|Year : 2022 | Volume
| Issue : 1 | Page : 1-4
Steps to improve cancer treatment facilities especially radiotherapy infrastructure in India
Manoj Gupta, Kishore Singh
Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||29-Dec-2021|
|Date of Acceptance||03-Jan-2022|
|Date of Web Publication||30-Mar-2022|
Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttatakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta M, Singh K. Steps to improve cancer treatment facilities especially radiotherapy infrastructure in India. J Can Res Ther 2022;18:1-4
| > Background|| |
As per the Globocan 2020 data, India witnesses approximately 1,324,413 new cancer cases every year, with 2,720,251 prevalent cases and 851,678 cancer deaths per year. The recorded incidence of cancer in India is at 97/100,000 people. It is seen that cancer incidence is rising, mainly due to better access to health infrastructure and lifestyle changed environment of today. Cancer is already one of the three-leading causes of disease-related mortality. India ranks third in cancer premature mortality in the age group of 0–69, in the world as per the WHO [Figure 1].
|Figure 1: National Ranking of Cancer as a Cause of Death at Ages <70 Years in 2019.|
Click here to view
In this scenario, it is vital to provide cancer treatment facilities which are accessible to the vast population that are in the rural areas and of the semi-urban population.
| > Problem|| |
- Most of the cancer treatment facilities are concentrated in urban areas, especially in large cities. Few centers are only in tier II and tier III cities
- Even though we have a large number of medical colleges spread out across the country, only a handful have oncology departments
- As per WHO guidelines for developing countries, one Linear Accelerator (Linac) per million populations is recommended. India has a population of 135 crores and accordingly requires 1350 Linac. Currently, India has approximately 545 teletherapy machines (180 tele cobalt machine and 365 Linac). Hence, there is a deficit of 800 linacs
- Every year about 40 units are added and 15 units are decommissioned, which makes the number of new units effectively added at 25. These 25 new units are just sufficient to take care of India's annual population growth, which is around 25 million per year. Hence, gap between demand and supply remains the same. This is reflected from the waiting period for radiotherapy department of public hospitals, which sometimes goes up to 1 year
- More than 50% of radiotherapy facilities are present in private sectors, thus further reducing radiation treatment facilities available for poor patients
- Hence even when the patients are diagnosed early, it is the logistical issues of visiting a cancer hospital available in few cities which force the patients to delay treatment, and this is one of the reasons for late-stage disease presentation
- Cancer management requires prolonged treatment, which may last for month together and poor patients cannot stay for so long away from their home due to logistic reasons as well as due to earning of their livelihood
- Cancer management also requires multiple visits to the hospital at regular interval and since the distance of hospitals from their home is more, it results in treatment interruption and reduced survival.
| > Solution|| |
The above problem can be solved by creating more treatment facilities which is uniformly distributed across the country and to plan in such a way that travel distance from their home to hospital is reduced. Following is being proposed,
- There is a dire need to establish a radiation oncology department in every medical college. This can happen only if radiation oncology departments are made mandatory departments in Medical Colleges through the National Medical Council. It may not be mandatory to purchase radiotherapy machine in the beginning, but it should be mandatory to appoint at least one faculty at each level, i.e., Professor, Associate, and Assistant Professor. There are presently 541 medical colleges in the country, out of which 278 are in the government sector and 263 are private medical colleges. Currently, only 87 medical colleges are offering MD radiation oncology courses
- Government should fund these medical colleges to develop minimum radiotherapy infrastructure with cheaper technologies (how to reduce the cost of Linac, will discuss later)
- The government of India plans to open one medical college in each district. Country has 741 districts; thus, 463 medical colleges are to be added in future making the total number of medical colleges in country 1004 (741 + 263 private medical colleges)
- If it is mandatory to open radiation oncology department in every medical college, the number of Linac will go to 1004 from the present number of 545
- Each radiation oncology department should have at least one professor, one associate professor and one assistant professor with four senior residents. Besides, two medical physicists and four radiotherapy technicians should be minimum paramedics needed to run one linac
- The biggest advantage for cancer patients will be that distance of hospital from home will be reduced drastically.
This will help in creating a vast infrastructure of cancer treatment facilities across the country and it will be much easier for patients to undergo cancer treatment at centers nearest to their residence and travel distance for patients will be reduced remarkably in view of the vision of our Honorable PM to establish one medical college in every district. This will help in early diagnosis and instituting early treatment either with chemotherapy or radiation, leading to achieve better cure rates and decrease disease-specific mortality.
