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Clinical outcomes and pattern of care in oral cancer treated with curative intent at two newly commissioned cancer centres in India: A real-world data analysis
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Received: ,
Accepted: ,
How to cite this article: Vadgaonkar RA, Thakur P, MacDuffie E, Goel P, Dravid C, Dora TK, et al. Clinical outcomes and pattern of care in oral cancer treated with curative intent at two newly commissioned cancer centres in India: A real-world data analysis. South Asian J Cancer. 2026;15:73-82. doi: 10.25259/SAJC_54_2025
Abstract
Objectives:
As India scales up cancer care delivery nationwide, the benchmarking of outcomes at newly established centers is critical to ensure the quality of care. The study was conducted to evaluate the demographic profiles, treatment, and clinical outcomes of oral cancer (OC) cases treated with curative intent during the first 5 years of operation of two newly established satellite centres in India.
Material and Methods:
This retrospective study included OC cases treated with curative intent between January 1, 2015, and December 31, 2020, at two cancer centers in India. To identify factors affecting disease-free survival (DFS) and overall survival (OS), univariate (Kaplan–Meier and log-rank) and multivariate (Cox regression) analyses were performed.
Results:
Data from 769 consecutive patients were analysed. Definitive treatments were curative surgery [n = 692 (90%)], radical radiotherapy [RT; n = 38 (5%)], and neoadjuvant chemotherapy [n = 39 (5.1%)] followed by surgery (n = 20) or RT (n = 19). Five-year DFS and OS rates for OC stages I, II, III, and IV were 79% and 80.2%, 67.2% and 67.2%, 42.2% and 44.6%, and 40.3% and 42.1%, respectively. On multivariate analysis, poor OS was associated with age >60 years, pathological stages III and IV, extra-nodal extension, lympho-vascular invasion, and grade III histology.
Conclusion:
This study underscores the importance of assessing the quality of cancer care in newly established centres. The findings provide a promising outlook as India continues to scale up distributed regional care and emphasize the need for targeted interventions and improved care protocols.
Keywords
Curative intent
Oral cancer
Outcomes
Radiotherapy
Surgery
INTRODUCTION
Oral cancer (OC) is the sixth most common cancer worldwide.[1,2] It accounts for a larger proportion of all cancers in many low- and middle-income countries (LMICs) than in high-income countries due to behavioural factors such as tobacco and alcohol use, as well as limited access to preventive and dental care.[3] In India, OC is among the top three most commonly diagnosed cancers, with more than 135,000 new cases reported in 2020.[2,4,5] These cases account for roughly one-quarter of the global OC burden, and this share is projected to increase to 26% by 2030.[6] Currently, standard curative-intent treatment for localised OC is typically delivered with a single modality (i.e., surgery or radiation alone), whereas locoregionally advanced OC requires multimodal treatment[7-9] , leading to 5-year overall survival (OS) rates of 70–80% and 50%, respectively.[9]
The Tata Memorial Centre (TMC) in Mumbai is the premier institute for the comprehensive management of cancer in India. Clinical outcomes of OC treatment at Tata Memorial Hospital (TMH), the main hospital of the TMC, have historically been on par with global standards.[10-12] To provide similar high-quality care throughout the country, with the uniform implementation and adoption of evidence-based guidelines,[13] the TMC established eight new cancer centres. Periodic audits of these institutes are of the utmost importance to assess the cancer burden and outcomes and guide future care.
Two of these recently commissioned centres, one located in a predominantly rural region of northwestern India and the other located in a semi-urban area of the country’s southern coastal region, have been operational since 2014 and 2015, respectively. These centres are geographically distant from TMH, Mumbai and have diverse catchment areas, allowing for the provision of high-quality cancer care outside of the typical reach of established urban centres. This study aimed to analyse the demographic profiles, treatment parameters, and clinical outcomes of OC cases treated with curative intent at these two centres in the first 5 years of their clinical service provision, and to benchmark quality metrics.
MATERIAL AND METHODS
Study design and participants
This retrospective study was approved by the centres’ institutional review boards [semi-urban centre, IEC/0621/12000014/001; rural centre, IEC/18/21]. All consecutive OC cases treated with curative intent at the rural centre between January 1, 2015, and December 31, 2019, and at the semi-urban centre between January 1, 2016, and December 31, 2020, were enrolled. Eligible patients had completed at least one definitive treatment [surgery or radiotherapy (RT)] at the enrolling centre. Patients who received definitive treatment at or were referred to another hospital, those with distant metastasis at presentation, and those who received treatment with palliative intent were excluded. Follow-up data were collected until December 31, 2021, for the rural centre and December 31, 2022, for the semi-urban centre. Sociodemographic, clinico-radiological, treatment, and clinical outcome data were extracted from available treatment summaries, electronic medical records, histopathological reports, and RT charts.
