Profile of Childhood Cancers From Hospital-Based Cancer Registries in India, 2012-19

OBJECTIVE

To describe the clinical pattern of childhood and adolescent cancers across India using hospital-based data in the National Cancer Registry Program.

METHODS

Records of 60720 cancer cases in the 0-19 year age group for the period 2012-2019 from 96 hospital-based cancer registries were reviewed. Childhood cancers were classified based on the International Classification of Childhood Cancer (ICCC). Descriptive analysis was used to examine the distribution of cancer by five-year age groups, sex and ICCC diagnostic groups and subgroups. Data were analysed using IBM SPSS software and visualised using R software.

RESULTS

3.2% and 4.6% of all cancer cases in India were among children in the 0-14 year and 0-19 year age groups respectively. The male-to-female ratio for all cancers was 1.72 for 0-14 years and 1.73 for 0-19 years. The four leading groups of cancers among 0-14 year olds were leukemia (40%), lymphoma (12%), central nervous system tumor (11%) and bone cancer (8%). The four leading cancers among the 0-19 year age group were leukemia (36%), lymphoma (12%), bone (11%) and central nervous system tumor (10%).

CONCLUSION

Cancers in the 0-14 and 0-19 age groups accounted for a considerable proportion of all cancers with significant male preponderance. Such information helps to fine-tune research and planning strategies.

An assessment of childhood cancer care services in India - gaps, challenges and the way forward

Background

Childhood cancers are emerging as an essential concern in India where there is lack of a specific programme component or policy to address childhood cancer control. There is limited information on the status and quality of childhood cancer care services in India. This paper describes the childhood cancer care services available at secondary and tertiary-level hospitals in India through a cross sectional study design.

Methods

The survey was conducted in 137 tertiary-level and 92 secondary-level hospitals in 26 states and 4 Union Territories (UTs), ensuring a uniform representation of public and private care hospitals. The study tool collected data on the organisational infrastructure, type of oncology services, health workforce, equipment, treatment and referral protocols, and treatment guidelines. Descriptive statistics was used to primarily present the health service status and data on childhood cancer care services in proportions and mean.

Findings

A dedicated pediatric oncology department was available in 41.6% of the public, 48.6% of private, and 64% Non Government Organization (NGO) managed tertiary-level hospitals. In 36 (39%) of the 92 hospitals providing secondary care, childhood cancer care was provided. The availability of bone (41.5%) and positron emission tomography (PET) scans (25.9%) was lower in public tertiary hospitals, whereas histopathology, computerised tomography (CT scan), and magnetic resonance imaging (MRI) were lower in public secondary hospitals than private and NGO managed hospitals for the corresponding level of care. Most tertiary hospitals had the required supportive care facilities except for play therapy and hospice care. Less than 50% of the public tertiary hospitals had stocks of the four categories of cancer-treating drugs and essential infrastructure for radiotherapy and chemotherapy. Most secondary-level hospitals not treating childhood cancer had referral linkages with tertiary hospitals.

Interpretation

The situational analysis of childhood cancer care services in India showed the concentration of availability of childhood cancer care services at the tertiary level of health care. There were gaps in the availability of specialised pediatric oncology care in all the tertiary hospitals. The availability of childhood cancer care services was higher in private and NGO-managed hospitals than in public hospitals. Integration of childhood cancer as a part of the national cancer control response should be taken up as a matter of priority. The need of the hour is to formulate a childhood cancer policy that will enable timely access to care universally.

Funding

World Health Organization, India provided funding and technical support.

Current Challenges of Asian National Children's Cancer Study Groups on Behalf of Asian Pediatric Hematology and Oncology Group

In Asia, a few countries have a long and established history of collaborative clinical trials successfully formed national children's cancer study groups, but many still do not have such groups. The process of forming national children's cancer groups is fraught with many hurdles, which varies among the countries. One of the basic requirements for running clinical trials is an affordable health care system in which most of the children with cancer can receive the proposed treatment. The health insurance coverage for children with cancer varies from <20% to as high as 100% among Asian countries, and the operation of clinical trials must also be adjusted accordingly. Shortage of research personnel is common, including medical, nursing, research coordinators, and data managers. The establishment of the Asian Pediatric Hematology and Oncology Group aims to provide a good platform for promotion of international clinical trials in the Asian countries.

Empirical Antitubercular Treatment for Lymphadenopathy: Are We Missing Lymphoma?

OBJECTIVE

To evaluate the proportion of patients who received empirical treatment with antitubercular therapy (ATT) prior to the diagnosis of Hodgkin lymphoma (HL) in the first multicentric, prospective study on HL from India, and to assess its impact on extent of disease at diagnosis and outcomes.

METHODS

Children < 18 y with biopsy proven HL were enrolled in InPOG-HL-15-01. Along with other clinical and epidemiological data, history of prior treatment with ATT was documented. All patients received treatment as per a risk-stratified, response-adapted strategy.

RESULTS

Out of 396, 115 (29%) children had received ATT prior to establishing a definitive diagnosis of HL. This cohort presented with advanced-stage disease (p = 0.001) and B symptoms (p = 0.001) in a higher proportion of cases. Consequently, those children were more likely to receive 6 rather than 4 cycles of chemotherapy (p = 0.001). They were more likely to have infradiaphragmatic involvement (p = 0.001). Overall survival and event-free survival were not different.

CONCLUSION

Empirical treatment with ATT in children presenting with lymphadenopathy continues to be practiced widely in India. The delay in diagnosis may contribute to children presenting with advanced-stage disease warranting more intensive treatment for successful outcomes.

