The Indian scenario of head and neck oncology - Challenging the dogmas

Comparison of magnetic resonance imaging and CT scan-based delineation of target volumes and organs at risk in the radiation treatment planning of head and neck malignancies

INTRODUCTION

Accuracy of target definition is paramount in radiation treatment planning. The optimal choice of imaging modality to define the tumor volume in head and neck tumors is debatable. The study compared MRI and CT scan-based delineation of target volume and Organs At Risk in head and neck cancers.

MATERIALS AND METHODS

54 head and neck carcinoma patients underwent rigid image registration of planning CT images with MRI images. The gross tumor volume of the primary tumor, node, and organs at risk were delineated on both CT and MRI images. A volumetric evaluation was done for gross tumors, nodes, and organs at risk. Dice Similarity coefficient (DSC), Conformity index(CI), Sensitivity index(SI), and Inclusion index(II) were calculated for gross tumor, node, brainstem, and bilateral parotids.

RESULTS

The mean volume of the tumor in CT and MRI obtained were 41 .94 cc and 34.76 ccs, mean DSC, CI, SI, and II of the tumor were 0.71, 0.56, 67.37, and 79.80. The mean volume of the node in CT and MRI were 12.16 cc and 10.24 cc, mean DSC, CI, SI, and II of the node were 0.61, 0.45, 62.47, and 64. The mean volume of the brainstem in CT and MRI was 24.13 cc and 21.21 cc. The mean volume of the right parotid in CT and MRI was 24.39 cc, 26.04 ccs. The mean volume of left parotid in CT and MRI, respectively, were 23.95 ccs and 25.04 ccs.

CONCLUSIONS

The study shows that MRI may be used in combination with CT for better delineation of target volume and organs at risk for head and neck malignancies.

Effect of the nasal airflow inducing manoeuvre on olfaction and quality of life after laryngectomy

OBJECTIVE

To assess the effectiveness of the nasal airflow inducing manoeuvre or 'polite yawn' technique in improving olfaction and quality of life in laryngectomised patients.

METHODS

Using a prospective study design, 42 patients scheduled to undergo laryngectomy at a tertiary care centre were subjected to olfaction testing before surgery and two weeks following the surgery. The nasal airflow inducing manoeuvre was taught, and the olfaction test was repeated with the patient performing the nasal airflow inducing manoeuvre. Quality of life was assessed using the Appetite, Hunger and Sensory Perception questionnaire with calculation of scores after the patient had learnt the nasal airflow inducing manoeuvre.

RESULTS

There was a significant reduction in the composite olfaction score, from a mean (standard deviation) baseline value of 4.01 (1.39) to 0.44 (0.51), two weeks after surgery (p < 0.001). After practising the nasal airflow inducing manoeuvre, the olfaction scores increased to 3.05 (1.32) (p < 0.001). Appetite, Hunger and Sensory Perception questionnaire scores ranged from 52 to 110 (normal range, 29-145), suggesting an improvement in the quality of life of patients.

CONCLUSION

The nasal airflow inducing manoeuvre, an inexpensive, simple, patient-friendly manoeuvre, can be used in the olfaction rehabilitation of patients undergoing laryngectomy.

Role of Narrow Band Imaging in Laryngeal Lesions: A Prospective Study from Southern India

To assess the utility of Narrow Band Imaging (NBI) as a diagnostic tool in evaluating laryngeal pathology in patients presenting with hoarseness. Study design: Prospective cross sectional diagnostic study. Methods: 200 patients with voice change were recruited and laryngeal findings documented with high definition flexible endoscopy with both white light and narrow band light and the representative still images recorded for analysis. The NBI intraepithelial papillary capillary loop (IPCL) patterns was compared with the histopathology report. Of the 200 patients evaluated, 84 lesions were biopsied which included both benign and malignant lesions. The sensitivity obtained was 73.3% [54.1-87.7% with 95% CI] and the specificity was 87% [75.1-94.6% with 95% CI] for detecting malignant lesions. NBI can be considered as a useful diagnostic tool in evaluating laryngeal pathology and can be used to detect early premalignant and malignant lesions.

