EGFR Mutation Testing: Changing Patterns of Molecular Testing in Brazil.

BACKGROUND: In Brazil, cancer is the second most common cause of death. Most patients in resource-limited countries are diagnosed in advanced stages. Current guidelines advocate for EGFR mutation testing in all patients with metastatic adenocarcinoma. Tyrosine kinase inhibitors are recommended in patients with advanced or metastatic disease harboring sensitizing mutations. In Brazil, there are limited data regarding the frequency of EGFR testing and the changes in patterns of testing overtime. MATERIALS AND METHODS: This was an observational, retrospective study. We obtained deidentified data from a commercial database, which included 11,684 patients with non-small cell lung cancer treated between 2011 and 2016 in both public and private settings. We analyzed the frequency of EGFR mutation testing over time. We also directly studied 3,664 tumor samples, which were analyzed between 2011 and 2013. These samples were tested for EGFR mutations through an access program to tyrosine kinase inhibitors in Brazil. RESULTS: Overall, 38% of patients were tested for EGFR mutations; 76% of them were seen in the private sector, and 24% were seen in the public center. The frequency of testing for EGFR mutations increased significantly over time: 13% (287/2,228 patients) in 2011, 34% (738/2,142) in 2012, 39% (822/2,092) in 2013, 44% (866/1,972) in 2014, 53% (1,165/2,184) in 2015, and 42% (1,359/3,226) in 2016. EGFR mutations were detected in 25.5% of analyzed samples (857/3,364). Deletions in Exon 19 were the most frequent mutations, detected in 54% of patients (463/857). CONCLUSION: Our findings suggest that the frequency of EGFR mutation in this cohort was lower than that found in Asia but higher than in North American and Western European populations. The most commonly found mutations were in Exon 19 and Exon 21. Our study shows that fewer than half of patients are being tested and that the disparity is greater in the public sector. IMPLICATIONS FOR PRACTICE: These data not only indicate the shortage of testing but also show that the rates of positivity in those tested seem to be higher than in other cohorts for which data have been published. This study further supports the idea that awareness and access to testing should be improved in order to improve survival rates in lung cancer in Brazil.

Surgery for CNS Tumors in the Brazilian National Health Care System.

PURPOSE: Resource limitations in low- and middle-income countries make the management of CNS tumors challenging, particularly in Brazil, a country with major disparities in socioeconomic status and access to health care. We aimed to evaluate cancer-related neurosurgical procedures in the public health care system. METHODS: On the basis of Brazil's public health system database, we collected data for neurosurgical procedures related to CNS tumors performed between January 2008 and November 2013. Information about the number of procedures, costs, length of stay, and number of inpatient deaths were analyzed for each state and then correlated to the state-specific population, gross domestic product per capita, and number of procedures. RESULTS: In all, 57,361 procedures were performed, the majority of them in the Southeast region. The mean length of hospital stay was 14.4 days, but longer hospital stay was reported for patients treated in the North. The inpatient mortality rate was 7.11%. Mortality rates decreased as the number of procedures (P < .001), gross domestic product per capita (P < .001), or state population increased (P < .001). On multivariate analysis, only the number of procedures (odds ratio, 0.93; 95% CI, 0.91 to 0.96; P < .001) and state population (odds ratio, 1.25; 95% CI, 1.13 to 1.38; P < .001) had an independent association with mortality. CONCLUSION: To the best of our knowledge, this is the first study to evaluate disparities in CNS tumor surgery in a middle-income country, confirming that regional disparities exist and that clinical and economic outcomes correlate with income level, number of procedures, and state population.

Quimioterapia em idosos: tradução do escore de toxicidade de hurria para o português / Chemotherapy in the elderly: translation of Hurria's toxicity score to portuguese

Objetivo: Traduzir e realizar a adaptação transcultural para a Língua Portuguesa do escore de toxicidade de Hurria, instrumento utilizado para avaliação de toxicidade à quimioterapia em idosos. Métodos: Realizada a tradução e adaptação transcultural do escore, seguindo a técnica proposta por Guilemin de tradução/retrotradução. Resultados: A tradução foi realizada por dois brasileiros fluentes em inglês, sendo um médico e um tradutor profissional. Sequencialmente, realizou-se a retrotradução do escore por dois profissionais independentes ao estudo, ligados a um serviço especializado de tradução linguística. Finalmente, um comitê formado por especialistas em Oncologia, Geriatria e Hematologia checou a consistência da tradução/retrotradução, chegando a um modelo final na Língua Portuguesa. Posteriormente, esse modelo sofreu avaliação prática em uma amostra de prontuários de um ambulatório de Oncogeriatria, com versão em português do instrumento atingindo alto grau de confiabilidade pelo teste estatístico de Kappa. Conclusão: A versão final do escore de toxicidade de Hurria em português mostrou-se clara, simples e de rápida aplicação, estando adequada para o uso na prática clínica.

