Delivery of cancer care in rural India: Experiences of establishing a rural comprehensive cancer care facility

Revolutionizing Rural Oncology: Innovative Models and Global Perspectives

For individuals living in rural areas, access to cancer care can be difficult. Barriers to access cross international boundaries and have a negative impact on treatment outcomes. Current models to increase rural access in the United States are reviewed, as is a system-wide approach to this problem in Australia. Ongoing efforts to increase access to clinical trials for patients in rural areas are also discussed.

Rural-urban disparity in cancer burden and care: findings from an Indian cancer registry

BACKGROUND

Cancer incidence and mortality vary across the globe, with nearly two-thirds of cancer-related deaths occurring in low- and middle-income countries. The rural-urban disparity in socio-demographic, behavioural, and lifestyle-related factors, as well as in access to cancer care, is one of the contributing factors. Population-based cancer registries serve as a measure for understanding the burden of cancer. We aimed to evaluate the rural-urban disparity in cancer burden and care of patients registered by an Indian population-based cancer registry.

METHODS

This study collected data from Varanasi, Uttar Pradesh, India, between 2017 and 2019. Sex and site-specific age-standardised rates for incidence and mortality per 100,000 population were calculated. Rural-urban disparities in cancer incidence and mortality were estimated through rate differences and standardised rate ratios (with 95% confidence intervals). Univariable and multivariable regressions were applied to determine any significant differences in socio-demographic and cancer-related variables according to place of residence (rural/urban). Crude and adjusted odds ratios with 95% confidence intervals were calculated.

RESULTS

6721 cancer patients were registered during the study duration. Urban patients were older and had better literacy and socioeconomic levels, while rural patients had higher odds of having unskilled or semi-skilled professions. Diagnostic and clinical confirmation for cancer was significantly higher in urban patients, while verbal autopsy-based confirmation was higher in rural patients. Rural patients were more likely to receive palliative or alternative systems of medicine, and urban patients had higher chances of treatment completion. Significantly higher incidence and mortality were observed for oral cancer among urban men and for cervical cancer among rural women. Despite the higher incidence of breast cancer in urban women, significantly higher mortality was observed in rural women.

CONCLUSIONS

Low- and middle-income countries are facing dual challenges for cancer control and prevention. Their urban populations experience unhealthy lifestyles, while their rural populations lack healthcare accessibility. The distinctness in cancer burden and pattern calls for a re-evaluation of cancer control strategies that are tailor-made with an understanding of urban-rural disparities. Context-specific interventional programmes targeting risk-factor modifications, cancer awareness, early detection, and accessibility to diagnosis and care are essential.

Exploring the financial burden due to additional mobility among cancer patients: A cross-sectional study based on National Sample Survey

BACKGROUND

Cancer imposes a substantial economic burden due to treatment costs, supportive care, and loss of productivity. Besides all the affecting factors, major concerns lead to significant financial burdens of cancer treatment, bringing unwanted huge unbearable direct and indirect treatment costs. The aim was to explore the nature of additional mobility/travel required for accessing health care for cancer patients and also to assess financial burden due to additional mobility/travel costs for cancer treatment.

METHODS

This study employed unit-level cross-sectional data from the 75th round (2017-18) of India's National Sample Survey (NSS). The primary analysis commenced with descriptive and bivariate analyses to explore mean health spending and out-of-pocket expenses. Subsequently, multivariable logistic regression models were utilized to estimate the associations between catastrophic health expenditure, distress financing, and the treatment location.

RESULTS

The findings highlight distinct healthcare utilization patterns: inpatient treatments predominantly occur within the same district (50.4 %), followed by a different district (38.8 %), and a smaller share in other states (10.8 %). Outpatients largely receive treatment in the same district (65.5 %), followed by a different district (26.8 %), and around 8 % percent in other states. Urban areas show higher inpatient visits within the same district (41.8 %) and different districts (33.5 %). Outpatients, particularly those seeking treatment in other states, experience higher total expenditures, notably with higher out-of-pocket expenses. Distress financing is more common among inpatients (20.6 %) and combined inpatient/outpatient cases (23.9 %), while outpatients exhibit a lower rate (6.8 %).

