Cancer is no longer a rare disease in India. With the probability of one in ten adults being affected by cancer and a large percentage of them not being able to access quality treatment, the theme of this year’s World Cancer Day -- ‘Close the Care Gap’ -- is very relevant to our country.
Due to its association with high morbidity and mortality, cancer evokes dread which is not justified by the success rate of currently available treatments, especially if detected early. Many cancers can be cured and even when it has metastasised and affected other parts of the body, the disease can be controlled and the patient provided a long, good quality life.
But this cannot be achieved through a few apex cancer treatment centres as is sought to be done today. Cancer has to become the concern of the entire health system. Only then will cancers be picked up at early stages, patients managed cost effectively closer to home and apex centres kept free to manage complex cases which only they are equipped to do.
Cancers manifest as symptoms which are presented to the general physician for treatment. If they are oriented to include cancer in their differential diagnosis of the symptoms, there is a greater chance of cancers being detected at early stages. This does not happen now as the general physician is not involved in cancer detection and management. If, instead, the health system prepares a pathway by which a clinician in primary or secondary care settings can present her diagnosis to a better equipped centre for validation and the results are intimated back to such doctors, they will have the motivation to detect cancers early.
India does not have enough treatment facilities to let specialised cancer centres take care of all detected cases. We have one qualified medical oncologist for 2,000 patients compared to 1:100 in the US. Of this, nearly 60% is concentrated in the top 10 metro/Tier 1 cities. To bring all patients to the apex centres will stretch their resources to unsustainable levels and increase the misery and expense of patients from distant locations.
But this is not necessary. Health system redesign integrated with technology can leverage the nature of cancer treatment to deliver patient-centred and cost-effective strategies for cancer management. Cancer care is delivered through multidisciplinary care based on planned protocols, which are amenable to decision making within narrow limits and can be digitally monitored. This supports the creation of a hub-and-spoke delivery system.
The specialised cancer centre at the apex of the pyramid could develop the treatment protocols, train the team, provide remote guidance to the teams attached to them and takes care of complicated cases referred to them.
At the next level are general hospitals, where specialists have been trained on cancer management and are linked to the apex centre through shared information and communication channels. A key requirement of quality cancer care is the multi-disciplinary tumour board. For general hospitals, this can be convened in a hybrid mode, with specialists in apex hospitals joining virtually when required.
Similar arrangements can also be made for case review and clinicians in the peripheral institutions provided access to teleconsultation should they need it. This system can be further linked to community and primary care centres where cases are detected and treated patients are referred back for post-treatment care, including rehabilitation and palliation.
This integrated cancer management system will benefit from the digital transformation proposed under the Ayushman Bharat Digital Mission. When individual electronic records are available, they will help provide preventive services to persons with risk factors and continually evaluate for onset of cancer. Their electronic medical records can be shared between participating institutions, with the consent of the patient, enabling seamless review and referral based on severity of the disease. The data will help in decision making for quality treatment, with developments in artificial intelligence adding to quality of care.
To effectively “close the care gap”, the cancer treatment system of the future cannot be conceived as a few standalone apex centres but as an integrated system involving specialised cancer centres, general hospitals and primary healthcare institutions linked through standardised treatment protocols and shared information and decision support systems.
Moni Abraham Kuriakose is former director of Cochin Cancer Research Centre and medical director of Karkinos Healthcare.
Rajeev Sadanandan is former additional chief secretary, department of health, Government of Kerala, and CEO, Health Systems Transformation Platform, New Delhi