78

CHAPTER 4

CASE STUDIES IN CANCER CARE

4.1 INTRODUCTION

In the field of allopathic medicine, the health care system and

delivery mechanism in India are pluralistic in nature, with many different
kinds of healthcare providers (public and private) in different settings, with
different delivery schemes providing cure and treatment for the patients’
illness. Cancer is one among the three deadly non-communicable diseases
classified in India by the Ministry of Health and Family Welfare with an
estimated 53% of annual deaths and is still considered as a life threatening
disease (ICMR 2006). Though the presence of advanced Medicare treatment
and better curative means are present to extend the survival rate, and enhance
the quality of life to the cancer patient by 83 percentage (Shantha 1996), yet
cancer is still dreaded socio-culturally, as a life threatening disease. Based on
the current trends of cancer occurrence in India, the ICMR (2006) report
projects that cancer occurrence would be on the rise from 3.78 million in 1990
(40.4% of all deaths) to 7.63 million in 2020 (66.7% of all deaths) and the
NCRP (1999) reports the increase in cancer case in the present decade is high
with more cases within the urban population, primarily due to an increase in
economic developmental activities and industrialization, changes in life-style
and resulting from improvement in socio-economic status .Hence, health
centers in cities and towns are engaged in the government pilot project to
eradicate cancer, having the NCRP1 to identify the initial phase, 15 metro
cites in India which have a high cancer prevalence. Chennai city is one
1
The NCRP (National Cancer Registry Programme ) a subdivision of the ICMR (Indian Council
for Medical Research)
 79

amongst the fifteen metro cities showing both high prevalence of cancer and
also evidence of the preventive measures taken by various health provider
agencies. These agencies have established across decades their service to
patients arriving from the state and other states too, thus demonstrating the
research need to select the case studies in Chennai.

4.2 CANCER CARE IN CHENNAI

Chennai is one of the metropolitan cities in India, the capital of

Tamil Nadu state, showing historic evolution of Modern allopathic cancer
care treatment with the genesis of 12 public hospitals to currently 800 or more
of public, semi private and private hospitals, clinics and health centers that
provide Medicare service from the primary to the tertiary level. Based on the
NCRP report (2000) amongst six cities Mumbai, Chennai, Delhi, Bangalore,
Bhopal and Barshi, Chennai is fourth in occurrence of cancer and is third in
the identification of a new case annually. In order to address the high
occurrence and deduction of cancer cases, cancer care treatment in Chennai
dates back to the early 19th century with the Madras Medical College hospital
offering service as the Oncology department, which was further augmented as
a department in other government teaching hospitals. Also, Adayar Cancer
Institute, an independent private owned cancer treatment centre started its
service in the mid 19th century and became the first independent cancer
treatment centre in the state with private ownership, and subsequently, the late
1980s saw the entry of many private owned hospitals under the stewardship of
medical professionals providing high tech quality Medicare treatment for
cancer till today.

The cancer treatment and cure given in Chennai hospitals caters to

patients from the city and predominantly from the towns and cities within the
state and a small percentage from other South and South-Eastern states of
India. In Chennai , the predominant cancer cases are females with 54%
 80

occurrence while the rest 46% are males and amongst the category of age in
both male and female, the occurrence of cancer is 63% and 75% respectively
for age between 40-60 years rather than 20-40 years2. The majority of patients
are Hindus (84%) followed by Muslims (9%), Christians (6%) and other
religious groups (1%)3 .

