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Cancer is a leading cause of death and disability in India, with over 1 million new cases diagnosed each year. The most common cancers in India are breast, cervical, oral, lung, stomach, colorectal, esophageal, and prostate cancers. With improved screening and a growing population, the cancer burden in India is expected to substantially increase in the coming decades. 

India faces unique challenges in cancer care and treatment. A majority of cancer patients are diagnosed at an advanced stage due to limited screening and awareness. Treatment costs are often catastrophic for patients and families, with over 70% of healthcare expenses being out-of-pocket. Access and affordability of quality cancer treatment remain a key barrier. 

Over the years, India has made steady progress in cancer care infrastructure and expertise. The government has expanded tertiary care facilities and rolled out screening programs for common cancers. Several specialized cancer hospitals and research centres have also emerged in the private sector. However, a large gap remains between the demand and supply of quality cancer care services.

Cancer treatment in India relies on conventional approaches like surgery, chemotherapy, radiation therapy and palliative care. With improving affordability, targeted therapies and immunotherapy are also gaining ground. But availability of the latest drugs and technologies remains limited. 

Domestic manufacturing of affordable generics and biosimilars is seen as a key enabler for improving access to cancer treatment in India. The government aims to boost local production and expand coverage to reduce reliance on expensive imports. Partnerships between the public and private sectors are vital to strengthening cancer research, manufacturing and treatment capabilities across India.

Common Cancers in India

India faces a rising burden of cancer cases, with current estimates indicating about 1.1 million new cases diagnosed and around 700,000 cancer deaths annually. The most prevalent cancer types in India differ somewhat between males and females. 

Among males, oral cancer is the most common, representing around one-third of all male cancers in India. This is often attributed to the widespread use of tobacco, betel quid, and other products in the country. After oral cancer, the most prevalent cancers in Indian males are lung, oesophagal, stomach, and colorectal cancers. 

For females, breast cancer is by far the most common, accounting for over a quarter of new cases. After breast cancer, cervical cancer is the next most prevalent in Indian women, representing about one-fifth of cases. Ovarian and oral cancers are also in the top five most common female cancers. 

The causes of cancer in India mirror global trends, with tobacco usage, infections, poor diet, and lack of physical activity being major contributing factors. However, there are some India-specific causes to consider as well. For example, the chewing of betel quid mixtures containing tobacco and areca nut increases oral cancer risk. The use of indoor coal fires for cooking, leading to indoor air pollution, also raises lung cancer risk in women. Preventing and treating infections like HPV and HBV could help lower cervical and liver cancer rates. Reducing tobacco usage remains one of the biggest prevention opportunities for reducing India’s overall cancer burden.

Cancer Treatment Approaches

There are several main approaches to treating cancer in India:

Surgery 

Surgery is often the first treatment given for cancer. The goal is to remove the tumour and surrounding tissue during an operation. Surgery is typically used for localized cancers that have not spread to other parts of the body. Common cancer surgeries include mastectomy for breast cancer, prostatectomy for prostate cancer, and colectomy for colon cancer. The extent of the surgery depends on the type and stage of the cancer.

Chemotherapy

Chemotherapy uses anti-cancer drugs that circulate throughout the body to kill cancer cells. It can be given before surgery to shrink tumours or after to kill any remaining cancer cells. Chemotherapy may also be used as the main treatment for cancers like leukaemia that have spread widely. Doctors often prescribe a combination of chemotherapy drugs that work in different ways to kill cancer cells. Chemotherapy is typically given in cycles for months.

Radiation Therapy 

Radiation therapy uses high-energy radiation beams to kill cancer cells and shrink tumours. It works by damaging cancer cell DNA so they can’t divide and grow. Radiation can be delivered externally using a machine that aims beams at the tumour. Or radioactive material can be placed inside the body near cancer cells in a procedure called brachytherapy. Radiation may be used before surgery to shrink a tumour or after to kill the remaining cancer cells. It is also used as the main treatment for some cancers.

