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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 4 | Issue 1
Page Nos. 1-191

Online since Friday, March 26, 2021

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MUSINGS  

COVID-19 pandemic: A story of helpless humans, confused clinicians, rudderless researchers, and a victorious virus! Highly accessed article p. 1
Pankaj Chaturvedi, Aditi Chaturvedi, Arjun Gurmeet Singh
DOI:10.4103/crst.crst_367_20  
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Pediatric cancers in India: The forgotten disease Highly accessed article p. 6
Venkatraman Radhakrishnan, Scott Howard, Catherine Lam
DOI:10.4103/crst.crst_375_20  
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COVID-19 pandemic, superbugs, and the oncologists! Highly accessed article p. 8
Abdul Ghafur
DOI:10.4103/crst.crst_52_21  
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Pain-Like a pinch of salt in a platter p. 10
Bablesh Mahawar
DOI:10.4103/crst.crst_342_20  
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COVID-19 and its socioeconomic impact p. 12
Abhishek Mahajan
DOI:10.4103/crst.crst_29_21  
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ORIGINAL ARTICLES Top

Neuropsychological functioning in long-term survivors of pediatric acute lymphoblastic leukemia: A prospective cross-sectional study Highly accessed article p. 19
Jisha Abraham, Surendran Veeraiah, Venkatraman Radhakrishnan
DOI:10.4103/CRST.CRST_278_20  
Background: Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Given the improvement in the survival of patients with ALL over the last few decades, the adverse effects of treatment and disease on survivors have become a major concern. Neuropsychological functioning has been reported to be affected in long-term survivors of ALL and can impact their quality of life. Objective: The objective of the study was to assess the neuropsychological functioning of long-term survivors of pediatric ALL. Materials and Methods: This prospective cross-sectional study was conducted at the Cancer Institute, Chennai, India, between March and August 2014. Pediatric patients with ALL who had survived at least 2 years after treatment and were in remission were included in the study. Various neuropsychological domains such as sustained attention, focused attention, verbal working memory, immediate memory, verbal learning, immediate recall, delayed recall, visuoconstructive ability, and visuomotor speed were assessed using age-appropriate tests. Data were analyzed using descriptive statistics and nonparametric tests such as the Mann–Whitney U and Kruskal–Wallis H-tests. P < 0.05 was considered statistically significant. Results: Of the 51 participants, there were 30 male and 21 female survivors. Their median ages at diagnosis and assessment were 8.6 years and 18.3 years, respectively. Adult survivors (n = 31) were found to have deficits in immediate memory, verbal learning, immediate recall, visuoconstructive ability, and visuomotor speed. Adolescent survivors (n = 20) were found to have deficits in immediate memory and verbal working memory. Survivors aged 8 years or more at diagnosis had better focused attention and verbal working memory, while those diagnosed at age <8 years had better visuoconstructive ability. Those with longer survival had better verbal working memory. Conclusions: Long-term survivors of pediatric ALL experience deficits in various neuropsychological functions. Adult survivors have deficits in immediate memory, visuoconstructive ability, verbal learning, immediate recall, and visuomotor speed, whereas adolescent survivors have deficits in immediate memory and verbal working memory.
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Economic and non-economic burden of cancer: A propensity score matched analysis using household health survey data of India p. 29
Roopali Goyanka
DOI:10.4103/crst.crst_6_21  
Background: Cancer affects the well-being not only of the patients but also of the other members of the household. Objectives: In this study, we assessed the nature and magnitude of the economic and non-economic burden on patients with cancer and their families due to the inpatient and outpatient cancer care. Materials and Methods: This study was conducted using the secondary data from the 75th round of the National Sample Survey Organization survey on health and morbidity, titled “Social Consumption: Health,” for the year 2017–2018. The burden of cancer on individuals was assessed in terms of the health-care expenditure and utilization of inpatient and outpatient cancer treatment. At the household level, cancer burden was assessed in terms of per person health-care expenditure, impact on the standard of living, strategies adopted for financing the health-care expenditure, and utilization of and expenditure on health-care by other members of the family. Propensity score matching was used to generate matched data separately for inpatient and outpatient cases and at individual and household levels to control for confounders. The difference in the burden between the matched cancer-affected and unaffected individuals/households was estimated using the average treatment effect. Results: For the year 2017–2018, data were available for a total of 113,823 households with 555,352 individuals across India. The mean out-of-pocket expenditure (OOPE) for a patient with cancer exceeded that of patients with other chronic diseases by ₹2895 for each outpatient visit and ₹52393 for each inpatient admission. The mean length of the hospital stay due to cancer was found to be 7 days longer than that due to any other chronic disease. The per person inpatient health-care expenditure for the other members of a cancer-affected household was ₹11,000 less than that of other members of the unaffected households. More than 50% of households with cancer patients had to borrow money to pay for inpatient care compared to control households. The share of OOPE for outpatient care in the monthly consumption expenditure of a cancer-affected household was twice as high as that of an unaffected household. Moreover, the number of outpatient visits for other ailing persons in a cancer-affected household was one-fourth that of an unaffected household. Conclusion: Cancer imposes an immense economic and non-economic burden on affected individuals and households. Therefore, there is a need to design appropriate health-care strategies for providing optimal financial support to patients with cancer.
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Impact of COVID-19 lockdown on patients with cancer in North Bihar, India: A phone-based survey p. 37
Ravikant Singh, Chanda Rai, Rohit Ishan
DOI:10.4103/crst.crst_349_20  
