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Rewriting Cancer Care In India

BIZ Cancer Centre Care For you Cover Story December 2018 Diagnostic Health and Wellness Onco Corner Patient Care Pharma Supportive Care

Rewriting Cancer Care In India

HCG - TRIESTA SCIENCES

Dr B S Ajaikumar, through the hub-and-spoke model of HCG Oncology, is bringing leading technology in cancer therapy to the country and making it both accessible and affordable to the masses

The year was 1975. India’s most talented and brilliant youth were fast flocking to become part of the huge Indian diaspora spread over West Asia, Europe and of course, the United States of America. At the peak decades of the brain drain, as human capital flight was often unpretentiously referred to, the much-coveted Green Card (the nickname for the Lawful Permanent Resident Card) from the US was the holy grail for young medicos from India. In his home in Bengaluru, a young man who had just graduated in medicine from the St John’s Medical College was also keen to make his way to the land of opportunity and better higher education.

Decades later, the young doctor has transformed into an oncologist of repute, who is rewriting the way cancer care is approached in India. The CEO and Chairman of HealthCare Global Enterprises (HCG) is revolutionising the entire healthcare sector in the country, particularly in making cancer care accessible and affordable. Though Dr B S Ajaikumar wanted to be a cardiologist, he changed his mind during his rotation days at the University of Virginia, where he saw cancer patients in pain and despair because in those days, cancer was considered a death sentence. “Even in an advanced country like the US, cancer patients were kept aside,” he says. “They were often shouting in pain, with very low doses of pain medication being given to them. I was told there was no treatment available for them.” Dr Ajaikumar wanted to shake up the system, usher in change, and bring respite to the suffering masses. After completing his residency training in oncology from the University of Virginia Hospital in Charlottesville, he did his fellowship in radiation and medical oncology at the MD Anderson Cancer Centre, often referred to as the ‘Mecca of Cancer’. “When I did my fellowship at MD Anderson, I saw a lot of patients coming there from across the US, from around the world, in fact, as a last hope,” he said. “Cancer was a challenge. Unlike other diseases, cancer is something that is created within your own body when abnormal cells are born. How they are born, how to treat them… understanding this was intriguing.”

The HCG Office, Bangalore
The HCG Office, Bangalore

Dr Ajaikumar Is Looking To Implement A Paradigm Shift In Cancer Care, Fromtraditional Practices Based On Evidencebased Medicine To An Entirely New Role Model Based On Precision Medicine.

In a recent interview, Dr Ajaikumar explained what propelled him to make the switch to oncology: “I have always fought for the underdogs, and I grew up in a family where a lot of value systems were important. My father was the dean of a law school; he used to have evening discussions on the political field of India and the world. I grew up in an environment where challenges were important for me.” Another motivating factor for him was having witnessed the cancer healthcare situation in India in the mid eighties. “The situation was pretty bad,” he said. “Cobalt therapy was the norm. Canada manufactures cobalt but not a single Canadian gets cobalt therapy because it is an inferior form of treatment.

But treatment centres in India used to use it extensively. Even now, some treatment centres justify it saying we are a poor country. Cancer does not differentiate between the poor and the rich. There is only one right treatment.” The champion of the underdogs says HCG would like to help patients live longer, better lives—and to improve cancer care—one centre at a time. “At HCG, each centre is a model of excellence, a place where physicians can achieve professional fulfilment and accomplish breakthroughs in patient care,” he said.

Looking at his impressive record of setting up over 20 comprehensive cancer care centres across the country in a hub-and-spoke model, Dr Ajaikumar is clearly on the path to achieving his dreams. He is also proud to have done this on the strength of his team alone, with absolutely no government backing or grant.

Earlier this year, HCG entered into a merger deal that saw Triesta joining hands with Strand Life Sciences Pvt Ltd, a bioinformatics company, in order to create an integrated platform that would cover the entire gamut of research and analytics involved in precision medicine.

