Alternative blood transfusion triggers: a narrative review

BACKGROUND

Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis.

MAIN TEXT

The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies.

CONCLUSION

Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.

Vaccination Effectiveness against Human Papillomavirus in Kazakhstan

OBJECTIVE

The purpose was to determine the effectiveness of human papillomavirus immunization and its impact on cervical cancer development in Kazakhstan.

METHODS

The current research is a case-control study with two groups: a main group and a control group. A total of 725 subjects participated in the research.

RESULTS

The association between vaccination and cervical cancer development was calculated both for the two groups as a whole and for individual patients, who were selected based on criteria of residence, presence of immunodeficiency or chronic cardiac or renal pathology, as well as analysis of age at which the vaccine dose was received. There was a statistically significant association between the absence of the human papillomavirus vaccine and the risk of cervical cancer in all groups. When considering the entire cohort, the chance of finding a risk factor (lack of vaccination) was almost 7 times higher in the main group than in the control group. Thus, an association between vaccination and cervical cancer risk was found in each of the pairs of subjects.

CONCLUSION

The effectiveness of vaccination in preventing cervical cancer was not observed in patients who were vaccinated after 18 years of age, while most patients in the control group were vaccinated in their teens. The practical significance of the research is not only to further study the problem of human papillomavirus (HPV) vaccination in Kazakhstan but also to popularize HPV immunization to prevent cervical cancer (CC).

Association of Genetic Markers with the Risk of Early-Onset Breast Cancer in Kazakh Women

Breast cancer is a global health problem. It is an age-dependent disease, but cases of early-onset breast cancer (eBC) are gradually increasing. There are many unresolved questions regarding eBC risk factors, mechanisms of development and screening. Only 10% of eBC cases are due to mutations in the BRCA1/BRCA2 genes, and 90% have a more complex genetic background. This poses a significant challenge to timely cancer detection in young women and highlights the need for research and awareness. Therefore, identifying genetic risk factors for eBC is essential to solving these problems. This study represents an association analysis of 144 eBC cases and 163 control participants to identify genetic markers associated with eBC risks in Kazakh women. We performed a two-stage approach in association analysis to assess genetic predisposition to eBC. First-stage genome-wide association analysis revealed two risk intronic loci in the CHI3L2 gene (p = 5.2 × 10-6) and MGAT5 gene (p = 8.4 × 10-6). Second-stage exonic polymorphisms haplotype analysis showed significant risks for seven haplotypes (p < 9.4 × 10-4). These results point to the importance of studying medium- and low-penetrant genetic markers in their haplotype combinations for a detailed understanding of the role of detected genetic markers in eBC development and prediction.

Five-year overall survival of patients with advanced bladder cancer in Kazakhstan: OSURK registry study

BACKGROUND

The goals of the OSURK registry study were to assess 5-year overall survival (OS) in patients with metastatic urothelial cancer diagnosed in 2017 in Kazakhstan and collect data on the use of various treatment options in routine clinical practice.

METHODS

Patients with newly diagnosed metastatic bladder cancer (BC) were retrospectively identified in the national register of Kazakhstan (ERCP) between January 2017 and January 2018. ERCP is the biggest register in the country and includes patient data from 17 regions. Investigators collected patient information and processed records online on the following anonymised data: demographical characteristics, received treatment and outcomes. Patients were included in the study if mBC was confirmed histologically and they had at least one visit to the cancer center during the follow-up period. The outcomes of interest were overall survival (OS), patient characteristics and treatment patterns.

RESULTS

Totally 480 adult patients with metastatic BC were included. Mean number of patients in one region per year was 28.2. Median age at diagnosis of mBC was 70.0 years (range, 30-100). Patients were predominantly male (81.3%), histological subtype of BC (urothelial carcinoma, etc.) was determined in 41%. Overall, 187 (39%) patients received systemic therapy for metastatic disease. Platinum-based chemotherapy was prescribed in 147 (76.8%) patients who received systemic treatment. The majority of treatment was with cisplatin (N=132, 70.6%). Sixty-four (13.3%) patients received ≥2 treatment lines. After median 60.5 months of follow-up the 5-year OS in patients with metastatic BC was 2.7%. The 1-, and 3-year OS rates were 31.0% and 9.8%, respectively. Median OS from the start of treatment was 7.3 months (95% CI 6.5-8.1).

CONCLUSIONS

The results of the OSURK study indicate the need for further implementation of innovative drugs in real practice in order to significantly increase the OS of patients with metastatic BC.

Characteristic Mutational Damages in Gastric and Colorectal Adenocarcinomas

INTRODUCTION

Gastric and colorectal adenocarcinomas are prevalent malignancies characterized by mutations in genes such as p53, RAS, and MDM2, which play crucial roles in tumorigenesis and cancer progression. Understanding the specific mutational patterns and their implications in these cancers was essential for identifying potential therapeutic targets.

AIM

To identify the nature of mutational disorders in the p53, p21Waf1, RAS and MDM2 genes, depending on the degree of cell differentiation by adenocarcinomas of the gastrointestinal tract.

METHODS

Genomic DNA was isolated from 200 samples of stomach tissue and 233 samples of colon and rectum adenocarcinomas. A total of 433 samples, including gastric adenocarcinomas, colon and rectum adenocarcinomas and adjacent tissues, were collected.

RESULTS

Genomic DNA was isolated, and mutational analysis of p53, RAS (HRAS, KRAS, NRAS), and MDM2 genes was performed using polymerase chain reaction, gel electrophoresis, and restriction enzyme analysis. The deletion of p53 exon-intron 5-6, as well as HRAS 12 and HRAS 61 mutations, were detected in 78% of poorly differentiated adenocarcinomas. The deletions of p53 exon-intron 7-9 - in 100% of moderately differentiated adenocarcinomas and 50-60% of adjacent tissues. The loss of WAF1 gene expression was registered in almost 90% of poorly differentiated adenocarcinomas and 20% of adjacent tissue samples. The KRAS and NRAS mutations in almost 63.9% of studied colon and rectal samples indicated autonomous cell growth. This explains the aggressive and metastatic growth of tumours and the ineffectiveness of growth factor inhibitors in colorectal cancer. Finding ways to influence specific substitutions in RAS genes could prevent and eliminate uncontrolled invasive tumour growth.

CONCLUSION

By identifying specific gene mutations and differences in genetic markers, the study provided insights for the development of targeted diagnostic methods and personalised treatment strategies, ultimately improving the clinical outcomes in the field of oncology.

Determination of genetic predisposition to early breast cancer in women of Kazakh ethnicity

Breast cancer (BC) is the most common type of cancer among women in Kazakhstan. To date, little data are available on the spectrum of genetic variation in Kazakh women with BC. We aimed to identify population-specific genetic markers associated with the risk of developing early-onset BC and test their association with clinical and prognostic factors. The study included 224 Kazakh women diagnosed with BC (≤40 age). Entire coding regions (>1700 exons) and the flanking noncoding regions of 94 cancer-associated genes were sequenced from blood DNA using MiSeq platform. We identified 38 unique pathogenic variants (PVs) in 13 different cancer-predisposing genes among 57 patients (25.4%), of which 6 variants were novel. In total, 12 of the 38 distinct PVs were detected recurrently, including BRCA1 c.5266dup, c.5278-2del, and c.2T>C, and BRCA2 c.9409dup and c.9253del that may be founder in this population. BRCA1 carriers were significantly more likely to develop triple-negative BC (OR = 6.61, 95% CI 2.44-17.91, p = 0.0002) and have family history of BC (OR = 3.17, 95% CI 1.14-8.76, p = 0.03) compared to non-carriers. This study allowed the identification of PVs specific to early-onset BC, which may be used as a foundation to develop regional expertise and diagnostic tools for early detection of BC in young Kazakh women.

Corrigendum: Systemic treatment of breast cancer. 1st Central-Eastern European professional Consensus Statement on breast cancer

[This corrects the article DOI: 10.3389/pore.2022.1610383.].

LGR5 as a potential therapeutic target for breast cancer: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Breast cancer is the world's most common malignancy. Despite significant advances in the diagnosis and treatment of the disease, the associated mortality rate is still high. Tumor initiating cells known as cancer stem cells with unique abilities are suspected responsible for therapy failure and poor prognosis. Leucine-rich repeat-containing G-protein-coupled receptor 5 (LGR5) is a cancer stem cell marker which promotes aggressive features in breast cancer cells. So, the aim of this study was to perform a systematic review and meta-analysis to evaluate LGR5 as a therapeutic target for breast cancer.

