Experience of bipolar androgen therapy (BAT) in Argentinian oncology centres

Background

Previous studies with bipolar androgen therapy (BAT) have shown clinical activity in metastatic Castration Resistant Prostate Cancer (mCRPC) as well as the potential to re-sensitise prostate cancer cells to prior androgen receptor-targeted agents. None of these studies had tested BAT after chemotherapy. In this study, we gathered real-world evidence from three centres in Argentina where BAT is being used in castration-resistant prostate cancer (CRPC), not only prior to chemotherapy but also after several lines of treatment.

Materials and methods

This retro-prospective nonrandomised multicentre cohort study included patients with mCRPC, who received BAT in different scenarios defined by the treating physician at three centres in Argentina.

Results

A total of 21 asymptomatic patients with mCRPC were included. There was a median of two lines before BAT, with nine patients (42.8%) receiving three or more lines, and 13 patients (61.9%) receiving chemotherapy previously. Previous lines included next-generation hormonal agents (NHA) in 100% (abiraterone 33.3% and enzalutamide 71.4%), chemotherapy in 61.9%, Radium-223 in 47.6% and others in 4.8%. The progression free survival (PFS) after BAT was 3.5 months (95% CI: 3.06-7.97). PSA50 response rate (RR) was 28.5% and the overall RR was 14.3%. Of the 17 patients who had disease progression, 9 had a rechallenge to NHA, achieving a 55% RR, 6 received other treatment (chemotherapy in 5 and ¹⁷⁷Lu-PSMA in 1) with a 66% RR and 2 best supportive care. The PFS2, calculated after the initiation of BAT in the 15 patients who received further therapy, was 7.93 months (95% CI: 6.73-NR). Treatment was overall well tolerated, with only two patients requiring hospitalisation and treatment interruption due to worsening pain.

Conclusion

To the authors' knowledge, this is the first publication of BAT in later lines of therapy in mCRPC. BAT showed clinical activity in this scenario. Our data supports that BAT may play a role in CRPC re-sensitisation after multiple treatment lines.

HOLA COVID-19 Study: Evaluating the Impact of Caring for Patients With COVID-19 on Cancer Care Delivery in Latin America

PURPOSE

The HOLA COVID-19 study sought to evaluate the impact of COVID-19 on oncology practices across Latin America (LATAM), challenges faced by physicians, and how practices and physicians adapted while delivering care to patients with cancer.

METHODS

This international cross-sectional study of oncology physicians in LATAM included a 43-item anonymous online survey to evaluate changes and adaptations to clinical practice. Multivariable logistic regression analyses were used to evaluate the association of caring for patients with COVID-19 and changes to clinical practice.

RESULTS

A total of 704 oncology physicians from 19 countries completed the survey. Among respondents, the most common specialty was general oncology (34%) and 56% of physicians had cared for patients with COVID-19. The majority of physicians (70%) noted a decrease in the number of new patients evaluated during the COVID-19 pandemic when compared with prepandemic, and 73% reported adopting the use of telemedicine in their practice. More than half (58%) of physicians reported making changes to the treatments that they offered to patients with cancer. In adjusted models, physicians who had cared for patients with COVID-19 had higher odds of changing the type of chemotherapy or treatments that they offered (adjusted odds ratio 1.81; 95% CI, 1.30 to 2.53) and of delaying chemotherapy start (adjusted odds ratio 2.05; 95% CI, 1.49 to 2.81). Physicians identified significant delays in access to radiation and surgical services, diagnostic tests, and supportive care.

CONCLUSION

The COVID-19 pandemic has significantly disrupted global cancer care. Although changes to health care delivery are a necessary response to this global crisis, our study highlights the significant disruption and changes to the treatment plans of patients with cancer in LATAM resulting from the COVID-19 health care crisis.

Implementation of a molecular tumour board in LATAM: the impact on treatment decisions for patients evaluated at Instituto Alexander Fleming, Argentina

BACKGROUND

The role of the molecular tumour board (MTB) is to recommend personalised therapy for patients with cancer beyond standard-of-care treatment. A comprehensive molecular analysis of the tumour in a molecular pathology laboratory is important for all targeted therapies approaches. Here we report the 1-year experience of the Instituto Alexander Fleming Molecular Tumour Board.

