Real-World Breast Cancer Patient Follow-Up Practices by Medical Oncologists in India-A Survey Report.

Amol PatelBackground In India, breast cancer patients' post-treatment follow-up practices are not known. We did this survey to understand how the breast cancer patients are followed-up and tried to explore the challenges associated with it. Methods We conducted a survey-based study among Indian oncologists. Seven questions were framed pertaining to follow-up practices. Answers were provided in the form of multiple options. Google forms platform was used. Survey was circulated through social media apps and through mail. We sought suggestions and opinions to address the challenges from participants. Results A total of 158 medical oncologists responded to this survey. 10% were not aware that only history and clinical examination are the scientific recommendations for follow-up. Ninety percent of the medical oncologists felt clinical breast examination as an uncomfortable practice for patients and physicians and 39% ordered a chest X-ray and an ultrasound abdomen. Annual mammogram was ordered by 83%, and blood investigations were recommended by 14% routinely. The majority (49.6%) felt that the absence of a female attendant, physician and patient factors were responsible for nonadherence to clinical breast examination. The DEXA scan was recommended by 84 (53%) medical oncologists regularly for patients on aromatase inhibitors, while 23 (14%) did not recommend it. Conclusion There is a disparity between scientific recommendations and real-world follow-up practices. A large number of medical oncologists relied on chest X-ray and ultrasound abdomen. There is an unmet need to address this issue.

Low-Dose Abiraterone in Metastatic Prostate Cancer: Is It Practice Changing? Facts and Facets.

PURPOSE: It is projected that approximately 50,000 new cases of prostate cancer will be diagnosed in 2020 in India. Survival has improved because of the development of effective drugs such as abiraterone acetate, but universal accessibility to treatment is not always possible because of cost constraints in lower- and middle-income countries. Recently, the National Comprehensive Cancer Network (NCCN) has included low-dose abiraterone (250 mg/day) with food as an alternative treatment option to full-dose abiraterone (1,000 mg/day) fasting. METHODS: The Science and Cost Cancer Consortium conducted a survey to evaluate the use of abiraterone in India and the opinions of medical oncologists about using low-dose treatment. Modeling was used to estimate potential financial benefits to individual patients and to estimate overall costs of health care in India if low-dose abiraterone is prescribed. RESULTS: Of 251 Indian medical oncologists who were invited to participate in the survey, 125 provided their e-mail address and received the survey; 118 responded (47% of the total). Of these, 25% were not aware of the recent NCCN recommendation, 55% were already prescribing low-dose abiraterone when resources were limited, 7% had already changed their practice, and 29% agreed to switch to a universal practice of using low-dose abiraterone with food; 9% of practitioners would not use low-dose abiraterone. Estimated mean per patient savings was US$3,640, with annual savings of US$182 million in India. CONCLUSION: Use of lower-dose abiraterone would increase access to treatment in India and globally and lead to large cost savings.

Immune checkpoint inhibitors: Real-world experience from India in advanced solid cancers that have progressed on chemotherapy.

CONTEXT: The immune checkpoint inhibitors (ICIs) nivolumab and pembrolizumab have shown dramatic efficacy with low toxicity in international studies of advanced solid cancers. No published Indian experience with ICIs exist other than isolated case reports. AIMS: The aim of this study is to evaluate real-world data about the efficacy and toxicity of ICIs in advanced solid cancers among Indian patients who have progressed on one or more prior lines of chemotherapy. MATERIALS AND METHODS: All patients with advanced solid cancers who received ICIs after the failure of chemotherapy at our center were retrospectively assessed. Information about efficacy and toxicity was collected and analyzed. RESULTS: The present study included 24 patients who had received ICIs for indications including non-small cell lung, bladder, head and neck, gastrointestinal, and unknown primary cancer. Patients had received a median of two prior lines of chemotherapy (range 1-5). Grade III or higher toxicity was seen in 8% of patients. Clinical benefit at 3 months was realized in 33% of evaluable patients. Twenty-six percentages of evaluable patients achieved a response, including one patient who achieved a complete response that is ongoing at 18 months. Median progression-free survival was 3 months, and median overall survival was 8 months at a median follow-up of 10 months. Among patients who achieved clinical benefit, the majority (84%) have an ongoing response at the time of data cutoff. CONCLUSIONS: Efficacy and toxicity of ICIs in the Indian population are similar to the experience seen in large international cohorts, and Indian oncologists may feel reassured using these agents in similar settings.

Poor nutritional knowledge and food restrictions among families of children with cancer and their impact: A cross-sectional study of 700 families.

