Choice of baseline hazards in joint modeling of longitudinal and time-to-event cancer survival data.

Longitudinal time-to-event analysis is a statistical method to analyze data where covariates are measured repeatedly. In survival studies, the risk for an event is estimated using Cox-proportional hazard model or extended Cox-model for exogenous time-dependent covariates. However, these models are inappropriate for endogenous time-dependent covariates like longitudinally measured biomarkers, Carcinoembryonic Antigen (CEA). Joint models that can simultaneously model the longitudinal covariates and time-to-event data have been proposed as an alternative. The present study highlights the importance of choosing the baseline hazards to get more accurate risk estimation. The study used colon cancer patient data to illustrate and compare four different joint models which differs based on the choice of baseline hazards [piecewise-constant Gauss-Hermite (GH), piecewise-constant pseudo-adaptive GH, Weibull Accelerated Failure time model with GH & B-spline GH]. We conducted simulation study to assess the model consistency with varying sample size (N = 100, 250, 500) and censoring (20 %, 50 %, 70 %) proportions. In colon cancer patient data, based on Akaike information criteria (AIC) and Bayesian information criteria (BIC), piecewise-constant pseudo-adaptive GH was found to be the best fitted model. Despite differences in model fit, the hazards obtained from the four models were similar. The study identified composite stage as a prognostic factor for time-to-event and the longitudinal outcome, CEA as a dynamic predictor for overall survival in colon cancer patients. Based on the simulation study Piecewise-PH-aGH was found to be the best model with least AIC and BIC values, and highest coverage probability(CP). While the Bias, and RMSE for all the models showed a competitive performance. However, Piecewise-PH-aGH has shown least bias and RMSE in most of the combinations and has taken the shortest computation time, which shows its computational efficiency. This study is the first of its kind to discuss on the choice of baseline hazards.

Breast cancer survival in India across 11 geographic areas under the National Cancer Registry Programme.

BACKGROUND: Population-based cancer survival is a key indicator for assessing the effectiveness of cancer control by a health care system in a specific geographic area. Breast cancer is the most common cancer among women in India, accounting for over one quarter of all female cancers. The objective of this study was to estimate the 5-year survival of female patients who were diagnosed with breast cancer between 2012 and 2015 from the existing Population-Based Cancer Registries (PBCRs) in India. METHODS: In total, 17,331 patients who had breast cancer diagnosed between 2012 and 2015 from 11 PBCRs were followed until June 30, 2021. Active methods were used to track the vital status of registered breast cancer cases. The study conducted survival analysis by calculating the difference between the date of first diagnosis and the date of death or censoring to estimate observed survival and relative survival using the actuarial survival approach and the Ederer-II approach, respectively. RESULTS: The 5-year age-standardized relative survival (95% confidence interval [CI]) of patients with breast cancer was 66.4% (95% CI, 65.5%-67.3%). Mizoram (74.9%; 95% CI, 68.1%-80.8%), Ahmedabad urban (72.7%; 95% CI, 70.3%-74.9%), Kollam (71.5%; 95% CI, 69.2%-73.6%), and Thiruvananthapuram (69.1%; 95% CI, 67.0%-71.2%) had higher survival rates than the national average. Conversely, Pasighat had the lowest survival rate (41.9%; 95% CI, 14.7%-68.6%). The 5-year observed survival rates for localized, regional, and distant metastasis in the pooled PBCRs were 81.0%, 65.5%, and 18.3%, respectively. CONCLUSIONS: The overall disparity in survival rates was observed across 11 PBCRs, with lower survival rates reported in Manipur, Tripura, and Pasighat. Therefore, it is imperative to implement comprehensive cancer control strategies widely throughout the country.

Assessment of spatial variation in lung cancer incidence and air pollutants: spatial regression modeling approach.

