Cancer cases on the rise, care options trail behind
Six months ago, Ashok (name changed), a resident of Hosapete in Vijayanagara district visited the Karnataka Cancer Therapy and Research Institute (KCTRI) in Hubballi, complaining of difficulties in swallowing, chest pain and weight loss, after a local doctor referred him to this hospital. Scans confirmed his worst fears. He had stage-2 oesophageal cancer.
The doctors suggested radiation and chemotherapy. While the initial investigation cost him Rs 25,000, the hospital said he would require 20 to 30 sittings. Each sitting would have cost between Rs 7,000 and Rs 13,000, depending upon the complications. The total estimate for his treatment was around Rs 6 lakh.
The 55-year-old grocery shop owner, who is the sole provider for his wife and two daughters, decided to visit an alternative medicine practitioner instead, who gave him some herbal powders.
On January 18, when he returned to the KCTRI, his pain had worsened. Tests confirmed that the cancer had progressed to stage four in just five months. The prognosis is grim, say doctors at the institute.
“I could not afford the allopathic treatment as it was costly. A relative informed me about the alternative medicine practitioner, who has cured many. Maybe it is my bad luck that I could not be cured,” says Ashok.
Like more than 60% of India’s population, Ashok is not covered under any insurance scheme as he battles cancer, one of the “costliest” ailments. Treatment options are often costly not only because of expensive medicines and surgeries, but also due to the inaccessibility of local, specialised treatment centres. Due to this, the patient and family members often need to travel to another city where they would have to stay for months to complete the treatment.
The higher cost of anti-cancer therapies is also compounded by the prolonged treatment duration, says Soumendu Sen, senior research fellow at the International Institute for Population Sciences, Mumbai. “In India, the lack of a robust financial safety net against health expenditures makes patients with chronic diseases vulnerable. For any type of cancer, the majority of the patients’ households pay the treatment cost out-of-pocket,” he adds.
Earlier this month, Sen, along with doctors from the Tata Memorial Centre published research on how even insurance reimbursements fail to protect breast cancer patients from financial hardships. Their study, published in the Lancet Regional Health Southeast Asia, also shows that high costs and insufficient coverage mean that out-of-pocket expenses for breast cancer treatment in India are too high to be met adequately by insurance reimbursement. The situation is more or less the same with other types of cancers.
The scenario is especially troubling, considering India’s cancer count is rising rapidly, with data from the Indian Council of Medical Research showing a projected rise in cancer cases from 14.61 lakh in 2022 to 15.7 lakh in 2025.
ICMR’s Bengaluru-based National Centre for Disease Informatics and Research has estimated an 11.6% rise in premature mortality and years lost due to cancer between 2021 and 2025.
More than 40% of India’s cancer burden is contributed by the seven most common types of cancer — lung (10.6%), breast (10.5%), oesophagus (5.8%), mouth (5.7%), stomach (5.2%), liver (4.6%), and cervix uteri (4.3%).
As per the 2020 report from the World Health Organisation’s International Agency for Research on Cancer, the estimated incidence of cancer cases in India (13,24,413) accounts for the third highest number of cancer cases after China (45,68,754) and the United States of America (22,81,658).
While the incidence rate of cancer in India is lower, when compared to developed countries, the mortality rate is higher due to late diagnosis. However, the absolute number of new cases is increasing due to population growth and better diagnostic facilities. It has been estimated that around 20 lakh people will be affected by 2040 due to this disease and almost 10 lakh cancer deaths shall be observed.
In 2020, 8.5 lakh Indians died due to cancer. Death due to breast cancer accounted for the highest share (11%) followed by lip, oral cavity (9%), cervix uteri (9%) and lung cancer (8%).
The country is home to the world’s second-largest number of tobacco users (over 28% of all adults in India). Of these, at least 12 lakh die every year from tobacco-related diseases including cancer.
“In earlier decades, stomach, penile and cervical cancer were more common, while in the recent decade, breast, lung and prostate are the most affected body parts in terms of prevalence in India,” says Sen.
Among women, the incidence of breast cancer is rising rapidly, he adds. In 2020, breast cancer accounted for 13.5% of all cancers and around 10.6% of all cancer-related deaths. Recent epidemiological studies also show that the incidence is increasing particularly among Indian women under the age of 40.
Inadequate treatment options
The treatment options, however, remain limited. Shamsundar S D, associate professor at Kidwai Memorial Institute of Oncology, Bengaluru, says every year, the institute registers around 25,000 new cases of cancer, leaving 120 doctors and postgraduation students to treat more than one lakh cases on average.
