Association of overweight and obesity with breast cancer in India

Cost-Effectiveness of Adjuvant Abemaciclib and Ribociclib in High-Risk Hormone Receptor-Positive Early Breast Cancer: An Indian Perspective

PURPOSE

Incorporating adjuvant cyclin-dependent kinase (CDK) 4/6 inhibitors abemaciclib and ribociclib along with endocrine therapy has been shown to improve invasive disease-free survival (iDFS) for hormone receptor-positive (HR+) human epidermal receptor 2-negative (HER2-) early breast cancer (EBC). This study assesses the cost-effectiveness of this strategy, along with adjuvant aromatase inhibitors from an Indian perspective.

METHODS

A Markov chain model evaluated the cost-effectiveness of abemaciclib and ribociclib with letrozole compared with letrozole alone for HR+/HER2- EBC from a payer perspective in India. Key measures included lifetime quality-adjusted life-years (QALY), life-years (LY), and total costs. This study explores two scenarios for effectiveness: a best-case (BC) scenario, where the benefit of CDK4/6 inhibitors in improving iDFS lasts a lifetime, and a worst-case (WC) scenario, where benefits disappear after 5 years. Probabilistic sensitivity analyses (PSA) were used to account for simulation uncertainty.

RESULTS

In the BC scenario, abemaciclib added 2.17 QALY and 4.96 LY, incurring ₹2,317,957.7 ($27,756.65 in US dollars [USD]) in additional costs. However, the incremental cost-effectiveness ratio (ICER) for abemaciclib exceeded India's willingness-to-pay threshold in the BC and WC scenarios. In the BC scenario, ribociclib added 0.98 QALY and 2.58 LY with added costs of ₹1,711,504.32 ($20,494.6 USD). The ICER for ribociclib also surpassed India's threshold in both scenarios. PSA showed that neither drug was cost-effective at the current market prices in either BC/WC scenario. The cost of abemaciclib and ribociclib needs to be reduced by at least 78.61% and 87.19%, respectively, to be cost-effective in the BC scenario.

CONCLUSION

The combination of adjuvant abemaciclib or ribociclib with letrozole is not cost-effective for HR+/HER2- EBC in India in either the BC or WC scenario.

An overview of therapeutic options of obesity management in India: the Integrated Diabetes and Endocrinology Academy (IDEA) 2023 Congress update

INTRODUCTION

With newer anti-obesity medications (AOMs) being introduced at a rapid pace, it is prudent to make a concise and updated clinical practice document that may help busy clinicians in daily clinical practice. A group of metabolic physicians, diabetologists, endocrinologists, and bariatric surgeons assembled during the Integrated Diabetes and Endocrine Academy 2023 Congress (IDEACON, July 2023, Kolkata, India) to compile an update of pharmacotherapeutic options for managing people with obesity in India.

AREAS COVERED

After an extensive review of the literature by experts in different domains, this update provides all available information on the management of obesity, with a special emphasis on both currently available and soon-to-be-available AOMs, in people with obesity.

EXPERT OPINION

Several newer AOMs have been shown to reduce body weight significantly, thus poised to make a paradigm shift in the management of obesity. While the tolerability and key adverse events associated with these AOMs appear to be acceptable in randomized controlled trials, pharmacovigilance is vital in real-world settings, given the absence of sufficiently long-term studies. The easy availability and affordability of these drugs is another area of concern, especially in developing countries like India.

Knowledge and awareness of breast cancer and breast self-examination among college-going female students in Delhi-NCR: a cross sectional study

Purpose

Breast cancer (BC) presents a major public health challenge world-over including India. While several risk-factors, early signs and symptoms of BC are known, the knowledge and awareness of this disease remains poor among the population. The present study aimed to determine the extent of knowledge and awareness of BC, its risk factors, early signs and symptoms and breast self-examination (BSE) practice as an early detection method among Indian college-going female students.

Design/methodology/approach

The authors conducted a cross-sectional survey at a University in Delhi-NCR. Data on socio-demographic, knowledge and awareness of BC including BSE was collected using a pretested questionnaire. Chi-square test and logistic regression analysis was performed. All tests were two-sided and significance was set at p < 0.05.

Findings

A total of 866 female students participated in the study with mean age of 22.32 (±0.146) years having mean body mass index (BMI) of 21.22 (±3.52). As high as 82.1% of the participants had heard of BC but while 74.8% thought early detection is possible, 70.7% believed BC cannot be prevented. Gene mutations (60.2%) were identified as a significant risk factor, while breast pain (61.4%) was commonly recognized as a sign of BC. Only 29.8% of students ever performed BSE. Increased odds of performing BSE (OR = 3.4) was found among students who recognized gene mutations as an important BC risk factor.

