The noted surgical oncologist heads a surgical oncology unit at Apollo Hospital.
Brought up in Srinagar, Kashmir where he studied at the Burn Hall School, Dr. Sameer Kaul did his MBBS from Government Medical College, Srinagar in 1978, followed by a Master’s in Surgical Oncology at the Tata Memorial Hospital, Mumbai.
Later, having acquired varied surgical skills at Nanavati Hospital, Jaslok Hospital, KEM Hospital and Breach Candy Hospital in Mumbai, Dr. Kaul left for London to work at the Royal Marsden Cancer Hospital. He got Fellowship in Oncology in London.
“I always intended to return to India and practice here. It was never my intention to stay on in London,” recalls Dr. Kaul. In 1993, he joined the Batra Hospital, New Delhi, as Consultant Surgical and Clinical Oncologist. And, now, for over 20 years, he is at the Apollo Cancer Institute, New Delhi, as Senior Consultant Surgical & Clinical Oncology. Dr. Kaul is one of the core founders and head of the Surgical Oncology Unit – I, known as Onkaulogy Kombine.
He conducts monthly outpatient clinics at Apollo Cancer Institute, Cancer Centenary Centre, Delhi and at various hospitals in Kashmir. Since 1998, Dr. Kaul has been the oncology adviser for the government of J&K, and is responsible for the entire planning of oncology services in the UT.
He is also the founding President of a successful non-governmental organization, which began as the Breast Cancer Patients Benefit Foundation (BCPBF) – now known as The Cancer Foundation. The foundation strives to offer better cancer care to economically underprivileged patients in India and spread awareness about the dreaded disease. It runs a Central Drug Repository and, most importantly, trains clinicians in the field of oncology across India and the neighbouring countries, as well as those from Congo, Mauritius and other places, often leading up to fellowship.
Dr. Kaul’s interest lies in popularizing innovative techniques in oncology. “I have pioneered several new technologies in India. The port insertion technology was brought to India by me,” he explains. The chemo port is a small, implantable device that attaches to a vein (usually in the upper chest area). It allows healthcare providers to draw blood and give treatments, including chemotherapy drugs, without a needle stick. A port can remain in place for weeks, months or even years. A young Kashmiri girl was the first cancer patient to receive the port. Unfortunately, she did not survive.
The other innovations pioneered in India by Dr. Kaul include Primary Reconstruction for Breast, and Radiofrequency Ablation.
Speaking about the holistic cancer treatments provided in current times, he explains that “besides medical oncologist, surgical oncologist and radiation oncologist, the team also includes, and very importantly, genetic counsellors and psychologists.”
Medical oncologists treat cancer using medication, including chemotherapy, immunotherapy, and targeted therapy. Surgical oncologists treat cancer using surgery, including removing the tumour and nearby tissue during an operation. A surgical oncologist can also perform certain types of biopsies to help diagnose cancer. Radiation oncologists treat cancer using radiation therapy, which is the use of high-energy x-rays or other particles to destroy cancer cells.
Further specialisations include oncologists who specialize in caring for specific groups of patients or groups of cancers, such as geriatric oncologists (for patients of age 65 and above), gynaecologic oncologists (reproductive organs), haematologist-oncologists (blood cancer), neuro-oncologists (cancer of brain, spine and nervous system) and paediatric oncologists ( for treating children).
Dr Kaul specialises in cancer of the organs, which excludes disorders of the blood stream, lymph nodes etc.
“Genetic counsellors,” he says, “are increasingly becoming a part of cancer treatment teams due to huge overlay of genetics.”
A cancer genetic counsellor, as Dr. Kaul explains, evaluates family health history and talks about risks for inherited cancer. Genetic education and counselling allow individuals to understand the risks, benefits, and limitations of genetic testing. This also allows individuals to consider possible medical uncertainties, cancer diagnoses, and/or medical management plans that accompany certain genetic test results. Asked about the fear of cancer which remains despite a great deal of advancements in the field of pharma and technology, he says: “Although cancer never causes certain death as in the case of, say a cardiac arrest, it is a painful lingering disability which can affect your work, your life and also the life of your care-givers, which in India is almost always the family. The added hopelessness of uncertain outcomes makes it a dreaded illness.”
And this is where the role of a psychologist becomes imperative. Dr Kaul adds that, although, he wades across other spheres of cancer, that is, the how and why, the aetiology of cancer, pathogenesis and general guidance, which is essential in patient care before and beyond surgery. Surgery, he says, is a miniscule part of the treatment – it is essential to include psychologists. Psychologists provide support to patients from prevention through diagnosis, treatment, recovery, or the dying process. They also aid and educate other healthcare professionals in areas that aim to improve patients’ well-being, such as how to optimally break bad news and care for patient and the caregiver.
