bluuebunny/crossref_metadata_2025 huggingface dataset:
Screen-Round–Based Risk Strategies for Population-Based Mammography Screening
Authors: Hsu C.
Published: September 2018

Background: The widespread use of organized screening strategies of mammography screening at population level stood a chance of reducing the threat to women's life from breast cancer. However, such a population-wide strategy is often faced with the questions like “How many rounds of mammography screening are require before detecting cancer in question?” and “Can the attendee be classified the low risk after several negative screening rounds?” In addition to the concerns on resource allocation for the purpose of planning an efficient population-based screening program, the recent emergence in precision medicine also makes it attractive for considering such a risk-based decision on breast cancer prevention under the context of mass screening. Aim: To quantify number of screen rounds required for detecting an asymptomatic cancer in question and dispensing with further invitation to screen. Methods: By applying a series of Bayesian negative–binomial family–based stochastic process models taking sensitivity and specificity into account, we elucidated the aforementioned issues based on the empirical data on population-based breast cancer screening program in Finland with international collaboration. The Finnish nationwide biennial mammographic screening program was implemented and targeted to women aged 50-59 years since 1988. The panel data on the regular invitation of eligible population by Pirkanmaa screening center excluding the women who had been diagnosed by breast cancer before their first invitation were enrolled in this study. Results: Based on the estimated results, we are able to determine the rounds of screens required before detecting an asymptomatic breast cancer according to the risk profile determined by age and the performance of screening tool. Based on the empirical data, an average of 2.77 (95% CI, 2.61-2.91) screen rounds will be required to detect an asymptomatic breast cancer cases. A woman may not be invited after a series of negative findings of 8 rounds of screen. Considering the sensitivity of 83% (95% CI, 61%–95%), the required screen rounds become 2.81 (95% CI, 2.65-2.94). The screening rounds required for the young (<55 years) and the old (≥55 years) age group, the corresponding figures was 2.81 (95% CI, 2.55-3.11) and 2.76 (95% CI, 2.43-3.05). Conclusion: We quantified the screen round, 2.77 on average, required to detect an asymptomatic breast cancer and 8 rounds of screen to dispense with further invitation based on the risk and the performance of screening tool. The findings may aid in risk-based interscreening interval determination but also provide information on resources required by different screening policies with target population with different risk levels.
The Role of Colorectal Cancer Risk Chromosomal Regions in Colombian Admixed Populations
Authors: Criollo-Rayo A. , Bohórquez M. , Lott P. , Carracedo A. , Tomlinson I. , Mateus G. , Castro J. , Echeverry M. , Carvajal L. ,   Grupo de Citogenética
Published: September 2018

Background: Several colorectal cancer susceptibility disease loci have been discovered through genome-wide association studies. However most of the variants were originally identified in Caucasian populations. Aim: To analyze the role of 20 known risk SNPs for colorectal cancer. Methods: Given that linkage disequilibrium is highly dependent on population demographic history and admixture background, we studied 20 risk SNPs in a pooled sample of 955 cases and 968 controls from admixed populations in Colombia. Results: The replication was reached for 11 out of 20 nominally associated SNPs; with allelic odds ratios (OR) ranging from 1.14 to 1.41, indicating a minimal increase in risk individually, however coinheritance of those SNPs resulted in an overall OR = 5.4 (95% CI: 3.052-9.731, P = 1.16E−08). Most of the variants followed a recessive model consistent with significant homozygous ORs distributed between 1.3 and 1.65. Among the most associated markers we found: rs4939827 (18q21.1, P = 7.35E−6), rs10411210 (19q13.11, P = 0.001), rs10795668 (10p14, P = 0.0024), rs4444235 (14q.2.2, P = 0.005), rs961253 (20p12.3, P = 0.006), rs16892766 (8q23.3, P = 0.011) and rs1050547 (8q24.21, P = 0.017). Conclusion: Our findings in Colombia have addressed the admixture and how this has influenced the risk associated with the known/unknown colorectal cancer regions, providing a comprehensive vision about several CRC-susceptibility SNPs identified in European populations, which also resulted, associated with an increased risk to CRC in the Colombian population, even though frequency and genetic structure differences accounted for those nonreplicated SNPs.
Women's Cancer Screening in Haiti: Increasing Access by Bringing Services to the Workplace
Authors: DeGennaro V. , Gibbs M. , Wilson C. , Louis N. , Kanyandekwe D. , Petterson C.
Published: September 2018