Research limitations/implications

Knowledge and awareness of BC including BSE among female college students were found to be below average. It is suggested that there is an urgent need for increasing BC awareness among young girls through workshops and mobile-health interventions.

Practical implications

This study provides new information on the level of knowledge and awareness of BC risk factors, sign and symptoms and self-examination practice among young college girls. Moreover, this study advocates the need for design and implementation of a sustainable digital health model for active population BC screening, which is not being done currently.

Social implications

BC is a highly aggressive disease, which is now one of the leading causes of morbidity and mortality in India and world over. Although the knowledge of BC risk factors and its signs and symptoms have increased, the awareness of these elements among the general population at large is low and/or missing, especially in India. Furthermore, as a consequence of unorganized screening programs in the country, majority of women are presenting young with locally advanced disease. Understanding the existing level of knowledge and educating school, college and University students of the pertinent factors and screening practices such as BSE could drastically help in improving the self-screening and/or clinical examination rates. This could potentially lead to early detection and improved prognosis, thus ameliorating disease burden.

Originality/value

This study is one of the few studies conducted in India among young female college students belonging to non-medical backgrounds, delineating the level of knowledge and awareness of BC risk factors and signs and symptoms along with practice of early detection method such as BSE. The study has a considerable sample size and provides valuable evidence for a need to implement programs incorporating digital health models for accelerating awareness and screening of young girls in both rural and urban settings.

Modifiable (Sleeping Pattern and Stress) and Non-Modifiable Risk Factors Associated with Breast Cancer: A Matched Case-Control Study in Delhi, India

BACKGROUND

An utmost increase of breast cancer burden during the last several decades was reported in Asian countries. Findings from literature confirm that risk factors of breast cancers can be modifiable and non-modifiable in nature.

OBJECTIVE

The present study is designed to identify specific modifiable and non-modifiable risk factors associated with breast cancer.

METHODS

A matched case-control study was conducted considering 187 cases as women diagnosed with breast cancer and 187 hospital-controls as women without having breast cancer visiting the hospital. Other than standard risk factors, stress is measured using Perceived Stress Scale (PSS) and stress is measured using Pittsburgh Sleep Quality Index (PSQI). Several modifiable and non-modifiable risk factors were assessed using conditional logistic regression to find out significant association with breast cancer.

RESULTS

Regular multi-vitamin uptake (OR = 3.38; 95%CI = 1.69 - 6.77; p-value = 0.001), poor sleep (OR = 11.29; 95%CI = 4.36 - 29.25; p-value < 0.001), irregular sleep (OR = 34.11; 95%CI = 10.03 - 115.92; p-value < 0.001) and severe stress (OR = 6.74; 95%CI = 3.06 - 14.81; p-value < 0.001) were found to be the highest odds ratio among all modifiable risk factor of breast cancer. Also, age at first childbirth less than 30 years (OR = 0.44; 95%CI = 0.25 - 0.78; p-value = 0.005) was found protective against breast cancer.

CONCLUSION

In our study, stress, sleeping pattern, and regular multi-vitamin uptake were found to be significant modifiable risk factors of breast cancer. None of the non-modifiable risk factors were found to be significantly associated with the risk of breast cancer.

A Narrative Review of the Risk Factors for Cancer and the Preventive Opportunities: Current Status, Future Perspectives, and Implications for India

Introduction Clinical cancer can arise from heterogenous pathways through various genetic mutations. Although we cannot predict the timeline by which an individual will develop cancer, certain risk assessment tools can be used among high-risk groups for focusing the preventive activities. As primary level of cancer prevention, healthy lifestyle approach is being promoted. The etiological factors for lung cancer include by-products of industrialization and air pollution. We need to factor the increase in household air pollution as well.

Methods “PubMed” database and Google search engines were used for searching the relevant articles. Search terms with Boolean operators used include “Cancer prevention,” “Missed opportunities in cancer causation,” and “incidence of risk factors.” This review includes 20 studies and other relevant literature that address the opportunities for cancer prevention.

Body The narrative describes the association between many of the risk factors and development of cancer. This includes tobacco, alcohol, infections, air pollution, physical inactivity, diet, obesity, screening and preventive strategies, chemoprevention, biomarkers of carcinogenesis, and factors that prolong the diagnosis of cancer.

Discussion Reports from basic science research provide evidence on the potential of biologically active food components and pharmacological agents for mitigating the risk of cancer and its progression. However, some reports from observational studies and randomized trials have been inconsistent. We need to recognize the impact of sociodemographic factors such as age, sex, ethnicity, culture, and comorbid illness on preventive interventions. Spiral computed tomographic scan is a robust tool for early detection of lung cancer.