CONCLUSION

The findings collectively suggest the importance of developing local healthcare infrastructures to reduce the additional mobility of cancer patients. The policy should focus to train and deploy oncologists in non-urban areas can help bridge the gap in cancer care proficiency and reduce the need for patients to travel long distances for treatment.

Community cancer screening at primary care level in Northern India: determinants and policy implications for cancer prevention

OBJECTIVE

Despite the established cancer screening programme for oral, breast and cervical cancer by the Government of India, the screening coverage remains inadequate. This study aimed to describe the determinants for oral, breast and cervical cancer prevention in a rural community at the primary care level of Northern India and its policy implications.

DESIGN

This was a camp-based project conducted for 1 year, using oral visual examination, clinical breast examination and visual inspection of cervix by application of 5% acetic acid according to primary healthcare operational guidelines. During the project, screen-positive participants were followed through reverse navigation. Information about socio-demographic profile, clinical and behavioural history and screening were collected. Predictors for screen-positivity and follow-up compliance were identified through multivariable analysis.

SETTINGS

Based on the aim of project, one of the remotely located and low socioeconomic rural blocks, having 148 villages (estimated population of 254 285) in Varanasi district, India was selected as the service site. There is an established healthcare delivery and referral system as per the National Health Mission of Government of India. Oral, breast, gallbladder and cervical cancers are the leading cancers in the district.

PARTICIPANTS

We invited all men and women aged 30-65 years residing in the selected block for the last 6 months for the screening camps. Unmarried women, women with active vaginal bleeding, those currently pregnant and those who have undergone hysterectomy were excluded from cervical cancer screening.

RESULTS

A total of 14 338 participants were screened through 190 camps and the majority (61.9%) were women. Hindu religion, tobacco use, intention to quit tobacco and presence of symptoms were significantly associated with screen-positivity. Nearly one-third (220; 30.1%) of the screened-positives complied with follow-up. Young age and illiteracy were significantly associated with lower compliance.

CONCLUSION

Poor follow-up compliance, despite the availability of tertiary cancer care, patient navigation, free transportation and diagnostic services, calls for research to explore the role of contextual factors and develop pragmatic interventions to justify 'close the care gap'. Community cancer screening needs strengthening through cancer awareness, establishing referral system and integration with the National Tobacco Control and Cancer Registry Programmes.

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.

Unusual localized gingival redness: a case report

Inflammation of the gingiva is one of the most common and routine findings in dental practice. These routine appearances of inflammatory gingivae can show peculiarity when associated with an underlying systemic condition or because of reactive, benign, or malignant pathologies. This case highlights minute clinical signs of the gingiva that deviate from the routine presentation and warrant further investigations. A 63-year-old woman presented with a chief complaint of severe pain in relation to the lower front teeth region for 1 month. Intraoral examination revealed a gingival lesion on the labial aspect of 41, 42, and 43, and an intraoral periapical radiograph showed mild bone loss. The lesion persisted despite oral prophylaxis, and a biopsy was advised. The final diagnosis was stage 1 gingival squamous cell carcinoma (GSCC). It is important to note that the non-descript presentation of GSCC in early stages often mimics benign traumatic or inflammatory lesions of the gingiva. Peculiar clinical features of GSCC of note include the lack of traditionally associated risk factors and localized red or ulcerative lesions with increased bleeding tendencies that do not respond to routine periodontal treatment within 2 weeks.

Development and validation of a comprehensive needs assessment tool to assess the burden of cancer chemotherapy patients attending a tertiary care hospital

INTRODUCTION

In India in 2020, there were an estimated 1.39 million cancers present in the country. Chemotherapy patients experience several problems such as ADRs (adverse drug reactions), and because of this, many dropouts have been happening. Also, there is a lack of communication between the patient and care providers (doctors).

