NAMS task force report on breast cancer in India

Epidemiology

According to the GLOBOCAN 2020, 19.3 million new cancer cases were diagnosed globally in 2020, and about 10.0 million died.¹ These cancer cases (excluding non- melanomatous skin cancers) are estimated to rise to 26 million in 2040, according to the report. Current cancer incidence rates are three times higher in high-income countries (HIC) as compared to low- and middle-income countries (LMIC).³ However, LMICs are expected to be largely responsible for the increase in cancer incidence worldwide over the next 50 years.⁴ Sixty percent of the global population resides in Asia, which accounts for 50% of cancer cases and 58% of cancer-related deaths. Furthermore, India ranks third in accounting for cancer cases, following China and the United States of America.⁵ The projected cancer burden in India is estimated to reach 2.08 million by 2040, representing a 57.5 % increase from 2020.

Breast cancer is the most common malignancy among women globally and in India. Approximately 200,000 new cases were reported in 2020, and it is expected that 232,832 cases will be diagnosed in 2025.² A higher incidence of breast cancer has been reported in urban population-based cancer registries (Hyderabad, Delhi, etc.) compared to rural registries (Barshi, Osmanabad, etc.). Among the data reported by hospital-based cancer registries, most diagnosed cases of breast cancer in females showed locoregional spread (57.0%), followed by localized disease (29.0%) and distant metastasis (10.3%).² A recent study from Mumbai (Tata Memorial Centre ) and Pune analyzed 912 patients diagnosed with breast cancer. The median age at diagnosis was 47 years (range, 23 to 85 years); 63.2% had pathologically confirmed axillary lymph node involvement, and 54% of patients had ER-positive disease. Approximately one-quarter of patients had HER2 - positive disease and, triple-negative breast cancer (TNBC) was present in 266 (29.1%) patients.⁶

Diagnostics: Radiodiagnosis and pathology

Radiodiagnosis imaging has two main categories of indications: Screening the healthy population for early detection of breast cancer and diagnostic breast imaging. The latter involves evaluating of women with breast complaints to determine whether the findings are cancerous or non-cancerous. Imaging is also required for clinical staging, treatment planning for breast cancer, and monitoring individuals who have been treated for breast cancer.

Mammography: Mammography is the primary imaging modality for breast cancer. Other modalities, such as ultrasound, MRI, and positron emission tomography - computed tomography (PET-CT), serve as supplementary tools to mammography in specific contexts. Mammography screening has been extensively studied and is a time-tested method proven to reduce breast cancer-related deaths in certain age groups. However, it is a resource-intensive approach, predominantly available in a few developed countries worldwide.

Currently, there is no structured population-based mammography screening program in the country and it is unlikely to be feasible in the foreseeable future due to its resource-intensive nature and the large population. For example, the number of mammography machines in India is only about 5% of that in the USA, despite India having a population more than three times that of the USA. A negligible proportion of women population in India undergo self-volunteered and self-funded periodic mammography examinations as a part of regular health check- ups in private hospitals for early detection of breast cancer, known as opportunistic screening. However, the protocol and standard of these screening are highly variable, and no precise data on the number of examinations or their benefits are available. A few small-scale, sporadic mammography screening studies have been conducted in India, sometimes utilizing mobile machines. Some of these are single-round assessments that show prevalence rather than incidence of breast cancer, and others lack long-term follow-up or mortality data.

As population-based mammography screening is not feasible in our country, promoting awareness about breast cancer and its early symptoms is crucial. The benefits of seeking immediate medical attention and the importance of early-stage diagnosis should be emphasized. While self-breast examination and clinical breast examination have been studied in other countries, they have not proven effective in reducing breast cancer-specific mortality. However, a long-term population screening study conducted by Tata Memorial Hospital (TMH), which utilized clinical breast examination by trained healthcare workers, demonstrated that this approach can help downstage the disease at presentation and may reduce mortality to some extent in specific age groups.⁷ This approach can be further explored on a large scale.

In India, breast imaging is primarily employed to evaluate women presenting with breast-related complaints, such as pain, lumps, and/or discharge, which is referred to as diagnostic breast imaging. This approach is useful for diagnosing breast diseases, cancer, or non-cancer. For women suspected of having breast cancer, imaging aids in confirming or ruling out breast cancer. If imaging indicates the presence of cancer, it is also used to obtain an image-guided biopsy for pathological confirmation. Once breast cancer is confirmed, imaging is used for staging, deciding on management, accessing the response to non-surgical management, and detecting recurrence in treated patients.

In pathology services, the following observations have been made:

Routine histopathology of breast cancer: The primary issue with pathology reporting of breast cancer in India is the lack of reporting essential features in histopathology reports and improper documentation of biomarkers. In a study conducted by the National Cancer Grid External Quality Assurance Scheme (NCGEQAS) at Tata Memorial Hospital in 2019, slides from a breast cancer excision were circulated for minimum data set reporting (unpublished observations). Overall, 89 out of 94 centers (95%) provided a concordant diagnosis, while five centers (05%) rendered a discordant diagnosis of invasive lobular carcinoma. The most significant challenges were observed in reporting lymph node status and margin assessments.

Biomarker reporting: The reported positivity rates for hormone receptors in breast cancer from India vary from 32% to 70%, indicating heterogeneity in testing practices across the country.⁸ According to American Society of Clinical Oncology-College of American Pathologists (ASCO-CAP) recommendations, key reasons for the underestimation of hormone receptors include delayed transport of excised specimens, delayed fixation, and insufficient monitoring of cold ischemia time. Pathologists often hesitate to document delays in specimen transport due to concerns about potential of persecution by patients or surgeons. While poor fixation is the main issue for ER/PR testing, HER2 results are affected by the use of non- in vitro diagnostic (IVD) or non- Food and Drug Administration (FDA)-approved antibodies and the lack of automated platforms nationwide. The reported positivity for HER2 in breast cancer ranges from 16% to 30%.^9,10 In the most recent NCGEQAS run in 2024 for HER2 immunohistochemistry, only 63 out of 172 participating centers (36.6%) centers used the FDA-approved Ventana 4B5 antibody on the Ventana machine, indicating significant heterogeneity in the use of the FDA-approved tests in laboratories. (Unpublished observations). The NCGEQAS experience has recently been published highlighting the increasing use of FDA-approved HER2 testing in consistently participating centers, leading to improved laboratory performances.¹¹ Interpretative errors in the HER2 test are common in centers lacking molecular diagnostic facilities, resulting in pressure on these services to perform more HER2 tests than usual. For the programmed death-ligand 1 (PDL1) assay in triple-negative cancer, pembrozulimab is the recommended drug, with the companion test being the PDL22C3 antibody performed on a Dako link48 machine. Most laboratories in India have Ventana machine installed due to the availability of numerous FDA approved antibodies, making the use of PDL22C3 antibody on a Dako machine impractical. In a NCGEQAS exercise, only 25 out of 118 laboratories that perform immunohistochemistry volunteered for this cycle. All laboratories except one used the VENTANA SP263 for PDL1 testing, indicating a lack of capability to perform the other test. Only one laboratory utilized the Dako 22C3 for this purpose. Despite this, overall test performance was commendable, with only 3 out of 19 centers reporting discordant results. While this is encouraging, it suggests that most centers in India are not equipped to conduct PDL1.

