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  • Factors associated with Gall Bladder

    cancer in Bihar-A case control study

    By

    Dr. Varsha Singh

    (MAE- FETP Scholar 2004-2006)

    NATIONAL INSTITUTE OF EPIDEMIOLOGY

    (Indian Council of Medical Research)

    Mayor VR Ramanathan Road, Chetpet, Chennai, 600031

  • Factors associated with Gall Bladder

    cancer in Bihar-A case control study By

    Dr. Varsha Singh

    (MAE- FETP Scholar 2004-2006)

    Dissertation project.

    Submitted in partial fulfillment of the requirements for the degree of

    Master of Applied Epidemiology (M.A.E) of

    Sree Chitra Tirunal Institute for Medical Sciences and

    Technology,

    Thiruvananthapuram Kerala-695 011.

    This workhas been done as part of the two year Field Epidemidlogy

    Training Programme (FETP) conducted at

    National Institute of Epidemiology,

    (Indian Council of Medical Research),

    Mayor V .R. Ramanathan Road, Chennai -600 031.

    January 2006

    11

  • CERTIFICATION

    This is to certify that this dissertation, entitled "Factors associated with Gall

    Bladder cancer in Bihar -A Case control study" submitted by.

    Dr Varsha Singh in partial fulfillment of the requirements for the degree of

    Master of ApJ?lied Epidemiology is the original work done by her and has

    not been submitted earlier in part or whole for any other (Publication or

    degree) purpose.

    Date Director

    lll

  • Table of contents

    List of tables

    Acknowledgements

    Abstract

    l.Introduction

    2.Rationale for study

    3.0bjectives

    4.Review of literature

    4.1.Introduction

    4.2.Incidence and prevalence

    4.3.Age & sex distribution

    4.4.Histopathol~gy

    4.5.Molecular pathology

    4.6.Genetic factors

    4.7.Staging

    4.8.TNM Classification

    4.9.Risk factors

    4.10.Prevention and control of Gall bladder cancer

    4.11.Conclusion

    5.Methodology

    5.1.Study' area

    5.2.Study population

    5.3 Study design

    5.4.0perational definitions

    5.5.Study team

    5.6. Sample size

    5.7. Data collection techniques and tools

    5.8.Ethical issues

    6.Results.

    6.1.study population

    Page

    number

    vi

    vii

    8

    9

    10

    10

    11

    12

    12

    13

    13

    14

    14

    16

    16

    17

    24

    25

    26

    26

    26

    26

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    27

    27

    28

    29

    33

    iv

  • 6.2.sociodemographic factors of cases and controls 29

    6.3.stratified analysis 31

    6.4.Dose response 31

    6.5.Multivariate analysis 32

    7. Discussion 33

    7.1. Incidence of gall bladder cancer in Bihar and associated factors 36

    7.2.Causality criteria 36

    7.3.Errors and biases 37

    8.Conclusion 38

    9.Recommendation 38

    10.references 39

    List of abbreviation 55

    Annexure 56

    v

  • List of tables Page Number

    Tablel.Univariate analysis for all cases and controls, Mahavir Cancer 45 Sansthan, Patna, Bihar, India

    Table 2. Univariate analysis for cases with gall stones and controls, 46 Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 3. Univariate analysis for cases without gall stones and controls, 47 Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 4.Association of missing breakfast to gall bladder cancer 48

    stratified by gender,Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 5. Association of missing breakfast to gall bladder cancer 49

    stratified by age,Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 6. Association of reuse of oil to gall bladder cancer stratified by 50

    gender,Mahavir Cancer Sansthan, Patna, Bihar, India

    Table7. Associatjon of reuse of oil to gall bladder cancer stratified by 51

    age ,Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 8. Association of gall bladder cancer to frequency of missing 52

    breakfast ,Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 9.Association of gall bladder cancer to frequency of reuse of oil 53

    Mahavir Cancer Sansthan, Patna, Bihar, India

    Table 1 O.Logistic regression analysis of factors associated with gall 54

    bladder cancer Mahavir Cancer Sansthan, Patna, Bihar, India

    Vl

  • I i ...

