Interpretation
Figure-1 represents thestate wise incidence of cervical cancer among women from 1990 to 2019.As evident from the maps (Fig. 1)decrement of incidence is not uniform over the time across the states. Some of the states like Jharkhand (-28.47%) and Gujarat (-23.27%) shows the highest percentage decline in incidence of cervical cancer in the period 1990–2000. Further in the next decennial (2000–2010)Himachal Pradesh (-30.87%) followed by West Bengal (-28.56%) takes the credit for highest percentage decrement in cervical cancer incidence. Overall, from 1990 to 2019 Jharkhand (-50.22%) records the highest percentage decrement followed by the Himachal Pradesh (-48.34%) (appendix Table1). Jammu & Kashmir report the lowest incidence (7.24 in 1990, 6.31 in 2000, 6.21 in 2010 and 6.13 in 2019) whereas Tamilnadu have the highest incidence (30.92 in 1990, 28.26 in 2000, 21.58 in 2010 and 19.91 in 2019) of cervical cancer from 1990 to 2019.
Figure-2 represents the state-wise mortality of cervical cancer among women for1990–2019. Figure-2 (A, B, C & D) represents thatmortality of cervical cancer has decreased over the time while thedecrementin the mortalityis not uniform over the time. Jammu & Kashmir have the lowest mortality level (4.59 per 100,000 women in 1990, 3.93 per 100,000 women in 2000, 3.57 per 100,000 women in 2010 and 3.38 per 100,000 women in 2019) whereas Tamilnadu records the highest mortality due to cervical cancer(20.73 per 100,000 women in 1990, 18.62per 100,000 women in 2000, 13.53 per 100,000 women in 2010 and 11.56per 100,000 women in 2019) from 1990 to 2019.Maps in Fig. 2 show that decrement in the incidence is not uniform across the statesover the time. Some of the states like Jharkhand (-30.42%) and Gujarat (-27.00%) show the highest percentage decline in mortality due to cervical cancer in the period 1990–2000. Further in the next decennial (2000–2010) West Bengal (-33.83%) followed by Himachal Pradesh (-33.02%) have the highest percentage decrement in cervical cancer mortality. Overall, from 1990 to 2019 Jharkhand (-56.16%) records the highest percentage decrement followed by the Himachal Pradesh (-53.37%) (appendix Table2).
Age-standardized cervical cancer incidence transition in India
Figure 3 indicates the overall variation in the ranks of age-standardized cervical cancer incidence over the three decades (1990 to 2019). Colours given to each state displays the region specification. There are total eight colours and for each, colour specification is given below in the Fig. 3. Dotted line shows the increase in the states ranking(increase in positional rank indicates that the state performs better than some states during the period) from the previous rank and full line shows the state has either remained same in their rank or have slipped below in rank (lowering in positional rank indicates that states haven’t improvedmuch in respect to the states whose ranks have increased during period). In Fig. 3 last column indicates the percentage change in incidence of cervical cancer. Among all the states and Union territories, percentage change is negative i.e. all the states and union territories have witnessed a decline in the incidence rateover the time. Percentage decrement in incidence is not uniform across the states which further leads to variation in states rank. Over the thirty years,ranks of only four sates namely Tamil Nadu (1st rank, -35.61 percentage change), Mizoram (3rd rank, -20.44 percentage change), Andhra Pradesh (22nd rank, -30.77 percentage change) and Jammu & Kashmir &Ladakh (32nd rank, -15.33 percentage change) have remained same and the ranks of remaining states have changed. First rank indicates the highest incidence of cervical cancer and last (32nd ) rank indicates the lowest value in age-standardized cervical cancer incidence. Highest percentage change in age standardized incidence is found in Jharkhand (-50.21%, 2nd rank in 1990 to 10th rank in 2019) followed by Himanchal Pradesh (-48.34%, 4th rank in 1990 to 17th rank in 2019) in contrast to the lowest change in incidence is observed in the state Uttar Pradesh (-7.86%, 19st rank in 1990 to 7th rank in 2019) followed by Karnataka (-8.24%, 6th rank in 1990 to 2nd rank in 2019). Only a single state namely Rajasthan have shown the increase in the incidence value over the time (0.43%, 28th rank in 1990 to 16th rank in 2019). In year 1990, 11 states rank lower than the national average (India 12th rank, incidence 16.65 per 100000) but in 2019 a total of 10 states rank lower than the national average (India 11th rank, incidence 13.1 per 100000).
Among seven northern states, half of the states (Himachal Pradesh, Delhi, Uttarakhand) have moved upward in their rank and other states like Punjab, Rajasthan, Haryana) have (Jammu & Kashmir and Ladakh) remained same in their rank, in north-eastern region of the country two states i.e.Arunachala Pradesh and Assam rank have decreased, however Mizoram has remained same in their positional rank and ranks of these five statesi.e. Nagaland, Meghalaya, Tripura, Sikkim, Manipur have increased.
