Mumbai: A quiet shift is underway in cancer care in India. Over the past six months, more patients have been prescribed immunotherapy, one of the newer advances in cancer treatment that has remained beyond the reach of many because of its prohibitive cost.The change has been driven mainly by the availability of a cheaper version of nivolumab, a key immunotherapy drug that Tata Memorial Centre (TMC) doctors say is “effective in 25 tumours and has about 100 indications”. Another factor is Indian research, including studies by TMC, suggesting that lower doses may work well in Indian patients in certain settings, potentially reducing treatment costs.Dr Imran Shaikh of Kokilaben Dhirubhai Ambani Hospital in Andheri says his prescriptions for nivolumab have risen by more than 50% in the past six months following the arrival of a cheaper biosimilar.“My patients are responding well to the drug. People who were earlier unsure whether they could afford a cycle costing over a lakh of rupees are comfortable with the new price tag of Rs 30,000,” Dr Shaikh told TOI.While it is too early to quantify the overall increase in prescriptions, the access gap has been stark. In 2022, only 2.8% of patients eligible for immunotherapy were receiving it, according to a TMC study. Dr Jyoti Bajpai, director of precision oncology at Apollo Hospitals in Navi Mumbai, who co-authored the study while at TMC, says there has been a “substantial increase” in prescriptions.Dr Kumar Prabhash, head of medical oncology at Tata Memorial Hospital in Parel, points to the gains immunotherapy has brought in some cancers, particularly melanoma, or skin cancer.“Earlier barely five out of 100 patients had long-term survival, but survival has now increased to 50% with immunotherapy,” said Dr Kumar, adding that some patients diagnosed with advanced lung cancer are now living for five years or longer.MSI-high colorectal cancer is another example of where immunotherapy can offer an alternative to conventional treatment in selected patients. “A patient of MSI-high type of colon cancer would earlier need chemotherapy, radiotherapy and surgery. But if he comes in early stages, then only immunotherapy works. The patient will have his native organ intact,” said Dr Kumar.A price cut is not enoughDespite the progress, India lags behind some countries in the availability of checkpoint inhibitors. Dr Shaikh said India offers only seven such drugs, compared with 35 in China. Apart from nivolumab, he said, the other six available in India are imported and can cost lakhs of rupees for a course of treatment.But the cost of cancer treatment could come down further following National Pharmaceutical Pricing Authority’s move, effective Nov 8, to cap trade margins on 137 anti-cancer medicines. The measure is projected to generate annual savings of Rs 2,500 crore and could offer relief across a range of treatments.But lower prices may not automatically translate into savings for patients. K M Gopakumar of Third World Network cautioned that hospitals that require patients to purchase medicines through their own pharmacies may have little incentive to stock cheaper alternatives.“Hospitals may favour more expensive original medicines because of higher margins. The cheaper versions may thus not be available to the patients as a result,” he said.Four more versions of nivolumab are expected to enter the market soon, potentially driving prices down further. “The price of the drug may drop from Rs 30,000 now to Rs 10,000, but will any place stock medicines that offer them lower margin?” he said.Dr Kumar said it remained to be seen whether the benefits of lower prices would reach patients. “We at Tata Memorial Centre make arrangements in such a way that patients have to pay the least for medicines,” he said.For Dr Bajpai, the real test is whether advances in medical and precision oncology reach patients regardless of their ability to pay. Cheaper biosimilars and evidence-based dosing strategies offer a way forward, but their promise will be realised only if lower costs translate into meaningful access to treatment.“The real success of innovation is not just how long patients live, but how many patients can access the treatment they need — without financial hardship,” said Dr Bajpai.Immunotherapy, however, is not a magic bullet. Its effectiveness varies according to the cancer type, stage and individual patient.“No medicine will work on all patients. Every medicine has indications in which it works and others in which it does not. Ditto with checkpoint inhibitors and other immunotherapy drugs,” said Dr Kumar.“Our research into short-course and low-dose approaches reflects the difficult choices patients face when cost becomes a barrier. With more affordable biosimilars, we have an opportunity to move towards evidence-based, full-dose, full-course treatment for many more eligible patients,” said Dr Bajpai.
