Does Endocrine Therapy for DCIS Patients Treated with Breast-Conserving Surgery Followed by Postoperative Radiation Therapy is Needed? A Brazilian Retrospective Cohort Study

PURPOSE/OBJECTIVE(S)

International previous clinical trials have demonstrated increased local control. Adjuvant endocrine therapy (ET) is a component of hormone receptor-positive breast ductal carcinoma in situ (DCIS) treatment. Previous trials have shown local control benefits. However, there are still questions regarding the reproducibility of those results in real-life scenarios and for different populations, especially in patients who received breast-conserving surgery followed by postoperative radiation therapy. Therefore, we retrospectively evaluated the impact of adjuvant ET for CDIS from a large State database in Brazil.

MATERIALS/METHODS

We retrospectively evaluated the Fundação Oncocentro de São Paulo (FOSP) database, which collects information on hospitals and oncology departments in the State of São Paulo, Brazil. The endpoints were local control (LC), disease-specific survival (DSS), and overall survival (OS). Moreover, we investigated the influence of medical practice (public health care system, insurance, private) and educational level (illiterate and incomplete middle school were grouped as low; complete middle school, high school, and undergraduate were grouped as medium/high).

RESULTS

Data from 2,192 patients who underwent breast-conserving surgery and postoperative radiotherapy and were treated between 2000 and 2020 were analyzed. The median follow-up time was 48.99 months (IQR 29.93 - 88.67). In the cohort, 53.33% (n = 1169) of patients received adjuvant ET, and 46.67% did not (n = 1023). Overall, patients not receiving adjuvant ET tend to be older (p = 0.021) and have a lower educational level (p < 0.001). Median OS and DSS were not reached. The 10-year OS and DSS for patients receiving adjuvant ET versus those not receiving it was 89.36% vs. 91.47% and 97.54% vs. 98.48%, respectively. The HR for OS for adjuvant ET vs. no ET was 0.96 (95% CI 0.63 - 1.4; p = 0.83). The HR for DSS for adjuvant ET vs. no ET was 0.79 (95% CI 0.29 - 2.12; p = 0.63). The only variable associated with survival was educational level. The 10-year OS was significantly higher for patients with medium/high educational levels (93.25% vs. 87.31%). The HR for death for medium/high versus low educational level was 0.51 (95% CI 0.32 - 0.83; p = 0.007). Recurrence rates were low in the cohort. Only 1.5% of patients had local recurrence, and 0.2% had a regional recurrence. There was no significant difference between recurrence rates for adjuvant ET (p = 0.19 and p = 0.78, respectively).

CONCLUSION

The benefits of adjuvant ET in DCIS patients found in international clinical trials could not be demonstrated in a Brazilian cohort. Educational level significantly impacted survival and ET usage, reflecting the influence of socioeconomic factors. Identifying these more vulnerable populations can allow for more precise interventions.

Brazilian Pediatric Patients with Gliomas: Treatment Characteristics and Survival Outcomes

PURPOSE/OBJECTIVE(S)

Despite being the second most frequent tumors in children, pediatric central nervous system (CNS) tumors are rare, and there are limited epidemiological data. The current study aimed to determine the survival rates of patients diagnosed with pediatric gliomas in Brazil, accounting for the influence of age, treatment modalities, and tumor site using population-based national database.

MATERIALS/METHODS

Patients diagnosed with pediatric gliomas of CNS from 1999-2020 were identified from The Fundação Oncocentro de São Paulo database. The Kaplan-Meier and the log-rank test were used for survival analysis.

RESULTS

A total of 1296 patients were included. The most common histologic tumor type were glioblastomas (38.27%; n = 496), pilocytic astrocytoma (32.87%; n = 426) and astrocytoma grade II (20.76%; n = 269) A total of 379 (29.24%) had brainstem tumor. The 1-year, 3-year 5-year OS for pilocytic astrocytoma were 93.72%, 89.98%, and 88.97%; for grade II 80,36%, 71,89%, 68,60%; for grade III 53,72%; 31,87%, 28,33%; and for glioblastoma 52,90%, 28,76%, 25,20%, respectively. Brainstem tumors had the worse OS compared to no brainstem tumors (p = 0.001). For high-grade glioma (grade III and IV) excluding brainstem tumors (n = 570), young patients had greater median OS (0 to 3 years: 22 months; 4 to 18 years: 13 months - p = 0.005). Regarding the treatment modalities, combined treatments were associated with higher median survival compared to less intensive therapy (surgery: 11 months; surgery and chemotherapy: 16 months; surgery, radiotherapy, and chemotherapy: 20 months; p = 0.005) CONCLUSION: In our cohort, low-grade gliomas had favorable prognoses and outcomes. Patients diagnosed with glioblastomas and brainstem gliomas had the worst OS. For high-grade gliomas, undergoing treatment de-intensification in the Brazilian pediatric population is associated with worse survival.

Timely Access to Oncological Treatment in Brazil: Analysis of the 60-Law Compliance in a State Database

PURPOSE/OBJECTIVE(S)

In oncology, time from diagnosis to treatment has already been shown to impact outcomes. In 2012, the Brazilian Government issued the 60-day Law, which stated that cancer treatment should start no longer than 60 days after histopathological diagnosis. However, there is scarce information on the effectiveness of the Law in improving timely access to treatment.

