Neerja Bhatla

Multimodal Prehabilitation in Indian Women with Advanced Ovarian Cancer: Enhancing Nutritional, Psychological, and Surgical Recovery

Malnutrition is common among women with gynecologic cancers, particularly advanced ovarian cancer, and adversely impacts treatment tolerance, surgical recovery, and quality of life. The neoadjuvant chemotherapy (NACT) phase provides a unique opportunity to introduce prehabilitation interventions to improve perioperative outcomes. To evaluate the feasibility and impact of a culturally tailored, home-based multimodal prehabilitation program on perioperative outcomes in Indian women with advanced ovarian cancer undergoing NACT.  Methods: Sixty women planned for NACT were enrolled and allocated to either a prehabilitation group (n = 30) or control group (n = 30). The intervention include yoga-based physiotherapy, individualized nutritional counseling, and psychological support. Outcomes assessed pre- and post-NACT included body mass index (BMI), hemoglobin, serum albumin, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), skeletal muscle index (SMI), Hospital Anxiety and Depression Scale (HADS) scores, in each group and between group comparisons of perioperative outcomes. Both groups showed significant within-group improvements in nutritional and inflammatory markers. Between-group comparisons revealed a smaller decline in BMI (-1.29 vs. -4.51; p < 0.001) and a greater reduction in HADS scores (-4.5 vs. -1.5; p =0.013) in the prehabilitation group. Hospital stay was significantly shorter in the prehabilitation group (median: 4 vs. 5.5 days;  p = 0.005), while reductions in intraoperative blood loss and postoperative complications did not reach statistical significance. Greater physiotherapy session attendance correlated with reduced BMI loss (ρ = -0.4187, p = 0.022). Multivariable analysis showed that prehabilitation and physiotherapy adherence were associated with smaller BMI declines, and prehabilitation reduced the odds of prolonged hospitalization. Implementing a culturally adapted multimodal prehabilitation program is feasible and improves short-term nutritional, psychological, and perioperative outcomes in women undergoing NACT for advanced ovarian cancer.

Diagnostic Translational Considerations for Global Health Settings: Portable Detection of Human Papillomavirus for Cervical Cancer Screening in India

PURPOSE Translation of diagnostic technology developed at the laboratory bench involves iterations of user feedback and design modifications. Learning about translational requirements early in the design process facilitates the development of feasible prototypes that have a better likelihood of implementation in global health settings. During our development of a portable system to detect human papillomavirus (HPV) for cervical cancer screening in India, we encountered and solved issues related to research translation. We report our findings to help others deploying diagnostic technology for global health. MATERIALS AND METHODS We designed a point-of-care system to process patient samples and diagnose HPV infection in the cervix. We continually shipped components of the system from the United States to our collaborating team in India to assess component condition and usability at the local site. We simultaneously developed HPV isothermal amplification assays that were fit for purpose. Cervical brush samples were used in our portable system for functional validation. RESULTS We found ideal transport methods to ensure component quality and reagent stability through the international shipment chain. Portable systems should be designed as simple as possible for correct usage at the local testing site. Usability tests drove our design improvements from 28% to 93% success rates. We demonstrated proof-of-concept functionality of our portable system for 13 cervical brush samples on-site, with a sensitivity of 100% and specificity of 88.9%. CONCLUSION Issues related to technology transfer for global health settings manifest during distribution and deployment of prototypes. We identified several issues during our synergistic design process and report recommendations on the basis of our experience.

Cancer of the cervix uteri: 2025 update

AbstractSince the publication of the 2021 FIGO Cancer Report, there has been further progress in the global effort to attain the WHO goal of cervical cancer elimination using a three‐pillar approach of vaccination, screening, and treatment. The HPV vaccination is now included in the national program of over 140 countries. Two‐dose schedules are being implemented in 80 countries and one‐dose schedules in 60 countries. Screening has seen major advances with the wider implementation of HPV testing, including the option of self‐sampling, portable screening and treatment devices, and the incorporation of artificial intelligence. Diagnostic accuracy is being enhanced with immunohistochemistry and receptor assays. Surgical treatment of invasive cancer is being revolutionized with the possibility of conservative surgery in very early stages, minimizing complications and adverse effects and offering feasibility of fertility sparing. New data on minimally invasive surgery are redefining the role of laparoscopy and robotic surgery in early stages with small tumor size. Sentinel lymph node evaluation is an emerging alternative to complete lymphadenectomy. Immunotherapy has opened up new possibilities for the management of recurrent and metastatic disease. This chapter discusses the management of cervical cancer based on the stage of disease, including attention to palliation and quality‐of‐life issues, with insights into the results from recent landmark trials.

