Call for Action: Making

quality cancer care

more accessible and
affordable in India
October 2022
 Prevent, screen and spread awareness with
least anxiety, low cost and avoiding
unnecessary stigma of cancer.
Treat with goal of the basic choice, early
access and modest cost.

Dr. Rajendra A Badwe

Director, Tata Memorial Centre

Cancer care has significantly evolved over

the years — not just in terms of tech-
enabled therapies and multidisciplinary
innovation, but also in terms of the
advancement in cancer prevention and early
detection strategies and methods. Given
better outcomes in terms of high-precision
treatments and good survival rates, the fear The myriad types of cancer threatening
of cancer gripping the patient’s minds has human lives today need a multilateral
considerably reduced over the years and we strategy plan to fight the disease. Initiatives
have leapfrogged to a way higher level of have to be categorized for prevention,
cancer care matching the best of centers screening and treatment of each cancer
worldwide. The focus is clearly on how we type. But at a broader level, there are some
can manage cancer the right way the first vital aspects to be considered. On the
time. We are now making rapid progress in prevention front, awareness campaigns
areas like molecular imaging and genomics stressing on lifestyle, food habits and
which will reflect in better outcomes based physical activity are necessary. Then at a
on proper diagnosis and targeted therapies, secondary level, massive screening drives
such that cancer recurrence can be for various cancers in high potential age
minimized to the extent possible, and groups need to be conducted. With this
cancer can be brought down to the level of a regard, technology could be of great help.
chronic disease. Advanced wireless, cloud-AI based and
portable Point of Care (POC) devices can
help reach the remotest part of the nation
Dr. B. S. Ajaikumar
and help in rapid diagnosis. Finally, at the
Executive Chairman, Healthcare Global
tertiary level, the diagnosed patients need to
Enterprises Limited (HCG)
have access to the best of healthcare
facilities and services for treatment. In
addition, each stakeholder- government,
private and community, needs to come
together to create an ecosystem for
furthering cancer care’s accessibility,
affordability and assurance in the nation.

Gautam Khanna
Chair, FICCI Health Services Committee & CEO, P
D Hinduja Hospital & MRC

ii Call for Action: Making quality cancer care more accessible and affordable in India
 It is an indisputable fact that India faces an epidemic of non-communicable diseases and cancer cases
continue to grow at an alarming rate. Moreover, as compared to other countries, cancer is diagnosed
at later stages in India, and consequently the mortality rates are higher and recovery rates lower.
Education of society at large, and doctors in particular, can play a major role in diagnosing cancer
early, thus ensuring better treatment outcomes and cures. Predictive and precision medicine have
come to the fore globally in the past few years and are helping to ensure that diagnostic and
therapeutic procedures lead to early diagnosis and targeted treatment, reducing morbidity and
mortality and improving quality of life of cancer survivors. Integrated diagnostics, where lab
medicine, pathology, radiology, nuclear medicine, and genomics come together, aided by artificial
intelligence algorithms and clinical data along with human expertise and experience, is also
increasingly being recognized as the future of the fight against cancer. While the cost of diagnostics
may currently appear prohibitive, if one evaluates the cost versus benefit ratio, it is weighed decisively
in favor of benefit, leading to overall lower costs of treatment. As these tests come into mainstream
and a large number of patients start using them, the costs in absolute terms are certain to come down
based on the economies of scale. Many more screening programs need to be systematically started,
based on cancers more prevalent in India, so as to diagnose cancers in the early stages. These also
need to be focused more specifically to those individuals having higher risk factors. Digital health
initiatives being encouraged by the Government of India can play a major role in identifying and
screening those at higher risk of developing cancer. The move toward a unique health identity, EHRs
and transportability of data across the nation will also help in this endeavor. A lot more needs to be
done to fight the burgeoning burden of cancer, and if the public and the private sector work in
tandem, then we can certainly conquer cancer as well as other non-communicable diseases.

Dr. Harsh Mahajan

Co-Chair, FICCI Health Services Committee and Founder & Chief Radiologist, Mahajan Imaging

Cancer has been a pandemic in making and today there is hardly any family that is not impacted by it.
Fear and cost associated with the disease cripples the family’s health in more ways than one. Indians,
irrespective of where they live, should have access to advanced cancer treatment, thereby building
hope and confidence to win over the disease. Progressive policy measures, new forms of investment,
as well as multi-stakeholder partnerships are needed to improve the country's cancer care
infrastructure at the grass root level. The EY FICCI paper on cancer care aims to address some of
these issues that can transform cancer care in India.

Ashok Kakkar
Chair, FICCI Task Force on Cancer Care and Managing Director, Varian Medical Systems International India
Pvt. Ltd

Comprehensive and integrated approach by a multidisciplinary team is the key to deliver best
outcome for cancer treatment. What works for a patient will work for the nation. Collaboration among
all stakeholders is imperative to effectively address India's growing cancer burden.

Raj Gore
Co-Chair, FICCI Task Force on Cancer Care and CEO, Healthcare Global Enterprises Limited (HCG)

Call for Action: Making quality cancer care more accessible and affordable in India iii
Foreword
Given the backdrop of a growing burden of cancer across patient records, robotics, AI-backed upskilling methods,
India, the Report by FICCI Task Force on Cancer Care daycare chemo, home care etc., are some of the
Infrastructure, in collaboration with EY, on “Call for strategies that are already in place to address these care
Action: Making quality cancer care more accessible and gaps.
affordable in India” is a timely initiative to highlight the
need for more effective policy measures aimed at Additionally, capacity and capability building, resource
proactive cancer prevention and treatments. This stratification around models of care, and workforce
knowledge paper will serve as a beacon of light to planning have been popular themes for discussion and
strengthen India’s strategy for cancer care and help it analysis. India has to further expand its complete cancer
serve as a model for other non-communicable diseases. care infrastructure, including prevention, care delivery,
The detailed epidemiology of various types of cancer in skilled workforce, technology, and equipment, in order to
every state of India and global comparisons described in increase its capacity and capabilities for treating and
this report highlight the substantial variations between managing cancer. This report goes into great detail about
the states for different types of cancer and serve as a the various approaches that care entities can employ in
useful reference for more targeted planning of cancer order to break the barriers that exist in cancer
control, commensurate with the trends of different management.
cancers in each state of India.
To make cancer care more effective and affordable for
It is crucial that cancer prevention and early diagnosis the entire population, we must improve workflow
are prioritized by society, governments, and the
efficiency and treatment outcomes. Using its trademark
healthcare ecosystem, given the nature of the disease as
ingenuity and frugality, India has an opportunity to find
a sign of physical, emotional, financial, and social distress
innovative solutions to bridge the existing care gaps for
that affects not just an individual but the entire family.
her citizens and to guide other developing and developed
Since awareness aims to educate and teach individuals
nations.
about previously unknown subjects by imparting
knowledge, changing attitudes or beliefs, and forming FICCI contributes to the healthcare sector as a change
healthy practices or behavior, awareness frequently agent to catapult policy and regulatory reforms through
precedes prevention. An essential component of recommendations and knowledge papers for the
prevention is changing current behaviors, which can only betterment of the sector. We are confident that the FICCI
be accomplished by creating sufficient public awareness.
Task Force on Cancer Care Infrastructure will create a
This report highlights how cancer screening helps in early conducive environment for the formulation of effective
identification for down-staging the disease as well as in policy measures and purposeful collaborations between
achieving a reduction in mortality and morbidity. Even the various stakeholders, which will in turn help create
though there is an established cancer screening program India’s cancer moonshot and ground-shot approach.
rolled out across the country, it still has many challenges
to deal with. Capacity constraints in terms of physical The FICCI-EY Report on ‘Call for Action: Making quality
infrastructure, talent, lack of training in the methods cancer care more accessible and affordable in India’, will
used for cancer screening, and deficiencies in the referral be released during the 16th edition of FICCI’s annual
mechanism are some of the roadblocks to the success of healthcare conference- FICCI HEAL 2022, scheduled on
this program. Quality data capture, data sharing, and Oct 10-12, 2022 on the central theme ‘Healthcare
timely referral are the keys to ensuring a continuum of Transformation: Driving India’s Economic Growth’.
care and are critical to the success of a screening
program. The successful implementation of cancer This report is a genuine attempt to comprehend the
screening programs depends heavily on education and existing cancer management scenario in India. There are
awareness. some interesting discussions and opinions on various
strategies that can change the way our healthcare
Some of the most cutting-edge cancer treatment community treats and manages cancer. We believe that
methods and technology are available in our country. these insights have the full potential to bring in the
However, we have a long way to go before we can ensure necessary push for the healthcare sector to make cancer
that cancer patients from every socioeconomic management more effective and seamless. This effort by
background receive the best possible care. In addition to FICCI will strengthen our resolve to develop policy
treatment, we must also take into account leveraging suggestions and promote partnerships for making cancer
technology to close the care gaps associated with care more accessible and affordable in India.
accessibility and affordability. Telemedicine, electronic

Mr Ashok Kakkar Mr Raj Gore

Chair, FICCI Task Force on Cancer Care and Managing Director, Co-Chair, FICCI Task Force on Cancer Care and CEO,
Varian Medical Systems International India Pvt. Ltd Healthcare Global Enterprises Limited (HCG)

iv Call for Action: Making quality cancer care more accessible and affordable in India
Preface
The untamed growth in incidence of various types of disease. However, insurance is essential but not sufficient
cancer over the years is a brewing health crisis that India condition for making cancer care affordable for all
must contain, control, and correct. Perhaps no other because without an efficient healthcare system no
disease is comparable in its devastating impact on the life economy can afford sustainable healthcare funding.
of patients and families given the scale of incidence, Hence cost effectiveness catalyzed by a culture of
mortality rate, affordability of treatment and the quality continuous improvement mindset, will be an essential
of a survivor’s life. Over the years we have certainly tenet of future healthcare delivery model for the policy
witnessed recognition of the issue by policy makers, makers and providers.
endeavors to create awareness and progress in both
The report is a follow up to two previous reports Call for
quality and quantity of care supply but the highly
Action: Expanding cancer care in India (2015) and FICCI-
undesirable situation of low awareness, late-stage
EY Call for Action: Expanding cancer care for women in
discovery and consequent high mortality and prohibitive
India (2017). The report is an attempt to understand the
levels of out-of-pocket expense for availing care,
state of cancer care in India - demand situation, supply
continues unabated. While there has been a reasonable
situation and outcomes and experiences, in an intimate
degree of understanding of risk factors related to
way to set clear imperatives and action plan to achieve
physical health factors and lifestyle, understanding of the
them, at the levels of policy makers, public health
nature of science of the disease is still at an early stage
system, private players and the public. The report has
and hence, constant endeavor to explore new territories
followed an approach of limited primary research,
for study is imperative for evolving an effective and
extensive secondary research to gather credible data
efficient care and control program. In this regard, one
points around disease and management at local and
area that may need focused study and could prove
global level supplemented by extensive discussions with
transformative in managing the disease is the causative
stakeholders including policy makers, public health
relationship between mental health and cancer.
experts, oncology specialists, private providers, health
Additionally, given the psycho-socio- physiological impact
insurance companies and NGOs to facilitate discovery of
of the disease on the patient, post incidence counseling
ground level situations and challenges and develop
can be a potent tool in effective management of the
meaningful recommendations that are potent, practical
disease which is severely lacking now. The robustness of
and progressive.
cancer registry continues to leave a lot to be desired,
though there has been progress over the years. We are grateful to FICCI for this opportunity to partner
with them on developing this report and the excellent
Given the rising incidence and mortality pattern, it is
support provided by them in facilitating the discussions
imperative that the country focuses on effective
with industry stakeholders and providing valuable inputs
prevention, targeted screening, and large-scale
from time to time. We are also deeply grateful to
awareness as the primary response to addressing the
everyone who gave us time to deliberate on various
disease burden by avoiding the unnecessary stigma
aspects of this report and share their valuable views,
attached to cancer. The key is to manage the disease in
insights and experiences, which has positively shaped the
the right way, the first time and at the last mile. This calls
form and content of this report.
for a holistic and comprehensive approach with the
patient at the core through multi-stakeholder It has been an enriching experience for us to work on this
partnerships, frugal innovation by the providers, and report and we sincerely hope it further strengthens the
progressive policy measures underpinned by technology, aspiration, agenda, and actions for a cancer health
which is predictive, personalized, and precise. system in India that can be an example to the world for
demonstrating that true cancer care for all is more than
Insurance will play a key role in mitigating out-of-pocket
just a rhetoric.
expenditure challenges families face owing to the

Farokh Balsara Vinay Raghunath Muralidharan Nair Kaivaan Movdawalla Srimayee Chakraborty
EY LLP EY LLP EY LLP EY LLP EY LLP

Call for Action: Making quality cancer care more accessible and affordable in India v
Executive Summary
Estimates indicate India’s reported cancer incidence in Of the reported cases in India, head and neck,
2022 to be 19 to 20 lakhs, whereas real incidence is gastrointestinal and lung contribute to 50% of incidence
1.5 to 3 times higher than the reported cases. among males and breast, cervix uteri and
gastrointestinal organs contribute to 50% of incidence
India faces significant challenge of a sizeable cancer in case of females.
incidence burden, which continues to grow further. The
2020 WHO ranking on cancer burden in terms of new Among these, cancer of the head and neck are found to
yearly cases being reported, ranked India at the third be progressing at a CAGR of 23%, prostate cancer at
position after China and the US, respectively. 19%, ovarian cancer at 11% and breast cancer at 8%
which is faster than the overall growth rate of
incidence.

Chart A: 2020 Organ-wise Incidence (‘000)

Head and neck Breast Gastrointestinal

306 416 1,593

256 253
142
59 54 246 276
14 78

India China US UK India China US UK India China US UK

Lung Cervix uteri Ovary

816 60
110 55
94

24
228
95 52 14 4 6

India China US UK India China US UK India China US UK

Source: SEER cancer statistics, Cancer research UK, Zeng at al 2021, NCRP Annual report 2020

High proportion of cases continue to be detected at The challenge of rising disease burden is further
late stages for major cancer types in India compounded by poor outcomes compared to global
counterparts across all major organ types
The issue of high disease burden is compounded with
late-stage detection caused mainly due to lack of While at one hand incidence is rising, deaths due to
awareness and low penetration of screening programs. cancer has remained among the top 5 causes of deaths
in India over the last decade. Estimates indicate that the
India has a poor detection rate across major cancer total deaths due to cancer have been ~8 to 9 lakh in
sites with 29%, 15% and 33% of breast lung and cervical 2020, causing the mortality to incidence ratio for
cancers being diagnosed in stages 1 and 2, respectively, different cancer types in India being among the poorest
which is significantly lesser than that in China, the UK compared to global counterparts.
and the US.

vi Call for Action: Making quality cancer care more accessible and affordable in India
Chart B: Mortality to Incidence ratio comparison across countries

Head and neck Gastrointestinal Lung

56% 52% 91% 88%
80% 75% 70%
33% 56% 61%
53%
23%

India China US UK India China US UK India China US UK

Breast Cervix Uteri Prostrate

51% 49%
62% 44%
54%
28% 42%
22% 30% 23%
17% 15%

India China US UK India China US UK India China US UK

Source: NCRP Annual report 2020, Global Cancer Observatory, 2020

Six states, which represent 18% of India’s population, incidence ratio), improvement in life expectancy and
have 23% share of the country’s reported incidence increase in GDP per capita.
burden and have the highest crude incidence rates
Given the current state of rising cancer disease burden
13 out of the 17 states covered by population-based and sub-optimal quality of outcomes, there is a
cancer registries (PBCRs), exhibit a rising cancer significant need to understand the current challenges
burden. Kerala, Mizoram, Tamil Nadu, Karnataka, and tailor make interventions across the different
Punjab, and Assam report the highest overall crude stages of disease management with a deep focus on:
incidence rates of cancers (above 130 cases per lakh
A. Awareness and prevention – Modifying exposure to
population).
risk factors that potentially lead to cancer
High burden of cancer incidence in India is resulting in B. Detection and diagnosis - Ensuring early detection
a high economic burden on account of productivity and accurate staging of the disease
losses and premature mortality
C. Treatment including palliative care - Driving
Based on reported cancer incidence and mortality multidisciplinary approach to treatment with focus
across age groups and years of potential productive life on affordability, equitable access, quality of
lost (YPPLL) due to the same, estimates indicate that outcomes and palliative care
the economic burden in terms of GDP losses is in the
range of US$11B. (0.4% of national GDP) in 2020. While the above represent core levers to drive cancer
control by reducing incidence and improving quality of
The same is projected to increase to US$36B to outcomes, expanding cancer registries and health
US$40B by 2030, driven by a projected increase in information systems for collecting standardized and
mortality (considering increasing cancer incidence comprehensive data for informed and evidence-based
partly offset by an improvement in mortality to policy decisions and research will form the foundation
for enabling the levers to drive change.

Call for Action: Making quality cancer care more accessible and affordable in India vii
Figure A: Cancer control framework

Incidence

C. B. A. Quality of life Mortality

Survivorship

Source: EY analysis

A. Awareness and prevention

Awareness Prevention

Knowledge: Awareness landscape in India is dominated Primary prevention involves limiting exposure to
by tobacco and tobacco-related cancers. Knowledge of carcinogenic risk factors. While there are several
other common cancers such as cervical is low. carcinogenic risk factors, modifiable risk factors such as
tobacco, alcohol, obesity, infectious and environmental
Attitude: Few people in India seemed to be concerned factors are amenable to prevention. While India
about cancer compared to other countries, implying a undertook several policy measures to reduce exposure
general attitude of indifference towards cancer. As per to risk factors, there is still significant progress
the UICC global survey, only 43% respondents in India required.
indicated that they were concerned or somewhat
concerned about developing cancer in their lifetime Enforcement of tobacco restrictions: Tobacco is
compared to a global average of 58%. associated with a large number of cancers such as lip,
tongue, mouth, oropharynx, larynx, esophagus, lung,
Chart C: Awareness level across organs (Based on multiple urinary bladder all of which together contribute to high
localised studies in India) mortality at present. Despite relatively high awareness
90%
compared to other risk factors, tobacco usage
72%
continues to be a major public health challenge in India.
While the government undertook measures for tobacco
44% control under the aegis of the National Tobacco Control
Programme and implemented the Cigarettes and Other
Tobacco Products Act, the current prevalence of adult
tobacco users continues to remain at 28.6% which is
Oral Breast Cervical higher than the global prevalence of 23.4%.

Source: Localized surveys, EY analysis As per NFHS 5 (2019-20), % of men > 15 years of age
using tobacco was > 40% for all north-eastern states,
Practice: Uptake of screening for breast, cervical and Madhya Pradesh, West Bengal and Gujarat which is
oral cancer and HPV vaccination is very low despite significantly alarming.
moderate levels of awareness.

viii Call for Action: Making quality cancer care more accessible and affordable in India
Chart D: Tobacco prevalence among adults in India programme, screening coverage is less than 5% of
population which is negligible when compared with
Smoke and Smokeless 3.4% global peers. Oral cancer has the lowest screening
tobacco prevalence 5.3%
coverage at 0.2% of the population. Capacity
Smokeless tobacco 17.9% constraints in terms of physical infrastructure and
prevalence 20.6%
workforce, lack of training of the methods for cancer
Smoking tobacco 7.2% screening among healthcare workers and deficiencies in
prevalence 8.7% referral mechanism are key roadblocks to the success of
Overall tobacco 28.6% the programme. Additionally, lack of data capture to
prevalence 34.5% maintain longitudinal health records of population right
from screening stage and ensuring tracking and follow
2016-17 2009-10
up with patients for effective referrals is a key deterrent
Source: GATS 2009-10 & GATS 2016-17 in the expansion and penetration of screening
programs.
Enabling inclusion of HPV vaccination in the National
Chart E: Screening coverage in India by population
Immunisation Program: Infectious risk factor mainly
% (NFHS-5)
includes HPV causing cervical cancer, which is easily
preventable through vaccination. India has made
Rural Urban
remarkable progress through the launch of indigenously
developed HPV vaccine which is priced 10 times lower 0.2% 0.2%
than the erstwhile available vaccines in the market32. Oral (M)

Despite achieving major milestones in indigenous HPV

vaccine launch, India is still to include the HPV vaccine 0.6% 0.9%
as part of its Universal Immunization Program. As of Oral (W)
October 2019, 100 countries around the world had
already introduced the HPV vaccine as part of their 0.4% 0.8%
national immunization schedule. Given the decade-old Breast
debate around the efficacy and safety of the HPV
vaccine in India, there is a need to conduct regular
1.1% 1.5%
studies to establish evidence for the same. There is also
Cervical
a continuous need to ensure accessibility to hygienic
toilets for all women.
Source: NFHS-5
Encouraging healthy behaviors: Obesity is associated
with several cancers such as breast, colorectal,
esophagus, stomach, etc. which contribute to high
C. Treatment including palliative care
incidence and mortality. Nearly one in four Indians is
Access to treatment
obese as per the NFHS-5. Similarly, alcohol is another
major risk factor which is associated with several Significant geographic skew in the presence of
cancers such as liver, breast, stomach, larynx, etc. comprehensive cancer centers in the country: Only
Almost one in five men consume alcohol in India with an ~175 districts in the country covering 40-45% of the
increase in per capita consumption of alcohol from 2.3 population have Comprehensive Cancer Centres
liters in 2005 to 5.5 liters in 2018. (CCCs)44. Of the 470 to 480 CCCs available in the
country ~40% are concentrated in metros and state
B. Detection and diagnosis
capitals. Severe gap continues in access to
Screening radiotherapy (RT) treatment in the country with RT
per million population of 0.4 vis-à-vis WHO
Despite the proven benefits of early identification for recommendation of 1 RT per million population:
downstaging the disease as well as in achieving a Penetration of RT equipment is low with ~640
reduction in mortality and morbidity, screening installations against the requirement of ~1,400 to
penetration of key cancers in India is very low: Across 1,500 in the country59.
focus cancers being screened under the NPCDCS

Call for Action: Making quality cancer care more accessible and affordable in India ix
Chart F: Penetration of RT equipment per million Affordability of treatment
population across countries
Financial burden of cancer care treatment is the highest
India 0.4 compared to other diseases.

Treatment cost for cancer care is financially prohibitive

China 0.8
and is almost 3x that of other non-communicable
Brazil 1.0 diseases (NCD). Additionally, treatment cost has been
increasing with cost of a single cancer hospitalization (in
Russia 1.1 public or private facility) exceeding average annual
expenditure of 80% population in 2017 vis-à-vis 60%
US 7.6 population in 2014.

Chart H: Baseline cost of comprehensive cancer treatment

Source: “World population”, worldpopulationreview.com, (INR lakhs)
“Directory of radiotherapy centres”, Dirac.iaea.org, EY
analysis 8.3
7.4
Availability of screening, diagnostic and treatment
planning equipment is low in India: Penetration of PET-
CT is low with ~360 installations against the 5.2
requirement of ~480 in the country67. Also, there are 4.2
~5 CT scanning machines per million population
compared to ~40 in high-income countries and ~13 in
upper middle-income countries64.

Access to specialized care of oncologists is

significantly constrained in India with incidence per
clinical oncologist (medical and radiation oncologist) Breast Cervix
at 315 compared to 120 in China and 137 in the US: Stage 1,2 Stage 3,4
India requires 2,500 to 3,000 additional medical
Source: EY analysis
oncologists and 700 to 800 surgical oncologists to
cater to current incidence while radiation oncologists
are adequate87. Cost of complete baseline multi-modal treatment
varies significantly depending on organ and stage of
Chart G: Incidence per oncologist across countries detection: For common cancers such as breast, cervix,
ovary and gall bladder cost of treatment in mid-tier
India 315 private hospitals escalates by 60 to 75% between Stage
1/2 vs. Stage 3/4 patients. The cost escalates further
Russia 269 with adoption of advanced therapies.

Brazil 170 With an increase in population coverage under some

form of insurance/ government sponsored health
US 137 coverage programs to ~54%, there is a need to ensure
adequate coverage under these programs based on
China 120 uniform standards of care that offers right treatment
and quality of outcomes for patients: Variation among
Source: “Global survey of clinical oncology workforce”, state government and PMJAY schemes is to the extent
Journal of Global Oncology, 2018, EY analysis of 40-275% for select surgical and medical procedures
with key schemes also not covering diagnostic
Only 1% to 2% population who need palliative care interventions/therapies such as PET-CT, biopsies,
have access to it in India compared to a global average genomics, targeted therapy and immunotherapy.
of 14%101: Most states in the country do not have an Additionally, high level study of cashless claims made by
enabling legislation and policy structure that supports patients covered under retail health insurance policies
integration of palliative care with public and private indicates 25 to 30% of their expenses are still made out-
healthcare set ups treating cancer patients. of-pocket, indicating the need to ensure design of
comprehensive care plans based on uniform standards
of care.

The complex challenges of the cancer control landscape

in India are further worsened by the lack of

x Call for Action: Making quality cancer care more accessible and affordable in India
comprehensive data w.r.t to incidence and mortality The challenges in the current system of cancer disease
which is representative of the Indian population. The management in the country have been further
population and hospital-based cancer registries set up corroborated by a survey carried out with 154 cancer
four decades ago, have so far been able to cover only patients and care givers. Gaps in the patient journey
10% of the population of the country with several states were characterized into seven key themes which need
such as Uttar Pradesh, Madhya Pradesh, Andhra to be addressed to improve experience and satisfaction
Pradesh, Rajasthan, Telangana and Orissa having of cancer patients in the country:
inadequate presence and penetration of registries122.

Table A: Gaps in patient journey across seven key themes

Theme 1 Theme 2 Theme 3 Theme 4 Theme 5 Theme 6 Theme 7

Delay in accessing Absence of single Inefficiencies in Lack of frequent, High cost of Gaps in post Psychological
care source of hospital processes transparent and treatment and lack treatment care burden of cancer
comprehensive and effective of quality care
authentic information communication facilities locally

58% patients had 39% patients 78% patients > 75% of 64% patients did 48% indicated 62% patients
their initial rely on expressed low patients not have any lack of used words like
diagnosis based on information satisfaction with expressed low form of awareness or no ‘tough’, ‘bad’,
symptom from family long wait times satisfaction with insurance/ response when ‘stress’, ‘pain’ to
physician/ promptness and scheme coverage asked about describe their
61% patients were specialist doctor courteousness of rehabilitation quality of life
diagnosed in Stage and 33% rely on communication 49% patients centers during treatment
2 and 3 family friends by clinical and travelled >50
and relatives to non-clinical staff kms for their Only 20% had 20% patients who
49% patients had treatment positive views were cured or
gather
their initial diagnosis about availability under remission
information for > 50% patients
done by GP of facilities for used words like
selecting cancer spent > INR 5
52% patients center for long term care ‘not normal’,
lakhs on their
undertook >5 tests treatment ‘weak’, ‘average’,
treatment
and more than one ‘neutral’ when
consult to confirm asked about
diagnosis quality of life
post treatment
51% patients took
more than 1 week to 56% patients did
conclude the diagnosis not have access
to any support
46% patients who group
undertook second
opinion cited lack of
confidence in initial
diagnosis and
suggested treatment

Source: EY survey of 154 cancer patients, EY analysis

While there are debilitating challenges in the current incidence of other countries such as China, Brazil and
state of cancer control in the country, the problems Thailand.
may further exacerbate in the future with an increase
Estimates indicate that with expectations of
in the disease burden due to intensification of risk
improvement in early diagnosis of cancers, in 2030 the
factors and ageing of the Indian population unless the
government plans for appropriate action. Estimates projected reported incidence will reach 40 to 45 lakhs
indicate that the reported cancer incidence will reach (crude rate: 250 to 280 per lakh population) with 50 to
60% of cases being diagnosed in stage 1 and 2.
250 to 280 per lakh population by 2030 from the
current level of 120 per lakh closely mirroring the

Chart I: Projections of real and reported incidence in 2030 (‘000)

4,570-6,100 4,180-4,570
600-800

2,570-3,430 1,400-1,870

1,714

Real incidence Demographic Risk factor exposure Real incidence Reported incidence Reported incidence
(2020) changes (2030) (2020) (2030)

Note: Refer <Annexure 3> for framework for projection of overall crude incidence adjusting for demographic and risk factor
exposures and prevalence

Call for Action: Making quality cancer care more accessible and affordable in India xi
With the expected increase in disease burden the infrastructure will further widen if no significant
demand supply gap in physical and medical intervention is undertaken by the government.

Chart J: Demand supply gap in medical infrastructure and workforce in 2022

2.6x

5,021
1.0x

1.4x
3,242 3,360 1.3x
2,690
2.0x
1,969 2,075
1,905
1.4x 1,550
1,305
656 640
484

CCC RT equipment Medical oncologists Surgical oncologists Radiation oncologists Medical physicists

Demand/Supply Demand Supply

Note: Cancer incidence estimated in 2022: ~19-20 lakhs

Source: “List of cancer treatment centres licensed by AERB”, aerb.gov.in, “Call for Action: Expanding cancer care in India” EY
report, 2015, nmc.org.in, Accr.natboard.edu.in, EY analysis, Refer <Annexure 5 - 9> for assumptions

Chart K: Demand supply gap in medical infrastructure and workforce in 2030

2.8x

10,875
1.1x

1.6x 8,090
7,295 2.5x
6,711
2.9x 5,177
3,905 4,145
1.1x 3,242
2,110
1,056 963 1,120

CCC RT equipment Medical oncologists Surgical oncologists Radiation oncologists Medical physicists

Demand/Supply Demand Supply

Note: Cancer incidence estimated in 2030: ~42 to 45 lakhs. With conservative cancer incidence estimate of ~29 to 30 lakhs in 2030,
the demand supply ratio for CCC, RT equipment, medical oncologists, surgical oncologists, radiation oncologists and medical
physicists stands at 0.9x, 2.0x, 2.3x, 1.1x, 0.8x and 1.7x, respectively.
Source: Accr.natboard.edu.in, nmc.org.in, EY analysis, Refer <Annexure 5 - 9> for assumptions

xii Call for Action: Making quality cancer care more accessible and affordable in India
Given below are the key challenges and the actions that the cancer control and management landscape in the
different stakeholders can undertake for strengthening country:

Key challenges Proposed actions Actions by

1 Awareness and Prevention
1.1 High tobacco prevalence which ► Drive stringent implementation of COTPA Government
is the cause of ~30 % cancers in amendment bill proposing stricter measures
the country. completely banning smoking in public places,
implementing warning labels on all forms of
packaging and bans on all forms of direct and indirect
advertising of smoking and smokeless tobacco.
► Increase tobacco taxation (currently 50 to 60% as
against WHO recommendation of 75%). Government

► Evaluate gradual banning of smoking and smoke-less

Government/Private
tobacco— undertake pilot projects to support farmers
players/NGOs
to switch from tobacco to alternate crops.
► Evaluate learnings from global peers to update
legislations and policies in India w.r.t tobacco use.
Examples of learnings from the latest bill proposed in Government
New Zealand:
► Reduce nicotine content in tobacco
► Reduce outlets selling tobacco
► Prohibit lifetime sale of tobacco to anyone born
after a certain year
1.2 Higher incidence of cervical ► Speedy decision on inclusion of HPV vaccine as part Government
cancer compared to developed of Universal Immunization Schedule.
nations. ► Conduct focused research and post-marketing Government, research
surveillance to establish scientific evidence of safetyinstitutes, vaccine
and efficacy of HPV vaccines. companies, private
providers
► Conduct effective roll-out of low-cost indigenous HPV
Government,
vaccine ‘Cervavac’ through mass vaccination drives
healthcare workers,
leveraging experience from recent COVID-19
residential societies,
vaccination program.
community support
► Raise awareness of genital and menstrual hygiene groups, NGOs
through initiatives such as building toilets in under-
developed regions. Government, local
► Evaluate learnings from global peers who have healthcare workers
significantly reduced cervical cancer incidence such
as Australia to guide policy decisions. Examples of
learnings from Australia include: Government, research
► Introduction of self-collection for cervical institutions
screening tests
► Specific budget allocation towards cervical
cancer elimination
► Clinical trials for producing evidence on the
interactions between HPV vaccination and HPV-
based screening
1.3 Increasing incidence of cancers ► Implement stricter regulations on alcohol availability Government
attributable to lifestyle related through taxation and prohibition.
factors such as alcohol, obesity. ► Advance and enforce strict measures for drunk
driving.
► Improve urban and rural planning to incorporate
adequate walking spaces, parks and cycling paths.
► Discourage consumption of fast-food and sugary
drinks through taxation slabs, restrictive advertising.
1.4 Need for recognition of non- ► Drive greater focus of awareness campaigns to Government, Non-
tobacco risk factors such as educate the general population about non-tobacco government
exposure to harmful UV stakeholders (Private

Call for Action: Making quality cancer care more accessible and affordable in India xiii
 Key challenges Proposed actions Actions by
radiation, air pollution, risk factors through traditional and social media providers, NGOs,
asbestos, alcohol, obesity etc., platforms. Healthcare startups,
is low. Pharmaceutical and
medical device
companies,
Corporates, Related
brands e.g., skin
creams for UV rays,
etc.)
► Leverage the right channel of communication to
ensure reach through local newspapers, radio
Media (news
advertisements, local cable network, posters and
networks,
banners in post offices and banks, involving village
newspapers, social
panchayat, religious or political leaders, local
media websites)
celebrity influencers.

1.5 Need for change in general ► Introduce early health education and active health Government,
attitude of indifference towards promotion in the curriculum of school students to educational
cancer or deep-rooted religious, shape young minds. Institutions
social or customary practices ► Leverage big data to find cancer patterns and
causing greater cancer risk. identifying ‘at risk’ populations which can help to
develop focused awareness and screening initiatives Government, health
with precise resource allocation: tech players

► Creating a health stack linked to cancer registry

and population health records which can capture
screening information coupled with application
of AI algorithms, can help identify patterns by
geography based on which the government can
take targeted awareness efforts.
► Conduct studies to establish the relationship of
mental health factors, stress, anxiety etc., with Technology
cancer incidence. companies (Fitness
► Evaluate incentivization or gamification of positive apps, smartphones, e-
healthy behaviors. commerce websites),
insurance players
2 Detection and Diagnosis
2.1 ~1,17,000 HWCs ► Central government to encourage state government Government
operationalized in India as of to not only adequately establish HWCs but also equip
Sep 2021 compared to the them with adequate staff.
aspired target of 1,50,000 ► Deploy female ANM/ staff nurse or female MO/CHO
HWCs. These centers are the at each HWC so that women feel safe and confident Government
first point of contact for NCD while attending breast and cervical cancer
screenings. screenings.
► Private players to partner with state government
Government, Private
under PPP model to improve screening coverage. An
providers
enabling PPP environment with a focus on improving
cancer related outcomes in the long term for select
villages/ cluster of villages/ sub-districts etc., need to
be ensured by different state governments to drive
increased participation of private organizations and
use their infrastructure and workforce to increase
the momentum of screening coverage and timely
referrals.
2.2 Vacancy of ~2 to 9% female ► Adequate and timely pay-outs with incentives to Government
ANMs at HWCs mainly due to deliver beyond expectations will motivate the staff to
shortfall in Gujarat, Himachal perform their duties and curb attrition.
Pradesh, Rajasthan, Tripura,
and Kerala. Similarly, shortfall
of 4% MOs exists in centers at
Orissa, Karnataka, and
Chhattisgarh.

xiv Call for Action: Making quality cancer care more accessible and affordable in India
 Key challenges Proposed actions Actions by
2.3 23% of the staff deployed at ► Training and CMEs for CHOs/ MOs who are the first Government/ CHO at
HWCs are untrained. States point of contact in HWCs, will be critical for the HWCs/ Private players
such as Andhra Pradesh, success of the program. Similarly, local GPs are also
Manipur, Rajasthan, Tamil critical in the ecosystem as they act as the first point
Nadu, and UTs such as of contact to several patients and should be part of
Andaman and Nicobar Islands these trainings.
and Ladakh have the lowest ► CHOs along with other HCPs should be armed with
number of trained HCPs. checklist capturing information on:
1. Risk factors
2. Benefits of screening
3. Treatment options available
4. Names, address, and contact details of referral
centers
5. Treatment costs and financing options
► Database of nearby diagnostic centers to be
maintained and made available to HCPs as well as
local GPs to get confirmatory tests done.
► Technology platforms like e-sanjeevni to be used to
help in driving remote training by experts and Government/ Private
doctors from private/ public institutions. Interactive players
e-modules clubbed with quick assessments rendered
periodically to the workforce can help assess the
training level of the field force and ensure mitigation
of gaps in knowledge appropriately.
2.4 Gaps in implementation of the ► Adequate workforce planning and timely recruitment
NPCDCS program and lack of at CHC and DH will help meet gaps in the workforce.
adequate workforce, ► Timeline should be set by the government for
technology, or equipment to implementation of the NPCDCS at CHC and DH and
enable specialists at CHCs and appropriate measures should be taken in case of Government
District hospitals to make a deviations. Surprise audits by authorities to ensure
diagnosis. As part of a survey functioning of this program in higher centers is a key
done by GoI, 27% CHCs and 13% requirement.
of DHs had not implemented
NPCDCS till 2017-2018.
2.5 Paper based non- standard data ► Drawing learnings from the latest Arogya Setu and NHA/ Government
capture and transfer regarding CoWIN experience and leveraging the ongoing
referral to a higher center, initiatives under the NDHM to create a single health
leading to gaps in identity (Health ID/ AB ID), implement a standard
communication and delays platform to undertake screening and track a patient
across the referral stream and till treatment linked to the Health ID/ AB ID/Aadhar
reduced interoperability of vital ID of population. Using a standard tech platform
patient health information. across all states will ensure that data is interoperable
across states. This data can further be linked with the
incidence data generated by registries and correlated
to identify patterns and draw meaningful insights for
cancer control interventions.
► Use of mhealth and robust data collection software
or apps will also empower the ASHAs, ANMs, MOs
and specialists with data regarding the patient.
► A clinical decision support tool for ASHAs can help in
ensuring proper data collection as well as support
ASHAs with standard screening guidelines and
triaging of patients according to risk level, promoting
the most appropriate next steps.
► Additionally, using AI based triaging and imaging NHA/ Government
tools to be used to support CMOs and radiologists
across centers to address workforce capacity issues.

Call for Action: Making quality cancer care more accessible and affordable in India xv
 Key challenges Proposed actions Actions by
2.6 Low population coverage (<2% ► Identify a brand ambassador (a national celebrity) to
in India) for all three cancers generate awareness regarding cancer screening and
due to lack of awareness of create an impactful campaign like the polio
cancer screening. KAP studies eradication campaign ‘Ek boond zindagi ki’.
done across HCPs in different ► Use various cancer months to drive a focused
cities reveal low rates of screening campaign every year for a particular
information on screening cancer. For example, every October, all private and
importance, methods, and even public providers ensure a huge emphasis on breast
self-practicing. Rate of oral cancer screening. Similar activities should be
cancer screening across men is undertaken for oral and cervical cancer as well.
low.
► Create health check days in HWCs, e.g., Women
health day (once a week). As a part of women health
check or targeted tobacco smoker screening camp,
people should be screened for respective type of
cancers. This will help eliminate the fear associated
with cancer screening. When women come for their
health needs, oral, cervical and breast examination
can be made a part of the health check and women Healthcare providers/
should be educated about any warning signs community workers/
associated with the disease. HWCs/ NGOs/
► Conduct focused cancer screening. campaigns in Corporates
communities or localities where screening coverage
is very low, e.g., camps in Gurudwaras to target the
Sikh population and encourage them to get screened.
► Posters with visual representations of the screening
method, signs and symptoms and information should
be displayed in the HWCs in vernacular language.
► Men have shown low screening participation across
all communities, as well as in urban and rural areas.
Targeted and inclusive education and information
dissemination for men will help improve screening
uptake for themselves as well as their families.
► Corporates and multinational companies can host
cancer screening camps in their offices to educate
and provide easy access to their staff to cancer
screening. They can also support NGOs who promote
cancer screening program through outreach
activities as a part of their CSR initiative.
2.7 Lack of coverage/ inclusion of ► Policy level changes and budget earmarking to
screening under the various include cancer screening as a part of various state
national/ state government and central government health initiatives like the
schemes, employee schemes Chiranjeevi scheme in Rajasthan or PMJAY should be
and retail health coverage plans evaluated. CGHS and ECHS schemes can include
limiting demand and uptake of diagnostic tests for cancer screening so that private
screening in the country. sector infrastructure can be utilized effectively. 50%
of the patients use government schemes in private
hospital for their treatment in Rajasthan. Inclusion of
screening under various government health coverage
schemes could ease out the burden on public Government/ Health
infrastructure and improve efficiencies of the Insurance Providers
program. Additionally, in the case of retail health
insurance plans, policyholders undertaking screening
should be incentivized through premium discounts
etc., to motivate them to undertake cancer
screening.
► Also, to ensure adequate focus and budget allocation
for cancer detection, the disease should be dealt with
separately and not merged with other lifestyle
diseases, such as diabetes and cardiovascular
diseases.

xvi Call for Action: Making quality cancer care more accessible and affordable in India
 Key challenges Proposed actions Actions by
2.8 Several cancers other than oral, ► Studies and research on low-cost early detection
breast and cervical are having a methods for cancers such as lung, gastrointestinal
high incidence and in certain and prostrate are critical to be evaluated for
cases also witnessing a high assessing their impact on downstaging the disease
growth in incidence e.g., lung and consequently improving outcomes. Leveraging
cancer, gastrointestinal cancer, technology tools such as AI in reviewing X-ray
prostate cancer. reports and shortlisting high risk potential targets
from a confirmatory screening perspective are Government/ Private
relevant use cases which need to be evaluated for research and health
improving early detection of lung cancer at a Pan- tech players
India level.
► Based on findings from such studies and availability
of low-cost screening methods, decision on
expanding coverage of the national screening
program to include other key cancers need to be
taken.
3 Treatment- Access to quality care
3.1 Comprehensive Cancer Centres ► Adopt a distributed hub and spoke cancer care model
(CCCs) are available only in 175 with levels of care varying depending upon the
districts with each CCC covering hierarchy of the centers:
a population of ~3 million. ► Level 3 centers could offer diagnosis and care
delivery for common cancers (Day care
Population chemotherapy, radiation therapies such as IGRT,
% Districts (Mn) per
IMRT, 3D CRT, lesser complex surgeries and
State with CCC CCC
basic lab services) closer to the home of
UP 18% 6.1 patients. Government and private medical
BH 8% 22.2 colleges/ district and sub- district hospitals in
the public sector and centers in Tier 2 cities of
MH 57% 1.8
private oncology/ multi-specialty chain can act
WB 37% 4.6 as spokes. Government/ Private
healthcare providers
MP 12% 4.7 ► Level 2 centers could offer comprehensive
TN 50% 1.6 cancer care in a geographic area and act as a
RJ 21% 4.7
tertiary cancer referral center. Large super
specialty hospitals attached to medical colleges
Source: “List of Cancer and centers in Tier 1 cities/ metros of private
Treatment Centres licensed by oncology/ multi-speciality chain can act as a
AERB”, aerb.gov.in, February Level 2 centers.
2021, EY analysis ► Level 1/ Apex centers should offer the most
Current state  proposed state: advanced therapies for common as well as rare
cancers. (Immunotherapy/ targeted therapy,
CCCs in 175 districts in 2022 
cyber knife, robotic surgeries, genomics).
CCCs in every major district with
Flagship hospitals and centers of Excellence in
1 center for 5000 new cases by
2030 private and public sector, such as TMH/ AIIMS,
SCIs and TCCCs, can act as a hub.
► Expedite the process of approval of projects and
release of funds under various VGF schemes
available currently with central and state
governments. Viability gap funding under these
schemes can cover up to 40% of project costs while
facilitating unencumbered land allotment and
approvals/ clearances within a specific timeline: Government

► Capital outlay of Rs 10,500 to 14,000 crores

(excluding land and medical technology such as
LINACs and PET-CT) is required to add ~40,000
incremental day care and surgical beds for
servicing increasing cancer incidence.
3.2 Need to improve local access to ► Address access challenges through hub and spoke
quality care facilities for general model, telehealth, day care chemotherapy centers, Government, Private
population. etc. Healthcare Providers

Call for Action: Making quality cancer care more accessible and affordable in India xvii
 Key challenges Proposed actions Actions by
► Support patients traveling for treatment away from
their homes with simple solutions such as daily food
vouchers for caregivers, tie-ups with nearby hotels or
service apartments, organizing local conveyance
from hotel to hospital.
3.3 Low penetration of RT facilities ► Adopt a tiered approach in offering radiotherapy
in India with 0.4 RT per million treatment to patients closer to their home.
against the WHO norm of 1 RT
per million58. % Radiotherapy patients
requiring treatment at Population coverage per
Level 1 Radiotherapy center (million)
RT per different levels
(apex)
State million ~5% CyberKnife, 22 10
Gamma Knife Government/private
SBRT, Tomo
Uttar Pradesh 0.2 healthcare providers
Bihar 0.1 10% - 15%
Level 2
~7 ~3
VMAT
Maharashtra 0.7
West Bengal 0.3
Level 3 (spokes)
80% - 85% 1.1 0.5
Madhya Pradesh 0.3 IGRT, IMRT, 3D CRT

Tamil Nadu 0.8 2022 2030

Rajasthan 0.3
Source: “List of Cancer ► To attain population coverage as mentioned in the
Treatment Centres licensed by above chart, there is a need to add ~890 RT
AERB”, aerb.gov.in, February equipment immediately and ~3,200 RT equipment by
2021, EY analysis 2030 with a capital outlay of INR40,000 to 45,000 Government
crores.
In developed countries such as ► Achieve the above model of distributed and equitable
the US, Japan, Germany, Italy, access to radiotherapy treatment by mandating
France, RT equipment oncology program and specifically radiotherapy
penetration is in the range of department creation across all public and private
2.6 to 7.6 RT per million medical colleges and in select district hospitals.
population while in fellow BRIC ► Additionally, hubs and COE centers should provide
nations — Brazil, Russia, China central physics services to their spokes to enable Government/private
penetration is in the range of uniform treatment planning under the guidance of healthcare providers
0.8 to 1.1. expert clinical resources available at such centers.
► While the government introduced Production Linked
~60% of RT centers are located
Incentive (PLI) scheme for domestic manufacturing
in districts with predominant
of oncology equipment and other medical devices in
urban population in India
2020 with an outlay of Rs 3,420 crores offering
incentive of 5% on incremental sales of goods
Current state  Proposed state:
0.4 RT per million in 2022  ~2 manufactured in India, the impact of it needs to be
RT per million by 2030 studied during the tenure of the scheme. The lessons
drawn from the scheme must be used to plug in gaps Government
and identify other critical components of the
oncological ecosystem which need to be promoted.
Considering both these aspects, the government
should bring back the scheme to facilitate “Make-in-
India” efforts to meet the demand of devices, drugs,
and equipment for cancer treatment in India.
► Given there is a substantial need to add 275 to 400
RT equipment per annum, volume commitments from Government/ Private
public and private sector can enable medical device healthcare providers/
companies to fast track their decision of setting up Private medical device
manufacturing/ assembly line set up in India. The manufacturers
domestic manufacturers of various oncological
devices may make the best use of upcoming medical
devices and pharmaceutical drugs parks to expand
their operations in the country.
► Domestic manufacturing alone cannot meet the
demand for cancer care equipment in India, Government
especially of the capital expensive equipment such as

xviii Call for Action: Making quality cancer care more accessible and affordable in India
 Key challenges Proposed actions Actions by
radiotherapy equipment required by the industry.
The same scenario has been witnessed in the aviation
and shipping industry, wherein facilitating imports of
capital-intensive equipment opens up an avenue for
employment in the service sector. By the same logic,
the government must provide with relief in custom
duties and GST for critical capital-intensive
equipment in cancer treatment in India. Reduction in
custom duties can effectively reduce the price of
treatment to the end consumers reducing the out-of-
pocket expenses.
► Current Custom duty and IGST together add a
cost of ~30% over the cost of radiotherapy
equipment imported and therefore, government
can be consider revising the same.
3.4 Low penetration of PET-CT ► Improve supply of trained nuclear medicine
machines in India with 0.25 PET physicians by increasing number of post graduate
Government
Scanners per million nuclear medicine seats to ~3X of current seat count
population67 while the of 67 MD and 35 DNB.
developed countries such as the
► Include PET-CT as a separate procedure for
US, Australia and many West
reimbursement across all the state government
European countries have 3 PET–
schemes
CT scanners per million
population68. ► As of today, select state schemes such as
MJPJAY, Telangana Arogyashri, Arogya
Current state  Proposed state: Karnataka, Swasthya Sathi which represent
0.25 PET Scanners per million to populous states such as Maharashtra,
State governments
0.75 PET Scanner per million by Telangana, Karnataka and West Bengal do not
2030 cover PET-CT as a reimbursable intervention/
procedure
► Inclusion of PET-CT in these schemes will spur
demand which will attract investments in setting
up Nuclear medicine facilities across more
locations
3.5 Low access to advanced ► Reduce custom duties on a broad range of reagent/
Government
therapies and genomics consumables used for cancer diagnostics and anti-
► ~75% oncologists using cancer drugs used in advanced chemotherapy to
NGS tests in the US 83 to effectively reduce the price of treatment to the end
guide treatment decision consumers, thereby also reducing the out-of-pocket
vs. significantly low expenses.
penetration in India.
► Bring advanced cancer diagnostics and therapies
such as gene panel for precision oncology, liquid
Government/ Health
biopsies, immunotherapy etc., under reimbursement
Insurance providers
schemes of government as well as private insurance
plans.
► Create an ecosystem to encourage innovation and
research by sharing data on Indian patients such as in
the case of genomics. Currently gene panels are
Government
developed mostly based on Caucasian gene pool data
as against Indian gene pool data required for
developing India specific gene panels.
3.6 High incidence per oncologist at ► Increase the number of medical oncology seats and
315 in India compared to 120 in surgical oncology seats by ~4X to 5X and 1.5X to 2X
China and 137 in the US respectively by increasing DNB seats to the extent
► Demand for number of feasible. This can be enabled by:
medical oncologists and ► Accreditation of multiple hospital units against Government
surgical oncologists is 2.6 individual hospital unit for the program.
times and 1.4 times of
► Relaxing 2-year clinical establishment criteria
current availability.
and minimum prescribed beds for DNB
commencement.

