Cancer Risk in Nepal: An Analysis from Population-Based Cancer Registry of Urban, Suburban, and Rural Regions.

Nepal is one of the high prevalent countries for tobacco use in Southeast Asia regions. Tobacco related cancer share the major burden since a decade, however, population-based estimates is still lacking. This study provides results from population-based cancer registries on tobacco-related cancer (TRCs) burden in Nepal. The data were collected by population-based cancer registry conducted in nine districts by Nepal Health Research Council. The districts were categorized in urban, semi-urban and rural regions on the basis of geographical locations and facilities available in the regions. Analysis was done to identify tobacco-associated cancer incidence, mortality and patterns along with cumulative risk of having cancer before the age of 75 years. Tobacco-related cancer was 35.3% in men and 17.3% in women. We found that every one in 36 men and one in 65 women developed tobacco-related cancer before age 75 in Nepal. Cancer of lung, mouth, esophagus and larynx were among the five most common tobacco-related cancers in both men and women. The incidence of tobacco-associated cancers was higher in urban region with age adjusted rate 33.6 and 17.0 per 100,000 population for men and women respectively compared to semi-urban and rural regions. Tobacco-associated cancer mortality was significantly higher compared to incidence. The prevalence of tobacco-related cancer found high in Nepal despite of enforcement of tobacco control policy and strategies including WHO framework convention on tobacco control. Concerned authorities should focus towards monitoring of implemented tobacco control policy and strategies.

Variations in cancer incidence, mortality and pattern exist in rural and urban areas. Understanding these differences helps in developing targeted cancer prevention and control strategies. However, no previous studies have explored the differences in cancer demographics between the rural and urban areas of Nepal. The data of Kathmandu Valley (urban area) Population-Based Cancer Registry (PBCR) and Rukum (rural area) PBCR were analysed to identify the differences in cancer pattern in rural and urban areas.The age-adjusted incidence rate (AAR) in Kathmandu was higher than that in Rukum (1.6 times among males and 1.9 times among females). The top two leading sites in males were lungs and stomach in both the regions; however, the rates were higher in Kathmandu. The incidence rate for cancer of the urinary bladder among males in Kathmandu was particularly higher – 4.4 times that of Rukum. In females, the leading site of cancer in Kathmandu was breast, which was eight times higher compared to Rukum, whereas the incidence rate of cervix cancer in Kathmandu is 30% less than in Rukum. The incidence of tobacco-related cancer was found to be higher in Kathmandu compared to Rukum.These findings reveal the need for different policy priorities for cancer control in the urban versus rural regions of Nepal, based on the different demographics of cancer in the two areas. Similar studies from other regions of Nepal are needed to develop a targeted cancer control strategy.

