Breast Cancer Management during Coronavirus Disease 2019 Pandemic: A Literature Review

Introduction Breast cancer is the most prevalent cancer found in women. The World Health Organization declared the coronavirus disease 2019 (COVID-19) as a public health emergency of international concern. Delaying treatment was associated with mortality. The aim is to evaluate breast cancer management during the pandemic.

Methods We searched articles evaluating the management of breast cancer in the midst of COVID-19 outbreak, by searching in PubMed, PubMed Central, and Oncology Society related websites. We only included articles discussing adult breast cancer management in COVID-19 era. The two reviewers screened the titles and abstracts.

Results Around 124 articles were found through the searching process. Eight observational trials, two review articles, six guidelines or recommendations, and one letter to the editor were included in final review. It was concluded that breast cancer posed a risk to contract COVID-19. Newly suspected breast cancer could be deferred for screening or diagnosis, except for special breast cancer cases with bleeding, invasive, and complicated tumors. The benefit of radiotherapy option in every case should be carefully weighed against the risk of infection. Oral chemotherapy and hormonal therapy drugs were preferred to be given than intravenous chemotherapy. The scheduled chemotherapy could be adjusted to reduce hospital visit. Each breast cancer patient is different, so they should be discussed in multidisciplinary team consisting of surgical, radiation, and medical oncologists, pathologist, radiologist, palliative care people, nurses, nutritionist, and others related to the field.

Conclusion The International Oncology Society has released recommendations for breast cancer during COVID-19 pandemic but there is still questionable-quality evidence.

W. WA, Yunda DK, Pranata R. The Association Between Triglyceride-Glucose Index as a Marker of Insulin Resistance and the Risk of Breast Cancer

BACKGROUND

This study aims to evaluate the association and dose-response between triglyceride-glucose (TyG) index and breast cancer.

METHOD

This is a multicenter case-control study conducted in six public referral hospitals in Indonesia. Cases are individuals aged 19 years or above who were diagnosed with breast cancer within 1 year of diagnosis, based on histopathology and immunohistochemistry. Controls were recruited from corresponding hospitals. TyG index was determined by the formula: ln (fasting TG [mg/dl] × fasting glucose [mg/dl]).

RESULTS

There were 212 participants in the breast cancer group and 212 participants in the control group. TyG index was higher in patients with breast cancer (median 8.65 [7.38, 10.9] vs. 8.30 [7.09, 10.84], p < 0.001). When compared with TyG quartile of Q1, Q4 was associated with an OR of 2.42 (1.77, 3.31), p < 0.001, Q3 was associated with an OR of 1.53 (1.21, 1.93), p < 0.001, Q2 was associated with an OR of 1.39 (1.12, 1.73), p = 0.002 for the risk of breast cancer. The dose-response relationship was nonlinear (p < 0.001). On univariate analysis, smoking (OR 2.15 [1.44, 3.22], p < 0.001), use of contraception (1.73 [1.15, 2.60], p = 0.008), alcohol consumption (OR 2.04 [0.96, 4.35], p = 0.064), and TyG Index >8.87 (OR 3.08 [1.93, 4.93], p < 0.001) were associated with risk of breast cancer. Independently associated with increased risk of breast cancer included smoking (OR 1.93 [1.23, 3.01], p = 0.004), use of contraception (OR 1.59 [1.02, 2.48], p = 0.039), and TyG Index >8.87 (OR 2.93 [1.72, 4.98], p < 0.001).

CONCLUSION

TyG index was associated with breast cancer in a nonlinear dose-response fashion.

Repurposing FIB-4 index as a predictor of mortality in patients with hematological malignancies and COVID-19

BACKGROUND

In this study, we aimed to investigate whether FIB-4 index is useful in predicting mortality in patients with concurrent hematological malignancies and COVID-19. We also aimed to determine the optimal cut-off point for the prediction.

METHODS

This is a single-center retrospective cohort study conducted in Dharmais National Cancer Hospital, Indonesia. Consecutive sampling of adults with hematological malignancies and COVID-19 was performed between May 2020 and January 2021. COVID-19 screening test using the reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal samples were performed prior to hospitalization for chemotherapy. FIB-4 index is derived from [age (years) × AST (IU/L)]/[platelet count (109/L) × √ALT (U/L)]. The primary outcome of this study is mortality, defined as clinically validated death/non-survivor during a 3-months (90 days) follow-up.

