The role of radiotherapy in newly diagnosed primary CNS lymphoma: A descriptive review and a pragmatic approach to clinical practice.

Earlier, prior to the development of effective systemic therapy, monotherapy with whole-brain radiotherapy (WBRT) was widely used to treat primary central nervous system lymphoma (PCNSL). Recently, chemotherapy, especially with high dose methotrexate (HDMTX), has largely replaced WBRT as upfront treatment, and the most accepted standard of care is induction with a combination drug therapy followed by consolidation therapy with either autologous stem-cell transplantation (ASCT) or radiation. Whilst WBRT is an effective component of treatment, it is occasionally associated with risk of permanent, irreversible neurotoxicity when doses of more than 30 Gy are used. Hence, there has been a strong focus on the optimization of radiotherapy (RT) which includes dose reduction in the consolidation phase. In this comprehensive review, we have summarized the progress on clinical results and evidence considering the role and use of radiation including combined treatment modalities, low-dose radiotherapy, and neurotoxicity. Finally, we present a practical approach to low-dose WBRT and boosting higher doses to the gross tumor that can be integrated into clinical practice.

Cancer and severe mental illness in low- and middle-income countries: The challenges and outlook for the future.

OBJECTIVE: Patients with severe mental illness (SMI) face health inequalities that lead to under treatment of diseases such as cancer and result in increased mortality. There is literature addressing this issue for SMI patients in high-income countries but few for those in low- and middle-income countries. This review aims to draw attention to the health inequalities and the compounding factors faced by SMI patients in low- and middle-income countries. The relevance of integration of psycho-oncology in the care of SMI patients with cancer is integral to reduce disparities and address varied contributory factors. METHODS: The literature review was conducted by searching through two databases which includes PubMed and Google Scholar. We searched for articles using keyword search terms: severe mental illness, SMI, schizophrenia, bipolar disorder, cancer, low- middle-income countries, low- and middle-income countries, psycho-oncology, HPV vaccine, cancer incidence, cancer mortality, cancer control, cancer screening, cancer treatment and palliative care. RESULTS: A total of 80 research articles were included in our literature review. We found that there was an increased requirement for adapting to the changing disease landscape in low- and middle-income countries. An improvement on aspects such as vaccination, screening and prevention is necessary, and also efforts to change social stance towards SMI is crucial. CONCLUSION: There is an increase incidence of cancer in low- and middle-income countries, and the number of patients with SMI in low- and middle-income countries is also rising. This is due to social, psychological, economical and healthcare factors. Low- and middle-income countries must consider improving these aspects in order to adapt to the changing landscape.

Helical tomotherapy for prostate cancer radiation therapy: An audit of early toxicity and quality of life.

BACKGROUND: Radiation plays a major role in the management of localized prostate cancer (CaP). There are limited studies reporting the quality of life (QOL) and toxicity with CaP tomotherapy. MATERIALS AND METHODS: This is a single-institutional prospective observational study evaluating the acute toxicity and QOL of patients with CaP receiving tomotherapy from May 2018 to October 2019. Toxicity assessed using radiation therapy oncology group toxicity grading. QOL assessed using International Prostate Symptom Score (IPSS) and QOL score. RESULTS: A total number of 74 patients received radiation therapy (RT), of which 25 had postoperative RT and 49 had radical RT. The median age was 71 years. During RT, 8 (10.8%) had Grade 2 gastrointestinal (GI) and 4 (5.4%) had Grade 2 genito urinary (GU) toxicities. At 3 months, 1 (1.4%) had Grade 2 GI, 1 (1.4%) had Grade 2 GU, and 1 (1.4%) had Grade 3 GU toxicities. At 6 months, 1 patient had Grade 2 GU and no Grade 2 GI toxicity noted. In postoperative RT Group, 2 (8%) Grade 2 GI and 1 (1.4%) Grade 2 genitourinary toxicity reported during radiation. At 3 months, 1 (1.4%) Grade 2 GI, 1 (1.4%) G2 GU, and 1 (1.4%) G3 GU toxicities noted. At 6 months, no ≥ Grade 2 noted. In radical RT group, during radiation 6 (12.2%) Grade 2 GI and 3 (6.1%) Grade 2 GU recorded. At 3 and 6 months, no ≥ Grade 2 GI/GU toxicity was recorded. No Grade 3/Grade 4 observed in radical RT group. One patient in radical RT and one in postoperative RT had severe IPSS symptom score. Results are comparable to reported studies. CONCLUSION: Our initial clinical experience with helical tomotherapy in CaP confirms lower rate of toxicities and no significant worsening of QOL with RT.