OBJECTIVES

Development and validation of a comprehensive needs assessment tool to assess the burden of chemotherapy on patients attending tertiary level health care facilities.

MATERIALS AND METHODS

Development and validation of comprehensive needs assessment in cancer chemotherapy involve several steps, including problem statement and literature review regarding the problem, domain generation, development of the preliminary questionnaire, face validation, statistical validation, and final draft of the tool.

RESULTS

A total of 10 experts are involved in face validation. The majority (80%) of the experts agreed with the grammar, clarity, and content of the tool. A few experts (20%) disagreed regarding the construction of the questionnaire, the appropriate level of understanding for the participants, and the content of the tool and suggested changes in the physical and psychological domains. The questionnaire has been re-structured according to the expert's suggestion before going for statistical validation. Internal consistency of the CNAT-CC was optimal, with a satisfactory Cronbach's alpha of 0.7 for the total scale.

DISCUSSION

The current study was focused on the development and validation of needs assessment in cancer chemotherapy patients. The CNAT-CC promises to be a comprehensive needs assessment tool that applies to a comparatively vast majority of patients undergoing cancer chemotherapy.

Effect of the Pandemic on Quality-of-Life Data Collection in Prostate Cancer Patients

Purpose

To understand the difficulties that happen during the quality of life (QoL) data collection in a pandemic and provide measures to overcome them.

Methods

We analyzed the recruitment and follow-up data of patients in one of our ongoing study whose aim was to collect the Adverse drug reactions and QoL (at regular intervals) in prostate cancer patients who were on docetaxel. Before the pandemic, we could enroll 31 patients in the study over four months. We analyzed the difficulties experienced by these patients and consultants in collecting QoL data during the pandemic, especially in situations with limited availability of resources and also where the patients are not technologically advanced.

Results

Due to the pandemic, we could not recruit a single new patient into the study. Complete QoL assessments were available in only two patients, and the disease progressed in five patients. QoL assessment was not possible in 19 of 31 enrolled patients. More than 44% of the enrolled patients had difficulty commuting to the hospital despite transport services to hospitals. Due to the risk of acquiring COVID19 infection during traveling to the hospital, follow-ups were affected.

Conclusion

There should be increased support for novel technologies that can successfully capture and transfer patients' QoL data to the treating consultant.

India needs a resilient cancer program

Background

We analyzed the trends for two important cancers affecting females, breast cancer and cervical cancer, using the Indian cancer registry data and correlated the findings with selected relevant sociodemographic and behavioral indicators.

Methods

We examined National Family Health Survey data for the respective states in which registries are located, on relevant indicators like multiparity, early childbearing, cervical examination, multiple sexual partners/high-risk sexual behavior, and HIV prevalence (for cervical cancer), multiparity, early childbearing, duration of breastfeeding, overweight, alcohol use, and clinical breast examination (for breast cancer). We used Global Adult Tobacco Survey smoking data.

Results

The top four positions in cancer cervix were all in registries from northeast India with a higher proportion of multiparous women (≥3 births; around 40%), whereas three major metros in the south and the national capital of Delhi, all with a relatively low proportion of multiparous women (11-25%) topped the chart for breast cancer. Overweight/obesity was higher in states with a higher incidence of breast cancer (23.3-31%) compared to states with a lower incidence (12.2-16%). No clear patterns emerged with regard to alcohol consumption, duration of breastfeeding or clinical breast examination.

Conclusion

The shift in the childbearing age group explains the increasing breast cancer rates in urban areas, whereas the persisting higher rate of multiparity explains higher cervical cancer rates especially in underserved states in the northeast. India needs to invest in transforming its cancer control program to be a more resilient one with a focus on screening and prevention.