    I ACKNOWLEDGEMENT

    Several dignitaries and institutions have extended their valuable time, advice and

    assistance to me during preparation of this thesis. I extend with gratitude my sincere

    thanks to:

    Prof. M.D. Gupte, Director National Institute of Epidemiology (NIE), Chennai for his

    valuable guidance amidst his very tight schedule.

    · Prof. K. Ramachandran, Formerly Professor and Head ofthe Department of Biostatistics,

    All India Institute of M_edical Sciences, New Delhi and presently Adviser to DG ICMR

    for Field Epide_n;iology Training Programme at NIE,. Chennai for his valuable teaching

    comments suggestions and advice.

    Dr. Manoj Murerkar,Deputy Director ,NIE and MAE-FETP course-coordinator for his

    close guidance and encouragement

    Dr R Ramakrishnan, Assistant Director, NIE, my preceptor for his valuable guidance and

    encouragement.

    Dr. Vidya Ramchandran, Assistant Director, NIE and Dr P Manickam Research Officer

    for their advice. and Mr. S. Satish librarian and Uma Manoharan Secretary to the FETP

    for their constant support and guidance.

    Dr. J.K.Singh, Director, Mahavir Cancer Sansthan and Dr.C.Khandelwal who were my

    local preceptors for their constant support and guidance

    My special thanks to Dr Yvan Hutin Resident advisor WHO to NIE for his guidance and

    boost up for work

    My family especially my husband Dr. Sunil Kumar Singh for bearing with me in this

    endeavor of hard work with patience.

    Last but not the least all the respondents who very graciously spared me their valuable

    time and information in addition to extending their cooperation and generous hospitality,

    which rendered the entire research, endeavor a very memorable, pleasant and profitable

    expenence.

    '' ~. 2-o-06 Date

    \/~~ Dr. Varsha Singh

    Vll

  • Abstract

    Background The annual incidence of gall bladder cancer in northern India (1 0 per 1 00,000) is one of the highest of the world. While studies elsewhere suggest that dietary factors are important, no data are available from Bihar to propose prevention activities. Methods We conducted a case-control study in a tertiary reference cancer treatment center in Patna, Bihar. We recruited incident, histopathologically-diagnosed cases of gall bladder cancer and selected controls among incident, histopathologically-proven malignancies of equivalent severity, including lung, leukemia and lymphoma between May and September 2005. We compared cases and controls with respect to demographic characteristics, education and dietary practices using odds ratios in univariate and multivariate analysis. Results In multivariate analysis the people of age more than 40 years (odds ratio [OR]: 2.82, 95% confidence interval [CI]: 1.44-5.56), female (OR: 7.04, 95% CI: 3.92-12.64), illiterate (OR: 2.67, 95% CI: 1.49-4.80), and missing breakfast (OR: 3.4, 95% CI: 1.74- 6.77) were found to be at greater risk of getting gall bladder cancer. Conclusion Skipping breakfast may increase the risk of cancer gall bladder in Bihar. Nutritional interventions should not only focus on the type and quantity of nutrients but also emphasize the importance of eating regularly.

    Key words: Gall bladder cancer, dietary factors,risk factor studies.

    8

  • Factors associated with gall bladder cancer in Bihar-A hospital Based

    case control study

    Introduction

    Gall bladder carcinoma was first described in 1777, even after two centuries of its first

    description; the tumor remains characterized by an unfavorable prognosis due to silent

    progression of the clinical course and limited knowledge of its etiology and poor

    scientific capability for epidemiological forecasting. The incidence of gallbladder cancer

    varies in different parts of the world. Overall incidence ranges from 0.11100000 to

    10.6/100000 in different cancer registries worldwide. 1 The prognosis is poor-only about

    a 32 percent fiv€.~year survival rate for lesions confined to the gallbladder mucosa and a

    10 percent one-year survival rate for more advanced stages2. The highest mortality rates

    have been reported among Chilean Mapuche Indians and Hispanics, among Bolivians,

    North American Indians, and Mexican Americans? There is no conclusive evidence that

    dietary factors ac! through cholelithiasis only. Increased parity, early age at first child

    have also been implicated as one of the risk factors in some of the studies. 3 Vegetables

    and fruits have protective effect and there has been some suggestion of inverse

    association with fiber intake, vitamin C and vitamin E that seems to ho.ld true for many

    other cancers. 3

    In India incidence varies in the different registries.