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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 730-735

Demography and pattern of care of patients with head-and-neck carcinoma: Experience from a tertiary care center in North India


1 Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha Cancer Hospital, Department of Medical Oncology, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India
2 Dept of Radiation Oncology, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India

Date of Submission11-Sep-2020
Date of Decision03-Dec-2020
Date of Acceptance04-Dec-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
B K Mishra
Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_286_20

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  Abstract 


Background: Head-and-neck cancer (HNC) is one of the most common cancers in India and requires a multidisciplinary approach for disease management.
Objectives: We aimed to report the demographic profile and pattern of care of patients with HNC and their treatment compliance at our center.
Materials and Methods: This single-center, retrospective study was conducted in the Department of Medical Oncology of Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India, from May 2018 to April 2020. Patients with HNCs of any sub-site, stage, and histology were included in the study. The patients underwent routine clinical and imaging evaluation, baseline investigations, and tissue biopsy. After diagnosis and staging, the cases were discussed by a multidisciplinary team for treatment planning. The number of patients presenting at our center within the specified time period, the intent of care, and the treatment received were recorded, and treatment compliance was assessed. Continuous and noncontinuous variables were described using median and proportions, respectively, and P < 0.05 was considered statistically significant.
Results: A total of 1229 patients were included in the analysis, of which 87% were male and 90% belonged to Uttar Pradesh, a state in northern India. The predominant (91%) histological type was squamous cell carcinoma. Majority (81%) of the patients presented with disease in a locally advanced stage, and oral cavity was the most common sub-site (71%), followed by the oropharynx (9.7%) and the hypopharynx and larynx (10%). The treatment intent was curative in 62%, palliative in 31%, and supportive in 6% of the patients. Of patients receiving curative treatment, 12% received two to three cycles of neoadjuvant chemotherapy followed by surgery, 25% underwent upfront surgery followed by adjuvant chemo-radiation or radiation, 7% underwent surgery alone, and 11% received radical chemo-radiation. Among patients receiving treatment with palliative intent, 13% received oral metronomic chemotherapy and 13% received some form of intravenous chemotherapy. About 78% of the patients complied with their cancer-directed therapies, with male patients showing significantly better compliance than the female ones.
Conclusion: This study reports the demographic profile and pattern of care of patients with HNCs from a newly developed tertiary care center in North India, and highlights the emergent need for a more dedicated cancer center in this region.

Keywords: Head neck cancer, patient demography, pattern of care, treatment compliance


How to cite this article:
Roy S, Mandal TK, Das S, Srinivas S, Agarwal A, Gupta A, Singh A, Singh A, Kuraparthy S, Kapoor A, Ghosh R, Mishra B K. Demography and pattern of care of patients with head-and-neck carcinoma: Experience from a tertiary care center in North India. Cancer Res Stat Treat 2020;3:730-5

How to cite this URL:
Roy S, Mandal TK, Das S, Srinivas S, Agarwal A, Gupta A, Singh A, Singh A, Kuraparthy S, Kapoor A, Ghosh R, Mishra B K. Demography and pattern of care of patients with head-and-neck carcinoma: Experience from a tertiary care center in North India. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jun 24];3:730-5. Available from: https://www.crstonline.com/text.asp?2020/3/4/730/304966




  Introduction Top


Head-and-neck cancers (HNCs) are malignancies of the upper aerodigestive tract including the nasopharynx, oral cavity, oropharynx, larynx, and hypopharynx, with squamous cell carcinoma (SCC) as the most common histological type. According to GLOBOCAN-2018 of the International Agency for Research on Cancer report, the incidence of HNCs is 834,860 cases per year, resulting in approximately 431,131 deaths per year.[1] HNCs constitute only 4%–5% of the cancer burden in the developed world. However, in India, they comprise roughly one-third of all the cancer cases.[2] As per the GLOBOCAN-2018 report, the incidence of oral cancers in India is 119,992 cases per year with 72,616 deaths per year. As per the Indian Council of Medical Research (ICMR) database, the incidence of HNCs of different anatomical sub-sites varies across India. Cancers of the lower region of the pharynx and tongue are predominant in Mizoram, those of the nasopharynx in Nagaland, and oral cavity cancers in Puducherry.[1],[2] This significant increase in the incidence of HNCs is due to extensive smoking and the use of tobacco, pan masala, and gutkha.

