The evolution of therapy for advanced or metastatic renal cell carcinoma (RCC) progressed over the past decade from using cytokine immunotherapy to targeted therapy which predominantly inhibits ...angiogenesis via the vascular endothelial growth factor (VEGF) and mammalian target of rapamycin (mTOR) pathways. Currently, there are several approved agents in the first-line (e.g. sunitinib, pazopanib, ipilimumab/nivolumab, bevacizumab/IFN-α combination and temsirolimus) and second-line settings (e.g. everolimus, axitinib, sorafenib, cabozantinib, nivolumab and lenvatinib/everolimus combination). These agents are used in sequence upon progression due to drug resistance or intolerable toxicities. The European Association of Urology (EAU), European Society for Medical Oncology (ESMO) and National Comprehensive Cancer Network (NCCN) guidelines recommend the use of these agents based on evidence from clinical trials and expert committee consensus. The recent approval of immune checkpoint inhibitors due to the encouraging results from clinical trials has expanded the treatment options for patients with advanced or metastatic RCC. This will hopefully improve the treatment outcomes, reduce toxicities and ameliorate quality of life for these patients.
Objective
The Asia Pacific Advanced Prostate Cancer Consensus Conference (APAC APCCC 2018) brought together 20 experts from 15 APAC countries to discuss the real‐world application of consensus ...statements from the second APCCC held in St Gallen in 2017 (APCCC 2017).
Findings
Differences in genetics, environment, lifestyle, diet and culture are all likely to influence the management of advanced prostate cancer in the APAC region when compared with the rest of the world. When considering the strong APCCC 2017 recommendation for the use of upfront docetaxel in metastatic castration‐naïve prostate cancer, the panel noted possible increased toxicity in Asian men receiving docetaxel, which would affect this recommendation in the APAC region. Although androgen receptor‐targeting agents appear to be well tolerated in Asian men with metastatic castration‐resistant prostate cancer, access to these drugs is very limited for financial reasons across the region. The meeting highlighted that cost and access to contemporary treatments and technologies are key factors influencing therapeutic decision‐making in the APAC region. Whilst lower cost/older treatments and technologies may be an option, issues of culture and patient or physician preference mean, these may not always be acceptable. Although generic products can reduce cost in some countries, costs may still be prohibitive for lower‐income patients or communities. The panellists noted the opportunity for a coordinated approach across the APAC region to address issues of access and cost. Developments in technologies and treatments are presenting new opportunities for the diagnosis and treatment of advanced prostate cancer. Differences in genetics and epidemiology affect the side‐effect profiles of some drugs and influence prescribing.
Conclusions
As the field continues to evolve, collaboration across the APAC region will be important to facilitate relevant research and collection and appraisal of data relevant to APAC populations. In the meantime, the APAC APCCC 2018 meeting highlighted the critical importance of a multidisciplinary team‐based approach to treatment planning and care, delivery of best‐practice care by clinicians with appropriate expertise, and the importance of patient information and support for informed patient choice.
Quality of life (QOL) of family caregivers of cancer patients is usually affected due to increase in caregiver burden. Their QOL has not garnered much attention by many including the health ...professionals and community. This study aims to explore the QOL of family caregivers of cancer patients in a multi-ethnic country in Asia and to investigate its associate factors.
This is a cross-sectional study where family caregivers and patients who were diagnosed of cancers within 12 months were recruited. QOL of caregivers were measured using The Caregiver Quality of Life Index-Cancer (CQOLC). Psychological distress was measured using Hospital anxiety and depressive scale. Logistic regression analysis was performed to determine the related factors of QOL of caregivers.
A total of 458 patients/caregiver pairs were included. Symptoms of anxiety and depression reported by caregivers were 24.9% and 24.2% respectively. Caregivers of patients with solid tumors have better CQOLC score compared to those who cared for patients with hematological cancers (91.25 vs 86.75). Caregivers of non-Malay ethnicity, those caring for patients with advanced stage cancer and with hematological cancers had significantly poorer QOL. QOL of caregivers are also significantly affected when patients demonstrated anxiety symptoms.
This study provides detailed evaluation of the QOL of caregivers of cancer patients in Malaysia. The significant psychological distress and low caregiver QOL indicate the urgent need for comprehensive supports for caregivers with cancer patients, especially those caring for patients with haematological cancers.
Transperineal ultrasound (TPUS) is an image-guided radiotherapy system used for tracking intrafraction prostate displacements in real time. The objectives of this study are to evaluate intrafraction ...prostate displacements and derive planning target volume (PTV) margins for prostate radiotherapy at our institution. The ultrasound (US) data of nine prostate cancer patients referred for VMAT radiotherapy was retrieved. Prior to beam on, patient position was set up with the US probe positioned transperineally with the aid of reference images (fused US and computed tomography images). In each fraction, prostate displacements in three directions superior/inferior (SI), left/right (LR) and anterior/posterior (AP) were recorded. PTV margins were determined using Van Herk's formula. To assess the prostate displacement time trend, continuous displacement data were plotted in 30-s intervals for eight minutes. The intrafraction prostate monitoring found a population mean setup error (M
) of 0.8, 0.1, - 1.7 mm, a systematic error of (∑
) 0.7, 0.4, 0.9 mm and random error (σ
) of 0.2, 0.1, 0.3 mm in SI, LR and AP directions, respectively. The PTV margin was found to be the largest in the AP direction at 2.5 mm compared with 1.9 mm and 1.1 mm for SI and LR directions, respectively. The PTV margin allowed for prostate radiotherapy at our institution was 2.5 mm in all directions. The prostate displacement time trend showed an increase in intrafraction displacements, with most patients were observed to have strong positive correlation between time and intrafraction prostate displacements in SI direction. TPUS is feasible for monitoring intrafraction displacement of the prostate and may facilitate PTV margin generation to account for such displacements during radiotherapy.