Treatment and follow-up
All treatment protocols were developed in accordance with the TMC’s Evidence Based Management (EBM) guidelines,[14] which are based on the available level of evidence and tailored for application in LMICs such as India. A key feature of these protocols is the multidisciplinary joint clinic (JC) discussion of all newly registered cases before the commencement of cancer-directed treatment. Definitive treatment for localised OC employs a single modality (radical surgery or, in selected cases, RT).[11,15] Adjuvant external-beam radiotherapy (EBRT) with or without concurrent chemotherapy (CCT) is then recommended, depending on the presence of adverse histopathological features and further risk stratification.[8,9] Neoadjuvant chemotherapy (NACT) is considered for medically fit patients with borderline resectable OC, and is followed by response assessment in the setting of JC discussion and definitive treatment.[12] Post-treatment follow-up every 2–3 months for the first 2 years, every 6 months for the following 3 years, and annually thereafter is recommended.
Follow-up data were collected for all patients fulfilling the inclusion criteria; those who did not complete follow-up were contacted by telephone to obtain updates on their disease status. Patients who did not respond by telephone or attend the clinic were considered lost to follow-up.
Study variables
Responses to definitive RT and NACT were characterized according to the RECIST v1.1 criteria.[16] The interval between surgery and the first day of adjuvant RT and the RT duration (first–last fraction delivery) were recorded. Treatment failure was defined as local (disease persistence or reappearance at or near the primary site), regional (disease in regional draining lymph-node basins), and/or distant (disease outside local and regional sites). The occurrence of second primary cancer was defined according to the international criteria for multiple primary cancers.[17]
The primary outcomes were OS and disease-free survival (DFS). OS was calculated from the date of cancer-directed treatment initiation to the date of last follow-up, last contact by telephone, or death of any cause. DFS was calculated from the date of cancer-directed treatment initiation to the date of documented local failure (LF), regional failure (RF), locoregional failure (LRF), distant failure (DF), second primary cancer, or death from any cause.
Statistical analysis
All statistical analyses were performed with SPSS (v29.0; IBM, Armonk, NY, USA). Descriptive statistics were calculated for the demographic, clinical, and treatment characteristics. Prognostic factors were identified by univariate analysis (UVA) with Kaplan–Meier curves and the log-rank test. Multivariate analysis (MVA) was performed with all factors found to be significant in the UVA using a Cox proportional-hazard model and forward stepwise selection. P<0.05 were considered to be significant.
RESULTS
Sociodemographic, clinical, and treatment characteristics
Overall cohort
In total, 769 patients [392 (51%) from the semi-urban and 377 (49%) from the rural centre] were enrolled [Figure 1]. The median age was 52 years, 20% of patients were aged ≤40 years, and 612 (79.6%)patients were men. The patients’ sociodemographic and clinical characteristics are summarised in Table 1. Most clinicodemographic characteristics were similar between centres; the rural patient population had less formal education and more agricultural employment than the semi-urban population [Supplementary Table S1]. The most common OC sites at presentation were the buccal mucosa, gingivobuccal sulcus, and retromolar trigone [together, n = 396 (51.5%)]. A majority [n = 449 (58.4%)] of patients presented with clinical stage IV disease according to the AJCC 7th edition.[18] A majority of patients [n = 712 (92.6%)] underwent curative surgery; 57 (7.4%) received definitive RT [Figure 1].
