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 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 1-2

Cost-Effective breast cancer care in India


Chennai Breast Centre, Chennai, Tamil Nadu, India

Date of Submission21-May-2018
Date of Acceptance11-Jun-2018
Date of Web Publication29-Jun-2018

Correspondence Address:
Selvi Radhakrishna
Chennai Breast Centre No 47, South Beach Avenue, MRC Nagar, Chennai - 600 028, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAMR.IJAMR_26_18

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How to cite this article:
Radhakrishna S. Cost-Effective breast cancer care in India. Int J Adv Med Health Res 2018;5:1-2

How to cite this URL:
Radhakrishna S. Cost-Effective breast cancer care in India. Int J Adv Med Health Res [serial online] 2018 [cited 2018 Sep 21];5:1-2. Available from: http://www.ijamhrjournal.org/text.asp?2018/5/1/1/235605



The burden of breast cancer is increasing in India. The 5-year survival rate ranges around 50% in India as against 80% in the developed countries. The higher mortality rates are attributed to late stage at presentation and disparities in cancer care. The healthcare system is challenged in many aspects from data collection, infrastructure for early detection, inadequate pathology services, fragmented treatment options especially radiotherapy, palliative care, and capacity building in all aspects of cancer care.

Established screening and treatment guidelines that are widely followed in the West cannot be replicated in India. Development of a cost-effective model for early detection, diagnosis, treatment, and aftercare along with a good palliative care program has the potential to prevent thousands of deaths every year. The Indian Council of Medical Research has published a consensus document on the management of breast cancer.[1] A multidisciplinary team approach to deliver evidence-based management for all breast cancer patients is essential to improve the outcomes.

Mammographic breast cancer screening is still being debated worldwide and is not suitable for population-based screening in India. Creating awareness about breast health is important, and self and clinical breast examinations continue to be relevant in India. Culturally and socially sensitive educational material should be made available through print, audio, and visual media. The National Health Mission has rolled out an ambitious cancer control program that includes clinical breast exam by Accredited Social Health Activist workers and Auxiliary Nurse Midwives. The vast majority of breast symptoms are not cancerous, and the healthcare providers should have standard protocols and adequate training to address most of the symptoms at a primary health care or secondary health care level. Diagnostic pathology could be centralized in district general hospitals and teaching hospitals to optimize resources and improve diagnostic yield.

Surgery continues to be the most effective treatment modality for breast cancer. While breast conservation is preferred in most Stage 1 and Stage 2 cancers and also in some locally advanced breast cancers after neoadjuvant chemotherapy, several nonclinical factors, such as the cost of radiotherapy, availability of radiotherapy facilities, travel and local stay, and time taken for the treatment are important determinants in the choice of surgery. The wider adoption of hypofractionation regimes have made treatment times shorter and increased machine time availability for more patients.[2],[3] Newer surgical techniques such as sentinel lymph node biopsy have become the standard of care in clinically node-negative patients. This is yet to be adopted widely in our country. The availability of frozen section facilities and the need for radioisotope and gamma camera for sentinel node identification are limiting factors. The technique of low axillary sampling, popularized by the Tata Memorial Hospital (TMH), is a good alternative and can be easily adopted by most centers, thereby reducing the morbidity after complete axillary clearance.[4]

The availability of generic drugs and biosimilars has made systemic and targeted therapies very cost-effective in India. With trastuzumab, there is evidence to support that shorter duration of trastuzumab has a similar benefit compared to 1 year of treatment.[5],[6] Newer drugs approved often have very small incremental survival benefits and are often very expensive. Equivalence and noninferiority trials are needed in the search for more cost-effective treatments. Simple cost-effective interventions such as intramuscular progesterone 500 mg 5 days before surgery improved overall survival in node-positive patients as shown in the study conducted by TMH, India.[7]

Integrating palliative care early into treatment and making it widely available is important in achieving improved quality outcomes for patients and caregivers and avoids unnecessary hospital admissions and indirect costs.

The National Cancer Grid (NCG) under the auspices of Tata trusts is working toward achieving cost-effective quality cancer care in our country. “Choosing wisely India” is a flagship initiative of the NCG that prioritizes investments in cancer care. The recommendations of this initiative will be published soon.

Comprehensive insurance schemes for patients below the poverty line have been rolled out by the Government, and this can be used for hospitalization and treatment in secondary and tertiary care facilities. A strong commitment to building, reforming, and funding public health sector capacity and quality is essential to realize the goal of universal health care, which would also ensure access to affordable and cost-effective breast cancer care.[8]



 
  References Top

1.
ICMR Subcommittee on Breast Cancer. Consensus Document for Management of Breast Cancer; 2017. Available from: http://cancerindia.org.in/wp-content/uploads/2017/11/Breast_Cancer.pdf. [Last accessed on 2018 Jun 21].  Back to cited text no. 1
    
2.
START Trialists' Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, et al. The UK standardisation of breast radiotherapy (START) trial A of radiotherapy hypofractionation for treatment of early breast cancer: A randomised trial. Lancet Oncol 2008;9:331-41.  Back to cited text no. 2
    
3.
Whelan T, MacKenzie R, Julian J, Levine M, Shelley W, Grimard L, et al. Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node-negative breast cancer. J Natl Cancer Inst 2002;94:1143-50.  Back to cited text no. 3
[PUBMED]    
4.
Parmar V, Hawaldar R, Nadkarni MS, Badwe RA. Low axillary sampling in clinically node-negative operable breast cancer. Natl Med J India 2009;22:234-6.  Back to cited text no. 4
[PUBMED]    
5.
Earl HM, Hiller L, Vallier AL, Loi S, Howe D, Higgins HB, et al. PERSEPHONE: 6 versus 12 months (m) of adjuvant trastuzumab in patients (pts) with HER2 positive (+) early breast cancer (EBC): Randomised phase 3 non-inferiority trial with definitive 4-year (yr) disease-free survival (DFS) results. J Clin Oncol 2017;36 (suppl; abstr 506).  Back to cited text no. 5
    
6.
Joensuu H, Kellokumpu-Lehtinen PL, Bono P, Alanko T, Kataja V, Asola R, et al. Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer. N Engl J Med 2006;354:809-20.  Back to cited text no. 6
[PUBMED]    
7.
Badwe R, Hawaldar R, Parmar V, Nadkarni M, Shet T, Desai S, et al. Single-injection depot progesterone before surgery and survival in women with operable breast cancer: A randomized controlled trial. J Clin Oncol 2011;29:2845-51.  Back to cited text no. 7
[PUBMED]    
8.
World Health Organization. The World Health Report 2010. Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010.  Back to cited text no. 8
    




 

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