Breast cancer survival in India across 11 geographic areas under the National Cancer Registry Programme

BACKGROUND

Population-based cancer survival is a key indicator for assessing the effectiveness of cancer control by a health care system in a specific geographic area. Breast cancer is the most common cancer among women in India, accounting for over one quarter of all female cancers. The objective of this study was to estimate the 5-year survival of female patients who were diagnosed with breast cancer between 2012 and 2015 from the existing Population-Based Cancer Registries (PBCRs) in India.

METHODS

In total, 17,331 patients who had breast cancer diagnosed between 2012 and 2015 from 11 PBCRs were followed until June 30, 2021. Active methods were used to track the vital status of registered breast cancer cases. The study conducted survival analysis by calculating the difference between the date of first diagnosis and the date of death or censoring to estimate observed survival and relative survival using the actuarial survival approach and the Ederer-II approach, respectively.

RESULTS

The 5-year age-standardized relative survival (95% confidence interval [CI]) of patients with breast cancer was 66.4% (95% CI, 65.5%-67.3%). Mizoram (74.9%; 95% CI, 68.1%-80.8%), Ahmedabad urban (72.7%; 95% CI, 70.3%-74.9%), Kollam (71.5%; 95% CI, 69.2%-73.6%), and Thiruvananthapuram (69.1%; 95% CI, 67.0%-71.2%) had higher survival rates than the national average. Conversely, Pasighat had the lowest survival rate (41.9%; 95% CI, 14.7%-68.6%). The 5-year observed survival rates for localized, regional, and distant metastasis in the pooled PBCRs were 81.0%, 65.5%, and 18.3%, respectively.

CONCLUSIONS

The overall disparity in survival rates was observed across 11 PBCRs, with lower survival rates reported in Manipur, Tripura, and Pasighat. Therefore, it is imperative to implement comprehensive cancer control strategies widely throughout the country.

Survival of patients with cervical cancer in India - findings from 11 population based cancer registries under National Cancer Registry Programme

Background

Cancer survival data from Population Based Cancer Registries (PBCR) reflect the average outcome of patients in the population, which is critical for cancer control efforts. Despite decreasing incidence rates, cervical cancer is the second most common female cancer in India, accounting for 10% of all female cancers. The objective of the study is to estimate the five-year survival of patients with cervical cancer diagnosed between 2012 and 2015 from the PBCRs in India.

Methods

A single primary incidence of cervical cancer cases of 11 PBCRs (2012-2015) was followed till June 30, 2021 (n = 5591). Active follow-ups were conducted through hospital visits, telephone calls, home or field visits, and public databases. Five-year Observed Survival (OS) and Age Standardised Relative Survival (ASRS) was calculated. OS was measured by age and clinical extent of disease for cervical cancers.

Findings

The five-year ASRS (95% CI) of cervical cancer was 51.7% (50.2%-53.3%). Ahmedabad urban (61.5%; 57.4%-65.4%) had a higher survival followed by Thiruvananthapuram (58.8%; 53.1%-64.3%) and Kollam (56.1%; 50.7%-61.3%). Tripura had the lowest overall survival rate (31.6%; 27.2%-36.1%). The five-year OS% for pooled PBCRs was 65.9%, 53.5%, and 18.0% for localised, regional, and distant metastasis, respectively.

Interpretation

We observed a wide variation in cervical cancer survival within India. The findings of this study would help the policymakers to identify and address inequities in the health system. We re-emphasise the importance of awareness, early detection, and increase the improvement of the health care system.

Funding

The National Cancer Registry Programme is funded through intra-mural funding by Indian Council of Medical Research, Department of Health Research, India, Ministry of Health & Family Welfare.

Efficacy of a herbal mouthwash for management of periodontitis and radiation-induced mucositis - A consolidated report of two randomized controlled clinical trials

BACKGROUND

Oral diseases like periodontitis and mucositis often require home care using topical agents in the form of mouthwashes. Many herbal mouthwashes are found to be beneficial; however lack proper scientific evidence to support their use.

OBJECTIVES

Study 1 evaluated clinical efficacy of herbal mouthwash in the management of chronic periodontitis in comparison with chlorhexidine mouthwash. Study 2 aimed at assessment of herbal mouthwash in patients of radiation-induced mucosititis.

METHODS

The novel herbal mouthwash used in the present study wa prepared from extracts of five plants namely Emblica Officinalis, Terminalia chebula, Terminalia bellerica, Glycyrrhiza glabra, and Azadirachta indica. 50 periodontitis patients were randomly allocated to two groups. As per allocation, they were instructed to use either herbal mouthwash or chlorhexidine mouthwash twice daily for two weeks after nonsurgical periodontal therapy. Similarly, patients with radiation-induced mucositis were randomly given herbal mouthwash and soda saline mouthwash. Intergroup and intragroup comparisons of continuous variables were conducted using paired and unpaired t-tests. Categorical variables were compared using the chi-square test.

RESULTS

Significant reductions in gingival bleeding, plaque accumulation, and pocket depth were noticed in periodontitis patients in both groups. Patients reported acceptable taste, freshness, and satisfaction after the use of herbal mouthwash. The herbal mouthwash group noticed a significant reduction in the severity of radiation-induced mucositis and analgesic requirements. The intensity of pain, dryness of mouth, oral hygiene, and need for the use of antibiotic and antifungal during radiotherapy was not significant among the groups.

CONCLUSION

The results of this preliminary clinical trial support the use of the tested herbal formulation mouthwash as an adjunct in the treatment of periodontitis as well as radiation-induced mucositis.

CLINICAL TRIAL REGISTRATION NUMBER

For Study 1: CTRI/2019/10/021574, Study 2: CTRI/2020/04/024851.

A Comparison Between Sequential Conventional and Hypofractionated Boost Following Whole-Breast Radiotherapy: A Propensity Score-Matched Analysis

BACKGROUND

The majority of local relapses after breast conservation therapy occur in the proximity of the primary lesion. Studies have shown that boost radiotherapy (RT) following conventional whole-breast radiotherapy (WBRT) of 50 Gy in five weeks improves outcomes. Boost RT also increases the risk of moderate skin reactions and fibrosis. The ideal boost RT dose and timing (sequential versus simultaneous) after hypofractionated radiotherapy schedules remain unclear. This retrospective propensity score-matched analysis assessed the outcome of sequential hypofractionated boost compared to conventional fractionated boost.

METHODS

The study was approved by the Institutional Review Board of the Regional Cancer Centre, Thiruvananthapuram, India. Patients with stage I-III breast cancer who have received adjuvant radiotherapy with a sequential boost of either hypofractionated RT (8 Gy in three fractions) or conventional fractionated RT (10 Gy in five fractions) after conservative breast surgery were identified from the radiotherapy planning records and included in this study. A 1:1 case matching was performed using a propensity score incorporating four known prognostic factors, namely, clinical and pathological composite stage, tumor grade, tumor biology (based on estrogen and/or progesterone and HER2 neu expression), and boost technique, which may have an impact on acute toxicity to make the two boost groups more homogenous.

RESULTS

After propensity score matching (PSM), there were a total of 166 patients, with 83 patients each in both conventional and hypofractionated boost RT groups. The median follow-up period was 30.7 months. At two years, locoregional recurrence-free survival (LRFS) was 98.8% in both groups. Disease-free survival (DFS) at two years for the hypofractionated group and conventional group was 91.5% and 96.3% (hazard ratio (HR): 2.5, 95% confidence interval (CI): 0.664-9.4, p = 0.161), respectively, with no statistically significant difference. Patients with grade 3 tumors who received hypofractionated boost had a statistically significant increased risk of recurrence (DFS: 88.9% versus 100%, HR: 60.559, 95% CI: 0.138-26613.2, p = 0.011). The overall survival (OS) at two years was 100% in both groups. There was no difference in acute skin toxicity between the two groups.

CONCLUSION

The present interim analysis shows similar locoregional recurrence-free survival, overall survival, and disease-free survival and acute skin toxicity for hypofractionated boost RT of 8 Gy in three fractions compared to the conventional boost of 10 Gy in five fractions. Hypofractionated boost is a feasible alternative option following hypofractionated whole-breast radiotherapy for women with breast conservation treatment. However, longer follow-up is required before forming definite conclusions.

Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes

Introduction

Oral cancer is a major public health concern in India. Both conventional and altered fractionation radiotherapy schedules have been used in curative treatment of oral cancer. This study aimed to retrospectively evaluate the clinical profile and treatment outcomes of patients with carcinoma buccal mucosa who underwent treatment with definitive hypofractionated accelerated radiotherapy.

Methods

A total of 517 patients treated from January 2011 to December 2016 were eligible for the analysis. All patients were treated with definitive hypofractionated accelerated radiotherapy schedule of 5,250 cGy in 15 fractions over 3 weeks. Survival estimates were generated using the Kaplan-Meier method.

Results

At a median follow-up of 77.4 months, 473 (91.5%) patients attained complete remission with radiation therapy. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 69% and 80.5%, respectively. The 5-year OS for stage I, II, III and IVa tumours was 80.3%, 84.4%, 81.4% and 73.7%, respectively, and the DFS was 75.7%, 73.2%, 69.6% and 60.2%, respectively. Age >50 years was found to be a significant factor affecting DFS (P = 0.026) and OS (P = 0.048) in multivariate analysis. Fifty-three (10.3%) patients developed osteoradionecrosis of the mandible.

Conclusion

Excellent outcome could be achieved in less-aggressive, low-volume carcinoma of the buccal mucosa with radical accelerated hypofractionated radiotherapy. A radiotherapy schedule over a 3-week period is useful in high-volume centres.

Treatment Outcomes of Adenoid Cystic Carcinomas of the Head and Neck Region-A Single-Institution Experience

Malu RafiObjectives  This study was undertaken to evaluate the characteristics and treatment outcomes of patients with adenoid cystic carcinomas of the head and neck region treated at a tertiary cancer center in south India. Materials and Methods  This was a retrospective study done on patients treated at the institute between 2004 and 2011. Clinicopathological details and treatment outcomes were captured from the treatment records to estimate the treatment outcomes and factors affecting them. Results  There were a total of 140 patients with mean age of presentation of 46 years and a median follow-up of 65 months. The most common single site of presentation was the oral cavity. One-hundred eighteen patients (84.3%) underwent primary surgical resection in which 38% had negative surgical margins. Ninety-nine patients were given adjuvant radiotherapy and 18 patients received radical radiotherapy, mostly for surgically inaccessible and inoperable tumors. Median time to recurrence and distant metastasis was 37 and 34 months, respectively. The overall survival and disease-free survival estimate using the Kaplan-Meier method were 92.3 and 71.9%, respectively, at 5 years. Surgical removal of the primary tumor and the nodal stage had the most significant impact on the overall survival outcomes of these patients. Conclusion  Surgery remains the most impactful treatment modality in the management of these rare epithelial tumors. The use of adjuvant radiotherapy may help to tackle the issues of perineural spread and inadequate surgical margins in technically difficult sites. Radical radiotherapy also has impressive response rates.

Spatiotemporal pattern of thyroid cancer incidence in South Kerala: A population-based study

Background

Thyroid cancer (TC) is the most common endocrine cancer and has been increasing over the past decades worldwide. A notable finding is that Kerala's capital Thiruvananthapuram ranks the first among men and the second highest among women in the incidence of TC in India. Reasons for this increase have not been established.

Objectives

Here, we investigated the spatiotemporal pattern of TC incidence in Thiruvananthapuram.

Materials and Methods

TC incidence data (n = 1937) of Population Based Cancer Registry Thiruvananthapuram, Kerala, India, between 2012 and 2016, were analyzed for identifying geographical patterns by spatial methods, temporal methods for studying spatial variation in TC incidence, distribution of age, gender, and histology in lowland (coastal), midland, and highland.

Results

Spatial clustering of TC incidence was identified consistently near the coastal region based on all geospatial analyses. 56.9%, 23.9%, and 19.2% of TC cases were observed in the coastal, midland, and highland areas, respectively. A significant clustered pattern of TC incidence was revealed by Moran's index I (0.49), high-high clusters by local Moran's, hotspot by Getis-Ord-Gi* (P < 0.05), point pattern analysis by nearest neighbor ratio and kernel density estimation. The relative risk of the significant cluster was obtained as 1.60 (95% confidence interval: 1.03-1.84) by SaTScan analysis.

Conclusion

This study identified spatial variations in the pattern of TC cases with significant clusters near the coastal region of Thiruvananthapuram. This would help to pinpoint the high-risk geographical areas of TC and for more effective cancer control programs.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Epstein-Barr virus dynamics and its prognostic impact on nasopharyngeal cancers in a non-endemic region

Background

Epstein-Barr virus (EBV) DNA quantification in nasopharyngeal cancer (NPC) is an indicator of the tumour burden, stage and survival. Although EBV dynamics in endemic regions has been extensively studied and reported, the data from non-endemic regions is sparse. This study attempts to investigate the EBV dynamics in NPC patients from a non-endemic region and also to identify the factors impacting the outcomes.

Materials and methods

This was a prospective observational study conducted at a tertiary care centre in South India and enrolled patients with non-metastatic, biopsy proven NPC, who were suitable for radical chemo-radiotherapy with or without induction chemotherapy. Two blood samples, one prior to initiation of any anticancer treatment, and second at 6 weeks post treatment, were collected to quantify EBV DNA using real-time quantitative polymerase chain reaction. Antibodies against EBV viral capsid antigen (EBV VCA IgM), EBV Early Antigen (EBV EA IgG) and EBV Nuclear Antigen (EBV EBNA IgG) were also measured in the sample. The impact of EBV dynamics on the outcomes was then analysed.

Results

The study included a total of 35 patients. Thirty-three had identifiable EBV DNA (94.3%) and a histological diagnosis of non-keratinising undifferentiated type of squamous cell carcinoma. There was no correlation between the EBV DNA and anti-EBV antibodies. There was a significant association between composite stage and pre-treatment DNA titre (p = 0.030). The mean EBV DNA titre was lower for patients with no clinically demonstrable disease at last follow-up and the reduction in EBV DNA titres was significant (p = 0.020) for those patients who remained disease free.

Conclusion

Plasma EBV DNA is an accurate and reliable biomarker for NPC for WHO type 2 and 3 tumours even in non-endemic regions.

OPEN TO ROBOTIC RIGHT DONOR HEPATECTOMY: A TECTONIC SHIFT IN SURGICAL TECHNIQUE

Robotic right live donor hepatectomy(r-LDRH) has been reported with reduced morbidity compared to open donor right hepatectomy(o-LDRH) in few recent series. Nevertheless, its routine use is debated. We present a large series comparing pure r-LDRH with o-LDRH. Consecutive r-LDRH performed from June 2018 to June 2020 (n = 102) were compared with consecutive donors undergoing o-LDRH (n = 152) from February 2016 to February 2018, a period when r-LDRH was not available at this centre. Propensity score matched (PSM) analysis of 89 case-control pairs was additionally performed. Primary endpoints were length of high dependency unit (HDU) & hospital stay and Clavien-Dindo graded complications among donors. Although r-LDRH took longer to perform (540 versus 462 mins, P<0.001), the post-operative peak transaminases levels(P<0.001), the length of HDU (3 versus 4 days, P<0.001) and hospital stay (8 versus 9 days, P<0.001) were lower in in donors undergoing r-LDRH. Clavien-Dindo graded complications were similar (16.67% in r-LDRH and 13.16% in o-LDRH). The rates of early allograft dysfunction (1.6% versus 3.3%), bile leak (14.7% versus 10.7%), and 1-year mortality (13.7% versus 11.8%) were comparable between r-LDRH and o-LDRH recipients. PSM analysis yielded similar results between the groups. These data support the safety and feasibility of r-LDRH in select donors. This article is protected by copyright. All rights reserved.

Effects of Revision Surgery and Surgical Margins on Outcome of Peripheral Soft Tissue Sarcomas: Experience from a Tertiary Cancer Care Centre

INTRODUCTION

The purpose of this study is to assess the impact of revision surgery, after unplanned excision, on oncological outcome and surgical morbidity in soft tissue sarcomas and also to assess the relation between margin status and oncologic outcome.

