The growing burden of cancer in India: epidemiology and social context

Outcome of early detection approach in control of breast, cervical, and oral cancer: Experience from a rural cancer center in India

In low- and middle-income countries most of the cancer patients attend the hospital at a late stage and treatment completion of these cases is challenging. The early detection program (EDP), in rural areas of Punjab state, India was initiated to identify breast, cervical, and oral cancer at an early stage by raising awareness and providing easy access to diagnosis and treatment. A total of 361 health education programs and 99 early detection clinics were organized. The symptomatic and self-interested (non-symptomatic individuals who opted for screening) cases visited the detection clinic. They were screened for breast, cervical, and/or oral cancer. Further diagnosis and treatment of screen-positive cases were carried out at Homi Bhabha Cancer Hospital (HBCH), Sangrur. Community leaders and healthcare workers were involved in all the activities. The EDP, Sangrur removed barriers between cancer diagnosis and treatment with the help of project staff. From 2019 to 2023, a total of 221,317 populations were covered. Symptomatic and self-interested individuals attended the breast (1627), cervical (1601), and oral (1111) examinations. 46 breast (in situ-4.3%; localized-52.2%), 9 cervical (localized-77.8%), and 12 oral (localized-66.7%) cancer cases were detected, and treatment completion was 82.6%, 77.8%, and 50.0%, respectively. We compared cancer staging and treatment completion of cases detected through EDP with the cases attended HBCH from Sangrur district in 2018; the difference between two groups is statistically significant. Due to the early detection approach, there is disease down-staging and improvement in treatment completion. This approach is feasible and can be implemented to control these cancers in low- and middle-income countries.

Regulatory landscape and challenges in CAR-T cell therapy development in the US, EU, Japan, and India

Chimeric Antigen Receptor-T cell (CAR-T) therapy has evolved as a revolutionary cancer treatment modality, offering remarkable clinical responses by harnessing the power of a patient's immune system to target and eliminate cancer cells. However, the development and commercialization of CAR-T cell therapies are accompanied by complex regulatory requirements and challenges. This therapy falls under the regulatory category of advanced therapy medicinal products. The regulatory framework and approval tools of regenerative medicine, especially CAR-T cell therapies, vary globally. The present work comprehensively analyses the regulatory landscape and challenges in CAR-T cell therapy development in four key regions: the United States, the European Union, Japan, and India. This work explores the unique requirements and considerations for preclinical studies, clinical trial design, manufacturing standards, safety evaluation, and post-marketing surveillance in each jurisdiction. Due to their complex nature, developers and manufacturers face several challenges. In India, despite advancements in treatment protocols and government-sponsorships, there are still several difficulties regarding access to treatment for the increasing number of cancer patients. However, India's first indigenously developed CAR-T cell therapy, NexCAR19, for B-cell lymphoma or leukemia, approved and available at a low cost compared to other available CAR-T therapies, raises great hope in the battle against cancer. Several strategies are proposed to address the identified hurdles from global and Indian perspectives. It discusses the benefits of aligning regulatory requirements across regions, eventually facilitating international development and enabling access to this transformative therapy.

Geraniol and citral: recent developments in their anticancer credentials opening new vistas in complementary cancer therapy

About 10 million people are diagnosed with cancer each year. Globally, it is the second leading cause of death after heart disease, and by 2035, the death toll could reach 14.6 million. Several drugs and treatments are available to treat cancer, but survival rates remain low. Many studies in recent years have shown that plant-derived monoterpenes, particularly geraniol and citral, are effective against various cancers, including breast, liver, melanoma, endometrial, colon, prostate, and skin cancers. This trend has opened new possibilities for the development of new therapeutics or adjuvants in the field of cancer therapy. These monoterpenes can improve the efficacy of chemotherapy by modulating many signaling molecules and pathways within tumors. Analysis of reports on the anticancer effects published in the past 5 years provided an overview of the most important results of these and related properties. Also, the molecular mechanisms by which they exert their anticancer effects in cell and animal studies have been explained. Therefore, this review aims to highlight the scope of geraniol and citral as complementary or alternative treatment options in cancer therapy.

EGFR-Tyrosine Kinase Inhibitor Retreatment in Non-Small-Cell Lung Cancer Patients Previously Exposed to EGFR-TKI: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis to assess the efficacy of EGFR-tyrosine kinase inhibitors (TKI) retreatment in advanced/metastatic non-small-cell lung cancer (NSCLC) patients. We systematically searched PubMed, Embase, Cochrane databases, ASCO, and ESMO websites for studies evaluating EGFR-TKI retreatment in advanced/metastatic NSCLC patients. All analyses were performed using R software (v.4.2.2). We included 19 studies (9 CTs and 10 retrospective cohorts) with a total of 886 patients. In a pooled analysis of all patients during retreatment with TKI, median OS was 11.7 months (95% confidence interval [CI] 10.2-13.4 months) and PFS was 3.2 months (95% CI 2.5-3.9 months). ORR was 15% (95% CI 10-21%) and DCR was 61% (95% CI 53-67%). The subanalysis by generation of TKI in the rechallenge period revealed a slightly better ORR for patients on 3rd generation TKI (p = 0.05). Some limitations include the high heterogeneity of some of the analyses and inability to perform certain subanalyses. Our results unequivocally support the benefit of EGFR-TKI rechallenge in EGFR-mutated NSCLC patients progressing on TKI treatment after a TKI-free interval. These findings may be especially valuable in areas where access to novel therapeutic drugs and clinical trials is limited.

Isolation, identification, and characterization of α- asarone, from hydromethanolic leaf extract of Acorus calamus L. and its apoptosis-inducing mechanism in A549 cells

Due to the presence of several active secondary metabolites, the traditional Indian and Chinese medicinal herb Acorus calamus L. has been utilized for both medical and culinary purposes since ancient times. A recent report has underscored the promising cytotoxic effect of A. calamus leaves extract against non-small cell lung cancer A549 cells. Thus, we want to separate the bioactive substance from the hydromethanolic extract of A. calamus leaves in the current investigation. Thin-layer chromatography was used to separate the compounds and different spectroscopic methods (UV, FTIR, NMR, and LCMS/MS) were used for the structure prediction. α-asarone was found to be the main bioactive compound present and it was isolated from A. calamus leaves extract. It exerted a good cytotoxic effect with an IC50 value of 21.43 ± 1.27 μM against A549 cells and IC50 value of 324.12 ± 1.32 μM against WI-38 cells. The induction of apoptosis in A549 cells by α-asarone was reaffirmed by the diverse differential staining methods including DAPI, Acridine Orange/Ethidium Bromide, and Giemsa staining. Additionally, α-asarone induced mitochondrial membrane potential (ΔΨm) dissipation with a concomitant increase in the production of ROS. Furthermore, it also increased expressions of caspase-3, caspase-9, caspase-8, DR4, and DR5 genes in A549 cells. In conclusion, α-asarone-induced apoptotic cell death in non-small lung cancer cells (A549) as a result of loss of mitochondrial function, increased ROS production, subsequent activation of an internal and extrinsic caspase pathway, and altered expression of genes controlling apoptosis. As a whole, α-asarone is a plausible therapeutic agent for managing lung cancer. HIGHLIGHTSIsolation of bioactive compound from hydromethanolic leaves extract of Acorus calamus L. by thin layer chromatography.Structural elucidation of the bioactive compound was carried out using different methods like UV analysis, FTIR, NMR, and LC-MS/MS analysis.A plausible mode of action revealed that α-asarone can induce apoptosis in lung cancer cells (A549).Communicated by Ramaswamy H. Sarma.

