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Purpose/Aim: Forward planned intensity-modulated radiotherapy (forward IMRT) with breath-hold (BH) technique is considered optimal by most practitioners for treating left-sided breast cancer. Regional nodal irradiation including axilla and supraclavicular fossa (SCF) increases can increase dose-to-organs at risk (OAR) especially lung. This study was done to assess the potential of inverse planned IMRT (inverse IMRT) to achieve significant reduction in dose to OAR. Materials and Methods: Ten patients with left-sided breast cancer treated with Active Breath Co-ordinator BH technique were included in the study. Forward IMRT plans were generated in both BH and free breathing (FB) scans. Inverse IMRT plans were generated in FB scan using Tomotherapy-Direct and Tomotherapy-Helical techniques. Contouring was done as per the ESTRO consensus contouring guidelines. The dose prescribed was 40 Gy in 15 fractions. Statistical significance was tested using one-way ANOVA for parametric data and Kruskall–Wallis test for nonparametric data. Multiple comparison tests were done by using Bonferroni test. P

Medical students in India completed an anonymous online questionnaire regarding mental health and wellbeing, including Oldenburg burnout ratings, CAGE questionnaires, and general health questionnaire (GHQ12). Out of 597 student responses, over 80% were characterised as experiencing burnout. This study highlights the need to further examine this issue, including possible causes and solutions.

Patients with severe mental illness (SMI) face health inequalities that lead to under treatment of diseases such as cancer and result in increased mortality. There is literature addressing this issue for SMI patients in high-income countries but few for those in low- and middle-income countries. This review aims to draw attention to the health inequalities and the compounding factors faced by SMI patients in low- and middle-income countries. The relevance of integration of psycho-oncology in the care of SMI patients with cancer is integral to reduce disparities and address varied contributory factors.The literature review was conducted by searching through two databases which includes PubMed and Google Scholar. We searched for articles using keyword search terms: severe mental illness, SMI, schizophrenia, bipolar disorder, cancer, low- middle-income countries, low- and middle-income countries, psycho-oncology, HPV vaccine, cancer incidence, cancer mortality, cancer control, cancer screening, cancer treatment and palliative care.A total of 80 research articles were included in our literature review. We found that there was an increased requirement for adapting to the changing disease landscape in low- and middle-income countries. An improvement on aspects such as vaccination, screening and prevention is necessary, and also efforts to change social stance towards SMI is crucial.There is an increase incidence of cancer in low- and middle-income countries, and the number of patients with SMI in low- and middle-income countries is also rising. This is due to social, psychological, economical and healthcare factors. Low- and middle-income countries must consider improving these aspects in order to adapt to the changing landscape.

Screening plays a vital role in early detection and treatment of breast cancer as evidenced by the success in screening programmes. Early screening and detection has led to effective interventions in early breast cancer improving the overall survival. There are controversies with breast cancer screening, and this chapter highlights the limitations and benefits of screening.

For breast cancer, as with any malignancy, any and every additional therapy advised, as an adjuvant, should be commensurate with the benefit accrued. While the benefit of adjuvant radiation therapy has been well established, for most patient groups, a clinical entity that has eluded a definite categorization is the group of patients having one to three lymph nodes with pathologically confirmed tumour involvement. Over the course of this chapter, we shall deliberate upon the existing evidence in an endeavor to help the radiation oncologist make an informed decision regarding the administration of adjuvant radiation therapy on encountering such a patient in the clinic until the long-term results of major randomized trials are available to settle the issue conclusively.

This chapter is an overview of the magnitude and changing trends in the incidence of breast cancer both globally and in India. The observations highlight the relationship between breast cancer and the Human Development Index; it also comprehensively covers the life habit-related risk factors, crude and age-adjusted incidence rates and the differences in incidence rate across the religious lifestyle practices, geographical regions and over time in India as reported by the National, Regional and Hospital Cancer Registries. Observations on the migration effect are also highlighted.

Radiotherapy (RT) plays an important adjuvant role in the management of early breast cancer. Accumulating evidence from multi-institutional trials has seen its role reducing in certain areas, as well as newer unexplored indications being incorporated. This has naturally led to traditional thinking being questioned, the answers of which when properly analysed through clinical trials could potentially encourage paradigm shifts in the physician decision-making process. This chapter endeavors to summarize current recommendations in various clinical scenarios and highlight a few pointers where the future directions might lie.

This chapter focuses on the techniques of radiation treatment delivery both in post-mastectomy and breast conservation scenarios.

