Patient-reported quality of life outcomes in Indian breast cancer patients: importance, review of the researches, determinants and future directions.

Breast cancer is a leading problem in developing world and India can be considered as one of the major contributors for incidence of breast cancer. In this article authors have reviewed quality of life studies on Indian breast cancer population. There are many factors which may hear common but cannot be neglected in case of Indian population. Policies and future directions to be implemented for breast cancer are also discussed.

Awareness of diagnosis and psychiatric morbidity among cancer patients--a study from South India.

Awareness regarding cancer diagnosis and its relationship to psychiatric morbidity was studied in 294 newly admitted cancer patients at an oncology center in South India. Fifty-four percent of patients were aware that they had cancer and were able to discuss their diagnosis; 46% of patients reported nonawareness of diagnosis. Discriminant function analysis revealed that oral cancers and relatives' awareness of the cancer was more prevalent in the group aware of diagnosis. More patients in the "unaware" group refused treatment for psychological distress. There was no difference between the two groups in patterns and prevalence of psychiatric morbidity. The study emphasizes the complexities in assessing awareness in cancer patients and a need to study its various components and relationship to psychological distress.

Psychological well-being among cancer patients receiving radiotherapy--a prospective study.

The impact of cancer on the psychological well-being of newly diagnosed cancer patients before and during the course of radiotherapy was assessed in 70 consecutive cancer patients. Most of the patients were over 40 years of age, women, illiterate and from a lower socioeconomic group. During the course of treatment there was a decrease in the well-being scores on some dimensions such as perceived family and primary group support. Improvements were seen in the dimensions of positive feelings, coping, social support other than the family and spiritual well-being. There were no changes in the dimensions of negative feelings and perceived ill-health. The results give a profile on well-being and the changes observed during radiotherapy.

Sacral chordomas: a 10-year study.

A retrospective analysis of 14 cases of sacral chordoma seen between 1984 and 1993 at the Kidwai Memorial Institute of Oncology is reported. The mean patient age was 54 years, with 13 males and one female. Seventy-one per cent of patients presented with symptoms related to a painful sacral mass. Eight patients underwent radical surgery and two had adjuvant radiotherapy. One patient had a partial tumour resection. Three patients received radical radiotherapy. Two patients were offered only pain relief medication. The median follow-up was 33 months. The actuarial overall survival (OS) at 5 years was 48%. In the 12 patients in whom curative therapy was attempted, the 5-year OS was 56% and progression-free survival was 36%. Four patients developed local recurrence and three developed distant metastasis.

Dysgerminoma of the ovary: a retrospective study.

A retrospective analysis of 22 patients with ovarian dysgerminoma who were treated between 1980 and 1987 was carried out. The median age at presentation was 24.5 years. A total of 15 patients were in stage I, one patient was in stage II and six patients were in stage III. Bilateral ovarian involvement was present in four patients. Conservative surgery was carried out in nine patients and 11 patients underwent radical surgery. Two patients had biopsy only. Fourteen patients received adjuvant radiotherapy and three patients received salvage radiation for recurrent disease. The 10-year actuarial survival rate was 81.8%. All 15 patients in stage I were alive and disease-free at a median follow-up of 125 months. Four patients (one in stage II and three in stage III) died of progressive or recurrent abdominopelvic disease. Pelvic recurrence occurred after conservative surgery in two patients in stage IA who had a tumour size greater than 10 cm, but they were salvaged with radical surgery, chemotherapy and radiotherapy. There were seven patients aged 20 years or less. All were alive and disease-free at a median follow-up of 127 months.

Efficacy and safety of granulocyte macrophage-colony stimulating factor (GM-CSF) on the frequency and severity of radiation mucositis in patients with head and neck carcinoma.

