INTERVIEW| Kerala matches west in treatment, but cancer mortality rate higher

Dr Moni Abraham Kuriakose co-founder, medical director, and CEO of Karkinos Kerala is a leading surgical oncologist and former director of the Cochin Cancer Research Centre and Narayana Health City, Bengaluru. A pioneer in technology-led, integrated cancer care, he leads Karkinos nationwide network of 85 community cancer clinics aimed at linking primary healthcare with oncology. He believes this model bringing diagnosis and support closer to the community can significantly improve Keralas persistently high cancer mortality. Excerpts from his interaction with TNIE You studied in Bristol and Ireland and worked in the US, yet returned to Kerala. What drew you back? My path changed when I was diagnosed with thyroid cancer during dental school at Manipal. That experience drew me to oncology. A Rotary scholarship took me to England, where oral cancer surgeries are done by maxillofacial surgeons, so I trained in that field. After 10 years in the UK, and 10 in the US, I still felt I should return homethough it wasnt planned. In 2003, after hearing Mata Amritanandamayi speak about establishing a voluntary cancer institute, I took a years leave from my tenured post at New York University to join Amrita. That one year became permanent. The cancer rates reported in Kerala are among the highest in the country. Why? Kerala has 134 cases per lakh, second only to Mizoram (140). The national average is 74. As far as Kerala is concerned, high life expectancy (77 years), westernised lifestyles, strong health-seeking behaviour, and better diagnostics all contribute. As people live longer and undergo more tests, more cancers are detected. What lifestyle factors matter most? About 30% of cancers are linked to tobacco and alcohol, and another 30% to obesity and related inflammation. Poor diets, refined foods, and sedentary lifestyles add to the risk. Previous generations walked kilometres daily; that culture is fading. How good is the cancer treatment in Kerala compared to advanced countries? Kerala has expanded from three cancer centres in the 1980s to 26 specialised centres today. Technologies and medicines are on par with Western countries. Yet mortality remains around 50%, compared to 30% in the US, mainly because 70% of the cases are diagnosed late. Thats where our system falls short. Why do outcomes remain poor despite better facilities? In other countries, primary healthcare doctors are an integral part of cancer care. In Kerala, however, the rest of the health system is not linked to cancer care. For heart disease and diabetes, primary doctors are involved. In the case of cancer, patients bypass the system and go straight to major centres. Early warning signs are missed. To bridge this gap, we launched Karkinos, which links cancer care to the broader healthcare system through community cancer clinics. These centres help people seek evaluation at the first symptom. We now have 85 clinics across India. Are we lacking in medicines and equipment, or in approach? Almost all advanced drugs and technologies available in developed countries are available here. Whats missing is process- and protocol-driven care. Patients often go doctor shopping, breaking continuity and lowering compliancebreast cancer guideline adherence can be as low as 60%. Doctors too sometimes work in silos instead of tumour boards. Unlike heart attacks, cancer isnt an immediate emergency, but fear often pushes patients to large centres and disrupts coordinated care. These systemic gapspoor continuity, low adherence, lack of integrationare why our outcomes lag. Should patients approach tumour boards themselves? No. The oncologist should take the lead. But every cancer case must be discussed by a tumour board. Once a plan is set, parts of the treatment like radiotherapy can be done in smaller centres. In Wales, which has a population similar to Keralas, there are only two major cancer centres, yet district hospitals deliver most treatments. Their outcomes are better because they rigorously follow protocols and nurse-led oncology care. That system of discipline is what we need. Do we have such protocols in Kerala? Yes. Kerala framed guidelines in 2000 and follows the National Cancer Grid. Under KASP insurance, tumour board review is mandatory. But adherence is poor, especially in the private sector. The guidelines exist largely on paper. What happens when a hospital lacks radiotherapy? Without tumour boards, hospitals treat patients with whatever they have... this is harmful. In our (Karkinos) Kattappana centre, tumour boards decide the plan and patients needing radiotherapy are referred to Kottayam. Thats how coordinated cancer care should work. Patients and families should insist on tumour board evaluation before starting treatment. How much of cancer is preventable? About 30% can be prevented and another 30% detected early. Avoiding tobacco, alcohol, obesity, low-fibre diets, and inactivity significantly reduces risk. Despite health awareness, why are cancer cases still increasing? Thats because diagnostics have become too sensitive. Thyroid cancer increased 100-fold in the US and South Korea when ultrasound began to be used widely, but deaths did not rise. We see the same pattern in Kerala. Guidelines say nodules under 1 cm shouldnt be treated as cancer, but fear pushes patients and doctors toward unnecessary surgery. Are small thyroid cancers dangerous? Not always. Japan has shown that thousands of such cases can be safely observed. In Bengaluru, weve followed patients for 15 years without surgery. Postmortem studies show up