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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 102

An overview of the genesis of preventive oncology unit at a tertiary cancer care hospital in a developing country – A concept paper


1 Department of Preventive Oncology, Healthcare Global Enterprise Ltd., KR Road, Bangalore, Karnataka, India
2 Department of Medical Oncology, Healthcare Global Enterprise Ltd., KR Road, Bangalore, Karnataka, India

Date of Submission24-Jun-2020
Date of Acceptance27-Nov-2020
Date of Web Publication24-Aug-2021

Correspondence Address:
Vinod K Ramani
Department of Preventive Oncology, Healthcare Global Enterprise Ltd., KR Road, Bangalore, Karnataka - 560 027
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpvm.IJPVM_356_20

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  Abstract 


Background: Preventing cancer is better than treating or curing it. Cancer prevention ensures reduced physical, emotional, financial burden to the individual. Methods: The focus of the preventive oncology unit at Healthcare Global (HCG) Enterprise Limited, Bangalore, India, is to increase the understanding of how lifestyle and risk of cancer are related. It also focusses on screening of normal individuals for estimating their risk of developing cancer, which in-turn can lead to earlier detection, improved treatment and outcomes. This unique endeavor started one year back, provides counseling and vaccination services for HPV (Human Papilloma Virus) and HBV (Hepatitis B Virus). Our outreach initiatives in collaboration with the State and City health Departments include screening camps, and awareness sessions focusing on HPV and HBV vaccination. Results: The focus of research is in the areas of cancer epidemiology, prevention, screening, and control. Such research involves a multidisciplinary approach involving the fields of epidemiology, biostatistics, behavioral science, nutrition, and basic science. Conclusion: This novel endeavor at a tertiary cancer hospital in a Developing Country is aimed at preventing the development or progression of the malignant cancer process.

Keywords: Early detection of cancer, mass screening, research


How to cite this article:
Ramani VK, Naik R. An overview of the genesis of preventive oncology unit at a tertiary cancer care hospital in a developing country – A concept paper. Int J Prev Med 2021;12:102

How to cite this URL:
Ramani VK, Naik R. An overview of the genesis of preventive oncology unit at a tertiary cancer care hospital in a developing country – A concept paper. Int J Prev Med [serial online] 2021 [cited 2021 Nov 28];12:102. Available from: https://www.ijpvmjournal.net/text.asp?2021/12/1/102/324549




  Introduction Top


During 2018, 9.6 million people worldwide have died due to cancer.[1] Globally, about 1 in 6 deaths is due to cancer.[1] In 2008, the economic impact of premature death and disability from cancer was 1.5% of World's GDP.[1] 40% of all cancer deaths can be prevented.[2] India contributes to 7.8% of the global cancer burden and 8.33% of the global cancer deaths.[3] Cancer risk depends on a combination of genes, lifestyle and environment.[4] Prevention ensures reduced physical, emotional, financial burden to the individual.

The preventive oncology unit at Healthcare Global (HCG) Enterprise Limited, Bangalore, India, was initiated during August 2019. Its focus is to increase the understanding of how lifestyle and risk of cancer are related. It also focusses on screening of normal individuals for estimating their risk of developing cancer, which in-turn can lead to earlier detection, improved treatment and outcomes.

HCG is the largest private cancer care provider in India. It has a network of 27 comprehensive cancer centers in India and abroad. Each center is provided with a business system, management expertise and capital resources to bring patient focused, state of the art cancer care. The hub and spoke model has helped to create an integrated approach to cancer care. Annually, >120,000 patients are treated through our centers. The group employs ~300 oncologists and 440 specialized Physicians. Also, the HCG foundation enables need-based patients through concessions and waiver of hospitalization costs. Since its inception during December 2006, around 4000 financially deserving patients have derived benefit from this noble cause. The academic programs at HCG include National board and University affiliated courses as well as Fellowship programs in the field of Oncology. This would provide the necessary infrastructure and manpower support for conducting research activities at HCG.[5]

Preventive Oncology as a Specialty was declared by Dr. Michael Shimkin during 1975, at the University of California, San Diego. It includes any measures taken to prevent development or progression of the malignant process. Because of their causal association with the modifiable risk factors, 50% of the cancers are preventable.[6] Preventing cancer is better than treating or curing it. Medical oncology clinics focus on secondary and tertiary levels of cancer prevention. The unique preventive unit set-up in our tertiary hospital one year back, provides counseling and screening services to normal individuals and assess his/her risk of developing cancer in the future. Vaccination services are provided for HPV (Human Papilloma Virus) and HBV (Hepatitis B Virus). Our outreach initiatives in collaboration with the State and City health Departments include screening camps, and awareness sessions focusing on HPV and HBV vaccination.

