Based on the Global Cancer Observatory (GLOBOCAN) 2022 data, India ranked third behind China and the United States in terms of the absolute number of cancer incidences globally. This pervasive health issue accounts for 9% of all fatalities attributable to non-communicable diseases (NCDs). Gastrointestinal (GI) cancers encompass a diverse group of malignancies originating from the digestive system, including cancers of the oesophagus, stomach, small intestine, colon, rectum, anal canal, liver, intrahepatic bile ducts, gallbladder, and pancreas.

According to the latest Indian Council of Medical Research (ICMR) report, there were an estimated 1.46 million new cancer patients in India in 2022, a number anticipated to rise to 1.57 million in 2025. Within this escalating burden, gastrointestinal tract malignancies constitute a considerable proportion of the cases. In 2022, India contributed 279,430 new GI cancer cases and 231,249 deaths. It ranked 4th globally in total GI cancer incidence, following China, Japan, and the USA.

Current Trends in GI Malignancies in India

Significant regional disparities characterise the cancer incidence across India. The Northeast region consistently exhibits the highest overall cancer incidence rates for both sexes. The exceptionally high age-adjusted incidence rates of GI cancers in India’s Northeast region, particularly in Aizawl and Papum Pare districts, when compared to the national average of other major cities, strongly indicate the presence of unique, localised aetiological factors.

The incidence and trends of specific types of GI cancer vary across India.

Oesophageal Cancer

This malignancy ranks as the 6th most common cancer overall in India, the 5th in males, and the 6th in females. Globally, India has the second highest incidence of oesophageal cancer, surpassed by China. The histological type of squamous cell carcinoma (SCC) remains the most prevalent, and interestingly, a declining trend has been observed for oesophageal cancer in India.

Stomach Cancer

In India, it is the 5th most common cancer among males and the 7th among females. In 2022, India was ranked 3rd globally for new stomach cancer cases. Similar to oesophageal cancer, a declining trend has been observed for stomach cancer in India.

Colorectal Cancer (CRC)

CRC is the 4th most incidental cancer in both sexes in India. An increasing trend in colon and rectal cancers has been observed across various regions of India, particularly in urban areas.

Liver Cancer (HCC)

Liver cancer is the 3rd leading cause of cancer-related death worldwide. Age-adjusted incidence rates of HCC in India range from 1 to 7.5 per 100,000 population (0.7-7.5 for men, 0.2-2.2 for women), with a male-to-female ratio of 4:1. An increasing trend in liver cancer has also been observed in India.

Pancreatic Cancer

In India, it ranks 24th in incidence and 18th in mortality. The incidence is higher in the elderly population (65-75 years) and is particularly elevated in Northeastern Indian regions. An increasing trend for pancreatic cancer has been observed, with projections indicating further increases due to lifestyle changes.

Gallbladder Cancer

This gallbladder cancer has high incidence in the Northern and Northeastern parts of India in both sexes. An increasing trend in the incidence of gallbladder cancer has also been observed. Globally, gallbladder cancer has the lowest incidence rate across all six continents.

The contrasting trends of declining incidence of stomach and oesophageal cancers alongside rising incidence of colorectal, liver, gallbladder, and pancreatic cancers in India point to a significant epidemiological shift. The decline in stomach and oesophageal cancers may be linked to improvements in hygiene, sanitation, and food preservation, as has been observed globally for gastric cancer. Conversely, the rise in colorectal, liver, gallbladder, and pancreatic cancers is likely driven by increasing urbanisation and associated lifestyle changes, such as increased consumption of red and processed meats and sugary foods, rising rates of obesity, diabetes, and reduced physical activity. A critical concern is that gallbladder and pancreatic cancers are often present at advanced stages in India.

Consequently, public health strategies must be be adapted to the changing landscape. While traditional preventive efforts, such as tobacco control for oesophageal cancer, remain crucial, there is an increasing need to focus on interventions related to diet, physical activity, obesity, and early screening for colorectal, liver, and pancreatic cancers. This shift has direct implications for the allocation of resources to specific diagnostic and treatment modalities. There is an urgent need for targeted research into the early detection of these cancers, enhanced public awareness campaigns for high-risk groups, and improved diagnostic infrastructure, particularly in regions with high incidence, such as North and Northeast India, for gallbladder cancer.

