Cancer management in Kashmir is in need of major changes. There is need of improvement in infra structure as well as manpower.

1. Cancer Scenario in Kashmir
Challenges & Opportunities
Prof. Shad Salim Akhtar
MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA)
Member AUICC Fellows, Fellow IDEA (ASCO)
Consultant Medical Oncologist
Chairman Board of Directors
Hakim Sanaullah Cancer Centre
Sopore, Kashmir, The State of Jammu & Kashmir

2. CANCER PATTERN

3. Ranking of Cancer as Cause of Death Worldwide
Bray F et al: CA Cancer J CLIN 2018;68:394–424

4. Projected From Census of 2011
3700
6900
All Cancers
Advanced
INDIA
• J&K Population: 12.5 million
• Kashmir Valley: 6.9 million
• Projected cancer incidence: 100/100,000
Cancer incidence in Kashmir

5. LICs Lo-MICs LRCs Up-MICs LMICs HICs World
20.1
7.1
12.9
7.9
5
3.8
1.1
13.3
5.1
7.9
4.9
2.92.2
0.6
2010 2030
81% 68% 71% 60% 64% 38% 51%
Percent Change
Worldwide Cancer Incidence
Income Group 2010 vs 2030 (in Millions)
Morgan GW: Improving Health Care & Cancer Services in Low Resource Countries JGO, Dec 2018:1-11

6. Wani MA et al: Ind Journal Cancer 2014;51:132
Cancer Cases in Kashmir Hospital Based Data
Number of Patients Per Year 2000-2012

7. Relative Frequency of Sites: SKIMS
2000-2012
Site No %age No/Yr
Esophagus 3031 19.9 233
Lung 2513 16.5 193
Stomach 1763 11.6 136
Colorectal 1118 7.4 86
Lymphomas 820 5.4 63
Skin 526 3.5 40
Laryngopharynx 456 3.0 35
Others 4966 32.7 382
Total 15193 100.0 1169
Site No %age No/Yr
Breast 1611 16.8 124
Esophagus 1231 12.9 95
Ovary 713 7.4 55
Colorectal 640 6.7 49
Stomach 632 6.6 49
Lung 437 4.6 34
Gallbladder 373 3.9 29
Others 3938 41.1 303
Total 9575 100.0 737
Males Females
Wani MA et al: Ind Journal Cancer 2014;51:132

8. 5.5
7.7
8.4
15.2
18.4
Breast Esophagus Ovary Colorectal Stomach
Iqbal QM et al: Int J Comm Med Public Health 2016;3:1672
Relative Frequency Cancer Sites Kashmir
Females 35-64 yrs

9. 3.2
7.5
11.9
18.4
18.6
Esophagus Lung Stomach Colorectal Skin
Relative Frequency Cancer Sites Kashmir
Males 35-64 yrs
Iqbal QM et al: Int J Comm Med Public Health 2016;3:1672

10. Age Group 15-34 Yrs
Ovary Breast Colorectal NHL My Leuk
6.97.1
10.1
12.4
14.1
NHL Colorectal My Leuk Ly Leuk Testis
7.1
8.28.2
10.510.7
Females
Males
Iqbal QM et al: Int J Comm Med Public Health 2016;3:1672

11. Annual Percent Change Colorectal Cancer incidence:
European countries Adults aged 20–39 years, 1990–2016.
Increasing trend
Vuik FER, et al. Gut 2019;68:1820–1826

12. Buckland D. Prescriber UK 2016
Manitoba Model

13. PREVENTION

14. Trends in prevalence of smoking at
ages 35-59 in men and women in the
United Kingdom, 1950-98.
Trends in mortality from lung
cancer in men and women in the
United Kingdom
BMJ 2000;321;323-329

15. KAP in Cancer Study in Kashmir
Response to Questions
• What is cancer?
• Dangerous disease 63.9%
• Fatal disease 11.5%
• Incurable disease 5.8%
• Risk factors for cancer
• Smoking 79%
• Early stage is curable 72.2%
• We can do nothing to lower the chances of getting
cancer 68.1%
• Ultrasound the best modality to diagnose cancer
Wani S et al: KAP about Cancer in Kashmir, Presented at 5th MCCLR, Srinagar April 2018.

16. Smoking Behavior in Kashmir
All Males Females
Prevalence 26.6% 41.6% 10.3%
Age at starting 17.3 yrs 17.5 yrs 14.9 yrs
Exposure at home 69.7% 72.1% 66.9%
Exposure at
workplace
67.9% 70.6% 61.4%
Exposure at public
places
35.2% 46.1% 23%
GATS Data 2016: WHO

17. SCREENING

18. Effect of Screening Mammography and
Adjuvant Therapy on Breast Cancer Mortality
Berry DA et al: N Engl J Med 2005;353:1784-92.
Data based on multiple models
Age adjusted breast
cancer mortality rates:
2003 vs 1989
24% less
Smith RA. NEJM 2007; 356:1362

19. Is Screening Feasible in Kashmir
• Disease burden is not so high
• Needs a lot of resources
• For effective screening process
• Dealing with false positives
• Delay in managing the detected cases
• Has to be a continuous process
• Regular call and recall
• Screening rounds at regular intervals

