DCF NewsLETTERVol. 16 No. 172 • FEBRUARY 2013 • PRICE `1.50 PER COPY

Dear Friends,

We all know that needs of the humanity and specially patients, keep on changing. Earlier patients only wanted good patient care, adequate treatment and symptom free, good quality of life. They were not concerned about the hospital interiors. Now-a-days, patients, specially the affl uent class, prefer fi ve star interiors also. Being patient centric hospital, we have renovated our A Block with a majestic new entrance lobby, automatic glass door (entrance and exit), Italian marble cladding on walls, wood paneling, LCD lights, roller blinds, granite bathrooms, patient friendly furniture and above all patient education videos / slides in Hindi and English, in the waiting area. Next time you come to Dharamshila Hospital, you will be overwhelmed by our interiors. The renovation for other block has also started. These are just physical / cosmetic needs, the real need for the population today is to be well aware about how to prevent cancer, monthly self examination, annual health check-ups, early diagnosis and adequate treatment to prevent recurrences.

Times of India, under the banner of Times Wellness organized a conference, “Dialogue on Cancer”. I was invited to explain the need for mass cancer awareness and what is Dharamshila Cancer Foundation And Research Centre doing for cancer awareness and cancer prevention. The excerpts from Times of India are reproduced in the next column. Let us all join hands to save ourselves from an impending cancer epidemic.

World Cancer Day 2013 (4 February 2013) focused on Target 5 of the World Cancer Declaration: Dispel damaging myths and misconceptions about cancer, under the tagline “Cancer - Did you know?” To mark the event, we at Dharamshila hospital decided that if we clear the myths in the minds of those who are the face of healthcare to the common people then we would succeed in clearing the myths of a large segment of population. In accordance with the thought, we invited participants from 10 different nursing colleges of Delhi and NCR region to come and join us on 2nd Feb 2013 for an oncology quiz and sessions related to the theme. The programme was a huge success and 70 students and 8 faculties took part in the event. The event started with a quiz, followed by unveiling of the theme by Dr. S. Khanna, Nurses role in preventive oncology by Mrs. Pragya Singh and a panel discussion headed by experts (Dr. Meenu Walia, Dr. R. Dawar, Dr. S.K. Kochar and Dr. H.M. Aggarwal), where students cleared their doubts about chemotherapy, surgery, radiation therapy and investigations done for cancer patients.

New Batch (2013 – 2016) of DNB Students of Medical Oncology and Surgical Oncology have joined and will further add on to the excellent patient care being offered at Dharamshila Hospital. To make cancer treatment affordable, we are not revising our schedule of charges except for surgical oncology, where rates have been made at par with Tata Memorial Hospital rates.

The take home messages for the medical fraternity by the faculty of National Oncology Congress 2013 are on Page 2 – 3.

Looking forward to get your valuable support

Thanking You

Dr. S. KhannaExecutive Director

PERMANENT URETERAL STENTS – A New Lease of Life!

Nearly all pelvic and retroperitoneal tumours give rise to ureteral obstruction, due to various reasons. This obstruction can be due to direct pressure effect of the tumour or secondary to the treatment related periureteral fi brosis or injury. Renal failure is a grave consequence, if both the ureters are blocked.

Conventionally per-cutaneous nephrostomy (PCN) and ureteral DJ-stents have been used to deobstruct the kidneys. Open ureteral surgeries are very diffi cult and have high failure rates, especially post Chemotherapy and Radiation Therapy. Both endoscopic and open procedures have their own share of shortcomings and advantages.

Conventionally an indwelling ureteric stent has been the procedure of choice from the patients’ and the surgeons’ perspective. However, these stents have their own shortcomings in the form of severe bladder irritative symptoms, fl ank pain, encrustation, stone formation and UTI. Hence, these need to be changed at periodic intervals and often have to be taken out altogether. PCNs, on the other hand are better as far as draining the kidneys is concerned. However, they have their own fl ip side. PCNs are cumbersome to maintain and are often source of infection. They can get clogged and also need to be changed at regular intervals. Besides they get damaged easily and are source of urinary leakages and give rise to nephrocutaneous fi stulas when misplaced. Hence, they too have their share of morbidity. PCNs also restrict a person’s social mobility. Looking at these aspects of morbidities, cost and recurrent surgeries,

Vol. 16 No. 172 • FEBRUARY 2013

a permanent indwelling ureteral stent, without the handicaps of conventional DJ stent, is a good option.

