1. CGHR.ORG/CANCER Twitter: CGHR_org CANCER MORTALITY IN INDIA On behalf of the Million Death Study Collaborators, and in partnership with Tata Memorial Hospital (Mumbai, India), St. John’s Research Institute (Bangalore, India), IARC (Lyon, France) and SEARO (Delhi, India) of WHO and the Centre for Global Health Research (Toronto, Canada) LANCET PRESS RELEASE: WEDNESDAY, MARCH 28, 2012 Prabhat.jha@utoronto.ca

2. CGHR.ORG/CANCER Twitter: CGHR_org Key findings About 0.6 Million (M) or 6 Lakh cancer deaths in 2010 Over 70% of cancer deaths occurred during ages 30-69 years (200,000 men and 195,000 women) At ages 30-69 years, the three commonest fatal cancers –Men: oral, stomach, and lung –Women: cervical, breast and stomach Tobacco-related cancers are over 40% of male and nearly 20% of female cancers Cancer death rates are similar in rural and urban areas Huge variation in cancer death rates across states- partly due to tobacco, and partly for reasons awaiting further discovery Cancer death rates 2-fold higher in the least educated compared to the most educated adults Cervical cancer death rates far less in Muslim women than among Hindu women Source: Dikshit et al, Lancet 2012

3. CGHR.ORG/CANCER Twitter: CGHR_org What’s new about this research? First large, nationally-representative study of cancer mortality in India, reflecting both urban and rural areas Previous cancer estimates have relied mostly on cancer registries in cities, but 70% of Indians live in rural areas Provides distribution of cancer deaths by area, educational level, and religion CGHR.ORG/CANCER Twitter: CGHR_org

4. Nationally representative sample (Sample Registration System) 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area) How was the study done?

5. CGHR.ORG/CANCER Twitter: CGHR_org How was the study done? 800 Registrar General of India field workers interviewed 122 thousand families of people who had died in 2001-2003 Written reports each coded independently by at least two physicians to attribute a probable cause of death (i.e., cancer) Cancer deaths grouped into broadly similar categories (i.e., oral, lip and pharynx; lung and trachea, etc.)

6. CGHR.ORG/CANCER Twitter: CGHR_org How was the study done? Calculated proportion of all cancer deaths by age, gender, and cancer type within the study Combined with national 2010 UN totals of deaths, and 2007-2009 state-specific SRS death rates Produced national and state estimates of rates and number of cancer deaths for 2010

7. CGHR.ORG/CANCER Twitter: CGHR_org 7137 of 122 429 study deaths were due to cancer, meaning about 600,000 cancer deaths across the whole of India in 2010. Some 71% (395,000) of cancer deaths occurred in people aged 30-69 years (200,100 men and 195,300 women). At ages 30-69, cancer deaths are:  8% of the 2.5 million total male deaths  12% of the 1.6 million total female deaths Key results Source: Dikshit et al, Lancet 2012

8. CGHR.ORG/CANCER Twitter: CGHR_org MEN Oral 45,800 or 23% Stomach 25,200 or 13% Lung 22,900 or 11% WOMEN Cervical 33,400 or 17% Stomach 27,500 or 14% Breast 19,900 or 10% Leading cancers in men and women, age 30-69 years Source: Dikshit et al, Lancet 2012

9. CGHR.ORG/CANCER Twitter: CGHR_org 47 of 1000 men will die of cancer 44 of 1000 women will die of cancer Risk of death from cancer For middle-aged Indians, the risk of dying before age 70 in the absence of other diseases: Source: Dikshit et al, Lancet 2012

10. CGHR.ORG/CANCER Twitter: CGHR_org MENWOMEN INDIA4744 Rural4645 Urban4942 Richer states 5146 Poorer states 39 Source: Dikshit et al, Lancet 2012 Deaths among 1000 30 year olds before age 70 from cancer, at 2010 death rates

11. CGHR.ORG/CANCER Twitter: CGHR_org MEN:84,000 or 42% of all cancers WOMEN:35,700 or 18% of all cancers Together: over 120,000 tobacco cancers Twice as many oral cancers as lung cancers Tobacco cancers in men and women, age 30-69 years Source: Dikshit et al, Lancet 2012

12. CGHR.ORG/CANCER Twitter: CGHR_org Risk of cancer death*, by state *For Indians aged 30, the risk of dying before age 70 from cancer in the absence of other diseases MenWomen Northeast States (highest risk) 112 of 1000 men will die of cancer 60 of 1000 women will die of cancer Bihar (lower risk) 25 of 1000 men will die of cancer 29 of 1000 women will die of cancer Source: Dikshit et al, Lancet 2012

13. CGHR.ORG/CANCER Twitter: CGHR_org Cancer: MEN aged 30-69 years

14. CGHR.ORG/CANCER Twitter: CGHR_org Cancer: WOMEN aged 30-69 years

15. CGHR.ORG/CANCER Twitter: CGHR_org Cancer (non tobacco/non infection): BOTH GENDERS aged 30-69 years

16. CGHR.ORG/CANCER Twitter: CGHR_org Cancer death rates by education, men and women aged 30-69 Source: Dikshit et al, Lancet 2012

