Tackling the Growing Burden of Cancer in India
The burden of cancer is growing in India. According to the World Health Organization, cancer comprises almost 20 percent of the non-communicable disease burden, with over 1.1 million cases recorded in 2018. Breast cancer, which is one of the most common cancers in India, has an over 14 percent incidence rate (WHO), and one woman dies of cervical cancer every 8 minutes in India, according to a doctor’s body attached to the National Institute for Cancer Prevention and Research (NICPR).
Unfortunately, India’s cancer crisis is compounded by the fact that a majority of the patients with cancer are diagnosed at the locally advanced stage (head and neck 66%; breast 57.0%, cervix uteri 60.0%; and stomach 50.8%, among others), as shown in this paper published in Pubmed, assessing the status and trends of cancer in India. What these figures consistently point at is the urgent need for strengthening and augmenting the existing diagnostic and treatment facilities, which are inadequate, often inaccessible and concentrated in urban centres and may also be financially not viable, especially for long term treatment and management for the economically weaker section of society.
While government schemes such as the Pradhan Mantri Jan Arogya Yojana (PM-JAY) provide beneficiaries with free and cashless treatment for cancer, the lack of awareness and resulting delay in screening and testing contributes to poor prognosis. Travelling to hospitals, lack of day care and palliative care also add to the disease burden. This is also why the burden of care falls disproportionately on the tertiary care centres such as medical colleges and superspecialty hospitals.
What then is the solution to this growing threat of cancer?
Doctors, policy makers, and patients unanimously agree that bringing care closer to home will improve the indicators for cancer in India. “If preliminary cancer detection and care can be done at a primary or Community Health Centre or district hospital, with basic blood tests, an ultrasound or X rays, under the supervision of a medical oncologist, and chemotherapy drugs can be administered, a patient will receive care closer to home and is more likely to follow through the entire course of treatment,” says Bengaluru based oncologist Dr Rajeev AG. It will also decrease the burden on tertiary care centres whose doctors can then focus on the terminal patients who need specialized therapy with specialized equipment. “Providing care closer to home also makes periodic monitoring easier, and reduces mortality and morbidity. If a patient has to travel long distances for care, they are likely to self-diagnose and stop or delay care,” adds the oncologist.
Issues such as travel time and expenses, loss of wages, vastly impact health seeking behaviour among patients belonging to the economically weaker sections. It is also a challenge policy makers designing schemes like the National Health Authority’s PM-JAY have been trying to address when beneficiaries need to travel long distances for care. For now, the revised Health Benefit Packages 2022 include new procedures, high-end drugs & diagnostics and have introduced a differential pricing opportunity that acts as an incentive for specialized private and public providers. “Adherence to the Standard Treatment Guidelines set by the NHA is also expected to improve the quality of services,” shared Dr Shankar Prinja, Executive Director, National Health Authority (NHA), while apprising Principals, Chief Medical Superintendents, and PM-JAY nodal officers of Medical Colleges who were attending a workshop by State Agency for Comprehensive Health and Integrated Services (SACHIS) which implements PM-JAY in Uttar Pradesh. While the scheme has brought cancer care and oncology services under its purview to prevent out-of-pocket-expenses of beneficiaries, access and logistics such as travelling long distances for care continue to be challenges. Currently, the cancer care scenario in Uttar Pradesh, like in other parts of the country, is very centralized and depends heavily on the tertiary care centers and super specialty institutions.
Bringing cancer care closer to home
In Assam a Distributed Model of Cancer Care is being championed by the Assam Cancer Care Foundation, to deliver affordable and quality care close to home. Under this model, a network of hospitals and medical colleges are categorized as apex tertiary care institutions and level 2 and 3 hospitals that provide diagnostics, and cancer day care services and palliative care at district hospitals.Supported by awareness for early screening and detection, this model envisions developing patient-centric institutions that overcome the challenges of accessibility and affordability by providing standardized care close to home.
Dr NC Prajapati, Director General of the Directorate of Medical Education, government of Uttar Pradesh, agrees that linkages within hospitals—from primary health centres, district hospitals, referral centres and tertiary care hospitals—will strengthen the decentralized system of care and help patients receive the care they deserve without having to travel to apex hospitals. “If linkages are strong, and doctors at the referral centres can electronically consult specialists at tertiary care centres, and a patient’s medical history is made available to them online, the practitioner at referral centres can provide treatment and care,” he says. These services could include initial screening, collecting and sending samples to labs, and initiating early treatment. While this requires upskilling and strengthening primary and secondary care centres and empowering the personnel, the existing Hospital Information Management System (HIMS) links Providers across the public health spectrum, and can trace patients across the Primary Health Centres (PHCs), Community Health Centres (CHCs), District Hospitals and Medical colleges, he adds. “Empowering this system is both doable, makes optimum utilization of advanced facilities for cancer care delivery, helps the patient and reduces the load on tertiary care centres and medical colleges,” says the DME. One of the key mandates of DME is also to promote research and test interventions which improve quality of care for the patient, and identify global and national best practices.
Roche India Healthcare Institute (RIHI), which undertakes research on patient pathways and service interventions for oncology and other therapeutic areas, has been working on numerous pilot programmes on distributed cancer screening and referrals. At Roche Access— a collaboration with Punjab State Government, they work on the overall cancer screening programme and on use of technology for appropriate referral of screen positives in Karnataka. “I believe the critical factor in the success of any screening programme lies in guiding the screen-detected patient to appropriate diagnosis and standardized care,” Lakshman Sethuraman, Chief Country Access Officer, Roche.
Stressing on the need for distributed cancer and rare disease care delivery, he shares how at Tata Memorial Hospital, Mumbai, nearly 60 per cent of new patients arrive from outside the state of Maharashtra, and over 40% of patients drop out of treatment due to financial and logistical hardships. “A solution to this challenge could be the setting up of a distributed care model in the ecosystem, leveraging technology and task shifting of activities lower down the pyramid of healthcare infrastructure. Several states have taken steps towards decentralizing cancer care, with leading examples being Assam and Kerala. Many other states have also initiated chemotherapy across all medical colleges/district hospitals, reducing dependency on nodal centers. Madhya Pradesh is a prime example of the same, with the district chemo centers administering chemo to 4000 patients in the first year of operation,” says Lakshman Sethuraman.
The path ahead
Sethuraman believes that the ideal scenario would be to work on a full-fledged cancer diagnosis module for the primary and secondary layers of healthcare. While this may be too vast an exercise, disaggregating and customizing solutions are feasible interventions. Identifying PM-JAY tests and procedures that can be done at primary or secondary level, and tailor capacity building to address those specific gaps. “Rather than asking, can you provide oncology service at a district level, we aim to ask the question, can you perform a Fine Needle Aspiration Cytology (a critical test for cancer detection) at a lower level. If yes, what are the equipment, skills and resources needed?” says Sethuraman.
Dr Prajapati believes that strong message alignment with print, electronic and social media, on cancer awareness and when to seek treatment, along with strengthening primary and secondary healthcare providers is the need of the hour.