The 2010 book Cancer: Emperor of All Maladies called the disease the "defining plague of our generation". According to the World Health Organization (WHO), cancer is the second-biggest cause of death after cardiovascular diseases, amounting to over 9.6 million deaths in 2018 worldwide. This translated to at least one in six people dying of cancer. By 2030, the worldwide annual toll is expected to rise to 13 million.
At the beginning of the 21st Century, the international community began to feel the need to scale up efforts against cancer. Consequently, Union for International Cancer Control, an international advocacy group, took the lead and declared 4 February World Cancer Day. On this day, various stakeholders, such as governments, NGOs, medical practitioners and international organisations, raise awareness about ways to prevent cancer and its diagnosis and treatment.
Cancer can no longer be considered a "first world" disease. With rapid industrialisation but poor social infrastructure, developing nations of Asia and Africa lead the dubious lists of cancer-related deaths and incidences. Asia and Africa accounted for 64.6 percent of total deaths in 2018. They also accounted for approximately half the cancer diagnoses worldwide.
Cancer in India
India is at the front line of the global war against cancer. In 2018, India had 2.25 million people suffering from the disease. Over 1.1 million new cases were recorded, while 780,000 died of the ailment — over 8 percent of the global tally.
No discussion on the state of cancer in India can be complete without looking into the urban-rural divide. A 2015 study published in the Indian Journal of Medical and Paediatric Oncology noted the stark divide in these words: "Though the incidence of cancer in rural India is nearly half of that of urban India, the mortality rates are double."
While blaming poor medical infrastructure for the higher toll in rural areas, Dr Swapnil Mane, an onco-surgeon based in Maharashtra’s Rahuri, said: "Most cases of cancer are diagnosed very late. Villagers visit quacks for dubious treatments and buy drugs without prescription. When patients finally go to cities, there are inordinate delays in diagnoses and treatment."
The divide is starker when it comes to the cancers that affect Indian women. While breast cancer is more prevalent among urban women, it is cervical cancer that affects more women in rural India. In 2018, over 44 percent of new cases of the disease were attributed to these two forms of cancer, killing nearly 150,000 women in the year.
"Poverty, multiple pregnancies, poor sanitary hygiene and lack of awareness are responsible for cervical cancer," Mane said, adding that the male-dominated rural society restricts women from openly seeking treatment.
On the other hand, late pregnancies, lack of breastfeeding culture and changing lifestyles due to rapid modernisation are some of the reasons for rising instances of breast cancer among urban women.
Dr Shyam Aggarwal, senior consultant at New Delhi's Sir Gangaram Hospital, said late diagnosis of breast cancer contributes to a high mortality rate. “In the western world, almost 80-90 percent of cases are detected in early stages. It is totally the opposite in India. So, the number of women who recover from breast cancer is abysmal in India,” he says.
With medical infrastructure concentrated in major cities, there is undoubtedly too much stress on available resources. Moreover, awareness about cancer-care, though better compared to rural areas, also remains low. “Large number of cancer cases are diagnosed quite late because people tend to not consult a doctor. Often, health remains the last priority for many people,” notes the oncologist.
Late detection of cancer is plaguing India. According to a Lancet report, survival rate of Indian patients is just 30 percent. Whereas, this rate touches 60 percent in the West, where large number of cancer cases are diagnosed in early stages.
Oral cancer continues to be the leading form of cancer for men in rural as well as urban India, accounting for 16 percent of new diagnoses among men in 2018. Tobacco chewing, especially among the poor, is considered the single biggest cause for oral cancer in India. In fact, as per one estimate, 30 to 60 percent of all cancers among men are due to tobacco consumption.
Mane and Aggarwal advocate a total abstinence from tobacco, arguing that cancers can be avoided by adopting healthy lifestyles. Aggarwal suggests that cancer is a result of urban sedentary lifestyle, further noting that quitting tobacco could help reduce cancer cases by at least 30 percent.
Other than preventive measures, the focus is generally on early diagnoses of cancer. “Cancer is totally curable if detected at Stage I and II,” says Mane, whose charitable trust is working towards creating awareness about cancer-care in rural Maharashtra.
Developments in cancer care
In, 2018, James P Allison and Tasuku Honjo jointly won the Nobel Prize for medicine for their breakthrough in cancer immunotherapy. Dr Shubhada Chiplunkar of the Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), who is researching on immune dysfunction in cancer patients, believes immunotherapy is revolutionising cancer treatment and will emerge as a strong alternative to chemotherapy and radiotherapy.
In simple words, immunotherapy is a form of treatment which helps the immune system to fight cancerous cells. "Cancer cells are intelligent too. They find new ways of changing the genetic makeup to resist targeted therapy. Cancer immunology uses a person's own immune system to kill these cancer cells. Cancer cells have developed a mechanism to evade the immune system but we now have found a way to block this and achieve very long-term cures in many cancers,” explains Sanjeev Redkar, president of San Francisco-based pharmaceutical company Apollomics Inc.
Cancer Immunotherapy is at its nascent stage in India but it is expected to grow in the coming years. “Right now, the therapy is very costly and likely to range between $4,000 to $6,000 in India. This is because the anti-bodies have to be imported from the West. We are trying to build a GMP (Good Manufacturing Practices) facility here (Tata Memorial Hospital). There are a lot of ethical approvals that we need to get too. It is indeed a long process,” says Chiplunkar supporting the idea of indigenously developing these anti-bodies to reduce treatment costs.
CAR-T, a newly-emerging form of immunotherapy, is attracting attention from experts. Redkar believes solutions like CAR-T nip cancer from the bud itself. “CAR-T is a personalised form of immune cell treatment. Basically, doctors will extract immune cells from your body, fire up your immune cells in an attacking mode and put them back into your blood system. One injection has resulted in near-cures for some blood cancers,” he says while warning that the treatment remains costly even in the US.
Notwithstanding the medical breakthroughs, cancer care also requires a holistic approach. Many patients, although medically recovered, continue to face several pyscho-social problems that impact their normal lives. Rehabilitating such survivors form a key part of “cancer survivorship”. While a well-developed idea in the US, where it began in the late 1980s, cancer survivorship in India is still limited to children.
Dr Purna Kurkure, the pioneer of “cancer survivorship” in India, says she took special interest in childhood cancer survivors due to her work as a paediatric oncologist. In 2009, she founded the UGAM programme to help childhood cancer survivors. “Childhood cancers are entirely curable. Children have an entire life ahead of them. We take care of their medical as well as psycho-social needs,” Kurkure says.
While Kurkure appreciates various initiatives for adult cancer survivors, she also points out the lack of consolidated effort. “It is a very NGO approach. They don’t label their initiative as survivorship. Survivorship needs to be developed in conjunction with doctors, involving both medical and pyscho-social aspects,” says Kurkure.
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Updated Date: Feb 04, 2019 15:37:56 IST