to 60% of elderly people have thyroid cancer without knowing it. Some cancers need monitoring, not aggressive treatment. But any symptom should be evaluated by a doctor. Which cancers should be feared? Anaplastic thyroid cancer is one of the few cancers that must be truly feared because it progresses extremely fast and survival can be as short as three months. Pancreatic and liver cancers are also very aggressive, mostly diagnosed late, and therefore have very low cure rates. Why is colon cancer increasing? Is it lifestyle-linked? In most casesnearly 80 to 90%colon cancer is connected to lifestyle, with only a small proportion being hereditary. The biggest factor is a low-roughage diet... theres no harm in eating meat, but people must balance it with fruits and vegetables. The good thing is that colon cancer is easy to detect through simple tests like FIT (faecal immunochemical test) but people must take the initiative to get screened. People say diet guidelines keep changing. What should we follow? The governments ideal plate remains the simplest and most reliable guide: half the plate should be fruits and vegetables, one quarter carbohydrates and the rest proteins. If people follow this, they wont have to chase every new diet trend. How was your experience working in the government sector? Only the government can create large-scale changeprogrammes like the Ernakulam District Cancer Control Programme are possible only through the public systembut the pace is extremely slow and heavily bureaucratic, which makes it difficult to meet timelines. Thats why I eventually stepped down after three years. The private sector offers advanced treatment, but it lacks the structure needed for organised, population-level cancer control. Why do bureaucratic delays persist? How can we fix them? Change will happen only when the public pushes for it because we are part of the system and elect those who run it. The problem is that we are illness-conscious, not wellness-conscious. When we launched an early detection package costing just Rs 2,000, hardly anyone came forward, though early diagnosis saves lives. Until people demand services and actively participate, delays will continue. How effective are cancer vaccines? The cervical cancer vaccine is extremely effective and has contributed to a clear drop in cases, which are now around 11 per lakh. It should be given at 12 to 14 years of age, but many people still hesitate because the benefits have not been communicated well enough. Why are younger people in Kerala getting cancer? We cannot pinpoint a single reason, but we know that breast cancer appears almost 10 years earlier in Kerala than in many other places, and oral cancer also occurs at younger ages, likely because habits like nicotine and gutka use begin early. National studies exist, but we still need Kerala-specific research to understand the trend better. What major differences do you see between healthcare in Kerala and the US? The US system follows strict guideline-based processes and patients willingly join clinical trials, which often leads to better outcomes. In Kerala, trials still carry a negative image, and that lack of participation slows innovation and limits access to the newest treatments. What role should centres like Regional Cancer Centre, Thiruvananthapuram, and Cochin Cancer Centre play? These institutions should become hubs of innovation and research rather than being judged only on the number of patients treated. Kerala needs its own protocols and technological advancements. Because of Dr Krishnan Nairs legacy, people still rush first to RCC, but what we need now is a decentralised model where PHCs do screening, taluk hospitals do biopsies, and district hospitals handle chemotherapy, with only rare and complex cases going to RCC or CCC. Are all cancers curable? If a cancer does not return within five years, most patients can be considered cured, although some cancers like breast cancer may recur later and need longer follow-up. There is no vaccine that prevents recurrence; early detection and proper treatment are what matter. How much does heredity contribute to cancer? Only about 5 to 10% of cancers are hereditary, mostly breast, colon, and ovarian cancers. The vast majority are not related to family history. Is cancer still a stigma? Yes, especially for younger patients. Many people still believe cancer is something to hide or fear though many cancers today are completely curable when detected early. What cancers are common among children? Childhood cancers are usually blood cancers and brain cancers, which are genomic rather than lifestyle-related. The good news is that treatment outcomes have improved dramatically, with cure rates now at 85 to 90% using chemotherapy and targeted therapy instead of older radiation-heavy approaches. Do men and women cope with cancer differently? Men often hide their emotions and carry the burden silently, while women tend to express themselves more and get more support. Understanding these differences helps doctors prepare patients mentally for the treatment journey, which is as important as the physical treatment. The US government rolled out the Cancer Moonshot. What was your experience with it? I had the opportunity to go to the White House as part of that. They wanted to tie up with India during the Moonshot programme implementation. That initiative began many years ago, and in the second phase, they wanted to broaden it to the rest of the world. We visited the White House and presented Indias agenda. The basic idea was that there is a huge amount of data availableclinical details, pathology, genomics, treatment