Paradox of Life

by | Oct 15, 2023

I met Dr Dilip Pawar by chance. But what a good chance it turned out to be. He is an oncologist turned clinical pharmacologist and a leading figure in the discovery of cancer drugs. A sagacious person of calm temperament, Dr Pawar worked with cancer patients throughout his career, especially the poor, and has seen suffering from very close quarters. I was surprised when he said that one out of every three cancer deaths in India is caused by poor diet, lack of awareness and failure to use cancer screening tests for early detection. All these factors are linked to poverty, which is also a barrier to accessing effective cancer therapies.

Dr Pawar comes from the poorest of the poor strata of society and grew up in Mumbai slums. His mother ensured that despite all odds he received a good education and he lived up to the challenge. A medical graduate from Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Dr Pawar did his post-graduation from Lokmanya Tilak Municipal Medical College, Sion, Mumbai, in Oncology. He later pursued a PhD, Fellowship in Clinical Pharmacology from the University of California, and Global Clinical Research training from the prestigious Harvard Medical School, and it was the plight of the poor not getting good cancer medicines that drove him into Cancer research.

After working for some time in the industry, basically, to understand the dynamics of the global pharmaceutical industry where a few corporations hold the most patents, he did an MBA in Pharmaceutical Marketing at Southern New Hampshire University, Manchester, USA, and later worked at Nicholas Piramal India Limited, Dr Reddy’s, and Unichem. He is considered the final word in Clinical Research and Pharmacovigilance, dealing with the understanding and prevention of adverse effects of any medicine.

Our discussions, held over tea in my house, meandered from the treatment of cancer to the end stage of life. Cancer is inherently a chronic disease with well-understood risk factors. If it is diagnosed early, surviving it is not much of an issue anymore. Early-stage cancer that hasn’t spread and isn’t too big is more likely to respond well to treatment. The problem is early detection, and it is not a small problem. Tests used by doctors to identify and treat cancer are different from those used for cancer screening. When it comes to your body, you know it best. If you notice anything that isn’t normal for you, or if something doesn’t feel quite right, speak up. If colon cancer is detected at an early stage, more than 90% of patients survive the disease for 5 years or longer.

Our hospitals are overcrowded, doctors are overworked, and the poor have no means to go to a private medical practitioner. So, early diagnosis of cancer remains a buzz word and unless people are approached at the community level, it is impossible to have any early cancer diagnosis. Increasing the reach of life-saving healthcare initiatives is crucial, and mobile screening vans that offer cancer screening to individuals where they live and work is one important method to do this. 

Working with Dr Chinnababu Sunkavalli and his Grace Cancer Foundation, Dr Pawar mobilized support for organizations donating buses and other equipment and what was once considered impossible happened.  The fact that there is no end to medical research and there is always more to learn is one of its great advantages. Their work has shown that if you find cancer early, the treatment went from something complicated, expensive, and terrible to something that was relatively simple—simple meaning we were already in the minimally invasive world of surgery.

But what moved Dr Pawar most was the plight of the end-stage cancer treatment, which is basically no treatment but pain management and nutritional support. It is common for cancer hospitals to discharge such patients saying let them be at home, but the idea of a home is indeed grossly misunderstood. Dr Pawar remembers living his early childhood in Goregaon in Mumbai where 16 people were living in a 100 sq.ft. room. We must roll out a system of affordable palliative care. This would need social awareness, voluntary work, and above all, committed nursing professionals. 

According to Dr Pawar, it is becoming more and more obvious that there will not be a single “cure” for cancer in the future. Instead, each patient will receive care that is tailored to meet their individual needs.  But for personalized medicine to become a reality, we must have a wide enough selection of medicines to address every type of cancer. Personalized vaccinations, cell therapy, gene editing, and microbiome treatments are four technologies that will transform how cancer is treated, according to Dr. Pawar.

By comparing the DNA sequences of the tumor and of healthy cells, it is possible to identify multiple cancer mutations and select the ones that are more likely to provoke a strong reaction from the immune system. The vaccines are administered as messenger RNA, a molecule that tells cells how to make a specific protein, in this case, a cancer antigen that strengthens the immune system’s defence against the tumor. Unlike with gene editing, vaccines do not directly edit human DNA, but just provide the message. Another advantage is that the production of messenger RNA is cheaper than that of other cancer treatments. In can be done. It can be done in India. And it will be done, according to Dr Pawar.

In 2018, US FDA approved cell therapy for cancer. Immune T-cells from the patient are taken and genetically modified to target a particular tumor antigen in a procedure known as CAR-T cell therapy. By engineering T-cells to carry a molecule, borrowed from another type of immune cells called natural killer cells, with the capacity to target 80 per cent of cancer cells, each patient will be treated by his/her own cellular material. Though CAR-T cell therapy is promising, these are still in the early stages of clinical trials and will need a few years before they can reach the market. Dr Pawar points to the PI hospital system, which is taking a global approach in the concurrent development and dissemination of CAR-T cell therapy.