20. EARLY DETECTION

21. Reasons for Delayed Presentation
Breast Cancer Pakistan-Patient Factors
Gulzar F et al: Cancer Management and Research 2019:11 1087–1096

22. Olesen F et al: Br J Cancer 2009; 101(suppl 2):S5-S8

23. 19.7
22.7
48.5
9.1
T1 T2 T3 T4
Breast Cancer in Kashmir
Size & Nodal Status at Presentation
Wani SQ et al: J Can Res Therap 2012;8:389
30.3
54
15.2
N0 N1 N2

24. 5.5
49.8
19.9
24.7
Stage1 Stage 2 Stage 3 Stage 4
Colorectal Cancer in Kashmir
Stage at Presentation
Bhat SA et al: Clin Surg 2019; 4: 2368

26. MANAGEMENT

27. Wilson LM et al: The Lancet 2018;391:1927-
Cancer Management Pathway
Pathology and Laboratory Medicine PALM

28. Wilson LM et al: The Lancet 2018;391:1927-
Global Workforce Capacity in PALM

29. SKIMS GMC Private Sector
Histopathology Yes Yes Yes
IHC Preliminary Preliminary (Preliminary)
FISH NA NA NA
Flow cytometry Yes NA NA
Cytogenetics NA NA NA
Genomics NA NA NA
Cancer Diagnostic Facilities in Kashmir
Overall quality of pathological workup needs lot of improvement

30. “As is your
Pathology so is
your Practice”
William Osler
Wilson LM et al: The Lancet 2018;391:1927-

31. By training a few of our pathologists Dr. Guru Charitable
Foundation has helped us to get reports as per CAP
guidelines at least from GMC.

32. SKIMS GMC Private Sector
CT scan 2 2 >10
MRI 1 1 >4
Gamma camera 1 0 1
Mammography NA 1 4
PET/CT 1 NA NA
Cancer Imaging Facilities in Kashmir
Long waiting period in Govt. sector
Quality of imaging?
Quality of reporting?

33. Effect of Radiological Review
Schlemmer HP et al: Global Challenges for Cancer Imaging. JGO; September 2018

34. Radiotherapy facilities Worldwide
Developed
Developing
Stewart BW et al: World Cancer Report IARC: 2003
Population
Radiotherapy facilities
RT is needed for 50-60% of pts
during the course of illness
IAAE recommendation =
1 RT unit for 250,000

35. Radiotherapy facility SKIMS GMC Private sector
Radiotherapy staff 8 5 1
Radiotherapy Cobalt 1 1 NA
Radiotherapy LineAc 1 ??1?? NA
Brachytherapy Yes NA/? NA
Electron therapy ?? NA NA
SBRT NA NA NA
Radiotherapy Facilities in Kashmir

36. SKIMS GMC Private Sector
Surgical Oncology 4 2 3
Med/Ped Oncology 2 3 4
Hematologist 3 1 1
HSCT Yes (Auto) No No
Palliative Care 1 0 1
Home care NA NA 2
Cancer Treatment Facilities in Kashmir
Research “Episodic”

37. Cancer Treatment Facilities in Kashmir
Hakim Sanaullah Cancer Center (Rural based)
Diagnostic facilities
Chemotherapy (Satellite center Srinagar)
Palliative Care (Satellite center Srinagar)
Surgical Oncology
Home care
Cancer Society of Kashmir
Diagnostic facilities
Day care chemotherapy
Home care
Other NGOs Indirect Help

38. PALLIATIVE CARE

40. 425
222
19
21
18
1
16
10
8
31
Ganderbal
Bandipora
Shopian
Kulgam
6

41. Pall Care: Symptoms at Presentation
Pain

42. <15 16-30 31-45 46-60 61-75 76-90 91-105 106-120 121-135 136-150 151-165 166-180 >180
81
1111
8
17
15
1818
16
33
20
30
78
Duration of Follow Up (Days)
Median80.5 + 110 Days
Data Available for 356
deceased patients
86% Died at home
Hakim Sanaullah Cancer Centre Pall Care
Centre Follow Up

43. Follow Up
• High incidence of abandonment
• Reasons:
• Transportation to & fro treatment facilities
• Financial toxicity
• Very few can afford
• Expensive investigations
• Targeted therapy
• Chemotherapy
• Lack of social support
• Cancer stigma

44. Cancer Survivorship in Kashmir
• No special survivorship programs
• No long term toxicity, side effect
management
• No rehabilitation programs
• Cancer continues to be a stigma

45. How Can We Be Supported?
• Awareness
• Mobile app for public awareness
• Prevention - antismoking
• Capacity building
• Workforce
• Logistic support for management
• Collaboration in research & development
• Twining and connecting the centers
• With each other
• With North America/Europe
• Data keeping & archiving
• Develop each centre as a specific training unit

46. Cancer Care in Conflict Zone Kashmir
• Awareness & early detection will suffer most
• Management obstacles:
• Transportation
• Investigations
• Outsourcing
• Availability of
• Doctors
• Staff
• Drugs
• Financial issues
• Continuous PALLIATIVE CARE may disappear

47. ACKNOWLEDGEMENTS

49. KASHMER Ambulance Service

50. THANK YOU FOR YOUR
ATTENTION