In April, 46-year-old Deepti De noticed a lump the size of a table tennis ball protruding from her throat. She lived with her husband and two sons a few kilometers away from Jorhat town, in the northeast Indian state of Assam. Her younger son Rinku, 30, a medical representative, took her to a doctor he knew well. After a few tests the word “cancer” hung thick in the air.

According to data from the Tata Memorial Centre, a grant-in-aid body under India’s Department of Atomic Energy, 100 out of every 100,000 urban Indians suffer from cancer. The number falls to 60 in rural India. In northeast India, however, the number rises to 275, which is similar to the disease’s rate of incidence in developed countries.

In the United States, for example, 300 out of every 100,000 people suffer from cancer. Developed countries tend to have higher cancer rates as people there live well into their old age, due to better healthcare facilities. Interestingly, northeast India has the lowest incidence of cancer among children in India.

“While our rates are lower than that of the US, since we have a much larger population, in absolute numbers our cancer burden is one of the highest in the world,” the Tata Memorial Centre’s head and neck cancer surgeon Dr Pankaj Chaturvedi said. Chaturvedi is at the forefront of the fight against tobacco products in India.

Highest cancer rates in the Northeast

According to the Indian Council of Medical Research, when adjusted for age, the top four Indian districts with the highest incidence of cancer among men and women are in the northeast. These are in the states of Mizoram, Arunachal Pradesh, Meghalaya and Assam.

In Mizoram, one in every five men and one in every six women are expected to develop cancer, in a lifespan of 74 years. In Meghalaya, one in every six men and one in every 10 women are expected to develop cancer. Cancers of the esophagus, lungs and stomach are the most common to affect men in the northeast, while women in the region are affected mostly by cancers of the breast, cervix uteri and esophagus.

“There are also some types of cancers, such as nasopharynx cancer (a rare kind of head and neck cancer), that is unique to the northeast,” Dr Chaturvedi said. Gall bladder cancers are also found to be prevalent around river basins in the region, allegedly due to heavy metal contamination in the water. A study on the issue is underway at the Tata Centre.

According to Dr Sam Tsering, a Nodal Officer for Arunachal Pradesh’s Cancer Control Program, stomach and liver cancers are also common in the state. The main cause of liver cancer was the prevalence of Hepatitis B virus, he said.

Limited facilities

In Jorhat town in Assam, Rinku’s elder brother grappled with the enormity of the diagnosis and made a quick decision. Rinku, his father and mother packed their bags, gathered all their savings — totaling just over Rs 40,000 (US$600) — and booked flights to Mumbai. The family was headed to the Tata Memorial Hospital, some 3,000km away.

Like them, a large number of cancer patients travel thousands of kilometers for treatment. About three-quarters of the patients at Mumbai’s Tata Memorial Hospital, India’s largest tertiary cancer care facility, come from the northeast.

In Birubari, a crowded neighborhood in Assam’s Guwahati city, the Dr Bhubaneswar Borooah Cancer Institute (BBCI) remains full of patients. Many are seen on wheelchairs, some accompanied by families. BBCI is one of the oldest cancer-care centers catering to the needs of the eight northeastern states.

The hospital’s director Dr AC Kataki said many people go outside the northeast for treatment because the region has had limited cancer-care facilities until lately, compared to the large number of patients. Things are slowly changing, however, he said. For instance, apart from BBCI, cancer treatment with radiotherapy is also available in Dibrugarh and Silchar areas of Assam. In fact, barring Sikkim state, regional cancer-care centers are available in all major towns of northeast India.

Consumption of tobacco, dietary factors, infections, alcohol, indoor air pollution and a sedentary lifestyle are some of the leading causes of cancer. “People consume a lot of smoked meat, the fermented variety of the raw betel nut, and tobacco consumption is high here. These are all carcinogenic substances,” Dr Kataki said.

High tobacco use

The proportion of cancer directly linked to tobacco use is highest in the state of Meghalaya, among both men and women, followed by the state of Tripura. Roughly half of all cancer cases in Meghalaya can be directly attributed to the use of tobacco-related products. At Assam’s BBCI, 56% of all cancers among men and 25% among women are linked to tobacco, according to their annual case study.

In the neighboring state of Arunachal Pradesh, the number of cancer patients is also on the rise. The state’s Papum Pare district recorded India’s highest cancer rate among women, and the second highest among men. However, with no airport in the region, people can only travel to other parts of the country via neighbor Assam’s capital city Guwahati, considered to be the gateway to the entire northeast.

Last year, the only tertiary cancer-care center in Arunachal Pradesh registered 840 patients, but according to Dr Tsering, there many cases go under-reported. Cancer continues to be spoken about in hushed tones in the northeast, despite its increasing incidence. Rinku declined to be photographed for the story as well.

Upon their arrival in Mumbai, his family reached the Tata Memorial Hospital at 9pm on a Friday. They were informed that the hospital would remain shut for the next two days. Rinku spoke little Hindi then, and his parents, almost none.

In Assam, they were a middle-class family, with a spacious home and respectable jobs. But a hotel room in Mumbai cost them Rs 1,000 (US$15) or more for just a night. At that rate their money would not last long. “I saw several people sleeping on the streets,” Rinku said. “I wondered if we have to live on the footpath too,” he said.