A Comparison of the Toxicities in Patients With Locally Advanced Head and Neck Cancers Treated With Concomitant Boost Radiotherapy Versus Conventional Chemoradiation.

PURPOSE: To compare the objective and patient-reported toxicities of concomitant boost radiotherapy (CBRT) and concurrent chemoradiation (CRT) in patients with locally advanced head and neck cancers. METHODS AND MATERIAL: In this prospective study, 46 patients with histologically proven stage III-IVA head and neck cancer were randomly assigned to receive either concurrent chemoradiation to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (40 mg/m2 IV weekly; control arm) or accelerated radiotherapy with concomitant boost radiotherapy (study arm) to a dose of 67.5 Gy in 40 fractions in five weeks. Acute toxicity was evaluated using RTOG toxicity criteria. The assessment was done weekly after initiation of treatment, at the first follow-up (six weeks), and at three months. The four main patient-reported symptoms of pain, hoarseness of voice, dryness of mouth, and loss of taste were also compared between the two groups to assess patient quality of life during treatment. RESULTS: The mean treatment duration was 37 days in the CBRT arm and 49 days in the CRT arm. Treatment-related interruptions were less in the study group,17.3% in the study, and 27.2% in the control with insignificant P-value. Grade III laryngeal toxicity was significantly higher in the study group (P=0.029). Other acute grade I-III toxicities (pharyngeal, skin, mucositis, and salivary) were comparable in both CRT and CBRT arms. Grade IV toxicities were seen only in the CBRT arm but were resolved at the first follow-up. Haematological toxicities and renal toxicities were significantly higher in the CRT arm, with significant P-values of 0.0004 and 0.018, respectively. CONCLUSION: In patients with locally advanced head and neck cancer, concomitant boost radiotherapy is well tolerated with acceptable local toxicity and minimal systemic toxicity as compared to conventional chemoradiation. It is a feasible option for patients with locally advanced head and neck cancer not fit for concurrent chemoradiation.

A prospective randomized trial comparing accelerated concurrent chemoradiotherapy with conventional concurrent chemoradiotherapy in locally advanced carcinoma cervix (IIA-IVA).

INTRODUCTION: Cervical cancer ranks fourth in women worldwide. The management requires a multidisciplinary approach. Concomitant chemoradiotherapy with cisplatin, followed by brachytherapy, is the standard approach. Accelerated radiotherapy (ART) can be used to decrease the treatment duration which can further lead to better outcomes. MATERIALS AND METHODS: Stages II, III, and IVA of carcinoma cervix were studied for 1 year. Ninety patients were randomized in control and study arms, 45 patients in each arm. The total dose of radiation was 50 Gy/25#/5 weeks from Monday to Friday in the control arm and 50 Gy/25#/4 weeks from Monday to Saturday in the study arm, with injection cisplatin 40 mg/m 2 intravenous infusion weekly in both the arms. RESULTS: The response was similar in both the arms at the first follow-up as well as at median follow-up. However, acute toxicities in the ART arm were more, but they were managed conservatively. CONCLUSION: ART can be used in patients of cervical cancers to decrease the total treatment time. The results were similar in both the groups but need to be studied over more number of patients.

A Prospective Observational Study Comparing Long-Course Conventional Neoadjuvant Chemoradiotherapy with Short-Course Radiotherapy Followed by Consolidation Chemotherapy with Delayed Surgery in Locally Advanced Rectal Cancer.