QbD-based co-loading of paclitaxel and imatinib mesylate by protamine-coated PLGA nanoparticles effective on breast cancer cells

Aim: Paclitaxel and imatinib mesylate are drugs used in the treatment of breast cancer. Conventional drug-delivery systems have limitations in the effective treatment of breast cancer using the drugs. Materials & methods: Combination index studies were used to identify the optimum ratio of both drugs showing maximum synergistic effect. Using a systematic quality-by-design approach, protamine-coated PLGA nanoparticles co-loaded with paclitaxel and imatinib mesylate were formulated. Further characterization and cell line evaluations were performed. Results: Encapsulation efficiency obtained was 92.54% for paclitaxel and 75.12% for imatinib mesylate. A sustained (24 h) and controlled zero-order drug release was obtained. Conclusion: Formulated nanoparticles had a low IC50 value and enhanced cellular uptake.

Burden of female breast cancer in India: estimates of YLDs, YLLs, and DALYs at national and subnational levels based on the national cancer registry programme

PURPOSE

Female breast cancer (BC) is the leading cause of cancer incidence and mortality in India, and accounted for 13.5% of new cancer cases and 10% of cancer-related deaths in 2020. This study aims to estimate and report the female BC burden in India at state level from 2012 to 2016 in terms of years of life lost, years lived with disability, and disability-adjusted life years (DALYs), and to project the burden for the year 2025.

METHODS

The cancer incidence and mortality data from 28 population-based cancer registries were analysed. The mean mortality to incidence ratio was estimated, and mortality figures were adjusted for underreporting. The burden of female BC was estimated at national and subnational levels using Census data, World Health Organisation's lifetables, disability weights, and the DisMod-II tool. A negative binomial regression is employed to project burden for 2025.

RESULTS

The burden of BC among Indian women in 2016 was estimated to be 515.4 DALYs per 100,000 women after age standardization. The burden metrics at state level exhibited substantial heterogeneity. Notably, Tamil Nadu, Telangana, Karnataka, and Delhi had a higher burden of BC than states in the eastern and north-eastern regions. The projection for 2025 indicates to a substantial increase, reaching 5.6 million DALYs.

CONCLUSION

The female BC burden in India was significantly high in 2016 and is expected to substantially increase. Undertaking a multidisciplinary, context-specific approach for its prevention and control can address this rising burden.

Radiation Therapy Technology Advances and Mitigation of Subsequent Neoplasms in Childhood Cancer Survivors

PURPOSE

In this Pediatric Normal Tissue Effects in the Clinic (PENTEC) vision paper, challenges and opportunities in the assessment of subsequent neoplasms (SNs) from radiation therapy (RT) are presented and discussed in the context of technology advancement.

METHODS AND MATERIALS

The paper discusses the current knowledge of SN risks associated with historic, contemporary, and future RT technologies. Opportunities for research and SN mitigation strategies in pediatric patients with cancer are reviewed.

RESULTS

Present experience with radiation carcinogenesis is from populations exposed during widely different scenarios. Knowledge gaps exist within clinical cohorts and follow-up; dose-response and volume effects; dose-rate and fractionation effects; radiation quality and proton/particle therapy; age considerations; susceptibility of specific tissues; and risks related to genetic predisposition. The biological mechanisms associated with local and patient-level risks are largely unknown.

CONCLUSIONS

Future cancer care is expected to involve several available RT technologies, necessitating evidence and strategies to assess the performance of competing treatments. It is essential to maximize the utilization of existing follow-up while planning for prospective data collection, including standardized registration of individual treatment information with linkage across patient databases.

Landscape of cancer clinical trials in India - a comprehensive analysis of the Clinical Trial Registry-India

Background

Cancer is one of the leading causes of morbidity and mortality in India. Clinical trials are critical for driving innovation in cancer therapy, diagnosis, and prevention. This study aims to depict the evolving landscape of cancer clinical trials in India by analysing the clinical trials registered in Clinical Trial Registry-India (CTRI).

Methods

We identified cancer trials registered in CTRI (between 2007 and 2021) using search terms adapted from the cancer types defined by the National Cancer Institute (USA). We then collated and analysed the publicly available information from CTRI (cancer subtypes, type of trial, treatment intent, type of intervention, sponsor type, recruitment countries) and used descriptive statistics to illustrate the overall as well as year-to-year trend.

Findings

In total, we identified 1988 cancer trials, the majority of which focused on treating cancer (63%) and rest of the trials aimed at optimising the operational aspects of surgery (19%), mitigating treatment-related toxicity (10.6%), or treating cancer-related symptoms (7.8%). Focusing on trials with the intent of treating cancer, we found that most were investigating solid tumours as opposed to haematological malignancies with the most prominent cancer subtypes being breast cancer (17%), head and neck cancer (9.8%), lung cancer (9.6%), and cervical cancer (6.6%). The number of trials conducted in a given cancer subtype from our analysis overall correlated to the incidence, mortality, and 5-year prevalence of the respective cancer subtype in India; however, head and neck cancer and cervical cancer were underrepresented in trials as compared with the disease burden. The most common type of intervention was investigational drugs. The most common sponsor types were global pharmaceutical industry (26%) and research institution and hospital (26%). Despite a relatively high cancer burden, the availability of cancer trials in the Northeastern states of India was limited.

Interpretation

There is a pressing need for clinical cancer research in India to be better aligned with the nation's healthcare needs and disease burden, focusing on prevalent and deadly cancers while ensuring the availability of clinical trials across geographic regions and underserved populations.

Funding

Pi Health USA, a fully owned subsidiary of BeiGene Ltd.

Health-related quality of life and its determinants among cancer patients: evidence from 12,148 patients of Indian database

BACKGROUND

Cancer survivors experience a decrement in health-related quality of life (HRQoL) resulting from the disease as well as adverse effects of therapy. We evaluated the HRQoL of cancer patients, stratified by primary cancer site, stage, treatment response and associated adverse events, along with its determinants.

METHODS

Data were collected from 12,148 patients, sampled from seven purposively chosen leading cancer hospitals in India, to elicit HRQoL using the EuroQol questionnaire comprising of 5-dimensions and 5-levels (EQ-5D-5L). Multiple linear regression was used to determine the association between HRQoL and various socio-demographic as well as clinical characteristics.

RESULTS

Majority outpatients (78.4%) and inpatients (81.2%) had solid cancers. The disease was found to be more prevalent among outpatients (37.5%) and inpatients (40.5%) aged 45-60 years and females (49.3-58.3%). Most patients were found to be in stage III (40-40.6%) or stage IV (29.4-37.3%) at the time of recruitment. The mean EQ-5D-5 L utility score was significantly higher among outpatients [0.630 (95% CI: 0.623, 0.637)] as compared to inpatients [0.553 (95% CI: 0.539, 0.567)]. The HRQoL decreased with advancing cancer stage among both inpatients and outpatients, respectively [stage IV: (0.516 & 0.557); stage III (0.609 & 0.689); stage II (0.677 & 0.713); stage I (0.638 & 0.748), p value < 0.001]. The outpatients on hormone therapy (B = 0.076) showed significantly better HRQoL in comparison to patients on chemotherapy. However, palliative care (B=-0.137) and surgery (B=-0.110) were found to be associated with significantly with poorer HRQoL paralleled to chemotherapy. The utility scores among outpatients ranged from 0.305 (bone cancer) to 0.782 (Leukemia). Among hospitalized cases, the utility score was lowest for multiple myeloma (0.255) and highest for testicular cancer (0.771).

CONCLUSION

Older age, lower educational status, chemotherapy, palliative care and surgery, advanced cancer stage and progressive disease were associated with poor HRQoL. Our study findings will be useful in optimising patient care, formulating individualized treatment plan, improving compliance and follow-up.

Endophytic fungi as a potential source of anti-cancer drug

Endophytes are considered one of the major sources of bioactive compounds used in different aspects of health care including cancer treatment. When colonized, they either synthesize these bioactive compounds as a part of their secondary metabolite production or augment the host plant machinery in synthesising such bioactive compounds. Hence, the study of endophytes has drawn the attention of the scientific community in the last few decades. Among the endophytes, endophytic fungi constitute a major portion of endophytic microbiota. This review deals with a plethora of anti-cancer compounds derived from endophytic fungi, highlighting alkaloids, lignans, terpenes, polyketides, polyphenols, quinones, xanthenes, tetralones, peptides, and spirobisnaphthalenes. Further, this review emphasizes modern methodologies, particularly omics-based techniques, asymmetric dihydroxylation, and biotic elicitors, showcasing the dynamic and evolving landscape of research in this field and describing the potential of endophytic fungi as a source of anticancer drugs in the future.