The burden of cancer is increasing worldwide due to ageing, growing populations and increased exposure to major risk factors, including unhealthy diet, sedentary lifestyle and for many populations, tobacco smoking (Global Burden of Disease Cancer Collaboration et al., 2015). This trend is part of a wider phenomenon of increasing burden of non-communicable diseases (NCDs) (World Health Organization, 2011). Deaths from NCDs are projected to increase from 38 million to 52 million between 2012 and 2030 (World Health Organization, 2014). The NCD burden is not evenly distributed, with more than 80% of all premature NCD deaths occurring in low- and middle-income countries (LMIC). The growing burden of cancer in developing countries is due to changes in lifestyle and reproductive factors, which complement a pre-existing high burden caused by infectious diseases (Bray, Jemal, Grey, Ferlay, & Forman, 2012; Kanavos, 2006). Much of the cancer burden in developing countries is preventable through lifestyle modification, tobacco control, screening and vaccination (Kanavos, 2006). As a result of overburdened, poorly developed and fragmented health care systems, the prevailing lack of prevention, early detection and treatment interventions contributes to a disproportionately higher cancer mortality in these countries. Given many competing priorities, governments and donor agencies lack the resources and strategic direction to address the scale of the NCD challenge (Reeler & Mellstedt, 2006). Underfinanced health care facilities are not able to offer complex and expensive cancer treatments (Global Burden of Disease Cancer Collaboration et al., 2015). Another important issue is the lack of appropriate data on cancer incidence, mortality and outcomes of services. These data are necessary to understand the extent of the cancer problem across the population, and to monitor status changes in incidence and mortality, including responses to cancer control initiatives, such as treatment and preventive programmes (Bray, Znaor, et al., 2015; Parkin, 2006). In this commentary, we provide an overview of cancer epidemiology and cancer registration challenges in LMIC, with a special focus on the Pacific Islands. There were an estimated 14.1 million new incident cancer cases and 8.2 million cancer deaths globally in 2012, with 57% of new cases and 65% of the cancer deaths occurring in the less developed countries (Ferlay et al., 2013). Large increase in global cancer burden is projected by 2025 (Bray, 2014). Increases in cancer incidence are projected to be proportionally greatest in LMIC (Bray et al., 2012). According to GLOBOCAN data, the overall age-standardised cancer incidence and cancer mortality rates in less developed regions were 147.7 and 98.4 per 100 000 people in 2012 (Ferlay et al., 2013). The most frequent cancer sites were lung, breast, stomach, liver and colon/rectum. By comparison, the corresponding cancer incidence and mortality rates in more developed regions were 267.2 and 108.5 per 100 000 respectively. The smaller elevation in mortality than incidence in more developed areas reflects both a difference in mix towards less lethal cancer types and better survival. The incidence gap is closing rapidly, however, as developing countries adopt "Western" lifestyle and health behaviours (Bray, 2014). In more developed areas, breast, prostate, lung and colorectal cancers comprise approximately half of all cancers, whereas in less developed areas, stomach, liver and cervical cancers play a more important role (Ferlay et al., 2015). Infectious agents play an important role in the genesis of these cancers highlighting the greater importance of infections as a cancer cause in developing countries. Infections are responsible for an estimated 25% of cancers in developing countries, whereas the corresponding proportion is about 10% in developed countries (Plummer et al., 2016). In recent decades, a cancer transition has taken place, however, with an increasing incidence of breast, colorectal and prostate cancers also taking place in less affluent populations which historically had a lower risk of these cancers (Bray et al., 2012). Changes in reproductive, dietary, metabolic, hormonal and behavioural factors are likely to be responsible for this transition. Pacific Islands countries and territories (PICTs) comprise 20 000–30 000 islands in the Pacific Ocean (World Health Organization Western Pacific Region, 2012). PICTs vary in stage of human development, size, culture and economic resources; however, they all face the triple burden of NCDs, communicable diseases and the impact of climate change (World Health Organization Western Pacific Region, 2012). PICTs have one of the highest NCD incidence rates in the world, comprising the leading cause of mortality. Relatively small populations, large physical areas with long distances, geographic isolation, reliance on overseas assistance and weak economies complicate the provision of the health care services that would be essential to address this increasing public health challenge. The cancer burden is thought to be increasing in the PICTs, although only limited quantitative evidence is available due to a paucity of cancer incidence and mortality data (Moore et al., 2010; Varghese, Carlos, & Shin, 2014). Eight of the 22 PICTs were included in the GLOBOCAN 2012 (Fiji, French Polynesia, Guam, New Caledonia, Papua New Guinea, Samoa, Solomon Islands and Vanuatu) (Ferlay et al., 2013). Most of these PICTs had national incidence data for some diagnostic time periods, but not Papua New Guinea and Solomon Islands, where all cancer rates or rates for neighbouring countries have been used to estimate cancer incidence. Meanwhile, mortality data were missing for Guam, Papua New Guinea, Samoa, Solomon Islands, and Vanuatu, where mortality estimates were derived from estimated national incidence rates and modelled survival. None of the PICTs were reflected in or contributed to the Cancer Incidence in Five Continents Volume X (CI5-X) publication (Forman et al., 2014), indicating their relatively low availability of high quality data. According to GLOBOCAN 2012, cancer incidence was estimated to be highest in New Caledonia (age-standardised rate (ASR) of 330.7 for men and 269.3 for women per 100 000) and in French Polynesia (ASR 287.4 for men and 227.3 for women per 100 000) (Ferlay et al., 2013). Similarly, age-standardised cancer mortality rates were estimated to be highest in French Polynesia (ASR 153.9 for men and 116.3 for women per 100 000) and New Caledonia (ASR 146.0 for men and 112.0 for women per 100 000). In all other countries, cancer incidence estimates were below the World average, with cancer incidence generally higher among women than men. The most common cancers among men were estimated to be prostate, lung, stomach, liver and lip/oral cavity cancers. For women, breast cancer was ranked as the most common cancer in all countries, except in Papua New Guinea where cervical cancer was most common. Notably Papua New Guinea accounts for over a third of the total Pacific population at over 6 million, thereby increasing the contribution of cervical cancer to the cancer burden in the Pacific region. A study examining cancer incidence in four PICTs (Fiji, Tonga, Cook Islands and Niue) reported that age-standardised cancer incidence was lower in these countries than among Pacific people living in New Zealand (Foliaki et al., 2011). Under-recording is likely to have contributed to these differences. Despite relatively low (reported) cancer incidence in many PICTs, cancer is one of the leading causes of death in the region (Carter et al., 2011, 2016; Pacific Regional Central Cancer Registry, 2015). There are distinguishing features of cancer epidemiology in the PICTs, such as very high thyroid cancer incidence in New Caledonia and French Polynesia (Ferlay et al., 2013), a high burden of cervical and uterine cancers, especially in Fiji and the Cook Islands (Foliaki et al., 2011; Law et al., 2013) and a high burden of oral cavity and pharyngeal cancers linked with betel nut chewing (Moore et al., 2010; Pacific Regional Central Cancer Registry, 2015). Nuclear tests conducted by France in French Polynesia and by the US in Marshall Islands have been linked to increased thyroid cancer and leukaemia rates (Bouchardy, Benhamou, de Vathaire, Schaffar, & Rapiti, 2011; Simon, Bouville, Land, & Beck, 2010). Data collected by population-based cancer registries (PBCR) are the gold standard for providing information on cancer incidence across geographic areas and for planning population-wide cancer control programmes (Bray, Znaor, et al., 2015). Full case ascertainment and unbiased information on cancer burden is optimally achieved where there is a well-functioning health care system. Availability as well as quality of cancer incidence and mortality data tends to increase with development and infrastructure levels, with many LMIC still without cancer registration systems in place or hospital- or pathology-based registration systems that are not population-based. In addition to cancer data, population denominator data are also needed in order to provide accurate information on cancer incidence rates. These data commonly come from censuses which may be rarely or irregularly conducted in developing countries (Valsecchi & Steliarova-Foucher, 2008). Population-based cancer registries systematically collect information on all cancers occurring in a defined population using multiple data sources, whereas hospital- and pathology-based registries collect information on cases treated/diagnosed in selected institutions or laboratories (Bray, Znaor, et al., 2015). While useful, such data may not be representative of the overall population experience and may contain important statistical biases from a population perspective. While data collected from hospital- or pathology-based registries may provide a misleading cancer profile for the general population, they still can be useful for hospital administration purposes, for reviewing clinical performance and for providing information about cancer profiles of people who obtain hospital/pathology services (Bray, Znaor, et