Impact of COVID-19 on cancer care in India: a cohort study.

BACKGROUND: The COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. METHODS: We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. FINDINGS: Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities). INTERPRETATION: The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Utility and relevance of modified lateral trapezius myocutaneous flap as a locoregional reconstructive option for medium-sized ablative defects in head and neck cancer-our experience.

PURPOSE: Lateral trapezius myocutaneous (LTMC) flap has been used less frequently for defects pertaining to head and neck cancer ablative surgical defects. This study is to assess the utility of LTMC flap with a new modification of the flap design. METHODS: This is a retrospective study using LTMC flap with modifications as a reconstructive option for intraoral & extraoral skin defects in head and neck cancer patients following ablative surgery, from August 2014 to October 2019 in a tertiary care hospital. The original technique of LTMC flap was modified for better results and outcomes. RESULTS: Thirty-five patients underwent lateral trapezius flap reconstruction for ablative defects of oral cavity, laryngopharynx, neck and parotid. Twenty-three patients (65.71%) underwent adjuvant radiation/radiation-chemotherapy while one patient defaulted. Two patients (5.71%) had major flap failure. After the loss of flap in these patients, the operative technique was further modified for better results. However, the disadvantage of using this flap is shoulder disability. Nonetheless in the present study, the disability was reduced after modifying the operating technique by preserving the spinal accessory nerve. CONCLUSION: The present study demonstrated minimal functional loss, low morbidity with satisfactory results, thus also reducing treatment cost. Thus, LTMC is a reliable reconstructive option in head and neck cancer patients for medium-sized defects.

Choosing Wisely India: ten low-value or harmful practices that should be avoided in cancer care.

The Choosing Wisely India campaign was an initiative that was established to identify low-value or potentially harmful practices that are relevant to the Indian cancer health-care system. We undertook a multidisciplinary framework-driven consensus process to identify a list of low-value or harmful cancer practices that are frequently undertaken in India. A task force convened by the National Cancer Grid of India included Indian representatives from surgical, medical, and radiation oncology. Each specialty had representation from the private and public sectors. The task force included two representatives from national patient and patient advocacy groups. Of the ten practices that were identified, four are completely new recommendations, and six are revisions or adaptations from previous Choosing Wisely USA and Canada lists. Recommendations in the final list pertain to diagnosis and treatment (five practices), palliative care (two practices), imaging (two practices), and system-level delivery of care (two practices). Implementation of this list and reporting of concordance with its recommendations will facilitate the delivery of high-quality, value-based cancer care in India.

Central Giant Cell Granuloma: Negotiating the Diagnostic and Management Dilemmas.

Introduction: Giant cell lesions of orofacial region although rare in presentation, have diagnostic and treatment challenges due to overlapping clinical, radiological, and histopathological signs. Background: We happened to come across a case, which presented to us with an aggressive jaw lesion of nonodontogenic origin, mimicking a malignancy and putting us in a conundrum with regard to work up and treatment. The sequential work up not only helped us reach a definitive diagnosis but also led us the draw algorithms for diagnosis of Giant cell lesions and management of Central giant cell granuloma. Conclusion: Meticulous planning along with molecular studies helps in better delineating one giant cell lesion from other.

Outcomes of Surgical Management for Parathyroid Adenomas.

Aim: Descriptive analysis of patients undergoing parathyroid adenoma surgery at a tertiary care hospital. Methodology: Patients with parathyroid adenoma operated from January 2016 to December 2020. Serum calcium and PTH were used to establish the diagnosis. Ultrasonography (USG) studies localized the adenoma. NIH criteria was used for decision regarding surgery. Patients were analyzed with regards to pre operative localization, biochemical monitoring and other outcomes. Results: Of the 15 eligible patients, all were symptomatic, with myalgia (34%) being the commonest symptom. Rome criteria confirmed the adequacy of the procedure by measuring intra operative drop in PTH. Average decrease in serum PTH level was 69.9% and serum calcium was 20.6% after excision of adenoma. The average size of excised adenoma was 2.5 cm. There were no post operative complications and all patients were normocalcemic on follow up. Conclusion: Parathyroidectomy is a simple, safe and effective solution that reduces the morbidity of symptomatic primary hyperparathyroidism patients. Pre operative localization studies affirm the diagnosis and intra operative biochemical confirmation clinches the adequacy of resection.