Objective: To describe the translation and transcultural adaptation of Hurria's chemotherapy toxicity score, a prediction tool to estimate chemotherapy toxicity in the elderly. Methods: The original English version of the score was translated to Portuguese using the forward and backward translation technique, as described by Guilemin. Results: The translation was performed by two Brazilians (a physician and a professional translator), both fluent in English. Two professionals from a specialized linguistic service, not related to the study, then carried out the backward translation. Finally, a medical committee composed of oncologists, geriatricians, and hematologists discussed the consistency of the score, choosing a final version of the instrument in Portuguese. This version was piloted-tested in medical charts in an Oncogeriatric service, with high reliability as tested by Kappa statistic test. Conclusion: The final version of Hurria's chemotherapy toxicity score in Portuguese proved to be an easy, clear, and quick tool, suitable for use in clinical practice.

Minimizing the uncertainties regarding the effects of delaying radiotherapy for Glioblastoma: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Previous studies have provided no clear conclusions regarding the effects of delaying radiotherapy (RT) in GBM patients. We present a systematic review and meta-analysis to address the effect of delayed RT on the overall survival (OS) of GBM patients. METHODS: A systematic search retrieved 19 retrospective studies published between 1975 and 2014 reporting on the waiting time (WT) to RT for GBM patients. The meta-analysis was performed by converting WT to RT studies intervals into a regression coefficient (ß) and standard error expressing the effect size on OS per week of delay. RESULTS: Data required to calculate the effect size on OS per week of delay were available for 12 studies (5212 patients). A non-adjusted model and a meta-regression model based on well-recognized prognostic factors were performed. No association between WT to RT, per week of delay, and OS was found (HR=0.98; 95% CI 0.90-1.08; p=0.70). The meta-regression adjusted for prognostic factors weighted by the inverse-variance (1/SE(2)) showed no clear evidence of the effect of WT to RT, per week of delay, on OS. CONCLUSIONS: This meta-analysis, despite limitations, provided no evidence of a true effect on OS by delaying RT in GBM patients.

Clinical features and overall survival among elderly cancer patients in a tertiary cancer center.

OBJECTIVE: To evaluate the epidemiological profile and overall survival of a large population of elderly individuals diagnosed with solid tumors in a tertiary hospital. METHODS: This retrospective study included patients aged >65 years, diagnosed with solid tumors between January 2007 and December 2011, at Hospital Israelita Albert Einstein, São Paulo, Brazil. The medical records were reviewed to obtain information about clinical variables and overall survival. RESULTS: A total of 806 patients were identified, and 58.4% were male. Mean age was 74 years (65 to 99 years). The most common types were prostate (22%), colorectal (21%), breast (19%), and lung cancer (13%), followed by bladder (8%), pancreas (6%), and other types (11%). The majority of patients were diagnosed at early stage disease. After a median follow-up of 27 months (15 to 45 months), 29% of the patients (234/806) died, predominantly in the group older than 70 years. For the entire cohort, the median 2-year survival rate was 71%. Median overall survival was not reached within the study period. In a multivariate analysis, age (HR: 1.35; 95%CI: 1.25-1.45; p<0.001) and disease stage (HR: 1.93; 95%CI: 1.75-2.14; p<0.001) were independent negative predictors of poor survival. CONCLUSION: The most prevalent tumors were prostate, colorectal, breast, and lung cancer, with the larger proportion diagnosed at initial stages, reflecting the great number of patients alive at last follow-up.