Age-standardized cervical cancer mortality transition in India
Figure 4 indicates the variation in ranks of age-standardized cervical cancer mortality among all ages over the three decades (1990 to 2019). The last column indicates the percentage change in mortality of cervical cancer. Across all states and Union territories percentage change is negative indicating all the states and union territories have witnessed a decline in the mortality over the time. The variation in the state ranking indicates that percentage decrement in mortality is not uniform.Overall, Tamil Nadu has performed worst in case of age-standardized cervical cancer incidence 30.92 (CI: 15.78 – 41.77) in 1990 to 19.91 (CI: 11.27 – 26.83) in 2019 and mortality 20.73 (CI: 10.88 – 27.6) in 1990 to 11.57 (CI: 6.31 – 15.59)) per 100,000 females in 2019 both. Whereas Jammu & Kashmir & Ladakh have performedwell in terms of age-standardized cervical cancer incidence 7.24 (CI: 4.48 – 18.14) in 1990 to 6.13 (CI: 3.95 – 15.71) in 2019 and mortality 4.6 (CI: 2.85 – 12.09) in 1990 to 3.39 (CI: 2.21 – 8.78) per 100,000 females in 2019. Both the highest and lowest performing states have maintained their rank over the period. In the year 1990, total 11 states have ranks lower than the national average (India 12th rank, mortality 10.9 per 100000 females) but in 2019 only 10 states show lower rankings than the national average (India 11th rank, mortality 7.38 per 100000 females).
Table 1: Trends in incidence and mortality of Cervical Cancerin India from 1990 to 2019 using Joinpoint Regression Analysis
Age Standardised Incidence rate
|
Age Standardised Mortality rate
|
Segment
|
Year
|
APC* (95% C.I.)
|
Segment
|
Year
|
APC* (95% C.I.)
|
1
|
1990-1995
|
-1.24* (-2.07, -0.40)
|
1
|
1990-1995
|
-1.58* (-2.46, -0.68)
|
2
|
1995-1998
|
1.47 (-2.31,5.39)
|
2
|
1995-1998
|
0.95 (-3.05,5.11)
|
3
|
1998-2005
|
-3.22* (-3.83, -2.59)
|
3
|
1998-2005
|
-3.52* (-4.17, -2.86)
|
4
|
2005-2012
|
-0.84* (-1.47, -0.20)
|
4
|
2005-2012
|
-1.67* (-2.34, -0.99)
|
5
|
2012-2015
|
2.49 (-1.33,6.45)
|
5
|
2012-2015
|
2.11 (-1.94,6.32)
|
6
|
2015-2019
|
-0.16 (-1.35,1.05)
|
6
|
2015-2019
|
-0.96 (-2.22,0.31)
|
AAPC*
|
1990-2019
|
-0.82* (-1.39, -0.25)
|
AAPC*
|
1990-2019
|
-1.35* (-1.96, -0.75)
|
Note: *, Indicates that the Annual Percent Change (APC) is significantly different from zero at the alpha = 0.05 level; APC, annual percentage change; AAPC, average annual percent change; CI, confidence interval
Trends in Age-Standardized Cervical Cancer Incidence and Death Rates Using Joinpoint Regression Analysis across India
Table 1 shows the APC and AAPC of incidence and mortality due to cervical cancer in India from 1990 to 2019). The regression model shows a significant declining trend in India between 1990 and 2019 for age standardized incidence rate (AAPC: −0.82; 95%CI: −1.39 to −0.25; p < 0.05) with highest decline in the period 1998-2005 (AAPC: −3.22; 95%CI: −3.83 to −2.59; p < 0.05) (Table 1, Figure 5a). Similarly, a significant declining trend has been observed in the age standardized mortality rate India between 1990 and 2019(AAPC: −1.35; 95%CI: −1.96 to −0.75; p < 0.05) with highest decline in the period 1998-2005 (AAPC: −3.52; 95%CI: −4.17 to −2.86; p < 0.05) (Table 1, Figure 5b).
