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Mankan AK, Shankar A, Limaye S, Ajaikumar BS, Nachane P, Singh N, Dawkhar S, Batra U, Bhosekar A, Ganguly S, Gawli P, Debnath K, Padalalu V, Reddy P, Sundaramoorthy S, Naveen KK, Bondarde S, Kumar P, Davis S, Ramkissoon SH, Chacko RT, Vidal L, Chico I, Hegedus A, Gupta S, Saini KS. Cancer Trials Ecosystem in India-Ready for Prime Time? JCO Glob Oncol 2024; 10:e2300405. [PMID: 38870438 DOI: 10.1200/go.23.00405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/12/2024] [Indexed: 06/15/2024] Open
Abstract
Executing global clinical trials for cancer is a long, expensive, and complex undertaking. While selecting countries global studies, sponsors must consider several aspects including patient pool, quality of trained investigators, competing trials, availability of infrastructure, and financial investment versus returns. With a large, often treatment-naïve, and diverse patient pool, relatively low cost, good quality health care facilities in urban areas, and a robust and well-trained workforce, India offers several advantages for conducting oncology clinical trials. However, there remains challenges, including a shifting regulatory environment in recent decades. With the implementation of the New Drugs and Clinical Trial Rules in 2019, India's regulatory atmosphere seems to have stabilized. In this article, we present a review of the evolving clinical trial landscape in India, highlight the current regulatory scenario, and discuss the advantages and challenges of selecting India as a potential location for conducting global oncology clinical trials.
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Affiliation(s)
| | - Abhishek Shankar
- Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Delhi, India
| | | | | | | | - Navneet Singh
- PostGraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Ullas Batra
- Rajiv Gandhi Cancer Centre, New Delhi, India
| | | | | | | | | | | | | | | | | | | | | | - Sanish Davis
- Indian Society for Clinical Research, Mumbai, India
| | | | | | | | | | | | - Sudeep Gupta
- Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Kamal S Saini
- Fortrea Inc, Durham, NC
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Rathi A, Sahay A, Shet TM, Patil A, Desai SB. Validation of Dual-Color Dual In Situ Hybridization for HER2/neu Gene in Breast Cancer. Arch Pathol Lab Med 2024; 148:453-460. [PMID: 37490416 DOI: 10.5858/arpa.2022-0543-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 07/27/2023]
Abstract
CONTEXT.— Human epidermal growth factor (HER2/neu) gene amplification, a poor prognostic factor in invasive breast cancer, has shown substantial utility as a predictive marker, with significantly improved survival following anti-HER2 therapies like trastuzumab. Dual-color dual in situ hybridization (D-DISH), a recently introduced fully automated assay for HER2/neu evaluation on light microscopy, has several advantages over fluorescence in situ hybridization (FISH). OBJECTIVE.— To standardize and validate the D-DISH assay using FISH as the gold standard and assess interobserver reproducibility in interpreting the D-DISH assay. DESIGN.— D-DISH was performed using the latest HER2 Dual ISH DNA Probe Cocktail assay (Ventana Medical Systems Inc, Tucson, Arizona) in 148 cases of invasive breast cancer. The same block was used for performing immunohistochemistry by Ventana PATHWAY anti-HER2/neu (4B5) antibody and FISH assay by ZytoLight SPEC ERBB2/CEN17 Dual Color Probe. D-DISH was separately interpreted by 4 pathologists blinded to FISH results. RESULTS.— Concordance of 98.65% and a Cohen κ value of 0.97 were observed between FISH and D-DISH. Intraclass correlation coefficient (0.93-0.97) and κ values (0.98-1.0) for interobserver reproducibility showed almost perfect agreement by D-DISH. Interobserver reproducibility was also evaluated for genomic heterogeneity, HER2 group categorization, and polysomy (κ values 0.42-0.74, 0.89-0.93, and 0.98-1.0, respectively). CONCLUSIONS.— We successfully validated the latest version of D-DISH assay as a substitute for FISH in predicting HER2 gene status with significant interobserver reproducibility, concluding that this D-DISH assay may be introduced in routine diagnostic services as a reflex test to ascertain HER2 gene status.
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Affiliation(s)
- Aditi Rathi
- From the Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ayushi Sahay
- From the Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Tanuja M Shet
- From the Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Asawari Patil
- From the Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sangeeta B Desai
- From the Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Malhotra G, Gattani RG, Shinde RK, Gianchandani SG, Nayak K, Salwan A. Significance of Serum Lactate Dehydrogenase as a Prognostic Marker and Outcome Predictor in Patients With Breast Cancer. Cureus 2024; 16:e55932. [PMID: 38601401 PMCID: PMC11004840 DOI: 10.7759/cureus.55932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Background Breast carcinoma has been the most prevalent cancer in women, with research-based evidence showing a significant rise in the incidence of cancer and related morbidity and mortality in the Indian subcontinent. The predictive value of plasmatic lactate dehydrogenase (LDH) levels has been studied in breast cancer. Numerous studies have connected high LDH values to a poor prognosis, increased risk of incidence, recurrence, and associated mortality in patients with breast carcinoma. This study aimed to assess the clinical profile of breast carcinoma and determine the correlation of serum lactate dehydrogenase levels with the stage of the disease and assessment of high-risk features using histopathology and immunohistochemistry. Methods A total of 75 patients with carcinoma breast were enrolled for this study and classified into two groups: upfront surgery and post-adjuvant therapy. Serum LDH levels were estimated a day before the surgery (baseline) and on postoperative days 1, 7, 14, and 30. The clinical tumor, node, metastasis (cTNM) staging was correlated with pathological tumor, node, metastasis TNM (pTNM) staging and immunohistochemistry findings. Results The clinical characteristics of breast cancer, serum LDH levels, and stage of the disease were collected and analyzed. A significant decreasing trend was noted in LDH values post-op days, and statistically significant higher LDH values were noted in the triple-negative group, positive lymph nodes, and positive lymphovascular invasion patients. Conclusion Regularly elevated levels or an unanticipated rise in serum LDH might indicate poor outcomes. Hence, this non-specific enzyme marker can be suggested to be used routinely to assess disease outcomes.
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Affiliation(s)
- Geetika Malhotra
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Rajesh G Gattani
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Raju K Shinde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Sanjeev G Gianchandani
- Minimal Access and Robotic Surgery, Anglia Ruskin University, Chelmsford, GBR
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Krushank Nayak
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
| | - Ankur Salwan
- Orthopaedic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
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Bhardwaj PV, Dulala R, Rajappa S, Loke C. Breast Cancer in India: Screening, Detection, and Management. Hematol Oncol Clin North Am 2024; 38:123-135. [PMID: 37330342 DOI: 10.1016/j.hoc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Breast cancer is the most common cancer in urban Indian women and the second most common cancer in all Indian women. The epidemiology as well as biology of this cancer seems to be different in the Indian subcontinent when compared with the West. The lack of population-based breast cancer screening programs and delay in seeking a medical consult due to financial and social reasons, including lack of awareness and fear related to a cancer diagnosis, results in delayed diagnosis.
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Affiliation(s)
- Prarthna V Bhardwaj
- Division of Hematology-Oncology, University of Massachusetts Chan Medical School - Baystate, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Renuka Dulala
- Division of Hematology-Oncology, Holyoke Medical Center, 575 Beech Street, Holyoke, MA 01040, USA
| | - Senthil Rajappa
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Road no. 10, Banjara Hills, Hyderabad, Telangana 500034, India
| | - Chandravathi Loke
- Division of Hematology-Oncology, University of Massachusetts Chan Medical School - Baystate, 759 Chestnut Street, Springfield, MA 01199, USA.
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Arvandi S, Razmjoo S, Zaheri Abdevand P. Risk factors and survival of triple-negative breast cancer among breast cancer patients: Ten-year cross-sectional study in the southwestern Iranian population. Health Sci Rep 2023; 6:e1767. [PMID: 38111745 PMCID: PMC10726015 DOI: 10.1002/hsr2.1767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023] Open
Abstract
Background Breast cancer results from genetic and epigenetic mutations, contributing significantly to cancer-related morbidity and mortality. This study aimed to determine the prevalence and survival rates of triple-negative breast cancer (TNBC) among breast cancer patients in southwestern Iran over a ten-year period. Methods This retrospective cross-sectional study aims to assess prognostic factors associated with survival in women diagnosed with breast cancer in Iran's southwestern region over a ten-year period (2007-2017). Data were collected from patients who visited the Clinical Oncology Department at Golestan Hospital in Ahvaz (the breast cancer center of the Southwestern country). The study enrolled women diagnosed with TNBC using a census method and data from medical records. The primary outcome (survival rates) and secondary outcomes (demographic data, diagnostic stages, and three receptors estrogen receptors [ER], progesterone receptor [PR], human epidermal growth factor receptor 2 [HER2] status) were collected. Results Breast cancer was diagnosed in 2641 women over ten years; TNBC was diagnosed in 227 individuals (8.59%). Statistical analysis revealed a significant correlation between negative ER status and TNBC (p > 0.05). Furthermore, the prevalence of TNBC differed significantly from that of other types of breast cancer (p = 0.0001). The variables of age, HER2, PR, and TNBC grade did not differ significantly (p > 0.05). The overall disease-free survival rate over 5 years was 88.1%, while the rate for individuals without recurrence was 77.97%. Conclusion This study highlights a differentially low incidence of TNBC in the southwestern part of Iran when compared to other regions; genetic or epigenetic influences may explain this discrepancy. ER-negative status is a crucial prognostic indicator in diagnosing TNBC. The incidence of this disease is expected to rise by 100% in 2 years and 77.97% in 5 years.
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Affiliation(s)
- Sholeh Arvandi
- Department of Radiotherapy, Faculty of Medicine, Golestan HospitalAhvaz Jundishapur University of Medical SciencesAhvazIran
| | - Sasan Razmjoo
- Department of Radiotherapy, Faculty of Medicine, Golestan HospitalAhvaz Jundishapur University of Medical SciencesAhvazIran
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Nag S, Dikshit R, Desai S, Mane A, Mhatre S, Neve R, Gurav M, Bhosale N, Perumal P, Kembhavi Y, Jethwa D, Badwe R, Gupta S. Risk factors for the development of triple-negative breast cancer versus non-triple-negative breast cancer: a case-control study. Sci Rep 2023; 13:13551. [PMID: 37599285 PMCID: PMC10440340 DOI: 10.1038/s41598-023-40443-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/10/2023] [Indexed: 08/22/2023] Open
Abstract
The risk factors for breast cancer have been defined in several studies but there is deficient data for specific subtypes. We report here the pathological characteristics of a breast cancer cohort and risk factors for patients with triple-negative disease. In this case-control study, a prospective breast cancer cohort was evaluated for demographic, reproductive, obesity-related and other risk factors using a validated questionnaire. Tumors were characterized for routine pathological characteristics and immunohistochemical markers of basal-like breast cancer. Patients with triple-negative breast cancer (TNBC) constituted cases and those with non-TNBC were controls. Odds ratios (OR) were calculated for each risk factor and independent associations were tested in an unconditional logistic regression analysis. Between 2011 and 2014, 1146 patients were recruited, of whom 912 [TNBC 266 (29.1%), non-TNBC 646 (70.9%)] with sufficient pathology material were analysed. Reproductive factors of parity, breastfeeding, age-at-menarche, age at first full-term pregnancy and oral contraceptive use were not significantly associated with TNBC. Higher body mass index (BMI > 24.9 vs ≤ 24.9, OR 0.89, 95%CI 0.63-1.24, p = 0.49) was not significantly associated while lesser waist circumference (> 80 cm vs ≤ 80 cm, OR 0.64, 95%CI 0.45-0.9, p = 0.012) and lower waist-to-hip ratio were significantly associated (> 0.85 vs ≤ 0.85, OR 0.72, 95%CI 0.51-1.0, p = 0.056), with TNBC. History of tobacco use was not significantly associated while lower socio-economic status was borderline associated with TNBC (socio-economic category > 5 versus ≤ 5, OR 0.73, 95%CI 0.50-1.06, p = 0.106). No factor was significant after adjustment for covariates. Central obesity seems to be preferentially associated with non-TNBC, and lower socio-economic status with TNBC in India, while most other conventional risk factors of breast cancer show no significant association with TNBC versus non-TNBC.
