Cancer is a disease that demands long-term, resource-intensive treatment, posing an especially heavy burden in low- and middle-income countries (LMICs). In nations like India, where a significant portion of the population comprises daily wage earners, farmers, and small shop owners living in villages, the challenges are even more pronounced. For these individuals, a cancer diagnosis can feel like a death sentence—not just due to the disease itself but because of the overwhelming socioeconomic impacts of treatment.

The reality of cancer treatment in LMICs

Cancer treatments such as surgery, chemotherapy, and radiation therapy demand time, money, and proximity to health care facilities. Surgical recovery can take at least a month, radiation therapy often lasts six to eight weeks, and chemotherapy can stretch over three to six months. Alongside the physical burden, the psychological stress of cancer—fear of recurrence, anxiety, depression, and lingering fatigue—can last for months or even years after treatment ends.

For patients from economically disadvantaged backgrounds, the cancer journey requires the full support of their families. Caretakers—whether they be spouses, parents, or children—play a crucial role in ensuring adherence to treatment protocols and in providing emotional and logistical support. This family-driven care environment can offer a sense of hope and encouragement to the patient. However, in India, where many households depend on daily wages, the story is far more complex.

The financial trap

Daily wage earners and laborers cannot afford to stop working for extended periods without jeopardizing their livelihood. They rely on their daily income not only to sustain their families but also to afford necessities like food and shelter. When cancer strikes, these patients face a harsh reality: leave their jobs to undergo prolonged treatment and risk financial ruin or continue working and risk their lives.

The financial strain begins at diagnosis and deepens as treatment progresses. Although surgery can be covered under government schemes like the Pradhan Mantri Jan Arogya Yojana (PMJAY), the subsequent phases of treatment—radiation therapy and chemotherapy—pose significant barriers. In Gujarat state, only 10 out of 33 districts have radiation therapy machines, forcing patients to travel long distances, often to major cities, to complete their treatment. Even with financial support from the government, such as a daily travel stipend of 200 rupees, patients lose their primary source of income. Caregivers, too, must leave their jobs, which further exacerbates the economic burden.

Myths, misconceptions, and low adherence

Another significant issue is the widespread myths and misconceptions surrounding cancer treatment. In many rural communities, cancer is still seen as an incurable disease, particularly when a patient’s condition worsens after starting chemotherapy or radiation therapy. Anecdotal stories circulate about patients whose health declined after receiving treatment, fueling fear and reluctance among others to seek care.

Modern radiotherapy techniques like 3D CRT (conformal radiotherapy) and IGRT (image-guided radiotherapy) have reduced side effects dramatically compared to older technologies like 2D RT and cobalt-based machines. Still, these advancements are not always well understood by the public. The fear of debilitating side effects often leads patients to forgo radiation therapy, which significantly increases their risk of recurrence.

The result is a vicious cycle: patients either delay or avoid necessary treatment, leading to advanced-stage cancer by the time they seek help, further reinforcing the stigma that “cancer is not curable.”

Structural challenges: Access and resources

The logistical barriers faced by rural cancer patients extend beyond financial issues and misinformation. The geographic distribution of oncology services in India remains skewed toward urban centers, leaving much of the rural population underserved. Tertiary care centers with specialized equipment and oncologists are few and far between. Even as the government offers advanced techniques like robotic surgery, HIPEC, and laparoscopic procedures at lower rates, these innovations rarely reach rural populations. The disparity between the latest cancer care technologies and their availability to the lowest strata of society raises the question: Are we truly closing the care gap?

The way forward: Practical solutions

To address the challenges in cancer care for low-income patients, several measures must be considered:

• Busting myths and misconceptions: A widespread education campaign is essential to dispel the myths surrounding cancer treatments, especially chemotherapy and radiation therapy. Many rural communities hold misconceptions that worsen patient outcomes due to non-adherence. Public health initiatives should focus on educating both patients and their families about the true side effects and benefits of modern cancer treatments, using local health care workers and community outreach programs.

• Supporting patients’ relatives: Given the long duration of cancer treatments, it is important to provide support not only for patients but also for their caregivers, who often have to leave their jobs to accompany the patient to major tertiary cancer centers. Programs could be developed to provide employment opportunities for caregivers during the patient’s treatment, either through temporary work near the treatment centers or financial assistance to offset the loss of income.

• Adequacy of government cancer hospitals and regional centers: While institutions like government cancer hospitals, regional cancer centers, and Tata Memorial Hospital provide critical services, they are not enough to cater to the vast population in need of care, especially in rural areas. These facilities often become overwhelmed, and the long distances that patients must travel to access them contribute to delays in treatment and poor adherence.

• Rethinking the allocation of advanced techniques: The government offers advanced procedures like robotic surgeries, HIPEC, and laparoscopic surgeries at reduced rates under PMJAY. However, it is essential to ensure that these treatments are provided in a manner that keeps both the surgeons motivated and the hospitals sustainable. Offering cutting-edge procedures at rates that strain hospital resources or demotivate surgeons may lead to a reduction in care quality or accessibility.

• Motivating oncologists in tier 2 and tier 3 cities: Establishing more AIIMS or Tata Memorial-like centers is not the sole solution to the health care gap. Instead, efforts should be made to motivate oncologists to practice in tier 2 and tier 3 cities, where access to specialized cancer care is still limited. This includes increasing super-specialty seats in medical training programs, offering financial incentives, and improving infrastructure in these regions to support advanced cancer treatments.

• Ensuring advanced techniques reach all strata of society: While advanced surgical techniques like free flaps, robotic surgeries, laparoscopic procedures, and therapeutic radiological interventions are available, they often remain out of reach for the lower socioeconomic strata due to non-affordability or lack of access. If we are to truly close the care gap, these latest techniques must be made accessible and affordable to everyone, regardless of their financial background.

Are we closing the care gap? Not yet

The current state of cancer care in India, particularly for daily wage earners and rural populations, reveals that while the government has made strides through initiatives like PMJAY, significant gaps remain. The burden of long treatment durations, financial strain, and deeply embedded myths make it difficult for patients to complete their cancer treatment, leading to higher mortality rates and a continued stigma around the disease.

If we are to truly close the care gap, we must go beyond building advanced cancer hospitals and offering high-tech surgeries. Instead, we must focus on empowering local health care systems, educating communities, and providing holistic financial support to both patients and their families. Only then can we hope to create an environment where every cancer patient, regardless of their socioeconomic background, can receive the care they need—and deserve.

In conclusion, while significant strides have been made in improving cancer care, particularly with government initiatives like PMJAY, we are not yet closing the care gap. As per the mission set by the Union for International Cancer Control (UICC), more needs to be done to ensure that every patient—regardless of economic status or geographic location—can access timely, affordable, and advanced cancer care.

Bhavin P. Vadodariya is a surgical oncologist in India.