A notable finding is that Kerala's capital Thiruvananthapuram has shown an increasing trend in lung cancer (LC) incidence. Long-term exposure to air pollution is a significant environmental risk factor for LC. This study investigated the spatial association between LC and exposure to air pollutants in Thiruvananthapuram, using Spatial Lag Model (SLM), Spatial Error Model (SEM), and Geographically Weighted Regression (GWR). The results showed that overall LC incidence rate was 111 per 105 males (age >60 years), whereas spatial distribution map revealed that 48% of the area had an incidence rate greater than 150. The results revealed a significant association between PM2.5 and LC. SLM was identified as the best model that predicted 62% variation in LC. GWR model improved model performance and made better local predictions in the southeastern parts of the study area. This study explores the effectiveness of spatial regression techniques for dealing spatial effects and pinpointing high-risk areas.

Spatiotemporal pattern of thyroid cancer incidence in South Kerala: A population-based study.

Background: Thyroid cancer (TC) is the most common endocrine cancer and has been increasing over the past decades worldwide. A notable finding is that Kerala's capital Thiruvananthapuram ranks the first among men and the second highest among women in the incidence of TC in India. Reasons for this increase have not been established. Objectives: Here, we investigated the spatiotemporal pattern of TC incidence in Thiruvananthapuram. Materials and Methods: TC incidence data (n = 1937) of Population Based Cancer Registry Thiruvananthapuram, Kerala, India, between 2012 and 2016, were analyzed for identifying geographical patterns by spatial methods, temporal methods for studying spatial variation in TC incidence, distribution of age, gender, and histology in lowland (coastal), midland, and highland. Results: Spatial clustering of TC incidence was identified consistently near the coastal region based on all geospatial analyses. 56.9%, 23.9%, and 19.2% of TC cases were observed in the coastal, midland, and highland areas, respectively. A significant clustered pattern of TC incidence was revealed by Moran's index I (0.49), high-high clusters by local Moran's, hotspot by Getis-Ord-Gi* (P < 0.05), point pattern analysis by nearest neighbor ratio and kernel density estimation. The relative risk of the significant cluster was obtained as 1.60 (95% confidence interval: 1.03-1.84) by SaTScan analysis. Conclusion: This study identified spatial variations in the pattern of TC cases with significant clusters near the coastal region of Thiruvananthapuram. This would help to pinpoint the high-risk geographical areas of TC and for more effective cancer control programs.

Development of a field-friendly automated dietary assessment tool and nutrient database for India.

Studies of diet and disease risk in India and among other Asian-Indian populations are hindered by the need for a comprehensive dietary assessment tool to capture data on the wide variety of food and nutrient intakes across different regions and ethnic groups. The nutritional component of the India Health Study, a multicentre pilot cohort study, included 3908 men and women, aged 35-69 years, residing in three regions of India (New Delhi in the north, Mumbai in the west and Trivandrum in the south). We developed a computer-based, interviewer-administered dietary assessment software known as the 'NINA-DISH (New Interactive Nutrition Assistant - Diet in India Study of Health)', which consisted of four sections: (1) a diet history questionnaire with defined questions on frequency and portion size; (2) an open-ended section for each mealtime; (3) a food-preparer questionnaire; (4) a 24 h dietary recall. Using the preferred meal-based approach, frequency of intake and portion size were recorded and linked to a nutrient database that we developed and modified from a set of existing international databases containing data on Indian foods and recipes. The NINA-DISH software was designed to be easily adaptable and was well accepted by the interviewers and participants in the field. A predominant three-meal eating pattern emerged; however, patterns in the number of foods reported and the primary contributors to macro- and micronutrient intakes differed by region and demographic factors. The newly developed NINA-DISH software provides a much-needed tool for measuring diet and nutrient profiles across the diverse populations of India with the potential for application in other South Asian populations living throughout the world.

Evaluation of factors influencing lymph node metastasis in endometrial cancers: A retrospective study.