Call for Action: Making quality cancer care more accessible and affordable in India xix
 Key challenges Proposed actions Actions by
► Demand for number of ► Increasing number of specialties per unit bed (5
medical physicists is 1.3 specialties against 3 specialties for 150 to 200
times that of current bedded hospitals; 4 specialties against 2
availability. specialties for 100 – 150 bedded hospitals).
The demand-supply gap is ► Encouraging senior practitioners to teach by
expected to widen further as provision of honorary degrees and stipends.
annual addition of medical
► Provide platforms for continuing medical education
oncologists and surgical
to enhance knowledge and skillsets of Oncologists.
oncologists is lower than
Additionally, ensure that research contribution by
expected requirement driven by All ecosystem players
clinicians is considered as a key criteria for
incidence and population (Private and Public)
accreditation/ qualification of centers for eligibility
growth.
under reimbursement programs offered by
Demand supply government and private insurance players.
gap (Demand/ ► Introduce oncology as a subject as part of the MBBS
Supply)
curriculum such that general physicians also acquire
2022 2030 basic skillsets required to recognize cancer
Medical symptoms, conduct screening and initial diagnosis
2.6 2.8 and refer patients to the right specialists/ referral
oncologists
centers
Surgical
1.4 1.6
oncologists
Radiation
1.0 1.1
oncologists
Government
Medical
1.3 2.5
physicists
Source: “List of cancer treatment
centres licensed by AERB”,
aerb.gov.in, “Call for Action:
Expanding cancer care in India” EY
report, 2015, nmc.org.in,
Accr.natboard.edu.in, EY analysis,
Refer <Annexure 5 - 9> for
assumptions

3.7 Lack of coordinated care, ► Empower GPs and upskill specialists (dentists, ENT,
variability in diagnosis and OBG, pulmonologist etc.) to play an effective role as
consultations leading to delay in gatekeepers
accessing care. ► Impart training so that they recognize relevant
symptoms and signs for streamlined referrals. Government, medical
► Develop and implement pathways that help colleges, private and
identify high-risk patients for faster movement public healthcare
through the stage-gates. providers,
oncologists,
► Provide access to structured referral database. diagnostic companies,
► Enforce standard protocols for diagnostic tests providers
across different organs so that clinicians, providers
and diagnostic centers all follow uniform practices.
► Build diagnostic facilities in day care centers through
tie-ups or setting up collection points.
3.8 Less than 2% of people ► All state governments should develop and roll out
requiring palliative care have policy structure encompassing capacity building,
access to it in India against the access to essential medicines, strengthening
global average of 14%101. palliative care facility at primary, secondary care
level and developing palliative care facility at tertiary
care level. Government

► Currently, only three states in India (Kerala,

Karnataka and Maharashtra) have a palliative
care policy
► Mandatorily integrate palliative care services with
care delivery at the PHCs, CHCs and district hospitals
in the country and also link with referral database to Government
ensure tracking and follow up with patients.

xx Call for Action: Making quality cancer care more accessible and affordable in India
 Key challenges Proposed actions Actions by
► Train auxiliary nurses and Asha workers to provide
counseling to cancer patients.
► Undertake efforts to include palliative care packages
Government/ Health
under reimbursement schemes of government as well
Insurance providers
as private insurance plans.
3.9 Lack of standard care delivery ► In similar lines as that of NCG, the NHA needs to
to patients establish/ formalize an Apex body which develops
► Lack of coordinated care and implements standard treatment protocols for
often leads to varied cancer care. The government should mandate Cancer
outcomes, misdiagnosis centers across the country to adopt either standards
and miscommunication provided by the Apex body or alternate standards
between providers, which are available for audit and review by such Apex
patients, and caregivers. body. Multidisciplinary Tumor Boards need to be a
key feature of the treatment guidelines and efforts
► Second opinion leads to
should be undertaken to recognize and authorize
change in diagnosis and
multiple MDT Boards across the country which can Government/ Private
treatment.
offer case review and opinion services to smaller providers/ Health
recommendations in 12% to
centers and spokes as envisaged to be set up in point Insurance providers
69% of cases
3.1 above. Compliance with the treatment guidelines
► 60% to 150% variability going forward should be considered as key criteria by
exists in reimbursement the government and private insurance players to
tariffs under schemes. decide eligibility for reimbursements /empanelment.
► 25% to 30% of medical
treatment costs are not
covered by private
insurance schemes based
on limited study conducted.

3.10 Need for single source of ► Develop and implement national helpline or Government
authentic cancer information ‘Arogyasetu’ like app providing support to patients
including platform for second diagnosed with cancer, including connecting patients
opinion for expert review of with expert doctors for second opinion.
suggested treatment plans. ► Provide access to a regularly updated public
database listing specialists along with their medical
credentials and accredited hospitals specializing in
cancer care.
► Hospital websites could evaluate providing
Private healthcare
information on patient feedback, contact details of
providers
survivors treated in same hospitals, treatment cost,
technology, and outcomes in addition to doctor
profiles and locations where facilities are available.
3.11 High wait times and amount of ► Adopt digital interventions such as automated Private providers,
paperwork in administrative messages to patients informing them of delays, insurance companies,
processes causing patient online appointment systems, online insurance startups, technology
dissatisfaction. approvals, etc. players
► Publish reports displaying adherence to waiting time
standards to reassure patient that continuous Private healthcare
process improvement efforts are being undertaken. providers

3.12 Need for frequent, transparent ► Deploy dedicated nurse navigator or care coordinator Government, Private
and effective communication programs in hospitals. healthcare providers,
with patients and caregivers. ► Drive usage of technology to provide administrative technology
updates electronically through mail or text. Provision companies, startups
for patient to login to access their health information
at any time to see their progress will be a critical
enabler for ensuring timely communication with
patients/caregivers.
3.13 Extreme psychological distress ► Drive integration of psycho-oncology in treatment Psycho-oncologists,
for patient and caregiver often plans. mental health expert,
needing professional private healthcare
intervention. providers

Call for Action: Making quality cancer care more accessible and affordable in India xxi
 Key challenges Proposed actions Actions by
► Care for caregiver— need to provide adequate
counseling for caregivers also.
► Training at every level from doctors, nurses, front
office and housekeepers on cultural sensitivity and
patient dignity.
► Redesign all processes to ensure empathy at every
step of treatment to reduce anxiety for already
vulnerable patients and their families.
4 Treatment – Affordability of quality care
4.1 Non uniform reimbursement ► Given that typical baseline comprehensive cancer
rates and rigid coverage limit treatment cost often exceeds INR5 lakhs, which is
per annum for the government also corroborated by the survey of 154 patients,
sponsored schemes there is a need for the government to make
► Wide variation in coverage reimbursement limit for cancer care under
of oncology procedures government schemes flexible to cover end-to-end
observed currently- e.g., treatment for cancer patients.
851 procedures covered by ► Determine uniform reimbursement rates across all
TN CMHIS vs. 189 state government schemes and PMJAY following a
procedures covered by structured approach keeping in mind a uniform
MJPJAY. standard of care and treatment plan developed by
► PMJAY provides fixed the Apex Body as recommended in point 3.9 above.
coverage of up to INR5 ► Additionally, a mechanism for accreditation of
lakhs per year per family. healthcare facilities both public and private delivering
Some of the state cancer care, needs to be developed and implemented
government schemes such based on which eligibility for reimbursement and
as MJPJAY, Telangana tariff benefits can be determined. Endeavors in this
Arogyashri, Mukh Mantri regard have been made by TMH in developing a 5-
Government
Punjab Cancer Raahat Kosh star rating based system for accreditation of facilities
scheme provides only and determining eligibility for reimbursement. The
INR1.5 to 2.0 lakhs of rating mechanism developed has been illustrated
coverage much lower than below for reference:
cost of multi-modal
treatment. Rating scale Process and reporting requirements
*1 Captures and reports patient information by
Current state  Proposed state: site and stage of disease.
Non-Standard, non-uniform *2 Additionally captures and reports
reimbursement rates with rigid complication rate.
cover  Standardized, uniform
*3 Additionally captures and reports
reimbursement rates in line with compliance to pre-defined and approved
quality of healthcare delivered treatment guidelines.
with flexible cover.
*4 Additionally captures and reports five-year
survival data.
*5 Additionally conducts research either to
change current treatment processes/
protocols or to improve outcomes.

4.2 Lack of comprehensive ► As highlighted in point 4.1 above, retail health

insurance coverage by retail insurance players should develop their care plans
health insurance players. ensuring comprehensive coverage across all stages
of patient journey based on treatment protocols
Health Insurance
Current state  Proposed state: developed/ approved by proposed Apex Body.
providers
70% - 75% of medical expenses Additionally, accreditation as mentioned in point 4.1
covered through insurance to above, should be a key criterion for these insurance
100% coverage players to determine reimbursement levels for cancer
care facilities.
4.3 Need for innovative ways to ► Encourage innovative financing models such as
raise capital and optimize costs impact bonds that can help improve access to these Government
► The cost of emerging emerging diagnostics and treatment modalities.
oncology diagnostics and ► Drive efficiencies across material, workforce and
Private healthcare
therapeutics such as medical equipment utilization to lower cost and
providers
precision oncology,

xxii Call for Action: Making quality cancer care more accessible and affordable in India
 Key challenges Proposed actions Actions by
immunotherapy and proton thereby sustainably service the government scheme
therapy are on the higher patients.
side and is out of reach for ► A structured program can help unlock efficiencies by
94% to 97% of Indian 15%- 30% across major cost heads.
population116.
4.4 High cost of treatment often ► Evaluate expansion of PMJAY scheme coverage to Government
leading to non-adherence of full include middle class population.
course. ► Strengthen processes on financial counseling of
patients about insurance or schemes, philanthropic
funding, patient assistance programs and complete
billing transparency. Private healthcare
providers
► Provide complete visibility about costs of treatment
during finalization of treatment plan.
5 Treatment - Cancer health records
5.1 Limited coverage under ► Improve coverage from the current 10% of
Population Based Cancer population with special focus on rural areas.
Registries (PBCR) Government
► Add population registries in states which do not have
► Only 38 PBCRs covering one currently.
~10% of the population with
► Make cancer a notifiable disease to strengthen the Government
most of them being
data availability with respect to cancer related
urban122. Only 1% of rural
mortality.
population is covered under
PBCRs123
► Several states such as
Uttar Pradesh, Madhya
Pradesh, Andhra Pradesh,
Rajasthan, Telangana and
Orissa having inadequate
presence and penetration
of registries.
5.2 Limited coverage under ► Make it mandatory to register hospital-based cancer Government
Hospital Based Cancer registry under NCDIR – NCRP for all hospitals with
Registries (HBCR) >50 beds.
► Only 268 HBCRs registered
under NCDIR –NCRP124.
With more than 43,486
private hospitals and
25,778 public hospitals in
India 1, the coverage under
HBCRs is meagre

1 Private Healthcare in India: Boons and Banes, www.institutmontaigne.org, November 2020

Call for Action: Making quality cancer care more accessible and affordable in India xxiii
xxiv Call for Action: Making quality cancer care more accessible and affordable in India
Table of

Contents
Chapter 1 – Cancer disease burden ....................................................... 2

Chapter 2: Maturity of India’s cancer control landscape ....................... 22

Chapter 2A: Awareness and Prevention ............................................ 22

Chapter 2B: Screening and Detection ............................................... 44
Chapter 2C: Treatment .................................................................... 62
(i) Treatment - Access ............................................................... 62
(ii) Treatment - Affordability ....................................................... 83
(iii) Treatment - Cancer health records .........................................95

Chapter 3: Improving the cancer patient journey ................................. 98

Annexures ........................................................................................ 108

1 Call for Action: Making quality cancer care more accessible and affordable in India
 1 Cancer disease burden

1 Call for Action: Making quality cancer care more accessible and affordable in India
Chapter 1 – Cancer disease burden
India faces a grave challenge of high cancer Despite the crude rate of incidence not being
incidence, which is growing at a faster pace as amongst the highest in India compared to other
compared to other developing countries geographies, the total incidence burden is high
due to the large population size of the country.
According to the 2020 WHO ranking on cancer
Considering growth in population and crude rate,
burden, India ranks at the third position after
India’s cancer incidence is estimated to be growing
China and the US, respectively, in terms of new
at a CAGR of 6.8% (2015 to 2020) which is
yearly cancer incidence being reported.
significantly higher than other developing
Based on the historical growth in reported cancer countries such as China (1.3%) (which has a
incidence (CAGR of 5% between 2012 to 2016), comparable population size), Brazil (4.5%) and
India’s cancer incidence crude rate is estimated to Indonesia (4.8%) as well as developed countries
be 122 per lakh population and age-specific such as UK (4.4%).
incidence (ASR-W*) rate is estimated to be 116
In 2022, around 19 to 20 lakh new cancer cases
per lakh population in 2020. While the estimated
are estimated to be reported in India. However,
age-specific incidence rate (ASR rate) for India is
the real incidence of cancer is conservatively
lower compared to other geographies, India’s real
estimated to be 1.5 to 3 times higher than the
ASR rate is expected to be higher than Thailand
reported incidence from cancer registries.
and Indonesia, and comparable with China and
Brazil (refer Chart 1).

Chart 1: Estimated incidence in 2020

Estimated# Real Reported - 2020

India Brazil Thailand Indonesia China US UK

Overall new 2,570–

1,714 475 131 397 4,569 2,282 458
cases (In 000s) 3,430

Incidence CAGR
6.8% 4.5% 7.8% 4.8% 1.3% 6.6% 4.4%
(15-20)

689 675

279 273 316

Estimated 182-242
122 145
incidence, 2020
(Crude rate)

362
320

174 - 232 215 205

164 141
Estimated 116
incidence, 2020
(ASR-W*)

Source: NCRP 2020 Annual report, Global cancer observatory for Brazil, Thailand, US, UK, China and Indonesia
#
Estimated incidence considering only population growth and crude rate CAGR, without considering impact of changes in risk factors
and improvement in diagnosis
*ASR-W is a weighted mean of the age-specific incidence rates. The weights are taken from the population distribution of the ‘World
Standard Population ‘defined by WHO, and the estimated incidence rate is expressed per lakh population for comparisons between
different geographies.
+
CAGR: Compound annual growth rate, measures the annual growth over multiple years by compounding over the time period.

Call for Action: Making quality cancer care more accessible and affordable in India 2
Real incidence for cancer in India is expected to
be 1.5 to 3x of reported incidence, mainly due
low population coverage of cancer registries and
significant under diagnosis Cancer care demand will be increasing
globally and especially in India, and we have
Some indicators for the gap between real and to modernize our care across all respects in
reported cancer incidence in India are: our country. India should campaign to
increase exponentially the awareness of
1. Differences in incidence data when compared
prevention, early detection and treatment,
between cancer registry and randomized automation in diagnostics, application of
screening studies precision medicine and personalized care
► Studies that compared incidence data which can make it more affordable.
from cancer registries and large
Dr. M I Sahadulla
randomized screening trials at Mumbai,
Chairman & Managing Director, KIMS Health –
Osmanabad and Trivandrum
India and GCC
demonstrated the real incidence to be
around 1.5 to 3 times higher than the
reported incidence.

Table 1: Gap between study and registry incidence

Study Registry Gap between study

incidence incidence v. registry
Location of Reference (per 1,000 (per 1,000 incidence (No. of
Study Organization study Site year pop) pop) times)
Mumbai Breast 1998-2018 0.64 0.21* 3.0
Tata Memorial
Mumbai Cervix 1998-2015 0.25 0.11* 2.3
Hospital
Osmanabad Cervix 1999-2007 1.35 0.42# 3.2
Sankaranarayanan
Trivandrum Oral 1996-2014 0.37 0.17^ 2.2
R et al 2021

*pooled crude incidence based on population-based cancer registry data for respective time periods for Mumbai
# pooled crude incidence based on population-based cancer registry data 1999-2007 for Barshi
^For oral cancer, incidence for lip, tongue and mouth have been considered from PBCR data, Thiruvananthapuram 1996-2014

2. Low population coverage of the Indian cancer of cancer incidence at a population level
registries are extrapolated from the reported
incidence in cancer registries and India’s
► Indian cancer registries cover only ~10%
very low coverage could potentially lead
of the population vis-à-vis >90% in the US
to a high margin of error.
and the UK and ~40% in China. Estimates

3 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 2: Global population coverage by national cancer registries

89% 91%

38%

10%

India China UK US

Source: NCRP Annual report, 2020, respective national PBCR registries

3. High under diagnosis Head and neck, gastrointestinal and lung

contribute to 50% cancer incidences in males and
► Leading oncologists believe that the
breast, cervix uteri and gastrointestinal organs
under-diagnosis could be to the tune of
in case of females. Head and neck, prostate and
more than 50% due to lack of diagnostic
ovarian cancer are growing at a faster pace than
infrastructure and low patient awareness.
other cancers
A research on stages of diagnosis with
around 500 breast cancer patients from ► Out of ~14 lakhs cancer cases in 2016, males
south India, 2006, revealed that almost contributed to 49% (47% in 2012) and females
53% of patients had delayed diagnosis due contributed to 51% (53% in 2012).
to low awareness and lack of organized
► Cancers of the head and neck and gastro-
and regular screening programs.2
intestinal organs constitute 21% and 18%
► The ongoing COVID-19 pandemic has respectively for males and 6% and 11%
impacted the speed of national cancer respectively for females out of the total
screening programs, decreased visits to incidence across the respective genders (refer
hospitals/general practitioners, reduced chart 3 below for gender wise and organ wise
referrals to specialist and lower diagnostic incidence).
tests, further accentuating the
► Cancers of the head and neck are growing at
underdiagnosis and delayed diagnosis
the highest overall CAGR (12-16) of 23%
situation since March 20203.
(CAGR of 25% in males vs. 16% in females). In
► Cohort studies reported a 38% males, it is followed by prostate cancer at 19%
reduction in pathological diagnostic while in females by ovarian and lung cancer at
tests and 43% reduction in radiological ~11%.
diagnostic tests at 41 cancer centers
► Breast cancer may be considered as a threat
across India during March-May 2020
with this organ type becoming the highest
period as compared to the
contributor (29%) to total incidence among
corresponding period in 2019.
females in India in 2016 and incidence rising

2Ali R, Mathew A, Rajan B. Effects of socio-economic and 3Ranganathan P et al. National Cancer Grid of India. Impact of
demographic factors in delayed reporting and late-stage COVID-19 on cancer care in India: a cohort study. Lancet Oncol.
presentation among patients with breast cancer in a major cancer 2021 Jul;22(7):970-976. doi: 10.1016/S1470-2045(21)00240-0.
hospital in South India. Asian Pac J Cancer Prev. 2008 Oct- Epub 2021 May 27. PMID: 34051879; PMCID: PMC8159191.
Dec;9(4):703-7. PMID: 19256763

Call for Action: Making quality cancer care more accessible and affordable in India 4
 among women at high CAGR of 8% during compared to 11% in 2016) has seen a
2012 to 2016. significant reduction with a negative CAGR of
13% (2012 to 2016).
► Cervix uteri, which was one of the top
contributing cancers in females (23% in 2012

Chart 3: Organ-wise incidence proportion to overall cancer incidence

Organ wise incidence proportion to total Organ wise incidence proportion to total
cancer cases, 2016: Males cancer cases, 2016: Females

-17% 5% 4% 7%
16%
3% 7%
3% 2% 6%
5%1% 25% 3% 4% 7%
21% 11%
11%
-1% 23% 4%
-6% 27% 5% 5%

18% 5%
6%
11%
8% 29%
11%
6% 11% 8%
5% -13%
6%
19%

Head and neck* Gastro intestinal** Lung Prostate Increase in

CAGR 2012-16
Leukemia*** Breast Cervix uteri Ovary
Decrease in
Others# Esophagus Thyroid Brain CAGR 2012-16

*CAGR for Leukemia, Thyroid, and Brain are from 2015-16

Source: NCRP annual report, 2020, Globocan 2012
*Head and neck includes tongue, mouth, hypopharynx and larynx
**Gastro-intestinal organs include stomach, rectum, colon, liver and gall bladder
***Leukemia includes NHL, Lymphoid and Myeloid Leukemia
# Others include cancers of the urinary tract, corpus uteri, etc.

Disease burden for head and neck, breast and cancers than India (these cancers contribute
ovary cancers is higher / on par with other to 60% cases in China and 34% in the US).
countries
► There has been a significant increase in breast
► Top three organs contributing to 43% of cancer cases in India and China between 2015
reported incidence in India in 2020 to 2020 (CAGR of 14% and 6% respectively),
(estimated) are head and neck (~3 lakhs), while the UK has shown a decline in incidence.
breast (~2.6 lakhs) and gastrointestinal
► While the incidence of brain cancer has
cancers (~2.5 lakhs).
increased in India, the US and the UK, China
► In 2020, India is estimated to have the highest has managed to achieve a significant
incidence and incidence CAGR across head reduction in brain cancer cases (by 6%).
and neck and ovarian cancers in comparison
► Against the increasing trend in incidence,
with China, the US and the UK (refer Table 2
cases of thyroid, leukemia, lung and cervix
below).
uteri cancer cases are estimated to have
► China and the US have higher cases of declined by 14%, 6%, 2% and 1%, respectively.
gastrointestinal, lung, prostate and thyroid

5 Call for Action: Making quality cancer care more accessible and affordable in India
 Ovarian cancer in India has grown by a CAGR reduction. The same has resulted in India
of 6% as against 1-2% CAGR for China and US, having the highest incidence of ovarian cancer
while UK has managed to achieve a 3% as compared to China, the US and the UK.

Table 2: Global comparison for organ-wise crude incidence in 000s and CAGR (2015-20)

Incidence 2020 (‘000) CAGR (2015-20)

Organ\Country India China US UK India China US UK

Head and neck 306 142 59 14 8% 2% 4% 4%

Breast 256 416 253 54 14% 6% 3% -1%

Gastrointestinal 246 1,593 276 78 4% 4% 2% 3%

Lung 95 816 228 52 -2% 1% 7% 3%

Cervix uteri 94 110 14 4 -1% 0% 3% 4%

Esophagus 83 324 18 10 11% 6% 5% --

Leukemia 64 85 61 11 -6% 0% 5% 2%

Ovary 60 55 24 6 6% 1% 2% -3%

Prostate 45 115 210 57 1% 10% 3% 3%

Brain 41 80 25 6 6% -6% 3% 2%

Thyroid 27 221 53 6 -14% 2% 1% 9%

Data for stage of diagnosis: US is for 2012-18, UK for 2019 & China is from 2009, India from 2016.
Source: SEER cancer statistics, Cancer research UK, Zeng at al 2021, NCRP Annual report 2020

The issue of high disease burden is compounded respectively, which is significantly lesser than that
with late-stage detection caused mainly due to in China, the UK and the US (refer chart 4).
lack of awareness and poor screening programs
This is one of the reasons for high mortality rate
India has a poor detection rate across major for cancers in India when compared to developed
cancer sites with only 29% and 15% of breast and countries such as the US and the UK, where early
lung cancers being diagnosed in stages 1 and 2, diagnosis has been a key reason for reduced
mortality.

Call for Action: Making quality cancer care more accessible and affordable in India 6
Chart 4: % of cases diagnosed at the following stages:

I II III IV Unknown I & II

Breast cancer Year of initiation of Participation

Country screening program rate*

4% 4% US 1995 94%
6% 7%
10% 17% 4%
10% UK 1988 88%
4% 16%
8%
China 2009 43%
32%
57% 34% India 2016 7%
47%
*Percentage of eligible women (30 to 69 years) who have a
49% screening mammogram at least once in 24 months. Data for the UK
29% 37% for 2019 and the US, China for 2016 to 2017; and India for 2016.
26%
WHO’s screening programs short guide for UK, SEER registry for
India USA UK China US, Chinese national cancer registry for China and International
Cancer Screening Network, Ministry of Health and Family Welfare.
2020-21 Annual Report for India

Lung cancer Year of initiation of Participation

Country screening program rate*
US 2011 32%
5% 5% 12%
24% UK 2013 30%
45% 46% China 2012 22%
43%
33%
Yet to start at country
India ~
18% level
35% 19% 18%
7%
7% 12%
*Percentage of eligible population (50 to 80 years) who have LCDT
24% screening. Data for the UK for 2019 and the US and China for 2016
15% 19% 13% to 2017; and India for 2016. Source: National Library of Medicines
India USA UK China for the UK, Centers for Medicare and Medicaid Services for the US,
Disparities in stage at diagnosis for five common cancers in China:
a multicenter, hospital-based, observational study

Cervix uteri cancer Year of initiation

of screening Effective Crude
Country program Coverage^ Coverage#
2% 4% 5% 1%
5% 4% US 1991 74% 91%
16%
42%
34% UK 1988 71% 89%
60% 36% China 2009 ~23% ~55%
9%
6% India 2007 ~1.2% ~30%
12%
57%
44% ^Effective coverage: The proportion of eligible women (15-49
33% 31% years) who report having had a pelvic exam and Pap smear in the
past three years; #Crude coverage: The proportion of women (15
India USA UK China to 49 years) who report having had a pelvic exam (regardless of
when the exam occurred).

7 Call for Action: Making quality cancer care more accessible and affordable in India
India is witnessing a rapid increase in burden of contributes to 4% (2 crore) of overall DALYs in
NCDs (including cancer) with the contribution of 2017, which represents an increase of 65-70%
NCDs to total deaths rising from 38% in 1990 to from 2.3% DALYs (~1.2 crore) contributed by
57% in 2017 cancer in 1990.

Fast-growing population coupled with rapid While the contribution of NCDs to total deaths has
urbanization in India has led to an overall been increasing (from 38% in 1990 to 57% in
economic rise, however with certain associated 2017), contribution of cancer deaths has almost
challenges, such as changes in lifestyle, unhealthy doubled during the same period (4% in 1990 to 7%
eating habits, tobacco smoking and rise in alcohol in 2017).
intake. As a result, the country is witnessing a
► As per ICMR reports, among overall cancer
shift toward higher proportion of non-
mortality in India for 2016, stomach and lung
communicable diseases (NCDs).
cancer contribute the most (9%) to the total
In 2017, NCDs contributed to 50% (24.2 crore) of cancer deaths. It is followed by breast and oral
the overall disability adjusted life years’ (DALYs) cancer contributing to 8% and 7%,
(48.6 crore) 4, a significant increase in comparison respectively, to the total cancer-related
to 31% (~16.0 crore) in 1990. Cancer alone deaths.

Chart 5: Proportion of total deaths in India over time

1990 2017

9% 11%
4%
7% 31%

Proportion of
total deaths in 54%
34%
India

50%

Communicable disease NCD excluding cancer Cancer Injuries

Source: India: Health of Nation’s state 2017, India-global burden of disease study 2017, World Bank death rate indicator

Given the above, India has an adverse mortality India vs. 23% in the US and 33% in the UK),
to incidence ratio worse than other countries prostate cancer (M/I ratio of 49% in India vs.
15% in US and 23% in the UK), Breast cancer
► India leads the organ wise mortality to
(M/I ratio of 51% in India vs. 17% in the US and
incidence ratio across all countries, except in
22% in the UK). For these cancer types,
the case of esophageal cancer where it is at
developed countries have been able to nearly
par with China.
halve the M/I ratio compared to India,
► In comparison with other countries, India has highlighting the need to draw learnings from
a significant journey to bridge w.r.t these countries and contextualize them in the
improvement in outcomes specifically for Indian context for improved outcomes.
Head and neck cancer (M/I ratio of 56% in

4 India: Health of Nation’s States, The India State-Level Disease Burden Institute for Health Metrics and Evaluation, 2017
Initiative, Indian Council of Medical Research
Public Health Foundation of India

Call for Action: Making quality cancer care more accessible and affordable in India 8
Table 3: Global comparison for organ-wise mortality to incidence ratio

Organs India (M/I) China (M/I) US (M/I) UK (M/I)

Head and neck 56% 52% 23% 33%
Gastro-intestinal 80% 75% 53% 56%
Lung 91% 88% 61% 70%
Prostate 49% 44% 15% 23%
Leukemia 73% 72% 39% 48%
Breast 51% 28% 17% 22%
Cervix uteri 62% 54% 42% 30%
Ovary 70% 68% 60% 68%
Brain 85% 82% 74% 78%
Esophagus 92% 93% 89% 84%
Others 57% 31% 15% 29%

Source: NCRP Annual report 2020, Global Cancer Observatory, 2020

Within India, out of the 17 states covered by and have 23% share of the total cancer burden of
population-based cancer registries (PBCRs), 13 the country.
states exhibit a rising cancer burden
Tamil Nadu, Karnataka, Punjab, and Maharashtra
Among all states and UTs covered by population- are the states where the crude incidence rate
based cancer registries (PBCRs), Kerala, Mizoram, among females is significantly higher than male
Tamil Nadu, Karnataka, Punjab, and Assam report cancer incidence. Conversely, for Assam,
the highest overall crude incidence rates of Meghalaya and Nagaland, the crude incidence
cancers (above 130 cases per lakh population) among males is much higher than female cancer
incidence.

Figure 1: Map of India with top organ cancer types and Table 4: Key state wise projected crude Incidence
crude rate per lakh population (2020) and CAGR trend

Crude rate per lakh population

High (CR>120) State/UT
Moderate (CR>70 & <120) (No. of Registries) Overall Male Female

Low (CR<70) Kerala (2) 181.6 188.7 175.4

No Data Karnataka (1) 151.7 132.3 172.6
Tamil Nadu (1) 148.6 135.4 161.5
Punjab (1) 144.0 126.4 163.7
Mizoram (1) 141.7 143.5 139.9
Assam (3) 138.6 151.6 125.8
Delhi (1) 113.5 111.7 115.5
Maharashtra (6) 97.2 88.8 106.2
Arunachal Pradesh (2) 94.1 91.0 97.1
West Bengal (1) 87.9 94.1 81.4
Madhya Pradesh (1) 87.8 85.3 90.4
Gujarat (1) 85.8 92.6 78.2
Head and neck Cervix uteri Meghalaya (1) 79.5 100.7 58.4
Sikkim (1) 70.5 67.8 73.5
Lungs Gastro
Tripura (1) 68.5 76.7 60.0
Breast Esophagus
Nagaland (1) 68.2 74.1 61.9
Ovarian
Manipur (1) 56.2 50.8 61.6

Source: NCRP annual reports, EY analysis. Refer <Annexure 1> for state-wise population and cancer registry coverage in 2016

9 Call for Action: Making quality cancer care more accessible and affordable in India
While there is a significant variation among ► Breast and ovarian: Most key states in
states in cancer incidence for different organs, regions, excluding north-east, have high
cancers of breast, ovaries and cervix uteri incidence of breast and ovarian cancer among
among females have a high incidence among females, with southern states of Karnataka,
most key states Kerala and Tamil Nadu having the highest
incidence followed by northern states of
► Head and neck: Madhya Pradesh, Gujarat and
Punjab and Delhi.
north-eastern states of Assam, Meghalaya and
Mizoram have a significantly high incidence of ► Cervix uteri: Almost all key states have a high
mouth, tongue and hypo-pharynx cancers, as incidence of Cervix uteri cancer with Mizoram
compared to other states. having the highest crude rate (38 per lakh
population) followed by Karnataka and Tamil
► Lung cancer: Mizoram has the highest
Nadu (29 per lakh population).
incidence of lung cancer among females (37
per lakh population) and among the highest ► Esophagus and Stomach: Meghalaya and
for males (22 per lakh population). Kerala and Mizoram have the highest incidence of
West Bengal also have a high incidence of lung esophagus and stomach cancers, both among
cancer, particularly among males. males and females.

Call for Action: Making quality cancer care more accessible and affordable in India 10
Table 5: 2020 Organ wise crude rates of key states for male

2020 Crude rates Organ wise (Male)

Hypo- Eso- Urinary
States\Organs Lung Mouth Tongue pharynx Pharynx Larynx phagus Stomach Bladder
Delhi 11 8 7 NA NA 5 5 NA 5
Punjab 7 4 4 NA NA 4 10 NA 4
Madhya Pradesh 9 14 8 3 NA 4 4 NA NA
West Bengal 22 7 6 NA NA 5 NA 5 5
Arunachal Pradesh NA NA NA 4 NA NA 5 16 NA
Assam 9 8 7 12 NA 4 16 7 NA
Manipur 9 NA NA NA NA 1 3 3 NA
Meghalaya 6 5 7 9 2 6 32 6 NA
Mizoram 22 3 1 9 NA 4 26 27 NA
Nagaland 4 3 NA 5 NA 4 7 9 NA
Sikkim 5 3 NA NA 2 2 5 12 NA
Tripura 11 4 4 3 NA 4 5 4 NA
Gujarat 7 18 9 2 NA 2 4 NA NA
Maharashtra 6 9 5 NA NA 3 4 3 NA
Karnataka 10 4 4 NA NA NA 5 7 NA
Kerala 25 9 8 NA NA 7 2 7 3
Tamil Nadu 12 10 8 NA NA 5 4 10 NA

Source: EY Analysis, 2012, 2014 and 2016 cancer registries

Table 6: 2020 Organ wise crude rates of key states for female

2020 Crude rates organ wise (Female)

Hypo- Eso- Gall Cervix
States\Organs Lung Mouth Tongue pharynx phagus Stomach Bladder Breast Ovary uteri
Delhi 7 NA 5 NA 5 NA 10 59 15 21
Punjab 5 NA NA NA 15 NA 3 69 12 25
Madhya Pradesh 5 8 6 NA 6 NA 5 50 12 19
West Bengal 13 6 NA NA NA 5 9 49 15 19
Arunachal Pradesh 5 NA NA NA 6 15 NA 27 11 NA
Assam 6 8 2 1 16 8 8 31 11 19
Manipur 15 NA NA NA NA 3 3 18 6 11
Meghalaya 4 9 2 2 27 8 3 9 2 10
Mizoram 37 NA NA NA 10 24 NA 35 8 38
Nagaland 4 NA NA NA NA 11 NA 12 4 16
Sikkim 9 NA NA NA 6 10 5 17 7 14
Tripura 5 5 2 NA 5 3 5 14 5 16
Gujarat 4 6 6 NA 5 NA 2 40 7 12
Maharashtra 4 7 1 NA 2 NA NA 55 11 17
Karnataka 9 9 NA NA 8 8 NA 67 15 29
Kerala 11 NA NA NA NA NA NA 82 15 17
Tamil Nadu 8 8 NA NA 6 10 NA 84 16 29

11 Call for Action: Making quality cancer care more accessible and affordable in India
Going forward, India is also witnessing An effective way to tackle the rising cancer
worsening of risk factors contributing to burden is by focusing on preventable cancer
cancer cases. According to studies, approximately 70% of
the Indian cancers are caused by potentially
modifiable and preventable risk factors 5.

Table 7: Risk factors by various cancer types

Cancer types Measuring parameters Head and

Risk factors and trends Breast neck Lung Cervical Ovarian
Median Age of
Marriage
Reproductive activity
Median age of
 X X  
1st Childbirth
Sexual habits and Usage of sanitary
poor hygiene napkins
X X X  X
Infection and India Prevalence of
immunity level HPV >Global average
X  X  X
Specific medical
Modifiable

condition/disease
-- X X X X 
% of Obese and
Obesity and physical
inactivity
overweight  X X  
population
% of population
Tobacco use
using tobacco
X    X
Alcohol % of population
consumption* drinking alcohol
  X X X
Environmental Pollution levels
pollution (PM2.5)
X X  X X

Family history  X X X 
Non-Modifiable

Genetic disposition  X X X 

Gender X X X  

Age     

Modifiable factors: the behaviors and exposures that can raise or lower a person's risk of cancer, and which can, in theory, be
changed.
Non-modifiable factors: factors which, in theory, cannot be changed or adjusted
*Recorded consumption of alcohol has increased by a CAGR of 2% over six years, whereas unrecorded consumption has increased by
10%, evidencing the behavioral habits of Indians with regard to illegal consumption of alcohol, or not providing data for the
consumption patterns
Refer <Annexure 2 > for major risk factors associated with different cancer types and their trend in the recent past in detail

A review of the trends in risk factors across disease burden for those states. Tobacco and
different states vis-à-vis trends in cancer alcohol consumption, obesity and physical
incidence for those states highlight that there is inactivity and pollution are among the key risk
an intensification of key risk factors which are factors which are potentially impacting cancer
potentially causing an adverse effect on the disease burden across states.

5 NCRP 2020 report

Call for Action: Making quality cancer care more accessible and affordable in India 12
Table 8: Correlation between various risk factors with cancer burden by organs in key States

Trends in Key states/Union Territory Potential effect in disease burden in the

Risk Factor (KS/UT) state/UT
Tobacco consumption Mizoram: Highest consumption of ► Mizoram has overall crude incidence per
tobacco in India across both genders lakh population (CR) of 156.9 which is the
National average
(Men – 73.1%, Women – 61.7%) 2nd highest among all the KS
consumption
► Expectedly, the CR for lung cancer is the
► Men – 38.0%
highest among all KS for women (36.8)
► Women – 8.9% and 3rd highest among men (21.7)
► And women in Mizoram have the highest
Smoking Tobacco is a risk
CR (40.0) among all KS for cervix uteri
factor for:
cancer
► Lung cancer
► Head and neck cancer
Meghalaya: Tobacco consumption by ► The CR (2.14, 9.17) for Pharynx
► Cervix uteri cancer men is 57.8% (2nd highest among men unspecified and hypopharynx (part of
in India) Head and neck) among men is the highest
Smokeless Tobacco is a and 2nd highest across all KS
risk factor for: ► The CR (31.9) for Esophagus among men
► Head and neck cancer is the highest across all KS
► Esophageal cancer ► The CR (5.35) for larynx among men is
► Stomach cancer the 2nd highest across all KS

► Urinary bladder West Bengal: Consumption of tobacco ► The CR (22.4) for lung cancer among
among men is 48.1% (26.6% higher men is the 2nd highest across all KS
than national average of tobacco
consumption among men)
Manipur: Consumption of tobacco by ► The CR for lung cancer among women is
women is 43.3% (5 times of the the 2nd highest across all KS (14.7)
national average)
Alcohol consumption Tamil Nadu: Consumption of Alcohol ► The CR (8.4) for tongue cancer (Part of
by men is 48.1% (more than twice the H&N) among men is the 2nd highest
National average
national average) across all KS
consumption
► Men – 22.4% Delhi: The only state where the ► Although the overall as well as gender
consumption of alcohol has grown in wise CR for the UT has come down
► Women – 0.7%
the last five years across both the slightly from 2014 to 2020, the CR for
genders (2% and 18% increase for men breast cancer for women has increased
Risk factor for: and women respectively) by 69% (from 34.8 to 58.8) during 2014-
► Breast cancer 20
► Head and neck cancer

Obesity and physical Punjab has 40.8% of obese women of ► Women in Punjab have the 4th highest CR
inactivity age 15 years and above and BMI>25 (25.3) among all KS for cervix uteri
cancer and 3rd highest CR (68.85) among
% of population with
all KS for breast cancer
greater 15yrs and BMI>25
Kerala has 38.2% of obese women of ► Women in Kerala have the 2nd highest CR
India average – 24%
age 15 years and above and BMI>25 (15.3) among all KS for ovarian cancer
and 2nd highest CR (81.5) among all KS
Risk factor for:
for breast cancer
► Breast cancer
Tamil Nadu has 40.2% of obese women ► Women in Tamil Nadu have the highest
► Cervix uteri cancer of age 15 years and above and CR (15.7) among all KS for ovarian
► Ovarian cancer BMI>25 cancer, 3rd highest CR (28.6) among all
► Gall bladder cancer KS for cervical cancer and highest CR
(83.6) among all KS for breast cancer

13 Call for Action: Making quality cancer care more accessible and affordable in India
 Trends in Key states/Union Territory Potential effect in disease burden in the
Risk Factor (KS/UT) state/UT
Air Pollution West Bengal: West Bengal had a PM2.5 ► Men in West Bengal have the 2nd highest
concentration of 78.2µg/m3 CR (22.4) among all KS for lung cancers
Standard of PM2.5
satisfactory air quality
Index - <60µg/m3

Risk factor for:

► Lung cancer
Working women Tamil Nadu: Proportion of employed ► Women in Tamil Nadu have the highest
women in Tamil Nadu is 37% CR (83.6) among all KS for Breast cancer
National average – 25.2%
Karnataka: Proportion of employed ► Women in Karnataka have the 4th highest
Risk factor for:
women in Karnataka is 35% CR (66.8) among all KS for Breast cancer
► Breast cancer

A comparative trend in key risk factors across highlighting the need for strong intervention at a
states highlight that most risk factors are policy level to encourage population to adopt
demonstrating a worsening trend across states more health appropriate behavior.

