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Hande V, Chopra S, Polo A, Mittal P, Kohle S, Ghadi Y, Mulani J, Gupta A, Kinhikar R, Agarwal JP. Transitioning India to advanced image based adaptive brachytherapy: a national impact analysis of upgrading National Cancer Grid cervix cancer guidelines. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 16:100218. [PMID: 37694176 PMCID: PMC10485789 DOI: 10.1016/j.lansea.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/05/2023] [Accepted: 05/03/2023] [Indexed: 09/12/2023]
Abstract
Background High-dose-rate image guided brachytherapy (IGBT) for cervical cancer leads to improved local control and reduced toxicity and is a critical component of treatment. However, transition to IGBT requires capacity upscaling. An institutional activity mapping and national impact analysis of such a transition were undertaken to understand feasibility. Methods Between September 2020 and March 2021, activity mapping was conducted in a high-volume centre that triaged cervical cancer patients for brachytherapy into four workflows; A: two-dimensional (2D) X-Ray point A-based intracavitary brachytherapy, B: CT point A-based intracavitary brachytherapy, C: MRI/CT-volume based intracavitary brachytherapy, D: MRI/CT volume-based intracavitary +/- interstitial brachytherapy. Clinical process time mapping was performed, and case scenarios for transition were modelled at the institutional and national levels based on available incidence and infrastructure levels. Treatment capacity changes were calculated, and potential strategies for workflow reorganisation were proposed. Findings Eighty-four patients were included in the study. The total time taken for the workflows A, B, C, and D were 176 min (57-208), 224 min (74-260), 267 min (101-302), and 348 min (232-383), respectively. The transition from workflow A to D through sequential steps led to 35%, 49%, and 64% loss of treatment capacity in the index institution. Solutions such as 10-hour or 12-hour overlapping shifts increased treatment capacity by 25% and 50% and performing single implants and delivering multiple fractions increased capacity by 100%. Twenty-three Indian states and Union Territories are predicted to be able to transition to advanced workflows. For four Indian states, it may be detrimental considering the current infrastructure level, and eight Indian states lacked brachytherapy access. Further financial investment is required in the latter 12 states for transition to advanced workflows. Interpretation Our study demonstrates that unplanned transition to IGBT can lead to treatment capacity loss and increase in waiting lists to access treatment. The proposed solutions of workflow reorganisation, using strategies such as single brachytherapy applicator implant and delivering multiple treatment fractions can improve access to treatment for women with cervix cancer in resource-strained and high patient-volume settings. We recommend state-wise solutions for the upscale from conventional 2D workflows to IGBT, subject to the availability of skilled personnel, infrastructure and training. Financial investments may be needed in some states to achieve this goal. Funding International Atomic Energy Agency (IAEA) supported the salary of VH through project E33042 that focussed on implementation strategies of image guided brachytherapy.
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Affiliation(s)
- Varsha Hande
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Supriya Chopra
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Alfredo Polo
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Prachi Mittal
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Satish Kohle
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Yogesh Ghadi
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Jaahid Mulani
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Ankita Gupta
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Rajesh Kinhikar
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
| | - Jai Prakash Agarwal
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Maharashtra, India
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Kulkarni R, Gupta S. Gynaecological Oncology in India: Past, Present and Future. Indian J Surg Oncol 2022; 13:76-80. [PMID: 36691500 PMCID: PMC9860008 DOI: 10.1007/s13193-022-01668-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
Abstract
Gynaecological cancers contribute to a substantial portion of the global cancer burden. Traditionally, these cancers have been treated by generalists, including gynaecologists and surgeons. However, owing to increasing sophistication and challenges in their management, a new sub-speciality of Gynaecologic Oncology, dedicated to these women's comprehensive care, has emerged in recent times. The emergence and evolution of this sub-speciality will facilitate a holistic approach to treating women suffering from gynaecological cancers, including tailored surgical techniques, fertility preservation, precision medicine, hormone modulators, targeted therapy and immunotherapy, which can be achieved within the framework of multidisciplinary management. Hence, we decided to write this synopsis to shed light on the evolution of this discipline in India and offer current and future perspectives.
