Cancer in Sri Lanka; trends, care and outcomes

Abstract Introduction The burden of cancer is increasing rapidly in Sri Lanka. However, limited data are available on incidence trends, diagnosis, treatment or outcomes of cancer in Sri Lanka. This oration encompasses a series of studies undertaken, Ÿ To describe the trends in incidence Ÿ To analyse stage at diagnosis, treatment and outcomes Ÿ To describe the long-term quality of life [QOL] after completion of treatment of cancer in Sri Lanka


Introduction
Cancer is the second most common cause of death in Sri Lanka [1]. Together with its rapidly aging population, cancer will have an increasingly major role in Sri Lanka's health system [2].
Researching into cancer incidence, trends, management, outcomes and disparities are important to identify areas where changes could be implemented to reduce the burden of cancer through measures to reduce incidence, early detection and better treatment strategies. However, a major limitation remains the lack of comprehensive information on incidence, trends, diagnostic and treatment pathways and its association with cancer outcomes which avert the identification of areas which are amenable to such interventions.
The National Cancer Control Program [NCCP] maintains the Sri Lanka Cancer Registry [SLCR]. NCCP data include all cancers treated at national cancer treatment centres and data from other major private and government hospitals, and pathology laboratories. This registry mainly contains sociodemographic and histologic data while staging data for some cancers are also included. In recent years, the SLCR has commenced collecting mortality statistics from death registries of hospitals in some provinces, but still remains largely incomplete [3]. Currently there is no systematic process to gather outcome data of any cancer in Sri Lanka. referrals to the Apeksha Hospital, Maharagama. All patients underwent a follow-up every six months.

Analysis
Categorical variables were described with numbers and percentages and continuous variables with mean/median with standard deviations. Survival analysis was done with Kaplan-Meier survival curves with disease recurrence as the censoring point. All analyses were performed using SPSS version 24.

Quality of life after treatment of cancer Study population
All women with non-metastatic breast cancer who underwent surgery for breast cancer at the Professorial Surgical Unit, Colombo during 2015-2018 and completed a minimum of one year follow up were invited to participate in the study. Fiftyfour women who responded were analysed using the validated EORTC QLQ-C30 and QLQ-BR23 questionnaires [8].

Analysis
The data were coded and analysed according to the scoring protocol described in the EORTC QLQ-30 manual using SPSS version 24 [8,9]. Non-parametric tests including Chi square test and Mann-Whitney U test were used for univariate statistical analyses.

Incidence and trends Breast cancer
This study included 19,755 patients with newly diagnosed primary invasive breast cancer over the study period [10] [4].

Incidence and trends Study Population
Details of all patients with breast, colorectal and thyroid cancers diagnosed between 01/01/2001 and 31/12/2010 were extracted from the publications of cancer incidence data of Sri Lanka by the NCCP [5].

Analysis
Age standardized rates of all cancers per 100,000 population were calculated using WHO age standardized populations including for age categories and by gender [6]. Joinpoint regression analysis was used to identify points where a statistically significant change over time in linear slope of the trend occurred [7].

Thyroid cancer
This study included a total of 7,681 thyroid malignancies diagnosed over the 10-year study period [12]. Results of thyroid cancer incidence in Sri Lanka with Joinpoint analysis of trends by gender, age group and histology subtype are shown in Table 3. We analyzed the concordance between guideline recommendations for use of adjuvant therapy for nonmetastatic breast cancer and actual rates of delivery [ The mean EORTC QLQ-C30 and QLQ-BR23 scores are shown in Table 9.

Discussion National Cancer Registry Data
The studies based on the Sri Lanka National Cancer Registry [SLCR] have shown a steady increase in the incidence of nearly all of the included common cancers over the 10-year study period. Overall, the rates of increase in incidence ranged between 2.5% to 8.5% per year.
There are many possible reasons for the observed increases in cancer incidence. One is the gradual increase in screen detected cancer [15]. Although Sri Lanka does not have national cancer screening programmes except for cervical cancer, many government and private institutions have started providing opportunistic cancer screening especially over the last decade [16]. Another likely contributor is better reporting and greater coverage of cancer data by the cancer registry [5].
Despite all these possible reasons for an 'artificial' increase in the incidence, it is likely that there has been a genuine increase in the incidence similar to many other developing countries [1]. Several factors have been proposed to be possible contributors towards this increase. These include westernization of lifestyle including increased consumption of processed and fatty food, sedentary lifestyle leading to increased obesity and increasing rates of alcohol and smoking [17].
In general, the highest incidence of cancers was seen in 60-70 age group. Further, the rate of rise in incidence was also observed to be higher in this age group. Sri Lanka has one of the fastest ageing populations in the world [18]. Older patients are more likely to have more comorbidities and a poorer survival from cancer [19]. Healthcare policy makers in the country need to consider all these factors in planning strategies, if they are to effectively deal with the increasing burden of cancer.
We propose several changes to improve the utility of data collected by the SLCR. First the coverage of cancer data collection needs to be improved. Introducing legislation, for example to make informing a cancer diagnosis compulsory to all pathologists or pathology laboratories are simple yet very effective ways to increase the completion. Further this could be used to improve the coverage additional data including the cancer stage. Thirdly, combining cancer data with cause of death data would provide accurate figures of cancer specific survival. Although this is more difficult as it requires a change in the system of death registration, such a change would be useful to identify the mortality not only of cancer, but of many other important diseases as well.