Immunotherapy

Immunotherapy boosts the body’s immune system to help it find and destroy cancer cells. Some immunotherapies involve taking drugs that enhance the immune response. Others involve removing some immune cells, modifying them to attack cancer, and putting them back into the body. Immunotherapy has become an important treatment for many cancers like melanoma and lung cancer. However, not all patients respond to immunotherapy drugs. Researchers are working on ways to improve responses.

Chemotherapy Drugs Used in India

Chemotherapy remains one of the major treatment modalities for cancer in India. Sure, there’s a rewritten version: One of the chemotherapy drugs commonly used is:

– Platinum agents like cisplatin, carboplatin, and oxaliplatin are used to treat various cancers including lung, ovarian, head and neck, colorectal etc. 

– Taxes like paclitaxel and docetaxel are used in breast, ovarian, lung, and other cancers.

– Antimetabolites like 5-fluorouracil, capecitabine, methotrexate etc. have activity against colorectal, breast, and other cancers.

– Vinca alkaloids like vincristine, vinorelbine, and vinblastine are used in haematological malignancies and solid tumours. 

– Anthracyclines like doxorubicin, epirubicin, and daunorubicin are commonly used in leukaemias, lymphomas, breast cancer etc.

Some of the widely used targeted therapies in India include:

– Trastuzumab for HER2+ breast cancer

– Imatinib for chronic myeloid leukaemia 

– Rituximab for Non-Hodgkin’s lymphoma

– Bevacizumab, cetuximab, panitumumab for colorectal cancer

– Erlotinib, gefitinib for EGFR mutant lung cancer

– Sorafenib, lenvatinib for liver and kidney cancer

– Pomalidomide, thalidomide for multiple myeloma

The availability and use of newer chemotherapy and targeted agents are also increasing in India, especially in major cancer centres.

Manufacturers of Anticancer Drugs in India

India has a robust domestic pharmaceutical industry that manufactures generic versions of many anticancer drugs. Some of the major Indian companies manufacturing chemotherapy medications include:

Ellia Cytocare

Noida – Specializes in oncology and generics. 90+ oncology drugs including oral solids, injectables and biologics. Key drugs: Lenalidomide, Thalidomide, Bortezomib, Sorafenib, Tamoxifen. Oncology formulation facility in India with a capacity of 200 million units per year.

Sun Pharma

One of the largest pharma companies in India, Sun Pharma manufactures several widely used chemo drugs including docetaxel, paclitaxel, irinotecan, oxaliplatin, gemcitabine, and capecitabine. The company exports its oncology products to over 50 countries.

Dr Reddy’s Laboratories 

Headquartered in Hyderabad, Dr Reddy’s manufactures over 190 oncology products including cisplatin, carboplatin, etoposide, imatinib, rituximab, trastuzumab and bortezomib. It is one of the leading exporters of oncology APIs globally.

Cipla 

A top Indian pharma company, Cipla manufactures over 155 cancer drugs across major treatment modalities like chemotherapy, immunotherapy and hormonal therapy. Some key products are etoposide, tamoxifen, letrozole, pemetrexed, erlotinib and sorafenib.  

Natco Pharma

Specializing in oncology and generics, Natco manufactures over 50 cancer drugs including lenalidomide, dasatinib, everolimus, bendamustine, azacitidine and cabazitaxel. Its exports span over 40 countries.

Cadila Healthcare

Manufactures over 30 oncology products including imatinib, irinotecan, docetaxel, oxaliplatin and leuprolide acetate. The company is one of the world’s largest producers of busulfan.

Alembic Pharma

Key chemo drugs manufactured by Alembic include cytarabine, doxorubicin, methotrexate, fluorouracil, cyclophosphamide and vinblastine. The company sells its products to more than 60 nations worldwide.

Intas Pharma 

Manufactures over 16 anticancer molecules including cabazitaxel, azacitidine, decitabine, lenalidomide, bortezomib and fulvestrant. Intas is one of the largest exporters of lenalidomide globally. 

