MNJ Institute of Oncology’s Palliative Care Program

MNJ Institute of Oncology was founded in 1955 with donations from philanthropists, notably Mehdi Nawaz Jung Bahadur, after whom the hospital is named. The government of India designated the hospital as a regional cancer in 1996.

The MNJ Institute of Oncology and Regional Cancer Center, Hyderabad, is the leading cancer facility in the Indian state of Andhra Pradesh (AP). It includes one of only a few palliative care facilities in all of India. Under strong and committed management over the past decade, MNJ has developed into a major cancer center serving a population of approximately 73 million in the state of AP and many people from four neighboring states.

MNJ Institute is the only center offering post-graduate training in radiation oncology in AP. With the addition of a second oncologist last year, MNJ Institute has developed an excellent pediatric oncology program that is working to improve survival rates in children with cancer. Now, through the efforts of Dr. M. R. Rajagopal (Dr. Raj) and his protégé Gayatri Palat, MNJ Institute is becoming a key player in the area of palliative care.

Trained as an anesthesiologist, Dr. Palat began her career with the World Health Organization in Calicut, where she met Dr. Rajagopal, a former professor of anesthesiology who has pioneered palliative medicine in the country and who now heads Pallium India, a charitable trust established to work at the national level to bring pain relief and palliative care to the suffering millions in India. The senior physician had been instrumental in establishing palliative services in Kerala. MNJ Institute established its pain and palliative care department just five years ago.

Since 2000, Dr. Palat has focused exclusively on chronic pain management and palliative care. When Dr. Rajagopal and Pallium India began collaborating with the American Cancer Society and INCTR to initiate the Indian Palliative Care Network in June 2006, she was identified as program director and has since been appointed as the Director of PAX (INCTR’s palliative care program) in India.

The goal of the joint initiative is to establish an ever increasing number of palliative care centers in India that can deliver care, train specialists, work with local government on issues such as drug availability, and provide community education and outreach. Over the past two years, MNJ Institute, Hyderabad in the south central part of India has become the regional training center for palliative care and training. The hospital offers four-week certification programs for palliative care specialists, and INCTR’s PAX has visited the institute on several occasions to assist with training and sensitization programs. Dr. Palat and her team are working to develop a network of regional palliative care centers devoted to education, policy and advocacy. While there are palliative care services in southern India, there are very few facilities in the northern region and developing an association with major centers in central and north India will be crucial to improving access to care throughout India. MNJ Institute is also conducting a poster program to raise public awareness about the importance of prevention and the early detection of cancer, as well as a tobacco program that targets the most important risk factor for cancer.

Dr. Palat notes that head and neck cancers have the highest incidence in this part of India, relating to the habit of chewing “pan.” Unfortunately, by the time patients’ receive medical help, two-thirds are in advanced stage and 80% need palliative care. The load is increasing every day. Yet palliative care is available to only 2% of those who need it.

The World Health Organization estimates that 2.5 million people in India are suffering from cancer, with another 2.7 million living with HIV and AIDS. The need is staggering. At MNJ Institute alone, a hospital with 280 beds, 10,000 new patients each year seek help.

“One of the great challenges is that cancer care is limited to the big cities,” notes Dr. Palat. “Patients are reluctant to seek medical treatment so far from home - it’s a formidable obstacle. Then there is the stigma of cancer, which interferes with treatment. And there are no provisions for patient support, which makes follow-up difficult.”

Our team at MNJ.

Another significant challenge is the availability of opioids. Dr. Palat and her team are working with the government to develop new policy affecting the availability and local manufacture of oral morphine.

Figure 1. Patient Statistics for the period from January, 2006 to June, 2007.

Figure 2. Morphine Consumption for the period from January, 2006 to June, 2007.

“It is a misconception that opioids are to be used only at the end of life,” says Dr. Palat. “We’re in a country where opium is cultivated, but it’s not available for medical purposes because of the fear of misuse. In 1986, opioids simply disappeared from the pharmacies, so doctors are not trained to administer them. Yet across the country, opium is freely available on the street. One good thing we have discovered is that when you talk to the public, they come asking for it. And when the public pressure is there, the politicians will take note. So we put a lot of energy into public awareness.”

The state government of AP has recently introduced a state-sponsored medical insurance system for people below the poverty line that provides free medical treatment for major chronic diseases, including cancer. By the end of the year, the population of the entire state will be insured. Patients can go to any hospital and get full medical treatment. At MNJ Institute, 90% of all hospital services are free. All outpatient treatment is free, and for those who cannot afford it, all palliative medication is free.

“We have introduced palliative care as part of this insurance package,” notes Dr. Palat. “This is a major achievement that will help us improve the quality of cancer services.”

Crowded waiting room at the palliative care clinic, MNJ.

Dr. Palat also hopes to expand palliative care services for patients with HIV/AIDS. Andhra Pradesh is the second-leading state in India for incidence of HIV infection.

“The reality is that people diagnosed with HIV just disappear,” she says. They don’t come back until they have symptoms.”

The palliative care team in MNJ tries to empower the families of the patients by educating family caregivers to deal with feeding, wound care, constipation and other complications that arise from the illness or its treatment. “In these instances, family caregivers are much better than the professionals because they do it with such love and dedication,” says Dr. Palat.

It is this grass-roots, home-care approach that will ultimately bring about a sea-change in expanding access to palliative care. “What we hope to do is develop a network of local palliative care centers that can become self-sustaining – centers providing family health care supported through local fundraising. If you are always looking for funds from outside sources to tackle big projects, you won’t achieve sustainability. We have to remember that palliative care is not like regular health care. This job goes beyond medicine to encompass advocacy, public awareness and family support.”

Marcia Landskroener for INCTR