Dosimetric Comparison of Four Different Radiotherapy Planning Techniques for Adjuvant Radiotherapy of Left-Sided Breast, Axilla, and Supraclavicular Fossa.

Purpose/Aim: Forward planned intensity-modulated radiotherapy (forward IMRT) with breath-hold (BH) technique is considered optimal by most practitioners for treating left-sided breast cancer. Regional nodal irradiation including axilla and supraclavicular fossa (SCF) increases can increase dose-to-organs at risk (OAR) especially lung. This study was done to assess the potential of inverse planned IMRT (inverse IMRT) to achieve significant reduction in dose to OAR. Materials and Methods: Ten patients with left-sided breast cancer treated with Active Breath Co-ordinator BH technique were included in the study. Forward IMRT plans were generated in both BH and free breathing (FB) scans. Inverse IMRT plans were generated in FB scan using Tomotherapy-Direct and Tomotherapy-Helical techniques. Contouring was done as per the ESTRO consensus contouring guidelines. The dose prescribed was 40 Gy in 15 fractions. Statistical significance was tested using one-way ANOVA for parametric data and Kruskall-Wallis test for nonparametric data. Multiple comparison tests were done by using Bonferroni test. P <0.05 was considered to denote statistical significance. Results: Inverse IMRT plans achieved superior homogeneity index compared to forward IMRT with BH. Tomotherapy-Direct reduced dose to ipsilateral lung, compared to the forward IMRT with BH while achieving similar doses to other OAR. Tomotherapy-Helical plans achieved significantly better conformity index and reduced maximum dose to left anterior descending artery compared to forward IMRT plans, but low dose to other OAR was significantly worse. Conclusion: For left-sided breast, axilla, and SCF radiotherapy, inverse IMRT with Tomotherapy-Direct plan achieved better homogeneity index and reduced dose to ipsilateral lung compared to forward IMRT with BH.

Call for Action to Address Equity and Justice Divide During COVID-19.

The coronavirus 2019 disease (COVID-19) is deepening the inequity and injustice among the vulnerable communities. The current study aims to present an overview of the impact of COVID-19 on equity and social justice with a focus on vulnerable communities. Vulnerable communities include, but not limited to, healthcare workers, those from lower socioeconomic backgrounds, ethnic or minority groups, immigrants or refugees, justice-involved populations, and people suffering from chronic diseases or mental illness. The implications of COVID-19 on these communities and systemic disparities beyond the current pandemic are also discussed. People from vulnerable communities' experience disproportionately adverse impacts of COVID-19. COVID-19 has exacerbated systemic disparities and its long-term negative impact on these populations foretell an impending crisis that could prevail beyond the COVID-19 era. It is onerous that systemic issues be addressed and efforts to build inclusive and sustainable societies be pursued to ensure the provision of universal healthcare and justice for all. Without these reinforcements, we would not only compromise the vulnerable communities but also severely limit our preparedness and response to a future pandemic.

Impact of St. Gallen surrogate classification for intrinsic breast cancer sub-types on disease features, recurrence, and survival in South Indian patients.

BACKGROUND: Breast cancer is a heterogeneous group of disease, and recently, intrinsic sub-typing on the basis of gene expression profiling is found to be a predictor of breast cancer clinical course. The St. Gallen has released surrogate classification for breast cancer sub-types depending on immunohistochemistry (IHC) markers. AIM: The aim of our study was to analyze the distribution of sub-types using IHC surrogate markers in our patient population and to assess the clinico-pathological factors in different sub-types. MATERIALS AND METHODS: A total of 635 non-metastatic patients who underwent radical intend treatment from January 2011 to December 2013 were included for this retrospective analysis. A statistical analysis was done by Windows SPSS version 20. The Chi-square test was used to examine the correlations of these sub-types with clinico-pathological parameters. The Kaplan-Meier method estimates were used for survival analysis. RESULTS: The median follow-up was 42.77 months (5 months to 112 months). Luminal B was the predominant group. Disease free survival (DFS) at 5 years was 95% in luminal A, 78% in luminal B HER-2 negative, 80% in luminal B HER-2 positive, 72% in triple negative, and 79% in HER-2/neu non-luminal. Tumor size, Ki67, T stage, N stage, and grade were significantly associated with DFS in all biological type with a P value of less than 0.05. CONCLUSION: Surrogate classification was successfully applied in our patient cohort. Luminal B and triple negative sub-groups were more prevalent in our patients, and this finding is at variance with published international data. Biological sub-type also emerged as an important predictor of survival.

