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Clinical outcomes of breast cancer treated with curative intent at two newly commissioned cancer centres in India: A real-world data analysis
, Tapas Dora2, Amita Sekhar Padhy4, Jayashree Ramesh Deshmukh2, Sneha Nachu1, Varsha Ramesh Bandal1, Anupurva Dutta5, Debashish Chaudhary6, Neeharika Alapati7, Jai Prakash Agarwal8, Umesh Mahanshetty1, Rajendra Badwe9, Ashish Gulia6,, Surbhi Grover3
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Received: ,
Accepted: ,
How to cite this article: Vadgaonkar RA, Das A, Macduffie E, Thakur P, Nittala R, Dora T, et al. Clinical outcomes of breast cancer treated with curative intent at two newly commissioned cancer centres in India: A real-world data analysis. South Asian J Cancer. 2026;15:44-52. doi:10.25259/SAJC_53_2025
Abstract
Objectives:
Breast cancer (BC) is the most common cancer in women globally and in India. This study analyzes demographic characteristics, treatment patterns, and clinical outcomes of BC patients treated at two satellite centres in India during the first five operational years.
Material and Methods:
All eligible women patients with BC treated between 2015 and 2020 were included in this retrospective study. Factors impacting disease-free survival (DFS) and overall survival (OS) were identified using univariate analyses with Kaplan–Meier curves and multivariable Cox regression.
Results:
In total, 1267 patients with a median age of 52 years [early breast cancer (EBC), n = 704 (55.6%); locally advanced breast cancer (LABC), n = 563 (44.4%)] were included. 5-year DFS and OS rates were 79.1% and 82.9%, respectively (EBC, 86.6% and 88.3%; LABC, 68% and 72.8%, respectively). On multivariable analysis, mastectomy and hormone receptor (HR)-negative histology were significantly associated with inferior DFS for patients with EBC. For those with LABC, DFS was adversely impacted by HR-negative histology, nodal metastasis, and chemotherapy non-receipt.
Conclusion:
This study provides insight into contemporary BC treatment patterns and outcomes at two newly commissioned tertiary cancer care centres in India. These findings support the viability of a hub-and-spoke model for cancer care, suggesting that quality of care can be maintained while improving geographic access to treatment and informing future interventions.
Keywords
Breast cancer
Curative intent
Outcomes
Surgery
Radiotherapy
INTRODUCTION
Breast cancer (BC) is the most common malignancy among women worldwide, with an estimated annual incidence of 2.3 million cases that constitute 11.7% of all cancer diagnoses.[1] With increased public awareness, access to healthcare facilities, and screening initiatives advance in low- and middle-income countries (LMICs) like India, rates of BC diagnosis are escalating rapidly, approaching parity with those observed in high-income countries (HICs).[2-4] In India, BC now accounts for 13.5% of all newly diagnosed cancer cases, surpassing cervical cancer over the past decade, and contributes to 10.6% of all cancer-related fatalities.[5] Reported 5-year overall survival (OS) rates are 85–95% for early breast cancer (EBC), 60–70% for locally advanced breast cancer (LABC), and 20–25% for metastatic disease.[6-9] These rates lag notably behind those reported for HICs, likely due to a combination of factors such as late-stage presentation, delayed treatment initiation, insufficient or fragmented treatment, and incomplete follow-up care.[6-10]
The Tata Memorial Centre (TMC) is a forefront institution in India for comprehensive cancer care, encompassing prevention, early detection, diagnosis, treatment, and research. The BC treatment guidelines and outcomes at Tata Memorial Hospital (TMH), Mumbai, the primary facility of the TMC, have been demonstrated to adhere to international standards.[10] In a strategic effort to decentralise cancer care, TMC has developed regional cancer centres across India.[11] These facilities function within a hub-and-spoke framework, wherein the regional centres (spokes) manage the prevention, early detection, and treatment of common cancers, while the central hubs handle more complex cases requiring specialised intervention.
Among the newly established centres, Centre 1 in northwestern India opened in 2014 and serves a predominantly rural population. Centre 2, on India’s southeastern coast, opened in 2015 and serves a semi-urban catchment. Both provide surgical, medical, and radiation oncology services, though radiation services were opened in 2019 at Centre 2. This study characterizes the demographic profiles, treatment parameters, prognostic factors, and survival outcomes of BC patients treated with curative intent during the first five years of operation at these two centres. To our knowledge, this is the first study to characterize BC outcomes at newly opened tertiary care facilities in India.