Understanding of disease status, prognosis and estimated cost of treatment among cancer patients: experience from a tertiary cancer centre in Nepal

Purpose

Lack of adequate knowledge about the disease is one of the key factors that misguide cancer patients and patients' caregivers in choosing a better management plan. The purpose of the study was to assess the patients' and caregivers' knowledge about the disease status and estimated treatment cost. Understanding of disease may improve adherence to treatment plans and quality of care.

Methods

It was a cross-sectional study where 120 cancer patients were selected based on convenience sampling and the availability of record files and relevant data. The site, stage and prognosis of disease recorded from patients and caregivers were compared with the record of outpatient department and inpatient files with the help of the Fisher's exact test. The patients' knowledge about their financial estimates was also recorded. Three patients were selected for in-depth interviews based on purposive sampling to further support the findings.

Results

Among 120 analysed patients, 60.83% were female. Around two-thirds of male patients (69.2%) and male caregivers (62.2%) knew about the site but only one-third of female patients (30.8%) and female caregivers (37.8%) knew the same. The primary responsibility for managing financial issues was caregivers in 89.16%. Only 7.5% knew the estimated cost. Nepali as the primary language and better education level is correlated with knowledge of disease status, among both patients and caregivers but was statistically significant only in knowing prognosis among native Nepali speaker caregivers (p < 0.001), and better-educated patients (p < 0.001). As per the in-depth interview, all three patients knew the site of their disease, but only the patient with breast cancer was aware of the stage of the disease. None of the patients were aware of their disease prognosis, treatment plan or the estimated cost of their treatment.

Conclusion

The level of understanding is low for most patients and their immediate caregivers, particularly among those who are female, not literate and whose primary language is not Nepali. Appropriate strategy should be adopted to enhance basic understanding among patients and caregivers in our setting.

Computer-Assisted Morphometric Comparative Analysis of Argyrophilic Nucleolar Organizer Regions (AgNORs) in Leukoplakia With Dysplasia and Oral Squamous Cell Carcinoma

Background Oral squamous cell carcinoma (OSCC) and oral leukoplakia (OL) with dysplasia are closely linked conditions in the oral cavity, with the latter often indicating precancerous changes, underscoring the urgency of early detection and intervention. Histopathological confirmation is crucial for accurate diagnosis. The nucleolar organizer region (NOR), specifically analyzed through silver-staining (argyrophilic NORs), provides insights into nuclear changes associated with the lesion. Computer-assisted morphometric analysis enhances precision and objectivity in evaluating AgNOR-related parameters. Aim To conduct a computer-assisted morphometric comparison of AgNORs using various NOR-related parameters in cases of OSCC and leukoplakia with dysplasia and to evaluate their diagnostic significance. Materials and methods A computer-assisted morphometric analysis was conducted using various NOR-related parameters, such as nuclear profile area, single AgNOR profile area per nucleus, total AgNOR profile area per nucleus, and number of AgNOR profiles per nucleus on a total sample of 90 specimens, which includes leukoplakia with dysplasia (30), OSCC (30), and a control group, including 30 samples of normal oral mucosa. A comparison was conducted on the morphometric values between the groups under investigation. Tukey's multiple comparison tests and ANOVA were used to analyze the data and determine the differences between the groups. Results The present investigation revealed a significant difference in all four AgNOR-related parameters between leukoplakia and OSCC in comparison to the control group (normal oral mucosa). Comparing OL (41.78 ± 0.46) and OSCC (62.78 ± 0.47) to the control group (35.93 ± 0.99), the mean value of nuclear profile area (A Nuc) was significantly greater. In comparison to the control group (3.40 ± 0.09), the mean value of a single AgNOR profile area per nucleus (A NOR) was found to be relatively lower in both research groups, OL (2.00 ± 0.02) and OSCC (1.39 ± 0.01). The total AgNOR profile area per nucleus (TA NOR) had a mean value of 10.61 ± 0.69 in OL and 12.05 ± 0.28 in OSCC, respectively, compared to 7.82 ± 0.38 in the control group. The study found that there was more number of profiles of AgNORs per nucleus (n NOR) in the study groups of OL (5.30 ± 0.29) and OSCC (8.69 ± 0.19) than in the control group (2.32 ± 0.11). Conclusion The parameters linked to the NOR are biologically informative and easy to check regularly in a pathology lab. Additionally, AgNORs give us important information that enables us to study the range of nuclear changes in malignant and potentially malignant lesions.

Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

State of cancer care in India and opportunities for innovation

Cancer is one of the leading causes of morbidity and mortality in India. Despite recent medical and technological advances, the cancer burden in India remains high and continues to rise. Moreover, substantial regional disparities in cancer incidence and access to essential medical resources exist throughout the country. While innovative and effective cancer therapies hold promise for improving patient outcomes, several barriers hinder their development and utilization in India. Here we provide an overview of these barriers, including challenges related to patient awareness, inadequate infrastructure, scarcity of trained oncology professionals, and the high cost of cancer care. Furthermore, we discuss the limited availability of cancer clinical trials in the country, along with an examination of potential avenues to enhance cancer care in India. By confronting these hurdles head-on and implementing innovative, pragmatic solutions, we take an indispensable step toward a future where every cancer patient in the country can access quality care.

Molecular docking and dynamic simulation studies of α4β2 and α7 nicotinic acetylcholine receptors with tobacco smoke constituents nicotine, NNK and NNN

Smoking constitutes a major global health problem. As it triggers various health hazards including cancers, cardiac and pulmonary illness, it is imperative to understand the mechanism of action of various smoke constituents on our cellular processes. Various in vitro studies have compiled the affinity of cigarette smoke constituents on various nicotinic acetylcholine receptors (nAChRs). But the nature of the intermolecular interactions contributing to this affinity and the key amino acids in the receptor active sites involved in this are not investigated so far. Here, we are examining the interaction of α7nAChR and α4β2nAChR on nicotine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N-nitrosornicotine (NNN), the physiologically significant constituents in smoke, through molecular docking and dynamics simulations study. The docking of α4β2nAChR structure with the ligands nicotine, NNK and NNN yielded docking scores of -41.45 kcal/mol, -59.28 kcal/mol and -54.60 kcal/mol, respectively, and that of α7nAChR receptor molecule with the ligands yielded docking scores of -59.54 kcal/mol, -71.06 kcal/mol and -70.86 kcal/mol, respectively. The study showed that NNK exhibited the highest affinity with the ligands which was confirmed by dynamics simulation. But higher stability of interactions as surmised from Molecular dynamics simulations was found for nicotine with α4β2nAChR and NNN with α7nAChR. The findings validate the in vitro studies comparing the affinities of these compounds. The study will be useful in formulating effective nAChR agonists to treat neurological disorders and antagonists for smoke deaddiction and improve health standards.Communicated by Ramaswamy H. Sarma.

Oncofertility awareness among primary care physicians in India

BACKGROUND

Primary care physicians not only coordinate referrals to oncology services but can play a crucial role in successful fertility preservation referrals in cancer-diagnosed patients. Hence, it is important to assess their knowledge and attitudes towards fertility preservation.

METHODS

An eighteen-item oncofertility survey was administered to primary care physicians between May 2019 to September 2020.  Results: A total of forty-six responses were received and analysed. About 60% of primary care physicians did not have adequate knowledge about available fertility preservation options and only 26-32% were aware of international guidelines recommending fertility preservation in cancer patients.  Conclusions: Imparting awareness and knowledge of fertility preservation and its options to primary care physicians could enable an integrated cancer care model while also facilitating successful oncofertility referrals in countries like India.

