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Oommen AM, Isaac R, Paul B, Weller D, Finkel ML, Thomas A, Ram TS, H. R. P, Cherian AG, Thomas V, Sadan V, Siva R, Rose A, Marcus TA, Jeyapaul S, K. SR, Malini T, N. S, Jebaraj P, John NO, Ramesh C, Raj C. JJ, Kumar S. R, B. V. B, Dorathy P. I, Murali V, N. P, K. K, Ranjani D. P. Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial. PLoS One 2024; 19:e0301385. [PMID: 38578742 PMCID: PMC10997089 DOI: 10.1371/journal.pone.0301385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/11/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION CTRI/2021/09/036130.
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Affiliation(s)
- Anu Mary Oommen
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Rita Isaac
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Biswajit Paul
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - David Weller
- University of Edinburgh, Edinburgh, United Kingdom
| | - Madelon L. Finkel
- Weill Cornell Medical College, New York, New York, United States of America
| | - Anitha Thomas
- Department of Gynaecologic Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Thomas Samuel Ram
- Department of Radiation Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Prashanth H. R.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Anne George Cherian
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Vinotha Thomas
- Department of Gynaecologic Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Vathsala Sadan
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Rajeswari Siva
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Anuradha Rose
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Tobey Ann Marcus
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Shalini Jeyapaul
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | | | - Tabeetha Malini
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Surenthiran N.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Paul Jebaraj
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Neenu Oliver John
- Department of Radiation Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Charles Ramesh
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | | | - Rakesh Kumar S.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Balaji B. V.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Irene Dorathy P.
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Valliammal Murali
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Prema N.
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Kavitha K.
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Priya Ranjani D.
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
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M Parvath ES, John NO, Sathyamurthy A, Ramireddy JK, Ram TS. Development and validation of a novel scoring system to predict the risk of uterine perforation during intracavitary brachytherapy for cervical cancer. J Gynecol Oncol 2023; 35:35.e35. [PMID: 38178701 DOI: 10.3802/jgo.2024.35.e35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/02/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVE To develop and validate a novel scoring system for predicting the risk of uterine perforation during brachytherapy (BT) in cervical cancer patients and to stratify patients based on this score to guide the use of ultrasound guidance during BT. METHODS Fifty patients with uterine perforation during BT between January 2018 and December 2020 were included. Common reasons for perforation were identified and a scoring system was developed. This was then applied to a cohort of 50 patients without perforation. The 2 cohorts were compared using the χ² test. To validate the scoring system, all newly diagnosed patients who underwent BT in 2021 were scored, and analysed using χ² test and receiver operator characteristic curves. RESULTS The mean score in the test cohort was 10.16 (range=7-14) and 5.92 (range=5-8) for patients with and without perforation. In the validation cohort, the mean score was 6.9 (range=5-10) and 9.33 (range=7-11) for those with and without perforation. Patients with a score <8 were classified as low risk, while those with a score ≥8 were classified as high risk. Among the criteria evaluated for validation, response to external beam radiotherapy, uterine position, cervico-uterine angle (uterine flexion), identification of cervical os at BT assessment, and the total score were significant predictors, while previous history of perforation, uterine length, and additional uterine anomaly were not. CONCLUSION The novel scoring system is an effective predictor of perforation risk during BT. Implementing this during BT assessment can optimize the need for ultrasound guidance during the procedure.
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Affiliation(s)
- Ezhil Sindhanai M Parvath
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, India
| | - Neenu Oliver John
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, India
| | - Arvind Sathyamurthy
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, India.
