Outcome of community based planned intervention targeting perceptions, attitudes and health seeking behaviour regarding cancers in New Delhi, India

Background: Cancer prevention and control needs to be based on effective implementation of all approaches. Community as well as individual level interventions to increase knowledge and early reporting have shown effectiveness. A community-based intervention trial was conducted to design, implement and test short-term outcomes of evidence based preventive strategies.Methods: A mixed methods, three phased study was conducted in three districts of Delhi, which were selected by a random process. Two randomly selected districts out of these three were intervention districts while third was the control. A total sample of 500 in each district was studied in quantitative pre and post -intervention phases. Multistage, stratified, cluster sampling was utilized. Pre-tested and validated tools were used.Results: Post intervention, statistically significant higher scores were observed in all domains in intervention districts as compared to control (p<0.01). Though comparison of slum versus non-slum showed significant increment in knowledge and practice scores, with higher scores for non-slum respondents, the attitudes were very similar (p>0.05). The increment score changes between males and females was similar in all classes of society versus control district. Comparison within the intervention and control groups revealed increased scores in intervention districts and decreased scores in control district, in all domains (p<0.05).Conclusions: Our study has helped in understanding the determinants of perceptions, attitude and practices regarding cancer in the community, This, helped in formulating the need-based intervention strategies. Testing the short-term outcome of intervention showed it to be effective.

Clinical outcome of patients with primary gliosarcoma treated with concomitant and adjuvant temozolomide: A single institutional analysis of 27 cases.

CONTEXT AND AIM: The prognosis of primary gliosarcoma (PGS) remains dismal with current treatment modalities. We analyzed the outcome of PGS patients treated with concurrent and adjuvant temozolomide (TMZ). SETTINGS AND DESIGN: Retrospective single institutional analysis. MATERIALS AND METHODS: We retrospectively evaluated 27 patients of PGS treated with radiotherapy (RT) and TMZ during 2007‑2012. STATISTICAL ANALYSIS USED: Overall survival (OS) was estimated by the use of Kaplan Meier method and toxicities were evaluate using common terminology criteria for adverse events version 2.0 (National Cancer Institute, USA). RESULTS: Median age at presentation and Karnofsky performance status was 45 years and 90 respectively and male: female ratio was 20:7. Patients received adjuvant RT to a total dose of 60 Gy at 2 Gy/fraction. All patients except 5 received adjuvant TMZ to a median number of 6 cycles. Grade 2 and 3 hematological toxicity was seen in 8% and 4% of patients respectively during concurrent RT. During adjuvant chemotherapy, 13.6% had Grade 3 thrombocytopenia and 9.5% had Grade 3 neutropenia. Median OS was 16.7 months (1 year and 2 year actuarial OS was 70.8% and 32.6% respectively). Adjuvant TMZ was associated with a better survival (median survival 21.21 vs. 11.93 months; P = 0.0046) on univariate analysis and also on multivariate analysis (hazard ratio 1.82, 95% confidence interval: 1.503‑25.58; P = 0.012). CONCLUSIONS: The results of our study, largest series of patients with PGS treated with concurrent and adjuvant TMZ shows an impressive survival with acceptable toxicity. We suggest TMZ be included in the “standard of care” for this tumor.

Role of adjuvant radiation in the management of central neurocytoma: Experience from a tertiary cancer care center of India.

BACKGROUND AND OBJECTIVE: Neurocytoma (NC) is a rare benign neuronal tumor. A complete excision remains curative for most of these tumors, but atypical histology and extra‑ventricular location often necessitates adjuvant therapy. We intended to explore the clinico‑pathological features and treatment outcome in patients of NC in our institute. MATERIALS AND METHODS: Medical records were reviewed and data collected on NC over a 6‑year period (2006‑2012) from the departmental archives. Disease free survival (DFS) was analyzed by Kaplan‑Meier method. RESULTS: A total of 18 patients met the study criteria. Fourteen patients had intra‑ventricular neurocytoma (IVNC), right lateral ventricle being the most common site of origin. Gross total resection and near total resection were achieved in eight cases each whereas tumor decompression and biopsy could be done in two cases. On post‑operative histopathological examination, eight patients were found to have atypical NC while 10 patients had typical NC. All patients underwent adjuvant radiation. The median dose of post‑operative radiation was 56 Gy. All patients were alive at their final follow‑up. One patient had both clinical and radiological evidence of local relapse. In the evaluable patients (n = 18), after a median follow‑up of 35 months the DFS rate at 2 years and 3 years are 100% and 83% respectively. CONCLUSION: Use of adjuvant radiation to a total dose of 56 Gy enhances the local control and achieves superior survival in patients of NC. Use of 3D conformal planning techniques may help us to achieve better therapeutic ratio in patients with NC.