al., 2015; Valsecchi & Steliarova-Foucher, 2008). There are many challenges with cancer registration in developing countries, including weak or non-existent health care infrastructures, lack of accurate death records and population data, complicating issues related to cultural norms and problems caused by political and economic instability, and mobile populations (Parkin & Sanghvi, 1991; Valsecchi & Steliarova-Foucher, 2008). In order to register all cases of cancer, data need to be collected from multiple sources, including hospitals, laboratories and death certificates (Bray, Znaor, et al., 2015). Lack of health care networks, poorly developed communications between different stakeholders as well as inability to uniquely identify individuals complicate the collection of these data (Valsecchi & Steliarova-Foucher, 2008). Underestimation of both cancer cases and deaths is commonplace where many people lack access to basic health care services and cancers and cancer deaths go unrecorded, as may apply in particular in the rural areas. People may die at home and be buried at home or otherwise locally without reporting to government authorities (Jedy-Agba et al., 2015). Poor transportation networks and phone connections, cultural and religious constraints, preference for traditional healing and taboos and stigmas relating to cancer contribute to an underestimation of numbers of cancer and a lack of follow-up for registered cases (Valsecchi & Steliarova-Foucher, 2008). In addition to these technical challenges, a lack of financial and material resources, trained personnel and support from governments, policymakers and health professionals further complicates cancer registration. As cancer registration involves considerable costs, regional registries collecting data on sub-national samples have been considered good options in some low-resource countries (Bray, Znaor, et al., 2015). When cancer data are collected, there may be issues with quality, such as low proportions of cases confirmed microscopically due to a lack of pathology services (Bray, Ferlay, et al., 2015). Cancer diagnoses may be based on clinical examination only, with greater uncertainty (Parkin & Sanghvi, 1991). Another important indicator of poorer data quality is a high percentage of cases registered from death certificates only (DCOs), reflecting incomplete case identification (Bray, Ferlay, et al., 2015). On the other hand, a total lack of DCOs may indicate failure to use death certificate information or to link death information to the cancer registry (Curado, Voti, & Sortino-Rachou, 2009). Accuracy of diagnostic information derived from death certificates is generally suboptimal. In addition, there may be specific problems in developing countries in relation to the quality of death certification, with information on causes of death often missing/erroneous and with certificates often completed by lay-people instead of medical doctors. In addition to cancer diagnosis and death data, other essential data may be missing or incomplete, including birth date, age and place of residence (Jedy-Agba et al., 2015). Lack of co-operation and difficulties in accessing data from several data sources may be caused by general distrust of government-related activities, lack of a culture of data collection and concerns about confidentiality (Jedy-Agba et al., 2015). Making cancer a registrable disease by government regulations can mitigate challenges in data collection and increase the authority of PBCR, although success is likely to depend on availability of resources and culture and politics of the country. Continuous monitoring and mentoring involving both local and international experts and sustainable funding models are often essential for ongoing, successful registration (Jedy-Agba et al., 2015). Commonly, low cancer data quality stems from overall weakness of health care system and, therefore, wide-ranging system-level improvements would materially improve registry quality. The first cancer registry in the PICTs was established in Papua New Guinea in 1958 (Foliaki et al., 2011). According to information from the World Health Organization, many PICTs have cancer registries nowadays (World Health Organization, 2016). In addition, most PICTs have collected census information in recent years (Secretariat of the Pacific Community, 2016). There are issues, however, with quality, coverage and completeness of cancer data (Dachs et al., 2008; Moore et al., 2010; Shin, Carlos, & Varghese, 2012). Many of the registration challenges mentioned earlier in this commentary are familiar to PICTs. Lack of infrastructure, coordination and funding, poorly developed health care systems, under-recording as well as poor quality of death certificates and diagnostic information complicate the collection of cancer data in many PICTs (Palafox et al., 2004). Along with vast distances between PICTs and degree of remoteness, the high proportions of foreign contract workers in some islands, and conversely the extent to which the birth population has migrated off-island impact the development of sustainable infrastructure. Different development agencies, including funders of new programmes, often request data in formats and using software modules that are not familiar to local data custodians complicating the meaningful collection and utilisation of data at the regional level. Many PICTs have close relationships with 'host' countries (the US, New Zealand and France) and are dependent on external aid, including health development. There is an opportunity to review health development assistance platforms with one of the major initiatives being health information and monitoring. Due to natural conditions, many PICTs are dependent on imported food (World Health Organization Western Pacific Region, 2012). Financial incentives, such as the Nuclear Claims Tribunal in the Marshall Islands, may facilitate the case finding of certain cancer types, but not others. Natural and other disasters have destroyed cancer registry databases in Nauru (Palafox et al., 2004), Niue (Foliaki et al., 2011) and American Samoa (Tsark, Cancer Council of the Pacific Islands, & Braun, 2007). Due to limited treatment options, people diagnosed with cancer may die off-island and, therefore, may not be registered. The Global Monitoring Framework of WHO, subsequent to the United Nations high-level meeting to "launch and all-out attack" on NCDs in 2011, specifically mentions the recording of cancer incidence by type of cancer per 100 000 population as an indicator to monitor 2025 targets; thereby placing an onus on countries to establish PBCR. The International Agency for Research on Cancer (IARC) in collaboration with major international and national partner organisations established the Global Initiative for Cancer Registry Development (GICR) in 2011 (International Agency for Research on Cancer, 2014, 2016). The aim of the GICR is to improve the coverage, quality and networking capacities of PBCR in LMIC. The GICR is organised around Regional Hubs for providing technical support and on-site training, assessing data quality and overall capacity for development, coordinating different activities and monitoring overall progress in the region. One of these is the emerging Pacific Islands Regional Hub which will focus on supporting cancer registries and improving data collection and data utilisation for cancer control in Fiji, New Caledonia, Papua New Guinea, Solomon Islands, Vanuatu, Guam, French Polynesia and Samoa. The Hub will be governed by an Advisory Board comprising regional experts from participating PICTs, along with Australia and New Zealand, and other local experts in the use of registry data to support local service delivery and research. The Pacific Islands Regional Hub will comprise a collaboration of registry experts, local public health practitioners and administrations. The registry experts will provide support and consultancy services for existing registries, such as ongoing training and assistance with registration, quality assurance, statistical analysis and research activities, whereas local PICT public health practitioners and administrators will give direction to the use of these data for local service delivery. There is no question that the Pacific Hub initiative should be tested, along with obligations to establish PBCR. It will be critical to continually monitor progress and reassess implementation in terms of strategic approaches, steps taken, and local involvement to ensure full participation and ownership of the initiative by Pacific countries, as well as sustainability and effectiveness of the Hub activities. The US-associated PICTs (American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, the Republic of the Marshall Islands and the Republic of Belau) established the Cancer Council of the Pacific Islands and the Pacific Regional Central Cancer Registry in the early 2000s (Pacific Regional Central Cancer Registry, 2015; Tsark, Cancer Council of the Pacific Islands, & Braun, 2007). This collaboration has enabled the development of culturally appropriate cancer control strategies and activities for the US-associated PICTs, with publication of cancer incidence rates for 2007–2012. The key to the success has been culturally appropriate approaches, local capacity building and leadership, and funding support. The Pacific Islands Regional Hub seeks to build on this experience and through collaborative arrangements, provide complementary support services for other PICTs that are attuned to their needs. In order to strengthen cancer registration in the PICTs, improvements in health care systems and infrastructure are needed more generally and in quality of death certificates and diagnostic information systems. The key strategies for achieving these improvements include building governance structures which coordinate the responsibilities and actions of different stakeholders and using culturally appropriate methods in order to ensure strong local engagement and sustainability. The potential of the emerging Pacific Islands Regional Hub to serve a useful role in advancing and coordinating these activities will be tested. None to declare.