Wellbeing and burnout in medical students in India; a large scale survey.

Medical students in India completed an anonymous online questionnaire regarding mental health and wellbeing, including Oldenburg burnout ratings, CAGE questionnaires, and general health questionnaire (GHQ12). Out of 597 student responses, over 80% were characterised as experiencing burnout. This study highlights the need to further examine this issue, including possible causes and solutions.

A dosimetric analysis of cardiac dose with or without active breath coordinator moderate deep inspiratory breath hold in left sided breast cancer radiotherapy.

BACKGROUND AND AIM: Cardiac toxicity is a major concern for left breast tangential field irradiation. The left ventricle and left anterior descending (LAD) artery are suggested to be radiosensitive and radiation to these structures leads to late lethal cardiotoxicity. Moderate deep inspiration breath hold (mDIBH) during radiation treatment delivery helps in reducing the cardiac dose. This study compares dosimetric parameters of heart with and without active breath coordinator (ABC) mDIBH during tangential field breast cancer radiation. STUDY TYPE: This is a dosimetric comparative study. MATERIALS AND METHODS: Forty-five consecutive patients with left-sided breast cancer who underwent breast-conserving surgery and adjuvant tangential field and radiotherapy with ABC mDIBH between November 2013 and September 2015 in our center were analyzed in this study. The ABC device was used for respiratory control and patients who could hold their breath for 20-30 s were considered for radiation with ABC mDIBH. Simulation scans of both free breathing (FB) and ABC mDIBH were done. Tangent field treatment plans with a dose prescription of 40 Gy/15 Fr were generated for each patient, in both scans. Target coverage, dose to the heart, LAD, and the left lung were documented with dose-volume histograms. RESULTS: Statistical Package for the Social Sciences, version 20 software, was used for analysis and the level of significance was set at P < 0.05. Mean heart dose was 308.5cGy with FB and 159cGy with ABC (P < 0.0001). Mean dose to the LAD was reduced by 53.81% (1320.64 cGy vs. 606.56 cGy, P < 0.001). Target coverage was equal in both the plans. CONCLUSION: We report that the use of ABC mDIBH technique resulted in a significant reduction in cardiac dose and hence can be considered as a promising tool for cardiac sparing.

Nasopharyngeal carcinoma: Experience and treatment outcome with radical conformal radiotherapy from a tertiary care center in India.

BACKGROUND AND AIM: The majority of nasopharyngeal carcinoma (NPC) reports on the outcome and prognostic factors are from endemic high-risk regions. Data on the outcome of Indian patients are sparse. In this study, we retrospectively analyzed the outcome of NPC patients treated radically with conformal radiotherapy (RT). The primary objective was to assess the outcome, and the secondary objectives were to assess treatment-related morbidities and the impact of various prognostic factors on the outcome. MATERIALS AND METHODS: Sixty-eight patients with biopsy-proven NPC who received radical conformal RT, i.e., three-dimensional conformal RT or intensity-modulated RT (IMRT) during 2004-2013 were analyzed. All patients received conformal RT with or without chemotherapy. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS, version 20.0) software, IBM, USA. Survival analysis was performed using Kaplan-Meier method. For calculating the hazard ratio of the prognostic factors, univariate and multivariate Cox regression analyses were done. Chi-square test was used to determine the association. RESULTS: In this study, with a median follow-up of 43 months, the overall survival (OS), disease-free survival, and cause-specific survival were 91, 85.2, and 98.4% at 2 years and 78.3, 72.8, and 88.2% at 3 years, respectively. The locoregional failure was low (3%), and the 5-year cause-specific survival with chemoradiation was excellent (79%), even with 50% of the patients being nonmetastatic Stage IV. Eleven out of 12 failures were distant metastases. The treatment-related late morbidities were acceptable and better with IMRT. Significant prognostic factors affecting the outcome were composite stage of the disease and the interval between diagnosis and treatment initiation. CONCLUSION: In locally-advanced NPC, excellent local control is possible with modern conformal RT with concurrent chemotherapy. Distant metastases remain a therapeutic challenge despite systemic chemotherapy. Novel systemic therapies are needed in the future for improving the OS of these patients.