Retrospective analysis: checkpoint inhibitor accessibility for thoracic and head and neck cancers and factors influencing it in a tertiary centre in India

Background: Access to cancer care is an issue in low and low middle-income countries. The problem is worse with respect to access to new therapies like checkpoint inhibitors. Hence, we decided to audit our practice in the head and neck and thoracic medical oncology unit from 2015 to 2019 to study the accessibility of checkpoint inhibitors and factors influencing it.

Methods: All patients who were registered in the head and neck and thoracic medical oncology unit between 2015 and 2019 were included in the study. Patients who received immunotherapy were identified from the prospective database of immunotherapy maintained by the department. We made a list of patients who were eligible for immunotherapy per year and identified how many of them received recommended immunotherapy. The indication for eligibility of immunotherapy was based on published pivotal data and it was applicable from the date of publication of the study online. Descriptive statistics were performed. For nominal and ordinal variable percentage with 95% confidence intervals (95% CI) was provided. Factors impacting the accessibility of immunotherapy were identified.

Findings: A total of 15,674 patients were identified who required immunotherapy; out of them only 444 (2.83%, 95% CI: 2.58–3.1) received it. Among head and neck cancer patients, 4.5% (156 out of 3,435) received immunotherapy versus 2.35% (288 out of 12,239) among thoracic cancer patients (p < 0.001). Among the general category (low socioeconomic), 0.29% (28 out of 9,405 ) versus 6.6% (416 out of 6,269) among the private category (high socioeconomic) received immunotherapy (p < 0.001). While 3.7% (361 out of 9,737) among males versus 1.39% (83 out of 5,937) females received immunotherapy (p < 0.001). There was also a temporal trend seen in the accessibility of immunotherapy (p < 0.001). Conclusion: The accessibility of immunotherapy is below 3% in India. Patients with head and neck cancers, those registered as private category and male patients had higher access to this therapy. There was also a temporal trend observed suggesting increased accessibility over the years.

Cost of open access publishing in otolaryngology-head and neck surgery

Objective
Open access (OA) publishing makes research more accessible but is associated with steep article processing charges (APCs). The study objective was to characterize the APCs of OA publishing in otolaryngology-head and neck surgery (OHNS) journals.

Methods
We conducted a cross-sectional analysis of published policies of 110 OHNS journals collated from three databases. The primary outcomes were the publishing model, APC for original research, and APC waiver policy.

Results
We identified 110 OHNS journals (57 fully OA, 47 hybrid, 2 subscription-only, 4 unknown model). After excluding 12 journals (2 subscription-only, 4 unknown model, 5 OA with unspecified APCs, and 1 OA that accepts publications only from society members), we analyzed 98 journals, 23 of which did not charge APCs. Among 75 journals with nonzero APCs, the mean and median APCs were $2452 and $2900 (interquartile range: $1082–3520). Twenty-five journals (33.3%) offered APC subsidies for authors in low- and middle-income countries (LMICs) and/or on a case-by-case basis. Eighty-five and 25 journals were based in high-income countries (HICs) and LMICs, respectively. The mean APC was higher among HIC journals than LMIC journals ($2606 vs. $958, p < 0.001).

Conclusion
APCs range from tens to thousands of dollars with limited waivers for authors in LMICs.

Community-based adult hearing care provided by community healthcare workers using mHealth technologies

Background
The rising prevalence of hearing loss is a global health concern. Professional hearing services are largely absent within low- and middle-income countries where appropriate skills are lacking. Task-shifting to community healthcare workers (CHWs) supported by mHealth technologies is an important strategy to address the problem.

Objective
To evaluate the feasibility of a community-based rehabilitation model providing hearing aids to adults in low-income communities using CHWs supported by mHealth technologies.

Method
Between September 2020 and October 2021, hearing aid assessments and fittings were implemented for adults aged 18 and above in two low-income communities in the Western Cape, South Africa, using trained CHWs. A quantitative approach with illustrative open-ended questions was utilised to measure and analyse hearing aid outcomes. Data were collected through initial face-to-face interviews, telephone interviews, and face-to-face visits post-fitting. Responses to open-ended questions were analysed using inductive thematic analysis. The International Outcome Inventory – Hearing Aids questionnaire determined standardised hearing aid outcomes.

