Question 1

Can you give an approximate cost range for cancer treatment? Doctors are often asked this when counselling patients, even before a formal case file is created.

Dr. Mohit Agarwal · Accepted Answer

The cost is very different for every cancer and every stage of cancer. It can vary from a few thousand rupees to a million rupees. Targeted therapies and immunotherapies were very costly when they first arrived, but generic versions are now available that are much more reasonable. A drug that used to cost about $5,000 for a single dose of immunotherapy now costs about $1,000 for a single dose. Wherever possible, we also arrange assistance programmes through the indications approved by the companies that make these drugs, so the patient benefits in terms of financial viability.

Question 2

Do we have targeted therapy and immunotherapy for all forms of cancer, or only for a few?

Dr. Mohit Agarwal · Accepted Answer

Not for all. You first need to identify the target in the cell, which is where NGS and special staining come in. Not every individual harbours those targets, but many do, and for them we have specific targeted drugs. Immunotherapy is not available blanketly either, but with present indications it is available for the majority of advanced cancers: about 70% of patients with advanced cancer would be eligible for some form of immunotherapy. There are specific criteria to be met; given outside them, it would not help the patient and would only be a financial waste.

Question 3

What investigations help us identify the targets on cancer cells?

Dr. Mohit Agarwal · Accepted Answer

We need genetic analysis and staining known as immunohistochemistry. When we take a biopsy specimen from the patient, we cut it into sections, make blocks and apply stains; the staining sometimes reveals the target on the cells. We then do mutation testing to see which mutations are present in the genes, so we can identify further targets to offer. We also do PD-L1 testing, which tells us whether the patient can receive immunotherapy. The combination of these staining protocols with NGS tells us the best way forward for the patient.

Question 4

Could you elaborate more on the next generation sequencing (NGS) you mentioned?

Dr. Mohit Agarwal · Accepted Answer

We take the biopsy specimen and extract the DNA from the cancer cell, then sequence it to identify where it has gone wrong in the DNA or RNA, which tells us why this individual developed the cancer. We check for mutations that may be the probable reason the patient developed it. Research is ongoing to counteract each change found on NGS, but at present we have drugs for a few specific changes and mutations. If we find one of those, we give that specific drug and the patient benefits.

Question 5

Most African countries lack PET-CT scanners, which makes exact diagnosis difficult. And when chemotherapy is the protocol decided in the home country, patients ask how chemotherapy given in Nigeria or Ethiopia differs from chemotherapy at an advanced centre such as Fortis Shalimar Bagh. How can that gap be filled?

Dr. Mohit Agarwal · Accepted Answer

Without a PET-CT, the second-best modality is a CT scan of all the probable areas (chest, abdomen and perhaps head and neck, depending on the cancer), which will give some answers on the stage of the disease. On treatment, chemotherapy is not a simple pill like a 500 mg paracetamol that works the same for everyone. It is calculated from the patient's height, weight and profile. There are specific mixing criteria; it cannot be mixed and given like an antibiotic. In India we have dedicated mixing units where full care is taken over contamination and dosing. Drugs must also be given over the right time: if an infusion written for 30 minutes is run much faster or slower than prescribed, the side effects and the effect of the drug can change, so sticking to the exact protocol keeps side effects lower. We also run specific monitors on the patient during chemotherapy, so that if a reaction starts we stop the infusion there and then, rather than the patient developing symptoms and going to the ICU. This happens once in 500 cases, but when it does it is very detrimental. Targeted therapies and immunotherapies must be kept at specific temperatures during mixing and administration, and some drugs are photosensitive, so we cover them with specific equipment to keep them out of sunlight.

Question 6

Doctors in Africa often see patients who cannot travel to India and must be managed within local constraints. Can they share a doctor's case note with a specialist in India for guidance?

Dr. Mohit Agarwal · Accepted Answer

We have an international online query option. A nominal amount is deposited and the reports can then be sent. The fee is kept nominal so that the reports that come in can be seriously addressed, because going through all the reports and deciding on a plan takes considerable effort. Once it is paid, the reports can be sent and whatever guidance is possible from them will be provided.

Question 7

Isn't the next generation sequencing procedure going to take a long time before giving the patient medication? How many days does it take to get the precise DNA gene mutation result and start the exact medication?

Dr. Mohit Agarwal · Accepted Answer

Previously it took 30 days, and it still does in most institutes, but at Fortis we have a very advanced machine and our turnaround time is only about five to six working days. Even including a Sunday, we would have a comprehensive NGS report by about the seventh day.

Question 8

Why does a structured doctor-to-doctor collaboration between the Indian specialist and the local referring doctor matter for patients?

Dr. Mohit Agarwal · Accepted Answer

It is the need of the day, and not only because the middleman is removed. When the patient goes back, the treatment does not end; the patient keeps facing new challenges day to day. Local doctors are very competent in handling those, but sometimes they need our inputs. If we are in touch from day one, we know the patient's journey through treatment and can guide them. Collaboration from day one between the international and local treating doctors is always best for the patient and the treating doctor. If a patient is considering coming to India, we are very happy to hold an online consultation with the local doctor on the prognosis and what to tell the patient, and to remove the obstacles and apprehensions the patient faces, because travelling abroad is not easy.

Live Discussion with Dr. Mohit Agarwal