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Affiliation(s)
- Shona Nag
- Medical Oncology, Jehangir Clinical Development Center, Pune, India
| | - Rajesh Dikshit
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sangeeta Desai
- Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anupama Mane
- Surgical Oncology, Jehangir Clinical Development Center, Pune, India
| | - Sharayu Mhatre
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Rakesh Neve
- Surgical Oncology, Jehangir Clinical Development Center, Pune, India
| | - Mamta Gurav
- Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Prema Perumal
- Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Yogesh Kembhavi
- Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Dinesh Jethwa
- Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Rajendra Badwe
- Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sudeep Gupta
- Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
- Tata Memorial Hospital/Centre, Room 1109, Homi Bhabha Block, Parel, Mumbai, 400012, India.
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Upadhyay AK, Prakash A. Clinicopathological Profile of Breast Cancer at a Tertiary Cancer Center in Jharkhand, India: A Descriptive Cohort Study. Cureus 2023; 15:e39990. [PMID: 37416049 PMCID: PMC10321568 DOI: 10.7759/cureus.39990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Breast cancer is the most common cancer in females worldwide including Indian urban areas. There is no concrete data on breast cancer epidemiology from the state of Jharkhand, India. Materials and methods The present study is a retrospectively conducted descriptive cohort study. A total of 759 patients were selected from the database from 2012 to 2022. The parameters taken for the study were age, sex, stage at the time of presentation, histological type, estrogen receptor (ER) status, progesterone receptor (PR) status, human epidermal growth receptor 2 (HER2) neu status (HER2/neu), site of metastasis for stage 4 diseases, parity, and significant family history. Results The median age for patients was 49 years (range: 19-91 years), with a clustering of 74.83% of cases between 31 and 60 years of age. Most of the patients were in stage III, with 365 (48.08%) cases. Bone was the commonest site of metastasis and was found in 41.25% of total cases. The total number of hormone receptor-positive patients was 384 (56.2%), the number of HER2/neu positive patients was 210 (30.7%), and triple-negative breast cancer was found in 184 cases (26.93%). Conclusion The pattern found in our Jharkhand patients was very much similar to other Indian studies with slightly more clustering of younger cases. The cases in India are almost a decade younger than the Western population and the same was replicated in our study. This is one of the largest studies on breast cancer profile and epidemiology from the eastern part of India. Most of our patients presented late, leading to a higher number of locally advanced (stage III) and metastatic (stage IV) cases. More awareness is required at the population level, including strict implementation of a robust screening program by our government, for improving the overall outcome.
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Tannock IF, Bouche G, Goldstein DA, Goto Y, Lichter AS, Prabhash K, Ranganathan P, Saltz LB, Sonke GS, Strohbehn GW, von Moos R, Ratain MJ. Patient-centred, self-funding dose optimisation trials as a route to reduce toxicity, lower cost and improve access to cancer therapy. Ann Oncol 2023:S0923-7534(23)00687-7. [PMID: 37230253 DOI: 10.1016/j.annonc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada; Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
| | - Gauthier Bouche
- Anticancer Fund, Meise, Belgium; Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Kumar Prabhash
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Leonard B Saltz
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabe S Sonke
- Department of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, & University of Amsterdam, Amsterdam, The Netherlands
| | - Garth W Strohbehn
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan; Section of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland & SAKK Competence Center, Bern
| | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Siddiqui B, Ahmed S, Sinha D, Sharma AVL. Molecular Classification of Breast Carcinoma in a Tertiary Hospital of India: the Recent Trends. Indian J Surg Oncol 2023; 14:176-180. [PMID: 36891434 PMCID: PMC9986149 DOI: 10.1007/s13193-022-01647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022] Open
Abstract
Breast cancer is a heterogeneous disorder with various subcategories of different cellular compositions, molecular alterations, and clinical behaviour and is dependent on numerous factors like grade, size, and hormonal receptors which influence the overall prognosis and response to the treatment. This study was done to determine the frequency of estrogen receptor (ER), progesterone receptor (PR), and Her2 neu positivity in breast cancer patients, further classifying them into their molecular types (luminal A, B, Her2 neu, and triple-negative) and studying their association with histological subtypes, lymph node status, and other epidemiological parameters. This was a 5-year retrospective study done on 314 patients. All relevant clinical data including the age, sex, and lymph node status along with the histological type and grade of the tumour were recorded, and immunohistochemical evaluation of Her2 neu, ER, and PR receptors was done. The results showed that ER was the most predominant immunomarker, followed by PR, with an inverse relationship between ER, PR, and Her2 neu. Among the molecular subtypes, luminal B showed the maximum prevalence followed by triple-negative and Her2 neu subtype. The least frequency was shown by luminal A. Our study concluded that molecular subtyping of breast carcinoma plays an important role in determining the prognosis, recurrence, and treatment. Increased expression of luminal B subtype can be correlated due to the advancing age of the patients.
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Affiliation(s)
- Bushra Siddiqui
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh Aligarh, 202001 India
| | - Saqib Ahmed
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh Aligarh, 202001 India
| | - Dipanjan Sinha
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh Aligarh, 202001 India
| | - Avadh Vihari Lal Sharma
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh Aligarh, 202001 India
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Ramaswamy A, Babu V, Kothari R, Abhinav R, Desouza A, Ventrapati P, Kumar A, Kapoor A, Das S, Engineer R, Saklani A, Ostwal V. Treatment of Metastatic Colorectal Cancers in Resource-Constrained Low- and Middle-Income Countries (LMICS) Scenario-Outcomes, Practice Patterns, and Commentary on Treatment Costs. South Asian J Cancer 2022; 11:293-298. [PMID: 36756109 PMCID: PMC9902092 DOI: 10.1055/s-0041-1736203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Anant RamaswamyIntroduction The overall survival (OS) of metastatic colorectal cancers (mCRCs) in clinical practice and resource-constrained low- and middle-income countries (LMICS) like India is not known. Materials and Methods Data of patients with mCRC treated between January 2013 and August 2017 were accessed from a prospectively maintained database. Demographics, disease characteristics, chemotherapeutic regimens, use of monoclonal antibodies, and survival outcomes in treated patients were collected and analyzed. Costs of treatment options as off 2017 were also interpreted. Results The data of 403 patients satisfied prespecified inclusion criteria and were included for analysis. The median age of the cohort was 48 years (range: 17-86) with a predominance of rectal cancers (63.3%), liver alone metastases (47.1%), and resected primary (69.7%). Signet ring histology was present in 82 patients (20.3%). The most commonly used first-line regimen (CT1) was modified capecitabine-oxaliplatin (53.3%). Two hundred and nineteen patients (54.3%) received second-line systemic therapy (CT2). Patients received a median of two lines of therapy (range: 1-6). MoAbs were used by 48 patients (13.4%) with CT1 and 34 patients (15.5%) with CT2. Median OS of the entire cohort was 17.61 months (95% confidence interval: 15.48-19.74), which was within the predicted range, as per investigator hypothesis. The presence of signet ring histology ( p <0.001), raised carcinoembryonic antigen at baseline ( p =0.017), and the absence of a resected primary ( p <0.001) predicted inferior median OS. Conclusions Survival of patients with mCRC in a resource-constrained LMIC scenario like India is approximately 12 to 15 months lower than published trial data. Limited access to targeted therapy and newer expensive treatment options due to financial constraints may contribute to this disparity.
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Affiliation(s)
- Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Vasu Babu
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Rushabh Kothari
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Ram Abhinav
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Pradeep Ventrapati
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Amit Kumar
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Akhil Kapoor
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Shasanka Das
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Dr. E Borges Road, Parel, Mumbai, India,Address for correspondence Vikas Ostwal Department of Medical Oncology, Tata Memorial Hospital, (HBNI)Dr. E Borges Road, Parel, Mumbai, 400 012India
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Kumar R, Abreu C, Toi M, Saini S, Casimiro S, Arora A, Paul AM, Velaga R, Rameshwar P, Lipton A, Gupta S, Costa L. Oncobiology and treatment of breast cancer in young women. Cancer Metastasis Rev 2022; 41:749-770. [PMID: 35488982 DOI: 10.1007/s10555-022-10034-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/14/2022] [Indexed: 12/20/2022]
Abstract
Female breast cancer emerged as the leading cancer type in terms of incidence globally in 2020. Although mortality due to breast cancer has improved during the past three decades in many countries, this trend has reversed in women less than 40 years since the past decade. From the biological standpoint, there is consensus among experts regarding the clinically relevant definition of breast cancer in young women (BCYW), with an age cut-off of 40 years. The idea that breast cancer is an aging disease has apparently broken in the case of BCYW due to the young onset and an overall poor outcome of BCYW patients. In general, younger patients exhibit a worse prognosis than older pre- and postmenopausal patients due to the aggressive nature of cancer subtypes, a high percentage of cases with advanced stages at diagnosis, and a high risk of relapse and death in younger patients. Because of clinically and biologically unique features of BCYW, it is suspected to represent a distinct biologic entity. It is unclear why BCYW is more aggressive and has an inferior prognosis with factors that contribute to increased incidence. However, unique developmental features, adiposity and immune components of the mammary gland, hormonal interplay and crosstalk with growth factors, and a host of intrinsic and extrinsic risk factors and cellular regulatory interactions are considered to be the major contributing factors. In the present article, we discuss the status of BCYW oncobiology, therapeutic interventions and considerations, current limitations in fully understanding the basis and underlying cause(s) of BCYW, understudied areas of BCYW research, and postulated advances in the coming years for the field.