MATERIAL AND METHODS
Study design and participants
Institutional Review Board approval was obtained prior to the commencement of this study (Centre 1, IEC/18/21; Centre 2, IEC/0621/12000014/001). This retrospective cohort analysis encompassed all female patients with BC who underwent primary treatment with curative intent at the two centres of interest. Excluded from the analysis were women referred to external hospitals, those presenting with distant metastases, and those receiving solely palliative treatment. The data analysis covered the periods from January 1, 2015, to December 31, 2019, for Centre 1, and from January 1, 2016, to December 31, 2020, for Centre 2. Comprehensive information, including demographic characteristics, clinical presentations, histological characteristics, molecular profiles, treatment specifics, and clinical outcomes, was extracted from available treatment summaries, histopathological reports, radiation therapy (RT) charts, and hospital-based electronic medical records. Follow-up data were collected until December 31, 2021, for Centre 1 and until December 31, 2022, for Centre 2.
Treatment details
Treatment protocols were derived from the TMC evidence-based management guidelines, tailored to the unique context of LMICs like India.[11,12] All newly registered cases were discussed comprehensively in multidisciplinary joint clinic sessions before the initiation of cancer-directed treatment. Following the confirmation of diagnoses and bilateral mammography, routine metastatic work-up with contrast-enhanced thoracic, abdominal, and pelvic computed tomography (CT) examinations and a bone scan or positron emission tomography/CT examination was performed for patients with LABC.
Patients with EBC (cT1–2, N0–1) without contraindication were offered breast-conserving surgery (BCS). For those with LABC (cT3–4, any N and T, cN2–3), neoadjuvant chemotherapy (NACT) was considered to reduce the tumour size before surgery. A subset of patients with LABC and smaller primary disease (cT3, N0–1) underwent surgery (mastectomy or BCS when feasible) followed by adjuvant treatment. Mastectomy was considered for patients unwilling to undergo or ineligible for BCS. Standard preoperative NACT was anthracycline-based.[10]
Post-NACT taxane-based chemotherapy was offered for patients with LABC in the adjuvant setting, and combined anthracycline- and taxane-based chemotherapy was recommended for all patients with node-positive disease.[10] Neo-adjuvant and adjuvant trastuzumab were considered for human epidermal growth factor receptor 2 (HER2)/neu-positive cases.[13] Premenopausal patients with hormone receptor (HR)-positive BC received tamoxifen, and post-menopausal patients were prescribed aromatase inhibitors.[14] Locoregional radiation therapy (LRRT) was prescribed after BCS[15], and post-mastectomy radiation therapy (PMRT)[16] was offered in all LABC cases with four or more positive axillary nodes. Post-treatment clinical follow-up visits every 3 months for the first 2 years, every 6 months for the subsequent 3 years, and annually thereafter were recommended. Patients who did not attend in person were contacted by telephone, and individuals who did not respond were considered to be lost to follow-up and censored from the statistical analysis.
Study variables
Post-NACT response assessment adhered to the RECIST v1.1 criteria.[17] Treatment failure was characterised by local (persistent or recurrent disease in the conserved breast or chest wall), regional (disease in draining regional lymph-node basins), and/or distant (disease beyond local or regional sites) manifestations. Second primary cancer cases were defined in accordance with international criteria for multiple primary cancers.[18] The primary study outcomes were OS and disease-free survival (DFS). OS was calculated from the date of cancer-directed treatment (NACT or surgery) 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 documentation of local failure (LF), regional failure (RF), locoregional failure (LRF), distant failure (DF), second primary cancer, or death of any cause.
Statistical analysis
The statistical analyses were conducted using SPSS (v29.0; IBM, Armonk, NY, USA). Descriptive statistics were computed to summarise demographic, clinical, and treatment characteristics. Prognostic factors were delineated through univariate analysis (UVA), employing Kaplan–Meier curves and the log-rank test. Multivariable analysis (MVA) was performed using a Cox proportional-hazard model that included all factors showing significance in the UVA and forward stepwise selection. The significance level was set to p <0.05.
