Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals

BACKGROUND

Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups.

METHODS

A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level.

RESULTS

A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data.

CONCLUSION

Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.

SALTT study: A retrospective analysis of 111 SAlivary gland tumors of Lung and Tracheobronchial Tree

INTRODUCTION

Primary pulmonary salivary gland-type tumours (PPSGT) are rare lung neoplasms arising from submucosal seromucinous glands in the central airway.

METHODS AND RESULTS

We retrospectively analysed the clinicopathological features of 111 PPSGTs diagnosed at our institute between 2003 and 2021. The mean age at diagnosis was 43.8 years(range 6-78 years) and a male-to-female ratio of 2:1. On imaging, 92 % of cases had centrally located tumours and 37.3 % were early stage. The histopathological types included 70 cases (63 %) of mucoepidermoid carcinoma (MEC), 31 cases (27.7 %) of adenoid cystic carcinoma (ADCC), two cases of myoepithelial carcinoma, one case each of acinic cell carcinoma (ACC), clear cell carcinoma (CCC), epithelial myoepithelial carcinoma (EMC) and 5 others [including adenocarcinoma of minor salivary gland origin(n = 3), carcinoma with sebaceous differentiation(n = 1) and poorly differentiated carcinoma of salivary gland type(n = 1)]. The size of the tumours found in the resection specimens ranged from 1 cm to 13 cm, with an average size of 4.9 cm. High-risk attributes such as lymphovascular invasion (LVI), perineural invasion (PNI), pleural involvement, positive resection margins, and nodal metastasis were identified in 15.3 %, 15.3 %, 13.6 %,15.2 % and 6.7 % of cases, respectively. These attributes were found to be more frequent in ADCC than in MEC. Surgery was the main treatment modality [68/84 (80 %) cases]. ADCC cases had more recurrence and distant metastasis than MEC cases. The 3- year overall-survival (OS) and recurrence-free survival(RFS) were better in patients with age lesser than 60 years(p-value <0.0001), low pT stage (p-value 0.00038) and lower grade of MEC(p-value-0.0067).

CONCLUSION

It is crucial to have an acquaintance with the morphologic spectrum and immunophenotypic characteristics of PPSGT to recognize them in this unusual location. In tandem, it is crucial to differentiate them from conventional primary non-small cell lung carcinoma, as the management protocols and prognostic implications differ significantly.

Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

Inequities in global cancer surgery: Challenges and solutions

The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.

External Quality Assurance Helps Improve Infrastructure for Testing Breast Biomarkers Across a Lower- and Middle-Income Country: Our Experience With Breast Biomarker Testing in the National Cancer Grid External Quality Assurance System in India

CONTEXT.—

Biomarkers in breast cancer need strict monitoring given their role in patient management.

OBJECTIVE.—

To study the impact that regular participation in the National Cancer Grid (NCG) external quality assurance (EQA) system has on concordance rates for biomarkers in breast carcinoma.

DESIGN.—

Tissue microarray (TMA) containing breast carcinomas was circulated to participating laboratories that performed immunohistochemistry for breast biomarkers. The returned TMAs were then assessed for test concordance.

RESULTS.—

A total of 105 laboratories participated in the estrogen receptor (ER) and progesterone receptor (PR) EQA system cycles, and 99 centers participated in the human epidermal growth factor 2 (HER2) EQA system. In the ER EQA in the first cycle only 1 laboratory had a 100% concordance, which improved to 59 of 77 (76.6%) and 85 of 97 (85.9%) in the fourth and fifth cycles, respectively. In the PR EQA the 100% pass rate jumped from zero to 52 of 76 (68.4%) in the fourth cycle and 86 of 97 (88.6%) in the last cycle. For HER2 EQA, the 100% pass rates were seen in 7 of 23 laboratories (30.4%) in the first cycle, 49 of 78 laboratories (62.8%) in the fourth cycle, and 48 of 94 laboratories (51.1%) in fifth cycle of EQA. Centers who participated in the NCG EQA system for a longer period often changed testing methodology, with consequent improvement in their laboratory concordance rates. An increasing trend for the use of automated platforms and of the US Food and Drug Administration-approved antibody for HER2 testing was observed.

CONCLUSIONS.—

Our experience demonstrates that laboratory performances improve with participation in an EQA system even in less perfect settings, and this drives the placement of more proficient practices across the country.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Paediatric and adolescent ectopic Cushing's syndrome: systematic review

OBJECTIVE

The data on clinical, biochemical, radiological characteristics, and outcomes in paediatric ectopic adrenocorticotropic hormone syndrome (EAS) are limited owing to rarity of the condition. We report three new cases and perform a systematic review of paediatric EAS.

DESIGN AND METHOD

Case records of paediatric and adolescent EAS patient's ≤20 years presenting at our centre between 1997 and 2021 were retrospectively reviewed, and a systematic review of the literature published between January 1970 and December 2022 was performed.

RESULTS

A total of 161 patients including 3 new patients from our centre were identified. Bronchial neuroendocrine tumours (NET) (28.5%), thymic NET (22.9%), primitive cell-derived tumours (18.6%), and gastro-entero-pancreatic-NET (13.7%) were the common causes. Primitive cell-derived tumours were the most common in the first decade (24/45, 53.4%) and were the largest (82 [60-100] mm), whereas bronchial NETs predominated during the second decade (42/116, 36.2%) and were the smallest (15 [10-25] mm). Computed tomography localized 92.9% (118/127) of paediatric EAS patients. Immediate postoperative remission was attained in 77.9% (88/113) patients, whereas 30.4% (24/79) relapsed over a median (IQR) period of 13 (8-36) months. Over a median (IQR) follow-up of 2 (0.6-4.6) years, 31.4% of patients died. The median survival was higher in bronchial NET than in other tumour groups. Distant metastasis and tumour size were independent negative predictors of survival.