Background: Cervical cancer is the leading cause of cancer-related death in Haiti yet the country does not provide sufficient screening. Working class women in Haiti are less likely to receive cancer screening or education than the poorest quartile of women. This is an untouched demographic not necessarily because of financial burdens but because most women work 6 days weekly and lack the time to seek healthcare and appropriate screening. Innovating Health International (IHI) and Share Hope recently implemented a cancer screening program using vaginal HPV self-swabs and clinical breast exams for working class women in Port-au-Prince. Aim: To not only bring much needed cervical cancer education, screening and treatment to an unreached demographic but also to assess the plausibility and acceptance by female factory workers to receive routine screening and treatment in clinics that reside within the workplace. Methods: The project began in September 2017 and will run for 12 months with plans to screen 4000 women with vaginal HPV swabs (QIAGEN careHPV) and clinical breast exams. Nurses perform clinical breast exam, teach self-breast exam, and instruct patients how to perform vaginal self-swab in the factory infirmary. Inclusion criteria for women include age 30 to 50 years. Women who screen positive for HPV will then be followed with visual inspection of the cervix with acetic acid (VIA) and thermocoagulation. Those who have suspicious masses in their breast have a breast ultrasound performed at the factory clinic. A smaller percentage of women with advanced disease will be referred to outside gynecology clinics. Results: Data collection is half-way completed and we´ll present full data in October. Over 3122 women have participated and received education on women's health issues during their lunch hour at the factories. Of all those sensitized, 2691 or 86.1% chose to have clinical breast exam. Of those who are eligible for HPV screening, 1948 or 93.8% of those eligible accepted testing. Of those tested, 344 or 16% were HPV-positive and all but a 5 completed VIA. For women who are HPV-positive, 69 or 20% were also VIA positive. All HPV-positive women received thermocoagulation except for 2, who were referred for colposcopy and loop electrocautery excisional procedure. There were 141 women who had a positive clinical breast exam and underwent breast ultrasound with only 2 requiring a biopsy. Conclusion: We seek to expand access to cervical cancer screening for the rural and working poor through using mobile health technologies coupled with community-based education and screening. HPV-positive women can undergo treatment by a traveling nurse with portable thermocoagulation therapy where they live or work, without the need to travel or leave work. With no doctor, no electricity, no pelvic exam for most women, and no stable infrastructure, we can screen women in rural areas and the working poor at their place of employment.
Fecal Hemoglobin Concentrations and Personalized Screening for Colorectal Cancer
Authors: Chen S.L.-S.
Published: September 2018

Background: Although cancer screening programs have been established in some Asian countries, resources are still insufficient to maintain high participation rates. The aim of this study was to assess whether any observed relationship persisted after adjusting for the pathologic stage of CRC to assess whether the increasing fecal hemoglobin (f-Hb) concentration on the risk of CRC death is partially explained by its intermediate influence on the pathologic stage of CRC and to propose the risk stratification by using f-Hb concentration for developing individual-tailored CRC screening. Methods: Over 1 million Taiwanese residents (n = 1,160,895) aged between 50 and 69 years participated in a biennial nationwide fecal immunochemical test (FIT) screening program between 2004 and 2009. The cohort was followed up over time to ascertain colorectal neoplasia and the causes of death until 2012. Cox regression model was operated to validate the definition of the surrogate end point such as tumor stage for the effect of f-Hb on CRC mortality and test the relationships between f-Hb in groups with increasing f-Hb and CRC mortality. The individual risk profiles based on f-Hb are proposed starting from average risk group to low risk and high risk group with biennial interscreening interval for risk prediction in advance colorectal cancer. Results: An incremental increase in both of baseline and updated f-Hb on the risk of advanced CRC cancer and CRC mortality were noted. A significant relationship was found between f-Hb and the risk for CRC mortality, increasing from a slightly increased risk for the category of f-Hb of 6 to 9 μg Hb/g (adjusted hazard ratio [HR] = 1.88; 95% CI, 1.41-2.50) to 33.04 (95% CI, 24.87-43.91) for the group with f-Hb ≥ 450 μg Hb/g as compared with the group with f-Hb of 1 to 5 ng Hb/mL (trend test, P < 0.001) at baseline after adjusting for age, gender. Taking 10-14 μg Hb/g (similar CRC mortality as general population) as standard, subjects with higher f-Hb at first screen should have a shorter interscreening interval with FIT. The screening interval could be altered to 1.5 year and 1 year for subjects with f-Hb of 15-19 μg Hb/g and f-Hb of 20-49 μg Hb/g, respectively. On the other hand, the interval between repeated FIT screens could be extended to avoid false positive cases for those with a lower f-Hb. The screening interval could be lengthened as 3 year for subjects with f-Hb of 6-9 μg Hb/g. Conclusion: We confirmed the direct relationship between f-Hb and colorectal cancer mortality, which is explained by the role of f-Hb as a surrogate for advanced CRC. Different interscreenings by different f-Hb concentrations are recommended. Individualized interscreening intervals by different f-Hb level or together with other factors could be further considered for personalized CRC screening.
Healthcare Providers´ Views on Cervical Screening: A Qualitative Study of Barriers to Cervical Screening in Malaysia
Authors: Yong C.J. , Hong L.L. , Lee K.Y. , Krishnasamy I. , Nasir N.H. Binti , Gravitt P. , Lee Y.K. , Woo Y.L.
Published: September 2018