17. CGHR.ORG/CANCER Twitter: CGHR_org Cancer deaths and rates by education, men aged 30-69 Illiterate Primary Above Secondary Estimated death '000s 79.234.316.2 Age-standardised rates Subtotal: tobacco- related cancer 39.337.518.2 Subtotal: infection- related cancer 24.317.87.6 Total Male 106.693.445.7 Source: Dikshit et al, Lancet 2012

18. CGHR.ORG/CANCER Twitter: CGHR_org Cancer deaths and rates by education, women aged 30-69 Illiterate Primary Above Secondary Estimated death '000s 140.215.35.4 Age-standardised rates Subtotal: tobacco- related cancer 19.510.17.2 Subtotal: infection- related cancer 41.221.710.3 Total Female 106.764.243.4 Source: Dikshit et al, Lancet 2012

19. CGHR.ORG/CANCER Twitter: CGHR_org Selected cancer rates by religion, women 30-69 years Type Standardised mortality ratio (and study deaths) HinduMuslim Cervical 1.06 (340) 0.68 (24) Oral 1.01 (190) 0.80 (24) Breast 0.92 (178) 1.43 (32) Source: Dikshit et al, Lancet 2012

20. CGHR.ORG/CANCER Twitter: CGHR_org Cervical cancer rates by state, women 30-69 years Age-standardised mortality rates per 100,000 Jammu & Kashmir AssamIndia 2.3 3.516.0 Source: Dikshit et al, Lancet 2012

21. CGHR.ORG/CANCER Twitter: CGHR_org Most cancer deaths in India are avoidable as they occur at younger ages and present late after cancer starts Most importantly, higher tobacco taxes reduce cancer Strategies to vaccinate, screen, and treat women with cervical cancer also work. Early detection of cancer dramatically improves the prospect of cure Big differences suggest more research on why common cancers are rare in parts of India Implications Source: Dikshit et al, Lancet 2012

22. CGHR.ORG/CANCER Twitter: CGHR_org www.cghr.org/cancer Follow us on Twitter: @CGHR_org The Lancet Paper and Web appendix Press release (English, Hindi, and main regional languages) Video release (English, Hindi, and main regional languages FAQs PowerPoint slides

23. CGHR.ORG/CANCER Twitter: CGHR_org Million Death Study Collaborators Indian Academic Partners (in alphabetical order): Clinical Epidemiology Resource and Training Centre Trivandarum: KB Leena, KT Shenoy (until 2005) Department of Community Medicine Gujarat Medical College Ahmedabad: DV Bala, P Seth KN Trivedi Department of Community Medicine Kolkatta Medical College Kolkatta: SK Roy Department of Community Medicine Regional Institute of Medical Sciences Imphal: L Usharani Department of Community Medicine S.C.B. Medical College Cuttack Orissa: Dr. B Mohapatra Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta Epidemiological Research Center Chennai: V Gajalakshmi, CV Kanimozhi Gandhi Medical College Bhopal: RP Dikshit, S Sorangi Healis-Seskarhia Institute of Public Health Mumbai: PC Gupta, MS Pednekar, S Sreevidya Indian Institute of Health & Family Welfare, Hyderabad: P Bhatia Institute of Health Systems Research Hyderabad: P Mahapatra (until 2004) St. John’s Research Institute St. John’s Academy of Health Sciences Bangalore: A Kurpad, P Mony, M Vaz, R Jotkar, S Rao-Seshadri, S Shrihari, S Srinivasan King George Medical College Lucknow: S Awasthi Najafgarh Rural Health Training Centre Ministry of Health Government of India New Delhi: N Dhingra, J Sudhir, I Rawat (until 2007) National Institute of Mental Health and Neurosciences Bangalore: G Gururaj (until 2004) North Eastern Indira Gandhi Institute of Regional Medical Sciences Shillong Meghalaya: FU Ahmed (until 2005), DK Parida Regional Medical Research Center ICMR Institute Bhubaneshwar: AS Karketta, SK Dar School of Preventative Oncology Patna: DN Sinha School of Public Health Post Graduate Institute of Medical Education and Research Chandigarh: N Kaur, R Kumar, JS Thakur Tata Memorial Hospital Mumbai: RA Badwe, RP Dikshit, K Mohandas Lead Partners: Office of the Registrar-General India RK Puram New Delhi India: C Chandramouli (Registrar General of India [RGI]), RC Sethi, B Mishra, S Jain (until 2008), DK Dey (until 2009), AK Saxena, MS Thapa, N Kumar, JK Banthia and DK Sikri (former RGIs) Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute Keenan Research Centre St. Michael’s Hospital Dalla Lana School of Public Health University of Toronto Canada: DG Bassani, P Jha (Principal Investigator), R Jotkar, R Kamadod, B Pezzack, S Rao-Seshadri, P Rodriguez, J Sudhir, C Ramasundarahettige, W Suraweera Affiliated Partners: Indian Council of Medical Research New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly (DG to 2008), L Kant, B Bhattacharya School of Population Health The University of Queensland Australia: AD Lopez, C Rao World Health Organisation Geneva and SEARO Office New Delhi: T Boerma, T Evans, A Fric, S Habayeb (former WHO Representative-India), S Khanum, C Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director) Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU) University of Oxford England: N Bhala, J Boreham, Z Chen, R Collins, R Peto, G Whitlock