Cancer Treatment in India

Cancer is the second most common cause of death in India. Most common cancers affecting the population in the country include breast cancer, lung cancer, oral cancer, gastric cancer, and cervical cancer. 

There are 27 government recognized cancer centers under the National Cancer Control Programme. In 2010, the central government launched a comprehensive National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS), which spans several districts across 21 states in the county.  

In a bid to offer uniform, quality treatment for patients across India, Mumbai’s Tata Memorial Hospital recently established a national cancer grid, which will link all the existing and proposed cancer centers.

Cancer is not a single disease, but a collection of more than a hundred diseases, developed due to the abnormal growth of cells in the body. Even tumors, masses of tissues formed by this growth, that arise from the same cell-type can be different. Individual cancers are made up of multiple clones of the same cancer cells under varying degrees of selective pressure to become more invasive and deadly.  

There are many common characteristics of the different types of cancers. They evade the surrounding tissue for healthy blood supply and the immune system to protect themselves. They also invade the blood and lymphatic systems to travel to other parts of the body like the liver, lungs, and bones. Earlier detection can help save lives. Screening mechanisms generally detect slower growing and more indolent cancers, which are characteristically less malignant and may not progress to endanger the patient’s life, whereas, malignant tumors can be identified between screenings. 

There are many cancer treatment options available for different types of the disease. A patient’s treatment plan depends on the type, stage, and grade of cancer they have. It is not uncommon for patients to go through multiple treatment combinations. 

When spotted early, tumors tend to be smaller, and they are easier to remove surgically or more likely to shrink after chemotherapy or radiation therapy. For instance, some types of lymphoma and leukemia can be treated with chemotherapy and radiation, while other tumors like breast and colorectal cancers are curable with surgery and chemoradiation. This article explores treatments available in India for cancers that are curable. 

Following are the options currently available for cancer treatment in India: 

• Surgery: A procedure when a surgeon removes tumors from the body.
• Radiation therapy: Radiotherapy uses high doses of radiation focused on the affected sites to kill cancer cells and shrink tumors.
• Chemotherapy: This uses drugs and pharmaceuticals to kill cancer cells.
• Immunotherapy: This stimulates the immune system to fight cancer.
• Hormone therapy: This is used to kill the growth of breast and prostate cancers that feed on hormones to grow.
• Stem-cell transplants: These are procedures that restore blood-forming stem cells in patients who have theirs destroyed by massive doses of chemotherapy and radiation.
• Precision medicine: Doctors use this based on their genetic understanding of the disease.
• Targeted therapy: This is a treatment that attacks cancer cells that grow and spread using targeted drugs.

Stage 0 Breast Cancer Treatment Options

Stage 0 breast cancer or lobular carcinoma is an abnormal growth in the lobules, a gland in the breasts that produces milk. However, it is non-invasive, which is why some oncologists prefer to call it lobular neoplasia as it refers to an abnormal growth without labeling it as cancer. At the same time, lobular carcinoma in situ (LCIS) indicates the increased risk of developing breast cancer. Doctors recommend regular clinical breast exams and mammograms or prescribe a hormone therapy drug called Tamoxifen, which prevents the growth of cancer cells.

Stage 1A Breast Cancer Treatment Options

Stage 1A breast cancer is less than 2 centimeters small and has not metastasized to the lymph nodes. In stage 2 B, lymph nodes have traces of tumor varying between 0.2 mm to 2.00 mm. Stage 1 cancers need immediate treatment, often radiation and surgery. Generally, doctors do not recommend chemotherapy for the earlier stages of breast cancer. Depending on the nature of cancer cells and risk factors, hormone therapy is sometimes an option.

Stage 2 Breast Cancer Treatment Options

Stage 2 breast cancer is treated with breast conservation surgery or sometimes with mastectomy. The difference between stages 2 A and B of breast cancer is the size of the tumors and its spread. Radiation is also required after surgery to kill the remaining traces of cancer. If chemotherapy is needed, radiation is delayed. 

Stage 3 Breast Cancer Treatment Options

Stage 3 breast cancer is between 5 centimeters and 2 inches long, which grows into surrounding tissues, or lymph nodes that are close. While it can be treated, it cannot be cured. They are mostly treated with neoadjuvant therapy which helps shrink the tumor before the main treatment, which in this case is breast conservation surgery. For human epidermal growth factor receptor 2 (HER2) positive tumors, trastuzumab, a targeted drug is given along with pertuzumab. Doctors advise radiation therapy after surgery, and in some cases, chemotherapy and/or hormone therapy is also given.

