Navigating cancer care in India: Reflections & imperatives

An underappreciated fact in all discussions about non-communicable diseases is the human population dynamics in recent history. The total population of India was 169 million in the year 1800; in 1947, it was 358 million and is currently 1380 million, while the corresponding life expectancy at birth was 25, 33 and 70 years, respectively12. The Indian population above the age of 50 years was about 68 million in 1970, and this increased to about 268 million in 20203. The most important risk factor for cancer and other non-communicable diseases is increasing age. As India’s population ages and increases, the incidence and burden of cancer will also increase, as these have in the past few decades4. Despite the lower incidence of cancer in India compared with many high-income countries, because of its large population, the number of cancer cases is high. It is estimated that currently, there are about 1.3 million new cancer cases and approximately 0.85 million deaths due to cancer every year, and these are estimated to increase to about 2.1 million and 1.3 million, respectively, by 20405. These numbers also suggest that approximately 60 per cent of individuals who are currently diagnosed with cancer in India will die of it, a proportion that is about 20-25 percentage points higher than that seen in developed countries. Lack of population-based systematic screening for common cancers, presentation in advanced stage and deficiency of geographically and socially well-distributed and adequate healthcare infrastructure are the main reasons for the relatively high case-fatality ratio.

In this context, India has several strengths. It has a robust indigenous pharmaceutical industry that produces cancer and other drugs at some of the lowest costs in the world. There is a large network of private-sector healthcare facilities ranging from low-cost to modern corporate facilities, many of which deliver good quality healthcare. The framework of public health infrastructure at the primary and secondary levels is well established, although it needs to be strengthened in many locations. From the cancer standpoint, a few solutions need to be implemented in the coming decades as India continues its journey towards becoming a fully developed nation. The following could be a brief manifesto for cancer control in India.

Strengthening the healthcare infrastructure and human resources to deliver cancer care - the hub-and-spoke model: Modern cancer management requires collaboration between various medical and paramedical professionals working together to plan the best possible plan for a given patient. Achieving high levels of multidisciplinary collaboration is not a trivial task. Expertise is scarce and not well distributed geographically. We need to implement the hub-and-spoke model of cancer care delivery in the next decade within the public sector to enable access to affordable, quality cancer care for patients close to their homes6. Hubs are tertiary care cancer centres that have all the infrastructure and human expertise in various disciplines to manage almost the entire range of cancer cases, including complex ones. Given India’s current and projected population size and cancer incidence, it may require about 30-50 hubs, geographically so distributed that individuals need not travel long distances to receive care. Spokes are smaller centres that have the facilities and human resources to treat common cancers and are appropriately linked to a nearby hub. Approximately 3-5 hubs are required for every spoke. India has several large, relatively sophisticated central and State health institutions, which can be readily deployed as cancer care hubs with some support for infrastructure and considerable support for the upgradation of human resources. In this context, it would be appropriate to point out that the output and quality of trained personnel, including medical and paramedical, need to be substantially enhanced.

Promoting prevention and early detection of cancers: The most effective strategies for reducing cancer mortality include prevention and early detection. Approximately one-third to one-half of cancer deaths are due to modifiable risk factors, such as unhealthy diets, tobacco use, physical inactivity and alcohol consumption. Some cancer-related risk factors like central obesity may be especially relevant to the Indian context7. Enhancing public awareness about cancer risk factors using a national action programme would mitigate the inevitable effect of development and urbanization, which have historically been closely associated with increasing incidence of cancer. This would need to be coupled with smart and implementable screening programmes, using evidence-based strategies such as visual inspection of the cervix with acetic acid and clinical breast examination which have been proven to reduce mortality89. Integrating prevention and early detection into national health strategies is essential for a proactive approach to cancer control.

Strengthening palliative care10: Palliative care is a critical component of comprehensive cancer care, aiming to improve the quality of life for the affected individuals and their families. Despite its proven benefits, palliative care is often underutilized, particularly in low- and middle-income countries. Expanding access to palliative care services, including pain management and psychosocial support, is imperative for addressing the holistic needs of individuals affected with cancer. The delivery of palliative care in India is further complicated by diverse sociocultural factors that influence perceptions of cancer and end-of-life care. Tailoring palliative care to accommodate the cultural sensitivities and health beliefs of the affected Indians is paramount for effective care delivery. Studies advocate for a culturally competent palliative care model that respects the values and preferences of cancer patients, facilitating a more holistic and patient-centred approach to care11.

The promise of precision oncology: The advent of precision medicine has ushered in a new era in cancer treatment, with therapies increasingly tailored to the genetic and molecular characteristics of an individual’s cancer12. This personalized approach has the potential to transform cancer treatment by improving efficacy and reducing side effects. However, the promise of precision oncology is contingent upon our ability to make these innovations accessible to all individuals, regardless of their socioeconomic status or geographical location. Bridging the gap between innovation and access remains a formidable challenge. A related challenge is making advanced molecular diagnostic testing available to individuals who need it. The hub-and-spoke model mentioned above will have to incorporate some of these provisions in a coherent manner.

Integrating digital health and artificial intelligence (AI)-based solutions in cancer care: The integration of artificial intelligence (AI) into healthcare, particularly in the domain of cancer care and control, represents a promising advance13. AI’s potential to transform oncological practices ranging from early detection and diagnosis to treatment selection and prognostication is likely to herald a new era. However, this technological revolution also brings with it a host of ethical, technical and practical challenges that must be addressed to realize its full potential while safeguarding patient welfare and equity in care access14. Incorporating digital platforms into routine workflows and the ability to store and compute digital data at scale are closely linked themes. As a first step, the implementation of a common electronic health record in all public sector cancer hospitals is of high relevance.

There are several other domains of action to enhance the quantity and quality of public sector cancer care delivery in India, which demand a separate in-depth review. However, concerted policy and implementation level focus on some of the above themes will deliver significant dividends in the near and medium-term horizons.