New hope on cancer

The promise of new therapeutics

Rockstar molecules

New and exciting compounds that target pathways feeding cancer cells. They leave healthy cells unscathed, shrink tumours and cause fewer sideeffects than chemo.

New-age beamers

High-resolution scans and X-rays. Pinpoint cancers accurately, spare good cells. The latest are imageguided, can track patient movement, and work real-time.

Surgery by nature

Minimally invasive is the mantra. Focus is on preserving organs: breasts, voice box, jaws, limbs, etc. The latest is to mimic the body's own rhythm, antibodies, enzymes.

The smart aimer

Targeted chemo or making anti-cancer drugs more tumour-specific. Aims the drug by placing "tags" to cancer cells. Point is to avoid damage to healthy tissue.

Rush for trial

Clinical trials drive cancer research today.The investment is enormous, although cancer is not the top killer. Over 800 compounds in the pipeline in the US.

Pan and scan

PET CT and MRI scans help doctors to locate and stage cancers accurately and know how far it has spread. Has come to India in the last 2-3 years.

Generic hope

Indian generic drug-makers are releasing "biosimilars" in the market, at an affordable cost. Promises to be a boon to many more cancer patients.

Diagnosed in June last year, Ray decided to give people an insight into her life and the new developments in cancer treatment. Poignant, often heart-wrenching and always full of optimism and courage, the daily chronicling of her journey into the unknown, in a way, encapsulates the story of cancer.Is the glass half-empty or half-full on the cancer front? It's hard to tell where you stand in the war against the dreaded C-word.

Modern medicine has conquered many diseases and halted others, but cancer has proved to be too smart, too complex, too hostile and too quick at outsmarting therapies. It has doubled its grip over the world in the last 20 years and struck deep roots in India-from 0.8 million in 2001 to 2.5 million people diagnosed now, says the World Health Organization.

But there's a sunny side to this grim storyline: an explosion of new research, treatments, therapeutics and drugs that is changing the way cancer is perceived, understood and treated. "In cancer, some problems can be solved, some can't be and some can't be solved yet. But hope for a cure is definitely on the cards," sums up Dr G.K. Rath, chief of the Rotary Cancer Hospital at All India Institute of Medical Sciences (AIIMS), Delhi.The idea of "cure" calls for a definition. "A majority of cancers recur in the first two-three years of diagnosis and hence a five-year survival has traditionally been equated with cure," says Dr R.A. Badwe, director of Tata Memorial Hospital & Cancer Research Institute (TMC), Mumbai.

Going by that, globally two-thirds of patients survive at least five years after diagnosis now, compared to just half of patients 40 years ago (J Clin Oncol, 2009). Since 1990, cancer mortality rates have declined by 15 per cent. The survival rate for all cancers has gone up from 50 per cent in 1975 to 66 per cent now, reports the American Cancer Society.

Topping the list are prostate (up from 69 to 100 per cent), breast (75 to 89), bladder (73 to 82), kidney (49 to 69), larynx (51 to 66) and so on. Childhood leukaemia, a disease that killed 75 per cent of the children it struck in the '70s, is now one where 73 per cent survive.

With uterine cervical cancer, radiation therapy has achieved long-term cure rates of 85-90 per cent. Some of the same percentages now prevail in India since most of the treatments in the US are now available in the country. The glass, however, remains stubbornly half-empty as some cancers still defy treatment: lung to pancreas, liver to oesophagus.It was a day like any other day. But try as he might, 40-year-old Ram Prakash (name changed) just couldn't get his arms through his shirt sleeves. Two days later, as he rammed his car into a tree for no apparent reason, he knew he was up against a major crisis. As a scientist cracking the IIT-ivy league echelons, he had faced his share of challenges. But this was an equation no algorithm or meta math could solve.

A fast-growing glioblastoma multiforme grade four tumour was spreading tentacles in his brain. As he entered the traumatic world of cancer, surgeries, chemotherapy and radiation, he asked the doctors. "If 1,00,000 people had this, how many would be alive in one year?" "Believe in miracles," they said. And he did chance across one when they enlisted him for the clinical trial of an experimental drug, bevacizumab.

