Concurrent Chemoradiation for Cancer of the Cervix: Results of a Multi-Institutional Study From the Setting of a Developing Country (India)

Strengthening Cancer Surveillance in India: Role of the National Cancer Registry Programme

Cancer registries are an integral part of cancer surveillance and play a vital role in collecting and managing surveillance data. The National Cancer Registry Programme in India, which has been functional since 1981, has a wide network of 269 hospital-based and 38 population-based cancer registries functioning throughout the country. Cancer registries monitor and describe the trends in cancer incidence and mortality over time. They also provide vital information on the cancer caseload, such as the number of cancer patients in a specified location or the number of patients availing of care at a specific hospital. As a part of cancer surveillance, registries also play a critical role in designing cancer control plans, gauging the impact of primary and secondary preventive measures, and strengthening health systems. The data on cancer incidence have provided critical inputs to the central, state, and local government to plan, prioritize, and mobilize health resources for cancer control interventions. The role of cancer registries as a surveillance tool could be further strengthened by long-term sustainability through strong political will, making cancer a notifiable disease to facilitate reporting and linking cancer registries with medical records for better data capture.

Pre-treatment hematological parameters as a cost effective predictive marker for response to concurrent chemo radiation in locally advanced cervical cancer

INTRODUCTION

Locally advanced cervical cancer is still a major cause of mortality in developing countries. Recently, personalized medicine has changed the treatment paradigm for many solid cancers but no robust biomarkers has yet been validated for predicting response to chemo radiation in cervical cancer patients.

AIM

To assess the role of hematological parameters as a cost-effective predictive marker of response to concurrent chemo radiation in cervical cancer patients.

MATERIALS AND METHOD

This is a retrospective analysis of 90 cervical cancer patients treated with concurrent chemo radiation in a tertiary cancer center. Clinical details of the patients were extracted from the case records. For end point evaluation, the pre-treatment levels of hemoglobin, neutrophil, lymphocyte, platelet, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) were compared and statistically analyzed between responders and non-responders. The optimal cutoff values of hematological parameters were estimated by the receiver operating characteristics (ROC) curve.

RESULT

Out of 90 patients, 60 (66.66%) were complete responders and remaining 30 (33.33%) were non-responders. The mean value of platelet, NLR, and PLR was significantly higher in the non-responder group. ROC curve analysis showed the optimal cut-off value of pre-treatment Hb, PLT, NLR and PLR to be 11 gm/dl, 3, 177 × 109/L, and 70 respectively.

CONCLUSION

Our study suggests that simple hematological markers like NLR, PLT count and PLR could be used as a cost effective pretreatment predictive marker for response to chemo radiation in cervical cancer patients.

Cancer Statistics, 2020: Report From National Cancer Registry Programme, India

PURPOSE

The systematic collection of data on cancer is being performed by various population-based cancer registries (PBCRs) and hospital-based cancer registries (HBCRs) across India under the National Cancer Registry Programme–National Centre for Disease Informatics and Research of Indian Council of Medical Research since 1982.

METHODS

This study examined the cancer incidence, patterns, trends, projections, and mortality from 28 PBCRs and also the stage at presentation and type of treatment of patients with cancer from 58 HBCRs (N = 667,666) from the pooled analysis for the composite period 2012-2016. Time trends in cancer incidence rate were generated as annual percent change from 16 PBCRs (those with a minimum of 10 years of continuous good data available) using Joinpoint regression.

RESULTS

Aizawl district (269.4) and Papumpare district (219.8) had the highest age-adjusted incidence rates among males and females, respectively. The projected number of patients with cancer in India is 1,392,179 for the year 2020, and the common 5 leading sites are breast, lung, mouth, cervix uteri, and tongue. Trends in cancer incidence rate showed an increase in all sites of cancer in both sexes and were high in Kamrup urban (annual percent change, 3.8%; P < .05). The majority of the patients with cancer were diagnosed at the locally advanced stage for breast (57.0%), cervix uteri (60.0%), head and neck (66.6%), and stomach (50.8%) cancer, whereas in lung cancer, distant metastasis was predominant among males (44.0%) and females (47.6%).

