Combating Cancer at Home and Abroad: Lessons from India and other LMICs

Jordan Francke, MD, MPH

According to GLOBOCAN 2020 estimates of cancer incidence and mortality, an estimated 19.3 new cancer diagnoses and 10.0 million cancer deaths occurred in 2020 (https://pubmed.ncbi.nlm.nih.gov/33538338/). Experts on this topic explored the emerging field of oncoanesthesia with an emphasis on low- and middle-income countries (LMICs) during the session, “Cancer Care Opportunities and Challenges for the Anesthesiologist in the Developing World,” co-sponsored by the World Federation of Societes of Anesthesiologists (WFSA), on Sunday, May 19 at the 2024 Annual Meeting, presented by IARS and SOCCA. Vijaya Gottumukkala, MBBS, MD, FRCA, FASA, professor of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center (MDA), moderated this fascinating session.

Shagun Bhatia Shah, MBBS, DA, DNB, FIMSA, MNAMS, an attending anesthesiologist in the department of anesthesiology and critical care at the Rajiv Gandhi Cancer Institute and Research Centre in Delhi, India, argued that while rates of cancers are higher in high-income countries (HICs), this is almost certainly a result of underreporting and under-detection of cancer in LMICs. The distributions of the most common cancers also vary widely depending on the country in question. For example, the most common cancer in most of North America and Europe is breast cancer. However, in Dr. Shah’s home country of India, oral cancer is most reported. Furthermore, in many sub-Saharan African countries, cervical cancer is most common, which represents an important opportunity for intervention given robust data showing that vaccination against the human papillomavirus in younger patients significantly reduces their risk of cervical cancer later in life.

Dr. Shah also reminded the audience that cancer in many patients’ cultures remains quite stigmatized, and as a result patients often present to the hospital very late in their disease course with metastatic disease. She argued that financial toxicity of cancer also plays a significant role in the “cancer gap” of differential outcomes between HICs and LMICs, particularly in India (https://pubmed.ncbi.nlm.nih.gov/34856151/). For many patients in LMICs, cancer treatment is either cost prohibitive, or drains patients and their families of nearly all their lifetime savings. Dr. Shah shared that significant cost reductions can be accomplished through utilizing resources that are at least 80% as effective as the resources in HICs but at a fraction of the cost, and she provided the examples of using glycopyrrolate and neostigmine to reverse neuromuscular blockade compared to sugammadex, or utilizing lactated Ringer’s compared to PlasmaLyte.

Dr. Gottumukkala built upon Dr. Shah’s presentation by reiterating that this topic is indeed relevant to an anesthesia audience – 80% of patients with cancer will require the services of an anesthesia provider during their cancer journey (https://www.mdanderson.org/research/departments-labs-institutes/institutes/institute-for-cancer-care-innovation.html). He is particularly interested in the intersection of enhanced recovery after surgery (ERAS) protocols and oncoanesthesia. In fact, Dr. Gottumukkala demonstrated that there is no patient population that benefits more from ERAS than the oncological patient. He demonstrated compelling evidence within thoracic anesthesia that the implementation of an ERAS protocol led to significantly more patients being able to complete their adjuvant chemotherapy sessions, and argued that oncoanesthesiologists controlling cancer patients’ pain and nausea in the perioperative period can have profound consequences for their longitudinal therapeutic goals (https://pubmed.ncbi.nlm.nih.gov/31014665/). He also shared that enrollment in an ERAS protocol has been shown to reduce the recurrence of colorectal cancers, likely from patients being able to make subsequent adjuvant therapy appointments on time (https://pubmed.ncbi.nlm.nih.gov/35234283/).

The next speaker, Rajiv Chawla, MBBA, MD, has held many important posts including president of the Indian Society of Neuroanesthesiology & Critical Care (ISNACC) as well as medical director of G B Pant Hospital (a leading tertiary care center of Delhi). Unfortunately, Dr. Chawla was unable to attend the conference in person, but recorded his presentation which was played to the audience. Dr. Chawla’s presentation focused on what is termed “integrative medicine,” which attempts to heal the whole person (mind, body, and spirit) and address physical, emotional, social, spiritual, and environmental factors that may be contributing to a patient’s disease process. Dr. Chawla asserted that Integrative Medicine is the future of care in India, and likely most countries in the world. He stated that it has profound potential to improve both palliative and curative therapies for oncological patients. He suggested that funding of integrative medicine must be increased, it must be taught to aspiring physicians in medical school, and further inquiry into its potential should be encouraged to researchers. Dr. Chawla emphasized that just as anesthesiologists expect “traditional medicine” providers to learn the basics of “Western medicine,” the converse is also true, and a patient (and their care team) benefits when providers understand a common language.