Oral cancer prevention and awareness in India

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Published: 29 Mar 2017
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Dr Pankaj Chaturvedi - Tata Memorial Centre, Mumbai, India

Dr Chaturvedi speaks with ecancer at EBMCI 2017 about oral cancer in India as a result of tobacco chewing.

Areca, or betel nut, is marketed as a breath freshener, and Dr Chaturvedi describes efforts to reduce usage from policy makers and community engagement.

He describes an overall decline in tobacco consumption in India, which he notes as a country of many differing populations, though no plans to tackle alcohol as a cancer-causing agent are yet in place.

Finally, Dr Chaturvedia calls on doctors and dentists to identify oral cancers early, and offer immediate guidance and counselling, so that more diseases are caught in more manageable stages.

Areca and tobacco chewing is also discussed by Dr Pantvaidya here.

Oral cancer is the commonest cancer in Indian men; it is the commonest cause of cancer-related death in Indian men and in some parts of India after breast and cervix cancer it is the number three cancer in Indian women. So it is a huge public health problem, we have around 100,000 new mouth cancers diagnosed every year and half of them die within twelve months of diagnosis.

What are the causes?

In India oral cancer is predominantly caused by any form of tobacco consumption but chewing tobacco is the number one cause of mouth cancer and 80-90% of mouth cancers are related to chewing tobacco. Apart from that we have the smoking form which is either cigarette and it is very unique that we have more people smoking the indigenous form of smoking which is beedi rather than cigarettes. Apart from chewing tobacco and smoking it is areca nut or supari or betel nut which is very, very common in India. It is another source of the high incidence of mouth cancer and unfortunately it is branded as a mouth freshener, it is very cheap and it is sold all over. Of course alcohol is the number three aetiology of oral cancer in India but broadly people who are using tobacco or alcohol or areca nut it is poor oral hygiene and oral hygiene is really bad in some parts of India. That contributes to such a high volume of oral cancer in India.

What can be done to reduce rates of oral cancer in India?

Once we know that a cancer has got known aetiology and with regards to oral cancer 90% of them have the known aetiology, namely tobacco, alcohol, areca nut, poor oral hygiene and perhaps, to a small extent, human papilloma virus. So of course we are talking about a preventable disease and therefore the government and society and the medical community have to work together to prevent this disease. Now the government on its part has done several efforts like it has enacted a law in 2003 called the Cigarette and Other Tobacco Products Act. Then there is the Food Safety Act of India which prohibits the sale of gutka which is a flavoured chewing tobacco in India, it is prohibited; similarly flavoured areca nut, some states have banned it. So here all these products which are being marketed in a misleading manner as a misbranded product, as a mouth freshener, need to be prohibited and that is what the government has done. But I think a lot of things can be done at the community level where we can do some awareness programmes because people who have not started the habit, we need to denormalise the behaviour in their mind rather than concentrating on people who are current users of tobacco where cessation is low despite every tobacco product containing a graphic warning. Our aim has to be focussed on children who have not yet started. Again NGOs, civil society, physicians, community, they all can participate in that effort of the government.

How effective are the government’s measures?

That’s always a challenge in a country where we have 1.25 billion people; we have around 275 million tobacco users and a lot of them come from the poor socioeconomic strata, they come from less literate society, they come from various traditional cultural beliefs. So to target that population, unlike in the West where you have smokers, you have educated people, you have one awareness programme or one campaign and it covers the entire population, in India we have to tailor make the programme and campaigns according to the target population which is very diverse. Moreover, what happens, this belief that tobacco and areca nut has been there for many years and this is part of our culture and tradition has to be broken. It takes a lot of time to make behavioural changes and the government is doing its effort but the changes are slow. What we are seeing currently from the National Family Health Survey and also many other surveys, that the consumption of tobacco is in decline and perhaps in days to come, because you must know India is the only country in the entire world which has enacted a law which makes the sale of tobacco to minors as a non-bailable offence. That means if someone sells tobacco to a minor he is imprisoned for seven years and a 100,000 rupees fine which is a very powerful law and it will serve as a deterrent. I’m sure that in days to come tobacco consumption and areca nut consumption will come down.

What the government is completely lacking that in a country where alcohol is the number two cause of non-communicable disease and even cancer, the Indian government does not have any health policy for decreasing alcohol use. Unfortunately alcohol control rests with the Department of Revenue and the mandate of the Department of Revenue is to maximise the revenue, not discourage the consumption.

Are there any messages you would like to say to the general public?

Oral cancer is the best model for screening. Screening means that it is one site which is visible to the individual every day when he brushes his teeth; it is seen to the people around them, at least their spouses when they see such lesions in the mouth, and it is a real paradox that our best model for screening we are getting our patients in very advanced stage and they are dying. So what can be done is, again, we need some social mobilisation for early detection and also prevention but I am worried about even the dental community, even the doctors, they are not aware of the early signs of cancer. Therefore we did a study, we found that of the six months’ delay in diagnosis three months delay was coming from the doctors being ignorant about the early signs of oral cancer and that is something we need to change.

My worry is that even doctors are unaware of the early signs of oral cancer. We did a study and we found that of the six months’ delay that happens in early diagnosis of oral cancer and that is why they present in late stage, three months was because of the lack of awareness among the patients who did not go to a clinic or did not visit a dentist but three months’ delay was because of the doctor not doing a proper investigation or not being aware of the early signs. So this is something that has to change and the medical community, whenever they have an opportunity, especially in high risk users, should examine the oral cavity, what we call opportunistic screening. Once they do opportunistic screening in a country where oral cancer is so epidemic I am sure that they will find some lesion which has to be referred to the doctor. Most important, we have one million doctors in India and if one million doctors did decide that they will offer opportunistic counselling to the patients who are indulging in any risk habit, and the risk habit can be poor oral hygiene, tobacco use, alcohol use, areca nut use, once they know that there is some risk habit in that individual they just have to spend an additional two minutes counselling that individual that this will lead to certain disasters, health disasters, in them. It is proven beyond doubt that the patient who is sitting in front of you who has come to you not for tobacco related illness but for an unrelated cause, if you spend two minutes extra with him and explain to him he is vulnerable, he is gullible and he is very receptive, this two minutes intervention will really motivate him to quit the risk habit and enjoy the benefit of a healthy lifestyle.