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SPECIAL SURVEY TREATING CANCER The Hope and The Hype Your chance of getting cancer in the prime of life is one in 10. Yet, few Indians undergo cancer screenings. If they did, mortality rates could decline by up to 70 per cent with new diagnostic and treatment regimes. In this exclusive survey India Today Plus evaluates the country's best cancer hospitals in terms of hi-tech facilities, equipment and expertise, with an update from leading oncologists on the mortal combat against malignant disease. By Prabha Chandran For a few days this may it gripped the imagination of the world. Newspapers frontpaged the story, websites were jammed with callers as were doctors' phones and fax lines. But when the hype and the hoopla settled, the latest "cancer cure'' remained nothing more than a promise--which worked brilliantly in mice. Such is the desperation, the pain, and the hope of cancer victims that every promise is hailed as a magic cure before reality kicks in. Yet, behind the hype, real progress is happening. Records at Chennai's Cancer Institute (WIA) for the last two decades show typical results: survival rates for head and neck cancers have doubled to 60 per cent, paediatric leukemias are up from 20 to 50 per cent, Hodgkin's disease from 40 to 70 per cent, locally advanced breast cancer from 20 to 60 per cent and similar figures for cervical and testicular cancer. Much of it is due to a silent revolution which has brought major advances from the field of nuclear physics, fibre optics, genetic engineering and infomatics into the oncologists' domain. "In the last 25 years there has been a paradigm shift,'' says Dr S.H. Advani, Mumbai's leading medical oncologist at Tata Memorial Hospital. "Malignancies which were 100 per cent incurable then are 80 per cent treatable today.''
Now the bad news: When did you last have a cancer check-up? Despite medical advances, mortality rates remain unacceptably high in India because the majority of cases are detected way too late. Cancer screenings rarely figure in annual health checks. If it did, oncologists say, as much as 70 per cent of the seven lakh new cases detected every year could be successfully treated since the commonest Indian cancers--oral and reproductive--are also the most easily controlled. However, that is changing fast as other cancers--breast, lung and bowel--associated with affluent lifestyles and carcinogenic urban environments are more complex. Meanwhile, we're still searching for 'The Cure'. Cancer is a cunning foe appearing in more than a hundred different forms and traceable to as many different genetic defects. "It grows like a symphony and you develop a lot of respect for it,'' says Dr Anandhi Johri a rising star in chemotherapy at Delhi's Sitaram Bharatiya Institute. "First, cancer has to overcome the body's natural defences. Then it must create a food source to grow. It must learn to move from its original site so it can spread throughout the body--there's a terrible beauty in this whole subversive chain of events,'' says this Fulbright scholar. Because there are so many cancers, there can be no one universal cure. So what we have instead is an armamentarium of weapons from the three forces--chemo, radiation, surgery--and each case is individually assessed for treatment because no two bodies behave alike.
Tumour Boards: As this leaves plenty of room for interpretation, opinions matter. Unlike, say heart surgery, there is no one superstar doctor whose magic scalpel will provide a cure. "If someone tells you he can cure you, it's either rubbish or bluff,'' says head surgical oncologist Dr L.J. D'Souza of Tata Memorial bluntly. "I've had patients return after 20 years with a new malignancy. In cancer, containment is the cure, it's a lifelong disease like diabetes.'' The best course of treatment should be debated by oncologists representing all three disciplines, each involving so vast a body of knowledge it's impossible for any one doctor to master. "There are no solo flights in oncology anymore, the accent is on teamwork,'' says Dr Sameer Kaul, surgical oncologist at Apollo Indraprastha hospital, New Delhi. "Some of the most famous cancer institutes in USA are headed by Indian doctors, some of whom even have equipment and processes named after them.'' Oncos is the Greek word for 'lump or mass' and logos means 'science'. It's a euphemism for cancer which has such powerful negative connotations that the Apollo Cancer Hospitals in Hyderabad and Chennai were obliged to change their names. While the dread of cancer is real, the weapons in the oncologists' armoury are sharper and smarter than ever before. This also makes the need for patient knowledge greater than in any other life-threatening disease. For ultimately, the sequencing of treatment depends on the individual. So, Dr D'Souza advises patients. "The first step is to become a VIP--Very Informed Person. Download everything you can on your particular type of cancer so you can ask intelligent questions and go for a second opinion,'' he says. "There are no emergencies in cancer as the disease has been there for a while.'' However, many patients waste precious time in medical shopping, end up confused and change treatments mid-stream. Should you use radiation to shrink a tumour before surgery or after to clean up the