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Affiliation(s)
- Rakesh Kumar
- Cancer Research Institute, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India. .,Cancer Research Program, Rajiv Gandhi Centre for Biotechnology, Trivandrum, India. .,Department of Medicine, Division of Hematology and Oncology, Rutgers New Jersey Medical School, Newark, NJ, USA. .,Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
| | - Catarina Abreu
- Department of Medical Oncology, Hospital de Santa Maria- Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Masakazu Toi
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sunil Saini
- Cancer Research Institute, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Sandra Casimiro
- Instituto de Medicina Molecular-João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Anshika Arora
- Cancer Research Institute, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, India
| | - Aswathy Mary Paul
- Cancer Research Program, Rajiv Gandhi Centre for Biotechnology, Trivandrum, India
| | - Ravi Velaga
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Pranela Rameshwar
- Department of Medicine, Division of Hematology and Oncology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Allan Lipton
- Hematology-Oncology, Department of Medicine, Penn State University School of Medicine, Hershey, PA, USA
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Luis Costa
- Department of Medical Oncology, Hospital de Santa Maria- Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.,Instituto de Medicina Molecular-João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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12
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Aziz Z, Naseer H, Altaf A. Challenges in Access to New Therapeutic Agents: Marginalized Patients With Cancer in Pakistan and the Need for New Guidelines. JCO Glob Oncol 2022; 8:e2100132. [PMID: 35175831 PMCID: PMC8863132 DOI: 10.1200/go.21.00132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cancer care disparities persist among the medically underserved patients with cancer in Pakistan. To determine the access that marginalized patients with cancer have to chemotherapy and newer targeted agents in Pakistan approved by essential medicine list 2017, the barriers that patients face in getting such access, the implications of the barriers for the effectiveness of treatment, and ways of overcoming those barriers, with particular attention to breast cancer (BC), diffuse large B-cell lymphoma (DLBCL), and chronic myeloid leukemia (CML), need to be addressed. Health care disparities and major barriers in access to essential targeted therapies in low- and middle-income countries![]()
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Affiliation(s)
- Zeba Aziz
- Department of Medical Oncology, Hameed Latif Hospital, Lahore, Pakistan
| | - Hafsa Naseer
- Department of Medical Oncology, Hameed Latif Hospital, Lahore, Pakistan
| | - Anjum Altaf
- School of Humanities and Social Sciences, Lahore University of Management Sciences, Lahore, Pakistan
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13
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Anand A, Mishra A, Damde H, Saxena A, Yadav SK, Sharma D. Molecular Profile and Clinico-pathological Characteristics of Breast Cancer in Central India: First Investigative Report. Indian J Surg Oncol 2022; 13:421-425. [DOI: 10.1007/s13193-022-01502-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/11/2022] [Indexed: 12/09/2022] Open
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14
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Gupta N, Jyani G, Rajsekar K, Gupta R, Nagar A, Gedam P, Prinja S. Application of Health Technology Assessment for Oncology Care in India: Implications for Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1740536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractA health system is considered efficient when it provides maximum health gains to the population from the available resources. Newer drugs, diagnostics and treatment strategies aim to improve the health of the population, however, they come at an increased cost. Therefore, for an efficient health system, it needs to be decided if the extra cost being incurred is justified to achieve the extra health gains. In this regard, health technology assessment (HTA) helps to make evidence informed decisions by evaluating relative cost and benefits of the available interventions. Economic evidence generated by HTA can also be used in framing standard treatment guidelines (STGs) for high-cost cancer care. In multi-payer systems like India, the decisions regarding the clinical management of patients are taken based on the patients' ability to pay, which creates inequities in utilization of healthcare. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) offers an opportunity to ensure equity as it reduces financial barriers, besides having a potential to affect efficiency by including only cost-effective interventions in the benefit package. As a result, informed clinical decisions based upon HTA evidence can make cancer treatment more efficient, equitable and affordable for the patients.
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Affiliation(s)
- Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Gaurav Jyani
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kavitha Rajsekar
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi
| | - Rakesh Gupta
- Department of Women and Child Development, Government of India, New Delhi
| | - Anu Nagar
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi
| | - Praveen Gedam
- National Health Authority, Ministry of Health and Family Welfare, Government of India, New Delhi
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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15
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Ranganathan P, Chinnaswamy G, Sengar M, Gadgil D, Thiagarajan S, Bhargava B, Booth CM, Buyse M, Chopra S, Frampton C, Gopal S, Grant N, Krailo M, Langley R, Mathur P, Paoletti X, Parmar M, Purushotham A, Pyle D, Rajaraman P, Stockler MR, Sullivan R, Swaminathan S, Tannock I, Trimble E, Badwe RA, Pramesh CS. The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research. Lancet Oncol 2021; 22:e369-e376. [PMID: 34216541 PMCID: PMC8328959 DOI: 10.1016/s1470-2045(21)00077-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/27/2021] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.
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Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Girish Chinnaswamy
- Division of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Durga Gadgil
- Research Administration Council, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shivakumar Thiagarajan
- Department of Head and Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Christopher M Booth
- Departments of Oncology and Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve, Belgium; Data Science Institute, Hasselt University, Diepenbeek, Belgium
| | | | - Chris Frampton
- Departments of Medicine and Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD, USA
| | | | - Mark Krailo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ruth Langley
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Prashant Mathur
- National Centre for Disease Informatics and Research, Bengaluru, India
| | - Xavier Paoletti
- University of Versailles Saint-Quentin-en-Yvelines, Versailles, France; Department of Biostatistics, Institut Curie, Saint-Cloud, France; Department of Statistics for Precision Medicine, INSERM U900, Paris, France
| | - Mahesh Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Douglas Pyle
- American Society of Clinical Oncology, Alexandria, VA, USA
| | - Preetha Rajaraman
- US Department of Health and Human Services, Washington, DC, USA; US Embassy, New Delhi, India
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | | | - Ian Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Edward Trimble
- Office of the Director, National Cancer Institute, NIH, US Department of Health and Human Services, Washington, DC, USA
| | - Rajendra A Badwe
- Departments of Administration and Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - C S Pramesh
- Departments of Administration and Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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16
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Gupta N, Verma RK, Gupta S, Prinja S. Cost Effectiveness of Trastuzumab for Management of Breast Cancer in India. JCO Glob Oncol 2021; 6:205-216. [PMID: 32045547 PMCID: PMC7051799 DOI: 10.1200/jgo.19.00293] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE We undertook this study to evaluate the incremental cost per quality-adjusted life-year (QALY) gained with use of adjuvant trastuzumab as compared with chemotherapy alone among patients with nonmetastatic breast cancer in India. METHODS We used a Markov model to estimate the incremental cost of using trastuzumab (for 1 year, 6 months, or 9 weeks) as compared with chemotherapy alone using a societal perspective, excluding indirect productivity losses. Although the outcomes (QALYs) in the standard chemotherapy arm were estimated after calibrating the model as per survival data from 2 Indian cancer registries, effectiveness estimates from the HERA trial and a joint analysis of the NSABP B-31 and NCCTG N9831 trials were used to estimate the consequences of 1-year trastuzumab use. The cost of treatment was estimated using national standard treatment guidelines and real-world use estimates for different treatment modalities as per data from Indian cancer registries. Probabilistic sensitivity analysis was undertaken to evaluate parameter uncertainty. RESULTS For 1 year of trastuzumab use, the incremental benefit per patient, incremental cost per QALY gained, and probability of being cost effective using HERA trial estimates were 1.29 QALYs, 178,877 Indian national rupees (INRs; US$2,558), and 4%, respectively, whereas the corresponding figures using joint analysis estimates were 1.69 QALYs, INR 134,413 (US$1,922), and 57.3%, respectively. CONCLUSION Use of trastuzumab for 1 year is not cost effective in India at the current price. However, trastuzumab use for 9 weeks is cost effective and should be included in clinical guidelines and reimbursement policies. A price reduction of 15% to 35% increases the probability of 1-year trastuzumab use being cost effective, to 90%.
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Affiliation(s)
- Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Rohan Kumar Verma
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sudeep Gupta
- Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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17
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Mutebi M, Anderson BO, Duggan C, Adebamowo C, Agarwal G, Ali Z, Bird P, Bourque JM, DeBoer R, Gebrim LH, Masetti R, Masood S, Menon M, Nakigudde G, Ng'ang'a A, Niyonzima N, Rositch AF, Unger-Saldaña K, Villarreal-Garza C, Dvaladze A, El Saghir NS, Gralow JR, Eniu A. Breast cancer treatment: A phased approach to implementation. Cancer 2021; 126 Suppl 10:2365-2378. [PMID: 32348571 DOI: 10.1002/cncr.32910] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.
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Affiliation(s)
- Miriam Mutebi
- Breast Surgical Oncology, Aga Khan University Hospital, Nairobi, Kenya
| | - Benjamin O Anderson
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Section of Surgical Oncology, Department of Surgery, University of Washington, Seattle, Washington
| | - Catherine Duggan
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Clement Adebamowo
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland.,Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.,Center for Bioethics and Research, Ibadan, Nigeria
| | - Gaurav Agarwal
- Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Zipporah Ali
- Kenya Hospices and Palliative Care Association, Nairobi, Kenya
| | | | - Jean-Marc Bourque
- Department of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Rebecca DeBoer
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Luiz Henrique Gebrim
- Department of Mastology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Referência da Saúde da Mulher, São Paulo, Brazil
| | - Riccardo Masetti
- Department of Women and Child Health, Catholic University, Rome, Italy
| | - Shahla Masood
- University of Florida Health Jacksonville Breast Center, Jacksonville, Florida
| | - Manoj Menon
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Anne Ng'ang'a
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - Nixon Niyonzima
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Uganda Cancer Institute, Kampala, Uganda
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Karla Unger-Saldaña
- Epidemiology Unit, Instituto Nacional de Cancerología - México, Mexico City, Mexico
| | - Cynthia Villarreal-Garza
- Tecnologico de Monterrey, Centro de Cancer de Mama, Hospital Zambrano Hellion, Monterrey, Mexico
| | - Allison Dvaladze
- Section of Surgical Oncology, Department of Surgery, University of Washington, Seattle, Washington
| | | | - Julie R Gralow
- Section of Surgical Oncology, Department of Surgery, University of Washington, Seattle, Washington
| | - Alexandru Eniu
- Hopital Riviera Chablais, Vaud-Valais, Rennaz, Switzerland
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18
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Sun X, Liu J, Ji H, Yang M, Lu Y. Clinicopathological Characteristics and Prognosis of Breast Cancer in Young Women - A Single Center Study in a Developing Country. Cancer Manag Res 2021; 13:1601-1607. [PMID: 33628050 PMCID: PMC7898785 DOI: 10.2147/cmar.s299066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Breast cancer (BC) in young women tends to be more aggressive. This study highlights the clinicopathological features and outcomes of young breast cancer (YBC) patients in a developing country. Methods Consecutive patients aged 35 years or younger with a pathologically confirmed diagnosis of breast cancer treated and followed up at our department were included. Medical records and follow-up databases were reviewed and documented. Results The rate of breast conservation and reconstruction surgery is higher in YBC patients. YBC patients are more likely to have tumors over 5cm, high-grade, hormone receptor negative, triple negative and stage III than old patients. There was no statistically significant difference in the pathological type, lymph node metastasis, and HER2 status. The median follow-up time was 96 months. The disease-free survival (DFS) was significantly worse in the YBC group. However, the overall survival (OS) had no difference between the two groups. Conclusion YBC patients had more aggressive pathological features, such as hormone receptor negative, triple negative, high-grade and advanced stage, and poorer DFS than the old counterparts.
