Assessment of utilization of anticancer drugs in cancer centre at tertiary care hospitals in Telangana region

Praveen Kumar T*1, Nadeem Ahmed2, Sravan Kumar B2, Chinna Eswaraiah M3 1Department of Pharmaceutics, Anurag Pharmacy College, Kodad (M), Suryapet (D), Telangana State. 508 206, India 2Department of Pharm D, Anurag Pharmacy College, Kodad (M), Suryapet (D), Telangana State. 508 206, India 3Department of Pharmacognosy, Anurag Pharmacy College, Kodad (M), Suryapet (D), Telangana State. 508 206, India


INTRODUCTION
Globally cancer remains a leading cause of death. According to International Agency for Research on Cancer, 7.6 million deaths were due to cancer, and 12.7 million new cases were being reported per year (Jemal et al., 2011;Ferlay et al., 2008). The etiology of cancer is multifactorial, which involves both genetic and environmental factors (Brannon-Peppas and Blanchette, 2004). It is a dreadful disease which brings psychological and social distress to the patients and relatives (Boyle and Ferlay, 2004;Binu et al., 2007). It is one of the leading causes of death in developed and developing countries. According to WHO, 13% of worldwide mortality was due to cancer in 2005. 10% of total mortality is due to cancer in 2002, and it is expected to rise up to 25-50% by 2020 in India. Hanahan and Weinberg identi ied six phenotypes of cancer (Hanahan and Weinberg, 2000). If uncontrolled cell growth occurs, it results in the death of the person (Chaffer and Weinberg, 2011). A great progress has been achieved towards early detection, understanding of the hallmarks of cancer, and treatment modalities, which are more curable (Hanahan and Weinberg, 2011;Pollack et al., 2009).
Carcinomas reported in males were lungs, bronchus, trachea, mouth, oropharynx, esophagus, stomach and while in females carcinoma of cervix, breast, mouth, oropharynx and esophagus Chemotherapy is a multimodality approach shown to be curative in cases of head and neck carcinoma, uterine carcinoma, cervix carcinoma, lung carcinoma, breast carcinoma, and colorectal carcinoma (Longo, 2012). Several factors, like Patient-related, tumour related, and treatment-related factors, in luences the decision of therapy (Joseph et al., 2014). Considerable ranges of chemotherapeutic agents are used to treat cancer at different stages. Antineoplastic drugs act on rapidly dividing cells, and their action is either speci ic or non-speci ic on the cell cycle (Rang et al., 2007). Chemotherapy refers to the treatment of cancer by the use of cytotoxic and other drugs as a standardized treatment regimen (Malhotra and Perry, 2003). It is the only therapy which acts systematically to reduce the disease from the entire body.
Regimens used in Chemotherapy are very complex and are associated with intolerable adverse reactions. Inappropriate use of a drug may lead to the increased cost of medical care, the incidence of adverse drug effects, and may also lead to mortality (Sachdeva and Patel, 2010). Drug utilization of anticancer agents has been changed in recent years due to a better understanding of the pathophysiology of carcinomas and also the introduction of newer drugs. Assessment of utilization of anticancer drugs research promotes the rational use of drugs and decreased adverse drug reactions in the patients (Kumar et al., 2018;Hawkey et al., 1990). It helps in comparing the prescribing pattern with existing standards, and steps can be taken to optimize anticancer therapy with improved ef icacy and less toxicity (Pentareddy et al., 2015).

MATERIALS AND METHODS
The study was Prospective and observational study carried out in various hospitals in Telangana region for a period of six months, and the sample size includes 300 patients. All the necessary details for the study were collected from the patient's medical record at the inpatient department, and the medical records were reviewed on a daily basis.

Study criteria
The study was carried out by considering the following inclusion and exclusion criteria

Inclusion criteria
All patients aged between 20-80 years receiving cancer treatment, and patients with or without comorbidities were included in the study.

Exclusion criteria
The patients who were pregnant or lactating, HIV positive patients, patients with psychiatric illness, Patients who are not willing to participate in studies, and Patients whose prescription is not reliable were excluded from the study.