Routine molecular testing in breast cancer for biomarkers: The primary biomarker regularly tested in breast cancer is HER2, using fluorescent in situ hybridization (FISH). However, this testing requires the establishment of molecular pathology services within Institutes and the presence of trained personnel. As HER2 testing has become mandatory, complex profiles are emerging. However, the practice of separating FISH from surgical pathology by sending samples to reference laboratories carries a risk of errors. Options and alternatives for FISH are discussed below.

Advanced molecular diagnostic and surrogates: In addition to ER, PR, and HER2, several other tests guide therapy decisions in breast cancer, including PI3k and ESR1 mutations in hormone-positive cancers, homologous recombination deficiency (HRD) in triple-negative breast cancers, and oncotype Dx for luminal cancers. Biomarkers that predict the need for chemotherapy in hormone-positive early breast cancer are essential; clinicians typically consider factors such as age, nodal status, Ki67, and gene expression profiling, with OncotypeDx being the standard choice recommended by most international guidelines. However, for economic reasons, many clinicians in India rely on alternate tests like Ki67 and CanAssist. There is insufficient evidence to confirm that high Ki-67 levels predict the efficacy of adjuvant chemotherapy or that patients with Ki-67-low breast cancer do not benefit from it.¹² Challenges associated with Ki67 include varying cut-off values, different counting methods, and significant effects from delayed fixation.¹³ A study at our institute found a significant difference in Ki67 values between breast cancer samples fixed immediately and those fixed after 1 to 6 hours. Lin’s concordance correlation coefficient (0.5350) indicated poor agreement between the two fixation times, highlighting the need for oncologists to be aware of how delayed fixation impacts Ki67 results. In a Delphi survey of oncologists in India, 84% preferred CanAssist, while 80% favored OncotypeDx for risk stratification.¹⁴ CanAssist utilizes five immunohistochemistry biomarkers—CD44 (a stemness marker), N-Cadherin and pan-Cadherin (cell adhesion and invasion markers), and ABCC4 and ABCC11 (drug exporters)—which are not proliferation markers but have shown some ability to predict better outcomes compared to traditional factors.¹⁵ While these tests provide better valuable information, it is essential to critically evaluate their scientific basis and the data behind them as these are often commercially driven. Looking towards IHC-4 translation and other gene-based options would be a more robust choice in India. HRD testing is available through several commercial platforms, including the gold standard Myriad myChoice CDx test for patients who can afford. However, HRD testing requires a NextSeq or HiSeq platform which is not feasible in many laboratories at present. Limited panel testing using MiSeq is the preferred method for Pi3K and BRCA mutation testing as an alternative to HRD tests in Indian patients. Most molecular tests are outsourced to commercial laboratories due to lack of resources and financial backing in institution-based laboratories. Consequently, effective marketing strategies from commercial laboratories have hindered the development of molecular diagnostics in even large cancer centers.

Treatment: Surgery, systemic treatment and radiotherapy

Surgery: The proportion of patients diagnosed with breast cancer at a younger age is notably higher in India compared to the high-income countries. In some studies, the median age of breast cancer presentation in India was found to be just 45 years; this is in sharp contrast to the USA, where the median age of presentation was 61 years.¹⁶ Additionally, patients in India tend to present with later stage disease compared to the West. More than 60% of patients in India present at Stage 3 or 4, while around 60% of patients in the USA are diagnosed at in-situ or Stage 1.

Delay in seeking healthcare: More than 50% of patients in India experience a delay of over 3 months before seeking medical care.

Delayed definitive management/inadequate treatment: Regarding 5-year overall survival rates, studies report 95% for stage I, 92% for stage II, 70% for stage III, and only 21% for stage IV patients.^10,16 The survival rate for breast cancer patients in India is lower compared to Western countries due to factors such as earlier age at onset, late stage presentation, delayed initiation of definitive management, and inadequate or fragmented treatment.^17,18

Limited Research Output: Despite the high burden of breast cancer in India, there is a lack of indigenous research contributing to global knowledge and innovation in breast cancer treatment. The high prevalence of poor-prognosis early-age breast cancer, despite the presence of low-risk hormonal profiles (early age at first childbirth, multiple pregnancies, prolonged breastfeeding, low prevalence of nulliparity, limited use of hormone replacement therapy, etc.), suggests the likely influence of as yet undetermined genetic, dietary, or environmental factors. However, due to the enormous patient load, specialists often lack time to dedicate to research.

Systemic therapy: Systemic therapy is a crucial component of modern breast cancer treatment, delivered by medical oncologists. It includes a range of drugs, such as chemotherapy, endocrine therapy, HER2 targeted therapy, other targeted therapies, and immunotherapy (primarily immune checkpoint inhibitors). Many generic, affordable versions of these drugs are available and are included in central and state health schemes in India. However, targeted therapies and immunotherapy are often expensive and not easily accessible due to financial constraints faced by the majority of breast cancer patients in the country. The following sections address some of the issues and potential solutions to enhance access to essential breast cancer drugs, as well as the infrastructure and expertise needed to administer them to eligible patients.