Results
Of the 152 adults in the community who self-reported hearing difficulties, 148 were successfully tested by CHWs during home visits. Most had normal hearing (39.9%), 24.3% had bilateral sensorineural hearing loss, 20.9% had suspected conductive hearing loss, and 14.9% had unilateral hearing loss, of which 5.4% had suspected conductive loss. Forty adults met the inclusion criteria to be fitted with hearing aids. Nineteen of these were fitted bilaterally. Positive hearing aid outcomes and minimal device handling challenges were reported 45 days post-fitting and were maintained at six months. The majority (73.7%) of participants fitted were still making use of their hearing aids at the six-month follow-up.

Conclusions
Implementing a hearing healthcare service-delivery model facilitated by CHWs in low-income communities is feasible. mHealth technologies used by CHWs can support scalable service-delivery models with the potential for improved access and affordability in low-income settings.

Machine Learning in Diagnosing Middle Ear Disorders Using Tympanic Membrane Images: A Meta-Analysis

Objective
To systematically evaluate the development of Machine Learning (ML) models and compare their diagnostic accuracy for the classification of Middle Ear Disorders (MED) using Tympanic Membrane (TM) images.

Methods
PubMed, EMBASE, CINAHL, and CENTRAL were searched up until November 30, 2021. Studies on the development of ML approaches for diagnosing MED using TM images were selected according to the inclusion criteria. PRISMA guidelines were followed with study design, analysis method, and outcomes extracted. Sensitivity, specificity, and area under the curve (AUC) were used to summarize the performance metrics of the meta-analysis. Risk of Bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool in combination with the Prediction Model Risk of Bias Assessment Tool.

Results
Sixteen studies were included, encompassing 20254 TM images (7025 normal TM and 13229 MED). The sample size ranged from 45 to 6066 per study. The accuracy of the 25 included ML approaches ranged from 76.00% to 98.26%. Eleven studies (68.8%) were rated as having a low risk of bias, with the reference standard as the major domain of high risk of bias (37.5%). Sensitivity and specificity were 93% (95% CI, 90%–95%) and 85% (95% CI, 82%–88%), respectively. The AUC of total TM images was 94% (95% CI, 91%–96%). The greater AUC was found using otoendoscopic images than otoscopic images.

Conclusions
ML approaches perform robustly in distinguishing between normal ears and MED, however, it is proposed that a standardized TM image acquisition and annotation protocol should be developed.

Children with Conductive Hearing Loss Fitted with Hearing Aids: Outcomes and Caregiver Experiences in South Africa

Introduction Hearing aids are a frequent management option for children with conductive hearing loss (CHL) and it is necessary to determine the efficacy of outcomes. Limited information regarding caregivers’ perceptions and experiences are available to examine outcomes in this population.

Objectives To describe hearing aid outcomes and caregivers’ experiences for children with CHL who wear behind-the-ear (BTE) hearing aids.

Methods Retrospective review of clinical data from 19 children between 0 and 13 years of age with CHL, who were fitted with BTE hearing aids between January 2017 and March 2020. Hearing aid outcomes were documented at one month post-hearing aid fitting, via average daily use and caregiver and teacher reports obtained through the Parents’ Evaluation of Aural/oral performance of Children (PEACH) and the Teachers’ Evaluation of Aural/oral performance of Children (TEACH). Telephonic surveys were conducted with 13 caregivers to explore their experiences. Qualitative data from open-ended questions were analyzed thematically.

Results The average hearing aid use was 6.5 hours/day (2.0 standard deviation, SD; range 4.1–10.3) for bilateral hearing aid users. Questionnaire results indicated that most children (PEACH – 83.3% and TEACH – 92.3%) used their hearing aids more than 75% of the time. Participants performed better in quiet environments with limited sensitivity to loud sounds at home and at school. Reported challenges included stigma and device compliance.

