Cancer Care in India: Complex Challenges in a Populous Nation

A Conversation with Rakesh Chopra, MD

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3.8.30_chopra.jpgWith 1.22 billion people, India is the second most populous country in the world. Experts project that cancer incidence in India will increase by more than two-thirds over the next 20 years, to approximately 1.7 million new cases per year. Due to a range of economic and social issues, most of India’s patients with cancer first present with advanced disease, adding another layer of complexity for the country’s oncology community. For this installment of the ongoing Oncology Worldwide series, The ASCO Post recently spoke with Rakesh Chopra, MD, a clinical oncologist at the Apollo Cancer Centre, New Delhi, India.

Medical Training

What were the influences in your life that steered you toward a career in medicine?

We have several physicians spanning four generations in my family. So, deciding to become a doctor actually came quite naturally.

Please briefly describe your medical school experience in India.

In addition to following a standard medical curriculum, as the first class at Delhi University College of Medical Sciences, we had the additional challenge of establishing the school as a highly competitive medical training institution. From the very beginning, our class scored equal to or surpassed two other medical schools at Delhi University. In addition to the classroom experience, we were required to intern in the largest public hospital in India (almost 9,000 beds), which offered a huge range of clinical material and fostered the skills essential to making critical clinical decisions immediately.

Following that experience, I did two 6-month stints, each focused on one specialty—internal medicine and dermatology. As a postgraduate, I did a fellowship in internal medicine at Armed Forces Medical College. In this very regimented environment, the academics were enhanced by a strong sense of discipline, which served me well later in my career.

Why did you choose oncology as a specialty?

Early in my internal medicine practice, it was clear that Northern India had no real medical oncology specialists. I saw this field as an opportunity to pioneer and help fill a much-needed void in care for patients with cancer in a country that suffers from a severe shortage of oncology professionals.

Challenges for Oncology in India

What are the greatest challenges facing the Indian oncology system?

3.8.30_quote-chopra.jpgFirst, there are only two rural registries in all of India. Such data limitations prevent us from knowing accurately the true burden of cancer in the nation and the range of cancer types. Moreover, in the context of India’s massive population and geographic size, the limited number of specialists severely constrains the delivery of treatment to rural areas. We also need more affordable medicines, supportive care, and supplements to be accessible in the vast rural communities.

So far, all oncology protocols have been developed in the West. We need to develop protocols based on India’s own population characteristics, centered on the constitution of the country’s diverse peoples. However, because of difficult economic times, cancer research funds are severely limited, which also hampers the collaborative work that needs to be expanded, both within this country and with other parts of the world. Clinical trials present a huge opportunity here, as we have a large treatment-naive and younger population that would serve research well.

There is also a need for smaller, multidisciplinary, well-equipped facilities to deliver comprehensive cancer care in the smaller townships and rural areas where much of the population remains underserved.

Oncology needs to be taught by oncology specialists earlier in the medical education process. This applies to physicians, nurses, and other paramedical professionals. Further, education of the community at large about cancer risks should be expanded, along with cancer screening and other preventive strategies that need greater emphasis.

Current Practice

Please describe your current clinical practice, perhaps highlighting an interesting case report?

I work out of the fourth largest corporate hospital in the world, which is also the largest corporate hospital outside the United States. My hospital practice, a tertiary cancer care facility, is combined with academic medicine, research, and a full-fledged, “super-specialty” training program.

One of my more interesting and challenging cases was a 20-year-old patient with Gardner’s syndrome who was given 15 days to live in an Australian facility. He returned to India for terminal care and to be with his family. I was familiar with the specific treatment of this disease, and after giving him heavy supportive care, he has been well for more than 10 years.

Politics and Cancer Care

Does the political climate in India affect access to quality care?

Yes. The government has permitted use of biosimilar and other generic drugs to be available at a fraction of the cost. At the same time, the Indian government needs to create or otherwise incentivize the development of more multidisciplinary cancer facilities that provide radiation, surgical, and medical oncology care. This is a major political challenge.

Future of Oncology in India

Any thoughts about the future of oncology practice in India?

A great deal of progress has been made in Indian cancer care over the past 30 years. However, the future of cancer care in India and elsewhere lies in preventing the preventable cancers and developing more personalized medicine. We’re going from broad-based to increasingly targeted approaches, and, more and more, we are focused on organ preservation. ■

Disclosure: Dr. Chopra reported no potential conflicts of interest.