| Parameters | Category | n= 769 (%) |
|---|---|---|
| Age (in years) | ≤40 | 154 (20.0) |
| 41–50 | 202 (26.3) | |
| 51–60 | 202 (26.3) | |
| >60 | 211 (27.4) | |
| Sex | Men | 612 (79.6) |
| Women | 157 (20.4) | |
| Highest education | No formal education | 329 (42.8) |
| Primary school | 165 (21.5) | |
| Secondary school | 142 (18.5) | |
| High school and above | 133 (17.3) | |
| Occupation | Homemaker/domestic help | 132 (17.2) |
| Professional/agriculture | 198 (25.7) | |
| Business/labourer | 439 (57.1) | |
| Oral cancer site | Buccal mucosa/GBS/RMT | 396 (51.5) |
| Tongue | 303 (39.4) | |
| Palate/Paranasal sinus | 50 (6.5) | |
| Mouth floor | 13 (1.7) | |
| Lip | 7 (0.9) | |
| Histology | Squamous cell carcinoma | 761 (99.0) |
| Adenoid cystic carcinoma | 5 (0.7) | |
| Other | 3 (0.3) | |
| Histological grade | Well-differentiated | 68 (8.8) |
| Moderately differentiated | 562 (73.1) | |
| Poorly differentiated | 105 (13.7) | |
| Unknown | 34 (4.4) | |
| Clinical stage (AJCC 7th edition)18 | cT | - |
| cT1 | 91 (11.8) | |
| cT2 | 178 (23.1) | |
| cT3 | 164 (21.3) | |
| cT4 | 336 (43.7) | |
| cN | - | |
| cN0 | 357 (46.4) | |
| cN1 | 141 (18.3) | |
| cN2 | 173 (22.5) | |
| cN3 | 98 (12.7) | |
| Clinical stage | I | 64 (8.3) |
| II | 111 (14.4) | |
| III | 145 (18.9) | |
| IV | 449 (58.4) |
GBS: Gingivobuccal sulcus, RMT: Retromolar trigone, AJCC: American Joint Committee on Cancer, cT: Clinical tumour, cN: Clinical nodal stage.
NACT cohort
Thirty-nine patients received NACT. The most commonly used agents were docetaxel and cisplatin [together, n = 20 (51.3%)], and most [n = 26 (66.6%)] patients received two cycles. Clinical reassessment after NACT identified partial response (PR) in 24 (61.5%) patients [Supplementary Table S2]. After the JC discussion, 20 (51.3%) patients who had received NACT underwent curative-intent surgery, and 19 (48.7%) received definitive RT (n = 11) or CCT and RT (n = 8).
Curative surgery cohort
In total, 712 (92.6%) patients (including 20 who had received NACT) underwent primary tumour resection [Figure 1, Table 2]. Neck dissection was performed in 689 (96.8%) cases (unilateral, 58.1%; bilateral, 41.9%), with a median of 40 [interquartile range (IQR), 29-54] lymph nodes dissected. The most common pathological stage in this cohort was IV [n = 405 (56.9%)]. At least one adverse pathological finding [lympho-vascular invasion (LVI), perineural invasion (PNI), positive surgical margins, positive (level-IV or -V) cervical lymph nodes, and extra-nodal extension (ENE)] was identified in 526 (73.9%) cases [Supplementary Table S3]. After surgery, 531 (76.7%) patients received adjuvant RT [n = 313 (45.2%)] or CCT and RT [n = 218 (31.5%)]. The most common dose and fractionation combination was 60 Gy in 30 fractions [n = 442 (80.4%)] and was delivered most commonly using a conventional 2D RT technique [n = 253 (46%)]. Weekly cisplatin administration was the most common form of CCT [n = 189 (81.1%)], and 160 (68.7%)patients received more than five CCT cycles. The median interval between surgery and RT initiation was 37 (IQR, 29-47) days, and the median adjuvant RT duration was 44 (IQR, 42-49) days [Supplementary Table S4]. Following curative surgery, 50.1% of the patients (73.4% at the semi-urban and 26.3% at the rural centre) underwent primary reconstruction [Table 2 and Supplementary Table S3].