Kidwai has long been known as one of the few public cancer treatment options in Karnataka. Patients and families from all over the state travel to Bengaluru for treatment. “Only 10 of the 31 districts in Karnataka have either a government or a private hospital to treat cancer. There are only three to four government-run hospitals in Karnataka that are equipped to treat cancer patients. Given the increasing number of cancer cases, there is a need for setting up more peripheral cancer centres,” Shamsundar says.
India currently has 39 specialised government-run cancer care hospitals. Ten more are planned to be set up. In addition, more than 250 cancer centres, including six dedicated cancer hospitals like the Tata Memorial Centre, function as a part of a grid run by the Department of Atomic Energy. Specialised cancer treatment units have been approved in all the 22 new AIIMS and 13 government medical colleges have been selected for upgrades to include cancer treatment.
But the numbers are gravely inadequate for a country of 1.4 billion people, and the facilities are out of reach for a large part of the rural population.
In 2022, a panel of lawmakers reviewing India’s cancer care scenario found that a 2013 Cabinet-approved scheme to improve the facilities at 39 cancer centres was yet to be implemented fully, even after 10 years.
The lack of such facilities means that not only are treatment options too expensive and inaccessible, they often come into the picture too late. “A primary reason for India’s high cancer mortality is late diagnosis, as approximately 80% of the cancer patients seek medical attention in advanced stages of disease,” the Parliamentary Standing Committee on Health noted in their 2022 report.
Shravan Nadkarni, a surgical oncologist at KCTRI, says that about 60% of cancer patients, especially from the rural background, come for a medical consultation only once the disease has progressed beyond cure. “This is mostly due to a lack of awareness about the availability of effective cancer treatment. They sometimes rely on ineffective alternative medicines which promise miracle cures,” he explains.
Noted oncologist Raghunadharao Digumarti, founder-director of Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, says that while chemotherapy and other basic cancer care is being provided to the patients in the government sector, there is a dire need for advanced diagnosis systems and therapeutic services, especially for transplant procedures. In addition, staffing in cancer centres and departments needs to be augmented, he adds.
Need for screening
Experts point out that regular cancer screening, especially for breast and cervical cancer, is the need of the hour to tackle the rising disease burden.
Unfortunately, without regular screening, breast cancer is commonly detected at third and fourth stages only, says Rekha A Nair, director of the regional cancer centre in Thiruvananthapuram. The centre has been carrying out awareness and screening camps across Kerala since 1981.
These awareness efforts are key, others explain. "We have a bus that travels across Tamil Nadu communicating the need for cancer screening to students, employees, and the general public. Such an outreach effort has impacted a substantial audience with 1,75,000 people benefiting from these campaigns,” says Hemanth Raj, executive vice-chairman of the Adyar Cancer Institute, Chennai.
Raj says the institute has conducted community-based screening programmes to detect early cervical, breast and oral cancer cases in several districts, reaching more than 1.25 lakh people.
In Karnataka, Kidwai Hospital has a satellite centre at Kalaburagi and similar units are being planned at Tumakuru, Mysuru, Shivamogga and Belagavi. “We need to set up peripheral cancer centres with basic facilities that can at least address the initial stages,” says Shamsundar.
The Union Health Ministry and a few state governments have been debating programmes for the vaccination of teenage girls against the human papillomavirus for protection against cervical cancer. But no final decision has been taken yet.
Insurance coverage
Flagging inadequate insurance coverage, the Parliamentary panel had also noted that insurance companies bank on the maximisation of profit and all cancer treatments are not covered in health insurance schemes.
They pointed out that besides the devastating effect of cancer in terms of morbidity, the cost involved in managing the disease put unbearable economic burdens on individuals and their families. One-third of households with individuals with cancer are estimated to spend more than half of their per-capita annual household expenditure on hospitalisation.
The panel recommended innovative health insurance packages to ensure adequate financial coverage for cancer treatment.
“Cancer treatment can become very expensive, and even an insurance policy may not be sufficient to cover such expenses. To overcome this, it is essential to get cancer-specific add-ons and covers that will provide lump-sum payments. These generally are affordable and can protect a person against a very big financial risk,” says Anuj Parekh, co-founder and CEO at Bharatsure, an insurance startup.
Cancer incidence has been rising in India due to increased detection and awareness, says Kalyan V Nadiminti, a medical oncologist and an assistant professor at the University of Wisconsin Carbone Cancer Center in the USA.
Noting that it is emerging as a major public health concern, he adds: “It requires a multipronged strategy involving a national cancer registry, improved access to well-trained staff and equipped facilities for treatment.”
(With inputs from Arjun Raghunath in Thiruvananthapuram, ETB Sivapriyan in Chennai, SNV Sudhir in Hyderabad and Gyanendra Keshri in New Delhi)
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