Clinical features and overall survival among elderly cancer patients in a tertiary cancer center / Características clínicas e de sobrevida global em pacientes oncológicos idosos num centro oncológico terciário

ABSTRACT Objective To evaluate the epidemiological profile and overall survival of a large population of elderly individuals diagnosed with solid tumors in a tertiary hospital. Methods This retrospective study included patients aged >65 years, diagnosed with solid tumors between January 2007 and December 2011, at Hospital Israelita Albert Einstein, São Paulo, Brazil. The medical records were reviewed to obtain information about clinical variables and overall survival. Results A total of 806 patients were identified, and 58.4% were male. Mean age was 74 years (65 to 99 years). The most common types were prostate (22%), colorectal (21%), breast (19%), and lung cancer (13%), followed by bladder (8%), pancreas (6%), and other types (11%). The majority of patients were diagnosed at early stage disease. After a median follow-up of 27 months (15 to 45 months), 29% of the patients (234/806) died, predominantly in the group older than 70 years. For the entire cohort, the median 2-year survival rate was 71%. Median overall survival was not reached within the study period. In a multivariate analysis, age (HR: 1.35; 95%CI: 1.25-1.45; p<0.001) and disease stage (HR: 1.93; 95%CI: 1.75-2.14; p<0.001) were independent negative predictors of poor survival. Conclusion The most prevalent tumors were prostate, colorectal, breast, and lung cancer, with the larger proportion diagnosed at initial stages, reflecting the great number of patients alive at last follow-up.

RESUMO Objetivo Avaliar o perfil epidemiológico e a sobrevida global em uma grande população de indivíduos idosos diagnosticados com tumores sólidos, em um hospital terciário. Métodos Estudo retrospectivo que incluiu pacientes com idade >65 anos, diagnosticados com tumores sólidos entre janeiro de 2007 e dezembro de 2011, no Hospital Israelita Albert Einstein, São Paulo, Brasil. Os prontuários médicos foram revisados para se obterem informações sobre variáveis clínicas e sobrevida global. Resultados Foi identificado um total de 806 pacientes, sendo 58,4% deles do sexo masculino. A média de idade foi de 74 anos (65 a 99 anos). Os tipos mais comuns de câncer foram de próstata (22%), colorretal (21%), de mama (19%) e de pulmão (13%), seguidos pelos de bexiga (8%), pâncreas (6%) e outros tipos (11%). A maioria dos pacientes foi diagnosticada em estágios iniciais. Depois de um seguimento médio de 27 meses (15 a 45 meses), 29% (234/806) estavam mortos, predominantemente no grupo com idade >70 anos. Para toda a coorte, a mediana de taxa de sobrevida em 2 anos foi 71%. A mediana de sobrevida global não foi alcançada dentro do período de estudo. Em análise multivariada, idade (HR: 1,35; IC95%: 1,25-1,45; p<0,001) e estadiamento (HR: 1,93; IC95%: 1,75-2,14; p<0,001) foram preditores negativos independentes de pior sobrevida. Conclusão Os tumores mais prevalentes foram de próstata, colorretal, mama e pulmão, com uma grande proporção diagnosticada em estádios iniciais, o que reflete em um grande número de pacientes vivos até o último seguimento.

Waiting time to radiotherapy as a prognostic factor for glioblastoma patients in a scenario of medical disparities.

OBJECTIVE: To evaluate the effect of waiting time (WT) to radiotherapy (RT) on overall survival (OS) of glioblastoma (GBM) patients as a reliable prognostic variable in Brazil, a scenario of medical disparities. METHOD: Retrospective study of 115 GBM patients from two different health-care institutions (one public and one private) in Brazil who underwent post-operative RT. RESULTS: Median WT to RT was 6 weeks (range, 1.3-17.6). The median OS for WT ≤ 6 weeks was 13.5 months (95%CI , 9.1-17.9) and for WT > 6 weeks was 14.2 months (95%CI, 11.2-17.2) (HR 1.165, 95%CI 0.770-1.762; p = 0.470). In the multivariate analysis, the variables associated with survival were KPS (p < 0.001), extent of resection (p = 0.009) and the adjuvant treatment (p = 0.001). The KPS interacted with WT to RT (HR 0.128, 95%CI 0.034-0.476; p = 0.002), showing that the benefit of KPS on OS depends on the WT to RT. CONCLUSION: No prognostic impact of WT to RT could be detected on the OS. Although there are no data to ensure that delays to RT are tolerable, we may reassure patients that the time-length to initiate treatment does not seem to influence the control of the disease, particularly in face of other prognostic factors.

