Over the course of his 40-year career, oncologist Dr Ramakant Deshpande has taken an active role in the evolution of cancer care in India and in 2017 he became the executive chairman of the Asian Cancer Institute, a cancer care centre aimed at delivering quality care while addressing affordability. He discusses India's oncology landscape and the challenges facing cancer care, such as the chronic shortage of specialists, and explains the role of the National Cancer Grid (NCG) in standarising clinical protocols and negotiating prices, and comments on the future of precision medicine, and cell and gene therapies.
Could you introduce yourself, detailing your role at the Asian Cancer Institute and your journey to becoming a renowned oncologist?
I am a qualified oncologist, venturing into the field in the early 1980s, commencing my career at the Kidwai Cancer Centre in Bangalore. Over the years, my professional journey has been deeply intertwined with the evolution of cancer care in India. Notably, my contributions extend to the Tata Memorial Hospital and, in the early 2000s, a pivotal role in the formation of the Asian Cancer Institute.
As the current Executive Chairman of the Asian Cancer Institute, my commitment extends beyond personal achievements to the overarching vision of creating a healthcare institution that caters to the diverse needs of the Indian population. The institute’s genesis in 2002-2003 was prompted by a recognition of the unmet need for comprehensive cancer care in India and a scarcity of private cancer centers. This void spurred a collective decision among like-minded professionals in the field to establish an institution that would transcend financial boundaries, ensuring that top-notch treatment is accessible to all.
Our growth trajectory has been steady, characterised by a move from a central location in Mumbai to multiple centres across the city, strategically positioned to overcome the challenges posed by the city’s vast expanse. Currently operating in various locations, our bed capacity has grown to approximately 200, with plans for further expansion. This expansion aligns with our core philosophy of addressing the entire pyramid of the population, serving both the affluent and the economically disadvantaged.
The landscape of cancer care in India presents multifaceted challenges. The anticipated doubling of cancer incidence underscores the urgency to establish coordinated treatment centres. However, this is met with obstacles, including the uneven distribution of medical infrastructure, especially in peripheral areas. While the government is working on solutions, the time required to establish medical colleges in every district remains a challenge.
Addressing affordability while delivering quality cancer care is paramount to our mission. We understand the financial constraints faced by a substantial portion of the population. Efforts are underway to enhance insurance coverage, with initiatives such as the Prime Minister’s insurance scheme, although challenges persist in terms of reimbursement and coverage. The broader context includes the evolving landscape of medical technologies, where the imperative to provide cutting-edge care intersects with the financial accessibility of such advanced treatments.
In essence, my role as Chairman encompasses not only overseeing the strategic growth of the Asian Cancer Institutes but also navigating the complex healthcare landscape in India. The journey involves addressing challenges, both systemic and financial, with an unwavering commitment to making quality cancer care accessible, regardless of socioeconomic background.
Can you shed some light on the current areas of research and clinical education you are engaged in, considering the landscape of cancer care in India?
Currently, our focus spans across the entire country, particularly in the realms of medical education and research within the field of cancer care. To comprehend the scope, it is essential to understand the journey to becoming a cancer specialist in India. It involves completing MBBS, a basic degree, followed by three years of post-graduate studies and an additional three years for super specialisation. This extensive training, totaling 11 years, means that specialists typically commence their practice around the age of 30.
In terms of numbers, we are currently grappling with approximately one-fourth or one-fifth of the required number of specialists in the country. To address this, our organisational efforts have seen the establishment of the National Cancer Grid (NCG), an association comprising over 350 institutions providing comprehensive or specialised cancer care. The advantage lies in collective negotiations for pricing with medical companies and the standardisation of clinical protocols for treatment and also conducting clinical trials across these institutions.
The NCG facilitates a joint effort to overcome challenges associated with the affordability and accessibility of cancer care. By uniting under a common framework, institutions can negotiate better prices for machines and treatments, leading to an overall improvement in the efficiency and cost-effectiveness of cancer care delivery.