Background: Cervical cancer is the third most common cancer affecting Malaysian women despite being highly preventable through screening. A national cervical cancer screening program has been established since 1969 to ensure early detection of cervical cancer. Nonetheless, the prevalence of cervical cancer in Malaysia remains high. Malaysia has been offering Pap tests for free in community health clinics since 1995, however only 47.3% of women have been screened. It has also been reported that nearly 40% of patients with cervical cancer presented at advanced stages of the disease. Government community healthcare professionals are the main stakeholders in the national cervical screening program. Therefore, understanding these healthcare professionals’ perspective of barriers associated with underutilization of cervical cancer screening is key to increase overall screening uptake. Aim: This study aimed to explore healthcare professionals’ views on perceived barriers to cervical screening in Malaysia. Methods: Qualitative in-depth semistructured interviews were carried out with 44 primary healthcare professionals consisting of family medicine specialists (N = 5), medical officers (N = 9), matrons and nurses (N = 20), laboratory technician (N = 5), registration staff and IT technicians (N = 5) involved in the cervical screening program at 5 different urban government healthcare clinics in Petaling district. The interviews were transcribed verbatim and analyzed using a thematic analysis approach. Results: Themes emerged were individual and system barriers. Individual barriers include knowledge/risk perception (lack of knowledge and awareness of cervical screening, low perceived risk), distress (Pap test is embarrassing or painful, previous negative Pap test experience and fear of a cancer diagnosis) and coping skills (remembering the appointment, managing responsibilities such as getting child care/elder care/coverage at work, ability to get transportation), social-cultural barrier (family support); while system barriers highlight the long waiting time for cervical screening, poor documentation, no national call-recall system, patient overload, lack of resources and manpower, lack of educational materials and problems with opportunistic screening. Conclusion: Sustainable screening interventions require approaches that address and resolve both individual and system barriers, such as exploring new methods and delivery of cervical screening, and providing education for the public and healthcare providers.
Clinical Efficacy of Combination Intravenous and Intraperitoneal Chemotherapy in the Treatment of Gastric Cancer With Peritoneal Carcinomatosis
Authors: Zhang S. , Feng R. , Pan Z. , Lin M. , Jiang T. , Huang X. , Xu Q. , Chen Q. , Yang S.
Published: September 2018

Background: Gastric cancer (GC) is prone to metastasis that typically resulted in peritoneal carcinomatosis (PC). GC patients with PC have an extremely poor clinic prognosis. Although GC is sensitive to chemotherapy, PC causes chemotherapy failure. Recent studies showed the combination of intravenous and intraperitoneal chemotherapy can significantly improve the survival rates in GC patients with PC. Aim: To identify the clinical and adverse effects of intravenous chemotherapy combined with intraperitoneal perfusion chemotherapy in the treatment of abdominal peritoneal carcinomatosis arising from gastric cancer. Methods: Retrospective analysis was performed on 49 patients with abdominal peritoneal carcinomatosis from gastric cancer who were treated at the Fujian Medical University Union Hospital between September 2010 and September 2015. The patients were divided into 2 groups based on treatment method: patients subjected to intravenous chemotherapy (n = 27), referred to as the simple group and patients subjected to combined intravenous and intraperitoneal chemotherapy (n = 22), referred to as the combination group. The short-term effects and adverse effects were evaluated based on treatment method, in conjunction with a related review of the results. The long-term effect was evaluated based on the survival rate and median survival time of both groups of patients at 12, 18, 24, 30, 36, and 60 months, as determined through follow-up. Results: Gender, age, ECOG scores before treatment, clinical stages, and the pathologic data of advanced GC patients of the 2 groups were equally distributed. The objective efficacy evaluation results showed that the objective response rate (ORR) and disease control rate (DCR) of the simple group after treatment were significantly lower than in the combination group. The median survival time (MST) of the simple group was (6.57 ± 0.75) months, which was significantly shorter than in the combination group (15.03 ± 2.31) months ( P < 0.05). In addition, the 12-, 18-, 24-, 30-, 36-, and 60-month survival rates of the simple group were all significantly lower than those of the combination group. Furthermore, combined therapy improved the physical condition of the patients. The incidence of adverse reactions in the 2 groups was not statistically significant; neither of the treatments resulted in severe complications. Conclusion: Compared with intravenous chemotherapy alone, the combined intravenous and intraperitoneal perfusion chemotherapy was more effective in improving quality of life and extending survival in time patients with abdominal peritoneal carcinomatosis from gastric cancer. In addition, the treatment produced only mild adverse effects, showing that it is tolerable and therefore worth further clinical study.
Lives and Economic Loss in Brazil Due to Lack of Radiotherapy Access in Cervical Cancer
Authors: Mendez L.C. , Moraes F.Y. , Castilho M.S. , Louie A.V. , Qu M.
Published: September 2018

