odisha with utmost urgency of HPV vaccine public health programs, The studies re- and advocacy. lt is also essential that the government port reduction of HPV infections by 86% among 18- to implement urgent cost-effective oral cancer screening 24-year-olds who had received three vaccine doses and awareness initiatives in such high-risk populations. and76% for those who had received one or two doses A recent study from lndia has convincingly demonstrat- 124,25). Hence, an affordable, safe vaccination program ed that oral cancer screening by trained health workers can also be implemented to impact incidence and mor- can lower mortality of the disease - especially in indi- tality of cervical cancer in Odisha. viduals with a history of tobacco use Training indi- [18]. One of the most striking finding in our population viduals on self examination of mouth can also be a sim- was identification of gastric cancer as the second ple and cost-effective strategy to increase community most common cancer among men. There are sever- aw.areness for oral cancer in Odisha. al potential reasons for the high prevalence of gas- Despite the overall nationally declining trend of tric cancer in Odisha. Though Helicobacter pylori (H. cervical cancer, the proportion of cervical cancer cas- pylori\ infection has been considered as one of the es among fen'lales in Odisha was much higher com- most important etiological factors for gastric cancer pared to other registries [5], The high prevalence of [26], some epidemiological studies from lndia have cervical cancer cases is most Iikely due to insufficient failed to confirm the association [271. The risk of H. screening and lack of state-wide government-spon- pyloriinfection is directly related to overall sanitary sored public health policies on prevention of cervical conditions and contaminated water is often implicat- cancer by screening procedures. The human papil- ed as a possible mode of transmission in rural areas (HPV) private loma virus test, available in sectors is without reliable supplies of potable water [28], A vast very expensive. Cytology screening for cervical can- population attending AHRCC clinics come from rural cer introduced in the lndian public health services areas and are therefore, likely to harbor H. pyloriin- since the 1970s could not be well established due fection in their stomach. The infection by H. pylori to lack of laboratory infrastructure including trained may be prevented by interrupting transmission of the personnel, such as cyto-technicians and pathologists infection by promoting sanitary habits, good waste quality process and continuous assurance [19], lt is disposal, clean water supply and planned housing to therefore, important that an alternative simpler, less minimize overcrowding [29]. expensive and promising screening method such as visual inspection of the cervix after application with Other factors demonstrated as significant dietary acetic acid (VlA) l21l be considered for cervical can- risk factors for gastric cancer in various parts of India cer prevention programs in Odisha. The advantage of include pickled food, high rice intake, spicy food, excess VIA is that it can be implemented through primary chilly consumption, consumption of high-temperature health-care workers and does not require a laborato- foods, smoked dried salted meat, use of soda and con- ry infrastructure. Moreover, the results are obtained sumption of dried salted fish [30], lmproved food hy- giene immediately following testing, allowing diagnosis and and dietary intervention with increased fruit and treatment to be implemented during the same visit vegetable intakes and decreased consumption of salt t.il. or salt-preserved foods may act as primary prevention measures to reduce risk of gastric cancer in the state The high prevalence of cervical cancer in the state [31]. Healthy policies aimed at gastric cancer control could also be attributed to lack of awareness about the such as disseminating information on diet changes, and disease and recent developments linking HPV to cervi- improving awareness may also help reducing gastric cal cancer. A recent survey conducted in the year 2015 cancer prevalence in Odisha. to assess community awareness of HPV screening and Elevated gastric vaccination in Odisha showed that 22.4% of the sur- cancer incidence rates have also been veyed population had heard of HPV and only tt.s% demonstrated in the coalmining populations [3.1]. Dietary practices and rich resource of coal mines in were aware that HPV caused cancer [22]. Community Odi- sha may account prevalence gastric awareness and buy-in is critical for cervical cancer pre- for such high of can- cer in the region needs vention [7]l and it is important that aggressive public which to be further explored. Effective health campaigns be developed in the state to increase interventions should also be designed and implemented for population working in coal-mining in- this awareness. Other public health measures such as dustries such health education, HPV vaccine, complimented with ro- as assessing interim markers of exposure which could be used as proxies gastric bust screening program at the state level will be essen- for cancer. tial to decrease cervical cancer prevalence in Odisha. Another important cancer requiring attention further Recent studies from Australia, one of the first countries research in Odisha is gall bladder cancer. Studies show to implement a fully government-funded, population- that incidence of gallbladder cancer parallels prevalence based HPV vaccination program, have reported major of gall stone disease with large and long-standing gall -- (?:fi,,r-, _ ) DOI:': r..:.2.:3':;37 t?