Genomics & Future Of Oncology In India

Dr. BS Ajaikumar, Chairman & CEO, HealthCare Global EnterprisesWith an aim to make advanced cancer care assessable to all, Dr. Ajai founded HCG and ever since has been the driving force behind the company's growth. He is a recipient of the Karnataka Rajyotsava Award.

The increasing number of cancer cases in India is a rising cause for concern. With nearly 1.5 million new cases, cancer has emerged as a major health challenge. This number is expected to double over the next two decades. The number of cancer cases among women is more than men in India, with breast, cervical, ovarian and uterine cancers making-up more than 70 percent of cancer among women.

Understanding cancer has always been a challenge, and that has led to poor outcomes. But, there has been a dramatic change in recent years. A better understanding of the disease, genomics, immunology of cancer, and with the technology advancements, we can target and treat the cancer cells solely, thereby avoiding the normal tissues. In spite of recent advances in the treatment of cancer with the advent of better surgical expertise, radiotherapy techniques and chemotherapeutic regimes over the past 20 years, the outcome and five-year survival of most advanced malignancies has improved only marginally. Many major drugs have an initial response, but the non-responder rates vary between 30 percent and 70 percent. Detection of cancer at an early stage, understanding the biology of cancer, stratifying the patients into responders and no-responders to treatment enable us to get precision medicine in place with an accurate diagnosis, rationalize treatment decision, identify prognostic biomarkers, and prognosticate the disease.

Traditionally, surgery, radiation, chemotherapy or targeted therapy is the standard way of treatment for any form of cancer based on retrospection. But today, it has changed to precision medicine. This means that when we deal with a patient, we can study and analyse the best possible treatment for that patient based on his/her predictive analysis that includes a genomics study and immunology study. This combined with advanced molecular imaging can give us a near perfect situation of the status of the disease,
along with the right mode of treatment. This may involve, for instance, limited surgery, radical surgery, precision radiation, chemotherapy, biotherapy or immunotherapy, based on the patient's presentation and markers.

When we talk about surgery for instance, in the past we did extensive surgery. But today, we employ target surgery. In breast cancer cases, there is no longer a need of mastectomy. Instead, we do a lumpectomy and analyse further to provide the best treatment. Today, with state of the art facility and the right technology available, we can achieve 90 percent disease-free survival in breast cancer cases and match the world standards.

Taking radiation for instance; in the past, we did radiation as a palliative treatment - pre-operative or post-operative treatment or in cases where surgery was not possible. But today, there is no palliative care. Radiation, even in metastasized cases, or advanced cases can be given not just to treat the disease, but also to cause an immunological response to other parts of the body. This has emerged as a matter of great interest in the field of medicine where radiation along with immunotherapy may become the answer when it comes to treating advanced cases. Today, using radiosurgery, we can treat tumours faster and more accurately, focussing only on the tumour rather than on tissues. For example, multiple lesions in the brain can be treated without causing any harm to the larger part of the brain.

Radiation, even in metastasized cases, or advanced cases can be given not just to treat the disease but also to cause an immunological response to other parts of the body

The integration of `Digital Pathology' for an expert opinion on the biology of the tumor enables us to identify specific molecular defects, establish new biomarkers and ensure accurate diagnosis. This also helps us to rationalize the treatment decision, prognosticate the disease and monitor the response in patients. Through Digital Pathology, doctors can now use Next Generation Sequencing (NGS) of the cancer genome from biopsy of the tissue and the tumour DNA from the blood sample to arrive at accurate results. `Radio genomics' is playing a significant role in understanding genetic variation associated with response to radiation by analysing radio-sensitivity index (RSI) and correlate between cancer imaging features and gene expression.

As experts, we believe that there has to be a significant change in treating cancer, and research is the first step to help us do that. We can cite many examples of patients who have benefited from the application of genomics research to their treatment. We need to move from a symptom-based approach to cancer care that gives us limited choices in treatments to a more gene/biochemical pattern-based approach so that we can offer patients personalized cancer medicine empowered by genomics. When we treat cancer this way, it not only improves treatment outcomes for the patients, but also helps to significantly bring-down the overall cost.

Thus, the success of `Genomic Medicine' can already be seen in clinical practice. Since the publication of Human genome project in 2000, integration of many cost effective diagnostic platforms, there has been a significant increase in our understanding of the biology of each cancer, making the disease highly treatable. Cancer is no more a deadly disease, but considered as a chronic lifestyle disease. If the cure is done in proper way i.e. the right way the first time.