response, personality traitsall of which, if collated and analysed using data science, can drive innovation. But thats difficult to do in America because data sharing across hospitals is highly regulated. That was what Biden was trying to change through the Moonshot, but it couldnt be fully implemented. In India, however, the Ayushman Bharat Digital Mission has created a legal framework for data sharing for innovation, and if implemented well, it can transform healthcare. You have spoken about willpower. Does belief in God make a difference? Belief acts like an anchor. Cancer brings physical, emotional, and financial burdens, and faith helps many people cope without falling apart. In India, most people grow up with some sense of God, which offers comfort. I have seen patients who, despite very poor odds, remained calm and convinced they would get betterand sometimes the disease simply melted away. I cannot prove belief caused it, but I have no doubt that faith and mental strength influence how patients endure treatment. What are your thoughts on integrating ayurveda with modern medicine? Ayurveda is a strong medical system, but its problem is a lack of structured clinical trials. It works but success often depends on the individual doctor. Modern medicine became reliable because processes were standardised and tested. Why must we shift from a curative model to a preventive one? People must realise that health is their responsibility. Cancer need not be feared if detected early. It is fundamentally a genomic disease that grows more aggressive as it progresses, but early-stage disease is manageable. Immunotherapy and advanced treatments help only when the disease is caught in time. Prevention and early detection will always outperform late treatment. How important is genomics in cancer treatment today? Genomics drives almost everything we do nowfrom identifying driver mutations to detecting recurrence through circulating tumour DNA. Earlier, we didnt have the tools to target specific mutations; now most innovation is built on cancer genomics. Are there regional variations in cancer across Kerala? Kerala doesnt have a statewide registry, but the registries in Thiruvananthapuram, Karunagappally and Malabar show mild variations. Some areas show more colon or breast cancer but, overall, Kerala is uniform. Across India, however, the differences are largesouth India has more breast cancer, north India more oral cancer, and the Gangetic belt more gallbladder cancer. Are breast cancer cases rising? Should women marry earlier? Breast cancer cases are rising, and one in four women today is at risk. Lifestyle factors and delayed pregnancies play a role, but I dont recommend early marriage. What I strongly recommend is regular screening and breast self-examination from a young age. Why is early detection so important? Early detection makes cancer completely curable. The problem is that people usually get tested only after symptoms begin. Self-examination and timely testing can save lives. How transformative can Ayushman Bharat be? If implemented fully, it can revolutionise healthcare. Like the banking system that lets us access money anywhere, a unified health data system will allow continuity of care, without compromising privacy. How advanced is China in this field? Are they relying on traditional systems? I worked for six months at the Beijing Cancer Center, and the transformation I saw between my first visit years ago and my recent visit three years back is remarkable. They are technologically far ahead... they conduct genomic testing for almost all tumours, funded by the government, and they have multiple robotic systems and well-trained surgeons. They also have traditional medicine, but they keep it separate rather than integrating it with modern treatment. Can AI reduce healthcare costs? Yes. In our work, smartphone-based imaging combined with AI reached almost the same accuracy as specialists. With larger datasets, AI will become even more precise. It democratises expertise and allows health workers to detect disease early at very low cost. How do you assess Keralas health-seeking behaviour? Keralas people seek care promptly, which is good, but they rush to large hospitals even for minor issues. We must build trust in local doctors for routine care and reserve tertiary centres for complex cases. What should an ideal cancer care system look like? Cancer care should be engineered like diabetes care. Every GP or ENT doctor must know how to screen common cancers and refer for biopsy. A virtual tumour board should decide treatment and routine therapies should be available locally. Only rare, complex cases should go to specialised centres. How do you approach terminal cases? I remind patients that none of us live forever. My role is to tell the truth with compassion and ensure they are cared for. Keralas palliative network is excellent and helps people die with dignity at home rather than in ICUs. Giving chemotherapy till the last day is easy; guiding families through the final phase is the real responsibility. Why are hospital deaths so high? Its partly culturalfamilies still rush to hospitals even when the end is near. We must educate people that dying at home, surrounded by loved ones, can be much more peaceful and reduces catastrophic medical expenses. Are we short of oncologists? Yes. Kerala needs far more medical oncologists, and training must expand beyond major centres. Diploma-type programmes across more hospitals could help. TNIE team: Kiran Prakash, Cithara Paul, Rajesh Abraham, Rajesh Ravi, Anna Jose Harikrishna B A Sanesh (photos) Pranav V P (video)