History Cancer Care in Kerala  

Dr. Babu Mathew#, Dr.Boben Thomas$*, Dr.TK Padmanabhan# ,Dr Chandramohan K#,

Regional cancer Centre, Trivandrum$  and GG Hospital Trivandrum$ and Caritas Hospital Kottayam*

          

The history of Modern Cancer Care in Kerala  dates back to nineteenth century.Infact the state of Kerala was formed in on  1 November 1956, when Indian parliament passed the  States Reorganisation Act , in which    Malayalam-speaking regions of the erstwhile regions of Cochin, Malabar, South Canara, and Travancore were joined together . So history of cancer care in Kerala  should be a history of cancer care in these regions. Travancore was ruled by Travancore Royal Family and they were the first ones to recommend and promote modern medicine, which was brought in here by British Colonial rulers. Modern medicine was first made available at 1811 to Royal family , their officials , then prisoners and lately general public. General hospitals of Trivandrum and Cochin were then established  more than 150 years ago. Travancore at those days boasted a better healthcare facility compared to Madras and Malabar Presidency (1) .In early 20th Century  Dr Mary Punnen Lukose, a lady doctor trained in England was appointed as Surgeon General of Kerala.(2)

Cancer Surgery

Surgery is the oldest modality of treatment..GeneraHospital of Trivandrum was established at 1865, this was followed by many treating facilities under government sector .Parrallely ,Missionary Surgeons from UK and a few West European countries came to the Southern part of India along with members of the various East India Companies from the beginning of the 17th century. Though the main aim was to spread religion, some of the missionary surgeons offered their professional skills to treat the local population. The treatment was given in Private hospitals known as Mission Hospitals. A mission hospital was started in Neyyoor, a few kilometers from Nagarkoil in 1838 by London Mission Society. By the turn of the 20th  century, this hospital developed into the biggest mission hospital in the world. Dr. Arthur Fells (1892-1902) and Dr. Bental (1901-1907) working in Neyyoor, published two articles in British Medical Journal and an Lancet, where they informed the medical world that Oral Cancer was very very common in this part of the world and they gave an account of the surgical management of cancer of the bucco gingival complex.

The commonest surgery was hemimandiblectomy without any reconstruction or plastic correction. Dr. T H Somervel (1922-45) was the most famous surgeon at LMS Hospital, Neyyoor. In his book ‘Knife and Life in India, has written that he used to do an average of 700 cancers a year (4). Apart from Oral cancers he has operated many  He was also an Olympian and mountaineer  and was recipient of by one Olympic medal for mountaineering in 1924 Paris Olympics). Dr. Ian Orr (1926-37) was famous as breast surgeon and epidemiologist. He first described the signs of symptoms of Oral submucous fibrosis. He also hypothesized that the type of tobacco and shell lime were responsible for the very high prevalence of Oral Cancer in the coastal areas of Travancore, compared to the hilly areas.          

Dr. R. Kesavan Nair after passing FRCS in 1930, joined General Hospital Trivandrum to become the first Civil surgeon in Travancore. He used to visit Neyyoor Mission Hospital on alternate Saturdays to study cancer surgery techniques from Dr. Somervel, whom he met in UK during his study. They were very close friends. When the Medical college Hospital Trivandrum was started the most qualified surgeon in Travancore-Cochin state Dr. Kesavan Nair was appointed as Prof. of surgery and Superintendent. A galaxy of famous surgeons after him, to name a few – Drs. K.Sivarajan, P.A. Abraham, P.A.Thomas, Jayasimhan and Mohandas treated cancers of breast, thyroid, prostate, head and neck by surgery. Dr. Thomas Cherian is the first exclusive surgical oncologist. He had a rare assortment of training in General Surgery, Plastic Surgery and Anesthesia and started the Dept. of Surgical Oncology in 1984, which later became department of surgical oncology of Regional cancer Centre, Trivandrum. He insisted on reconstruction of the defects along with surgery or plastic correction duly in all patients(6).