In India, non-communicable diseases are growing and so are incidences of cancer. Many such
occurrences could be attributed to lifestyle disorders and established risk factors. Targeted
measures on prevention of cancer and its early diagnosis could substantially curtail the
growing disease burden in our country. It must start with collective efforts on building
awareness for early warning signs and symptoms. Followed by population-based screening
programs and cancer registries for early diagnosis and appropriate interventions. Improving
cancer care affordability, accessibility and research capabilities would enable improved
outcomes. Making cancer, a notifiable disease across India would ascertain its actual
prevalence; establish comprehensive cancer registries and enable targeted interventions.

Dr. Bishnu Prasad Panigrahi

MD, Group Head – Medical Strategy and Operations Group, Fortis Healthcare Limited

Call for Action: Making quality cancer care more accessible and affordable in India 14
Table 9: Comparison of various risk factors metrics by key states

PM2.5
% household % household (Measure
population > 15yrs population > 15yrs of % of population for air
1 % of Mean age
of age using age drinking alcohol >15yrs with BMI>25 quality )
women of
tobacco (2019-21) (2019-21) (Overweight/ Obese) 2019
currently marriage
State/UT Women Men Women Men Women Men (µg/m3) employed for women
India 9% 38% 1% 22% 24% 23% 83.2 25% 22.1
Delhi 2% 26% 1% 28% 41% 38% 86.7 23% 23.7
Punjab 0.4% 13% 0.1% 28% 41% 32% 73.4 22% 23.5
Madhya
10% 46% 0.4% 20% 17% 16% 60.3 28% 21.4
Pradesh
West Bengal 11% 48% 1% 26% 23% 16% 78.2 19% 21.2
Arunachal
19% 50% 18% 57% 24% 28% 25.9 30% NA
Pradesh
Assam 22% 52% 6% 27% 15% 16% 48.4 18% 22.3
Manipur 43% 58% 2% 48% 34% 30% 36.1 40% NA
Meghalaya 28% 58% 1% 36% 12% 14% 49.9 42% NA
Mizoram 62% 73% 1% 30% 24% 32% 42.3 25% NA
Nagaland 14% 48% 1% 31% 14% 24% 37.9 34% NA
Sikkim 12% 42% 15% 36% 35% 36% 29.4 31% NA
Tripura 51% 57% 4% 36% 22% 24% 48.6 22% NA
Gujarat 9% 41% 0.1% 6% 23% 33% 63.4 33% 22.5
Maharashtra 11% 34% 0.2% 17% 24% 20% 58.1 37% 22.5
Karnataka 9% 27% 0.3% 23% 30% 45% 51.3 35% 22.3
Kerala 2% 17% 0.3% 26% 38% 31% 51.1 23% 23.2
Tamil Nadu 5% 20% 0.1% 33% 41% 41% 47.2 37% 23.0
1
< 30 ug/m3 – good AQI, >30 ug/m3 and <60ug/m3 – satisfactory AQI, >60ug/m3 – Poor AQI
Source: Use of Tobacco, use of alcohol, obesity, currently employed and mean age of marriage from NFHS 5 (2019-2021) & NFHS 4
(2015-2016)

Financial burden for cancer treatment is highest treatment which results in loss of income, quickly
compared to all diseases, making it unaffordable drains household resources and forces population
for >80% of population; Cost of single into poverty.
hospitalization for cancer care is 3x of any other
In 2018, the average cost of single hospitalization
NCD
for cancer was Rs 22,520 in public hospital and Rs
As the contribution of cancers to death and 93,305 in private hospitals, which was
hospitalization in India continues to grow at an significantly higher than all other NCDs and
alarming rate, it is a ticking time bomb that is communicable diseases. Further, the cost of
increasingly affecting not just the health but the hospitalization in private hospitals has shown an
economy of the country as well. increasing trend at 5% CAGR since 2014, similar
to other NCDs.
The high cost of cancer care (the highest among
all NCD disease types) along with usually lengthy

15 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 6: Hospitalization cost for key non-communicable and communicable diseases across public and private
facilities in 2018.

Disease Hospitalisation cost per case (Rs) - 2018

Public Private

Cardiovascular 6,635 -13% 54,970 6%

Respiratory non-infectious 3,346 -9% 24,049 6%

Non-communicable
diseases
Cancer 22,520 -2% 93,305 5%

Neuro 7,235 -1% 41,239 5%

Infectious and parasitic 2,054 -9% 15,208 7%

Communicable
diseases
Gastro-Intestinal 3,847 -8% 29,870 6%

Negative CAGR 2014-18 Positive CAGR 2014-18

Source: NSS 75

Cancer treatment remains unaffordable for the average household expenditure for ~80% of the
majority of quintile 1 and 2 population as their population.
annual per capita expenditure is lower than even
Single cost of hospitalization at private hospitals is
the public cost of single hospitalization.
around four times compared to hospitalization at a
For rural sections, the cost of single public hospital, which makes it unaffordable for
hospitalization in a public hospital is higher than any section of rural population and affordable only
for the last quintile of urban population.

Call for Action: Making quality cancer care more accessible and affordable in India 16
Chart 7: Affordability of cancer care by quintile populations in rural & urban areas across public and private
facilities

Average annual per capita expenditure (in INR)

1,75,000
Urban Rural
1,64,892
Cost of single
1,50,000
hospitalization
2017-18
1,25,000
Private facility
Rural – 85,326
1,00,000
Urban –1,06,548
75,000 62,314

45,000
50,000
30,000
24,000 Public facility
25,000 17,004 Rural – 23,905
Urban –19,982
21,360
13,716 16,800
- 10,500
*MPCE class

Percentage of Q1 Q2 Q3 Q4 Q5
20% 40% 60% 80% 100%
Population

Source: NSS 75, NSS 72

* Quintile class of Monthly Per Capita Expenditure (MPCE) refers to the 5 quintile classes of the rural/Urban all-India distribution
(estimated distribution) of population by UMPCE.

Some key facts in India demonstrating high cost of ► Cancer has contributed to 70.3% in overall
cancer care in comparison to other NCDs are as cases of NCD related catastrophic health
follows: expenditure (CHE). CHE for a household is
when the household spends on health amount
► Mean out of pocket expenditure (OOPE) for
which exceeds household consumption
cancer hospitalization is ~three times the
expenditure by 10%.
mean OOPE of all NCDs.

Table 10: Mean OOPE and CHE for NCDs and cancer (the values in the above table for all NCDs is calculated basis
overall hospitalizations due to NCDs in 2017)

Disease Mean OOPE (In Rs.) % of household with CHE

All NCDs 21,131 47%
Cancer 61,299 33%

Source: Geetha R Menon et al, Burden of non-communicable diseases and its associated economic costs in India, 2020, NCRP 2020,
EY Analysis

While the cost of cancer treatment is on the rise, improvement in screening and diagnosis of
it is expected that cancer incidence will cancers of certain organs such as breast, cervix
demonstrate double digit growth over the next and head and neck in line with developed
10 years driven by worsening of risk factors and countries such as the US and the UK.
improvement in timely diagnosis and detection
► Scenario 1: If 50% cases are detected at stage
The reported cancer incidence in 2030 is expected 1 and 2, then there would be 42 lakhs
to increase to 253 to 277 per lakh population, incidences in 2030
representing a high CAGR of 9 to10% over the
next 10 years expected to be driven by

17 Call for Action: Making quality cancer care more accessible and affordable in India
► Scenario 2: With a further improvement in ► Demographic changes, including an increasing
detection rate to 60%, reported incidence is proportion of aged population, are estimated
estimated to be around 46 lakhs in 2030 to contribute at 3 to 4% CAGR to the increase
in overall real incidence during 2020 to 2030
Prevalence of all types of cancers for the year
2020 is estimated to be around 59-60 lakh cases. ► Risk factor exposures are estimated to
With real incidence of cancer estimated to grow at contribute at 2 to 2.5% CAGR to the increase
a CAGR of 5-6%, cancer prevalence in the year in overall real incidence during 2020 to 2030
2030 is expected to reach 1.1 crores.

Chart 8: Projections of overall real incidence across two scenarios during 2020-30

Real incidence estimates Reported incidence estimates

Drivers
2030
Demographic Risk factor Estimated 2030 2030
2020 changes exposure Incidence 2020 Scenario 1 Scenario 2

CAGR 3-4% 2–2.5% CAGR 9-10%

600-800 4,570-6,100 4,570

4,180
1,400-1,870
Incidence growth
2,570-3,430
estimate (‘000s nos.)
1,714

Incidence per 1 lakh

182 - 242 277 - 369 121 253 277
population (Crude)

Prevalence estimate
5,900-6,000 11,000-11,200
(‘000)

Scenario 1 – An improvement in diagnosis rate where 50% of cancers are detected in stages I and II
Scenario 2 – An improvement in diagnosis rate where 60% of cancers are detected in stages I and II

Note: Refer <Annexure 3> for framework for projection of overall crude incidence adjusting for demographic and risk factor
exposures and prevalence

High burden of cancer incidence in India is Based on reported cancer incidence and mortality
accompanied by a high economic burden on across age groups and years of potential
account of productivity losses and premature productive life lost (YPPLL) due to the same, the
mortality economic burden in terms of GDP losses is
estimated in the range of US$ 11 B. (0.4% of
When individuals exit the workforce temporarily or
national GDP) in 2020.
permanently due to cancer, this represents loss of
productivity for the society. Understanding of The same is projected to increase to US$ 36-40 B
economic burden of cancer in the form of by 2030, driven by projected increase in mortality
productivity losses can provide a valuable context (considering increasing cancer incidence partly
to inform population-based resource allocation offset by an improvement in mortality to incidence
decisions for cancer prevention and control. ratio), improvement in life expectancy and
increase in GDP per capita.

Call for Action: Making quality cancer care more accessible and affordable in India 18
Chart 9: Calculation of estimated economic burden

2020 CAGR 2030

Reported Incidence ‘000s nos. 1,714 9-10% 4,180–4,570

M/I ratio % of incidence 43% -5.4% 25%

Mortality ‘000s nos. 738 3-4% 1,027-1,125

Life expectancy Years 70 0.4% 73

YPPLL Years 5,814 4.4% 8,956

GDP per capita INR 000 p.a. 142 8% 307

Economic burden US$ billion US$11b 13-14% US$36-40b

Source: Pearce et al. BMC Cancer (2016), Estimation of economic burden of COVID-19 using DALYs and Productivity Losses in
Kerala state, India, RBI estimates, Worldbank.org, UN.org, IARC (WHO)
Notes:
1. A study published in 2018 on productivity losses due to premature mortality from cancer in Brazil, Russia, India, China, and
South Africa (BRICS countries) estimated combined annual losses of US$46.3B. in 2012, which was 0.33% of combined GDP of
these countries.
2. Studies on productivity losses as a % of GDP due to premature cancer-related mortality in US and Europe estimated the same to
be 0.7% (2020) and 0.6% (2008) of GDP, respectively.

19 Call for Action: Making quality cancer care more accessible and affordable in India
Call for Action: Making quality cancer care more accessible and affordable in India 20
 2
Maturity of India’s
cancer control

21 Call for Action: Making quality cancer care more accessible and affordable in India
Chapter 2: Maturity of India’s cancer control
landscape

Chapter 2A: Awareness and Prevention

The adage ‘prevention is better than cure’ holds Early investments in cancer awareness and
unequivocally true in the context of cancer. Given prevention therefore seem to be a cost-effective
the nature of the disease as a harbinger of severe measure to help achieve reduced cancer incidence
social, financial, physical, emotional, and in the long run.
psychological distress which impacts not just an
An integrated approach to cancer management
individual but the entire family, it is crucial that
will always include prevention strategies.
the society, governments, and the healthcare
Increased awareness will lead to more cases being
ecosystem prioritizes cancer prevention and early
diagnosed at early stages, which will in turn
diagnosis.
necessitate increased capacity for treatment.
As per the 2020 WHO report on cancer, Prevention also calls for a multi-stakeholder
approximately one-third to one-half of all cancers approach involving governments, healthcare
are preventable globally. Primary prevention workers, NGOs, community support groups and
involves interventions that minimize exposure to most importantly the public who need to engage in
carcinogens such as tobacco cessation, limiting healthy behaviors for their own wellbeing.
alcohol consumption, maintaining a healthy diet,
One cannot help but draw parallels with the recent
increased physical activity, reduced exposure to
COVID-19 pandemic when it comes to awareness
radiation and HPV vaccination. Secondary
and prevention of cancer. Notwithstanding the
prevention involves screening techniques which
obvious differences in nature of both diseases
can detect cancer before the appearance of
with COVID-19 being highly communicable and
symptoms such as pap smear, mammography,
spreading rapidly while cancer being non-
colonoscopy, etc.
communicable where symptoms take time to
Awareness often precedes prevention since it manifest, the governments across the world can
seeks to educate and inform people about topics replicate similar coordinated response strategies
which are hitherto unknown to them by imparting for cancer as implemented for COVID-19. Cancer
knowledge, influencing attitudes or beliefs, and is by all means an impending pandemic likely to
shaping healthy practices or behavior. explode. Starting with robust data capture of
Modification of existing behaviors is an important testing and cases, raising awareness among
aspect of prevention, which is achievable only by people to make them engage in healthy behaviors
raising adequate awareness among the public. like washing hands, practicing social distancing
and wearing masks, conducting mass vaccination
While there have been many technological and
drives as well as development of indigenous
medical advancements in cancer treatment
vaccines — all of these initiatives are highly
transforming it from a ‘fatal’ to a ‘curable’ disease,
relevant even in the context of cancer awareness
the journey from diagnosis to treatment is a long
and prevention. While COVID-19 was an
and arduous process that affects quality of life.
unprecedented event that took the world by
Also, in a developing nation like ours, equitable
storm, cancer is still a known devil and with the
distribution of advanced treatment modalities is a
lessons learned from COVID-19 management,
complex challenge given the high socio-economic
government and society should now proactively
disparity on the demand side and resource
plan and act toward cancer prevention thereby
limitations in terms of healthcare financing and
building a healthy future for the nation.
trained medical professionals on the supply side.

Call for Action: Making quality cancer care more accessible and affordable in India 22
 Advanced cancer care begins with creating increased awareness, early diagnosis and an
emphasis on preventive healthcare. That brings into play, among other things, predictive and
personalized health checks, genomics, and integrated technology. Alongside, we need to also
address the issue of affordability and access to treatment and ensure that all stakeholders of
the healthcare ecosystem - hospitals, pharmaceutical companies, insurance providers,
technology services and homecare work collaboratively to ensure this.

Dilip Jose
Managing Director and CEO, Manipal Health Enterprises Private Limited

Awareness

Questionnaire-based surveys covering three key healthcare context. A modified framework based
elements — Knowledge, Attitude, and Practice on KAP theory6 in the context of cancer
(KAP)— can typically measure awareness in the awareness is illustrated below.

Figure 2: Modified framework based on KAP theory in the context of cancer awareness

Knowledge
► Risk factors
► Signs and symptoms
“Am I likely to ► Screening methods “Do I have the
get this ► Vaccination required means to
disease?” take action?”

Perceived Perceived
susceptibility feasibility

Attitude Practice
► Ignorance ► Access
Perceived
► Fear ► Availability
severity
► Indifference ► Financing options
► Complacency ► Family support
► Responsibility ► Community
avoidance acceptance

“How severely will this

disease impact me and my
family?”

6 Roelens, Kristien & Verstraelen, Hans & van Egmond, Kathia & partner violence in Flanders, Belgium. BMC public health. 6. 238.
Temmerman, Marleen. (2006). A knowledge, attitudes, and 10.1186/1471-2458-6-238.
practice survey among obstetrician-gynaecologists on intimate

23 Call for Action: Making quality cancer care more accessible and affordable in India
An effective awareness intervention should respondents to get a perspective on awareness
prompt the target individual to seek more among today’s urban workforce. Going forward,
information or knowledge, question existing the report refers to them as ‘localized surveys’,
beliefs or attitudes, and think about how to ‘global survey’ and ‘professional’s survey’.
overcome barriers to practice healthy behavior.
Once there is enough conviction about
susceptibility to the disease, the severity or
impact should they contract the disease, and
feasibility of the action needed, there may be a The Indian Council of Medical Research
favorable shift toward healthy behaviors. (ICMR) predicts a 12% increase in cancer
diagnosis in India over the next five years.
The subsequent section attempts to derive The most common forms of cancer are
qualitative insights from various awareness breast cancer, cervical cancer, and oral
surveys across the three elements of Knowledge, cancer. Despite enhanced medical research
Attitude and Practice (KAP) as per above and progressive transformation in this field,
framework. This is followed by exploration of we need to strengthen initiatives that
reasons and implications pertaining to the improve access to high-quality care,
particular insight. including screening, early detection,
treatment, and cancer care continuum.
Over the years, researchers in India have Increasing awareness, extending holistic
conducted several localized surveys for awareness knowledge, and promoting a healthy
of common cancers, out of which 20 surveys have lifestyle can contribute to the fight against
been studied for this report. 7 For a global cancer.
perspective, the report also considers insights
Anurag Yadav
from the International Public Opinion Survey on
CEO, IHH Healthcare India
Cancer 2020 led by the Union for International
Cancer Control (UICC). Additionally, as part of
research for this paper, EY conducted an online
survey among its professionals with over 1000

7 Refer Annexure for list of localized surveys

Call for Action: Making quality cancer care more accessible and affordable in India 24
Knowledge

Tobacco and tobacco-related cancers dominate ► Compilation of responses from localized

the awareness landscape in India. Knowledge of surveys to the basic question ‘Are you aware
other common cancers such as cervical is low. of this cancer?’ indicated that less than half
Recognition of non-tobacco risk factors, such as the respondents were aware of cervical cancer
exposure to harmful UV radiation, is weak.

Chart 10: Compilation of responses from localized surveys to the question ‘Are you aware of this cancer?’

Sankeshwari et al., Oral Breast Cervical

100% 94%
Murali et al., 89%
90% 90%
Agrawal et al., 91% Kumar et al., 92%
Thilak et al., 87%
80% Elango et al., 86%
Yambem et al., 75% 72%
70% Sharma et al., 74%
Awareness of cancer

60% Gangane et al., 66%

Gadgil et al., 57% Dahiya et al., 50%
50% Patra et al., 54%
44%
40% Reichheld et al., 49%
Sidharthar et al.,
30% 45%

20%
Ramavath et al., 24%
10%

0%
2008 2010 2012 2014 2016 2018 2020 2022
Year

Greater awareness of oral cancer is partly of breast cancer in urban cities has led to a
attributed to the role of government and powerful community of women survivors
media in transmitting information on harmful actively sharing their experiences on social
effects of tobacco through warning labels on media which in turn encourages more women
packaging and advertising campaigns. to get screened.
Government guidelines for warning signs on
Given its popularity as the most common
tobacco packaging have evolved from a subtle
information source, it is crucial that media
scorpion sign to graphic imagery of mouth
engage in responsible content generation.
cancer with unambiguous messaging of
While the government has been regulating
‘Tobacco causes painful death’. Graphic
media through mandatory warnings on
advertisements narrating cancer patient
smoking scenes in films and banning direct
stories such as the ‘Mukesh’ campaign, which
advertisements for cigarettes and tobacco-
was run before every movie, also relayed
based products, surrogate advertising is still
information about ill effects of tobacco. Such
widely prevalent with top celebrities endorsing
campaigns, however, run the risk of
mouth fresheners, ‘elaichi’ and paan masala
desensitizing the target audience while being
brands which have same brand names and
aired repeatedly which led to various memes
similar packaging as their company’s tobacco
on social media featuring Mukesh.
products. The proposed Cigarettes and Other
Social media campaigns popularizing cancer Tobacco Products Act (COTPA) 8 amendment
awareness events have led to a natural bill seeks to implement stronger measures to
association of the ‘pink ribbon’ with breast ban all forms of indirect advertising.
cancer in the minds of people. Rising incidence

8 Ministry of Health and Family Welfare website

https://main.mohfw.gov.in

25 Call for Action: Making quality cancer care more accessible and affordable in India
The lack of coverage in popular media can reproductive activities as a risk factor
partially explain lower levels of awareness of (indicated in the chart below). In such a
cervical cancer. It also has some level of scenario, family physicians, primary
stigma surrounding it since the culture of India healthcare workers, local GPs, RMOs can
does not encourage open conversations about educate their patients about the importance of
sexual practices. The professional survey also genital and menstrual hygiene, sexual
reflects a similar situation, where very few practices, encouraging open conversations
respondents identified sexual habits and about stigmatized cancers such as cervical.

Chart 11: Respondents who recognized the risk factor among their top 5 choices

74%

51% 48% 45% 44% 42%

33%
28%

12%
7%

Sexual habits and

Family history

Reproductive
Environmental

Genetic disposition

physical inactivity
consumption

condition/disease
Tobacco use

immunity level
Infection and

Special medical

poor hygiene
Alcohol
pollution

activity
Obesity and

The following chart indicates responses from information in urban areas alongside relatives,
the professional’s survey and illustrates how friends, and family.
online search is also a popular source of

Chart 12: Respondents who indicated the source as one from which they obtained information on cancer risk
factors

50%
41% 38% 36% 36%
29%
18%
Family physician/
Relatives/ friends/

Disclaimers/ warnings

Cancer support groups/

reasearch papers

published on products
Hoardings, Social media

Educational material
Online searches,
communicated through
TV, Radio, Print media,

colleges, education
centers, workplace
shared in schools,
educational material
Advertisements/

doctor
family

NGOs

In disadvantaged groups with low education a popular source due to access limitations. In
and income levels, online searches may not be such cases, leveraging the right channel of

Call for Action: Making quality cancer care more accessible and affordable in India 26
 communication to ensure reach through local However, in India, fewer than half identified it
newspapers, radio advertisements, local cable as a risk factor.
network, posters and banners in post offices
In the same global survey, when asked about
and banks, involving village panchayat,
what according to them should their
religious or political leaders, local celebrity
government be doing to prevent cancer,
influencers, becomes extremely important in
Indians believed that regulating tobacco usage
creating awareness.
should be the top priority. Most other
► In the UICC global survey, danger posed by countries seem to have moved on from
exposure to UV rays was the second most tobacco and indicated access and research
globally recognized risk factor after tobacco. funding as key expectations from their
governments.

Figure 3: People’s views on the most important government actions by country

► Affordable cancer ► Affordable cancer

► Regulate tobacco use
services services
► Affordable cancer
► Research support and ► Research support and
services
India US funding UK funding
► Raise public awareness
► Equal access ► Equal access

► Affordable cancer
► Improve air quality ► Affordable cancer
services
services
► Affordable cancer
► Research support and
services ► Regulate tobacco use
China Japan Australia funding
► Equal access ► Timely access
► Equal access

► Research support and ► Timely access ► Affordable cancer

funding services
► Affordable cancer
► Investment in health services ► Raise public awareness
Germany infrastructure Brazil Kenya
► Investment in health ► Investment in health
► Timely access infrastructure infrastructure

At present, tobacco dominates cancer Attitude

awareness in India, efforts need to be
undertaken to raise awareness about non- Fewer people in India seemed to be concerned
tobacco risk factors such as alcohol, obesity, about cancer compared to other countries,
and environmental carcinogens. Given that implying a general attitude of indifference
some of these risk factors like obesity are also towards cancer
causes of other NCDs like diabetes and
► The UICC global survey indicated that only
cardiovascular diseases, it is important to
43% of respondents in India indicated that
focus on educating people about its harmful
they were very concerned or somewhat
effects for overall well-being of the nation.
concerned about developing cancer in their
lifetime, which was lower than the average of
58% globally.

27 Call for Action: Making quality cancer care more accessible and affordable in India
 Kenya represented the highest levels of targeted screening initiatives. The
concern for cancer, with 82% respondents parliamentary standing committee on health
indicating that they were worried about and family welfare has recently submitted a
cancer. Cancer as a subject has drawn severe report on cancer to Rajya Sabha 9, wherein the
public ire due to a high number of deaths in committee has highlighted the importance of
Kenya. Media coverage of cancer related news collecting data by setting up population-based
stories also led to widespread awareness. In cancer registries in under-represented areas
2019, Kenyans spearheaded protests to call to and integrating this data with real time
on the government to declare cancer a health information. Such data can be used to
national emergency after three prominent identify incidence patterns to drive targeted
public figures succumbed to the disease. The prevention initiatives. For patterns which are
Government of Kenya in 2020 announced a already available, such as the high incidence
new program to vaccinate every girl who of GI cancers in North-East India mentioned
reaches 10 years of age against HPV. This earlier, focused investments around screening
serves as an interesting case study to can help in early detection.
illustrate how a strong public voice is a
► Health promotion and education in schools to
powerful means for enforcing governments to
shape young minds could be one of the ways
act.
to build positive health attitudes. This could
► Society and family, which propagates a certain also lead to children becoming effective
manner of thinking in individuals, often shape ‘change agents’ for the society. Large number
attitudes and beliefs at an early age. For of school children in Delhi participating in
example, cultural association with certain awareness drives about air pollution is an
carcinogens like use of areca nut in several example that illustrates this concept.
religious and social customs in India, which is
► Targeted campaigns in colleges such as
a known risk factor for oral cancer, could
education about harmful effects of tobacco,
impede its recognition as a harmful substance.
importance of safe sex, genital and menstrual
The belief that these customs have been
hygiene, sanitation can also help shape
prevalent for ages and there has not been any
positive attitudes of the youth when they are
adversity in the family often discourages
at their most vulnerable to prevent indulgence
people from modifying their behaviors.
in unhealthy behaviors.
Similarly, improper methods used in
preservation of processed meat through Practice
curing and smoking is seen as one of the
reasons for the high incidence of stomach Uptake of screening for breast and cervical
cancer in North-East India. Therefore, cancer and HPV vaccination is low despite fair
targeted campaigns focused on regions or awareness and a positive attitude. Tobacco
cultures where a specific custom or practice is continues to be one of the leading causes of
linked to cancer, such as educating about cancer despite awareness levels being high.
harmful effects of areca nut and improper
► Compilation of responses from localized
meat preservation techniques, can help
surveys indicates a gap between the number
modifying long rooted existing behaviors.
of people who have knowledge of screening
Leveraging big data to identify ‘at risk’ techniques and those who undergo screening
population for specific cancers can drive as indicated in the chart below

9 Department-related parliamentary standing committee on health management: prevention, diagnosis, research & affordability of
and family welfare, 139th report on Cancer care plan & cancer treatment

Call for Action: Making quality cancer care more accessible and affordable in India 28
 Chart 13: Responses from localized surveys indicating a gap between the number of people who have
knowledge of screening techniques and those who undergo screening

Cervical cancer Breast cancer

PAP smear Self breast examination (SBE)

40% 47% 29%

24%
14% 7% 20% 12%
8% 7% 6% 3%

Kumar and Singh et al, Nelson et al, Paunikar et al., Murali, 2020 Prusty et al.,
Tanya, 2014 2014 2018 2017 2021

HPV vaccination among HCPs Clinical breast examination (CBE)

80% 41% 44%
66%
45% 20%
20% 14%
7% 6% 6% 6%

Swarnapriya et Ganju et al, Chellapandian et Paunikar et al., Javaid et al., Prusty et al.,
al, 2015 2017 al 2021 2017 2020 2021

Knowledge Practice

Data capture and management are essential to overall personal health records of an
to ensure awareness initiatives are being tied individual.
to practice outcomes. The government should
► The following chart provides common reasons
institute a structured referral mechanism for
cited for not undertaking periodic screening
directing positive screened cases toward
tests for cancer detection in the professional’s
district hospitals or other tertiary care centers
survey. Besides lack of awareness,
for treatment. Currently, the cancer registry
respondents have also highlighted
only captures incidence data basis confirmed
affordability, access, and social stigma as
diagnosis. With the introduction of unique
barriers to screening.
health ID or ABHA number, well-integrated
systems can enable linking of screening data

Chart 14: Respondents indicated below reasons for not undertaking periodic screening tests for cancer
detection

43% 41%

30%
21%
12%
Lack of awareness about

regarding options available

cancer screening tests

nearby screening centers

Social stigma/ Discomfort

Cost associated with
the benefits of cancer

(Lab/Radiology centre,

to undertake screening
Lack of availability of

trained doctors etc.)

for cancer screening
Lack of awareness
screening

tests

29 Call for Action: Making quality cancer care more accessible and affordable in India
 These challenges are perhaps more prominent individual requires self-motivation and support
in rural areas and villages, where traveling to from family and friends to modify existing
a center in the city for screening or behaviors and perceptions. For example, the
accompanying their child for vaccination association of smoking with being ‘cool’
implies losing their livelihood for the day especially among urban youth and ‘smoke
which seems excessive for someone who is breaks’ being a popular means for employee
asymptomatic and dealing with more acute bonding in corporate cultures may discourage
day-to-day problems. Also, given the strong people from giving it up, fearing non-
patriarchal social structures in some acceptance by peers. Despite there being a
communities where the male head of the ban on smoking in public places, several
family makes decisions, obtaining permission workplaces, airports, restaurants have
to undergo screening for breast or cervical designated smoking zones. The proposed
cancer is not an option that many women Cigarettes and Other Tobacco Products Act
choose to exercise. (COTPA) amendment bill seeks to ban these
designated smoking areas to curb public
While society largely perceives cancer care as
smoking in its entirety.
a tertiary care intervention with specialized
oncologists and treatment being delivered in Examples of awareness initiatives
hospitals with state-of-the-art technology, it is
► The National Program for Prevention and
predominantly primary healthcare which
Control of Cancer, Diabetes, Cardiovascular
drives awareness and screening. Training of
Disease and Stroke (NPCDCS) covers
frontline ASHA workers to deliver services like
awareness initiatives taken by the
family health counseling along with screening
Government of India. The NPCDCS organizes
and vaccination is therefore critical for uptake
media campaigns such as National Cancer
in practice.
Awareness Day, World Diabetes Day etc., for
► Availability of facility and reputation among raising awareness on risk factors, prevention,
population largely influences the awareness of management of NCDs and promotion of
centers for cancer treatment in the state. 10 healthy lifestyle through use of print,
For example, cities with a reputed cancer electronic and social media for continued
center such as PGI in Chandigarh, Regional community awareness. Under the program,
Cancer Centre in Trivandrum see a greater NCD Clinics are also being set up to provide
number of people opting for public hospitals services for common NCDs, including
for cancer treatment. When it comes to screening for common cancers such as oral,
awareness of financing options, the major breast and cervical. The Indian Council of
source of expenditure is either family savings Medical Research (ICMR) has designed a web
or borrowings 11. This reflects low awareness portal to disseminate information on prevalent
of schemes and cancer insurance, which is cancers to the general public.12
driven by low penetration. With the inclusion
► Non-government stakeholders such as private
of cancer treatment packages under healthcare providers, community support
Ayushman Bharat, this might change with a
groups and startups can also play a role in
greater number of people opting for schemes. raising cancer awareness. Examples of some
Despite high awareness levels, tobacco usage such initiatives being undertaken in India are:
continues to be highly prevalent in India. While
► Fortis Healthcare organizes various
practice through lifestyle changes has fewer
activities and camps with the public for
external barriers compared to screening, an
cancer awareness. Fortis hosted the Pink

10 Raj
S, Piang LK, Nair KS, Tiwari VK, Kaur H, Singh B. Awareness 11 Nair,Kesavan & Raj T.P, Sherin & Tiwari, Vijay & Piang, Lam.
regarding risk factors, symptoms and treatment facilities for (2013). Cost of Treatment for Cancer: Experiences of Patients in
cancer in selected states of India. Asian Pac J Cancer Prev. Public Hospitals in India. Asian Pacific journal of cancer prevention:
2012;13(8):4057-62. doi: 10.7314/apjcp.2012.13.8.4057. PMID: APJCP. 14. 5049-54. 10.7314/APJCP.2013.14.9.5049
23098516. 12

https://www.icmr.gov.in/pdf/press_realease_files/Newsletter_Engl
ish_March_2022.pdf

Call for Action: Making quality cancer care more accessible and affordable in India 30
 Walkathon— a 4 km walk for cancer and 6 townships across the region. It has
survivors, RWAs and schoolgirls for breast also organized screening camps in villages
cancer awareness. Other initiatives across Gurgaon and rural Haryana as part
include organizing pink and purple runs, of its ‘Cancer Mukt Gurgaon’ initiative.
free cancer screening camps at various
► Onco.com 14 is an online platform that acts
locations. The Department of
as a one-stop shop for people to access
Haematology, Haemato-Oncology and
cancer information. The start-up also
Bone Marrow Transplant at Fortis
organizes events and campaigns to raise
Memorial Research Institute regularly
awareness of cancers. Individuals and
does blood screening camps for early
families impacted by cancer diagnosis can
detection of cancers.
also refer to the platform for planning out
► CAPED 13 – Cancer Awareness, Prevention their treatment options, second opinion,
and Early Detection is a registered trust financing options, etc.
which specifically focuses on raising
Social media has emerged as a powerful
cancer awareness and screening for
platform, especially for breast cancer
female cancers in the Delhi NCR region. As
campaigns. Example of one such campaign by
per its website, CAPED has conducted
leading healthcare provider Acibadem in
awareness workshops in over 20
Turkey15:
corporates, 26 educational institutions,

"Prevention is better than cure" is an old adage. It applies very well to Cancer. As an NCD, the
growth of cancer in India is a terrible tragedy and contributes to destitution, poverty, illness
of not just the patient but an entire family. Whilst rapid strides have been made in detection
and management of cancer, it still casts a massive burden on the society and the healthcare
burden of our nation.
Timely detection through screening and education along with preventing the population from
consumption of cancer causing agents such as tobacco and related products, vaccination
against some cancers, is the way forward. Research in this field must continue to be
supported and pollution of air and ingestibles related to cancer causing substances must be
reduced.

Dr. Narottam Puri

Principal Advisor-QCI; Board Member & Former Chairman- NABH; Advisor- FICCI Health Services;
Advisor- Medical Operations, Fortis Healthcare Ltd.

13 CAPED website https://www.capedindia.org 15 https://www.ihhhealthcare.com/newsroom/our-stories/power-

14 Onco,com website https://onco.com of-pink

31 Call for Action: Making quality cancer care more accessible and affordable in India
 Acibadem Healthcare in Turkey, part of the IHH Healthcare group, ran a global ‘Pink Scarf’ campaign
by enlisting key opinion leaders, NGOs, celebrities and social media influencers. The campaign uses a
traveling ‘pink scarf’ as a motif with ambassadors across seven countries, including Russia, Romania,
Serbia, Croatia, Kenya, Dubai and Jordan, taking turns to upload daily videos. Acibadem Healthcare
also collaborated with an NGO to put together a gift box for actors, actresses, artists and
sportswomen. The themed box contained a brochure that explained self-examination, a token gift for
female health check-up, a mug and a “favor necklace” designed and created by famous journalist Ayşe
Arman.

► Celebrity role-models can act as important co-founded an organization ‘Stand Up to

influencers when it comes to raising Cancer’ which focuses on raising
awareness. Several instances have been seen awareness and funding for cancer
globally when celebrity news of cancer research. Couric famously underwent a
diagnosis or their personal decisions on colonoscopy on air in 2000, which
cancer treatment has led to an unprecedented increased the number of colonoscopies in
increase in screening and referrals, some of the US from 15 to 18.1 per month.
which are 16: ► News around Kylie Minogue’s diagnosis led
► News story about Angelina Jolie’s decision to 40% increase in breast screening in
to have genetic testing for the BRCA1 Australia
gene broke in 2013 and she subsequently ► Nancy Reagan’s decision not to have
underwent risk reducing mastectomy breast-conserving surgery in 1987 led to
(RRM). Data collected from 12 family 25% increase in mastectomy for breast
history clinics and 9 regional genetics cancer
services in the UK showed a 2 to 2.5-fold
increase in referrals, doubling of demand Closer home in India, the polio eradication
for BRCA1/2 testing and an increase in program involving superstar Amitabh Bachchan as
the number of enquiries for RRM in the the face of the campaign was a huge success. His
immediate months following Jolie’s media ‘do boond zindagi ki’ catchphrase, which resonates
story. in every Indian’s mind today, led to more mothers
traveling to Pulse Polio camps in rural India to get
► Jade Goody, a reality star, was diagnosed
their children vaccinated soon after the
and died of cervical cancer between mid-
advertisement was aired. The government can
2008 and mid-2009. 4,00,000 extra
evaluate similar campaigns involving influencers
women were screened for cervical cancer
such as local and national celebrities, respected
in England in the same period
religious, political or community leaders, to spread
► American Journalist Katie Couric, who lost cancer awareness. Posters and banners in public
her husband to colorectal cancer and later places like post offices or banks, advertisements

16 Evanset al.: The Angelina Jolie effect: how high celebrity profile
can have a major impact on provision of cancer related services.
Breast Cancer Research 2014 16:442.

Call for Action: Making quality cancer care more accessible and affordable in India 32
on local cable network are some of the ways to to undergo screening. These inspiring stories also
achieve the required reach in smaller towns and influence attitudes of their social media followers
villages. who now perceive cancer as something that they
can defeat, compared to few decades ago when
In a welcome recent trend, a number of celebrity
cancer was depicted as the most powerful brand
cancer survivors in India have started sharing
of death in mainstream media.
their cancer stories on social media urging people

Prevention diagnosis for the same is possible through genetic

testing.
As highlighted earlier, primary prevention involves
limiting exposure to carcinogenic risk factors. The measurement of associated burden of risk
Nature of intervention usually depends on type of factor is possible through ‘population attributable
risk factor and its associated burden. fraction (PAF)’, which is the estimated
proportional reduction in population disease or
Risk factors can be broadly categorized into mortality that would occur if exposure to a risk
behavioral (tobacco, alcohol, diet), infectious factor were reduced to an alternative ideal
(HPV, hepatitis), environmental (UV rays, air exposure scenario 17.
pollution, occupational exposures) and others
(genetic or hereditary, age, gender). Of these, The chart below plots the PAF18 of these
modifiable risk factors, such as tobacco, alcohol, modifiable risk factors against the mortality19
obesity, infectious and environmental are associated with the different cancers 20 that they
amenable to prevention. While hereditary causes lead to in order to identify various cancer
of cancer are non-modifiable risk factors, the early prevention strategies.

17 WHO Report on Cancer, 2020 https://www.cancer.gov/about-cancer/causes-

18 WHO Cancer Country Profile 2020 India prevention/risk/obesity
19 Cancer Today (iarc.fr) Parsa N. Environmental factors inducing human cancers. Iran J
20 https://ncdirindia.org
Public Health. 2012;41(11):1-9. Epub 2012 Nov 1. PMID:
23304670; PMCID: PMC3521879.
https://www.cancer.gov/about-cancer/causes-
prevention/risk/alcohol

33 Call for Action: Making quality cancer care more accessible and affordable in India
 Chart 15: PAFs of modifiable risk factors against the mortality associated with the different cancers

High
Infectious, 21.7%
Population attributable fractions (PAFs)

Tobacco, 17.4%

ENABLE ENFORCE

ENLIGHTEN ENCOURAGE

Alcohol, 6.5%

Environmental, 1.6%
Obesity, 0.7%

Low

Low Mortality from associated cancers High

► Enforce tobacco restrictions: Tobacco is breast, colorectal, esophagus, stomach, etc.,

associated with a large number of cancers which contribute to high incidence and
such as lip, tongue, mouth, oropharynx, mortality. However, the burden of risk from
larynx, esophagus, lung, urinary bladder, all of obesity is not as significant as tobacco or HPV.
which together contribute to high mortality at Obesity is a common risk factor for other
present. Despite relatively high awareness NCDs such as diabetes and cardiovascular
compared to other risk factors, tobacco usage diseases and therefore it is important to
continues to be a major public health manage obesity for overall health of the
challenge in India, which faces the unique dual nation. ‘Encouraging’ people to engage in
burden of smoke and smokeless tobacco. healthy diets and regular exercise through
Prevention of tobacco therefore requires active health promotion could be a possible
stringent ‘enforcement’ by the government intervention.
through various measures such as taxation,
Alcohol is another major risk factor which is
curbs on public smoking and bans on indirect
associated with several cancers, such as liver,
advertising.
breast, stomach, larynx, etc. It also has a
► Enable HPV screening and vaccination: relatively higher risk burden compared to
Infectious risk factor mainly include HPV obesity and therefore a combination of
causing cervical cancer, which is easily ‘encouraging’ people to abstain and
preventable through vaccination. There is a ‘enforcement’ through taxation, bans on
disproportionate burden of cervical cancer in promotion and advertising and policies such as
developed and developing countries, mainly reduced hours of sale could be some of the
due to lack of screening and vaccination preventive strategies.
practices. Prevention of cervical cancer
► Enlighten about ill effects of environmental
therefore requires ‘enablement’ by improving
carcinogens: Environmental risk factors
access to screening, making low-cost vaccines
include air pollution, exposure to UV radiation,
available and destigmatizing conversations
radon, asbestos, and other carcinogens
around sexual health.
associated with lung cancers and melanoma.
► Encourage healthy behaviors: Obesity is As seen in the previous section, awareness of
associated with several cancers such as these risk factors is presently low, and the

Call for Action: Making quality cancer care more accessible and affordable in India 34
 immediate need therefore is to ‘enlighten’ become a new crisis that is unfolding in some
people about risks of exposure to these countries like the US with its sales rapidly
carcinogens. Policy interventions such as increasing among the youth.
environmental standards and regulations, ► Many state governments have implemented
robust energy policies could be other areas of laws banning the sale, manufacture, and
primary prevention which may gain traction in distribution of gutkha, khaini, paan masala
the near future, given that we are already containing tobacco under the Food Safety and
seeing unprecedented levels of air pollution in Regulation Act.
our major cities.
The government has recently drafted the
Given that tobacco control and HPV vaccination COTPA amendment bill which was put in public
emerge as the two most actionable and priority domain for comments. The proposed
interventions, the following sections cover these amendment calls for stricter measures
in further detail. including:
► Eliminating designated smoking areas
Tobacco control
from workplaces, airports, and
What has been done? restaurants to achieve complete ban on
smoking in public areas
► The Government of India has undertaken
► Ban on all forms of indirect advertisement
several measures when it comes to tobacco
including using of brand name, trademark,
control starting with instituting the National
colors, layout and presentation for
Tobacco Control Programme (NTCP) in 2007 -
marketing or advertising other goods,
2008 to raise awareness, implement tobacco
services, and events
laws and provide cessation services to tobacco
addicts. The NTCP is being implemented in ► Raising the age of sale allowed to persons
677 districts across 36 states/ UTs from 18 years to 21 years
presently 21. ► Prescribing minimum quantity to eliminate
► The government has been actively the sale of loose cigarettes
discouraging use of tobacco products through ► Increasing radius where sale is disallowed
implementation of the Cigarettes and Other from 100 yards to 100 meters of
Tobacco Products Act (COTPA 2003), which educational institutions
banned sale to persons below 18 years of age,
While it is still to be seen whether this bill will
sale within hundred yards of educational
get passed in the parliament, it is a
institutions, promotion and advertisements of
progressive legislation by the government
products and smoking in public places. The
which could motivate more users to quit. The
government also recently implemented new
proposed bill has already drawn flak from
specified health warnings on tobacco product
farmers, traders and retailer associations
packs which cover 85% of the display area
actively led by tobacco industry lobbies who
with graphic health warning image and
claim the harsh amendments would impact
messaging along with quit line number for
the livelihood of farmers and increase illicit
supporting users willing to quit.
trade.
► India also took the bold step of banning all
forms of Electronic Nicotine Delivery Systems What has been achieved?
(ENDS) 22 such as e-cigarettes and vapes
► As per the Global Adult Tobacco Survey
across the value chain prohibiting production,
(GATS), overall prevalence of tobacco among
manufacturing, sale, import, export, stocking,
adult population has reduced by six
distribution, and transfer. Initially marketed by
percentage points between 2009 - 2010 and
the tobacco industry as a means to drop the
2016 - 2017. While this is most certainly an
smoking habit, addiction to ‘vapes’ has
achievement, the current prevalence of 28.6%

21 Ministry of Health and Family Welfare, Annual Report, 2021-22 Health. 2020 Aug;5(8):e426. doi: 10.1016/S2468-
22 Chakma JK, Kumar H, Bhargava S, Khanna T. The e-cigarettes 2667(20)30063-3. PMID: 32768432.
ban in India: an important public health decision. Lancet Public

35 Call for Action: Making quality cancer care more accessible and affordable in India
 is still higher than the global prevalence of students between ages 13 to 15 years. While
23.4%, indicating that there remains more to the prevalence has shown a declining trend of
be done. tobacco users from 16.9% in 2003 to 8.5% in
► The government has also conducted four 2019, it is still an alarming statistic
rounds of the Global Youth Tobacco Survey considering the young age at which children
(GYTS), which is a school-based survey for are being exposed to tobacco.