Individuals are at increased risk of cancer because of modifiable and non-modifiable risk factors, which are the targets for preventive strategies. In our unit, we elicit history based on the individual's predisposition for cancer stratified by gender, concurrent medical illness, family history, age, lifestyle, and occupation. We also screen for risk factors such as tobacco use, unhealthy diet (low fruit and vegetable intake), alcohol use, lack of physical activity, sexually transmitted infection, infection by (HBV), radiation exposure, urban (air pollution) or rural (pesticide) existence, occupational exposure and indoor smoke from household use of solid fuels. Non-modifiable risk factors include genetic factors, which are implicated in 10% of the cancers.[6]

The unit's head is a senior Medical oncologist and technical support is provided by a Radiation oncologist. A community Physician provides consultation at the unit and is the interface for walk-in beneficiaries, relatives of patients and remission patients suspecting a relapse. The unit derives its roots from the feedback of cancer patients who opine that they would have utilized screening services at early stages of their disease, rather than going through the long-drawn treatment process. The multi-disciplinary approach involves accessing services from Oncology specialists, Obesity surgeon, Genetic counselors, Physiotherapist, and Yoga trainers.

The comprehensive 2-hour cancer screening program has been a recent introduction, and the package encompasses radiology (whole body MRI: WB MRI), endoscopy and blood tests to detect cancers of Oropharyanx, gastrointestinal tract, liver, lungs, brain, breast, cervix, blood, kidney, prostate, and many more.


  Literature Review for WB MRI Top


For screening services, MRI could concentrate on organ systems as per the patient's risk profile or to look for common lethal diseases (e.g. colon, lung, breast cancer). Lauenstein T C et al.[7] opine that WB MRI should be supplemented with blood tests (CBC, PSA) and other laboratory tests. Lee S.Y's[8] study reports that WB MRI could be used in cancer screening and regular health evaluation. Kwee R.M[9] state that based on current evidence, WB MRI for preventive health screening of asymptomatic subjects should be offered in a research setting or for genetically predisposed individuals. Such subjects should be informed of incidental indeterminate findings, lack of verification data and substantial false positive findings. The results from Richard S's[10] study show that accuracy of MRI is high for detecting diseases of certain organs such as liver, brain, spine, pancreas, and kidneys. Anupindi S A[11] infer that among children with genetic predisposition for cancer, WB MRI is a valuable screening tool due to its high sensitivity, specificity, and NPV.

MRI is an alternative for CT screening due to the multiplanar imaging, high spatial resolution, anatomical, and functional imaging capabilities. The radiofrequency energy and magnetic fields used in MR imaging do not pose biological risk when compared with PET/CT. WB MRI is a useful diagnostic tool for detection of incidental masses in otherwise healthy patients.[12] WB MRI finds cancer tumors in <2% of patients without symptoms. Some of these tumors may not cause problems in future. Such scans, unlike specific tests could miss cancerous lesions thus providing a false sense of security to the beneficiary.[13] The accuracy of MRI is only fair in the assessment of certain organs such as lung, prostate, colon, and breast.[10]

Content

Objectives of our unit include

  • Screening of asymptomatic and apparently healthy individuals to detect pre-cancerous lesions or early stage of cancer,
  • Increasing beneficiary awareness of early signs and symptoms,
  • Referral services for diagnosis and treatment,
  • Collaboration with State health units for outreach screening activities,
  • Research and academic activities,


Family history assessment of beneficiaries includes

  • Information about both maternal and paternal relatives,
  • Information on at least first (parents, siblings, children), and second degree (aunts, uncles, nieces, nephews, grandparents) relatives,
  • Type of cancer, age at diagnosis and age at death for each family member with cancer, current age of family members living with cancer,
  • Environmental exposures (radiation, smoking, occupational exposures),
  • Genetic counseling and evaluation,


Common sites for cancer in India are oral cavity, lungs,[18] prostate, esophagus and stomach in males, and breast, cervix, and oral cavity in females. The focus of research in Preventive Oncology is in the areas of cancer epidemiology, prevention, screening, and control. Such research involves a multidisciplinary approach involving the fields of epidemiology, biostatistics, behavioral science, nutrition, and basic science.

The educational and awareness initiatives of the Unit include lecture sessions for Corporate employees, group counseling for health workers and beneficiaries, one-to-one counseling for visitors to the clinic, and training sessions for Government Medical Officers.

[Table 1] lists the specific activities of our Unit. The American Cancer Society (ACS) guidelines for cancer screening are shown in [Table 2]. [Table 3] depicts the National Cancer Institute's (NCI) guidelines for cancer screening of high risk individuals. The screening tools used in our Preventive Oncology unit is listed in [Table 4]. [Table 5] enlists the cancer biomarkers and its utlity for the purpose of screening.
Table 1: List of activities in our Unit

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Table 2: ACS guidelines for screening[14]

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Table 3: NCI guidelines for screening of individuals at high risk[15]

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Table 4: Screening tools used for common cancers in our unit[16]

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Table 5: Cancer Biomarkers and their potential uses for screening[17]

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CDC recommended vaccination schedule

  1. Dosing schedule for HPV:


    • <15 yr age: 2 doses (6 months apart)
    • 15 to 26 yrs: 3 doses (current, 1 month later, 5-6 months later)
    • 27 to 45 yrs: catch-up vaccination,
    • >45 yrs: not used,
    • Males upto age 21 yrs can be vaccinated,


  2. Dosing schedule for HBV:


    • 0, 1, 6 month schedule
    • Booster dose for immunocompromised individuals, hemodialysis patients (anti-HBs <10 mIU/ml)


Fellowship in preventive oncology unit

The one-year course in our Unit will train a Community Physician in the mechanisms involved in interplay of genetic, neurobiological, psychological and environmental factors for initiation for risk factors, and methodological approach for cancer prevention. The coursework includes: Prevention of organ specific tumors, Causal inference and evidence-based decisions, Community interventions, Biomarker assessment, Oncogenes and molecular epidemiology, and Occupation and Environment.