PATIENTS AND METHODS

The MTB of the Instituto Alexander Fleming was launched in December 2019 in a monthly meeting. In each interactive monthly session, five cases were presented and discussed by the members. These cases were referred by the treating oncologists. The MTB recommendations were sent to each physician individually, and to the rest of the meeting participants. This was discussed with the patients/families by the treating oncologist. The final decision to choose therapy was left to the treating physicians. Of the 32 patients presented at MTB, 28 (87.5%) had potentially actionable alterations and only 4 (12.5%) had no actionable mutation. Six (19%) patients received a local regulatory agency approved drug recommendation, nine (28%) patients received an off-label approval treatment recommendation and three (9%) patients did not receive the treatment due to access and reimbursement of the drug.

CONCLUSION

In most of the cases evaluated, the MTB was able to provide treatment recommendations based on targetable genetic alterations. Molecular-guided extended personalised patient care is effective for a small but clinically significant proportion of patients in challenging clinical situations. We believe that the implementation of a MTB is feasible in the Latin America (LATAM) region.

Sensitivity and specificity of strain rate for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with adriamycin with or without trastuzumab

Background

Medical literature states that a global longitudinal strain rate (GLS) <−19% and further reductions in relation with baseline GLS may predict long term left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with Adriamycin (A) with or without trastuzumab (T). However, there is not strong evidence to support the use of this technique in daily clinical practice.

Purpose

To analyze the sensitivity (S) and specificity (Sp) of GLS <−19% or its relative 10, 15 and 20% reduction form baseline, for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T.

Methods

Patients were prospectively assessed with a cardiac echoDoppler + GLS at baseline, every 3 months during the first year and every 4 months thereafter. We assessed the S and Sp of GLS <−19% or its relative >10%, >15% and >20% reduction form baseline after treatment with A with or without T as predictors of cardiotoxicity (defined as a >10 percentage points decrease of left ventricular ejection fraction to a value below the lower normal limit with respect to baseline).

Results

136 out of 884 patients (16%) had GLS measured at each visit: 83 patients (60%) and 53 patients (40%) treated with A or A+T respectively. Patients were followed up to 31±6 months. Mean age was 51±12 years. The table shows the baseline characteristics of both groups. 10 out of 83 patients in group A (12%) and 18 out of 53 P in group A+T (34%) developed cardiotoxicity. Baseline left ventricular ejection fraction and GLS were 61±4,7% and −20,18±2,6% in group A, and 58,7±5,8% and −19,5±2,6 post treatment. In this group, GLS S and Sp were 50 and 80%, respectively. In the group A+T, the best GLS cutoff was −19%, with a 60% sensitivity and 78% specificity.

Conclusions

In our non-selected cohort of patients, nor GLS or its percentage reductions along follow up predicted the reduction of left ventricular ejection fraction and the developing of cardiotoxic ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T. The systematic use of this tool should be further investigated and validated at each center to help establish its usefulness in daily practice.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics

Neoplasias del tracto genitourinario: historia de los grandes avances

Se presenta una reseña histórica de los avances en oncología en tumores genitourinarios. Avances que, desde su incorporación al arsenal terapéutico, no se modificaron hasta la actualidad. Y muchos de ellos son usados en otros modelos tumorales.

Multidisciplinary approach to COVID-19 and cancer: consensus from scientific societies in Argentina

Introduction

The world is living through an outbreak of an acute respiratory syndrome caused by a new betacoronavirus known as coronavirus 2 (SARS CoV-2), which has been declared an international public health emergency by the World Health Organisation. Cancer patients are a very special population in this setting since they are more susceptible to viral infections than the general population. Several recommendations have been made on this issue, most of them based on expert opinion and institutional experience. It is essential to gather the evidence available for decision making.

Objective

To review the evidence available in order to create a multi-institutional position from the perspective of scientific societies in Argentina involved in the management of cancer patients.

Methodology

The review included two phases: 1) search and systematic revision of the medical literature; 2) consensus and revision of the document drafted by national scientific societies involved in the management and care of cancer patients using the modified Delphi method. The final results were presented at a videoconference with all the participants. Also, additional comment and recommendations were discussed. The final document was revised and approved for publication by the members of the panel.

Results

The consensus panel included 18 representatives from scientific societies from Argentina who assessed the evidence and then made recommendations for the management of cancer patients in our country. International guidelines (CDC; ASCO, NCCN and ESMO) were considered as a background for analysis, as well as institutional guidelines and an open ad hoc survey administered to 114 healthcare professionals from the scientific societies involved in this study.