Background: Cervical cancer collects the highest survival benefit from radiotherapy (RT) among all malignancies. A large gap between oncological demand and RT availability exists for cervical cancer in Brazilian Public Health System (BPHS). Aim: To evaluate cost-effectiveness of universal access to RT and chemo-radiation (CRT) for untreated cervical cancer patients in the BPHS. Methods: The incremental cost was calculated based on the direct medical cost from a payer's perspective and the proportion of new cases with unmet RT/CRT needs in 2016. The incremental effectiveness was evaluated by life-year (LY) gain based on life expectancy, cervical cancer incidence and the number of cancer deaths due to lack of RT/CRT access as previously described. The incremental cost-effectiveness ratio (ICER) was calculated from direct medical costs and LYs. The indirect costs from mortality-related productivity loss (MRPL) were estimated based on life expectancy, wage and labor force participation rate. The MRPL was compared with direct medical cost. All costs and effectiveness were age-adjusted based on 2016 Brazilian data and discounted at 3% per year. Costs were adjusted to 2016 U.S. dollars. One-way sensitivity analysis was performed to assess the robustness of the model. Results: The annual cost to close RT gap was $14.3 million, with additional cost of $4.1 million to close the CRT gap. The average years of potential life lost per death was 20.5. Cost per life saved was $10,820 for RT alone (ICER: $528/LY) and $18,919 for CRT (ICER: $584/LY), respectively. The MRPL due to shortage of RT/CRT were 70/81 million respectively. Conclusion: Providing universal access to RT/CRT for cervical cancer patients in the BPHS will incur low cost per life-year saved and provide large economical gain by saving thousands of lives.
The AMAZONA Project: Retrospective Cohort Study Describing Breast Cancer Patients' Characteristics and Survival in Brazil
Authors: Caleffi M. , Simon S. , Bines J. , Werutsky G. , Nunes J. Soares , Pacheco F. Chalu , Segalla J. Getúlio , Gomes A. , Van Eyll B.M. Adam , Gimenes D.L. , Crocamo S. , Freitas-Junior R. , Dal Lago L. , Queiroz G. Silva , Jobim de Azevedo S. , Rosa D. Dornelles , Delgado G. , Borges G. Santos , do Nascimento Y. Verônica , Zaffaroni F. , Martínez-Mesa J. , Barrios C.
Published: September 2018

Background: Breast cancer is the most common cancer in women in Brazil and worldwide. There is large variation in survival among patients and molecular subtypes are important prognostic factors. However, most of the data comes from developed countries such as the United States and in Europe. Aim: Our goal was to describe breast cancer patients' demographic and pathologic characteristics, as well as their survival according to estimated molecular subtypes, assessed by common immunohistochemistry stains. Methods: AMAZONA study is a retrospective cohort conducted from June 2008 to January 2009 including women of at least 18 years old, with histologically proven breast cancer diagnosed in the period between 1 January 2001 and 31 December 2001 and between 1 January 2006 and 31 December. Estimated molecular subtypes by local immunohistochemical stains were luminal A, luminal B, HER-2 positive and triple-negative. Data were obtained from medical records and public databases. Kaplan-Meier method was used for data description and log-rank test for comparison between the subgroups. Results: 2296 patients were included in this analysis. Mean age was 54 years. Most subjects included came from hospitals located in the southeast region of the country, treated in the public health system and had stage II invasive ductal carcinoma of breast. Regarding subtype, 71.3% had hormonal receptor positive disease, 15.7% were HER-2 positive and 21.1% had triple-negative breast cancer. Overall survival (OS) was significantly different among molecular subtypes and was independent of pathologic stage for stages II and III patients. For stage III patients 5-years OS for luminal A subtype was 75.8% and for triple-negative was 56.1% ( P .0002). Conclusion: Classification of breast cancer patients in predicted molecular subtypes using immunohistochemistry is currently available in most underdeveloped countries and is a useful prognostic tool that goes beyond clinical or pathologic stage.
Symptomatic Presentation, Diagnostic Delays and Advanced Stage Among Cervical Cancer Patients in Mexico
Authors: Unger-Saldaña K. , Alvarez-Meneses A. , Isla-Ortiz D.
Published: September 2018