CRISPR/Cas9 has already changed the field of gene editing by making it much simpler and faster to modify DNA sequences with high precision. It is very much doable to use CRISPR gene editing to remove a gene from immune T cells that encodes a protein called PD-1 that tumor cells can use to evade an immune attack. Dr Pawar even envisions off-the-shelf CAR-T cell therapy that is sourced from donors. By making two edits to the donor T-cells- to attack only cancer cells versus indiscriminately attacking the patient’s cells, and to cloak the T-cells so they don’t appear foreign to the body and deliver a more robust reaction, cancer can be effectively treated.

But perhaps the most exciting is going to be oncologists teaming up with microbes. In inflammatory disorders like cancer, the microbiome can help to stimulate an immune system that has been repressed and to regulate an overactive immune system. As our knowledge of the interaction between the immune system and the gut microbiome grows, we know that within the microbiome there are peptides that mimic antigens on the surface of tumors. These can be used to make the tumor visible to the immune system again.

The paradox of life is that it carries death with it as a body moves around with its shadow. Both are inseparable. But by having more light, shadows can be less frightening. Dr Pawar’s son has already become a medical doctor and he is doing his integrated master’s in Spain. His daughter is in architecture school and one of her dreams is to design an end-stage living module. May Dr Pawar’s tribe increase! 

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18 Comments

  1. Thanks Prof Tiwariji, for bringing out the noble deeds of another dedicated doctor!

    Your efforts to highlight the need for social awareness on cancer treatment are commendable!!

  2. Stupendous I should say.
    Your blog on Dr. Dilip Pawar highlighting his work on the dreaded word/disease – Cancer is an eye opener. The work already done and being done by him in caging Cancer is why I say it’s stupendous. Your bringing forth the intricacies for a common man to understand and explaining to fight the appalling disease is very appreciable. Kudos to you.
    All of us by now are aware if diagnosed early, cancer is curable but the million dollar question – How to know when that ‘early’ is in fact early?
    In my opinion especially for senior citizens a periodic body check and tests is a must even if apparently all seems fine. No harm there…
    Thanks Arun ji for this informative write.

  3. As a medical professional I simply loved your simple & lucid manner of highlighting the complex treatment modalities for cancer available today. Your sincere efforts to have a personalised approach, early screening measures are praiseworthy. I would like to join you in your noble task if possible.

  4. Socioeconomic status has always been a barrier to accessing adequate medical care. Being diagnosed with cancer only makes it harder to receive appropriate timely intervention. With overworked hospital staff, limited resources and treatment options, it only add to the already existing obstacles in receiving medical care. Healthcare needs some serious policy changes and advocates for timely and quality care. Appreciate all the efforts by Dr. Pawar, Dr. Chinnababu Sunkavalli and Grace Cancer Foundation.

  5. ‘Our hospitals are overcrowded, doctors are overworked, and the poor have no means to go to a private medical practitioner. So, early diagnosis of cancer remains a buzz word and unless people are approached at the community level, it is impossible to have any early cancer diagnosis’ Well put Prof Tiwari, community is where people live and interact with all that which is life, unless a way is found to meet the monster at the household level the battle will be far too long and wasteful of resources.

    Dr Pawar is courageously unpacking the process while showing the best way, unless science is integrated in a way that will address medical problems where they occur – cell level, academic degrees will be at most only be black and white substances with no value in this life.

    Dr Pawar is showing the world that solutions to human suffering are not just a domain of the rich and powerful but even those from the lowest rungs in the ladder of society, indeed may his tribe increase, more and more.
    May we all be inspired to do what is in our power to do, where we are for our common good!

  6. Because of the remarkable complexity of the cancer treatment trajectory and the increased focus on cost effectiveness, therapy is usually provided via an outpatient approach of care. A “broken,” “fractured,” or “siloed” healthcare system is what this model of care is described as because it requires patients to interact with a variety of healthcare professionals, such as oncology care providers, surgical specialists, and primary care providers, across multiple locations and healthcare environments, including acute care services, cancer centers, and primary health clinics. The actual cancer treatment is frequently multi-modal and may combine radiation therapy, systemic therapy, and/or surgical treatment.