-:J7 8,".34'i $ i 1 4 1 A 1 ?lj ISSN 2lTlj-'.:t, stones being associated with a higher risk of gallbladder There are several limitations to our study. The da- cancer 1321. Gall stone disease has also been impllcated tabase created was based on AHRCC in-patient records ds orre of the most important risk factors for gall bladder only. Hence, patients treated on an out-patient basis cancer in northern lndia [33]. However, the importance or those who underwent primary surgical treatment at of gall stone disease as a causal factor for gall bladder private clinics and other surgical units may have been cancer in Odisha needs further investigation. missed leading to under-estimation of some site-specif- ic patients Epidemiological studies show significant association cancer cases. Moreover, the majority of ad- AHRCC came between aflatoxin exposure and gall bladder cancer mitted at from the neighboring districts. Odisha is a large state with several private and district 134,:lItl. Aflatoxins, the toxic metabolites of Aspergillus hospitals offering cancer treatment. Hence, data only flovus and Aspergillus porositicus fungi, are naturally oc- AHRCC can- curring contaminants of food and has been classified as from may not truly represent the status of cer in Odisha state. However, in the absence of an es- a class t human carcinogen by the IARC [S]. Rice (Oryzae population-based sativa L.) is the most important staple food crop in east- tablished cancer registry in Odisha, ern lndia and bulk of rice is grown in kharif or wet sea- data from AHRCC can be regarded as the best possible son. Frequent and heavy rainfall and floods particularly estimates of cancer prevalence in Odisha. near harvest in coastal areas of Odisha wet the crop and Despite its limitation, this study has highlighted the make panicles more prone to invasion by Aspergillus need for increased attention to some of the important species and may likely attribute to rising proportion of cancers in the state. These data are particularly useful in gall bladder cancer cases in the state. regard to selecting and implementing high impact can- Environmental pollutants may also be implicated as cer control programs. Aggressive screening and tobac- important factor for gall bladder cancer in Odisha, Sig- co control should be implemented for cervical and oral nificant association of gall bladder cancer has been re- cancers. Analytical studies should be focused on gastric ported with the levels of heavy metals i.e. nickel, chro- and gall bladder cancers to determine etiology and oth- mium and cadmium in the water [33,36]. Proximity to er associated causes for the high prevalence of these coal industries and mining exposures [S] may be factors cancers in the state and allowing targeted public health that need to be explored as possible causes associat- programs specific for the region. ed with gall bladder cancer in Odisha. Better designed &ckn*wl*dg*ments case-control studies or cohort studies looking at various heavy metals are required to establish them as causal We are grateful to Dr. Lalatendu Sarangi, Director factors for gall bladder cancer in Odisha. AHRCC for his help in co-ordination and administrative support for the project and the data entry operators for Other prevalent cancers noted in Odisha were lung digitization of the data. and breast cancers. Apart from well established risk fac- tors for lung cancer such as tobacco, diet and outdoor *latsrxqnt Cantlict af tnlerest air pollutants fi7l, high prevalence of lung cancer in the region could be result of exposure to environmental The authors declare no conflict of interest. contaminants associated with mining industries in the Authors' Contribution state [38,39]. Breast cancers more commonly occurred among younger women aged s 45 years. The rise in in- All authors have equally contributed to the concep- planning, cidence of breast cancer alO,5-2% per annum has been tualization, designing, conduct, analysis, re- seen across all regions of lndia and in all age groups but viewing, writing up and editing the final manuscript. more so in the younger age groups (< 45 years) 14*,4'11. ReferencrE The high prevalence of breast cancers in Odisha could 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, et al. (2007) be associated with socio-economic and life-style chang- Cancer statistics, 2007. CA Cancer J Clin 57: 43-66. es such as late childbearing, dietary changes and associ- (2018). ated changes in menstrual patterns. 2. Globocan lndia 3. Globocan 2018 Cancer Overtime. Our study also noted that overall prevalence of can- cer varied geographically across districts of Odisha with 4. (2019) National Cancer Registry Programme. About NCRP. higher prevalence of cancers in districts which were in 5. (2019) NCRP annual reports. proximity preva- closer to AHRCC. This discrepancy in 6. (2019) NCRP network. lence could due to easier access to AHRCC for patients 7. (2019) Department of steel and mines, Government of Odi- from the more proximal districts. lt may be speculated sha. that cancer patients may have been treated in other (2018) IARC identification hospitals in districts away from AHRCC and could not be 8. monographs on the of carcino. genic hazards to humans. captured in the AHRCC database. Probable exclusion of such cases may have resulted in under-counting of over- 9. Shukla VK, Prakash A, Tripathi BD, Reddy DC, Singh S (1998) Biliary heavy metal concentrations in carcinoma of all cancer cases thereby attenuating the true population the gall bladder: case-control study. BMJ 317:1288-1289. estimates in districts away from AHRCC. DOI: 1i: :t:it\:S I ti:378-341tJ1141$1?6 tssN: 21r1t)_.:n.r;:

