Rising Thyroid Cancer Incidence in Southern India: An Epidemic of Overdiagnosis?

Global burden of thyroid cancer among adolescents and young adults, 1990-2021, and projections to 2050: an analysis based on the GBD 2021

Objective

To evaluate the global burden of thyroid cancer (TC) among adolescents and young adults (AYA) aged 15-39 years from 1990 to 2021, with projections to 2050, and identify demographic and regional disparities.

Methods

Using Global Burden of Disease (GBD) 2021 data, we analyzed incidence, prevalence, mortality, and disability-adjusted life years (DALYs) across 204 countries. Time-series projections to 2050 were generated using autoregressive integrated moving average (ARIMA) models.

Results

Global thyroid cancer incidence among AYA increased by 150% from 19,268 cases in 1990 to 48,203 in 2021, with persistent gender disparities: females exhibited a 2021 incidence rate of 2.38 per 100,000, threefold higher than males (0.88 per 100,000). Regional analysis revealed the highest burden in the Middle East and North Africa (2.49 per 100,000 in 2021). Projections indicate that by 2050, global prevalence will reach 103.62 per million, accompanied by an incidence rate of 11.41 per 100,000 and a DALYs burden of 34.41 per million, reflecting an 18% increase from 2021. Mortality rates show a modest rise from 0.37 per million in 1990 to a projected 0.42 per million in 2050. Socioeconomic disparities are pronounced: lower-Sociodemographic Index (SDI) regions face a projected 23% incidence increase by 2050, contrasting with a 12% decline in high-SDI regions, highlighting widening healthcare inequities.

Conclusion

The growing burden of thyroid cancer among AYA populations demonstrates critical gender and geographic disparities, disproportionately affecting females and lower-resource regions. Mitigation requires enhanced early detection protocols, optimized treatment pathways, and targeted resource allocation to vulnerable populations.

Unifocal Conventional Papillary Thyroid Carcinoma with Coexisting Caseating Granulomatous Inflammation in India

Thyroid cancer remains one of the leading endocrine malignancies with Conventional Papillary Thyroid Carcinoma (CVPTC) being the most commonly reported cancer. Caseating granulomatous inflammation is an unusual presentation in the thyroid even in places with high incidence of tuberculosis. The association of CVPTC with caseating granulomatous inflammation is infrequent. It can occur as a result of chronic inflammation which subsequently leads to DNA damage by producing nitric oxide and reactive oxygen species resulting in carcinogenesis. Other than tuberculosis, necrotizing granulomas in the thyroid can also be found in association with fungal diseases, plasma cell granulomas and palpation thyroiditis. We report a case of a 46-year-old lady who presented with neck swelling and dysphagia. Examination of the neck showed a firm, non-tender swelling involving the right lobe of the thyroid that moved with deglutination. The thyroid profile was normal. Ultrasound neck revealed a solitary nodule in the right lobe of the thyroid with heterogeneous architecture and increased vascularity. Fine needle aspiration (FNA) suggested Nodular colloid goitre (Bethesda Category II). Intraoperatively, the gland was stony hard and was found adherent to the underlying muscles with no obvious lymphadenopathy. A gross examination of the right hemithyroidectomy specimen revealed a single nodule with the cavity filled with multiple grey-white papillary excrescences along with an adjacent cystic cavity filled with colloid. Histopathological examination was suggestive of unifocal conventional papillary thyroid carcinoma with surrounding caseating granulomatous inflammation involving the right lobe of the thyroid (pT2 Nx Mx). CVPTC with coexisting caseating granulomatous inflammation is a rare presentation. The exact pathology of caseating granulomatous inflammation in our case is unknown. However, chronic inflammation might have played a role in tumorigenesis.

Incidence of Cancers in Kerala, India: A Review of Population-Based Registry Data

PURPOSE

Kerala in India leads the nation in both Human Development Index and Sustainable Development Index. The state is a harbinger for the rest of the country in matters of health. Documentation of cancer trends and quantifying the cancer burden is crucial for planning oncology services in the country. In this study, we aim to perform a time series analysis using data from the National Cancer Registry.

METHODS

Data for crude incidence, age-adjusted incidence, and disease-specific incidence were extracted from published reports of the Population-Based Cancer registries at Kollam and Thiruvananthapuram. Data collected between 2006 and 2008 were analyzed and published in 2010. Data collected between 2012 and 2016 were published in 2020. Descriptive statistics was used for analysis.

RESULTS

Age-adjusted incidence rates increased from 121.7 per 100,000 men to 137.8 in Thiruvananthapuram from 2006-2008 to 2012-2016 period. Among women, in Thiruvananthapuram, the age-adjusted rates increased from 108.3 to 127.3. In Kollam, the age-adjusted incidence rate increased from 113.3 to 127.1 among men and 89.7 to 107.1 among women. Lung and breast cancers remain the most common cancers among men and women.