Radiotherapy: Radiotherapy of the remaining breast post-surgery is an integral part of the breast cancer treatment, delivered by radiation oncologists. It can result in up to 50% improvement in local control, which translates to saving approximately one life for every four local controls achieved.¹⁹ In patients with node-positive cancer, post- mastectomy radiotherapy leads to a reduction of up to 69% in the relative risk of loco-regional recurrence, preventing one death for every 1.5 loco-regional recurrences avoided over 20 years.^19,20 The effectiveness of this treatment has been established across various tumor sizes and grades, regardless of the nodal burden. Additionally, regional nodal radiotherapy has been found to offer further benefits for patients with more advanced cancers. Notably, studies from India demonstrate comparable benefits of radiotherapy to those seen in stage-matched patients from Western data, confirming its effectiveness amongst Indian women.^21,22

Hospital-Based Cancer Registry (HBCR) data revealed that 57% of patients presented with loco-regional disease, while 29% present with localized cancer.² Consequently, it is expected that over 85% of breast cancer patients will require radiotherapy during their lifetime, with the majority being potentially curable. However, many patients in India face a significant burden of locally advanced, incurable breast cancers requiring optimal symptomatic control.¹⁶ For these patients, radiotherapy offers effective and durable symptom management, helping to maintain their quality of life while also improving objective response rates to the treated breast tumor.²³

Existing health system framework for the provision of cancer care in India

To address the threat of cancer in India, the Government of India has established 599 NCD Clinics at the district level and 3,274 NCD Clinics at the community health center level under the NPCDCS. Additionally, the flagship national insurance program, Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (ABPM- JAY), was launched.

In 2018, India embarked on an ambitious path to enhance its health system and provide quality cancer care. At the population level, initiatives under the National Health Mission (NHM) were rolled out in over 215 districts to prevent, control, and screen for common NCDs (diabetes, hypertension, and common malignancies such as oral, breast, and cervical cancers). Screening for oral, breast, and cervical cancers is a critical component of service delivery under Ayushman Arogya Mandirs (formerly known as Health and Wellness Centers) implemented at the primary health care level [Figure 4]. Other initiatives, such as promoting healthy eating and regular physical activity, aim to encourage healthier lifestyles. The central government is also implementing the strengthening tertiary care for cancer scheme to improve cancer care facilities at the tertiary level. By 202, six State Cancer Institutes were operational, and the establishment of 19 additional State Cancer Institutes (SCIs) and 20 Tertiary Care Cancer Centers (TCCCs) has been approved.³⁰ Furthermore, oncology is a focus area for the new AIIMS facilities and many upgraded institutions under the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY). In Indian cities like Bhopal, Patna, Bhubaneswar, Jodhpur, Raipur and Rishikesh the new All India Institute of Medical Sciences (AIIMS) are fully functional.³⁰

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Figure 4:

Indian health system framework – cancer care. NCD: Non-communicable disease

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Supply side barriers

There are several supply-side barriers to cancer care in India, including:

Skewed geographical distribution of cancer treatment facilities: There is a skewed distribution of cancer care facilities in India, with many areas facing a shortage of services. The number of cancer care facilities is higher in urban areas, especially in major metropolitan cities, whereas rural and remote areas have a limited number of cancer care facilities. This unequal distribution of cancer care facilities can be attributed to a range of factors, including inadequate infrastructure and resources, lack of awareness and education among the population, and insufficient funding and support from the government. In addition, the high cost of cancer treatment and lack of access to affordable healthcare services further exacerbate the problem of unequal distribution of cancer care facilities, particularly for people from economically disadvantaged backgrounds.

The existing evidence suggests that nearly 60% of specialist facilities are located in the southern and western regions of India.²⁹ However, over 50% of the population resides in the eastern and central regions, creating a distortion in service provision. For example, at least half of cancer patients will require radiotherapy at some point. However, data given by the Atomic Energy Regulation Board reveal that 26% of the population residing in India’s eastern area has immediate access to only 11% of radiotherapy facilities [Figures 5 and 6].

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Figure 5:

Population & cancer mortality against the corresponding proportion of cancer care facilities in India. Source: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70115-9/abstract?version%253DprinterFriendly=

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Figure 6:

State-wise distribution of cancer care centres in India. Source: National Cancer Grid, https://www.ncgindia.org/hospitals-and-institutions/members

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Lack of treatment facilities: Radiotherapy is an essential component in the management of breast cancer patients and is used in conjunction with chemotherapy or surgery for both curative and palliative purposes. Modern-day cancer care increasingly requires a joint multimodality approach.³ It is estimated that approximately 50% of all cancer patients are cured by surgery, 40% by radiotherapy alone (or combined with other surgery/chemotherapy), and 10% by chemotherapy alone (or combined with other surgery/chemotherapy).³ The treatment of breast cancer requires a multimodal approach using all three modalities.

Present radiotherapy infrastructure in India: The radiotherapy centers in India have either teletherapy facilities alone or both teletherapy and brachytherapy facilities [Table 1]. The Directory of Radiotherapy Centers (DIRAC) 2012 from the IAEA has classified India alongside the poorest Sub-Saharan African countries, which have fewer than one radiotherapy machine per million people⁷³ [Figure 7]. Globally, India has the largest number of people living below the World Bank’s poverty line of US$ 1.25 per day.⁶⁴ Currently, there are a total of 954 RT machines (736 linear accelerators, 174 telecobalt units, 33 Tomotherapy units, and 11 Cyberknife units) [personal communication from Atomic Energy Regulatory Board (AERB)].

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Figure 7:

Availability of radiotherapy equipment across different countries. Source: “World population”, worldpopulationreview.com “Directory of radiotherapy centres”, Dirac.iaea.org. RT: Radiotherapy

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Per capita radiotherapy statistics in India: In most high-income countries, there is at least one radiotherapy unit available for every 250,000 people,⁵ which translates to an average of four radiotherapy machines per million population. Applying this factor to India indicates a total requirement of 5000 radiation therapy units in India now [Table 2]. Based on the current number of installed units in India, this reflects a shortfall of over >4500 machines. According to the WHO, there should be one teletherapy unit for every million people. There would still be a major shortage of teletherapy units in the country [Table 2]. While the number of teletherapy units has increased since this data was published; however, this is still lower than the optimal number.

