Gaps in care pathways create gaps in survival - A Conversation on
Breast Cancer as a Public Health Challenge
The introduction of universal screening for breast cancer as part of India’s shift to comprehensive primary health care in 2017, was a major step forward in our aspiration to achieve universal health care. Eight years later, we take stock of where we have reached in implementing this policy and the challenges being faced. This is a conversation between Prof. (Dr) Biswajit Dubashi (BD), Medical Oncology, JIPMER, and Deputy Medical Superintendent (DMS) Regional Cancer Centre, Pondicherry, steered by Dr Monika Aroquiadasse (MA), public health consultant, JIPMER School of Public Health, with Dr T.Sundararaman (TS) also and Dr Yogesh Jain (YJ) also participating on specific issues.
MA: Welcome to this conversation and our thanks for your agreeing to participate. We could start with your own professional experience in this area. What is the case load of sort of breast cancers that you see in your department and some basic figures to help us get a sense of the magnitude of the problem, and is it increasing over time.
BD: The annual cancer load at JIPMER is somewhere around 6,000 to 6,500 new patients every year, and of these breast cancer patients were to 650 to 700 patients. Of these those presenting with metastasis (spread to other parts of the body) upfront will be approximately around 15 percent. And the rest are patients with locally advanced or early breast cancers. About four years back we had about 400 to 450 breast cancer patients per year, two years back when we had a ICMR study ongoing, it was 550 cases/year, and the last year we have almost 700. So yes, the case load is sharply increasing. These are all new cases.
MA: What would be the total number of cases under treatment at any time? And what are our figures on 5-year survival?
BD: In a month we are seeing about 60 new patients and about 300 old patients coming for follow up. The number of patients on follow up are much larger. Once a patient starts treatment here, it may require many years follow up- but not all are able to make it for the follow up here. The cumulative number under care here for breast cancer is more like 450 patients and every month this increases. Our five-year survival will be around 40 percent. So this 40% are additional patients that will get added on to every year. Over the last 10 years we would be having about 5000 survivors. These are approximate numbers based on my recall.
MA: And how many doctors handle this load?
BD: There are three medical oncologists, now increased to five in the last 1 year. There are in addition three surgical oncologists and nine radiation oncologists and four general surgeons who actively take care of breast cancers. But note, that this is for all cancers and breast cancer is only ten percent of the total cancer load.
MA: Thanks. To now move on to the national scene. Could you give us a sense of the breast cancer epidemiology at the national level?
BD: The incidence of the breast cancer in India will range somewhere between 25 to 40 per 100,000. The incidence is higher in the South. In fact, as per the Population Based Cancer Registry, Chennai has the highest incidence, touching 45 per 100,000. And Mumbai and other major metropolis are in 28 to 40 range.
YJ: I have heard an estimate that says that one in nine women in UK will get breast cancer in their lifetime. Are there corresponding estimates for India?
BD: The estimate of 44 per 100,000 is the incidence rate. In contrast the life-time risk of development cancer is one in 28 in India. Approximately one in every 28 women will over their lifetime develop breast cancer. Lifetime risk is estimated on the assumption of current incidence and mortality rates remaining same throughout the lifespan of a person living. And it’s always an estimate. But incidence rate is based on biopsy proven cases as recorded.
TS: The question is whether the mortality due to breast cancer is higher in India despite the incidence being much lower? In a reply to a parliamentary question, the government put this at 98,337 deaths in a single year, 2022, making this the highest reported for any country in the world. (PQ 1227, 9th Feb, 2024). In women in the 30 to 69 age group, it is the second most common cause of mortality.
BD: Agreed. In the USA incidence is close to 200 per 100,000 is the incidence and it is higher in most high-income countries. Our incidence rate is one-fourth to one sixth of this, but our mortality rates are much higher. So, more women (per 100,000 population) die of breast cancer in India than in the West. Much of this is because most women are diagnosed at a later stage and the access to quality care is constrained. Breast cancer is one of the leading causes of death in women in India, and therefore a major public health challenge
MA: Is age a determinant? What are the other risk factors for breast cancer? Breast cancer is one disease which has very few social determinants and actionable risk factors beyond the genetic profile. Would you agree on this statement, sir?
