IJHNS
10.5005/jp-journals-10001-1132
Head and Neck Cancer Burden in India

REVIEW ARTICLE

Head and Neck Cancer Burden in India
Manik Rao Kulkarni

ABSTRACTIntroduction: Head and neck cancer in India has distinct
demographic profile, risks factors, food habits, and personaland family history. They are emerging as major public healthproblems in India, which are lifestyle related, have a lengthy
latent period and need dedicated infrastructure and humanresource for treatment. Need based and coordinated researchfor understanding the threats to the nation from chronic diseases
such as head and neck cancers and ways to defy such threats
will assume increasing importance.
Magnitude of problem in India: Overall, 57.5% of global headand neck cancers occur in Asia especially in India. Head andneck cancers in India accounted for 30% of all cancers. In India,
60 to 80% of patients present with advanced disease ascompared to 40% in developed countries. A slow decline in theincidence of most of head and neck cancers has been
documented in India.
Management of head and neck cancers in India: The problemof managing head and neck cancers in India is somewhat
different, as compared to the west. The major shortcoming is tocope up, with the loss to follow-up, which makes the task of
conducting and reporting the end results of clinical trials awfully
difficult.
Conclusion: The highest priority for cancer control should begiven to the burden of head and neck cancer in India. The
emphasis should be on preventing the onset and detecting thedisease at an early stage. In developing countries like India,
implementing cancer control activities has to be prioritized,
making optimal use of limited resources to deliver the utmost
benefit to the largest number of people.
Keywords: Head and neck cancer, Incidence, Etiology,
Management, Tobacco, Oral cancer, Radiotherapy, Burden.
How to cite this article: Kulkarni MR. Head and Neck Cancer
Burden in India. Int J Head and Neck Surg 2013;4(1):29-35.
Source of support: Nilphysiological needs, and crucial for appearance, expression,and social interaction. Head and neck cancers can cause
varying degrees of structural deformities, and functional
handicaps, depending on the site, size, and patterns of
spread, thereby compromising well-being and self-esteem.
The quality of life can be further worsened by treatment ofhead and neck tumors which can induce additional
mutilation.3
In our surge toward becoming a healthier, wealthier andfinest nation, need based and coordinated research forunderstanding the threats to the nation from chronic diseases
such as head and neck cancers and ways to defy such threats
will assume increasing importance.4
Magnitude of problem in India: Overall, 57.5% of global
head and neck cancers (excluding esophageal cancers) occur
in Asia especially in India, for both sexes.5
Head and neck cancers in India accounted for 30% of
all cancers in males (Fig. 1) except Dibrugarh in Assam(49.6%). In females they constitute 11 to 16% of all sites ofcancers (Fig. 2). Among them, tongue and mouth in males
contribute to more than one-third of the total cancers except
in Dibrugarh where hypopharynx (34.5%) was the major
contributor and among females mouth cancer was theleading cause (Fig. 3).6
Over 200,000 cases of head and neck cancers occur eachyear in India. Nearly 80,000 oral cancers are diagnosed every
year in our country.7 Nearly two-thirds of oral cancers arelocated in the buccogingival sulcus, where the betel quid is
kept for long periods in the oral cavity. The location andetiology of this buccogingival cancer may warrant the term‘the Indian oral cancer’. Maximum number of mouth cancers

Conflict of interest: None

INTRODUCTION
Head and neck cancers in India are emerging as major publichealth problems, which are lifestyle related, have a lengthy
latent period and need dedicated infrastructure and humanresource for treatment. In India, 6.5% of the total populationis represented by older persons (60 years and above).1 The
burden of cancer in India is on the rise with the control of
infectious diseases and increased longevity of the growing
population.
Head and neck cancer in India has distinct demographic
profile, risks factors, food habits, family and personal
history.2 The head and neck region constitute several
delicate, intricately organized structures vital for basic

Fig. 1: Top cancers in India in both sexes8,25International Journal of Head and Neck Surgery, January-April 2013;4(1):29-35