Stage 4 Breast Cancer Treatment Options

Breast cancer at stage 4 is invasive and would have spread to other organs in the body like the lungs, distant lymph nodes, the skin, bones, liver, or brain. It is called ‘advanced’ or ‘metastatic.’ Focused treatment modalities like surgery and radiation do not suffice as cancer has spread to other distant sites. Doctors use palliative care to relieve symptoms. If there is no response to treatment, progression while on chemotherapy, hormone therapy, and HER2 drugs.

Testicular cancer is a malignant tumor in the testicles, the male reproductive gland which produces the hormone, testosterone. The treatment of testicular cancer depends on its type and stage. Testicular cancers may be classified into three broad categories: pure seminomas, non-seminomas, and mixed germ cell tumors. 

Stage 1 Testicular Cancer Treatment

For stage 1 testicular cancer, the treatment usually begins with surgery to remove the testicles and the spermatic cord. If the cancer has not spread beyond the testicles, the patient is monitored meticulously for 10 years. After this, there are multiple treatment options. Radiotherapy helps kill traces of tumor cells after surgery removes it. This includes 10-12 cycles given over two to three weeks. After radiation, one or two cycles of chemotherapy with carboplatin after surgery. Patients prefer chemotherapy to radiotherapy as it is less painful.

Radiation after surgery removes the testicle; one treatment option is radiation to the retroperitoneal lymph nodes (located at the back of the abdomen). The dosage is higher than that given for stage 1 cancers. Radiation may only be an option instead of chemo if the lymph nodes aren’t enlarged from the cancer spread. Chemotherapy is another option. The drugs used are etoposide, cisplatin, and bleomycin given in different regimens.

Non-seminomas need to be tested for tumor markers like alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). They indicate a germ cell tumor. In the case of stage 1 non-seminoma, if the tumor marker levels are high even after the tumor has been removed and the CT scan doesn’t show the tumor, doctors typically recommend chemo.

Stage 2 Testicular Cancer Treatment

For stage 2 non-seminomas, surgery first removes the testicle and spermatic cord and other treatment options like chemotherapy and retroperitoneal lymph node dissection (RPLND) is explored. The latter removes lymph nodes at the back of the abdomen. A close watch is necessary to make sure the cancer does not come back.

Stage 3 Testicular Cancer Treatment Options

In most stage 3 seminomas and non-seminomas can be cured even if they have spread. Surgery is usually followed by chemotherapy depending on the risks. If doctors suspect that the tumor might be aggressive, they recommend chemotherapy before a biopsy or surgery to remove the testicles. If the cancer has metastasized to the brain, radiation therapy is given to the brain, or both are provided. If the tumors in the brain are not bleeding or causing symptoms, doctors may recommend chemotherapy first.

Treatment For Recurrent Testicular Cancer

Recurrent testicular cancer usually happens within the first two years after treatment. A second opinion is crucial in the case of relapse before a treatment plan is mapped. Treatment of recurrent germ cell tumors depends on the nature of the initial treatment and the location of the recurrent cancer. If the cancer comes back in the retroperitoneal lymph nodes, then surgery is only done to remove the nodes. The results of the surgery determine whether further treatment is needed.

If a tumor recurs after chemotherapy or if treatment is not working, different chemo is prescribed, which typically includes ifosfamide, cisplatin, and either etoposide, paclitaxel, or vinblastine. If treatment is not effective, doctors recommend high-dose chemo followed by a stem cell transplant. You may also ask your healthcare team if newer clinical trials are available. Rare types of testicular cancer like Sertoli and Leydig cell tumors are treated with surgery. Radiation therapy and chemotherapy are generally ineffective in such cases.

Prostate cancer is one of the most common types of cancer in men. It occurs in the prostate gland, which nourishes and transports seminal fluid. When detected early, it can be contained and managed effectively. 

The treatment plan for prostate cancer is charted only after identifying the following:

1. The size of the tumor
2. The extent of spread
3. Its chances of coming back

Stage 1 Prostate Cancer Treatment Options

In stage 1 prostate cancer, the tumor has not spread into the prostate. If a prostate-specific antigen (PSA) test reads high, then it is likely that the tumor is aggressive and will relapse. Active surveillance is mandatory for the early stages of a tumor to gauge its nature and change treatment accordingly. Radiation therapy kills prostate cancer cells and keep them from multiplying at an abnormal rate. It may be administered externally or internally. Radical prostatectomy is another treatment option, which surgically removes the prostate and surrounding tissues that have been affected.

Stage 2 Prostate Cancer Treatment Options

Stage 2 testicular cancer also has the same treatment options as those for stage 1- regular surveillance, radiation therapy, and radical prostatectomy. If the Gleason scores (an indicator that measures the aggressiveness of cancer) are high, then the dosage of radiation is increased.

Stage 3 Prostate Cancer Treatment Options

Stage 3 is when the cancer has spread beyond the prostate and surrounding organs like the rectum, bladder, and lymph nodes. Doctors recommend external radiation plus hormone therapy or brachytherapy. Radical prostatectomy is also combined with the removal of pelvic lymph nodes. 