Background Polish and Australian randomized studies compared short-course radiotherapy (RT) with immediate surgery and long-course chemoradiotherapy (CRT) with delayed surgery. In these studies, similar long-term survival and local control have been reported for both these approaches, but pathological complete response (pCR) is not better with short-course RT. Moreover, studies have shown better tumor downstaging with delayed surgery. In this context, the use of short-course RT with delayed surgery may have some advantages and needs to be tested in clinical trials. Patients and Methods This was a two-arm, prospective, observational study, in which preoperative short-course RT followed by two cycles of chemotherapy was compared with the conventional neoadjuvant CRT in locally advanced rectal cancer. The primary end points were the rate of complete response and toxicity profile. The secondary end points were the rate of R0 resection, overall survival, and progression-free survival. The data obtained from the two arms were analyzed using Pearson's chi-square test to determine the statistical significance between the two treatment arms. Results The pCR rate was 6.7% in the study arm and 0 in the control arm ( p = 0.343). The RO resection rates were 92.8 and 92.3% in the study and control arms, respectively. The rates of grade 3and 4 acute toxicity in the study and control arms were 14.2 and 61.5%, respectively ( p = 0.011). The rates of grade 3 and 4 late toxicity in the study and control arms were 21.4 and 15.3%, respectively ( p = 0.686). Conclusions The pCR rates and the late toxicities in both arms are comparable. The major advantages of the 5 × 5 Gy regimen with chemotherapy in a neoadjuvant setting are a significant reduction in acute toxicities and better patient compliance along with similar efficacy as that of the standard regimen.

Comparison of iso-effective and cost-effective high-dose-rate brachytherapy treatment schedules in cervical cancer - regional cancer center experience.

PURPOSE: The study is to evaluate the difference between outcomes of two high-dose-rate fractionation schedules in the treatment of intracavitary brachytherapy (ICBT) of cervical cancer. MATERIAL AND METHODS: A retrospective analysis of 163 cervical cancer patients was completed. All patients received external beam radiotherapy (EBRT) to whole pelvis with concurrent weekly chemotherapy, followed by ICBT with either 7 Gy per fraction in three fractions (arm A) or 9 Gy per fraction in two fractions (arm B). Median follow-up was 19 months. The outcomes were compared in terms of 2-year actuarial local control, disease-free survival, overall survival, and late toxicity in the two treatment arms. RESULTS: The 2-year actuarial local control rates in arm A and arm B were 88.5% and 91.5%, respectively. The actuarial 2-year disease-free survival rates in arm A and arm B were 85.9% and 82.6%, respectively. The actuarial 2-year overall survival in arm A and arm B were 95.7% and 100%, respectively (p = 0.06). There were 12.7% and 15.2% local failures in arm A and arm B, respectively. Distant metastases were seen in 8.5% and 7.6% in arm A and arm B, respectively. The 2-year actuarial risk of developing late rectal toxicity in arm A and arm B were 5.6% and 5.4%, respectively. The 2-year actuarial risk of developing late bladder toxicity in arm A and arm B were 2.8% and 2.2%, respectively. CONCLUSIONS: ICBT treatment with 9 Gy in two fractions offers equivocal local control rates and survival rates in cancer cervix cases with many advantages of short overall treatment time, improved patient compliance, cost effectiveness, and reduced exposure to aesthetic agents. The toxicities observed were few, low grade, and easily manageable.

Knowledge of breast cancer risk factors and methods for its early detection among the primary health-care workers in Shimla, Himachal Pradesh.

BACKGROUND: Breast cancer is an increasing health problem in India. Screening for early detection should lead to a reduction in mortality from the disease. Majority of the population, especially in rural areas, contact health-care system through primary health-care workers. AIM: To know the knowledge of breast cancer risk factors and methods for its early detection among the primary health-care workers in Shimla district, Himachal Pradesh. MATERIALS AND METHODS: A descriptive cross-sectional study questionnaire study was conducted among primary health-care workers (both males and females) in Shimla district, Himachal Pradesh. The data were analyzed using SPSS software version 16. The statistical tests used were t-test, ANOVA, and Fisher's exact test. P = 0.05 was considered statistically significant. RESULTS: Out of a total of 120 patients, there were 46 males (38.3%) and 74 females (61.7%). The mean age of the population was 48.5 ± 5.3 years, with a range of 25 and 57 years. The mean knowledge score percent of the present population was 71.04 ± 18.3. The mean knowledge score was higher among males (73.9 ± 19.8) as compared to females (69.2 ± 17.2). Approximately 43.3% of the participants had very good knowledge about risk factors followed by 31.7% having excellent knowledge, 20% having good knowledge, and 5% having poor knowledge. CONCLUSION: The overall mean knowledge percent about breast cancers among primary health-care workers in this study was very good, slightly higher among males and postgraduates, but to make it universal, reinforcement of educational programs can be planned for them.

