LEADING HEALTHCARE PROVIDER Fortis Healthcare saw oncology (science of treatment of cancer) revenues jump 53% in FY23, the fastest growing among the hospital's key specialties. With a 13% share in overall revenues of ₹5,107 crore, it was second only to cardiac sciences (18%) in Fortis' total revenue share. Apollo Hospitals, which treats over 125,000 cancer patients per year, derives 25% revenues from oncology. It accounts for around 18% of total revenue of Max Healthcare, while for Narayana Health it is 14%.

From a business point of view, cancer is emerging as the new cardiology for major Indian private hospital chains. All four hospital chains have invested in robotics to offer precision cancer treatment.

Swiss pharmaceutical major F. Hoffmann-La Roche, global leader in oncology medicines, has lined up over 20 new product launches in the next three-five years for India. Roche, a leader in the area with a 10% share of the domestic market, has seen its brands — Perjeta (74% year-on-year growth in 2022) and Tecentriq (118% YoY growth) — being among India's top five oncology brands. Of the top five cancer drugs with highest incremental value additions in 2022 — Perjeta (Pertuzumab) and Herceptin (Trastuzumab) — were from Roche.

In 2019, Indian oncology start-ups working on new drug research, development of chimeric antigen receptor (CAR-T) cell therapy, imaging devices witnessed their highest funding to date of $27.2 million. Rising incidence of cancer is giving a new fillip to the business of oncology.

The Silent Killer

Cancer accounts for one in six deaths globally, about 10 million deaths annually, according to the World Health Organization. India ranks third after China and the U.S. on cancer burden. Unlike developed nations where over 70% cases are diagnosed early, in India, almost 70% are reported in advanced stages. The 30% early detection is mostly in urban centres.

A recent report by global consultancy EY (in collaboration with industry chamber FICCI) states India's reported cancer incidence is 19-20 lakh, but real incidence could be between 1.5 and 3 times higher than reported cases. It estimates the economic cost of cancer due to loss of disability adjusted life years (DALY) to India's GDP as anywhere between $36 billion and $40 billion by 2030.

According to the FICCI-EY report, only 175 districts covering 40-45% of the population have comprehensive cancer centres (CCCs). Of the 480-odd CCCs, 40% are in metros and state capitals. This has made demand-supply gap in India's cancer ecosystem — preventive care, early diagnosis and treatment — glaring, and hence a huge opportunity for healthcare providers.

Of the 70 cancer centres set up during 2018-2021, 25 were single-specialty hospitals. However, with significant growth in incidence and 40% of new cancer patients requiring comprehensive treatment, the FICCI-EY study estimates India needs another 572 CCCs by 2030 for seamless treatment. They will require an additional 10,000-15,000 day-care and 25,000 surgical beds. Given the current capital expenditure trend, (₹50-80 lakh per bed in metro/Tier-1 cities and ₹30-35 lakh in Tier-2 cities), it calls for additional investment of ₹10,500-14,000 crore, excluding cost of land and high-value medical equipment such as radiotherapy and PET-CT machines. No wonder leading corporate hospitals are ramping up their cancer-care offerings. Standalone cancer-care hospitals and diagnostic centres and digital solutions for screening are on the rise as well, while new forms of diagnosis and treatment of cancer are being offered by start-ups.

The Revenue Earner

"The first set of (corporate) hospitals was built on cardiology. Today, Apollo, Fortis, all of them, are going very strong on cancer. The biggest component of investment is in increasing the number of beds, infrastructure, etc," says Rana Mehta, partner and healthcare leader, PwC.

"Apollo cancer centres have been growing at 25% year-on-year, with 18 centres and over 325 specialists across the network delivering high-end precision oncology. With a strong focus on early diagnosis and personalised molecular oncology for surgical, medical and high-precision radiation treatment, Apollo has built a robust ecosystem to manage cancers," says Preetha Reddy, executive vice chairperson, Apollo Hospitals Enterprise.

Fortis is also bolstering its cancer-care services. "Oncology is a large and high-growth area. In the last two-three years, the contribution would have gone up at least 50% and the growth rate would be higher than all other specialties," says Anil Vinayak, group COO, Fortis Healthcare. "More and more of our hospitals are providing oncology services. We are also setting up new facilities and initiatives such as day care where we provide chemotherapy and other basic services," he adds.

