Emerging advances in nanomedicine for breast cancer immunotherapy: opportunities and challenges

Breast cancer is one of the most common causes of cancer-related morbidity and mortality in women worldwide. Early diagnosis and an appropriate therapeutic approach for all cancers are climacterics for a favorable prognosis. Targeting the immune system in breast cancer is already a clinical reality with notable successes, specifically with checkpoint blockade antibodies and chimeric antigen receptor T-cell therapy. However, there have been inevitable setbacks in the clinical application of cancer immunotherapy, including inadequate immune responses due to insufficient delivery of immunostimulants to immune cells and uncontrolled immune system modulation. Rapid advancements and new evidence have suggested that nanomedicine-based immunotherapy may be a viable option for treating breast cancer.

Real-world multicenter study of the safety and efficacy of netupitant plus palonosetron fixed-dose combination to prevent chemotherapy-induced nausea and vomiting among Malaysian patients receiving moderately or highly emetogenic chemotherapy

AIM

A large proportion of cancer patients are at high risk for chemotherapy-induced nausea and vomiting (CINV), but the choice of anti-emetics for CINV in Malaysia is limited.

METHODS

This was a real-world study of a fixed-dose combination of netupitant and palonosetron (NEPA) to inhibit CINV in adult patients receiving moderately (MEC) or highly emetogenic chemotherapy (HEC) for solid/hematological malignancies at eight Malaysian centers. Each HEC/MEC cycle received one dose of NEPA + dexamethasone for CINV prevention. Complete response (no emesis, no rescue medication) (CR), no more than mild nausea (severity score ≤ 2.5), and complete control (CR) (no more than mild nausea) during the acute (0-24 h), delayed (25-120 h), and overall (0-120 h) phases post-chemotherapy were measured. Treatment-related adverse events (AEs) were recorded.

RESULTS

During March 2016-April 2018 (NMRR-17-3286-38282), NEPA + dexamethasone was administered to 54 patients (77.8% solid, 22.2% hematological malignancies). Note that 59.3% received HEC, while 40.7% received MEC regimen. During the overall phase of the first cycle, the majority had CR (77.8%), no more than mild nausea (74.1%), and complete control (61.1%). Seventeen patients received two consecutive cycles at any point of chemotherapy cycles. During the overall phases across two consecutive cycles, all patients achieved CR, and the majority reported no more than mild nausea and complete control. No grades 3-4 AEs were reported.

CONCLUSIONS

NEPA had sustained efficacy and tolerability at first administration and across two cycles of MEC/HEC for CINV prevention.

Oncologist-led BRCA counselling improves access to cancer genetic testing in middle-income Asian country, with no significant impact on psychosocial outcomes

BACKGROUND

Identifying patients with BRCA mutations is clinically important to inform on the potential response to treatment and for risk management of patients and their relatives. However, traditional referral routes may not meet clinical needs, and therefore, mainstreaming cancer genetics has been shown to be effective in some high-income and high health-literacy settings. To date, no study has reported on the feasibility of mainstreaming in low-income and middle-income settings, where the service considerations and health literacy could detrimentally affect the feasibility of mainstreaming.

METHODS

The Mainstreaming Genetic Counselling for Ovarian Cancer Patients (MaGiC) study is a prospective, two-arm observational study comparing oncologist-led and genetics-led counselling. This study included 790 multiethnic patients with ovarian cancer from 23 sites in Malaysia. We compared the impact of different method of delivery of genetic counselling on the uptake of genetic testing and assessed the feasibility, knowledge and satisfaction of patients with ovarian cancer.

RESULTS

Oncologists were satisfied with the mainstreaming experience, with 95% indicating a desire to incorporate testing into their clinical practice. The uptake of genetic testing was similar in the mainstreaming and genetics arm (80% and 79%, respectively). Patient satisfaction was high, whereas decision conflict and psychological impact were low in both arms of the study. Notably, decisional conflict, although lower than threshold, was higher for the mainstreaming group compared with the genetics arm. Overall, 13.5% of patients had a pathogenic variant in BRCA1 or BRCA2, and there was no difference between psychosocial measures for carriers in both arms.

CONCLUSION

The MaGiC study demonstrates that mainstreaming cancer genetics is feasible in low-resource and middle-resource Asian setting and increased coverage for genetic testing.

