Sex disparity in childhood cancer in India: a multi-centre, individual patient data analysis.

BACKGROUND: Sex disparity and its determinants in childhood cancer in India remain unexplored, with scarce information available through summary statistics of cancer registries. This study analysed the degree of sex bias in childhood cancer in India and its clinical and demographical associations. METHODS: In this retrospective, multicentre cohort study, we collected individual data of children (aged 0-19 years) with cancer extracted from the hospital-based records of three cancer centres in India between Jan 1, 2005, and Dec 31, 2019, and two population-based cancer registries (PBCRs; Delhi [between Jan 1, 2005, and Dec 31, 2014] and Madras Metropolitan Tumour Registry [between Jan 1, 2005, and Dec 31, 2017]). We extracted data on age, sex, and confirmed diagnosis of malignancy (according to the International Classification of Diseases-10 coding),and excluded participants if they were without a recorded diagnosis, had a benign diagnosis, had missing sex information, resided outside of India, or were a donor for haematopoietic stem cell transplantation (HSCT). The primary outcome was the male-to-female incidence rate ratio (MF-IRR) in the two PBCRs and the male-to-female ratios (MFR) from the hospital-based and the HSCT data. For PBCR data, MF-IRR was estimated by dividing the MFR by the total population at risk. MFR was analysed for patients seeking treatment at the cancer centres and for those undergoing HSCT. Logistic regression analyses were done to explore the association of clinical and demographical variables with sex of the patients seeking treatment and those undergoing HSCT in hospital-based data and multivariable analyses were done to determine independent sociodemographic predictors of sex bias. Annual time trends of MFR and MF-IRR during the 15-year study period were ascertained by time series regression analyses. FINDINGS: We included 11 375 children from PBCRs in the study. 26 891 children from hospital-based records were screened, and data from 22 893 (85·1%) were included (including 514 who underwent HSCT). Residence details were missing for 257 (1·1%) of 22 893 patients from hospital-based records. The crude MFR of children at diagnosis was in favour of boys: 2·00 (95% CI 1·92-2·09) in the Delhi PBCR and 1·44 (1·32-1·57) in Madras Metropolitan Tumour Registry. The MF-IRRs for cancer diagnosis were also skewed in favour of boys in both PBCRs (Delhi 1·69 [95% CI 1·61-1·76]; Madras Metropolitan Tumour Registry 1·37 [1·26-1·49]). The MFR for children seeking treatment from hospital-based records was 2·06 (95% CI 2·00-2·12) in favour of boys. In subgroup analyses, the proportion of boys seeking treatment was higher in northern India than southern India (p<0·0001); in private centres than in centres providing subsidised treatment (p<0·0001); in patients with haematological malignancies than those with solid malignancies (p<0·0001); in those residing 100 km or further from the hospital than those within 100 km of a hospital (p<0·0001); and those living in rural areas than those living in urban areas (p=0·0006). The MFR of 514 children who underwent HSCT was 2·81 (95% CI 2·32-3·43) in favour of boys. Time trend analysis showed that MFR did not show any significant annual change in either the overall cohort or in any of the individual centres for hospital-based data; however, the analysis did show a declining MF-IRR in the Delhi PBCR from 2005 to 2014 (p=0·031). INTERPRETATION: The sex ratio for childhood cancer in India has a bias towards boys at the level of diagnosis, which is more pronounced in northern India and in situations demanding greater financial commitment. Addressing societal sex bias and enhancing affordable health care for girls should be pursued simultaneously in India. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Cancer survival in Africa, central and south America, and Asia (SURVCAN-3): a population-based benchmarking study in 32 countries.

