Correspondence
Huaxi Student Society of Oncology Research, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China (LD, FN, JW); and Department of Thoracic Cancer, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37# Guoxuexiang, Chengdu, 610041, Sichuan, China (YL) 1
2
3
Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538. Wang J, Kushner K, Frey JJ 3rd, Ping Du X, Qian N. Primary care reform in the Peoples’ Republic of China: implications for training family physicians for the world’s largest country. Fam Med 2007; 39: 639–43. Deng L, Na FF, Wang JW, et al. Insufficient screening knowledge in Chinese interns: a survey in ten leading medical schools. Asian Pac J Cancer Prev 2011; 12: 2801–06.
Cancer care in Sikkim, India Rengaswamy Sankaranarayanan1 briefly describes the deficiencies in cancer care in India. He mentioned the cervical cancer screening programme in the Himalayan state Sikkim, located in the fairly remote and underserved northeastern region of India. Although the programme has been implemented in the state, it has recently faced legal issues over safety aspects of the vaccination programme.2 Also, in the absence of reliable and comprehensive cancer care facilities and specialists in Sikkim, most of the patients with cancer have to travel to distant places—eg, Kolkata, Delhi, and Mumbai—for definitive oncology treatment and follow-up. Although the cost of treatment is reimbursed by the state government, such a facility is available only to patients with valid domicile documents and to state government employees.3 With a growing population coming into the state for work, a large proportion of the population of the state has to incur huge costs not only for treatment, but also for travel and accommodation, in addition to the loss of income for more than one family member. A major hurdle in providing specialised and comprehensive e301
cancer care is the small number of cases in the state. For most cancer sites, the yearly incidence of new cases is seldom in double figures.4 This low incidence is due to the small population in the state (600 000 as per the 2011 census).5 Creating extensive infrastructure within the state for a small population might not be cost effective. At the same time, the health needs of the population cannot be ignored. The state has a long way to go before the entire population has convenient access to the entire range of oncology services within the state with financial assistance or insurance cover without disparities for residents and nonresidents. A possible solution lies in converting Himalayan states like Sikkim into health-care hubs. The hilly Indian states have a temperate climate, by contrast with the tropical climate in the rest of the country, and hence could provide a more comfortable environment for convalescence. Such a measure would make expensive cancer care infrastructure cost effective. I declare no competing interests.
Abhijeet Bhatia [email protected] Sikkim Manipal Institute of Medical Sciences, Gangtok 737102, India 1
2
3
4
5
Sankaranarayanan R. Cancer prevention and care in India: an unfinished agenda. Lancet Oncol 2014; 15: 554–55. Sarkar D. Sikkim to go slow on multimillion cervical cancer vaccine project. Himalayan Mirror (Gangtok Ed) May 11, 2013: 1. Verma Y, Pradhan P. Population based cancer registry, Sikkim state. Three year report of population based cancer registries 2009–2011. Bangalore: National Centre for Disease Informatics and Research, National Cancer Registry Program, 2013, 492–509. Verma Y, Pradhan PK, Gurung N, et al. Population-based cancer incidence in Sikkim, India: report on ethnic variation. Br J Cancer 2012; 106: 962–65. Provisional population totals paper 1 of 2011: Sikkim. New Delhi: The Registrar General and Census Commissioner, Government of India. 2010–11 http://www.censusindia.gov.in/2011prov-results/prov_data_products_sikkim.html (accessed June 12, 2014).
ASPECCT: panitumumab versus cetuximab for colorectal cancer We read with interest the Article by Timothy Price and colleagues,1 in which they reported that panitumumab and cetuximab provide similar overall survival and toxicity profiles as would be expected in heavily pretreated patients with colorectal cancer. Their results also showed that the incidence of grade 3 or 4 hypomagnesaemia was greater in patients receiving panitumumab than in those receiving cetuximab, although the incidence of severe skin toxicities was similar in the two groups. A meta-analysis of randomised studies that included panitumumab and cetuximab in the treatment of several cancer types showed that risk of the hypomagnesaemia to be even higher for panitumumab than for cetuximab.2 Magnesium is absorbed in the gut and reabsorbed in the ascending limb of the loop of Henle by TRMP6, the activation of which is mediated by EGFR signalling. Magnesium wasting is thought to be caused by anti-EGFR agents inhibiting the regeneration of tubular epithelial cells and the activation of TRMP6.3,4 Hence, it is biologically plausible that higher affinity binding of panitumumab to EGFR might contribute to a difference in the incidence of severe hypomagnesaemia between the panitumumab and cetuximab groups, as suggested by Price and colleagues. However, hypomagnesaemia was the only toxicity more frequently noted in patients receiving panitumumab than in those receiving cetuximab in the study. Additionally, the results showed that these anti-EGFR antibodies provide no difference in overall survival benefit in heavily pretreated patients with colorectal cancer. Whether the higher affinity binding of panitumumab to EGFR than that of cetuximab causes a difference www.thelancet.com/oncology Vol 15 July 2014
Huaxi Student Society of Oncology Research, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China (LD, FN, JW); and Department of Thoracic Cancer, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37# Guoxuexiang, Chengdu, 610041, Sichuan, China (YL) 1
2
3
Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538. Wang J, Kushner K, Frey JJ 3rd, Ping Du X, Qian N. Primary care reform in the Peoples’ Republic of China: implications for training family physicians for the world’s largest country. Fam Med 2007; 39: 639–43. Deng L, Na FF, Wang JW, et al. Insufficient screening knowledge in Chinese interns: a survey in ten leading medical schools. Asian Pac J Cancer Prev 2011; 12: 2801–06.