An innovative self expanding biocompatible stent offers a new ray of hope for this class of patients. This stent: Memokth (Pnn Medicals-Denmark) is made of nitinol alloy and has been shown to remain in situ (now 7 years follow up are available) without the said complications. It is nearly asymptomatic when placed in ureter and has not shown any tissue growth or encrustations at check ureterscopy. Although, some degree of expertise is needed for its placement, it is good option to salvage renal function.

We, at Dharamshila Hospital and Research Centre are proud to announce the fi rst Memokath placement in India. The said patient had carcinoma cervix four years back, which was successfully treated by a combination of surgery, chemotherapy and Radiation therapy. However, she had urosepsis and renal insuffi ciency due to obstructive uropathy. She had to be taken up for repeated stenting or PCN to salvage her right kidney, which had multiple ureteral fi brotic obstructions. She had no locoregional or distant cancer residuals or relapse. After discussions in tumour board, Memokath (20 cm size) was placed in her right ureter in October 2012. She didn’t have any peri-operative complications. At present, she is in healthy and stable condition and she is off medications for the fi rst time in last four years.

This stent is costing about 1.7 lakhs. However, its long term durability and obviating the need for repeated PCN’s / DJ stenting or an open procedure, makes it much more patient friendly and cost-effective. The morbidity associated with various repetitive procedures is also obviated. After a period of one year, this permanent stent is more cost effective then the conventional procedures and we recommend its use in selected cases.

Dr. Shilpi Tiwari, M.S., DNBConsultant – Uro Oncology

Dr. Meenu Walia, MD, DNBConsultant – Medical Oncology

Highlights and Carry Home Messages of theNATIONAL ONCOLOGY CONGRESS – 2013

Breast Cancer – The Pink EpidemicJanuary 18 - 19, 2013

On the 18th and 19th of January 2011, we organized our National Cancer Congress 2013 on Breast Cancer – The Pink Epidemic and we bring you some of the highlights of what we did during these two days of academics with a lot of fun thrown in and Carry Home Messages.

An Interactive Live Workshop on surgery for breast cancer was held on January 18, 2013 at DHRC. Dr. Niranjan Naik, Senior consultant, surgical oncology DHRC discussed in detail regarding emerging trends in management of ca breast. According to him now-a-days majority of females prefer breast conservative surgeries to maintain cosmesis. He discussed about recent advances in treatment protocol, Staging workup and treatment planning for the patient.

Live workshop started from OT. Dr Mudit agrawal was coordinator from OT while Dr Anshuman was the operating surgeon along with plastic surgery and reconstructive team of Dr Ashutosh and Dr Richa kumar. Art and craft of prolonged anaesthesia delivered by Dr Neha, Dr Amit Jain, Dr Ankur Verma.

Audience in the conference hall were eagerly waiting for surgical procedure. Moderators were Prof K. N. Chintamani from Safdarjang Hospital, Dr. S.V.S Deo, IRCH, AIIMS and Dr Sharan Choudhri from DHRC, renowned oncosurgeon of breast cancer. They enlightened the audience with their great knowledge and experience along with down to earth personality. During interactive session Prof. Chintamani told that primary breast reconstruction is preferred after mastectomy in women of all ages. There are two primary means of breast reconstruction - autologous reconstruction, which uses the patient’s own tissue or implant reconstruction. Each of these covers a wide range of techniques.Autologous reconstruction is usually done with fl aps, which may be moved from the back or abdomen while maintaining the blood supply to the tissue, or which may be performed with microvascular surgery, reattaching small blood vessels with an operating microscope to re-establish blood supply.

Examples of the former are the TRAM fl ap from the abdomen (using the rectus abdominus muscle) and the latissimus dorsi fl ap from the back. Microvascular fl aps include TRAM fl aps (with a modifi ed technique) and the newer perforator fl aps, like the DIEP fl ap (taken from the abdomen but without muscle) as well as TUG (using tissue from the inner thigh) and GAP (gluteus) fl aps. These fl aps give very nice results, but are larger operations and leave additional scars. Implant reconstruction can sometimes be done at the time of mastectomy; more commonly a temporary infl atable implant called a tissue expander is placed, gradually infl ated with saline in the offi ce, and then replaced at a later operation with a permanent implant. The choice of reconstruction is complex and depends to some extent on the type of treatment used for the breast cancer, particularly radiation treatment. When the indications for postoperative radiotherapy are unknown, pre-mastectomy sentinel node biopsy, delayed-implant reconstruction, or delayed reconstruction is preferable.

The role of radiation theraphy in the treatment of breast Cancer is dramatically changing as breast conserving therapy is being used in an increasing proportion of patients with early-stage disease.

