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  Most popular articles (Since December 19, 2017)

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A step-wise guide to performing survival analysis
Santam Chakraborty
January-June 2018, 1(1):41-45
Survival analysis refers to statistical techniques which have been designed to circumvent the issues arising out of incomplete information regarding the time until which a desired event or endpoint occurs. The reasons for this may be manifold, for example, lost to follow-up, dropouts from the study, lack of sufficient research budget, and short follow-up period. It is one of the common but complicated analysis done in trials. The current article provides a step-wise guide toward understanding survival functions and performing it.
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Current management strategies in gallbladder cancers
Vikas Ostwal, Sanyo Dsouza, Shraddha Patkar, Sherly Lewis, Mahesh Goel, Krunal Khobragade, Anant Ramaswamy
January-June 2018, 1(1):2-9
Gallbladder cancers (GBC) are common in the Indo-Gangetic belt of India. Most consensus guidelines in the West have considered GBC as part of the biliary tract cancer spectrum; however, considering the markedly higher burden of GBC in India, there is a need to have specific management treatment strategies in the Indian scenario. The extent of surgical resections, the use of staging laparoscopies, the optimum adjuvant therapy for resected high-risk GBC (T3 or T4 disease and node-positive disease), as well as the preferred second-line chemotherapeutic regimens for advanced GBC are questions that remain incompletely defined and answered. The current review presents a synopsis of currently available evidence and emerging approaches in the treatment of GBC.
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Novel therapeutic options for recurrent metastatic salivary gland tumors: Review of ongoing clinical trials
Avinash Pandey, Manish Kumar, Heena Shahi, Aishwarya Kumari, Shivkant Singh
January-June 2018, 1(1):10-18
The clinical behavior and biology of recurrent malignant salivary gland tumors are myriad with slow-growing indolent disease at the one end of spectrum and aggressive symptomatic illness with metastases to bone, lung, and liver at the other end. Several different agents and combination chemotherapy regimens have been explored in patients whose disease is symptomatic with response rates between 15% and 40%. Recently, molecular studies have evolved to reveal targetable biomarkers which can be further explored in the therapeutic landscape with specific targeted therapies. A subset of tumors also expresses hormone receptors and hence is amenable to conventional antihormonal agents to obtain a possibly meaningful benefit. We searched for all ongoing and completed clinical trials involving chemotherapy, targeted therapy, hormonal therapy, and immunotherapy valid for patients with recurrent metastatic salivary gland tumors. We present the current viable therapeutic options for such a cohort of patients in routine clinical practice.
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From the Editor's Desk
Vanita Noronha
January-June 2018, 1(1):1-1
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Adjuvant chemotherapy protocols for lung cancer
Sameer Shrirangwar, Manasi Sharma, Sunny Jandyal, Shruti Kate
January-June 2018, 1(1):19-40
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Cancer care: Challenges in the developing world
Chepsy C Philip, Amrith Mathew, M Joseph John
January-June 2018, 1(1):58-62
Objective: Cancer care in the developing world remains a challenge. Limitations in the diagnosis, poverty, and knowledge are recognized as some of the challenges. Health-care financing and treatment facilities are limitations toward availing cancer care. An assessment of the extent of the burden and strength of available infrastructure is limited. We performed an assessment to gather information from young oncologists in the developing world to identify similarities and differences among the countries. Methods: Information on services was gathered using a questionnaire from young oncologists participating in the American Society of Clinical Oncology annual meet selected to represent various developing countries. Descriptive statistics were used to report results. Results: The median doctor: outpatient ratio was 1:20 (1:2–1:80). Median: staffing ratio in an oncology ward was 1:6 (1:2–1:20). Four (22.2%) respondents reported complete social security support for health care in oncology. Stem cell transplant facility was reported as available in 8 (44.4%) centers out of 20. South Asian respondents reported the highest out-of-pocket expenditure (65%) and the least doctor: outpatient ratio at 1:20. Conclusion: Cancer care challenges appear similar in the regions surveyed. Additional strategies to improve the health-care infrastructure and provide a health security net to treat all cancer patients are required to benefit the efforts to tackle the growing burden of cancer in the developing countries.
