Indian Journal of Cancer
Home  ICS  Feedback Subscribe Top cited articles Login 
Users Online :1392
Small font sizeDefault font sizeIncrease font size
Navigate here
  Search
 
  
Resource links
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
 »  Article in PDF (245 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free)  

 
  In this article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 » Acknowledgment
 »  References
 »  Article Tables

 Article Access Statistics
    Viewed2519    
    Printed92    
    Emailed1    
    PDF Downloaded397    
    Comments [Add]    
    Cited by others 3    

Recommend this journal

 

  Table of Contents  
MINI SYMPOSIUM: HEAD AND NECK
Year : 2012  |  Volume : 49  |  Issue : 1  |  Page : 15-20
 

Feasibility of organ-preservation strategies in head and neck cancer in developing countries


Department of Head and Neck Oncology, Mazumdar-Shaw Cancer Center, Narayana Hrudayalaya, Bangalore, India

Date of Web Publication25-Jul-2012

Correspondence Address:
N P Trivedi
Department of Head and Neck Oncology, Mazumdar-Shaw Cancer Center, Narayana Hrudayalaya, Bangalore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.98909

Rights and Permissions

 » Abstract 

Background: Chemoradiotherapy is an established strategy for organ preservation in head-neck cancer. These protocols are associated with added toxicity and need support infrastructure. Practice setup and availability of resources vary at the community level in developing countries. Aim: To evaluate the feasibility of organ-preservation strategies in different settings in developing countries. Settings and Design : Survey. Materials and Methods: In a questionnaire-based study, questions were directed to clinicians with varied practice setups to gather information regarding infrastructure, finance, and feasibility of organ-preservation protocols and their current practice trends. Statistical Analysis: Descriptive. Results: Responses from 100 clinicians with focused practice in head-neck oncology were analyzed. Sixty-one percent clinicians were practicing organ preservation for advanced head-neck cancers in their practice. However, 65% centers lacked sufficient infrastructure to support organ-preservation protocols. Forty percent patients were treated on cobalt-radiotherapy machine. Fifty-nine percent of clinicians suggested that less than third of their patients were fit to undergo chemoradiation and 67% believed that adherence to treatment protocol was observed in less than two-thirds of cases. Based on their experience 82% clinicians felt that only one-third patients requiring salvage would actually undergo treatment. The majority of the patients (68%) used personal funds for treatment and less than one-third of the patients could afford complete treatment. Conclusions: The infrastructure needed to support organ-preservation protocols varies significantly between centers in developing countries. It may not be feasible to perform organ-preservation strategies in certain centers and feasibility guidelines should be made for their judicious use in developing countries.


Keywords: Chemoradiotherapy, developing country, India, head and neck cancer, larynx and pharynx cancer, organ preservation


How to cite this article:
Trivedi N P, Kekatpure V D, Trivedi N N, Kuriakose M A, Shetkar G, Manjula B V. Feasibility of organ-preservation strategies in head and neck cancer in developing countries. Indian J Cancer 2012;49:15-20

How to cite this URL:
Trivedi N P, Kekatpure V D, Trivedi N N, Kuriakose M A, Shetkar G, Manjula B V. Feasibility of organ-preservation strategies in head and neck cancer in developing countries. Indian J Cancer [serial online] 2012 [cited 2019 Nov 18];49:15-20. Available from: http://www.indianjcancer.com/text.asp?2012/49/1/15/98909



 » Introduction Top


Head and neck cancer is more prevalent in developing countries and accounts for about one-third of all cancer cases. [1],[2] Delivery of a novel treatment modality in a resource-constrained environment is challenging. Many factors, like the availability of infrastructure, patient resources and logistical support have an impact on the feasibility of newer treatment in the community and affects disease outcome. [3],[4],[5]

Any innovation in the management of cancer with the promise of improved outcome would generate optimism and physician and patients alike would adopt the treatment strategy with hope. Management of head and neck cancer has changed significantly in past decade and has moved from an era of radical surgery to newer non-surgical organ preservation protocols, especially for laryngo-pharyngeal cancers. These protocols provide an opportunity to preserve vital organs, but have

toxicities. [6],[7],[8],[9] They also need considerable infrastructure, support services and patient resources to produce the same results as in clinical trials. [3],[10],[11],[12] Failure to adhere to the treatment protocol may result in an adverse outcome compared to conventional treatment modality. [13],[14] Many clinicians in developing countries follow clinical guidelines set in developed countries but may lack the necessary infrastructure resulting in compromised clinical care.