Radiotherapy for cancer

Brachy therapy

Dr. Somervel introduced brachy- therapy for cancer using Radium needles for the first time in India. In 1933 Radium needles were purchased for the General Hospital Trivandrum. Dr. R. Kesavan Nair was the custodian of these needles. When he was appointed as the first Supdt and Prof. of surgery in Medical College Hospital, he had transferred these needles to the Radium ward of MCH. There were radiation treatment (both branchy therapy nd tele therapy) in the General Hospital Ernakulam, Medical College Hospital Calicut before 1960.

Tele Therapy

 A tele therapy machine - Eldorado A with Mercury Shield was installed in the Medical College Hospital, Trivandrum in 1957. This was the first tele therapy facility in Kerala. In addition to the Eldorado A Machine, there was a 250 KVP X Ray machine before 1960 in MCH to treat.

 There was no treatment planning system and the Radiation dose and fraction calculations were done manually by Shri. Ponnunni Kartha the first physicist in Kerala. The field was marked with a special ink made by mixing Gentian violet with Silver Nitrate; was used to mark the field. Patients with this dark violet marking were not allowed to take food from the Medical College canteen or a few hotels in the Medical College Junction. Drs. M.P. Joseph, Mahadevan Pillai, and Thomas Stephen were DMR diploma holders who headed the Radiology Dept. in the formative years of the Dept. They concentrated in Radio diagnosis more. Dr. Gangadharan was the first MD Radiology from Lucknow and joined in 1960. He was interested in treatment than diagnosis. Drs. Moideen Kully, C.P. Mathew, M. Krishnan Nair, C.D. Joseph and T. K. Padmanabhan are stalwarts who developed the Dept. till 1981. The significant improvements in the Dept. of Radiology before 1981, was procurement of 2 new Cobalt machines, one Linear accelerator and one scelectron. MD (Combined) and Diploma courses were also started before 1980.

Internal therapy and Nuclear Medicine

 A Scintillation counter for measuring Radioactive Iodine up take was purchased for the ICMR Cell of MCT and used in the study of thyroid patients from 1966. Dr. K P Poulose of the General Medicine Department was in charge of the Thyroid clinic and Dr. T. P. Ramachandran was the physicist who did the up take studies. In 1969 when Dr. Thangavelu left MCT, the ICMR cell was closed and the counter was shifted to the Radiology Dept. of MCH. It is only after the formation of RCC internal therapy was started. But the nidus of the Nuclear medicine was established much earlier.

Medical Oncology

Treating cancer using medicine was started only after the Second World War  based on the finding that Nitrogen Mustard reduced the white blood cell count of the human gunnia pigs in the concentration camps. The use of chemotherapy in cancer started I in Kerala in the late 50s or early 60s. There were only 2 drugs to start with. Cyclophosphamide and Methotrexate oral tablets.These drugs were used only by physicians in Trivandrum medical college since no 'oncologists were available as they were radiologists using x-ray to take pictures and to treat cancer.  Cyclophosphomide as injection was used by senior physicians to treat leukaemia,lymphoma,multiple myeloma and any inoperable and metastatic cancer .These patients were referred to radiologists only when they thought radiation may be given,and not for opinion. Methotŕexate was used by Prof.K.N.Pai mainly to treat chorionic tumours because all these patients were referred to him by gynaecologists. In the late 60s Mitomycin was available in large quantities. It is rarely used nowadays.Around that time Prof. C.P.Mathew and Dr. Krishnan Nair  rejoined the radiology department  after postgraduation and they are  started using chemotherapy more widely . The request for cancer drugs were made in Radiology departments and not from medicine department as was done before. Still other drugs were not available for curative treatment.Later Dr. T.K.Padmanabhan joined the department and by mid70s drugs like 5FU, Vincristine,inj Methotrexate and later Procarbazine were available in Indian market and real curative treatment could be given to cancer patients.wellknown combination chemo regimes like CMF,COPP,COP etc could be given. By early 80s, Actinomycin D,and Adriamycim were available in Indian markets. Soon many more curative treatment regimes could be given to patients with Wilm's tumour, lymphomas,leukemias,chorionic tumours etc.With the formation of RCC,decision was taken to give chemotherapy free of cost to deserving patients with chemocurable cancers.This was a major step in the history of cancer treatment in Kerala.By early 90s drugs like platinum compounds,Taxanes,Gemcytabine,Irinotecan etc were available and qualified medical oncologists entered the field of cancer management .Radiology departmènt was bifurcated  into diagnostic radiology and radiotherapy. Radiologists who had combined degree in diagnostic radiology and radiotherapy could opt for one of these specialities .Those who opted for radiotherapy became radiotherapists ,later known as radiation oncologists who gradually confined their practice to the treatment of cancer with radiation. 

