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.

A cost-efficiency and health benefit approach to improve urban air quality

When ambient air quality standards established in the EU Directive 2008/50/EC are exceeded, Member States are obliged to develop and implement Air Quality Plans (AQP) to improve air quality and health. Notwithstanding the achievements in emission reductions and air quality improvement, additional efforts need to be undertaken to improve air quality in a sustainable way - i.e. through a cost-efficiency approach. This work was developed in the scope of the recently concluded MAPLIA project "Moving from Air Pollution to Local Integrated Assessment", and focuses on the definition and assessment of emission abatement measures and their associated costs, air quality and health impacts and benefits by means of air quality modelling tools, health impact functions and cost-efficiency analysis. The MAPLIA system was applied to the Grande Porto urban area (Portugal), addressing PM10 and NOx as the most important pollutants in the region. Four different measures to reduce PM10 and NOx emissions were defined and characterized in terms of emissions and implementation costs, and combined into 15 emission scenarios, simulated by the TAPM air quality modelling tool. Air pollutant concentration fields were then used to estimate health benefits in terms of avoided costs (external costs), using dose-response health impact functions. Results revealed that, among the 15 scenarios analysed, the scenario including all 4 measures lead to a total net benefit of 0.3M€·y(-1). The largest net benefit is obtained for the scenario considering the conversion of 50% of open fire places into heat recovery wood stoves. Although the implementation costs of this measure are high, the benefits outweigh the costs. Research outcomes confirm that the MAPLIA system is useful for policy decision support on air quality improvement strategies, and could be applied to other urban areas where AQP need to be implemented and monitored.

[Immune reconstitution inflammatory syndrome related with infliximab interruption in patient with Crohn's disease and active tuberculosis]

Tumor necrosis factor alpha inhibitors are associated with an increased risk of active tuberculosis. However, its interruption in this setting may trigger a paradoxical response to tuberculosis treatment, as an immune reconstitution inflammatory syndrome. We present the case of a 36-year-old patient, with Crohn's disease, treated with infliximab for the last 8 years, who was admitted with miliary tuberculosis. A pan-susceptible Mycobacterium tuberculosis strain was isolated. Infliximab was interrupted and standard antituberculous therapy was started, as well as systemic corticotherapy, without any clinical or radiological improvement. After exclusion of other opportunistic infections and primary or acquired immunodeficiency, we considered the possibility of an immune reconstitution inflammatory syndrome triggered by infliximab interruption. Thus, infliximab was reintroduced after 2 months of antituberculous therapy and clinical and radiological improvement was observed.

Identification of Plantago lanceolata pollen allergens using an immunoproteomic approach

BACKGROUND

Airborne Plantago pollen triggers respiratory allergies in Mediterranean countries.

OBJECTIVES

We aimed to study sensitization in patients with seasonal respiratory allergy and identify proteins of Plantago lanceolata pollen that could be responsible for hypersensitivity reactions in sensitized patients. We also determined the airborne pollen concentration of Plantago species from 2004 to 2011.

METHODS

IgE-binding proteins were analyzed and characterized using 1D and 2D gel electrophoresis and immunoblotting with sera from individuals sensitized to P lanceolata pollen extracts, mass spectrometry analysis, and protein data mining. We used aerobiological methods to study airborne pollen.

RESULTS

P lanceolata pollen accounts for 3% of the annual pollen spectrum in the air of Porto. Of a total of 372 patients, 115 (31%) showed specific IgE levels to P lanceolata pollen extracts. All sera from P lanceolata-allergic patients recognized 8 prominent groups of IgE-reactive allergens. Separation of proteins using 2D gel electrophoresis followed by identification with mass spectrometry revealed the presence of other IgE-reactive components that could be involved in sensitization.

CONCLUSIONS

We detected proteins in P lanceolata pollen extracts that, to our knowledge, have not yet been studied and could worsen sensitization to this weed pollen species. The proteins identified were involved in a variety of cellular functions. By applying 2D electrophoresis and immunoblotting with a pool of 2 sera from different P lanceolata-allergic patients, we obtained a more detailed characterization of the P lanceolata allergen profile.

Non-Hodgkin's lymphoma (NHL) patients at a VA medical center: Comorbidity and treatment