RESULTS

There were a total of 70 patients with hematological malignancies and COVID-19 in this study. Median FIB-4 Index was higher in non-survivors (13.1 vs 1.02, p<0.001). FIB-4 index above 3.85 has a sensitivity of 79%, specificity of 84%, PLR of 5.27, and NLR of 0.32. The AUC was 0.849 95% CI 0.735-0.962, p<0.001. This cut-off point was associated with OR of 16.70 95% CI 4.07-66.67, p<0.001. In this study, a FIB-4 >3.85 confers to 80% posterior probability of mortality and FIB-4 <3.85 to 19% probability. FIB-4 >3.85 was associated with shorter time-to-mortality (HR 9.10 95% CI 2.99-27.65, p<0.001). Multivariate analysis indicated that FIB-4 >3.85 (HR 4.09 95% CI 1.32-12.70, p = 0.015) and CRP> 71.57 mg/L (HR 3.36 95% CI 1.08-10.50, p = 0.037) were independently associated with shorter time-to-mortality.

CONCLUSION

This study indicates that a FIB-4 index >3.85 was independent predictor of mortality in patients with hematological malignancies and COVID-19 infection.

Multiple Myeloma Management in COVID-19 Era

Introduction Coronavirus disease 2019 (COVID-19) has become a world pandemic since early 2020. The complexity of handling multiple myeloma (MM) has increased substantially during this pandemic. The objective of this review is to know the current recommendation to manage MM in the COVID-19 era.

Materials and Methods Electronic databases, including PubMed central and PubMed, were used to conduct a literature search. It was conducted on May 18, 2020, using the keywords “multiple myeloma” AND “COVID-19” AND “Prevalence OR Impact OR treatment OR prophylactic.” The included articles were review articles, recommendations, case reports or series, or population-based studies (cross-sectional, cohort, case-control, or interventional), and full-text if available.

Results A total of 124 articles were identified through the search strategy. The two reviewers screened titles and abstracts of all articles. Most articles were excluded because of ineligible to the criteria. Ultimately, 18 articles were included in the final evaluation. MM patients might have higher risk to become severe COVID-19 if they got infected due to their immunocompromised condition. Due to the pandemic, precise treatment priorities should be made by considering its benefit and the risk of MM progression. For the young, especially healthy patients, the most effective therapy should be offered and tailored to the patient’s goal. Several MM societies have published the recommendation regarding the special stage of MM.

Conclusion Myeloma societies in the world have released recommendations related to the management of myeloma patients. However, there is scarce of evidence to do the recommendation.

Effect of melatonin supplementation in combination with neoadjuvant chemotherapy to miR-210 and CD44 expression and clinical response improvement in locally advanced oral squamous cell carcinoma: a randomized controlled trial

BACKGROUND

Squamous cell carcinoma of the oral cavity (OSCC) is the sixth most common malignancy. Surgery is mainstay treatment for oral cancers. Surgery in locally advanced OSCC presents many challenges primarily because the head and neck have critical structures that can be damaged by tumor or treatment. It is thought that neoadjuvant chemotherapy (NC) in locally advanced OSCC is able to shrink tumor size. Chemoresistancy is a problem due to hypoxic microenvironment characterized by increased expression of HIF-1α. It is also regulated by miR-210 as well as increased expression of CD44 and CD133. Melatonin has a powerful antioxidant and oncostatic effects that are expected to improve tumor hypoxia and clinical response. Fifty patients with OSCC were included and randomized. miR-210 and CD44 expression were measured before and after intervention using qRT-PCR absolute quantification, and clinical response was evaluated according to RECIST 1.1 criteria. This study aims to determine the effect of melatonin in improving the clinical response of patients with locally advanced oral squamous cell carcinoma (OSCC) after neoadjuvant chemotherapy to miR-210 and CD44 expression.

RESULTS

Melatonin administration reduced miR-210 levels but not significant (p = 0.767). CD44 expression also decreased in the melatonin group compared with placebo yet was not significant (p = 0.103). There was a decrease in the expression of miR-210 and CD44 followed by a decrease in the percentage of residual tumor but not significant (p = 0.114).