CONCLUSION

There has been an increase in both crude and age-adjusted incidence rates in Kerala. However, these changes are in line with global trends in cancer incidence. Lifestyle changes and reduced tobacco and alcohol use will help decrease the incidence of cancer in Kerala.

Evaluating the Diagnostic Role of ACR-TIRADS and Bethesda Classifications in Thyroid Nodules Highlighted by Cyto-Histopathological Studies

OBJECTIVE

To evaluate the accuracy of thyroid imaging reporting and data system (ACR-TIRADS) and the Bethesda system for reporting cytopathology (TBSRCP) classifications for identifying or ruling out thyroid malignancy in relation to the gold standard (post-surgical pathology).

METHODS

This cross-sectional study included 573 patients with single or multiple thyroid nodules. Patients were evaluated using the TIRADS and the TBSRCP classification. The data from a cohort of patients who underwent surgery (77/573, 13.4%) were correlated with post-operative pathology and the relevant clinical features of the patients.

RESULTS

Of 573 patients, 545 (95.1%) were euthyroid, 24 (4.1%) were hypothyroid, and 4 (0.8%) were hyperthyroid; 419 (73.1%) had benign nodules (Bethesda II), 115 (20.1%) had intermediate (Bethesda III, IV), and 39 (6.8%) had Bethesda V and VI nodules. Four-hundred twenty (73.3%) patients were categorized as TIRADS 2,3, and 153 (26.7%) were categorized as TIRADS 4,5. The Bethesda and TIRADS classifications concorded significantly in thyroid nodule diagnosis (K=14.9%, P<0.001).Thyroid malignancy was significantly associated with microcalcification and interrupted halo, while benign nodules were significantly associated with macrocalcification and complete halo type (P=0.041, P=0.005, respectively). The TBSRCP could significantly detect malignant thyroid nodules with a sensitivity, specificity, PPV, and NPV of 64.1%, 98.1%, 85.0%, and 94.1%, respectively (K=88.2%, P<0.001), while the respective values for the TIRADS classification were 63.5%, 76.0%, 84.6%, and 50.0% (K=34.8%, P=0.001).

CONCLUSION

The TIRADS and TBSRCP are essential primary steps for evaluating thyroid nodules and both are complimentary. Hence, each patient with thyroid nodules should be evaluated by both approaches before opting for surgery. Highly suspicious TIRADS categories TR4 and TR5 need further evaluation by fine needle aspiration cytology.

Role of Genetic Testing in the Management of Indeterminate Thyroid Nodules in the Indian Setting

The increased detection of thyroid nodules in the human population has led to an increase in the number of thyroid surgeries without an improvement in survival outcomes. Though the choice for surgery is straightforward in malignant thyroid nodules, the decision is far more complex in those nodules that get categorized into indeterminate thyroid nodules (ITN) by fine needle aspiration. Therefore, there is a pressing need to develop a tool that will aid in decision-making among the ITN. In this context, the development of various molecular testing (MT) panels has helped to confirm or rule out malignancy, reducing unnecessary surgeries and potentially guiding the extent of surgery as well. Currently, such tests are widely used among the Western population but these MT panels are not used by the South Asian population because of non-availability of validated panels and the high cost involved. There is a need to develop a suitable panel which is population-specific and validate the same. In this review, we would focus on current trends in the management of ITN among the South Asian population and how to develop a novel MT panel which is cost-effective, with high diagnostic accuracy obviating the need for expensive panels that already exist.

A long-term retrospective cohort-based risk-benefit analysis of augmenting total cumulative I-131 activity to 37GBq in differentiated thyroid cancer patients with skeletal metastases

OBJECTIVE

Skeletal metastases in differentiated thyroid cancer (DTC) patients are associated with poor prognosis. The objective was to determine the maximum I-131 cumulative activity that could be safely administered without compromising efficacy. The secondary objective was to identify other prognostic factors affecting survival outcomes.

MATERIALS AND METHODS

This was a retrospective cohort study done at a tertiary-care institution comprising of data from January 1990-June 2020. 489 DTC patients having skeletal metastases with ≥12 months follow-up were included. Ninety-six percent of patients had thyroidectomy followed by radioiodine therapy for skeletal metastases. All patients were on oral suppressive levothyroxine tablets. External beam radiotherapy (EBRT) and oral tyrosine kinase inhibitors were used whenever indicated. The main outcome measures were overall survival (OS), progression-free survival (PFS), and adverse-events.