e19559

Background: We hypothesized that measures of comorbidity may help explain the number of treatments administered to patients with non-Hodgkin's lymphoma. Methods: We performed a retrospective, IRB approved protocol, using chart review of all patients diagnosed with non-Hodgkin's lymphoma at the VANJHCS from January 1, 1997 through December 31, 2008. Records were reviewed for demographic, clinical, pathological data, the number of chemotherapy regimens, radiation therapy, and total number of treatments and survival. We tabulated the Charlson Comorbidity Index (CMI), the Kaplan-Feinstein Comorbidity Index (KFI), the Cumulative Illness Rating Scale (CIRS), International Prognostic Index (IPI), and performance status (PS) were tabulated for 100 patients seen at a VA Medical Center. Results: There were 100 patients with median (M) age 62 years (27–89). There were 61 deaths (61%) with M survival(MS) 1068 days(13–3976). The M Stage was 1(0–4), M LDH was 204 IU/L (88–1905), M Hgb 12.3gm/dL (7.3–17.4), M Albumin was 3.8g/dl(1.2–5.4), M Zubrod Performance Status(PS) was 1(0–4) in 50 pts(50%). The M CMI was 6(1–12), M KFI was 3(1–3), M CIRS17 was 1.7(1–3.15). The M total number of systemic therapy regimens received was 1(0–4.5), M radiotherapy was 0(0–1) and the overall M total treatment regimens used was 1 (0–4.5). IPI was a significant predictor in the use of radiation therapy (p<0.054) but did not correlate with the use systemic therapy. The CMI was a predictor of the use of systemic chemotherapy (p<0.007), and the total number of treatments received (p<0.011), but not the KFI or the CIRS 17. The performance status did not predict for the number of treatments. In a Cox regression analysis, the number of treatments did not affect survival. Conclusions: This data provides evidence that one measure of comorbidity, the CMI, may partially explain the number of systemic therapy treatments, and total treatments received by NHL patients. Further work in larger groups of pts is warranted.

No significant financial relationships to disclose.

Comorbidity and survival of hepatocellular carcinoma patients at a VA medical canter

e15682

Background: To determine whether comorbidity indices predict survival in hepatocellular carcinoma (HCC) pts. Methods: In an IRB approved protocol, we reviewed the records of pts with tissue diagnosis of HCC seen at a VA Medical Center between 1/1/1999 to 12/31/2008. Comorbidity was assessed with four comorbidity indices, the Charlson Comorbidity Index (CMI), the Kaplan- Feinstein Index (KFI), the Cumulative Illness Rating Scale (CIRS), and VA Comorbidity Scale (VACS). Demographics, ECOG PS, stage, alpha-fetoprotein (AFP) at diagnosis, hepatitis B (HBV) and C (HCV) status, alcohol use, and iron overload were also reviewed. Cox survival regression analysis was performed. Results: There were 44 pts. All pts were men. The median (M) age at diagnosis was 60.5 years (range 35–86). The overall M survival was 230 days (4–2784). There were Stage I 12 (27%) pts, Stage II 7 (16%) pts, Stage III 14 (32%) pts, and Stage IV 11 (25%) pts. The M ECOG PS was 1.0 (0–4), stage 3 (1–4), CMI 5.75 (1–16), CIRS15 3.0 (1–5), CIRS16 6.0 (1–14), CIRS17 2.0 (0.83–5.0), CIRS18 0 (0–2), CIRS19 0 (0–1), KFI 3.0 (1–3), VACS 6.0 (2–9), and AFP 56.35 (1.1–379567). HBV was positive in 10 pts (23%), HCV 26 (59%) pts, alcohol use 37 (84%) pts, and iron overload 11 (25%) pts. In univariate survival analysis, stage (p<.038), ECOG PS (p<.001), AFP (p<.009), presence of iron overload (p<.006), and CMI (p<.019) were significant in predicting survival. However, age, HBV, HCV, alcohol use, CIRS15, CIRS16, CIRS17, CIRS18, KFI, and VACS were not significant for survival. In multivariate survival analyses that included stage and a comorbidity index, the CMI approaches significance (p<.077). Conclusions: In this sample, the CMI was a predictor for survival in pts with HCC. Further analysis in a larger sample is needed to provide a more definitive conclusion. This was supported by the New Jersey Commission for Cancer Research 09–1133-CCR-EO.

No significant financial relationships to disclose.

Comorbidity and survival in cancer patients receiving palliative care

9066

Background: Comorbidity has received increasing attention in the assessment of patients with early stage cancer, or at diagnosis. We studied whether three indices of comorbidity, the Charlson Comorbidity Index (CMI), the Cumulative Illness Rating Scale (CIRS), and the Kaplan Feinstein Index (KFI) add prognostic information for cancer patients receiving palliative care. Methods: In an IRB approved protocol, 103 patients with advanced cancer were seen at the time they were starting palliative care. They had a Karnofsky Performance Status (KPS) determination, and were followed longitudinally. Comorbidity scores were coded from the medical record. At this time, all patients had died and survival analyses were performed. Results: The median age was 69 years (range 41–87), median Karnofsky Performance Status (KPS) was 70% (range 20–90); primary sites were lung 41 pts (40%), prostate 23pts (22%), colorectal 10 pts (10%), other cancers 29 pts (28%). Median survival was 111 days (range 4–1,145 days). Median CMI was 10 (range 4–14), CIRS15 4 (2–5), CIRS16 9 (4–12), CIRS17 2.3 (1.5–3.33), CIRS18 1 (0–3), KFI 2 (0–3). In univariate survival analyses, when bisected by median values, the KPS, age, CMI, and subscales of the CIRS (CIRS 16, CIRS 17, CIRS18) were significantly related to survival, but not the KFI. In multivariate Cox regression analyses that included KPS (p<0.0001) and age (p<0.003) and a comorbidity index, the CMI (p<0.0001), and certain subscales of the CIRS were independently predictive of survival, specifically the CIRS 15 (p<0.0001), CIRS16 (p<0.0001), CIRS 17 (p<0.0001), and CIRS18 (p<0.0001). The primary site was not an independent survival predictor. Conclusion: In patients with advanced cancer receiving palliative care, measures of comorbidity may contribute to refining estimates of prognosis and ultimately to health care resource utilization. The optimal comorbidity measure remains to be determined. These results will be confirmed in larger populations. Supported in part by the Soros Open Society Institute Project Death in America and VA HSRD IIR 02–103