site? Is chemotherapy a better choice? In the best hospitals today, these decisions are guided by 'tumour boards' comprising experts in pathology, radiation, medical and surgical oncology. But the sad truth is the majority of patients are not treated by certified oncologists and the few specialists are simply overwhelmed with patient load. The dozen or so regional cancer centres in the country service barely 10 per cent of those stricken with this disease and most private and charitable hospitals don't have oncologists on their staff, this being a relatively new discipline. But if oncologists are in short supply, medical physicists who man the new generation of nuclear and laser machines are even thinner on the ground. Complicating cancer treatment further is the fact that there are no established guidelines. "Your protocols depend on lab analysis of previous cases,'' says Dr Vinod Kochupillai, director of the Rotary Cancer Hospital, All India Institute of Medical Sciences (AIIMS). "So cancer treatment remains a research-oriented speciality.'' While this may give government-supported institutes with a teaching facility an edge, Internet access and new telemedicine hook-ups in some private hospitals now offer consultations with top-notch doctors and scientists abroad. So success depends more than ever on an informed choice of hospital and the expertise of the members of its tumour boards--botch it up the first time and the rest of life could well be spent in painful, futile, damage control. Costs: In such a scenario, only the best centres offer the best odds, but how many can afford them? While most government centres do offer free or subsidised facilities, the cost of drugs, lab tests and radiation could still add up to Rs 50,000 for an average case. In private hospitals, a couple of lakh rupees would cover the costs of surgery, radiation and drugs depending on the type of cancer. Several hospitals like the Apollo group, the Rajiv Gandhi Cancer Institute, the RCC Trivandrum offer in-house medical insurance schemes where a one-time payment covers the family for treatment including the cost of drugs up to a certain amount. Only one medical insurance group offers coverage against cancer. An insurance cover will go some way towards offsetting medical costs given the fact that cancer is a lifelong disease; that one cycle of treatment is seldom enough and that chemotherapy costs for certain types of blood cancers are simply astronomical: one can spend as much as Rs 12 lakh over eight cycles of chemo treatment with no guarantee of a cure. This, of course, is relative. Blood cancer treatment in the West costs around Rs 50 lakh, and now that the latest drugs are available here, treatment is as good as anywhere. Similarly, the world class X knife radiosurgery facility available at the Apollo Cancer Hospitals and AIIMS costs $2,500 to 3,000 as compared to $15,000 for similar treatment in the West. Most oncologists admit the hardest part of their job is dealing with the relentless emotional pressure from distraught patients and their families: "When you've had 25 families crying on your shoulder all day, you want to go home and grow vegetables,'' says Dr Johri. Some private hospitals now have specialists in palliative care and provide treatment for terminally ill patients in their homes. There are also agencies like the Indian Cancer Society, Cancer Sahyog, Ashraya, Sahayta, etc., in practically every big metro where volunteers and survivors provide emotional support and counselling for those trying to come to grips with their illness. These are all important considerations when it comes to choice of hospital. Before listing the merits of the best superspeciality hospitals in the country, however, here's an update from leading oncologists on the new treatment and diagnostic modalities to look for: Radiation Oncology: Two decades ago radiation therapy was synonymous with burns, extensive irradiation and iffy results. Now, says Dr S. Bhargava, former head of AIIMS Rotary Cancer Institute: "Our ability to deliver the target dose to the target area is complete and the benefits far outweigh the side effects.'' How did this happen? First, the revolution in diagnostic radiology. Extensive use of CT Scans and high-powered computers with 3D graphics provide a clearer picture of tumours, their exact location and their intricate relationship with normal tissue. These revolutionary advances in fast imaging technology make it possible to pinpoint a tumour with sub-millimetre accuracy. Even cancers which are invisible to the naked eye can now be excised with the superior imaging of radiographic surgery. At the most advanced centres, treatment is plotted on a computer simulator after feeding in CT Scan slices and calculating radiation distribution throughout the body. The new generation of radiation equipment covers a range of photons, electrons and iridium isotopes which are designed to work at certain depths, on specific organs delivering high dose radiation to the target area with virtually no spillover effect on surrounding tissues. Radiation destroys the ability of cells to reproduce and is sufficient to control early, localised tumours and those which cannot be reached by surgery. Sometimes radiation is used before surgery to shrink a cancer or after to keep remaining cells from growing again.
