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Background In India, breast and cervical cancers account for two-fifths of all cancers and are predominantly prevalent among women in the reproductive age group. The Government of India recommended screening of breast and cervical cancer among women aged 30 years and over. This study examines the socio-economic and regional variations of breast and cervical screening among Indian women in the reproductive age. Methods A full sample of 707,119 women aged 15–49 and a sub-sample of 357,353 women aged 30–49 from National Family Health Survey-5 (2019-21) were used in the analysis. Self-reported ever screening for breast and cervical cancer for women aged 15–49 and women aged 30–49 were outcome variables. A set of socio-economic and risk factors associated with breast and cervical cancer screening were used as the predictors. Logistic regression was used to understand the significant correlates of cancer screening and, concentration index and concentration curve were used to assess the socio-economic inequality in breast and cervical cancer screening. Results The proportion of breast and cervical cancer screening among women aged 30–49 were 877 and 1965 per 100,000 women respectively. Cancer screening was lower among women who were poor, young, had lower educational attainment and resided in rural areas. The concentration index was 0.2 for ever screening of breast cancer and 0.15 for cervical cancer among women aged 30–49 years. The concertation curve for screening of both breast and cervical cancers was pro-rich. Women with higher educational attainment [OR:1.46, 95% CI: 1.31–1.62], aged 40–49 years [OR:1.35; 95% CI: 1.28–1.43], resided in the western [OR:1.62; 95% CI:1.4–1.87] or southern [OR:6.66; 95% CI:5.93–7.49] region had significantly higher odds of up taking either of the screening. The pattern of breast and cervical cancer screening among women aged 15–49 was similar to that of women 30–49. Conclusion The overall proportion of cancer screening among women in 30–49 age group is low in India. Early screening and treatment can reduce the burden of these cancers. Creating awareness and providing knowledge on cancer could be a key strategy for reducing the burden of breast and cervical cancers among women in the reproductive age in India.

Objective To estimate the catastrophic health expenditure and distress financing of breast cancer treatment in India. Methods The unit data from a longitudinal survey that followed 500 breast cancer patients treated at Tata Memorial Centre (TMC), Mumbai from June 2019 to March 2022 were used. The catastrophic health expenditure (CHE) was estimated using households’ capacity to pay and distress financing as selling assets or borrowing loans to meet cost of treatment. Bivariate and logistic regression models were used for analysis. Findings The CHE of breast cancer was estimated at 84.2% (95% CI: 80.8,87.9%) and distress financing at 72.4% (95% CI: 67.8,76.6%). Higher prevalence of CHE and distress financing was found among rural, poor, agriculture dependent households and among patients from outside of Maharashtra. About 75% of breast cancer patients had some form of reimbursement but it reduced the incidence of catastrophic health expenditure by only 14%. Nearly 80% of the patients utilised multiple financing sources to meet the cost of treatment. The significant predictors of distress financing were catastrophic health expenditure, type of patient, educational attainment, main income source, health insurance, and state of residence. Conclusion In India, the CHE and distress financing of breast cancer treatment is very high. Most of the patients who had CHE were more likely to incur distress financing. Inclusion of direct non-medical cost such as accommodation, food and travel of patients and accompanying person in the ambit of reimbursement of breast cancer treatment can reduce the CHE. We suggest that city specific cancer care centre need to be strengthened under the aegis of PM-JAY to cater quality cancer care in their own states of residence. Trial Registration CTRI/2019/07/020142 on 10/07/2019.

Background The study examined the socio-economic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisis. Methods We used primary data of 500 patients with breast cancer sought treatment at India’s one of the largest cancer hospital in Mumbai, between June 2019 and March 2022. This study is registered on the Clinical Trial Registry of India (CTRI/2019/07/020142). Kaplan–Meier method and Cox-hazard regression model were used to calculate the probability of treatment discontinuation. Results Of the 500 patients, three-fifths were under 50 years, with the median age being 46 years. More than half of the patients were from outside of the state and had travelled an average distance of 1,044 kms to get treatment. The majority of the patients were poor with an average household income of INR15,551. A total of 71 (14%) patients out of 500 had discontinued their treatment. About 5.2% of the patients died and 4.8% of them discontinued treatment due to financial crisis. Over one-fourth of all deaths were reported among stage IV patients (25%). Patients who did not have any health insurance, never attended school, cancer stage IV had a higher percentage of treatment discontinuation due to financial crisis. Hazard of discontinuation was lower for patients with secondary (HR:0.48; 95% CI: 0.27–0.84) and higher secondary education (HR: 0.42; 95% CI: 0.19–0.92), patients from rural area (HR: 0.79; 95% CI: 0.42–1.50), treated under general or non-chargeable category (HR: 0.60; 95% CI:0.22–1.60) while it was higher for the stage IV patients (HR: 3.61; 95% CI: 1.58–8.29). Conclusion Integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality. Provisioning of free treatment for poor patients may reduce discontinuation of treatment.