MATERIALS/METHODS

We retrospectively evaluate the Fundação Oncocentro de São Paulo (FOSP) database, which collects information on hospitals and oncology departments in the State of São Paulo, Brazil. The primary endpoint was time from diagnosis to first treatment (TDT), and we investigated the influence of medical practice (public health care system - SUS, insurance, private) and year of diagnosis (before and after 2012) on TDT. A sensitivity analysis was performed to evaluate information bias.

RESULTS

The database included 943,660 cancer patients diagnosed between 2000 and 2020. The median age was 62 years (range 0 - 113). The mean TDT was 65.95 days (SD 149.36), and the median time was 32 days (range 0 - 6891). Data was extremely skewed to the left, reflecting the fact that for 30.76% of patients (n = 290,262), the TDT was equal to 0 days. After excluding those patients, the mean TDT was 99.03 days (SD 173.85). Mean TDT was higher after the institution of the Law (63.1 versus 70.2 days, p < 0.001). On univariable analysis, there was a significant difference between mean times between medical practice (p < 0.001), and patients in the public health care system consistently showed longer intervals (82.1 days versus 58.3 and 39.3 for SUS, insurance, and private, respectively). This pattern remained in the sensitivity analysis. Overall, 59.9% of patients began treatment up to 60 days after diagnosis. However, 30.76% of these patients had TDT equal to zero. The proportion of patients with a TDT > 60 days was higher for SUS patients (39.52%). After the Law, the proportion of patients with a TDT > 60 days increased from 28.8% to 37.95%.

CONCLUSION

The approved and instituted 60-day Law did not improve timely access to treatment. Patients in the Public Healthcare System have experienced longer TDT, which could reflect barriers to access to care. The significant proportion of patients with a TDT of 0 days suggests information bias, which means that the actual scenario might be worse. There is an urgent need for public policies to ensure compliance with the Law.

A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia

AIMS

Reports of stereotactic arrhythmia radioablation (STAR) in patients with refractory ventricular tachycardia after catheter ablation are limited to small series. Here, we carried out a systematic review and meta-analysis of studies to better determine the efficacy and toxicity of STAR for ventricular tachycardia.

MATERIALS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines, eligible studies were identified on Medline, Embase, Cochrane Library and the proceedings of annual meetings to 10 February 2023. Efficacy was defined as a ventricular tachycardia burden reduction >70% at 6 months; safety was defined as <10% of any grade ≥3 toxicity.

RESULTS

Seven observational studies with a total of 61 patients treated were included. At 6 months, the ventricular tachycardia burden reduction was 92% (95% confidence interval 85-100%) and use of fewer than two anti-arrhythmic drugs was seen in 85% (95% confidence interval 50-100). Six months after STAR, an 86% reduction (95% confidence interval 80-93) in the number of implantable cardioverter-defibrillator shocks was observed. The rates for improved, unchanged and decreased cardiac ejection fraction were 10%, 84% and 6%, respectively. Overall survival at 6 and 12 months was 89% (95% confidence interval 81-97) and 82% (95% confidence interval 65-98). The cardiac-specific survival at 6 months was 87%. Late grade 3 toxicity occurred in 2% (95% confidence interval 0-5%) with no grade 4-5 toxicity.

CONCLUSION

STAR demonstrated both satisfactory efficacy and safety for the management of refractory ventricular tachycardia and was also associated with a significant decline in anti-arrhythmic drugs consumption. These findings support the continued development of STAR as a treatment option.

Stereotactic radiosurgery for brain metastases from small cell lung cancer without prior whole-brain radiotherapy: A meta-analysis

OBJECTIVES

Assess upfront Stereotactic radiosurgery (SRS) effectiveness for small cell lung cancer (SCLC) brain metastases (BM). Where possible, a comparison with whole-brain radiotherapy (WBRT) was performed.

METHODS

Following PRISMA and MOOSE guidelines, eligible studies were identified on Medline, Embase, Cochrane Library, and proceedings of annual meetings between inception and July 01, 2020.

RESULTS

Nine observational studies with 1638 patients were included. The median overall survival (OS) was 8.3 months (95% CI 7.1-9.5 months, I2 = 0%). OS rate at 12 months was 39% (95% CI 31-44%, I2 = 0%). The relative risk between SRS and WBRT for the OS at 12 months was 1.33 (95% CI 1.13-1.51, P = 0.0001). The projected OS for 6, 12, 18- and 24-months comparing SRS with WBRT was 67% vs. 57%, 39% vs. 29%, 22% vs. 15% and 15% vs 9%, favoring SRS (P < 0.001). The LC rate at 12 months was 93% (95% CI 91-94%, I2 = 0%). The distant brain failure rate (DBFR) at 12 months was 41% (95% CI 33-48%, I2 = 52%, P = 0.08). The SRS or WBRT as salvage treatment after upfront SRS was 32% and 19%, respectively. The freedom from neurologic death at 12 months was 87% (95% CI 84-89%).

CONCLUSION

Based on the pooling of a large sample of retrospective studies our meta-analysis suggests that for high selected SCLC patients with limited BM upfront SRS produces favorable lesion control and survival outcomes. These findings support the design of randomized clinical trial to confirm the role of SRS in this clinical scenario.