BD: Age is an independent risk factor. It is well known that as the age increases, the incidence of breast cancer increases. Above 50 years the incidence of breast cancer is higher. The statement on social determinants is somewhat true. Earlier past history of radiation was a major risk factor, but with better radiation therapy becoming available, this is now rare. In terms of relative risk, genetic profile is the main risk factor. I mean, we know that the breast cancer genetic actual genetic risk is only 5 to 10%. The most common association is with BRCA genes, and the risk of developing breast cancer is somewhere between 7 to 10%. In high-risk groups it may be as high as 17%. We do have a genetic clinic running and are able to offer genetic testing for those who ask for/require it.
The other known risk factors all have a low relative risk, only in the 1.2 to 1.5 range. Which means that there is no significant increase in risk for the individual. These risk factors include nulliparous women, women with early menopause, women who have not done breast-feeding, diet, obesity and alcohol intake. However, given the sheer number of breast cancers which we see these factors have significant population attributable risk and therefore are important. Take obesity for example, premenopausal obesity does not increase the risk. But postmenopausal obesity definitely increases the risk, and lowering such obesity in the population would be associated with lower incidence of breast cancer. Which, in a context of a growing sedentary lifestyle requires preventive and promotive measures on the population scale. So, these risk factors are important too.
TS: You mentioned genetic testing facility in JIPMER. How widespread is genetic testing available in India now? Is it now a standard? Should it be made available across all medical colleges at least?
BD: For genetic testing one requires sequencing platforms, a Sanger sequencing or next generation sequencing is the technology which is required. Even at JIPMER, we do not have an in-house facility of doing the test. We have to outsource. There are private labs with a capacity to handle high volumes, which are able to do this. The problem with opening multiple labs, is that one requires volumes to be viable. If we do only 10 patients per month, each test will cost Rs 20,000 or more. But as the volume increases it can come down to Rs 5000 per test or less.
TS: So, what is the plan to increase access? Would it make sense for the public sector to offer such a service that many people can plug in and use both from public hospitals and private hospitals, because then it can bring down the cost. Who should be offered genetic testing, and what would be the consequences for a person testing positive for a suspect gene?
BD: Agreed. ICMR came up with a project called the diamond project, where they developed this capacity in 8 to 10 public facilities. Now there are about 18 centres in the public sector, and these are developed as regional hubs with government financing for equipment, and even for the initial testing. It will not be completely free, of course, but at some cost. This started some three to four years back, and there is support from Japan for this. But there is still much coordination and collaboration between centers that is required.
Genetic testing in breast cancer is crucial for identifying patients who may benefit from targeted therapies, risk-reducing strategies, and familial counseling. Currently most guidelines recommend genetic testing in high-risk breast cancer patients- and high-risk could include age less than 45 at time of diagnosis, bilateral cancers, family history of certain types of cancers, male breast cancer, and in what is called triple negative breast cancer. In some contexts, based on emerging data, cost-effectiveness, and population-specific risks, universal genetic testing for all patients with breast cancer may be offered to identify mutation carriers missed by traditional risk criteria. Genetic testing is also advised in normal patients with a strong family history of breast, colorectal or ovarian cancers. Genetic testing facilities preventive strategies in relatives, and supports personalised treatment in those with cancer.
TS: This is as regards genetic markers. What about the somatic markers. What is the capacity requirement for this?
BD: Somatic markers are markers on cancer cells, that indicate and guide the treatment plan that would work for a given patient. These tests are done on the biopsy sample. These are part of the treatment management of the tumor. There are three main ones- HER2 and endocrine receptors for estrogen and progesterone (ER and PR). Now testing for these markers is obligatory. We must not treat breast cancer without knowing these three receptors status. That is out of question. The capacity for these tests were also part of the diamond project, but this needs to expand much further, much faster.