Organ preservation strategy is a preferred mode of treatment for cancer of the larynx and pharynx but in a large developing country where vast differences exist in treatment delivery across communities, it is important to evaluate the existing practice facility, understand its limitations and implement guidelines judiciously. It is important to bring these factors to the notice of practicing physicians to form the basis for sound clinical practice.


 » Materials and Methods Top


This is a survey-based study. We developed a questionnaire to bring out information regarding current practice in head-neck cancer, feasibility of organ preservation and factors influencing the treatment decision amongst head and neck oncologists practicing in developing countries.

Questionnaires were circulated to clinicians with focus on the treatment of head and neck cancer. Clinicians were reassured of the confidentiality of their data to obtain honest answers. We circulated this questionnaire in ahe nnual meeting of the Foundation of Head Neck Oncology (FHNO) in Bangalore and through email to other clinicians across India. It was also sent to clinicians practicing in other developing countries (with the help of the Fellowship Department of the Union for International Cancer Control-UICC). We circulated it across the community to clinicians with different seniority, in different sub-specialties and amongst various practice settings to cover different regions, cultures and socioeconomic status. Responses from clinicians with focused head neck cancer practice were included in the final analysis.

The questionnaire was divided into four main domains (Supplement 1). The first and second domain focused on the basic information about the clinicians, their practice setting and the availability of resources. The third domain focused on issues relating to organ preservation protocols. The fourth domain focused on specific treatment options for various head and neck cancers. The clinicians were requested to provide a comment regarding their current practice and important factors influencing their decision-making in the comment section.

Data was collated in a spreadsheet and analyzed in a descriptive fashion. The questionnaire used in the study was self-designed and was based on knowledge of organ preservation and common issues relating to community practice. All the responses were evaluated for infrastructure support, feasibility of organ-preservation protocols and various treatment options. Differences in availability of resources and feasibility of various treatments were also evaluated amongst different practice setups (Private, Academic). Quantitative answers were classified into four groups (<10%, 10-30%, 30-60% and >60% patients). Number of clinicians (%) selecting each answer (i.e. <10% patients) for a question was calculated to draw inferences.


 » Results Top


One hundred and fifty questionnaires were distributed at the FHNO conference and 40 through e-mails to head and neck oncologists from India and other developing countries. About 100 clinicians from the FHNO conference in Bangalore and 20 clinicians across India (Email) responded to te questionnaire. Twelve feedbacks were received from other developing countries (Pakistan, Bangladesh, Nepal, Indonesia, Taiwan, Egypt, Iran, Mexico and Turkey). One hundred out of a total 132 clinicians had provided the complete information and had head and neck cancer as their main practice and were included in the final analysis.

[Table 1] shows data regarding the infrastructure and practice setup. It shows equal distribution of the questionnaire across the community and setup. About half (47%) of clinicians practiced only in the academic setup while about one-third (31%) were treating patients exclusively in private practice setup. Thirty-nine percent clinicians did not have multidisciplinary tumor board (MDT) at their institute and 62% of them had no access to any MDT outside their institute for referrals. MDT was not available to 55% clinicians in the private sector and 23% clinicians in the academic center. Only 45% clinicians had all the support services of rehabilitation and pain-palliation therapy available, while 14% clinicians had no support services. Support services were not available to 88% clinicians in the private setup and 38% clinicians in academic centers. About half of the patients (53%) paid out of pocket for their treatment. About 45% patients in academic institutes had government funding while about 80% patients were paying on their own in private practice setting.
Table 1: Data regarding infrastructure and practice settings

Click here to view


The majority of clinicians (83%) followed National Comprehensive Cancer Center (NCCN) guidelines. Seventy-one percent clinicians wished to have intensity-modulated radiation treatment (IMRT) for organ preservation treatment, the majority (83%) of patients were treated by non-IMRT techniques. About 40% patients were treated with non-3D-CRT (three-dimensional conventional radiotherapy) and non-IMRT techniques. The percentage of patients treated with IMRT was higher in academic institutes than in private setting (22% vs. 10%). The majority of the clinicians (76%) were using concurrent chemoradiotherapy (CTRT) for organ preservation protocol while 24% used neoadjuvant chemotherapy with concurrent CTRT.