Cancer care in Sikkim, India Rengaswamy Sankaranarayanan1 briefly describes the deficiencies in cancer care in India. He mentioned the cervical cancer screening programme in the Himalayan state Sikkim, located in the fairly remote and underserved northeastern region of India. Although the programme has been implemented in the state, it has recently faced legal issues over safety aspects of the vaccination programme.2 Also, in the absence of reliable and comprehensive cancer care facilities and specialists in Sikkim, most of the patients with cancer have to travel to distant places—eg, Kolkata, Delhi, and Mumbai—for definitive oncology treatment and follow-up. Although the cost of treatment is reimbursed by the state government, such a facility is available only to patients with valid domicile documents and to state government employees.3 With a growing population coming into the state for work, a large proportion of the population of the state has to incur huge costs not only for treatment, but also for travel and accommodation, in addition to the loss of income for more than one family member. A major hurdle in providing specialised and comprehensive e301
cancer care is the small number of cases in the state. For most cancer sites, the yearly incidence of new cases is seldom in double figures.4 This low incidence is due to the small population in the state (600 000 as per the 2011 census).5 Creating extensive infrastructure within the state for a small population might not be cost effective. At the same time, the health needs of the population cannot be ignored. The state has a long way to go before the entire population has convenient access to the entire range of oncology services within the state with financial assistance or insurance cover without disparities for residents and nonresidents. A possible solution lies in converting Himalayan states like Sikkim into health-care hubs. The hilly Indian states have a temperate climate, by contrast with the tropical climate in the rest of the country, and hence could provide a more comfortable environment for convalescence. Such a measure would make expensive cancer care infrastructure cost effective. I declare no competing interests.
Abhijeet Bhatia [email protected] Sikkim Manipal Institute of Medical Sciences, Gangtok 737102, India 1
2
3
4
5
Sankaranarayanan R. Cancer prevention and care in India: an unfinished agenda. Lancet Oncol 2014; 15: 554–55. Sarkar D. Sikkim to go slow on multimillion cervical cancer vaccine project. Himalayan Mirror (Gangtok Ed) May 11, 2013: 1. Verma Y, Pradhan P. Population based cancer registry, Sikkim state. Three year report of population based cancer registries 2009–2011. Bangalore: National Centre for Disease Informatics and Research, National Cancer Registry Program, 2013, 492–509. Verma Y, Pradhan PK, Gurung N, et al. Population-based cancer incidence in Sikkim, India: report on ethnic variation. Br J Cancer 2012; 106: 962–65. Provisional population totals paper 1 of 2011: Sikkim. New Delhi: The Registrar General and Census Commissioner, Government of India. 2010–11 http://www.censusindia.gov.in/2011prov-results/prov_data_products_sikkim.html (accessed June 12, 2014).
ASPECCT: panitumumab versus cetuximab for colorectal cancer We read with interest the Article by Timothy Price and colleagues,1 in which they reported that panitumumab and cetuximab provide similar overall survival and toxicity profiles as would be expected in heavily pretreated patients with colorectal cancer. Their results also showed that the incidence of grade 3 or 4 hypomagnesaemia was greater in patients receiving panitumumab than in those receiving cetuximab, although the incidence of severe skin toxicities was similar in the two groups. A meta-analysis of randomised studies that included panitumumab and cetuximab in the treatment of several cancer types showed that risk of the hypomagnesaemia to be even higher for panitumumab than for cetuximab.2 Magnesium is absorbed in the gut and reabsorbed in the ascending limb of the loop of Henle by TRMP6, the activation of which is mediated by EGFR signalling. Magnesium wasting is thought to be caused by anti-EGFR agents inhibiting the regeneration of tubular epithelial cells and the activation of TRMP6.3,4 Hence, it is biologically plausible that higher affinity binding of panitumumab to EGFR might contribute to a difference in the incidence of severe hypomagnesaemia between the panitumumab and cetuximab groups, as suggested by Price and colleagues. However, hypomagnesaemia was the only toxicity more frequently noted in patients receiving panitumumab than in those receiving cetuximab in the study. Additionally, the results showed that these anti-EGFR antibodies provide no difference in overall survival benefit in heavily pretreated patients with colorectal cancer. Whether the higher affinity binding of panitumumab to EGFR than that of cetuximab causes a difference www.thelancet.com/oncology Vol 15 July 2014