| Parameter | Category | Total |
|---|---|---|
| Primary surgery | Composite resection | 330 (46.3%) |
| Glossectomy | 272 (38.2%) | |
| Wide excision | 69 (9.7%) | |
| Maxillectomy | 36 (5.1%) | |
| Other | 5 (0.7%) | |
| Neck dissection | Yes | 689 (96.8%) |
| Unilateral | 400 (58.1%) | |
| Bilateral | 289 (41.9%) | |
| Reconstruction | Yes | 357 (50.1%) |
| PMMC flap | 269 (75.4%) | |
| Free flap | 88 (24.6%) | |
| Post-NACT pathological stage (n= 20) | ypT | |
| ypT0 | 1 (5.0%) | |
| ypT1 | 0 (0.0%) | |
| ypT2 | 5 (25.0%) | |
| ypT3 | 3 (15.0%) | |
| ypT4 | 11 (55.0%) | |
| ypN | ||
| ypN0 | 9 (45.0%) | |
| ypN1 | 3 (15.0%) | |
| ypN2 | 2 (10.0%) | |
| ypN3 | 6 (30.0%) | |
| Upfront surgery pathological stage (n= 692) | pT | |
| pT0 | 1 (0.1%) | |
| pT1 | 75 (10.5%) | |
| pT2 | 179 (25.9%) | |
| pT3 | 180 (26.0%) | |
| pT4 | 257 (37.1%) | |
| pN | ||
| pN0 | 334 (48.3%) | |
| pN1 | 100 (14.5%) | |
| pN2 | 120 (17.3%) | |
| pN3 | 138 (19.9%) | |
| Pathological stage (post-NACT and upfront surgery; n= 712) | I | 58 (8.1%) |
| II | 113 (15.9%) | |
| III | 136 (19.1%) | |
| IV | 405 (56.9%) | |
| Adverse surgical factors Perineural invasion | Present | 344 (48.3%) |
| Absent | 368 (51.7%) | |
| Lympho-vascular invasion | Present | 214 (30.1%) |
| Absent | 498 (69.9%) | |
| Positive margin | Yes | 13 (1.8%) |
| No | 699 (98.2%) | |
| Surgical margin status | Positive | 13 (1.8%) |
| Close (<5 mm) | 108 (15.2%) | |
| Negative and | 591 (83.0%) | |
| wide (>5 mm) | ||
| Positive nodes on neck dissection (n= 689) | Yes | 369 (53.6%) |
| 1–2 | 206 (55.8%) | |
| 3–4 | 86 (23.3%) | |
| 5–6 | 38 (10.3%) | |
| >6 | 39 (10.6%) | |
| Median (IQR) | 2 (1–4) | |
| Extra-nodal extension (n = 369) | Present | 226 (61.2%) |
| Absent | 486 (68.3%) | |
| Level -IV/V nodal disease (n= 369) | Yes | 29 (7.8%) |
| No | 683 (96.2%) | |
| Adverse pathological factors | ≥1 | 154 (21.6%) |
| >1 | 372 (52.2%) | |
| 0 | 186 (26.1%) |
PMMC: Pectoralis major myocutaneous, NACT: Neoadjuvant chemotherapy, IQR: Interquartile range.
Definitive radiotherapy cohort
Definitive RT was delivered to 57 (7.4%) patients, including 19 who had received NACT. Fifty-two (91.2%) of these patients received EBRT alone [n = 18 (31.6%)] or with CCT [n = 34 (59.6%)]. A few patients with localised disease received brachytherapy alone as definitive treatment [n = 1 (1.8%)] or as a boost following EBRT with [n = 1 (1.8%)] or without [n = 3 (5.3%)] CCT [Supplementary Table S5]. The most commonly received EBRT dose and fractionation combination was 70 Gy in 35 fractions [n = 39 (68.4%)], and the most commonly used technique was conventional 2D RT [n = 28 (49.1%)]. CCT was prescribed for 35 (61.4%) patients, and the most frequent prescription was weekly cisplatin [n = 33 (94.3%)]. The median EBRT duration was 50 (IQR, 41-53) days.
Treatment outcomes
The overall cohort was followed for a median of 43 months; 504 (65.5%) patients were disease-free, 206 (26.8%) had experienced treatment failure, and 59 (7.7%) patients were of unknown status. The curative surgery cohort was followed for a median of 69 months; 472 (66.3%) patients were disease-free, 185 (26%) had experienced treatment failure, and 55 (7.7%) patients were of unknown status. In the definitive RT cohort, 3-month post-treatment response assessments showed complete response (CR) in 12 (21.1%) patients, PR in 9 (15.8%) patients, and disease progression in 15 (26.3%) patients. This cohort was followed for a median of 12 months; 32 (56.1%) patients were disease-free, 21 (36.8%) had experienced treatment failure, and 4 (7%) patients were of unknown status [Supplementary Table S6].
Survival outcomes
At the end of the study period, 383 (49.8%) patients in the overall cohort were alive, and 327 (42.5%) had died, 183 (23.8%) due to progressive disease, and 144 (18.7%) due to other causes. The median DFS and OS durations in the overall cohort were 51 (IQR-9-60 months) and 58 months (IQR-12-61 months), and the 5-year DFS and OS rates were 48.9% and 49.5%, respectively. In the definitive RT cohort, the median DFS and OS durations were 5 (IQR-3-21 months) and 10 months (IQR-4-32 months), and the 3-year DFS and OS rates were 16% and 21.1%, respectively. The 5-year DFS and OS rates in the curative surgery cohort were 51.1% and 51.9%, respectively. In the NACT cohort, the median DFS and OS durations were 7 (IQR-3-27 months) and 8 months (IQR-4-27 months), and the 2-year DFS and OS rates were 27.5% and 29.8%, respectively. Survival rates did not differ between centres [Supplementary Figures S1-S4].