Study procedure
Prescriptions were studied based on inclusion and exclusion criteria. Recognized prescriptions were taken into consideration as per study criteria. Required information is collected from the patient's prescription. Data was illed into the specially designed patient data entry forms.

Data analysis
The prescriptions were analyzed according to the type of cancer, percentage of encounters with the classi ication of drugs prescribed per patient, percentage of most common anticancer drugs received. This data was analyzed by using Microsoft Excel, and results were presented as percentages.

RESULTS AND DISCUSSION
The main aim of this study is to promote the rational use of drugs to the populations. The present study shows the demographics and most common class of cytotoxic agents prescribed in tertiary care cancer centers.

Gender wise distribution of cancer patients
Among 300 patients selected in our study, 111 (37 %) were males, and 189 (63 %) were female patients. Greater prevalence of cancer was observed in females, which occupies the major portion in different forms of cancer in our study. Females are highly prone to cancer due to their weaker immune system and reproductive disturbances majorly breast cancer because their breast cells are exposed to estrogen and progesterone. The results were given in Figure 1.

Age-Wise Distribution of Cancer Patients
The age-wise distribution of the patients showed a higher incidence of cancer in different age groups. The study revealed that 170 (56.66 %) cancer cases were evident in the age groups between 71 to 80 years. The next susceptible age group of a patient prone to cancer was found to be 51 to 60 years, 60 (20 %). Followed by 50 (16.66 %) cases were identiied in 41 -50 age group. In the 31-40 age group, 25 (8.33 %) cases were identi ied. 25 (8.33 %) cases were identi ied in 61-70 age group. 10 (3.33 %) cases were seen in the 20 -30 age group. It is observed that 20 -30 age group were less susceptible to cancer in our study. Cancer risk increases after the age of 50 and half of all cancers occur at the age of 60 and above. According to the National Cancer Institute, one-quarter of new cancer diagnoses are in 60 to 75 aged people. The results were presented in Figure 2.
Gender Wise Incidence of Substance abuse,

Smokers and alcohol consumers
A total of 160 patients were found to have Substance abuse in the study. Among them, 99 were male patients, and 61 were female patients. A total of 127 patients were found to have a habit of smoking in the study. Among them, 86 were male patients, and 41 were female patients. Males are more susceptible to lung and throat cancer due to smoking and tobacco intake. It was found that 92 patients were alcohol consumers, 35 were male patients, and 57 were female patients. The results were tabluated in Table 1.

Incidence of various comorbidities
Hypertension was present in 68 patients, among them, 32 were male patients, and 36 were females patients. Diabetes was found in 82 patients, 24 were males, and 58 were females. CNS disorders were found in 46 patients, 20 were males, and 26 were females were suffering with CNS disorders. Asthma was found in 46 patients, 11 were males, and 35 were females. Epilepsy was found in 26 patients, 15 were males, and 11 were females. Thyroid was found in 32 patients, 9 were males, and 23 were females. Hypertension, hyperlipidemia, osteoarthritis, hypothyroidism, diabetes mellitus, and coronary artery disease are the most common associated comorbid conditions in cancer survivors. The results were given in Table 2.

Incidence of various cancers
11 different types of cancers were observed in the study. The highest incidence is in lung cancer (14.66%), followed by blood cancer (13.66%). In females, the highest incidence is in breast cancer (17.46%), followed by blood cancer (14.81 %). The cancers were found to be affecting every systems of the body, which reveals the non-speci ic nature of the disease. Lungs cancer was found in 44 patients, 23 were males, and 21 were females. Pancreatic cancer was observed in 32 patients, 8 were male, and 24 were female. Skin cancer was observed in 33 patients, 13 males, and 20 females. GIT cancer was observed in 33 patients, 15 were males, and 18 were females. The blood cancer was found in 41 patients. Among them, males were 13, and females were 28. The other forms of cancer reported were in Table 3.