Accelerated partial-breast irradiation (APBI) is a localized form of radiotherapy in which focused radiation is delivered after lumpectomy to the tumour bed (Correa et al., Pract Radiat Oncol 7:73–9, 2017). It is considered in a select group of early breast cancer (EBC) patients, who have undergone breast conservation surgery (BCS). Conventionally, breast conservation treatment includes breast conservation surgery and whole-breast radiation (WBRT). However, because of the time involved, the need for daily treatment and cost issues, breast conservation therapy has not been used to the maximum. APBI is an approach which treats lumpectomy cavity with 1–2 cm margin; since the volume treated is less, dose delivered per day can be increased and hence total dose and treatment time can be decreased. This leads to growing interest in APBI. Various techniques to deliver APBI have been developed and are being evaluated in phase I–III clinical trials. APBI has emerged as a safe alternative to WBRT in a select group of EBC patients; however, the relative role of different techniques is yet to be identified. This chapter comprehensively covers the indications, rationale, the devices used to deliver APBI, the various techniques of APBI and the toxicity profile following APBI.

This chapter provides an overview of psychological impact, which might result from the diagnosis, treatment and associated sociocultural and psychological factors. Psychological assessments, possible options to improve psychological well-being and overall quality of life are highlighted, and it does not cover pharmacotherapy of mental health disorders and other alternative therapies that are offered in some oncology settings to improve well-being.

The aim of a breast conservation surgery (BCS) is to achieve complete excision of the tumor with clear surgical margins while preserving the normal breast as much as possible. Intra-operative margin assessment helps to achieve negative margins, decreasing the need for re-excision. Intra-operative gross margin evaluation is a cost-effective and easy technique; however, data available regarding its adequacy are limited. We aim to find the minimum adequate gross margin required to achieve microscopic tumor-free margins and assess the relation if any of margin status with the tumor type, grade, nodal status and immunohistochemical (IHC) markers. A total of 178 patients who underwent BCS from the years 2013–2018 in our tertiary care center were selected, excluding the ones who underwent prior neoadjuvant chemotherapy and excision biopsy. A retrospective chart review was done, and the minimum adequate cutoff of gross margins required to achieve negative margins, without any positive or close margins, was evaluated. Ten exceptional cases were excluded. Among the 168 cases, 147 (87.5%) had negative and 21 (12.5%) had close or positive margins. On evaluation, maintaining an average gross margin of 5.5 mm gave a positive predictive value of 95.45%. The sensitivity and specificity were 71.43% and 76.19%, respectively, with an accuracy of 72%. No correlation was obtained between gross margin status and tumor characteristics. Gross margin evaluation is a fast and cost-effective method which can be easily set up in any hospital setting with limited resources to ensure negative margins during BCS.

Background: Breast cancer is a heterogeneous group of disease, and recently, intrinsic sub-typing on the basis of gene expression profiling is found to be a predictor of breast cancer clinical course. The St. Gallen has released surrogate classification for breast cancer sub-types depending on immunohistochemistry (IHC) markers. Aim: The aim of our study was to analyze the distribution of sub-types using IHC surrogate markers in our patient population and to assess the clinico-pathological factors in different sub-types. Materials and Methods:A total of 635 non-metastatic patients who underwent radical intend treatment from January 2011 to December 2013 were included for this retrospective analysis. A statistical analysis was done by Windows SPSS version 20. The Chi-square test was used to examine the correlations of these sub-types with clinico-pathological parameters. The Kaplan-Meier method estimates were used for survival analysis. Results: The median follow-up was 42.77 months (5 months to 112 months). Luminal B was the predominant group. Disease free survival (DFS) at 5 years was 95% in luminal A, 78% in luminal B HER-2 negative, 80% in luminal B HER-2 positive, 72% in triple negative, and 79% in HER-2/neu non-luminal. Tumor size, Ki67, T stage, N stage, and grade were significantly associated with DFS in all biological type with a P value of less than 0.05. Conclusion: Surrogate classification was successfully applied in our patient cohort. Luminal B and triple negative sub-groups were more prevalent in our patients, and this finding is at variance with published international data. Biological sub-type also emerged as an important predictor of survival.

