A cancer drug. Representative photo: calliope/Flickr, CC BY 2.0
- The progression-free survival of a certain type of lung cancer among participants of an Indian study was found to be 12.1 months shorter than that among those in a US study.
- The stark difference can be explained by the drugs: the US study used osimertinib (Rs 6,500/tablet) and the Indian study used gefitinib (Rs 250/tablet).
- This is one indication among many of the ways in which the survival rates of cancers in India are lower than in many other countries, and is lowest among the poorest.
The man’s face lit up as I explained the five-year survival rates with different treatment options for his mother’s breast cancer. “There is almost a 90% chance of cure if we give her trastuzumab” – targeted therapy for a type of breast cancer, I said. I was speaking to him in 2020 at the oncology department at the Christian Medical College (CMC), Vellore.
But his hope quickly turned to despair when he learned that injectable trastuzumab costs Rs 20,000 per dose and that his mother will require 13 doses. He is a smallholding farmer from a village in Karnataka. He was not poor enough to be eligible for state health insurance and not rich enough to afford the treatment.
Globally, the five-year prevalence of different types of cancer has been over 50 million cases, plus nearly 10 million cancer-related deaths. India reported a rise of nearly 324% in cancer cases from 2017 to 2018, according to the 2019 National Health Profile. Breast and lung cancers are associated with high remission rates if they are detected early, yet they continue to be the leading causes of cancer-related mortality.
The COVID-19 pandemic made things worse: cancer care was heavily affected in India with large disruptions in the registration of new patients, follow-ups of previously registered patients, outpatient chemotherapies, cancer surgeries and radiotherapy administration. Cancer screening at more than 70% of hospitals in India was also interrupted, according to a cohort study published in The Lancet Oncology a year ago.
With newer diagnostic techniques and treatment options, cancer prognosis has drastically improved – yet they remain inaccessible to a large section of the Indian population due principally to prohibitively high costs.
Newer therapies have transformed the outlook towards cancer from being considered a death sentence to a chronic disabling condition thanks to significantly improved survival rates. Patients now receive multiple lines of treatment that keep the cancer’s growth under check even if the first-line treatment fails.
The progression-free survival (PFS)[footnote]The time after treatment for which the patient still has the disease but it doesn’t get worse[/footnote] of a certain type of lung cancer has improved from a few months to 10 months in India. This, however, is still significantly shorter than the PFS of 22.1 months in similar patients in a US-based study. The stark difference can be explained by the use of different drugs. The US study used a drug called osimertinib (Rs 6,500 per tablet) which is significantly more than gefitinib (Rs 250 per tablet), the drug used in the Indian study. This links cancer survival at the level of cost of drugs to affordability among different patient populations.
Access to different cancer therapies is determined largely by financial contingencies. For example, chemotherapy for breast cancer – a well-established procedure – costs around Rs 1.7 lakh in India (assuming no complications occur during the treatment). The addition of newer forms of therapy could take the additional expense from Rs 20,000 to Rs 2,00,000 per cycle depending on the type of breast cancer.
Another new alternative, immunotherapy, which is now frequently used as first-line therapy for multiple cancers, is associated with lesser side-effects and better survival but imposes a large financial burden. The inability to access these better treatment options pushes the lesser privileged to opt for cheaper and more toxic chemotherapy regimens.
The intersection of financial and gender inequities can play a major role in exacerbating survival disparities in India. For example, males and patients who can afford private sector healthcare have better access to newer therapies that can increase their chance of survival. High out-of-pocket expenditure (OOPE) in seeking care pushes members of marginalised communities further into poverty.
Geographic inequity also plays a big part. Despite having the country’s highest cancer prevalence, India’s Northeast has the most underdeveloped health infrastructure in the country.
With basic cancer care being unaffordable for the majority, replicating success in cancer survival in India is a challenge. These inequities lead to delayed diagnoses or push patients to resort to cheaper and often less- or even non-scientific treatment options. This worsens the overall prognosis and increases the burden of terminally ill patients on the healthcare system.
