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Editorial- Cancer research in India : miles to go
TR Santhoshkumar
EDITORIAL
CANCER RESEARCH IN INDIA : MILES TO GO
TR Santhoshkumar
Integrated Cancer Research Program,
Rajiv Gandhi Center for Biotechnology, Trivandrum -695014
Correspondence to : [email protected]
Globally, each year, cancer kills more people
than HIV, TB and malaria combined . 1
Cancer is the second most common cause of
disease-related death, after cardiovascular
diseases, in the United States. This is the
case in India also. It is estimated that, there
are 2 to 2.5 million cancer patients at any
given point of time, with about 0.7 million
new cases coming every year and nearly half
of them dying every year, in our country. 2
Two-thirds of new cancer cases are
presented in the advance and incurable
stage, at the time of diagnosis. More than
70% of these affected patients are in the
prime of their life, between the ages of 30
and 69 years.3 With increasing life
expectancy
and
changing
lifestyles
concomitant with development, the number
of cancer cases is expected to be almost three
times the current number.4
Over the years, we have made significant
progress in our efforts to combat the disease
in specific areas, such as cancer control
program, primary prevention, early
detection and screening, establishing model
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treatment centers across the country,
providing basic patient care interventions
such as surgery, radiotherapy and
chemotherapy through regional centers and
educating the public on cancer prevention at
various levels. The cancer control program,
implemented through the Ministry of Health
and Family Welfare, has played a crucial role
for this success and our cancer control
program remains as a good model among
developing nations. Similarly, the cancer
registry established by ICMR in 1981, by
networking cancer registries across the
country, offers reliable data on the magnitude
of cancer in India and has also laid the
foundation for augmenting the cancer control
program.5 These models, even though
operated through two different government
agencies, helped to devise appropriate
strategies to implement cancer control
program in our country through their
multilevel integration in planning and
monitoring of diverse activities. Apart from
supporting programs aiming to achieve
primary prevention and early detection of
cancer, the national cancer control program
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Editorial- Cancer research in India : miles to go
TR Santhoshkumar
also helped in establishing basic treatment
facilities for cancer across the country and in
enhancing capacity building measures with
modest financial support to Regional Cancer
Centers and Oncology wings of medical
colleges. Collectively, these measures
reduced the burden of several cancers such
as cervical cancer, mainly because of possible
early detection at a treatable stage.
Even though our cancer control program for
alleviating cancer burden in India received
appreciation from within the country and
outside for its achievements in recent years,
we failed to translate similar kind of success
in cancer research despite the involvement
of a large number of scientists and
organizations in cancer research activities.
Because of that, our cancer control program
also suffered in critical areas, such as making
available novel and affordable screening
tools, launching innovative diagnostics /
early detection tools and in providing
affordable treatment options. In fact, India
had ignored the importance of integrated
approach in cancer research and also the
significance of basic and translational
research on certain cancers unique to our
region, so global visibility of Indian cancer
research remains dismal. Over the years, the
major focus of our research has been on
cancer epidemiology and basic laboratory
research, with limited focus on clinical
studies. India’s contributions to drug
discovery efforts, preclinical cancer models,
development of novel diagnostics, cancer
immunology and large scale genomics
studies on cancer prevalent in our region are
negligible. The reasons for such an
unsatisfactory performance are multifactorial. Lack of a regulatory funding
agency to integrate and support cancer
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research in India has also significantly
contributed for this, despite the active
involvement of a large number of researchers.
India’s cancer research activities are spread
among several agencies including national
institutes, 23 Regional Cancer Centers,
Indian Institute of Science, Indian Institutes
of Technology, University departments and
CSIR-funded
organizations
and
Laboratories
under
Department
of
Biotechnology and ICMR. Closer analysis
reveals that, we have only a few cancer
research centers, where patient care,
education and training as well as basic and
translational research are actively pursued in
an integrated manner under one umbrella.
