Article ID: WMC003626ISSN 2046-1690An Overview of Oral Cancer in Indian Subcontinentand Recommendations to Decrease its Incidence.Corresponding Author:Dr. Zahid Ullah Khan,Assistant professor, Community Medicine Department, NIMS Medical College, Abbottabad., House No: 01,Opposite Police Colony Gate No: 02, Kalapul, Mansehra Road, Abbottabad., 22010 - PakistanSubmitting Author:Dr. Zahid U Khan,Assistant professor, Community Medicine Department, NIMS Medical College, Abbottabad., House No: 01,Opposite Police Colony Gate No: 02, Kalapul, Mansehra Road, Abbottabad., 22010 - PakistanArticle ID: WMC003626Article Type: Research articlesSubmitted on:05-Aug-2012, 04:46:02 PM GMTPublished on: 06-Aug-2012, 05:07:32 PM GMTArticle URL: http://www.webmedcentral.com/article_view/3626Subject Categories:CANCER Keywords:Oral Cancer in Indian Subcontinent and Preventive RecommendationsHow to cite the article:Khan Z. An Overview of Oral Cancer in Indian Subcontinent and Recommendations toDecrease its Incidence. . WebmedCentral CANCER 2012;3(8):WMC003626Copyright: This is an open-access article distributed under the terms of the Creative Commons AttributionLicense(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.Source(s) of Funding:I have not taken any funding for this article from any other party and its only my work and have not been fundedby any third party.Competing Interests:NoWebmedCentral > Research articles Page 1 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMAn Overview of Oral Cancer in Indian Subcontinentand Recommendations to Decrease its Incidence.Author(s): Khan ZAbstract.TheObjectiveofthisarticleistoreviewthecurrentprevalence and risk factors for oral carcinoma acrosstheIndiansubcontinent.OralcancerisincreasinginIndiansubcontinentmainlyduetolackofhygiene,tobaccouse,chewingtobaccoleaves,smokingandmany other factors which are discussed in detail in thisarticle. Cancer is the second most common cause ofmortalityandmorbiditytodayaftercardiovascularproblems. Oral cancer is the eleventh most commoncancer in the world and two third deaths due to oralcanceroccursindevelopingworld,outofwhichonethird occurs in Indian Subcontinent. Human papillomavirus is a known risk factor oral cancer specially type16 and 18.This is causing not only huge impact onthe health of the community but also the economy oftheIndi ansubconti nentcountri es.Wehavesummarizedfewrecommendationsinthisarticle,bywhi choral cancercanbetackl edi nIndi ansubcontinent.Wehaverecommendeddifferentapproaches from primary prevention to secondary andtertiarypreventionmethods.Theseincludebetterhygiene,healtheducation,andproperscreeningmethods to detect those at risk, earlier treatment andsmokingcessationclinics,properlegislationatgovernment level and global approach as well.Table of Contents1. Introduction---- 41.1 Indian Subcontinent---- 41.2 Oralcancer------ 41.2.1 The international scenario for oral cancer--- 42.Thescenari ofororal canceri ntheIndi anSubcontinent--- 52.1 Cancer registration in the Subcontinent------- 53.Thepl anofacti onfororal canceri ntheSubcontinent---- 63.1 The vision3.2 The mission-- 143.3 Core values-- 143.3.1 Science --- 14 3.3.2 Trust ----- 143 . 3 . 3 S o c i e t y - - -15 3 . 4 Ov e r v i e w - - -153 . 5 C u r i n g o r a l c a n c e r - -15 3. 6Faci ngt hechal l engeof t obacco- -163.7Buildingcapacitythroughco-ordination--16 3 . 8 Su s t a i n i n g t h e u n i q u e n e s s - -16 3 . 9 Ot h e r c h a l l e n g e s - -173 . 9 . 1 P s y c h o l o g i c a l a s p e c t s - -17 3 . 9 . 2 E c o n o mi c a s p e c t - -17 4.SAOCFseffortsinaddressingthechallenges--174. 1Addr essi ngt hevar i ousaspect s- -17 4 . 2 B u i l d i n g c o mp e t e n c i e s - -18 4.3Bridgingresearchandpracticalefforts--18 4. 4Fac i ngt hebur denof di s eas e- -184 . 5 A d d r e s s i n g d i s p a r i t i e s - -194.6 Professional workforce -- 194. 7St r engt heni ngt her esear chbase- -19 4.8Creationofaplatformforunitedefforts--20 4.9Creati ngmedi aandpubl i cawareness--20 4.10Establishinganddevelopingcollaborations--20 4.11 Creating and upgrading tangible evidence based -- 215. Experience with technical and policy solutions --215 . 1 S o l u t i o n s - -215 . 1 . 1 P r i ma r y p r e v e n t i o n - -22WebmedCentral > Research articles Page 2 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PM5.1.2Costeffectivenessofprimaryprevention--225 . 1 . 3 Co mmu n i t y i n t e r v e n t i o n s - -23 5 . 1 . 4 Ma s s me d i a i n t e r v e n t i o n - -23 5.1.5 Sufficient evidence for long term oral cancer riskReduction for the South Asian region-- 23 5 . 1 . 6 S e c o n d a r y p r e v e n t i o n - -245.1.7Costeffectivenessofsecondaryprevention--245 . 1 . 8 Me d i c a l i n t e r v e n t i o n s - -24 5.2 Programmatic approach and structural challenges-- 24 5 . 3 T o b a c c o c e s s a t i o n c l i n i c s - -25 5 . 4 E c o n o mi c i n t e r v e n t i o n s - -255.5Politicalapproachesandstructuralchallenges--255 . 6 L e g i s l a t i o n - -26 5 . 7 Gl o b a l s t r a t e g y - -27 5.8 Reasons for current lack of activity or ineffectivelegislationandImplementationinSouthAsiancountries -- 276. Conclusion -- 27 7. References -- 281. Introduction 1.1 IndianSubcontinentTheIndianSubcontinentisaregionoftheAsiancontinentontheIndiantectonicplatesouthoftheHimalayas,formingalandmasswhichextendssouthwardintotheIndianOcean.ItisalsocalledSouth-Asiansubcontinent,Indo-Paksubcontinentorsimply South-Asia or the Subcontinent. Geographically,theIndiansubcontinentisapeninsularregioninsouth-central Asia, rather resembling a diamond whichis delineated by the Himalayas on the north, the HinduKushinthewestandArakaneseintheeast;andwhich extends southward into the Indian Ocean withtheArabianSeatothesouthwestandtheBayofBengaltothesouth-east.Withallsevencountriesincluded,theareacoversabout4.4millionsquarekilometres,whichis10%oftheAsiancontinentor2.4%oftheworld'ssurfacearea.Someacademicshold,thatthetermSouthAsiaismorecommoninEurope and America as compared to subcontinent orIndian subcontinent. A booklet published by the UnitedStatesDepartmentofStatei n1959i ncl udesAfghanistan,Ceylon(SriLanka),India,NepalandPakistanaspartofsubcontinentregion,Indiansubcontinent: Geology and Geography. The ColumbiaElectronicEncyclopaedia,6thedition,ColumbiaUniversityPress,2003.CentralAsiacomprisingofPakistan,India,Bangladesh,Nepal,Bhutan,SriLankaandanislandoffthesoutheasterntipoftheIndianpeninsulaisalso,oftenconsideredaspartofthe subcontinent.)Historically forming the Greater Indian subcontinent orpartofBri ti shEmpi rewerePaki stan,Indi a,Bangladesh,Nepal,OffshoreofSriLanka,MaldivesandBhutan.TheregionalsoincludesthedisputedTerritory of Aksai Chin and Jammu and Kashmir whicharenowcontrolledbyXinjiangprovinceofChina.Overall,itaccountsforabout34%ofworld' spopulation.Here we consider only Afghanistan, India,Pakistan, Nepal, Bangladesh and Sri Lanka along withJammuandKashmiraspartofsubcontinent.(AfterPartition:India,Pakistan,andBangladesh.