Sarbani Ghosh Laskar

PURPOSE: The incidence of cancer is rising in India, and radiotherapy plays a vital role in the management of most cancers. More radiotherapy centers are being set up across the country to cater to this need. Quality assurance (QA) of radiotherapy is crucial to minimize risks and ensure best outcomes for all patients receiving radiotherapy. We outline an effort to develop a standardized radiotherapy QA program implementable across India through a consensus process among stakeholders. METHODS: The team structured a Standardised Unified Radiotherapy QA model (SURAQSA), a program of pan-India radiotherapy QA incorporating elements of radiotherapy trials QA, adapted for the Indian health care system. Engagement of a cross-section of radiation oncologists working across India to achieve consensus on the issue was essential. This paper describes the consensus development process among the diverse Indian centers/professionals in support of the SURAQSA program. The statement was introduced to clinicians through the vehicle of an abbreviated Delphi consensus process, with guidance from the Royal College of Radiologists (United Kingdom). We outline the elements of the SURAQSA program and describe the consensus adopted. RESULTS: Thirteen centers from across India were represented in the workshop. Three of the consensus statements on external QA of each center, prospective peer review of contours, plan quality measures, and protocol-driven management, as the basic requirements received unanimous support. Consensus was also achieved on the pilot subsite for this exercise with minor disagreement. CONCLUSION: This report showed feasibility of a wide stakeholder engagement to deliver focused outputs and is a huge step toward formulating site-specific radiotherapy QA programs. The process allowed oncologists to highlight the need to take essential steps for radiotherapy safety across centers with varying availability of trained manpower and infrastructure.

Objectives: HPV‐negative oropharyngeal squamous cell cancer (OPSCC) is associated with poor clinical outcomes. The main objective of this study was to evaluate prognostic factors of OPSCC treated with definitive chemoradiotherapy (CTRT). Materials and Methods: Consecutive patients of OPSCC treated with definitive CTRT in a tertiary care center from January 2013 to December 2017 were analysed retrospectively. Kaplan–Meier method was used for survival analysis, Log‐rank test was used for univariate analysis (UVA), and Cox regression method was used for multivariate analysis (MVA). Results: Out of 630 eligible patients, 543 (86.1%) had locally advanced stage according to AJCC 7 ^th edition. HPV status was known for 500 patients, of which 55 (11%) tested p16 positive, reflecting a predominantly HPV‐negative cohort. Chemo‐radiotherapy was offered to 447 (71%) patients. Intensity‐modulated‐radiotherapy (IMRT) technique was used for 163 (25.9%) patients. On UVA KPS ≤ 80 ( p = 0.001), p16 negative tumours ( p < 0.001), T3‐T4 stage ( p < 0.001), advanced group stage (AJCC 8 ^th ed.) ( p < 0.001), conventional RT technique ( p < 0.001), RT dose < 66 Gy EQD2 ( p < 0.001) and residual disease after treatment ( p < 0.001) were associated with poor Locoregional control (LRC) rates. On MVA p16 negative tumours (HR 3.1 [95% CI 1.8–5.3]), T3‐T4 stage (HR 1.6 [95% CI 1.2–2.2]), conventional RT technique (HR 1.6 [95% CI 1.5–2.3]), RT dose < 66 Gy EQD2 (HR 2.2 [95% CI 1.5–3.4]) were independent prognostic factors for poor LRC. These variables were also significant for local control, disease‐free free and overall survival. Conclusion: In this predominantly HPV‐negative OPSCC cohort, HPV status, T stage, RT technique, and RT doses > 66 Gy were independent prognostic factors for all outcomes.

Introduction: Buccal mucosa cancers are the most prevalent oral cavity cancers in South Asia, often attributed to widespread tobacco use. The current NCCN guidelines generally advise against primary surgery for locally very advanced (cT4b) buccal cancers involving the masticatory space and infratemporal fossa (ITF). However, some surgeons have adopted an aggressive surgical approach for T4b oral squamous cell carcinoma, involving composite resections and ITF clearance. Materials and Methods: This is a retrospective analytical survival study of 91 patients with very locally advanced buccal mucosa cancers with involvement of ITF (cT4b), who underwent radical surgery in the form of bi‐alveolar composite resection with ITF clearance and Modified Neck Dissection from 2017 to 2023. Results: At a median follow‐up of 27 months, 54.9% of patients were alive and disease‐free. The estimated mean 3‐year overall survival (OS) and disease‐free survival were 48% and 44%, respectively. In multivariate survival analysis, maxillary sinus involvement ( p = 0.008), no response to neoadjuvant chemotherapy ( p = 0.004), and nodal involvement ( p = 0.05) were independent predictors of poor OS. Patients with high ITF involvement ( n = 23) had a higher rate of distant metastasis compared to those with low ITF involvement ( n = 68; p < 0.015). Presence of extra‐nodal extension also significantly reduced survival across both groups (median OS: 10 months vs. 6.8 months; p = 0.037). Conclusion: ITF clearance is a safe and effective approach for managing locally very advanced (cT4b) buccal cancers.

Background: The expanding use of systemic therapies for recurrent and metastatic head and neck cancer has raised major concerns regarding affordability and equitable access, particularly across countries with differing income levels and health financing structures. Methods: We conducted a comparative affordability and budget‐reach analysis of commonly used systemic agents—pembrolizumab, nivolumab, cetuximab, gefitinib, and erlotinib—across seven countries (United States, United Kingdom, Australia, South Africa, India, Pakistan, and Bangladesh) representing high‐, upper‐middle‐, and lower‐middle‐income settings. Results: Immunotherapy was unaffordable across all settings. Six‐month pembrolizumab costs corresponded to 7994% of monthly income in India, 4311% in Pakistan, 3133% in Bangladesh, and remained above catastrophic thresholds in high‐income countries (591% in the United States; 903% in the United Kingdom). In contrast, oral tyrosine kinase inhibitors were substantially less costly, with gefitinib requiring 171%–412% of monthly income in South Asia and falling below thresholds in Pakistan and Bangladesh. The cost of treating one patient with pembrolizumab could fund treatment for 18–22 patients with gefitinib in South Asia. Conclusions: Despite modest survival benefits, current immunotherapy pricing severely limits global accessibility. Policy reform and pricing strategies are needed to ensure equitable cancer care.