RESULTS

There were 347 (71%) females and 324 (66%) had follicular carcinoma thyroid. Median follow-up was 78 (interquartile range, IQR: 37-153) months. 333 patients (68%) received ≤37GBq I-131 cumulative activity (group 1) and 156 patients (32%) received >37GBq cumulative RAI activity (group 2). Overall median OS and PFS were 74 (95% confidence interval (CI): 62.2-85.8) and 48 (95%CI: 40.5-55.4) months, respectively. The 5-, 10-, 15- and 20-year estimated overall survival probabilities were 55.7%, 28.4%, 14% and 8.3%, respectively. On multivariate analysis, age(<55years) (p<0.001), female gender(p = 0.01), cumulative I-131 activity >37GBq (p<0.001) and EBRT(p = 0.001) were favourably associated with OS; no factors were significantly associated with PFS. The median OS for groups 1 & 2 were 51 versus 90 months (p<0.001) & median PFS for groups 1 & 2 were 45 versus 53 months respectively (p = 0.9). However, cumulative activity >37GBq resulted in more adverse events (2.4%), particularly bone marrow suppression (3.5%).

CONCLUSION

For better survival outcomes, cumulative I-131 activity upto 37GBq could be administered with acceptable toxicity to DTC patients with skeletal metastases.

Proportion of papillary thyroid microcarcinoma in Kerala, India, over a decade: a retrospective cohort study

Background

Overdiagnosis is a phenomenon where an indolent cancer is diagnosed that otherwise would not have caused harm to the patient during their lifetime. The rising incidence of papillary thyroid cancer (PTC) in various regions of the world is attributed to overdiagnosis. In such regions, the rates of papillary thyroid microcarcinoma (PTMC) are also rising. We aimed to study whether a similar pattern of rising PTMC is found in Kerala, a state in India, where there has been a doubling of thyroid cancer incidence over a decade.

Methods

We conducted a retrospective cohort study in two large government medical colleges, which are tertiary referral facilities in the state of Kerala. We collected data on the PTC diagnosis in Kozhikode and Thrissur Government Medical colleges from 2010 to 2020. We analysed our data by age, gender and tumor size.

Results

The incidence of PTC at Kozhikode and Thrissur Government Medical colleges nearly doubled from 2010 to 2020. The overall proportion of PTMC in these specimens was 18.9%. The proportion of PTMC only marginally increased from 14.7 to 17.9 during the period. Of the total incidence of microcarcinomas, 64% were reported in individuals less than 45 years of age.

Conclusion

The rise in the number of PTCs diagnosed in the government-run public healthcare centres in Kerala state in India is unlikely to be due to overdiagnosis since there was no disproportionate rise in rates of PTMCs. The patients that these hospitals cater to may be less likely to show healthcare-seeking behavior or ease of healthcare access which is closely associated with the problem of overdiagnosis.

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.

Correlation of TIRADS and Bethesda Scoring Systems with Final Histopathology of Thyroid Nodules - An Institutional Experience

Fine needle aspiration cytology (FNAC) reduces the number of unnecessary thyroid surgeries for patients with benign nodules and appropriately triages patients with thyroid cancer to appropriate treatment. This was a observational study done on cases presenting with clinical suspicion of thyroid malignancy which underwent ultrasonography followed by FNAC of thyroid nodule. Ultrasonographic characterization of nodules was based on Thyroid Imaging Reporting and Data System (TIRADS) and cytology reporting was based on Bethesda system. All recruited patients underwent thyroidectomy. Pre-operative cytology and ultrasonography features were compared with final histopathology report. In our study, Bethesda system of cytology reporting for thyroid nodules had a better sensitivity, specificity and diagnostic accuracy than TIRADS system of ultrasound reporting. Bethesda system in FNAC had a larger area under the ROC curve (0.91) as compared to ultrasound TIRADS (0.70). Malignancy rate of TIRADS 5 nodules was 97.1% with significant p value (0.022). 100% of Bethesda VI lesions were malignant according to final histopathology report. Ultrasound TIRADS could pre-operatively predict malignancy in 63.6% of indeterminate thyroid nodules which were malignant according to post-operative histopathology. The overall concordance of ultrasound TIRADS, Bethesda system and histopathology was 69.8%. Higher TIRADS and Bethesda scoring among thyroid nodules was associated with increased risk of malignancy. US TIRADS is a good predictor of malignancy in indeterminate thyroid nodules.

Modulatory role of miRNAs in thyroid and breast cancer progression and insights into their therapeutic manipulation

Over the past few decades, thyroid cancer has become one of the most common types of endocrine cancer, contributing to an increase in prevalence. In the year 2020, there were 586,202 newly diagnosed cases of thyroid cancer around the world. This constituted approximately 3.0% of all patients diagnosed with cancer. The World Health Organization reported that there will be 2.3 million women receiving treatment for breast cancer in 2020, with 685,000. Despite the fact that carcinoma is one of the world's leading causes of death, there is still a paucity of information about its biology. MicroRNAs (miRNAs; miRs) are non-coding RNAs that can reduce gene expression by cleaving the 3' untranslated regions of mRNA. These factors make them a potential protein translation inhibitor. Diverse biological mechanisms implicated in the genesis of cancer are modulated by miRNA. The investigation of global miRNA expression in cancer showed regulatory activity through up regulation and down-regulation in several cancers, including thyroid cancer and breast cancer. In thyroid cancer, miRNA influences several cancers related signaling pathways through modulating MAPK, PI3K, and the RAS pathway. In breast cancer, the regulatory activity of miRNA was played through the cyclin protein family, protein kinases and their inhibitors, and other growth promoters or suppressors, which modulated cell proliferation and cell cycle progression. This article's goal is to discuss key miRNA expressions that are involved in the development of thyroid and breast cancer as well as their therapeutic manipulation for these two specific cancer types.

