Mumbai: Doctors in India are increasingly testing “dose optimisation” to make high-cost treatments affordable while cutting side-effects, and Tata Memorial Hospital’s latest findings underline how big the impact can be.
The Parel-based premier cancer hospital found that giving one-tenth of the standard dosage of a modern anti-cancer treatment drug worked just as effectively and caused fewer side-effects. Their research proves that the monthly bill for the drug — part of the newest branch of anti-cancer treatment called immunotherapy — could thus drop from Rs 4.4 lakh to Rs 18,700.
Ultra-Low Dosage
“This is an ultra-low dosage of an immunotherapy drug called nivolumab that is increasingly being used for multiple cancers, including head and neck and lungs,” said the study’s senior author Dr Kumar Prabhash.
In the world’s largest randomised study on nivolumab, conducted on 500 patients with previously treated or advanced disease, one-year overall survival was 27.3% in the nivolumab group versus 16.9% with standard chemotherapy. Infections, diarrhoea and hospitalisations were lower with nivolumab, said the article published in the Journal of Clinical Oncology.
“Around 80% of patients around the world can’t use such drugs because of the price tag. We are trying to find the least possible dose that is most effective,” said Dr Prabhash. In drug discovery, the practice is usually the opposite: to find the maximum tolerable dose, usually a level below the “toxic” mark, to ensure it works against the said disease.
When Lesser Is More
The nivolumab experiment is only the latest of low-cost adaptations of expensive medicines and treatment protocols seen in the country in the past few years. Fewer vaccine shots and reduced dosage of tuberculosis drugs are the most prominent of these efforts, though such efforts are more often seen in cancer due to the high cost of medications. “Dose optimisation” is a term that doctors in India and Canada worked on to improve access to effective cancer medicines for years.
Immunotherapy also saw experiments on shorter treatment duration to reduce costs. In 2022, at the Immuno-Oncology Society of India’s 2nd Annual National Congress, oncologists from 13 Indian centres reported that shortening immunotherapy from the Western norm of 2 years to 6 to 8 months still delivered meaningful outcomes, with around 42% of participants showing clinical benefit.
One-Dose HPV Vaccine
Outside cancer, the same cost-and-toxicity logic is shaping public health decisions. One example is India’s newly launched HPV vaccination drive— girls in the 14-15 age group will receive a single dose of the vaccine, though children in the US and the UK get 2 shots.
“Due to a trial held in India, the International Agency for Research on Cancer (IARC) has data that proves that taking even 1 shot of the HPV creates enough antibodies as 2 or 3 shots,” said Dr Nitin Shah of the Indian Academy of Pediatrics (IAP). Fifteen years back, the Indian govt stopped 3 ongoing trials on the HPV vaccine after a few girls in tribal belts in Gujarat and Andhra Pradesh died after receiving the vaccine. “Investigations later revealed that the deaths occurred due to other diseases or suicide,” said Dr Shah.
However, 3 distinct groups emerged due to the stoppage: girls who got only 1 shot, those who got 2 shots, and another who got 3 shots. With the 15-year evidence, the IARC and the World Health Organisation last year announced that even 1 dosage would work as efficiently. In India’s private sector, doctors still prefer to give 2 or 3 shots of up to Rs 11,000 each to girls under 14 years, but the IAP will soon announce that 1 dose would work for girls under 20 years of age (2 doses for those over 20).
Tuberculosis care is also moving towards safer, optimised dosing. India launched the BPaL-M regimen in March 2025 after a 3-year trial, focusing on reducing the toxicity associated with antibiotic linezolid.
One of the objectives of the national technical team of TB experts was to reduce the toxicity of one of the antibiotics, linezolid, which was associated with myelosuppression (low blood cell counts), neuropathy, serotonin syndrome, and lactic acidosis. The 3-year trial showed that instead of giving 600 mg of linezolid daily for 6 months, Indians did well with 600 mg for 13 weeks, followed by 300 mg for the rest of the treatment period.
But…
Despite the innovations to reduce costs and side-effects, experts said that such efforts rarely reached patients getting treated at private hospitals. “We are looking for cost-effective medication, something that is needed at the ground level, something that the middle classes will benefit from,” said Dr Rajendra Badwe, former director of Tata Memorial Centre.
The benefits from these experiments are confined to the public sector only.
The industry, for one, rarely ‘adapts’ to the minimum effective dose findings, sticking to the dosages cleared in the first trial and regulatory clearances.
Consider a long-term trial by TMC director Dr Sudeep Gupta on an expensive antibody drug called trastuzumab, given to patients with HER2-positive breast cancer for 12 months as supportive therapy. Generic versions of the drug then cost Rs 4-5 lakh for the 21-month course. Dr Gupta’s study published in JAMA in 2020 showed that the outcome of 3 months of the medicine was no different from the 1-year course. While Tata Memorial Hospital followed this protocol for long, said Dr Badwe, not all in the private sector did.