Aiming to reduce the aggressive statistics of cancer occurrence in

Chennai, Medicare advances are boosted by medical tourism, beneficial
National Healthcare policy (2002) and the liberal National and State budget
for the healthcare sector, thus, improving the cancer care delivery process
within the city. In spite of the constant increase in the complexities in medical
procedure and its integration into building planning and design, these national
developments in the field of Medical Oncology have necessitated buildings to
further integrate, amalgamate and focus the Medicare process with a holistic
patient –centered perspective. This holistic perspective on the Indian
Medicare process had amended the hospital administrative system, the
hospitality and service method towards the patients and relatives, and
significantly manifests on the cancer care built environment to house the
facilities with the patient as the primary user’s need as the prerogative. Hence,
in today’s Indian context, with more awareness and perspective for “holistic”
treatment for cancer patients and with the advent of social realization on the
user friendly environment, the dimension with inclusive therapeutic design of
cancer care becomes inevitable and vital for the healthcare provider to
respond to and integrate. This is an important perspective realized and
followed by the private providers but primal and untrained in public
healthcare providers.

2
Based on the PBCR (Population based Cancer Registry, 2000) Registy, Chennai, 2004
3
Census of India, 2001
 81

4.3 SELECTION OF THE CASE STUDIES

The selection of the case studies of the cancer care facilities in

Chennai were primarily based on the physical characteristics of the cancer
care provider (public or private types), the building physical typology
(horizontal courtyard or vertical tower block) and the user group types. The
selection of case studies is representative of the number of cancer cases
treated in the selected case studies in Chennai in a five year span (1996-2001)
where CS1 is 20%, CS2 is 2%, CS3 is 17%, CS5 is 5%, and while CS4 is 1%
based on PBCR 1999-2000 4 .The first two case studies are public sector
hospitals, the third case study is a public-private collaborative type while the
last two case studies are totally owned by the private sector. The following are
the names of the case studies selected for research study:

1. CS1: Oncology Department – Madras Medical College

Hospital (General Hospital), Chennai
2. CS2: Arignar Anna Memorial Cancer Institute-Kanchipuram5
3. CS3: Adyar Cancer Institute – Chennai
4. CS4: Oncology Department, Dr.Kamachi Memorial Hospital,
Chennai
5. CS5: Oncology Department, Apollo specialty hospital,
Chennai.

In spite of the varied categories the cases studies expressed, the

commonality and similarities observed across the case studies are the
Medicare process in terms of treatment, cure and preventive measures leading
to basic sequence of activities and meaning of space within the patient use

4
Individual Registry Data: 1999-2000-Population Based Cancer Registry, Chennai, 2004
5
CS2 is in Kanchipuram a town near Chennai and the selection of CS2 was realized due to the its
purpose to served exclusively to the cancer patient with the ambience of hospice, predominance
service to patient from Chennai and the only representative of the typology.
 82

zones. The research focuses on the three zones within the case studies that
shows a higher level of experience, usage and utility of the built space by the
user and most importantly the liberty and choice given for the primary user
(the patient) to provide his purpose and need with least impact dictated on the
Medicare process .The areas of study with the case studies are:

 Outpatient area
 Diagnostic area
 Inpatient area

4.4 DESCRIPTION OF THE CASE STUDIES

The description of the selected case studies provides information on

the background, namely, the physical, geographical location, physical layout,
the salient Medicare facilities in the hospital /department, the architectural
features and the respondents profiles to provide the setting in which the
subsequent stages of research are conducted.

4.4.1 Case Study 1: Oncology Department – Madras Medical College

Hospital, Chennai

Location: The hospital along with the medical college was

established in 1835 and is one of the first medical colleges in India (Table 4.1
Figure B). The campus is located in central Chennai opposite the Central
railway station and close to the public transport system. The General Hospital
with 2029 beds is also a medical institution with undergraduate and post
graduate programmes; the hospital provides Medicare treatments to major
diseases and illness and has independent building blocks serving each
specialty and is sprawled in the western site of the campus while the eastern
side constitutes the college. In the hospital site of 1, 06,580 sq m, 60 % of the
site is built structure, while a mixture of old and new blocks occupy the
remaining areas. Both the new and old blocks are fitted to the site offensively
 83

with the new block disproportionately extended from the old block
(Figure 4.1, Figure 4.2A).

