Breast cancer in India: Present scenario and the challenges ahead

Inhibition of NF-κB-Mediated Proinflammatory Transcription by Ru(II) Complexes of Anti-Angiogenic Ligands in Triple-Negative Breast Cancer

Nuclear factor kappa beta (NF-κB) plays a pivotal role in breast cancer, particularly triple-negative breast cancer, by promoting inflammation, proliferation, epithelial-mesenchymal transition, metastasis, and drug resistance. Upregulation of NF-κB boosts vascular endothelial growth factor (VEGF) expression, assisting angiogenesis. The Ru(II) complexes of methyl- and dimethylpyrazolyl-benzimidazole N,N donors inhibit phosphorylation of ser536 in p65 and translocation of the NF-κB heterodimer (p50/p65) to the nucleus, disabling transcription to upregulate inflammatory signaling. The methyl- and dimethylpyrazolyl-benzimidazole inhibit VEGFR2 phosphorylation at Y1175, disrupting downstream signaling through PLC-γ and ERK1/2, ultimately suppressing Ca(II)-signaling. Partial release of the antiangiogenic ligand in a reactive oxygen species-rich environment is possible as per our observation to inhibit both NF-κB and VEGFR2 by the complexes. The complexes are nontoxic to zebrafish embryos up to 50 μM, but the ligands show strong in vivo antiangiogenic activity at 3 μM during embryonic growth in Tg(fli1:GFP) zebrafish but no visible effect on the adult phase.

Expression of cell surface zinc transporter LIV1 in triple negative breast cancer is an indicator of poor prognosis and therapy failure

Triple negative breast cancers (TNBC) are an aggressive molecular subtype of breast carcinoma (BC) identified by the lack of receptor expression for estrogen, progesterone, & human epidermal growth factor receptor-2. Lack of tangible drug targets warrants further research in TNBC. LIV1, is a zinc (Zn) transporter known to be overexpressed in few cancer types including BCs. Recently, in the United States of America, FDA approved the use of a new drug targeting LIV1, antibody drug conjugate SGN-LIV1A for treatment of TNBC patients. Though LIV1 also has a role in modulating immune cells by its differential transport of Zn, a correlation between the tumor cell expression of LIV1 and immune cell infiltrations were scantily reported. Further adequate baseline data on LIV1 expression in other populations have not been documented. Our objective was to screen a large Indian cohort of TNBC patient samples for LIV1, categorize the immune cell infiltration using CD4/CD8 expression and correlate the findings with therapy outcomes. Further, we also investigated for LIV1 expression in matched samples of primary & secondary tumors; pre & postchemotherapy in TNBC patients. Results showed an elevated expression of LIV1 in TNBC samples as compared to adjacent normal, the mean Q scores being 183.06 ± 6.39 and 120.78 ± 7.37 (p < 0.0001), respectively. Similarly, LIV1 levels were elevated in secondary tumors than primary & in patient samples postchemotherapy as compared to naïve. In the TNBC cohort, using automated method, cell morphology parameters were computed and analysis showed LIV1 levels were elevated in grade 3 TNBC samples presenting with altered cell morphology parameters namely cell size, cell perimeter, & nucleus size. Thus indicating LIV1 expressing TNBC samples portrayed an aggressive phenotype. Finally, TNBC patients with 3+ staining intensity showed poor survival (4.44 year) as compared to patients with 2+ LIV1 expression (5.47 year), emphasizing that LIV1 expression is a poor prognostic factor in TNBC. In conclusion, the study reports elevated expression of LIV1 in a large Indian TNBC cohort; high expression is a poor prognostic factor and correlated with aggressive disease and indicating the need for LIV1 targeted therapies.

Is FAST FORWARD the Way Forward in Radiotherapy for Locally Advanced Breast Cancer - Learnings From the COVID Pandemic

INTRODUCTION

Low middle-income countries (LMICs), including India, have paucity of external beam radiotherapy (RT) machines leading to prolonged wait times for RT. Delay in delivery of RT has been shown to adversely affect outcomes in locally advanced breast cancer (LABC). With the availability of results of multiple randomized controlled trials, hypofractionated RT delivered over 3 to 4 weeks became the standard of care in breast cancer RT.

METHODS

We conducted a retrospective audit of 172 LABC patients treated with ultrahypofractionated adjuvant RT (radiotherapy completed in 1 week) during the COVID pandemic. Log rank and Cox-regression model used for univariate and multi-variate analyses.

RESULTS

No patient developed grade 3 esophagitis. Grade 2 esophagitis requiring short term narcotic analgesics was seen in 12 (6.9%) patients. Grade 2 or higher toxicity peaked between 2 and 3 weeks after RT. The estimated 2 and 3- year recurrence free survival (RFS) for the cohort is 87.1 % and 81.4 %, respectively. The estimated 2 and 3-year overall survival for the cohort is 95% and 91.3%. On multivariate analysis, presence of extra-nodal extension was found to be an independent factor associated with worse RFS (P = .028).

CONCLUSIONS

FAST FORWARD protocol RT in LABC appears well tolerated.

Burden of female breast cancer in India: estimates of YLDs, YLLs, and DALYs at national and subnational levels based on the national cancer registry programme

PURPOSE

Female breast cancer (BC) is the leading cause of cancer incidence and mortality in India, and accounted for 13.5% of new cancer cases and 10% of cancer-related deaths in 2020. This study aims to estimate and report the female BC burden in India at state level from 2012 to 2016 in terms of years of life lost, years lived with disability, and disability-adjusted life years (DALYs), and to project the burden for the year 2025.

METHODS

The cancer incidence and mortality data from 28 population-based cancer registries were analysed. The mean mortality to incidence ratio was estimated, and mortality figures were adjusted for underreporting. The burden of female BC was estimated at national and subnational levels using Census data, World Health Organisation's lifetables, disability weights, and the DisMod-II tool. A negative binomial regression is employed to project burden for 2025.

RESULTS

The burden of BC among Indian women in 2016 was estimated to be 515.4 DALYs per 100,000 women after age standardization. The burden metrics at state level exhibited substantial heterogeneity. Notably, Tamil Nadu, Telangana, Karnataka, and Delhi had a higher burden of BC than states in the eastern and north-eastern regions. The projection for 2025 indicates to a substantial increase, reaching 5.6 million DALYs.

CONCLUSION

The female BC burden in India was significantly high in 2016 and is expected to substantially increase. Undertaking a multidisciplinary, context-specific approach for its prevention and control can address this rising burden.

Knowledge, attitude, and practice of breast self-examination is associated with general self-care and cultural factors: a study from Tamil Nadu, India

AIM

Breast cancer is the most prevalent type of cancer among women. One form of care related to early detection of breast cancer is breast self-examination (BSE). However, evidence on knowledge, attitude, and practice (KAP) of BSE and its determining factors are minuscule in an Indian context. Therefore, the present study primarily examined the prevalence of KAP of BSE. Further, its association with general self-care and cultural factors was determined.

METHODS

This cross-sectional study obtained data from 412 women (Mn age = 26.63) from two rural localities of Vellore district, Tamil Nadu, India. Self-reported questionnaires of KAP of BSE, self-care, and cultural factors were applied. Statistical analyses include independent sample t-test and binomial logistic regression.

RESULTS

The majority of the sample had inadequate knowledge (58%), unfavourable attitudes (73.8%), and poor practice (89.6%) of BSE. The general self-care among the sample was moderate. Self-care was found to be a significant predictor of knowledge (b = 0.07, p < .05) and attitude (b = 0.092, p < .05) toward BSE. Shyness was identified as a negative predictor of KAP. Discouraged breast health discussions predicted inadequate knowledge, and not being educated by family/friends had a negative impact on knowledge and practice. A preference for same-gender physicians led to an unfavourable attitude toward BSE.

CONCLUSION

The observed negative trends in KAP of BSE are concerning. The results imply that girls and women should be educated and encouraged to practice BSE and promote self-care behaviours. At the same time, efforts to reduce cultural barriers may be helpful to promote the KAP of BSE.

