Background. The early integration of supportive care in oncology improves patient-centered outcomes. However, data is lacking regarding how to achieve this in resourcelimited settings. We studied whether patient navigation increased access to multidisciplinary supportive care among Mexican patients with advanced cancer. Materials and Methods. This randomized controlled trial was conducted between 08/17 and 04/2018 at a public hospital in Mexico City. Patients aged ≥18 with metastatic tumors ≤six weeks from diagnosis were randomized (1:1) to a patient navigation intervention or usual care. Patients randomized to patient navigation received personalized supportive care from a navigator and a multidisciplinary team. Patients randomized to usual care obtained supportive care referrals from treating oncologists. The primary outcome was the implementation of supportive care interventions at 12 weeks. Secondary outcomes included advance directive completion, supportive care needs, and quality of life. Results. 134 patients were randomized: 67 to patient navigation and 67 to usual care. Supportive care interventions were provided to 74% of patients in the patient navigation arm vs. 24% in usual care (difference 0.50, 95% CI 0.34-0.62; p<0.0001). In the patient navigation arm, 48% of eligible patients completed advance directives, compared to 0% in usual care (p<0.0001). At 12 weeks, patients randomized to patient navigation had less moderate/severe pain (10 vs. 33%; difference 0.23, 95% CI 0.07-0.38; p = 0.006), without differences in quality of life between arms. Conclusions and Relevance. Patient navigation improves access to early supportive care, advance care planning, and pain for patients with advanced cancer in resource-limited settings. The Oncologist 2020;9999:• •
Background: Early specialized palliative care improves quality of life of patients with advanced cancer, and guidelines encourage its integration into standard oncology care. However, many patients fail to obtain timely palliative/supportive care evaluations, particularly in limited-resource settings. We aimed to determine the proportion of patients with advanced cancer who received an assessment of symptoms and were referred to supportive and palliative care services during the first year after diagnosis in a Mexican hospital. Methods: Individuals with newly diagnosed advanced solid tumors and 1 year of follow-up at the oncology clinics in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City from October 2015 to April 2016 were included in this retrospective study. Results: Seventy-seven patients were included. Forty-two (54.5%) were referred to the various supportive care services during the first year after diagnosis, and 23 (29.8%) were referred to the palliative care clinic. The most commonly assessed symptoms by oncologists were pain (77.9%), anorexia (74.0%), fatigue (68.8%), and nausea (55.8%), while depression/anxiety were evaluated in 10 (12.9%) patients. The oncologist offered to clarify treatment goals in 39 (50.6%) cases and evaluated the understanding of diagnosis/illness and prognosis in 22 (28.5%). Conclusion: Palliative and supportive care services were widely underutilized, which may be related to a lack of standardized symptom assessments and poor end-of-life communication. Novel strategies are needed to improve the implementation of tools for systematic symptom assessment and to optimize the integration of supportive care interventions into oncology care in developing countries.
Background: Anal cancer, a relatively rare malignancy, has been steadily increasing in risk groups such as male that have sex with men (MSM), male and female with HIV and HPV infection, and women with previous cancer of the genital tract. Squamous cell carcinoma of the head and neck, genital tract and anal canal are associated with high-risk HPV types. When HPV integrates in the host cell genome in squamous cells, the result is overexpression of the viral oncogenic proteins E6 and E7, which interact with cellular proteins to initiate neoplastic transformation and upregulation of p16INK4A and Ki-67 proliferation antigen. The increasing interand intra-observer variability in the diagnosis of dysplastic lesions makes necessary the use of these surrogate markers. We analyzed the prognostic role of HPV status and p16/Ki67 expression in malignant lesions of the anal canal.Methods & Materials: Retrospective study (2013-2016) of 38 patients of 19-78 years, average age 43.5 year-old. Of which 25 male (66%) and 13 female (34%). Histologic grade of biopsies were: Invasive carcinoma n = 8; ACIN II/III n = 8; condyloma n = 9; biopsies with benign anal lesions n = 14 (fistula, fissure, hemorrhoid).HPV detection. Nested-real time PCR of E6/E7 sequences that differentiate HPV of high and low oncogenic risk. Expression of p16INK4a and Ki67 was carried out by immunohistochemistry following manufacturing instructions. Clinical records were reviewed.Results: All 8 invasive carcinoma were HR-HPV and p16/Ki67 positive: 6 women, one with cervical cancer, one HIV + ,one with CML; one male HIV + with two biopsies and a history of condyloma.Of 8 ACIN II/III: 7 were males, 6 HIV + , 5 HR-HPV and 4 p16/Ki67 positive; one woman HIV + , HR-HPV, p16/Ki67 positive. Viral load was high in most invasive carcinoma and ACIN II/II HIV + patients. All condyloma cases were males: 5 LR-HPV, 2 HR/LR HPV, 2 HPV negative; all were p16/Ki67 negative. Most patientes with malignant lesions had history of condyloma. Benign lesions were all HPV and p16/Ki67 negative. All HR-HPV were HPV-16 with one HPV-18.Conclusion: HPV status and molecular markers expression are useful indicators of patients at risk of developing neoplasic lesions. Apparently condyloma are a risk factor for developing anal cancer.
124 Background: Although referral to supportive care (SC) services improves quality of life in patients with cancer, several barriers can hamper access to SC, particularly in developing countries with limited resources. We studied patient-reported barriers for accessing SC in a cancer center in Mexico City, and factors associated with those barriers. Methods: Patients with metastatic cancer enrolled in a randomized clinical trial of patient navigation to improve access to SC in a public cancer center in Mexico City (NCT03293849) were included. At baseline, sociodemographic and clinical characteristics were collected, and patients answered a survey in which they reported barriers to obtain cancer treatment and SC. We analyzed the frequency of reported barriers using descriptive statistics, and explored if sociodemographic factors were associated with a higher likelihood of reporting any barrier. Results: 134 patients were included between 08/17 and 04/18. Median age was 60 years (range 23-93; 51.5% male); 89.5% lived in urban areas; 42.5% had less than high school education; 12% had formal employment; and 27.3% had no insurance coverage. 61% had gastrointestinal, 16 % genitourinary, and 23 % other tumors. Home-to-hospital time was < 2 hours (h) in 60%, 2-6 h in 27%, and ≥6 h in 13%. 47.7% of the patients reported a household income of less than 630 USD/month. The mean number of reported barriers was 1.96 (Standard Deviation 1.77). 78% identified at least one barrier to care, and 35% reported ≥3 barriers (range 1-8). The most commonly reported barriers were: financial burden (47%), beliefs about treatment (28%), lack of transportation (22%), fear (19%), home-to-hospital distance (16%), patient-provider communication (13%), employment (9%), and caregiving for other people (3%). Patients living in rural areas more often reported home-to-hospital distance as a barrier than those living in urban areas (69 vs 11%, p < .01). Conclusions: Most patients with metastatic cancer seen at a cancer center in Mexico identified at least one barrier to cancer care, with some reporting up to 8. Many of the reported barriers are potentially modifiable through patient navigation or SC interventions.
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