Ultraprocessed Foods and Cancer in Low-Middle-Income Countries.

Low middle income countries (LMICs) are the predominant contributors to global cancer-related mortality and are projected to bear the greater share of the global cancer burden in the next few decades. Among other factors, lifestyle changes have been linked to the rising incidence of cancer in these countries. As one of the keys to a healthy lifestyle, a balanced diet plays a major role in the preservation of health. Globalization and rapid urbanization have prompted a paradigm shift in various aspects of daily life in LMICs; the influence on dietary choices has been particularly noticeable. Studies show a concerning rise in the sale and consumption of ultraprocessed foods in these countries. In addition to hyperpalatability, this trend has been attributed to various other factors including convenience, availability, economic considerations, and marketing strategies. Although several studies from LMICs recognize and recommend the need for effective public health measures to reduce the consumption of these foods, findings from certain studies suggest that established public health strategies occasionally fail in the real-world scenario. Barriers to effective policymaking also contribute to the prevailing dietary trends. This review of studies from the LMIC setting demonstrates the current problem, limitations of established public health measures, and the complexities associated with effective policymaking. In view of the threat posed to cancer risk, there is an urgent need to curb the consumption of ultraprocessed foods in LMICs. National policymakers therefore need to circumnavigate the challenges effectively to ensure timely achievement of the United Nations sustainable development goals.

Radiotherapy travel times - is time running out in India?

Inequitable radiotherapy availability in India leads to non-compliance in many cases, as patients need to travel long distances for treatment; this has long-term implications for achieving the United Nations sustainable development goals. Notably, the number of functional radiotherapy units in India is below the limit recommended by the World Health Organization, and most centers in this vast country are located in urban centers. This creates a serious barrier to accessibility for the socioeconomically disadvantaged sections of the rural population. Recent reports suggest that despite the availability of free treatments for a wide variety of cancers, many patients are non-compliant owing to the high costs incurred on travel to distant centers. In view of the current distribution of radiotherapy units, and the low ratio of radiotherapy units serving the vast population, distances traveled for radiotherapy are likely to have considerable impact on realization of the United Nations sustainable development goals. It is also likely to have considerable impact on the existing weak infrastructure of healthcare facilities, as poor cancer control will increase the need for palliative care and support, thereby further reducing resource allocation to cancer control. Policies directed towards reducing travel times for radiotherapy are currently lacking in India. However, this issue needs urgent consideration to ensure optimal utilization of available resources. Until measures to reduce travel time can be implemented, reducing travel-related patient distress may improve compliance in the short term; urgent measures in this regard will help achieve the targets of the United Nations sustainable development goals.

Elimination of cervical cancer as a public health problem-how shorter brachytherapy could make a difference during COVID-19.

The World Health Organization has called for elimination of cervical cancer as a public health problem and has adopted strategies in this regard. However, the estimates for achieving the goals depend on the ability to provide timely treatment in a certain proportion of cases. The coronavirus disease 2019 pandemic has had a serious impact on healthcare delivery in many low and middle income countries (LMICs) with the highest burden of cervical cancer; funds and infrastructure are being reallocated to deal with the emergency, and cancer care has been seriously affected. In the absence of clear and reliable estimates, the exact extent of disruption remains unclear. It is, therefore, essential that pragmatic approaches are adopted to save lives. There has been considerable debate regarding the use of the 9 Gy × 2 fractions high dose rate brachytherapy schedule for the treatment of locally advanced cervical carcinoma. However, in LMICs with the highest global burden of locally advanced cervical cancer cases, radiation facilities have been using this fractionation schedule in many cases to deal with the overwhelming number of patients, who would have otherwise been denied timely treatment. In view of the current pandemic, and the difficulties in accessing and delivering timely healthcare, mortality owing to delayed treatment cannot be denied in LMICs, which already have underequipped healthcare facilities. Use of the shortest available fractionation schedule to provide timely treatment would serve to save more lives in regions with high incidence and mortality from the disease.

Prognostic Nutritional Index and Clinical Response in Locally Advanced Cervical Cancer.