CONCLUSION

This study provides a framework for assessing the status and trends of cancer in India. It shall guide appropriate support for action to strengthen efforts to improve cancer prevention and control to achieve the national noncommunicable disease targets and the sustainable development goals.

Locally Advanced Breast Cancer (LABC): Real-World Outcome of Patients From Cancer Institute, Chennai

PURPOSE

There are sparse data on the outcome of patients with locally advanced breast cancer (LABC). This report is on the prognostic factors and long-term outcome from Cancer Institute, Chennai.

METHODS

This is an analysis of untreated patients with LABC (stages IIIA-C) who were treated from January 2006 to December 2013.

RESULTS

Of the 4,577 patients with breast cancer who were treated, 2,137 patients (47%) with LABC were included for analysis. The median follow-up was 75 months (range, 1-170 months), and 2.3% (n = 49) were lost to follow-up at 5 years. The initial treatment was neoadjuvant concurrent chemoradiation (NACR) (77%), neoadjuvant chemotherapy (15%), or others (8%). Patients with triple-negative breast cancer had a pathologic complete response (PCR) of 41%. The 10-year overall survival was for stage IIIA (65.1%), stage IIIB (41.2%), and stage IIIC (26.7%). Recurrence of cancer was observed in 27% of patients (local 13% and distant 87%). Multivariate analysis showed that patients with a tumor size > 10 cm (hazard ratio [HR], 2.19; 95% CI, 1.62 to 2.98; P = .001), hormone receptor negativity (HR, 1.45; 95% CI, 1.22 to 1.72; P = .001), treatment modality (neoadjuvant chemotherapy, HR, 0.56; 95% CI, 0.43 to 0.73; P = .001), lack of PCR (HR, 2.36; 95% CI, 1.85 to 3.02; P = .001), and the presence of lymphovascular invasion (HR, 1.97; 95% CI, 1.60 to 2.44; P = .001) had decreased overall survival.

CONCLUSION

NACR was feasible in inoperable LABC and gave satisfactory long-term survival. PCR was significantly higher in patients with triple-negative breast cancer. The tumor size > 10 cm was significantly associated with inferior survival. However, this report acknowledges the limitations inherent in experience of management of LABC from a single center.

Patterns of cervical cancer brachytherapy in India: results of an online survey supported by the Indian Brachytherapy Society

Purpose

Cervical cancer is the most common gynecological cancer in India. Uniform protocol-based treatment is important for achieving optimal outcomes. We undertook a survey to investigate patterns of care with special regard to patterns of care in cervical cancer brachytherapy in India.

Material and methods

A 17-question online survey was sent to radiation oncologists across India. Respondents were required to have a minimum of 1-year experience. One response per center was accepted and deemed as representative.

Results

Out of 116 centers, 59 responses were generated. Two-thirds (66.1%) were from academic centers and the majority (96.6%) used high-dose-rate (HDR) brachytherapy. The centers treated an average of 255 patients per year (median 161 patients, IQR 76-355). The majority were locally advanced cancers (FIGO 2009 stage II-IV 87.5%). External beam radiotherapy (EBRT) schedules were fairly consistent, administering doses of 45-50 Gy over 5 weeks. Brachytherapy was performed towards EBRT completion by 37/59 (62%) and 43/59 (74.3%) centers used a schedule of 7 Gy × 4 fractions (HDR). Brachytherapy was commonly performed under anesthesia (spinal/general: 44% each) with ultrasound (USG) guidance (29%). Computed tomography (CT) imaging (65%) and orthogonal X-rays (35%) represented the most common imaging for planning, while point A prescription (66%) or GEC-ESTRO based parameters (35%) with manual/geometric methods represented the most common methodology for dose volume prescription and optimization. Overall treatment time (OTT) reported was within 49-56 days in 50%. Complex implants (IC + IS) were performed for more than 30% of cases by 3 centers.

