Address at the Golden Jubilee Celebration of the Cancer Institute (Wia)

Cancer Treatment : Challenges

I am indeed delighted to participate in the Golden Jubilee celebrations of the Cancer Institute, Adyar. I greet the organizers, distinguished doctors, guests and dedicated paramedical staff on this occasion. This institute is the result of the pioneering work done by Dr (Mrs) S. Muthulakshmi Reddy. I have been studying the work done by Cancer Institute in the past five decades. The Institute has done pioneering work in the area of tobacco induced oral cancer. You have been able to identify the radiosensitive action of Bleomycin, which has been used to treat oral cancer patients in conjunction with chemotherapy. This has resulted in high percentage of successes in treating oral cancer cases. I congratulate the entire team on this significant accomplishment. You have also created a regional cancer registry, which will be useful in treating and following up the patients. One area I would like to suggest where the institute could take humane action is in providing supportive therapy and psychological care to the patients who have been brought to the hospital at an advanced stage of the disease. Because of your vast experience in the field for the last 5 decades treating 10,000 patients per year, you could be the role model for treating those patients in advanced stage. I was thinking what thoughts I can share with you. Hence, I have selected the topic ?Cancer Research & Challenges?.

Insights into Life

I would like to share a few experiences of people and their pain and possible solution. Last year I was at the Centre for Cellular & Molecular Biology at Hyderabad. I met hundreds of young scientists working on the genetic origin and manifestation of diseases, particularly Cancer. The young scholars very enthusiastically shared with me their knowledge of molecular biology and cellular research. They told me about the information encrypted on the DNA of a cell and how both problems and solutions to the human lives reside on the software that nature has embedded in each life it creates. In a way, these young minds were dealing with the questions that were so far confined in the domain of sages and philosophers.

Cancer, unlike many other diseases that come from the external factors, like infections, life styles and other environmental and physiological stressors, emanate from within the cell. The life software embedded in the DNA material gets mutated and start growing in a way that is not in-line with the cells around. Life turns against itself. The tragedy becomes unfathomable when it happens too early.

Sometime back, I met one gentleman whose 6-year-old grand child was on periodic blood transfusion for Thallesemia. The permanent solution, doctors told me was a bone marrow transplant. The bone marrow of the child was not matching even between siblings and the parents. Unmatched bone marrow transplant is not done in India, I was told, and even in the West it is done experimentally. I met the child who is unaware of the time bomb that is ticking inside him. I prayed for him, for this was the only thing I could do. Today, standing before this gathering of cancer experts, I think I must share with you my concern for these and other patients who live under the shadow of uncertain life. What can we do to strengthen the doctors? capabilities in such a situation? In India, we have limited beds for B.M.T. This has to be increased in multiple hospitals and also concentrate on Stem Cell research which is the live source for bone marrow production. Also when the medical community finds that a person has cancer, in addition to treating him, he should also provide him psychological support. This support should be in the form of giving him an advice to live a normal life. He should be advised not to change anything, including his identity. He should keep himself intact, should not consider himself just as a cancer patient and re-discover his inner self ? personal, professional, social and spiritual.

Stem Cell Research

Newer knowledge emerging out of research on stem cells from abroad and India has to be taken note of and studied. In fact, regenerative medicine is fast getting established as a complete branch of medical science. The embryo starts out as a mass of undifferentiated cells, which then divide, multiply and go down differential paths to take the shape of various tissues and organs of the body. The mechanisms which constitute this orderly process of differentiation is fast getting understood at the laboratory level. And the state-of-the-art in this area holds the promise of regenerating tissue that malfunctions due to injury, age, disease or genetic abnormality. Whether large volumes of cells can be produced from stem cells is yet to be seen. I hope that the day is not far when the similar six year old boy I met, will get a tailor-made bone marrow out of stem cells to survive for the next sixty years and beyond. This institute can carry out research in this area for promoting enhanced probability of success in cancer treatment.