(BBC,2007-08-08).1.2 Oral cancerThetermoralcavityreferstolips,buccalmucosa,alveolar ridges, retro molar trigone, hard palate, floorofthemouthandanteriortwo-thirdsofthetongue.Oral cancer or oral cavity cancer, a subtype of headandneckcancer,isanycanceroustissuegrowthlocated in the oral cavity [3]. There are several typesoforal cancers,somebei ngsquamouscel lcarcinomas,basalcellcarcinomas,veraciouscarcinomas,nasopharyngealcarcinomas,malignantmel anoma,amel obl astoma,mucoepi dermoi dcarcinoma, and so on; around 90% are squamous cellcarcinomas,originatinginthetissuesthatlinethemouthandlips.Manyotherdifferenttypesofcarcinomas of oral cavity can finally become malignantandresultinasquamouscellcarcinoma.Oralormouth cancer most commonly involves the tongue. Itmay also occur on the floor of the mouth, cheek lining,gingiva (gums), lips, palate (roof of the mouth), maxillaor mandible. Most oral cancers look very similar underthemicroscopeandarecalledsquamouscellcarcinoma.Thesearemalignantandtendtospreadrapidly.Theseoralcancersareheterogeneousandarisefromdifferentpartsoftheoralcavity,withdifferentpredisposingfactors,prevalence,andtreatmentoutcomes.ItisthesixthmostcommoncancerreportedgloballywithanannualincidenceofWebmedCentral > Research articles Page 3 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMover 300,000 cases, of which 62% arise in developingcountries.Thereisasignificantdifferenceintheincidenceoforalcancerindifferentregionsoftheworld. The age-adjusted rates of oral cancer vary fromover20per100,000populationsinIndia,to10per100,000intheUnitedStates,andlessthan2per100,000 in the Middle East [4]. In comparison with theU.S.population,whereoralcavitycancerrepresentsonlyabout3%ofmalignancies,itaccountsforover30% of all cancers in India. The variation in incidenceandpatternoforal canceri sduetoregi onaldifferences in the prevalence of risk factors. But sinceoral cancer has well-defined risk factors; these may bemodifiedgivingrealhopeforprimaryprevention.Despitethefactthattheoralcavityisaccessibleforvi sual exami nati onandthatoral cancerandpremalignantlesionshavewell-definedclinicaldiagnostic features, oral cancers are typically detectedin their advanced stages. In fact, in India, 60-80% ofpatients present with advanced disease as comparedto40%indevelopedcountries.Consistentwithpatientspresentingformedicalcarewithmoreadvanced disease in India compared with developedcountries,overallsurvivalisalsoreduced.Earlydetection would not only improve the cure rate, but itwouldalsolowerthecostandmorbidityassociatedwithtreatment.Theprecancerouslesionsandconditionsoforalcancerarearayofhopeinprevention.The precancerous lesions are:1. Leukoplakia2. Erythroplakia3.Palatalchangesamongstreversesmokers(smoker's palate)The precancerous conditions are:1. Oral submucous fibrosis2. Oral lichen planusThe above mentioned conditions and lesions provideanopportunityforearlydetectionandthushelpprevent the malignant changes that may occur in themand then thus proceed to oral cancer. If diagnosed intheearlyphase,stoppingthetobaccohabitcanreversethecondition.Thus,ifappropriatemeasuresforearlydetectionandwithgoodpubliceducationcarried out, nipping the problem in the bud would bepossible.Classification of oral cancer is as follows:Oral cancerClassification and external sourcesICD-10C00.-C006.ICD-9140-146DiseasesDB 9288MeSHD009959International classification of oral tumors by Americansociety of cancer.1.2.1 The internationalscenario for oral cancerCanceristhesecondmostcommoncauseofmorbidityandmortalityintheworldtodayaftercardiovascular problems. Six million people die due tocancer every year. It is estimated that by 2020 therewill be 15 million new cases every year. Oral cancer isthe eleventh most common cancer in the world with anestimated267,000casesand128,000deathsinaround 2000, two-third of which occurs in developingcountries.TheIndiansubcontinentaccountsforone-third of the world burden. The incidence from oralcancerisincreasinginseveralpartsoftheworldparticularlyinAustralia,JapanandpartsofEurope.Oro-pharyngealcancerisasignificantpartoftheglobalburdenofcancer.Oralcanceroccurrenceisparticularlyhighinmales.Incidenceratesfororalcancervaryinmenfrom1to10casesper100,000populationsinmanycountries.Tobaccoandalcoholareregardedasthemajorcausesfororalcancer.There are strong synergistic effects on oral cancer riskwhen a person is both a smoker and drinker. This riskis generally increased as compared to being smokerordrinkeralone.Thepopulation-attributablerisksofsmokingandalcoholconsumptionhavebeenestimatedto80%formales,61%forfemales,and74%overall.TheevidencethatsmokelesstobaccocausesoralcancerwasconfirmedrecentlybytheInternationalAgencyforResearchonCancer.Tobaccouse,includingsmokelesstobacco,andexcessivealcoholintakeestimatedtoaccountforabout 90%of or al cancer s. ( Nai r MK,SankaranarayananR.EpidemiologicleadstocancercontrolinIndia.CancerCausesControl.1991July,2(4):263-5).The58thWorldHealthAssemblyResolutiononCancerPreventionandControl(WHA58.22,25May2005)urgedmemberstatestodevelopandreinforcenationalcancercontrolprogrammes, prioritizing preventable tumours and riskfactorsintervention(http://screening.iarc.fr).Focusison cancers amenable to early detection and treatment,such as oral cancer.2. The scenario for oral cancerWebmedCentral > Research articles Page 4 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMin Indian SubcontinentThe problem of cancer is universal; the only variationoccursintypes,siteorotherclinicoepidemiologicparameters.Tobaccochewingwasidentifiedasitscauseaboutcenturyagobutcontinuedpracticeandresearchproveditasthemostimportantavoidablefactor of oral cancer. Head and neck cancers accountfor one of the fourth of all cancers in Indian males. Insouth Asia oral cancers account for about up to 40%of all cancers. In India the incidence of oral cancer isabout3-7timesmorecommonascomparedtoresource rich countries. India tops in the prevalence oforal cancer in the world and remains the commonestcanceramongstthemalepopulation.OralcanceristhethirdmostcommoncancerinIndiaaftercervicaland breast cancer amongst women. In India, the agestandardized incidence rate of oral cancer is reportedat 12.6 per 100,000 people. The increased prevalenceof the oral cancer in the Indian subcontinent seems tobe due to the high exposure to sunlight due to farming,smoking and other smokeless tobacco habits, alcohol,spicy food, and neglect of overall oral health. It is saidthat one third of all oral cancers are preventable andone third of them occur due to risk factors. The highestage-adjustedincidencefororalcancerishighestinIndia, i.e. 15.7 per100, 000 and lowest in Japan whichis 0.2 per 100,000 and the difference is predominantlydue to use of tobacco between the two nations. In theWest,thecanceroftongueandfloorofmouthiscommon whereas in Indian subcontinent the cancersofgingivalandbuccalmucosaarecommonduetoplacementoftobaccoquidintheoralcavity.Thiscancer of gingivobuccal complex is termed as Indianoralcancer(OralCancerPreventionandResearchFoundation, India).Human Papilloma Virus (HPV) especially types 16 and18 are known risk factors (there are over 100 variables)andindependentcausativefactorfororalcancer(Gilsion et.al. John Hopkins).Symptomsassociatedwithoralcancerareasfollows:Skin lesions, lump or ulcer:1. On tongue, lips or other mouth area2. Usually small3. Most often pale colored, rarely dark or discoloured4. Early signs include white patch (Leukoplakia) or ared patch (Erythroplakia) on soft tissues of the mouth5.Usuallypainlessinitiallybutmaydevelopwithburning sensation as the tumour advancesAdditionalproblemsandsymptomsassociatedwithoral cancers maybe1. Tongue problems2. Swallowing difficulty3. Mouth sores that do not resolve in 14 daysSigns and tests for oral cancer: An examination ofthemouthbyaphysicianordentistorotherhealthcare provider shows a visible and /or palpable mass orlesion on the lip, tongue or mouth. A tissue biopsy ofthe lip or tongue or other oral tissues and microscopicexaminationofthelesionconfirmsthediagnosisoforalcancer.Thepersonmaydevelopdifficultyinspeaking and swallowing with oral cancer.TheinformationemergingfromVietnamandChinaindicate that oral cancer incidence have tripled since1980,partlyduetochewingofbetelquidalthoughtobacco is generally not added to betel quid in theseregions.InsomepartsofPakistan,AfghanistanandIndiaitistheleadingcancerinmenandthirdmostcommoncancerinfemalesintheseareas.Culturaland hereditary factors are considered as risk factors inthese parts and along with that, a lack of awareness,poor oral hygiene and fruit and vegetable lacking dietsare also important risk factors in this connection. Oralcanceriscommonformofcancerandaccountsformuch of cancer related deaths in Indian males. (SujhaSubramanianet.al,BulletinoftheWorldHealthOr gani zat i on; Resear chAr t i cl eDOI :10.2471/BLT.08.053231).Incaseoforalcancerthegreatestriskfactoristobacco. It is important to mention here that tobacco isalso one of the largest causes of preventable deaths inthe world.1.Therelationoforalcancerwithtobaccoiswellestablished and documented. Since 1985, eight casecontrol studies conducted in India have given