HCG was recently featured in case studies done by the Harvard in Dr Ajaikumar’s own words, is one-of-a-kind. “Having gone public, now we have nearly 26 centres across India and Africa,” he said. “So globally, we are the largest network in oncology, with over 70,000 patients annually. Using technology—virtual tumour boards, teleradiology, tele physics, PET scans in Tier 2 cities—we are taking cancer treatment to the doorstep of patients. Except for parts of Uttar Pradesh, Kashmir and maybe Bihar, patients can go to an HCG cancer centre, get their treatment, come back and sleep in their own beds. And these are high-end centres. You take Ranchi, Nashik, Vijayawada, Vizag or Shimoga—everywhere we have dedicated oncology centres. Nobody like us exists globally. This is, in a nutshell, my journey in healthcare in India.”

Dr Ajaikumar firmly believes no cancer patient should be travelling miles to receive treatment. “Even if they are diagnosed with having only six months to a year to live, what good is that time if they are away from home?” he queries. “The money goes into the travelling for treatment, and the family becomes penniless. So even though private equity firms told me that return on investment would be low, I had decided that I would do it the right way, using the hub-and-spoke model, to treat cancer the right way the first time.” His conviction has paid off. Business schools across the US and Europe are learning the HCG model of cancer treatment now.

Dr Ajaikumar is looking to implement a paradigm shift in cancer care, from traditional practices based on evidence-based medicine to an entirely new role model based on precision medicine. Genetic sequencing and predictive analysis play a major role in precision medicine. “It is the complexity of the heterogeneity of cancer that makes cancer treatment a challenge,’ he said. Even after four decades of practising as an oncologist, he said he was still learning new things about the disease with each patient that he treats.

Rewriting Cancer Care In India 1

“I HAVE ALWAYS FOUGHT FOR THE UNDERDOGS, AND I GREW UP IN A FAMILY WHERE A LOT OF VALUE SYSTEMS WERE IMPORTANT. I GREW UP IN AN ENVIRONMENT WHERE CHALLENGES WERE IMPORTANT FOR ME.”

Dr B S Ajaikumar, CEO & Chairman of HealthCare Global Enterprises (HCG)

He would like to change the entire terminology that surrounds cancer, right from metaphors that equate cancer with corruption, end of hope and death. In medical parlance, the change his team at HCG is already working towards is in the nomenclature of the disease. He explained that terms like Stage 4 and palliative care brought about a sense of hopelessness in patients, and that in this age of precise diagnosis, this need not be the case. “With the availability of highly precise diagnostics like PET scans, we can precisely say where the disease is located,” he said. “We can pinpoint that it has spread from the breast to one single bone and this is how we are going to treat it, and this will be the outcome. We do not need the ancient nomenclature anymore and we are redoing this, at least at HCG, so that it gives a better understanding to the patient and to the public.”

HCG was instrumental in introducing high-end technologies like the CyberKnife™ robotic radiosurgery system and TomoH™, a completely integrated 3D conformal IG-IMRT system to India. It brought in advanced bone marrow transplant therapies as well as molecular imaging

The passionate doctor is very optimistic on the advances in genome sequencing and molecular diagnostics being the game-changers when it comes to cancer treatment. “The initiative we have taken in molecular imaging is in developing new molecules,” he elaborated. “So there are some targeted molecules, like PSMA for prostate cancer. This means that the molecule will attach to the cancer cells only, and it will highlight where the cancer cells are. And you can also initiate a treatment—like the alpha treatment—that will only go attack those highlighted areas, called Immuno-PET, without disturbing the normal cells. So this will be another great turnaround for cancer patients.”