Tata Memorial Centre (TMC) includes
under its umbrella the Tata Memorial
Hospital (TMH), the largest cancer hospital
in India, established in 1952 and the
Advanced Centre for Treatment Research
and Education in Cancer (ACTREC),
envisioned to function as a national centre for
treatment, education and research in cancer. 6
TMC is an autonomous grant-in-aid
institution under the Department of Atomic
Energy, where advanced patient care as well
as research and training in Oncology are
seriously linked with somewhat appreciable
interaction between clinicians and researcher
in research endeavors. Several DBT-funded
national organizations such as National
Institute of Immunology ( NII), National
Centre for cell Sciences (NCCS), CDFD
even though active in cancer research for
quite a long time, their academic programs
still suffers significantly due to lack of direct
link with cancer hospitals.
Majority of the cancer research projects in
India are carried out by basic researchers,
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with limited involvement of medicallytrained community. The few clinicians
actively involved in cancer research in India,
mostly stay away from patient care and
clinical practice; consequently their research
is also generally confined to basic aspects of
cancer, with minimal clinical relevance and
interdisciplinary approach. In most cancer
care centers, clinicians are extremely busy in
managing the increasing number of patients
in clinics; so they are finding it difficult to
get sufficient time for active research. In
most of the cancer research programs being
implemented in India, clinical partners
remain as co-investigators merely to ensure
the availability of patient samples or to
satisfy the minimum requirements to get the
program financed through funding agencies.
Improper
education
and
training,
unattractive reward mechanisms, lack of
protected time for research due to increased
work load, lack of enough advanced research
centers with facilities for preclinical and
clinical research contribute as barriers in
retaining the best clinicians in cancer
research.
The main issues that cancer research
currently faces are the lack of interactions
between clinicians and basic scientists as well
as the lack of an integrated agency to
monitor cancer research, training, education
and funding in India. Despite having about
2000 Indians dying of cancer every day,
cancer research never received a primacy of
national significance from any of the
funding agencies or Government. Over
decades, medical research in India has given
more attention to communicable diseases
such as tuberculosis and leprosy. Despite the
participation of large number of centers for
cancer research, research on cancer in India
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is in its preliminary stage, with focus more on
the epidemiology and basic biology of cancer.
We are yet to understand the casual factors
for several cancers predominant in our region
and yet to initiate major research projects
focusing the needs of the society. These
deficiencies are aggravated further by the lack
of enough financial support and the lack of a
single leading agency to regulate funding and
review projects on cancer. In India, cancer
research is supported by all of the national
funding agencies, namely DBT, DST, and
ICMR. However, for all of them, funding for
cancer research is not a priority and typically
cancer research projects are evaluated and
funded along with other projects in
biosciences. Lately, DBT has emerged as the
major source of funds for cancer research.
However, several recent developments suggest
that we have realized the importance of
investing more on cancer research to make a
meaningful progress in our fight against this
dreaded disease. DBT, the major funding
source for biotechnology sector in India, for a
long time considered cancer biology as
among other chronic diseases such as
neuroscience,
cardiovascular
disease,
reproductive biology, metabolic disease etc.
for funding purpose. But, recently DBT
created a dedicated task force to review and
fund projects in cancer biology, emphasizing
the importance of investing more in this area.
After its recent restructuring, the task force
has initiated several measures to augment and
accelerate cancer research programs in India.
The special call released by DBT to initiate
Units of Excellence (UOE) in cancer for
strengthening research resources around
leaders in cancer biology with national
relevance but global competitiveness as well
as the Virtual National Cancer Institute
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(VNCI) program to virtually connect the
"Existing Excellence in Small Places" in
cancer research by setting up a Virtual
National Cancer Institute are two promising
signs of this changing attitude. This trend is
also reflected in the participation of Indian
institutions and cancer researchers in several
prominent clinically relevant cancer research
programs around the world. Participation of
India in International Genome Consortium
launched in 2008 to generate comprehensive
high resolution genomic data on major
cancer types is also a welcome approach to
enhance our visibility as well as to know
more about the common cancer types in our
population with a global perspective.
Initiation of global breast cancer
transcriptomics study, launching of
multicentre
curcumin
clinical
trial,
initiation of multicenter HPV vaccine trials,
large population based study to understand
the role of HPV in head and neck cancers
with European Union support etc. also
reflects realization of the need for promotion
of cancer research. A high-power delegation
team under the leadership of the former
Secretary of DBT visited National Cancer
Institute, USA (NCI) to establish
international collaboration with an aim of
developing India’s capacity in cancer
research and seeking out an opportunity to
link with NCI.