Background: Even though cancer of the cervix uteri is a preventable and highly curable disease, in Mexico it is the second cause of cancer mortality among women. According to the last National Survey of Health and Nutrition (2012) , Papanicolaou test screening coverage in Mexico is estimated at 45%. Additionally, studies have revealed quality problems in the taking and interpretation of Papanicolaou test tests and a lack of follow-up in ∼60% of women with positive Pap smears. To date there is no information on the time intervals of care for cervical cancer patients in Mexico. Aims: To quantify the intervals of care from the detection of a possible cervical cancer to the beginning of cancer treatment, describe the form of presentation and identify perceived barriers to timely care. Methods: We surveyed 427 patients that received a new cervical cancer diagnosis between 6.01.16 and 5.31.17 in the 2 largest public hospitals located in Mexico City available for uninsured cancer patients. Approximately 2/3 patients reside in Mexico City metropolitan area and 1/3 in surrounding states. All patients signed informed consent. Participants' medical files were reviewed. We gathered data on: dates necessary to estimate the intervals of care, sociodemographic characteristics, form of cancer identification (symptoms vs screening), perceived barriers of care and cancer clinical stage. Results: Clinical stages at diagnosis were: 9.5% in situ, 16.9% stage I, 25.2% stage II, 20.2% stage III, 17.8% stage IV and 10.5% not known. The median duration of the patient interval (time between symptom discovery and first medical consultation) was 24 days (IQR = 5.5-72), in comparison with 175 days (IQR = 101-272) for the health system interval (time between first medical consultation and treatment start). The diagnosis interval (first consultation to diagnosis) had a median duration of 99 days (IQR = 43-204) and the treatment interval (time between diagnosis and treatment start) a median of 57 days (IQR = 37-78). Only 15% (64/427) patients identified the problem through screening. The most common symptom of presentation was vaginal bleeding in 65.9% (236/363) cases. The main perceived barriers of diagnostic delay were: lack of information of available health services (63%), long waiting times between appointments (52%) and diagnostic medical errors in the first services consulted (38%). Conclusion: The vast majority of cervical cancer cases among uninsured women in the Mexico City metropolitan area have symptomatic presentations. Additionally, these patients face delays of ∼6 months between the first medical consultation and the confirmation of cancer. Low coverage of screening and diagnostic delays are the most likely explanations of the high mortality rates of cervical cancer that persist in Mexico despite the 30-year implementation of the national screening program.
Severity of Complications and Long-Term Survival After Laparoscopic Total Gastrectomy With D2 Lymph Node Dissection for Advanced Gastric Cancer: A Propensity Score-Matched Study
Authors: Li Z.
Published: September 2018

Background: Increasing numbers of studies have shown that postoperative complication is a negative predictor of long-term survival outcomes in in various malignancies. However, the impact of severity of complications on long-term survival for patients with gastric cancer still remains unclear. Aim: This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC). Methods: The study analyzed 571 patients with AGC who underwent LTG in a single institution between April 2008 and June 2015. Patients were divided into 2 groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo (C-D) classification. Long-term survival outcomes were compared between groups in the propensity score-matched cohort. Results: The groups were well balanced after the propensity score matched. The complication (C) group was associated with decreased 5-year cancer-specific survival (CSS) (65.1% vs 76.2%, P = 0.049). Subgroup analysis showed that the severe complication (C-D grade > II) group was associated with decreased 5-year overall survival (OS) (46.3% vs 65.9%, P = 0.042) and cancer-specific survival (CSS) (53.7% vs 74.4%, P = 0.030). However, a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication (C-D grade II) group and matched NC group (68.9% vs 72.2%, P = 0.578; 75.6% vs 77.8%, P = 0.649; respectively). Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS. Further analysis showed that older age, lower body mass index (BMI), and combined resection were independent risk factor for the occurrence of severe complications. Conclusion: Severe complications adversely affected long-term survival outcomes after LTG with D2 lymph node dissection for AGC. More attention should be paid to patients at high risk for severe complications in preoperative assessment and postoperative management.
Outcomes in Patient Undergoing Maxillectomy for Squamous Cancer Invading Maxilla in a Rural Tertiary Care Institute in Socioeconomic Poor Group of Patients
Authors: Deshmukh S. , Patwa R. , Naik S. , Ankolikar S. , Zade B.
Published: September 2018

Background: Oral cancer accounts for more than 250,000 new cases of cancer in India. Oral cancer combining all sites of cancer in oral cavity is the single commonest cancer in males in India. Oral cancer involving upper alveolus and primary maxillary sinus tumors are a surgical challenge due to the complex surgery and rehabilitation. Aim: Optimal treatment strategy for treatment of squamous cancer invading maxillary sinus. Methods: This is a retrospective study of clinicopathological features, treatment, rehabilitation and outcome of all patients who underwent surgical treatment of tumor invading maxillary sinus over a period of 30 months in a rural cancer hospital. Results: Out of a total of 47 patients, 26 (55.3%) were males and 21 (44.7%) were females. Median age was 56 year with youngest patient of 23 year and oldest 88 year old. Primary maxillary sinus cancers were 19.1%, palatal tumors were 10.6% and 70.3% were buccal mucosa and upper alveolus cancers. Early cancers were 51% and locally advanced were 49%. Total maxillectomy was performed in 59.6%, partial maxillectomy in 34.1% and extended maxillectomy in 6.3% of the patients. Histology was squamous carcinoma in all patients and 85.1% were grade 2. Peripheral neural invasion was present in 14.9%, lympho-vascular emboli in 23.4%, and surgical margins were positive in 10% of the patients. Eighty percent patients underwent reconstruction by free microvascular flap. Fifty-one percent patients received postoperative chemoradiotherapy while 25.5% received only radiotherapy and 19.1% received no adjuvant treatment. At a mean follow-up of 11 months 74.5% patients are alive. Good speech was achieved in 70% and intelligible speech in 17% of the patients, while 12.8% were not able to speak. Solid food swallowing was achieved in 36.2%, semisolid in 27.6%, liquid in 19.1% of the patients and 12.8% remained on nasogastric tube feeds. Conclusion: Surgical resection with reconstruction by microvascular flap and postsurgical chemoradiotherapy in locally advanced cancers is key for improved survival and successful rehabilitation in cancer invading maxilla.
Oral Squamous Cell Carcinoma: Patterns of Recurrence and Predictors of Early Mortality. The Urgent Need for Biomarker
Authors: Lakshminarayana G.
Published: September 2018