Drugs like ‘Leukeran’ and ‘Myleran’ were used by very few doctors in Medical College hospital in 1960s. Dr. K.V. Krishna Das was the pioneer in treating hematologic malignancies using drugs. It was always an individual decision. There were no Tumour Boards or Noon clinics in those days. The first lymphoma clinic was started in RCC and Drs. MKN, K.V.K and M.A Alykutty were the first members of this clinic. Later Noon clinics in RCC were started.

Newer cancer chemotherapeutic agents were constantly being introduced into the market. One of these was Mytomycin C, recommended for solid tumours. Before 1970 Dr. C.P.Mathew used to give intra-arterial perfusion of Mitomycin C for Head and Neck cancers, through a canula inserted to the respective branch of the external carotid artery. The canula was kept in situ till the end of the recommended courses. Injections of Mytomycin C was given through the canula. A case control study was never carried out nor any statistics were collected to scientifically evaluate this method of treatment then.

Immunotherapy

 Going through the book ‘Knife and Life in India’ by Dr. T.H. Somervel, we can see that he used to give TAB Vaccine for his cancer patients. Dr. C. P. Mathew used to give TAB vaccine to his patients in MCH Trivandrum during 1970-72 and in Kottayam Medical College when he was transferred to Kottayam. Again it is sad to state that s scientific evaluation was never done to assess the efficacy of this treatment in improving the survival or quality of life in the subjects studied. The knowledge about the immune system was preliminary in the early second half of the 20th century. The study of the genetic profile of tumours to create specific molecules by genetic engineering, targeting specific receptor sites was not available before 1975.

Pain Control and Palliative Care

Pain control and Palliative care clinics were started in RCC in 1989. Before that the terminally ill used to suffer severe pain and other distressing symptoms and die miserably. I have seen terminally ill patients being abanded in the cancer wards by relatives. Some patients committed suicide to escape the suffering. 

Morphine was the common analgesic given to cancer patients. Morphine was available in injection form. Opium was available for permit holders in opium vendor shops. This scenario has changed due to the initiative taken by Dr. Jan Sternward WHO Director during 1980s. An International Work Shop was held in RCC in 1992 to lay down the protocol for management of pain in India. RCC with the help of the College of Pharmaceutical Sciences, Trivandrum manufactured morphine in liquid form. Today morphine tablets are available freely across the counter with a prescription from a doctor.

Community Oncology

More than 2/3 cases of common curable cancers (Oral, breast and uterine cervix) used to report to a cancer hospital in advanced stages (III and IV) in the last century. There were no cancer awareness programmes or screening facilities for the general population.

 A community cancer screening programame for Uterine Cervical Cancer was going on from 1979 at the Primary Health Centre, Thrikkadavoor under the leadership of Dr. N. Sreedevi Amma.