There is sparse data on the outcomes of combined chemotherapy and hormonal therapy (CHT) in patients with metastatic breast cancer (MBC). This retrospective analysis of HR-positive, HER2-negative MBC patients treated between January 2015 and December 2020 with a combination of chemotherapy (capecitabine or oral cyclophosphamide) and hormonal therapy evaluated their progression-free survival (PFS) and overall survival (OS).The study included 224 patients with a median age of 53 (26–91) years, a median of 3 (0–12) prior treatment lines and a median follow-up of 21.2 (1.7–87.0) months. There were 195 (87.1%) PFS events and 154 (68.8%) deaths, with a median PFS of 8.8 (95% CI 7.0-10.6) months and a median OS of 16.7 (95% CI 13.5–19.9) months. In univariable analyses, ECOG PS (≤ 1 vs. ≥ 2, PFS 14.9 vs. 6.0 months, HR 0.32, 95% CI 0.23–0.44, p  < 0.001; OS 36.2 vs. 11.0 months, HR 0.29, 95% CI 0.20–0.42, p  < 0.001) and duration of most recent endocrine therapy (> 12 vs. ≤ 12 months, PFS 11.7 vs. 6.9 months, HR 0.32, 95% CI 0.23–0.44, p  = 0.023; OS 21.9 vs. 15.0 months, HR 0.70, 95% CI 0.49–0.99, p  = 0.047) were significantly associated with survival. In multivariable Cox analyses, better ECOG PS (HR 0.29, 95% CI 0.19-0.43, p<0.001) and capecitabine-based chemotherapy (HR 0.60, 95% CI 0.37-0.99, p=0.043) were significantly associated with higher OS. The chemo-hormonal therapy regimens were well tolerated, with 21 (9.4%) patients experiencing any grade ≥3 toxicity. Chemo-hormonal therapy is an effective treatment in heavily pre-treated MBC patients, including those with visceral metastases. Trial registration: CTRI/2022/01/039242

BackgroundHealth technology assessment (HTA) is a valuable tool for informing the efficient allocation of resources in healthcare. However, the resource-intensive nature of HTA can limit its application, especially in low-resource settings. Adapting HTA processes by assessing the available international evidence offers a pragmatic approach to provide evidence for decision-making where resources are constrained.ObjectiveThis study piloted an adaptive HTA (aHTA) method to evaluate 10 cancer interventions.MethodsWe arranged a joint collaboration with the International Decision Support Initiative and the National Cancer Grid in India to form a working group of clinicians and health economists. We conducted a rapid review of HTA reports and economic evaluations for ten prioritised common cancer interventions for breast, lung, and head and neck cancers. We extracted data on cost-effectiveness, conducted a price benchmarking analysis, estimated treatment costs and calculated the treatment’s share of the national insurance family allowance. Finally, we determined through qualitative appraisal whether the intervention would likely to be considered cost-effective in the Indian context.ResultsOf the 10 interventions assessed, 9 had sufficient evidence to make determinations on the likely cost-effectiveness. Three were potentially cost-effective (one after a price discount and another by using the generic price), while five were not, and one was only cost-effective in a subgroup. One intervention required a full HTA due to remaining uncertainty. Information on the likely cost-effectiveness, clinical and safety benefits, and treatment costs was consistently found through publicly available evidence. Assessment methods were modified slightly across the 10 interventions, including expanding the data extraction criteria, updating the calculations and broadening the evidence retrieval.ConclusionThe aHTA method is a feasible resource-sensitive alternative to traditional HTA for informing decision-making in resource-constrained settings when ample international data on cost-effectiveness for a given topic is available.