Functional Zoning: The Oncology department established in

1915 consists of oncology outpatient and diagnostic facilities located in the
two storied X-ray block (Figure 4.2) located at the rear side of the Outpatient
block and Tower block. The south wing of the X-ray block has consultation
rooms and radiation therapy unit with a common waiting area on the ground
floor and a radiation therapy ward for men and women on the first floor (65
bed for males and 75 bed for females) (Figure 4.2A and C). The cobalt
therapy block is inconspicuously fitted on the rear side of the X-ray block and
is almost impossible to identify the entry. Further, the adjacent Surgery block
contains the female radiation ward to accommodate the increased number of
cases (Figure 4.2B). And in Tower Block, the male and female chemotherapy
and surgery ward of total 15 numbers for oncology is shared with other
specialties on the fourth floor in the western Tower block (Figure 4.2C).

4.4.2 Case Study 2: Arignar Anna Memorial Cancer Institute -

Kanchipuram

Location: This Institute is a referral hospital with 95% of the cases

being referred from various government secondary and tertiary care
government hospitals, namely, the District Hospital and General hospital
located in and around the state of Tamil Nadu (Figure 4.3 B). The institution
established in 1969 initially was part of the General Hospital in Kanchipuram
and in 1980 moved to the current independent campus with a capacity of 300
beds located on the outskirts of Kanchipuram 6 town, on the National
Highway-45 thus, enabling the patients from various parts of the state to avail
the service (Figure 4.3A).

6
Kanchipuram is a historic city and District Headquarters situated on the northern East Coast of
Tamil Nadu and is adjacent to Bay of Bengal and Chennai city and is bounded in the north by
Thiruvallur district and Chennai district, in the south by Villuppuram district in the east by the
Bay of Bengal and is 50 km from Chennai city.
 A-Site Plan B Location Map

Source: Public Work Department, Chennai, Tamil Nadu ,2002 Drawing not to scale
open
SITE PLAN CASE STUDY 1 Site area =1,06,580 sq.m area
40%
Built-up area=76,490 sq.m
built up
MADRAS MEDICAL COLLEGE HOSPITAL, area
CHENNAI Open area= 50090 sq.m 60%

Built-up area vs Open area

Figure 4.1 Site Plan : Madras Medical College Hospital, Chennai

84
 85

A. Radiology block -ground floor-

Outpatient and diagnostic area

C. Radiology block-first floor

- general ward

B. Tower block - fourth floor ward

Figure 4.2 Floor Plan: Madras Medical College Hospital, Chennai

 86

Functional Zoning: The plan layout of the institute is horizontal

spread type with two-storied and three-storied wards block, is located
in 13,53,500 sq.m site with the building occupying 7% of site area
(Figure 4.4A, B). The institute is a horizontal structure with a central corridor
spanning across the building from the main entrance, passing through various
facilities and terminating in the wards, while the departments are anchored
independently on the circuitous corridor with adequate open space between
them. The building with less percentage of site coverage and connecting
department physical profile provides the indoor-outdoor coalition ideal. The
functional hierarchy of the outpatient area and diagnostic area are provided in
the front while the patient wards with a singular modular plan are located at
the rear with a distinct distance between the male and female wards
(Figure 4.4A). The operation theatre and administrative sections are located
on the first floor followed by additional male and female wards (Figure 4.4B)
for post-operative care.