Waiting time to radiotherapy as a prognostic factor for glioblastoma patients in a scenario of medical disparities / Tempo de espera para a radioterapia como um fator prognóstico em pacientes com glioblastoma em um cenário de disparidades médicas

Objective To evaluate the effect of waiting time (WT) to radiotherapy (RT) on overall survival (OS) of glioblastoma (GBM) patients as a reliable prognostic variable in Brazil, a scenario of medical disparities. Method Retrospective study of 115 GBM patients from two different health-care institutions (one public and one private) in Brazil who underwent post-operative RT. Results Median WT to RT was 6 weeks (range, 1.3-17.6). The median OS for WT ≤ 6 weeks was 13.5 months (95%CI , 9.1-17.9) and for WT > 6 weeks was 14.2 months (95%CI, 11.2-17.2) (HR 1.165, 95%CI 0.770-1.762; p = 0.470). In the multivariate analysis, the variables associated with survival were KPS (p < 0.001), extent of resection (p = 0.009) and the adjuvant treatment (p = 0.001). The KPS interacted with WT to RT (HR 0.128, 95%CI 0.034-0.476; p = 0.002), showing that the benefit of KPS on OS depends on the WT to RT. Conclusion No prognostic impact of WT to RT could be detected on the OS. Although there are no data to ensure that delays to RT are tolerable, we may reassure patients that the time-length to initiate treatment does not seem to influence the control of the disease, particularly in face of other prognostic factors. .

Objetivo Avaliar o efeito do tempo de espera (TE) até radioterapia na sobrevida global de pacientes com glioblastoma como um fator prognóstico confiável. Método Estudo retrospectivo de 115 pacientes com glioblastoma, que foram submetidos à radioterapia pós-operatória, em dois serviços diferentes no Brasil (um público e outro privado). Resultados Mediana de TE para radioterapia foi de 6 semanas (variação, 1,3-17,6). A mediana de sobrevida para TE ≤ 6 semanas foi de 13,5 meses (IC95%, 9,1-17,9) e para TE > 6 semanas foi de 14,2 meses (IC95%, 11,2-17,2) (HR 1,165, 0,770-1,762; p = 0,470). Na análise multivariada, as variáveis associadas à sobrevida foram perfomance status (p < 0,001), extensão da ressecção (p = 0,009) e tratamento adjuvante (p = 0,001). Conclusão Não se observou impacto prognóstico para TE até a radioterapia na sobrevida. Diante de outros fatores prognósticos, é possível assegurar de que o espaço de tempo até a radioterapia não parece influenciar o controle da doença. .

Prevalence of renal insufficiency in elderly cancer patients in a tertiary cancer center.

OBJECTIVE: To estimate the prevalence of abnormal glomerular filtration rate in elderly patients with solid tumors. METHODS: A retrospective study with patients aged >65 years diagnosed with solid tumors between January 2007 and December 2011 in a cancer center. The following data were collected: sex, age, serum creatinine at the time of diagnosis and type of tumor. Renal function was calculated using abbreviated Modification of Diet in Renal Disease (MDRD) formulae and then staged in accordance with the clinical practice guidelines published by the Working Group of the National Kidney Foundation. RESULTS: A total of 666 patients were included and 60% were male. The median age was 74.2 years (range: 65 to 99 years). The most prevalent diagnosis in the study population were colorectal (24%), prostate (20%), breast (16%) and lung cancer (16%). The prevalence of elevated serum creatinine (>1.0mg/dL) was 30%. However, when patients were assessed using abbreviated MDRD formulae, 66% had abnormal renal function, stratified as follows: 45% with stage 2, 18% with stage 3, 3% with stage 4 and 0.3% with stage 5. CONCLUSION: To the best of our knowledge, this was the first study to estimate the frequency of renal insufficiency in elderly cancer patients in Brazil. The prevalence of abnormal renal function among our cohort was high. As suspected, the absolute creatinine level does underestimate renal function impairment and should not be used as predictor of chemotherapy metabolism, excretion and consequent toxicity.

