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Wednesday, Nov 13th

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Home News and Update Year 2013 The cruel economics of cancer care

The cruel economics of cancer care

Every year, tens of thousands of cancer patients flock from all over the country to the Tata Memorial Hospital in Mumbai, India's premier cancer treatment institution. They travel miles away from home for reasons such as the absence of treatment facilities closer to where they live, and the quality of care that the hospital provides. Importantly, many come because they have nowhere else to go. The Indian government–funded Tata Memorial is one of the few government institutions that can provide the gamut of quality cancer care for free or at highly–subsidised rates.

The significance of this cannot be overstated.

"It is a myth that cancer is just a health issue," says the World Cancer Day website run by the Union for International Cancer Control. "Cancer negatively impacts families' ability to earn an income, with high treatment costs pushing them further into poverty."

With very little by way of government or insurance–sponsored healthcare, it is estimated that nearly 39 million Indians are pushed into poverty by all sorts of healthcare costs. With cancer that is not difficult to imagine.

Cancer treatment runs into lakhs of rupees especially when the disease is detected in advanced stages requiring radical intervention in the form of surgery and/or expensive new drugs and diagnostics. And it is widely acknowledged that a majority of cancer cases in India are detected later rather than sooner. By one estimate, over 45 per cent of families with one cancer patient face catastrophic expenditures and 25 per cent are pushed below the poverty line (BPL).

This is alarming. For one, cancer in India and all other developing countries is on the rise as a result of greater industrialisation, urbanisation, changing lifestyles, and an increase in average life expectancy. The Indian government's National Cancer Control Programme, estimates that there are between 2 and 2.5 million cancer patients in the country at any given point of time. Recent reports suggest that India is adding one million new cases of cancer every year. Doctors fear that South Asia (India, Pakistan, Bangladesh) could account for nearly 50 per cent of the world's cancer cases by the end of the decade. (Data here is more accurate than the first one – note the difference)

Inadequate infrastructure

Unfortunately, neither awareness of the disease nor the medical infrastructure to detect and treat it have kept pace with its growth. Consider, for instance, the number of oncologists in the country. It is estimated that India has only 2000 oncologists while it needs thrice as many. Just 10 institutes reportedly offer Medical Council of India (MCI)–approved speciality courses in oncology. Until two years ago, they had only 200 seats between them. Even a premier institution such as Tata Memorial complains of not enough hands. The hospital has 450,000 follow–up patients every year and an annual registration of 50,00 new patients. However, its permanent staff is limited to 150 doctors, at best. The same ratio in a foreign country would be 700 doctors for 30,000 annual registrations of new patients, a senior hospital official recently told the media.

The cruel economics of cancer care

It is but obvious that a shortage of doctors will take its toll on the number of hospitals offering cancer care. While there has been an uptick in investment in cancer treatment centres in the cities, patients in smaller towns and rural areas continue to be deprived. As per a BCG study in 2010, as opposed to the 200 cancer centres in existence, India needed at least 840. While the government does own many regional cancer centres, they are often ill–equipped or badly–managed. In recent years, most of the investment has occurred in the private sector where treatment is far more expensive than in a government institution.

Setting up a fully–fledged cancer hospital is capital–intensive – a 100–bed hospital in a city could reportedly cost as much as Rs 50 crore. And human resources – not just doctors, but also nurses, technicians etc – are also a continuing challenge.

Sophisticated diagnostics, a very important element of cancer therapy, are not easily available either. For instance, in recent years drugs have been developed that work on only certain sub–groups of patients and it is important that they be identified using specific diagnostic tests. But these are not widely–available.

Low awareness

It does not help that patients reach an oncologist/treatment centre only when the disease has considerably advanced making treatment that much more expensive and survival less likely. Here, it is not just the absence of infrastructure that is the culprit but also awareness. Consider breast and cervical cancers. These are the two leading causes of the disease in Indian women and accounted for 17 per cent and 10 per cent of cancer mortalities among them, according to a 2010 study published in The Lancet.

Both cancers can be detected early if screening is undertaken in an age–appropriate manner. Breast cancer can be detected through self examination which takes only 1 hour per year; screening using ultrasound, mammography, diagnosis using breast exams and mammograms, MRI etc.among other screening technologies. Mammography is the single most screening and diagnostic technology that can detect breast cancer earlier. According to American Cancer Society, 34% of breast cancer mortality is down from 1990 with the help of annual mammograms for early detection combined with treatment. India do not have such a policy. The conventional method to detect cervical cancer is the pap smear of the cells of the cervix that are studied under a microscope for abnormalities. More recently, reports suggest that a simple vinegar test – swabbing the cervix with vinegar and watching with the naked eye for a colour change – could save millions of lives without the need for a laboratory or highly–trained staff.