MATERIALS AND METHODS

We undertook a retrospective analysis of prospectively maintained database of 153 patients with peripheral soft tissue sarcomas treated in our institute from 2006-2010.

RESULTS

Postoperatively, 111(72.5%) patients had negative margins, 20(13.1%) had close margins and 22(14.4%) had planned positive margins. Local recurrence rate was 19.8% in patients with negative margins and 28.6% for patients with close or positive margins (p= 0.007). There was no statistically significant difference in rates of distant metastases (18.9% vs 21.4%, p value 0.56) and five-year overall survival (82.5% Vs 79.8%, p value 0.41) between margin negative and close/positive groups. The five-year overall survival rates were 80.4 vs 77.8% (p =0.42) and five-year disease-free survival rates were 72.4% vs 70.2% (p=0.3), in the revision surgery group and primary surgery group respectively.

CONCLUSION

Margin status after excision of soft tissue sarcoma is not a direct predictor for overall survival or distant metastasis. Revision surgery after an unplanned excision does not carry worse survival compared to primary surgery group.

Immunoexpression of TTF1 and p63 Differentiates Lung Adenocarcinomas in Sputum Samples

Context

Differentiating NSCLC as either adeno or squamous type and identification of Epidermal Growth Factor Receptor (EGFR) mutations is clinically relevant for lung cancer patients for selecting treatment. Thyroid transcription factor-1 (TTF-1) and p63 were demonstrated as useful markers for histologic typing of lung cancer. Mutation and overexpression of EGFR has been reported in a subset of non-small cell lung cancers. If these markers can be validated for the differential diagnosis of adenocarcinoma in a sputum sample itself, it will be highly beneficial for lung cancer patients.

Aims

To evaluate whether immunocytochemical expression of TTF-1, p63, and EGFR proteins in sputum samples can be used for differential diagnosis of lung adenocarcinoma by comparing with that of the corresponding tissue samples.

Settings and Design

Ninety sputum samples and matched tissue samples were used for the study.

Subjects and Methods

Monolayered smears and cell blocks of sputum and the corresponding tissue samples were immunostained with the standard ABC method. The expression patterns of these markers were analyzed statistically and compared with clinic-pathological parameters.

Statistical Analysis Used

Chi-square test and paired t-test.

Results

The p63 protein had a positive expression in 73.9% of SCC whereas TTF1 had positive expression in 75.8% of ADC. The EGFR expression was positive in 27 cases of adenocarcinoma, 21 cases of SCC and 19 cases of NSCLC.

Conclusions

Immunocytochemistry of the aforementioned antibodies in sputum samples can be used as supplementary evidence for the subtyping of NSCLC.

Educational Status, Cancer Stage, and Survival in South India: A Population-Based Study

PURPOSE

Lower socioeconomic status is associated with more advanced cancer at the time of cancer diagnosis. It is unknown whether this leads to inferior survival in low- and middle-income countries. Here, we explore the association between educational level and survival in South India.

METHODS

The Trivandrum Cancer Registry (3.3 million population) was used to identify all cases of breast and cervical cancer (women) and oral cavity (OC) and lung cancer (men) diagnosed during 2012-2014. Educational level was classified as illiterate/primary school, middle school, and secondary school and above. Survival was measured from date of diagnosis using the Kaplan-Meier method. Cox proportional hazards regression modeling was used to describe the associations among education, stage of cancer at diagnosis, and survival.

RESULTS

The study population included 3,640 patients with breast (n = 1,727), cervical (n = 425), OC (n = 702), and lung (n = 786) cancer. Educational level was 27%, 23%, and 32% for illiterate/primary, middle, and secondary school and above, respectively. The 5-year survival rate for breast cancer was 59%, 68%, and 73% (P = .001); for cervical cancer, 51%, 52%, and 60% (P = .146); and for OC cancer, 42%, 35%, and 48% (P = .012) for illiterate/primary, middle school, and secondary school and above, respectively. The survival gradient across social groups was substantially attenuated when stage was added to the multivariable model. There was no observed difference in survival across educational groups for lung cancer (2%, 4%, and 3%; P = .224).

CONCLUSION

Data from this population-based study in South India demonstrate that patients from a lower educational background have inferior survival and that this is at least partially explained by having more advanced disease at the time of diagnosis. Public health efforts are needed to facilitate timely diagnosis and reduce disparities in cancer outcomes.

Phase IIb trial comparing two concurrent cisplatin schedules in locally advanced head and neck cancer

Background:

Concurrent chemoradiation with 3 weekly cisplatin (100 mg/m²) is the standard of care for locally advanced head and neck cancer. However, this regimen has been shown to be associated with lesser compliance and higher toxicities. Hence, there is a need to explore alternative concurrent cisplatin regimens.

Objectives:

The objective of this study was to compare the efficacy and toxicities of 3 weekly cisplatin (100 mg/m²) with weekly cisplatin (40 mg/m²) concurrently with radiation in patients with locally advanced head and neck cancer.

Patients and Methods:

This phase IIb trial randomized 56 patients with Stage III and IV squamous cell carcinoma of oropharynx, hypopharynx, and larynx to Arm A or Arm B. Arm A received cisplatin 100 mg/m² 3 weekly and Arm B received cisplatin 40 mg/m² weekly concurrently with radiation. The primary end point was disease-free survival (DFS) and secondary end points were overall survival (OS) and acute toxicity. DFS and OS were estimated using Kaplan–Meier method, and log-rank test was used to assess the difference in these distributions with respect to treatment.

Results:

The 2-year DFS in Arm A and Arm B was 64.5% and 52.8%, respectively (P = 0.67). The OS at 2 years was 71% and 61.1% in Arm A and Arm B, respectively (P = 0.61). There were no significant differences in acute hematological, renal, or mucosal toxicities between the two arms.

Conclusion:

This study showed a nonsignificant improvement in DFS and OS in the 3 weekly cisplatin arm over the weekly arm with comparable toxicities. The trial is registered with Clinical Trial Registry of India (CTRI registration number: CTRI/2013/05/003703, URL-http://ctri.nic.in).

Sociodemographic Factors and Stage of Cancer at Diagnosis: A Population-Based Study in South India

PURPOSE

Lower socioeconomic status is associated with inferior cancer survival in high-income countries, but whether this applies to low- and middle-income countries is not well described. Here, we use a population-based cancer registry to explore the association between educational level and stage of cancer at diagnosis in South India.

METHODS

We used the Trivandrum District population-based cancer registry to identify all cases of breast and cervical cancer (women) and oral cavity (OC) and lung cancer (men) who were diagnosed from 2012 to 2014. Educational status—classified as illiterate/primary school, middle school, or secondary school or higher—was the primary exposure of interest. Primary outcome was the proportion of patients with advanced stage disease at diagnosis defined as stage III and IV (breast, cervix, or OC) or regional/metastatic (lung).

RESULTS

The study population included 4,547 patients with breast (n = 2,283), cervix (n = 481), OC (n = 797), and lung (n = 986) cancer. Educational status was 22%, 19%, and 26% for illiterate/primary, middle, and secondary school or higher, respectively. Educational status was missing for 33% of patients. The proportion of all patients with advanced stage disease was 37% (breast), 39% (cervix), 67% (OC), and 88% (lung). Patients with illiterate/primary school educational status were considerably more likely to have advanced breast cancer (50% v 39% v 36%; P < .001), cervix cancer (46% v 43% v 24%; P = .002), and OC cancer (77% v 76% v 59%; P < .001) compared with patients with higher educational levels. The proportion of patients with advanced lung cancer did not vary across educational levels (89% v 84% v 88%; P = .350).

CONCLUSION

A substantial proportion of patients in South India have advanced cancer at the time of diagnosis. This is particularly true among those with the lowest levels of education. Future health awareness and preventive interventions must target less-educated communities to reduce delays in seeking medical care for cancer.