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Affiliation(s)
- Xiaoliang Sun
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Jun Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Haoyang Ji
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Meng Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yao Lu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, People's Republic of China
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19
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Sentinel Lymph Node Biopsy in Early Breast Cancer Using Methylene Blue Dye Alone: a Safe, Simple, and Cost-Effective Procedure in Resource-Constrained Settings. Indian J Surg Oncol 2021; 12:210-217. [PMID: 33814855 DOI: 10.1007/s13193-020-01273-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022] Open
Abstract
Sentinel lymph node biopsy (SLNB) is done by different techniques in clinically node-negative patients with early breast cancer. In this study, we aim to estimate the identification rates, positivity rates, cost-effectiveness, and outcomes for patients who underwent sentinel node biopsy using methylene blue dye alone. This was a retrospective review of 172 patients with early breast cancer (cT1-3, N0) who underwent SLNB using methylene blue dye alone between January 2014 and December 2018 including their follow-up details until December 2019. The mean age was 51 ± 10.3 (range: 28 to 76) years. There were 63 (36.6%) patients with cT1 tumor, 108 (62.7%) with cT2, and only 1 patient with cT3 tumor. Breast conservation surgery was performed in 62 (36%) while the remaining 110 (64%) underwent simple mastectomy. Sentinel nodes were successfully identified in 165 (95.9%) with a positivity rate of 23.6%. There was no dye-related adverse reactions intra-operatively. The mean duration of follow-up was 26.68 ± 15.9 months (range: 1-60). Chronic arm pain was present in 7 (4%) while none of the patients had lymphedema or restriction of shoulder joint motion. There were no documented axillary nodal recurrences in this cohort. Eight (4.65%) patients were detected to have systemic metastasis. One patient died of brain metastasis from bilateral breast cancer. The mean disease-free survival was 57 months (95% CI: 55-59). Sentinel lymph node biopsy using methylene dye alone is a safe, simple, and cost-effective alternative to isosulfan blue or radio isotope technique in surgical centers with resource constraints.
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20
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Kumar RV, Panwar D, Amirtham U, Premalata CS, Gopal C, Narayana SM, Patil Okaly GV, Lakshmaiah KC, Krishnamurthy S. Estrogen receptor, Progesterone receptor, and human epidermal growth factor receptor-2 status in breast cancer: A retrospective study of 5436 women from a regional cancer center in South India. South Asian J Cancer 2020; 7:7-10. [PMID: 29600224 PMCID: PMC5865104 DOI: 10.4103/sajc.sajc_211_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aim: The aim of the study was to analyze the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status over 7 years in South Indian women with breast cancer. Further analysis of a subgroup was done to study clinically defined subtypes and the role of preanalytical factors in needle core biopsies (NCBs) and excised specimens. Materials and Methods: This was a retrospective study from January 2010 to December 2016. Patients diagnosed with invasive breast cancer and available immunohistochemistry (IHC) reports of ER, PR, and HER2 status were analyzed. The cases for the year 2016 were analyzed further to observe the impact of preanalytical factors on the IHC staining patterns and surrogate status. Results: A total of 5436 patients were included with a median age of 48 years. Among these, 65% were ≤ 55 years. The overall incidence of hormone receptor (HR)-positive patients was 48%; HER2 positive, 15%; and triple-negative breast cancer (TNBC), 37%. The incidence of HR positive, HER2 positive, and TNBC were 45%, 16%, and 39% and 53%, 13%, and 34% in patients <56 years and over 55 years, respectively (P < 0.001). There was an increase in HR positivity and decrease in TNBCs over time. There was no significant difference in the staining patterns in NCBs and excised specimens. Conclusion: With time, there is an increase in hormone-positive tumors which may be attributed to better IHC techniques and tissue handling. There was no statistical difference in the patterns of ER, PR, and HER2 immunostaining in core biopsy and excised specimens.
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Affiliation(s)
- Rekha Vijay Kumar
- Department of Pathology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
| | - Dipti Panwar
- Department of Pathology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
| | - Usha Amirtham
- Department of Pathology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
| | | | - Champaka Gopal
- Department of Pathology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
| | | | | | - K C Lakshmaiah
- Department of Medical Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
| | - S Krishnamurthy
- Department of Surgical Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India
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21
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Ostwal V, Kapoor A, Engineer R, Saklani A, deSouza A, Patil P, Arya S, Ankathi SK, Chopra S, Patil M, Jain S, Ramaswamy A. Systemic chemotherapy and short-course radiation in metastatic rectal cancers: A feasible paradigm in unresectable and potentially resectable cancers. South Asian J Cancer 2020; 8:92-97. [PMID: 31069186 PMCID: PMC6498721 DOI: 10.4103/sajc.sajc_174_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The optimal use and sequencing of short-course radiotherapy (SCRT) in metastatic rectal cancers (mRCs) are not well established. Materials and Methods: We retrospectively reviewed the records of mRC patients receiving SCRT followed by palliative chemotherapy between January 1, 2013, and December 31, 2016, in Tata Memorial Hospital. Patients were classified as having “potentially resectable” disease (local and metastatic) or “unresectable” disease at baseline based on prespecified criteria. Results: A total of 105 consecutive patients were available for analysis. The median age of patients was 48 years (range: 16–62 years), and 57.1% were male patients. Signet ring histology was seen in 13.3% of patients. The most common site of metastases was liver limited (29.5%), nonloco-regional nodes (12.4%), and lung limited metastases (9.5%). Chemotherapeutic regimens administered were capecitabine-oxaliplatin (70.5%), modified 5 fluorouracil (5 FU)-leucovorin-irinotecan-oxaliplatin (10.5%), and modified 5 FU-leucovorin-irinotecan (8.6%). Targeted therapy accompanying chemotherapy was administered in 27.6% of patients. About 42.1% of patients with potentially resectable disease and 11.1% with the unresectable disease at baseline underwent curative-intent resection of the primary and address of metastatic sites. With a median follow-up 18.2 months, median overall survival (OS) was 15.7 months (95% confidence interval: 10.42–20.99). Patients classified as potentially resectable had a median OS of 32.62 months while patients initially classified as unresectable had a median OS of 13.04 months (P = 0.016). The presence of signet ring morphology predicted for inferior mOS (P = 0.021). Conclusions: SCRT followed by systemic therapy in mRC is a feasible, efficacious paradigm for maximizing palliation, and achieving objective responses. The classification of patients based on resectability was predictive of actual resection rates as well as outcomes. Signet ring mRC show inferior outcomes in this cohort of patients.
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Affiliation(s)
- Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Akhil Kapoor
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashwin deSouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Prachi Patil
- Department of Medical Gastroenterology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Supreeta Arya
- Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | | | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Mangesh Patil
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Shanu Jain
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Jonnada PK, Sushma C, Karyampudi M, Dharanikota A. Prevalence of Molecular Subtypes of Breast Cancer in India: a Systematic Review and Meta-analysis. Indian J Surg Oncol 2020; 12:152-163. [PMID: 33994741 DOI: 10.1007/s13193-020-01253-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/15/2020] [Indexed: 12/24/2022] Open
Abstract
In the last two decades, India has witnessed a substantial increase in the incidence of breast cancer and associated mortality. Studies on the prevalence of molecular subtypes of breast cancer in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the prevalence of molecular subtypes of breast cancer. A complete literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms ((molecular classification) OR (molecular subtypes)) AND (breast cancer)) OR (breast carcinoma)) AND (prevalence)) AND (India). Two reviewers independently reviewed the retrieved studies. The screened studies satisfying the eligibility were included. The quality of included studies was assessed using the selected STROBE criteria. The overall pooled prevalence of luminal A, luminal B, HER2-enriched, and triple-negative breast cancer (TNBC) subtypes of breast cancer were 0.33 (95% CI 0.23-0.44), 0.17 (95% CI 0.12-0.23), 0.15 (95% CI 0.12-0.19), and 0.30 (95% CI 0.27-0.33), respectively. Subgroup analyses were performed by mean age of patients, time period, region, and sample size of the study. Among molecular subtypes of breast cancer, luminal A was the most prevalent subtype followed by TNBC, luminal B, and HER2-enriched subtypes. The overall prevalence of TNBC in India is high compared to other regions of the world. Additional research is warranted to identify the determinants of high TNBC in India. Differentiating TNBC from other molecular subtypes is important to guide therapeutic management of breast cancer.
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Affiliation(s)
- Pavan Kumar Jonnada
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M H Marigowda road, Bangalore, Karnataka 560029 India
| | - Cherukuru Sushma
- Department of Pathology, AmPath Laboratory Pvt. Limited, Citizens Hospital, Hyderabad, India
| | - Madhuri Karyampudi
- Department of Radiation Oncology, MNJ Institute of Oncology, Hyderabad, India
| | - Anvesh Dharanikota
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M H Marigowda road, Bangalore, Karnataka 560029 India
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Kulkarni A, Kelkar DA, Parikh N, Shashidhara LS, Koppiker CB, Kulkarni M. Meta-Analysis of Prevalence of Triple-Negative Breast Cancer and Its Clinical Features at Incidence in Indian Patients With Breast Cancer. JCO Glob Oncol 2020; 6:1052-1062. [PMID: 32639876 PMCID: PMC7392736 DOI: 10.1200/go.20.00054] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Breast cancer is the most common cancer in women in India, with higher incidence rates of aggressive subtypes, such as triple-negative breast cancer (TNBC). METHODS A systematic review was performed to compute pooled prevalence rates of TNBC among patients with breast cancer, and clinical features at presentation were systematically compared with non-TNBC in an Indian cohort of 20,000 patients. RESULTS Combined prevalence of TNBC among patients with breast cancer was found to be on the higher side (27%; 95% CI, 24% to 31%). We found that the estrogen receptor (ER) expression cutoff used to determine ER positivity had an influence on the pooled prevalence and ranged from 30% (ER/progesterone receptor [PR] cut ff at 1%) to 24% (ER/PR cutoff at 10%). Odds for TNBC to present in the younger age-group were significantly higher (pooled odds ratio [OR], 1.35; 95% CI, 1.08 to 1.69), with a significantly younger mean age of incidence (weighted mean difference, -2.75; 95% CI, -3.59 to -1.92). TNBC showed a significantly higher odds of presenting with high grade (pooled OR, 2.57; 95% CI, 2.12 to 3.12) and lymph node positivity (pooled OR, 1.39; 95% CI, 1.21 to 1.60) than non-TNBC. CONCLUSION Systematic review and meta-analysis of 34 studies revealed a high degree of heterogeneity in prevalence of TNBC within Indian patients with breast cancer, yet pooled prevalence of TNBC is high in India. High proportions of patients with TNBC present with aggressive features, such as high grade and lymph node positivity, compared with patients without TNBC. We emphasize the need for standardized methods for accurate diagnosis in countries like India.