Five-year DFS and OS rates for patients with stages I, II, III, and IV OC were 79% and 80.2%, 67.2% and 67.2%, 42.2% and 44.6%, and 40.3% and 42.1%, respectively [Figures 2 and 3]. Acute and late toxicities were reported in patients who received RT; 5–6% of these toxicities were Radiation Therapy Oncology Group grade ≥ 3 [Supplementary Table S7].
Failure, salvage treatment, and survival
In the overall cohort, 166 (21.6%) patients experience LRF and 55 (7.2%) experienced DF with or without LRF [Figure 4, Supplementary Table S6]. Following recurrence, second curative treatments were offered to 24 (11.8%) patients. Three-year OS rates for cases who had developed LF, RF, LRF, and DF were 24.5%, 17.5%, 12.6%, and 0%, respectively. Second primary cancer was identified in 9 (0.9%) patients.
Factors associated with survival outcomes
UVA demonstrated that inferior 5-year DFS and OS in the overall cohort were associated with primary grade III histology, locoregionally advanced disease, advanced stage (III, IV), and non-surgical treatment (definitive RT); advanced age at presentation (>60 years) and the lack of formal education were associated with only poor OS [Table 3]. On MVA, worse 5-year DFS and OS were associated with grade III histology, locoregionally advanced disease, advanced nodal stage (cN2, N3), and non-surgical definitive treatment [Table 4]; advanced age was associated with inferior OS.
| Factor | Category | Disease-free survival | Overall survival | ||||
|---|---|---|---|---|---|---|---|
| 3 years | 5 years | p (log rank) | 3 years | 5 years | p (log rank) | ||
| Age (years) | ≤40 | 60.7% | 49.5% | 0.11 (6.05) | 61.6% | 60.0% | <0.01 (12.03) |
| 41–50 | 57.4% | 54.2% | 60.9% | 54.2% | |||
| 51–60 | 54.0% | 51.0% | 57.9% | 51.3% | |||
| >60 | 48.2% | 39.4% | 50.8% | 36.9% | |||
| Sex | Men | 53.5% | 46.5% | 0.10 (2.78) | 56.7% | 47.4% | 0.13 (2.27) |
| Women | 59.0% | 57.6% | 61.8% | 58.0% | |||
| Education | No formal education | 51.4% | 44.9% | 0.08 (6.82) | 55.0% | 44.9% | 0.03 (8.71) |
| Primary school | 51.8% | 47.2% | 52.5% | 48.4% | |||
| Secondary school | 54.8% | 50.2% | 60.4% | 50.8% | |||
| High school and above | 65.3% | 59.6% | 67.4% | 60.8% | |||
| Occupation | Homemaker/domestic | 59.5% | 56.5% | 0.25 (2.81) | 62.9% | 55.5% | 0.33 (2.23) |
| help | |||||||
| Professional/agriculture | 51.8% | 45.0% | 54.4% | 44.1% | |||
| Business/laborer | 54.4% | 48.3% | 57.3% | 50.6% | |||
| Primary tumor grade | I | 63.2% | 60.2% | 0.001 (51.61) | 70.5% | 67.4% | 0.001 (54.61) |
| II | 59.2% | 52.6% | 62.2% | 52.8% | |||
| III | 31.6% | 25.3% | 32.4% | 30.4% | |||
| Disease extent | Localized | 77.3% | 71.0% | 0.001 (42.20) | 81.5% | 71.4% | 0.001 (45.67) |
| Locoregionally advanced | 47.7% | 42.0% | 50.4% | 42.9% | |||
| Clinical tumor stage | cT1–2 | 68.0% | 64.1% | 0.001 (33.02) | 72.8% | 64.8% | 0.001 (36.39) |
| cT3–4 | 47.2% | 40.3% | 49.3% | 41.9% | |||