Smart Nanozymes for Cancer Therapy: The Next Frontier in Oncology.

Nanomaterials that mimic the catalytic activity of natural enzymes in the complex biological environment of the human body are called nanozymes. Recently, nanozyme systems have been reported with diagnostic, imaging, and/or therapeutic capabilities. Smart nanozymes strategically exploit the tumor microenvironment (TME) by the in situ generation of reactive species or by the modulation of the TME itself to result in effective cancer therapy. This topical review focuses on such smart nanozymes for cancer diagnosis, and therapy modalities with enhanced therapeutic effects. The dominant factors that guide the rational design and synthesis of nanozymes for cancer therapy include an understanding of the dynamic TME, structure-activity relationships, surface chemistry for imparting selectivity, and site-specific therapy, and stimulus-responsive modulation of nanozyme activity. This article presents a comprehensive analysis of the subject including the diverse catalytic mechanisms of different types of nanozyme systems, an overview of the TME, cancer diagnosis, and synergistic cancer therapies. The strategic application of nanozymes in cancer treatment can well be a game changer in future oncology. Moreover, recent developments may pave the way for the deployment of nanozyme therapy into other complex healthcare challenges, such as genetic diseases, immune disorders, and ageing.

Use of Indocyanine Green Fluorescence Imaging in Thoracic and Esophageal Surgery.

BACKGROUND: Fluorescence imaging using indocyanine green in thoracic and esophageal surgery is gaining popularity because of the potential to facilitate surgical planning, to stage disease, and to reduce postoperative complications. To optimize use of fluorescence imaging in thoracic and esophageal surgery, an expert panel sought to establish a set of recommendations at a consensus meeting. METHODS: The panel included 12 experts in thoracic and upper gastrointestinal surgery from Asia-Pacific countries. Before meeting, 7 focus areas were defined: intersegmental plane identification for sublobar resections; pulmonary nodule localization; lung tumor detection; bullous lesion detection; lymphatic mapping of lung tumors; evaluation of gastric conduit perfusion; and lymphatic mapping in esophageal surgical procedures. A literature search of the PubMed database was conducted using keywords indocyanine green, fluorescence, thoracic, surgery, and esophagectomy. At the meeting, panelists addressed each focus area by discussing the most relevant evidence and their clinical experiences. Consensus statements were derived from the proceedings, followed by further discussions, revisions, finalization, and unanimous agreement. Each statement was assigned a level of evidence and a grade of recommendation. RESULTS: A total of 9 consensus recommendations were established. Identification of the intersegmental plane for sublobar resections, localization of pulmonary nodules, lymphatic mapping in lung tumors, and assessment of gastric conduit perfusion were applications of fluorescence imaging that have the most robust current evidence. CONCLUSIONS: Based on best available evidence and expert opinions, these consensus recommendations may facilitate thoracic and esophageal surgery using fluorescence imaging.

Enhanced recovery after surgery in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: national survey of peri-operative practice by Indian society of peritoneal surface malignancies.