METHODS

This systematic review and meta-analysis were performed using databases of Web of Science, Scopus, and PubMed. We searched these databases with LGR5 and Breast Cancer and related keywords based on mesh database until Oct12, 2021. All studies that reported the rate of LGR5 high expression with Immunohistochemistry in breast cancer patients were included in this review. We used the STATA and random effect model for data analysis.

RESULTS

Finally, 7 studies including 2632 breast cancer samples were studied. The pooled prevalence of LGR5 high expression in breast cancer was 36 % (CI95%: 26-47.5%, I2= 95.5) and in triple negative was 48.6% (CI95%: 38.4-58.7%, I2= 0.0).

CONCLUSION

Our findings show that the rate of LGR5 high expression in breast cancer in general and especially in triple negative was considerable and it seems that this is a potential therapeutic target for breast cancer.

SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer

OBJECTIVE

To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer.

METHODS

In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort.

RESULTS

A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy.

CONCLUSIONS

Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

Early integration of palliative care into oncological care: a focus on patient-important outcomes

BACKGROUND

Globally, cancer remains one of the leading causes of mortality. Palliative care is designed to meet a range of cancer patients' priority issues, including the management of pain and other cancer-associated symptoms. Routine palliative care envisages the provision of not just medical therapy, but also psychological support, social support and spiritual assistance. What constitutes the best model for palliative care remains a matter of debate.

AIM

This review was undertaken with the aim to discuss different aspects of early integration of palliative care into oncological care, with a focus on patient-important outcomes.

METHODS

A comprehensive search of publications was conducted with a focus on integrative palliative care for incurable cancer patients. For this purpose, the following databases and search engines were used: Scopus, PubMed, Cochrane Library, Research Gate, Google Scholar, eLIBRARY and Cyberleninka.

RESULTS

A comprehensive approach with early integration of different medical services appears to be the most promising. Integrative palliative care is best provided via specialised interdisciplinary teams, given that all members maintain systemic communications and regularly exchange information. This model ensures that timely and adequate interventions are provided to address the needs of patients.

CONCLUSION

Further research is needed to pinpoint the most optimal strategies to deliver palliative care and make it as tailored to the patient's demands as possible.

Systemic Treatment of Breast Cancer. 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified based on the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The professional guideline primarily reflects the resolutions and recommendations of the current ESMO, NCCN and ABC5, as well as that of the St. Gallen Consensus Conference statements. The recommendations cover classical prognostic factors and certain multigene tests, which play an important role in therapeutic decision-making. From a didactic point of view, the text first addresses early and then locally advanced breast cancer, followed by locoregionally recurrent and metastatic breast cancer. Within these, we discuss each group according to the available therapeutic options. At the end of the recommendations, we summarize the criteria for treatment in certain rare clinical situations.

Assessing breast cancer screening results through the lens of COVID-19 pandemic

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Background: In January, 2020 World Health Organization (WHO) declared the COVID-19 outbreak as the first global health emergency. Lockdowns and restrictive procedures with the full and partial cancellation of preventive measures, including breast cancer (BC) screening, took place in Kazakhstan in 2020-2021. Purpose of this study: to determine the impact of the COVID-19 pandemic on BC screening results. Methods: The main screening indicators before (2018-2019) and during the COVID-19 pandemic (2020-2021) were studied: planned coverage and number of examined patients, the proportion of BI-RADS categories (where BI-RADS categories 4-5 are accepted as suspicious for malignancy, additional imaging by ultrasound and/or mammography followed biopsy is recommended), the number of detected cancer cases, the stage of the disease according to the screening database and the Electronic Cancer Registry. Results: 1,624,667 women underwent BC screening in 2018-2019 (96.2% of the planned amount of 1,688,829 women). 1,532,591 (79.4%) women were examined in 2020-2021, though the planned amount was 1,930,515. Before the epidemic, 23,296 patients received BI-RADS categories 4-5 (1.43% from examined women) and were referred for additional ultrasound and mammography examination, in 2020-2021 – 25,008 women (1.63%). 74.2% (1,205,094 women) had BI-RADS category 1 in 2018-2019 and 63.4% (971,754 patients) – during the pandemic. In 2018-2019 - 3,377 BC cases were detected (cancer detection rate was 2.0 per 1000 investigations). In 2020-2021 - 2,474 BC cases were identified (cancer detection rate 1.6 per 1000 investigations). Proportion of screen-detected cancers in stage 0-I was 45.1% in 2018-2019 and 47.5% in 2020-2021. During the pandemic, the number of participants who underwent BC screening significantly decreased (by 20.6% of the planned). The level of cancer detection decreased too (by 22.8%). There was an increase in patients requiring further examination (BI-RADS categories 4-5) and decrease the number women with BI-RADS 1. With an increase in indications for additional ultrasound and radiological examination, the number of revealed cancers reduced by 1.5 times (in 2018-2019, 14.5% patients with BI-RADS categories 4-5 had BC confirmed, in 2020-2021 – only 9.9%). Conclusions: BC screening has been significantly reduced during the COVID-19 pandemic. At the same time, attention should be paid to the increase in overdiagnosis of mammographic pathology, possibly due to an increase in the density of breast tissue on the background of nonspecific inflammation accompanied by lymphadenopathy. The impact of COVID-19 on BC is still unknown. Further research will be needed to confirm the link between COVID-19 and mammography picture and BC.

Overall survival of children with brain tumors after radiation therapy in Kazakhstan

e22011

Background: Tumors of the central nervous system in children occupy the 2nd place in frequency in the structure of malignant neoplasms of childhood and the 1st place among solid tumors. They make up about 20% of all malignant neoplasms of childhood and are mainly represented by brain tumors. The purpose of the study was to analyze the survival rate depending on various factors during radiation therapy (RT) of brain tumors in children. Methods: Retrospective study included 277 patients who received RT from 2016 to 2020 at the Pediatric Oncology Center of the Kazakh Research Institute of Oncology and Radiology. The average follow-up time was 34.3 months. The median age was 9.5 years. RT was performed on a linear accelerator “TrueBeam”, in a single dose of 1.8 Gy, total 50.4-54.0 Gy, 5 fractions per week. Survival distributions was estimated by Kaplan and Meier curves and survival differences were evaluated using the log-rank test. IBM SPSS Statistics V23 was used for statistical analyses. Results: The overall survival (OS) rate of 277 patients was 70.8%, with an average life time of 55.6 months, 95% confidence interval (CI) (51.9 - 59.2). Children under 10 years of age showed a 12.5 % worse OS compare to children after 10 years of age. In patients with unconfirmed morphological verification, OS is 31.5% worse than in children with confirmed morphological verification. In children with grade I-II tumor differentiation, OS was 30.6% higher than in children with grade III-IV tumors. The method of RT (conformal RT, IMLT), gender of patients did not have a statistically significant effect on OS. Conclusions: Our study showed that OS rate depends on various factors, such as age, presence of morphology verification, and the degree of tumor differentiation. RT allows to achieve better survival in patients older than 10 years who received RT with a morphologically confirmed diagnosis of GI-II. RT is one of the main treatments for brain tumors in children.[Table: see text]

Prevalence of HPV and cytological abnormalities in young women in Almaty, Kazakhstan

e22503

Background: Cervical cancer (CC) is the second most common type of cancer for women worldwide. 99% of cases of CC are associated with high-risk human papillomaviruses (HPV HR). Unfortunately, data on the epidemiology of HPV in Kazakhstan are limited, especially in young kazakhstani women. This study was provided to determine the prevalence of HPV HR and the cytological abnormalities in young Kazakhstani women, which will allow strengthening control in the existing CC screening in this age. Methods: 101 women aged 18-30 years were invited to this cross-sectional study. Women were mentally healthy and did not have a positive human papillomaviruses (HPV) history. Cervical samples for HPV were analyzed with using of Cobas 4800 HPV test. Cytological examination of smears with using the Bethesda terminology system and HPV test were conducted at Kazakh Institute of Oncology and Radiology. Results: The mean age of the study group was 21.0±2.8 years (range 18-30 years). Prevalence of HPV was 11,8% (12 cases). HPV 16 and 18 were the most common type in analyzed cases (5,9%). Cytological abnormalities occurred in 19,8% (20 cases). The Mann-Whitney test of the frequency of cytological abnormalities showed that the ASCUS and LSIL was significantly more found in the group up to 25 years. The HSIL was more common in a group of women 25 years and older and accounted for 1.9 % out of 2 cases (p < 0.05). Conclusions: The results of this study confirm the need for HPV vaccination of adolescent girls and improvement of the existing screening through the inclusion of women to screening from 25 years of age. Changing of CC screening through implementation of HPV screening with cytological triage of HPV - positive of women can reduce the burden of CC in young age in KazakhstanPrevalence of high risk HPV and cytological abnormalities in young women in Almaty, Kazakhstan.

