Assessment of Caregivers' Strain during Radiation Therapy of Head-and-Neck Cancer Patients: An Institutional Report using Modified Caregivers' Strain Index Scale.

AIMS: Very little works have been reported on the issues of burden perceived by the caregivers of head-and-neck cancer (HNC) patients. Job of the caregiver is complex, and it limits their social, psychological, and economical well-being. Our study aims at assessing caregivers' strain during radiation therapy (RT) of HNC patients using the Modified Caregivers' Strain Index (MCSI) Scale. MATERIALS AND METHODS: In this single-institutional cross-sectional study, we interviewed caregivers of HNC patients undergoing curative RT. Along with MCSI, a 13-point questionnaire, which was self-administered in local languages; we collected baseline data of patients and their caregivers. Scores were evaluated. For each question, score varies 0-2. Higher the Median Hazard Score (H Score), more was the level of the strain. RESULTS: We interviewed 24 participants. Response rate was 100%. About 45.8% of patients were in Stage III. The median age of caregivers was 40 years; 58.3% were male, 79.2% were employed, and 58.3% were belonging to the upper-lower class. Nearly 66.6% were spouse of the patients and 70.8% belong to joint family. In MCSI score analysis, H Score was 22 (range 14) with a minimum score of 14 and maximum score of 26. The most common score was 20. About 65.1% of participants responded Score 2 in all aspects of strain indices. Travel time had a significant positive association with total H Scores (Pearson's r = 0.663, P < 0.05). CONCLUSION: Majority of the caregivers was suffering from severe physical, personal, emotional, and social/financial strain. This issue must be addressed in holistic cancer care.

Clinical audit of dose-escalated radical radiotherapy for advanced cervical carcinoma using a pragmatic protocol (3 fractions of 8 Gy HDR brachytherapy).

INTRODUCTION: Recent image-guided brachytherapy data suggests, dose-escalation to a cumulative EQD2 (equivalent dose delivered at 2 Gy/#) of ≥87 Gy is associated with significantly better disease control. We present a clinical audit of a pragmatic radical radiotherapy protocol for advanced cervical cancer, using fewer fractions of brachytherapy than in the presently most popular protocol. MATERIAL & METHODS: Between July 2015 and December 2018, 96 consecutive advanced cervical carcinoma patients were treated by pelvic external beam radiotherapy (EBRT) (50 Gy/25fractions/5 weeks) ± weekly intravenous chemotherapy followed by image guided high dose rate (HDR) brachytherapy, using intracavitary/interstitial/hybrid techniques (intended point A dose: 8 Gy/fractions) × 3 fractions (cumulative target EQD2 ≥ 86 Gy). Insertion was done individually for each fraction of treatment. RESULTS: All patients completed their intended radiation protocol. 93.8% patients achieved complete response, while 6.2% patients achieved only partial response; no patients had stable/progressive disease. Out of the patients with partial response, 4.2% (4 out of 5 cases) cases of central/nodal residual disease underwent salvage surgery. At a median follow up of 21 months, 8.3% (8) patients had local failure, 1.1% (1) had nodal failure and 3.1% (3) had distant failures. Median Failure Free Survival was 29 months (26.5-31.5 months). On follow up, 6.3% and 3.2% patients had grade 2 or worse rectal and bladder morbidities respectively. CONCLUSION: The protocol under study has been safe and effective in achieving dose-escalated radical chemoradiation in advanced cervical carcinoma. The use of fewer insertions of brachytherapy is logistically easier & can also be expected to improve compliance.

Dosimetric analysis of Deep Inspiratory Breath-hold technique (DIBH) in left-sided breast cancer radiotherapy and evaluation of pre-treatment predictors of cardiac doses for guiding patient selection for DIBH.

INTRODUCTION: The risk of radiotherapy-associated cardiovascular disease has been a concern for decades in breast cancer survivors. The objective of our study is to evaluate the dosimetric benefit of Deep Inspiratory Breath-hold technique (DIBH) on organs-at-risk (OAR) sparing in left-sided breast cancer radiotherapy and to find out pre-treatment predictors of cardiac doses for guiding patient selection for DIBH. MATERIAL AND METHODS: Pre-radiotherapy planning CT scans were done in Free Breathing (FB) and in DIBH [using Active Breathing Coordinator system (ABC™)] in 31 left sided breast cancer patients. 3DCRT plans were generated for both scans. Comparison of anatomical and dosimetric variables were done using paired t test and correlation was evaluated using Pearson correlation. Linear regression was used to get independent predictors of cardiac sparing and Receiver Operating Characteristic (ROC) curve analysis was done to find out the specific threshold of the predictors. RESULTS: There was a 39.15% reduction in mean heart dose in DIBH compared to FB (2.4 Gy vs 4.01 Gy) (p < 0.001), 19% reduction in maximum Left Anterior Descending (LAD) dose and a 9.9% reduction in ipsilateral lung mean dose (p = 0.036) with DIBH. A significant correlation was observed between reduction in Heart Volume in Field (HVIF) and Maximum Heart Depth (MHD) with reduction in mean heart dose. Reduction in HVIF (ΔHVIF) independently predicted cardiac sparing. CONCLUSION: DIBH leads to significant reduction in OAR doses and is suggested for all patients of left-sided breast cancer undergoing radiotherapy. However, HVIF and MHD predicted for cardiac sparing and threshold criteria of ΔHVIF and ΔMHD may be used by centres with high workload to select patients for DIBH.