[Table 2] shows data regarding the finance and feasibility of organ-preservation protocols. For ease of understanding results, responses were divided into <2/3 rd (<10%, 10-30%, 30-60% patients) and more than 2/3 rd (>60% patients) groups. The last two columns of [Table 2] highlight these findings. Almost everyone (93%) thought financial considerations played a major role in selecting treatment options. Half the clinicians (48%) believed that more than 2/3 rd patients needed multimodality therapy in their routine practice. The majority of the clinicians (86%) thought that less than 2/3 rd patients could afford whole primary treatment. Almost all (97%) clinicians thought that less than 2/3 rd patients could afford cost of salvage treatment. Half the clinicians (51%) committed that they modified standard treatment in about 1/3 rd cases due to financial reasons. Many clinicians (91%) believed that less than 2/3 rd patients were fit to undergo organ preservation treatment in their setup. About 67% clinicians thought adherence to treatment protocol was observed in less than 2/3 rd cases in actual practice. More clinicians in academic centers (44%) compared to private practice (16%) suggested adherence to protocol in more than 2/3 rd cases at their institutes.
Table 2: Data regarding organ-preservation protocol

Click here to view


Seventy-seven percent clinicians believed positron emission tomography (PET) scan was essential for evaluating the response/recurrence in organ-preservation protocols. Only half the clinicians (51%) had access to PET scan and the majority of the clinicians (93%) agreed that less than 2/3 rd patients could afford it. Half the clinicians (50%) thought that less than 10% patients with recurrent/residual disease actually undergo salvage procedure. The common cause for not undergoing salvage was inoperable disease, poor performance status and financial reason in 48, 23 and 29% instances respectively. Many (34%) also suggested lack of motivation and depression after recurrence as another important factor.

[Table 3] describes treatment options selected by clinicians. Less than half (40%) the clinicians preferred surgery and radiotherapy as the method to treat moderately advanced laryngeal cancer. More clinicians practicing in academic centers (60%) preferred organ preservation for this group compared to private practitioners (30%). About half (50%) the clinicians chose surgery for advanced oropharyngeal cancers in private practice while 83% clinicians in academic institutes preferred organ preservation with CTRT. About 2/3 rd clinicians preferred surgery and radiotherapy over organ preservation for advanced hypopharyngeal cancers.
Table 3: Data regarding treatment selection for various head neck subsites

Click here to view


The response from clinicians from `other developing countries was similar to Indian clinicians. Six out of ten clinicians were radiation oncologists and the majority practiced in academic institutes (8/10). Four centers did not have any support services. The majority of the patients (77%) were treated by non-3D radiation techniques. Eight agreed that finance played a major role in selecting treatment options. Seven clinicians suggested that less than 30% were fit for organ-preservation protocol and less than 10% ultimately underwent salvage procedure. Half of them (5) preferred to use organ-preservation protocols to treat advanced cancers.

Respondents also suggested other reasons in addition to financial restrictions for poor compliance. According to them poor follow-up (72%); poor functional status of patient (60%), inadequate infrastructure (50%) and support service (30%) and non-availability of MDT (30%) were main reasons for the inability to strictly follow the treatment guidelines. Many (73%) preferred to combine guidelines with their clinical experience in selecting the appropriate treatment.


 » Discussion Top


A number of factors apart from disease have an impact on feasibility of new treatment in community and actual outcome in the community may be different from the trial outcome. [3],[4],[5] Patients are managed in various centers in developing countries as it is not feasible to centralize the treatment of cancer due to large volume, logistics and associated cost. Treatment guidelines set in developed countries may not be advisable in certain situations and one needs to have one's own treatment guidelines based on the availability of resources.

Many patients with head and neck cancer present at an advanced stage. [1] A combination of radiotherapy and chemotherapy provides an opportunity to preserve organ and function for these cases compared to conventional treatment (surgery followed by radiotherapy). [6],[7][,8] However, there can be discordance between clinical trial data and population-based outcome and survival can be affected in different circumstances. [3],[4],[5],[15],[16],[17],[18],[19],[20] Toxicities and cost of treatment have increased with current organ-preservation protocols. [21] Lack of completion of treatment is known to have a deleterious effect on survival. [13],[14] All these data are from the developed world and there is no study published from developing nations demonstrating the feasibility of organ-preservation protocols. [3] This is an initial effort to evaluate the current status in developing countries to generate more objective studies.

