In this article Dr Prasad shares his views on chronic disease management based on four key principles organ focus, standardised global care guidelines, multidisciplinary approach and tumour board and patient centric cancer care.
When a disease persists for a long time, it presents different challenges. Whether it is diabetes, asthma or hypertension, chronic disease management is the key. This essentially entails helping the patient live a ‘normal’ life, despite there being no cure for the ailment.
As an oncologist, I see cancer patients today live longer than ever before. We have newer and smarter treatment modalities for cancer getting approved on a regular basis. According to National Cancer Institute, USA, 67 per cent of people diagnosed with cancer have survival rates of at least five years. That’s a remarkable increase of over 20 per cent in the last four decades.
The Indian Council of Medical Research (ICMR) registry also reports a similar trend in cancer survival, despite almost 60 per cent of cancer cases in India being diagnosed at an advanced stage. In other words, even when there’s no cure per se available, medical science can help patients lead a good quality of life.
Cancer is counted among the top 10 chronic diseases globally. However, the term ‘cancer’ refers not just to one disease, but a collection of more than 100 diseases – from breast cancer and colon cancer to blood cancer and skin cancer – with wide-ranging characteristics that usually call for varied treatments.
Cancer management depends on multiple factors, such as type of cancer, disease response, remission or relapse, tolerance to treatment, age and overall health of the patient, to name some. Studies show that lifestyle changes, early detection and timely treatment can help prevent and cure many cancers, including breast cancer, cervical cancer, oral cancer, prostate cancer and skin cancer. Also, treating an early stage cancer is nearly 80 per cent more cost-effective and the survival rates are five times higher than at later stages.
Current cancer treatments include chemotherapy, immunotherapy, radiation therapy, and surgery. However, modalities are changing rapidly. For instance, most cancers needed chemotherapy or other IV drug treatments in the past. But today an increasing number of patients – almost 30 per cent in case of lung cancer patients – are treated with targeted therapy, mostly by way of oral medications!
With targeted therapies, researchers are looking at targeting the cancer-causing genetic changes in tumours – no matter where the cancer develops in the body – to combat the disease. Similarly, precision medicine can help predict targetable mutations and figure out how the body would process certain drugs even before one takes them.
We can no longer look at cancer treatment as a one-sizefits-all; it has to be tailored to each individual, such that the therapies work with the body’s makeup to help fight cancer in the most effective manner.
Immunotherapy, also called biotherapy, is another cancer treatment, powered by one’s own immune system.
There are two common types of immunotherapy. First, monoclonal antibodies, which are designed to recognise and attack cancer cells, and have an overall good response with limited side effects. Second, checkpoint inhibitors that work by blocking checkpoint proteins from binding with their partner proteins. This prevents the “off” signal from being sent, allowing the T cells to kill cancer cells.
Vaccines are also a type of immunotherapy that work to boost the body’s immune system to fight cancer. There are vaccines, such as the Human Papilloma Virus (HPV) vaccine that help prevent cancers caused by a virus, and vaccines that are used to treat certain cancers, such as prostate cancer and cervical cancer, by activating the immune cells. Researchers are in the process of testing vaccines for several types of cancer.
Traditionally, we have approached cancer unlike most other diseases with potential for turning chronic; not associating it with the organ that it impacts. Of course, this is no longer true for the medical fraternity. Today, we have colleagues who have spent years understanding how the disease not only impacts a specific organ but certain different parts of an organ.
For instance, head and neck cancers comprise over 17 sites, including oral cavity, nasal cavity, and ear, to name some. We need to look at cancer from an organ site approach, whereby there are dedicated teams for each type of cancer.
However, the awareness among patients with regards to organ site focus and how it impacts the course of their treatment, chances of recurrence, and post-treatment life is still quite low. For many of them, especially semi-rural and rural patients, all types, and stages of cancer are associated with life-limiting illness.
Hence, a major area of growth as we look to effective chronic disease management would also be to educate patients and people at large about how every cancer isn’t the same in terms of its symptoms, risk, survival, and life post treatment. Disseminating a lot more knowledge about organ site-focus can go a long way in reducing anxieties around the disease.
Cytecare is one of the first private hospitals in India to offer organ sitefocus-based oncology care. Our practice is based on four prominent pillars — organ site focussed and specialist oncologists, standardised global guidelines and tumour board, patientcentric culture and clinical research. The multidisciplinary team of clinicians is strongly guided by national as well as global protocols, such as the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), National Health Service (NHS), Indian Council of Medical Research (ICMR) and Tata Memorial Hospital.
Going forth, we must look at building organ site-focus capabilities that understand the varied emotional impacts associated with the difference organ-related cancers. For instance, the mental make-up of a patient with breast cancer is likely to very different than that of a patient with lung cancer. Accordingly, not just counselling, but the very nature of treatments and therapies in the future should be directed towards effectively managing the same.
