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|Year : 2020 | Volume
| Issue : 1 | Page : 115-117
News from the world of oncology
|Date of Submission||01-Jan-2020|
|Date of Decision||01-Jan-2020|
|Date of Acceptance||02-Jan-2020|
|Date of Web Publication||26-Feb-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. News from the world of oncology. Indian J Cancer 2020;57:115-7
| » Geography Rather Than Need Determines Access to Palliative Care|| |
A report card titled “America's Care of Serious Illness: 2019” by R. Sean Morrison, MD, and Diane E. Meier, MD, a collaborative effort of Centre to Advance Palliative Care (CAPC) and the National Palliative Care Research Centre (NPCRC) has pointed out that access to and the degree of expertise of hospital-based palliative care in the United States of America (USA) is more related to geography than need. It reported that 90% of hospitals with palliative care were in urban areas and only 17% of rural hospitals with 50 or more beds had palliative care programs in place. A major chunk of an estimated total of 12 million adults and more than 400,000 children living with chronic illnesses across the nation are deprived of palliative care services, though the country is allegedly the highest spender on health with 91% of its population having health insurance.
The report found that urban, not-for-profit hospitals were more likely to provide palliative services than for-profit hospitals. The likelihood of hospitals having a palliative care team increases with hospital size. For a fact, 94% of US hospitals with more than 300 beds have a palliative care team, compared to 62% of hospitals with 50–299 beds. Besides this, hospitals with lesser than 50 beds constitute more than two-thirds of the total hospitals in USA but they account for only 1.2 million patient admissions (4% of all admissions).
Dr Jagannath Dev Sharma, Head of department of Pathology and Principal investigator Cancer Registry, Indian Council of Medical Research (Kamrup district) and Hospital Based Cancer Registry (HBCR) when enquired about the access to palliative care in India states that “Like with infrastructure and other specialized services, the availability of palliative services is scarce in semi-urban, rural and even tier two cities. Unless you are living in one of the 8 tier one cities in India, your awareness and access to palliative care will be limited.” He further adds that, “In the light of the heavy cancer burden in north-east India, there is a huge potential for establishing palliative care services and implementing it both for cancer and other non-communicable diseases”
Palliative care especially early supportive care provides significant cost savings to a hospital and individuals in the long run, in terms of lesser ward, intensive care unit admissions and interventions but the logistics for sustaining a specialized trained team providing outpatient, inpatient, emergency, home care and hospice services, in the long run doesn't fit in the cost saving model. There isn't enough net revenue generation hence it doesn't make to the top the priority-list of the for-profit-hospitals. Sustainable models of palliative care despite location and geography, should be proposed. The ground level incorporation of advances in specialized palliative care access and training a palliative care workforce, changes in reimbursement policy, evidence-based quality initiatives and enhanced clinical training could more feasibly be undertaken and executed for the same.
| » Artificial Intelligence in the World of Oncology|| |
Artificial intelligence (AI) has been a useful tool in many health-related fields. It has made inroads from the traditional statistical and spatial mathematical modelling for prediction of natural phenomena to sophisticated predictive models in medical sciences. The physical techniques in AI include medical devices used in complex medical and surgical situations. In health care, AI could facilitate the process of timely diagnosis and real-time analysis of disease. The editorial titled “What to expect from AI in oncology?” published in Nat Rev Clin Oncol. 2019;16 (11):655 has reviewed the new aspects of AI in oncology.
Machine learning and deep learning, e.g. convolutional neural networks, are being used increasingly in the field of precision oncology to determine variations in gene expressions, mutations, aberrations by profiling of cancer genomes, biomedical, and molecular networks. In diagnosis of cancerous lesions in pathology and radiology, trained AI system can distinguish features of malignancy from benign through imaging techniques. Encouraging results have been obtained by using AI in real-time analysis of potentially malignant tissues. AI's diagnostic ability can be utilized to optimize the workload of pathologists and radiologists and reduce waiting time for diagnosis among patients. By training cost-intensive AI systems, we can determine the aberrations, forecast outcomes, and associations in cancer diagnosis. Multiomics data integration has helped in maximizing the effect of radiotherapy in clinical trials.
AI tools face challenges like standardization of AI tools given the multitude of Machine Learning (ML) options developed by different institutions. Clinicians are yet to affirm that AI is dependable to produce similar results in similar clinical situations. The investment required for setting up AI tools though initially high, in the long run would prove cost-effective. AI tools need careful financial planning, sufficient, trained staff in AI, which may not be possible in the near future. AI tools show promising results in terms of more time for clinicians for patient care, which otherwise would have been spent in diagnosis. Improved patient care is feasible, provided that the time allocated on patient visits and the number of trained staff scarcity doesn't rise.
However, it is important to remember that though AI has shown some results, at present have merely scratched the surface of the utility of these tools in oncology. Harvesting potential benefits of AI tools in medicine would require a multidisciplinary approach involving regulatory bodies, patients, families of patients and clinicians.
Dr. Alexandru Floares, President of Solutions of Artificial Intelligence Applications (SAIA) and chief executive officer of Artificial Intelligence Expert and OncoPredict, Romania opines that “Statistical Methods are still dominant even though there is a paradigm shift in the use of artificial intelligence in oncology. It is not a smooth evolution from traditional statistical methods to artificial intelligence.”