Serum TSH Level as a Simple Efficient Tool to Assess the Risk of Thyroid Malignancy in Euthyroid Patients with Indeterminate Cytology - A Cohort Study

Context

A significant number of fine-needle aspiration cytology (FNAC) for thyroid nodules is reported as indeterminate. Expensive molecular testing can give a clue to the possibility of malignancy in this group. The effectiveness of serum thyroid-stimulating hormone (TSH) levels as a diagnostic tool in euthyroid patients with indeterminate cytology has not been previously studied, especially in the Indian population.

Aims

This study was conducted to evaluate the predictive efficacy of serum TSH in the early diagnosis and treatment of malignancy.

Settings and Design

This is a retrospective cross-sectional study on a cohort of patients who presented to our department with complaints of thyroid swelling and underwent thyroidectomy.

Methods and Material

Euthyroid patients who underwent thyroid surgery for newly diagnosed thyroid nodules with FNAC reported as indeterminate cytology were included in our study. Based on the histopathological report, the patients were divided into two groups and into quartiles based on TSH values.

Statistical Analysis Used

The mean difference in the numerical variables between groups was compared using the independent two-sample 't' test for parametric data and Mann-Whitney 'u' test for non-parametric data. A logistic regression analysis was done with age, sex, TSH level and nodule size as dependant variables and malignancy as the independent variable.

Results

There were 211 patients in group A and 93 in group B. Patients with malignancy confirmed on final histopathology showed higher serum TSH levels compared to benign nodules (2.93 ± 1.067 vs 1.73 ± 1.051, P = <0.001). The mean TSH levels of all types of malignant nodules correlated with our test model (>2.185 mIU/L).

Conclusions

Serum TSH above 2.185 mIU/mL is a good predictor of malignancy in indeterminate nodules. It is an inexpensive, safe and reliable diagnostic screening test for the risk of malignancy in an indeterminate nodule.

Diagnostic utility of CK19 and galectin-3 in differentiating papillary thyroid carcinoma from nonneoplastic lesions of thyroid

Background

Thyroid neoplasm is one of the most common endocrine neoplasms. The diagnosis and the distinction between malignant and benign neoplasms can be difficult, but it has clinical, therapeutic, and prognostic significance. Hence, it is necessary to make precise diagnosis by using biomarkers.

Materials and Methods

This is a laboratory observational study considering histologically diagnosed cases of papillary thyroid carcinoma (PTC) and nonneoplastic thyroid lesions. Immunohistochemistry (IHC) staining was done on tissue sections of all cases for CK19 and galectin-3 using appropriate positive and negative controls. The expression of immunomarkers was evaluated by a semi-quantitative method as negative, weak positive, moderate positive, and strong positive. The data were entered in Microsoft Excel sheet and were analyzed using SPSS 22 version software.

Results

A total of 52 cases were considered for the study, of which 26 cases each were PTC and nonneoplastic lesions of thyroid. Among the 26 PTC cases, 6 were classical variant of PTC (CVPTC) and 20 were follicular variant of papillary thyroid carcinoma (FVPTC). Among 26 nonneoplastic cases, 13 each were nodular hyperplasia cases and lymphocytic thyroiditis. There was a statistically significant (P < 0.01) association of CK19 and galectin-3 expression between CVPTC and FVPTC. There was no statistically significant association (P = 0.271) of CK19 expression between PTC and nonneoplastic cases. There was a statistically significant association (P = 0.003) of galectin-3 expression between PTC and nonneoplastic cases.

Conclusion

Galectin-3 expression can be used to differentiate PTC from nonneoplastic lesions of thyroid in ambiguous cases. Galectin-3 and CK19 expression can be used to classify PTC into CVPTC and FVPTC.

Adolescent and young adult cancers in India-Findings from the National Cancer Registry Programme

BACKGROUND

The adolescent and young adult (AYA) age group is a bridge between pediatric and adult age groups. The present study describes the epidemiology of cancers in the AYA age group in India.

METHODS

The data of primary site cancers in the age group of 15-39 years from the 28 Population Based Cancer Registries (PBCRs') and 58 Hospital Based Cancer Registries under the National Cancer Registry Programme for the reporting year 2012-2016 was analysed.

