Nidhi Gupta

India faces a growing cancer burden, with late diagnosis, high treatment costs, and out-of-pocket expenditure posing challenges to achieving universal cancer care (UCC). This paper examines the role of health technology assessment (HTA) in informing priority setting, strategic purchasing, and resource allocation for cancer care in India, and discusses its contribution toward achieving UCC. We undertook a targeted review of published literature and policy documents describing India's UCC initiatives and institutionalization of HTA. Bibliographic databases were searched to identify HTA and economic evaluation studies in oncology conducted under the aegis of Health Technology Assessment in India (HTAIn), the central HTA agency of the Government of India. The HTAIn website was additionally reviewed to identify completed oncology HTA reports. Evidence was synthesized narratively to describe the applications of HTA and key challenges in translating HTA evidence into policy and practice. HTA has informed multiple dimensions of publicly financed cancer care in India, including selection of interventions for health benefit packages under Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana, development and refinement of treatment and program guidelines, and generation of value-based prices to inform pricing and reimbursement decisions. Applications span cancer prevention and screening, pharmaceuticals, radiotherapy, and other treatment modalities. HTA also provides a framework for considering efficiency, equity, financial risk protection, and health-system implications when allocating limited resources. HTA can play a pivotal role in advancing UCC in India by supporting transparent, evidence-informed priority setting and strategic purchasing. Strengthening mechanisms for timely HTA, evidence uptake, periodic reassessment, and linkage with reimbursement and pricing decisions are important to maximizing health gains, promoting equity, and reducing financial hardship.

Germ cell tumours of the testis: 10-year survival data from a tertiary care centre in India Nidhi Gupta1,a, Kislay Dimri1, Aanchal Arora2, Awadhesh Kumar P

Gestational trophoblastic neoplasia (GTN) is a rare and malignant condition arising from the maternal placental tissue. It is a highly chemo sensitive tumor, EMACO (etoposide/methotrexate/dactinomycin alternating with cyclophosphamide and vincristine) is the most common multiagent chemotherapy used for patients with high risk. An audit was conducted for patients with gestational trophoblastic disease (GTN) receiving EMACO regimen during the past five years at a tertiary care referral centre. Records were analysed for efficacy, toxicity and outcomes with EMACO regimen. Total of eight patients received EMACO during the study period. Median age at presentation was 25 years. All patients, except one gave a history of an antecedental molar pregnancy. The mean duration of development of GTN from the index pregnancy was 3.4 months. FIGO stage I, II and III were seen in one, three and four patients respectively. The average quantitative human chorionic gonadotrophin (hCG) prior to starting EMACO was 157,705 IU/L (6149-629,442 IU/L). The mean number of EMACO cycles for achieving normal hCG levels was 4 (2-6). All but one patient also received two additional cycles of consolidation chemotherapy. Grade 3/4 neutropenia was seen in seven patients. Hepatotoxicity was seen in one patient. At a median follow up of 36 months (18-50 months), all but one patient was alive, and four patients have successfully conceived, while three delivered healthy babies after receiving EMACO regimen. EMACO is a highly effective regimen with manageable toxicity, good patient compliance and fertility preservation. EMACO administration requires experienced multidisciplinary team approach which can help to adequately monitor response, manage toxicity, provide supportive care and detect early relapses.

Pregnancy coexisting with the diagnosis of malignancy is rare. It poses a major management dilemma to the oncologist where adequate oncology outcomes need to be weighed against the fetal well-being. Use of chemotherapy during pregnancy is determined by the type of malignancy, stage, gestational age, chemotherapy agent, and the risk of placental transfer.A 33-year-old female patient presented with a gradually progressive breast lump. After adequate workup, the patient was diagnosed with infiltrating duct carcinoma left breast (T3N0M1), with liver metastases and triple-negative breast cancer. Subsequently, the patient received detailed counseling about treatment, prognosis, and contraceptive use to avoid conception and was started on palliative chemotherapy with doxorubicin, cyclophosphamide, and docetaxel. Radiology was performed for response assessment after eight cycles of chemotherapy. It demonstrated an accidental pregnancy of 22 weeks and 4 days gestation with major malformations including corpus callosum agenesis with ventriculomegaly, skeletal dysplasia including hypoplastic upper limbs, and absent radius in one arm. The patient underwent medical termination of pregnancy and further oncology treatment as per response and standard treatment guidelines.Chemotherapy should be strictly avoided for pregnant patients in the first trimester given its teratogenic effects, leading to major fetal malformations. The use of multiple drugs makes it difficult to establish a causal role of a particular chemotherapeutic agent with specific malformation. Adequate anticonception counseling and pregnancy tests should be offered to women diagnosed with cancer who are in the reproductive age group, prior to starting chemotherapy.

Introduction Multiagent chemotherapy forms the backbone for the management of osteosarcoma. The globally accepted chemotherapy regimens for osteosarcoma include a combination of Adriamycin, cisplatin, and high-dose methotrexate (HDMTX). However, non-HDMTX regimens are predominantly used in India, secondary to patient profile, toxicity, administration, logistics, and financial constraints. We present our outcomes with a two-drug dyad chemotherapy consisting of Adriamycin and cisplatin in a resource-limited setting. Objective To determine the disease free and overall survival of osteosarcoma patients and to evaluate the prognostic factors affecting OS for patients with localized disease. Material and Methods The study was a record-based analysis of all osteosarcoma patients presenting at a tertiary care referral center during the period from 2010 to 2019. A total of 127 patients of osteosarcoma were identified, who were evaluated for their demographic and clinical profile, while treatment details and outcomes were evaluated in 123 patients as disease-free survival (DFS) and overall survival (OS). Univariate and multivariate analysis was done for factors influencing OS. Results The median age at presentation was 18 years and extremities were the most common site of presentation. Localized disease (LD) was seen in 102 (80%) patients, while 25 (20%) patients had metastatic disease (MD). Overall, 83 (84%) patients with LD underwent surgery, of whom 65 (78%) underwent limb salvage surgery, while 18 (22%) underwent amputation. Only 72 (73%) patients completed the planned six cycles of chemotherapy. At a median follow-up of 50.4 (range: 1–166.3) months, the 5-year OS for patients with LD and the entire cohort was 53 and 43%, respectively. For patients with MD, the 1- and 2-year OS were 41 and 7%, respectively. The 3- and 5-year DFS for patients with LD was 41 and 35%, respectively. Primary tumor measuring less than 12 cm (p = 0.03) and patients undergoing surgery (p = 0.003) were found to be statistically significant for improved OS on univariate analysis but not on multivariate analysis. Conclusion The two-drug dyad chemotherapy was well tolerated with manageable toxicity. The outcomes were comparable with Indian studies using non-HDMTX regimens that report a 5-year survival of within 50 to 60%, but were inferior to global outcomes and the dose-dense OGS-12 protocol used in India. Raising awareness for early diagnosis, improving the nutritional status, incorporation of sequential third drug (ifosfamide), use of dose-intensive regimens for selected patients, and increasing compliance to treatment may further help improve the outcomes.

Real world data of Ewing sarcoma from a resource-limited setting with poor compliance to treatment leading to poor outcomes Nidhi Gupta1, Kislay Dimri1, Su