Impact of post‑operative radiation on coronary arteries in patients of early breast cancer: A pilot dosimetric study from a tertiary cancer care center from India.

BACKGROUND: The significant impact of postoperative radiotherapy (PORT) on cardiac morbidity in patients of early breast cancer (EBC) undergoing breast‑conserving surgery has been shown in different studies. The present study was conducted to assess the impact of surgery and the side of involvement on radiation dose to left anterior descending artery (LAD) and Left circumflex coronary artery (LCx). MATERIALS AND METHODS: Totally, 58 patients of EBC were randomly chosen for this dosimetric study and planned with tangential field technique without intensity modulation (IM). Heart, LAD, and LCx (n = 55) were contoured. Dose volume histograms were analyzed to determine the Dmax (maximum dose) and Dmean (mean dose) of LAD and LCx. Student’s t‑test was used for comparative analysis of the means. RESULTS: The mean Dmax of LAD for left (L) EBC was 3.17 Gray (Gy) while for right (R) EBC it was 0.86 Gy (P = 0.007; 95% C.I, 1.14–3.48). The mean Dmean of LAD for L‑EBC and R‑EBC were 1.97 Gy and 0.79 Gy, respectively (P = 0.029; 95% C.I, 0.77–1.60). The mean‑Dmax of LCx for patients with L‑EBC (2.9 Gy; range: 1.2–4.35 Gy) was statistically higher than that for R‑EBC (1.3 Gy; range: 0.7–3.2 Gy) (P = 0.045). The mean‑Dmean of LCx for L‑EBC (2.1 Gy; range: 0.6–3.6 Gy) was also significantly higher than that of L‑EBC (0.9 Gy; range: 0.7–2.1 Gy) (P = 0.03). There was no significant impact of the pattern of surgery on LAD dose, but significance was noted for LCx dose parameters (P = 0.04 and 0.08 for m‑Dmax and m‑Dmean of LCx). CONCLUSION: This pilot dosimetric study confirms the assumption that patients with left‑sided EBC are at higher risk of developing long‑term cardiac morbidity when treated with PORT due to increased dose to LAD.

Modern chemoradiation practices for malignant tumors of the trachea: An institutional experience.

Background: Malignant tumors of the trachea are rare. A multimodality treatment approach is often necessary. Outcomes of radical non-surgical approaches are sparse. Radiation combined with sequential or concurrent chemotherapy is an important treatment option. Materials and Methods: We present an analysis of outcomes using modern radiotherapy and chemotherapy for tracheal tumors. Results: Radiation dose escalation using modern techniques is of benefit for these tumors. The results with chemotherapy are encouraging. Conclusions: Radiation plays a distinct role and should be a part of treatment for these tumors. The role of chemotherapy needs to be studied further.

Role of extracorporeal irradiation in malignant bone tumors.

Aims and Objectives: Extracorporeal irradiation (ECI) is relatively a rare method used in the management of malignant bone tumors (MBT). It consists of en-bloc removal of the tumor bearing bone segment, removal of the tumor from the bone, irradiation, and re-implantation back in the body. We report our preliminary experience of using ECI for management of MBT. Materials and Methods: From year 2009 to 2010, 14 patients with primary MBT were enrolled into this study. The eligibility criteria included histopathological proof of malignancy, no evidence of distant metastases, and suitability for limb preservation therapy. Surgery was performed about 4 weeks after completion of neoadjuvant chemotherapy. The affected bone segment was resected, irradiated extracorporeally with a dose of 50 Gy and reimplanted. Local control, complications and short-term survival were studied. Functional outcome was assessed by Musculoskeletal Tumor Society (MSTS) scoring system. Results: There were 10 males and four females with median age of 14 years. Histopthologically, nine patients had osteosarcoma (OS) and five had Ewing's sarcoma family of tumors (ESFT). Distribution of primary site was as follows: Femur eight patients, tibia five patients and humerus one patient. At a median follow-up was 22 months, three patients (two OS, one ESFT) had local recurrence. Two patients (14%) developed wound infection in the perioperative period. The 2 year local recurrence free survival was 73% and mean MSTS score was 88. Conclusion: Results of our study suggest that ECI is technically feasible in the management of MBT and provides decent local control and short-term survival rates.