Cancer data from the National Cancer Institute, Maharagama
Although still in very early stages, this data collection project has shown useful results and has also shown the feasibility of collecting cancer data efficiently and cost effectively.

Breast cancer
To our knowledge, this is the largest published cohort of breast cancer patients in Sri Lanka and the most comprehensive especially in relation to treatment characteristics. We identified considerable lapses in the concordance between guideline recommendations and the delivery of cancer care [13,14]. For instance, only 75% women with absolute indications for radiotherapy have received adjuvant radiotherapy. Difficulties and limitations in access, patient co-morbidities, socioeconomic factors and poor health literacy are some of the known factors that may have limited the use of optimum adjuvant therapy.
Government of Sri Lanka has initiated several strategies with the aim of improving access to treatments and the quality of care for patients with cancer in the country. For instance, a program has been implemented to procure linear accelerators and to station radiation oncology centres in each of the nine provinces of the country to improve the access to radiotherapy [20]. Further action is needed to improve the availability resources including chemotherapy, endocrine and targeted therapy to ensure easier access with minimal delays. In addition, multidisciplinary team [MDT] to discuss and provision of care may improve quality of care and ensure all patients receive standard guideline concordant care. Advances in information technology will allow smaller base hospitals to obtain specialist cancer advise by joining MDT meetings held at tertiary hospitals online.
There are several limitations in our study. Incomplete and missing data were identified mainly in relation to adjuvant therapy and treatment modalities. Nevertheless, this is thus far the largest and most comprehensive cohort of patients with breast cancer reported from Sri Lanka.

Colorectal cancer
In this study, we have described disease characteristics and treatment patterns in a cohort of patients with newly diagnosed colorectal cancer in Sri Lanka.
Advanced stage at diagnosis was one of the most prominent features with nearly 57% had locally advanced or metastatic disease at presentation. Use of adjuvant therapy appeared to have been well in concordance with the standard guidelines. For instance, over 99% of stage III colorectal cancers have received either neoadjuvant or adjuvant chemotherapy. However, the overall chemotherapy rate of 87.5% may point towards overuse of chemotherapy especially among patients with low risk stage I and II disease.
There are several limitations in this study too similar to breast cancer study. Incomplete and missing data were identified mainly in relation to adjuvant therapy and treatment modalities is a major limitation.

Future
Future plans for the data repository include coverage of cancers beyond breast and colorectal and expansion to include data from other national cancer treatment centres. Many of the Sri Lankan public sector hospitals are in the process of converting from paper based to electronic data recording systems. Hence, linkage of these databases in the future is realistic which would potentially allow access to many patient and cancer related information as well as follow-up data from these hospital databases.
Many potential challenges are anticipated which include trained manpower for data collection, and long-term project funding. While the challenges remain real, with wider participation of stakeholders including the relevant government organizations we believe it will be possible to overcome these challenges successfully.

Quality of life
This prospective cohort study evaluated the post-treatment long-term QOL in Sri Lankan female patients diagnosed with breast cancer has shown substantially poor QOL in sexual functioning and enjoyment, breast and arm symptoms and hair loss domains while the impact on global health status including physical, social and emotional functions were minimal.
According to our findings, the low sores in breast related symptoms measured by BR-23 seems to be a major contributing factor for the lower QOL in breast cancer patients. Taking this into consideration, it is necessary to take measures to address the burden of breast related symptoms of these patients following surgery as these are easily preventable with adequate care. The HRQL of these patients may be improved by simple measures such as addressing sexual issues by referring them for counselling and prescribing topical applications, offering physiotherapy to alleviate arm symptoms, provision of wigs to combat hair loss following treatment. Provision of regular contact with the patients through trained cancer care nurses to recognize these issues and provide advice may help improve QOL in these domains which ultimately will help improve overall QOL.