The recommendations are grouped as follows: 1) general care interventions—training of the personnel, cleaning and disinfection of the hospital premises and patient scheduling; 2) treatment decisions—patient care, surgeries, immunosuppressive therapy, radiotherapy and screening; 3) ethical considerations—optimisation of resources, end-of-life care for critically-ill patients; 4) management of hospitalised patients; and 5) wellbeing of the healthcare team.

The general recommendation arising from the study is that the management of cancer patients must adapt to the exceptional pandemic status quo without disregarding treatment or cure options. Moreover, healthcare professional accompaniment of all patients should not be neglected. All healthcare professionals must make a significant joint effort to create multidisciplinary teams to discuss the most appropriate measures for each particular situation.

Conclusions

The scientific evidence available on this topic worldwide is in progress. This together with the epidemiologically shifting scenario poses unprecedented challenges in the management of cancer amidst this global pandemic. Furthermore, the key role of the healthcare structural organisation appears evident, such as the drafting of clear guidelines for all the stakeholders, adaptability to constant change and an interdisciplinary shared vision through consensus to provide adequate care to our cancer patients in the light of uncertainty and fast-paced change.

Intermediate-risk prostate cancer treated with external beam radiotherapy (EBRT): A risk group with heterogeneous behavior

145

Background: In men with intermediate-risk prostate cancer (IR-PC) treated with low dose EBRT, the addition of androgen deprivation therapy (ADT) prolongs overall survival. Zumsteg proposes a subdivision for de IR-PC group: favorable or unfavorable. Purpose: retrospective evaluation of EBRT efficacy according to IR-PC subgroups (favorable or unfavorable). Methods: From the institutional radiotherapy department database, from 2000 to 2011, 95 men with IR-PC were identified and subdivided as follows: Favorable Risk (FR) – Gleason 3+4 or less and positive prostate biopsies (ppb) not exceeding 50% and only one intermediate-risk factor excluding 4+3; Unfavorable risk (UR) – Gleason 4+3 or at least 2 intermediate-risk factors or at least one intermediate risk factor and ppb >50%. Results: 95 patients were included in the analysis, mean FUP 6.2 years. 32.6% (31) had >50% ppb, 14.7% (14) had Gleason 4+3, 38.9% (37) had 2 intermediate-risk factors. 42.1% (40) were FR and 57.9% (55) were UR. Median EBRT dose: 79.8Gy. Only 25% of FR patients received some hormonal therapy treatment. There were no differences in time to Prostatic Specific Androgen (PSA) nadir (FR 12 vs UR 13 months; p= .50), biochemical relapse free survival (RFS) (FR 60 vs US 58 months; p= .80), or doubling time PSA (FR 12 vs UR 11 months; p= .19). Biochemical relapse (BR) and local relapse (LR) rates were lower for FR (BR: FR 27.5 vs UR 38.2%, p= .17; LR: FR 5 vs UR 14.5%, p= .40). Local RFS (FR 13.6 vs UR 9.6 years; p= .11) and distant RFS (FR 13.1 vs UR 12.4 years; p= .65) were longer for FR patients. Conclusions: Short course ADT is the standard treatment in IR-PC patients when EBRT is indicated, especially if they have UR features. In our study IR-PC group had heterogeneous outcomes and, in spite the study limitations, FR patients had a trend for better prognosis even with a very low use of ADT. If Favorable IR-PC patients may avoid ADT morbidity should be answered by a randomized trial.

[Chylopericardium and bilateral chylothorax in a breast cancer patient]

Non traumatic chylopericar dium is mostly secondary to infection, congenital or neoplastic disease that invade mediastinal lymph nodes and modify the normal lymphatic flow. It is associated to chylothorax in approximately 3% of cases. We report the case of a 52 years old woman with diagnosis of advanced breast cancer. She was admitted with bilateral pleural effusion and echocardiographic signs of cardiac tamponade. A CT scan disclosed multiple mediastinal lymphadenopathy. The level of tryglicerides in pleural effusion was 372 mg/dl. A percutaneous pericardiocentesis was performed, obtaining chyle, with 984 mg/dl of tryglicerides and cholesterol 90 mg/dl levels. Treatment strategy was modified. We reviewed pathophysiology, diagnostic criteria and treatment of this rare entity.