CONCLUSION

In OSCC, the addition of 20-mg melatonin to neoadjuvant chemotherapy (NC) reduced the expression of miR-210 and CD44 and decreased the percentage of tumor residue; however, no statistically significant result was observed.

TRIAL REGISTRATION

This study is registered to ClinicalTrials.gov under trial registration number: NCT04137627 with date of registration on October 22, 2019-retrospectively registered, accessible from: https://clinicaltrials.gov/ct2/show/NCT04137627.

Three Years Survival of Elderly Cancer Patients in Indonesia: Do We Need a Different Approach?

BACKGROUND

the number of elderly people in Indonesia is increasing. Additionally, cancer prevalence among older patients is also increasing. However, studies assessing clinical factors associated with the survival of elderly patients with cancer are still lacking. This study aimed to investigate the survival of geriatric patients with cancer and associated factors.

METHODS

this was a retrospective cohort study. Subjects were geriatric patients with cancer aged >60 years, enrolled between 2013 and 2015 in Dharmais Cancer Hospital. Data were retrieved from medical records and consisted of gender, age, cancer type, stage, Eastern Cooperative Oncology Group (ECOG) performance status (PS), body mass index (BMI), Charlson Comorbidity Index, and type of treatment. Cox regression analysis was used to identify independent prognostic factors for survival.

RESULTS

a total of 249 patients were enrolled, with a median age of 66 (60-85) years. The most common cancer was of the lung, followed by breast, colorectal, and uterine cervical cancers. The median survival time was 24 months. Cox multivariate analysis was performed by gender stratification. Advanced stage cancer (III-IV) was identified as the risk factor for mortality in female patients (hazard ratio [HR] 2.72; 95% confidence interval [CI] 1.53-4.80; p = 0.001), while poor performance status (ECOG 2 - 4) was the risk factor in male group (HR 1.82; 95% CI 1.01-3.24; p = 0.04).

CONCLUSION

the survival of elderly patients with cancer is affected by traditional prognostic factors. Advanced cancer stage was significant independent prognostic factor in female patients, while poor performance status was significant in male patients.

Characteristics and treatment response of chronic lymphocytic leukemia patients in Dharmais National Cancer Centre Hospital, Indonesia

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Background: Chronic lymphocytic leukemia (CLL) was a common hematological malignancy in America and Europe, but rarely found in Asia. Differences in clinical characteristics and treatment response were suspected. This study aimed to find out characteristics and treatment response of patient with CLL in Dharmais National Cancer Centre Hospital Indonesia. Methods: This was a retrospective cohort study of CLL patients in Dharmais Hospital during 2013-2015. Data were retrieved from medical record included patients’ demography, blood examination, bone marrow puncture, and immunophenotyping. Prognosis factors such as Rai and Binet staging system were studied. Results: A total of 36 CLL patients were retrieved. Most of patients (58.3%) were male. Median age was 58.5 years old. As much as 25.9% of patients were asymptomatic. There were 17 patients (47.2%) with negative CD5, and most of them (63.2%) had isolated splenomegaly (p = 0.019). Twenty patients (55.6%) were high-risk based on Rai staging group, but there were only 14 patients (38.9%) were high-risk based on Binet staging group. Positive CD13 was found in 30.6% patients and classified as high risk Rai (p < 0.001) and Binet (p = 0.043) staging group. Treatment response was available in 12 cases, consisted of 8 (66.7%) partial responses, 3 (25.0%) progressive diseases, and 1 (8.3%) stable disease. Conclusions: Chronic lymphocytic leukemia is a rare disease in Indonesia. Patients tend to be younger and have worse prognosis. Many cases are categorized as high-risk and present without specific clinical symptoms. Early detection is challenging in the future for better management of CLL cases.

[Comparison of Effectiveness of Gefitinib, Erlotinib, and Afatinib in Advanced Non-small Cell Lung Cancer Patients with EGFR Mutation Positive in Indonesian Population]

Background and objective

EGFR-tyrosine kinase inhibitors (EGFR-TKIs) were used to treat non-small cell lung cancer (NSCLC) patients with EGFR mutation positive. This study aims to compare the effectiveness of first line TKIs; gefitinib, erlotinib, and afatinib in the treatment of advanced stage NSCLC patients with EGFR mutation positive in the Indonesian population.