Conclusions

Our survey suggested a fairly uniform treatment paradigm for cervical cancer brachytherapy, with a progressive shift from 2D to 3D image-based parameters for planning, with persistence of point A based prescription. Further efforts are needed to augment and ease this transition.

Cisplatin Chemoradiotherapy vs Radiotherapy in FIGO Stage IIIB Squamous Cell Carcinoma of the Uterine Cervix: A Randomized Clinical Trial

Importance

The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology and Obstetrics (FIGO) stage IIIB squamous cell carcinoma of the uterine cervix is not robust. This study reports the final results of a randomized clinical trial of concurrent cisplatin-based CT-RT and radiotherapy alone (RT) in women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix.

Objective

To investigate the benefit of concurrent CT-RT in FIGO stage IIIB squamous cell carcinoma of the uterine cervix.

Design, Setting, and Participants

This phase 3 open-label randomized clinical trial accrued 850 women in Mumbai, India, between July 7, 2003, and September 22, 2011. Of 2121 screened, 850 women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix suitable for concurrent cisplatin chemotherapy were randomly assigned to CT-RT and RT using block randomization (1:1). The data were updated for a minimum follow-up period of 5 years until December 2016. The final analyses were performed in February and March 2017. This single-institution study was conducted at a tertiary cancer center setting.

Interventions

Randomization to receive RT (RT arm), comprising a combination of external beam RT (50 Gy in 25 fractions over 5 weeks) and brachytherapy, or to receive in addition to the same RT concurrent weekly cisplatin chemotherapy (40 mg/m2 per week) (CT-RT arm).

Main Outcomes and Measures

The primary end point was 5-year disease-free survival (DFS), defined as the time between the date of randomization and the date of any recurrence or death (whichever occurred first) in the intent-to-treat population.

Results

This trial included 424 women assigned to CT-RT (mean [SD] age, 49.4 [7.9] years) and 426 women assigned to RT (mean [SD] age, 49.3 [7.9] years). At a median follow-up of 88 months (interquartile range, 61.3-113.1 months), there were 222 recurrences and 213 deaths in the CT-RT arm and 252 recurrences and 243 deaths in the RT arm. The 5-year DFS was significantly higher in the CT-RT arm (52.3%; 95% CI, 52.2%-52.4%) compared with the RT arm (43.8%; 95% CI, 43.7%-43.9%), with a hazard ratio for relapse or death of 0.81 (95% CI, 0.68-0.98) (P = .03). Similarly, the 5-year overall survival (OS) was significantly higher in the CT-RT arm (54.0%; 95% CI, 53.9%-54.1%) compared with the RT arm (46.0%; 95% CI, 45.9%-46.1%), with a hazard ratio for death of 0.82 (95% CI, 0.68-0.98; P = .04). After adjusting for prognostic factors, CT-RT continued to be significantly superior to RT for DFS and OS. There was a higher incidence of acute hematological adverse effects in the CT-RT arm.

Conclusions and Relevance

Chemoradiotherapy using weekly cisplatin results in significantly better DFS and OS compared with RT in women with stage IIIB squamous cell carcinoma of the uterine cervix. This study provides level 1 evidence in the largest clinical trial reported so far in favor of concurrent weekly cisplatin chemotherapy in this setting.

Trial Registration

clinicaltrials.gov Identifier: NCT00193791.

Indian Brachytherapy Society Guidelines for radiotherapeutic management of cervical cancer with special emphasis on high-dose-rate brachytherapy

Brachytherapy (BT) for locally advanced cervical cancer is vital for optimal outcomes. There is heterogeneity in brachytherapy treatment practice for cervical cancer across India. In an attempt to standardize various processes involved in cervical cancer brachytherapy, the expert members of the Indian Brachytherapy Society (IBS) developed a document related to radiation therapy treatment of cervical cancer with special emphasis on brachytherapy. The guidelines are based on high quality clinical evidence, expert opinion and consensus wherever evidence was lacking. The document provides a guide for external beam radiation and details of all the processes involved in high-dose-rate (HDR) brachytherapy including patient selection, preparation, principles and technique of BT applications, target and normal tissue definition, dose prescriptions, BT planning, reporting parameters, common complications of BT and their management, scope for research, etc. In summary, we present here practical tips and tricks, recording and reporting of cervical cancer brachytherapy, which can be implemented in various clinical environments and forms the basis of this report.