Comparison of Low- and High-dose Rate Brachytherapy in Carcinoma Cervix: Results From a Randomized Study.

Purpose: We are reporting results of a randomized study with the aim to compare the results of low-dose rate (LDR) versus high-dose rate (HDR) brachytherapy in locally advanced carcinoma cervix patients. Material and methods: Sixty cases of carcinoma of uterine cervix in Stage IIB-IIIB (FIGO) were included from a period of January 2002 to March 2003 and were randomized into HDR brachytherapy (6 Gy/fraction for 4 sessions) or LDR brachytherapy (27 Gy/single session) arm after completion of external beam radiotherapy (50 Gy/25#/5 weeks). Results: In HDR arm, 16/30 (53.33%) patients experienced complete response. In LDR arm, complete response was experienced by 13/30 (43.33%) of patients. Locoregional control in HDR group was 54.54%, 57.14% and 71.42% at 6, 9 and 12 months, respectively. Locoregional control in LDR group at 6, 9 and 12 months was 45%, 63.63% and 42.85%, respectively. Conclusion: The results of our study indicate that LDR and HDR groups are similar in locoregional control in the management of carcinoma uterine cervix. HDR brachytherapy can safely substitute LDR brachytherapy applications.

Clinical and pathological response rates of docetaxel-based neoadjuvant chemotherapy in locally advanced breast cancer and comparison with anthracycline-based chemotherapies: Eight-year experience from single centre.

Introduction: The administration of neoadjuvant chemotherapy (NACT) prior to local therapy is advantageous for women with locally advanced breast cancer (LABC), since it can render inoperable tumors resectable and can increase rates of breast conservative surgeries. Materials and Methods: We retrospectively analyzed LABC patients who received NACT from January 2000 to December 2007. Out of 3000 case records screened, 570 (19%) were LABC and 110/570 (19%) treatment-naïve patients started on NACT were analyzed. Ninety-one (37 docetaxel [D], 54 anthracycline [A]) patients were eligible for response and survival analysis. Pathological complete remission (pCR) was defined as no evidence of malignancy in both breast and axilla. Results: Median age of the whole cohort was 45 years (range 25-68 years). Premenopausal were 42% and estrogen receptor + 49.5%. Most (90%) were T4 tumors and 70% were Stage IIIB. Median numbers of preoperative cycles were six and three in the D and A group respectively. Overall clinical response rates for breast primary were 74.3% and 53.7% (CR 28.6% vs. 16.7%, P=0.58) while for axilla ORR were 75.7% vs. 54.8% (51.4% vs. 40.4% CR, P=0.77) respectively for D and A. Corresponding pCR rates were 19% vs. 13% respectively. There was no significant difference in disease-free (three-year 56.84% vs. 61.16%, P=0.80) and overall survival (three-year 70% vs. 78.5%, P=0.86) between the two groups. Conclusions: Although pCR rates were higher with docetaxel-based NACT, it did not translate into superior disease-free survival / overall survival compared to anthracycline-based chemotherapies.

Economic cost analysis in cancer management and its relevance today.

The global cancer burden has shown a distinct shift in the last two decades and its financial impact can be large, even among patients living in high resource countries, with comprehensive health insurance policies. It is hard to imagine its impact on patients of developing countries where insurance policies exist infrequently and often cost becomes the greatest barrier in availing cancer treatment. It is recognized that these costs include the direct cost of disease treatment and care, indirect costs accrued by the patient and the family, and economic losses to the society as a whole. Economic cost analysis or cost-effectiveness analysis has emerged as a basic tool in the evaluation of health-care practices. To date, these cost data have been collected only sporadically, even in the most developed countries, and there is a great need for incorporating economic cost assessment practices in developing countries, so that patients and their families can access the care adequately. The current review has been done using pubmed and medline search with keywords like cancer, cost-analysis, cost-effectiveness, economic burden, medical cost, etc.