"Nothing was proven at that point, but I had nothing to lose," he says. Twenty-nine months later, with clear MRIs and no recurrences, he is facing life with a bit more confidence.Patients like him demonstrate how quickly cancer treatment is changing. That change is clear to veterans who have been in and out of cancer wards for long. As a student at AIIMS in the '70s, Rath remembers beaming X-rays mostly on paediatric tumours "to make those behave better". But those were high-energy electromagnetic waves that passed through the body, depositing energy all along, not just on the tumour.

"From 2004-05, the next wave of radiation technology-with focused beams, targeting a well-defined tumour-started coming in," says Rath. "They help doctors to locate the cancer, know how far it has spread and beat it down in a versatile, accurate and precise manner."

In his unit at AIIMS, Rath now has all the latest devices crammed under its roof: PET-CT scans to see changes in the activity of cells, state-of-the-art Intensity Modulated Radiation Therapy (IMRT) machines to focus radiations on cancer-affected areas only, Image Guided Radio Therapy (IGRT) devices to deliver correct doses even if the tumour cells move during the treatment, stereotactic, proton and particle radio systems to shoot beams into tumours at the speed of light."A patient's quality of life has improved dramatically," points out Dr Harit Chaturvedi, chief consultant and director, surgical oncology, Max Healthcare, Delhi. That's because, all new developments-from high-end scanners and X-rays, immunohistochemistry (to analyse and identify cancer cell types), targeted chemotherapy, organ preservation to minimally invasive surgery-are focussed on power and precision to reduce patient trauma.

"The problem with radiation or chemotherapy is, while they prevent cancers from spreading, they also damage healthy cells, resulting in serious side effects," he says. Because cancer therapeutics are commonly delivered though the blood, only a small fraction reaches the target tumour. To obtain maximum benefit, a high dose of drug has to be administered. "A lot of effort is on to make the drugs more tumour-specific," says Chaturvedi.The god is in biology. Oncology is no longer a one-size-fits-all field. "We are now entering an era of personalised cancer medicines, in which treatment is tailored to the unique genetics of the individual or the tumour," says Dr Rakesh Jalali, neurooncologist with TMC.

Five reality checks

Chennai beware: The city has the highest cancer rate per 1,00,000.

Top slot: Lung cancers highest among men, breast in women.

Capital woes: At 11 per 1,00,000,Delhi women top global charts in gall bladder cancer.

Midlife crisis: Indian women between 45 and 55 are at a greater risk.

Up in smoke: Seven out of 10 tobaccorelated deaths occur between age 30 and 69 in India.

Even in the early-90s, when he was an MD at PGIMER in Chandigarh, cancer biology remained shrouded in mystery. "A breast cancer was just a breast cancer; a glioma just that. There was a blanket therapy."

Now researchers know that each cancer is different and the effort is to treat a tumour according to a whole set of personalised parameters-age of the patient, the stage, grade and type of the tumour, the pathology and possibility of recurrence and so on.Clinical trials are the engine driving cancer research today. They make it possible to demystify cancer biology. "Globally, the investment in cancer research is enormous," says Venkatesh V. Reddy, senior pharma analyst with PharmARC Analytic Solutions in Bangalore.

In the US, 800 compounds are in the pipeline, just on cancer, although its spread is much less than as cardiovascular diseases or diabetes. "Cancer cells are so smart that you need that kind of investment," says Reddy. Clinical trials establish the efficacy of some of the new and exciting compounds that attack cancers at the molecular level.

"They target growth signals that feed cancer cells, leave healthy cells unscathed, shrink tumours, help patients feel better and cause fewer side-effects than chemo," points out Reddy. Bevacizumab is the first in a decade to be approved in 2009 by the USFDA to treat the deadly glioblastoma.

India, however, lags behind in clinical research. "We must do our own original studies or become the clinical trial call centre of the world," says Jalali.The scope for innovation in surgery is often more limited. But new approaches are pouring out of the nation's OTs. Ask Badwe. He has managed to combine surgery with the body's natural rhythm.

