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.

Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer.

BACKGROUND: Whether patients with early-stage oral cancers should be treated with elective neck dissection at the time of the primary surgery or with therapeutic neck dissection after nodal relapse has been a matter of debate. METHODS: In this prospective, randomized, controlled trial, we evaluated the effect on survival of elective node dissection (ipsilateral neck dissection at the time of the primary surgery) versus therapeutic node dissection (watchful waiting followed by neck dissection for nodal relapse) in patients with lateralized stage T1 or T2 oral squamous-cell carcinomas. Primary and secondary end points were overall survival and disease-free survival, respectively. RESULTS: Between 2004 and 2014, a total of 596 patients were enrolled. As prespecified by the data and safety monitoring committee, this report summarizes results for the first 500 patients (245 in the elective-surgery group and 255 in the therapeutic-surgery group), with a median follow-up of 39 months. There were 81 recurrences and 50 deaths in the elective-surgery group and 146 recurrences and 79 deaths in the therapeutic-surgery group. At 3 years, elective node dissection resulted in an improved rate of overall survival (80.0%; 95% confidence interval [CI], 74.1 to 85.8), as compared with therapeutic dissection (67.5%; 95% CI, 61.0 to 73.9), for a hazard ratio for death of 0.64 in the elective-surgery group (95% CI, 0.45 to 0.92; P=0.01 by the log-rank test). At that time, patients in the elective-surgery group also had a higher rate of disease-free survival than those in the therapeutic-surgery group (69.5% vs. 45.9%, P<0.001). Elective node dissection was superior in most subgroups without significant interactions. Rates of adverse events were 6.6% and 3.6% in the elective-surgery group and the therapeutic-surgery group, respectively. CONCLUSIONS: Among patients with early-stage oral squamous-cell cancer, elective neck dissection resulted in higher rates of overall and disease-free survival than did therapeutic neck dissection. (Funded by the Tata Memorial Centre; ClinicalTrials.gov number, NCT00193765.).

Head and neck cancers in India.

Head and neck cancers constitute a third of the cancer burden in India. These cancers have unique patient characteristics, presentation, and etiological differences from those in the West. Socioeconomic constraints, large patient population, scarcity of trained health workers, and inadequate infrastructure are major challenges faced in the management of these cancers. Despite these constraints, patients are treated with evidence based guidelines that are tailored to the local scenario.

The Role of Supraclavicular Flap in Reconstruction Following Resection in Buccal Mucosa Carcinoma.

Buccal mucosa is one of the common subsite for oral carcinoma. Following excision of the buccal mucosa tumor mass various pedicled and free flaps have been used to reconstruct the oral cavity defect. In this age of free flaps various locoregional pedicled flaps have been underrated and overlooked and supraclavicular flap is one of them. This flap meets the functional and cosmetic acceptance of the buccal mucosa defect reconstruction with minimal morbidity to the donor site. This paper presents author's experience of using supraclavicular flap in 10 patients of carcinoma buccal mucosa. In all cases surgical defect was completely covered by the flap, there was no necrosis of the flap. Functional and cosmetic outcome was acceptable in all the patients without compromising oncological clearance.

N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY: We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes. METHODS: Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS). RESULTS: Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%. CONCLUSION: Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

Imaging for Laryngeal Malignancies: Guidelines for Clinicians.

Radiology has always been an important component in the evaluation of patients with head and neck cancers. Images that are appropriately acquired and systematically interpreted provide comprehensive information on local, regional, and distant disease extent. This impacts treatment decisions for primary or recurrent disease, and aids in prognostication and patient counselling. The recent significant advances in technology and instrumentation for treatment of head neck cancers have taken place in parallel with an increasing sophistication in radiodiagnostic systems. This is especially true for laryngeal neoplasms where there is now greater focus on functional outcomes and personalised treatment, thus expanding the scope and value of imaging. PURPOSE: To formulate evidence-based guidelines on imaging for cancers of the larynx, from diagnosis and staging to monitoring of disease control after completion of treatment. METHODS AND MATERIALS: A multidisciplinary analysis of current guidelines and published studies on the topic was performed. RESULTS: On the basis of evidence gathered, guidelines were drawn up; optimal suggestions were included for low-resource situations. CONCLUSION: These guidelines are intended as an aid to all clinicians dealing with patients of laryngeal cancers. It is hoped that these will be instrumental in facilitating patient care, and in improving outcomes.

Delayed tracheal necrosis presenting with stridor: A rare complication of surgery for differentiated thyroid cancer.

Tracheal necrosis (TN) is a rare life-threatening complication of thyroidectomy, generally diagnosed in the early postoperative period with neck swelling or subcutaneous emphysema. Late presentation with stridor has not been reported till date. We present a case of TN three weeks after surgery with stridor, managed with sternohyoid muscle cover.

The Role of Infrahyoid Flap in Tongue Defect Reconstruction Following Tumour Excision.

