From Pollution to Prevention: Combating Lung Cancer in India By Soumya Reddy Neravetla, MD, FACS, Cardiovascular/Thoracic Surgery

Lung cancer is a silent epidemic in Southeast Asia, claiming 166,260 lives annually and making it the leading cause of cancer mortality in the region, like most of the world. In India alone, there are 72,510 new cases and 66,279 deaths each year, highlighting a growing public health crisis. Unlike in the United States, where lung cancer rates are gradually declining, India has seen a troubling increase in incidence—from 6.62 per 100,000 in 1990 to 7.7 per 100,000 in 2019. This stark contrast underscores the urgent need for targeted interventions to combat this disease.

Lung cancer presents approximately a decade earlier in India as compared to Western countries, with a mean age at diagnosis of 54–70 years. This earlier onset could be attributed to the overall younger population (median age 28.2) and unique risk factors like air pollution.  Several studies have reported between 40 and 50% cases in India are non-smokers.In addition to air pollution, occupational exposure to chromium, cadmium, arsenic, and coal products increase risk. Biomass fuel usage is a common risk in rural areas.

Tobacco, however, remains the primary culprit.  India is the second largest consumer and third largest producer of tobacco in the world. Among adults, 42% of men and 14.2% women currently either smoke or use smokeless tobacco; khaini and bidi are the most used smokeless and smoked products, respectively. The mean age of starting daily tobacco use is just 18.7 years, and three out of ten adults working indoors have been exposed to second handsmoke.

Additionally, hookah use, prevalent in the Kashmir region,has also been associated with increased rates of lung cancer.While tobacco use has decreased significantly from 47% in 2000 to 29% in 2018, it remains the highest globally.  India has been consistently moving forward with tobacco cessation efforts, included the recent launch of a nationwide “Tobacco Quit Line”.

There is limited data about lung cancer screening in India and Southeast Asia. While data shows that low-dose computed tomography can effectively identify potentially malignant lung nodules, the high false-positive rate—due to a significant incidence of granulomatous diseases like TB and histoplasmosis—complicates implementation in India. Further studies are essential to better understand how to effectively utilize screening in this context.

Unfortunately, this high rate of granulomatous disease also leads to significant delays in diagnosis with many cancer patients being initially treated for TB.  Thus, most cases are diagnosedin advanced stages.  In addition, even among early stage patients, a significant proportion do not undergo curative resection or treatment, further exacerbating mortality rates.

Addressing lung cancer in India requires a multifaceted approach, particularly in developing effective screening strategies. While it may take time and resources to develop implement these initiatives, the importance of prevention cannot be overstated.

Given that tobacco use remains the most cause of lung cancer, ongoing efforts to reduce consumption are crucial. In addition, efforts to decrease pollution and workplace exposure should be increased. By prioritizing risk factor reduction while developing early detection methods, India can significantly impact lung cancer mortality rates and ultimately save lives.