Umesh Mahantshetty,

Professor, Radiation Oncology & GYN DMG Member On behalf of Department of Radiation Oncology & Medical Physics

Tata Memorial Hospital

Mumbai, India

Building Radiotherapy Capacity

for

‘Treatment of Cervical Cancer in India’

NONE!

DISCLOSURES

0 20000 40000 60000 80000 100000 120000 140000 160000

Lip, oral cavity

Ovary

Colorectum

Cervix uteri

Breast

23161

26834

27415

122,844

144937

15631

19549

20789

67, 477

70218

Mortality Incidence

FIVE MOST COMMON CANCERS IN INDIAN WOMEN

ESTIMATED No. OF NEW CASES & DEATHS : YEAR 2012 *

* estimates based on GLOBOCAN 2012

AGE STANDARDISED (WORLD POPULATION) WOMEN CANCER

INCIDENCE RATES PER 100,000 POPULATION IN FEMALES

20.1 21.2 19.3

24.6 28.2 27.5

31.3 30.3 33.7

23.2 23.3

16.6

19.3 20.2 15.7 17.4

12.9 10.5

4.8 7.2 7.2 6.5 7.2 7.6 8.3 6.9

7.3

1.3 1.4 1.6 2.3 2.5 2.4 3.2 3.6 5.3 0

5

10

15

20

25

30

35

40

1970 1975 1980 1985 1990 1995 2000 2005 2010

Breast Cervix Uteri Ovary Corpus Uteri Year

SOURCE : BOMBAY CANCER REGISTRY, REPORTS 1970- 2010

1980 1985 1990 1995 2000 2005 2010 2014 2016 Co 60 80 87 130 185 245 256 247 238 224 LA 2 6 13 23 34 68 157 308 347 Brachy 8 11 31 49 66 73 163 232 251

0

50

100

150

200

250

300

350

400

Num

ber o

f uni

ts

Unit ↓Year→

COBALT

LA

BT

Radiation therapy facilities in India: Update from Atomic energy Regulatory Board March 2016

INDIAN POPULATION : 1.2 billion

International norm: 2 machines/million population

India : 0.33/million

Kannan V et al; IJROBP 94 (4) 2016

MAJOR DISPARITY - Academic Vs Corporate - Urban Vs Rural - Health care Accessibility - Manpower & Expertise

Datta et al. Telemedicine and e-Health 21 (7) July 2015

LMIC’s:

NATIONAL CANCER REGISTRY PROGRAM (NCRP)

INDIAN COUNCIL FOR MEDICAL RESEARCH 2012-2014 REPORTS

POPULATION BASED REGISTERIES HOSPITAL BASED REGISTERIES

8

TATA MEMORIAL CENTRE, MUMBAI, INDIA TERTIARY CANCER CENTRE EXPERIENCE

ADVANCED CENTRE FOR TREATMENT RESEARCH AND EDUCATION IN CANCER

TMC: Radiotherapy Paraphernalia

• TATA MEMORIAL HOPSITAL – Accelerators

1. UNIQUE 2. TRUEBEAM 3. Clinac 6Ex (Varian), 120 MLC 4. Trilogy (Varian) 5. Novalis TX (Varian) 6. Tomotherapy

– Telecobalt 1. Theratron 780 (MDS) 2. Theratron 780C (MDS) 3. Elite 80 (MDS) 4. Equinox 80 (MDS)

– Simulators 1. Ximatron (Varian) 2. Somatom CT-Sim (Siemens) 3. Fly-through (GE) 4. C-Arm 5. USG

– Brachytherapy 1. MicroSelectron-HDR V30 2. MicroSelectron-HDR V18

• ACTREC – Accelerators

1. TRUEBEAM 2. Tomotherapy

– Telecobalt 1. Bhabhatron II

– Simulator 1. Oldelf (Nucletron)

– Brachytherapy – IBU 1. MicroSelectron-HDR V30

TRENDS OF CERVICAL CANCER

TATA MEMORIAL HOSPITAL : 1941-2015*

2050

4679

9055

13642

16635 15083

12801

8780

0 2000 4000 6000 8000

10000 12000 14000 16000 18000

No.