Abstract P4-12-22: Curative hypofractionated radiotherapy for stage I-III breast cancer patients- Experience from a tertiary cancer centre in South India

Background Randomized controlled trials in Western population have demonstrated hypofractionated radiotherapy to be a safe and effective option as compared to radiation doses of 45- 50Gy in 25 fractions at 1.8-2 Gy/fraction for breast cancer patients. However, most of the patients in such studies had early stage, good prognostic disease and the efficacy and safety in patients with higher stage disease is debated. In Indian centres, patients typically present at younger age with symptomatic or locally advanced disease. Protracted treatment times remain a significant hurdle for many patients who have to travel to distant places for treatment. This retrospective analysis assesses the outcome of patients with stage I-III breast cancers who were treated with hypofractionated regimen (40Gy/15 fractions over 3 weeks with 2.67Gy/fraction each day) following either conservative surgery or mastectomy with or without regional nodal irradiation. Materials and Methods: Patients with stage I-III Breast cancers treated at Regional Cancer Centre, Thiruvananthapuram, India during 1st Jan 2013 to 31st Dec 2015 were identified from the Hospital Based Cancer Registry. Among a total of 3577 patients, 642 (18%) were found to have received adjuvant hypofractionated radiotherapy and were included in this analysis. The study was approved by the Institutional Review Board. The mean age was 50.2 years (range 20 - 78 years). There were 4 males. The clinical stages were I, II and III for 5.9%, 38% and 33.4% patients; stage was not known for 22.4% who underwent excision of the breast lump prior to reporting. The molecular subtypes were hormone receptor (HR) +, HER-2 - (46.1%), HR+, HER + (10.6%), HR-, HER2 + (13.6%) and Triple Negative (26%), unknown (2.8%). Majority (62.5%) underwent primary surgery while the remaining received neoadjuvant systemic therapy prior to surgery. Sixty-eight percent patients underwent modified radical mastectomy (MRM) and 32% underwent breast conservation. Chemotherapy was received by 95% patients and all HR+ patients received endocrine therapy. Only 55.5% of the HER 2+ patients received anti-HER2 therapy. Overall Survival (OS), and Disease Free Survival (DFS) were assessed using Kaplan Meier analyses for the entire cohort and according to stage, lymphovascular emboli (LVE), grade, molecular subtypes and type of surgery. Multivariable Cox regression analysis was performed to assess for prognostic factors. Results All 642 patients were included in this analysis. At a median follow up of 53 months, 122 (19.0%) patients had relapsed. The first site of recurrence was loco-regional alone for 6 (4.9%) patients. Among the 112 (91.8%) patients who failed at distant sites, 16 had loco-regional disease as well. Four (3.3%) patients recurred with contralateral breast cancer. The median time to recurrence was 26 months. The 4-year DFS and OS were 81.5% and 88.8% for the entire cohort. Patients with higher clinical and pathological stage, LVE, triple negative biology and those who had undergone MRM had poorer outcome. Pathological stage was the only independent prognostic factor for both OS and DFS. Radiotherapy was well tolerated; grade of skin toxicity was 0, 1, 2and 3 for 56.2%, 39%, 4.3% and 0.5% patients respectively. Conclusion The results of this study appear to confirm the efficacy and safety of the use of hypofractionated radiotherapy in Stage I-III breast cancers. Loco-regional recurrences were quite low and DFS and OS do not seem to be compromised in spite of higher disease stage and younger population. Keywords: Breast cancer, radiotherapy, hypofractionation

Citation Format: Anand Sebastian, Preethi Sara George, J V Ammu, K R Rajeev, Beela Sarah Mathew. Curative hypofractionated radiotherapy for stage I-III breast cancer patients- Experience from a tertiary cancer centre in South India [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-22.

Immunocytochemistry on Sputum Samples Predicts Prognosis of Lung Cancer

Context

Despite sputum cytology being accepted as a simple and noninvasive diagnostic method for lung cancer, the clinical usefulness of sputum for evaluation of prognosis is yet to be explored. Validation of some of the markers in sputum for prognosis prediction will be highly useful for selective therapy.

Aims

This study was aimed to evaluate a reliable panel of immunocytochemical markers for their significance to predict survival.

Materials and Methods

We have analyzed the expression of p53, p16, galectin-3, and epidermal growth factor receptor (EGFR) proteins in sputum samples processed in a mucolytic agent/cellblock and compared the same with that of the corresponding tissue samples.

Results

Overexpression of p16 and EGFR was found to have a better survival benefit, whereas positive p53 and galectin-3 expressions had shorter period of survival. Expression patterns of all these four proteins were more or less similar in smears, cellblocks of sputum, and tissue samples except for slight changes in staining intensity which was not found to be statistically significant. No significant difference was found in the association of these proteins with survival pattern between sputum and tissue samples.

Conclusion

This is the first report of immunocytochemistry of a panel of markers on cells exfoliated in sputum samples which suggests that analysis of immunocytochemical markers in sputum samples can be attempted as a cost-effective and reliable predictor of prognosis and survival. Accumulation of mutated p53, overexpression of galectin-3, and lower expression of p16 and EGFR proteins were found to predict poor prognosis for lung cancer.

Transition of cancer in populations in India

BACKGROUND & OBJECTIVES

An assessment of transition of cancer in India during the past 30 years, according to changes in demographic and epidemiologic risk factors was undertaken.

MATERIALS & METHODS

Cancer registry data (http://www.ncdirindia.org), (population coverage <10%), was compared with transition in life-expectancy and prevalence on smoking, alcohol and obesity. We fitted linear regression to the natural logarithm of the estimated incidence rates of various cancer registries in India.

RESULTS

Burden of cancer in India increased from 0.6 million in 1991 to 1.4 million in 2015. Among males, common cancers are lung (12.0%), mouth (11.4%), prostate (7.0%), and tongue (7.0%) and among females, they are breast (21.0%), cervix-uteri (12.1%), ovary (6.9%), and lung (4.9%) in 2012. Increased life-expectancy and population growth as well as increased use of alcohol and increased prevalence of overweight/obesity reflected an increase in all cancers in both genders except a reduction in infection-related cancers such as cervix-uteri and tobacco-related cancers such as pharynx (excludes nasopharynx) and oesophagus.

INTERPRETATION & CONCLUSION

Transition in demographics and epidemiologic risk factors, reflected an increase in all cancers in both genders except a reduction in a few cancers. The increasing incidence of cancer and its associated factors demands a planned approach to reduce its burden. The burden assessment needs to be strengthened by increasing the population coverage of cancer registries. Continued effort for tobacco prevention and public health efforts for reducing obesity and alcohol consumption are needed to reduce the cancer burden.

Lung cancer: Presentation and pattern of care in a cancer center in South India

BACKGROUND

In India lung cancer is the most commonly diagnosed malignancy in males and an increasing trend in the incidence is reported from the National Cancer Registry programme.

AIMS

The aim of this study is to find out the recent trends in presentation and management of lung cancer at Regional Cancer Centre, Trivandrum.

METHODS

Published reports of hospital based cancer registries (HBCR) and population based cancer registries (PBCR) of Trivandrum were compared with reported statistics from other parts of India and global data.

RESULTS

Lung is the leading site of cancer in males (15%) getting treatment at Regional Cancer Centre , Trivandrum in 2013 as per the HBCR. There is an increase in the age adjusted incidence rate of lung cancer among males in the Trivandrum PBCR from 14.6 to 18.5 during 2012 -2014. Among the patients who were treated at the Center majority (55.2%) presented with distant metastases with adenocarcinoma as the most common histological type (28.5%) and only 15.7% had undergone treatment with curative intent.

CONCLUSIONS

Lung cancer is the major cancer affecting males in India with a high incidence in Trivandrum and a very low percentage of patients receiving curative treatment which could be due to the high prevalence of tuberculosis and scarce availability of facilities and trained manpower for thoracic oncology.

Cytomorphologic Spectrum of Hurthle Cell Lesions of Thyroid: A Study of 54 Cases

INTRODUCTION

Lesions of the thyroid gland composed of Hurthle cells constitute a wide spectrum of pathological entities ranging from benign hyperplastic nodules with Hurthle cell metaplasia at one end to malignancies like Hurthle cell carcinomas. The cytological distinction of these entities is not only diagnostically challenging but are also critical since they influence treatment decisions.

