Transforming post pandemic cancer services.

This paper outlines the impact of the COVID-19 pandemic on cancer services in the UK including screening, symptomatic diagnosis, treatment pathways and projections on clinical outcomes as a result of these care disruptions. A restoration of cancer services to pre-pandemic levels is not likely to mitigate this adverse impact, particularly with an ageing population and increased cancer burden. New cancer cases are projected to rise to over 500,000 per year by 2035, with over 4 million people living with and beyond cancer. This paper calls for a strategic transformation to prioritise effort on the basis of available datasets and evidence-in particular, to prioritise cancers where an earlier diagnosis is feasible and clinically useful with a focus on mortality benefit by preventing emergency presentations by harnessing data and analytics. This could be delivered by a focus on underperforming groups/areas to try and reduce inequity, linking near real-time datasets with clinical decision support systems at the primary and secondary care levels, promoting the use of novel technologies to improve patient uptake of services, screening and diagnosis, and finally, upskilling and cross-skilling healthcare workers to expand supply of diagnostic and screening services.

Assessment of areca nut use, practice and dependency among people in Guwahati, Assam: a cross-sectional study.

BACKGROUND: Areca nut is the fourth most commonly used psychoactive substance worldwide after tobacco, alcohol and caffeine. In India, it is perceived in various ways, ranging from a 'fruit of divine origin' in Hindu religious ceremonies to a mouth freshener. Areca nut use both on its own and with tobacco additives is addictive. The aim of this study was to understand the pattern of areca nut consumption, to determine the Knowledge, Attitude and Practices (KAP) among areca nut users and the dependency associated with areca nut use. METHODS: A cross sectional study was conducted in Guwahati, Assam using a self-administered questionnaire eliciting the pattern of areca nut consumption, KAP among users and understanding their dependency using Betel Quid Dependence Scale. The chewers of areca nut alone with or without betel quid, gutkha and tobacco participated in the study. Areca nut users were selected using purposive sampling method from the vendor shops of all the four assembly areas of the city. Their participation was voluntary and free not to answer or quit the survey. The data was analysed using SPSS software. RESULTS: A total of 500 participants were approached in all four areas, 479 completed the survey (response rate 95%). The people who participated in the study were mostly male with an average age of 40 years, educated to secondary level or higher, married and self-employed. Betel quid with tamul was the most prevalent form of areca nut chewing in both men and women. About 441 (92%) participants experienced pleasure when chewing areca nut and 327 (68%) chewed it to relieve stress. Only 86 (18%) of subjects had ever tried to quit chewing areca nut and 387 (81%) thought that it was highly addictive. The results revealed relatively high levels of endorsement for 'physical and psychological urgent need' (mean = 43%) and 'increasing dose' (mean = 50%), whereas endorsement level for 'maladaptive use' was low (mean = 16%). CONCLUSION: Areca nut use (tamul) is of major concern in India and many Southeast Asian countries and its use has been increasing across the globe. The evidence suggests a dependence similar to tobacco use and policy makers need to refine its strategy for control of its use by engaging with multiple stakeholders and adapting it to local context with surveillance and cessation guidelines in order to address this issue.

Oncology-Based Palliative Care Development: The Approach, Challenges, and Solutions From North-East Region of India, a Model for Low- and Middle-Income Countries.

BACKGROUND: Access to palliative care within healthcare systems of low- and middle-income countries (LMICs) has never been more pronounced than in current times. The Lancet Commission Report (2018) estimates that 80% of global serious health-related suffering (SHS), which demands access to palliative care for its relief, are in LMICs. Cancer is a major contributor to SHS and a rapidly growing burden in LMICs. Similar to many LMICs, cancer is a leading cause of death in India. The North-East Region (NER) of India has a high prevalence of cancer and paucity of services for cancer and palliative care. OBJECTIVES: To describe the strategies used to initiate and strengthen palliative care services integrated with the comprehensive cancer care initiatives in the state of Assam in NER. METHODS: After an initial assessment of the status of palliative care in the NER, a multipronged strategy was adopted that aligned with the WHO framework recommended for initiating palliative care services. A core team working with a government and private collaborative strategized and activated supportive policies, education, and training and improved access and availability to essential drugs, while implementing the components synchronously within the state. SIGNIFICANCE: This project demonstrates an informed regional adaptation of the WHO model. It highlights the strengths of integrating palliative care within cancer care program right from its inception. It emphasizes the sustainability of services activated across public healthcare systems, as compared with the donor- or champion-driven initiatives. The outcome of this project underlines the relevance of this model for LMIC regions with similar health systems and sociocultural and economic contexts.