OPEC study: An international multicenter study of ovarian preservation in endometrial cancers

OBJECTIVE

To evaluate the feasibility and oncological safety of ovarian preservation in early stage endometrial adenocarcinoma (EC) patients aged 40 and below.

METHODS

A total of 11 institutions from eight countries participated in the study. 169 of 5898 patients aged ≤40 years were eligible for the study. Patients with EC treated between March 2007 and January 2019 were retrospectively assessed.

RESULTS

The median duration of follow-up after EC diagnosis was 59 months (4-187). Among 169 participants, ovarian preservation surgery (OPS) was performed in 54 (31.9%), and BSO was performed in 115 (68.1%) patients. Although patients younger than 30 years of age were more likely to have OPS than patients aged 30 to 40 years (20.4% vs. 9.6%, P = 0.021), there was no significant difference by the mean age. There were no other relevant baseline differences between OPS and BSO groups. The Kaplan-Meier analysis revealed no difference in either the overall survival (P = 0.955) or recurrence-free survival (P = 0.068) among patients who underwent OPS, and BSO.

CONCLUSION

OPS appears to be safe without having any adverse impact on survival in women aged ≤40 years with FIGO Stage I EC.

Colorectal cancer screening results in the regions of Kazakhstan with different levels of cancer prevalence

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Background: In Kazakhstan colorectal cancer (CRC) occupies the third position in the structure of total oncological incidence and mortality. Kazakhstan is a country with a large territory, with different geographical, industrial characteristics and dietary habits of the population. So CRC prevalence levels vary from region to region: in 2013 the highest regional incidence rate is 6 times higher than the lowest. CRC population screening among men and women aged 50-70 years was started in 2011 in Kazakhstan. Methods: Within 10 years of the screening, 9 532 927 men and women were examined, 3419 CRC cases were detected. Coverage of target population ranged from 78.4% in 2012 to 53.1% in 2020. The analysis of screening indicators was carried out: cancer detection rate, the proportion of 0-1 stages, the ratio to the underlying incidence, the relationship with the dynamics of CRC incidence and mortality. According to the incidence rate in 2011-2020 regions of the country are conditionally divided into three groups: group A – high level (31.04-23.5 per 100 thousand population), group B – medium level (20.5-15.0%ooo), C - low level (11.6- 8.1%ooo). Results: The average annual CRC detection rate for 10 years of screening was 0.4% (4 cancer cases per 1000 examined), in groups A - 0.5%, B - 0.4% and C - 0.3%. The detection ratio of stage 0-I was 0.08%: in groups A - 0.10%, B - 0.09% and C - 0.05%. The average annual incidence rates were in groups A - 27.2 per 100 thousand population, B - 18.7%ooo and C - 9.8%ooo. During time of g-FOBT applying (2011-2013), the average annual incidence rates in the groups were in groups: A - 25.8%ooo, B - 16.4%ooo, C - 8.2%ooo. During time of using FIT (i-FOBT, 2014-2020), the average annual incidence rates increased to 27.0%ooo, 20.0%ooo and 9.9%ooo respectively. The greatest increase in the incidence was noted in groups B and C (22.7% and 22.2%), the smallest in group A (4.7%). Screening increased the CRC incidence from 15.5%ooo in 2011 to 16.5%ooo in 2020 and reduced mortality from 9.3%ooo (2011) to 8.0%ooo (2020). Conclusions: Screening increased the incidence (6.5%) and decreased the mortality from CRC (14%) for 10 years in Kazakhstan. There is a particularly significant effect of screening on the growth of some indicators (incidence and mortality rates, cancer detection rate and early cancer detection) in regions with a low CRC prevalence.

SUCCOR cone study: conization before radical hysterectomy

OBJECTIVE

To evaluate disease-free survival of cervical conization prior to radical hysterectomy in patients with stage IB1 cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009).

METHODS

A multicenter retrospective observational cohort study was conducted including patients from the Surgery in Cervical Cancer Comparing Different Surgical Aproaches in Stage IB1 Cervical Cancer (SUCCOR) database with FIGO 2009 IB1 cervical carcinoma treated with radical hysterectomy between January 1, 2013, and December 31, 2014. We used propensity score matching to minimize the potential allocation biases arising from the retrospective design. Patients who underwent conization but were similar for other measured characteristics were matched 1:1 to patients from the non-cone group using a caliper width ≤0.2 standard deviations of the logit odds of the estimated propensity score.

RESULTS

We obtained a weighted cohort of 374 patients (187 patients with prior conization and 187 non-conization patients). We found a 65% reduction in the risk of relapse for patients who had cervical conization prior to radical hysterectomy (hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.16 to 0.75, p=0.007) and a 75% reduction in the risk of death for the same sample (HR 0.25, 95% CI 0.07 to 0.90, p=0.033). In addition, patients who underwent minimally invasive surgery without prior conization had a 5.63 times higher chance of relapse compared with those who had an open approach and previous conization (HR 5.63, 95% CI 1.64 to 19.3, p=0.006). Patients who underwent minimally invasive surgery with prior conization and those who underwent open surgery without prior conization showed no differences in relapse rates compared with those who underwent open surgery with prior cone biopsy (reference) (HR 1.94, 95% CI 0.49 to 7.76, p=0.349 and HR 2.94, 95% CI 0.80 to 10.86, p=0.106 respectively).

CONCLUSIONS

In this retrospective study, patients undergoing cervical conization before radical hysterectomy had a significantly lower risk of relapse and death.

Open vs minimally invasive radical trachelectomy in early-stage cervical cancer: International Radical Trachelectomy Assessment Study

BACKGROUND

Minimally invasive radical trachelectomy has emerged as an alternative to open radical hysterectomy for patients with early-stage cervical cancer desiring future fertility. Recent data suggest worse oncologic outcomes after minimally invasive radical hysterectomy than after open radical hysterectomy in stage I cervical cancer.

OBJECTIVE

We aimed to compare 4.5-year disease-free survival after open vs minimally invasive radical trachelectomy.

STUDY DESIGN

This was a collaborative, international retrospective study (International Radical Trachelectomy Assessment Study) of patients treated during 2005-2017 at 18 centers in 12 countries. Eligible patients had squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma; had a preoperative tumor size of ≤2 cm; and underwent open or minimally invasive (robotic or laparoscopic) radical trachelectomy with nodal assessment (pelvic lymphadenectomy and/or sentinel lymph node biopsy). The exclusion criteria included neoadjuvant chemotherapy or preoperative pelvic radiotherapy, previous lymphadenectomy or pelvic retroperitoneal surgery, pregnancy, stage IA1 disease with lymphovascular space invasion, aborted trachelectomy (conversion to radical hysterectomy), or vaginal approach. Surgical approach, indication, and adjuvant therapy regimen were at the discretion of the treating institution. A total of 715 patients were entered into the study database. However, 69 patients were excluded, leaving 646 in the analysis. Endpoints were the 4.5-year disease-free survival rate (primary), 4.5-year overall survival rate (secondary), and recurrence rate (secondary). Kaplan-Meier methods were used to estimate disease-free survival and overall survival. A post hoc weighted analysis was performed, comparing the recurrence rates between surgical approaches, with open surgery being considered as standard and minimally invasive surgery as experimental.