Overall and Event Free Survival of Childhood Cancer - Report From a Hospital-based Cancer Registry in Northern India, 2013-21

OBJECTIVE

Using data from a hospital-based cancer registry (HBCR) in the private sector in Northern India, we provide overall survival (OS) and event-free survival (EFS) for childhood cancer patients.

METHODS

All newly diagnosed childhood (age <18 years) cancer patients in our HBCR registered between March 1, 2013 till July 31, 2021 were eligible. 3-year and 5-year OS (death was an event), EFSc (death, progression/relapse was an event), and EFSa (death, progression/relapse, abandonment of treatment was an event) were calculated using the Kaplan-Meier method. Regression analysis was done to see their association with demographic, diagnostic and treatment variables.

RESULTS

705 newly diagnosed children (36.2% female) with cancer were registered. Common cancers were leukemias (26%), CNS tumors (20%) and bone tumors (16%). 202 (28.6%) had experienced an event at median follow up of 1.95 years (range 0-8.14 years), which included 23 (3.3%) who abandoned treatment. The 3-year OS, EFSc, EFSa were 70.8%, 64.4% and 63.6%, respectively. Correspondingly, 5-year OS, EFSc, EFSa were 66%, 58.6% and 57.5%, respectively. There was no significant difference by age group, gender, nationality, and if cancer directed treatment initiated elsewhere. The OS, EFSa and EFSc by the main and the extended International Childhood Cancer Classification categories varied significantly (P<0.001).

CONCLUSION

We add more recent registry-based OS data on childhood cancer in India and present the first estimates on EFS.

ICU Admissions and Outcomes of Childhood Cancer Patients in Single Tertiary Hospital in the Private Sector in India

Ramandeep Singh AroraBackground  Modern-day treatment of childhood cancer is punctuated by the necessary need for intensive care. This study was performed to understand the intensive care unit (ICU) admission rates and factors associated with ICU admission in a cohort of newly diagnosed childhood cancer patients in India. Materials and Methods  All childhood (age <18 years) patients in the hospital-based cancer registry who had registered between March 1, 2013, and May 31, 2018, formed the cohort. ICU admissions were recorded and demographic and clinical factors associated with ICU admission were investigated. ICU admission rates were the primary outcome of interest and secondary outcomes were ICU admission rates for sick/supportive reasons, ICU admission rates for surgical/procedural reasons and mortality during ICU admission. Results  In a cohort of 258 children (66% males, 61% from India, and median age 7 years), 149 (58%) patients needed one or more ICU admission (median one with range of one to five) with total 204 ICU admission episodes. While age group, gender, and nationality were not significantly associated with ICU admission, cancer type was (highest in neuroblastoma (82%) and central nervous system (CNS) tumors (71%)). Sick/supportive care ICU admissions were significantly higher in patients of younger age, Indian origin, and certain cancers (leukemias, lymphomas). Surgical/procedural ICU admissions were significantly higher in international patients and certain cancers (CNS tumors, neuroblastomas, and soft tissue sarcomas). There were 17 ICU deaths (11% of patients admitted to ICU) and all but one were from sick/supportive care ICU admissions. Conclusion  Our study highlights higher than reported ICU admission rates and lower than reported mortality in children with cancer in low- and middle-income countries. We next plan to develop more specific ICU admission criteria, prospectively evaluating severity metrics in these patients, and explore the development of a high dependency unit.

Communication transforms the impact of the COVID-19 pandemic on children with cancer and their families

BACKGROUND

The COVID-19 pandemic altered healthcare systems globally, causing delays in care delivery and increased anxiety among patients and families. This study examined how hospital stakeholders and clinicians perceived the global impact of the COVID-19 pandemic on children with cancer and their families.

METHODS

This secondary analysis examined data from a qualitative study consisting of 19 focus groups conducted in 8 languages throughout 16 countries. A codebook was developed with novel codes derived inductively from transcript review. In-depth analysis focused on the impact of the COVID-19 pandemic on children with cancer and their families.

RESULTS

Eight themes describing the impact of the pandemic on patients and their families were identified and classified into three domains: contributing factors (COVID-19 Policies, Cancer Treatment Modifications, COVID-19 Symptoms, Beliefs), patient-related impacts (Quality of Care, Psychosocial impacts, Treatment Reluctance), and the central transformer (Communication). Participants described the ability of communication to transform the effect of contributing factors on patient-related impacts. The valence of impacts depended on the quality and quantity of communication among clinicians and between clinicians and patients and families.

CONCLUSIONS

Communication served as the central factor impacting whether the COVID-19 pandemic positively or negatively affected children with cancer and families. These findings emphasize the key role communication plays in delivering patient-centered care and can guide future development of communication-centered interventions globally.

Addressing the Gap in Research Methodologies Education in Pediatric Oncology in the Eastern Mediterranean Region

PURPOSE

Formal training in clinical research methodologies is limited in limited-resource countries. Through collaboration among high- and middle-resource settings and in response to an identified need verbalized by regional pediatric oncology practitioners, Pediatric Oncology East & Mediterranean Group and St Jude Global developed a workshop focused on capacity building in research skills. Here, we describe its structure, implementation, and early results.

METHODS

Leveraging virtual capabilities, the format included lectures and small group breakout exercise sessions, for 3 hours per day on 2 consecutive days per week for 2 consecutive weeks. Topics included basics of study design, introduction to health care statistics, research ethics, data registries, and scientific writing. Applicants were required to submit an abstract for a potential research project. Each breakout group selected one abstract for further development and presented the final version in a groupwide session. The participants' experience was evaluated through an online survey.

