Teleoncology: A Solution for Everyone? A Single-Center Experience with Telemedicine during the Coronavirus Disease 2019 (COVID-19) Pandemic

Since the beginning of the COVID-19 pandemic, the use of telehealth was rapidly implemented without previous evidence. The ONCOTELEMD study aimed to evaluate the opinion of patients attended via telemedicine during this period and to study factors that condition patient preferences on its use. Included patients had a confirmed cancer diagnosis and were contacted by telephone between 13 March and 30 April 2020, in the Medical Oncology Service of Hospital Parc Taulí, Sabadell. A 12-question survey was presented to them between 4 February and 19 April 2021. Statistical analysis was carried out using chi-square and multivariable logistic regression tests. Six hundred forty-six patients were included; 487 responded to the survey. The median age was 68 years (27–90), 55.2% were female. Most patients had a surveillance visit (65.3%) and were diagnosed with colorectal or breast cancer (43% and 26.5%, respectively); 91.8% of patients were satisfied, and 60% would accept the use of telemedicine beyond the pandemic. Patients aged more than 50 years (OR 0.40; 95% CI, 0.19–0.81; p = 0.01) and diagnosed with breast cancer (OR 0.45; 95% CI, 0.26–0.69; p < 0.001) were less predisposed to adopt telehealth in the future. Patients agreed to be informed via telehealth of scan or lab results (62% and 84%, respectively) but not of new oral or endovenous treatments (52% and 33.5%, respectively). Additionally, 75% of patients had a medium or low-null technologic ability, and 51.3% would only use the telephone or video call to contact health professionals. However, differences were found according to age groups (p < 0.0001). In total, patients surveyed were satisfied with telemedicine and believed telehealth could have a role following the COVID-19 pandemic. Moreover, our results remark on the importance of individualizing the use of telehealth, showing relevant data on patient preferences and digital literacy.     

Extended Delay to Treatment for Stage III-IV Non–Small-Cell Lung Cancer and Survival: Balancing Risks During the COVID-19 Pandemic

BackgroundDue to the coronavirus disease 2019 (COVID-19) pandemic, patients may encounter lung cancer care delays. Here, we sought to examine the impact of extended treatment delay for stage III-IV non–small-cell lung cancer on patient survival.Materials and MethodsUsing National Lung Screening Trial (NLST) and National Cancer Data Base (NCDB) data, Cox regression analysis with penalized smoothing splines was performed to examine the association between treatment delay and all-cause mortality for stage III-IV lung adenocarcinoma and squamous cell carcinoma. In the NCDB, propensity score-matched analysis was used to compare cumulative survival in patients who received “early” versus “delayed” treatment (ie, 0-30 vs. 90-120 days following diagnosis).ResultsCox regression analysis of the NLST (n = 392) and NCDB (n = 275,198) cohorts showed a decrease in hazard ratio the longer treatment was delayed. In propensity score-matched analysis, no significant differences in survival were found between early and delayed treatment for patients with stage IIIA, IIIB (T3-4,N2,M0), IIIC, and IV (M1B-C) adenocarcinoma and patients with IIIA, IIIB, IIIC, and IV squamous cell carcinoma (all log-rank P > .05). For patients with stage IIIB (T1-2,N3,M0) and stage IV (M1A) adenocarcinoma, delayed treatment was associated with improved survival (log-rank P = .03, P = .02). The findings were consistent in sensitivity analysis accounting for wait time bias.ConclusionIn this national analysis, for patients with stage III-IV adenocarcinoma and squamous cell carcinoma, an extended treatment delay by 3 to 4 months was not associated with significantly decreased overall survival compared to prompt treatment. These findings can be used to guide decision-making during the ongoing COVID-19 pandemic.     

Cancer Care Delivery Challenges Amidst Coronavirus Disease – 19 (COVID-19) Outbreak: Specific Precautions for Cancer Patients and Cancer Care Providers to Prevent Spread

Coronavirus outbreak has affected thousands of people in at least 186 countries which has affected the cancer care delivery system apart from affecting the overall health system. Cancer patients are more susceptible to coronavirus infection than individuals without cancer as they are in an immunosuppressive state because of the malignancy and anticancer treatment. Oncologists should be more attentive to detect coronavirus infection early, as any type of advanced cancer is at much higher risk for unfavorable outcomes. Oncology communities must ensure that cancer patients should spend more time at home and less time out in the community. Oncologists and other health care professionals involved in cancer care have a critical opportunity to communicate to their patients to pass on right information regarding practice modifications in view of COVID-19 outbreaks. Countries must isolate, test, treat and trace to control the coronavirus pandemic. There is a paucity of information on novel coronavirus infection and its impact on cancer patients and cancer care providers. To date, there is no scientific guideline regarding management of cancer patients in a background of coronavirus outbreak.     