Breast Cancer: a new project

The suffering of cancer does not remain confined to the patient alone. It often engulfs the entire family and the social surroundings. The emotional trauma is just intense. The Bangalore Cancer Research Foundation conducted a unique multi-institutional study with DRDO with the participation of Defence Institute of Psychological Research (DIPR), Defence Institute of Physiology and Allied Sciences (DIPAS) and Centre for Cellular and Molecular Biology (CCMB). The study was aimed at establishing the relationship of the stress of breast cancer patients with the neuro-endocrine response leading to immune modulation, which will determine the prognosis to treatment or progression of the disease. The perceived stress of the patients will be influenced by the social support being provided by the spouses and caregivers and hence in the study a systems approach was made to evaluate the stress of the patients in the social ambience. Patients of breast cancer, their spouses and equal number of the care givers served as volunteers for the study.

Standard psychological methods were used to quantify the stress of the patients, their coping strategies, blood cortisol, cell mediated immunity and humoral immunity were measured in all the three groups. The study revealed specific correlation of the stress of the patients with the immune responses. Patients who received adequate social support had lower level of perceived stress and their prognosis to surgical, radiation and chemotherapy were better than those who had higher level of perceived stress due to inadequate emotional support from the spouses and care givers. The primary message, which emanated from the study, indicates that for successful prognosis, it will be essential to combine psychotherapy along with the conventional medical management of cancer. It also emphasises the necessity to address the problem at the mind-body complex where the etiological factor may have the root. The sample size is small. Elaborate further research in this area is very vital.

Study on Cervical Cancer

The application of indigenous technology to make healthcare affordable as well as accessible has brought me together to Prof. Kakarla Subba Rao. We worked together on many projects that will be useful for rural people. In one such project of Society for Biomedical Technology (SBMT) of DRDO (Defence Research & Development Organisation) named TULASI, mass screening of cervical cancer was undertaken by the Nizam?s Institute of Medical Sciences (NIMS) and Deccan College of Medical sciences (DCMS). More than 50 camps in tribal and rural areas as well as in the urban slums have been conducted to screen women for cervical cancer at their door-step. Prof. M R Raju, through his Mahatma Gandhi Memorial Medical Trust, has also done some good work in Bhimavaram. A number of factors have emerged leading to cervical cancer. Early marriage, multiple childbirths and lack of reproductive hygiene, generally prevalent in lower socio-economic groups have been shown to be associated with increased risk of cervical cancer. The study also established the positive effect of use barrier methods of contraception in protecting the females against human papilloma virus. Although, TULASI Project has succeeded in creating awareness about this most prevalent of female cancers in India, an effective follow-up and treatment system to treat cervical cancer patients has yet to be established.

Affordable & Accessible Therapeutics

Treatment of cancer involves any one but most often a combination of radiation, chemotherapy and surgery. Genetic diagnosis can help to take good decisions while charting the course of therapy. On the drug side, instead of looking for agents that kill dividing cells, researchers are now looking for agents that encourage cell to get destroyed. Inside a growing ball of cancer cells, the blood supply can run short, so the cells begin to suffocate. Malignant cancers get over this problem by sending out a signal to the body to grow new arteries into the tumour. These arteries characteristically grow like a crab-claw that first gave cancer its Greek name. Many drugs, called angiogenic agents, are now available to destroy these supply lines. These drugs are imported and are very expensive. Industry-hospital-research institution consortia need to be established to develop affordable indigenous products.

Optimisation of Chemotherapy

Chemotherapy often destroys healthy cells together with the intended cancerous ones. A firm in Pune has developed algorithms describing interaction between normal cells, malignant cells and nutrients. The algorithms also take into account the pharmaco-kinetics of the drug. Together with inputs on patient?s age, height and weight and the type and volume of the tumour, the mathematical model can design an optimal drug schedule minimising side effects. The type and volume of tumour can be automatically deduced from the CT or MRI scans. This is a good example of how advances in many disciplines of science such as Biomedical engineering, Image processing, control systems, mathematical modelling and pharmacology are helping in the development of better and effective treatment for cancer patients.

