Household cooking fuel and gallbladder cancer risk: a multi-centre case-control study in India

PURPOSE

Gallbladder cancers (GBC), unique to certain geographical regions, are lethal digestive tract cancers, disproportionately affecting women, with limited information on risk factors.

METHODS

We evaluated the association between household cooking fuel and GBC risk in a hospital-based case-control study conducted in the North-East and East Indian states of Assam and Bihar. We explored the potential mediation by diet, fire-vents, 'daily exposure duration' and parity (among women). We recruited biopsy-confirmed GBC (n = 214) men and women aged 30-69 years between 2019 and 2021, and controls frequency-matched by age, sex and region (n = 166). Information about cooking fuel, lifestyle, personal and family history, female reproductive factors, socio-demographics, and anthropometrics was collected. We tested associations using multivariable logistic regression analyses.

RESULTS

All participants (73.4% women) were categorised based on predominant cooking fuel use. Group-1: LPG (Liquefied Petroleum Gas) users in the previous 20 years and above without concurrent biomass use (26.15%); Group-2: LPG users in the previous 20 years and above with concurrent secondary biomass use (15.9%); Group-3: Biomass users for ≥ 20 years (57.95%). Compared to group-1, accounting for confounders, GBC risk was higher in group-2 [OR: 2.02; 95% CI: 1.00-4.07] and group-3 [OR: 2.01; 95% CI: 1.08-3.73] (p-trend:0.020). These associations strengthened among women that attenuated with high daily consumption of fruits-vegetables but not with fire-vents, 'daily exposure duration' or parity.

CONCLUSION

Biomass burning was associated with a high-risk for GBC and should be considered as a modifiable risk factor for GBC. Clean cooking fuel can potentially mitigate, and a healthy diet can partially reduce the risk among women.

Chronic Exposure to Drinking Water Arsenic and Gallbladder Cancer Risk: Preliminary Evidence from Endemic Regions of India

BACKGROUND

Evidence linking arsenic in drinking water to digestive tract cancers is limited. We evaluated the association between arsenic levels in groundwater and gallbladder cancer risk in a case-control study (2019-2021) of long-term residents (≥10years) in two arsenic-impacted and high gallbladder cancer risk states of India-Assam and Bihar.

METHODS

We recruited men and women aged 30 to 69 years from hospitals (73.4% women), with newly diagnosed, biopsy-confirmed gallbladder cancer (N = 214) and unrelated controls frequency-matched for 5-year age, sex, and state (N = 166). Long-term residential history, lifestyle factors, family history, socio-demographics, and physical measurements were collected. Average-weighted arsenic concentration (AwAC) was extrapolated from district-level groundwater monitoring data (2017-2018) and residential history. We evaluated gallbladder cancer risk for tertiles of AwAC (μg/L) in multivariable logistic regression models adjusted for important confounders [Range: 0-448.39; median (interquartile range), T1-0.45 (0.0-1.19); T2-3.75 (2.83-7.38); T3-17.6 (12.34-20.54)].

RESULTS

We observed a dose-response increase in gallbladder cancer risk based on AwAC tertiles [OR = 2.00 (95% confidence interval, 1.05-3.79) and 2.43 (1.30-4.54); Ptrend = 0.007]. Participants in the highest AwAC tertile consumed more tubewell water (67.7% vs. 27.9%) and reported more sediments (37.9% vs. 18.7%) with unsatisfactory color, odor, and taste (49.2% vs. 25.0%) than those in the lowest tertile.

CONCLUSIONS

These findings suggest chronic arsenic exposure in drinking water at low-moderate levels may be a potential risk factor for gallbladder cancer.

IMPACT

Risk factors for gallbladder cancer, a lethal digestive tract cancer, are not fully understood. Data from arsenic-endemic regions of India, with a high incidence of gallbladder cancer, may offer unique insights. Tackling 'arsenic pollution' may help reduce the burden of several health outcomes.

Linking population-based cohorts with cancer registries in LMIC: a case study and lessons learnt in India

OBJECTIVES

In resource-constrained settings, cancer epidemiology research typically relies on self-reported diagnoses. To test a more systematic alternative approach, we assessed the feasibility of linking a cohort with a cancer registry.

SETTING

Data linkage was performed between a population-based cohort in Chennai, India, with a local population-based cancer registry.

PARTICIPANTS

Data set of Centre for Cardiometabolic Risk Reduction in South-Asia (CARRS) cohort participants (N=11 772) from Chennai was linked with the cancer registry data set for the period 1982-2015 (N=140 986).

METHODS AND OUTCOME MEASURES

Match*Pro, a probabilistic record linkage software, was used for computerised linkages followed by manual review of high scoring records. The variables used for linkage included participant name, gender, age, address, Postal Index Number and father's and spouse's name. Registry records between 2010 and 2015 and between 1982 and 2015, respectively, represented incident and all (both incident and prevalent) cases. The extent of agreement between self-reports and registry-based ascertainment was expressed as the proportion of cases found in both data sets among cases identified independently in each source.

RESULTS

There were 52 self-reported cancer cases among 11 772 cohort participants, but 5 cases were misreported. Of the remaining 47 eligible self-reported cases (incident and prevalent), 37 (79%) were confirmed by registry linkage. Among 29 self-reported incident cancers, 25 (86%) were found in the registry. Registry linkage also identified 24 previously not reported cancers; 12 of those were incident cases. The likelihood of linkage was higher in more recent years (2014-2015).

CONCLUSIONS

Although linkage variables in this study had limited discriminatory power in the absence of a unique identifier, an appreciable proportion of self-reported cases were confirmed in the registry via linkages. More importantly, the linkages also identified many previously unreported cases. These findings offer new insights that can inform future cancer surveillance and research in low-income and middle-income countries.

Time intervals and patient-level factors in oral cancer diagnostic pathways: An application of the WHO framework in India

BACKGROUND

Oral cancer, a leading cancer-site in India, is often detected at advanced stages. We evaluated the time intervals from first symptom to help-seeking and diagnosis among oral cancer patients.

METHODOLOGY

In this cross-sectional study, we recruited 226 consecutive oral cancer patients (mean age ( ± SD) 51.9 years ( ± 10.9); 81.9% men; 70.3% advanced stage) registered for diagnosis and treatment, between 2019 and 2021 at a cancer care centre in South India. We used WHO framework and previously standardized tools to record time intervals (appraisal, help-seeking and diagnostic) and baseline characteristics. We utilized multivariable logistic regression models to test the associations between 'prolonged (i.e., over 1 month) time intervals') and patient-level factors to estimate odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Over a half of patients presented with prolonged appraisal (60%) and help-seeking intervals (57%), and a third (34%) reported prolonged diagnostic interval. Patients with no formal education, no routine healthcare visits, no self-reported risk factors, and those who did not perceive initial symptoms to be serious were 2-4 times more likely to have prolonged appraisal and help-seeking than the rest. High travel costs and self-decision for visiting healthcare facility prolonged help-seeking. Diagnostic interval was prolonged only among women OR= 2.7 (95% CI: 1.2-6.1)) and in patients whose first doctor's opinion was 'nothing to worry' OR (=7.3 (95% CI: 2.6-20.5)). 'Correct knowledge of cancer' shortened appraisal and help-seeking intervals and 'incorrect knowledge and negative beliefs' prolonged diagnostic interval.

CONCLUSION

Our findings highlight that interventions targeting sociocultural and economic determinants, symptom awareness, sensitizing persons at risk (especially women) and primary care providers might reduce overall time to diagnosis. Further, patients without any known risk factors for oral cancer might be at-risk for prolonged appraisal interval. These might help inform 'pull' strategies for cancer control in India and similar settings.

Effect modification by sex for associations of fine particulate matter (PM2.5) with cardiovascular mortality, hospitalization, and emergency room visits: systematic review and meta-analysis

Particulate matter with aerodynamic diameter no larger than 2.5 μm (PM2.5) has been linked to cardiovascular diseases (CVDs) but evidence for vulnerability by sex remains unclear. We performed systematic review and meta-analysis to synthesize the state of scientific evidence on whether cardiovascular risks from PM2.5 differ for men compared to women. The databases Pubmed, Scopus, Embase, and GreenFILE were searched for studies published Jan. 1995 to Feb. 2020. Observational studies conducting subgroup analysis by sex for impacts of short-term or long-term exposure to PM2.5 on target CVDs were included. Data were independently extracted in duplicate and pooled with random-effects meta-regression. Risk ratios (RRs) for long-term exposure and percent changes in outcomes for short-term exposure were calculated per 10 μg/m3 PM2.5 increase. Quality of evidence of risk differences by sex was rated following Grading of Recommendations Assessment, Development and Evaluation (GRADE). A total of 12,502 articles were screened, with 61 meeting inclusion criteria. An additional 32 studies were added from citation chaining. RRs of all CVD mortality for long-term PM2.5 for men and women were the same (1.14; 95% CI: 1.09, 1.22) indicating no statistically different risks. Men and women did not have statistically different risks of daily CVD mortality, hospitalizations from all CVD, ischemic heart disease, cardiac arrest, acute myocardial infarction, and heart failure from short-term PM2.5 exposure (difference in % change in risk per 10 μg/m3 PM2.5: 0.04 (95% CI, -0.42 to 0.51); -0.05 (-0.47 to 0.38); 0.17 (-0.90, 1.24); 1.42 (-1.06, 3.97); 1.33 (-0.05, 2.73); and -0.48 (-1.94, 1.01), respectively). Analysis using GRADE found low or very low quality of evidence for sex differences for PM2.5-CVD risks. In conclusion, this meta-analysis and quality of evidence assessment of current observational studies found very limited evidence of the effect modification by sex for effects of PM2.5 on CVD outcomes in adults, which can inform clinical approaches and policies.