Background: In India, the coronavirus disease-2019 (COVID-19) outbreak led to an extensive lockdown, leaving the other time-sensitive medical conditions, such as cancer unaddressed. Patients with cancer are extremely vulnerable to infections owing to their already immunocompromised status and the need for prolonged treatment. Objectives: We aimed to study the impact of the COVID-19 lockdown on the utilization of health-care services by patients with cancer in the Muzaffarpur district of North Bihar, India. Materials and Methods: This descriptive, cross-sectional study was conducted at a preventive oncology clinic in the Muzaffarpur district of North Bihar in India. All consecutive patients registered in the population-based cancer registry of Muzaffarpur were telephonically contacted between April 15, 2020, and May 7, 2020, during the first phase of the nationwide lockdown. The patients were asked questions related to their disease, treatment status, and impact of the lockdown on their treatment. Detailed responses were recorded and analyzed. Results: The study comprised 210 patients of which majority were women (62.9%) and aged more than 40 years (77.1%). A total of 162 (77%) patients were found to be affected by the lockdown, of which 137 (65.4%) missed their scheduled visits, 1 (0.5%) missed surgery, 1 (0.5%) missed chemotherapy, and 24 (11.4%) could not get the prescribed drugs. Most patients who missed their scheduled appointments were aged more than 60 years, women, inhabitants of rural areas, with multiple comorbidities, or belonged to the lower middle-income economic strata. About 70% of the patients faced transportation issues, and 55% experienced financial problems during the lockdown. Conclusion: The lockdown led to difficulties in accessing cancer care in almost 80% of the patients with cancer. This suggests the need for strategic planning of health-care services for patients with cancer during the current pandemic, by means of telemedicine consultation, home-based palliative care services, and ensuring the availibility of essential cancer drugs.
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Cancer-related fatigue and its impact on quality of life in patients with central nervous system tumors: A cross-sectional analysis p. 44
Gunjesh Kumar Singh, Litty Varghese, Nandini Menon, Ochin Dale, Vijay M Patil
DOI:10.4103/crst.crst_364_20  
Background: Cancer-related fatigue (CRF) has a high prevalence in individuals with cancer, especially in those with central nervous system (CNS) tumors, and impacts the quality of life (QOL). However, there are limited data on CRF in Indian patients with CNS tumors. Objective: We aimed to estimate the CRF scores in patients with CNS tumors. Materials and Methods: This cross-sectional study was conducted in the Department of Medical Oncology of the Tata Memorial Hospital in Mumbai, India, between May 2019 and August 2019. Patients with CNS tumors aged ≥18 years, who presented to the Neuro-Oncology Disease Management Group, were enrolled in the study. The Functional Assessment of Chronic Illness Therapy Fatigue Scale was used to collect data related to well-being and fatigue. Data were captured in a single visit. Descriptive statistics and multiple regression analyses were performed to identify the factors associated with a high fatigue score. Results: There were 100 patients in our cohort with a median age of 40 (range, 18–64) years. The median fatigue score was 36. The median physical well-being, social well-being, emotional well-being, functional well-being, and Functional Assessment of Cancer Therapy-General (FACT-G) scores were 19, 19.9, 18, 17, and 72, respectively. There was a significant correlation between the fatigue score and the various subscales of FACT-G (P < 0.0001). The associated risk factors for CRF were age (P = 0.021), poor Eastern Cooperative Oncology Group-Performance Status (ECOG PS) (2–3) (P < 0.0001), general category based on the payment ability of the patient (P = 0.004), ongoing treatment status (P = 0.0003), and the presence of recurrent disease (P = 0.001). Conclusion: CRF is common in patients with CNS tumors and impacts all aspect of the QOL. It is affected by age, ECOG PS, payment ability, treatment status, and disease recurrence status.
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Non-small-cell lung cancer metastasis to unusual sites: A retrospective case series p. 50
Sandip Ganguly, Joydeep Ghosh, Anisha Gehani, Archisman Basu, Meheli Chatterjee, Deepak Dabkara, Bivas Biswas
DOI:10.4103/crst.crst_359_20  
Background: The majority of all lung cancers are non-small-cell lung cancers (NSCLCs). They usually spread to the pleura, brain, adrenal gland, lungs, liver, and bones. However, clinical data for NSCLC metastasizing to unusual sites are sparse in the literature. Objectives: We aimed to assess the pattern of metastases to unusual sites and evaluate the clinicopathological characteristics, treatment details, and outcomes of patients with NSCLC. Materials and Methods: This retrospective case series was conducted in the Department of Medical Oncology of a tertiary cancer center in Eastern India between May 2011 and December 2018. Patients with cytologically or biopsy-proven treatment-naive stage IV NSCLC were included in this audit. Sites other than the pleura, brain, adrenal gland, lung, liver, and bones were considered as unusual sites of metastases. Clinicopathological characteristics, site of metastases, treatment details, and outcomes were recorded. Data were described using descriptive statistics, survival was estimated using the Kaplan–Meier analysis, and log-rank test was used to determine survival estimates. Results: A total of 1549 patients with metastatic NSCLC were registered, of which 121 (7.8%) had metastases to unusual sites. The median age of the cohort was 72 years (range, 19–87 years), and the male:female ratio was 7:1. The most common site of unusual metastasis was the skin with soft tissue, followed by the kidney; metastasis to these sites was seen in 31 (2%) and 26 (1.6%) patients, respectively. Systemic chemotherapy was given to 67 (55.3%) patients. At a median follow-up of 11.2 months (95% confidence interval [CI], 6.8–17.5), the median progression-free survival of the cohort was 5.9 months (95% CI, 3.8–9.1). Conclusions: In <10% of the patients, NSCLC can spread to unusual sites, most commonly to the skin/soft tissue and the kidney. A detailed discussion with the radiologists is necessary to distinguish NSCLC that has metastasized to unusual sites from second primary tumors and to avoid unnecessary tissue biopsies from these areas.
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ORIGINAL ARTICLE-REAL WORLD DATA Top