evidenceoftheroleoftobaccosmokingandchewinginoralcancercausation.Fiveofthesestudiesreportedsignificant estimated relative risks (as odds ratios) tocurrentchewersofpaanwithtobaccocomparedtonon-chewers, in men the relative risk varied from 1.8(95% CI: 1.2-2.7) to 5.8 (95% CI: 3.6-9.5) ( Rao andDesai,1998;Raoetal.,1994;Nandakumaretal.,1990; Balaram et al., 2002; Dikshit and Kanhere, 2000)and the values for women ranged from 30.4 (95% CI:12.6-73.4)forcurrentchewersto42.4(95%CI:23.8-75.6),chewersinthetwostudiesthatincludedwomen (Nandakumar et al., 2000 and Balaram et al.,2002).2. The risk of developing oral cancer is high in casesof chewable tobacco. The incidence of oral cancer isWebmedCentral > Research articles Page 5 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMhighest of all cancer amongst men (12%) as comparedto women (8%).3.Smokingmayalsoleadtodevelopmentoforalcancer; however the chances of laryngeal cancers aremore in case of smoking rather than oral cancer.4.Paan(chewableleaftobaccomainlyinPakistan,India and Bangladesh) is said to be the most potentriskfactorforthedevelopmentoforalcancer.ThecombinationofArecanut,limeandtobaccoisthepossible reason behind the increased risk.5.AcasecontrolstudyconductedinIndiarevealedthatthechancesofdevelopmentoforalcanceramongst men who were tobacco chewers were six foldhigherthannon-chewers.Asfarasthefemalepopulation was concerned the risk was as high as 46times more in females who had never chewed tobacco.6.Otherthanlifestylefactors,therearephysicalfactorsl i keradi ati onswhi chhaveal sobeenassociated with oral cancer and exposure to x-rays.7. Since risk factor is so profound and well established,undoubtedly curbing the use of tobacco is one of themajorstepstopreventoralcanceroccurrence(http://www.xomba.com/user/rawnak).8. The increasing use of tobacco amongst the youngerpopulationsandchildrenalongwithlackoforalhygiene has largely contributed to the sharp increasei n t h e o c c u r r e n c e o f o r a l c a n c e r(http://www.xomba.com/user/rawnak).9. Nutritional factors like diet that is deficient in fruitsand vegetables could further increase the risk.10. Biological factors include viral and fungal infections.HPVtype16ismostlyassociatedwiththeoralcancerswhichoccuronthebackofthetongue(http://www.xomba.com/user/rawnak).11. One of the prominent factors associated with it isage (usually above 40 years).Recently,astudyfromIndiademonstratedthatoralcancer screening by trained health workers can lowermortality of the disease especially in individuals with ahistoryoftobaccouse[6].Inthisrandomized,controlledtrialofalmost192,000people,carriedoutoveraneight-yearperiod,therewasasignificantreductioninmortalityintheinterventionarm(29.9cases per 100,000) versus the control arm (45.4 casesper100,000),duetodetectionoforalcanceratanearlystage.Acost-effectivenessanalysisrevealedthat an oral cancer visual inspection by trained healthworkerscanbecarriedoutforunderU.S.$6perperson. The incremental cost per life-year saved wasU.S.$835fortheall-screenedpopulationandU.S.$156 in the high-risk population namely, individualswith a tobacco habit (Zeb et al, 2006; 2008). Currentusersofnasalsnuffaproductwhichisrelativelyuncommon now faced a relative risk of 3.9 (p Research articles Page 6 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PM3.1 The visionTocreateaSouthAsianOralCancerFoundation(SAOCF)andtobecomearegionalauthorityincombatingtheburdenoforalcancerthroughpreventi on,earl ydi agnosi s,treatmentandrehabilitation and set an example of dedicated servicethroughfuturisticscience,totheinternationalcommunity. 3.2 The missionTo create a region, free from oral cancer:1.Themi ssi onofSAOCFi stol i beratetheSubcontinentfromthedeadlyclawsoforalcancer,especially in view of the fact that our region tops theFigures of oral cancer sufferersWe aim to accomplish our mission by:1.Establishingachainofcentresacrosstheregionand making the service for oral cancer prevention andearlydetection,accessibletoallthecitizensoftheSubcontinent.2. Prevention, in view of the fact that it is the only curefor oral cancer, would remain the mainstay.3. Bringing about development of dental professionalsbytrainingtheminthelatestoralcancerdetectiontechniques, thus making it possible for them to preventoral cancer through early detection.4.Aidingdevelopmentandprovidingsupporttomultidisciplinaryapproachinscientificandresearchrelatedactivitiesinthefieldoforalcancerdetectionand prevention.5.Providingnecessarysupportforconductingoralcancerresearchandtomakeprovisionsfortimelytransferoftheresearchoutcomesforpracticalapplication.6.Acoordinationofvariousagenciesandrelatedorganizationsforestablishingamultidisciplinaryapproach to face the challenge of oral cancer.3.3 Core valuesIn our efforts to provide service for oral cancer, we willgive priority to improvement of scientific technologiesandmakingthemavailabletothepeopleviadentalprofessionals, based on the following core values.3.3.1 ScienceOur programmes and activities to support oral cancertrainingforthedentalprofessionals,andinformationdissemination will be carried out on scientific basis3.3.2 TrustOurresourcesandprogrammeswillbemanaged,conducted,andevaluatedinamannerthatupholdsthe trust placed in us by the people.3.3.3 SocietyOurprogrammesandactionswillaimtoimprovehealth, especially oral health, of all people through aservice that provides both prevention and treatment oforal cancer.3.4 OverviewTheSAOCF' sStrategi cPl ani stomaketheSubcontinent,aregionfreefromoralcancer.Thedrivingforcesbehindourplanaretoadoptneededchange and to respond to the needs of the people weserve. Just as we initiate this programme, we embarkonthestrategicplanmindfulofthemomentumwithwhichtheepidemicoforalcancerisspreading,thetrends that are involved and the means by which wecanencouragepeopletoconsiderhealthastheirpriorityandensurethattheyhavetheaccesstothebestservices,whichcanbenefittheregion.Thisstrategic plan is drafted in a way that addresses themultitude of challenges that tobacco intervention canoffer. The goals and objectives of this plan are centredon:1.Knowledgethatwillhelpusinunderstandingdisease processes, their underlying causes as well astheconceptsthatdeterminepopulationdynamicsrelated to those diseases.2. Advances in oral cancer detection techniques thatprovidemeansforearlydiagnosisofpre-cancerousand cancerous lesions, with ease and precision. Alsoensuringdisseminationoftheadvancedscienceforprofessional development.3.Innovati onanddevel opmentofexcel l entcommunication infrastructure that would enable us topropagatethemessageofpreventionandearlydetection and simultaneously help dental professionalsto get connected to the community directly and provideWebmedCentral > Research articles Page 7 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMthem education as well as service.4.Theplanistosetforthanaggressiveagendatoenhancetraininganddevelopmentofmembers.TheDentalAssociationsandDentalCouncilsofmemberstates recognizes the need to translate advances andprogress for bringing excellence in service through thecommuni cati onofthei nformati ontoheal thprofessionals,professionalorganizations,andtothepublic, through organized efforts.3.5 Curing oral cancer1. Putting a stop to the soaring statistics of oral cancerin the region and considering the face that India ranksfirstintheprevalenceoforalcancer,hasraisedtheneed to curb the disease.2. Curing oral cancer is an ambitious goal of SAOCF,which is sought to be achieved through early detectionandpreventi on.SAOCFal sorecogni zestheimportance of partnerships in mobilizing an integratedhealthpromotionenterprisecomprisinghealthprofessionals, voluntary health organizations, industryand government.3. To combat the rapid growth of oral cancer statisticswill require a greater ability to learn and absorb newtechniquesandcreateasoundinfrastructureforservice through the centres.3.6 Facing the challenge oftobacco1.Thefunctionsoftaste,expressionoffeelings,speechanditscontributiontoaesthetics,toalargeextent, make the oral cavity a unique organ.2. Dental professionals are closely associated with thehealth