OBJECTIVES: The role of lymphadenectomy in the management of early endometrial cancer remains controversial. The aim of our study was to evaluate risk factors associated with nodal metastases in endometrial cancer and to devise a predictive risk model based on the significant risk factors in predicting node metastasis. MATERIALS AND METHODS: A retrospective study was conducted on women diagnosed with uterus-confined endometrial cancer, and who underwent surgical staging with pelvic and/or paraaortic lymphadenectomy from our center during July 1, 2017 to June 30, 2019. Clinical details, Magnetic Resonance imaging (MRI)-detected myometrial invasion, and pre and post-operative histological details of tumor were correlated with pelvic and/or para-aortic lymph node metastasis. Risk factors were assessed using logistic regression model and risk models devised. RESULTS: 128 patients were included in the study. Paraaortic lymphadenectomy was done in 72.7% patients. Nodal metastasis was seen in 14.8% of patients. Logistic regression analyses revealed lymphovascular invasion (P = 0.002), parametrial involvement (P = 0.017) and nonendometrioid histology (P = 0.004) to be significant risk factors. Tumor size >2 cm, grade 3 and deep myometrial invasion had higher risk for nodal metastasis, although non-significant. Risk models were derived with sensitivity of 79-89.5%, specificity of 58.7-69.7%, Negative predictive value (NPV) of 95-97% and accuracy of 63-71%. CONCLUSION: Lymphovascular invasion, nonendometrioid histology and parametrial involvement are independent predictors of lymph node metastasis in endometrial cancer. Risk models using these risk factors can better predict the risk of nodal metastasis and thus avoid lymph node dissection in low risk patients. Our risk models had reasonably good sensitivity in nodal metastasis prediction and require further validation.

COVID-19 Impact on Newly Diagnosed Breast Cancers at Regional Cancer Centre, Thiruvananthapuram-An Audit.

Geethu Babu The coronavirus pandemic has created havoc in every aspect of life including cancer care and was declared a pandemic. This audit was conducted to study the impact of the pandemic on diagnosis and treatment of newly diagnosed breast cancer patients at a tertiary cancer center in South India. A total of 1,647 patients who registered at Regional Cancer Centre (RCC), Thiruvananthapuram, Kerala, India for breast cancer during the period April 1, 2020, to September 30, 2020 (COVID-19 period) as well as April 1, 2019, to September 30, 2019 (pre-COVID-19 period) were included in the study. Data regarding the geographic distribution, stage at presentation, time factors for reporting for care, diagnosis, and treatment, referral for care elsewhere were collected and analyzed. The study was approved by the Institutional Review Board. Means and ranges were calculated for continuous type variables, and numbers and percentages for categorical variables. To determine whether there were significant differences between the two groups, independent t -test was used for continuous variables and chi-square test for categorical type of variables. A notable reduction (36%) in newly diagnosed breast cancer patients was seen in 2020 when compared with 2019. There was a significant difference in the geographic distribution of patients in both cohorts ( p = 0.001) and a notable reduction in the number of patients reporting to RCC for treatment from the northern districts of Kerala (81%) and outside Kerala (89.5%). There was no significant difference in the time (in weeks) since symptom onset and reporting to hospital or the clinical stage at diagnosis between the groups. Also, coronavirus disease 2019 (COVID-19) did not seem to negatively impact time intervals between date of registration and pathological diagnosis or start of primary treatment. More patients received neoadjuvant systemic therapy during 2020 compared with 2019, and this difference was statistically significant ( p = 0.004). There was no difference in the type of surgery (breast-conserving surgery vs. modified radical mastectomy). The results demonstrate that COVID-19 did not appear to negatively impact the diagnosis and treatment of newly diagnosed breast cancer patients. However, this is largely attributable to the significantly less number of patients who registered, for whom the departments were able to maintain timely cancer care despite the difficult pandemic times. Significantly more patients received neoadjuvant systemic therapy in 2020.

Association between the Worst Pattern of Tumor Invasion and Epithelial-mesenchymal Transition and their Prognostic Impact on Early-stage Oral Tongue Squamous Cell Carcinoma.

