Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 46, Num. 1, 2009, pp. 1-4

Indian Journal of Cancer, Vol. 46, No. 1, January-March, 2009, pp. 1-4

Editorial

Tackling the cancer Tsunami

Kumar P, Bhattacharyya GS, Dattatreya S, Malhotra H

Tata Memorial Hospital, Mumbai
Correspondence Address:Tata Memorial Hospital, Mumbai
kp_prabhash@rediffmail.com

Code Number: cn09001

WHO′s prediction about the surge in cancer incidence is well known. By next year (2010), cancer will overtake cardiac diseases and become the No. 1 killer. The brunt will be borne by developing countries - regions with the fewest resources (financial, human, and infrastructure) to tackle this onslaught. The Government of India has taken cognizance of these facts and has demonstrated its remarkable commitment by increasing the budgetary allocation for the National Cancer Control Program (NCCP) by several folds in the current five year plan.

We now have the responsibility to join hands and do our bit to tackle cancer head on. How do we do that? The usual standard answer is to optimize delivery of service, education and research that will address the problems of the Indian people. Easier said than done!

There are three broad socio-economic groups in our country. The top 10 to 15% have a lifestyle that matches that of the crθme-de-la-crθme and can afford the best treatment anywhere in the world. The financially challenged majority (55 to 60%) really worry about their next meal on a daily basis. The focus for them needs to be on prevention rather than cure. The third group is the middle class (25 to 40%). They are educated and motivated; they understand the treatment plan and expected outcome; they are net savvy and not afraid to ask questions. They also represent a population that is equivalent to that of the USA. Their ability to spend is better than before. They are willing to stretch their budgets and tighten their belts; and a small helping hand can do wonders to their ability to complete the planned treatment.

So there is no such thing as one size fits all.

Corporate hospitals and hospital chains (Apollo, Max, HCG, Wockhardt, Fortis, etc) are coming up with compact multimodality cancer therapy which the rich are able to utilize. So we shall not discuss this group further.

For the middle class and the poor, let us now explore the role of lateral thinking in tackling the cancer Tsunami.

