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EDITORIAL COMMENTARY
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 111-112

Editorial on the topic: Gynecological cancers: A summary of published Indian data


1 Department of Gynaecological Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
2 Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India

Date of Web Publication3-Aug-2016

Correspondence Address:
T S Shylasree
Department of Gynaecological Oncology, Tata Memorial Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-330X.187574

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How to cite this article:
Shylasree T S, Bajpai J. Editorial on the topic: Gynecological cancers: A summary of published Indian data. South Asian J Cancer 2016;5:111-2

How to cite this URL:
Shylasree T S, Bajpai J. Editorial on the topic: Gynecological cancers: A summary of published Indian data. South Asian J Cancer [serial online] 2016 [cited 2019 Aug 23];5:111-2. Available from: http://journal.sajc.org/text.asp?2016/5/3/111/187574

It is pleasing to note that there is an increase in number of publications on topics related to Gynecological Oncology in the last decade. This probably reflects a trend toward Gynecology Oncology being given a separate subspecialty status in recent years. Introspection with regard to academic medicine and thus, medical publishing is gaining momentum in India across all specialties. The authors have effectively summarized the published literature in India and deserve applause.

There is an increase in the number of publications in areas of basic sciences in the past 2 years and incidentally, all are on ovarian cancer. The interest could be due to the dismal prognosis ovarian cancer has despite advances in chemotherapeutics. Technologically equipped laboratory facilities and improved recruitment of scientists within the medical environment have renewed interest in basic and translational medical research and better communication between academic clinicians and scientists in India.

Studies related to disease demographics are few. It is not surprising as there is lack of standardized cancer referral pathway and very few population-based cancer registries making it difficult to comment on disease numbers and distribution accurately. There is a positive trend toward hospital-based disease-specific registries and electronic medical records which might improve data collection in future. Cancer should be made notifiable or reportable disease across private and public sector to get realistic estimates of cancer prevalence and incidence.

Studies quoted in the article on diagnostic pathology even though retrospective in nature are contributory both in numbers and differential diagnosis. This probably is due to the culture of preserving slides and blocks for many years in most pathology departments across the country and is commendable.

Papers on radiodiagnostics are few. It is understandable as the majority of gynecological cancers were being treated using clinical or surgical staging. Increase in availability of advanced radiological imaging techniques along with the need for accuracy in the preoperative clinical staging to tailor treatment and the pressure to detect asymptomatic recurrences will probably shoot up the number of publications in this area.

Large retrospective studies published on cancer cervix from various cancer centers show that numbers are adequate to plan prospective collaborative trials from major institutions within the country. The incidence of advanced cervical cancer treated with primary chemoradiotherapy is unusually high in India, and most women are treated in institutions due to the availability of radiotherapy machines. Hence, there is a great potential to lead the world with regard to managing bulky and advanced cervical cancer by pooling data from various institutions.

The rate of detection of asymptomatic vault recurrence by performing periodic vault smear is low throughout the world. The study quoted in the article confirms this. The added usefulness of vault smear posthysterectomy is still debatable as most women with recurrence were symptomatic in the study. As most recurrences are seen within 2-3 years following surgery performing vault smears during this period could be an alternative cost-effective strategy compared to the current follow-up method.

A study on advanced cervical cancer treated with chemoradiotherapy has quoted cervical cancer recurrence is higher in women with persistent human papillomavirus (HPV) infection. "Test of cure" is a method which involves testing persistent high-risk HPV infection in posttreatment cervical intraepithelial lesion follow-up and has been incorporated into the national screening program in many parts of the world. This has reduced the duration and frequency of follow-up smears. As vault smears taken postirradiation are difficult to interpret, and clinical examination is unsatisfactory due to postradiation changes, an alternative strategy such as HPV testing could be utilized in this setting. This will have an impact on duration and frequency of follow-up and might negate the cost of the test itself. Further trials are needed in this area.

Advanced ovarian cancer is one of the most dreaded diseases in Gynecology Oncology. Publications on outcomes in advanced ovarian cancers are largely retrospective audits from large volume centers and a few feasibility studies.

Audits on clinical outcomes in ovarian cancers show similar results to published literature but might have all the drawbacks of retrospective design. What needs to be looked at are the frequent delays in completing the prescribed chemotherapy cycles given the economic constraints of funding one's own treatment. Other area which needs emphasis is whether treatment-related adverse effects and clinical outcome are similar to that compared to world literature when multiple chemotherapy treatment cycles are given to patients where population prevalence of chronic malnutrition is high even without added cancer cachexia. The above variables which are not accounted for in standard published trials could alter the clinical outcome in our population. The results from the large intraperitoneal (IP) chemotherapy audit quoted in the article showed much better results with regard to completion of treatment and treatment-related adverse effects compared to published randomized controlled trials (RCT's). It remains to be seen whether this can be reproduced in other cancer centers. With dose-dense chemotherapy showing better results with relatively fewer complications, this method might be favored over IP chemotherapy by patients and clinicians.

There are few retrospective studies on surgery and adjuvant radiation in early endometrial cancer from India. The jury is still out on the need and extent of lymphadenectomy with or without adjuvant radiation to improve patient survival outcomes and will be debated endlessly in national and international meetings. Minimal access surgery (laparoscopic and robotic) in endometrial and cervical cancer is here to stay and there are hardly any articles on laparoscopic approach and only one on robotics. Both techniques are catching up in many centers and hopefully will contribute to the existing data in near future.

Given the rarity and age of onset of vulval cancer, it's difficult to draw conclusions on disease demographics. In the published study on data spanning over 24 years, more than 50% of patients had advanced vulval cancer. In the last decade, the trend of utilizing chemoradiation in a neoadjuvant setting instead of primary radiation alone or primary exenteration has become the standard of practice in advanced vulvar cancer based on Phase II studies. It is unlikely we will have evidence from RCTs given the rarity of the disease.

The retrospective studies published on gestational trophoblastic neoplasia (GTN) have less than 100 patients in the analysis and might not be representative of GTN in the population as the incidence of hydatidiform mole is higher in the Asian population. This could largely be due to GTN being treated in obstetrics and gynecology units all over the country and lack of standard management protocols and referral criteria both in public and private hospitals.

The cervical screening program has become a bugbear for medical professionals, policy makers, politicians, and media in India. We are at crossroads of simply following the successful national screening program from developed countries versus finding practical solutions to fit the vast population in the reproductive age group here. There are excellent population-based prevalence studies from India, which have tested innovative yet effective screening methods keeping cost and clinical effectiveness in mind. The availability of HPV vaccine is complicating the scene as to which screening and preventive strategy need to be pursued. Let's hope that the dust will settle in the near future and we will all collectively agree as a nation on this topic in which the disease mortality and maternal mortality collectively contribute to large numbers of preventable deaths in young women and that is "not acceptable."




 

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