Background: The prognostic nutritional index (PNI), a marker of immune-nutrition balance, has predictive value in the survival and prognosis of various cancers. However, the impact of PNI on response to chemoradiation is poorly understood.Materials and Methods: A total of 583 women with locally advanced cervical cancer from two centers were clinically assessed for complete response after chemoradiation. The baseline PNI was individually recorded, and the significance of association between PNI and complete response was analyzed using logistic regression. ROC (receiver operating characteristics) curves were analyzed to determine the cutoff value of PNI that significantly predicted complete response.Results: Logistic regression analysis demonstrated that the PNI was significantly associated with complete response following chemo radiation (p < 0.0001). Analysis of the ROC curve for PNI demonstrated an optimal cut off value of 44.8 (p < 0.0001, sensitivity 66.7, and specificity 88.5); the area under the ROC curve was 0.813 (Youden's index J, 0.7519).Conclusions: The PNI is significantly associated with clinical complete response to chemoradiation in locally advanced cervical cancer. Low baseline PNI may lower the likelihood of complete response after chemoradiation. In particular, those with PNI values below 44 should be carefully monitored during treatment; nutritional interventions may offer benefit in these women.

Pelvic side wall recurrence in locally advanced cervical carcinoma treated with definitive chemoradiation-clinical impact of pelvic wall dose.

OBJECTIVE: Pelvic side wall dose in locally advanced cervical carcinoma treated with definitive chemoradiation has been debated. The present study investigated relationship of disease recurrence with dose for the pelvic side wall. It also attempted to identify minimal dose that significantly reduced recurrence. METHODS: Pelvic side wall recurrence at median 24 months was assessed clinically and radiologically across three groups of patients receiving variable pelvic wall doses using no parametrial boost, external beam or interstitial boost, or dose escalated combined external beam with interstitial boost. RESULTS: At 24 months, recurrence occurred in 3/155 boost vs 40/130 no boost patients. (p < 0.0001). Receiver operating characteristic curve analysis demonstrated cut-off pelvic wall dose to be 58.9 Gy (p < 0.0001). Dose escalated combined boost showed no significant benefit compared to single modality parametrial boost (p = 0. 0.553). CONCLUSION: Mean pelvic wall dose of at least 58.9 Gy offers clinically significant benefit in pelvic wall control. Doses recommended by guidelines should be adhered to in the patients' best interests. ADVANCES IN KNOWLEDGE: This preliminary study determined a relationship between recurrence rates and dose to the pelvic side wall and also a cut-off dose that significantly improved pelvic wall control in locally advanced cervical cancer.

Predictors of chemoradiation related febrile neutropenia prophylaxis in older adults - Experience from a limited resource setting.

AIM: To identify risk factors that lower efficacy of antibiotic prophylaxis of febrile neutropenia among older patients on chemoradiation. BACKGROUND: Audit of institutional data showed that older adults are at higher risk of febrile neutropenia during chemoradiation. In limited resource settings widespread use of Granulocyte-Colony Stimulating Factor (G-CSF) is not economically feasible and antibiotics are used commonly. Despite compliance with antibiotics, prophylaxis is inadequate in many patients owing to patient and tumor related factors. MATERIALS AND METHODS: Data from records of 219 older patients receiving antibiotic prophylaxis during chemoradiation were studied. Baseline assessment data and predisposing factors for febrile neutropenia were recorded. All patients received prophylactic fluoroquinolones. Incidence of febrile neutropenia and association with predisposing factors at baseline was analyzed by multiple logistic regression. RESULTS: 38.4% developed febrile neutropenia despite compliance. Multiple logistic regression revealed geriatric assessment (G8) score and tumor stage to be significant predictors of febrile neutropenia while on antibiotics (p < 0.0001). Odds ratios for two significant predictors G8 score and tumor stage, respectively, were 2.9 (95% CI 1.8036-4.6815) and 2.7 (95% CI 1.7501-4.1318). Correlation between these two significant predictors was found to be low in our cohort (Spearman's coefficient of rank correlation (rho) - 0.431, p < 0.0001). CONCLUSION: G8 score and tumor burden are significant predictors of efficacy of antibiotic prophylaxis among older adults receiving chemoradiation. In older patients having poor G8 scores and advanced tumors, antibiotic prophylaxis is unsuitable. Interestingly, co-morbidities and poor performance status did not impact efficacy of antibiotic prophylaxis among our elderly patients.

Reduced Dose Intensity of Chemotherapy may not Lead to Inferior Palliation in Locally Advanced Carcinoma of the Gall Bladder: An Experience from a Regional Cancer Centre in Eastern India.

