Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : June | Volume : 4 | Issue : 3 | Page : 2378 - 2383

Forecasting Breast Cancer Cases requiring Radiotherapy at a Teaching Hospital in Nepal.

SATHIAN B, SREEDHARAN J , SHARAN K*, SURESH B N , NINAN J , JOY T, ABHILASH E S

*(Lecturer)[Ph.D(Biostatistics) Scholar],DeptofCommunityMedicine,Manipal CollegeofMedicalSciences,**(Ph.D)Biostatistics,Asst. Director Research Division,Gulf Medical UniversityAjman, (UAE),***(MD)Asst Prof,Deptof radiotherapy,ManipalUniversity,Udupi,Karnataka,(India).****(MD,DNB,MNAMS, FaeMS, FIMSA, FCCP)Professor, Dept of Physiology,****** (MSc)Lecturer, Dept of Anatomy,ManipalCollegeofMedical Sciences,(Nepal)*****(MSc)Lecturer, Dept ofradiotherapy,Manipal Teaching Hosp,Pokhara(Nepal)

Correspondence Address :
Dr. Brijesh Sathian. MD(AM), M.Sc, PGDCA, Ph.D (Biostatistics) Scholar, Lecturer, Department of Community Medicine, Manipal College of Medical Sciences, Deep Height 16, PO BOX 155, Pokhara, (Nepal0.Phone No: 9804180332 Email:brijeshstat@gmail.com

Abstract

Objective: The aim of this study was to determine the trends and to estimate the future load of patients with breast cancer requiring radiotherapy at Manipal Teaching Hospital, Pokhara, Nepal.
Materials and Methods: A retrospective study was carried out on the data collected from the treatment records of patients who were treated with radiotherapy at the department of Radiation Oncology at Manipal Teaching Hospital (MTH), Pokhara, between September 2000 and December 2008. Descriptive statistics and statistical modelling were used for the analysis and the forecasting of data.
Results: Seventy patients were found to have been treated with radiotherapy for breast cancer during the study period. The patients’ mean age was 49.9 years (95% CI: 47.6, 52.3). Curative treatment was given to 80% and palliative treatment to the remaining 20% of the patients. Patients from the age group of 45-64 years were more likely to receive curative 76.2% radiotherapy. The compliance to treatment was 100% among the age group of 25-44 years and 90.5% among the group of 45-64 years, as compared to only 66% among patients older than 65 years. (p = 0.03). The number of patients receiving radiotherapy for breast cancer showed a pattern of increasing trend. Excluding the constant term from the equation, the cubic model was the best fitted with R2 = 0.95, p = 0.001 for the forecasting of breast cancer cases. Using this model, the number of breast cancer cases treated with radiotherapy at the hospital by the year 2015 was estimated to be 194.
Conclusion: Breast cancer cases in Nepal show an increasing trend and treatment facilities are bound to be hard pressed in providing the necessary health care to the public. Nepal should adopt better strategies for the early detection of the disease and improvise on the resources required for the treatment of this malady.

Keywords

Breast cancer, radiotherapy, future trend, incidence

Introduction
Breast cancer is the most common cancer and the leading cause of cancer deaths among women worldwide (1).Although the causes and the natural history of breast cancer remain unclear, epidemiological research has uncovered genetic, biological, environmental and lifestyle risk factors for the disease. Over the past several decades, the risk of breast cancer in developed countries has increased by one to two percent annually (2) .While the data for developing countries are limited, cancer registries suggest that age-standardized incidence rates are rising even more rapidly in low-incidence regions such as Africa and Asia (3). Radiotherapy is an integral treatment component in the multimodal treatment approach for many patients with breast cancer. Perez and colleagues estimate that breast cancers constitute 25% of the patients visiting the radiotherapy OPD. Radiotherapy is used to reduce the loco-regional recurrence and the possible improvement in survival among these patients. Radiotherapy is also used with a palliative intent to achieve symptom relief. The aim of this study was to determine the trends and to estimate the future load of patients with breast cancer requiring radiotherapy at Manipal Teaching Hospital, Pokhara, Nepal.

