Cancer care and cure

The Tata Memorial Hospital in Mumbai, which offers world standards in the treatment of cancer, is implementing a programme of further modernisation.

T.S. SUBRAMANIAN recently in Mumbai

THE room is spacious, the curtains drawn, the lighting soft. Several bright-eyed children are engrossed in his or her own activity. One child is busy using yellow building blocks to erect a tower. Another hugs fluffy dolls. A third child is furiously ped alling his tricycle. It is indeed difficult to believe that these children are suffering from cancer.

This is the children's ward in the Tata Memorial Hospital (TMH), Mumbai, a premier institution devoted to prevention, diagnosis, treatment of and research in various types of cancer. It is a teaching hospital, all set to become a deemed university. A maj or programme of renovation of the hospital and modernisation of the facilities is now under way in the TMH.

TMH is the largest cancer hospital in the country in terms of number of patients registered. Last year, about 28,000 patients registered and 18,000 were found to have contracted cancer. About 60 per cent of these 18,000 were treated at TMH.

According to doctors and researchers in the TMH, a "revolution" has taken place in the treatment of childhood cancers. The patients go through the treatment regime "enthusiastically" and 75 per cent of them are cured completely. The revolution is not con fined to the treatment of children but of adults too. This has been accomplished by multi-modal treatment involving surgery, chemotherapy (treatment with drugs) and radiotherapy (treatment by radiation). Radical surgery has given way to minimal surgery. In a majority of cases, the organs affected are no longer removed. In 70 per cent of breast cancer cases, the breast is retained. In throat cancer, the sound box is not removed, and the patient retains the faculty of speech.

But doctors are worried about the rising incidence of cancer in men owing to the use of tobacco, and the high rate of cervical cancer in women. These cancer types are not only entirely preventable but curable if diagnosed early. Most of the cancers are l ifestyle related: among men because of addiction to tobacco; cervical cancer among women due to early marriage, malnutrition, repeated pregnancies, chronic infection and poor hygiene; and breast cancer among women who married late, had fewer children and did not breast-feed their infants.

Dr. Ketayun A. Dinshaw, Director, Tata Memorial Centre, and Professor and Head, Department of Radiation Oncology, TMH, said, "The scourge of the century is the use of tobacco. A majority of cancers that occur among men in our country are in the head and the neck: in the oral cavity, the larynx, the pharynx and the oesophagus. All these are entirely due to tobacco. We are fighting a major battle against the tobacco companies, against the ethos of propagating tobacco in various forms." She said that the c oming decade will see a spurt in tobacco-related cancer types.

According to Dr. A.N. Bhisey, Director, Cancer Research Institute (CRI), located in TMH, research done by the CRI at the instance of the Government of India revealed that even plain paan masala that had no tobacco could cause tumours.

THE biggest advance in the field was the multi-modal approach. Dr. S.H. Advani, Head, Department of Medical Oncology, said: "In the treatment of childhood cancers, we have done wonders. The treatment of adults has undergone a tremendous change... Today w e are doing minimal surgery. We just remove the tumour and give chemotherapy."

Dr. Advani, who exudes optimism, said: "Medical oncology (which did not exist in India until 26 years ago) has had a major impact in converting many incurable forms of cancer into curable ones." Before the advent of oncology, all children afflicted with cancer died. Today, 75 per cent of them are cured. "The survival rate for leukaemia, zero earlier, is now 70 per cent. We feel we have achieved something," Dr. Advani said.

According to Dr. Dinshaw, the Indian Council of Medical Research cancer registry data had predicted that by 2000 there would be one million new cancer cases annually in India, and at any given time there would be two to three million cancer cases (Fro ntline, August 22, 1997). This is where the pioneering role of the TMH comes. Its genesis is interesting. In 1938, Lady Meherbai Tata was diagnosed with leukaemia for which there was no treatment in India. She was taken to the Memorial Sloan Ketterin g Cancer Centre, New York, but she died. The House of Tatas then decided to set up a multi-disciplinary cancer treatment centre. The Tata Memorial Hospital was founded in 1941. Lady Meherbai Tata's husband Dorabji Tata was instrumental in starting it. Th ere were only three or four hospitals in the world then which employed a multi-disciplinary approach but the TMH started off with that. This involved prevention, early diagnosis, treatment, investigative and support services, rehabilitation and terminal care.

Dr. Dinshaw is optimistic that current research will unravel the molecular basis of cancer and lead to a "revolution" in combating it. Rapid progress had already been made in the treatment of cancer with improved technology, evaluation and methods of tre atment. But she is appalled by the ignorance in the country on the causes of cancer.

Dr. Dinshaw, who was appointed Director, TMH, in November 1995 and Director, Tata Memorial Centre, in March 1997, told Frontline: "Today, we are in the era of biological medicine. In the next 25 years, medicine for the treatment of cancer will tot ally change. Molecular biology is going to be the answer. Besides, there is gene therapy. It is not something we are dreaming about or predicting. They are very much there in more and more areas."

IN 1952, the Indian Cancer Research Centre (ICRC) was established with stalwarts like Dr. V.R. Khanolkar at the helm. In 1957, the Tatas handed over the hospital to the Union Ministry of Health and Family Welfare. In 1962, in order to give a bigger thrus t to the TMH's programmes, with radiation playing a major role, the administrative control of the TMH was transferred to the Department of Atomic Energy (DAE), when Dr. Homi J. Bhabha was Chairman of the Atomic Energy Commission. The TMH is now fully sup ported and governed by the DAE.