CONCLUSIONS

Aetiological profile of paediatric and adolescent EAS is distinct from that of adults. Bronchial NETs have the best long-term survival, whereas distant metastasis and tumour size predict poor survival.

Leveraging national and global political determinants of health to promote equity in cancer care

Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces-the political determinants of health-influence every level of the cancer care continuum. We explore the "3-I" framework, which structures the upstream political forces that affect policy choices in the context of actors' interests, ideas, and institutions, to examine how political determinants of health underlie cancer disparities. Borrowing from the work of PA Hall, M-P Pomey, CJ Ho, and other thinkers, interests are the agendas of individuals and groups in power. Ideas represent beliefs or knowledge about what is or what should be. Institutions define the rules of play. We provide examples from around the world: Political interests have helped fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials-that is, in the distribution of epistemic power. Finally, historical institutions have helped perpetuate disparities related to racist and colonialist legacies. Present institutions have also been used to improve access for those in greatest need, as exemplified by the Butaro Cancer Center of Excellence in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally.

Virtual clinical trials

Virtual clinical trials refer to clinical trials that take advantage of digital technologies, including computer and mobile device apps, web-based tools, and remote monitoring devices, for one or more of the trial processes, such as participant recruitment, counseling, informed consent, measurement of endpoints, and/or adverse event monitoring, to obviate or reduce the need for participant visits to the trial site. The advantages of such trials may include higher recruitment rates, better compliance, lower dropout rates, reduction in time for trial completion, and lower costs. The use of such trials increased manifold during the COVID-19 pandemic and is likely to continue in the future.

Using a Nominal Group Technique to Develop a Science Communication Curriculum for Health Professionals and Clinical Researchers

Effective science communication is fundamental to closing the gap from research and innovation to clinical implementation. Existing paradigms of science communication are often challenged by a lack of skill and engagement, particularly from those who progress the science. Currently, a standardized curriculum on science communication, with global applicability, does not exist. The purpose of this project is to address the gap in training by health professionals and clinical researchers through the development of a globally relevant curriculum for science communication. The nominal group technique (NGT) was used whereby a convenience sample of eleven science communication experts from across the globe generated, discussed, and arrived at a consensus on topics that should be included in a standardized science communication curriculum. Experts represented diverse backgrounds within the health sciences. Due to the COVID-19 pandemic and geographical constraints, the NGT was conducted virtually. The consensus-building methodology allowed for each expert to equally present ideas and collaborate with one another to create a robust and comprehensive curriculum for effective science communication. Expert panelists reached a consensus on 10 essential components of a standardized global science communication curriculum. Following the refinement of the curriculum topic areas, a virtual meeting with project co-investigators was held to review the topics and discuss relevance, applicability, and appeal to the local contexts. A standardized science communication curriculum is needed for health professionals and clinical researchers. The NGT achieved expert consensus on the core topics. The next steps are to develop the course ensuring optimal participation from learners across the globe.

Allocation of authorship and patient enrollment among global clinical trials in oncology

BACKGROUND

Oncology randomized controlled trials (RCTs) are increasingly global in scope. Whether authorship is equitably shared between investigators from high-income countries (HIC) and low-middle/upper-middle incomes countries (LMIC/UMIC) is not well described. The authors conducted this study to understand the allocation of authorship and patient enrollment across all oncology RCTs conducted globally.

METHODS

A cross-sectional retrospective cohort study of phase 3 RCTs (published 2014-2017) that were led by investigators in HIC and recruited patients in LMIC/UMIC.

FINDINGS

During 2014-2017, 694 oncology RCTs were published; 636 (92%) were led by investigators from HIC. Among these HIC-led trials, 186 (29%) enrolled patients in LMIC/UMIC. One-third (33%, 62 of 186) of RCTs had no authors from LMIC/UMIC. Forty percent (74 of 186) of RCTs reported patient enrollment by country; in 50% (37 of 74) of these trials, LMIC/UMIC contributed <15% of patients. The relationship between enrollment and authorship proportion is very strong and is comparable between LMIC/UMIC and HIC (Spearman's ρ LMIC/UMIC 0.824, p < .001; HIC 0.823, p < .001). Among the 74 trials that report country enrollment, 34% (25 of 74) have no authors from LMIC/UMIC.

CONCLUSIONS

Among trials that enroll patients in HIC and LMIC/UMIC, authorship appears to be proportional to patient enrollment. This finding is limited by the fact that more than half of RCTs do not report enrollment by country. Moreover, there are important outliers as a significant proportion of RCTs had no authors from LMIC/UMIC despite enrolling patients in these countries. The findings in this study reflect a complex global RCT ecosystem that still underserves cancer control outside high-income settings.

Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility

Background

The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy.

Methods

This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups.

Results

Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy.

Conclusion

The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

The "Weekday Effect"-Does It Impact Esophageal Cancer Surgery Outcomes?

