JCO Global Oncology最新文献

Purpose: Breast cancer is the most common cancer in women in Brazil. Despite universal coverage through the Unified Health System (Sistema Único de Saúde [SUS]), major inequities in access, timely diagnosis, and treatment persist when compared with the private sector. We assessed 5-year overall survival (OS) according to health care coverage to provide robust real-world evidence of survival inequities.

Methods: This retrospective cohort study included 63,663 women with invasive breast cancer diagnosed between 2012 and 2019 using the largest South American hospital-based cancer registry (Registro Hospitalar de Câncer da Fundação Oncocentro de São Paulo). Survival probabilities were estimated using the Kaplan-Meier method, and differences across groups were tested with log-rank statistics. Cox proportional hazards models were applied to assess the association between health care coverage and mortality, adjusting for demographic, clinical, and treatment variables.

Results: Patients in the public system (83%) were older, had lower educational attainment, were more often diagnosed with advanced-stage disease (41% v 21.0%), and were less likely to receive minimal standard treatment (75% v 81%). The 5-year OS rate was 66.2% in the SUS group and 79.7% in the private care group. After adjustment, patients with SUS faced a 53% higher risk of death (hazard ratio, 1.53 [95% CI, 1.44 to 1.63]).

Conclusion: Universal health coverage does not guarantee equitable outcomes. Disparities in the stage at diagnosis, treatment access, and social determinants translate into marked survival inequities. Our findings highlight the urgent need for system-level reforms and targeted investments in oncology capacity in Brazil and across the low- and middle-income countries.

Purpose: Building equitable research collaborations between high-income countries (HICs) and low- and middle-income countries (LMICs) requires effective coordination among international ethical review committees, which is often logistically challenging. This case report presents the insights gained when acquiring ethical approval for a cervical cancer research program conducted jointly by the University of Pennsylvania and the University of Botswana.

Methods: We conducted a descriptive case study of the Ipabalele project, a 6-year HIC-LMIC partnership involving three complex research protocols that required approvals by multiple distinct ethical bodies. We analyzed various challenges affecting review procedures, timelines, and staffing. We then documented strategies employed in Ipabalele and other global initiatives to strengthen ethical review processes and build research capacity in LMICs.

Results: In Ipabalele, ethical approvals were initially delayed by 2 years because of fragmented review processes with variable timelines and conflicting recommendations. Innovations to the process included centralizing institutional review board oversight within Botswana, implementing joint virtual meetings among review bodies, enhancing digital infrastructure, and streamlining research staffing and communication.

Conclusion: By providing practical strategies, this study highlights how empowered local leadership, centralized review processes, joint review mechanisms, and intentional capacity building can overcome logistical barriers in multinational ethical review.

Purpose: We studied the prevalence of somatic mutations in EGFR, KRAS, BRAF, and NRAS among Brazilian patients with early-stage non-small cell lung cancer (NSCLC). We also explored the association between these mutations and clinicopathologic characteristics.

Methods: We screened 557 patients diagnosed with NSCLC who underwent EGFR, KRAS, BRAF, and NRAS gene sequencing by next-generation sequencing (NGS) or RT-PCR (EGFR only) between 2021 and 2023. We analyzed the frequency of mutations in these genes and their association with clinical characteristics among 399 patients with early-stage nonsquamous NSCLC.

Results: Among 399 patients with early-stage nonsquamous NSCLC included in the analysis, we identified mutations in 218 (54.6%), totaling 224. The median age was 67 years, and most were female (58.9%). The most frequently mutated genes were EGFR and KRAS. Actionable genomic alterations were found in 137 cases, representing 34.3% of the entire cohort and 62.8% of patients with mutations. In cases with actionable mutations identified by NGS, EGFR mutations accounted for 68.0%, followed by KRAS (27.3%) and BRAF (4.7%). We found a significant association between histologic subtype and grade, as well as between tumor T stage and histologic subtype. A higher frequency of EGFR mutations was observed among females. We noted an association between mutated EGFR and the lepidic subtype, mutated KRAS and the mucinous/colloid subtype, and between the nonmutated genotype and the solid/micropapillary subtype.

Conclusion: This study provides an overview of the genomic landscape of early-stage nonsquamous NSCLC in Brazilian patients. The high prevalence of mutations observed in our cohort underscores the importance of genomic testing in this setting, enabling selection of patients suitable for targeted approved therapies or clinical trials.

Purpose: Breast cancer (BC) is a significant health challenge in Nigeria, exacerbated by early onset, advanced-stage diagnosis, and high prevalence of triple-negative tumors. Access to genetic testing and counseling is scarce, with minimal capacity for hereditary cancer services. Despite these barriers, there is strong interest in expanding care to include genetic testing and improve understanding of familial risk. The purpose of this study was to develop and assess the effectiveness of a BC genetics education program for Nigerian health care providers (HCPs).

Methods: A multidisciplinary international team developed a four-module hybrid education program combining asynchronous online learning and an in-person didactic session. Invitations were circulated to HCPs in tertiary hospitals across Nigeria. Knowledge improvement was assessed using standardized pre- and postmodule tests.

Results: Thirty-one physicians and nurses participated. All online modules had significant knowledge improvement, with the largest score increases in BRCA1/2 genetic counseling (mean change, 1.9 [95% CI, 1.3 to 2.5]; P < .001) and BRCA1/2 clinical management (mean change, 1.6 [95% CI, 1.2 to 2.1]; P < .001). The subsequent in-person workshop had additional, albeit smaller, module increases. Aggregated analysis showed a 23.0% increase in knowledge after the online training (P < .001), with a further 10.1% gain after the in-person workshop (P = .007). Overall knowledge improved from 45.0% at baseline to 87.0% post-training, representing a 43.0% absolute gain (P < .001).