Conclusion Infectious etiology for specific cancers provides opportunities for prevention and treatment. The complex interplay between man and microbial flora needs to be dissected, for understanding the pathogenesis of relevant malignancies. For reducing the morbidity of cancer, we need to focus on prevention as a priority strategy and intervene early during the carcinogenic process.

Cost Effectiveness of Trastuzumab for Management of Breast Cancer in India

PURPOSE

We undertook this study to evaluate the incremental cost per quality-adjusted life-year (QALY) gained with use of adjuvant trastuzumab as compared with chemotherapy alone among patients with nonmetastatic breast cancer in India.

METHODS

We used a Markov model to estimate the incremental cost of using trastuzumab (for 1 year, 6 months, or 9 weeks) as compared with chemotherapy alone using a societal perspective, excluding indirect productivity losses. Although the outcomes (QALYs) in the standard chemotherapy arm were estimated after calibrating the model as per survival data from 2 Indian cancer registries, effectiveness estimates from the HERA trial and a joint analysis of the NSABP B-31 and NCCTG N9831 trials were used to estimate the consequences of 1-year trastuzumab use. The cost of treatment was estimated using national standard treatment guidelines and real-world use estimates for different treatment modalities as per data from Indian cancer registries. Probabilistic sensitivity analysis was undertaken to evaluate parameter uncertainty.

RESULTS

For 1 year of trastuzumab use, the incremental benefit per patient, incremental cost per QALY gained, and probability of being cost effective using HERA trial estimates were 1.29 QALYs, 178,877 Indian national rupees (INRs; US$2,558), and 4%, respectively, whereas the corresponding figures using joint analysis estimates were 1.69 QALYs, INR 134,413 (US$1,922), and 57.3%, respectively.

CONCLUSION

Use of trastuzumab for 1 year is not cost effective in India at the current price. However, trastuzumab use for 9 weeks is cost effective and should be included in clinical guidelines and reimbursement policies. A price reduction of 15% to 35% increases the probability of 1-year trastuzumab use being cost effective, to 90%.

An update on physical health and economic consequences of overweight and obesity

Overweight and obesity (OW and OB) have been on the increase globally and posed health risks to the world's population of all ages, including pre-born babies, children, adolescents, adults and elderly people, via their comorbid conditions. Excellent examples of comorbidities associated with obesity include cancer, cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM). In this article, we aimed to review and update scientific evidence regarding the relationships between obesity and its common physical health consequences, including CVD, T2DM, hypertension, ischemic stroke, cancer, dyslipidemia and reproductive disorders. In addition, the economic burden of OW and OB will be discussed. Abundant evidence is found to support the associations between obesity and other diseases. In general, the odd ratios, risk ratios or hazard ratios are often higher in OW and OB people than in the normal-weight ones. However, the molecular mechanism of how OW and OB induce the development of other diseases has not been fully understood. Figures also showed that obesity and its-related disorders exert enormous pressure on the economy which is projected to increase. This review highlights the fact that obesity can lead to numerous lethal health problems; therefore, it requires a lot of economic resources to fight against this epidemic.

Could Anthropometric and Lipid Parameters Reflect Susceptibility to Breast Cancer? Comparison of Newly Diagnosed Breast Cancer and Apparently Healthy Women

Objectives:

To determine and compare the serum lipid profiles and anthropometric parameters of newly diagnosed BC patients and healthy women.

Methods:

Serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), very low density lipoprotein cholesterol (VLDL-C), triglyceride (TG) and TC: HDL-C were measured in consent obtained newly diagnosed BC patients (n=155) and age matched apparently healthy females (n=75). Weight (W), height (H), waist circumference (WC), hip circumference (HC) and mid upper arm circumference (MUC) of each women were recorded. Cut off values for each parameter was found by receiver operative characteristic (ROC) curves and risk associated with was calculated using SPSS version 16.

Results:

Majority (67%) of BC women were postmenopausal. The mean TC, HDL-C, LDL-C, VLDL-C, TC: HDL-C, TG concentrations of BC patients who were not on cholesterol lowering drugs (n= 126) were 234 mg/dL (±51), 43 mg/dL (±10), 164 mg/dL (±44), 27 mg/dL (±14), 5.7(±1.7) and 135 mg/dL (±69) respectively. TC, LDL-C and TC: HDL-C of BC patients were significantly elevated when compared with healthy females. Significant difference in serum lipid profile parameters was not observed (p> 0.05) according to the menopausal status of BC and healthy women. One third (30.3%) of BC patients were overweight and 45% were obese. Majority had elevated WC (72%), W: H ratios (89%) and MUC (89%). BMI, W: H and MUC of BC women were significantly higher (p<0.05) when compared with healthy females.