Conclusions Children with CHL used their hearing aids for comparable hours (5–8 hours/day), as reported for children with sensorineural hearing loss, but less than the recommended 10 hours/day required for adequate language development. Caregivers reported benefits equivalent to expectations, with challenges similar to those reported in high-income countries.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Impact of COVID-19 Pandemic on Patterns of Care and Outcome of Head and Neck Cancer: Real-World Experience From a Tertiary Care Cancer Center in India

PURPOSE
The COVID-19 pandemic has caused unprecedented health, social, and economic unrest globally, particularly affecting resource-limited low-middle–income countries. The resultant curfew had made the access to and delivery of cancer care services an arduous task. We have reported the patterns of care and 1-year outcome of head and neck squamous cell carcinoma (HNSCC) treatment before and during COVID-19 lockdown at our institution.

MATERIALS AND METHODS
Patients who underwent radiation therapy (RT) for nonmetastatic HNSCC between March 1, 2020, and July 31, 2020, were included in the COVID-RT group, and those who were treated between October 1, 2019, and February 29, 2020, were included in the preCOVID-RT group.

RESULTS
A total of 25 patients were in the COVID-RT group, and 51 patients were in the preCOVID-RT group. An increase in the incidence of locally advanced cancers across all subsites was observed in the COVID-RT group. There was a steep increase in the median overall RT treatment duration (52 v 44) and median break days during RT (10 v 2) in the COVID-RT group. The median follow-up period of all patients was 18 months. The progression-free survival at 1 year in the COVID-RT group and preCOVID-RT group was 84% and 90%, respectively (P = .08), and overall survival at 1 year was 86% and 96%, respectively (P = .06).

CONCLUSION
Our study elucidates the adverse impact of the COVID-19 curfew on cancer care and has demonstrated safe delivery of RT for HNSCC without major acute adverse effects. Despite a significant increase in treatment breaks, early outcome data also suggest that 1-year progression-free survival and overall survival are comparable with that of the pre–COVID-19 times; however, longer follow-up is warranted.

Cochlear implantation in South Africa (part 2)

Cochlear implantation is a timeous and cost-effective solution for severe-to-profound sensorineural hearing loss (SNHL) and has transformed the lives of many individuals with significant hearing loss. The advent of cochlear implantation has meant that, for the first time, one of the senses (hearing), having been entirely lost, can be restored. The previous article in this series sketched the problem of severe-toprofound SNHL, and how cochlear implantation can overcome this, how a cochlear implant (CI) works, the history of cochlear implantation and the principles of the multidisciplinary CI team. The current status of cochlear implantation in South Africa (SA) is the subject of discussion in this article, the second of this two-part series on cochlear implantation. It comprises a study of the best available current data on the status of CI in SA.

Cochlear implantation in South Africa (part 1)

Cochlear implantation is a timeous and cost-effective solution for severe-profound sensorineural hearing loss, and has transformed the lives of many individuals with significant hearing loss. The advent of cochlear implantation has meant that, for the first time, one of the senses (hearing), having been entirely lost, can be restored. This, the first of a two-part series on cochlear implantation in South Africa (SA) puts global (and especially SA) hearing loss in perspective, sets out the principles of cochlear implantation and briefly sketches the history of this world-changing technology.

The management of head and neck cancer in Africa. What lessons can be learned from African literature?

There is a significant dearth of contextually relevant information related to the management of head and neck cancer (HNC) in Africa. The aim of this letter was to put forward the findings from our larger systematic review to describe the current management of HNC patients in Africa and to identify gaps and present potential solutions. Sixty-six articles were included and analysed with descriptive statistics, a narrative synthesis, and thematic analysis. Surgical resection remains the primary medical intervention in Africa, whilst chemotherapy and radiation services remain limited. There was no mention of multidisciplinary team input in the management of these patients, including no description of any rehabilitative treatments. There are significant resource shortages ranging from access to medical equipment to both skilled medical and rehabilitative staff. The findings from this study imply that the management of HNC in Africa requires a possible transdisciplinary approach to improve access to services. Health professionals also need to explore a community-based level approach to care to improve access. There needs to be more context-specific research to improve contextually relevant teaching and practice in HNC.