Prioritizing the expenses of breast cancer treatment makes sense- not just in developing countries, but across the globe.

Abstract

‘‘We Still Need Studies on the Value of the TIVAD for Cancer Patients?’’ by Isidoro Di Carlo and Adriana Toro. We thank Drs. Di Carlo and Toro for their comments on our article [1]. They have expressed the opinion that surgical cut down methods to access larger veins is a potential option. Such methods are seldom resorted to in present times as percutaneous methods have been standardized and are well accepted, because these are minimally invasive and more convenient for the patient. The awareness and acceptability of totally implantable venous access device (TIVAD) amongst patients and health care providers is low in developing countries. We noted a perceptible increase in awareness and acceptability of TIVAD during the study period. Even in high-income countries, the satisfaction with TIVAD is not absolute. Onethird of the patients were not satisfied with port care outside the hospital as reported by Kreis et al. [2] mainly attributed to poor awareness, despite TIVAD has been a standard of care for decades now. We agree that the judgment of the patients is incomplete, because the two groups experienced either of the infusion modalities and not both. A randomized crossover study would be ideal to reveal this, which is difficult to perform. As noted in the conclusion, although TIVAD is accepted as the standard of care, PIVA is a valid option in a subgroup of patients requiring 6 or less than 6 cycles of chemotherapy, more so in developing countries with scant resources. Most breast cancer patients in India have to find funds for their treatment on their own, and this is a major challenge for patients, their families, and the hospitals [3]. The per capita annual income (at 2004–2005 prices) for the Indian population is pegged at Indian Rupees (INR) 39,961 in 2013–2014. Affordability is a major issue with TIVAD in India as the cost of the TIVAD is approximately INR 15,000 in a public hospital system, when offered on a noprofit basis. In fact, the cost of TIVAD is sometimes higher than the cost of entire chemotherapy in a few first-line chemotherapy regimens. Although we appreciate the sentiments of Drs. Di Carlo and Toro, we cannot agree with their contention that using PIVA for chemotherapy is ‘‘unethical’’ in developing countries. Often, the precious and scarce financial resources of the patient or hospital system are used for providing the basic multimodal therapy and avoiding whatever nonessential expense that can be avoided. TIVAD is often one such ‘‘nonessential’’ expense. While in a utopian world, most if not all cancer patients should receive chemotherapy via a TIVADs, the real-world fact is that a vast majority of cancer patients being treated around the world are administered chemotherapy sans— TIVAD, via PIVA. Can this reality be called unethical? We think that what might be unethical is not offering any chemotherapy at all to some patients, if one was to insist on using TIVAD in all patients. The current study in fact provides insights into which patients would benefit more from and therefore should be offered TIVAD, and which patients can be safely spared of TIVAD implantation and would not have major detriments by administration of chemotherapy via PIVA [1]. K. R. Singh Department of Surgery, King Georges Medical University, Lucknow, India