For Geetha Manjunath, it all began when a close family member was diagnosed with the most advanced form of breast cancer. At the time, Manjunath was the lab director at a research centre of a multinational digital printing major. Given her expertise as a computer scientist, she felt compelled to act.
The company had set aside a third of her budget for experimentation and innovation. With the help of her team, she began talking to doctors and visiting hospitals. As part of their healthcare focus, Manjunath and her colleagues had been working with cameras that monitored heart rates. They then began looking into a special type of infrared camera that detects breast cancer and also started collecting thermal images.
“We read that thermal images are not used in all hospitals because they are very hard to interpret,” Manjunath told TechCircle.
That’s when she decided to apply artificial intelligence, which was also the focus of her doctoral research, to understand how breast cancer can be detected at the early stages.
Not long after, Manjunath launched a breast cancer screening startup called Niramai, which is an abbreviated form of non-invasive risk assessment with machine learning and artificial intelligence.
Though incorporated in 2016, Niramai was officially launched in January last year.
Manjunath invited Nidhi Mathur, a former executive at Hewlett Packard, to be a co-founder. The duo had worked together previously for a few years, and like Manjunath, Mathur too had first-hand experience of a family member coping with cancer.
At Niramai, they developed a handheld device which uses heat to identify tumours and malignant tissues. The information is mapped onto an image, which is then fed into the AI algorithm to reveal whether the tissue is cancerous or not. Data analytics generates a report, which mentions a breast health score.
“If the score is high, then most likely it will be cancer and we mention that,” Manjunath explained.
In rural areas, the startup uses a triaging method. This means that it only identifies the people that need to be taken to a hospital. To shortlist the most serious cases, Niramai generates a ‘traffic light’ report, which indicates the extent of tissue malignancy through three colours— red, green and yellow. If the colour red is generated, then the person is sent to a hospital for further tests. Niramai charges rural users Rs 100 for the triaging report.
Across the spectrum
Besides portability, Niramai’s USP is that the device is non-invasive, radiation-free and can be used on women even below 40-45 years of age. Most significantly, this means that cancer can be detected at an early stage. Mammography, which is based on X-rays and is widely considered the gold standard for breast cancer screening, can only be used for women above the age of 40-45 years.
Manjunath said that Niramai’s device is used for the entire breast cancer continuum of care, which starts with preventive screening and diagnosing whether a patient needs a biopsy. This is followed by treatment monitoring, which involves determining whether a particular course of treatment is effective or not. Lastly, there is screening for cancer survivors, where the patients are tested every six months or so.
Niramai imports its thermal imaging devices from Sweden and loads the AI and software-as-a-service (SaaS) solution, called Thermalytix, onto the device. Currently, the startup offers the end-consumer only a screening test, while it sells its devices to hospitals and diagnostic centres. The startup also offers training, installation and end-to-end service at 12 hospitals and diagnostic centres.
“Typically, the solution is used for preventive screening. We give both the hardware and software solution,” Manjunath said.
Niramai has priced its solution at Rs 1,000-1,500 per screening, depending on the hospital. In contrast, a mammogram typically costs Rs 3,000-3,500 per screening, depending on the machine used.
Niramai’s offering quickly caught the eye of early-stage investors, with pi Ventures, Axilor Ventures, Ankur Capital and 500 Startups investing seed money in April last year. Flipkart co-founder Binny Bansal pitched in as well.
Bridges to cross
For Niramai, the top priority is developing a novel solution that is 100% accurate each time it is used. Convincing doctors, according to Manjunath, was the next challenge.
“Why would they want to use [a new product] from a startup?” she asks.
But perhaps an even bigger hurdle is scientific acceptance. Dr Ramesh Byrapaneni, managing director at early-stage investment firm Endiya Partners, feels the biggest challenge that Niramai faces is whether its device is equal to or superior to existing methodologies, particularly mammography.
The device must also be accepted by the medical community in the country and have the requisite approvals from regulatory bodies like the US Food and Drug Administration (FDA). For this, the startup must conduct a large clinical trial of its device.
“We have conducted clinical trials in collaboration with radiologists and oncologists of reputed cancer hospitals like HCG and Narayana Health. The trials have proven the accuracy of our solution to be better than mammography. Our solution was also approved by the Indian Food and Drugs Administration in July,” said Manjunath.
Niramai has applied for 10 patents for its thermal imaging technology in the US and has received approval for six. It is yet to get the go-ahead for patents in India and Europe.
In October last year, the US FDA said that it didn’t find scientific evidence to support thermography for breast cancer screening. It also stated that mammography remained the most beneficial method of diagnosis.
Byrapaneni also has doubts about whether Niramai’s devices will catch on given that even mammography machines still haven’t gained widespread acceptance in India, where the traditional method of self-examination is more commonplace.
Manjunath, however, said that while a regular thermography scan requires highly trained and skilled professionals to analyse the heat images, Niramai’s AI and machine learning solution overcomes that difficulty by running those images through an algorithm.
Niramai will also have to work on getting its revenue model right. It currently earns by charging hospitals and diagnostic centres a one-time fee upfront for buying the device. The startup also generates revenue on a sharing basis where the hospitals and centres are charged for each screening they conduct.
Byrapaneni feels the pay-per-use model for medical equipment has not succeeded in India, where only those devices that are manufactured in large quantities, such as stents and disposables, have managed to generate revenues.
Niramai is also not the only Indian startup exploring this pain point. VC-backed UE LifeSciences Inc and bootstrapped MyCliniCare also use handheld screening devices and tap other branches of science to help detect cancer, while Sequoia Capital-backed OncoStem has created tests to predict cancer recurrence.
But while there are naysayers, others like Ankur Capital Fund co-founder Ritu Verma are thinking positively. She believes that alternative technology of the kind Niramai offers will unlock the Indian market, where expensive interventions will not make inroads. The fact that such devices are being marketed directly to the consumer also works in their favour, Verma feels.
Spreading the word
If you ask Manjunath, the biggest challenge the startup faces is awareness.
According to a study by peer-reviewed medical journal Lancet, only 66 out every 100 women diagnosed with breast cancer between 2010 and 2014 had survived. It cited low awareness as a major cause for the high mortality rate.
“Many are not aware that breast cancer is so pervasive that 1 in 25 women can have the disease in India,” Manjunath said. “They also don’t think of preventive screening. It’s always reactive.”
There is also no awareness about the kind of tests available, she added.
With this in mind, Niramai conducts health camps with corporates and ties up with non-governmental organisations (NGOs) in rural areas.
“We do 50-60 screenings on weekdays and 150 over the weekends. Today, if you take a mammography, you cannot do more than 20 or maybe 12 per day,” said Manjunath.
The startup is also working on its expansion plans. Niramai is developing a mobile app, for which it is running trials with gynaecologists. Besides this, it also offers women free risk assessment on its website.
Currently present in Bengaluru, Mysore, Hyderabad, Mumbai, Dehradun and Pune, the startup plans to launch in Delhi in November. India is its sole focus at present, but Manjunath said Niramai may venture into the Asian and European markets next year.