BACKGROUND: Population-based cancer survival is a key measurement of cancer control performance linked to diagnosis and treatment, but benchmarking studies that include lower-income settings and that link results to health systems and human development are scarce. SURVCAN-3 is an international collaboration of population-based cancer registries that aims to benchmark timely and comparable cancer survival estimates in Africa, central and south America, and Asia. METHODS: In SURVCAN-3, population-based cancer registries from Africa, central and south America, and Asia were invited to contribute data. Quality control and data checks were carried out in collaboration with population-based cancer registries and, where applicable, active follow-up was performed at the registry. Patient-level data (sex, age at diagnosis, date of diagnosis, morphology and topography, stage, vital status, and date of death or last contact) were included, comprising patients diagnosed between Jan 1, 2008, and Dec 31, 2012, and followed up for at least 2 years (until Dec 31, 2014). Age-standardised net survival (survival where cancer was the only possible cause of death), with 95% CIs, at 1 year, 3 years, and 5 years after diagnosis were calculated using Pohar-Perme estimators for 15 major cancers. 1-year, 3-year, and 5-year net survival estimates were stratified by countries within continents (Africa, central and south America, and Asia), and countries according to the four-tier Human Development Index (HDI; low, medium, high, and very high). FINDINGS: 1 400 435 cancer cases from 68 population-based cancer registries in 32 countries were included. Net survival varied substantially between countries and world regions, with estimates steadily rising with increasing levels of the HDI. Across the included cancer types, countries within the lowest HDI category (eg, CÔte d'Ivoire) had a maximum 3-year net survival of 54·6% (95% CI 33·3-71·6; prostate cancer), whereas those within the highest HDI categories (eg, Israel) had a maximum survival of 96·8% (96·1-97·3; prostate cancer). Three distinct groups with varying outcomes by country and HDI dependant on cancer type were identified: cancers with low median 3-year net survival (<30%) and small differences by HDI category (eg, lung and stomach), cancers with intermediate median 3-year net survival (30-79%) and moderate difference by HDI (eg, cervix and colorectum), and cancers with high median 3-year net survival (≥80%) and large difference by HDI (eg, breast and prostate). INTERPRETATION: Disparities in cancer survival across countries were linked to a country's developmental position, and the availability and efficiency of health services. These data can inform policy makers on priorities in cancer control to reduce apparent inequality in cancer outcome. FUNDING: Tata Memorial Hospital, the Martin-Luther-University Halle-Wittenberg, and the International Agency for Research on Cancer.

Conditional survival in patients treated for gastric cancer with a curative intent.

BACKGROUND AND OBJECTIVES: Conditional survival (CS) provides the probability that a patient who has already survived a certain number of years after treatment will survive an additional number of years. We aim to study the CS of patients with gastric cancer. METHODS: Patients who underwent curative intent treatment for gastric cancer in a single institution between 2007 and 2018 were included in the analysis. The probability (CS) that a patient who has already survived x years will survive an additional y year, was calculated as CS (y/x) = S(x + y)/S(x). RESULTS: The probability of surviving an additional 3 years if a patient had already survived 1, 2, 3, 4, and 5 years after treatment were 64.2%, 74.5%, 81.6%, 83.2%, and 88.2%, respectively whereas the 4-, 5-, 6-, 7-, and 8-year actuarial OS were only 47.2%, 43.2%, 41%, 39.4%, and 38.2%, respectively. The independent prognostic factors associated with poor survival were age >60 years, T stage ≥T3, N stage ≥N2, proximal tumor location, and lymph node ratio > 0.18. Patients with these high-risk features showed the greatest increase in CS3 over time. CONCLUSION: CS estimates provided a more dynamic prognostic information over time for patients treated for gastric cancer with curative intent.

Development of paediatric non-stage prognosticator guidelines for population-based cancer registries and updates to the 2014 Toronto Paediatric Cancer Stage Guidelines.

Population-based cancer registries (PBCRs) generate measures of cancer incidence and survival that are essential for cancer surveillance, research, and cancer control strategies. In 2014, the Toronto Paediatric Cancer Stage Guidelines were developed to standardise how PBCRs collect data on the stage at diagnosis for childhood cancer cases. These guidelines have been implemented in multiple jurisdictions worldwide to facilitate international comparative studies of incidence and outcome. Robust stratification by risk also requires data on key non-stage prognosticators (NSPs). Key experts and stakeholders used a modified Delphi approach to establish principles guiding paediatric cancer NSP data collection. With the use of these principles, recommendations were made on which NSPs should be collected for the major malignancies in children. The 2014 Toronto Stage Guidelines were also reviewed and updated where necessary. Wide adoption of the resultant Paediatric NSP Guidelines and updated Toronto Stage Guidelines will enhance the harmonisation and use of childhood cancer data provided by PBCRs.

Essential TNM: a registry tool to reduce gaps in cancer staging information.