Treatment facilities and delivery vary significantly between various centers and socioeconomic classes in a large developing country like India. A few large cancer centers are equipped with state-of-the-art facilities and are capable of delivering most of the treatment modalities while only a select group of patients can afford them. A few centers and isolated private clinics have very basic resources and still continue to manage patients with head and neck cancer. This pattern is unlikely to change in the near future. Evidence-based guidelines are based on studies conducted in an ideal practice set-up and rarely take community factors into consideration. Most of the recent published literature, current conferences and seminars focus on organ-preservation strategies but hardly any stress is given to develop feasibility guidelines for these important regimes.

Appropriate infrastructure, availability of MDT and support of allied health services are essential for any successful organ preservation protocol. Radiation treatment with IMRT is better than 3D-CRT in reducing treatment-related complications and in improving the overall quality of life (QOL). [22] It may not be possible to treat patients with chemoradiotherapy on cobalt machine due to severe toxicities. Our study suggests that the majority of patients were treated by non-IMRT techniques (83%) and 40% of all patients were still treated with cobalt radiation. MDT brings all specialty clinicians together which is integral to organ-preservation strategy as periodic response evaluation and timely intervention is a must for the overall success of treatment. Organ-preservation treatment is quite intense and toxic and needs active rehabilitation throughout the treatment and on follow-up. [23],[24],[25] Only 1/3 rd centers (35%) had MDT and necessary support services available to implement the complete organ preservation protocol. Academic or regional cancer centers had better infrastructure compared to private clinics and institutions. This also reflected in their practice in opting for organ preservation treatment more frequently compared to private clinics.

Organ preservation treatment involves significant costs. Cost of nutrition and other support, cost of repeated investigations, and regular follow-up would entail a large burden in addition to primary treatment. Patients travel a long distance for treatment and follow up in our country. Patients and family need to spend significant time for repeated visits which substantially increases the cost of treatment. Treatment of complications and salvage surgery is always a real possibility which adds to the cost. In a scenario where around half (51%) the patients pay by themselves, finance would play a significant role. Actually very few patients would complete the whole treatment-follow up according to this study.

Many patients with advanced head-neck cancer have compromised nutrition and functional status. According to treating physicians, very few patients were fit and treatment dose and schedules were compromised in many cases to reduce treatment-related morbidity. Necessary investigation modalities to assess response were not available in the majority of cases and hardly any patient underwent salvage procedure due to various reasons [Table 1] and [Table 2]. Response evaluation, salvage treatment and adherence to treatment protocol are essential components and outcome would be dismal in their absence.

Our study showed that only 1/3 rd (35%) centers had ideal structure to support organ preservation, few patients could actually afford the complete treatment, adherence to treatment protocol was poor, follow-up rates were dismal and salvage surgery rates negligible. Even with this background, more than half (61%) the clinicians suggested that they might treat advanced larynx-pharynx patients with chemoradiotherapy based on guidelines formulated in developed countries. Apart from financial constraints, administrating intense treatment without proper infrastructure, MDT and support services are major issues of concern. These treatment regimes need support from the whole team rather than an individual for optimal outcome. This is significantly lacking in our country according to our survey (about 76% clinicians delivered chemoradiotherapy without ideal set-up). Organ preservation strategy has potential to improve outcome but uniform treatment policy may not be appropriate with wide variation in the practice environment in developing countries. As lack of compliance can significantly influence survival, it becomes necessary to have strong data about organ-preservation protocols from developing countries demonstrating their feasibility, efficacy and safety before implementing them in widespread clinical practice.

There are many limitations of this study. It is a survey and there is potential for bias of responders. The designed questionnaire was based only on our knowledge of organ preservation and community practice, was not validated and could be inadequate. There were only ten responses from adjacent countries and they might not reflect the actual scenario in other developing nations. Feasibility of conventional surgery was not evaluated simultaneously as the main focus of this article is not to compare between two modalities. Organ preservation for larynx and pharynx cancer is a preferred method of treatment but better selection criteria should be formed to improve outcome. This is an initial effort to evaluate the feasibility of organ preservation in developing countries despite these limitations. Care was taken to circulate the questionnaire across the country in order to get as much factual information as possible. All different practice setups, different specialties and different seniority levels of clinicians were well represented in the survey. Survey represents realistic assessment of infrastructure and support services. A select group of responders with major head-neck practice would probably represent the actual scenario in the rest of the community.