RESULTS
Demographic and clinical characteristics
During the study period, a total of 1267 patients met the inclusion criteria; data from these patients were included in the analysis [Figure 1].
The median age at diagnosis was 52 [interquartile range (IQR), 43–60] years, and 674 (53.2%) patients were post-menopausal. Notably, 31.5%(n = 399) of the patients had no formal education, and 89.9% (n = 1139) identified as homemakers. EBC was diagnosed in 55.6% of patients (n = 704), and LABC was identified in 44.4% (n = 563) of patients. Invasive ductal carcinoma (IDC) was the predominant histological subtype in 1230 (97.1%) cases, and 66.8% (n = 846) of cases exhibited grade III histology. Stage II, according to the 7th edition of the American Joint Committee on Cancer’s manual [19] , was the most frequently observed [n = 645 (50.9%)]. Across EBC patients, 64.3% (n = 453) were HR+, 25.7% (n = 181) were HER2+, and 23.7% (n = 167) were TNBC. Across LABC patients, 58.3% (n = 328) were HR+, 32.2% (n = 181) were HER2+, and 25.2% (n =142) were TNBC. Other sociodemographic and clinical characteristics of the study sample are provided in [Table 1, Supplementary Tables S1 and S2].
| Parameter | Category | All (n= 1267) | EBC (n= 704) | LABC (n= 563) |
|---|---|---|---|---|
| Age (years) | ≤40 | 232 (18.3%) | 135 (19.2%) | 97 (17.2%) |
| 41–50 | 361 (28.5%) | 199 (28.3%) | 162 (28.8%) | |
| 51–60 | 364 (28.7%) | 191 (27.1%) | 173 (30.7%) | |
| >60 | 310 (24.5%) | 179 (25.4%) | 131 (23.3%) | |
| Median (IQR) | 52 (43–60) | 52 (42–61) | 52 (42–60) | |
| Menopausal status | Pre/peri-menopausal | 593 (46.8%) | 334 (47.4%) | 259(46.0%) |
| Post-menopausal | 674 (53.2%) | 370 (52.6%) | 304(54.0%) | |
| Highest education | No formal education | 399 (31.5%) | 211 (30.0%) | 188(33.4%) |
| Primary school | 272 (21.5%) | 154 (21.9%) | 118(21.0%) | |
| Secondary school | 264 (20.8%) | 141 (20.0%) | 123(21.8%) | |
| Higher secondary and above | 332 (26.2%) | 198 (28.1%) | 134(23.8%) | |
| Occupation | Homemaker/domestic help | 1139 (89.9%) | 633 (89.9%) | 506(89.9%) |
| Professional/agriculture | 39 (3.1%) | 23 (3.3%) | 16(2.8%) | |
| Business/labourer | 89 (7.0%) | 48 (6.8%) | 41(7.3%) | |
| BC laterality | Right | 609 (48.1%) | 337 (47.9%) | 272(48.3%) |
| Left | 647 (51.1%) | 362 (51.4%) | 285(50.6%) | |
| Synchronous bilateral | 11 (0.9%) | 5 (0.7%) | 6(1.1%) | |
| Predominant quadrant | UOQ | 404 (31.9%) | 248 (35.2%) | 156 (27.7%) |
| LOQ | 98 (7.7%) | 55 (7.8%) | 43 (7.6%) | |
| UIQ | 187 (14.8%) | 117 (16.6%) | 70 (12.4%) | |
| LIQ | 93 (7.3%) | 56 (8.0%) | 37 (6.6%) | |
| Central | 209 (16.5%) | 109 (15.5%) | 100 (17.8%) | |
| Multiple quadrants | 60 (4.7%) | 22 (3.1%) | 38 (6.7%) | |
