By Dr Suresh Rao

Mangaluru, Nov 2: As an oncologist with thirty years of experience in the management of cancer, initially, as a teaching faculty and presently managing a cancer hospital with my oncology colleagues to give affordable and scientific quality care to people diagnosed with cancer, these are certain observations.

Cancer unfortunately is a major cause of mortality today having a significant impact on the country’s financial/ social and psychological well being.

Observations are in three parts:

1. Perception in people regarding treatment of cancer
2. Interaction with non health sectors
3. Regarding the pitfalls in the medical community

Generally, while treating individuals diagnosed with cancer for the last three decades, there are three major categories of cost involved as per the presentation of the disease in most of the patients. However, there will be exceptions to this rule in some of the rare cancers that are diagnosed.

Category I

Cancers presenting in stage I– This is about twenty percent of the patients on presentation and the treatment will generally be a single modality one that is either surgery or radiation or sometimes chemotherapy. The cost of this single modality treatment generally does not exceed Rs 75,000 - 3 lac. This gives good quality of life and the best scientifically validated survival results which is a cure in about 80-90 percent of the patients. However, there will be exceptions to this rule. In a small minority of young patients the cancer may behave aggressively and may require treatment with monoclonal antibodies or newer drugs and the results may not be good and the cost could be higher.

Category II

Cancers presenting in stage II, stage III and non metastatic stage IV cancers— This is about fifty percent of the presentation and a significant number of these are completely curable. In cervical and head and neck cancers, about forty to fifty percent of stage III and non metastatic stage IV cancers are completely curable. Non metastatic stage IV cancer means an oral cancer with lymph nodes in the neck, but not in the liver, lung or other far off areas. Category II cancer will generally require all three modalities (surgery, radiation and chemotherapy) of treatment. This treatment of three modalities (surgery, radiation and chemotherapy) can last from four to six months and the cost can vary from Rs 3 lac to Rs 5 lac for the entire treatment depending on the number of modalities of treatment that are used. However,
there will be a few exceptions in young patients with aggressive cancer where the cost can be higher.

Category III

Cancers presenting in stage IV and incurable- Thirty percent of patients present with advanced incurable cancers like stage IV lung cancers / liver cancers /metastatic ovarian cancer and high grade brain tumors. This category also includes relapsed cancers from category I and II. The cost can vary from few thousand rupees to lac or even crore. The life span of these patients is generally a few months to a year even with the best possible treatment that we have today. Maximum financial / psychological burden is in this category.

As a doctor practicing oncology the ideal situation would be that no one should be diagnosed with cancer, which is not going to be the scenario in my lifetime. God forbid should I be confronted with a situation to deal with the big C what would be the approach toward treatment and its cost? The decision would be based on purely scientific data and on the treatment modalities that are available. With a fixed deposit or insurance of three to five lac of rupees it is adequate to treat most cancers that are curable. In case of an exceptional diagnosis wherein a bone marrow transplant may be curative and may cost a lot at a very good center with expertise in the treatment of a disease like multiple myeloma it would be sensisble to dispose of a significant amount of the assets.

But, if it is an incurable cancer with limited survival it is very important to carefully understand the scientific evidence in terms of risk benefit ratio and the quality of life for additional survival. It is a tough battle against cancer as one encounters failure but the doctor and patient are prepared to fight it out. Most of the oncologists and their patients never lose courage against the battle with cancer. Many times it is the doctor and patient who succeed and get the upper hand, but many a time they encounter failure. The doctors and the courageous patients fight on and on.

Interactions with the non health sector

As an Oncologist working for three decades like most medical professionals, it is a stressful job as it is a field which deals with human life. It cannot be compared with other jobs.

Interaction with other aspects of life apart from hospital work is a different world where the medical profession is merging. Doctors generally begin the day very early going to the hospital and return late in the evening working not less than twelve hours a day. My son is grown up and is now an engineering student and frankly my contribution in his upbringing has been minimal and his mother helped him all the way. She took care of his needs attending PTA meetings and teaching him good values.

There was an elderly patient diagnosed with prostate cancer which had spread to his bones. He was in severe pain and required radiation to reduce his pain and control the disease. His son who had come from USA was told regarding the incurable nature of his father’s illness and that most patients have an overall survival of 2 to 4 years with reasonable quality of life. But he wanted to avail a benefit of Rs 10,000 from a government scheme. He died two years later from cardiac cause. I was invited by his family to attend the 13th day function as per the Hindu tradition. His children and grandchildren who are all settled in the US came and there were more than a thousand people who attended the lunch. It was difficult to understand why the son or the patient who wanted to save a few thousand rupees during the treatment
were now spending lacs on this function.

A holiday for my twenty fifth wedding anniversary cost a lac of rupees for three days at a luxury hotel. By the third day we all began to miss home food and within three to four days most of us completely forgot about the time spent at the luxury hotel. The cost of a good bike will vary from Rs 1.9 lac to Rs 2.6 lac on the road. A movie or a comedy show will cost about Rs 1000. People in my ancestral village say that cultivation is done in two ways. A small part where no pesticide is used is kept for personal consumption and the rest where pesticides are sprayed is for sale in the market.

A friend purchased a new model of a diesel car which cost him around Rs ten lac and he sold it after a year for Rs 5.4 lac. He said that he had made a mistake in the choice of his vehicle and if he waits for another year it will not even fetch him Rs two lac. He said he cannot fight with the car company as it will be futile, but he told me had he paid Rs 4-5 lac for treatment of his or any member of his family and it was not successful, he would blame the medical fraternity and question the doctors competence.