Prevalence of renal insufficiency in elderly cancer patients in a tertiary cancer center / Prevalência de insuficiência renal em pacientes idosos com câncer em um centro de tratamento oncológico

Objective To estimate the prevalence of abnormal glomerular filtration rate in elderly patients with solid tumors. Methods A retrospective study with patients aged >65 years diagnosed with solid tumors between January 2007 and December 2011 in a cancer center. The following data were collected: sex, age, serum creatinine at the time of diagnosis and type of tumor. Renal function was calculated using abbreviated Modification of Diet in Renal Disease (MDRD) formulae and then staged in accordance with the clinical practice guidelines published by the Working Group of the National Kidney Foundation. Results A total of 666 patients were included and 60% were male. The median age was 74.2 years (range: 65 to 99 years). The most prevalent diagnosis in the study population were colorectal (24%), prostate (20%), breast (16%) and lung cancer (16%). The prevalence of elevated serum creatinine (>1.0mg/dL) was 30%. However, when patients were assessed using abbreviated MDRD formulae, 66% had abnormal renal function, stratified as follows: 45% with stage 2, 18% with stage 3, 3% with stage 4 and 0.3% with stage 5. Conclusion To the best of our knowledge, this was the first study to estimate the frequency of renal insufficiency in elderly cancer patients in Brazil. The prevalence of abnormal renal function among our cohort was high. As suspected, the absolute creatinine level does underestimate renal function impairment and should not be used as predictor of chemotherapy metabolism, excretion and consequent toxicity. .

Objetivo Estimar a prevalência de taxa de filtração glomerular alterada em pacientes idosos diagnosticados com tumores sólidos. Métodos Estudo retrospectivo de pacientes com mais de 65 anos de idade, diagnosticados com tumores sólidos entre janeiro de 2007 e dezembro de 2011 em um centro de tratamento oncológico. Foram coletados dados sobre sexo, idade, creatinina sérica à época do diagnóstico e tipo de tumor. A função renal foi calculada utilizando a versão simplificada da equação MDRD (Modification of Diet in Renal Disease) e depois estratificada de acordo com as diretrizes de prática clínica do Working Group of the National Kidney Foundation. Resultados Foram incluídos 666 pacientes, sendo 60% do sexo masculino. A idade mediana foi 74,2 anos (variação de 65 a 99 anos), e os diagnósticos mais prevalentes na população do estudo foram câncer colorretal (24%), de próstata (20%), mama (16%) e pulmão (16%). A prevalência de creatinina sérica elevada (>1,0mg/dL) foi 30%. No entanto, quando os pacientes foram avaliados utilizando a forma abreviada da equação MDRD, 66% tinham uma função renal anormal assim estratificada: 45% em estádio 2, 18% em estádio 3, 3% em estádio 4 e 0,3% em estádio 5. Conclusão Até onde sabemos, este foi o primeiro estudo a estimar a frequência de insuficiência renal em pacientes idosos com câncer no Brasil. A prevalência de função renal alterada na coorte estudada foi alta. Como suspeitávamos, o nível absoluto de creatinina subestima a alteração na função renal e não deve ser usado como preditor de metabolismo, excreção e consequente toxicidade dos agentes quimioterápicos. .

Initial care and outcome of glioblastoma multiforme patients in 2 diverse health care scenarios in Brazil: does public versus private health care matter?.

BACKGROUND: The aim of this study was to describe the epidemiological and survival features of patients with glioblastoma multiforme treated in 2 health care scenarios--public and private--in Brazil. METHODS: We retrospectively analyzed clinical, treatment, and outcome characteristics of glioblastoma multiforme patients from 2003 to 2011 at 2 institutions. RESULTS: The median age of the 171 patients (117 public and 54 private) was 59.3 years (range, 18-84). The median survival for patients treated in private institutions was 17.4 months (95% confidence interval, 11.1-23.7) compared with 7.1 months (95% confidence interval, 3.8-10.4) for patients treated in public institutions (P < .001). The time from the first symptom to surgery was longer in the public setting (median of 64 days for the public hospital and 31 days for the private institution; P = .003). The patients at the private hospital received radiotherapy concurrent with chemotherapy in 59.3% of cases; at the public hospital, only 21.4% (P < .001). Despite these differences, the institution of treatment was not found to be an independent predictor of outcome (hazard ratio, 1.675; 95% confidence interval, 0.951-2.949; P = .074). The Karnofsky performance status and any additional treatment after surgery were predictors of survival. A hazard ratio of 0.010 (95% confidence interval, 0.003-0.033; P < .001) was observed for gross total tumor resection followed by radiotherapy concurrent with chemotherapy. CONCLUSIONS: Despite obvious disparities between the hospitals, the medical assistance scenario was not an independent predictor of survival. However, survival was directly influenced by additional treatment after surgery. Therefore, increasing access to resources in developing countries like Brazil is critical.