Building Capacity for Global Cancer Research: Existing Opportunities and Future Directions

Cancer incidence and mortality are increasing in low- and middle-income countries (LMICs), where more than 75% of global cancer burden will occur by the year 2040. The primary drivers of cancer morbidity and mortality in LMICs are environmental and behavioral risk factors, inadequate prevention and early detection services, presence of comorbidities, and poor access to treatment and palliation. These same drivers also contribute to marked cancer health disparities in high-income countries. Studying cancer in LMICs provides opportunities to better understand and address these drivers to benefit populations worldwide, and reflecting this, global oncology as an academic discipline has grown substantially in recent years. However, sustaining this growth requires a uniquely trained workforce with the skills to pursue relevant, rigorous, and equitable global oncology research. Despite this need, dedicated global cancer research training programs remain somewhat nascent and uncoordinated. In this paper, we discuss efforts to address these gaps in global cancer research training at the US National Institutes of Health.

Cervical Cancer Care Continuum in South India: Evidence from a Community-based Screening Program

In India, cervical cancer screening is conducted at various levels; however, after screening, the adherence to the cancer care continuum is barely understood. This study evaluated a community-based cancer screening program conducted in a rural setting (Tirunelveli and Tuticorin districts) in South India and reviewed the completion of care continuum. In this longitudinal descriptive study involving secondary data collection, data from the case records of 2192 women who were consecutively screened between March 2015 and May 2016 were included. All women underwent conventional cytology-based screening (Pap smear) and Visual Inspection with Acetic Acid (VIA). Those for whom either test was positive were referred for histopathological confirmation. Patients with confirmed precancerous conditions and unsatisfactory Pap smears were referred for further management. In total, 2192 women were screened [age range, 17-69 years; mean (standard deviation), 39.2 (8.5)]. Common symptom and sign were white discharge per vaginum (34.9%) and cervical erosion (34.4%), respectively. The VIA was positive for 24% (523/2178; 14 women did not cooperate for VIA) and 113 (5.1%) had epithelial cell abnormality in the Pap smear test. Per histopathology findings, one woman had non-keratinizing squamous cell carcinoma. Seven, three, and four had cervical intraepithelial neoplasia I, II and III, respectively. Of 2192, 807 were eligible for referral (597 had positive results on either Pap or VIA). Among the 807 women referred, only 74 (9.2%) women visited the referral center. The follow-up rate was very poor accounting to fragmentation of care continuum. The success of the screening program depends on the completion of the care continuum.

Mutational Landscape for Indian Hereditary Breast and Ovarian Cancer Cohort Suggests Need for Identifying Population Specific Genes and Biomarkers for Screening

BACKGROUND

Breast and ovarian cancers are the most prevalent cancers and one of the leading causes of death in Indian women. The healthcare burden of breast and ovarian cancers and the rise in mortality rate are worrying and stress the need for early detection and treatment.

METHODS

We performed amplicon sequencing of 144 cases who had breast/ovarian cancer disease (total 137 cases are patients and seven are tested for BRCA1/2 carrier) Using our custom designed gene panel consisting of 14 genes, that are associated with high to moderate risk of breast and ovarian cancers. Variants were called using Torrent Variant Caller and were annotated using ThermoFisher's Ion Reporter software. Classification of variants and their clinical significance were identified by searching the variants against ClinVar database.

RESULTS

From a total of 144 cases, we were able to detect 42 pathogenic mutations in [40/144] cases. Majority of pathogenic mutations (30/41) were detected in BRCA1 gene, while (7/41) pathogenic mutations were detected in BRCA2 gene, whereas, (2/41) pathogenic mutations were detected in TP53 gene and BRIP1, PALB2, and ATM genes respectively. So, BRCA genes contributed 88.09% of pathogenic mutations, whereas non-BRCA genes contributed 11.91% of pathogenic mutations. We were also able to detect 25 VUS which were predicted to be damaging by in silico prediction tools.

CONCLUSION

Early detection of cancers in the Indian population can be done by genetic screening using customized multi-gene panels. Indications of our findings show that in the Indian population, apart from the common BRCA genes, there are other genes that are also responsible for the disease. High frequency mutations detected in the study and variants of uncertain significance predicted to be damaging by in silico pathogenicity prediction tools can be potential biomarkers of hereditary breast and ovarian cancer in Indian HBOC patients.