Clinical database Network

Clinical networking is an important area where certain progress has been made. A Clinical database can help in refining clinical features, documenting response to treatment and bringing out geographical or genetic variations. Increasing numbers of hospitals are using computers. However, feeding in the clinical inputs into the network requires recording of detailed symptoms through a checklist of clinical signs. Physicians are needed to think in a structured format and still not lose social and emotional contact with the patient.

Application of Clinical data base network in cancer has been attempted by Indo-American Cancer Institute at Hyderabad. Some other institutions in certain other areas may have similar databases. The database links text to images, process and protocols. They are attempting a seamless fusion of text and images along with communication among patients, their doctors, and other service providers. This can be suitably adapted for clinical data of cancer and developed into a Cancer Database Network. I am told that the regional cancer registry can be extended to provide this database. Two advantages are immediately apparent. Firstly pattern recognition is improved. With a large database covering more number of subjects than an individual or even an institution can expect to study, a networked database improves pattern recognition. Secondly, statistically significant evidence can be generated and validated with other Institutions in the country and abroad. Intensive practice of clinical medicine would improve on both these counts.

Networking of institutions

There are number of hospitals providing cancer treatment in Chennai and in neighbouring areas. It will be useful to network these cancer treatment centers for enabling consultancy among specialists and directing the patients to the right type of specialists who may be available in one of the networked institutions. This type of consultations among experts will generate confidence among medical community to undertake treatment of complex cancer cases and enable them to cure the disease with cumulative experience. Also, it will be useful to have monthly or bi-monthly conferences among the specialists of different centers to discuss the special cases treated during that period. This will create treatment synergy between centers. During one of my visits I found that cancer centers have immunologists, physiologists and psychologists working together. This model could also be followed by other centers to provide psychological support to the patients which will facilitate faster recovery.

Awareness

Patient?s own vigilance and clinician?s alertness are the primary ways in detecting early onset of cancer. Today, histo-pathological and Fine Needle Asparation (FNA) examination are most important tests to tell us about the nature of the cancer, and its aggressiveness. Recent advances in laboratory medicine like Fluorescent Activated Cell Sorting (FACS), Polymerase Chain Reaction (PCR), Fluorescent in-situ hybridisation (FISH) can be employed for more refined diagnosis. A wide variety of tools are involved in these tests. The costs are high and certain non-commercial investments need to be mobilised to make them available in more and more hospitals. The tumors are best diagnosed by contrast CT, spiral CT and MRI. More sophisticated MR Spectroscopy, PET have come in. Image transmission between multiple hospitals and Tele-medicine connected mobile laboratories, linking multiple hospitals in districts hold a great promise.

Conclusion

Availability of comprehensive cancer centres like Cancer Institute, Adyar is a significant step forward in dealing with the most challenging healthcare problem of our times. However, we need an active connectivity of general practitioners with this institute to make a major impact in terms of reaching the needy as well as helping them out. The mission of offering the best available patient care, the most sophisticated education to physicians and patients and be the leader in the cancer research is indeed a very challenging task. This mission demands highest of the human capabilities in intelligence, innovation and perseverance.

It is also equally important that the general public is educated about the healthcare risks of exposure to carcinogenic agents as a result of life-styles and habits. To this end, education of children on this subject should begin as early as in the primary schools so that children do not get initiated into bad habits and thus remain immune from the impact of such disease. We must make every effort to make India tobacco-free. Let our new generation enjoy health and prosperity and do not succumb to the needless waste of human life. Cancer cure and cancer research are indeed twin challenges to the medico and health-care community. Challenge transforms into mission of pain removal and thereby provides useful life that is close to the God. I wish the Cancer Institute all success in their mission of ?Let my brain remove the pain?.

May God bless you.