| Extensive disease | 36 (2.8%) | 4 (0.6%) | 32 (5.7%) | |
| Unknown | 180 (14.2%) | 93 (13.2%) | 87 (15.5%) | |
| Histology | IDC | 1230 (97.1%) | 678 (96.3%) | 552(98.0%) |
| ILC | 9 (0.7%) | 2 (0.3%) | 7 (1.2%) | |
| Other | 28 (2.2%) | 24 (3.4%) | 4 (0.7%) | |
| Mucinous carcinoma | 12 | 11 | 1 | |
| Metaplastic carcinoma | 8 | 5 | 3 | |
| Papillary neoplasm | 6 | 6 | 0 | |
| Adenoid cystic carcinoma | 1 | 1 | 0 | |
| Invasive cribriform carcinoma | 1 | 1 | 0 | |
| Histological grade | I | 36 (2.8%) | 27 (3.8%) | 9 (1.6%) |
| II | 312 (24.6%) | 187 (26.6%) | 125 (22.2%) | |
| III | 846 (66.8%) | 459 (65.2%) | 387 (68.7%) | |
| Unknown | 73 (5.8%) | 31 (4.4%) | 42 (7.5%) | |
| Clinical stage | IA | 120 (9.5%) | 120 (17.0%) | 0 (0.0%) |
| IIA | 344 (27.2%) | 344 (48.9%) | 0 (0.0%) | |
| IIB | 301 (23.8%) | 240 (31.1%) | 61 (10.8%) | |
| IIIA | 192(15.2%) | 0 (0.0%) | 192(34.1%) | |
| IIIB | 227 (17.9%) | 0 (0.0%) | 227 (40.3%) | |
| IIIC | 83 (6.6%) | 0 (0.0%) | 83 (14.7%) | |
| Receptor status | HR+/HER2+ | 201 (15.9%) | 106 (15.1%) | 95 (16.9%) |
| HR+/HER2– | 580 (45.8%) | 347 (49.3%) | 233 (41.4%) | |
| HR–/HER2+ | 161 (12.7%) | 75 (10.7%) | 86 (15.3%) | |
| TNBC | 309 (24.4%) | 167 (23.7%) | 142 (25.2%) | |
| Unknown | 16 (1.3%) | 9 (1.3%) | 7 (1.2%) |
According to the 7th edition of the American Joint Committee on Cancer’s manual. BC: Breast cancer, EBC: Early breast cancer, LABC: Locally advanced breast cancer, IQR: Interquartile range, UOQ: Upper outer quadrant, LOQ: Lower outer quadrant, UIQ: Upper inner quadrant, LIQ: Lower inner quadrant,IDC: Invasive ductal carcinoma, ILC: Invasive Lobular carcinoma, HR: Hormone re tor, HER2: Huma iderma rowth factor re tor 2, TNBC: tri le-n tive breast cancer.
Treatment characteristics
EBC
Of the 704 women diagnosed with EBC, 54.5% (n = 384) underwent mastectomies and 45.5% underwent breast-conserving surgery. [Figure 1]. NACT was administered to the other 87 (12.4%) patients, yielding a complete clinical response (CR) in 12 (13.8%) cases, a partial response (PR) in 29 (33.3%) cases, and a disease progression in 19 (21.8%) cases. After NACT, mastectomy was performed in 33 (37.9%) cases, and BCS was performed in 54 (62.1%) cases. Additional pathological details are provided in Table 2 and Supplementary Tables S3 and S4. Adjuvant chemotherapy and LRRT were delivered to 566 (80.4%) and 495 (70.3%) patients, respectively. Among HR+ EBC patients, 92.9% (n = 421) received hormone therapy, and 68.0% (n = 123) of HER2+ EBC patients received trastuzumab [Supplementary Table S5]. Additional clinico-pathological details are provided in Table 2 and Supplementary Tables S3 and S4.