Survival Rate Disparities

A concerning aspect of the GI cancer burden in India is the significantly lower survival rates compared with those in developed countries. For instance, the 5-year survival rate for patients with oesophageal cancer in India is only 10.8%, starkly contrasting with Japan’s 47.8%. The overall survival for oesophageal cancer in India ranges from 5% to 30%, with the majority of cases (70-80%) detected at an inoperable stage. Similarly, colorectal cancer survival in India is considerably lower than that in developed countries.

The stark disparity in 5-year survival rates for GI cancers between India and developed countries can be attributed to two reasons: the biology of the disease and, more importantly, to critical shortcomings in the cancer care continuum available to the huge population at risk. Patients in India die from GI cancers at a higher rate and are frequently diagnosed when treatment options are limited. This situation can be attributed to inadequate early detection mechanisms, including a lack of widespread screening programs, low public awareness of symptoms, and limited diagnostic infrastructure, especially in rural areas. Furthermore, timely access to treatment is hindered by significant geographic disparities in healthcare facilities, with cancer care often concentrated in metropolitan areas. Financial barriers, primarily high out-of-pocket (OOP) expenditures, also prevent many from accessing necessary care. In addition, human resource shortages, including oncologists and specialised staff, contribute to these challenges. While some urban centres in India offer advanced care, the overall quality and standardisation of care can vary, thus impacting treatment effectiveness.

Therefore, improving survival rates necessitates a multi-pronged approach that addresses the entire cancer care pathway, from primary prevention and early detection to accessible, affordable, high-quality treatment and palliative care. This survival gap also underscores the urgent need for research on context-specific interventions that can improve outcomes despite existing resource limitations.

Key Risk Factors to Address

The prevalence of GI cancer in India is influenced by a complex interplay of modifiable and non-modifiable risk factors, many of which are linked to broader public health challenges. Tobacco and alcohol consumption are significant risk factors for various GI malignancies in India. Certain dietary patterns contribute to the risk of developing gastrointestinal cancer. Risk factors for stomach cancers include starch-rich and low-protein diets; high consumption of salty, spicy, and fermented foods; processed meats; fried foods; nitrates; and specific cooking practices such as roasting, grilling, deep frying, sun-drying, salting, curing, and pickling. Similarly, high consumption of grilled and processed meat, fried food, and foods rich in cholesterol and nitrosamines is associated with an increased risk of colorectal and pancreatic cancers. Specific infections such as Helicobacter pylori (for stomach cancers) and HBV/HCV (for HCC) play a crucial role in the aetiology of certain cancers. Obesity and diabetes mellitus (DM) are important risk factors for nonalcoholic steatohepatitis (NASH), which can progress to HCC. Obesity is also a risk factor for oesophageal and colorectal cancer. There is a strong connection between low socioeconomic status and certain GI cancers such as oesophageal SCC. Low socioeconomic status can lead to increased exposure to risk factors such as cheaper forms of tobacco, poor hygiene, and inadequate diets. It also limits access to clean water and sanitation.

The high prevalence of common modifiable risk factors, such as tobacco, alcohol, and unhealthy dietary patterns across multiple GI cancers, combined with their known links to other non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, indicates a significant opportunity for integrated public health interventions. This interconnectedness suggests that a holistic public health approach targeting these shared risk factors (e.g., comprehensive tobacco and alcohol control, promotion of healthy diets, and encouragement of physical activity) would yield benefits across various cancer types and other NCDs. This represents a more efficient and effective strategy than addressing each disease in isolation. Therefore, investment in primary prevention programs focused on lifestyle modification and behavioural change, with an emphasis on physical activities and exercise, can have a far-reaching positive impact on India’s overall public health.

