Trends and future burden of tobacco-related cancers incidence in Delhi urban areas: 1988�12

Introduction: Tobacco products are the major contributors for various cancers and other diseases. In India, tobacco-related cancers (TRCs) contribute nearly half of the total cancers in males and one-fifth in females. Objective: The objective of the study is to investigate 25-year trends and projection of TRCs for 2018�22. Methods: Joinpoint analysis was performed to assess the trends of TRCs on world age-adjusted rates. Age-period-cohort model with power link function was performed to project the future incidence burden of TRCs in urban Delhi. Results: During the 25 years, a total of 67,129 TRCs (53,125 males and 14,004 females) were registered which was 25.4% of total cancer cases registered. Males contributed 39.1% and females 10.8% of total cases. In males, TRCs declined significantly from 1988 to 2003 with estimated annual percentage change (EAPC) = ?0.91% and thereafter increasing trend was observed with EAPC = 3.42%, while in females, the EAPC values were 2.2% and 3.54% respectively for the same period. The total burden of TRCs will be doubled in 2018�22 with around 46% change due to cancer risk and around 54% due to population age and size in both the genders. The average annual count in males will be 7310 in 2018�22 as compared to 3571 in 2008�12 while in females this count will be increased to 2066 from 955 based on recent slope. Conclusion: The incidence of TRCs is increasing due to increase in population age, size, and factors other than population. TRCs are the preventable cancers, and load of these cancers can be controlled with strictly adhering the policy and acts.

Male breast cancer: A single institute experience.

BACKGROUND: Male breast cancer (MBC) is a rare disease and accounts for 1% of all breast cancers. There is limited data on MBC from India. The aim of our study was to assess clinico‑pathological parameters and outcome in MBC patients. MATERIALS AND METHODS: This analysis was carried out in 76 patients of MBC who were registered at Institute Rotary Cancer Hospital of All India Institute Of Medical Sciences between 1996 and 2012. Patients’ records were retrospective reviewed and data obtained from the computer database using International Classification of Diseases code (C‑50). RESULTS: The median age was 59 years (range: 28‑80). The median duration of symptoms was 11 months (range: 0.5‑40). Breast lump was the most common presenting symptom (left > right side). American Joint Committee on Cancer (7th edition) stage distribution was Stage I‑2.6%, Stage II‑13.1%, Stage III‑59.3% and Stage IV‑25%. Modified radical mastectomy was the commonest surgical procedure. Moreover, 30% of tumors were high‑grade and 70% had pathological node positive disease. Estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 (HER2)/neu positivity was 80% and 28%, respectively. Triple negative breast cancer constituted 19% of cases. With a median follow‑up of 36 months, 3 years relapse free survival and overall survival was 60% and 80%. Advanced stage and visceral metastasis at baseline predicted poor outcome. CONCLUSION: MBC constituted 0.8% at our institute. Our study population had a longer time to presentation, advanced disease at presentation, more HER2/neu positivity and triple negativity higher than the available literature.

Neck dissection in lymph node-negative oral cancer.

D’Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R, Agarwal JP, Pantvaidya G, Chaukar D, Deshmukh A, Kane S, Arya S, Ghosh-Laskar S, Chaturvedi P, Pai P, Nair S, Nair D, Badwe R; Head and Neck Disease Management Group. (Head Neck Services, Department of Medical Oncology, Advanced Center for Treatment, Research and Education in Cancer, Clinical Research Secretariat, and the Departments of Radiation Oncology, Head Cytology, Radio-diagnosis, and Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India.) Elective versus therapeutic neck dissection in node-negative oral cancer. N Engl J Med 2015;373:521–9.

Young breast cancer: A single center experience.

BACKGROUND: Breast cancer in women aged less than 35 years is uncommon and accounts for 1‑2% of all breast cancer in the West. There is a paucity of data on young breast cancer from India. The aim of this study was to analyze the clinical, pathological, prognostic factors and outcome in young breast cancer patients. MATERIALS AND METHODS: This analysis was performed in 251 patients aged <35 years or less (defined as breast cancer in the young), who were registered at our institute over an 11 year period between 2001 and 2011. RESULTS: The median age was 31 years (range 18‑35). Positive family history (siblings and parents) was elicited in only 10 patients. The TNM stage distribution was: Stage I was 2.5%, stage II ‑ 20.5%, stage III ‑ 55% and stage IV - 22%. The median clinical tumor size was 5.1 cm. Modified radical mastectomy was the most common surgical procedure and this was done in 79% of cases. 40% of tumors were high grade and 60% had pathological node positive disease. Estrogen and Progesterone and human epidermal growth factor receptor 2/neu positivity were 33% and 29% respectively. Triple negative breast cancer constituted 31% of patients. With a median follow‑up of 30 months, 3 years relapse free survival and overall survival was 51% and 66%. CONCLUSION: Young women constituted 8% of breast cancer cases. Advanced disease at presentation and triple negativity (nearly one third of patients) results poor outcome.

