The Telegraph
Saturday , April 12 , 2014
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Region bias deepens cancer burden

New Delhi, April 11: Nivedita Sinha watched helplessly as the 52-year-old breast cancer patient from Bihar decided to accept radical mastectomy instead of breast conservation treatment only to avoid an extra six weeks’ stay away from home.

Doctors at the Tata Memorial Centre, Mumbai, had given the patient two options — radical mastectomy with chemotherapy, or breast conservation treatment that would preserve her breast but mean a longer stay in Mumbai.

“Her breast could have been saved but she gave it up just to avoid the problems she and her family would face trying to stay in Mumbai,” said Sinha, a volunteer who works with patients at the Tata Memorial Centre.

“Many patients don’t exercise the best possible option because they can’t get them close enough to home,” Sinha, a former bank official who has survived breast cancer that struck her 14 years ago, added.

A new research report released today has, in the most comprehensive manner yet, described India’s growing cancer burden and the regional imbalances in treatment facilities that force patients like the woman from Bihar into taking hard decisions.

It has cautioned that 360 of India’s 381 medical colleges lack the full range of cancer treatment facilities — surgical, medical and radiation oncology departments on the same campus. (See chart)

A team of oncologists from the Tata Medical Centre, Calcutta, and other academic institutions across India and Britain did the research. The oncologists have used the report, published today in the journal Lancet Oncology, to urge India’s political leaders to increase funding for both cancer care and cancer research.

“The solution to India’s growing cancer burden lies in political commitment,” Mohandas Mallath, a senior consultant at the Tata Medical Centre, Calcutta, and lead author of the report, said in a written media statement.

He added: “The extent to which illness and death from cancer will increase in the next 20 years will depend on investments made in health care delivery, tobacco control, and cancer research.”

The report estimates that 10 lakh new cancer cases are diagnosed each year in India, a number predicted to rise to 17 lakh by 2035. Only three in 10 cancer patients in India survive more than five years after diagnosis.

India’s incidence of cancer is about 94 per 100,000 people, about half the global average of 182, or just over a third of the developed countries’ figure of 268.

“But in absolute numbers, the burden of cancer in India is enormous,” said Richard Sullivan, a professor and the director of the Institute of Cancer Policy at King’s College, London, and a co-author of the report.

The doctors believe that the mismatch between India’s growing burden of cancer and access to affordable cancer care — because of uneven distribution of human resources and treatment facilities — is among the biggest challenges to effective cancer management in the country.

About 26 per cent of India’s population lives in eastern India, which accounts for only 11 per cent of the country’s facilities with cancer radiotherapy.

“The uneven distribution of cancer facilities at times makes patients take tough decisions,” Sullivan told The Telegraph. The choice of radical mastectomy exercised by the breast cancer patient from Bihar whom Sinha met at the Tata Memorial Centre illustrates this.

Cancer surgery and radiotherapy services are available on a “highly inequitable geographic basis”, and radiotherapy remains under-resourced. The last systematic analysis in 2007 had revealed that India had only 347 radiotherapy units against a requirement of 1,059 units.

The concentration of oncology services in western and southern India forces many patients from the northern, central and eastern regions to travel for therapy. Despite recent investments to establish facilities in eastern India, doctors say, this movement of patients continues.

“A long stay in Mumbai, or any distant city, is difficult for many families from eastern or northern India — it just adds to the treatment costs,” said Sinha, who declined to provide details of the woman from Bihar, citing patient confidentiality.

The report has warned that patients like her, forced to travel to distant cities for cancer treatment, typically have to stay in overcrowded and unhygienic dharamsalas or lodges.

That increases the risk of infections, which means many patients might be unable to complete treatment in time, the doctors said.

This, along with late diagnosis, they said, could be among the factors contributing to India’s high cancer mortality ratio.

Cancer treatment is likely to mean catastrophic expenditures from the patients’ own pockets because of extremely low levels of government funding for health care in India, said C.S. Pramesh, a senior oncologist at the Tata Memorial Centre, Mumbai.

The gaps in oncology services can at times hurl a patient into a dilemma over where to seek treatment. When Rama Devi, a former agricultural scientist in Hyderabad, was diagnosed with cartilage cancer — pelvic sarcoma — her treatment required the services of a surgical oncologist, an orthopaedic surgeon, and a plastic surgeon.

The oncology clinic she approached did not have the other consultants. “We had to convince the three doctors to work as a team in a single institution — not easy to do — and perform the surgery,” Rama Devi told this newspaper.

The report estimates that more than 75 per cent of cancer expenditure in India comes directly from patients’ personal expenses. India needs to take steps to expand the financial protection for patients with cancer, Sullivan said.

While several state governments have introduced public-funded medical insurance plans, the oncologists said, these schemes are not designed to address the cost and complexity of treating cancer. They may need to be redesigned to fully cover the financial burden of cancer.

The report has also called for better regulation of the quality of cancer care that patients receive in both government and private-sector medical institutions.