RESULTS

The median age adjusted incidence rate (AAR) was 22.2 per 100,000 among males and 29.2 per 100,000 among females. The age-specific incidence rate increased with increasing age in both genders with the highest recorded numbers in the 35-39 age group. The proportion of myeloid leukaemia and non-Hodgkin's lymphoma was highest in the 15-24 age group. Cancers of the breast, thyroid, mouth and tongue constituted the leading sites between 30 and 39 years. There was a significant increase in the incidence among AYA males (APC=0.9) between 1985 and 2015, while a decline in incidence was observed for females, which was not significant (APC=-0.2). The majority of patients had locoregional spread of cancer at the time of diagnosis. The projected number of cancer cases in both genders are expected to increase to 178,617 in 2025.

CONCLUSION

Cancers in the AYA population are a concern in India. Since AYA oncology appears to be evolving in India, a robust health care system and suitable AYA cancer care policies and programmes are strongly needed to improve disease outcomes and survival.

Residual Thyroid Tissue on Postoperative Diagnostic 131 I Radioactive Whole-Body Scan After Surgery in Differentiated Thyroid Cancer: A Tertiary Referral Centre Experience

Residual thyroid tissue after total thyroidectomy in differentiated thyroid cancers is considered an independent risk factor for recurrence. Guidelines recommend following up patients after surgery with thyroglobulin (Tg), neck ultrasonography, and occasionally whole-body radioactive scan. However, the results of serum thyroglobulin and whole-body radioiodine scan are often discordant. The present study was undertaken to determine the levels of serum-stimulated thyroglobulin to complement the findings of residual thyroid tissue in the radioactive whole-body scan. One hundred twenty-six patients had undergone a radioiodine (¹³¹ I) whole-body scan (WBS) during the study duration, and 121 were available for analysis. The thyroglobulin level (measured by the CLIA method) was recorded at the time of these scans. The data was analysed to determine the level of stimulated thyroglobulin correlating with residual thyroid tissue, locoregional, and distant metastasis as assessed by WBS. The presence of residual thyroid tissue was noted in an overwhelmingly high 94% of cases. Twenty-four of the 28 patients with stimulated Tg < 2 ng/dl had residual thyroid tissue on a WBS. The discordancy rate (positive moderate - large WBS and negative serum thyroglobulin) of 64.28% was seen. Using ROC the serum thyroglobulin cut-offs levels for the loco-regional disease were found to be 27.705 ng/dl and 94.770 ng/dl for distant metastasis. The results highlight the fact that serum Tg levels cannot be used as an accurate predictor of the extent of the remnant thyroid tissue. Irrespective of the quality of surgery, which was analysed based on the centre and surgical specialty, over 90% of cases had residual thyroid tissue on WBS. The use of only stimulated Tg levels for follow-up may be inaccurate. Serum Tg is a useful test along with radioactive whole-body scans to distinguish local disease, loco-regional disease, and distant metastasis.

Butein induces intrinsic pathway of apoptosis, vimentin proteolysis, and inhibition of cancer stem cell population in a human papillary thyroid cancer cell line

Epithelial-mesenchymal transition (EMT) and cancer stem cells (CSCs) play an essential role in metastasis of papillary thyroid cancer (PTC). Further mesenchymal marker vimentin is linked with metastasis and cancer stem cell generation. Hence, inhibition of EMT and effective elimination of CSCs offers a novel target for the development of new therapeutic agents. The present study observed that at lower concentration, butein, a major bioactive chalcone, significantly inhibits NPA (papillary thyroid cancer cell line) cell migration and reduces extracellular acidification rate (ECAR) an indicator of enhanced glycolysis, required for cell migration. Additionally, at lower concentrations, butein treatment also suppresses vimentin phosphorylation, an essential step in cell migration, proving its potential against cell migration. Phosphorylation of vimentin is crucial in the protection of vimentin from caspase-mediated proteolysis. Interestingly, butein activates caspase-3 for the apoptosis execution at higher concentration; hence, total levels of vimentin were investigated. Butein induces caspase-3 mediated proteolysis of vimentin. Vimentin and glycolysis are essential for maintaining CSCs; therefore, aldeflour assay and side population assay were performed to investigate the effect of butein on CSCs. Our data suggest butein mediates the reduction in CSCs population. Here we report a novel mechanism of butein mediated inhibition of NPA cells migration by suppressing vimentin phosphorylation and its subsequent proteolysis. Collectively our data suggest the potential of butein as an innovative anticancer therapeutic agent for PTC management.