The Indo-Danish Oral cancer screening project started in 1969, screened a population around a circle 3 KM in diameter as part of the study. ‘Medical Camps’ in remote areas were introduced before 1970 under political request. In line with that ‘Cancer Detection Camps’ were organized in remote areas and high risk areas. These were conducted under the leadership of Drs. Susan George, Jacob Zachariah, C.T. Mathew, M. Krishnan Nair; and the PGs under them helped in conducting the camps. Later these sporadic camps were conducted in two phases. The first phase was cancer awareness cum training for local volunteers who were trained to identify the high risk persons for oral, breast and cervical cancer. The second phase was to have a cancer detection camp in the trained area to diagnose cancer and pre-cancer. The detected patients were treated locally or referred appropriately to a cancer treatment facility.

In the National Cancer Control Programme of the Govt. of India 1984, Main thrust is given to Primary Prevention of tobacco related cancers and early detection of cancer of easily accessible sites. To generate manpower and standardize the procedures of screening a Community Oncology Division was started in India in 1985 in RCC, Trivandrum

The policy of the Govt. of Kerala for Cancer Prevention and Detection for the next 10 years (2018-2027) is based on the experience gained from the various Innovative Primary Prevention and Screening Programme tested by the Community Oncology division, RCC, Trivandrum.

 

Medical Records Library and National Cancer Registry Programme

In the MCH a Medical Records Library was functioning with the support of the Rockfeller Foundation from 1955. Academic staff like Dr. P.J. Geevarghese, Dr. V. C. Mathew Roy, Dr. B. K. Hareendran Nair used the data from this library for publishing prolifically. However, there was only incomplete data about cancers in this library. An untrained worker (Ms. Ammal) was in charge of collecting the case file of cancer patients and submitting it to the library before 1981. She had to fight with the PGs to get completed case files.

In 1981, a Hospital Based Cancer Registry was started under the ICMR National Cancer Registry Programme. Shri. P. Gangadharan was in charge. Later population based cancer Registry for Trivandrum District was started. These Registries are giving important information about cancer for professionals to publish papers or make proposals for new projects.

 

Cancer Care for Life

Modern cancer treatment is expensive. Before the RCC Era, there was no insurance coverage or Governmental programmes for support to cancer patients. To make cancer treatment accessible to all “the Cancer Care for Life” a new insurance policy was started in RCC in 1986 by Dr. M. Krishnan Nair. In Kerala, Cancer treatment is free to all children below 19 years, and there are several governmental and NGO programmes to give financial and social support to cancer patients. To sum up, I would like to remark that unlike in the pre RCC Era, cancer is not now considered as a death sentence. Moreover several misconceptions and taboos about cancer are slowly getting erased from the community. Today cancer is looked up on as a predominantly preventable and curable disease. Most of the patients have a positive outlook about their disease outcome.        

 

References

 

  1. Missionaries , the Princely State and British Paramountcy in Travancore and Cochin, 1858-1936", Ph. D. Thesis, University of London, 1994. Koji Kawashima Journal of the Japanese Association for South Asian Studies, 7, 1995
  2. Historical analysis of the development of health care facilities in Kerala State, India V RAMAN KUTTY India HEALTH POLICY AND PLANNING; 15(1): 103–109
  3. Bentall WC. Cancer in Travancore: A Resume of 1,700 Cases. Ind Med Gaz. 1908 Dec;43(12):452-458. PMID: 29006611; PMCID: PMC5183183.
  4. Somervell TH. Conservative Surgery in Malignant Disease. Ind Med Gaz. 1935;70(3):131-135.
  5. knife and like in INDIA Being the Story of a Surgical Missionary

at Neyyoor, Travancore  T. HOWARD SOMERVELL LONDON HODDER AND STOUGHTOJL FifSl printed 1940

6. Chandramohan K. Dr. Thomas cherian; father of cancer surgery in kerala. Indian J Surg Oncol. 2014;5(4):263-265. doi:10.1007/s13193-014-0362-z