Background: Patients with lymphoma often seek care from multiple healthcare providers before receiving a diagnosis. Delays in timely referral result in many patients presenting at advanced stages, leading to poor outcomes, despite the fact that most lymphomas are treatable and curable. Objectives: The primary objective was to evaluate diagnostic and treatment intervals among patients with lymphoma. The secondary objectives were to identify factors contributing to delays and to document the common presenting symptoms. Materials and Methods: A descriptive, cross-sectional study was conducted in the Department of Clinical Oncology at Bir Hospital and Department of Hematology at Civil Service Hospital, Kathmandu, Nepal, between March 2024 and February 2025, after obtaining approval from the Institutional Review Board. Data on interval durations and most contributing factors were collected through face-to-face interviews using a structured questionnaire. Results: Among the 45 patients with lymphoma, diagnostic delays were identified in 35 (77.8%) cases, while 8 patients (17.8%) experienced treatment delays. The median diagnostic interval was 112 days (interquartile range (IQR): 123 days, range: 21-271 days), and the median treatment interval was 14 days (IQR: 14 days, range: 2-48 days). Diagnostic delay was linked to receiving empirical antitubercular therapy (P, 0.042) and initially consulting informal healthcare providers (P, 0.002), whereas treatment delay was more commonly observed among patients with no formal education (P, 0.014). Conclusion: The majority of patients experienced a prolonged diagnostic interval. This finding highlights the urgent need to improve early detection, referral pathways, and diagnostic services to ensure timely diagnosis and better outcomes for patients with lymphoma.

Purpose:The purpose of this study was to compare the efficacy of oral morphine (MOR) with oral tramadol (TRM) in control of pain as well as physical well-being in patients (pts) with moderate cancer pain (MCP) using the Edmonton Symptom Assessment Scale (ESAS). Methods:An Institutional Review Board (IRB) approved randomised phase II trial was performed in opioid-naive pts with MCP as defined by pain score in numerical rating score (NRS) of 4-6. Patients were randomised to receive MOR syrup 5 mg 4 hourly or TRM 50 mg four times a day. Titration of dose was done in both groups for 3 days in case of inadequate pain control as per standard recommendation for MOR or until the maximum recommended daily dose for TRM. MOR was changed to prolonged release form on Day 4. The primary endpoint was the number of early responders, defined as pts with at least 20% reduction in pain intensity on NRS on Day 3. The secondary outcome was the number of patients with highly meaningful pain reduction, defined as a decrease in pain intensity on NRS by ≥5 and improvement in physical well-being with ESAS at Day 7. Results:Sixty-eight pts consented and were randomised, 34 in each arm. The primary endpoint occurred in 94.1% pts in MOR and 55.9% in TRM (p < 0.001). The number of patients with highly meaningful pain reduction was significantly higher in MOR than in TRM (76.5% versus 32.35%; p < 0.001). Improvement in general physical well-being as assessed by ESAS was better in the MOR group. No difference in adverse effects was noted between the treatment arms. Conclusion:In this study, MOR was superior to TRM in the control of pain with statistically significant differences in the primary and secondary endpoints. Therefore, early use of MOR skipping the World Health Organization sequential analgesic ladder for MCP may be a higher value option in resource-scarce country with limited access to healthcare.

Introduction: In Nepal, breast cancer is the second most common cancer accounting for a large number of deaths.The subtype Triple-negative breast cancer (TNBC) is linked to poor prognosis and is characterized by the absence of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2). This study describes the outcome of women with TNBC as compared to other breast cancers in Bir Hospital in Nepal. Methods: This was a cross-sectional study conducted in Bir Hospital, National Academy of Medical Sciences. The breast cancer data in Department of Surgery and Department of Oncology were collected from July 2021 to June 2024. The study data on demographic details, clinical findings, radiological and pathological investigations, operative procedures, neoadjuvant/adjuvant therapy, surgical and oncological outcomeswere collected. The study approval was taken from Institutional Review Board of National Academy of Medical Sciences. Results: There were 72 breast cancer patientsout of which 10 (13.8 %) were TNBC. Majority of the cases (70%) underwent modified radical mastectomy and 60% of them had received neoadjuvant therapy in TNBC cases. One out of 10 had positive margin post mastectomy. The proportion of TNBC patients with postoperative wound infection, seroma and flap necrosis were 10% each. The mean lymph node positivity was less in TNBC group as compared to other breast cancers.There was one recurrence, one metastasis and no mortality till one year follow up. Conclusion: The surgical outcome was satisfactory and with neo-adjuvant, surgery and adjuvant therapy, there is less tumor recurrence and satisfactory disease free survival and overall survival.

