Forty-one-year-old Roopa Vasudeva was a fun-loving and always-laughing corporate trainer at a Gurgaon company. But in April this year her world came crashing down on her when she was diagnosed with breast cancer. “I was exactly the same age as my mother when she was diagnosed with breast cancer in 1985. I had accompanied my mother and mother-in-law for a regular check-up when my mammogram appeared doubtful. I was asked to go for an MRI but that too was inconclusive. Still sceptical, the doctors told me to get a biopsy done. And that surely said – malignant.”

In Vasudeva’s case, there was no lump, and no other symptom. “It was just a cluster of calcification, as the doctors termed it, which had turned cancerous.” Vasudeva underwent lumpectomy – a medical term for surgical removal of the cancerous portion of the breast -- and radiation therapy after the surgery for seven weeks. It was awareness in her case that led to a really early detection and hence an effective cure. “The initial shock and trauma was obvious. We were covered under a corporate insurance. But for most people that may not be the option. And then, to bear the cost of cancer treatment can be really difficult,” she said.

Six months later, Vasudeva is back to being her feisty self. “I was partying all through my radiation sessions despite the side-effects. I believe in living life to the full. And a disease as this has to be treated like a small hurdle. One has to just leave it behind with strength and smiles.”

The spreading disease
The increasing incidence of breast cancer cases in India in the last few years has set alarm bells ringing. It has now emerged as the number one cancer in women in urban areas across India (breastcancerindia.net). The statistics are alarming. As per the latest figures across studies in major cities, 25-30 percent of all cancers in women occur in the breast. And 50 percent patients of breast cancer fall in the age bracket of below 50 years of age. The dreaded disease is affecting more and more young women and in a far aggressive form. Two decades ago it accounted for 15-20 percent of all cancers in women.

According to Dr Vani Parmar, convener of breast cancer working group at the Tata Memorial Centre, Mumbai, “There is a 1.2 percent annual increase in the number of women with breast cancer, which is not really alarming. The media has played a major role in spreading awareness about the disease in the last few years. This has surely resulted in more number of cases coming to the fore. That also means that more people come to us in the early stages of the disease, when it is treatable. And that has brought down the severity of the disease.”

With advances in technology, contemporary breast cancer treatment with surgery as the mainstay is ably supported by chemotherapy, targeted therapy radiation therapy and hormone therapy. The surgical options today are breast conservation surgery – with or without oncoplasty (reconstruction surgery). Several other techniques like wire guided or ultrasound guided localisation surgery for suspicious impalpable (abnormalities that are not felt) breast lesions, radio-guided occult lesion localisation (ROLL), sentinel lymph node biopsy, frozen section etc., are also being used for the treatment of breast cancer.

In early breast cancer, accelerated partial breast irradiation (APBI) has now emerged as a major paradigm shift in the developed countries. “In India, we are using APBI but mammosite, SAVI, Contura, all these instruments are prohibitively expensive and are not available for use. The prognostic multi-gene markers (oncotypeDx, Mammaprint, PAM 50) are also not routinely available so we are not able to always tailor therapy,” said Dr PK Julka, dean (academic) and professor, department of radiotherapy and oncology at the All India Institute of Medical Sciences (AIIMS), New Delhi.

Are hospitals well-equipped?
Dr Sudeep Gupta, deputy director, CRC-ACTREC (advanced centre for treatment, research and education in cancer) and general secretary, women’s cancer initiative – Tata Memorial Centre, Mumbai, said, “Most tertiary care hospitals (both public and private) in big cities are reasonably well-equipped to treat breast cancer. However, hospitals in smaller cities, which also have a significant population of women with breast cancer, have inadequate resources to treat this disease. This leads to an undesirable situation where women have to travel far from their places of residence to receive good quality treatment.” Dr Bhawna Sirohi, breast cancer specialist and medical oncologist, who has formerly worked with Max Hospitals and is now on a sabbatical, said, “Expertise is an issue and how it is used to deliver cancer care at the ground level is a cause for concern. Anybody from a surgeon or radiation oncologist to a general physician or even a gastroenterologist or urologist can prescribe chemotherapy (which is a highly specialised medication) these days, even though they are not trained to do so. But there are no checks in India. Anybody can do what they like – with no consequences – and patients don’t have a clue anyway. Only a trained medical oncologist should be allowed to do so. Indian health service is in need of urgent reconfiguration or the patients will be the losers in getting suboptimal treatment.” Dr Vedant Kabra agreed. “Looking at the nuances of breast cancer care, everything from surgery to radiation and chemotherapy should definitely be handled by experts and specialists in the field,” said the additional director of surgical oncology at the Fortis Memorial Research Institute, Gurgaon.

Another problem is availability of equipment in hospitals. “The country needs about 1,500-2,000 radiation machines. There are only 300 available across India and they too, for various reasons, are asymmetrically distributed,” said Dr Anusheel Munshi, senior consultant, department of radiation oncology, Fortis Memorial Research Institute, Gurgaon. As per Dr Munshi, the cost of installing a basic radiation machine comes to anything around '2-4 crore. And, with the number of patients increasing each day, best technology does not reach all. Though government hospitals have nominal radiation charges, the waiting period is very long, he said, and so timely administration, the most important element in the treatment of cancer, is lost.