BACKGROUND

Increased 30-day mortality rates have been reported in patients undergoing elective surgery later compared with earlier in the week. However, these reports have been conflicting for esophageal surgery. We conducted a study to assess the differences in outcomes of patients undergoing surgery for esophageal cancer earlier in the week (Tuesday) versus later (Friday).

METHODS

This retrospective analysis of a prospectively maintained database included patients with esophageal cancer who underwent esophageal resection in a tertiary cancer center between 1 January 2005 and 31 December 2017. We compared patients operated on Tuesdays versus Fridays. The primary outcome was a composite of major morbidity (defined as Clavien-Dindo grade 3 or more) and/or mortality. Secondary outcomes included duration of post-operative ventilation, and length of ICU and hospital stay.

RESULTS

Among 1300 patients included, 733 were operated on a Tuesday and 567 on a Friday. Patient and surgery characteristics were similar in the two groups. The primary outcome (composite of major morbidity and mortality) was 23.6% in the Tuesday group versus 26.3% in the Friday group. Mortality was similar in the two groups (6.0%). Multivariable logistic regression analysis showed that the day of surgery was not a predictor of major morbidity or mortality.

CONCLUSIONS

In patients undergoing esophagectomy at tertiary care high volume cancer center, there was no difference in major morbidity and mortality whether the surgery was performed early in the week (Tuesday) or closer to the weekend (Friday).

A National Cancer Grid pooled procurement initiative, India

In health systems with little public funding and decentralized procurement processes, the pricing and quality of anti-cancer medicines directly affects access to effective anti-cancer therapy. Factors such as differential pricing, volume-dependent negotiation and reliance on low-priced generics without any evaluation of their quality can lead to supply and demand lags, high out-of-pocket expenditures for patients and poor treatment outcomes. While pooled procurement of medicines can help address some of these challenges, monitoring of the procurement process requires considerable administrative investment. Group negotiation to fix prices, issuing of uniform contracts with standardized terms and conditions, and procurement by individual hospitals also reduce costs and improve quality without significant investment. The National Cancer Grid, a network of more than 250 cancer centres in India, piloted pooled procurement to improve negotiability of high-value oncology and supportive care medicines. A total of 40 drugs were included in this pilot. The pooled demand for the drugs from 23 centres was equivalent to 15.6 billion Indian rupees (197 million United States dollars (US$)) based on maximum retail prices. The process included technical and financial evaluation followed by contracts between individual centres and the selected vendors. Savings of 13.2 billion Indian Rupees (US$ 166.7million) were made compared to the maximum retail prices. The savings ranged from 23% to 99% (median: 82%) and were more with generics than innovator and newly patented medicines. This study reveals the advantages of group negotiation in pooled procurement for high-value medicines, an approach that can be applied to other health systems.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Randomised controlled trials evaluating anticancer therapies in haematological cancers: an overview of global research activity

Background

Design, results, and interpretation of oncology randomised controlled trials (RCTs) have changed substantially over the past decade. In this study, we describe all RCTs evaluating anticancer therapies in haematological cancers published globally during 2014-2017 with comparisons with solid tumours RCTs.

Methods

A PubMed literature search identified all phase 3 RCTs of anticancer therapy for haematological cancers and solid tumours published globally during 2014-2017. Descriptive statistics, chi-square tests and the Kruskal-Wallis test were used to compare RCT design results, and output between haematological cancers and solid tumours as well as for different haematological cancer subtypes.

Results

694 RCTs were identified; 124 in haematological cancers and 570 in solid tumours. Overall survival (OS) was the primary endpoint in only 12% (15/124) of haematological cancer trials compared to 35% (200/570) in solid tumours (p < 0.001). Haematological cancer RCTs evaluated the systemic novel therapy more often than the solid tumour RCT (98% versus 84%, p = 0.002). Use of surrogate endpoints like progression-free survival (PFS) and time to treatment failure (TTF) were more common in haematological cancers than solid tumours (47% versus 31%, p < 0.001). Within haematological cancers, the use of PFS and TTF was more prevalent in chronic lymphocytic leukaemia and multiple myeloma as compared to others (80%-81% versus 0%-41%, p < 0.001). Seventy-eight percent of haematologic trials were funded by industry as compared to 70% of solid tumour trials. Only 4% (5/124) of haematologicalcancer trials were led by investigators in upper-middle and lower-middle-income countries as compared to the 9% of solid tumour trials.

Conclusion

The fact that only 12% of haematological cancer RCTs are designed to show improvements in OS is of grave concern for the field and the care of future patients. This is further compounded by the highly prevalent use of alternative primary endpoints that are rarely valid surrogates for OS in haematological cancers.

The next big questions in cancer research

Our understanding of tumorigenesis and cancer progression as well as clinical therapies for different cancer types have evolved dramatically in recent years. However, even with this progress, there are big challenges for scientists and oncologists to tackle, ranging from unpacking the molecular and cellular mechanisms involved to therapeutics and biomarker development to quality of life in the aftermath of therapy. In this article, we asked researchers to comment on the questions that they think are important to address in the coming years.

National Cancer Grid Virtual Tumor Boards of Head and Neck Cancers: An Innovative Approach to Multidisciplinary Care

PURPOSE

Virtual tumor board (VTB) via videoconference facility involving multiple specialists in the decision making for various tumors is well accepted, especially in high-income countries. Information on virtual tumor boards for head and neck cancers especially from low- and middle-income countries is sparse. In this study, we have audited the findings of the National Cancer Grid VTBs performed for head and neck cancers.