of this complex environment. The challenge oralcancer poses is increased threat not only to the healthoforalcavity,buttooverallhealth.Theincreasingmorbidityandmortalityassociatedwiththisoraldisease has made the health of oral cavity a cause ofgreat concern.3. In the context of increasing threat of oral cancer andthe importance of dental professionals in its preventionand early detection, SAOCF will take a step forward ina unique way.4.Also,tostrengthenthestandofthetobaccointerventioninitiative,weseektobridgethegapsbetween various professionals and their organizations,byestablishingactivecommunicationwiththemandusing various media for the same.5.Withtheeffortstostrengthenthefootholdofthedentists and the summation of the ongoing efforts ofthe various professionals and organizations we aim toreach the summit of our mission. It won't be difficult toimagine a day, when oral cancer and the associatedmorbidityandmortalitywillbecomenon-existent,resultinginhumanitylivinghealthierandmoreproductive life.3.7 Building capacity throughco-ordination1.TheuniqueroleoftheSAOCFinoralcancerprevention and early detection, attributing to its targetprofessionals and the mode of function, is its greatestprospect for its leadership role.2.Thecombinationoforalcancerprevention,earlydetection,cureandpromotionoforalhealth,consequentlyoverallhealth,enablestheSAOCFtodiversifyitsgoal.Enrootingthegoalinvariousprofessions and disciplines would help us materialize it.3. Providing the necessary training to strengthen oralhealth professionals in oral cancer will help us in thedevelopmentofaneffectivetaskforceagainstoralcancer.Itisequallyessentialtocommunicatetheinitiative to the people so as to make them realize thepotential health benefit that such a step would have.Thisfurtherstrengthenstheroleofthedentalprofessionals against cancer.3.8 Sustaining the uniquenessTo achieve our vision and attaining the ultimate goal ofmakingtheSubcontinentacancerfreeregion,ourdiverseinvestmentsandcoordinationwithvariousdisciplines need to be carefully balanced.1.Althoughweseektoundertakemultidisciplinaryaction through a multidisciplinary task force, the visionandstrategies,adoptedandexecutedthroughthediverse professional groups, with the dental professionassumingthecentralrole,iswhatmakesoureffortsunique.2. It is through this uniqueness that we aim to assumeleadershipandsetanexampleforallprofessionalorganizations to cooperate and coordinate with themin their efforts.3.9 Other challengesOralcancerisnotadiseasethataffectsthehealthalone.Italsoaffectsthesocio-economiclifeofthepatient. Similarly, the burden of prevention, treatmentandrehabilitationofthediseaseisalsofeltontheWebmedCentral > Research articles Page 8 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMnational economy.3.9.1 Psychological aspects1. The very sound and the idea of the word "cancer" isenoughtoputthestrongestpersonindespair.Theeffectofthewordonthepersonalityofthepersonstarts right from the time a biopsy is demanded for thediagnosis;withheightenedanxietytillthereportsarrive.2. Once the patient is confirmed to have oral cancer oreven for that matter pre-malignant lesion, the role ofthe doctors/dentists is very crucial.3.Thedeleteriouseffectoforalcanceronthepsychosocialwellbeingofthepatientisoneofthemajor challenges faced by doctors. Also, if the canceristreatedonce,thefearofrecurrenceorrelapsecurtails the person's happiness and confidence.4.Theeffectofcancersurgerythatleadstothedisfigurement of face, changes the complete insigniaoftheperson.SAOCFaimstoaddresstheseproblems by training dental professionals to deal withthese aspects of cancer.3.9.2 Economic aspect1. The effect of oral cancer treatment takes a heavytollonthefinancialconditionoftheperson.Thetreatment is expensive, apart from its side effects.2.Oralcancerisnowshiftedfromthehighincomecountries to middle and low income countries, whichalready suffer from dearth of resources. India has themaximumnumberoforalcancersufferersandtheresources to serve such a huge number remain limited.3. The most pragmatic answer to such a situation isPREVENTION.TheSAOCFaimsatpreventionandearly detection. Before the disease reaches the stateofhighermorbidityandmortality,ithastobeprevented or identified early and treated effectively.4.PreventionandearlydetectionistheSAOCF'sanswer for the economic impact of the disease.4.1 Addressing the variousaspects:1. We will continue this battle against cancer and itswidespread ill effects on health and its other aspectsas well.2.Enablingthepeopletoleadahealthylifeinahealthyenvironmentneedsamultilateralandmultidisciplinary approach.3. Efforts to enable people to combat oral cancer willbe carried out in a way that educates them and makesthemawareofthepre-malignantlesionsandcondi ti onssothattheycanapproachheal thprofessionalsattherighttimeandcangettherighttreatment.4. Lack of awareness, misconceptions that culminateintolatedetectionofthediseasewillbeaddressedwithallourmight,throughourwellreachedserviceand extensive awareness programmes.5. To extend our network to every citizen through aninfrastructureofcentrechainandtheawarenessprogrammes is our noble and prime goal. Through thiswe seek an enhanced interaction and support from themasses, so that the SAOCF becomes strong and rockstable on which we would build a healthy geographicregion.4.2 Building competencies:1. With significant research and advancement in oralcancer detection and treatment techniques, there is anincreased responsibility to get them reaching to all theprofessionals and oral health professionals in specific.2.Tobringaboutanimprovementineverydentalclinic and skills of every dental professional needs avariety of flexible and innovative training programmesfor early detection and diagnosis of oral cancer so thata competent task force, for addressing every aspect oftobacco can be set-up.3. Carrying out research and development and gettinginto the mainstream poses an array of challenges thatneed to be dealt with, if the outcomes of the researchare to be adapted to benefit the common people.4.3 Bridging research andpractical efforts:1.Despi tethefactthatoral cancerandi tsconsequencescanbetotallyprevented,treatedandcontrolled, there exists a significant gap in the public'sknowledge,attitudesandbehaviours.Variouspreventive measures that can significantly reduce theoralcancerburden,contributetobridgingthegapbetweenresearchanddevelopmentandpublicawareness.2.Togetknowledgedisseminatedinawaythatwillhelppeopleadoptbehaviourpatterns,whichwillimprove their health and of those associated with them,andhelpthemmakeappropriatedecisions.Anenhanced and sound system of communication, whichutilizesallthemeasuresandmethodsfortimelyWebmedCentral > Research articles Page 9 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMknowledge and information sharing, will be set-up.3.SAOCFwilltakeefforts,notonlytoequiptheprofessionals with knowledge and skill, but also to getthemconnectedwiththepopulationinaneffectivemanner, which can educate and make them aware.4.4 Facing the burden of thedisease:The far reaching efforts of oral cancer on the physical,social,psychologicalandeconomicwellbeingofaperson and the increasing number of affected people,pose a huge challenge.1.Theincreasingnumberofpeopleaffectedbythedi sease,mostofwhobel ongtotheweakersocio-economic section, has made it difficult to reachthe affected people.2.Theincreaseintheprevalenceofriskfactorandsusceptiblebehaviourinthesocietyhasturnedthedemographicstoagreaternumberofyoungerandpoorersufferers.Anintensifiedapproachfortheprevention of risk factors and behaviour is the need ofthe day. The younger population especially needs tobe protected.4.5 Addressing disparities:Oral cancer has now become a greater threat becauseitisaffectingpeoplewhobelongtothelowersocio-economic strata. They have very limited accessto education, prevention and treatment. This segmentofthepopulationismorevulnerabletooralcancerbecause of higher exposure to the risk factor (tobacco)which complicates the situation further. This shows theglaringdisparitiesthatwouldresultinoralcancerstatistics. In