An assessment of childhood cancer care services in India - gaps, challenges and the way forward.

Background: Childhood cancers are emerging as an essential concern in India where there is lack of a specific programme component or policy to address childhood cancer control. There is limited information on the status and quality of childhood cancer care services in India. This paper describes the childhood cancer care services available at secondary and tertiary-level hospitals in India through a cross sectional study design. Methods: The survey was conducted in 137 tertiary-level and 92 secondary-level hospitals in 26 states and 4 Union Territories (UTs), ensuring a uniform representation of public and private care hospitals. The study tool collected data on the organisational infrastructure, type of oncology services, health workforce, equipment, treatment and referral protocols, and treatment guidelines. Descriptive statistics was used to primarily present the health service status and data on childhood cancer care services in proportions and mean. Findings: A dedicated pediatric oncology department was available in 41.6% of the public, 48.6% of private, and 64% Non Government Organization (NGO) managed tertiary-level hospitals. In 36 (39%) of the 92 hospitals providing secondary care, childhood cancer care was provided. The availability of bone (41.5%) and positron emission tomography (PET) scans (25.9%) was lower in public tertiary hospitals, whereas histopathology, computerised tomography (CT scan), and magnetic resonance imaging (MRI) were lower in public secondary hospitals than private and NGO managed hospitals for the corresponding level of care. Most tertiary hospitals had the required supportive care facilities except for play therapy and hospice care. Less than 50% of the public tertiary hospitals had stocks of the four categories of cancer-treating drugs and essential infrastructure for radiotherapy and chemotherapy. Most secondary-level hospitals not treating childhood cancer had referral linkages with tertiary hospitals. Interpretation: The situational analysis of childhood cancer care services in India showed the concentration of availability of childhood cancer care services at the tertiary level of health care. There were gaps in the availability of specialised pediatric oncology care in all the tertiary hospitals. The availability of childhood cancer care services was higher in private and NGO-managed hospitals than in public hospitals. Integration of childhood cancer as a part of the national cancer control response should be taken up as a matter of priority. The need of the hour is to formulate a childhood cancer policy that will enable timely access to care universally. Funding: World Health Organization, India provided funding and technical support.

Dosimetric Comparison of Different Dose Calculation Algorithms in Postmastectomy Breast Cancer Patients Using Conformal Planning Techniques.

Background: The aim of the current study was to compare three different dose-calculating algorithms, i.e., superposition (SP), fast SP (FSP), and convolution (CV), for breast cancer patients treated with intensity-modulated radiotherapy (IMRT) and field-in-Field forward plan IMRT (FiF-FP-IMRT). Materials and Methods: The current retrospective study involved 100 postmastectomy breast cancer patients who were given radiotherapy using IMRT and FiF-FP-IMRT planning techniques. All the initially SP-calculated plans were recalculated with the same monitor units for FSP and CV algorithm without change in any of the other planning parameters. The isodose distribution and various plan evaluating parameters, for example, conformity index (CI), homogeneity index, and uniformity index target volume and normal structure doses were compared and analyzed for all the different algorithm calculated plans. Results: In the IMRT plans, all the target and normal structure dose-volume parameters showed a significant difference between all the three different algorithms with P < 0.05. In the FiF-FP-IMRT plans, CV algorithm showed a significant difference in most of the target and normal structure dose-volume parameters. Among quality indexes, only CI showed a significant difference between all the algorithms in both the planning techniques. R50 showed a significant difference with the CV algorithm in both the planning techniques. Conclusion: The change in the dose calculation algorithm resulted in dosimetric changes which must be evaluated by the medical physicists and oncologists while evaluating treatment plans. In the current study with breast patients, the results obtained for target and normal structure doses using the CV algorithm are overestimated as compared to SP and FSP algorithms, producing variable results in air and bony normal structures. However, the ipsilateral lung V5 parameter and the ipsilateral humeral head mean dose were found to be underestimated by the CV algorithm as compared to the SP and FSP algorithm in both the planning techniques.

Biochemical analysis of saliva in head and neck cancer patients receiving definitive chemoradiotherapy.