Material and Methods

This hospital based study was conducted with the data available at the Department of Radiotherapy and Oncology, Manipal Teaching Hospital, Pokhara (MTH). Pokhara is a major town in the Western development region of Nepal and MTH is the only cancer treatment centre in this region. The data of breast cancer cases treated by external radiotherapy between September 2000 and December 2008 was collected from the department archives. The age of the patient, the date of presentation, the intent to treat (curative vs. palliative) and whether or not the patient completed the prescribed treatment, were recorded. The data was analysed using Excel 2003, R 2.8.0 Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSS Inc; Chicago, IL, USA) and the EPI Info 3.5.1 Windows Version. The chi-square test was used to examine the association between different variables. A p-value of < 0.05 (two-tailed) was used to establish statistical significance. The annual numbers of patients visiting the centre for radiotherapy was then plotted against the corresponding year in the x-axis. Curve fitting, also known as regression analysis, was used to find the "best fit" line or curve for a series of data points. Linear, Logarithmic, Inverse, Quadratic, Cubic, Compound, Power, Exponential and Growth models were chosen to fit to the obtained curve. The F-test was used for selecting the best fitting curve for the testing of hypothesis. P-value was taken as significant when < 0.05 (two-tailed). R2 values > 0.80 were taken as significantly better for prediction (4). Prior approval for the study was obtained from the institutional research ethical committee.

The decision regarding the selection of a suitable approach for prediction is governed by the relative performance of the models for monitoring and prediction. It should also adequately interpret the phenomenon under study. The cubic model selected here could closely fit curves for estimated and observed breast cancer cases (Table/Fig 1). While building models, the extremities (maximums and minimums) play a great role. If the points are scattered more, the curve tries to adjust with maximum number of observed points. The cubic model is a third degree polynomial, represented by the equation y = m0 + m1 * x + m2 * x2 + m3 * x3, where m0 is the constant term and m1, m2, m3 are coefficient terms 5,6. Without the constant term, the equation of this model is y = m1 * x + m2 * x2 + m3 * x3. This equation was the best fit equation in the forecasting of cancer cases from our data and the equation for predicting the total number of breast cancer cases receiving radiotherapy at our centre is Y= 7.171X - 1.837X2 + 0.134X3, where Y is the number of breast cancer cases presenting annually and X is the corresponding year (1=2000, 2=2001, 3=2002, 4=2003 and so on).

Results

A total of 70 breast cancer patients treated by radiotherapy in the aforementioned period were analyzed. The patients’ ages ranged from 25 to 69 years, the mean age being 49.9 years (95% CI: 47.6, 52.3). (Table/Fig 2)depicts the annual numbers of patients with breast cancer receiving radiotherapy from the year 2000 onwards. The numbers of the cases had an increasing trend that reached a peak in 2006, showing a sharp decline in the years 2004, 2005 and in 2007 before recovering back in 2008.



(Table/Fig 3) displays compliance to treatment in various age categories. It can be noted that the younger age group of 25-44 years had 100% compliance to treatment, while the age groups of 45-64 and 65-74 years had a 90.5 and a 66.7% completion rate, respectively. The difference was found to be statistically significant (p = 0.03). (Table/Fig 4) shows the age group and the intent to treat. Patients from the age group of 25-44 years were more likely to receive curative radiotherapy (86.4%), while the patients between 45 and 64 years of age were more likely to receive palliative radiotherapy.



The data were modelled using the curve fitting method. (Table/Fig 5) depicts the model summary and the parameter estimates including the constant term for different models. When the constant term was included, the p values were >0.05 in all the models and none of the models were best fitted. After excluding the constant term, all curves (except for inverse curve) fitted well with the data. (Table/Fig 6) displays the model summary and the parameter estimates excluding the constant term for different models and (Table/Fig 1) shows the fitted curves for observed breast cancer cases. However, with the highest R2 value, the cubic model is the best fit, with R2 = 0.83, p = 0.001 and shape of the curve also conforming well to the observed data, as compared to other curves.


(Table/Fig 7) depicts the observed number of cases until 2008 and the estimated number of cases along with confidence intervals up to 2015. The observed and the estimated number of cases have a fair degree of coincidence up to 2008. This model can thus be considered to be able to project the data with reasonable precision. The projected numbers of breast cancer patients visiting the centre for radiotherapy using this model hint at an increasing trend from 2009 onwards. One hundred and ninety four patients are expected to visit the centre for radiotherapy for breast cancer by the year 2015.

Discussion

The cancer prevalence rate in Nepal is unknown due to the lack of a population based national cancer registry. However, every year, at least 17,000 new cancer cases are estimated and the figure is expected to go up considerably in the future (1). The increasing rates of newly diagnosed cases of breast cancer in developing countries are bound to put a stress on their limited resources available for treatment. Moreover, establishing a radiotherapy centre is a very expensive undertaking. Nepal has only 4 centres which are equipped to treat patients with radiotherapy, to date. In our study, using the curve fitting method, we tried to estimate the number of breast cancer cases that are expected to undergo radiotherapy in this region of Nepal in the near future.