RESULTS

Attendance included 29 registrants from 12 countries and six disciplines. Each breakout group was assigned a themed category: cohort studies, clinical trials, or registries. Critical feedback from the breakout sessions helped strengthen the selected projects, which included a retrospective study, a prospective observational study, a prospective interventional study, and a registry proposal. After the workshop, participants were invited to further develop their original abstracts, and three proposals received additional mentoring, one of which was a multi-institutional prospective study that was subsequently submitted through the Pediatric Oncology East & Mediterranean Group network for implementation. The postworkshop survey revealed an overall highly positive experience, and feedback provided potential themes for future workshops.

CONCLUSION

This workshop demonstrated the potential for collaborative network partnerships in targeting research training gaps in pediatric oncology. Lessons learned will be applied to future workshops to strengthen research in limited-resource settings.

Comparative treatment costs of risk-stratified therapy for childhood acute lymphoblastic leukemia in India

BACKGROUND

To evaluate the treatment cost and cost effectiveness of a risk-stratified therapy to treat pediatric acute lymphoblastic leukemia (ALL) in India.

METHODS

The cost of total treatment duration was calculated for a retrospective cohort of ALL children treated at a tertiary care facility. Children were risk stratified into standard (SR), intermediate (IR) and high (HR) for B-cell precursor ALL, and T-ALL. Cost of therapy was obtained from the hospital electronic billing systems and details of outpatient (OP) and inpatient (IP) from electronic medical records. Cost effectiveness was calculated in disability-adjusted life years.

RESULTS

One hundred and forty five patients, SR (50), IR (36), HR (39), and T-ALL (20) were analyzed. Median cost of the entire treatment for SR, IR, HR, and T-ALL was found to be $3900, $5500, $7400, and $8700, respectively, with chemotherapy contributing to 25%-35% of total cost. Out-patient costs were significantly lower for SR (p < 0.0001). OP costs were higher than in-patient costs for SR and IR, while in-patient costs were higher in T-ALL. Costs for non-therapy admissions were significantly higher in HR and T-ALL (p < 0.0001), representing over 50% of costs of in-patient therapy. HR and T-ALL also had longer durations of non-therapy admissions. Based on WHO-CHOICE guidelines, the risk-stratified approach was very cost effective for all categories of patients.

CONCLUSIONS

Risk-stratified approach to treat childhood ALL is very cost-effective for all categories in our setting. The cost for SR and IR patients is significantly reduced through decreased IP admissions for both, chemotherapy and non-chemotherapy reasons.

Ensuring quality in contextualised cancer management guidelines for resource-constraint settings: using a systematic approach

To address the wide variation in access to cancer care in India requires strengthening of infrastructure, trained oncology workforce, and minimisation of out-of-pocket expenditures. However, even with major investments, it is unlikely to achieve the same level of infrastructure and expertise across the country. Therefore, a resource stratified approach driven by evidence-based and contextualised clinical guidelines is the need of the hour. The National Cancer Grid has been at the forefront of delivery of standardised cancer care through several of its initiatives, including the resource-stratified guidelines. Development of new guidelines is resource and time intensive, which may not be feasible and can delay the implementation. Adaptation of the existing standard guidelines using the transparent and well-documented methodology with involvement of all stakeholders can be one of the most reasonable pathways. However, the adaptation should be done keeping in mind the context, resource availability, budget impact, investment needed for implementation and acceptability by clinicians, patients, policymakers, and other stakeholders. The present paper provides the framework for systematically developing guidelines through adaptation and contextualisation. The process can be used for other health conditions in resource-constraint settings.

Deviation from delivery of radiation therapy to childhood cancer patients: A retrospective audit

BACKGROUND

Planning and coordination of the delivery of radiation therapy (RT) can be challenging in resource-limited settings. In this retrospective study, we describe the profile of children undergoing radiation and analyze deviation from some accepted norms.

PROCEDURE

Data on all children (<18 years of age) with cancer who completed RT from January 2009 to December 2019 were retrieved. Diagnostic groups with more than five patients were included in the analysis for deviations in RT (time to start [TTS]; total dose delivered [TDD] in gray; and time to complete [TTC]). We investigated reasons for deviation.

RESULTS

Two hundred seven children received RT as front-line treatment (68% Indian, 59% male). Most common diagnoses were brain tumors (44%), lymphomas (13%), leukemias, and soft tissue sarcomas (10% each). TTS deviation was seen in 23.6%, TTD in 6.0%, and TTC in 24.7%, while 43.4% had at least one deviation in any of these three parameters. Deviation in TTS varied significantly by location of preceding treatment and by cancer (greatest deviation in sarcomas), with issues around access to health care being the most common reason. Deviation in TTC varied significantly by cancer (greatest deviation in sarcomas and medulloblastoma), with myelotoxicity being the most common reason.

CONCLUSIONS

Our study adds to the limited literature on RT quality for children with cancer in resource-limited settings. Certain cancers (sarcomas and medulloblastomas) and patient groups (preceding treatment outside our institute) had the maximum deviation. Barriers to accessing care and myelotoxicity were the two main reasons for this deviation.

Highlighting Differences in Cancer Epidemiology in India: A Descriptive Report from a Private Sector Hospital-Based Cancer Registry in Delhi for the Years 2013 to 2017

Introduction Cancer continues to grow in number. Knowing the epidemiology helps in prevention and treatment. Existing hospital-based cancer registries (HBCRs) provide little data of private sector including patients for medical tourism.

Objectives The aim of this study was to describe the distribution of cancer at a tertiary center in the private sector in North India for all cancer patients.

Materials and Methods Cases were ascertained from the Oncology Outpatient Department of Max Super Specialty Hospital, Saket, between January 1, 2013, and December 31, 2017, and from pathology database since July 2015. They were abstracted into National Cancer Registry Program (NCRP) core pro forma. We conducted a descriptive analysis of distribution by age, gender, nationality, site, stage, and treatment.