| Clinical nodal stage | cN0–1 | 62.3% | 55.6% | 0.001 (33.99) | 65.8% | 55.7% | 0.001 (35.72) |
| cN2–3 | 40.0% | 35.7% | 42.4% | 38.1% | |||
| Clinical stage | I | 85.6% | 79.0% | 0.001 (49.54) | 86.9% | 80.2% | 0.001 (52.09) |
| II | 72.5% | 67.2% | 78.3% | 67.2% | |||
| III | 57.2% | 42.2% | 61.2% | 44.6% | |||
| IV | 44.6% | 40.3% | 46.9% | 42.1% | |||
| Definitive treatment modality | Surgery | 57.2% | 51.1% | 0.001 (59.93) | 60.6% | 51.9% | 0.001 (60.28) |
| Radiotherapy | 16.0% | 16.0% | 14.1% | 14.1% | |||
| Factor | Category | Disease-free survival | Overall survival | ||
|---|---|---|---|---|---|
| HR (95% CI) | p | HR (95% CI) | p | ||
| Age (years) | ≤40 | NS | Ref. | ||
| 41–50 | 1.00 (0.70–1.43) | 0.99 | |||
| 51–60 | 1.39 (0.99–1.97) | 0.06 | |||
| >60 | 1.93 (1.39–2.68) | 0.001 | |||
| Grade | I | Ref. | |||
| II | 0.97 (0.63–1.49) | 0.89 | 1.10 (0.68–1.77) | 0.69 | |
| III | 1.72 (1.07–2.76) | 0.03 | 2.09 (1.24–3.52) | <0.01 | |
| Disease extent | Localized | Ref. | |||
| Locoregionally advanced | 2.16 (1.53–3.06) | 0.001 | 2.42 (1.68–3.49) | 0.001 | |
| Clinical nodal stage | cN0–1 | Ref. | |||
| cN2–3 | 1.33 (1.06–1.67) | 0.01 | 1.39 (1.10–1.76) | <0.01 | |
| Definitive treatment modality | Surgery | Ref. | |||
| Radiotherapy | 2.40 (1.67–3.47) | 0.001 | 2.77 (1.89–4.06) | 0.001 | |
HR: Hazard ratio, CI: Confidence interval, NS: Not significant.
In the curative surgery cohort, inferior 5-year DFS and OS were associated on UVA with advanced age, grade III histology, advanced stage, LVI, PNI, positive surgical margins, pathologically positive cervical lymph nodes in general and at level IV or V, and ENE; a lack of formal education was associated with inferior OS [Table 5, Supplementary Tables S8 and S9]. On MVA, inferior 5-year OS in this cohort was associated with advanced age, grade III histology, advanced stage, LVI, and ENE. Inferior DFS was associated with advanced age, advanced stage, LVI, ENE, and positive surgical margins [Table 6, Supplementary Tables S8 and S9]. The definitive RT cohort was too small for the examination of clinically relevant associations [Supplementary Table S10].
| Factor | Category | Disease-free survival | Overall survival | ||||
|---|---|---|---|---|---|---|---|
| 3 years | 5 years | p(log rank) | 3 years | 5 years | p(log rank) | ||
| Age (years) | ≤40 | 61.9% | 50.5% | 0.02 (10.36) | 62.8% | 61.2% | 0.001 (17.56) |
| 41–50 | 63.0% | 59.9% | 68.3% | 59.9% | |||
| 51–60 | 58.1% | 54.8% | 61.4% | 54.8% | |||
| >60 | 48.7% | 39.8% | 51.5% | 39.8% | |||
| Sex | Men | 56.1% | 48.8% | 0.11 (2.54) | 59.6% | 49.8% | 0.15 (2.10) |
| Women | 61.3% | 59.8% | 64.3% | 60.3% | |||
| Education | No formal education | 53.7% | 46.9% | 0.12 (5.79) | 57.4% | 46.8% | 0.04 (8.55) |
| Primary school | 54.8% | 49.9% | 55.6% | 51.3% | |||
| Secondary school | 58.6% | 53.7% | 64.9% | 54.5% | |||
| High school and above | 66.8% | 61.0% | 69.7% | 63.0% | |||