Leading corporate hospitals are also investing heavily in high-end technology. Apollo, for instance, has established a proton cancer therapy centre that enables non-invasive procedures using high-energy beams to target tumours without affecting healthy tissues. "The aim is to drive safer and more effective treatments by being at the forefront of technology and research, globally. Apollo has introduced CyberKnife S7 (a kind of robotic radiation therapy) and South Asia's first Pencil Beam Proton Therapy," says Reddy.

Fortis' Gurugram facility has India's second MRlinea, which allows imaging while radiation is in progress. The hospital has a very strong bone marrow transplant programme and treats thousands of leukemia patients from India and abroad. Max Institute of Cancer Care (MICC)'s cutting-edge medical equipment, on the other hand, includes the highly advanced Robotic Surgery System (Da Vinci) for precise surgeries.

Hospitals are also adding cancer treatment facilities in Tier-I and Tier-II cities. "More than 75% of specialty healthcare is provided by the private sector. Large corporate hospital chains are expanding to Tier-II and III cities, and creating a hub-and-spoke infrastructure," says Poornima Srinivasan, consultant, healthcare and life sciences, Frost & Sullivan.

"Oncology today is a fine example of adopting new knowledge, new technology to deliver best outcomes with care and empathy," says Dr. Harit Chaturvedi, chairman, Max Institute of Cancer Care. Max has had close to 200 academic publications in oncology in three years.

The growth drivers are many. India has a large population and with increased awareness and screening, and government initiatives, the ability to detect will improve. Other reasons include the ability of a larger section to access treatment modalities, increased penetration of health insurance post Covid, and rising effectiveness of cancer treatment, especially in early stages. "Cancer will remain the fastest-growing segment in the medium term. It is at a stage where cardiac treatment was a while ago," says Fortis' Vinayak.

Hospital chains believe scale will drive treatment costs ahead. The demand-supply gap is providing an opportunity for single specialty players as well. With a chain of 22 CCCs, the over three decade-old, Bengaluru-based Healthcare Global Enterprise Ltd (HCG), has seen the fastest expansion in recent years. "We have invested in 10 new cancer centres in the last six-seven years, leading to revenues growing in double digits. The company is also investing in the expansion of its centres in Bengaluru and Ahmedabad and looking at in-organic opportunities," says Raj Gore, CEO, HCG.

Rise of Diagnostic Players

Despite the growth in private hospital chains, the government remains the single-most important player in cancer-care infrastructure development in the country. The Centre has approved 19 State Cancer Institutes' (SCIs) and 20 Tertiary Cancer Care Centres (TCCCs). Several upcoming AIIMS institutions and those approved for upgradation under the Pradhan Mantri Swasthya Suraksha Yojna are adding cancer treatment facilities. Around 50% of cancer cases — oral, cervical, and even breast cancers are preventable if diagnosed early, making screening and diagnosis the two most important components of cancer-care infrastructure. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, under the National Health Mission, is looking to strengthen the infrastructure, HR development, and screening of population (30 years and above) for such diseases via 1.5 lakh Ayushman Bharat Health and Wellness Centres.

Tata Trusts is a major player partnering with state governments in this segment. In fact, Tata Trusts Cancer Initiative (TTCI) is helping states establish cancer-care networks. In Assam, for instance, it is helping the government build South Asia's largest affordable cancer-care network with 17 diagnostic and treatment centres across the state. Ten hospitals are operational already. TTCI's distributed cancer-care model will see at least one crore of the 3.4 crore population of Assam being screened for cancer soon. "The plan is to screen 30% of Assam's population in three years... With seven more centres (one cancer hospital attached to a medical college and six diagnostic and day-care treatment centres) coming up, the whole of Assam will be covered. And if we can do it in Assam, we can do it in any state," says Dr. Sanjiv Chopra, CEO, TTCI.

Tata Trusts is also establishing a network of cancer-care centres comprising day-care specialities, onco-pathology labs, screening kiosks and hospitals, in partnership with state governments of Andhra Pradesh, Jharkhand, Maharashtra, Uttar Pradesh and Karnataka. The 82-bed Ranchi Cancer Hospital & Research Centre (RCHRC) has been the most recent addition.