Real-world data of second-line immunotherapy in metastatic clear cell renal cell carcinoma: A retrospective study Highly accessed article p. 55
Waseem Abbas, Anjali Aggarwal, Promila Pankaj, Rachna Jain
DOI:10.4103/CRST.CRST_247_20  
Background: Targeted therapies have prolonged the survival of patients with metastatic renal cell carcinomas (RCC). However, the majority of patients with metastatic RCC develop treatment resistance and disease progression. The programmed cell death protein 1 inhibitors offer a new ray of hope for such patients. Objectives: The primary objective of this study was to evaluate the overall survival (OS) of patients with relapsed metastatic RCC treated with immunotherapy in the second-line setting. The secondary objectives were to assess the safety profile and objective response rate (ORR) for nivolumab. Materials and Methods: This retrospective study was conducted in the Department of Medical Oncology at the Max Institute of Cancer Care, a tertiary care center in Delhi, India. Patients with histologically proven stage IV RCC who had progressed on first-line tyrosine kinase inhibitors (TKIs) and treated with at least four cycles of nivolumab at our center between December 2015 and January 2019 were enrolled in the study. The OS, progression-free survival (PFS), immune-mediated adverse events (irAEs), and ORR were determined. Results: Out of 50 patients with metastatic RCC who progressed on first-line TKIs, 19 received immunotherapy with nivolumab. The median age of the patients was 62 years (range, 31–71 years); the male-to-female ratio was 2:1. The median follow-up time and duration of treatment were 11 months (range, 2–23) and 4.5 months (95% confidence interval [CI], 3.52–5.96), respectively, and 8 (42.1%) patients were alive at the time of analysis. The median OS was 13 months (95% CI, 10.4–15.5) from the start of nivolumab therapy, and the median PFS was 8 months (95% CI, not evaluable). The best response was progressive disease in 47.3%; the ORR was 26.3%. Grade 1/2 and grade 3/4 adverse events were observed in 68.4% and 10.5% of the patients, respectively. Adverse events of any grade were reported in 13 (68.6%) patients. Fatigue and hypothyroidism were the most frequently observed irAEs associated with nivolumab and occurred in 4 (21%) and 11 (57.8%) patients, respectively. Four (15.7%) patients developed grade 1 pruritus. No fatal toxicities were recorded. Conclusion: Nivolumab is efficacious and safe as a second-line treatment option for metastatic RCC in Indian patients.
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HEALTH SYSTEMS AND QUALITY IMPROVEMENT Top