RESULTS

Of 646 patients, 358 underwent open surgery, and 288 underwent minimally invasive surgery. The median (range) patient age was 32 (20-42) years for open surgery vs 31 (18-45) years for minimally invasive surgery (P=.11). Median (range) pathologic tumor size was 15 (0-31) mm for open surgery and 12 (0.8-40) mm for minimally invasive surgery (P=.33). The rates of pelvic nodal involvement were 5.3% (19 of 358 patients) for open surgery and 4.9% (14 of 288 patients) for minimally invasive surgery (P=.81). Median (range) follow-up time was 5.5 (0.20-16.70) years for open surgery and 3.1 years (0.02-11.10) years for minimally invasive surgery (P<.001). At 4.5 years, 17 of 358 patients (4.7%) with open surgery and 18 of 288 patients (6.2%) with minimally invasive surgery had recurrence (P=.40). The 4.5-year disease-free survival rates were 94.3% (95% confidence interval, 91.6-97.0) for open surgery and 91.5% (95% confidence interval, 87.6-95.6) for minimally invasive surgery (log-rank P=.37). Post hoc propensity score analysis of recurrence risk showed no difference between surgical approaches (P=.42). At 4.5 years, there were 6 disease-related deaths (open surgery, 3; minimally invasive surgery, 3) (log-rank P=.49). The 4.5-year overall survival rates were 99.2% (95% confidence interval, 97.6-99.7) for open surgery and 99.0% (95% confidence interval, 79.0-99.8) for minimally invasive surgery.

CONCLUSION

The 4.5-year disease-free survival rates did not differ between open radical trachelectomy and minimally invasive radical trachelectomy. However, recurrence rates in each group were low. Ongoing prospective studies of conservative management of early-stage cervical cancer may help guide future management.

Natural killer cell activity level in colorectal cancer screening in an average risk population

Introduction

Increased natural killer cell activity (NKCA) is linked to reduced risk of colorectal cancer (CRC). Several prior studies have investigated the association of NKCA and the incidence of CRC in high-risk subjects. The aim of our study was to investigate NKCA sensitivity in diagnosing advanced neoplasia (AN) and CRC in an average risk population.

Material and methods

NKCA was assessed by an enzyme-linked immunosorbent assay (ELISA) blood test in average risk subjects with a range of 25-2500 pg/ml set for ELISA. NKCA higher than 200 pg/ml was defined as negative. The performance of NKCA was evaluated using measures such as sensitivity, specificity, negative and positive predictive values (NPV, PPV), clinical utility index, etc. In addition, odds ratios for developing CRC using logistic regression models were calculated.

Results

NKCA was evaluated in 354 average risk individuals (mean age: 58.5 years; 36.2% male). The diagnostic accuracy of NKCA for CRC and AN was 75.5% and 72.3% respectively, with 96.4% NPV. The NKCA test demonstrated a good negative clinical utility index for CRC and AN (0.664 and 0.741, respectively). Individuals with low NKCA had 6.84 times higher odds of having CRC (95% CI: 2.31-20.27; p < 0.001). NKCA was higher in men vs. women (548.5 pg/ml vs. 500.0 pg/ml) and lower in smokers (412 pg/ml vs. 544 pg/ml), non-exercisers (413 pg/ml vs. 653.5 pg/ml), alcohol users (389 pg/ml vs. 476 pg/ml), and native Kazakhs and other Asian ethnic groups (446 pg/ml vs. 514 pg/ml).

Conclusions

A high NKCA level has potential ability to rule out CRC and AN in an average risk population.

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators

INTRODUCTION

Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce.

OBJECTIVE

To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database.

METHODS

The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified.

RESULTS

The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m² (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0-84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation.

CONCLUSIONS

In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.

Colorectal Cancer Screening with Computed Tomography Colonography: Single Region Experience in Kazakhstan

Background/Aims

The aim of our study was to determine the efficacy of computed tomography colonography (CTC) in screening for colorectal cancer (CRC).

Methods

A total of 612 females and 588 males aged 45 to 75 years were enrolled in CTC screening. CTC was performed following standard bowel preparation and colonic insufflation with carbon dioxide. The main outcomes were the detection rate of CRC and advanced adenoma (AA), prevalence of colorectal lesions in relation to socio-demographic and health factors, and overall diagnostic performance of CTC.

Results

Overall, 56.5% of the 1,200 invited subjects underwent CTC screening. The sensitivity for CRC and AA was 0.89 and 0.97, respectively, while the specificity was 0.71 and 0.99, respectively. The prevalence of CRC and AA was 3.0% (18/593) and 7.1% (42/593), respectively, with the highest CRC prevalence in the 66-75 age group (≥12 times; odds ratio [OR], 12.11; 95% confidence interval [CI], 4.45-32.92). CRC and AA prevalence were inversely correlated with Asian descent, physical activity, and negative fecal immunochemical test results (OR=0.43; 95% CI, 0.22-0.83; OR=0.16; 95% CI, 0.04-0.68; OR=0.5; 95% CI, 0.07-3.85, respectively).

Conclusions

Our study revealed high accuracy of CTC in diagnosing colonic neoplasms, good compliance with CTC screening, and high detection rate of CRC.

Cervical cancer screening: Twelve years experience of the Kazakhstan National Screening program

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Background: Cervical cancer (CC) is the most common gynecological cancer in Kazakhstan (KZ). Standardized incidence rate of CC was 16.7 per 100, 000, while the mortality rate was 5, 9 per 100, 000, in 2020. The National Cervical Screening program in KZ uses cytology (Pap test) from 2008, which is free of charge for women aged 30 to 70 years of age with an interval of 4 years. In 2017 Experts from ImPact Mission and analyzed existing CC screening revealed a number of recommendations aimed at reducing the screening interval and increasing the coverage. The purpose of this study was to analyze results of CC screening in KZ and his impact on CC incidence and mortality. Methods: Coverage, the number of screened women, the level of pre-cancer detection and cervical cancer during screening have been obtained from specific reports (form № 025, № 08) for 2008-2020. Results: The total number of screened women for 2008 were 554 283 women. There is a decrease in screening coverage to 45.9% in 2017 due to a decrease in funding. in this regard, in 2017, a number of changes were made to the existing screening program. In 2020 after the CC screening improvement 786 690 women were examined during the screening program, coverage rate was 66, 2%, . Analysis of screening results showed a marked increase in the detection of precancerous lesion from 0, 136 in 2008 to 0, 87 with an increasing by 37%. The analysis of CC incidence revealed significant changes: after the introduction of screening, an increase in the incidence rate is noted from 15.5 in 2008 to 20.1 per 100, 000 female population in 2015. Since 2015, there has been a significant decrease to 16.7 per 100, 000 women. Conclusions: Despite the positive results of screening, an increse the screening coverage, improvement in the detection of the initial stage of CC, mortality rate from CC and a one-year mortality remain high, which makes it necessary to improve the screening of CC in KZ through the introduction of HPV-screening

Effect of digital technologies on mammographic screening in the Republic of Kazakhstan

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Background: Since 2011 breast cancer (BC) has been the most common cancer in the Republic of Kazakhstan (RK) with the incidence of 43 per 100,000, and the third most common cause for cancer deaths with 9.4 deaths per 100,000 in 2019. Nationwide population-based screening program was implemented in the RK in 2008 inviting women aged 50–60 years every 2 years, with the subsequent expansion of the target group age to 40-70 years in 2018. The majority of screening mammography units was screen-film units at a time of program’s initiation. Gradual conversion to digital mammography (DM) has begun in 2014. This paper examines the impact of digital technologies on BC screening results on the example of the largest city in the RK - Almaty. Methods: We analyzed BC screening indicators such as incidence, mortality, proportion of early stage cancers, cancer detection rate. In order to assess the influence of transition to DM we divided the studied period to two stages: stage A (2008-2013)- when screen-film mammography (SFM) was widely used, and stage B (2014-2019)- when DM became prevalent in screening. Results: 598,058 women underwent BC screening from 2008 to 2019 in Almaty, 969 cancers were detected. At a time of program introduction in 2008 all 10 units used for screening were SFM units. The number of SFM units steadily increased from 10 in 2008 to 19 in 2014 and to 30 in 2019. Proportion of DM units concomitantly grew from 0% in 2008 to 47% in 2014 and to 83% in 2019. During the stage A 282 BC cases were detected (cancer detection rate 1 per 100,000 investigations). During the period B 687 BC cases were identified (cancer detection rate 2 per 100,000 investigations). Proportion of early stage cancers (0-I stage) rose from 26.7% in stage A to 41.0% in stage B. Widespread implementation of screening in 2008 led to a steady increase in BC incidence from 51 per 100,000 in 2008 to 63 per 100,000 in 2014. A noticeable decline in BC incidence has been evident since 2015 following 7 years of BC screening with incidence rate as low as 47.2 per 100,000 in 2019. Proportion of early stage BC among all newly diagnosed cases increased from 73.6% in 2008 to 86.6% in 2019. The average proportion of early stage BC was 77.5% for period A compared to 85,9% for stage B. Mortality rate was also affected by screening- it dropped by 38% from 20.6 per 100,000 in 2008 to 12.8 per 100,000 in 2019. Conclusions: BC state in Almaty reflects the general situation with BC in the whole country. Mammographic screening positively affected both BC incidence and mortality in Almaty. Increased utilization of digital technologies in screening resulted in rise in the proportion of early (0-I) stage BC by 21.4% and in the proportion of I-II stage BC by 13%. We suggest that, based on these results, further digitalization of mammographic screening should be strongly advised and digital to screen-film units ratio should be one of the main indicators for BC screening quality audit.