Background: The burden of oral cancer in the Indian subcontinent is high. It is compounded by the fact of its high mortality due to late presentation. Despite strict selection criteria for curative treatment a substantial proportion develop early relapse and death. This subset of patients have an exceptionally resistant disease, even though they present at a curable stage. They pose a unique challenge to the treating physician because of the sudden transition to palliative options. Aim: The objective of the current study is to analyze the patterns of relapse and predictors of early mortality in oral squamous cell carcinoma patients treated with curative intent. Methods: We performed a retrospective study in a homogenous cohort of 88 oral squamous cell carcinoma patients who underwent primary surgery with intent to cure. The demographic, staging, treatment, histopathology parameters (tumor differentiation, margins, depth of invasion, deep tissue infiltration, perineural invasion, lympho-vascular invasion, presence of lymph node metastasis, number of metastatic lymph nodes, extra nodal extension) and follow-up details were extracted from the existing database. We tabulated the results for patterns of relapse and predictors of early mortality. Results: 15 (17%) patients died of disease in our study. 11 (12.5%) patients died within 9 months of diagnosis. 7 patients had local and/regional relapse, 7 developed distant metastasis, 1 patients had dermal metastasis. Deep tissue infiltration ( P = .013) and presence of nodal metastasis ( P = .015) were significant for disease-related mortality on bivariate logistic regression. Conclusion: Deep tissue infiltration and presence of nodal metastasis predicted for disease-related early mortality. These parameters directly corresponds to staging, more specifically to pathologic stage, which are available only after completion of primary surgery. This underscores the need for reliable biomarkers to predict early disease related mortality, initially at the time of diagnosis.
Telemedicine: Bridging the Gap Between Rural and Urban Oncologic Healthcare in Kenya
Authors: Mbunya S. , Asirwa C. , Felker D.
Published: September 2018

Background: The AMPATH Consortium has served to greatly expand healthcare in western Kenya. Gaps and limitations in care still exist, especially in oncology care in rural areas. Telemedicine provides a lower cost, practical method to maximize physician resources and limit cost and stress to families with socioeconomic limitations in rural Kenya. The following paper seeks to discuss the importance of developing a telemedicine model in western Kenya and the many advantages telemedicine can bring, as well as discuss the telemedicine model being developed by AMPATH Oncology. Aim: Integrate paper-based medical records into the AMPATH AIDS EMR; Identify sustainable telemedicine tools to integrate into the EMR; Establish networking in rural clinics; Budget in IT personnel at each clinic to assist in patient setup with central site; use solar as primary power source for devices to aid in power issues. Only 45% of Kenyans have access to power; Use cellular networks for communication; Maximize time allocated for physicians to see patients; Decrease travel time to clinics as only 32% of Kenyans live in urban environments. Methods: Cost analysis of remote clinic locations and associated costs;

Clinic budget estimate for networking and telemedicine support position;

Cost summary and savings Results: Estimated costs for the operations budget for the 17 rural outreach clinics include the costs of hardware, solar networking setup, and internet at a total $3400/wk. This will decrease after the first year to $1700 for maintenance costs of equipment. Personnel consists of 1 local person to support the system and will be a weekly cost of $1870. Lost time for physicians due to road travel totals ∼100 hours weekly. Estimated salaries for an oncologist at $30/h leads to a cost of $3007/wk in lost productivity. It should be noted that lodging and per diem expenses are not included in the estimated expenses that total $6114/wk. By doing telemedicine at the rural clinics in an ideal 48 workable week situation. The savings of $528,000 is a clear evidence that this is financially feasible solely based on travel savings over 5 years. For this reason, the actual savings is ∼$264,000 and still makes a strong argument for this being the right move. Conclusion: Telemedicine is a viable and necessary resource for developing oncologic care in rural Kenya. We believe that telemedicine represents a natural evolution in healthcare in Kenya to support its rural population. Telemedicine helps maximize the limited physician resources and allows them to reach a larger audience without tying up their time in lengthy commutes. Last, telemedicine should assist patients to overcome the barriers of cost and time that limit their treatment. Future challenges and gains will be made with the evolution of the newly formed national health insurance system. Gaining support and reimbursement from telemedicine visits will be crucial to ensuring the success of telemedicine.
Challenges and Opportunities for Cancer Care in Regional Australia: The Health Professional´s Perspective
Authors: Crawford-Williams F. , Goodwin B. , March S. , Ireland M. , Chambers S. , Aitken J. , Dunn J.
Published: September 2018