Abstract P3-13-04: Clinical features and genetic alterations in patients (pts) with HER2-positive breast cancer (BC) and central nervous system (CNS) metastases (mets) in the real world

Introduction: Pts with HER2-positive metastatic BC (mBC) often develop CNS mets, which is associated with poor prognosis and negative impact on quality of life. Resistance to anti-HER2 treatment can lead to disease progression; furthermore, many therapies do not cross the blood-brain barrier, leading to an unmet need for effective CNS mets treatment. In this real world study, we explored the molecular profile and clinical features of pts with CNS and non-CNS mets to better understand tumor biology in these populations. Methods: This retrospective, cross-sectional, observational study evaluated pts with CNS mets or non-CNS mets at the time of HER2-positive mBC diagnosis using the Flatiron Health-Foundation Medicine Clinico-Genomic Database (FH-FMI CGDB). The database comprised de-identified data from ~280 US cancer clinics (~800 sites of care), and included pts with FMI comprehensive genomic profiling assays covering >300 cancer-related genes. Descriptive analyses were conducted for baseline demographic, clinical, and biomarker characteristics, as well as genetic alterations including single nucleotide variants (SNVs), copy number alterations (CNAs), and rearrangements. T-tests were used to compare continuous variables, chi-squared tests for categorical variables, and non-parametric tests for non-normal distributions. Results: Of 8204 pts with BC in the CGDB, 6111 females 18+ yrs were diagnosed with mBC on or after 1-1-2011, of whom 919 had HER2-positive mBC, and 314 had an FMI assay up to 120 days after mBC diagnosis. This study population included 45 pts with CNS mets and 269 pts with non-CNS mets (Table). FMI data were derived from the primary tumor (29% from breast) or a metastatic lesion (19%, 12%, and 4% from liver, lymph nodes, and brain, respectively). Pts with CNS vs non-CNS mets were significantly younger at initial and at mBC diagnosis (p=0.04). At mBC diagnosis, a higher percentage of pts with CNS vs non-CNS mets had ≥3 sites of mets (p=0.01) and mets sites in adrenal glands (p=0.01), while there was a trend toward lower rates of lung and liver mets (not significant [NS]). Pts with CNS mets were more likely to be hormone receptor-negative vs pts with non-CNS mets (NS). Missing data for HER2 results by IHC or FISH, tumor grade, and histology limited the interpretation of any observed differences. Pts with CNS vs non-CNS mets were more likely to have SNVs in TP53 (82% vs 64%, p=0.03) and CNAs in ERBB2 (60% vs 43%, p<0.05). The most common mutations in pts with CNS mets were TP53 (82%) and PIK3CA (29%), followed by ERBB2, BRCA1, ESR1, CDH1, MLL2, and ATRX (<9% each). The most common CNAs in pts with CNS mets were ERBB2 (60%) and MYC (20%), followed by CCND1, FGF19, FGF3, FGF4, and CCNE1 (13% each). Rearrangements were rare and no clear differences were observed between pts with CNS and non-CNS mets. Conclusions: Despite its small sample size, our analysis is one of the largest real world genomic studies in HER2-positive pts with CNS mets to date. Pts with CNS mets at mBC diagnosis showed potential distinguishing clinical and genetic features, including younger age, a higher proportion with adrenal gland mets and ≥3 sites of mets, and a higher prevalence of SNVs in TP53 and CNAs in ERBB2. Cautious interpretation is needed due to the small sample, unique pt population, and heterogeneity in tissue location. Further analyses can help elucidate the biology of CNS mets in these pts with a high unmet need.

Table. Demographic, clinical, and genetic characteristics of the study populationVariableCNS mets (n=45)Non-CNS mets (n=269)Total (N=314)p-valueMedian age at mBC diagnosis, years (interquartile range [IQR])55 (47-62)60 (51-68)59 (49-68)0.04Median age at early BC diagnosis, years (IQR)51 (43-60)55 (48-64)55 (46-64)0.04<45 years14 (31)54 (20)68 (22)45-64 years24 (53)148 (55)172 (55)≥65 years7 (16)67 (25)74 (24)Race, n (%)White23 (51)174 (65)197 (63)0.09Black/Asian4 (9)31 (12)35 (11)Other10 (22)43 (16)53 (17)Missing8 (18)21 (8)29 (9)Group stage at initial diagnosis, n (%)aI<4 (<9)25 (9)26 (8)0.12II22 (49)88 (33)110 (35)III11 (24)76 (28)87 (28)IV6 (13)59 (22)65 (21)Missing5 (11)21 (8)26 (8)Number of metastatic sites, n (%)111 (24)110 (41)121 (39)0.01213 (29)90 (34)103 (33)≥321 (47)69 (26)90 (29)SNVs (selected a priori), n (%)bTP5337 (82)173 (64)210 (67)0.03PIK3CA13 (29)97 (36)110 (35)0.45ERBB2<4 (<9)21 (8)24 (8)1ESR1<4 (<9)7 (3)10 (3)1PTEN<4 (<9)12 (4)14 (4)1CNAs (most common in all pts), n (%)bERBB227 (60)115 (43)142 (45)0.047MYC9 (20)61 (23)70 (22)0.84FGF196 (13)45 (17)51 (16)0.72aGroup stage is documented at the time of initial diagnosis in the pt health record or determined based on T, N, and M stage based on AJCC version at the time of the patient’s diagnosis, and does not include staging collected after systemic/radiation therapy, progression, and/or neoadjuvant treatment, if any.bp-values were not adjusted for multiple comparisons. Data not shown: additional univariate analyses of 129 genes on SNVs, CNAs and rearrangements yielded the following genes with the highest prevalence in pts with CNS mets: TP53 (82%), PIK3CA (29%), ERBB2 (<9%), CDH1 (<9%), ESR1 (<9%), BRCA1 (<9%), MLL2 (<9%), ATRX (<9%), and GATA3 (<9%) for SNVs; ERBB2 (60%), MYC (20%), CCND1 (13%), FGF19 (13%), FGF3 (13%), FGF4 (13%), and CCNE1 (13%) for CNAs; and CDK12 (<9%) and NF1 (<9%) for rearrangements.

Citation Format: Preet K. Dhillon, Peter Lambert, Thibaut Sanglier, Adam Knott, Eleonora Restuccia, Sanne L. de Haas, Chiara Lambertini. Clinical features and genetic alterations in patients (pts) with HER2-positive breast cancer (BC) and central nervous system (CNS) metastases (mets) in the real world [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-13-04.

Feasibility of investigating the association between bacterial pathogens and oral leukoplakia in low and middle income countries: A population-based pilot study in India

BACKGROUND

Certain oral bacterial pathogens may play a role in oral carcinogenesis. We assessed the feasibility of conducting a population-based study in India to examine the distributions and levels of Porphyromonas gingivalis, Fusobacterium nucleatum and Prevotella intermedia in relation to oral leukoplakia (a potentially malignant disorder) and other participant characteristics.

METHODS

This exploratory case-control study was nested within a large urban Indian cohort and the data included 22 men and women with oral leukoplakia (cases) and 69 leukoplakia-free controls. Each participant provided a salivary rinse sample, and a subset of 34 participants (9 cases; 25 controls) also provided a gingival swab sample from keratinized gingival surface for quantitative polymerase chain reaction (qPCR).

RESULTS

Neither the distribution nor the levels of pathogens were associated with oral leukoplakia; however, individual pathogen levels were more strongly correlated with each other in cases compared to controls. Among controls, the median level of total pathogens was the highest (7.55×104 copies/ng DNA) among persons of low socioeconomic status. Salivary rinse provided better DNA concentration than gingival swab for qPCR analysis (mean concentration: 1.8 ng/μl vs. 0.2 ng/μl).

CONCLUSIONS

This study confirms the feasibility of population studies evaluating oral microbiome in low-resource settings and identifies promising leads for future research.

Abstract PS10-20: Neoadjuvant (neoadj) and adjuvant (adj) treatment patterns in HER2-positive early breast cancer (EBC): Analysis of US real-world oncology data

OBJECTIVES

Over the last decade, new treatment options have transformed the standard of care for patients (pts) with HER2-positive EBC and the treatment landscape continues to evolve. The primary objectives of our study were (1) to describe and compare the demographic and clinical characteristics of pts with HER2-positive EBC who received neoadj or adj treatment, (2) to describe the common neoadj and adj regimens according to hormone receptor (HR) status, and (3) to describe trends in neoadj treatment use from 2011 to 2019 in a US real-world setting.

METHODS

Unstructured and structured electronic health record-derived data were analyzed from the US Flatiron Health de-identified database (2011-2020), a longitudinal database of >2.4 million pts with cancer in >280 clinics, largely from community-based practices. Eligible pts had HER2-positive EBC (diagnosis: Jan 1, 2011-Jul 31, 2019; follow-up: until Feb 29, 2020). Systemic or oral anti-neoplastic treatments with initiation either prior to (neoadj) or within 6 months (adj) of the first primary surgery date were included. Adj treatment also required at least 6 months of follow-up and was captured for up to 1 year after initiation of adj therapy.

RESULTS

Pts with HER2-positive EBC treated in the neoadj setting, versus those in the adj setting alone, were more likely to be younger, pre-menopausal, have HR-negative disease, clinical stage II or III stage disease (refer to footnote in Table 1), have received treatment at an academic center, and were ~2 times as likely to have bilateral mastectomies (Table 1). Conversely, race/ethnicity as well as tumor grade, histology and laterality did not differ by neoadj versus adj treatment. The most common therapies are presented in Table 1. There was an upward trend in the annual percentage of pts diagnosed with HER2-positive EBC who initiated neoadj treatment starting in 2011 (<20% of pts) and peaking in 2017 (~50% of pts). Most pts (78%) who received neoadj therapy were treated with a taxane-based chemotherapy regimen and a dual blockade of HER2 with trastuzumab plus pertuzumab (HP). A minority of neoadj pts (11%) received an anthracycline-based regimen plus HER2-targeted therapy. As expected, most pts received HER2-targeted therapy alone with HP post-surgery. The most common chemotherapy for adj-only pts included a taxane-based regimen combined with H (+/- P). Hormonal therapy was mostly administered post-surgery (adj-continuation: 61%; adj-only: 78%) with low use in the neoadj setting (9%). When evaluating pts by HR status, pts with HR-positive EBC more commonly received hormonal and ‘other’ therapy; adj-only pts with HR-negative disease more commonly received HER2-targeted therapies with taxanes (83% v 54%), irrespective of the additional use of platinum-based chemotherapy (64% v 38%) or anthracyclines (15% v 8%).

