Contributing to a higher cause

Humility is Dr Sudeep Gupta’s middle name. That’s the personal. As for professional attributes, the director of the Tata Memorial Centre (TMC), Mumbai, has plenty to distinguish himself as one of India’s foremost figures in the field of oncology. That includes global recognition as a clinical researcher and well-honed expertise in breast and gynaecological cancers.

An alumnus of the All India Institute of Medical Sciences, New Delhi, Dr Gupta has been with TMC since 2001. In this interview with Christabelle Noronha, he speaks about India’s burgeoning cancer burden, what can be done to cope with it, and how he manages the stress of battling a disease as implacable as any Excerpts:

India’s cancer burden is getting heavier with every passing year and our public health system is ill-equipped to cope with the crisis. How can we, as a country, do better in handling this emergency?

India’s cancer burden is growing every year and there are two reasons for it: some cancers are becoming more prevalent and, importantly, our population is increasing and growing older. Life expectancy at the time of India’s independence was 32 years; today it is 70 years. People surviving to an old enough age are at risk of developing cancers and cardiovascular diseases. There are about 1.4-1.5 million new cancer cases in India every year. This is expected to increase to 2.1 million new cases in the next 15 years.

More than 850,000 patients die of cancer every year in our country, or about two-thirds of those diagnosed with the disease. We need a multi-pronged strategy to handle this burden better. In terms of service, we need to open and strengthen existing tertiary healthcare facilities for cancer care. By tertiary facilities I mean those in the public sector, because India already has some of the best private-sector hospitals in the world for all diseases, not just cancer. The problem is that an overwhelming majority of our population cannot access those hospitals due to financial reasons.

Health being a public good and a concern of the state, we must ensure that government health facilities have all the components of cancer care available. We must either strengthen whatever exists or open new facilities in a way that cancer care is ‘distributed’. Everything should not be concentrated in a few regions or locations.

India has adequate — or, at least, not grossly inadequate — medical care facilities, including for cancer. But their distribution is not uniform, with much of it concentrated in urban centres. Over the past 15 years, TMC has taken steps to set up a hub-and-spoke model for cancer care. It has nine hospitals in six states and two more are being set up.

India also has regional cancer centres that are, in government parlance, called tertiary cancer care centres, and we have not-for-profit institutions and charitable hospitals dedicated to cancer care. All of these can be woven into a coherent whole in a way that public sector cancer care can be delivered in a hub-and-spoke model, in a distributed manner, all over India.

Are people from some regions more prone to cancer than others?

People everywhere are prone to cancer. The big divide we refer to is between urban and rural areas. In urban India the incidence of cancer is 110-150 new cases per 100,000 population per year; in rural India the number is 50-60 per 100,000 population. This suggests that people residing in rural locations are less susceptible to cancer.

The urban-rural divide is also significant for some cancer conditions, such as breast cancer. In Mumbai, the incidence of breast cancer among women is about 35 new cases per 100,000 population per year, while in rural India it is approximately one-third of this. Conversely, cervical cancer is more common in rural India.

Does your research indicate why cancer incidence is higher in one place than another?

The precise reasons are not known. Most of the variation could be lifestyle-related; some hereditary and genetic factors are also responsible but that’s a small proportion. The biggest factor contributing to cancer incidence is lifestyle, which has to do with food, exercise, obesity, smoking and tobacco use, alcohol use, hygiene and infections. These factors determine which cancer could occur and in which part of the body.

With breast cancer — my area of interest — the reasons relate to having the first child at an older age, having fewer children, less breastfeeding, obesity and deficient physical activity, alcohol consumption, breast density and the hereditary component.

But cervix cancer incidence in Mumbai is currently at about eight cases per 100,000 population per year, down from 23 per 100,000 in 1976. The decline in cervical cancer incidence in Mumbai and almost all other parts of India happened in the pre-vaccine era, when population-level screening was not implemented. Although the precise reasons are unknown, it is likely that improved hygiene and nutrition, changing reproductive patterns, and adoption of safe sexual practices could have contributed.

TMC is an exception in more ways than one. But replicating such institutional excellence in the public health sector has been a struggle. Why so?