  Conclusion Top


Our goal is to generate relevant knowledge in the areas of cancer epidemiology and prevention, which eventually will make a significant impact on reducing the morbidity of cancer. This novel endeavor in a tertiary cancer hospital in a Developing Country will enable dissipation of cancer phobia and empower individuals with knowledge about cancer. This in-turn will enable navigation for screening services and behavioral change initiatives for others in their community. In the near future, we intend to conduct chemoprevention trials with nutrient supplements such as Vitamin D and other drugs such as tamoxifen, aspirin, and finasteride.

Challenges in preventive oncology

  • Cancer develops over decades by multiple processes, some of which may be irreversible by adulthood,
  • Varieties of cancers each with its set of causes and potential preventive strategies,
  • Etiological cohort studies and prevention intervention trials with cancer as outcome, require large sample size (tens of thousands) and long duration of follow-up.


Acknowledgement

Dr. Nalini Rao, Radiation Oncologist, HCG.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cancer fact sheets. World Health Organization. Available from: who.int/health-topics/cancer. [Last accessed on 2020 Apr 08].  Back to cited text no. 1
    
2.
Cancer control: Knowledge into action. WHO Guide for effective Programmes: Module 3: Early detection. Geneva: World Health Organization; 2007. PMID: 24716262.  Back to cited text no. 2
    
3.
Saranth D, Khanna A. Current status of cancer burden: Global and Indian scenario. Biomed Research Journal 2014;1:1-5.  Back to cited text no. 3
    
4.
Cancer prevention, American Institute for Cancer Research. Available from: aicr.org. [Last accessed on 2020 Apr 08].  Back to cited text no. 4
    
5.
Healthcare Global Enterprise Limited. Available from: www.hcgoncology.com. [Last accessed on 2020 Apr 09].  Back to cited text no. 5
    
6.
Panchal PH. Trailing the path to preventive oncology. Adv Cancer Prev 2016;1:104.  Back to cited text no. 6
    
7.
Lauenstein TC, Semelka RC. Emerging techniques: Whole-body screening and staging with MRI. J Magn Reson Imaging 2006;24:489-98.  Back to cited text no. 7
    
8.
Lee SY, Park HJ, Kim MS, Rho MH, Han CH. An initial experience with the use of whole body MRI for cancer screening and regular health checks. PLoS One 2018;13:e0206681.  Back to cited text no. 8
    
9.
Kwee RM, Kwee TC. Whole body MRI for preventive health screening: A systematic review of the literature. J Magn Reson Imaging 2019;50:1489-503.  Back to cited text no. 9
    
10.
Semelka R. Why MRI should replace CT for whole body screening. Medscape Radiol 2004;5.  Back to cited text no. 10
    
11.
Anupindi SA, Bedoya MA, Lindell RB, Rambhatla SJ, Zelley K, Nichols KE, et al. Diagnostic performance of whole body MRI as a tool for cancer screening in children with genetic cancer predisposing conditions. Am J Roentgenol 2015;205:400-8.  Back to cited text no. 11
    
12.
Available from: https://www.choosingwisely.org/patient-resources/whole-body-scans-to-screen-for-cancer/. [Last accessed on 2019 Dec 26].  Back to cited text no. 12
    
13.
Ulus S, Suleyman E, Ozcan UA, Karaarslan E. Whole-body MRI screening in asymptomatic subjects: Preliminary experience and long-term follow-up findings. Pol J Radiol 2016;81:407-14.  Back to cited text no. 13
    
14.
American cancer society prevention and early detection guidelines. Available from: cancer.org/healthy. [Last accessed on 2020 Apr 09].  Back to cited text no. 14
    
15.
Cancer screening overview, National Cancer Institute. Available from: cancer.gov/about-cancer/screening. [Last accessed on 2020 Apr 10].  Back to cited text no. 15
    
16.
Cancer recommendations. U.S Preventive Services task force. Available from: uspreventiveservicestaskforce.org. [Last accessed on 2020 Apr 09].  Back to cited text no. 16
    
17.
Henry Lynn N, Hayes DF. Cancer biomarkers. Mol Oncol 2012;6:140-6.  Back to cited text no. 17
    
18.
Vaccines & Immunizations. Centers for Disease control and prevention. Available from: cdc.gov/vaccines/schedules/hcp/imz/adult.html. [Last accessed on 2020 Apr 09].  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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