Review of the unmet medical need for vaccination in adults with immunocompromising conditions: An Indian perspective

Immunocompromised (IC) populations are at increased risk of vaccine-preventable diseases (VPDs). In India, the concern of VPDs in IC populations is particularly acute due to the prevalence of crowded living situations, poor sanitation and variable access to healthcare services. We present a narrative review of IC-related disease and economic burden, risk of VPDs and vaccination guidelines, based on global and India-specific literature (2000-2022). IC conditions considered were cancer, diabetes mellitus, chronic kidney disease, respiratory disorders, disorders treated with immunosuppressive therapy, and human immune deficiency virus (HIV). The burden of IC populations in India is comparable to the global population, except for cancer and HIV, which have lower prevalence compared with the global average. Regional and socioeconomic inequalities exist in IC prevalence; VPDs add to the burden of IC conditions, especially in lower income strata. Adult vaccination programs could improve health and reduce the economic impact of VPDs in IC populations.

Redefining Cancer Research Priorities in Low- and Middle-Income Countries in the Post-COVID-19 Global Context: A Modified Delphi Consensus Process

PURPOSE

The post-COVID-19 funding landscape for cancer research globally has become increasingly challenging, particularly in resource-challenged regions (RCRs) lacking strong research ecosystems. We aimed to produce a list of priority areas for cancer research in countries with limited resources, informed by researchers and patients.

METHODS

Cancer experts in lower-resource health care systems (as defined by the World Bank as low- and middle-income countries; N = 151) were contacted to participate in a modified consensus-seeking Delphi survey, comprising two rounds. In round 1, participants (n = 69) rated predetermined areas of potential research priority (ARPs) for importance and suggested missing ARPs. In round 2, the same participants (n = 49) rated an integrated list of predetermined and suggested ARPs from round 1, then undertook a forced choice priority ranking exercise. Composite voting scores (T-scores) were used to rank the ARPs. Importance ratings were summarized descriptively. Findings were discussed with international patient advocacy organization representatives.

RESULTS

The top ARP was research into strategies adapting guidelines or treatment strategies in line with available resources (particularly systemic therapy) (T = 83). Others included cancer registries (T = 62); prevention (T = 52); end-of-life care (T = 53); and value-based and affordable care (T = 51). The top COVID-19/cancer ARP was strategies to incorporate what has been learned during the pandemic that can be maintained posteriorly (T = 36). Others included treatment schedule interruption (T = 24); cost-effective reduction of COVID-19 morbidity/mortality (T = 19); and pandemic preparedness (T = 18).

CONCLUSION

Areas of strategic priority favored by cancer researchers in RCRs are related to adaptive treatment guidelines; sustainable implementation of cancer registries; prevention strategies; value-based and affordable cancer care; investments in research capacity building; epidemiologic work on local risk factors for cancer; and combatting inequities of prevention and care access.

A burden shared: the financial, psychological, and health-related consequences borne by family members and caregivers of people with cancer in India

In India, approximately 1.4 million new cases of cancer are recorded annually, with 26.7 million people living with cancer in 2021. Providing care for family members with cancer impacts caregivers' health and financial resources. Effects on caregivers' health and financial resources, understood as family and caregiver "financial toxicity" of cancer, are important to explore in the Indian context, where family members often serve as caregivers, in light of cultural attitudes towards family. This is reinforced by other structural issues such as grave disparities in socioeconomic status, barriers in access to care, and limited access to supportive care services for many patients. Effects on family caregivers' financial resources are particularly prevalent in India given the increased dependency on out-of-pocket financing for healthcare, disparate access to insurance coverage, and limitations in public expenditure on healthcare. In this paper, we explore family and caregiver financial toxicity of cancer in the Indian context, highlighting the multiple psychosocial aspects through which these factors may play out. We suggest steps forward, including future directions in (1) health services research, (2) community-level interventions, and (3) policy changes. We underscore that multidisciplinary and multi-sectoral efforts are needed to study and address family and caregiver financial toxicity in India.

A Cross-Sectional Study on the Epidemiology of Newly Diagnosed Breast Cancer Patients Attending Tertiary Care Hospitals in a Tribal Preponderant State of India: Regression Analysis

INTRODUCTION

Breast cancer (BC) is globally prevalent and the leading cause of death due to cancer in females. Due to changes in risk factor profiles, improved cancer registration, and cancer detection, its incidence and death rates have risen over the past three decades. Both modifiable and immutable risk factors for BC make up a sizable portion of the total risk factors.  Methodology: This was a hospital-based cross-sectional study carried out in the Department of Surgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi. Consecutive sampling was done with a complete enumeration of all newly diagnosed cases of breast cancer >15 years old. Those who consented to participate and those who were extremely ill, deaf, or dumb were excluded from the study.

RESULTS

A total of 88 patients were included. Maximum patients diagnosed with breast cancer belonged to the age group of 40-50 years (37.5%), Hindu by religion (76.1%), non-tribal (80.68%), illiterate (89.8%), married (98.9%), housewives (92%), and of class IV socio-economic status (SES) (65.9%).

CONCLUSION

Regular training of Sahiya (the local name of Accredited Social Health Activist (ASHA) in Jharkhand), empowerment of screening clinics for cancer, and upgraded diagnostic facilities for timely referral should be stressed upon.

Current Status of Research on Targeted Therapy Against Central Nervous System Tumors in Low- and Lower-Middle-Income Countries

OBJECTIVE

In recent decades, a significant body of research has focused on targeted therapies for the treatment of central nervous system (CNS) tumors to enhance the effectiveness of management strategies. However, most of these efforts have been centered in high-income countries, which renders the generalizability of their results to low- and middle-income countries questionable. Therefore, in this review, we systematically investigated the status of research conducted on targeted therapy for CNS tumors in low- and lower-middle-income countries to elucidate the contribution of these countries in advancing neuro-oncology.

METHODS

A systematic search of 3 databases was performed using a predefined search strategy. After screening the articles based on our inclusion/exclusion criteria, the data were extracted to a predesigned Excel worksheet.

RESULTS

A review of 44 included studies showed that India, Iran, and Lebanon were the only countries with a contribution to this field. All included studies were laboratory or animal experiments, and there were no clinical studies in this field. The most investigated CNS tumor was malignant glioma, and gene-targeted therapy was the most investigated category of targeted therapies in these countries.

CONCLUSIONS

Low- and lower-middle-income countries comprise more than half of the world population, but they are deprived of targeted therapies against CNS tumors. Although there are basic experiments performed on this subject, they originate in a limited number of these countries. Therefore, targeted therapy is in its preliminary stage in these countries.

A. Incidence, Patterns, and Severity of Potential Drug Interactions Among Cancer Patients on Chemotherapy in a Tertiary Care Hospital

Objective

To study the incidence of potential drug−drug interactions (DDIs) and evaluate their pattern and severity in cancer inpatients.

Materials and Methods

A detailed clinical data and prescriptions of 150 inpatients with different malignancies were subjected to DDI screening using Micromedex software. The frequency of potential DDIs and their types, patterns, and severity were investigated.

Results

A total of 360 potential DDIs were present in 111 (74%) of 150 inpatients, dominated by female (67.33%) and breast cancer (30%) patients. The incidence of severe interactions was 63.88%, moderate interactions 35.83%, and mild interactions 0.27%. The potential mechanisms of DDIs were 38.33% pharmacodynamic, 48.33% pharmacokinetic, and 13.33% unspecified. The drug interactions were found to be positively correlated ( p < 0.01) with the 6–10 number of prescribed medicines.

Conclusion

According to this study, the number of medicines prescribed to cancer inpatients increased the chance of DDIs. As a result, the drug surveillance program could save a sizable number of patients from the potentially hazardous clinical effects of DDIs.