A vision to incorporate healthcare innovations and adopt new technologies in a manner that becomes accessible and thus, a value proposition is something that Dr Ajaikumar is adept at. HCG was instrumental in introducing high-end technologies like the CyberKnife™ robotic radiosurgery system and TomoH™, a completely integrated 3D conformal IG-IMRT system to India. It brought in advanced bone marrow transplant therapies as well as molecular imaging. Under his leadership, HCG EKO, Kolkata, became the first hospital in the country to treat cancer patients using the Accuracy Radixact® system. “Being at the forefront of the fight against cancer, HCG strives to offer precision treatment to cancer patients, reinforcing the ideology—the right way, the first time,” said Dr Ajaikumar. “The practice of adopting cutting-edge technologies like the Radixact System, along with our clinical expertise, has enabled us to move one step closer towards precise and personalised care, therefore improving the quality of life of cancer patients.” This farsighted vision is what spurred Dr Ajaikumar to acquire molecular diagnostic lab Triesta. Earlier this year, HCG entered into a merger deal that saw Triesta joining hands with Strand Life Sciences Pvt Ltd, a bioinformatics company, in order to create an integrated platform that would cover the entire gamut of research and analytics involved in precision medicine. From proprietary analytics to clinical research and genomic technologies, the platform will help build the HCG biorepository too.

“Our aspiration is to do complete human genome sequencing,” Dr Ajaikumar said in an interview last year. “There is this concept of gene editing, the CRISPR technology. We are trying to partner in this and if it successful, it will be another revolutionary change. Not only for cancer; what we learned from cancer, we can apply to other diseases like diabetes and other inherited genetic disorders. This kind of genetic editing HCG was instrumental in introducing high-end technologies like the CyberKnife™ robotic radiosurgery system and TomoH™, a completely integrated 3D conformal IG-IMRT system to India. It brought in advanced bone marrow transplant therapies as well as molecular imaging. can make a huge difference and it can actually eliminate certain diseases altogether.” He affirmed that a lot of research is still pending in this field to ensure that gene editing does not create other kinds of diseases.

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His avid interest in research and innovation has also led him to lend a helping hand to the startup industry. His daughter, Anjali Ajaikumar, who is VP-Strategy & Quality at HCG, works actively with him in engaging with the startup environment. “We’ve tied up with a Hyderabad-based group where we are trying to incubate about 15-20 healthcare startups through Lumos, an accelerator programme,” he said. “We have also invested in a few early-stage companies and are getting into certain areas like apps for home care. We also mentor startup groups. We are trying to help the startups in various ways. It could be in terms of developing a new device, maybe in genomics, or in creating a simple blood test to identify cancer or a low-cost blood test for the rural population which can give us information about cancer and diseases like diabetes.” He believes that there are brilliant young people in India who can come up with great ideas. “All they may need is support, not just mentoring but financial help too,” he said. “These ideas are very interesting for me, as an oncology centre. Also, thanks to the number of centres we have, we can also help them accelerate their programmes.” He knows there may be some failures but that is to be expected, he says. “Failures are equally good,” he says. “We should celebrate them also as we learn from them.”

In fact, Dr Ajaikumar is keen on introducing the concept of randomised trials to alternative medicine streams like homeopathy and Ayurveda. “When somebody comes and says this is good for cancer, how do you prove it, and how do you know? So we say, let us do a trial and based on the trial we can show whether this particular nutrient what you have is good,” he explained, insisting that going by anecdotal evidence will not be enough to compete with the West. “You have to do trials to see and that is what the West has done really well. Follow-up is a problem in India. We are putting together some IT systems to see that the follow-up of patients is done properly. But eventually, we want to be leaders in research.” He bemoans the lack of research in the country, likening the country to being ‘very good copycats’. “Any drug comes out of the West, we can copy in no time,” he said. “But are we original inventors? We are not. Research is not happening in India, which is very sad.” He is committed to spending more on, and enabling, research in various fields.

“As a doctorpreneur, my vision is to focus on good patient outcomes, patient safety and make treatment affordable and accessible,” he averred. And he believes in enabling other doctors to fulfil their potential by turning entrepreneurs themselves, or by giving them a hand in their entrepreneurial journey. He has partnered with Dr Kamini Rao, under the Milann brand name, to establish multiple infertility centres across India. “She is also an entrepreneur who wanted to do something similar like HCG—hub and spoke across India— and she loved our model,” said Dr Ajaikumar. “I said, why not encourage entrepreneurship. That was always a plan of my game-plan—encouraging other doctor-entrepreneurs. Becausedoctors have to become entrepreneurs. The most successful healthcare models are run by doctors.”