Synoptic reporting in lung cancers using Lung Cancer Reporting and Data System (LC-RADS): The road ahead for standardization of imaging in lung cancer staging p. 61
Abhishek Mahajan
DOI:10.4103/CRST.CRST_155_20  
Words are the most important and sometimes the only medium of communication between a radiologist and a treating physician. The concept of structured reporting in radiology was well received in the face of growing concerns to overcome the limitations of unstructured reporting such as interobserver variations, errors in communication, and lack of standardization of reporting that primarily affect the patients who seek health care away from their diagnostic centers. With the introduction of synoptic reporting in radiology, it is now possible to standardize the reporting of diseases in a more comprehensive and less time-consuming manner, thus magnifying the impact of a radiological report in the further management of the disease under analysis. We aim to develop a standardized synoptic reporting template for lung cancers that would comprise and collate all the required computed tomography (CT) findings and demographic details of the patients. This will help the treating physicians and surgeons to plan the further course of disease management. It will also help to standardize the follow-up CT scans performed for the patients post any given treatment regimen with special reference to the likely complications caused by a particular treatment, such as radiation-related lung injury, immunotherapy-related toxicity, and surgical complications requiring urgent interventions.
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ORIGINAL ARTICLE: GERIATRIC ONCOLOGY SECTION Top

Polypharmacy and potentially inappropriate medication use in older Indian patients with cancer: A prospective observational study p. 67
Vanita Noronha, Anant Ramaswamy, Shreya Chandrashekhar Gattani, Renita Castelino, Manjunath Nookala Krishnamurthy, Nandini Menon, Vijay M Patil, Vikram S Gota, Shripad Banavali, Kumar Prabhash
DOI:10.4103/crst.crst_50_21  
Background: Polypharmacy and the use of potentially inappropriate medications (PIMs) are important issues in older patients with cancer. Objectives: We aimed to study the prevalence of polypharmacy, and the use of PIMs, including the peri-chemotherapy supportive care regimens in older Indian patients with cancer. Materials and Methods: This was an analysis of a prospective observational study of patients aged 60 years and over with a diagnosis of malignancy who were assessed in the geriatric oncology clinic at the Tata Memorial Hospital (Mumbai, India). Patients on five or more medications were considered to have polypharmacy; excessive polypharmacy was defined as ten or more medications and PIMs were defined and categorized according to the Beers criteria. Results: Between June 2018 and October 2020, 285 patients were enrolled in the study. Polypharmacy was noted in 55% of the patients and excessive polypharmacy in 13%. Polypharmacy was noted in 70% of the patients with lung cancer, compared to 45% for other malignancies, P < 0.001. Unindicated medications such as vitamins and calcium were being taken by 20% of the patients and 23% were taking alternative medications (ayurvedic/homeopathic/naturopathic). Eighty percent of the patients were taking PIMs, commonly proton-pump inhibitors (33%) and tramadol (30%). The median number of PIMs was 2 (interquartile range, 1–2). Of the peri-chemotherapy supportive care medications, 53% were potentially inappropriate, commonly intravenous antihistamines in 39%, histamine H2 blockers in 15%, and steroids in 12%. Conclusions: Polypharmacy and PIM use are common problems in older Indian patients with cancer. Recognizing the problem and taking steps to ensure safe medication prescription practices should be a priority.
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POETRY IN ONCOLOGY Top

COVID, stigma and karma p. 74
Mansi Haresh Khanderia
DOI:10.4103/CRST.CRST_289_20  
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PATIENT/CAREGIVER CORNER Top

My experience with a culture p. 75
Mohammed Iqbal
DOI:10.4103/crst.crst_366_20  
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Cancer care is all about decision, care, and guidance p. 77
Shikha Sinha
DOI:10.4103/crst.crst_5_21  
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REVIEW ARTICLES Top

