Cancer care in India – a wake up call!

India is witnessing over 14, 00, 000 new cancers and over 8, 50, 000 deaths every year with the figures expected to double by 2040, writes Dr. P. Raghu Ram, Founding Director KIMS-USHALAKSHMI Centre for Breast Diseases, Hyderabad.

Hyderabad: National Cancer Awareness Day is celebrated on 7th November to mark the anniversary of the renowned Nobel Prize laureate, Madame Curie. She is recognised for her ground-breaking discoveries, which have contributed immensely to the ongoing battle against cancer. The Day is dedicated to understanding the significance of the disease burden and its impact, and equally, underscoring the importance of early detection, which is essential to save lives.

Facts & Realities

With over 14, 00, 000 new cancers being diagnosed & over 8, 50, 000 deaths every year, the Cancer ‘tsunami’ in India has rapidly emerged to become a major public health concern. The real incidence of cancer is 1.5 to 3 times higher than the reported incidence, which is mainly due low population coverage of cancer registries (10%) and significant under diagnosis.

The Global Cancer Observatory (GLOBOCAN) projects that these figures are expected to double by 2040. According to the 2020 WHO ranking on cancer burden, India ranks at the third position after China and USA, respectively, in terms of new yearly cancer incidence being reported. The grim statistics from WHO reveal that 1 in 9 Indians will develop cancer in their lifetime and one in 15 will die of it.

What is even more alarming is that the incidence of cancer is increasing at a significantly faster rate when compared with other developing countries. India’s cancer incidence is estimated to be growing at a CAGR (Compound Annual Growth Rate) of 6.8% (2015 to 2020) which is significantly higher than other developing countries such as China (1.3%) (which has a comparable population size), Brazil (4.5%) and Indonesia (4.8%) as well as developed countries such as UK (4.4%).

Top three organs contributing to 50% of reported incidence in India are head & neck, breast and gastrointestinal cancers. Lung cancer is the most common cancer in men and Breast cancer is the most common cancer affecting women in India. Due to lack of awareness, absence of a robust nationwide screening programme, inadequate healthcare staffing/infrastructure, limited affordability, and most importantly, inequitable & poor access to care, over 70% of cancer patients in India present in advanced stages, with significantly higher mortality when compared with High-Income Countries. Many succumb to the illness within a year of being diagnosed.

Solutions

The diagnosis of cancer causes severe social, financial, physical, emotional, and psychological distress which impacts not just an individual but the entire family. It is therefore crucial to focus upon cancer prevention, ensure early detection & provide effective treatment. In fact, cancer prevention, screening and early diagnosis are the most cost-effective and efficacious measures to prevent and control the cancer burden in India.

Prevention

As per the most recent WHO report on cancer, approximately one-third to one-half of all cancers are preventable. Cancer prevention should be made an integral part of the cancer care, with active involvement of primary healthcare services and facilities. Primary Prevention must involve interventions that minimize exposure to carcinogens such as tobacco cessation, limiting alcohol consumption, maintaining a healthy diet, increased physical activity, reduced exposure to radiation and HPV vaccination.

The Ayushman Bharat Programme, which was launched by the Government of India in 2018 should be leveraged in this endeavour.

Awareness

Creating awareness and empowering people is fundamental to ensure early detection, which is the key to saving more lives. For example, The Pink Ribbon Campaign launched by Ushalakshmi Breast Cancer Foundation, a not for profit Breast Cancer Charity in 2007 created the much needed awareness about the importance of early detection in the Telugu States and has successfully addressed the taboo associated ‘breast cancer’ through a number of innovative initiatives over the past 16 years.

This has resulted in transformative change to the mindsets, with increasing number of women over 40 years of age in the region presenting themselves for annual screening Mammograms. Whilst the government has banned direct advertisements for cigarettes and tobacco based products, surrogate advertising is still widely prevalent with several celebrities endorsing mouth fresheners, ‘elaichi’ and paan masala brands. There is an urgent need to curb this surrogate advertising through a robust implementable legislation.

Early Detection

Certain cancers can be detected early by way of screening. Screening techniques can detect cancer very early before the appearance of symptoms, which has a potential to save scores of lives (For example: pap smear for cervical cancer, mammography for breast cancer, colonoscopy for colon cancer). The pan India screening programme that was launched by the Government of India under the auspices of National health Mission in 2016 aims to comprehensively screen for oral, cervical and breast cancers.

However, the latest figures released by National Family Health Survey (NHFH – 5) reveal that only 1.1% of the population have been screened for cervical cancer and less than 1% for breast and oral cancer. These dismally low figures must be addressed as a matter of urgency by the Government under the auspices of National Programme for Prevention and Control of Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS).

Robust Cancer Registries

Having robust Cancer registries is fundamental to improving cancer outcomes. Comparing the socio-demographic data of the patients, geographic trends in cancer incidence and cancer types helps to assess the risk factors, identify high-risk groups, and plan interventions for cancer prevention and screening. There are currently only 38 Population Based Cancer Registries (PBCRs) that cover only 10% of the Indian population.

The irony is that most of them are located in urban areas with only 2 PBCRs solely dedicated to rural areas, where 70% of India’s population reside. Furthermore, funding constraints of the registries often limit their ability to ensure the quality of the data collected. Big states such as Andhra Pradesh, Haryana, Chhattisgarh, Himachal Pradesh, Jharkhand, Odisha, and Rajasthan still do not have a single registry.

Much as there are 268 Hospital Based Cancer Registries that only record cancer patients in the hospital, there is a pressing need for more PBCRs to be made available & functional, particularly in rural areas.

Cancer must be classified as “Notifiable disease”

The Parliamentary Standing Committee for Health & Family Welfare recommended that cancer should be classified as a “notifiable disease” in September 2022. However, this has not translated to reality. Making cancer a “notifiable disease” will not only ensure a robust database of cancer deaths, but will also help in accurately determining the incidence and prevalence of the disease in the country.

Comprehensive Cancer Centres

The best possible treatment that tailors to individual needs of patients can only be provided by a dedicated Multidisciplinary teams within the confines of “Comprehensive Cancer Centres”, which provide treatment modalities under one roof and are often supported by robust diagnostic services including radiology services, advanced lab services, such as immunohistochemistry, molecular diagnostics and nuclear medicine facilities.

There are currently around 500 Comprehensive Cancer Centres (CCCs) in the Country, out of which 25 to 30% are government-owned while the rest are either private or trust-based facilities. Most CCCs are located in metros and state capitals. As a consequence, most patients living in rural areas have to travel long distances for getting comprehensive cancer treatment, thus causing tremendous inconvenience, hardships and agony to them and their caregivers.

And therefore, rapidly increasing cancer care infrastructure on a war footing in towns and rural areas, is absolutely essential.

Conclusion

Managing cancers in India is a unique scenario with its own challenges. Although we are living in times of phenomenal scientific advancements, there are many barriers to accessing high quality cancer care in the Country. Much as some centres of excellence in India provide cutting edge cancer care comparable to the best in the world, there is a long way to go before we can ensure cancer patients from every socioeconomic background receive the best possible care.

In addition to treatment, we must also take into account leveraging technology to close the care gaps associated with accessibility and affordability. The Government must seriously consider making Cancer a “Notifiable Disease”. The National Cancer Day is a stark reminder that time bound concrete short and long term implementable steps be taken by the powers that be to strengthen actions which improve access to prevention, early detection & treatment, all of which are essential to transform the delivery of cancer care in Bharat.