This phase 2 study evaluated the safety of adjuvant chemoradiation (CTRT) for breast cancer. From April 2019 to 2020, 60 patients with stage II-III invasive breast cancer planned for adjuvant taxane-based chemotherapy and radiotherapy (RT) were accrued. Local ± regional (excluding the internal mammary nodal region) RT (40 Gy in 15 fractions ± boost) was started with the third cycle of an adjuvant taxane in a 3-weekly schedule or with the eighth cycle in a weekly schedule. Thirty-six patients received 3-weekly paclitaxel regimen and 24 received weekly paclitaxel regimen. The commonly used technique was three-dimensional conformal RT which was employed in 58% of patients. Regional RT, including the medial supraclavicular region, was done in 42 patients (70%). No dose-limiting (grade 3 or 4) toxicity was documented and all patients completed CTRT without any treatment interruption. The median ejection fraction pre and post CTRT 6 months was 60% ( = 0.177). The median value of cardiac enzyme (Troponin T ng/L) decreased from 37 to 20 ( = 0.009) post CTRT 6 months. Of the 54 patients who underwent the pulmonary function tests, there was no significant difference in various parameters like functional vital capacity (FVC) (2.29 versus 2.2 L, = 0.375), forced expiratory volume at 1 second (FEV1) (1.86; 1.82; = 0.365), FEV1/FVC (81.5; 81.43; = 0.9) and diffusion lung capacity for carbon monoxide (88.3; 87.6; = 0.62). At a median follow-up of 34 months, the 3-year actuarial rate of disease-free survival and overall survival was 75% and 98.3%, respectively. Quality of life scores (QOL) improved after treatment for most of the domains comparable to the pre-RT scores. Taxane-based adjuvant CTRT is a safe option and results in minimal toxicity and excellent compliance. It has favourable impact on cardio-pulmonary profile and QOL scores.

Abstract The incidence of breast cancer is increasing rapidly in urban India due to the changing lifestyle and exposure to risk factors. Diagnosis at an advanced stage and in younger women are the most concerning issues of breast cancer in India. Lack of awareness and social taboos related to cancer diagnosis make women feel hesitant to seek timely medical advice. As almost half of women develop breast cancer at an age younger than 50 years, breast cancer diagnosis poses a huge financial burden on the household and impacts the entire family. Moreover, inaccessibility, unaffordability, and high out-of-pocket expenditure make this situation grimmer. Women find it difficult to get quality cancer care closer to their homes and end up traveling long distances for seeking treatment. Significant differences in the cancer epidemiology compared to the west make the adoption of western breast cancer management guidelines challenging for Indian women. In this article, we intend to provide a comprehensive review of the management of breast cancer from diagnosis to treatment for both early and advanced stages from the perspective of low-middle-income countries. Starting with a brief introduction to epidemiology and guidelines for diagnostic modalities (imaging and pathology), treatment has been discussed for early breast cancer (EBC), locally advanced, and MBC. In-depth information on loco-regional and systemic therapy has been provided focusing on standard treatment protocols as well as scenarios where treatment can be de-escalated or escalated.

Denovo metastatic young breast cancer (dnmYBC), defined as age <40 years, is a challenging entity, with a significant burden and sparse data from low and middle-income countries. We analysed the prospectively collected data of dnmYBC women from 2015 to 2016. There were 188 dnmYBC with a median age of 35.5 years. Of these, hormone receptor positive (HR+) were 72 (38.3) %, triple-negatives (TNBC) were 45 (23.9) %, Human Epidermal Growth Factor Positive (HER2+) were 42 (22.4) % and triple positives were 29 (15.4) %. TNBC women predominantly had visceral 40 (88.9%) metastasis, HR+ had nodal 51 (70.8%) and skeletal 10 (13.8%), while HER2+ women had higher brain metastasis (BM) 16 (38.1%).At a median follow-up of 39.8 [Interquartile range (IQR): 24-55.5] months, the median event-free survival (EFS) was 9.3 (95% CI; 8.1-10.4) months for the entire cohort and 1-year, 2-year and 3-year predicted EFS were 47.8%, 13.4% and 3%, respectively. The median EFS was superior in HR+ women.[15.7 months, hormone receptor (HR)-0.53;95% CI-9.8-21.7; p-0.013] versus (11.4 months, 95 %CI-5.9-16.8) in TNBC versus (7.7 months, 95% CI-6.0-9.5) in HER-2 + women and without BM at baseline [9.3 versus 3.0 months (with BM), HR-5.65; CI-1.72-17.9; -0.001]. Median EFS was superior in the treatment-naïve (155, 82.4%) versus prior-treated (33, 17.5%) women, 35.5 (95% CI:12.24-58.72) versus 12.4 (95% CI:11.45-13.51) months; -0.000]. The HER2+ women who received targeted therapy in the first line had a significantly superior median EFS of 13.0 versus 7.7 months (HR -0.465:CI 0.22-0.57: -0.038). Denovo mYBC is associated with an aggressive course, poor prognosticators include HR negative disease, brain metastasis, inadvertent prior treatment and inadequate access to targeted therapies. Early diagnosis, prompt treatment and expanding accessibility are warranted to improve care.