Demand side challenges: To understand demand-side challenges or barriers, it is essential to understand them at individual and community levels. Most of the barriers have overlapping levels as these levels have their parts to play while attributing demand-side challenges [Figure 8].⁷⁴

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Figure 8:

Demand side barriers in cancer treatment. Source: https://www.sciencedirect.com/science/article/abs/pii/S1877782113001641

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At individual level: Although tobacco use, lifestyle choices, and alcohol consumption have been proven to be causes of cancer, impediments related to treatment delays also significantly add to the cancer mortalities burden.⁷⁵ A systematic review identifying various delay stages in cancer diagnosis confirmed that there are identifiable stages between recognizing a symptom, first presenting to a health care professional, subsequent diagnosis, and initiation of treatment.⁷⁵ The various reasons for the delay in treatment-seeking behavior at the individual level were:

Lack of awareness and perceived seriousness of signs and symptoms: For early diagnosis and the prompt initiation of therapy, it is crucial to recognize cancer signs and symptoms as soon as possible. A study conducted in Odisha found that most patients had never heard of cancer, and less than one-sixth were aware of carcinogenic factors.⁷⁴ Low levels of knowledge, educational status, and perception of the illness severity are the leading causes of delay in getting cancer treatment.^76,77

Given the lack of awareness and the fact that many cancer symptoms resemble those of other more prevalent benign conditions, it might be difficult for the patients to connect their symptoms to cancer.⁷⁸ One can argue that these factors could contribute to delayed consultation and prolonged watchful waiting⁷⁴ [Figure 9].

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Figure 9:

Awareness among the cancer patients in India. Source: Call for Action: Making quality cancer care more accessible and affordable in India, October 2022 - EY analysis report

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Financial constraints: Lower financial capabilities often lead individuals to adopt a more fatalistic and pessimistic when seeking healthcare.⁷⁹ Patients with low socioeconomic status (SES) tend to be diagnosed with more advanced cancers, receive less aggressive treatment, and face a higher risk of dying in the 5 years of diagnosis.^80,81 A study from India reported financial constraints as the major barrier to seeking treatment.⁷⁴ The analysis of the World Health Survey showed that low-household SES was significantly associated with cervical and breast screening rates in low-income countries.⁸⁰

At the Individual and Community level

Psychological stress and social inhibition

Negative attitudes, stereotypes, and discrimination toward cancer patients are common in many societies.^82,83 Studies have found that cancer patients often experience social inhibition when speaking with community members about their symptoms.^73,74 Cancer-related stigma is not only associated with delayed treatment-seeking behavior but also with poor self-esteem, stress, anxiety, depression, and social isolation in different patient groups^84,85 [Figure 10].⁸⁶

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Figure 10:

A conceptual framework of cancer stigma. Source: https://www.sciencedirect.com/science/article/pii/S2347562521001827

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A meta-synthesis exploring barriers to health-seeking behavior among Malaysian breast cancer patients indicated that stress and a sense of denial were two prominent psychological factors linked to delays in seeking treatment.⁸⁷ This suggests that various social and psychological reasons hinder immediate treatment consultation or access to advanced care and surgery.

Belief in alternative therapy: According to estimates, cancer patients spend an average of an additional 139 days consulting various healthcare systems, including traditional healers and alternative medicine practices such as Ayurveda and homeopathy.⁷⁴ A cross-sectional study in Bangladesh demonstrated that the likelihood of alternative medicine delaying treatment-seeking behavior was four times higher among Bangladeshi Breast Cancer Patients.⁸⁸ In India, an exploratory study revealed that nearly half of the cancer patients reported being treated with complementary and alternative medicine (CAM).⁸⁹ Thus, belief in alternative therapies whether due to influenced or due to financial constraints has led to delays in availing conventional cancer treatment⁹⁰ [Figure 11].⁷⁴

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Figure 11:

Qualitative qualifiers affecting the treatment-seeking pathways. Source: https://www.sciencedirect.com/science/article/abs/pii/S1877782113001641

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At the individual and health system level

Human resource barriers to access to breast cancer care

While human resources are essential for providing cancer care in India, several challenges impede their effectiveness, as outlined in Figure 12.

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Figure 12:

Human resources-related barriers to access to breast cancer care.

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Shortage of skilled personnel: There is a shortage of healthcare professionals involved in oncology care at all levels of care, which limits the capacity to provide timely and comprehensive cancer care, particularly in rural and underserved areas. India exhibits a shortage of oncologists, with 2000 oncologists for 10 million patients, which is further skewed toward urban areas.^16,29,93 Additionally, there is a notable north-south divide in availability, with about 60% of specialist facilities and the workforce located in southern and western India. Figure 13 depicts the shortage in demand and supply of treatment providers for cancer care.⁹³

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Figure 13:

Difference in demand and supply of human resources.

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Furthermore, it has been noted that 27% of CHCs and 13% of district hospitals had not implemented the national program for control of non-communicable diseases in 2017- 2018 due to a lack of workforce or equipment necessary for diagnosing cancers. This is in line with the general perception of primary care physicians on the limited utility of referrals to secondary-level health centers due to a shortage of specialists and equipment for confirmatory diagnosis and staging.

Shortage of female staff: The scarcity of female doctors, particularly in the context of breast cancer care, presents additional challenges to healthcare delivery in India. Several studies have reported the unavailability of female staff acts as a barrier to accessing breast cancer-related care due to cultural, religious, and social values.^94,95 The lack of female healthcare providers has been found to create barriers to open communication, leading to delays in seeking care, reluctance to undergo screenings, and decreased adherence to treatment recommendations.

High workload and burnout: The burden of cancer care in India is notably high, with each oncologist facing a staggering workload of 315 cases per practitioner, significantly surpassing the workload per oncologist in countries like China and the United States [Figure 14].⁹⁶ This overwhelming demand for medical and surgical oncologists exceeds the current availability by 2.6 and 1.4 times, respectively.⁹³ Consequently, skilled professionals experience immense pressure, impacting the quality of care, timely diagnosis, and patient attrition rates.

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Figure 14:

Comparison of incidence per clinical oncologist (radiation + medical). Source: https://ascopubs.org/doi/full/10.1200/JGO.17.00188

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Research has elucidated various factors contributing to this strain on the healthcare system. For instance, studies have revealed that auxiliary nurse midwives (ANMs) in India, who play crucial roles in primary healthcare delivery, are often burdened with multiple responsibilities under national healthcare programs during scheduled work hours.⁹⁷ This situation results in the neglect of cancer care services, as resources are diverted to address other pressing healthcare needs.

Furthermore, investigations into specialized cadres of medical oncologists from LMICs, including India, have underscored the alarming volume of work undertaken by these professionals.⁹⁸ The median number of annual consultations per medical oncologist in India stands at 475, significantly higher than the corresponding figure in other LMICs, which is around 350. Such high caseloads inevitably lead to burnout among healthcare staff, impacting their well-being and further straining the healthcare system’s capacity to deliver quality cancer care.