Frequency of Programmed Death Receptor Ligand 1 Expression and Clinicopathological Factors Associated With Metastatic Triple-Negative Breast Cancer at a Tertiary Cancer Care Centre in South India

Purpose Triple-negative breast cancer (TNBC) has a poor outcome compared to other subtypes. Immune checkpoint inhibitors (ICIs) have changed the treatment paradigm in metastatic diseases as well as in neoadjuvant setting. The response to these agents is affected by programmed death ligand 1 (PDL1) receptor expression which are reported objectively as a score. PDL1 is a prognostic marker also. Here, we present clinicopathological characteristics of metastatic TNBCs, report the proportion of PDL1 expression and its association with clinicopathological factors as well as survival. Methods This is a prospective study carried out at a tertiary cancer care centre in South India. Case records of all breast cancer patients treated in two years between August 2021 and July 2023 were reviewed, patients with metastatic TNBC were selected. Patient's characteristics, histological features, molecular profile, and treatment were analyzed. PDL1 testing was carried out on pretreatment tumor tissue sections with immunohistochemistry (IHC) (Dako 22C3). PDL1 staining was interpreted as negative or positive based on combined positive score (CPS), with an expression less than 10 considered negative. Results A total of 118 patients were analyzed. With a median age of 46 years (36-65 years), 52.5% (62/118) were premenopausal. Family history of Ca Breast was seen in 22% (26/118) patients. A majority of patients had left-sided tumor 55.9% (66/118). Visceral metastasis was more common 96.6% (82/118) than skeletal. Radical intent of treatment was adopted in 10% as patients had oligometastatic disease at presentation. As front-line treatment, anthracycline-based chemotherapy was administered to the majority 54.2% (64/118). The PDL1 expression with CPS more or equal to 10 was seen in 32.2% (38/118) patients. Survival was associated with menopausal status (p value=0.000) and family history (p value=0.028) but not with PDL1 nor sidedness in our study. Estimated survival at 12 months in PDL1 negative case is 10 ± 0.29 months, while in PDL1 positive case it is slightly more at 10 ± 0.75 months, but difference was not found to be statistically significant (p value=0.15). Conclusion TNBCs are highly aggressive subtype with limited treatment options and poorer outcomes. Our study shows PDL1 expression in 31.66% of the cases similar to other literature from India. Survival is associated with menopausal status and family history. No association was found between survival and PDL1 as well sidedness in our study.

Glucocorticoid receptor: a harmonizer of cellular plasticity in breast cancer-directs the road towards therapy resistance, metastatic progression and recurrence

Recent therapeutic advances have significantly uplifted the quality of life in breast cancer patients, yet several impediments block the road to disease-free survival. This involves unresponsiveness towards administered therapy, epithelial to mesenchymal transition, and metastatic progression with the eventual appearance of recurrent disease. Attainment of such characteristics is a huge adaptive challenge to which tumour cells respond by acquiring diverse phenotypically plastic states. Several signalling networks and mediators are involved in such a process. Glucocorticoid receptor being a mediator of stress response imparts prognostic significance in the context of breast carcinoma. Involvement of the glucocorticoid receptor in the signalling cascade of breast cancer phenotypic plasticity needs further elucidation. This review attempted to shed light on the inter-regulatory interactions of the glucocorticoid receptor with the mediators of the plasticity program in breast cancer; which may provide a hint for strategizing therapeutics against the glucocorticoid/glucocorticoid receptor axis so as to modulate phenotypic plasticity in breast carcinoma.

3D tomosynthesis evaluation of breast parenchymal density and its association with malignant lesions and menopausal status

BACKGROUND

Breast cancer that has a high mortality rate is now known to decrease due to early detection with the advent of digital breast tomosynthesis (DBT or 3D tomosynthesis) screening, especially in those with dense breasts. The risk of breast cancer related to 'changes' in breast density over time remains controversial as breast density and age have an inverse relationship. Breast density as an independent risk factor for breast cancer is known, but its association with menopausal status, if any, has not been studied thoroughly.

METHOD

All patients referred for 3D mammography with breast lesions from June 2022 to January 2023 were considered. Patients were categorized as pre-, peri, and post-menopausal, and each category was further sub-classified based on the breast density as either dense or non-dense and the lesion type, whether benign or malignant. The Statistical analysis was performed using a chi-square test to evaluate whether any association exists between malignancy and menopausal status.

RESULT

A total of 60 patients, with 20 in each category of menopausal stage, were imaged and evaluated. 35% of women had non-dense breasts, while 65% had dense breast parenchyma. Breast density and lesion type were associated significantly (p-value = 0.05) where, out of the 23 benign lesions, 48% occurred in dense women, and 52% in non-dense women respectively. In our study, both benign (N = 7) and malignant (N = 13) lesions occurred in equal numbers in the pre-and peri‑ menopausal women, whereas the number of benign and malignant lesions in the post-menopausal women were 9 (45%) and 11 (55%), respectively. Even though no statistically significant association was found between menopausal status and malignancy in our study, out of the 37 malignant lesions, a majority (76%) of lesions occurred in those having dense breasts (N = 28).

CONCLUSION

Earlier, the notion was that older women had a higher risk of breast cancer compared to younger, but this study has shown that malignancy and menopausal status have a p-value of 0.754, which is not statistically significant. However, both malignant and benign lesions were found more in women having high breast density, in keeping with previous literature. Hence, precaution and care should be taken during pre-, peri, and post-menopausal phases, especially in those patients with high breast density. Apart from breast density, many other risk factors for breast cancer exist, therefore breast density alone is not sufficient to govern the need for screening in women.

Breast Cancer in India: Screening, Detection, and Management

Breast cancer is the most common cancer in urban Indian women and the second most common cancer in all Indian women. The epidemiology as well as biology of this cancer seems to be different in the Indian subcontinent when compared with the West. The lack of population-based breast cancer screening programs and delay in seeking a medical consult due to financial and social reasons, including lack of awareness and fear related to a cancer diagnosis, results in delayed diagnosis.

Clinicopathological Significance and Expression Pattern of Bcl2 in Breast Cancer: A Comprehensive in silico and in vitro Study

B-cell lymphoma/leukemia gene-2 (Bcl-2) is the primary proto-oncogene that has been shown to work by preventing apoptosis/programmed cell death. Bcl-2 combines a variety of cell-generated signals associated to the survival and death of cells. In glioma, lung, and breast cancer, Bcl-2 over-expression has been linked to an increase in invasion and migration. Many treatment regimens that target Bcl2 have been established and approved, and thus increasing the survival rates of the patients. The primary goal of this research was to recognize new therapeutic compounds that target Bcl2 and assess Bcl2 expression pattern in BC patients. We used various bioinformatic tools as well as several in vitro assays to look out the expression and inhibition of Bcl2 in BC. Our study depicted that Bcl2 had a strong connection with tumour stroma, notably with suppressor cells originating from myeloid tissues. Moreover, in vitro and in silico research identified Paclitaxel as a promising natural substance that targets Bcl2. Overall, this work shows that Bcl2 overexpression accelerates the development of BC, and that targeting Bcl2 in combination with other drugs will dramatically improve BC patient's response to treatment and prevent the emergence of drug resistance.

Clinical Profile of Triple-Negative Breast Cancer: A Hospital-Based Study

Introduction Triple-negative breast cancer (TNBC) is a new concept and an important area of investigation. In Western country's literature, different studies reported on TNBC and all indicated the poor prognostic aspect of this molecular subtype over other types of breast cancer. However, there is a scarcity of comprehensive data from India. Hence, the present study was carried out to look at the epidemiological and clinical characteristics of TNBC in the Indian population. Methods The present study was performed between January 2020 and June 2021 at a tertiary care hospital in Eastern India. A total of 150 patients with TNBC were enrolled in the study. The epidemiological and clinical features of enrolled patients were collected and reviewed. Results The median age of patients at TNBC presentation was 45.53 years (24 to 74 years). The median tumor size was reported to be 5.32 cm. Of 150 patients, 94(62.67%) showed enlarged lymph nodes and 56 (37.33%) patients had no lymph node enlargement. In the present study, 85 (56.67%) patients were in the pre/perimenopausal stage at presentation, whereas 65 (43.33%) patients were in the postmenopausal stage. Upon evaluating the spread of TNBC, it was observed that a maximum of patients 60 (40%) were at the T4 stage and 56 (37.33%) at the N0 condition. The clinical staging of TNBC reported a maximum of 74 (49.33%) patients at the IIA, and IIB stages followed by 53 (35.33%) patients at the IIIA, IIIB, and IIIC stages and a minimum of 11 (7.33%) patients at stage IV. Only five (3.33%) patients were reported with a family history of breast cancer. Of all patients, 126 (84%) had detected early breast cancer thereby applicable for surgery at the time of presentation, whereas 71 (47.33%) patients were eligible for radiation therapy and 138 (92%) patients received chemotherapy. A total of 112 (74.67%) patients were found alive after 24 months of follow-up, 22 (4.67%) patients were observed with remission, and 11 (7.33%) patients died due to TNBC progression. During the course of follow-up, five (3.33%) patients were lost in the study.  Conclusion TNBC is an aggressive malignancy that has a high risk of systemic relapses in the first two years after diagnosis. For more mature evidence on TNBC, longer follow-up of patients is necessary.