BACKGROUND:Nepal is one of the high prevalent countries for tobacco use in Southeast Asia regions. Tobacco related cancer share the major burden since a decade, however, population-based estimates is still lacking. This study provides results from population-based cancer registries on tobacco-related cancer (TRCs) burden in Nepal.METHODS:The data were collected by population-based cancer registry conducted in nine districts by Nepal Health Research Council. The districts were categorized in urban, semi-urban and rural regions on the basis of geographical locations and facilities available in the regions. Analysis was done to identify tobacco-associated cancer incidence, mortality and patterns along with cumulative risk of having cancer before the age of 75 years.RESULTS:Tobacco-related cancer was 35.3% in men and 17.3% in women. We found that every one in 36 men and one in 65 women developed tobacco-related cancer before age 75 in Nepal. Cancer of lung, mouth, esophagus and larynx were among the five most common tobacco-related cancers in both men and women. The incidence of tobacco-associated cancers was higher in urban region with age adjusted rate 33.6 and 17.0 per 100,000 population for men and women respectively compared to semi-urban and rural regions. Tobacco-associated cancer mortality was significantly higher compared to incidence.CONCLUSION:The prevalence of tobacco-related cancer found high in Nepal despite of enforcement of tobacco control policy and strategies including WHO framework convention on tobacco control. Concerned authorities should focus towards monitoring of implemented tobacco control policy and strategies.

5530 Background: Cervical cancer is the leading cause of cancer and cancer-related deaths among women in Nepal, due in part to a lack of access to screening and limited medical providers trained to diagnose and treat women with preinvasive cervical disease. Cancer Care Nepal has partnered with The University of Texas MD Anderson Cancer Center (MD Anderson) and the American Society of Clinical Oncology (ASCO) to implement a ‘train the trainer’ (TOT) program to teach visual inspection with acetic acid (VIA), colposcopy, cervical biopsy, cryotherapy, thermal ablation, and loop electrosurgical excision procedure (LEEP). Methods: An initial cervical cancer prevention course was held in Kathmandu, Nepal in November 2019, supported by ASCO and with faculty from Civil Service Hospital, Bhaktapur Cancer Hospital, and National Academy of Medical Sciences and MD Anderson. As a continuation of this program, a TOT course was implemented for local specialists from five participating institutions throughout Nepal to learn how to deliver these trainings. Each participating institution then holds their own local course for nurses and doctors in their region. The training is complemented with monthly Project ECHO (Extension for Community Healthcare Outcomes) telementoring videoconferences. Results: The program was launched in November 2021. To date, two TOT training courses (2-day duration) have been held for clinicians from the 5 participating regions. Due to COVID-19 pandemic travel restrictions, didactic lectures were held virtually with MD Anderson and ASCO staff and included epidemiology of cervical cancer, screening guidelines, colposcopy, and treatment of cervical dysplasia. This was followed by hands-on training using simulation models to teach VIA, colposcopy, ablation and LEEP, led by the Nepalese faculty who had participated in the 2019 course. There were 41 participants in total (23 in the first course and 18 in the second course), including 21 gynecologists, 4 gynecologic oncologists, 1 medical oncologist, 1 general practitioner, and 14 nurses. 39 participants (73%) completed both the pre- and post- survey results. 86% of respondents from the first course and 100% of respondents from the second course reported that they intended to change their practice as a result of knowledge gained from the course. In addition, Cancer Care Nepal became a new hub for Project ECHO and held its first session in January 2022, with 20 participants representing two regions. The specialists from each of the 5 participating sites will be holding local courses for doctors and nurses in their respective regions throughout 2022. Conclusions: Our work shows that the TOT strategy can widen the reach of training in cervical cancer prevention in Nepal. Despite travel restrictions during the COVID-19 pandemic, global health training and mentoring can continue, though they require adaptions and use of virtual platforms.