Moving beyond organisational aspects, the landscape of cancer treatment itself has evolved. Historically, cancer care was often simplified to surgery or radiotherapy. However, with the advent of chemotherapy in the late 20th century and subsequent advancements like targeted therapy and precision medicine, the approach has become more nuanced.
Precision medicine, evolving since the 1980s, has revolutionised cancer treatment. The latest development involves next-generation sequencing (NGS), an expensive but highly precise testing regime. While the cost may be a current challenge, widespread adoption is crucial as it informs targeted therapies, paving the way for a more cost-effective and personalised approach to cancer treatment.
Yet, challenges persist in manufacturing targeted therapies due to patents, making them prohibitively expensive. Immunotherapy, a relatively recent addition to cancer treatment, holds promise but is a work in progress. Striking a balance between technological advancements, affordability, and international regulations remains a complex endeavor.
On the manufacturing front, countries like India and Bangladesh have faced challenges due to international patent agreements. While the infrastructure for drug manufacturing is readily available, cooperation from developed nations and considerations for cost are imperative for sustainable progress in cancer care. The voluntary release of patents by some companies is a positive step, indicating a potential shift towards more accessible and affordable cancer treatments.
In essence, our involvement in research and clinical education revolves around addressing the shortage of specialists, streamlining treatment protocols through collaborative efforts, and navigating the evolving landscape of cancer care with a focus on precision medicine and targeted therapies.
Could you elaborate on the role of different stakeholders, particularly the government, in the context of cancer care in India? Additionally, how is India involved in clinical trials, from phase one onwards, and what improvements or challenges exist in this domain?
The role of the government with respect to cancer care in India is multifaceted. Firstly, the government actively supports costs for individuals insured under government schemes, including government employees. This support involves negotiating favorable rates with suppliers, ensuring that medical treatments are more accessible and cost-effective. The Prime Minister’s scheme further extends this support, contributing to the affordability of cancer care. Tax concessions are granted to incentivise drug manufacturing, fostering an environment conducive to the pharmaceutical industry.
In terms of clinical trials, India is actively participating in numerous trials, both multinational and domestically initiated. The clinical trial landscape spans from phase I trials to advanced stages, reflecting a robust engagement in research and development. While significant progress has been made, there is acknowledgment that more can be done to enhance the clinical trial ecosystem.
The National Cancer Grid (NCG) plays a pivotal role in this context. With over 800,000 new cancer patients registering with the NCG, it serves as an ideal platform for initiating and conducting clinical trials. While many institutions are well-prepared for such endeavors, there is recognition that improvements and expansions can be made. The NCG’s potential to facilitate quick initiation and obtain results efficiently makes it a valuable asset in advancing clinical research and cancer care in the country.
Is India well-prepared to adopt and provide access to precision medicine, and cell and gene therapies, how do you foresee the trajectory of these advanced therapies in the country?
The adoption of advanced therapies, such as precision medicine, and cell and gene therapies, presents a unique set of challenges and opportunities in India. While these treatments are globally discussed and readily accessible in countries like the US, India faces certain barriers, including linguistic diversity and varying levels of awareness about clinical trials among the population.
The linguistic diversity, with 13 official languages in India, poses a challenge in terms of providing information and conducting clinical trials in a way that is accessible to individuals speaking different languages. Additionally, there may be a need for increased awareness and education about clinical trials, ensuring that potential participants fully understand the nature and benefits of these advanced therapies.
I have great confidence in the intelligence and adaptability of the Indian population, particularly with the support of well-informed relatives. While I recognise that the widespread adoption of advanced therapies might not happen immediately, I firmly believe that India is on a trajectory to make significant progress in this direction over the next decade. My optimism stems from the anticipation that as awareness, education, and understanding of these advanced treatments grow, India will actively engage in and contribute to the advancements in precision medicine and advanced therapies. I envision a future where India not only embraces these treatments but also emerges as a substantial contributor to global academic advancements in this transformative field.