Radiation dose escalation by percutaneous interstitial brachytherapy in locally advanced non-small cell lung cancer.

Management of locally advanced non-small cell lung cancer is associated with a poor overall survival using concurrent chemoradiotherapy. Therefore, newer approaches to treatment which enable dose escalation are warranted. Interstitial brachytherapy in lung is a new emerging concept with many distinct advantages. We report here a case of locally advanced non-small cell lung cancer with residual disease after conventional treatment. The patient was successfully treated using percutaneous interstitial brachytherapy and is disease-free at 18-month follow-up.

Field-in-field technique for upper abdominal malignancies in clinical radiotherapy.

BACKGROUND: In upper abdominal malignancies (UAM), due to the presence of multiple inhomogeneous tissues, a wedge-based conformal treatment planning results in high-dose regions inside the target volume. AIM: This study was designed to explore the feasibility of using a field-in-field (FIF) technique in different UAM and its efficacy in reducing the high-dose regions. MATERIALS AND METHODS: Twelve patients of UAM (which included malignancies of the gastroesophageal junction, stomach, gall bladder, and pancreas) were selected for this study. Computed tomography (CT) scans were performed and three-dimensional conformal wedge plans were generated for all the cases. The same plan was copied with the wedges removed and a FIF plan was generated. The two plans were compared for mean, maximum, and median doses; dose received by 2% (D2) and 98% (D98) of the target volume; volume receiving> 107% (V > 107%) and < 95% (V Statistical Analysis: Statistical analysis was performed with SPSS, version 10.0. RESULTS: For all the cases, the FIF technique was better than wedge-based planning in terms of maximum dose, D2, V > 107%, and CI; there was a statistically significant reduction in monitor units. With regard to doses to critical structures, there was marginal dose reduction for the kidneys and spinal cord with FIF as compared to wedge-based planning. CONCLUSION: The FIF technique can be employed for UAM in place of wedge-based conformal treatment plans.

Burden of cancer and projections for 2016, Indian scenario: gaps in the availability of radiotherapy treatment facilities.

Plausible projections of future burden of cancer in terms of incident cases and requirement of radiotherapy treatment facilities at the national and state level are useful aids in planning of cancer control activities. The present communication attempts to provide a scenario for cancer in India during the year 2001 and its likely change by 2016 for all sites of cancer as well for selected leading sites. Further, a study was made of: (i) the state-wise distribution of radiotherapy treatment facilities and short falls; and (ii) pattern of investment of finances through central assistance by Government of India for cancer control activities during the various plan periods. The age, sex and site-wise cancer incidence data along with populations covered by 12 Indian population based cancer registries were obtained from the eighth volume of Cancer Incidence in Five Continents (CIV-VIII) and other published reports. Pooled age sex, site specific cancer incidence rates for twelve registries were estimated by taking weighted average of these registries with respective registry population as weight. Population of the country and states according to age and sex for different calendar years viz. 2001, 2006, 2011 and 2016 were obtained from the report of Registrar General of India. Population forecasts were combined with the pooled incidence rates of cancer to estimate the number of cancer cases by age, sex and site of cancer for the above 5-yearly periods. The existing radiotherapy facilities available in the country for cancer treatment during the year 2006 was based on the published reports and updated through personal communication from the Ministry of Health of India. During the year 2001, nearly 0.80 million new cancer cases were estimated in the country and this can be expected to increase to 1.22 million by 2016 as a result of change in size and composition of population. The estimated numbers were greater for females (0.406 millions, 2001) than males (0.392 millions, 2001). Lung, esophagus, stomach, oral and pharyngeal cancers are much higher in men while in women, cancers of cervix and breast are predominant forms followed by those of oral cavity, stomach and esophagus. Considering all the sources, it was noted that during the year 2006, there were 347 teletherapy units in the country as against a requirement of 1059. The state-wise analysis of the distribution of RCCs, and radio-therapy units shows wide gaps in the availability of facilities. The existing treatment facilities for cancer control in-terms of radiotherapy and financial allocation are woefully inadequate to take care of even the present load. The only way to fight this scourge under such circumstances is to have pragmatic programmes and policies based on currently available scientific information and sound public health principles.

Sarcomatoid carcinoma of the maxillary sinus: a rare head and neck tumor.

