Opioid: Plenitude versus pittance

The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.

Locally advanced cervical cancer – neoadjuvant chemotherapy followed by concurrent chemoradiation and targeted therapy as maintenance: A phase II study

Aim: The survival in locally advanced cervical cancer remains low. We evaluated the role of neoadjuvant chemotherapy (NACT), chemoradiotherapy (CRT), followed by gefitinib maintenance in locally advanced cervical cancer. Materials and Methods: Twenty-five patients with locally advanced carcinoma cervix were enrolled between July 2012 and May 2013. Patients received 6 weekly doses of NACT Paclitaxel (60 mg/m2) and carboplatin (AUC 2), followed by CRT and brachytherapy. The analysis of epidermal growth factor receptor (EGFR) expression was carried out by immunohistochemistry. Gefitinib (250 mg daily) was given as maintenance therapy for 1 year after completion of chemoradiation. Comparison of EGFR expression and survival outcomes was done. Results: Twenty-four of 25 patients completed the neoadjuvant chemotherapy and concurrent chemoradiotherapy. Post-CRT, all patients were started on gefitinib maintenance, and twenty patients completed the intended 1 year of gefitinib maintenance. Nineteen (76%) patients had a radiological complete response to NACT. EGFR was moderately or strongly expressed in 86.3% of the patients. The 3-year overall survival was 69.8%, and 3-year progression-free survival was 51.4%. Expression of EGFR was not found to be a significant factor affecting overall survival or progression-free survival. Conclusions: Weekly neoadjuvant chemotherapy is associated with a good response rate in locally advanced cervical cancer. Neoadjuvant chemotherapy, chemoradiation, followed by gefitinib maintenance gives good survival outcome in patients with locally advanced cervical cancer.

Clinico-pathological characteristics and treatment outcome in invasive lobular carcinoma of the breast: An Indian experience

BACKGROUND: Invasive lobular carcinoma (ILC) is the second most common histologic subtype of breast cancer and accounts for 10%–15% of all breast cancers in the west. There is a scarcity of data on ILC from the Indian subcontinent. This report intends to present the patterns of care, survival outcomes, and prognostic factors of ILC treated in a tertiary care institute. MATERIALS AND METHODS: This retrospective analysis included consecutive patients diagnosed with ILC and registered at our Institute between 2009 and 2016. RESULTS: We included 97 patients with a median age of 53 years (range 28–80). American Joint Committee on Cancer (7th edition) stage distribution was stage I-8.24%, stage II-45.36%, stage III- 34.10%, and stage IV-12.30%. Bilateral breast cancer was seen in 8 cases. Estrogen receptor, progesterone receptor, and HER 2/neu positivity was 90%, 85%, and 9%, respectively. Triple-negative breast cancer constituted 5% of cases. Twenty-nine events were recorded (systemic and locoregional relapse) with a median follow-up of 3.5 years. Three years relapse-free survival (RFS) and overall survival were 80% and 60%, respectively. Bones were the most common site of metastasis. Age <45 years [HR-1.4 (0.8–2.1), P < 0.001] and advanced clinical tumor stage [T4, HR-2.1 (1.1–3.8), P = 0.001] were associated with poor RFS. CONCLUSION: ILC constituted 2.5% of breast cancer cases at our institute. Triple negativity and HER-2/neu positivity were seen in 9% and 5% of cases, respectively. Age <45 years and advanced clinical tumor stage were associated with poor RFS.

Radiation injury to the spinal cord in head and neck cancers: does field arrangement have a role.

STUDY DESIGN: A study of eight cases of head and neck cancers, to see if the cord was getting a higher dose in the antero-posterior (A-P) fields, compared to the bilateral (B/L) fields. OBJECTIVE: Radiation damage to the spinal cord is a critical issue for the radiation oncologists. This study was conducted to evaluate, if the dose to the spinal cord is higher by the antero-posterior (A-P) fields, compared to the bilateral (B/L) fields. MATERIALS AND METHODS: Eight cases of head and neck cancer were taken in our study. Two beam arrangements were placed in the treatment planning system, the B/L and the A-P fields. The DVH's for the cord dose were recorded and compared in both plans, with a standard fraction size of 200 cGy/fraction. RESULTS: The mean dose to the spinal cord was 168.06 cGy in A-P arrangement, while it was 133.75 cGy in the B/L arrangement. CONCLUSION: A-P field arrangement in head and neck malignancies delivers a higher dose to the spinal cord. Therefore, we need to spare the cord at an earlier dose limit.

Clinical features and prognostic factors of early breast cancer at a major cancer center in North India.

BACKGROUND: Data on the clinical profile of early breast cancer (EBC) from India is scant. Due to differences in genetics, environment, lifestyle, socio-demographic structure and ethnicity, the presentation and behavior of breast cancer in India may be different. AIMS: To analyze the clinical presentation and outcome of EBC patients. SETTINGS AND DESIGN: A single center retrospective study. MATERIALS AND METHODS: Data from 487 EBC patients registered and treated at our institute from 1993 through 1999 were analyzed. Cox's multivariate regression test was used to determine prognostic factors for overall and disease-free survival (OS & DFS). RESULTS: The median age was 47 years and 49.7% patients were pre-menopausal. Ninety-six per cent patients presented with a lump. Stages I, IIa, and IIb comprised 7.8%, 38.8%, and 47.6% respectively. Only 11.3% patients opted for breast-conserving surgery (BCS) while the remaining 88.7% underwent modified radical mastectomy (MRM). Adjuvant chemotherapy was administered to 275 (56.5%), and radiotherapy to 146 (29.9%). Estrogen receptor status was known in 173, of whom 93 (53.7%) were positive. Most patients were prescribed Tamoxifen for 5 years. At a median follow-up of 48 months, 126 (25.9%) patients had relapsed (systemic 107, loco-regional 19) and 94 (19.3%) had died. Five-year DFS and OS were 73% and 78%, respectively. On multivariate analysis, four positive nodes adversely influenced survival (P< 0.01). CONCLUSIONS: The median age at presentation was 47 years, significantly lower than most Western figures. The majority (86.4%) had a lump size > two cm. BCS was done in only 11% and the rest underwent MRM. Nodal involvement was the significant prognostic factor.