MA: There is a clear consensus that reduction in mortality requires screening, early detection followed by prompt treatment. We also learn that Health Technology Assessments favor clinical breast examination by a trained nurse or a doctor once in three to five years as the most cost-effective method for screening. The consensus is also that while self-examination can be a part of awareness, it is not an acceptable method of screening. And mammography or ultrasound are not required at the screening stage. So, would you agree on this?
BD: I hold the same view. The earlier insistence on mammography was based on studies in western countries that showed that screening with mammograms reduced the risk of mortality. But even here you need to screen about 1500 to 2000 women to prevent one mortality. Further, it’s not like we just do one mammogram and it’s done. So, let’s say from the age of 50, if you start doing every mammogram two years and the life span is around 70, you need to do at least 10 mammograms over 20 years. So, 10 mammograms per person for 2000 people will help you save one life. It’s okay to do a mammogram if it was easy to do and cost effective. But in a population like India, it is shown not to be cost effective to do a mammogram. This is part of many studies. Some years back, TMH I think, came up with a report on 20 years of screening for breast cancer, where the breast examination was done by 12th standard qualified women with a two-to-four-week training. This was a randomized study comparing screened women and not-screened women and it showed that for every 700 clinical breast examinations done as screening, you can prevent mortality in one patient.
Training for clinical breast examination as screening can easily be organized and one can ensure that all nurses in PHCs and HWCs (or AAMs) are trained to do this. And it’s not like every year one has to repeat the screening. It is only every three to five years. I think it is worth taking this method to scale.
TS. A clarification. Do you think this attention to mobile mammogram vans is misplaced. And what about ultrasound? Could they be a good screening test? Even if these are not screening tests, are they essential for confirmation. In some of the protocols that are being recommended, I see clinical examination at the primary care level, followed by one round of confirmation with USG or mammogram at the district hospital and then only referral to the tertiary hospital for biopsy and start of treatment. I fear that this could be a dangerous waste of time for the patient. Should these be a necessary part of a protocol or care pathway for confirmation? And if so, why not get this confirmation done all at once at the tertiary care centre, rather than a visit to the district hospital. Do we need this intermediate stage?
BD: I do not think both ultrasound or mammogram are frontline screening options. Both are
very, very tough to do on scale and in the field. In fact, ultrasound is more difficult than mammogram, because in mammogram the technician can go and take an x-ray and come back and the specialist can read it. Ultrasound interpretation has to be done locally and it requires a lot of training. So, for screening, in our setting it has to be clinical breast examination.
But once there is a suspicious lump, it would be good to get a mammogram and/or ultrasound done at the district hospital. About 80 out of 100 lumps would be obviously benign, and only 20 out of 100 would need to go for biopsy. And in fact, the district level should also be able to do the biopsy. But we have not reached that level. But USG and mammogram at district hospital by trained radiology technician and using the Berard score is reliable. Only if the score is above three does one need a biopsy. Guidelines are already in place.
But if you take the other option, instead of sending only 20, one is referring all the 100 women to the tertiary cancer center, where even getting a date for mammogram or USG may take weeks. An in between stage should if well-organized reduce the time taken for confirmation and start of treatment. Of course, where the tumor is clearly malignant on clinical examination, we could do the biopsy without waiting for the mammogram- but that is true wherever the mammogram is done. The problem happens in the intermediate groups where we are not sure whether it is benign or malignant. In JIPMER, it takes a longer time than other places because mammogram dates are usually only after three or four weeks wait. So, I would really urge that this level of confirmation is done at district hospital and when patient comes here, we can straightaway do the biopsy.
TS: Another important clarification. Are there time boundaries or time standards – for the time that can elapse between when nurse picks up a suspected lesion, the time for confirmation and start of treatment?