Accurate information on the extent of disease around the time of diagnosis is an important component of cancer care, in defining disease prognosis, and evaluating national and international cancer control policies. However, the collection of stage data by population-based cancer registries remains a challenge in both high-income and low and middle-income countries. We emphasise the lack of availability and comparability of staging information in many population-based cancer registries and propose Essential TNM, a simplified staging system for cancer registries when information on full Tumour, Node, Metastasis (TNM) is absent. Essential TNM aims at staging cancer in its most advanced disease form by summarising the extent of disease in the order of distant metastasis (M), regional lymph node involvement (N), and tumour size or extension, or both (T). Flowcharts and rules have been developed for coding these elements in breast, cervix, prostate, and colon cancers, and combining them into stage groups (I-IV) that correspond to those obtained by full TNM staging. Essential TNM is comparable to the Union for International Cancer Control TNM stage groups and is an alternative to providing staging information by the population-based cancer registries that complies with the objectives of the Global Initiative for Cancer Registry Development.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study.

BACKGROUND AND OBJECTIVES: Laparoscopic resection for rectal cancer has short-term benefits when compared to open resection. The aim of this study was to compare the long-term oncological outcomes of laparoscopic and open resection for rectal cancer following neoadjuvant chemoradiation (NCRT). METHODS: In this propensity matched study, a series of 72 patients who underwent laparoscopic surgery for rectal cancer following NCRT between 2004 and 2010 (Lap group) were matched with 72 patients who underwent open surgery for rectal cancer in the same period (Open group). The survival and recurrence patterns were compared between the two groups. RESULTS: After a median follow-up of 69.5 months (range 1-138 months), local recurrence rate was observed in 4 patients (5.5%) and 7 patients (9.7%) in the Lap and Open groups, respectively (P = 0.35). The 5- and 10-year disease-free survival in the Lap and Open groups were 61.3% versus 47.9% and 48.8% versus 41%, respectively (P = 0.16). The 5- and 10-year overall survival was 66.9% versus 60.2% and 49% versus 46.2% in the Lap and Open groups, respectively (P = 0.38). CONCLUSION: Laparoscopic surgery following NCRT for low and mid third rectal cancers was associated with similar long-term oncological outcomes when compared to open surgery.

Paediatric cancer stage in population-based cancer registries: the Toronto consensus principles and guidelines.

Population-based cancer registries generate estimates of incidence and survival that are essential for cancer surveillance, research, and control strategies. Although data on cancer stage allow meaningful assessments of changes in cancer incidence and outcomes, stage is not recorded by most population-based cancer registries. The main method of staging adult cancers is the TNM classification. The criteria for staging paediatric cancers, however, vary by diagnosis, have evolved over time, and sometimes vary by cooperative trial group. Consistency in the collection of staging data has therefore been challenging for population-based cancer registries. We assembled key experts and stakeholders (oncologists, cancer registrars, epidemiologists) and used a modified Delphi approach to establish principles for paediatric cancer stage collection. In this Review, we make recommendations on which staging systems should be adopted by population-based cancer registries for the major childhood cancers, including adaptations for low-income countries. Wide adoption of these guidelines in registries will ease international comparative incidence and outcome studies.

Human Papillomavirus-Attributable Head and Neck Cancers in India-A Systematic Review and Meta-Analysis.

PURPOSE: Head and neck cancer accounts for about one third of the global burden in India. Mucosal high-risk human papillomavirus (HPV) has been hypothesized as a contributory risk factor for head and neck cancer (HNC) but its prevalence in Indian patients is not well established. Therefore, this systematic review and meta-analysis aimed to estimate the prevalence of HPV in HNC in India and their attributable fraction by considering the biomarkers of carcinogenesis, p16, and HPV E6/E7 mRNA. METHODS: A systematic literature search was done in Medline via PubMed, Embase, Scopus, ScienceDirect, ProQuest, and Cochrane to identify studies on HPV and HNC in the Indian population, published between January 1990 and October 2022. Fifty-four eligible studies were identified and relevant clinical information was collected. Meta-analysis was conducted to estimate the pooled prevalence of HPV DNA, p16INK4a, and E6/E7 mRNA percent positivity by random-effect logistic regression model using Metapreg, STATA 18. RESULTS: Thirty-four high-quality studies were taken for meta-analysis. The pooled prevalence of HPV in HNC was 20% (95% CI, 12 to 32) with a high level of heterogeneity (I2 = 90.79%). The proportion of HPV in oropharyngeal cancer (OPC; 22% [95% CI, 13 to 34]) and laryngeal cancer (LC; 29% [95% CI, 17 to 46]) was higher than in oral cancer (OC; 16% [95% CI, 8 to 30]). The HPV-attributable fraction of OPC, considering the E6/E7 mRNA and p16 positivity, was 12.54% and 9.68%, respectively, almost similar to LC (11.6% and 9.57%), while it was much lower in OC (3.36% and 4%). CONCLUSION: The HPV-attributable fraction is considerably lower for OC, suggesting a negligible causative role of HPV in OC. A significant proportion of OPC and LC are attributed to HPV; however, their exact causative role is unclear because of the presence of other known risk factors.

