January 2015

Medical Landscape in Oncology

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The challenges of treating patients in our country are enormous. The solutions have to be tailored to their socioeconomic conditions, says Dr Ashok Mehta, Medical Director, Brahma Kumaris’ Global Hospital & Research Centre, Mumbai

Dr Ashok Mehta,  Medical Director,  Brahma Kumaris’ Global Hospital & Research Centre, Mumbai

Dr Ashok Mehta,
Medical Director,
Brahma Kumaris’ Global Hospital &
Research Centre, Mumbai

It is recognized that with over a million new patients every year in India and 14 million worldwide and also number of available treatments, there is a great demand for oncologists who are experts in treatment of cancer to deliver appropriate, better and standardized care.

Oncologists are experts in different fields of cancer treatment. Surgical oncologist is a surgeon who specializes in surgical treatment of cancer. There is trend towards super specialization in surgical oncology such as head and neck cancer, gynecological cancer, breast cancer, and the like.

“High treatment cost is one of the major reasons where cancer care is out of reach for millions of people”

A radiation oncologist is a specialist physician who uses ionizing radiation such as megavoltage X-rays (linear accelerator) or radionuclides in the treatment of cancer. Radiation can be given as a curative modality, either alone or in combination with surgery and/or chemotherapy. It may also be used palliatively, to relieve symptoms in patients with incurable cancers. Radiation oncologists are supported by medical physicists who plan to deliver the cancericidal dose to the tumor without damaging the normal tissues.

Medical oncologist is a physician who specializes in medical treatment using chemotherapeutic drugs, hormones and targeted therapy. There is super specialty of hematology-oncology to treat blood cancers, cancers of the lymphatic system and carry out bone marrow transplantation. A large number of patients require more than one modality of treatment mentioned above. Ideally, a cancer patient should be seen by various specialists in a tumor board before starting the treatment and a joint decision should be arrived at offering the best option for treatment. A tumor board may consist of the oncologists and other specialists such as imaging specialists, interventional radiologists, surgical pathologists, intensivists, etc.

PET-CT has revolutionized medical diagnosis in oncology. It combines functional imaging obtained by PET depicting the metabolic activity in the body which is correlated with anatomic imaging obtained by CT scanning. An obstacle to the wider use of PETCT is the difficulty and cost of producing and transporting the radiopharmaceuticals used for PET imaging. The half life of radioactive fluorine used to trace glucose metabolism (using fluorodeoxyglucose, FDG) is two hours only. Its production requires a very expensive cyclotron. In absence of tumor board many specialists prefer to refer the patients for opinions of other colleagues.

Evidence based practice is being promoted in most parts of the world and has impacted the cancer practice even in our country. Evidence based medicine is a process of systematically finding, appraising and using contemporary research findings as basis for clinical decisions. It asks questions, finds and appraises the relevant data and harnesses that information for everyday clinical practice. It is a daunting task for a busy clinician since medical evidence base is increasing exponentially. It is virtually impossible for an individual specialist to maintain up-to-date comprehensive knowledge even in his own field of practice. Specialists have not only to treat the patients but have to be familiar with frontline research.

Growing use of web-based technology and electronic decision support help physicians improve overall care of the patients, since the knowledge is not only used by specialists but also in training resident staff, nursing staff, pharmacists, and other support staff of the hospital. As a busy senior consultant in a practice of surgical oncology, I frequently use Internet and web based technology, online guidelines and protocols, which have been developed across multiple jurisdictions but originate mostly in North America and Europe. Use of these protocols helps to improve overall care of the patients and results in improved long term survival. Staff specialists remain up-todate with latest evidence using other information sources such as journals, research databases, conferences, etc. Clinicians often use onco-informatics perceived by him to provide high quality support. Resident doctors and fellows specializing in cancer use them more often than others on daily or weekly basis especially chemotherapy protocols.

In our country, patients travel long distances for diagnosis and treatment. This is not only expensive but entails disruption of family. The challenges of treating patients in our country are enormous. The solutions have to be tailored to their socioeconomic conditions. Multimodal treatment in which surgery, radiation therapy, and chemotherapy, are either used sequentially or concurrently, are very demanding logistically for the patients. For marginal improvement of cure rates statistically it may not be practical to offer prolonged treatment which leaves patients exhausted. Many patients receive toxic treatment with chemotherapeutic drugs with serious sideeffects.

Genomes of tumors have been sequenced. They are more complex than expected. Genetically targeted therapies were introduced in some of the cancers. First commonly mutated genes were identified and seen if these genes are mutated in a particular cancer. Then sequence and identify the mutations to be able to say exactly what genes are defective in patient’s tumor. We can then figure out signaling pathways affected by the mutations and target them. For example, drugs that specifically address mutations in the EGFR (epidermal growth factor receptors), in one type of lung cancer (adenocarcinoma) when administered to block those receptors, the tumors just melt away. Some breast cancers which have Her-2neu receptor (human epidermal growth factor receptor) respond to a drug Trastuzumab. Also, TKI (tyrosine- kinase inhibitors) target kidney cancer e.g. Sorafenib, or androgen receptor antagonist drug Enzalutamide for prostate cancer.

In future molecular profiling and targeted treatments could help withhold such treatments from women who have excellent survival rates predicted by genetic sub typing. Potential of molecular profiling and genomic studies can be applied in more individualized approach to breast cancer treatment. Results of molecular profiling studies will have enormous impact. New genomic tests can look at 1000 genes and by accurately predicting drug response may improve survival by helping oncologist to select the appropriate treatment regimen. At present time very high costs have prevented their widespread use.

Though a number of cancer centers have come up in different parts of country, development of cancer facilities has not been able to keep up with the demand largely on account of high initial investments, low paying power of general population, shortfall of specialists and skilled manpower. It is estimated that there are about 160 government hospitals and 350 private hospitals providing oncology treatment. However, when recurrences occur or complex surgeries are contemplated many patients prefer to go or are referred to reputed major cancer centers in metro cities where they have to wait long for their turn for treatment. High treatment cost is one of the major reasons where cancer care is out of reach for millions of people.

One of the solutions to provide more cancer centers would be to encourage Private Public Partnership projects with free/subsidized land and concessions in taxes. This will reduce the cost of the project and eventually become more affordable to the citizens.

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