By Dr. Moni Abraham Kuriakose – Medical Director, Karkinos Healthcare & CEO, Karkinos Healthcare, Kerala
Cancer is a devastating disease. It is now the second most common reason for morbidity and mortality among the Indian population. Cancer is a disease of aging, modified by environmental and genetic risk factors. Epidemiological transition of the population and better access to cancer diagnosis and reporting in India are considered as the main factors that drive the increase in cancer incidence.
Cancer incidence had increased from 63.4 per lakh population in 1990 to 81.2 per lakh population in 2016. Within the country, the states of Kerala and Mizoram had the maximum increase of 74.1 to 135.3 per lakh population during the same period. Unless there are early and effective interventions, the cancer incidence in the rest of the states will rise to match the level of the high-incidence states (like Kerala and Mizoram) and is likely to increase above 440 per lakh population.
The International Agency for Research on Cancer, GLOBOCAN project, predicted that India’s cancer burden will nearly double in the next 20 years to clock 1.7 million cases by 2035. Ageing and India’s burgeoning population alone do not attribute to this predicted rise of cancer incidence in our country, but several other factors cause cancer. Although ageing of the population is not modifiable, there are modifiable risk factors, such as infection and lifestyle. Unhealthy sedentary lifestyle, lack of exercise, and high-calorie food leading to obesity are modifiable risk factors driving the cancer increase.
“On one side we have the aging population and the high-risk factors rising the cancer incidence and on the other side poor access to quality cancer care driving the cancer burden of India.”
It is now clearly established that tobacco and its associated product use is the significant risk factor for the development of cancers. Tobacco can be consumed in a variety of forms, like smoking (cigarettes, beedis, etc.) or smokeless tobacco chewing (gutka, pan, etc.). Excessive alcohol consumption is also known to cause various cancers, including mouth and liver cancers. Added to all these factors, delayed marriage and poor sexual health can result in cancer. Change in cancer risk profile is reflected in the change in current pattern of cancer. The cancers caused by infections such as cervical, stomach, and penile cancer are on the decline, however there is an increase in cancer associated with lifestyle and aging such as breast, oral, colorectal, and prostate cancers.
On one side we have the aging population and the high-risk factors rising the cancer incidence and on the other side poor access to quality cancer care driving the cancer burden of India. Indian population has disparities in wealth, education and literacy, gender inequities, and other socio-economic conditions that make access to equitable quality cancer care all the more difficult.
Early Detection can have a Major Payback
The outcome of cancer treatment is primarily dependent on the stage of cancer at diagnosis. Early stages of cancer or pre-cancer diseases are often asymptomatic. Although early detection of cancer needs to take place at the primary healthcare level, the primary healthcare care physicians often lack training in identifying early warning signs of common cancers and suspecting asymptomatic early-stage diseases. In addition, the public is misled by the myths associated with cancer, and they lack awareness on the signs of common cancers. To add to the woes are the stigma and fatalistic attitude towards cancer among the public. Controlling cancer is, therefore, a public health issue than a mere upgradation of cancer care infrastructure. This needs a changing attitude of public and medical community towards cancer and changing the health seeking behaviors from ‘illness to wellness’.
Preventive measures need to be combined with the introduction of early cancer detection strategies. Identifying the ‘at-risk population’ who are susceptible to developing cancers in their lifetime, followed by the introduction of targeted cancer screening among those individuals, is very important. Over 80% of cancers in the Indian population are in the breast, mouth, cervix, colon, and lungs. Fortunately, these cancers can be prevented or can be detected early by simple, minimally invasive clinical tests.
The average total cancer care cost for a patient in India is estimated as Rs. 1,16,216. Out of which 93% of all the spending are estimated as out-of-pocket expenses.
Cancer Delivery Process Needs Radical Changes
Along with strategies to prevent and to early detect cancer, there must be measures to improve the quality and the process of cancer delivery. Cancer treatment has evolved from a time when it was a rare disease with limited availability of specialists to a disease that is very common now. In fact, according to the WHO estimation, about 1 in 10 Indian adults will experience one form of cancer at some point in their lifetime. This necessitates moving cancer care from major stand-alone cancer centers that are located in major cities. The management of cancer must be made similar to other common non-communicable diseases by incorporating cancer care as part of multi-specialty hospitals and, even more importantly, integrating early detection and prevention as part of primary healthcare. This is a need of the hour.