4.4.3 Case Study 3: Adayar Cancer Institute – Chennai

Location: The Adayar Cancer Institute of Chennai is South India's

first comprehensive cancer care centre and the country's second. The Institute
has consistently laid emphasis on advanced medical care and research in the
field, bringing refined scientific technology and patient care to the poorest in
the land. The Adayar Cancer Institute was started in 1954 initially as a small
institute in Adayar, a locality in South Chennai; the centre consists of
consultation rooms, wards, treatment and surgical units but the linear narrow
site limited future developments for more wards and diagnostic facilities.
Hence subsequently, the institute moved and developed to a full-fledged
centre in the present site at Guindy situated in the institution zone of the city
(Figure 4.5A, B). Today, the whole functioning in the old site has been shifted
to the new site, with the former only housing the free wards with minimal
staff and free.
 B-Location Map

Site area = 13,53,500

Built-up area = 1,00,550
Open area = 12,52,950

builtup
area
7%

A-Site Plan open

area
Source: Public Work Department, Chennai, Tamil Nadu ,2002 Drawing not to scale 93%
SITE PLAN CASE STUDY 2
Built-up area vs Open area
ARINGAR ANNA MEMORIAL CANCER INSTITUTE-KANCHIPURAM

Figure 4.3 Site Plan: Aringar Anna Memorial Cancer Institute - Kanchipuram

87
 88

A. Ground floor plan-Outpatient area-diagnostic area-ward area

B. First floor Plan - Ward area

Figure 4.4 Floor Plan : Aringar Anna Memorial Cancer Institute -

Kanchipuram
 89

accommodation to the relatives, while the new campus contains all the
outpatient, diagnostic and inpatient facilities, and hence, for research studies,
the new campus is studied . Annually, more than 95,000 to 100,000 patients
from all parts of India visit the Institute, where the treatments are either free
or subsidized. The Institute has 428 beds, of which 120 are at the Adayar site
and the balance are treated in Guindy.

Functional Zoning: The institute campus is 5,66,142 sq.m site

with a total of 26% built plot coverage containing a central spin road with five
building blocks overlooking the central loop road (Figure 4.5,A). The central
Main block is the largest on the campus and contains the common free
consultation and diagnostic facilities on the ground floor with administration,
laboratories and research facilities on the first and second floor (Figure 4.6,A).
The main entrance to the central block leads to an octagonal double-storied
waiting area connected to the consultation cubicles. Apart from the Main
block, two General ward blocks are present for free-payment cases and one
Radiology block is present along with the Paid OP block (Figure 4.6, B-E).
The paid OP block is independent in operation and serves exclusively for the
affordable paying group of patients in terms of consultation and individual
ward admission.

4.4.4 Case Study 4: Oncology Department, Dr. Kamakchi Memorial

Hospital, Chennai

Location and Building Functional Zoning: Dr. Kamakchi

Memorial Hospital is a private hospital, started in 2004 and owned by the
physician offering multispecialty care to all illnesses. The site is located in
Pallikaranai, a suburb in South Chennai with the site 3430 sq.m has with
building plot coverage of 34% and open space 66% as per Figure 4.7A,B. The
 A-Location Map
A-Site Plan

Source: CR Narayana Rao &Associates, Chennai,,2002 Drawing not to scale

SITE PLAN CASE STUDY 3 Site area = 5,66,142 sq.m built up NORTH
areaopen
Built-up area = 1,50,000 sq.m area
26%
open
ADAYAR CANCER INSTITUTE – Open area = 4,16142 sq.m
area
CHENNAI 74%

Built up area Vs Open area

Figure 4.5 Site Plan : Adayar Cancer Institute, Chennai

90
 91

C. Paid OP Block-
ground floor-
A. Main block-ground floor-Outpatient –diagnostic Outpatient area
area

B. Radiology block-ground floor–diagnostic area

D. Paid OP Block -
first floor-Inpatient
area

E. Ward block
– Gr. floor-
Inpatient area

Figure 4.6 Floor Plan : Adayar Cancer Institute, Chennai

 92

hospital is stacked vertically into four stories with radiation treatment,

laboratory service at the basement, main entry and consultation on the ground
floor and wards, namely, general ward, two bed ward, single bed ward located
on the first, second and third floor. The linearity of the site determines the
planning layout of the hospital with the presence of a double loaded corridor
and semicircular stairs to break and relieve the user from the longitudinal plan
(Figures 4.8 A, B, and C).