METHODS

All patients discussed in the head and neck VTBs at our center between December 2016 and February 2022 were included in the study. Details such as the type of institute sending patients for discussion, its location, subsites within the head and neck region, histopathology, treatment setting or question for the VTB, and availability of guidelines for such patient scenarios were assessed. Also, a survey was sent to assess the usefulness of the VTBs.

RESULTS

A total of 208 patients were discussed in 54 VTB sessions. The most common head and neck sites discussed in the VTBs were the oral cavity (n = 64, 30.7%) followed by skull base/nose and paranasal sinuses/eyelid-orbit tumors (n = 49, 23.5%). Nonsquamous cell carcinoma was the most common histopathology discussed; recurrent cancers/residual diseases were the most common treatment settings (n = 134, 64.4%) for which there were no existing guidelines. Survey results showed that most VTB decisions were implementable, and respondents felt that VTBs were a useful educational tool as well.

CONCLUSION

Our study affirms the feasibility of VTBs in low- and middle-income countries' health care systems for managing uncommon malignancies and clinical situations, which act as an important educational platform.

Definitive radiation therapy with dose escalation is beneficial for patients with squamous cell cancer of the esophagus

Objective

We report the long term follow-up, toxicity, and outcomes of patients with localized squamous cell carcinoma of the esophagus(ESCC) who underwent definitive chemo-radiotherapy(dCRT) at our institute.

Materials and Methods

Patients diagnosed with carcinoma post cricoid, upper cervical and thoracic oesophagus and treated with dCRT between January 2000 and March 2012 were retrospectively analyzed. Radiotherapy was delivered in two phases to a maximum dose of 63Gy in daily fractions of 1.8Gy using conventional or conformal techniques. OS and PFS were defined from date of registration and were calculated by Kaplan-Meier method with comparisons between different subgroups performed using log-rank test. All data were analysed using SPSS Version 22.

Results

Three hundred and fourteen patients with ESCC treated with dCRT were included in this analysis. Median age at presentation was 56 years and median KPS at presentation was 70. Two-third of patients were treated with conformal technique. Median dose of radiation delivered was 60Gy(range 30.6Gy-70Gy). Neoadjuvant chemotherapy was administered in about 35% patients and 57% patients received concurrent chemotherapy. About 10% patients required hospitalization during treatment due to complications and 7 patients did not complete treatment. Grade 1/2 dermatitis and mucositis was seen in 77% and 71% patients respectively. Complete response at first follow up was observed in 56% of patients. At a median follow up of 56 months, 77 patients were alive with controlled disease. The 1- and 3-yr OS were 80% and 62% respectively. Median PFS was 28 months; 1- and 3-yr PFS were 66% and 46% respectively. A higher RT dose was found to be a significant predictor for OS and PFS on both uni- and multivariate analysis.

Conclusion

Our study highlights that the delivery of higher RT doses (≥63Gy) is feasible in this patient group and that a higher RT dose was associated with significantly better PFS and OS.

Comorbidity between lung cancer and COVID-19 pneumonia: role of immunoregulatory gene transcripts in high ACE2-expressing normal lung

BACKGROUND

SARS-CoV-2 (COVID-19) elicits a T-cell antigen-mediated immune response of variable efficacy. To understand this variability, we explored transcriptomic expression of angiotensin-converting enzyme 2 (ACE2, the SARS-CoV-2 receptor) and of immunoregulatory genes in normal lung tissues from patients with non-small cell lung cancer (NSCLC).

METHODS

This study used the transcriptomic and the clinical data for NSCLC patients generated during the CHEMORES study [n = 123 primary resected (early-stage) NSCLC] and the WINTHER clinical trial (n = 32 metastatic NSCLC).

RESULTS

We identified patient subgroups with high and low ACE2 expression (p = 1.55 × 10^-19) in normal lung tissue, presumed to be at higher and lower risk, respectively, of developing severe COVID-19 should they become infected. ACE2 transcript expression in normal lung tissues (but not in tumor tissue) of patients with NSCLC was higher in individuals with more advanced disease. High-ACE2 expressors had significantly higher levels of CD8+ cytotoxic T lymphocytes and natural killer cells but with presumably impaired function by high Thymocyte Selection-Associated High Mobility Group Box Protein TOX (TOX) expression. In addition, immune checkpoint-related molecules - PD-L1, CTLA-4, PD-1, and TIGIT - are more highly expressed in normal (but not tumor) lung tissues; these molecules might dampen immune response to either viruses or cancer. Importantly, however, high inducible T-cell co-stimulator (ICOS), which can amplify immune and cytokine reactivity, significantly correlated with high ACE2 expression in univariable analysis of normal lung (but not lung tumor tissue).

CONCLUSIONS

We report a normal lung immune-tolerant state that may explain a potential comorbidity risk between two diseases - NSCLC and susceptibility to COVID-19 pneumonia. Further, a NSCLC patient subgroup has normal lung tissue expressing high ACE2 and high ICOS transcripts, the latter potentially promoting a hyperimmune response, and possibly leading to severe COVID-19 pulmonary compromise.