Table 2:Age standardised Incidence and death rates of cervical cancer for India and its states in 2019 and their Average Annual Percentage Change (AAPC) from 1990 to 2019
State
|
Incidence
|
Death
|
Rates in 2019, 95% UI (per 100 000 females)
|
AAPC, 95% CI (%, 1990-2019)
|
Rates in 2019, 95% UI (per 100 000 females)
|
AAPC, 95% CI (%, 1990-2019)
|
India
|
13.10 (10.18,17.09)
|
-0.82* (-1.39, -0.25)
|
7.38 (5.71,10.13)
|
-1.35* (-1.96, -0.75)
|
Andhra Pradesh
|
9.81 (6.34,16.96)
|
-1.26* (-1.42, -1.09)
|
5.34 (3.50,9.67)
|
-1.75* (-1.88, -1.61)
|
Arunachal Pradesh
|
14.01 (9.20,20.68)
|
-1.05* (-1.16, -0.93)
|
7.99 (5.52,10.95)
|
-1.51* (-1.63, -1.39)
|
Assam
|
10.68 (7.49,19.26)
|
-0.50 (-1.23, 0.24)
|
6.39 (4.63,12.52)
|
-1.19* (-1.73, -0.64)
|
Bihar
|
11.46 (7.79,18.89)
|
-0.49* (-0.55, -0.43)
|
6.55 (4.49,11.13)
|
-1.01* (-1.12, -0.89)
|
Chhattisgarh
|
14.81 (10.36,20.30)
|
-0.92* (-1.43, -0.41)
|
8.71 (6.30,12.97)
|
-1.14* (-1.64, -0.64)
|
Delhi
|
11.87 (8.50,15.78)
|
-2.07* (-2.51, -1.62)
|
7.11 (4.81,9.26)
|
-2.63* (-3.42, -1.82)
|
Goa
|
7.02 (4.55,11.46)
|
-1.31* (-1.67, -0.96)
|
3.58 (2.35,6.27)
|
-1.99* (-2.05, -1.93)
|
Gujarat
|
13.26 (9.31,18.80)
|
-0.53 (-1.47, 0.42)
|
7.12 (5.04,10.56)
|
-1.29* (-2.10, -0.47)
|
Haryana
|
7.85 (5.20,15.03)
|
-0.62 (-1.65, 0.42)
|
4.32 (2.85,9.54)
|
-1.07 (-2.21, 0.10)
|
Himachal Pradesh
|
11.66 (8.05,16.25)
|
-2.30* (-2.82, -1.77)
|
6.49 (4.70,8.81)
|
-2.59* (-3.33, -1.85)
|
Jammu & Kashmir and Ladakh
|
6.13 (3.95,15.71)
|
-0.62* (-0.76, -0.48)
|
3.39 (2.21,8.78)
|
-1.06* (-1.17, -0.94)
|
Jharkhand
|
13.18 (9.84,18.37)
|
-2.21* (-2.57, -1.85)
|
7.87 (5.84,10.94)
|
-2.74* (-3.06, -2.42)
|
Karnataka
|
19.83 (11.86,27.51)
|
-0.31 (-1.00, 0.39)
|
11.14 (6.67,15.10)
|
-0.77 (-1.61, 0.07)
|
Kerala
|
9.35 (6.57,12.92)
|
-1.07 (-2.21, 0.08)
|
4.77 (3.29,6.49)
|
-1.88* (-2.41, -1.34)
|
Madhya Pradesh
|
13.41 (9.77,17.92)
|
-0.64* (-0.85, -0.44)
|
7.88 (5.85,10.47)
|
-1.05* (-1.25, -0.86)
|
Maharashtra
|
16.75 (11.08,22.65)
|
-0.41 (-0.94, 0.13)
|
9.26 (6.22,12.29)
|
-1.04* (-1.59, -0.49)
|
Manipur
|
9.25 (5.90,14.93)
|
-0.87* (-1.13, -0.61)
|
5.59 (3.78,8.86)
|
-1.10* (-1.68, -0.51)
|
Meghalaya
|
11.40 (7.59,16.99)
|
-1.14* (-1.56, -0.71)
|
6.84 (4.86,9.84)
|
-1.42* (-1.61, -1.24)
|
Mizoram
|
18.99 (9.50,29.21)
|
-0.72* (-1.26, -0.18)
|
10.90 (5.64,16.15)
|
-1.11* (-1.72, -0.50)
|
Nagaland
|
12.95 (7.59,19.42)
|
-1.23* (-1.36, -1.10)
|
7.57 (4.81,10.93)
|
-1.55* (-1.67, -1.42)
|
Odisha
|
7.10 (4.42,17.34)
|
-1.32* (-1.96, -0.67)
|
4.22 (2.64,10.63)
|
-1.66* (-1.88, -1.44)
|
Other Union Territories
|
9.50 (6.34,14.04)
|
-1.44* (-1.74, -1.14)
|
5.14 (3.56,7.72)
|
-1.85* (-2.01, -1.68)
|
Punjab
|
13.00 (9.65,17.82)
|
-0.43* (-0.83, -0.02)
|
7.14 (5.10,9.72)
|
-0.95* (-1.46, -0.44)
|
Rajasthan
|
11.77 (8.32,17.92)
|
0.05 (-0.71, 0.82)
|
6.26 (4.25,10.45)
|
-0.65 (-1.53, 0.25)
|
Sikkim
|
9.72 (6.61,14.78)
|
-1.35* (-1.78, -0.93)
|
5.47 (3.90,7.88)
|
-1.85* (-2.05, -1.65)
|
Tamil Nadu
|
19.91 (11.27,26.83)
|
-1.49* (-1.94, -1.04)