PURPOSE: To assess impact of relative total dose intensity (RTDI) on clinical benefit among patients with locally advanced carcinoma gall bladder receiving gemcitabine-cisplatin (GemCis). Comparison of clinical benefit among patients receiving variable RTDI was the primary objective. The secondary objective was an impact of RTDI on chemotherapy toxicity. METHODS: One-hundred twenty-one patients with locally advanced inoperable carcinoma gall bladder undergoing chemotherapy with three weekly gemcitabine-cisplatin chemotherapies (gemcitabine 1000 mg/m(2) on day 1 and 8, cisplatin 70 mg/m(2) on day 1) were studied. Clinical benefit and treatment toxicity was assessed. Total dose of chemotherapy and relative total dose intensity, the proportion of planned dose actually received was calculated. RESULTS: RTDI of at least 50 % conferred substantial clinical benefit compared to lower RTDI (75.49 vs. 21.05 %). RTDI above 50-59 % did not improve clinical benefit; two-tailed p values of RTDI >60 % vs. RTDI >50 % and RTDI >70 % vs. RTDI >50 % were 1.000 and 0.4266, respectively. Subsequent extended cholecystectomy rates did not significantly improve among patients who received RTDI greater than 50-59 %; two-tailed p values of RTDI >60 % vs. RTDI >50 % and RTDI >70 % vs. >50 % were 0.0920 and 0.5648, respectively. Significantly higher neutropenia and anemia of at least grade 2 occurred with RTDI >70 % vs. RTDI 50-59 %; two-tailed p values 0.0019 and 0.0048, respectively. CONCLUSIONS: Relative total dose intensity of chemotherapy higher than 60 % among patients with inoperable locally advanced carcinoma gall bladder conferred no significant improvement in clinical benefit and subsequent rates of extended cholecystectomy. Higher RTDI however led to significantly increased toxicity among these patients.

Sequential chemoradiation in locally advanced head and neck cancer after induction chemotherapy: an induction chemotherapy schedule more suited to a limited resource setting.

BACKGROUND: In our experience, induction docetaxel, platinum, and fluorouracil (TPF) chemotherapy and sequential chemoradiation in locally advanced head and neck cancer lowers compliance owing to their considerable toxicity. Most of our head and neck cancer patients have locally advanced disease at presentation. Physicians frequently prefer paclitaxel-cisplatin induction chemotherapy instead, because of better patient tolerance. MATERIALS AND METHODS: A total of 207 locally advanced head and neck cancer patients receiving paclitaxel and cisplatin prior to chemoradiation from November 2010 to October 2013 were studied retrospectively. Parameters like febrile neutropaenia, treatment compliance, and response rates were compared to our institutional retrospective data with TPF chemotherapy. Response was assessed by Response Evaluation Criteria in Solid Tumours (Recist) version 1.1. Toxicity was assessed by Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 during chemotherapy. Radiation Therapy Oncology Group (RTOG) acute toxicity criteria were used for assessment during chemoradiation. RESULTS: Febrile neutropaenia with paclitaxel- cisplatin was significantly lower 3.4% (7/207) versus 44.5% (73/164) with TPF chemotherapy (two-tailed P value < 0.0001). A 95.7 % (198/207) paclitaxel-cisplatin patients completed chemoradiation versus 87% with TPF. The difference was significant (two-tailed P value = 0.0070). Response rate at treatment completion with paclitaxel -cisplatin was 89.7% versus 88% with TPF chemotherapy. No significant differences were observed (two-tailed P value = 0.7007). CONCLUSION: Induction paclitaxel and cisplatin with sequential chemoradiation in locally advanced head and neck cancer is more suitable in a limited resource setting. Lower toxicity, better compliance, and comparable response are encouraging in our study cohort.

Incidence of hospitalization in patients receiving short course palliative cranial radiotherapy on outpatient basis in a limited resource setting - Experience from a regional cancer center in India.

