Cancer Research in India: What do We Need to do

Dr B S Ajaikumar
Chairman and CEO
HealthCare Global Enterprises Ltd

Cancer is expected to be a major problem in developing countries like India and cancer research in India has grown in size and impact over the past few years. This article briefly reviews improvements that should be made to translate research into improvements in cancer outcomes and public health.

India is home to brilliant clinicians and researchers who focus on different aspects of cancer care from the development of low-cost cancer screening tools for the masses, to advanced studies on the molecular and genetic characteristics of tumour cells and their implications for treatment. Nonetheless, India is faced with some formidable health challenges that have a tremendous impact on research and specifically, cancer research. There is a growing burden of cancer and a shortage of healthcare professionals, because of which, doctors are compelled to spend most of their times in the clinics and hospitals and can dedicate very little or no time to investigative lab research. Many hospitals and institutes do not have the required infrastructure to support high-quality cancer research. Moreover, because of poor funding and limited opportunities, a lot of our scientists are forced to look for alternatives to research in India. The time has come for us to give due recognition to the tremendous potential of research to help cancer patients live healthier and longer lives. If we are to change the research orientation of our country, it is going to take a strong research-focussed agenda and the individual and collective effort of all those involved. A report1 published in the illustrious journal Nature in 2015 has observed that India has a low scientific workforce density (the number of scientists compared to the size of the population) with only 200 ,000 full-time researchers and about 4 out of 10 Indian-born researchers working abroad

Cancer research in India

Currently, India's national cancer programme places a strong emphasis on epidemiological research (i.e. research on health and disease in a population) to help control cancer and the setting up of a nationwide cancer registry. In the public sector, some of the big players in cancer research in India include th¬e Department of Science and Technology, the Department of Atomic Energy Research and the Indian Council of Medical Research. The Department of Biotechnology has also funded over 300 projects that studied cancer diagnosis, prognosis, biomarkers, chemotherapeutic agent development and identification of new targets for therapy.2

Reflecting this increase in cancer research, the number of Indian cancer publications increased from 300 papers in 1990 to almost 1500 papers in 2010 .3 It was good to note that almost two thirds of these papers featured an Indian scientist as the primary or corresponding author, indicating that an Indian scientist had a prominent role in the research. In a paper3 published in The Lancet Oncology in 2014, a group of scientists who did an in-depth qualitative and quantitative assessment of cancer publications from India observed that cancer research in the country was largely focused on the genetics of cancer and on chemotherapy. Overall, centres in New Delhi, Maharashtra, Tamil Nadu, Uttar Pradesh, West Bengal, Karnataka, Kerala, Chandigarh and Andhra Pradesh were actively involved in cancer research. Generally, more research was carried out on the common cancers such as cervical and head and neck cancer, as well as breast and liver cancers.

Genomics research has the potential to revolutionize cancer care

Within the area of cancer research, I believe that cancer genomics research has enormous, untapped potential. Genomics research is the basis for genomic medicine which is a relatively new branch of medicine where doctors use a person's genetic information to choose the best possible line of treatment and cancer care. Think about this: there was a time when doctors were able to profile only 1 mutation in a single gene at a time which revealed a fraction of what was going on in the tumour and gave us a limited "one size fits all" view of possible therapies. Today, the situation is different. Our understanding of the human genome has given us tools with which we can do "massively parallel deep sequencing" of genes that reveals the multigene mutation profile of a tumour at "one go". This gives us a comprehensive understanding of the processes that drive an individual's cancer. This is only possible because scientists and clinicians invested their time and efforts to understand the genomics of cancer.

Across the country, several laboratories do in-depth studies on the gene profiles of cancers, gene signatures of tumours (i.e. a list of genes that are typically "on" or "off: in a cancer cell), the upregulated and downregulated genes/gene mutations and other alterations seen in normal vs . cancerous cells (i.e. genes that "on" in cancer cells but "off" in normal healthy cells and vice versa) and develop innovative high-throughput technologies to help us mine data and draw conclusions that have a clinical impact. Studies on cancer genomics are done using tissue cultures, animal models and patient samples and I believe that the government and other agencies should continue to fund these types of projects.