1. All these years, the RCC at IGIMS, Patna was the only cancer hospital in the whole of Bihar. Thousands of patients came to Tata Hospital for treatment - traveling three to five days for each visit. About eight years ago, a Temple Trust decided to build Mahavir Cancer Sansthan, a comprehensive cancer center from the donations they received. This hospital has progressed steadily, with more than 15,000 new cancer patients being registered and treated here last year. It is also recognized for university postgraduate degrees in various oncology disciplines as well as conducting international clinical trials. Other religious organizations have successfully taken similar initiatives in healthcare (e.g. Satya Sai Hospital, Bangalore and Amrita Institute of Medical Sciences, Cochin).
2. The business community has an important role in corporate social responsibility. Today this goes beyond just writing a check. Some of them have a structured and long-term focus in healthcare as well. The cancer center at Gorakhpur (established by Geeta Press), Meherbhai Cancer Center at Tatanagar (by the house of Tatas) and Jindal Hospital in Haryana are examples of hospitals fulfilling such a responsibility to society.
3. Can profit-making hospitals offer cost-effective healthcare to the middle class? Dr Devi Shetty′s cardiac care center (Narayana Hrudayalaya) at Bangalore has shown how state-of-the-art cardiac care can be given to patients at a price which is less than that at many government hospitals (which are supposed to provide free treatment). In fact, he has more than halved the cost of cardiac operations - by promoting efficient use of infrastructure. His center performs a staggering 25 heart operations a day, each OT being used for 14 to 16 hours every day. But he continues to visualize and pursue further improvement. With an investment of 20 million euro, Dr Shetty is developing a health city which will have 5000 inpatient beds and cater to 15,000 to 20,000 outpatients per day. The model is to generate income from the outpatient clinics that will be utilized to provide inpatient care virtually free.
4. So where does it leave the majority at the bottom of the socio-economic pyramid? Most people believe that people surviving on less than a euro a day may not be able to avail of healthcare at all. Several state governments (Goa, Jharkhand, Nagaland) have provided their people with mediclaim insurance policy for cancer care. This provides a fixed cover for cancer treatment, with the concerned state government picking up the tab for the insurance premium. An experiment by the Karnataka government has gone a step further and is a real eye-opener. The Yeshashvini Co-operative Farmers Health Care Scheme requires that individuals contribute only about 2 euro a year. More than 2 million people have already joined the scheme, and are eligible for free medical treatment (including surgery) at designated top-of-the-line hospitals (Mallya Hospital and Narayana Hrudayalaya). In one year (June 2006 - June 2007), a total of 39,583 surgeries and around 50,000 free OPD consultations were done under this scheme - shattering the myth that voluntary subscription medical insurance is not possible for those living below the poverty line.
5. In most cities, the most important tertiary care center remains the teaching Medical College hospital. Unfortunately most medical colleges in our country do not offer comprehensive cancer care. SMS Medical College, Jaipur is an exception. Using the public private partnership model, top-of-the-line imaging facilities (CT scan and MRI scan) are available at the SMSH at economical rates. They are also procuring a state-of-the-art linear accelerator with IMRT and IGRT facility. Through funds from the National Cancer Control Program, they have developed the Birla Cancer Center to provide comprehensive cancer treatment (the three vital pillars of Radiation Oncology, Surgical Oncology and Medical Oncology) under one roof. This center already caters to about 10,000 new cancer patients every year.
6. We need community-based initiatives for wider implementation. Dr Abhay Bang has shown that rural mothers and village health workers can be trained to manage even sick neonates (with community acquired pneumonias) at home. This approach has reduced the neonatal mortality by 70% and infant mortality rate by 57% in the Gadchiroli district. Deepak Foundation has also been successful in reducing infant mortality in the villages of Baroda District. For cancer, Tata Memorial Centre is the apex cancer referral center for India. It has set up links with two rural centers in Maharashtra (Barshi Cancer Centre near Sholapur and Walwalker Hospital near Chiplun) to help them establish and upgrade to a cancer center. This involves financial, technical and human resource commitment on an ongoing basis. Thus optimal cancer care is now available at doorsteps in rural Maharashtra.
7. Cancer screening can also be done in India in a meaningful manner. Dr. Sankaranarayanam R has shown in his study in India that cervical cancer screening and oral cancer screening are feasible with the use of non-medical, high school or university graduates as well as nurses who are trained in simple techniques of visual inspection for these cancers. Such simple techniques have reduced mortality, especially in the high-risk population.
8. More than 50% of cancers in India are related to smoking and lifestyle. Our honorable Health Minister, Dr Anbumani Ramadoss, has been aggressively following an anti-tobacco approach. Now our law prohibits smoking in public places. The World Congress on Tobacco or Health is also being conducted in Mumbai in March 2009.
9. Cost is an important factor in cancer treatment. With the above research the cost may reduce but more needs to be done. Dr Purvish M Parikh has investigated prolonged infusion (low dose) gemcitabine in lung cancer. It appears that this schedule has similar efficiency to standard dose gemcitabine for one third of the cost. Hematologists at CMC Vellore have used arsenic as first line therapy in APML after being impressed with its use by Vaidya Balendu Prakash, an ayurvedic specialist. This was used in patients who could not afford regular treatment and gave promising results. Radiation therapy instruments are one of the most costly components of cancer management. The indigenous development of Bhabhatron by BARC and its clinical testing by TMH has the potential to decrease the cost of such radiotherapy machines and save crores of rupees for India.
10. Many NGOs help cancer patients in many ways (e.g. Tata Trusts by generous donations for their treatment, V-Care by providing emotional support and counseling, Indian Cancer Society by rehabilitating them during and after therapy, Make-a-Wish-Foundation by making wishes come true, etc). Some of these NGOs stand out by providing innovative services. For instance MAX Foundation has distributed free drugs to more than 13,500 patients of CML and GIST in India since November 2002 (and 35,000 across the globe). AmeriCares and AmeriCares India Foundation is another example. Over the last ten years they have provided US$ 45 million worth of aid to India, which has benefitted an estimated 10 million Indians. They are a nonprofit disaster medical relief and humanitarian medical aid organization which provides immediate response to emergency medical needs - and supports long-term humanitarian assistance programs - for all people around the world, irrespective of race, creed or political persuasion. In 2008 they delivered US$1 billion worth of medicines, medical supplies and other relief to people in 87 countries. Their work also includes helping partner NGOs working with cancer patients.
11. In US, SEER data provides information on about half the cancer patients. In India, such data was lacking. Most of the registries were hospital based and provided only demographic data. The Indian Council for Medical Research (ICMR) initiated the Cancer Atlas project under the leadership of Nandkumar. This increased the information available threefold - covering 3% of India′s population. This was unique in using an Internet based protocol for data collection. ICMR has also recognized the Mumbai population based cancer registry as the model registry for India. This is run by Dr Arun Kurkure and Dr Yeole of the Indian Cancer Society (ICS), since decades. It is a wealth of information providing trends and predictions of immense value for cancer control planning.
12. Need-based clinical research has been encouraged since Independence. Mahatma Gandhi had said that research is of no use if it does not serve the purpose of reducing suffering and improving the health of our people. This cannot be over-emphasized. The Indian Co-operative Oncology Network (ICON) is an Academic Research Organisation (ARO) that has shown exceptional foresight in developing the infrastructure to perform state-of-the-art clinical trials and nurturing human resources to develop investigator initiated studies. Since 1999, this organization has conducted several workshops and training programs all over India. The other strength of this organization is the focus on education - for oncologists, for consultants from other specialists, for GPs as well as for the lay public. The promotion of oncology training and education (PromOTE India) programs are just one such example. Last year, they trained more than 1,500 doctors in 10 states of India.
13. With few qualified oncologists and such a large number of cancer patients, it is obvious that a significant number are treated by other doctors. Under the circumstances, it was felt vital that such physicians be given appropriate guidelines to optimize therapy. This mantle has been ably taken by the ICMR guidelines′ taskforce set up by Dr Kishore Chaudhry and headed by Dr GK Rath. They have already put on their website the guidelines for three diseases and are developing 28 others.

We have many other examples in our country, where individuals, institutions and organizations have shown the will and intellectual capability to demonstrate how the cancer Tsunami can be handled. We recommend even more thinking "outside the box". For this we leave you with the example of how Formula One racing has helped Great Ormond Street Hospital (GOSH). Professor Elliot and doctors from GOSH identified that the transfer of patients from the operation theater into the ICU was a challenge and influenced mortality rates significantly. Impressed by the speed and precision of how the formula one team went through the pit stop process, they brainstormed to learn from each other. The dramatic improvement in the outcome of children undergoing surgery at GOSH was thanks to dividing the handover process into four phases - pre handover (Phase 0), equipment and technology handover (Phase 1), information handover (Phase 2) and discussion and plan (Phase 3).

Did anyone ever predict that Formula One car racing had so much to offer to medicine? Such pearls of wisdom are waiting to be plucked - provided we keep our eyes and mind open. Expand your horizon. Ask and you shall not be denied. Anticipate and innovate to prevent cancer and cure more patients. Let no one be denied the right to treatment.^[20]

References

Copyright 2009 - Indian Journal of Cancer