During his entrepreneurial journey, Dr Ajaikumar has received umpteen prestigious awards, including the E&Y Start-Up Entrepreneur of the Year Award as well as the Asian Health Care Leadership Awards. Under his leadership, cancer care in India has seen a paradigm shift, and cancer has been redefined as a chronic disease. While he is focused on making cancer care accessible and affordable to the masses, he is also putting the spotlight on outcomes. He calls this value-based medicine. He talks about the instance when Harvard Business School approached HCG to do a case study on the HCG model. He mentions the cost difference was clear: breast cancer treatment that costs $30,000 in the US was being done here for $3,000. HCG was then asked about the outcomes. “They looked at our great cancer study for the the past five years, and the outcome was 88 per cent, compared with 89 per cent in the best centres in the US,” he said. “So it is very clear statistically that we are offering the same technology, the same care and the same outcome at a clearly lower cost.”

A vision to incorporate healthcare innovations and adopt new technologies in a manner that becomes accessible and thus, a value proposition is something that Dr Ajaikumar is adept at.

Dr Ajaikumar insists on making the best, cutting-edge treatment available to as many as possible, regardless of economic status. This is because inferior treatment, which may come at a very low cost, inevitably translates to more distress and suffering, and later many more diseases for the affected person. “I make the argument that the poor man should really get the best of care as he gets only one chance to get it right,” he stated. “If the cancer comes back, he will suffer all the more, not only physically but economically also.”

He wants to work towards a system where if an institute says it provides cost-effective treatment, the effectiveness should be measured against the outcome, which should be compared to global standards.

He is also of the opinion that there should be independent statutory bodies, on the lines of the National Accreditation Board for Hospitals & Healthcare Providers (NABH) to conduct audits to ensure standards are adhered to.

The self-described social entrepreneur is also actively involved in doing his bit for society, outside of his chosen domain as well. He has founded several NGOs, which have carried out tremendous developmental work in the Gundlupet district, Karnataka, which are focused on multiple aims and objectives, right from providing financial aid for needy cancer patients, to the empowerment of 15,000 women through self-help groups, educating 550 children by providing a local school with required support over the last 20 years, and spreading awareness against social ills.

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Dr Ajaikumar insists on making the best, cutting-edge treatment available to as many as possible, regardless of economic status. This is because inferior treatment, which may come at a very low cost, inevitably translates to more distress and suffering, and later many more diseases for the affected person.

“The reason I started the women’s self-help groups is that economics is important for healthcare,” he explained. “It is important for the economically weaker section of the society to get the same treatment and the same outcome as those who are wealthy. This is obviously not happening.” HCG a pilot study with women in Mysore and Ooty and found was that most of them were struggling to pay the interest on the money they borrow at 16-17 per cent. “We wanted to do a preventive healthcare camp, screening for breast and cervix cancer but all the women had the same story of financial struggle,” he said. “And these women work so hard, nearly 18 hours a day, and all of them had poor nutrition.”

This is what prompted Dr Ajaikumar to come up with the plan of the self-help groups, which has transformed this community that includes 62 villages. “If you visit them today, you will see relatively wealthy villagers with no more bank loans,” he said, joyfully. “They are using the money they earn for education, business activities, healthcare. They come for the self-help group meetings well-dressed and nutrition level have gone up.” Dr Ajaikumar strongly feels this is the model the entire country should adopt to alleviate poverty, rather than to rely on subsidies and freebies.

This charitable work is in addition to the good work Dr Ajaikumar does through the HCG group of hospitals, which subsidises care for 20 per cent of its patients. The marathon runner and voracious reader, who believes that the common man is his mentor, clearly believes in leading by being the change he wants to see in the world.

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