In a study, he established that women undergoing breast cancer surgeries during the luteal phase of their menstrual cycle (when the presence of hormone progesterone is more) had higher survival rates and less chances of a recurrence.

TMC used this hypothesis on 1,000 women and found a 30 per cent reduction in mortality. "And all at just Rs 65 and no side-effects," says Badwe with a smile.Cost is really the killer in India. Namita Chauhan, 40, of Delhi credits her recovery from breast cancer to a new molecule drug, Herceptin. "Yes, you do get the new drugs here, but how many can afford it," she asks.

She needed 15 doses and had to shell out a prohibitive Rs 1 lakh for each dose. The good news is: the best centres for cancer in India are believed to be AIIMS in Delhi and TMC in Mumbai, both of which subsidise the rates.

The real-time radiation device, Tomotherapy, at TMC-the only such in South Asia-was bought at a cost of Rs 24 crore. TMC charges Rs 2,000 from 80 per cent of those who cannot afford to pay. "But doctors also push up costs," says Reddy. "Many are too eager to recommend high-end drugs and devices to patients, to stay ahead of the competition."

The cancer burden might just get lighter when generic drug-makers enter the market with a larger platter of made-in-India "biosimilars"."We will cure cancer," has been the mantra of scientists for the last five decades-from the rise of megavoltage radiotherapy in the '50s to the birth of artificial antibodies in the '90s.

There's a new excitement as treatments move toward targeted therapies, super molecules and evermore high-precision radiation. With exciting new therapeutics in the pipeline, can cancer finally be conquered? "I certainly think so," says Rath with infectious optimism.

"When I look back, I am struck by the progress we have made since the time I started my career at AIIMS 36 years ago." One of the senior-most consultants at AIIMS, Rath expects a cure for cancer over the next 15 years ("And certainly within my lifetime").That brings new hope to people like Subhash Mishra, a 50-something professor at IIT-Guwahati, who was diagnosed with a grade three brain cancer last year. Mishra never agonised over "why me", never went through the yoyo curve of denial and despair.

In fact, as a scientist he "rather enjoyed" being a part of the high-tech world of battling cancer. "I was curious to understand the real-time Trilogy radiation system at TMC," he says. "There was no time to get scared." He went to hospitals alone, always discouraged those who wanted to accompany him. And often took classes before checking in for a chemoradiation session. He knows that cancer kills, but refuses to take it seriously in an era of therapeutic promise: "Yes, I have cancer, So what?"

Anurag Basu, 35 - Leukaemia survivor

He was diagnosed with acute leukaemia in 2004 and was told by doctors that he had little chance of surviving."My wife was eight months pregnant and I was determined to live and see my child," he says. For the next one-and-a-half years, Basu battled cancer through chemotherapy and refused to let it take over his life. He began shooting for Gangster during his final dose of chemotherapy and penned Life in a... Metro. Looking back, he says the experience changed him a lot. "You learn the value of life when you see death closely. My first priority used to be work, but now it is my family," he says.

Namita Chauhan, 40 - Breast cancer survivor

"You are the most beautiful bald lady in the world"-that's what her husband had told her at the height of her cancer trauma. Five years later she is finally facing life with confidence. Yes, she took Herceptin-the original targeted therapy against cancer. "The new drugs might be available but are they affordable," she asks. She had to take 15 doses and each was for a lakh. She still winces at the memory. "The new drugs will make a difference only if they are within the common man's reach," she says.

Voices from the field

"Targeted therapy is the buzzword in the treatment of cancers, whether it is myeloid leukaemia, breast, colon or lung cancer." - Dr R.A. BadweDirector, Tata Memorial Hospital & Cancer Research Institute, Mumbai

"In cancer, some problems can be solved, some can't be solved yet. But hope for a cure is on the cards." - Dr G.K. Rath, Chief, DR. B.R.A.I. Rotary Cancer Hospital, AIIMS, Delhi

"A patient's quality of life, a much-ignored issue in our country, has improved dramatically as a result of the new innovations in cancer therapy." - Dr H. Chaturvedi, Chief Consultant & Director, Surgical Oncology, Max Healthcare, Delhi.