BD: Definitely. Studies have established that delays on the care pathways lead to decline in survival rates. For example, one key performance indicator is time from suspected diagnosis to time of starting treatment. This should be less than 6 weeks. Similarly, if initiation of chemotherapy is delayed by more than 12 weeks after primary surgery, survival falls. So yes, we definitely need to stick to timelines. In a recent ICMR study where we were one of the participating centres, in the formative phase our data showed that only 40% of our patients could start treatment in 6 weeks. We are working on reducing this delay with the objective of 100% of patients starting treatment within 6 weeks.
TS: One more clarification. The proportion of eligible women who have been screened for breast cancer, even in a place like Puducherry is somewhere between 15 and 35%. Given our extensive PHC network, why is the coverage so low. In 2017, government had declared universal screening for breast and cervical cancer for women over 35 or 40. One can understand that screening for cervical cancer requires more inputs, but why is it so low even for breast cancer screening where inputs are minimal?
BD: I have no study as such, but my experience is that the mindset of seeing mammograms as the only form of screening, and waiting for portable mammograms to arrive has contributed to this delay. A bigger problem is that screening is not part of a primary care routine. Screening has to be done on a regular basis. Now, people just generally conduct some camps every year to just highlight that there is a breast cancer awareness month and just do some screening on a particular group of people who turn up. Next year, the persons screened may change.
There is also hesitancy in women coming forward for screening. Some of it is taboos. Some of it is lack of trained women doing this. Some of it is lack of education as well as individual counselling. Screening must be done by trained ANMs working on the frontlines close to families and who have their trust. It is important to have women doctors and trained nurses to do the screening.
Finally, I also think that there is no structured training programme ensuring that all nurses posted in PHCs and HWCs and in the district are trained. There are good training modules with simulation models available- but a structured training programme covering all frontline workers is still lacking.
MA: Moving on to the treatment modalities. Could you give us a broad overview of the main treatment modalities of breast cancer? A simple, popular description, such as should be part of the public understanding on this disease.
BD: Let me begin by stating that breast cancer is not a single disease. There are broadly three types of breast cancer:
- hormone receptor positive (There are two types of hormone receptions -ER and PR).,
- HER 2 positive and
- triple negative where all three receptors are negative.
Treatment modalities depend on the receptor type. For all three types basic treatment is surgery. Surgery cures, unless recurrence occurs. Surgery can be partial or it can be total mastectomy viz removal of the breast. There has to be greater awareness that when partial breast removal is recommended, the chances of recurrence are not more, and patients need not insist on total removal.
There are two kinds of recurrence. One is a local recurrence. Another is a systemic recurrence. Local recurrence is taken care by radiotherapy. And systemic recurrence is taken care by the chemotherapy and the targeted therapy with hormones if they are hormone receptor positive.
So basically, treatment is multi-modal- combining the four main modalities of surgery, chemotherapy, radiation, hormone therapy. And depending on what kind of breast cancer, the modalities of treatment, the sequence of these modalities will change.
For example, if hormone receptor positive and early breast cancer, then begin with surgery, then chemotherapy, then hormone therapy and often radiation therapy. If it’s a triple negative, then most likely the patient will require neoadjuvant chemotherapy before the surgery. In some we give chemotherapy, see the response, then opt for surgery and post-surgery radiation and chemo. HER2 also has its regime.
Chemotherapy is basically from two classes of drugs- the anthracyclines and the taxines. One or two of each type. Anthracycline can be either Adriamycin or Epirubicin in combination with cyclophosphamide. And taxines are usually paclitaxel or docetaxel. These are the two broad ranges for neoadjuvant targeted therapy. If patient is HER2 positive, then we give one of the biologics- trastuzumab and pertuzumab. And, if it is triple negative, you can use immunotherapy also in addition to the chemotherapy. In short, chemotherapy is the back-bone, and on top of it we add the targeted and the immunotherapy as required.
TS: Does radiotherapy become mandatory for all breast cancers? And is this only after surgery?