Lack of adequate training in the workforce: Since breast cancer screening tests are dependent on observation, they have a high reliance on the skill set of the healthcare provider. Therefore, it is crucial to invest in the training of healthcare professionals to ensure effective screening. Of the current workforce deployed at HWCs nationwide, 26% still require training to perform screening tests. Among the ASHA workers, who form the backbone of the public health program in India, at least 23% need training for screening NCD patients, including those with malignancies. Additionally, nearly 16% of the 2,761 medical officers stationed in these facilities require training on the screening program and techniques [Figure 15].⁹⁹

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Figure 15:

Percentage of trained health and wellness centre staff for prevention, screening, and management of NCDs, including cancer. Source: https://europepmc.org/article/nbk/nbk525285. NCDs: Non-communicable diseases, MPW-W: Multipurpose worker-women, MPW-M: Multipurpose worker-Men, ASHA: Accredited social health activist.

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Gaps in training and continuing medical education: The failure of healthcare providers to recognize the signs and symptoms of breast cancer and to consider it as a potential diagnosis has emerged as a significant barrier to the timely detection and treatment of this disease. Studies investigating the knowledge, attitudes, and practices of healthcare providers across various cities have revealed low levels of awareness regarding breast cancer screening, available methods, and the practice of self-breast examination. For instance, research conducted in northern India uncovered a lack of awareness among 49% of healthcare workers regarding the risk factors and early detection methods associated with breast cancer.¹⁰⁰ These findings underscore the critical need for capacity-building initiatives and ongoing medical education to bridge these knowledge gaps.

Furthermore, studies have highlighted deficiencies in capacity-building efforts, with one-fourth of the staff at Ayushman Arogya Mandirs, healthcare facilities providing primary care services, lacking formal training. An Indian study reported the median time to diagnosis from the first contact with a provider as 30 [IQR 10-60] days, majorly due to a lack of awareness in identifying the cancer symptoms both among patients and primary care providers.¹⁰¹ Thus, these gaps in training and education contribute to delays in the diagnosis of breast cancer, hindering efforts to identify and treat the disease at an early stage when outcomes are typically more favorable.

Poor doctor-patient communication: Effective communication between physicians and patients is crucial, as it has been consistently linked to positive health outcomes, including increased patient satisfaction, compliance with treatment plans, and overall improvement in health status. However, studies have revealed that patient-doctor communication in South Asia is often perceived as dissatisfying by patients, primarily due to a predominant pattern of one-way communication by healthcare providers.^94,95 The literature highlights that this deficiency in communication has significant implications for the accuracy and timeliness of diagnosis and treatment of breast cancer, highlighting the role of health system factors in shaping patient experiences and outcomes. While some studies have noted instances of comforting behavior exhibited by doctors, concerns have been raised regarding the attitude of paramedical staff and hospital administration.¹⁰² Negative interactions with these healthcare professionals further exacerbate patients’ dissatisfaction and impede their ability to navigate the complexities of breast cancer diagnosis and treatment.

Training of manpower remains an Achilles’ heel in our ever-expanding cancer service strategy. More centers should be encouraged to establish in-house training for radiation oncologists, medical physicists, and radiotherapy technicians.

The current training in Radiation Oncology is short and quite generalized. Promoting site specialization in breast cancer oncology is essential for improving quality. Site-specific (e.g., breast cancer) Certificate courses or fellowships in high-throughput regional cancer centers must be encouraged and officially recognized. Additionally, international exposure should also be encouraged to understand the safeguards inherent to starting clinical practices. Hypofractionation and use of regional nodal irradiation remain topical issues, and mandatory seminars and certification should be encouraged to allow the same implementation.

Centers should be incentivized to start medical physics training and internship programs. Clinical site specialization of medical physicists during internship could be offered given the complex treatment processes. Radiotherapy quality assurance, junction dosimetry, as low as reasonably achievable (ALARA) principles, and its implementation in breast radiotherapy must be encouraged so that cardiac, lung, and brachial plexus doses do not compromise patient safety during breast radiotherapy.

Radiotherapy technicians must be well versed in the implementation of all treatment types and image guidance processes and also flag to clinicians any on-treatment adverse events. This, therefore, means that they are practically well-trained to ascertain when toxicities are more than envisaged. A career pathway for bright radiographers to be upgraded to dosimetrists after bridging courses are established could help address both skill upliftment issues and fulfill the need for more radiotherapy planning stuff by all departments.

Communication skills training is important across staff categories, and regular programs should organize regular programs to ensure that the benefits, risks, and both short- and long-term adverse events are communicated appropriately and in detail to patients.

Other barriers

Inadequate population coverage under cancer prevention and screening programs: There is a lack of cancer prevention and screening programs in India, which can lead to delayed diagnosis and treatment. This can result in poorer outcomes for cancer patients. The national cancer screening program in India has been in operation since November 2016. However, population coverage for cancer screening has been extremely low. Since 2018, when cancer screening was included in the National Health Mission’s larger NCD screening program, India has made some progress. To date, 1.1% of the population has undergone cervical cancer screening, and less than 1% have received breast or oral cancer screening. Due to easy access to screening facilities, opportunistic screenings in private hospitals, and increased public awareness, screening coverage in urban regions is marginally better than that in rural ones. However, coverage for oral cancer screening among men in both urban and rural areas is low [Figure 16].

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Figure 16:

Screening coverage in India by percentage of population.

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Due to inadequate screening systems and low awareness, late-stage disease identification exacerbates the problem of a high disease burden. Only 29% of breast cancers are detected at stages 1 and 2, respectively, India has a poor detection rate across major cancer sites, which is much lower than that in China, the UK, and the US [Figure 17]. This low rate of early diagnosis contributes to India’s high mortality rate for malignancies, especially when compared to industrialized nations like the US and the UK, where early detection has been crucial in reducing mortality.

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Figure 17:

Percentage of cases diagnosed at various stages of breast cancer.