Improving access to cancer care among rural populations in India: Development of a validated tool for health system capacity assessment.

BACKGROUND: Cancer burden in India is rapidly growing, with oral, breast, and uterine cervix being the three most commonly affected sites. It has a catastrophic epidemiological and financial impact on rural communities, the vast majority of whom are socio-economically disadvantaged. Strengthening the health system is necessary to address challenges in the access and provision of cancer services, thus improving outcomes among vulnerable populations. OBJECTIVE: To develop, test, and validate a health system capacity assessment (HSCA) tool that evaluates the capacity and readiness for cancer services provision in rural India. METHODS: A multi-method process was pursued to develop a cancer-specific HSCA tool. Firstly, item generation entailed both a nominal group technique (to identify the health system dimensions to capture) and a rapid review of published and gray literature (to generate items within each of the selected dimensions). Secondly, tool development included the pre-testing of questionnaires through healthcare facility visits, and item reduction through a series of in-depth interviews (IDIs) with key local stakeholders. Thirdly, tool validation was performed through expert consensus. RESULTS: A three-step HSCA multi-method tool was developed comprising: (a) desk review template, investigating policies and protocols at the state level, (b) facility assessment protocol and checklist, catering to the Indian public healthcare system, and (c) IDI topic guide, targeting policymakers, healthcare workforce, and other relevant stakeholders. CONCLUSIONS: The resulting HSCA tool assesses health system capacity, thus contributing to the planning and implementation of context-appropriate, sustainable, equity-focused, and integrated early detection interventions for cancer control, especially toward vulnerable populations in rural India and other low-resource settings.

Epidemiology of rare cancers in India and South Asian countries - remembering the forgotten.

Background: Rare cancers (RCs) are challenging to manage and are "forgotten cancers" though they collectively constitute a significant proportion of all cancers (∼20%). As a first step towards streamlining care, there is an unmet need to map the epidemiology of RCs in South Asian Association for Regional Collaboration (SAARC) countries. Methods: The authors collected data from 30 Population-Based Cancer Registries (PBCR) of India and the published national registries of Nepal, Bhutan and Sri Lanka (SL) and compared them with the standard RARECAREnet RC list. Findings: With the standard definition of crude incidence rates (CR) ≤6/100,0000 per population, 67.5%, 68.3%, 62.3% and 37% of all incident cancers qualify as RCs in India, Bhutan, Nepal and SL, respectively. An arbitrary cut-off CR ≤3 appears more appropriate with 43%, 39.5%, 51.8% and 17.2% of cancers identified as RCs, respectively, due to the lower cancer incidence.There are similarities and notable differences between the RC lists of the SAARC region with that of the European RC list. Oral cavity cancers are rare in Europe, while pancreas, rectum, urinary bladder and melanomas are common. In addition, uterine, colon and prostatic cancers are rare in India, Nepal and Bhutan. In SL, thyroid cancer is common. There are gender-related and regional differences in RC trends in the SAARC countries. Interpretation: There is an unmet need in SAARC nations to capture epidemiological nuances in rare cancers. Understanding the unique issues in the developing world may guide policymakers to adopt appropriate measures to improve RC care and tailor public health interventions. Funding: None.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: a matched case-control study of short-term outcomes.