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Affiliation(s)
- Rohini Kulkarni
- Department of Gynaecological Oncology, Tata Memorial Centre, Homi Baba National Institute, Mumbai, 400012 India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012 Maharashtra India
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Maluf FC, Zibetti GDM, Paulino E, de Melo AC, Racy D, Ferrigno R, Uson Junior PLS, Ribeiro R, Moretti R, Sadalla JC, Nogueira Rodrigues A, Carvalho FM, Baiocchi G, Callegaro-Filho D, Angioli R. Recommendations for the treatment of vulvar cancer in settings with limited resources: Report from the International Gynecological Cancer Society consensus meeting. Front Oncol 2022; 12:928568. [PMID: 36203438 PMCID: PMC9530794 DOI: 10.3389/fonc.2022.928568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/25/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Due to scant literature and the absence of high-level evidence, the treatment of vulvar cancer is even more challenging in countries facing limited resources, where direct application of international guidelines is difficult. Recommendations from a panel of experts convened to address some of these challenges were developed. Methods The panel met in Rio de Janeiro in September 2019 during the International Gynecological Cancer Society congress and was composed of specialists from countries in Africa, Asia, Eastern Europe, Latin America, and the Middle East. The panel addressed 62 questions and provided recommendations for the management of early, locally advanced, recurrent, and/or metastatic vulvar cancer. Consensus was defined as at least 75% of the voting members selecting a particular recommendation, whereas a majority vote was considered when one option garnered between 50.0% and 74.9% of votes. Resource limitation was defined as any issues limiting access to qualified surgeons, contemporary imaging or radiation-oncology techniques, antineoplastic drugs, or funding for the provision of contemporary medical care. Results Consensus was reached for nine of 62 (14.5%) questions presented to the panel, whereas a majority vote was reached for 29 (46.7%) additional questions. For the remaining questions, there was considerable heterogeneity in the recommendations. Conclusion The development of guidelines focusing on areas of the world facing more severe resource limitations may improve medical practice and patient care.
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Affiliation(s)
- Fernando Cotait Maluf
- Hospital BP Mirante, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- *Correspondence: Fernando Cotait Maluf,
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Maluf FC, Dal Molin GZ, de Melo AC, Paulino E, Racy D, Ferrigno R, Uson Junior PLS, Ribeiro R, Moretti R, Sadalla JC, Nogueira-Rodrigues A, Carvalho FM, Baiocchi G, Callegaro-Filho D, Abu-Rustum NR. Recommendations for the prevention, screening, diagnosis, staging, and management of cervical cancer in areas with limited resources: Report from the International Gynecological Cancer Society consensus meeting. Front Oncol 2022; 12:928560. [PMID: 36059643 PMCID: PMC9434552 DOI: 10.3389/fonc.2022.928560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/01/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Nearly 85% of cervical cancer new cases are diagnosed in limited resources countries. Although several strategies have been proposed to reduce the disease burden, challenges remain to provide the best possible care. We report recommendations from an expert consensus meeting convened to address from prevention to management of cervical cancer in limited resources countries. Methods The expert panel, composed by invited specialists from 38 developing countries in Africa, Asia, Eastern Europe, Latin America, and the Middle East, convened in Rio de Janeiro in September 2019, during the Global Meeting of the International Gynecological Cancer Society (IGCS). Panel members considered the published scientific evidence and their practical experience on the topics, as well as the perceived cost-effectiveness of, and access to, the available interventions. The focus of the recommendations was on geographic regions rather than entire countries because medical practice varies considerably in the countries represented. Resource limitation was qualified as limited access to qualified surgeons, contemporary imaging or radiation-oncology techniques, antineoplastic drugs, or overall funding for provision of state-of-the-art care. Consensus was defined as at least 75% of the voting members selecting a particular answer of the multiple-choice questionnaire, whereas the majority vote was considered as 50% to 74.9%. Results Consensus was reached for 25 of the 121 (20.7%) questions, whereas for 54 (44.6%) questions there was one option garnering between 50% to 74.9% of votes (majority votes). For the remaining questions, considerable heterogeneity in responses was observed. Discussion The implementation of international guidelines is challenging in countries with resource limitations or unique health-care landscapes. The development of guidelines by the health care providers in those regions is more reflective of the reality on the ground and may improve medical practice and patient care. However, challenges remain toward achieving that goal at political, economic, social, and medical levels.