Key Drivers to Implement an Evidence-based Tobacco Control Programme in Schools of India: A Mixed-Methods Study.

BACKGROUND: Adolescence is an influential stage in students' lives when lifelong behaviours such as tobacco use are formed. During these years, school teachers are important role models for tobacco control among students. A study was conducted among school personnel and administrators to understand the key drivers for implementing an evidence-based school tobacco control program. METHODOLOGY: A cross-sectional, mixed-method study was conducted in five districts of Assam, India. The quantitative study was conducted among 565 school personnel across 40 Government-aided schools. Data was collected by means of an anonymous, self-administered questionnaire. Qualitative data was generated from 15 focus group discussions (FGDs) among 146 participants - District Program Officers, Block Education Officers, Cluster Coordinators, Headmasters and Teachers. RESULTS: While the prevalence of smoked tobacco was low (3%), the use of smokeless tobacco was higher (40%), and the prevalence of use of areca nut without tobacco (65%) was still higher among school personnel. They were aware of the school policies prohibiting the use of tobacco among students within or outside school buildings or during school-sponsored activities (81%); they had rather limited knowledge about policy for themselves (58%). There was lack of access to training materials about prevention of tobacco use among youth. The FGDs amongst school personnel resulted in several constructive suggestions on tobacco control in schools mainly in training school teachers, monitoring the program and incentives for execution of the program. However, there was a reluctance to implement a smokeless tobacco control programme since many were current users of smokeless tobacco and areca nut. CONCLUSION: Tobacco control policies as well as training school personnel in schools need to improve and further measures must be taken to prohibit use of areca nut, which contains carcinogens. The existing system of the education department can be utilised to implement tobacco control programmes effectively.

Cancer patients' experience of oncology services in Assam, India.

BACKGROUND: Cancer patients' experience is dependent on the complex interaction between the patient, carer, healthcare practitioners and healthcare system. The aim of the study was to assess the experience of cancer patients in Assam in order to identify potential areas for improvement in delivering high quality cancer care. METHODS: A cross sectional patient experience survey was conducted in 400 patients using structured interviews and pre-tested questionnaires that collected patient-reported outcomes including access to cancer care, experience while availing cancer services across the pathway, waiting times, communication and counselling support, out-of-pocket expenditure and advice regarding available insurance schemes and financial support. RESULTS: The cancer patient's experience of accessing healthcare in Assam is variable with principal challenges being financial constraint and geographical distance to healthcare facilities. Overall, patients' experience during registration, first consultation, pre-treatment and during treatment was good with high satisfaction rates expressed in several of the areas assessed. Areas that were identified for improvement were better explanation of long-term side effects of treatment, enhanced guidance in choosing treatment options and greater support from healthcare professionals to help patients cope with the psychological, emotional and physical aspects of their cancer diagnosis, treatment and recovery. CONCLUSION: Understanding cancer patient experiences across their journey is critical to delivering accessible and affordable care. Effective, adaptive and responsive communication remains the anchor of excellent patient-centred care especially in resource constraint settings. POLICY STATEMENT: The paper provides an insight into critical areas focusing on diagnosis, treatment, continuum of care and communication during cancer patients' care in India. Healthcare policy needs to focus on developing a robust, holistic, healthcare system in terms of accessibility, affordability and psychosocial care, including counselling and financial support, to ensure better cancer outcomes.

Prevalence of use of tobacco, alcohol consumption and physical activity in the North East region of India.