| Parameter | Category | All (n = 1267) | EBC(n = 704) | LABC(n= 563) |
|---|---|---|---|---|
| Surgery type | Mastectomy | 857 (67.6%) | 384 (54.5%) | 473 (84.0%) |
| BCS | 410 (32.4%) | 320 (45.5%) | 90 (16.0%) | |
| Axillary dissection | Yes | 1215 (95.9%) | 676 (96.0%) | 539 (95.7%) |
| ≤6 | 60 (4.9%) | 38 (5.6%) | 22 (4.1%) | |
| >6 | 1155 (95.1%) | 638 (94.4%) | 517 (95.9%) | |
| Median (IQR) | 21 (15–27) | 20 (14–26) | 21 (15–28) | |
| Pathological stage | 0 | 46 (3.6%) | 15 (2.1%) | 31 (5.5%) |
| IA | 140 (11.0%) | 100 (14.2%) | 40 (7.1%) | |
| IIA | 391 (30.9%) | 311 (44.2%) | 80 (14.2%) | |
| IIB | 275 (21.7%) | 186 (26.4%) | 89 (15.8%) | |
| IIIA | 188 (14.8%) | 51 (7.2%) | 137 (24.3%) | |
| IIIB | 57 (4.5%) | 5 (0.7%) | 52 (9.2%) | |
| IIIC | 170 (13.4%) | 36 (5.1%) | 134 (23.8%) | |
| Adverse prognostic factors | ||||
| Perineural invasion | Present | 253 (20.0%) | 144 (20.5%) | 109 (19.4%) |
| Absent | 1005 (79.3%) | 557 (79.1%) | 448 (79.6%) | |
| Unknown | 9 (0.7%) | 3 (0.4%) | 6 (1.1%) | |
| Lympho-vascular invasion | Present | 632 (49.9%) | 324 (46.0%) | 308 (54.7%) |
| Absent | 626 (49.4%) | 377 (53.6%) | 249 (44.2%) | |
| Unknown | 9 (0.7%) | 3 (0.4%) | 6 (1.1%) | |
| Positive surgical margin | Yes | 54 (4.3%) | 22 (3.1%) | 32 (5.7%) |
| No | 1204 (95.0%) | 679 (96.2%) | 525 (93.3%) | |
| Unknown | 9 (0.7%) | 3 (0.4%) | 6 (1.1%) | |
| Axillary node status | Negative | 521 (42.9%) | 362 (53.4%) | 159 (29.5%) |
| Positive | 594 (57.1%) | 314 (46.4%) | 380 (70.5%) | |
| Metastasis, 1–3 nodes | 346 (66.4%) | 226 (72.0%) | 120 (31.6%) | |
| Metastasis, 4–9 nodes | 215 (41.3%) | 60 (19.1%) | 155 (40.8%) | |
| Metastasis, >9 nodes | 133 (25.5%) | 28 (8.9%) | 105 (27.6%) | |
| Median (IQR) | 4 (2–8) | 2 (1–4) | 6 (3–10) | |
| Extra-nodal extension | Present | 314 (24.8%) | 143 (20.3%) | 171 (30.4%) |
| Absent | 944 (74.5%) | 558 (79.3%) | 386 (68.6%) | |
| Unknown | 9 (0.7%) | 3 (0.4%) | 6 (1.1%) | |
| DCIS | Present | 669 (52.8%) | 400 (56.8%) | 269 (47.8%) |
| Absent | 589 (46.5%) | 301 (42.8%) | 288(51.2%) | |
| Unknown | 9 (0.7%) | 3 (0.4%) | 6 (1.1%) | |
After NACT and upfront surgery, according to the 7th edition of the American Joint Committee on Cancer’s manual. BC: Breast cancer; EBC: Early breast cancer, LABC: Locally advanced breast cancer, BCS, Breast-conserving surgery, IQR: interquartile range; DCIS: Ductal carcinoma in situ.
LABC
Of the 563 women with LABC, 84.0% (n = 473) underwent mastectomies, and 16.0% (n = 90) underwent breast-conserving surgery. NACT was administered to the other 345 (61.3%) patients, yielding CR in 31 (9%) cases, PR in 204 (59.1%) cases, and disease progression in 64 (18.6%) cases. Following NACT, mastectomy was performed in 272 (78.8%) cases, and BCS was performed in 73 (21.2%) cases. Additional pathological details are provided in Table 2 and Supplementary Tables S3 and S4. Adjuvant chemotherapy and LRRT were administered to 492 (87.4%) and 446 (79.2%) patients, respectively. Among HR+ LABC patients, 89.0% (n = 292) received hormone therapy, while 72.4% (n = 131) of HER2 + LABC patients received trastuzumab. [Supplementary Table S5]. Additional clinico-pathological details are provided in Table 2 and Supplementary Tables S3 and S4.
