Head and neck cancer screening: Bridging gaps in early detection and equity

Regional

Population-Based Cancer Registries (PBCR) Report 2012-2014 presents the variation in HNC cases in different regions, along with their comparison to the international data from five continents. The key findings of the top 5 subsites among HNCs are represented in the graph [Figure 2].^[19]

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Figure 2: Highest reported AARs for head and neck cancer subtypes by gender

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When ranking both national and international data, as per incidence the Top five positions for both genders were occupied by Indian PBCRs for all sub-sites except Nasopharynx and Larynx in males.

Data from Hospital-Based Cancer Registries (HBCR) Report 2012–2016 showed the mouth was the leading site in TMH (14%), Dibrugarh (14.9%), Guwahati (12.7%), and Chennai (9.7%) amongst males. In females, Cancer mouth was commoner in Bangalore (9.9%) and Guwahati (5.1%).^[20]

Gender

HNCs show a marked male predominance. In India, men account for over 70% of HNC cases (1,90,928 of 2,47,924 cases).^[1] Previous studies have reported a male-to-female ratio for HNC cases in the Indian population ranging from 2:1 to 5:1, although the gap is narrowing in urban regions due to changing lifestyle patterns.^[21,22] According to GLOBOCAN 2022 data, the age-standardized incidence rate (ASIR) for lip and oral cavity cancers in India was 14.7 per 100,000 for men and 5.0 per 100,000 for women, highlighting a significant gender disparity. This is due to higher exposure to tobacco, alcohol, and occupational risks. In India, the lifetime risk of developing HNC is 1 in 33 for males and 1 in 107 for females.

According to the second round of Global Adult Tobacco Survey (GATS) data of 2016-17, 42.4% of males, and 14.2% of females use tobacco in India.^[23] This disparity may be due to the social stigma surrounding tobacco use among women in the state, contributing to its lower prevalence in females. As per a study done in Biharstudy population was rural Indian tobacco chewers, 91% were male. In comparison, pan chewing was reported in 65% of males and 35% of females.^[24]GATS 2009-2010 reported Dual tobacco use significantly higher in men (9.3%) than women (1.1%), with a male: female ratio of 8.5:1. Women showed greater susceptibility to SLT-related oral cancers, with a meta-analysis reporting an OR of 12.4 in women versus 4.7 in men [Figures 3 and 4].^[25]

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Figure 3: Global head and neck cancer incidence trends (2012, 2022, 2025)

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Figure 4: Head and neck cancer (HNC) mortality trends

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Government initiatives

Launched in 2010, the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) opportunistic screening for common cancers, including oral, breast, and cervical cancers, at the primary health care level. Trained Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) conduct visual oral cavity examinations during population-based screening of individuals aged 30 years and above.^[26]

The AYUSH Bharat program, through its Integrative Health Clinics and Wellness Centers, facilitates early detection of cancers such as oral and head-neck malignancies via community-based outreach aligned with traditional health practices. The Ayushman Arogya Mandir initiative, under Ayushman Bharat, delivers comprehensive primary health care including screening for common cancers. As of December 15, 2023, these centers have conducted 32.8 crore oral cancer screenings.^[27,28]

Pilot programs, mobile screening units, and tele-oncology

The National Mobile Medical Units (NMMUs), implemented under the National Health Mission (NHM), enhance healthcare accessibility in remote and underserved regions through mobile facilities such as medical vans, boat clinics, dental and eye units, functioning under both rural and urban health missions. As of June 2023, 1,525 units were operational nationwide, ensuring delivery of essential services in hard-to-reach areas. Mobile technology has also been leveraged for oral cancer screening; mobile applications like Oncogrid have demonstrated high accuracy in early detection, achieving a 90% confirmation rate for malignant or potentially malignant lesions during community-based screening.^[28,29]

OncoNet-Kerala, developed by the Centre for Development of Advanced Computing (C-DAC), pioneered teleoncology in India by linking the Regional Cancer Centre, Thiruvananthapuram, with peripheral hospitals to support early diagnosis, follow-up, treatment, prevention, and tele-education. Complementary initiatives such as ‘Swasth Kiosks’ offer free cancer screening and awareness services across multiple sites. Building on these models, the Ministry of Health and Family Welfare launched OncoNet India, an integrated tele-oncology network, connecting Regional and Peripheral Cancer Centers nationwide. Similarly, mobile medical units like that conducted by the Sri Venkateswara Institute of Cancer Care and Advanced Research (SVICCAR), Tirupati, expand outreach for oral cancer screening in underserved populations.^[30,31]

Public–private partnerships have further strengthened cancer control efforts. Tata Trusts, in collaboration with the Tata Memorial Centre, operate diagnostic mobile units in rural and semi-urban areas for detection of oral precancerous lesions and have established major oncology institutions such as the Tata Memorial Hospital and Tata Medical Center. Joint ventures like the Assam Cancer Care Foundation, initiated by Tata Trusts and the Government of Assam, aim to build India’s first statewide cancer care grid to improve accessibility, affordability, and continuity of cancer treatment.^[31]