Assessment of COVID-19 severity using computed tomography imaging: A systematic review and meta-analysis Highly accessed article p. 78
Prerit Jugalkishor Sharma, Abhishek Mahajan, Swapnil Rane, Atanu Bhattacharjee
DOI:10.4103/crst.crst_292_20  
Computed tomography (CT) imaging has been reported to be a reliable tool for the evaluation of suspected cases and follow-up of confirmed cases of coronavirus disease 2019 (COVID-19). Despite the generation of a considerable amount of imaging data related to COVID-19, there is a need for an updated systematic review and meta-analysis pertaining to the questions of clinical significance. We aimed to analyze the correlation between abnormal chest CT findings and disease severity in patients with COVID-19. We searched for case series/studies published in the English language until March 24, 2020 that reported the clinical and chest CT imaging features of confirmed cases of COVID-19 in the PubMed database. A total of 208 studies were screened, and 71 were finally included in the meta-analysis. Study characteristics and relative risk (RR) estimates were extracted from each article and pooled using the random-effects meta-analysis model. There were a total of 6406 patients studied in a total of 71 studies; the male to female ratio was 1.08:1, and the mean age was 45.76 years; of these, 2057 patients from 14 studies were categorized into severe (24.3%) and mild (75.7%) disease groups. Imaging features that were more frequently noted in patients with severe disease than in those with mild disease included bilateral lung involvement (88.7% vs. 49.8%), scattered distribution (80.4% vs. 46.5%), multiple lobe involvement (95.7% vs. 59.6%), consolidation (88.3% vs. 60.3%), crazy-paving pattern (45.4% vs. 27.6%), air-bronchogram sign (29.7% vs. 15.1%), interlobular septal thickening (84.2% vs. 55.8%), and subpleural line (36.8% vs. 26.4%) differences between the two disease groups were statistically significant (P < 0.001). For 3778 patients in 29 studies, a significant pooled RR estimate was associated with abnormal chest CT findings in patients with COVID-19 (RR, 5.46%; 95% confidence interval [CI], 3.72%–8.04%; I2 = 86%). Individual assessment of the CT features revealed that a significant pooled RR estimate was associated with pure ground-glass opacity (GGO) (RR, 1.63%; 95% CI, 1.12%–2.38%; I2 = 79%), while lower pooled RR estimates were associated with CT features like crazy-paving pattern (RR, 1.37%; 95% CI, 1.10%–1.71%; I2 = 60%), consolidation (RR, 0.47%; 95% CI, 0.32%–0.7%; I2 = 83.5%), GGO with consolidation (RR, 0.73%; 95% CI, 0.52%–1.02%; I2 = 75%), and air-bronchogram sign (RR, 0.58%; 95% CI, 0.36%–0.96%; I2 = 94%). In conclusion, the number, location, extent, and type of radiological lesions are associated with COVID-19 progression and severity, suggesting the feasibility of using CT imaging in the assessment of disease severity in all age groups and efficient allocation of resources for patient management at the institutional level.
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Do oncology nurses have sufficient knowledge of exercise oncology? A mini narrative review p. 88
Chidiebere Emmanuel Okechukwu
DOI:10.4103/crst.crst_315_20  
There is a need to broaden the knowledge of oncology nurses about exercise prescription and recommendations for the improvement of quality of life and physical and mental health of patients with cancer and survivors. In addition, oncology nurses need to have comprehensive knowledge regarding the physiological mechanisms underlying these improvements. Through this mini review, we aimed to describe the level of expertise of nurses in the field of exercise oncology and identify appropriate solutions to improve this knowledge. Articles concerning exercise and oncology nursing practices published between January 1996 and September 2020 were searched in the PubMed electronic database; relevant articles were selected, full-text articles were assessed, and important information was extracted. A standard exercise oncology curriculum needs to be developed and implemented for oncology nursing practitioners and those training in oncology nursing. Oncology nurses should be trained in exercise oncology, rehabilitation, and exercise prescription and follow-up. This could boost the rate of adherence to self-managed/home-based exercise routine among cancer survivors.
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DRUG REVIEW Top