Treatment outcomes
The median follow-up duration was 42 (IQR, 33–55) months. Most [n = 1057 (83.5%)] patients remained alive, and 170 (13.4%) died [94 (7.4%) of progressive disease and 76 (6%) of other causes]. The follow-up status of 40 (3.2%) patients was unknown. The observed patterns of failure were isolated LF [n = 18 (1.4%)], isolated RF [n = 5 (0.4%)], LRF [n = 1 (0.1%)], and DF with or without LRF [n = 113 (8.9%)] as illustrated in Supplementary Table S6. Five-year DFS was 79.1% for all patients, 86.7% for EBC patients, and 69.3% for LABC patients. Five-year OS was 82.9% across all patients, 88.4% across EBC patients, and 72.9% across LABC patients [Figures 2 and 3, Supplementary Figures S1 and S2].
Factors impacting survival
On multivariate analysis, receipt of post-BCS radiotherapy was associated with improved DFS (p = 0.02) and OS (p = 0.03). Among patients with EBC, HR-negative histology was associated with inferior DFS (p <0.01), and mastectomy was associated with inferior DFS (p = 0.03) and OS (p = 0.02). Among patients with LABC, lympho-vascular invasion (p <0.01) and positive lymph nodes (p = 0.02) were associated with inferior DFS, while post-mastectomy radiotherapy was associated with improved DFS (p = 0.01). HR-negative histology and non-receipt of adjuvant chemotherapy were associated with inferior DFS (all p <0.01) and OS (p <0.01, p = 0.01). [Supplementary Tables S7 and S8].
DISCUSSION
Over the past few decades, breast cancer treatment access in India has expanded substantially in response to the growing disease burden.[1] Within this dynamically evolving healthcare system, it is essential to establish baseline data regarding newly opened tertiary cancer centres. This study characterized the outcomes of 1,267 breast cancer patients treated with curative intent at two cancer centres during the first five years of operation. Five-year DFS and OS were comparable to high-volume care centres, and factors impacting survival included HR status, lymph node status, and post-BCS or post-mastectomy RT receipt, as well as adjuvant chemotherapy receipt.
Clinico-demographic characteristics of the present study population are consistent with those of patients treated at the Tata Memorial flagship hospital (TMH), Mumbai, India, as reported in a 2009-2018 audit study and other Indian cohorts.[2,6,10] The median age in the current study was 52 years, similar to the average age of 50 years for the TMH cohort.[10] This age profile is slightly more than a decade younger than the average age at which BC is typically diagnosed in high-income country (HIC) populations.[20] Stage distribution differed, with a higher proportion of early-stage disease observed in the present cohort.[10] This shift may reflect increased public health awareness[21], improved access to breast cancer screening[22], and the expansion of treatment facilities[23]. The majority of individuals in our cohort presented with IDC and grade III histology, consistent with previous findings.[10,24,25] In the present sample, 62% of patients were HR positive, 29% were HER2 positive, and 24% had triple-negative breast cancer; the corresponding percentages for the TMH cohort were 55%, 15%, and 32%, respectively.[10] These distributions are similar overall, but with a notable doubling of the HER2-positive population in the regional cohort; statistical comparison to determine whether this represents a true difference between populations was not possible.
