There was never a dull moment during Dr Kurt Schalper's recent visit to Kerala. “Yesterday, I decided to walk around. I went from the hotel to the beach and met some fishermen. They shared a few stories. Their English wasn't great, but we could communicate. On my way back, I took a bus. It was a lovely experience,” says Schalper, assistant professor of pathology and director, Translational Immuno-oncology Laboratory, Yale Cancer Center, United States.
Schalper brims with enthusiasm as our conversation veers to immunotherapy. “My lab is trying to understand and predict responses to immunotherapy in solid tumours,” says Schalper. “What we do essentially is that we study genomics and the immunophenotype of samples before patients get immunotherapy treatment, and then we try to understand why some benefit and some don't. The lab is now trying to use these findings clinically.”
Schalper was in India for the MVR CANCON 2018, an international conference held at the MVR Cancer Centre and Research Institute in Kozhikode, Kerala, from September 28 to September 30 (the theme was 'consensus and controversies in oncology'). At the conference, speculation was that this year's Nobel Prize for Medicine would go to a cancer researcher, with a few delegates accurately predicting that it would be someone researching immunotherapy. James P. Allison of the MD Anderson Cancer Center, United States, and Tasuku Honjo of Kyoto University, Japan, were awarded the prize for their research in immunotherapy.
Immunotherapy will be one of the mainstays of treatment in many solid cancers in the years to come. It empowers the body's own immune system, with drugs, vaccines and cell-based therapies, and uses it as a weapon in the fight against cancer. The interplay between cancer and immunity is interesting. The body's immune system always tries to reject cancer, but is overpowered at some point in time. Cancer is notoriously associated with low immunity. Patients then try everything under the sun to improve their immunity, especially while undergoing chemotherapy.
Immunotherapy has gained much momentum in recent years, says Dr Narayanankutty Warrier, medical director, MVR Cancer Centre and Research Institute. “It has been available in India for the last three or four years,” he says.
In India, the most important cancers treated with immunotherapy are lung cancer, head and neck cancer and urothelial cancers, says Dr Prasad Narayanan, senior consultant, medical oncology, Cytecare Cancer Hospitals, Bengaluru. The role of immunotherapy in breast cancer is not yet defined. “But triple-negative breast cancer, a hard-to-treat breast cancer that has a higher incidence in India, can be treated with immunotherapy. It is upcoming now,” he says. Narayanan says there has been some real breakthrough in controlling cancer with immunotherapy. “It started with tough cancers like malignant melanoma, hepatocellular cancer and advanced lung cancer, where immunotherapy has actually resulted in outcomes that were never heard of before,” he says.
Antibody-based conjugates, a complex of a drug attached to an antibody, are also gaining popularity, says Dr George Thomas Budd, professor of medicine at the Cleveland Clinic, US. “Antibodies are something your body normally makes to attack bacteria and germs,” he explains. “Antibodies can be engineered to attack tumour cells. We can attach chemotherapy drugs to the antibodies so that they will be delivered directly to the cancer cells. This has been proven useful in many cancers, including breast cancers.”
Cancer is no longer a death sentence, says Anni Sharma, a breast cancer survivor from Chandigarh. “The cancer patients we see in movies almost always end up dying, which is not the case in real life,” says the 32-year-old marketing professional. With the advancements in oncology, many cancers are now curable. New diagnostic tools and improved surgical care help survivors return to a normal life. Sharma married her college friend Kunal in 2013. Six months into her marriage, she felt a lump in her right breast, and was diagnosed with invasive ductal carcinoma, the most common type of breast cancer. “It was stage 2A when I was diagnosed; the cancer hadn't progressed to the lymph nodes,” she says.
She had breast-conserving surgery, a less radical procedure than mastectomy. Her tumour was sent for clinical diagnosis and was found to be hormone receptive. “There were chances that it was caused by oestrogen dominance,” says Sharma, who is now undergoing the last lap of hormone therapy.
Breast conservation surgery, where only the affected part is removed, and breast reconstruction post mastectomy are now available in India, though not widely practised. “Breast surgery has evolved from an ablative surgical specialty to a reconstructive subspecialty,” says Dr Dinesh Thekkinkattil, consultant oncoplastic breast surgeon with Lincoln County Hospital, United Kingdom. “The keystone of present-day oncoplastic breast surgery is to combine oncological principles with plastic surgical skills. Patients can have their cancer treatment with minimal treatment-related morbidities and good cosmetic outcome, and hence better quality of life.” However, it is important that patients are well informed of their treatment options, he adds.
