Liver Cancer in Guatemala: An Analysis of Mortality and Incidence Trends From 2012 to 2016

PURPOSE Guatemala has the highest mortality and incidence of liver cancer in Central and South America. The aim of this study is to describe the extent of liver cancer in the country from 2012 to 2016 and the associated risk factors. METHODS A secondary analysis was performed using liver cancer mortality and morbidity data and data on risk factors, such as hepatitis B virus infection, cirrhosis, and alcoholism. RESULTS Analysis revealed that liver cancer causes approximately 20% of cancer deaths in the country, is more frequent in the population older than age 65 years old, and is increasing in those age 30 to 44 years. More than 25% of deaths occurred in the North and West regions. The incidence of major risk factors for development of liver cancer has decreased. CONCLUSION The high mortality of liver cancer compared with its incidence indicates that most patients are diagnosed at late stages. To reduce the burden of liver cancer, creation of strategies for earlier detection is needed.

Treatment Compliance as a Major Barrier to Optimal Cervical Cancer Treatment in Guatemala

PURPOSE Despite being the only hospital to provide comprehensive cervical cancer treatment to many medically underserved Guatemalan women, no assessment of the cervical cancer patient population at the Guatemala Cancer Institute has been performed. To understand the demographics of the patient population, their treatment outcomes, and access to care, we sought to assess treatment compliance of patients with cervical cancer at the Guatemala Cancer Institute and its effects on patient outcomes. METHODS A retrospective chart review was conducted of patients with cervical cancer between 2005 and 2007 and assessed for follow-up through December 2015. Demographics and clinical characteristics were tabulated. A Kaplan-Meier curve to model compliance was generated. RESULTS Ninety-two patients with invasive cancer were analyzed. Most presented with squamous cell carcinoma (73%) and at locally advanced stages (IIB, 51%; IIIB, 33%). Most (75 of 92, 81.5%) initiated treatment after diagnosis, but 18.5% (17 of 92) were lost to follow-up before treatment initiation. For treatment, 97% received external beam radiation, 84% brachytherapy, and 4% concomitant chemotherapy. Nearly 20% of patients were lost to follow-up in the first 6 months and 65% in the first 5 years. Of the 67 patients who completed treatment, only 15 (16% of the initial cohort) were diagnosed with a recurrence. No deaths were recorded. CONCLUSION The low recurrence rate and no documented deaths suggest a correlation with the low compliance rate and poor follow-up. This finding highlights the need to examine more fully the barriers to compliance and access to care among this population to optimize the treatment of cervical cancer.

Mutational Profile of Driver Genes in Brazilian Melanomas

PURPOSE Mutation testing of the key genes involved in melanoma oncogenesis is now mandatory for the application of targeted therapeutics. However, knowledge of the mutational profile of melanoma remains largely unknown in Brazil. PATIENTS AND METHODS In this study, we assessed the mutation status of melanoma driver genes BRAF, NRAS, TERT, KIT, and PDGFRA in a cohort of 459 patients attended at Barretos Cancer Hospital between 2001 and 2012. We used polymerase chain reaction followed by Sanger sequencing to analyze the hot spot mutations of BRAF exon 15 (V600E), NRAS (codons 12/13 and 61), TERT (promoter region), KIT (exons 9, 11, 13, and 17), and PDGFRA (exons 12, 14, and 18) in tumors. The mutational profile was investigated for associations with demographic, histopathologic, and clinical features of the disease. RESULTS The nodular subtype was most frequent (38.9%) followed by the superficial spreading subtype (34.4%). The most frequent tumor location was in the limbs (50.0%). The mutation rates were 34.3% for TERT and 34.1% for BRAF followed by NRAS (7.9%), KIT (6.2%), and PDGFRA (2.9%). The BRAF ( P = .014) and TERT ( P = .006) mutations were associated with younger patients and with different anatomic locations, particularly in the trunk, for the superficial spreading and nodular subtypes, respectively ( P = .0001 for both). PDGFRA mutations were associated with black skin color ( P = .023) and TERT promoter mutations with an absence of ulceration ( P = .037) and lower levels of lactate dehydrogenase. There was no association between patient survival rates and mutational status. CONCLUSION The similar mutational profile we observe in melanomas in Brazil compared with other populations will help to guide precision medicine in this country.