Cetuximab Concurrent with Radiotherapy in Unresectable, Locally Advanced Squamous Cell Carcinoma of Head and Neck: Real-World Evidence from a Tertiary Care Hospital

Cetuximab (EGFR-targeted IgG1 monoclonal antibody) has shown to improve the treatment outcomes in head and neck cancer. The evidence on the beneficial outcomes of cetuximab with radiotherapy (RT) in unresectable patients of locally advanced squamous cell carcinoma of head and neck (LA-SCCHN) is limited in real-life practice. The present study evaluated the treatment outcomes of cetuximab concurrent with RT in Indian patients with unresectable LA-SCCHN. We retrospectively reviewed fifty-one patients with unresectable LA-SCCHN between January 2013 and December 2017, who were treated with cetuximab concurrently with RT. Tumor response and disease-free survival (DFS) were estimated. Tumor response using RECIST (1.1) criteria reported complete response in 66.7%, partial response in 31.4% and progressive disease in 1.9% of the patients. The overall response rate was 98%. The 1-year and 2-year DFS was 85% and 69% respectively. The median DFS was significantly better in stage 3 than stage 4. The most common toxicity observed was mucositis and skin reactions (grade 3). Cetuximab concurrent with RT was effective in Indian patients with unresectable, LA-SCCHN and had an acceptable toxicity profile in real-life practice. The real-life beneficial evidence of the combination is consistent with the results documented in the randomized controlled trials.

Mapping of head and neck cancer patient concerns inventory scores on to Euroqol-Five Dimensions-Five Levels (EQ-5D-5L) health utility scores

BACKGROUND

The purpose of this paper is to map the number of concerns on the dimensions in Head and Neck Patient Concerns Inventory (PCI) on to the health utility (HU) index scores on Euroqol-Five Dimensions-Five levels {EQ-5D-5L) .

METHODS

This is a cross-sectional survey conducted in patients who have completed their treatment. Four candidate models were considered, three based on ordinary least squares regression (OLS) and one two-parts model.

RESULTS

A reduced OLS model based on 'Physical and functional', 'Treatment-related', and 'Psychological, emotional and spiritual well-being' domains was found best on the estimation sample. This was validated externally on a separate sample.

CONCLUSIONS

This is the first study that mapped a non-QOL tool to generate HU scores on EQ-5D-5L. The proposed mapping algorithm can estimate the cost-utility in economic evaluation studies when HU scores are not directly available. The algorithm will be best suited for studies in low-middle income countries.

Nimotuzumab combined with radiotherapy for the treatment of hypopharyngeal cancer - A case report from a tertiary cancer center

BACKGROUND

Nimotuzumab is a monoclonal antibody against epidermal growth factor receptor which can be combined with chemotherapy and radiotherapy for the treatment of locally advanced unresectable squamous cell carcinoma of head-and-neck region and its role has already been established in India.

AIM

The aim of this case report is to show the role of nimotuzumab in carcinoma hypopharynx.

METHODS

We report a patient with Stage III carcinoma of hypopharynx, who received radiotherapy along with weekly nimotuzumab due to his comorbidities. The patient had tolerated the treatment very well without any major side effects.

RESULTS

The patient is on regular follow-up with a complete response (CR) of the disease and with the disease-free interval (DFI) of 7 months.

CONCLUSIONS

Nimotuzumab along with radiotherapy can be safely given in the patients with carcinoma hypopharynx, who are ineligible for chemotherapy.

RELEVANCE FOR PATIENTS

Nimotuzumab can be added with radiotherapy to the patients with head-and-neck malignancies who are ineligible for chemotherapy to improve the clinical outcome with minimal toxicity.

Microvascular reconstruction for head and neck cancers in high risk population: clinical outcomes and complications

INTRODUCTION

Microvascular reconstruction is the gold standard for reconstruction in oral cavity cancers. Age and comorbidities determine the type of reconstruction. We aimed to analyse the impact of high-risk comorbidities on perioperative morbidity.