A commentary on cancer prevention and control in India: Priorities for realizing SDGs

In India, cancers along with cardiovascular diseases contribute to significant mortality and morbidity. With less than 10 years remaining towards achieving Sustainable development Goals (SDGs), public health systems in India need to be critically assessed and strengthened, for addressing non-communicable diseases (NCDs) in general and cancers in particular. Our Commentary address the public health response to cancer prevention and control, with specific pointers based on emerging evidence. The relevant issues are stratified as: emphasis on the critical appraisal of national programs, strengthening primary health care (PHC) systems, enhancing focus on client and community centricity, exploring integrative approaches to cancer management and stepping up implementation and multidisciplinary research. Ongoing surveillance is essential to assess the current and future trends of cancer as well as the outcomes of prevention and treatment measures. For revitalizing comprehensive PHC, much depends on our epidemiological capacity and surveillance systems which impart information for local planning. It is imperative to address the cultural barriers and societal norms, which limit the acceptability and participation in screening programs. SDG 3 has ushered the wellbeing agenda at an opportune time. There is a compelling need to conduct research on an integrated approach (ayurveda complimenting allopathic medication) for the treatment of cancer. The unique challenges posed by the rise in NCD morbidity in LMIC, requires horizontal integration of the health systems with new services focused on cancer control.

Establishment and validation of a risk prediction model for high-grade cervical lesions

OBJECTIVE

To establish and validate a risk prediction model for cervical high-grade squamous intraepithelial lesions (HSIL).

METHODS

This retrospective study included patients who underwent cervical biopsies at the Cervical Disease Centre of Maternal and Child Hospital of Hubei Province between January 2021 and December 2021.

RESULTS

A total of 1630 patients were divided into the HSIL + cervical lesion group (n = 186) and the ≤ LSIL cervical lesions group (n = 1444). LSIL, ASC-H, HSIL and SCC, high-risk HPV, HPV16, HPV18/45, multiple HPV strains, acetowhite epithelium, atypical vessels, and mosaicity were independently associated with HSIL + lesions. These factors were used to establish a risk prediction model with a demonstrated area under the curve (AUC) of 0.851 and a C-index of 0.829. Calibration curve analysis showed that the model performed well, with a mean absolute error (MAE) of 0.005. The decision curve showed that the model created by combining the risk factors was more specific and sensitive than each predictive variable.

CONCLUSION

The model for predicting HSIL demonstrated promising predictive capability and might help identify patients requiring biopsy and treatment.

Exploring Perception of Terminally Ill Cancer Patients about the Quality of Life in Hospice based and Home based Palliative Care: A Mixed Method Study

Objectives

The objectives of the study were to evaluate the perceptions and performance of terminally ill cancer patients regarding the quality of palliative care at different settings and to measure their quality of life (QOL) at the end of life.

Material and Methods

This comparative, parallel and mixed method study was conducted at the Community Oncology Centre, Ahmedabad, among 68 terminally ill cancer patients as per inclusion criteria; who were receiving hospice (HS)-based and home (HO)-based palliative care under 2 months permitted by the Indian Council of Medical Research. In this parallel and mixed method study, qualitative findings were supplemented by quantitative data with both components executed simultaneously. Interview data were recorded by taking extensive notes during interviews along with an audio recording. Interviews were transcribed verbatim and a thematic approach was adopted. QoL questionnaire ('FACIT© System') was used for the assessment of QOL in terms of four dimensions. Data were analysed using the appropriate statistical test on Microsoft Excel.

Results

The qualitative data (primary component) analysed under five themes - staff behaviour, comfort and peace, enough and consistent care, nutrition and moral support, in the present study favours a HS-based setting more than a HO-based setting. Among all four subscale scores, physical well-being and emotional well-being subscale scores were statistically significantly associated with the place of palliative care. Functional Assessment of Cancer Therapy-General (FACT-G) total score was high among patients getting HO-based palliative (mean = 67.64) care than HS-based palliative care (mean = 56.56) and the difference between total FACT-G scores was statistically significant (unpaired t-test = 2.20, P = 0.03).

Conclusion

Overall, with the primary component favouring HS care and higher scores obtained in HO-based patients, the present study advocates the necessity for palliative services to expand their coverage regardless of whether they are provided at HS or HO, as it has improved the QOL of cancer patients significantly.

A Multi-centric retrospective study into the epidemiological distribution of breast cancer patients in India

BACKGROUND

A multicentric private hospital-based retrospective study was conducted to understand the epidemiology of breast cancer in terms of demographics and clinical characteristics (staging and hormone receptor status) at the time of diagnosis.

METHODS

The data for 5,688 female breast cancer patients were collected from the hospital and clinical records of four study centres. All statistical analysis was performed using Microsoft Excel 2016 and R software. Survival was estimated by the Kaplan-Meier method and compared by the log-rank test. A P value of <.05 was considered statistically significant.

RESULTS

The mean and median age of the study population was 52.6 (± 12.4) years and 53.0 (range 51-54 across the four centers) years, respectively. About 68% of patients were in the age category of 41 65 years, 17.6% were <40 years old among whom 23.4% of patients reported a positive family history. Most of the patients (66.3%) were diagnosed at an early stage (Stage I and II). The 3-year OS probability was 100%, 97.5%, 94.1%, and 74.7% for TNM Stages I, II, III, and IV, respectively. The 3-year RFS was 95.7%, 95.5%, 84.5%, and 49% for TNM Stages I, II, III, and IV, respectively.

CONCLUSION

The present study highlights the epidemiological distribution of breast cancer patients. It emphasizes the importance of disease awareness among the urban and educated female population as most patients were diagnosed at earlier stages and demonstrated higher OS and RFS than reported in government registries.

Dietary diversity and association with non-communicable diseases (NCDs) among adult men (15-54 years): A cross-sectional study using National Family and Health Survey, India

A healthy and diversified diet is essential for preventing several non-communicable diseases (NCDs). Given the increasing evidence of diet-related health burdens and the rising prevalence of NCDs among Indian adults, the present study aims to explore dietary diversity patterns among adult men in India and their association with non-communicable diseases (NCDs). For this purpose, the study used the fourth round of the National Family and Health Survey (NFHS-4) to analyze adult male samples (n = 1,12,122). Dietary Diversity Scores (DDS) were computed by the weighted sum of the number of different food groups consumed by an individual. The prevalence of diabetes, heart disease, and cancer among adult men is considered a non-communicable disease. Bivariate and logistic regression was carried out to examine the association between DDS and NCDs by estimating chi-squared tests (χ2-test), odds ratio (OR), and 95% confidence interval (CI). The prevalence of diabetes, heart disease, and cancer among adult men in India is 2.1 percent, 1.2 percent, and 0.3 percent, respectively. Results show a positive association between dietary diversity score and the prevalence of the non-communicable disease. High-level dietary diversity scores increase to two times the likelihood of diabetes (OR 2.15 with p<0.05) among adult men than to better-off counterparts while controlling all the covariates. However, a moderate dietary diversity score significantly decreases the likelihood of heart disease (OR 0.88 with p<0.10) and Cancer (OR 0.71 with p<0.05) for adult men compared to a lower score of dietary diversity. In addition, age, marital status, drinking and smoking habits, occupation, and wealth index are also significantly associated with the odds of non-communicable diseases among adult men.

Psychosocial and emotional morbidities after a diagnosis of cancer: Qualitative evidence from healthcare professional cancer patients

AIM

This inquiry aimed to; (1) examine the psychosocial and emotional sequelae associated with cancer patient-hood experience in healthcare professionals (HCPs) in Uganda, (2) generate evidence to inform clinical and nursing practice about the needs of HCP patients with cancer.

DESIGN

This was a qualitative phenomenological study.

METHODS

The study was conducted among HCP cancer patients and survivors recruited from oncology and palliative care settings in Uganda. Data were collected via audio-taped, face-to-face or telephone open-ended interviews. Interviews were transcribed verbatim. Thematic analysis was used.

RESULTS

Eight HCP cancer patients and survivors participated in the study. Their mean age was 56 years, range 29-85 years. Three major themes emerged: (1) From a healthcare provider to a patient, (2) Socioeconomic challenges, and (3) Coping and support strategies.