Methods

A retrospective cohort study of 88 NSCLC patients with EGFR mutation positive treated with gefitinib (n=59), erlotinib (n=22), and afatinib (n=7) was performed in national cancer hospital in Indonesia.Inclusion criteria were stage Ⅲb or Ⅳ NSCLC with adenocarcinoma subtype. Subjects less than 18 years or with a history of other malignancy were excluded. Outcomes were treatment response, progression-free survival (PFS), and mortality rate.

Results

Complete response, partial response, and stable disease were shown in 1.1%, 35.2%, and 31.8% of subjects, respectively. There were 31.8% of subjects developed progressive disease during treatment. Regarding EGFR mutation positive profile, a total of 56.8% subjects had deletion in exon 19, 42% subjects had mutation in exon 21, and rare mutation in exon 18 was found in 3.4% of total subjects. Demography and clinical characteristics had no significant association with the risk of progressive disease. The median PFS of subjects was 11 months (95%CI: 6.8-15.2 months). There was no statistical difference of PFS between treatment groups.

Conclusion

Gefitinib, erlotinib, and afatinib have similar effectiveness in advanced stage NSCLC with EGFR mutation positive. Afatinib tends to be associated with longer PFS but further investigation is required.

Non-Small Cell Lung Carcinoma in Women: A Retrospective Cohort Study in Indonesia

BACKGROUND

the increasing incidence of lung cancer in female patients has been observed in Indonesia. Lung cancer in female might have different biology process than male, but it has never been evaluated in Indonesia. This study aimed to know characteristics and survival of female patients with non-small-cell lung carcinoma (NSCLC) in Dharmais National Cancer Centre Hospital.

METHODS

a retrospective cohort study was performed among NSCLC female patients in Dharmais Cancer Hospital (DCH) between January 2005 and December 2015. Survival analysis was done using the Kaplan-Meir estimation curve with proportional assumption test. Independent prognostic factors were analyzed using the Cox proportional hazard model with a hazard ratio (HR) and its 95% confidence interval (CI).

RESULTS

a total of 956 NSCLC cases were retrieved during the study; 268 (28.0%) were female patients. Mean of age in female patients was 56.9 (11.87) years old. Among female patients, 21 (7.8%) were smokers, 244 (91.1%) had adenocarcinoma subtype, and 261 (98.0%) were in advanced stage (III-IV). Median survival was slightly longer in female than male patients (14.9 months vs. 12.2 months; log-rank p=0.055). Significant prognostic factors for survival were older age (>50 y.o) (HR = 0.681; 95% CI = 0.467 - 0.992; p= 0.045) and positive eGFR mutation (HR = 0.393; 95% CI = 0.251 - 0.615; p<0.001).

CONCLUSION

female patients contributed to about 28% of all NSCLC cases. They were mostly non-smokers, have more adenocarcinoma histopathology and eGFR mutation. Survival tended to be longer in female than male patients. Age over 50 years and the presence of eGFR mutation were good prognostic factors to survival in female lung cancer patients.

Early-menarche as Determinant Factor for Metabolic-risks: An Epidemiology Perspectives among Adolescent Girls aged 13-15 years old in Jakarta-Indonesia

Background and Objectives:Early menarche predicts higher body mass index (BMI) and adiposity in adult life, and it has been associated with risk factors of cardiometabolic diseases such as elevated triglycerides and waist circumferences also higher risk of adult diabetes. This study aims to explore early-menarche as determinant factor for metabolic-risks among adolescent girls aged 13-15 years old.Methods and Study Design:This cross-sectional study was undertaken in adolescent girls aged 13-15 years in all five municipalities in Jakarta-Indonesia, from January 2014 to Mei 2016. Data collected by using standardized measures for dietary intake, nutritional status indicators, physical activity level, blood pressure, blood glucose and lipid profile, and statistically analyzed by independent-t or Mann-Whitney test, and Pearson or Spearman correlation test.Results and Conclusions:A total of 194 adolescent girls were participated in this study. Early menarche was found in 22.68% of all subjects. There was no association between menarche status and daily macronutrients intake pattern and physical activity level score. Early menarche subjects had significantly higher BMI (p<0.001), CDC-percentile (p<0.001), WHO Z-score (p<0.001), and waist circumference values (p=0.02). Furthermore, early menarche subjects also had higher systolic blood pressure (p=0.035), total cholesterol level (p=0.028), LDL-cholesterol level (p=0.013), and triglyceride level (p=0.026). There was no association between menarche status and diastolic blood pressure, fasting blood glucose, HDL-C level, lipid profile ratio. In conclusion, early menarche is an important determinant factor of metabolic risks, and balance between dietary intake and physical activity level should be prioritized among them. 