| Occupation | Homemaker/domestic help | 60.3% | 57.2% | 0.42 (1.76) | 63.8% | 59.5% | 0.50 (1.40) |
| Professional/agriculture | 54.1% | 47.0% | 57.8% | 46.2% | |||
| Business/laborer | 57.7% | 51.2% | 60.9% | 53.7% | |||
| Grade | I | 68.7% | 65.4% | 0.001 (29.21) | 76.8% | 73.4% | 0.001 (32.38) |
| II | 59.6% | 52.9% | 62.7% | 52.9% | |||
| III | 34.4% | 27.5% | 37.1% | 33.4% | |||
| Pathological tumor stage | pT1–2 | 70.5% | 65.9% | 0.001 (31.25) | 73.3% | 65.9% | 0.001 (29.46) |
| pT3–4 | 49.3% | 42.6% | 53.1% | 43.7% | |||
| Pathological nodal stage | pN0–1 | 67.1% | 59.6% | 0.001 (51.05) | 71.0% | 64.2% | 0.001 (51.67) |
| pN2–3 | 39.9% | 36.6% | 42.4% | 41.0% | |||
| Pathological stage | I | 89.2% | 89.2% | 0.001 (57.82) | 89.2% | 89.2% | 0.001 (57.27) |
| II | 76.8% | 65.3% | 83.5% | 67.0% | |||
| III | 61.1% | 48.8% | 62.7% | 46.6% | |||
| IV | 45.3% | 41.8% | 49.4% | 44.7% | |||
| Lympho-vascular invasion | No | 64.9% | 57.3% | 0.001 (37.31) | 69.0% | 60.4% | 0.001 (45.70) |
| Yes | 39.2% | 36.3% | 41.1% | 37.0% | |||
| Perineural invasion | No | 66.9% | 57.8% | 0.001 (21.33) | 70.8% | 68.6% | 0.001 (24.33) |
| Yes | 46.9% | 44.2% | 49.8% | 45.1% | |||
| Extra-nodal extension | No | 66.6% | 58.6% | 0.001 (57.51) | 70.8% | 58.7% | 0.001 (63.28) |
| Yes | 36.1% | 34.6% | 37.5% | 37.5% | |||
| Positive margin | No | 57.8% | 51.7% | <0.01 (9.54) | 61.2% | 52.3% | 0.02 (5.94) |
| Yes | 12.8% | 12.8% | 23.1% | 23.1% | |||
| Margin status | Clear | 59.2% | 51.7% | 0.13 (2.29) | 62.6% | 52.3% | 0.09 (2.90) |
| Close | 50.2% | 50.2% | 53.6% | 50.3% | |||
| Positive node | No | 72.3% | 62.7% | 0.001 (56.59) | 75.7% | 61.7% | 0.001 (55.16) |
| Yes | 42.7% | 40.4% | 46.1% | 43.2% | |||
| Positive level-IV/V nodes | No | 58.3% | 52.0% | 0.01 (6.60) | 62% | 52.9% | <0.01 (7.97) |
| Yes | 47.4% | 47.4% | 29.9% | 29.9% | |||
| Factor | Category | Disease-free survival | Overall survival | ||
|---|---|---|---|---|---|
| HR (95% CI) | p | HR (95% CI) | p | ||
| Age (years) | ≤40 | Ref. | Ref. | ||
| 41–50 | 0.95 (0.67–1.36) | 0.77 | 0.95 (0.6–1.39) | 0.80 | |
| 51–60 | 1.27 (0.89–1.81) | 0.18 | 1.32 (0.91–1.90) | 0.14 | |
| >60 | 1.58 (1.14–2.19) | <0.01 | 1.85 (1.31–2.60) | 0.001 | |
| Grade | I | Ref. | Ref. | ||
| II | 0.83 (0.52–1.35) | 0.45 | 1.15 (0.66–1.99) | 0.63 | |
| III | 1.54 (0.90–2.63) | 0.12 | 2.12 (1.16–3.87) | 0.01 | |
| Pathological stage | I | Ref. | Ref. | ||
| II | 2.55 (1.05–6.19) | <0.01 | 1.93 (0.77–4.76) | 0.16 | |
| III | 4.60 (1.97–10.77) | 0.001 | 4.15 (1.77–9.80) | 0.001 | |
| IV | 5.04 (1.18–11.63) | 0.001 | 4.14 (1.79–9.55) | 0.001 | |
| Lympho-vascular invasion | No | Ref. | Ref. | ||
| Yes | 1.29 (1.00–1.66) | <0.05 | 1.43 (1.11–1.85) | <0.01 | |
| Extra-nodal extension | No | Ref. | Ref. | ||
| Yes | 1.58 (1.21–2.06) | 0.001 | 1.67 (1.27–2.20) | 0.001 | |
| Positive margin | No | Ref. | Ref. | ||
| Yes | 2.16 (1.05–4.46) | 0.04 | 1.87 (0.85-4.11) 0.116 | ||
HR: Hazard ratio, CI: Confidence interval.
