From detection to treatment, precision is improving cancer care in India

One in five men and one in six women in the world develop cancer in their lifetime. In 2018, an estimated 784,000 (or 8.17 per cent) of them were Indians, according to the World Health Organization. A report published by The Lancet said that cancer deaths in India have more than doubled between 1990 and 2016. It’s the country’s second biggest killer after cardiovascular diseases and the Indian Council of Medical Research is concerned that India does not have the infrastructure to deal with these rising incidents. 

Reporting from Gurugram, the world’s most polluted city and consequently a hotbed of carcinogens, I am cautious in estimating that cancer research and treatment in India is making progress. I wrote last year about how doctors are now better equipped to deal with complex tumours with major hospitals deploying advanced surgical robotics, such as the da Vinci robotic surgical system, which is guided by 3D imaging and is less invasive and more accurate.

Radiation or radiotherapy, one of the three major fields of oncology, along with surgical and medical, is now at the centre of innovation. Apollo Hospital in Chennai last month introduced South Asia to its first Proton Cancer Centre. It’s the most sophisticated form of radiotherapy in the world because of its focus on two aspects: delivery of high doses of targeted radiation to the tumour and reduced adverse effects of radiation on the rest of the body. It uses high-energy proton beams rather than X-rays to destroy cancer cells.

Apollo Hospital’s Proton Therapy Centre in Chennai

The system is marked by precision. In conventional radiotherapy, healthy cells absorb large amounts of radiation and a low-intensity dose is delivered to the tumour. Proton therapy intensifies the delivery to the affected area by using a pencil beam, which is guided by more accurate imaging. It’s quick through the body, deposits less radiation in the healthy cells and reaches its peak intensity at the tumour site.

“Protons have the ability to limit the doses of radiation to exactly the tumour spot,” says Rakesh Jalali, director, Apollo Proton Cancer Centre in Chennai.

In 2010, Medanta in Gurugram was the first Indian hospital to introduce Cyberknife VSI, a robotic system that significantly increased the accuracy and intensity of radiation compared to conventional machines. The hospital recently passed the Postal Dosimetry Audit jointly conducted by the World Health Organization and the International Atomic Energy Agency to optimise delivery of radiation in treatments. The hospital has conducted over 1,340 Cyberknife procedures. It has also conducted 780 TomoTherapy sessions, a form of Intensity Modulated Radiation Therapy (IMRT) that uses refined X-rays — one that is increasingly being used in radiation oncology as an alternative to conventional radiation.

A linear accelerator (LINAC) radiotherapy machine at Max Hospital in Delhi

BLK Super Speciality Hospital in Delhi, which was also among the first to introduce Cyberknife VSI in India, treated its first cancer patient in March using the Radixact 9, a machine that delivers the most advanced form of TomoTherapy in the country.

The most common cancers in men are throat, lung and prostate, and in women breast and uterus. “More than 70 per cent of these patients need radiotherapy, either alone or  with chemotherapy,” says S Hukku, chairman and senior consultant, radiation oncology at BLK. 
 

Imaging is the key, he says. The Radixact 9 machine is a CT scanner and a linear accelerator in one machine. It also provides 3D imaging for a more accurate targeting of the cancer cells. “The impact on the healthy tissues and subsequently the side effects of radiation, therefore, are drastically reduced,” he adds. 

Citing an example of a breast cancer patient, Hukku says the dose to the heart and the lungs through the course of the treatment is 50 per cent less compared to other radiotherapy machines.

Another important feature of the machine is adaptive radiotherapy. In conventional radiotherapy, a standard course of treatment continues for about four weeks without any change in the dose. Several patients tend to lose a lot of weight during the treatment. “The machine tracks the changing anatomy of the tumour and signals its shrinking so that the radiation can be reduced accordingly,” explains Hukku.

The machine can also perform Stereotactic Body Radiation Therapy (SBRT), also called radiosurgery, a shorter course of radiation lasting one to five days that targets the tumour with beams from different angles and is used to treat a few specific types of cancers such as lung or prostate.

While most kinds of cancers require a multi-disciplinary treatment, the new technology in radiation oncology behind Proton Therapy and advanced TomoTherapy is encouraging independent use of this painless procedure. “In stages 1 and 2 of head and neck cancers, such as that of the base of tongue or voice box, TomoTherapy can be used as a curative form of treatment,” says Hukku.

While the Radixact 9 is at present the most advanced machine for TomoTherapy in India, Hukku says that the introduction of real-time imaging in this machine, which is expected in the next six months, will make it even more accurate.

Not just radiology but the use of technology is increasing accuracy in all spheres of oncology — starting from screening and early diagnosis. In breast and cervical cancer screening, the pap smear is being replaced by more accurate investigative tools that study the aspirate taken from the cervix. 
 

Traditional mammography has gone digital, which leads to much better imaging that can help in early detection. Even liquid biopsy — analysing urine, blood and saliva — for DNA of cancer cells is being explored.

Interventional radiology, which uses minimally-invasive, image-guided techniques for diagnosis and treatment of cancers has become very sophisticated. “It’s become the fourth arm of cancer treatment,” says Harit Chaturvedi, chairperson, Max Institute of Cancer Care, Max Hospitals. “We can now successfully block a major artery supplying to a tumour to buy more time or accurately inject a drug into the tumour using interventional radiology.”

Chaturvedi explains that artificial intelligence is being incorporated even in chemotherapy to limit drug interactions. “We use software that are programmed to predict drug interactions,” he says. It is sometimes not possible for the human mind to remember the correlation of all drugs. And that’s where computers can chip in.

While most innovations in cancer care are aimed at making the screening, diagnosis, staging and treatment more accurate to improve the quality of the patient’s, oncologists are hopeful of the research and trials being conducted in immunotherapy — the biological therapy that boosts the natural defences of the body to detect and fight cancer cells.

“I have a few patients undergoing trial treatments who were not expected to survive beyond six months, but since they have been put on immunotherapy coupled with traditional treatments, they continue to improve even after three years,” says Chaturvedi.

Hukku says that immunotherapy holds a lot of promise. “In a lot of trials, immunotherapy is being mixed with radiation therapy”. Oncologists say it will take two to three years, at least, to know if immunotherapy has the potential to become an alternative treatment.

Chaturvedi says that while immunotherapy is the most talked about in research, precision, as of today, is the buzzword at cancer institutes. “From detection to treatment, precision is improving every aspect of cancer care in India.”