METHODS

This is a retrospective study of 317 patients undergoing microvascular reconstruction from January 2014 to December 2017. High risk patients were based on age, American Society of Anaesthesiologists (ASA) grade (III/IV) and Charlson comorbidity index (CCI) score >4; overall, 73 out of 317 patients were evaluated.

RESULTS

Median age was 59 years. Five patients (6.8%) had complete flap failures and seven (9.5%) had minor complications (wound breakdown, bleeding, wound dehiscence, partial flap loss). ASA score of IV was significantly associated with morbidity while age >65 years and CCI >4 was not associated. The overall flap success rate was 93.2%.

CONCLUSIONS

A high-risk population has nearly similar outcomes for microvascular reconstruction as a younger age group. High ASA score adversely affects surgery-related outcomes.

Efficacy and safety of nimotuzumab in unresectable, recurrent, and/or metastatic squamous cell carcinoma of the head and neck: A hospital-based retrospective evidence

Context:

Role of nimotuzumab in locally advanced head and neck cancer (HNC) is well established in India; however, no clinical evidence is available for its role in recurrent and/or metastatic HNC.

Aims:

The aim of this study is to evaluate the efficacy and safety of nimotuzumab when added to standard treatment in unresectable, recurrent, and metastatic squamous cell carcinoma of the head and neck (SCCHN).

Settings and Design:

Hospital records of 14 patients diagnosed with recurrent and/or metastatic HNC with histologically confirmed squamous cell carcinoma and being treated with nimotuzumab along with standard treatments from December 2010 to December 2016 were retrospectively evaluated.

Subjects and Methods:

The tumor response rate and overall survival (OS) were analyzed. Toxicity and adverse events (AEs) were assessed as per common terminology criteria for adverse events (CTCAE) v 4.

Results:

Oral cavity was most commonly involved region followed by hypopharynx and oropharynx. At 24 weeks after completion of treatment, overall response rate (complete response (CR) + partial response (PR)) was 75%. Survival rate at 1, 2, and 3 years was 77.80%, 64.81%, and 64.81%, respectively. At a median follow-up of 15.17 months, median OS was not reached. All AEs were either Grade I (66.7%) or Grade II (33.3%). No Grade III or Grade IV AEs were observed. No added toxicity was observed due to nimotuzumab.

Conclusions:

In the first of its kind study, the addition of nimotuzumab to standard treatment showed promising response rate as well as survival outcomes in recurrent and/or metastatic SCCHN patients without producing additional toxicity.

Efficacy and safety of concurrent chemoradiotherapy with or without Nimotuzumab in unresectable locally advanced squamous cell carcinoma of head and neck: Prospective comparative study - ESCORT-N study

Background:

Nimotuzumab is an anti-epidermal growth factor receptor monoclonal antibody which can be added to chemoradiotherapy (CRT) to improve efficacy for management of locally advanced squamous cell carcinoma of the head and neck (LASCCHN). We prospectively evaluated the efficacy and safety of nimotuzumab with CRT for LASCCHN and compared with CRT alone.

Materials and Methods:

In this prospective study, 29 LASCCHN (Stage III–IVb) patients received Nimotuzumab plus CRT or CRT alone. Treatment included six cycles of cisplatin (40–50 mg/week) or carboplatin (area under the curve-based), nimotuzumab (200 mg/week), and radiotherapy (60–70 Gy). Tumor response was evaluated as per response evaluation criteria in solid tumors criteria. MoS was estimated using the Kaplan–Meier method. Toxicity and adverse events (AE's) were assessed as per CTCAE v 4.0.

Results:

At 24 weeks after completion of treatment, the tumor response rate (complete response, partial response, stable disease) was 53.3% and 35.7% favoring nimotuzumab arm while progression of disease was 40% and 35.7% in Nimotuzumab plus CRT and CRT groups, respectively. However, the objective response rate was 57% and 30% in favor of nimotuzumab arm. At median follow-up of 45.5 months, MoS was 33 months in Nimotuzumab plus CRT and 27 months in CRT group. The 5-year survival rate was 33.3% in Nimotuzumab plus CRT versus 7.1% in CRT group. Nimotuzumab was observed to be safe with no additional AE's such as hypersensitivity, hypomagnesemia, and allergic reaction was reported.