Right from diagnosis to posttreatment prescriptions, we need to create an environment that isn’t overwhelming and alienating but one that instils hope, confidence, and positivity. Each one of us – surgeons, doctors, therapists, radiologists, nutritionists, nurses, counsellors – need to see it as our collective and core responsibility rather than an addition to our busy schedules. Be it offering them sufficient information support and procedure-related advantages and disadvantages in a language of their choice or mind and body wellness programs, we need to go from addressing the cancer at the site to managing the disease that engulfs the mind, lives, and communities.
As Suresh Ramu, Co-founder and CEO, Cytecare Cancer Hospitals, rightly puts it, "India needs to invest in more patient-centric cancer care systems, with an organ-site approach. We must adopt a holistic way of dealing with chronic diseases – that are often misunderstood and not diagnosed and treated on time. Patient-centricity has to be at the heart of chronic disease management. Right from pain management and rehabilitation services, to onco-nutritional support, mind-body medicine and home care support services, Cytecare was founded on the principle of ‘Fighting Cancer the Right Way’.
With healthcare taking centre stage during the pandemic, this could be a truly transformative phase that changes the way we address health and chronic disease management.
Once the cancer is stable during treatment or in remission and life feels normal again, it’s important to remember that the battle isn’t over yet. With chronic disease management, the road ahead is long. And there are bound to be ups and downs along the way.
In order to ensure that the journey doesn’t get too uphill or lonely, it’s vital to nurture a strong support system. At Cytecare, for instance, we foster a sense of community to help patients cope better. Our Patient Navigator support system, a one-of-its-kind support system, encourages cancer survivors to share their personal experiences with others in similar situations. Patients find it comforting to hear survivors talk about their experience of managing pain, undergoing chemotherapy and other treatments, communicating with doctors, drawing strength from family and friends.
Families of people living with cancer also need support. We have seen that when caregivers are cared for, it can make a big impact in terms of optimal outcomes for the patient. It’s prudent for cancer care centres to invest in patient support groups, wellness groups, social workers, psychologists, and counsellors as part of their work with families. Extra hands and empathetic hearts can make the journey with cancer less stressful.
It is crucial that cancer patients take care of their mental and physical health. Mental health is closely linked to physical health. A disturbed state of mind can further affect emotional and psychological wellbeing. Chronic stress is known to trigger inflammation in the body and can cause fatigue, depression, irritability, and severe headaches.
Being diagnosed with a lifethreatening disease and undergoing treatment can cause much distress. And the pandemic has only further aggravated the emotional and mental impact that one experiences while navigating a chronic illness. Right from concerns about being immunocompromised to greater anxiety about an uncertain financial future, the trigger points are plenty.
At Cytecare, our team of psychooncologists help patients to navigate mental health issues and find a healthy outlet for their emotions. It is essential to help patients manage the psychosocial challenges of diagnosis and treatment of cancer.
The quality of care over time is critical to chronic disease management. For cancer, it is important to adopt a multi-disciplinary approach. It’s not just about cancer care, but patient care. For instance, co-existing medical conditions, if any, also need to be addressed effectively to ensure overall health and well-being of patients.
As healthcare providers, our focus tends to be on new, multidimensional models of service delivery for improved patient outcomes. That’s essential – but so is patient satisfaction. We need to look at continuity of care from both perspectives – that of the patient and that of the provider.
From medical, radiation and surgical oncologists to pain and palliative care experts, all cancer care centres need to be armed with a comprehensive team of professionals, who have a deep understanding of the complex disease. Cytecare’s integrated oncology works with a world-class team of 25 plus cancer specialists - One of the largest such team in India.
We also have a multi-disciplinary tumour board to ensure that each patient not only gets expert care – from the medical oncologist, the radiation oncologist, the surgical oncologist and the pathologist, among others – but also that there is strict governance of care.
Technology can be a potent tool in bridging the healthcare gap, by moving medical care out of the traditional setting into places where people live and work. This is particularly empowering in a country like India where an overwhelming majority of patients have advanced stage of cancer at the time of diagnosis.
During the pandemic, the ability to offer remote/virtual consultations has helped healthcare providers to offer suitable consultations and reduce the risks of infection, while dealing with limited hospital resources. Several cancer patients, who are at high-risk of infection, managed to get regular advice from their doctors via teleconsultations, without having to travel to the hospital.
The pandemic also saw patientcentred home care being integrated with more traditional hospital-centred care. In time, the primary setting for the delivery of care to certain patients with cancer is likely to shift from the hospital to the home – courtesy better cancer treatments, advent of oral therapies, shortened hospital visits, longer survival, and most patients’ desire to be cared for at home for as long as possible.
Smart technologies have further facilitated timely, evidence-based care for seamless healthcare delivery. Smart ICUs, for instance, offer valuable benefits of continuous remote surveillance, such as prevention of infections, early detection of organ failures and timely resuscitation of patients as well as helping devise disease-specific protocols and effective strategies.