Table 11: Change in prevalence: GATS 2009-10 & GATS 2016-17

Total adult Type of tobacco users (in Cr)

population in Number of
crore (Age 15 adult tobacco Both smoke
Year of GATS and above) users in crore Smoke only Smokeless only and smokeless
2016-17 93.2 26.7 6.7 16.7 3.2
Prevalence 28.6% 7.2% 17.9% 3.4%
2009-10 79.6 27.5 6.9 16.4 4.2
Prevalence 34.5% 8.7% 20.6% 5.3%
Change in prevalence 5.9% 1.5% 2.7% 1.9%

What further needs to be done? implementing warning labels on all forms of

packaging and bans on all forms of
► To counter the global challenge of tobacco,
advertising.
WHO launched the MPOWER23 policy package
in 2008 to assist country level However, when it comes to taxation, India falls
implementations. MPOWER comprises the six below the WHO minimum recommendation24
key interventions to discourage use of of 75% tax share of retail price of tobacco.
tobacco: Currently, India levies 28% GST, which is the
► M- Monitor tobacco use and prevention highest tax slab. Additional taxes such as
policies National Calamity Contingent Duty (NCCD) and
compensation cess take the incidence up to
► P- Protect people from tobacco smoke
50-60%25. Government has set up an expert
► O- Offer help to quit tobacco use group in 2021 with a mandate of suggesting
► W- Warn about the dangers of tobacco various tax rate models for consideration in
► E- Enforce bans on tobacco advertising, preparation of FY23 and future Union
promotion, and sponsorship budgets 26. Tax rates, however, remained
► R- Raise taxes on tobacco unchanged in this year’s budget. There is a
need to further explore tax reforms to meet
Since its launch, 146 countries have adopted WHO recommendations and discourage
at least one of the MPOWER measures. India tobacco sale.
has also started implementing MPOWER
measures, such as offering help to quit ► The proven harmful effects of tobacco often
tobacco use through its mCessation program, beget the question on why not abolish tobacco
which utilizes mobile technology for tobacco altogether with a complete ban on production.
cessation. The passing of the COTPA Not many countries have ventured on this
amendment bill may further strengthen four path but for Bhutan, which enacted a national
other MPOWER initiatives like monitoring tobacco ban in 2004.
tobacco usage through GATS and GYTS, The most common reasons for not abolishing
completely banning smoking in public places, tobacco are the impact on government

23 https://www.who.int/initiatives/mpower 25 https://www.dailypioneer.com/2022/columnists/raise-tobacco-

24 https://www.who.int/europe/activities/promoting-taxation-on- tax-to-heal-economy-and-people
26 https://www.livemint.com/news/india/government-sets-up-
tobacco-products
expert-panel-on-tobacco-tax-policy

Call for Action: Making quality cancer care more accessible and affordable in India 36
 revenue collection, livelihood of tobacco- Bhutan29 was perhaps the only country which
producing farmers, increase in smuggling and abolished domestic production and sale of
black marketing, and a broader societal tobacco with 100 percent tax on specified
question on whether governments should small amounts of tobacco legally imported for
enforce personal choices of people. personal use. The government imposed a fine
on illegal users, which was later amended to
Alternate farming could be a possible option
constitute a fourth-degree felony with three to
to protect the livelihood of tobacco farmers.
five years of imprisonment. However, the
Towards this effect, India’s largest cancer care
WHO tobacco survey indicated that usage of
provider, HealthCare Global Enterprises Ltd
smokeless tobacco among Bhutanese youth
(HCG) is successfully steering an alternate
had gone up from 9.4% in 2009 to 22% in
farming project in Hunsur, which is a tobacco
2019. Despite the stringent measures
belt in Karnataka by supporting farmers to
imposed, demand for tobacco continued to
shift from growing tobacco to sandalwood.
remain strong, leading to vigorous smuggling
The government could consider piloting
from across the border. Following the COVID-
similar projects across the country by
19 outbreak, when cases started to increase
empowering tobacco farmers to switch to
due to smugglers crossing the border without
other crops.
any testing protocols, the Bhutan government
As per a WHO study27, India loses up to 1% of repealed the ban on import of tobacco for
its GDP every year due to diseases and deaths commercial purposes while continuing the ban
caused by tobacco, including cancer and other on domestic production and sale. The
NCDs. The economic cost attributable to government has pledged to engage in
tobacco considering medical costs and awareness campaigns and nicotine
mortality costs of premature death was replacement approaches towards its tobacco
estimated to be US$27.5 billion, as per the cessation efforts. This case study from Bhutan
study. The average annual revenue collection shows a possible downside of increase in
from tobacco products stands at smuggling across the border if strong
approximately US$7 billion28. Therefore, in vigilance is not maintained to curb illicit trade.
theory, the cost of tobacco seems to far
► The below chart indicates 30several countries
outweigh its earnings when considering the
such as Canada, Mexico, Australia, the United
costs of premature deaths.
Kingdom, New Zealand have less than 15%
prevalence of tobacco users. Many of these
countries are moving toward ‘endgame’ goals
aimed at reducing prevalence to less than 5%.

27 https://www.who.int/india/news/detail 29 https://www.moneycontrol.com/news/trends

28 https://www.business-standard.com/article/economy-policy 30 https://data.worldbank.org/indicator

37 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 16: Prevalence of current tobacco use (% of adults) – World Bank data 2018

Global prevalence: 23.4% Less than 20% Between 20% – 30% Over 30%

UK:
16.1%

Russia:
Canada: 27.1%
13.6%
France:
US: 33.6%
23.4% China:
25.7% Japan:
20.5%

Mexico:
13.4%
India:
28.6%
Brazil: Indonesia:
13.2% 37.2%

Australia:
14%

South Africa:
20.4%
New Zealand:
14.2%

New Zealand recently announced some drastic expected to hit the market by end of the year.
measures in a bid to become ‘smoke-free’ by The vaccine ‘Cervavac’ developed by Serum
202531. The final legislation which is expected to Institute of India and the department of
pass in December 2022 sets out the following biotechnology is expected to be priced at
three measures: INR200 to 40032 vis-à-vis INR3,000 price of
the two vaccines presently being marketed by
► Drastically reducing nicotine content in
Merck and GSK. Launching the vaccine at 10
tobacco to make it less addictive
times lower price is a significant milestone
► Reducing number of outlets selling tobacco by which if rolled out effectively has the potential
90 to 95% to accelerate India’s fight against cervical
cancer.
► Prohibiting lifetime sale of tobacco to anyone
born from 2009 onwards ► Government has rolled out population-based
prevention and screening initiatives for
The third measure effectively means anyone born
common NCDs, including cervical cancer
from 2009 cannot take up smoking, in contrast to
under Ayushman Bharat Health and Wellness
interventions in most countries which mandate a
Centres. Recommended method for cervical
minimum age of say 18 or 21 years after which
cancer screening is Visual Inspection through
they are allowed to smoke. The US town of
Acetic acid (VIA). These services are being
Brookline adopted a similar strategy, where they
provided through trained frontline workers
introduced a bylaw in September 2021 that
(ASHA, ANM, MPWs).
forever prohibits anyone born after 1999 from
purchasing tobacco and vape products. What has been achieved?

HPV vaccination and screening ► The 2020 report of the National Cancer
Registry Programme observes a significant
What has been done?
decrease in cervical cancer incidence rates in
► India has recently announced the launch of its 10 PBCRs between 2012 to 2016. These
first indigenously developed HPV vaccine

31 https://www.dnaindia.com/world 32 India’s
first indigenously developed vaccine for cervical cancer:
All you need to know”, indianexpress.com, Sept 2022

Call for Action: Making quality cancer care more accessible and affordable in India 38
 statistics are however prior to the launch of important, as indicated earlier in the
NCD screening program by the government. awareness section.

What further needs to be done? Australia 33 has pledged to be the first nation to
eliminate cervical cancer by 2035. Some
► India is still to include the HPV vaccine as part
initiatives undertaken by the Australian
of its Universal Immunization Program. As of
Government include:
October 2019, 100 countries around the
world had already introduced the HPV vaccine ► Early inclusion of HPV vaccination in 2007 as
as part of their national immunization part of the national immunization program. As
schedule. Few states, such as Delhi and per WHO country profiles for cervical cancer,
Punjab, have introduced vaccination programs among girls turning 15 years in 2020, 7 in 10
from 2016 onwards. girls in Australia have received their final HPV
vaccination dose. Australia reported a drop in
► With the expected launch of the indigenous
incidence from 7.4 cases per 100,000
vaccine ‘Cervavac’ by end of the year, there is
females in 1982 to 3.7 cases per 100,000
a need to ensure effective roll-out through
females in 2018, predominantly driven by
mass vaccination drives similar to what the
vaccination34.
government recently implemented for COVID-
19. A ‘Cowin’ like app can be an effective ► National cervical screening program using
measure to streamline the vaccination HPV test as primary screening method. Under
process. the program, 8 in 10 women have been
screened in the last five years. In 2017, the
► Given the decade-old debate around the
Australian government changed the frequency
efficacy and safety of the HPV vaccine in
of testing from every two years to a five-
India, there is a need to conduct regular
yearly test.
studies to establish evidence of the same. In
the past, the government halted the HPV ► Introduction of self-collection for cervical
vaccine trial in Gujarat and Andhra Pradesh screening tests in 2021 to encourage many
after seven girls who had received the vaccine more women to take the test by making the
reportedly died during the trial. While the process easier, more comfortable, and less
government enquiry concluded those deaths invasive.
were unrelated to the vaccine later, the ► Spending of close to US$386 million on HPV
unfortunate event raised several questions vaccines and distributing around 6.4 million
around the safety of the HPV vaccine, which doses since 2012 – 2013. In 2021,
requires scientific evidence to allay any fears. government announced additional funding of
Post-marketing surveillance linking US$5.8 million to develop National Cervical
vaccination to reduced incidence is also Cancer Elimination Strategy.
critical as visible impact of HPV vaccination
will take several years. ► The funding shall support Australia’s largest
clinical trial, the Compass Trial, for producing
► The government should continue to focus on evidence on the interactions between HPV
initiatives such as accessibility to hygienic vaccination and HPV-based screening.
toilets for all women. Education regarding Outcomes of the trial will be used to improve
genital and menstrual hygiene is also screening to ensure participants continue to
receive the right care.

33 https://www.health.gov.au 34 https://www.canceraustralia.gov.au/cancer-types/cervical-

cancer/statistics

39 Call for Action: Making quality cancer care more accessible and affordable in India
 Alcohol policy in India is a state subject. While
some state governments such as Gujarat,
Bihar, Manipur have prohibited alcohol and are
With an increase in the incidence and ‘dry states’, easy access to illicit liquor is
prevalence of cancer, it is important to thriving. The Ministry of Social Justice &
spread awareness and hasten early
Empowerment has instituted a scheme 36
detection through scalable screening
which provides financial assistance up to 90 to
programs at the grassroot level whilst
improving access to high quality affordable 95% to voluntary organizations for running
treatment options. At Fortis, we focus on Integrated Rehabilitation Centre for Addicts
enabling access to the entire spectrum of (IRCAs), Regional Resource and Training
cancer care, ranging from preventive Centres (RRTCs), for holding Awareness-cum-
Oncology to precision medicine and high- de-addiction camps (ACDC) and Workplace
end radiation treatment. With focus on Prevention Programmes, etc.
early detection and adoption of vaccines like
HPV vaccine, cancer survival rates can be Around 14 countries 37 in the world have
improved and collaborative programs with enacted prohibitionary measures for alcohol
Public Private partnerships will be of consumption, a vast majority of them being
immense help. Islamic countries such as Yemen, UAE,
Pakistan, Saudi Arabia, Bangladesh, etc.
Dr. Ashutosh Raghuvanshi
Managing Director & CEO, Fortis Healthcare Limited Obesity

► Earlier seen as a rich nation problem, obesity

rates have seen an increase across all
Other risk factors countries in the past decade due to physical
Alcohol inactivity and unhealthy diets.

► Excessive alcohol consumption not just causes In today’s world, awareness of healthy diet
cancers like breast, liver and pharynx, but is and regular exercise seems to be higher than
also responsible for several social issues such what it was a decade ago, especially in urban
as domestic violence, poverty, increase in areas. It is not uncommon to see people
crime and drunk driving. tracking their daily ‘steps’ and ‘calories’, which
have been driven by multiple digital apps and
Similar to WHO’s MPOWER policy package for smartwatches in the market. However,
tobacco control, WHO recommends guidelines sustaining these healthy behaviors requires a
known as SAFER35 to reduce alcohol lot of self-motivation and an enabling
consumption across countries. The SAFER environment such as access to walking areas,
interventions involve: time to engage in physical activity such as
► S- Strengthen restrictions on alcohol sports, gym, yoga, etc.
availability
Incentivizing or gamification of positive health
► A- Advance and enforce drink driving
behaviors can also drive a person’s motivation
counter measures
to engage in healthy behavior. Fitness apps
► F- Facilitate access to screening, brief and various smartphone games provide
interventions, and treatment badges, reward points and leader boards to
► E- Enforce bans or comprehensive celebrate a milestone achievement and
restrictions on alcohol advertising, motivate individuals to reach this milestone.
sponsorship, and promotion Creating an ecosystem of rewarding health
► R- Raise prices on alcohol through excise behavior by linking insurance companies and
taxes and pricing policies e-commerce players to use this information
can be evaluated as illustrated below.

35 https://www.who.int/initiatives/SAFER 37 https://www.worldatlas.com/articles

36 https://socialjustice.gov.in/schemes

Call for Action: Making quality cancer care more accessible and affordable in India 40
 Similarly, sporting events and promotion of used to raise awareness and encourage people
events such as yoga day by schools, colleges, to adopt healthy lifestyles.
corporates, residential societies etc., can be

E-commerce website
Milestone steps used to purchase
Wearable fitness Insurance companies
achievement wearable fitness
trackers notify use this information
celebrated by tracker offers
on milestones to create a health
posting on social discount on gym
achieved based score and develop
media and online shoes for rewarding
on total steps customized care plans
support groups milestone steps
achievement

Mandatory labels on food packaging providing competitions organized by schools, colleges,

nutrient and calorie details of ingredients can also universities, corporates, residential societies could
make people aware of what constitutes their diet, also encourage people to take up some form of
which might prompt them to make healthier food physical activity.
choices. Events such as yoga day, sporting

The UK recently
announced a ‘Better
Health’ campaign38
which reveals a set of
measures relating to
the government’s
obesity management
strategy. Some of the
measures include:
► Banning
advertisement of
foods high in fat,
sugar, salt on
television and
online media before
9 pm when children
are most likely to
see them.
front-of-pack nutritional labeling using ‘traffic
Consultations are being held by the
light’ scheme.
government on whether to extend these bans
at all times of the day. ► Expansion of NHS services to include weight
management services through self-care apps
► Ending ‘Buy one Get one Free’ offers on foods
and online tools. The government will offer
containing high salt, sugar, fat
incentives to doctors and primary care staff
► Calorie content labels to be added to food for supporting obese people in their weight
items being sold by restaurants, cafes and loss journey and becoming ‘healthy weight
takeaways with more than 250 employees. coaches’. The government has also
The UK government has already implemented encouraged GPs to prescribe exercise and
more social activities to help people keep fit.

38 https://oen.org.uk/2020/08/21/a-summary-of-the-uk-

governments-tackling-obesity-strategy/

41 Call for Action: Making quality cancer care more accessible and affordable in India
Some of the prohibitionary measures adopted by ► In April 2022, EU published a ‘Restrictions
countries include high taxes on fast- food chains Roadmap’ to regulate hazardous chemicals
and manufacturers of sugary beverages. For including carcinogens such as formaldehyde 40.
example, Japan in 2008 introduced ‘Metabo’ law
► In US, the Environmental Protection Agency
which fined employers if their employees failed to
(EPA) bans 41 carcinogens such as dioxins,
meet specified goals in an annual waist
asbestos, hexavalent chromium, etc.
measurement check-up. Denmark introduced a ‘fat
tax’ in 2011 on processed food containing more Hereditary risk factors
than 2.3% of saturated fat. However, the
government of Denmark repealed the same law in Certain cancers are caused by inherited gene
2012 since people started crossing the porous EU mutations which suggests that individuals who
borders to Sweden and Germany in order to shop have a family history of such cancers have an
for butter, milk, cheese, oil, meat etc., which increased likelihood of developing the cancer in
impacted Danish retailers putting jobs at risk. The their lifetime.
Kerala government in India also proposed a similar
Genetic testing can help identify the inherited
measure in 2016 of imposing 14.5% fat tax on
gene mutations. For example, women who have a
burgers, pizzas and other junk food served by
family history of breast cancer could consider
branded restaurants. The UK implemented a
getting themselves tested for BRCA1 gene. People
‘sugar-tax’ in 2018, which created slabs for
who test positive for this gene have higher
taxation depending on the sugar content in drinks
chances of developing breast cancer. In addition
to motivate businesses to reduce the amount of
to breast cancer, genetic testing is also available
sugar in their beverages 39.
for other type of cancers such as ovarian, colon,
Environmental risk factors thyroid, prostate, pancreatic, melanoma,
sarcoma, kidney and stomach cancer. 42
Exposure to chemicals and other substances in the
Knowledge of a higher likelihood of acquiring
environment can also cause cancer. For example,
cancer could lead to some preventive actions such
second-hand tobacco smoke, asbestos and
as chemoprevention or surgical interventions such
outdoor air pollution are risk factors for lung
as prophylactic mastectomy. Chemoprevention
cancer. Drinking water that has large amounts of
involves the use of certain drugs to lower the risk
arsenic can cause skin, bladder and lung cancers.
of cancer. Some examples of chemoprevention
Regulations by ministries engaged in environment include the use of tamoxifen or raloxifene, which
protection, food safety etc., play an important reduces the risk of breast cancer and finasteride
role in reducing exposure to hazardous chemicals. which reduces the risk of prostate cancer.
Monitoring Air Quality Index (AQI) and quality of Chemoprevention is, however, an emerging
drinking water are simple but important steps to science and is not very commonly used for cancer
avoid exposure to hazardous chemicals. prevention at present. Surgical interventions for
cancer prevention include mastectomy and
Indian government has banned some harmful
salpingo-oophorectomy for removal of breasts,
substances in pesticides, some of which are known
ovaries and fallopian tubes in women diagnosed
carcinogens. Few examples of carcinogenic
with positive gene mutation for breast or ovarian
chemicals banned by other countries are listed
cancer43.
below.
However, genetic testing has certain limitations. A
► Poland and the US prohibited indoor tanning
positive genetic test does not mean that the
salons for people under the age of 18 to
individual will develop the cancer for sure, it just
reduce risk of exposure to UV rays, which is a
indicates higher chances. Similarly, absence of a
risk factor for melanoma.
gene mutation or a negative result does not mean
the person will never develop cancer, as there are

39 https://medium.com/illumination-curated 42https://www.cancer.net/navigating-cancer-care/cancer-
40 https://www.packaginglaw.com/news basics/genetics
41 https://www.businessinsider.com
43 https://www.cdc.gov/genomics/disease/breast_ovarian_cancer

Call for Action: Making quality cancer care more accessible and affordable in India 42
multiple risk factors which can cause cancer as related social aspects such as depression, anxiety,
seen in the preceding sections. Genetic testing is guilt, family tensions are associated with a
also expensive and therefore not a viable option positive test outcome.
for everyone with a family history of cancer. Other

The Cancer Genetics Clinic at Fortis Healthcare, managed by experienced genetic counselors, evaluates
people with a personal or family history of cancers that may have genetic links. This includes conditions
such as hereditary colon cancer and colon polyps, hereditary breast and ovarian cancer, gastric cancer,
endocrine tumor and cancers (adrenal cancer, pheochromocytoma and paraganglioma, thyroid
cancers), renal cancer, melanoma, pancreatic cancer, sarcoma and additional rare cancers.
The goal of the genetics clinic is to provide a personalized cancer risk assessment, counseling on the
process and results of any genetic testing, determining whether other family members need genetic
evaluation methods to minimize the risk of cancer through surveillance, management and in some cases
prophylactic surgery or oral medication.
Common reasons for considering evaluation at The Cancer Genetics Clinic include - diagnosis of cancer
at an earlier than average age (less than age 50 for common cancers like colon or breast cancer), more
than one relative with the same or related cancers in the family, individuals with more than one primary
cancer and individuals with rare or unusual cancers.

43 Call for Action: Making quality cancer care more accessible and affordable in India
Chapter 2B: Screening and Detection

Cancer screening helps in early identification for of downstaging or high probability of reducing
downstaging the disease as well as achieve mortality if detected early.
reduction in mortality and morbidity
Oral, breast and cervical cancers are three major
Screening helps in identifying an unrecognized cancers that qualify as pre-requisites to
disease by application of a test to people who are implement a country wide screening program.
asymptomatic but may have the disease or early Some developed countries with high GDP spend on
signs of the same. Most countries have initiated healthcare also focus on screening of colorectal,
and implemented cancer screening programs in lung and prostate cancers.
cancers with a high incidence and high propensity

Chart 17 – Five-year survival rate based on stage of diagnosis

Five-year survival rate based on stage of diagnosis.

12%
Lung cancer
70%
Probability of
3.30% patients living up
Oral cancer
60.20% to five years is
significantly
14.90% higher if cancer
Breast cancer
76.30% is detected in
early stages.
7.90%
Cervical cancer
73.20%
Advanced Stage Early Stage

The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by
avoiding risk factors, early detection via screening, and proper treatment

Source: WHO.int

With an increasing incidence of cervical and breast recommends undertaking measures to eliminate
cancer and the possibility of improving mortality cervical cancer by 2030 and reduce breast cancer
and clinical outcomes due to early detection, WHO mortality globally by 2040.

Call for Action: Making quality cancer care more accessible and affordable in India 44
Chart 18: WHO recommendations for cervical and breast cancer

Cancer Type Recommendation

Breast cancer Reduce global breast cancer mortality by 2.5%
per year by 2040 and prevent 2.5m deaths 5 years survival rate
using the 3 pillars: High
income South
1. Health promotion for early detection
World wide countries India Africa
2. Timely Diagnosis
5/6 9/10 6/10 4/10
3. Comprehensive Breast Cancer Management
Cervical cancer Eliminate cervical cancer globally by 2030
1. Fully Vaccinate 90% girls by age 15 years
2. Screen 70% women with high performance test (PAP/ VIA) by 35 years and 45 years of age
3. Treat 90% of women identified with cervical disease

In terms of screening coverage, WHO recommends a PAP test for all women above 21 years
every 3 years till 65 years if age. In countries with low resources, WHO recommends to use VIA
with 5% acetic acid for mass screening and PAP as confirmatory test.

Source: WHO.int

In addition, various countries have implemented of disease has improved outcomes in terms of
screening programs for other cancer types with survival rates and quality of life.
high incidence and found that early identification

Chart 19: Learnings on screening for other cancer types

Cancer Type Learnings on screening

Oral cancer In India, visual inspection provides the opportunity to screen all negative patients for any oral
lesion with the help of a trained healthcare worker or a community health worker. Treatment of
patients with early-stage oral cancer indicates improved rates of survival and quality of life.

Lung cancer International Early Lung Cancer Action Program (I-ELCAP) results in the US have shown a 10-
year survival of 88% in patients with stage I lung cancer, which were identified during screening.
The result further saw a reduction of 20% in deaths due to lung cancer in the National Lung
Screening Trial (NLST) with low dose computed tomography in comparison with chest
radiograph. NLST conducted three annual CT scans.
Colorectal High resource developed countries like US and Canada use colonoscopy once every 10 years to
cancer screen patients. A low-cost model used by countries like Japan, China, the UK is to do a fecal
immunological test or fecal occult blood test

Source: WHO.int; govt websites

45 Call for Action: Making quality cancer care more accessible and affordable in India
 While India’s cancer screening program aims to
comprehensively cover oral, cervical and breast
cancers, the coverage achieved to date is very
The biggest challenge today in India is that low compared to other countries
all major cancers get detected at advanced
stages. This affects the clinical outcomes, Based on the prevalence and increasing numbers
cost of treatment and overall mortality and of cancer cases in India, Government’s focus has
morbidity. The most effective way to change been to screen for cervical, breast and oral
the outcomes in cancer is through cancers as part of population-based screening
combination of awareness, prevention, early under National Program for Prevention and
detection, and comprehensive care. Once Control of Cancer, Diabetes, Cardiovascular
we all join our hands together at every level Diseases and Stroke (NPCDCS). While the
to provide integrated cancer care, we can government launched the NPCDCS in 2010 as part
change the outcomes in next 3 to 5 years. of the wider National Health Mission, it started
population-based screening for cancers in 2016
Dr. Raajiv Singhal under the NCD screening agenda.
Managing Director and CEO, Marengo Asia healthcare

Table 12: Cancer screening coverage and guidelines in India

Type of Age of Frequency of

Cancer screening Method of Screening Screening Referral mechanism
Oral visual Positive cases referred to CHC or DH for
Oral cancer 30-65 years Once in 5 years
examination (OVE) confirmation or biopsy
Positive cases referred to PHC/CHC/DH for
Cervical Visual inspection further evaluation and management of pre-
30-65 years Once in 5 years
cancer with Acetic acid (VIA) cancerous conditions where gynecologist/
trained lady officer is available
Positive cases referred to Surgeon at CHC/DH
Breast Clinical Breast
30-65 years Once in 5 years for confirmation using a breast sound probe
cancer examination (CBE)
followed by biopsy as appropriate

Source: Operational framework, management of common cancers, MoHFW, GoI report

Along with breast and cervical cancers, most Further, few developed countries like the US,
other countries have also covered colorectal Canada, Japan, and Malaysia have also included
cancer as part of their screening programs. lung cancer as part of their screening program.

Table 13: Country wise national cancer screening programs in the world
Singapore

Sri Lanka
Australia
Germany

Malaysia

Thailand
Canada

Japan
China
India

USA
UAE

UK

Organ
Breast            
Cervical             
Oral  
Colorectal           
Lung    
Skin 
Liver 
Head and Neck 
Gastric  

Source: Country websites

Call for Action: Making quality cancer care more accessible and affordable in India 46
Limited resources and absence of a low cost, India has so far been able to screen only 1.1% of
effective and safe diagnostic tool for colorectal their population for cervical cancer and less than
and lung cancer are the main reason for their 1% for breast and oral cancer. The screening
absence from the national screening programs. coverage in urban areas is slightly better than
Further, private healthcare providers rural areas, primarily due to easy access to
opportunistically screen prostate cancer with an screening facilities, opportunistic screenings
increasing incidence in urban India. India’s offered in private hospitals as well as increased
inclusion of oral cancer under the cancer awareness amongst the population. However, oral
screening program as compared to other cancer screening coverage amongst men across
countries is due to the high incidence of oral urban and rural areas is equally very low.
cancer across men and women being witnessed in
Other countries, including low-income ones like Sri
the country.
Lanka, Indonesia, Bangladesh, and Nepal, have
been able to achieve a higher screening coverage
than India for cervical cancer. For breast cancer,
the UK and the US have been able to cover over
70% of their population, Singapore continues to
Recent advancements in Oncology
combined with breakthrough technology
see an improvement in their screening coverage
have remarkably improved patient as India lags significantly.
outcomes. Yet a significant number of
Chart 20: Screening coverage in India by percentage
cancer patients come late to hospitals either
of population
because of poor understanding of symptoms
or late screening. The need of the hour
remains regular mass screening camps and
0.20%
awareness sessions across strata.
0.90%
0.20%
Dr. Abhinay Bollineni 0.20%
CEO, KIMS Hospitals 0.70%
0.60% 0.80%

0.40% 0.60%

1.50%
1.10% 1.10%
India’s performance on cancer screening
Rural Urban India
India’s national cancer screening program has
been running since November 2016, however Cervical cancer Breast Cancer
penetration in terms of population coverage has Oral Cancer (W) Oral Cancer (M)
been very low. India made progress since
Source: NFHS-5
2018 when cancer screening became a part of the
larger NCD screening program under National
Health Mission

47 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 21: India vs. other countries — cervical and breast cancer screening penetration (% of population covered)

Breast Cancer Cervical Cancer

77%
78.2%

69%
67%

67%
62%
70.6%

54%
47%
40%

27%
24%
12%

10%
37.9%

9%
7%

6%
5%

2%
2%
Singapore

Thailand

India
Bhutan

Indonesia

Malaysia
Bangladesh

Nepal

Sri Lanka
>1%

US UK Singapore India Screened in last 5 years Ever screened

Source: govt websites

India’s diverse terrain and population across dictates the screening coverage of these cancers
states, maturity of existing healthcare across states.
infrastructure and spending capacity of each state

Chart 22: Percentage of population screened in India for top 3 cancers till 2021

Oral cavity Oral

State/Union territory Cervix Breast women cavity men
India 1.2% 0.6% 0.7% 0.2%
Chandigarh 0.9% 0.0% 0.2% 0.1%
Delhi 0.4% 0.2% 0.7% 0.1%
Haryana 0.5% 0.2% 0.3% 0.2%
Himachal Pradesh 0.7% 0.3% 0.3% 0.1%
Jammu & Kashmir 0.3% 0.2% 0.6% 0.1%
Ladakh 0.2% 0.2% 0.1% 0.0%
Punjab 1.9% 0.3% 0.4% 0.1%
Rajasthan 0.3% 0.1% 0.2% 0.1%
Uttarakhand 0.3% 0.1% 0.3% 0.1%
Chhattisgarh 0.3% 0.2% 0.2% 0.2%
Madhya Pradesh 0.7% 0.5% 0.7% 0.1%
Uttar Pradesh 1.0% 0.3% 0.6% 0.2%
Bihar 0.5% 0.2% 0.3% 0.2%
Jharkhand 0.4% 0.1% 0.2% 0.1%
Odisha 0.7% 0.1% 0.2% 0.1%
West Bengal 0.1% 0.1% 0.1% 0.1%
Arunachal Pradesh 0.7% 0.3% 0.4% 0.2%
Assam 0.2% 0.2% 0.2% 0.3%
Manipur 1.3% 1.0% 0.6% 0.1%
Meghalaya 0.4% 0.3% 0.4% 0.1%
Mizoram 3.8% 1.6% 0.7% 0.1%
Nagaland 0.2% 0.2% 0.3% 0.1%
Sikkim 0.5% 0.2% 0.6% 0.3%
Tripura 0.4% 0.3% 0.4% 0.0%
Daman & Diu 0.4% 0.1% 0.1% 0.1%
Goa 0.9% 1.0% 0.5% 0.3%
Gujarat 0.2% 0.1% 0.2% 0.1%
Maharashtra 1.7% 1.0% 1.0% 0.1%
Andaman & Nicobar Islands 1.9% 1.3% 9.5% 0.7%
Andhra Pradesh 3.2% 0.6% 5.0% 0.8%
Low High
Karnataka 0.5% 0.2% 0.4% 0.1%
Kerala 2.3% 1.5% 0.5% 0.1%
Lakshadweep 1.2% 0.3% 0.2% 0.1%
Puducherry 5.3% 2.9% 1.2% 0.2%
Tamil Nadu 7.0% 3.8% 0.9% 0.2%
Telangana 2.1% 0.3% 1.8% 0.4%

Source: NFHS 5; Towards universal health coverage April 2018- Nov 2020, EY analysis

Call for Action: Making quality cancer care more accessible and affordable in India 48
 With advancements in medical sciences, mortality and morbidity associated with cancer can
be largely prevented. We need mass scale campaigns to increase awareness, de-stigmatize
cancer and universal screening of common cancers, especially in rural areas where two-thirds
of our population lives. Apart from the routine tests and markers, for those who are at high
risk and those diagnosed with cancer, advanced diagnostics like genetic testing can
significantly improve outcomes through personalized interventions and precision medicine.

Dr. Vandana Lal

Executive Director and Chief Technical Officer, Dr Lal PathLabs Ltd

Given the availability of strong public health activities, etc. The government ranked Karnataka,
infrastructure, Tamil Nadu and Andhra Pradesh Chhattisgarh, Andhra Pradesh, Gujarat, and
are leading among the larger states in cancer Maharashtra as top five states and Chandigarh,
screening coverage, more specifically for cervical Pondicherry and Daman and Diu as top three UTs
and breast cancer. on the above parameters. Jharkhand, Manipur,
Rajasthan, Tripura, and Bihar were the worst
Among other states, Kerala, Mizoram, and performing states and Andaman & Nicobar Islands,
Puducherry are progressing in the screening Ladakh and Lakshadweep, the worst performing
coverage for both cervical and breast cancer. UTs. Delhi has opted out of the AB-HWC program.
Additionally, Manipur is progressing in the
screenings for breast cancer. Key challenges in cancer screening leading to
low coverage
For oral cancer screening in both men and women,
while the overall coverage remains very low The government has included and prioritized
across most states. Andhra Pradesh, Telangana, screening of the three cancers as a part of the
Maharashtra, and Andaman & Nicobar are NPCDCS and is working toward achieving the set
progressing better that other states in terms of target of opening 1,50,000 health and wellness
screening coverage. centers (HWCs) across India by December 2022 to
run this program under the umbrella of universal
In FY 2021-22, GoI ranked all the states and UT’s
primary health coverage. However, multiple
based on criteria like availability of stipulated
challenges remain which are impacting the
trained HR, initiation of screenings, availability of
achievement of desired objectives of the
diagnostic tools and medications, utilization of
screening program.
telemedicine services, conducting wellness

49 Call for Action: Making quality cancer care more accessible and affordable in India
Table 14: Key challenges in enforcement of the screening program

Area Target Status Comment

Capacity - 1,50,000 HWCs by 1,17,000 HWCs set up as Availability of adequate number of HWCs
Physical December 2022 within 30 of March 2022 across the country remains a challenge.
infrastructure min distance for the Further, even at existing HWCs, not all have
covered population with the availability of dedicated space for cervical
appropriate infrastructure or breast examination, considering privacy
for cancer screening and infection control requirements.
Capacity - Each sub-center is As of March 2021, there is Along with physical infrastructure, having
Workforce supposed to be manned by a shortage of 2.9% of trained and adequate staff to cover the
availability 1 CHO, 5 ASHA and 2/3 female health worker/ ANM population for the HWC is equally important.
multi-purpose workers and mainly due to shortfall in Lack of female health worker directly impacts
at PHC level 1 Medical Gujarat, Himachal Pradesh, the screening coverage for breast and
officer and other staff as Rajasthan, Tripura, and cervical cancer screening due to social and
per IPHS norms. Kerala. In medical officers, privacy reasons.
there is a shortage of about Lack of adequate workforce at higher referral
4% MO’s as against those centers also limits the success of any
proposed at the PHC level screening program as confirmed diagnosis
mainly in Orissa, and thereby treatment is delayed, defeating
Karnataka, and the purpose of early detection.
Chhattisgarh.
Capacity – 100% of workforce at 23% of the staff currently With an untrained workforce, conducting
Training HWCs trained for cancer deployed in these HWCs screening is a big challenge. Mere availability
screening are untrained. of personnel does not guarantee a successful
screening campaign.
Capacity - Refer all ‘at risk’ cases to 27% CHCs and 13% of DHs One of the main features of Health and
Referral higher center had not implemented Wellness Centers is to triage and refer
network NPCDCS till 2017-18. patients to the appropriate referral centers.
However, readiness of these referral centers
to accept these patients is a challenge.
At the district hospital where NPCDCS was
implemented by the government, less than
10% of the facilities had all tools for cancer
screening.
Capacity - Data Central government to Paper-based data capture No use of technology to capture all relevant
capture and deploy robust IT software and transfer in regard to information of the patient with regards to
transfer for data capturing and referral to a higher center high-risk behavior, risk factors or screening
referral management; method and result.
ASHAs to have States which are using their own software
smartphones, MPWs a pose the risk of interoperability when trying
tablet and CHOs a handheld to align to a national data repository
device and desktop for MOs
Awareness Aim is to use different Low awareness levels Awareness, knowledge, and attitude toward
techniques of information, among healthcare workers cancer screening also become important in a
education, and and the community about national screening program.
communication to make cancer screening based on
everyone aware about various studies
cancer screening
Affordability Screening and treatment ~55% of cancer patients Cancer, being the disease with highest cost
and financing post diagnosis at are required to rely on of treatment among NCDs, has a significant
government center is free private healthcare facilities impact on financial condition of those
of cost for the patient for treatment. Limited impacted.
coverage provided by
Ayushman Bharat and state
healthcare schemes and
only ~10% -12% private
insurance penetration.

Source: National Non communicable disease monitoring survey; AB-HWC survey report 2021

Call for Action: Making quality cancer care more accessible and affordable in India 50
1. Lack of physical Infrastructure space and were very small to be an HWC. To have
separate space for cervical and breast
While the aspiration is to open 1,50,000 HWCs
examination in these centers would be impossible.
across India by Dec 2022, around 1,17,440 HWCs
were operationalized as of March 2022. However, States like Maharashtra, Punjab, and Chandigarh
availability of dedicated space for cervical or exceeded their targets of operationalizing HWCs
breast examination, considering privacy and achieving 104%-189% of their targets as of
infection control requirements, has been a September 2020. On the other hand, states like
challenge in the execution of cancer screening. Rajasthan, Bihar, Orissa, Haryana, Ladakh and
The AB-HWC assessment done in 2021 pointed Tripura could not achieve more than 45% in 2020.
that 15% of the HWCs visited were in a rented

Chart 23: Number of HWCs operationalized vs. targeted Chart 24: Number of patients screened (in lakhs) in
across India as of September 2021 HWCs in India for top three cancers

1,793
1,50,000
1,17,440 1,509

1,10,000 915

74,947 504 773 976

70,000 419
475
38,595 260
40,000

Jun-21
Dec-20

Dec-21
Aug-20

Apr-21

Aug-21
Feb-21

Feb-22
Oct-20

Oct-21
17,149
15,000

2018-19 2019-20 2020-21 2021-22 Dec-22

Oral Cancer Breast Cancer
Achieved Target Cervical Cancer

Source: Operational framework, management of common Source: Report by MOHFW on Ayushman Bharat health and
cancers, MOHFW, India wellness centres 2022

So far in the last two years, despite the lockdown 2. Lack of capacity of workforce:
imposed and other challenges across the nation
due to COVID-19, a steady increase in screening According to rural health statistics report, 2021,
numbers across the three cancers at the HWCs is as of March 2021, there is a shortage of 2.9% of
worth noting. However, the target set in the female health worker/ANM due to shortages in
operational guidelines for screening, detection states like Gujarat, Himachal, Rajasthan, and
and prevention of hypertension, diabetes and Tripura. Lack of female health worker directly
common cancers, is to cover a total population of impacts the screening coverage for breast and
50% in the first year, cumulative 65% of cervical cancer screening due to social and privacy
population in the second year and a cumulative reasons. In medical officers, there is a shortage of
80% population in the third year in each SC and about 4% MO’s as against the proposed at PHC
PHC. level.

51 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 25: Human resource gap in Indian public healthcare ecosystem

Crude incidence rate for cancer per lakh population

108.4 107.7 85.7 104.6 151.75 115.34 159.6 131.6

Required ratio: 0.23

SC/PHC per 1,000 0.6
population*
0.29 0.28
Average distance to SC/PHC 0.14 0.2 0.17 0.19 0.10
0.19 0.13 0.19 0.18 0.11 0.19 0.16 0.13
is 2.4 km
Required ratio: 0.40
ANM at sub-centers and PHC
per 1,000 population* 0.59
0.45
0.24 0.24 0.31 0.29 0.22 0.3 0.26 0.19 0.3
As per OG, 2 ANMs are 0.18 0.22 0.21 0.2 0.20
required per center for
conducting screening
Required ratio: 0.60

Surgeons at CHCs per 1 lakh 0.47

0.31 0.26 0.25
population* 0.10 0.1 0.05 0.02 0.13 0.05 0.14 0.12
0.01 0.03 0.01 0.005

Required ratio: 0.60

Obstetricians and 0.42

0.3 0.37
Gynecologists at CHCs per 1
0.14 0.16 0.19 0.28 0.18 0.22 0.14
0.27
0.11 0.14 0.13 0.1
lakh population* 0.04

Required ratio: 1.5

13

Doctors at district hospital 1.4 3 2.0 2.5 0.8

4.3 1.8 2.2 1.9 3 1.9 4.5 1.5 1.7 2
per 1 lakh population
India Assam Maharashtra Madhya Pradesh Karnataka Punjab Kerala Tamil Nadu

Additional workload due to screening will potentially require further expansion of infrastructure and capacity beyond
the current recommended guidelines

Rural health statistic 2016 Rural health statistic 2021

Source: Rural health statistics, 2020-21; EY analysis

Lack of adequate training of workforce 26% remain to be trained to conduct screening

tests.
A trained healthcare professional can perform
cancer screening methods that are recommended Amongst the ASHA workers who form the core of
for all three cancers in India. Since these the public health program in India, at least 23%
screening tests are based on observation, they need to be trained for screening patients for
have a high reliance on the skill set of the NCD’s including cancers. Of the 2,761 medical
healthcare professional. Training of healthcare officers posted in these centers, almost 16% need
workers, therefore, becomes extremely important to be trained with regards to the screening
in ensuring effective screening. Of the existing program and methods of screening.
workforce deployed at HWCs across the country,

Chart 26: No. of trained HWC staff for prevention, screening, and management of NCDs including cancer

2,761 3,142 102,855 36,386 493,796

16% 16% 23%

28% 32%

84% 84% 77%

72% 68%

Medical Officer Staff Nurse MPW-W MPW-M ASHA

Trained Untrained

Source: Towards universal health coverage, report by MoHFW April 2018- Nov 2020

Call for Action: Making quality cancer care more accessible and affordable in India 52
Challenges in the referral network detection. In India, CHCs and district hospitals
need to have the available staff and technology to
The two pillars of a screening program —early
confirm a diagnosis and start the treatment for
diagnosis and fast commencement of treatment —
positive cases. Gaps in implementation of the
can help improve the outcomes. The referral
NPCDCS program and lack of adequate technology
network thus becomes an important part of the
or equipment to enable the specialists to make a
program. Any delays at this level, defeats the
diagnosis are all limiting factors that need to be
purpose and efforts put into screening and early
addressed.