Counters Dr Sirohi, “As far as technology advancement and equipment is concerned, we may be on a par with the world but what we seriously lack is providing quality care to each and every patient walking in through the door.” While those who have access to quality treatment have greater chances of survival, there are thousands who do not even get primary treatment for breast cancer. She said, “Unless we set a benchmark of our own results, we cannot improve. Hospitals need to be transparent in publishing their morbidity and mortality figures, infection rates, response rates, survival data, all on a monthly basis and this can only happen when everything is computerised so that everything can be audited with potential for less number of errors in prescribing.
“We are also far away compared to developed countries in not being site-specific in cancer therapy – it has been shown that for a surgeon who is trained in and does adequate number of breast surgeries, the cosmesis and long-term complication results are better as compared to a general cancer surgeon with low volume breast cancer work. Sadly, we have very few breast cancer surgeons in India. But this is changing now,” she added.

However, Dr Parmar holds a completely different point of view. “There are 27 regional cancer centres (RCCs) spread across India. They treat large numbers of patients but these are not accounted for because they are not advertised.” Dr Kabra added, “Apart from these RCCs, there is a reasonable number of trained surgeons across the country but it is not enough for every woman with breast cancer to reach the right person for treatment.”

Affordability is a concern
However, the question remains – does every breast cancer patient in India have access to the best available treatment irrespective of her financial status? “The modern day treatment is extremely expensive and will continue to be costlier because of the increasing investments in research and development. Therefore, many patients cannot afford even basic treatment,” said Dr Julka. He explained that though chemotherapy is administered free to patients at AIIMS, the antibody used costs '50,000 and is not free. Moreover, the number of chemotherapy sessions depends on the prognosis and varies from person to person. An entire course of chemotherapy can cost '2-25 lakh, depending upon various factors, said Dr Vineeta Goel, senior radiation oncologist, Max Super Speciality Hospital, Patparganj, New Delhi.

More sessions, more cost. “Every new technology or drug, especially targeted therapy, may not be good enough and/or cost-effective,” said Dr Kabra. “The advantages provided by them may not be significant enough to justify their high cost. Also, using technology without adequate training may not give you the same results. We need to tailor them to our needs and budget, without compromising on care.”

“We need to come up with viable cost-effective treatments, which can be done if we have a body, or bodies, to handle all such financial blocks. Moreover, the government needs to take interest in making sure that every cancer patient is treated with minimum best care,” said Dr Sirohi. Technologically, radiation oncology might have taken a huge leap in the last decade with Orthovoltage machines and Cobalt machines being replaced by sophisticated linear accelerators and intensity modulated radiotherapy and image-guided radiotherapy being considered modern radiotherapy approaches in treatment. But the cost of treatment remains a concern. “Radiation therapy cost could vary from '30,000-40,000 to '2.5 lakh, depending upon the sophistication in delivery technique and the duration of administration,” said Dr Munshi.

At the Tata Memorial Centre, under the department of atomic energy, half the people are treated free of cost and the rest pay a very nominal amount, said Dr Parmar. “Quality care in India at low cost is possible now. Generics of essential anticancer drugs are available at low cost. The government also provides subsidy for cancer treatment, especially at Tata. There are also cancer treatment support programmes such as the Rajiv Gandhi Jeevandayee Arogya Yojana and other NGOs that take care of treatment costs for cancer patients.” However, this is only one of its kind hospital for cancer patients. How many people actually make it to Tata with the waiting being unreasonably long? (The 15 days to a month-long wait can be fatal for some cancer patients.) Should the government not aim at having more such centres across India?

What the government needs to do
With greater awareness and advances in technology, there is hope of catching the disease early and improving the survival rate. But is the best treatment cost-effective? Affordability, too, remains a gnawing issue. So, what should be done?

“The government has a very important role in creating trained human resource and making medications and equipment available at affordable cost,” said Dr Gupta. “Availability of trained human resource (oncologists, nurses, counselors, physiotherapists, etc.) is the most vital link in delivering high quality cancer care – more important than fancy equipment and expensive medications,” he added. Dr DC Doval, director, medical oncology, Rajiv Gandhi Cancer Institute, New Delhi, is of the view that government needs to promote generic drugs in a big way and provide subsidy on medicines for cancer.

The cost for breast cancer treatment begins to accrue right from diagnostics and mounts as the treatment progresses with surgery, therapy, medication, and diet. Pre and post operative precautions, care and regular tests (pathological as well as diagnostic), all further add up to the cost. “The government needs to ensure a widespread insurance cover for all in the country. In India, people are usually covered by a panel or have personal insurance; something that a big segment of population cannot afford,” said Dr Munshi. “There are good number of hospitals with reasonable facilities and some with world class facilities in India. However, they cannot cater to the large population that we have. There is no denying the fact that a committed and strong-willed government should join hands with healthcare professionals, provide them with adequate facilities, empower them and make things available in all geographical locations,” said Dr Kabra. He also cited the need for better facilities in government hospitals with a wider reach, judicious use of investigations and medicines, low-cost private centres and involvement of NGOs and CSRs – all to combat the disease that is affecting women across the country.