The burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990-2016

Abstract

Background: Previous efforts to report estimates of cancer incidence and mortality in India and its different parts include the National Cancer Registry Programme Reports, Sample Registration System cause of death findings, Cancer Incidence in Five Continents Series, and GLOBOCAN. We present a comprehensive picture of the patterns and time trends of the burden of total cancer and specific cancer types in each state of India estimated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 because such a systematic compilation is not readily available.

Methods: We used all accessible data from multiple sources, including 42 population-based cancer registries and the nationwide Sample Registration System of India, to estimate the incidence of 28 types of cancer in every state of India from 1990 to 2016 and the deaths and disability-adjusted life-years (DALYs) caused by them, as part of GBD 2016. We present incidence, DALYs, and death rates for all cancers together, and the trends of all types of cancers, highlighting the heterogeneity in the burden of specific types of cancers across the states of India. We also present the contribution of major risk factors to cancer DALYs in India.

Findings: 8·3% (95% uncertainty interval [UI] 7·9-8·6) of the total deaths and 5·0% (4·6-5·5) of the total DALYs in India in 2016 were due to cancer, which was double the contribution of cancer in 1990. However, the age-standardised incidence rate of cancer did not change substantially during this period. The age-standardised cancer DALY rate had a 2·6 times variation across the states of India in 2016. The ten cancers responsible for the highest proportion of cancer DALYs in India in 2016 were stomach (9·0% of the total cancer DALYs), breast (8·2%), lung (7·5%), lip and oral cavity (7·2%), pharynx other than nasopharynx (6·8%), colon and rectum (5·8%), leukaemia (5·2%), cervical (5·2%), oesophageal (4·3%), and brain and nervous system (3·5%) cancer. Among these cancers, the age-standardised incidence rate of breast cancer increased significantly by 40·7% (95% UI 7·0-85·6) from 1990 to 2016, whereas it decreased for stomach (39·7%; 34·3-44·0), lip and oral cavity (6·4%; 0·4-18·6), cervical (39·7%; 26·5-57·3), and oesophageal cancer (31·2%; 27·9-34·9), and leukaemia (16·1%; 4·3-24·2). We found substantial inter-state heterogeneity in the age-standardised incidence rate of the different types of cancers in 2016, with a 3·3 times to 11·6 times variation for the four most frequent cancers (lip and oral, breast, lung, and stomach). Tobacco use was the leading risk factor for cancers in India to which the highest proportion (10·9%) of cancer DALYs could be attributed in 2016.

Interpretation: The substantial heterogeneity in the state-level incidence rate and health loss trends of the different types of cancer in India over this 26-year period should be taken into account to strengthen infrastructure and human resources for cancer prevention and control at both the national and state levels. These efforts should focus on the ten cancers contributing the highest DALYs in India, including cancers of the stomach, lung, pharynx other than nasopharynx, colon and rectum, leukaemia, oesophageal, and brain and nervous system, in addition to breast, lip and oral cavity, and cervical cancer, which are currently the focus of screening and early detection programmes.

Funding: Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Figure 1

Crude annual incidence rate of all cancers together in the states of India, 1990 and 2016 The states of Chhattisgarh, Jharkhand, Telangana, and Uttarakhand did not exist in 1990, as they were created from existing larger states in 2000 or later. Data for these four new states were disaggregated from their parent states based on their current district composition. These states are shown in the 1990 map for comparison with 2016.

Figure 2

Crude MI ratio of all cancers together in the states of India by sex, 2016 MI=mortality-incidence. *MI ratio is is calculated by dividing crude death rate per 100 000 by the crude incidence rate per 100 000. The sequence of the states is from the lowest to the highest epidemiological transition level in 2016.

Figure 3

Percentage of total cancer DALYs due to different types of cancers by sex in India, 2016 DALYs=disability-adjusted life-years. *The other neoplasm category was not included in this figure. The types of cancers are colour-coded in groups based on their ranking in both sexes combined.

Figure 4

Change in DALYs for different types of cancers in India, 1990–2016 DALYs=disability-adjusted life-years.

Figure 5

Age-specific DALYs for different types of cancers by sex in India, 2016 DALYs=disability-adjusted life-years.

Figure 6

Change in incidence rate of different types of cancers in India, 1990–2016

Figure 7

Crude DALY rates in the states of India for the ten cancers responsible for the highest DALYs in India, 2016 DALY is presented as rate per 100 000. DALY=disability-adjusted life-year. ETL=epidemiological transition level.

Figure 8

Ranking of crude death rates in each state of India for the 20 cancers causing the highest number of deaths by sex in India, 2016 The sequence of the states is from the lowest to the highest epidemiological transition level in 2016.