of C

ervi

x Ca

ncer

Cas

es

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Stage I Stage II Stage III Stage IV

10.0

28.2

54.1

7.7 9.1

17.1

63.3

10.6 11.8

19.7

68.5

6.1

28.0

65.3

9.5

35.2

51.7

3.6

9.1

28.8

44.5

5.2

13.8

29.6

46.3

10.2 10.8

27.7

51.3

8.0 10.4

35.0

47.1

7.4

17.0

39.2 34.2

9.6

1985 1989 1993 1997 2000 2002 2004 2006 2008 2012

Tata Memorial Hospital Cancer Registry (1985-2012)

Significant Down Staging!

120.00 108.00 96.00 84.00 72.00 60.00 48.00 36.00 24.00 12.00 0.00

dfsmonths

1.0

0.8

0.6

0.4

0.2

0.0

Cum

Sur

viva

l

1988-1994 : 55% at 8 yrs

1984-1987: 45% at 8 yrs

1979-1983 : 35% at 8 yrs

P = 0.000

J Cancer Res Ther. 2013 Oct-Dec;9(4):672-9)

CERVICAL CANCER – RETROSEPCTIVE ANALYSES FIGO Stage IB-IIIB (N = 6234 pts)

OVERALL OUTCOME WITH RADIATION IMPROVED OVER TIME DUE TO

REFINEMENT IN RADIATION DOSES ESP. BRACHYTHERAPY

EVIDENCE BASED CLINICAL GUIDELINES

PROSPECTIVE TRIALS & INTERNATIONAL COLLABORATION

GYNAE JOINT CLINIC : 1978-1979

OUTCOME ANALYSIS

IMPROVED COMPLIANCE AND FOLLOW–UP

UPGRADATION OF RADIATION FACILITIES

CERVICAL CANCER

LESSONS LEARNT : 1995-2000

ACTION PLAN

Tata Memorial Hospital Evidence Based Guidelines

EBM MEETINGS : February

SERVICE

RESEARCH

EDUCATION

ADOTPED BY MAJORITY OF CENTERS IN INDIA

• FIGO Stage I-III : LDR Vs HDR Brachytherapy: 1996 : closed

• FIGO Stage Ib / IIb : Neo-adjuvant CT + Sx Vs CT + RT : 2003

• FIGO Stage IIIb : Chemo-radiation Vs Radiation Alone : 2003

• FIGO Stage IIb : 3D Conformal Vs Intensity Modulated RT:2004

• Locally Adv. Disease : Evaluation of PET / CT-PET : 2004 : closed

• IAEA Studies : 2# Vs 4# ICA - HDR by CT Vs No CT:600 pts closed

: HIV Positive Pts : CRT Vs RT : 53 /325 pts closed

• Curcumin Study (II/III) : Double blind placebo controlled Ph III study

• EMBRACE study : MR Based Brachytherapy in Cervical Cancers

• Vault Cancers : TOMO Based IMRT / IGRT

• INTERTECC (NCI funded): Pelvic IMRT with BM Sparing Chemo-radiation

Prospective Clinical Trials / Studies in Cervical Cancers

INVESTIGATOR INITIATED & INTERNATIONAL COLLABORATIVE

BRACHYTHERAPY IN CERVICAL CANCERS In corporation of Newer Imaging Modalities

• 2D Planning : Orthogonal X-ray Based (STD)

• 3D Planning : TMH Experience

- MRI: TMH-Initial Experience; Int. J. Gynae Cancer: 2011

- US: TMH Experience; Radio. Oncol 2012

- CT Scan: Interstitial Brachytherapy : Brachytherapy 2013

• Routine GYN Practice:

- Average 7 (3- 9) Cx ICA/ daily + 1-2 Interstitial /wk cases

- 3-4 X-ray; 2-3 CT; 1 MR Based Planning

MRI BASED PLANNING CONVENTIONAL PLANNING

CT- BASED MUPIT PLANNING

ADVANCES IN GYN BRACHYTHERAPY PLANNING

Retrospective and feasibility study : Dec 2006 - May 2008

(N = 24)

Tata Memorial Hospital Participation in International Multicentric Studies

- Refine treatment standards

- International Recognition (GYN GEC-ESTRO Reasearch Network)