AIM: To investigate incidence of toxicity and related hospitalization among patients treated at our institute by a short course of palliative cranial radiotherapy against a longer, widely established schedule. BACKGROUND: Shorter schedule palliative cranial radiotherapy is more convenient for patients and reduce waiting times. Although many studies have established safety of short schedules, the need for hospitalization due to acute treatment toxicity remains under-explored. Hospital admissions are an economic burden both for the patient and healthcare system in a limited resource setting. Delivery of treatment on an outpatient basis and within shorter times is preferred by patients, caregivers and healthcare staff. MATERIALS AND METHODS: This was a prospective study on 68 patients treated with palliative whole brain radiotherapy between November 2010 and October 2012. One group received 20 Gy in 5 fractions over 1 week and the other group, 30 Gy in 10 fractions over 2 weeks. Treatment toxicity due to cranial radiotherapy was assessed as per RTOG acute and late toxicity criteria. Need for hospitalization owing to acute toxicity was also noted. Significant differences in the study parameters between the two groups were calculated by Fisher's t-test. RESULTS: Requirement for hospital stay due to acute toxicity was not significantly different between the two groups. Patients in both groups experienced similar toxicity both during and after treatment. CONCLUSIONS: The shorter course entailed no significant increase in toxicity related admissions, suitable for limited resource settings where patient transport is difficult, there are financial constraints, and the healthcare system is overburdened.

Haemoglobin levels may predict toxicities in patients on pelvic chemoradiation for carcinoma of the cervix-experience of a regional cancer centre.

BACKGROUND: Haemoglobin levels and tissue oxygenation influence tumour outcome in carcinoma cervix radiotherapy. The clinical impact of haemoglobin levels on acute normal tissue toxicity during radiation and interaction with chemotherapy in carcinoma of the cervix is underexplored. This paper aims to explore this issue. METHODS: Treatment toxicity among 227 patients with squamous cell carcinoma of the cervix stages II B-IV A, receiving pelvic radiotherapy or chemoradiation at our institute, were studied prospectively. The baseline and weekly haemoglobin levels during treatment were recorded. Acute toxicities were recorded using Radiation Therapy Oncology Group (RTOG) acute toxicity and Common Terminology Criteria for Adverse Events (CTCAE) criteria, version 4. For the analysis, patients were divided into two groups, depending on nadir haemoglobin levels. A cut-off value for anaemia was selected at 12 gm/dL. Toxicity was compared between anaemic and non-anaemic groups. RESULTS: Patients on chemoradiation and having haemoglobin levels >12 gm/dL suffered significantly higher dermatitis (two-tailed p value = 0.0288) and vaginal mucositis (two-tailed p value = 0.0187) of at least RTOG acute toxicity grade 2, compared with the anaemic group. In contrast patients receiving radiotherapy alone did not experience any significantly greater mucocutaneous toxicity if haemoglobin was >12 gm/dL. Anaemia had significantly greater impact on malaise and neutropenia (two-tailed p value <0.0001) of CTCAE grade 1 and above among chemoradiation patients, as opposed to those receiving radiotherapy alone (two-tailed p values = 0.0012 for neutropenia and 0.0422 for malaise). CONCLUSION: Haemoglobin values >12 gm/dL significantly worsen acute mucocutaneous toxicity in locally advanced cervical cancer patients receiving chemoradiation. Similar effects are not observed in the absence of chemotherapy.

Bladder Carcinoma after ABVD Chemotherapy for Hodgkin's Lymphoma: A Case Report.

The treatment of lymphomas may result in the development of second malignancies, as evident by the numerous reports in the literature. Treatment with cyclophosphamide-based chemotherapy regimens may lead to bladder lesions such as haemorrhagic cystitis and also to carcinoma of the urinary bladder. Previous pelvic radiotherapy treatment is also implicated as a cause for local second cancers. We present the case of a patient treated for Hodgkin's lymphoma, who was diagnosed with transitional cell carcinoma of the bladder soon after treatment completion. On completion of 6 cycles of ABVD chemotherapy the patient was on follow-up. Two months after treatment completion the patient complained of dysuria and was investigated for a suspected urinary tract infection. Urine microscopy did not reveal any abnormality. Symptomatic treatment was prescribed and cystoscopy was arranged. The cystoscopic findings suggested an irregular growth overlying the trigone and the biopsy reported it as transitional cell carcinoma. This case report demonstrates that symptoms attributed to common medical causes in patients treated for cancer may be a sign of second malignancy. This case report also demonstrates the need for a thorough evaluation of patients' complaints during follow-up, although the likelihood for the occurrence of a second malignancy may be low. The assumption that these symptoms were due to a commonly occurring urinary tract infection would have had serious implications leading to a delay in the treatment of the bladder cancer.