Background
There is a paucity of data on the use of intraoperative radiotherapy (IORT) with low-energy X-rays in Malaysian women with early breast cancer. The aim of this study is to evaluate the ...clinical, cosmetic, and patient-reported outcomes in low- and high-risk early breast cancer patients treated with breast conserving surgery (BCS) and IORT.
Methodology
Patients suitable for BCS who were treated with IORT between January 2016 and June 2019 from three centres were analysed. They were divided into low-risk and high-risk groups based on the risk of recurrence according to the TARGeted Intraoperative radioTherapy (TARGIT) A and B study criteria. Outcomes of interest included local recurrence, wound complications, and radiation toxicity, with a subset analysed for cosmetic and patient-reported outcomes.
Results
Within a median follow-up of 31 months, there were 104 and 211 patients in the low- and high-risk groups, respectively. No significant difference was observed in local recurrence rates (low-risk, 1.0% vs. high-risk, 1.4%;
p
= 1.000). Both cohorts exhibited low frequencies of severe wound complications ranging between 1.4 and 1.9%. No major radiation toxicities were reported in either group. In the subgroup analysis, low-risk patients had significantly better mean scores in the subscales of inframammary fold and scar. Based on the BREAST-Q patient-reported outcomes questionnaire, seven out of nine parameters were scored similarly between both groups with no significant difference.
Conclusion
This study showed that the use of IORT in both low- and high-risk early breast cancers is efficacious and safe with low recurrence rates and an acceptable toxicity profile.
Introduction
This study was conducted to compare pain response between single and multiple fraction palliative radiotherapy and to describe prognostic factors affecting treatment response in ...University of Malaya Medical Centre (UMMC).
Methods
The case records of 162 patients with uncomplicated painful bone metastases treated with palliative radiotherapy from 2006 to 2014 were analyzed. Treatment outcomes were pain score response, analgesic score response, response according to International Consensus Endpoints (complete response and overall response) at 4, 12, and 24 weeks, retreatment rate, symptomatic skeletal events (SSEs), and prognostic factors.
Results
At 24 weeks, pain score response for single and multiple fraction group was 82.3% and 88.5%, analgesic score response was 54.8% and 61.5%, and overall response according to International Consensus Endpoint was 61.3% and 67.7%, respectively. There was no statistically significant difference in treatment response between the 2 treatment groups for all endpoints. ECOG (<2 vs ≥2: aOR 3.405, 95% CI 1.708‐6.790, P = .001) and primary breast and prostate (breast vs others: aOR 5.231, 95% CI 1.973‐13.869, P = .001; prostate vs others: aOR 5.522, 95% CI 1.493‐20.420, P = .01) were significant variables on multivariate analysis.
Conclusion
Single fraction radiotherapy is as effective as multiple fraction radiotherapy for the palliation of uncomplicated bone metastases.
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.
Background:
Financial toxicity is the outcome of the objective financial burden and subjective financial distress experienced by patients receiving cancer treatment.
Objective:
To validate the ...English and Malay versions of the COmprehensive Score for financial Toxicity (COST) questionnaire in a multiethnic setting with a pluralistic healthcare system.
Intervention/methods:
A cross-sectional study was conducted on 720 adults with cancer from public and private hospitals across Malaysia. Reliability was estimated using Cronbach’s α for internal consistency. Construct validity was assessed by exploratory factor analysis. Criterion validity was tested using the European Organization for Research and Treatment of Cancer’s Quality of Life Questionnaire.
Results:
Overall, 362 respondents answered the English language questionnaire and 358 answered the Malay version. Both versions achieved high reliability (Cronbach’s α: .91 and 0.96, respectively). Exploratory factor analysis via the parallel analysis method identified a single factor solution with eigenvalues of 6.244 and 6.544, explaining 56.80% and 59.50% of variances, respectively. Low positive correlations and strong negative correlations were observed with global health status and financial difficulty, respectively. Subgroup analyses indicated that both versions performed well across diverse patient groups.
Conclusion:
The English and Malay versions of COST are psychometrically robust in measuring financial toxicity in multiethnic settings with pluralistic health systems and across diverse subgroups of cancer patients with varying clinical characteristics.
Implications for Practice:
The COST tool should be useful in accurately identifying patients with cancer who experience financial toxicity in Malaysian settings and potentially other similar settings.
What is Foundational:
Early identification of patients experiencing financial toxicity using validated tools in oncology practice would enable timely intervention.
Purpose
This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation‐induced skin toxicity.
...Methodology
A total of 21 breast cancer patients who underwent breast‐conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid‐term skin toxicities were evaluated at 3 and 6 months post‐IORT.
Results
The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post‐IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post‐IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose.
Conclusion
EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient‐specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.
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