Over the past few decades, there has been growing support for the idea that cancer needs an interdisciplinary approach. Therefore, the international cancer community has developed several strategies as outlined in the WHO non-communicable diseases Action Plan (which includes cancer control) as the World Health Assembly and the UICC World Cancer Declaration, which both include primary prevention, early diagnosis, treatment, and palliative care. This paper highlights experiences/ideas in cancer control for international collaborations between low, middle, and high income countries, including collaborations between the European Union (EU) and African Union (AU) Member States, the Latin-American and Caribbean countries, and the Eastern Mediterranean countries. These proposals are presented within the context of the global vision on cancer control set forth by WHO in partnership with the International Union Against Cancer (UICC), in addition to issues that should be considered for collaborations at the global level: cancer survival (similar to the project CONCORD), cancer control for youth and adaptation of Clinical Practice Guidelines. Since cancer control is given lower priority on the health agenda of low and middle income countries and is less represented in global health efforts in those countries, EU and AU cancer stakeholders are working to put cancer control on the agenda of the EU-AU treaty for collaborations, and are proposing to consider palliative care, population-based cancer registration, and training and education focusing on primary prevention as core tools. A Community of Practice, such as the Third International Cancer Control Congress (ICCC-3), is an ideal place to share new proposals, learn from other experiences, and formulate new ideas. The aim of the ICCC-3 is to foster new international collaborations to promote cancer control actions in low and middle income countries. The development of supranational collaborations has been hindered by the fact that cancer control is not part of the objectives of the Millennium Development Goals (MGGs). As a consequence, less resources of development aids are allocated to control NCDs including cancer.

