Building Radiotherapy Capacity for Treatment of Cervical Cancer in India
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1 Building Radiotherapy Capacity for Treatment of Cervical Cancer in India Umesh Mahantshetty, Professor, Radiation Oncology & GYN DMG Member On behalf of Department of Radiation Oncology & Medical Physics Tata Memorial Hospital Mumbai, India
2 DISCLOSURES NONE!
3 FIVE MOST COMMON CANCERS IN INDIAN WOMEN ESTIMATED No. OF NEW CASES & DEATHS : YEAR 2012 * Breast Cervix uteri Colorectum , ,844 Ovary Lip, oral cavity Mortality Incidence * estimates based on GLOBOCAN 2012
4 AGE STANDARDISED (WORLD POPULATION) WOMEN CANCER INCIDENCE RATES PER 100,000 POPULATION IN FEMALES Year Breast Cervix Uteri Ovary Corpus Uteri SOURCE : BOMBAY CANCER REGISTRY, REPORTS
5 Radiation therapy facilities in India: Update from Atomic energy Regulatory Board March INDIAN POPULATION : 1.2 billion LA COBALT BT Number of units Unit Year Co LA Brachy
6 International norm: 2 machines/million population India : 0.33/million MAJOR DISPARITY - Academic Vs Corporate - Urban Vs Rural - Health care Accessibility - Manpower & Expertise LMIC s: Kannan V et al; IJROBP 94 (4) 2016 Datta et al. Telemedicine and e-health 21 (7) July 2015
7 NATIONAL CANCER REGISTRY PROGRAM (NCRP) INDIAN COUNCIL FOR MEDICAL RESEARCH REPORTS POPULATION BASED REGISTERIES HOSPITAL BASED REGISTERIES
8 8
9 TATA MEMORIAL CENTRE, MUMBAI, INDIA TERTIARY CANCER CENTRE EXPERIENCE ADVANCED CENTRE FOR TREATMENT RESEARCH AND EDUCATION IN CANCER
10 TMC: Radiotherapy Paraphernalia TATA MEMORIAL HOPSITAL Accelerators 1. UNIQUE 2. TRUEBEAM 3. Clinac 6Ex (Varian), 120 MLC 4. Trilogy (Varian) 5. Novalis TX (Varian) 6. Tomotherapy Telecobalt 1. Theratron 780 (MDS) 2. Theratron 780C (MDS) 3. Elite 80 (MDS) 4. Equinox 80 (MDS) Simulators 1. Ximatron (Varian) 2. Somatom CT-Sim (Siemens) 3. Fly-through (GE) 4. C-Arm 5. USG Brachytherapy 1. MicroSelectron-HDR V30 2. MicroSelectron-HDR V18 ACTREC Accelerators 1. TRUEBEAM 2. Tomotherapy Telecobalt 1. Bhabhatron II Simulator 1. Oldelf (Nucletron) Brachytherapy IBU 1. MicroSelectron-HDR V30
11 No. of Cervix Cancer Cases TRENDS OF CERVICAL CANCER TATA MEMORIAL HOSPITAL : *
12 Tata Memorial Hospital Cancer Registry ( ) Significant Down Staging! Stage I Stage II Stage III Stage IV
13 CERVICAL CANCER RETROSEPCTIVE ANALYSES FIGO Stage IB-IIIB (N = 6234 pts) 1.0 Cum Survival : 55% at 8 yrs : 45% at 8 yrs : 35% at 8 yrs P = dfsmonths OVERALL OUTCOME WITH RADIATION IMPROVED OVER TIME DUE TO REFINEMENT IN RADIATION DOSES ESP. BRACHYTHERAPY J Cancer Res Ther Oct-Dec;9(4):672-9)
14 CERVICAL CANCER LESSONS LEARNT : GYNAE JOINT CLINIC : OUTCOME ANALYSIS IMPROVED COMPLIANCE AND FOLLOW UP UPGRADATION OF RADIATION FACILITIES ACTION PLAN EVIDENCE BASED CLINICAL GUIDELINES PROSPECTIVE TRIALS & INTERNATIONAL COLLABORATION
15 Tata Memorial Hospital Evidence Based Guidelines EBM MEETINGS : February SERVICE RESEARCH EDUCATION ADOTPED BY MAJORITY OF CENTERS IN INDIA
16 Prospective Clinical Trials / Studies in Cervical Cancers INVESTIGATOR INITIATED & INTERNATIONAL COLLABORATIVE FIGO Stage I-III : LDR Vs HDR Brachytherapy: 1996 : closed FIGO Stage Ib / IIb : Neo-adjuvant CT + Sx Vs CT + RT : 2003 FIGO Stage IIIb : Chemo-radiation Vs Radiation Alone : 2003 FIGO Stage IIb Locally Adv. Disease IAEA Studies : 3D Conformal Vs Intensity Modulated RT:2004 : Evaluation of PET / CT-PET : 2004 : closed : 2# Vs 4# ICA - HDR by CT Vs No CT:600 pts closed : HIV Positive Pts : CRT Vs RT : 53 /325 pts closed Curcumin Study (II/III) EMBRACE study Vault Cancers : Double blind placebo controlled Ph III study : MR Based Brachytherapy in Cervical Cancers : TOMO Based IMRT / IGRT INTERTECC (NCI funded): Pelvic IMRT with BM Sparing Chemo-radiation
