Cardiovascular disease, manifesting principally as heart attacks and brain strokes, is the leading cause of death globally. In India too, it emerged in recent decades as the top cause of adult deaths. However, an international collaborative study of 2,00,000 people in 27 countries reported in 2019 that cancer recently overtook cardiovascular disease in high income countries. The study noted cardiovascular disease remained the leading cause of death in low and middle income countries (LMICs).
Cancer is growing as a major cause of disease, disability and death in LMICs too, though it trails cardiovascular disease in the list of killer diseases. The rise in cancer burden in these countries is both due to increasing incidence of new cancers and inability of health services to provide timely detection and treatment. Cancer cases are rising due to higher levels of population exposure to unhealthy diets, physical inactivity, air pollution, environmental toxins, tobacco products and alcoholic beverages. An Indian Council of Medical Research study projected a 12.8 percent increase in the incidence of cancer cases in India between 2020 and 2025. In 2022, India had 14.1 lakh new cancer cases and 9.1 lakh deaths due to cancer. These estimates are likely to be short of the real cancer burden.
Decline in cardiovascular mortality rates in high income countries over the past four decades happened not only due to better diets, less smoking and more exercise but also due to many life-saving treatments. Effective therapies emerged from basic and clinical research. They were widely applied, resulting in many deaths being averted. While many behavioural risk factors are common to cancer and cardiovascular disease, highly effective treatments were less visible and impactful in the cancer arena—till recently.
However, the last decade has seen many advances in the diagnosis and treatment of cancer. Organ imaging as well as laboratory techniques in tissue histology and pathology have advanced greatly. Integration of clinical data with new molecular data (germ line genomics, tumour genomics, epigenomics, pharmacogenomics and circulating tumour DNA) greatly increased diagnostic precision and personalised approaches to treatment. Artificial intelligence is providing great support for enhancing these diagnostic capabilities.
Novel treatments have emerged, through development of targeted therapies and monoclonal antibodies. Some of these antibodies can destroy the outer wall of a cancer cell while others can block the connection between the cell and proteins that promote cell growth. CAR-T cell therapies are providing a pathway for customising cancer therapy by collecting T-lymphocytes from the patient’s own immune system and training them to attack cancer cells. Surgery, radiation therapy, chemotherapy, targeted drug therapies and immunotherapy have now become the five pillars of cancer treatment.
Despite these remarkable advances, access to cancer diagnostics and treatments is still limited for patients in low and middle income countries and for poor people in high-income countries. While treatments for childhood cancers have been shown to be remarkably successful, they are not benefiting many children in low and middle income countries. The World Health Organization reports that while over 80 percent of children with cancer are cured in high-income countries, less than 30 percent in developing countries benefit.
Poor cancer care results from late detection, lack of capacity in primary health care facilities, delayed referrals to more advanced healthcare facilities, limited availability of well-trained personnel and well-equipped cancer care facilities, high cost of tests and treatments, and gaps in follow-up care for treated patients. Palliative care for terminally ill patients is not widely available. Amongst the general public, there is a considerable lack of awareness of the causes, clinical manifestations, facilities and options for care. This results in delayed self-referral for evaluation, inadequate investigations, ineffective treatments and poor health outcomes.
All of these deficiencies are related to the design, resourcing and performance of the country’s health system, which is a composite of public, private and voluntary healthcare providers. Central and state governments together provide the governance of this mixed health system. The central government shapes policy and states steer the services, with financial resources flowing from both.
From specialists in cancer diagnostics to frontline health workers and informal care providers, the range of people engaged in cancer care is large, while their numbers are short of need. Their geographic distribution is skewed across states and urban-rural divides. Inability to adopt a pluralistic approach to cancer care deprives the benefits that can accrue from some traditional systems of medicine.
While a national programme for cancer control exists, it has not kept pace with diagnostic and therapeutic advances, nor has it scaled up financial and human resources to needed levels. Primary care services must provide the platform for prevention, early diagnosis, timely referral and continuity of follow-up care. District and medical college hospitals must provide different levels of advanced diagnostic and therapeutic facilities. Private sector’s capacity and skills may be engaged as needed, to supplement the public sector’s capabilities.
As India shapes and strengthens its Ayushman Bharat programme, cancer care has to be firmly positioned amidst its range of publicly financed healthcare services. Cancer-related diagnostics and treatments often become prohibitively expensive for patients and impoverishing for families. Much of the high cost is due to import of equipment, diagnostic reagents and drugs.
Domestic capacity for their production has to be scaled up, including production of biosimilars of highly effective drugs. Pooled procurement of drugs can effectively reduce medicine costs. The National Cancer Grid, a network of over 250 cancer centres in India, piloted pooled procurement of 40 cancer drugs. Median savings of 82 percent were achieved (range: 23 to 99 percent), with an estimated cost saving of `13.2 billion. Such practices, if widely adopted, can greatly reduce the financial burden on governments, patients and families.
(Views are personal)
(ksrinath.reddy@phfi.org)
K Srinath Reddy | Distinguished Professor of Public Health, PHFI, and author of Pulse to Planet