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Affiliation(s)
- Apurv Kulkarni
- Indian Institute of Science Education and Research, Pune, India
| | - Devaki A. Kelkar
- Prashanti Cancer Care Mission, Pune, India
- Center for Translational Cancer Research: A Joint Initiative of Prashanti Cancer Care Mission and Indian Institute of Science Education and Research, Pune, India
| | - Nidhi Parikh
- Indian Institute of Science Education and Research, Pune, India
| | - Lingadahalli S. Shashidhara
- Indian Institute of Science Education and Research, Pune, India
- Center for Translational Cancer Research: A Joint Initiative of Prashanti Cancer Care Mission and Indian Institute of Science Education and Research, Pune, India
| | - Chaitanyanand B. Koppiker
- Prashanti Cancer Care Mission, Pune, India
- Center for Translational Cancer Research: A Joint Initiative of Prashanti Cancer Care Mission and Indian Institute of Science Education and Research, Pune, India
| | - Madhura Kulkarni
- Prashanti Cancer Care Mission, Pune, India
- Center for Translational Cancer Research: A Joint Initiative of Prashanti Cancer Care Mission and Indian Institute of Science Education and Research, Pune, India
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Doval DC, Radhakrishna S, Tripathi R, Kashinath RI, Talwar V, Batra U, Mullapudi NA, Kumar K, Dewan AK, Chaturvedi H, Tayal J, Mehta A, Gupta S, Nimmagadda RBV. A multi-institutional real world data study from India of 3453 non-metastatic breast cancer patients undergoing upfront surgery. Sci Rep 2020; 10:5886. [PMID: 32246015 PMCID: PMC7125186 DOI: 10.1038/s41598-020-62618-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/16/2020] [Indexed: 12/27/2022] Open
Abstract
The present analysis reports the clinical, pathological, treatment profile and overall survival (OS) and disease-free survival (DFS) outcomes of consecutive breast cancer patients from three Indian centres, who underwent curative surgery as their first treatment. Among the 3453 patients, stage I, II, and III cases were 11.75%, 66.79%, and 21.64%, respectively while hormone receptor positive/HER2 negative, triple negative (TNBC) and hormone receptor any/HER2 positive cases were 55.2%, 24.2% and 20.6%, respectively. The five-year OS in the entire cohort, node-negative and node-positive patients were 94.1% (93.25–94.98), 96.17% (95.2–97.15) and 91.83% (90.36–93.31), respectively, and the corresponding DFS were 88.1% (86.96–89.31), 92.0% (90.64–93.39) and 83.93% (82.03–85.89), respectively. The five-year OS in hormone receptor positive/HER2 negative, TNBC and HER2 subgroups were 96.11% (95.12–97.1), 92.74% (90.73–94.8) and 90.62% (88.17–93.15), respectively, and the corresponding DFS were 91.59% (90.19–93.02), 85.46% (82.79–88.22) and 81.29% (78.11–84.61), respectively. This is the largest dataset of early breast cancer patients from India with survival outcome analysis and can therefore serve as a benchmark for future studies.
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Affiliation(s)
- Dinesh Chandra Doval
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India.
| | - Selvi Radhakrishna
- Department of Surgical Oncology, Chennai Breast Centre, Chennai, Tamil Nadu, India
| | - Rupal Tripathi
- Department of Research, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Renu Iyer Kashinath
- Department of Medical Oncology, Apollo Cancer Institutes, Chennai, Tamil Nadu, India
| | - Vineet Talwar
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | | | - Kapil Kumar
- Department of Surgical Oncology, Fortis Hospital, Delhi, India
| | - Ajay Kumar Dewan
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | | | - Juhi Tayal
- Department of Research (Biorepository), Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Anurag Mehta
- Department of Laboratory and Transfusion Services, Rajiv Gandhi Cancer Institute & Research Centre, Delhi, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ramesh B V Nimmagadda
- Department of Medical Oncology, Apollo Cancer Institutes, Chennai, Tamil Nadu, India.
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Chakraborty S, Wadasadawala T, Ahmed R, Coles C, Chatterjee S. Breast Cancer Demographics, Types and Management Pathways: Can Western Algorithms be Optimally used in Eastern Countries? Clin Oncol (R Coll Radiol) 2019; 31:502-509. [DOI: 10.1016/j.clon.2019.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 04/24/2019] [Accepted: 05/24/2019] [Indexed: 12/24/2022]
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Hariharan N, Rao TS, Naidu CK, Raju KVVN, Rajappa S, Ayyagari S, Krishnamohan MVT, Murthy S, Suryadevara A, Boleneni N. The Impact of Stage and Molecular Subtypes on Survival Outcomes in Young Women with Breast Cancer. J Adolesc Young Adult Oncol 2019; 8:628-634. [PMID: 31259658 DOI: 10.1089/jayao.2019.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Young women form a unique cohort in breast cancer, with evidence suggesting a later stage at presentation with more aggressive cancers. We aimed at evaluating the prognostic significance of young age and the impact of stage and molecular subtypes on survival. We conducted an audit of a prospectively maintained database at our institute between 2010 and 2014. All women with available receptor status and documented follow-up were included. The young breast cancer (YBC) cohort comprised 103 women and 230 women constituted the comparator arm (45-55 years). The median follow-up was 4 years. The YBC had a higher incidence of hormone negative tumors (61.1% vs. 46.3%, p = 0.012, significant [S]); however, both groups were similar in their stage at presentation. On classification into luminal subtypes, triple negative breast cancer was more common in the YBC cohort (50.5% vs. 29.6%, p = 0.001, S). The 5-year disease-free survival (DFS) was significantly worse in the YBC cohort (70.3% vs. 78%, p = 0.03, S). This detriment appeared to be significantly more in women presenting with operable breast cancer (77.2% vs. 82.6%, p = 0.012, S). Among the Luminal subtypes, there was no significant difference in the DFS between the two groups. Young age is a negative prognostic factor among women presenting with breast cancer. Further studies are required to evaluate whether any specific stage or molecular sub-type is particularly vulnerable to a poor outcome despite treatment.
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Affiliation(s)
- Nisha Hariharan
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - T Subramanyeshwar Rao
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Chandra K Naidu
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - K V V N Raju
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Senthil Rajappa
- Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Santa Ayyagari
- Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - M V T Krishnamohan
- Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Sudha Murthy
- Department of Pathology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Aparna Suryadevara
- Department of Radiation Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Naren Boleneni
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
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Mullapudi NA, Kirti KK, Padmanaban N, Nimmagadda R, Radhakrishna S. Outcomes of Breast Cancer Management from an Urban Specialist Breast Center in South India. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_206_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Context and Aims: The disease pattern and presentation of breast cancer in India are thought to differ from the West. The purpose of this study is to describe and to discuss the presentation, clinicopathological data, and survival from an urban specialist breast center in Southern India. Materials and Methods: Prospectively collected data were analyzed for clinicopathological details, treatment variables, and survival outcomes were analyzed. Cumulative survival curves were estimated using the Kaplan–Meier method for patients treated from 2007 to 2011. Results: A total of 1671 patients were operated at our center from January 2007 to December 2016. Average age at diagnosis was 54.2 years. Over 70% had Stage I and Stage II disease, infiltrating duct carcinoma was predominant in 88.2%. Average clinical tumor size was three centimeters. Breast conservation was performed in 22.4%. Sentinel lymph node biopsy was performed in 44.6%. Estrogen-receptor positivity was seen in 64.6%, 22.2% were Her2Neu positive. Triple negative disease was seen in 19.1%. Survival analysis was done using the Kaplan–Meier curves for 540 patients treated from 2007 to 2011. The median follow-up of surviving patients was 70 months with 10% lost to follow-up. In our study population, the 5 years overall survival rate is 88.3% and disease-free survival is 85.7%. Conclusion: Our study reflects a higher percentage of early breast cancer with outcomes comparable to the West. More research is required to understand the genetic predisposition in our population.
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Affiliation(s)
- Naga Amulya Mullapudi
- Department of Oncoplastic Breast Surgery, Chennai Breast Centre, Chennai, Tamil Nadu, India
| | - Kabeer Katherine Kirti
- Department of Oncoplastic Breast Surgery, Chennai Breast Centre, Chennai, Tamil Nadu, India
| | | | - Ramesh Nimmagadda
- Department of Medical Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Selvi Radhakrishna
- Department of Oncoplastic Breast Surgery, Chennai Breast Centre, Chennai, Tamil Nadu, India
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Bhaskar S, Rastogi K, Gupta S, Jindal A, Bhatnagar AR, Jain S. A Study of Hormone Receptor Status in Breast Carcinoma and use of HER2-Targeted Therapy in a Tertiary Care Center of India. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_172_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Aims: The aim is to study the hormone receptor status, association of HER2 expression with prognostic factors and use of HER2-targeted therapy in North Indian breast cancer patients. Subjects and Methods: Immunohistochemistry reports of 288 breast cancer patients registered in the department of Radiotherapy, SMS Medical College, Jaipur in 2015–2016 were analyzed for estrogen receptor (ER), progesterone receptor (PR), and c-erb B-2 protein (HER2/neu) expression. Equivocal HER2 (2+) was further confirmed by fluorescent in situ hybridization (FISH). Number of patients receiving HER2/neu-targeted therapy was also studied. Results: For ER, positive status was more common (56%), whereas for PR and HER2/neu, negative status was more common (59% and 60% resp.). HER2 status was unknown for 25% patients. The percentage of equivocal HER2 (immunohistochemistry 2+) cases showing amplification on FISH was also high (56.7%). The percentage of eligible cases for targeted therapy actually receiving it was low (28%). The percentage of triple negative phenotype (ER-/PR-/HER2-) was high (29.8%). Triple-negative breast cancer phenotype was more common in young-aged premenopausal women but was not statistically significant. All HER2/neu + cases were infiltrating ductal carcinoma. HER2/neu expression was significantly higher with large tumor size (P = 0.001), high tumor grade (P < 0.001), advanced stage (P = 0.001), greater number of positive lymph nodes (P = 0.02), and ER/PR negativity (P < 0.001). Conclusions: Most of the breast cancer patients are ER and/or PR positive and HER2/neu negative. The percentage of triple-negative phenotype is higher. More than half of HER2/neu 2+ cases show amplification on FISH assay. The percentage of eligible patients actually receiving targeted therapy is low. HER2/neu protein expression is significantly higher with adverse features such as large tumor size, high grade, advanced stage, greater number of positive lymph nodes, and ER/PR negativity.