Background Radiation plays a major role in the management of localized prostate cancer (CaP). There are limited studies reporting the quality of life (QOL) and toxicity with CaP tomotherapy. Materials and methods This is a single-institutional prospective observational study evaluating the acute toxicity and QOL of patients with CaP receiving tomotherapy from May 2018 to October 2019. Toxicity assessed using radiation therapy oncology group toxicity grading. QOL assessed using International Prostate Symptom Score (IPSS) and QOL score. Results A total number of 74 patients received radiation therapy (RT), of which 25 had postoperative RT and 49 had radical RT. The median age was 71 years. During RT, 8 (10.8%) had Grade 2 gastrointestinal (GI) and 4 (5.4%) had Grade 2 genito urinary (GU) toxicities. At 3 months, 1 (1.4%) had Grade 2 GI, 1 (1.4%) had Grade 2 GU, and 1 (1.4%) had Grade 3 GU toxicities. At 6 months, 1 patient had Grade 2 GU and no Grade 2 GI toxicity noted. In postoperative RT Group, 2 (8%) Grade 2 GI and 1 (1.4%) Grade 2 genitourinary toxicity reported during radiation. At 3 months, 1 (1.4%) Grade 2 GI, 1 (1.4%) G2 GU, and 1 (1.4%) G3 GU toxicities noted. At 6 months, no ≥ Grade 2 noted. In radical RT group, during radiation 6 (12.2%) Grade 2 GI and 3 (6.1%) Grade 2 GU recorded. At 3 and 6 months, no ≥ Grade 2 GI/GU toxicity was recorded. No Grade 3/Grade 4 observed in radical RT group. One patient in radical RT and one in postoperative RT had severe IPSS symptom score. Results are comparable to reported studies. Conclusion Our initial clinical experience with helical tomotherapy in CaP confirms lower rate of toxicities and no significant worsening of QOL with RT.

BACKGROUND AND AIM: The majority of nasopharyngeal carcinoma (NPC) reports on the outcome and prognostic factors are from endemic high-risk regions. Data on the outcome of Indian patients are sparse. In this study, we retrospectively analyzed the outcome of NPC patients treated radically with conformal radiotherapy (RT). The primary objective was to assess the outcome, and the secondary objectives were to assess treatment-related morbidities and the impact of various prognostic factors on the outcome. MATERIALS AND METHODS: Sixty-eight patients with biopsy-proven NPC who received radical conformal RT, i.e., three-dimensional conformal RT or intensity-modulated RT (IMRT) during 2004–2013 were analyzed. All patients received conformal RT with or without chemotherapy. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS, version 20.0) software, IBM, USA. Survival analysis was performed using Kaplan–Meier method. For calculating the hazard ratio of the prognostic factors, univariate and multivariate Cox regression analyses were done. Chi-square test was used to determine the association. RESULTS: In this study, with a median follow-up of 43 months, the overall survival (OS), disease-free survival, and cause-specific survival were 91, 85.2, and 98.4% at 2 years and 78.3, 72.8, and 88.2% at 3 years, respectively. The locoregional failure was low (3%), and the 5-year cause-specific survival with chemoradiation was excellent (79%), even with 50% of the patients being nonmetastatic Stage IV. Eleven out of 12 failures were distant metastases. The treatment-related late morbidities were acceptable and better with IMRT. Significant prognostic factors affecting the outcome were composite stage of the disease and the interval between diagnosis and treatment initiation. CONCLUSION: In locally-advanced NPC, excellent local control is possible with modern conformal RT with concurrent chemotherapy. Distant metastases remain a therapeutic challenge despite systemic chemotherapy. Novel systemic therapies are needed in the future for improving the OS of these patients.

Background and Aim: Cardiac toxicity is a major concern for left breast tangential field irradiation. The left ventricle and left anterior descending (LAD) artery are suggested to be radiosensitive and radiation to these structures leads to late lethal cardiotoxicity. Moderate deep inspiration breath hold (mDIBH) during radiation treatment delivery helps in reducing the cardiac dose. This study compares dosimetric parameters of heart with and without active breath coordinator (ABC) mDIBH during tangential field breast cancer radiation. Study Type: This is a dosimetric comparative study. Materials and Methods: Forty-five consecutive patients with left-sided breast cancer who underwent breast-conserving surgery and adjuvant tangential field and radiotherapy with ABC mDIBH between November 2013 and September 2015 in our center were analyzed in this study. The ABC device was used for respiratory control and patients who could hold their breath for 20–30 s were considered for radiation with ABC mDIBH. Simulation scans of both free breathing (FB) and ABC mDIBH were done. Tangent field treatment plans with a dose prescription of 40 Gy/15 Fr were generated for each patient, in both scans. Target coverage, dose to the heart, LAD, and the left lung were documented with dose-volume histograms. Results: Statistical Package for the Social Sciences, version 20 software, was used for analysis and the level of significance was set at P < 0.05. Mean heart dose was 308.5cGy with FB and 159cGy with ABC (P < 0.0001). Mean dose to the LAD was reduced by 53.81% (1320.64 cGy vs. 606.56 cGy, P < 0.001). Target coverage was equal in both the plans. Conclusion: We report that the use of ABC mDIBH technique resulted in a significant reduction in cardiac dose and hence can be considered as a promising tool for cardiac sparing.