BD: If you are removing partial breast, i.e breast conservation surgery, then everybody will have to receive radiation. If you are completely removing the breast, then only those with higher risk factors like T3 and above, which is more than 5-centimeter tumor, or with significant spread to lymph nodes receive radiotherapy. The radiation does not need to differentiate between the three types of cancer.
MA: With incidence increasing and screening detecting more cases is the existing installed capacity to handle this level of breast cancers adequate. Even in JIPMER only 40% are initiating treatment in six weeks. But Pondicherry has over 8 medical colleges and an equal number of other tertiary medical care centres. Can this help manage this load?
BD: Pondicherry has one of the highest numbers of medical colleges, but in spite of so many medical colleges, confirmation of diagnosis and surgery happens in about four centers. The problem is that because breast cancer requires multimodality treatment, even this is just not good enough. Three of these centres just do the surgery and send the patient onward to the higher centers for getting treatment for radiation and chemo without any assurance or facilitation down the care pathway. That’s okay from their point of view, but it’s not okay if you have to improve survivals, for most will require multi-modality management for survival
And unless all the centers have a radiation and medical oncologist as well surgeons this is not going to happen. And then many patients will require even higher levels of treatment like lymph node dissection or breast reconstruction etc. If we are saying that basic treatment can be provided at a hospital with some compromise on the quality of life and some compromise on some survival, then maybe some of the centers, doing what they can do, works. But if you are going to say that, no, we need to assure a good quality of life, the standard treatment that is required to have the best survival feasible, then obviously the multimodality management has to come in.
Now one approach to this is more cancer centres. There are 31 regional cancer centers are available in the country. Apart from those 31 regional cancer centers, maybe there are a few more medical colleges which might be having radiation facility. I don’t know that those numbers are, but they are low. That is where we stand. And this is a gap we need to close, since the whole effort at screening implies access to multi-modal treatment. At JIPMER, we witness the number of breast cancer cases going up every year, and we may soon reach 1000 or even 1500. And we will not be able to provide for them all, and there would be many more delays. So, I don’t know how, but the balance has to lie somewhere, with more tie-ups and networks.
MA: Could you elaborate this approach that you are suggesting?
BD: We need to build a system of coordination and cooperation between facilities, and have a virtual multi-modality oncology board to assure this. Let’s say there is a medical college which has only surgeons and does not have medical oncologists or radiation oncologists. The surgeon in such a medical college hospital should make the treatment plan in coordination with other centres using the virtual tumor board where facilities with this capacity are networked. The tele-consultation facility to facilitate this is easy to establish or already exists- but the virtual multimodality board is challenge. Thus, a medical college can confirm diagnosis and do the surgery, and send here for chemotherapy, or we can do the chemo here first and then send it back to them for surgery after which it comes back here for radiation and so on.
TS: Are you saying that despite so much tertiary care development in Puducherry, there is no other hospital with radiotherapy. Are there any established protocols or networks currently?
BD: No there is no other facility with radiotherapy. The Pondicherry Cancer Trust has a radiation machine, but what is happening there is the surgeons are operating at different time points and just sending for radiation. That’s not called multimodality treatment. There has to a board and a care coordinator. I would also emphasize the need for professional counselling for every patient with breast cancer, on an ongoing basis. This could be integrated with or linked to the care coordination.
TS: So, the minimum seems to be the establishment of clear treatment protocols, which sort of exist, and then a board that is the platform for coordinator, and a number of care coordinators with whom patient is registered who helps the patient navigate the entire care pathway, across different providers and modalities, even within the hospital, without leaving it the patients and their families. What about private providers- will they be tied in, especially if they are part of the PM-JAY or other insurance mechanism. How do we cope with the increasing cases that will result if screening picks up.