Background: Cancer specialists working in rural and regional Australia may experience unique difficulties when compared with their metropolitan counterparts, as they often have higher workloads, spend longer hours in clinical practice, and experience professional and social isolation. Previous research has identified accessibility and distance from services, a shortage of workforce, limited availability of specialists and allied health providers, suboptimal chemotherapy administration, and reduced availability of radiotherapy services as predictors of poorer outcomes in regional areas. Yet to date, limited research has focused on the perspective of the regional healthcare professionals. Aim: This study aimed to identify the factors which health professionals believe influence clinical care and outcomes for people with cancer in regional areas of Australia, to confirm existing barriers and identify any new insights specific to the health professional perspective. Methods: Semistructured interviews were conducted with regional oncology health professionals of varying backgrounds. Interview questions explored health professional´s perspectives on barriers to cancer care for patients, factors which influence clinical care, and access to support in regional areas. Data were interpreted using an inductive thematic analysis approach. Results: Two global themes were identified: rural culture and the health system. Within these global themes, health professionals discussed barriers to cancer care in regional areas, predominantly associated with travel, limited workforce, and poor communication within the health system. Participants also noted many positive aspects of cancer care in regional areas, including more personalised care for the patients and faster career progression for professionals. Conclusion: Despite recent innovations aimed at improving rural cancer care, including innovative models of care and increased infrastructure, regional health professionals still perceive many barriers to cancer care in regional Australia. These are predominantly associated with patient demographics, travel difficulties, and inadequate governance. However, there are also many notable benefits to receiving care in regional areas which have been absent from previous literature. These positive factors should be incorporated in efforts to enhance regional cancer care through the recruitment of health professionals to regional areas and development of regional community support networks. An understanding of the experiences of health professionals working in oncology settings in regional areas is a key step toward improving care and providing recommendations to health services and policymakers, particularly regarding recruitment and retention.
A New Predictive Model for Breast Cancer Survival in New Zealand: Development, Internal and External Validation, and Comparison With the Nottingham Prognostic Index
Authors: Elwood M. , Tin S. Tin , Tawfiq E. , Marshall R.J. , Phung T.M. , Lawrenson R. , Campbell I. , Harvey V.
Published: September 2018

Background: Women diagnosed with breast cancer, their doctors, and their families, would find a valid estimate of her prognosis helpful in planning treatment and support. Assessing prognosis is complex as many factors influence it. Several predictive models have been produced, but none has been developed or tested on patients in New Zealand (NZ). Aim: We aimed to develop and validate a NZ predictive model (NZPM) for breast cancer, and compare its performance to a widely used UK-developed model, the Nottingham Prognostic Index (NPI). Methods: We developed a model to predict 10-year breast cancer-specific survival, using data collected prospectively in the largest population-based breast cancer registry in NZ (Auckland, 9182 patients), and assessed its performance in this data set (internal validation) and in an independent NZ population-based series of 2625 patients in Waikato (external validation). The data included all women with primary invasive breast cancer diagnosed from 1 June 2000 to 30 June 2014, with follow-up to death or to 31 December 2014. We used multivariate Cox proportional hazards regression to assess predictors and to estimate the probability of breast cancer mortality within 10 years, and therefore 10-year survival, for each patient. We assessed observed survival by the Kaplan-Meier method. We assessed discrimination by the C-statistic, and calibration by comparing predicted and observed survival rates for patients in 10 groups ordered by predicted 10-year survival. We compared this NZPM with the NPI in the validation data set. Results: The final NZPM used continuous variables of age, tumor size, and number of positive lymph nodes, and categorical variables of ethnicity, tumor stage, tumor grade, ER and PR receptors, HER2 status, and histologic type of tumor. Discrimination was good: C-statistics were 0.84 for internal validity and 0.83 for independent external validity. For calibration, for both internal and external validity, the predicted 10-year survival probabilities in 10 groups of patients, ordered by predicted survival, were all within the 95% confidence intervals (CI) of the observed Kaplan-Meier survival probabilities. The NZPM showed good discrimination even within the prognostic groups defined by the NPI. Conclusion: These results for the NZPM show good internal and external validity, transportability, potential clinical value, and its clear superiority over the NPI. Further research will assess other potential predictors, other outcomes, performance in specific subgroups of patients, and compare the NZPM to other models, which have been developed in other countries and have not yet been tested in NZ.
Roles of Embryonic Field in Neuroblastomas: A New Perspective Study Based on SEER Database
Authors: Tai J. , Chen J. , Wai S. , Ji T. , Li X. , Ni X.
Published: September 2018