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Once-a-week versus once-every-3-weeks cisplatin in patients receiving chemoradiation for locally advanced head-and-neck cancer: A survey of practice in India
Gautam Goyal, Vijay M Patil, Vanita Noronha, Amit Joshi, Satvik Khaddar, Sajak Kakkar, Ritesh Pruthy, Purvish Parikh, Kumar Prabhash
January-June 2018, 1(1):63-67
Purpose: High-dose (100 mg/m2) cisplatin with radiotherapy is the standard practice in locally advanced head-and-neck squamous cell carcinoma. Use of this regimen in resource- constrained and economically constrained countries like India is difficult. Methods: This study was a cross-sectional survey conducted among Indian oncologists treating head-and-neck cancer. The survey consisted of 25 questions relevant to general day-to-day practice in head-and-neck oncology. It included questions regarding the most common drug used in the concurrent chemoradiation (CRT) setting, the most common schedule of administration of cisplatin, the doses used in once-a-week or once-every-3-week cisplatin chemoradiotherapy, toxicities, and preventive strategies. Descriptive analysis was performed using SPSS software version 20. Results: Responses were obtained from 257 oncologists practicing in various oncology centers throughout the country. The agent most commonly used for radiosensitization was cisplatin (n = 243; 94.6%). The once-a-week regimen of cisplatin was the favored regimen (87.9%, n = 226). The reason for favoring the once-a-week regimen was better tolerance (n = 153, 59.5%). The once-every-3-weeks cisplatin schedule was prescribed for >50% of head-and-neck cancer patients by 23 participants only (8.9%). Conclusion: In this nationwide Indian survey, the majority of clinicians preferred the once-a-week cisplatin schedule for CRT in locally advanced head-and-neck cancer patients, due to better tolerance.
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Quality of life without toxicity or symptoms analysis of a randomized controlled clinical trial comparing efficacy of cabazitaxel versus docetaxel in recurrent head and neck cancer
Vijay Patil, Amit Joshi, Vanita Noronha, Sachin Dhumal, Arun Chandrasekharan, Nikhil Pande, Sameer Shrirangwar, Anup Toshniwal, Siddharth Turkar, Kushal Gupta, Vikas Talreja, Abhishek Mahajan, Shashikant Juvekar, Atanu Bhattacharjee, Kumar Prabhash
January-June 2018, 1(1):46-50
Background: This analysis was done with the aim to study the overall impact of docetaxel and cabazitaxel treatment using quality-adjusted time without symptoms and toxicity (QTWiST) analysis in head and neck cancer patients receiving second-line treatment. Methods: Overall survival (OS) was partitioned in three health states for QTWiST analysis. Toxicity (TOX) state was defined as the cumulative number of days spent in grade 3 or above toxicity postrandomization and before progression. TWiST state was defined as the cumulative number of days spent postrandomization and before progression without grade 3 or above toxicity. REL state was defined as the time spent in days postprogression till death. A threshold utility analysis was performed. Results: The restricted mean TOX state duration in cabazitaxel arm was 2.26 days (95% confidence interval [CI] 1.12–3.40) versus 1.54 days (95% CI 0.56–2.53 days) in docetaxel arm. In threshold utility analysis, the mean difference in QTWiST was in favor of docetaxel arm and ranged from −7.194 (utility for TOX) to −35.96. For any combination of utility score of REL >0, with any combination of utility score of TOX, the difference in mean QTWiST between the two arms was >14 days (i.e. >10% of OS), in favor of docetaxel arm which is considered clinically meaningful. Conclusion: Patients randomized to docetaxel arm had a higher QTWiST score than patients in cabazitaxel arm. There was a suggestion that docetaxel led to better quallity of life without toxicity or symptoms, which would require confirmation in a larger study.