17 BRACHYTHERAPY IN CERVICAL CANCERS In corporation of Newer Imaging Modalities 2D Planning : Orthogonal X-ray Based (STD) 3D Planning : TMH Experience - MRI: TMH-Initial Experience; Int. J. Gynae Cancer: US: TMH Experience; Radio. Oncol CT Scan: Interstitial Brachytherapy : Brachytherapy 2013 Routine GYN Practice: - Average 7 (3-9) Cx ICA/ daily Interstitial /wk cases X-ray; 2-3 CT; 1 MR Based Planning
18 ADVANCES IN GYN BRACHYTHERAPY PLANNING CONVENTIONAL PLANNING MRI BASED PLANNING CT- BASED MUPIT PLANNING
19 Retrospective and feasibility study : Dec May 2008 (N = 24)
20 Tata Memorial Hospital Participation in International Multicentric Studies - Refine treatment standards - International Recognition (GYN GEC-ESTRO Reasearch Network) TOTAL ACCRUAL : 1400 PATIENTS TMH CONTRIBUTION : 100 PATIENTS IN 3 YEARS A phase II Multicentric International Study by GEC - ESTRO Network
21 MR IMAGE BASED BRACHYTHERAPY EMBRACE STUDY : 1400 PATIENTS TMH ACCRUAL: 100 PATIENTS Stage IIB and IVA Stage IIIB Stage IVA Stage IIB Stage IIIB P=0.013 P=0.241 IIB IIIB IVA IIB IIIB IVA EXCELLANT LOCAL CONTROL RATES FOR ALL STAGES COST BENEFIT ANALYSES : ONGOING
22 TMH Study Image Based Brachytherapy in cervical Cancer CT and MRI correlation: Ongoing Research MR 4 CT Series1 Series MR CT Series1 Series
23 Image Based Brachytherapy in cervical Cancer TAUS and MRI correlation (TMH data) In collaboration with Peter Mac Melbourne Trans abdominal Ultrasonography : Cost effective imaging modality 32 Applications with MRI Compatible Applicator Anterior Reference Points : 96 % Posterior Reference Points : 72 % Magnitude of Variation (>15%) : < 8% Significant Correlation between the USG and MRI Reference Points Suggest : Use of USG for ICA Planning (21/2 D Planning) Mahantshetty et al. Rad. Onc. Aug. 2011
24 TATA MEMORIAL CENTRE IN COLLABORATION WITH BARC INDIGENOUS TECHNOLOGY COST EFFECTIVE SOLUTIONS Bhabhatron II INDIGENOUS COBALT MACHINE Siddhartha INDIGENOUS LINEAR ACCELERATOR HDR Brachytherapy Simulator-Imagin
25 Pramesh CS et al. Lancet Oncol INFRASTRUCTURE - To minimize the DISPARITY between Rural & Urban set-ups - Support Cost- effective Radiation Facilities in rural India COMMUNITY PROGRAMS - HEALTH INSURANCE SCHEMES : Rural & Urban - Enhance National Cancer Control Program Activitites
26 TRAINING AND EXCHANGE PROGRAMS IAEA, UICC, GCIG, ESTRO, ASTRO, AROI, IBS ETC. Bilateral Exchange programs WORKSHOPS & TRAINING PROGRAMS : ONGOING - AROI-ESTRO TEACHING COURSES - HANDS ON WORKSHOPS / ANNUAL PRACTICUM MULTI-DISCIPLINARY MEETINGS AT VARIOUS FORUMS - ASSOC. OF Rad. Oncol of India (AROI) : CME s / Conferences - ASSOC. of GYN ONCOl of India (AGOICON) - Women s Cancer Initiative Tata Memorial Centre India
27 specific problems of the country Pramesh CS et al. Indian J Med Paediatr Oncol 2014;35: NCG OF INDIA : 2012 (funded by Department of Atomic Energy, Govt of India) Mandate: Linking of cancer centers across India Presently consists of 62 cancer care centres across entire length and breadth of the country and has 4 components - Patient Care Uniform and evidence based cancer care across centers - Education and Training - exchange of expertise and mentoring between the centers, National cancer library - Collaborative Research Research network to conduct cooperative research catering Country specific needs. - Cancer Policy Development of National cancer plan to identify and tackle
28 TELE-RADIOTHERAPY NETWORK Datta et al. Telemedicine and e-health 21 &7) July 2015
29 Thank you
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