Pregnancy associated breast cancer: An institutional experience.

BACKGROUND: Pregnancy‑associated breast cancer (PABC) has been defined as breast cancer diagnosed during pregnancy or within 1 year of delivery. There is a paucity of data on PABC from India. The aim of our study was to assess the clinical‑pathological parameters and outcome of PABC at Institute Rotary Cancer Hospital, All India Institute of Medical Sciences. MATERIALS AND METHODS: We screened approximately 3,750 cases registered from January 2001 to December 2012 and found 26 cases of PABC. Patients’ records were obtained from the computer database using International Classification of Diseases code (C‑50). RESULTS: The median age was 26 years (range 20‑35). The median duration of symptoms was 11.5 months. The American Joint Committee on Cancer stage distribution was Stage I ‑ 1, Stage II ‑ 3, Stage III ‑ 14 and in Stage IV ‑ 8 patients. Median clinical tumor size is 5.5 cm. Four patients were presented with the inflammatory breast cancer. Positive family history was elicited in three patients. Twenty‑one patients were diagnosed after delivery, two patients in the first trimester, two patients in the second trimester and three patients in the third trimester. Estrogen receptor (ER), progesterone receptor (PR) negativity and human epidermal growth factor receptor 2 (HER2/neu) positivity was 56% and 38%, respectively. Nearly, 40% of patients had a high‑grade tumor and 70% had pathological node positivity. With a median follow‑up of 33 months, 3 years relapse free survival and overall survival was 40% and 50% respectively. Bone was the most common site for systemic relapse. CONCLUSIONS: PABC constituted 0.7% of all breast cancer patients. It is associated with advanced stage at presentation. Half of them were ER/PR negative and one‑third was HER2/neu positive.

Triple‑negative breast cancer: An institutional analysis.

AIM: Triple‑negative breast cancer (TNBC) is defined by the lack of expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER 2)/neu. It has been identified as an independent poor prognostic factor for survival. The aim of this study was to compare the clinico‑pathological characteristics and treatment outcomes of patients with TNBC and non‑TNBC. MATERIALS AND METHODS: We carried out an analysis of 706 patients with invasive breast cancer between January 2007 and December 2011 in whom information on the status of ER, PR, and HER2/neu were available. RESULTS: One hundred and fifty‑five patients (21.9%) patients had TNBC. Patients with TNBC had a significantly lower median age [46.2 vs. 49.8 years; P = 0.005, 95% confidence interval (CI): 0.98 to 2.38] and a higher proportion of high‑grade tumors as compared to the non‑TNBC group (43 vs. 24%; P < 0.0001). After a median follow‑up of 30 months, the three‑year relapse‑free survival (RFS) was significantly lower in the TNBC group (76 vs. 64%; log rank P = 0.002). Three‑year overall survival (OS) was lower in the TNBC group but not statistically significant. Age <49 years, higher nodal stage, and larger tumor size (>5 cm) were associated with poor outcome. CONCLUSION: TNBC is significantly associated with younger age and high‑grade tumors and constitutes 21.9% of all breast cancers in our institute. Triple negativity was a significantly poor prognostic factor for RFS but not OS.

Outcome of combined modality treatment including neoadjuvant chemotherapy of 128 cases of locally advanced breast cancer: Data from a tertiary cancer center in northern India.