Comparison of breast cancer and cervical cancer stage distributions in ten newly independent states of the former Soviet Union: a population-based study

Background

Screening for breast cancer and cervical cancer in the newly independent states of the former Soviet Union is largely opportunistic, and countries in the region have among the highest cervical cancer incidence in the WHO European Region. We aimed to compare the stage-specific distributions and changes over time in breast cancer and cervical cancer incidence in the newly independent states of the former Soviet Union.

Methods

We collected breast cancer and cervical cancer incidence data from official statistics from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Ukraine, and Uzbekistan for the years 2008–17 by tumour, node, metastasis (TNM) stage, and by age where population-based cancer registry data were available. We used log-linear regression to quantify the changes over time in age-standardised rates.

Findings

During the period 2013–17, more than 50% of breast cancer cases across the analysed countries, and more than 75% of breast cancer cases in Belarus, Kazakhstan, and Ukraine, were registered at stages I–II. The proportion of stage I breast cancer cases was highest in the screening age group (50–69 years) compared with other ages in Moldova and the Russian registries, but was highest in those aged 15–49 years in Georgia and Ukraine. Breast cancer stage-specific incidence rates increased over time, most prominently for stage I cancers. For cervical cancer, the proportions of cancers diagnosed at a late stage (stages III and IV) were high, particularly in Moldova and Armenia (>50%). The proportion of stage I cervical cancer cases decreased with age in all countries, whereas the proportions of late stage cancers increased with age. Stage-specific incidence rates of cervical cancer generally increased over the period 2008–17.

Interpretation

Our results suggest modest progress in early detection of breast cancer in the newly independent states of the former Soviet Union. The high proportions of early-stage disease in the absence of mammography screening (eg, in Belarus) provide a benchmark for what is achievable with rapid diagnosis. For cervical cancer, there is a need to tackle the high burden and unfavourable stage-specific changes over time in the region. A radical shift in national policies away from opportunistic screening toward organised, population-based, quality-assured human papillomavirus vaccination and screening programmes is urgently needed.

Funding

Union for International Cancer Control, WHO Regional Office for Europe, and Ministry of Health of Ukraine.

The Life Quality and Sexual Function of Women Underwent Radical Hysterectomy

Background:

Up to date, there no studies were conducted on the quality of life (QL) and sexual function (SF) of women from Kazakhstan treated for cervical cancer. The study was aimed at the assessment of the QL and SF of women of the Kazakh population who underwent radical hysterectomy compared with chemo-radiotherapy group.

Methods:

The study was conducted prospectively on 157 women of the Kazakh population. 92 women underwent radical hysterectomy (RH) and 65 underwent chemo-radiotherapy (CRT). The information was collected before treatment (T1), 6 months (T2) and 12 months (T3) after treatment.

Results:

The women’s average age was 41.12 ± 5.4 in the RH group and 47.24 ± 6.1 in the CRT group (p = 0.2). We did not detect significant differences between both groups according to the QLQ C-30 questionnaire (T1). The differences between the RH and CRT groups (p≤0,05) were observed in terms of physical functioning, fatigue, nausea and vomiting, pain during the T2 period. High rates of emotional functioning (p = 0.03), global health and QL (p = 0.02), and symptoms of fatigue (p = 0.04) were detected in the RH group compared to the CRT group during T3. However, pain symptoms (p = 0.001), nausea and vomiting and loss of appetite (p = 0.03) were dominated the CRT group. According to the results of FSFI-6 in the RH group, indicators for the domains “desire” (p = 0.02), “excitement” (p = 0.03), and “orgasm” (p = 0.05) were high, unlike in the CRT group during the T3 period. Nevertheless, the number of complains on the ‘pain during intercourse’ in the CRT group was higher than in the RH group (p = 0.001).

Conclusion:

Women who underwent RH had better health scores, global health status, and SF compared with patients treated with CRT.

Overall survival in patients with metastatic renal cell carcinoma in Russia, Kazakhstan, and Belarus: a report from the RENSUR3 registry

Background

Real‐world data describing outcomes of treatment among metastatic renal cell carcinoma (mRCC) patients are limited and heterogeneous.

Aim

RENSUR3 registry study assessed real‐world data on the use of therapies in mRCC and overall survival (OS) in Russia, Kazakhstan, and Belarus.

Methods

Patients were included in the retrospective multicenter registry study. To be eligible, patients were required to have mRCC diagnosed from January 2015 to January 2016. Anonymized data were collected through an online registry. The outcomes of interest were patient characteristics, treatment patterns, and OS.

Results

1094 mRCC patients were identified. Mean age was 62.3 (SD, 11.2) years. Four hundred and forty‐four (41%) patients were 65 years and older. Primary tumor has not been removed in 503 (46%) patients. Subtype of RCC based on WHO classification (clear‐cell or other) has been reported in 402 (37%) patients. In total, 595 (54.4%) patients received systemic therapy for metastatic disease. 58% of elderly patients (≥65) were not treated compared to 37% of younger patients. Cytokines and targeted therapy were used in 298 (50.1%) and 297 (49.9%) of 595 treated patients, respectively. Median OS was 11.9 months (95% CI 10.9‐12.9). The 1‐ and 3‐year OS rates were 49.6% and 19.3%.

Conclusions

Half of patients received no systemic therapy or had only cytokines for mRCC in Russia, Kazakhstan, and Belarus, which doubtless negatively affected OS in this population. Novel therapies should be considered as life prolonging and a priority.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer

BACKGROUND

Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse.

METHODS

We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group.

RESULTS

Mean age was 48.3 years (range; 23-83) while the mean BMI was 25.7 kg/m² (range; 15-49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07; 95% CI, 1.35 to 3.15; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76; 95% CI, 1.75 to 4.33; P<0.001) and those without the use of a uterine manipulator had similar disease-free-survival to the open surgery group (HR, 1.58; 95% CI, 0.79 to 3.15; P=0.20). Moreover, patients that underwent minimally invasive surgery with protective vaginal closure had similar rates of relapse to those who underwent open surgery (HR, 0.63; 95% CI, 0.15 to 2.59; P<0.52).

CONCLUSIONS

Minimally invasive surgery in cervical cancer increased the risk of relapse and death compared with open surgery. In this study, avoiding the uterine manipulator and using maneuvers to avoid tumor spread at the time of colpotomy in minimally invasive surgery was associated with similar outcomes to open surgery. Further prospective studies are warranted.

Trends of Colorectal Cancer Prevalence in Kazakhstan Related to Screening

We carried out an analysis of the total incidence of colon cancer throughout Kazakhstan. Retrospectively, according to the regional reports on endoscopic screening, the study showed an increase in the age-related incidence of colorectal cancer (CRC) cases from 2004–2008 to 2009–2014. The peak of morbidity in both periods was noted in the age category of >70 years. The indicators of the territorial distribution of CRC incidence make it possible to divide the regions into areas with low or high rates of CRC. Specific indicators showed newly diagnosed cases of CRC stages I, II, III, and IV in 2004–2018. The incidence rates of stages I and II showed a two-fold increase (35%–67.4%) and the incidence of stage IV showed a decline from 19.3% to 13.1% and of stage III from 45.7% to 19.5% from 2004 to 2018, respectively. An analysis of CRC incidence throughout Kazakhstan showed an increase in the overall incidence. Since population-based CRC screening was introduced in 2011, the morbidity was found to increase for stages I and II.