order to bridge these disparities, SAOCFwill direct its action towards:1.Provisionofeasyandaccessible,detectionandtreatment services.2. Awareness and education programmes.3.Preventionthroughactionagainstriskfactors,especially tobacco.4.Provisionofeducationalresourcestoboththeprofessionals and public.4.6 Professional workforce:1. Adequately trained professionals are the lifeblood ofeducation,practiceandresearch.Researchers,educators, and practitioners should reflect the diversityoftheoralcancerchallengeintheregionandthushave a broad mix of skills.2.Thereisavariationintheoralcancerdistributionacrosstheregionanditsdiversecommunities.However,theresearchandprofessionaldentalworkforcedoesnotadequatelyrepresentthecomposition and the diversity of the country.3. Data show that under-represented minority dentistsplayalargeroleinincreasingaccesstounderserveandminoritypopulations.Theycaninfluenceotherhealthprofessionalstobemoreculturallysensitive,andserveasrolemodelstootherminoritiesandtowould-be educators or researchers.4. To achieve proper coverage in the rural areas, alltrained dental health professionals after completion oftheircoursehavetodoa1yearcompulsoryworkposting in rural areas, which will be paid according tothe government regulations.5. In terms of diversity, the magnitude of the challengeis perhaps best expressed by looking at the "pipeline",or the number of under-represented minority dentistsand students in the dental schools.6. Sustained efforts, new partnerships, and innovativeandflexibleprogrammesareneededtoensureacompetent, diverse and robust research workforce.7.Thereisthusaneedforadiverseandequaldistribution of personnel to face the challenge.4.7 Strengthening theresearch base:1.Strongresearch-orientedacademicenvironmentsareneededtodeveloptheintellectualtalentforresearch,andtoenableexistinginvestigatorstoacquire and expand their skills in new areas of science.2. Oral health research can be carried out in a numberofsettingsincludingdentalschools,differentcomponents of academic health centres, hospitals andindependent research institutions.3. The capacity of dental schools to conduct researchand to serve as training grounds for future researchersis important for the future of clinical and applied oralhealth research.4. However, major barriers must be overcome. Theseincludeacriticalshortageoffaculty,alackofintegration between the basic and clinical sciences inpre-doctoralprograms,inadequateincorporationofresearchintothedentalcurriculum,andfinancialshortfalls.5.Effortstobolstertheresearchinfrastructuretoensure a workforce that is adequate both in numbersandability,isneededtomeetthedemandsofthechanging oral health needs of the community.WebmedCentral > Research articles Page 10 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PM4.8 Creation of a platform forunited efforts:1.Creationofaplatformthatallowsactivitiesandinputs from professionals from diverse backgrounds isessentialforcompilationandmaximizationofeffortsand outcomes.2.Itisvitaltoset-upadynamicplatformandundertakemultilateralandinclusiveresearchforcompilingatangibleevidencebase,whichcanultimately benefit the common man.3.Utilizingthedifferentmodesofmediaandcommunicationtotranslateresearchintopracticalbenefit.4. Thus such a dynamic and inclusive platform wouldprovide for activities as well as resultant benefits.4.9 Creating media and publicawareness:1.AsdefinedinHealthyPeople2010,healthcommunication"encompassesthestudyanduseofcommunicationstrategiestoinformandinfluenceindividualandcommunitydecisionstoenhancehealth."2.Basedontheabovedefinition,communicationeffortsaremeanttoensurethattargetaudiencesbecomeinformed,changebehaviour,andmakedecisionsthatwillimproveclinicalcareandhealthoutcomes.3.Targetaudiencesincludehealthcareproviders,consumers, the research community, and other groupssuchaseducators,policymakers,industry,andthemedia.4.Oneofthemai nchal l engesofourheal thcommunicationeffortsistofindthemosteffectivewaystocommunicateanddisseminatehealthinformation, clinical information and research findings,to target audiences.4.10 Establishing anddeveloping collaborations:1.Thechangingneedsoftheregion,haveunfoldedmanychallengesandpossibilitiesthatneedtobetakenintoconsideration.Thankstothisfact,thenecessity to collaborate with the various channels oftechni cal experti secannotbeoverl ookedorunder est i mat ed. Thusf or devel opi ngt hecollaborationsnetworkSAOCFhassetupthefollowing Goals2. Establishing communications with key stake holdersand informing them at the right time about our variousinitiativesanddevelopments.Communicationofthisnature will not get SAOCF the recognition of being oneamongvariousprofessionalbodies.Therecognitionandacknowledgementofourworkisthekeytothediversification of our vision and goal.3. In course of our efforts for establishing our identityandgainingrecognitionasoneamongvariousprofessionalandscientificbodies,SAOCFwilldoitslevel best to contribute to various disciplines throughour knowledge base and built capacity.4.Theassociationthatweseekwiththevariousprofessionalandscientificbodieswouldbebilateral.Throughouractivitiesandinvestmentsinvariousdi sci pl i nes,wewi l l al soattracti nterestandinvestments from these disciplines in SAOCF.5. This nature of association will result in multi-lateralbenefits and development.4.11 Creating and upgradingtangible evidence base:1.TheprovisionsthataremadeontheSAOCFwebsite provide an excellent resource for creation of atangible data base. To make the facility more effective,we have set the following goals.2. The provisions available through the website shouldbe made suitable for use; this will be the first target ofthepreliminarystage.Toachievethistask,wewillprovide training to professionals for using the provision.Also, we aim to make the modules for the people easyand self explanatory.3. Unless these two are not implemented together, theutilizationwillberestrictedtonetsavvypeopleinmetros and large cities.4. A thorough training of importance and utilization ofthe SAOCF provisions is vital. It should be done at theright time and in the right way.5.Therehavebeeneffortsrightfromthetimeofpreliminary development of the website that provisionsoftheinitialquestionnairesthatareaskedtothepatients record accurate data; similarly, throughout thepatientdentistinteraction,thedataqualityismaintained.6.Oncetheinitialmodulesareimplemented,qualityimprovement of the questionnaire will begin, based onresponse to the first stage.7.Creationofalargeevidencebaseneedsagooddealofdocumentation.Theprocesswillnotbecomplete,unlessthedatacollectedissortedandanalyzed.WebmedCentral > Research articles Page 11 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PM8. Efforts will be made to put the data in the correctpockets. The data base thus generated will be morepractical and helpful.9.Awellmanagedandtangibleevidencebasecreationneedseffortsfromthepreliminarystagesitself.5. Experience with technicaland policy solutionsNoncommunicablediseasessuchascancerareemergingasthemainchallengeandmajorpublichealth problems in India. These diseases are mostlylifestylerelatedandhavealonglatentperiodandneed special infrastructure and personals and humanresources for managing it. Population based registrieswithintheNationalCancerRegistryprogrammeandoutsidethenetworkhasprovidedapictureofthepatternsofcancerinIndia,thoughitdoesnotrepresent all areas in India but only some parts of it asshown in the Figure 6. The number of new cancers inIndia annually is presented in table 5.Following are the different type of interventions whichcan be applied in reduction and cure of oral cancer inSouth Asia.5.1.1 Primary preventionPrimarypreventioneliminatesexposuretotheriskfactors or cancer causing agents. Primary preventionsfor the type of cancers that areof greatest concern indevelopingcountriesareimmunizationagainstthecausativeagentsandtreatinginfectiousagents,implementingdietaryinterventions,introducingtobaccocontrolprogrammers,reducingexcessivealcoholconsumptionandusingchemoprophylaxis.Oral Submucous Fibrosis (OSF) is a condition which