Incidence of various stages in cancer
The total patients included in the study were categorized according to the stages of cancer. It was observed that 47 patients were in stage 1 cancer, 11 were males, and 36 were females. 86 patients were in stage 2 cancer, 35 were males, and 51 were females. 103 patients were in stage 3 cancer, 45 were males, and 58 were females. 64 patients were in stage 4 cancer, 20 were males, and 44 were females. It was observed that the highest incidence of cancer in females was in stage 3 (30.68 %), followed by stage 2 (26.98%). Among males, the highest incidence of cancer was in stage 3 (40.54%), followed by stage 2 (31.53%). The results were pre-sented in Table 4.

Gender wise incidence in chemotherapy regimen
There are many types of cancer treatment. But most people have a combination of treatments, and triple is mostly used in comparison to single and double drug therapy regimen. In our study, single therapy was given to 23 males and 39 females. Double therapy was given to 60 males and 98 females. Triple therapy was given to 28 males and 52 females. The results were summarized in Table 5.

List of anticancer drugs observed in our study
It was observed that 54 drugs were prescribed for different cancers patients in our study. The most commonly used class of anticancer agents was tyrosine kinase inhibitors (10drugs) and monoclonal antibodies (10 drugs). 6 drugs were prescribed from antibiotics, 4 drugs were prescribed from Alkylating agents, plant alkaloids, and steroid hormones category. 3 drugs from Antimetabolites category and 1 drug was prescribed form Pyramidine antagonist, Purine Antagonist, Nitrogen Mustards category, Bisphosphonates, Vaccine, Pyramidine Analogs, Folic Acid Analogs, and Pyramidine Analogs, Topoisomerase Inhibitor, enzymes.

Prescription pattern of each anticancer drug
Cancer treatment has various options such as chemotherapy, surgery, radiation therapy, immunotherapy and monoclonal antibody therapy. The choice of therapy depends on the location of the tumor, stage of disease, physical and mental state of the patient. The principle in a combination of chemotherapy is to use different drugs that act by different cytotoxic mechanisms. Cytotoxic drug actions are not speci ic to tumor cells and can damage normal cells; also, as a result, they cause several side effects in patients. Most of the cytotoxic drugs are potentially hazardous substances which cause mutagenic, teratogenic, or carcinogenic effects in individuals. These substances may also cause secondary neoplasm in patients who were taking the treatment. So extreme care must be taken in handling and administrating of anticancer drugs.
Out of 300 prescriptions analyzed, 62 patients were prescribed with single-drug therapy. The results were summarized in Figure 3.
It was observed that 158 patients were prescribed with double drug therapy. The results were summarized in Figure 4.
In our study, it was observed that 80 cancer patients were prescribed with three drugs. The results were summarized in Figure 5.
It was observed that 17 drugs were prescribed in skin cancer. 18 drugs in Breast cancer, 25 drugs in Gastro-Intestinal Cancer, 26 drugs in Lung Cancer, 29 drugs in Blood Cancer, 5 drugs in Lymphoma cancer, 7 drugs in oral Cancer, 9 drugs in Prostate cancer, 12 drugs in pancreatic cancer and 13 drugs in Genito Urinary Cancer.
Out of 300 cancer patients, 54 drugs were given in single, double, and triple therapy.
About 54 drugs were prescribed to 300 patients.

CONCLUSION
From the present study, we can conclude that the prevalence of cancer is more in females than males. Lung cancer, followed by blood cancer, was observed in major cases. Double and triple therapy was given widely to the patients. Most of the cases were in stage 3 and stage 2. Carboplatin is a commonly used anticancer drug. It was observed that Carboplatin was given to 30 (10%) patients followed by Chlorambucil to 27 patients (9%) and Vinblastine 26 patients (8.6%). Drug use evaluation studies are helpful for systematic quality improvement. All these observations improves prescribing practice by the implementation of standard guidelines, which results in providing cost-saving and better quality of life. We conclude that the use of anti-cancer drugs was found to be rational.