The pandemic brutally highlighted the limitations of our healthcare system. However, it is not just COVID-19 that revealed the capacity issues with our system, the burden of several chronic diseases like cancer, TB, HIV, and diabetes are some other instances of how our healthcare infrastructure is reeling under immense pressure.
A recent report by Ernst & Young and FICCI has stated that the cancer incidence in India for the year 2022 was estimated to be 19 to 20 lakhs, whereas real incidence is estimated to be 1.5 to 3 times higher than the reported cases.
Now an essential question that arises here is: Does our health system has the capacity to address such a large number of cancer cases?
Cancer does not only affect families or an individual but also has a high economic and social cost as it results in severe productivity losses and premature deaths. Based on reported cancer incidence and mortality across age groups and years of potential productive life lost (YPPLL), estimates indicate that the economic burden in terms of GDP losses is approximately INR 899434 crore which is 0.4% of the national GDP in 2020. The same is projected to increase to approximately INR 3269984 crore by 2030.
The number of estimated cancer cases in India is roughly equal to the current population of countries like Latvia (18,36,934) or Slovenia (20,79, 632). If these cases are two times higher than the reported ones, then they are more than the population of a country like Georgia (39,70, 666). If cases are three times higher, then they are more than the total population of a country like Singapore (59,64,248).
The 2020 WHO rankings on cancer burden, in terms of new yearly reported cases, ranks India at the third position after China and US, respectively. But in organ-specific cancers like head & neck, cervix, breast and ovary, India reports more patients than China, US and UK.
The report says high tobacco prevalence is the cause of approximately 30% of cancer cases in the country. Six states-Kerala, Mizoram, Tamil Nadu, Karnataka, Punjab, and Assam report the highest overall crude incidence rates of cancers which is greater than 130 cases per lakh population.
The report further states that this burden continues to grow exponentially.
According to Dr. Navneet Singh, Professor of Pulmonary Medicine & Faculty-in-charge, Lung Cancer Clinic at Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, air pollution and climate change, contamination of the food chain (by uncontrolled use of pesticides for farming) and excess plastic and pollutants in soil and water are some of the key reasons behind the increase in the cases of cancer (especially amongst non-smokers).
Capacity of India’s health infrastructure to treat such a large chunk of cancer cases
It is often seen that whenever we come across a case of cancer involving a celebrity or a high-profile person, they often travel overseas for their treatment. Traveling thousands of kilometers via flight, these celebrities get the best and the most technologically advanced treatment in some of the world’s finest medical institutions. This tells a lot about the quality of cancer care and the health infrastructure in the country.
“Concerns about privacy and competence of treating doctors (oncologists) are major reasons here,” says Dr. Navneet Singh on the trend of celebrities flying out for cancer treatment. “Sometimes, certain drugs are only available in North America or Europe. In some cases, access to some kind of treatment is also not available locally,” he adds.
As per the report only approximately 175 districts in the country, covering 40-45% of the population, have comprehensive cancer centers (CCCs). Of the 470 to 480 CCCs available in the country, around 40% are concentrated in metros and state capitals alone.
A severe gap continues in access to radiotherapy (RT) treatment in the country with an RT per million population of 0.4 – vis-à-vis WHO recommendation of 1 RT per million population.
Penetration of RT equipment is also low with close to 640 installations against the requirement of approximately 1400 to 1500 in the country.
Also, there are around 5 CT scanning machines per million population in India, compared to 40 in high-income countries and 13 in upper-middle-income countries.
India requires 2500 to 3000 additional medical oncologists and 700 to 800 surgical oncologists to cater to current incidence, highlights the report.
The report states that more than 50% of patients took more than 1 week to conclude the diagnosis. 46% of patients who undertook a second opinion cited a lack of confidence in the initial diagnosis and suggested treatment. 49% of patients traveled more than 50 km for their treatment. These findings of the report are also aligning with what oncologists are observing on a day-to-day basis.
