Effect of Community-Based Health Education on Misconceptions Related to Caregiving for Cancer among Elderly in a Rural Area of Puducherry: A Pre-Post-Intervention Study.

Background and Aim: Families are crucial in providing comprehensive support to cancer patients, including physical, psychological, spiritual, and financial assistance. Unfortunately, cancer-related myths and stigma can have detrimental effects on those affected and their caregivers. This study aims to remove the misconceptions prevailing in a rural population of Puducherry regarding caregiving for cancer among elderly through a health education campaign. Materials and Methods: A pre- and post-intervention study was conducted among 217 adults above 18 years of age in a rural area of Puducherry. The intervention was delivered through pamphlet distribution, health talks, and discussion. Attitude, beliefs, and knowledge regarding the misconceptions about cancer were assessed in a five-point Likert scale and then the difference in the proportion of subjects with misconceptions about cancer before and after the intervention was tested using the McNemar test. Results: Among the respondents, 77% were females, 15% were illiterate, and 9.6% had a history of cancer in the family. About 23% felt cancer lends a bad name to the family and 24% considered palliative care as not necessary since end-stage cancer patients would die. Post-intervention, the perception that herbal items or diets may treat cancer declined from 45% to 18%, and that a cancer patient in the family lends bad name to the family declined from 23% to 3% (P < 0.001). Conclusions: Community-based intervention can effectively reduce misconceptions related to caregiving for cancer among elderly in rural areas. These interventions can also improve the quality of care and support provided to cancer patients.

Mapping of Palliative Care Services and Challenges in Implementation of National Program for Palliative Care in Puducherry.

Objectives: The purpose of this study was to map ongoing palliative care services and describe the characteristics of providers, recipients, level of care, and approach. Second, it seeks to investigate the difficulties encountered in implementing NPPC in the Puducherry district of UT Puducherry. This study aims to review the challenges in its implementation. Material and Methods: The study using both quantitative and qualitative design, including geospatial mapping of organisations, describing service delivery characteristics and exploring challenges faced in implementing NPPC, was conducted from July 2021 to January 2022. In-depth interviews were conducted with seven healthcare providers, four patients and three caregivers, as well as key informant interviews with six doctors in administration. Results: Thirteen organisations providing palliative care to population of Puducherry district of union territory Puducherry and neighbouring districts of Tamil Nadu were identified. Mapped organisations were primarily concentrated in urban areas. Morphine was available only at three medical colleges, providing outpatient palliative care services. Non-governmental organisations provided only home-based palliative care services and the hospices provided both in-patient and home-based services. Key barriers perceived by the health system were difficulty in procuring morphine, inadequate personnel and inadequate funding. Few barriers perceived by patients/family were stigma faced in community, psychological challenges and poor quality of care. Conclusions: Palliative care services are mainly available in urban areas and through private hospices. There is a need to implement palliative care program through the public health system to improve the accessibility in the rural areas.

Correlation between Quality of Life and Burden in Caregivers of Advanced Stage Cancer Patients on Best Supportive Care.

Objectives: Patients with advanced cancer with incurable diseases are generally cared for by their families in India. There is a lack of data on the perceived caregiver burden, quality of life (QOL) of patients and caregivers in India, especially among cancer patients not on any oncologic management. Material and Methods: We conducted a cross-sectional study among 220 patients of advanced cancer on best supportive care and their respective 220 family caregivers. Our primary objective was to identify a correlation between caregiver burden and QOL. After taking informed consent from both patients and caregivers, we assessed the QOL of the patient using the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative Care (QLQ C15PAL) questionnaire from the patient, assessing the Caregiver Burden using Zarit Burden Interview, assessing the QOL of the caregiver using the WHO QOL BREF Questionnaire, in a single session during their routine follow-up in the Palliative Care Clinic of our institution. Results: We noticed a statistically significant negative (Spearman) correlation between the Caregiver Burden as assessed by Zarit Burden Interview (ZBI) and the psychological (r = -0.302, P < 0.01), social (r= -0.498, P < 0.01) and environmental (r = -0.396, P < 0.01) domains of the WHO QOL BREF Questionnaire. Caregiving Burden as assessed ZBI total score was noted to have a statistically significant negative correlation with physical functioning (r = -0.37, P < 0.01), emotional functioning (r = -0.435, P < 0.01) and global QOL scores (r = -0.499, P < 0.01) assessed from the patient using the EORTC QLQ C15 PAL questionnaire. It also had a statistically significant small positive correlation with EORTC QLQ C15 PAL symptom scores, such as dyspnoea, insomnia, constipation, nausea, fatigue and pain. The median caregiver burden score was 39, showing higher burden as compared to previous studies. Caregivers who were spouses of the patient, illiterate, homemakers, with low-income families reported higher burden. Conclusion: A high perceived caregiving burden is associated with impaired QOL in family caregivers of advanced cancer patients on best supportive care. Multiple patient related factors and demographic factors tend to affect burden of the caregiver.