Purpose: We aimed to determine the association between the worst pattern of tumor invasion (WPOI) and epithelial-mesenchymal transition (EMT) in early-stage oral tongue squamous cell carcinoma (OTSCC) with no adverse features and their impact on 2-year disease-free survival (DFS) and overall survival (OS) rates. Methods: This prospective observational study included treatment-naive 50 patients who underwent primary surgery for OTSCC (pT1T2N0M0; AJCC 8th edition, with no adverse features) from June 1, 2020, to March 31, 2021 (minimum follow-up period, 2 years). WPOI (low- or high-invasive) and EMT (E-cadherin, N-cadherin, and vimentin expression at the tumor invasive front) were assessed. Results: High invasive WPOI was seen in 66% and low invasive in 34%. 80% of the patients had EMT. No statistically significant association was found between WPOI and EMT. The OS and DFS at 2 years were 90% and 80% respectively. WPOI had statistically significant impact on 2-year DFS (100% for low & 69.7% for high, p-value 0.014). EMT did not significantly affect DFS or OS rates. Conclusions: In early stage OTSCC with no adverse features, WPOI can be a promising predictor for disease recurrence. However, this should be validated for modifying treatment guidelines.

Somatic mutational landscape across Indian breast cancer cases by whole exome sequencing.

Breast cancer (BC) has emerged as the most common malignancy among females. The genomic profile of BC is diverse in nature and complex due to heterogeneity among various geographically different ethnic groups. The primary objective of this study was to carry out a comprehensive mutational analysis of Indian BC cases by performing whole exome sequencing. The cohort included patients with a median age of 48 years. TTN, TP53, MUC16, SYNE1, and OBSCN were the frequently altered genes found in our cohort. The PIK3CA and KLC3 genes are driver genes implicated in various cellular functions and cargo transportation through microtubules, respectively. Except for CCDC168 and PIK3CA, several gene pairings were found to be significantly linked with co-occurrence. Irrespective of their hormonal receptor status, RTK/RAS was observed with frequently altered signaling pathways. Further analysis of the mutational signature revealed that SBS13, SBS6, and SBS29 were mainly observed in our cohort. This study supplements the discovery of diagnostic biomarkers and provides new therapeutic options for the improved management of BC.

Survival of patients with cervical cancer in India - findings from 11 population based cancer registries under National Cancer Registry Programme.

Background: Cancer survival data from Population Based Cancer Registries (PBCR) reflect the average outcome of patients in the population, which is critical for cancer control efforts. Despite decreasing incidence rates, cervical cancer is the second most common female cancer in India, accounting for 10% of all female cancers. The objective of the study is to estimate the five-year survival of patients with cervical cancer diagnosed between 2012 and 2015 from the PBCRs in India. Methods: A single primary incidence of cervical cancer cases of 11 PBCRs (2012-2015) was followed till June 30, 2021 (n = 5591). Active follow-ups were conducted through hospital visits, telephone calls, home or field visits, and public databases. Five-year Observed Survival (OS) and Age Standardised Relative Survival (ASRS) was calculated. OS was measured by age and clinical extent of disease for cervical cancers. Findings: The five-year ASRS (95% CI) of cervical cancer was 51.7% (50.2%-53.3%). Ahmedabad urban (61.5%; 57.4%-65.4%) had a higher survival followed by Thiruvananthapuram (58.8%; 53.1%-64.3%) and Kollam (56.1%; 50.7%-61.3%). Tripura had the lowest overall survival rate (31.6%; 27.2%-36.1%). The five-year OS% for pooled PBCRs was 65.9%, 53.5%, and 18.0% for localised, regional, and distant metastasis, respectively. Interpretation: We observed a wide variation in cervical cancer survival within India. The findings of this study would help the policymakers to identify and address inequities in the health system. We re-emphasise the importance of awareness, early detection, and increase the improvement of the health care system. Funding: The National Cancer Registry Programme is funded through intra-mural funding by Indian Council of Medical Research, Department of Health Research, India, Ministry of Health & Family Welfare.

Papillary Thyroid Carcinoma Arising from Thyroglossal Cyst-an Institutional Experience over a Decade.