AIM

To critically analyze the cytomorphology of cases of Hurthle cell lesions in FNACs and to characterize cytological features shown to be statistically signific ant in predicting Hurthle cell neoplasm (HCN).

METHODS

During the period from January 2014 to August 2015, 1667 cases of thyroid FNAs were done at our centre, of which 54cases,showed a predominance of hurthle cells, i.e. more than or equal to 50% hurthle cells (≥=50%).These cases were included in the study and were critically reviewed for 9 cytomorphologic features which included cellularity, architecture, and percentage of Hurthle cells, background colloid, chronic inflammation, nucleoli, intranuclear cytoplasmic inclusions (INCI), nuclear grooves and transgressing blood vessels (TBV). The results were evaluated by using univariate and stepwise logistic regression (SLR) analysis; statistical significance was achieved at P-value < 0.05.

RESULTS

Out of the 9 parameters studied, the cytological features shown to be statistically significant in predicting HCN and distinguishing them from benign hurthle cell lesions(BHCLs) were increased cellularity, non-macro follicular architecture, >90% Hurthle cells, absence of background colloid and absence of chronic inflammation.

DNA Replication Licensing Proteins for Early Detection of Lung Cancer

Background:

To identify and characterize malignant and premalignant cells in sputum and matched tissue samples with reference to expression of minichromosome maintenance proteins (MCM2, MCM5) and cell division cycle protein 6 (CDC 6) and to assess their potential as biomarkers of premalignant and malignant lesions of the lung and associations with clinicopathological features.

Methods:

Expression of MCM2, MCM5 and 6 proteins in sputum samples and corresponding tissues was assessed by immunocytochemistry, and correlated with histological findings.

Results:

For characterization of malignant, metaplastic or dysplastic cells, CDC6 protein had the highest sensitivity of 87.7%. All the three markers together had a sensitivity of 94.4%. Furthermore these proteins could be employed to assess the proliferative potential of precancerous or atypical cells, as overexpression increasing with the stage of disease and degree of metastasis.

Conclusion:

The assessed markers can be utilized in routine cytopathology laboratories to supplement conventional morphological evaluation so that the sensitivity of sputum cytology can be enhanced. Potential applications in predicting the clinical behavior of lung lesions and predicting prognosis and survival deserve further attention.

Cancer Incidence and Mortality: District Cancer Registry, Trivandrum, South India

Background: Cancer is emerging as a major cause of morbidity and mortality in low and middle-income countries. Cancer registry figures help for planning and delivery of health services. This paper provided the first results of cancer incidence and mortality [Crude (CR) and age-standardized (ASR)] rates (world-standard population) of Trivandrum district, South India and compared with other registries under the network of National Cancer Registry Programme (NCRP), Government of India. Materials and Methods: Trivandrum district cancer registry encompasses a population of 3.3 million, compiles data from nearly 75 sources (hospitals and diagnostic laboratories) and included under the NCRP in 2012. During 2012-2014, registry recorded 15,649 incident cases and 5667 deaths. Proportion of microscopic diagnosis was 85% and ‘Death certificate only’ was 8%. Results: Total cancer incidence (CRs) rates were 161 and 154 (ASR: 142.2 and 126) and mortality rates were 66 and 49 (ASR: 54 and 37) per 105 males and females respectively. Common cancers in males were lung (ASR:19), oral cavity (ASR:15), colo-rectum (ASR:11.2), prostate (ASR:10.2) and lymphoma (ASR:7) and in females, breast (ASR:36), thyroid (ASR:13.4), cervix-uteri (ASR:7.3), ovary (ASR:7) and colo-rectum (ASR:7). Nationally, the highest CRs for breast, prostate, colo-rectum, corpus-uteri and urinary bladder cancers and low incidence of cervix-uteri cancer were observed in Trivandrum. Conclusion: Cancer incidence (CR) in Trivandrum was the highest in both genders in India (except Aizwal). This is mainly due to the highest lifeexpectancy in Kerala. Also, an epidemiologic transition in cancer pattern is taking place and is changing to more similar to “western” jurisdictions.

Cancer Survival Estimates Due to Non-Uniform Loss to Follow-Up and Non-Proportional Hazards

Background: Cancer survival depends on loss to follow-up (LFU) and non-proportional hazards (non-PH). If LFU is high, survival will be over-estimated. If hazard is non-PH, rank tests will provide biased inference and Cox-model will provide biased hazard-ratio. We assessed the bias due to LFU and non-PH factor in cancer survival and provided alternate methods for unbiased inference and hazard-ratio. Materials and Methods: Kaplan-Meier survival were plotted using a realistic breast cancer (BC) data-set, with >40%, 5-year LFU and compared it using another BC data-set with <15%, 5-year LFU to assess the bias in survival due to high LFU. Age at diagnosis of the latter data set was used to illustrate the bias due to a non-PH factor. Log-rank test was employed to assess the bias in p-value and Cox-model was used to assess the bias in hazard-ratio for the non-PH factor. Schoenfeld statistic was used to test the non-PH of age. For the non-PH factor, we employed Renyi statistic for inference and time dependent Cox-model for hazard-ratio. Results: Five-year BC survival was 69% (SE: 1.1%) vs. 90% (SE: 0.7%) for data with low vs. high LFU respectively. Age (<45, 46-54 & >54 years) was a non-PH factor (p-value: 0.036). However, survival by age was significant (log-rank p-value: 0.026), but not significant using Renyi statistic (p=0.067). Hazard ratio (HR) for age using Cox-model was 1.012 (95%CI: 1.004 -1.019) and the same using time-dependent Cox-model was in the other direction (HR: 0.997; 95% CI: 0.997- 0.998). Conclusion: Over-estimated survival was observed for cancer with high LFU. Log-rank statistic and Cox-model provided biased results for non-PH factor. For data with non-PH factors, Renyi statistic and time dependent Cox-model can be used as alternate methods to obtain unbiased inference and estimates.

Saxagliptin co-therapy in C-peptide negative Type 1 diabetes does not improve counter-regulatory responses to hypoglycaemia

AIMS

To test the hypothesis that dipeptidyl peptidase-4 inhibition in C-peptide negative Type 1 diabetes would reduce glucose variability and exposure to hypoglycaemia and therefore may indirectly enhance counter-regulatory responses to subsequent hypoglycaemia.

METHODS

We conducted a 12-week double-blind, randomized, placebo-controlled crossover study. The study was conducted in a tertiary hospital outpatient clinic, with additional studies performed in a clinical research centre. After obtaining informed consent, we recruited 14 subjects with moderately well controlled Type 1 diabetes (HbA1c 64 ± 2 mmol/mol) of long duration (20.5 ± 2.7 years). The subjects received 12 weeks' therapy with oral saxagliptin (5 mg) or placebo. Glucose variability, assessed via continuous glucose monitoring, together with frequency of hypoglycaemia, hypoglycaemia awareness and symptomatic, cognitive and counter-regulatory hormone responses to experimental hypoglycaemia, were assessed. Additional outcome measures included HbA1c level, weight, total daily insulin dose and adverse events.

RESULTS

Saxagliptin co-therapy did not reduce glucose variability (low blood glucose index, average daily risk range), hypoglycaemia frequency or awareness and did not improve counter-regulatory hormonal responses during experimental hypoglycaemia (area under the curve for adrenaline 25 775 vs. 24 454, for placebo vs saxagliptin, respectively; P = 0.76).

CONCLUSIONS

No additional benefit of dipeptidyl peptidase-4 inhibition co-therapy with saxagliptin in the management of Type 1 diabetes was observed.

Evaluation of stapled closure following laryngectomy for carcinoma larynx in an Indian tertiary cancer centre

BACKGROUND AND AIM

Stapling devices are used for pharyngeal closure after laryngectomy for the past few decades although it has not gained wide acceptance. This study is aimed at evaluating the role of stapler in pharyngeal closure after laryngectomy.

METHODS

Thirty consecutive patients who underwent stapled laryngectomy at our institution from October 2004 to February 2008 were evaluated retrospectively. Linear stapler (Proximate TX 60; Ethicon Inc.) was used for closure of neopharynx.