Feasibility of monitoring Global Breast Cancer Initiative Framework key performance indicators in 21 Asian National Cancer Centers Alliance member countries

Background

The Global Breast Cancer Initiative (GBCI) Framework, launched by the World Health Organisation (WHO) in 2023, emphasises assessing, strengthening, and scaling up services for the early detection and management of breast cancer. This study aims to determine the feasibility of monitoring the status of breast cancer control in the 21 Asian National Cancer Centers Alliance (ANCCA) countries based on the three GBCI Framework key performance indicators (KPIs): stage at diagnosis, time to diagnosis, and treatment completion.

Methods

We reviewed published literature on breast cancer control among 21 ANCCA countries from May to July 2023 to establish data availability and compiled the latest descriptive statistics and sources of the indicators using a standardised data collection form. We performed bivariate Pearson's correlation analysis to measure the strength of correlation between stage at diagnosis, mortality and survival rates, and universal health coverage.

Findings

Only 12 (57%) ANCCA member countries published national cancer registry reports on breast cancer age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR). Indonesia, Myanmar, and Nepal had provincial data and others relied on WHO's Global Cancer Observatory (GLOBOCAN) estimates. GLOBOCAN data differed from the reported national statistics by 5-10% in Bhutan, Indonesia, Iran, the Republic of Korea, Singapore, and Thailand and >10% in China, India, Malaysia, Mongolia, and Sri Lanka. The proportion of patients diagnosed in stages I and II strongly correlated with the five-year survival rate and with the universal health coverage (UHC) index. Three countries (14%) reported national data with >60% of invasive breast cancer patients diagnosed at stages I and II, and a five-year survival rate of >80%. Over 60% of the ANCCA countries had no published national data on breast cancer staging, the time interval from presentation to diagnosis, and diagnosis to treatment. Five (24%) countries reported data on treatment completion. The definition of delayed diagnosis and treatment completion varied across countries.

Interpretation

GBCI's Pillar 1 KPI correlates strongly with five-year survival rate and with the UHC index. Most ANCCA countries lacked national data on cancer staging, timely diagnosis, and treatment completion KPIs. While institutional-level data were available in some countries, they may not represent the nationwide status. Strengthening cancer surveillance is crucial for effective breast cancer control. The GBCI Framework indicators warrant more detailed definitions for standardised data collection. Surrogate indicators which are measurable and manageable in country-specific settings, could be considered for monitoring GBCI indicators. Ensuring UHC and addressing health inequalities are essential to early diagnosis and treatment of breast cancer.

Funding

Funding for this research article's processing fee (APC) will be provided by the affiliated institution to support the open-access publication of this work. The funding body is not involved in the study design; collection, management, analysis and interpretation of data; or the decision to submit for publication. The funding body will be informed of any planned publications, and documentation provided.

Breast self-examination practices among young rural women and its associated knowledge and attitudes in Tirunelveli District, Tamil Nadu

CONTEXT

Breast self-examination (BSE) is a simple and cost-effective screening procedure in downstaging breast tumors.

AIM

To assess the BSE practices and its associated knowledge and attitudes of rural women from Tirunelveli District, Tamil Nadu during the COVID-19 pandemic.

SETTINGS AND DESIGN

A descriptive cross-sectional survey design was employed, and snowball sampling was used to recruit the sample of rural women from Tirunelveli.

MATERIALS AND METHODS

Women ages 18-60 willing to take part were included. Data were collected online through a self-developed questionnaire.

STATISTICAL ANALYSIS

Responses were analyzed using SPSS Version 20. Descriptive statistical analysis was used to present the general details and responses of the rural women through percentages. Using the appropriate tests, the mean differences of the BSE attitudes based on the personal variables were computed using one-way ANOVA.

RESULTS

A total of 433 rural women (Mean age: 29.20 ± 9.35 years) from Tirunelveli responded to the online Knowledge, Attitude and Practice (KAP) questionnaire. Regular health checkups were undergone by 27.48% of women and 9.24% underwent breast cancer (BC) screening in the past. While 68.36% had heard of BC, 61% knew it could be detected in the early stages. Insufficient knowledge regarding BSE techniques was evident among the women. Knowledge about BC was highest among those earning more than 20,001 INR, women aged 36-45, widowed/separated/divorced women, and diploma graduates. Overall, BSE and BC knowledge score was low, with correspondingly low attitudes and practices.

CONCLUSION

Findings showed the KAP among rural Tirunelveli women to be low.

Tata Memorial Centre Evidence Based Management of Breast cancer

ABSTRACT

The incidence of breast cancer is increasing rapidly in urban India due to the changing lifestyle and exposure to risk factors. Diagnosis at an advanced stage and in younger women are the most concerning issues of breast cancer in India. Lack of awareness and social taboos related to cancer diagnosis make women feel hesitant to seek timely medical advice. As almost half of women develop breast cancer at an age younger than 50 years, breast cancer diagnosis poses a huge financial burden on the household and impacts the entire family. Moreover, inaccessibility, unaffordability, and high out-of-pocket expenditure make this situation grimmer. Women find it difficult to get quality cancer care closer to their homes and end up traveling long distances for seeking treatment. Significant differences in the cancer epidemiology compared to the west make the adoption of western breast cancer management guidelines challenging for Indian women. In this article, we intend to provide a comprehensive review of the management of breast cancer from diagnosis to treatment for both early and advanced stages from the perspective of low-middle-income countries. Starting with a brief introduction to epidemiology and guidelines for diagnostic modalities (imaging and pathology), treatment has been discussed for early breast cancer (EBC), locally advanced, and MBC. In-depth information on loco-regional and systemic therapy has been provided focusing on standard treatment protocols as well as scenarios where treatment can be de-escalated or escalated.

CRISPR-based therapeutic targeting of signaling pathways in breast cancer

Breast cancer remains a leading cause of death for women worldwide, and new treatment strategies are needed. There are innumerable anomalous genes that are responsible for the multi-factorial carcinogenesis pathway. Although several disease-causing mutations have been detected, therapy frequently focuses on attenuating the manifestation of the disease rather than harmonizing the mutation in the target area. The advent of CRISPR-Cas9 technology has revolutionized genome editing, allowing for precise and efficient manipulation of gene expression. The purpose of this review paper is to summarize recent progress in the use of CRISPR-based approaches to target key signaling pathways associated with breast cancer progression. The first section introduces basic concepts of CRISPR technology, focusing on its application in genome editing and transcriptional regulation followed by an overview of aspects involving complex signaling pathways in breast cancer such as P13K/AKT/mTOR, EPK/MAPK and Wnt/β catenin. An extensive literature search using PubMed and Google Scholar is performed for information retrieval. Further, the role of CRISPR-based interventions in regulating gene expression revealed, altered pathway activity and potential therapeutic consequences are discussed. This review will be a valuable addition to providing comprehensive knowledge of CRISPR-Cas-mediated therapeutic targeting in breast cancer.

Occurrence and Distribution of Cancers with Emphasis Upon Oral Cancers in Registered Oncology Institutes of South India - A Retrospective Study

Background

In the past two decades, the growing economy associated with changes in lifestyle-related behavior is partially responsible for the increasing cancer burden in India. To assess the occurrence and distribution of oral cancer based on the analysis of hospital records from registered oncology institutes of South India over a period of three years.

Materials and Methods

A multicenter, retrospective study was conducted at seven major hospitals in South India to assess the incidence and distribution of cancer among patients over a period of three years (2016-2018). Data were collected on a custom-made validated proforma. Analysis was done using R commander software.

Results

A total of 156090 various types of cancers were reported to the included institutes over a three-year period, an almost similar gender distribution was observed, males (n = 78806, 42.99% per lakh) compared to their female counterparts (n = 77284, 42.16% per lakh). Among males' lung cancer was the most common type with 17709 cases (9.65% per lakh) and among females, breast cancer was the leading cancer type with 22855 total cases (12.46% per lakh). Over a period of three years, a total of 21084 records of malignancies pertaining to oral cavity were identified accounting for 13.51% of cases. Among oral cancers, tongue was the most common site to be involved accounting for 44.22% (2016-2018) cases followed by buccal mucosa (14.69%), least common site to be involved was lip which accounted for 3.49% of the total oral cancer cases.

Conclusion

Breast cancer was the most common cancer followed by lung cancer. Oral cancers occupied second among males and fifth rank in the order of occurrence among females. Tongue was the most common site followed by buccal mucosa. The least common site affected by oral cancer was the lip.