Oral health knowledge and practices among primary healthcare workers in Shimla District, Himachal Pradesh, India.

CONTEXT: Primary healthcare workers being grassroot workers in rural areas can be effective in oral health promotion in these areas. AIM: To assess oral health knowledge and practices among primary healthcare workers in Shimla district in Himachal Pradesh. SETTING AND DESIGN: A cross-sectional study. SUBJECTS AND METHODS: A cross-sectional study was conducted to assess oral health knowledge and practices of primary healthcare workers in Shimla using a self-administered questionnaire. STATISTICAL ANALYSIS USED: Data were analyzed using SPSS package version 16. The tests used were t-test and Fisher's exact test. A P value < 0.05 was considered statistically significant. RESULTS: Of 130 subjects, there were 60 (46.2%) males and 70 (53.8%) females. The mean age of the population was 48.4 ± 5.9 with a range of 25-57. The mean knowledge score percent of the population was 51.9 ± 18.2. It was higher for males (52.3 ± 15.0) when compared with females (51.5 ± 20.7). The mean knowledge score percent was positively associated with education and negatively associated with age. Tooth brush was used by 97.7% and tooth paste by 121 (93.1%). The frequency of brushing twice was reported by 79 (60.8%). CONCLUSION: Though the overall knowledge about oral health is good among primary healthcare workers, the understanding about various aspects is lacking. Therefore, it is recommended that health workers should be given education to enhance knowledge and practices toward oral healthcare and to increase their screening capacity for common dental problem which will serve the community in long way.

DCE-MRI and parametric imaging in monitoring response to neoadjuvant chemotherapy in breast carcinoma: a preliminary report.

PURPOSE: Neoadjuvant chemotherapy is recommended in patients with locally advanced breast cancer. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) enables evaluation of the tumour neovasculature that occurs prior to any volume change, which helps identify early treatment failures and allows prompt implementation of second-line therapy. MATERIAL AND METHODS: We conducted a prospective study in 14 patients with histopathologically proven breast cancer. DCE-MRI data were acquired using multisection, T1-weighted, 3D vibe sequences with fat suppression before, during, and after IV bolus injection (0.1 mmol/kg body weight, Gadoversetamide, Optimark). Post-processing of dynamic contrast perfusion data was done with the vendor's Tissue 4D software to generate various dynamic contrast parameters, i.e. Ktrans, Kep, Ve, initial area under the time signal curve (IAUC), apparent diffusion coefficient (ADC), and enhancement curve. Patients underwent MRI examinations at baseline, and then after two cycles, and finally at completion of chemotherapy. RESULTS: Based on Sataloff criteria for pathological responses, four patients out of 14 were responders, and 10 were non-responders. At the 2nd MRI examination, IAUC was significantly smaller in responders than in non-responders (p = 0.023). When the results of the first and second MRI examinations were compared, Kep decreased from baseline to the second MRI (p = 0.03) in non-responders and in responders (p = 0.04). This change was statistically significant in both groups. The ADC values increased significantly in responders from baseline to the third MRI (p = 0.012). CONCLUSIONS: In our study, IAUC and ADC were the only parameters that reliably differentiated responders from non-responders after two and three cycles of chemotherapy.

Breast cancer risk factor evaluation in a Western Himalayan state: A case-control study and comparison with the Western World.