BACKGROUND: Cancer patients in the North East Region (NER) of India have poorer survival rates compared with the rest of India. This is due to late stage at presentation related to poor awareness, risk factors such as use of tobacco, alcohol consumption and less physical activity, This study aims to determine the association between socio-demographic characters and use of tobacco, alcohol consumption and physical activity among people in the NER. METHODS: A cross-sectional study of 1400 participants was conducted across Assam, Nagaland and Meghalaya in the NER. A questionnaire was developed to study the socio-demographic profile and factors such as use of tobacco, alcohol consumption and physical activity among participants. Multivariate analysis was performed to understand tobacco and alcohol use and physical activity and a logistic regression analysis was performed to understand the association of different independent variables with lifestyle practice. RESULTS: Use of tobacco and alcohol consumption was highest amongst males, 25-44 years age range and middle income group as defined in this study. The main reasons given for quitting tobacco and alcohol were becoming aware of the harmful effects of using tobacco, pressure from family and friends, and noticing a deterioration in health. Over 90 % of tobacco users and consumers of alcohol initiated this between 10-30 years of age. In all, 62 % of participants rarely or never engaged in any physical recreational activity. CONCLUSION: Patterns of use of tobacco and consumption of alcohol and recreational physical activity undertaken in the NER show a strong relationship with gender, age and household income. POLICY IMPLICATIONS: The paper finds a close association of different pattern of modifiable habits which are the risk factors for cancer in the Northeast Region. The limited awareness about the risk factors strengthen the case of context specific prevention strategies and constant reinforcement of behavior communication strategies by using multipronged approach.

Cigarettes and Other Tobacco Products Act (COTPA) implementation in education institutions in India: A crosssectional study.

INTRODUCTION: Tobacco use is a major risk factor for cancer and other non-communicable diseases and is the single largest cause of preventable deaths worldwide causing premature death. There are various laws and legislations for tobacco control in India. The Cigarettes and Other Tobacco Products Act (COTPA) 2003 was enacted in 2004 but is not enforced rigorously. The aim of this study was to determine any violation of COTPA Section 4 (prohibition of smoking in public places) around educational institutions and Section 6b (prohibition of sale of tobacco products near educational institutions). METHODS: A cross-sectional, observational study was conducted in 307 schools and colleges selected across 12 districts in 5 states in India. Data were collected by the tobacco control coordinators. From the centre of the city, the coordinators travelled in four different directions to a maximum distance of 10 km radius. Along the path, any educational institutions that were encountered were surveyed for violation of COTPA Sections 4 and 6b. RESULTS: Out of 307 schools surveyed across the five states, an average of 85% of the schools violated Section 4 and an average of 69% violated Section 6b. CONCLUSIONS: A coordinated effort by all stakeholders, especially by the police, educational institutions, and the community, is required. Adherence to the guidelines on Tobacco-Free Educational Institutions can improve the implementation of COTPA in and around educational institutions.

Assessment of Knowledge and Screening in Oral, Breast, and Cervical Cancer in the Population of the Northeast Region of India.

PURPOSE: The burden of cancer is increasing globally, with poor outcomes in terms of morbidity and mortality in patients, especially in low- and middle-income countries. Lack of awareness of the risk factors, symptoms, and signs of common cancers in addition to inadequate cancer prevention programs at the community level are a major hindrance to the early detection of cancer. METHODS: A cross-sectional study was conducted in the North East Region (NER) of India, with a sample population of 1,400 participants from Assam (n = 1,000), Meghalaya (n = 200), and Nagaland (n = 200). The questionnaire developed for the study consisted of sociodemographic profile, knowledge about cancer (oral, breast, and cervical), its warning signs, risk factors, and attitude toward cancer screening. Statistical analysis was performed using STATA version 13.0. RESULTS: Among all the participants, 59% had heard about oral cancer, 50% about breast cancer, and 31% about cervical cancer. A limited understanding of risk factors, symptoms, and signs was reported for oral cancer (45%), breast cancer (54%), and cervical cancer (63%). A total of 34% of participants were aware of cancer screening. Among those who were aware of cancer screening, only six people had undergone any form of cancer screening, and 71% cited media as the major source of information. CONCLUSION: The level of cancer awareness is low in the NER. A multipronged approach is needed with assistance from government and nongovernment organizations for training, providing adequate human resources and equipment, and developing cancer screening infrastructure. This needs to be coupled with mass media communication and interpersonal communication through frontline health workers.