Siloed healthcare is no match for a malignant, insidious, and pervasive disease like cancer. Over recent decades, countries and regions across the world have discovered that – in the absence of a cure – a networked and holistic approach to cancer care is vital. In this vein and drawing from the transformational work of the Organisation of European Cancer Institutes (OECI) and the US National Comprehensive Cancer Network (NCCN), India launched its own National Cancer Grid (NCG) in 2012 in the hope of improving cancer care in the country and facilitating cancer research.
Uniformity & Quality
The project was born out of the Tata Memorial Hospital, India’s largest and oldest cancer centre, at a point where a new approach was needed to counter the rising cancer incidence in the country. As the institution’s director CS Pramesh reminisces, “Tata Memorial Hospital was expanding significantly at that time, but we were still only able to treat around ten percent of the cancer patients in India. This led us to amplify our vision beyond just expanding our hospital, focusing on getting all cancer centres across India to provide uniform standards of care.”
He continues, “Our aim was threefold: establishing uniform care standards, developing human resources to handle the increasing cancer burden, and fostering a collaborative platform for multicentre cancer research. Over the years, the network’s growth has been substantial, with initiatives extending beyond hospitals to encompass a broader range of institutions.”
Indeed, from the initial 17 cancer centres that made up the NCG back in 2012, the network now includes over 300 organisations, from professional societies to patient groups, NGOs, and research institutions. The NCG has established uniform treatment guidelines which have been adopted by government-funded insurance schemes like Ayushman Bharat (covering over 500 million people).
Moreover, it has launched various quality assurance programs within cancer diagnostics and treatments and implemented technology-based solutions to help patients facing long distance journeys to receive treatment.
A final piece of the puzzle is a multidisciplinary virtual tumour board system where each patient undergoes a review by a panel of experts before treatment decisions are made, promoting collaborative and specialised care. Pramesh notes that this is especially beneficial for smaller centres lacking diverse expertise.
Affordability
In a populous but resource constrained country like India, that spends less than three percent of its GDP on healthcare according to the World Bank, affordability is crucial. Over the past three years, the NCG has also had a big impact in this regard by allowing for collective pricing negotiations with pharma companies for cancer medicines.
As noted Indian oncologist and Executive Chairman of the Asian Cancer Institute Ramakant Deshpande points out, “The NCG is helping to improve the affordability and accessibility of cancer care in India. By uniting under a common framework, institutions can negotiate better prices for machines and treatments, leading to an overall improvement in the efficiency and cost-effectiveness of cancer care delivery.”
Pramesh adds that “the method of individual centres procuring cancer medicines directly from the industry works well in larger, high-volume centres like ours but poses numerous problems in smaller centres or those situated in geographically challenging areas. These problems include higher costs, uncertainty about drug quality, and supply chain disruptions, causing treatment delays for patients.”
He continues, “therefore, in 2020 our initiative compiled the demand for drugs from various centres – which significantly exceeded what a single centre could request – to collectively negotiate with pharmaceutical companies. We secured remarkable discounts, ranging from 23 percent to an incredible 99 percent off the Maximum Retail Price (MRP) of these drugs. The average discount we achieved was an impressive 84 percent. All this has substantially reduced the overall costs of treatment for cancer.”
Clinical Trials
The next step, and the third pillar of the NCG’s founding aims, is to leverage the network for oncology clinical trials. Not only would this provide early access to cutting edge treatments for the Indian patients involved in these trials, but it would also increase the likelihood of innovative medicines eventually being launched in the Indian market.
“With over 800,000 new cancer patients registering with the NCG, it serves as an ideal platform for initiating and conducting clinical trials,” highlights Deshpande. “The NCG’s potential to facilitate quick initiation and obtain results efficiently makes it a valuable asset in advancing clinical research and cancer care in the country.”
However, the road towards establishing greater clinical trial numbers in India, including via the NCG, does not look particularly smooth. “There is room for improvement, particularly in terms of strengthening a central monitoring system to ensure systematic oversight of all trials, although efforts are underway to address this challenge,” admits Deshpande. He continues, “India’s linguistic diversity, with 13 official languages, also poses a challenge in terms of providing information and conducting clinical trials in a way that is accessible to individuals speaking different languages. Additionally, there may be a need for increased awareness and education about clinical trials, ensuring that potential participants fully understand the nature and benefits of these advanced therapies.”
Pramesh is similarly cautious on India’s clinical trial potential, highlighting a common complaint globally: overworked physicians without the time or energy to conduct clinical trials. “To alleviate this, we established a clinical trials unit to handle the logistics of research, such as study designs, contract negotiations, and biostatistics, reducing the burden on clinicians,” he points out. “We also introduced a workshop on clinical research methods to address the lack of training in undergraduate and postgraduate medical education.”
Finally, funding was a big barrier, leading the NCG to only initiate funding for clinical trials with certain conditions: multicentric, multi-disciplinary research collaboration, a focus on common or regionally unique cancers, an emphasis on cost-effective interventions, and a commitment to sharing research data in the public domain.
These initiatives have already seen substantial results. Pramesh states, “We have already held numerous large-scale clinical trials covering various research areas from epidemiological studies to phase III practice-changing studies. Notably, the Indian Council of Medical Research (ICMR) and the NCG have recently agreed to match funding, doubling the resources available for cancer clinical research.”