CONCLUSIONS

Neoadj therapy use has increased, which is in line with changes in the standard anti-HER2 therapies that have occurred since 2013. Despite considerable variation, neoadj pts are mostly treated with dual HER2 blockade and chemotherapy, with a preference for taxane-based regimens.

Table 1. Summary of key demographics and clinical characteristicsCharacteristic*Neoadj (n = 394)Adj (n = 696)Age at diagnosis, mean (IQR)55 (46, 64)61 (51, 69)Race / ethnicity- Non-Hispanic white237 (60)433 (62)- Other134 (34)218 (31)- Unknown23 (6)45 (7)Menopausal status- Postmenopausal219 (56)495 (71)ECOG PS- 0203 (52)277 (40)- 152 (13)86 (12)- 2+7 (2)13 (2)- Unknown132 (34)320 (46)Combined clinical stage†- Clinical stage I30 (8)364 (52)- Clinical stage II167 (42)216 (31)- Clinical stage III104 (26)57 (8)- Unknown93 (24)59 (9)Type of surgery- Lumpectomy155 (41)435 (63)- Mastectomy225 (59)261 (37)- Unknown14 (4)0Year of Diagnosis- 2011-1245 (11)180 (26)- 2013-14109 (28)209 (30)- 2015-1698 (25)170 (24)- 2017-19142 (36)137 (20)Practice type (EHR format)- Community348 (88)659 (95)- Academic46 (12)37 (5)ER-positive and/or PR-positive280 (71)557 (80)Most common treatment regimens, n (%)‡Pts with HER2-positive EBC, with available treatment dataNeoadjn = 280- TCH / TCHP43 (15) / 176 (63)- ACT + H/HP§14 (5) / 18 (6)- Any hormonal therapy25 (9)Adj continuationn = 266- H / HP only171 (64) / 38 (14)- Any hormonal therapy163 (61)- T (H / HP) + other¶35 (13)Adj-onlyn = 642- Any hormonal therapy500 (78)- TCH / TCHP223 (35) / 43 (7)- T (H / HP) + other¶106 (17)*P <0.05 (t-test) when comparing pts in the neoadj and adj treatment groups for the clinical characteristics listed (with the exception of race / ethnicity where no major differences were noted). †Clinical stage prior to the start of systemic treatment, which is close to the time of diagnosis for neoadj pts and after the time of surgery for adj pts. ‡‘Other’ therapies accounted for 5% of regimens. §The majority of anthracycline use was a TCH / HP regimen. ¶‘Other’ treatments include CD20 monoclonal antibody, CDK 4/6 inhibitors, antimetabolites (e.g., gemcitabine) and clinical trial study drugs (not specifically listed/known). A, anthracycline; adj, adjuvant; C, a platinum-based compound; ECOG PS, Eastern Cooperative Oncology Group Performance Status; EHR, electronic health record; ER, estrogen receptor; H, trastuzumab; IQR, interquartile range; neoadj, neoadjuvant; P, pertuzumab; PR, progesterone receptor; pts, patients, T, taxane.

Citation Format: Preet K. Dhillon, Carlos Flores, Thibaut Sanglier, Vincent Antao, David Tesarowski, Anita Fung, Devin Incerti, Eleonora Restuccia, Patricia Luhn. Neoadjuvant (neoadj) and adjuvant (adj) treatment patterns in HER2-positive early breast cancer (EBC): Analysis of US real-world oncology data [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS10-20.

Association of baseline systemic corticosteroid use with overall survival and time to next treatment in patients receiving immune checkpoint inhibitor therapy in real-world US oncology practice for advanced non-small cell lung cancer, melanoma, or urothelial carcinoma

Immune checkpoint inhibitors (CPIs) have expanded treatment options for patients with solid tumors. Systemic corticosteroids (CSs) have an indispensable role in cancer care, but CS-related immunosuppression may counteract the CPI-driven antitumor immune response. This retrospective study investigated the association between baseline CS use (bCS; ≤14 days before, ≤30 days after CPI initiation) and clinical outcomes in patients with advanced non-small cell lung cancer (aNSCLC), melanoma (aMel), or urothelial carcinoma (aUC). We analyzed data from the Flatiron Health electronic health record-derived de-identified database for adults diagnosed with aNSCLC, aMel, or aUC between January 2011 and June 2017 who received ≥1 CPI monotherapy in any treatment line. Associations of bCS use with overall survival (OS) and time to next treatment (TTNT) were estimated using multivariable Cox proportional hazards models adjusting for demographic and clinical characteristics (i.e., ECOG performance status, site of metastases). In total, 2,213 patients were diagnosed with aNSCLC (n = 862), aMel (n = 742), or aUC (n = 609) and received ≥1 CPI administration. Most patients (67%-95%) received CSs, many during the baseline period (19%-30%). Patients with bCS use had shorter median OS than those with no bCS use for aNSCLC (6.6 vs 10.6 months; P= .00018), aMel (16.4 vs 21.5; P= .095), and aUC (4.1 vs 7.7; P= .0012). bCS use was associated with shorter OS (not significant for aMel) and TTNT in adjusted multivariable analyses, and clinical outcomes were not explained by prior CS use or other measured confounders. These findings suggest a potential association between bCS use and decreased CPI effectiveness, warranting further investigation.

Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4)

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHCs had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHCs, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Abstract 5388: Association of baseline systemic corticosteroid use with time to next treatment in patients with advanced melanoma, non-small cell lung cancer or urothelial cancer receiving cancer immunotherapy in US clinical practice

Background: Corticosteroids (CS) are often prescribed with cancer treatment to alleviate symptoms, treat comorbidities and manage treatment-related adverse events. The immunosuppressive properties of CS may decrease the effectiveness of cancer immunotherapy (CIT), and the effect may vary by tumor site. This study explored the association of baseline CS (bCS) use with time to next treatment (TTNT) in CIT-treated patients with advanced melanoma (aMel), advanced non-small cell lung cancer (aNSCLC) or advanced urothelial cancer (aUC).

Methods: The Flatiron Health electronic health record-derived de-identified database was used to select patients diagnosed with aMel, aNSCLC or aUC between January 1, 2011, and June 30, 2017, who received CIT alone in any treatment line and were followed through March 30, 2018. bCS included intramuscular or intravenous administrations or oral orders ≤ 14 days before and ≤ 30 days after the CIT start date. TTNT is a measure of intermediate outcomes, such as cancer progression, in real-world data sources. A TTNT event was defined as initiation of a new line of non-maintenance treatment or death within 60 days of the last CIT treatment during the index line of therapy. Other patients were censored at the latter of either their last CIT administration or last recorded visit. The association of bCS with TTNT was estimated using multivariable Cox proportional hazards models adjusting for key baseline characteristics, including prior CS use.

Results: Most patients were white men aged 66 to 72 years; median follow-up across tumor types was 3.9 to 5.5 months. One-fifth to one-third (19%-30%) of patients received bCS. More than half of patients (58%-61%) received a new treatment line during the study period, the milestone for measuring TTNT. Patients receiving bCS were more likely to have stage IV disease at diagnosis, brain or liver metastases (aNSCLC, aUC) and poorer ECOG performance status (aUC) at baseline. After adjusting for these and other important potential confounders, including prior CS use, bCS use was associated with shorter TTNT compared with no bCS use in multivariable models (aMel HR, 1.28 [95% CI: 1.03, 1.58]; aNSCLC HR, 1.40 [1.16, 1.70]; aUC HR, 1.36 [1.06, 1.82]).

Conclusions: After adjustments for measured confounders, patients receiving bCS had a shorter TTNT than those who did not receive bCS, suggesting a shorter treatment duration that may limit the potential long-term benefits of CIT use. TTNT is commonly used as a proxy for disease progression in real-world data sources; however, treatment changes could be due to reasons other than progression. Further studies are needed to confirm these observations.

Keywords/Indexing: Lung cancer: non-small cell; Melanoma/skin cancers

[A.D. and P.K.D. contributed equally to this work.]

Citation Format: Alexandra Drakaki, Preet K. Dhillon, Heather Wakelee, Stephen Y. Chui, Jinjoo Shim, Matthew Kent, Viraj Degaonkar, Tien Hoang, Virginia McNally, Patricia Luhn, Ralf Gutzmer. Association of baseline systemic corticosteroid use with time to next treatment in patients with advanced melanoma, non-small cell lung cancer or urothelial cancer receiving cancer immunotherapy in US clinical practice [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5388.

"Real-world" outcomes and prognostic indicators among patients with high-risk muscle-invasive urothelial carcinoma

INTRODUCTION

There is no current standard of care for patients with high-risk muscle-invasive urothelial carcinoma (MIUC) after neoadjuvant chemotherapy and surgical resection or for those who cannot receive or decline cisplatin-based perioperative chemotherapy. Understanding current, real-world treatment patterns may help inform decisions from clinical, research, and population health management perspectives. We examined real-world treatment patterns, survival outcomes, and prognostic factors among Medicare beneficiaries with high-risk MIUC who did not receive adjuvant treatment after surgical resection.

METHODS

We identified patients with high-risk MIUC in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database who underwent surgical resection (radical cystectomy and/or radical nephroureterectomy). Eligible patients had indicators of high-risk MIUC and surgical resection between 2001 and 2013. Demographic and clinical characteristics, including comorbidities, American Joint Commission on Cancer (AJCC) stage, tumor stage/grade and nodal status, and distribution of neoadjuvant treatment by the year of surgical resection were evaluated. Overall survival (OS) and disease-free survival (DFS) were assessed for the full cohort and by subgroups using Kaplan-Meier survival analysis. Adjusted Cox proportional hazards models were used to evaluate patient demographics and clinical characteristics associated with OS and DFS.