29Manik Rao Kulkarni

among males was seen after the age of 55 years except in
Mumbai where it is more common in the age group of 45 to
49 years, whereas there is much variation seen in females.8
Around 40,000 cases of pharyngeal cancers excluding
nasopharyngeal cancers (31% of global cases) and nearly
29,000 cases of laryngeal cancers (18% of global cases)
occur in India every year. India stands second placein prevalence of esophageal cancers (77,000), after china.5
Regional differences in the prevalence of risk factors
are the reason behind the variability in incidence and patternof head and neck cancer. Most of the oral lesions are detectedin their advanced stages although oral cavity is accessible
for visual examination. In fact, 60 to 80% of patients present
with advanced disease in India, as compared to 40% indeveloped countries, consistent with which, the overall
survival is also reduced.9
In an other study at Kidwai Memorial Institute of
Oncology, in Bengaluru, 2004-2005, pharyngeal cancers

was the leading sites of cancer in males (14.1%), especiallyhypopharynx (Fig. 4) and then oral cavity (11.2%). In females,
next to cancer cervix and breast, cancers of oral cavity(11%), and esophagus remained most common cancers.10
INCIDENCE
Bhopal has the worlds highest age standardized incidenceof both tongue (10.9) and mouth cancers (9.6) in males.
Trivandrum has a high incidence of oropharyngeal cancers
in males.
The world’s highest incidence of cancers associated withtobacco are found in districts of northeast, central andsouthern India. The world’s highest incidence of cancers inmen of the lower pharynx (11.5 per 100,000 people) andtongue (7.6 per 100,000 people)6 are reported in Aizawl
district of northeastern India. One of the highest incidence
rates of mouth cancer among men is found in Pondicherry(8.9 per 100,000) (Fig. 5).
A ‘belt of thyroid’ cancer has been identified in womenin coastal districts of Goa, Karnataka and Kerala. Sitespecific age adjusted incidence rates for oropharynx andhypopharynx are highest in kamrup (Fig. 6).
In pediatric age group incidence of head and neck tumors
is quite rare (0.25%), with the ratio of 1.8:1 in males andfemales.22 Five percent of all cancers in children are headand neck malignancies. Most commonly found are thelymphomas (43.39%) followed by the rhabdomyosarcoma(20.75%). The malignant lesions were largely seen above
5 years of age (69.81%), maximum occurring in the agegroup of 10 to 12 years (47.17%).11
TIME TRENDS IN CANCER RATES IN INDIA

Fig. 2: Proportion (%) of head and neck cancers relative to allsites, across various regions in India (2004-2006)8

A slow decline in the incidence of most of the head andneck cancers has been documented in India (Table 1). It is

Fig. 3: Stack diagram (100%) showing proportion of each headand neck cancer sites relative to all head and neck cancers in males,in various regions in India (2004-2006)8

Fig. 4: The proportion of given sites of cancer, based on recent
HBCR (2004-2006)830

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Head and Neck Cancer Burden in India

Fig. 5: Incidence of various cancers in some cities in India24

observed that trends in tongue, hypopharynx and larynx are
declining in almost all the population-based registries whilecancer of mouth is either on the rise or stable.12 Oral cancers
overall has decreased gradually for males since 1986, but
has been stable for females. In both sexes less than 40 years,
the incidence of oral cancers has been stable since 1986.5
The overall annual incidence of cancer in children under
15 years of age raised from 11.22 to 14.03 cases/100,000
person-years in 1994 to 1996, an increase of 25%. In thetime period of 1973 to 1975 an even greater increase in theincidence of pediatric head and neck malignancies has
been noted.11•

for nonsmokers. This risk may multiply to as much as
seventeen times greater for exceedingly heavy smokersof 80 or more cigarettes per day. About one-fourth oforal cancer cases are attributable to cigarette smoking.
More than 60 carcinogens are present in cigarette smoke
and at least 16 in smokeless tobacco have been
identified.14
Besides smoking, use of smokeless tobacco is extremely
prevalent. The use of betel quid (pan) is extremely

ETIOLOGY IN INDIA
Most head and neck cancer cases and deaths are due to bothindividual predisposition linked to certain genetic
characteristics, and exposure to carcinogens caused bylifestyle behaviors. In addition, exposure to two or more offollowing risk factors has a synergistic effect in increasingoral cancer risk.13• Tobacco smoking in the form of cigarettes, bidis, cigars/
chutta/cheroot, dhumti (Goa), the water pipes/hookah(north India), reverse chutta smoking (in coastal regionsof Andhra Pradesh and Orissa), hookli (Gujarat) andchillum (northeastern parts of India). Around 57% of
all men and 11% of women in India, between 15 and49 years of age use some form of tobacco. Results fromthe global youth tobacco survey in India show that about
10 to 20% of students in 8th to 10th grades (about 1315 years), currently use tobacco in some form.
The strong association of cancers of the pharynx andoral cavity with the tobacco use is well recognized.
Epidemiological studies show that the risk of developing
oral cancer is five to nine times greater for smokers thanFig. 6: Site-specific age-adjusted incidence rates6
Table 1: Decline in age-adjusted incidence rates in males from1966 to 19975
Cancer site

Change in age-adjusted
incidence rates (%)