BD: I have already said that with current capacity we cannot cope. That is why there are only two ways of coping. Either you increase the number of cancer centers or you develop a coordination across facilities, so that we reduce inflow and manage patients better. I think we are not even talking about the private sector. Most of our patients cannot afford the full course of treatment and will need free or subsidized care. I think the method to go ahead is district level capacity building. Take the example of Tamil Nadu, which has at least a medical college in every district. These colleges are tertiary care centres which must have this capacity. They must be able to manage all those treatments which are not very toxic, which can be easily protocolized. Much of chemotherapy and hormone therapies can be done at those hospitals. The reviews can be done by telemedicine. This will actually decrease 40 to 50% of the load on the major tertiary cancer center. And then the tertiary cancer center can actually start doing higher level of treatment management. So, we are not even looking at the private centers, even if you actually catch the district level.
TS: It is interesting that you say this. Is not private sector engagement the big hope? Do you think there’s a scope for a public-private partnership to rope in the private sector?
BD: The current reimbursement under PM-JAY, even the revised rates is not enough for private hospitals to be interested in this. So most private hospitals do not offer free care even under insurance or are even rejecting patients from getting treatment on those protocols. So, I don’t think they are any solution except for a small part of the population. Many of them are into holding screening camps, but in what I have observed, much of this is to popularize their hospitals in new areas. Not sure how much screening occurs. Then patients get drawn in and spend money on diagnostic testing, especially mammograms and other scans and often for a wider range of diagnostics than required and over multiple visits. And most of these patients would have spent this money for a benign lesion. And eventually they cannot offer the full treatment required for a patient with cancer and costs are prohibitive. I would strongly urge that screening camps are limited to public providers and done by trained public sector nurses and doctors. There are far too many moral hazards and waste of money in any other approach.
MA: Moving on to the problem on the costs and access to medicines. One major barrier we see in breast cancer management is the treatment cost, especially for chemotherapy in both public and private settings. So, can you help us understand the typical cost range, sir, for patient per year for first, second- and third-line treatment?
BD: Another complex question. Basic chemotherapy is six to 8 cycles and the costs are about Rs 5000 per cycle or about Rs 40,000 per patient. There are generics also available. Though individual patients may find it difficult, it is not difficult to fit it into a government budget. But these are with public procurement. In the private sector and on retail purchase the prices may be three times higher or more.
The cost for the targeted therapy and immunotherapy is higher. Take for example trastuzumab which is essential for HER2 positive, which is about 20% of all breast cancer patients. Trastuzumab was very expensive, till it was under patent and there were no Generic drugs. But once the generic drugs came in, the prices have come down drastically from 1,50,000 to almost like 10,000 per patient/dose. Its’ even cheaper now and we are able to give it to over 90 percent of patients who need it, whereas four years back less than 10 percent of our patients could afford it. In metastatic setting it remains difficult because it has to be given continuously for many years and the cost again becomes a problem.
TS: The story of trastuzumab is interesting. Roche was planning to extend its patent but faced with patent challenges and a public outcry and the threat of possible compulsory licensing, they backed off. But what about other current second line, third line drugs? How many of them are still candidates for cost reduction to ensure access?
BD: Cost of the targeted drugs require reduction. TDM-1 is one drug. That is an antibody drug conjugate, quite expensive, but it’s a very useful drug, especially in HER2 positive in a metastatic setting, as well as an adjuvant when they do not have initial response to Trastuzumab. There is clear survival benefit. Currently one dose will cost around Rs 55,000.
Immunotherapy which in the neo-adjuvant and adjuvant setting has shown benefit and costs 2 lakhs per session every 3 weeks, we need to give, over 16 doses, it’s about Rs 20-25 lakhs. But with some patient assistant program, I think per year cost now is fixed at 10 lakhs. So that’s also quite expensive because 10 lakhs is not a small amount. Pembrolizumab and Nivolumab are the two immunotherapy drugs. Pembrolizumab is the one which is approved in breast cancer. Fortunately, the patent on pembrolizumab and nivolumab are expiring next year, and after that hopefully the costs will come down. Then there are some other targeted therapies which are like Rs 12,000 per dose in the metastatic setting and we will need to give it till progression.
TS: There is no reason why some of these cannot be made available at much lower prices. Many of these new medicines are biologics, and there are special problems with biologics. We will need a policy change to get biologics into the generic space.