Substantial number of breast cancer (BC) patients undergoing radiation therapy (RT) develop local recurrence over time. During RT therapy, cells can gradually acquire resistance implying adaptive radioresistance. Here we probe the mechanisms underlying this acquired resistance by first establishing radioresistant lines using ZR-75-1 and MCF-7 BC cells through repeated exposure to sub-lethal fractionated dose of 2Gy up to 15 fractions. Radioresistance was found to be associated with increased cancer stem cells (CSCs), and elevated EpCAM expression in the cell population. A retrospective analysis of TCGA dataset indicated positive correlation of high EpCAM expression with poor response to RT. Intriguingly, elevated EpCAM expression in the radioresistant CSCs raise the bigger question of how this biomarker expression contributes during radiation treatment in BC. Thereafter, we establish EpCAM overexpressing ZR-75-1 cells (ZR-75-1 EpCAM ), which conferred radioresistance, increased stemness through enhanced AKT activation and induced a hybrid epithelial/mesenchymal phenotype with enhanced contractility and invasiveness. In line with these observations, orthotopic implantation of ZR-75-1 EpCAM cells exhibited faster growth, lesser sensitivity to radiation therapy and increased lung metastasis than baseline ZR-75-1 cells in mice. In summary, this study shows that similar to radioresistant BC cells, EpCAM overexpressing cells show high degree of plasticity and heterogeneity which ultimately induces radioresistant and metastatic behavior of cancer cells, thus aggravating the disease condition.

Despite advances in treatment, there is rising mortality in elderly patients with breast cancer. We aimed to conduct an audit of non-metastatic elderly breast cancer patients to understand the predictors of outcome. Data collection was done from electronic medical records. All time-to-event outcomes were analysed using Kaplan-Meier method and compared using log-rank test. Univariate and multi-variate analysis of known prognostic factors was also done. Any p-value ≤0.05 was considered statistically significant. A total of 385 elderly (>70 years) breast cancer patients (range 70-95 years) were treated at our hospital from January 2013 to December 2016. The hormone receptor was positive in 284 (73.8%) patients; 69 (17.9%) patients had over-expression of HER2-neu, while 70 (18.2%) patients had triple-negative breast cancer. A large majority of women (N = 328, 85.9%) underwent mastectomy while only 54 (14.1%) had breast conservation surgery. Out of 134 patients who received chemotherapy, 111 patients received adjuvant, while the remaining 23 patients received neoadjuvant chemotherapy. Only 15 (21.7%) patients of the 69 HER2-neu receptor-positive patients received adjuvant trastuzumab. Adjuvant radiation was given to 194 (50.3%) women based on the type of surgery and disease stage. Adjuvant hormone therapy was planned using letrozole in 158 (55.6%) patients, while tamoxifen was prescribed in 126 (44.4%). At the median follow up of 71.7 months, the 5-year overall survival, relapse-free survival, locoregional relapse-free survival, distant disease-free survival, breast cancer-specific survival were 75.3%, 74.2%, 84.8%, 76.1% and 84.5%. Age, tumour size, presence of lymphovascular invasion (LVSI) and molecular subtype emerged as independent predictors of survival on multi-variate analysis. The audit highlights the underutilisation of breast-conserving therapy and systemic therapy in the elderly. Increasing age and tumour size, presence of LVSI and molecular subtype were found to be strong predictors of outcome. The findings from this study will help to improve the current gaps in the management of breast cancer among the elderly.