RESULTS

A total of 665 patients were included in the analysis, with a mean age of 75.5 years; most were men (61%) and had AJCC stage IIIA disease (69%). Neoadjuvant treatment increased over the entire study period, both overall (from 12% to 46%) and cisplatin based (from 5% to 38%). Median OS for the entire cohort was 23.1 months (95% confidence interval: 18, 27); median DFS was 13.5 months (95% confidence interval: 11.3, 16.8). AJCC stage IIIB/IVA was the most significant predictor of poor prognosis for both OS and DFS, followed by non-white race and comorbidity burden.

CONCLUSION

The prognosis for high-risk patients with MIUC remains poor, with significant risk of mortality within 2 years of radical cystectomy despite increasing use of neoadjuvant treatment. Unmet treatment needs persist for this difficult-to-treat patient population despite the increasing use of cisplatin-based neoadjuvant chemotherapy.

Leveraging Existing Cohorts to Study Health Effects of Air Pollution on Cardiometabolic Disorders: India Global Environmental and Occupational Health Hub

Air pollution is a growing public health concern in developing countries and poses a huge epidemiological burden. Despite the growing awareness of ill effects of air pollution, the evidence linking air pollution and health effects is sparse. This requires environmental exposure scientist and public health researchers to work more cohesively to generate evidence on health impacts of air pollution in developing countries for policy advocacy. In the Global Environmental and Occupational Health (GEOHealth) Program, we aim to build exposure assessment model to estimate ambient air pollution exposure at a very fine resolution which can be linked with health outcomes leveraging well-phenotyped cohorts which have information on geolocation of households of study participants. We aim to address how air pollution interacts with meteorological and weather parameters and other aspects of the urban environment, occupational classification, and socioeconomic status, to affect cardiometabolic risk factors and disease outcomes. This will help us generate evidence for cardiovascular health impacts of ambient air pollution in India needed for necessary policy advocacy. The other exploratory aims are to explore mediatory role of the epigenetic mechanisms (DNA methylation) and vitamin D exposure in determining the association between air pollution exposure and cardiovascular health outcomes. Other components of the GEOHealth program include building capacity and strengthening the skills of public health researchers in India through variety of training programs and international collaborations. This will help generate research capacity to address environmental and occupational health research questions in India. The expertise that we bring together in GEOHealth hub are public health, clinical epidemiology, environmental exposure science, statistical modeling, and policy advocacy.

Vegetarian Epidemiology: Review and Discussion of Findings from Geographically Diverse Cohorts

Epidemiologic cohort studies enrolling a large percentage of vegetarians have been highly informative regarding the nutritional adequacy and possible health effects of vegetarian diets. The 2 largest such cohorts are the European Prospective Investigation into Cancer and Nutrition-Oxford (EPIC-Oxford) and the Adventist Health Study-2 (AHS-2). These cohorts are described and their findings discussed, including a discussion of where findings appear to diverge. Although such studies from North America and the United Kingdom have been important, the large majority of the world's vegetarians live in other regions, particularly in Asia. Findings from recent cohort studies of vegetarians in East and South Asia are reviewed, particularly the Tzu Chi Health Study and Indian Migration Study. Important considerations for the study of the health of vegetarians in Asia are discussed. Vegetarian diets vary substantially, as may associated health outcomes. Cohort studies remain an important tool to better characterize the health of vegetarian populations around the globe.

Association of Long-Term Exposure to Fine Particulate Matter and Cardio-Metabolic Diseases in Low- and Middle-Income Countries: A Systematic Review

: Background: Numerous epidemiological studies indicated high levels of particulate matter less than2.5 μm diameter (PM2.5) as a major cardiovascular risk factor. Most of the studies have been conducted in high-income countries (HICs), where average levels of PM2.5 are far less compared to low- and middle- income countries (LMICs), and their socio-economic profile, disease burden, and PM speciation/composition are very different. We systematically reviewed the association of long-term exposure to PM2.5 and cardio-metabolic diseases (CMDs) in LMICs.

METHODS

Multiple databases were searched for English articles with date limits until March 2018. We included studies investigating the association of long-term exposure to PM2.5 (defined as an annual average/average measure for 3 more days of PM2.5 exposure) and CMDs, such as hospital admissions, prevalence, and deaths due to CMDs, conducted in LMICs as defined by World Bank. We excluded studies which employed exposure proxy measures, studies among specific occupational groups, and specific episodes of air pollution.

RESULTS

A total of 5567 unique articles were identified, of which only 17 articles were included for final review, and these studies were from Brazil, Bulgaria, China, India, and Mexico. Outcome assessed were hypertension, type 2 diabetes mellitus and insulin resistance, and cardiovascular disease (CVD)-related emergency room visits/admissions, death, and mortality. Largely a positive association between exposure to PM2.5 and CMDs was found, and CVD mortality with effect estimates ranging from 0.24% to 6.11% increased per 10 μg/m3 in PM2.5. CVD-related hospitalizations and emergency room visits increased by 0.3% to 19.6%. Risk factors like hypertension had an odds ratio of 1.14, and type 2 diabetes mellitus had an odds ratio ranging from 1.14-1.32. Diversity of exposure assessment and health outcomes limited the ability to perform a meta-analysis.

CONCLUSION

Limited evidence on the association of long-term exposure to PM2.5 and CMDs in the LMICs context warrants cohort studies to establish the association.

Serum Calcium Concentrations, Chronic Inflammation and Glucose Metabolism: A Cross-Sectional Analysis in the Andhra Pradesh Children and Parents Study (APCaPS)

BACKGROUND

Evidence suggests a role for elevated serum calcium in dysregulated glucose metabolism, linked through low-level chronic inflammation.

OBJECTIVES

We investigated the association of elevated serum calcium concentrations (corrected for albumin) with markers of dysregulated glucose metabolism and type II diabetes and tested if these associations were accounted for by chronic inflammation in a rural Indian population.

METHODS

A cross-sectional analysis of participants aged 40-84 y from the Andhra Pradesh Children and Parents Study (APCaPS; n = 2699, 52.2% women) was conducted. Comprehensive information on household, sociodemographic, and lifestyle factors; medical and family history; physical measurements; blood measurements including fasting plasma glucose (FPG), fasting insulin (FI), serum calcium, albumin, phosphorous, vitamin D (in a subset), and creatinine were analyzed. Additionally, in a random sample of healthy participants (n = 1000), inflammatory biomarkers (interleukins 6 and 18, soluble intercellular adhesion molecule 1, adiponectin, and high-sensitivity C-reactive protein) were measured and an inflammatory score (IScore) calculated.

RESULTS

After adjustments for sociodemographics, lifestyle factors, and anthropometry the highest calcium quartile (Q4 compared with Q1) was associated with FI (β = 1.4 µU/ml; 95% CI: 1.2, 1.5 µU/ml; P-trend < 0.001), the homeostasis model assessment for insulin resistance (HOMA-IR) (β = 1.4; 95% CI: 1.2, 1.5; P-trend < 0.001), and was modestly associated with FPG (β = 2.1 mg/dL; 95% CI: -0.9, 5.2 mg/dL; P-trend = 0.058) and prevalent type II diabetes (OR = 1.6; 95% CI: 1.0, 2.6; P-trend= 0.020). In the healthy subgroup, the association of the highest calcium quartile was similar for FI and HOMA-IR. Additional adjustment with IScore did not alter the associations. Further, in a subset, all these associations were independent of endogenous regulators of calcium metabolism (serum vitamin D, phosphorus, and creatinine). Independently, after accounting for potential confounders, the highest IScore quartile (Q4 compared with Q1) was positively associated with FPG, FI, HOMA-IR, and prevalent prediabetes, and also with serum calcium concentrations in men.

CONCLUSIONS

Elevated serum calcium was positively associated with markers of dysregulated glucose metabolism and prevalent type II diabetes in a rural Indian population. Chronic inflammation did not mediate this association but was independently associated with markers of dysregulated glucose metabolism. Inflammation might be responsible for elevated serum calcium concentrations in men.

Integrating Breast Cancer Evaluation With a Cervical Cancer Toolkit for Low-Resource Settings

Purpose

To address high breast cancer (BC) mortality globally and especially in low- and middle-income countries (LMICs), resource-stratified screening and treatment guidelines have been provided by global expert groups. How these guidelines are implemented and aligned with facility readiness in low-resource settings is less well understood. We propose to modify, apply, and evaluate a cervical cancer toolkit designed to evaluate facility readiness in LMICs as an implementation science tool for the treatment of BC.

Methods

We will draw upon an existing toolkit for cervical cancer, the Improving Data for Decision Making in Global Cervical Cancer Programs (IDCCP) developed by the Centers for Disease Control and Prevention, WHO, and the George W. Bush Institute. The IDCCP includes 13 domains—for example, services, staffing, infrastructure, procurement and supply chain, equipment and supplies, referral pathways, etc—by which to assess facility readiness, and information on six categories is available in India’s District Level Household and Facility Level Survey (2012 to 2013). We applied the IDCCP toolkit for cervical cancer screening in India using District Level Household and Facility Level Survey data and propose to extend this work to include BC screening evaluation per Indian government guidelines—clinical breast exam followed by ultrasound, with or without mammography, followed by biopsy as needed across the four tiers of India’s public health care system. As a test of construct validation, we will correlate facility readiness for BC screening at the district level with self-reported BC examination data at the district level using the National Family Health Survey-4 (2015 to 2016).

Results

Composite scores that summarize the six categories for cervical cancer yield wide variation in facility readiness across 30 states and union territories, with a trend toward higher scores for higher levels of the public health care system. Some consistencies emerge for higher-performing states, such as Maharashtra and Goa. We will conduct similar analyses for BC screening after modifying the tool kit for BC.

Conclusion

The modified toolkit for either BC alone or in combination with cervical cancer can be considered an implementation science tool to by which assess facility readiness of health centers in LMICs and for understanding gaps in the implementation of government guidelines.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.

Association between empirically derived dietary patterns with blood lipids, fasting blood glucose and blood pressure in adults - the India migration study

BACKGROUND

Dietary patterns (DPs) in India are heterogenous. To date, data on association of indigenous DPs in India with risk factors of nutrition-related noncommunicable diseases (cardiovascular disease and diabetes), leading causes of premature death and disability, are limited. We aimed to evaluate the associations of empirically-derived DPs with blood lipids, fasting glucose and blood pressure levels in an adult Indian population recruited across four geographical regions of India.