A comparative study of remote sensing classification methods for monitoring and assessing desert vegetation using a UAV-based multispectral sensor

Restoration programs require long-term monitoring and assessment of vegetation growth and productivity. Remote sensing technology is considered to be one of the most powerful technologies for assessing vegetation. However, several limitations have been observed with regard to the use of satellite imagery, especially in drylands, due to the special structure of desert plants. Therefore, this study was conducted in Kuwait's Al Abdali protected area, which is dominated by a Rhanterium epapposum community. This work aimed to determine whether Unmanned Aerial Vehicle (UAV) multispectral imagery could eliminate the challenges associated with satellite imagery by examining the vegetation indices and classification methods for very high multispectral resolution imagery using UAVs. The results showed that the transformed difference vegetation index (TDVI) performed better with arid shrubs and grasses than did the normalized difference vegetation index (NDVI). It was found that the NDVI underestimated the vegetation coverage, especially in locations with high vegetation coverage. It was also found that Support Vector Machine (SVM) and Maximum Likelihood (ML) classifiers demonstrated a higher accuracy, with a significant overall accuracy of 93% and a kappa coefficient of 0.89. Therefore, we concluded that SVM and ML are the best classifiers for assessing desert vegetation and the use of UAVs with multispectral sensors can eliminate some of the major limitations associated with satellite imagery, particularly when dealing with tiny plants such as native desert vegetation. We also believe that these methods are suitable for the purpose of assessing vegetation coverage to support revegetation and restoration programs.

Real-world experience of first-line afatinib in patients with EGFR-mutant advanced NSCLC: a multicenter observational study

BACKGROUND

This study aimed to evaluate the efficacy, side-effects and resistance mechanisms of first-line afatinib in a real-world setting.

METHODS

This is a multicenter observational study of first-line afatinib in Malaysian patients with epidermal growth factor receptor (EGFR)-mutant advanced non-small cell lung cancer (NSCLC). Patients' demographic, clinical and treatment data, as well as resistance mechanisms to afatinib were retrospectively captured. The statistical methods included Chi-squared test and independent t-test for variables, Kaplan-Meier curve and log-rank test for survival, and Cox regression model for multivariate analysis.

RESULTS

Eighty-five patients on first-line afatinib from 1st October 2014 to 30th April 2018 were eligible for the study. EGFR mutations detected in tumors included exon 19 deletion in 80.0%, exon 21 L858R point mutation in 12.9%, and rare or complex EGFR mutations in 7.1% of patients. Among these patients, 18.8% had Eastern Cooperative Oncology Group performance status of 2-4, 29.4% had symptomatic brain metastases and 17.6% had abnormal organ function. Afatinib 40 mg or 30 mg once daily were the most common starting and maintenance doses. Only one-tenth of patients experienced severe side-effects with none having grade 4 toxicities. The objective response rate was 76.5% while the disease control rate was 95.3%. At the time of analysis, 56 (65.9%) patients had progression of disease (PD) with a median progression-free survival (mPFS) of 14.2 months (95% CI, 11.85-16.55 months). Only 12.5% of the progressed patients developed new symptomatic brain metastases. The overall survival (OS) data was not mature. Thirty-three (38.8%) patients had died with a median OS of 28.9 months (95% CI, 19.82-37.99 months). The median follow-up period for the survivors was 20.0 months (95% CI, 17.49-22.51 months). Of patients with PD while on afatinib, 55.3% were investigated for resistance mechanisms with exon 20 T790 M mutation detected in 42.0% of them.

CONCLUSIONS

Afatinib is an effective first-line treatment for patients with EGFR-mutant advanced NSCLC with a good response rate and long survival, even in patients with unfavorable clinical characteristics. The side-effects of afatinib were manageable and T790 M mutation was the most common resistance mechanism causing treatment failure.

Management of advanced prostate cancer in a middle-income country: real-world consideration of the Advanced Prostate Cancer Consensus Conference 2017

OBJECTIVE

To examine the results of the Malaysian Advanced Prostate Cancer Consensus Conference (MyAPCCC) 2018, held for assessing the generalizability of consensus reached at the Advanced Prostate Cancer Consensus Conference (APCCC 2017) to Malaysia, a middle-income country.