Despite advances, radiation treatment is not without side effects, most of which are site dependent. Doctors prefer to deliver radiation in small doses over a five-day period for an average of five to six weeks. "These are broad guidelines as factors like age, tumour type, physical condition, etc., are all taken into account before a final decision is made,'' says radiation oncologist Dr S.C. Pande. Among India's best-known radiation oncologists are Dr K. Dinshaw who heads the Tata Memorial Hospital in Mumbai, Dr Janos Stumpf of the Apollo Cancer Hospital, Chennai, Dr S.C. Sharma at PGI, Chandigarh, Dr Krishnan Nair at Regional Cancer Centre, Trivandrum, Dr G.K. Rath at AIIMS, New Delhi. Medical Oncology: Better known as chemotherapy, it is the youngest of the three disciplines and is increasingly being used at the beginning rather than the end of the treatment. It includes an array of 50 drugs to kill cancer cells usually in combination with surgery, radiotherapy or hormone therapy. "Perhaps the future of cancer therapy lies in drugs and away from the mutilating effects of surgery and radiation,'' suggests Dr Badri Saxena, former director of the Indian Council of Medical Research. Certainly, there is a whole new field of gene therapy opening up in the next millennium in which smart drugs will take on the abnormal genes which make cells malignant in the first place. The latest drug for breast cancer, tamoxifen, is also undergoing clinical trials in a couple of leading institutes in India. However, these drugs are prohibitively expensive given the huge research component--some cost between Rs 10,000 and 12,000 a vial. Imported drugs cost up to $1,000 a vial though some Indian pharmaceutical companies like Dabur are now making cancer drugs. "Of this 50 per cent is taxes,'' complains Dr Rakesh Chopra, medical oncologist at Apollo Indraprastha, "which should not be the case with life-saving drugs.'' The other problem for patients in chemotherapy is wrong dosage--too much can destroy organs and kill the patient, too little can lead to resistant cancers and less than optimal survival chances. Under-prescribing is a common tendency in India, particularly among doctors who are not medical oncologists and are cowed by the severe side effects of toxic drugs. As in radiation therapy, there is a dearth of trained medical oncologists in India--of the 156 medical schools only one offers the speciality on its curriculum. In such a scenario patients need to educate themselves. So while every drug has its protocols, Dr Chopra suggests this general rule of thumb: chemotherapy dosage is calculated by body surface--height, weight and organ function. An average Indian woman with a body surface of 1.5 mts and a man with 1.7 mts should multiply this with 50 ml per sq metre, i.e. if body surface is 1.5 mts then the dosage should be 75 ml. It's easy to check the vial for correct dosage. While there has been a reduction in toxicity and side effects with modern drugs, chemotherapy still leads to hair loss (though this regrows), ulcers, digestive and reproductive tract problems and low blood counts. Some of this can be countered with regular antidotes while the bigger problem of falling blood counts has been brought under control with "growth factors'', drugs which accelerate cell reproduction. This is how bone marrow and stem cell transplants came into being. As new clinical trials of hormones, drugs and gene-based therapies light up corners of darkness in our understanding of how cancer behaves, there is every reason to believe new fronts will open up in the fight against cancer. "This is the dawn of the future of cancer therapy,'' says Richard Klausner, director of the US National Cancer Institute. "For the first time I believe we will eventually conquer cancer.'' In the next century drugs will be tailored to tumours and cancer will be expressed not in terms of location but the genes they occupy, says the latest report in an American newsmagazine. Till then, advises Dr Advani: "Ask your doctor if there is anything better in the world than what he is prescribing.'' We recommend: India's best medical oncologists today are Dr S.H. Advani at Tata, Dr Ramesh B.V. Nimmagadda at Apollo, Chennai, Dr V. Kochupillai at AIIMS, New Delhi, Dr G. Sagar at Cancer Institute (WIA), Chennai, Dr Pankaj Shah, Ahmedabad and Dr M. Chandy at Vellore. Surgical Oncology: Cancer surgery has come a long way from the days when expansive cutting of organs and tissue was the norm. Then, a radical mastectomy involved not just breast removal but lymph nodes, chest walls and even rib removal. Today the buzzword