PROVIDING PEOPLE-FOCUSED CANCER CARE

BY V. SHANTA, Executive Chairman (Honorary), Cancer Institute (WIA)
2005 Ramon Magsaysay Foundation Awardee for Public Service
Presented at the 2005 Magsaysay Awardees' Lecture Series Magsaysay Center, Manila, 01 September 2005

In 1949, the facilities for the diagnosis and treatment of cancer in Madras Presidency were extremely meagre. There were only two general hospitals with radiotherapy facilities (2 high voltage machines in Madras and one at Vizag). The management of cancer was anybody's business - village quacks, charlatans, G.P.s and surgeons. There was no follow up nor any mortality statistics.

Origin & Growth

In 1949, the Womens' Indian Association Cancer Relief Fund was established by Dr. Muthulakshmi Reddy, a pioneer social reformer. Its objectives were to create public consciousness (both in the people and government) regarding cancer and to establish a cancer diagnostic and treatment centre with modern facilities for surgical, radio therapeutic and palliative care of cancer patients, essentially the poor and the middle class. The rich always went to Britain for their treatment.

Cancer Institute (WIA) - 1954

In 1954, under very difficult circumstances, they succeeded in establishing the Cancer Institute (WIA). In 1955 April, soon after taking my M.D. (Post Graduate degree equivalent to the American board), I joined the fledgling Cancer Institute as its RMO, in preference to the teaching position in the Government Women & Children Hospital to which I had been selected, purely on sentimental grounds.

The Cancer Institute (WIA) in 1955 was a cluster of huts to house the patients and a single central building with 12 beds for surgical cases and housing the operation theatre, the radiologic equipment and the basic laboratories of pathology, (both tissue and clinical) and bio-chemistry. There was no dearth of patients but great paucity of funds. Looking back now, after 50 years, I often wonder what made me go on under such hard conditions of daily survival. It was probably a stubborn refusal to accept defeat, probably the faith that the patients had in us, probably the belief that we were doing God's work and that God would not let us down!! However it be, help did come. It came in the shape of a cable from Canada on the Christmas Eve of 1956, announcing the part gift of a Cobalt-60 teletherapy unit. This was installed in 1957, amidst of lot of publicity by AECL. It was the first spervoltage radiation unit in the Asia-Pacific region, and it made us famous.

This gift was the first of such international philanthropy from Canada, Germany, the Netherlands and Denmark. They set us on the road that has brought me to Manila to receive the prestigious Ramon Magsaysay Award. At the Institute, the award is not viewed as a personal distinction but as another of God's blessings to shield us and further our mission.

Problems in Therapeutic Care

The patients flooding the Institute in the early years were advanced cancers of the mouth and throat (93%) in men and 94.26% of cervical cancer in women (Table)

Innovative Treatment : Concept born out of necessity

The arrival of the teletherapy unit, God's own gift, helped us in the design of a novel method of treatment to meet the problems of advanced cancers and enhanced our ability to bring more patients within scope of curative surgery. While the 5 yr. survival by conventional treatment in late disease was 31.2%, it was enhanced to 58.6%, by the new technique (Pre Op.RT+Surgery) (Tables)

The tables are an indication of the advanced disease encountered and our attempts to contain them.

The first of our targets had been achieved to demonstrate to the people, the medical profession and the Government that the cancers prevalent in our region were curable very, if they were "Early" and not so badly even if they were "Late", and that a diagnosis of cancer was not a "Death Sentence".

We, of course, knew this was only the beginning, that a hard road lay ahead of us, that much more had to be done in education, prevention and "Early detection", and above all to prevent a migration from the more accessible and curable cancers to the much more difficult sites of lung, liver and esophagus and halt the tobacco invasion from the west.

Tobacco Control

In the early years we were only two, but as the years passed the anti-tobacco campaign has become strong the world over. Today in Tamil Nadu, smoking is prohibited in all public transport, in all public places, in public advertisements and in films. The sale of cigarettes to teenagers below eighteen is a penal offence and restrictions are placed even on the stocking of tobacco in shops. There are "Tobacco Cessation" clinics all over the country and I am proud to say that the tobacco cessation team at the Cancer Institute (WIA) carried away the first prize awarded by the WHO. "Tobacco or Health" is an official All India Programme.

Chingleput Survey

Our early detection project began in 1960 with "Opportunistic Screening" in Chingleput District. 10775 individuals in 5 taluks of Chingleput were examined (4842 women, 3239 men and 2694 children). 67 cancers and 63 pre cancers were detected. The stage distribution of cancer of the cervix in the survey series was just the reverse of what was seen at the Institute, early Ca. 69.57 in the survey and 5.76 at the Institute (Table).

The data was revealing and was an indication for a larger pilot study.

