Professor Rajendra Badwe, you’ve been given the task of describing here at the conference in Lyon the state of oncology in India. India is a fantastic and amazing country and a lot is happening. I want to ask you first of all about cost effective care, I know this is one of the things you’re concentrating on. Surely that’s being taken regard of everywhere in the world? What new things have you got to offer from India?
What we do in India is over and above the standard guidelines being implemented we look at existing molecules being tested for a newer indication.
So you’re trying to keep away from automatically going for the latest and therefore most expensive?
Right. So my costs, say for example, the study that we finished and published in The Journal of Clinical Oncology last year looked at an injection which would cost $2 in breast cancer and that gave us about 10% improvement in disease free and 9% improvement in deaths related to breast cancer.
That was using progesterone?
Just a single injection of progesterone prior to surgery.
Now, let me clear this up – using drugs in unlicensed indications is quite familiar in medicine but what you’re saying is that it’s not been well founded in terms of clinical trials.
Yes. So once a drug is proven to be effective in one indication it’s rarely explored in other indications.
What can you do about that?
The only thing that we can look at is if the drug’s all properties are well delineated, leave it for the clinicians that here is a drug that has ten different properties. Say, for example, as a clinician I’m looking at a drug that increases cell to cell adhesion, is there an existing drug on the shelf that has the property? Why don’t I test it?
So you actually would do the tests then?
Yes, and we tested this in 1,000 women with breast cancer randomly allocated, 500 received the injection, 500 did not receive and we have a difference which is remarkable.
Now that’s a problem though because drug companies are not easily going to find the funding for that sort of research, are they?
Such research is going to be supported by government money, federal money. So we had the Indian government supporting this kind of research.
It sounds as if you’re on to something really good here but how do you see that model, that approach, being used elsewhere?
In the great majority of cancers I’m sure there are indications for which we could test. Say for example, vitamin D3 is something which is tested really in the West. We have metformin which is emerging as an important drug in breast cancer. So metformin cost-wise is miniscule but if it is proven I’m sure it will be implemented everywhere, lots more stand to benefit.
It sounds as if there are some great ideas here but it also sounds, to me, very daunting actually putting these molecules through the necessary large scale tests. Will it actually happen?
It can happen if there is federal support. I’m sure about it.
So what kind of advice would you give to help make this happen? Just a plea to get that federal support which has to come out of taxes?
Yes. If there is a low cost study, say for example, this kind of a study versus a new molecule study, the cost difference would be about one-tenth. So we’re not looking at a huge amount of money, it’s quite a small money. If we test ten molecules even if one of them clicks we have got a big difference in outcome from the patients’ point of view.
Now you mentioned progesterone, you mentioned metformin, how much scope do you think there is overall in the armoury of drugs that we have already for doing real benefit to cancers that they’re not already being used in?
I think there is a fairly large benefit that can come in. I can give you another example of a drug which is a radiosensitizer. This drug costs half a dollar, this was tested in a study called DAHANCA in Denmark. An excellent improvement. So a drug that can be, if proven today, tomorrow everybody can use it, it’s that kind of… without batting a lid whether it’s going to be costly for my pocket or not.
I want to ask you also about the use of guidelines because I know guidelines are ubiquitous now but you also have to take account of infrastructure, don’t you, and you’re doing this in India, aren’t you, right now?
We have evolved our guidelines that have incorporated a matrix of the quality of evidence and the kind of infrastructure so that for a given infrastructure a clinician sitting in his office can decide what’s the best evidence for that infrastructure so that the best care for that infrastructure can be implemented at the same time.
But this has to be done methodically, though, doesn’t it, with actual research to show how to implement particular guidelines in particular situations.
This kind of effort has also happened in the United States and globally. This was done by Professor Ben Anderson as part of the Breast Global Health initiative. They have done exactly the same kind of thing and it is effective.
So what kind of call would you make out to medical bodies all over the world to gear their guidelines towards actually the real world, so to speak?
What you said rightly is that there are plenty of guidelines. Every individual region based on their cultural needs, their infrastructure, their monetary ability to take on, decide or evolve guidelines which are implemented. So guidelines that we have evolved in India are also implementable in Africa. So there are a lot of governments in Africa come to us saying that, ‘Your guidelines are followed here.’
But you need to match them to the infrastructure.
So it’s no good recommending a therapy if it can’t be obtained locally.
You need to tailor make them to the infrastructure.
Let me ask you about screening, though, because India has a burgeoning economy and everybody wants to get tested for everything. What is the basis for which screening for cancer you would use and which screenings you might pass over?
Screening is a huge endeavour and we need to have some solid robust yardsticks completely proven before we can implement that. So, for example, for uterine cervical cancer and for oral cancer there is good evidence that it reduces mortality and implementation is very easy, say visual inspection of cervix or visual inspection of oral cavity. These two at least can be implemented anywhere. As against that, if I were to look at breast cancer screening, prostate cancer screening, lung cancer screening, colon cancer screening, none of these have had robust endpoints of all cause mortality being reduced and in absence of that I’m a bit wary to implement that because of two reasons. One, huge cost and the huge amount of work that would come out of such screening. Any screening as a mandatory requirement will increase incidence so imagine a 40-50% increase in the numbers that come to you, not easy for an infrastructure that is opening at the seams to take on some more, so we don’t do it.
Nevertheless, there seems to be clear victories of screening in some settings for breast cancer and also perhaps for prostate cancer too so what would you place as the top priorities for effort in the Indian situation in order to reduce the burden of these common cancers?
In India prostate cancer is extremely low, we have a prostate cancer incidence which is below five per hundred thousand as against somewhere like 70-100 per hundred thousand in the majority of the Western countries. So I’m not so much worried at the moment. I would look at it in a decade down the line.
And also, of course, the preventive aspect is important. Indians are obviously doing the right things at the moment or in the past.
Yes, from the prevention point of view there are two or three things which are working well for India. One is anti-tobacco. Tobacco almost accounts for 40% of cancers and that is a prime target for government and all the non-government agencies to see that it is reduced. The second bit is infection related cancers which are also down in the last decade or so, whether it is uterine cervical cancer, whether it is penile cancer, whether it is stomach cancer, any of these are reducing with time with plain, simple interventions like running water and good sanitation.
What about diet as well in India because you have a very interesting diet?
The third bit that colon cancer is low entirely because of the huge amount of vegetarian diet with high roughage that goes in. So when somebody says that I’m non-vegetarian in India he probably has either meat or chicken or fish twice a week and he would term himself as non-vegetarian and he will have five different vegetables with it.
So what are you doing as Director of the Tata Medical Memorial Centre to keep things that way so that you do not get these common cancers?
We do try and explain to everybody that what you’re doing at the moment is excellent, don’t change.
Don’t eat this fast food.
And the second bit is exercise. In metropolitan India obesity is a rising problem and we are doing enough proactively to see that if it reduces. In fact, we’ve convinced the government to see that instead of having a mass transport which takes people through vehicles, let there be travelators up to about 5km.
So they walk a little bit as well.
Yes. Well, look, there’s so much we could talk about, Rajendra, it’s great to see you here. Thank you so far and we look with growing interest at the Indian situation. Thank you very much.
A pleasure talking to you. Thank you.