As seen in the (Table/Fig 6), from the year 2009 onwards, the cases show an increasing trend. From (Table/Fig 1) it is clear that breast cancer patients from the age group of 45-64 years presented the most to our department. In many countries where the incidence of breast cancer is great enough to pose a public health problem, the government, medical professionals, and the public may not recognize its importance. Advocacy directed to government officials and policy makers can place breast cancer on the national agenda, encourage the development of systematic health policies and service protocols and increase women’s access to the detection and treatment services (7). From this study, it was found that 17% of patients in the age group of 65-74 years, 24% patients in the age group of 45-64 years and 14% patients in the age group of 25-44 years were not likely to receive curative radiotherapy. In other studies, elderly patients have been observed to be more likely to receive palliative rather than curative radiotherapy (8). Considering the compliance to treatment, the age group of 25-44 years had 100% completion, the age group of 45-64 years had 90.5 completion and the age group of 65-74 years had 66.7% completion. There is a statistical relationship between the age group and completion (p = 0.03) in breast cancer radiotherapy treatment. The issue of patient access is a significant factor in many published reports that consider the development of radiation oncology services (9),(10),(11),(12),(13).

Using the curve fitting method, we estimated the number and the trend of breast cancer cases which had to receive radiotherapy at MTH from the years 2002 to 2015. The cubic model provided closely fitted curves for estimated and observed cancer cases (Table/Fig 1). While building models, the extremities (maximums and minimums) play a great role. If the points are scattered more, the curve tries to adjust with maximum number of observed points. Therefore, it might give over-and under-estimation inevitably, but that is not the case in all the situations. A sudden annual decrease and increase in the trend is possible, as the curve cannot exactly connect these data points because of its shape. For adjusting the over-and under-estimation, the model gave wide confidence intervals in the cases of some years (Table/Fig 7). In our study, the future annual estimated breast cancer-cases (Table/Fig 6) showed an increasing trend of the disease after the year 2010. Such an increase might be convincing as the cancer incidence in developing countries is expected to rise principally due to the possible decline of mortality from infectious diseases, population growth and increasing life expectancy(14). Our study hereby establishes the applicability of statistical modelling in predicting the cancer incidence in the Nepalese context. (Table/Fig 8)

Conclusion

Considering that the projections of our hospital data show a continuously increasing trend, it can be appreciated that breast cancer is on rise in Nepal. Thus, in the near future, there might be a discrepancy between the necessity and the delivery of health care for these patients. The Nepal Government must now be geared up to promote better strategies for health promotion, prevention, the earlier diagnosis and the treatment of breast cancer cases in the coming years.

Key Message

1. Introduction
Breast cancer is the most common cancer and the leading cause of cancer deaths among women worldwide.
2. Discussion
a. Without the constant term, the equation of this model is y = m1 * x + m2 * x2 + m3 * x3. This equation was the best fit equation in the forecasting of cancer cases from our data.
b. In many countries where the incidence of breast cancer is great enough to pose a public health problem, the government, medical professionals and the public may not recognize it’s importance.
c. Considering the compliance to treatment, the age group of 25-44 years had 100% completion, the group of 45-64 years had 90.5% completion and the age group of 65-74 years had 66.7% completion.
3. Conclusion
In the near future, there might be a discrepancy between the necessity and the delivery of health care for breast cancer patients.

Acknowledgement

Dr. B M Nagpal, CEO Manipal Education and Medical group Dean, Manipal College of Medical Sciences, P O Box No 155, Deep Heights Pokhara (Nepal), for permitting the authors to use the hospital documents for the study.

References

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Ngoma, T. Organization of cancer services in low resource environments—the Tanzania experience. (Abst). Cancer Strategies for the New Millennium. 1998: (10): 19-20,
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Olmi P, Ausili-Cefaro G. Radiotherapy in the elderly: a multicentric prospective study on 2060 patients referred to 37 Italian radiation therapy centers. Rays. 1997; 22(1 Suppl):53-6.
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Wigg DR, Morgan GW. Radiation oncology in Australia: workforce, workloads and equipment 1986-1999. Australas Radiol. 2001;45(2):146-69.
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Burrell JE. Radiation therapy at the crossroads. Adm Radiol J. 1999 ;19(2-3):22-4.
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