Table 15: Implementation of NPCDCS program at CHC and DH

CHC DH
NPCDCS NPCDCS Not NPCDCS NPCDCS Not
Implemented implemented Implemented implemented
(n=281) (n=105) (n=290) (n=44)
Availability of NCD clinic (including
49.5% 1.9% 60.3% 61.4%
cancers)
Routinely undertaking Screening for
Oral cancer 38.1% 23.8% 60.3% 52.3%
Breast cancer 39.1% 22.9% 58.3% 59.1%
Cervical cancer 34.9% 20.0% 52.8% 59.0%
Availability of technology to screen
NA NA 9.7% 13.6%
cancer

Source: National non-communicable disease monitoring survey 2017-18

Diagnostic infrastructure gaps at CHC and DH that less than 10% of the facilities had all tools for
level are worrying. ICMR, MoHFW and National cancer screening.
Center for Disease Information and Research,
Bengaluru conducted the National Non- Knowledge, Attitude and Awareness
Communicable Disease Monitoring Survey from One of the major shortcomings in the healthcare
2017 to 2018 with 415 CHCs and 335 district ecosystem is the lack of understanding,
hospitals across the country. As per survey acceptance, and practice of cancer screening
results, 27% CHCs and 13% of DHs had not regime within the healthcare practitioners (HCPs).
implemented NPCDCS. The implementation of
NPCDCS at the district hospital level highlighted

Table 16: Knowledge and Practice (KAP) of breast cancer signs, symptoms, risk, and practice of Breast Self-
Examination (BSE) study done in HCPs across Indian cities

Knowledge and Knowledge of Signs and Knowledge of Practice

Study Year practice of BSE by HCP risk factors symptoms BSE BSE
Kalliguddi et al. 2017 Bengaluru, Karnataka 58% 60% 18% 10%
Dahiya et al. 2018 New Delhi 60% 66% 59% 49%
Singh et al. 2018 Chhattisgarh 60% 40% 19% 10%
Yambem and
2019 Gangtok, Sikkim 39% 29% 46% 41%
Rahman et al.

Such low percent of HCPs knowing and practicing Even for cervical cancer, a high number of
BSE reflects the need to educate and train HCPs healthcare professionals cited various reasons —
as well and address the social taboo associated fear of detecting a disease, perception of pain
with BSE. incurred during examination, being uncomfortable
during an internal examination — for hesitating to
get an examination done on themselves.

53 Call for Action: Making quality cancer care more accessible and affordable in India
Table 17: KAP study done in HCPs across India for cervical cancer

Knowledge of Knowledge
Pap Smear as about VIA as Never
screening screening undertaken an
Study Year State method method exam for self
Gedam JK and Rajput DA. (study
2017 Mumbai 65.60% 11.01% 74%
done in nurses)
Narayana G, Suchitra MJ, Sunanda G,
2017 South India 2% 52.10% 86.6%
et al. (study done in OBGY dept)
Khanna D, Khargekar N and Budukh
2019 Varanasi 46% 92%
A. (study done in CHWs)

Awareness and screening coverage in Her/Him (DESH) program, a mobile screening

community program for breast, oral, and cervical cancer.
Data were collected on participants' cancer
The government conducted a baseline survey in knowledge, and attitudes towards screening,
Assam, India, as part of the Detect Early and Save diagnosis, and treatment.

Table 18: Findings of DESH program

Findings %
Not aware of cancer screening facility or undergone screening 92.9%
Consumption of beetle nut 90.0%
Aware that beetle nuts cause cancer 46.90%
Negative stigma about Cancer diagnosis 42%-57%
Believed that Cancer is punishment from God <30%
Fear of Cancer screening <20%

Source: Cancer screening program in low and middle income countries -Strategies for success

These results highlighted the stigma behind for low number of women turning out for cancer
cancer and misconceptions about the disease and screenings, who live and seek permissions from
screening practices. It highlights actionable the men in their household to step out of the
targets for intervention in cancer education with a house.
large rural community. Education to address
preventable causes of cancer and to correct As per NFHS-5, screening behavior does not
misconceptions and stigma is a critical component change much across various wealth percentiles,
in ensuring the successful implementation of caste, or religion. However, Sikh and Muslim
cancer screening programs. women tend to be reluctant to get breast and
cervical cancer screening done. On the other
Oral cancer remains the least diagnosed cancer hand, men and women from the highest wealth
amongst the three, even though factors percentile and in older populations have better
associated with privacy for screening and socio cancer screening practices. In men, however, oral
cultural taboos, which are generally associated cancer screening practices are low across all
with breast and cervical examination, are absent parameters, therefore indicating that affordability
when it comes to oral cavity examination. The is not the only reason for low screening numbers.
discussions with clinicians regarding oral cancer
highlighted that men do not come forward for oral Affordability and financing related challenges
cancer screening due to fear of not being All states have relied largely on the funds provided
accepted in the society on account of through the National Health Mission, and some
disfigurement caused by surgeries, inability to states have mobilized funds from other pool like
afford treatment including plastic surgery as well State Funds, District Mineral Funds, Panchayati
as fear of loss of income. Another study suggests Raj Institutions Funds etc., to operationalize
that ignorance and lack of positive attitude HWCs. However, mobilization of funds from state
towards cancer screening could also be a reason

Call for Action: Making quality cancer care more accessible and affordable in India 54
to district was quite often delayed, as per the AB- NOTE: In a survey conducted by EY, 62% of the
HWC evaluation report 2021. people incurred OOPE for a screening test. 20%
(300 people out of 1,500) respondents who did
For affordability standpoint, while the screening
not undertake a screening test said that high
and treatment in government hospital is free or at
OOPE was the reason for not getting screened
a minimal cost, this isn’t the picture in the private
for cancer.
sector. About 51% of the population in India
prefers to get treatment done in a private Findings of EY survey on cancer screening
institution. With the high cost of diagnostics and
cancer treatment in India in the private sector and We conducted a survey to understand the
only 10-12% private insurance penetration, the knowledge of people regarding cancer screening
proportion of OOPE incurred for cancer treatment methods and their willingness to get screened. EY
is huge. This is also a limiting factor for some conducted the survey across Tier 1 (53%), Tier 2
families to avoid screening tests for cancer unless (43%) and Tier 3 (4%) cities, where the total
the symptoms start appearing. This leads to late- number of respondents was 1,034, of which 90%
stage diagnosis and poor outcomes in terms of were between 20 to 40 years of age.
mortality and morbidity.

Chart 27: Are you aware of any specific cancer Chart 28: Have you or your family undertaken any
screening test? cancer screening test?

1%
1%
23%

45%
54%
77%

No Yes Did not respond No Yes Did not respond

Out of 804 people who responded, 45% of the This not only indicates lack of awareness but also
respondents were not aware of any cancer lack of willingness to undertake any screening
screening tests and 77% of the responders said test. Out of the 23% people who had taken any
they or their families have never undertaken any cancer screening test, 62% said that they incurred
cancer screening test so far. Respondents out-of-pocket expense to get the screening done.
mentioned about tests like PAP smear, Out of the 21% repsondents who did not incur any
colonoscopy, mammogarphy, PSA and self breast out-of-pocket expense, 65% got screening done
examination as possible screening tests that they under the government screening program and the
were aware of. rest of them used their private insurance to get
the test done.

Chart 29: Did you incur out-of-pocket expense for Chart 30: How frequently did you undertake
screening tests? screening?

21% 17%
24%
46%
3%
4%
62% 23%

Quarterly Annually
No Yes Did not respond Once in 2 years Once in 5 years
Did not respond

55 Call for Action: Making quality cancer care more accessible and affordable in India
We also explored the reasons for not undertaking test because of lack of availability of nearby
any screening tests. Lack of awareness about the screening center. High cost associated with OOPE
benefits of cancer screening was the major reason for these test was a reason for 16% people, and
cited by 38% of the responders and 11% saying 4% said that social stigma associated with cancer
they did not know about possible options available screening tests de-motivated them to get a
for screening. Only 5% people did not undertake a screening done.

Learnings from around the world

Challenges Learnings from around the world

Infrastructure Increasing demand for screening programs:
and capacity
One of the key areas of concern for India is the lack of utilization of primary care and early
restraint
detection services. To be effective, the population needs to be actively engaged in understanding
the benefits of early detection. There is scope to use multiple channels to address this — in the UK,
the NHS and local GPs send out regular reminders to registered patients for screening tests e.g.,
mammography.
Robust data collection on screening and incidence:
Most developed countries like US and UK have a very robust mechanism to monitor and track
patients screened for cancers. This not only helps in providing continuous health support to
patients who have tested positive, but the data can be used to re-iterate strategies and ensure
focused programs in areas with low compliances.
M health in cancer screening:
CMC Vellore, WCMC New York, medic mobile, Mumbai and Center for Population Health Sciences,
UK, conducted a pilot study in three poor, low health literacy communities, RUHSA, Mungeli
(Chhattisgarh) and Padhar (MP) from 2016 to 2018, screening 8686 patients by 25 community
health workers and supported by 9 nursing staff at VLHC and sub centers. Each of the community
health workers was given a mobile device with low-cost SIM card-based application to collect
demographic information, symptoms, behavior, and tests undertaken (either screening or
confirmatory) along with the results. Out of 8686 people screened, majority were screened for
oral cancer (98%). The positivity rate for cervical cancer was 28% and 5% for Oral cancer. Out of
these, 37% and 31% patients came for follow up for the respective cancers.
Benefits of mhealth:
1. More credibility to CHW
2. End-to-end tracking of respondents at CHW and nursing level from screening to confirmation
to treatment initiation and adherence
3. Data collected and traced back to patients who did not appear for confirmatory tests
4. App had a provision to document demographics, symptoms, and risk behaviors along with
tests and reports both screened at CHW level and confirmatory at secondary/tertiary care
hospital, thereby giving full information access to healthcare providers
5. ASHAs and ANMs used the app for monitoring screening participation, loss of follow up and
treatment protocols. The app helped identifying and bridging gaps in community awareness
regarding these cancers
Awareness Overcoming informational barrier and stigma by presenting screening as a health check
about Cancer
The targeted lung health check program in the UK was a pilot project that screened lung cancer
screening
patients by framing it as a one stop-lung health check rather than cancer screening. The program
registered people aged between 55 to 74 who were smokers in one of the 14 participating GP
clinics and invited them for a lung health check at convenient community venues. Mobile CT
scanners were kept nearby shopping centers, to minimize transport cost and increase
accessibility. Participants were provided information at an early stage.
This strategy could also work for women’s cancer and breast screening purpose. Providing
women, a generic health check on specific days, such as gynecology day once a week/ month will
encourage women to report their health issues. The health check for women should include both
breast and cervical screening for cancer. Healthcare workers should also educate women about
warning signs and symptoms of the disease as well as teach self-breast examination.

Call for Action: Making quality cancer care more accessible and affordable in India 56
 Challenges Learnings from around the world
Affordability In 2004, the UK’s primary care practices began receiving financial incentives for achieving certain
and financing standards in clinical indicators related to chronic disease conditions, showing improvements in
several clinical outcomes, especially in diabetes. In the UK, the GP Quality Outcomes Framework
(QOF) was used to incentivize primary care screening. In the US, the Affordable Care Act sets out
additional incentives/payments to providers to focus on the wellness and prevention agenda.

Sources: Mobile technology and cancer screenings – A lesson from India; govt websites

Learnings from the Korean National Cancer 50% of the people in the bottom of population
Screening Program: being covered by national health insurance
premiums by 2005. Gradually, the program helped
Korean national cancer screening program is one include various communities in the cancer
of the successful screening programs that has screening program and reduce out-of-pocket
shown significant improvement across all cancers expenditure to provide free screenings. Various
in the country. The program started with covering studies done on the model clearly highlight the
public servants and private school staff in 1980, importance of national free/insurance led cancer
led to uniform increase in coverage with almost screening program.

Chart 31: Population % screened across South Korea from 2002 to 2020 showing stark improvement in screening
penetration across cancers

68.4%
58.5%
55.4% 54.8%
49.2%

36.9% 36.6%
33.1%

15.8% 14.1% 15.4%

12.7% 12.7% 10.5%

All Stomach cancer Colorectal Liver cancer Breast cancer Uterine cancer Lung cancer
cancer

2002 2020

Source: Cancer screening in Koreans – A focused group approach, Shin young Lee and Eunice E. Lee

Recommendations

Challenges Recommendations
Infrastructure 1. Using the allocated budget for not only opening all 1,50,000 HWCs by December 2022 but
and Capacity ensuring that the centers hire fully trained staff along with adequate representation of
restraint trained female staff to educate the people regarding cancer screening and early warning
signs.
2. Instituting financial model at the grass root level to incentivize CHO and their teams to
conduct effective screenings in their respective areas.
3. Hospitals must leverage technology across the patient journey for effective tracking and
monitoring of the screening program. Use of mhealth and robust data collection software
or apps empowering the ASHAs, ANMs, MOs and specialists with data regarding the
patient. A clinical decision support tool for ASHAs can help in ensuring proper data
collection as well as support ASHAs with standard screening guidelines and triaging of
patients according to risk level, promoting the most appropriate next steps.

57 Call for Action: Making quality cancer care more accessible and affordable in India
 4. Using AI based triaging and imaging tools to support CMOs and radiologists across centers
to address workforce capacity issues.
5. Use of software and IT system to create a seamless referral mechanism highlighting any
dropouts or deviations from the pathway to take appropriate actions.
Awareness about 1. Conduct-focused cancer screening campaigns in communities or localities where screening
Cancer screening coverage is very low. For instance, to-do camps in Gurudwaras targeting the Sikh
population and encourage them to get screened.
2. Vernacular language should be used in all posters while visually representing various
screening methods, signs and symptoms and information regarding different cancers in
HWCs.
3. Men have showed low screening participation across all communities as well as in urban
and rural areas. Targeted and inclusive education and information dissemination for men
will help improve screening uptake for themselves as well as their families.
4. Encourage corporate hospitals to adopt villages to enhance awareness and perform
screenings.
5. Corporates and multinational companies can host cancer screening camps in their offices
to educate and provide easy access to their staff to cancer screening. They can also
support NGOs who promote cancer screening program through outreach activities as a part
of their CSR initiatives.
Affordability and 1. Policy level changes and budget earmarking to include cancer screening as a part of
Financing various state and central government health initiatives like the Chiranjeevi scheme in
Rajasthan or PMJAY. Inclusion of diagnostic tests for cancer screening as a part of CGHS
and ECHS schemes can help utilize private sector infrastructure effectively. Estimates
indicate more than 50% of the patients use government schemes in private hospital for
their treatment in Rajasthan. This could ease out the burden on public infrastructure and
improve efficiencies of the program.
2. Government to encourage private insurance players to cover cancer screening as a part of
their offerings.

Use of technology in Cancer screening: use of technology as an aid to support national

programs. Many new startups and innovative
India has seen a major leap in the use and
companies have designed tools that can help
adoption of digital technology in healthcare during reduce the time for screening of various diseases
the pandemic. From barely using HIS to using a and provide accurate results. Some companies
mobile device to capture patient information and have worked on seamless pathways for screening,
make interventions to using AI for diagnosis, early detection, and treatment of diseases such as
innovation in digital health has taken a front seat cancers to ensure continuum of care. Some such
in the last two years. There are many use cases examples are illustrated below to highlight how
where technology was used to combat the technology can help resolve challenges regarding
pandemic around the globe. India also successfully accuracy, timeliness and workforce constraints
created a track and trace eco-system to ensure while undertaking a population based national
the safety and curb the infection rates. There has screening program.
been enough research and development on the

Call for Action: Making quality cancer care more accessible and affordable in India 58
 Case study on Qure.ai
Qure.AI, an Indian startup, has developed an AI-based lung disease screening tool, which can detect up to 30
abnormal indications in a chest X-ray. They tap into deep learning technology to provide automated interpretation
of radiology exams like X- rays, CTs and other imaging techniques. They conducted two studies, one in India and
one in Philippines, that significantly improved the case identification of TB patients in the area and reduced the time
taken to enroll these patients into a care pathway.

Year/Duration Location Sample size Results

2018 / Baran, UP, 13,000 ► Within two months of deployment, TB notification rates went
18 months India up from 67.8 to 90.14
► Increase in new TB patient enrolment from 62% to 85%
► Screening turnaround time >2 min
► Reduction in enrolment in treatment by 2.5 days
► Decrease in drop out of presumptive patients to TB enrolment
from 72% to 53%
Philippines 2,00,000+ 8,700 TB patients diagnosed were put under TB regime. TB
screening results shared in less than 1 min
resulted in same day confirmatory test, which otherwise spanned
from 0-2 weeks.

Qure.ai has trained this AI algorithm on 35 lakh patient scans to identify at least 30 abnormal lesions including
malignant lesions in a chest X-ray. It is now used to screen patients for lung cancer who have already got a chest
X-ray done.

Qure.AI in collaboration with AstraZeneca has screened over 46,000 X-rays in 90 countries to identify 8% nodules
incidentally.

With diagnostic labs doing huge no. of X-rays in the country for preventive health checks in private hospitals and for
TB screening at government level, just having an AI-algorithm screen these X-rays for Lung Cancer can act as a
screening tool to investigate further.

Country Institute Usage

Malaysia Qualitas medical group- a Uses the AI algorithm to triage all chest X-rays taken of local workers,
GP practitioner- chain trying to identify incidental lung nodules indicative of cancer.
India Assam Cancer Care Suspicious nodules are detected though the AI algorithm in chest X-rays
Foundation, Assam taken for individuals screened during door-to-door screening program
India VPS lakeshore hospital, Facilitating early lung cancer changes in all Chest X-rays taken in the
Kerala hospital

Case study on learnings from CoWIN/COVID-19

To combat COVID-19, government bodies across the world quickly adopted to digital technology to
track, trace, and prevent covid infections from spreading. Arogya Setu was a good example of 21.7
crore people downloading the app to be a part of India’s mission to fight against COVID-19. It not only
tracks and traces the infected patients but also provides information about signs and symptoms,
prevention, and treatment protocols to follow. During the first phase of pandemic when there was a lack
of understanding about the disease, the app helped people to be informed about their risk status and
even undertake an assessment if you felt you had some symptoms. This is the first time we witnessed
end to end digitization of the diagnostic players, both public and private, and becoming part of the
digital ecosystem developed and monitored by the Indian government.

To fight with the upcoming cancer epidemic, we will need to leverage the penetration of mobile phones
to our advantage. Creating a longitudinal, multi-stakeholder platform for registration, screening,
treatment, and monitoring will be vital in this process.

59 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 32: Illustrative patient pathway using technology

Screening is done
based on the standard
government
guidelines and result
entered in the app

CHW/ ASHA at PHC level or Uses cancer triaging app to

nurse at hospital level register identify high risk patients
the patient on cancer screening through AI-based symptom
app using Aadhaar card/ AB id checker and risk profiling
card and helps the patient to
download the same app on their
mobile phone Result Patient receives
Positive notification about the
screening result on
► Government receives information about their phone/ cancer
patients tested positive for tracking their screening app
treatment initiation and compliance
► Government uses data to strengthen
screening programs, budgeting resources,
and introducing policies supporting cancer Result
early detection and treatment Negative
► Moves to the queue for
next check-up based on
recommended
frequency/ duration.
► Receives information
about signs and
symptoms to watch out
► CHW or CMO or Staff nurse, guides for and self -
the patient to the nearest higher examination (if any)
center for confirmatory test. ► Information about
Strengthen the referral system by nearest center for
raising request online. screening based on
► The patient on his mobile app their location
• Receives information on
confirmatory test received on
mobile app
• Location of nearest center for
referral and testing listed in the
app/ appointment taken
• Information on treatment At hospital
options, financial support, ► The doctor receives the complete information about
disease progression, mental screening test and risk profile on the app using the same
health helpline etc., provided on identifier used for patient registration.
the app ► Confirmatory tests are performed, and results uploaded on
the app.
► Treatment initiated for positive patients and regime
uploaded on the app
Patient
► Based on result patient received updates on the next
screening date or supportive information about the disease
treatment options, nearest treatment centers, financial
support etc.
► All patient treatment prescriptions/ discharge summaries are
uploaded on the app for patient as well as doctors to view.

Call for Action: Making quality cancer care more accessible and affordable in India 60
Table 19: Possible technology interventions in the patient journey to make cancer care affordable and accessible

Challenges Solution Technology Impact Illustrative examples

Significant gap in Awareness Digital , AI Patients Saathhealth – adoptive AI powered
awareness about generation platform to improve health outcomes
cancer risks, through targeted CancerU- An online membership platform
symptoms and messaging for cancer patients and cancer caregivers
warning signs to educate, empower, and engage them to
become advocates for their healthcare.

Awareness
Absence of Point of care AI, ML Patients, Nirmai.AI – Handheld and home care point
testing in devices for easy providers of care device used for breast self
screening and faster and examination to screen for breast Cancer.
program screening Community Zilico – Handheld point of care device for
programmes screening cervical cancer, that delivers
result in minutes with the quality of a Pap
Screening Smear
Method
Lack of trained Machine learning CDSS and ML Providers Qure.ai- Imaging based AI algorithm that
specialists for algorithms and can help identify abnormal lung finding
diagnosis, e.g., clinical decision indicative of malignant changes
radiologist support tools that
can help reduce
the specialist's
burden
Diagnosis
Lack of access to Use of technology Digital Providers Onward Assist- AI-based digital
quaternary care for information pathology pathology
settings or expert sharing and and Mfine; eSanjeevni- Video teleconsultation
oncologists second opinion telemedicine platform to take a second opinion from
across the platform renowned oncologist
country
Second
Opinion
Lack of clinical App/ digital Digital Community Karkinos – technology-led platform for
pathway to track platform platform that programme oncology that can help patients take a self
the patient cuts across and assessment, supports the patient through
journey from all patient providers the journey of confirmed diagnosis to
screening, touchpoints helping in finding the nearest treatment
diagnosis and centers and doctor.
Clinical treatment
Pathways
Lack of a Automation of AI Proivders Simbo.AI – AI-based dr assistant using
standardised patient records, speech to text technology for intelligent
platform not including clinical record keeping
record patient data and findings Augnito.Ai- AI-based speech to text
details and technology
Patient medical records
health to be used across
record care settings
Adequate Use telemedicine Telemedicine HCP’s eSanjeevni – Video consultation platform
training for HCP’s platform to used during Covid to train doctors in Tier
initiate training 1 and 2 cities on covid treatment
from experts protocols. Can be used to train ASHA,
across public and ANM’s and CHO’s at HWC’s
private
organisations
Training

61 Call for Action: Making quality cancer care more accessible and affordable in India
Chapter 2C: Treatment

(i) Treatment - Access

To provide optimal treatment to patients, there is to six years at a CAGR of ~8% (in 2016, 275 to
a need for centers which provide holistic and 325 CCCs were present in India) 46, there still
multidisciplinary treatment options to patients exists significant geographic skew in access of
across treatment modalities such as medical, patients to multi-modal treatment options.
radiation and surgical oncology. Typically,
70% of the CCCs are in Western, Southern and
“Comprehensive Cancer Centres” provide all these
Northern India, which has 43% of population.
treatment modalities under one roof and are often
Northeast with 4% of population has around 3% of
supported by robust diagnostic services including
CCCs. The most underserved areas are Central
radiology services, advanced lab services, such as
and Eastern India with 54% of the population but
immunohistochemistry, molecular diagnostics
with only 27% of CCCs 47.
etc., and nuclear medicine facilities.
Bihar, Jharkhand, Uttar Pradesh, Odisha and
Comprehensive Cancer Centres in India are
Assam are the top five states with least
skewed towards the Southern, Western and
penetration of CCCs in India.
Northern parts of India.

An analysis of centers providing all three

modalities of cancer treatment in India highlights
that there are 470 to 480 Comprehensive Cancer
Centres (CCCs) in India out of which ~200 also Cancer care in India needs to see
provide PET-CT services 44. Around 25 to 30% of penetration in many underserved areas of
the CCCs are government-owned while the rest the country. This area of clinical care is
are either private or trust-based facilities. rapidly becoming a strong need for early
diagnosis and effective prevention.
Additionally, only 135 - 160 of 681 medical
colleges (60% of these 135 - 160 medical colleges Dr. Nandakumar Jairam
are government-owned) 45 offer comprehensive Advisor, Sheares Healthcare and independent
cancer care in India. While there has been an consultant
increase in the number of CCCs over the last five

44 “List of Cancer Treatment Centres licensed by AERB”, 46“Call for Action: Expanding cancer care for women in India” FICCI
aerb.gov.in, February 2021, “List of Nuclear Medicine Facilities (FLO) EY report, 2017
licensed by AERB”, aerb.gov.in, March 2021, EY analysis 47Census 2001, Census 2011, EY analysis
45 nmc.org.in, EY analysis

Call for Action: Making quality cancer care more accessible and affordable in India 62
Figure 4: Map depicting state-wise penetration of CCCs

Source:
1. “List of Cancer Treatment Centres licensed by AERB”, aerb.gov.in, February 2021
2. “List of Colleges teaching MBBS and PG Courses”, National Medical council, NMC.org.in
3. “Population of India as per census 2011”, Censusindia.gov.in, Census2011.co.in
4. EY Analysis

Zone States
Central Chhattisgarh, Madhya Pradesh, Rajasthan, Uttar Pradesh
East Bihar, Jharkhand, Odisha, West Bengal
North Delhi, Haryana, Himachal Pradesh, Punjab, Jammu and Kashmir, Ladakh, Uttarakhand
Northeast Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura
South AP, Kerala, Karnataka, Pondicherry, Tamil Nadu, Telangana,
West Maharashtra, Gujarat, Goa

63 Call for Action: Making quality cancer care more accessible and affordable in India
The penetration of CCCs is skewed toward ~1.3 per 1,000 people 51 against 2.9 per 1,000 in
metros and state capitals leading to travel and the US, 4.3 per 1,000 in China and 13.0 per
temporary relocation requirement for getting 1,000 in Japan52. Industry average capital
comprehensive cancer treatment. expenditure per bed 50 to 80 lakhs in metro/Tier
1 cities and 30 to 35 lakhs in Tier 2 cities 53, 54.
The top eight major metros (Delhi, Mumbai,
Assuming bed addition requirement mainly in Tier
Bangalore, Chennai, Hyderabad, Kolkata, Pune
2 cities total capital expenditure for addition of
and Ahmedabad) contribute to ~30% of CCCs and
35,000 to 40,000 beds would range from
the rest of the state capitals further contribute
INR10,500 crores to 14,000 crores 55. This
~10% of CCCs. Of the 640 districts in India as per
estimate excludes the cost of land and cost of high
Census 2011, only ~175 districts have CCCs.
value medical equipment such as radiotherapy
These 175 districts cover 40% to 45% of the
machines and PET-CT machines. The above
population, thereby necessitating balance ~55% to
estimate is based on cancer incidence crude rate
60% of population to travel outside their districts
CAGR of ~10%, which considers the impact of
for comprehensive cancer care treatment44.
increase in screening and diagnosis. At a
conservative 5% growth in incidence crude rate,
there will be an additional requirement of 7,000 to
10,000 day-care beds and ~12,000 surgical beds
requiring an outlay of INR6,000 to 11,000 crores
Focus needs to be on rapid increase in
by 2030.55
cancer care infrastructure outside of the top
20 cities in India. Government has good Private sector has made rapid strides in improving
health insurance schemes for the needy.
access by setting up network of Comprehensive
Proper reimbursement rates and prompt
Cancer Centres across different cities in India.
payment cycle will encourage private
players to set up the infrastructure in the
required geographies.

Rushank Vora
Director (Partner), ICICI Venture Cancer incidence across various forms is
ballooning. This is happening across age
groups. Given the lifestyle patterns this is
likely to be one of the biggest focus areas for
With significant growth in incidence and with 40% healthcare. Private investments in helping
of new cancer patients 48 requiring comprehensive build diagnosis and treatment capabilities
cancer treatment across all three modalities, it is will go a long way in providing better
quality lives for cancer patients. Multi-
necessary that India add another 572 CCCs by
specialty hospitals building cancer care
2030 for seamless cancer treatment 49.
capabilities through linear accelerators, and
Considering all reported cancer patients are medical and surgical oncology programs are
currently being able to avail treatment, the key to both early detection and treatment.
incremental load forecasted will require an
additional 10,000 to 15,000 day-care beds and Puncham Mukim
~25,000 surgical beds 50. This will add further Managing Director, Everstone Capital
pressure on availability of hospital beds, which is

48 “Call for Action: Expanding cancer care in India”, EY, July 2015 53 “JST investments- KIMS Hospital – IPO – Review”, JST

49 EY analysis. Refer Annexure 9 for assumptions Investments.com, June 2021

50
54“Re-engineering Indian healthcare 2.0”, FICCI EY, August 2019,
EY analysis. Refer Annexure 7 for assumptions EY analysis
51 Protecting India: Public Private Partnership for vaccinating
55 EY analysis
against COVID-19, FICCI EY report, 2020, EY analysis
52 Hospital beds (per 1000 people), data.worldbank.org

Call for Action: Making quality cancer care more accessible and affordable in India 64
Table 20: Comprehensive cancer network by key players in the private sector

Hospital Cities Comprehensive Cancer Centres Geographical coverage

Andhra Pradesh, Gujarat, Jharkhand, Karnataka,
HCG 19 21 (31 LINAC)
Maharashtra, Odisha, Rajasthan, West Bengal
Andhra Pradesh, Chhattisgarh, Gujarat, Maharashtra,
Apollo 12 13 (23-25 LINAC)
NCR, Odisha, Tamil Nadu, Telangana, UP, West Bengal
Chhattisgarh, Jammu and Kashmir, Karnataka, NCR,
NH 9 10
Telangana, West Bengal

Fortis 7 8 Karnataka, Maharashtra, NCR, Punjab, West Bengal

Manipal 6 6 Andhra, Goa, Karnataka, NCR, Rajasthan,

Max 5 9 NCR, Punjab

Sterling 4 4 Gujarat

Aster 2 2 Karnataka, Kerala

Medanta 1 1 NCR

KIMS 1 1 Kerala

Source: “List of cancer treatment centres licensed by AERB”, aerb.gov.in, HCG Investor presentation, August 2022

Comprehensive cancer care requires early detection infrastructure, leveraging Tumour

boards for personalized and effective treatment, and digital interventions geared towards
holistic patient engagement. CVC’s investment in HCG is towards promoting this philosophy
and delivering high quality cancer care at affordable prices. CVC remains keen to play a
broader role in India’s healthcare sector development.

Amit Soni
Partner, CVC Capital Partners

65 Call for Action: Making quality cancer care more accessible and affordable in India
 HCG’s Hub & Spoke model

Oncology focused healthcare chain, HCG serves a population base of 64 crore with presence in 9 states
and 19 cities through its network of 21 Comprehensive Cancer Centers. Two-third of its Centers are in
Tier 2/3 towns. Their flagship unit in Bangalore acts as the hub while the facilities in smaller cities, Tier
2/3 towns act as spoke. This hub and spoke model not only lower the physical movement of patients but
also helps transfer the knowledge gained through groundbreaking work done at its Center of Excellence
to the spokes. HCG started entering Tier 2/3 cities almost two decades ago and has gradually
strengthened all its centers with upgraded technologies, thereby making all its centers comprehensive
as cancer care requires a multi-disciplinary approach to treatment. HCG is a pioneer in making Linear
Accelerators available in smaller cities, and with total 31 LINAC installations it has established the
largest base of LINACs in the country provided by any private hospital chain benefiting large number of
cancer patients across the country. To address standardization of cancer care, HCG established central
Multi-Disciplinary Tumor Board at its Hub in Bangalore. HCG organizes Multi-Disciplinary Tumor Board
reviews every week to discuss difficult and complex cases where over 250 oncologists across India
participate. The Centers in Tier 2 cities provide treatment locally with the central medical physicist team
in the hub performing the radiation treatment planning. Remote reporting of PET-CT through RIS PAC
leverages the talent in the Center of Excellence to provide quality diagnosis and treatment at the
spokes. To further ease patient inconvenience of regular travel to seek treatment, HCG is setting up
chain of day-care chemotherapy centers. It currently has total of 9 day-care centers in the states of
Karnataka, Gujarat and Odisha. The company is expected to launch first day care center with radiation
facility in Bangalore in the fiscal year 2025.

Figure 5: HCG’s Multi-Disciplinary Treatment (MDT) approach that ensures better outcomes for each patient

Call for Action: Making quality cancer care more accessible and affordable in India 66
Figure 6: HCG’s class leading Multi-Disciplinary Tumor Board – planned, programmed and result oriented

Medanta’s cancer care model

Medanta’s Multi-disciplinary Care (MDC) model of cancer treatment extends beyond the usual definition
of combining surgical oncology, medical oncology, and radiation oncology. The model builds and
increases inter-departmental synergy to optimize treatment for each cancer case through a Disease
Management Group, or DMG, that comprises experts from the Cancer Institute and other super-
specialties. This mix of clinician changes from case to case depending on the patient’s unique needs that
are defined by disease progression, co-morbidities, underlying conditions, genetics, and other
vulnerabilities.
A typical treatment team includes oncologists, site-specific cancer surgeons, radiation experts,
transplant surgeons, reconstruction surgeons, radiologists and pathologists, supported by physicians,
super-specialty nurses, dieticians, rehabilitation therapists, psychologists and pharmacists. The DMG
draws up the most optimal, holistic treatment plan and ensures 100% execution under one roof thanks
to the availability of high-end diagnostics, advanced therapies and cutting-edge robotic surgical
technologies.
Medanta’s patient-first approach also reflects in its unique architectural planning that places all facilities
on the same floor increasing convenience by minimizing patient movement. The hospital also assigns a
Case Manager who handholds the patient throughout their treatment journey at every touch-point. The
goal is to deliver the best possible end-to-end cancer treatment while also empowering patients to
maintain their quality of life.

67 Call for Action: Making quality cancer care more accessible and affordable in India
 viability gap fund of INR118 crore and fixed
grant of INR15 crore at attainment of
operational capacity
Transformation in cancer care will only
happen when the government notifies Similarly, to encourage private investment in Tier
cancer as a notifiable disease, this will help 2 and Tier 3 cities and to treat patients under
realise the actual magnitude of the burden. PMJAY, the Indian government launched a
The paradigm shift in oncology practice is Viability Gap Funding (VGF) scheme 57 under which
taking place, one that was technology and private players will be incentivized with land
clinician dependent, to now a patient allotment, facilitated with various clearances
centric one, the future is an oncologist for within specific timelines and 40% VGF of project
your cancer type. The cancer management
costs. Under the scheme, private players are
teams for your cancer type is a reality today
expected to build, design, finance, manage,
and this ensures superior outcomes, one
that enables patients to win over cancer,
operate, and maintain the facilities with quality
Apollo Cancer Centres is emblematic to this. standards and provide services under PMJAY.

While these VGF schemes seem to incentivize

Dinesh Madhavan
President- Group Oncology and International, Apollo
private players to invest in Tier 2 and Tier 3
Hospitals Enterprise Ltd markets, we are yet to see success stories
emerging out and there has been no notable
mention of project completions under the schemes
till date. Faster decision making by government
To enable the private sector to further access, the
authorities in granting approvals under the
government should provide required capital
schemes would be a key enabler to drive capacity
support through Viability Gap Funding (VGF) /
creation at the last mile.
Public Private Partnership (PPP).
Penetration of Radiotherapy (RT) equipment
Odisha government in 2018 launched an
closely follows that of CCC distribution. As of
affordable healthcare project with an aim to set up
2021, the number of RT per million population
100 to 200 bedded hospitals in 25 identified
stands at 0.4 against the WHO recommendation
locations through PPP model 56. The private
of 1 per million.58
players will design, finance, build and operate the
hospital for period of 32 years before transferring Developed countries such as the US, Japan,
the asset to the government. The Government in Germany, Italy, France have RT equipment
turn will provide unencumbered land, facilitate penetration of 2.6 to 7.6 RT per million population
approvals, and provide viability gap funding while fellow BRIC nations — Brazil, Russia, China
support for the first 5 years of operations. are in the range of 0.8 to 1.1 indicating significant
need for addition of Radiotherapy equipment in
► For 100 bedded spokes, a fixed viability gap
India given that 50 to 60% of cancer patients
fund of INR14 crores, Maximum additional
require radiotherapy treatment as per
viability gap fund of INR79 crores and fixed
International Atomic Energy Association (IAEA)
grant of INR6 crore at attainment of
guidelines.
operational capacity
► For 200 bedded hubs, a fixed viability gap
fund of INR51 crores, maximum additional

56 “Affordable Healthcare Project” Odisha.gov.in, September 2019 58 Munshi A, Ganesh T, Mohanti BK. Radiotherapy in India: History,
57 “Broad Guidelines for Private Investments in setting up of current scenario and proposed solutions. Indian J Cancer. 2019
Hospitals in Tier 2 and Tier 3 cities subsequent to PMJAY”, Press Oct-Dec;56(4):359-363. doi: 10.4103/ijc.IJC_82_19. PMID:
Information Bureau, Pib.gov.in, January 2019 31607709, EY analysis

Call for Action: Making quality cancer care more accessible and affordable in India 68
Chart 33: Penetration of RT equipment across different countries

RT per million
US 7.6
Japan 6.1
Germany 3.5
Italy 3.2
France 2.6
Russia 1.1
Brazil 1.0
China 0.8
India 0.4

Source: “World population”, worldpopulationreview.com, “Directory of radiotherapy centres”, Dirac.iaea.org, EY analysis

While WHO recommends a norm of 1 RT per machine) and minimal distance required to be
equipment per million population58, an assessment traveled by patients to avail treatment also
of factors, such as current and future cancer highlights that 1 to 2 RT equipment would be
incidence projection of India, typical RT equipment required per million population.
productivity (i.e., number of patients to be treated

Chart 34: Framework for assessment of optimal RT requirement basis machine capacity, number of fractions per
patients and incidence of cancer

2022 2030

On average, 70 -100 fractions are done in each On average, 100 fractions are done in each RT
RT per day per day

@25 fractions per patients, 560 - 800 new @20 - 25 fractions per patients, 800 - 1000
patients can be treated per annum new patients can be treated per annum

With 60% of new patients eligible for RT. 950 – With 60% of new patients eligible for RT. 1,300
1,350 cancer patients can be addressed – 1,700 cancer patients can be addressed

With incidence of 120 per lac, 7.5 - 11 lakhs With incidence of 260 per lac, 5 – 6.5 lakhs
population can be addressed population can be addressed

~1 per million ~1.5 – 2.0 per million

Source: EY analysis

With availability ~640 RT installations in the Even with newer technologies enabling quicker
country currently, there is a requirement of ~850 methodologies to treat the patients with 20
to 900 additional RT installations in the current fractions against 25 fractions with the same
state59 to meet the population coverage criteria equipment63, the number of RT equipment/ million
which is expected to further grow given the requirement will still move from 1 per million to
expected increase in the number of cancer cases 1.5 to 2.0 million in the next 8 to 10 years.
in the next decade.

59 EY analysis. Refer Annexure 5 for assumptions

69 Call for Action: Making quality cancer care more accessible and affordable in India
In absolute terms, we need to add another 890 RT therapies, such as CyberKnife, Gamma Knife,
equipment immediately and ~3,200 RT equipment SBRT, and Tomotherapy (Level 1). Therefore, in
by 203059 considering ease of access to patients, order to drive effective utilization of installed
optimal utilization of equipment, and operational equipment, efficient capital management, efficient
life of the equipment. The addition of 50 to 60 RT deployment, and utilization of available skilled
per annum 60, which is the current trend, will not clinical resources, the government can consider a
address the wide gaps that the country is facing three-tier model, wherein they ensure level 3
today or expected to face going forward. There is LINAC in each district cluster with >10 lakh
a need for an average addition of ~400 population and a level 2 equipment for three such
equipment every year59 for the next eight years clusters and Level 1 equipment in state capitals
to bridge the demand-supply gap. It is pertinent to and key cities such that it forms 5% of the total
note that if all 681 medical colleges in the country installed capacity.
add LINACs to the tune of 500 to 550
The addition of equipment, even in a tiered model,
installations, there will be availability of RT
requires huge capital outlay, which is estimated in
equipment in ~334 districts out of 640 districts59
the range of ~INR40,000 to 45,000 crores with
in the country which is a near two-fold increase in
LINACs costing anywhere between INR12 to 20
the district coverage of RT equipment vis-à-vis
crores 61, 62 depending on its features and
current state (currently ~175 districts are being
functionalities. The capital outlay covers the cost
covered by RT equipment).
of the imported equipment and associated 30%
Further basis discussions with key radiation import duty. Additionally, the healthcare service
oncologists, therapies such as IGRT, IMRT, 3D CRT provider needs to invest in physical infrastructure
(Level 3) can manage 80 to 85% of RT cases while to house the equipment in line with AERB
another 10% will require therapies such as VMAT requirements.
(Level 2) and only 5% of cases require advanced

Table 21: Summary of RT Equipment and capital outlay requirement

2022 2030
Capital Outlay Capital Outlay
Type of RT Equipment Count required (INR Cr) Count required (INR Cr)
Level 3 (IGRT, IMRT, 3D CRT) 750-800 9,300-10,000 2,650-2,700 33,100-33,700
Level 2 (VMAT) 65-70 1,050-1,150 300-320 5,000-5,300
Level 1 (CyberKnife, Gamma
55-60 1,150-1,250 170-175 3,500-3,650
Knife, SBRT, Tomo)
Total 850-900 11,500-12,400 3,100-3,200 41,500-42,650

Source: EY analysis

The count required can be further optimized by twice of what has been estimated in the above
~20% if we are able to treat patients with lesser table.
number of fractions (@20 against the current
The above estimate is based on cancer incidence
@25) 63. The count required has been computed
crude rate CAGR of ~10%, which considers the
assuming complete utilization of LINAC with ~100
impact of increase in screening and diagnosis. At a
patients getting treated per day. Underutilization
conservative 5% growth in incidence crude rate,
of equipment with ~50 patients getting treated
there will be an additional requirement of ~2,200
per day would take the LINAC requirement to
RT equipment by 2030 mandating an average

60 EY analysis 63 Tibdewal, Anil et al. (2022). Impact of the First Wave of COVID-

61 “In Pune, Rotary International’s first woman president says India 19 Pandemic on Radiotherapy Practice at Tata Memorial Centre,
is now a ‘help-giving nation’”, ww.indianexpress.com July 2022 Mumbai: A Longitudinal Cohort Study. JCO Global Oncology. 8.
62 “Kamakshi Hospitals gets radiotherapy facility”, www.hindu.com,
10.1200/GO.21.00365
August 2021

Call for Action: Making quality cancer care more accessible and affordable in India 70
annual addition of ~275 equipment every year treatment. India has ~5 CT scanners per million
with a minimum capital outlay of ~30,000 population compared to 40 in high-income
crores.59 countries and ~13 in upper middle-income
countries 64. Further, there is a skew towards Top
8 Metros contributing to ~23% and state capitals
another 10%.65
Early screening, access to high-quality PET-CT can help in making more accurate
advanced diagnostics coupled with diagnosis, thereby helping in better treatment
personalized healthcare (precision
planning leading to improved outcomes and
medicine) can help in delivering equitable
survival rate. Unlike CT and MRI, which show
and better patient treatment outcomes in
cancer patients. Precision Oncology anatomic detail, PET images show biochemical or
Diagnostics will play a pivotal role in physiologic phenomena. PET can often distinguish
guiding physicians/oncologists to make between benign and malignant lesions which CT
effective treatment decisions at the right and MRI cannot. Studies typically have indicated
time, increasing the chances of patients’ 4% to 15% improvement in overall accuracy of
survival, and reducing the economic burden staging/restaging and a 30% to 50% improvement
of patients on treatment costs. Besides, we in the confidence of lesion localization 66. India has
need to address the lack of awareness 0.25 PET–CT scanners per million population 67
among masses on the diagnosis and
while the developed countries such as the US,
treatment front. Collaboration between
Australia and many West European countries have
government stakeholders and private
healthcare players across the ecosystem can 3 PET–CT scanners per million population68. While
help in addressing this critical gap. high capital expenses are a major inhibitor in
‘Affordable’ cancer diagnostics and equipment addition, operational challenges and
treatment is another crucial area which expenses are a barrier to scale up as follows:
needs to be looked upon, as this has been a
bottleneck in delivering quality cancer care ► AERB regulation mandates trained staff for
for all. nuclear medicine facilities operating PET-CT
equipment. With limited medical colleges
Ameera Shah having a PET-CT, trained staff are in short
MD, Metropolis Healthcare Limited supply. 14 colleges offer 67 MD–nuclear
medicine seats and 13 colleges offer 35 DNB –
nuclear medicine currently69.
► With not all the PET-CT service providers
The availability of screening, diagnostic and
having in-house cyclotron for isotopes (there
treatment support equipment, such as CT, PET-
are only 19 medical cyclotron facilities 70 in the
CT and Mammography, is also highly under-
country), extensive air connectivity becomes
penetrated in India requiring significant ramp up.
key, as isotopes need to be supplied within 3
There is a wide usage of CT for cancer detection to 4 hours. Given the low half-life of the FD-G
and treatment in many ways. It is helpful in cancer (~110 minutes) 71, wastage is on the higher
screening, diagnosing the presence of tumor, side.
cancer staging, guiding biopsy procedures,
► Radiopharmaceuticals were part of Schedule K
guiding local treatments, such as radiofrequency
of Drugs and Cosmetics Act and Rules (As
ablation, planning external beam radiation
amended up to the 31 December 2016) 72. The
therapy/ surgery and determining response to

64 “Computed tomography (CT) scanners”, data.oecd.org 68 PET Scanner (per 1 million) humanhealth.iaea.org
65“List of Licenced X-ray facilities”, aerb.gov.in, Aug 2022, EY 69 Accr.natboard.edu.in, nmc.org.in
Analysis 70Sharma AR. Nuclear Medicine in India: A Historical Journey.
66Griffeth LK. Use of PET/CT scanning in cancer patients: technical Indian J Nucl Med. 2018 Nov;33(Suppl 1):S5-S10. doi:
and practical considerations. Proc (Bayl Univ Med Cent). 2005 10.4103/0972-3919.245053. PMID: 30533977; PMCID:
Oct;18(4):321-30. doi: 10.1080/08998280.2005.11928089. PMC6243721
PMID: 16252023; PMCID: PMC1255942 71Fludeoxyglucose F 18 Injection, www.accessdata.fda.gov
67“List of Nuclear Medicine Facilities licensed by AERB”, 72“Drugs & Cosmetics rules, 1945 (As amended up to the 31st
aerb.gov.in, March 2021, EY analysis December,2016)” Ministry of Health and Family Welfare

71 Call for Action: Making quality cancer care more accessible and affordable in India
 act exempts the items under Schedule K from and 840 PET-CT systems by 203075 at a capital
measures covered in the Chapter IV. The outlay of INR700 to 850 crores 76 immediately and
treatment of radiopharmaceutical items in the INR5,000 to 6,000 crores by 2030. While this
Drugs, Medical devices and Cosmetics Bill, estimate is based on cancer incidence crude rate
202273 will be clear with the introduction of CAGR of ~10%, even at a conservative 5% growth
the new bill in parliament. If the new bill makes in incidence crude rate, there will be an additional
batch controls and drug licenses mandatory, it requirement of ~460 PET-CT equipment by 2030
will further impact the operating cost incurred requiring a capital outlay of ~3,200 crores75.
by nuclear medicine facilities. Coverage of PET-CT service as a separate
procedure for reimbursement under all
► While PMJAY covers PET-CT, some of state
government sponsored schemes as well as
insurance schemes (MJPJAY, Telangana
inclusion of PET-CT in OPD setting with cashless
Arogyashri, Arogya Karnataka, Swasthya
reimbursement under private health policies will
Sathi) have no provision to cover PET-CT
be one of the key enablers to attract investment in
related expenses as part of the scheme
PET-CT capacity creation for the country.
reimbursement separately110, 109, 112, 107.
Consequently, often centers providing Mammography, another equipment, used for
treatment under these schemes do not offer screening and diagnosing breast cancer can help
PET-CT scanning as part of the diagnostic reduce deaths from breast cancer among women
protocol, which not only inhibits demand and aged 40 to 74 years at who are at average risk of
hence investment in capacity creation but it breast cancer, with the evidence of benefit being
also likely to impact clinical decisions on right strongest for women aged 50 to 69 years 77. India
treatment protocols and hence outcomes. has ~1.7 mammography equipment per million65
Also, while private health insurance policies, population compared to 70 in the US, 65.1 in
with provision of claiming pre and post Korea, 33.8 in Japan and 20 in Australia 78. While
hospitalization expenses, might cover for PET- penetration at the overall level is low, there is a
CT but in most cases, the insurers do not huge skew toward metros, with top eight metros
provide cashless coverage for PET-CT contributing to 35%65.
services. Additionally, patients covered under
private insurance policies are in most cases Advanced diagnostic tests such as flow cytometry,
unable to claim for PET-CT services if the IHC, cytogenetics and molecular diagnostics, are
hospitals do not admit them as IP patients. highly skewed toward the North and Western India
having 60% revenue share while East and
On a conservative basis, if we assume 50% of new Northeast being lowest with 18% revenue share.
cancer patients require PET-CT with each one of Top 7 metros contribute to 70% to 80% revenue
them requiring three scans for staging, interim from these tests. Digital pathology is yet to take
response evaluation, and response evaluation at off in a significant way with the current share
treatment completion74, we require a total of 480 being negligible. Huge capital requirement
PET-CT systems currently and ~1,200 PET-CT upwards of INR1 to 1.25 crores for scanners is
systems by 2030. With ~360 installed PET-CT acting as an impediment for adoption of digital
facilities67, this will translate to incremental pathology79.
requirement of 120 PET-CT systems immediately

73 “New Drugs, Medical devices and Cosmetics Bill, 2022”, 77 Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for

prsindia.org breast cancer. JAMA. 2005 Mar 9;293(10):1245-56. doi:

74 Khan SH. “Cancer and positron emission tomography imaging in 10.1001/jama.293.10.1245. PMID: 15755947; PMCID:
India: Vision 2025”, Indian Journal of Nuclear Medicine, Volume PMC3149836
31, Issue 4, Page 251 – 254, 2016 78 “Mammography machines”, data.oecd.org
75 EY analysis, refer Annexure 6 for assumptions 79 EY analysis
76“Cancer imaging using PET-CT: Genesis and current state in
India”, Express healthcare, Jan 2018, EY Analysis

Call for Action: Making quality cancer care more accessible and affordable in India 72
 Improving access to cost effective and accurate diagnostics for Tier 2 cities — Dr Lal

Dr Lal PathLabs (LPL) has a strong network of 277 labs, 4,700+ patient service centers and 10,000+
sample pickup-up points covering more than 1,500 cities. LPL offers a wide menu comprising 250
different tests in oncology, of which 190 tests are genomic tests.