In India, despite the significant cancer burden, there is a paucity of tertiary cancer care centers. As a result, the few existing centers have to cater to a high volume of patients and are therefore deluged. Although studies in the past have reported the demographic profile and pattern of care distribution in patients with HNCs from cancer centers in the northern states of India, there is a lack of recent information on this aspect.[3],[4],[5],[6]

Therefore, we aimed to bridge this knowledge gap in the literature by performing an audit of the demographic profile, clinical characteristics, treatment details, and compliance of HNC patients registered and treated at a newly developed tertiary cancer center in North India. Our study highlights the emergent need for a more dedicated cancer care center in this region to manage the high patient volumes.


  Materials and Methods Top


General study details

This was a single-center, retrospective study conducted in the department of medical oncology of a newly developed tertiary cancer care center, Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India, between May 2018 and April 2020. As this was a retrospective analysis, approval from the institutional ethics committee was not required as per institutional policy, and the need for obtaining written informed consent was also waived; consent for treatment was taken before the initiation of therapy. The study was conducted according to the various ethical guidelines including the Declaration of Helsinki and the ICMR recommendations.

Participants

All consecutive patients with primary HNCs arising from any sub-site (oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, and others), histology, and Stage (I–IV) and aged more than 15 years with an Eastern Cooperative Oncology Group Performance Status (ECOG-PS) of =4 were included in the study. Patients who visited our center for a second opinion, those partially treated at other centers, those with a past history of chemo-radiation, and those with second primary tumors were excluded from the study. All the patients after registration underwent routine clinical examination, baseline investigations, imaging studies as per the requirement, and tissue biopsy for diagnosis. After diagnosis and staging, the cases were discussed by a multidisciplinary team (MDT) constituted by the departments of medical oncology, surgical oncology, radiation oncology, pathology, radiology, and pain and palliative care for treatment planning and were then referred for treatment to the respective subspecialties. Staging of different sites of HNCs was performed as per the American Joint Committee on Cancer 7th edition.

Variables

The primary end points of this study were the number of patients presenting at our center within the duration of the study period, the treatment intent, and the treatment received. Our secondary end point was to assess treatment compliance.

Definitions

Compliance was defined as adherence to the intended therapy by the patients from the day of initiation of cancer-directed therapy to the completion of treatment without any gap for 90 days. Noncompliance to therapy was defined as patients defaulting before the initiation of therapy or after starting the therapy.

Study methodology

All the patient data were retrieved from the electronic medical records of the hospital. To assess the pattern of care, the following data were collected: sex, address, ECOG-PS, tumor site, stage of the tumor, intent of treatment, treatment details, and compliance to treatment. After completion of the treatment, patients were advised to visit the clinic regularly for a follow-up once every 3 months in the 1st year; once every 4 months in the 2nd and 3rd years; and thereafter, once in 6 months.

Statistics

No formal sample size calculation was done for this study. The Statistical Package for the Social Sciences, IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA), software was used for data analysis. Continuous variables were described using median with interquartile range, and noncontinuous variables were described using proportions with 95% confidence intervals (CIs). A two-sided P < 0.05 was considered statistically significant.