Stages of Cancer
Dr. Kaul elaborates on the stages of cancer and treatments. Cancer is typically labelled and understood in stages from I to IV, with IV being the most serious. There is also a stage 0 and sub-stages of each stage. Stage 0 means there’s no cancer, only abnormal cells with the potential to become cancer. Stage I means the cancer is small and only in one area and is in early stage. Stage II and III mean the cancer is larger and has grown into nearby tissues or lymph nodes. Stage IV means the cancer has spread to other parts of your body. It’s also called advanced or metastatic cancer.
It’s important to understand the cancer stage for treatment, possible outcomes and research based on database of stage treatments. The stages are decided based on information from test results (clinical stage) or possibly the tumour itself (pathologic stage). The tests include blood test, X-ray, MRI, CT scan, ultrasound and biopsy, among others. The results are discussed by the tumour board to plan out the process and staging of treatment.
The treatment for Stage IV patients, in most cases, is not about cure but of quality prolonged life. There have been cases of patients getting cured at stage 4, however, for the majority the re-defined cure is keeping the person alive. Even in cured patients, there is always a chance of recurrence, except perhaps in Stage 1 & 2 patients.
With newer techniques of immunotherapy and targeted therapy, which have a better sideeffects profile than chemotherapy, many are living a normal life.
One of the other diagnosis and preventive care includes the proteomics approach to identify the characteristics of drug-resistant cancer cells and discover targets that can overcome drug resistance that develops during anti-cancer treatment.
While genomics is the study of the complete set DNA in an organism, proteomics is the comprehensive study of the complete set of proteins in an organism. Analyzing the proteome of a patient’s cancer can also provide information on how to best diagnose and treat the patient. In the past researchers often studied patients’ cancer genomes and proteomes separately. In 2016, three research teams combined the comprehensive analysis of patients’ cancer genomes and proteomes, creating a new area of research called proteogenomics, which produces a more complete and unified picture of cancer biology than analyzing genomics and proteomics separately. Dr Kaul adds that 30% of cancers are caused by genetics.
In the proteogenomics approach, Dr Kaul cites the example of Angelina Jolie, who at age 37 underwent a preventive double mastectomy after learning she had an 87% risk of developing breast cancer due to a defective BRCA1 gene from her maternal side of the family. Following the mastectomy, which lowered her chances of developing breast cancer to under five per cent, Jolie had a breast reconstructive surgery. Two years later, after annual test results indicated possible signs of early ovarian cancer, she underwent a preventive surgery for removal of an ovary and its fallopian tube, as she had a fifty per cent risk of developing ovarian cancer due to the same genetic anomaly.
Discussing the role of genetics and change of lifestyle and environment, Dr Kaul gives the example of the people of Japan who migrated to North America. The second and third generations had developed breast cancers with no prior cases in their families in Japan. The cancers had developed owing to changes in lifestyles and habitats. Such changes and other studies are monitored by the International Agency for Research on Cancer in Lyon, France and The Union for International Cancer Control (UICC), Geneva, Switzerland.
The regional and state-wise data on cancer, in India, is monitored by the Indian Council of Medical Research (ICMR) through the National Cancer Registry Programme (NCRP) with a network of cancer registries across the country.
The other set of diagnosis and treatments include Molecular diagnosis, radioimmune conjugates and chemotherapeutic agents. Molecular testing can reveal changes or alterations (mutations) in a person’s genes that may cause illness or disease. It is essentially a way of understanding pathways at cellular level, which can be interrupted with new agents, resulting in targeted therapy. Radioimmunotherapy (RIT) represents a selective internal radiation therapy, while chemotherapeutic agents (also referred to as antineoplastic agents) are used to directly or indirectly inhibit the uncontrolled growth and proliferation of cancer cells.
However, explaining these new techniques, Dr. Kaul adds: “In India the last-mile outreach of information and awareness has a long way to go.”
As per the World Bank report, India falls in the lower-middle income group and the health budget is a meagre 2.1% (2022-23). He believes that although projects like Ayushman Bharat Digital Mission and local area public health care centres have made considerable progress, India has a long way to go in medical care.
“The health care system needs to be a value-driven system where a person spending a few hundreds to lakhs of rupees knows he has received value for his money. It is not just about affordability,” he reiterates.
“The government,” he says, “needs to set its priorities and increase health budgets and at the same time encourage research.”