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High cost of cancer treatment: The high and increasing cost of healthcare presents a major public health challenges in India. The amount of impoverishment and debt caused by high out-of-pocket expenses (OOPE) is growing as households continue to be the main source of funding for healthcare. Significantly, the OOPE for people with cancer is 2.5 times higher than for those with other disorders. The cost of cancer treatment can drive individuals and families into severe misery and even insolvency. Even Although the cost of treating cancer patients in hospitals is the highest among all NCDs, ineffective health financing systems and a heavy reliance on out-of-pocket medical expenses force many cancer patients to resort to desperate measures to afford their treatment.¹⁰³

One of the studies assessing the financial toxicity associated with cancer treatment reported that the prevalence of catastrophic health expenditure due to outpatient treatment was 80.4%, while the prevalence due to cancer-related hospitalization was 29.8%. The overall prevalence of impoverishment was 67% as a result of outpatient cancer treatment and 17.2% due to hospitalization [Figure 18].¹⁰⁴

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Figure 18:

Financial toxicity due to cancer treatment in India. Source: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1065737/full, CHE: Catastrophic health expenditure.

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Inadequate health insurance coverage: Inadequate health insurance coverage can limit their ability to access cancer care services [Figure 19].¹⁰⁴

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Figure 19:

Coverage of health insurance in India. Source: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1065737/full, NGO: Non governmental organization.

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Overall, these barriers to cancer care in India highlight the need for improved infrastructure, increased availability of healthcare professionals and cancer drugs, and expanded access to health insurance and cancer prevention and screening programs.

To implement the NPCDCS program under the auspices of universal primary health coverage, the government has included and prioritized screening for the three cancers as part of the program and is working to meet the goal of opening 1,50,000 health and wellness centers (HWCs) throughout India by December 2022. However, several challenges exist that are impacting the screening program from achieving its desired objectives [Table 3].

Recommendations to close the human resource gaps for cancer care

Closing the human resource gaps for cancer care requires a comprehensive and multi-dimensional approach that addresses workforce shortages, enhances training and education, and fosters professional development. We propose the following recommendations [Figure 20] to strengthen the health system building block of human resources to ensure access to quality cancer care:

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Figure 20:

Recommendations to close the human resource gaps for cancer care.

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Expansion of training programs in key areas of breast cancer care: The chronic shortage of staff for the provision of oncology care demands investment in expanding the capacity of medical schools, nursing programs, and allied health training institutions to produce more healthcare professionals specialized in key areas of cancer care, such as medical oncology, surgical oncology, radiation oncology, oncology nursing, palliative care, and supportive care.^93,105 This could involve increasing the number of training slots, establishing new training programs, or offering scholarships and incentives to attract students to oncology-related fields. Furthermore, such programs should focus on both clinical and non-clinical aspects of cancer care, including communication skills, patient-centered care, and interdisciplinary collaboration.

Capacity-building initiatives and continuing medical education: Structured capacity-building sessions based on comprehensive programs that cover various aspects of cancer care, including prevention, screening, diagnosis, treatment, and palliative care, should be organized for existing healthcare professionals to enhance their skills and knowledge in cancer care.¹⁰⁶

Healthcare professionals should be provided with a variety of continuing education opportunities, including workshops, seminars, conferences, webinars, and online courses that focus on emerging trends, best practices, and evidence-based guidelines in cancer care. These activities should be accredited and provide healthcare professionals with continuing medical education (CME) credits.

Efficiency and resource optimization through defined workflows: Interdisciplinary teamwork plays a pivotal role in improving patient outcomes and ensuring holistic care for individuals affected by cancer. By fostering collaboration among healthcare professionals from diverse disciplines, including oncologists, surgeons, nurses, social workers, psychologists, rehabilitation specialists, and community health workers, healthcare systems can effectively address the complex needs of cancer patients across the continuum of care.^106,107 One key aspect of fostering interdisciplinary teamwork is the development of clear guidelines and algorithms for service delivery, particularly in the context of breast cancer care.

Task shifting and task sharing: India’s structured workforce of primary care professionals and community health workers presents a valuable resource for expanding access to cancer care, particularly in resource-constrained settings. By leveraging the skills and capabilities of non-physician healthcare providers, such as nurse practitioners, physician assistants, community health workers, and peer educators, tasks and responsibilities can be delegated effectively under appropriate supervision and training. Task-shifting and task-sharing strategies can optimize healthcare delivery efficiency and improve access to cancer care services, especially in communities where access to specialized healthcare facilities is limited.

Drawing inspiration from successful models implemented in other countries, such as Peru, we can explore innovative approaches to community-based cancer care. For instance, Peru developed a model that trained community health promoters for outreach, professional midwives for clinical breast examinations, doctors for fine- needle aspiration biopsy sampling with ultrasound for triage, and patient navigators to ensure treatment adherence.¹⁰⁸ This holistic approach effectively addressed accessibility barriers and improved outcomes for the population.

Moreover, evidence from a 20-year prospective cluster-randomized trial conducted in Mumbai underscores the potential impact of task-shifting in cancer care. Primary health workers, with a minimum educational qualifications of matriculation, were trained to perform clinical breast examinations every 2 years. This intervention resulted in a reduction in the staging of breast cancer at diagnosis and a significant decrease in mortality among women aged 50 years and older.¹⁰⁹ This demonstrates the feasibility and effectiveness of training non-specialized healthcare workers to conduct essential cancer screening activities within a relatively short training period.

Empowerment of health providers through standard treatment protocols: Standard treatment protocols empower healthcare providers in decision-making while providing care to patients with breast cancer. Studies highlight that healthcare providers perceive the lack of standard treatment protocols as a hurdle in the provision of care for breast cancer in the communities. Therefore, it is essential to ensure access to defined protocols and necessary training covering all aspects of care, including screening, diagnosis, staging, treatment modalities (such as surgery, chemotherapy, radiation therapy, and targeted therapy), follow-up care, and supportive care interventions.

Furthermore, standard treatment protocols should be regularly reviewed and updated based on emerging evidence and advancements in breast cancer research and treatment. Healthcare providers should be involved in the review process to provide feedback and insights from their clinical experiences, ensuring that the protocols remain relevant and effective in addressing evolving challenges in breast cancer care.

Leveraging plurality in care pathways: Studies have shown that a significant proportion of patients with breast cancer utilize traditional, complementary, and alternative medicine (TCAM) systems.^109,110 Therefore, the TCAM providers should be linked to the formal healthcare system to ensure standard, timely care to the patients. Adequate training should be ensured for the TCAM providers to ensure they have a comprehensive understanding of breast cancer, including its diagnosis, treatment modalities, and potential interactions with TCAM therapies. This training should emphasize evidence-based practices and promote safe and effective integration of TCAM with conventional cancer care. Additionally, structured pathways for integrative care that outline clear guidelines and protocols for collaboration between TCAM providers and formal healthcare professionals should be developed.