Although, stand-alone cancer centers are very effective in developed nations (where there exists a robust primary and secondary health care), in developing countries like India such a model is a failure. These tertiary cancer centers provide high-caliber clinical service and infrastructure that attracts patients from far away locations. By doing so, the tertiary cancer centers over-stretch their available resources. In addition, patients, along with their family members, travel far and wide seeking care at these centers, causing overall increase in non-medical expenses. These costs are estimated to be about 20% of the total cancer care expenses incurred by a patient.
The average total cancer care cost for a patient in India is estimated as 1,16,216 rupees. Out of which 93% of all the spending are estimated as out-of-pocket expenses. This includes only the direct payment made by an individual for services to healthcare institutions. Other indirect expenses such as insurance premium, contributions to employers, taxes, travel and subsistence cost and loss of earnings during the treatment are excluded in this estimation.
Cancer associated financial toxicities can often be a personal tragedy and can be worse than treatment related toxicities. Cancer is one of the primary causes of health-related catastrophic poverty, which requires three generations to recover. The current cancer treatment cost is about five-folds lower in India compared to developed nations. The treatment costs are expected to increase in India by many folds in the next decade. The primary driver is the over dependence on imported medications, diagnostic tests, and equipment. The other key driver is the stage of diagnosis of cancer. In a recent study estimating the cost of oral cancer treatment in India, it was found that the unit cost of treating advanced stage cancer was found to be 42% higher than early-stage disease.
Karkinos Healthcare – Leading Efforts in Controlling India’s Cancer Burden
Karkinos Healthcare is strategically attempting to address the increasing cancer burden with a firm belief that technology would be the biggest equalizer of the future. The core of Karkinos Healthcare is to create an up-to-date dynamic knowledge base and curate that knowledge to distribute, democratize, and integrate cancer care throughout the healthcare milieu. This is encapsulated in Karkinos Healthcare’s concept of empathy-driven “cancer center without walls”, making use of the cancer care knowledge curated by the cancer centers and experts to the community and integrate the two services.
The core objective of Karkinos Healthcare is to create an up-to-date dynamic knowledge base and curate that knowledge to distribute, democratize, and integrate cancer care throughout the healthcare milieu.
This is most vividly illustrated in Karkinos Healthcare’s construct of creating distributed ‘community cancer clinics’ that are established in partnership with existing medical facilities so that a citizen will be able to access cancer care within two hours of travel. These community cancer clinics focus on early detection of five cancers – oral, breast, cervical, colorectal, and lungs. These cancers are chosen as they together constitute over 80% of cancer burden of India and those that can be detected early by relatively minimally invasive tests and if detected early, they are amenable to curative treatment.
In addition, cancer treatments such as chemotherapy, supportive care, and surveillance will be carried out in these centers in partnership with cancer treatment centers of the network. Also, the goal is to upskill primary care clinicians and nurses in cancer care. This is with the realization that cancers are not diagnosed by oncologists but are identified by the primary care physicians and dentists.
Karkinos Healthcare’s protocol gets updated dynamically by curating content from a global knowledge repository using Natural Language Learning Algorithms, so that the treating doctors will have up-to-date knowledge and insight into managing a particular tumor.
When it comes to treatment, Karkinos Healthcare firmly believes that all patients undergoing treatment should be managed as per established national or international protocols. The Karkinos Healthcare protocol is dynamic. Unlike conventional protocols, which are updated periodically (i.e., only when the protocol committee meets after several-year intervals), Karkinos Healthcare’s protocol gets updated dynamically by curating content from a global knowledge repository using Natural Language Learning Algorithms. This will ensure that the treating doctors, even located in remote facility, will have up-to-date knowledge and insight into managing a particular tumor.