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Affiliation(s)
- Sandeep Bhaskar
- Departments of Radiotherapy, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Kartick Rastogi
- Departments of Radiotherapy, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Shivani Gupta
- Departments of Radiotherapy, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Arpita Jindal
- Departments of Pathology, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | | | - Sandeep Jain
- Departments of Radiotherapy, SMS Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
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Ramaswamy A, Ostwal V, Pande N, Sharma A, Patil S, Thippeswamy R, Ghadyalpatil N, Roy R, Peshwe H, Poladia B, Rajamanickam D, Rangarajan B, Neelesh Reddy PR, Pandita V, Mukherjee A, Thoke A, Sarkar A, Satish CT, Shashidara H, Banavali SD. Practice patterns and outcomes with the use of regorafenib in metastatic colorectal cancer: Results from the Regorafenib in Metastatic colorectal cancer - An Indian exploratory analysis study. South Asian J Cancer 2019; 8:22-26. [PMID: 30766846 PMCID: PMC6348777 DOI: 10.4103/sajc.sajc_173_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Regorafenib is considered a standard of care as third-line therapy in metastatic colorectal cancers (mCRCs). MATERIALS AND METHODS The study was based on a computerized clinical data form sent to oncologists across the country for entry of anonymized patient data. The data entry form was conceived and generated by the coordinating center's (Tata Memorial Hospital) gastrointestinal medical oncologists and disseminated through personal contacts at academic conferences as well as through E-mail to various oncologists across India. RESULTS A total of 19 physicians contributed data resulting in 80 patients receiving regorafenib who were available for the evaluation of practice patterns. The median age was 55 years (range: 24-75). Majority had received oxaliplatin-based (97.5%), irinotecan-based (87.5%), and targeted therapy (65%), previously. Patients were primarily started on reduced doses of regorafenib upfront (160 mg - 28.8%, 120 mg - 58.8%, and 80 mg - 12.5%). The median duration of treatment (treatment duration) with regorafenib was 3.1 months (range: 0.5-18), while the median progression free survival was 3.48 months (range: 2.6-4.3). Forty-five percent of patients required dose modifications due to toxicities, and the most common were (all grades) hand-foot syndrome (68.8%), fatigue (46.3%), mucositis (37.6%), and diarrhea (31.3%). CONCLUSIONS Majority of physicians in this collaborative study from India used a lower dose of regorafenib at the outset in patients with mCRC. Despite a lower dose, there was a significant requirement for dose reduction. Duration of treatment with regorafenib as an efficacy end point in this study is similar to available data from other regions as it is the side effect profile.
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Affiliation(s)
- Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nikhil Pande
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Atul Sharma
- Department of Medical Oncology, Dr. B. R. A IRCH, AIIMS, New Delhi, India
| | - Shekar Patil
- Department of Medical Oncology, HCG, Bengaluru, Karnataka, India
| | - Ravi Thippeswamy
- Department of Medical Oncology, Sri Shankara Cancer Hospital, Bengaluru, Karnataka, India
| | - Nikhil Ghadyalpatil
- Department of Medical Oncology, Yashoda Cancer Institute, Hyderabad, Telangana, India
| | - Rakesh Roy
- Saroj Gupta Cancer Centre and Research Institute, Kolkata, West Bengal, India
| | - Harish Peshwe
- Department of Gastroenterology and Hepatology, Healthway Hospitals, Panjim, Goa, India
| | | | | | | | - P. R. Neelesh Reddy
- Department of Medical Oncology, Columbia Asia Hospital, Bengaluru, Karnataka, India
| | - Vimal Pandita
- Department of Medical Oncology, Max Superspeciality Hospital, Dehradun, Uttarakhand, India
| | - Ashis Mukherjee
- Department of Oncology, Netaji Subhash Chandra Bose Cancer Research Institute, Kolkata, West Bengal, India
| | - Aniket Thoke
- Department of Oncology, Sanjeevani CBCC USA Cancer Hospital, Raipur, Chhattisgarh, India
| | - Abhijit Sarkar
- Saroj Gupta Cancer Center and Research Institute, Kolkata, West Bengal, India
| | - C. T. Satish
- Department of Medical Oncology, HCG, Bengaluru, Karnataka, India
| | - H. Shashidara
- Department of Medical Oncology, HCG, Bengaluru, Karnataka, India
| | - S. D. Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Wadasadawala T, Lewis S, Parmar V, Budrukkar A, Gupta S, Nair N, Shet T, Badwe R, Sarin R. Bilateral Breast Cancer After Multimodality Treatment: A Report of Clinical Outcomes in an Asian Population. Clin Breast Cancer 2018; 18:e727-e737. [DOI: 10.1016/j.clbc.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/03/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Sudeep G, Sanjoy C, Jagdish N, Shyam A, Manish S, Alurkar SS, Anil K, Smruti BK, Shona N, Amit A, Vijay A, Chacko R, Chirag D, Chanchal G, Pavithran K, Poonam P, Krishna P, Rejiv R, Rao RR, Sahoo TP, Ashish S, Randeep S, Sankar S, Arun W, Binay S, Priyanka B, Advani SH. Current Treatment Options for Human Epidermal Growth Factor Receptor 2-Directed Therapy in Metastatic Breast Cancer: An Indian Perspective. Indian J Med Paediatr Oncol 2018. [DOI: 10.4103/ijmpo.ijmpo_201_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractHuman epidermal growth factor receptor 2 (HER2)-positive is an aggressive subtype of breast cancer and has historically been associated with poor outcomes. The availability of various anti-HER2 therapies, including trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine (TDM-1), has remarkably improved the clinical outcomes in patients with HER2-positive metastatic breast cancer (mBC). However, there is a need to optimize treatment within this population, given the wide variability in clinical presentation. Additionally, geographical and socio-economic considerations too need to be taken into account. To clarify and collate evidence pertaining to HER2-positive metastatic breast cancer, a panel of medical and clinical oncologists from across India developed representative clinical scenarios commonly encountered in clinical practice in the country. This was followed by two meetings wherein each clinical scenario was discussed in detail and relevant evidence appraised. The result of this process is presented in this manuscript as evidence followed by therapeutic recommendations of this panel for management of HER2-positive mBC in the Indian population.
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Affiliation(s)
- Gupta Sudeep
- Department of Medical Oncology, Tata Memorial Centre, ACTREC, Navi Mumbai, Maharashtra, India
| | - Chatterjee Sanjoy
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Nigade Jagdish
- Medical, Roche Products (India) Pvt. Ltd., Mumbai, Maharashtra, India
| | - Aggarwal Shyam
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
| | - Singhal Manish
- Department of Medical Oncology, Indraprastha Apollo Hospitals, New Delhi, India
| | - SS Alurkar
- Department of Oncology, Apollo Hospitals, Ahmedabad, Gujarat, India
| | - Kukreja Anil
- Medical, Roche Products (India) Pvt. Ltd., Mumbai, Maharashtra, India
| | - BK Smruti
- Department of Medical Oncology, Bombay Hospital, Mumbai, Maharashtra, India
| | - Nag Shona
- Department of Oncology, Jehangir Hospital, Pune, Maharashtra, India
| | - Agarwal Amit
- Department of Medical Oncology, BL Kapoor Hospital, Delhi, India
| | - Agarwal Vijay
- Department of Medical Oncology, Healthcare Global, Bengaluru, Karnataka, India
| | - R Chacko
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Desai Chirag
- Hemato-Oncology Clinic, Vedanta Super Speciality Hospital, Ahmedabad, India
| | - Goswami Chanchal
- Department of Oncology, Medica Superspecialty Hospital, Kolkata, West Bengal, India
| | - Keechilat Pavithran
- Department of Medical Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Patil Poonam
- Department of Medical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
| | - Prasad Krishna
- Department of Medical Oncology, Kasturba Medical College, Mangalore, Karnataka, India
| | - Rajendranath Rejiv
- Department of Medical Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - RR Rao
- Department of Medical Oncology, Max Super Speciality Hospital, Delhi, India
| | - TP Sahoo
- Department of Medicine, Chirayu Medical College, Bhopal, Madhya Pradesh, India
| | - Singh Ashish
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Singh Randeep
- Department of Oncology, Artemis Hospital, Gurgaon, Haryana, India
| | - Srinivasan Sankar
- Department of Medical Oncology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Warrier Arun
- Department of Medical Oncology, Aster Medicity Hospital, Kochi, Kerala, India
| | - Swarup Binay
- Medical Roche Products (India), Mumbai, Maharashtra, India
| | | | - SH Advani
- Medical Oncology, Mumbai, Maharashtra, India
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Bahl A, Singh R, Wadhwa J, Gupta S, Ahmed M, Uppal PN, Parikh PM, Aggarwal S. Practical consensus recommendations regarding the management of HER2 neu positive early breast cancer. South Asian J Cancer 2018; 7:102-105. [PMID: 29721473 PMCID: PMC5909284 DOI: 10.4103/sajc.sajc_111_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations with regards to the use of these agents and the management of HER2 neu early breast cancer for the benefit of community oncologists.
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Affiliation(s)
- A. Bahl
- Deparment of Medical Oncology, Max Hospital, New Delhi, India
| | - R. Singh
- Department of Medical Oncology, Artemis Hospital, Gurugram, India
| | - J. Wadhwa
- Department of Medical Oncology, Medanta Hospital, Gurugram, India
| | - S. Gupta
- Department of Medical Oncology, Sarvodaya Hospital, New Delhi, India
| | - M. Ahmed
- Department of Radiation Oncology, Jolly Grant Himalayan Institute, Dehradoon, India
| | - P. N. Uppal
- Department of Surgical Oncology, Jaipur Golden Hospital, New Delhi, India
| | - Purvish M. Parikh
- Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
| | - S. Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
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Haitsma G, Patel H, Gurumurthy P, Postma MJ. Access to anti-cancer drugs in India: is there a need to revise reimbursement policies? Expert Rev Pharmacoecon Outcomes Res 2018; 18:289-296. [DOI: 10.1080/14737167.2018.1444479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Gertruud Haitsma
- Department of Pharmacy Practice, JSS College of Pharmacy, Mysore, JSS University, Mysore, India
- Department of Pharmacy, Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), University of Groningen, Groningen, The Netherlands
| | - Himanshu Patel
- Department of Pharmacy Practice, JSS College of Pharmacy, Mysore, JSS University, Mysore, India
| | | | - Maarten J. Postma
- Department of Pharmacy, Unit of PharmacoTherapy, -Epidemiology & -Economics (PTE2), University of Groningen, Groningen, The Netherlands
- Institute of Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
- Department of Epidemiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
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Abstract
There is a global mandate even in countries with low resources to improve the accuracy of testing biomarkers in breast cancer viz. oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2neu) given their critical impact in the management of patients. The steps taken include compulsory participation in an external quality assurance (EQA) programme, centralized testing, and regular performance audits for laboratories. This review addresses the status of ER/PR and HER2neu testing in India and possible reasons for the delay in development of guidelines and mandate for testing in the country. The chief cause of erroneous ER and PR testing in India continues to be easily correctable issues such as fixation and antigen retrieval, while for HER2neu testing, it is the use of low-cost non-validated antibodies and interpretative errors. These deficiencies can however, be rectified by (i) distributing the accountability and responsibility to surgeons and oncologist, (ii) certification of centres for testing in oncology, and (iii) initiation of a national EQA system (EQAS) programme that will help with economical solutions and identifying the centres of excellence and instill a system for reprimand of poorly performing laboratories.