Robotic esophagectomy and 3-field lymphadenectomy with intraoperative nerve monitoring

The standard of care for esophageal malignancies has evolved over the years from open transthoracic esophagectomy to a minimally invasive approach due to the reduction in surgical trauma and significant impact on postoperative outcomes. Minimally invasive approaches include video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery. These minimally invasive approaches have an attendant learning curve that early-career surgeons are required to negotiate before achieving proficiency in the procedure. Recurrent laryngeal nerve injury is a particularly significant problem, especially in the presence of enlarged supracarinal lymph nodes, which mandate a 3-field lymphadenectomy. With technological advances and the use of intraoperative nerve monitoring, iatrogenic nerve injury can at best be avoided or at least be recognized, and corrective measures can be undertaken to reduce postoperative morbidity. In this video tutorial, we demonstrate a standard robot-assisted esophagectomy and a 3-field lymphadenectomy with the use of intraoperative nerve monitoring followed by an esophagogastric anastomosis with the triangulating stapling technique.

Transcriptomics in Tumor and Normal Lung Tissues Identify Patients With Early-Stage Non-Small-Cell Lung Cancer With High Risk of Postsurgery Recurrence Who May Benefit From Adjuvant Therapies

PURPOSE

The prognosis of patients with non-small-cell lung cancer (NSCLC), traditionally determined by anatomic histology and TNM staging, neglects the biological features of the tumor that may be important in determining patient outcome and guiding therapeutic interventions. Identifying patients with NSCLC at increased risk of recurrence after curative-intent surgery remains an important unmet need so that known effective adjuvant treatments can be offered to those at highest risk of recurrence.

METHODS

Relative gene expression level in the primary tumor and normal bronchial tissues was used to retrospectively assess their association with disease-free survival (DFS) in a cohort of 120 patients with NSCLC who underwent curative-intent surgery.

RESULTS

Low versus high Digital Display Precision Predictor (DDPP) score (a measure of relative gene expression) was significantly associated with shorter DFS (highest recurrence risk; P = .006) in all patients and in patients with TNM stages 1-2 (P = .00051; n = 83). For patients with stages 1-2 and low DDPP score (n = 29), adjuvant chemotherapy was associated with improved DFS (P = .0041). High co-overexpression of CTLA-4, PD-L1, and ICOS in normal lung (28 of 120 patients) was also significantly associated with decreased DFS (P = .0013), suggesting an immune tolerance to tumor neoantigens in some patients. Patients with DDPP low and immunotolerant normal tissue had the shortest DFS (P = 2.12E-11).

CONCLUSION

TNM stage, DDPP score, and immune competence status of normal lung are independent prognostic factors in multivariate analysis. Our findings open new avenues for prospective prognostic assessment and treatment assignment on the basis of transcriptomic profiling of tumor and normal lung tissue in patients with NSCLC.

Lung Cancer Management in Low and Middle-Income Countries

Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.

Participation of Lower and Upper Middle-Income Countries in Clinical Trials Led by High-Income Countries

IMPORTANCE

Many randomized clinical trials (RCTs) led by high-income countries (HICs) now enroll patients from lower middle-income countries (LMICs) and upper middle-income countries (UMICs). Although enrolling diverse populations promotes research collaborations, there are issues regarding which countries participate in RCTs and how this participation may contribute to global research.

OBJECTIVE

To describe which UMICs and LMICs participate in RCTs led by HICs.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of all oncology RCTs published globally during January 1, 2014, to December 31, 2017, was conducted. The study cohort was restricted to RCTs led by HICs that enrolled participants from LMICs and UMICs. Study analyses were conducted in November 1, 2021, to May 31, 2022.

MAIN OUTCOMES AND MEASURES

A bibliometric approach (Web of Science 2007-2017) was used to explore whether RCT participation was proportional to other measures of cancer research activity. Participation in RCTs (ie, percentage of RCTs in the cohort in which each LMIC and UMIC participated) was compared with country-level cancer research bibliometric output (ie, percentage of total cancer research bibliometric output from the same group of countries that came from a specific LMIC and UMIC).

RESULTS

Among the 636 HIC-led RCTs, 186 trials (29%) enrolled patients in LMICs (n = 84 trials involving 11 LMICs) and/or UMICs (n = 181 trials involving 26 UMICs). The most common participating LMICs were India (42 [50%]), Ukraine (39 [46%]), Philippines (23 [27%]), and Egypt (12 [14%]). The most common participating UMICs were Russia (115 [64%]), Brazil (94 [52%]), Romania (62 [34%]), China (56 [31%]), Mexico (56 [31%]), and South Africa (54 [30%]). Several LMICs are overrepresented in the cohort of RCTs based on proportional cancer research bibliometric output: Ukraine (46% of RCTs but 2% of cancer research bibliometric output), Philippines (27% RCTs, 1% output), and Georgia (8% RCTs, 0.2% output). Overrepresented UMICs include Russia (64% RCTs, 2% output), Romania (34% RCTs, 2% output), Mexico (31% RCTs, 2% output), and South Africa (30% RCTs, 1% output).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, a substantial proportion of RCTs led by HICs enrolled patients in LMICs and UMICs. The LMICs and UMICs that participated in these trials did not match overall cancer bibliometric output as a surrogate for research ecosystem maturity. Reasons for this apparent discordance and how these data may inform future capacity-strengthening activities require further study.