BACKGROUND: Neoadjuvant chemoradiation (nCRT) currently is commonly incorporated into the multimodal treatment of locally advanced rectal cancers. This study aimed to compare the short-term outcomes and oncologic adequacy of laparoscopic and conventional open surgery for rectal cancer after nCRT. METHODS: A series of 72 patients who underwent laparoscopic surgery (Lap group) for rectal cancer after nCRT were matched for type of surgery, gender, and American Society of Anesthesiologists (ASA) class with 72 patients who underwent conventional surgery during the same time period (Open group). The short-term outcomes were compared between the two groups of patients. RESULTS: No significant difference was found between the two groups in terms of age, distance of tumor from the anal verge, body mass index, or posttreatment pathologic stage of the disease. There were significant differences between the Lap and Open groups in terms of blood loss (median: 200 vs 400 ml; P < 0.001), duration of surgery (median: 270 vs 240 min; P < 0.001), time to passing of first flatus (median: 2 vs 3 days; P < 0.001), time to start of normal diet (median: 5 vs 6 days; P < 0.001), and hospital stay (median: 12 vs 15 days; P < 0.001). A significant difference in the number of lymph nodes harvested was not identified between the two groups, although more patients in the Open group had a positive circumferential resection margin than in the Lap group (10 vs 1%; P = 0.03). The short-term benefits of laparoscopic surgery also were observed when the 64 patients who underwent abdominoperineal resection (APR) in each of the two groups were compared separately. CONCLUSION: Laparoscopic surgery for rectal cancer, especially laparoscopic APR, after nCRT is safe and associated with earlier recovery of bowel function, a shorter hospital stay, and an oncologically adequate specimen compared with conventional open surgery.

Identification and validation of plasma biomarkers for diagnosis of breast cancer in South Asian women.

Breast cancer is the most common malignancy among women globally. Development of a reliable plasma biomarker panel might serve as a non-invasive and cost-effective means for population-based screening of the disease. Transcriptomic profiling of breast tumour, paired normal and apparently normal tissues, followed by validation of the shortlisted genes using TaqMan® Low density arrays and Quantitative real-time PCR was performed in South Asian women. Fifteen candidate protein markers and 3 candidate epigenetic markers were validated first in primary breast tumours and then in plasma samples of cases [N = 202 invasive, 16 DCIS] and controls [N = 203 healthy, 37 benign] using antibody array and methylation specific PCR. Diagnostic efficiency of single and combined markers was assessed. Combination of 6 protein markers (Adipsin, Leptin, Syndecan-1, Basic fibroblast growth factor, Interleukin 17B and Dickopff-3) resulted in 65% sensitivity and 80% specificity in detecting breast cancer. Multivariate diagnostic analysis of methylation status of SOSTDC1, DACT2, WIF1 showed 100% sensitivity and up to 91% specificity in discriminating BC from benign and controls. Hence, combination of SOSTDC1, DACT2 and WIF1 was effective in differentiating breast cancer [non-invasive and invasive] from benign diseases of the breast and healthy individuals and could help as a complementary diagnostic tool for breast cancer.

Psychosocial issues and concerns of cancer patients due to COVID-19 pandemic lockdown.

BACKGROUND: The COVID-19 pandemic lockdown has posed numerous unique challenges for cancer patients, families and healthcare workers. However, the reports on psychosocial issues associated with such situations are scarce. This study aims to determine the psychosocial issues faced by cancer patients during COVID-19 pandemic lockdown. METHODS: Cancer patients irrespective of diagnosis and treatment status were assessed for fear of progression (FOP), distress and quality of life (QOL) using Fear of Progression- Short Form, Distress Thermometer and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) 30, respectively. The demographics, disease and treatment related details were obtained from case record form. Psychological issues and concerns were collected using a structured interview. Descriptive statistics, Mann Whitney U-test and Linear Regression were performed using SPSS ver 20.0. RESULTS: Among the 219 patients, 118 (52.5%) had either interruption in their on-going cancer treatment or the initiation of cancer treatment was delayed as a result of COVID-19 lockdown. Overall, 74% of the patients experienced distress, 55.3% experienced FOP and 58% had low global health status. Pain followed by fatigue remained as major issues among patients during lockdown. Interruption in treatment and logistical issues were strongly associated with increased distress (p = 0.026) and FOP (p = 0.004). Global health status (p = 0.037), emotional functioning (p = 0.000), social functioning (p = 0.000) and financial concerns (p = 0.046) differed significantly between patients with and without treatment interruption. Age (ß = -0.159), mode of transport (ß = -0.135), challenges in meeting daily needs (ß = -0.245) and being out-casted by the society (ß = -0.227) predicted distress. CONCLUSION: More than half of the patients had interruptions in their treatment as a result of COVID-19 lockdown. Cancer patients have had increased physical and psychological concerns as a result of the pandemic situation and its associated changes. Specific guidelines ought to be framed for providing continued and holistic cancer care for patients during such lockdown.