No significant financial relationships to disclose.

A phase II trial of epirubicin (E), estramustine phosphate (EP), and celecoxib (C) as second line treatment of patients (pts) with hormone resistant prostate cancer (HRPC)

14567

Background: Celecoxib, epirubicin, and estramustine phosphate affect prostate cancer cells through different mechanisms. All three could be synergistic. We studied the effects of this combination on PSA, response, toxicity and survival in pts with HRPC. Methods: Pts after progression from first line taxane-based chemotherapy with rising PSA and radiographic progression were eligible. Treatment was E30 mg/m2 iv on day 1 and 8 of each 4 week cycle; EP 280 mg po bid daily × 3 days every wk × 2 followed by 2 wks rest; C 400 mg po bid daily for 28 days. All pts were assessed for response every 2 cycles. Dose modifications for hematologic and hepatorenal toxicity were made. RECIST criteria and PSA decline>50% were used to define response. Results: Sixteen pts enrolled, and 13 are evaluable for toxicity and response. Two withdrew before treatment and one for toxicity. The Median (M) age was 71.5 yrs (59–87), ECOG PS 1 (0–1), Gleason score 7 (4–9), LDH 172 (131–244), Hgb 11.1 (8.8–11.9), PSA 75 (6–814). Pts received M 4 cycles (2–10). Nine (69%) pts had soft tissue and 12 (92%) pts had bone metastases. For radiographic response, 11 pts were evaluable; 6 had stable disease and 2 had complete response by CT. Two pts had response by bone scan. Nine (69%) pts had PSA response. The M survival was 441 days (10–995). There were 5 SAE - DVT, diarrhea, bowel obstruction, cord compression and myocardial infarction. There was good renal and cardiac tolerance. Conclusions: This combination was safe and showed good and durable response as a second line regimen.

[Table: see text]

Combination therapy with docetaxel (D) and celecoxib (C) in patients (pts) with hormone resistant prostate cancer (HRPC)

14519

Background: Cox-2 expression is an independent predictor of survival and is over expressed in 89.3% of pts with HRPC. Cox-2 expression has angiogenic and cytoprotective effects. Its suppression could lead to angiogenesis inhibition and increase chemotherapy sensitivity. D in low doses and C are angiogenesis inhibitors. The main objectives were to study the effects on PSA, time to progression (TTP), toxicity and survival. Methods: In a two stage, phase II trial designed for 66 pts, 30 pts with HRPC and evidence of biochemical and radiographic progression were treated with D 30 mg/m2 IV/wk for 3 wks and C 400 mg po bid for 4 wks of each cycle. Response evaluation after every two cycles was made. RECIST criteria and PSA reduction by >50% for biochemical response were used. Independent safety monitoring for renal (R) and cardiovascular (CV) toxicity were made. Results: Thirty (30) evaluable pts received minimum of 2 cycles, median (M) 4.5 (range 2–8). The M age was 74 yr (55–94), ECOG PS 1 (0–2), Hb 11.8 g/dl (8.6–14.6), and PSA 92.5 ng/dl (15.3–4192). Metastases were present in 24 pts (80%) by bone scan and 25 pts (83.3%) by CT scan. Twelve (12) pts (40%) had PSA response of >50% and 4 pts (13.3%) had PSA normalization. By CAT scan, 3 pts (10%) had CR, 5 pts (16.7%) had PR, and 12 pts (40%) had SD. By bone scan 1 pt (4.8%) had a major response. The M TTP by PSA was 3.65 mos (0.87–12.0). With 27% pts still alive, the M survival was 10.9 mos (3.0– 30.7+), with 95% CI for the mean (9.3–15.2). One pt (3.3%) withdrew due to abdominal discomfort, 2 pts (6.6%) had grade III diarrhea and 1 pt (3.3%) had grade III nail toxicity. Conclusions: 66.7% pts had soft tissue response (CR+PR+SD), and 13.3% pts had PSA normalization. Safety analysis for R and CV toxicity demonstrated excellent safety of this regimen. Considering the unfavorable prognostic indicators of this population the MST of 10.9 mos indicates the activity of this combination.

[Table: see text]