METHODS

We used cross-sectional data from the Indian Migration Study (2005-2007). Study participants included urban migrants, their rural siblings and urban residents and their urban siblings from Lucknow, Nagpur, Hyderabad and Bangalore (n = 7067, mean age 40.8 yrs). Information on diet (validated interviewer-administered, 184-item semi-quantitative food frequency questionnaire), tobacco consumption, alcohol intake, physical activity, medical history, as well as anthropometric measurements were collected. Fasting-blood samples were collected for estimation of blood lipids and glucose. Principal component analysis (PCA) was used to identify major DPs based on eigenvalue> 1 and component interpretability. Robust standard error multivariable linear regression models were used to investigate the association of DPs (tertiles) with total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), triglycerides, fasting-blood glucose (FBG), systolic and diastolic blood pressure (SBP and DBP) levels.

RESULTS

Three major DPs were identified: 'cereal-savoury' (cooked grains, rice/rice-based dishes, snacks, condiments, soups, nuts), 'fruit-vegetable-sweets-snacks' (Western cereals, vegetables, fruit, fruit juices, cooked milk products, snacks, sugars, sweets) and 'animal food' (red meat, poultry, fish/seafood, eggs) patterns. High intake of the 'animal food' pattern was positively associated with levels of TC (β = 0.10 mmol/L; 95% CI: 0.02, 0.17 mmol/L; p-trend = 0.013); LDL-C (β = 0.07 mmol/L; 95% CI: 0.004, 0.14 mmol/L; p-trend = 0.041); HDL-C (β = 0.02 mmol/L; 95% CI: 0.004, 0.04 mmol/L; p-trend = 0.016), FBG: (β = 0.09 mmol/L; 95% CI: 0.01, 0.16 mmol/L; p-trend = 0.021) SBP (β = 1.2 mm/Hg; 95% CI: 0.1, 2.3 mm/Hg; p-trend = 0.032); DBP: (β = 0.9 mm/Hg; 95% CI: 0.2, 1.5 mm/Hg; p-trend = 0.013). The 'cereal-savoury' and 'fruit-vegetable-sweets-snacks' patterns showed no association with any parameter except for a positive association with diastolic blood pressure for high intake of 'fruits-vegetables-sweets-snacks' pattern.

CONCLUSION

Our results indicate positive associations of the 'animal food' pattern with cardio-metabolic risk factors in India. Further longitudinal assessments of dietary patterns in India are required to validate the findings.

Single nucleotide polymorphisms as markers of genetic susceptibility for oral potentially malignant disorders risk: Review of evidence to date

•

We reviewed single nucleotide polymorphisms for oral pre-cancer susceptibility.

•

All of them were pathway based candidate gene association studies.

•

The current level of evidence is very limited.

•

Integrated characterization of germline/somatic alterations in oral cancer & pre-cancer is needed.

Background

Oral cancers are preceded by oral potentially malignant disorders (OPMD). Understanding genetic susceptibility for OPMD risk could provide an opportunity for risk assessment of oral cancer through early disease course. We conducted a review of single nucleotide polymorphism (SNP) studies for OPMD risk.

Methods

We identified all relevant studies examining associations of SNPs with OPMD (leukoplakia, erythroplakia and oral sub-mucous fibrosis) conducted world-wide between January, 2000 and February, 2016 using a combined keyword search on PubMed. Of these, 47 studies that presented results as odds ratios and 95% CI were considered for full review.

Results

The majority of eligible studies that explored candidate gene associations for OPMD were small (N < 200 cases), limiting their scope to provide strong inference for any SNP identified to date in any population. Commonly studied SNPs were genes of carcinogen metabolism (n = 18 studies), DNA repair (n = 11 studies), cell cycle control (n = 8 studies), extra-cellular matrix alteration (n = 8 studies) and immune-inflammatory (n = 6 studies) pathways. Based on significant associations as reported by two or more studies, suggestive markers included SNPs in GSTM1 (null), CCND1 (G870A), MMP3 (-1171; promotor region), TNFα (-308; rs800629), XPD (codon 751) and Gemin3 (rs197412) as well as in p53 (codon 72) in Indian populations. However, an equal or greater number of studies reported null or mixed associations for SNPs in GSTM1 (null), p53 (codon 72), XPD (codon 751), XRCC (rs25487 C/T), GSTT1 (null) and CYP1A1m1 (MspI site).

Conclusion

Candidate gene association studies have not yielded consistent data on risk loci for OPMD. High-throughput genotyping approaches for OPMD, with concurrent efforts for oral cancer, could prove useful in identifying robust risk-loci to help understand early disease course susceptibility for oral cancer.

Socioeconomic patterning of chronic conditions and behavioral risk factors in rural South Asia: a multi-site cross-sectional study

OBJECTIVES

Our aim was to examine relationships between markers of socioeconomic status and chronic disease risks in rural South Asia to understand the etiology of chronic diseases in the region and identify high-risk populations.

METHODS

We examined data from 2271 adults in Chennai, Goa and Matlab sites of the Chronic Disease Risk Factor study in South Asia. We report age-sex adjusted odds ratios for risk factors (tobacco, alcohol, fruit-vegetable use and physical activity) and common chronic conditions (hypertension, diabetes, overweight, depression, impaired lung and vision) by education, occupation and wealth.

RESULTS

Respondents with greater wealth and in non-manual professions were more likely to be overweight [OR = 2.48 (95% CI 1.8,3.38)] and have diabetes [OR = 1.88 (95% CI 1.02,3.5)]. Wealth and education were associated with higher fruit and vegetable [OR = 1.89 (95% CI 1.48,2.4)] consumption but lower physical activity [OR = 0.52 (95% CI 0.39,0.69)]. Non-manual workers reported lower tobacco and alcohol use, while wealthier respondents reported better vision and lung function.

CONCLUSIONS

Ongoing monitoring of inequalities in chronic disease risks is needed for planning and evaluating interventions to address the growing burden of chronic conditions.

Radiation Oncology in India: Challenges and Opportunities

Rising cancer incidence and mortality in India emphasize the need to address the increasing burden of this disease and the stark inequities in access to radiotherapy and other essential medical treatments. State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75% of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas, where most of India׳s population lives. A long-term government commitment to machine purchase and human resource development in the public sector is needed to improve access. A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programs between institutions in high- and low-income countries to exchange knowledge and expertise, and nongovernmental and state-sponsored schemes to sponsor and support patients in their cancer journey. Strengthening of cancer registries and regulatory bodies with authority to enforce minimum standards is also required to improve care. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.

Breast Cancer Awareness and Prevention Behavior Among Women of Delhi, India: Identifying Barriers to Early Detection

BACKGROUND

Globally, breast cancer (BC) has become the leading cause of mortality in women. Awareness and early detection can curb the growing burden of BC and are the first step in the battle against BC. The aim of this qualitative study was to explore the awareness and perceived barriers concerning the early detection of BC.

METHODS

A total of 20 focus group discussions (FGDs) were conducted during May 2013–March 2014. Pre-existing themes were used to conduct FGDs; each FGD group consisted of an average of ~10 women (aged ≥18–70 years) who came to participate in a BC awareness workshop. All FGDs were audio taped and transcribed verbatim. The transcripts were inductively analyzed using ATLAS.ti. Based on emerged codes and categories, thematic analysis was done, and theory was developed using the grounded theory approach.

RESULTS

Data were analyzed in three major themes: i) knowledge and perception about BC; ii) barriers faced by women in the early presentation of BC; and iii) healthcare-seeking behavior. The findings revealed that shyness, fear, and posteriority were the major behavioral barriers in the early presentation of BC. Erroneously, pain was considered as an initial symptom of BC by most women. Financial constraint was also mentioned as a cause for delay in accessing treatment. Social stigma that breast problems reflect bad character of women also contributed in hiding BC symptoms.

CONCLUSIONS

Lack of BC awareness was prevalent, especially in low socioeconomic class. Women’s ambivalence in prioritizing their own health and social and behavioral hurdles should be addressed by BC awareness campaigns appropriately suited for various levels of social class.

Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015

BACKGROUND

In September, 2015, the UN General Assembly established the Sustainable Development Goals (SDGs). The SDGs specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. We provide an analysis of 33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015).

METHODS

We applied statistical methods to systematically compiled data to estimate the performance of 33 health-related SDG indicators for 188 countries from 1990 to 2015. We rescaled each indicator on a scale from 0 (worst observed value between 1990 and 2015) to 100 (best observed). Indices representing all 33 health-related SDG indicators (health-related SDG index), health-related SDG indicators included in the Millennium Development Goals (MDG index), and health-related indicators not included in the MDGs (non-MDG index) were computed as the geometric mean of the rescaled indicators by SDG target. We used spline regressions to examine the relations between the Socio-demographic Index (SDI, a summary measure based on average income per person, educational attainment, and total fertility rate) and each of the health-related SDG indicators and indices.

FINDINGS

In 2015, the median health-related SDG index was 59·3 (95% uncertainty interval 56·8-61·8) and varied widely by country, ranging from 85·5 (84·2-86·5) in Iceland to 20·4 (15·4-24·9) in Central African Republic. SDI was a good predictor of the health-related SDG index (r2=0·88) and the MDG index (r2=0·92), whereas the non-MDG index had a weaker relation with SDI (r2=0·79). Between 2000 and 2015, the health-related SDG index improved by a median of 7·9 (IQR 5·0-10·4), and gains on the MDG index (a median change of 10·0 [6·7-13·1]) exceeded that of the non-MDG index (a median change of 5·5 [2·1-8·9]). Since 2000, pronounced progress occurred for indicators such as met need with modern contraception, under-5 mortality, and neonatal mortality, as well as the indicator for universal health coverage tracer interventions. Moderate improvements were found for indicators such as HIV and tuberculosis incidence, minimal changes for hepatitis B incidence took place, and childhood overweight considerably worsened.

INTERPRETATION

GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be sufficient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to effectively address the expanded scope of the health-related SDGs.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors-the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI).