Future treatment of larynx and pharynx cancer would be with organ-preservation strategies and it is important to focus on the feasibility of these treatments in the community. Though about 83% clinicians referred to NCCN guidelines, they had to modify them in > 2/3 rd of cases. They probably did not feel confident in delivering the complete protocol in their practice environment. This further highlights that proper guidelines with requirements for each new strategy may be of great help to treating physicians in developing countries and can improve the outcome of a large number of patients.


 » Conclusion Top


Availability of infrastructure, support services and finance varies significantly in different clinical practice settings in developing countries. Organ-preservation protocol may not be feasible in all situations and should be used in the appropriate setup.


 » Acknowledgment Top


We acknowledge the support of FHNO (Foundation of Head and Neck Oncology) and UICC- fellowship department (Union for International Cancer Control) for helping us in conducting this survey.

 
 » References Top

1.Sankaranarayanan R, Masuyer E, Swaminathan R, Ferlay J, Whelan S. Head and neck cancer: A global perspective on epidemiology and prognosis. Anticancer Res 1998;18:4779-86.  Back to cited text no. 1
[PUBMED]    
2.International Agency for Research on Cancer (IARC): Cancer Incidence in Five Continents Vol. 9. IARC Scientific Publication No. 160. In: Curado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, et al, editors. 2008.  Back to cited text no. 2
    
3.Sanabria A, Domenge C, D'cruz A, Kowalski LP. Organ preservation protocols in developing countries. Curr Opin Otolaryngol Head Neck Surg 2010;18:83-8.  Back to cited text no. 3
[PUBMED]    
4.Rothwell PM. Factors that can affect the external validity of randomized controlled trials. PLoS Clin Trials 2006;1:e9.  Back to cited text no. 4
[PUBMED]    
5.Rothwell PM. External validity of randomised controlled trials: 'To whom do the results of this trial apply?'. Lancet 2005;365:82-93.  Back to cited text no. 5
[PUBMED]    
6.The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324:1685-90.  Back to cited text no. 6
[PUBMED]    
7.Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091-8.  Back to cited text no. 7
[PUBMED]    
8.Calais G, Alfonsi M, Bardet E, Sire C, Germain T, Bergerot P, et al. Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma. J Natl Cancer Inst 1999;91:2081-6.  Back to cited text no. 8
[PUBMED]    
9.McLaughlin BT, Gokhale AS, Shuai Y, Diacopoulos J, Carrau R, Heron DE, et al. Management of patients treated with chemoradiotherapy for head and neck cancer without prophylactic feeding tubes: The University of Pittsburgh experience. Laryngoscope 2010;120:71-5.  Back to cited text no. 9
[PUBMED]    
10.Wineland AM, Stack BC Jr. Modern methods to predict costs for the treatment and management of head and neck cancer patients: Examples of methods used in the current literature. Curr Opin Otolaryngol Head Neck Surg 2008;16:113-6.  Back to cited text no. 10
[PUBMED]    
11.Menzin J, Lines LM, Manning LN. The economics of squamous cell carcinoma of the head and neck. Curr Opin Otolaryngol Head Neck Surg 2007;15:68-73.  Back to cited text no. 11
[PUBMED]    
12.Lang K, Menzin J, Earle CC, Jacobson J, Hsu MA. The economic cost of squamous cell cancer of the head and neck: Findings from linked SEER-Medicare data. Arch Otolaryngol Head Neck Surg 2004;130:1269-75.  Back to cited text no. 12
[PUBMED]    
13.Cathcart CS, Dunican A, Halpern JN. Patterns of delivery of radiation therapy in an inner-city population of head and neck cancer patients: An analysis of compliance and end results. J Med 1997;28:275-84.  Back to cited text no. 13
[PUBMED]    
14.Patel UA, Patadia MO, Holloway N, Rosen F. Poor radiotherapy compliance predicts persistent regional disease in advanced head and neck cancer. Laryngoscope 2009;119:528-33.  Back to cited text no. 14
[PUBMED]    
15.Hoffman HT, Porter K, Karnell LH, Cooper JS, Weber RS, Langer CJ, et al. Laryngeal cancer in the United States: Changes in domographics, patterns of care, and survival. Laryngoscope 2006;116 (Suppl 111):1-13.  Back to cited text no. 15
    