Results Among the 15,850 confirmed cases, 8,034 (51%) were males. Nearly 1.8% of patients were pediatric (<15 years) and 30.1% geriatric (>65 years). A high proportion of patients (13%) came from outside India and 27% from outside Delhi-National Capital Region. The most common cancers in males were prostate (10.9%), lung (10%), and mouth (7.6%). Stomach was the most common site of cancer in international male patients. Four of the top ten cancers in males were of the gastrointestinal tract (esophagus, stomach, colon, and rectum). The most common cancers in females were breast (37.4%), ovary (7.1%), and corpus uteri (5.6%). Tobacco-related cancers accounted for 36.9% of cancers in males and 11.3% in females. The composite stage in males was IV in 54%, followed by stage III (21%), stage II (15%), and stage I (10%). In females, stage IV was 33%, stage III was 23%, stage II was 28%, and stage I was 16%. As registry included outpatient record visits and pathology records, not all registered patients received treatment at Max Super Specialty Hospital. Overall, 49.8% of male patients and 49.7% of female patients received treatment at Max Super Specialty Hospital. Data quality metrics matched other national HBCRs.

Conclusion We highlight the differences from other NCRP HBCRs, with prostate cancer being the top cancer in males and gastrointestinal cancers forming major proportion among all. Socioeconomic status of our patients, referral bias, and international medical tourism could be responsible.

Resilient health care in global pediatric oncology during the COVID-19 pandemic

Background

In the face of unprecedented challenges because of coronavirus disease 2019, interdisciplinary pediatric oncology teams have developed strategies to continue providing high‐quality cancer care. This study explored factors contributing to health care resilience as perceived by childhood cancer providers in all resource level settings.

Methods

This qualitative study consisted of 19 focus groups conducted in 16 countries in 8 languages. Seven factors have been previously defined as important for resilient health care including: 1) in situ practical experience, 2) system design, 3) exposure to diverse views on the patient's situation, 4) protocols and checklists, 5) teamwork, 6) workarounds, and 7) trade‐offs. Rapid turn‐around analysis focused on these factors.

Results

All factors of health care resilience were relevant to groups representing all resource settings. Focus group participants emphasized the importance of teamwork and a flexible and coordinated approach to care. Participants described collaboration within and among institutions, as well as partnerships with governmental, private, and nonprofit organizations. Hierarchies were advantageous to decision‐making and information dissemination. Clinicians were inspired by their patients and explained creative trade‐offs and workarounds used to maintain high‐quality care.

Conclusions

Factors previously described as contributing to resilient health care manifested differently in each institution but were described in all resource settings. These insights can guide pediatric oncology teams worldwide as they provide cancer care during the next phases of the pandemic. Understanding these elements of resilience will also help providers respond to inevitable future stressors on health care systems.

This multinational, multicenter, qualitative study illustrates how pediatric oncology providers used resilient health care strategies, illuminating creative solutions to mitigate impact, many of which may outlast the pandemic.

The impact of COVID-19 pandemic on access to treatment for children with cancer in India and treating center practices

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led the Indian government to announce a nationwide lockdown on March 23, 2020. This study aimed to explore the impact of the pandemic on the accessibility of care for children with cancer and to view strategies adopted by hospitals for service delivery.

METHODS

Weekly average of childhood cancer (≤18 years) patient registrations during pre-lockdown period (January 1 to March 23, 2020) were compared with post-lockdown period (March 24 to May 31, 2020). The effect on the scheduled treatment was investigated for post-lockdown period. A survey of health care providers was conducted to determine centers' adopted strategies.

RESULTS

In 30 participating centers, 1146 patients with childhood cancer (797 pre-lockdown period and 349 post-lockdown period) were registered. The weekly average registration was 67.3 and 35.5 patients during pre-lockdown and post-lockdown respectively (decline of 47.9%). Although most centers experienced this decline, there were 4 that saw an increase in patient registrations. The distribution of patients registered post-lockdown was found significantly different by age (lesser older age, P = .010) and distance (lesser travel distance, P = .001). 36.1% of patients, who were scheduled for any of the treatment modalities (chemotherapy, surgery, radiotherapy, and hematopoietic stem cell transplantation) during the post-lockdown period, experienced delays. Centers adopted several strategies including modifications to treatment protocols, increased use of growth factors, and increased support from social organizations.

CONCLUSIONS

This multicenter study from India suggests that the COVID-19 pandemic and the lockdown impacted 2 out of 3 children with cancer. The effect of this on survival is yet to be established.

Treating early-stage Hodgkin lymphoma in resource-limited settings: InPOG-HL-15-01 experience

BACKGROUND

Hodgkin lymphoma (HL) in childhood is an eminently curable disease. Excellent outcomes can be achieved even in resource-limited settings and increasingly, the focus is on limiting long-term toxicity. Contemporary treatment incorporates a risk-stratified, response-adapted approach using multiagent chemotherapy with or without low-dose radiotherapy (RT). Many developing countries continue to use ABVD (adriamycin, bleomycin, vinblastin, and dacarbazine)-based regimen owing to limited acute toxicity, cost, and ease of delivery. We report outcomes of children with early-stage HL using limited cycles of ABVD-based treatment in the first prospective multicentric collaborative study from India InPOG-HL-15-01.

METHODS

Children <18 years with biopsy-proven HL were enrolled. Patients with stages I and IIA with or without bulky disease were classified as having early-stage disease. Patients were planned to receive four cycles of ABVD subject to satisfactory early response assessment (ERA) scheduled after two cycles of chemotherapy. RT was limited to patients with bulky disease or those with suboptimal ERA.