Modelling the impact of a smallpox attack in India and influence of disease control measures

OBJECTIVES

To estimate the impact of a smallpox attack in Mumbai, India, examine the impact of case isolation and ring vaccination for epidemic containment and test the health system capacity under different scenarios with available interventions.

SETTING

The research is based on Mumbai, India population.

INTERVENTIONS

We tested 50%, 70%, 90% of case isolation and contacts traced and vaccinated (ring vaccination) in the susceptible, exposed, infected, recovered model and varied the start of intervention between 20, 30 and 40 days after the initial attack.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated and incorporated in the model the effect of past vaccination protection, age-specific immunosuppression and contact rates and Mumbai population age structure in modelling disease morbidity and transmission.

RESULTS

The estimated duration of an outbreak ranged from 127 days to 8 years under different scenarios, and the number of vaccine doses needed for ring vaccination ranged from 16 813 to 8 722 400 in the best-case and worst-case scenarios, respectively. In the worst-case scenario, the available hospital beds in Mumbai would be exceeded. The impact of a smallpox epidemic may be severe in Mumbai, especially compared with high-income settings, but can be reduced with early diagnosis and rapid response, high rates of case finding and isolation and ring vaccination.

CONCLUSIONS

This study tells us that if smallpox re-emergence occurs, it may have significant health and economic impact, the extent of which will depend on the availability and delivery of interventions such as a vaccine or antiviral agent, and the capacity of case isolation and treatment. Further research on health systems requirements and capacity across the diverse states and territories of India could improve the preparedness and management strategies in the event of re-emergent smallpox or other serious emerging infections.

Call for Action to Address Equity and Justice Divide During COVID-19

The coronavirus 2019 disease (COVID-19) is deepening the inequity and injustice among the vulnerable communities. The current study aims to present an overview of the impact of COVID-19 on equity and social justice with a focus on vulnerable communities. Vulnerable communities include, but not limited to, healthcare workers, those from lower socioeconomic backgrounds, ethnic or minority groups, immigrants or refugees, justice-involved populations, and people suffering from chronic diseases or mental illness. The implications of COVID-19 on these communities and systemic disparities beyond the current pandemic are also discussed. People from vulnerable communities' experience disproportionately adverse impacts of COVID-19. COVID-19 has exacerbated systemic disparities and its long-term negative impact on these populations foretell an impending crisis that could prevail beyond the COVID-19 era. It is onerous that systemic issues be addressed and efforts to build inclusive and sustainable societies be pursued to ensure the provision of universal healthcare and justice for all. Without these reinforcements, we would not only compromise the vulnerable communities but also severely limit our preparedness and response to a future pandemic.

How to Use a Prioritised Approach for Treating Hematological Disorders During the COVID-19 Pandemic in India?

The current pandemic coronavirus, SARS-CoV-2, is known to cause severe infection (COVID-19) in patients with comorbidities, particularly cancer or an immunosuppressed state. Most healthcare systems in the country are likely to be overwhelmed soon if the pandemic moves to a stage of community transmission. Currently, limited evidence is available for managing patients with hematological disorders during the COVID-19 pandemic. The current review summarises the possible challenges clinicians are likely to face, key considerations to guide decision making, and possible solutions to the anticipated challenges. Disease specific recommendations and possible guidance for decision making have been suggested for most hematologic diseases that are feasible in our health setup. It is not meant to replace individual clinical judgment, but to provide a template to formulate local policies.

Status of barium studies in the present era of oncology: Are they a history?

With the advent of the modern imaging technologies, the present era of oncology is seeing steady decline in requests for barium studies due to the many reasons. It is prudent to mention here, that, barium examinations cannot be made obsolete! Our aim to preserve the age old technique of barium studies not only to keep it going on but also for the betterment and appropriate management of the patient. Our goal is not to “save” barium studies simply to keep this technology alive, per se, but rather to preserve barium radiology for the quality in patient care.