Real-world data: towards achieving the achievable in cancer care

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all?

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.

Early Clinical Outcomes, Patterns of Failure, and Acute Haematologic Toxicity of Image-Guided Volumetric Modulated Arc Therapy (IG-VMAT) in the Definitive Treatment of Locally Advanced Carcinoma Cervix

Purpose:

To evaluate clinical outcomes and failure patterns in patients with locally advanced cervical cancer (LACC) treated definitively using image-guided volumetric-modulated arc therapy (IG-VMAT).

Methods and materials:

This retrospective review included 18 consecutively treated patients with LACC. Treatment consisted of IG-VMAT and concurrent chemotherapy followed by intracavitary radiotherapy. The primary end points were overall survival (OS) and disease-free survival (DFS). Acute haematologic toxicity was evaluated using Radiation Therapy Oncology Group (RTOG) criteria.

Results:

A total of 16 patients were either stage IIB or IIIB and the median follow-up was 30.5 months (interquartile range: 13-36.25 months). The 2-year DFS was 63.3% (95% confidence interval [CI]: 52.8%-72.4%) and 2-year OS was 72.2% (95% CI: 62.1%-80.5%). There were 7 treatment failures, predominantly in-field. Acute haematologic toxicity was low.

Conclusions:

IG-VMAT is associated with favourable outcomes for patients with LACC.

Meeting report, “First Indian national conference on cervical cancer management - expert recommendations and identification of barriers to implementation”

Objective

In India, cervical cancer accounts for almost 14% of all female cancer cases. Although poverty continues to cast a wide net over the Indian subcontinent, the preceding three decades have borne witness to improvements in nutrition and sanitation for many citizens. However, due to an absence of a national immunization program to cover human papillomavirus (HPV) vaccination and lack of accessible cervical cancer screening, the disease is characterized by late detection, lack of access to affordable and quality health care, and high mortality rates. Treatment of cervical cancer is stage-specific and depends on the patient’s age, desire to preserve fertility, overall health, the clinician’s expertise, and accessibility to resources. There is a paucity of uniform treatment protocols for various stages of cervical cancer in India. Considering all these parameters, a need to optimize treatment paradigms for the Indian population emerged.

Methods/materials

Three expert panel meetings were held in different regions of India from 2016 to 2017. They were comprised of 15 experts from across the country, and included surgical oncologists, radiation oncologists, and medical oncologists. The panel members reviewed the literature from both national and global sources, discussed their clinical experience and local practices and evaluated current therapeutic options and management gaps for women diagnosed with cervical cancer.

Results

This article summarizes the expert opinion from these meetings. It discusses the available resources and highlights the current therapeutic options available for different cervical cancer stages: early stage disease, locally advanced tumors, recurrent/persistent/metastatic cancer. An Indian consensus governing treatment options emerged, including guidelines for use of the only approved targeted therapy in this disease, the anti-angiogenesis drug, bevacizumab.

Conclusions

The panel concluded that given the availability of state-of-the-art imaging modalities, surgical devices, radiotherapeutics, and novel agents in several population-dense urban centers, a uniform, multi-disciplinary treatment approach across patient care centers is ideal but not realistic due to cost and a paucity of third party payors for most Indian citizens. Preventative strategies including visual inspection with acetic acid to screen for precursor lesions (i.e., cervical intraepithelial neoplasia) with immediate referral for cervical cryotherapy and possible large-scale roll-out of the HPV vaccine in the near future can be expected to reduce mortality rates significantly in this country.