Conclusion:

Addition of Nimotuzumab to standard CRT showed improved survival rate in unresectable, LASCCHN patients without producing additional toxicity.

Evolving multidisciplinary treatment of squamous cell carcinoma of the head and neck in India✰

In this article, we highlight the evolution of a multimodal approach in the overall management of squamous cell carcinoma of the head and neck (SCCHN) in India; present advances in technology (newer surgical techniques), novel medical and radiotherapy (RT) approaches; review their roles for an integrated approach for treating SCCHN and discuss the current role of immunotherapy in SCCHN. For locally advanced (LA) SCCHN, the multidisciplinary approach includes surgery followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy. Improved surgical techniques of reconstruction and voice-preservation are being implemented. Advanced forms of high-precision conformal techniques like intensity-modulated radiotherapy are used to deliver highly conformal doses to tumors, sparing the surrounding normal tissue. Compared with RT alone, novel CT regimens and targeted therapeutic agents have the potential to improve locoregional control and survival and reduce treatment-induced toxicities. Several clinical trials have demonstrated efficacy, safety, and quality of life benefits of adding cetuximab to RT regimens in LASCCHN. Studies have also suggested a cetuximab-related laryngeal preservation benefit. At progression, platinum-based CT combined with cetuximab (a monoclonal anti-epidermal growth factor receptor antibody) is the only validated option available as the first-line therapy. Thus, an integrated multidisciplinary approach plays a key role in maximizing patient outcomes, reduction in treatment related morbidities that consequently impact quality of life of survivors.

A prospective, comparative analysis of acute toxicity profile between three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) in locally advanced head and neck cancer patients

INTRODUCTION

The advances of modern radiotherapy have emerged with the development of conformal radiotherapy techniques, such as the three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT). We prospectively compared acute toxicities and treatment-compliance between IMRT and 3DCRT in patients with locally advanced head and neck carcinoma.

METHOD

80 patients were enrolled in this comparative prospective non-randomized study. Inclusion criteria were patients with locally advanced carcinoma of hypopharynx, oropharynx and larynx. 40 patients were treated with IMRT and 40 patients with 3DCRT to dose of 70 Gy in 35 fractions, along with concurrent cisplatin weekly chemotherapy. All patients were assessed weekly during chemoradiotherapy treatment and after 3 months of the treatment.

RESULTS

15 patients (38.4%) versus 8 patients (20.51%) developed grade 3 mucositis in the 3DCRT and IMRT group respectively (p= <0.001). At three months post chemo-radiotherapy treatment, 17 patients (43.6%) versus 7 patients (17.9%) had grade 2 dysphagia in 3DCRT and IMRT group respectively (p = 0.029). At three months post radiotherapy, grade 3 xerostomia was seen in 3 patients (7.6%) in 3DCRT group versus no patient (0%) in IMRT group (p = 0.006). IMRT group had lower incidence of grade 3 dermatitis (p = 0.043), weight loss of the patients during the treatment (p = 0.126), lesser requirement of nasogastric intubation (p = 0.003) and better treatment-compliance (p = 0.336) compared to 3DCRT.

CONCLUSION

IMRT reduced the incidence of severe mucositis, dysphagia, xerostomia, weight-loss of the patients, requirements for nasogastric tube and it improved the treatment-compliance compared to 3DCRT in locally advanced head neck cancer patients treated by chemo-radiotherapy.

Modifying gap junction communication in cancer therapy

AIM

Drug delivery is crucial for therapeutic efficacy and gap junction communication channels (GJIC) facilitate movement within the tumour. Pro-drug activation, a modality of cancer therapy leads to Ganciclovir triphosphate (GCV-TP) incorporation into newly synthesized DNA resulting in cell death. The objective was to enhance, with Histone deacetylase inhibitors (HDACi) and All Trans Retinoic Acid (ATRA), GJIC, crucial for drug delivery, and with combination, abrogate the observed detrimental effect of Dexamethasone (DXM).