FINDINGS

Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6-58·8) of global deaths and 41·2% (39·8-42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa.

INTERPRETATION

Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

METHODS

We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). Total deaths increased by 4·1% (2·6-5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8-18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6-16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9-14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.

INTERPRETATION

At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Healthy life expectancy (HALE) and disability-adjusted life-years (DALYs) provide summary measures of health across geographies and time that can inform assessments of epidemiological patterns and health system performance, help to prioritise investments in research and development, and monitor progress toward the Sustainable Development Goals (SDGs). We aimed to provide updated HALE and DALYs for geographies worldwide and evaluate how disease burden changes with development.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2015. We calculated DALYs by summing years of life lost (YLLs) and years of life lived with disability (YLDs) for each geography, age group, sex, and year. We estimated HALE using the Sullivan method, which draws from age-specific death rates and YLDs per capita. We then assessed how observed levels of DALYs and HALE differed from expected trends calculated with the Socio-demographic Index (SDI), a composite indicator constructed from measures of income per capita, average years of schooling, and total fertility rate.

FINDINGS

Total global DALYs remained largely unchanged from 1990 to 2015, with decreases in communicable, neonatal, maternal, and nutritional (Group 1) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). Much of this epidemiological transition was caused by changes in population growth and ageing, but it was accelerated by widespread improvements in SDI that also correlated strongly with the increasing importance of NCDs. Both total DALYs and age-standardised DALY rates due to most Group 1 causes significantly decreased by 2015, and although total burden climbed for the majority of NCDs, age-standardised DALY rates due to NCDs declined. Nonetheless, age-standardised DALY rates due to several high-burden NCDs (including osteoarthritis, drug use disorders, depression, diabetes, congenital birth defects, and skin, oral, and sense organ diseases) either increased or remained unchanged, leading to increases in their relative ranking in many geographies. From 2005 to 2015, HALE at birth increased by an average of 2·9 years (95% uncertainty interval 2·9-3·0) for men and 3·5 years (3·4-3·7) for women, while HALE at age 65 years improved by 0·85 years (0·78-0·92) and 1·2 years (1·1-1·3), respectively. Rising SDI was associated with consistently higher HALE and a somewhat smaller proportion of life spent with functional health loss; however, rising SDI was related to increases in total disability. Many countries and territories in central America and eastern sub-Saharan Africa had increasingly lower rates of disease burden than expected given their SDI. At the same time, a subset of geographies recorded a growing gap between observed and expected levels of DALYs, a trend driven mainly by rising burden due to war, interpersonal violence, and various NCDs.

INTERPRETATION

Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence and correlates of achieving recommended physical activity levels among children living in rural South Asia-A multi-centre study

Background

We report the prevalence of recommended physical activity levels (RPALs) and examine the correlates of achieving RPALs in rural South Asian children and analyse its association with anthropometric outcomes.

Methods

This analysis on rural South Asian children aged 5–14 years (n = 564) is a part of the Chronic Disease Risk Factor study conducted at three sites in India (Chennai n = 146; Goa n = 218) and Bangladesh (Matlab; n = 200). Data on socio-demographic and lifestyle factors (physical activity (PA); diet) were collected using an interviewer-administered questionnaires, along with objective anthropometric measurements. Multivariate logistic regression models were used to examine whether RPALs (active travel to school (yes/no); leisure-time PA ≥ 1 h/day; sedentary-activity ≤ 2 h/day) were associated with socio-demographic factors, diet and other forms of PA. Multivariate linear regression models were used to investigate associations between RPALs and anthropometrics (BMI- and waist z-scores).

Results

The majority of children (71.8 %) belonged to households where a parent had at least a secondary education. Two-thirds (66.7 %) actively travelled to school; 74.6 % reported ≥1 h/day of leisure-time PA and 55.7 % had ≤2 h/day of sedentary-activity; 25.2 % of children reported RPALs in all three dimensions. Older (10–14 years, OR = 2.0; 95 % CI: 1.3, 3.0) and female (OR = 1.7; 95 % CI: 1.1, 2.5) children were more likely to travel actively to school. Leisure-time PA ≥ 1 h/day was more common among boys (OR = 2.5; 95 % CI: 1.5, 4.0), children in Matlab, Bangladesh (OR = 3.0; 95 % CI: 1.6, 5.5), and those with higher processed-food consumption (OR = 2.3; 95 % CI: 1.2, 4.1). Sedentary activity ≤ 2 h/day was associated with younger children (5–9 years, OR = 1.6; 95 % CI: 1.1, 2.4), children of Goa (OR = 3.5; 95 % CI: 2.1, 6.1) and Chennai (OR = 2.5; 95 % CI: 1.5, 4.3) and low household education (OR = 2.1; 95 % CI: 1.1, 4.1). In multivariate analyses, sedentary activity ≤ 2 h/day was associated with lower BMI-z-scores (β = −0.3; 95 % CI: −0.5, −0.08) and lower waist-z-scores (β = −1.1; 95 % CI: −2.2, −0.07).

Conclusion

Only one quarter of children in these rural areas achieved RPAL in active travel, leisure and sedentary activity. Improved understanding of RPAL in rural South Asian children is important due to rapid socio-economic transition.

Multiple Stakeholder Perspectives on Cancer Stigma in North India

BACKGROUND

Cancer is a leading cause of death worldwide. A large proportion of cancer deaths are preventable through early detection but there are a range of social, emotional, cultural and financial dimensions that hinder the effectiveness of cancer prevention and treatment efforts. Cancer stigma is one such barrier and is increasingly recognized as an important factor influencing health awareness and promotion, and hence, disease prevention and control. The impact and extent of stigma on the cancer early detection and care continuum is poorly understood in India.

OBJECTIVES

To evaluate cancer awareness and stigma from multiple stakeholder perspectives in North India, including men and women from the general population, health care professionals and educators, and cancer survivors.

MATERIALS AND METHODS

A qualitative study was conducted with in-depth interviews (IDIs) and focus group discussions (FGDs) among 39 individuals over a period of 3 months in 2014. Three groups of participants were chosen purposively - 1) men and women who attended cancer screening camps held by the Indian Cancer Society, Delhi; 2) health care providers and 3) cancer survivors.

RESULTS

Most participants were unaware of what cancers are in general, their causes and ways of prevention. Attitudes of families towards cancer patients were observed to be positive and caring. Nevertheless, stigma and its impact emerged as a cross cutting theme across all groups. Cost of treatment, lack of awarenes and beliefs in alternate medicines were identified as some of the major barriers to seeking care.

CONCLUSIONS

This study suggests a need for spreading awareness, knowledge about cancers and assessing associated impact among the people. Also Future research is recommended to help eradicate stigma from the society and reduce cancer-related stigma in the Indian context.

Trends in mouth cancer incidence in Mumbai, India (1995-2009): An age-period-cohort analysis

INTRODUCTION

Despite tobacco control and health promotion efforts, the incidence rates of mouth cancer are increasing across most regions in India. Analysing the influence of age, time period and birth cohort on these secular trends can point towards underlying factors and help identify high-risk populations for improved cancer control programmes.

METHODS

We evaluated secular changes in mouth cancer incidence among men and women aged 25-74 years in Mumbai between 1995 and 2009 by calculating age-specific and age-standardized incidence rates (ASR). We estimated the age-adjusted linear trend for annual percent change (EAPC) using the drift parameter, and conducted an age-period-cohort (APC) analysis to quantify recent time trends and to evaluate the significance of birth cohort and calendar period effects.

RESULTS

Over the 15-year period, age-standardized incidence rates of mouth cancer in men in Mumbai increased by 2.7% annually (95% CI:1.9 to 3.4), p<0.0001) while rates among women decreased (EAPC=-0.01% (95% CI:-0.02 to -0.002), p=0.03). APC analysis revealed significant non-linear positive period and cohort effects in men, with higher effects among younger men (25-49 years). Non-significant increasing trends were observed in younger women (25-49 years).

CONCLUSIONS

APC analyses from the Mumbai cancer registry indicate a significant linear increase of mouth cancer incidence from 1995 to 2009 in men, which was driven by younger men aged 25-49 years, and a non-significant upward trend in similarly aged younger women. Health promotion efforts should more effectively target younger cohorts.

Breast Cancer Awareness at the Community Level among Women in Delhi, India

BACKGROUND

To assess women's awareness from diverse sections of society in Delhi regarding various aspects of breast cancer (BC)--perceptions, signs and symptoms, risk factors, prevention, screening and treatment.

MATERIALS AND METHODS

Community-level survey was undertaken in association with the Indian Cancer Society (ICS), Delhi during May 2013-March 2014. Women attending BC awareness workshops by ICS were given self-administered questionnaires before the workshop in the local language to assess BC literacy. Information provided by 2017 women was converted into awareness scores (aware=1) for analysis using SPSS. Awareness scores were dichotomized with median score=19 as cut off, create more aware and less aware categories. Bivariate and multivariate analysis provided P-values, odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Broadly, 53.4% women were aware about various aspects of BC. Notably, 49.1% women believed that BC was incurable and 73.9% women believed pain to be an initial BC symptom. Only 34.9% women performed breast self-examination (BSE) and 6.9% women had undergone clinical breast-examination/mammography. 40.5% women had higher awareness (awareness score>median score of 19), which was associated with education [graduates (OR=2.31; 95%CI=1.78, 3.16), post-graduates (OR=7.06; 95%CI=4.14, 12.05) compared to ≤high school] and socio-economic status (SES) [low-middle (OR=4.20; 95%CI=2.72, 6.49), middle (OR=6.00; 95%CI=3.82, 9.42) and upper (OR=6.97; 95%CI=4.10, 11.84) compared to low SES].

CONCLUSIONS

BC awareness of women in Delhi was suboptimal and was associated with low SES and education. Awareness must be drastically increased via community outreach and use of media as a first step in the fight against BC.

Adoption of Information and Communication Technologies for Early Detection of Breast and Cervical Cancers in Low- and Middle-Income Countries

PURPOSE

In response to the growing burden of breast and cervical cancers, low- and middle-income countries (LMICs) are beginning to implement national cancer prevention programs. We reviewed the literature on information and communication technology (ICT) applications in the prevention of breast and cervical cancers in LMICs to examine their potential to enhance cancer prevention efforts.

