Access Cancer Care India: affordable, integrated multi-cancer early detection to improve equitable cancer outcomes

Of the 1.3 billion population of India more than 70% live in the rural areas. Cancer has a catastrophic impact on the rural men and women of India, the vast majority of whom are socio-economically disadvantaged with one fourth live below national poverty line. Studies have shown that among the rural population in India expenditure on cancer treatment is among the highest for any disease due to the advanced presentation. The cost for treating advanced and metastatic disease are much higher than early stage disease. Treatment is financed mostly through borrowings, sale of assets and contributions from friends and relatives. Over 60% of the households who seek care from the private sector incur catastrophic out of pocket expenditure. Fatality rates are also significantly higher for the common cancers like breast and oral cancers in rural compared to the urban populations.2 Late presentation with more expensive disease coupled to nascent universal health coverage to protect against catastrophic expenditure typifies the 'double burden' not only in India but across the world. Improving the implementation of affordable early detection services to cancer coupled to addressing downstream cancer pathways at provider level is key to reducing such inequalities.

A strong and responsive cancer health system is necessary to ensure that the screen positive (in presence of a screening programme) and/or symptomatic individuals have access to prompt diagnosis and those detected with cancer have access to appropriate treatment. Rural population in India are socio-economically disadvantaged and vulnerable to huge inequity in cancer care.3 Our hypothesis is that improving their participation to the cancer early detection pathway through careful investigation into the implementation barriers at the levels of individuals, providers and systems to design strategies and policies that are evidence and context-specific based, will lead to better outcomes.

This study focuses on implementation research for a well-validated, integrated early detection interventional approach for cancer (secondary prevention) in the context of a complex lower middle- income country, India. The three states for the study provide different and comparative implementation ecosystems to dissect out critical issues and barriers (logistical, political, social and economic) to support national scale up and inform other comparable countries globally. This intervention targets three site-specific cancers - oral, cervical and breast - that, combined are responsible for 28% of premature mortality in India and 12% globally, in particular for women. Scaling up these proven secondary prevention interventions would significantly address 1/3rd reduction in premature mortality as part of SDG 3.4, and our focus on the most vulnerable populations (the rural populations in some of the hard to reach areas in India) will ensure this approach meets WHO's ambition of expanding Universal Health Coverage to a billion population.

There are several evidence-based strategies to potentially improve the access and quality of cancer early detection for the rural vulnerable populations in India. Our study will evaluate which of these strategies are implementable in a range of settings, and once implemented whether they can address the local needs, capacities and expectations, and what factors determine this. Finally, we will also assess scalability and sustainability of the interventions with proven effectiveness. There is an urgent need to tailor promotive health care to the changed health delivery system in the post- COVID-19 era. Our planned study will give an opportunity to objectively evaluate the impact of the pandemic in the context of access to cancer early detection and treatment.
Fit of Study within Call
This study focuses on implementation research for a well-validated, integrated early detection interventional approach for cancer (secondary prevention) in the context of a complex lower middle- income country, India. The three states for the study provide different and comparative implementation ecosystems to dissect out critical issues and barriers (logistical, political, social and economic) to support national scale up and inform other comparable countries globally. This intervention targets three site-specific cancers - oral, cervical and breast - that, combined are responsible for 28% of premature mortality in India and 12% globally, in particular for women. Scaling up these proven secondary prevention interventions would significantly address 1/3rd reduction in premature mortality as part of SDG 3.4, and our focus on the most vulnerable populations (the rural populations in some of the hard to reach areas in India) will ensure this approach meets WHO's ambition of expanding Universal Health Coverage to a billion population.