Change (%)

TongueOropharynx
Larynx
Mouth
Hypopharynx

14-5.7
6.1-0.8
13.8-7
7.5-5.7
10-5.959.3 decrease
87 decrease
49 decrease
24 decrease
41 decrease

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31

Manik Rao Kulkarni

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widespread in many parts of India. In addition, zarda,
gutka, kharra, mawa, and khainni are custom mixed by
vendors and are all dry mixtures of areca nut flakes,
lime, tobacco power.9 It is also used as a moist snuff
containing lime with tobacco, vegetable oil and water(Naswar/Nass) and also in the form of dried tobacco
applied on gums and teeth.5
Betel quid chewing, well known to cause
precancerous conditions of the mouth like submucosal
fibrosis has been identified as an oral carcinogen inhumans, with evidence for a dose–response relationship,by the International Agency for Research on Cancer.15
A recent Population Based Cancer Registry (PBCR)
report shows that the proportion of cancers related totobacco use among males in India, varies from 33.4%
in Bangalore to 50.6 in Ahmedabad. The relative
proportion of tobacco cancers, varies from 15.2 in bothBangalore and Chennai to 10.7 in Delhi among females.9
Head and neck cancer risk markedly increases whensmoking duration is more than twenty years and the dailyfrequency of smoked cigarettes is higher thantwenty.16,17
Alcohol consumption regularly, is associated with anincreased risk for oral cancer, which is dose-dependent.
Regular consumption of 4 to 5 drinks daily, the risk fororal cavity cancer is 2- to 3-fold higher than among
nondrinkers. Overall, 7 to 19% oral cavity cancer cases
are attributable to heavy alcohol drinking.18
Alcohol alone and in combinations with smoking: The
addition of alcoholic drink, to intake of tobacco in any
form further increases the risk for oral cancer by elevenfold.18 A case control study on oral cancer (buccal andlabial mucosa) in Thiruvananthapuram, showed that
alcohol alone conferred a nonsignificant odds ratio of
2.6, however there was a significant odds ratio seen withalcohol with bidi smoking (8.5), alcohol and pan tobacco
chewing (20), and with alcohol, pan and smoking
altogether (31.4%).5
Recent evidence suggests that human papilloma virus(HPV) may be linked with some oropharyngeal and oral
cancers. HPV-16 has been detected in up to 22% andHPV-18 has been found in up to 14% of oral cancers
cases.
Sexual behaviors are linked with cancer risk at thehead and neck cancer sites that have previously been
associated with HPV infection. Having a history of six
or more lifetime sexual partners and four or more lifetime
oral sex partners has been linked with cancer of theoropharynx.19
Oral cavity lichen planus, in specific the erosive form,
may be associated with an enhanced cancer risk. Iron
deficiency anemia in combination with dysphagia and

•

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•

postcricoid webs (Plummer-Vinson syndrome) is
associated with a high risk for development of carcinomaof the oral cavity, oropharynx and esophagus.15,20
Nutrition and cancers: Regular vegetable consumption
and fish in the diet have been shown to be protective, ina case control study in India on various head and neckcancers, with nonconsumers having 2-fold risks. To alesser extent butter milk and pulses were also found to
be protective.
Oral precancerous conditions: In India majority of oralcavity cancers are preceded by precancerous lesions,which have similar etiology to oral cavity cancers andare almost solely found in tobacco users. There are threemajor types of lesions. The commonest form being
leukoplakia (Indian prevalence 0.2-5.2%) with malignant
transformation rates 0.13 to 10%. Erythroplakias are themost severe of all the precancerous lesions and carry amuch higher risk of malignancy transformation thanleukoplakia. The other precancerous lesion being
submucosal fibrosis with malignant transformation of
about 17% and is considered as important factor in theincreasing incidence of oral cancers in individuals
35 years and below in India.5
Chronic actinic exposure is associated with theoccurrence of carcinomas of the lip vermilion.
Immunosuppression appears to predispose someindividuals to an enhanced risk for oral cancers. In anumber of patients who have undergone kidneytransplantation and receiving immunosuppressive
medications, cancers of the lip have been reported.
Similarly in some of the young AIDS patients oral
carcinomas have even been documented.14