Papillary carcinoma constitutes 80% of thyroglossal duct cyst carcinoma (TGCC). The mainstay of treatment for TGCC is Sistrunk procedure. Due to lack of clear-cut guidelines in managing TGCC, the role of total thyroidectomy, neck dissection and adjuvant radioiodine therapy is still debatable. This was a retrospective study which included cases of TGCC treated in our institution over a period of 11 years. The aim of study was to assess the need for total thyroidectomy in management of TGCC. Patients were divided into two groups based on the surgical treatment they underwent and the treatment outcomes were compared. The histology was papillary carcinoma in all cases of TGCC. Overall, 43.3% of TGCCs had a focus of papillary carcinoma in total thyroidectomy specimen. Lymph node metastasis was noted only in 10% of TGCC and not identified in isolated papillary carcinoma confined to thyroglossal cyst. 7-year overall survival (OS) for TGCC was 83.1%. Prognostic factors like extracapsular extension or lymph node metastasis did not affect OS. Addition of total thyroidectomy and neck dissection to Sistrunk procedure did not offer any survival advantage. In a case of TGCC, FNAC should be done from any clinically suspicious thyroid nodules or lymph nodes. TGCC has a good prognosis following treatment and none of the cases in our series has disease recurrence during follow-up. Sistrunk procedure was an adequate procedure for treatment of TGCC with clinically and radiologically normal thyroid gland.

Three-week hypofractionated radiotherapy in early glottic cancer-a single institution retrospective study.

Background: Radiotherapy is a standard treatment option for early glottic carcinoma (stage I and II) with a fraction size of 2-2.2 Gy over 5-7 weeks. This study evaluates the outcome and prognostic factors of a 3-week hypofractionated treatment in early glottic malignancy. Materials and Methods: The case records of 329 eligible patients with stage I and II glottic carcinoma recorded at the institution from 2003 to 2008 were retrospectively analysed. All patients were treated in a Cobalt-60 machine to a dose of 52.5 Gy in 15 fractions (3.5 Gy/fraction) over 3 weeks. Results: Eighty-three percent had stage I disease. The local control rate at 5 years was 91.9%. On univariate analysis, stage I and II patients without subglottic extension had better local control. Disease extension to the subglottis fared poorly on multivariate analysis. After salvage treatment, the 5-year disease-free survival rate was 96.1% and the functional larynx preservation rate was 94.9% for stage I and 83.9% for stage II. The rate of severe complications was 2.1%. Conclusion: Comparable results with low morbidity are achievable with a 3-week hypofractionation in early glottic cancers and it offers better patient convenience. Highlights: In early glottic cancer, hypofractionated radiation provides excellent local control.Subglottic extension is a poor prognostic factor.5-year disease-free survival rate of 96.1%.5-year functional larynx preservation rate of 94.9%.Severe complication rate of 2.1%.

Risk factors and prevalence of cervical squamous intraepithelial lesions among women in south India: A community-based cross-sectional study.

Background: ">Cervical cancer in India accounts for one-fifth of the global burden. Well-defined precancerous stages help early detection of the disease. Apart from human papillomavirus, the risk factors include age, education, occupation, early age at marriage and first delivery, abortions, and multiple sexual partners. Prevalence and risk factors for cervical squamous intraepithelial lesions (SIL) among women by Pap smear screening in south India were analyzed through a cross-sectional study. Methods: ">Women from rural and urban area were motivated by local accredited social health activists to attend pre-fixed Pap smear clinics in government hospitals. Pap smears collected in these clinics were taken to the Regional Cancer Centre, Thiruvananthapuram, processed, and cytology reports were prepared. Multiple logistic regression analysis was used to identify risk factors for SIL and high-grade SIL (HSIL). Results: ">The number of SIL was 67 out of 10,580 and HSIL was 39. Having higher education (Odds Ratio, OR:0.05(95% Confidence Interval, CI: 0.01-0.2), being married but living single (OR : 5.3, 95%CI:2.4-11.5), Having >2 abortions (OR:21, 95% CI:4.5-24), having younger age at delivery (OR : 0.1, 95% CI:0.01-0.3) and having unhealthy cervix (OR: 16.4, 95% CI:6.2-42.7) were the factors found to be the associated risk factors in multiple regression analysis. Conclusion: ">Pap smear screening can be focused on women with risk factors such as low education, married but living single, having >2 abortions, younger age at delivery, and unhealthy cervix on per speculum examination.