PURPOSE: Based on the clinical evidence of mucosal protection by GM-CSF during cytotoxic chemotherapy, a pilot study was undertaken to determine the safety and mucosal reaction of patients receiving GM-CSF while undergoing definitive conventional fractionated radiotherapy in head and neck carcinoma. METHODS AND MATERIALS: Patients were considered eligible if buccal mucosa and oropharynx were included in the teleradiation field. Ten adult patients with squamous cell carcinoma of head and neck (buccal mucosa--8 and posterior 1/3 tongue--2) were entered into the trial. Radiation therapy was delivered with telecobalt machine at conventional 2 Gy fraction and 5 fractions/week. The radiation portals consisted of two parallel opposing lateral fields. GM-CSF was given subcutaneously at a dose of 1 microg/kg body weight, daily, after 20 Gy until the completion of radiation therapy. Patients were evaluated daily for mucosal reaction, pain, and functional impairment. RESULTS: The median radiation dose was 66 Gy. Eight patients received > or = 60 Gy. The tolerance to GM-CSF was good. All 10 patients completed the planned daily dose of GM-CSF without interruption. Mucosal toxicity was Grade I in four patients till the completion of radiotherapy (dose range 50-66 Gy). Six patients developed Grade II reaction, fibrinous mucosal lesions of maximum size 1.0-1.5 cm, during radiotherapy. None developed Grade III mucositis. The maximum mucosal pain was Grade I during GM-CSF therapy. In two patients after starting GM-CSF the pain reduced in intensity. Functional impairment was mild to moderate. All patients were able to maintain adequate oral intake during the treatment period. Total regression of mucosal reaction occured within 8 days following completion of radiotherapy. CONCLUSIONS: GM-CSF administration concurrently with conventional fractionated radiotherapy was feasible without significant toxicity. The acute side effects of radiotherapy namely mucositis, pain, and functional impairment were nil to minimal. The results are suggestive of mucosal protection by GM-CSF during radiotherapy and warrants further study in randomized double blind trial.

Extrapolated response dose as a potential tool in radiotherapy and chemo-radiotherapy of head and neck cancers.

An analysis of head and neck cancer patients treated by radiotherapy (RT) alone (114 patients) and by chemo-radiotherapy (RT + CT) (115 patients) was carried out; the doses varied from 40-77 Gy and 35-71 Gy in RT and RT + CT groups respectively. The chemotherapy (CT) (induction/concurrent) drugs used were 5-FU, cisplatin, methotrexate either single or in combination. Extrapolated response dose values were evaluated with alpha/beta values of 10, 2.5 and 6 Gy for acute, late complications and tumour response, respectively. Dose enhancement factor (DEF) and Therapeutic gain factor (TGF) values were evaluated on the basis of ERD for patients receiving 5-FU RTCT (72 patients). ERD vs late complication rate and response rate curves were drawn for RT, RT + CT (< 7 cycles), RT + CT (> 6 cycles) and RT + CT (cumulative). DEF values for response rate were 0.95, 0.95 and 0.82 for the three RT + CT groups respectively. Similarly DEF values for late complication rate were evaluated as 0.87, 0.93 and 0.88. TGF values for RT + CT were 1.09, 1.02 and 0.93. TGF values indicated lack of significant influence of CT on clinical outcome. The correlation of ERD with late complication, response and status at last follow up (NED) was statistically significant for both groups (P < 0.01). ERD did not correlated with acute complication in RT group (P > 0.01). From the present analysis, in RT + CT treatments of head and neck cancers, an ERD value of 69 Gy is suggested as the limit for an acceptable 5% late complication rate.

Descriptive epidemiology of childhood cancers in Bangalore, India.

While fairly complete and reliable incident data on childhood cancers are available from the registries in India, mortality and survival information is not. Information concerning the latter was obtained by the Bangalore cancer registry through active follow-up involving visits to homes of patients. Between 1982 and 1989, 617 cases of cancers in childhood were registered, giving an age-standardized incidence rate of 84.8 and 48.4 per million in male and female children, respectively. Active follow-up provided mortality/survival information in 532 or 86.2 percent of these cases. Overall, observed five-year survival was 36.8 percent (both genders combined) with a relative survival of 37.5 percent when childhood mortality in the general population was taken into account. The five-year relative survival was best for thyroid carcinoma (100 percent) followed by Hodgkin's disease (73 percent) and retinoblastoma (72.9 percent). Survival was comparatively low, being 9.9 percent in acute nonlymphatic leukemia and less than 20 percent in rhabdomyosarcoma and the category grouped as 'other malignant neoplasms.' Survival in Hodgkin's disease was influenced by clinical stage at presentation, but was not statistically significant possibly due to small numbers.