Hub and Spoke model: Hub lab with expanded test menu cover all immunoassay and cancer screening
tests and services tier 2 cities with quality diagnostics at cost effective pricing.

Digital Histopathology: LPL processes up to 1,400 samples a day at its histopathology center in its
National Referral Lab. Histopathology centers are operational at eight different locations.

LPL led the path in ‘Digital Histopathology’, as the first lab in India to install a high throughput whole
slide image digital scanner. This tele-pathology platform holds the key to making histopathology future
ready, more efficient, and scalable. The labs across the country can train themselves and prepare
histopathology slides and upload these images on the digital platform which the specialists and experts
in LPL’s histopathology centers can analyze.

Preventive screening for cancer as part of common panels: Test panel includes Prostate-Specific
Antigen (PSA) Test, Pap smear, cervical screen, etc., which addresses screening requirement of high-
risk group.

Leveraging AI for better accuracy: LPL has partnered with Ibex Medical Analytics to offer a Prostate
TRUS Biopsy AI Panel with reflex to IHC that eliminates the need for a second opinion. LPL also utilizes
AI for Digital Breast Cancer Panels with quantitative measurements of biomarkers and
microphotographs in the report.

Precision oncology, an emerging field which will not help in cancer cure. Of the patients on
involves molecular profiling of tumors to identify whom the precision medicine is done, targetable
targetable alterations, and which is realized mutation is identified in 30% to 40% of cases for
through advancement in genomics and data which treatment is available. 80% of these
science, is advisable for all advanced stages of patients who undergo targeted treatment realize
cancers. For 60%+ cases in India, the detection excellent outcomes 82.
happens in late stages 80, 81, where surgery alone

4basecare is a precision oncology company with a vision to make technology accessible and affordable.
The company endeavors to offer the gene test panel at the rate of PET- CT scan, which is about 1/10th
cost of gene panel available in the market. It has so far succeeded in reducing the price by 1/4th of
market which it has achieved through import substitution of consumables and machinery used in the
process and by process and protocol optimization. 4basecare has been able to indigenize part of the
process while it still relies on the imports for DNA extraction and sequencing.

75% of the oncologists in the US use genomics as outcome, the treatment decisions in the future
a tool of treatment wherein In India 83, genomics is could be more data based rather basis empirical
leveraged only on 1% of eligible population. evidence as it is today.
Insurance companies and the government should
With high levels of under penetration, there
play a role in including these advanced tests in
should be a focus toward encouraging investment
their panel and offer coverage. With more
towards CT, PET-CT, MRI, mammography and
information and data being generated on the
molecular diagnostics. Further, these tests need
Indian genome, kind of mutation, treatment and
to be brought under insurance schemes such that

80 82 Discussions with industry stakeholders

Cancer prevention and control in India,
https://main.mohfw.gov.in/ 83 Freedman AN, et al. Use of Next-Generation Sequencing Tests
81Mathur P, et al. Cancer Statistics, 2020: Report from National to Guide Cancer Treatment: Results From a Nationally
Cancer Registry Programme, India. JCO Glob Oncol. 2020 Representative Survey of Oncologists in the United States. JCO
Jul;6:1063-1075. doi: 10.1200/GO.20.00122. PMID: Precis Oncol. 2018 Nov;2:1-13. doi: 10.1200/PO.18.00169.
32673076; PMCID: PMC7392737 PMID: 35135159

73 Call for Action: Making quality cancer care more accessible and affordable in India
patient can avail these services in outpatient WHO norm of 1 per 100085. With the Indian
setting through inclusion of these services as part medical education system able to successfully
of a National Consensus based Standard double the number of MBBS positions during the
Treatment Protocol/ Standard of Care. recent decades to 91,927 MBBS seats 86, India
shall meet and maintain the WHO norm in the next
Incidence per clinical oncologists at 315 is high
few years, although geographical skew in the
compared to 120 of China and 137 of the US.
availability of doctors is likely to continue.
While there are adequate radiation oncologists,
However, the situation with the availability of
huge gap is seen in current count of medical and
oncologists is not encouraging. As per our
surgical oncologists against the requirement.
estimates, there are 3,500 radiation oncologists,
With 15 lakh doctors 84 registered with the state ~2,000 medical oncologists and ~1,900 surgical
and the National Medical Commission, the doctors oncologists which is low when compared with
per 1000 in India are ~1, which is aligned with the global counterparts.

Chart 35: Comparison of incidence per clinical oncologist (radiation + medical oncologists)

Incidence per Oncologist

China 120

US 137

Germany 170

Brazil 170

Russia 269

India 315

Source: “Global survey of clinical oncology workforce”, Journal of Global Oncology, 2018, EY analysis

High-level estimates indicate that while current Institute, etc., will help address part of this
availability of radiation oncologists is adequate, demand-supply gap.
we require additional 2,500 to 3,000 medical
The demand-supply gap is as acute in medical
oncologists and an additional 700 to 800 surgical
physicists as in oncologists. There are ~1,550
oncologists to cater to current incidences 87. With
medical physicists in India, while the requirement
incidence increasing at a CAGR of 10% to 12% for
is upwards of ~2,100 88. The gap in demand and
next eight years, the annual addition of ~240 DM/
supply will widen in the next few years, with
DNB medical oncologists and ~280 MCH/ DNB
demand expected to grow by ~200 per year while
surgical oncologists69 will be insufficient to
effective addition to be at around ~70 per
address the demand-supply gap. The organ
annum87.
specific fellowship programs offered by RGUHS,
RGCI, HCG, NH, Apollo, Tata, Adyar cancer

84 “Protecting India: Public Private Partnership for vaccinating 86 With 91,927 MBBS seats, 612 medical colleges operative in

against COVID-19” EY FICCI report, December 2020 India: Health minister gives breakup, medicaldialogues.in, July
85 Kumar R, Pal R. India achieves WHO recommended doctor 2022
87 EY analysis, refer Annexure 8 for assumptions
population ratio: A call for paradigm shift in public health 88 “Radiation therapy sources, equipment and installations”, AERB
discourse! J Family Med Prim Care. 2018 Sep-Oct;7(5):841-844.
doi: 10.4103/jfmpc.jfmpc_218_18. PMID: 30598921; PMCID: safety code, aerb.gov.in
PMC6259525

Call for Action: Making quality cancer care more accessible and affordable in India 74
 While cancer care in India has focused on developing infrastructure, it is equally important to
develop skilled specialists and allied doctors such as psychologists, pain specialists,
physiotherapists, and patient navigators to help run these units. A space largely ignored in
cancer care is the prevention and screening aspect as well as palliative care and rehabilitation.
Cancer patients in India deserve the whole spectrum of care, irrespective of affordability and
where they live.

Dr. Shona Nag

Sr. Medical oncologist and Director oncology department, Sahyadri Hospitals Private Limited

Chart 36: Demand-supply gap of medical oncologists

12,000

10,000

8,000

6,000

4,000

2,000

-
2022 2023 2024 2025 2026 2027 2028 2029 2030

No. of Drs required Supply of doctors

Note: The supply includes only DM and DNB medical oncologists and does not include organ specific fellowship programs
Source: EY Analysis, nmc.org.in

Chart 37: Demand-supply gap of surgical oncologists

8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
-
2022 2023 2024 2025 2026 2027 2028 2029 2030

No. of Doctors required Supply of doctors

Note: The supply includes only MCH and DNB Surgical oncologists and does not include organ specific fellowship programs
Source: EY Analysis, nmc.org.in

75 Call for Action: Making quality cancer care more accessible and affordable in India
The government is trying to ramp up the
availability of doctors across specialties by
increasing the number of seats through86
Over the next 25 years of India’s economic
i. Upgrading district/ referral hospitals to
growth, we will experience increasing
medical colleges (157 such colleges
lifespans, high levels of exposure to
approved). environmental carcinogens, and unchecked
ii. Strengthening/ upgradation of existing state tobacco/narcotics use, all of which will
government/central government medical contribute to an explosion in cancer
colleges to increase MBBS and PG seats. incidence. We must take this opportunity to
Upgradation of government medical colleges build a safer future for our children by
increasing the number of healthcare
by construction of super specialty blocks. In
professionals and clinical researchers to 10
this regard, the government has approved a
times from current levels. By doing so, India
total of 75 projects.
will be able to replicate the success of the
iii. Setting up the new AIIMS. The government software industry and become a healthcare
has approved 22 AIIMS and Undergraduate provider for the world.
courses have started in 19 AIIMS.
Viren Prasad Shetty
iv. Relaxation in the norms for setting up of a
Whole-time Director & Group COO, Narayana
medical college in terms of requirement for Hrudayalaya Limited
faculty, staff, bed strength and other
infrastructure.
While it is critical to add more PG seats for medical
While these have resulted in 75% increase in UG
and surgical oncologists, it is also critical to
seats and 93% increase in PG seats from 201489,
continuously enhance their skillsets in line with
the significant gap and a growing demand in
the advancements in technology and emergence
medical and surgical oncologists requires further
of new treatment regimes.
concerted efforts to bolster access to doctors.

J&J Medical has attempted to enhance access to skilled surgical clinical talent by imparting hands-on
training to budding and practicing doctors and mentoring them to clinical perfection with an aim to
enhance their surgical skills. To achieve this, J&J Medical established the Ethicon Institute of Surgical
Education (EISE) in 199390 and currently are present in two locations: Chennai and Mumbai. In 2018,
J&J launched the first of its kind institute on wheels to address India’s needs in surgical education by
reaching doctors at their doorsteps across different Tier 1 and Tier 2 towns. The company is furthering
its cause for surgical skill building in the country by investing and partnering with Proximie, a
technology platform that uses a combination of AI/ML and augmented reality to allow clinicians to
virtually ‘scrub in’ and collaborate with each other. It further aspires to roll out a tele mentorship
program with an algorithm scoring of surgeries w.r.t clinician performance while providing access to
mentors and recommendations on improvement areas.

Similar collaborative efforts are required by all the advancement in oncology treatment are
stakeholders involved in providing core or allied illustrated below 91, 92:
oncology services to upskill clinical talent specially ► Targeted therapies becoming part of standard
in Tier 2 and Tier 3 cities, given the rapid strides treatment for many cancers in the 2010s
in oncology treatment regimens and technology
► Minimally invasive and robotic surgeries have
over the last two decades. Some of recent
become standard for more and more cancers
in the past ten years

89 UG medical seats increased by 75%, PG medical seats by 93% 91 “Top 10 medical advancements in cancer research history”,

since 2014: Govt, indiatoday.in, March 2022 Proclinical.com, February 2021

90 Ethicon Institute of Surgical Education Commemorates Two
92 “A Decade of Progress in Cancer Care, and What’s Next”,
Decades of Advancing Medical Education in India”, J&J.in, Memorial Sloan Kettering Cancer Center, February 2020
February 2013

Call for Action: Making quality cancer care more accessible and affordable in India 76
► Significant progress made in immunotherapy Oncologists should come forward and upskill
with the approval of first checkpoint inhibitor specialists especially those who are first port of
in 2011 by USFDA call for some of key cancers — dentist, ENT (oral
► Approval of Chimeric antigen receptor (CAR) T cavity cancer), OBG (cervical, breast cancer),
cell therapy by FDA in 2017 to treat some pulmonologist (lung cancer) etc., such that they
kinds of lymphomas and for certain patients identify cancer symptoms accurately and refer to
with relapsed or advanced leukemia oncologists at the right time. There is also a need
for introduction of oncology as a subject as part of
► Approval of first human cancer treatment
the MBBS curriculum such that general physicians
vaccine by USFDA with Sipuleucel-T in 2010
also acquire basic skillsets required to recognize
and BCG Live and Talimogene laherparepvec
cancer symptoms early on and direct patients to
subsequently
oncologists. Upskilling primary care physicians
► Use of liquid biopsies (blood test) in the place such that they identify high-risk candidates or red
of more complicated tissue biopsy flags and refer them for appropriate screening
► Dawn of a new era of precision medicine programs will result in early diagnosis and
(Personalized medicine) with the first DNA- treatment.
sequencing test getting approved by the FDA
in 2017 In order to deliver safe, appropriate and efficient
care with improved patient outcomes, there is a
► Increasing use of Particle Beam Therapy and
need for uniform standards for prevention,
SBRT
diagnosis, and treatment of cancer across India
Continuing medical education platforms need to enabled by evidence-based management
be provided by ecosystem players to ensure that guidelines. India with vast variation in resources,
the large pool of oncologists in the country have infrastructure and expertise requires guidelines
an active environment to enhance their knowledge which are not only rigorously developed but also
and skillsets. feasible, applicable in real world and acceptable to
all stakeholders.93

NCG (National cancer Grid), spearheaded by TMH and with a network of 255 cancer centers, research
institutes, patient advocacy groups, charitable organizations and professional societies 94 has
developed guidelines for management of cancers based on best available international and local
evidence considering the above key factors. Further, the guidelines are resource stratified, dividing the
guidelines into optional (State of art), optimal (value driven) and essential (value with access to
resources). The NCG evaluates adherence to these guidelines by conducting institutional peer reviews.

NCG furthers access by having training, extending medical education and collaborative research under
its ambit. NCG also works on improving affordability by bringing down the cost of drugs, consumables,
and equipment for small and medium-sized cancer centers through group negotiations and web enabled
e-tendering platforms.

Given that there is a significant geographic skew major role. Tata Trust is not only setting up
in the availability of physical and human cancer research and treatment centers in Tier
infrastructure for cancer care and there is a 1/2 cities such as Varanasi, Tirupati,
significant need to provide care closer to the Bhubaneshwar, Ranchi, Allahabad, and
home setting of patients, the need for a tiered Mangalore but is also partnering with State
distributed care approach is of prime governments to build state- wide cancer
importance. To enable this agenda, industry facilities.
participants such as Tata trusts are playing a

93 NCG Guidelines manual 2021, tmc.gov.in parliamentary standing committee on health and family welfare,
94“Cancer care plan & management: prevention, diagnosis, September 2022
research & affordability of cancer treatment”, Department-related

77 Call for Action: Making quality cancer care more accessible and affordable in India
 Distributed model of cancer care – Assam

The Assam Cancer Care Foundation, which is a joint partnership between the Government of Assam
and Tata Trust, spearheads this initiative set up in 2017.

As against one apex cancer care center handling the cancer patient’s journey end-to-end, the
‘Distributed Cancer Care Model’ is conceptualized with different level of centers closer to the patients’
homes interlinked with the apex centers, handling diagnosis and care delivery, thereby shifting the load
away from apex hospitals and providing high-quality cancer care closer to home and reducing out-of-
pocket expenses for patients. 95

Table 22: Overview of capabilities at different levels

Oncology services Allied facilities

Nuclear Lab Research / Community
Radiation Medical Surgical Medicine Services Academics outreach
Level 1 (Apex
High end
centers)
Level 2 Advanced
Level 3 Basic
Level 4

Source: “Distributed Model of Cancer care”, Assamcancercarefoundation.org

The network will have 17 different hospitals catering to 50,000 patients per year96 (@ incidence of
138.6 per lakh will cover 3.1 crore population and @344 per lakh will cover 1.45 crore population
assuming 10% growth as per the projection model in the Chapter 1 of this report) with a potential to
eventually cover 35% to 50% of cancer patients in Assam over the next 8 to 10 years 97.

As Phase 1, a network of 10 hospitals is being developed with 1 apex institute, 4 level 2 and 5 level 3
institutes across Assam. Seven hospitals were inaugurated in April 2022 and the remaining three will
be completed by Dec 2022. The seven inaugurated hospitals will cover 30,000 patients annually. As
part of the next phase, foundation has for seven centers was laid out and they are expected to be
operational by 2024.

Telehealth services would be provided by the network of hospitals which will consist of a central hub at
Guwahati as DiNC (Digital Nerve Center) and other hospitals with Tele-radiology and Virtual Tumor
Board (VTB) services.

95 M. Kuriakose et al. Developing a Model of Distributed, Decentralized Digitally Connected Cancer Control Program, Journal of Global

Oncology 2018 4: Supplement 2, 240s-240s

96 “‘Largest’ network of hospitals under Tata Trusts’ cancer control model coming up in Assam”, The Print, April 2022
97 “Cancer care gets major fillip in Assam”, indiglobalmedia.com, August 2022, EY analysis

Call for Action: Making quality cancer care more accessible and affordable in India 78
 Distributed Cancer Care Network by Karkinos

Technology-led oncology platform, Karkinos is trying to disrupt the way oncology treatment is provided
in India and is working towards setting up a distributed cancer care network to provide quality care
closer to home at affordable prices. The platform provides a comprehensive platform for patients w.r.t
their oncology care needs that can be availed across multiple locations across the country and is
enabled by proprietary technology tools which are powered by clinical intelligence and interoperability.

Figure 7: Karkinos model of distributed cancer center by partnering with existing healthcare providers

Source: “Building Capacity with distributed cancer care network”, Karkinos.in

Karkinos employs a proprietary digital platform for seamless management of oncology cases across the
entire ecosystem while providing curated and peer reviewed oncology clinical protocols, workflows, and
processes, and access to panel of senior oncologists via the Virtual Tumor Boards, and specialist
opinions. It employs an array of digital technologies such as telemedicine, tele oncology, interoperable
digital health records to enable management of cancer cases in non-metro/ rural areas.

Karkinos helmed by a strong team with clinical and business background offers a capital efficient model
to address the key barriers patients face with respect to access and affordability. Expansion of entities
offering such a distributed cancer care model is a critical need given the current constraints on resource
availability for oncology care in the country.

Note: Refer Annexure 9 for Karkinos’s approach to management of patient journey.

79 Call for Action: Making quality cancer care more accessible and affordable in India
 Sahyadri’s efforts to enable access

While plenty of tertiary care hospitals exist, all patients do not have access to them, mainly due to
economic grounds. Tertiary hospitals could partner with smaller clinics around them and up skill the
doctors for early diagnosis and referrals. Sahyadri Hospital has made strides toward such an effort.
They have launched an online certification program called OncoPro online, which is an oncology basics
course for general practitioners educating them in a three-hour interactive module, three months ago.
On completion of the module, doctors receive a basic certification. It has received a great response and
over 1,000 doctors have signed up. Sahyadri plans to develop a module for caregivers and nurses in the
future.

Sahyadri also has a strategy to conduct cancer screening camps in partnership with smaller clinics
around their cancer center at the clinic itself. This will help gain the confidence of practicing doctors and
involve the community in cancer screening as well.

Sahyadri oncology unit regularly conducts Multi-Disciplinary Tumor (MDT) boards where cases get
discussed and the best management options are decided. The aim is to make the MDT available through
the internet to all other Sahyadri units — even those outside Pune and make it virtual.

One of the USPs of the Sahyadri Group is to make medical care more affordable. To fulfill this purpose
for cancer patients, Sahyadri, in partnership with Rotary International, has put up a Linear accelerator
and will from September 2022 offer free radiotherapy, chemotherapy and cancer surgery to eligible
patients under the Ayushman scheme at Surya hospitals.

Data management, especially for outcome analysis, is extremely important. Sahyadri is working toward
this by incorporating new software for data capture. They have data managers currently and there are
plans to develop a cancer registry as well.

Precision oncology is the future of cancer care. Sahyadri is making efforts in this direction by
establishing the city’s first bio bank along with a molecular tumor board with international experts.

Just 1% to 2% of people who need palliative care access to it 100. In addition to the challenge of
in India have access to it, far below the global access to palliative care, strict regulations on
average of 14%. Kerala is one exception in India opiate supply had left morphine and opioids
where 26% of people needing palliative care have largely unavailable for use in pain relief till 2014.
access to it.
With the passage of amendment to the NDPS Act
Palliative care meant to improve quality of in 2014, there has been an improvement in
patient’s life, when integrated with standard availability of such medicines. To address the
oncology care, has proven clinical benefit by availability of qualified physicians, the Medical
helping alleviate symptom burden, enhance illness Council of India recognized palliative care as a
and prognostic understanding, improve both the postgraduate specialty in 2010. As of 2019, Tata
quality of life and overall survival for patients. Memorial Hospital, Mumbai; GCRI, Gujarat; and
Multiple studies have shown lower depression and AIIMS, Delhi; offer postgraduate courses. Further,
higher length of survival for palliative care palliative medicine has been part of the M.B.B.S.
groups.98, 99 curriculum since 2019. These steps are in the
right direction and should be further augmented
More than 54 to 60 lakh Indians require palliative
with integration of palliative care service along
care every year, but only 1% to 2% of them have

98 Nickolich MS, El-Jawahri A, Temel JS, LeBlanc TW. Discussing the Evidence for Upstream Palliative Care in Improving Outcomes in

Advanced Cancer. Am Soc Clin Oncol Educ Book. 2016;35:e534-8. doi: 10.1200/EDBK_159224. PMID: 27249764
99 Oliver D. Improving patient outcomes through palliative care integration in other specialised health services: what we have learned so far

and how can we improve? Ann Palliat Med. 2018 Oct;7(Suppl 3):S219-S230. doi: 10.21037/apm.2018.05.05. Epub 2018 May 28. PMID:
29860858
Bag S et al. Palliative and End of Life Care in India - Current Scenario and the Way Forward. J Assoc Physicians India. 2020
100

Nov;68(11):61-65. PMID: 33187039

Call for Action: Making quality cancer care more accessible and affordable in India 80
with care delivery at the PHCs, CHCs and district number of volunteers with skeletal staff of doctors
hospitals in the country. and nurses not only helps in taking care of
patients at the institute but provides a robust
Kerala’s community-based palliative care services
homecare. Kerala is one among the three states
supported by state policies and CanSupport’s
(Karnataka and Maharashtra being the other two)
home based care have been successful in
with Palliative care policy. The focus of Kerala
providing a reliable, cost-effective palliative care
state policy on palliative care is on training
to patients that can serve as a model for building
providers and volunteers and establishing
palliative care capacity in India.
palliative care programs, especially in the primary
Kerala has over 1,550 palliative care unit and the care setting, and providing funding for
community-based organization and NGOs run 450 community-based palliative care services. As a
of them101. Kerala’s community-based model is result, approximately 90% of India’s palliative care
driven by the massive involvement of public and service providers are in Kerala, a state that has
civil society. The model supported by a huge only 3% of the country’s population.

CanSupport runs India's largest free home-based palliative care program catering to patients in NCR
since 1997. Presently, CanSupport palliative care teams care for 2,600 cancer patients and their
families with a help of trained and multidisciplinary teams which consist of a doctor, a nurse, and a
counselor. Referrals come from several hospitals that treat cancer in the city, as well as from past
beneficiaries and through the helpline.

Each team cares for 50 to 60 patients at any given time102.

► The nurses are the coordinators and decide which patients are to be visited in consultation with the
doctor and counselor. Apart from nursing needs, they also educate caregivers on nutrition,
oral/wound/ostomy care, and prevention of bedsores.
► Psychosocial support is provided mainly by counselors who are trained to listen and address
patients and caregivers’ emotional, social, financial, and spiritual concerns. They help them come
to terms with the prognosis of the disease, advise patients on practical matters, and assist patients
to mend relationships with parents, siblings, or children.

With the support of CanSupport's homecare teams, patients and their families are able to come to
terms with the reality facing them and manage most of the problems associated with a terminal illness
within the comfort of their homes.

Key enablers for improving provision and access integration of palliative care services with public
to palliative care services in the country are an and private healthcare set ups through an
enabling policy structure across the country and institutionalised set up.

“Palliative care in Kerala: a success story”, www.thehindu.com,

101 102Yeager A et al. CanSupport: a model for home-based palliative
March 2020 care delivery in India. Ann Palliat Med. 2016 Jul;5(3):166-71. doi:
10.21037/apm.2016.05.04. PMID: 27481319

81 Call for Action: Making quality cancer care more accessible and affordable in India
 Cancer continues to be a persistent and very permanent part of most families these days.
Whilst the incidence and diagnosis has improved, we remain at Aster even more optimistic
about the management and quality of life of our cancer survivors.
Aster International Institute of Oncology (AIIO) is a network of hospitals providing easily
accessible and affordable cancer care in India and Gulf Council countries. The motto of our
international cancer grid is “Complete cancer care. With you - Every step of the way”.
The multidisciplinary team approach integrates all clinical services including surgical
oncology, medical oncology, radiation oncology, nuclear medicine therapy, head and neck
oncology, breast surgery and oncoplasty, gynec oncology.
The services will be by DMG (Disease Management Group) focusing on therapy as well as
prevention, screening, diagnosis, treatment, survivorship, and palliative end-of-life care
under one roof and ensures uniform care. A robust joint MDT discussion of each and every
patient’s treatment and it’s application to individualised patient decision making, makes it
truly personalised for each patient with most recent evidence based oncology guidelines and
protocols. This will result in highest standard of care and QOL (quality of life).
AIIO is equipped with latest iteration of daVinci Robot. Minimal access robotic oncology
surgeries has revolutionized oncological surgeries allowing surgeons to perform complex
surgical procedures with minimal pain and faster recovery hence benefitting the patient
tremendously.
AIIO has been certified as Centre of Excellence to treat peritoneal surface malignancies, one
of the deadliest group of cancers. Therapeutic procedures like cytoreductive surgery with
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and Pressurized Intraperitoneal
Aerosol Chemotherapy (PIPAC) has been a boon to patients, making a palliative condition
into a curative one.
Complex combined micro vascular plastic surgeries coupled with major oncosurgery
resections gives best quality of life and cosmetic and optimal functional outcomes.
Immunotherapy is referred to as a “miracle in the making” by several oncologists. AIIO has
adopted immunotherapy including ambulatory chemo port based pump based
chemotherapy.
We are proud to acquire the latest technological advancements in the field of radiation
therapy in the form of Intraoperative Radiation Therapy (IORT) and Image-Guided Radiation
Therapy (IGRT). Both these machines incorporate imaging techniques to provide highly
accurate modulated gamma radiation with minimal side effects while reducing the cancer
treatment duration.
The clinicians at AIIO are motivated by the credo of providing value based health care
without compromising on clinical outcomes.
Coupled with MDT team of nutritionist and Onco counsellors and Rehabilitation specialists
all available under one roof in AIIO truly makes it most unique and state of art complete
cancer center and International Institute of Oncology.

Alisha Moopen
Deputy MD, Aster DM Healthcare LImited

Call for Action: Making quality cancer care more accessible and affordable in India 82
(ii) Treatment - Affordability

Cost of complete multimodal treatment INR4 lakhs. Cost goes beyond INR5 lakhs if
varies depending on the stage of detection cancer is diagnosed at Stage 3 or 4 103.
and treatment plan and often is upwards of

Chart 38: Baseline and advanced treatment cost of common cancer types detected at Stage 1 or 2

20.2

8.0 8.4 8.0

5.2 4.2 4.5 4.2

Breast Cervix Ovary Gall Bladder

Baseline Advanced

Source: EY analysis

Baseline treatment is the basic minimum metros. Baseline cost of common cancers such as
treatment required to treat cancer at a private breast, cervix, ovary, gall bladder range from
non-COE setup in a Tier 1 city. The treatment cost INR4.2 to 5 lakhs if the cancer is detected at
can increase by more than 80% if the patient Stage 1 or 2 and upwards of INR5 lakhs if
avails advanced treatment, such as targeted detected at Stage 3 or 4, indicating a minimum
therapy, IGRT, IMRT, robotic surgeries and cost escalation of 20% driven by increase in
molecular diagnostics at Centres of Excellence in radiotherapy costs.

Chart 39: Baseline and advanced treatment cost of common cancer types detected at Stage 3 or 4

24.6

12.5
8.3 7.4

Breast Cervix

Baseline Advanced

Source: EY analysis

Contribution of chemotherapy in the overall cost surgery in the overall cost of cancer care is lower
of cancer care drastically increases for patients for patients diagnosed with advanced stages of
choosing advanced treatment. Contribution of cancer.

103 EY analysis

83 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 40: Contribution of cost of different treatment modality for breast cancer

Baseline treatment (Stage 1 or 2) Advanced treatment (Stage 1 or 2)

4%
12%
32%
46% 18%
66%
22%

Baseline treatment (Stage 3 or 4) Advanced treatment (Stage 3 or 4)

11% 3%5%
10%
20% 40%

22% 60%

29%

Medical Radiation Surgery Molecular diagnostics Others

Source: EY analysis

A survey of ~90 patients treated in private / trust- While 46% of the population in India continues to
based hospitals corroborates the above estimates remain uncovered currently, there is a
with 70% of them confirming that they are significant shift toward financing of care by
spending >INR5 lakhs for comprehensive private and public payors and hence an adequate
treatment. coverage and reimbursement linked to the right
quality of care and outcomes is a critical need.

Chart 41: Changing payer mix: individual to institutional

Population coverage Changing payer mix: individual to institutional

Commercial insurance 4-5% 4% 12% 19-20%

Employee schemes (CGHS, ESIS) 5-6% 5% 10% 10-15%

Government schemes 3% 16% 32% 40-45%

Uncovered population 86% 75% 46% 20-30%

2007-08 2010-11 2021 2025P

Source: EY analysis, IRDAI annual report 2020 -21, Irdai.gov.in, “Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-
PMJAY)”, pib.gov.in, July 2021

Call for Action: Making quality cancer care more accessible and affordable in India 84
While multiple government schemes providing coverage provided by state governments over and
insurance coverage for non-affording population above the PM-JAY scheme.
were active since 2007, coverage has significantly
increased since the roll out of PM-JAY in 2018 Government schemes along with ESI, ESIC and
CGHS may cover almost 60% of population
which has been further enhanced by add on
eventually over the next three to four years. 104

Table 23: Overview of key government schemes:

Coverage Claim Amount

Year of Reimbursement (No. of since inception
Scheme State Inception Limit Beneficiary Procedures) (INR Cr)
Pradhan Mantri
Jan Arogya INR5 lakhs per 50 Crore
All India 2018 ~1,393 3,483
Yojana (PM- family per annum Individuals
JAY)105
Dr.YSR
INR5 lakhs per ~1.3 crore
Aarogyasri AP 2007 ~2434 2,457
family per annum families
Scheme 106
INR2 lakhs per ~0.85 crore
Arogyasri 107 Telangana 2014 ~949 1,273
family per annum families
INR5 lakhs per
family and
additional INR5
Biju Swasthya ~0.9 crore
Odisha 2018 lakhs for the women ~1592 931
Kalyan Yojana 108 families
members of the
family after exhaust
of initial limit
INR5 lakhs per
Ayushman Bharat-
family per annum ~1.43 crore
Arogya Karnataka Karnataka 2018 ~1628 NA
for BPL and RSBY families
Scheme 109
beneficiaries
INR1.5 lakhs per
Mahatma Jyotirao family per annum
Phule Jan Arogya Maharashtra 2012 (for renal transplant NA ~1212 9,319
Yojana 110 INR2.5 lakhs per
annum per family)
Chief Minister's
Comprehensive INR5 lakhs per ~1.37 crore
Tamil Nadu 2009 ~1150 NA
Health Insurance family per annum families
Scheme 111
Swathya Sathi INR5 lakhs per 2.3 Crore
West Bengal 2017 ~1502 1,873
scheme 112 family per annum families
Mukh Mantri
Punjab Cancer INR1.5 lakhs per
Punjab 2011 NA NA 866
Raahat Kosh Cancer patient
Scheme 113

104“Health Insurance for India’s Missing Middle”, NITI Aayog, 108 bskydashboard.odisha.gov.in
October 2021 109 arogya.karnataka.gov.in
105www.pmjay.gov.in, “About Pradhan Mantri Jan Arogya Yojana 110 jeevandayee.gov.in
(PM-JAY)”, nha.gov.in 111 cmchistn.com
106 ysraarogyasri.ap.gov.in 112 swasthyasathi.gov.in
107 aarogyasri.telangana.gov.in 113 mmpcrk.gov.in

85 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 42: Number of oncology services covered by different government schemes

851

604

418
308 328

189

PM-JAY Arogyasri BSKY (Odisha) AB-ArK MJPJAY CMCHIS (Tamil

(Telangana) (Karnataka) (Maharashtra) Nadu)

Source: pmjay.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in, arogya.karnataka.gov.in, jeevandayee.gov.in, cmchistn.com.

Note: Basis analysis of procedures classified under Medical, Radiation and Surgical oncology

Number of oncology procedures covered varies cover certain procedures required for
from 189 to 851 across various government comprehensive and advanced treatment such as
schemes. Coverage of different procedures varies PET CT, biopsies, NGS, targeted therapy.
significantly. All government schemes do not

Table 24: Coverage of government schemes across different treatment categories

Dr.YSR Telangana TN- Arogya Swasthya

Category PMJAY ArogyaSri Arogyasri MJPJAY CMCHIS BSKY Karnataka Sathi
Nuclear Medicine
Yes Yes Yes No Yes Yes No No
(PET-CT)

Biopsies Yes Yes Yes No Yes Yes Yes Yes

NGS No No No No No No No No

Targeted
Yes Yes Yes No Yes Yes No Yes
therapy

Immunotherapy No No No No No No No No

SBRT/ SRS Yes Yes Yes Yes Yes Yes Yes Yes

Source: pmjay.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in, arogya.karnataka.gov.in, jeevandayee.gov.in, cmchistn.com,

swasthyasathi.gov.in

Call for Action: Making quality cancer care more accessible and affordable in India 86
Table 25: Coverage of Govt. schemes across different Chemotherapy medications

TN- Arogya Mukhyamantr

Dr.YSR Telangana MJPJA CMCHI Karnatak Swasthy i Amrutum
Formulation Indication Organ PMJAY ArogyaSri Arogyasri Y S BSKY a a Sathi Yojana
Liver/
HCC/ TC/
Sorafenib Thyroid/ Y Y N N Y Y Y Y Y
RCC
Kidney
Trastuzumab BC Breast Y Y Y N Y Y N Y N
NHL,
Rituximab Blood Y Y Y Y Y Y N N Y
PMBCL, CLL
Bevacizumab RCC, CRC Kidney N Y N Y N N N N N
Lapatinib BC Breast Y N N N N Y N Y N
Geftinib LC Lung Y Y N N N Y Y Y Y
Melanoma,
GIST, GC,
CML, ALL, Blood,
Imatinib Y Y N Y Y Y Y Y Y
AML, MM, GI, Skin
CLL,
Chondroma
Thyroid/
Pazopanib TC/ RCC N N N N Y N Y Y N
Kidney
LC/ RCC/ Lung/
Chondroma Kidney/
Erlotinib Y Y N N Y Y Y Y Y
/ Pancreatic Bone/
cancer Pancreas

Source: pmjay.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in, arogya.karnataka.gov.in, jeevandayee.gov.in, cmchistn.com,

swasthyasathi.gov.in, ma.gujarat.gov.in

Based on the limited data available on the claim There is a huge variation in the reimbursement
amount, around INR150 to 200 crores are being rates of different state schemes. Further cost at
claimed under PM-JAY, Arogyasri (AP) per year private hospitals in metros are considerably
and INR80 to 100 under MMPCRKS (Punjab) per higher than government schemes.
year for oncology services.

Chart 43: Reimbursement rates for thyroidectomy (Total) – Package

50,000

35,899
32,900 30,786 30,000

20,000 22,000

PMJAY Dr.YSR Telangana MJPJAY TN-CMCHIS BSKY Swasthya Sathi

ArogyaSri Arogyasri

Note: The above rates are Tier 1/ Category 1/ NABH/ Grade A rates
Source: pmjay.gov.in, ysraarogyasri.ap.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in jeevandayee.gov.in, cmchistn.com,
swasthyasathi.gov.in

87 Call for Action: Making quality cancer care more accessible and affordable in India
Chart 44: Reimbursement rates for TURBT – Package

49,686
43,600
40,022 39,000

30,000 30,000 30,000

25,000

PMJAY Dr.YSR Telangana MJPJAY TN-CMCHIS BSKY Arogya Swasthya

ArogyaSri Arogyasri Karnataka Sathi

Note: The above rates are Tier 1/ Category 1/ NABH/ Grade A rates
Source: pmjay.gov.in, ysraarogyasri.ap.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in jeevandayee.gov.in, cmchistn.com,
swasthyasathi.gov.in

Chart 45: Reimbursement rates for Gastrectomy (Total/ Any type) - Package

1,50,000

1,10,974
97,500

52,500 50,000
40,000 39,850

PMJAY Dr.YSR Telangana MJPJAY TN-CMCHIS BSKY Swasthya Sathi

ArogyaSri Arogyasri

Chart 46: Reimbursement rates for Radical Nephrectomy (Open) - Package

56,101
52,500
49,300 50,000 50,000

40,000 40,000

PMJAY Dr.YSR Telangana MJPJAY TN-CMCHIS BSKY Swasthya Sathi

ArogyaSri Arogyasri

The rates offered by different government hospitals in metro and Tier 1 cities indicated that
schemes varied to the extent of 40% to 275% in thyroidectomy (Total) cost was higher by a
TURBT, total thyroidectomy, Gastrectomy (Total/ minimum of 180% and TURBT cost higher by 30%
Any type), Radical Nephrectomy (Open) package. compared to PMJAY rates114.
Further, High-level analysis of cost at the private

Call for Action: Making quality cancer care more accessible and affordable in India 88
Chart 47: Reimbursement rates for Chemotherapy - Trastuzumab

31,941
30,000
27,600

20,000

PMJAY Dr.YSR ArogyaSri BSKY Swasthya Sathi

Source: pmjay.gov.in, ysraarogyasri.ap.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in jeevandayee.gov.in, cmchistn.com,

swasthyasathi.gov.in

~60% differential observed between the rates chemotherapy, use of low MRP generic medicines
offered by BSKY and Swasthya Sathi. With drug can help manage costs of treatment.
costs being the major driver of cost of

Table 26: Reimbursement rates for radiotherapy package

Tata Memorial
Therapy/ PMJAY Dr.YSR Telangana TN-CMCHIS BSKY (NABH Centre,
Procedure (Tier I) ArogyaSri Arogyasri MJPJAY (Category A1) package cost) Mumbai
74,999 75,000
27,300 21,000 68,000 (28-33 31,531 (6
3D CRT (up to 30 (up to 30 31,500
(6 Fractions) (6 Fractions) fractions) Fractions)
fractions) fractions)
114,000 75000
SRS/ SBRT 106,600 89,000 130,000 (4
(up to 30 (up to 5 75,000 90,000
with IGRT (4 fractions) (4 fractions) fractions)
Fractions) fractions)

Source: pmjay.gov.in, ysraarogyasri.ap.gov.in, aarogyasri.telangana.gov.in, bsky.odisha.gov.in jeevandayee.gov.in, cmchistn.com,

tmc.gov.in

3D CRT and SRS/SBRT cost in a private COE and should be flexible with the reimbursable limit
hospital in a metro or in a private non-COE per family with the focus on driving clinical
hospital for tier 1 city would cost above 1.2+ lakhs outcomes. There should be a thrust from the
(20 to 33 fractions) and 1.9+ lakhs (20 to 33 government to ensure the availability of modern
fractions) respectively114. These are higher by treatment options to the patients. To put this to
45% to 60% in comparison to the highest rates action, the government, in the short term, can
offered among the government schemes. create a multi-disciplinary review board which can
review cases and confirm the treatment plan
The huge variation in the reimbursement rates of
adopted and in medium/ long term, encourage
different government schemes among different
stakeholders to design and align to accreditations.
states and against private hospitals indicate that
Cancer specific accreditation by American College
the reimbursement rates need to be fixed in a
of Surgeons, National Cancer Institute, American
structured approach keeping in mind a uniform
Society of Radiation Oncologists, and American
standard of care and treatment plan which will
college of radiation oncology in the US have
provide the right quality of outcome.
helped improve patient outcomes such as survival
Further, the government schemes should consider rate and quality of life.
wide variation in cost of treatment by stage of
The private sector should drive efficiencies across
detection, treatment pathway and organs affected
material, workforce and medical equipment

114 EY analysis

89 Call for Action: Making quality cancer care more accessible and affordable in India
utilization to lower cost and thereby sustainably treatment related costs. Even if it does, there
service the Government scheme patients. Leading are conditions for coverage at different stages of
players improve workforce productivity by cancer. On an average, cancer patients pay 30%
minimizing nonvalue adding administrative of their medical expenses out of their own
activities, improve equipment utilization by pocket114.
operating them for more than 15 hours and lower
Typically, a comprehensive health insurance plan
material costs by structured supplier evaluation
covers treatment modalities approved by
and negotiation process. A structured program
government regulatory bodies and for which
can help unlock efficiencies by 15% to 30% across
clinical efficiency is available. Major plans issued
major cost heads.115
by the insurance companies indicate that they
Major insurance companies normally cover cover day care and pre and post hospitalization
oncology under the comprehensive health expenses. Pre and post hospitalization expenses,
insurance plans. The extent of services covered which includes diagnostics, are generally paid out-
under the plan depends on the policy taken by of-pocket and then reimbursed with the original
the policyholder and may not cover all cancer bills

Table 27: Brief overview of plans offered by key health insurance players

Pre and Post Hospitalization

Insurance company Key Insurance Plans Daycare expense
Family Health Optima Insurance Plan Yes Yes
Star health Star Comprehensive Yes Yes
Mediclassic Yes Yes
Optima Secure Yes Yes
HDFC ERGO
Optima Restore Yes Yes
ihealth Yes Yes
ICICI Lombard
Ihealth plus Yes Yes
The New India
Mediclaim No Yes
Assurance
National insurance National Mediclaim Yes Yes
United India
Individual Platinum Plan Yes Yes
assurance

Source: Joinditto.in

However, high-level analysis of patient bills ~85% of their hospital visit costs and 25 to 30% of
indicates that insured patients on an average incur their medical expenses out-of-pocket.

