While fairly complete and reliable incident data on childhood cancers are available from the registries in India, mortality and survival information is not. Information concerning the latter was obtained by the Bangalore cancer registry through active follow-up involving visits to homes of patients. Between 1982 and 1989, 617 cases of cancers in childhood were registered, giving an age-standardized incidence rate of 84.8 and 48.4 per million in male and female children, respectively. Active follow-up provided mortality/survival information in 532 or 86.2 percent of these cases. Overall, observed five-year survival was 36.8 percent (both genders combined) with a relative survival of 37.5 percent when childhood mortality in the general population was taken into account. The five-year relative survival was best for thyroid carcinoma (100 percent) followed by Hodgkin's disease (73 percent) and retinoblastoma (72.9 percent). Survival was comparatively low, being 9.9 percent in acute nonlymphatic leukemia and less than 20 percent in rhabdomyosarcoma and the category grouped as 'other malignant neoplasms.' Survival in Hodgkin's disease was influenced by clinical stage at presentation, but was not statistically significant possibly due to small numbers.

In the stereotactic body radiotherapy (SBRT) and immunotherapy era, we are moving toward an “immunological radiation plan”, i.e., radiation scheduling with abscopal effect as a vital endpoint as well. The literature review of part A enumerates the advantages of the intermediate dose of SBRT 6–10 Gy per fraction, appropriate use of dose painting, proper timing with immunotherapy, and the potential of immunoadjuvants to maximize cell kill in the irradiated lesions, found to have improved the abscopal effects. Part B summarizes part A, primarily the findings of animal trials, forming the basis of the tenets of the proposed model given in part C to realize the true abscopal potential of the SBRT tumor cell kill of the index lesions. Part C proposes a theoretical model highlighting tumor vasculature integrity as the central theme for converting “abscopal effect by chance” to “abscopal effect by design” using a harmonized combinatorial approach. The proposed model principally deals with the use of SBRT in strategizing increased cell kill in irradiated index tumors along with immunomodulators as a basis for improving the consistency of the abscopal effect. Included is the possible role of integrating immunotherapy just after SBRT, “cyclical” antiangiogenics, and immunoadjuvants/immune metabolites as abscopal effect enhancers of SBRT tumor cell kill. The proposed model suggests convergence research in adopting existing numerous SBRT abscopal enhancing strategies around the central point of sustained vascular integrity to develop decisive clinical trial protocols in the future.

PurposeThe primary purpose of hospital-based cancer registries is assessing patient care. Clinical stage–based survival and treatment-based survival are some of the key parameters for such assessment. Because of the challenges in obtaining follow-up parameters, a separate study on patterns of care and survival was undertaken by the Indian National Cancer Registry Program. The results for cancer of the female breast are presented here.Patients and MethodsData abstracted in a standardized patient information form were transmitted online to a central repository. Treatment patterns were assessed for 9,903 patients diagnosed between January 1, 2006, and December 31, 2008, from 13 institutions. Survival analysis was restricted to 7,609 patients from nine institutions wherein follow-up details (as of December 31, 2012) were available for at least 60% of patients.ResultsThe overall 5-year survival rates with breast-conserving surgery (BCS) and mastectomy (MS) were 94.0% and 85.8%, respectively, for stage II disease (adjusted hazard ratio, 2.40; 95% CI, 1.8 to 3.2) and 87.1% and 69.0%, respectively, for stage III disease (hazard ratio, 2.82; 95% CI, 2.2 to 3.7). Patients who had MS did better with systemic therapy (chemotherapy and/or hormone therapy), whereas patients with BCS required just local radiation therapy to achieve best survival.ConclusionThis observational study in the natural setting of care of patients with cancer in India showed significantly decreased survival with MS when compared with BCS. The reasons for lower survival with MS and the biologic or scientific rationale of the necessity of systemic therapy to achieve optimal survival in patients undergoing MS but not in those with BCS need further investigation.

Anti-angiogenics, radiotherapy (especially stereotactic body radiotherapy, SBRT)/chemotherapy, and immunotherapy form a critical trimodal approach in modern cancer therapy. The normalization window, however short, is the beachhead for the strategic initiation of a decipherable disruption of cancer cells. This opening can be the opportunity for designing controlled stepwise cancer cell death (CCD) and immunological augmentation. The next step is to induce immunogenic cell death (ICD) through chemotherapy/radiotherapy concurrently with the facilitation of professional phagocytosis. Immunotherapy at this stage, when interstitial pressure decreases considerably, leads to the improved perfusion of oxygen with solutes and improved immune-friendly pH and is additionally expected to open up the tumor microenvironment (TME) for a “flood” of tumor-infiltrating lymphocytes. Furthermore, there would be enhanced interaction in “hot” nodules and the incorporation of immune reaction in “cold” nodules. Simultaneously, the added adjuvant-assisted neoantigen–immune cell interaction will likely set in a virtuous cycle of CCD induction followed by tumor cell-specific antigenic reaction boosting CCD, in turn promoting the normalization of the vasculature, completing the loop. There should be a conscious concern to protect the extracellular matrix (ECM), which will nurture the long-term immunological cross-talk to discourage dormancy, which is as essential as obtaining a complete response in imaging. The caveat is that the available therapies should be appropriately ranked during the start of the treatment since the initial administration is the most opportune period. A fast-paced development in the nanomedicine field is likely to assist in all the steps enumerated.

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