Relationship of Oncotype Dx score with tumor grade, size, nodal status, proliferative marker Ki67 and Nottingham Prognostic Index in early breast cancer tumors in Saudi Population

BACKGROUND

Oncotype Dx is a 21-gene recurrence score, which is used as a diagnostic tool for the recurrence of breast cancer. It is also used to determine the benefit of chemotherapy for breast cancer in early stages. This study investigates the relationship of Oncotype Dx with pathological prognostic markers of protein Ki 67, Nottingham Prognostic Index (NPI) and tumor grade.

METHODS

Data for early breast cancer patients treated at our tertiary care center was collected for statistical analysis. Data for patients from 2014 to 2018 was recorded for patient's age, ER/PR status, Ki 67, nodal status, tumor grade, NPI along with Oncotype Dx score. Metric measurements were described as mean ± SD and the non-metric data was represented by frequency (%). Chi-square or Fisher's exact tests as well as logistic regression was applied to assess the associations at 95% CI.

RESULTS

Among 156 breast cancer patients, the mean age was 55.7 ± 9.4 years. The tumors were classified into Grade-I (12.8%), Grade-II (67.3%) and Grade-III (19.9%). Ki67 score was 12.8 ± 12.0 and NPI score was 3.7 ± 0.8. The mean Oncotype Dx score was 17.0 ± 9.1; it was 14.1 ± 6.8 for Grade-I tumors; 15.7 ± 7.5 for grade -II tumors; and 23.2 ± 12.3 for grade-III tumors [Mean Oncotype Dx score across Tumor grades was compared by ANOVA (η = 0.121), p < 0.001]. While logistic regression analyses for the dichotomized Oncotype Dx higher score (≥25) was significantly associated with grade-III tumors odds ratio (OR) = 13.72 (95% CI: 1.62-115.89), higher Ki67 (>20) OR = 14.40, (95% CI: 1.44-143.71), average NPI score (2.41-3.40), OR = 13.60, (95% CI: 1.57-117.94) to poor NPI (>5.4). The association of Oncotype Dx with age, tumor size and nodal status was statistically not significant.

CONCLUSIONS

This study revealed that age, Ki67, tumor size and nodal status did not have a statistically significant impact on Oncotypye Dx recurrence score in the targeted patient population. There was a significant correlation of low grade node negative patients with Oncotype Dx while high grade node negative patients had poor correlations with Oncotype Dx. The use of Oncotype Dx has shown to be less cost-effective and has no noticeable association with improved life expectancy in the targeted patient population (i.e., hormone positive, node negative cases) in comparison with current clinical practices in Saudi Arabia and it is less likely to be cost-effective in this group of patients.

Controversies Regarding Ovarian Suppression and Infertility in Early Stage Breast Cancer

A common side effect of chemotherapy in breast cancer is early menopause in premenopausal patients, which is mainly a result of an indirect form of ovarian ablation, and is associated with substantial impairment of quality of life. Suppressing the production of ovarian estrogen has been shown to reduce the recurrence of hormone receptor-positive early breast cancer in premenopausal women, but whether it has an added advantage over tamoxifen is being discussed. Types of permanent ablation of the ovarian function include surgical oophorectomy and radiation-induced ovarian failure. Both are associated with similar response rates in hormone receptor-positive metastatic breast cancer. Medical castration with luteinizing hormone-releasing hormone analogs (LHRHa) has the benefit of being a reversible approach. Another advantage that premenopausal patients who wish to reduce the risk of developing premature ovarian insufficiency induced by chemotherapy may be offered LHRHa irrespective of whether they desire pregnancy and their age at diagnosis. This also helps reduce the risk of menopausal signs and symptoms as well as the loss of bone density in the long-term, which are primary concerns for women. This is of utmost importance to premenopausal women who do not want to conceive after treatment or are not candidates for fertility preservation strategies because of age. It should be emphasized that for women who are interested in fertility preservation, gamete cryopreservation remains the first option, and LHRHa is not an alternative. During chemotherapy, however, temporary ovarian suppression with LHRHa may be given to women who either have no access to a fertility clinic or who have declined chemotherapy or have contraindications.

