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PURPOSELower socioeconomic status is associated with more advanced cancer at the time of cancer diagnosis. It is unknown whether this leads to inferior survival in low- and middle-income countries. Here, we explore the association between educational level and survival in South India.METHODSThe Trivandrum Cancer Registry (3.3 million population) was used to identify all cases of breast and cervical cancer (women) and oral cavity (OC) and lung cancer (men) diagnosed during 2012-2014. Educational level was classified as illiterate/primary school, middle school, and secondary school and above. Survival was measured from date of diagnosis using the Kaplan-Meier method. Cox proportional hazards regression modeling was used to describe the associations among education, stage of cancer at diagnosis, and survival.RESULTSThe study population included 3,640 patients with breast (n = 1,727), cervical (n = 425), OC (n = 702), and lung (n = 786) cancer. Educational level was 27%, 23%, and 32% for illiterate/primary, middle, and secondary school and above, respectively. The 5-year survival rate for breast cancer was 59%, 68%, and 73% (P = .001); for cervical cancer, 51%, 52%, and 60% (P = .146); and for OC cancer, 42%, 35%, and 48% (P = .012) for illiterate/primary, middle school, and secondary school and above, respectively. The survival gradient across social groups was substantially attenuated when stage was added to the multivariable model. There was no observed difference in survival across educational groups for lung cancer (2%, 4%, and 3%; P = .224).CONCLUSIONData from this population-based study in South India demonstrate that patients from a lower educational background have inferior survival and that this is at least partially explained by having more advanced disease at the time of diagnosis. Public health efforts are needed to facilitate timely diagnosis and reduce disparities in cancer outcomes.

Byline: Rebecca. George, Aparna. Prakasan, K. Anila, K. Jagathnath Krishna, Elizabeth. Iype, K. Jayasree, Kunnambath. Ramadas Background: The eighth edition of the American Joint Committee on Cancer (AJCC) for oral [...]

Oral cancer is often preceeded by precancerous lesions and conditions, such as leukoplakia, erythroplakia and oral submucous fibrosis. One of the approaches for control of oral cancer is to detect oral precancerous lesions early in the development and prevent their malignant transformation to invasive cancer either by chemoprevention or by surgical excision of the lesions with concurrent control of tobacco and alcohol use and other specific etiological factors. However, the value of specific approaches, such as surgery in long-term control of lesions and prevention of malignant transformation is not known. We describe our experience with cold knife surgical excision of oral leukoplakia diagnosed in the context of a community-based oral cancer cluster randomized oral cancer screening trial in Kerala, jointly organized by the Regional Cancer Centre, Trivandrum and the International Agency for Research on Cancer of the WHO, Lyon. France. During the period from January 1997 to December 2002, 111 subjects underwent surgical excision- Thirteen patients were found to have malignancy on histopathology and were not considered for further analysis. At the last follow-up, 9 (13%) patients could not be traced and 19 (27%) patients died due to causes other than oral cancer. Of the remaining 70 cases, 48 (68-6%) were remaining disease free with no evidence of recurrence or new lesions, 16 (16.9%) developed new leukoplakic lesions, (one patient developed recurrence as well), three (4.2%) developed recurrence. Recurrence was more common among those who continued the habits, but this was not statistically significant. There were four (5 7%) cases of malignant transformation during the mean follow-up period of 8-1 years. The superiority of surgical excision over other modalities of management of leukoplakia could not be established in the present study.