Emcure Pharma

Manufactures over 60 oncology products including drugs like imatinib, dasatinib, erlotinib, sorafenib, sunitinib, vinorelbine, and leuprolide acetate. The company exports to over 70 countries.

Lupin

Headquartered in Mumbai, Lupin manufactures over 115 generic oncology drugs. Key products include etoposide, doxorubicin, cyclophosphamide, capecitabine and tamoxifen.

The wide range of anticancer drugs produced domestically has helped in meeting the rising demand for affordable chemotherapy in India. The export focus of many companies also makes quality drugs accessible globally.

Domestic vs Imported Drugs 

India relies heavily on imported anticancer drugs, with estimates suggesting that over 80% of the drugs used for cancer treatment are imported. Only about 15-20% of the anticancer drugs used in the country are manufactured domestically.

There are several reasons behind the low domestic production of anticancer drugs in India:

– Lack of technical capabilities: The manufacturing of anticancer drugs involves complex processes and technology that Indian pharma companies have traditionally lacked expertise in. Setting up capabilities for manufacturing anticancer biologics is also capital-intensive.

– Focus on generics: Indian pharma companies have historically focused more on developing generic versions of off-patent drugs rather than innovative new molecules. Most of the domestically manufactured anticancer drugs are generic versions of drugs whose patents have expired.

– High costs and low margins: The costs of manufacturing anticancer drugs domestically are high while margins tend to be lower compared to other therapeutic areas. This makes the economics unattractive for pharma companies.

– Regulatory hurdles: Stringent regulatory requirements for manufacturing and testing of anticancer drugs pose hurdles for Indian companies. Getting approvals for new drugs also tends to be time-consuming.

However, the tide is slowly turning, as more Indian companies are now developing capabilities for manufacturing anticancer drugs and investing in R&D. The government is also providing incentives to boost domestic manufacturing. But imports are likely to continue dominating shortly. Access to cutting-edge anticancer drugs at affordable prices will depend on Indian companies partnering with global innovators. Striking the right balance between imports and domestic production remains a key challenge.

Drug Approval Process

The development and approval of new anticancer drugs in India involves several regulatory bodies and multiple phases of clinical trials. 

Regulatory Bodies

The Central Drugs Standard Control Organization (CDSCO) is the national regulatory body for pharmaceuticals and medical devices under the Ministry of Health and Family Welfare. The CDSCO is responsible for approving new drugs and regulating clinical trials in coordination with state licensing authorities.

The Drug Controller General of India (DCGI) heads the CDSCO and gives final approval for new drugs. The DCGI relies on the recommendations of the Subject Expert Committees, which evaluate safety, efficacy and risk-benefit data from clinical trials.

Clinical Trial Requirements

Before a new anticancer drug can be approved in India, it must undergo clinical trials to demonstrate safety and efficacy. The clinical trial process normally involves four phases:

– Phase 1 trials evaluate safety and dosage in a small group of patients.

– Phase 2 trials assess efficacy and side effects in a larger group of patients with the disease. 

– Phase 3 trials compare the new drug to existing treatments in a large patient population.

– Phase 4 trials monitor long-term safety and efficacy after the drug is approved.

The DCGI requires data from all phases of clinical trials conducted in India as part of the approval application. However, for global anticancer drugs already approved in other major markets like the US or EU, the DCGI may grant approval based on Phase 3 data without conducting local clinical trials. This can help expedite access while ensuring safety and efficacy are established.

Overall, the drug approval process aims to ensure the quality, safety and effectiveness of new anticancer medicines for Indian patients. The regulatory bodies and clinical trial requirements provide checks and balances for bringing innovative oncology treatments to market.

Anticancer Drug Suppliers

India has a robust pharmaceutical industry that produces and supplies a wide range of anticancer drugs domestically. Some of the leading anticancer drug manufacturers, dealers, and suppliers in India include:

• Ellia Cytocare: Based in Noida – Specializes in oncology and generics. 90+ oncology drugs including oral solids, injectables and biologics. Key drugs: Lenalidomide, Thalidomide, Bortezomib, Sorafenib, Tamoxifen. Oncology formulation facility in India with a capacity of 200 million units per year.