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Affiliation(s)
- Tanuja Shet
- Department of Histopathology, Tata Memorial Centre, Mumbai, India
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Prabhu JS, Korlimarla A, Anupama CE, Alexander A, Raghavan R, Kaul R, Desai K, Rajarajan S, Manjunath S, Correa M, Raman R, Kalamdani A, Prasad M, Patil S, Gopinath KS, Srinath BS, Sridhar TS. Dissecting the Biological Heterogeneity within Hormone Receptor Positive HER2 Negative Breast Cancer by Gene Expression Markers Identifies Indolent Tumors within Late Stage Disease. Transl Oncol 2017; 10:699-706. [PMID: 28704710 PMCID: PMC5506875 DOI: 10.1016/j.tranon.2017.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/27/2017] [Indexed: 12/20/2022] Open
Abstract
Hormone receptor positive (HR+) breast cancers are a heterogeneous class with differential prognosis. Although more than half of Indian women present with advanced disease, many such patients do well. We have attempted identification of biologically indolent tumors within HR+HER2- tumors based on gene expression using histological grade as a guide to tumor aggression. 144 HR+HER2- tumors were divided into subclasses based on scores derived by using transcript levels of multiple genes representing survival, proliferation, and apoptotic pathways and compared to classification by Ki-67 labeling index (LI). Clinical characters and disease free survival were compared between the subclasses. The findings were independently validated in the METABRIC data set. Using the previously established estrogen receptor (ER) down stream activity equation, 20% of the tumors with greater than 10% HR positivity by immunohistochemistry (IHC) were still found to have inadequate ER function. A tumor aggression probability score was used to segregate the remainder of tumors into indolent (22%) and aggressive (58%) classes. Significant difference in disease specific survival was seen between the groups (P = .02). Aggression probability based subclassification had a higher hazard ratio and also independent prognostic value (P<.05). Independent validation of the gene panel in the METABRIC data set showed all 3 classes; indolent (24%), aggressive (68%), and insufficient ER signaling (7%) with differential survival (P = .01). In agreement with other recent reports, biologically indolent tumors can be identified with small sets of gene panels and these tumors exist in a population with predominantly late stage disease.
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Affiliation(s)
- Jyothi S Prabhu
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India.
| | - Aruna Korlimarla
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - C E Anupama
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Annie Alexander
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Rohini Raghavan
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Roma Kaul
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Krisha Desai
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Savitha Rajarajan
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
| | - Suraj Manjunath
- Department of Surgical Oncology, Department of Pathology, St. John's Medical College Hospital, Bangalore, India
| | - Marjorrie Correa
- Department of Surgical Oncology, Department of Pathology, St. John's Medical College Hospital, Bangalore, India
| | - R Raman
- Shankara Cancer Hospital and Research Centre, Bangalore, India
| | | | - Msn Prasad
- Shankara Cancer Hospital and Research Centre, Bangalore, India
| | - Shekar Patil
- Shankara Cancer Hospital and Research Centre, Bangalore, India
| | | | - B S Srinath
- Shankara Cancer Hospital and Research Centre, Bangalore, India
| | - T S Sridhar
- Division of Molecular Medicine, St. John's Research Institute, Bangalore, India
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Thakur KK, Bordoloi D, Kunnumakkara AB. Alarming Burden of Triple-Negative Breast Cancer in India. Clin Breast Cancer 2017; 18:e393-e399. [PMID: 28801156 DOI: 10.1016/j.clbc.2017.07.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/16/2017] [Indexed: 01/11/2023]
Abstract
Breast cancer is the most prevalent cancer among women worldwide. Among the different breast cancer subtypes, triple-negative breast cancer (TNBC), which is more prevalent among younger age women, is the most aggressive form. Numerous clinicopathologic studies performed throughout the world strongly support the utterly poor prognoses and high recurrence rate of TNBC. The present report details a thorough data survey from Google and PubMed on the burden of TNBC worldwide and other associated factors, with special emphasis on its ever increasing incidence among Indian women. Our analysis revealed that the proportion of TNBC ranges from 6.7% to 27.9% in different countries, with the highest reported percentage in India among all, followed by Indonesia, Algeria, and Pakistan. Most of the other countries (Netherlands, Italy, London, Germany) had a TNBC incidence less than the mean level (ie, 15%). The high incidence of TNBC in the Indian population is associated with vivid risk factors, which primarily include lifestyle, deprivation status, obesity, family history, high mitotic indexes, and BRCA1 mutations. The treatment of TNBC is greatly hampered due to the lack of targeted therapies. Hence, it requires earnest attention towards extensive research for the prevention and development of treatment modalities with high efficacy.
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Affiliation(s)
- Krishan K Thakur
- Cancer Biology Laboratory & DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Assam, India
| | - Devivasha Bordoloi
- Cancer Biology Laboratory & DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Assam, India
| | - Ajaikumar B Kunnumakkara
- Cancer Biology Laboratory & DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Assam, India.
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Hingmire SS, Sambhus MB, Kelkar DS, Joshi S, Parikh PM, Bharath R. Efficacy and safety of short course adjuvant trastuzumab combination chemotherapy in breast cancer. South Asian J Cancer 2017; 6:47-50. [PMID: 28702403 PMCID: PMC5506806 DOI: 10.4103/sajc.sajc_68_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The adjuvant short course 9-week trastuzumab combination therapy for human epidermal receptor 2 positive breast cancer patients may often be considered as a cost-effective and safe option and has important implications for the Indian subcontinent as well as other developing countries. However, such regimens of shorter duration trastuzumab therapy like FinHer, offered in view of economic constraints, may not be able to achieve globally comparable cure rates in early breast cancer especially with high-risk women with more than 3 lymph node positive. Methods and Material: Outcome of 21 patients with HER2 positive breast cancer was treated with short course trastuzumab combination chemotherapy in the adjuvant setting was studied. Results: Out of 21 patients 15 are alive and disease free with a follow up of up to 73 months (median follow up 42 months).
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Affiliation(s)
- Sachin S Hingmire
- Department of Oncology, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Mahesh B Sambhus
- Department of Oncology, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Dhananjay S Kelkar
- Department of Oncology, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Sujit Joshi
- Department of Oncology, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Purvish M Parikh
- Department of Oncology, Asian Institute of Oncology, Mumbai, Maharashtra, India
| | - R Bharath
- Department of Oncology, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
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Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol 2017; 13:289-295. [PMID: 28181405 DOI: 10.1111/ajco.12661] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/03/2016] [Accepted: 12/03/2016] [Indexed: 12/01/2022]
Abstract
Breast cancer has ranked number one cancer among Indian females with age adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women. Data reports from various latest national cancer registries were compared for incidence, mortality rates. The age adjusted incidence rate of carcinoma of the breast was found as high as 41 per 100,000 women for Delhi, followed by Chennai (37.9), Bangalore (34.4) and Thiruvananthapuram District (33.7). A statistically significant increase in age adjusted rate over time (1982-2014) in all the PBCRs namely Bangalore (annual percentage change: 2.84%), Barshi (1.87%), Bhopal (2.00%), Chennai (2.44%), Delhi (1.44%) and Mumbai (1.42%) was observed. Mortality-to-incidence ratio was found to be as high as 66 in rural registries whereas as low as 8 in urban registries. Besides this young age has been found as a major risk factor for breast cancer in Indian women. Breast cancer projection for India during time periods 2020 suggests the number to go as high as 1797900. Better health awareness and availability of breast cancer screening programmes and treatment facilities would cause a favorable and positive clinical picture in the country.
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Affiliation(s)
- Shreshtha Malvia
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | | | - Uma S Dubey
- Birla institute of Technology, Pilani, Rajasthan, India
| | - Sunita Saxena
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
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Geethamala K, Murthy VS, Vani BR, Rao MS, Thejaswini MU, Padmaja KP. Comparison of Immunocytochemistry and Immunohistochemistry on Breast Carcinoma: A Boon or a Bane? J Lab Physicians 2017; 9:5-10. [PMID: 28042209 PMCID: PMC5015499 DOI: 10.4103/0974-2727.187915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Breast carcinoma is the most common cancer among women in the urban Indian population. Conventionally, immunohistochemistry (IHC) is done to determine the hormone receptor status of the tumor. Immunocytochemistry (ICC) on fine-needle aspiration cytology (FNAC) was carried out to determine the same hormone receptor status of the tumor. Objective: The study was undertaken to evaluate the diagnostic reliability of performing estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her2/neu) receptor status on FNAC by ICC and to compare the results with IHC. Materials and Methods: A 2 years 6 months prospective study conducted in the Department of Pathology, ESIC Medical College and PGIMSR and ESIC Model Hospital, Rajajinagar, Bengaluru, wherein 100 breast carcinoma patients' samples both cytology and histology were collected. IHC and ICC were done by peroxidase antiperoxidase technique. Validations of the receptor status were analyzed using sensitivity, specificity, positive and negative predictive values (PPV and NPV), and kappa statistics for agreements between ICC and IHC. Results: ICC was positive for ER, PR, and Her2/neu in 53, 50, and 22 cases, respectively. For ER, a cytohistologic correlation of 98%, with a sensitivity of 96.3%, specificity of 100%, and PPV and NPV being 100% and 95.7%. For PR, concordance of 97%, with a sensitivity of 94.3%, specificity of 100%, and PPV and NPV being 100% and 94%. Her2/neu had an agreement of 89%, with a sensitivity of 72%, specificity of 95.5%, and PPV and NPV being 85.7% and 90.1%. Conclusion: ICC has been a boon and can be a paramount diagnostic adjunct to the routine investigations.
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Affiliation(s)
- Kempula Geethamala
- Department of Pathology, Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
| | | | | | - Madireddi Sudha Rao
- Department of Pathology, ESIC Medical College and PGIMSR, Rajajinagar, Bengaluru, Karnataka, India
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Mir MA, Manzoor F, Singh B, Raja W, Jeelani S, Zargar WA, Ahmad FF, Ko AZ, Sofi IA. Clinicopathological Profile of Breast Cancer Patients at a Tertiary Care Hospital in Kashmir Valley. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ss.2017.83018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Adusumilli P, Konatam ML, Gundeti S, Bala S, Maddali LS. Treatment Challenges and Survival Analysis of Human Epidermal Growth Factor Receptor 2-positive Breast Cancer in Real World. Indian J Med Paediatr Oncol 2017; 38:22-27. [PMID: 28469333 PMCID: PMC5398102 DOI: 10.4103/0971-5851.203511] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
CONTEXT Advent of trastuzumab has brought tremendous changes in the survival of human epidermal growth factor receptor 2 (Her2)-positive breast cancer patients. Despite the availability of the drug, it is still out of reach for many patients. There is very limited real world data regarding treatment challenges and survival analysis of these patients. AIMS AND OBJECTIVES Primary objective is disease-free survival (DFS) and secondary objective is overall survival (OS) and toxicity profile. STATISTICS Statistical analysis is done using GraphPad Prism 7.02. MATERIALS AND METHODS This is a retrospective study of all patients diagnosed with Her2-positive (Her2+) nonmetastatic invasive breast cancer from January 2007 to December 2013. RESULTS In the period of this study, 885 patients are diagnosed with carcinoma breast, of which 212 are Her2/neu positive (23.9%). Of the 212 patients, only 76 (35.8%) patients received trastuzumab along with chemotherapy. Patients receiving trastuzumab with chemotherapy have longer 5-year DFS compared to those receiving chemotherapy alone, 92% and 52.6%, respectively (P = 0.0001). Five-year OS is 90.5% and 41.7% in those patients who received chemotherapy with and without trastuzumab, respectively (P = 0.0001). Seven patients (9.45%) developed Grade II reversible diastolic dysfunction. Grade II/III peripheral neuropathy due to paclitaxel is the main adverse effect seen in 21 patients. CONCLUSION In spite of improvement in DFS and OS with trastuzumab, the number of patient receiving targeted therapy is very low due to financial constraints which need to be addressed to bridge the gap in survival of Her2+ patients.