is organ preservation and a lumpectomy (localised tumour removal) may be preferred wherever feasible. "We want to preserve organs, form and function,'' says surgical oncologist Dr Kaul. "If there is a cancer requiring mutilating surgery, we try and reduce it first through radiation and chemotherapy.'' Minimal surgery combined with good reconstruction work--ask if microvascular reconstruction is available--has gone a long way towards preserving patients' emotional well-being and quality of life. The new generation of lasers and laproscopic surgery means minimally invasive procedures are possible when the area to be cleared is small. Laser surgery is being used for head and neck cancers, larynx and cervical cancer. The Tata Memorial has an ultrasonic dissector for liver cancer, which is the best equipment in the world. At other hospitals like Apollo, the larynx, once commonly removed, is now preserved as much as possible by leaving behind the vocal cords, or a small valve is placed so a patient can speak later. Breast reconstruction is common and modern-day colostomies have done away with the bag. These are small beginnings but the accent on organ preservation, quality of life after cancer and cosmetic reconstruction is growing. The best hospitals have tissue banks, skin sheets, bone and dura to make prosthesis. When deciding on cancer surgery, post-operative therapy facilities are of crucial importance. So is a dedicated blood bank since cancer surgeries can last for several hours. As in the case of radiation and medical oncology, surgery should only be entrusted to a certified oncologist who understands the nature of the disease and its response to multimodality treatments. "A surgeon will remove a lump but an oncologist understands the systemic nature of the disease. He knows where the cancer is likely to go next, he knows how much and where to involve other oncologists and will operate so as not to leave behind any trace of micro-metastasis. Your vision is tubed,'' says Dr Kaul. More important, he also knows when not to operate--70 per cent of the time at Tata's because most patients come with advanced disease. Since cancer cells are invisible to the naked eye, how can one be certain of complete removal? A modern, well-equipped cancer hospital should have a frozen section attached to the operating theatre. Since particular cancers are associated with particular proteins, surrounding tissue is lab-tested in the frozen section to ensure the surgery has been scientifically correct. When it comes to choosing a surgeon, "the first choice is the best choice,'' says Dr D'Souza. "Here I do a lot of salvage surgery undoing the work of other surgeons. Our aim is to conserve organ function without compromising on the disease but this can only happen in the early stages.'' Dr D'Souza also runs Shanti Avedna in Mumbai which has a branch in Delhi and is the only hospice of its kind for terminally ill cancer patients. We recommend: Dr Prafulla Desai and Dr. L.J. D'Souza at Tata's, Dr Hemant Raj at Apollo Chennai, Dr Aruna Chandrashekhar at Adyar and Dr Devendra Patel in Ahmedabad. © Living Media India Ltd |
Apart from hi-tech
diagnosis and accurate delivery systems for treatment, it is the multimodality approach
combining chemotherapy, radiation and surgery which has proved more effective in attacking
malignancies. The new generation of smart drugs, laser surgery, high dose precision
radiation and computerised pathology have taken cancer treatment into the next millennium.
Also, the emphasis on organ preservation, cosmetic surgery and prosthesis has reduced the
psychological trauma of physical mutilation. 
Traditional cobalt
machines, in which a Cobalt 60 radioisotope delivers high energy gamma rays, are still the
norm in most cancer centres in our country but are a generation behind the linear
accelerators, X knifes and gamma knifes which have ushered in the era of "conformal
radiotherapy'', so called because the radiation conforms exactly to the tumour. It can be
more effectively delivered in a variety of ways. While these innovations enable doctors to
be far more accurate and aggressive in treating cancer, the equipment is so highly capital
intensive it's beyond the reach of all but the best centres. As Dr Y.P. Bhatia, director
of the Rajiv Gandhi Cancer Institute points out: "Radiation oncology is the mainstay
of any cancer hospital but even without the X knife facility it costs around Rs 10 to 15
crore to establish.'' However, the problem is not merely one of lack of funds but the
acute and growing shortage of highly skilled radiation oncologists and physicists.