METHODS

Cell lines (NT8E, and HeLa) were pre-treated with Valproic Acid (VPA) (1 mM), 4 Phenyl Butyrate (4PB) (2 mM), ATRA (10 μM) and Dexamethasone (1 μM). Protein quantitated with the Bicinchoninic (BCA) assay for cell lysates, membrane and soluble fractions was assessed with Western blotting for Connexins (43, 26 and 32) and E-Cadherin. A qRT-PCR was done for CX 43-GJA1, CX 26-GJB2, CX 32-GJB1 and E-Cadherin, and normalized with Glyceraldehyde Phosphate dehydrogenase (GAPDH). Further, localization of Connexins (CX) and E-Cadherin, GJIC competence, pre-clinical in-vitro studies and the mechanism of cell death were evaluated.

RESULTS

There was no toxicity or change in growth patterns observed with the drugs. In both the cell lines CX 43 localized to the membrane whereas CX 32 and CX 26 were present but not membrane bound. E-Cadherin was present on the membrane in NT8E and completely absent in HeLa cells. Effects of HDACi, DXM and ATRA were seen on the expression of Connexins and E-Cadherin in both the cell lines. NT8E and HeLa cell lines showed enhanced GJIC with 4PB [30 %], VPA [36 %] and ATRA [54 %] with a 60 % increase in cytotoxicity and an abrogation of Dexamethasone inhibition on combination with VPA or ATRA.

CONCLUSION

An enhancement of GJIC function by HDACi and ATRA increased cytotoxicity and could be effective in the presence of Dexamethasone, when combined with ATRA or VPA.

Dosimetric comparison of coplanar and non-coplanar volumetric-modulated arc therapy in head and neck cancer treated with radiotherapy

Purpose

To evaluate the dosimetric variations in patients of head and neck cancer treated with definitive or adjuvant radiotherapy using optimized non-coplanar (ncVMAT) beams with coplanar (cVMAT) beams using volumetric arc therapy.

Materials and Methods

Twenty-two patients of head and neck cancer that had received radiotherapy using VMAT in our department were retrospectively analyzed. Each of the patients was planned using coplanar and non-coplanar orientations using an optimized couch angle and fluences. We analyzed the Conformity Index (CI_RTOG), Dose Homogeneity Index (DHI), Heterogeneity Index (HI_RTOG), low dose volume, target and organs-at-risk coverage in both the plans without changing planning optimization parameters.

Results

The prescription dose ranged from 60 Gy to 70 Gy. Using ncVMAT, CI_RTOG, DHI and HI_RTOG, and tumor coverage (ID_95%) had improved, low dose spillage volume in the body V_5Gy was increased and V_10Gy was reduced. Integral dose and intensity-modulated radiation therapy factor had increased in ncVMAT. In the case of non-coplanar beam arrangements, maximum dose (D_max) of right and left humeral head were reduced significantly whereas apex of the right and left lung mean dose were increased.

Conclusion

The use of ncVMAT produced better target coverage and sparing of the shoulder and soft tissue of the neck as well as the critical organ compared with the cVMAT in patients of head and neck malignancy.

Impact of comorbidities on perioperative outcomes for carcinoma of oral cavity

INTRODUCTION

Surgical management of oral cavity carcinoma involves composite resection with reconstruction. Comorbidities increase the risk of perioperative complications. Objective stratification is important for uneventful recovery. The Charlson Comorbidity Index and the Washington University Head and Neck Comorbidity Index were used to assess perioperative morbidity and mortality.

MATERIALS AND METHODS

This was a prospective study of 531 patients with head and neck squamous cell carcinoma who were treated between January 2014 and December 2017. Patients' comorbidity scores on the Charlson Comorbidity Index and Washington University Head and Neck Comorbidity Index were recorded.