Universal health coverage has been shown to improve cancer outcomes equitably along with promoting financial stability among survivors and their families. Countries do recognise this. For example, in the US, the Affordable Healthcare Act requires chemotherapy costs to be covered for all insured patients. In Mexico, access to care and survival for breast and childhood cancer patients improved after the creation of Seguro Popular, the public health insurance scheme covering a wide range of services.
In India, the Pradhan Mantri Jan Arogya Yojana currently covers 150 packages related to cancer. The multidisciplinary care offered under this scheme is an important step in establishing standardised cancer care across the country.
Several Indian states have also attempted to ease the financial burden of cancer patients. The Swasthya Sathi Scheme in West Bengal and the Chief Minister’s Comprehensive Health Insurance Scheme in Tamil Nadu offer free treatment to eligible patients in many tertiary care hospitals. These schemes, however, are able to cover only basic chemotherapy and surgical charges. Newer treatment options still remain inaccessible.
To supplement government programmes, non-governmental organisations such as the Indian Cancer Society serve as a beacon of hope for many underprivileged cancer patients. The society sanctions up to Rs 5 lakh to help the patients to get good-quality cancer care they seek.
Even before the pandemic, a study using National Sample Survey data found that nearly 55 million people fell below the poverty line in 2011-2012 due to OOPE on healthcare. The cost of medicines in particular is one of the most significant OOPE after non-medical costs. OOPE has continued to be high after the pandemic as well.
This fact may limit India from achieving universal health coverage. An insufficient health budget, struggling public healthcare services and the promotion of private healthcare will only render care more expensive and inaccessible.
Combining India’s potential to be the ‘pharmacy of the world’ and policies controlling the cost of these drugs can effectively solve this problem. Promoting the production of generic cancer drugs could significantly reduce the cost of care.
For example, innovator trastuzumab (brand name Herceptin), used to treat breast cancer, costs nearly Rs 60,000 per dose whereas its biosimilar molecule costs only Rs 20,000 per dose. A 2021 study conducted at CMC Vellore showed comparable outcomes between innovator trastuzumab and biosimilar trastuzumab. So it is possible that costs can be reduced without affecting the quality of care.
Equitable tertiary care nonetheless remains a far-fetched dream in India. A practical solution would be improving primary prevention through effective screening and early diagnosis. Screening has been shown to improve overall survival by detecting early-stage cancer combined with appropriate treatment.
The National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke offers free screening for oral, breast and cervical cancer. Strengthening this scheme by improving the workforce and infrastructure and by increasing awareness will help in diagnosing various cancers at an early curable stage. Improving the accuracy of data and coverage of population- and hospital-based cancer registries will help in producing good quality data-backed policies.
Since a majority of clinical trials take place in the US and other high-income countries, new treatments that are undergoing these trials but which might greatly benefit ailing patients are only accessible to residents of high-income countries and affluent medical tourists in these countries. This inequity in cancer research is also a major hurdle in cancer care. The lack of trials could be secondary to poor funding and infrastructure in various states.
Funding more clinical trials in India, monitored by appropriate local ethics committees, would open up treatment options for patients who have exhausted all available therapies. Improving the infrastructure of existing institutions and opening new healthcare centres in cancer-dense parts of the country can help in promoting research in India.
Finally, focusing on care and not cure for patients with terminal-stage cancer will help in the proper utilisation of resources. Improving palliative care services will provide affordable care close to home and decrease the burden of terminally ill patients on tertiary care centres. The large referral hospitals often deal with terminally ill patients. Equipping health workers with skills to provide palliative care at local primary and community healthcare centres will make basic care more accessible.
Solving the problem of inequity wouldn’t just include providing accessible healthcare but also good quality healthcare. Patient-centred models which focus on delivering healthcare to disadvantaged patients would help in bridging the gap between high-cost quality care and accessible care. Keeping in mind this unaddressed pandemic of cancer, the policymakers should strive to design a well-funded National Cancer Control Programme with universal reach and accessibility to have an impact on cancer control.
Parth Sharma is an intern and Siddhesh Zadey is the cofounding director – both at the Association for Socially Applicable Research (ASAR), Pune.