In a wide-ranging interview, Dr Sajjan Rajpurohit, Senior Medical Oncologist, Rajiv Gandhi Cancer Institute and Research Centre (RGCIRC) talks about the cancer scenario in India. Explains that late detection, lack of awareness and affordable care are the main reasons for the high cancer mortality rates in the country
Cancer has taken centre stage and is in an upsurge, with more and more people being detected with the disease, still we don’t have enough oncologists. Why do you think there is a dearth of specialists in oncology?
The value of detecting cancer early is significant. Although the situation has improved in recent years, India still has one of the worst records for both identification of cancer and survival from it. Late detection, lack of awareness and affordable care are the main reasons for the high cancer mortality rates in the country. However, awareness on cancer has improved from what it was ten years ago, but still much more needs to be done. The number of cancer cases are burgeoning due to increased urbanisation, air and water pollution and change in lifestyle, like increased use of tobacco, preservatives and processed food, use of alcohol, tobacco, obesity, etc.
As per a report by EY, the prevalence of cancer in India is expected to increase from an estimated 3.9 million in 2015 to an estimated 7.1 million people by 2020. There is a significant dearth of well-trained oncologists across the three streams – medical, surgical and radiation oncology. India has only about 1500 medical oncologists and we would require atleast 10,000. Atleast one medical oncologist is needed for 100,000 people and we have a huge gap. Many medical oncologists are present only in the urban areas or tier I cities. In tier II and tier III cities, it is difficult to get a medical oncologist and we don’t have enough surgical and radiation oncologists. Cancer being a chronic disease, there is an urgent need for increased oncologists’ presence in tier II and tier III cities. For example, in Uttar Pradesh, apart from Lucknow, almost all other districts lack optimal oncology facility, even AIIMS in Jodhpur does not have medical oncologists. Government needs to lay huge focus on delivering the oncology facility atleast in tier II and tier III cities.
Can you tell us how the oncosurgery has developed in the recent years and what are the innovations which can be expected in the next five years?
As setting up a cancer hospital is capital-intensive, we have only about 10 to12 cancer centres of excellence pan India which provide gamut of quality cancer treatment matching the world class cancer centres. With few centres of excellence, many patients from the rural, interior towns and district wait for months together to get the treatment. In certain cases, a Stage I cancer patient is treated when it reaches Stage 4 and becomes incurable and their lives are being put at risk. For example, in AIIMS Delhi, the average time to begin a radiation is four months due to huge patient load. There has to be a sense of urgency and prompt diagnosis is vital in cancer treatments.
If the treatment duration extends, it means increased rounds of chemotherapy, with more side effects. The state government should ensure that a financial aid be given to the cancer patients. Though some states are doing it, but it should be made mandatory.
Do you think precision medicine for cancer care will be the way forward in cancer treatment?
Precision medicine is a personalised medicine. We get information about genetic changes in the tumour, which can help decide which treatment will work best for an individual. The doctors will go for next gen sequencing, check how the proteins are formed and study the epigenetic changes and various other factors, which make the tumour behave in a particular manner. So, it helps them to design specific treatments for certain forms of cancer. Mostly, people with breast, lung cancers usually have their cancers tested for certain genetic changes when they are diagnosed. Many cancers which have high incidence in India like gall bladder, stomach and pancreatic cancers is still evolving.
Many oncologists are trying to move towards understanding the basic biology of cancer patients. Instead of focussing on disease, we are now more focussed on patients. It helps us to detect how and whether chemotherapy will work for a patient or how much effect a drug will have on the patient. Precision medicine helps a doctor to be more aware of the biology of the disease. Treatment using precision medicine can be expensive. It is beyond the reach of 90 per cent of our population.
How are various sectors working towards bringing in cost efficiency right now?
Bringing cost efficiency in cancer treatment is the need of the hour, as this disease as huge financial implications in an individual and his/ her family. Apart from other non-communicable diseases, cancer treatments should be given an impetus and more generous funding by the central and the state governments. On an average, the cost of standard cancer treatment in a private hospital is Rs 5 to 10 lakhs. If we involve precision medicine, newer immunotherapy drugs cost will go upto Rs 1 crore.
Tell us about the myths which exist about chemotherapy?
