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Report Screening for Cervix and Breast Cancer in Mumbai Slums
The population of Mumbai is around 13 million (2001 census), making it the third largest conurbation in the world. A staggering 30% of the population live in slums which, for all practical purposes, can be considered a parallel city. According to the Maharashtra State Government’s slum census of 1976 (the only slum census ever taken), around 20% of these households lived below the poverty line. The current picture is not significantly different. The degree of deprivation of life in the slums is enormous, and is not due to poverty alone. The dwellings provide little protection from the elements, especially the torrential monsoon of Mumbai. There is a perennial shortage of water (a survey in 1981 found a ratio of 203 users per municipal tap) and the taps provide water for only an hour every day. The lack of sanitation is an even worse problem. A 1981 survey found that there were nearly 100 people per toilet. Consequently, children squat wherever they can. To make matters worse, there are also illegal (and hence unregulated) small industrial units within the slums, which are a major source of pollution. Hence, although a majority (80%) of the household incomes may well be above the poverty line, the reality of life in the slums is appalling and fraught with health hazards. The Tata Memorial Hospital, established in 1943, has been the principle cancer treatment center in South Asia for some time. Over the years, it has become clear that more than 70% of patients with cancer present with advanced disease, making treatment difficult, expensive and frequently ineffective. Since 1993, the center has therefore increased its focus on the prevention and early detection of common cancers. In 1997, the center received a National Institute of Health RO1 grant for “Early Detection of Breast and Cervix Cancer among Women.” This project involves screening of women from low socio-economic groups, using simple, low-cost technology. The principle aims of the study are:
When we started the process of sampling eligible women (aged between 35 and 64 who had resided in the selected areas for a year), we quickly realized that the electoral register and other available population lists could not provide us with the information required. We therefore divided the slum areas of Mumbai into geographical clusters and by simple random techniques selected 10, with an average of 15,000 eligible women in each. Each cluster was then randomized by geographical demarcations (e.g., railway lines and major roads) into group A (the intervention arm) and group B (the control arm). Women with 10th grade education and above (preferably living in the same areas) were recruited and trained for a period of three months at the hospital. Screening began in May 1998. We had planned to screen women annually six times. However, we realized by the end of 1998 that this was unattainable and therefore moved to a more feasible target of screening at 18-month intervals, four times. Currently, screening in the intervention arm has taken place twice. The final round will be completed in 2004. Thereafter, a registry will be kept of the incidence and mortality of breast and cervix cancer in the ‘intervention’ and ‘control’ areas until December 2010. At first, compliance with ‘invitation-for-screening’ in the intervention arm was 76%, but fell to 68% during the second round. Compliance with health-education meetings in the control group was around 91%. Among women who attend for clinical breast examinations, only 80 - 90% undergo screening for cervix cancer (Muslim women allow only breast examination during the Islamic holy month of Ramadan). The compliance with referral for treatment for women deemed positive by screening was 61% for breast cancer and 67% for cervical cancer. Only 40-60% of women confirmed as having invasive cancer completed treatment. Some of the data are presented in the following tables (Tables 1-5). Very useful information is expected to be generated from this study, which will ultimately guide the breast and cervix cancer screening strategies in this country. This information should be available to us from 2006 onwards. In the meantime, however, the following points may be of interest for others who may be contemplating such studies in the future, in similar conditions:
Table 2: Compliance with ‘invitation-for-screening’ – 2nd
round
Table 3: Compliance with referral for treatment – 1st round
HSIL: High-grade squamous intraepithelial lesion; LSIL: Low-grade squamous intraepithelial lesion * Interval Cases NA: Not applicable Table 4: Self referrals (control arm)
NA: Not applicable Table 5: Frank Malignancies Detected (1st and 2nd rounds - over 3 years)
K.A. Dinshaw; S.S.Shastri; S.Singh; S. Aranke; G.Mishra; R. Pilankar; I.Mittra; Tata Memorial Centre, Mumbai, India
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Copyright © 2010 The International Network For Cancer Treatment and Research