The Karkinos Healthcare’s cancer knowledge engine will learn from its own database of patients undergoing treatment with a specific protocol and response to the treatment and gain newer insights, which is hitherto unknown and specific to the Indian population and context. This dynamically curated and self-learning oncology knowledgebase is in the core of Karkinos Healthcare’s decision support system and forms its dynamic cancer care pathway. This information supports all aspect of cancer care from early detection, diagnosis, staging, treatment, supportive care, and surveillance, throughout the lifecycle of cancer care continuum. Rather than being available to a select few specialists in prestigious institutions, such knowledge will be democratized and made available to cancer health providers everywhere.
Also, the protocols curated from the scientific literature needs to be individualized for a specific patient through a multi-disciplinary tumor board*. The principle of “I to We”, where individualization of cancer treatment plan is made by a multi-disciplinary team rather than an individual is at the core of Karkinos Healthcare’s personalized treatment planning process. Because of its network architecture, the expertise can be pooled together from far and wide institutions based on their experience in the field to make treatment decision for a specific patient getting treatment anywhere in its network. The knowledge generated from the response to the treatment will be fed back to the Karkinos Healthcare Knowledge Engine to create newer insights.
The principle of “I to We”, where individualization of cancer treatment plan is made by a multi-disciplinary team rather than an individual, is the core of Karkinos Healthcare’s decision-making process.
Karkinos Healthcare sets itself apart from other healthcare organizations by emphasizing new knowledge creation as a focus area. Despite the fact that knowledge is created in a distributed manner across its network and from around the world, it is conceiving a state-of-the-art center for complex cancers and an advanced central cancer diagnostic lab to support such activity. The data analytical engine driven by Artificial Intelligence and Machine Learning will evaluate the pattern of treatment and its response. These insights will further refine and assist the clinicians to constantly improve the clinical outcome.
The data curation, to drive the knowledgebase engine, will come from every touch point in the patients’ care continuum: screening, diagnosis, staging, treatment, response, and surveillance. Also curated from the clinical, radiologic, pathology, genomic, and environmental factors in hitherto unmatched scale.
Therefore, in a sustained manner, Karkinos Healthcare will unify the core verticals of cancer care into a digitally-assisted ecosystem that screens, diagnoses, treats, and follows-up based on well documented clinical protocols that match global health standards.
This knowledgebase will also empower the patients and the public about the risk factors of cancer and on how to mitigate them and how to seek cancer care in an unbiassed fashion. At every patient touchpoint, the user/patient will be offered digital services that enhances their experience with user-friendly applications and other user-friendly digital communication systems. Although, the successful outcome of the treatment is largely dependent on several factors, the team at Karkinos Healthcare will constantly ensure a supportive, unbiased, transparent environment for the patient to return to normalcy.
To execute the program Karkinos Healthcare has brought together four groups of professionals: Clinicians, Information Technologists, Digital Transformation Experts and Data Scientists. The four group of professionals, in unison, will work on a focused digitally-enabled ecosystem to address the global issue of cancer control.
Overall, Karkinos Healthcare, based on our distributed model of care, will re-orient cancer practice and research to support closer collaboration between general healthcare and cancer care.
Karkinos Healthcare has, thus, embarked on a bold journey with its scalable, state-of-the-art technology platform, curated for oncology, to transform cancer care that can be delivered closer to the patient’s home in an end-to-end manner.
*A tumor board is a group of doctors and other health care providers with different specialties that meets regularly to discuss on making individualized treatment plan for a specific cancer patient and to share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient.
About Moni Abraham Kuriakose MD, FRCS
Dr. Kuriakose is the Medical Director of Karkinos Healthcare and the CEO of Kerala Operations.
Dr. Kuriakose was the Founding Director of Cochin Cancer Research Centre and has previously served Narayana Health City, Bangalore as Director of Surgical Oncology and Director of Mazumdar Shaw Centre for Translational Research, Chairman of Head and Neck Institute, Amrita Institute of Medical Sciences. He has served New York University as a faculty in Head and Neck Surgery, He holds a joint appointment as Professor and Vice Chairman of Head and Neck Oncology, Roswell Park Cancer Institute.
He has over 250 peer reviewed publications and seven international patents to his credit. He is the author of a four-volume textbook titled ‘Contemporary Oral Oncology‘. He has served Indian Head and Neck Cancer Society (FHNO) as its Past President and is the current President of International Academy of Oral Oncology (IAOO).