Ripretinib: A narrative drug review p. 93
Silpa S Kumar, Arun Philip, Keechilat Pavithran
DOI:10.4103/crst.crst_308_20  
Gastrointestinal stromal tumors (GISTs) are rare primary neoplasms of the gastrointestinal tract, mesentery, or omentum. In the past, for patients with resectable tumors, surgery was the only viable treatment option. However, therapy of GISTs has undergone a fundamental change with the advent of receptor tyrosine kinase inhibitors primarily targeting the tyrosine-protein kinase KIT and the platelet-derived growth factor receptor alpha (PDGFRA). Ripretinib is one such novel Type-II tyrosine switch control inhibitor which is used in the treatment of advanced KIT proto-oncogene-driven and PDGFRA-induced tumors, including GISTs. The Food and Drug Administration approved ripretinib on May 15, 2020, for the treatment of adult patients with progressive GISTs who had undergone prior treatment with three or more kinase inhibitors. A comprehensive search in PubMed and other sources were done, using the search terms, “GIST” and ripretinib. On combining all the abstracts and conference proceedings, here we present a comprehensive review on ripretinib's history, pharmacology, and clinical applications.
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REVIEW ARTICLE: ONCOLOGY UPDATES Top

Recent updates in systemic therapy of breast cancer: A brief narrative review Highly accessed article p. 99
Shalabh Arora, Ajay Gogia
DOI:10.4103/crst.crst_335_20  
Breast cancer is the most common malignancy and the leading cause of cancer-related deaths in women globally. Systemic therapy of breast cancer has evolved rapidly in the past few years. In this brief review, we aim to summarize the potentially practice-changing recent updates in the management of breast cancer. We searched the PubMed database for randomized clinical trials for breast cancer treatment conducted over the past 2 years. In addition, abstracts and results of studies reported at major oncology meetings were evaluated. A total of 95 randomized clinical trials were included to prepare this review. Multiple new therapeutic options for almost all subsets of breast cancer have emerged in the past 2 years. Most importantly, for hormone-receptor-positive breast cancer, addition of abemaciclib to endocrine therapy in the adjuvant setting and alpelisib for PIK3CA-mutant refractory advanced disease have been shown to improve the survival outcomes. Addition of pembrolizumab or atezolizumab to neoadjuvant chemotherapy has significantly increased the pathological complete response rate for early triple-negative breast cancer, while adjuvant metronomic capecitabine for 1 year has led to improved disease-free survival. Moreover, adjuvant adotrastuzumab emtansine fared better than trastuzumab in the management of residual disease after neoadjuvant treatment for human epidermal growth factor receptor 2 (HER2)-positive breast cancer, while tucatinib and neratinib have shown meaningfully improved progression-free survival in HER2-positive advanced disease, including patients with cranial nervous system involvement. Expanding access to these advances is soon expected to transform the way we treat breast cancers.
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REVIEW ARTICLE-BIOMARKER SERIES Top

NTRK-A narrative review Highly accessed article p. 110
Ullas Batra, Shrinidhi Nathany, Mansi Sharma
DOI:10.4103/crst.crst_11_21  
Lung cancer diagnostics and therapeutics have witnessed a paradigm shift in the last decade because of the discovery of targetable biomarkers and rapid approvals of the corresponding targeted therapies. The prognosis of biomarker-driven tumors has improved, and hence, testing for the presence of targetable biomarkers is now a mandate according to both national and international recommendations. Apart from the common and canonical alterations in the epidermal growth factor receptor, anaplastic lymphoma kinase, and ROS1 genes, NTRK fusions, although rare, are gaining clinical importance as targetable alterations. With entrectinib and larotrectinib making their way into the phase III trials, a comprehensive knowledge about the biology, molecular diagnostic techniques, ongoing trials, and available drugs for NTRK-fusion-positive lung cancers is essential. Therefore, we performed a narrative review of the already published literature. The PubMed, Embase, and Scopus databases were searched using the keywords “biology of NTRK,” “TRK,” “NTRK” and “NSCLC.” A total of 32 relevant articles were reviewed. In this review, we have described the biology, signaling pathways, detection methods, and treatment for NTRK-fusion-positive cancers.
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RESIDENTS CORNER Top

The journey from author to reviewer p. 115
Sunny Chi Lik Au
DOI:10.4103/crst.crst_350_20  
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The transition of academic meetings in 2020 p. 117
Sunny Chi Lik Au
DOI:10.4103/crst.crst_1_21  
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EDITORIALS Top

“My cancer is cured, but I do not feel normal”: A commentary on neuropsychological outcomes of pediatric acute lymphocytic leukemia in India p. 119
Soumitra Shankar Datta, Arnab Mukherjee
DOI:10.4103/crst.crst_49_21  
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Cancer-related fatigue: A burden unreported by patients, undiagnosed by physicians, and unaddressed in research p. 121
Venkata Pradeep Babu Koyyala
DOI:10.4103/crst.crst_58_21  
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Current systemic therapy options in advanced clear cell renal cell cancer p. 124
Akhil Kapoor
DOI:10.4103/crst.crst_59_21  
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Conundrum of polypharmacy in geriatrics: Less is better than more p. 127
V Rajesh, Mahadev Rao
DOI:10.4103/crst.crst_60_21  
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MOLECULAR TUMOR BOARD Top