BACKGROUND: Radiation therapy leads to salivary gland damage that causes xerostomia, the standard radiation-induced complication during radiotherapy that affects the quality of life in head and neck cancer patients. This study was conducted at a tertiary cancer institute in Punjab state to analyze the influence of radiation therapy on various parameters and substances of saliva. MATERIALS AND METHODS: Sixty head and neck cancer patients who underwent conventional radiotherapy on a Cobalt machine were included. Saliva was collected in both stimulated and unstimulated states. Stimulated whole saliva was collected by applying two to three drops of citric acid solution (2%) over the dorsum of the tongue bilaterally at 30-s intervals for 2 min. Biochemical changes in the whole saliva were evaluated by biochemical methods at baseline, completion of therapy, and 3 and 6 months post-radiotherapy completion. RESULTS: The lowest concentration of proteins was seen after the therapy in unstimulated and stimulated saliva. Salivary protein levels showed a rising trend toward baseline in 3- and 6-month posttherapy samples. The peak value (0.4 mg/dl) was reached in the stimulated saliva after therapy. Salivary amylase did not show a consistent concentration graph. The salivary concentrations of sodium, potassium, and chloride showed peak values after radiotherapy. The lowest salivary pH was obtained at completion of therapy, both in unstimulated and stimulated saliva. After 3 months of chemoradiotherapy, the saliva reached a pH value of 8.3, whereas 6-month posttherapy sample showed a pH value of 8.4 in both unstimulated and stimulated saliva. CONCLUSIONS: At the completion of chemoradiotherapy, the total salivary protein, albumin, and inorganic components (calcium, magnesium, phosphorus) showed a downward trend from the baseline values due to the damage caused to the acinar part of the salivary gland by radiotherapy. The rise in salivary electrolytes' concentrations is attributed to the fact that even though there is loss of absorptive property of the tubular portion of the salivary gland, it retains its secretory property. Saliva becomes thick, scarce, tenacious, and acidic during the period of chemoradiotherapy.

Dose Agreement Analysis of Treatment Planning System-Calculated Doses and Markus Chamber-Measured Doses in the Near-Surface Region for Breast Cancer Patients' Conformal Treatment Plans.

Background: Surface/skin dose measurement is one of the most challenging tasks for clinical dosimetry in radiotherapy and comparison with almost all the commercially available treatment planning systems (TPSs) brings a significant variation with the measured dose. Aims and Objectives: In the current study, doses calculated from the TPS in the near-surface region for conformal plans (both three-dimensional conformal radiotherapy [3DCRT] and intensity-modulated radiotherapy [IMRT]) of 35 breast cancer patients were evaluated and compared with the doses measured with Markus chamber. Materials and Methods: The computed tomography (CT) images of a solid water slab phantom with a Markus chamber (at different depths ranging from 1 mm to 5 mm from the surface) were taken and imported into the TPS. All the conformal treatment plans made in TPS were executed on a linear accelerator and dose agreements between TPS calculated and chamber measured doses were analysed. Results: Results showed that this TPS underestimated the calculated doses in the superficial region by up to 26% and 21%, respectively, with respect to mean and maximum dose values obtained within the effective volume of the chamber used. Conclusion: The uncertainty of doses in the superficial region should be kept in mind when evaluating treatment plans for superficial tumours in TPS.

Functional and biochemical changes in the thyroid gland following exposure to therapeutic doses of external beam radiotherapy in the head-and-neck cancer patients.

CONTEXT: Majority of the head-and-neck cancers are locoregionally advanced at the time of diagnosis. Hence, radiotherapy (RT) portals will invariably cover the whole neck and thus, the thyroid gland which may lead to its dysfunction. AIMS: The purpose of this study is to identify the functional and biochemical changes in the thyroid gland following RT to the neck using single-photon emission computed tomography-computed tomography (SPECT-CT) and thyroid function tests (TFTs). SUBJECTS AND METHODS: In this prospective study, 45 patients of the head-and-neck cancer, receiving RT with or without chemotherapy were investigated. Baseline TFTs and thyroid scans (on SPECT-CT) were done, and the same were repeated at the completion of RT, at 3 and 6 months. RESULTS: All patients received a minimum of 30 Gy to the whole neck. Baseline TFTs and thyroid scans were normal. None of them developed hypothyroidism clinical or subclinical (C/S) at the completion of RT. Six patients developed hypothyroidism (four subclinical, two clinical) at 3 months of the completion of treatment. At 6 months of follow-up 14 patients (31.1%) developed hypothyroidism (ten subclinical, four clinical) with P≤ 0.01. All patients having clinical or subclinical hypothyroidism had decreased uptake on thyroid scan. Patients having decreased uptake on thyroid scan only, with normal TFTs and no symptoms of hypothyroidism were zero at the completion of RT, 1 at 3 months follow-up, and seven at 6 months follow-up. CONCLUSIONS: Hypothyroidism (C/S) is an under-recognized but significant complication of therapeutic doses of RT to the neck. In our study, we recognized hypothyroidism as early as 3 months following the completion of RT. Hence, tests to evaluate functional and biochemical changes in the thyroid gland should be instituted as early as 3 months following RT.