Challenges in the Management of Lung Cancer: Real-World Experience from a Tertiary Center in South India.

Lung cancer is one of the most common cancers and an important cause of cancer-related mortality. Recent advances in targeted therapy and immunotherapy have improved outcomes, but these have limited penetration in resource-constrained situations. We report the real-world experience in treating patients with lung cancer in India. A retrospective analysis of baseline characters, treatment and outcomes of patients with lung cancer seen between January 2015 to December 2018 ( n = 302) at our center was carried out. Survival data were censored on July 31, 2019. A total of 302 patients (median age: 57 years [range, 23-84 years]; males [ n = 203; 67.2%]) were registered. Adenocarcinoma was the most common histology ( n = 225, 75%). The testing rate of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation analysis in stage IV adenocarcinoma ( n = 191) was 67% and 63%, respectively. Systemic therapy (chemotherapy/gefitinib) was started after a median of 62 days (range, 1-748) from presentation and 38 days (range, 1-219 days) from diagnosis. The median progression-free survival (PFS) and overall survival (OS) were 4.3 months (95% CI, 3.2-5.4) and 9.0 months (95% CI, 7.6-10.5), respectively in the 141 patient without targetable mutations who started palliative chemotherapy. Of the 58 patients who tested positive for EGFR mutation, 41 (71%) started an EGFR tyrosine kinase inhibitor (TKI), and the median PFS and OS in these patients were 8.5 months (95% CI, 5.6-11.4) and 18.4 months (95% CI, 12.2-24.6), respectively. Only 1 out of 10 patients with stage IV ALK -positive adenocarcinoma was started on ALK inhibitor. On multivariate analysis of OS for patients who started on palliative chemotherapy, response to first-line treatment, long distance from the center, use of second line therapy, and a delay of > 40 days from diagnosis to treatment predicted improved survival. Despite providing free diagnostic and treatment services, there was considerable delay in therapy initiation, and a significant proportion of treatment noninitiation and abandonment. Measures should be taken to understand and address the causes of these issues to realize the benefits of newer therapies The apparent paradox of improved survival in those with long delay in initiation of treatment could be explained based on a less aggressive disease biology.

Treatment Seeking Behavior, Treatment Cost and Quality of Life of Head and Neck Cancer Patients: A Cross-Sectional Analytical Study from South India.

BACKGROUND: Head and neck cancer constitute one-third of all cancers. Due to the complex nature of Head and Neck Cancer treatment, expenditure on cancer treatment are higher and the Quality of Life of patients is also compromised. The objectives of the study were to determine the time taken by patients for seeking care from registered medical practitioners, time to definitive diagnosis and treatment initiation, expenditure incurred, and Quality of Life. METHODS: The present study was a cross-sectional descriptive involving outpatient with head and neck cancer reported to the department of radiotherapy, regional cancer center, JIPMER. The quality of life was assessed using validated FACT-Hand N scales. RESULTS: The preferred first contact for seeking care for most was the private sector (52%). The median (IQR) presentation interval, diagnostic interval, and treatment initiation interval were 36.5 (16 - 65.7), 14 (7 - 31.5), and 65.5 (45 - 104) days respectively. The average indirect cost incurred was INR 8424 (4095-16570) in JIPMER, which was spent over an average duration of 240 days. The median (IQR) wage loss by the patients and/or caregivers was INR18000 (5250-61575). The source of expenditure was mainly from their family savings (56%). Functional well-being was severely impaired. The patients with occupation, head of the family, and early stage of cancer had a statistically significant quality of life. CONCLUSION: The majority of the patients were diagnosed in the regional cancer center, JIPMER although their preferred first point of contact was private practitioners. The average time interval from diagnosis to treatment initiation was more than two months. The expenditure during the treatment was mainly because of indirect cost and wage loss. The functional quality of life was severely impaired for the majority of the cases.