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

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

Neoadjuvant Chemoradiotherapy and Surgery for Esophageal Squamous Cell Carcinoma Versus Definitive Chemoradiotherapy With Salvage Surgery as Needed: The Study Protocol for the Randomized Controlled NEEDS Trial

Background

The globally dominant treatment with curative intent for locally advanced esophageal squamous cell carcinoma (ESCC) is neoadjuvant chemoradiotherapy (nCRT) with subsequent esophagectomy. This multimodal treatment leads to around 60% overall 5-year survival, yet with impaired post-surgical quality of life. Observational studies indicate that curatively intended chemoradiotherapy, so-called definitive chemoradiotherapy (dCRT) followed by surveillance of the primary tumor site and regional lymph node stations and surgery only when needed to ensure local tumor control, may lead to similar survival as nCRT with surgery, but with considerably less impairment of quality of life. This trial aims to demonstrate that dCRT, with selectively performed salvage esophagectomy only when needed to achieve locoregional tumor control, is non-inferior regarding overall survival, and superior regarding health-related quality of life (HRQOL), compared to nCRT followed by mandatory surgery, in patients with operable, locally advanced ESCC.

Methods

This is a pragmatic open-label, randomized controlled phase III, multicenter trial with non-inferiority design with regard to the primary endpoint overall survival and a superiority hypothesis for the experimental intervention dCRT with regard to the main secondary endpoint global HRQOL one year after randomization. The control intervention is nCRT followed by preplanned surgery and the experimental intervention is dCRT followed by surveillance and salvage esophagectomy only when needed to secure local tumor control. A target sample size of 1200 randomized patients is planned in order to reach 462 events (deaths) during follow-up.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT04460352.

Gender discrimination in surgical oncology: An in-house appraisal

Introduction

Gender discrimination (GD) though rarely blatant, may present indirectly within a surgical department in the form of subtle inequities, differing standards, and bias. GD encompasses a wide spectrum including academic development, surgical opportunities and sexual harassment.

Methods

We conducted an online survey to analyse the perceived incidence of GD in the surgical oncology department at a tertiary care cancer centre in India. The questionnaire consisted of 15 questions and was mailed to the entire department including trainees and faculty. Anonymity was maintained while collecting the data only of the participants' gender and whether they were faculty or trainee. Collated responses were analysed using proportions.

Results

The questionnaire was sent out to 200 recipients of whom 56% (112/200) responded via an online survey. Respondents included 84% of faculty (42/50) and 46.6% of trainees (70/150). GD was perceived by 28% of female trainees (7/25) as compared to 6.6% of male trainees (3/45), whereas amongst faculty, GD was perceived by 26.6% of female faculty (4/15) compared to 14.8% of male faculty (3/27). Approximately 13% of our trainees and 12% of our faculty mentioned that GD affected their professional performance or mental well-being. GD was experienced in terms of work experience and opportunities by a majority of trainees (13%) and faculty (9.5%). There was a significant lack of awareness about recourse to an institutional grievance committee by trainees (47%) compared to faculty (14%). About 7% of trainees and 12% of faculty acknowledged that they may have been responsible for intentional/unintentional GD.

Conclusion

Gender discrimination can present in subtle or overt fashion in surgical departments and requires active sustained efforts to allow both genders to feel equally empowered. Establishing a system to objectively evaluate gender equity while avoiding stereotyping for certain roles can help minimize GD.

Cancer Medicines: What Is Essential and Affordable in India?

PURPOSE

The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are available in routine practice.

METHODS

This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice.

RESULTS

The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P < .001) and work exclusively in the private health system (52% v 17%, P < .001). 14/20 most commonly selected medicines were conventional cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system.

CONCLUSION

Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India.

Is Clinical Research Serving the Needs of the Global Cancer Burden? An Analysis of Contemporary Global Radiation Therapy Randomized Controlled Trials

PURPOSE

Randomized controlled trials (RCTs) are the cornerstone of delivering sustained improvements in cancer outcome. To inform radiation therapy research policy and prioritization, we analyze the radiation therapy RCT landscape including comparison with trials of systemic therapies over the same period, with a specific focus on funding and disparities across income settings.

METHODS AND MATERIALS

This retrospective cohort study identified all phase 3 RCTs evaluating anticancer therapies published from 2014 to 2017. RCTs were classified according to anticancer modality and country of origin. Descriptive statistics were used to compare key characteristics of radiation therapy RCT studies according to study design characteristics, tumor types evaluated, types of intervention appraised, treatment intent and main funding sources.

RESULTS

The study cohort included 694 RCTs of which 64 were radiation therapy RCTs (9%) compared with 601 systemic therapy RCTs (87%). Among all radiation therapy RCTs, 47% of them focused on 2 areas of evaluation: (1) combining radiation therapy with systemic agents (25%) and (2) changes in dose fractionation (22%). The most common cancers studied were head and neck (22%), lung (22%), and breast (14%), with cervical cancer trials representing only 3% of the cohort. Among the radiation therapy RCTs, 33% of them met their primary endpoint, and 62% assessed interventions in the curative setting compared with 31% in systemic therapy RCTs. For their country locations, 77% of radiation therapy RCTs took place in high-income countries, 13% in low-and-middle-income countries, and 11% in both high-income and low-and-middle-income countries. For funding, 17% of radiation therapy RCTs received funding from industry compared with 79% of systemic therapy RCTs.

CONCLUSIONS

This study highlights the need for greater investment in radiation therapy RCTs and the need to look at the disparities in conducting RCTs globally. The study emphases the urgent need for more capacity building for cancer clinical trials in low-and-middle-income countries and more sustainable funding sources.