METHODS

Six key sections were chosen: (1) high-risk localized and locally advanced prostate cancer, (2) oligometastatic prostate cancer, (3) castration-naïve prostate cancer, (4) castrate resistant prostate cancer, (5) use of osteoclast-targeted therapy and (6) global access to prostate cancer drugs. There were 101 consensus questions, consisting of 91 questions from APCCC 2017 and 10 new questions from MyAPCCC 2018, selected and modified by the steering committee; of which, 23 questions were assessed in both ideal world and real-world settings. A panel of 22 experts, comprising of 11 urologists and 11 oncologists, voted on 101 predefined questions anonymously. Final voting results were compared with the APCCC 2017 outcomes.

RESULTS

Most voting results from the MyAPCCC 2018 were consistent with the APCCC 2017 outcomes. No consensus was achieved for controversial topics with little level I evidence, such as management of oligometastatic disease. No consensus was reached on using high-cost drugs in castration-naïve or castration-resistant metastatic prostate cancer in real-world settings. All panellists recommended using generic drugs when available.

CONCLUSIONS

The MyAPCCC 2018 voting results reflect the management of advanced prostate cancer in a middle-income country in a real-world setting. These results may serve as a guide for local clinical practices and highlight the financial challenges in modern healthcare.

Retrospective Analysis of Cancer Care Performance and Survival Outcome for Nasopharyngeal Carcinoma at a leading Cancer Treatment Centre in Malaysia 2008-2012

Objective:

This report focuses on a private medical centre cancer care performance as measured by patient survival outcome for up to 5 years.

Methods:

All patients with nasopharyngeal cancer treated at SJMC between 2008 and 2012 were enrolled for this observational cohort study. Mortality outcome was ascertained through record linkage with national death register, linkage with hospital registration system and finally through direct contact by phone.

Result:

266 patients treated between 2008 and 2012 were included for survival analysis. 31% of patients were diagnosed with Early NPC Cancer (Stage I or II), another 44% with Locally Advanced Cancer (Stage III) and 25% with late stage IV metastatic cancer. 2%, 27% and 67% had WHO Class I, II and III NPC respectively.
The overall survival at 5 years was 100% for patients with Stage I disease, 91% for Stage II disease, 72% for Stage III disease, and decreasing to 44% for Stage IV disease. Overall survival at 5 years for all stages was 73%.

Conclusion:

SJMC is among the first hospitals in Malaysia to embark on routine measurement of the performance of its cancer care services and its results are comparable to any leading centers in developed countries.

Financial Toxicity After Cancer in a Setting With Universal Health Coverage: A Call for Urgent Action

BACKGROUND

Financial toxicity negatively affects the well-being of cancer survivors. We examined the incidence, cost drivers, and factors associated with financial toxicity after cancer in an upper-middle-income country with universal health coverage.

METHODS

Through the Association of Southeast Asian Nations Costs in Oncology study, 1,294 newly diagnosed patients with cancer (Ministry of Health [MOH] hospitals [n = 577], a public university hospital [n = 642], private hospitals [n = 75]) were observed in Malaysia. Cost diaries and questionnaires were used to measure incidence of financial toxicity, encompassing financial catastrophe (FC; out-of-pocket costs ≥ 30% of annual household income), medical impoverishment (decrease in household income from above the national poverty line to below that line after subtraction of cancer-related costs), and economic hardship (inability to make necessary household payments). Predictors of financial toxicity were determined using multivariable analyses.

RESULTS

One fifth of patients had private health insurance. Incidence of FC at 1 year was 51% (MOH hospitals, 33%; public university hospital, 65%; private hospitals, 72%). Thirty-three percent of households were impoverished at 1 year. Economic hardship was reported by 47% of families. Risk of FC attributed to conventional medical care alone was 18% (MOH hospitals, 5%; public university hospital, 24%; private hospitals, 67%). Inclusion of expenditures on nonmedical goods and services inflated the risk of financial toxicity in public hospitals. Low-income status, type of hospital, and lack of health insurance were strong predictors of FC.

CONCLUSION

Patients with cancer may not be fully protected against financial hardships, even in settings with universal health coverage. Nonmedical costs also contribute as important drivers of financial toxicity in these settings.