Clinical Profile and Survival Outcome of Endometrial Cancer with p53 Mutation.

Clinicopathologic classification of endometrial cancer imperfectly reflects the tumor biology. Pathologic categorization - especially in high-grade tumors - results in an imprecise estimation of the risk of disease, recurrence, and death. Molecular subtyping is emerging as the standard of care in diagnosis and treatment of endometrial cancers. Molecular markers are important prognostic factors in tumor dissemination and early recurrence of endometrial cancers. TP53 mutation is an important prognostic factor for both serous and endometrioid cancers. The study aims to compare the clinical profile and overall survival of endometrial cancers with and without p53 mutation. Sixty-three patients who underwent surgical staging for carcinoma endometrium were included in the study.TP53 mutation status was determined based on p53 expression by immunohistochemistry (IHC) as a p53 wild or p53 mutant type. Data were analyzed for the clinical profile, p53 mutation status on IHC, histological pattern, tumor grade, stage of the disease, lymph node spread, recurrence pattern, treatment received, 2-year disease-free survival, and overall survival. Recurrence was noted in 12.7% patients after 2-year follow-up, of which 75% patients had p53 mutation. Significant association was seen between p53 expression and high-grade tumors, stage, cervical involvement, and adnexal involvement. The 2-year overall survival of the p53 wild type was 97.2% and the p53 mutant type was 91.7%. The 2-year disease-free survival for the p53 wild type was 94.3% and the disease-free survival of the p53 mutant variety was 83.5%. The 2-year disease-free survival for endometrioid carcinoma with p53 wild type was 100% and p53 mutant variety was 86.2% (p value 0.033). About 15.9% (10) patients were reassigned to the high-risk group needing chemotherapy and radiation according to the ESGO ESTRO 2021 consensus classification, due to their p53 mutation status. IHC to assess somatic p53 mutation may be done in endometrial biopsies irrespective of their histology. This may help to identify that the aggressive tumors thereby help in tailoring surgery, planning adjuvant treatment, and follow-up.

A cross-sectional investigation of regional patterns of diet and cardio-metabolic risk in India.

BACKGROUND: The role of diet in India's rapidly progressing chronic disease epidemic is unclear; moreover, diet may vary considerably across North-South regions. METHODS: The India Health Study was a multicenter study of men and women aged 35-69, who provided diet, lifestyle, and medical histories, as well as blood pressure, fasting blood, urine, and anthropometric measurements. In each region (Delhi, n=824; Mumbai, n=743; Trivandrum, n=2,247), we identified two dietary patterns with factor analysis. In multiple logistic regression models adjusted for age, gender, education, income, marital status, religion, physical activity, tobacco, alcohol, and total energy intake, we investigated associations between regional dietary patterns and abdominal adiposity, hypertension, diabetes, and dyslipidemia. RESULTS: Across the regions, more than 80% of the participants met the criteria for abdominal adiposity and 10 to 28% of participants were considered diabetic. In Delhi, the "fruit and dairy" dietary pattern was positively associated with abdominal adiposity [highest versus lowest tertile, multivariate-adjusted OR and 95% CI: 2.32 (1.03-5.23); Ptrend=0.008] and hypertension [2.20 (1.47-3.31); Ptrend<0.0001]. In Trivandrum, the "pulses and rice" pattern was inversely related to diabetes [0.70 (0.51-0.95); Ptrend=0.03] and the "snacks and sweets" pattern was positively associated with abdominal adiposity [2.05 (1.34-3.14); Ptrend=0.03]. In Mumbai, the "fruit and vegetable" pattern was inversely associated with hypertension [0.63 (0.40-0.99); Ptrend=0.05] and the "snack and meat" pattern appeared to be positively associated with abdominal adiposity. CONCLUSIONS: Cardio-metabolic risk factors were highly prevalent in this population. Across all regions, we found little evidence of a Westernized diet; however, dietary patterns characterized by animal products, fried snacks, or sweets appeared to be positively associated with abdominal adiposity. Conversely, more traditional diets in the Southern regions were inversely related to diabetes and hypertension. Continued investigation of diet, as well as other environmental and biological factors, will be needed to better understand the risk profile in this population and potential means of prevention.