Dosimetric comparison between interstitial brachytherapy and volumetric-modulated arc therapy for tumor bed boost in breast cancer.

PURPOSE: To dosimetrically compare high-dose-rate interstitial brachytherapy (HDR-BT) with volumetric-modulated arc therapy (VMAT) for tumor bed boost, following breast conservative treatment. MATERIAL AND METHODS: 50 patients with early-stage breast cancer who underwent breast conservation surgery, followed by either HDR-BT (n = 25) of 15 Gy in 6 fractions over a period of 3 days, or VMAT dose of 16 Gy in 8 fractions (n = 25) for tumor bed boost, were retrospectively reviewed. All patients received whole breast irradiation of 46 Gy in 23 fractions. Dosimetric parameters for organs at risk (OARs), including ipsilateral and contralateral lungs, heart, contralateral breast, skin, and ribs, were evaluated with the help of dose-volume histograms (DVH). RESULTS: Heart sparing was similar in both modalities (left-sided breast irradiation, HDR-BT D2cc 20.5% vs. VMAT 30.2%, p-value = 0.243; right-sided breast irradiation, D2cc 6.5% vs. 4.4%, p-value = 0.165). Left-sided cases received higher dose to heart compared to right-sided patients. Interstitial brachytherapy resulted in significantly less dose to contralateral breast (D2cc 4.3% vs. 9.6%, p-value < 0.0001), ipsilateral lung (D2cc 27.6% vs. 73.2%, p-value < 0.0001), contralateral lung (D2cc 4.2% vs. 14.5%, p-value < 0.0001), ribs (D2cc 24.1% vs. 41.2%, p-value < 0.0001), and skin (D2cc 77.3% vs. 95%, p-value < 0.0001). CONCLUSIONS: HDR-BT-based tumor bed boost irradiation results in significantly lower doses to most organs at risk with similar heart sparing compared to VMAT.

Diagnostic delay for head and neck cancer in South India: A Mixed-methods Study.

BACKGROUND: Early diagnosis is an important aspect of quality of cancer care.Analysis of the diagnostic delays and the reasons for delay helps to plan strategies to improve cancer care. OBJECTIVES: To determine the primary, secondary, and total diagnostic delay of patients diagnosed with head and neck cancer and to explore the reasons for the delay from the patient perspective. METHODS: Explanatory mixed method design was used. Two hundred persons with a confirmed diagnosis of head and neck cancer attending the ENT (ear, nose, throat) cancer clinic in a teaching hospital before the initiation of treatment were included in the study. The median delay and the association of the delay with the various factors were analyzed. Sixteen one-to-one interviews of patients were done to identify the reasons for the delays from the patient perspective. RESULTS: Median primary, secondary, and total diagnostic delays were 30 days, 30 days, and 73 days, respectively. Statistically, primary delay was found significantly longer among ever users of smokeless tobacco and significantly longer secondary delay was found among those with age less than 60 years. The reasons for the delay were grouped in the categories (i) Symptom appraisal delay due to low perceived seriousness and (ii) health-seeking behavior delay. CONCLUSIONS: The diagnostic delay was considerable. Measures to enhance symptom appraisal by improving health literacy, opportunistic screening, and strengthening the referral system would decrease diagnostic delay.