Health-related quality of life and psychological distress among cancer survivors in a middle-income country

OBJECTIVES

Quality of life and psychological well-being are important patient-centered outcomes, which are useful in evaluation of cancer care delivery. However, evidence from low-income and middle-income countries remains scarce. We assessed health-related quality of life (HRQoL) and prevalence of psychological distress (anxiety or depression), as well as their predictors, among cancer survivors in a middle-income setting.

METHODS

Through the Association of Southeast Asian Nations Costs in Oncology study, 1490 newly diagnosed cancer patients were followed-up in Malaysia for 1 year. Health-related quality of life was assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and EuroQol-5 (EQ-5D) dimension questionnaires at baseline, 3 and 12 months. Psychological distress was assessed by using Hospital Anxiety and Depression Scale. Data were modeled by using general linear and logistic regressions analyses.

RESULTS

One year after diagnosis, the mean EORTC QLQ-C30 Global Health score of the cancer survivors remained low at 53.0 over 100 (SD 21.4). Fifty-four percent of survivors reported at least moderate levels of anxiety, while 27% had at least moderate levels of depression. Late stage at diagnosis was the strongest predictor of low HRQoL. Increasing age, being married, high-income status, hospital type, presence of comorbidities, and chemotherapy administration were also associated with worse HRQoL. The significant predictors of psychological distress were cancer stage and hospital type.

CONCLUSION

Cancer survivors in this middle-income setting have persistently impaired HRQoL and high levels of psychological distress. Development of a holistic cancer survivorship program addressing wider aspects of well-being is urgently needed in our settings.

Breast Cancer Survival at a Leading Cancer Centre in Malaysia

BACKGROUND

GLOBOCAN12 recently reported high cancer mortality in Malaysia suggesting its cancer health services are under-performing. Cancer survival is a key index of the overall effectiveness of health services in the management of patients. This report focuses on Subang Jaya Medical Centre (SJMC) care performance as measured by patient survival outcome for up to 5 years.

MATERIALS AND METHODS

All women with breast cancer treated at SJMC between 2008 and 2012 were enrolled for this observational cohort study. Mortality outcome was ascertained through record linkage with national death register, linkage with hospital registration system and finally through direct contact by phone or home visits.

RESULTS

A total of 675 patients treated between 2008 and 2012 were included in the present survival analysis, 65% with early breast cancer, 20% with locally advanced breast cancer (LABC) and 4% with metastatic breast cancer (MBC). The overall relative survival (RS) at 5 years was 88%. RS for stage I was 100% and for stage II, III and IV disease was 95%, 69% and 36% respectively.

CONCLUSIONS

SJMC is among the first hospitals in Malaysia to embark on routine measurement of the performance of its cancer care services and its results are comparable to any leading centers in developed countries.

Gefitinib as first line therapy in Malaysian patients with EGFR mutation-positive non-small-cell lung cancer: A single-center retrospective study

The present retrospective, single-center study evaluated the objective response rate (ORR) and progression-free survival (PFS) of epidermal growth factor receptor (EGFR) mutation-positive Malaysian patients with advanced lung adenocarcinoma treated with gefitinib. During May 2008 to July 2013, 33 patients with Stage IV, EGFR mutation-positive non-small-cell lung cancer (NSCLC) were identified and received gefitinib (250 mg) as first line treatment. The primary and secondary end points were ORR, PFS and safety, respectively. A total of 18 (54.5%) and 2 (6.1%) patients achieved partial response (PR) and complete response (CR) to gefitinib therapy, respectively, yielding an ORR of 60.6% (95% CI, 42.1–77.1%). Patients with exon 20 or 21 mutations (n=6, 66.7%) tended to have better ORR compared with exon 19 (n=22, 59.1%). The median PFS was 8.9 months in Malaysian patients with EGFR mutation-positive NSCLC, treated with gefitinib. The majority of treatment-related toxicity was mild in nature. The most frequently reported adverse events included dry skin (39.4%), skin rash (27.2%), and dermatitis acneiform (15.2%). In conclusion, Malaysian patients with locally advanced and metastatic EGFR mutation-positive NSCLC responded favorably to gefitinib therapy in terms of ORR, median PFS, and tolerability, the results of which were consistent with those of the IPASS study conducted in an Asian population. Considering the efficacy and safety profile of gefitinib, it is a favorable option for the first-line treatment of Malaysian patients with EGFR mutation-positive NSCLC. However, future long-term studies in a larger population of Malaysian patients are required to support whether the prolonged PFS conferred by gefitinib will translate into prolonged overall survival.