Table 28: Extent of out-of-pocket expense for Insured patients

% Out-of-pocket
Spend share Visits Spend Major cost heads not covered
IP 91% 17% 20% Pharmacy, Radiation therapy
OP 9% 100% 100% Diagnostics, Pharmacy
Total 100% 86% 27%

Source: EY analysis

100% of OP visits and 15% to 20% of IP Visits are radiation therapy are the major contributors of
out-of-pocket. Diagnostics, pharmacy, and their out-of-pocket expenses across IP and OP.

115 “Re-engineering Indian healthcare 2.0”, EY FICCI report, 2019

Call for Action: Making quality cancer care more accessible and affordable in India 90
Figure 8: Oncology patient flow and areas covered by insurance

Source: EY analysis

While there have been cancer specific plans and The cost of emerging oncology diagnostics and
fixed benefit policies being introduced in the therapeutics such as precision oncology,
market, a comprehensive health insurance immunotherapy and proton therapy are on the
covering all aspects of treatment is critical to higher side and is out of reach for majority of
improve affordability. Additionally, a focus on Indian population.
wellness programs with a free annual cancer
► Immunotherapy is highly expensive, costing
checkup will help in identifying cancer at early
INR2 to 3 lakhs a month, making it
stages and help insurance companies in
unaffordable for 94% to 97% of the cancer
collaboration with providers to reduce claim
patients who could benefit from it. 116 NLEM
payouts through early detection of patients at
has added 63 anti-cancer medicines under the
which stages the cost of treatment is relatively
‘essential medicine list’, which is typically
lower.
taken up by NPPA for price control. 117
However, NLEM has not included
Immunotherapeutic agents in the list
considering factors such as usefulness for the
A collaboration between various public and majority of cases of cancer patients, risk-
private stake holders will help reach quality benefit ratio, cost- effectiveness, established
cancer care to the needy people. therapeutic efficacy and availability in
Democratizing the resources will drive India.118
down cost and speed of delivery. It will also
reduce the cost of establishing a cancer
center by group purchase of critical
equipment.

Dr. Manivannan Selvaraj

Founder and Managing Director, Kauvery Group of
Hospitals

116Indicus data, 2014, 1. “Mumbai doctors innovate low-cost 117 Nation list of Essential Medicines 2022
cancer therapy”, timesofindia.indiatimes.com, June 2022 118 National list of Essential Medicines (NLEM) 2022 Report

91 Call for Action: Making quality cancer care more accessible and affordable in India
Table 29: Cost of Immunotherapy drugs

Immunotherapy Dose on Cost in India FDA recommended

Drug Indication product (INR) dose Cost in US
Melanoma, NSCLC, RCC, $10,474.0
200 mg every 3
Keytruda HNSCC, UC, cHL, CRC, 100mg/ 4ml 2,36,500 8 per
weeks
HCC, MCC, cSCC infusion
Melanoma, NSCLC, RCC,
240 mg every 2
Opdivo cHL, HNSCC, UC, ESCC, 100mg/ 10ml 99,500 per infusion
weeks
CRC, GEJ cancer
UC, NSCLC, SCLC, HCC, 840 mg every 2
Tecentriq 840mg/ 14ml 2,77,708 (840mg)
Melanoma weeks
10 mg/kg every 2 $4,045.03
Imfinzi NSCLC 500mg/ 10ml 1,89,585 weeks or 1,500 mg for 10ml
every 4 weeks (500mg)

Source: “US FDA drug labels (accessed on Sep 7, 2022)”, accessdata.fda.gov, “Keytruda list price”, Keytruda.com, “Opdivo pricing
information”, bmspricinginformation.com, “Tecentiq prices”, drugs.com, “Imfinzi prices”, drugs.com, “Cost of drug prices in India
(accessed on Sep 7, 2022)”, 1mg.com

► Cancer genome sequencing, which is helpful in treatment using proton beams. The
treatment for advanced stages of cancer, approximate cost of one course of proton
costs on average between INR2 to 3 lakhs.119 beam therapy treatment in the US is ~INR1.2
► 10% to 15% of the patients receiving radiation crores 120 and in India it costs around INR25 to
therapy would be eligible/ benefit from 30 lakhs. 121

Technology adoption at Apollo

Apollo Proton Cancer Centres introduced Pencil Beam Proton therapy for the first time in India and this
is the only proton beam therapy center in South Asia, ASEAN and Middle east, commissioned and
operated at India’s only JCI accredited cancer center. This is the most precise cancer treatment
technology that treats the most complex cancers. It provides a ray of hope to 3.5 billion people across
147 countries. Today it has successfully treated over 1,000 patients and is one among the three global
training centers.

Apollo Cancer Centres has over 16 robotic units. Through our collaboration with various technology
partners, we have ensured that minimal invasive surgery has scaled new heights and recovery is faster
with a better quality of life. With the introduction of the latest Cyberknife S7 FIM and Zap X to India, we
are redefining the integration of technology and expertise for better outcomes and ensuring that
patients are winning over cancer.

119“Kerala gets its first cancer genome sequencing machine” 121 “Apollo Hospitals inaugurates Proton Cancer Centre”,

Times of India, February 2022 thehindu.com, January 2019

120 “National Hadron Beam Facility”, tmc.gov.in

Call for Action: Making quality cancer care more accessible and affordable in India 92
 Addressing cancer care in India will require aggressive focus on all aspects of prevention,
early detection, diagnosis, and treatment as well as new financing and payment options. India
already provides exceptional cancer care in some leading healthcare centers. We need to
increase our focus and investment in innovation around areas like immunotherapy (e.g.,
indigenous development of CAR T-cells). We also need to address the mental health and
support aspects of cancer care not only for patients but also for their families and loved ones.

Pankaj Sahni
CEO, Medanta - The Medicity

KOIS invested in partnership with Roche and TMH has announced a development impact bond in 2017
allowing social investors to fund the transmission of best practices of HER two testing protocols and
standardization of cost of breast cancer treatment through biosimilars at six to eight government
hospitals. With an overarching goal of early screening, process improvement at partner hospitals and
access to targeted therapy, the initiative shall screen 20 lakh women and treat 10,000 to 20,000 breast
cancer patients over a period of five years and improve treatment success rate from current from 40%
to 70 to 75%. With outlay of $35 to 40 M, the fund will provide support to partner hospitals in
conducting screening, provide funding support for necessary bio-marker tests, enable process
improvements, and extend financial support to patients unable to pay out-of-pocket or through
insurance for HER-2+ breast cancer treatment and care.

This project is at the feasibility stage with the government of Karnataka and Assam showing interest in
the model
Source: “Five Things We Learned About Partnerships for Cancer Funding in Asia”, accessh.org, July 2019, KOIS CARING
FINANCE, Impact report 2017

The Hachioji city government in 2017 launched a social impact bond to fund colorectal screening program
for its at-risk residents. The screening for colorectal cancer in the city was lower compared to national
average leading to delays in treatment, higher healthcare cost, and suboptimal health outcomes. Project
cost for the three-year screening project in Hachioji was ¥8.8 million to 9.7 million, while the anticipated
savings from the early detection of this cancer through reduced medical expenses is upwards of ¥16
million. The project led to an increase in cancer screenings in the city from 9% to 27% in the target group
and helped detect 84 early stage cases, resulting in significant healthcare savings.

Similar partnerships and innovative models are required for making the modern therapies available to the
common population
Source: “The rise of social impact bonds in Japan”, Japantimes.co.jp, January 2019, “Hachioji City SIB on Increasing the Rate of
Residents Receiving Bowel Cancer Screenings”, golab.bsg.ox.ac.uk

93 Call for Action: Making quality cancer care more accessible and affordable in India
Call for Action: Making quality cancer care more accessible and affordable in India 94
(iii) Treatment - Cancer health records

National Cancer Registry Program (NCRP) in a well-defined population from multiple sources
instituted in 1982, functions through Population such as government hospitals, private hospitals,
and Hospital Based Cancer Registries (PBCR and nursing homes, clinics, diagnostic labs, imaging
HBCR) across different states in India. centers, hospices and registrars of births and
deaths. As cancer is not a notifiable disease,
► There are 38 PBCRs covering around 10% of dedicated staffs need to actively collect the data
the population as of now 122. The registries in by visiting the above-mentioned institutions and
high population states UP and Bihar has been examining documentations such as death
only added in 2017 or 2018. Big states such certificates.
as Andhra Pradesh, Haryana, Chhattisgarh,
Himachal Pradesh, Jharkhand, Odisha, and While some of the states have made cancer
Rajasthan still do not have a single registry. notifiable disease, the Indian Government should
With 10% population being covered, the declare it as a notifiable disease applicable across
coverage is inadequate even in states with India, which will help strengthen the data
presence of registries. Rural population is availability125 through wider coverage with limited
largely uncovered. 123 resources and funding. Developed and western
countries have made cancer notification
► There are 268 Hospital Based Cancer mandatory with nationwide cancer registry
Registries 124 under NCDIR –NCRP as of now available in countries such as England and Wales,
with relatively higher presence in southern United States of America, Scotland, the Nordic
and northern parts of India. countries, Canada, Australia, New Zealand and
Population Based Cancer Registries systematically Israel.126
collect data on all new cases of cancer occurring

Apollo Hospital Based Cancer Registry (AHBCR):

► Apollo Hospital-based Cancer Registry program (AHBCR) has been launched to develop unit level
Cancer Registries for clinical outcome improvement, research, and epidemiological studies.
► The AHBCR is an active method of data collection, with the collection of data from hospital records.
The data has been used for estimation of the load of the disease for the country, and the incidence
rate.
► The availability of data on a continuous basis has its special importance. The uniformly collected
long-term data helps in understanding the trends in cancer occurrence.
► To maintain consistency across 14 units developed a hospital-based caser registry template with
146 fields. The AHBCR template has a total of 146 fields which provides details information about
records information, demographic details, histopathology, clinical information, patient conversion,
diagnosis, treatment, outcome, progression, and follow-up details.
► Apollo HBCR has 46 incremental data fields that will enrich our dataset, impact of that field would
be utilized to identify patient cohorts, R&D trails, benchmark clinical outcomes, and treatment
modality.
► The AHBCR data abstractor’s user manual was developed based on our AHBCR template, which
provides brief guidelines on how to curate the data from medical records and IT reports, process
timelines, and governance.

125 Vaitheeswaran Kulothungan et al. Burden of cancers in India -

122 https://pbcr.ncdirindia.org/
Report of National cancer registry programme, ICMR – NCDIR,
123 estimates of cancer crude incidence, YLLs, YLDs and DALYs for
2020 2021 and 2025 based on National Cancer Registry Program, May
2022, BMC Cancer volume 22, Article number: 527 (2022)
124“Cancer care plan & management: prevention, diagnosis,
research & affordability of cancer treatment”, Parliamentary
126Lakshmaiah KC et al. Cancer notification in India. South Asian J
standing committee on health and family welfare, September 2022 Cancer. 2014 Jan;3(1):74-7. doi: 10.4103/2278-330X.126542.
PMID: 24665453; PMCID: PMC3961875.

95 Call for Action: Making quality cancer care more accessible and affordable in India
Progress in Data science and digital technology
can be leveraged to derive meaningful insights
from the cancer registry and electronic patient
records data and guide medical and policy decision Cancer is a growing disease burden in India
making. This will also enable us to design with more than a million new cases every
interventions that helps us precisely allocate year. While we scale up awareness and
resources towards awareness, prevention, capacity to deal with the disease, with the
screening, and treatment. amount of data we generate, India also has
the opportunity to become the key to
solving the cancer mystery lock for the
world through use of technology and
analytical disruption.

Mitesh Daga
Managing Director, TPG Capital

AI powered Digital Twins accelerating research and clinical care in Cancer

NeuranceAI is a Bangalore based healthtech company founded by industry veterans (Dr. Ajay Bakshi,
Neurosurgeon – ex CEO Max, Manipal & IHH-India and Dr. Rohit Gupta, Computer Scientist – ex Strand
Lifesciences & MedGenome) that has developed an AI powered technology to convert all patient records
(e.g., labs, radiology reports, prescriptions, clinical summaries etc.) into structured & standardized
digital twins. Originating in aviation, Digital Twin technology creates a digital replica of physical objects
(e.g., a jet engine) and enables improved performance by studying advanced computational simulations
generated digitally.

In collaboration with one of the most respected Cancer Institutes in India, NeuranceAI is developing
Digital Twins for cancer patients. Given possible improvement in survival, most cancer patients end up
receiving multiple diagnostics tests and therapies (imaging scans, genetic tests, histochemistry,
surgery, chemotherapy & radiotherapy) at multiple sites across several years creating very complex and
hard to understand medical records. NeuranceAI powered Digital Twins convert all medical records into
an integrated multimodal (clinical, pathological, radiological etc.) and multiscale (from genes to whole
body) perspective, which is chronologically sorted and enables doctors and researchers to zoom in or
out across time and levels of detail. It is anticipated that once deployed this technology will significantly
accelerate research and improve oncologists’ ability to deliver high quality care to their patients.

Our understanding of cancer is improving thanks to large investments in understanding

genetics and molecular biology of cancer. More recently Artificial Intelligence technologies
have started creating excitement as the next big wave of innovation in Oncology. From
AlphaFold’s protein structure predictions to faster drug discovery and improved diagnostics-
a tsunami of advances are going to happen over next few years.

Dr. Ajay Bakshi

Co-Founder & CEO, NeuranceAI

Call for Action: Making quality cancer care more accessible and affordable in India 96
 3
Improving the cancer
patient journey

97 Call for Action: Making quality cancer care more accessible and affordable in India
Chapter 3: Improving the cancer patient journey

The term ‘Quality of Life (QoL)’ is often used and This chapter attempts to explore the various pain-
referenced in the context of cancer care. WHO points and challenges faced by cancer patients
defines QoL as an individual's perception of their through their long and arduous journey of care.
position in life in the context of the culture and Key improvement areas have also been
value systems in which they live and in relation to highlighted, which providers and other
their goals, expectations, standards, and stakeholders can work on and enhance their
concerns 127. support to cancer patients in their journey.

Spirituality /
Religion / Physical
Personal beliefs Pain, discomfort,
Motivation, inner fatigue Time has come for us, to truly integrate the
strength digital power in a patient's journey. At one
end, we could use this for screening and
Environment early detection and on the other to focus on
Psychological
Access to quality specialisation, quality standards and to
Self-esteem, body
care, home
image, strengthen research
environment, Quality of Life appearance
discrimination
Dr. Harit Chaturvedi
Social Level of Chairman, Max Institute of Cancer Care
relationships independence
Personal, Mobility, work
professional and capacity, daily
provider activities
Patient journey mapping
In order to understand what cancer patients feel,
As illustrated in the figure above, cancer impacts
think, believe and experience, EY conducted a
almost every facet of QoL. It is therefore
pan-India survey of 154 respondents comprising
important for providers, governments and society
cancer patients and caregivers through a third-
at large to adopt a holistic approach for cancer
party agency. The below picture represents the
care, which is not just concerned with eradication
respondent profiles. Results from this survey have
of disease or symptom but also incorporates a
been used to map out the patient journey and
human element wherein patient’s wellbeing is seen
highlight the gaps across various touchpoints.
as primary goal.

127 https://www.who.int/tools/whoqol

Call for Action: Making quality cancer care more accessible and affordable in India 98
Chart 48: Respondent profiles

Respondent profiles
Gender profile Age profile Disease progression

43%
5% Cured/ Remission
27% 25% 41%
Treatment ongoing
54%
5% Relapse
42% 58%
Male Female <20 20 - 40 40 - 60 >60

Geographical coverage Organ impacted

Metro/ Tier I Tier II/ III

Metro / Tier I ► Delhi ► Kolhapur Brain/ Head & Neck: 8%
► Mumbai ► Patna Oral: 10%
Tier II / Tier III
► Bangalore ► Ludhiana
► Chennai ► Gorakhpur Breast: 29%
► Kolkata ► Purnia
Blood/
► Ahmedabad ► Vadodra Lung: 6% Lymph: 10%
► Hyderabad ► Bhubaneswar
► Pune ► Varanasi
Gastro: 11%
► Chandigarh
► Warangal
► Coimbatore Prostate/ Cervical/
► Raipur Ovarian: 11%
► Bhopal
► Amritsar
► Kochi
Bone: 4%
► Visakhapatnam
► Jaipur
► Agra
► Kanpur
Others (12%): Rectum, Cheeks,
Testicles, Uterus, Thoracic etc

The below infographics depict a cancer patient’s survey against each stage in order to identify the
journey, though characterized by massive various pain-points experienced by cancer
variability, summarized into five key stages. It also patients through their journey.
indicates various insights emerging from the

1 2 3 4 5
Awareness of symptoms Acceptance of Access to Active Adjusting to
and screening diagnosis cancer care treatment new life

Notices Consults Undergoes Experiences Confirms Seeks Evaluates Selects Finalizes Starts Undergoes Seeks Gets cured or Follows Slowly
symptom or GP test distress and diagnosis information treatment provider treatment treatment therapy update from goes into survivorship resumes life
undergoes range of strong options plan cycles provider remission care plan
screening emotions
Relapse
Regime change

1 2 3 4 5

77% of the patients or their 47% of the patients indicated 48% of the patients 49% of the patients traveled 48% of the patients
families had never it was difficult to conclude the indicated it was difficult to >50 kms for their treatment indicated lack of
undertaken any screening diagnosis conclude the treatment plan awareness or no
response when asked
46%of the patients who about rehabilitation
52% of the patients undertook 64% of the patients did not
58% of the patients had their undertook second opinion cited centers
>5 tests and more than one have any form of insurance/
initial diagnosis based on lack of confidence in initial
consult to confirm diagnosis scheme coverage Only 20% had positive
symptom diagnosis and suggested
views about availability of
treatment
62% of the patients used facilities for long term care
61% of the patients were 56% of the patients did not 61% of the patients preferred words like ‘tough’, ‘bad’,
diagnosed in Stage 2 and 3 have access to any support private hospitals for their ‘stress’, ‘pain’ to describe 20% of the patients who
group treatment their quality of life during were cured or under
treatment remission used words like
66% of the patients indicated 38% patients reported using ‘not normal’, ‘weak’,
49% of the patients had their 51% of the patients took more
they were not aware of latest non-allopathic treatment ‘average’, ‘neutral’ when
initial diagnosis done by GP than 1 week to conclude the
technologies available for options asked about quality-of-life
diagnosis
cancer treatment post treatment

99 Call for Action: Making quality cancer care more accessible and affordable in India
Voice of patients:

“
Lack of information
around disease renders us to
make ill-informed
“If clear transparency is provided by hospital
administration from the very first step, there
would be no communication gap in
between to choose for second opinion
“More empathy from the healthcare
provider and less waiting time
between tests
decisions at times

“
Non availability of
good hospitals locally “High cost, high waiting
time during procedures and
finalization of procedures
“
CGHS beneficiaries not entertained
on priority, and unnecessary time
wasted in the name of paperwork
“
More result
oriented, less
patient-oriented

“
Doctors did not guide
properly, no care provided
once surgery is done
“Recovery of the patient is not as expected,
delays in getting surgery appointments,
confusion with respect to treatment prognosis
“
Going through treatment to counter
relapse has reduced the overall
conviction in the treatment

Following broad themes characterizing various gaps in the patient journey emerge from the insights
highlighted above:

Theme 1: Delay in accessing care miscommunication between doctors and

burgeoning costs for the patient who pays for
► Low prevalence of screening practice implies every consult and test, increased anxiety while
most people get diagnosed only when there is waiting for every test result. In addition to the
a noticeable symptom, by which time the delay, the entire process of confirming a
cancer may have progressed beyond Stage-1 cancer diagnosis generates a sense of distrust
► The first point of contact is usually GPs who in the patient if there is a high degree of
play a critical role in the cancer journey as variation in the test results and medical
gatekeepers. It is therefore important that advice. Treatment sees a similar trend. Cancer
GPs have adequate information about which patients often seek second opinion before
test to initially prescribe against which finalizing treatment plan. According to a 2015
symptom. It is also crucial to have a strong literature review 128, a second opinion leads to
referral mechanism so that the right change in diagnosis and treatment
specialists are being tapped by the GP. recommendations in 12 to 69% of cases.
► The Government should develop standard ► Co-ordinated cancer care with standard
protocols for diagnostic tests across different guidelines for diagnosis and treatment along
cancers so that clinicians, providers, and with seamless sharing of health information
diagnostic centers all follow uniform practices. across providers backed by technology is
Also, day care centers should either have therefore essential to reduce the number of
diagnostic facilities or tie up with diagnostic repeat tests and move the patient quickly
collection centers to provide greater access to from diagnosis to treatment. It is also
molecular diagnostics, histopathology, important to restore the trust of the patient
genomics etc., to patients since lack of confidence in the diagnosis stage
will make the patient sceptical about
► Patients tend to undergo multiple consults and
treatment, which in a disease like cancer has a
tests before confirming the cancer diagnosis.
degree of uncertainty with regimen changes
Lack of coordinated care at times leads to
and relapse not being uncommon.
misdiagnosis with varied test results,

128Ruetters, D., Keinki, C., Schroth, S. et al. Is there evidence for a systematic review. J Cancer Res Clin Oncol 142, 1521–1528
better health care for cancer patients after a second opinion? A (2016).

Call for Action: Making quality cancer care more accessible and affordable in India 100
National Cancer Grid (NCG) is an initiative by Government of India which was created in 2012 with the
aim of providing uniform standards of patient care across the country, spanning prevention, diagnosis
and treatment. The stated objectives also include providing specialized training and education and
facilitating collaborative research.

Since 2012, NCG has grown to a large network of ~255 cancer centers in India. While NCG has already
developed standard guidelines for various cancers, adherence is not mandatory and is optional for the
individual member institution. In order to achieve its objective, robust implementation with periodic
review and audit mechanism is essential.

In 2022, the NCG also set up the Koita Centre for Digital Oncology to enable adoption of digital health
tools across partner hospitals and drive initiatives like EMR adoption and data interoperability. The
center also focuses on digitization of health records and patient registries, with the ultimate goal of
transitioning to AI-based care.

The NCG website also provides links to expert second opinion through the ‘Navya’ portal, which
connects patients to specialists from reputed hospitals. Recently, PMJAY has also roped in services of
‘Navya’ to verify the line of treatment being prescribed by hospitals under Ayushman Bharat in order to
arrest any instances of over-treatment.

Theme 2: Need for a single source of comprehensive and authentic cancer information

► Post diagnosis, patients need

to take decisions on various 5%
4% Family physician/ Specialist doctor
aspects such as finalizing
9%
treating doctor, hospital, How did you
Friends/family/relatives
second opinion and treatment get to know 39%
10% Cancer support groups/ NGOs
about a
plan. The survey revealed that particular
patients usually rely on Online search
cancer center
information provided by for treatment?
Advertisement- Print/ TV/Radio/ Hoardings
doctors followed by friends,
Any other (Camps, etc)
family and relatives when it 33%
comes to deciding upon the
provider. Patients seeking
cancer information also use cancer support groups
and online searches. Cancer support groups and What are the key reasons for selecting a particular
doctor or hospital for treatment?
online searches are also used by patients seeking
cancer information. Dependence on multiple %
Of respondents who ranked the criteria
information sources sometimes leads to confusion among their top 3 reasons
and also increases the probability of encountering Rank
incorrect or unauthentic information. 1 Reputation of doctor 66%
► To counter this, a single reliable source providing all
required information is one way which can help 2 Hospital brand and reputation 66%
reduce the time between diagnosis to treatment.
Further, evaluating a government-run helpline or 3 Reference from other doctor 43%
‘Arogyasetu’ like app that provides support to
Recommendation by
patients by addressing their questions may help 4 41%
family/relatives/friends
gain access to timely information.
Affordable cost compared to
► Since most patients consider reputation of doctor 5 30%
other hospitals
and hospital as the reason for selection of provider,
access to a regularly updated database listing 6 Close to place of residence 29%
practicing doctors and oncology specialists along
One of the first comprehensive
with their medical credentials and accredited 7
cancer centers in the region
18%
hospitals specializing in cancer care could aid
patients making faster and more informed 8 Previous experience 6%
decisions.

101 Call for Action: Making quality cancer care more accessible and affordable in India
► Providers can also use these
survey insights to update their 2% Doctor profile
10%
websites with information on
Locations where facilities available
areas which patients seek
12% What information 34%
before finalizing treatment was available to Patient feedback on facility/experience with
you basis which doctors and staff wait times/outcomes
center. As highlighted from the you formed an Treatment cost
survey, patients want to know opinion on a
about doctor profiles, locations 16% particular cancer Technology used and associated outcomes
center?
where facilities are available, Any other
patient feedback, treatment 26%
cost, and technology. While
most hospitals provide
information about doctor profiles and facilities, access to patient feedback through testimonials,
creating a platform of cancer survivors who have undergone treatment in the same hospital to share
their experiences and transparent sharing of information on cost and outcomes may also help
patients.

Theme 3: Inefficiencies in hospital processes important to recognize that digital cannot

replace the human touch, especially when it
► The most common reason cited by patients comes to a disease like cancer. Comfort with
dissatisfied with their experience was high high-level automation is still evolving in India
waiting times. From a patient perspective, and therefore gradual integration of
waiting times between tests and delays in technology starting only with non-patient
scheduling appointments and surgeries seems facing administrative activities is essential so
like a general sense of indifference from that patients do not get overwhelmed. Also,
providers, which leads to widening trust deficit given that a large proportion of people in India
between patient and provider. Another area of do not have access to computers or the
process inefficiency highlighted by patients
internet easily, it becomes imperative to
was a large amount of paperwork associated
respect the interest of all patients from varied
with scheme beneficiaries.
socio-economic groups. Similarly, moving
► Adoption of simple technology interventions form-filling and paperwork to online modules
such as automated messages to patients should ensure availability in vernacular
informing them of delays, online appointment languages to cater to all patients.
systems which patients can themselves access ► Providers could also consider displaying
to book consultation slots without depending performance statistics on waiting times each
on receptionist or call center, online form month to re-assure patients of hospital’s
filling and approval process for scheme intent to improve efficiency. For instance, in
beneficiaries etc., could be some methods to the UK, monthly NHS Performance Statistics
bridge these gaps. While technology can help reports the provider-wise performance against
in making processes more efficient, it is target on cancer waiting times.

The NHS, UK currently has nine performance standards on cancer waiting times, which are proposed to
be streamlined to the following three standards:
1. A 28-day faster diagnosis standard (FDS) ensures the patients urgently referred, or having breast
symptoms, or having been picked up through screening, either have cancer ruled out or receive a
diagnosis within 28 days.
2. A 62-day referral to treatment standard, meaning patients who receive a cancer diagnosis will start
treatment within nine weeks from the date of referral.
3. A 31-day decision to treat to treatment standard, so that cancer patients receive their first
treatment within a month of a decision to treat following diagnosis.
The NHS publishes adherence to established standards as part of its monthly performance statistics,
which is an important quality indicator. Publishing performance against set targets also provides
visibility to patients, assuring them of the provider’s intent to bridge the gap on waiting times.

Call for Action: Making quality cancer care more accessible and affordable in India 102
Theme 4: Need for frequent, transparent, and any time is also an option providers can
effective communication between provider and evaluate. Again, while the providers can easily
patient give access to information through
technology, interpretation of the information,
► Any cancer patient’s journey is fraught with
which would inevitably contain medical terms,
uncertainties around the effectiveness,
needs to be done personally.
duration, and total cost of treatment. In such
a situation, patients and caregivers expect ► Having a dedicated nurse navigator or cancer
regular updates from the provider on their care coordinator in such a scenario is an
recovery. Cancer treatment is a long process effective solution, which some of the hospitals
which involves multiple cycles. While the have adopted. The role of nurse navigator is
effect of treatment may take time to manifest, to help patient navigate the complex
patients usually experience side effects almost treatment journey. In addition to assisting the
immediately after a single cycle. This worries patient on various administrative processes,
patients and their families who start nurse navigators also provide regular updates
questioning whether the treatment is working, and address various questions and concerns
which at times leads to patients to dropping of patients and caregivers. They also help in
out of treatment. breaking down complex medical diagnosis
information into simpler terms, which allows
► Given the large number of patients seen by a
patients to understand where they are in the
specialist in a day, it might not be feasible for
treatment process. Given the extreme
the doctor to personally spend so much time
proximity to patients and caregivers, it is
with patients and their caregivers. In order to
essential that nurse navigator courses and
ensure that the patients do not see this as an
training modules are designed to incorporate
act of indifference, the provider must provide
cultural sensitivity and patient dignity into
its patients regular updates electronically
their curriculums.
through mail or texts. Allowing the patient to
access his own file online to check progress at

The country of Malta 129 recently introduced nurse navigators to its cancer care services, to make
systems more patient centered. The initiative, lauded by the WHO, has demonstrated benefits such as
faster diagnosis, shorter time between diagnosis and start of treatment, increased patient and
caregiver knowledge, better adherence to recommended care, and reported improvements in quality of
life. The roll-out and evolution of the nurse navigator model initially involved collecting and analyzing
data to understand where service gaps existed from patient perspectives, and then making the case to
the Ministry for Health for investment. The business case demonstrated how the nurse navigator role
could benefit the overall health system, not only showing improvements to patient experience and a
reduction in service complaints, but also fewer hospital admissions and support for other members of
multidisciplinary teams.

129 https://www.who.int/europe/news/item/15-09-2022-malta--nurse-navigators--embody-patient-centred-care

103 Call for Action: Making quality cancer care more accessible and affordable in India
Theme 5: High cost of treatment and lack of treatment center that they could trust in their
quality care facilities locally location. Most patients had to undertake this
travel for 3 to 12 months.
► Affordability continues to be a major area of
concern for cancer patients. In the survey, Increased financial burden of indirect costs
64% of patients mentioned they did not have including travel and stay expenses, along with
any insurance or scheme coverage. More than the social burden of adjusting to a new city
half of the patients reported spending over whilst being outside the ambit of
INR5 lakhs on their treatment. In a country neighborhood or community support adds a
where annual per capita income (at current layer of distress for patients and caregivers.
prices) is INR1.5 lakhs 130, cancer treatment Many patients also report feeling guilty about
has the potential of bankrupting entire the toll their treatment takes on the lives of
households. Some key concerns regarding their family members and caregivers.
affordability voiced by patients are illustrated Additionally, traveling long distance for
below. treatment often emerges as a barrier to
treatment adherence.

Some simple steps such as providing daily

39% 21% 21% 19%
food vouchers or coupons to caregivers,
having tie-ups with nearby hotels or service
Fear significant Can only finance Lack confidence in Concerned about
reduction in their treatment by a healthy outcome their lack of apartments to provide accommodation
savings selling assets or
taking on debt
even after quality
treatment
insurance
coverage
options at subsidized rates, organizing local
conveyance from hotel to hospital, can help in
From a provider’s perspective, it is important enabling a supportive environment for
that the provider gives its patients and patients and their caregivers outside the
caregivers adequate visibility about the cost of confines of their homes.
the treatment during finalization of the
Efforts should be undertaken to deliver care to
treatment plan. Financial counseling informing
the patient near or within the comforts of
patients about insurance or scheme cover,
their home. Post-COVID-19, a larger
philanthropic funding options, patient
proportion of the population is comfortable
assistance programs as well as ensuring
with tele-consultation, which is reflected in the
complete billing transparency are some
survey as well with 37% of patients indicating
proactive steps that providers can focus upon
they would prefer to avail doctor consultation
to earn patient trust. Also, given that patients
near or at their residence. 25% also indicated
highlight low insurance coverage as a key pain
that they would prefer to undergo
point, the government could consider
chemotherapy services near their residence.
expansion of population coverage under
PMJAY to additionally include middle class A hub-and-spoke model of cancer care
population under the same. wherein the provider delivers common
► Non-availability of local cancer care facilities services like chemotherapy to patients
led to 78% of patients undertaking travel for through satellite or day care centers can help
treatment as indicated by the survey. 42% of bridge the gap around access. Details of the
patients had to travel more than 100 current state and recommendations around
kilometers. A third of patients who undertook affordability and access have been covered in
travel did so due to the absence of a an earlier chapter.

130 https://www.business-standard.com/article/economy-policy

Call for Action: Making quality cancer care more accessible and affordable in India 104
Theme 6: Gaps in post-treatment care ► Facilities for rehabilitation and long-term care
need to be made available. Patients and
► Cancer is seen as a chronic illness, which
caregivers also need to be made aware of
means that it never really goes away. Once
such facilities should they find it difficult to
there is a visible reduction in symptoms,
manage by themselves.
patients take a break from treatment and start
coming to terms with the ‘new normal’ of their ► Palliative care should be well-integrated in the
life. It is, however, essential they continue overall care plan of a cancer patient post
monitoring their health, maintain curated treatment. Community-based models with
diets, regulated activity along with periodic institutions providing supporting role are the
check-ups and follow-up consultations. way forward for palliative care.
► Providers need to engage in continuous ► Government should integrate alternative
follow-up with cancer patients post treatment medicine such as AYUSH, Yoga, Naturopathy
to ensure their well-being. Providers should into palliative care, in order to harness their
train caregivers and empower them to provide potential benefits. These interventions can
basic care at home and ensure immediate play an important role by providing relief from
access to nurse or doctor for any emergency. pain while also helping the psychological and
spiritual aspects of patient care.

Kerala government has been integrating palliative care with healthcare policy at all levels in a three-tier
system. The policy specifies neighborhood networks with trained staff who can identify patient needs
and provide home care at the primary level. The next two tiers are community health centers providing
in-patient care, taluk hospitals with staff trained to deal with emergencies: then a division of palliative
medicine at all medical colleges and general and district hospitals.

Civil society and volunteer groups have also played an instrumental role in the success of the palliative
care model in the state. Kerala today has 1,550 palliative care units, 450 of which are run by
community-based organizations and NGOs. Just 2% of people who need palliative care in India have
access to it, far below the global average of 14%. The figure for Kerala stands above 26%.131

Theme 7: Psychological burden of cancer whether the disease will come back, low self-
esteem due to body image issues such as loss
► Cancer patients tend to experience a range of
of hair. Perhaps the patient experiences the
negative emotions in their journey from
most devastating emotion when relapse
‘person’ to ‘patient 132’.
occurs, causing a sense of hopelessness.
► Staring with fear of disease, which often
► Psychological distress of cancer patients
manifests as a lack of screening practice, the
causes a significant difference in their mental
initial diagnosis results in shock, disbelief, and
and emotional health, which needs
disappointment. Acceptance of diagnosis is at
professional intervention. Positive mindset
times linked to spirituality or religious beliefs
and attitude is crucial in keeping up with the
with people relying on their faith and in God to
journey of cancer treatment, and therefore
give them strength to fight cancer, while many
integration of psycho-oncologists and
people choose to accept the diagnosis as pre-
therapists in the care process is important.
destined. Acceptance then gives way to
Psycho-oncologists can help patients cope
anxiety about how to inform family and
with the diagnosis and counsel them through
friends, how to plan treatment, how to
the journey to ensure they are not impacted
temporarily give up working, how to manage
by mental health issues. They can also help
finances, etc. Feelings of guilt also prevail
provide support and care to the caregiver,
with patients thinking of themselves as a
since a cancer diagnosis of a loved one equally
source of inconvenience to their family
devastates families as well.
members during the treatment process. Post
treatment, constant worry and uncertainty

131 https://www.thehindu.com/society/palliative-care-in-kerala-a-success-story
132 ecancer 2022, 16:1342, https://doi.org/10.3332/ecancer.2022.1342

105 Call for Action: Making quality cancer care more accessible and affordable in India
► Cancer support groups can play an important ► As providers, ensuring empathy at every step
role in supporting the patient through the by redesigning processes from the point of
psychological burden. Having undergone a view of the patient, could be one way to
similar journey, sharing of stories by cancer support them emotionally and mentally. The
survivors, along with providing access to entire eco-system of care, from doctor to
relevant information and people, could be a nurse to receptionist to pharmacist and right
great source of strength for a cancer patient. up to the housekeeping staff, should be made
to undergo compulsory training on cultural
sensitivity, humility and patient dignity.

Call for Action: Making quality cancer care more accessible and affordable in India 106
 Annexures

107 Call for Action: Making quality cancer care more accessible and affordable in India
Annexures
Annexure 1
State-wise population and cancer registry coverage in 2016

State/UT Population (In Crores) % Population coverage by PBCRs

Kerala 3.4 17%

Mizoram 0.1 97%

Tamil Nadu 7.8 6%

Karnataka 6.6 13%

Punjab 3.0 7%

Assam 3.4 13%

Delhi 1.8 94%

Maharashtra 12.1 23%

Arunachal Pradesh 0.2 64%

Meghalaya 0.3 60%

Madhya Pradesh 8.0 3%

West Bengal 9.7 5%

Gujarat 6.6 9%

Sikkim 0.1 98%

Tripura 0.4 98%

Nagaland 0.2 37%

Manipur 0.3 98%

Source: Census 2001 & 2011, PBCR 2016, EY Analysis

Call for Action: Making quality cancer care more accessible and affordable in India 108
Annexure 2
Following are the major risk factors associated with different cancer types and their trend in the recent
past:

Risk factor: Reproductive factors

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Reproductive factors ► Studies have shown that a woman’s risk of developing breast cancer is related to her
Risk factor for exposure to hormones that are produced by her ovaries.
► Breast Cancer ► Reproductive factors that increase the duration and/or levels of exposure to ovarian
hormones have been associated with an increase in breast cancer risk. These factors include
► Ovarian Cancer
increased median age of marriage, delayed childbirth, early onset of menstruation, late onset
of menopause and changing breast-feeding pattern

Trends of Exposure

► The median age of marriage among women age 25-49 in India is 19.2 years in 2021, up from
16.1 years in 1993
Delayed childbirth
► The median age at first birth among women age 25-49 in India is 21.2 years in 2021, up from
19.4 years in 1993

► Based on studies conducted, average age of menarche varies across India. Across majority of
Early onset of
the studies, it has emerged that 12-12.5 years is the typical age for menarche in India in
menarche
2017, which is a decrease of 1 year compared to 2005

► Total fertility rate (TFR), the average number of children that would be born to a woman if she
experiences the current fertility pattern throughout her reproductive span (15-49 years), has
Declining parity seen a steady decline from 3.4 in 1992-93 to 2 in 2019-21
level
► Women in rural areas have higher fertility, on average, than women in urban areas (TFR of 2.1
versus 1.6 children)

► While the median duration of exclusive breastfeeding has increased from 2.9 months in 2015-
16 to 3.9 months in 2019-21 and the median duration of any breastfeeding has also
Changing breast-
increased from 29.6 months to 32.1 months during the same period, on an average, children
feeding pattern
in urban areas are breastfed for shorter duration (median duration of 25.8 months) than their
counterparts in rural areas (median duration of 33.5 months).

► The oral contraceptive prevalence rate among currently married women age 15-49 who use
any forms of contraceptives increased from 4.3% in 2015-16 to 5.4% in 2019-21
Increasing oral ► Among currently married women age 15-49, women from Jammu & Kashmir (9.4%), Odisha
contraceptive use (10.9%), West Bengal (20.4%), Assam (28.5%), Arunachal Pradesh (15.9%), Mizoram (15.2%),
Sikkim (23.3%) & Tripura (32.6%) use higher proportion of oral contraceptives than national
average consumption i.e., 5.4% of overall women in 2019-21.

Source: MoHFW: Ministry of Health and Family Welfare, NFHS-5

109 Call for Action: Making quality cancer care more accessible and affordable in India
Risk factor: Sexual habits and poor hygiene

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Sexual habits & poor ► Sexual promiscuity and poor menstrual hygiene are key risk factors linked with cervical
hygiene cancer
► Cervical cancer

Trends of Exposure

► In India, 64% women age 16-24 use sanitary napkins, 50% use cloth, and 15% use locally
prepared napkins, as per NFHS-5, 2022, compared to 42%, 62% & 16 % of respective hygienic
Menstrual hygiene methods of protection during the menstrual period in 2015-16
► 73% of rural women use a hygienic method of menstrual protection, compared with 90% of
urban women

► Reported prevalence of multiple sexual partners and high-risk sexual behavior in India has
Poor sexual
decreased from 0.7% in 2016 to 0.3% in 2021 among women and 7% in 2016 to 4% in 2021
history
among men

Risk factor: Infection and immunity level

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Infection and ► According to studies, HPV types 16 and 18 are responsible for almost 70% of cervical
immunity level cancers
► Cervical cancer ► Studies on gallbladder cancer revealed consistent associations with chronic bacterial
► Gall bladder cancer infections, such as S.typhi, S. paratyphi and H. pylori
► Various studies in India have documented presence of gall stone in 70–90% of patients with
gall bladder cancer

Trends of Exposure

► While the global prevalence of cervical HPV 16/18 among women is 4%, the prevalence in
India is 5%
HPV Infection
► Studies carried out in India have highlighted higher than national average prevalence rate of
HPV in select regional pockets, viz., West Bengal (5.8%), Varanasi (9.7%) and Tamil Nadu (14%)

► The adult HIV prevalence among males (15-49) years was 0.24% in 2019 and 0.20% for
females during the same period

HIV Infection ► The states which have adult HIV prevalence higher than the national averages are Mizoram
(2.32%), Nagaland (1.45%), Manipur (1.18%), Andhra Pradesh (0.68%), Meghalaya (0.54%),
Telangana (0.49%), Karnataka (0.47%), Delhi (0.41%), Maharashtra (0.36%), Punjab (0.27%)
and Tamil Nadu (0.23%)

► Helicobacter species has been associated with increased risk of gall bladder cancer
Bacterial Infection ► A systematic review of 37 studies on typhoid and 18 studies on paratyphoid in India between
1950 – 2015, highlighted 9.7% and 0.9% prevalence of typhoid and paratyphoid respectively
increasing risk for gall bladder cancer

► In a study conducted in 2019, out of 213 patients with gallstones across two centers in North
Gall Stones India and North East India, metaplasia was present in 86% of routine cholecystectomy
specimen for symptomatic gallstone of patients operated.