Given the substantial role of the TMC in the training and education of the regional centre staff, it might be anticipated that treatment paradigms would be harmonised across institutions. However, the opening of a new centre is fraught with logistical, technical, and educational challenges, potentially limiting the ability to consistently administer guideline-concordant care. In the first 5 years of the new centres’ operation, approximately two-thirds of the patients (55% of those with EBC and nearly 85% of those with LABC) underwent mastectomy. This rate notably exceeded that at TMH, which is approximately one-third of the patients (36% of patients with EBC and 57% of those with LABC). [10] The delivery of NACT to patients with EBC was consistent at the regional centres and TMH (~9% and 11%, respectively); in contrast, NACT was administered to 47% of patients with LABC at the regional centres and 78% of those at TMH.[10] This disparity may have contributed to the difference in mastectomy rates, given the reduced likelihood of tumour shrinkage and consequent reduced BCS eligibility due to the lesser utilisation of NACT at the regional centres. However, this explanation does not fully account for the difference in surgeries performed in patients with EBC. Several factors may influence the choice of surgery; they include NACT availability or tolerability, surgeons’ comfort and experience with different surgical approaches, adjuvant LRRT availability and patient preferences, and considerations related to compliance with adjuvant LRRT completion, which is imperative after BCS but may be optional in some cases after mastectomy.[10]
The administration of adjuvant LRRT in this study aligns with international recommendations [15,16], which advocate for various dose and fractionation schedules [26,27], emphasising a preference for hypofractionated schemes. More than 90% of patients in our cohort who had undergone BCS received the recommended adjuvant LRRT. Additionally, the proportion of post-mastectomy patients with adverse features corresponded closely to the proportion receiving PMRT. Endocrine therapy was prescribed to 73% of patients with HR-positive EBC and 94% of those with HR-positive LABC. In India and in HICs, higher out-of-pocket treatment costs have been associated with lower adherence to endocrine therapy.[28,29] While the focus of this study did not extend to endocrine treatment adherence, it is encouraging that this crucial aspect of treatment was initiated for a majority of eligible patients. Trastuzumab, a targeted therapy for HER2-positive BC, was prescribed to more than two-thirds of eligible patients. The out-of-pocket cost of trastuzumab has been identified as a significant barrier to the receipt of HER2-directed therapy in India, where only 4–21% of patients report being able to afford this treatment.[10,13,30,31] The increasing availability of financial support for healthcare, facilitated by government subsidies and more affordable insurance schemes, appears to be contributing to the trend of increased trastuzumab access for patients with HER2-positive BC in India.
The DFS rates for patients with EBC and LABC at the regional centres align closely with those reported for TMH,[10] although direct comparison was not possible due to differences in reporting intervals. Despite the lack of directly comparable OS data and the limited availability of contemporary survival statistics for Indian populations, outcomes in this study were similar to historical reports.[2] The determination that mastectomy and HR-negative histology were associated with inferior DFS in the EBC cohort and HR-negative histology, nodal metastasis, and non-receipt of chemotherapy were associated with this outcome in the LABC cohort partially mirrors findings from TMH, where nodal metastasis and HR-negative status were identified as poor prognostic factors for patients with EBC, and node-positive status, lympho-vascular invasion, and mastectomy were identified as such factors for patients with LABC.[10]
Several limitations of this study can be attributed to its retrospective design. Analyses relied on the data from previous medical records that may have been incomplete. In addition, inherent biases regarding data collection and electronic medical recording were not accounted for. Moreover, the study closely followed treatment initiation without recording patient adherence to treatment. Lastly, this study describes a limited patient population from two tertiary care centres and cannot be directly extrapolated to other centres. Despite this constraint, the study findings offer crucial insight into BC treatment outcomes and serves as valuable benchmark for the assessment of outcomes at new centres established in the future.
This study revealed directions for the future with the potential to significantly shape practice as expansion with regional centre establishment continues in India. A critical focus is the observed increase in BCS performance in this population; this treatment option can be considered to be highly viable, given our finding that a substantial proportion of patients appropriately received adjuvant LRRT. The adoption of ultra-hypofractionated RT emerges as a noteworthy area of interest [26,27] in the current setting and on a global scale, and these centres have the opportunity to serve as models for the widespread implementation of this treatment approach. Additionally, the study highlights the increased accessibility of HER2-targeted therapy over time. An understanding of the trajectory and dynamics of this increase may aid the identification of factors that could further accelerate access to this crucial treatment.
TAKE HOME MESSAGE
This study has demonstrated that newly established cancer centres in India have been able to simultaneously and efficiently scale up the delivery of guideline-concordant BC care that is comparable to that provided at established centres. This promising finding suggests the feasibility of the hub-and-spoke model being used in India and supports the continued scaling up of satellite sites to increase the delivery of distributed regional care across the country. The study has also demonstrated the ability to benchmark quality metrics alongside clinical outcomes, a critical step in ensuring that national cancer treatment guidelines are implemented to promote excellent patient care throughout the country. As India continues to implement this distributed hub-and-spoke model in the health system, the two regional centres examined in this study can serve as exemplary models for the scaling up of cancer care in other LMICs in the context of the global increase in the prevalence of cancer.
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 not required as patients’ 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: The research was supported by Penn Global, University of Pennsylvania, and the Penn Global Indian Research and Engagement Fund.
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