CONTEXT: Breast cancer incidence is increasing rapidly in India. The lifestyle, built, genetic makeup, reproductive and breastfeeding patterns are quite different in Indian females when compared to the Western population. Generalizing the Western data to the population residing in the Himalayan region would breed inaccuracies. AIM: The aim of our study was to identify risk factors in our own population in a Western Himalayan state of Himachal Pradesh, India. SUBJECTS AND METHODS: A case-control study with 377 cases of invasive breast cancer and 346 hospital-based controls was conducted for 1 year. The data were collected by interviewing the individuals during their visit to hospital using a questionnaire. The data were analyzed using standard statistical techniques using SPSS version 17 software. RESULTS: Factors found to have strong association with invasive breast cancer on multivariate analysis are late age at first childbirth >30 years, which is the strongest risk factor associated, late age of menopause > 50 years, high socioeconomic class, and age of female above 50 years. CONCLUSION: In our females, age >50 years, late age of menopause (>50 years), late age at first childbirth (>30 years), and high socioeconomic status were found to be major risk factors associated with breast cancer. Several factors implicated in the Western data were not found to be significant in our study. We need to identify such aspects in reproductive and breastfeeding patterns of women and spread awareness regarding the same.

Green Tobacco Sickness: A Brief Review.

Green tobacco sickness (GTS) is the condition that mainly affects the tobacco harvesters. The condition is prevalent in Asian and South American tobacco harvesters. The present review was conducted to discuss the etiology, epidemiology, symptoms, and prevention of GTS. It is caused by the absorption of nicotine through the skin while the workers are engaged in handling the uncured tobacco leaves. The symptoms include nausea, vomiting, pallor, dizziness, headaches, increased perspiration, chills, abdominal pain, diarrhea, increased salivation, prostration, weakness, breathlessness, and occasional lowering of blood pressure. The prevalence of GTS varies from 8.2 to 47% globally. The use of personal protective equipment like water-resistant clothing, chemical-resistant gloves, plastic aprons, and rain-suits with boots should be used by the tobacco farmers to prevent its occurrence. An international-level awareness campaign has to be taken up and more stringent workers safety regulations have to be formulated.

Association between oral health status and oral health-related quality of life among the prison inmate population of kanda model jail, Shimla, Himachal Pradesh, India.

The prison population is a challenging one with many health problems including oral health. In a country such as India, the information regarding the oral health status in prisoners is scant. So, a cross-sectional study was carried out among a 311 prison inmate population of Kanda model jail, Shimla, Himachal Pradesh, India, to assess the dental caries levels, periodontal health status, and oral health-related quality of life (OHRQoL). Dental caries was present among 71.8% of the population and the mean decayed missing and filled teeth index (DMFT) of the population was 5.1 ± 2.1. Calculus was seen among 54.9% of the population. The mean severity score, summed for the 14 items in the scale was 14.57. Dental caries, periodontal disease, the number of missing teeth were significantly associated with OHRQoL. The population had a higher level of oral diseases and one half of the population reported that their oral condition had negatively impacted them in some way, thereby affecting their quality of life.

Oral Cancer Knowledge, Attitudes and Practices: A Survey of Undergraduate Medical Students in Himachal Pradesh, India.

