India Responds to Its Growing Cancer Crisis

India Responds to Its Growing Cancer Crisis

Dr. Shailesh V. Shrikhande
India is a country at a crossroads. With a population of more than 1 billion people, India has a growing middle class that’s projected to reach 200 million by 2020,1 and more people are living in cities. Modernization, however, may have had unwanted repercussions. Gastrointestinal (GI) cancers are now affecting a greater proportion of the population.

Experts think that one reason for this change is that growing numbers of urban dwellers are developing lifestyle habits similar to those in the West.2 Studies have shown that Indians have increased the amount of meat and other animal-based products they eat, along with an uptake in average daily sugar and fat consumption.3 Furthermore, research reveals that a large percentage of the population does not exercise.4 The more rural parts of India have their own lifestyle challenges, with tobacco use topping the list, although anti-smoking campaigns are helping to bring down the number of tobacco users in these areas.5

In the following interview, Shailesh V. Shrikhande, MD, of the Tata Memorial Centre, in Mumbai, India, discusses GI cancers in India and how the steps being taken to address them align with the theme of the GI Cancers Symposium, “Multidisciplinary Care: Local Practice, Global Outcomes.”

Q: Colorectal cancer is the most common GI cancer in India.6 In your opinion, what is contributing to the growing number of cases?

Dr. Shrikhande: It is important to put this statistic into perspective. Compared to the West and the Far East, the incidence of colorectal cancer is far less. In fact, incidence, which is a measure of new cases occurring each year, has not increased dramatically. What has increased is prevalence, the proportion of disease affecting the population. We believe the growing number of cancers can be attributed to the Westernization of our diet, which has become more reliant on fast foods, meat, and fatty foods, as well as a more sedentary lifestyle. The role of genetics has not yet been fully investigated.

Another growing problem is the number of people younger than age 40 who are developing colorectal cancer, especially low rectal cancer. According to retrospective studies conducted at Tata Memorial Centre that reviewed patient records over the past 5 years, these cancers are often large, aggressive, and detected late. As a result, many are not resectable, and outcomes tend to be poor. These findings were first published in the Indian Journal of Gastroenterology in March 2014 and later in the Indian Journal of Surgical Oncology in April 2017.7,8 At this point, we don’t know why so many young people are developing such large tumors. The studies suggest that inadequate access to health care and socioeconomic factors may play a role.

Q: Is there a difference in the kinds of GI cancers people in India get compared to other parts of the world?

Dr. Shrikhande: The incidence of pancreatic cancer is low in India compared to the United States. According to recent data, the number of cases in the United States is 12.4 per 100,000 men and women, and in India, the numbers are 0.5 to 2.4 per 100,000 men and 0.2 to 1.8 per 100,000 women.9 Interestingly, although we have fewer cases of pancreatic cancer than many other countries, we perform a relatively high number of pancreatic resections, largely because we have expertise that is widely acknowledged and recognized in this region. Also, many cases are periampullary cancer, not the classical pancreatic head cancer that is more commonly reported in the West. Between 2002 and 2011, the number of Whipple surgeries performed each year at Tata Memorial Centre increased from 16 to 60, and in the past 4 years, my service has performed more than 500 Whipple resections for pancreas and periampullary cancers.10 

A type of GI cancer of great concern in India is gallbladder cancer, which has a frighteningly higher number of cases in the northeastern part of India, near the Ganga River, than in the western part of the country. Research has shown that India has a distinctive kind of gallbladder cancer. It could arise from water pollution, heavy metal poisoning, biliary parasitic infections, and even Salmonella infections. At this point in time, we’re just not sure; research is ongoing.11

Q: One of your areas of expertise is minimally invasive pancreatic resection. What are the latest findings about this approach?

Dr. Shrikhande: There are a few centers worldwide, including the Mayo Clinic, in Rochester, Minnesota, and the University of Pittsburgh, that specialize in this procedure. The term “minimally invasive pancreatic resection” refers to the Whipple procedure performed either laparoscopically or robotically. This surgery is demanding and is best performed on carefully selected patients—for example, those who are not obese and have smaller tumors not close to major vascular systems.

Furthermore, not only are the resections difficult, the reconstruction is equally complex. In fact, an analysis of the research gathered worldwide on this procedure published in March 2017 in the journal HPB could not say conclusively that laparoscopy is superior to open surgery.12 It appears to show more promise when the tumor is in the body or tail of the pancreas. Those tumors do not require a complex reconstruction after resection.

The technology we have available has potential, but we need to use it wisely after adequate and objective training requirements are met. If not handled properly, technology will not bring about superior outcomes.

Q: What kind of training do surgeons need in order to perform minimally invasive pancreatic resections?   

Dr. Shrikhande: We’re in the process of developing training programs. We know there is a steep learning curve for even conventional pancreatic cancer surgery, which is why surgeons should train at a high-volume center, defined as one that performs approximately 60 to 80 resections per year.

Q: For the past several years, India has been working toward improving the quality of cancer care. What steps has the country taken, and have they made a difference?

Dr. Shrikhande: In 2012, we established the National Cancer Grid, which has grown exponentially over the past 5 years.13 Conceived as a way to unify cancer care in this large, vast country, the grid now has 114 cancer centers. We have been working to ensure that the flow of patients is more uniformly distributed across the country. We have already seen dramatic results, with affordable care reaching more people and hospitals following uniform, high-quality standards. But we aren’t there yet. For example, India has one doctor per 2,000 patients, while in the United States, there is one doctor per 390 patients. We are trying to get closer to that number by training more oncologists and influencing policymakers.

We have also changed our approach to care by establishing disease management groups in our hospitals. Each group has dedicated surgical oncologists, radiation oncologists, medical oncologists, and clinicians from all other allied specialties that are focused on one specialty, such as GI and hepatopancreatobiliary oncology. We regularly use a multidisciplinary approach, with surgical, medical, and radiation oncologists working closely together. These steps have improved the quality of care for all patients with cancer.

Finally, prevention is an ongoing goal. We are working to educate people about the dangers of tobacco, which Indians have long chewed. We are also sending a clear message that the number of GI cancers are increasing, and by eating healthier foods and maintaining a healthy lifestyle, people have a better shot at keeping these cancers at bay.

Q: What are your goals for practice in India? Where would you like the country to be in 10-15 years?

Dr. Shrikhande: We need to continue to develop a skilled workforce, as well as convince policymakers to spend money on health care. To date, India spends less than 2% of the gross development product on health care, compared to 17% spent in the United States. Cancer surgery is underused, and providing complex care to low-resource parts of the country remains a major challenge.14 We are addressing these issues by training and mentoring young oncologists and developing centers of excellence for complex surgery.

Perhaps the biggest change coming is the construction of a new facility on the campus of Tata Memorial Centre. The new facility will have 600 beds and offer state-of-the-art care, leading the way for more progress in the years to come. 

–Marilyn Fenichel