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The ising incidence o lung cance in India: An analy ical s udy on causes,
ends and public heal h implica ions
*1Vani a Pa il, 2Sandhya Khade, 3Sh ibhiksha Jadha , 4Sanika Mo e
*1P o , Depa men o Compu e Applica ions and Managemen , D.Y. Pa il Ins i u e o Compu e
Applica ions and Managemen , Aku di, Pune
2,3,4S uden , Depa men o Compu e Applica ions, D.Y. Pa il Ins i u e o Compu e Applica ions and
Managemen , Aku di, Pune
Abs ac :
Lung cance has eme ged as one o he mos impo an public heal h conce ns in India o e he las
decade. Recen esea ch published be ween 2018 and 2025 highligh s signi ican changes in incidence,
his ological dis ibu ion, molecula pa e ns, and socioeconomic bu den. Popula ion-Based Cance
Regis ies (PBCRs) epo ising o s able-bu -high incidence in many egions, wi h Mizo am
con inuing o eco d he highes age-adjus ed a es in Asia. Hospi al-based coho s e eal
adenoca cinoma su passing squamous cell ca cinoma, while molecula s udies documen a high
p e alence o Epide mal G ow h Fac o Recep o (EGFR) mu a ions and Anaplas ic Lymphoma
Kinase (ALK) ea angemen s.
Despi e ad ances, o e hal o pa ien s a e s ill diagnosed a S age IV, wi h median su i al a ound
10–12 mon hs. Risk a ibu ion s udies con i m obacco, pa icula ly bidi smoking, as he dominan
cause, bu biomass uel exposu e, long- e m incense use, and wo sening u ban ai pollu ion also
con ibu e signi ican ly. The inancial bu den o a ge ed he apies and immuno he apies emains
ca as ophic o amilies, o cing many o discon inue ea men p ema u ely.
This s udy syn hesizes Indian e idence published be ween 2018 and 2025 o p esen a comp ehensi e
analysis o incidence, isk ac o s, his ological and molecula ends, s age o diagnosis, su i al
ou comes, and socioeconomic implica ions. Ou indings indica e ha lung cance in India is la gely
p e en able, bu add essing i equi es s ong obacco con ol, clean household ene gy, u ban ai
quali y managemen , ea ly de ec ion, and inancial p o ec ion o pa ien s.
Keywo ds:
Lung cance ; India; Bidi smoking; Ai pollu ion; Public egis y; Public heal h.
1. In oduc ion:
Lung cance is now ecognized as one o he leading causes o cance - ela ed mo ali y in India, and
ecen s udies ha e shown ha he disease bu den is inc easing in se e al egions. Be ween 2018 and
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2025, new da a om he Indian Council o Medical Resea ch (ICMR) – Na ional Cance Regis y
P og amme (NCRP) and hospi al-based s udies ha e deepened ou unde s anding o his malignancy.
Acco ding o PBCR upda es published be ween 2019 and 2022, lung cance anks among he op i e
cance s in Indian men, wi h age- adjus ed incidence a es (AARs) highes in Mizo am (38.8 pe
100,000 men and 37.9 pe 100,000 women) [1]. U ban cen e s such as Delhi, Bangalo e, and Chennai
show s eady inc eases in incidence, e lec ing bo h en i onmen al exposu es and imp o ed de ec ion.
His ological pa e ns a e also shi ing. A 2020 upda e om he All India Ins i u e o Medical
Sciences (AIIMS) epo ed adenoca cinoma as he mos common sub ype (34%), su passing
squamous cell ca cinoma (28.6%) [18]. Mul icen e hospi al s udies conduc ed be ween 2021 and 2023
con i m his end, showing adenoca cinoma a 35–40% o cases [21]. This aligns wi h global pa e ns
and is belie ed o esul om changes in obacco consump ion, ising exposu e o biomass uels and
ai pollu ion, and imp o ed diagnos ic echniques.