isdebilitatingandpotentiallycancerousiscausedprimarilybychewingarecanutsanditsmixturesasdemonstratedbynumerousstudiesandotherevidences(Murtietal.,1995).Theconditionmayextendsometimesbeyondmouthtooesophagus(Misraetal.,1998).ThehighmalignantpotentialofOSFiswellestablished(Murtietal.,1985).Assmoking is one of the main causes of oral cancer soprimary prevention is one of the best interventions toreduce the risk of oral cancers by minimizing the useof tobacco.5.1.2 Cost effectiveness ofprimary preventionThecosteffectivenessstudiesofprimarypreventiveintervention are relatively rare and are mostly availablein high income countries. For example studies in theUnitedKingdom(UK)andUnitedStatesofAmerica(USA) shows that the costs of treating and screeningofanindividualforhelicobacterpyloriinfectiontoreducetheriskofstomachcancerrangesfromUS$25,000 to US$ 50,000 per life year saved but anotherstudyshowedthatthecosteffectivenessoftheinterventionwouldbemoreinColumbiawherethecost of health care interventions are less and stomachcancers are common. In a study on costs of tobaccorelated cancers for the ICMR (Tata Memorial center,Mumbai,India),thedirectandmedicalandnonmedical costslike travelling and indirect costs , likeloss of income during treatment and premature deathwere assessed in a cohort of 195 oral cancer patientsfor three years from 1990. The average total costs percancer patient, discounted at the 1999 level amountedtobeabout350,000Indianrupeeswithdirectcostsamounting to 13% of total costs. The costs of 163 500totaltobaccorelatedcancersdiagnosedinIndiain1999asestimatedforthisstudyamountedtobeaboutRs.57,225billion(ICMR,2001).Apartfromfinancialcoststobaccousershaveahigherriskofprematuredeathascomparedtononusers.Inaretrospective study conducted in Chennai (India), therelative risk of death in men who were smokers was2.1 (Gajalakshmi and Peto, 2002). Thus anti-tobaccointerventionisoneofthemostcost-effectiveandbeneficialinterventiontopreventcancerandcancerrelateddeathsbesidesmanyotherdiseases.Infactmany longitudinal studies have shown that the risk oflung cancer decreases slowly after quitting smoking tillit reaches to the level of nonsmokers after 10 years ofquitting (IARC, 1986).5.1.3 Community interventionsA large controlled educational intervention trial in threestates of India with ten years of annual follow up wasconductedduring1967-88.Messagesimpartedthrough personnel communication were reinforced bydocumentaries,slides,posters,exhibitions,folkdramas,radiomessagesandnewspapersarticles(Gupta et al. 1986a). The educational intervention wassignificantly effective in decreasing the use of tobaccoand increased the quitting rate of smoking in two areas(Ernakulum, Kerala and Srikakulam, Andhra Pradesh),assessed after five and ten years of follow up (9% andWebmedCentral > Research articles Page 12 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PM14.3% in Ernakulum and 17% and 18.3 in Srikakulam).ThisresultedinthesubstantialreductionintheincidenceofLeukoplakia,aprecancerouslesiontoonly 40- 60% of the incidence rate in the interventionareawithsmokinghavinghigherlevelofreductionthan the chewing group (Gupta et al, 1992). Within theintervention area the incidence of oral lesions was lessinthosewhogaveupsmokinghabit(Guptaetal,1995). These results underscore the great potential forprimary prevention of oral lesions and cancers throughanti-tobaccointerventionsandcessationoftobaccouse.InasimilarinterventionstudyconductedinSriLanka,thequitratesafter5yearsofinterventioninmen and women respectively were 26.5% and 36.7%comparedto1.1%and1.5%inacontrolcohort(Anantha et al, 1995).5.1.4 Mass media interventionMediaplaysaveryimportantrolenowadayssoifeffectively used it can be of significant use to mobilizethemassandcreateawarenessamongthegeneralpublicabouttherisksofsmokinganditshazards.Newspapers, Television, radio and internet all can beusedforthispurposeforconveyingthemessagetothegeneralpublic.In1990,informationaboutthehazardsoftobaccowerebroadcastedonAllIndiaRadio (the only radio medium at that time), through 30Sundaymorningepisodesin16languagesfrom84stations.Communitysurveysintwostatesshowedabout 30% listenership among the potential audienceinbothstateswhereinKarnatakaabout6%ofthelisteners reported to have quitted smoking and 4.3% inGoa.Inadditionaboutonethirdoftobaccousersintendedtoquitandanotherthirdhadreducedtheirconsumption and intended to quit as well (Chaudhary,1994).Thisclearlystatesthatradiocommunicationhadpotentialbenefitsevenduring1990,swheretheway of communication was less and media was not asdeveloped as today as most of the people today haveaccesstosomesortofcommunicatorymediaeitherinternet or radio or Television or newspapers. Besidesradio and television, newspapers can also be used toconveyanti-tobaccomessagethrougharticlesonsmokinghazardsanddifferentcartoonstoreflectitshazards and to encourage the public to avoid tobaccouse.5.1.5 Sufficient evidence forlong term oral cancer riskreduction for the South AsianregionAll the above efforts points to the utility of scaling upsimilar educational efforts through incorporating theminto routine regional governments health programmesandmasscommunicationandtoaddanti-tobaccoeducationinschoolscurriculum.Besidesthisthereshouldbemadevoluntaryorganizationsandtheseorganizationscanalsoplayaroleineducatingthepeople about smoking and tobacco hazards and thusthey can make a difference as well.5.1.6 Secondary preventionSecondarypreventi onconsi stsofscreeni ngprogrammestodetectandtreatprecursorsoforalcancerthuspreventingorreducingtheincidenceofhighly invasive cancers. Effective screening can detectinvasivecancersveryearlyandthusimprovethelikelihoodthattreatmentwillbesuccessful.Thecosteffectivenessofsecondarypreventiondependsonmanyfactorsincludingthecostsofdiagnostictests,theprevalenceofdiseaseandtheavailabilityofeffective treatments.5.1.7 Cost effectiveness ofsecondary preventionThecosteffectivenessofsecondarypreventionfororal cancer ranges from US$ 1300 to US$ 6,200 peryearoflifesaved.(JamisonDT,BremanJG,etal,editors. Washington (DC), World Bank, NCBI, 2006).5.1.8 Medical interventionsMedicalinterventionsincludesurgicalremovalofthetumors, chemotherapy and radiation. As compared tooralcancertreatmentcosteffectiveness,thecosteffecti venessoftreatmentforstomachandesophageal cancers are worse and ranges from US$53,000toUS$163,000peryearoflifesaved.Ingeneralthestandardoftreatmentindevelopingcountriesislesswellorganizedandnotavailabletoeverybody due to its costs as compared to developedcountries.Thepreventiveinterventionsarealsodifferentindevelopinganddevelopedcountrieswithbetter preventive interventions in developed countries.The availability of cost effective methods of preventionandtreatmentforcancersinlowandmiddleincomecountries varies significantly depending on the type ofWebmedCentral > Research articles Page 13 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMcancer, with a substantial effects on the equity of theoutcomes.5.2 Programmatic approachand structural challengesAs smoking is one of the major causes and risk factorsfororalcancerinSouthAsiasotheSouthAsiangovernmentsi.e.Pakistan,India,Bangladesh,SriLanka, Nepal, Maldives and Jammu and Kashmir havealllauncheddifferentawarenessprogrammersatdifferentlevelstodiscouragesmokingandcreateawarenessamongpeopletoavoidsmokinganddevelop clean habits. These programmes range fromadvertisements on Television, Radios and newspapersto work shops and posters preparation and organizingralliesandseminarsindifferentplacesandinstitutions about smoking and its adverse effects onhealthandasapossibleriskfactornotonlyfororalcancer but also lung cancer,oesophygeal cancer andother cancers. In few Indian and few states of Nepalshopkeepersareinformednottosellcigarettestoyoungstersbelow16yearsofagebuttheseisnolegislation passed about it yet in any of these countries.The basic problem in this part of the world is that mostpeopleareilliterateandtheydonothaveaccesstoTelevisionandradiossotheydontgettheproperawarenessaboutit.Theproblemintheeducatedpopulationisthattheyarealthoughawareoftheeffectsofitbuttheyeitheruseitasafashionortorelive