Nanomedicine-Based Drug-Targeting in Breast Cancer: Pharmacokinetics, Clinical Progress, and Challenges

Breast cancer (BC) is a malignant neoplasm that begins in the breast tissue. After skin cancer, BC is the second most common type of cancer in women. At the end of 2040, the number of newly diagnosed BC cases is projected to increase by over 40%, reaching approximately 3 million worldwide annually. The hormonal and chemotherapeutic approaches based on conventional formulations have inappropriate therapeutic effects and suboptimal pharmacokinetic responses with nonspecific targeting actions. To overcome such issues, the use of nanomedicines, including liposomes, nanoparticles, micelles, hybrid nanoparticles, etc., has gained wider attention in the treatment of BC. Smaller dimensional nanomedicine (especially 50-200 nm) exhibited improved in vivo effectiveness, such as better tissue penetration and more effective tumor suppression through enhanced retention and permeation, as well as active targeting of the drug. Additionally, nanotechnology, which further extended and developed theranostic nanomedicine by incorporating diagnostic and imaging agents in one platform, has been applied to BC. Furthermore, hybrid and theranostic nanomedicine has also been explored for gene delivery as anticancer therapeutics in BC. Moreover, the nanocarriers' size, shape, surface charge, chemical compositions, and surface area play an important role in the nanocarriers' stability, cellular absorption, cytotoxicity, cellular uptake, and toxicity. Additionally, nanomedicine clinical translation for managing BC remains a slow process. However, a few cases are being used clinically, and their progress with the current challenges is addressed in this Review. Therefore, this Review extensively discusses recent advancements in nanomedicine and its clinical challenges in BC.

Persistence of patient-detected breast cancer over time: 1990-2019

BACKGROUND

The continued presentation of patient-detected breast cancer (BC) and associated characteristics over time is understudied.

METHODS

In a large institutional cohort of first primary stage 0-IV patients with BC in 1990-2019 (n = 15,827), diagnostic method (patient-detected [PtDBC] [n = 5844]; mammography-detected [MamDBC] [nondiagnostic] [n = 9248]; and physician-detected [PhysDBC] [n = 736]) and patient and tumor characteristics including age, race, TNM stage, and hormone-receptor status were reviewed. Pearson χ2 tests for bivariate comparisons and logistic regression for patient detection-associated factors were used.

RESULTS

In a cohort from 1990 to 2019, the proportion aged 50-74 years (55%-63%; p < .001) and non-White race (9%-37%; p < .001) increased over time. Percentage PtDBC decreased over time but case numbers increased (1990-1999: 44% [n = 1399]; 2010-2019: 34% [n = 2349]; p < .001). Excluding stage 0, PtDBC declined from 47% to 41% over time (p < .001). In 2010-2019, 21% of cases were stage 0, 91% of which were mammography detected (n = 1439). Seventy percent of patient-detected cases were stage II-IV (stage II, 44%; stage III, 20%; stage IV, 6%; p < .001). In adjusted logistic regression, the odds of PtDBC decreased over time (2000-2009: odds ratio [OR], .65 [95% CI, .58-.72]; 2010-2019: OR, .54 [95% CI, .49-.60]), with age <40 years OR, 15.81, and Black and non-White other at 50% increased risk.

CONCLUSIONS

The relative proportion of PtDBC decreased to a constant 34%-40% of total cases after 1990-1999. PtDBC case numbers increased in subsequent years (2000-2019), and were consistently higher stage. Interval cancers, mammography-screening uptake, breast health awareness of age groups outside screening guidelines, and underserved socioeconomic groups may be related to the continued significant PtDBC incidence.

PLAIN LANGUAGE SUMMARY

After decades of mammography-screening availability, symptomatic patient-detected breast cancer declined over time from 44% to a persistent rate of 34% in our institutional cohort. The persistence of patient-detected breast cancer over time presents a difficult situation for patients and care givers without clear diagnosis pathways for younger and older women outside recommended screening guidelines, who often present with higher stage and more lethal characteristics. More timely diagnosis and treatment including breast health awareness, prompt presentation of breast problems, outreach to younger age and minority groups, and provision of specialized training and care delivery for symptomatic patient-detected breast cancer are needed.

Breast cancer: A comparative review for breast cancer detection using machine learning techniques

Breast cancer is the most common cancer among women globally and presents a significant challenge due to its rising incidence and fatality rates. Factors such as cultural, socioeconomic, and educational barriers contribute to inadequate awareness and access to healthcare services, often leading to delayed diagnoses and poor patient outcomes. Furthermore, fostering a collaborative approach among healthcare providers, policymakers, and community leaders is crucial in addressing this critical women's health issue, reducing mortality rates, alleviating, and the overall burden of breast cancer. The main goal of this review is to explore various techniques of machine learning algorithms to examine high accuracy and early detection of breast cancer for the safe health of women.

A Randomized Clinical Study to Compare the Perioperative Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block Over Thoracic Epidural in Modified Radical Mastectomy

Aim This study aims to compare the effectiveness of ultrasound-guided erector spinae block (ESB) with thoracic epidural (TE) in managing postoperative pain among breast cancer (BC) surgery patients. Methods A total of 42 patients were enrolled and randomly divided into two groups, each comprising 21 participants. Primary endpoints assessed included intraoperative fentanyl consumption, postoperative pain scores, and the need for rescue analgesia. Secondary endpoints encompassed intraoperative hemodynamic changes and the incidence of postoperative nausea and vomiting (PONV). Results The study found no significant difference in intraoperative fentanyl requirement (p=0.62) or postoperative pain scores measured using numerical rating scores (NRS) throughout the 48-hour postoperative period. None of the patients in either group required rescue analgesia. Notably, there was a statistically significant difference in postoperative nausea and vomiting at the two-hour mark, favoring the erector spinae block. Both groups exhibited comparable hemodynamic changes during intraoperative monitoring. Conclusions Our investigation concludes that the ESF offers equivalent analgesic efficacy to the thoracic epidural during both surgery and the postoperative period without inducing any significant hemodynamic instability. Considering the lower complication rate associated with paraspinal blocks compared to neuraxial blocks, the ESB presents itself as a promising alternative method for effective pain relief in mastectomy procedures.

Association of Dietary Factors and Physical Inactivity with Molecular Subtypes of Breast Cancer- Hospital Based Case-Control Study

Improper diet and physical inactivity are environmental risk factors for breast cancer (BC). This study evaluated the association of dietary risk factors and physical activities with different molecular subtypes of BC. We conducted a case-control study among 130 cases of BC and 150 age-matched controls. Demographic data and tissue marker status were obtained. Diet was assessed using Food Frequency Questionnaire and physical activity was determined using Physical Activity Questionnaire. The association between diet and physical activity with the cancer status was evaluated by Pearson's Correlation. Among the various dietary factors, refined oil displayed a weak albeit significant positive correlation (r = 0.344) to Luminal B subtype of BC. Consumption of all kinds of non-vegetarian food exhibited significant elevation in BC risk with OR > 1.9 (95% CI 0.825-2.707). A higher odds ratio (>1.66) was observed in individuals who had a limited intake of fruits. Furthermore, a strong association was found between low physical activity and breast cancer risk, with around 14.6% of cases being distinctly linked to this risk (OR = 3.33, 95% CI 1.158-9.403, p < 0.01). In essence, while dietary factors exhibited a negative correlation with breast cancer risk, the risk was heightened by physical inactivity.

A Study on the Factors and Prediction Model of Triple-Negative Breast Cancer for Public Health Promotion

This study was conducted to identify the risk causes and predictive models based on the clinical features of patients with breast cancer classified as triple-negative breast cancer (TNBC) and non-triple-negative breast cancer (non-TNBCs) using Korean cancer statistics. A total of 2045 cases that underwent three types of hormone receptor tests were obtained from Korean cancer data in 2016. Research data were analyzed with the software SPSS Ver. 26.0. TNBC and non-TNBCs accounted for 12.4% and 87.6% of the data, respectively. Tubular and lobular tumors occurred most frequently in the external quadrant of the breast (C50.4-C50.5; 43.1%). Compared to non-TNBCs, the incidence of TNBC was the most common in patients under the age of 39 (19.5%), followed by those over the age of 70 (17.3%). Tumors larger than 2 cm accounted for 16.0%, which was higher than the number of tumors smaller than 2 cm. Cases in stage IV cancer represented 21.7% of the data. Additionally, 21.0% of the patients were in the SEER stage of distant metastasis, which was the most prevalent SEER (surveillance, epidemiology, and end outcomes) stage. Neoadjuvant therapy was administered more frequently, with a rate of 24.1%. In the logistic regression and decision-making tree model, the variables that affected TNBC were age, differentiation grade, and neoadjuvant therapy. The predictive accuracies of logistic regression and decision-making tree models were 87.8% and 87.6%, respectively. In a decision-marking tree model, the differentiation grades of TNBC affect neoadjuvant therapy, and neoadjuvant therapy affects the cancer stage. Therefore, in order to promote the health of breast cancer patients, it is urgent to apply an intensive early health check-up program for those in their 40s and 50s with a high prevalence of TNBC. For patients with breast cancer, in TNBC cases, except for poorly differentiated cases, neoadjuvant therapy must be applied first at all differentiation grades. The establishment of a policy system is necessary for the success of this process.