IGF-1 Levels Among Adolescent Girls Living In Jakarta and It's relation to Nutritional Status

Background and Objective:Insulin-like growth factor (IGF)-1 is one of the hormones that plays a role in the growth of adolescent girls. Its level will rise at puberty and begin to decline at the end of puberty. High IGF-1 levels in adult is associated with the incidence of breast cancer. This study aims to know the level of IGF-1 and investigates its relationship with dietary intake, nutritional status, and physical activity of adolescent girls aged 13-15 in Jakarta.Methods and Study Design:This cross-sectional study used secondary data from a previous study (titled "Determinant Factor Levels of Estradiol, IGF-1, and Early Menarche in Adolescent Girls Aged 13-15 in Jakarta: Nutritional Epidemiology Study Related to Breast Cancer Risk Factors") and primary data from stored blood serum to measure IGF-1 levels by colorimetric method. The secondary data such as dietary intake, anthropometric data, and physical activities were obtained from 178 subjects with a total population sampling method.Results and Conclusions:There was a positive correlation between IGF-1 levels and carbohydrate intake (p=0.041, r=0.153) and a negative correlation between IGF-1 levels and fat intake (p=0.042, r=-0.152). No correlation between IGF-1 and body mass index was found, but there was a tendency that IGF-1 values would increase in overweight and decrease in obesity. IGF-1 levels have nonlinear pattern by carbohydrates intake, fat intake and nutritional status. In conclusion, the adolescent girls should maintain their nutritional status by maintaining diet, choosing the right and balanced foods, as well as increasing physical activities.

Correlation between carbohydrate, protein and fat intake with serum c-reactive protein level in lung cancer patients stage IIIB-IV

Introduction: The aim of the study is to determine the correlation between carbohydrate, fat and protein intake with the serum C-Reactive Protein level in lung cancer patients stage IIIB – IV. The progression of lung cancer is influenced by immune system, genetic factors and inflammatory response, therefore CRP can be relied as one of the parameters for predicting cancer cell growth.Methods: The research with cross sectional design was conducted in Dharmais Cancer Hospital Jakarta. Subjects were recruited by consecutive sampling, 49 subjects with lung cancer stage IIIB- IV who currently not receving any treatment in Dharmais Hospital participating in this study A total of 49 subjects with lung cancer stage IIIB- IV who currently not receving any treatment were taken using consecutive sampling method. Results: The mean age of subject was 55,82 + 12,26 years old and 63,3% were male. The median value of CRP is 23,82 (0,30 - 207,29) mg/L.Conclusion: This study did not showed significant correlation between carbohydate, protein and fat intake with serum CRP level (p = 0,919; p = 0,257; p = 0,986, respectively). But on additional analysis we did found that there was a negative, non significant correlation between protein intake and serum CRP level in cancer patient stage IV, as well as fat intake and serum CRP level.