Treatment of breast cancer patients from a public healthcare system in a private center: costs of care for a pilot public-private partnership in oncology.

OBJECTIVE: To describe the flow and costs associated with the diagnosis and treatment of patients with breast cancer who come from the public healthcare system and were treated at Hospital Israelita Albert Einstein. METHODS: Between August 2009, and December 2011, 51 patients referred by the Unified Public Healthcare System (SUS) had access to Hospital Israelita Albert Einstein for diagnostic radiology, medical oncology, radiotherapy, and oncologic/breast reconstruction surgery. The data were collected retrospectively from the hospital records, patient charts, pharmacy records, and from the hospital billing system. RESULTS: The total sum spent for diagnosis and treatment of these 51 patients was US$ 1,457,500.00. This value encompassed expenses with a total of 85 hospitalizations, 2,875 outpatient visits, 16 emergency room visits, and all expenses associated with these stays at the hospital. The expenditure for treatment of each patient submitted to biopsy, breast conserving surgery, adjuvant chemotherapy without trastuzumab (a regime with taxane followed by anthracycline), radiotherapy, and 5 years of tamoxifen was approximately US$ 25,500.00. CONCLUSION: Strategies for cost-reduction of treatment in the private setting are necessary to enable future large-scale public-private partnerships in oncology.

Treatment of breast cancer patients from a public healthcare system in a private center: costs of care for a pilot public-private partnership in oncology / Pacientes com câncer de mama oriundas do Sistema Único de Saúde tratadas no setor privado: custos de um piloto de parceria público-privada em oncologia

OBJECTIVE: To describe the flow and costs associated with the diagnosis and treatment of patients with breast cancer who come from the public healthcare system and were treated at Hospital Israelita Albert Einstein. METHODS: Between August 2009, and December 2011, 51 patients referred by the Unified Public Healthcare System (SUS) had access to Hospital Israelita Albert Einstein for diagnostic radiology, medical oncology, radiotherapy, and oncologic/breast reconstruction surgery. The data were collected retrospectively from the hospital records, patient charts, pharmacy records, and from the hospital billing system. RESULTS: The total sum spent for diagnosis and treatment of these 51 patients was US$ 1,457,500.00. This value encompassed expenses with a total of 85 hospitalizations, 2,875 outpatient visits, 16 emergency room visits, and all expenses associated with these stays at the hospital. The expenditure for treatment of each patient submitted to biopsy, breast conserving surgery, adjuvant chemotherapy without trastuzumab (a regime with taxane followed by anthracycline), radiotherapy, and 5 years of tamoxifen was approximately US$ 25,500.00. CONCLUSION: Strategies for cost-reduction of treatment in the private setting are necessary to enable future large-scale public-private partnerships in oncology.

OBJETIVO: Descrever os fluxos e os custos associados ao diagnóstico e tratamento de pacientes com câncer de mama provenientes do Sistema Único de Saúde e tratadas no Hospital Israelita Albert Einstein. MÉTODOS: Entre agosto de 2009 e dezembro de 2011, 51 pacientes do Sistema Único de Saúde tiveram acesso à estrutura do Hospital Israelita Albert Einstein para os serviços de radiologia, oncologia, radioterapia e cirurgia oncológica/reconstrutora de mama. Os dados foram coletados retrospectivamente, a partir do registro hospitalar de câncer, prontuários, registros de farmácia e do sistema de cobrança do hospital. RESULTADOS: O valor total gasto para o diagnóstico e tratamento dessas 51 pacientes foi de R$ 2.915.000,00. Esse valor compreendeu os gastos com um total de 85 internações, 2.875 atendimentos ambulatoriais, 16 atendimentos no pronto atendimento e todos os custos associados a essas passagens pelo hospital. O valor gasto para o tratamento de cada paciente submetida à biópsia, setorectomia, quimioterapia adjuvante sem trastuzumabe (esquema com taxano seguido de antraciclina), radioterapia e 5 anos de tamoxifeno, foi de, aproximadamente, R$ 51.000,00 CONCLUSÃO: Estratégias de redução do custo do tratamento na rede privada seriam necessárias para permitir futuras parcerias público-privadas em grande escala, em oncologia.

Treatment of a frail older patient with diffuse large B-cell lymphoma on maintenance dialysis: attenuated immunochemotherapy and adapted care plan.