Strengthening breast cancer screening program through health education of women and capacity building of primary healthcare providers

Background

Globally and in India, breast cancer is a prevalent malignancy. India saw 178,361 new cases and 90,000 deaths in 2020. Timely detection is vital, highlighting the importance of Breast Self-Examination (BSE), especially in low-income settings. Strengthening BSE in awareness and screening efforts is urgent. Despite awareness, practical application lags due to women's reluctance. Effective execution demands partnerships, a multi-sectoral strategy, and training grassroots workers.

Objective

To address these challenges, the present study aims to strengthen the breast cancer screening program using BSE strategy and adopting a referral mechanism for the diagnosis and treatment of suspect cases.

Methods

A community-based study occurred in specific districts of Rajasthan (2017-2022), enhancing breast cancer screening for women aged 30-65. It involved healthcare providers and local women, utilizing tools like the MT-DM-GP6620 Breast Inspection Model, educational booklets, and semi-structured schedules. The strategy encompassed knowledge assessment, capacity building for healthcare providers, BSE training, increasing women's breast cancer awareness, suspect case referrals, and phone-based follow-up.

Results

Our study encompassed 157,225 women aged 30-65 in Jodhpur, Jalore, and Pali districts. Initial breast self-examination (BSE) awareness was below 1%. BSE training reached 218,978 women using booklets and demonstrations, with 72% aged 30-65 and the rest 15-30. Follow-ups reinforced BSE, leading to 745 identified suspect breast cancer cases, mostly due to painless lumps (332 cases). Capacity-building workshops involving 824 medical and paramedical staff strengthened early breast cancer detection in Jodhpur and Jalore, in collaboration with the district health department.

Conclusion

The study model's success suggests its applicability in other Rajasthan districts, Indian states, and global breast cancer prevention programs. While positive outcomes were evident, challenges related to culture, cost, and benefits warrant consideration. The approach prioritized early detection through community engagement, reducing patient and government burdens. Community involvement and healthcare engagement were pivotal, with breast self-examination proving effective for enhancing awareness and early detection. Promoting BSE education can significantly enhance breast cancer awareness and early detection.

Prospective Study of Incidence and Impact of Comorbidities on Breast Cancer Survival from India

PURPOSE

To report comorbidity burden in newly-diagnosed treatment-naïve breast cancer patients and its effect on survival.

METHODS

Prospective observational study in which demographic, comorbidity and outcome data from a consecutive cohort of patients diagnosed and treated between September 2019 to September 2021 were collected. Charlson Comorbidity Index (CCI) score was calculated for all and proportion of each comorbidity was determined at diagnosis (baseline), at conclusion and six-months post-treatment. Univariate and multivariate analysis was done for impact of various demographic and disease-related factors on the incidence of comorbidities as well as on progression free survival (PFS) and overall survival (OS).

RESULTS

Out of five hundred patients who consented for the study, 416 patients completed planned treatment and only 206 patients had physical follow-up due to COVID-19 pandemic. Incidence of comorbidity at the three time-points was 24%, 32% and 26% respectively. The difference was significant compared to baseline at both the time-points (p<0.05). Hypertension and diabetes were the most common types (incidence 15%-21% and 12-18% respectively) of comorbidities. Advancing age, post-menopauusal status and not being married were significant factors for presence of comorbidities. Median follow-up was 27 months (95% CI 26.25-28.55 months). Presence of multiple comorbidities was a poor prognostic factor for both PFS (2-yr PFS 85% vs 77%) and OS (2-yr OS 89% vs 79%) (both p=0.04) but no such correlation for CCI score.

CONCLUSION

Breast cancer treatment impacted incidence of comorbidities. Presence of multiple comorbidities had an adverse impact on survival. Hence, further research on treatment optimization is required in patients with substantial comorbidities.

The cytotoxic potential of sinapic acid on luminal A breast cancer; a computational and experimental pharmacology approach

Breast cancer is a highly concerning and prevalent disease that impacts a significant proportion of women worldwide, whose repeated exposure to therapies leads to resistance for drugs; making it alarming to identify novel chemotherapeutic agents. Sinapic acid is a phenolic acid that occurs naturally and is known to exhibit cytotoxic action in a variety of cancer cell types. In the present study, we utilized cell cytotoxicity assays to assess the cytotoxic potential of sinapic acid on various breast cancer subtypes. In addition, we assessed the cell migration rate, cell apoptosis, and cell cycle phases. Moreover, we utilized multiple system biology tools to predict the potential targets, and molecular docking was performed on the hub targets followed by molecular dynamic (MD) simulations. Cytotoxicity assay was performed on cell lines MCF7, T47D, MDA-MB-468, and SKBR3 at different time exposures of 24, 48, and 96 h. Our results revealed sinapic acid to be potent on MCF7 and T47D cell lines. The cell cycle analysis and cell apoptotic assays revealed sinapic acid to cause cell death by apoptosis majorly in the G0/G1 phase. Computational biology revealed KIF18B and VKORC1 to possess the highest binding affinity of -6.5 and -7.5 kcal/mol; displayed stable trajectories on MD run. The cytotoxicity of sinapic acid on luminal A cell lines may be due to the modulation of VKORC1 and KIF18B with major cell death in the G0/G1 phase. However, the mechanism has been proposed via in silico tools, which need further validation using wet lab protocols.Communicated by Ramaswamy H. Sarma.

Glucose-conjugated glutenin nanoparticles for selective targeting and delivery of camptothecin into breast cancer cells

Receptor-mediated drug delivery systems are a promising tool for targeting malignant cells to suppress/inhibit the malignancy without disturbing healthy cells. Protein-based nanocarrier systems possess numerous advantages for the delivery of variety of chemotherapeutics, including therapeutic peptides and genes. In the present work, glucose-conjugated camptothecin-loaded glutenin nanoparticles (Glu-CPT-glutenin NPs) were fabricated to deliver camptothecin to MCF-7 cells via GLUT-1 transporter protein. Initially, Glu-conjugated glutenin polymer was successfully synthesized through reductive amination reaction, and this was confirmed by FTIR and 13C-NMR. Then, camptothecin (CPT) was loaded into Glu-conjugated glutenin polymer forming Glu-CPT-glutenin NPs. The nanoparticles were studied for their drug releasing capacity, morphological shape, size, physical nature, and zeta potential. The fabricated Glu-CPT-glutenin NPs were found to be spherical in shape and amorphous in nature with 200-nm size range and a zeta potential of - 30 mV. Furthermore, MTT assay using Glu-CPT-glutenin NPs confirmed concentration-dependent cytotoxicity against MCF-7 cells after 24-h treatment, and IC50 was found to be 18.23 μg mL-1. In vitro cellular uptake study demonstrated that the Glu-CPT-glutenin NPs had enhanced endocytosis and delivered CPT in MCF-7 cells. A typical apoptotic morphological change of condensed nuclei and distorted membrane bodies was found after treatment with IC50 concentration of NPs. The released CPT from NPs also targeted mitochondria of MCF-7 cells, significantly increasing the level of reactive oxygen species and causing the damage of mitochondrial membrane integrity. These outcomes confirmed that the wheat glutenin can positively serve as a significant delivery vehicle and enhance the anticancer potential of this drug.

Recognising socio-cultural barriers while seeking early detection services for breast cancer: a study from a Universal Health Coverage setting in India

BACKGROUND

Breast cancer is the commonest cancer among women in India, yet the uptake of early detection programs is poor. This leads to late presentation, advanced stage at the time of diagnosis, and high mortality. Poor accessibility and affordability are the most commonly cited barriers to screening: we analyse socio-cultural factors influencing the uptake of early detection programmes in a Universal Health Coverage (UHC) setting in India, where geographical and financial barriers were mitigated.

METHODS

Two hundred seventy-two women engaging in an awareness-based early detection program were recruited by randomization as the participant (P) group. A further 272 women who did not participate in the early detection programme were recruited as non-participants (NP). None of the groups were previously screened for breast cancer. Interviews were conducted using a 19-point questionnaire, consisting of closed-ended questions regarding demographics and social, cultural, spiritual and trust-related barriers.

RESULTS

The overall awareness about breast cancer was high among both groups. None of the groups reported accessibility-related barriers. Participants were more educated (58.09% vs 47.43%, p = 0.02) and belonged to nuclear families (83.59% vs 76.75%, p = 0.05). Although they reported more fear of isolation due to stigma (25% vs 14%, p = 0.001), they had greater knowledge about breast cancer and trust in the health system compared to non-participants.

