JOIN USWhen 50-year-old Rajan R was diagnosed with lung cancer, he was devastated. Like others who had been handed the cancer card, he thought his life was over. But after browsing the internet and consulting a leading oncologist in the city, he felt more hopeful.
The knowledge that treatments for lung cancer had evolved dramatically over the past five years, made him optimistic. In addition to eight new chemotherapy drugs, researchers had developed new, targeted medicines that attacked genetically deviant cells. And, advances in immunotherapy added to the new mix of remedies.
"Exciting developments in lung cancer treatments have changed the prognosis for many," says Dr Shyam Aggarwal, Senior Consultant Oncologist, Sir Ganga Ram Hospital, Delhi. New, personalised treatment protocol treats cancer as a genetic disease, based on the finding that cancer genes vary from one person to another.
Now, oncologists rely on gene expression assays to identify which cancer patients are at low risk for spread, and who will or won't benefit from a particular therapy. Lung cancer, for instance, is driven by four genes,
and treatment should ideally cater to genetic variations. "It's criminal to ignore the genes," says Zoya Brar, Co-founder and MD, Core Diagnostics, who predicts that targeted cancer treatments will become a global treatment norm.
Looking at Rajan's case, it's easy to understand why genetic testing is a game changer. Since his tumour tested positive for EGFR mutation (present in over 50% of lung cancer patients), his doctor put him on a new drug called Tagrisso (osimertinib), developed specifically for the treatment of EGFR-mutant lung cancer. The results were dramatic. "I was able to go for my annual hike in the mountains," said Rajan.
Not everyone is as lucky as him. So far, the approach to treatment of lung cancer has been standard; a one-size-fits-all protocol that involves a lung biopsy, usually followed by surgery, radiation and chemo, either alone or in combination. The outcome varies from one patient to the next.
But what else can we expect? India has 10 lakh new cancer patients every year and barely enough specialists to treat them. The ratio of medical oncologists to patients is estimated at 1600 patients per medical oncologist, much higher than in the West (US - 100:1 and UK - 400:1), according to the E&Y Report Call for Action: Expanding cancer care in India; July, 2015.
Precision medicine
For precision medicine to become a reality in clinical settings, many factors must be taken into consideration. Since targeted therapies are customised on the basis of the genetics of each patient's cancer cells, they require sophisticated diagnostic tools and involve a complex decision-making process.
But how can this be achieved in a country with a mere 15 labs equipped with the technology and expertise to do genetic paneling and a dearth of oncologists willing to embrace the idea of precision medicine?
"There's a pool of us who keep up with global medical advances, and are excited to take them forward here," answers Dr Aggarwal. In his own hospital practice, he routinely recommends genetic paneling to lung cancer patients.
Like him, there is a small pool of specialists committed to the provision of personalised treatment. This is made possible by global bio-pharmaceutical companies, who are breaking barriers in their attempts to make new, life-extending cancer drugs more accessible.
Making an entry into diagnostics has been a major shift for some pharmas that grapple with multiple considerations: is the patient fit enough for a tissue biopsy, and how many genetic mutations to test for?
Another factor crucial to precision medicine is the need for trained genetic counsellors. Currently, genetic counsellors in hospitals are focused on pre-natal testing and counselling, and there's a glaring dearth of counsellors in oncology.
Despite the constraints, enthusiastic oncologists are embracing new technologies, such as the "liquid" biopsy. Though this isn't as reliable as a solid tumour biopsy, a liquid biopsy is sometimes the only option for a patient with advanced cancer: it involves just a blood sample, and serves to monitor the effectiveness of treatment, detect genetic mutations and help doctors plan the next phase of treatment.
Indeed, the future looks brighter for lung cancer patients in India. But straddling the new world of personalised treatments calls for an overhaul of clinical settings. We need to build genetic literacy, affordable gene tests, and establish formal guidelines for genetic education in medical colleges.
(The author is a microbiologist who writes on health issues)