RESULTS

There were 28 males and 2 females with mean age of 54.5 years (54.5 ± 11.2). Nineteen of these patients (63.3%) had salvage laryngectomy and two patients (6.7%) had laryngectomy for a second primary tumor. Twenty-eight patients had total laryngectomy (TL), whereas two had extended TL. Eight patients had salivary leak (26.7%). Of these, 6 (75%) had prior radiation. All salivary leaks except one were managed conservatively. Follow-up ranged from 7 to 54 months (median: 21 months). Seven patients (23.3%) developed recurrence, six at the stoma, of which 5 (83.3%) had initial extension of disease to the subglottis. Four-year disease-free survival was 54.4%.

CONCLUSION

Pharyngeal closure by linear stapler is an efficient and safe method of fashioning the neopharynx after laryngectomy with no added risk of occurrence of pharyngocutaneous fistula in primary and salvage laryngectomies.

Temporal Trends and Future Prediction of Breast Cancer Incidence Across Age Groups in Trivandrum, South India

BACKGROUND

Increasing breast cancer (BC) incidence rates have been reported from India; causal factors for this increased incidence are not understood and diagnosis is mostly in advanced stages. Trivandrum exhibits the highest BC incidence rates in India. This study aimed to estimate trends in incidence by age from 2005- 2014, to predict rates through 2020 and to assess the stage at diagnosis of BC in Trivandrum.

MATERIALS AND METHODS

BC cases were obtained from the Population Based Cancer Registry, Trivandrum. Distribution of stage at diagnosis and incidence rates of BC [Age-specific (ASpR), crude (CR) and age-standardized (ASR)] are described and employed with a joinpoint regression model to estimate average annual percent changes (AAPC) and a Bayesian model to estimate predictive rates.

RESULTS

BC accounts for 31% (2681/8737) of all female cancers in Trivandrum. Thirty-five percent (944/2681) are <50 years of age and only 9% present with stage I disease. Average age increased from 53 to 56.4 years (p=0.0001), CR (per 105 women) increased from 39 (ASR: 35.2) to 55.4 (ASR: 43.4), AAPC for CR was 5.0 (p=0.001) and ASR was 3.1 (p=0.001). Rates increased from 50 years. Predicted ASpR is 174 in 50-59 years, 231 in > 60 years and overall CR is 80 (ASR: 57) for 2019- 20.

CONCLUSIONS

BC, mostly diagnosed in advanced stages, is rising rapidly in South India with large increases likely in the future; particularly among post-menopausal women. This increase might be due to aging and/or changes in lifestyle factors. Reasons for the increased incidence and late stage diagnosis need to be studied.

Utility of fine needle aspiration cytology in evaluation of lymphadenopathy - An audit from a Cancer Centre in South India

BACKGROUND

Cytological evaluation and diagnosis of lymphadenopathy plays an important role in distinction between reactive hyperplasia and malignancy.Being a tertiary cancer care centre, lymph node enlargement clinically suspected to be due to malignancy constitute the commonest indication for fine needle aspiration cytology (FNAC) at our centre. The aim of this study was to determine the utility of FNAC in evaluating enlarged lymph nodes and to categorizethe causes of lymphadenopathy diagnosed byFNAC at our centre.

MATERIAL AND METHODS

Data was collected from the records of department of Pathology over a period of three months from January to March 2014. The data was analyzed and various parameters studied.

RESULTS

There were 2000 aspirates over a period of three months of which 270 (13.5%) were from lymph nodes. Of these, 130 cases (48.2%) have metastatic deposits.We also came across 16 cases (5.9%) of lymphoma, 5 cases (1.9%) of granulomatous lymphadenitis, 2 cases (0.7%) of suppurative lesion and 99 cases (36.7%) of reactive hyperplasia during this period. In 3 cases (1.1%), the lesion turned out to be of salivary gland origin. Aspirates were suboptimal for diagnosis in 15 cases (5.5%). Aspirates were more in males (181) as compared to females (89). The most common site of aspiration was the cervical lymph node(64.5%),followed by supraclavicular=81(30%), inguinal=33(12.22%), axillary=19(7.04%) sub mental=1(0.37%) and others=7(2.59%). Apart from metastatic carcinomas other metastatic malignancies we came across were malignant melanoma, neuroblastoma, germ cell tumor and synovial sarcoma.

CONCLUSION

FNAC of lymph nodes helps in rapid diagnosis of lymphadenopathy.Categorizingthe cause of lymph node enlargement as metastatic malignancy,lymphoma, reactive change, inflammatory cause,suppuration etc. can be done by FNAC.In patients with known histologically proven malignancy in whom a subsequent enlargement of lymph node occurs,a cytological diagnosis of metastasis helps in avoiding unwanted surgery for confirming metastasis.In patients without a previous diagnosis of malignancy, FNAC not only confirm metastatic deposit but in most conditions give a clue regarding site of primary. The use of immunocytochemistry and cell block preparations have increased the scope of FNAC.

Comparative analysis of cell morphology in sputum samples homogenized with dithiothreitol, N-acetyl-L cysteine, Cytorich(®) red preservative and in cellblock preparations to enhance the sensitivity of sputum cytology for the diagnosis of lung cancer

BACKGROUND

Lung cancer claims highest rate of cancer related mortality worldwide, mainly due to late diagnosis and distant metastasis. Sputum cytology is the simplest, non-invasive and cost effective technique but it has low sensitivity due to lack of robust processing methods to retrieve all the diagnostic materials clogged in mucus, inflammatory exudates and blood.

METHODS

This study have compared conventional pick and smear method of sputum processing with samples prepared by homogenization methods using N-acetyl-l-cysteine, Dithiothreitol (DTT), CytoRich red solution and cell blocks (CBs) with respect to screening time, quality of staining, cellularity, smear background, nuclear and cytoplasmic morphology preservation, and diagnostic efficacy. The significance of CB prepared from homogenised samples for immunocytochemistry, protein extraction, Genomic DNA and RNA extraction were also evaluated on a cohort 3,185 samples. The significance of the morphological features in each of the techniques was statistically analysed using SPSS 11 software.

RESULTS

The smear background clarity, staining quality and diagnostic efficacy of samples processed in red solution was found to be superior to the conventional method (P < 0.0001), where as samples homogenized in DTT showed a better cellularity (P < 0.0001). CBs prepared from samples homogenized in red solution were found to be very significant (P < 0.0001) in increasing the diagnostic efficacy compared to other two methods. Immunocytochemistry and DNA extraction were found possible in CBs as well as from the cell suspension. A combined analysis of smears and CBs found to improve the sensitivity of sputum cytology.

CONCLUSION

The study suggests homogenization of sputum in CytoRich ® red solution and cellblock preparations routinely for all samples to improve the sensitivity of sputum cytology. IHC and DNA extraction can be performed in sputum samples suggesting the role of sputum samples for ancillary techniques.

Role of lymphadenectomy and its impact on survival in endometrial carcinoma - an institutional experience

Pelvic and para aortic lymph nodes are the common sites of metastasis in endometrial carcinoma. The role of lymphadenectomy is widely discussed in literature with varying results. In this study we did a retrospective analysis of endometrial cancer patients to correlate lymphadenectomy with overall and disease free survival.

METHODS

A retrospective review of 110 patients with carcinoma endometrium who underwent staging laparotomy at our institute during the period 2006-2010. Patients who underwent node dissections were categorized as group I and the rest as group II. Median lymph node count was 10. Grade of the tumor, nodal status and lymphadenectomy were correlated with overall and disease free survival.

CONCLUSION

Lymph node metastasis and grade of tumor are significant predictors of survival. Lymphadenectomy did not show significant survival benefit. It has helped to upstage the disease so that appropriate adjuvant therapy could be planned. A prospective randomized control trial with complete pelvic and para aortic node dissection and uniform adjuvant therapy considering nodal status may help to answer the confusion regarding lymphadenectomy.

Effect of vitamin D supplementation on glycaemic control and insulin resistance: a systematic review and meta-analysis

AIMS

To systematically review the evidence for the effect of vitamin D supplementation on glycaemia, insulin resistance, progression to diabetes and complications of diabetes.