Do you believe India will be a hub for making advanced medical treatments more affordable, considering the vast population and the potential impact on accessibility?
The goal is to make these treatments accessible to as many people as possible. While achieving 100 percent affordability might be ambitious, even reaching 50 percent would be a significant stride. Given India’s vast population, covering 50 percent would be akin to catering to a population equivalent to that of the United States and Europe combined. This, in itself, represents a substantial impact, making these advanced treatments more widely accessible and addressing a considerable portion of the population’s healthcare needs.
How do you assess the role of the private sector in advancing healthcare, research, and science in India?
In the healthcare sector, it is crucial to understand that the private and government sectors play complementary roles rather than being in competition. The standard benchmark for a country’s healthcare expenditure is often suggested to be around 4 percent to 6 percent of GDP. In India, the government currently allocates approximately 1.6 percent to 1.8 percent of GDP, with plans to increase this to 2.5 percent in the coming years.
However, the private sector is a substantial contributor, providing over 2.5 percent towards overall healthcare in India. It is important to recognise that this contribution does not imply that people are left without treatment. The private sector plays a crucial role in filling the gap, offering beds, and delivering care to a significant extent.
The collaboration between the private and government sectors is vital for a holistic healthcare system. Private hospitals and healthcare providers contribute significantly to clinical care, ensuring that a substantial portion of the population receives the necessary medical attention.
Furthermore, the private sector’s involvement in research is an area that requires attention. While research may not be immediately perceived as revenue-generating, it is integral to advancements in medical knowledge and the development of innovative treatments. In more developed healthcare systems like in the US, private industries allocate substantial budgets to hospitals for conducting clinical trials and research. This collaborative approach ensures that hospitals are willing participants in advancing medical knowledge.
In India, there is an evolving understanding of the importance of collaboration between industry leaders and the healthcare sector. The realization that research and innovation are essential for long-term progress is gaining traction. As minds open to these possibilities, positive changes are expected, and collaborative efforts are likely to address challenges and foster advancements in healthcare in India.
Are there comprehensive policies in place to address diseases like cancer across India, considering the diverse population?
India has established cohesive policies, akin to the approach taken for the COVID-19 vaccine. The regulatory framework, including FDA policies, ethical review boards, and scientific protocols, is in place to govern clinical trials and research. However, there is room for improvement, particularly in strengthening a central monitoring system to ensure systematic oversight of all trials, and efforts are underway to address this challenge.
What are the ambitions of the Asian Cancer Institute, specifically in terms of patient care and outcomes?
The primary goal of the Asian Cancer Institute is to provide the best standard of care for patients. The focus is not only on treatment but also on achieving positive outcomes over time. The ambition is to ensure that patients not only survive but live a near-normal lifespan. This includes restoring individuals to physical normalcy, enabling them to continue their work until a typical retirement age. The institute aims to deliver the best proven treatments as demonstrated by clinical trials while ensuring cost-effectiveness.
Looking ahead 3 to 5 years, what are your hopes for oncology in India?
Our vision is clear – we aim for standardised, accessible, and affordable cancer care for all Indians, yielding optimal results. The goal is to significantly increase the percentage of people receiving top-notch cancer care, striving for 70-80 percent accessibility within the next five years. Despite the challenges, I am optimistic about the substantial improvement we can achieve in the near future.
Do you have a message for our audience, especially our Indian audience, regarding healthcare improvement?
In conclusion, I would like to emphasise the transformative potential of a robust public education policy focused on prevention, particularly in the context of healthcare. Addressing preventable factors could lead to a significant reduction, up to 30 percent to 40 percent, in cancer cases. Simultaneously, strengthening pharmaceutical policies to lower costs could ensure broader access to healthcare for the remaining percentage. While there might not be a permanent solution to complex issues like cancer, an adaptive and evolving strategy is essential. Let us collectively strive for a system that ensures accessible and affordable healthcare for all.