Background: This study presents the preliminary results of a randomized controlled trial (RCT) initiated in January 2006 in India to evaluate the effectiveness of clinical breast examination (CBE) in reducing breast cancer mortality as compared to a no‐screening control group reported significant downstaging in the intervention group. The present manuscript reports long‐term follow‐up outcomes. Methods: Women 30–69 years old from 133 intervention clusters and 141 control clusters were invited to participate. Women in the intervention arm underwent three rounds of CBE every 3 years. CBE‐positive women were reexamined by a physician, and triple‐assessment was performed on those confirmed to have abnormalities. All participants were followed through home visits and linkage with population‐based cancer registry. Results: Of the 55,843 eligible women in the intervention arm, 95.7% had CBE at least once and 11.5% were CBE‐positive. Breast cancers were diagnosed in 335 participants in the intervention group and 273 in the control group (N = 59,447). Age‐standardized incidence rate of early cancer was 30.4 of 100,000 in the intervention and 21.9 of 100,000 in the control group, with a rate ratio (RR) of 1.4 (95% confidence interval [CI], 1.1–1.8). The age‐standardized breast cancer mortality rates were 11.3 and 11.1 per 100,000 in intervention and control arms, respectively (RR, 1.1; 95% CI, 0.8–1.5) after 15 years. Five‐year breast cancer survival rates were 77.0% in the intervention and 71.2% in the control groups (overall p value =.043). Conclusions: Triennial CBE screening failed to demonstrate any mortality benefit despite achieving a shift toward earlier stage at detection and improved survival in the intervention arm. CBE is a valuable tool for diagnosis of breast cancer in symptomatic women especially in areas where mammography and/or breast cancer screening programs are not widely available. The authors demonstrated that an "early diagnosis" approach can be as effective as clinical breast examination screening in reducing breast cancer mortality. These observations have major policy implications. [ABSTRACT FROM AUTHOR]

Objective To evaluate oral cancer screening by visual inspection. Methods A cluster randomized controlled trial was initiated in Trivandrum district, Kerala, India. Of 13 population clusters, seven were randomly allocated to three rounds of screening between 1996 and 2004, while standard care was provided in six (control arm). An activity-based approach was employed to calculate costs associated with various components of the screening trial. Information on the resources used and on clinical events in each trial arm was derived from trial databases. Total costs for each cluster were estimated in 2004 United States dollars (US$). The incremental cost per life-year saved was calculated for all eligible individuals and for high-risk individuals (i.e. tobacco or alcohol users). Findings The proportion of oral cancers detected at an early stage (i.e. stage I or II) was higher in the intervention arm than the control arm (42% versus 24%, respectively). The incremental cost per life-year saved was US$ 835 for all individuals eligible for screening and US$156 for high-risk individuals. Oral cancer screening by visual inspection was performed for under US$ 6 per person. Conclusion The most cost-effective approach to oral cancer screening by visual inspection is to offer it to the high- risk population. Targeted screening of this group will ensure that screening can be offered at a reasonable cost in a limited-resource setting. Objectif Evaluer le depistage du cancer buccal par examen visuel. Methodes Un essai controle randomise en grappes a ete lance dans le district de Trivandrum, dans l'Etat du Kerala, en Inde. Parmi les 13 grappes de population, 7 avaient ete affectees aleatoirement a trois tournees de depistage entre 1996 et 2004, tandis que les 6 autres (bras temoins) recevaient des soins standard. Les couts associes aux differentes composantes de l'essai de depistage ont ete calcules en procedant par activites. Des informations sur les ressources utilisees et les evenements cliniques dans chaque bras de l'essai ont ete tirees de bases de donnees d'essai. Le cout total pour chaque grappe a ete estime en dollars des Etats-Unis d'Amerique (US $) de 2004. Le cout marginal par annee de vie epargnee a ete calcule pour tous les individus admissibles dans l'etude et pour ceux a haut risque (c.-a-d. les consommateurs de tabac et d'alcool). Resultats La proportion de cancers buccaux detectes a un stade precoce (c.-a-d. au stade I ou II) etait plus elevee dans le bras d'intervention que dans le bras temoin (42 % contre 24 % respectivement). Le cout marginal par annee de vie epargnee etait de US $ 835 pour l'ensemble des individus admissibles dans l'etude et de US $156 pour les individus a haut risque. Le depistage du cancer buccal par examen visuel a ete pratique pour un cout inferieur a US $ 6 par personne. Conclusion La demarche la plus efficace sur le plan economique pour depister le cancer buccal par examen visuel consiste a proposer cet examen a la population a haut risque. Le depistage cible de ce groupe garantit la possibilite de proposer ce depistage a un cout raisonnable dans un pays a ressources limitees. Objetivo Evaluar el cribado del cancer de boca mediante inspeccion visual. Metodos Se llevo a cabo un ensayo controlado aleatorizado por conglomerados en el distrito de Trivandrum, Kerala, India. De 13 conglomerados de poblacion, siete se asignaron aleatoriamente a tres rondas de cribado realizadas entre 1996 y 2004, y en los otros seis se ofrecio la atencion habitual (grupo control). Se empleo un metodo basado en la actividad para calcular los costos asociados a diversos componentes del ensayo de cribado. La informacion relativa a los recursos empleados y los eventos clinicos en cada grupo de ensayo se extrajo de la base de datos correspondiente. Los costos totales para cada conglomerado se estimaron en dolares de los Estados Unidos (US$) de 2004. Se calculo el costo marginal por ano de vida ganado para todas las personas elegibles y para las personas de alto riesgo (es decir, consumidores de tabaco o alcohol). Resultados La proporcion de canceres de boca detectados en un estadio inicial (es decir, estadio I o II) fue mayor en el grupo de intervencion que en el grupo de control (42% frente a 24%, respectivamente). El costo marginal por ano de vida ganado fue de US$ 835 para todas las personas elegibles para el cribado, y de US$156 para las personas de alto riesgo. El cribado mediante inspeccion visual costo menos de US$ 6 por persona. Conclusion La opcion mas costoeficaz para cribar el cancer de boca mediante inspeccion visual consiste en ofrecer el tamizaje a la poblacion de alto riesgo. El cribado focalizado de tales grupos garantiza que ese tipo de examen se pueda ofrecer a un costo razonable en los entornos con recursos limitados., Une traduction en francais de ce resume figure 2, la fin del article. Al final de/articulo se facilita una traduccion al espanol Introduction Oral cancer is a major health problem [...]