MANAGEMENT OF HEAD AND
NECK CANCERS IN INDIA
The problem of managing head and neck cancers in India issomewhat different, as compared to the West. The major
shortcoming is to cope up, with the loss to follow-up, whichmakes the task of conducting and reporting the end resultsof clinical trials awfully difficult.
Based on the Hospital Based Cancer Registries (HBCR)
report 2004 to 2006, in both sexes, microscopic examination
was the most widely used method of diagnosis for the headand neck cancers. Over 80% of cancers in both sexes had
regional spread of disease at the time of diagnosis except in
Mumbai where 77.8 and 72.4% in males and females
respectively had regional spread.
Diagnostic infrastructure in many parts of India is scarce.
The services of a pathologist or pathology/cytology center
which are crucial for diagnosing cancer are not available
in many districts in India. There is a significant urban
concentration of facilities because of economic and
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Head and Neck Cancer Burden in India

geographic constraints and lack of man power. A significant
number of cancers diagnosed in the population are not treated.
Treatment facilities are also mostly restricted to urban
areas of the country. There are no uniform protocols for
management, the affordability and availability of cancer
treatment shows broad disparities. Radiotherapy is the mostcommon modality of treatment for head and neck cancers
in various prominent cities in India (Fig. 7). Surgery withradiotherapy being the most common form of treatment
given in Mumbai (36.9% cases) (Table 2) .
Treatment results are about 20% less than what isobserved for similar conditions in more developed countries,
mostly due to late diagnosis and inappropriate treatment.
Childhood cancers are highly curable but this has not beenachieved in India due to lack of access to quality care andlack of support systems. 21 The highest 5 years age
standardized relative survival for tongue, hypopharnx,
laryngeal cancer was seen in Mumbai (Table 3).
The head and neck cancers prognosis has notexperienced a considerable enhancement, despite theadvancements and great strides that have been made inrecent decades. Since 5-year survival is directly related tostage at diagnosis, the need is for early diagnosis, which
depends upon a wise clinician or patient who may identify
a suspicious symptom or lesion, while it is still at an earlyFig. 7: Most common modality of treatment given for head andneck cancers in various prominent cities in India8stage.14 Mortality in India due to head and neck cancers is
at least half of the incidence, basically due to latepresentation of patients for treatment5 (advanced stage
III = 39%, IV = 23%).2
In India, the high incidence of head and neck cancers isfurther compounded by the fact that there are only about
200 trained head and neck oncologists, the bulk of them inthe six major cities. As a result, a large number of patientsare referred for primary radiation therapy, irrespective ofstage and probability of disease control. The bulk of thecancer load is managed by a dozen regional cancer centers,
which are government funded, overburdened with patients,
have a long waiting lists and no specialized head and neckdivisions. The concept of health insurance in India is notwidely established and affordability is a major problem inIndia.7
Population based 5-year survival for patients with thegroup of oral cavity cancers is approximately 50% in the
United States, ranges from 45 to 49% in Europe andapproximately 30% in India (Fig. 8). There has been very
little progress in overall 5-year survival over the last 3
decades; although 5-year survival for localized cancers
exceeded 80% in the United States, it was approximately
60% in selected developing countries. The overall survival
which is poor reflects the advanced stage at diagnosis forthe vast majority of these cancers, as 5-year survival seldom
exceeds 40% for patients with regional disease and 15%
for those who have disease with distant metastasis.22
Although illiteracy and poverty are the often cited
reasons for our neglect toward extent of quality of life inhead and neck cancer patients, it is actually the lack ofphysician awareness, and the nonavailability of valid toolsthat are responsible for the paucity of quality of life studies
in India.3
Based on the survival studies from Mumbai in year 2000,
less than 25% of cancers were localized in the organ oforigin at diagnosis and depending on the subsite, the 5-year
survival for localized cancers ranged from 53 to 80%. Thosewith regional spread of disease, experienced a 3-foldincreased risk of death, and those with distant metastasis
experienced a 6-fold excess risk.12

Table 2: Relative proportion of head and neck cancer patients according to the type of treatment given in males 2004-2006(consolidated report of the HBCRs: 2004-2006)8
Type of treatment

MumbaiBengaluru

Chennai

Trivandrum

Dibrugarh

Surgery
Radiotherapy
Chemotherapy
Surgery + radiotherapy
Surgery + chemotherapy
Radiotherapy + chemotherapy
All three modalities

19.7%
18.8
6.1
36.9
0.8
15.5
2.2

11%
54.8
5.2
16
0.8
10.6
0.2

4.2%
44.7
1.2
17.9
0
28.2
3.9

7.2%
44.6
5.4
9.9
0.8
26.2
5.5

3.3%
85.9
2.3
4.4
0.2
3.4
0.6

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33

Manik Rao Kulkarni

Fig. 8: Five-year relative survival rates of head and neck cancers
in Mumbai in 200223