Opportunities and challenges in cervical cancer screening program in Kazakhstan: Results after imPACT review

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Background: Cervical cancer is the second most common cancer in women worldwide, where the majority of registered patients are in developing countries. Screening programs in developed countries have reduced morbidity and mortality from cervical cancer by more than 2 times. Cervical cancer (CC) is the most common gynecological cancer in Kazakhstan (KZ). Standardized incidence rate of CC was 18.2 per 100,000, while the mortality rate was 6.2 per 100,000, in 2019. The National Cervical Screening program in KZ uses cytology (Pap test) from 2008. Screening program funded by the State budget. In 2016, Experts of imPACT Mission analyzed the CC screening and made recommendations for improvement. Since 2018 target age of CC screening expanded to 30-70 years and shortened the interval to 4 years, strengthened the control of patients with pre-cancerous pathology. Until 2018, people came to a fixed age; today we start CC screening within the target age at any age at the time of the first visit. The purpose of this study is to analyze cytological screening results in KZ after imPACT recommendations. Methods: Coverage, the number of screened women, the level of pre-cancer detection and cervical cancer during screening have been obtained from specific reports (form № 025, № 08) for 2008-2019. Results: The total number of screened women was in 6.775.975. There is a decrease in the number of screened women by 32% from 2008 to 2017. Since improvement of CC screening we increased coverage from 49.9% in 2017 (abs. number 409.124) to 89% in 2019 (abs. number 954.322). According to the results of screening, 2603 cases of CC were registered in 12 years. Analysis of screening results showed a marked increase in the detection of CC with an increasing by 67%. The persentage of registered cases of ASH+HSIL increased from 0.136% to 0.673%. Conclusions: there has been an increase in the coverage by screening of the target population since the screening update. During the study period, there has been an improvement in the detection of precancerous pathology and cancer in the early stage. Despite the positive results of screening, sufficient coverage by screening, certain successes in detecting the initial stage of CC, mortality rate from CC remain high, which makes it necessary to improve the screening of CC in KZ through the introduction of HPV-screening.

The results of a study of the concordance of RAS status in liquid and invasive biopsies in patients with metastatic colorectal cancer in the Republic of Kazakhstan

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Background: Liquid biopsy is increasingly of interest as an alternative to invasive biopsy of solid tumors for predicting, making decisions about the treatment and monitoring of the disease. Particular preference is given to liquid biopsy in cases where it is not possible to obtain a sufficient amount of material or material of poor quality with a tumor biopsy. However, in order to find out the clinical significance of circulating tumor DNA (ctDNA), it is important to first establish the sensitivity of the method using tumor-plasma consistency studies. Methods: We selected 38 patients with a confirmed diagnosis of colorectal cancer (CRC), in whom was established the progression of the disease. All patients underwent two diagnostic methods, which we divided conditionally into 2 groups: A – invasive biopsy from available metastatic foci; to detect mutations in exons 2, 3, and 4 the KRAS gene used a reagent kit to detect 18 point mutations in codons 12,13,61,117,146 and a reagent kit to identify 10 mutations of the NRAS gene in codons 12,13,61,146 (Entrogen) on a Rotor-Gene 6000 Amplifier; B - liquid biopsy, to determine 21 mutations in the codons 12,13,59,61,117,146 of the KRAS gene, 18 mutations in the codons of 12,13,59,61,117,146 of the NRAS gene, was used Idylla automated molecular diagnostic system. Results: Of the 38 studied samples of group A: 22 (57.9%) had wild type KRAS, 16 (42.1%) were mutated, in group B: wild type had 25 (65.8%) patients, mutated - 13 (34, 2%). Thus, we see a discrepancy in the results in 3 (7.9%) of 38 cases. Conclusions: The results indicate a high degree of sensitivity (92.1%) of liquid biopsy as a diagnostic method, but confirmation of concordance with traditional tissue biopsy requires further in-depth study of this issue in a larger sample of patients.

Next generation sequencing analysis of key genes in breast cancer patients from Kazakh population

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Background: Breast cancer (BC) shows a high incidence both in Kazakhstan and worldwide. Approximately 20-30% of cases of hereditary breast cancer are caused by presence of BRCA1/2 genes defects. Also, there are additional genes, which can increase the risk of BC and they are still under study. In our study we identify new, detectable and objective markers of key cancer genes by next-generation sequencing (NGS) of young BC patients in Kazakh population. Methods: The study enrolled 235 unrelated patients from Kazakh population(the average age 34.25 ± 4.56) with BC. Genomic DNA was obtained from peripheral blood and sequencing was performed using TruSight Cancer Kit on the MiSeq platform. Studio Variant was used to annotate and interpret genetic variants. 26(11.1%) patients had a maternal family history of BC, 21 (80.8%) of them had first- degree relatives diagnosed with BC at different age. Results: Bioinformatics analysis of NGS data identified 23,915 variants in 83 genes. 64 pathogenic variants in the heterozygous state were found in 62 (26.4%) patients, 8 (12.5%) variants were not previously described in databases (LOVD, ClinVar, 1000 Genomes, ESP6500 and ExAC). The most frequent pathogenic mutations were in the genes BRCA1 (24 variants (37.5%) and BRCA2 (18 (28.1%)). Additional pathogenic variants were identified in the non-BRCA genes (APC, ATM, BLM, CHEK2, PALB2, TP53, ERCC2, FANCA, FANCM, NBN, PMS1, PMS2, SDHB and XPA). A hereditary history was recorded in 29.1% and 27.8% of representatives of the group with pathogenic mutations in the BRCA1 and BRCA2, respectively, higher compared to the group of patients without pathogenic mutations and to the group of patients with non-BRCA genes. Conclusions: The frequent and novel germline mutations in BRCA1/2 and non-BRCA genes were identified by NGS. Diagnostic and prevention tools for key genes are considered to be developed and included in the National guidelines of Republic of Kazakhstan after final statistic data processing.

Quality of life of cervical cancer patients after specialized treatment in Kazakhstan

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Background: In Kazakhstan cervical cancer (CC) ranks 2nd in morbidity and mortality among women with malignant neoplasms. 88% of women are diagnosed in stages 1-2. Age range of patients with cervical cancer is becoming younger with women age 35-55 years old. This urges implementation of an effective system for assessing and maintaining the quality of life of people with CC who undergo special treatment. Methods: During study we used The EORTC quality of life questionnaire (QLQ C-30) Version 3.0 on 157 patients with stage 1-2 CC, 1+ year after chemoradiotherapy (CRT, n = 65) and surgical treatment (ST, n = 92). For statistical analysis, we used the Wilcoxon rank-sum test and the chi-square test using SPSS version 22.0. Results: When analyzing limitations in everyday activities (work etc) (sign 1), 13.8% -18.5% of patients with cervical cancer noted “significant” and “very strong” impact on quality of life after CRT compared with 1.1% - 3.3% of patients after ST (p < 0.001). Study showed that there is a strong correlation between treatment method and quality of life (table 1). 35.4% of patients after CRT have noted “significant” difficulties in carrying out work requiring a higher level of physical effort (sign 2). In contrast, only 16.3% of patients after ST noted “significant” difficulties, which is 2.2 times less (p < 0.006). Assessment revealed a moderate quantitative correlation (table 1). 16.9% of patients after CRT noted severe pain (sign 3) compared with 2.2% of patients who received ST (p < 0.001). Assessment revealed a moderate quantitative correlation (table 1). Absence of feeling of weakness (sign 4) was greater among patients from the ST group - 21.7% compared with CRT - 9.2% (p < 0.03). Assessment revealed a strong quantitative correlation (table). 15.4% of patients after CRT, compared with 2.2% of patients who received ST (p < 0.001) have noted that their physical condition and treatment had a “very strong” impact on their personal life (sign 5). Conclusions: Assessment revealed that CC patients who received CRT showed lower physical and social indicators of quality of life. [Table: see text]

SATEN III—Splitting Adjuvant Treatment of stage III ENdometrial cancers: an international, multicenter study

Introduction

The purposes of this study were to compare adjuvant treatment modalities and to determine prognostic factors in stage III endometrioid endometrial cancer (EC).

Methods

SATEN III was a retrospective study involving 13 centers from 10 countries. Patients who had been operated on between 1998 and 2018 and diagnosed with stage III endometrioid EC were analyzed.