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Affiliation(s)
- Fernando Cotait Maluf
- Hospital Beneficiência Portuguesa (BP) Mirante, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- *Correspondence: Fernando Cotait Maluf,
| | | | | | | | - Douglas Racy
- Hospital Beneficiência Portuguesa (BP) Mirante, São Paulo, Brazil
| | - Robson Ferrigno
- Hospital Beneficiência Portuguesa (BP) Mirante, São Paulo, Brazil
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Shinghal A, Paul S, Chopra S, Gurram L, Scaria L, Kohle S, Rane P, A D, Puravath J, Jain J, Swamidas J, Ghosh J, Gupta S, Rath S, Laskar SG, Agarwal JP. Effect of COVID-19 Pandemic on Gynecological Cancer Radiation During Complete Nationwide Lockdown: Observations and Reflections From Tertiary Care Institute in India. Adv Radiat Oncol 2021; 6:100725. [PMID: 34075350 PMCID: PMC8159674 DOI: 10.1016/j.adro.2021.100725] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/29/2021] [Accepted: 05/07/2021] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To report real-world compliance to radiation in gynecologic cancers during the complete lockdown phase of COVID-19 pandemic. METHODS AND MATERIALS From March 23, 2020, until June 30, 2020, complete lockdown was imposed in India. During this period there was restructuring of cancer care and radiation oncology department due to operational policies prevalent in the institution, and the care for gynecological cancer was based on the evolving international recommendations. Institutional review board approval was obtained to audit patterns of care during the complete lockdown phase. Descriptive variables were used to report on patient characteristics, compliance, delays, toxicity, and observed deviations in recommended care. RESULTS During the lockdown period spanning 100 days, treatment of 270 and telephonic follow-up of 1103 patients with gynecological cancer was undertaken. Of 270 new patients, due to travel restrictions, 90 patients were referred to the facilities in vicinity of their residence. Of the remaining 180 patients, 138 were planned for complete treatment at our institution and 42 were referred to our center for brachytherapy. Of 138 patients, only 106 (76%) completed the planned external radiation. Twenty-four (26%) patients completed full course of concurrent chemotherapy, 11 (12%) received chemotherapy dose reduction, and 57 (62%) received no concurrent chemotherapy. Treatment delay of up to 3 weeks was noted in 8.6% patients due to COVID-19 infection. No grade 4 to 5 acute sequelae were observed. No excess adverse effects were observed in high-risk population. Low rate of symptom burden was observed among 1103 patients on telephonic follow-up. With 100 (9.6%) patients reporting symptoms, among these, 54% (54 of 100) had complete resolution of symptoms within 4 weeks of teleconsultation, and 10% had disease progression. CONCLUSIONS Low compliance with planned treatment was observed for radiation and concurrent chemotherapy due to lockdown and fear of contracting COVID-19 and will likely lead to increased risk of cancer-related mortality. Rapid restructuring of care is needed to prevent the same as COVID-19 pandemic further evolves.