Fully Automatic Treatment Planning for External-Beam Radiation Therapy of Locally Advanced Cervical Cancer: A Tool for Low-Resource Clinics

Purpose The purpose of this study was to validate a fully automatic treatment planning system for conventional radiotherapy of cervical cancer. This system was developed to mitigate staff shortages in low-resource clinics. Methods In collaboration with hospitals in South Africa and the United States, we have developed the Radiation Planning Assistant (RPA), which includes algorithms for automating every step of planning: delineating the body contour, detecting the marked isocenter, designing the treatment-beam apertures, and optimizing the beam weights to minimize dose heterogeneity. First, we validated the RPA retrospectively on 150 planning computed tomography (CT) scans. We then tested it remotely on 14 planning CT scans at two South African hospitals. Finally, automatically planned treatment beams were clinically deployed at our institution. Results The automatically and manually delineated body contours agreed well (median mean surface distance, 0.6 mm; range, 0.4 to 1.9 mm). The automatically and manually detected marked isocenters agreed well (mean difference, 1.1 mm; range, 0.1 to 2.9 mm). In validating the automatically designed beam apertures, two physicians, one from our institution and one from a South African partner institution, rated 91% and 88% of plans acceptable for treatment, respectively. The use of automatically optimized beam weights reduced the maximum dose significantly (median, −1.9%; P < .001). Of the 14 plans from South Africa, 100% were rated clinically acceptable. Automatically planned treatment beams have been used for 24 patients with cervical cancer by physicians at our institution, with edits as needed, and its use is ongoing. Conclusion We found that fully automatic treatment planning is effective for cervical cancer radiotherapy and may provide a reliable option for low-resource clinics. Prospective studies are ongoing in the United States and are planned with partner clinics.

Time Intervals From Onset of Clinical Manifestations to Treatment in Patients With Cancer at Hospital General San Felipe, Tegucigalpa, Honduras

PURPOSE In cancer, clinical staging is related to outcomes, and this is linked to the evolution of the disease over time. In Honduras, cancer mortality is high, and time intervals from onset of symptoms to treatment of cancer are not known. We conducted a cross-sectional study to determine these intervals. PATIENTS AND METHODS This investigation was carried out from April 25 to August 30, 2018, and included 202 patients at the main cancer referral center in Honduras. For the purposes of the study, information was obtained from patients, their caregiver, medical records, or treatment cards. Patients older than age 18 years were included after informed consent was signed. RESULTS The mean time interval from onset of symptoms to cancer treatment was 232 days. Different intervals of time were identified, and the mean of these intervals was calculated in days as follows: 68 days from onset of symptoms to first medical evaluation; 146 days from first evaluation to oncologist consultation; 26 days from cancer specialist to the pathology report; and 86 days from the histopathologic diagnosis to the beginning of treatment. Once diagnosis was established, the average elapsed times to chemotherapy, radiotherapy, surgery, and chemoradiotherapy were 88, 102, 76, and 154 days, respectively ( P < .05, when surgery is compared against chemotherapy and radiotherapy). CONCLUSION The mean time interval from symptom presentation to treatment in patients with cancer is more than 7 months. This could explain the advanced stages of disease seen at the time of treatment in Honduras, which decrease chance of cure and increase the mortality rate of cancer). Appropriate intervention to decrease these intervals must be taken to reduce mortality.

Journey of the Patient With Melanoma: Understanding Resource Use and Bridging the Gap Between Dermatologist, Surgeon, and Oncologist in Different Health Care Systems