Mumbai-based Karkinos Healthcare, a start-up, co-founded by former Tata executive R. Venkataramanan, runs a pilot cancer screening programme in Kerala's Idukki district. While nearby Ernakulam has six cancer specialty hospitals, Idukki has none. Karkinos offers phygital screening and then helps those who need further investigation, treatment, or palliative care navigate the entire process by partnering with existing healthcare providers, clinicians, diagnostic facilities, day-care chemotherapy facilities, tertiary hospitals, and apex centres. Karkinos' major differentiation is its virtual command centre that acts as a central disseminator of information and guidance and keeps all treating clinicians and ground staff connected to the system. Karkinos has multiple revenue streams, including organising screening camps for employees of big corporate houses. The business it generates for partners is another source of income. The company has started similar services in West Bengal, Manipur and Madhya Pradesh and has screened close to 1.3 million people. It has also partnered with 70 hospitals in these states. "We will screen 5 million people in the next two and a half years. We are now in four states, in a couple of years, we may get to 10 states," says Venkataramanan. While the Tata Group has an 18% stake in Karkinos, RIL has about 5%.

Similarly, the government-led partnership platform in cancer care is the National Cancer Grid (NCG), anchored by the Tata Memorial Centre, the grant-in-aid institution of the Department of Atomic Energy. NCG aims to create a network of cancer centres, research institutes, patient groups and charitable institutions across India. Over 270 hospitals, including Max Institute of Cancer Care and Tata Memorial Centre, are members of the network.

Mumbai-based Epigeneres Biotech is another example of an Indian firm that is hoping to provide innovative solutions in the area of cancer detection. The company claims that the RNA bio-markers technology it developed (along with Tzar Labs, Singapore, a promoter family owned entity that holds the IP rights) in 2021 is a breakthrough in molecular diagnostics to detect early-stage cancer as it can even detect cancer in stage zero (i.e., before tumor formation) through a simple blood test. "It is the first prognostic, non-invasive, and safe test for cancer detection. The technology can help determine whether cancer is absent, imminent, or present and also detect the different stages of the disease," says Anish Tripathi, MD, Epigeneres. The company has already set up a pilot lab in Mumbai and plans to expand its capacity to handle 100 to 150 samples a day in the next couple of months.

Medicines & Innovations

Market research firm IPSOS values the Indian oncology medicine market at ₹5,318 crore in 2022, a 26% growth YoY (a CAGR of 11% from 2018 to 2022). Rising cancer cases, an increase in drug launches and product approvals, growing research activities by pharma companies, paying capacity of patients, different government and private insurance schemes, etc., are all contributing to the growth. While 63 anti-cancer medicines are under the price-control list prepared by the National Pharmaceutical Pricing Authority (NPPA), new-age therapies are expected to drive future growth.

Frost & Sullivan's Srinivasan says the use of immunotherapy for cancer treatment can improve overall survival rates by up to 30%. "The aggressive approach by Indian pharma companies towards research commercialisation has translated to around 122 transactions between 2017 and Q12022. The combined value of these could be $73.2 million, of which 18% is marked for oncology," says Srinivasan. Immunotherapy, however, costs around ₹2-3 lakh a month, making it unaffordable for 94-97% of patients. Immunotherapeutic agents are not a part of NPPA's price-control list.

In May 2022, Roche Pharma India announced the launch of PHESGO, revolutionising HER2+ve breast cancer treatment by combining two monoclonal antibodies (Pertuzumab and Trastuzumab), administered by a single subcutaneous injection. It reduced the time patients need to spend in hospitals by 90%. "PHESGO enhances the efficiency of the healthcare system since it requires less preparation and administration time. Faster administration frees up time for both patients and healthcare professionals and provides cost-saving benefits, driving workflow optimisation and budget efficiencies. Since its launch, more than 1000 HER2+ breast cancer patients have already benefited from PHESGO," says V. Simpson Emmanuel, MD and CEO, Roche Pharma India.

In October 2021, Roche launched Tecentriq, the only approved immunotherapy in India for Hepatocellular Carcinoma (HCC), changing the treatment paradigm for people with liver cancer. "Early diagnosis of HCC is difficult. There are 32,000 new incidences of HCC in India, of which 43% go undiagnosed... Over 1,500 patients suffering with HCC have benefitted from Tecentriq. Our focus has been to bring Roche innovations to India at the earliest," says Emmanuel. Roche is also conducting more Global Clinical Trials in the country to speed up drug access for cancer patients.

Roche is not alone. Leading Indian companies have all announced plans to focus more on oncology. "In India, we are now a leading oncology player. Our aspiration is to be in the top three and eventually become No. 1. Our medicines are largely driven by biologics and also some small molecules," says Dr. Sharvil Patel, MD, Zydus Lifesciences. The company is already among the top five players, and was the fastest-growing firm in the oncology segment in FY23 with 9% of its ₹4,911 crore Indian formulation business coming from this segment.