RESULTS

Four hundred ten patients were enrolled over 30 months from 27 centers. One hundred thirty-four were classified as having early-stage disease. Fifty-three (40%) of these had bulky disease. One hundred ten (83%) of this cohort achieved complete or very good partial ERA. Fifty-four (40%) received RT. At a median of 52 months since diagnosis, 5-year event-free survival (EFS) and overall survival (OS) is 94% and 95.5%, respectively. Treatment-related mortality and abandonment were <1%.

CONCLUSION

Limited cycles of ABVD with RT to selected patients is a very effective option for patients with early-stage disease in resource-limited settings.

Shared care for children with cancer in India through social and healthcare partnerships during the COVID-19 pandemic

Background

The COVID pandemic posed a challenge for the tertiary centers to continue treatment. Some tertiary centers were designated as COVID‐only hospitals, making it difficult for existing childhood cancer patients to continue their treatment at those centres. The need for shared care in childhood cancer was perceived by Cankids and its partnering childhood cancer‐treating centers in North and East India.

Aim

We aim to show how Cankids upscaled its shared care model to ensure that COVID designated hospitals connected with other hospitals who have to continue to provide care to childhood cancer patients in the pandemic and thus ensured the continuation of treatment for these patients.

Methods and result

The need assessment of the beneficiaries was done in discussion with the hospital of origin and destination hospital. The need for shared care was also discussed with the families and consent was taken before shifting their children. Cankids with the help of advisors identified cases of high risk that need immediate attention, proactive regular monitoring, and help in care planning with the perspective and recommendation of the multiple providers. The shared care unit came forward with reasonable and discounted packages for treatment.

There was a total of five hospitals requiring shared care, and 55 children were supported from April to November 2020. The median age was 8 years and their hospital of origin are in Bihar, Uttar Pradesh, West Bengal, and Delhi. The expenditure on the treatment of the 55 patients was INR 61 61 636 ($ 84 843), with a median of INR 41765 (IQR 19491–174 129) on each patient. Total 291 trips for the transport were arranged and all the patients combined stayed 174 days at Cankids accommodation facility.

Conclusion

The shared care helped the patients access standard treatment and reduce the financial burden.

Delivery of services to childhood cancer survivors in India: A national survey

Background: Continuum of care is an important concern for childhood cancer survivors. Studies from high-income countries indicate a significant development in services to these survivors. Similar information is unavailable from India. Methods: An online survey form was developed and sent to 86 centers. Data were collected over a 6-month period in 2017. Results: Fifty nine centers responded (44.1% private sector, 33.9% public, and 22.0% charitable trust). The services are mainly provided (91%) within routine oncology clinics. There is no upper age limit (61%) or time period limit (63%) for follow-up at most of the centers. The major barriers for follow-up are distance, lack of knowledge, lack of adequate facilities, and patient priority for follow-up. Conclusion: This survey provides baseline information on current service provided to childhood cancer survivors in India. There is a need to inform, educate, and sensitize the survivor and their family as well as improving services.

Estimated National and State Level Incidence of Childhood and Adolescent Cancer in India

BACKGROUND

Hitherto, incidence burden of childhood cancer in India has been derived from GLOBOCAN data. Recent analyses have challenged whether this accurately measures the true incidence of childhood cancer.

OBJECTIVE

To use observed data rather than simulation to estimate the number of children (0-14 years), as well as number of children and adolescents (0-19 years), in India who develop cancer every year at the national and state/union territory (UT) level.

METHODS

Age-specific (five year groups), sex-specific, and state/UT specific population data from India Census 2011 was used. Global average incidence rates from the International Incidence of Childhood Cancer 3 (IICC3) report were used. Incidence rates per million person-years for the 0-14 years and 0-19 years age groups were age-adjusted using the world standard population to provide age-standardized incidence rates, using the age-specific incidence rates for individual age groups (0-4 years, 5-9 years, 10-14 years, and 15-19 years).

RESULTS

The national number of children (0-14 years) and, children and adolescents (0-19 years) that may develop cancer every year based on 2011 census are 52,366 and 76,805 persons respectively. Cancer type specific incidence is provided for each state/UT for these age ranges. This national incidence is approximately double of the GLOBOCAN 2018 estimates of incidence of children diagnosed and registered with cancer and the differential is greater in girls.

CONCLUSIONS

Our analysis proposes new estimates of incident childhood cancer cases in India for children and adolescents. Future regional, national and international research on childhood cancer epidemiology and healthcare accessibility would help further refine these estimates.

Adapting Management of Sarcomas in COVID-19: An Evidence-Based Review

With the novel coronavirus disease (COVID-19) being declared a global pandemic by the World Health Organization, the Indian healthcare sector is at the forefront to deliver optimal care. Patients with cancer especially are at serious risk for increased chances of morbidity and mortality due to their immunocompromised state. Currently there is a paucity of definitive guidelines for the management of sarcomas during the pandemic in a resource-constrained and diverse population setting like India. Health care professionals from various specialties involved in the management of sarcomas have collaborated to discuss various aspects of evidence-based sarcoma management during the COVID-19 pandemic. This article provides structured recommendations for HCP to adapt to the situation, optimize treatment protocols with judicious use of all resources while providing evidence-based treatment for sarcoma patients.

An Ethnographic Study of the Moral Experiences of Children with Cancer in New Delhi, India

There is a paucity of research examining children’s experiences with cancer in India. Childhood ethics is an emerging field, focusing on the moral dimension of children’s experiences, to promote children’s participation in their health care. A focused ethnography, using a moral experience framework, was conducted to better understand children’s participation in decisions, discussions, and actions in three oncology settings in New Delhi, India. We interviewed key informants, retrieved key documents, and conducted semi-structured interviews and participant observations with children. All 22 children demonstrated interest in varying aspects of their cancer care. Certain factors facilitated or impeded their participation. Some children became distressed when they lacked information about their treatment or were not given opportunities to enhance their understanding. The results advance our understanding of the moral experiences of children with cancer in India for healthcare professionals, policy makers, families, and interested others.