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A Bayesian approach for dynamic treatment regimes in the presence of competing risk analysis
Atanu Bhattacharjee, Gajendra K Vishwakarma, Souvik Banerjee
January-June 2018, 1(1):51-57
Background: A sequencing rule is considered to formulate the dynamic treatment regime (DTR). This sequence rule is based on the clinical relevance, prior evidence about the best performing therapy, and the requirement to treat a patient in a specific scenario. The challenge occurs when the study offers a concluding remark about best effective therapy among all possible combinations of treatment management schedules treated with a sequence rule. The time-to-event data analysis is the only available method to figure out the best effective treatment in the context of oncology research. However, the presence of the competing risk event of death in the time-to-event analysis is unavoidable, and it becomes challenging to decide regarding the best effective treatment strategy. Methodology: In this article, we describe the statistical methodology to handle the competing risk time-to-event data analysis in DTR. The analysis is performed with the Bayesian approach to help determine the best effective treatment strategy. Results: We introduce the OpenBUGS function, which provides the comparison and estimation of different treatment sequences in time-to-event competing risk data analysis adopting the newly proposed statistical approach. Conclusion: This method is efficient to guide the personalized medicine in oncology setup through the supportive decision rule.
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The enemy within
J Barrett
July-December 2018, 1(2):96-97
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Making a case for cancer research in India
Vanita Noronha
January-June 2018, 1(1):71-74
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Pleural mass imaging - A quick primer
Raajit Chanana, Vijay Patil, Vanita Noronha, Amit Joshi, Kumar Prabhash
January-June 2018, 1(1):68-70
A 35-year-old female patient with no comorbidities and no history of addictions presented with a 2 week history of intermittent right-sided chest pain without any associated symptoms. On local examination, there was dullness over the right infrascapular and right infra-axillary area along with decreased breath sounds over the corresponding areas. Computed tomography scan revealed a well-defined lobulated heterogeneously enhancing pleural-based mass. What is the most likely diagnosis?
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Love in the time of cancer
Vikas Talreja
July-December 2018, 1(2):75-77
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Hypothyroidism post-chemoradiation on outcomes in head-and-neck cancer
Vijay M Patil, Vanita Noronha, Amit Joshi, Tanmoy Kumar Mandal, Atanu Bhattacharjee, Alok Goel, Vikas Talreja, Arun Chandrasekharan, Nikhil Pande, Anant Ramaswamy, Kumar Prabhash
July-December 2018, 1(2):84-91
Background: Hypothyroidism is a known side effect of head-and-neck cancer treatment and might improve outcomes. However, whether the development of hypothyroidism or maintaining a hypothyroid state remains a factor is unclear. Methods: Once-a-week versus once-every-3-weeks cisplatin chemoradiation in locally advanced head and neck cancer was a Phase III open-label, noninferiority randomized study conducted by our group in the Medical Oncology Department of Tata Memorial Hospital, Mumbai, India. The database of this study was assessed for this analysis. Hypothyroidism was defined as a serum thyroid-stimulating hormone (TSH) level of above 5 uIU/ml. Duration of hypothyroidism was defined as cumulative duration in days postrandomization that the patient spent in hypothyroid state before progression. The relationship between duration of hypothyroidism (continuous variable) and peak TSH values and outcomes (locoregional failure [LRF] rate, progression-free survival [PFS], and overall survival [OS]) were analyzed. Results: Higher duration of time spent in a hypothyroid state had a favorable impact on PFS (HR: 0.996, 95% CI: 0.994–0.999, P = 0.007), and OS (HR: 0.995, 95% CI: 0.991–0.999, P = 0.016). This favorable impact on LRF (HR: 0.963, 95% CI: 0.929–0.997, P = 0.034), PFS (HR: 0.996, 95% CI: 0.993–0.999, P = 0.005), and OS (HR: 0.993, 95% CI: 0.987–0.999, P = 0.022) was confirmed on multivariate analysis too. Peak TSH value between 30 and 40 uIU/ml provided the maximum benefit for LRF with HR of 4.76 (standard error (SE) of HR as 0.627, P = 0.01). Conclusion: A longer duration and higher state of hypothyroidism (TSH – 30–40 Iu/ml) provided the maximum improvement in outcomes, this is an interesting hypothesis which needs to be confirmed with more studies.