By 1965-66, the ICRC, later renamed the Cancer Research Institute (CRI), merged with the TMH to become the Tata Memorial Centre (TMC). This meant that basic research was added to clinical research, service, education and training. The TMC is the overarch ing institution under which come the TMH and the CRI.

Dr. Dinshaw said that from 1962, the TMH had made remarkable strides and had reached levels of excellence that were acknowledged locally, regionally and internationally. In the last two years, the TMH had embarked on a programme of total upgradation of a ll facilities. Wards had been renovated to make them more patient-friendly.

On February 25, Dr. Anil K. Kakodkar, Director, Bhabha Atomic Research Centre, inaugurated several new facilities in the Departments of Radiodiagnosis, Radiation Oncologist and Medical Physics. Dr. S.P. Sukhatme, Chairman, Atomic Energy Regulatory Board, said the TMH was testimony to the level of excellence possible in this country.

Dr. Luis Jose De Souza, Head, Department of Surgery, and chief, gastro-intestinal service, said the TMH had eight operation theatres, and five of them were being "completely modernised". In 1999, it performed 4,430 surgical procedures, 1,629 minor surgic al procedures and 2,892 endoscopies. The outpatient department dealt with 20,000 new cases every year. Dr. De Souza said the Department of Surgery had become a super speciality this year, and M.Ch. would be awarded in surgical oncology. The TMH produced 35 to 40 Ph.Ds a year.

Dr. Advani said children constituted ten per cent of the patients in his Department of Medical Oncology. They get chemotherapy. Leukaemia is the most common disease among children and it is the most curable form. Out of every 100 cases, about 70 are cure d. "Every week we do one bone marrow transplant. With that our cure rate has gone up remarkably," he added.

Dr. Advani said that 20 years ago acute lymphoblastic leukaemia was 100 per cent fatal. "Today we can confidently say that 75 per cent of the children will be totally cured."

While leukaemia was treated with chemotherapy, tumours in the breasts, lungs, head and neck, stomach, and ovaries required the multi-disciplinary approach: surgery, chemotherapy and radiotherapy. Although chemotherapy had side-effects, most of them could be prevented by drugs.

New biological treatments had been developed. One involved the use of monochlonal antibodies which targeted only tumour cells, and normal cells were not killed. Enzyme inhibitors was an area of tremendous interest. Although the cause of most of the cance rs was not known, the process of the development of the cancerous cells was clearly understood, which facilitated newer forms of treatment. In future, treatment would attack/treat the cancerous/defective cells which had gone out of control. The treatment would not last months because the defect in the genes would be repaired. Dr. Advani said, "I am hopeful of another revolution in ten years."

According to Dr. Ashok Mohan, Advisor to the Director and Projects Coordinator, TMC, what was unique about the TMH was that it not only treated patients but gave them total care. Seventy per cent of the patients were treated free of cost. Since a patient would have to stay for weeks, accommodation was needed for his relatives. So homes had been set up at Ghatkopar, Dadar, Parel and Bandra where the relatives could stay free of cost or at minimal charges. There was a tie-up with BEST for running buses fr om Ghatkopar to TMH. When the patients returned for check-ups, they could stay in these homes.

Dr. I. Mittra, Chief of Breast Services and Professor of Surgery, calls himself "a three-way schizophrenic": he is a practising surgeon; he is a Ph.D. (in cancer biology) doing research in the laboratory; and he does public health research work in the co mmunity.

Dr. Mittra said, "New treatment modalities have been evolved now in the preservation of the breast, eliminating the trauma caused by removal. You don't remove the breast now but only the tumour/lump." This was achieved by "the combined expertise" of the surgeon, a pathologist, a radiologist and a medical oncologist. "I may remove the tumour. But its margins should be such that tumourous cells are not left behind. Even if tumourous cells are seen, we have developed criteria to decide how much can be left behind. If the margins are grossly positive, we will re-excise the area. If they are minimally positive, we can leave the area as such," Dr. Mittra said. Sixty per cent of the patients with breast cancer at the TMH now received breast conserving surgery . In the early 1980s, it was about five per cent.

Dr. Mittra said, "The incidence of breast cancer is rising rapidly. It is related to economic and industrial development. The reason behind the rise is that women are getting empowered and they are getting emancipated. This is a contradiction." The incid ence was four to five times higher in the West than in India.

Since prevention was better than cure, the TMH had embarked upon a major programme of early detection of breast and cervical cancer. The programme covered 1.5 lakh women from poor economic backgrounds in 10 areas of Mumbai, with funding from the National Institutes of Health, United States. This was a large randomised trial in which one group did clinical examination of the breast and another visual examination of the cervix. The survey would be done every 18 months over six years. According to Dr. Mitt ra, it is one of the largest community-based trials ever conducted.

Dr. De Souza said, "Our aim is to conserve the organs wherever possible." His personal interest was in palliative care which came in when the disease could not be treated any more. At that stage, pain relief was important so that the patient could pass away peacefully.

NUCLEAR medicine deals with the use of radiopharmaceuticals and radiation for the investigation, diagnosis and treatment of diseases. If nuclear medicine using radio isotopes has made big advances in India, the credit should go to a team of pioneers incl uding Dr. V.K. Iya, 72, who retired as Director of the Isotope Group, Bhabha Atomic Research Centre (BARC), Trombay.

According to Dr. Iya, the three strong elements of the nuclear medicine programme in India are the availability of radiopharmaceuticals; the availability of advanced electronic systems to measure radio isotopes; and clinical expertise. Dr. Iya said: "Som e of our nuclear medicine centres are on a par with those anywhere in the world. In the entire field of radiation medicine which includes nuclear medicine and radiation oncology, the TMH is one of the finest institutions."