Breast Cancer During Pregnancy

Breast cancer remains the most common cancer in women. A diagnosis of cancer during pregnancy is uncommon. In recent decades, obstetricians are seeing an increasing number of women who become pregnant or desire to become pregnant after breast cancer treatment because of a delay in childbearing for a variety of reasons, including cultural, educational, and professional. Consequently, breast cancer in young women often occurs before the completion of reproductive plans. A discussion among the patient, the oncologist, and the obstetrician on the relative benefits of early delivery followed by treatment versus commencement of therapy while continuing the pregnancy is of utmost importance in order to reach a consensual decision. The best available evidence suggests that pregnancy after breast cancer increases the risk of recurrence. The birth outcome in women with a history of breast cancer is no different from that in the normal female population; however, increased risks of delivery complications have been reported in the literature. As concurrent pregnancy and breast cancer are uncommon, there are no data from large randomized trials; hence, recommendations are mainly based on retrospective studies.

Arabic version of the Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC): a validity and feasibility study

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC) is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis (kappa = 0.91) and a high sensitivity (97%) and specificity (94%).

A decision impact, decision conflict and economic assessment of routine Oncotype DX testing of 146 women with node-negative or pNImi, ER-positive breast cancer in the U.K

Background:

Tumour gene expression analysis is useful in predicting adjuvant chemotherapy benefit in early breast cancer patients. This study aims to examine the implications of routine Oncotype DX testing in the UK.

Methods:

Women with oestrogen receptor positive (ER+), pNO or pN1mi breast cancer were assessed for adjuvant chemotherapy and subsequently offered Oncotype DX testing, with changes in chemotherapy decisions recorded. A subset of patients completed questionnaires about their uncertainties regarding chemotherapy decisions pre- and post-testing. All patients were asked to complete a diary of medical interactions over the next 6 months, from which economic data were extracted to model the cost-effectiveness of testing.

Results:

Oncotype DX testing resulted in changes in chemotherapy decisions in 38 of 142 (26.8%) women, with 26 of 57 (45.6%) spared chemotherapy and 12 of 85 (14.1%) requiring chemotherapy when not initially recommended (9.9% reduction overall). Decision conflict analysis showed that Oncotype DX testing increased patients' confidence in treatment decision making. Economic analysis showed that routine Oncotype DX testing costs £6232 per quality-adjusted life year gained.

Conclusion:

Oncotype DX decreased chemotherapy use and increased confidence in treatment decision making in patients with ER+ early-stage breast cancer. Based on these findings, Oncotype DX is cost-effective in the UK setting.

Providing monovalent oral polio vaccine type 1 to newborns: findings from a pilot birth-dose project in Moradabad district, India

PROBLEM

Poliovirus transmission remained a public health challenge in western Uttar Pradesh, India in late 2005 and early 2006. In 2006, the India Expert Advisory Group for Polio Eradication concluded that, given the peak incidence of polio among children 6 to 12 months of age, a targeted birth dose of oral polio vaccine may be necessary to interrupt intense poliovirus transmission in high risk areas.

APPROACH

The Government of Uttar Pradesh, the National Polio Surveillance Project and the United Nations Children's Fund (UNICEF) implemented a pilot birth-dose project aimed at identifying and vaccinating all newborns with a dose of oral polio vaccine within 72 hours of birth in an effort to evaluate operational feasibility and potential impact on population immunity.

LOCAL SETTING

The project was piloted in Moradabad district: zone 7 in Moradabad City (urban setting), Kunderki block (rural setting) and in select birthing hospitals.

RELEVANT CHANGES

Between July 2006 and February 2007, 9740 newborns were identified, of which 6369 (65%) were vaccinated by project personnel within 72 hours of birth. Project coverage (for total newborns vaccinated) ranged from 39% (in zone 7) to 76% (in Kunderki block) of the estimated number of newborns vaccinated during previous supplemental immunization activities.