Next day, on January 20, 2013, we organized a full day conference on Evolving Management of Breast Cancer at the Hotel Hilton Double Tree, Mayur Vihar, Delhi.Magnitude of the ProblemProf. G. K. Rath, (Chief IRCH, AIIMS, New Delhi)• Breast cancer is the commonest cancer in urban Indian females, and the second

commonest in the rural Indian women. • The numerous myths and ignorance that prevail in the Indian society result in an

unrealistic fear of the disease. It is hardly surprising that the majority of breast cancer patients in India are still treated at locally advanced and metastatic stages.

• Lack of an organized breast cancer screening program, paucity of diagnostic aids, and general indifference towards the health of females in the predominantly patriarchal Indian society do not help early diagnosis of breast cancer.

• Over one lakh new breast cancer patients are estimated to be diagnosed annually in India.

• The incidence of this disease has been consistently increasing, and it is estimated it has risen by 50% between 1965 and 1985.

• The rise in incidence of 0.5–2% per annum has been seen across all regions of India and in all age groups but more so in the younger age groups (< 45 years).

• In general, breast cancer has been reported to occur a decade earlier in Indian patients compared to their western counterparts.

• While the majority of breast cancer patients in western countries are postmenopausal and in their 60s and 70s, the picture is quite different in India with premenopausal patients constituting about 50% of all patients.

• More than 80% of Indian patients are younger than 60 years of age. • Young age has been associated with larger tumor size, higher number of

metastatic lymph nodes, poorer tumor grade, low rates of hormone receptor-positive status, earlier and more frequent loco regional recurrences, and poorer overall Survival.

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Diagnosis in Breast Cancer(Dr. C. S. Bal, Professor in Nuclear Medicine, AIIMS, Delhi) and Dr. R. Dawar (Director Academics & HOD – Pathology & Transfusion Medicine, DHRC, Delhi• The progression from histology to molecular biology in Breast Cancer highlighting

the impact of molecular profi ling in the classifi cation and management of Breast Cancer.

• Fine needle Aspirations or core needle biopsies to prevent scarring incisions.• Imaging modalities like C.T. and MRI rely on detecting anatomic changes for

the diagnosis, staging and follow-up. • PET has the ability to demonstrate abnormal metabolic activity, and 18F-2-

deoxy-D-glucose (FDG) PET provides important tumor-related qualitative and quantitative metabolic information that may be critical for the diagnosis and follow-up.

• The combination of PET and CT allows the functional PET and anatomical CT images to be acquired under identical conditions and then they are rapidly co-registered.

• This combined system has advantages over CT alone as functional information is added to morphological data, and this combined system has advantages over PET alone because pathological areas of tracer uptake are better localized and the image acquisition time is reduced. • PET CT is recommended for evaluation of clinical stage 3 and 4 patients.

The major roles for PET/CT in breast cancer are for detecting and localizing metastasis and monitoring the response to treatment and early detection of recurrence.

Breast Cancer Surgery Dr. G. S. Gopinath (Director – Surgical Oncology, Bangalore), Dr. Mukul Trivedi (Professor – Surgical Oncology, GCRI, Ahmedabad), Dr. Vijay Kumar (Director – Kidwai Institute of Oncology, Bangalore), Dr. Ravi Kannan (Director – Cacachar Cancer Hospital And Research Centre, Silchar) and Dr. Sharan Choudhri (Senior Consultant – Dharamshila Hospital And Research Centre, Delhi)• The preferred method of treatment for many women with early breast cancer

is conservative surgical therapy (principally lumpectomy and axillary dissection followed by breast irradiation.

• Sentinel node biopsy is being investigated as an alternative to standard axillary lypmph node dissection.

• For women who choose mastectomy, immediate reconstruction of the breast is now routinely performed with a prosthetic implant or autologus tissue.

• Stage I and Stage II breast cancers are early cancers that are not fi xed to the skin or muscle. If lymph nodes are involved, they are not fi xed to each other or to underlying structures. Modifi ed radical mastectomy continues to be appropriate for some patients, but breast conservation therapy is now regarded as the optimal treatment for most.

• Six prospective randomized trials have shown no difference in survival when mastectomy is compared with conservative surgery plus radiation for Stage I and Stage II breast cancer

• Reconstruction is available for women who need a total mastectomy or whose partial mastectomy leaves an unacceptable deformity.

• Reconstructive surgery can be delayed or performed immediately, and uses either breast implants or autologous tissue.

