Immunotherapy for cancer in India: who it suits, cost

How it works: Releases the immune system's brakes rather than poisoning cancer cells
Main class: Checkpoint inhibitors, given by drip every few weeks
Testing first: PD-L1, MSI or TMB testing often decides whether you are eligible
Responds well: Melanoma, some lung, kidney, bladder and head and neck cancers
Side effects: Different from chemotherapy: immune-related, and need prompt attention
Cost: Among the more expensive treatments anywhere. Written estimate before you travel

How it actually works

Your immune system is capable of killing cancer cells, and often does so unnoticed. Cancers that grow have usually found a way to switch that response off. Many do it by pressing on molecular brakes called checkpoints, which normally exist to stop the immune system attacking healthy tissue. The cancer exploits them and becomes effectively invisible.

Checkpoint inhibitors block that trick. They do not poison the cancer the way chemotherapy does, and they do not burn it the way radiation does. They release the brake, and your own immune cells do the work. That difference explains almost everything else about immunotherapy: why responses can last a long time once they begin, why they can take longer to appear, and why the side effects look nothing like chemotherapy's.

Which cancers respond, and which do not

This is where honesty matters most, because immunotherapy has been reported so enthusiastically that many patients arrive expecting it to be an option for everything. It is not.

Often responds

Melanoma, where immunotherapy transformed the outlook
Some non-small cell lung cancers, particularly with high PD-L1
Kidney and bladder cancer
Some head and neck cancers
Hodgkin lymphoma
Any tumour found to be MSI-high or mismatch-repair deficient, whatever the organ

Usually responds poorly

Most pancreatic cancers
Most prostate cancers
Many breast cancers, though some triple-negative cases respond
Glioblastoma and most brain tumours
Tumours described as immunologically cold, with few immune cells inside them

Testing is what settles this. PD-L1 levels, microsatellite instability (MSI) and tumour mutation burden (TMB) all help predict whether your immune system can be recruited. If this testing has not been done on your biopsy, ask about it, because it can be the difference between a treatment that works and an expensive one that does not.

What treatment involves

Testing on your tumour tissue. PD-L1, MSI or wider molecular testing on the existing biopsy sample. A fresh biopsy is sometimes needed.
Eligibility decision. Your oncologist weighs the test results, your cancer type and stage, and any autoimmune conditions you have.
Infusions. Given by drip, typically every two to four weeks, each taking under an hour. There is no hair loss and most people feel well afterwards.
Monitoring. Blood tests before each dose watch the thyroid, liver, kidneys and other organs for immune-related effects.
Response assessment. Scans after some weeks. Responses can be slower to appear than with chemotherapy, and a tumour can briefly look larger before it shrinks.
Continuation. Treatment often runs for many months or up to two years when it is working, which for international patients usually means continuing at home under guidance.

Side effects are different, not absent

People often hear that immunotherapy is gentler than chemotherapy. In terms of day-to-day feeling that is frequently true: no hair loss, less nausea, and many patients continue working. But the side effects it does cause are a different category and should be taken seriously.

Because the treatment releases an immune brake, the immune system can attack healthy tissue as well. That can inflame the thyroid, the bowel, the liver, the lungs, the skin or, less commonly, other organs. Most cases are manageable, often with steroids, but they need to be reported and treated promptly rather than waited out. A new persistent cough, diarrhoea, unusual tiredness or a rash are not things to ignore on immunotherapy.

This has a practical consequence for medical travel: you need a clear plan for who monitors you and who you contact once you are home. Ask about that specifically before you begin.

What it costs in India

Immunotherapy drugs are among the most expensive cancer treatments in the world, and that is true everywhere. India is significantly less expensive than Western countries for the same drugs, and biosimilar versions of some agents are available, which reduces cost further. Even so, this is usually the costliest part of any plan that includes it, and the total depends on how many cycles you receive.

Because of that, the value of testing first cannot be overstated. Establishing whether your tumour is likely to respond, before committing to an expensive course, is the single most useful thing an oncologist can do for you here. You receive a written estimate covering the drug, the infusions and the monitoring before you commit, with no fee to us built in; the hospital pays us, so your bill is never marked up.

Questions patients ask

Is immunotherapy better than chemotherapy?

Not universally. For some cancers it works far better and is now the standard first treatment. For many others chemotherapy remains more effective. They are also used together in some plans. Which is right depends on your cancer type and on testing, not on which sounds more modern.

Will immunotherapy work for my cancer?

That depends on the type of cancer and on markers in the tumour itself, particularly PD-L1, MSI status and tumour mutation burden. Melanoma, some lung, kidney and bladder cancers respond well. Pancreatic and prostate cancers usually do not. Testing your biopsy is what gives a real answer rather than a hopeful one.

Does it cause hair loss?

No. Hair loss is a chemotherapy effect, not an immunotherapy one. Most people on immunotherapy keep their hair and feel reasonably well day to day. The side effects to watch for are different: inflammation of the thyroid, bowel, liver, lungs or skin.

Can I have it if I have an autoimmune disease?

It needs careful thought. Because immunotherapy releases immune brakes, it can worsen an existing autoimmune condition such as rheumatoid arthritis, lupus or inflammatory bowel disease. It is not always ruled out, but your oncologist must know about the condition and the medicines you take for it before deciding.

How long will I need treatment?

Often many months, and sometimes up to two years while it continues to work. That rarely fits inside a single trip, so most international patients start treatment in India and continue at home under an agreed plan. Establish that arrangement before you begin rather than afterwards.

What is CAR-T, and is it the same thing?

No, though both harness the immune system. CAR-T involves collecting your own T-cells, re-engineering them in a laboratory to recognise your cancer, and returning them to you. It is used mainly for certain blood cancers rather than solid tumours, and it is a far more involved and costly process than a checkpoint inhibitor infusion.