Patient Involvement in Care and Breast Cancer Patients’ Quality of Life - a Structural Equation Modeling (SEM) Approach

In cancer patients, improving the quality of life is a basic goal of treatment, with the patient – physician relationship as a major factor. Therefore the aim of this structural equation modeling study was to analyze the influence of patient involvement in care on quality of life in 411 breast cancer patients undergoing outpatient chemotherapy and radiotherapy. Two questionnaires were used: 1-patient-physician questionnaire, 2-EORTC QLQC-30 (to measure QOL). The structural equation model exhibited an excellent data fit (Chi-Square= 31.04 / RMSEA= 0.042), T-values for all paths with the exception of that between patient satisfaction and emotional- cognitive function, were significant. According to the findings, various aspects of the physician-patient relationship are significantly and positively associated with quality of life and increasing patient involvement in care by increasing trust and satisfaction, was associated with marked improvement. The findings of this study emphasized the importance of an effective relationship between doctor and patient as a contributing factor for improving the quality of life. Therefore it is suggested that policymakers and decision-makers active in strategic planning for the health system and physicians responsible for treatment pay more attention to developing and improving relationships with patients as an approach to improving patient outcomes, particularly with reference to quality of life.     

A Minimum Of 100 Tumor Cells in a Single Biopsy Sample Is Required to Assess Programmed Cell Death Ligand 1 Expression in Predicting Patient Response to Nivolumab Treatment in Nonsquamous Non–Small Cell Lung Carcinoma

IntroductionProgrammed death ligand 1 (PD-L1) expression is a predictive biomarker for patient response to nivolumab in nonsquamous NSCLC. However, the number of biopsy samples and tumor cells (TCs) required to assess PD-L1 expression remains unclear.MethodsA total of 222 biopsy samples from 80 patients with nonsquamous NSCLC treated with nivolumab were collected. Number of TCs and PD-L1 score were compared among the sample containing the largest number of TCs (Max-TC), the sample containing the smallest number of TCs (Min-TC), and the total samples from each patient. The impact of the number of samples and TCs on the prediction of patient response to nivolumab with use of PD-L1 scores was evaluated.ResultsThere was a mismatch in PD-L1 scores less than 1% and those of at least 1% between Max-TC and the total samples in one patient (1%) and between Max-TC and Min-TC in six patients (8%). The optimal number of TCs to match PD-L1 expression less than 1% versus at least 1% between Max-TC and Min-TC was 100 (sensitivity = 0.676 and 1 – specificity = 0.333). PD-L1 expression of at least 1% in Min-TCs containing at least 100 TCs was associated with longer progression-free survival (median 7.6 versus 1.8 months [p < 0.01]) and overall survival (median not reached versus 9.9 months [p = 0.04]) compared with PD-L1 expression less than 1%. However, there were no differences in progression-free survival (median 3.9 versus 2.3 months [p = 0.37]) or overall survival (median 9.7 versus 7.6 months [p = 0.60]) between PD-L1 expression of at least 1% and PD-L1expression less than 1% in Min-TCs containing fewer than 100 TCs.ConclusionSingle biopsy samples containing at least 100 TCs are required to evaluate PD-L1 expression for predicting patient response to nivolumab.     

Does Tumor Size Predict Response to Neoadjuvant Chemotherapy in the Modern Era of Biologically Driven Treatment? A Nationwide Study of US Breast Cancer Patients

