Perceptions of oncology as a career choice among the early career doctors in Pakistan.

BACKGROUND: Lack of oncologists is a growing global concern. With the rise in cancer burden across the world, the supply-demand mismatch of the oncology workforce is projected to increase. Furthermore, oncology is a low-ranked field of choice among medical students, and without understanding the perceptions and concerns of early-career doctors regarding oncology, any investments made in cancer care will be futile. This study aims to determine the opinions of young doctors and the factors most affecting their preferences in order to devise focused strategies to attract more doctors into oncology. METHODS: A cross-sectional study was conducted on 300 early-career doctors across various public and private hospitals in Pakistan, from March to November 2019. A close-ended, self-administered questionnaire was used to assess their opinions in terms of the workplace environment, scope, and the emotional and financial aspects of oncology. Data was analyzed using SPSS version 23 and the influence (positive or negative) of the perceptions on the choice of oncology as a career was determined by binary logistic regression analysis. RESULTS: Almost three-quarters of the participants did not want a career in oncology. The top positive perceptions about oncology in descending order were: progressive field, gender-neutral, stable working hours, financially healthy, and work-family balance. Top negative perceptions were: lack of oncologic facilities in hospitals, radiation exposure, need for private practice, poor patient prognosis, high patient load, and depressing environment. Participants who attended private medical school (p < 0.10), planned to live abroad (p < 0.10), had an oncologist (p < 0.05), cancer survivor or death due to cancer in the family (p < 0.05), were more likely to adopt oncology as a career. Those who believed that poor patient prognosis can have an impact on career choice were less likely to prefer oncology (p < 0.05). CONCLUSION: Despite the rising cancer burden, early career doctors are reluctant to join oncology. Curricular, infrastructural and policy changes are needed at the level of medical school, oncology training and practice to recruit more young doctors and minimize the existing paucity of the oncologic workforce.

A review of access to cancer facilities in Punjab, Pakistan.

BACKGROUND: Punjab is the most populous province of Pakistan, with only 12 countries in the world succeeding it in terms of population. AIMS: This review article has the objective of providing novel statistics regarding available cancer therapeutics in Punjab across four different sectors-including government, semi-private, trust and private sectors. METHODS AND RESULTS: Keywords such as "cancer treatment," "facilities," "Pakistan," were used to search Pubmed Database. 36 results were generated: after sifting based on a personal reference list as well as for relevance, 16 articles were finally reviewed. Novel statistics regarding current state of access to cancer facilities were drawn from personal references as well as from studies conducted in other LMICs. There is a gross deficit of oncological services in Punjab, with the ratio of medical oncologists to population being 0.027 per 100, 000, and every oncologist checking 1300-1500 patients annually. Only 21.4% of the population has access to radiotherapy facilities. Major problems include lack of healthcare professional awareness; poor infrastructure including drug access, radiotherapy, and cancer pain management facilities; lack of planning; and lack of educational and research programs. CONCLUSIONS: Improving education & training, developing infrastructure based on public-private-partnership models, building cancer registries and organizing national cancer screening programs, as well as encouraging basic health education and research in oncology, are measures that can ensure Punjab's healthcare delivery system becomes capable of handling increasing incident burden of cancer.

Radiotherapy alone with concurrent chemoradiotherapy plus temozolamide in locally advanced soft tissue sarcoma at Mayo Hospital Lahore: A randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of combining an oral chemotherapeutic agent temozolamide with radiotherapy in the management of the un-resectable non-metastatic soft tissue sarcomas compared with radiotherapy alone. METHODS: The randomised controlled phase 3, double-arm study was conducted at King Edward Medical University/Mayo Hospital, Lahore, Pakistan, from December 2012 to July 2017. Patients with all sub-types of locally advanced un-resectable soft tissue sarcomas were randomised into two groups. Group-A received radiotherapy alone while Group-B received concomitant chemoradiotherapy with temozolamide after receiving two cycles of standard chemotherapy. Response was evaluated according to response evaluation criteria in solid tumours through computed tomography scan or magnetic resonance imaging after 6 weeks following completion of radiotherapy. SPSS 21 was used for data analysis. RESULTS: Of the 64 patients, 32(50%) were assigned to each group. The mean age of Group-A was 36.25±20.31 and of Group-B 37.84±15.79 years .There were 18(56.3%) males in Group-A and 20(62.5%) in Group-B. Improvement in trends of overall response rate was observed in Group-B 24(75%) compared to 18(56.3%) in Group-A (p=0.12).. CONCLUSIONS: Though not statistically significant, there was improvement in response rate with the addition of temozolamide to standard radiation therapy.

Tissue Nuclear Matrix Protein Expression 22 in Various Grades and Stages of Bladder Cancer.