CONCLUSIONS

The major socio-cultural barriers identified were joint family setups, lower education and awareness, and lack of trust in healthcare professionals. As more countries progress towards UHC, recognising socio-cultural barriers to seeking breast health services is essential in order to formulate context-specific solutions to increase the uptake of early detection and screening services.

Transitioning India to advanced image based adaptive brachytherapy: a national impact analysis of upgrading National Cancer Grid cervix cancer guidelines

Background

High-dose-rate image guided brachytherapy (IGBT) for cervical cancer leads to improved local control and reduced toxicity and is a critical component of treatment. However, transition to IGBT requires capacity upscaling. An institutional activity mapping and national impact analysis of such a transition were undertaken to understand feasibility.

Methods

Between September 2020 and March 2021, activity mapping was conducted in a high-volume centre that triaged cervical cancer patients for brachytherapy into four workflows; A: two-dimensional (2D) X-Ray point A-based intracavitary brachytherapy, B: CT point A-based intracavitary brachytherapy, C: MRI/CT-volume based intracavitary brachytherapy, D: MRI/CT volume-based intracavitary +/- interstitial brachytherapy. Clinical process time mapping was performed, and case scenarios for transition were modelled at the institutional and national levels based on available incidence and infrastructure levels. Treatment capacity changes were calculated, and potential strategies for workflow reorganisation were proposed.

Findings

Eighty-four patients were included in the study. The total time taken for the workflows A, B, C, and D were 176 min (57-208), 224 min (74-260), 267 min (101-302), and 348 min (232-383), respectively. The transition from workflow A to D through sequential steps led to 35%, 49%, and 64% loss of treatment capacity in the index institution. Solutions such as 10-hour or 12-hour overlapping shifts increased treatment capacity by 25% and 50% and performing single implants and delivering multiple fractions increased capacity by 100%. Twenty-three Indian states and Union Territories are predicted to be able to transition to advanced workflows. For four Indian states, it may be detrimental considering the current infrastructure level, and eight Indian states lacked brachytherapy access. Further financial investment is required in the latter 12 states for transition to advanced workflows.

Interpretation

Our study demonstrates that unplanned transition to IGBT can lead to treatment capacity loss and increase in waiting lists to access treatment. The proposed solutions of workflow reorganisation, using strategies such as single brachytherapy applicator implant and delivering multiple treatment fractions can improve access to treatment for women with cervix cancer in resource-strained and high patient-volume settings. We recommend state-wise solutions for the upscale from conventional 2D workflows to IGBT, subject to the availability of skilled personnel, infrastructure and training. Financial investments may be needed in some states to achieve this goal.

Funding

International Atomic Energy Agency (IAEA) supported the salary of VH through project E33042 that focussed on implementation strategies of image guided brachytherapy.

Self-Care Behaviour of Patients With Breast Cancer in the Management of Side Effects of Chemotherapy

Aim The breast is the leading site of cancer among females. Chemotherapy is the standard treatment of breast cancer and it results in multiple side effects. Apart from pharmacological management, self-care behaviors may significantly influence the management of these side effects. The study aimed to assess the self-care behavior of patients with breast cancer in the management of side effects of chemotherapy. Methods A longitudinal descriptive study was conducted at the Daycare chemotherapy unit of the Radio Therapy Department, Government Medical College Hospital Thiruvananthapuram, Kerala, India. In total, 170 female patients with breast cancer receiving their first cycle of chemotherapy participated in the study. Self-care behavior was the primary outcome variable of the study. Sociodemographic and clinical data were measured by using a structured questionnaire. The severity of side effects and self-care behaviors for their management were measured by a Self Care Diary (SCD). Result A total of 170 with breast cancer receiving chemotherapy participated in the study. The severity of side effects and self-care behaviors for their management were measured at two separate time intervals, T1 and T2. Severe fatigue was found in 80.0% of participants at T1 and 61.2% at T2. Vomiting (47.7%), mucositis (48.2%), and nausea (49.1%) were also found to be severe at T1, but these side effects were moderate (53.8%, 58.8%, and 51.8% respectively) at T2. Despite the high number of self-care behaviors used to prevent infection, nausea/vomiting, bleeding, decreased appetite, sleeping difficulty, and constipation, overall self-care behaviors were found to be poor. A negative correlation was found between self-care behavior and side effects of chemotherapy. Conclusion The study revealed a negative correlation between self-care behaviors and side effects. This indicates that supportive education and training should be given to patients and caregivers to enhance the self-care behaviors of patients to manage the side effects.

Chitosan-encapsulated nickel oxide, tin dioxide, and farnesol nanoparticles: Antimicrobial and anticancer properties in breast cancer cells

Breast cancer is the most frequent cancer in women; however, it is curable in most cases (up to 80 %) when detected and treated at an early non-metastatic stage. Nanotechnology has led to the development of potential chemotherapeutic techniques, particularly for tumor treatment. Nanotechnology has therapeutic and pharmaceutical applications. Chitosan, a natural polymer derived from chitin, has been extensively studied for its potential applications in a wide range of fields. This includes medicine for its anticancer properties. In the present study, Chitosan-encapsulated-NiO-TiO2-Farnesol hybrid nanomaterials (CNTF HNMs) were synthesized and characterized using several techniques, including electron microscopy (TEM, FE-SEM), spectroscopy (UV-visible [UV-Vis], Fourier Transform Infrared [FT-IR] spectroscopy, and photoluminescence [PL]), energy-dispersive X-ray spectroscopy (EDX) composition analysis, X-ray diffraction, and dynamic light scattering (DLS) analyses. With an estimated average crystallite size of 34.8 nm, the face-cantered cubic crystalline structure of the CNTF HNMs is identified. Cell viability assay by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide), DAPI (4',6-diamidino-2-phenylindole) staining, dual AO/EtBr (Acridine Orange/ Ethidium bromide), JC-1 (5,5,6,6'-tetrachloro-1,1',3,3' tetraethylbenzimi-dazoylcarbocyanine iodide), DCFH-DA (Dichloro-dihydro-fluorescein diacetate), Annexin V-FITC (Fluorescein isothiocyanate) /PI (Propidium Iodide), and cell cycle study was used to assess the ability of nanoparticles (NPs) to kill MDA-MB-231 cells. The CNTF HNMs had high antibacterial effectiveness against multi-drug resistant extended-spectrum beta-lactamases (ESBL)-producing gram-negative bacterial pathogens and reference strains. The findings suggest that NPs increased the number of reactive oxygen species (ROS), changed the Δψm, and initiated apoptosis. There is enormous potential for CNTF HNMs as both antibacterial and anticancer agents.

Clinicopathological profile of breast cancer from Chhattisgarh India: A single-center hospital-based study

Background

Global breast cancer incidence is increasing at an annual rate of 3·1%. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%). However, the data from different parts of India are still lacking and the study was conducted to assess the burden of disease at tertiary referral centers in central India.

Material and Methods

Retrospective record analysis (June 2013-June 2017) of data from outdoor clinics and pathology reports. The patients aged <15 yrs, nonresidence of Chhattisgarh, and diagnosed outside the study period were excluded. The triple assessment was used to diagnose all breast lumps (sensitivity 99%).

Results

Eighty patients were diagnosed having breast carcinoma. The mean age for breast cancer was 39 ± 3.028 years (ranged 31-50 years). Twenty patients had locally advanced breast carcinoma. The predominant religion was Hindu 55.00%. The referral pathway to seek medical care for breast cancer was via a gynecologist in 40% (32/80). Familial breast cancers were in 0.03% (3/80) of patients. None breast cancer patients have previous histology-proven benign breast disease. The mean size of the breast cancer lump was 3.56 cm (ranged 1.0-11.0 cm). Overlying skin ulceration (n = 2), skin infiltration/peau-d'- orange (n = 2), skin tethering (n = 4), and bloody nipple discharge were found in one patient. Breast cancer was diagnosed during lactation (postnatal period) in one patient. The maximum number of patients have tumor size >5 cm (72.6%). Immunohistochemistry and pathological analysis was done on core biopsy (n = 20) and surgical procedure (n = 60). Modified radical mastectomy was done in 52, breast conservative surgery with Sentinal Lymph node biopsy and axillary lymph node dissection in 6, and toilet mastectomy in two patients. The predominant tumors were solid (n = 79/80), with both solid and cystic types (1/80). The solid and cystic lesion on FNAC was of C3b type, and an excision biopsy revealed medullary carcinoma of the breast. Invasive ductal carcinoma-no special type (IDC-NST) was observed to be the most common histopathologic type (n = 70/80), followed by medullary carcinoma (n = 2), metaplastic carcinoma (n = 1), papillary carcinoma (n = 4), Paget disease with DCIS (n = 1), mucinous carcinoma (n = 1), invasive lobular carcinoma (n = 1). One male patient with breast cancer and two female patient having bilateral breast cancer also have IDC-NST.Scarff Bloom Richardson Grade was predominantly graded 2 in 46.25% (37/80) of breast cancer patients (Grade 1 = 9, Grade 2 = 37, Grade 3 = 34). Lymphovascular (LVI) and perineural invasion (PNI) were predominantly without LVI and PVI. (Lymphovascular present and perineural invasion present = 4, Lymphovascular present and perineural invasion absent = 32, Lymphovascular absent and perineural invasion absent = 42, Lymphovascular absent and perineural invasion present = 2). Histological examination of axillary lymph nodes showed the presence of malignant cells in all. Triple-negative breast carcinoma was 26.58% (21/79). Most breast cancer presented at stage II A = 37.5% (30/80) and II B = 28.7% (23/80) of the AJCC staging system.