BackgroundTumor size has historically been used to stage breast cancer and guide treatment recommendations. The importance of tumor biology in long-term outcomes is increasingly being acknowledged. No large studies have examined the relative roles of tumor size and receptor status on response to neoadjuvant chemotherapy (NAC) in breast cancer.Patients and MethodsThe National Cancer Database was queried for women who underwent NAC and surgery for unilateral clinical stage I to III (cT1-3) invasive breast cancer from 2010 to 2013. Multivariable logistic regression models were used to assess the relation between receptor status, tumor size, and pathologic complete response (pCR) while controlling for other biologic, sociodemographic, diagnosis, and treatment factors.ResultsWe included 38,864 women in this study, most presented with cT2 disease (55%). Patients predominantly had estrogen receptor (ER)/progesterone receptor (PR)-positive (ER/PR⁺) HER2⁻ (45%) or ER/PR⁻ HER2⁻ (28%) disease. Nineteen percent (7432 patients) had a pCR. cT3 (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.59-0.70) but not cT2 cancers (OR, 0.95; 95% CI, 0.89-1.02) were associated with lower pCR rates compared with cT1 disease. HER2⁺ (ER/PR⁺ HER2⁺: OR, 2.94; 95% CI, 2.72-3.18; ER/PR⁻ HER2⁺: OR, 6.45; 95% CI, 5.92-7.02) and ER/PR⁻ HER2⁻ cancers (OR, 3.94; 95% CI, 3.68-4.22) were more likely to experience pCR than those with ER/PR⁺ HER2⁻ cancers. Receptor status was more strongly associated with pCR than tumor size.ConclusionTumor size is independently associated with pCR after NAC after controlling for receptor status, although the effect of receptor status is stronger. These data reinforce the importance of receptor status as well as tumor size, each of which might act as surrogates for tumor biology, in setting expectations for outcomes in patients who undergo NAC.     

Can We Overcome the Effect of Conflicts in Rendering Palliative Care? An Introduction to the Middle Eastern Cancer Consortium (MECC)

The Middle East has been experiencing an ongoing political conflict for the past several decades. This situation has been characterized by hostility often leading to violence of all sources. At times, such a conflict led to the outbreak of a military war, which was followed by an enmity between religious, ethnic, cultural, and national populations. In such environmental situations, palliative care professionals often confront major challenges including bias, mistrust, and mutual suspicion between patients and their treating clinicians. In order to overcome such obstacles, while rendering palliative care services, all professionals involved need careful planning and execution of their treatment plans. The latter is however possible, and sometimes successful even across lines of conflict, thereby promoting understanding, mutual respect, and tolerance between the involved communities and individuals.     

Observational Study on Patient’s Satisfactions and Quality of Life (QoL) Among Cancer Patients Receiving Treatment with Palliative Care Intent in a Tertiary Hospital in Malaysia

The main objective of palliative treatment for cancer patients has been to maintain, if not improve, the qualityof life (QoL). There is a lack of local data on satisfaction and QoL among cancer patients receiving palliativetreatment in Malaysia. This study covers patients with incurable, progressive cancer disease receiving palliativetreatment in a teaching hospital in Kuala Lumpur, comparing the different components of QoL and correlationswith patient satisfaction. A cross-sectional survey using Malay validated SF36 QoL and PSQ-18 (Short Form)tools was carried out between July 2012 -January 2013 with 120 cancer patients receiving palliative treatment,recruited into the study after informed consent using convenient sampling. Results showed that highest satisfactionwere observed in Communication Aspect (50.6±9.07) and the least in General Satisfaction (26.4±5.90). TheMental Component Summary (44.9±6.84) scored higher when compared with the Physical Component Summary(42.2±7.91). In this study, we found that patient satisfaction was strongly associated with good quality of lifeamong cancer patients from a general satisfaction aspect (r=0.232). A poor significant negative correlation wasfound in Physical Component (technical quality, r=-0.312). The Mental Component showed there was a poornegative correlation between time spent with doctor (r=-0.192) and accessibility, (r=-0.279). We found that feelingat peace and having a sense of meaning in life were more important to patients than being active or achievinggood physical comfort. More studyis needed to investigate patients who score poorly on physical and mentalcomponent aspects to understand their needs in order to achieve better cancer care.     

Cancer incidence in migrants to New South Wales (Australia) from the Middle East, 1972–91

The incidence of cancer in migrants to New South Wales (NSW) from Cyprus, Egypt, Iran, Iraq, Israel, Lebanon, Syria, and Turkey has been compared with that in the Australian-born population using data from the NSW Central Cancer Registry for 1972–91. Age-standardized incidence rates showed overall cancer incidence to be less common in migrants from each Middle Eastern country than in the Australian-born. There was a clear pattern of generally low rates for cancers of the mouth and pharynx, esophagus, colon and rectum, lung (men only), ovary, prostate and testis, and melanoma. Cancers which tended to be more common in migrants were nasopharynx, stomach (women only), liver (men only), gallbladder (chiefly in women), bladder (men only), and thyroid. Breast cancer did not show a uniform pattern among migrant groups, rates being high in the Egyptian-born but low in Lebanese-born women. The overall low incidence of cancers related to tobacco and alcohol, and to a high fat, low fiber diet, emphasizes the potential role of preventable lifestyle factors in the burden of cancer in Australia.     