We cannot prevent cancer, detect it early, diagnose, treat, and palliate it without reliable data. Continuous, systematic collection, analysis, and interpretation of cancer-related data are essential to effectively plan, implement and evaluate cancer control activities and policies. Enhancing routine health information systems to ensure that cancer-related data are well captured is essential, just as fostering functioning cancer surveillance systems, particularly population-based cancer registries (1,2). Population-based cancer registries play a critical role in the planning of national cancer control and prevention strategies, monitoring and evaluation of cancer care services, as well as cancer epidemiological and clinical research (1).

BackgroundYunnan province is located in south western China and is one of the poorest provinces of the country. This study examines the premature mortality burden from common causes of deaths among an urban region, suburban region and rural region of Kunming, the capital of Yunnan.MethodsYears of life lost (YLL) rate per 1,000 and mortality rate per 100,000 were calculated from medical death certificates in 2003 and broken down by cause of death, age and gender among urban, suburban and rural regions. YLL was calculated without age-weighting and discounting rate. Rates were age-adjusted to the combined population of three regions. However, 3% discounting rate and a standard age-weighting function were included in the sensitivity analysis.ResultsNon-communicable diseases contributed the most YLL in all three regions. The rural region had about 50% higher premature mortality burden compared to the other two regions. YLL from infectious diseases and perinatal problems was still a major problem in the rural region. Among non-communicable diseases, YLL from stroke was the highest in the urban/suburban regions; COPD followed as the second and was the highest in the rural region. Mortality burden from injuries was however higher in the rural region than the other two regions, especially for men. Self-inflicted injuries were between 2–8 times more serious among women. The use of either mortality rate or YLL gives a similar conclusion regarding the order of priority. Reanalysis with age-weighting and 3% discounting rate gave similar results.ConclusionUrban south western China has already engaged in epidemiological pattern of developed countries. The rural region is additionally burdened by diseases of poverty and injury on top of the non-communicable diseases.