METHODS

Systematic review and meta-analysis. We searched databases including MEDLINE, EMBASE and the Cochrane Library for randomized controlled trials comparing vitamin D or analogues with placebo. We extracted data on fasting glucose, glycaemic control, insulin resistance, insulin/C-peptide levels, micro- and macrovascular outcomes and progression from non-diabetes to diabetes. Studies were assessed independently by two reviewers according to a pre-specified protocol.

RESULTS

Fifteen trials were included in the systematic review. Trial reporting was of moderate, variable quality. Combining all studies, no significant improvement was seen in fasting glucose, HbA(1c) or insulin resistance in those treated with vitamin D compared with placebo. For patients with diabetes or impaired glucose tolerance, meta-analysis showed a small effect on fasting glucose (-0.32 mmol/l, 95%CI -0.57 to -0.07) and a small improvement in insulin resistance (standard mean difference -0.25, 95%CI -0.48 to -0.03). No effect was seen on glycated haemoglobin in patients with diabetes and no differences were seen for any outcome in patients with normal fasting glucose. Insufficient data were available to draw conclusions regarding micro- or macrovascular events; two trials failed to show a reduction in new cases of diabetes in patients treated with vitamin D.

CONCLUSIONS

There is currently insufficient evidence of beneficial effect to recommend vitamin D supplementation as a means of improving glycaemia or insulin resistance in patients with diabetes, normal fasting glucose or impaired glucose tolerance.

Comparison of esophagectomy with and without thoracotomy in a low-resource tertiary care center in a developing country

Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60-480 min), which was more than that of open group surgery whose average duration was 261.96 min (60-360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200-500 mL) in minimally invasive group compared with 312.50 (200-500 mL) in open group (P-value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4-24) days in MIS group compared with 12.19 (5-24) days in open group (P-value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P-value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0-19) nodes were removed in MIS group compared with an average of 7.26 (0-12) nodes in open group (P-value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve.

Comparative evaluation of ASA classification and ACE-27 index as morbidity scoring systems in oncosurgeries

The primary intention of the study was to find out whether Adult Comorbidity Evaluation Index (ACE-27) was better than the American Society of Anaesthesiologists’ (ASA) risk classification system in predicting postoperative morbidity in head and neck oncosurgery. Another goal was to identify other risk factors for complications which are not included in these indexes. Univariate and multivariate analyses were performed on 250 patients to determine the impact of seven variables on morbidity-ACE-27 grade, ASA class, age, sex, duration of anaesthesia, chemotherapy and radiotherapy. In univariate analysis ACE-27 index, ASA score, duration of anaesthesia, radiotherapy and chemotherapy were significant. As both comorbidity scales were significant in univariate analysis they were analyzed together and separately in multivariate analysis to illustrate their individual strength. In the first multivariate analysis (excluding ACE-27 grade) ASA class, duration of anaesthesia, radiotherapy and chemotherapy were significant. The positive predictive value (PPV) of this model to predict morbidity was 60.86% and negative predictive value (NPV) was 77.9%. The sensitivity was 75% and specificity 62.2%. In the second multivariate analysis (excluding ASA class) ACE-27 grade, duration of anaesthesia and radiotherapy were significant. The PPV of this model to predict morbidity was 62.1% and NPV was 76.5%. The sensitivity was 61.6% and specificity 70.9%. In the third multivariate analysis which included both ACE-27 grade and ASA class only ASA class, duration of anaesthesia, radiotherapy and chemotherapy remained significant. In conclusion, ACE-27 grade and ASA class were reliable predictors of major complications but ASA class had more impact on complications than ACE-27 grade.

Disability adjusted life years for cancer patients in India

The disability adjusted life year (DALY) has been employed to quantify the burden of diseases. This measure allows for combining in a single indicator "years of life lived with disabilities (YLD)" and "years of life lost from premature death (YLL)" . The present communication attempts to estimate the burden of cancers in-terms of YLL, YLD and DALY for "all sites" and leading sites of cancer in India for the years 2001, 2006, 2011 and 2016. The YLL, YLD and DALY were estimated by employing Global Burden of Disease (GBD) methodology using the DISMOD procedure. The published data on age, gender and site specific cancer incidence and mortality for the years 2001-2003 relating to six population-based cancer registries viz. Bangalore, Barshi, Bhopal, Chennai, Delhi and Mumbai, expectation of life by gender for urban areas of the country for 1999-2003 and the projected population during years 2001, 2006, 2011 and 2016 were utilized for the computations. DALYs were found to be lower for males (2,038,553, 2,313,843, 2,656,693 and 3,021,708 for 2001, 2006, 2011 and 2016 respectively) as compared to females (2,560,423, 2,961,218, 3,403,176 and 3,882,649). Amongst males, highest DALYs were contributed by cancer of the lung and esophagus while in females they were for cancers of breast and cervix uteri. It is estimated that total DALYs due to cancer in India combined for both genders would increase from 4,598,976 in 2001 to 6,904,358 by 2016. Premature mortality is a major contributor to disease burden. According to the present estimates, the YLL component of DALY is about 70.0%. The above described computations reveal an urgent need for initiating primary and secondary prevention measures for control of cancers.

Pesticides and breast cancer risk: a comparison between developed and developing countries

BACKGROUND

A large number of studies in Europe and US find little or no association between pesticides and breast cancer, adding to the increasingly dominant view that pesticides are not causally related to breast cancer. We investigated whether there are any differences in the levels of pesticides like dichlorodiphenyltrichloroethane (DDT), dichlorodiphenyldichloroethylene (DDE), polychlorinated biphenyls (PCB), hexachlorobenzene (HCB) and hexachlorocyclohexane (HCH) and their effect for the development of breast cancer between developed and developing countries.

METHODS

A pubmed search for literature on pesticides, organochlorines, organophosphates and breast cancer risk from 1990 through 2009 was carried out.

RESULTS

The level of pesticide exposure is higher in developing world than the developed world. DDT is found to be positively associated with breast cancer risk. Results for other pesticides are equivocal. There is a dearth of studies in developing countries, which cannot be made up for generalizing the results from developed countries to the developing and third world.

CONCLUSIONS

More studies are needed in the developing and third world countries, investigating the relation between pesticides and breast cancer risk as the sheer amount of pesticides being relentlessly used in these countries due to lack of proper government regulations.

Patient and disease related factors associated with lost-to follow-up/drop-outs of cervical cancer patients: a study at a Major Cancer Hospital in South India

OBJECTIVE

Cervical cancer is the one of most common cancer in India, and a significant proportion of patients do not complete the prescribed courses of treatment and post therapy surveillance, due to deficiencies in treatment availability, accessibility, affordability and other socio-demographic factors.

MATERIALS AND METHODS

Cervical cancer patient data for the year 2006-2007 were collected during June-August, 2008 from the Regional Cancer Centre (RCC), Thiruvananthapuram, Kerala, India and investigated for socio-economic, demographic and disease (SEDD) related factors impacting patients to drop-out during treatment and patients to loss to follow-up (LFU) post therapy. Odds ratio (OR) for drop-out and LFU and their 95% confidence intervals (CIs) according to SEDD factors were estimated through logistic regression model.

RESULTS

Among a total of 784 patients, 94 (12%) did not complete the initially planned treatment and among 690 cases who had completed the initially planned treatment, 34% were lost to follow up (LFU). In the multivariate analysis, higher chances of LFU for older patients (OR=1.8; 95% CI: 1.1-3.1), widowed/divorced/separated/unmarried (OR=1.5; 95%CI: 1.0-2.1), middle school education (OR=1.8; 95% CI: 1.0-3.1), poorer performance status (OR=2.4; 95% CI: 1.2-5.0) and in higher stages (OR= 4.6; 95% CI: 2.1- 10.3). Higher chances of drop-outs were noted for patients with medium income (OR=2.0; 95% CI: 1.0-4.1), higher stages (OR=4.8; 95% CI: 1.9-12.2) and ischemic heart disease (OR=3.4; 95% CI: 1.1-10.9).

