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
DISCLOSURES NONE!
FIVE MOST COMMON CANCERS IN INDIAN WOMEN ESTIMATED No. OF NEW CASES & DEATHS : YEAR 2012 * Breast Cervix uteri Colorectum 20789 27415 70218 67, 477 144937 122,844 Ovary 19549 26834 Lip, oral cavity 15631 23161 0 20000 40000 60000 80000 100000 120000 140000 160000 Mortality Incidence * estimates based on GLOBOCAN 2012
AGE STANDARDISED (WORLD POPULATION) WOMEN CANCER INCIDENCE RATES PER 100,000 POPULATION IN FEMALES 40 35 30 25 20 15 10 5 0 23.2 23.3 19.3 20.1 21.2 16.6 4.8 33.7 31.3 30.3 28.2 27.5 24.6 19.3 20.2 17.4 15.7 12.9 7.2 7.2 6.5 7.2 7.6 8.3 6.9 1.3 1.4 1.6 2.3 2.5 2.4 3.2 3.6 10.5 7.3 5.3 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year Breast Cervix Uteri Ovary Corpus Uteri SOURCE : BOMBAY CANCER REGISTRY, REPORTS 1970-2010
Radiation therapy facilities in India: Update from Atomic energy Regulatory Board March 2016 400 350 INDIAN POPULATION : 1.2 billion LA 300 250 COBALT BT Number of units 200 150 100 Unit Year 50 0 1980 1985 1990 1995 2000 2005 2010 2014 2016 Co 60 80 87 130 185 245 256 247 238 224 LA 2 6 13 23 34 68 157 308 347 Brachy 8 11 31 49 66 73 163 232 251
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
NATIONAL CANCER REGISTRY PROGRAM (NCRP) INDIAN COUNCIL FOR MEDICAL RESEARCH 2012-2014 REPORTS POPULATION BASED REGISTERIES HOSPITAL BASED REGISTERIES
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TATA MEMORIAL CENTRE, MUMBAI, INDIA TERTIARY CANCER CENTRE EXPERIENCE ADVANCED CENTRE FOR TREATMENT RESEARCH AND EDUCATION IN CANCER
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
No. of Cervix Cancer Cases 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 TRENDS OF CERVICAL CANCER TATA MEMORIAL HOSPITAL : 1941-2015* 16635 15083 13642 12801 9055 4679 2050 8780
Tata Memorial Hospital Cancer Registry (1985-2012) Significant Down Staging! 70.0 68.5 65.3 63.3 60.0 50.0 40.0 30.0 28.2 39.2 35.2 35.0 29.6 28.0 28.8 27.7 54.1 51.7 51.3 46.3 47.1 44.5 34.2 20.0 10.0 17.0 13.8 10.0 11.8 10.8 9.1 9.59.1 10.4 6.1 19.7 17.1 10.6 7.7 10.2 8.07.4 5.2 3.6 9.6 0.0 Stage I Stage II Stage III Stage IV 1985 1989 1993 1997 2000 2002 2004 2006 2008 2012
CERVICAL CANCER RETROSEPCTIVE ANALYSES FIGO Stage IB-IIIB (N = 6234 pts) 1.0 Cum Survival 0.8 0.6 0.4 1988-1994 : 55% at 8 yrs 1984-1987: 45% at 8 yrs 1979-1983 : 35% at 8 yrs 0.2 0.0 P = 0.000 0.00 12.00 24.00 36.00 48.00 60.00 72.00 dfsmonths 84.00 96.00 108.00 120.00 OVERALL OUTCOME WITH RADIATION IMPROVED OVER TIME DUE TO REFINEMENT IN RADIATION DOSES ESP. BRACHYTHERAPY J Cancer Res Ther. 2013 Oct-Dec;9(4):672-9)
CERVICAL CANCER LESSONS LEARNT : 1995-2000 GYNAE JOINT CLINIC : 1978-1979 OUTCOME ANALYSIS IMPROVED COMPLIANCE AND FOLLOW UP UPGRADATION OF RADIATION FACILITIES ACTION PLAN EVIDENCE BASED CLINICAL GUIDELINES PROSPECTIVE TRIALS & INTERNATIONAL COLLABORATION
Tata Memorial Hospital Evidence Based Guidelines EBM MEETINGS : February SERVICE RESEARCH EDUCATION ADOTPED BY MAJORITY OF CENTERS IN INDIA
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
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: 2011 - US: TMH Experience; Radio. Oncol 2012 - CT Scan: Interstitial Brachytherapy : Brachytherapy 2013 Routine GYN Practice: - Average 7 (3-9) Cx ICA/ daily + 1-2 Interstitial /wk cases - 3-4 X-ray; 2-3 CT; 1 MR Based Planning
ADVANCES IN GYN BRACHYTHERAPY PLANNING CONVENTIONAL PLANNING MRI BASED PLANNING CT- BASED MUPIT PLANNING
Retrospective and feasibility study : Dec 2006 - May 2008 (N = 24)
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
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 31 55 08 28 45 07 24 39 06 15 27 04 12 10 02 07 05 00 01 01 00 IIB IIIB IVA 31 55 08 29 51 08 26 43 07 16 28 04 12 10 02 07 05 00 01 01 00 EXCELLANT LOCAL CONTROL RATES FOR ALL STAGES COST BENEFIT ANALYSES : ONGOING
TMH Study 10 11 12 Image Based Brachytherapy in cervical Cancer CT and MRI correlation: Ongoing Research 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 MR 4 CT Series1 Series2 9 5 8 7 6 10 11 12 3 2.5 2 1.5 1 0.5 0 1 2 3 4 MR CT Series1 Series2 9 5 8 6 7
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
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
Pramesh CS et al. Lancet Oncol 2014. 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
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
specific problems of the country Pramesh CS et al. Indian J Med Paediatr Oncol 2014;35:226-7. 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
TELE-RADIOTHERAPY NETWORK Datta et al. Telemedicine and e-health 21 &7) July 2015
Thank you mahantshettyum@tmc.gov.in