Multi-center feasibility study evaluating recruitment, variability in risk factors and biomarkers for a diet and cancer cohort in India.

BACKGROUND: India's population exhibits diverse dietary habits and chronic disease patterns. Nutritional epidemiologic studies in India are primarily of cross-sectional or case-control design and subject to biases, including differential recall of past diet. The aim of this feasibility study was to evaluate whether a diet-focused cohort study of cancer could be established in India, providing insight into potentially unique diet and lifestyle exposures. METHODS: Field staff contacted 7,064 households within three regions of India (New Delhi, Mumbai, and Trivandrum) and found 4,671 eligible adults aged 35-69 years. Participants completed interviewer-administered questionnaires (demographic, diet history, physical activity, medical/reproductive history, tobacco/alcohol use, and occupational history), and staff collected biological samples (blood, urine, and toenail clippings), anthropometric measurements (weight, standing and sitting height; waist, hip, and thigh circumference; triceps, sub-scapula and supra-patella skin fold), and blood pressure measurements. RESULTS: Eighty-eight percent of eligible subjects completed all questionnaires and 67% provided biological samples. Unique protein sources by region were fish in Trivandrum, dairy in New Delhi, and pulses (legumes) in Mumbai. Consumption of meat, alcohol, fast food, and soft drinks was scarce in all three regions. A large percentage of the participants were centrally obese and had elevated blood glucose levels. New Delhi participants were also the least physically active and had elevated lipids levels, suggesting a high prevalence of metabolic syndrome. CONCLUSIONS: A high percentage of participants complied with study procedures including biological sample collection. Epidemiologic expertise and sufficient infrastructure exists at these three sites in India to successfully carry out a modest sized population-based study; however, we identified some potential problems in conducting a cohort study, such as limited number of facilities to handle biological samples.

Evaluation of Factors Affecting Margin Positivity and Persistent Disease After Leep for Cervical Intraepithelial Neoplasia.

BACKGROUND: Cervical intraepithelial neoplasia (CIN) is the precursor lesion of cervical cancer. Untreated high-grade CIN significantly increases the risk of developing invasive cancer. Conization is the main treatment. Loop electrosurgical excision procedure (LEEP) is the most common conization method used. The study aims to assess the risk factors associated with positive margin and persistent disease after LEEP for CIN. MATERIALS AND METHODS: A total of 156 patients who underwent LEEP during 2011-2018 included in the study. We analyzed the socio-demographic characteristics, colposcopy details, dimensions of LEEP specimen (thickness, length, volume) and histopathology (margin positivity, grade). Persistent disease was histologically confirmed by repeat LEEP and hysterectomy. RESULTS: Margin positivity was noted in 33.3% (52) patients. Residual disease was noted in 26.2% (41) of the patients who had undergone a repeat LEEP or hysterectomy. There was a significant association between margin positivity and Swede score of 5 or more, a high-grade lesion on IFCPC score, inner margin involvement, LEEP done in a single pass. The cutoff for margin positivity was length of 0.513 cm and thickness of 0.35 cm. A significant association between residual disease and margin positivity, postmenopausal status, Swede score of 5 or more, high-grade lesion on IFCPC score, inner margin involvement was observed. The chance of residual disease was less if the cone specimen had minimum length of 0.775 cm and minimum thickness of 0.65 cm. CONCLUSION: When in doubt regarding the margins, it is always better to perform multiple passes for lesions with a high Swede score with an initial smear of HSIL. Postmenopausal women with inner margin positivity have a high chance of residual disease and should be either kept on close follow-up or consider a repeat procedure.

Educational Status, Cancer Stage, and Survival in South India: A Population-Based Study.