Background: Tobacco smoking is a major risk factor for many diseases. We sought to quantify the burden of tobacco-smoking-related deaths in Asia, in parts of which men's smoking prevalence is among the world's highest. Methods and Findings: We performed pooled analyses of data from 1,049,929 participants in 21 cohorts in Asia to quantify the risks of total and cause-specific mortality associated with tobacco smoking using adjusted hazard ratios and their 95% confidence intervals. We then estimated smoking-related deaths among adults aged [greater than or equal to]45 y in 2004 in Bangladesh, India, mainland China, Japan, Republic of Korea, Singapore, and Taiwan--accounting for ~71% of Asia's total population. An approximately 1.44-fold (95% CI = 1.37-1.51) and 1.48-fold (1.38-1.58) elevated risk of death from any cause was found in male and female ever-smokers, respectively. In 2004, active tobacco smoking accounted for approximately 15.8% (95% CI = 14.3%-17.2%) and 3.3% (2.6%-4.0%) of deaths, respectively, in men and women aged $45 y in the seven countries/ regions combined, with a total number of estimated deaths of ~1,575,500 (95% CI = 1,398,000-1,744,700). Among men, approximately 11.4%, 30.5%, and 19.8% of deaths due to cardiovascular diseases, cancer, and respiratory diseases, respectively, were attributable to tobacco smoking. Corresponding proportions for East Asian women were 3.7%, 4.6%, and 1.7%, respectively. The strongest association with tobacco smoking was found for lung cancer: a 3- to 4-fold elevated risk, accounting for 60.5% and 16.7% of lung cancer deaths, respectively, in Asian men and East Asian women aged [greater than or equal to]45 y. Conclusions: Tobacco smoking is associated with a substantially elevated risk of mortality, accounting for approximately 2 million deaths in adults aged $45 y throughout Asia in 2004. It is likely that smoking-related deaths in Asia will continue to rise over the next few decades if no effective smoking control programs are implemented. Please see later in the article for the Editors' Summary., Introduction Tobacco smoking is a major risk factor for many diseases, including cardiovascular disease (CVD), respiratory disease, and cancers of the lung and multiple other sites [1,2]. In the US [...]