Diet and estradiol level in adolescent girls

AbstractBackground Nutritional intake in adolescent girls in Indonesia has been well studied, but there has been little study on its influence on serum estradiol levels. A high estradiol level has been associated with higher risk of breast carcinogenesis.Objective To evaluate the influence of dietary factors on serum estradiol concentration in adolescent girls.Methods A community-based survey was conducted in female junior high school students in Jakarta from January 2014 to January 2015. Nutritional intake was assessed by semi-quantitative food frequency questionnaires (FFQ), which included the intake of total energy (kcal), carbohydrate (g), protein (g), fat (g), fiber (g), and phytoestrogen (g). Based on the Indonesian recommended daily allowance (RDA), energy and nutrient intakes were categorized as minimal (<70%), low (70-99.9%), normal (100-129.9%), and high (≥130%). Serum estradiol levels were measured during the follicular phase using an enzyme-linked immunosorbent assay (ELISA).Results A total of 189 girls aged 13-15 years were enrolled from 8 junior high schools across the municipalities of Jakarta. Twenty-eight (14.8%) subjects were overweight or obese. Median estradiol level was 41.83 (range 13.14-136.5) pg/mL. Serum estradiol level was significantly correlated with energy, protein, and fat intake. Estradiol level was also significantly associated with carbohydrate (P=0.030) and fat (P=0.036) intake status. Multivariate analysis revealed that intake of energy, protein, and fat, as well as body mass index (BMI) were independent predictors of estradiol levels. However, due to its importance as energy source, we included carbohydrate intake in the final equation to predict estradiol level as follows: E2 = 60.723 – 0.053 (energy) + 0.185 (carbohydrate) + 0.483 (protein) + 0.491 (fat) – 1.081 (BMI).Conclusion Serum estradiol levels in adolescent girls aged 13-15 years are influenced by diet, especially fat intake. Estradiol levels can be predicted from energy, carbohydrate, protein, and fat intake, as well as BMI. [Paediatr Indones. 2016;56:134-8.].

New Paradigm in Treating Cancer: Right on Target

Cancer prevalence is increasing every year and now cancer is the third highest cause of death in developing countries. Effective anticancer treatment can prolong life and improve the patient's quality of life. Targeted therapy is a new therapeutic modality which targets specific molecules in the cancer cell and disrupts dysregulated signaling pathways involved in carcinogenesis. Since targeted therapy does not attack normal cells, its side effects are considered low compared to chemotherapy. More than 15 drugs have been approved for treatment in various human cancers. These drugs can largely be grouped into tyrosine kinase inhibitors and monoclonal antibodies. This review will focus on the most common agents within both groups.

Clinicopathology Profile and Bone Involvement of Multiple Myeloma Patients in Dharmais National Cancer Hospital, Indonesia

BACKGROUND

Even though rarely found in Indonesia, the incidence of multiple myeloma (MM) is increasing every year. Bone involvement of MM is the most often a clinical disorder which leads to worsening clinical conditions and low quality of life of patients.

PURPOSE

To determine the clinicopathology profile of bone involvement of MM patients in Indonesia.

MATERIALS AND METHODS

The cross-sectional study of MM conducted at Dharmais National Cancer Hospital (DNCH) by collecting data from medical records of MM patients who came to DNCH in period 2008-2012.

RESULTS

There were 39 MM patients all with age above 60 years. There were 56.4% male and 43.6% female patients. Most were diagnosed at stage III (32.4%), and 41% had obesity. The comorbid conditions were anemia (82.9%), hypoalbuminemia (60%), increased creatinine level (38.5%), increased β2 microglobulin level (94.1%), increased LDH level (23.1%) and plasmocytes above 30% (65%), but only 4.2% patients presented with hypercalcemia. Meanwhile, bone involvement occurred in 76.9% of MM patients with 4 lesions on average and a maximum of 16 lesions. The locations of bone lesions were spine (70%), skull (70%), pelvis (33.3%), humerus (30%), and femur (30%).

CONCLUSIONS

The incidence of MM in Indonesia is increasing annually with bone involvement in more than three-fourths, but interestingly without hypercalcemia.

Effect of hypoxia-inducible factor-1α induction by CoCl₂ on breast cancer cells survival: influence of cytochrome-c and survivin

Background: Tumor tissue usually became hypoxic due to disruption of oxygen supply. Adaptation response to hypoxia is mediated by transcription factor, hypoxia- inducible factor-1α (HIF-1α). HIF-1α signaling is known to increase the expression of pro-apoptotic protein cytochrome-c, and anti- apoptotic survivin. In this study we wanted to analyze the role of HIF-1α on breast cancer cells survival through pro-apoptosis cytohrome-c and anti-apoptosis survivin regulation.Methods: Breast cancer cell lines T47D were induced by CoCl2 then harvested to analyze the expression of HIF-1α, protein cytochrome-c, mRNA survivin and cell viabilities.Results: HIF-1α induction by CoCl2 causes the increase of  protein and mRNA of HIF-1α, cytochrome-c protein, and survivin mRNA, but does not cause the changes in cell viability.Conclusion: HIF-1α induction have no effects on breast cancer cell line T47D viabilities due to the balance regulation between pro-apoptosis expression cytochrome-c and anti-apoptosis survivin.