Challenges to GI Cancer Research in the Indian Context

The escalating burden of GI cancers in India necessitates a robust and dedicated research ecosystem tailored to the country’s unique epidemiological, genetic, and socioeconomic landscapes. Institutions such as the Indian Council of Medical Research (ICMR) and The National Cancer Grid (NCG) can play a vital role in facilitating research networks, clinical trials, and standardisation of cancer care across the nation. Large tertiary and academic research centres should be incentivised to maintain biorepositories and engage in genomic research on various cancers. A fundamental impediment to effective cancer control and research in India is the significant data gaps, inconsistencies, and outdated nature of the national cancer registries. The 2022 Parliamentary Standing Committee Report on Health and Family Welfare highlighted these concerns, recommending that cancer should be classified as a notifiable disease nationwide to improve real-time data collection. However, only 17 states implemented this recommendation. This lack of robust, real-time, and granular data directly affects evidence-based policymaking. Similarly, researchers lack comprehensive baseline data to design impactful studies, track epidemiological shifts, or evaluate intervention effectiveness. Clinical research is often deprioritised in India because of the immense patient burden on the healthcare systems. Limited financial resources are allocated for clinical research, as much of the global drug development is concentrated in Western countries. The absence of well-established academic research networks and limited patient referral for clinical trials further hinders research growth.

Opportunities and Strategic Imperatives for Future Research

India possesses a large, diverse, and often treatment-naïve patient pool, which provides distinct advantages for conducting clinical trials and genomic studies. The genetic diversity of the Indian population indicates that genomic studies conducted elsewhere may not fully capture the unique mutations or disease patterns relevant to Indian patients. Therefore, indigenous genomic research is essential for identifying specific biomarkers, developing tailored therapies, and understanding local disease aetiologies (e.g., gastric cancer from Nagaland/Kashmir and gallbladder cancer along the Ganges belt). Advances in next-generation sequencing (NGS) and preclinical models offer powerful resources for investigating GI cancer pathophysiology, identifying biomarkers, screening drugs, and personalised treatment. Furthermore, artificial intelligence (AI) and liquid biopsy technologies show promise for the early detection and management of disease progression and metastases from GI cancers. Broad molecular profiling using NGS is crucial for detecting actionable alterations in Indian patients in order to guide personalised precision medicine.

Funding should be directed towards studies on specific dietary habits, environmental exposures, and genetic predispositions prevalent in high-incidence regions such as Northeast India. This includes focused research into unique pathologies, such as mucinous/signet ring colorectal cancer and advanced gallbladder cancers, which are particularly prevalent in the Indian subcontinent.

Non-invasive colorectal cancer (CRC) screening methods, such as blood-and-stool-based biomarkers, have the potential to improve early detection. Innovative studies are needed in the Indian context to demonstrate the all-cause mortality benefit with such screening before it can be offered to patients in the clinic as a routine. Support is needed for the development of affordable, context-specific screening tools, such as non-invasive biomarkers and endoscopic devices adaptable to rural settings.

Innovation in clinical cancer research in India includes dose de-escalation trials, drug repurposing, and the development of indigenously developed cost-effective cellular therapies such as CAR-T cell therapy. Clinical trial sites should be decentralised beyond metro cities to access India’s diverse patient pool, particularly in rural areas. Implementation of digital platforms and telemedicine can facilitate patient recruitment and follow-up. Fostering a culture of clinical research among oncologists and ensuring patient awareness of trials as a potential care option are also crucial.

CONCLUSION

Gastrointestinal (GI) cancers constitute a significant and growing public health concern in India and contribute significantly to the nation’s overall cancer burden. The epidemiological landscape of GI cancers in India is undergoing a transition characterised by a decline in stomach and oesophageal cancers and a concomitant rise in colorectal, liver, gallbladder, and pancreatic cancers. This shift is largely attributed to lifestyle changes, urbanisation, and the adoption of Western dietary patterns. The stark survival gap between India and other developed nations highlights critical deficiencies in early detection, access to care, and treatment infrastructure. While the challenges are substantial, India’s unique epidemiological landscape coupled with advancements in research and technology presents unparalleled opportunities for developing context-specific and impactful solutions. The imperative for indigenous research on India-specific risk factors and genetic profiles, combined with the strategic adoption of precision medicine and innovative screening technologies, holds the potential to transform cancer care.