Apart from work done in individual laboratories, we also need to carry out population-wide research on cancer genetics. Most data available today are based on studies carried out with Western populations. While human beings across the world have very similar DNA, there are small variations that are typical to people of a certain ethnicity that could affect disease susceptibility and the way individuals respond or do not respond to drugs. Consider, for example, the Tay-Sachs disease that shows a much higher incidence among those with Ashkenazi Jewish ancestry than most other populations.4 Similarly, there could be certain mutations that are specific to the Indian population that predispose us to certain cancers or affect the way we respond to treatment, but we are not yet aware of it because we have not studied these cancers amongst the Indian population. This is something that must be addressed.

A few years ago, India set up the first Indian Genome Variation Consortium5, a comprehensive population-wide genome study that revealed variations in about 900 genes, many of which were linked to several diseases including cancer. On similar lines, we must now focus on developing a specialized Cancer Genome Bank that will serve as a centralized repository to collect cancer biopsies from across the country and analyse their gene profiles. If we can link the gene profiles to data about the patient's treatment regimen and the result of the treatment, we may find possible links between genomic data and clinical outcomes that will help doctors in the future make better clinical choices with regards to the choice of therapy.

The future of cancer research in India

I believe pharmaceutical companies must step up and play a bigger role in cancer research in India. Pharmaceutical companies must be willing to fund projects that focus on Indian patient cohorts and new molecules. In fact, I would even suggest that when it comes to funding, the pharmaceutical companies should make a conscious effort to put a fixed proportion of their profits into research. It would also be beneficial for big pharmaceutical players to tie up with hospitals and research centres to fund more projects that will take molecules from the "bench to the bedside". We must also step aside from our tendency to have a "copycat" mentality. In my opinion, we spend a lot of time developing biosimilars of molecules that have been produced in western labs, instead of doing original research and coming up with new molecules ourselves. India has some of the finest researchers and scientists, not to mention a potentially large biorepository of tumour material that we must use to our advantage.

In conclusion, cancer research and cancer genomics research need a far greater thrust in India and we must address several factors including: the need for more funding and grants; the need for state-of-the-art infrastructure and research facilities to make quality research possible; and the encouragement of partnerships between pharmaceutical companies and research institutes or hospitals. At HCG, we have taken the initiative to move from a symptom-based approach to cancer care that gave us limited choices in treatments to a more gene/biochemical pattern-based approach to cancer care so we can offer patients personalized cancer medicine empowered by genomics. When we treat cancer this way, it not only improves treatment outcomes for the patients but also helps to significantly bring down the overall cost. Other experts have also noticed this—a Harvard Business School publication6 in 2013 compared HCG Oncology care with the U.S . average care and observed that while the outcomes were remarkably similar (for breast cancer), the treatment cost was just USD 2900 at HCG compared to an average of $22,000 in the U.S. We believe that this approach is the way of the future because it enables us to treat cancer the right way, the first time and we hope that other hospitals and institutes across the country adopt a similar approach to cancer treatment.
References:

1. Van Noorden R. India by the numbers. Nature. 2015 May 14;521(7551):142-3 .
2. Ministry of Science and Technology. Department of Biotechnology. http://www.dbtindia.nic.in/program-medical-biotechnology/chronic-disease -biology/cancer-research/
3. Sullivan R et al. Cancer research in India: national priorities, global results. Lancet Oncol. 2014 May;15(6):e213-22.
4. US National Library of Medicine. Genetics Home Reference. Tay-Sachs disease. https://ghr.nlm.nih.gov/condition/tay-sachs-disease#statistics
5. Indian Genome Variation Consortium.. The Indian Genome Variation database (IGVdb): a project overview. Hum Genet. 2005 Oct;118(1):1-11.
6. Govindarajan V et. al. Delivering World Class Health Care Affordably. Harvard Business Review, November 2013.