There are 2 to 2.5 million cancer patients in India at any given point of time. Additionally, about 0.7 million new cancer cases are detected every year and nearly half die every year. Cancer is a huge burden, both on the people and the government. Yet the means to fight cancer are not easily available. From detection technology to chemotherapy drugs everything is expensive. Cost is one of the detrimental factors pushing patients to die in oblivion.
Current status
India is at par when compared to any country in the world in terms of advanced technology and experienced surgeons for cancer treatment. The problem is that these facilities are concentrated in some areas, mainly the metropolitan cities. Cancer detection and treatment facilities vary widely in rural India where 70 per cent of the population resides. “Yes, we do have all the facilities available. Unfortunately, concentrated in cities and not in remote areas or villages in the country,” explains Dr Anthony Pais, Head of Oncoplastic Breast Surgery Unit, Narayana Health City, Bangalore. Concurring Dr Ganesha D Vashishta, Chief Medical Oncologist, BGS Global Hospitals, Bangalore says, “Cancer care is centralised in the cities, and not easily accessible to the rural population. Though state-of-the-art facilities are available, only few patients can afford that.”
Public vs private
Taking into account the huge difference between private and public healthcare in India, one would assume that cancer care is better in the private healthcare setting. In reality, cancer centres in India, despite and state-of-the-art-technology, leave much to be desired. “In private settings, situation should have been ideal but unfortunately it is the opposite,” laments Dr Pais.” The high costs and competition have driven centres to do a lot of unethical work,” he reveals.
“Hospitals who are only after financial returns have no quality control or audit on surgeries, type of chemotherapy and indications for radiotherapy etc.,” he adds.
Talking about positives of cancer care in private settings, Dr Vashishta says, “The private setting is well equipped with the latest machines and better infrastructure where patients get individual care and have shorter waiting time, but is expensive.”
Agreeing Prof Dr Anita Ramesh, Professor Medical Oncology, Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Porur says, “Private care hospitals provide comprehensive cancer treatment which is costly. Expensive chemo therapeutic drugs are used and unnecessary surgeries take place due to corporate pressure to increase the revenue. Even high end radio therapeutic techniques are used for palliative cases and patients are made to pay. If the doctor cannot satisfy the goals and target of the private hospital he is asked to leave.”
Cancer care in the public sector is delivered by 17 regional cancer research and treatment centres spread across India. Efforts are ongoing to develop oncology wings in government medical college hospitals to fill up the geographical gaps in the availability of cancer treatment facilities in the country. “In the public setting, cancer care is mainly given by regional cancer centres and major medical colleges where the facilities are okay and comparable to the facilities available in private sector,” says Dr Jayaprakash Madhavan, Chief of Radiation Oncology, KIMS Pinnacle Cancer Centre, Thiruvananthapuram.
However, the public sector has its own challenges. They are dependent on the government for funds and since cancer treatment technologies are expensive they have to wait till the funds are mobilised. Besides, they have huge patient load and fewer oncology specialists which makes cancer care very challenging for public sector centres. “Public settings are lacking in infrastructure, there is longer waiting period for patients and doctor to patient ratio is huge,” laments Dr Vashishta. “In public hospitals, the patient load is too much and individual care or even standard of care cannot be given,” says Dr Ramesh. Explaining further, Dr Pais says, “In a public set up the problem of finance, out-dated machines, lack of availability of chemotherapeutic drugs and a lack of dedicated and motivated staff makes cancer treatment ineffective.”
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| Tumour Board helps in multidisciplinary approach to cancer care |
Mismatched care
Much is said about multidisciplinary approach to cancer care. Medical collaboration is of utmost importance in cancer treatment. Many hospitals emphasise on Tumour Boards which consist of surgeons, medical oncologists, radiation oncologists, and other specialists who work together to provide the best treatment plan for cancer patients. How far is this approach applied in the Indian settings? Not often. There is a huge mismatch of therapy recommendation, burdening the patient with long bills. Tumour Boards are not common sites although their assessment can enhance treatment. Dr Ramesh explains that if a patient consults the surgeon first he opts for surgery while if he approaches a radiation oncologist then he is given radiation first. “Most of the hospitals do not have Tumour Boards and cases are not discussed in multidisciplinary meetings. Individual decision taken may not be good for the patient,” he adds.
“The type of therapy to be used should be decided by the Tumour Board and not by one radiation oncologist, especially in private setups,” emphasises Dr Pais.
Skyrocketing costs
Cancer care is dynamic and a continuous process. It is needless to say that cancer care is expensive. “Cancer treatment facilities require large capital investment and hence treatment is more expensive,” explains Dr Madhavan.
Elaborating on costs, Dr Vashishta says, “Cancer care is expensive because of expensive infrastructure; costly machines including radiotherapy machines; expensive anticancer drugs; longer hospitals stays; advanced cancers need longer duration of therapies increasing the treatment costs.”
In fact, cancer drugs are the single largest cost factor that the patient has to deal with. A single dose of most cancer drugs are in the vicinity of Rs 50,000 – Rs 75,000. Even the generic versions of the branded drug are not within easy reach of the patients.
“Price of the chemo drugs are also high because pharma companies have to spend so much for drug development clinical trials and till the approval of the drug in the open market. If they test thousands of molecules, one or two drugs may be successful to recover the expense and get profit. Companies are forced to fix the price and insist on exclusive market rights by patent rates. So many newer drugs are uniformly priced all over the world. So many cases are pending in courts regarding exclusive market rights and patency in India. Unless we change, many new molecules for treatments are not going to be marketed in India in early phase,” insists Dr Madhavan.
Drastic measures required
Price control of cancer drugs is not only necessary but imminent. It is the need of the hour. India has taken drastic measures to check drug pricing in the last few years. In 2012, India deferred patents and exclusive sales of cancer drugs; Novartis’s Gleevec, Pfizer’s Sutent and Roche’s Tarceva. In addition, Bayer AG lost a legal battle to protect the Indian patent on its Nexavar kidney cancer medicine. On the other hand, Roche gave up the patent for Herceptin, a breast cancer drug. However, this has not made a drastic impact on the drug pricing. Cancer patient support groups and healthcare activists are demanding an even bigger discount, hoping to emulate the ripple effect caused by domestic competition that drove down prices for HIV medicines in the past. There is universal consensus across board on making cancer care affordable and this needs a multi-sectoral effort. “No curable cancers should be left untreated,” insists Dr Madhavan. “Cancer prevention, early detection and appropriate treatment can reduce cancer related mortality considerably. There should be close co-operation between public and private centres to make cancer care affordable,” he adds.
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