    A patient-centered approach to care, which places the patient’s particular requirements, preferences, and values at the heart of a thorough and coordinated treatment plan, is in fact required to overcome the difficulties posed by a fragmented cancer care system. An increasingly popular method for enhancing the standard and continuity of care throughout the cancer care continuum is a mobile phone-based system. These objectives, however, are predicated on the underlying presumption that patients have access to necessities for daily survival, are part of a social support system, and possess the physical, psychological, and socioeconomic capacity to manage their own healthcare needs and successfully navigate a complicated healthcare system. The truth is considerably grimmer than we can even conceive, as Dr. Pawar correctly points out.

  7. I always used to wonder why you and Dr Kalam had been so passionately involved with medical technologies. After reading this blog I can see what captivates an engineering mind in developing medical treatments. “According to Dr Pawar, it is becoming more and more obvious that there will not be a single “cure” for cancer in the future. Instead, each patient will receive care that is tailored to meet their individual needs. But for personalized medicine to become a reality, we must have a wide enough selection of medicines to address every type of cancer. Personalized vaccinations, cell therapy, gene editing, and microbiome treatments are four technologies that will transform how cancer is treated.” I can see the best engineering brains have already gone into cancer treatment and with time the engagement will only intensify.

  8. About ten years ago, Sir, you introduced me to teleradiology, and since then, I must have handled hundreds of images that radiologists have read and reported. I had an intriguing experience last month. On a computer screen, two identical black-and-white images of hazy forms are displayed side by side. A fifteen-year-old radiologist has marked an area on the left where he thinks the fuzzy forms are prostate cancer that is slowly spreading. An artificial intelligence (AI) computer program has carried out the same action on the other side of the screen, and the outcomes are almost the same.

    The AI algorithm has examined thousands of MRI scans, including the black-and-white image of a patient with prostate cancer. I am aware that the AI model operates autonomously, locating the prostate and outlining regions that may be cancerous. Even radiologists admit that when prostate cancer is present, AI will assist less skilled radiologists in identifying it and flagging anything that might be misdiagnosed as cancer. When it comes to the nexus between cancer research and artificial intelligence, this model is just the beginning. Even though there are countless possible uses, a lot of this development is focused on AI tools for cancer imaging.

  9. कैंसर एक जटिल बीमारी है जो आनुवंशिक प्रवृत्ति, पर्यावरणीय जोखिम और जीवन शैली विकल्पों सहित कईयों कारकों के संयोजन के कारण विकसित हो सकती है। हालांकि बीमारी को रोकना हमेशा संभव नहीं होता है, फिर भी व्यक्ति इस बीमारी के विकास के जोखिम को कम करने के लिए कुछ कदम तो उठा ही सकते हैं।

    स्वस्थ रहने के सबसे प्रभावी तरीकों में से एक स्वस्थ जीवनशैली अपनाना है, जिसमें फलों, सब्जियों और साबुत अनाज से भरपूर संतुलित आहार खाना, नियमित शारीरिक गतिविधि में शामिल होना, स्वस्थ वजन बनाए रखना, तंबाकू और अत्यधिक शराब के सेवन से बचना, और अपनी त्वचा को धूप की क्षति से बचाना शामिल है।

    कैंसर की समझ लोगों को इस बीमारी से पीड़ित लोगों की बेहतर सहायता करने में सक्षम बनाती है, साथ ही लोगों को संभावित रूप से कैंसर को रोकने के जोखिमों को कम करने में भी मदद करती है। लोगों को उपचार के लिए ले जाने के लिए समय निकालने से लेकर, दूसरों को (और खुद को भी) बेहतर खाने के लिए जानने और प्रोत्साहित करने तक, कैंसर के प्रति जागरूक होने से कई तरह की मदद मिलती है।

    अनुशंसित कैंसर स्क्रीनिंग परीक्षण के साथ अद्यतन रहने की बात तो बराबर है पर व्यवस्था का भारी अभाव है। दिशानिर्देशों का पालन करके, और कैंसर के बारे में बेहतर जानकारी प्राप्त करके, लोग अपने स्वास्थ्य जोखिम को काफी कम कर सकते हैं, और एक स्वस्थ और खुशहाल जीवन का आनंद ले सकते हैं। डा. पवार और डा. चिन्ना बाबू के प्रयास सराहनीय हैं।

  10. Dear Sir, Great blog on the most dreaded disease. Hats off to Dr Pawar and Dr Chinnababu for their effort to address the root cause with early detection of the disease. Most people do not come forward for the early diagnosis test because they feel that if the test reveals that he/she has cancer, that is the end of their life. This effort needs a lot of effort in educating the villagers and urbanites alike. First, everybody has to be confident that this dreadful disease can be treated/managed if detected early. They need to be shown many examples, so they confidently subject themselves to screening. With advancements in technology, there is hope for conquering this disease. May the tribe of Dr Pawars and Dr Chinnibabus grow multifold to provide hope for the hopeless patients of this terminal disease. Thank you once again for an educative writeup creating hope for everyone

  11. Thank you for using your blog to draw attention to yet another crucial topic. The goal of early cancer diagnosis is to identify symptomatic individuals as soon as possible to give them the best chance of a successful course of treatment. A reduced chance of survival, more treatment-related issues, and higher cost of care are all consequences of delayed or inaccessible cancer therapy. By delivering care at the earliest possible stage, early diagnosis improves cancer outcomes, making it a crucial public health approach in all contexts.