Natco Pharma, a well-established player in oncology with brands catering to diseases, including breast, bone, lung and ovarian cancer, is targeting 20 product launches (including cancer) a year with over 12% growth. It has six oncology brands with over ₹10 crore in sales, and has introduced additional therapy options for liver, kidney and prostrate cancers, besides launching a new medicine for ovarian cancer.

Hyderabad-based Dr Reddy's Laboratories, on the other hand, considers immuno-oncology to be its area of focus and is developing a global biosimilar business. The company has over 25 drug development programmes in the immuno-oncology segment that are developed both internally as well as through partnerships and in-licensing deals. Six are in the clinical trial stage and seven products are in the filing stages (for regulatory approval), according to the company.

Biocon has three oncology products — Pegfilgrastim, Trastuzumab and Bevacizumab — that are approved, two — Denosumab and Pertuzumab — in the late-stage development phase, and two undisclosed products in early stages of development. Bicara Therapeutics, an associate of Biocon based in Boston, is working on precision immunotherapy with BCA 101, a first-in-class epidermal growth factor receptor.

Laurus Labs, which saw its bulk drug business in the oncology segment grow 82% in Q4FY23, is expecting its investment (27.57% stake) in ImmunoACT to provide the firm access to the emerging CGT technology and India’s first indigenously developed CAR-T therapy for blood cancer patients.

Research Driven

"In the past two years, firms working on cancer drug research, in-vitro diagnostics for cancer, and radiation therapy solutions, have attracted investor interest. The cancer immunotherapy market is also gaining pace, since it has fewer side effects than traditional treatments such as chemotherapy and radiation therapy," says Neha Singh, co-founder of Tracxn, a start-up data platform. According to Singh, Indian oncology start-ups have received just $159 million in funding till date.

With global technology leaders focusing on cancer, innovation offers a lot of possibilities. Dileep Mangsuli, head, India development centre, Siemens Healthineers, says precision medicine is one such ground-breaking technology that revolutionises cancer detection by enabling earlier and more accurate diagnoses. "It considers comprehensive patient information to identify the most effective treatments and offers cost-effective alternatives to complex cancer care. The MAGNETOM Free.Star MRI device (of Siemens Healthineers) represents a significant advancement. Unlike traditional MRI machines that require large amounts of helium, the MAGNETOM Free.Star operates with only 700 millilitres of helium. Additionally, we have developed a remote cockpit solution for managing MR stations, expanding access to rural areas and facilitating global expansion," he adds.

Bengaluru-based Niramai Health Analytix, a deep-tech healthcare company that offers a novel radiation-free, non-touch breast cancer screening solution, is another example of Indian innovation in this segment. Nirmai's first product, SMILE-100 System, a AI-powered breast thermography device helps healthcare personnel review, measure and analyse thermally significant indications in the breast region. It was cleared by the US FDA last year. Indian companies, including ImmunoACT and Immuneel Therapeutics, involved in the development of CAR-T cell therapy, are also looking to make the technology affordable.

Karkinos has research collaborations with institutes, including IITs. "We work with people both in India and abroad to develop new drugs/treatments. These are investigator-driven research projects. We also do clinical trials for overseas partners," says Venkataramanan.

The Way Ahead

In September 2022, the Department Related Parliamentary Standing Committee on Health and Family Welfare, came out with a 224-page report on Cancer Care Plan & Management: Prevention, Diagnosis, Research & Affordability of Cancer Treatment. The report acknowledged the importance of the 'Strengthening of Tertiary Cancer Care Centres Facilities Scheme' that was approved 10 years ago, but signalled out a major problem. The 19 SCIs and 20 TCCCs are expected to be completed only by March 31, 2024. It also pointed out that despite the government's claims on cancer treatment facilities in new AIIMS, only 6 among the 22 new ones currently have cancer treatment facilities. The panel suggested the classification of cancer as a notifiable disease to make reporting of cancer deaths mandatory.

Recently, Tata Trusts put up a screening camp in Ranchi in the midst of a kisan mela. "Of the 1,200 random people who were screened, four tested positive for cancer, who are currently undergoing treatment at Ranchi cancer hospital," says TTCI's Dr. Chopra. "A lot of walking cancer cases are roaming around, undiagnosed." That's the problem India needs to tackle first, if it wants to control cancer in the long run.

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