  Results Top


During the 2-year period (May 2018 to April 2020), a total of 1925 patients were screened for enrollment in the study, of which 696 were excluded. A total of 1229 patients were finally included in the analysis [Figure 1]. The demographic details of the patients are presented in [Table 1]. Nearly 87% of the patients were male, and 90% were from Uttar Pradesh, with the remaining 10% presenting from West Bengal, Bihar, and Madhya Pradesh. Around 73% of the patients had an ECOG PS of 0–1. SCC was the predominant histological type and was observed in 1113 (90.6%) patients, adenocarcinoma was observed in 13 (1.1%), and other histological types in the remaining 78 (6.3%) patients. Most patients (998 [81%]) presented with disease in a locally advanced Stage (III, IVA, B, and C); among them, 442 (36%) had carcinomas of the buccal mucosa, 271 (22%) had carcinomas of the tongue, and 127 (10%) had alveolar carcinoma.
Figure 1: Flowchart for patient selection

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Table 1: Baseline characteristics of the patients with head-and-neck cancers treated at Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India

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[Table 2] presents the intent of therapy, treatment decision, and treatment offered. The planned intent was curative in 770 (62%) patients and palliative in 384 (31%) patients. In the remaining 75 (6%) patients with terminally advanced diseases and poor PS, the intent was to provide best supportive care only. Of the 770 patients who were planned for curative intent therapies, 448 (36%) were planned for upfront surgery, 183 (15%) for two to three cycles of neoadjuvant chemotherapy (NACT) followed by response assessment, and 116 (9.4%) for radical chemo-radiation. The patients planned for curative and palliative intent therapies were further categorized based on the treatment modality they received. [Table 3] presents the modality-wise distribution of the patients and their compliance to therapy.
Table 2: Intent of therapy and treatment decision of the patients with head-and-neck cancers treated at Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India

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Table 3: Treatment modality.wise distribution of patients and their compliance in the patients with head-and-neck cancers treated at Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India

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Of the 183 patients who were planned for NACT followed by response assessment, 151 (82%) actually received two to three cycles of NACT with a curative intent. The NACT used was mainly platinum-based doublets (docetaxel/paclitaxel plus cisplatin/carboplatin) or triplets (docetaxel, cisplatin/carboplatin, and fluorouracil [5-FU]) depending on the age, comorbidity, and the ECOG-PS of each patient. The rationale for NACT was either borderline resectability or organ preservation. Patients who progressed after NACT received palliative chemotherapy and/or radiotherapy. Among the patients who were planned for curative intent therapy, 274 (22%) underwent upfront surgery followed by adjuvant radiation, 46 (3.7%) underwent surgery followed by adjuvant chemo-radiation, 84 (6.8%) underwent surgery alone, and 140 (11%) patients received radical chemo-radiation. For patients treated with radical chemo-radiation or adjuvant chemo-radiation, either weekly cisplatin 40 mg/m2 or carboplatin with area under the curve 2 (if not fit for cisplatin) was used. Of those planned for palliative intent therapy, 167 (13%) patients received oral metronomic chemotherapy (celecoxib 200 mg twice daily, methotrexate 12 mg/m2 once in a week, and erlotinib 100 mg daily); 162 (13%) received some form of palliative chemotherapy, either single agent or in doublets (such as paclitaxel, carboplatin, gemcitabine, and cisplatin as per the physicians' choice); and 103 (8%) were offered best supportive care only.

Analysis of compliance to therapy revealed that 78% of the patients complied with their cancer-directed therapy. Factors affecting compliance and the association between the various categorical variables are summarized in [Table 4]. Compliance to therapy was statistically significantly associated with sex (odds ratio: 1.5; 95% CI: [0.98–2.3]; P = 0.059), suggesting that male patients were more compliant than female ones. However, age, ECOG-PS, and intent of therapy were not found to be significantly associated with compliance.
Table 4: Factors affecting compliance based on logistic regression analysis of the patients with head-and-neck cancers treated at Homi Bhabha Cancer Hospital, Tata Memorial Center, Varanasi, India