Maternal Diet During Pregnancy and its Association with Medulloblastoma in Children: A Children’s Oncology Group Study (United States)

Fruit, vegetables, vitamin C, and folate during pregnancy have been suggested as protective factors for medulloblastoma/primitive neuroectodermal tumor (PNET), a common brain tumor in children. The authors sought to replicate these findings and investigate other aspects of diet. Mothers of 315 cases under age six at diagnosis and 315 controls were interviewed about their pregnancy diet. The authors observed modest, inverse associations for fruits/juices (odds ratio (OR) for highest compared to lowest category = 0.6, 95% confidence interval (CI): 0.3, 1.1) and vitamin C (OR = 0.6, 95% CI: 0.4, 1.1). In contrast to the previous study, folate and vegetables showed no association. As hypothesized, cured meats were not associated with medulloblastoma/PNET, in contrast to other childhood brain tumors. An inverse association with nonfresh peaches and similar fruits (OR = 0.5, 95% CI: 0.3, 0.8) and a positive association with nonchocolate candy (OR = 1.7, 95% CI: 1.0, 3.0) replicated previous findings. French fries (OR = 2.4, 95% CI: 1.2, 4.9) and chili peppers (OR = 1.8, 95% CI: 1.0, 3.0) were associated with medulloblastoma/PNET. The results suggest that some aspects of diet are worthy of further research.     

Menstrual and reproductive factors in relation to mammographic density: the Study of Women’s Health Across the Nation (SWAN)

Menstrual and reproductive factors may increase breast cancer risk through a pathway that includes increased mammographic density. We assessed whether known or suspected menstrual and reproductive breast cancer risk factors were cross-sectionally associated with mammographic density, by measuring area of radiographic density and total breast area on mammograms from 801 participants in the Study of Women’s Health Across the Nation (SWAN), a multi-ethnic cohort of pre- and early perimenopausal women. From multivariable linear regression, the following menstrual or reproductive factors were independently associated with percent mammographic density (area of dense breast/breast area): older age at menarche (β = 10.3, P < 0.01, for >13 vs. <12 years), premenstrual cravings and bloating (β = −3.36, P = 0.02), younger age at first full-term birth (β = −8.12, P < 0.01 for ≤23 years versus no births), greater number of births (β = −6.80, P < 0.01 for ≥3 births versus no births), and premenopausal status (β = 3.78, P < 0.01 versus early perimenopausal). Only number of births remained associated with percent density after adjustment for age, race/ethnicity, study site, body mass index (BMI), and smoking. In addition, stratified analyses revealed that the association with number of births was confined to women within the lowest BMI tertile (β = −12.2, P < 0.01 for ≥3 births versus no births). Our data support a mechanism for parity and breast cancer that involves mammographic density among pre- and early perimenopausal women that may be modified by body size.     

Māori and Pacific Peoples With Multiple Myeloma in New Zealand are Younger and Have Inferior Survival Compared to Other Ethnicities: A Study From the Australian and New Zealand Myeloma and Related Diseases Registry (MRDR)

Background: Māori and Pacific peoples (MPP) in New Zealand (NZ) have poorer health outcomes than other ethnicities. However, this has not been clinically investigated in multiple myeloma (MM). Using data from the Australian and NZ Myeloma and Related Diseases Registry for all participating centers in NZ, we compared MPP demographics, clinical characteristics, diagnostics, treatment, and outcomes to non-MPP.Patients and Methods: MPP were defined as having ≥1 grandparent of this heritage. We tested ethnicity as a predictor of overall survival (OS) with multivariable Cox regression.Results: Of 568 NZ patients with MM (September 2012 to April 2021) and ethnicity data, 138 were MPP. They were diagnosed younger than non-MPP (median age 63 [IQR: 57-72] vs. 70y [62-77], P < .001). Obesity (53 vs. 27%, P < .001), diabetes (24 vs. 8%, P < .001), renal insufficiency (28 vs. 17%, P = .005), pulmonary disease (10 vs. 5%, P = .02) and FISH abnormalities (54 vs. 42%, P = .04) were more common in MPP, and a lower proportion received first-line drug therapy (88 vs. 94%, P = .03) and autologous stem cell transplant (ASCT) (age <70y: 56 vs. 70%, P = .03). OS for MPP was shorter than non-MPP even after adjusting for age, comorbidities, disease stage, performance status, FISH abnormalities and treatment (HR 1.58 [1.04-2.39], P = .03).Conclusion: MPP with MM in NZ were younger, a greater proportion had comorbidities and FISH abnormalities at diagnosis, fewer received first-line treatment and/or ASCT, and they had poorer OS than non-MPP. Investigation of modifiable factors to improve outcomes and discern why MM occurs at a younger age in MPP is needed.     

