ADDRESS AT THE INAUGURATION OF THE FIRST ALL INDIA SEMINAR ON NATIONAL COMPREHENSIVE CANCER NETWORK AT BHAGWAN MAHAVEER CANCER HOSPITAL & RESEARCH CENTRE
22-12-2002 : Jaipur
Cancer: The chaos within
Friends, I am indeed delighted to be with the Bhagwan Mahaveer Cancer Hospital & Research Centre. Suffering and salvation are both created by the God Almighty to guide human souls. Seeing a medical institution emerging out of the spiritual path shown by Bhagawan Mahaveera and the enlightened spirit of KG Memorial Trust is such a beautiful experience. My greetings to members of the Trust and the experts present here.
Insights in to Life
I would like to share few experiences of people and their pain and possible solution. Recently I was at the Centre for Cellular & Molecular Biology at Hyderabad. I met hundreds of young scientists working on the genetic origin and manifestation of diseases particularly Cancer. The young scholars were very enthusiastically shared with me their knowledge of molecular biology and cellular research. They told me about the information encrypted on the DNA of a cell and how both problems and solutions to the human lives reside on the software that nature embedded in each life it creates. In a way, these young minds were dealing with the questions that were so far confined to the domain of sages and philosophers.
Cancer, unlike many other diseases that come from the external factors, like infections, life styles and other environmental and physiological stressors, emanate from within the cell. The life software embedded in the DNA material gets mutated and start growing in a way that is not in-line with the cells around. Life turns against itself. The tragedy becomes unfathomable when it happens too early.
Sometime back, I met one gentleman whose 6-year-old grand child was on periodic blood transfusion for thalsymia. The permanent solution, doctors told me was a bone marrow transplant. The bone marrow of the child was not matching even between siblings and the parents. Unmatched bone marrow transplant is not done in India, I was told, and even in the West it is done experimentally. I met the child who is unaware of the time bomb that is tickling inside him. I prayed for him, for this was the only thing I could do. Today, standing before this gathering of cancer experts, I think I must share with you my concern for these and other patients who live under the shadow uncertain life. What can we do to strengthen the doctors' capabilities in such a situation? In India, there are less than 100 beds for B.M.T. This has to be increased in multiple hospitals and also Stem Cell is the live source for bone marrow production. It is indeed only in research phase.
Stem Cell Research
Newer knowledge emerging out of research on stem cells from abroad and India has to be taken note of and studied. In fact, regenerative medicine is fast getting established as a complete branch of medical science. The embryo starts out as a mass of undifferentiated cells, which then divide, multiply and go down differential paths to take the shape of various tissues and organs of the body. The mechanisms that underline this orderly process of differentiation is fast getting understood at the laboratory level. And the state-of-the-art in this area holds the promise of regenerating tissue that malfunctions due to injury, age, disease or genetic abnormality. A Japanese team has successfully created stem cells from the embryonic cells from the mice to create cells that secrete insulin and glucagon, two hormones normally made by the pancreas. Whether large volumes of cells can be produced from stem cells is yet to be seen. I hope that the day is not far when the similar six year old boy I met, will get a tailor-made bone marrow out of stem cells to survive for the next sixty years and beyond. For such a mission, BMT and Stem Cell production are vital. Research for Stem Cells and development of BMT are important needs. This hospital can be an interface to take benefit of research to the patient.
Breast Cancer: a new project
The suffering of cancer does not remain confine to the patient alone. It often engulfs the entire family and the social surroundings. The emotional trauma is just intense. The Bangalore Cancer research Foundation conducted a unique multi-institutional study with DRDO with the participation of Defence Institute of Psychology (DIPR), Defence Institute of Physiology (DIPAS) and Centre for Cellular and Microbiology (CCMB). The study was aimed at establishing the relationship of the stress of breast cancer patients with the neuro endocrine response leading to immune modulation, which will determine the prognosis to treatment or progression of the disease. The perceived stress of the patients will be influenced by the social support being provided by the spouses and caregivers and hence in the study a system approach was made to evaluate the stress of the patients in the social ambience. Patients of breast cancer, their spouses and equal number of the care givers served as volunteers for the study.
Standard psychological methods were used to quantify the stress of the patients, their coping strategies, blood cortisol, cell mediated immunity and humoral immunity were measured in all the three groups. The study revealed specific correlation of the stress of the patients with the immune responses. Patients who received adequate social support had lower level of perceived stress and their prognosis to surgical, radiation and chemotherapy were better than those who had higher level of perceived stress due to inadequate emotional support from the spouses and care givers. The primary message, which emanated from the study, indicates that for successful prognosis, it will be essential to combine psychotherapy along with the conventional medical management of cancer. It also emphasises the necessity to address the problem at the mind-body complex where the etiological factor may have the root. The sample size is small. Elaborate further research in this area is very vital.
A New Approach
Cancer treatment needs new mindset. I would like to share a vision of "Patients deserve the best" here. I will organise my thoughts into four areas and can lead to a road map of a collaborative work between different clinical experts, medical and other research institutions, industries, and other organisations. There is a need to create cancer awareness and taking cancer diagnostics to detect cancers in the early stage. The therapeutic procedures need to be made affordable and accessible thereby minimising travel of patients for treatment and follow-up. A clinical database network can be established to effectively tackle the cancer with a long term prevention-rehabilitation perspective. Finally, focussed efforts are needed to derive practical clinical applications from the findings of the Human Genome Project.