    Early diagnosis is one technique, while screening is another. It is described as the presumed detection of undiagnosed disease in a population of individuals who appear healthy and asymptomatic using tests, examinations, or other processes that may be quickly and cheaply administered to the target population. The entire screening process, from inviting the target group to providing access to effective care for those who are identified with disease, must be included in a screening program.

    However, it is important to realize that, in contrast to early detection, cancer screening is a unique and more complicated public health strategy that necessitates additional funding, infrastructure, and coordination. Only when the screening programs’ efficacy has been established, when there are adequate resources to reach the target population, when there are facilities to confirm diagnoses and provide treatment, and when the disease is prevalent enough to warrant screening, should screening be conducted. I’m afraid that all of this is evasive, neither happening nor likely to happen.

  12. Dear Sir, Very informative blog on cancer treatment. Unfortunately, ONE of my relative recently diagnosed with tongue cancer, however being a doctor family, my brother diagnosed the tumour at a very early stage and the tumour is operated successfully. We are expecting good outcome of surgery and.a long fruitful life of the patient.

    Yes, early diagnosis is the key factor in cancer treatment, but the diet management plays and important role. Intermittent fasting helps the cancer gene to be in dormant state for a long period. Hopefully in near future we will have personalised gene therapy available in market for cancer treatment and will be able to save more lives. Warm Regards,

  13. Thanks for sharing the challenges of cancer patients…may the force be with Dr Pawar and others like him.

  14. An authentic picture of the plight of cancer patients from most credible people! As a Healthcare management researcher, I see the issue of high disease burden compounded with late-stage detection caused mainly due to lack of awareness and low penetration of screening programs. India has a poor cancer detection rate of some 30%, with only 15% of breast-lung cancers being diagnosed in stages 1 and 2, respectively, which is significantly lesser than that in China, forget about the developed world.

    While at one hand incidence is rising, deaths due to cancer have remained among the top 5 causes of deaths in India over the last decade. The total deaths due to cancer were more than 10 lakhs in 2022, causing the mortality to incidence ratio for different cancer types in India being among the poorest compared to global counterparts.

    Given the current state of rising cancer disease burden and sub-optimal quality of outcomes, there is a significant need to understand the current challenges and tailor interventions across the different stages of disease management with a deep focus on awareness, detection, and end-stage treatment.

    Dr Dilip Pawar is spot on emphasizing the urgent need of support to end of life palliative care. It can’t be left alone upon the nursing homes and society must rise to the occasion with financial support. I suggest a mobile phone based digital platform for registering every cancer patient and tracking their needs pooling upon the resources and soliciting them from wherever they can come. Interested donors my give whatever little amount they feel like giving that can reach the needy patient in an anonymous way. Thank you for posting Sir.

  15. Great blog. Very informative. And thank you for highlighting the wonderful work also being done by the Grace Cancer Foundation and Dr. Chinnababu Sunkavalli through innovative methods to reach the rural poor in need of healthcare.

  16. Respected Sir, your blog on Dr. Dilip Pawar and his life’s work is incredibly sympathetic. The need for social assistance has increased as a result of rising cancer prevalence and survival rates combined with earlier patient discharges from hospitals. Acute treatments, treatments for remission, and long-term monitoring and treatment plans are all components of comprehensive cancer care. Given their current workload, health care institutions frequently struggle to offer everyone access to social support networks. There aren’t many caregivers, and even when there are, they frequently lack the knowledge, abilities, or resources essential to satisfy the requirements of cancer patients.

    Numerous difficulties arise when providing care, and the caregivers themselves frequently require social support. Despite these demands, the majority of social assistance services are only intended for patients. Knowing who requires social support is essential given the incidence of cancer and the requirements of cancer patients and those who care for them. For effective patient care, social support services must also be scalable and widely accessible. We must investigate novel approaches to employing digital tools to identify patients who might benefit from social support, as well as possible benefits of digital social support programs.

  17. Great Blog. Very educative. Congratulations to Dr Pawar. Thank you Arun ji for writing on such exemplary people concerned about poor of India.

  18. Very inspiring story about a family of doctors committed to improving quality of life and fighting cancer!

    With scientific advances and technology, there’s hope for neutralizing cancer …

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