Weakly supervised learning on unannotated hematoxylin and eosin stained slides predicts BRAF mutation in thyroid cancer with high accuracy

Deep neural networks (DNNs) that predict mutational status from H&E slides of cancers can enable inexpensive and timely precision oncology. Although expert knowledge is reliable for annotating regions informative of malignancy and other known histological patterns (strong supervision), it is unreliable for identifying regions informative of mutational status. This poses a serious impediment to obtaining higher prognostic accuracy and discovering new knowledge of pathobiology. We used a weakly supervised learning technique to train a DNN to predict BRAF V600E mutational status, determined using DNA testing, in H&E stained images of thyroid cancer tissue without regional annotations. Our discovery cohort was a tissue microarray of only 85 patients from a single hospital. Yet, on a large independent external cohort of 444 patients from other hospitals, the trained model gave an AUC = 0.98 (95% CI: 0.97-1.00), which is much higher than the previously reported results for detecting any mutation using H&E by DNNs trained using strong supervision. We also developed a visualization technique that can automatically highlight regions the DNN found most informative for predicting mutational status. Our visualization is spatially granular and highly specific in highlighting regions with strong negative and positive regions and move us towards explainable artificial intelligence. Using t-tests, we confirmed that the proportions of follicular or papillary histology and oncocytic cytology, as noted for each patient by a pathologist who was blinded to the mutational status, were significantly different between mutated and wildtype patients. However, based solely on these features noted by the pathologist, a logistic regression classifier gave an average AUC = 0.78 in 5-fold CV, which is much lower than that obtained using the DNN. These results highlight the potential of weakly supervised learning for training DNN models for problems where the informative visual patterns and their locations are not known a priori. This article is protected by copyright. All rights reserved.

Spatial clustering and meso-scale correlates of thyroid disorder among women in India: evidence from the National Family Health Survey (2015–16)

Purpose

Thyroid disorders are a major public health burden. Generally, women exhibit higher differentials in the prevalence of these disorders. This study focuses on the socio-economic and behavioural correlates of thyroid disorders along with their spatial clustering among women of reproductive age in India.

Methods

The study uses dataset from the fourth National Family Health Survey (NFHS-4) carried out in 2015–16 to assess self-reported thyroid disorders. Poor–rich ratio (PRR) and concentration index (CI) were used to study the variation in thyroid disorder among women arising out of economic inequality. Moran’s I statistics and bivariate local spatial autocorrelation (BiLISA) maps were used to understand spatial dependence and clustering of thyroid disorder. Spatial lag and error models were applied to examine the correlates of the disorder.

Results

Thyroid disorder prevalence was higher among women from socio-economically better-off households. Adjusted effects showed that users of iodized salt were 1.14 times more likely to suffer from a thyroid disorder as compared to non-users, which is contrary to the general belief that a higher percentage of consumption of iodide salt leads to a lower prevalence of thyroid disorder. A higher autoregressive coefficient (0.71) indicated significantly higher spatial clustering in thyroid disorders.

Conclusions

The prevalence of thyroid disorder in India depends appreciably on spatial and various ecological factors. Sedentary lifestyles among women may be aggravating diseases, which has strong linkage with thyroid disorders. It is strongly recommended to effectively integrate universal salt iodization with activities geared towards the elimination of iodine deficiency disorders.

Economics of cancer care: A community-based cross-sectional study in Kerala, India

Background:

The estimated incidence of cancer cases in Kerala for 2014 was 31,400 and the mortality associated with it was 13,816. Although the treatment of cancer has shown remarkable advances, it has come with increasing costs.

Objective:

The objective of this study is to estimate the economic burden of cancer in Vypin Block Panchayat at Ernakulam by analyzing the average total direct and indirect cost of cancer care, socioeconomic status, and cost of cancer care between government and private hospitals.

Materials and Methods:

A cross-sectional study was conducted for 2 months from March to April 2018. The study was conducted by utilizing an annotated cost questionnaire for completion by patients. Total direct and indirect cost was estimated. Appropriate statistical tests were used.

Results:

Direct cost for cancer care contributed 75% toward the cost of illness and the remaining was found to be indirect cost. Loss of income (44%) contributed to the largest chunk of indirect cost. The average direct cost for cancer care was found to be Rs. 25,606 and the average indirect cost was Rs. 8772. The average total cost of cancer care was calculated to be Rs. 34,378. Significant statistical variation was found between the cost of cancer care in private and government hospitals. The economic burden of cancer in this Vypin Block Panchayat was found to be Rs. 218,256,977/-

Conclusion:

The ratio of average income to average cost in this study is skewed which indicates the lack of affordability for cancer care in this population. A very large gap, therefore, exits between income levels and cost of cancer care clearly indicating a vast gap between affordability and cost of treatment, which clearly necessitates the need for a definite policy and state intervention for a mass cancer care program.