Conclusions:

The lipid parameters TC, LDL-C and TC: HDL-C above 203 mg/dL, 139 mg/dL and 3.9 respectively were risk factors. Among anthropometric measures, BMI>25 kg/m² showed the highest risk while elevated W:H and MUC were also significant risk factors among the study group.

Lifelong vegetarianism and breast cancer risk: a large multicentre case control study in India

BACKGROUND

The lower incidence of breast cancer in Asian populations where the intake of animal products is lower than that of Western populations has led some to suggest that a vegetarian diet might reduce breast cancer risk.

METHODS

Between 2011 and 2014 we conducted a multicentre hospital based case-control study in eight cancer centres in India. Eligible cases were women aged 30-70 years, with newly diagnosed invasive breast cancer (ICD10 C50). Controls were frequency matched to the cases by age and region of residence and chosen from the accompanying attendants of the patients with cancer or those patients in the general hospital without cancer. Information about dietary, lifestyle, reproductive and socio-demographic factors were collected using an interviewer administered structured questionnaire. Multivariate logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals for the risk of breast cancer in relation to lifelong vegetarianism, adjusting for known risk factors for the disease.

RESULTS

The study included 2101 cases and 2255 controls. The mean age at recruitment was similar in cases (49.7 years (SE 9.7)) and controls (49.8 years (SE 9.1)). About a quarter of the population were lifelong vegetarians and the rates varied significantly by region. On multivariate analysis, with adjustment for known risk factors for the disease, the risk of breast cancer was not decreased in lifelong vegetarians (OR 1.09 (95% CI 0.93-1.29)).

CONCLUSIONS

Lifelong exposure to a vegetarian diet appears to have little, if any effect on the risk of breast cancer.

BMI is a Better Indicator of Cardiac Risk Factors, as against Elevated Blood Pressure in Apparently Healthy Female Adolescents and Young Adult Students: Results From a Cross-Sectional Study in Tripura

BACKGROUND

Anthropometric measures are used as indicators of elevated blood pressure, but reported to have variable sensitivity among populations. This study was undertaken to identify the better indicator of Cardiac-risk factors by statistical comparison of BMI, Waist circumference, and Waist to Height (WtHr) ratio in apparently healthy adolescents and young adult female students of Tripura.

MATERIALS AND METHODS

A cross-sectional study was conducted in a resource limited setup on 210 apparently healthy female adolescents and young adult students in Tripura. Mean (±SD) of all parameters were compared (ANOVA) to recognize significant independent (anthropometric measures) and dependent factors (blood pressure indices and so on). Correlation (r) analysis was used to identify the better (p) indicator of blood pressure indices (dependent variable) and its impact was assessed by Multiple Regression analysis.

RESULTS

blood pressure indices are comparatively higher in obese and overweight participants with statistically significant (95.5% confidence) mean differences. Significant correlation with dependent factors is observed with BMI followed by WtHr and Waist Circumference. Impact of anthropometric measures with blood pressure Indices is most significant for BMI (P ≤ 0.020) followed by WtHr (P ≤ 0.500) and waist circumference (P ≤ 0.520).

CONCLUSION

BMI is a superior indicator of blood pressure indices and can identify participants at risk even in apparently healthy adolescent and young adult females.

Burden of preventable cancers in India: Time to strike the cancer epidemic

India has a rapidly growing population inflicted with cancer diagnosis. From an estimated incidence of 1.45 million cases in 2016, the cancer incidence is expected to reach 1.75 million cases in 2020. With the limitation of facilities for cancer treatment, the only effective way to tackle the rising and humongous cancer burden is focusing on preventable cancer cases. Approximately, 70% of the Indian cancers (40% tobacco related, 20% infection related and 10% others) are caused by potentially modifiable and preventable risk factors. We review these factors with special emphasis on the Indian scenario. The results may help in designing preventive strategies for a wider application.

Obesity and Cancer: Concepts and Challenges

The rates of overweight and obesity are increasing worldwide in both developed and developing countries. Obesity is a major public health problem as it is associated with many diseases, including diabetes, hypertension, dyslipidemia, atherosclerosis, and some types of cancer. Breast cancer is a malignancy in which both the risk of development and the prognosis are negatively impacted by the obese state. The precise mechanisms pathophysiologically linking obesity and cancer are still under investigation. The biological basis for these associations includes both systemic and local tissue effects and white adipose tissue inflammation appears to be a critical component. A comprehensive understanding of the mechanisms linking obesity, inflammation and cancer may provide an opportunity for the development of strategies to attenuate the negative impact of obesity.