Risk ac o analysis om ecen Indian case–con ol s udies shows ha bidi smoking ca ies an odds
a io (OR) o 4.2–8.3 o lung cance , which is highe han o ciga e e smoking (OR 2.0–5.0) [16].
Biomass uel exposu e inc eases isk by wo- o h ee old in women [15]. Ai pollu ion, pa icula ly
PM2.5 exposu e in me opoli an ci ies like Delhi, con ibu es o 8–12% o u ban lung cance cases
[16]. Long- e m incense use has also been iden i ied as a smalle bu signi ican con ibu o , wi h ORs
a ound 1.5–2.0.
Molecula da a om 2018–2025 p o ide new insigh s in o he Indian lung cance p o ile. EGFR
mu a ions a e ound in 23–30% o Indian pa ien s [18, 19], while ALK ea angemen s a e de ec ed
in 10–12% [20]. ROS1 ea angemen s occu in 2-3% o cases. These a es a e close o Eas Asian
han Wes e n coho s, p o iding oppo uni ies o a ge ed he apies bu also exposing inequi ies due o
inancial inaccessibili y. The clinical eali y emains g im: o e 55% o Indian lung cance pa ien s
p esen wi h S age IV disease [17], while only 20–25% a e de ec ed a po en ially cu able S ages I–II.
Median su i al o hese ad anced cases emains 10–12 mon hs [22]. High ea men cos s—₹60,000–
100,000 pe mon h o a ge ed agen s—cause ca as ophic heal h expendi u es, wi h many amilies
o ced o discon inue ea men p ema u ely.
This pape consolida es Indian da a published be ween 2018 and 2025. I aims o: (1) documen
incidence and epidemiological ends; (2) analyze isk ac o s; (3) examine his ological and molecula
pa e ns; (4) e alua e s age a p esen a ion and su i al; and (5) assess public heal h and inancial
implica ions.
2. Theo e ical backg ound:
Lung cance is a malignan neoplasm o he espi a o y epi helium and one o he mos agg essi e
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cance s encoun e ed in clinical medicine. I s de elopmen is in luenced by bo h en i onmen al
exposu es and molecula al e a ions, which oge he d i e ca cinogenesis, his ological sub ype
pa e ns, and clinical ou comes. In India, unde s anding hese mechanisms is pa icula ly impo an
because o he in e play be ween unique isk ac o s such as bidi smoking, biomass uel, and ai
pollu ion, alongside gene ic suscep ibili y ma ke s like EGFR and ALK.
2.1. Classi ica ion o lung cance :
Lung cance s a e b oadly classi ied in o wo ca ego ies: non-small cell lung cance (NSCLC), which
accoun s o abou 85–90% o cases, and small cell lung cance (SCLC), which con ibu es 10–15%.
NSCLC is u he subdi ided in o adenoca cinoma (ADC), squamous cell ca cinoma (SCC), and la ge
cell ca cinoma. His o ically, SCC was he p edominan sub ype in Indian popula ions, pa icula ly
among male smoke s. Howe e , con empo a y coho s ha e documen ed a ise in adenoca cinoma,
which now comp ises 30–40% o cases in e ia y cen e s [21]. SCLC, hough less common, is
clinically signi ican o i s agg essi e beha io , ea ly me as asis, and ini ial esponsi eness o
chemo he apy, ollowed by apid elapse. In Indian s udies, i s p e alence has emained a ound 15–
16% [17].
2.2. Ca cinogenesis: en i onmen al and gene ic d i e s:
Ca cinogenesis in lung cance ollows a mul is ep model, whe e epea ed exposu e o ca cinogens
ini ia es DNA damage and d i es mu a ions in oncogenes and umo supp esso genes.
1.
Tobacco: Bidi smoke deli e s highe concen a ions o a , nico ine, and ca bon monoxide han
ciga e es. Case–con ol s udies epo odds a ios o 4.2–8.3 o hea y bidi smoke s, compa ed
o 2.0–5.0 o ciga e e smoke s [16]. This makes bidis a pa icula ly dange ous o m o
obacco.
