Abstract P1-10-02: A Novel Attempt To Improve Long-Term Patient Follow-Up in a Low Resource Urban Setting

The lack of either a nationalized health care structure or widespread health insurance in most developing nations is at the root of many of our health care challenges. Amongst them is the loss to follow-up of a majority of patients treated at tertiary care centers. As a consequence, outcomes data from such countries are notoriously non representative. While there have been numerous published reports of treatment outcomes of cancers from India, the reported numbers as a proportion of originally treated patients are probably less than half. We have attempted a simple solution to this problem, made possible primarily by the revolution of low cost mobile cell phones and almost universal access.

Methods.

St. John's Medical College Hospital is a tertiary care centre located in Bangalore, India. We established a patient support group called Aadhara (“Support” in Sanskrit). Aadhara has employed two women with training in counseling and clinical research. Both were provided with cell phones. At the time of initial breast cancer diagnosis, patients are enrolled in a long term follow-up study. Cell phone numbers, address and other contact details of patients and/or next of kin are obtained. The patients and their family are informed about the psycho-social support available at Aadhara that include counseling, psycho-education, talks on psycho-social aspects of the disease, nutrition, news letters, meeting long-term survivors and community breast cancer awareness programs. They are provided phone numbers and email ids to get in touch with the counselors as needed. The patients or their family are contacted by the counselors on a monthly basis. However the patients are free to get in touch with the counselors by just making a “missed call” to the cell phone numbers.

Results

Aadhara has been operational for close to two years. During this period we have enrolled 121 patients into our longitudinal observational study. There have been 11 deaths in our cohort. The most gratifying outcome has been the loss of only 2 patients to follow-up. This represents a greater than 95% follow-up. The costs of this entire program have been made available by a philanthropic organization and are approximately USD 2000 per month. Represented as per patient cost, this is less than USD 20/patient per month and could probably be halved as the enrollments grow. Discussion

The rapid and deep penetration of mobile phone services in India present opportunities for obtaining better metrics of the consequences of medical treatment. This model has the advantage of scalability and diminishing per patient costs as the numbers grow. It is also portable to other clinical conditions where long-term outcomes are needed to guide health care interventions. This is “proof-of-concept” that improved outcome measures can be obtained in low resource settings at costs that are a fraction of the cost of treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-02.

Prenatal cocaine exposure increases anxiety, impairs cognitive function and increases dendritic spine density in adult rats: influence of sex

Cocaine exposure during pregnancy can impact brain development and have long-term behavioral consequences. The present study examined the lasting consequences of prenatal cocaine (PN-COC) exposure on the performance of cognitive tasks and dendritic spine density in adult male and female rats. From gestational day 8 to 20, dams were treated daily with 30 mg/kg (ip) of cocaine HCl or saline. At 62 days of age, offspring were tested consecutively for anxiety, locomotion, visual memory and spatial memory. PN-COC exposure significantly increased anxiety in both sexes. Object recognition (OR) and placement (OP) tasks were used to assess cognitive function. Behavioral tests consisted of an exploration trial (T1) and a recognition trial (T2) that were separated by an inter-trial delay of varying lengths. Male PN-COC subjects displayed significantly less time investigating new objects or object locations during T2 in both OR and OP tasks. By contrast, female PN-COC subjects exhibited impairments only in OR and only at the longest inter-trial delay interval. In addition, gestational cocaine increased dendritic spine density in the prefrontal cortex and nucleus accumbens in both genders, but only females had increased spine density in the CA1 region of the hippocampus. These data reveal that in-utero exposure to cocaine results in enduring alterations in anxiety, cognitive function and spine density in adulthood. Moreover, cognitive deficits were more profound in males than in females.

Deer velvet supplementation decreases the grade and metastasis of azoxymethane-induced colon cancer in the male rat

Since deer velvet (DV) extract promotes angiogenesis, its ability to modulate the growth and invasiveness of colon tumours was investigated. Male Wistar rats were each given a subcutaneous injection of azoxymethane (AOM) at 15 mg/kg once a week for 3 weeks. One week following the last dose of AOM the rats received either 1g/kg of DV delivered in a cube of raspberry gelatin or plain raspberry gelatin daily for 26 weeks. At necropsy, tumours were measured and the distance from the anus was recorded. Tissue samples were categorised according to the Astler-Coller system. The results showed that there were no significant differences in most parameters examined (i.e. body weight gain, multiplicity, tumour volume and incidence). The only statistically significant differences seen were associated with metastasis and tumour grade. Specifically, more of the tumours in the DV-treated rats were of a lower grade compared to the controls, both when all tumour sites were considered (0.91 vs. 0.66, p<0.0001), as well as those located only in the colon (0.95 vs. 0.84, p<0.03). Therefore, this study can confidently conclude that DV does not increase the incidence, multiplicity, metastasis or tumour volume of AOM-induced colon cancer in the rat.

The spectrum of anorectal malformations in Africa

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.

MMCTP: a radiotherapy research environment for Monte Carlo and patient-specific treatment planning

Radiotherapy research lacks a flexible computational research environment for Monte Carlo (MC) and patient-specific treatment planning. The purpose of this study was to develop a flexible software package on low-cost hardware with the aim of integrating new patient-specific treatment planning with MC dose calculations suitable for large-scale prospective and retrospective treatment planning studies. We designed the software package 'McGill Monte Carlo treatment planning' (MMCTP) for the research development of MC and patient-specific treatment planning. The MMCTP design consists of a graphical user interface (GUI), which runs on a simple workstation connected through standard secure-shell protocol to a cluster for lengthy MC calculations. Treatment planning information (e.g., images, structures, beam geometry properties and dose distributions) is converted into a convenient MMCTP local file storage format designated, the McGill RT format. MMCTP features include (a) DICOM_RT, RTOG and CADPlan CART format imports; (b) 2D and 3D visualization views for images, structure contours, and dose distributions; (c) contouring tools; (d) DVH analysis, and dose matrix comparison tools; (e) external beam editing; (f) MC transport calculation from beam source to patient geometry for photon and electron beams. The MC input files, which are prepared from the beam geometry properties and patient information (e.g., images and structure contours), are uploaded and run on a cluster using shell commands controlled from the MMCTP GUI. The visualization, dose matrix operation and DVH tools offer extensive options for plan analysis and comparison between MC plans and plans imported from commercial treatment planning systems. The MMCTP GUI provides a flexible research platform for the development of patient-specific MC treatment planning for photon and electron external beam radiation therapy. The impact of this tool lies in the fact that it allows for systematic, platform-independent, large-scale MC treatment planning for different treatment sites. Patient recalculations were performed to validate the software and ensure proper functionality.