| | - Jeba Karunya Ramireddy
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, India
| | - Thomas Samuel Ram
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, India
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John NO, Irodi A, Thomas HMT, Abraham V, Sasidharan BK, John S, Pavamani SP. Utility of Mid-treatment DWI in Selecting Pathological Responders to Neoadjuvant Chemoradiotherapy in Locally Advanced Esophageal Cancer. J Gastrointest Cancer 2023; 54:447-455. [PMID: 35347663 DOI: 10.1007/s12029-022-00818-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Pathological complete response correlates with better clinical outcomes in locally advanced esophageal cancer (LA-EC). However, there is lack of prognostic markers to identify patients in the current setting of neoadjuvant chemoradiotherapy (NACRT) followed by surgery. This study evaluates the utility of mid-treatment diffusion-weighted imaging (DWI) in identifying pathological responders of NACRT. METHODS Twenty-four patients with LA-EC on NACRT were prospectively recruited and underwent three MRI (baseline, mid-treatment, end-of-RT) scans. DWI-derived apparent diffusion coefficient (ADC) mean and minimum were used as a surrogate to evaluate the treatment response, and its correlation to pathological response was assessed. RESULTS Mid-treatment ADC mean was significantly higher among patients with pathological response compared to non-responders (p = 0.011). ADC difference (ΔADC) between baseline and mid-treatment correlated with tumor response (p = 0.007). ADC at other time points did not correlate to pathological response. CONCLUSION In this study, mid-treatment ADC values show potential to be a surrogate for tumor response in NACRT. However, larger trials are required to establish DW-MRI as a definite biomarker for tumor response.
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Affiliation(s)
- Neenu Oliver John
- Department of Radiation Oncology, Ida B. Scudder Cancer Centre, Christian Medical College, Tamil Nadu, Vellore, 632004, India
| | - Aparna Irodi
- Division of Clinical Radiology, Department of Radiodiagnosis, Christian Medical College, Tamil Nadu, Vellore, 632004, India
| | - Hannah Mary T Thomas
- Department of Radiation Oncology, Ida B. Scudder Cancer Centre, Christian Medical College, Tamil Nadu, Vellore, 632004, India
| | - Vijay Abraham
- Department of Surgery, Christian Medical College, Tamil Nadu, Vellore, 632004, India
- Department of Upper GI Surgery, The Queen Elizabeth Hospital, Woodville South, Adelaide, 5011, Australia
| | - Balu Krishna Sasidharan
- Department of Radiation Oncology, Ida B. Scudder Cancer Centre, Christian Medical College, Tamil Nadu, Vellore, 632004, India
| | - Subhashini John
- Department of Radiation Oncology, Ida B. Scudder Cancer Centre, Christian Medical College, Tamil Nadu, Vellore, 632004, India
| | - Simon P Pavamani
- Department of Radiation Oncology, Ida B. Scudder Cancer Centre, Christian Medical College, Tamil Nadu, Vellore, 632004, India.
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Ram TS, Thomas V, Sathyamurthy A, Ramireddy JK, John NO, Thomas A, Peedicayil A. Training for next-generation gynaecologic surgical & radiation oncologists - opportunities & challenges. Indian J Med Res 2021; 154:338-345. [PMID: 35295005 PMCID: PMC9131764 DOI: 10.4103/ijmr.ijmr_1734_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The global increase in cancer burden is a challenge for countries with scarce resources. Amongst all the malignancies, gynaecological cancer still continues to have a high incidence and prevalence leading to significant morbidity and mortality. While a multipronged strategy of decreasing the gynaecological cancer burden is a global priority, one of the key strategies to decrease the morbidity and mortality is to train gynaecological oncology specialists. Most of the developed nations have an established gynaecologic oncology training programme in the form of a well-designed curriculum and skill training. However, in developing countries where the actual disease burden of these cancers is highest, such focused training programmes have only started emerging and evolving over the past two decades. While it is a positive step to initiate such training programmes in a country like India, there are still gaps in the uniformity of curriculum and training. Also, exposure to modern practices in gynaecologic oncology surgery, chemotherapy and technology in radiation oncology, especially brachytherapy, is still insufficient in many centres. This review discusses some of the challenges and opportunities in the still evolving programmes for training gynaecologic oncologists in India.
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Affiliation(s)
- Thomas Samuel Ram
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India,For correspondence: Prof Thomas Samuel Ram, Department of Radiation Oncology Unit I, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore 632 004, Tamil Nadu, India e-mail:
| | - Vinotha Thomas
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arvind Sathyamurthy
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jeba Karunya Ramireddy
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India
| | - Neenu Oliver John
- Department of Radiation Oncology, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Thomas
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abraham Peedicayil
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
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