METHODS

Ten databases of peer-reviewed and gray literature were searched using an automated strategy for English-language articles on the use of mobile health (mHealth) and telemedicine in breast and cervical cancer prevention (screening and early detection) published between 2005 and 2015. Articles that described the rationale for using these ICTs and/or implementation experiences (successes, challenges, and outcomes) were reviewed. Bibliographies of articles that matched the eligibility criteria were reviewed to identify additional relevant references.

RESULTS

Of the initial 285 citations identified, eight met the inclusion criteria. Of these, four used primary data, two were overviews of ICT applications, and two were commentaries. Articles described the potential for mHealth and telemedicine to address both demand- and supply-side challenges to cancer prevention, such as awareness, access, and cost, in LMICs. However, there was a dearth of evidence to support these hypotheses.

CONCLUSION

This review indicates that there are few publications that reflect specifically on the role of mHealth and telemedicine in cancer prevention and even fewer that describe or evaluate interventions. Although articles suggest that mHealth and telemedicine can enhance the implementation and use of cancer prevention interventions, more evidence is needed.

Reproductive Tract infections and Premalignant Lesions of Cervix: Evidence from Women Presenting at the Cancer Detection Centre of the Indian Cancer Society, Delhi, 2000-2012

OBJECTIVES

Burden of cervical cancer (CC) is highest for women in low- and middle-income countries (LMICs). Human papillomavirus (HPV) is implicated as the necessary cause of CC although a number of other factors aid the long process of CC development. One among them is the presence of reproductive tract infections (RTIs). This study investigated the associations between RTIs and CC from India.

METHODS

This study utilized secondary data from the Cancer Detection Centre of the ICS, Delhi. Data were accessed from MS access database and were analyzed using MS Excel and SPSS 16.0. Multivariate analysis using unconditional logistic regression produced odds ratios (ORs) and 95 % confidence intervals (CIs).

RESULTS

This study used data from 11,427 women over a period of 2000-2012. Women with RTIs had Candida, Trichomonas vaginalis (TV) or coccoid infections with all having similar prevalence (~4-5 %). 9.4 % of women had premalignant lesions of cervix; ASCUS was most common (7.9 %) followed by LSIL (1.3 %). TV was significantly associated with ASCUS, LSIL and all premalignant lesions of cervix (P < 0.001). Regression discovered an important association of TV with premalignant lesions of cervix (OR 2.79; 95 % CI 2.14, 3.64).

CONCLUSIONS

Earlier studies have depicted associations between TV and HPV with possible enhancement of HPV virulence due to TV. Lack of awareness and hygiene, and limited access to gynecologists in LMICs lead to frequent and persistent RTIs which aid and abet HPV infection and CC occurrence. These also need to be addressed to reduce CC and RTIs among women in LMICs.

Using implementation science to advance cancer prevention in India

Oral, cervical and breast cancers, which are either preventable and/or amenable to early detection and treatment, are the leading causes of cancer-related morbidity and mortality in India. In this paper, we describe implementation science research priorities to catalyze the prevention and control of these cancers in India. Research priorities were organized using a framework based on the implementation science literature and the World Health Organization's definition of health systems. They addressed both community-level as well as health systems-level issues. Community-level or "pull" priorities included the need to identify effective strategies to raise public awareness and understanding of cancer prevention, monitor knowledge levels, and address fear and stigma. Health systems-level or "push" and "infrastructure" priorities included dissemination of evidence- based practices, testing of point-of-care technologies for screening and diagnosis, identification of appropriate service delivery and financing models, and assessment of strategies to enhance the health workforce. Given the extent of available evidence, it is critical that cancer prevention and treatment efforts in India are accelerated. Implementation science research can generate critical insights and evidence to inform this acceleration.

DNA methylation markers for oral pre-cancer progression: A critical review

Although oral cancers are generally preceded by a well-established pre-cancerous stage, there is a lack of well-defined clinical and morphological criteria to detect and signal progression from pre-cancer to malignant tumours. We conducted a critical review to summarize the evidence regarding aberrant DNA methylation patterns as a potential diagnostic biomarker predicting progression. We identified all relevant human studies published in English prior to 30th April 2015 that examined DNA methylation (%) in oral pre-cancer by searching PubMed, Web-of-Science and Embase databases using combined key-searches. Twenty-one studies (18-cross-sectional; 3-longitudinal) were eligible for inclusion in the review, with sample sizes ranging from 4 to 156 affected cases. Eligible studies examined promoter region hyper-methylation of tumour suppressor genes in pathways including cell-cycle-control (n=15), DNA-repair (n=7), cell-cycle-signalling (n=4) and apoptosis (n=3). Hyper-methylated loci reported in three or more studies included p16, p14, MGMT and DAPK. Two longitudinal studies reported greater p16 hyper-methylation in pre-cancerous lesions transformed to malignancy compared to lesions that regressed (57-63.6% versus 8-32.1%; p<0.01). The one study that explored epigenome-wide methylation patterns reported three novel hyper-methylated loci (TRHDE; ZNF454; KCNAB3). The majority of reviewed studies were small, cross-sectional studies with poorly defined control groups and lacking validation. Whilst limitations in sample size and study design preclude definitive conclusions, current evidence suggests a potential utility of DNA methylation patterns as a diagnostic biomarker for oral pre-cancer progression. Robust studies such as large epigenome-wide methylation explorations of oral pre-cancer with longitudinal tracking are needed to validate the currently reported signals and identify new risk-loci and the biological pathways of disease progression.

Associations between active travel and adiposity in rural India and Bangladesh: a cross-sectional study

Background

Data on use and health benefits of active travel in rural low- and middle- income country settings are sparse. We aimed to examine correlates of active travel, and its association with adiposity, in rural India and Bangladesh.

Methods

Cross sectional study of 2,122 adults (≥18 years) sampled in 2011–13 from two rural sites in India (Goa and Chennai) and one in Bangladesh (Matlab). Logistic regression was used to examine whether ≥150 min/week of active travel was associated with socio-demographic indices, smoking, oil/butter consumption, and additional physical activity. Adjusting for these same factors, associations between active travel and BMI, waist circumference and waist-to-hip ratio were examined using linear and logistic regression.

Results

Forty-six percent of the sample achieved recommended levels of physical activity (≥150 min/week) through active travel alone (range: 33.1 % in Matlab to 54.8 % in Goa). This was more frequent among smokers (adjusted odds ratio 1.36, 95 % confidence interval 1.07–1.72; p = 0.011) and those that spent ≥150 min/week in work-based physical activity (OR 1.71, 1.35–2.16; p < 0.001), but less frequent among females than males (OR 0.25, 0.20–0.31; p < 0.001). In fully adjusted analyses, ≥150 min/week of active travel was associated with lower BMI (adjusted coefficient −0.39 kg/m², −0.77 to −0.02; p = 0.037) and a lower likelihood of high waist circumference (OR 0.77, 0.63–0.96; p = 0.018) and high waist-to-hip ratio (OR 0.72, 0.58–0.89; p = 0.002).

Conclusions

Use of active travel for ≥150 min/week was associated with being male, smoking, and higher levels of work-based physical activity. It was associated with lower BMI, and lower risk of a high waist circumference or high waist-to-hip ratio. Promotion of active travel is an important component of strategies to address the growing prevalence of overweight in rural low- and middle- income country settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2411-0) contains supplementary material, which is available to authorized users.

Report from a symposium on catalyzing primary and secondary prevention of cancer in India

Purpose

Oral, breast, and cervical cancers are amenable to early detection and account for a third of India’s cancer burden. We convened a symposium of diverse stakeholders to identify gaps in evidence, policy, and advocacy for the primary and secondary prevention of these cancers and recommendations to accelerate these efforts.

Methods

Indian and global experts from government, academia, private sector (health care, media), donor organizations, and civil society (including cancer survivors and patient advocates) presented and discussed challenges and solutions related to strategic communication and implementation of prevention, early detection, and treatment linkages.

Results

Innovative approaches to implementing and scaling up primary and secondary prevention were discussed using examples from India and elsewhere in the world. Participants also reflected on existing global guidelines and national cancer prevention policies and experiences.

Conclusions

Symposium participants proposed implementation-focused research, advocacy, and policy/program priorities to strengthen primary and secondary prevention efforts in India to address the burden of oral, breast, and cervical cancers and improve survival.

A review of breast cancer awareness among women in India: Cancer literate or awareness deficit?

Background

Breast cancer is the most common female cancer worldwide including India, where advanced stages at diagnosis, and rising incidence and mortality rates, make it essential to understand cancer literacy in women. We conducted a literature review to evaluate the awareness levels of risk factors for breast cancer among Indian women and health professionals.

Methods

A structured literature search using combined keywords was undertaken on bibliographic databases including MEDLINE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health (CINAHL) and SCOPUS. Searches were restricted to research published in English language peer-reviewed journals through December, 2014 in India.

Results

A total of 7066 women aged 15–70 years showed varied levels of awareness on risk factors such as family history (13–58%), reproductive history (1–88%) and obesity (11–51%). Literacy levels on risk factors did not improve over the 8-year period (2005–2013). On average, nurses reported higher, though still varied, awareness levels for risk factors such as family history (40.8–98%), reproductive history (21–90%) and obesity (34–6%). Awareness levels were not consistently higher for the stronger determinants of risk.

Conclusion

Our review revealed low cancer literacy of breast cancer risk factors among Indian women, irrespective of their socio-economic and educational background. There is an urgent need for nation- and state-wide awareness programmes, engaging multiple stakeholders of society and the health system, to help improve cancer literacy in India.

Intra-household evaluations of alcohol abuse in men with depression and suicide in women: A cross-sectional community-based study in Chennai, India

Background

Harmful effects of alcohol abuse are well documented for drinkers, and adverse effects are also reported for the physical and emotional well-being of family members, with evidence often originating from either drinkers or their families in clinic-based settings. This study evaluates intra-household associations between alcohol abuse in men, and depression and suicidal attempts in women, in community-based settings of Chennai, India.