OBJECTIVE: To study the tissue nuclear matrix protein 22 (NMP22) expression in bladder carcinoma biopsy and correlate it with prognostic factors like stage and grade of bladder cancer. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Pathology and Urology Departments, King Edward Medical University/Mayo Hospital, Lahore, Pakistan from January to October 2019. METHODOLOGY: Data of all bladder cancer patients' biopsy blocks, presenting to histopathology section, was collected. NMP22 protein expression levels were analysed by immunohistochemical staining using a quantitative scoring method defined by staining intensity (I), and percentage of positive-stained cells (P). Data was analysed by SPSS version 22. Chi-square test and crosstabs were used to correlate grade and stage of urothelial tumors with gender and NMP22 expression. p ≤0.05 was taken as significant. RESULTS: A total of 95 paraffin blocks of bladder carcinoma biopsies with data were retrieved for the study. NMP22 was expressed immunohistochemically in 87/95(91.6%) of cases and was negative in 8/95(8.4%) of cancers. Correlation of intensity of NMP22 staining with histologic grade showed that 58.3% of high grade BC expressed NMP22 strongly, 23.6% moderately and 11.1% weakly. In low grade tumors, no biopsy (0/23) expressed strong expression. Moderate intensity in 8.69% and weak in 78.26% of tumors (p<0.001). Intensity of staining with stage of tumor association revealed that 40.8% of stage I tumor showed strong staining, 16.9% moderate, and 32.3% weak staining pattern. In stage II tumors 54.1% showed strong, 29.1% moderate, and 12.5% weak NMP 22 expression. (p=0.148).  Conclusion: NMP 22 is highly expressed in urinary bladder carcinoma and in male patients. It has strong association with grade and weak association with stage of tumor. Immunohistochemical expression of this protein can help in better detection and prognostic prediction of bladder carcinoma. Key Words: Bladder carcinoma, Grade, Immunohistochemistry, NMP22, Stage.

Association of p53 Overexpression with Hormone Receptor Status and Triple Negative Breast Carcinoma.

OBJECTIVE: To determine association of p53 overexpression with hormone receptor status in breast carcinoma. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Department of Pathology in collaboration with Department of Oncology, King Edward Medical University, Lahore, from January 2017 to January 2018. METHODOLOGY: All adult female patients coming to Department of Oncology with reports of breast cancer biopsy and receptor status were included. Their age, type of surgery, grade of cancer, stage of cancer, and hormone receptor status were noted from records. P53 immunomarker was applied on tumor containing tissue blocks. Pearson Chi-square test was run for strength of association between the variables using SPSS V. 22. RESULTS: Mean age of 91 patients at diagnosis was 48 years ±12.49. Fifty-five (60.4%) patients had ER positive tumors, 36 (39.6%) were ER negative, 53 (58.2%) had PR positive status, and 38 (41.8%) were negative. Same number was seen in HER2 neu staining. Out of 91 cases, 31 (34.1%) were p53 positive and 60 (65.9%) were negative. Out of 55 (60.4%) ER positive cases, 11 (12.1%) were positive for p53 and 44 (48.4%) were p53 negative (p<0.001). PR positive cases (53/58.2%) showed p53 positivity in 7 (7.7%) and negativity in 46 (50.5%) cases (p< 0.001). HER2 positive cases were positive for p53 stain in 8 (8.8%) and negative in 45 (49.5%) cases (p<0.001). Fifteen (16.48%) biopsies were negative for all three hormone receptors. P53 was positive in all of these hormone receptor negative tumors (15/15, 100%), although 9 (60%) showed strong positivity and 6 (40%) exhibited weak staining intensity of p53. CONCLUSION: P53 overexpression is less frequent in hormone receptor positive breast cancers. However, hormone receptor negative (triple negative) tumors overwhelmingly overexpress p53 protein in tumor cells. P53, detected either immunohistochemically or serologically, can serve to predict poor prognosis and survival in breast cancer patients, unless newer anti-p53 treatments are introduced in Pakistan.

Adequacy of Pain Control in Patients With Advanced Cancer in Pakistan.

PURPOSE:: Pain is highly prevalent in advanced cancer and requires aggressive management. However, pain management in cancer is minimally investigated in Pakistan. This cross-sectional study explores the adequacy of pain management in patients with advanced stage cancer in Pakistan. METHOD:: From January 2017 to May 2017, a cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan. A total of 218 patients with cancers were interviewed, and 136 patients with pain ≥5 on a Numerical Rating Scale for pain were included in the study. Demographic of patients and clinical characteristics of tumors were also evaluated. RESULTS:: Only about one-third of the patients with advanced cancer reported adequate pain management. Chi-square test, χ2 (1, n = 136) = 33.038, P < .05, indicated that pain scores were inversely associated with pain control; inadequate pain control was observed in patients with higher pain score and vice versa. Of the 55.88% of patients who were prescribed morphine, only 6 patients were compliant with treatment recommendations. Most patients were prescribed nonopioid medications and tramadol and codeine, which are weak opioid medications. CONCLUSION:: The rate of undertreatment of cancer pain in Pakistan is alarming. Inadequate clinicians' training, patients' and caregivers' beliefs, lack of availability of opioid medications, and socioeconomic factors are some of the barriers to effective pain control. A multidisciplinary team approach is necessary to follow the World Health Organization pain ladder guidelines for the treatment of cancer pain.

Frequency and correlates of symptoms of anxiety and depression among young caregivers of cancer patients: a pilot study.

OBJECTIVES: To determine the frequency of symptoms of anxiety and depression among the young caregivers of family members with cancer and their correlation with role of gender, age and socio-economic status. RESULTS: A total of 87.8% of caregivers were between 11 and 16 years of age, with 94.6% reported having support from another caregiver. At least 95% of caregivers reported symptoms of anxiety with a higher predisposition among females. Around 73% of caregivers had low monthly incomes followed by (22.9%) middle and (4.1%) high monthly incomes. Care givers belonging to low income groups were more likely to report anxiety and depressive symptoms (70%). Young adults 17-18 years of age reported fewer symptoms of anxiety (10.9%) than their younger counterparts. Reported symptoms of anxiety and depression decreased when the number of care givers increased-2 (67.5%), 3 (16.2%), 4 (5.4%). Increased hospital stay was associated with increased frequency of symptoms, but not beyond 5 weeks.

Trigeminal Neuralgia: A Clinical Review for the General Physician.

General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article.