Fighting Lung Cancer in India: Overcoming Barriers to Equitable Care

Lung cancer is increasingly becoming a significant health concern in India, with reports suggesting it was the second most common cancer in Indian males in 2020. It was the leading cause of cancer-related deaths worldwide in both high Human Development Index (HDI) and low HDI countries. Over the course of the last decade, the number of lung cancer cases diagnosed each year in India has risen, attributable to a confluence of several factors. 

The COVID-19 pandemic made matters worse by delaying diagnosis and treatment. Between March 1 and May 31, 2020, there was a 54% reduction in the number of new cancer patients registered, and nearly half the patients were lost to follow-up in many centers in India. With the increasing burden and changing trends of lung cancer, the understanding of its biology and the science of its treatment has also evolved. 

In western nations, the widespread availability of newer diagnostic techniques and optimization of existing treatment as well as newer modalities have led to the improvement in survival of patients with lung cancer. However, limited access to these new treatment modalities in India is still a matter of concern.

Changing Trends, Awareness and Air Pollution

As the number of people smoking has decreased in many countries, a change in patterns and a parallel rise in lung cancer among non-smokers has been observed. Adenocarcinoma, a type of lung cancer, is now the most common type, with an increasing number of non-smokers and women being diagnosed with it. Indoor fuel use-related and traffic-related air pollution has been linked to a higher risk of lung cancer among non-smokers. Worsening air quality in India and prolonged exposure to polluted air could partially contribute to this changing trend.

Despite recent advances in cutting-edge diagnostics and therapeutics, patients with lung cancer in India are mostly diagnosed at an advanced stage, where a complete cure is rarely possible. This could be attributed in part to poor awareness of the disease in both patients and healthcare workers as well as misdiagnosis in a proportion. 

As an example, even today, many patients are diagnosed with tuberculosis and administered anti-tuberculosis therapy based solely on symptoms and chest X-ray findings, without confirmation of tuberculosis in a microbiology lab. In a study done in Bihar, one in three patients were initially erroneously diagnosed with tuberculosis and were treated empirically for 1 to 6 months before they were diagnosed with lung cancer. 

At this point it needs to be emphasized that this issue should not detract from the substantial burden that TB continues to impose on the country's public health and the mammoth efforts to combat it. Rather, the lack of equitable access to high-quality diagnostics makes it hard for the clinician to differentiate between these two scourges, leading to significantly poorer outcomes for patients affected by either of them.

Lack of Quality and Equitable Cancer Care in India

The past decade has seen the discovery of many targetable mutations in stage IV lung cancer. This has led to renewed hope and significant improvement in survival for patients. The presence of  these targetable mutations known as “drivers” is associated with better outcomes. The occurrence of a particular mutation in the EGFR gene is generally the highest in the Asian population(up to 50%), including Indian patients. 

With widespread advanced molecular testing available, the detection of these and other mutations in patients with lung cancer is becoming commonplace. Gefitinib, the first drug given as an oral tablet used for targeting the EGFR mutation in lung cancer improved the survival without tumour growth among patients with the mutation. It is available across India at reasonably affordable prices. Osimertinib (sold under the brand name Tagrisso) is the latest 3rd generation tablet for the same type of cancer that is remarkably better at prolonging survival for these patients. 

Though Osimertinib has become the standard drug prescribed in western countries, this is not the case in India. The cost of Osimertinib(nearly INR 2 lakhs per month) in India is roughly 30 to 40 times that of Gefitinib(approx. INR 5000 per month) making the former unaffordable for most Indian lung cancer patients. Though these newer treatments and advanced molecular testing are available in principle, they are out of reach of most Indian patients.

Another breakthrough in lung cancer therapy that has improved survival of patients in the last decade is immunotherapy. Less than 3% of Indian patients with lung cancer who require immunotherapy have access to it, as shown by a recent study conducted at the Tata Memorial Center in Mumbai. The major barrier to access is economic, with most approved immunotherapy drugs priced upwards of INR 1.5 lakh for a single dose. 

Gender inequality also plays a major role as males have more access to healthcare in general and cancer treatment modalities in specific. The lack of national standardized treatment protocols also contributes to patients receiving substandard care. Palliative care, an integral part of the management of stage IV lung cancer, was received by only 2% eligible patients according to the National Cancer Registry Program Report, 2020. 

The role of geographic inequity in cancer care is often neglected. Despite having one of the highest cancer incidences in the country, the northeastern part of India has the most neglected infrastructure and resources for cancer care. It takes patients days of travel to reach comprehensive cancer centers which cater to huge populations, often after months of suboptimal treatment. As nearly half of patients present with advanced stage cancer, their outcome is often poor.

The Way Forward

Government supported awareness campaigns to educate both patients and healthcare workers are the need of the hour. These campaigns could focus on risk factors, symptoms, early detection, and treatment of lung cancer. Spreading awareness through mass media, anti-tobacco policies and rehabilitation of tobacco users will go a long way. 

There is a need for better infrastructure for diagnostic testing, including microbiological testing for tuberculosis and imaging techniques for detecting lung cancer. This will improve the accuracy of diagnoses and ensure that patients receive appropriate treatment in a timely manner. Adequate training needs to be provided for healthcare workers in differentiating tuberculosis and lung cancer and give appropriate referrals when necessary. 

Promoting policy reforms regulating the cost of drugs and producing quality-controlled generic drugs will help in cutting down the costs of cancer care. India, often referred to as the 'World's Pharmacy,' has the potential to achieve this goal. The inauguration of tertiary-level cancer centers in Assam is a move in the right direction, but this needs to be complemented with a good network of hospitals connecting neighboring states to make an impact in cancer care. Promoting such growth in infrastructure and training of healthcare care providers will make cancer care more accessible to those who need it the most, regardless of their ability to pay.

However, this does not mean that providing equitable care should happen at the cost of high-quality care. Fostering high-quality cancer research in India by the government as well as private sector through the avenue of clinical trials has the potential to bring state-of-the-art treatments within reach of Indian patients. However, to prevent the possible exploitation of vulnerable patients, it is critical that these clinical trials be subject to strict regulations and oversight by ethical committees. In light of all the challenges mentioned above, preventive medicine needs more attention than ever before. Adequate funding and resource allocation in the public health system will help us in fighting not just preventable cancers but various other preventable diseases as well.

---

Edited by Parth Sharma

Image by Deekshith Vodela