When asked about the main barriers to cancer treatment access in the country, Dr. Singh says, “In many cases, it includes a combination of one or more of the following like delay in diagnosis, delayed referrals by initial evaluating physicians, traveling times and distances to cancer centers, affordability of cancer treatment and non-availability of specific treatments or interventions.”
Oncologists believe some of the most cutting-edge cancer treatment methods and technology are available in our country, but we still have a long way to go before these can be made accessible for patients from all kinds of socioeconomic backgrounds.
“Challenges faced by treating oncologists include – inability to offer curative intent treatment if the patient is at the advanced stage or presents a metastatic disease; inability of patient or caregivers to afford cancer care; lack of access to novel biological drugs, and limited centers offering cancer treatment in the vicinity of patients geographical area of residence which they can easily visit”, explains Dr. Navneet.
Today, the treatment cost for cancer care is almost 3 times that of other non-communicable diseases (NCD), says the report. Additionally, treatment cost has been increasing with the cost of a single cancer hospitalization (in a public or private facility), exceeding the average annual expenditure of 80% population in 2017 vis-à-vis 60% population in 2014. The report highlights that 64% of patients did not have any form of insurance or scheme coverage and more than 50% of patients spent Rs. 5 lakhs on their treatment.
The situation demands strategic efforts from all the relevant stakeholders – government, private players, NGOs, research institutes, vaccine companies, health care workers and community support groups.
For instance, high tobacco prevalence is the cause of 30% of cancers in the country. It is a major reason for the government to ensure strict implementation of laws like COTPA (Cigarettes and other Tobacco Products-Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. The new amendment bill which proposes stricter measures like implementing a complete ban on public smoking, printing warning labels on all forms of packaging and prohibition on all forms of direct and indirect advertising of smoking and smokeless tobacco can also play a vital role in curbing the rising incidence of cancer in our country. It is also a good time to consider a graded ban on smoking and smokeless tobacco.
The agencies should also try and implement WHO’s recommendation of 75% taxation on tobacco as compared to the current 50-60%. Private players and civil society should come together to roll out behavior change campaigns, educating the masses about tobacco risks. The use of modern-day tools like social media can be instrumental in making the messaging more impactful.
There is also an immense need to focus on environmental risks which are emerging as new causes of cancer like rising plastic pollution or air quality issues in our cities and more. Strengthening the capacity of the system and encouraging more R&D activities to study the linkage between environmental degradation and cancer is the key to tackle this new form of risk to human health.
Early detection and accurate staging of the disease are key measures in the management of cancer cases. There is a need for private as well as state authorities to partner and explore various options to improve screening coverage. Conducting focused cancer screening will help to detect the disease at an early stage as well as build more awareness around the disease. Organizing screening camps at the offices of big multinational companies or at places of religious importance can prove to be a game changer in the way we tackle this rising disease.
To improve access to cancer treatment, stakeholders should plan and adopt a distributed hub and spoke cancer care model which will help them provide varying levels of care and reach the last mile. This model will also be helpful in ensuring the optimum utilization of medical resources and reducing the burden of care on the existing health infrastructure.
Government, private research, and health tech players must encourage studies and research on low-cost early detection methods for cancers.
Finally, policy-level efforts such as providing adequate budget allocation for the cancer programme and upgradation of treatment facilities are some of the most direct ways to make cancer treatment in the country more robust. It is also extremely important that all the planning and implementation for this disease is dealt with separately and not merged with other lifestyle diseases such as diabetes or other cardiovascular diseases.
Dr. Jaimini Sarkar is PhD in Science from the University of Mumbai. For a decade she worked as a Faculty for M.Sc.-Biotechnology at the University of Mumbai. She is recipient of S. Ramaseshan Science Writing Fellowship at Current Science Association, Indian Academy of Sciences at Bengaluru. She writes for The Wire, Current Science, Science reporter, BMJ, Down-To-Earth, Srote etc.
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