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Affiliation(s)
- Abhishek Shinghal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Sonz Paul
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre For Treatment and Education in cancer, Tata Memorial Centre (ACTREC), Parel, Homi Bhabha National Institute, Mumbai, India
- Corresponding author: Supriya Chopra
| | - Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Libin Scaria
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Satish Kohle
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Priyanka Rane
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Dheera A
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - John Puravath
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Jivanshu Jain
- Department of Radiation Oncology, Advanced Centre For Treatment and Education in cancer, Tata Memorial Centre (ACTREC), Parel, Homi Bhabha National Institute, Mumbai, India
| | - Jamema Swamidas
- Department of Radiation Oncology, Advanced Centre For Treatment and Education in cancer, Tata Memorial Centre (ACTREC), Parel, Homi Bhabha National Institute, Mumbai, India
| | - Jaya Ghosh
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Mumbai, India
| | - Sushmita Rath
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Mumbai, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Parel, Homi Bhabha National Institute, Mumbai, India
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Kumar A, Chopra S, Gupta S. Contribution of Tata Memorial Centre, India, to cervical cancer care: Journey of two decades. Indian J Med Res 2021; 154:319-328. [PMID: 35295006 PMCID: PMC9131759 DOI: 10.4103/ijmr.ijmr_339_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Cervical cancer continues to be a major public health concern in India and other low- and middle-income countries. Tata Memorial Centre, India, has been at the forefront in providing treatment, developing best practice guidelines for low-cost efficacious interventions, conducting practice-changing randomized trials and engaging in regional and international collaborations for education and research in cervical cancer. This review summarizes how cervical cancer research and clinical care has evolved over the past two decades at the Tata Memorial Centre, right from testing low-cost public health screening of cervical cancers to the incorporation of the latest technological advancements and providing high-quality evidence for therapeutic management of cervical cancer. The various ongoing strategies for improving survival, toxicity reduction, translational research studies, educational activities and teaching programmes initiated by the Tata Memorial Centre at both national and international levels are discussed.
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Affiliation(s)
- Anuj Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India,For correspondence: Dr Supriya Chopra, Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 400 012, Maharashtra, India e-mail:
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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7
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Mansha MA, Sadaf T, Waheed A, Munawar A, Rashid A, Chaudry SJ. Long-Term Toxicity and Efficacy of Intensity-Modulated Radiation Therapy in Cervical Cancers: Experience of a Cancer Hospital in Pakistan. JCO Glob Oncol 2021; 6:1639-1646. [PMID: 33112682 PMCID: PMC7605376 DOI: 10.1200/go.20.00169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To report the chronic toxicity and disease outcomes attributable to intensity-modulated radiation therapy (IMRT) in patients with cervical cancer. METHODS AND MATERIALS Between January 2014 and December 2018, a retrospective review of medical records of patients with cervical cancer who received radiation therapy with IMRT was performed. Disease and treatment-related details were documented. Follow-up notes were reviewed, and severity of late toxicities was recorded. Overall survival (OS) and disease-free survival (DFS) at 3 years were estimated. RESULTS A total of 222 patients’ records were reviewed. Mean age was 50.7 years. Median follow-up duration was 33 months (range, 2-70 months). The most common toxicity was vaginal stricture (grade 2, n = 59, 26.6%; grade 3, n = 4, 1.80%), followed by proctitis (grade 2, n = 24; 10.8%; grade 3, n = 7; 3.20%). Seven patients (grade 2, n = 5, 2.3%; grade 3, n = 2; 0.90%) developed cystitis, and only 5 (grade 2; 2.3%) were found to have colitis. None of the patients had grade 4 or grade 5 toxicities. There was a significant difference in late complications in patients with nodal disease or those who underwent prior surgery (P < .05). Three-year OS and DFS rates were 79.7% and 81.9%, respectively. Patients with tumor size > 5 cm and those with pelvic lymph node metastasis had poor survival rates (P < .05). CONCLUSION IMRT is an effective and well-tolerated technique that should be considered in patients with lymph node disease and in postoperative patients. There is an inverse relationship between tumor size and nodal involvement with respect to OS and DFS.
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Affiliation(s)
- Muhammad Atif Mansha
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Tabinda Sadaf
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Asmara Waheed
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Amna Munawar
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Asma Rashid
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Samreen Javed Chaudry
- Clinical and Radiation Oncology Department, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
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8
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Swamidas J, Pradhan S, Chopra S, Panda S, Gupta Y, Sood S, Mohanty S, Jain J, Joshi K, Ph R, Gurram L, Mahantshetty U, Prakash Agarwal J. Development and clinical validation of Knowledge-based planning for Volumetric Modulated Arc Therapy of cervical cancer including pelvic and para aortic fields. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 18:61-67. [PMID: 34258410 PMCID: PMC8254199 DOI: 10.1016/j.phro.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 12/24/2022]
Abstract
A knowledge-based planning model was configured for VMAT of cervical cancer. Knowledge-based plans were comparable, and for some OARs, outperformed clinical plans. Improved organ sparing was observed, when individual patient geometry was considered.