BACKGROUND: Preoperative concurrent chemoradiation therapy (CRT) with either capecitabine or 5-florouracil/leucovorin (5 FU/LV) is the standard of care in locally advanced rectal cancer (LARC). Literature comparing the toxicity and response of these two regimens in Indian patients is sparse. Our objective was to compare the pathological response (PR) and clinical outcome of capecitabine versus 5 FU/LV in CRT for LARC. MATERIALS AND METHODS: Sixty patients with LARC treated with preoperative CRT with capecitabine or 5FU/LV from January 2009 to May 2014 were analyzed. Ryan's tumor regression grading was used for PR assessment and tumor downstaging was defined as a reduction in the T and N stages by at least one level. Toxicity was assessed with RTOG acute toxicity assessment criteria and CTCAE 4.0 version. Statistical analysis was done using IBM SPSS 20 software. Percentage of patients with respect to response rates and toxicities was computed in each of the treatment groups. To test the statistical significance of the difference in PR rates and toxicities between the two groups, Chi-square test was used. Kaplan–Meier estimate of survival rate was computed for each group. To test the statistical significance of the difference in survival rate, the log-rank test was applied. RESULTS AND CONCLUSION: The two groups (5 FU/LV vs. capecitabine) were comparable with respect to pathological complete response (20% vs. 24%), pathological downstaging (76% vs. 69%), sphincter preservation rates, and acute complication rates. Both regimens were well tolerated. Overall survival and disease-free survival also did not show a statistically significant difference between the two groups (P values 0.720 and 0.255, respectively). In summary, our analysis showed the equivalence of both regimens in the preoperative CRT setting.

Purpose Vaginal primary malignant melanoma (VPMM) is a rare aggressive mucosal melanoma. Surgery plays the most important role in treatment, providing better local control and survival than radiation. There are many reports of urethral malignant melanoma where bladder preservation was done after radical urethrectomy. However, bladder preservation in anterior VPMM with urethral involvement is not discussed.

Locally advanced breast cancer (LABC) is best managed by neoadjuvant chemotherapy followed by surgery and radiotherapy. Recent reports suggest that complete pathological response is associated with improved survival. Major concern of using concurrent chemoradiation in LABC is toxicity and cosmesis, and only very few studies addressed this issue. This study is carried out to study the feasibility, toxicity profile, pathological response of neoadjuvant anthracycline-based chemotherapy followed by concurrent chemoradiation with biweekly paclitaxel in locally advanced breast cancer patients. Fourteen patients with LABC were enrolled into this prospective feasibility study during the period 2005–2006, but only 12 patients completed the study protocol. Patients were treated with four cycles of adriamycin + cyclophosphamide followed by concurrent chemoradiation with paclitaxel and then underwent surgery. Patient characteristics, toxicity during treatment, pathological response were all documented, and patients were followed up for a minimum of 10 years to assess the long-term survival and toxicity with this approach. Most of our patients were in the high-risk biological group (ER, PR negative or HER 3+). Major toxicity reported was radiation-related acute grade ¾ cutaneous toxicity, in four patients leading to radiation treatment break. Two patients had delay in surgical wound healing. Regarding response to treatment four patients had complete pathological response (both primary and nodal), and two patients had complete nodal response with residual at primary. At the time of last follow-up, six out of 12 patients were alive without disease. Out of the alive six patients, four had pathological complete response and two had pathological nodal complete response. All the six patients having pathological complete response at the nodal site are alive without disease. No major toxicity has been reported at 10 years. Addition of radiation to neoadjuvant chemo is feasible with improved pathological response and overall good outcome in good responders, especially nodal complete responders. For patients with non-luminal type LABC, overall survival is poor but nodal pathological CR patients with non-luminal LABC are surviving even at 10 years with no additional late morbidity.