Radiation oncologists are trained in diagnosing, treating with radiation, giving chemotherapy, providing end of care treatment including pain management (including tablet morphine use), as well as educating community about cancer prevention, running early cancer detection program, framing strategies to combat cancer rise and promoting a healthy lifestyle to beat cancer. If it becomes mandatory to appoint radiation oncology faculty in medical college, it will help in the management of cancer patients in the following ways:
- Immediately after appointment, even there is no radiation treatment machine available in medical colleges, they can immediately help by running a cancer OPD and IPD where they will diagnose, investigate and stage the patients and if chemo is required as the first treatment, will provide that as they are well trained in chemotherapy. Here, it is important to mention that number of medical oncologists is not many and most of them are concentrated in tier 1 or some tier 2 cities and for poor patients, it is not possible to travel such a long distance for chemotherapy
- Patients who have been operated or given radiation and now require either adjuvant or palliative chemotherapy will be catered at the district level
- Follow-up can be done at the district level, which will reduce the travel distance for patients as well as burden of follow-up patients on big hospitals
- They will provide end of care treatment for terminally ill patients, including effective pain management at the district level near to their home
- Gradually, they will also make efforts to procure radiotherapy machines and will reduce the gap between demand and supply
- Adequate radiation oncology workforce is available in our country for this purpose, unlike medical and surgical oncologists who are few and mainly concentrated in few centers, mainly in tier 1 and some tier 2 cities and mostly in corporate sectors
- After the establishment of treatment facilities, it will be expanded further by outreach activity to do early diagnosis/screening and prevention of cancer as well as cancer education, particularly for school students (as part of National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke)
- Further establishment of population-based cancer registries and hospital based cancer registries will strengthen the collection of data and improve the quality of information about the status of cancer by the National Cancer Registry Project by ICMR, which is having abysmally low (10% coverage of India) at present.
| > How to Cut the Cost of Linear Accelerator?|| |
There are only two companies in the world, which manufacture linear accelerators, Elekta (Sweden) and Varian (USA). The cost of the linear accelerator is very high due to the incorporation of state-of-the-art technology development such as image-guided radiation therapy (IGRT), stereotactic radiosurgery (SRS), and stereotactic body radiotherapy (SBRT). Due to the exorbitant cost, it is difficult to procure and install the large number of these machines required to handle cancer burden in the country. Hence, there is a dire need to cut down the cost of these equipment but at the same time without compromise in quality of treatment. There is also a need to make optimum use of equipment as well. The most common cancers in our country are Ca lung, head-and-neck cancers, Ca cervix and Ca breast. Majority of patients with these cancers present in advanced stages and can be treated with three-dimensional conformal radiotherapy or intensity-modulated radiotherapy (IMRT) with two-dimensional (2D) image verification. There is no need to have high technology radiation delivery facilities such as IGRT, SRS, and SBRT in these machines, which are very expensive technologies. If Industry partners are taken into confidence and asked them to manufacture low-energy linac with IMRT with 2D image verification only it will cut the cost drastically. Industry partners can do it if government ensures to purchase linac in bulk on a yearly basis, as done by Government of Brazil. Other measure is to waive off custom duties on radiotherapy equipment which is currently approximately 20%. This will further reduce the cost.
| > Minimum Radiotherapy Equipment for Each Medical College|| |
- Single energy low-energy linear accelerator with IMRT with 2D verification
- HDR Cobalt brachytherapy with three channels. This is mainly required to treat ca cervix patients. One machine can be shared between 3 and 4 districts. This will bring down the overall cost
- CT Simulator. Most common cancers such as lung, cervix, and breast can be simulated in existing diagnostic CT scan with some modifications
- For other tumors which may need dedicated wide-bore CT Simulator, the same may be shared between 4 and 5 districts. This will again bring down the overall cost
- Dosimetry instruments can also be shared between districts.
| > Role of All India Institute of Medical Sciences|| |
- Presently, 22 AIIMS are being established and plan is to have at least one AIIMS in each state. These AIIMS may function as referral centers of district medical colleges for patients who need high technology treatment like IGRT, SRS, SBRT, etc., Department of Radiation Oncology of all AIIMS should be funded liberally so that all technologies should be made available which includes cyber knife, tomotherapy, MRI-based Linac, intraoperative radiotherapy, image guided brachytherapy, etc.,
- All AIIMS should start MSc Medical Physics and BSc Radiotherapy Technology programs besides routine MD courses. This will help to increase the number of health-care professional, especially medical physicists and radiotherapy technologists
- Oncology services of AIIMS will work on the hub and spoke model and will be mentor institute for all district medical colleges in a state.
The most important step in this model is to make it mandatory for all medical colleges to have Radiation Oncology department and NMC can do the same. So far, Radiation Oncology is an optional subject as per NMC guidelines. I would like to reiterate that procuring radiotherapy equipment is not to be made mandatory, it is only radiotherapy faculty which should be made mandatory. The reason is that private medical colleges might object to invest so much of money for procuring radiotherapy machines. However, once faculty is appointed and cancer services are started, gradually, these medical colleges might procure machines too and can start MD course as per NMC guidelines.
| > Conclusion|| |
It is very important to reduce the distance of cancer treatment facilities for patients so that they can continue their prolonged treatment conveniently and can also get palliative care at their doorstep. This can be done by making the radiation oncology department mandatory in medical colleges by National Medical Council. The vision of having one medical college in each district will further improve cancer care facilities. Optimum use of radiotherapy equipment and use of appropriate technology without getting influenced by market forces will help in reducing the cost of development of radiotherapy infrastructure across the country.
| > References|| |
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al.
Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-49.
Munshi A, Ganesh T, Mohanti BK. Radiotherapy in India: History, current scenario and proposed solutions. Indian J Cancer 2019;56:359-63.
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National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS) Operational Guidelines (revised: 2013-17). Directorate General of Health Services Ministry of Health & Family Welfare Government of India 2013.