Equitable global health partnerships are essential to promote innovative research and strengthen research capacity to address critical public health challenges, but how to optimally evaluate such collaborations is unclear. This was a sequential, multi-method study that utilized an electronic survey informed by the literature followed by semi-structured interviews to comprehensively evaluate the experience of participating in a global research-capacity building collaboration between Nepal and U.S. clinicians and investigators. De-identified quantitative survey were analyzed to calculate descriptive and summary statistics, along with crosstabs of each variable by group. Groups were defined based on country-of-origin and Chi Square statistics calculated to assess for statistically significant differences (p<0.05) between groups. Interviews were analyzed using a descriptive qualitative approach to develop an overall thematic map. 22 survey responses (52.4% response rate) were analyzed; 13 (59.1%) from Nepal, 9 (40.9%) from the U.S. Eight participants (4 Nepal; 4 U.S.) were interviewed. Over the course of the project, all participants reported gaining experience and confidence with research. The majority of participants "strongly agreed" there was a shared understanding of goals, priorities and strategies (Nepal, 58.3%, n = 7; U.S., 88.9%, n = 8;) and that power was shared equally (Nepal, 58.3%, n = 7; U.S., 55.6%, n = 5). The over-arching theme that emerged from the interviews was the importance of 'establishing community' which participants discussed within the broader context of COVID-19. Overall, team members reported strong bi-directional benefit and a greater emphasis on perceived benefits versus challenges. Our survey tool and interview guide, designed to holistically evaluate the impact of a global partnership across various levels of the Social Ecological Model, with particular attention to power dynamics and equity, can be adapted and used by others engaged in similar research capacity collaborations.

Introduction: Malnutrition is one of the most frequent disorders among cancer patients. It is seen in 50-90% of cancer patients. This high prevalence of malnutrition is very concerning as it is associated with reduced effective treatment, functional status, quality of life and survival. The aim of the study was to find out the prevalence of malnutrition among cancer patients in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among 95 cancer patients in the Department of Clinical Oncology of a tertiary care centre from 25 January 2022 to 25 July 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: 1192/2078/79). Convenience sampling was done. Patients were screened using Patient-Generated Subjective Global Assessment for malnutrition. Point estimate and 95% Confidence Interval were calculated. Results: Among 95 cancer patients, 22 (23.15%) (15.10-32.90, 95% Confidence Interval) were malnourished. Conclusions: The prevalence of malnutrition was found to be lower than in other studies done in similar settings. Nutritional assessment and support should be an integral part of care for gastrointestinal cancer.

Introduction:Quality palliative care, which prioritizes comfort and symptom control, can reduce global suffering from non-communicable diseases, such as cancer. To address this need, the Nepalese Association of Palliative Care (NAPCare) created pain management guidelines (PMG) to support healthcare providers in assessing and treating serious pain. The NAPCare PMG are grounded in World Health Organization best practices but adapted for the cultural and resource context of Nepal. Wider adoption of the NAPCare PMG has been limited due to distribution of the guidelines as paper booklets.Methods:Building on a long-standing partnership between clinicians and researchers in the US and Nepal, the NAPCare PMG mobile application ("app") was collaboratively designed. Healthcare providers in Nepal were recruited to pilot test the app using patient case studies. Then, participants completed a Qualtrics survey to evaluate the app which included the System Usability Scale (SUS) and selected items from the Mobile App Rating Scale (MARS). Descriptive and summary statistics were calculated and compared across institutions and roles. Regression analyses to explore relationships (α = 0.05) between selected demographic variables and SUS and MARS scores were also conducted.Results:Ninety eight healthcare providers (n = 98) pilot tested the NAPCare PMG app. Overall, across institutions and roles, the app received an SUS score of 76.0 (a score > 68 is considered above average) and a MARS score of 4.10 (on a scale of 1 = poor, 5 = excellent). 89.8% (n = 88) "agreed" or "strongly agreed" that the app will help them better manage cancer pain. Age, years of experience, and training in palliative care were significant in predicting SUS scores (p-values, 0.0124, 0.0371, and 0.0189, respectively); institution was significant in predicting MARS scores (p = 0.0030).Conclusion:The NAPCare PMG mobile app was well-received, and participants rated it highly on both the SUS and MARS. Regression analyses suggest end-user variables important to consider in designing and evaluating mobile apps in lower resourced settings. Our app design and pilot testing process illustrate the benefits of cross global collaborations to build research capacity and generate knowledge within the local context.