To Evaluate the Role of Positron Emission Tomography-Computerized Tomography in Initial Staging of Carcinoma Breast.

BACKGROUND: Breast cancer is the most common cancer in urban and second common in rural Indian women. In India, in spite of the best treatment available being given to the patients they lose their lives because of paucity of diagnostic aids and lack of an organized breast cancer screening program. Early detection, accurate staging, and initiation of appropriate therapy are the key factors for improving the treatment outcome and prognosis of the disease for the patients. Traditional staging methods include clinical examination, blood tests, chest X-ray, ultrasound of the abdomen, and/or skeletal survey. As these tests lack sensitivity and specificity, these are being scaled down. The hybrid positron emission tomography-computerized tomography (PET-CT) is a unique tool in the field of imaging modalities that combines the effectiveness of PET and CT. This study was undertaken to assess the efficacy and accuracy of PET-CT as a single-session staging modality in the very initial stage itself and if it can replace the conventional means of staging. METHODS: This was a cross-sectional study conducted in the Radiotherapy department at GGS Medical College and Hospital Faridkot from March 2014 to October 2015. 52 patients with newly diagnosed and histopathologically proven carcinoma breast were staged by conventional modalities (clinical examination, blood tests, X-ray chest, mammography, ultrasonography abdomen, skeletal survey) and by 18F-fluorodeoxyglucose (18F FDG) PET/CT. PET-CT images were used for the detection, localization, staging of tumors and detection, evaluation, and diagnosis of metastatic lesions, disease burden and organ function along with treatment planning and planning therapeutic procedures. Following the completion of initial study, the results of 18F FDG PET-CT staging in comparison with conventional staging method were assessed. Along with this, the accuracy, changes in staging of cases of carcinoma breast and cost-effectiveness of 18F-FDG PET-CT were also studied. RESULTS: All the pathologic entities identified by conventional imaging were also perceived with 18F-FDG PET/CT. Therefore, we recommend the use of PET/CT as an important imaging modality for initial diagnosis of carcinoma breast.

Association of elevated levels of C-reactive protein with breast cancer, breast cancer subtypes, and poor outcome.

BACKGROUND AND PURPOSE: Inflammation and caner are linked in a bidirectional manner. C-reactive protein (CRP) is an important inflammatory marker. The aim of the study was to test whether the inflammatory marker, CRP at the time of diagnosis of breast cancer is associated with metastasis, recurrence, and death in breast cancer patients from Malwa region of Punjab where breast cancer is widely feared. MATERIAL AND METHODS: Two hundred and forty-two breast cancer patients and 242 age and sex matched controls were included in the study. CRP levels were estimated using fully automated bio analyzer Erba200. Follow up interviews were conducted at an interval of 3, 6, 9, 12, 15, 18, 21, 24, and 27 months to determine the outcome among breast cancer patients. RESULTS: Elevated levels of CRP were found among the diseased in comparison with controls (P < 0.0001). Higher CRP levels associated significantly with poor outcome including metastasis and recurrence among breast cancer patients [P = 0.03; 95% confidence interval; odds ratio: 2.954 (0.9125-9.561)]. CONCLUSION: Elevated levels of CRP associated significantly with increased risk of breast cancer and poor outcome. CRP estimation may be a simple and inexpensive tool for the risk assessment and outcome of the disease in Malwa region of Punjab where incidence of breast cancer is reported to be very high.

Genomic alterations associated with HER2+ breast cancer risk and clinical outcome in response to trastuzumab.