Outcomes of COVID-19 and risk factors in patients with cancer

Patients with cancer are at higher risk for adverse coronavirus disease 2019 (COVID-19) outcomes. Here, we studied 1,253 patients with cancer, who were diagnosed with severe acute respiratory syndrome coronavirus 2 at a tertiary referral cancer center in India. Most patients had mild disease; in our settings, recent cancer therapies did not impact COVID-19 outcomes. Advancing age, smoking history, concurrent comorbidities and palliative intent of treatment were independently associated with severe COVID-19 or death. Thus, our study provides useful insights into cancer management during the COVID-19 pandemic.

A Reporting Tool for Adapted Guidelines in Health Care: The RIGHT-Ad@pt Checklist

BACKGROUND

Adaptation of existing guidelines can be an efficient way to develop contextualized recommendations. Transparent reporting of the adaptation approach can support the transparency and usability of the adapted guidelines.

OBJECTIVE

To develop an extension of the RIGHT (Reporting Items for practice Guidelines in HealThcare) statement for the reporting of adapted guidelines (including recommendations that have been adopted, adapted, or developed de novo), the RIGHT-Ad@pt checklist.

DESIGN

A multistep process was followed to develop the checklist: establishing a working group, generating an initial checklist, optimizing the checklist (through an initial assessment of adapted guidelines, semistructured interviews, a Delphi consensus survey, an external review, and a final assessment of adapted guidelines), and approval of the final checklist by the working group.

SETTING

International collaboration.

PARTICIPANTS

A total of 119 professionals participated in the development process.

MEASUREMENTS

Participants' consensus on items in the checklist.

RESULTS

The RIGHT-Ad@pt checklist contains 34 items grouped in 7 sections: basic information (7 items); scope (6 items); rigor of development (10 items); recommendations (4 items); external review and quality assurance (2 items); funding, declaration, and management of interest (2 items); and other information (3 items). A user guide with explanations and real-world examples for each item was developed to provide a better user experience.

LIMITATION

The RIGHT-Ad@pt checklist requires further validation in real-life use.

CONCLUSION

The RIGHT-Ad@pt checklist has been developed to improve the reporting of adapted guidelines, focusing on the standardization, rigor, and transparency of the process and the clarity and explicitness of adapted recommendations.

PRIMARY FUNDING SOURCE

None.

Priorities for cancer research in low- and middle-income countries: a global perspective

Cancer research currently is heavily skewed toward high-income countries (HICs), with little research conducted in, and relevant to, the problems of low- and middle-income countries (LMICs). This regional discordance in cancer knowledge generation and application needs to be rebalanced. Several gaps in the research enterprise of LMICs need to be addressed to promote regionally relevant research, and radical rethinking is needed to address the burning issues in cancer care in these regions. We identified five top priorities in cancer research in LMICs based on current and projected needs: reducing the burden of patients with advanced disease; improving access and affordability, and outcomes of cancer treatment; value-based care and health economics; quality improvement and implementation research; and leveraging technology to improve cancer control. LMICs have an excellent opportunity to address important questions in cancer research that could impact cancer control globally. Success will require collaboration and commitment from governments, policy makers, funding agencies, health care organizations and leaders, researchers and the public.

Salvage radiotherapy for postoperative locoregional failure in esophageal cancer: a systematic review and meta-analysis

Locoregional recurrences following surgery for esophageal cancers represent a significant clinical problem with no standard recommendations for management. We conducted this systematic review and meta-analysis with the objective of studying safety and efficacy of salvage radiotherapy in this setting. All prospective and retrospective cohort studies, which studied patients who developed locoregional recurrence following initial radical surgery for esophageal cancer and subsequently received salvage radiation therapy (RT)/chemoradiation with all relevant information regarding survival outcome and toxicity available, were included. The quality of eligible individual studies was assessed using the Newcastle-Ottawa Scale score for risk of bias. R package MetaSurv was used to obtain a summary survival curve from survival probabilities and numbers of at-risk patients collected at various time points and to test the overall heterogeneity using the I2 statistic. Thirty studies (27 retrospective, 3 prospective) published from 1995 to 2020 with 1553 patients were included. The median interval between surgery and disease recurrence was 12.5 months. The median radiation dose used was 60 Gy and 57% received concurrent chemotherapy. The overall incidence of acute grade 3/4 mucositis and dermatitis were 8 and 4%, respectively; grade 3/4 acute pneumonitis was reported in 5%. The overall median follow-up of all studies included was 27 months. The 1-, 2- and 3-year overall survival (OS) probabilities were 67.9, 35.9 and 30.6%, respectively. Factors which predicted better survival on multivariate analysis were good PS, lower group stage, node negativity at index surgery, longer disease-free interval, nodal recurrence (as compared to anastomotic site recurrence), smaller disease volume, single site of recurrence, RT dose >50 Gy, conformal RT, use of concomitant chemotherapy and good radiological response after radiotherapy. Salvage radiotherapy with or without concomitant chemotherapy for locoregional recurrences after surgery for esophageal cancer is safe and effective. Modern radiotherapy techniques may improve outcomes and reduce treatment-related morbidity.