Cancer survival in Africa, Asia, and Central America: a population-based study.

BACKGROUND: Population-based cancer survival data, a key indicator for monitoring progress against cancer, are not widely available from countries in Africa, Asia, and Central America. The aim of this study is to describe and discuss cancer survival in these regions. METHODS: Survival analysis was done for 341 658 patients diagnosed with various cancers from 1990 to 2001 and followed up to 2003, from 25 population-based cancer registries in 12 countries in sub-Saharan Africa (The Gambia, Uganda), Central America (Costa Rica), and Asia (China, India, Pakistan, Philippines, Saudi Arabia, Singapore, South Korea, Thailand, Turkey). 5-year age-standardised relative survival (ASRS) and observed survival by clinical extent of disease were determined. FINDINGS: For cancers in which prognosis depends on stage at diagnosis, survival was highest in China, South Korea, Singapore, and Turkey and lowest in Uganda and The Gambia. 5-year ASRS ranged from 76-82% for breast cancer, 63-79% for cervical cancer, 71-78% for bladder cancer, and 44-60% for large-bowel cancers in China, Singapore, South Korea, and Turkey. Survival did not exceed 22% for any cancer site in The Gambia; in Uganda, survival did not exceed 13% for any cancer site except breast (46%). Variations in survival correlated with early detection initiatives and level of development of health services. INTERPRETATION: The wide variation in cancer survival between regions emphasises the need for urgent investments in improving awareness, population-based cancer registration, early detection programmes, health-services infrastructure, and human resources. FUNDING: Association for International Cancer Research (AICR; St Andrews, UK), Association pour la Recherche sur le Cancer (ARC, Villejuif, France), and the Bill & Melinda Gates Foundation (Seattle, USA).

Locally Advanced Breast Cancer (LABC): Real-World Outcome of Patients From Cancer Institute, Chennai.

PURPOSE: There are sparse data on the outcome of patients with locally advanced breast cancer (LABC). This report is on the prognostic factors and long-term outcome from Cancer Institute, Chennai. METHODS: This is an analysis of untreated patients with LABC (stages IIIA-C) who were treated from January 2006 to December 2013. RESULTS: Of the 4,577 patients with breast cancer who were treated, 2,137 patients (47%) with LABC were included for analysis. The median follow-up was 75 months (range, 1-170 months), and 2.3% (n = 49) were lost to follow-up at 5 years. The initial treatment was neoadjuvant concurrent chemoradiation (NACR) (77%), neoadjuvant chemotherapy (15%), or others (8%). Patients with triple-negative breast cancer had a pathologic complete response (PCR) of 41%. The 10-year overall survival was for stage IIIA (65.1%), stage IIIB (41.2%), and stage IIIC (26.7%). Recurrence of cancer was observed in 27% of patients (local 13% and distant 87%). Multivariate analysis showed that patients with a tumor size > 10 cm (hazard ratio [HR], 2.19; 95% CI, 1.62 to 2.98; P = .001), hormone receptor negativity (HR, 1.45; 95% CI, 1.22 to 1.72; P = .001), treatment modality (neoadjuvant chemotherapy, HR, 0.56; 95% CI, 0.43 to 0.73; P = .001), lack of PCR (HR, 2.36; 95% CI, 1.85 to 3.02; P = .001), and the presence of lymphovascular invasion (HR, 1.97; 95% CI, 1.60 to 2.44; P = .001) had decreased overall survival. CONCLUSION: NACR was feasible in inoperable LABC and gave satisfactory long-term survival. PCR was significantly higher in patients with triple-negative breast cancer. The tumor size > 10 cm was significantly associated with inferior survival. However, this report acknowledges the limitations inherent in experience of management of LABC from a single center.

Expression of cancer stem cell markers CD24, EPHA1 and CD9 and their correlation with clinical outcome in epithelial ovarian tumours.