That’s a good question, and I don’t know if it has an objective answer. TMC has an 84-year legacy and it was created by pioneers, including the Tatas, who wanted to inculcate a culture of excellence. When we set up other centres, we try to replicate the ‘Tata culture’ in terms of skilled and hardworking staff dedicated to patient welfare.

All institutions are products of the circumstances in which they are born. Since your question is specifically about public-sector healthcare institutions, I can give you the example of AIIMS, Delhi, where I trained. AIIMS was set up to be a model of healthcare research and education for the rest of India, and it has served that mission admirably.

Cancer diagnosis and treatment are big business in India, especially in urban centres. How effective can private healthcare organisations be in the context, particularly when it comes to regulations and oversight?

I think private healthcare organisations have come of age in India. They provide good quality care to patients from a certain strata of society. Many of them are run like a business, which I suppose is how they were created. That said, I think regulation needs to be strengthened in India.

The modern practice of medicine, particularly in cancer, is not opinion-based. Just because Dr Sudeep Gupta thinks a certain treatment is good doesn’t mean that it should be given. Medical care today is evidence-based, which means that investigators have conducted studies and clinical research and figured out various lines of treatment in terms of what should be recommended and to whom.

Public-private collaboration is of the essence in cancer care. Is enough of this happening in India, and in what manner can this be enhanced?

Some of it is happening, but not enough. The National Cancer Grid, a public-private collaboration of more than 30 organisations, includes many private healthcare entities. Corporate social responsibility donations given to public sector organisations also demonstrate the importance of public-private partnerships.

At TMC, the Tata Trusts are, of course, a vital partner, but there are several other organisations and numerous other donors who have partnered with us to create capacity and infrastructure. In this context, I would like to say that the Tata Trusts and the Tata group are a beacon of hope in India. 

The ‘distributed care’ care model that the Tata Trusts have been working with — where the endeavour is to provide cancer patients with care and treatment closer to their homes — has delivered promising results. What’s your view of the model, and can it be extended to cover the entire country?

I think it’s a fantastic example of how to deliver cancer diagnoses and treatment. Those are the operative words. When you have an ailment (not just cancer) and have to travel [in Mumbai] from Parel to Bandra, you feel inconvenienced. Imagine, then, the plight of those with serious illnesses who have to travel thousands of kilometres or live away from home for prolonged periods. It is simply not acceptable.

The hub-and-spoke model I referred to earlier is one way of providing distributed cancer care. I think this needs to be extended to cover the entire country. It is up to Indian society, including the government and non-government organisations, to make this happen.

Treatment for cancer means making difficult choices and many a time this is fraught with pitfalls. How do you go about making these choices?

Sometimes there is no straightforward path. For example, if there is a patient who has experienced cancer relapses three times in a year, then on the fourth occasion there is a choice about whether to continue treatment or focus on symptom control and give that patient a better quality of life. There are many such dilemmas, and we require a high level of expertise and empathy to navigate them.

If you had a wish list to improve cancer care and treatment in India, what would be on it?

First, to create more public-sector hospitals that will treat cancer in an evidence-based manner. Second, adequate provision of trained experts and other personnel to deliver that treatment. Third, adequate infrastructure for public healthcare facilities. And fourth, better compliance with existing guidelines for cancer care. 

Finally, and critically, accessibility to treatment in terms of affording its cost. In the last few years, several new and expensive treatments and drugs have been discovered. Some of them are quite effective but are beyond the means of most of our population. The idea, then, is to find a way by which some of these treatments can be made accessible to a large proportion of our population.

It is said that cancer specialists have to live with stress and anguish to a greater degree than doctors in other disciplines. How do you manage?

I don’t know whether cancer specialists have to live with more or less stress, but, yes, there is an element of anguish because cancer claims a large number of lives. I think all doctors have their ways of coping with this.

I always emphasise to my colleagues that we should never become robotic or deadened in our feelings. When we are confronted with so much suffering and death every day of our lives, our brains may switch off. We must not allow this to happen.

Everybody has coping mechanisms. Some doctors listen to music, some paint or watch movies. Since childhood, I have been fond of classical literature. I also watch old-time movies with my children and that helps.

Are your children inclined to follow in your footsteps?

They are not. But if I were given a chance to start over, I would become an oncologist once again. It’s a personal choice.