Carcinoma tongue is one of the commonest cancer of head and neck in India. Various pedicled and free flaps have been used to reconstruct the tongue defect following glossectomies. In this era of free flaps various loco- regional pedicled flaps have been overlooked and infrahyoid flap is one of them. This flap meets the functional and cosmetic acceptance of the tongue defect reconstruction with minimal morbidity to the donor site. This paper presents author's experience of using infrahyoid flap in 10 patients of carcinoma tongue. In all the patient's tongue defect was closed with the infrahyoid flap, in 1 case flap necrosed fully and in 1 partially. Functional outcome and quality of life in all the patients were acceptable.

The Role of Pedicled Latissimus Dorsi Flap in Scalp Defect Reconstruction Following Tumour Excision.

Scalp is a common site for skin tumors mainly squamous cell carcinoma and basal cell carcinoma. It is always challenging to reconstruct the scalp defect following tumor excision. Conventional methods of skin grafting or rotation flap is not always feasible for large scalp defect. This paper presents the author's experience in 3 patients of scalp tumors in which conventional methods were not sufficient to reconstruct the defect, hence pedicled latissimus dorsi flap was used considering the flap size to cover the defect and reach needed for the pedicled flap. In all the 3 cases latissimus dorsi myocutaneous was able to reach the defect site and cover the large scalp defect area; thereby serving as an alternative to free flap which is technically more challenging, skill based and less feasible in normal surgical settings.

Targeted Therapy for Medullary Thyroid Cancer: A Review.

Medullary thyroid cancers (MTCs) constitute between 2 and 5% of all thyroid cancers. The 10-year overall survival (OS) rate of patients with localized disease is around 95% while that of patients with regional stage disease is about 75%. Only 20% of patients with distant metastases at diagnosis survive 10 years which is significantly lower than for differentiated thyroid cancers. Cases with regional metastases at presentation have high recurrence rates. Adjuvant external radiation confers local control but not improved OS. The management of residual, recurrent, or metastatic disease till a few years ago was re-surgery with local measures such as radiation. Chemotherapy was used with marginal benefit. The development of targeted therapy has brought in a major advantage in management of such patients. Two drugs-vandetanib and cabozantinib-have been approved for use in progressive or metastatic MTC. In addition, several drugs acting on other steps of the molecular pathway are being investigated with promising results. Targeted radionuclide therapy also provides an effective treatment option with good quality of life. This review covers the rationale of targeted therapy for MTC, present treatment options, drugs and methods under investigation, as well as an outline of the adverse effects and their management.

Relative value of ultrasound, computed tomography and positron emission tomography imaging in the clinically node-negative neck in oral cancer.

AIM: To determine the most accurate noninvasive imaging modality for occult metastasis in clinically node-negative necks in oral squamous cell carcinoma from a granulomatous disease endemic region. METHOD: Prospective, observational study comparing ultrasound (US), contrast enhanced computed tomography (CECT) and positron emission tomography-computed tomography (PET-CT). Level wise assessment of neck nodes with each imaging modality was performed and compared with final histopathology. RESULTS: Eighty-five necks were evaluated in 70 patients. Sensitivity, specificity and accuracy of the three modalities were 78.9, 68.75 and 73.25% for US, 73.6, 85.4 and 80.2% for CECT, and 81.5, 54.1 and 66.2% for PET-CT, respectively. CECT performed better than US and PET-CT scan particularly in levels IB and II (accuracy of 81.4 and 88.3% for CECT, 73.25 and 79.1% for US, and 68.6 and 68.6% for PET-CT scan, respectively). Concordance with histology was best with CECT (κ = 0.615) followed by US (κ = 0.461) and PET-CT (κ = 0.337). CONCLUSION: The quest for the most accurate imaging modality in clinically node-negative necks continues. US alone is inadequate. While PET-CT may not be a specific imaging modality in detecting occult cervical nodal metastasis in endemic regions of chronic granulomatous diseases, the performance of PET CECT in this setting remains to be evaluated. CECT scan, routinely used in imaging for primary disease, is fairly accurate in detecting nodal metastasis. However, in early oral cancers that are generally treated without any imaging for the primary tumor, management of the neck will largely depend on clinical judgment.

Organ preservation strategies: Review of literature and their applicability in developing nations.

There has been a change in practice in locally advanced laryngopharyngeal cancers toward non-surgical treatment modalities. Although, there have been landmark trials pertinent to organ preservation, their applicability in developing nations is a topic of much debate. The organ preservation concept was based on the findings of pivotal trials by the Veterans Affairs, European Organization for Research and Treatment of Cancer group and Radiation Therapy Oncology Group. Subsequently numerous studies have been designed to evaluate intensification of treatment as well as study toxicity and tolerability. This review critically analyses current evidence for larynx preservation, experience from various centers on organ preservation strategies as well as applicability of these protocols to developing nations.

Management of thyroid cancers.

Thyroid cancers cover a large spectrum of disease with diametrically opposite prognosis. At one end of the spectrum we have the well differentiated cancers which carry an excellent prognosis, while at the other end there is anaplastic cancer with high mortality rates and dismal prognosis. Management of thyroid cancers still has some controversial issues due to lack of randomized controlled trials. Extent of surgery, extent of neck dissection, role of radioiodine treatment and thyroid stimulating hormone suppression are still debatable. In this review, we highlight these controversial issues and give guidelines for the management and follow up of patients with thyroid cancer.