Objectives: The Enhanced recovery after surgery (ERAS) program is designed to achieve faster recovery by maintaining pre-operative organ function and reducing stress response following surgery. A two part ERAS guidelines specific for Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was recently published with intent of extending the benefit to patients with peritoneal surface malignancies. This survey was performed to examine clinicians' knowledge, practice and obstacles about ERAS implementation in patients undergoing CRS and HIPEC. Methods: Requests to participate in survey of ERAS practices were sent to 238 members of Indian Society of Peritoneal Surface malignancies (ISPSM) via email. They were requested to answer a 37-item questionnaire on elements of preoperative (n=7), intraoperative (n=10) and postoperative (n=11) practices. It also queried demographic information and individual attitudes to ERAS. Results: Data from 164 respondents were analysed. 27.4 % were aware of the formal ERAS protocol for CRS and HIPEC. 88.4 % of respondents reported implementing ERAS practices for CRS and HIPEC either, completely (20.7 %) or partially (67.7 %). The adherence to the protocol among the respondents were as follows: pre operative (55.5-97.6 %), intra operative (32.6-84.8 %) and post operative (25.6-89 %). While most respondents considered implementation of ERAS for CRS and HIPEC in the present format, 34.1 % felt certain aspects of perioperative practice have potential for improvement. The main barriers to implementation were difficulty in adhering to all elements (65.2 %), insufficient evidence to apply in clinical practice (32.4 %), safety concerns (50.6 %) and administrative issues (47.6 %). Conclusions: Majority agreed the implementation of ERAS guidelines is beneficial but are followed by HIPEC centres partially. Efforts are required to overcome barriers like improving certain aspects of perioperative practice to increase the adherence, confirming the benefit and safety of protocol with level I evidence and solving administrative issues by setting up dedicated multi-disciplinary ERAS teams.

Addition of docetaxel or abiraterone to androgen deprivation therapy in metastatic hormone-sensitive prostate cancer in Indian population.

BACKGROUND: The addition of docetaxel or abiraterone to androgen deprivation therapy (ADT) achieves superior survival outcomes in metastatic hormone-sensitive prostate cancer (mHSPC) in predominantly Western population. We sought to evaluate the treatment outcomes of adding docetaxel or abiraterone to ADT in Indian population. METHODS: We reviewed the medical records of ninety patients with newly diagnosed mHSPC who received treatment between January 2015 and June 2018. Patients received ADT alone or ADT + docetaxel or ADT + abiraterone as initial treatment. Monthly clinical evaluation and prostate-specific antigen (PSA) measurement were done. Outcome measures analyzed included PSA decline <90%, serological complete response (sCR) (PSA < 0.2 ng/ml), and progression to CRPC. Outcome variable was compared using Fisher's exact test. RESULTS: Patients received ADT alone (n = 37) or ADT + docetaxel (n = 31) or ADT + abiraterone (n = 22). The median age was 67.5 years (range, 41-87 years) and the median PSA was 88.5 ng/ml (range, 1.12-4000). PSA decline <90% was seen in 22 (73%), 24 (86%), and 17 (94%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. sCR was achieved in 5 (17%), 10 (36%), and 9 (50%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. Progression to CRPC was observed in 18 (60%), 11 (39%), and 2 (11%) patients in the ADT alone, ADT + docetaxel, and ADT + abiraterone groups. CONCLUSION: The addition of docetaxel or abiraterone to ADT achieves a deeper serological response and reduces progression to CRPC compared to ADT alone in mHSPC patients of Indian origin. Longer follow-up is required to comment on overall survival and also to determine which combination (ADT + docetaxel or ADT + abiraterone) is superior to others, if at all.

Perception, magnitude, and implications of cancer-related fatigue in breast cancer survivors: Study from a developing country.

BACKGROUND: We have analyzed perceptions, magnitude, interventions adopted, and overall implications of cancer-related fatigue (CRF) in breast cancer survivors (BCSs). METHODOLOGY: BCSs who attended follow-up clinic at our institute between January and June 2018 were asked to fill a questionnaire focused on assessing an individual's perception, severity, potential causes, implications on quality of life, and measures taken to deal with CRF. RESULTS: Sixty-five patients were included. Fifty-four (83%) had undergone surgery, 59 (91%) chemotherapy, 43 (66%) radiation therapy, and 36 (55%) hormonal/targeted therapy. Sixty-two (95%) patients experienced any grade CRF. Fifty-five (85%) patients experienced moderate to severe CRF affecting work (58%) and activities of daily living (27%). CRF was perceived as generalized weakness by 54 (83%) patients, diminished concentration/attention span by 24 (37%) patients, decreased motivation and interest in usual activities by 29 (45%) patients, and emotional labiality by 16 (25%) patients. Fifty-six patients (86%) believed that fatigue was due to the effect of cancer treatment on the body, while only 8 (12%) attributed it to underlying cancer. CRF had negative impact on mood, daily activities, interpersonal relationships, and professional work in 40 (62%), 39 (60%), 13 (20%), and 10 (15%) patients, respectively. Measures taken to overcome CRF were increased physical exercise, psychosocial interventions, mind-body interventions, and pharmacological interventions in 32 (49%), 8 (12%), 28 (43), and 17 (26%) patients, respectively. Thirty-nine (60%) patients reported persistence of CRF after completion of treatment while it took up to 6 months, 6-12 months, and more than 12 months for resolution of CRF in 13, 10, and 3 patients, respectively. CONCLUSION: Development and persistence of CRF remains a major health concern, and current interventions are not able to mitigate this problem. Further research in this field is warranted.