Unlocking India's Potential in Managing Endocrine-Disrupting Chemicals (EDCs): Importance, Challenges, and Opportunities

Endocrine-disrupting chemicals (EDCs) are a prime concern for the environment and health globally. Research shows that in developing countries such as India both the environment and human populations are severely exposed to EDCs and consequently experience rising incidents of adverse health effects such as diabetes and cancers. In this paper, we discuss the current EDC management approach in India, critically assess its limitations, and describe opportunities for potential improvements. Foremost, current EDC management actions and interventions in India are fragmented and outdated, and far behind the modern and comprehensive approaches adopted in the European Union and other developed countries. Strong and well-planned actions are required on various fronts of science, policy, commerce, and public engagement. These actions include the adoption of a dedicated and modern regulatory framework for managing EDCs, enhancing capacity and infrastructure for EDC monitoring in the environment and human population, employing public-private partnership programs for not only managing EDCs but also in the sectors that indirectly contribute toward the mismanagement of EDCs in the country, and raising awareness on EDCs and promoting health-preserving consumption habits among the public. As India hosts a large proportion of the global human population and biodiversity, the success or failure of its actions will substantially affect the direction of global efforts to manage EDCs and set an example for other developing countries.

Nanoparticle-Mediated PRDX2 Inhibition for Specific Targeting of CHK2-Null Colorectal Cancer

Synthetic lethality is a pragmatic targeted cancer therapy approach in which cancer cells harboring genetic alterations are exploited for the specific killing of cancer cells. Earlier, we have established a synthetic lethal (SL) interaction between two genes that are CHK2 and PRDX2 in colorectal cancer (CRC) cells. The SL interaction between CHK2 and PRDX2 resulted in selective targeting of CHK2-defective CRC cells. N-Carbamoyl alanine (NCA) is a PRDX2 inhibitor and is a peptide-like organic compound, which degrades after oral administration in harsh gastric pH. To overcome the limitations of NCA, a chitosan-based nanocarrier was developed for the entrapment of NCA. In this study, we targeted the SL interaction between PRDX2 and CHK2 using NCA-loaded chitosan nanoparticles (NCA-Chit NPs) to selectively inhibit the CHK2-null HCT116 cells. NCA-Chit NPs were assessed for various physicochemical characterizations such as the hydrodynamic diameter (size), zeta potential, and polydispersity index using a Zetasizer. Additionally, morphological studies for the shape and size of NPs were confirmed by transmission electron microscopy, scanning electron microscopy, and atomic force microscopy. Cellular uptake of NPs was confirmed using confocal microscopy, which exhibited that nanoparticles were able to internalize into the HCT116 cells. Blank Chit NPs were found to be cytocompatible as they did not exert any cytotoxic effects on hTERT, L929, and Caco-2 cells (intestinal epithelial cells). Importantly, NCA-Chit NPs were quite hemocompatible also. In the form of an NCA-chitosan nanoformulation, the efficacy was enhanced by about 8 times compared to free form of NCA towards selective killing of CHK2-null HCT116 cells as compared to HCT116 cells. The chitosan-based nanoformulation for NCA was developed to augment the efficacy of the NCA for enhanced cell death of colorectal cancer cells having CHK2 defects.

Situational analysis of the quality of palliative care services across India: a cross-sectional survey

Objective

Palliative care services in India were established in the 1980s but there is no detailed up-to-date knowledge about the quality-of-service provision nationally. We aim to describe the current quality of palliative care provision in India, as measured against nationally adopted standards.

Method

A digital survey adapted from the Indian Association of Palliative Care Standards Audit Tool was administered to 250 palliative care centres.

Results

Two hundred and twenty-three (89%) palliative care centres participated - 26.4% were government-run, while the rest include non-governmental organisations, private hospitals, community-led initiatives and hospices. About 200 centres 'often' or 'always' fulfilled 16/21 desirable criteria; however, only 2/15 essential criteria were 'often' or 'always' fulfilled. Only 5.8% provide uninterrupted access to oral morphine.

Significance of the results

Palliative care centres in India are falling short of meeting the essential quality standards, indicating the urgent need for new initiatives to drive national change.

Survival pattern of colorectal cancer in Sub-Saharan Africa: A systematic review and meta-analysis

Cancer incidence is relatively low in sub-Saharan Africa (SSA), however, prognosis is expected to be poor in comparison with high-income countries. Comprehensive evidence is limited on the survival pattern of colorectal cancer patients in the region. We conducted a systematic review and meta-analysis to investigate the pattern of colorectal cancer survival in the region and to identify variation across countries and over time. We searched international databases MEDLINE, Scopus, Embase, Web of Science, ProQuest, CINAHL, and Google Scholar to retrieve studies that estimated survival from colorectal cancer in SSA countries from inception to December 31, 2021 without language restriction. Due to between-study heterogeneity, we performed a random-effects meta-analysis to pool survival rates. To identify study-level sources of variation, we performed subgroup analysis and meta-regression. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guideline and the protocol was registered in PROSPERO database (CRD42021246935). 23 studies involving 10,031 patients were included in the review, of which, 20 were included in the meta-analysis. The meta-analysis results showed that the pooled 1-, 2-, 3-, 4-, and 5-year survival rates in SSA were 0.74 (95% CI, 0.66-0.81), 0.50 (95% CI, 0.41-0.58), 0.36 (95% CI, 0.27-0.47), 0.31 (95% CI, 0.22-0.42), and 0.28 (95% CI, 0.19-0.38) respectively. Subgroup analyses indicated that the survival rate varied according to year of study, in which those conducted in recent decades showed relatively better survival. The 5-year survival was higher in middle-income SSA countries (0.31; 95%CI: 0.17-0.49) than low-income countries (0.20; 95%CI: 0.11-0.35), however, the difference was not statistically significant. In conclusion, survival from colorectal cancer is low in sub-Saharan Africa compared to other regions. Thus, intervention strategies to improve screening, early diagnosis and treatment of colorectal cancer should be developed and implemented to improve survival in the region.

Being sick to a cancer patient: pathways of delay in help seeking and diagnosis of cancer in India

There is evidence that cancer mortality and morbidity could be reduced when the disease is diagnosed and treated at an early stage. The paper examines the pathways of delay of cancer diagnosis in an Indian setting. It draws on a qualitative study conducted among cancer survivors and family members of cancer patients in the city of Bengaluru, South India. The results show that a substantial part of the delay occurred at the stage of initial formal help seeking wherein patient and family-led, disease-related and systemic factors together played a major role. Patient-led factors included trivialisation and normalisation of symptoms as part of general fatigue and aging; unrealistic risk perceptions that linked causality of cancer merely to heredity and behavioural risk factors; fear of being diagnosed as cancer patient; gender related reasons including family's gender performance expectation, lower agency of women to seek help and lower prioratisation of women's health in the household and access related issues including financial constraints and unavailability of specialised hospitals nearby. Disease-related factors included the presence of comorbidity, cancer's mimicking of symptoms of other diseases and absence of distinguishable symptoms at the initial stage for certain types of cancers. The practitioner-led and system-led factors such as trivialisation of symptoms by general practitioners, non cancer-specific referrals, and lack of cancer screening facilities accounted for a major part of delay after the formal help seeking. The paper argues that the mere knowledge of cancer symptoms did not always lead to early diagnosis due to the interplay of these factors. The ongoing cancer prevention and control interventions in India need to be informed of these micro level factors while developing strategies to prevent avoidable delays in cancer diagnosis.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset

Background

India is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth).

Methods

We analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of “ask and advise” services.

Results

Nationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model.

Conclusions

This study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

Patterns of Treatment and Outcomes in Epithelial Ovarian Cancer: A Retrospective North Indian Single-Institution Experience

PURPOSE

Ovarian cancer (OC) is ranked as the third most common gynecologic cancer in various Indian cancer registries. In India, OC is seen in the younger age group, with a median age < 55 years being reported by most of the studies. The majority of patients are diagnosed in advanced stage (70%-80%), where the long-term (10-year) survival rate is poor, estimated at 15%-30%. The aim of this study was to evaluate clinical epidemiology, treatment patterns, and survival outcomes in patients with epithelial OC.