Use of technology: Leveraging telemedicine and teleconsultation platforms in cancer care can revolutionize access to specialized services, especially in remote and underserved areas of India. By connecting cancer patients with oncology specialists regardless of geographical location, these platforms address the shortage of oncologists and improve access to timely and quality care.^111,112

In addition, the emergence of artificial intelligence (AI)-based technologies for breast cancer screening offers a promising solution to the challenges of early detection, particularly in regions with limited access to specialists and cultural barriers. Technologies such as iBreastExam, Mammoassist, Niramai, and Mammoalert use AI algorithms to detect abnormalities indicative of breast cancer.¹¹² Studies have shown that untrained healthcare workers can effectively use these AI-based devices with minimal training, achieving greater sensitivity than traditional clinical breast exam methods.

Incentivization for workforce retention: Policies and incentives should be implemented to attract and retain healthcare professionals in cancer care, including career advancement opportunities, workload management strategies, financial incentives, recognition, and support for work-life balance.

Promote research and innovation: It is essential to encourage research and innovation in cancer care workforce development, including studies on workforce needs, best practices in training and education, and novel models of care delivery. These studies can help inform workforce planning and resource allocation strategies to ensure that the healthcare system is equipped to meet the growing demands for cancer care services. Research efforts should focus on evaluating the effectiveness of existing training and education programs for healthcare professionals involved in cancer care. Studies should assess the impact of different training modalities, curriculum content, and teaching methods on knowledge acquisition, skill development, and clinical practice outcomes. By implementing these recommendations, healthcare systems can address human resource gaps in cancer care, strengthen the capacity of the workforce, and improve the quality and accessibility of cancer care services for individuals affected by cancer.

Recommendations for addressing the demand side barriers

The recommendations are classified as immediate-term, medium-term, and long-term to address this gap.

Radiodiagnostics

The identified gaps and recommendations to address the gaps in the field of radiodiagnostics are listed in Table 4.

Pathology

Pathology is a critical specialty involved in the diagnosis of breast cancer. The management of breast cancer is dependent on the identification of subtypes of breast cancer. To address the gaps identified, the following recommendations are suggested.

Careful specimen transport: The specimen should ideally be sent immediately after removal to the histopathology laboratory. In instances where delayed transport is expected, the specimen should be sliced to ensure proper formalin penetration during transport, and this is especially crucial for a mastectomy specimen. Drawing inspiration from the UKNHS, a specimen transport van that carries the specimen in refrigerated boxes should be available at centers that plan to send the specimen out. Additionally, a network of specimen transport systems and sample tracking across the country should be set up at least at far-off places. Make surgeons more aware of the harmful effects of delayed fixation. Training should focus on making controlled single or cruciate incisions into the lesion, preserving the integrity of key margins while allowing for immediate penetration of fixatives.

Audit of biomarkers across each cancer center: European countries have established a system for auditing reported biomarkers in every hospital. This system ensures that any deviations are identified and investigated through root-cause analysis to address issues impacting test results.

Certification for quality pathology services and compulsory participation in an EQAS program: In spite of free NCGEQAS services, most government institutes do not participate to avoid the spotlight. Compulsory EQAS should be complemented with a cancer center’s along with good pathology practice certification.

• Availability of FDA approved antibodies through a common portal like GEM after cost negotiation.

• Replacing FISH with D-DISH or validated chromogenic hybridization assays

In most developed nations, a HER2 score of 2+ is reflex tested with FISH. While a molecular laboratory may not be available at most centers, the D-DISH chromogenic in situ hybridization can be performed on the automated Ventana platform, though it requires some training. We have recently published data demonstrating high concordance between D-DISH and FISH. Separate funding will be necessary to support such initiatives.

• Zonal oncopathology laboratory empowerment with molecular sequencers and know-how to generate patient population-specific panels.

• Development of gene-based predictive test akin to OncotypeDx in Indian population.

Surgery

To address critical gaps and deficiencies in human resources for breast cancer treatment in India, it’s essential to implement targeted strategies across different timeframes. Here are recommendations classified based on their implementation timeframe.

2. Medium-term (3-5 years)

(i) Specialized fellowships: Expand fellowship programs in breast oncology, surgical oncology, medical oncology, radiation oncology, and breast imaging to train a cadre of specialized healthcare professionals dedicated to breast cancer care.

(ii) Interdisciplinary training: Develop interdisciplinary training programs and tumor boards involving oncologists, surgeons, radiologists, pathologists, nurses, and psychologists to foster collaboration and improve care coordination for breast cancer patients.

(iii) Workforce redistribution: Implement policies to incentivize healthcare professionals to work in underserved areas by offering financial incentives, career development opportunities, and infrastructure support.

3. Long-term (>5 years)

(i) Academic Partnerships: Foster collaborations between medical institutions, academic universities, and research centers to establish comprehensive breast cancer training and research programs, including postgraduate courses and research fellowships.

(ii) Subspecialty certification: Work towards establishing subspecialty certification in breast oncology for healthcare professionals to recognize expertise and promote standardized care delivery in breast cancer treatment.

(iii) Continuing education: Develop continuous professional development programs, online courses, and tele-education platforms to facilitate ongoing learning and skill enhancement for healthcare professionals engaged in breast cancer care.

(iv) Health workforce planning: Conduct workforce needs assessments and long-term planning to anticipate future demand for breast cancer care services and ensure adequate human resources capacity to meet growing needs.

Collaboration among government agencies, professional associations, academic institutions, and healthcare providers is essential for the successful implementation of these programs.

Key issues/gaps in the human resource component

(i) Immediate: There is an urgent need to ensure an appropriate understanding of hypofractionated radiotherapy practices that are emerging in breast cancer. Clinicians and Medical Physicists must attend breast cancer site-specific workshops to understand the nuances of breast radiotherapy planning. National and International bodies should be approached immediately to ensure multiple courses on breast radiotherapy planning are available through various regional centers across the country.

It is imperative that, alongside the enhancement of infrastructure for radiotherapy across India, the shortage of skilled manpower in radiotherapy practices is addressed. Nodal centers must be encouraged to start training programs on Medical Physics and Radiotherapy technician courses.

