Room for “Precision Oncology – A centerpiece of cancer care in the 21st century”
Reforms of the last budget continue to stabilize and grow the Indian economy. Most analysts and leading indices have a positive outlook on economic growth in India.On the back of a 2014-15 budget that focused on middle class tax relief, policies for uplifting farmers and the poor, uncovering black money, and boosting agriculture, the 2015-16 budget promises to be populist and is expected to balance economic growth with fiscal conservatism in terms of deficit management. As several public schemes like Jandhan, Safe India, Green India, Clean India, Skill India, Make in India take deeper roots and begin to transform our society, realization of the dream of providing high quality medical service in each village and city by 2022 (described in the “Amrut Mahotsav Vision for Team India” framework by Mr. Modi), will require prioritization of the development of medical services with adequate budgetary allotment. Addressing the disease burden of populous India is a daunting challenge. Although diabetes, infectious disease, and heart disease are at the top of the “burden-list”, the socio-economic burden of cancer cannot be ignored, primarily due to its terminal nature and the high-cost of clinical management.
As we mature into a leading economy, mean disposable income in urban households will continue to rise. Combined with the trend of lowering the cost of genetic testing, several genetic cancer diagnostic tests, which have a high price tag today, will become affordable for the urban population. However if we wish to succeed in effectively lowering the overall economic burden of cancer in India, the testing must be brought to a much larger population.
Precision oncology relies on testing for certain unique genetic characteristics of tumors that are targetable for optimizing the therapeutic choices and drug regimens to maximize the benefit of treatment. The western world is guided by carefully designed and well maintained databases of such genetic characteristics of tumors and draws upon this wealth of information to guide clinical decisions. The activity of cataloging such genetic information is a large scale endeavor and should remain in the public domain to avoid disproportionate monetization of such information. A few other nations, albeit developed economies, have already begun documentation of genetic variation in respective populations. Several funding models (e.g. entirely public-funded, public private partnership, open or closed consortia, multi-national initiatives etc.) are available to setup such initiatives. The 100K GenomeAsia project is one example of a multi-national initiative.
Another major challenge for the adoption of precision oncology testing is the lack of a consistently practiced standard of care guidelines where we can insert or mandate genetic testing. This does not imply compromised quality of care but poses the challenge of adopting a state-of-the-art test in a highly heterogeneous consumer market. Many times oncologists question the high-cost of genetic testing and place disproportionate expectations on the test. Genetic testing is designed to increase the objectivity of the treatment choices instead of eliminating the need for other clinical tests. It improves the overall clinical cancer care we can provide by preventing some empirical choices that may be suboptimal for the patient, thereby reducing the total cost of the treatment. Wouldn’t it be useful to know how effective the therapeutic choice will be and what the quality of the patient’s life is going to be during the course of treatment and beyond?
If we accept this argument, the next criticism faced by precision oncology testing is that the clinical report for these tests are currently based on western databases so how relevant is the report to Indian patients? This now becomes a circular argument and begs us to address the creation of a genetic database for our country. In addition, if we do not do this today, someone else will and we may have to pay for our own data. Although most useful for precision oncology, larger scale genetic data cataloging is also of great use to understand the genetic basis of other diseases. Because such activity is expected to be a multi-year project with a high price tag the earlier we begin the earlier can we reap the benefits. As DNA sequencing becomes more and more affordable this century will belong to molecular diagnostics, and precision oncology stands to benefit the most. The 2016-17 union budget will continue to focus on fiscal policy, make in india, swachchh bharat, and agricultural relief, but if we are serious about meeting the 2022 deadline for cost effective healthcare we should not ignore this for long. The promise is that we are creating the infrastructure to lower the cost of cancer care.
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