METHODS

This was a retrospective analysis of patients with epithelial OC who were treated at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, over a period of 9 years, from January 2010 to December 2018.

RESULTS

OC constituted 2.94% of all cancers registered. Epithelial OC constituted 88.4% of all OCs, with a median age 50 years. More than two third of patients belonged to rural background and the majority (76.9%) of the patients were in stage III or IV at the time of diagnosis. The main presenting symptoms were abdominal distension/bloating (46.5%) and gastrointestinal disturbances (35.2%). The most common histologic types were serous (65.9%) followed by mucinous carcinoma (15%). Median overall survival for the whole study cohort was 30 months (95% CI, 28.0 to 31.9). Median overall survival for stage I, II, III, and IV was 72, 60, 30, and 20 months, respectively.

CONCLUSION

Most of the patients presented in advanced stage of the disease and have poor outcome. Delay in diagnosis and improper management before registering in tertiary cancer center and lack of tertiary care facilities are the root causes of poor outcomes. The general population and primary care physicians need to be made aware of OC symptoms.

Exploring uncertainty measures in convolutional neural network for semantic segmentation of oral cancer images

SIGNIFICANCE

Oral cancer is one of the most prevalent cancers, especially in middle- and low-income countries such as India. Automatic segmentation of oral cancer images can improve the diagnostic workflow, which is a significant task in oral cancer image analysis. Despite the remarkable success of deep-learning networks in medical segmentation, they rarely provide uncertainty quantification for their output.

AIM

We aim to estimate uncertainty in a deep-learning approach to semantic segmentation of oral cancer images and to improve the accuracy and reliability of predictions.

APPROACH

This work introduced a UNet-based Bayesian deep-learning (BDL) model to segment potentially malignant and malignant lesion areas in the oral cavity. The model can quantify uncertainty in predictions. We also developed an efficient model that increased the inference speed, which is almost six times smaller and two times faster (inference speed) than the original UNet. The dataset in this study was collected using our customized screening platform and was annotated by oral oncology specialists.

RESULTS

The proposed approach achieved good segmentation performance as well as good uncertainty estimation performance. In the experiments, we observed an improvement in pixel accuracy and mean intersection over union by removing uncertain pixels. This result reflects that the model provided less accurate predictions in uncertain areas that may need more attention and further inspection. The experiments also showed that with some performance compromises, the efficient model reduced computation time and model size, which expands the potential for implementation on portable devices used in resource-limited settings.

CONCLUSIONS

Our study demonstrates the UNet-based BDL model not only can perform potentially malignant and malignant oral lesion segmentation, but also can provide informative pixel-level uncertainty estimation. With this extra uncertainty information, the accuracy and reliability of the model’s prediction can be improved.

A single centre study from western India to evaluate the frequency of developing second and subsequent multiple primary malignancies among cancer survivors

Aim

This study was designed to evaluate the frequency of developing second and subsequent primary cancers among cancer survivors.

Methods

We have retrospectively analyzed 121 multiple primary cancer patients treated at Bhagwan Mahavir Cancer Hospital and Research Centre, Jaipur, Rajasthan, India from the last 20 years. The survival analysis was performed by Kaplan-Meier methodology.

Results

The prevalence of multiple primary malignant tumors (MPMTs) was 1.51% (121/8000), with a male to female ratio of 1:1.42. In males most of the reported MPMTs were synchronous and most common first primary cancer cases were head & neck and lung whereas, in females most of the reported MPMTs were metachronous and most common first primary cancer cases were breast and gynaecological malignancies. Family history was reported in 15 cases. Maximum 33.05% patients received combined treatment of chemotherapy, radiotherapy and 91.73% (111/121) of patients with MPMTs were effectively followed up, 35 (28.92%) patients died and 5-year survival rate of the remaining 86 patients was 68.46%.

Conclusions

In the present observational study the most frequent sites of MPMTs in men were head & neck and lung whereas, in women breast and gynaecological sites were common. Therefore, careful monitoring and follow up are required for these patients.

“I want to live, but …” the desire to live and its physical, psychological, spiritual, and social factors among advanced cancer patients: evidence from the APPROACH study in India

Background

The limited access to palliative care resources along with the social stigma around cancer largely explains the poor quality of life (QoL) of Indian advanced cancer patients. As advanced cancer patients with poor QoL often harbour a desire for hastened death (DHD), it is imperative to understand factors affecting DHD, or the desire to live (DTL) among advanced cancer patients in India. We aim to examine the relationship between DTL and physical, psychological, spiritual, and social factors measuring patients’ QoL alongside their awareness of their late cancer stage.

Methods

We surveyed 200 patients from a tertiary cancer hospital in India to collect their DTL, awareness of cancer stage, demographic characteristics, and standardized measures for patients’ QoL. We used a linear probability regression model to quantify the association between these factors and patients’ DTL among the final sample of 192 patients with no missing information for the variables of interest.

Results

Among the various domains affecting cancer patients’ QoL, we found that the pain severity score (ranging from 0 to 10) and psychological distress score (ranging from 0 to 42) are negatively associated with the DTL. One point increase in each score reduced the DTL by 2.2% (p < 0.05) and 0.7% (p < 0.05), respectively. Our results also showed that patients whose perceived socio-economic status (SES) is poor have a 16% (p < 0.05) lower probability of DTL, compared to those with higher SES (lower middle class, upper middle class, and wealthy). Controlling for caste, religion, gender, age, marital status and years of education, we found psychological distress is statistically higher among patients belonging to this bottom SES.

Conclusions

We found that pain severity, psychological distress and perceived low SES are negatively associated with the desire to live in advanced cancer patients. Future research should focus on developing interventions to improve physical pain and psychological distress, particularly for patients who are socially and economically disadvantaged.

Docking simulation and ADMET prediction based investigation on the phytochemical constituents of Noni (Morinda citrifolia) fruit as a potential anticancer drug

Morinda citrifolia is a traditional plant used in Asian and African countries for its wide nutraceutical and therapeutic effects for the treatment of various ailments. The fruit of M. citrifolia has various biological properties such as anti-bacterial, anti-oxidant, anti-cancer. Using the molecular docking based investigation; we explored around twenty three bioactive phytochemicals in M. citrifolia fruit against human cancer. MAPK6 (mitogen-activated protein kinase 6) was selected as target protein and these twenty three phytochemicals along with a known MAPK6 inhibitor were docked against the target protein. The docking scores of the bioactive phytochemicals against MAPK6 protein range between - 4.5 kcal/mol to - 7.9 kcal/mol and the docking score of the standard drug (CID: 447077) was - 7.3 kcal/mol. Based on the binding affinity five phytochemicals asperuloside (- 6.7 kcal/mol), asperulosidic acid (- 7.2 kcal/mol), deacetylasperulosidic acid (- 7.0 kcal/mol), eugenol (- 6.8 kcal/mol) and rutin (- 7.9 kcal/mol) were chosen for further evaluation. These five compounds were further investigated through RC plot analysis, density function theory and ADMET properties. Stable linkage of protein-ligand interaction was observed through RC plot, density function theory showed the structural stability and reactivity of bioactive compounds through the energy gap between HOMO and LUMO and the ADMET (adsorption, distribution, metabolism, excretion and toxicity) studies showed the safety profile of the bioactive compounds. These in silico results support the utilization of M. citrifolia fruit in the traditional medication and the initiation for the development of new drug against human cancer through in vivo and in vitro evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40203-022-00130-4.

Cancer research in Pakistan: Opportunities, challenges and the way forward

Chronic disease disparities, in low and middle income countries (LMICs), need to be addressed through research to improve health equity. Most LMICs including Pakistan have a huge burden of non communicable disease (NCDs) like cancer and a high number of deaths due to cancer. National Cancer Control Programmes are recommended for countries with high cancer burden like Pakistan to ensure systematic implementation of evidence based strategies for cancer control however there is limited capacity for evidence generation through research. We describe the existing status for cancer registries and research in Pakistan and suggest a syndemic framework to prioritize contextually relevant research which can advance cancer health equity for Pakistani population.