Rare case of Skene gland adenocarcinoma with RET-rearrangement p. 130
Suresh Kumar Bondili, George Abraham, Vanita Noronha, Amit Joshi, Vijay M Patil, Nandini Menon, Omshree Anil Shetty, Anuradha Chougule, Santosh Menon, Pratik Chandrani, Abhishek Mahajan, Kumar Prabhash
DOI:10.4103/crst.crst_39_21  
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IMAGE CHALLENGE Top

A mysterious localized spinal whiteout p. 136
George Abraham, Nandini Sharrel Menon, Sunil R Chopade, Vanita Noronha, Vijay M Patil, Amit Joshi, Kumar Prabhash
DOI:10.4103/crst.crst_365_20  
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STATISTICAL RESOURCE Top

Algorithm to choose the appropriate test for comparison between two groups p. 139
Sampada B Dessai, Vijay M Patil
DOI:10.4103/crst.crst_45_21  
The current manuscript describes the method of selection of statistical tests for comparing two groups. In this article, we discuss the factors on which the selection of tests depends and provide an algorithm for the selection of the inferential statistical test.
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LETTERS TO EDITOR Top

Aprepitant for patients with head-and-neck cancer receiving once-a-week cisplatin with radiation: Is it required? p. 141
Vanita Noronha, Hollis D'souza, Amit Kumar Choudhary, Vijay M Patil, Gunjesh Kumar Singh, Amit Joshi, Nandini Menon, Kumar Prabhash
DOI:10.4103/crst.crst_9_21  
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Efficacy of physical activity in mitigating cancer metastasis p. 142
Chidiebere Emmanuel Okechukwu
DOI:10.4103/crst.crst_372_20  
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Huge mixed germ cell tumor of the ovary clinically mimicking pregnancy in an adolescent girl: A case report p. 143
Thirunavukkarasu Arun Babu, Padmapriya Balakrishnan, Vijayan Sharmila
DOI:10.4103/crst.crst_287_20  
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Is yoga effective in mitigating cancer-related fatigue? p. 146
Chidiebere Emmanuel Okechukwu
DOI:10.4103/crst.crst_373_20  
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Leiomyoma of the tunica albuginea: A rare cause of intrascrotal mass p. 147
Kavita Mardi
DOI:10.4103/crst.crst_325_20  
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Exposure to a high level of arsenic in drinking water and the risk of bladder cancer in Taiwan p. 149
Chidiebere Emmanuel Okechukwu
DOI:10.4103/crst.crst_374_20  
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Palliative and symptom-directed care at diagnosis in hematologic malignancies: Need for hematology-oncology and anesthesia-pain services to join forces p. 151
Suvir Singh
DOI:10.4103/crst.crst_44_21  
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Time for cancer to be designated a notifiable disease in India p. 153
Ventrapati Pradeep
DOI:10.4103/crst.crst_22_21  
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Authors' reply to Ventrapati p. 154
Rohan Thomas Mathew, Rohan Shetty, Manavalan Vijayakumar
DOI:10.4103/crst.crst_35_21  
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How COVID-19 impacted the care of patients with cancer p. 155
Rakesh Chopra
DOI:10.4103/crst.crst_24_21  
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Cancer care delivery amidst the COVID-19 pandemic: Common challenges and counter measures p. 156
Abhishek Shankar, Deepak Saini
DOI:10.4103/crst.crst_21_21  
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Authors' reply to Shankar et al. and Chopra p. 158
Avinash Pandey
DOI:10.4103/crst.crst_37_21  
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Lost-to-follow-up for cervical cancer screening p. 159
Geetu Bhandoria, Vijay Ahuja, SP Somashekhar
DOI:10.4103/crst.crst_46_21  
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Cervical cancer screening in India p. 160
Sampada Dessai
DOI:10.4103/crst.crst_10_21  
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Cytologic abnormalities noted in the cervical smears of high-risk persons p. 161
SP Somashekhar, Geetu Bhandoria, Vijay Ahuja
DOI:10.4103/crst.crst_48_21  
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Cancer-related anemia in Northeast India: Many questions and few answers p. 163
Swaratika Majumdar, Arun S Shet
DOI:10.4103/crst.crst_13_21  
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Anemia in treatment-naive patients with cancer p. 164
Bidyut Krishna Goswami