Importance of anatomical subsite in correlating risk factors in cancer of the oesophagus--report of a case--control study.

In Bangalore, cancer of the oesophagus is the third most common cancer in males and fourth most common in females with average annual age-adjusted incidence rates of 8.2 and 8.9 per 100,000 respectively. A case-control investigation of cancer of the oesophagus was conducted based on the Population-based cancer registry, Bangalore, India. Three hundred and forty-three cases of cancer of the oesophagus were age and sex matched with twice the number of controls from the same area, but with no evidence of cancer. Chewing with or without tobacco was a significant risk factor. In both sexes chewing was not a risk factor for cancer of the upper third of the oesophagus. Among males, non-tobacco chewing was a significant risk factor for the middle third but not for the other two segments and tobacco chewing was a significant risk factor for the lower third of the oesophagus, but not for the other two segments. Bidi smoking in males was a significant risk factor for all three segments being highest for the upper third, less for the middle third and still less for the lower third. The risk of oesophageal cancer associated with alcohol drinking was significant only for the middle third.

Improving cancer radiotherapy with 2-deoxy-D-glucose: phase I/II clinical trials on human cerebral gliomas.

PURPOSE: Evaluation of tolerance, toxicity, and feasibility of combining large fraction (5 Gy) radiotherapy with 2-deoxy-D-glucose (2DG), an inhibitor of glucose transport and glycolysis, which has been shown to differentially inhibit repair of radiation damage in cancer cells. METHODS AND MATERIALS: Twenty patients with supratentorial glioma (Grade 3/4), following surgery were treated with four weekly fractions of oral 2DG (200 mg/kg body weight) followed by whole brain irradiation (5 Gy). Two weeks later, supplement focal radiation to the tumor (14 Gy/7 fractions) was given. Routine clinical evaluation, x-ray computerized tomography (CT), and magnetic resonance (MR) imaging were carried out to study the acute and late radiation effects. RESULTS: All the 20 patients completed the treatment without any interruption. The vital parameters were within normal limits during the treatment. None reported headache during the treatment. Mild to moderate nausea and vomiting were observed during the days of combined therapy (2DG + RT) in 10 patients. No significant deterioration of the neurological status was observed during the treatment period. Seven patients were alive at 63, 43, 36, 28, 27, 19, and 18 months of follow-up. In these patients, the clinical and MR imaging studies did not reveal any late radiation effects. CONCLUSIONS: Feasibility of administering the treatment (2DG + 5 Gy) is demonstrated by the excellent tolerance observed in all 20 patients. Further, the clinical and MR studies also show the absence of any brain parenchymal damage.

Serum vitamins' status in oral leucoplakias--a preliminary study.

Vitamins, such as A, beta carotene, C, E, B12 and folate, are the micronutrients with the strongest evidence of having a link to cancer prevention and control. Deficiency of these vitamins at the dietary, systemic or mucosal level will interact with tobacco use and increase the risk of oral precancerous lesions. The objective of this study was to (1) establish the baseline circulating levels of these vitamins in our normal population with and without tobacco use and (2) compare these levels with the values obtained in cases of oral leucoplakias. 50 normal controls with 25 each in chewers and non-chewers, matched for age and sex, were selected. 50 cases of oral leucoplakias (clinically detectable white patches) from the field constituted the study group. Simultaneous measurement of serum vitamin B12 and folate were carried out by radioassay. The other serum vitamins were estimated spectrophotometrically. Except for serum vitamin E, all the other serum vitamin levels were significantly decreased in oral leucoplakias compared to the controls. Cancer chemopreventive agents acting as inhibitors of both initiation and promotion, as analysed in our population, is promising for further intervention trials.

A case-control investigation on cancer of the ovary in Bangalore, India.