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Health-related quality of life in patients with multiple myeloma on novel agents: Report from a tertiary cancer center in rural India
Vineetha Raghavan, Avaronnan Manuprasad, PB Sajeev Kumar, Zoheb Raj, Praveen Kumar Shenoy, Chandran K Nair
July-December 2018, 1(2):92-95
Background: Multiple myeloma is a disease where health-related quality of life (HRQoL) is an important treatment end point. There are limited quality of life data of patients on novel antimyeloma agents, especially from developing countries. Methods: All adult patients diagnosed with multiple myeloma who were on novel agents for a period of at least one year and attended our clinic between July 15, 2015 and July 30, 2015 were included in the study. They were asked to fill local language versions of European Organization for Research and Treatment of Cancer Questionnaire Core 30 (EORTC QLQ-C30), supplemented by the myeloma-specific module, and the outcomes were analyzed. Mean scores of the study population were compared with EORTC reference values. A higher score for a functional domain indicates a higher level of functioning, whereas a higher symptom score indicates a higher symptomatic burden. Results: Of the total 64 patients, median age was 60 years and 60% (n = 38) were females. Median duration from diagnosis was 23 months (12–92 months). Mean QoL score for global quality of life was 55.3 and was comparable to the reference score. Our patients had significantly lower physical function score and higher financial strain compared to the reference population. The most common symptom was pain (60%), and the most common adverse effect was peripheral neuropathy (60%). Sixty-five percent of the patients were worried about future health and 42% about dying. Conclusion: Our patients with multiple myeloma have lower HRQoL compared to the reference population in many domains, despite being on novel agents.
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Hypersensitivity reactions to paclitaxel with a modified dexamethasone intravenous premedication regimen
Vanita Noronha, Deborah Enting, Ravi Thippeswamy, Amit Joshi, Vijay Maruti Patil, Kumar Prabhash
July-December 2018, 1(2):78-83
Background: The conventional paclitaxel premedication regimen consists of two oral dexamethasone doses of 20 mg each taken 12 h and 6 h before paclitaxel administration. For the sake of convenience, the premedication regimen has been modified with a single dose of dexamethasone administered intravenously 30–60 min before paclitaxel, omitting the oral doses. We assessed the rate of hypersensitivity reactions (HSRs) when a modified dexamethasone regimen was used. Materials and Methods: This was an observational prospective cohort study in patients receiving paclitaxel chemotherapy. We recorded demographics, prior history of allergy and comorbidities, diagnosis, chemotherapy regimen with schedule, details of HSRs, and details of rechallenge. Descriptive analysis and simple percentages were performed. Results: Between February 2011 and May 2011, 310 patients received 495 cycles of paclitaxel chemotherapy. The median age was 50 years, 77% of patients were female. Sixty-nine percent of patients had breast and gynecologic malignancies. Forty-four percent of patients were chemonaive. Sixty-eight percent of the paclitaxel cycles were once-in-3-week regimens; the remaining 32% were once a week. In all the paclitaxel cycles, a modified premedication regimen was administered. The dose of intravenous dexamethasone was 0 (n = 20), 8 mg (n = 210), 12 mg (n = 1), 16 mg (n = 56), and 20 mg (n = 163). The incidence of HSRs was 1.6%, with 1.2% incidence of severe hypersensitivity. No patient required hospitalization for the management of hypersensitivity. Three patients were rechallenged with paclitaxel after the development of hypersensitivity; all tolerated rechallenge without further infusion reactions. Conclusion: A modified dexamethasone premedication regimen is a safe and convenient option with a low risk of hypersensitivity.
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Immunotherapy protocols in lung cancer
Nandini Menon, Sharada Mailankody
July-December 2018, 1(2):139-162
Immunotherapy has emerged as a valuable treatment option in many advanced malignancies (especially lung cancer). The PD-1 inhibitors (nivolumab and pembrolizumab) and the PD-L1 inhibitors (durvalumab and atezolizumab) have been approved for use in various cancers, alone or in combination with chemotherapy. The protocols for the PD-1/PD-L 1 blockers are listed below. The various indications for these PD-1/PD-L1 blockers, baseline evaluation, monitoring during therapy, and guidelines for the management of immune-related adverse events are described below.
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Stepwise cox regression analysis in SPSS
Sampada Dessai, Vijai Simha, Vijay Patil
July-December 2018, 1(2):167-170
This article is a beginners' guide for performing Cox regression analysis in SPSS. The article provides practical steps toward performing Cox analysis and interpreting the output of SPSS for Cox regression analysis. Along with it, the article touches on the test to be performed before performing a Cox regression analysis and its interpretation.