Structural, spectroscopic, optical, dielectric and mechanical study of pure and l-Proline doped ammonium dihydrogen phosphate single crystals

Single crystals of pure and l-Proline (LP) C5H9NO2 doped ammonium dihydrogen phosphate (ADP) (NH4) H2PO4 were grown by slow evaporation solution technique (SEST) at ambient conditions. Powder X-ray diffraction (PXRD) analysis was carried out to confirm the crystal structure and no additional phase was observed due to doping except a systematic variation in peak intensities. FT-Raman analysis also confirms that there is no additional phase formation due to doping. Fourier transform infrared spectral analysis was done to examine the presence of various functional groups in the grown crystals. UV-VIS-NIR spectroscopic analysis was carried out to see the change in optical transparency of pure ADP and crystals due to LP with different doping concentrations. The high-resolution X-ray diffraction (HRXRD) analysis was carried out to examine the crystalline perfection and observed reasonable changes with LP doping. Second harmonic generation (SHG) efficiency measurement was done to examine the enhancement in the nonlinear optical characteristics of the grown crystals. The dielectric behavior of the samples shows that the dielectric constant decreased with increase the value of frequency. The effect of LP dopant on crystal morphology, mechanical properties of ADP has also been presented in this paper. The above studies reveal the effect of incorporation of LP into the lattice of ADP crystals.

Fetal cardiac dextroposition in the absence of an intrathoracic mass: sign of significant right lung hypoplasia

We reviewed our experience of fetal cardiac dextroposition in the absence of an intrathoracic mass. Ten cases were found by fetal echocardiography to have a normal cardiac axis, but the heart was shifted into the right chest and the amount of right lung tissue was reduced. At birth seven of the infants had confirmed structural heart disease (70%), including three with scimitar syndrome. Two infants had additional extracardiac anomalies (20%). Seven infants born at term had clinical pulmonary hypertension with a diagnosis of right lung hypoplasia in all of them. Two neonates died owing to significant heart disease (one with scimitar syndrome and the other with hypoplastic left heart syndrome). Of the three pregnancies that were terminated, the two fetuses with autopsies had severe right lung hypoplasia. Fetal cardiac dextroposition and right pulmonary artery hypoplasia in the absence of an intrathoracic mass are important signs of right lung hypoplasia, which can be associated with significant pathologic cardiac and extracardiac conditions.

Breast cancer in pregnancy--our experience with six patients in the University Hospital, Kuala Lumpur

Presentation of breast cancer during pregnancy is a rare situation and one that requires a multidisciplinary approach involving an obstetrician, surgeon and oncologist. Management should be along the same principles as in non-pregnant patients and delay is not justifiable. Mastectomy and axillary clearance is the best option, followed by chemotherapy, which is safe after the first trimester. Radiation if required should be delayed until after delivery of the baby. We present here our experience with 6 patients who presented with breast cancer during pregnancy. Five patients refused any treatment until after delivery, while one underwent only a mastectomy and axillary clearance. The outcome was poor; all of them died between 14 months and 52 months. The poor outcome probably reflects the late stage at presentation in four of the patients (State 3 and 4) rather than the delay in treatment, while delay in treatment in the two who presented with early cancer (Stage 1 and 2) led to a more advanced stage after delivery.

Iatrogenic ureteric injuries

Damage to the lower ureters during pelvic surgery is a serious and well-recognised complication. This iatrogenic injury, when undetected intra-operatively, continues to give rise to significant patient morbidity. In 1987, this Department was referred 18 cases of iatrogenic ureteric injuries. 16 patients were from gynaecologic surgery and 2 patients were from general surgery. Only 4 cases (24%) were detected and referred intra-operatively. 13 patients presented post-operatively with various symptoms viz., anuria, loin pain and urinary leak per vagina. Good recovery of urinary function was achieved in all cases after urological intervention, usually by ureteric re-implantation.

Xanthogranulomatous pyelonephritis. A report of two cases

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis affecting adults and children. Two patients with the disease are reported.