Methods

This community-based cross-sectional study of chronic disease risk factors and outcomes was conducted in n = 259 households and n = 1053 adults (aged 15 years and above) in rural and urban Chennai. The Alcohol Use Disorder Identification Test (AUDIT) score was used to classify alcohol consumption into ‘low-risk', ‘harmful’, ‘hazardous’ and ‘alcohol dependence’ drinking and the Patient Health Questionnaire (PHQ-9) score to classify depression as ‘mild’, ‘moderate’, ‘moderate-severe’ and ‘severe’. Multivariate logistic regression models estimated the association of depression in women with men’s drinking patterns in the same household.

Results

A significant 2.5-fold increase in any depression (PHQ-9 ≥ 5) was observed in men who were ‘alcohol-dependent’ compared to non-drinkers (OR = 2.53; 95 % CI: 1.26, 5.09). However, there was no association between men’s drinking behavior and depression in women of the same household, although suicidal attempts approached a significant dose–response relationship with increasing hazard-level of men’s drinking (p = 0.08).

Conclusion

No significant intra-household association was observed between men’s alcohol consumption and women’s depression, though an increasing (non-significant) trend was associated with suicidal attempts. Complex relationships between suicidal attempts and depression in women and male abusive drinking require further exploration, with an emphasis on intra-household mechanisms and pathways.

Recommendations for screening and early detection of common cancers in India

Cancers of the breast, uterine cervix, and lip or oral cavity are three of the most common malignancies in India. Together, they account for about 34% of more than 1 million individuals diagnosed with cancer in India each year. At each of these cancer sites, tumours are detectable at early stages when they are most likely to be cured with standard treatment protocols. Recognising the key role that effective early detection and screening programmes could have in reducing the cancer burden, the Indian Institute for Cytology and Preventive Oncology, in collaboration with the US National Cancer Institute Center for Global Health, held a workshop to summarise feasible options and relevant evidence for screening and early detection of common cancers in India. The evidence-based recommendations provided in this Review are intended to act as a guide for policy makers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control for the three most common cancers in India.

Cancer detection rates in a population-based, opportunistic screening model, New Delhi, India

BACKGROUND

In India, cancer accounts for 7.3% of DALY's, 14.3% of mortality with an age-standardized incident rate of 92.4/100,000 in men and 97.4/100,000 in women and yet there are no nationwide screening programs.

MATERIALS AND METHODS

We calculated age-standardized and age-truncated (30-69 years) detection rates for men and women who attended the Indian Cancer Society detection centre, New Delhi from 2011-12. All participants were registered with socio-demographic, medical, family and risk factors history questionnaires, administered clinical examinations to screen for breast, oral, gynecological and other cancers through a comprehensive physical examination and complete blood count. Patients with an abnormal clinical exam or blood result were referred to collaborating institutes for further investigations and follow-up.

RESULTS

A total of n=3503 were screened during 2011-12 (47.8% men, 51.6% women and 0.6% children <15 years) with a mean age of 47.8 yrs (±15.1 yrs); 80.5% were aged 30-69 years and 77.1% had at least a secondary education. Tobacco use was reported by 15.8%, alcohol consumption by 11.9% and family history of cancer by 9.9% of participants. Follow-up of suspicious cases yielded 45 incident cancers (51.1% in men, 48.9% in women), consisting of 55.5% head and neck (72.0% oral), 28.9% breast, 6.7% gynecological and 8.9% other cancer sites. The age-standardized detection rate for all cancer sites was 340.8/100,000 men and 329.8/100,000 women.

CONCLUSIONS

Cancer screening centres are an effective means of attracting high-risk persons in low-resource settings. Opportunistic screening is one feasible pathway to address the rising cancer burden in urban India through early detection.

Type of vegetarian diet, obesity and diabetes in adult Indian population

Background

To investigate the prevalence of obesity and diabetes among adult men and women in India consuming different types of vegetarian diets compared with those consuming non-vegetarian diets.

Methods

We used cross-sectional data of 156,317 adults aged 20–49 years who participated in India’s third National Family Health Survey (2005–06). Association between types of vegetarian diet (vegan, lacto-vegetarian, lacto-ovo vegetarian, pesco-vegetarian, semi-vegetarian and non-vegetarian) and self-reported diabetes status and measured body mass index (BMI) were estimated using multivariable logistic regression adjusting for age, gender, education, household wealth, rural/urban residence, religion, caste, smoking, alcohol use, and television watching.

Results

Mean BMI was lowest in pesco-vegetarians (20.3 kg/m²) and vegans (20.5 kg/m²) and highest in lacto-ovo vegetarian (21.0 kg/m²) and lacto-vegetarian (21.2 kg/m²) diets. Prevalence of diabetes varied from 0.9% (95% CI: 0.8-1.1) in person consuming lacto-vegetarian, lacto-ovo vegetarian (95% CI:0.6-1.3) and semi-vegetarian (95% CI:0.7-1.1) diets and was highest in those persons consuming a pesco-vegetarian diet (1.4%; 95% CI:1.0-2.0). Consumption of a lacto- (OR:0.67;95% CI:0.58-0.76;p < 0.01), lacto-ovo (OR:0.70; 95% CI:0.51-0.96;p = 0.03) and semi-vegetarian (OR:0.77; 95% CI:0.60-0.98; p = 0.03) diet was associated with a lower likelihood of diabetes than a non-vegetarian diet in the adjusted analyses.

Conclusions

In this large, nationally representative sample of Indian adults, lacto-, lacto-ovo and semi-vegetarian diets were associated with a lower likelihood of diabetes. These findings may assist in the development of interventions to address the growing burden of overweight/obesity and diabetes in Indian population. However, prospective studies with better measures of dietary intake and clinical measures of diabetes are needed to clarify this relationship.

Evidence-informed frameworks for cost-effective cancer care and prevention in low, middle, and high-income countries

Evidence-informed frameworks for cost-effective cancer prevention and management are essential for delivering equitable outcomes and tackling the growing burden of cancer in all resource settings. Evidence can help address the demand side pressures (ie, pressures exerted by people who need care) faced by economies with high, middle, and low incomes, particularly in the context of transitioning towards (or sustaining) universal health-care coverage. Strong systems, as opposed to technology-based solutions, can drive the development and implementation of evidence-informed frameworks for prevention and management of cancer in an equitable and affordable way. For this to succeed, different stakeholders-including national governments, global donors, the commercial sector, and service delivery institutions-must work together to address the growing burden of cancer across economies of low, middle, and high income.

Aspirin use after a prostate cancer diagnosis and cancer survival in a prospective cohort

Experimental and clinical data suggest that aspirin and other nonsteroidal inflammatory drugs may delay the progression of prostate cancer through inhibition of the COX pathway and its effects on cellular proliferation, apoptosis, and angiogenesis. Epidemiologic data support a reduced risk of prostate cancer incidence with aspirin use, yet no evidence exists about whether aspirin after diagnosis influences progression or survival. We conducted a prospective study of 3,986 participants of the Health Professionals Follow-up Study, with a prostate cancer diagnosis between January 1, 1990, and December 31, 2005. We used Cox proportional hazards regression to evaluate the association between aspirin use after diagnosis and the development of metastases or fatal prostate cancer through January 31, 2008, adjusting for risk factors associated with incidence and mortality in this cohort, prediagnostic aspirin use, Gleason score, tumor-node-metastasis (TNM) stage, and primary treatment. In total, 265 men developed bony or other organ metastases or fatal prostate cancer during the 18 years of follow-up. We observed no association between updated aspirin use after diagnosis and lethal prostate cancer [tablets/week: <2: HR, 1.12; 95% confidence interval (CI), 0.72-1.72; 2-5: HR, 1.05; 95% CI, 0.62-1.80; ≥ 6: HR, 1.08; 95% CI, 0.76-1.54; P(trend) = 0.99]. The results remained unchanged when we examined aspirin use at baseline only (P(trend) = 0.70) or frequency of use (d/wk; P(trend) = 0.35) or limited the outcome to fatal prostate cancer (P(trend) = 0.63). There was no association between aspirin use after a prostate cancer diagnosis and lethal disease in this cohort of prostate cancer survivors.

Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity

BACKGROUND

The South-East Asia region (SEAR) accounts for one-quarter of the world's population, 40% of the global poor and ∼30% of the global disease burden, with a disproportionately large share of tuberculosis (35%), injuries (30%), maternal (33%) and <5-year-old mortality (30%). In this article, we describe the disease burden and status of epidemiological research and capacity in the SEAR to understand, analyse and develop capacity in response to the diverse burdens of diseases in the region.

METHODS

Data on morbidity, mortality, risk factors, social determinants, research capacity, health education, workforce and systems in the SEAR were obtained using global data on burden of disease, peer-reviewed journals, World Health Organization (WHO) technical and advisory reports, and where available, validated country reports and key informants from the region.

RESULTS

SEAR countries are afflicted with a triple burden of disease-infectious diseases, non-communicable diseases and injuries. Of the seven WHO regions, SEAR countries account for the highest proportion of global mortality (26%) and due to relatively younger ages at death, the second highest percentage of total years of life lost (30%). The SEAR exceeds the global average annual mortality rate for all three broad cause groupings-communicable, maternal, perinatal and nutritional conditions (334 vs 230 per 100 000); non-communicable diseases (676 vs 573 per 100 000); and injuries (101 vs 78 per 100 000). Poverty, education and other social determinants of health are strongly linked to inequities in health among SEAR countries and within socio-economic subgroups. India, Thailand and Bangladesh produce two-thirds of epidemiology publications in the region. Significant efforts to increase health workforce capacity, research and training have been undertaken in the region, yet considerable heterogeneity in resources and capacity remains.

CONCLUSIONS

Health systems, statistics and surveillance programmes must respond to the demographic, economic and epidemiological transitions that define the current disease burden and risk profile of SEAR populations. Inequities in health must be critically analysed, documented and addressed through multi-sectoral approaches. There is a critical need to improve public health intelligence by building epidemiological capacity in the region.