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Prevalence of tobacco use among school-going adolescents in India: A systematic review of the literature
B Kumara Raja, V N Kavitha Devi
July-December 2018, 1(2):110-115
Individuals who initiate tobacco use during adolescence are likely to continue the use into adulthood, and this constitutes a major risk factor for premature death. The purpose of this study was to systematically review existing literature on the prevalence of tobacco use among school-going adolescents in India. Records were searched from the various databases such as PubMed, PubMed Central, Cochrane Library, Embase, and Google Scholar for studies published from 2000 to 2018. A total of 20 studies with a total population of 50, 390 were reviewed. The prevalence of tobacco smoking among school-going adolescents ranged from 5.9% to 49%. The common risk factor for tobacco usage among school-going adolescents was found to be peer pressure. Parents' smoking behavior, family conflict, stress, and curiosity were also found to be additional risk factors. The prevalence of tobacco usage among school-going adolescents was found to be high. These findings emphasize the need for formulating strict tobacco control policies at school premises.
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Treatment-induced hypothyroidism in head-and-neck cancer – Is it a crystal ball?
Tarun Puri
July-December 2018, 1(2):118-120
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Systemic treatment options in bladder cancer
Rahul Ravind, Kumar Prabhash, Amit Joshi, Vijay Patil, Vanita Noronha
July-December 2018, 1(2):98-109
Since the 1980's, with the advent of MVAC (methotrexate, cisplatin, vinblastine, adriamycin) the role of chemotherapy for bladder cancer was defined. Since then, multiple chemotherapy regimens have been used and the field of chemotherapy has reached a therapeutic plateau. In the last decade, there have been recent updates in the systemic options used in bladder cancer. Early stage disease is managed with cystectomy. The role of neoadjuvant chemotherapy is well established and the trimodality approach for bladder preservation is widely being practiced worldwide. With the advent of immunotherapy, the survival pattern has changed in patients with metastatic disease, and still, more research work needs to be done. Here we aim to review all the latest trends in the systemic treatment options of bladder cancer.
  175 33 -
Cystic brain lesions: Guess the mess
Anurag Gupta, Vanita Noronha, Kumar Prabhash, Amit Joshi, Vijay Patil, Abhishek Mahajan
July-December 2018, 1(2):163-166
A 67-year-old male patient, who is a known case of squamous cell carcinoma of esophagus received neoadjuvant chemotherapy (NACT). However, post 3 cycles of NACT, he had a fall. Computed tomography brain was performed which revealed a well-defined ring-enhancing lesion in the right cerebellar hemisphere. In the given clinical scenario, diagnosis of brain metastasis was made, and the patient received whole-brain radiation therapy. However, the patient deteriorated further and magnetic resonance imaging was performed. What is the diagnosis?
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Current treatment landscape and emerging management options for extremity sarcoma
Siddharth Turkar
July-December 2018, 1(2):121-138
Malignant tumors of extremity are mostly of mesenchymal origin and arise from bone or extraskeletal soft tissue. Combination chemotherapy has greatly increased the survival of non-metastatic localized osteosarcoma and Ewing's sarcoma; however, there is conflicting evidence regarding the role of neoadjuvant and adjuvant chemotherapy in soft tissue sarcoma due to the rarity and heterogeneous population. Despite intensive multimodal therapy and valiant efforts, most of the patients with relapsed and metastatic sarcoma will succumb to their disease. Molecular studies like next-generation sequencing have revealed various targetable biomarkers which can be further explored in the therapeutic landscape with specific targeted therapies. We reviewed all ongoing and completed clinical trials involving chemotherapy, targeted therapy, and immunotherapy valid for patients with extremity sarcoma. We present the current viable therapeutic options for such a cohort of patients in routine clinical practice.
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Modified dose dexamethasone premedication for paclitaxel use
Sharada Mailankody
July-December 2018, 1(2):116-117
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Induction chemotherapy in recurrent, unresectable esthesioneuroblastoma
Sachin Dhumal, Nilesh Sable, Vijay M Patil, Dilip Harindran Vallathol, Kumar Prabhash
July-December 2018, 1(2):171-172
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