Cancer of the ovary is the sixth leading cancer among females in Bangalore, and is a leading site of cancer in other population-based cancer registries in India. A case-control investigation was conducted utilizing the data from the population-based cancer registry in Bangalore. In addition to the core patient information, certain other details pertaining to consumption of tobacco, reproductive and obstetric factors and those related to the practice of family planning, including the method adopted, were available with the registry, for the period 1982-1985. Identical information was also available for patients residing in the registry area who did not have cancer. Ninety-seven cases of ovarian cancer in ever-married women were age-matched with 194 controls from the same area who showed no evidence of cancer. The risk of ovarian cancer was not influenced by tobacco habits, alcohol consumption, diet or the various reproductive factors. However, tubectomy as a method of family planning appeared to reduce the risk of development of ovarian cancer. This reduction in risk was not influenced by parity or age of the woman at the time of birth of the first child.

PIP: Researchers used data from the population-based cancer registry in Bangalore, India, for the period 1982-1985 to conduct a case control study to examine the effect of tobacco, alcohol, dietary practices, and reproductive factors on the development of ovarian cancer. Cases included 97 ever-married women with ovarian cancer. Controls consisted of two sets of age-matched ever-married women living in the same residential area who had no evidence of cancer. A history of practicing family planning was associated with a significant decreased risk of ovarian cancer (odds ratio [OR] = 0.29; p = 0.01). When the researchers considered the family planning method as well as possible confounding factors (e.g., nulliparity, gravidity, and maternal age at first birth), tubectomy reduced the risk of developing ovarian cancer (OR = 0.25; p = 0.02). When they only considered papillary serous cystadenocarcinoma, which accounted for 45.4% of all ovarian cancer cases, the OR was even lower (0.16). The numbers were too small for the other types of ovarian cancer to calculate the OR. Tobacco chewing, alcohol consumption, dietary practices, and other reproductive factors (e.g., parity and maternal age at first birth) did not influence the risk of ovarian cancer. These findings suggest that tubectomy reduces the risk of ovarian cancer. If other studies confirm these findings, perhaps tubectomy can be a preventive measure against ovarian cancer in high-risk nulliparous populations in the West.

Descriptive epidemiology of lymphoid and haemopoietic malignancies in Bangalore, India.

Lymphoid and haemopoietic malignancies as a group constitute one of the important cancers in India, as elsewhere in the world. While information on incidence and mortality of these cancers, and that on survival, are available from most developed countries, there are very few reports describing this experience in developing ones. Population-based cancer registration commenced in Bangalore, India, in January 1982, under the auspices of the Indian Council of Medical Research. This source provides fairly complete and reliable incidence data, but, in order to obtain mortality and survival information, active follow-up involving visits of homes of patients was undertaken. Between 1982 and 1989, 1397 cases of lymphoid and haemopoietic malignancies were registered in the Bangalore cancer registry, giving an age-adjusted incidence rate of 7.7 and 4.8 per 100,000 in males and females respectively. Active follow-up provided mortality/survival information in 1267 or 90.7% of these cases. The overall observed 5-year survival for these cancers combined (both sexes) was 26%, and relative survival 28.4%. The 5-year survival rate was lower in all the individual lymphomas and leukaemias as compared with similar reports from the developed countries. Survival in Hodgkin's disease was influenced by clinical stage and age at presentation.

Incidence, mortality and survival in cancer of the cervix in Bangalore, India.

Cancer of the cervix is the most common cancer among women in India, constituting between one-sixth to one-half of all female cancers with an age-adjusted incidence rate ranging from 19.4 to 43.5 per 100,000 in the registries under the National Cancer Registry Programme (NCRP) (Annual Reports, NCRP, ICMR). It has been estimated that 100,000 new cases of cancer of the cervix occur in India every year, and 70% or more of these are Stage III or higher at diagnosis. However, the incidence of cancer of the cervix as suggested in this report appears to be on the decline in Bangalore. Besides incidence and clinical stage at presentation knowledge of survival is essential to complete the picture of establishing baseline indicators to monitor and evaluate cancer control programmes. Survival analysis was carried out in 2121 patients diagnosed during 1982-89 in the population of Bangalore, India. The observed 5 year survival was 34.4% and the relative survival 38.3%. Clinical stage at presentation was the single most important variable in predicting survival. The 5 year observed survival for stage I disease was 63.3%, for stage II 44.0%, for stage III 30.3% and for stage IV 5.7%.