• The most commonly used autologous tissue is the TRAM (transverse rectus abdominis myocutaneous) fl ap. The latissimus dorsi muscle also can be used.

• In some cases, free fl aps are used• Reasons for undergoing reconstruction include Inability to wear clothes, dislike

of the external prosthesis and weariness of the mastectomy deformity. • Women tend to be satisfi ed with the result of reconstruction when it is delayed

months or years after mastectomy. • Chemotherapy or radiation therapy will not interfere with the reconstruction.• Immediate reconstruction is more convenient for patients, less expensive, and

limits exposure to anesthesia risk. The aesthetic results tend to be better and the patient does not have to live with a deformity, even temporarily.

Chemotherapy in Breast Cancer Dr. Shyam Aggarwal (Senior Consultant – Medical Oncology, SGRH, New Delhi), Dr. J. S. Sekhon (Senior Consultant – Medical Oncology, DMC, Ludhiana) and Dr. Anish Maru (Senior Consultant – Medical Oncology, DHRC, Delhi)

• Chemotherapy and hormonal therapies are very important aspect of breast cancer management from early to meatastatic cancer.

• All patients with tumor size more than 0.5 cm require systemic treatment based on nodal status, hormonal receptor status (ER, PR) and Her 2 neu status.

• Select group of patients with tumor size less than 0-5 cm, Grade I, ER, PR positive, Her 2 neu negative can be spared of chemotherapy and only hormonal treatment is required.

• All node negative patients requires 6 cycles of adjuvant chemotherapy with Anthracyclines and all node positive patients are treated with a combination of Anthracyclines and Taxanes treatment.

• All patients who are Her 2 neu three plus, in addition require treatment with testuzumab for one year.

• Patients with Locally advanced breast cancer are treated with neoadjuvant chemoyherapy Anthracyclines and Taxanes plus-minus Testzumab depending upon Her 2 neu status.

Radiotherapy in Breast Cancer Dr. Shaleen Kumar (Prof. & Head Department of Radiotherapy, SGPGI, Lucknow) and Prof. R. K. Kapoor, (Department of Radiotehrapy, PGIMER, Chandigarh) • Adjuvant irradiation improves local control following both mastectomy and

breast-conserving surgery. For women at high risk of relapse, it also increases survival.

• The greatest concern following adjuvant breast irradiation is of an increase in cardiovascular mortality after 15–20 years.

• New techniques of breast irradiation including conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have been shown to reduce cardiac and lung irradiation.

• Improved dosimetry within the breast may improve both local control and cosmesis. • Women are deciding to have treatment of breast cancer with a safe and effective

form of radiation therapy known as “breast brachytherapy”. • This method of therapy, which delivers radiation directly into a tumor site from

the inside out, is a way to save most of the normal breast tissue, preserve the cosmetic appearance of the breast, and avoid the physical and emotional trauma of extensive breast removal surgery

• Accelerated partial breast irradiation (APBI) is currently being explored as an alternative option to deliver adjuvant radiation therapy (RT) after lumpectomy in selected patients with early stage breast cancer treated with breast conserving therapy (BCT).

• Although there are several different types of RT that can be used to deliver APBI, techniques using brachytherapy have been the most frequently used modality. The reported 5-year and 10-year rates of local tumor control have been excellent

• Interstitial brachytherapy can be a diffi cult technique to teach and learn. It requires the use of multiple catheters, widespread patient acceptance is limited.

• In recognition of these problems, a logistically simpler, technically more reproducible, and patient “friendly” device the Mammo site breast brachytherapy catheter are available to deliver APBI.

DHRC Oration Prof. (Dr.) Ramesh Dawar, Director Academics & HOD – Pathology & Transfusion Medicine, DHRC.

The prestigious Fifth DHRC Oration was delivered by Prof. Dr. Ramesh Dawar, Director Academics & HOD – Pathology & Transfusion Medicine, DHRC. Speaking on “Cancer Screening Revisited”, She highlighted the increase in the incidence of breast cancer in our country and patients reporting to doctors with advance stage disease. She then talked of the different Breast Cancer Screening Programs being

carried out by different countries and the results obtained. She highlighted some of the problems of over diagnosis and over treatment encountered by many of them. Emphasizing the need for every country to evolve than own guidelines for the kind of program best suited to the needs of that country. Details of very modifi ed, cost effective Screening Programme, that has been instituted at DHRC and the result of 5 years experience was shared by Dr. R. Dawar with the delegates. It was amply demonstrated that even with the resource crunch our country faces modifi ed screening programme can be carried out with ample benefi t to the society at large.

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