Introduction: Febrile neutropenia (FN) is the most frequent complications reported during cytotoxic chemotherapy treatment. Granulocyte colony stimulating factor (GCSF) is used to reduce neutropenia and related complications. This study compares short versus long acting filgrastim for reduction of chemotherapy induced FN. Methods: Histologically confirmed solid cancer patients (n=112) receiving either high risk or intermediate risk chemotherapy regimens for FN were randomized into two groups. Group one received filgrastim 300 mcg subcutaneously for five days and group two received pegfilgrastim 6 mg subcutaneously single dose, starting after 24 hours after completion of chemotherapy during each chemotherapy cycle. The primary end point was the occurrence of FN. The secondary end points were number of hospital visits, duration of hospital stay and total direct costs of filgrastim and pegfilgrastim. Results: Fifty six patients were analyzed in each group. The incidence of FN was significantly lower in pegfilgrastim group (42.90%) than filgrastim group (69.6%), p<0.004. The mean hospital visits were 1.84±1.93 in filgrastim group and 0.84±1.19 in pegfilgrastim group with 58.90% and 33.90% hospital admission respectively in both groups. The mean duration of stay was 4.14±3.69 days in filgrastim group and 2.36±3.35 days in pegfilgrastim group. The mean cost (Nepali rupees) of filgrastim and pegfilgrastim was 20162.50+6645.37 (US$168.17±55.42) and 32210.71±10429.43($268.67±86.99) respectively. Conclusion: Single dose of pegfilgrastim was significantly better than multiple doses of filgrastim for reducing FN incidence in cancer patients receiving chemotherapy.

Variations in cancer incidence, mortality and pattern exist in rural and urban areas.Understanding these differences helps in developing targeted cancer prevention and control strategies.However, no previous studies have explored the differences in cancer demographics between the rural and urban areas of Nepal.The data of Kathmandu Valley (urban area) Population-Based Cancer Registry (PBCR) and Rukum (rural area) PBCR were analysed to identify the differences in cancer pattern in rural and urban areas.The age-adjusted incidence rate (AAR) in Kathmandu was higher than that in Rukum (1.6 times among males and 1.9 times among females).The top two leading sites in males were lungs and stomach in both the regions; however, the rates were higher in Kathmandu.The incidence rate for cancer of the urinary bladder among males in Kathmandu was particularly higher -4.4 times that of Rukum.In females, the leading site of cancer in Kathmandu was breast, which was eight times higher compared to Rukum, whereas the incidence rate of cervix cancer in Kathmandu is 30% less than in Rukum.The incidence of tobacco-related cancer was found to be higher in Kathmandu compared to Rukum.These findings reveal the need for different policy priorities for cancer control in the urban versus rural regions of Nepal, based on the different demographics of cancer in the two areas.Similar studies from other regions of Nepal are needed to develop a targeted cancer control strategy.

PURPOSE:To evaluate stress levels among the health care workers (HCWs) of the radiation oncology community in Asian countries.METHODS:HCWs of the radiation oncology departments from 29 tertiary cancer care centers of Bangladesh, India, Indonesia and Nepal were studied from May 2020 to July 2020. A total of 758 eligible HCWs were identified. The 7-Item Generalized Anxiety Disorder, 9-Item Patient Health Questionnaire, and 22-Item Impact of Events Scale-Revised were used for assessing anxiety, depression, and post-traumatic stress disorder. Univariate and multivariate analysis was done to identify the causative factors affecting mental health.RESULTS:A total of 758 participants from 794 HCWs were analyzed. The median age was 31 years (IQR, 27-28). The incidence of moderate to severe levels of anxiety, depression, and stress was 34.8%, 31.2%, and 18.2%, respectively. Severe personal concerns were noticed by 60.9% of the staff. On multivariate analysis, the presence of commonly reported symptoms of COVID-19 during the previous 2 weeks, contact history (harzard ratio [HR], 2.04; CI, 1.15 to 3.63), and compliance with precautionary measures (HR, 1.69; CI, 1.19 to 2.45) for COVID-19 significantly predicted for increasing anxiety (HR, 2.67; CI, 1.93 to 3.70), depression (HR, 3.38; CI 2.36 to 4.84), and stress (HR, 2.89; CI, 1.88 to 4.43) (P < .001). A significant regional variation was also noticed for anxiety, stress, and personal concerns.CONCLUSION:This survey conducted during the COVID-19 pandemic revealed that a significant proportion of HCWs in the radiation oncology community experiences moderate to severe levels of anxiety, depression, and stress. This trend is alarming and it is important to identify and intervene at the right time to improve the mental health of HCWs to avoid any long-term impacts.