CONCLUSION

Drop-out rates are associated with disease related factors and patients in the LFU group were affected mainly by SEDD factors. Physicians should be aware of patients' different needs in these two different phases, thus improving the retention rate in the near future of cancer treatment.

Trends in incidence and mortality rates of squamous cell carcinoma and adenocarcinoma of cervix--worldwide

The objective of the present paper is to summarize and quantify the trends in incidence and mortality rates of cervical squamous cell carcinoma (SCC) and adenocarcinoma (AC) worldwide. All indexed publications, which provided information on time trends in incidence or mortality rates of cervix cancer, published during the past 12 years were included. The details of studies have been identified through searches on the MEDLINE database. Cytology screening as well as changes in socio-economic profile have led to declines in cervical SCC incidence and mortality rates worldwide. Higher percentage decline in SCC is observed in countries where organized screening programmes are available. The results suggested that Pap smear screening has played a significant role in the reduction in SCC in the US, Canada, New South Wales, and in almost all European countries (except in Ireland) as well as in some of the Asian countries. Increasing incidence and mortality rates of cervical AC has reported in many countries such as the US, Canada, UK, Iceland, Sweden, England, Spain, Finland, Slovakia, Slovenia, the Netherlands particularly among young women. However the increase was mainly in earlier periods till 1995 and stable or declining trends in cervical AC have been observed in later periods in many of the above countries such as the US, UK, Canada, Sweden. The increasing risk of AC suggested a major role for an increasing prevalence of persistent oncogenic HPV infection and its cofactors, whereas the down-turn in period effects in several countries during the 1990 s provided evidence that cytology screening is detecting more preinvasive ACs than in previous decades and suggested that screening might be starting to have a protective impact on AC. The decline in AC incidence might be due to improved specimen collection as well as due to increased awareness of AC precursors among cytopathologists and clinicians, improvements in laboratory training and quality assurance. In conclusion, cytology screening in combination with HPV screening for high-risk HPV types may maximize the possibilities of having early cervical lesions detected and treated.

Obesity and kidney cancer risk in women: a meta-analysis (1992-2008)

We conducted a quantitative summary analysis to assess whether obesity carries higher relative risk in women than men. The studies included in this quantitative review were all cohort and case-control studies, which provided information on kidney cancer risk associated with obesity/overweight, published between 1992 and 2008. The details of studies have been identified through searches on the MEDLINE database. We first estimated the risk associated with a unit increase in BMI (1 kg/m(2)) for individual studies using logit-linear model. After deriving the natural logarithm of the risk per unit of BMI for all studies, we calculated a pooled estimate and corresponding 95% confidence interval (CI) as a weighted average of the risk values obtained in individual studies, by giving a weight proportional to its precision. A total of 28 studies (15 cohort studies and 13 case-control studies) provided kidney cancer risk according to BMI in women. The relative risks (RR), which showed statistical significance, ranged from 1.04 to 1.12 per unit increase in BMI in various cohort studies. The pooled risk was 1.06 (95% CI=1.05-1.07) per unit increase in BMI based on cohort studies. Among all the studies, which reported association in both men and women, the pooled risk was slightly higher in women. In conclusion, the present analysis reported slightly a higher kidney cancer risk due to obesity in women than men. Increasing prevalence of obesity with higher proportion among women may be responsible for the rising incidence rates in women.

Urinary bladder cancer risk among motor vehicle drivers: a meta-analysis of the evidence, 1977-2008

BACKGROUND

The aim of the study was to summarize bladder cancer risk in motor vehicle drivers and railroad workers using meta-analysis techniques.

METHODS

We retrieved all published results (3 cohort studies and 27 case-control studies) during 1977-2008. We assessed the heterogeneity of the results assuming a fixed-effect model. For cohort studies, the observed and the expected number of cases were added, respectively, to yield pooled observed/expected ratio. For case-control studies, we calculated pooled odds ratio (OR) and corresponding 95% confidence interval (CI) as a weighted average of the ORs in each study, by giving a weight proportional to the inverse of the variance of the ORs.

RESULTS

No overall meta-analysis was performed because of heterogeneity in results. The overall pooled risk among motor vehicle and railroad workers based on all cohort studies was 1.08 (95%: 1.00-1.17). The overall pooled risk among truck drivers was 1.18 (95% CI: 1.09-1.28 based on 18 case-control studies). The stratified analysis by year of publication indicated that pooled risk among truck drivers was 1.20 (95% CI: 1.00-1.40) for the period 1998-2008. The corresponding risk for the period 1977-1987 was 1.30 (95%: 1.16-1.46). The overall pooled risk among bus drivers was 1.23 (95% CI: 1.06-1.44 based on 10 case-control studies). The pooled risk among bus drivers was 1.21 (95% CI: 0.72-2.01) for the period 1998-2008 and the corresponding risk for the period 1977-1987 was 1.30 (95%CI: 1.10-1.53). The pooled risk among railroad workers was 1.20 (95% CI: 1.02-1.41 based on 15 case-control studies). Stratified analysis by year of publication was not statistically significant among railroad workers.

CONCLUSION

The pooled analysis suggested an increased bladder cancer risk among motor vehicle drivers and railroad workers. However, the risk among these workers is reduced in recent publications compared to the earlier publications.

Obesity and kidney cancer risk in men: a meta-analysis (1992-2008)

We conducted a quantitative summary analysis to evaluate the recent evidence of kidney cancer risk according to body mass index (BMI) among men. The studies included in this quantitative review were all cohort and case-control studies, which provided information on kidney cancer risk associated with obesity/overweight, published between 1992 and 2008. The details of studies have been identified through searches on the MEDLINE database. We first estimated the risk associated with a unit increase in BMI (1 kg/m(2)) for individual studies using logit-linear model. After deriving the natural logarithm of the risk per unit of BMI for all studies, we calculated a pooled estimate and corresponding 95% confidence interval (CI) as a weighted average of the risk obtained in individual studies, by giving a weight proportional to its precision. A total of 27 studies (13 cohort studies and 14 case-control studies) that provided kidney cancer risk according to BMI in men were included in the present analysis. The strength of association was almost similar in most of the cohort studies (relative risk (RR) ranged from 1.04-1.06 per unit increase in BMI) and in one study RR was 1.08. There was no heterogeneity across studies (p-value= 0.164). The pooled risk was 1.05 (95% CI= 1.04-1.06) per unit increase in BMI based on the cohort studies. The present analysis confirmed the evidence of kidney cancer risk with increased BMI in men and obesity may be responsible at least in part for the rising incidence rates.

In vitro multiplication ofVanilla planifolia using axillary bud explants

A clonal propagation method has been developed for efficient multiplication ofVanilla planifolia. Multiple shoots were developed from axillary bud explants using semi-solid Murashige and Skoog (MS) medium supplemented with N⁶-benzyladenine (BA, 2 mg l^-1) and α-naphthaleneacetic acid (NAA, 1 mg l^-1). The multiple shoots were transferred to agitated liquid MS medium with BA at 1 mg l^-1 and NAA at 0.5 mg l^-1 for 2-3 weeks, and subsequently cultured on semi-solid medium. Using this method, an average of 42 shoots were obtained from a single axillary bud explant over a period of 134 days. Use of an intervening liquid medium has been found to enhance multiplication of shoots inV. planifolia.

Clonal multiplication of Gardenia jasminoides Ellis through axillary bud culture

An efficient clonal multiplication system was developed for in vitro propagation of crocin - producing Gardenia jasminoides Ellis plants. Murashige and Skoog's (MS) medium containing 6-benzylaminopurine (BAP 1 mg l(-1)) and indole-3-butyric acid (IBA 1 mg l(-1)) resulted in multiple shoot initiation at the rate of 21 shoots per explant in 60 d of culture. Transfer of the microshoots into liquid MS medium supplemented with BAP (5 mg l(-1)) with two subcultures of 15 d duration in the same medium resulted in 400 ± 25 shoots per explant. Efficient rooting was achieved in MS medium supplemented with α-naphthaleneacetic acid (5 mg l(-1)). The in vitro raised plants were hardened in a greenhouse and transplanted to the field successfully. The method described will be useful for rapid multiplication of Gardenia for commercial exploitation.