Practical Consensus Recommendations for Optimizing Risk versus Benefit of Chemotherapy in Patients with HR Positive Her2 Negative Early Breast Cancer in India.

Breast cancer is a public health challenge globally as well as in India. Improving outcome and cure requires appropriate biomarker testing to assign risk and plan treatment. Because it is documented that significant ethnic and geographical variations in biological and genetic features exist worldwide, such biomarkers need to be validated and approved by authorities in the region where these are intended to be used. The use of western guidelines, appropriate for the Caucasian population, can lead to inappropriate overtreatment or undertreatment in Asia and India. A virtual meeting of domain experts discussed the published literature, real-world practical experience, and results of opinion poll involving 185 oncologists treating breast cancer across 58 cities of India. They arrived at a practical consensus recommendation statement to guide community oncologists in the management of hormone positive (HR-positive) Her2-negative early breast cancer (EBC). India has a majority (about 50%) of breast cancer patients who are diagnosed in the premenopausal stage (less than 50 years of age). The only currently available predictive test for HR-positive Her2-negative EBC that has been validated in Indian patients is CanAssist Breast. If this test gives a score indicative of low risk (< 15.5), adjuvant chemotherapy will not increase the chance of metastasis-free survival and should not be given. This is applicable even during the ongoing COVID-19 pandemic.

Overview of Breast Cancer and Implications of Overtreatment of Early-Stage Breast Cancer: An Indian Perspective.

The prevalence and mortality of breast cancer is increasing in Asian countries, including India. With advances in medical technology leading to better detection and characterization of the disease, it has been possible to classify breast cancer into various subtypes using markers, which helps predict the risk of distant recurrence, response to therapy, and prognosis using a combination of molecular and clinical parameters. Breast cancer and its therapy, mainly surgery, systemic therapy (anticancer chemotherapy, hormonal therapy, targeted therapy, and immunotherapy), and radiation therapy, are associated with significant adverse influences on physical and mental health, quality of life, and the economic status of the patient and her family. The fear of recurrence and its devastating effects often leads to overtreatment, with a toxic cost to the patient financially and physically in cases in which this is not required. This article discusses some aspects of a breast cancer diagnosis and its impact on the various facets of the life of the patient and her family. It further elucidates the role of prognostic factors, the currently available biomarkers and prognostic signatures, and the importance of ethnically validating biomarkers and prognostic signatures.

Palliative chemotherapy with or without cetuximab in recurrent or metastatic squamous cell carcinoma of the head and neck: Indian tertiary care retrospective analysis.

BACKGROUND: We report our experience with Indian patients who received palliative chemotherapy with/without cetuximab for recurrent/metastatic squamous cell carcinoma of the head and neck (R/M SCCHN). METHODS: Data from 229 R/M SCCHN patients treated with cetuximab and chemotherapy (n = 140) or chemotherapy alone (n = 89) were retrospectively analyzed for response rate (RR), progression-free survival (PFS), overall survival (OS), and safety. RESULTS: Patients receiving cetuximab with chemotherapy demonstrated significant increase in RR (77.1% vs 44.9%, P = .0001), PFS (8.1 vs 6.1 months, P = .039), and OS (11.8 vs 8.0 months, P = .002) compared with patients receiving chemotherapy alone. Continuing cetuximab and changing chemotherapy combination (second line and beyond) in fit patients doubled OS (13.5 vs 6.1 months, P = .001). Adverse effects, except skin reactions (more in the cetuximab with chemotherapy group; P = .001), were similar in both groups. CONCLUSION: Adding cetuximab to chemotherapy improved ORR, PFS, and OS in Indian R/M SCCHN patients, and cetuximab was well tolerated.