National Cancer Grid of India Consensus Guidelines on the Management of Cervical Cancer

Standard guidelines for the management of early and locally advanced cervical cancer are available from various academic consortiums nationally and internationally. However, implementing standard-of-care treatment poses unique challenges within low- and middle-income countries, such as India, where diverse clinical care practices may exist. The National Cancer Grid, a consortium of 108 institutions in India, aims to homogenize care for patients with cervical cancer by achieving consensus on not only imaging and management, but also in addressing potential solutions to prevalent challenges that affect the homogenous implementation of standard-of-care treatment. These guidelines therefore represent a consensus statement of the National Cancer Grid gynecologic cancer expert group and will assist in homogenization of the therapeutic management of patients with cervical cancer in India.

Survival in Head and Neck Cancers - Results of A Multi- Institution Study

BACKGROUND

The prime output of Hospital Based Cancer Registries is stage and treatment based survival to evaluate patient care, but because of challenges of obtaining follow-up details a separate study on Patterns of Care and Survival for selected sites was initiated under the National Cancer Registry Programme of India. The results of stage and treatment based survival for head and neck cancers by individual organ sites are presented.

MATERIALS AND METHODS

A standardized Patient Information Form recorded the details and entered on-line at www.hbccrindia.org to a central repository - National Centre for Disease Informatics and Research. Cases from 12 institutions diagnosed between 1 January 2006 and 31 December 2008 comprised the study subjects. The patterns of treatment were examined for 14053 and survival for 4773 patients from five institutions who reported at least 70% follow-up as of 31 December 2012.

RESULTS

Surgical treatment with radiation for cancer tongue and mouth showed five year cumulative survival (FCS) of 67.5% and 60.4% respectively for locally advanced stage. Chemo-radiation compared to radiation alone showed better survival benefit of around 15% in both oro and hypo-pharyngeal cancers and their FCS was 40.0%; Hazard Ratio (HR):1.5;CI=1.2-1.9) and 38.7%; (HR):1.7; CI=1.3-2.2).

CONCLUSIONS

The awareness about the requirement of concurrent chemo-radiation in specifically cancers of the oro and hypopharynx has to be promoted in developing countries. The annual (2014) estimate number of new Head and Neck cancers with locally advanced disease in India is around 140,000 and 91,000 (65%) patients do not receive the benefit of optimal treatment with ensuing poorer survival.

Decreased Survival With Mastectomy Vis-à-Vis Breast-Conserving Surgery in Stage II and III Breast Cancers: A Comparative Treatment Effectiveness Study

Purpose

The primary purpose of hospital-based cancer registries is assessing patient care. Clinical stage–based survival and treatment-based survival are some of the key parameters for such assessment. Because of the challenges in obtaining follow-up parameters, a separate study on patterns of care and survival was undertaken by the Indian National Cancer Registry Program. The results for cancer of the female breast are presented here.

Patients and Methods

Data abstracted in a standardized patient information form were transmitted online to a central repository. Treatment patterns were assessed for 9,903 patients diagnosed between January 1, 2006, and December 31, 2008, from 13 institutions. Survival analysis was restricted to 7,609 patients from nine institutions wherein follow-up details (as of December 31, 2012) were available for at least 60% of patients.

Results

The overall 5-year survival rates with breast-conserving surgery (BCS) and mastectomy (MS) were 94.0% and 85.8%, respectively, for stage II disease (adjusted hazard ratio, 2.40; 95% CI, 1.8 to 3.2) and 87.1% and 69.0%, respectively, for stage III disease (hazard ratio, 2.82; 95% CI, 2.2 to 3.7). Patients who had MS did better with systemic therapy (chemotherapy and/or hormone therapy), whereas patients with BCS required just local radiation therapy to achieve best survival.

Conclusion

This observational study in the natural setting of care of patients with cancer in India showed significantly decreased survival with MS when compared with BCS. The reasons for lower survival with MS and the biologic or scientific rationale of the necessity of systemic therapy to achieve optimal survival in patients undergoing MS but not in those with BCS need further investigation.