Awareness of palliative care among doctors of various departments in all four teaching medical colleges in a metropolitan city in Eastern India: A survey.

OBJECTIVE: To enquire about the level of awareness regarding various important aspects of palliative medicine among doctors of various departments in four Medical Colleges in Kolkata through a questionnaire. MATERIALS AND METHODS: A questionnaire was developed by few members of Indian Association of Palliative Care. It was distributed, to a convenience sample of doctors who worked at various departments in all four teaching hospitals in Kolkata. The distribution and collection of questionnaires was carried out within four months. RESULTS: The results suggested that 85% of the doctors felt that cancer was the commonest reason for the palliative care teams to be involved. Seventy four percent of the doctors mentioned that pain control was their prime job; 53% said that they are enjoying their encounter with palliative care, so far; 77% of the doctors thought breaking bad news is necessary in further decision making process; only 22% of the doctors reported the WHO ladder of pain control sequentially, 35% of the doctors believed other forms of therapies are useful in relieving pain, 35% of the doctors thought that they gave enough importance and time for pain control; 77% said that they had heard about a hospice, among them still 61% of the doctors thought that the patients should spend last days of their life at home. Thinking of the future, 92% of the doctors think that more and more people will need palliative care in the coming days. CONCLUSION: Amongst the doctors of various departments, there is a lack of training and awareness in palliative care. Almost all the doctors are interested and they are willing to have more training in pain control, breaking bad news, communication skills and terminal care.

Effect of bladder distension on dosimetry of organs at risk in computer tomography based planning of high-dose-rate intracavitary brachytherapy for cervical cancer.

PURPOSE: Distension and shape of urinary bladder may vary during intracavitary brachytherapy (ICBT) for cervical cancer, significantly affecting doses to bladder, rectum, sigmoid colon and small intestine and consequently late radiation toxicities. This study is to evaluate the effects of different fixed volume bladder distention on dosimetry, assessed by three dimensional image based planning, in different organs at risk during the treatment of cervical cancer with ICBT. MATERIAL AND METHODS: Forty seven cervical cancer patients (stage IB to IVA) were qualified for ICBT following external beam radiotherapy. Urinary bladder was distended with different volumes of normal saline instilled by a Foley's catheter. Planning CT scans were performed after insertion of applicators and three dimensional treatment planning was done on Brachyvision(®) treatment planning system (Varian Medical Systems, Palo Alto, CA). Dose volume histograms were analyzed. Bladder, rectum, sigmoid colon and small intestine doses were collected for individual plans and compared, based on the amount of bladder filling. RESULTS: Mean dose to the bladder significantly decreased with increased bladder filling. However, doses to the small volumes (0.1 cc, 1 cc, 2 cc) which are relevant for brachytherapy, did not change significantly with bladder filling for bladder, rectum or sigmoid colon. Nevertheless, all dose values of small intestine are decreased significantly with bladder filling. CONCLUSIONS: Bladder distension has no significant effect on doses received during brachytherapy by relevant volumes of bladder, rectum and sigmoid colon except intestine where values are decreased with bladder distension. A larger study with clinical correlation of late toxicities is essential for proper evaluation of this strategy.

Fatigue in breast cancer patients on adjuvant treatment: course and prevalence.

INTRODUCTION: Fatigue is a major complain in breast cancer patients and survivors. Patterns and degree varies with schedule and type of the treatment. Different co-factors may aggravate fatigue. Multimodal approach is helpful in managing fatigue. AIM: To quantify prevalence, course and degree of fatigue in breast cancer patients on adjuvant treatment and effectiveness of different management approach. MATERIALS AND METHODS: One Hundred and ten post-mastectomy breast cancer patients (Stage I to Stage III) were assessed. Patients on chemotherapy were assessed one week before, day after chemotherapy and two weeks later in every cycle. Patients on External Beam Radiation Therapy (EBRT) were assessed one week before and every week during radiation. Assessment was continued on second and fourth week of follow up. Functional Assessment of Chronic Illness Therapy - Fatigue subscale (FACIT-F) was used for assessment. Significant cofactors were also searched for. RESULTS: Eighty four percent patients experienced fatigue. Fatigue was more prevalent during chemotherapy (91%) than EBRT (77%). Patients on Chemotherapy exhibit peak fatigue day after Chemotherapy and decreased level until the next cycle. Significant increase of fatigue was seen only in first cycle. Patient on EBRT had gradually increased fatigue during the course of treatment. Lower degree of fatigue was present in post treatment period. Anemia was a significant cofactor causing fatigue (P < 0.05). Blood Transfusion improved fatigue scores. CONCLUSION: Fatigue increases during chemotherapy and or EBRT. Different intervention strategies are needed to address the issue.