RESULTS

The median age of the cohort was 49 years. Median Charlson Comorbidity Index score was 3 and Washington University Head and Neck Comorbidity Index was 0. There were five mortalities with a Charlson Comorbidity Index score of 4 or more. Fifteen patients had either infection, leak or postoperative bleeding. A Charlson Comorbidity Index of 4 or more was associated with higher event rate and poor overall survival (p=0.001).

CONCLUSION

Higher Charlson Comorbidity Index score is associated with increased incidence of peri-operative morbidity and mortality, while the Washington University Head and Neck Comorbidity Index is a poor predictor of the same.

Nimotuzumab with intensity-modulated radiation therapy in unresectable and platinum-ineligible locally advanced head-and-neck cancer

Background:

Outcomes with conventional treatment are poor in patients with squamous cell carcinoma of head and neck (SCCHN). Treatment options are further limited for patients ineligible to receive platinum-based chemotherapy due to various factors such as geriatric age, comorbidity, and organ dysfunctions. The present study retrospectively evaluated the effectiveness of nimotuzumab when added to radiation therapy in unresectable, locally advanced SCCHN patients who were ineligible for platinum-based chemotherapy.

Materials and Methods:

The medical records of 21 patients with unresectable, locally advanced head-and-neck cancer and histologically confirmed squamous cell carcinoma who were ineligible for platinum-based chemotherapy treated with nimotuzumab and intensity-modulated radiation therapy (IMRT) from 2012 to 2017 were retrospectively analyzed. The tumor response rate and overall survival (OS) were analyzed. Patients were assessed for toxicity and adverse events (AEs) as per CTCAE version 4. Statistical analysis was performed using SPSS software.

Results:

The median number of doses of nimotuzumab received was 6, and median dose of radiotherapy was 60 Gy. The tumor response rate was calculated at 24 weeks after the completion of radiotherapy and was as follows: 76.2% (16) of patients showed complete response, 9.5% (2) of patients showed partial response, 4.8% (1) of patients showed stable disease, and 9.5% (2) of patients showed progression of disease. Median OS was 21 months, whereas 1-year survival rate was 63.7%. No Grade 3 or Grade 4 AEs were observed.

Conclusion:

Nimotuzumab with IMRT has achieved promising clinical outcomes in unresectable locally advanced SCCHN patients who are ineligible for platinum-based chemotherapy, without accumulation of toxicity.

Safety and efficacy of nimotuzumab with concurrent chemoradiotherapy in unresectable locally advanced squamous cell carcinoma of head and neck: An Indian rural hospital experience

Context:

Nimotuzumab is the only anti-epidermal growth factor receptor monoclonal antibody which can be safely added to concurrent chemoradiotherapy (CRT) to improve efficacy in the management of unresectable, locally advanced squamous cell carcinoma of head and neck (LA-SCCHN). However, the evidence available on this is limited.

Aims:

We retrospectively investigated efficacy and safety of nimotuzumab when combined with chemoradiation for LA-SCCHN.

Settings and Design:

Hospital records of 39 patients from January 2012 to December 2016 diagnosed with locally advanced (Stage III-IVb), unresectable SCCHN, and treated with concurrent CRT with weekly nimotuzumab were reviewed retrospectively after fulfilling the inclusion/exclusion criteria.

Subjects and Methods:

Tumor response was calculated as per response evaluation criteria in solid tumors criteria 1.1. Association of tumor response with independent variables was assessed. Overall survival (OS) and progression-free survival (PFS) were calculated. All patients were assessed for toxicity as per common terminology criteria for adverse events Common Terminology Criteria for Adverse Events v 4.0 (U.S. Department of health and human services, National Institutes of Health, National Cancer Institute).