PIP: Cervical cancer is the most common form of cancer among women in India, with an estimated 100,000 new cases developing annually in the country. 70% or more of these cases are stage 3 or higher at diagnosis. When establishing baseline indicators to monitor and evaluate cancer control programs, it is necessary to have incidence, clinical stage at presentation, and survival data on the disease. This paper presents findings from the analysis of survival data on 2121 patients diagnosed with cervical cancer during 1982-89 in the population of Bangalore, India. The observed five-year survival was 34.4%, while relative survival was 38.3%. Clinical stage at presentation was the single most important variable in predicting survival. More precisely, the five-year observed survival for stage 1 disease was 63.5%, 44.0% for stage 2, 30.3% for stage 3, and 5.7% for stage 4.

Spinal cord compression by primary non-Hodgkin's lymphoma.

Epidural Cord Compression (ECC) by primary lymphomas is rare entity and constitutes less than 3% of total malignant lymphoma with Non-Hodgkin's Lymphoma (NHL), diffuse large cell type being the most common histological subtype. In this paper 16 cases of primary NHL with cord compression seen at the Department of Medical Oncology, during the period 1988-1990 are reviewed. At presentation all patients had undergone Laminectomy with decompression of epidural mass. The histological diagnosis of NHL was subclassified according to the International working formulation and was evaluated for disease process elsewhere in the body. All patients with ECC by lymphoma received high dose steroids with concurrent Radiotherapy (local) and combination Chemotherapy. These patients had longer duration of neurological deficit prior to treatment had poor response. After 6 courses of chemotherapy 50% of the patients had complete neurological recovery (CR), 31% had partial neurological recovery (PR) and in 19% there was no neurological recovery (NR).

Survival in breast cancer: a population-based study in Bangalore, India.

Survival from cancer reflects the aggressiveness of the disease, the effectiveness of treatment and host factors such as age. While hospital-based survival rates are typically used to evaluate the care provided in a particular hospital, population-based survival reflects the effectiveness of the overall cancer control strategy in the region. Here, we report the survival experience of 1514 breast cancer patients registered by the Bangalore population-based registry during 1982-1989. There have been very few reports on survival from cancer in India, mainly because of poor patient follow-up and inadequate system of registration of death. This has been largely overcome in this study by means of active follow-up through visits of homes of patients. Scrutiny of medical records and matching with death certificates, was also carried out in a small proportion (12%) of cases. Thus, information on vital status (whether dead or alive) as on January 1, 1993 was available for 1334 (88%) subjects and partial follow up data were available for a further 34 (2%). The observed 5 year survival was 42.3% and the corresponding relative survival was 46.8%. The observed survival was 57.4% for localized disease, 45.8% for direct extension, 37% for those with regional node involvement, 14.2% for distant metastasis and 38.3% for those with unstaged disease. The clinical extent of disease and the educational status were independent predictors of survival.

Efficacy of an anti-tobacco community education program in India.

In a study on 'Assessment of Efficacy of an Anti-Tobacco Community Education Program' on Kolar District of Karnataka, India, an experimental and two control areas were chosen based on comparable population, health, and socioeconomic parameters. The two main objectives were to prevent individuals from taking up the tobacco habit among those who currently did not smoke or chew tobacco, and to stop the tobacco habit in those who did smoke or chew tobacco. A baseline tobacco-habit survey of the population was followed by anti-tobacco education of the community in the experimental area only. Two years later, a repeat survey of the population was conducted, followed by a final survey after a further three years. Methods of health education of the community included screening of films, exhibits, and personal contact with a display of photographs of the harmful effects of tobacco. The results were evaluated through changes in prevalence rates, quitters' rates, and initiation rate. The final survey showed that in the experimental area, the decline in the prevalence rate in the combined sample compared with the baseline rates was 10.2 percent in males and 16.3 percent in females, with a corresponding quitter's rate of 26.5 percent in males and 36.7 percent in females. Among men, a higher proportion (30.2 percent) had given up chewing compared with smoking (20.4 percent).