Surgical Oncology Practice in the Wake of COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome (SARS-CoV-2) outbreak has placed unprecedented challenges globally dismantling healthcare systems and forcing rapid transformations of healthcare services. In patients with cancer, these changes are having profound effects on vital aspects of their care. It has been advised that hospitals discontinue elective surgery and work on triage of nonemergent surgical procedures during the pandemic. The purpose of this article is to highlight the recommendations and adapted workflow from the private and public tertiary level hospitals in India advising on the best practices and views on better patient management, redesigning of SOPs for OR, surgeon, and staff safety and resumption of cancer care especially from surgical perspective. Different concerns are addressed that are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

A multi-institutional real world data study from India of 3453 non-metastatic breast cancer patients undergoing upfront surgery.

The present analysis reports the clinical, pathological, treatment profile and overall survival (OS) and disease-free survival (DFS) outcomes of consecutive breast cancer patients from three Indian centres, who underwent curative surgery as their first treatment. Among the 3453 patients, stage I, II, and III cases were 11.75%, 66.79%, and 21.64%, respectively while hormone receptor positive/HER2 negative, triple negative (TNBC) and hormone receptor any/HER2 positive cases were 55.2%, 24.2% and 20.6%, respectively. The five-year OS in the entire cohort, node-negative and node-positive patients were 94.1% (93.25-94.98), 96.17% (95.2-97.15) and 91.83% (90.36-93.31), respectively, and the corresponding DFS were 88.1% (86.96-89.31), 92.0% (90.64-93.39) and 83.93% (82.03-85.89), respectively. The five-year OS in hormone receptor positive/HER2 negative, TNBC and HER2 subgroups were 96.11% (95.12-97.1), 92.74% (90.73-94.8) and 90.62% (88.17-93.15), respectively, and the corresponding DFS were 91.59% (90.19-93.02), 85.46% (82.79-88.22) and 81.29% (78.11-84.61), respectively. This is the largest dataset of early breast cancer patients from India with survival outcome analysis and can therefore serve as a benchmark for future studies.

Catheter Fracture of Subclavian Venous Chemoport Device at Costoclavicular Junction: Pinch-off Syndrome.

Chemoport is most commonly used venous access devices for instillation of chemotherapeutic drugs in cancer care. Mechanical complications like catheter fracture can lead to serious morbidity, albeit occurring rarely. We present a case of a 35-year-old lady, a case of carcinoma breast, who had spontaneous fracture of chemoport access device in subclavian vein at the level of clavicle after four successful cycles of chemotherapy. The fracture was suspected on chest x-ray and was subsequently confirmed on contrast linogram. The patient was successfully managed with endovascular interventional technique without suffering any ill effects. It is a rare presentation of pinch-off syndrome.

Significance of perineural invasion in locally advanced bucco alveolar complex carcinomas treated with surgery and postoperative radiation ± concurrent chemotherapy.

BACKGROUND: The purpose of this study was to evaluate prognostic factors, locoregional control, and survival in locally advanced bucco-alveolar complex cancers. METHODS: A retrospective review of 83 patients treated between January 2009 and December 2012 with bucco-alveolar complex cancers was conducted. All patients had surgery and adjuvant radiotherapy with intensity-modulated radiotherapy (IMRT) with/without concurrent chemotherapy. Survival analysis was performed using Kaplan-Meier and multivariable Cox regression model. RESULTS: On univariate and multivariate analysis, perineural invasion (PNI) was found to be an independent adverse risk factor. Patients with PNI-positive disease had significantly worse 2-year disease-free survival (DFS), locoregional failure free survival, and overall survival (OS) as compared to patients with PNI-negative disease (P < 0. 001, 0.001 and < 0. 001) respectively. CONCLUSION: Compared with patients with PNI-negative disease, patients with PNI-positive disease had much worse outcome despite aggressive adjuvant treatment. It warrants escalation of therapy and modification in radiation portals to cover neural pathways in patients with PNI-positive disease.