HEAD AND NECK CANCER CONTROL IN INDIA:
INTERVENTIONS BY PRIMARY PREVENTION•

The most effective prevention strategy is reduction in
consumption of tobacco in all forms. These cancers canbe prevented to a large extent through a comprehensive
tobacco control program which includes education,awareness, legislation, community participation andtobacco cessation services especially targeted at teenage
students who pick up habit at an early time.
A proportion of cancers are considered to be related tothe dietary practices. The role of diet takes special
importance in countries like India, which are fast surging
toward industrialization and westernization. Timely
action has to be taken to spread the significance of ahealthy diet rich in vegetables and fruits. A recent study
shows that consumption of vegetables, iron, zinc, copper,
ascorbic acids, beta carotene are associated withdecreased risk of precancerous conditions. 5 Moreattention has been given recently, on particular aspectsof the Indian diet, such as vegetarian diet, additives infood and spices. The role of turmeric (Curcuma longa),a common constituent in Indian cuisines, has received
specific interest for cancer prevention. Researchers havealso investigated cumin seeds, chilies, herbal health•foods, and a variety of plant seeds for their apparent
cancer preventive properties.23
For prevention of cancers related to infectious agents
such as HPV and hepatitis B virus, vaccination strategies
have to be efficiently utilized.
Mass examinations (screenings): Early detection should
therefore be an important strategy–through the two
principal routes of public education and screening. As
oral cancer has well-defined risk factors, these may be
modified giving real hope for primary prevention. The
most widely used screening test for oral cancer is visualinspection of the oral cavity.10 The test performance is
acceptable in terms of specificity, sensitivity andpredictive value and, hence, a suitable screening testfor oral cancer.11,22
Need of the hour: A multidisciplinary approach to cancer
treatment is necessary and this has to be made available
at all Regional Cancer Centers, district hospitals andtertiary care centers. The services of a trained surgeon
and a clinical oncologist are required to plan the most
apt treatment. Radiotherapy services are still themainstay of treatment given to the major proportion ofadvanced head and neck cancers in India. Optimal
strategies have to be identified and implemented, given
the long waiting lists of patients and the distance they
have to travel to reach treatment facilities. Patients forpalliative treatment and curative treatment need to be
identified at the beginning of the treatment plan. An
essential list of drugs has to be prepared for cancer
chemotherapy and the chemotherapy facilities have to
be made available in all treatment centers. Rehabilitation
and availability of prosthetics are to be made accessible
at lower costs.
HUMAN RESOURCE GENERATION
A large number of trained personnel in various specialties
are required for control of cancer. These include
epidemiologist, cytotechnologists, cytotechnicians andnurses trained in palliative care and in care of patients on
chemotherapy and radiotherapy, medical personnel in all

Table 3: Comparison of 5-year age standardized relative survival of major head and neck cancer sites between various registries23
Cancer site

TongueOral cavity
TonsilOropharynx
Nasopharynx
Hypopharynx
Esophagus
Larynx34

Five-year age standardized relative survival (0-74 years) (%)
Barshi
1993-00

Bhopal1991-95

Chennai
1990-99

Karunagappally
1991-97

Mumbai
1992-99

11.8
26.1
—
—
—
10.0
5.3
15.7

13.1
37.5
—
—
—
2.0
3.6
15.7

23.4
36.7
15.6
20.7
—
15.0
8.6
—

29.6
45.3
—
—
—
15.5
18.5
28.3

29.7
36.0
16.6
20.4
24.7
23.1
16.2
36.0

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Head and Neck Cancer Burden in India

aspects of cancer treatment, physiotherapists andoccupational therapists, counselors and more importantly
trained head and neck cancer surgeons.
PALLIATIVE CARE
Palliative care and pain relief are essential to impart goodquality of life for the cancer patients. Oral morphine is thebasis for management of cancer pain and this has to be madeavailable at all centers.
CONCLUSION
The highest priority for cancer control should be given to
the burden of head and neck cancer in India. With manyhead and neck cancers are difficult to manage, but being
highly preventable, the emphasis, therefore, should be on
preventing the onset and detecting the disease at an earlystage. In developing countries like India, implementing
cancer control activities has to be prioritized, making
optimal use of limited resources to deliver the utmost benefit
to the largest number of people.
ACKNOWLEDGMENT
I sincerely want to thank Dr Pankaj Chaturvedi, Associate
Professor, Tata Memorial Hospital, Mumbai for his
inspiration and guidance and also would like to thank Dr
Guruprasad Bhatt for his timely help.
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ABOUT THE AUTHOR
Manik Rao Kulkarni
Assistant Professor, Department of ENT and Head and Neck Surgery
Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, Indiae-mail: drmanvrk@rediffmail.com

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