A nationwide consortium is essential to ensure that patient-specific quality assurance practices are maintained across all treating centers. A national breast cancer radiotherapy treatment protocol is essential. This should encompass all aspects of breast radiotherapy treatment, be practical, and should address all issues needed for treatment in cobalt and linear accelerator-based centers. This protocol can be implemented in a phased manner, starting with regional centers agreeing on the processes, followed by smaller centers across the country.

Government and non-government institutions must be encouraged to allow external peer review of breast radiotherapy services and protocols.

Additionally, it must be essential for all clinical staff to attend communication skills programs across the country. This could include mandatory attendance of workshops and certification courses. The government must ensure repeated revision courses with a gap of 3-5 years to allow continued education.

Radiotherapy technicians must undergo image guidance training and should be certified for the same. Programs must be available nationally to do so.

Under-utilization of palliative breast radiotherapy for regional symptom control and improving patient quality of life remains a matter of concern. Various reasons, including referral bias and lack of coherent multidisciplinary team working, could be contributory factors. Enhancing knowledge and breast cancer, multidisciplinary team working is an area of need, and national policies to enroll multidisciplinary team (MDT) across the country and provide guidance for successful protocol-driven teamwork should be encouraged.

(ii) Medium-term: The Government of India plans to open one medical college in each district across the country. Radiotherapy departments must be made essential, at least within two adjacent districts, within the next five years.

New centers for training Medical Physicists and Radiotherapy technicians should be commissioned across the country.

A bridging course should be allowed to train radiotherapy technicians to allow them to plan radiotherapy treatments under supervision (dosimetrists). This will allow the technicians to have a career pathway and also help institutions safely address radiotherapy planning bottlenecks. The government should work with nodal bodies such as the Atomic Energy Regulatory Board to establish such courses.

Radiotherapy-specific nurses must be trained across the country to allow appropriate management of any and all adverse events and provide patients with information and support during therapy. ASHA workers should also be trained to counsel patients on their breast radiotherapy treatment and highlight any unaddressed adverse events.

(iii) Long term: Each center must have site-specific (breast cancer) radiation oncologists and radiotherapy planners.

Nodal centers should be identified, and leaders in the field must be encouraged to draw a breast cancer radiotherapy-specific audit and research plan.

(iv) Key issues/gaps in the current infrastructure, facilities, technologies, policies, programs, etc.: More centers that allow patients to get radiotherapy treatment near their homes must be encouraged. Such centers must have essential quality assurance systems, SOPs, and audit processes in place.

All centers treating breast cancer must be encouraged to provide cardiac-sparing radiotherapy strategies, at least using multi-leaf collimators. Given the strong relationship between heart dose and cardiac morbidity and mortality, it is important that hardware (multi-leaf collimators, gating cameras) and compatible software are available in all centers.

All centers, including smaller centers, should be included within a national program to establish clinical protocol-based treatment processes in breast radiotherapy. This would include internal audit processes.

All centers should participate in an external peer review process.

A national audit process must be in place that will allow analysis, collation, and publication of treatment-related near misses and accidents.

The audit process above should also ensure that site-specific outcomes of breast cancer radiotherapy planning are in place.

Equitable distribution of cancer care services

Inequitable distribution of cancer care services has been identified as one of the major barriers to providing comprehensive breast cancer care in the country. Focusing on underserved areas in the development of cancer care infrastructure can help overcome this barrier.

Manpower training

There is a significant shortage of human resources especially medical oncologists and medical physicists. With the development of infrastructure, trained manpower will be required for treating cancer patients. Many medical colleges associated with tertiary care centers currently lack these departments. Policymakers may consider establishing these departments in top medical colleges where adequate training can be provided in the future to overcome this barrier.

Expansion of infrastructure

In diagnostics, there is a critical need for digital mammography machines and radiotherapy services to treat patients with breast cancer in India.

Improved access to systemic treatment drugs

The cost of breast cancer treatment is increasing as newer and more effective drugs are incorporated into treatment. We have classified the drugs as essential and optimal [Table 5]. Access to essential drugs should be improved to increase the proportion of patients who can receive such treatment.

Access to genetic counseling and testing

Approximately 18% of women with breast cancer have a genetic mutation. Despite a significant decrease in the cost of testing, access to genetic testing remains limited for many patients. The inclusion of genetic counselor teleconsultation and genetic testing in PM-JAY may improve access for a significant number of beneficiaries.

Screening program for breast cancer

The incidence of breast cancer in urban India is steadily increasing. We need a two-pronged approach. A screening program with clinical breast examination and an augmentation of diagnostic mammography infrastructure may be cost-effective for the Indian scenario.

Awareness programs

A significant proportion of patients present with advanced breast cancer. Programs using mass media channels have the potential to increase public awareness of breast cancer.

Industry-academia partnership for research and development

Most innovation in breast cancer treatment originates from the West, resulting in the ever-increasing cost of newer cancer drugs. Industry-academia partnerships and funding for research and development are needed to bring innovation from the countryside and keep the cost of cancer care under control.

Early introduction of breast cancer in curriculum of medical education:

Every physician in the country should be familiar with common cancer presentations and diagnostic workups. There is a significant delay between the presentation of a patient and the appropriate referral to an oncology center. This can be reduced by including breast cancer early in medical education.

Training programs

Establish short-term educational programs and workshops for healthcare professionals, including oncologists, surgeons, radiologists, pathologists, nurses, and allied health professionals, to improve their knowledge and skills in breast cancer diagnosis, treatment, and survivorship care.

Interdisciplinary training

Develop interdisciplinary training programs and tumor boards involving oncologists, surgeons, radiologists, pathologists, nurses, and psychologists to foster collaboration and improve care coordination for breast cancer patients.

Patient advocacy

There is a significant unmet need for breast cancer patient advocates in India who can play a critical role in bridging the gap between policy makers and patients. NGOs and community stakeholders need to form such disease- specific patient advocacy groups.

Awareness campaigns

In addition to policy makers, NGOs and community stakeholders need to be involved in awareness campaigns. Key community stakeholders can be selected as ambassadors for such campaigns.

Philanthropic donations for access to treatment and research

Most research funding in India comes from government agencies. However, NGOs can play a critical role in channeling philanthropic donations to improve access to treatment and promote indigenous research.

Patient support groups

Patient support groups can help patients navigate their treatment and survivorship issues, and NGOs can help bring together patients and survivors from multiple oncology centers to address their needs..