|
11.57 (6.31,15.59)
|
-1.98* (-2.29, -1.67)
|
Telangana
|
9.76 (6.03,16.26)
|
-1.47* (-1.52, -1.41)
|
5.07 (3.23,9.03)
|
-2.08* (-2.18, -1.98)
|
Tripura
|
10.64 (7.00,15.99)
|
-1.36* (-1.51, -1.21)
|
6.25 (4.36,9.15)
|
-1.70* (-1.82, -1.57)
|
Uttar Pradesh
|
13.48 (9.21,21.21)
|
-0.26 (-0.74, 0.22)
|
7.79 (5.43,13.89)
|
-0.72* (-1.15, -0.30)
|
Uttarakhand
|
12.32 (8.80,19.28)
|
-1.22* (-1.33, -1.11)
|
6.83 (4.94,11.45)
|
-1.74* (-1.83, -1.66)
|
West Bengal
|
9.67 (7.06,13.94)
|
-1.11* (-1.87, -0.35)
|
5.24 (3.89,7.89)
|
-1.83* (-3.02, -0.62)
|
Trends in Age-Standardized Cervical Cancer Incidence and Death Rates Using Joinpoint
Regression Analysis across the states of India
Results from table 2 shows the Age standardized rates and AAPC of Cervical Cancer incidence and Death in India and its states in 1990 - 2019. The age - standardized incidence and death rates of cervical cancer in India is found to be 13.10 (95% UI 10.18,17.09) and 7.38 (95% UI 5.71,10.13) per 100,000 females respectively. The highest age standardized incidence rate of Cervical Cancer is observed in Tamilnadu 19.91 (95% UI 11.27,26.83), followed by Karnataka 19.83 (95% UI 11.86,27.51) and Mizoram 18.99 (95% UI 9.50,29.21) per 100,000 females. However, the lowest age standardized Incidence rate of Cervical Cancer is observed in Jammu & Kashmir and Ladakh 6.13 (95% UI 3.95,15.71), followed by Goa 7.02 (95% UI 4.55,11.46) and Odisha 7.10 (95% UI 4.42,17.34) per 100,000 females. A similar pattern is observed in the mortality among states as observed in Incidence. The highest age standardized Death rate of Cervical Cancer is observed in Tamilnadu 11.57 (95% UI 6.31,15.59), followed by Karnataka 11.14 (95% UI 6.67,15.10) and Mizoram 10.90 (95% UI 5.64,16.15) per 100,000 females. However, the lowest age standardized Death rate of Cervical Cancer is observed in Jammu & Kashmir and Ladakh 3.39 (95% UI 2.21,8.78) followed by Goa 3.58 (95% UI 2.35,6.27) and Odisha 4.22 (95% UI 2.64,10.63) per 100,000 females.
For Incidence, all of the states have shown a significant declining trend except Gujarat (AAPC: −0.53; 95%CI: −1.47 to 0.42; p > 0.05), Assam (AAPC: −0.50; 95%CI: −1.23 to 0.24; p > 0.05) , Haryana (AAPC: −0.62; 95%CI: −1.65 to 0.42; p > 0.05), Karnataka (AAPC: −0.31; 95%CI: −1.00 to 0.39; p > 0.05) , Maharashtra (AAPC: −0.41; 95%CI: -0.94 to 0.13; p > 0.05) , Uttar Pradesh (AAPC: −0.26; 95%CI: −0.74 to 0.22; p > 0.05) and Kerala (AAPC: −1.07; 95%CI: −2.21 to 0.08; p > 0.05) where non-significant declining trend was observed and Rajasthan (AAPC: 0.05; 95%CI: −0.71 to 0.82; p > 0.05)where non-significant increasing trend is observed.(Table 2, Supplementary Fig 1)All of the states have shown a significant declining trend in mortality except Haryana (AAPC: −1.07; 95%CI: −2.21 to 0.10; p > 0.05), Karnataka (AAPC: −0.77; 95%CI: −1.61 to 0.07; p > 0.05) and Rajasthan (AAPC: −0.65; 95%CI: −1.53 to 0.25; p > 0.05), where non-significant declining trend is observed.(Table 2, Supplementary Fig 2)