stress. Both in India and Pakistan, there is banonsmokinginpublicplacesbutrarelyseentobefollowed or obeyed by people and there is less actionfrom the government or legislative authorities againstthosewhodisobeyorviolatetheroles.ThereareprogrammesaboutadverseeffectsofsmokingonTelevisionbutasmostofthesecigarettecompaniesareinternationalcompaniessotheygetthestatetelevisionandotherprivatechannelseasilyhiredforpublicity of their cigarettes and other tobaccos. Thereneedstobestrictlegislationagainstsmokingfromtheseregionalgovernmentsandthosewhodonotabidebythelawshouldbepunished.Smokingadvertisementsshouldbebannedontelevisionandradios and strong anti smoking campaigns should belaunched.Moreawarenessneedstobecreatedamongstthepublicaboutsmokinghazardsandsmoking should be strictly banned in all public placesand those found guilty of disobeying the law should befined. Besides antismoking campaign more is neededto be done in creating awareness among the generalpopulation about regular use of brush and tooth paste,useoflessPaans(chewableformoftobaccointhesubcontinent) and discourage the use of Alcohol.5.3 Tobacco cessation clinicsAlthough informal tobacco cessation clinics have beeninuseinPakistan,India,SriLankaandBangladeshforlongtimebutnoevaluationreportsareavailablefrom any of these countries. The recent of availabilityofnicotinereplacementtherapyintheshapeofnicotine patches and Buproprion has prompted severalhealth facilities to set up tobacco cessation clinics forpeople who want to quit smoking but cannot do it ontheirown.Theseclinicsaremostlyfundedbytheregionalgovernmentsandsomeofthemarealsoworkinginprivatesectorandtheseclinicsemploypharmacologictherapyinadditiontobehaviouraltherapy which may include different strategies rangingfromtelephonecalls,individualcounselling,rationalemotivetherapyandyogawithpranayamwhichhasshown encouraging results (Shastri, et al, 2003).5.4 Economic interventionsEconomicanalysisbyseveralagencieshasshownthat tobacco is a net drain on an economy. Demandside interventions such as advertising and promotionbans, smoking restrictions as well as increase in pricethrough taxation are all effective at reducing tobaccorelatedoralcancers,mortalityandmorbidity.Measurestoreducethesupplyoftobaccointhesecountries have been met with less success except incontrol of smuggling to some extent but neverthelessaids given to farmers in some parts of these countrieshave seen a shift amongst the farmers from tobaccocultivationtoothercropscultivationandthusfurtherstepsmustbetakentoencouragethefarmerstocultivate other crops instead of tobacco. The farmersshould be given special aid for this as once suggestedbyWorldBankaswellin1999(WorldBank,1999).Research carried out in Indian state of Karnataka hasshown the willingness of framers to shift from tobaccocultivation to other crops like dairying and cotton cropsif given some aid and assistance by the government(Panchamukhi,2002).Additionallyphasingoutgovernment support to tobacco production and findingsubstitute crops for revenue generation and export willaid in the transition to a tobacco free society.5.5 Political approaches andstructural challengesWebmedCentral > Research articles Page 14 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMTheSouthAsiangovernmentsaretakingstepsonindividual levels to counter the risk of oral cancer andsmoking but not much on regional level and together.Theseincludemoretaxesontobaccosimports,decreasing the subsidies for tobaccos and increasingthecostofci garettessothatpeopl ecanbediscouraged from smoking. As south Asia and Pacificaccounts for the highest smoking related deaths in theworldabout40%.Menarecommonsmokersinthispart of the world and females are rare smokers in thisregionwhereasthisgapisnarrowinhighincomecountriesmainlyEuropeandAmerica.About1.1billion people smoke currently and about four- fifths oftheseareresidinginthelowandmiddleincomecountries. Nearly all the South Asian governments areimplementing more taxes on cigarettes and tobacco toraise the cost of the habit and discourage smoking thisway.Onlyeducatingconsumersthattobaccoorsmoking is injurious to health is not sufficient as mostlythe people underestimate the future risk to their healthandyoungpeoplearemorepronetodevelopandadopt to risky behaviors and life styles. Although mostof these countries have done some sort of legislationto ban smoking in public places, implement high taxesontobaccobutmoreeffortsareneededandmoresteps should be taken be these regional governments.Interventionproveneffectscanbetoincreasethetaxesontobacco,disseminatinginformationabouthealth risks in the general public, restricting smoking inpublicplaces,banningadvertisingandincreasingaccesstotherapies.Somegovernmentsinthedeveloping countries are using the tobacco tax evenfor health care purposes.Governmentinterventionsthatcouldaffectpeoplesattitudestowardssmokingandknowledgeaboutthehazardsofsmokingcanalsobeveryhelpful.Ascigarettes are the most widely publicized products intheworldsostrongantismokingcampaigninthepublic alongwith education and information campaignscan counter this hazardous effect of smoking. Thesegovernments can also publicize reports about smokinghazardsthroughhealthministryanddirectingallthesmokingmanufacturercompaniestoputwarninglabelsonpackages,broadcastingantismokingmessages in the media.Thegovernmentscanal soprovi deni coti nereplacementtabletsatlowcoststosmokerssothatthey can quit the habit of smoking. The challenge hereisthatmostofthesegovernmentstakemoneyfromthesecompanieswhileissuinglicensesbeforelaunchingtheirproductsandalsotakefinancialaidfrom these companies during their election campaigns.These tobacco manufacturers also provide money tomediatopromotetheirproductsandadvertisetheirtobaccoproducts.Fortunatelymostdemandsideinterventions are cost effective and even cost savingas well. A 70 % increase in the price of tobacco couldavert 10- 26 % of all smoking related deaths worldwide.SuccessfulinterventionsinPolandandSouthAfricawentwellevenwiththemodestincreaseinprice,almostdoublingthepricesovershorttime(DCP2,Chapter 8; Levine and others 2004). Despite the priceincreasebeingthemostcosteffectivemeasuretocountertobaccoconsumption,thispublichealthmeasureisgrosslyunderutilized.Indeedwhenadjustedforpurchasingpower,thepriceoftobaccoproductsactuallyfellintheSouthAsianregionbetween 1990 and 2000.There should be fewer taxes on the daily use materialforhygiene.Moreawarenessshouldbecreatedamongthegeneralpublicaboutdailybrushingtheteeth twice, less alcohol consumption, in case of anyoral trauma inspection of the wound in oral region by asurgeon or physician and to avoid use of hot food ordrinks for longer time.5.6 LegislationIn the South Asian region, Pakistan, India and NepalalongwithSriLanka,healthresearchers,lawyers, NGO,s,healthcareprovidersalongwithothershavejointly proposed more stringent actions to curb the useoftobaccoandhavecalledonthegovernmentsoftheircountriestomakemorecomprehensivelegislation on advertisement, sale and use of tobacco.IndiaalsopassedabillthroughLokSabhaon30thApril,2003addressingalltypesoftobaccoproductsknown as Bill, 2001.The bill prohibits advertising andsportsponsorshipbytobaccocompaniesalthoughsuch legislation is not in place in Pakistan, Bangladesh,NepalandAfghanistan.Afghanistanistheworldleading opium producer currently and efforts are underway by the international community to halt the opiumtradesomehow.Thebillalsoprohibitssmokinginpublicplacestoprotectnonsmokersespeciallychildren from environmental smoke. It has put a banon selling of tobacco to persons below 18 years of ageandwithin100metersofeducationalinstitutions,governmentandsemi-governmentoffices.Clearhealth warnings are made mandatory on all packagesinlocallanguagesandinEnglish,alongwithtarandnicotine content, to inform the public about the risk oftheusingtheproduct(Gupta,2001).ThisbillisawaitingpresidentialapprovalinIndiaandthenextWebmedCentral > Research articles Page 15 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMstep will be to tackle the issues of enforcement once itbecomes law and the law enforcement agencies haveto play a really active and honest role in implementingittotacklethetobaccoproblem.Itwillneedthesupport of all professionals and especially healthcareprofessi onal shavetosupportthi si deaandimplementation of the law besides all the citizens andinfluential Figures in this country. 