Results:

At 6 months after completion of treatment, objective response rate was 97.44% with 26 (66.67%) patients attaining Complete response (CR), 12 (30.77%) patients with Partial response (PR), and one patient (2.56%) had stable disease. Subgroup analysis did not show a significant association of tumor response with independent factors. OS at 1 and 2-year was 100% and 72.9%, while PFS at 1 and 2-year was 87% and 54.40%. The incidence of Grade I, II, III, and IV toxicity was 30%, 18.18%, 41.82%, and 10%, respectively. No grade V toxicity was observed. Common adverse events observed were mucositis (33.64%), skin reaction (24.55%), neutropenia (20.91%), vomiting (18.18%), and diarrhea (2.73%).

Conclusions:

Nimotuzumab is an efficacious and safe option when added to concurrent CRT in unresectable, LA-SCCHN.

Assessment of Caregivers' Strain during Radiation Therapy of Head-and-Neck Cancer Patients: An Institutional Report using Modified Caregivers' Strain Index Scale

Aims:

Very little works have been reported on the issues of burden perceived by the caregivers of head-and-neck cancer (HNC) patients. Job of the caregiver is complex, and it limits their social, psychological, and economical well-being. Our study aims at assessing caregivers' strain during radiation therapy (RT) of HNC patients using the Modified Caregivers' Strain Index (MCSI) Scale.

Materials and Methods:

In this single-institutional cross-sectional study, we interviewed caregivers of HNC patients undergoing curative RT. Along with MCSI, a 13-point questionnaire, which was self-administered in local languages; we collected baseline data of patients and their caregivers. Scores were evaluated. For each question, score varies 0–2. Higher the Median Hazard Score (H Score), more was the level of the strain.

Results:

We interviewed 24 participants. Response rate was 100%. About 45.8% of patients were in Stage III. The median age of caregivers was 40 years; 58.3% were male, 79.2% were employed, and 58.3% were belonging to the upper-lower class. Nearly 66.6% were spouse of the patients and 70.8% belong to joint family. In MCSI score analysis, H Score was 22 (range 14) with a minimum score of 14 and maximum score of 26. The most common score was 20. About 65.1% of participants responded Score 2 in all aspects of strain indices. Travel time had a significant positive association with total H Scores (Pearson's r = 0.663, P < 0.05).

Conclusion:

Majority of the caregivers was suffering from severe physical, personal, emotional, and social/financial strain. This issue must be addressed in holistic cancer care.

Assessment of DNA repair susceptibility genes identified by whole exome sequencing in head and neck cancer

Head and neck cancer (HNC), the sixth most common cancer globally, stands second in India. In Northeast (NE) India, it is the sixth most common cause of death in males and seventh in females. Prolonged tobacco and alcohol consumption constitute the major etiological factors for HNC development, which induce DNA damage. Therefore, DNA repair pathway is a crucial system in maintaining genomic integrity and preventing carcinogenesis. The present work was aimed to predict the consequence of significant germline variants of the DNA repair genes in disease predisposition. Whole exome sequencing was performed in Ion Proton™ platform on 15 case-control samples from the HNC-prevalent states of Manipur, Mizoram, and Nagaland. Variant annotation was done in Ion Reporter™ as well as wANNOVAR. Subsequent statistical and bioinformatics analysis identified significant exonic and intronic variants associated with HNC. Amongst our observed variants, 78.6% occurred in ExAC, 94% reported in dbSNP and 5.8% & 9.3% variants were present in ClinVar and HGMD, respectively. The total variants were dispersed among 199 genes with DSBR and FA pathway being the most mutated pathways. The allelic association test suggested that the intronic variants in HLTF and RAD52 gene significantly associated (P < 0.05) with the risk (OR > 5), while intronic variants in PARP4, RECQL5, EXO1 and PER1 genes and exonic variant in TDP2 gene showed protection (OR < 1) for HNC. MDR analysis proposed the exonic variants in MSH6, BRCA2, PALB2 and TP53 genes and intronic variant in RECQL5 genetic region working together during certain phase of DNA repair mechanism for HNC causation. In addition, other intronic and 3'UTR variations caused modifications in the transcription factor binding sites and miRNA target sites associated with HNC. Large-scale validation in NE Indian population, in-depth structure prediction and subsequent simulation of our recognized polymorphisms is necessary to identify true causal variants related to HNC.