Conclusion

The clinico-epidemio and histological profile of breast cancer in Chhattisgarh is similar to other parts of India. Scarff Bloom Richardson Grade was predominantly grade 2 in 46.25% (37/80) contrary to Grade III (70%) in other series from India.

Nanotechnology revolutionises breast cancer treatment: harnessing lipid-based nanocarriers to combat cancer cells

One of the most common cancers that occur in females is breast cancer. Despite the significant leaps and bounds that have been made in treatment of breast cancer, the disease remains one of the leading causes of death among women and a major public health challenge. The therapeutic efficacy of chemotherapeutics is hindered by chemoresistance and toxicity. Nano-based lipid drug delivery systems offer controlled drug release, nanometric size and site-specific targeting. Breast cancer treatment includes surgery, chemotherapy and radiotherapy. Despite this, no single method of treatment for the condition is currently effective due to cancer stem cell metastasis and chemo-resistance. Therefore, the employment of nanocarrier systems is necessary in order to target breast cancer stem cells. This article addresses breast cancer treatment options, including modern treatment procedures such as chemotherapy, etc. and some innovative therapeutic options highlighting the role of lipidic nanocarriers loaded with chemotherapeutic drugs such as nanoemulsion, solid-lipid nanoparticles, nanostructured lipid carriers and liposomes, and their investigations have demonstrated that they can limit cancer cell growth, reduce the risk of recurrence, as well as minimise post-chemotherapy metastasis. This article also explores FDA-approved lipid-based nanocarriers, commercially available formulations, and ligand-based formulations that are being considered for further research.

Correlation Between Circulating Cell-Free DNA Levels and Breast Cancer Subtypes: A Prospective Observational Study

INTRODUCTION

Breast cancer (BC), a heterogeneous disease, is one of the leading causes of cancer-related deaths among women worldwide. Circulating cell-free DNA (cfDNA) levels have been persistently reported to be elevated in BC patients. In the current study, we evaluated the correlation between the cfDNA levels in patients with BC and its subtypes.

METHODS

We recruited newly diagnosed, histopathologically confirmed BC patients aged >18 years (N=39), who did not have any previous malignancy, from the Department of Surgical Oncology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar, India. A total of 6 ml of venous blood was collected from each subject; of this, 1 ml was subjected to complete blood count (CBC), and 4 ml was transferred to a clot-activated collection vial for plasma separation and the cfDNA isolation thereof. In addition to the basic demographic history of each patient, the information on the cancer subtype was as also recorded from the medical records of each patient. All the data were analysed by GraphPad Prism Version 8 (Insightful Science, LLC, San Diego, California, United States). One-way ANOVA was used to test the difference between more than two groups. Pearson correlation was also estimated between cfDNA levels and various CBC indices. A two-tailed p-value<0.05 was considered statistically significant.

RESULTS

The mean age of included patients was 48.6±8.20 years. The mean levels of cfDNA were 2.81±2.39 ng/µL. The mean counts of various blood cell types and other indices of CBC were in the normal range. Compared to BC patients with estrogen receptors (ER+), the cfDNA levels were significantly higher in patients with human epidermal growth factor receptor 2 (HER2+) and triple-negative BC (TNBC) (p<0.05).  Conclusion: The elevated levels of cfDNA in patients with BC can be a prognostic marker for the disease subtype. However, more replicative studies are warranted to substantiate our findings.

Detection of Axillary Lymph Node Involvement in Early-Stage Breast Cancer: Comparison between Staging 18F-2-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography-Computed Tomography Scans, Mammography, and Sentinel Lymph Node Biopsy

Aims

The aim of this study was to evaluate the role of 18F-2-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) scan in the detection of axillary lymph node (ALN) involvement and comparison with sentinel lymph node biopsy (SLNB) in operable early-stage breast cancer (EBC).

Settings and Design

It is a retrospective analysis of staging PET-CT scan of EBC.

Methods

A total of 128 patients with histopathologically proven breast cancer (BC) were included in the study. Preoperative mammography supplemented with ultrasonography and staging 18F-FDG PET-CT scan was done for all patients. Surgery was done within 30 (mean ± standard deviation = 13.8 ± 10.5) days of staging. SLNB was performed in patients without PET-positive ALNs. All patients with positive sentinel nodes and PET-positive ALNs underwent axillary lymph node dissection (ALND).

Statistical Analysis Used

The comparison between categorical variables was made by Chi-square/Fisher's exact test as applicable. For continuous variables comparisons, Student's t-test and one-way analysis of variance tests were used.

Results

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT scan for detection of ALN involvement were 41.7%, 93.2%, 92.1%, and 45.6%, respectively. Sensitivity, specificity, PPV, and NPV of mammography were 84.5%, 54.5%, 78.0%, and 68.6%, respectively. Sixteen out of 46 (34.7%) patients with negative ALNs in PET-CT scan finally showed involvement in histopathology report after SLNB resulting in upstage of the disease. The size of tumor deposits in sentinel nodes was significantly smaller than PET-positive ALNs (P = 0.01). Our observations correlate with the results of earlier studies published in the literature.

Conclusions

18F-FDG PET-CT scan cannot substitute SLNB for ALN screening in EBC. The limitations are most marked in smaller and micrometastatic tumor deposits in ALNs and may be attributed to limitations of PET resolution. However, PET-positive nodes showed good specificity for disease involvement in our study. Therefore, ALND can safely be performed by omitting SLNB in such cases.

An interpretable decision-support model for breast cancer diagnosis using histopathology images

Microscopic examination of biopsy tissue slides is perceived as the gold-standard methodology for the confirmation of presence of cancer cells. Manual analysis of an overwhelming inflow of tissue slides is highly susceptible to misreading of tissue slides by pathologists. A computerized framework for histopathology image analysis is conceived as a diagnostic tool that greatly benefits pathologists, augmenting definitive diagnosis of cancer. Convolutional Neural Network (CNN) turned out to be the most adaptable and effective technique in the detection of abnormal pathologic histology. Despite their high sensitivity and predictive power, clinical translation is constrained by a lack of intelligible insights into the prediction. A computer-aided system that can offer a definitive diagnosis and interpretability is therefore highly desirable. Conventional visual explanatory techniques, Class Activation Mapping (CAM), combined with CNN models offers interpretable decision making. The major challenge in CAM is, it cannot be optimized to create the best visualization map. CAM also decreases the performance of the CNN models. To address this challenge, we introduce a novel interpretable decision-support model using CNN with a trainable attention mechanism using response-based feed-forward visual explanation. We introduce a variant of DarkNet19 CNN model for the classification of histopathology images. In order to achieve visual interpretation as well as boost the performance of the DarkNet19 model, an attention branch is integrated with DarkNet19 network forming Attention Branch Network (ABN). The attention branch uses a convolution layer of DarkNet19 and Global Average Pooling (GAP) to model the context of the visual features and generate a heatmap to identify the region of interest. Finally, the perception branch is constituted using a fully connected layer to classify images. We trained and validated our model using more than 7000 breast cancer biopsy slide images from an openly available dataset and achieved 98.7% accuracy in the binary classification of histopathology images. The observations substantiated the enhanced clinical interpretability of the DarkNet19 CNN model, supervened by the attention branch, besides delivering a 3%-4% performance boost of the baseline model. The cancer regions highlighted by the proposed model correlate well with the findings of an expert pathologist. The coalesced approach of unifying attention branch with the CNN model capacitates pathologists with augmented diagnostic interpretability of histological images with no detriment to state-of-art performance. The model's proficiency in pinpointing the region of interest is an added bonus that can lead to accurate clinical translation of deep learning models that underscore clinical decision support.