• Sun Pharma: One of the largest generic drug makers in India, Sun Pharma supplies many widely used chemotherapy medications such as docetaxel, gemcitabine, irinotecan, and oxaliplatin among others. The company has manufacturing facilities across several states in India.

• Dr Reddy’s Laboratories: Headquartered in Hyderabad, Dr Reddy’s is another major supplier of generic anticancer drugs in India and exports to many countries globally. They manufacture medications like erlotinib, lenalidomide, sorafenib, sunitinib and more.

• Cipla: Based in Mumbai, Cipla is one of the oldest pharmaceutical companies in India. They manufacture and distribute a wide range of anticancer drugs including imatinib, rituximab, pemetrexed, etoposide, and bortezomib. 

• Natco Pharma: Specializing in oncology and generics, Natco Pharma supplies important cancer drugs like lenalidomide, sorafenib, and everolimus to hospitals and pharmacies across India. Their manufacturing facilities are located in Hyderabad.

• Emcure Pharmaceuticals: Headquartered in Pune, Emcure manufactures and distributes several chemotherapy drugs including erlotinib, leuprolide, tretinoin, and asparaginase. The company has a pan-India presence.

• Cadila Healthcare: Based in Ahmedabad, Cadila Healthcare supplies popular anticancer medications like imatinib, irinotecan, and pegfilgrastim as well as biosimilars of rituximab and trastuzumab. They ship their products to more than 50 countries across the globe.

• Intas Pharmaceuticals: Intas, headquartered in Ahmedabad, manufactures and supplies chemotherapy medications like bendamustine, bortezomib, decitabine, and lenalidomide as well as monoclonal antibodies. Their products are exported globally.

This is just a sampling of the major domestic players involved in the manufacturing and distributing of anticancer drugs in India. With considerable expertise and manufacturing capabilities, Indian pharma companies are helping expand access to essential chemotherapy medications.

Addressing Affordability

India has one of the lowest per capita healthcare expenditures in the world, putting many life-saving cancer treatments out of reach for a large portion of the population. However, efforts are underway to improve access and affordability of anticancer drugs:

• Government programs: The National Pharmaceutical Pricing Authority regulates prices for essential medicines, including many cancer drugs. State governments also provide free or subsidised treatment for the poor. Central government health schemes provide some coverage for cancer care.

• Domestic manufacturing: Local companies are working to produce cheaper generics and biosimilars of patented cancer drugs. This expands treatment options at lower price points. 

• Advocacy and assistance: Patient advocacy groups lobby for lower drug prices and increased government healthcare spending. Charities help patients access treatment by providing drugs, finances and other assistance.

• International aid: Global health organisations are partnering with the Indian government, domestic manufacturers and healthcare providers to improve services and access for cancer patients across the country.

• Research and innovation: Indian pharmaceutical companies are developing novel dosage forms and drug delivery systems to make treatment more effective and affordable. Academic research also aims to find new targets for affordable anticancer drugs.

While costs remain high, concerted efforts by stakeholders in the public and private sectors aim to make quality cancer care available to more socioeconomic groups in India. Continued progress will depend on policies that balance innovation with access, and partnerships across the healthcare ecosystem.

The Road Ahead

India’s journey in providing affordable and accessible cancer care is far from over. While there has been tremendous progress, several challenges remain.

Challenges

• Increasing Cancer Burden: With India’s population growing and ageing, the number of new cancer cases is projected to substantially increase in the coming decades. Resources and infrastructure will need to expand to meet the rising demand for cancer care.

• Regional Disparities: There is a stark divide in cancer care between urban and rural areas. Rural patients face difficulties in accessing screening, early diagnosis and quality affordable treatment. Bridging this cancer care divide remains a priority. 

• Drug Shortages: While domestic manufacturing has expanded, shortages of essential cancer medicines still occur. Maintaining adequate stocks and preventing drug scarcity requires continued efforts.