Sarcomatoid carcinomas are rare tumors. These tumors have been reported at other sites, but head and neck origin is extremely uncommon. We report here a rare case of sarcomatoid carcinoma involving the maxilla. Only four such cases with maxillary origin have been discussed in English literature earlier. As compared to squamous cell carcinoma of maxilla, this variant is associated with poor prognosis and advanced disease at presentation, as was also seen in our case. There are no standard recommendations for management owing to the rarity of this histology. Surgery and radiotherapy form the mainstays of treatment. Exploration of the role of chemotherapy and novel targeted therapy agents is warranted in order to improve treatment results.

Normal tissue complication probability of fibrosis in radiotherapy of breast cancer: accelerated partial breast irradiation vs conventional external-beam radiotherapy.

AIMS: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment. MATERIALS AND METHODS: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study. RESULTS: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P < 0.001). CONCLUSIONS: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer.

Radiofrequency ablation of hepatic metastasis: results of treatment in forty patients.

AIM: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. MATERIALS AND METHODS: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. RESULTS: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. CONCLUSIONS: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size.

A prospective study evaluating surgery and chemo radiation in muscle invasive bladder cancer.

AIM: The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation. MATERIALS AND METHODS: Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation. RESULTS: Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups. CONCLUSION: Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient.

Comparison of computed tomography and magnetic resonance based target volume in brain tumors.

PURPOSE: This study was mainly framed to study the difference in tumor volumes as seen on computed tomography (CT) and magnetic resonance (MR) and their significance in planning. MATERIALS AND METHODS: Twenty-five patients with brain tumor of different diagnoses who underwent stereotactic radiotherapy were included in this study. CT and MR imaging was done for all the patients with 2.5 mm slice thickness. The CT tumor volume and MR tumor volume were measured and compared with each other. The center of mass (CM) of the tumor volume delineated on CT and MR were computed and the shift between the two CMs was determined. RESULTS: The mean and median volume of the tumor as measured from MR scans was 19.67 cc +/- 13.73 and 16.13 cc (range: 3.25 cc-50.37 cc). Similarly, the mean and median volume of the tumor as measured from CT scans was 15.05 cc +/- 10.13 and 11.63 cc (range: 3.0 cc-36.25 cc) respectively. The mean and median CM shift between CT and MR was 5.47 mm and 5.21 mm respectively. CONCLUSION: The study demonstrates that MR is an indispensable imaging modality in radiotherapy for planning brain tumors.

Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study.

BACKGROUND AND AIMS: Radiation induced wet desquamation of skin in carcinoma breast patients is a painful condition. In this study topical beclomethasone dipropionate spray was used as prophylaxis with the purpose of reducing risk of the wet desquamation of skin in irradiated field. MATERIALS AND METHODS: Sixty patients of carcinoma breast were planned for postoperative loco regional radiotherapy (50 Gy in 25 fraction over five weeks) were prospectively randomized into two groups (1) steroid group-patients were advised to use beclomethasone dipropionate spray in irradiated axilla from day one of radiotherapy, (2) control group-patients were not allowed to use any topical agent in irradiated area. Radiation induced skin reaction was noted in terms of erythema, dry desquamation and wet desquamation weekly till end of prescribed 50 Gy dose of the radiation therapy. STATISTICAL METHOD: Chi-square test was used to see the statistical significance of the difference in wet desquamation between two arms of the study. Chi-square value and P-value was calculated for the difference of wet desquamation in two study arms. RESULT: In steroid group 4/30 (13.33%) patients developed wet desquamation of the axillary skin at the end of the radiotherapy. For the control group, this figure was 11/30 (36.66%). The difference in wet desquamation of the axillary skin in the two groups was statistically significant (P-value = 0.0369). CONCLUSION: Topical steroid (beclomethasone dipropionate spray) for skin during radiotherapy significantly reduces the risk of wet desquamation of the skin.

Sweat gland carcinoma with lung metastases.

Sweat gland carcinoma is a rare skin tumor. The tumor has propensity to spread to lymph nodes and distant metastases has been reported. Their exact incidence in the Indian setting is not known. Aspects related to treatment are also not clearly defined. Though surgery forms the initial treatment approach, adjuvant treatment has not been properly explored. We report here a case of sweat gland carcinoma with bilateral lung metastases.