Background: Neuroblastoma is the most prevalent malignancy in children. G. Barry Pierce once suggested the regulatory roles of embryonic field in the carcinoma. However, no related article can be found until now. Aim: To investigate the roles of embryonic field in neuroblastoma. Methods: In the current study, patients with neuroblastoma were initially selected from SEER Database (1973-2014). Demographic information (such as age, gender and race) as well as clinical presentations were collected. Based on the blastoderms (ectoderm/mesoderm/entoderm) of organs, where were the primary sites of tumors, patients were then categorized into 3 different groups (low-risk, intermediate-risk, and high-risk). Differences in the demographic information, therapeutic methods and outcomes were then analyzed among the 3 groups. Results: The analytic cohort included 5623 patients in total. The primary sites which originate from mesoderm accounted for 35.0% of all malignant tumors, and the majority from entoderm was olfactory neuroblastoma (75.3%). Neuroblastoma from entoderm had the smallest tumor size, with the diameter of 43.89 ± 20.84 cm. More lymph nodes were found to be involved when tumors grow along with organs or tissues originating from mesoderm. Radiation seems having little impact on the prognosis of patients. Conclusion: Cellular similarity plays important roles in the prognosis of patients with neuroblastoma, however, radiation treatment has little impact. In addition, enhancing the immune state of patients is very important for the good prognosis during the course of treatment. More attentions should be paid to the relationship between tumorogenesis and embryogenesis.
An Assessment of Cancer Pain Control in an LMIC Oncology Clinic
Authors: Joseph A. , Salako O. , Alabi A. , Adenipekun A.
Published: September 2018

Background: Cancer has become a leading cause of morbidity and mortality in adults globally. Pain is universally one of the most commonly encountered symptoms by health and supportive care providers involved in care of cancer patients. Inadequate pain control negatively impacts the patient´s quality of life, and may slow down the healing process. Health care providers often ignore pain control as a target of treatment as they focus on reducing the tumor burden. Pain management should be considered an important target and end point in the treatment of cancer patients. Aim: To assess the prevalence of pain, oncologists´ prescribing patterns; and efficacy of pain control in the Radiotherapy Department of the Lagos University Teaching Hospital. Methods: Adult cancer outpatients were assessed using a Universal Pain Assessment Tool and followed up for 2-6 weeks thereafter. Pain scores were assessed at first interview and at the follow-up appointment within 2 weeks minimum and 6 weeks maximum. Results: 347 adult clinic attendees were recruited, assessed, and followed up with interviewer-administered questionnaires over a close-out period of 6 weeks. There was an 85% (298 respondents) prevalence of pain in the study group; with over half of respondents characterizing their pain in the moderate to severe ranges. [Figure: see text] 9 out of 10 respondents stated the cancer was the primary source of their pain. Other sources of pain were medical tests; and treatment-related such as chemotherapy and radiation therapy. 86 patients (29% of study group) were not asked about pain by their attending physician, and all respondents stated their physician had not used any pain assessment tool to determine the nature or severity of their pain. [Figure: see text] Oral nonsteroidal analgesics were the most frequently prescribed form of pain control (237 patients), with radiotherapy coming in second (69 patients). The only available strong opioid analgesics at the oncology pharmacy were oral morphine and parenteral pentazocine. Oxycodone, fentanyl pethidine, and hydromorphone were unavailable. Interventional (e.g., cordotomy) and alternative (e.g., massage) forms of pain control were not prescribed in any patients. 43 respondents (15%) despite being in pain, did not receive any form of treatment or recommendation for pain control. At follow-up appointment 2-6 weeks after; 4 out of 10 respondents had not obtained pain relief from instituted measures. [Figure: see text] Conclusion: Undertreatment of cancer pain remains a major concern. The treatment process must begin with a proper and thorough evaluation of the patient's pain; a clear pain control goal and end point target; and regular reevaluation with application of guidelines when adequate control is not achieved. Inclusion of pain assessment and management guidelines in medical training would be of benefit to reduce the prevalence of inadequately controlled pain in patients living with cancer; ultimately improving their quality of life.
Prayer Therapy in a Case of Acute Myeloid Leukemia in Kenya: The Good, the Bad and the Ugly
Authors: Ochieng R.M. , Kirimi F.
Published: September 2018

Background: Cancer, which accounts for 7% of deaths per year in Kenya, is the third highest cause of death after infectious and cardiovascular diseases. Awareness campaigns have tended to focus on leading cancers including breast and cervical for women as well as prostate and esophageal for men. Consequently, less common cancers such as acute myeloid leukemia (AML) are rarely properly understood by the general population and a section of the medical fraternity. Diagnoses of AML results in shock, denial and confusion to the diagnosed, family and friends as they receive contradicting information about the condition from diverse sources. The situation is handled differently by different people with many resorting to prayer. This paper, written from the lens of a caregiver, is based on data collected from a case of AML in a 32-year-old male Kenyan who lost his life within 6 weeks of diagnosis. Aim: The aim of the paper is to share experiences on the advantages and disadvantages of prayer as support to cancer patients, their family and friends. Methods: A purposively selected sample of 16 people (5 male and 11 female) of Christian Protestant orientation who participated in prayers was used. Data were collected by the researcher through participant of observation and interviews. Results: Findings discuss how prayers were conducted individually and in groups both physically and through social media platforms. Prayer items that included healing, peace and strength to the diagnosed and family, financial breakthrough and doctors' work are discussed. The immense benefits of prayer and its disadvantages to the diagnosed, his family and friends are discussed. Conclusion: The paper concludes that prayer goes a long way in cancer support.