MA: One last question. I’m particularly referring to the whole of plastic surgery and the breast reconstructive surgery. Where is the bottleneck on that? Is that something that it should be on offer? Can it be universalized? What’s your take on that?
BD: Breast cancer surgery has been revolutionized. Very few need to get the breast completely removed. Breast conservation surgery is also more feasible due to better chemotherapy- and this is much easier. Reconstruction surgery requires a plastic surgeon on the team and takes a lot of OT time- which is problem considering that there are so many patients waiting for surgery. Then the counseling for the patients. So many of the patients do not even understand the rehabilitative, reconstructive process. People believe that till the breast is there, they are at risk of developing malignancy. Though we clearly tell them that the risk is the same whether you remove the complete breast or you remove partial. But they are not easily convinced. So these are some challenges at the ground level which we are facing. But even in JIPMER, the breast conservation surgery rates are much, much lower.
Everybody used to undergo complete removal of breast 2 to 3 decades back. At our center now, I think the breast conservation surgery rate is 20-25% and this can still go up with more training and understanding and all that. But reconstructive surgery even at JIPMER is at much lower level.
If we go into offering more patients such surgery, the waiting is going to be long and I’m not sure how we are going to push them into all this. It needs a much higher level of treatment management; when we are looking at the care not only as part of survival packages, but as part of quality-of-life packages.
TS: Thank you for this conversation. I hope we have a good readership from both policy makers and public health managers. During field visits, I am perturbed by how the public health of breast cancer is perceived. Managers report on number of women screened without any information on what happens in the rest of the care pathway. And screening is trivialized and equated with entry into the app. There is no review of what the screening found and did. It is bizarre. There is really no engagement of public health professionals with the organization of care across the entire care pathway. Beyond screening, all the rest falls into the clinical domain which is often part of another directorate. For the public health person, accountability seems to cease with app entry, not even the nurse training, because that too requires specialist support. And for the clinicians, the scope is limited to the individual patients before them and what can be done by them in that particular facility.
BD: I think also there is a lot of discordance between the public health and the clinical, even in a setup like JIPMER. I mean, the public health keeps doing their activities separately. We look at our side. There’s no interaction between the public health and the clinician’s terms of what exactly is required to address the problems faced. So, there are lots of challenges. And the problems are with both the public health personnel and the clinician.
TS: And with the lack of a legal framework, viz a right to healthcare law that makes it an obligation to ensure coordination across multiple providers and facilities with the patient’s interest at the centre. What we are talking off is not so entirely new. To my knowledge UK’s NHS and Thailand’s UCS do have such systems in place and so do many other countries which have assured universal health care. So, it can be done…. here and now. Its not only a problem of individual clinicians and public health managers. Public policy must recognize that the appropriate response to the unacceptable level of breast cancer mortality is a systems-wide approach that has to go far beyond just screening for breast cancer.
About the Participants:
Prof (Dr) Biswajit Dubashi, is currently Professor Medical Oncology, at Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), and Deputy Medical Superintendent at Regional Cancer Centre, Puducherry. He got his MD in Internal Medicine from JIPMER in 2004 and his DM in Medical Oncology from Adyar Cancer Institute in 2008. He has been in the faculty of department of medical oncology since 2009 and professor since 2020. He has been principal investigator in seven research projects, many of which are under ICMR and has a number of research publications to his credit, including two on breast cancer research- one of which is on biomarkers and the other on designing and implementation of healthcare model in patients with stage 2 breast cancer.
Dr. Monika Aroquiadasse is a public health researcher specializing in Oral Medicine and Radiology, and a Masters in Public Health from JIPMER. Currently, she serves as a Consultant with the National Tobacco Regulatory Forum, where she contributes to the development and implementation of policies aimed at tobacco control and regulation. Deeply committed to reducing health inequities, Dr. Aroquiadasse integrates her clinical knowledge and public health expertise to advocate for equitable access to healthcare