4.4.5 Case Study 5: Oncology Department, Apollo Specialty Hospital,

Chennai

Location and Building Functional Zoning : The five -storied

hospital building initially called as Apollo cancer hospital, established in
1990 ,was an extension of the main Apollo Hospital (commencement in1983)
in order to cater to the increasing demand for cancer care treatment. The
hospital is located in Teynampet in Central Chennai (Figure 4.9A,B), with the
hospital functions only in one part of the building and partly occupying a
floor in the second part of the building. Initially, the hospital was an exclusive
cancer care treatment centre, but today, the hospital houses treatment and
surgery for orthopedic and neurology too. The 250 bed hospital has the
cancer care diagnostic facilities in the basement along with the radiology
consultation room and reception, while specialist consultation rooms with
common and separate waiting are located on the ground floor, while the
Operation Theater and Intensive Care Unit (ICU) are on the first floor
(Figures 4.10A-B and 4.11A-D). The wards are of single bed special ward,
3-bed, 2-bed wards with toilet facilities attached and separate. The hospital
floor layouts show the rigid space utilization and constrain spatial scale
leaving restricted common space for the user to negotiate and utilize.
 93

A . Site Plan

B. Location Map

Site area =3430 sq.m

Built-up area =1150 sq.m
Open area = 2280 Sq.m Building
area,
34%
Open
area ,
66%

Built up vs Open area

Figure 4.7 Site Plan : Dr. Kamatchi Memorial Hospital – Chennai

 94

A. Second and Third Floor - Diagnostic and Inpatient area

B. Ground and First Floor - Outpatient area Diagnostic and

Inpatient area

C. Basement Floor- Diagnostic area

Figure 4.8 Floor Plan : Dr. Kamatchi Memorial Hospital – Chennai

 95

A. Site Plan

B. Location Map

area, Site area = 1200 sq.m

33%
Built-up area = 400 sq.m
Open area = 800sq.m

Open
area ,
67%

Built up vs/open area

Figure 4.9 Site Plan : Apollo Cancer Hospital – Chennai

 96

A.Basement floor- Diagnostic B.Ground floor -

area Outpatient area

Figure 4.10 Floor Plan : Apollo Cancer Hospital – Chennai

 97

A. Second Floor - Inpatient area B. Third floor - Inpatient area

C. Fourth Floor - D. Fifth floor- Inpatient area

Inpatient area

Figure 4.11 Floor Plan : Apollo Cancer Hospital – Chennai

 98

4.5 RESPONDENTS CHARACTERISTICS

A Total of 695 respondent feedbacks were obtained from all the

five case studies, with 68% from the patients, 22% from the relatives and 11%
from the medical staff treating the patients (representing 5% of the population
of the subjects in the case studies). The selection and number of respondents
in the case studies represented 5% of the patient population of the study area
(i.e Chennai) in order to get the definite users result findings representative of
the region. Based on the patient population present at the time of survey in
Chennai, the selection of respondents represented a confidence level of 95%
and confidence interval range from 13%-15% (for Outpatient and Diagnostic
patients) and 15%-18% (for Inpatient area). The 695 respondents (of patients,
relatives and medical staff) surveyed the hospital in the three zones,
namely ,Outpatient, Diagnostic and Inpatient area with the frequency
percentage being 31%, 30% and 39% respectively, for the three areas (Tables
4.1-4.3 and Figures 4.12-4.14). The respondent chosen for study was selected
to ensure maximum diversity of both the user type and on the respondent’s
characteristics in the five cases. Respondent characteristics in terms of their
gender, age, ethnicity, economic activity, prevalence of disabilities are
reviewed to understand the respondents’ reply and behavior.