Background: Breast cancer is now the most common cancer in many parts of India and the incidence varies from 12 to 31/100000, and is rising. Locally advanced breast cancer (LABC) accounts for 30 - 35% of all cases of breast cancers in India. LABC continues to present a challenge and imposes a major health impact in our country. Materials and Methods: We carried out a analysis of our LABC patients who received neoadjuvant chemotherapy (NACT) at our hospital over a 10-year period, from January 1995 to December 2004. We analyzed the response to NACT, disease-free survival (DFS), and overall survival (OS). Results: Patients with stages IIIA, IIIB, and IIIC were included. LABC comprised of 26.24% (609 patients) of new patients. One hundred and twenty-eight (31.1%) patients received NACT. Median age was 48 years and estrogen receptor was positive in 64%. Chemotherapy protocol was an FEC (5-Fluorouracil, Epirubicin, Cyclophosphamide) regimen in the following doses: Cyclophosphamide 600 mg/m2, 5-FU 600 mg/m2, and Epirubicin 75 mg/m2 given every three weeks, six doses, followed by modified radical mastectomy (MRM) and locoregional radiotherapy. The overall response rate (complete response (CR) + partial response (PR)) was 84.4%, clinical CR (cCR) was 13.3% and pathological CR (pCR) was 7.8%. Median DFS and OS were 33 and 101 months, respectively. The disease-free survival (DFS) and overall survival (OS) at five years were 41 and 58%, respectively. Conclusions: This study analyzes the outcome in patients who received NACT, in the largest number of LABC patients from a single center in India, and our results are comparable to the results reported from other centers.

Management of patients with breast cancer: are we ready in India for sentinel lymph node biopsy?

Breast cancer is the commonest cancer among women worldwide. Surgery plays an important role in its management. Axillary lymph node dissection has been the standard of care for staging, prognostication and control of axillary disease for almost a century. However, this time-tested paradigm is shifting gradually in the western world, because of the increasing use of screening mammography resulting in the detection of a large proportion of node-negative early breast cancers and a significant incidence of axillary lymph node dissection-related arm morbidity. Minimally invasive and less morbid procedures such as sentinel lymph node biopsy are being used more commonly in the West. However, the western experience cannot be directly extrapolated to the Indian scenario because of the differences in patient profile, treatment standards and expertise available. There is a need to critically analyse these issues before the Indian medical community advocates sentinel lymph node biopsy as a routine procedure for managing patients with breast cancer.

Neoadjuvant chemotherapy followed by surgical cytoreduction in advanced epithelial ovarian cancer.

AIMS: To study the role of neoadjuvant chemotherapy (NACT) followed by surgical cytoreduction in the management of advanced epithelial ovarian cancers. MATERIALS AND METHODS: A retrospective analysis of 82 patients with advanced epithelial ovarian cancers (stage IIIC and IV) who were treated with NACT followed by surgical cytoreduction between 1995 and 2004 was performed. Response to NACT, optimal cytoreduction rate, disease-free survival and overall survival were analyzed. RESULTS: There were 59 patients (72%) with stage IIIC disease and 23 (28%) with stage IV disease. Diagnosis was established by imaging, ascitic fluid cytology and CA-125 estimations in 75% and by laparotomy in 25% of the patients. After NACT, complete response occurred in 17 patients (20.7%), 50 (61.0%) had partial response and no response was documented in 15 (18.3%) patients. Optimal surgical cytoreduction could be achieved in 72% of the patients. At the median follow-up of 34 months (range 6-102 months), 5-year disease-free and overall survivals were 31 and 32% respectively. The median disease free interval was 25.4 months. On multivariate analysis, degree of optimal cytoreduction was the only factor (P < 0.05) affecting survival. CONCLUSIONS: NACT followed by surgical cytoreduction is a promising treatment strategy for the management of advanced epithelial ovarian cancers. A significant number of patients exhibit response to NACT. Downstaging following NACT leads to higher optimal cytoreduction rates and improved survival in comparison to historical controls.

Phase II study of cisplatin, etoposide and paclitaxel in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction.

BACKGROUND: Unresectable and metastatic gastric cancers carry a poor and dismal prognosis. Several phase II studies have identified effective anticancer drugs. AIMS: To evaluate safety and efficacy of low-dose cisplatin, etoposide and paclitaxel (CEP) based combination chemotherapy in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction. SETTING AND DESIGN: Prospective single-arm phase II study. MATERIALS AND METHODS: Thirty-three patients were enrolled onto this study, out of which, all but one received cisplatin 15 mg/m 2, etoposide 40 mg/m 2 and paclitaxel 50 mg/m 2, given on day 1 and 4 every week for three weeks in a 28-day cycle. Survival analysis was done using SPSS program. RESULTS: Median age of group was 56 years. Twenty-five were males. Twenty-nine had metastatic/inoperable disease and four patients had recurrent disease. Liver was the commonest metastatic site seen in 15 patients. With a median of 2 cycles per patient, a total of 76 cycles was administered. Grade III or IV toxicity were seen in 11 (35%) patients; diarrhea, 5 patients; vomiting, 3 patients; and neutropenia, 7 patients, 5 of whom also had fever). One patient died of neutropenic fever. Best responses, seen in 32 evaluable patients, were 2 CR (6.1%), 21 PR (63%) and 3 SD (9.2%). Four patients were considered operable after chemotherapy. With median follow-up of 11 months in surviving patients, median OS was 10 months and PFS was 8 months. Median OS was 13 months in responders versus 8 months in nonresponders (P =0.04). Seven patients survived> 12 months. CONCLUSION: Combination of low-dose CEP shows good clinical response and an acceptable toxicity profile in advanced or metastatic adenocarcinoma of gastric/gastroesophageal cancers. Whether addition of 5 FU or capecitabine adds to the benefit should be explored. This may be tested with other standard/conventional protocols in a randomized fashion.