Background and Purpose Knowledge-based planning (KBP) is based on a model to estimate dose-volume histograms, configured using a library of historical treatment plans to efficiently create high quality plans. The aim was to report configuration and validation of KBP for Volumetric Modulated Arc Therapy of cervical cancer. Materials and methods A KBP model was configured from the institutional database (n = 125), including lymph node positive (n = 60) and negative (n = 65) patients. KBP Predicted plans were compared with Clinical Plans (CP) and Re-plans (Predicted plan as a base-plan) to validate the model. Model quality was quantified using coefficient of determination R2, mean square error (MSE), standard two-tailed paired t-test and Wilcoxon signed rank test. Results Estimation capability of the model was good for the bowel bag (MSE = 0.001, R2 = 0.84), modest for the bladder (MSE = 0.008) and poor for the rectum (MSE = 0.02 R2 = 0.78). KBP resulted in comparable target coverage, superior organ sparing as compared to CP. Re-plans outperformed CP for the bladder, V30 (66 ± 11% vs 74 ± 11%, p < .001), V40 (48 ± 14% vs 52 ± 14%, p < .001), however sparing was modest for the bowel bag V30 (413 ± 191cm3 vs 445 ± 208cm3, p = .037) V40 (199 ± 105cm3 vs 218 ± 127cm3, p = .031). All plans were comparable for rectum, while KBP resulted in significant sparing for spinal cord, kidneys and femoral heads. Conclusion KBP yielded comparable and for some organs superior performance compared to CP resulting in conformal and homogeneous target coverage. Improved organ sparing was observed when individual patient geometry was considered.
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Affiliation(s)
- Jamema Swamidas
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Sangram Pradhan
- Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Subhajit Panda
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Yashna Gupta
- Department of Radiotherapy, All India Institute of Medical Sciences, Rishikesh, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Sahil Sood
- Homi Bhabha National Institute, Mumbai, India.,Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Samarpita Mohanty
- Homi Bhabha National Institute, Mumbai, India.,Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Jeevanshu Jain
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Kishore Joshi
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Reena Ph
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Lavanya Gurram
- Homi Bhabha National Institute, Mumbai, India.,Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Umesh Mahantshetty
- Homi Bhabha National Institute, Mumbai, India.,Department of Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Vishakapatnam, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Jai Prakash Agarwal
- Homi Bhabha National Institute, Mumbai, India.,Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India.,Department of Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
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Carvajal F, Carvajal C, Merino T, López V, Retamales J, Martín ES, Alarcón F, Cuevas M, Barahona F, Véliz I, Ríos JA, Becerra S. Radiotherapy for cervical cancer: Chilean consensus of the Society of Radiation Oncology. ACTA ACUST UNITED AC 2021; 26:291-302. [PMID: 34211780 DOI: 10.5603/rpor.a2021.0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 01/30/2021] [Indexed: 11/25/2022]
Abstract
Background Cervical cancer is a public health problem in Latin America. Radiotherapy plays a fundamental role both as definitive or adjuvant treatment. There are important intra and inter-country differences regarding access and availability of radiotherapy facilities in this region. The aim of a study was to standardize the basic clinical and technical criteria for the radiation treatment of patients with CC in Chile and provide a guide for Latin American Radiation Oncologists. Materials and methods Forty-one expert radiation oncologists from the Chilean Radiation Oncology Society made a consensus using the Delphi methodology. Results There was a high degree of agreement for each of the recommendations. Those with the lowest percentage were related to the definition of the conformal 3D technique as the standard for definitive external radiotherapy (81%) and the criteria for extended nodal irradiation (85%). Conclusions These recommendations present an updated guide for radiotherapy treatment of patients with cervical cancer for Latin America. Those should be implemented according to local resources of each institution.