PURPOSE: Lower socioeconomic status is associated with more advanced cancer at the time of cancer diagnosis. It is unknown whether this leads to inferior survival in low- and middle-income countries. Here, we explore the association between educational level and survival in South India. METHODS: The Trivandrum Cancer Registry (3.3 million population) was used to identify all cases of breast and cervical cancer (women) and oral cavity (OC) and lung cancer (men) diagnosed during 2012-2014. Educational level was classified as illiterate/primary school, middle school, and secondary school and above. Survival was measured from date of diagnosis using the Kaplan-Meier method. Cox proportional hazards regression modeling was used to describe the associations among education, stage of cancer at diagnosis, and survival. RESULTS: The study population included 3,640 patients with breast (n = 1,727), cervical (n = 425), OC (n = 702), and lung (n = 786) cancer. Educational level was 27%, 23%, and 32% for illiterate/primary, middle, and secondary school and above, respectively. The 5-year survival rate for breast cancer was 59%, 68%, and 73% (P = .001); for cervical cancer, 51%, 52%, and 60% (P = .146); and for OC cancer, 42%, 35%, and 48% (P = .012) for illiterate/primary, middle school, and secondary school and above, respectively. The survival gradient across social groups was substantially attenuated when stage was added to the multivariable model. There was no observed difference in survival across educational groups for lung cancer (2%, 4%, and 3%; P = .224). CONCLUSION: Data from this population-based study in South India demonstrate that patients from a lower educational background have inferior survival and that this is at least partially explained by having more advanced disease at the time of diagnosis. Public health efforts are needed to facilitate timely diagnosis and reduce disparities in cancer outcomes.

Risk factors according to estrogen receptor status of breast cancer patients in Trivandrum, South India.

Estrogen receptor (ER) status is an important biomarker in defining subtypes of breast cancer differing in antihormonal therapy response, risk factors and prognosis. However, little is known about association of ER status with various risk factors in the developing world. Our case-control study done in Kerala, India looked at the associations of ER status and risk factors of breast cancer. From 2002 to 2005, 1,208 cases and controls were selected at the Regional Cancer Center (RCC), Trivandrum, Kerala, India. Information was collected using a standardized questionnaire, and 3-way analyses compared ER+/ER- cases, ER+ cases/controls and ER- cases/controls using unconditional logistic regression to calculate odds ratios and 95% confidence intervals. The proportion of ER- cases was higher (64.1%) than ER+ cases. Muslim women were more likely to have ER- breast cancer compared to Hindus (OR = 1.48, 95% CI = 1.09, 2.02), an effect limited to premenopausal group (OR = 1.87, 95% CI = 1.26, 2.77). Women with higher socioeconomic status were more likely to have ER+ breast cancer (OR = 1.48, 95% CI = 1.11, 1.98). Increasing BMI increased likelihood of ER- breast cancer in premenopausal women (p for trend < 0.001). Increasing age of marriage was positively associated with both ER+ and ER- breast cancer. Increased breastfeeding and physical activity were in general protective for both ER+ and ER- breast cancer. The findings of our study are significant in further understanding the relationship of ER status and risk factors of breast cancer in the context of the Indian subcontinent.

Breastfeeding and breast cancer risk in India: a multicenter case-control study.

Breast cancer incidence is low in India compared with high-income countries, but it has increased in recent decades, particularly among urban women. The reasons for this pattern are not known although they are likely related to reproductive and lifestyle factors. Here, we report the results of a large case-control study on the association between breastfeeding and breast cancer risk. The study was conducted in 2 areas in South India during 2002-2005 and included 1,866 cases and 1,873 controls. Detailed information regarding menstruation, reproduction, breastfeeding and physical activity was collected through in-person interview. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by unconditional logistic regression models. Breastfeeding for long duration was common in the study population. Lifetime duration of breastfeeding was inversely associated with breast cancer risk among premenopausal women (p-value of linear trend, 0.02). No such protective effect was observed in postmenopausal women, among whom a protective effect of parity was suggested. A reduction of breast cancer risk with prolonged breastfeeding was shown among premenopausal women. Health campaign focusing on breastfeeding behavior by appropriately educating women would contribute to reduce breast cancer burden.