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Mouth cancer cases have doubled since mid-1980s
India is in the grip of an oral-cancer epidemic, largely caused by increase in tobacco-chewing and smoking. This data makes out a case for banning not just gutka, where tobacco is added to other food materials, but also chewing tobacco itself which has not been banned.

THE DIRECTORS of Regional Cancer Centers have written letters to Prime Minister and Union Health Minister, urging nationwide implementation of the gutka ban. Confronted with a near-doubling of mouth cancer rates since the mid-1980s, policy-makers and tobacco-control activists have cause to worry whether the ban on gutka is too-little-too-late. The cancer registry data published by Gujarat Cancer Research Center over the 20-year period spanning 1985 and 2006, when analyzed by Mumbai’s Healis-Sekhsaria Institute of Public Health, reveals a near-doubling of oral cancer rates across different age-groups.

The cohort (group) of males who attained the age of 34 in 1995 suffered 2.1 oral cancer cases per lakh males between the ages of 25 and 34 (10-year-span). The cohort of males that was 10 years older (i.e. which attained the age of 34 in 1985) had suffered only 1.2 oral cancer cases per lakh between the ages of 25 and 34. The as-yet-unpublished analysis (which is an update of a study published in Journal of Medical Association in 1999 titled Mouth Cancer in India – A New Epidemic?) included cancer of the cheeks, lower and upper jaw, hard and soft palate and gums in males only.

This steep trend continued as the youngest cohort attained the age of 44 in 2006; it suffered 15.9 oral cancer cases between the ages of 35 and 44. Again, this was close to double the rate of older age group (8.5 oral cancer cases per lakh males between 35-44), and nearly three times the cancer rate (5.6 oral cancer cases) of another age group that was 20 years older.

Between the two older groups, the same trend-line was visible. Those who attained the age of 54 in 2006 showed roughly double the cancer incidence of the oldest group (34.1 as against 17.6 cases) between the ages of 45 and 54.

Overall, this research says that the rate of cancer has doubled in the two decades between 1985 and 2006. It confirms what cancer surgeons all over the country are saying from their observation: India is in the grip of an oral-cancer epidemic, largely caused by increase in tobacco-chewing and smoking. This data makes out a case for banning not just gutka, where tobacco is added to other food materials, but also chewing tobacco itself which has not been banned. Chewing tobacco per se is not subject to the gutka ban, and continues to be freely available in various forms such as “filter khaini”, tobacco eaten with betel leaf paan and as tobacco that is hand-mixed with lime. It also makes out a case for banning bidis and cigarettes, which have a somewhat less direct relationship with mouth cancer.

Dr Prof Santanu Chaudhuri, an eminent oncologist and Director of RST Regional Cancer Hospital, Nagpur,confirms this trend. “A study carried out in RST Regional Cancer Hospital, which was published in the Journal of the Academy of Medical Sciences, indicates that oral cavity cancer is becoming very common in young population of 25-40 years of age. Ten years back, it was common between 40–60 year of age. In 1995-96, the incidence was 17% i.e. out of 500 patients, 85 belonged to the younger age group. This rose to 25% in 2002–03 (150 out of 600) and 33% in 2006-07 (231 out of 700),” says Dr Santanu, citing the study.

“Tobacco has turned out to be the biggest menace in the field of oncology,” he adds. “It is a preventable cause of cancer. Various studies have clearly proved that, use of tobacco causes oral cancer. In my clinical practice, I am shocked to see young people who have tobacco addiction coming to us with oral cancers and that too, in advanced stages. This trend of increase in number of young patients coming with tobacco induced oral cancer has become very prevalent in central India in recent times.”

“We are seeing many families destroyed because of the cancer related mortalities due to tobacco. We are losing the young generation of India to tobacco. This generation, who are supposed to be the builders of the Nation, are destroying themselves due to this tobacco curse,” Dr Santanu laments.

Another study by Balchandra B Yeole titled Trends in Incidence of Head and Neck Cancers in India, published in the Asian Pacific Journal of Cancer Prevention in 2007, explainsthe risk-ratios between bidi-smoking, tobacco-chewing and different kinds of cancer: “Risk ratio of bidi smokers was higher for cancers of oropharynx (RR=10.4) and Larynx (RR=7.7) than chewers (RR=3.3) and (RR=7.8) for oropharynx and larynx. Whereas risk in chewers is higher for cancer of oral cavity (RR=6.0) and oropharynx (RR=4.5) than in bidi smokers (RR=2.1) for oral cancers and (RR=2.4) for hypopharynx. Those combining the habit of smoking and chewing have a much higher risk, almost multiplicative compared to those indulging in only the single habit. The risk of combined habits is particularly high for cancers of oropharynx (RR=31.7), hypopharynx (RR=16.9) and larynx (RR=20.1)… It is worthwhile noting that bidi smokers have a much higher risk of oropharyngeal and laryngeal cancer than that of cigarette smokers.”

About 30% of the oral cancer patients coming in nowadays are in their 20s and 30s, observes Dr Pankaj Chaturvedi, Associate Professor of Tata Memorial Hospital. He has been examining about 200 oral cancer patients every week since 2002 at this Regional Cancer Center, where patients come not only from all over the Maharashtra, but also from many distant and neighbouring states of India. His observations are borne out by many other oncologists and surgeons all over the country.

Dr Prakash Gupta, Director of Healis-Sekhsaria Institute of Public Health, and a reputed research scientist, has participated in many all-India and global studies on the connection between tobacco use and cancers. Dr Gupta says, “Our analysis, based on data released by Gujarat Cancer Research Center in 2008, shows a trend that is probably countrywide and continuing even today. I have zero hesitation in saying that India’s oral cancer profile continues to get younger, and ongoing research will give conclusive proof of this. There is a clear connection between India’s rising oral cancer and the continuing success of the tobacco industry relentlessly promoting smoking and tobacco-chewing among school-children and college age youths. Notwithstanding the state-level bans on gutka and rising excise duties on cigarettes, this predatory industry is far from defeated.”

Dr. Dhawal Shah, ENT, head & neck cancer and laser surgeon practicing at at Baroda, says, “I definitely agree that oral and orophayrngeal cancers have increased to a great extend in younger age group viz. 25-35 yrs of age. Among the reasons that have contributed to this disaster is the status symbol of chewing tobacco and even smoking cigatettes in young school-going children 10 - 18 age. This is observed more in village schools. Although gutka has been banned in Gujarat and many other states, pan masalas with different trade names like Vimal, Zatpat, Parag and Pan Villas are freely sold with separate pouches of tobacco, and at the same price as gutka. Various carcinogenic factors are found even in pan masala. Worsening matters are stressful and sedentary lifestyles, unbalanced diet and poor oral hygiene in young generations.

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