Call for Action: Making quality cancer care more accessible and affordable in India 110
Risk factor: Obesity and physical inactivity

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Obesity and physical ► Overall, there has been a slight increase in the mean BMI for women from 21.9 in 2015-16 to
inactivity 22.4 in 2019-21.
Risk factor for: ► The mean BMI for men is the same as that of women (22.4) in 2019-21, a slight increase
from 21.9 for women and 21.8 for men in 2015-16
► Breast cancer
► Obesity has increased in both men and women in India during the last five years, proportion
► Cervical cancer
of overweight/obese women aged 15-49 increased from 21% in 2015-16 to 24% in 2019-21
► Ovarian cancer and that of men increased from 19% to 23%
► Gall bladder cancer ► The proportion of overweight children grew from 2.1% in 2015-16 (NFHS-4) to 3.4% in 2019-
Obesity is a growing 20 (NFHS-5)
concern. ► Overall BMI in Delhi (24.25), Haryana (23.2), Punjab (23.9), Sikkim (24.1), Karnataka (24),
Kerala (23.5) and Tamil Nadu (24.15) are higher than the national average of 22.4
It is the leading cause
of several non- ► Proportion of population with BMI higher than normal is more in most other countries in
communicable and comparison i.e., the US, the UK, Brazil, Thailand, China.
progressive diseases,
such as hypertension,
diabetes and those
related to liver and
increased risks of
stroke

Obesity across countries in 2018

Obesity and overweighted population across countries

India Brazil Thailand Indonesia China US UK

Male Female

Source: NFHS-5, Global obesity Observatory 2018

*For Thailand breakup between male female not available

111 Call for Action: Making quality cancer care more accessible and affordable in India
State wise trend – population with overweight and obese BMI (>=25)

Percentage of population age > 15yrs with obesity and overwighted across key states in
India

23%
India
24%

38%
Delhi
41%

32%
Punjab
41%

16%
Madhya Pradesh
17%

16%
West Bengal
23%

28%
Arunachal Pradesh
24%

16%
Assam
15%

30%
Manipur
34%

14% Male
Meghalaya
12%
Female
32%
Mizoram
24%

24%
Nagaland
14%

36%
Sikkim
35%

24%
Tripura
22%

33%
Gujarat
23%

20%
Maharashtra
24%

45%
Karnataka
30%

31%
Kerala
38%

Call for Action: Making quality cancer care more accessible and affordable in India 112
Risk factor: Tobacco use

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Tobacco consumption ► 38% of men and 9% of women aged 15 and over currently use any tobacco products
Risk factor for: ► Among men as well as women, the use of tobacco is higher in rural areas (43% for men and
11% for women) than in urban areas (32% for men and 6% for women)
► Lung cancer
► There is an equally clear and continual decrease in tobacco use with increasing wealth
► Head and neck
quintiles. Over 21% men in the highest wealth quintile use tobacco, in comparison with 58% of
cancer
men in the lowest wealth quintile. 17% women in the lowest wealth quintile use tobacco.
► Cervical cancer
► More than 60% men and about 10% of women with no/less than five years of schooling use
About 3 in 10 Indian some form of tobacco
tobacco users said ► 46% men smoke an average of five or more cigarettes/bidis each day
they tried to stop using ► Use of tobacco is significantly higher among men in India (38%) than the US (28%) and the UK
tobacco in any form in (17%) while slightly lower in case of females (US – 18%; UK-14%), while developing nations
the 12 months like Indonesia and China have much higher tobacco consumption for men (Indonesia – 71%;
preceding the NHFS-5 China – 49%) and lower for women (Indonesia – 4%; China – 2%)
survey
61% female and 54%
males who visited a
doctor/health care
provider in the 12
months preceding the
survey were advised to
stop

Tobacco consumption across countries

Tobacco Consumption across countries 2020

71%

49%
41% 41%
28%
16% 18% 17% 14%
13%
9%
3% 4% 2%

India Brazil Thailand Indonesia China US UK

Male Female

Source: World Bank data 2020

Regional tobacco use by gender

Tobacco use by sex and residence % of females and males in India, age 15-49 (2019-21)

43%
38%
29%

11% 9%
6%

Females Males
Urban Rural Total

Source: NFHS-5

113 Call for Action: Making quality cancer care more accessible and affordable in India
Risk factor: Alcohol consumption

Key Risk Factor Reasoning for high propensity to cancer by the risk factors

Alcohol consumption ► 19% of men and 1% of women aged 15 and over consume alcohol currently
Risk factor for: ► The proportion of men who drink alcohol decreased, from 29% to 22%, between 2015-16
(NHFS-4) and 2019-21 (NFHS-5). During that period, the proportion of women who consume
► Breast cancer
alcohol also declined from 1.2% to 0.7%.
► Head and neck
► Among the women who consume alcohol, 17% drink almost every day and 37% about once a
cancer
week. Among the men who consume alcohol, 15% drink alcohol almost every day and 43%
Alcohol has been about once a week
shown to permanently
damage the DNA
strands in the cell,
inhibit DNA repair
processes from
functioning and lead to
nutritional deficiencies
Even moderate alcohol
intake has been shown
to increase the risk of
developing female
breast cancer

Consumption of alcohol over time across genders

% of men and women who consumed alcohol

31.9% 29.2%
22.4%

2.2% 1.2% 0.7%

Females Males
2005-06 2015-16 2019-21

The following table provides a per capita alcohol consumption in India in 2010 vs. 2016

Recorded consumption has increased by a CAGR of 2% over the 6 years whereas unrecorded consumption
has increased by 10%, evidencing the behavioral habits of Indians, with regards to illegal consumption of
alcohol, or not providing data for the consumption patterns.

The consumption by Indian males over both years has been almost 2x of the WHO South-East Asia Region
benchmark
Consumption of alcohol over time across genders

Alcohol per capita (15+) consumption (in liters) in India

2010 2016
Recorded 2.7 3.0
Unrecorded 1.5 2.6
Total** 4.3 5.7
Total males/females 7.1 1.3 9.4 1.7
WHO South-East Asia Region 3.5 4.5

Source: NFHS-5, WHO: Global status report on alcohol and health 2018

Call for Action: Making quality cancer care more accessible and affordable in India 114
Annexure 3
Framework for projection of overall crude incidence adjusting for demographic and risk factor
exposures

1. Calculation of the crude rate using pooled 2012-

2016 data from population-based registries
Calculation of population using decadal population
2. Calculation of CAGR of crude rate using 2012
growth rate during 2001-11
crude rate data and using this project the crude
rates for future years

Projected crude rate for Projected population

year for the year

Total projected incidence for population adjusted for

demographical changes

(1 + ∆PAF (%))
Adjustment for risk factor exposures

Total projected incidence for population adjusted for change in

demographics and risk factor exposure

Framework for adjusting incidence rates based on risk factor exposure

Population Attributable
Fraction (PAF) Difference
Risk factor profile¶ India UK India UK UK v. India
Tobacco prevalence (%, 2019) 8.60 16.10 8.60 16.10 7.50
Alcohol per capita consumption
5.61 11.45 1.62 3.30 1.68
(liters, 2019)
BMI >25 kg/m2 (%, 2019) 19.70 63.70 1.95 6.30 4.35
Physical inactivity prevalence (%,
34.03 35.86 0.47 0.50 0.03
2016)
Cumulative difference in exposure (∆PAF%) 13.56

Parameter Risk factor exposure correction

Additional cases expected if PAFs
Estimated Incidence year x ΔPAF expressed as a ratio
mirror the UK levels
Incidence adjusted for risk factor Estimated Incidence year + Additional cases expected if PAFs mirror the
exposure UK levels

Multiple risk factor exposure is not factored in this calculation, nor are other risk factors for specific cancers such as infectious
agents, low fiber diet etc.
Source: WHO Global health observatory; Katrina et al, (2018)

115 Call for Action: Making quality cancer care more accessible and affordable in India
Framework for projection of prevalence: estimation of survival ratio

Parameter Method of estimation

Survival ratio, ► Pooled five-year survival of solid tumors was calculated from data
2010-14 ► Pooled survival data from CONCORD-3 study, for India, was 32.9% which is 5%
higher as compared to figure used by Takier et al. for 1999
► Assuming a similar improvement in the one year survival a non-linear regression curve
was fitted to obtain survival rates with the two known points
► Survival for the projected year was assumed to be unchanged

Curve-fit – non-linear regression

Survival% Years
0.606 1
0.487 2
0.417 3
0.367 4
0.329 5
0.298 6
0.271 7
0.248 8
0.228 9
0.210 10

Survival Rate
0.7
0.6
0.5
0.4
Survival ratio

0.3
0.2
0.1
0.0
0 1 2 3 4 5 6 7 8 9 10 11
Years

y = -0.172ln(x) + 0.606

Call for Action: Making quality cancer care more accessible and affordable in India 116
Framework for projection of prevalence: estimation of prevalence to incidence (P/I) ratio

The non-linear regression curve is used to calculate year-on-year prevalence or survival based on the reported
incidence level for all cancer types for women. The P/I ratio for the derived prevalence was then plotted till a
steady state was reached

5.0
4.5
4.0 3.48 3.49 Steady state
3.37
3.5 P/I ratio was
2.80 observed to
P/I Ratio

3.0
2.5 be 3.49
2.0
1.5
1.0 0.61
0.5
0.0
0 5 10 15 20 25 30 35
Year

Prevalence (all sites)year= (Steady state P/I ratio) x (Reported incidence year)

Incidence (’000) 1,231 1,313 1,400 1,493 1,592

P/I
Survival ratio Year Year Year Year Year Prevalence Incidence (Prevalence/
-0.172ln(x) + 0.606 1 2 3 4 5 (’000) (’000) Incidence)
0.606 Yr 1 746 746 1,231 0.61
0.487 2 599 796 1,395 1,313 1.06
0.417 3 513 639 848 2,000 1,400 1.43
0.367 4 452 547 681 905 2,586 1,493 1.73
0.329 5 405 482 584 727 965 3,162 1,592 1.99

Illustrative: Calculation of prevalence to incidence ratio

(Incidence for the year) x Summation of prevalence Estimated

(Corresponding survival ratio) for the year incidence

117 Call for Action: Making quality cancer care more accessible and affordable in India
Annexure 4
List of localized surveys for awareness insights

1. Taneja N, Chawla B, Awasthi AA, Shrivastav KD, Jaggi VK, Janardhanan R. Knowledge, Attitude, and Practice on
Cervical Cancer and Screening Among Women in India: A Review. Cancer Control. 2021 Jan-
Dec;28:10732748211010799. doi: 10.1177/10732748211010799. PMID: 33926235; PMCID: PMC8204637.
2. Gravely S, Fong GT, Driezen P, Xu S, Quah AC, Sansone G, Gupta PC, Pednekar MS. An examination of the
effectiveness of health warning labels on smokeless tobacco products in four states in India: findings from the TCP
India cohort survey. BMC Public Health. 2016 Dec 13;16(1):1246. doi: 10.1186/s12889-016-3899-7. PMID:
27964733; PMCID: PMC5154141.
3. Chellapandian P, Myneni S, Ravikumar D, Padmanaban P, James KM, Kunasekaran VM, Manickaraj RGJ, Puthota
Arokiasamy C, Sivagananam P, Balu P, Meesala Chelladurai U, Veeraraghavan VP, Baluswamy G, Nalinakumari
Sreekandan R, Kamaraj D, Deiva Suga SS, Kullappan M, Mallavarapu Ambrose J, Kamineni SRT, Surapaneni KM.
Knowledge on cervical cancer and perceived barriers to the uptake of HPV vaccination among health
professionals. BMC Womens Health. 2021 Feb 12;21(1):65. doi: 10.1186/s12905-021-01205-8. PMID:
33579263; PMCID: PMC7881592.
4. Ramakant P, Singh KR, Jaiswal S, Singh S, Ranjan P, Rana C, Jain V, Mishra AK. A Survey on Breast Cancer
Awareness Among Medical, Paramedical, and General Population in North India Using Self-Designed
Questionnaire: a Prospective Study. Indian J Surg Oncol. 2018 Sep;9(3):323-327. doi: 10.1007/s13193-017-
0703-9. Epub 2017 Sep 5. PMID: 30287991; PMCID: PMC6154372.
5. Reichheld A, Mukherjee PK, Rahman SM, David KV, Pricilla RA. Prevalence of Cervical Cancer Screening and
Awareness among Women in an Urban Community in South India-A Cross Sectional Study. Ann Glob Health. 2020
Mar 16;86(1):30. doi: 10.5334/aogh.2735. PMID: 32211300; PMCID: PMC7082824.
6. Pradhan A, Oswal K, Adhikari K, Singh A, Kanodia R, Sethuraman L, Venkataramanan R, Sorensen G, Nagler E,
Pednekar M, Gupta P, Purushotham A. Key Drivers to Implement an Evidence-based Tobacco Control Programme
in Schools of India: A Mixed-Methods Study. Asian Pac J Cancer Prev. 2021 Feb 1;22(2):419-426. doi:
10.31557/APJCP.2021.22.2.419. PMID: 33639656; PMCID: PMC8190370.
7. Yadav A, Singh PK, Yadav N, et alSmokeless tobacco control in India: policy review and lessons for high-burden
countriesBMJ Global Health 2020;5:e002367.
8. Prusty, R.K., Begum, S., Patil, A. et al. Knowledge of symptoms and risk factors of breast cancer among women: a
community based study in a low socio-economic area of Mumbai, India. BMC Women's Health 20, 106 (2020).
https://doi.org/10.1186/s12905-020-00967
9. Sahu DP, Subba SH, Giri PP. Cancer awareness and attitude towards cancer screening in India: A narrative review.
J Family Med Prim Care. 2020 May 31;9(5):2214-2218. doi: 10.4103/jfmpc.jfmpc_145_20. PMID: 32754476;
PMCID: PMC7380789.
10. Singh PK, Yadav A, Singh L, Singh S, Mehrotra R. Social determinants of dual tobacco use in India: An analysis
based on the two rounds of global adult tobacco survey. Prev Med Rep. 2020 Mar 4;18:101073. doi:
10.1016/j.pmedr.2020.101073. PMID: 32257776; PMCID: PMC7125349.
11. Prusty RK, Begum S, Patil A, Naik DD, Pimple S, Mishra G. Increasing breast cancer awareness and breast
examination practices among women through health education and capacity building of primary healthcare
providers: a pre-post intervention study in low socioeconomic area of Mumbai, India. BMJ Open. 2021 Apr
27;11(4):e045424. doi: 10.1136/bmjopen-2020-045424. PMID: 33906843; PMCID: PMC8088239.
12. Nisha B, Murali R. Impact of Health Education Intervention on Breast Cancer Awareness among Rural Women of
Tamil Nadu. Indian J Community Med. 2020 Apr-Jun;45(2):149-153. doi: 10.4103/ijcm.IJCM_173_19. Epub
2020 Jun 2. PMID: 32905196; PMCID: PMC7467190.
13. Mishra GA, Shaikh HA, Pimple SA, Awasthi AA, Kulkarni VY. Determinants of Compliance to Population-Based Oral
Cancer Screening Program among low Socioeconomic Women in Mumbai, India. Indian J Community Med. 2021
Apr-Jun;46(2):210-215. doi: 10.4103/ijcm.IJCM_190_20. Epub 2021 May 29. PMID: 34321728; PMCID:
PMC8281837.
14. Shankar A, Roy S, Rath GK, Chakraborty A, Kamal VK, Biswas AS. Impact of Cancer Awareness Drive on
Generating Understanding and Improving Screening Practices for Breast Cancer: a Study on College Teachers in
India. Asian Pac J Cancer Prev. 2017 Jul 27;18(7):1985-1990. doi: 10.22034/APJCP.2017.18.7.1985. PMID:
28749636; PMCID: PMC5648409.

Call for Action: Making quality cancer care more accessible and affordable in India 118
15. Mathew G, Sebastian SR, Benjamin AI, Goyal V, Joseph J, Sushan A, Samuel AK, Sheeja AL. Community-based
burden, warning signs, and risk factors of cancer using public-private partnership model in Kerala, India. J Family
Med Prim Care. 2020 Feb 28;9(2):745-750. doi: 10.4103/jfmpc.jfmpc_1030_19. PMID: 32318413; PMCID:
PMC7114058.
16. Shin SS, Carpenter CL, Ekstrand ML, Wang Q, Grover S, Zetola NM, Yadav K, Sinha S, Nyamathi AM. Cervical
cancer awareness and presence of abnormal cytology among HIV-infected women on antiretroviral therapy in
rural Andhra Pradesh, India. Int J STD AIDS. 2019 May;30(6):586-595. doi: 10.1177/0956462419825950.
Epub 2019 Feb 27. PMID: 30813859; PMCID: PMC6510620.
17. Pramesh, C & Chaturvedi, Harit & Reddy, Vijay & Saikia, Tapan & Ghoshal, Sushmita & Pandit, Mrinalini & K,
Govind Babu & Ganpathy, K & Savant, Dhairyasheel & Mitera, Gunita & Booth, Christopher. (2019). Choosing
Wisely India: ten low-value or harmful practices that should be avoided in cancer care. The Lancet Oncology. 20.
10.1016/S1470-2045(19)30092-0.
18. The Lancet Oncology. Progress on tobacco control and e-cigarettes. Lancet Oncol. 2022 Aug;23(8):961. doi:
10.1016/S1470-2045(22)00454-5. PMID: 35901815.
19. Rashid S, Labani S, Das BC. Knowledge, Awareness and Attitude on HPV, HPV Vaccine and Cervical Cancer among
the College Students in India. PLoS One. 2016 Nov 18;11(11):e0166713. doi: 10.1371/journal.pone.0166713.
PMID: 27861611; PMCID: PMC5115771.
20. Krishnamoorthy Y, Ganesh K, Sakthivel M. Prevalence and determinants of breast and cervical cancer screening
among women aged between 30 and 49 years in India: Secondary data analysis of National Family Health Survey -
4. Indian J Cancer. 2022 Jan-Mar;59(1):54-64. doi: 10.4103/ijc.IJC_576_19. PMID: 33753601.

Annexures 5
Key Assumptions in computing RT requirement

No. of people requiring radiotherapy 60% of total new patients

Incidence of Cancer (Annual) - 2022 120 Per lakh of population
Incidence of Cancer (Annual) – 2030 260 Per lakh of population
Incidence of Cancer (Annual) – 2030 (Conservative) @ 5% crude
177 Per lakh of population
incidence rate growth
Number of fractions per patients 25
Number of Fractions per day (Capacity/ Optimal) 100
Number of Fractions per day (@50% utilization) 50
Working days 200
Equipment requiring replacement (2022) 15
Equipment requiring replacement (by 2030) 500
Ratio of Level 3 (Basic LINAC): Level 2 (VMAT): Level 1 (SBRT/Tomo) 1:3:22

Key steps in computing RT requirement

1. Clustering of districts with population lesser than 10 lakhs
2. Estimation of optimal requirement basis key assumptions detailed out in the assumptions table
3. Mapping of Current RT basis list in AERB website. Increment of 24% added to each district to bridge
the gap of actual RT count (640) and count available in the AERB website (537)
4. Incremental requirement for 2022 and 2030 computed at the district level
5. Optimal RT requirement and Current RT is split into multiple levels within each state basis the ratio of
Level 3: Level 2: Level 1 assumption in the assumptions table
6. Increment requirement for each level computed at the country level
7. Capital outlay estimated basis cost assumptions for different type of LINAC equipment

119 Call for Action: Making quality cancer care more accessible and affordable in India
Annexure 6
Key Assumptions in computing PET-CT requirement

No. of people requiring PET-CT 50% of total new patients

No. of scans required per person 3
No. of scans per day per machine 18
No. of working days 300

Note: Same incidence assumptions as annexure 5

Annexure 7
Key Assumptions in computing requirement of Day care and Surgical beds

70% of total new patients

% New cases requiring/receiving chemotherapy
20% of prevalent cases
Number of chemotherapy cycles per patient 4–6
Number of chemotherapy cycles per day care
3
bed/day
% New cases requiring/receiving surgical treatment 70% of total new patients
Average length of stay for surgeries 5
No. of operational days 365

Note: Same incidence assumptions as annexure 5

Annexure 8
Key Assumptions in computing requirement of oncologists and medical physicist

Number of patients treated by medical oncologist

480
per year
Number of patients treated by medical oncologist
320
per year
Number of surgeries by surgical oncologist per day 1–2
Number of days on which surgery is performed per
300
year
Number of patients treated by medical physicist per
500
year

Note: Same incidence assumptions as annexure 5

Call for Action: Making quality cancer care more accessible and affordable in India 120
Annexure 9
Key Assumptions in computing requirement of CCCs

Number of patients treated by a CCC per year 2,000

% Patients receiving multimodal treatment 40%

Notes:
1. Each district/ district cluster with sizable new cancer patients per year (>2,500) to have at least one CCC.
2. Requirement computed at district cluster level (Cluster of nearby districts with > 10 lakh population)
3. Same incidence assumptions as annexure 5

Annexure 10
Karkinos’s approach to management of patient journey

Key stages of
patient journey Karkinos’s approach to management of patient journey
► Online proprietary risk assessment tool including
questionnaire with 64-65 parameters for patients to
assess their risk susceptibility for cancer.
1. Awareness
► Validation of submitted information at command centre by
trained team. Call backs to patient by trained nurses to
verify and validate information wherever required.
► Based on risk assessment patient can be guided to
undertake screening tests at partner locations near to the
patient’s home setting. Screening tests could include
Clinical Breast Examination (CBE), USG, Mammogram, CT
etc., Results of the screening test will be recorded in the
health records of patient maintained by Karkinos.
2. Screening and
Diagnostics

► Based on outcomes of the screening test patient can be

guided to local health facility for biopsy. Results of the
biopsy will be maintained in health records of patient at
Karkinos. Depending on the results, the case will be taken
forward for evaluation by Virtual Tumor Board.

► Karkinos’s inhouse team of expert clinicians to evaluate

every patient case in Virtual Tumor Board and generate
3a). Treatment appropriate treatment protocol to be recommended for
patient care. Karkinos has currently empanelled ~450
clinicians on board.

121 Call for Action: Making quality cancer care more accessible and affordable in India
Key stages of
patient journey Karkinos’s approach to management of patient journey
3b). Treatment and ► Patient’s will be provided option to take up treatment at
Post any of the partner locations of Karkinos. Karkinos has Chemo Day Surgical
Care Center Center
Treatment plans to partner with ~50 treatment centers in year 1,
~100 in year 2 and ~400 in year 3.
► Patient’s can also choose to opt out of the Karkinos
network and take up treatment with any other provider of
their choice.
► Karkinos will be partnering with insurance companies to Radiation Palliative Care
provide different coverage options for patients such as – Center Center
► Option 1 End to end managed care from risk
assessment to treatment and post treatment care
► Option 2 Only risk assessment, screening and
diagnostics
► Option 3 Risk assessment, screening, diagnostics
and treatment protocol/case review by Tumour Board
► A key enabler to the entire program will be the end to end
health record of the patient which will be maintained and
managed across the patient journey. Karkinos’s
proprietary interoperable EMR system is aimed towards
ensuring seamless patient information exchange and
clinical decision making a possibility in this program.

Call for Action: Making quality cancer care more accessible and affordable in India 122
Abbreviations
Abbreviation Full form
3D CRT 3-Dimensional Conformal Radiation Therapy
AB Ayushman Bharat
AB - ArK Ayushman Bharat-Arogya Karnataka Scheme
ABHA Ayushman Bharat Health Account
ACDC Awareness-cum-de-addiction Camp
AERB Atomic Energy Regulatory Board
AI/ML Artificial Intelligence/ Machine Learning
AIIMS All India Institute of Medical Sciences
AHBCR Apollo Hospital Based Cancer Registry
ALL Acute Lymphoblastic Leukemia
AML Acute Myeloid Leukemia
ANM Auxiliary Nurse Midwife
AP Andhra Pradesh
APJCP Asia Pacific Journal for Cancer Prevention
AQI Air Quality Index
ASEAN Association of Southeast Asian Nations
ASHA Accredited Social Health Activist
ASR Age-specific incidence rates
ASR-W Age-specific incidence rates – weighted
AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy
BC Breast Cancer
BMI Body Mass Index
BPL Below Poverty Line
BRICS Brazil, Russia, India, China, and South Africa
BSKY Biju Swasthya Kalyan Yojana
CAGR Compounded Annual Growth Rate
CAPED Cancer Awareness, Prevention and Early Detection
CAR – T Cell Chimeric antigen receptor T Cell
CBE Clinical Breast Examination
CCCs Comprehensive Cancer care Centres
CDSS Clinical Decision Support System
CGHS Central Government Health Scheme
CHCs Community Health Centres
CHE Catastrophic Health Expenditure
CHL Classical Hodgkin Lymphoma
CHO Community Health Officer
CHW Community Health Worker
CLL Chronic Lymphocytic Leukemia
CMCHIS Chief Minister's Comprehensive Health Insurance Scheme

123 Call for Action: Making quality cancer care more accessible and affordable in India
Abbreviation Full form
CML Chronic Myeloid Leukemia
COE Centre of Excellence
COTPA Cigarettes and Other Tobacco Products Act
CR Crude Rate
CRC Colorectal Cancer
cSCC Cutaneous Squamous Cell Carcinoma
CSR Corporate Social Responsibility
CT Computed Tomography
DALY Disability Adjusted Life Year
DESH Detect Early and Save Him/Her
DH District Hospital
DiNC Digital Nerve center
DM Doctorate of Medicine
DMG Disease Management Group
DNA Deoxyribonucleic Acid
DNB Diplomate of National Board
ECHS Ex-Servicemen Contributory Health Scheme
EISE Ethicon institute of Surgical Education
EMR Electronic Medical Record
ENDS Electronic Nicotine Delivery Systems
ENT Ear, Nose and Throat
EPA Environmental Protection Agency
ESCC Esophageal Squamous Cell Carcinoma
ESI Employees' State Insurance
ESIC Employees' State Insurance Corporation
ESIS Employees' State Insurance Scheme
EU European Union
FD-G Fludeoxyglucose (18 F)
FDS Faster Diagnosis Standard
FICCI Federation of Indian Chambers of Commerce and Industry
FY Financial Year
GATS Global Adult Tobacco Survey
GC Gastric Cancer
GCRI The Gujarat Cancer & Research Institute
GDP Gross Domestic Product
GEJ Gastro Esophageal Junction
GI Gastrointestinal
GIST Gastrointestinal Stromal Tumor
GoI Government of India
GP General practitioner
GST Goods and Services Tax
GYTS Global Youth Tobacco Survey
H&N Head and Neck
HBCR Hospital Based Cancer Registry
HCC Hepatocellular Carcinoma
HCG Healthcare Global Enterprises Ltd
HCP Healthcare Practitioner
HER2 Human Epidermal Growth Factor Receptor 2
HIS Health Information System

Call for Action: Making quality cancer care more accessible and affordable in India 124
Abbreviation Full form
HNSCC Head and Neck Squamous Cell Carcinoma
HPV Human Papillomavirus
HR Human Resources
HWC Health and Wellness Centre
IAEA International Atomic Energy Association
IARC International Agency for Research on Cancer
ICMR Indian Council of Medical Research
I-ELCAP International Early Lung Cancer Action Program
IGRT Image Guided Radiation Therapy
IGST Integrated Goods and Services Tax
IHC Immunohistochemistry
IMRT Intensity Modulated Radiation Therapy
INR Indian Rupee
IP Inpatient
IPHS Indian Public Health Standards
IRCA Integrated Rehabilitation Centre for Addicts
IRDAI Insurance Regulatory and Development Authority of India
IT Information Technology
JCI Joint Commission International
KAP Knowledge, Attitude and Practice
KS Key States
LC Lung Cancer
LCDT Lung Cancer Diagnostic Test
LINAC Linear Accelerator
LPL Dr Lal PathLabs Ltd
M/I Mortality to Incidence
MBBS Bachelor of Medicine, Bachelor of Surgery
MCC Merkel Cell Carcinoma
MCH Master of Chirurgiae
MD Doctor of Medicine
MDC Medanta’s Multi-disciplinary Care
MDT Multi-Disciplinary Tumor board/ Multi-Disciplinary Treatment
MJPJAY Mahatma Jyotirao Phule Jan Arogya Yojana
MM Multiple Myeloma
MMPCRK Mukh Mantri Punjab Cancer Raahat Kosh
Mn Million
MO Medical Officer
MOHFW Ministry of Health and Family Welfare
MP Madhya Pradesh
MPCE Monthly Per Capita Expenditure
MPW Medical Peace Work
MRI Magnetic Resonance Imaging
MRP Maximum Retail Price
NA Not Available
NABH National Accreditation Board for Hospitals
NCCD National Calamity Contingent Duty
NCD Non-communicable diseases
NCDIR National Centre for Disease Informatics and Research
NCG National Cancer Grid

125 Call for Action: Making quality cancer care more accessible and affordable in India
Abbreviation Full form
NCR National Capital Region
NCRP National Cancer Registry Programme
NDPS Narcotic Drugs and Psychotropics Substances Act
NFHS National Family Health Survey
NGO Non-Government Organisation
NGS Next-Generation Sequencing
NH Narayana Hrudayalaya Limited
NHA National Health Authority
NHL Non-Hodgkin's Lymphoma
NHS National Health Service
NISER National Institute of Science Education and Research
NLEM National List of Essential Medicines
NLST National Lung Screening Trial
NPCDCS National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
NSCLC Non-small Cell Lung Cancer
NSS Nation Sample Survey
NTCP National Tobacco Control Programme
OBG Obstetrics and gynecology
OOPE Out Of Pocket Expenditure
OPD Outpatient Department
OVE Oral Visual Examination
P/I Prevalence/Incidence
PACS Picture Archiving and Communication System
PAF Population Attributable Fraction
PBCR Population-Based Cancer Registry
PET Positron Emission Tomography
PET-CT Positron Emission Tomography – Computed Tomography
PG Post Graduate
PGI Post Graduate Institute
PHCs Primary Health Centers
PLI Production Linked Incentive
PM Particulate Matter
PMBCL Primary Mediastinal Large B-cell Lymphoma
PMJAY Pradhan Mantri Jan Arogya Yojana
PPP Public private partnership
PSA Prostate Specific Antigen
QOF Quality Outcomes Framework
QoL Quality of Life
RBI Reserve Bank of India
RCC Renal Cell Carcinoma
RGCI Raji Gandhi Cancer Institute
RGUHS Rajiv Gandhi University of Health Sciences
RIS Radiology Information System
RMO Resident Medical Officer
RRTC Regional Resource and Training Centre
RSBY Rashtriya Swasthya Bima Yojana
RT Radiotherapy
RWA Resident Welfare Association
SBE Self Breast Examination

Call for Action: Making quality cancer care more accessible and affordable in India 126
Abbreviation Full form
SBRT Stereotactic Body Radiation Therapy
SC Sub Centre
SCI State Cancer Institute
SCLC Small Cell Lung Cancer
SEER Surveillance, Epidemiology and End Results Program
SRS Stereotactic Radiosurgery
SSKM Seth Sukhlal Karnani Memorial Hospital
TB Tuberculosis
TC Thyroid Cancer
TCCC Tertiary Cancer Care Centre
TFR Total Fertility Rate
TMH Tata Memorial Hospital
TURBT Transurethral Resection of Bladder Tumor
UAE United Arab Emirates
UC Ulcerative Colitis
UG Under Graduate
UICC Union for International Cancer Control
UK United Kingdom
UMPCE Urban Monthly Per Capita Expenditure
UP Uttar Pradesh
USA United States of America
USFDA U.S. Food and Drug Administration
USG Ultrasonography
USP Unique Selling Point
UT Union Territory
UV Ultraviolet
VGF Viability Gap Funding
VIA Visual Inspection through Acetic Acid
VMAT Volumetric Modulated Arc Therapy
VTB Virtual Tumor Board
WHO World health Organization
YLD Years of Healthy Life Lost Due to Disability
YLL Years of Life Lost
YPPLL Years of Potential Productive Life Lost

127 Call for Action: Making quality cancer care more accessible and affordable in India
Call for Action: Making quality cancer care more accessible and affordable in India 128
Acknowledgements
Dr. Abhinay Bollineni Abrarali Dalal Alisha Moopen
CEO, KIMS Hospitals CEO, Sahyadri Hospitals Private Limited Deputy MD, Aster DM Healthcare Limited

Ajay Grover Dr. B. S. Ajaikumar Dr. Ajay Bakshi

GM, Vision Care, Cluster (AUNZ, HK, IN, TW), Executive Chairman, Healthcare Global Co-Founder & CEO, NeuranceAI
Johnson & Johnson Vision Care Enterprises Limited (HCG)
Amit Soni
Dr. Ambika Rajvanshi Ameera Shah Partner, CVC Capital Partners
CEO, CanSupport MD, Metropolis Healthcare Limited
Ashutosh Kumar
Anurag Yadav Dr. Asha Kapadia Head – Corporate Planning, Strategy,
CEO, IHH Healthcare India Chief of Medicine & Head, Department of Healthcare Global Enterprises Limited (HCG)
Oncology, P. D. Hinduja Hospital
Dr. Ashutosh Raghuvanshi Dr. Bishnu Prasad Panigrahi
Managing Director & CEO, Fortis Healthcare Ashok Kakkar Group Head – Medical Strategy and
Limited Chair, FICCI Task Force on Cancer Care and Operations Group, Fortis Healthcare Limited
Managing Director, Varian Medical Systems
Dilip Jose International India Pvt. Ltd Dr. Gaurav Tripathi
Managing Director and CEO, Manipal Health Sr. VP - Health Management, Aditya Birla
Enterprises Dinesh Madhavan Health Insurance Company Limited
Private Limited President- Group Oncology and
Harmala Gupta
International, Apollo Hospitals Enterprise
Giridharan Iyer Ltd Founder-President, CanSupport
Marketing Director, Varian Medical Systems
International India Pvt. Ltd Dr. Harit Chaturvedi Dr. K Madan Gopal
Chairman, Max Institute of Cancer Care Sr. Consultant (Health), NITI Aayog
Hitesh Goswami
Co-Founder & CEO at 4baseCare Dr. K G Kallur Dr. Nandakumar Jairam
Director of molecular imaging and nuclear Advisor, Sheares Healthcare and
Dr. Manivannan Selvaraj medicine, Healthcare Global Enterprises independent consultant
Founder and Managing Director, Kauvery Limited (HCG), Bangaluru Dr. Raajiv Singhal
Group of Hospitals
Mitesh Daga Managing Director and CEO, Marengo Asia
Pankaj Sahni Healthcare
Managing Director, TPG Capital
CEO, Medanta (Global Health Limited)
Puncham Mukim Dr. Rakesh Rathore
Raj Gore Head of products, Aditya Birla Health
Managing Director, Everstone Capital
Co-Chair, FICCI Task Force on Cancer Care Insurance Company Limited
and CEO, Healthcare Global Enterprises Dr. Rajendra A Badwe
Dr. Ritu Garg
Limited (HCG) Director, Tata Memorial Centre
Chief Growth & Innovation Officer, Fortis
Prof Ramesh S Bilimagga Dr. Ravi Gaur Healthcare Limited
Prof. Emeritus in Radiation Oncology and Founder, DRG Path labs
Rushank Vora
Senior Consultant - Radiation Oncology,
Healthcare Global Enterprises Limited (HCG) Rupesh Choubey Director (Partner), ICICI Venture
VP & Head – Provider Network, Aditya Birla
Rohit Ghosh Dr. Shona Nag
Health Insurance Company Limited
Founding Member & Chief Strategy Officer, Sr. Medical oncologist and Director oncology
Dr. Shekhar Patil department, Sahyadri Hospitals Private
Qure.ai
Sr Consultant, Medical oncology, Healthcare Limited
Dr. M I Sahadulla Global Enterprises Limited (HCG)
Dr Vandana Lal
Chairman & Managing Director, KIMS Health
- India and GCC Dr. Sushil Beriwal Executive Director and Chief Technical
Vice President- Medical Affairs, Varian USA Officer, Dr Lal PathLabs Ltd
Dr. Srirupa Das
Director, Medical affairs, Johnson & Johnson Dr. Vishal Bhatia Vineet Gupta
Medical India Senior Strategic Solutions Manager, Varian Director-Government Affairs, Varian Medical
Systems International India Pvt. Ltd
R Venkataramanan Dr. Vishal Rao
Founder and CEO, Karkinos Healthcare Surgical oncologist, Group Director for Head
& Neck Surgical Oncology and Robotic
Viren Prasad Shetty Surgery, Healthcare Global Enterprises
Group COO, Narayana Hrudayalaya Limited Limited (HCG)

129 Call for Action: Making quality cancer care more accessible and affordable in India
We are thankful to the Cognitrex Team for supporting us
in executing the patient survey for this report.
► Cognitrex Consultants Private Limited is a market
research, business and market Intelligence company
with focus exclusively on life sciences & healthcare
segments headquartered at Gurgaon, India. The firm
works across various allied industry segments such
as pharmaceuticals, medical Devices, medical
Equipment, Hospital, CRO, etc. The firm works
across various functions as mentioned below:
► Market assessment
► Competitive intelligence and market intelligence
► Key Opinion Leader (KOL) perceptions
► Market entry strategy
► Sales force bench marking, pipeline tracking,
brand share tracking, regulatory dynamic,
win-loss deal assessment

We are grateful for strategic direction, contribution, and

constant guidance for the paper to:

Ashok Kakkar
Chair, FICCI Task Force on Cancer Care and Managing
Director, Varian Medical Systems International India Pvt.
Ltd

Raj Gore
Co-Chair, FICCI Task Force on Cancer Care and CEO,
Healthcare Global Enterprises Limited (HCG)

Gautam Khanna
Chair, FICCI Health Services Committee; CEO, PD
Hinduja Hospital & MRC

Dr Harsh Mahajan
Co-Chair, FICCI Health Services Committee; Founder &
Chief Radiologist, Mahajan Imaging Centre

Dr Narottam Puri
Principal Advisor-QCI; Board Member & Former
Chairman- NABH; Advisor- FICCI Health Services;
Advisor- Medical Operations, Fortis Healthcare Ltd

Dr Alok Roy
Immediate Past Chair- FICCI Health Services Committee;
Chairman & Managing Director at Medica Synergie Pvt
Ltd

We are thankful to the FICCI Health Services Team for all

the support that they have provided for this report:

Praveen K Mittal
Senior Director, FICCI

Shilpa Sharma
Consultant, FICCI

Sarita Chandra
Joint Director, FICCI

Aayushi Panwar
Research Associate, FICCI

Call for Action: Making quality cancer care more accessible and affordable in India 130
EY Team

Core team Writing and Editing team

Muralidharan Nair Aishwarya Nair Vikram D Choudhury

Kaivaan Movdawalla Arkaprabha Sanyal Shweta Sharma
Srimayee Chakraborty B Babu
Vs Krishnan Eisha Anand
Ankur Dhandharia Shambhavi Sharan Design team
Tara Ravi Arunkumar D
Rajeev Birdi
Shobhna Mishra Dhruv Kothari
Arif Jamaal
Anesh Ramiya Franklin S Varghese
Akash Chaudhary Shreekanth R Merugu
Ankur J Thakur Vamsi Ratnala
Abinash Naik Arjun Girish
Kanika Jain Krish A Dudani
Prateek Kanade Samarth A Patil

131 Call for Action: Making quality cancer care more accessible and affordable in India
Notes

Call for Action: Making quality cancer care more accessible and affordable in India 132
Notes

133 Call for Action: Making quality cancer care more accessible and affordable in India
EY offices
Ahmedabad Hyderabad
22nd Floor, B Wing, Privilon THE SKYVIEW 10
Ambli BRT Road, Behind 18th Floor, “SOUTH LOBBY”
Iskcon Temple, Off SG Survey No 83/1, Raidurgam
Highway Hyderabad - 500 032
Ahmedabad - 380 059 Tel: + 91 40 6736 2000
Tel: + 91 79 6608 3800
Jamshedpur
Bengaluru 1st Floor, Shantiniketan
12th & 13th floor Building, Holding No. 1
“UB City”, Canberra Block SB Shop Area, Bistupur
No. 24, Vittal Mallya Road Jamshedpur – 831 001
Bengaluru - 560 001 Tel: + 91 657 663 1000
Tel: + 91 80 6727 5000
Kochi
Ground Floor, ‘A’ wing 9th Floor, ABAD Nucleus
Divyasree Chambers NH-49, Maradu PO
# 11, Langford Gardens Kochi - 682 304
Bengaluru - 560 025 Tel: + 91 484 433 4000
Tel: + 91 80 6727 5000
Kolkata
Chandigarh 22 Camac Street
Elante offices, Unit No. B-613 3rd Floor, Block ‘C’
& 614 Kolkata - 700 016
6th Floor, Plot No- 178-178A Tel: + 91 33 6615 3400
Industrial & Business Park,
Phase-I Mumbai
Chandigarh - 160 002 14th Floor, The Ruby
Tel: + 91 172 6717800 29 Senapati Bapat Marg
Dadar (W), Mumbai - 400 028
Chennai Tel: + 91 22 6192 0000
Tidel Park, 6th & 7th Floor
A Block, No.4, Rajiv Gandhi 5th Floor, Block B-2
Salai Nirlon Knowledge Park
Taramani, Chennai - 600 113 Off. Western Express Highway
Tel: + 91 44 6654 8100 Goregaon (E)
Mumbai - 400 063
Delhi NCR Tel: + 91 22 6192 0000
Golf View Corporate Tower B
Sector 42, Sector Road Pune
Gurugram - 122 002 C-401, 4th floor
Tel: + 91 124 443 4000 Panchshil Tech Park, Yerwada
(Near Don Bosco School)
3rd & 6th Floor, Worldmark-1 Pune - 411 006
IGI Airport Hospitality District Tel: + 91 20 4912 6000
Aerocity, New Delhi - 110 037
Tel: + 91 11 4731 8000

4th & 5th Floor, Plot No 2B

Tower 2, Sector 126
Gautam Budh Nagar, U.P.
Noida - 201 304
Tel: + 91 120 671 7000
Ernst & Young LLP About FICCI
EY | Building a better working world Industry's Voice for Policy Change

EY exists to build a better working world, helping to Established in 1927, FICCI is the largest and oldest
create long-term value for clients, people and society apex business organisation in India. Its history is
and build trust in the capital markets. closely interwoven with India's struggle for
independence, its industrialization, and its emergence
Enabled by data and technology, diverse EY teams in as one of the most rapidly growing global economies.
over 150 countries provide trust through assurance
and help clients grow, transform and operate. A non-government, not-for-profit organisation, FICCI is
the voice of India's business and industry. From
Working across assurance, consulting, law, strategy, influencing policy to encouraging debate, engaging
tax and transactions, EY teams ask better questions to with policy makers and civil society, FICCI articulates
find new answers for the complex issues facing our the views and concerns of industry. It serves its
world today. members from the Indian private and public corporate
sectors and multinational companies, drawing its
EY refers to the global organization, and may refer to
strength from diverse regional chambers of commerce
one or more, of the member firms of Ernst & Young
and industry across states, reaching out to over
Global Limited, each of which is a separate legal entity.
2,50,000 companies.
Ernst & Young Global Limited, a UK company limited by
guarantee, does not provide services to clients. FICCI provides a platform for networking and
Information about how EY collects and uses personal consensus building within and across sectors and is the
data and a description of the rights individuals have first port of call for Indian industry, policy makers and
under data protection legislation are available via the international business community.
ey.com/privacy. EYG member firms do not practice law
where prohibited by local laws. For more information
about our organization, please visit ey.com.
FICCI Health Services Team
Ernst & Young LLP is one of the Indian client serving member firms of
EYGM Limited. For more information about our organization, please visit [email protected]
www.ey.com/en_in.

Ernst & Young LLP is a Limited Liability Partnership, registered under the
Praveen Mittal
Limited Liability Partnership Act, 2008 in India, having its registered Senior Director
office at 22 Camac Street, 3rd Floor, Block C, Kolkata – 700016 [email protected]
© 2022 Ernst & Young LLP. Published in India.
All Rights Reserved.
Shilpa Sharma
Consultant
ED None [email protected]
EYIN2210-001
Sarita Chandra
This publication contains information in summary form and is therefore
intended for general guidance only. It is not intended to be a substitute Joint Director
for detailed research or the exercise of professional judgment. Neither [email protected]
EYGM Limited nor any other member of the global Ernst & Young
organization can accept any responsibility for loss occasioned to any
person acting or refraining from action as a result of any material in this
Bhupesh Tiwari
publication. On any specific matter, reference should be made to the Senior Assistant Director
appropriate advisor. [email protected]
AJ
Aayushi Panwar
Research Associate
[email protected]

Web: www.ficci.in; www.ficci-heal.com

Twitter: www.twitter.com/ficci_india ;
https://twitter.com/ficci_heal

FB: www.facebook.com/ficciindia | Blog: blog.ficci.com