There are innumerable examples of our interaction with government officials / banks where generally the rules are applied as per the books for most of us. If you go to a government office for some certificate, a form needs to be filled and then it may take days or weeks to get the documents. In a bank to apply for a loan the manager
will make sure all the documents are perfect before he sanctions the loan. But in a hospital you can never put the patient through this torture. We never ever shout or create a scene at the office of the DC or SP even if we have to wait for hours or do not get the documents for months even though their salary is paid with the taxpayer’s money.

The health sector is slowly and firmly merging in its behavior with the non health sector. There will be more legal papers to be signed in future by the patients and family so that the medical professional is safe. All aspects of treatment, its side effects and failures running into pages will be put in writing. I think this will put the patient at a disadvantage in terms of cost and faith in the system will further erode. Once the doctor considers his patients purely as a consumer we would
have crossed the sacred line in this profession and this is happening very rapidly.

Can doctors do better in changing the perception of the tag of high cost in treatment of cancer?

As a radiation oncologist with my wife, an oral pathologist the general impression in my family was that my son would choose the medical field as his profession. But he decided to skip Biology after his class ten and wanted to be an engineer.

He gave me two reasons:

1. Medical profession is too hectic and stressful with no time for oneself
2. It is a very noble and satisfying profession because you can save someone’s life, but it can also be the most corrupt as when it comes to one’s health we have to believe the doctor

The first thing that crossed our mind was that he would have heard the innumerable conversations at dinner with colleagues and many a time the conversation was about the lack of professionalism and ethics that some in our fraternity practice.

As the line between health and non health sector is fading, the same methodology to promote health is being applied.

1. People ask for quotations regarding the treatment cost like we do while buying an equipment at our hospital or a home appliance
2. In big hospitals it is common to see desks that will help the patient arrange to pay hospital bills as monthly EMI like in banks for a housing loan
3. There will be boards outside reputed hospitals offering discounts of 20-30 % on various investigations, doctor’s fees like you see at a supermarket
4. There are paid articles/ paid news / social media etc giving medical information (no article is free) which are sometimes useful, but many a time totally misleading
5. Then of course, innumerable uncontrolled messages on whatsApp or other social media regarding quick fix solutions to cancer cure that are sometimes very expensive

Most patients who are in the incurable stages of cancer try this method all over the world.

It is very important to get adequate information regarding the treatment and its benefits more so in cancer management. All results of treatment for cancer are in statistical numbers giving the time of survival and the percentage. There is disease free survival, overall survival and progression free survival. The issue of quality of life that the treatment induced side effects cause need to be understood too. Even for a medical person who is not an oncologist it is almost impossible to choose the right option of treatment if he / she goes through the scientific literature. So a non medical person is totally lost and the only source of information for a layman apart from the treating doctors is the internet and social media. To quote an example, an 80 year old man was in good health and driving his vehicle. A routine ultrasound showed a small lesion at the head of the pancreas. His son-in=law from USA who is a doctor insisted on a PET Scan which was suggestive of probable cancer. Then, on the persistence of his family, the patient underwent tests, with the doctors using advanced scopes and biopsy techniques to confirm the presence of cancer. He developed a leak of bile, which can happen and was in the critical care unit. Pancreatic cancer is one of the most difficult to treat and the results are very poor as the surgery is risky even in a young patient.

A general feeling among people who can afford the treatment is that the most advanced and expensive treatment will give the best chances of survival which is never true. A hospital quotation for breast cancer of Rs 30-40 lac is considered good by many who take the internet as reference. But there are genuine cases where trial drugs have shown promise and although very expensive, may be administered with a clear understanding that it may not be the standard of care.

The government spends huge money on management of cancer and starts large hospitals with hundreds of beds spending thousands of crores. Cancer is a chronic illness and requires multiple visits by the family, so starting a large hospital where people have to travel hundreds of miles is not feasible and will not benefit many who want
to avail treatment there. When you see patients diagnosed with cancer from far off areas using the corridors of large government hospitals to take rest, it shows the inhuman way and the indignity that a fellow human being is subjected to. In view of the huge number of patients, the appointments given may take a month or more before initiation of the treatment. This waiting of more than a month for diagnosis, staging and then treatment is not acceptable for a disease like cancer. The reasonable time to start treatment is one week from the first visit to the doctor in most of the cancers. Instead of spending thousands of crores on a large hospital, a most modern cancer hospital can be commissioned with Rs 50 crore at a district headquarters. This district cancer hospital has to be managed by honest members of society
with government funding (that is the taxpayer’s money) to run it efficiently with accountability at every step. I am sure we can find a few honest people with integrity in every district who will not be influenced by powerful people.

About 95% of the patients are grateful to the doctor and appreciate his work. People diagnosed with cancer undergo tremendous stress during their treatment and follow up visit. Majority of our patients during follow up visits after the conclusion of treatment experience decreased sleep one or two days prior to their scheduled visit. They anxiously wait for the scan results and once it is told that the reports are normal they go home relieved. This happens every four months for years together and it is the same for all patients who may be a doctor/engineer/ home maker or a farm laborer by profession.

Cancer is the leading cause of death in USA in most of its states. The medical community should also remember that a medical error or a wrong decision is the third leading cause of death in the US. The pattern must be similar all over the world. This is the reality that the medical profession must accept and do everything possible to reduce it.

A small percentage of the doctors may not be ethical and an even smaller percentage of the patients/ caregivers create problem to the healthcare professionals for which the whole healthcare system is being penalized. I feel that the onus is on the medical profession to correct the anomaly or else we may be heading for difficult times.

Dr Suresh Rao, Mangalore Institute of Oncology (MIO) director and Radiation Oncology head