Among Non-profit initiatives, Biocon Limited’s mHealth-based Oral Cancer Screening Program facilitates early detection through remote image-based evaluation by specialists, screening over 70,000 individuals and training more than 1,000 frontline workers since 2011. The Alamelu Charitable Foundation advances equitable cancer care by establishing and equipping treatment centers to enhance accessibility for underserved populations.^[31,32]

The NFHS-5 (2019–2021) survey revealed persistently low oral cancer screening coverage across India, with only 1.2% of men and 0.9% of women aged 30–49 undergoing screening.^[33] Participation rates varied widely by region, ranging from 0% in Ladakh and Lakshadweep to 6.3% in Andhra Pradesh and 10.1% among women in the Andaman and Nicobar Islands. Southern states such as Tamil Nadu and Kerala demonstrated relatively higher coverage (12– 15%) supported by stronger public health systems, whereas several northern states, including Uttar Pradesh and Bihar, reported rates below 5% due to infrastructural and workforce limitations. Strikingly, even high-incidence regions such as East Khasi Hills in Meghalaya (78.5 per 100,000) showed minimal screening participation (1.2%).^[29-34]

Workforce shortages and urban-rural disparities

India faces uneven distribution of screening centers, diagnostic facilities, and trained ENT specialists or dentists. As of 2020, there were fewer than eight doctors per 10,000 population and around 12,000 ENT specialists, mostly concentrated in urban areas.^[35,36] Cancer screening and pathology services are similarly , with fewer than 500 oncopathologists nationwide. NFHS-5 highlighted the need for better infrastructure, trained personnel, and consistent reporting systems for oral cancer screening.^[34]

Cultural barriers and stigma

Social stigma surrounding tobacco and alcohol use, both of which are major causes of HNCs, disclosure and screening. Misconceptions such as cancer being contagious, a curse, or untreatable remain widespread.^[37,38] Many rely on traditional healers before seeking formal care. Studies show limited awareness about smokeless tobacco (SLT) risks, with many perceiving it as harmless or even beneficial.^[39] Youth-targeted marketing of tobacco products and weak enforcement of the Cigarettes and Other Tobacco Products Act 2003 (COTPA) trade/distribution, contributed to early SLT use. Despite regulations, compliance remains poor, especially around educational institutions, perpetuating the problem.^[40,41]

Lack of awareness and health literacy

Limited awareness of HNC symptoms and screening remains a key barrier, especially in rural areas. Public education largely focuses on breast and cervical cancer, leaving HNCs overlooked. Studies reveal that while many have heard of oral cancer, few recognize its symptoms or risk factors.^[42,43]Delayed help-seeking, often due to misinterpreting warning signs, leads to late-stage presentations with over 80% diagnosed at advanced stages in some tertiary centers.^[44,45]

Financial constraints and lack of insurance coverage

High medical costs and inadequate insurance hinder participation in screening programs. Despite free government screening, follow-up investigations and treatment often require out-of-pocket spending.^[46] Over 80% of Indians lack health insurance, with 70% of total health expenditure being private and mostly paid directly by households. Many resort to borrowing or selling assets for treatment, pushing millions into poverty each year.^[45,46]

Technological barriers

Digital health initiatives using mobile apps, SMS reminders, and AI tools show promise in enhancing cancer awareness and screening accessibility.^[47] However, poor internet connectivity, limited device compatibility, and digital illiteracy, especially in rural and elderly populations, restrict their reach. Digital health adoption for noncommunicable diseases in India remains limited compared to developed countries.^[48]

Tobacco use

Tobacco is the leading risk factor for head and neck cancers worldwide, contributing to 50–60% of cases, with smokers facing a nearly 10-fold increased risk of head and neck squamous cell carcinoma compared to never-smokers.^[51]In India, over 267 million users consume diverse forms, including bidis (smoked by 71.8 million adults, or 14% of smokers) and smokeless tobacco (SLT) such as khaini - a tobacco, lime mixture - the most commonly used tobacco product, being used by every ninth adult (17.9% of men), gutkha - a tobacco, lime, areca nut mixture (6.8%), and betel quid with tobacco (5.8%), deeply embedded in rural cultural practices.^[23,52,53] Bidi smoking delivers higher nicotine and tar than cigarettes, elevating risks for oral, pharyngeal, and laryngeal cancers, while Indian SLT products contain potent carcinogens like tobacco-specific nitrosamines (TSNAs), areca nut-derived nitrosamines, toxic metals, and PAHs.^[54-56]SLT use is strongly linked to precancerous lesions, with nearly 70% of oral cancers preceded by conditions like leukoplakia and oral submucous fibrosis (OSF), particularly rising among youth.^[56]

