For John R. Adler, invenor of a robotic radiosurgery system that can treat tumours in any part of the body, India offers a clean slate to bring about a paradigm change in cancer care. And he isn't losing any time.
His machine, CyberKnife, which costs about Rs30 crore a piece, was recently installed at Healthcare Global Enterprises Ltd (HCG) in Bangalore and at Apollo Speciality Cancer Hospital in Chennai, the only two machines in south Asia according to the Indian owners.
But for Adler, also a professor of neurosurgery and radiation oncology at Stanford University Medical Centre in California, US, this is just the beginning.
"I want to get more involved and support large clinical trials in India and other parts of Asia, as the trial process has become very bureaucratic in the US," he said.
That might hold him in better stead as his critics are harping about a lack of good and sufficient clinical data on CyberKnife. The device uses realtime image guidance technology to deliver precise radiation doses, avoiding healthy tissues. This is a technological marvel at the moment, trying to achieve what a surgeon does with his knife, but the cost is prohibitive, said Amit Agarwal, medical oncology consultant at the Fortis Hospital in New Delhi.
The proponents are "pushing the envelope a little too early and too much", he said, though he is convinced about the safety and reduced side effects in comparison to existing treatments.
At the All India Institute of Medical Sciences (AIIMS), urologist N.P. Gupta, who uses another robotic surgery system called Da Vinci, says that in his specialty of localized prostrate cancer, there isn't enough long-term data yet from CyberKnife cases.
Adler and B.S. Ajai Kumar, chairman and chief executive of HCG, remain unfazed.
"I have faced a lot of resistance," says Adler--from 1994, when he first used the device to treat brain tumour, to about 2000, when the technology was finally ready for widespread use.
"The technology is very cost effective, cheaper than standard radiation; but in a place like America, cost effectiveness works against you. In India, we have a chance to provide it for the masses as for a few thousand dollars you supplant much more dangerous treatment and surgery," he said.
In India, Adler may not be right about financial costs, since a CyberKnife treatment could cost Rs4-5 lakh, against Rs50,000-Rs1.5 lakh for a standard radiation therapy. Adler argues there has to be a quality measure too, when a six-seven week radiation therapy is reduced to a five-six day out-patient procedure with fewer side effects.
Kumar, who is experimenting with payments in instalments for the treatment, claims he hasn't denied the CyberKnife treatment to a deserving patient in the last few weeks that HCG has been offering this service. "There is a business model for every category and we have started equated monthly instalment payment for patients in centres at Bangalore, Delhi and Ahmedabad," he said.
Adler, whose firm Accuray Inc. manufactures the machine, says that with time, when volume picks up and costs come down, healthcare providers can adopt multiple business models to offer the technology.
He added that new types of cancers are responding to the technology, as are non-cancer conditions as well. In an ongoing trial at MD Anderson Cancer Centre in Houston, Texas, US, researchers have encouraging results from using the machine in atrial fibrillation--abnormal bleeding in the heart, which is the leading cause of strokes worldwide.
HCG, which received private equity funding last year, including $20 million (Rs94.4 crore) from Premji Invest, is looking to raise Rs30 crore by December. Premji Invest is an investment firm owned by Azim Premji, chairman of Wipro Ltd, India's third largest software exporter.
Even as cancer specialists sharpen their gaze on CyberKnife, the machine has triggered a regional battle among hospitals. Agarwal of Fortis says there's a proposal by a group of hospitals in north India to bring at least three-four CyberKnifes to the region, including at least one in Delhi.
His fear, though, is that "in India you start selling something for the lung and healthcare providers start offering it for so many other indications".
Adler aims at making it the standard cancer care in years to come. "In 100 years of surgery, you just have about six to 10 randomized controlled trials which everyone considers best. It takes about 20 years to produce such data and by that standard, CyberKnife still has some time," he said.
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