PURPOSE New scientific evidence has led to modifications in the clinical practice of handling melanoma. In health care systems, there is currently a wide variety of clinical procedures to treat cancer, and the various routes have different effects on the survival of patients with cancer. Thus, this article aimed to evaluate the journey of patients with melanoma in the public and private health care systems in Brazil from the viewpoint of different medical professionals involved in the diagnosis and treatment of the disease. The study also considers the resources used for the complete delivery cycle of health care at different stages of the evolution of melanoma. METHODS We conducted a behavioral study by applying a questionnaire to a group of medical professionals. A nonprobabilistic sampling method for convenience was used, justified by the heterogeneous national incidence and the limited availability of medical professionals who diagnose and treat melanoma. RESULTS The questionnaire was answered by 138 doctors, including doctors from the Brazilian states with the highest concentration of medical specialists and regions with a higher melanoma incidence. The results of this study have the potential to enrich our understanding of the reality of Brazilian health care systems and, at the same time, allow us to discuss the multiple ways in which professionals from diverse specialist fields understand and explain decision making in health care. CONCLUSION Health care decision making is complex and, among other factors, depends on the diversity of available health resources and the knowledge of which treatments provide the greatest benefit to patients and greatest value to the system as a whole. This work can inform debates and reflection that are applicable not only in Brazil, but also in various other countries with similar realities.

Standardization of Education of Patients With Cancer in a Low- and Middle-Income Country: A Quality Improvement Project Using the Cancer and You Booklet

PURPOSE The Butaro Cancer Centre of Excellence is the first comprehensive referral cancer center in Rwanda and at its inception did not have a standardized patient education program. Partners in Health/Inshuti Mu Buzima and the Rwandan Ministry of Health conducted a quality improvement project to increase patient knowledge by implementing a standardized oncology education program using picture-based and culturally appropriate materials designed for patients with cancer in low- and middle-income countries. METHODS Four Rwandan nurses were trained to provide patient education using the Cancer and You education booklet created by Global Oncology. A pre- and post-test design was used to evaluate patients’ knowledge of cancer, treatment, and management of adverse effects. Nurses administered a posteducation questionnaire in Kinyarwanda to determine patients’ level of satisfaction with the education session and booklet. The four nurses were interviewed at the completion of the project for their feedback. A total of 40 oncology patients were included in the pilot project, of which 85% reported completing primary school or less. RESULTS On average, participants improved 19% (95% CI, 13.9% to 24.1%; standard deviation, 16%) from pre- to postevaluation, demonstrating a significant increase in knowledge ( P ≤ .001). Nearly all patients (97.5%) reported that they were either satisfied or very satisfied with the education program. Oncology nurses gave positive feedback, highlighting that it was helpful to have a standard tool for education with descriptive illustrations for those patients with low literacy. CONCLUSION Implementation of a standardized patient education program demonstrated a statistically significant increase in patient knowledge and a high level of satisfaction among patients and nurses. The project serves as an example for other low- and middle-income countries looking to standardize oncology patient education.

Scientific Productivity and Cancer-Related Mortality: A Case Study of a Positive Association in Colombia

PURPOSE Cancer morbidity represents an increasing public health issue; this worldwide phenomenon also is true for emerging upper-middle-income countries, such as Colombia. The main purpose of this study was to uncover the relationship between scientific productivity and cancer-related mortality in our setting. METHODS We conducted a temporal-trend ecologic study by means of bibliometric analysis from records of publications from SCOPUS database with Colombian institutional affiliations between 2000 and 2015. Productivity and overall mortality were estimated and compared using econometric modeling to identify potential correlations. Additional exploratory analyses per six most frequent cancer sites were performed. RESULTS Of 2,645 publication records retrieved, 1,464 (55.3%) met selection criteria to be classified as Colombian scientific production (interobserver agreement, 92.96%; κ = 0.859; 95% CI, 0.800 to 0.918). Overall, 79.6% of the records corresponded to original or in-press articles; furthermore, almost half (49.7%) embodied descriptive study designs. Selected records reported a median of five authors and three different affiliations per publication; 66% had been cited at least once up to September 2017. The most-studied cancer-specific locations were cervix (16.1%), breast (11.5%), and stomach (9.8%), but nonspecific locations had the largest combined participation (23.4%). An increasing trend in scientific productivity was correlated to decreasing trend in overall cancer mortality, which was reported as an inverse proportional relationship in the linear regression modeling ( r = −0.958; P < .001). Graphic analyses per cancer-specific sites revealed heterogeneous behaviors of this relationship. CONCLUSION Colombian cancer-specific scientific productivity demonstrated a steady growth as opposed to a decreasing mortality trend in the recent years. The research output is predominantly descriptive with relatively low interinstitutional partnership and low impact in the international scientific community.