Clinicopathological Profile of Breast Cancer at a Tertiary Cancer Center in Jharkhand, India: A Descriptive Cohort Study

Introduction Breast cancer is the most common cancer in females worldwide including Indian urban areas. There is no concrete data on breast cancer epidemiology from the state of Jharkhand, India. Materials and methods The present study is a retrospectively conducted descriptive cohort study. A total of 759 patients were selected from the database from 2012 to 2022. The parameters taken for the study were age, sex, stage at the time of presentation, histological type, estrogen receptor (ER) status, progesterone receptor (PR) status, human epidermal growth receptor 2 (HER2) neu status (HER2/neu), site of metastasis for stage 4 diseases, parity, and significant family history. Results The median age for patients was 49 years (range: 19-91 years), with a clustering of 74.83% of cases between 31 and 60 years of age. Most of the patients were in stage III, with 365 (48.08%) cases. Bone was the commonest site of metastasis and was found in 41.25% of total cases. The total number of hormone receptor-positive patients was 384 (56.2%), the number of HER2/neu positive patients was 210 (30.7%), and triple-negative breast cancer was found in 184 cases (26.93%). Conclusion The pattern found in our Jharkhand patients was very much similar to other Indian studies with slightly more clustering of younger cases. The cases in India are almost a decade younger than the Western population and the same was replicated in our study. This is one of the largest studies on breast cancer profile and epidemiology from the eastern part of India. Most of our patients presented late, leading to a higher number of locally advanced (stage III) and metastatic (stage IV) cases. More awareness is required at the population level, including strict implementation of a robust screening program by our government, for improving the overall outcome.

Socio-economic variations of breast cancer treatment and discontinuation: a study from a public tertiary cancer hospital in Mumbai, India

BACKGROUND

The study examined the socio-economic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisis.

METHODS

We used primary data of 500 patients with breast cancer sought treatment at India's one of the largest cancer hospital in Mumbai, between June 2019 and March 2022. This study is registered on the Clinical Trial Registry of India (CTRI/2019/07/020142). Kaplan-Meier method and Cox-hazard regression model were used to calculate the probability of treatment discontinuation.

RESULTS

Of the 500 patients, three-fifths were under 50 years, with the median age being 46 years. More than half of the patients were from outside of the state and had travelled an average distance of 1,044 kms to get treatment. The majority of the patients were poor with an average household income of INR15,551. A total of 71 (14%) patients out of 500 had discontinued their treatment. About 5.2% of the patients died and 4.8% of them discontinued treatment due to financial crisis. Over one-fourth of all deaths were reported among stage IV patients (25%). Patients who did not have any health insurance, never attended school, cancer stage IV had a higher percentage of treatment discontinuation due to financial crisis. Hazard of discontinuation was lower for patients with secondary (HR:0.48; 95% CI: 0.27-0.84) and higher secondary education (HR: 0.42; 95% CI: 0.19-0.92), patients from rural area (HR: 0.79; 95% CI: 0.42-1.50), treated under general or non-chargeable category (HR: 0.60; 95% CI:0.22-1.60) while it was higher for the stage IV patients (HR: 3.61; 95% CI: 1.58-8.29).

CONCLUSION

Integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality. Provisioning of free treatment for poor patients may reduce discontinuation of treatment.

FokI polymorphism of Vitamin D receptor gene and deficiency of serum Vitamin D increases the risk of breast cancer in North Indian women

INTRODUCTION

Breast cancer is a leading cause of cancer morbidity and mortality in females. Decreased availability of Vitamin D within breast cells, contributed by deficiency of serum Vitamin D and polymorphisms of Vitamin D receptor genes are possible risk factors for breast cancer.

OBJECTIVES

To study the association of FokI polymorphism of the Vitamin D Receptor gene with breast cancer in females and to study the levels of Vitamin D in breast cancer patients.

MATERIALS AND METHODS

VDR gene FokI genotyping was done by PCR-RFLP method and levels of serum Vitamin D were estimated by ELISA. Statistical analysis was done with SPSS v.21.

RESULTS

Serum Vitamin D was significantly lower in newly diagnosed breast cancer patients than in healthy controls (P = 0.016). Females with serum Vitamin D levels in the highest quartile have a lesser risk of breast cancer than those with serum Vitamin D levels in the lowest quartile (O. R = 2.4421, C.I = 1.09-5.45, P = 0.029). The risk of developing breast cancer is higher in women with the polymorphic T allele for VDR FokI genotype (CT/TT) than those homozygous for the wild C allele (CC). (O.R. = 4.295, C.I. = 2.2110-8.3451, p-value = <0.0001). Levels of serum Vitamin D were significantly higher (p < 0.001) in ER + patients and significantly low in those presenting with higher stages of cancer (p = 0.009).

CONCLUSIONS

FokI polymorphism of VDR gene and low circulating Vitamin D levels increase the risk of developing breast cancer in North Indian females. Serum Vitamin D can be used as a prognostic factor.

Assessment of late treatment-related symptoms using patient-reported outcomes and various factors affecting return to work in survivors of breast cancer

Introduction

Breast cancer is the most common cancer in women worldwide. Survival in these patients has increased because of early diagnosis and multimodality treatment methods. Return to premorbid functional status after treatment is essential for rehabilitation and good quality of life. Many patients suffer from late treatment-related symptoms which affect their return to premorbid status. Various health-related and work-related variables also affect the return to premorbid status.

Materials and methods

This is a cross-sectional study in which 98 patients with breast carcinoma who received curative treatment were included 6-12 months post-radiotherapy completion. Patients were interviewed to assess their type of work and hours of work prior to diagnosis and at the time of the study. The extent to which they are able to return to their pre-diagnosis level of work was noted and various factors that were hindering them were documented. Treatment-related symptoms were assessed using selected questions from NCI PRO-CTCAE (version 1.0) questionnaire.

Results

The median age of diagnosis of patients included in the study was 49-50 years. The most common symptoms experienced by patients were fatigue (55%), pain (34%) and oedema (27%). 57% of patients were employed before diagnosis, of which only 20% were able to return to their employment post-treatment. All patients were involved in household work prior to diagnosis and 93% were able to get back to their routine household work, with 20% of patients requiring frequent work breaks. About 40% of patients reported social stigma as a factor that hindered them from returning to work.

Conclusion

Most patients return to household work post-treatment. Fatigue, pain and social stigma were the most common barriers to return to employment. Patient-reported outcomes and functional assessments can enable better survivorship care.

A Comparative Study of Placebo Versus Opioid-Free Analgesic Mixture for Mastectomies Performed Under General Anesthesia Along With Erector Spinae Plane Block

Background and objectives Breast cancer is the most frequent cancer among women, globally. Postoperative pain after mastectomy not only causes slow recovery and prolonged hospital stay but can also increase the risk of chronic pain. For patients undergoing breast surgery, effective perioperative pain management is required. Various approaches have been introduced to overcome this, such as opioids, non-opioid analgesics, and regional blocks. The erector spinae plane block is a new regional anesthesia technique used in breast surgery to provide adequate intraoperative and postoperative analgesia. Opioid-free anesthesia is a multimodal analgesia technique that does not use opioids and thus prevents opioid tolerance after surgery. This study aims to investigate whether administering an opioid-free analgesic mixture lowers the pain score and the need for analgesics during and after surgery. Material and methods In this randomized prospective comparative clinical study, 66 patients of the American Society of Anesthesiologists (ASA) psychological status (PS) class 1 and 2, aged 18 to 80, were included. Group M received erector spinae plane block + general anesthesia + opioid-free analgesic mixture (1 mcg/cc dexmedetomidine + 1 mg/cc ketamine + 100 mg/cc magnesium sulfate prepared in a 20 ml syringe). Group N received erector spinae plane block + general anesthesia + 20ml of normal saline infusion. The primary outcome was to assess pain scores in the perioperative period. The secondary outcomes were to compare the time for the first rescue analgesia requirement perioperatively, intraoperative hemodynamic profile, and postoperative patient satisfaction. A p<0.05 was considered to be statistically significant. Results All patients were females undergoing modified radical mastectomy or breast conservative surgery + axillary sampling + latissimus dorsi flap reconstruction. The visual analog scale (VAS) scores were less than or equal to 3 in zero, first, and second hours postoperatively in both groups. The pain was moderate i.e., less than 4 in almost all time intervals in both groups. Group M had a better intraoperative hemodynamic profile, including mean arterial pressure and heart rate when compared to group N. In group M, the time of request for rescue analgesia was 726.67±390.99 minutes, while it was 468±278.79 minutes in group N. The total analgesic requirement was less in group M than in group N, but this was not statistically significant. Conclusion Multimodal analgesia with erector spinae plane block and opioid-free analgesic mixture provides effective perioperative analgesia and a better intraoperative hemodynamic profile in patients undergoing breast cancer surgery under general anesthesia.