Can Strand-HCG alliance change the economics of cancer care in India?
What does this say about cancer care when one of the foremost cancer specialists and promoter of the largest cancer hospital in the country says there’s much “wastage” in cancer treatment in the country?
To put it crudely, according BS AjaiKumar, “Of all the cancer cases we see, 33 percent are under treated, 33 percent are over treated and 33 percent are rightly treated.” For perspective, his hospital chain, Health Care Global (HCG), sees about 50,000 new patients every year. He was speaking at the launch of the new Strand-Triesta Centre for Cancer Genomics in Bangalore last Friday. A joint initiative of Strand Life Sciences and HCG, the new Centre is meant to be a one-stop window for genomic diagnostics of cancer.
It’s fair to call it the first systematic effort in the country to bring about a new standard of care in cancer treatment. Why this is needed is because each cancer is unique and tumour profiling that genomics diagnostics provide, allows a clinician to home in on the uniqueness early on. For instance, if the tumour is diagnosed to be the recurring-type, then the doctor need not wait for it to metastasise and recur, she can look for early detection and start the treatment. Tumour profiling also paves the way for some US FDA-approved targeted therapy drugs for certain tumour types. For instance, in breast cancer, hospitals routinely do a genetic test to check if the tumour is Her-2 positive which makes its suited for the highly effective drug Herceptin. But a comprehensive tumour profiling can provide new insights, like, say, P53 or PIK3Ca mutations which warrant a combination therapy and result in much better outcomes.
In their routine course as well as in the initial study with 100-odd patients that Triesta researchers have conducted, they’ve found using genomics diagnostics not only saves time but reduces the cost of treatment by 40 percent and the side-effects by 60 percent. That’s a humongous saving, both at the individual and the collective level. After all, cancer is already the biggest killer: At 7.1 million deaths globally and 700,000 deaths in India in 2012, cancer deaths exceed those caused by TB, HIV/AIDS and malaria combined.
Apart from the opportunity to reduce cost and improve clinical outcomes, this collaboration also provides a rare chance to raise awareness among the physicians to lead smaller studies and use evidence to dent the skyrocketing costs of cancer care. Unlike the US where if a doctor considers cost in the treatment regimen she runs the risk of being accused of “rationing” health care, in India such doctors will win accolades and goodwill from patients. Though it’s also true that the way many corporate or private hospitals are structured — giving a cut to the doctors for the total cost of drugs/diagnostics prescribed such doctor-led evangelism will not come about easily.
Kiran Mazumdar-Shaw, Biocon chairman who is facilitating some experimentation at Mazumdar Shaw Medical Foundation, thinks investigator-initiated studies are needed today more than ever because for far too long Indian doctors have relied on Western data. She was perhaps speaking from her own experience at Biocon when she said, “Doctors don’t listen to us [and ask for clinical trial data].” About time Indian doctors generated data for Indian patients from India!
Even in the US, some doctors are waking up to the challenge and for the first time are revolting against the system. This example from Sloan-Kettering is encouraging.
A big challenge, not to forget a path-breaking opportunity, that lies ahead is creating a national standard of care. It is presumptuous to say so when Strand is handling just about 500 cases a month, though scaling up fast, and HCG caters to about 5 percent of the 1 million new cases in India every year. Still, there’s hope in one of the most unregulated health care markets in the world. Most medical associations follow the US guidelines. In diabetes, after much effort, a protocol was established which was approved by the Indian Council of Medical Research in 2006 but as Dr Anoop Misra, director of the Centre of Internal Medicine at Fortis Hospital in New Delhi who spearheaded that initiative, says, “Violations are rampant with no regulations.” The last diabetes care guidelines from ICMR came in 2006, with no further updates.
Being the enigma that cancer is, the more technology-led initiatives gather evidence, the easier it will be to develop local cancer care models. While the cancer burden is high in India, 1 million new cases every year, the available resources are puny. The money spent on cancer care in India is equivalent to 0.05 percent of the Gross National Income, as against 0.11 percent in China and 1.02 percent in the US, according to a 2013 Nature Reviews Clinical Oncology paper.
As India builds a cancer institute in the National Capital Region, on the lines of the US National Cancer Institute, the private sector must prevail upon it to set up an accompanying centre like the National Institute for Health and Care Excellence (NICE) of UK, and organize its own resources to set up something like Cancer Research UK (a charity that works with all stakeholders and funds research). As more and more state governments opt for insurance schemes which are not tied to outcomes, cancer care will spiral out of control. As Dr AjaiKumar admitted, hospitals will be forced to give inadequate cancer care to the ever-growing pool of Below Poverty Line card holders and create more side effects.
It’s neither bad medicine nor poor ethics to consider cost in cancer care. For many of us today who live long and survive cardiac diseases, we might eventually die of cancer.
PS: Recommended reading, a re-plug: Living with Cancer