Results

A total of 990 women were identified; 317 with stage IIIA, 18 with stage IIIB, and 655 with stage IIIC diseases. The median follow-up was 42 months. The 5-year disease-free survival (DFS) of patients with stage III EC by adjuvant treatment modality was 68.5% for radiotherapy (RT), 54.6% for chemotherapy (CT), and 69.4% for chemoradiation (CRT) (p=0.11). The 5-year overall survival (OS) for those patients was 75.6% for RT, 75% for CT, and 80.7% for CRT (p=0.48). For patients with stage IIIA disease treated by RT versus CT versus CRT, the 5-year OS rates were 75.6%, 75.0%, and 80.7%, respectively (p=0.48). Negative peritoneal cytology (HR: 0.45, 95% CI: 0.23 to 0.86; p=0.02) and performance of lymphadenectomy (HR: 0.33, 95% CI: 0.16 to 0.77, p=0.001) were independent predictors for improved OS for stage IIIA EC. For women with stage IIIC EC treated by RT, CT, and CRT, the 5-year OS rates were 78.9%, 67.0%, and 69.8%, respectively (p=0.08). Independent prognostic factors for better OS for stage IIIC disease were age <60 (HR: 0.50, 95%CI: 0.36 to 0.69, p<0.001), grade 1 or 2 disease (HR: 0.59, 95% CI: 0.37 to 0.94, p=0.014; and HR: 0.65, 95%CI: 0.46 to 0.91, p=0.014, respectively), absence of cervical stromal involvement (HR: 063, 95% CI: 0.46 to 0.86, p=0.004) and performance of para-aortic lymphadenectomy (HR: 0.52, 95% CI: 0.35 to 0.72, p<0.001).

Discussion

Although not statistically significant, CRT seemed to be a better adjuvant treatment option for stage IIIA endometrioid EC. Systematic lymphadenectomy seemed to improve survival outcomes in stage III endometrioid EC.

Mutation Spectrum of Cancer-Associated Genes in Patients With Early Onset of Colorectal Cancer

Background: Colorectal cancer (CRC) incidence is rising worldwide, as well as in the Republic of Kazakhstan, while its occurrence is also increasing in the younger population. Hereditary forms associated with the development of colon and rectal cancer and early-onset CRC have never been studied in the population of Kazakhstan. The aim of this research was to investigate the spectrum of CRC-related gene mutations to determine which mutations cause early onset of CRC in the Kazakhstan population.

Methods: The study included 125 unrelated patients from Kazakhstan (range 17–50 years in age) with early onset CRC. Genomic DNA was obtained from peripheral blood of the patients. Next-generation sequencing was performed using the TruSightCancer Kit on the MiSeq platform. The Studio Variant was used to annotate and interpret genetic variants.

Results: Bioinformatics analysis of Next-generation sequencing data revealed 11,152 variants from 85 genes, of them, 3,790 missense, 6,254 synonymous variants, 44 3′UTR variants, 10 frameshift variants, five stop-gain variants, four in-frame deletions, two splice donors, one splice acceptor variant, and 1,042 intron or non-coding variants. APC, BRCA2/1, ALK, BRIP1, EGFR, FANCA, FANCD2, FANCI, HNF1A, MEN1, NSD1, PMS2, RECQL4, RET, SLX4, WRN, and XPC genes mutated most often. According to the ACMG guidelines and LOVD/ClinVar databases, 24 variants were pathogenic (10 frameshifts, five missenses, five stop-gain, one in-frame deletion, and three splice-site mutations), and 289 were VUS with population frequency <1%, 131 of them were attributed as deleterious. In the study, 50% of all pathogenic mutations found in Kazakhstani patients with early CRC onset were identified in the subgroups with a family history of CRC and primary multiple tumors. In APC, pathogenic mutations were most often (21%).

Conclusion: Pathogenic and likely pathogenic mutations were found in 20 (16%) out of 125 patients. Eight novel pathogenic mutations detected in FANCI, APC, BMPR1, ATM, and DICER1 genes have not been reported in previous literature. Given the high frequency and wide spectrum of mutations, NGS analysis must be carried out in families with a history of CRC/CRC-related cancers with the purpose to identify cause-effective mutations, clarify the clinical diagnosis, and prevent the development of the disease in other family members.

Mutational analysis of key genes in patients from the Kazakh population with early onset of breast cancer

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Background: Breast cancer (BC) represents the most common malignancy and has the highest mortality among women, both in the world and in Kazakhstan. Approximately 20-30% of cases of hereditary BC are caused by presence of BRCA1/2 genes defects. Also, there are additional genes which can increase the risk of BC and they are still under study.The aim of this study was to identify new, detectable and objective markers of key cancer genes by next-generation sequencing (NGS) of young BC patients. Methods: Blood was collected from 129 BC patients (average age 34.87±5.587). DNAs were extracted using GeneJET Genomic DNA Purification Kit. NGS was done on the MiSeq platform using TruSightCancer Kit. NGS data were analyzed by the MiSeq Reporter v. 2.4 software. Variant annotation and interpretation was done by Variant Studio 3.0 software. Results: We perform the NGS and did the detailed bioinformatics analysis of sequences of 16 key genes of BC (BRCA1/BRCA2, BRIP1, ATM, CDH1, CHEK2, NBN, NF1, PALB2, STK11, TP53, RAD51C, RAD51D, BARD1, MUTYH and FANCC). At all 3016 variants were detected, 1080 (35.8%) out of which were missense; 1494 (49.5%) synonymous; 17 (0.6%) frameshifts; 2 (0.06%) inframe deletions, 8 (0.3%) stop gained; 4 (0.1%) splice variant, 411 (13.6%) intron or non-coding variants. We identified 24 pathogenic and likely pathogenic mutations in 31 patients (24% of all patient cohort), 3 mutations are novel. All mutations were in heterozygous state and were rare or had frequency data not available (NA) in 1000G, ESP6500and ExAC databases. Analysis of mutation type revealed 17 frameshift mutations, 2 missense mutations, 8 stop gained mutations, 4 mutations involving uncorrected splicing. Out of the 31 pathogenic and likely pathogenic variants, were detected 14 in BRCA1, 9 in BRCA2, 4 in TP53 genes, 3 in PALB2 and 1 in NBN. (BRCA2: c.6468_6469delTC, c.7567_7568delCT, c.9976A > T, c.8174G > A, c.2442delC, c.2808_2811delACAA, c.9253delA, c.9409dupA and c.6058G > T; BRCA1: c.2498delT, c.5224C > T, c.3020C > G, c.3352C > T, c.5530+1G > A, c.5341-2delA and BRCA1-c.5329dupC in 6 cases; NBN: c.657_661delACAAA; PALB2: c.172_175delTTGT, c.1034T > G and c.18_22delGAAGC; TP53- c.156dupA, c.1024C > T, c.844C > T and c.584T > C). The most frequent genes were BRCA1 (45%) and BRCA2 (29%). Conclusions: The study focused on identifying mutation profile of early onset BC using NGS. Clinically significant variants was detected which are promising biomarkers for the successful diagnosis and therapy of BC at women in reproductive age.

The results of colorectal cancer screening in the Republic of Kazakhstan during the period from 2013 to 2018

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Background: Colorectal cancer (CRC) remains one of the actual problems in oncology. In 2017, in the structure of oncopathology of the Republic of Kazakhstan (RK), CRC took the 3rd place in terms of incidence - 17.5, and in mortality - 8.2 per 100 thousand people. The population screening of CRC has been introduced in the Republic of Kazakhstan since 2011, among the population aged 50 to 70 years, with a survey interval every 2 years. Fecal immunochemical test (FIT) and total colonoscopy (TC) were introduced in 2013. Methods: For the period 2013 - 2018, 5133602 subjects were examined. The analysis of screening indicators was carried out: the number of positive results of FIT, completion rate of follow-up colonoscopy and CRC detection rate. The analyzed groups were divided into regions with: A - high (26 - 30.7 per 100 thousand people), B - medium (13.2-21.8), C - low (5.9 - 10.8) incidence. Results: The positive FIT for the study period was found on average, in 1.23% (62971) positive results in the Republic of Kazakhstan, in group A it was 1.50% (27675), in group B - 1.26% (17178), and in group C - 0.94% (18118). The number of TC: in group A - 76.1% (21067), in group B - 75.8% (13016), in group C was 66.7% (12080), in total - 46163 cases in the Republic of Kazakhstan, which is 73.3% of indications. During the period of study 2480 patients with colorectal cancer were identified: in group A - 0.07% (1236), in group B - 0.05% (638), in group C - 0.03% (606) people. Conclusions: For regions with different incidence rates is necessary to define performance indicators to improve the quality assurance in CRC screening.