PURPOSE: To determine the prevalence of poor food knowledge and food restrictions among families of children with cancer and assess their impact on nutritional outcomes. METHODS: In this cross-sectional study of 700 families of children with cancer who attended a referral cancer clinic, parents were asked 9 questions about nutritional knowledge ("Knowledge score") and 12 questions about food restrictions ("Restriction score"). Secondary outcomes included the nutritional status of children and possible socio-demographic associations of poor food knowledge. FINDINGS: Commercial foods were considered more nutritious than homemade foods. Restriction of protein and energy-rich foods was frequent. Low knowledge scores were associated with rural background, poverty, and illiteracy. Low parental knowledge scores were associated with low weight and low height of the child. High restriction scores were associated with low weight but not low height. CONCLUSIONS AND IMPLICATIONS: Harmful perceptions are widely prevalent in parents of children with cancer and targeted educational interventions may have a role in improving malnutrition in these children.

Carcinoma of Unknown Primary Presenting as Peripheral Symmetric Gangrene.

Cancer of unknown primary accounts for almost 4-5% of all invasive cancers and consists of tumors from various primary sources with considerable heterogeneity in biology and behaviour. Most of these tumors present with symptoms due to distant metastasis. Histology, immunohistochemistry and molecular profiling is the mainstay for diagnosis. In most cases of adenocarinoma associated with paraneoplastic acral vascular syndrome (PAVS), a site in the lung, ovary or uterus is discernible. Here we report a case of metastatic adenoarcinoma of unknown primary presenting as PAVS, a case which to the best of our knowledge has not been reported in published literature.

Newer medical therapies for metastatic soft tissue sarcoma.

INTRODUCTION: Metastatic/advanced soft tissue sarcoma has a poor prognosis conventionally, treatment options have been limited. In recent years, this area has been a rich ground for research with many new drugs being approved and several more in the pipeline. With multiple new treatment options available, it is vital to keep up pace with this rapidly changing field. Areas covered: Recent data regarding use of novel agents in advanced soft tissue sarcoma is reviewed with a focus on clinical applicability. The goal is to guide the clinician into choosing appropriate lines of therapy for the individual patient in light of recent availability of multiple new treatment options. Expert commentary: Patients with advanced soft tissue sarcoma can expect to receive several lines of therapy in the modern era. Tumor histology should ideally guide the choice of therapy. The new FDA approved second line drugs viz, trabectedin, pazopanib and eribulin should be considered first after failure of doxorubicin-based chemotherapy. Additional options have become available, such as antiangiogenic agents, mTOR inhibitors, and several new molecules targeting specific oncogenic pathways. All these agents have a role in treating soft tissue sarcoma, and careful individualization of therapy can help achieve optimal outcomes in these challenging patients.

Hyperbaric oxygen with cord blood transplants: Filling the donor gap.

Aljitawi OS, Paul S, Ganguly A, Lin TL, Ganguly S, Vielhauer G, Capitano ML, Cantilena A, Lipe B, Mahnken JD, Wise A, Berry A, Singh AK, Shune L, Lominska C, Abhyankar S, Allin D, Laughlin M, McGuirk JP, Broxmeyer HE. (Division of Hematologic Malignancies and Cellular Therapy; Hematology and Transplantation Translational Research Laboratory ; Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas; Division of Hematology/Oncology and Bone Marrow Transplantation Program, University of Rochester Medical Center, Rochester, New York; Department of Urology, University of Kansas Medical Center, Kansas City, Kansas; Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana; Cardiovascular Research Institute, Department of Biostatistics, Department of Radiation Oncology, Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas; Cleveland Cord Blood Center, Cleveland, Ohio; Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA.) Erythropoietin modulation is associated with improved homing and engraftment after umbilical cord blood transplantation. Blood 2016;128:3000-10.

Pediatric Hematopoietic Stem Cell Transplantation in India: Status, Challenges and the Way Forward : Based on Dr. K. C. Chaudhuri Oration 2016.

Hematopoietic stem cell transplantation (HSCT) refers to therapies that aim to eliminate a patient's hematopoietic and immune system and replace it with his own (autologous) or someone else's (allogenic) system. The applications of this therapy are vast and growing, and include several malignant and benign diseases incurable by any other existing modalities. Pediatric patients constitute a minority of HSCT recipients with unique concerns. Despite substantial progress in the last two decades, limitations due to financial, infrastructural, manpower and research constraints act as barriers to fulfilling the large need for pediatric HSCT services in our country. Limited availability of unrelated donors and cord blood units is another constraint. Here in this oration, we discuss the current issues pertaining to pediatric HSCT in India and describe our experience with the same.