Human epidermal growth factor receptor 2 positive (HER2+) breast cancer (BC) is an aggressive BC subtype characterized by HER2 overexpression/amplification. Genomic alterations of HER2 and others have been reported to be associated with, HER2 overexpression and prediction of trastuzumab-response. Here, we aimed at identifying germline and somatic alterations associated with HER2+ BC and evaluating their association with clinical outcome in response to trastuzumab therapy given to HER2+ BC patients. Global Sequencing Array (GSA) and polymerase chain reaction-restriction length polymorphism (PCR-RFLP) techniques were used to determine alterations in HER2 and other HER2-interacting as well as signaling-related genes in HER2+ BC. In addition, 20 formalin fixed paraffin-embedded tissue samples were also evaluated by GSA for identifying significant variations associated with HER + BC as well as response to trastuzumab therapy. A germline variant in HER2 (I655V) was found to be significantly associated with the risk of the disease (p < 0.01). A nonsense mutation in PTPN11 (K99X), a pathogenic CCND1 splice site variant (P241P), a hotspot missense mutation in PIK3CA (E542K) and a hotspot missense mutation in TP53 (R249S); were observed in 25%, 75%, 30% and 40% of the HER2+ BC tissue samples, respectively. Mutant CCND1 (P241P) and PIK3CA (E542K) were found to be significantly associated with reduced disease-free survival (DFS) in patients treated with trastuzumab (p: 0.018 and 0.005, respectively). These results indicate that HER2, PTPN11, CCND1 and PIK3CA genes are important biomarkers in HER2+ BC. Moreover, the patients harboring mutant CCND1 and PIK3CA exhibit a poorer clinical outcome as compared to those carrying wild-type CCND1 and PIK3CA.

Assessment of Adequacy of Pain Management and Analgesic Use in Patients With Advanced Cancer Using the Brief Pain Inventory and Pain Management Index Calculation.

PURPOSE: The objective of this cross-sectional, noninterventional, 6-month observational study was to assess the adequacy of pain management in patients with cancer admitted to the Oncology Department of Guru Gobind Singh Medical College in Faridkot, India. METHODS AND MATERIALS: A total of 348 patients with cancer were recruited for evaluation of the prevalence of inadequate cancer pain management using the Brief Pain Inventory Pain Management Index. RESULTS: The current study included 127 males (36.5%) and 221 females (63.5%). The most prevalent cancer type was genitourinary; 268 patients (77%) had inadequately managed pain. A significant correlation was observed between poorly managed pain and age groups, analgesic used, and body mass index. CONCLUSION: Our observation of inadequate pain management among 77% of patients indicates that pain management was insufficient in three quarters of the patients in this study. Accumulating data regarding the inadequacy of cancer pain management is crucial to improve symptom management. Better management of pain not only alleviates pain symptoms but also increases the quality of life for patients with cancer.

Assessment of Cancer-related Fatigue among Cancer Patients Receiving Various Therapies: A Cross-sectional Observational Study.

OBJECTIVE: The objective of this cross-sectional, noninterventional 3-month observational study was to analyze the prevalence of the cancer-related fatigue (CRF) in cancer patient populations with correlation of CRF with different treatment modalities. MATERIALS AND METHODS: A descriptive study was carried out jointly by the pharmacology and oncology departments of a tertiary care center in the Malwa region of Punjab. The data collection was performed by administering the validated Brief Fatigue Inventory (BFI) after obtaining the informed consent. RESULTS: One hundred and twenty-six cancer patients were recruited with the mean age of 49.13 years ± 14.35 (standard deviation). There are statistical correlations found between fatigue and chemotherapy agents such as vinblastine, dacarbazine, and cyclophosphamide. CONCLUSION: We observed that CRF is a symptom that is experienced by majority of cancer patients, irrespective of the diagnosis, or type of treatment received. In addition, assessing CRF before and after treatment will facilitate health-care practitioner to treat this symptom.

Changing Trends of Skin Cancer: A Tertiary Care Hospital Study in Malwa Region of Punjab.