Comparative treatment costs of risk-stratified therapy for childhood acute lymphoblastic leukemia in India

BACKGROUND

To evaluate the treatment cost and cost effectiveness of a risk-stratified therapy to treat pediatric acute lymphoblastic leukemia (ALL) in India.

METHODS

The cost of total treatment duration was calculated for a retrospective cohort of ALL children treated at a tertiary care facility. Children were risk stratified into standard (SR), intermediate (IR) and high (HR) for B-cell precursor ALL, and T-ALL. Cost of therapy was obtained from the hospital electronic billing systems and details of outpatient (OP) and inpatient (IP) from electronic medical records. Cost effectiveness was calculated in disability-adjusted life years.

RESULTS

One hundred and forty five patients, SR (50), IR (36), HR (39), and T-ALL (20) were analyzed. Median cost of the entire treatment for SR, IR, HR, and T-ALL was found to be $3900, $5500, $7400, and $8700, respectively, with chemotherapy contributing to 25%-35% of total cost. Out-patient costs were significantly lower for SR (p < 0.0001). OP costs were higher than in-patient costs for SR and IR, while in-patient costs were higher in T-ALL. Costs for non-therapy admissions were significantly higher in HR and T-ALL (p < 0.0001), representing over 50% of costs of in-patient therapy. HR and T-ALL also had longer durations of non-therapy admissions. Based on WHO-CHOICE guidelines, the risk-stratified approach was very cost effective for all categories of patients.

CONCLUSIONS

Risk-stratified approach to treat childhood ALL is very cost-effective for all categories in our setting. The cost for SR and IR patients is significantly reduced through decreased IP admissions for both, chemotherapy and non-chemotherapy reasons.

Lung Cancer Management in Low and Middle-Income Countries

Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.

Smokeless tobacco use and oral potentially malignant disorders among people living with HIV (PLHIV) in Pune, India: Implications for oral cancer screening in PLHIV

INTRODUCTION

In India, smokeless tobacco (SLT) is a predominant form of tobacco used among people living with HIV (PLHIV). Despite SLT being a risk factor for oral potentially malignant disorders (OPMDs), no prior studies have quantified the association of OPMDs with SLT use among PLHIV. This limits the planning of preventive and control strategies for oral cancer among PLHIV, who are at higher risk for the disease.

METHODS

We enrolled 601 PLHIV and 633 HIV-uninfected individuals in an oral cancer screening study at BJ Government Medical College, Pune, India. Oral cavity images were collected using an m-Health application and reviewed by three clinicians. Participants with two clinician positive diagnoses were deemed to have suspected OPMDs. Prevalence ratios (PRs) were used to quantify the association between suspected OPMDs and SLT use among PLHIV. PRs for current SLT users, across HIV status and use duration were also estimated. Corrected PRs were obtained by modifying the maximum likelihood estimation. Models were adjusted for age, smoking, alcohol use and CD4 counts.

RESULTS

Of those enrolled, 61% were men, median age was 36 years (IQR: 28-44), and 33% currently use SLT. Proportion of current SLT users was similar across PLHIV and HIV-uninfected groups but use duration for current SLT use was higher among PLHIV(p<0.05). Among PLHIV, current SLT users had a 5-times (95% CI:3.1-7.0) higher prevalence of suspected OPMDs, compared to non-users. Relative to HIV uninfected individuals with the same SLT use duration, significant associations with suspected OPMDs were seen for PLHIV with<10 use years (PR: 3.5, 95% CI: 1.5-8.1) but not for PLHIV with≥10 use years (PR: 1.3, 95% CI: 0.9-1.8).

CONCLUSION

PLHIV that are current SLT users are at high risk of OPMDs and potentially oral cancer. The development of strategies for screening, early detection, and management of OPMDs must be considered for this group.

Cancer Medicines: What Is Essential and Affordable in India?

PURPOSE

The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are available in routine practice.

METHODS

This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice.

RESULTS

The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P < .001) and work exclusively in the private health system (52% v 17%, P < .001). 14/20 most commonly selected medicines were conventional cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system.

CONCLUSION

Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India.

Digital Inequalities in Cancer Care Delivery in India: An Overview of the Current Landscape and Recommendations for Large-Scale Adoption

Introduction

COVID-19 pandemic has caused major disruptions to delivery of various cancer care services as efforts were put to control the outbreak of the pandemic. Although the pandemic has highlighted the inadequacies of the system but has also led to emergence of a new cancer care delivery model which relies heavily on digital mediums. Digital health is not only restricted to virtual dissemination of information and consultation but has provided additional benefits ranging from support to cancer screening, early and more accurate diagnosis to increasing access to specialized care. This paper evaluates the challenges in the adoption of digital technologies to deliver cancer care services and provides recommendation for large-scale adoption in the Indian healthcare context.

Methods

We performed a search of PubMed and Google Scholar for numerous terms related to adoption of digital health technologies for cancer care during pandemic. We also analyze various socio-ecological challenges—from individual to community, provider and systematic level—for digital adoption of cancer care service which have existed prior to pandemic and lead to digital inequalities.

Results

Despite encouraging benefits accruing from the adoption of digital health key challenges remain for large scale adoption. With respect to user the socio-economic characteristics such as age, literacy and socio-cultural norms are the major barriers. The key challenges faced by providers include regulatory issues, data security and the inconvenience associated with transition to a new system.

Policy Summary

For equitable digital healthcare, the need is to have a participatory approach of all stakeholders and urgently addressing the digital divide adequately. Sharing of health data of public and private hospitals, within the framework of the Indian regulations and Data Protection Act, is critical to the development of digital health in India and it can go a long way in better forecasting and managing cancer burden.

Burden of cancers in India - estimates of cancer crude incidence, YLLs, YLDs and DALYs for 2021 and 2025 based on National Cancer Registry Program

Background

Cancer is the major cause of morbidity and mortality worldwide. The cancer burden varies within the regions of India posing great challenges in its prevention and control. The national burden assessment remains as a task which relies on statistical models in many developing countries, including India, due to cancer not being a notifiable disease. This study quantifies the cancer burden in India for 2016, adjusted mortality to incidence (AMI) ratio and projections for 2021 and 2025 from the National Cancer Registry Program (NCRP) and other publicly available data sources.

Methods

Primary data on cancer incidence and mortality between 2012 and 2016 from 28 Population Based Cancer Registries (PBCRs), all-cause mortality from Sample Registration Systems (SRS) 2012–16, lifetables and disability weight from World Health Organization (WHO), the population from Census of India and cancer prevalence using the WHO-DisMod-II tool were used for this study. The AMI ratio was estimated using the Markov Chain Monte Carlo method from longitudinal NCRP-PBCR data (2001–16). The burden was quantified at national and sub-national levels as crude incidence, mortality, Years of Life Lost (YLLs), Years Lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs). The projections for the years 2021 and 2025 were done by the negative binomial regression model using STATA.

Results

The projected cancer burden in India for 2021 was 26.7 million DALYs_AMI and expected to increase to 29.8 million in 2025. The highest burden was in the north (2408 DALYs_AMI per 100,000) and northeastern (2177 DALYs_AMI per 100,000) regions of the country and higher among males. More than 40% of the total cancer burden was contributed by the seven leading cancer sites — lung (10.6%), breast (10.5%), oesophagus (5.8%), mouth (5.7%), stomach (5.2%), liver (4.6%), and cervix uteri (4.3%).

Conclusions

This study demonstrates the use of reliable data sources and DisMod-II tools that adhere to the international standard for assessment of national and sub-national cancer burden. A wide heterogeneity in leading cancer sites was observed within India by age and sex. The results also highlight the need to focus on non-leading sites of cancer by age and sex. These findings can guide policymakers to plan focused approaches towards monitoring efforts on cancer prevention and control. The study simplifies the methodology used for arriving at the burden estimates and thus, encourages researchers across the world to take up similar assessments with the available data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09578-1.