Some advancements mesmerise you with their simplicity, and the use of tear fluid in cancer detection in one of them. “Tear fluid is proven to be an excellent sample source for non-invasive molecular diagnostics,” says Dr Rohit Shetty, vice chairman, Narayana Nethralaya, Bengaluru. Researchers and clinicians at Narayana Nethralaya's GROW research lab are actively contributing to the knowledge and development of point-of-care molecular diagnostic kits that use tears for detection of biomarkers for various diseases, including cancer. “All it requires is placing a drop of tear fluid in the kit, which can then detect the presence of proteins or biochemical factors associated with cancer,” says Shetty. What makes these tear-based kits a powerful cancer diagnostic tool is that they can help detect cancer early and in a larger population.
Then, there is robotics, which has ushered in an era of infinite applications and possibilities in oncosurgery. Take, for instance, Revti Sahay, 52, from Sarjapur, Bengaluru, who was diagnosed with stage 3A colorectal cancer. She opted for robotic surgery four years ago instead of the conventional one as she didn't want a colostomy bag attached to her stomach for the rest of her life. She was advised to go for robotic surgery by Dr Somashekhar S.P., chairman and head of surgical oncology at Manipal Comprehensive Cancer Center, Manipal Hospitals. Sahay had seen pictures of da Vinci, the surgical robot, but had no clue about how it would perform the surgery. Somashekhar told her that it would be a precise operation that would help save her sphincter (the muscular part of the colon that controls defecation). “That was big news for me,” she recalls. “I said I would do anything to not have that bag, which I dreaded would limit all my activities. It was important for me to have a normal life. Who wouldn't want to have a normal life?”
Looking back, Sahay is delighted with the surgery outcome. “The robotic surgery helped me save my sphincter. I just have a four-inch scar on my tummy,” she says. “I didn't experience much pain as the robot reached the point without disturbing the nerves. The blood loss was also less, and I recuperated fast despite being a diabetic.”
Sahay had a colostomy bag attached for six months after the surgery, and then the reversal surgery was done conventionally. “The experience of conventional surgery was very different,” she says. “It was rather painful, whereas the robotic surgery was a cakewalk.” But what we have achieved so far with robotic surgeries is just the tip of the iceberg, says Somashekhar.
Dr Srinivas Chilukuri, senior consultant radiation oncologist at Apollo Proton Cancer Centre, Chennai, could not make it to the conference, but he had something exciting to talk about—proton beam therapy that uses protons instead of radiation to treat cancer. “Proton therapy is the most sophisticated form of radiation therapy that damages tumours very locally with potentially zero or very low doses to surrounding structures, leading to better patient outcomes, less side-effects and better quality of life,” he says. “The reason for its utmost precision is that the entire energy of the proton beams is released in a small area in the tumour and hence the radiation damage is zero or minimal beyond the tumour.” These unique properties make it the most suited for complex tumours in brain, lung, liver, prostate and tumours in children.
The first and most important step in any precision radiotherapy is accurate visualisation of the target. "We cannot shoot the target if we cannot see it properly,” says Dr Anand Narayan, a radiation oncologist at G. Kuppuswamy Naidu Memorial Hospital, Coimbatore. “The advent of better imaging modalities like high definition MRI, CT scan and PET scan have helped us a lot to make tumour localisation more accurate.”
The second step is to deliver radiation to the target with precision. Advances in computation and improvement in radiation delivery machines have played a vital role in making radiation treatment more target-specific. “We use IMRT (intensity-modulated radiotherapy) in various forms, where the radiation will come from multiple angles, all concentrating on one point,” says Narayan. “It is exactly like on a stage, where you have numerous lights focusing on the dancer.”
Image-guided radiotherapy helps to improve cancer control in moving tumours like prostate cancer, wherein tumours move owing to intestinal peristalsis (constriction and relaxation of muscles) and lung cancer, which moves with breathing.
Sadly, many patients are not aware of the newer treatment modalities. Shyamala, a breast and colon cancer survivor from Kozhikode, encourages cancer patients to make use of the advancements and stay away from quacks. A retired nurse, Shyamala was diagnosed with cancer 15 years ago. Back then, the imaging techniques were at the nascent stage, surgical techniques and rehabilitation options were limited, and hence limb amputations were more common. “It is heartening to find that today there are better treatment options for cancer patients,” says the 61-year-old marathon runner and dancer.
New treatments are invariably expensive, and that often deters patients. Sharma knew about DNA sequencing tests that can tell which genes are abnormal and can provide a gene profile of cancers, based on which doctors can opt for the best line of treatment for the patient. “Genomic testing was not available in India then and it cost around Rs 1.5 lakh to Rs 2 lakh abroad at that point in time. I was not willing to shell out so much money. I think now it is available in India for Rs 20,000,” she says.
Sharma found the conventional treatment to be an expensive affair, too. “I spent around Rs 10 lakh for my cancer treatment. Each PET scan cost me Rs 25,000,” she says. There are other factors like diet requirement that add to the overall treatment cost, she adds.
“Insurance companies in India do not generally cover you, once you are diagnosed with cancer. They don't cover cancer survivors, too,” rues Sharma. “There is one company that covers cancer patients but the premium is way too high, and the coverage is minimal.”