Stage 4 Prostate Cancer Treatment Options

Cases of stage 4 prostate cancer are rarely cured. However, the tumor has spread to the bladder, rectum, lymph nodes, organs, or bones. In this stage, hormone therapy may be combined with surgery, radiation, or chemotherapy, external radiation, chemotherapy, and surgery. Surgery relieves symptoms like bleeding or urinary obstruction. Bisphosphonate drugs inhibit the growth of cancer cells and help prevent cancer cells.

The thyroid gland releases hormones that play a vital role in the metabolism, growth, and development of the human body. Thyroid cancer occurs in the cells of this gland. It may be divided into two broad categories.

1. Follicular thyroid cancer 
2. Papillary thyroid cancer

Stage 1 Thyroid Cancer Treatment Options

Stage 1 follicular and papillary thyroid cancers may be treated in different forms depending on the size and the nature of the tumor. The thyroid glands may be removed fully (in a total thyroidectomy) or partially in a lobectomy.

Stage 2 Thyroid Cancer Treatment Options

For stage 2 thyroid cancers, doctors usually recommend total thyroidectomy or lobectomy. However, these surgeries may be followed by hormone therapy or radiotherapy (given internally or externally) depending on the nature and the growth of the tumor.

Stage 3 Thyroid Cancer Treatment Options

Stage 3 thyroid cancers are treated with the same treatment modalities as for stage 2, but radiation may be of higher dosage or energy.

Stage 4 Thyroid Cancer Treatment Options

Stage 4 thyroid cancers are rarely curable but can be treated with radioactive iodine, external beam radiation therapy, hormone therapy, and a clinical trial of chemotherapy.

Melanoma is a type of skin cancer that occurs in the pigment-producing cells (called melanocytes) of the body. These cells can mutate, become a tumor, and spread fast. While there are other types of skin cancer that are more common, melanoma is known to metastasize quickly.

The general rule of thumb for the treatment of melanomas is that the efficiency of a treatment depends on the stage and location of the tumor. However, there are other risk factors like the overall health of the patient and gene mutations in the tumor cells. 

Stage 0 Melanomas Treatment

Stage 0 melanoma is also called in situ melanoma, and occurs when the cancer has not penetrated too deep into the skin layer. It can be removed by surgery, where both the tumor and a thin layer of healthy tissue around it are removed. Some doctors prescribe imiquimod cream (or Zyclara) or radiation therapy instead of the traditional excision. Mohs surgery, a precise surgical technique, is another option where very thin layers of skin are removed layer by layer meticulously, saving the cancer-free, healthy tissues. Generally prescribed for sensitive regions of skin like the face, the surgery takes hours and helps the skin look better after treatment.

Stage 1 Melanomas Treatment

Stage 1 melanoma is treated with wide excision most often. Doctors recommend a sentinel lymph node biopsy (SLNB) to detect cancer in nearby lymph nodes. If there is no cancer in the lymph nodes, follow-up is still advised. If the tumor is found, then additional treatment is recommended with immune checkpoint inhibitor or targeted therapy drugs. 

Stage 2 Melanomas Treatment

The standard treatment for stage 2 melanomas is wide excision, which depends on the thickness and the location of the melanoma. SLNB results depend on whether follow-ups need to be done or immune checkpoint inhibitors, and targeted therapy drugs need to be used for adjuvant treatment.

Stage 3 Melanomas Treatment

Stage 3 melanomas are those that have reached the lymph nodes at the time of diagnosis. After surgery, adjuvant treatment (therapy provided after the initial treatment to reduce the risk of the cancer coming back) with immune checkpoint inhibitor or with targeted therapy drugs is considered. 

Stage 4 Melanomas Treatment

At Stage 4 melanomas have reached the lymph nodes when or other distant areas in the body. These tumors of the skin or enlarged lymph nodes cause symptoms. A combination of surgery, radiation therapy, and palliative care helps alleviate these symptoms, but the tumor itself is rarely cured. 

Tumors that have metastasized in internal organs are removed depending on the places the tumor has reached, and how likely it is to cause symptoms. In recent times, newer forms of immunotherapy and targeted drugs have proved more effective than chemotherapy.

Immunotherapy drugs such as pembrolizumab (Keytruda) or nivolumab (Opdivo) are used as checkpoint inhibitors, especially in people who do not have mutations in their B-Raf genes (which is a protein-coding gene). These drugs help shrink tumors for a longer time. However, in about half of the reported melanoma cases, there are gene changes in BRAF. Newer targeted therapies use combine a BRAF inhibitor and a MEK inhibitor

A few melanomas have changes in the C-KIT gene for which doctors recommend targeted drugs such as imatinib and nilotinib. A small percentage of people with stage 4 melanoma have been helped by interleukin-2 (IL-2), where higher doses have been useful but with more severe side effects. 

