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Table 2 Availability of Resources for Management of Cervical Cancer in India

From: Meeting report, “First Indian national conference on cervical cancer management - expert recommendations and identification of barriers to implementation”

Resources Availability in India
Loop Electrocautery Excision Procedure It is a safer procedure as compared to cold knife conization, but is not very common in India as it requires expensive machines [62].
Radical trachelectomy It is an expensive surgical option, thus unaffordable by women in poor-resource setting who are known to be more commonly diagnosed with cervical cancer.
Surgical expertise As per the ASCO resource-stratified clinical practice guideline, fertility sparing treatment requires surgical expertise which may not be easily available in the basic or limited settings [63].
Radiotherapy There is a one radiotherapy machine per 2-5 million cancer patients which highlights the lack of accessibility to radiotherapy.
The use of brachytherapy in India is limited due to following reasons.
• Lack of radiation oncologists and radiotherapy technologists.
• Private hospitals favour other techniques including IMRT and IGRT over brachytherapy.
• Implementation of latest advancements in brachytherapy is limited to a few premier hospitals [64].
However, despite all these challenges, the use of brachytherapy has shown a surge in India.
Chemotherapy Chemotherapeutic drugs are available in India, but the associated cost is high.
• A recent observational study by Kolasani et al. (2016) assessed the variation in prices of anti-cancer drugs (chemotherapy) in India. Physicians might not prescribe the low-priced drug due to lack of information on quality, conflict of interest, and a belief that new drug is better than the older [65].
• Thus, if awareness is raised among the treating physicians about the quality of the low-priced drugs, it will increase the accessibility and affordability of the treatment to lower and middle-class patients in India.
• Pharmaceutical companies and government should also make efforts to reduce the drug prices to lower the economic burden on the patients. [64]
CCRT Annually, 38,771 patients with cervical cancers in India do not receive CCRT, resulting in poorer survival. [66]
HDR and interstitial brachytherapy • Ir-192 is commonly used for HDR brachytherapy in state government funded hospital in India, but its replacement with Co-60 will be a cost-effective option in developing countries like India. [64]
• Few studies in Indian settings have assessed the applicability of interstitial brachytherapy in patients not suitable to undergo intracavitary brachytherapy. [67,68,69]
Bevacizumab • The cost-effectiveness analysis of bevacizumab has been conducted using the Markov decision tree in 240 patients enrolled in the GOG trial. The study concluded that ICER associated with bevacizumab could be reduced by introducing biosimilars, and/or other cheaper and efficacious anti-angiogenesis agents. [70]
• Roche is currently running 'The Blue Tree' program for cancer patients in India. This program covers several aspects to help cancer patients ranging from “diagnostics, funding of treatment, information, post-treatment job search, assistance with documentation for reimbursement and free medicines where possible.”
Pelvic exenteration procedure • This procedure requires tremendous economic and psychosocial support which a developing country like India largely lacks.
• Poverty and illiteracy further makes optimal rehabilitation of these patients difficult [50].
• There is a need of increase in beds at ICUs in both private and public hospitals with the expected rise in number of cancer patients. The associated high cost of ICUs in private hospitals and lack of its coverage under health insurance, the oncology patients has to borrow or sell assets for admission to ICUs [71].
Palliative Care • There is a huge lack of manpower in Indian hospitals to provide palliative care to cancer patients [72].
• Thus, it is not possible to provide palliative care to all cancer patients in India.
  1. Abbreviations: ASCO American Society of Clinical Oncology, IMRT Intensity-modulated radiotherapy, IGRT Image-guided radiotherapy, Ir Iridium, CCRT Concurrent radiotherapy, Co Cobalt, ICER Incremental cost-effectiveness ratio, ICU Intensive care units