LESSONS LEARNED

Birth-dose coverage among newborns was lower than expected. Expansion costs were estimated to be high, with marginal impact. The project, however, provided opportunities to strengthen newborn tracking systems which have increased the number of newborns and young infants vaccinated during supplemental immunization activities and enrolled in routine programmes.

Proton pump inhibition is a feasible primary alternative to surgery and balloon dilatation in adult peptic pyloric stenosis (APS): report of six consecutive cases

INTRODUCTION

Surgery has been the gold standard in the treatment of adult pyloric stenosis (APS). The introduction of proton pump inhibitors (PPIs) in 1989 revolutionised the treatment of peptic ulcer disease and its complications.

PATIENTS AND METHODS

We carried out a prospective study to evaluate the effectiveness of PPIs as an alternative to surgery for treatment of APS. Six consecutive patients admitted with a diagnosis of adult peptic pyloric stenosis between November 1999 and August 2002 were studied. The diagnosis was confirmed with endoscopy. All patients were commenced on a twice-daily dose of intravenous PPI. This was changed to oral treatment after 2 days. Main outcome measures evaluated were resolution of symptoms on PPIs and failure of medical therapy.

RESULTS

There were five females and one male. Median age at diagnosis was 72 years (range, 30-90 years). Median duration of symptoms was 2 weeks (range, 1-5 weeks). Of the patients, five had a history of peptic ulcer disease. Complete resolution was achieved in 5 patients (83%). Median duration for resolution of symptoms was 9 days (range, 5-14 days). All patients were changed to oral PPIs after 2 days. One patient did not respond to oral therapy and required surgical intervention (pyloroplasty). Median follow-up was 26 months (range, 6-48 months). There was no recurrence of symptoms. All patients were discharged on low-dose PPI.

CONCLUSIONS

This study supports the view that proton pump inhibitors are a safe and feasible alternative to surgery in adult pyloric stenosis secondary to peptic ulcer disease.

Vitamin A status of children in the urban slums of Karachi, Pakistan, assessed by clinical, dietary, and biochemical methods

We assessed the vitamin A status of 532 children with an age range of 6-60 months who were living in slum areas of Karachi, Pakistan, using three methodologies: clinical eye examination, dietary vitamin A intake, and serum retinol level. No definite clinical signs of xerophthalmia were observed in any of these children. The mean +/- SD vitamin A intake estimated from a food frequency questionnaire for the group with inadequate (low and deficient) serum retinol levels (< 20 micrograms/dl) was 362 +/- 332 retinol equivalents (RE) compared with 431 +/- 332) RE in the group with adequate serum levels (P < 0.005). Deficient serum retinol levels (< 10 micrograms/dl) were present in 12 children (2%); two of these had a healed corneal scar. Low serum retinol levels (10-19 micrograms/dl) were present in 46%, while 51% children had adequate levels (> or = 20 micrograms/dl). The mean +/- SD serum retinol level for the inadequate (< 20 micrograms/dl) and adequate groups were 15.3 +/- 2.8 and 26.6 +/- 6.7 micrograms/dl, respectively. These results suggest that a significant number of children in these communities have low vitamin A levels and thus may constitute an at risk group. These results also suggest that the dietary intake method may be a simple and inexpensive screening tool for assessment of vitamin A status in communities.

Chloramphenicol therapy of typhoid fever

In a prospective study we compared two different dosage regimens of IV chloramphenicol succinate (100 mg/kg/day and 75 mg/kg/day) in children with culture proven typhoid. Trough and peak blood samples, obtained at 48 hrs, were analysed for free chloramphenicol by high pressure liquid chromatography (HPLC). Although the mean trough (8.8 +/- 7.7 versus 5.4 +/- 2.6 mcg/ml) and peak (19.9 +/- 12.2 versus 15.4 +/- 6.1 mcg/ml) chloramphenicol concentrations were comparable in both groups, a significantly wider range was found in the group receiving 100 mg/kg/day. Potentially toxic levels (greater than 30 mcg/ml) developed in two patients with liver dysfunction. Chloramphenicol in a dosage of 75 mg/kg/day is adequate and safe for the treatment of paediatric typhoid.