Such initiatives will certainly help us in
capacity-building for cancer research with
possible incremental successes in the near
future. Nevertheless, all these measures are
insufficient, especially in addressing a
complex disease such as cancer and to make
substantial transformative developments in
cancer research and in cancer care. In this
scenario, it is better to review the success
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stories from USA after the launch of the war
on cancer and the concerted measures taken
by them to improve cancer care, especially to
strengthen their research capacity. In general,
most of our accomplishments against cancer
are from the pioneering work carried out at
USA with the critical involvement of two
agencies NIH and NCI. In the United States,
the National Cancer Institute (NCI), part of
the National Institute of Health (NIH) under
the Department of Health and Human
Services is the primary agency that coordinates cancer research and the US
National Cancer Program. NCI was
established as the principal agency for cancer
research in 1937 and later in 1971 was
entrusted further with coordinating the US
National Cancer Program, immediately after
the launch of the war on cancer in January
1971 by the former President Richard M.
Nixon. This land mark declaration aiming to
launch an intensive campaign to find a cure
for cancer tremendously helped shift the
focus of cancer biology from laboratory
research to understanding the pathogenesis of
the most feared disease and also to improve
the care of cancer patients.7
Cancer Progress Report 2013, published
recently by the American Association of
Cancer Research (AACR), highlights the
scientific discoveries and achievements made
against cancer by comparing the survival rate
of patients with cancer in 2013 against that
in earlier years.1 The NCI estimates that
approximately 13.7 Americans with a history
of cancer were alive as on January 1, 2012;
almost 2 million more than what was
estimated during 2008 and more than 10
million than that of 1971’s estimates. This is
in fact contributed by many decades of
enormous funding in basic, translational and
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clinical research by the federal government,
philanthropic individuals and organizations
and private sector after the declare of war
against cancer.1 It is disheartening to note
that most of the landmark successes made in
the war was in fact made in USA with
minimal contributions from other nations.
Most people believe that we could have
achieved much more success against the
enemy if a concerted similar kind of effort
was made by other nations also since the
enemy is same everywhere.
The significant successes by NCI in the
sector of drug discovery are an eye opener
for a country like India where unique
traditional systems of treatments are in place
from ancient times. Approximately one half
of the chemotherapeutic drugs currently
used by oncologists for cancer treatment
were discovered and/or developed at NCI. 8
NCI’s
Developmental
Therapeutics
Program (DTP), one of the unique drug
discovery effort, have screened more than
80,000 compounds since 1990, using the
current screening system.The drug discovery
efforts initiated by NCI led to the successful
development of several targeted therapeutics,
many of which will be available for clinical
use soon.
In India, despite the active involvement of a
large number of scientists working on
natural products and on drug screening
efforts, we are yet to develop a novel drug or
molecule against cancer. Isolated research
activities, lack of inter-institutional and
industry partnership, inadequate advanced
facilities, lack of large investment and lack of
a regulatory agency to coordinate, monitor
and fund cancer research all contributed for
this scenario. Most people think that in a
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developing country such as India, preventive
oncology and early detection are more
important than cancer drug discovery.
However, it is time for us to invest more on
drug development, considering the enormous
trained manpower in diverse areas of basic
research, combinatorial chemistry and natural
product-experts spread over our national
institutions. The available knowhow in the
country can be easily mobilized for
understanding cancer and also for devising
novel therapeutics as was done by NCI,
several years ago. Several of the
pharmaceutical
companies,
such
as
GlaxoSmithKline (GSK), Dr. Reddy’s Lab,
Shantha Biotech, Dabur Pharma, Eli Lilly are
active in India and it is a good sign for us that
almost all of them do have research and
development activities related to cancer. Dr.
Reddy's Laboratories has identified cancer
drug development as a major focus area in
India. Shantha Biotech has targeted oncology
as its primary area of interest for conducting
R&D activities.