PURPOSE OF THE STUDY: Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy worldwide. Its incidence increases with age and about 40% of cases occur in patients over 70 years. Herein, we describe a case of a frail elderly patient with renal insufficiency and DLBCL treated with R-mini-CHOP. CASE REPORT: A 77-year-old man on maintenance hemodialysis started experiencing persistent fatigue. He was diagnosed with a large mass on the left lobe of the lung. Biopsy demonstrated a DLBCL, CD20 positive. The patient was assigned clinical stage IIBX, with a high age-adjusted international prognosis index. A proper geriatric assessment revealed a frail patient. Thus, an adapted chemotherapy regimen was proposed which consisted of R-mini-CHOP every 21 days, with a reduction of 10% in the doses of doxorubicin and cyclophosphamide. During the treatment, the patient went through regular dialysis sessions, 3 times per week, with an extra session performed 12 h after each chemotherapy administration. The patient experienced no adverse events or grade 3/4 toxicities. After 6 cycles of R-mini-CHOP, the patient achieved unconfirmed complete remission, and consolidation radiotherapy was performed. At the last follow-up, he was still in unconfirmed complete remission, with a progression-free survival of 11.3 months. CONCLUSIONS: R-mini-CHOP represented a reasonable treatment option for this patient with renal failure. The oncogeriatric approach led to a successful management of this frail patient, highlighting that an adapted plan of care is a key issue to improve the outcomes of elderly cancer patients.

Patterns of care and outcomes in elderly patients with glioblastoma in Sao Paulo, Brazil: a retrospective study.

OBJECTIVE: To analyze how elderly patients with glioblastoma are managed in Brazil. MATERIAL AND METHODS: We identified 30 patients aged ≥ 65 years treated between 2003 and 2011 at Albert Einstein Hospital in Sao Paulo. We retrospectively reviewed medical records to obtain data on clinical variables, treatment and outcomes. Overall survival (OS) was evaluated using Kaplan-Meier methods and compared using a Wilcoxon log-rank test. RESULTS: The median age was 73 years. The majority of patients (73.2%) underwent surgical intervention. Following surgery, 80% received radiotherapy (RT), and of those, 79.2% were treated with concurrent temozolomide (TMZ). The median progression free survival and OS were 5 and 10.6 months, respectively. Patients with a KPS ≥ 70 had a median OS of 16.2 months, compared to 6.4 months for those with a KPS <70 (p=0.032). For those patients in whom biopsy only was performed, the median OS was 5.3 months, as compared to 7.8 months for those who underwent partial resection and 18.6 months for those treated with gross total resection (p=0.021). A longer survival was found among patients who received RT versus those who did not (11 months vs. 1 month, p=0.003), as well as for those treated with chemoradiation (13.6 months vs. 6.4 months, p<0.0001). CONCLUSIONS: This study brings new information about the management of elderly patients with glioblastoma in Brazil. Our data may suggest that elderly patients who undergo cytoreductive surgery and adjuvant RT with concurrent TMZ can do better than those with less aggressive treatment.

Glioblastoma: approach to treat elderly patients / Glioblastoma: enfoque no tratamento de pacientes idosos

Treating elderly cancer patients is a challenge for oncologists, especially considering the several therapeutic modalities in glioblastoma. Extensive tumor resection offers the best chance of local control. Adequate radiotherapy should always be given to elderly patients if they have undergone gross total resection and have maintained a good performance status. Rather than being ruled out, chemotherapy should be considered, and temozolomide is the chosen drug. A comprehensive geriatric assessment is a valuable tool to help guiding treatment decisions in elderly patients with glioblastoma.

O tratamento de idosos com câncer é um desafio para a prática oncológica, especialmente no que se refere à terapêutica multimodal do glioblastoma. Nessa população, a ressecção ampla do tumor oferece a melhor chance de controle local e, naqueles pacientes que mantenham um bom performance status, a radioterapia complementar deve sempre ser levada em consideração. A quimioterapia também tem um papel no tratamento, sendo a temozolomida a droga de eleição. Frente à heterogeneidade desses pacientes, uma avaliação geriátrica ampla é um instrumento valioso no auxílio da decisão terapêutica em idosos com glioblastoma.

Glioblastoma: approach to treat elderly patients.