2.
Biomass Fuel: Combus ion o wood, dung cakes, and c op esidues p oduces high le els o
polya oma ic hyd oca bons and benzene, linked wi h lung cance among nonsmoking u al
women [15].
3.
Incense Bu ning: Long- e m incense use (>30 yea s) was associa ed wi h an OR o 2.3 in an
Indian case–con ol s udy.
4.
Ai Pollu ion: S udies in Delhi demons a e a 1.2–1.5- old inc ease in isk wi h ising PM2.5
exposu e [16].
5.
Occupa ional Exposu es: Wo ke s in asbes os, cons uc ion, and pes icide indus ies show
ele a ed isks (OR ~2.0–2.5).
Toge he , hese exposu es explain India’s unique isk p o ile, dis inc om Wes e n popula ions whe e
ciga e e smoking alone p edomina es.
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2.3. Clinical p esen a ion and na u al his o y:
Indian pa ien s o en p esen la e, ypically a S age III o IV disease. Symp oms such as ch onic cough,
hemop ysis, and weigh loss a e equen ly mis aken o ube culosis (TB) o ch onic obs uc i e
pulmona y disease (COPD), leading o delayed e e als. In he AIIMS coho , 55% o pa ien s
p esen ed a S age IV [17]. Simila ly, he Kolka a s udy ound ha mo e han 55% o cases we e
ad anced a diagnosis. The na u al his o y is poo : un ea ed NSCLC ca ies a median su i al o less
han 12 mon hs, while SCLC o en p og esses wi hin 6–9 mon hs [22]. E en wi h ea men , su i al
ou comes emain signi ican ly lowe han in de eloped coun ies.
2.4. Molecula pa hology:
Ad ances in molecula biology ha e iden i ied d i e mu a ions in lung cance . These include:
1.
EGFR mu a ions: Found in 25–30% o Indian adenoca cinoma pa ien s [18, 19].
2.
ALK ea angemen s: P esen in ~11% o Indian adenoca cinoma pa ien s [20].
3.
KRAS and TP53 mu a ions: Less commonly s udied in Indian coho s bu con ibu e globally
o umo igenesis.
4.
ROS1 ea angemen s: Occu in 2–3% o cases.
The p esence o EGFR and ALK mu a ions posi ions Indian pa ien s close o Eas Asian han Wes e n
popula ions. Clinically, hese bioma ke s ha e e olu ionized ea men by enabling a ge ed he apies
such as y osine kinase inhibi o s (TKIs) and ALK inhibi o s, which signi ican ly p olong su i al in
mu a ion-posi i e pa ien s. Howe e , eal-wo ld applica ion in India is limi ed. Many pa ien s canno
a o d molecula es ing, and a ge ed he apies emain una o dable o he majo i y. This inequi y
highligh s he gap be ween heo e ical ad ances and p ac ical ou comes.
2.5. Public heal h amewo k:
F om a public heal h pe spec i e, lung cance is a disease wi h high p e en abili y bu poo p ognosis
once diagnosed. Models o popula ion-a ibu able ac ion (PAF) sugges ha elimina ing obacco use
could p e en up o 70% o lung cance s in India. In e en ions a ge ing biomass uels could u he
educe isk in u al women. A simpli ied causal pa hway can be cons uc ed:
1.
Exposu es: Tobacco (especially bidis), biomass uel, incense, ai pollu ion, occupa ion.
2.
Biological Impac : DNA damage -> EGFR/ALK mu a ions -> his ological sub ype changes.
3.
Clinical Mani es a ion: La e-s age p esen a ion, poo su i al ou comes.
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This amewo k unde sco es he impo ance o bo h p ima y p e en ion ( obacco con ol, clean uels,
pollu ion egula ion) and seconda y p e en ion (ea ly de ec ion, molecula es ing).