Chemotherapy helps some people with stage 4 melanoma, but other treatments are preferred. Dacarbazine (DTIC) and temozolomide are chemo drugs that are most often used, either in combination or by themselves. Palliative care is essential as most of these drugs cause severe side effects.

If the initial treatment did not remove lymph nodes, the melanoma might return to these lymph nodes. It may then be removed by lymph-node dissection followed by adjuvant treatment like radiation therapy, immunotherapy, and targeted therapy If surgery is not an option, radiation therapy, or systemic treatment (immunotherapy, targeted therapy, or chemotherapy is used.

Cervical cancer occurs in the cells of the cervix, which is the lower part of the uterus that  connects to the vagina. The human papillomavirus (a sexually transmitted infection) plays a significant role in the development of tumor in the cervix. Regular screenings and receiving a vaccination help minimize the risk of getting the disease.

The stage of cervical cancer is essential in choosing treatment. Other factors that impact treatment include the exact location of cancer within the cervix, the type of cancer, age, overall health, and whether the patient desires to have children. 

Carcinoma in situ is when cervical cancer is at its early stages. It is when cancer cells lie in the surface layer of the cervix and have not spread into deeper layers of the cells. These pre-cancerous changes can sometimes recur in the cervix or the vagina, which is why the region needs to be under active surveillance. The doctor may include pap-tests and colposcopy in your follow-ups.

The treatment modalities that squamous cell carcinoma can be approached with are cryosurgery, laser surgery, loop electrosurgical excision procedure, cold knife conization, simple hysterectomy.

Treatment options for adenocarcinoma in situ are hysterectomy and cone biopsy.

Stage 1 Cervical Cancers Treatment

Stage 1 cervical cancers can be cured if the treatment is planned optimally. 

Surgery is the primary treatment modality for cervical cancer in stage 1, but it depends on the age of the patient, and if they wish to have a child. Doctors recommend a cone biopsy for women with stage 1A1 cervical cancer; in this procedure, a cone-shaped tissue is removed from a woman’s cervix. A hysterectomy removes the uterus and the cervix and is usually recommended for women with stage 1 cervical cancer. Lymph node removal, chemoradiation, radiation, and clinical trials are options that you could explore after consulting your healthcare team. 

Stage 2 Cervical Cancers Treatment

In stage 2 cervical cancer, the tumor has spread outside the cervix into the other surrounding parts of the body. Chemoradiation is the primary modality in the treatment of stage 2 cervical cancer. It is given simultaneously with radiation therapy for better results. Chemoradiation may be given after surgery. Cisplatin or cisplatin plus 5-fluorouracil are effective chemo drugs.

Radical hysterectomy, removal of the lymph nodes in the pelvis and the back of the abdomen. Radiation may be given in varying dosages depending on the size and the spread of the tumor. {patients are also advised to check with various healthcare supporters if clinical trials are available.

Stage 3 Cervical Cancers Treatment

Stage 3 cervical cancer has spread to ligaments and lower regions of the vagina. It usually calls for cisplatin or cisplatin plus fluorouracil. Radiation therapy may be administered by external beam radiation and brachytherapy. 

Stage 4 Cervical Cancers Treatment

Stage 4 of cervical cancer has metastasized too deeply to be cured, but its symptoms can be managed. It has spread to the pelvis and other distant regions of the body. Treatment options are radiation therapy and chemo to slow the growth of cervical cancer. The standard chemo regimen includes cisplatin or carboplatin along with another drug such as paclitaxel, gemcitabine, or topotecan. The targeted therapy drug bevacizumab can be given along with chemo or immunotherapy alone with pembrolizumab.

Lymphomas are a group of blood cancers that affect the lymphatic system. The location of the lymphomas, the spread, and the effect on different parts of the body are found through diagnostic staging. Hodgkin’s disease, a type of lymphoma where the blood cancer starts in the lymphatic system, has shown to be favorable in terms of cure when the right treatment is administered.

Stages 1 Lymphomas Treatment

In stage 1 lymphoma, the cancer is found in the lymph node region or has invaded one extra-lymphatic organ or site. These may be treatable and in some cases curable.

Stages 2 Lymphomas Treatment

In stage 2 lymphoma, the cancer is in two or more lymph nodes on the same side of the diaphragm. Treatment is usually given in higher dosage than for favorable disease. 

Stages 3 or 4 Lymphomas Treatment

At Stages 3 or 4 lymphomas have affected areas on both sides of the diaphragm. It has spread to the liver, bone marrow, or lungs. They have the same treatment and prognosis. They can only be controlled, not treated.