5.7 Global strategyInMay,1999,theWorldHealthAssemblywhichisgoverningbodyoftheWorldHealthOrganizationpassed a legislation called Framework Convention onTobaccoControl(FCTC)thatcouldaddresscrosscountryissueslikeadvertisingandpromotion,agriculturaldiversification,smuggling,taxesandsubsidies (WHO, 2000, Chaudhary, 2000). About 160membersoftheUnitedNationhaveparticipatedinthesenegotiationsandthisconventionwasadoptedbyWorldHealthAssemblyin2003.ThistreatyhasbeenratifiedbymostmembersoftheUnitedNationandithaspavedthewayforstrongandeffectivecontrol of tobacco use and advertisement at nation aswell as international level. 5.8 Reasons for current lack ofactivity or ineffectivelegislation and implementationin South Asian countriesThere are multiple factors which are causing obstaclesin the effective tobacco control policy implementationatbothnationalandregionallevel.AtregionallevelthereislackoftrustbetweenthememberstatesofSouthAsianregionandtheirborderdisputes.Atnationallevels,corruptioninpoliticsinvolvingpoliticiansacceptingmoneyasbribesfromthetobacco companies so they are not sincere in tacklingthisprobleminmostofthesecountries.Anotherproblem at the public level is lack of awareness andsocialsupportforthosepeoplewhowanttoquitsmokingbutcantdoitduetolackoftobaccocessation clinics and other facilities.6. ConclusionIndianSubcontinentisaregionwhichishighlyaffectedwithlotsofdiseasesincludingoralcancer.Many of steps have to be taken to improve the currentsituation.Thisisjustaninitiativeinthatdirection.Muchisstillneededtobedoneatboththeregionallevel and national level in all these countries. There isalso a greater need for more efficient steps to be takenby all these countries to create awareness among thegeneral public, provide aid to farmers to cultivate othercrops and to provide health care access and facilitiesto the general public, effective screening programmesto detect cancers at early stages and thus making thetreatment possible and cheaper. There is also a greatneed at the regional level between these countries toworkwithoneanothertocounterthisproblemandthusdecreasetheincidenceoforalcancerasitsincidenceisoneofthehighestinthisregionascompared to the rest of the world.References:1."Indiansubcontinent".NewOxfordDictionaryofEnglish New York: Oxford UniversityPress, 2001; p. 929.2. "Indian subcontinent". Geology and Geography. TheColumbia Electronic Encyclopaedia, 6th ed. ColumbiaUniversity Press, 2003.3.Werning,JohnW(May16,2007).Oralcancer:diagnosis, management, and rehabilitation. pp. 1.4.Sankaranarayanan,R.,etal.,Headandneckcancer:aglobalperspectiveonEpidemiologyandprognosis. Anticancer Res, 1998. 18(6B): p. 4779-86.5.Sankaranarayanan,R.,etal.,Aetiologyoforalcancerinpatientslessthanorequalto30yearsofage. Br J Cancer, 1989. 59(3): p. 439-40.6. Sankaranarayanan, R., et al., Effect of screening onor al cancer mor t al i t yi nKer al a, I ndi a: acluster-randomizedcontrolledtrial.Lancet,2005.365(9475): p. 1927-33.7. Subramanian, S., et al., Cost-effectiveness of oralcancerscreening:resultsfromaClusterrandomizedcontrolled trial in India. Bull World Health Organ, 2009.87(3): p. 200-6.8.PhukanRk,ZomawiaE,NarainK,HazarikaNC,Mahanta J(2005). Tobacco use and stomach cancer inMizoram,India.CancerEpidemiolBiomarkersPrev,14, 1892-6.9.NairMK,NambiKS,AmmaNSetal(1999).PopulationstudyinthehighnaturalbackgroundradiationareainKerala,India.RadiateRes,152(Supply), S145-8.10.SiddiqueeBH,AlauddinMH,ChoudhurryAA,AkhtarN(2006).Head&NeckSquamousCellCarcinoma(HNSCC)5yearsstudyatBSMMU.WebmedCentral > Research articles Page 16 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMBangladesh Med Res Counc Bull, 32, 43-8.11. Tyagi BB, Verma K, Singh RP (2001). Is incidenceof cancer on decline in Delhi, capital of India? Indian JCancer, 38, 8-16.12. Thomas G, Hashibe M, Jacob BJ et al (2003). Riskfactorsformultipleoralpremalignantlesions.IntJCancer, 107, 285-91.13.ZebA,RasoolA,NasreenS(2008).CancerincidenceinthedistrictofDir(NorthWestFrontierProvince), Pakistan: a preliminary study. J Chin MedAssoc, 71, 62-5.14.ShantaV,GajalakshmiCK,SwaminathanR,Ravi chandranK,Vasanthi L,(2002).CancerregistrationinMadras,MetropolitanTumorRegistry,India. Eur J Cancer, 30A, 974-8.15. Yeole BB (2007). Trends in the incidence of HeadandNeckCancersinIndia.AsianPacificJcancerPrev, 8, 607-12.16.KhanH,KhwajaMI,KhwajaMR.Dilemmaofcancer screening in Pakistan. Asian Pacific J CancerPrev, 7, 340-117.Gajalakshmi, C K & Shanta, V. Lifestyle and riskofstomachcancer:ahospitalbasedcasecontrolstudy. Int J Epidemiol.1996; 25 (6): 1146- 1153.18. Chaudhary, K. Control or Promotion the Paradox.Tobacco Control SAARC Edition 1994; 1:4.19. Gupta, P.C, Sinor, P.N, Bhonsle, R.B, Pawar, V.Sand Mehta, H.C. Oral Submucous Fibrosis in India: Anewepidemic?TheNationalMedicalJournalofIndia1998; 11: 113- 116.20. Jafarey, N.A, Mahmood, Z & Zaidi, S.H.M. Habitsanddietarypatternsofcasesofcarcinomaoforalcavity and oropharynx. J. Pakistan med. Assoc. 1977;27:340- 434.WebmedCentral > Research articles Page 17 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMIllustrationsIllustration 1Front Page Of the articleWebmedCentral > Research articles Page 18 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMIllustration 2The scenario for oral cancer in Indian Subcontinent WebmedCentral > Research articles Page 19 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMTable 1-Numbers of South Asian Registries in the series of nine volumes of CIVIllustration 3Table 01WebmedCentral > Research articles Page 20 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 2- A Cancer Journal for Clinician (http://caonline.amcancersoc.org/misc/about.shtml).Illustration 4Figure 01WebmedCentral > Research articles Page 21 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 2- A Cancer Journal for Clinician (http://caonline.amcancersoc.org/misc/about.shtml).Illustration 5Figure 02WebmedCentral > Research articles Page 22 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMIllustration 6TableWebmedCentral > Research articles Page 23 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMTable 5. Number of new cases of Cancer per Annum in India. (National Center RegistryProgramme in India, ICMR & National Cancer Institute(http://www.cancer.gov/cancertopics/types/head-and-neck).Illustration 7Table 5WebmedCentral > Research articles Page 24 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 3- Percentage data for the five most prevalent cancers in countries of South Asia(Globocan 2002)(Asian Pacific Journal of Cancer Prevention, Vol 10, AsianEpidemiology Supplement, 2009).Illustration 8Figure 03WebmedCentral > Research articles Page 25 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 6. Commonest Cancers in Indian males and females in different regions of India.Illustration 9Figure 06WebmedCentral > Research articles Page 26 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 4. Male Mouth Cancer Incidence /100,000 over time (Waterhouse etal., 1982; Muir et al., 1987; Parkin et al., 1992, 1997, 2002, Curado et al.,2007).Illustration 10Figure 4WebmedCentral > Research articles Page 27 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMFigure 5. Male Tongue Cancer Incidence /100,000 over time (Waterhouse et al., 1982;Muir et al., 1987; Parkin et al., 1992, 1997, 2002, Curado et al., 2007).Illustration 11Figure 05WebmedCentral > Research articles Page 28 of 29WMC003626 Downloaded from http://www.webmedcentral.com on 06-Aug-2012, 05:07:33 PMDisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview,contentspostedonthiswebportaldonotundergoanyprepublicationpeeroreditorialreview.Itiscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. 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