Doctors also recommend that those at high risk for these cancers take certain precautions since there is now enough information on some key risk factors.

However, voluntary screening is abysmally low in India even among the educated. And the government has yet to make a big enough dent in early diagnosis/prevention through public screening. For instance, late last month it was reported that not even 50 per cent of the targeted population turned up for a government cancer screening camp in northern India in spite of celebrity endorsements and aggressive canvassing by the state health department and India's National Rural Health Mission. And even when they attend camps, patients are often lost to follow–up.

All this directly impacts survival post–diagnosis. Earlier this year, a University of Michigan study found that women in developed countries survive roughly a decade longer than than those in poor–to–middle–income countries after a breast cancer diagnosis. The authors studied around 300 women in the rural district Udipi in Karnataka which is one of India's better states when it comes to healthcare. They found that less than nearly 70 per cent were diagnosed in the late stages of cancer effectively knocking off a decade from their survival.

The five–year survival rate for Indian women with breast cancer is reportedly about 60 per cent compared with 79–85 per cent in developed countries. Since Indian women tend to develop breast cancer a decade earlier than their western counterparts, this suggests that many die at a relatively young age.

Awareness is surprisingly also an issue among general physicians, the first port of call for patients, who might miss the early warning signs or mistake them for something else. This is also true for non–oncologist specialists. This is evident from the fact that the ministry of health agreed last year to partner an initiative to train graduate and post–graduate medical students in cancer detection and general awareness of the disease through a series of workshops in government medical colleges.

High costs

This combination of short supply and late detection have jacked up cancer treatment which, even without these, is not cheap. While there is no nationwide survey on cancer's economic burden there are some small studies.

According to a July 2011 paper by the Indian Statistical Institute, the average cost of cancer care per patient in government hospital the All India Institute of Medical Sciences in New Delhi amounted to Rs 36,812. (The study looked at patients who underwent radiotherapy which it said accounted for a major portion of cancer treatment cost). To put that in perspective, a family of five that spends less than Rs 4080 per month in rural areas and Rs 5000 per month in urban areas is considered to be below the poverty line. And reports suggest that in private hospitals, the cost of cancer treatment can range between Rs 2 to 8 lakhs.

A study published in 2013 in the Public Library of Sciences on the Economic Burden of Cancers on Indian Households found that cancer–affected households had significantly higher rates of borrowing and asset sales for financing outpatient care. And the 2010 The Lancet study found that the death rate in cancer is higher among the uneducated poor than among the wealthy.

In 2010, 5,56,400 people across the country died of various types of cancer, according to this study. And the 30–69 age group, the productive age group, accounted for 71 per cent or 3,95,400 of the deaths.

Rays of hope

The Indian state is belatedly taking corrective steps. Last month, the Cabinet Committee for Economic Affairs reportedly approved a scheme to invest Rs 4,697 crore to strengthen tertiary care facilities and reduce the waiting period for diagnosis and treatment. The intent is to provide access to free or affordable treatment. The Centre will also facilitate states and union territories to set up cancer institutions thus enhancing the availability of specialized treatment such as radiation and medical oncology in so–called under–served areas. The plan is to set up 20 state cancer institutes and 50 tertiary care cancer centres and also augment the volume and quality of human resources available to staff these institutions through training and mentoring programmes.

The private sector has already stepped up investment in cancer treatment, galvanized by the demand–supply mismatch. Advanced technologies such as radiation machines that allow even small or trickily–situated tumours to be burned non–invasively are now available in some private institutions. Earlier, these tumours might have been considered either inoperable or the surgical procedure high–risk with low chances of success.

Given the high cost of setting up a fully–fledged cancer hospital, some corporates are opting for expanding medical oncology, which is predominantly an outpatient service comprising of chemotherapy drug delivery, to smaller towns and cities.

Since care in the private sector comes at a cost, some state governments such as those of Andhra Pradesh, Maharashtra, and Karnataka have in recent years included cancer treatment in state–sponsored health insurance schemes that pay for the care of below–poverty–line families in private facilities.

Source
Money Control

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