Figu e. 1: Pa hway o lung cance in India
3. Li e a u e e iew:
3.1. Incidence ends in India:
Figu e. 2: Incidence T ends in India
Recen da a om he Indian Council o Medical Resea ch (ICMR) – Na ional Cance Regis y
P og amme (NCRP) and Popula ion- Based Cance Regis ies (PBCRs) show a he e ogeneous bu
consis en ly high bu den o lung cance ac oss he coun y. Mizo am con inues o eco d he wo ld’s
highes incidence a es, wi h age-adjus ed incidence a es (AARs) o 38.8 pe 100,000 in men and 37.9
pe 100,000 in women. This igu e has emained s able since 2018 bu con inues o e lec he hea y
obacco use in he egion. O he u ban egis ies, including Delhi, Bangalo e, and Chennai, ha e
epo ed ising incidence ends [1]. Delhi’s PBCR showed an AAR o 13.2 in men and 6.2 in women
in 2021, e lec ing an inc easing end since he ea ly 2000s. Chennai and Bangalo e egis ies ha e
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simila ly shown mode a e bu s eady inc eases in incidence, linked o bo h changes in diagnos ic
capaci y and en i onmen al exposu es. Toge he , hese indings sugges ha while some high-
incidence a eas emain s able, me opoli an ci ies a e expe iencing ising lung cance a es,
unde sco ing he disease’s e ol ing public heal h impo ance.
Table. 1: PBCR Lung Cance Incidence in India (2018–2023)
Regis y
Men AAR (/100,000)
Women AAR (/100,000)
T end
Mizo am
38.8
37.9
Highes , s able
Delhi
13.2
6.2
Rising
Bangalo e
10.5
4.8
Rising
Chennai
9.9
3.7
Rising
Mumbai
8.4
3.5
Mode a e inc ease
3.2. Tobacco smoking as a dominan isk ac o :
Figu e. 3: Causes o Lung Cance in India
Mul iple case–con ol s udies published be ween 2018 and 2023 ein o ce ha obacco use emains he
single la ges con ibu o o lung cance in India [16]. Unlike Wes e n coun ies, bidi smoking is mo e
p e alen in u al and semi-u ban popula ions, and i ca ies g ea e ca cinogenic po en ial. Odds a ios
(ORs) o bidi smoking ange be ween 4.2 and 8.3, compa ed o 2.0–5.0 o ciga e e smoking [16].
This highligh s he disp opo iona e isk aced by lowe socioeconomic g oups, who also ha e less
access o heal hca e se ices. Addi ionally, smokeless obacco, hough no di ec ly associa ed wi h lung
cance , has been no ed as a co- ac o in popula ions wi h high obacco bu den. The dual use o
smokeless and smoked obacco inc eases isk h ough addi i e ca cinogenic pa hways. Despi e he
Ciga e es and O he Tobacco P oduc s Ac (COTPA) amendmen s and public heal h campaigns,
en o cemen emains weak, pa icula ly in no he n and no heas e n s a es.
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3.3. Biomass uel and indoo ai pollu ion:
Household ai pollu ion (HAP) om biomass uels is ano he signi ican con ibu o , pa icula ly
among women in u al households. S udies om No h India published in 2019 and 2021 epo ha
long- e m exposu e o cooking smoke om wood, c op esidues, and dung cakes doubles o iples
lung cance isk [15]. Women exposed o biomass smoke o o e 15 yea s ha e ORs anging om 1 .8
o 3.0. Despi e na ional p og ams p omo ing lique ied pe oleum gas (LPG) unde he P adhan Man i
Ujjwala Yojana (PMUY), adop ion emains incomple e. Many households con inue using biomass
uels due o a o dabili y and supply chain challenges. Consequen ly, women and child en emain
disp opo iona ely a ec ed.