Implementation of HPV vaccination pilot project in Kazakhstan: Successes and challenges

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Background: Cervical cancer (CC) is the second most frequent cancer of women after breast cancer. Prophylactic vaccines for human papillomavirus (HPV) are being introduced in many countries more than 10 years ago. The standardized incidence of СС in Kazakhstan (KZ) in 2017 was 17.1 per 100,000 women. From 2013 to 2016, there was a pilot project of school-based HPV vaccination of adolescent girls in four districts of KZ. Vaccination was carried out with two vaccines (Gardasil and Cervarix) on the choice of parents in a three-dose regimen. Due to the high rejection of vaccination, this program was completed in 2016. Aim of study was to analyze the results of HPV vaccination in KZ. Methods: The results of vaccination of adolescent girls from 9 to 15 years old were evaluated. We analyzed database registry of Kazakhstani vaccinated girls to evaluate vaccine coverage in four district of KZ. Results: A total 11,648 adolescent girls were fully vaccinated during the pilot program for 2013-2016. The average age of the vaccinated is 12.67 ± 1.04. In 2013, immunization was performed for 1,816 girls aged 11–13 years. In 2014, the age range of the target group was expanded to 15 years. The number of vaccinated girls increased to 5,699 adolescent girls. 7,136 girls were fully vaccinated in 2015. 10,004 girls have not received full doses of vaccine. Overall coverage rates of fully vaccinated were 14.8%. The majority of coverage results was stastically similar except for Almaty, where coverage was higher than the average coverage (17.9% vs. 14.8%, p < 0.05). Conclusions: Pilot project of vaccination in Kazakhstan was declared unsuccessful. This situation is associated with a lack of information campaigns on vaccination. This findings highlights the need for phased implementation of vaccination through an educational campaign of parents.

International radical trachelectomy assessment: IRTA study

BACKGROUND

Radical trachelectomy is considered a viable option for fertility preservation in patients with low-risk, early-stage cervical cancer. Standard approaches include laparotomy or minimally invasive surgery when performing radical trachelectomy.

PRIMARY OBJECTIVE

To compare disease-free survival between patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive (laparoscopic or robotic) radical trachelectomy.

STUDY HYPOTHESIS

We hypothesize that minimally invasive radical trachelectomy has similar oncologic outcomes to those of the open approach.

STUDY DESIGN

This is a collaborative, multi-institutional, international, retrospective study. Patients who underwent a radical trachelectomy and lymphadenectomy between January 1, 2005 and December 31, 2017 will be included. Institutional review board approval will be required. Each institution will be provided access to a study-specific REDCap (Research Electronic Data Capture) database maintained by MD Anderson Cancer Center and will be responsible for entering patient data.

INCLUSION CRITERIA

Patients with squamous, adenocarcinoma, or adenosquamous cervical cancer FIGO (2009) stages IA2 and IB1 (≤2 cm) will be included. Surgery performed by the open approach or minimally invasive approach (laparoscopy or robotics). Tumor size ≤2 cm, by physical examination, ultrasound, MRI, CT, or positron emission tomography (at least one should confirm a tumor size ≤2 cm). Centers must contribute at least 15 cases of radical trachelectomy (open, minimally invasive, or both).

EXCLUSION CRITERIA

Prior neoadjuvant chemotherapy or radiotherapy to the pelvis for cervical cancer at any time, prior lymphadenectomy, or pelvic retroperitoneal surgery, pregnant patients, aborted trachelectomy (intra-operative conversion to radical hysterectomy), or vaginal approach.

PRIMARY ENDPOINT

The primary endpoint is disease-free survival measured as the time from surgery until recurrence or death due to disease. To evaluate the primary objective, we will compare disease-free survival among patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive radical trachelectomy.

SAMPLE SIZE

An estimated 535 patients will be included; 256 open and 279 minimally invasive radical trachelectomy. Previous studies have shown that recurrence rates in the open group range from 3.8% to 7.6%. Assuming that the 4.5-year disease-free survival rate for patients who underwent open surgery is 95.0%, we have 80% power to detect a 0.44 HR using α level 0.10. This corresponds to an 89.0% disease-free survival rate at 4.5 years in the minimally invasive group.

Initial Study of Sexual Function Among Cervical Cancer Survivors in Almaty, Kazakhstan

Background: There were not any evaluation of sexual dysfunction of cervix cancer patients in Almaty, Kazakhstan, to date. The study of 58 CC patients is an attempt to start filling this gap and to develop recommendations for the treatment of this kind of patients. Aim: The objective of this study was to examine sexual function of cervical cancer (CC) survivors receded different treatment approaches. Methods: 58 women subjected to CC treatment of at least 1 year in the past were examined at the initial stage of the research. The examined women were split into 5 groups by treatment methods: conization of cervix, hysterectomy with removal of ovaries, hysterectomy without removal of (one or both) ovaries, chemotherapy with radiotherapy, and those passed exclusively radiotherapy. The sexual function of the examined women was evaluated through Female Sexual Function Index (FSFI) instrument consisted of 19 questions. The questions were mainly related to the main aspects like desire, arousal, lubrication, orgasm, satisfaction and pain. The data were collected by online and face-to-face interviews. Results: The median age of the 58 interviewed women was 44.5 years. 49 of the interviewees reported that they experienced desire. 79% of the interviewed women had sexual activity, among which 74% answers pointed out high lubrication condition above 2 within 0-5 possible range, 66% indicated high score of excitation, while 72% replied positively on orgasm section of the questionnaire. The highest portion of sexual active women experienced satisfaction (76%) although 33 of the interviewees felt the pain during coitus. The total FSFI score varied between 3.9 and 32.4 in the group of women who reported their sexual activity. Conclusion: This study demonstrates that lower total score of sexual function index is found in the patients passed chemotherapy with radiotherapy, or those cured exclusively with radiotherapy. In parallel, the highest score is traced in the women treated surgically. Therefore, it proves that surgery is more preferable treatment to keep higher level of sexual function in patients with cervix cancer. For the purpose of higher accuracy at the next stages of the research the inclusion of control group of women without history of cancer and with similar social, economic and demographic characteristics is needed.

Screening for Cervical Cancer in Kazakhstan

Background: Cervical cancer is the second most common cancer in women worldwide, where the majority of registered patients are in developing countries. Screening programs in developed countries have reduced morbidity and mortality from cervical cancer by more than 2 times. Cervical cancer (CC) is the most common gynecologic cancer in Kazakhstan. In 2016, the standardized incidence rate of CC was 19.1 per 100,000, while the mortality rate was 7.1 per 100,000. The National Cervical Screening program in Kazakhstan has been using cytology (The Papanicolaou test) since 2008, free for women aged 30 to 60 years and performed at 5-year intervals. Despite the introduction of cytologic screening, the mortality rate remains high. Aim: The purpose of this study is to analyze the effectiveness of cytologic screening in Kazakhstan. Methods: Coverage analysis, the number of screened women, the level of precancer detection and cervical cancer during screening have been obtained from specific reports (form no. 025, no. 08) for 2008-2016. Results: The number of screened women totaled at 4,460,320. There has been a decrease of 32% in the number of screened women within the nine-year period. Furthermore, the coverage rate has decreased within the said period by 27%, from 72.9% in 2008% to 45.9% in 2016, with the highest coverage in 2012. According to the results of the screening, 1576 cases of CC were registered. The analysis of the screening results showed a marked increase in the detection of CC with an increase of 37%. At the same time, the percentage of detection of the initial stage during screening remains insufficient and for 2016 was 50.8%. The percentage of registered cases of ASH+HSIL increased from 0.136% to 0.673%. Conclusion: An analysis of the cytologic screening for 2008-2016 showed a high incidence of CC. Despite sufficient coverage and relative success in detecting the initial stages of CC, the mortality rate remains high. Thus, it is necessary to improve the effectiveness of CC screening in Kazakhstan through the introduction of HPV-screening.