DISCUSSION
In this study, the demographic profiles, treatment parameters, and clinical outcomes of 769 OC cases at two of the TMC newly commissioned centres were analysed. The demographic and clinical characteristics of the cases at both centres were found to mirror those at TMH, Mumbai.[10] The relatively young patient profile was consistent between centres and with other reports from India.[1,12] The predominance of men in the cohort is typical for OC worldwide[1,3] and slightly exceeded the 75% men predominance recorded at TMH, Mumbai.[10] The distributions of primary disease locations and clinical stages at presentation were similar to those at TMH, Mumbai.[10]
In the curative surgery cohort, which included patients who had received adjuvant treatment, the 5-year OS and DFS rates were worse for patients with pathological stage III/IV OC. In contrast, the 5-year DFS of patients who received surgery and adjuvant treatment did not differ significantly according to stage at TMH, Mumbai.[10] As the TMH, Mumbai data were collected more than a decade before the analysis of outcomes at the satellite centres, this difference may reflect the improvement of the ability to accurately stage OC, possibly due to increased utilisation of imaging at diagnosis and improved disease characterisation. The interval between surgery and the initiation of adjuvant RT in the present cohort (37 days) aligns with the standard-of-care recommendation of 6 weeks and is shorter than the 45-day interval reported for TMH, Mumbai.[10] The median RT duration of 44 days in our cohort is similar to the 45 days reported for TMH, Mumbai[10] and suggests that most patients completed RT with no significant treatment break.
A small proportion of patients in the present cohort received NACT, which resulted in PR or CR in just under two-thirds of cases, allowing for subsequent curative-intent surgery. These findings are similar to those reported for TMH, Mumbai.[12]
The findings of this study highlight several aspects of care quality that differed between sites. Nearly all patients with pathological stage III/IV OC received adjuvant treatment. CCT and RT were delivered to most patients with the high-risk features of positive margins and ENE. Weekly cisplatin treatment was prescribed to most of these patients, but only 68% of them completed five or more cycles, most often due to toxicity during treatment. The proportion of patients who completed five or more cycles of CCT was larger at the rural than at the semi-urban centre, suggesting that geographic, socioenvironmental, and/or economic factors impact treatment tolerance or compliance. This finding may represent an opportunity to investigate the causes of early chemotherapy discontinuation at each site. In addition, a much larger proportion of reconstructive surgeries was performed at the semi-urban centre than at the rural centre. This may be attributable to the differential availability of plastic surgery services and highlights the need to increase the availability of these services where they are lacking.
The promising data generated in this study suggest that most patients with OC at the recently commissioned cancer centres are receiving evidence-based, guideline-concordant care. Most characteristics and indicators determined in this analysis for the satellite centres were similar to those previously reported for the main centre, suggesting the successful establishment of high-quality care using a huband-spoke model. This study establishes a framework for subsequent audits, with acknowledgement of the value of electronic medical records for data upkeep.
Limitations of this study include its retrospective nature, which may have led to the biasing of outcome findings based on data availability. In addition, information on social risk factors, including tobacco and betel nut use, was lacking. Although previous studies have failed to demonstrate that tobacco use has a significant impact on the clinical outcomes of OC, such use may vary substantially among geographically distinct populations, which could impact the patient populations presenting at different sites.[10] Finally, 10% of patients in this cohort were lost to follow-up, as expected in rural and semi-urban settings, and their ultimate clinical outcomes are unknown. Despite these limitations, this study provides important measures of OC treatment outcomes that can be used as benchmarks for the evaluation of outcomes at other newly established centres in the future.
TAKE HOME MESSAGE
This study underscores the importance of providing uniform, evidence-based cancer care across diverse geographical regions and serves as a foundation for future evaluations of newly established cancer centres in India and beyond. It represents a significant step toward the achievement of better outcomes for patients with OC in underserved areas.
Ethical approval:
The study was approved by the Institutional Review Boards at Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, India, number IEC/0621/12000014/001, dated 4th June 2021, and Homi Bhabha Cancer Hospital, Sangrur, India, number IEC/HBCH/18/21, dated 15th July 2021.
Declaration of patient consent:
Patient's consent is not required as patient’s identity is not disclosed or compromised.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: This research was supported by Penn Global, University of Pennsylvania, and the Penn Global Indian Research and Engagement Fund.
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