Dr. Ankeeta Menona Jacob, Mangalore
ORCID ID 0000-0002-9839-3556
| » Self-Testing for Cervical Cancer Screening|| |
Cervical cancer is more prevalent in developing countries than West, on account of lack of wide application of Human Papilloma virus (HPV) vaccination and screening programmes. The screening came into practice with development of Papanicolaou test in 1942. Currently, the conventional Pap smear More Details and the liquid-based, thin layer preparation are used for screening. HPV testing is also used either in isolation or combined with Pap smear. Four HPV testing methods are FDA approved, out of which “Cobas HPV test” is approved for primary HPV testing without a Pap smear. These screening methods are very efficient in early detection. Of course, the suspicious or positive results are followed by colposcopy for confirmation and treatment. There are certain barriers to universal application of these tests, like fear, shame, distance from a medical facility, time limitations, cultural or religious considerations, lack of access and need of follow up. This makes it less penetrant, especially in India, resulting in cervical cancer still being a major killer in women. This brings in the need of more convenient testing alternatives.
Self-sampling for HPV is an emerging modality. Given an option, a woman may prefer taking her own sample, rather than going to a provider for cervical secretions sampling. A review published in May 2019 in BMJ Global by Yeh PT, et al. titled “Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Glob Health. 2019;4 (3):e001351, included 33 studies with 369,000 participants. It was found that women who took their own samples were twice as likely to accept HPV screening as by the service providers. This association of likelihood further increased in cases where HPV self-sampling kits were mailed directly to women's homes or offered door-to-door by a health worker, compared to when they were offered on-demand. In another recent randomized clinical trial titled “Effect of Mailed Human Papillomavirus Test Kits vs Usual Care Reminders on Cervical Cancer Screening Uptake, Precancer Detection, and Treatment: A Randomized Clinical Trial” published in November 2019 in JAMA Network Open; women aged 30 to 64 years, with no Pap test within 3 years and 5 months, and no history of hysterectomy, the comparator arm received usual care (annual reminders and ad hoc outreach from primary care centres) and the intervention arm received usual care plus a mailed HPV self-sampling kit. There were 9960 women in the intervention arm and 9891 in the control arm. In the intervention arm, 12 women with cervical intraepithelial neoplasia 2+ were detected compared to 8 in the control arm. This study concluded that mailing HPV kits to under-screened women increased screening uptake 1.5 times compared with usual care alone.
According to the views of Dr Renu Raina Sehgal, Senior Gynaecology Consultant, Artemis Hospital, Gurugram, India, “Incidence rate for carcinoma cervix in Indian women is 22 per 100,000 women per year, which is the highest in South Asia. Facilities are not available uniformly in the country and there are areas with a shortage of gynecologists, pathologists, laboratories and colposcopists, thus limiting the establishment of an effective screening program. Visual inspection with acetic acid (VIA) and cryotherapy performed in the same visit (screen and treat approach) has been found to be effective, feasible and cost effective for resource constrained settings. But Federation of Obstetrics and Gynaecological Societies of India still recommends the use of HPV testing as the best method for cervical cancer screening. In this scenario, self-sampling may prove to be a very good option in Indian settings which can be implemented through primary health centers and ASHA workers with minimal education and training”.
HS Darling, Gurugram
| » Psychological Interventions Have Long-Term Effects in Reducing Fear of Cancer Recurrence|| |
Despite complete cure, fear of cancer recurrence (FCR) remains a major concern for most cancer patients. In a paper published recently by Nina M Tauber et al. titled “Effect of Psychological Intervention on Fear of Cancer Recurrence: A Systematic Review and Meta-Analysis” in J Clin Oncol 37:2899-2915, the effect of psychological intervention on the fear of cancer recurrence in patients suffering from cancer has been studied in details in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
FCR is defined as “fear, worry, or concern about cancer returning or progressing”. Patients who have had their cancer cured may fear of recurrence while those with active disease may have fear that their stable disease may progress. Low levels of FCR may be beneficial to patients as it keeps them alert to any signs/symptoms of recurrence but when this fear becomes excessive (22%–87% patients have moderate to high grade FCR), it can be devastating for the patients leading to depression, poor quality of life and overuse of healthcare services.
Meta-analysis of twenty-three controlled trials involving adults greater than 18 years of age who underwent any psychological intervention consisting of >50% psychological methods like cognitive-behavioral, psycho-educative, imagery, and meditation was done. Physical interventions like yoga and exercise were included if they formed less than 50% of the interventions, remaining being psychological interventions. Both traditional and contemporary cognitive behavioral therapies (CBTs) were used, the latter being more efficacious. Half of the patients underwent therapies as a group and other half as individuals but in both cases the therapy was delivered face to face.
The number of sessions varied from 1 to 15 (an average of 6.6 sessions per individual). The studies included survivors of ovarian, prostate, breast and mixed cancers with three studies having patients with active cancer. There was no co-relation between the number of sessions and the effect on FCR over long-term. Young patients with newly diagnosed cancer are more prone to FCR but the effects of interventions on FCR were not affected by these factors.
The studies showed that there was a statistically significant effect on FCR after psychological interventions which was maintained on an average of 7 months after the interventions were delivered. Managing FCR is an unmet need in cancer survivors. FCR stabilizes over time and the fact that the effect of psychological interventions on FCR last over long-term make it worthwhile to utilize them in managing FCR to improve the quality of life in cancer survivors. The study suggested that future studies should be conducted to analyze the effectiveness of individual psychological intervention on FCR along with planning on how to tailor the dose of psychotherapy for each individual.
Neha Chauhan, Bangalore