In India, considering the demographic profiles, Dr. Kaul believes it is essential to strike a balance between socialism and capitalism. “Retrograde laws need to be disposed of to encourage a scientific temperament for original research. Brain drain is very much a reality. Experts from India are sought in the West for research,” he says.
In India, the Indian Council of Medical Research ICMR, an autonomous body, although one of the oldest and largest medical research bodies in the world, does not receive sufficient funds from the Government of India. Dr Kaul says that the only way it could function properly in India is by way of a Public Private Partnership (PPP) model.
It is not that the health models in the US and Europe have no problems. In fact, every new President has announced a new healthcare model, however, the issues in India are precariously huge. Affordability, awareness, good facilities are some of the issues besides medical health insurance. As per Statista, in financial year 2022, India’s life insurance penetration stood at around three per cent, while the non-life insurance penetration was much lower at one per cent. The overall penetration for the industry was over four per cent in 2022.
According to the 2021 NITI Aayog report, The Ayushman Bharat scheme covers approximately 50% of the population. Around 20% of the population is covered under social health insurance and private voluntary health insurance. The remaining 30% of the population lacks any financial backing for healthcare treatment – this segment is termed the ‘missing middle’ because they are not poor enough to be covered by government-subsidized schemes but not rich enough to afford private health insurance. However, the actual number of uncovered individuals is much higher due to the existing coverage gap in the Ayushman Bharat scheme.
Medical procedures of cancer treatment, transplants etc. are expensive. Overburdened government hospitals often delay in offering timely treatment which makes individuals seek medical care in the costlier private hospitals. The Insurance Regulatory and Development Authority (IRDAI) has directed all health insurance companies to offer obligatory Arogya Sanjeevani policies since April 2020. However, the policy provides coverage up to Rs 5 lakh – 10 lakhs for essential healthcare treatment, which is not sufficient to cover advanced treatments, transplants, and critical surgeries.The funds available for training of doctors are almost non-existent.
AI and Robotics
Dr Kaul has trained in several techniques, besides the ones already mentioned, such as radiofrequency ablation (minimally invasive technique that shrinks the size of tumours, nodules or other growths in the body), and induced coagulative necrosis in cancer patients (causing cell death with radiofrequency). He has also trained in immediate breast reconstruction and performed this procedure on the first 200 cases in the country.
Another field he has worked in is robotics. For some types of cancers, traditional open surgery may not be the best option. With robotic surgery, specially trained surgeons use robotic technology, including tiny surgical tools and a computer console, to remove a patient’s cancer. While he has worked with robotics, he says there is much more to come with the new technologies such as Artificial Intelligence and perhaps many more in the future.
About his work in Kashmir, Dr Kaul has been associated with several private hospitals, and has been going there once a month for almost thirty years now. Currently he is associated with a hospital in Anantnag, in a semi-rural region. Although he sees patients there on a regular basis, the surgeries are done in Apollo Hospital, Delhi. He is working on providing surgery there also.
As everywhere else, there has been a change in demographics and hence the associated cancers. With almost twenty years added to human life, there is an increase in cancers of the old age such as gastrointestinal, lung and prostrate, while some others may have gone down.
As observed by Dr. Kaul, the lifestyle of Kashmiris, that is, consumption of high amounts of red meat, large quantities of oil and high degree of smoking among males, is the main cause of gastrointestinal, breast and lung cancers. Dr Kaul smilingly adds that “moderation is not a way of life for the Kashmiris, whether it is eating, mehman-nawaazi – hospitality – or emotions.”
Another factor, and a very important one, is the interconnected or the inter-family marriage in the community that doubles the risk of birth defects and genetic disorders. Multiple studies have established consanguinity as a high cause for birth defects and abnormalities.
Although the conflict and related stress are not counted among the direct causative factors, the prolonged conflict in the Valley has laid bare the state of the medical systems and dire shortage of facilities. This however, as Dr Kaul elaborates, is true for not just the whole country but the entire world, awakened by the rude shock of the pandemic. Covid in a way restored the balance, right up to WHO, in terms of money spent on research on communicable versus non-communicable diseases.
About his work in future, Dr Kaul says that till now 70% of his time was spent in clinical work, but he is slowly working at reversing this to give more time to his passions, which include his foundation, entrepreneurship and politics – he’s the spokesperson of National Conference. He enjoys playing the noat – a clay/copper pitcher used in Kashmiri folk music – besides singing folk songs.
Jaspreet Kaur is a Delhi-based architect, urban designer, Trustee Lymewoods & Span Foundation and Consulting Editor of Kashmir Newsline.