INTRODUCTION: Skin cancer constitutes a small but significant proportion of patients with cancer. Although the presence of eumelanin in dark skin is protective against the development of skin cancer, it is increasingly being diagnosed in the Indian population. AIM: To study the profile of skin cancer patients presenting to a tertiary hospital in Malwa area of Punjab, India. MATERIALS AND METHODS: Retrospective study was done to analyse the profile of skin cancer patients who attended the institution over one year from 1(st) December 2013 to 30(th) November 2014. A comprehensive review of aetiology and related risk factors was done to correlate the environmental factors with high skin cancer prevalence in this region. RESULTS: Skin cancer constituted (3.18%) 84 out of 2638 patients registered with cancer of all types. The age of the patients was 62±14.2 years and ranged from 27 to 92 yrs. Basal cell carcinoma (BCC) was the most common histological type(46/84, 54.76%) followed by squamous cell carcinoma (SCC) (31/84, 36.91%) and malignant melanoma (MM) (7/84, 8.33%). Male: female ratio was found to be 0.79:1. BCC showed higher female preponderance (p<0.05). Head and Neck was the commonest site involved (p<0.05). Majority (88%) of patients were from rural area. 92% of patients were directly into the profession of agriculture with history of prolonged exposure to sunlight. CONCLUSION: Skin cancer constitutes a small but significant proportion of patients with cancers. This study highlights a paradoxically increasing trend of BCC and female preponderance. Head and neck is the most common site involved. Exposure to Ultra Violet B (UVB) radiation and higher levels of arsenic in drinking water has been reported to be associated with skin cancers. Limited studies show that levels of arsenic and pesticides were higher in the samples of drinking water in Malwa area of Punjab. Therefore a multipronged strategy to provide safe drinking water supply and discouraging the indiscriminate use of pesticides is recommended.

Tolerance of skin grafts to postoperative radiotherapy.

AIM: The aim was to evaluate the integrity and functional outcomes of skin grafts following external beam radiotherapy (EBRT). MATERIALS AND METHODS: A prospective study of 15 patients, in whom EBRT was planned after their wound coverage with split-thickness skin graft (STSG). Parameters evaluated include defect size, time to postoperative radiotherapy, total radiotherapy dose, delays and interruptions in radiotherapy, wound complications, and the need for further surgical interventions. RESULTS: In all the 15 (6 men, 9 women) patients of STSG, radical doses of EBRT, that is, 50-70 Gy in 25-35 fractions are delivered over around 6 weeks. All STSGs were placed on healthy vascular tissue beds. Median time to initial radiotherapy after grafting was 3 weeks (range 3-6 weeks). There were no interruptions in radiotherapy treatment. In one patient, there was partial skin graft loss after radiotherapy that was adequately managed with conservative treatment. No patient requires further surgical intervention. CONCLUSION: Adjuvant postoperative radiotherapy can be delivered to STSGs without significant complications. Postoperative radiotherapy can be started as early as 3-4 weeks after skin grafting. Skin grafts should be placed on well-vascularized healthy tissues. Minor skin graft loss resulting from postoperative radiotherapy can usually be treated conservatively.

Imatinib mesylate induced erythroderma: A rare case series.

Imatinib is a tyrosine kinase inhibitor approved as a first line treatment for chronic myeloid leukemia and gastrointestinal stromal tumors. Usually the drug is well-tolerated with hematological adverse effects being most commonly seen. Dermatological side effects are seen in 9.5-69% of patients on imatinib; majority of which are minor and self-limiting. We, hereby, report a case series of erythroderma occurring secondary to imatinib in two patients with chronic myeloid leukemia. Both the patients improved upon the discontinuation of the drug. The literature review revealed only six probable cases of erythroderma due to imatinib. So, this case series is being reported for the rarity of this adverse effect of imatinib.

Quality of life in cancer patients undergoing chemotherapy in a tertiary care center in malwa region of punjab.

OBJECTIVE: The objective of this prospective, non-interventional, 4-month observational study was to analyze and compare patient-reported quality of life (QOL) and their physical/psychosocial symptom burden during their respective chemotherapy sessions. MATERIALS AND METHODS: A prospective and descriptive study was carried out jointly by Pharmacology and Oncology Departments of a tertiary care center in Malwa region of Punjab. The data collection was performed by administering validated questionnaire/response after taking informed consent. RESULTS: A total of 131 cancer patients were recruited with the mean age of 49.05 ± 14.35 (SD (standard deviation)) years. As per the QOL scoring of Global Health Status (GHS) and four items of symptom scale, that is, insomnia, pain, appetite loss, and constipation, and financial difficulties attained a significance difference. GHS significantly improved in group three as compared to group one, indicating that the patient's overall health/QOL improved as the chemotherapy session progressed. CONCLUSION: Although QOL scoring system did not show significant improvement in all areas (except insomnia, pain, appetite loss, constipation, and financial difficulties) with reference to their respective chemotherapy cycles, but a judicious diagnosis with an appropriate treatment including chemotherapy may lessen the negative perception of cancer as a deadly and fatal disease in our rural population.