3.4. Ou doo Ai Pollu ion (PM2.5 and NOx):
Ai pollu ion in u ban India has eme ged as a mode n epidemic. Delhi and o he me opoli an egions
consis en ly ank among he wo ld’s mos pollu ed ci ies. Long- e m exposu e o PM2.5 le els
exceeding Wo ld Heal h O ganiza ion (WHO) limi s has been shown o inc ease lung cance isk by
1.5–2.0 imes [16]. Recen coho s udies es ima e ha ai pollu ion accoun s o 8–12% o lung cance
cases in majo Indian ci ies. Vehicle emissions, indus ial discha ges, and cons uc ion dus a e he
majo con ibu o s. Unlike obacco, which p ima ily a ec s men, ai pollu ion inc eases isk in bo h
gende s and ac oss socioeconomic s a a. This makes i a p essing en i onmen al and heal h policy
issue.
3.5. His ological shi s in lung cance :
His o ically, squamous cell ca cinoma domina ed he his ological spec um o Indian lung cance .
Howe e , mul iple hospi al-based s udies be ween 2018 and 2025 ha e con i med a clea shi owa d
adenoca cinoma [21]. A en-yea coho analysis om he all India Ins i u e o Medical Sciences
(AIIMS), published in 2020, ound adenoca cinoma in 34% o pa ien s, su passing squamous
ca cinoma a 28.6% [18]. By 2022, mul icen e s udies ac oss Delhi, Mumbai, and Bangalo e epo ed
adenoca cinoma a es o 38–40% [21]. Squamous ca cinoma accoun ed o 25–30%, while small cell
lung cance emained s able a 10–15% [17]. This ansi ion e lec s global ends and is likely d i en
by mul iple ac o s: a shi om un il e ed bidis o il e ed ciga e es, inc easing biomass and ai
pollu ion exposu e, and imp o ed diagnos ic accu acy h ough immunohis ochemis y and molecula
es ing.
3.6. Molecula epidemiology: EGFR, ALK, and ROS1:
Molecula p o iling has become inc easingly common in India, pa icula ly a e ia y ca e cen e s.
Among non-small cell lung cance (NSCLC) pa ien s, Epide mal G ow h Fac o Recep o (EGFR)
mu a ions a e ound in 23–30% o cases [18, 19]. This p e alence is highe han in Wes e n
popula ions (~10–15%) and close o Eas Asian a es. Anaplas ic Lymphoma Kinase (ALK)
ea angemen s a e de ec ed in app oxima ely 10–12% o adenoca cinoma cases [20], while ROS1
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ea angemen s occu in 2–3%. These indings a e clinically impo an because hey enable he use o
y osine kinase inhibi o s (TKIs), which signi ican ly imp o e su i al in mu a ion- posi i e pa ien s.
Howe e , access o molecula es ing emains limi ed due o cos ba ie s. Many pa ien s in ie -2 and
ie -3 ci ies emain undiagnosed, and hose who es posi i e o en canno a o d a ge ed he apy. This
dispa i y e lec s India’s dual heal hca e sys em, whe e ad anced echnologies coexis wi h limi ed
a o dabili y.
3.7. S age a diagnosis and su i al ou comes:
Despi e ad ances in diagnos ics, mo e han hal o Indian pa ien s con inue o p esen wi h ad anced
disease. Hospi al audi s be ween 2018 and 2023 consis en ly epo ha o e 50% o pa ien s a e
diagnosed a S age IV, wi h only 20% de ec ed a po en ially cu able S ages I–II [17]. Median su i al
emains poo a 10–12 mon hs o non-small cell lung cance (NSCLC) [22], wi h sligh ly be e
ou comes in pa ien s ecei ing a ge ed he apies. Small cell lung cance (SCLC) con inues o ca y a
dismal p ognosis, wi h median su i al less han 8 mon hs [22]. The lack o sys ema ic sc eening
p og ams is a majo ac o . Low-dose compu ed omog aphy (LDCT) sc eening, which is alida ed
in e na ionally, has no been implemen ed a he na ional le el in India. Diagnosis is o en delayed due
o symp om o e lap wi h ube culosis and ch onic obs uc i e pulmona y disease (COPD).
