Monday, August 19, 2013

Cancer Care in India: Patented Cancer Drugs or Basic Radiation Therapy Units?

Rising cost of cancer treatment in India due to lack of generics for third generation wonder drugs  to treat cancer has recently initiated an interesting debate. See this:

To me, this debate does not make any sense. Advocating for cheaper Trastuzumab for these unfortunate cancer patients from India sounds like crusading for a delicacy such as 'foie gras' for those who do not even have access to a piece of bread to get rid of hunger. Most of Indian cancer patients die of cancer even without being officially diagnosed with this disease. However, majority of the cancer patients are not dying because they can not afford to buy fancier third generation drugs such as lapatinib or trastuzumab, rather it is lack of basic infrastructure for cancer treatment such as availability of team of specialists including surgical oncologists, medical oncologists, experienced histopathologists (to make diagnoses on tumor biopsies), radiation oncology units with state-of-art equipments in every district level cities/towns in India. Most of the cancer patients in India are being diagnosed with it by general surgeons on the operation table while being operated for some other or associated benign conditions. 

Real journey of turmoil starts now for the families of these cancer patients when (with immense fear of losing their relative, compounded by their inability to arrange finances to be able to travel to one of those few metropolitan cities which is where cancer hospitals/centers are) they start searching for a good cancer center where they could manage to travel to and live within their meager resources for their patient's treatment. Getting their patient admitted in those cancer hospitals itself is a herculean task for these families. It is hard to believe that Uttar Pradesh, most populous state of India, does not have a single medical oncologist in the entire state. Cancer care in the state of Uttar Pradesh is totally in the hands of a few radiation therapists (~20 radiation therapists for a population of 20 million people) residing in < 4-5 functional radiation therapy units, who are over burdened with cancer patients. Most of these patients do have to wait for 2-3 months for their turn when their first radiation therapy session starts. On top of this, most of these sessions are often not complete either due to interruption in power supply in the middle of a session or radiation equipment being broken, making their cycle of therapy sessions incomplete or ineffective. 

Radiotherapy (RT) is one of the major modalities of cancer treatment and about 60% of these patients, no matter which type or stage of cancer they have, will require RT as curative or palliative (reducing symptoms of the disease) intent. International guidelines recommend one megavoltage therapy equipment for every 1,20,000 population, for every 250 new patients providing about 6,250 treatments per year. These calculations are based on the assumption that 50% of the patients could be treated for cure (30 to 40 increments) and 50% of the remaining, for palliation (10 to 20 increments). Therefore, 125 patients × 35 treatments (4375) and 125 patients × 15 treatments (1875), respectively, totaling to 6250 treatments. Taking all types of patients treated and various type of treatments, the above number appears legitimate for planning treatment facilities in an RT center (Ravichandran et al., 2009).

Many cancer centers in India still lack capabilities of simple techniques for tumor localization such as iso-centric simulator x-ray machines, treatment planning systems, 3D imaging capabilities, and mould room facilities. In India, for a population of about 1.1 billion, at the cancer incidence rate of 70 per 100,000 population, 60% of them requiring radiation therapy, they would need about 1155 machines assuming a load of 400 per treatment machine annually. Presently, there are only 400 Cobalt-60 teletherapy
machines (very basic first generation radiation therapy machine which is no more used in any developed country), about 25% of them served more than 10 years (which is way beyond their normal age; 5-7 years) needing urgent replacements, thus making majority of them non-functional, or even non-effective. Availability of only 1/3 rd number (half of that 1/3rd number of available units are non-reliable too boot) of machines compromises with the quality of patient care which may have implications in the optimal outcome. This grim scenario definitely needs improvement.  

As mentioned earlier, Cobalt 60 unit which is what is most commonly used radiotherapy equipment available in India, has become obsolete and has been long replaced by Linear Accelerator (Linac) machines in developed world. Cobalt 60 units provide relatively high energy gamma rays for radiotherapy which are ideally suited for treatment of head and neck cancers and other superficially located tumors such as breast cancers. They are not adequate for treatment of deep seated tumors and have the added disadvantage of decreasing output with decay of source and the need for source replacement within 5-7 years. Disposal of decayed source is another major concern. The edges of the radiation beams coming out of a Linac machine are much more sharply defined than those of a cobalt machine, allowing additional precision in dose delivery. The dose rate per minute is variable and can be turned up very high allowing the patient to be located at substantial distance from the machine in order to create large fields necessary for total skin or total body irradiation while still maintaining adequate dose rate. With cobalt, the rate is determined by the amount of cobalt source in the machine and cannot be regulated. This is why Linac machines are safer and cause lesser side-effects which is a very important considerations for Indian patients most of whom especially women patients are malnourished and can not survive the side-effects of radiotherapy given by Cobals 60 machines. 

Building basic infrastructure for effective and functional radiotherapy units for the whole country will have long term economical impact as well for the general health of a country like India where more and more people are going to live longer, owing to the recent advances in bio-medical sciences such as better immunization programs, availability of life saving medicines and enough food to feed more people than ever in the past. Radiotherapy is not even expensive, especially considering the size of budget India allocates for buying new military gadgets, and their ambitious project to go to the moon in near future. Most of us will be surprised to note that the cost of ~1 military jet fighter is almost comparable to the entire cost for radiation therapy for most average sized countries. In fact, together with surgery, radiotherapy still remains the most cost-effective way of curing cancer. 

I am not against making third generation wonder drugs (which are still covered by foreign patent laws) cheaper for developing countries like India, but focusing solely on this aspect is going to serve only a minority of patients and distracts from the real issue of building basic infrastructure for cancer care. Also, these 3rd generation drugs are not the permanent cure, all they do is probably add few months to few years in the life of a cancer patient. Better attention to basic research to find out etiology of many unique cancer types prevalent in Indian patients, developing prevention strategies, new clinical trials, opening new and more cancer care centers in every district level towns, and most importantly training new generation of physicians in several sub-specialties of oncology is the key which could enable Indian health-care system to fight cancer. 

Bibliography: Ravichandran R. Has the time come for doing away with Cobalt-60 teletherapy for cancer treatments. J Med Phys. 2009 Apr;34(2):63-5.


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