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Affiliation(s)
- Praveen Adusumilli
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Meher Lakshmi Konatam
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sadashivudu Gundeti
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Stalin Bala
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Lakshmi Srinivas Maddali
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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44
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Chauhan R. The Relevance of Established Risk Factors in Context to Indian Breast Cancer Patients. WOMENS HEALTH 2016. [DOI: 10.15406/mojwh.2016.03.00063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sable M, Pai TD, Shet T, Patil A, Dhanavade S, Desai SB. Triple-Negative Breast Cancer: A Comprehensive Study of Clinical, Histomorphological, and Immunohistochemical Features in Indian Patients. Int J Surg Pathol 2016; 25:230-237. [PMID: 27612858 DOI: 10.1177/1066896916667815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Triple-negative breast cancers (TNBCs) are characterized by negative expression for estrogen (ER), progesterone (PR), and human epidermal growth factor 2 (HER2) receptors. Although the majority of basal-like breast cancers (BLBCs) diagnosed based on gene expression profiling belong to the TNBC group, both entities are not synonymous. Core BLBCs are TNBCs, which are positive for basal cytokeratin (CK) and/or epidermal growth factor receptor (EGFR). We aimed to study and correlate a TNBC cohort for various histomorphological features and immunohistochemical (IHC) profile in Indian patients. We studied 205 naïve TNBCs for histopathological features, which were further evaluated for basal CKs-namely, CK5/6, CK14, CK17-and EGFR expression to classify them as core BLBCs, using criteria of any basal CK and/or EGFR positivity and 7-negative phenotype (7NP). Among 205 TNBCs, 91% of cases were core BLBCs, and absence of ductal carcinoma in situ (DCIS) was significantly associated ( P = .014) with core BLBC. Geographic necrosis was correlated with expression of CK17 ( P = .002) and EGFR ( P = .038). A ribbon-like trabecular pattern and absence of DCIS were associated with CK17 ( P = .0002 and P = .043, respectively) and CK14 ( P = .04 and P = .0008, respectively). TNBC is a heterogeneous subgroup with adverse clinicopathological features, and many of them show significant correlation with basal CKs. TNBCs cannot be classified as core BLBC or 7NP based on morphological features, except absence of DCIS. However, this study illustrates the heterogeneity in TNBCs on the basis of IHC markers.
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46
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Affiliation(s)
- Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
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47
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Der EM, Gyasi RK, Tettey Y, Edusei L, Bayor MT, Jiagge E, Gyakobo M, Merajver SD, Newman LA. Triple-Negative Breast Cancer in Ghanaian Women: The Korle Bu Teaching Hospital Experience. Breast J 2016; 21:627-33. [PMID: 26547900 DOI: 10.1111/tbj.12527] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Breast cancers that have negative or extremely low expression of estrogen receptor and progesterone receptor and non-amplification of human epidermal growth factor receptor-2 (HER2)/neu are termed triple-negative breast cancer (TNBC). The majority of TNBC tumors belong to the biologically aggressive basal subtype, and they cannot be managed with targeted endocrine or anti-HER2/neu agents. In western, high resource environments, risk factors for TNBC include younger age at diagnosis and hereditary susceptibility. Women of African ancestry in the United States and in continental Africa have higher frequencies of TNBC, prompting speculation that this risk may have an inherited basis and may at least partially explain breast cancer survival disparities related to racial/ethnic identity. Efforts to document and confirm the breast cancer burden of continental Africa have been hampered by the limited availability of registry and immunohistochemistry resources. Our goal was to evaluate the breast cancers diagnosed in one of the largest health care facilities in western Africa, and to compare the frequencies as well as risk factors for TNBC versus non-TNBC in this large referral tertiary hospital. The Korle Bu Teaching Hospital is affiliated with the University of Ghana and is located in Accra, the capital of Ghana. We conducted an institutional, Department of Pathology-based review of the breast cancer cases seen at this facility for the 2010 calendar year, and for which histopathologic specimens were available. The overall study population of 223 breast cancer cases had a median age of 52.4 years, and most had palpable tumors larger than 5 cm in diameter. More than half were TNBC (130; 58.3%). We observed similar age-specific frequencies, distribution of stage at diagnosis and tumor grade among cases of TNBC compared to cases of non-TNBC. Ghanaian breast cancer patients tend to have an advanced stage distribution and relatively younger age at diagnosis compared to Caucasian Americans and African Americans. The triple-negative molecular marker pattern was the most common subtype of breast cancer seen among this sample of Ghanaian women, regardless of age, tumor grade, or stage of diagnosis. Research into the molecular pathogenesis of TNBC may help elucidate the reasons for its increased prevalence among women with African ancestry.
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Affiliation(s)
- Edmund M Der
- University of Ghana Medical School and Korle-Bu Teaching Hospital, Accra, Ghana
| | - Richard K Gyasi
- University of Ghana Medical School and Korle-Bu Teaching Hospital, Accra, Ghana
| | - Yao Tettey
- University of Ghana Medical School and Korle-Bu Teaching Hospital, Accra, Ghana
| | - Lawrence Edusei
- University of Ghana Medical School and Korle-Bu Teaching Hospital, Accra, Ghana
| | - Marcel T Bayor
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Evelyn Jiagge
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Sofia D Merajver
- University of Michigan Medical School, Ann Arbor, Michigan.,Center for Global Health, University of Michigan, Ann Arbor, Michigan
| | - Lisa A Newman
- University of Michigan Medical School, Ann Arbor, Michigan.,Center for Global Health, University of Michigan, Ann Arbor, Michigan
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48
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Sandhu GS, Erqou S, Patterson H, Mathew A. Prevalence of Triple-Negative Breast Cancer in India: Systematic Review and Meta-Analysis. J Glob Oncol 2016; 2:412-421. [PMID: 28717728 PMCID: PMC5493252 DOI: 10.1200/jgo.2016.005397] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Purpose There is considerable variation in prevalence rates of triple-negative breast cancer (TNBC) reported by various studies from India. We performed a systematic review and literature-based meta-analysis of these studies. Methods We searched databases of Medline, Scopus, EMBASE, and Web of Science for studies that reported on the prevalence of TNBC in India that were published between January 1, 1999, and December 31, 2015. We extracted relevant information from each study by using a standardized form. We pooled study-specific estimates by using random-effects meta-analysis to provide summary estimates. We explored sources of heterogeneity by using subgroup analyses and metaregression. Results Data were obtained from 17 studies that involved 7,237 patients with breast cancer. Overall combined prevalence of TNBC was 31% (95% CI, 27% to 35%). There was substantial heterogeneity across the studies (I2 of 91% [95% CI, 88% to 94%]; P < .001) that was not explained by available study level characteristics, including study location, definition of human epidermal growth factor receptor 2 or estrogen receptor, mean age of participants, proportion of patients with premenopausal cancer, grade 3 disease, or tumor size > 5 cm. Overall combined prevalence of hormone receptor–positive and human epidermal growth factor receptor 2–positive breast cancer was 48% (95% CI, 42% to 54%) and 27% (95% CI, 24% to 31%), respectively. There was no evidence of publication bias. Conclusion Prevalence of TNBC in India is considerably higher compared with that seen in Western populations. As many as as one in three women with breast cancer could have triple-negative disease. This finding has significant clinical relevance as it may contribute to poor outcomes in patients with breast cancer in India. Additional research is needed to understand the determinants of TNBC in India.
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Affiliation(s)
- Gurprataap S Sandhu
- , , and , University of Pittsburgh Medical Center, Pittsburgh, PA; and , Markey Cancer Center, University of Kentucky, Lexington, KY
| | - Sebhat Erqou
- , , and , University of Pittsburgh Medical Center, Pittsburgh, PA; and , Markey Cancer Center, University of Kentucky, Lexington, KY
| | - Heidi Patterson
- , , and , University of Pittsburgh Medical Center, Pittsburgh, PA; and , Markey Cancer Center, University of Kentucky, Lexington, KY
| | - Aju Mathew
- , , and , University of Pittsburgh Medical Center, Pittsburgh, PA; and , Markey Cancer Center, University of Kentucky, Lexington, KY
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Takalkar UV, Asegaonkar SB, Kulkarni U, Kodlikeri PR, Kulkarni U, Saraf M, Advani S. Clinicopathological Profile of Breast Cancer Patients at a Tertiary Care Hospital in Marathwada Region of Westen India. Asian Pac J Cancer Prev 2016; 17:2195-8. [DOI: 10.7314/apjcp.2016.17.4.2195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Mahajan P, Kulkarni A, Narayanswamy S, Dalal J, Halbe V, Patkar S, Bhatt A. Reasons why patients fail screening in Indian breast cancer trials. Perspect Clin Res 2015; 6:190-3. [PMID: 26623389 PMCID: PMC4640011 DOI: 10.4103/2229-3485.167100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: An increased number of screen failure patients in a clinical trial increases time and cost required for the recruitment. Assessment of reasons for screen failure can help reduce screen failure rates and improve recruitment. Materials and Methods: We collected retrospective data of human epidermal growth factor receptor (HER2) positive Indian breast cancer patients, who failed screening for phase 3 clinical trials and ascertained their reasons for screen failure from screening logs. Statistical comparison was done to ascertain if there are any differences between private and public sites. Results: Of 727 patients screened at 14 sites, 408 (56.1%) failed screening. The data on the specific reasons for screen failures was not available at one of the public sites (38 screen failures out of 83 screened patients). Hence, after excluding that site, further analysis is based on 644 patients, of which 370 failed screening. Of these, 296 (80%) screen failure patients did not meet selection criteria. The majority -266 were HER2 negative. Among logistical issues, 39 patients had inadequate breast tissue sample. Sixteen patients withdrew their consent at private sites as compared to six at public sites. The difference between private and public sites for the above three reasons was statistically significant. Conclusion: Use of prescreening logs to reduce the number of patients not meeting selection criteria and protocol logistics, and patient counseling to reduce consent withdrawals could be used to reduce screen failure rate.
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Affiliation(s)
- P Mahajan
- Department of Clinical Operations, Clininvent Research Pvt. Ltd, Mumbai, India
| | - A Kulkarni
- Department of Medical and Regulatory Affairs, Clininvent Research Pvt. Ltd, Mumbai, India
| | - S Narayanswamy
- Department of Clinical Operations, Clininvent Research Pvt. Ltd, Mumbai, India
| | - J Dalal
- Department of Clinical Operations, Glaxosmithkline Pharmaceuticals Ltd, Mumbai, India
| | - V Halbe
- Department of Clinical Operations, Glaxosmithkline Pharmaceuticals Ltd, Mumbai, India
| | - S Patkar
- Department of Clinical Operations, Glaxosmithkline Pharmaceuticals Ltd, Mumbai, India
| | - A Bhatt
- President, Clininvent Research Pvt. Ltd, India
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