Figu e. 4: S age a Diagnosis o Lung Cance in India
3.8. Financial and socioeconomic bu den:
One o he mos s iking indings om ecen s udies is he ca as ophic inancial impac o lung
cance ea men . Ta ge ed he apies and immuno he apies cos ₹60,000–100,000 pe mon h, a
beyond he each o mos Indian households. Mul iple epo s om 2020 o 2023 desc ibe pa ien s
selling asse s, aking loans, o abandoning ea men due o cos . E en when pa ien s ini ia e he apy,
many discon inue p ema u ely because o inancial s ess. This “ inancial oxici y” has eme ged as a
c i ical de e minan o su i al ou comes, alongside clinical and biological ac o s.
4. Da a and me hodology:
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4.1. Da a Sou ces This s udy syn hesized da a om mul iple Indian sou ces be ween 2018 and 2025 o
p o ide a comp ehensi e o e iew o lung cance ends, causes, and implica ions. The p ima y da a
sou ces included:
1.
Popula ion-Based Cance Regis ies (PBCRs): Managed by he Indian Council o Medical
Resea ch (ICMR), hese egis ies co e o e 30 geog aphic loca ions. Upda es be ween 2019
and 2022 p o ided incidence a es s a i ied by egion, gende , and age [1]. Fo example,
Mizo am epo ed AARs o ~38.8 pe 100,000 in men and ~37.9 in women in 2020–2021.
2.
Hospi al-Based Cance Regis ies (HBCRs): Ins i u ions such as AIIMS (All India Ins i u e
o Medical Sciences) in Delhi, Ta a Memo ial Hospi al in Mumbai, and PGIMER
(Pos g adua e Ins i u e o Medical Educa ion and Resea ch) in Chandiga h con ibu ed
de ailed his ological and clinical da a. Be ween 2018 and 2023, hese egis ies collec i ely
epo ed mo e han 20,000 lung cance cases [17, 18].
3.
Case–Con ol S udies: Recen Indian s udies (2018–2023) p o ided odds a ios (ORs) o isk
ac o s such as bidi smoking (OR 4.2–8.3), ciga e e smoking (OR 2.0–5.0), biomass uel
exposu e (OR 1.8–3.0), and ai pollu ion (OR 1.5–2.0) [16].
4.
Molecula Epidemiology S udies: Mul icen e analyses om Delhi, Mumbai, and Bangalo e
documen ed EGFR mu a ions in ~23–30% o non-small cell lung cance (NSCLC) pa ien s
[19], ALK ea angemen s in ~10–12% [20], and ROS1 ea angemen s in ~2–3%.
5.
Socioeconomic and Financial S udies: Su eys published be ween 2020 and 2023 examined he
cos o lung cance ea men . The median mon hly cos o a ge ed he apy was ₹60,000–
100,000, wi h ~65% o amilies epo ing ca as ophic heal h expendi u e.
4.2. Inclusion c i e ia and da a cleaning To ensu e me hodological consis ency, he ollowing
inclusion c i e ia we e applied: only s udies conduc ed in India be ween 2018 and 2025, pee - e iewed
jou nal publica ions, NCRP epo s, o o icial HBCR da ase s, and s udies ha epo ed incidence
a es, odds a ios, su i al ou comes, o ea men cos s. We excluded case epo s, global s udies
wi hou Indian-speci ic da a, o s udies published be o e 2018. Da a we e ha monized by con e ing
incidence a es o age-adjus ed pe 100,000 popula ion, s anda dizing odds a ios ac oss s udies, and
no malizing cos da a o 2023 Indian Rupees (₹).
5. Resul s and analysis:
This sec ion p esen s he consolida ed indings om he li e a u e e iew, highligh ing key s a is ics
and ends.
Table. 2: Majo isk ac o s and odds a ios (2018–2025)