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  Discussion Top


This study presents the data of 1229 patients with HNCs who were treated with either curative or palliative intent from a newly developed single center in North India, and reports their compliance to therapy. Most of the patients (90%) belonged to the various districts of Uttar Pradesh, and the remaining presented from the neighboring states such as Bihar, West Bengal, and Madhya Pradesh. Similar to our study, Mohanti et al. had reported their experience with 2167 patients with HNCs along with their management, compliance to treatment, and treatment outcomes from a regional center in North India.[5] Nandi et al.'s audit of the demographic details and pattern of care of patients with cancer from a single center in Uttar Pradesh, India, showed that HNCs were the most common cancer type among men in this region.[6] Although carcinomas of the gall bladder has been found to be predominant in this region,[7] HNCs form the main bulk of cancer cases in men seen in the daily clinics.[6],[8]

Treatment of HNCs requires a multidisciplinary approach consisting of surgical oncology, medical oncology, radiation oncology, and pain and palliative care specialists.[9] Therefore, at our center, post diagnosis, staging, and pretreatment evaluation, treatment planning was done in a joint MDT before starting therapy, which helped avoid disparities in the standard of care. In our hospital, we treat each case after a decision taken at our MDT meetings. The median age, sex ratio, and histology of our patients were similar to those reported in the Western literature.[10],[11] A large proportion of patients with HNCs in India present with advanced primary tumors and nodal metastasis. Majority of our patients (81%) presented with locoregionally advanced disease (III–IV) and primary oral cavity cancer (70%) tumors, which is in agreement with other published reports from India.[12] The main reason for the higher incidence of oral cavity cancers in northern India is the addiction to tobacco chewing (paan, gutkha, and khaini) and smoking.[13],[14]

About 62% of our patients who were eligible for curative intent therapy needed multimodality treatment for their advanced stage diseases, which meant longer treatment time, longer stay at a place near the hospital, and need for adequate supportive care. This was the major factor for poor treatment compliance, as more than 70% of our patients traveled a distance of 300 km or more to visit our center and came from a low socioeconomic background.[15] Surgery followed by adjuvant radiation with or without chemotherapy (26%), surgery alone (6.8%), NACT followed by surgery (11%),[16] and radical concurrent chemo-radiation (11%) were delivered with a curative intent to a large proportion of patients from our newly developed center[17] in a short period of time. In addition, we reported the intent of therapy and assessed the patients' compliance to therapy, of which there are very few reports in the published Indian literature.[18],[19] The strength of our study is the analysis of the initial treatment intent and modality-wise distribution of a large cohort of patients with HNCs and their compliance to therapy.

Compliance to anticancer therapy is a key factor in the outcome of HNC treatment. Mohanti et al. reported only 56% compliance with the prescribed treatment in their cohort.[5] Similarly, Sharma et al. assessed the compliance in 47 older patients with HNCs and found that 62% complied with the treatment.[20] Pandey et al. studied 324 patients with HNCs who received radiotherapy and found that 76 patients did not comply with the treatment.[21] They also found that compliance to therapy was not significantly associated with the disease stage, ECOG-PS, and intent of treatment. In our study, 78% of the patients complied with treatment, despite being faced with several challenges such as traveling long distances, financial difficulties, and long duration of stay away from home during their treatment.

The limitations of our study include its retrospective nature, the short duration of follow-up, and the lack of analysis of the clinical outcomes. We had to exclude one-third of the patients screened due to incomplete data. These missing patients' data may have introduced some form of selection bias in the overall data of the head-and-neck sites/sub-sites. Moreover, the older patients in the cohort did not undergo a geriatric assessment before therapy. Other limitations were that all the factors for noncompliance could not be elicited and the data for patients who referred outside could not be analyzed.


  Conclusion Top


This retrospective study reports the demographic profile and the pattern of care among patients with HNCs from a newly developed tertiary cancer care center in North India. This audit also highlights the emergent need for a more dedicated cancer center in this region to better manage the patient load and suggests that enhancing the infrastructure in the existing centers should be the long-term goal to achieve.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  


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Introduction
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