BACKGROUND: Oral cancer is the sixth most common cancer among Indian males and the third most common cancer among Indian females. Early detection of oral cancers makes them more amenable to treatment and allows the greatest chance of cure. Lack of awareness among the health care providers is the most significant factor in delaying diagnosis and treatment of oral cancer. So the aim of the study was to assess the knowledge, attitude and practices of oral cancer among undergraduate medical students in Indira Gandhi Medical College, Shimla, India. MATERIALS AND METHODS: A cross-sectional questionnaire study was conducted among 186 undergraduate medical students between the third to fifth years in Indira Gandhi Medical College, Shimla. The questionnaire consisted of 15 questions, five each on knowledge, attitudes and practices. The data were analysed by Statistical Package for the Social Sciences version 16. Test used were t-test, Chi-square and ANOVA. RESULTS: The response rate of the study was 96.5%. The mean knowledge percent of the sample was good. Mean knowledge percent was higher in females than males. Higher percentage of students in 5(th) year (internship) had excellent knowledge. The knowledge and practices about risk factors was not satisfactory. One hundred and twenty four (66.6%) of the subjects disagreed/strongly disagreed that their knowledge regarding the prevention and detection of oral cancer is current adequate. One hundred and seventy six and (94.6%) agreed/strongly agreed that there is need for additional training/information regarding oral cancer. CONCLUSION: It can be concluded that though the mean knowledge of the population was good but the knowledge and practices about risk factors had to be reinforced among these students so that they can help the patients in tobacco and alcohol cessation and contribute in prevention of oral cancers.

Knowledge, attitude and practices about oral cancers among dental students in H.P Government Dental College, Shimla-Himachal Pradesh.

AIM: The aim was to assess the knowledge, attitude and practices among undergraduate dental students about oral cancer. MATERIALS AND METHODS: A cross-sectional questionnaire study was conducted among undergraduate dental students between the 3rd and 5th years in H.P Government Dental College, Shimla. The questionnaire consisted of 15 questions, five each on knowledge, attitudes and practices. The data were analyzed by Statistical Package for the Social Sciences (SPSS Inc., version 16 for Windows, Chicago, IL, USA). RESULTS: The response rate of the study was 90.6%. There were 23 (21.5%) males and 84 (78.5%) females in the study. There was a predominance of females (78.5%). The average knowledge percentage for the entire population is 81.9% (excellent knowledge). Tobacco and alcohol were correctly identified by 63.5% of the subjects. Squamous cell carcinoma was described as the most common type of oral cancer by 105 (98.3%) of the students. 60.7% of the subjects strongly disagreed that their knowledge regarding the prevention and detection of oral cancer is current and adequate, and 99% agreed that there is a need for additional training/information regarding oral cancer. About 92.5% of the subjects used to educate their subjects about the harmful effects of tobacco and alcohol. CONCLUSION: The study implies that the knowledge, especially about the etiological factors of oral cancer needs to be reinforced throughout the undergraduate dental courses so that they can use the same in educating and motivating the masses to adapt healthy lifestyles.

Relationship between oral health status and oral health related quality of life in adults attending H.P Government Dental College, Shimla, Himachal Pradesh--India.

OBJECTIVES: To describe Oral Health Related Quality of Life (OHRQoL) in adults attending the Outpatient Department (OPD) of Public health Dentistry, H.P Government Dental College, Shimla, and to assess the relationship between clinical measures of oral health status and oral health related quality of life. METHODS: A cross sectional study was carried out for a period of three months on 351 subjects reporting to the OPD of Public health Dentistry, H.P Government Dental College, Shimla. Subjects were examined systemically for dental caries, periodontal disease using DMFT index and CPI index. OHRQoL was measured using the 14 - item Oral Health Impact Profile questionnaire (OHIP-14). Also the data on education, socio economic status and reasons for seeking dental care was collected. RESULTS: There were 158 males and 193 females participating in the study. The mean age of study population was 35.7 ± 9.33. The mean total OHP-14 score was 9.5 ± 9.4; 35.6% of the subjects reported one or more OHIP problems 'fairly often or very often'. When the prevalence of impacts fairly /very often was modeled using logistic regression, presence of decayed teeth, presence of periodontal disease (CPI score >2) and number of missing teeth remained significantly associated with OHRQoL after adjusting for gender and episodic dental care. CONCLUSION: OHIP-14 scores were significantly associated with the clinical oral health status indicators, independently of gender and socio economic inequalities in oral health.

Knowledge and attitudes about HIV/AIDS of students in H.P. Government Dental College and Hospital, Shimla, India.