Kanchipuram Story

The Chingleput study was limited because our funds were meager. A larger pilot study would need much more financial resource. We turned to the WHO for help in 1964. The response was immediate, NORAD (the Norwegian Aid Agency) agreed to finance the pilot study and Prof. Eker, Director of the Norwegian Cancer Centre at OSLO was deputed to organize the project. A major difficulty developed at this juncture, NORAD was channeling its aid through WHO and SEARO's (South East Asia Regional Office) would sign the agreement only with the State Government and not with the Cancer Institute.

A pioneering programme in a developing country like the "Kanchipuram Pilot Project" needed missionary zeal which no difficulty could deter. A bureaucratic organization is the least desirable mechanism. Prof. Eker resigned soon and I was forced to follow suit. The project floundered as it was bound to.

Feasibility Programme (Tindivanam)

We were able to obtain a modicum of funds from the ICMR only in 1989 for a pilot project. The ICMR, however, restricted our study to cervical cancer.

The Kanchipuram team was boycotted by the rural folk because it was unfamiliar and included men. We, therefore, decided that the centre point of our programme would be the Village Health Nurse and only our women medical officers would be involved. A feasibility study was, therefore, initiated in Tindivanam Taluk (A small Revenue Unit) to train the VHN and evaluate her performance.

It covered a population of 475,756 with a female population of 233,825. The eligible women for screening were 61000(approximate). The study concluded that the VHN was well suited to be trained in the detection of an abnormal cervix and for taking an adequate Pap Smear. A clinical concordance rate of 80% was achieved (Table). However, the motivation rating was poor.

The fact that a population screening could be done using the VHN in the rural areas was a step forward.

The South Arcot Experience

The Thindivanam project closed in 1992. The results had given us a fillip to continue and enlarge our programme, but we needed funds. Most unexpectedly the Government of India on its own released us Rs. 25000/- for continuing our "Early Detection" programme.

This programme was to cover South Arcot and was to be done in collaboration with the State Public Health Service. The long-term objective was to integrate "Rural Early cancer Detection" into the routine Health Delivery System of the State. The target concerns were as earlier, oral in men and cervix and breast in women.

The project was to include 1. Establishment of 3 permanent "Early Cancer Detection & Prevention Centres" in South Arcot 2. Training of Government Public Health Personnel (Doctors, Health Educators, VHNs and Cyto Technicians) from the District 3. Education & Palliative care.

The responsibilities of the Cancer Institute (WIA) and the Public Health services were demarcated. The training programme and the establishment of the 3 centres at the Government Hospitals at Cuddalore, Villupuram and Chidambaram came under the Institute, the implementation of screening, education and palliative care was the responsibility of the hospitals and their health staff.

The personnel trained included 258 m4edical officers, 672 VHNs, 30 Block Health Educators and 2 cyto technicians.

In addition, the rural facilities established were a training school for VHNs and other para medical staff and 2 cytology labs for negative screening. Educational material consisting of audio visual cassettes, spot video cassettes, flip charts etc. were provided.

The population of South Arcot was 4,201,869. The population screened was only 298,899 i.e. 7%. The number of early cancers detected were not given except in the case of the cervix. Even here, the stages I & II combined were only 29.8%, less than at the Cancer Institute (WIA) gynic clinic (37.99%) during the same period. This was again a disappointment. It is our conviction that we are not likely to make any headway in our "Early Detection" programme unless we have an autonomous network of centres dedicated to the programme. If only the international aid organizations could provide us just 15% of the funds spent on "Aids" and 5 years' time, the net work can be built!!

Before I close, I would like to just give a birds' eye view of other areas of our work at the Institute.

The Institute is now comprised of four units: the Hospital of 428 beds, a Research Centre, Dr.Muthulakshmi College of Oncological Sciences and the Centre of "Preventive Oncology". In early years, we did all the work, clinical as well as epidemiological. Now the Preventive Oncology group has taken over all the fieldwork and the anti-tobacco programme.

The logo of the Institute is, "Today's Research is Tomorrow's Treatment". Our service programmes touches only a fraction of the population, but the fruits of Basic Research can be universal. Fleming is dead, but the antibiotics are immortal!!! There is very intense research going on in our molecular laboratory on cervical cancer. Predictors of Cellular transformation, of prognosis, of radiation response, chemical sensitization and potentiation of the radiation effect, the "Dendritic Vaccine" to potentiate chemo therapeutic effects, the molecular pathways of cervical cancer and ways to counter them.

Palliative and Domiciliary care is active in the hands of our Associate "Sanctuary".

Last but not least was the generation of super specialists, technologists and scientists (since 1965 & 1983) to carry out our mission all over the country. Unfortunately, for us, however, these proposed missionaries often end up in the United States.