Developing a Screening Tool for Serious Health-related Suffering for Low- and Middle-Income Countries – Phase-1: Domain Identification and Item Generation

Objectives:

The Lancet Commission on Global Access to Palliative Care and Pain Relief reported significant levels of health-related suffering globally, with the highest incidence in the low- and middle-income countries. The report describes suffering as health-related when it is associated with illness or injury of any kind and suffering as serious when it cannot be relieved without professional intervention and when it compromises physical, social, spiritual, and/or emotional functioning. This paper describes the preliminary development phase of a tool for screening Serious Health-related Suffering (SHS) at individual patient level, suitable to the healthcare settings in India. The study was conducted by the National Cancer Grid-India, with support from the Indian Association of Palliative Care.

Materials and Methods:

Domain identification and item generation were conducted according to the recommendations for tool development by the American Psychological Association and World Health Organisation quality of life instrument. The consensus for domain questions and associated items was achieved using Delphi, nominal group technique, expert review, and polling.

Results:

The Phase-1 study for developing the screening tool for SHS contextualised to resource-limited settings generated a bilevel questionnaire. The initial level assesses and scores the physical, emotional, social, spiritual, and financial domains of health-related suffering. The next level assesses seriousness, through functional limitation and patient’s preference.

Conclusion:

The generation of domains, items, and screening questions for health-related suffering and its seriousness completes the preliminary phase of developing the SHS screening tool applicable to a resource-limited healthcare setting. Field testing of the tool is being conducted as Phase-2 of this study, to validate it in clinical settings.

Tobacco and cancer awareness program among school children in rural areas of Ratnagiri district of Maharashtra state in India

Background

Promoting awareness of tobacco and cancer in the community needs multipronged efforts. We performed a study to evaluate whether we could raise awareness about the harmful effects of tobacco, oral and esophageal cancer among school students by providing them health education. Moreover, we also compared the awareness level in students of age group 12 to ≤14 years with the age group >14 to 18 years.

Methods

We conducted an awareness program in the schools of Ratnagiri district of Maharashtra state. Students aged 12-18 years participated in this study. We provided health education to school students using a standard presentation; the presentation was rich in illustrations depicting the harmful effects of tobacco as well as oral and esophageal cancer's signs, symptoms, diagnosis, treatment, and preventive measures. After the health talk, a questionnaire was circulated. The questions were focused on tobacco, signs, and symptoms of the diseases along with early detection, prevention, and treatment of cancer.

Results

A total of 1354 students participated in the program. Totally, 567 (41.9%) students were from 6th to 8th grade (Group A, age group 12 to ≤14) and 787 (58.1%) students were from 9th to 12th standards (Group B, age group >14 to 18). Overall scores were high, ranging from 69% to 98%. Group A scored in the range of 69% to 95%, and Group B scored in the range 72%-98% The difference between the two groups was found to be statistically significant (P-value ≤0.05).

Conclusion

A standardized health education program helped to raise awareness about the harmful effects of tobacco and cancer amongst school children. Further studies are needed to evaluate whether educating school children has an impact on community understanding of the disease.

Research studies on screening tests

Screening tests are done to diagnose asymptomatic disease in apparently healthy people with the aim to reduce mortality and morbidity from the disease. Certain criteria need to be fulfilled before we adopt population-level screening for any disease. Several biases exist in evaluating screening studies, and the ideal study design would be a randomized trial with hard endpoints such as mortality and morbidity.

Equivalence trials

In an equivalence trial, researchers aim to show that a new intervention is more or less similar to an existing standard of care, i.e., the two are “equivalent”. In this article, we discuss some aspects of the design, analysis, interpretation and reporting of equivalence trials.

Non-inferiority trials

Studies sometimes aim to show that a new intervention is not substantially worse than the existing standard of care while offering some benefits, for example, lower cost, decreased toxicity, or easier administration. Such studies are called non-inferiority (NI) trials. In this article, we look at some aspects of NI trials.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Incidence of SARS-CoV-2 infection among asymptomatic patients undergoing preoperative COVID testing prior to cancer surgery: ASPECT study

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic, with high rate of asymptomatic infections and increased perioperative complications, prompted widespread adoption of screening methods. We analyzed the incidence of asymptomatic infection and perioperative outcomes in patients undergoing cancer surgery. We also studied the impact on subsequent cancer treatment in those with COVID-19.

METHODS

All patients who underwent elective and emergency cancer surgery from April to September 2020 were included. After screening for symptoms, a preoperative test was performed from nasopharyngeal and oropharyngeal swabs before the procedure. Patients were followed up for 30 days postoperatively and complications were noted.

RESULTS

2108 asymptomatic patients were tested, of which 200 (9.5%) tested positive. Of those who tested positive, 140 (70%) underwent the planned surgery at a median of 30 days from testing positive, and 20 (14.3%) had ≥ Grade III complications. Forty (20%) patients did not receive the intended treatment; 110 patients were retested in the Postoperative period, and 41 (37.3%) tested positive and 9(22%) patients died of COVID-related complications.

CONCLUSION

Routine preoperative testing for COVID-19 helps to segregate patients with asymptomatic infection. Higher complications occur in those who develop COVID-19 in postoperative period. Prolonged delay in surgery after COVID infection may influence planned treatment.

Building research capacity in India: The Masters in Clinical Research program at the Tata Memorial Centre

Clinical research is an essential part of evidence-based medicine. The conduct of high-quality clinical research requires the backing of strong infrastructure, especially well-trained clinical research professionals. Tata Memorial Centre is the largest public cancer center in India and has been offering a Masters degree in Clinical Research since 2014. In this article, we look at the need for clinical research training, the evolution of this course and the impact it has had on clinical research capacity in India