BACKGROUND: There has been variability between laboratories in the identification of cancer stem cells (CSCs) markers for epithelial ovarian cancer (EOC). We have evaluated three new surface markers for EOC to identify CSCs precisely. METHODS: Three new putative CSCs specific surface markers CD9, CD24 and EPHA1 identified by a bioinformatics approach were evaluated in normal ovary, fallopian tube and ovarian tumours. RESULTS: The expression of CD9 alone was observed in normal ovarian surface epithelium and fallopian tube whereas CD24 and EPHA1 were not expressed (n= 5). CD24 was expressed in all tumours (N= 101) while CD9 and EPHA1 were expressed in 89 and 71 tumours, respectively. The statistical analysis showed significant correlation of the stage of the disease (p< 0.0001), type of surgery (p< 0.0001) and residual disease (p< 0.0001) with overall survival. Although expression of CD9, CD24 and EPHA1 was observed in the majority of tumours there was no significant correlation with outcome. In patients who underwent primary surgery, increased expression of CD24 significantly correlated with poor survival. The expression of CD24 was significantly reduced (p< 0.002) upon analysis of paired sections from patients prior to surgery and at interval debulking surgery (n= 16). CONCLUSION: These findings suggest that overexpression of these new markers may be useful in identifying and targeting ovarian CSCs and CD24 may be a putative CSCs marker in ovarian cancer.

Childhood cancers in Chennai, India, 1990-2001: incidence and survival.

Childhood cancers (age at diagnosis: 0-14 years) comprise a variety of malignancies, with incidence varying worldwide by age, sex, ethnicity and geography, that provide insights into cancer etiology. A total of 1,334 childhood cancers registered in population-based cancer registry, Chennai, India, during 1990-2001 and categorized by International Classification of Childhood Cancer norms formed the study material. Cases included for survival analysis were 1,274 (95.5%). Absolute survival was calculated by actuarial method. Cox proportional hazard model was used to elicit the prognostic factors for survival. The age-standardized rates for all childhood cancers together were 127 per million boys and 88 per million girls. A decreasing trend in incidence rates with increasing 5-year age groups was observed in both sexes. The top 5 childhood cancers were the same among boys and girls: leukemias, lymphomas, central nervous system neoplasms, retinoblastomas and renal tumors. The highest 5-year absolute survival was observed in Hodgkin's disease (65%) followed by Wilm's tumor (64%), retinoblastomas (48%), non-Hodgkin's lymphomas (47%), osteosarcomas (44%), acute lymphoid leukemia and astrocytoma (39%). Multifactorial analysis of age at diagnosis and sex showed no differences in the risk of dying for all childhood cancers. Completeness of treatment and type of hospital combination emerged as a prognostic factor for survival for all childhood cancers together (p < 0.001), acute lymphoid leukemia (p < 0.001) and non-Hodgkin's lymphoma (p = 0.04). A Childhood Cancer Registry with high-resolution data collection is advocated for in-depth analysis of variation in incidence and survival.

Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial.

BACKGROUND: Cervical cancer is the most common cancer among women in developing countries. We assessed the effect of screening using visual inspection with 4% acetic acid (VIA) on cervical cancer incidence and mortality in a cluster randomised controlled trial in India. METHODS: Of the 114 study clusters in Dindigul district, India, 57 were randomised to one round of VIA by trained nurses, and 57 to a control group. Healthy women aged 30 to 59 years were eligible for the study. Screen-positive women had colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Those with larger precancerous lesions or invasive cancers were referred for appropriate investigations and treatment. Cervical cancer incidence and mortality in the study groups were analysed and compared using Cox regression taking the cluster design into account, and analysis was by intention to treat. The primary outcome measures were cervical cancer incidence and mortality. RESULTS: Of the 49,311 eligible women in the intervention group, 31,343 (63.6%) were screened during 2000-03; 30,958 control women received the standard care. Of the 3088 (9.9%) screened positive, 3052 had colposcopy, and 2539 directed biopsy. Of the 1874 women with precancerous lesions in the intervention group, 72% received treatment. In the intervention group, 274,430 person years, 167 cervical cancer cases, and 83 cervical cancer deaths were accrued compared with 178,781 person-years, 158 cases, and 92 deaths and in the control group during 2000-06 (incidence hazard ratio 0.75 [95% CI 0.55-0.95] and mortality hazard ratio 0.65 [0.47-0.89]). INTERPRETATION: VIA screening, in the presence of good training and sustained quality assurance, is an effective method to prevent cervical cancer in developing countries.