Mind you, TMH is not driving it. To say that would be undermining the effort of many, many people. NCG is extremely democratic. Most ideas have come from member centers. For instance, guidelines for treatment is not a new idea; we have set these in the past. Typically, they are formed by getting a group of experts from elite cancer institutes, who look at the guidelines from abroad and select a bunch based on evidence. We [at NCG] are not trashing that effort, it’s systematically done.
But they are extremely cumbersome for physicians to follow. Some guidelines for single cancer, like colorectal, run into 70 pages. The moment you have 70 pages, no chance a busy physician would even turn the pages. So we made it very concise—two pages, and in an algorithmic format.
Guidelines for the treatment
The Ken: You mean input-based?
Yes, all that the clinician needs to do is to fill the specific figures/report outcomes in the matrix and the algorithm comes up with a treatment recommendation. For instance, if your patient has early breast cancer, then what’s the size of the tumor, has it spread to lymph nodes or any other part of the body, what is the biopsy report, etc. You fill in the data and the guidelines will tell if surgery has to be followed by radiation or chemo and so on. The same information is available in 72 pages otherwise.
An important part of this method is that the moment you get new evidence, you revise your guidelines. Our first set of guidelines came in 2017; a revision is underway as we speak.
The Ken: Talk about one instance of data-based treatment driving this revision.
Take the breast cancer drug, Herceptin. [Sold in India by Roche (the innovator), Mylan and Biocon; costs upwards of Rs 10 lakh ($14,286) for a full cycle.] It’s a breakthrough drug. We did a survey in 2008 at TMH where we looked at what proportion of women eligible to get the drug actually get it. It was 8%. Half of those got the drug because they were part of the clinical trial. Effectively, only 4% could afford to take the drug. This is true in most cancers based on western guidelines.
Analyzing the stats
We looked at data afresh. A study shows that instead of a year if you give Herceptin for nine weeks, it is almost as effective as giving it for a year and at a fraction of the cost. We put this in the guidelines and now we repeated the survey, 10 years after the first survey. Now, 50% of women who need this drug are getting it, up from 4%. Of course, we were supported by philanthropic money, but still. We cannot allow ‘perfect’ to become the enemy of ‘good’. This practice is now being adopted in several other low-income countries, including several in Africa.
The Ken: Have you been able to reduce migration?
A lot of patients travel for the second opinion. Even coming from a capital city like Bhubaneswar in Orissa to Mumbai—to see the doctor, do the tests, come back to the oncologist and go back home—is an ordeal. We created an online second opinion platform in partnership with Navya Networks. Any patient, either from India or anywhere in the world, can take a photo of their reports and upload them.
We have given them, at the backend, a set of minimum requirements, what reports to collate in a structured manner for each cancer. For example, if it’s lung cancer, then we need a chest X-ray, a biopsy, a CT scan; and if there are other symptoms, then an MRI or a PET scan.
Suggestions for the growth
Entire scans can be uploaded. This is then structured and sent to experts at NCG. I get formal and informal reports seeking a second opinion. But to look at 75 pages of a report over email isn’t possible. But if it comes in a structured format, it takes just 3-4 minutes to give my opinion.
This platform has machine learning technology at the backend which continually improves it. It already comes up with 2-3 suggestions, which takes into account evidence elsewhere in the literature. In many cases, this is all that the patient requires. If the second opinion is different from the local doctor’s prescription, she can share it with the local doctor.