• Financial Hardships: Many patients face severe financial distress due to the high costs of cancer treatment. Most healthcare spending in India is out-of-pocket. More financial protection and subsidized care are needed.

• Stigma: Social stigma around cancer negatively impacts early detection and treatment outcomes. Greater public awareness is essential to remove stigma and enable timely care-seeking.

Future Outlook

– The National Cancer Grid aims to expand capacity and access to quality, uniform cancer care across India. Over time, it holds promise to reduce regional disparities.

– Government initiatives to expand health insurance coverage and provide financial assistance for cancer treatment will help mitigate costs for patients.

– With growth in domestic manufacturing, the availability and affordability of cancer medicines should continue to improve.

– Leveraging telemedicine and mobile technology can aid awareness, screening, treatment monitoring and palliative care across geographies.

– Prioritizing cancer research and data collection will allow more tailored solutions for local needs and populations.

– Stronger public-private partnerships can promote resource sharing, outreach and the latest innovations for cancer control in India.

FAQs

1. What are the most common types of cancer in India?

The most common types of cancer in India vary between males and females. For males, oral cancer is the most prevalent, followed by lung, oesophagal, stomach, and colorectal cancers. Among females, breast cancer ranks the highest, followed by cervical cancer, ovarian cancer, and oral cancer.

2. What are the main approaches to treating cancer in India?

Cancer treatment in India typically involves several modalities, including surgery, chemotherapy, radiation therapy, and immunotherapy. The choice of treatment depends on factors such as the type and stage of cancer, as well as the patient’s overall health.

3. Which chemotherapy drugs are commonly used in India?

Several chemotherapy drugs are widely used in India for treating various types of cancer. Some commonly used ones include platinum agents like cisplatin and carboplatin, taxanes like paclitaxel and docetaxel, antimetabolites like 5-fluorouracil and methotrexate, and anthracyclines like doxorubicin.

4. What are the major manufacturers of anticancer drugs in India?

India has several major pharmaceutical companies involved in the manufacturing of anticancer drugs. Some prominent ones include Sun Pharma, Dr Reddy’s Laboratories, Cipla, Natco Pharma, and Cadila Healthcare, among others. These companies produce a wide range of chemotherapy medications and biosimilars to meet the demand for affordable cancer treatment.

5. Why does India rely heavily on imported anticancer drugs?

While India has a robust domestic pharmaceutical industry, a significant portion of anticancer drugs are still imported. This reliance on imports is due to factors such as the complexity of manufacturing anticancer drugs, historical focus on generic drugs rather than innovative molecules, high manufacturing costs, and stringent regulatory requirements. However, efforts are underway to boost domestic production and reduce dependence on imports.

6. How does the Indian government address the affordability of cancer treatment?

The Indian government implements various measures to improve access to affordable cancer treatment, including regulating drug prices through the National Pharmaceutical Pricing Authority, providing free or subsidised treatment for the poor through government healthcare schemes, and encouraging domestic manufacturing of cheaper generics and biosimilars. Additionally, international aid and patient assistance programs help alleviate financial burdens for cancer patients.

7. What are the challenges facing cancer care in India?

Some of the key challenges in cancer care in India include the increasing cancer burden, regional disparities in access to healthcare, shortages of essential cancer medicines, financial hardships for patients, and social stigma surrounding cancer. Addressing these challenges requires concerted efforts from policymakers, healthcare providers, pharmaceutical companies, and civil society organizations.

8. What initiatives are underway to improve cancer care in India?

Several initiatives are underway to improve cancer care in India, including the National Cancer Grid to expand access to quality care, government programs to expand health insurance coverage, efforts to strengthen domestic manufacturing of cancer drugs, leveraging telemedicine for outreach and monitoring, prioritizing cancer research, and fostering public-private partnerships for resource sharing and innovation. These initiatives aim to enhance cancer control and improve outcomes for patients across India.

The road ahead will require concerted planning, policies and participation from all healthcare stakeholders to chart the course for a cancer-free future. With continued efforts, quality cancer care can become a reality for all in India.