DOI:10.4103/crst.crst_27_21  
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Prevalence of anemia among patients with cancer: A complex phenomenon p. 166
Neeraj Gour, Suraj Chawla
DOI:10.4103/crst.crst_18_21  
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Authors' reply to Gour et al., Majumdar et al., and Goswami p. 167
Avinash Pandey
DOI:10.4103/crst.crst_34_21  
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Health-care system-related factors are the major contributors to time to diagnosis in solid tumors in children in India p. 168
Ishita Maji, Jyotsna Sharma, Ramandeep Singh Arora
DOI:10.4103/crst.crst_12_21  
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Authors' reply to Maji et al. p. 169
Saksham Singh, Prakruthi S Kaushik, Nuthan Kumar
DOI:10.4103/crst.crst_36_21  
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One foot in the door: Financial toxicity in patients with cancer receiving active chemotherapy p. 170
Arpan A Patel
DOI:10.4103/crst.crst_19_21  
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Digging deeper into cancer-associated financial toxicity in low- and middle-income countries p. 172
Arjun Gupta, Bishal Gyawali
DOI:10.4103/crst.crst_4_21  
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Cancer – Too costly to cure? p. 173
Vidya Jha, TA Dinesh, Prem Nair
DOI:10.4103/crst.crst_30_21  
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Authors' reply to Patel, Gupta et al., and Jha et al. p. 174
Devanshi Kalra, Nandini Menon, Vijay M Patil
DOI:10.4103/crst.crst_55_21  
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A new hope for patients with cancer in North India p. 176
Anshul Singla, Alok Goel
DOI:10.4103/crst.crst_14_21  
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Authors' reply to Singla et al. p. 177
Bal Krishna Mishra, Somnath Roy, Tanmoy Kumar Mandal, Sudeep Das, Sujay Srinivas, Anshul Agarwal, Anuj Gupta, Arpita Singh, Anil Singh, Sambasivaiah Kuraparthy, Akhil Kapoor, Ranti Ghosh
DOI:10.4103/crst.crst_33_21  
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RET gene fusions/rearrangements as biomarkers for lung carcinoma p. 177
Avinash A Rasalkar, Saloni Bhatia, Divijendra Natha Reddy Sirigiri
DOI:10.4103/crst.crst_15_21  
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Authors' reply to Rasalkar et al. p. 179
Ullas Batra, Shrinidhi Nathany, Mansi Sharma
DOI:10.4103/crst.crst_42_21  
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Electronic medical records: Issues after implementation p. 180
Suchitra Kataria, Vinod Ravindran
DOI:10.4103/crst.crst_7_21  
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Roll out of electronic medical records in public health facilities and the way ahead p. 181
Ankit Singh, Priya Ravi, Neha Ahire
DOI:10.4103/crst.crst_8_21  
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Path beyond tyrosine kinase inhibitors: Full of riddles and puzzles p. 182
Ullas Batra, Shrinidhi Nathany
DOI:10.4103/crst.crst_53_21  
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Exploring novel combinations of targeted therapy in the journey of epidermal growth factor receptor-mutant lung cancers p. 184
Veda Devakumar, Nirmal Vivek Raut, Namrata Britto
DOI:10.4103/crst.crst_51_21  
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Study of intransigence of the epidermal growth factor receptor in non-small cell lung cancer p. 185
Teesta Katte, Divijendra Natha Reddy Sirigiri, Avinash A Rasalkar
DOI:10.4103/crst.crst_20_21  
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Authors' reply to Devakumar et al., Katte et al., and Batra et al. p. 187
Suresh Kumar Bondili, Vanita Noronha, Anuradha Chougule, Kumar Prabhash
DOI:10.4103/crst.crst_56_21  
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Old is always not gold in geriatric oncology assessment p. 188
Venkatraman Radhakrishnan
DOI:10.4103/crst.crst_17_21  
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Authors' reply to Radhakrishnan p. 189
Vanita Noronha, Anant Ramaswamy, Shreya Gattani, Kumar Prabhash
DOI:10.4103/crst.crst_54_21  
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COVID-related increase in pelvic and para-aortic lymphadenopathy in patients with cervical cancer p. 190
Vijay Ahuja, Geetu Bhandoria, SP Somashekhar
DOI:10.4103/crst.crst_40_21  
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