10. AIPH university. 27. Phukan RK, Narain K, Zomawia E, Hazarika NC, Mahanta J (2006) Dietary habits and gastric cancer in Mizoram, In- 11. A^harya Harihar Regional Cancer Center: Cancer Odisha. dia. J Gastroenterol 41:418-424. 12. lnfernational Statistical Classification of Diseases and Re- 28. Ahmed KS, Khan AA, Ahmed l, Tiwari SK, Habeeb A, et al. lated Health Problems 1Oth Revision. (2007) lmpact of household hygiene and water source on 13. Epi-info. Centers for Disease Control and Prevention. the prevalence and transmission of Helicobacter pylori: A South lndian perspective. Singapore Med J 48: 543-549. ''14. Orissa population census data 2011. 29, Karimi P, lslami F, Anandasabapathy S, Freedman ND, l5.Jayalekshmi PA, Gangadharan P, Akiba S, Koriyama C, Kamangar F (2014) Gastric Cancer: Descriptive Epidemi- Nair RR (20'l 1) Oral cavity cancer risk in relation to tobacco ology, Risk Factors, Screening, and Prevention. Cancer chewing and bidi smoking among men in Karunagappal- Epidemiol Biomarkers Prev 23: 700-7 13. ly, Kerala, lndia: Karunagappally cohort study. Cancer Sci (2000) 102: 460-467. 30. Mathew A, Gangadharan P, Varghese C, Nair MK Diet and gastric cancer: A case- control study in South ln- 16. Coelho KR (2012) Challenges of the oral cancer burden in dia, Eur J Cancer Prev 9; 89-97. .lndia. J Cancer Epidemiol20'12. 3l.Bonequi P, Meneses-Gonz{lez F, Correa P, Rabkin CS, 17.Panda B, Rout A, Pati S, Chauhan AS, Tripathy A, et al. Camargo MC (2013) Risk factors for gastric cancer in Latin (2012) lobacco control law enforcement and compliance America: a meta-analysis. Cancer Causes Control 24:217- in Odisha, lndia-implications for tobacco control policy and 231. practice. Asian Pac J Cancer Prev 13: 4631-4637. 32. O'Keeffe F, Lorigan G, Butler F (1989) Ultrasound findings '18, Daftary DK (2010) Temporal role of tobacco in oral carcino- in carcinoma of the gall bladder. lri J Med Sci 158: 48-49. genesis:A hypothesis prioritize precan- for the need to on 33. Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, et cer. lndian Journal of Cancer 1: 105-107. al. (2011) Population-based study to estimate prevalence 19. Sankaranarayanan R, Budukh AM, Rajkumar R (2001) Et and determine risk factors of gall bladder diseases in the fective screening programmes for cervical cancer in low- rural Gangetic basin of North lndia. HPB (Oxford) 13: 117- and middle-income developing countries. Bull World Health 125. Organ 79: 954-962. 34. Nogueira L, Foerster C, Groopman J, Egner P, Koshiol J, et (2015) 20. Sankaranarayanan R, Nene BM, Dinshaw K, Rajkumar R, al. Association of aflatoxin with gallbladder cancer in Shastri S, et al. (2003) Early detection of cervical cancer Chile. JAMA 313: 2075-2077 . with visual inspection methods: A summary of completed 35. Koshiol J, Gao YT, Dean M, Egner P, Nepal C, et al. (2017) and on-going studies in lndia. Salud P0blica de Mexico 3: Association of aflatoxin and gallbladder cancer. Gastroen- s399-3407. terology 153:488-494. 21 . Bobdey S, Sathwara J, Jain A, Balasubramaniam G (2016) 36. Pandey M (2006) Environmental pollutants in gallbladder Bi.rrden of cervical cancer and role of screening in lndia. carcinogenesis. J Surg Oncol 93: 640-643. lndian J Med Paediatr Oncol 37: 278-285. 37. Lam WK, White NW, Chan-Yeung MM (2004) Lung cancer 22.Khanna N, Ramaseshan A, Arnold S, Panigrahi K, Macek epidemiology and risk factors in Asia and Africa. lnt J Tu- MD, et al. (2015) Community awareness of HPV screening berc Lung Dis 8: 1045-1057. and vaccination in Odisha. Obstet Gynecol lnt 20'15. 38.Jenkins WD, Christian WJ, Mueller G, Robbins KT (2013) 23. (2018) IARC Cancer today. Population cancer risks associated with coal mining: A sys- tematic review. PLoS One 8: e71312. 24.Tabrizi SN, Brotherton JM, Kaldor JM, Skinner SR, Cum- mins E, et al. (2012) Fall in human papillomavirus preva- 39. Hendryx M, O'Donnell K, Horn K (2008) Lung cancer mor- lence following a national vaccination program. J lnfect Dis tality is elevated in coal- mining areas of Appalachia. Lung 206:1645-1651. Cancer 62 1-7. 40. Murthy NS, Agarwal (2007) 25. Garland SM, Kjaer SK, Muffoz N, Block SL, Brown DR, UK, Chaudhry K, Saxena S A et al. (20'16) lmpact and effectiveness of the quadrivalent study on time trends in incidence of breast cancer-lndian scenario. Eur J Cancer Care (Engl) 16: 1 human papillomavirus vaccine; A systematic review of 10 85-1 86. years of real-world experience. Clin lnfect Dis 63; 519-527. 4l.Agarwal G, Pradeep PV, AggarwalV, Yip CH, Cheung PS (2007) Spectrum of breast cancer in Asian women. World 26. Thirumurthi S, Graham DY (2012) Helicobacter pylori infec- J Surg 3'l:1031-1040. tion in lndia from a western perspective. lndian J Med Res 136:549-562.

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