Dabur Pharma is yet
another company focusing on cancer research
and anti-cancer products. Eli Lilly is
conducting trials in cancer treatment, in
addition to developing new molecules for
treatment of lung cancer. Piramal Life
Sciences’ drug development program also
spans cancer drug-screening and targeted
therapeutic-development against cancer.
Most pharmaceutical companies consider
India as the preferred nation for clinical trial
of cancer drugs and therapeutics because of
the large pool of cancer patients and the low
cost involved for the trials. Preference of
India as a region suitable for clinical trials in
the development of new-generation anticancer and targeted drugs in turn will help to
make the drugs easily available to our
patients. Overall, the changing environment
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appears to be promising for initiating major
research programs on cancer drug discovery
under a common regulatory body.
In line with the US success model, we need
to take several measures to harness our
potential and augment our capacity for
making significant progress. Some of the
measures could be
1.
Establishing an Indian National
Cancer Institute (INCI) under the Ministry
of Health and Family Welfare, linking
national cancer control programs, and cancer
registry so that all relevant measures to
reduce cancer burden, such as cancer care,
cancer research, education, training, clinical
trials, and drug discovery can be integrated
and brought under a single agency. This
agency should be envisioned as a primary
funding source for cancer research, treatment
and cancer care in our country based on
priority areas identified from time to time
with a focus on cancers unique to our
country and which received less attention
earlier and by other developed countries. It is
a fact that in a country such as India, self
sufficiency in cancer research and cancer care
cannot be attained only by public sector
initiatives. Investments have to be mobilized
from private and non-government sectors for
cancer research and cancer care. Unlike in
US, we have miserably failed to attract
significant financial support from private
sector for our research in all areas of
biomedical research, even for our fight
against dreaded disease such as cancer,
despite the presence of several successful
industrial giants in the country. The Indian
National Cancer Institute should be
entrusted to identify all sources of funding
for cancer research and cancer care from
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within India and outside, in order to
strengthen cancer research. This agency in
consultation with experts from different
domains such as basic researchers, clinicians,
epidemiologist, social activists, financial
experts, etc. can identify priority areas plus
modalities to implement a successful cancer
research and cancer care program in India.
Over the years, India has made significant
impact on several areas such as medicinal
chemistry, nanotechnology, drug delivery etc.
with direct impact on improving cancer care.
Unfortunately, such isolated success is
confined to organizations such as CSIR labs,
IITs or national institutes. Their translational
potential has not been exploited. Presence of
an Indian National Cancer Institute with
experts in diverse areas may help to mobilize
these knowhow for effective translational
application in cancer, with appropriate reorientation.
2.
Establishing more cancer centers with
advanced treatment and research facilities,
especially for translational cancer research, in
selected states, under a common regulatory
body such as INCI, as described above.
Because of the involvement of high cost for
advanced new treatment options for cancer,
India is facing a major challenge in ensuring
equitable best quality cancer care to all. Early
detection methods, best infrastructural
facilities for cancer surgery and radiotherapy
and implementation of modern treatment
options are the foundations of good cancer
care. The numbers of cancer care facilities
and cancer research centers are not adqaute,
considering the burgeoning population and
rising incidence of cancer. Establishing
several advanced treatment centers with
clinical and basic research, directly under a
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national agency may help to test and
translate viable newer treatment options at
an affordable rate and to bring cost effective
models of patient care to India on par with
advanced nations. This also will promote the
best cancer research teams, focusing on
regional needs, to flourish around these
clinical centers.
3.
Implementation of national-level
training and career development programs
for clinicians, so as to attract more trained
clinicians into research and to encourage
them to take forward both research and
clinical practice simultaneously.
4.
Providing
enhanced
financial
support to existing cancer research centers
for capacity building in areas where our
strength is week such as developing
preclinical
models,
imaging
tools,
diagnostics, and advanced genomics.
5.
Engagement of a good number of
clinical and basic researchers trained in
cancer research, retuning to India from
abroad, utilizing the prestigious pioneering
programs launched by several funding
agencies (Ramanujan fellowship, INSPIRE,
Ramalingaswamy fellowship etc.) in the best
cancer research centers of the country.
6.