Treating elderly cancer patients is a challenge for oncologists, especially considering the several therapeutic modalities in glioblastoma. Extensive tumor resection offers the best chance of local control. Adequate radiotherapy should always be given to elderly patients if they have undergone gross total resection and have maintained a good performance status. Rather than being ruled out, chemotherapy should be considered, and temozolomide is the chosen drug. A comprehensive geriatric assessment is a valuable tool to help guiding treatment decisions in elderly patients with glioblastoma.

Perfil clínico e laboratorial da Leishmaniose visceral aguda: relato de dois casos / Clinical and laboratorial profile of the acute american visceeral leishmaniasis: tho cases report

Introdução: A leishmaniose visceral americana (LVA) representa, atualmente, uma das principais endemias de natureza parasitária no Estado do Pará. Entretanto, a sua prevalência real tem sido subestimada face à dificuldade de identificação da forma aguda da doença, devido á sintomatologicamente pouco específica. Objetivo: Relatar as caracteristicas clínicas e laboratoriais de dois casos de LVA aguda atendidos no ambulatório do Programa de Leishmanioses do Instituto Evandro Chagas (FUNASA), em Belém, Pará, em agosto de 2002

Auto-exame das mamas: freqüência do conhecimento, prática e fatores associados / Breast self-examination: frequency of knowledge, practice and associated factors

OBJETIVO: estudar a freqüência do conhecimento e prática do auto-exame de mamas (AEM), caracterizando alguns fatores que influenciam sua prática. MÉTODO: durante um mês, foram entrevistadas 505 mulheres atendidas no Centro de Saúde Escola - Marco (CSE-Marco) e no anexo Unidade Materno-Infantil por meio de questionário referente ao conhecimento e prática do AEM e possíveis fatores associados. Verificou-se a correlaçäo entre as variáveis através do teste de chi2. RESULTADOS: das mulheres entrevistadas, 96,0 por cento conheciam o AEM. Dentre essas, 58,9 por cento conheceram-no pela imprensa. Contudo, o meio que proporcionou prática mais correta foi a orientaçäo médica (37,5 por cento). Apenas 21,8 por cento das mulheres realizavam o exame mensalmente. O principal motivo da näo-realizaçäo foi o desconhecimento da técnica (48,2 por cento). Mulheres entre 30 e 39 anos (30,2 por cento) apresentaram maior prática mensal do exame e 58,2 por cento das que o realizavam corretamente tinham pelo menos ensino médio incompleto. Em 58,7 por cento dos casos, o ginecologista näo incentiva a prática do AEM. CONCLUSÄO: o AEM é conhecido por praticamente todas as entrevistadas, embora mais de um terço destas näo o realize, principalmente por desconhecimento da técnica. O meio de comunicaçäo que levou a orientaçäo mais eficiente foi a orientaçäo médica, contudo, esta atingiu reduzido número de pacientes. Houve interferência do grau de escolaridade e faixa etária na prática do AEM, näo intervindo a presença de casos de câncer na família

Tratamento da hanseníase em uma unidade básica de saúde / Hansen's disease treatment at a basic health center

Introdução: A eliminação da hanseníase na Região Norte está prevista para longo prazo, após 2005, sendo a taxa de prevalência da doença na região igual ou maior a 10 casos para cada 10.000 habitantes. Objetivo: Analisar os resultados do tratamento de hanseníase na Unidade Básica de Saúde da Sacramenta (UBS-Sacramenta) de janeiro de 2000 a julho de 2001. Método: Análise descritiva dos prontuários de 65 pacientes matriculados no programa de tratamento de hanseníase da UBS-Sacramenta, realizado no consultório de doenças transmissíveis, de janeiro de 2000 a julho de 2001. Os dados foram coletados através da aplicação de protocolo sobre os prontuários e análise do livro da ata. Resultados: A maioria dos pacientes (86 por cento) resisia na própria Sacramenta e apena 9 por cento repetia o tratamento. Observou-se 68 por cento de assiduidade e, em 37 por cento de casos, os familiares recebiam a medicação. Durante o tratamento, 52 por cento dos pacientes não relataram queixas quanto ao seu estado geral. Houve apenas 2 por cento de abandonos, obtendo-se 44 por cento de altas. Persitiram lesões em 62 por cento dos pacientes que receberam alta. Considerações Finais: O esquema polioquimioterápico de tratamento está sendo bem conduzido na UBS-Sacramenta, e suas poucas deficiências resultam tanto da falta de estrutura da Unidade quanto da indisciplina dos pacientes