Yes, a number of myths do exist about chemotherapy. I have seen patients who are scared, angry and try to walk away before the treatment. Chemotherapy is nothing but the drugs which are infused into a patient which work against the cancer cells. As they are able to inhibit the rapidly growing cells, they have growth impairment of the bone marrow cells, hair cells and cells of the gut. Chemothrapy induces alopecia (hair loss), alterations in the mouth, lowering of immunity and blood platelets, but all those side effects are amply studied. In the past one decade, there has been huge advancements.
Many chemotherapy drugs are in part designed to prevent nausea and vomiting, or reduce their severity. Many patients think that they have to be admitted to hospital, but nowadays many chemotherapy drugs are taken orally or as an injection. There is no extended hospital stay, they can continue with their professional lives. Tolerating chemotherapy has become easier. Many doctors also help the patients to reverse side effects. For example, many patients worry about alopecia. Now, we have devices to prevent alopecia. But, the flipside of chemotherapy is that it is less precise as it acts upon 40 to 50 percent of the tumours and the rest will require subsequent drugs. That is why we are moving towards more precise and target-oriented drugs. Nevertheless, chemotherapy is a very important component of cancer treatment, especially in advanced stages.
Can you give us details about the research you are involved in?
With human effort, we have come over many deadliest of communicable diseases like plaque, polio and small pox. To a large extent, people are able to survive even HIV, what is ailing the human race is cancer. So, we need to really focus on our research over cancer. We have long recognised that cancer occurs mostly in people who have less immunity. That is why geriatric population and people who had transplants and are under immuno suppressants get cancer. However, in the last five years, there has been an increase in the research on the drugs of T cell as they directly go and kill the cancer cells. Currently, with a team of clinical oncologist and basic researchers, I’m working on a research to find, which all are immunogenic tumours in the body. Besides, we are also planning on a project with the Indian Council of Medical Research (ICMR) as well as private bodies where we would be doing research on Chimeric Antigen Receptor (CAR) T cells.
Tell us about the role of immunotherapy in cancer and the cost involved?
I have access to newer immunotherapy drugs. So, my patients get the advantage out of it but the cost of drugs is a huge obstacle. A month’s therapy could cost around Rs 3 to 4 lakhs. If we see the global scenario of immunotherapy, five years down the line, we will have better drugs and lesser use of chemotherapy to control and cure cancer. For those immuno drugs to be affordable in India, it will require atleast another decade. If the government is able to understand and try to put a research impetus by giving grants for immunotherapy research in cancer then it might be availed in our country much earlier.
Apart from immuno therapy, there is targeted therapy which has been there for eight years. In 2000, the first targetted oral drug called imatinib was launched for chronic myelogenous leukemia. Since then, we have 60 to 70 oral targeted drugs across various malignancies. So, we are not only moving ahead in the immunotherapy, but we are making our chemotherapies more safer and tolerable, also moving towards getting oral drugs, which can treat cancers like chronic myelogenous leukemia, acute lymphocytic leukemia, multiple myeloma. Our medical management of cancer is becoming more precise and target oriented with more use for immunotherapies and lesser use of chemotherapies.
How can insurance as a sector play a role in making the patient care more affordable and accessible?
Unfortunately, many of the insurance players are excluding the cancer treatments’ basic health packages or they cover them inadequately. Many of them refuse to pay up for cancer treatments of people who have smoking habits, or tobacco use. There needs to be a government insurance with a corpus of Rs 5 to 10 lakh for a standard cancer treatment. Government panels like Central Government Health Scheme (CGHS,) Employees State Insurance Corporation (ESIC) are tremendously helping people on cancer treatment, but only 10 per cent of them are covered by it. We need a universal health insurance against NCDs.
Of late, the government’s move on the regulation of drugs is benefiting lot of people, but the government should ensure that the generic drug supplies are of quality and must not be affected due to price control. The government and private sector should work in tandem. While government helps the public with the insurance, private sector should have packages, by which they can accommodate people for cancer treatments immediately. The model of the US and the UK can be referred, where all the cost is borne by the respective state governments.
How RGCIRC is different from other cancer institutes?
Rajiv Gandhi Cancer Institute & Research Center (RGCIRC) is one of the largest pioneer private cancer institute in India, which has treated almost two lakh cancer patients for the past two decades. There is an element of empathy towards the patients and the family. The cost here is affordable. Moreover, all advanced treatments which are available globally are rapidly adopted by the centre.
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