Novel Strategy of Training the Accredited Social Health Activists via Application-Based Telemedicine for Cervical Cancer Screening by Human Papillomavirus Self-Sampling: The TRACK Study

PURPOSE This pilot study is aimed to analyze a novel strategy of cervical cancer screening by training of Accredited Social Health Activist (ASHA) workers via telemedicine to counsel women for human papillomavirus (HPV) self-sampling. MATERIALS AND METHODS This is a pilot, community-based, prospective, single-arm study. Physicians trained the ASHA workers regarding self-sampled HPV testing via a mobile application and telephonically using videos and e-pamphlets, who in turn trained the clients in community. The HPV kits were transported via prepaid courier service. RESULTS Four hundred and sixty-five women of age group 30-65 years were tested by 47 teletrained ASHA workers. The mean age of ASHA worker and clients was 39.47 ± 6.45 and 37.26 ± 8.38 years, respectively. Of the ASHA workers, 91.7% were satisfied with the information provided during telecounseling, 95.7% could understand the contents of mobile app easily, and 93.6% could fill the data of clients in app easily. Of the clients, 99.6% were satisfied with counseling by ASHA workers and 98% found it easy to self-sample. The acceptability of this strategy among clients was 58.2%. The feasibility of this strategy (percentage of clients who find it easy/those who did self-sampling) was around 99%. Among those screened, 11.8% were high-risk HPV-positive and 85.5% had follow-up at the study center. CONCLUSION The current study highlights a novel strategy of cervical cancer screening by incorporating the role of telemedicine in training ASHA workers and their role in improving the screening by home-based delivery of HPV kits with promising results.

Human papillomavirus vaccination: Good clinical practice recommendations from the Federation of Obstetric and Gynecological Societies of India

AbstractHuman papillomavirus (HPV) vaccination offers an excellent prospect for the primary prevention of cervical cancer. The bivalent and quadrivalent vaccines are both available in India. The nonavalent vaccine is licensed but not yet available. However, there still remain controversies regarding the vaccination of older women, immunocompromised females and other special groups. To provide recommendations for HPV vaccination in India. The Federation of Obstetric and Gynecological Societies of India (FOGSI) convened an expert group on cervical cancer prevention to formulate good clinical practice recommendations (GCPR) with respect to vaccine efficacy and safety, target groups, optimal timing and dosing schedules. HPV vaccines are licensed for females aged 9–45 years in India and have been seen to be safe and effective. FOGSI recommends HPV vaccination of all girls &lt;15 years of age as the best target group, in whom two‐doses at an interval of 6 months, extendable to 18 months, are recommended. Three‐doses are recommended in girls &gt;15 years of age, immunocompromised persons and sexual assault survivors. Older women and women with abnormal screening results may be vaccinated with an understanding that vaccination does not protect against already acquired infections and screening has to continue. Single‐dose vaccination results are promising. Increased awareness is required to reduce vaccine hesitancy. HPV vaccination should be the priority to achieve the elimination of cervical cancer. The introduction of affordable HPV vaccines and reduced dose schedules will improve coverage.

Patterns of care for vulvar cancer and insights from revised FIGO staging: a retrospective study

The objective of this study was to evaluate the clinicopathological characteristics and patterns of care among women diagnosed with vulvar malignancy at a tertiary care teaching institute. Additionally, the study aimed to analyse the implications of revised FIGO staging system on stage shift and patient outcomes. A retrospective observational study was conducted, wherein hospital records of biopsy-proven cases of vulvar cancers managed over a period of 10 years were comprehensively reviewed. The assignment of FIGO staging was performed utilizing both 2009 and 2021 FIGO staging systems for comparative analysis. Statistical analysis was performed using STATA version 17. Survival curves were constructed using the Kaplan-Meier method, with differences assessed using the log-rank test. Additionally, multivariable analysis was conducted using the Cox proportional hazard model. A total of 82 cases meeting the inclusion criteria were enrolled in the study. Management patterns varied widely, with the majority undergoing surgery (73.2%), followed by definitive radiotherapy with or without chemotherapy (10.9%), neoadjuvant radiotherapy and subsequent surgery (4.9%), and palliative care (10.9%). Post-operative radiotherapy was administered in 31.7% of cases. The disease-specific recurrence rate was found to be 32.9%, and the mortality rate was 30.5%. The median Disease-Free Survival (DFS) was 17 months (interquartile range [IQR]: 1-36 months), while the Overall Survival (OS) was 27 months (IQR: 9-52 months). Upon application of the 2021 staging system, a stage shift was observed in 18% of cases of advanced vulvar cancer. The 3-year DFS and OS were reduced for stage IIIA and stage IVA, while showing improvement for stage IIIB. The revised FIGO 2021 staging system offers enhanced simplicity in its application within clinical practice and demonstrates improved correlation with prognosis. Approximately 18% cases experienced restaging under the updated system. Not applicable.