Primary gastrointestinal non Hodgkin's lymphoma chemotherapy alone an effective treatment modality: experience from a single centre in India.

BACKGROUND: Gastrointestinal tract (GI) is the most frequently involved extra nodal site in non-Hodgkin's lymphoma (NHL). Surgery, radiotherapy and chemotherapy (CT) have been used mostly in various combinations, but lately chemotherapy alone has emerged as an effective option. The purpose of this study is to evaluate efficacy of CT alone in treatment of primary GI-NHL and to compare the results with combined CT+surgery. SETTING AND DESIGN: Retrospective analysis of case records of GI NHL patients. MATERIALS AND METHODS: Over a 15-year period (1986-2000), 77 new cases of primary GI-NHL were registered at our center. GI-NHL was defined according to standard criteria. All patients received chemotherapy. RESULTS: The median age was 32 years (Range 9-80). Endoscopy / CT guided biopsies were performed in 42% (32) of patients for the purpose of diagnosis. Laparotomy was done in 58% (45) of patients to establish a diagnosis or as primary or debulking treatment. Stomach and intestines were involved in 47% (36) and 53% (41) patients respectively. Early stage disease was present in 37% (29). Seventy eight percent of tumors were intermediate to high grade, 43% (33) received only CT while 57% (44) received CT+surgery. Five years EFS and OS were: 72% and 65% for all patients; 72% and 67% for CT only group; 60% and 64% for CT+surgery group (P=.05). Four patients died of neutropenic infection. CONCLUSION: Organ-preservation strategy using chemotherapy alone (CT) can be successfully employed in a significant number of patients with primary GI-NHL.

Organ-preserving multimodality management of squamous cell carcinoma of anal canal.

AIM: To study the efficacy of an organ-preserving, sequential chemoradiation therapy for squamous cell carcinoma of the anal canal, and of salvage surgery in those in whom this treatment fails. METHODS: Forty biopsy-proven untreated patients (28 men) with squamous cell carcinoma of the anal canal received two cycles of chemotherapy using cisplatin and methotrexate, followed by 45 to 60 (median 50) Gy external beam radiotherapy. Salvage surgery was offered to those in whom this treatment failed. Overall survival, disease-free survival and colostomy-free survival were analyzed. RESULTS: Most patients (n=35; 87%) had T3 or T4 lesions and 5 (12.5%) had involvement of inguinal nodes. Thirty-one patients (77.5%) had complete response after chemoradiation. Only three patients (7.5%) developed chemotherapy-related grade 3 mucositis and myelosuppression. Radiotherapy-related toxicity included grade III cystitis in one patient and grade III proctitis in three patients. Three patients had post-treatment anal stenosis requiring repeated dilatation and two had chronic non-healing ulcers at the anal verge. Nine patients had failure of chemoradiation or disease recurrence; of these, only 5 could undergo salvage surgery. After a median follow up of 60 months, overall survival, disease-free survival and colostomy-free survival were 80%, 77.5% and 72.5%, respectively. CONCLUSION: Chemoradiation is effective in the treatment of squamous cell anal cancer and has acceptable toxicity. Surgical salvage may be useful in those with failure of this treatment.

Surgical management of skin cancers: experience from a regional cancer centre in North India.