BackgroundEcosystem services rendered by the butterflies are important for the sustenance of community interaction. Butterfly species have also coevolved with the host and nectaring plants. In the adult condition, they mostly rely on nectar, while in the larval condition, they feed on the leaves of their host plants. Butterfly species are sensitive to changes in environmental parameters and are considered excellent indicators of ecosystem health. The study of species diversity and richness indices aids in better ecosystem management. The present study's goal was to determine butterfly diversity in the urban–rural gradient of Purulia district, West Bengal, India, a part of the Chota Nagpur Plateau. We aim to complement crucial information on butterfly conservation management in Purulia, West Bengal, India, and other similar geographical areas with the findings of this study.ResultsIt was found that out of 3809 sampled butterflies, the individual contribution of the family Nymphalidae was the highest (51.24%), followed by Lycaenidae (18.40%), Pieridae (17.32%), Papilionidae (9.74%), and Hesperiidae (3.12%). A total of 54 butterfly species were observed in the urban–rural gradient, out of which the urban region contained 49 species, the suburban region had 32 species, and the rural region had 30 species. Significant differences were observed in butterfly abundance for the sites, seasons, and families during the study period. PERMANOVA and ANOSIM for species abundance and species presence-absence data show that all three sites are significantly different. Results Both PCoA and NMDS revealed clear differences among sites (groups) in terms of species abundance and presence-absence data. According to the findings of this study, the urban region has the highest species richness, followed by the suburban and rural regions. We discovered that urban areas have the highest butterfly abundance, followed by suburban and rural areas. Numerous butterfly species prefer the bushes dominated by Lantanacamara in the urban region with the highest species richness. Aside from this invasive weed, the site also contains Tridaxprocumbens, Catharanthusroseus, Synedrellanodiflora, and Ocimumamericanum, which are well known for being butterfly nectaring plants. In the case of the suburban region, members of the Lycaenidae family contributed the highest percentage after Nymphalidae, which was dominated by Tridaxprocumbens and Sphagneticolatrilobata, which was preferred by the members of the Lycaenidae family observed during the survey, this site also contained Ixoracoccinea, Catharanthusroseus, and Lantanacamara. This site, in terms of nectaring plants, remains homogeneous in a rural region.ConclusionsOut of 3809 butterfly individuals, the family Nymphalidae contributed the most, followed by Lycaenidae, Pieridae, Papilionidae, and Hesperiidae. Both species richness and butterfly abundance were highest in urban regions, followed by sub-urban and rural regions. The current study has shown that this particular geographic location can sustain a variety of butterfly species. However, it is important to note that conservation planning is necessary not only for the butterfly species but also for the nectaring plant species that contribute to the diversity of these insects. The conservation of butterfly species can also lead to the achievement of ecosystem services they provide.

