Background: Lung cancer is a worldwide health problem. Brazil is no different with over 31,000 new cases estimated in 2018 nationwide. Unfortunately the majority of cases are diagnosed in advanced stage. Molecular testing for driver alterations, such as EGFR and ALK are mandatory as they are both prognostic and predictive biomarkers to recommend target therapy for metastatic disease. Many guidelines advocate to use a tyrosine kinase inhibitors (TKI) as first line therapy on advanced NSCLC (nonsmall cell lung cancer) based on increased PFS data compared with chemotherapy. In Brazil, molecular testing and target therapy for EGFR and ALK are not widely available in public health system. Aim: We aimed to evaluate the prevalence of patients with advanced NSCLC tested for EGFR and/or ALK that who received target therapy in a public health hospital in southern Brazil. Methods: All patients with NSCLC adenocarcinoma stage IIIB-IV from January 2013 through March 2018 were included. Medical records were reviewed to evaluate for molecular testing and target treatment. Results: We found a total of 261 patients diagnosed with NSCLC (adenocarcinoma). Out of these, 102 patients were staged IIIB/IV or with relapsed disease. In 49/102 (48.4%) cases some molecular testing was performed; EGFR 36 (35.3%), mutEGFR: 9/36 (25%), unknown (UK): 8/36 (22.2%); ALK: 19 (18.6%), without transloc. (w-o): 6/19 (31.6%); wtransloc: 1/19 (5.3%); UK 3/19 (15.8%). Out of 102 patients, only nine (8.8%) were included in a clinical trial; 6/102 (5.9%) received a TKI outside of a clinical trial setting. Only 2/6 received TKI as first line treatment whether the remaining 4/6 received a TKI on second line or beyond. Conclusion: Only half of the patients with advanced NSCLC were tested for either EGFR or ALK. Of these patients, 25% tested positive for a mutation in EGFR and 5.3% were found to have an ALK-rearrangement. Only 6 received TKI. Both molecular testing and target therapy are restricted by the public healthcare system. We depend on clinical trials or the pharmaceutical industry support, in many cases, to test for and identify such patients with target therapies. Treatment of lung cancer in Brazil contradicts a number of guidelines, expert's recommendations and best clinical practice. Unfortunately, legal measures are expensive and deleterious to national financial sustainability, but in many cases represent the only form to guarantee access to a TKI treatment. We found many systematic problems (loss of some patient's data) as a result from cross-sectional study. This may contribute to small number of patients. However the challenge to offer better treatment of lung cancer patients in Brazil was not affected.
Background According to pathologico-clinical features, patients diagnosed with localized prostate cancer (PCa) are stratified into distinct risk groups (low-risk, intermediate-risk or high-risk). Data have demonstrated that 68 Gallium-prostate-specific membrane antigen positron emission tomography ( 68 Ga-PSMA PET/CT) is superior to conventional radiological exams (CT or MRI and bone scintigraphy) in the primary staging of high-risk localized PCa. However, it is still unknown if in a population of high-risk PCa, there would be a subgroup of patients with a higher probability of identifying metastatic disease by the 68 Ga-PSMA PET/CT. Materials and Methods Data from patients with localized PCa who underwent 68 GA-PSMA PET/CT for primary staging from four institutions were retrospectively collected. We selected patients with at least one D'Amico classification risk factor (International Society of Urological Pathology ≥ IV and/or prostate-specific antigen > 20 ng/ml). To detect an association between extent of disease and number of risk factors as well as International Society of Urological Pathology prostate cancer grade, contingency tables were used, and Fisher Exact Test was performed. Results Between 2016 and 2020, 60 patients underwent a 68 GA-PSMA PET/CT for primary staging of high-risk localized PCa. Regarding the number of risk factors, 37 patients (62%) had one risk factor, and 23 (38%) had two risk factors. In the subgroup of patients with metastatic disease (n = 22), those with two risk factors had higher incidence of metastatic disease, and it was statistically significant ( p = 0.011 ). Conclusion This retrospective analysis demonstrated that 68 GA-PSMA PET/CT was able to identify advanced disease in more than one-third of patients with high-risk disease especially those with two adverse risk factors.
BACKGROUND: Immune checkpoint inhibitors (ICI) have shown clinical benefit among patients with advanced kidney cancer. Their cost burden hardens its access, especially in low- and middle-income countries. To set solutions, the impact of geographical and socioeconomic differences in the clinical outcomes and survival of renal cell carcinoma (RCC) patients needs to be explored. OBJECTIVE: This review aimed to understand if geographical differences affected the clinical outcomes of RCC patients receiving immunotherapy. METHODS: This study reviewed 45 studies that examined the OS and PFS of RCC patients undergoing ICI (2010–2020) selected from a 3028-study database search conducted on PubMed and grey literature. The selected studies were divided into groups: Asia, multicentric studies, Europe and Anglo-America. The lethality and income of the geographical locations were measured and discussed. RESULTS: Weighted average (WAVG) of mPFS and mOS were 8,47 months, and 40,6 months in Asia. The WAVG of mOS were 12.2 months, and 20.22 months in the Anglo-American population (15 studies; 943 patients). In multicentric studies (4 studies; 1834 patients) the WAVG mPFS was 10,06. European group (13 studies; 3143 patients) had 6.1 and 20.24 months mPFS and mOS, respectively. The exploratory analysis on income and RCC lethality has shown an absolute decline of 8.7% (CI 10.1 to 7.3% - p < 0.05) in RCC lethality, when income is raised by 100% . CONCLUSION: Clinical benefit from ICI varies across the globe. A wide access to ICI, and evaluation of biological aspects of the disease will allow a better understanding of the impact of geographic regions in the clinical outcome of patients receiving ICI and the etiology of potential differences.
Background: Toxicity analysis in randomized studies is classically reported as maximum grade toxicity occurring during the course of treatment. Unfortunately, the duration of toxicity is neglected. Patients receiving targeted therapy like gefitinib frequently have low grade continuous toxicities. Longitudinal toxicity analysis may be a more appropriate method of quantifying and comparing toxicity. Method: EGFR mutated NSCLC patients treated with gefitinib or pemetrexedcarboplatin as a part of randomized study were selected for this analysis. Patients were evaluated on the 7th day after the start of therapy and then on days 15, 21, 42, 63, 84,105 and then subsequently every 2 months till progression. Toxicities in accordance with CTCAE version 4.02 occurring during each visit were documented at each visit. Three toxicities were selected for this analysis and these were diarrhea, skin rash and fatigue. R software was used for analysis. Maximum grade toxicity and longitudinal time-toxicity analysis was performed. Toxicities were compared between the 2 arms using both methods. Result: Among the 290 patients, half each were randomized to gefitinib and pemetrexed-carboplatin arm respectively. Any grade diarrhea was seen in 22% of patients receiving gefitinib as opposed to 12% receiving pemetrexed-platinum (p-0.12%). Similar higher proportion of toxicity was seen in gefitinib arm for skin rash (33% versus 13%, p-0.00).The proportion of fatigue in gefitinib and pemetrexed-platinum arm were similar (6% versus 9%, p-0.59). The longitudinal time-toxicity analysis revealed that both rash and diarrhea were higher and more sustained in gefitinib arm. The difference area under the curve for rash and diarrhea were 10 units (p-0.192) and 21.89 units (p-0.09) respectively. The fatigue was similar in both arms (p-0.779) Conclusion: Longitudinal time-toxicity analysis provides information which is clinically relevant and might impact patients quality of life and hence should be performed in patients receiving targeted therapies.
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