Futuristic goal can be set among cancer hospitals and research institutions. Diagnostic and treatment results need to be discussed and analysed. Diagnostic accuracy, response to treatment, cure results needs to be discussed among similar cancer cure institutions. Then the national capability of cancer cure will enhance. Citizens will be thankful to the healers.
Affordable & Accessible Therapeutics
Treatment of cancer involves any one but most often a combination of radiation, chemotherapy and surgery. Genetic diagnostic can help to take good decisions while charting the course of therapy. On the drug side, instead of looking for agents that kill dividing cells, researchers are now looking for agents that encourage cell to get destroyed. Inside a growing ball of cancer cells, the blood supply can run short, so the cells begin to suffocate. Malignant cancers get over this problem by sending out a signal to the body to grow new arteries into the tumour. These arteries characteristically grow like a crab-claw that first gave cancer its Greek name. Many drugs, called angiogenic agents, are now available to destroy these supply lines. These drugs are imported and are very expensive. Industry-hospital-research institution consortia need to be established to develop affordable indigenous products.
Optimisation of Chemotherapy
Chemotherapy often destroys healthy cells together with the intended cancerous ones. An industrial firm in Pune has developed algorithms describing interaction between normal cells, malignant cells and nutrients. The algorithms also take into account the pharmaco-kinetics of the drug. Together with inputs on patients' age, height and weight and the type and volume of the tumour, the mathematical model can design an optimal drug schedule minimising side effects. The type and volume of tumour can be automatically deduced from the CT or MRI scans. This is a good example of how advances in many disciplines of science such as Biomedical engineering, Image processing, control systems, mathematical modelling and pharmacology are helping in the developing better and effective treatment for cancer patients
Clinical database Network
Clinical networking is an important area where certain progress has been made. A Clinical database can help in refining clinical features, documenting response to treatment and bringing out geographical or genetic variations. Increasing numbers of hospitals are using computers. However, feeding in the clinical inputs into the network requires recording of detailed symptoms through a checklist of clinical signs. Physicians are needed to think in an in structured format and still not lose social and emotional contact with the patient.
Application of Clinical data base network in cardiology has been attempted by CARE Foundation and Indo-American Cancer Institute at Hyderabad. Some other institutions in certain other areas may have similar databases. The database links text to images, process and protocols. They are attempting a seamless fusion of text and images along with communication among patients, their doctors, and other service providers. This can be suitably adapted for clinical data of cancer and developed into a Cancer Database Network. Two advantages are immediately apparent. Firstly pattern recognition is improved. With a large database covering more number of subjects than an individual or even an institution can expect to study, a networked database improves pattern recognition. Secondly, statistically significant evidence can be generated and validated with other Institutions in the country and abroad. Intensive practice of clinical medicine would improve on both these counts.
Application of Genome
We are for the first time in a position to see that our genetic code is not a precious manuscript but rather a digital file on a floppy that can be edited. The bio-technologists can cut bits of texts out, add bits in, rearrange paragraphs or write over words. I discussed human genome with my medical friends. Its challenges and potentials are in front of us.
The prime risk of cancer is age. The longer one lives, the more mistakes are accumulated in the genes. Mutation in the p53 gene is almost the defining feature of a lethal cancer. In over 90% lung cancers TP53 gene is broken. In 55% of all human cancers it is broken. Like any other gene, this gene is inherited as a pair. People born with one faulty version of out of the two have a 90% chance of getting cancers and usually at an early age.
Environmental risk factors, such as cigarette smoking and working with carcinogenic agents accelerate the ageing process. Smoking damages the lungs, which require recurrent repair thus making the cells older early. Tissues that are specially prone to cancer tend to be tissues that do a lot of cell division throughout life either for repair or for other reasons like skin, testis, breast, colon, stomach, white blood cells. The cancer is seen in an altogether new light now and the information provided by Human Genome Project is going to give many new directions to the understanding and management of cancer. This Institute can consider launching special projects and research in this regard.
Availability of comprehensive cancer centres such as this Institute is a significant step forward in dealing with the most challenging healthcare problem of our times. However, we need an active connectivity of general practitioners with this institute to make a major impact in terms of reaching the needy as well as helping them out. The mission of offering the best available patient care, the most sophisticated education to physicians and patients and be the leader in the cancer research is indeed very challenging demanding highest of the human capabilities in intelligence as well as efforts and perseverance.
The trend in the country so far has been that institutions of healthcare and research mission turn into crowded hospitals within first few years itself and the doctors as well as the leadership lose interest in the research. In many medical institutions in the country, research has slipped into a low priority because of patient care intensity. There are still publications but most of them are not cited by the others outside our own system. The clinical data that come with the patients is a very valuable research material that can lead to enlisting research partners from excellent medical institutions elsewhere. From the beginning this institute can set-up a system to collect and record clinical data deploying the powerful IT tools available for this purpose in our country.
The Institute can also take up a comprehensive study on oral cancer prevalent in the isolated desert inhabitants. I can see a movement starting in Bhagawan Mahaveer Cancer Hospital & Research Centre on Treatment and Research for freeing the humanity from the pain and suffering of cancer. The Institute need to integrate itself with other Institutions and with the clinicians in the districts. The efforts of this Institute must create knowledge that is something new and worthwhile in the world in a decade time. Cancer cure and cancer research are indeed twin challenges to the medico and health community. Challenge transforms into mission of pain removal and thereby providing useful life that is close to the God. May God bless you.