Adequate antenatal care (ANC) is crucial to reduce maternal/neonatal deaths, but the proportion of mothers with appropriate ANC is lower in most low- and middle-income countries (LMICs) than in high-income countries. Furthermore, in many LMICs, including Bangladesh, there are intra-country disparities, and rural regions have substantially lower adequate ANC than urban regions. In this cross-sectional study, we performed secondary analyses on Bangladesh Demographic and Health Survey 2017–18 data to examine the rural-urban differences in adequate initiation, number, and quality of ANC. Women of reproductive age (i.e., 15-49-year-olds) with at least one birth in the three years before the survey were included. After reporting the prevalence of adequate ANC by rural-urban place, simple and multivariable logistic regression analyses were performed to examine the association. Among 4974 women, 1331 and 3643 were from urban rural regions, respectively. The proportions of mothers who initiated the visits in the first trimester, had at least four ANC visits, and had quality ANC were 47.5% (95% confidence interval (CI): 44.6–50.3), 59.0% (95% CI: 56.3–61.8), and 27.1% (95% CI: 24.6–29.6) in urban regions, and 33.4% (95% CI: 31.6–35.1), 42.8% (95% CI: 41.0–44.7), and 14.5% (95% CI: 13.1–15.8) in rural regions, respectively. These differences in ANC utilization were observed regardless of most sociodemographic and socioeconomic characteristics. After adjusting for sociodemographic and socioeconomic characteristics, compared to urban mothers, rural mothers had lower odds of at least four ANC visits (adjusted odds ratio (AOR): 0.77, 95% CI: 0.65–0.91) and quality ANC (AOR: 0.79, 95% CI: 0.65–0.97) but the odds for timely initiation (AOR: 0.85, 95% CI: 0.73–1.01) was not significant. Findings of this study showed significant disparities between rural and urban regions regarding appropriate ANC coverage, and the importance of improving ANC coverage among some sociodemographic groups to reduce these disparities, especially among mothers with low socioeconomic status.

Despite steady decreases in the cancer burden in industrialized countries, its rapid increase in the developing world means that the number of cancer cases and deaths will likely more than double worldwide over the next two decades ([1][1]). Already a leading cause of death around the globe, cancer

Lung Cancer in Nepal

A comparative study on physicochemical characteristics of household dust from a metropolitan city and a remote village in China

This paper benchmarks the performance of OECD rural regions with other types of OECD regions over the period 1995-2010. OECD regions are classified into three types according to the OECD regional typology and into four types according to the extended OECD typology. The latter classifies rural regions into rural regions close to cities and rural remote regions. The analysis focuses on two time-periods: the first prior to the global financial crisis covering 1995 to 2007 and the second capturing the effects of the crisis from 2007- 2010. The results display a relative stable trend in settlement patterns among urban and rural regions over the last 15 years. Level comparisons reveal important differences between urban and rural regions. The latter are characterised with low density, long distances and lack of critical mass in comparison to other OECD regions. Notable differences are also present within rural regions. In terms of performance, rural regions record the highest average growth in GDP per capita and in productivity but also the highest volatility in growth rates during the pre-crises period. Within countries, rural regions record the fastest rate of growth in GDP per capita in 40% of OECD countries considered. Among rural regions, those close to a city are the most dynamic in GDP per capita, productivity and population growth during 1995-2007. The effects of the crisis have been more severe in urban regions in GDP, GDP per-capita and employment rates. Rural regions in contrast have suffered a higher increase in unemployment rates. Overall the effects of the crisis will likely have a more lasting effect on rural regions, particularly in remote rural regions, due to their thinner and less diversified economic base. In sum this paper finds stark difference between rural and urban regions and between rural regions close to cities and remote rural regions which suggests the need for a differentiated policy approach capable of addressing the different types of challenge.