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Affiliation(s)
- Felipe Carvajal
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile.,Departamento de Oncología Básico Clínica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Claudia Carvajal
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Tomás Merino
- Departamento de Hemato-Oncolgía. Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento del Cáncer, Ministerio de Salud, Santiago, Chile
| | - Verónica López
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Javier Retamales
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Evelyn San Martín
- Departamento de Radio Oncología, Hospital Clínico de Magallanes, Punta Arenas, Chile
| | - Freddy Alarcón
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Mónica Cuevas
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Francisca Barahona
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Ignacio Véliz
- Departamento de Radio Oncología, Instituto Nacional del Cáncer, Santiago, Chile
| | - Juvenal A Ríos
- Programas para el Futuro, Facultad de Estudios Interdisciplinarios, y Escuela de Medicina, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
| | - Sergio Becerra
- Departamento del Cáncer, Ministerio de Salud, Santiago, Chile
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10
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Chauhan AS, Prinja S, Srinivasan R, Rai B, Malliga JS, Jyani G, Gupta N, Ghoshal S. Cost effectiveness of strategies for cervical cancer prevention in India. PLoS One 2020; 15:e0238291. [PMID: 32870941 PMCID: PMC7462298 DOI: 10.1371/journal.pone.0238291] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/13/2020] [Indexed: 01/20/2023] Open
Abstract
The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30-65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort.
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Affiliation(s)
- Akashdeep Singh Chauhan
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytology and Gynaecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhavana Rai
- Department of Radiation Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - JS Malliga
- Department of Preventive Oncology, Cancer Institute (WIA), Adyar, Chennai, India
| | - Gaurav Jyani
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Sushmita Ghoshal
- Department of Radiation Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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11
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Chopra S, Mittal P, Viswanathan A, Tharavichitkul E, Zubizarreta E, Nout RA, Yap ML, Grover S, Rodin D, Rai B, Gondhowiardjo S, Shrivastava SK. Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all? Clin Oncol (R Coll Radiol) 2019; 31:529-538. [PMID: 31229379 DOI: 10.1016/j.clon.2019.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/11/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
Despite the advances in the primary prevention of cervical cancer, there is an absolute increase in the incidence of cervical cancer as a result of an increase in world population. A vast majority of patients in low and low-middle income countries continue to present at a locally advanced stage, necessitating treatment with chemoradiation and brachytherapy. There is a dearth of equipment and trained professionals for the treatment of cervical cancer, especially in low and low-middle income countries. There is an urgent need to improve treatment availability and develop better treatments. Worldwide trends, however, reveal a low number of therapeutic and innovative research trials in cervical cancer. The present article elucidates the existing challenges and provides solutions to improve outcomes. The proposed strategies hinge on strengthening collaborations for global advocacy.
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Affiliation(s)
- S Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - P Mittal
- Homi Bhabha National Institute, Mumbai, India; Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - A Viswanathan
- Department of Radiation Oncology, Johns Hopkins University Medical Center, Baltimore, Maryland, USA
| | - E Tharavichitkul
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - E Zubizarreta
- Division of Human Health, International Atomic of Energy Agency - Vienna International Centre, Vienna, Austria
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Center LUM, Leiden, the Netherlands
| | - M L Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, New South Wales, Australia; Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, New South Wales, Australia; School of Public Health, The University of Sydney, Camperdown, Australia
| | - S Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA; Botswana-UPENN Partnership, University of Botswana, Gaborone, Botswana
| | - D Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - B Rai
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Gondhowiardjo
- Department of Radiotherapy, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - S K Shrivastava
- Department of Radiation Oncology, Apollo Hospital, Belapur, Navi Mumbai, India
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12
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Chopra S, Shukla R, Budukh A, Shrivastava SK. External Radiation and Brachytherapy Resource Deficit for Cervical Cancer in India: Call to Action for Treatment of All. J Glob Oncol 2019; 5:1-5. [PMID: 31166825 PMCID: PMC6613665 DOI: 10.1200/jgo.18.00250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Supriya Chopra
- Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Richa Shukla
- Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Atul Budukh
- Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
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13
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Chuang L. Can We Apply National Cancer Grid of India Consensus Guidelines for the Management of Cervical Cancer in Low-Resource Settings? J Glob Oncol 2018; 4:1-4. [PMID: 30085893 PMCID: PMC6223502 DOI: 10.1200/jgo.18.00074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Linus Chuang
- Western Conneticut Health Network, Larner College of Medicine at University of Vermont, Danbury, VT
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