Patient tracking during treatment of children with cancer in India - An exploratory study

BACKGROUND

Abandonment of treatment, a major cause of treatment failure in low- and middle-income countries like India, is particularly high during the diagnostic and initial phase of treatment. Tracking of patients during this risk period may reduce treatment abandonment rates and increase quality of care.

AIM

The primary aim was to pilot the use and check the acceptability of a tool for tracking children with cancer in New Delhi during the initial part of their treatment. Secondary aim was to estimate abandonment rates among these patients.

METHODS

This prospective study was carried out in two centers of North India in New Delhi and enrolled children less than 18 years diagnosed with cancer at these centers and who had registered with Cankids for social support. Parent support group (PSG) workers maintained contact with the child's family at least once a week for the first 12 weeks. Details of each contact and subsequent action were recorded in a customized book (called "You are not alone" or YANA Book). Descriptive analysis of these contacts was done in Microsoft Excel and presented in frequencies and percentages. The five-point Likert scale was used to check the acceptability of the tool among the PSG workers.

RESULTS

Seven PSG workers enrolled and tracked 81 patients (73% male with a median age of 6 years). During the 12-week study period, 986 contacts were attempted and three (3.7%) patients had abandoned their treatment. All PSG workers strongly agreed that the YANA book was simple to understand and use, decreased their workload, and helped provide better assistance to patients.

CONCLUSION

The tool for patient tracking was well accepted by the PSG workers and considered easy to use. We now plan to implement our model as a routine service at all the partnering hospitals in India.

Exploring the Financial Toxicities of Patients with Locally Advanced Head and Neck Malignancies, Being Treated in a Private Sector Hospital in North India: A Thematic Analysis

Background:

The high cost of cancer diagnosis and treatment is a global concern. Evidence derived, mostly from high-income countries, shows how it gradually impacts the personal and household financial condition causing the increased psychosocial burden of the patient and their families (termed “financial toxicity”).

Aim:

To qualitatively explore the financial toxicities in patients with advanced head and neck malignancies in India, and to consider how it impacts the patient and his family.

Methods:

Interviewing a purposive sample of 8 patients using semi-structured interviews face to face. Interviews were transcribed verbatim, and a thematic content analysis was carried out.

Results:

Four major themes were identified: burden and amplifying factors, impact, rescue and relieving factors, and learning and innovation. The burden of cost relates to diagnosis, treatment and non-medical costs which gets amplified while navigating the healthcare labyrinth. Emerging themes describe financial journey of cancer patients, the issues faced by them and the ways they tackle these issues during their treatment. Healthcare system factors like limited availability of adequate/comprehensive/meaningful insurance and reimbursements potentiate the toxicity. The financial toxicity leads to a significant adverse financial, psychological and social impact on the patient and the family. While moving through the process of care, there were a few learnings and innovations which patients proposed.

Conclusion:

This study provides qualitative evidence of the considerable and pervasive nature of financial toxicity in head and neck cancer patients in India. The findings have implications for all cancer patients and highlight the unmet need of psychosocial support for these patients.

Childhood cancer survivorship and late effects: The landscape in India in 2020

Survivorship care is a major area of focus in the holistic management of childhood cancer with current knowledge and information almost exclusively from high-income countries. In this review, we summarize the state of scientific knowledge, service delivery, advocacy initiatives, and research efforts in this field in India. Twenty-one single-center studies published until today (20 in the last decade) confirm some of the well-documented issues in childhood cancer survivors and highlight the high prevalence of hepatitis B and hepatitis C infection in our survivors. Heterogeneity in methodology, outcome metrics, and quality precludes drawing further conclusions, and the ongoing multicenter Indian Pediatric Oncology Group study would address this. Besides the usual model of follow-up clinics in hospital settings, innovative models of service delivery led by not-for-profit organizations are being developed. Advocacy initiatives driven by survivors and support groups are also under way. All of these portend a promising future.

Immunization of Children with Cancer in India Treated with Chemotherapy - Consensus Guideline from the Pediatric Hematology-Oncology Chapter and the Advisory Committee on Vaccination and Immunization Practices of the Indian Academy of Pediatrics

JUSTIFICATION

Children with cancer need to be immunized against the common vaccine-preventable diseases after completion and sometimes during ongoing treatment of cancer. However, the immunization schedule for these children needs to be altered due to disease and treatment related immune-suppression. Consequently, there are many guidelines/practice statements from around the world to address this issue, however, there is no such comprehensive guideline from India catering to the need of Indian children with cancer.

PROCESS

A guideline was drafted after reviewing the available literature. The draft guideline was discussed and modified in a meeting attended by pediatric oncologists from the PHO chapter and vaccine experts from the ACVIP of the IAP. Subsequently, the modified draft was reviewed and recommendations were finalized.

OBJECTIVES

To review the current evidence and generate a nationally relevant guideline for immunization of children receiving chemotherapy for cancer.

RECOMMENDATIONS

Live vaccines are contraindicated during and up to 6 months after end of chemotherapy. Non-live vaccines are also best given after 6 months from the end of treatment for durable immunity. Annual inactivated influenza vaccine is the only vaccine recommended for all children during chemotherapy whereas hepatitis B vaccine is recommended only for previously unimmunised children with risk of transfusion associated transmission of infection. Post-treatment re-immunization/catch-up schedule largely depends on the pre-chemotherapy immunization status. Sibling immunization should continue uninterrupted except for oral polio vaccine which needs to be substituted by the injectable vaccine. Inactivated influenza vaccine is recommended and varicella vaccine is encouraged for all contacts including siblings.

