What we did was to have a round table meeting of a number of stakeholders on the cost-effective evidence-based delivery of breast cancer care to women at the secondary health level. So, all of us are aware that there are a number of tertiary care hospitals that deliver good quality care to breast cancer patients which are largely located in urban centres and in the large urban centres, metropolitan India. But there are about 300 medical colleges, medical schools as you would call them in the West, that see a bulk of patients that are largely from rural or semi-urban locations and this round table meeting brought together these stakeholders in order to deliberate upon the cost effective and practical and feasible suggestions for the delivery of breast cancer care.

So this round table was targeted to policy planners and not necessarily to physicians. We had a very successful round table where everybody expressed their views and we hope to be able to bring out the policy document that will lay down a roadmap for the strengthening of the infrastructure at that level.

One of the things that was unanimously agreed upon was to recommend to the policy planners on having a mammography unit, a diagnostic mammography unit, at each of those 300 medical schools which will help in the diagnosis but which will also help in treatments such as breast conserving surgery. We also recommended, for example, that there should be a radiation therapy machine at each of those 300 centres and that it preferably be a linear accelerator. So those are the sort of policy suggestions that the round table agreed upon.

Was there a consideration in policy for more basic care where there is less funding?

This was largely directed towards the care of patients who are already diagnosed who have breast cancer and our remit was not to discuss early detection and awareness. So we did not discuss that aspect but, for example, the other thing that we talked about which is very important was to strengthen the pathology services. So you know a large number of breast cancer patients get diagnosed in these centres but they don’t necessarily have enough access to modern diagnostic techniques on their tumours which will enable the rational use of treatments. So in the context of breast cancer we specifically discussed the performance of tests, of critical tests such as the oestrogen receptor, the progesterone receptor and the HER2 testing. That is not accessible to most patients or to many patients and we thought that we should deliberate on how to make that universally accessible to our patients. It’s difficult but it can be done. So, for example, these are relatively labour intensive and sophisticated tests that need a lot of standardisation and the round table actually decided that rather than mandating the infrastructure at every single location, these tests could actually be centralised. So in each region there could be a few centres that could have the facilities for performing such tests but that all the tumours from all patients be sent to these central facilities for such testing.

You know that we have a very inexpensive drug in the form of Tamoxifen that has been unequivocally been shown to save lives. It can only be used if you have a reliable estimation of the oestrogen receptor. We also recommended that other basic drugs such as anthracyclines, taxanes and also trastuzumab or Herceptin be available to all eligible patients in India.

It is a not so easy thing to achieve but I think we have to make a start and the organisation of this infrastructure is actually more important than the money spent on it. So somebody has to think of a way to organise the infrastructure and once that happens things will fall into place. One of the other things that was interesting was that we also recommended systematic data capture in these locations because many things happen, there are many treatments that take place but there is a lack of systematic capture of patterns of delivered care as well as outcomes. Unless that happens on a systematic basis in many parts of the country we will not have a baseline with which to compare ourselves in the future. So we had a very nice discussion with a number of stakeholders and we hope to be able to bring out a nice document that will lay down the essentials of how we should go about it in the near future.