PURPOSE Although cancer is an important and growing public health issue in Nepal, the country lacked any population-based cancer registry (PBCR) until 2018. In this study, we describe the establishment of the PBCR for the first time in Nepal and use the registry data to understand incidence, mortality, and patterns of cancer in the Kathmandu Valley (consisting of Kathmandu, Lalitpur, and Bhaktapur districts), which comprises 10.5% of the estimated 29 million population of Nepal in 2018. MATERIALS AND METHODS The PBCR collects information from facilities and communities through the active process. The facilities include cancer or general hospitals, pathology laboratories, hospice, and Ayurvedic centers. In the communities, the field enumerators or female community health volunteers collected the data from the households. In addition, the Social Security and Nursing Division under the Department of Health Services, which provides subsidy for cancer treatment of underprivileged patients, was another major source of data. The collected data were verified for residence, accuracy, and completeness and then entered and analyzed using CanReg5 software. RESULTS In the Kathmandu Valley, the PBCR registered 2,156 new cancer cases with overall age-adjusted incidence rate for all cancers of 95.7 per 100,000 population (95.3 for males and 98.1 for females). The age-adjusted mortality rate for males was 36.3 (n = 365) and for females 27.0 (n = 305) per 100,000 population. We found that the commonest cancers in males were lung and stomach, whereas in females, they were breast and lung cancer. Gallbladder cancer was among the top five common cancers in both sex. CONCLUSION These findings provide a milestone to understand the cancer burden in the country for the first time using the PBCR and will be helpful to develop and prioritize cancer control strategies.

Background Molecular testing of lung adenocarcinoma has become standard in clinical practice because the studies have shown that the use of targeted therapies increases the overall survival and quality of life in these patients. The primary aim of this study is to see the prevalence of common driver gene mutations (DGM) in advanced adenocarcinoma of lung in Nepalese population.MethodsRetrospective collection of information regarding age, gender, and DGM in advanced lung adenocarcinoma was gathered covering the period from January 2022 to July 2023. Data was analyzed by using SPSS-20 using descriptive statistical tools in terms of frequency and percentage.ResultsAmong 112 patients, 25% had Epidermal Growth Factor Receptor (EGFR) mutation, with exon 19 deletion being more prevalent (17 patients) compared to exon 21 L858R point mutation (nine patients). The occurrence of EGFR mutation was higher in males (14.29%) than in females (10.71%). Anaplastic Lymphoma Kinase (ALK)translocation was identified in six patients, while only one patient exhibited ROS1 rearrangement. Approximately 3% of patients did not undergo successful DGM tests due to insufficient tissue in the biopsy sample.Conclusions A quarter of patients diagnosed with advanced lung adenocarcinoma carry EGFR mutations. Sufficient tissue sampling is necessary to conduct driver mutation tests effectively.

Purpose: To evaluate stress levels of health care workers in Radiation Oncology in Nepal during COVID-19. Methods: A total of 46 eligible health care workers working in radiation oncology departments of two tertiary care hospitals in Nepal were enrolled in this study from May 2020 to July 2020. The 7- item Generalized Anxiety Disorder, 9- item Patient Health Questionnaire, and 22-item Impact of Events Scale-Revised were used for assessing anxiety, depression, and post-traumatic stress disorder. Precautionary measures are taken by the health care workers and satisfaction of organizational preparedness was also assessed. Results: Responses to the given questionnaire of all the participants were assessed. The median age was 33 years. The majority of participants had the mild impact of anxiety (70%), depression (75%), and post-traumatic stress (89%). Most of the participants (97.9%) followed hand hygiene as precautionary measures. Though anxiety and depression were mild, worry about family members getting COVID-19 was more (65.2%). Approximately half of the responders thought that organizations were concerned about their safety and necessary precautionary measures were taken. Conclusion: This survey highlighted the importance of taking measures for addressing the need of health care workers and finding out a solution to eliminating mild anxiety and depression amongst them.

Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Continuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informally, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in response to the needs of their patients. In other words, continuing professional development is any learning outside of undergraduate or postgraduate training or education that helps us maintain and improve our performance. CPD mainly encompasses self-directed and practice-based learning activities in addition to supervised education or training. CPD designates the period of education and training of doctors or health care providers commencing after completion of both basic and postgraduate medical education, thereafter extending throughout each one’s professional life. The value and importance of CME and CPD are self-evident to every doctors and health care providers. CME-CPD actually starts early on in our career but the actual importance of CME-CPD is most relevant after specialization which may be years long in a doctor’s life. Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Continuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informally, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in response to the needs of their patients.1 In other words, continuing professional development is any learning outside of undergraduate or postgraduate training or education that helps us maintain and improve our performance. CPD mainly encompasses self-directed and practice-based learning activities in addition to supervised education or training. CPD designates the period of education and training of doctors or health care providers commencing after completion of both basic and postgraduate medical education, thereafter extending throughout each one’s professional life.2 The value and importance of CME and CPD are self-evident to every doctors and health care providers. CME-CPD actually starts early on in our career but the actual importance of CME-CPD is most relevant after specialization which may be years long in a doctor’s life. Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Continuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informally, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in response to the needs of their patients.1 In other words, continuing professional development is any learning outside of undergraduate or postgraduate training or education that helps us maintain and improve our performance. CPD mainly encompasses self-directed and practice-based learning activities in addition to supervised education or training. CPD designates the period of education and training of doctors or health care providers commencing after completion of both basic and postgraduate medical education, thereafter extending throughout each one’s professional life.2 The value and importance of CME and CPD are self-evident to every doctors and health care providers. CME-CPD actually starts early on in our career but the actual importance of CME-CPD is most relevant after specialization which may be years long in a doctor’s life. Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Con - tinuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informal - ly, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in re - sponse to the needs of their patients. Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Con - tinuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informal - ly, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in re - sponse to the needs of their patients. Continuing Medical Education (CME) is the educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. Typically, Con - tinuing Professional Development (CPD), or Continuing Physician Professional Development (CPPD) includes all activities that doctors undertake, formally and informal - ly, including CME, in order to maintain, update, develop, and enhance their knowledge, skills, and attitudes in re - sponse to the needs of their patients.

Background Myelosuppression remains a major toxicity in cancer patients receiving chemotherapy, and is associated with considerable morbidity, mortality and cost. Objective The present study aims to investigate the prevalence and incidence of myelotoxicity, anemia and neutropenia in the adult cancer population, and further to determine the factors influencing them. Methods This was a cross-sectional observational study conducted at National Academy of Medical Sciences, Bir Hospital, Kathmandu. A total of 170 subjects eligible for the study were enrolled for analysis. Prevalence and incidence of myelotoxicity anemia, neutropenia and myelotoxicity at enrollment and during study were investigated. Factors influencing development of myelotoxic event were determined. Results Of 170 enrolled patients, the prevalence of myelotoxicity, anemia and neutropenia at enrolment was 54 (31.8%), 20 (11.8%) and 28 (16.6%), respectively, with 27 (16%) mild and 12 (7.1%) moderate type of anemia. Incidence of myelotoxicity, anemia and neutropenia during treatment was 90 (52.94%), 44 (26%) and 53 (31.2%) respectively, with 70 (41.2%) mild, 39 (22.9%) moderate and 5 (2.9%) severe type of anemia. Age (OR: 0.49; p < 0.047), and baseline Hb (OR: 1.29; p < 0.01) were found to be independent predictors associated with anemia. Hb (OR: 2.42, CI: 1.79-3.28; p < 0.001) and smoking (OR: 0.49: p = 0.03) were found to be independent factors associated myelotoxicity. Conclusion Our study confirmed a high incidence rate of myelotoxicity, neutropenia and anemia in a considerable number of Nepalese cancer patients receiving chemotherapy, and that baseline Hb, smoker and older adults are at more risk, these patients should be evaluated carefully and a prophylactic measure should be adopted accordingly so as to prevent toxicity and improve quality of life during cancer treatment.

Plasmablastic lymphoma is a rare and aggressive lymphoma reported to be commonly associated with immunodeficiency state. It possesses a challenge to the clinician owing it aggressiveness and poor prognosis. No standard of care treatment is available for the disease. Here we report a case of an immunocompetant 67 years female who is unique in her presentation as she did not have any of the conventional clinical features and had a history of urothelial carcinoma three months back.