Alcohol consumption

Alcohol is an independent carcinogen and acts synergistically with tobacco.^[57] Alcohol is implicated in approximately 70% of HNC cases globally, and when combined with tobacco, the risk may increase up to 40-fold.^[58] Data from the 2017 NMB survey reported a higher prevalence of alcohol (8.7%) than tobacco use (7.9%) in India, with significantly greater use among males (15.8%) than females (2.4%).^[59] In another population study, over 50% of Indian alcohol users were also tobacco users, indicating substantial co-abuse.^[60] The INHANCE Consortium’s large-scale pooled study found that among never-smokers, consuming ≥3 alcoholic drinks per day significantly increased the risk of HNC (OR 2.04; 95% CI: 1.29–3.21), particularly for oropharyngeal and hypopharyngeal cancers.^[61]

Human papillomavirus (HPV)

Recent evidence links rising HNSCC rates to HPV infection, despite declining tobacco use.^[62] In 2012, about 38,000 HNC cases were linked to HPV globally, with a disproportionately higher burden in developed countries compared to less developed ones. Approximately 30% of oropharyngeal cancers that mainly affect the tonsils and base of the tongue are HPV-related, accounting for around 29,000 cases annually. In contrast, HPV was associated with fewer cases of the oral cavity (4,400) and laryngeal cancers (3,800), based on limited case series data. The World Cancer Report 2012 attributed 30.8% of oropharyngeal cancers to HPV, compared to just 2.2% for oral cavities and 2.4% for laryngeal cancers.^[63] Particularly in developed countries, the burden of oropharyngeal cancers associated with high-risk HPV types has increased significantly.^[64,65] The average prevalence rate of HPV DNA-positive HNC in India is 26%, based on a review of PCR-based studies, mainly focused on OSCC.^[66]

HPV vaccination, particularly quadrivalent and nonavalent vaccines targeting HPV-16/18, holds promise for reducing oropharyngeal cancer incidence, yet national coverage remains low at approximately 1.3% among girls aged 15-18 years per NFHS-5 data, with inclusion into the Universal Immunization Program for ages 9-14 years pending despite endorsement by the National Technical Advisory Group on Immunization (NTAGI).^[67,68] Pilot vaccination programs in Punjab and Sikkim achieved coverage rates exceeding 90%, demonstrating feasibility and acceptance for broader rollout to curb India’s estimated 121,302 HPV-related cancers by 2025.^[69]

Other viral infections

The Epstein–Barr virus (EBV) has been firmly established as a major etiological agent in the pathogenesis of NPC since 1973.^[70] Although studies done on the Indian population with EBV-related nasopharyngeal carcinoma are rare, significant evidence suggests a positive correlation between the two.^[71] Furthermore, several studies have reported associations between hepatitis B and C infections and HNC. HCV prevalence was 7.8% in HNC cases, 12.8% in HNSCC and 3.4% in other HNC types, while HBV was present in about 11% of nasopharyngeal carcinoma patients.^[72-76]

Poor oral hygiene (POH) and dental health

POH is strongly associated with an elevated risk of oral cancer and may enhance the carcinogenic effects of known risk factors such as tobacco and alcohol. This association persists even after adjusting for confounders including tobacco use, alcohol consumption, education level, and socioeconomic status.^[77] POH is common, particularly in low-income groups. According to the National Oral Health Survey, over 60% of rural Indians have untreated dental problems, increasing their cancer risk. Tooth brushing ≥2 times/day, dental visits, denture use, and ≥3 caries were linked to reduced risk of oral, pharyngeal, and laryngeal cancers. Conversely, >5 missing teeth, gum bleeding, periodontal disease, and mouthwash use were associated with increased oral cancer risk.^[78] According to a study by WHO, dental caries prevalence in India ranged from 23.0% to 71.5% in 12-year-olds, 48.1% to 86.4% in adults (35–45 years), and 51.6% to 95.1% in the elderly (65–74 years). Periodontal disease prevalence ranged from 15.3% to 77.9% in adults and 19.9% to 96.1% in the elderly.^[79]

Poor diet and nutrition

Diets low in fruits and vegetables, often due to socioeconomic deprivation, may increase HNC risk by approximately 2-fold. Between 2021 and 2023, an estimated 194.6 million people in India were undernourished, according to the FAO. Additionally, the 2024 SOFI report by the United Nations highlights that 55.6% of India’s population cannot afford a healthy diet, underscoring the country’s significant nutritional and food security challenges.

Occupational and environmental exposures

India, the largest pesticide producer in Asia and the twelfth globally in usage, faces widespread exposure risks due to its predominantly agrarian population.^[80] Many are engaged in outdoor work, such as farming or manual labor, leading to prolonged sun exposure which is a recognized risk factor for lip cancer.^[81]

Poor education and socioeconomic status

Illiteracy, poverty, and lack of awareness contribute to higher exposure to risk factors and delayed healthcare-seeking.^[7]As per a study done in Bihar 26% (47 out of 179) of tobacco chewers were illiterate, whereas only 7.2% (13 out of 179) held a graduate degree. The majority (59%) reported a monthly income ranging between Rs. 5,000 and Rs. 10,000. In terms of occupation, 32% were farmers and 22% were laborers.^[24]