Design of Site-Specific Microwave Phased Array Hyperthermia Applicators Using 434 MHz Reduced Cavity-Backed Patch Antenna

Cancers of the neck, breast, and lower extremities are common malignancies diagnosed in India with a higher incidence of advanced-stage disease. Phased array (PA) applicators reported for hyperthermia treatment (HT) of the breast have small focal region and high cross-coupling, and those reported for lower extremities provide regional heating and limited steering. In this study, we present the numerical design of site-specific PA applicators for HT of large solid tumors in the neck, breast, and lower extremities using a miniaturized 434 MHz cavity-backed water-loaded patch antenna. The fabricated antenna has 38 × 36 mm2 aperture, more than 90% power coupling, 25 MHz bandwidth, and good agreement between simulated and measured specific absorption rate (SAR) in phantom. The site-specific applicators demonstrated less power reflection (<-17.9 dB) and cross-coupling (<-26.8 dB) for 5 mm inter-ring spacing. SAR indicators for 64 cc tumor at varying locations in simplified layered three-dimensional (3D) tissue models of the neck, breast, and leg showed average power absorption ratio (aPAratio ) ≥ 3.16, target to hotspot quotient (THQ) ≥ 0.57, 25% iso-SAR coverage (TC25 ) ≥ 81%, and 50% iso-SAR coverage (TC50 ) ≥51.8%. Simulation results of site-specific applicators for 3D inhomogeneous patient models showed aPAratio  ≥ 5.98, THQ ≥ 0.9, TC50  ≥ 86%, and 100% TC25 for all sites. It is concluded that the 434 MHz miniaturized cavity-backed patch antenna can be used to develop high-density PA applicators with 12-24 antennas for HT of large solid tumors (≥4 cm) in the neck, breast, and lower extremities with 3D steering ability and less cross-coupling (≤-26.8 dB). © 2020 Bioelectromagnetics Society.

Sex Representation in Clinical Trials Associated with FDA Cancer Drug Approvals Differs Between Solid and Hematologic Malignancies

BACKGROUND

Proportionate female representation in health research is necessary for scientific rigor and health equity. We aimed to assess the representation of women in clinical trials leading to U.S. Food and Drug Administration (FDA) cancer drug approvals.

MATERIALS AND METHODS

Trials supporting FDA cancer drug approvals between July 2008 and June 2018 were sourced from PubMed and ClinicalTrials.gov. The ratio of female to male trial enrollment was compared with cancer incidence and mortality in the U.S. using International Agency for Research on Cancer data. Reproductive tract and breast cancers were excluded. Odds ratios (ORs) and 95% confidence intervals (CIs) comparing trial enrollment with population incidence and mortality were calculated.

RESULTS

A total of 186 trials leading to 170 FDA cancer drug approvals showed slight female underrepresentation compared with overall cancer incidence in the U.S. (OR, 0.97; 95% CI, 0.95-0.98, p < .0001). Female enrollment for drugs approved between 2008-2013 and 2014-2018 was unchanged (OR, 1.02; 95% CI, 0.99-1.05, p = .25). There was slight female underrepresentation in hematological trials (OR, 0.95; 95% CI, 0.91-0.998; p = .040 for leukemia; OR, 0.95; 95% CI, 0.90-0.997; p = .040 for lymphoma) and significant female underrepresentation in colorectal (OR, 0.72; 95% CI, 0.69-0.76; p < .0001), pancreas (OR, 0.85; 95% CI, 0.78-0.93; p = .0004), lung (OR, 0.77; 95% CI, 0.75-0.80; p < .0001), kidney (OR, 0.63; 95% CI, 0.60-0.67; p < .0001), and thyroid cancer trials (OR, 0.26; 95% CI, 0.23-0.28; p < .0001) compared with U.S. incidence.

CONCLUSION

Female underrepresentation has persisted within solid organ tumor trials but is less notable in hematologic trials. Additional work is required to identify drivers of such disparity.

IMPLICATIONS FOR PRACTICE

Adequate gender representation in clinical trials is a matter of health equity. This study demonstrates that women remain underrepresented in trials across hematological and solid organ trials compared with cancer incidence and mortality in women, with the disparity worse in a number of solid organ tumor types. There are thus still significant improvements to be made regarding adequate representation of women in trials. Studies exploring the reasons for ongoing disparity in gender representation are warranted to help clinicians to rectify this.

Thyroid Cancer Incidence in India Between 2006 and 2014 and Impact of Overdiagnosis

CONTEXT/OBJECTIVE

Increases of thyroid cancer (TC) incidence emerged in the past several decades in several countries. This study aimed to estimate time trends of TC incidence in India and the proportion of TC cases potentially attributable to overdiagnosis by sex, age, and area.

DESIGN

TC cases aged 0 to 74 years reported to Indian cancer registries during 2006 through 2014 were included. Age-standardized incidence rates (ASR) and TC overdiagnosis were estimated by sex, period, age, and area.

RESULTS

Between 2006 to 2008 and 2012 to 2014, the ASRs for TC in India increased from 2.5 to 3.5/100,000 women (+37%) and from 1.0 to 1.3/100,000 men (+27%). However, up to a 10-fold difference was found among regions in both sexes. Highest ASRs emerged in Thiruvananthapuram (14.6/100,000 women and 4.1/100,000 men in 2012-2014), with 93% increase in women and 64% in men compared with 2006 to 2008. No evidence of overdiagnosis was found in Indian men. Conversely, overdiagnosis accounted for 51% of TC in Indian women: 74% in those aged < 35 years, 50% at ages 35 to 54 years, and 30% at ages 55 to 64 years. In particular, 80% of TC overdiagnosis in women emerged in Thiruvananthapuram, whereas none or limited evidence of overdiagnosis emerged in Kamrup, Dibrugarh, Bhopal, or Sikkim.