Table 4.1 Types of Respondents

Respondents Total number Percentage

Patient 470 68
Relatives 150 21
staff 75 11
 99

Staff
11%

Relatives
21%

Patient
68%

Figure 4.12 Types of Respondents

Table 4.2 Types of respondents based on Case Studies

Category of
Case Case Case Case Case Total
the Total
Study 1 Study 2 Study 3 Study 4 Study 5 %
respondent
Patient 100 100 150 60 60 470 68
Relatives 30 30 30 30 30 150 21
Staff 15 15 15 15 15 75 11

25

20

15
staff

10 Relatives
Patient
5

0
CS1 CS2 CS3 CS4 CS5

Figure 4.13 Types of respondents based on case studies

 100

Table 4.3 Types of respondents based on the Functional zones

Zone Total number Percentage

Outpatient area 215 31
Diagnostic area 205 29
Inpatient area 275 40

OP Area
31%
IP Area
40%

Diag.Area
29%

Figure 4.14 :Types of respondents based on the Functional zones

4.5.1 Patient respondent profile

The 470 patients selected from the case studies are the primary
respondents of the study and were asked to provide details about themselves,
including their gender, age, level of mobility, economic and ethnic
background as per the following Tables 4.4-4.8 and Figures 4.15-4.19.

Table 4.4 Patient Profile – Gender

Gender Total number Percentage

Male 235 50
Female 235 50
 101

Female
50% Male
50%

Figure 4.15 Patient Profile – Gender

Table 4.5 Patient Profile – Age

Age Total number Percentage %

20-40 years 213 45
41-60 years 257 55

20-40 yrs
45%
41-60 yrs
55%

Figure 4.16 Patient Profile – Age

Table 4.6 Patient profile – Physical ability to move

Ability to move Total number Percentage

Abled 166 35
Physically disabled 304 65
 102

Abled
35%

Disabled
65%

Figure 4.17 Patient Profile – Physical ability to move

Table 4.7 Patient Profile – Ethnic Group

Ethnic profile Total number Percentage

Hindu 347 74
Muslims 55 11
Christian 31 7
Others 10 2
Data not provided 27 6

Data not
Others provided
6%
Christian 1%
7%

Muslim
11%

Hindu
75%

Figure 4.18 Patient Profile – Ethnic Group

 103

Table 4.8 Patient Profile – Income Status

Annual income Total number Percentage

Less than Rs.50,000 184 39
Rs.50,001- Rs.1,50,000 88 19
Rs.1,50,001- Rs.3,00,000 100 21
Rs.3,00,001 and more 64 14
Data not provided 34 7

Data not
provided
Rs.3,00,001 7%
and more
14% Less than
Rs. 50,000
39%

Rs. 1,50,001-
Rs.3,00,000
21%

Rs.50,001-
Rs.1,50,000
19%

Figure 4.19 Patient Profile – Income Status

4.5.2 Relative Respondent Profile

The 150 relatives selected from the case studies are the respondents
of the study and were asked to provide details about their gender and age, as
per the following Tables 4.9-4.10 and Figures 4.20-4.21.
 104

Table 4.9 Relatives Profile – Gender

Gender Total number Percentage

Male 75 50
Female 75 50

Female Male
50% 50%

Figure 4.20 Relatives Profile – Gender

Table 4.10 Relative Profile – Age

Age Total number Percentage

20-40 years 80 53
41-60 years 70 47

41-60 yrs
47%
20-40 yrs
53%

Figure 4.21 Relative Profile – Age

 105

4.5.3 Staff Respondent Profile

The 75 staff selected from the case studies are the respondents of
the study and were asked to provide details about their gender and age as per
the following Tables 4.11-4.12 and Figures 4.22-4.23.

Table 4.11 Staff Profile – Gender

Gender Total number Percentage

Male 32 43

Female 43 57

Male
43%

Female
57%

Figure 4.22 Staff Profile – Gender

 106

Table 4.12 Staff Profile – Age

Age Total number Percentage

20-40 years 48 64

41-60 years 27 36

41-60 yrs
36%

20-40 yrs
64%

Figure 4.23 Staff Profile – Age