Pediatric Normal Tissue Effects in the Clinic (PENTEC): An International Collaboration to Analyse Normal Tissue Radiation Dose–Volume Response Relationships for Paediatric Cancer Patients

With advances in multimodality therapy, childhood cancer cure rates approach 80%. However, both radiotherapy and chemotherapy can cause debilitating or even fatal late adverse events that are critical to understand, mitigate or prevent. QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) identified radiation dose constraints for normal tissues in adults and pointed out the uncertainties in those constraints. The range of adverse events seen in children is different from that in adults, in part due to the vulnerability/characteristics of radiation damage to developing tissues, and in part due to the typical body sites affected by childhood cancer that lead to collateral irradiation of somewhat different normal tissues and organs compared with adults. Many childhood cancer survivors have a long life expectancy and may develop treatment-induced secondary cancers and severe organ/tissue injury 10, 20 or more years after treatment. Collaborative long-term observational studies and clinical research programmes for survivors of paediatric and adolescent cancer provide adverse event data for follow-up periods exceeding 40 years. Data analysis is challenging due to the interaction between therapeutic and developmental variables, the lack of radiation dose–volume data and the fact that most childhood malignancies are managed with combined modality therapy. PENTEC (Pediatric Normal Tissue Effects in the Clinic) is a volunteer research collaboration of more than 150 physicians, medical physicists, mathematical modellers and epidemiologists organised into 18 organ-specific working groups conducting a critical review and synthesis of quantitative data from existing studies aiming to: (1) establish quantitative, evidence-based dose/volume/risk guidelines to inform radiation treatment planning and, in turn, improve outcomes after radiation therapy for childhood cancers; (2) explore the most relevant risk factors for toxicity, including developmental status; (3) describe specific physics and dosimetric issues relevant to paediatric radiotherapy; and (4) propose dose–volume outcome reporting standards for publications on childhood cancer therapy outcomes. The impact of other critical modifiers of normal tissue radiation damage, including chemotherapy, surgery, stem cell transplantation and underlying genetic predispositions are also considered. The aims of the PENTEC reports are to provide clinicians with an analysis of the best available data to make informed decisions regarding radiation therapy normal organ dose constraints for planning childhood cancer treatment, and to define future research priorities.     

Maternal Use of Recreational Drugs and Neuroblastoma in Offspring: A Report from the Children’s Oncology Group (United States)

Objective To evaluate whether maternal use of recreational drugs around conception and pregnancy influences the risk of childhood neuroblastoma. Methods Self-reported use of recreational drugs from one month prior to pregnancy until diagnosis was assessed among mothers of 538 children with neuroblastoma (diagnosed 1992–1994 and identified through the Children’s Cancer Group and Pediatric Oncology Group) and 504 age-matched controls (identified by random-digit dialing). Odds ratios (OR) and 95% confidence intervals (CI) were estimated using unconditional logistic regression, adjusting for age at diagnosis and household income. Results Maternal use of any illicit or recreational drug around pregnancy was associated with an increased risk of neuroblastoma in offspring (OR = 1.82, 95% CI: 1.13, 3.00), particularly use of marijuana in the first trimester of pregnancy (OR = 4.75, 95% CI: 1.55, 16.48). Marijuana use in the month before pregnancy did not increase risk. The effect of gestational marijuana exposure was strongest in subjects diagnosed before age one. Evaluation of recreational drugs other than marijuana was limited by infrequent use, and analyses of drug use by fathers were not carried out due to missing data. Conclusions Maternal recreational drug use and marijuana use during pregnancy were associated with increased risk of neuroblastoma in offspring. Further examination of these drugs and the risk of childhood cancer is warranted.