Afatinib versus methotrexate as second-line treatment in Asian patients with recurrent or metastatic squamous cell carcinoma of the head and neck progressing on or after platinum-based therapy (LUX-Head & Neck 3): an open-label, randomised phase III trial

BACKGROUND

Treatment options are limited for patients with recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC) following progression after first-line platinum-based therapy, particularly in Asian countries.

PATIENTS AND METHODS

In this randomised, open-label, phase III trial, we enrolled Asian patients aged ≥18 years, with histologically or cytologically confirmed recurrent/metastatic HNSCC following first-line platinum-based therapy who were not amenable for salvage surgery or radiotherapy, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0/1. Patients were randomised (2 : 1) to receive oral afatinib (40 mg/day) or intravenous methotrexate (40 mg/m2/week), stratified by ECOG performance status and prior EGFR-targeted antibody therapy. The primary end point was progression-free survival (PFS) assessed by an independent central review committee blinded to treatment allocation.

RESULTS

A total of 340 patients were randomised (228 afatinib; 112 methotrexate). After a median follow-up of 6.4 months, afatinib significantly decreased the risk of progression/death by 37% versus methotrexate (hazard ratio 0.63; 95% confidence interval 0.48-0.82; P = 0.0005; median 2.9 versus 2.6 months; landmark analysis at 12 and 24 weeks, 58% versus 41%, 21% versus 9%). Improved PFS was complemented by quality of life benefits. Objective response rate was 28% with afatinib and 13% with methotrexate. There was no significant difference in overall survival. The most common grade ≥3 drug-related adverse events were rash/acne (4% with afatinib versus 0% with methotrexate), diarrhoea (4% versus 0%), fatigue (1% versus 5%), anaemia (<1% versus 5%) and leukopenia (0% versus 5%).

CONCLUSIONS

Consistent with the phase III LUX-Head & Neck 1 trial, afatinib significantly improved PFS versus methotrexate, with a manageable safety profile. These results demonstrate the efficacy and feasibility of afatinib as a second-line treatment option for certain patients with recurrent or metastatic HNSCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01856478.

Evaluating access to essential medicines for treating childhood cancers: a medicines availability, price and affordability study in New Delhi, India

Introduction

Limited access to essential medicines (EMs) for treating chronic diseases is a major challenge in low-income and middle-income countries. Although India is the largest manufacturer of generic medicines, there is a paucity of information on availability, price and affordability of anti-neoplastic EMs, which this study evaluates.

Methods

Using a modified WHO/Health Action International methodology, data were collected on availability and price of 33 strength-specific anti-neoplastic EMs and 4 non-cancer EMs. Seven 'survey anchor' hospitals (4 public and 3 private) and 32 private-sector retail pharmacies were surveyed. Median price ratios (MPRs) were calculated by comparing consumer prices with international reference prices (IRPs).

Results

On average, across survey anchor areas (hospital and private-sector retail pharmacies combined), the mean availability of anti-neoplastic EMs and non-cancer medicines was 70% and 100%, respectively. Mean availability of anti-neoplastic EMs was 38% in private-sector retail pharmacies, 43% in public hospital pharmacies and 71% in private hospital pharmacies. Median MPR of lowest-priced generic versions was 0.71 in retail pharmacies. The estimated cost of chemotherapy medicines needed for treating a 30 kg child with standard-risk leukaemia was INR 27 850 (US$442) and INR 17 500 (US$278) for Hodgkin's lymphoma, requiring 88 and 55 days' wages, respectively, for the lowest paid government worker.

Conclusion

Most anti-neoplastic EMs are found in survey anchor areas, however, mean availability was less than non-cancer medicines; not meeting the WHO target of 80%. Medicine prices were relatively low in New Delhi compared with IRPs. However, the cost of chemotherapy medicines seems unaffordable in the local context.

Improved outcome at end of treatment in the collaborative Wilms tumour Africa project

BACKGROUND

The Collaborative Wilms Tumour (WT) Africa Project has implemented an adapted WT treatment guideline in sub-Saharan Africa as a multi-centre prospective clinical trial. A retrospective, baseline evaluation of end-of-treatment outcome was performed for a 2-year period prior to the introduction of this guideline. The collaborative project aims to reduce both treatment abandonment and death during treatment to less than 10% for improving survival.

PROCEDURE

All participating centres obtained local Institutional Research Board (IRB) approval and implemented the adapted WT treatment guideline. End-of-treatment outcome was documented for 2 years. It was divided into alive without evidence of disease, treatment abandonment, death during treatment and persistent disease. The outcome of children enroled in the first 2 years of the prospective clinical trial has been compared to the outcome before the start of the project.

RESULTS

One hundred twenty-two patients were included in the baseline evaluation (2011-2012) and 133 in the first 2 years of the collaborative clinical trial (2014-2015). The percentage of patients alive without evidence of disease at the end of treatment increased from 52% (63/122) to 68% (90/133; P = 0.01). Treatment abandonment decreased from 23% (28/122) to 13% (17/133; P = 0.03). Death during treatment decreased from 21% (26/122) to 13% (17/133; P = 0.07).

CONCLUSION

This collaboration, using relatively simple and low-cost interventions, led to a significant decrease in treatment abandonment and increase in survival without evidence of disease at the end of treatment.