Global variation in patterns of care and time to initial treatment for breast, cervical, and ovarian cancer from 2015 to 2018 (VENUSCANCER): a secondary analysis of individual records for 275 792 women from 103 population-based cancer registries in 39 countries and territories.

Background Heat waves have devastating health effects on human populations. Our previous study shows that heat waves had a higher risk for stroke mortality in Nanjing. Despite many studies of mortality risk for heat waves in urban areas, few studies have examined the spatial variations among different regions. Objectives We analyzed the stroke mortality of a heat wave in 2010 in Nanjing, China and investigated the spatial variability of stroke mortality risk between heat wave days and non-heat wave days. Methods Within each town of Nanjing, we calculated the stroke mortality during the heat wave (July 30–August 22, 2010) and a reference period (July 30-August 22, 2009). We estimated the rate ratios (RRs) of urban, suburban, and rural regions. Spatial autocorrelation was used to measure the spatial patterns of heat wave mortality. The Anselin Local Moran's I statistic was applied to identify the statistically significant spatial clusters. Results Stroke mortality in both the heat wave and the reference period were spatially clustered, with the Moran’s Index of 0.147 and 0.089. During the reference period, two HH spots(areas with high stroke mortality surrounded by other areas with high stroke mortality) were found in rural regions and the clusters in urban and suburban regions were not significant. During the heat wave, the two hot spots in rural regions remained while an HL spot(areas with high mortality surrounded by other areas with low mortality) was discovered in the suburban region. During the heat wave, the RRs of stroke mortality were 2.25(95%CI,1.03-4.27) in the urban area, 4.14(95%CI,2.77-5.95) in the suburban area, and 1.66(95%CI,1.33-2.05) in the rural area. Conclusions We found that stroke mortality risk from heat waves in Nanjing has clear spatial patterns. During the heat wave, suburban regions have the highest and spatially clustered stroke mortality risk. These findings revealed the importance of the health impact of heat waves in suburban areas.

Background and Objective: An overview of the update of cancer incidence summary findings will be of help to researchers and clinicians for quick reference of facts in cancer control. To present an overview of cancer incidence available from the recent population-based cancer registries (PBCRs) in India from 2009 to 2011. Materials and Methods: Data on age-adjusted incidence rates and cumulative risks of cancer at various sites were collected for both sexes for six major cancer sites from the first report of the National Cancer Registry Programme (NCRP) on 25 PBCRs in India for the years 2009-2011. Site-specific risks in terms of one out of the total number of persons who develop cancer were computed. The summaries, in the form of ranges, are presented in six regions of the country in which the 20 PBCRs are located. The range of age-adjusted rates (AARs) and one out of the number of persons who develop cancer as a lifetime risk in the age of 0-64 years is presented. Results: In different regions, the highest risks for males for developing cancer in the various major sites studied were as follows: One out of 67 for cancer in the lungs in the Northeast, one out of 27 for cancer in the esophagus in the Northeast, one out of 71 for cancer in the mouth in the western region, one out of 100 cancer in the tongue in the rural western region, one out of 333 for cancer in the prostate in the northern region, and one out of 33 for cancer in the stomach in the northeastern region. The highest risks for the various sites studied were as follows: one out of 36 for cancer in the breast in the south, one out of 59 for cancer in the cervix in the western region, one out of 125 for cancer in the ovary in the northern region, one out of 63 for cancer in the esophagus in the northeastern region, one out of 250 for cancer in the mouth in three regions, and one out of 125 for cancer in the gall bladder in the western and central regions. Overall, for all cancers there is a risk of one out of 8-27 persons and one out of 10-25 persons among males and females, respectively, in the Indian population who are likely to develop cancer of any site in their lifetime during the age of 0-64 years. Conclusion: Female breast cancer in the southern region and esophagus and stomach cancers among males in the northeast region were of the highest magnitudes.