Dosimetric Comparison and Feasibility of Simultaneous Integrated Boost (SIB) in Treatment of Malignant Gliomas Using Intensity Modulated Radiotherapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT)

Objective: To evaluate the dosimetric parameters of Simultaneous Integrated Boost in the treatment of malignant gliomas and compare the SIB plans of VMAT and IMRT. Methodology: CT and MRI of 28 patients were used for generating SIB plans with VMAT and IMRT. A dose of 2Gy per fraction was prescribed to the CPTV and 2.4Gy to the GPTV for a total of 25 fractions. The plans were accepted only if they met the set of planning objectives defined in the protocol. Results: We could achieve the planning objectives in all the SIB plans. Although GPTV coverage was statistically better in VMAT (98.67% vs 98.19% ;p=0.024) the difference is not clinically meaningful. The conformity index for GPTV was higher in IMRT (0.83 vs 0.76; p=0.001). The coverage of CPTV was better in IMRT (97.88% vs 96.87%; p=0.021). But the conformity index of CPTVannulus was higher in VMAT (0.72 vs 0.67; p=0.01). There was no difference in homogeneity index of GPTV and CPTV annulus between the plans. The mean dose received by normal brain was higher in IMRT (28Gy vs 24.2Gy; p<0.001). Ipsilateral optic nerve has received lesser Dmax in IMRT (44.2Gy vs 46.95Gy; p=0.02). No difference was seen in Dmax of brainstem, optic chiasm, contralateral optic nerve. The treatment times and monitor units were significantly less in VMAT. Conclusion: SIB is dosimetrically feasible for hypofractionation in malignant gliomas using IMRT and VMAT. IMRT plans had better boost conformity, lower ipsilateral optic nerve and brainstem maximum doses compared to VMAT. Whereas, VMAT had better coverage, better overall PTV conformity, lower normal brain mean dose, lower monitor units and lesser treatment times. Although planning of VMAT is cumbersome and time consuming, the advantage of reducing treatment time is beneficial to the patients' comfort and better managing of patient load in high volume centres.

Assessment of Psychological Distress and its Effect on Quality of Life and Social Functioning in Cancer Patients.

PURPOSE: The diagnosis of cancer and its treatment can make patients psychologically distressed. The purpose of this study is to evaluate the level of psychological distress and social functioning in cancer patients and to assess the association of these parameters with the quality of life (QOL) experienced by the patient. PATIENTS AND METHODS: All cancer patients attending palliative care clinic who can understand and speak English or Tamil language were taken into the study. An interview technique with a questionnaire is used for data collection after informed consent. The questionnaire consisted of four sections, namely, demographic variables, general health questionnaire, WHO QOL-BREF, and SCARF social functioning index. All questionnaires were translated into the Tamil Language and were evaluated by the experts for content validity. RESULTS: The median scores obtained are psychological distress = 44 (11-98), WHO QOL = 64 (36-117), and social function = 51 (29-79). Out of 251 patients, 30% had severe psychological distress, 25.6% had poor QOL, and 23.2% were with severely affected social function. Skilled laborers had better scores compared to unskilled laborers (P < 0.05). Family size (<2 children) had a positive impact on the QOL (P = 0.008). Patients from urban locales had better social functioning than rural counterpart (P = 0.047), but no difference was observed in distress level or QOL. Increased growth hormone distress score of the patients had a negative impact on both QOL (r = -0.522) and social function (r = -0.244). QOL correlated positively with social function (r = +0.247). CONCLUSION: Psychosocial stress associated with cancer and its treatment can impact the QOL and social functioning of the patient and needs to be addressed along with the cancer-directed therapy. Decreasing the symptom burden and distress level by palliative care intervention might improve the QOL and social function.

Skeletal muscle metastasis from carcinoma cervix: a case report.

Cervical cancer is the most common malignancy in Indian women. Cervical cancer usually spread by local extension and through the lymphatics to the retroperitoneal lymph nodes. Direct invasion of muscles by primary growth is more common than by metastatic involvement. We present a case of carcinoma of the cervix post radiotherapy to pelvis who on follow up presented with biceps muscle metastases as the initial sign of disseminated disease.

Hemophilia of orbit.

Hemophilic pseudotumor is an uncommon complication of factor VIII and IX deficiencies in the coagulation cascade and occurs in a wide spectrum of bones and soft tissues. We present a six-year-old boy with hemophilic pseudotumor localized in the right orbit. He showed a favorable response to radiation therapy after unsuccessful treatment with factor VIII replacement therapy with no recurrence till eight months. Radiotherapy in the treatment of pseudotumors in hemophiliacs should be strongly considered, particularly in severely affected patients who do not respond to conservative therapy.