CONCLUSIONS

Relatively high and increasing TC ASRs emerged in Indian regions where better access to health care was reported. In India, as elsewhere, new strategies are needed to discourage opportunistic screening practice, particularly in young women, and to avoid unnecessary and expensive treatments. Present results may serve as a warning also for other transitioning countries.

Cancer Statistics, 2020: Report From National Cancer Registry Programme, India

PURPOSE

The systematic collection of data on cancer is being performed by various population-based cancer registries (PBCRs) and hospital-based cancer registries (HBCRs) across India under the National Cancer Registry Programme-National Centre for Disease Informatics and Research of Indian Council of Medical Research since 1982.

METHODS

This study examined the cancer incidence, patterns, trends, projections, and mortality from 28 PBCRs and also the stage at presentation and type of treatment of patients with cancer from 58 HBCRs (N = 667,666) from the pooled analysis for the composite period 2012-2016. Time trends in cancer incidence rate were generated as annual percent change from 16 PBCRs (those with a minimum of 10 years of continuous good data available) using Joinpoint regression.

RESULTS

Aizawl district (269.4) and Papumpare district (219.8) had the highest age-adjusted incidence rates among males and females, respectively. The projected number of patients with cancer in India is 1,392,179 for the year 2020, and the common 5 leading sites are breast, lung, mouth, cervix uteri, and tongue. Trends in cancer incidence rate showed an increase in all sites of cancer in both sexes and were high in Kamrup urban (annual percent change, 3.8%; P < .05). The majority of the patients with cancer were diagnosed at the locally advanced stage for breast (57.0%), cervix uteri (60.0%), head and neck (66.6%), and stomach (50.8%) cancer, whereas in lung cancer, distant metastasis was predominant among males (44.0%) and females (47.6%).

CONCLUSION

This study provides a framework for assessing the status and trends of cancer in India. It shall guide appropriate support for action to strengthen efforts to improve cancer prevention and control to achieve the national noncommunicable disease targets and the sustainable development goals.

Thyroid cancer "epidemic" also occurs in low- and middle-income countries

Thyroid cancer incidence varies greatly between and within high-income countries (HICs), and overdiagnosis likely plays a major role in these differences. Yet, little is known about the situation in low- and middle-income countries (LMICs). We compare up-to-date thyroid cancer incidence and mortality at national and subnational levels. 599,851 thyroid cancer cases in subjects aged 20-74 reported in Cancer Incidence in Five Continents volume XI from 55 countries with at least 0.5 million population, aged 20-74 years, covered by population-based cancer registration, and 22,179 deaths from the WHO Mortality Database for 36 of the selected countries, over 2008-2012, were included. Age-standardized rates were computed. National incidence rates varied 50-fold. Rates were 4 times higher among women than men, with similar patterns between countries. The highest rates (>25 cases per 100,000 women) were observed in the Republic of Korea, Israel, Canada, the United States, Italy, France, and LMICs such as Turkey, Costa Rica, Brazil, and Ecuador. Incidence rates were low (<8) in a few HICs (the Netherlands, the United Kingdom, and Denmark) and lowest (3-4) in some LMICs (such as Uganda and India). Within-country incidence rates varied up to 45-fold, with the largest differences recorded between rural and urban areas in Canada (HIC) and Brazil, India, and China (LMICs). National mortality rates were very low (<2) in all countries and in both sexes, and highest in LMICs. The very high thyroid cancer incidence and low mortality rates in some LMICs also strongly suggest a major role of overdiagnosis in these countries.

Diagnosis and Management of Hypothyroidism: Addressing the Knowledge-Action Gaps

Hypothyroidism presents a large epidemiological burden in India. As a result of subtle and nonspecific clinical symptoms and signs, the condition often goes undiagnosed and is not adequately treated when it is detected. There is heterogeneity in the diagnostic and treatment approaches to hypothyroidism. As a result of the physiological changes in thyroid hormones with age and illness, it is important to tailor the diagnosis and management of this condition in specific populations including pregnant women, infants, children, geriatric patients, and those with comorbid conditions. Enhanced understanding and education of physicians and patients can help to improve the outcomes of treatment in hypothyroidism which should be focused on patient-centered care. Policies and reforms should be crafted and implemented at the national level to curb public health challenges of hypothyroidism. This publication summarizes the recommendations of a national advisory board meeting to identify and bridge the gaps in understanding of the diagnosis and treatment of hypothyroidism in India. As a complement to clinical judgment, these recommendations will foster the diagnosis and management of hypothyroidism in the community and clinics for the benefit of the patients.

FUNDING

Merck Ltd, India.