FoundationOne as a relevant tool for comprehensive genomic profiling and assessment of tumor mutation burden in the era of precision oncology in India

e23096

Background: Comprehensive genomic profiling (CGP) is gaining acceptability globally, but clinical experience in developing countries like India is limited. CGP identifies genomic alterations (GA), with tumor mutation burden (TMB) and microsatellite status (MSI), revealing therapeutic options such as targeted inhibitors and immunotherapies. We sought to evaluate the mutation frequency and actionability across tumors. Methods: Metastatic and/or refractory patients (referred to Personalized Cancer Medicine Clinic) underwent CGP analysis, including calculation of TMB and MSI, using a targeted NGS panel (FoundationOne, 53 samples; FoundationOne Heme, 4 samples). This panel detects all relevant classes of GA: base substitutions, small indels, rearrangements and copy number changes. Mutation frequencies were compared with the larger Foundation database. TMB status was reported as low (≤5 mutations/Mb), intermediate (6-19 mut/Mb) or high (≥20 mut/Mb). Results: The most common tumor types were lung (23%), breast (14%) and sarcoma (12%); other tumor types, including unknown primary constituted the rest (51%). Most samples were from metastatic sites (60%). Oncogenic GA were found in 131 genes across all tumor subtypes and affected major pathways: apoptosis/cell cycle (31%), PI3K (14%), transcriptional regulation (13%), and receptor tyrosine kinases (10%). Among these GA, 38 were considered actionable and were distributed across 43 (75%) samples. Therapies with FDA approval for the tumor type analyzed were indicated for 18 samples; an additional 25 samples had GA associated with therapies FDA approved for another indication. More than 1 actionable GA was identified in 24/43 (56%). TMB status was low in 36 (63%), intermediate in 19 (33%) and high in 2 (3.5%). High TMB status correlated with high MSI status (p < 0.001). Trend observed in the mutation frequency was comparable with the larger Foundation database. Conclusions: This is the first study in India showing CGP identified actionable targets associated with FDA approved therapies in approx. 32% of cases. TMB status identified 2/57 samples with high mutation burden for whom immunotherapy might be relevant.

Acute leukemia in children: A review of the current Indian data

Acute leukemias are the most common diagnostic group of childhood cancer. This review summarizes the published literature on reported current outcomes of childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) from India. Overall survival in ALL ranged from 45% to 81% (commonly >60%) and event-free survival ranged from 41% to 70% (commonly >50%). Outcome data for AML was patchy with varying duration of follow-up, but it can be inferred that 50-80% of treated patients had experienced an event (toxic death, refractory disease or relapse). It is imperative that going forward focus should be on collaborative efforts, which promote treatment of patients on risk-stratified adapted protocols based on local infrastructure, improvement in supportive care and encourage prospective multi-center clinical trials.

Pilot initiative in India to explore the gonadal function and fertility outcomes of a cohort of childhood cancer survivors

CONTEXT:

Steady improvement in childhood cancer outcomes has led to a growing number of survivors, many of who develop long-term sequelae. There is limited data about these sequelae (including those related to fertility) on childhood cancer survivors from India.

AIMS:

We undertook a prospective pilot study on childhood cancer survivors from India to assess their gonadal function and fertility.

SUBJECTS AND METHODS:

A pediatric oncologist and a reproductive medicine specialist assessed 21 childhood cancer survivors. The risk of infertility was established using disease and treatment variables. Current status of puberty, sexuality, and fertility were assessed using clinical and biochemical parameters. Outcomes were correlated with risk group of infertility. Information was also ascertained on counseling with regards to risk of infertility.

RESULTS:

The cohort included 21 survivors (71% males) with a median age of 18 years who were off treatment for a median age of 7 years. Ten (48%) survivors were at low risk for infertility, 9 (43%) at medium risk and 2 (9%) at high risk. Gonadal dysfunction was seen in 3 (14%) survivors: 0/10 (0%) low risk, 1/9 (11%) medium risk, and 2/2 (100%) high risk. None of the survivors, who are at high risk or medium risk of infertility, received any counseling before treatment.

CONCLUSIONS:

This prospective pilot study of a cohort of childhood cancer survivors from India demonstrates a deficiency in the information provided and counseling of patients/families at the time of diagnosis with regards to the risk of infertility. Fertility outcomes of childhood cancer survivors were congruent with recognized risk groups for infertility. Future action points have been identified.

Epidemiology of cancers among adolescents and young adults from a tertiary cancer center in Delhi

Background and Objectives:

Although cancer in adolescents and young adults (AYAs) is increasingly an area of focus, there is a paucity of clinical and epidemiological data from developing countries. Our objective was to analyze the geographical distribution, sex ratio, histology, and disease patterns of cancers in AYA.

Materials and Methods:

All patients aged 15-29 years with the diagnosis of cancer who were registered with two hospitals in New Delhi during a 12-month period from January 2014 to December 2014 were included. Basic demographic information on age, sex, location of stay, and nationality was available. Using cancer site and morphology codes, the cancers were grouped by the Birch classification of AYA cancers. Clinical information on disease and treatment status, was retrospectively studied.

Results:

There were 287 patients (57.5% male, 85.4% Indian origin) registered with 54 (18.8%), 97 (33.8%), and 136 (47.4%) patients in the 15-19, 20-24, and 25-29 years age groups, respectively. The three most common cancer groups were carcinomas (40.8%), lymphomas (12.9%), and leukemias (10.4%). The three most common sites in carcinomas were gastrointestinal tract (GIT), genitourinary tract, and breast. The most prevalent cancers in younger AYA (15-19 years) were leukemias, lymphomas, central nervous system neoplasms, and in contrast, older AYA (25-29 years) suffered mainly from GIT Carcinomas, lymphomas. The leading cancers were breast and GIT carcinomas in females and lymphomas and GIT carcinomas in males.

Conclusion:

The occurrence of cancer in AYA in India has been described. The distribution differs from the only previous report from India as well as the US Surveillance Epidemiology and End Results database, which can be attributed to a referral bias along with the factual difference in cancer etiology and genetics.