Conclusion: This hybrid training program significantly improved provider knowledge of hereditary BC genetics in Nigeria and offers a scalable, culturally tailored model for expanding BC genetic services in low-resource settings. While promising, the modest sample size and limited follow-up warrant further evaluation and broader rollout to confirm long-term effectiveness.

Purpose: The International Agency for Research on Cancer and St Jude Children's Research Hospital established Targeting Childhood Cancer through the Global Initiative for Cancer Registry Development, a collaboration to accelerate change in childhood cancer registration in selected countries. We summarize the overall situation of the first 5-year implementation period highlighting key commonalities and challenges encountered.

Methods: Following the Global Initiative for Cancer Registry Development model, Georgia, Mexico, South Africa, and Vietnam were selected as implementation sites. We established a team per country, assessed the general and childhood cancer registration situation, and implemented targeted support via online meetings and site visits. Multimodal situational assessments were organized in four domains: Context, Governance, Procedures, and Dissemination. Key challenges were identified in each domain and mapped to critical attributes for evaluating surveillance systems.

Results: The scope, modalities, and coverage of cancer registration across countries vary in important ways; only South Africa has a specific childhood cancer registry. Not all registries in the four countries included nonmalignant tumors of the CNS, reported cancers using the childhood cancer-specific system International Childhood Cancer Classification third edition, or reported any survival information. Common challenges identified in all four countries included irregular financial support, instability in personnel, and difficulties in access and data sharing; none had an advisory committee. These challenges affect sustainability and data quality.

Conclusion: Partnerships are valuable to accelerate change but take time to consolidate before impact is observed. Childhood cancer surveillance needs definitive support as a key component of the WHO Global Initiative for Childhood Cancer.

Purpose: One crucial use of telemedicine that is underreported is its role in providing health services in conflict-affected zones. The aim of this report is to describe the process and challenges of implementing a telemedicine-based radiation oncology (RO) clinic in a war zone in southern Lebanon, and to assess its effectiveness in providing care to patients with cancer residing in this unsafe, resource-limited area.

Methods: After the outbreak of the Lebanese-Israeli war in October 2023, we had to shift our RO clinic in Nabatieh Governmental Hospital to an exclusively remote clinic without on-site physicians. Consultations, treatment planning, and follow-ups were conducted virtually by physicians at the American University of Beirut Medical Center. Patient data and imaging were shared electronically between both hospitals, and treatment was administered locally by trained staff.

Results: From October 2023 to September 2024, 669 new patient consultations were completed remotely. Despite infrastructure limitations, including lack of electronic health records and occasional connectivity issues, we developed a model to ensure care continuity was largely maintained for the local patients with cancer.

Conclusion: Telemedicine can serve as a tool for delivering cancer care in times of war, improving access and equity for underprivileged groups in the face of severe logistical and infrastructural challenges.

Purpose: Risk/treatment stratification for children with neuroblastoma (NB) relies on clinical, histologic, and genomic factors. However, most children with cancer live in low- and middle-income countries (LMIC), where access to advanced methods for stratification is limited. To address this unmet need, we developed a novel risk/treatment classification, the Adaptive Clinical Neuroblastoma Risk Groups (ACNRG) using clinical prognostic biomarkers.

Patients and methods: A survival tree regression analysis of the International Neuroblastoma Risk Group (INRG) Data Commons (N = 14,501, diagnosed 1990-2014) was performed using univariate Cox regression models (age, International Neuroblastoma Staging System, serum lactate dehydrogenase [LDH], and serum ferritin) of event-free survival (EFS), separately for test and validation sets. Within each terminal node of the survival tree, the proportion of patients by initial treatment assignment and outcome achieved on that treatment were used to subjectively assign risk/treatment intensity (low-, intermediate-, and high-risk). For additional validation, the ACNRG was descriptively compared with INRG classification. Guidelines were developed for determining INRGs Staging System (INRGSS) in LMIC, using the minimum essential versus optimal imaging/biopsy procedures.

Results: Twelve statistically, clinically significant unique pretreatment risk groups of INRGSS/age/LDH/ferritin were identified (5-year EFS): low-L1/any/any/any (92% ± 0.5%); intermediate-L2/<18 months/<1,400/any (88% ± 1%), MS/any/<1,400/any (86% ± 1.5%), M/<12 months/<1,400/any (76% ± 2.3%); intermediate/high-L2/<18 months/≥1,400/any (73% ± 4.7%), L2/≥18 months/<1,400/<30 (68% ± 3.4%), L2/≥18 months/<1,400/≥30 (59% ± 3.7%), MS/any/≥1,400/any (52% ± 6.3%); high-L2/≥18 months/≥1,400/any (46% ± 4.7%), M/12-18 months/<1,400/any (64% ± 4.1%), M/<18 months/≥1,400/any (60% ± 1.6%), M/≥18 months/any/any (28% ± 0.8%). The concordance and discordance rates of ACNRG versus INRG were 86.6% and 13.4%, respectively (n = 8,152 nonmissing-data intersection).

Conclusion: The ACNRG classification, using easily obtained clinical markers, is highly prognostic. The ACNRG could transform risk and treatment stratification, improve accuracy of treatment intensity decisions, and potentially improve outcome, for the large number of children with NB in LMIC. Prospective validation of the ACNRG classification is planned in a pilot trial.