A phase II Multicentric International Study by GEC - ESTRO Network

TOTAL ACCRUAL : 1400 PATIENTS

TMH CONTRIBUTION : 100 PATIENTS IN 3 YEARS

Stage IIIB

P=0.013

Stage IIB and IVA

Stage IIIB

Stage IIB Stage IVA

P=0.241

IIB IIIB IVA

31 55 08

28 45 07

24 39 06

15 27 04

12 10 02

07 05 00

01 01 00

IIB IIIB IVA

31 55 08

29 51 08

26 43 07

16 28 04

12 10 02

07 05 00

01 01 00

MR IMAGE BASED BRACHYTHERAPY EMBRACE STUDY : 1400 PATIENTS

TMH ACCRUAL: 100 PATIENTS

EXCELLANT LOCAL CONTROL RATES FOR ALL STAGES

COST BENEFIT ANALYSES : ONGOING

0 0.5

1 1.5

2 2.5

3 3.5

1

2

3

4

5

6

7

8

9

10

11

12

Series1

Series2

0 0.5

1 1.5

2 2.5

3 1

2

3

4

5

6

7

8

9

10

11

12

Series1

Series2

MR

CT

MR

CT

Image Based Brachytherapy in cervical Cancer CT and MRI correlation: Ongoing Research

TMH Study

Image Based Brachytherapy in cervical Cancer TAUS and MRI correlation (TMH data)

In collaboration with Peter Mac Melbourne

• Trans –abdominal Ultrasonography : Cost effective imaging modality • 32 Applications with MRI Compatible Applicator • Anterior Reference Points : 96 % • Posterior Reference Points : 72 % • Magnitude of Variation (>15%) : < 8%

Significant Correlation between the USG and MRI

Reference Points

Suggest : Use of USG for ICA Planning (21/2 D Planning)

Mahantshetty et al. Rad. Onc. Aug. 2011

Bhabhatron II

INDIGENOUS COBALT MACHINE

Simulator-Imagin HDR Brachytherapy

Siddhartha

INDIGENOUS LINEAR ACCELERATOR

TATA MEMORIAL CENTRE IN COLLABORATION WITH BARC INDIGENOUS TECHNOLOGY – COST EFFECTIVE SOLUTIONS

• INFRASTRUCTURE

- To minimize the DISPARITY between Rural & Urban set-ups

- Support Cost- effective Radiation Facilities in rural India

• COMMUNITY PROGRAMS

- HEALTH INSURANCE SCHEMES : Rural & Urban

- Enhance National Cancer Control Program Activitites

Pramesh CS et al. Lancet Oncol 2014.

• Bilateral Exchange programs

• WORKSHOPS & TRAINING PROGRAMS : ONGOING

- AROI-ESTRO TEACHING COURSES

- HANDS ON WORKSHOPS / ANNUAL PRACTICUM

• MULTI-DISCIPLINARY MEETINGS AT VARIOUS FORUMS

- ASSOC. OF Rad. Oncol of India (AROI) : CME’s / Conferences

- ASSOC. of GYN ONCOl of India (AGOICON)

- Women’s Cancer Initiative – Tata Memorial Centre India

TRAINING AND EXCHANGE PROGRAMS

IAEA , UICC, GCIG, ESTRO, ASTRO, AROI, IBS ETC….

• NCG OF INDIA : 2012 (funded by Department of Atomic Energy, Govt of India)

• Mandate: Linking of cancer centers across India

• Presently consists of 62 cancer care centres across entire length and breadth of the

country and has 4 components

- Patient Care – Uniform and evidence based cancer care across centers

- Education and Training - exchange of expertise and mentoring between the

centers, National cancer library

- Collaborative Research – Research network to conduct cooperative research

catering Country specific needs.

- Cancer Policy – Development of National cancer plan to identify and tackle

specific problems of the country

Pramesh CS et al. Indian J Med Paediatr Oncol 2014;35:226-7.

Datta et al. Telemedicine and e-Health 21 &7) July 2015

TELE-RADIOTHERAPY NETWORK

Thank you mahantshettyum@tmc.gov.in