Establishing newer state-of-the-art
facilities for themes, in which our command
is extremely weak, such as transgenic
facilities, preclinical models, drug discovery
efforts (similar to the Development
Therapeutic Program of NCI) and advanced
genomics facilities in selected cancer
research centers under Indian National
Cancer Institute to help us build adequate
strength in these areas.
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7.
It is a facts that the successful drug
screening program adopted by NCI that led
to the identification of a significant number
of current cancer drugs does not have any
representative cervical cancer or oral cancer
cells, the two predominant cancer types of
India among the 51 cancer cell line panel
and in downstream preclinical models. At the
same time, more women die from cervical
cancer every year in India than anywhere else
in the world, average 5 year survival rate is
48.7%. Similar is the case for oral cancer that
ranks among the top three types of cancer in
our country. The Indian national cancer
institute can initiate a program on drug
development on similar lines of NCI
programme employing region specific cancer
models at the level of preliminary screening,
preclinical models and clinical models to
enable discovery effort to generate better
drugs against such cancers. Agencies such as
Ayush, institutes such as CDRI, NIN and
pharmaceutical R&D centers and other
relevant industries in India can significantly
contribute for the success if integrated for a
specific purpose.
8.
Separate task forces to monitor
research programs and support grant
applications in crucial areas of cancer research
such as cancer drug discovery, cancer
prevention models, low cost cancer treatment
approaches, innovative cancer vaccine
models,
low
cost
early
cancer
detection/diagnosis methods as well as
clinical trials may be initiated under NCI.
9.
Setting up a dedicated agency to
monitor clinical trials on cancer drugs,
vaccines, and therapeutics is an important
area since it requires experts from diverse
disciplines and national agencies.
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TR Santhoshkumar
In the current global fiscal circumstances,
even in the USA, the federal funding for
medical research is declining. Economic
situation in India is also not rosy.
Establishing an Indian National Cancer
Institute is hence a major task. Concrete
proposals for integrating existing cancer
research institutes and regional cancer
centers in addition to proposals to start new
advanced research and clinical facilities have
to come from key experts in the area of
cancer research and treatment. One of the
major challenges is to find a suitable body of
experts, who can make such a proposal
before the Government in India. An
independent institute or funding agency
cannot be entrusted with such a major task,
considering the socio-political dimensions
and complexities involved in such a venture
which needs heavy investments. In the USA,
American Association of Cancer Research,
the oldest and major gathering of a large
pool of cancer researchers and clinicians, has
emerged as a powerful body to influence the
US congress in decision-making in cancerrelated issues.
The Indian Association of Cancer Research
(IACR) though a similar body has limited
activities and is yet to emerge as a powerful
body to influence the Government in
decision making. Indian Association of
Cancer Research was established in 1971
with an aim to advance research in all
aspects of cancer, to promote interaction
among scientists in this field, and to spread
awareness about cancer among common
people. Currently, it has more than 600 life
members. Compared to AACR, IACR
Health Sciences 2013;2(4):JS001
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activities are limited to publication of IACR
Newsletter
and conduct of an annual
meeting. In order to begin the game, the
IACR needs to be revamped. They have to
initiate new measures to harness the
opportunities to improve cancer care and
cancer research. Given the recent predictions
of increasing cancer incidence in India, it is
an opportune time for all cancer researchers,
clinicians and policy makers in our country
to make necessary steps to convey to the govt.
that cancer research has to be identified as a
national priority to improve all aspects of
cancer care in our country.
References
1. AACR Cancer progress report. 2013
2. http://www.nihfw.org
3. Cancer mortality in India: a
nationally representative survey. The
Lancet 2012.
4. J Ferlay, HR Shin, F Bray, D
Forman, C Mathers, DM Parkin.
GLOBOCAN v1.2/Cancer incidence
and mortality worldwide. IARC
Cancer Base number 10 International
Agency for Research on Cancer, Lyon
(2010) .http://globocan.iarc.fr.
5. National
Cancer
Registry
Programme. Three year report of
population based cancer registries
2006–2008:
incidence
and
distribution of cancer (first report of
20 PBCRs in India) Indian Council
of Medical Research, Bangalore 2010.
6. http://www.actrec.gov.in/
7. http://www.cancer.gov/
8. http://dtp.nci.nih.gov/
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