The purpose of this cross-sectional survey was to assess the knowledge and attitudes towards patients with HIV/AIDS among dental students in H.P. Government Dental College, Shimla, India. In November 2011, a survey was conducted of all the dental students of the college using a forty-five-item, self-administered questionnaire. The total mean knowledge score was 68.3 percent (good knowledge). The mean knowledge score was statistically higher in the clinical group than in the preclinical group. A majority of the students were aware of the association between HIV and oral candidiasis (89.1 percent), major aphthous (83.2 percent), and Kaposi's sarcoma (68.9 percent). Only 4.9 percent had professional attitudes about treating patients with HIV/AIDS. Male students had significantly fewer negative attitudes and higher positive attitudes than female students. The overall attitude score was significantly higher in the clinical group than in the preclinical group. Although a majority of the students had good knowledge, there were some inadequacies in their knowledge; those were more frequently seen in the preclinical students. It is important that dental students, as future dentists, develop not only the necessary practical skills but also knowledge and attitudes that will prepare them to treat patients with HIV/AIDS.

Knowledge of, attitude towards, and prevalence of tobacco use among dental students in Himachal Pradesh State, India.

AIM: The aim of the study was to assess the prevalence of tobacco use and knowledge of and attitude towards cessation counselling among dental students in Himachal Pradesh State, India. METHOD: The present study was conducted with the 219 third-year Bachelor of Dental Surgery (BDS) students in the five dental colleges of Himachal Pradesh during the month of March 2012. The Global Health Professional Students Survey (GHPSS) questionnaire, developed by the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC) and the Canadian Public Health Association, was used in this study. The data were evaluated using statistical software and statistically tested with the chi-square test. RESULTS: The response was 210 (96%). Lifetime prevalence was 15% for smoking and 2% for tobacco use other than for smoking. Eighteen (9%) students were current smokers and four (2%) were tobacco users other than for smoking. Male students were significantly (P<0.001) more likely than female students to be current cigarette smokers. Approximately 14 (47%) of sometime smokers had smoked on school property and two (50%) of the sometime users of other tobacco products had used those products on school property. As for attitudes, 169 (85%) felt that health professionals serve as role models for their patients and the public. Only 17 (8.5%) of surveyed students had received formal instruction in smoking-cessation approaches during their training and 167 (84.3%) thought that health professionals should receive specific training on cessation techniques. CONCLUSION: Although the current prevalence of tobacco use among third-year dental students in Himachal Pradesh is low, it still needs to be addressed by providing them with the necessary skills and support to quit smoking successfully and to provide counselling.

Knowledge of risk factors and early detection methods and practices towards breast cancer among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India.

BACKGROUND: Breast cancer is an increasing health problem in India. Screening for early detection should lead to a reduction in mortality from the disease. It is known that motivation by nurses influences uptake of screening methods by women. This study aimed to investigate knowledge of breast cancer risk factors and early detection methods and the practice of screening among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh. MATERIALS AND METHODS: A cross-sectional study was conducted using a self-administered questionnaire to assess the knowledge of breast cancer risk factors, early detection methods and practice of screening methods among 457 nurses working in an Indira Gandhi Medical College, Shimla-H.P. Chi square test, Data was analysed using SPSS version 16. Test of significance used was chi square test. RESULTS: The response rate of the study was 94.9%. The average knowledge of risk factors about breast cancer of the entire population is 49%. 10.5% of nurses had poor knowledge, 25.2% of the nurses had good knowledge, 45% had very good knowledge and 16.3% of the nurses had excellent knowledge about risk factors of breast cancer and early detection methods. The knowledge level was significantly higher among BSC nurses than nurses with Diploma. 54% of participants in this study reportedly practice BSE at least once every year. Less than one-third reported that they had CBE within the past one year. 7% ever had mammogram before this study. CONCLUSIONS: Results from this study suggest the frequent continuing medical education programmes on breast cancer at institutional level is desirable.