16.Carvalho AL, Hashimoto IN, Califano JA, Kowalski LP. Trends in the incidence and prognosis for head and neck cancer in the United States: A site-specific analysis of the SEER database. Int J Cancer 2005;114:806-16.  Back to cited text no. 16
    
17.Chen AY, Halpern M. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg 2007;133:1270-6.  Back to cited text no. 17
[PUBMED]    
18.Olsen K. Reexamining the treatment of advanced laryngeal cancer. Head Neck 2010;32:1-7.  Back to cited text no. 18
    
19.Wolf GT. Reexamining the treatment of advanced laryngeal cancer: The VA laryngeal cancer study revisited. Head Neck 2010;32:7-14.  Back to cited text no. 19
[PUBMED]    
20.Forastiere AA. Larynx preservation and survival trends: Should there be concern? Head Neck 2010;32:14-7.  Back to cited text no. 20
[PUBMED]    
21.Lang K, Sussman M, Friedman M, Su J, Kan HJ, Mauro D, et al. Incidence and costs of treatment-related complications among patients with advanced squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 2009;135:582-8.  Back to cited text no. 21
[PUBMED]    
22.Vergeer MR, Doornaert PA, Rietveld DH, Leemans CR, Slotman BJ, Langendijk JA. Intensity-modulated radiotherapy reduces radiation-induced morbidity and improves health-related quality of life: Results of a nonrandomized prospective study using a standardized follow-up program. Int J Radiat Oncol Biol Phys 2009;74:1-8.  Back to cited text no. 22
[PUBMED]    
23.Rieger JM, Zalmanowitz JG, Wolfaardt JF. Functional outcomes after organ preservation treatment in head and neck cancer: A critical review of the literature. Int J Oral Maxillofac Surg 2006;35:581-7.  Back to cited text no. 23
[PUBMED]    
24.Akst LM, Chan J, Elson P, Saxton J, Strome M, Adelstein D. Functional outcomes following chemoradiotherapy for head and neck cancer. Otolaryngol Head Neck Surg 2004;131:950-7.  Back to cited text no. 24
[PUBMED]    
25.Agarwala SS, Cano E, Heron DE, Johnson J, Myers E, Sandulache V, et al. Long-term outcomes with concurrent carboplatin, paclitaxel and radiation therapy for locally advanced, inoperable head and neck cancer. Ann Oncol 2007;18:1224-9.  Back to cited text no. 25
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Head and neck cancers in India
Mitali Dandekar,Vidisha Tuljapurkar,Harsh Dhar,Aru Panwar,Anil K. DCruz
Journal of Surgical Oncology. 2017; 115(5): 555
[Pubmed] | [DOI]
2 Head and neck cancer treatment in a developing country: A survey-based study in Brazil
Aline Lauda Freitas Chaves,Andre Lopes Carvalho,Alvaro Sanabria,Nirav P. Trivedi,Robson Ferrigno,Luiz Paulo Kowalski
Journal of Cancer Policy. 2017; 13: 18
[Pubmed] | [DOI]
3 Organ preservation with chemoradiation in advanced laryngeal cancer: The problem of generalizing results from randomized controlled trials
Alvaro Sanabria,Aline L.F. Chaves,Luiz P. Kowalski,Gregory T. Wolf,Nabil F. Saba,Arlene A. Forastiere,Jonathan J. Beitler,Ken-ichi Nibu,Carol R. Bradford,Carlos Suárez,Juan P. Rodrigo,Primož Strojan,Alessandra Rinaldo,Remco de Bree,Missak Haigentz,Robert P. Takes,Alfio Ferlito
Auris Nasus Larynx. 2017; 44(1): 18
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
 

    

  Site Map | What's new | Copyright and Disclaimer
  Online since 1st April '07
  © 2007 - Indian Journal of Cancer | Published by Wolters Kluwer - Medknow