AIMS: To review the disease profile and treatment outcome of patients with primary skin malignancies treated at a regional cancer centre. SETTINGS AND DESIGN: Surgical oncology unit of a tertiary care regional cancer centre. Evaluation of treatment outcome of patients with skin cancer from Surgical Oncology database was done. MATERIALS AND METHODS: Retrospective analysis of records of 77 patients with skin cancers treated between 1995 and 2002 was conducted. Profile of patients with skin cancer, surgical details including the management of primary tumour, regional lymph nodes and reconstructive procedures performed and survivals were analysed. STATISTICAL ANALYSIS: All computations were done using the Statistical Package for Social Sciences (SPSS-9). Descriptive statistics were calculated in a standard fashion and survival analysis was performed using Kaplan-Meier method. RESULTS: Skin cancers constituted 2.4% (77/3154) of patients with cancer treated in the surgical oncology department. Squamous cell carcinoma (SCC) was the most common histological type (55.8%) followed by melanoma (26.1%) and basal cell carcinoma (BCC, 18.1%). Forty one percent of patients had undergone some form of intervention elsewhere before being referred. Reconstruction was required in 55.8% patients with large postresection defects. Regional lymph nodal dissection was required in 32.4% of total patients. Five-year median disease-free survival for the entire study population was 75%. CONCLUSIONS: Skin cancers constitute a small but significant proportion of patients with cancer. Unlike in the Western countries, SCC is the commonest histologic variety. Primary level inadequate intervention is very common. Optimal results can be obtained with radical surgery and optimal surgical margins along with a reconstructive procedure when needed.

Breast conservation therapy for breast cancer: patient profile and treatment outcome at a tertiary care cancer centre.

BACKGROUND: Breast conservation therapy is a well-established treatment modality for early breast cancer. It is not widely practised in developing countries because of a lack of awareness and treatment facilities, and physician and patient bias. We analysed our experience of breast conservation therapy. METHODS: We retrospectively reviewed 102 patients who had undergone breast conservation surgery and axillary dissection for breast cancer. Surgery was followed by 45 Gy of radiation to the whole breast and 15-20 Gy of tumour bed boost. All high risk patients received adjuvant systemic therapy. The disease profile, morbidity and treatment outcome were analysed. RESULTS: Out of 902 patients, 102 underwent breast conservation therapy (90 had early breast cancer and 12 had locally advanced breast cancer). Only 19.6% of patients with early breast cancer received breast conservation therapy. One-third of the patients had had a prior surgical intervention. The mean tumour size was 2.8 cm, 44% had nodal involvement and 29% were oestrogen- and progesterone-receptor negative. At a mean follow up of 32 months, only 1 patient had local recurrence, and the 5-year projected disease-free and overall survival were 82% and 88%, respectively. CONCLUSION: Breast conservation therapy should be offered to suitable breast cancer patients. Strict adherence to protocol-based therapy and active multidisciplinary coordination are crucial for a successful breast conservation therapy programme. Education of the patient as well as the physician population is necessary for increasing the breast conservation therapy rates in India.

A new technique of postoperative pancreatico gastric enterocutaneous fistula repair using de-tubularised afferent loop.

Postoperative fistula involving upper gastrointestinal tract surgery is a rare but troublesome occurrence. Reoperation on these patients is challenging and needs to be individualised. Various methods are described including primary closure, bypass procedures, serosal patch repair and Roux-en-Y repair. We present a new technique of repair using afferent loop that provided a vascularized bowel segment, which used in an anatomical fashion for closure of fistula.

Prevalence and risk factors for development of lymphedema following breast cancer treatment.

BACKGROUND: Early detection and multimodality therapy has resulted in an overall improvement of survival among breast cancer patients. Despite a significant shift in the treatment approach from radical mastectomy to breast conservation a significant number of patients develop lymphedema. This study was conducted to evaluate the prevalence and risk factors for development of lymphedema. SETTINGS AND DESIGN: Retrospective analysis for prevalence of lymphedema in a tertiary care regional cancer centre. MATERIAL AND METHODS: Three hundred treated breast cancer patients with a minimum follow up of one year were evaluated for the prevalence and risk factors for lymphedema. Lymphedema was assessed using a serial circumferential measurement method. More than 3 cm difference in circumference is considered as clinical significant lymphedema. Univariate and multivariate analysis were performed for evaluating the risk factors by using the Chi square test and Cox logistic regression analysis. RESULTS: The prevalence of clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema. The prevalence of lymphedema was 13.4 % in patients treated with surgery only where as the prevalence was 42.4% in patients treated with surgery and radiotherapy. Stage of the disease, body surface area > 1. 5 m2, presence of co-morbid conditions, post operative radiotherapy and anthracycline based chemotherapy were significant risk factors in univariate analysis where as axillary irradiation and presence of co-morbid conditions have emerged as independent risk factors in multivariate analysis (P < 0.001). CONCLUSION: Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Presence of co-morbid conditions and axillary radiation significantly increases the risk of lymphedema. A combination of axillary dissection and axillary radiation should be avoided whenever feasible to avoid lymphedema.