Referral Process Enhancement: Innovative Approaches and Best Practices.

OBJECTIVE: This study aimed to enhance the efficiency of the referral system at the Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC) in Muscat, Oman by reducing the average time for new patients' acceptance and the delay between patient acceptance and their first appointment. METHODS: A one-group pretest-posttest quasi-experimental project was conducted from Quarter 2 of 2022 to Quarter 2 of 2023. Data collected during the pretest and posttest phases were compared to evaluate the impact of interventions on the average days for patient acceptance and the time to first appointment after acceptance. The intervention involved developing a comprehensive referral system incorporating technology development, improved accessibility, orientation materials, internal training, policy formulation, criteria definition, and tailoring acceptance criteria to specialty programs. Awareness campaigns were also conducted to educate patients about the referral process and available transportation options. The project followed the FOCUS PDCA (Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act) approach for implementation. RESULT: Significant improvements were observed in the oncology referral process, with the average days for patient acceptance decreasing from 4.3 days to 1.3 days post-implementation. Statistical analysis confirmed the significance of this change (F-value = 46.25, p < .0001). Similarly, the average days to first visit appointment after acceptance decreased from 8.6 days to 4.0 days, with statistical support (F-value = 6.29, p < .0). CONCLUSION: This study represents a significant advancement in optimizing the oncology referral process. When considered in conjunction with previous research findings, it underscores the importance of ongoing efforts to enhance efficiency in patient referrals.

Improving Care Continuity in Oncology Settings: A Lean Management Approach to Minimize Discharges Without Follow-Up Appointments.

OBJECTIVE: This study aimed to reduce the number of patients discharged without scheduled follow-up appointments by implementing lean management principles. METHODS: Conducted at the Sultan Qaboos Comprehensive Cancer Center in Muscat, Oman, the research utilized a one-group pretest-posttest quasi-experimental design to evaluate the impact of lean management interventions on the rate of patient discharges without follow-up appointments. Strategies such as the Kaizen principle, Gemba Walks, cross-functional collaboration, standard work procedures, and waste reduction were employed to enhance operational efficiency. RESULTS: Spanning from Quarter 3 of 2022 to Quarter 2 of 2023, the study demonstrated a significant decrease in the percentage of patients discharged without planned follow-up appointments. The rate dropped from 9% in September 2022 to 0% in March 2023, with statistically significant differences observed (X2= 65.05, p value=<.0001). CONCLUSION: By effectively implementing lean management principles, this research successfully enhanced care continuity for oncology patients after being discharged.

Reducing the Risk of Fall among Oncology Patients using Failure Modes and Effects Analysis.

OBJECTIVE: This project aimed to mitigate the risk of falls among oncology patients using Failure Modes and Effects Analysis (FMEA) in the outpatient setting.



Methods: The project was conducted within outpatient settings, specifically encompassing outpatient clinics, daycare, radiology and radiotherapy, and rehabilitation at the SQCCCRC. The project employed an observational analytical design to assess the fall risk assessment procedure in outpatient settings. The project integrated a 7-step procedure for conducting an FMEA methodology, including defining the system or process, identifying potential failure mode, evaluating the effects of each failure mode, Assigning severity, likelihood, and detection of occurrence ratings, and identifying and implement corrective actions. In addition, Risk Priority Numbers (RPNs) were used to identify the impact of the interventions in reducing the risk of patient fall assessment and management.



Result: In the patient fall screening process, interventions yielded substantial reductions in RPNs for failure modes like "Wrong assessment" (57% decrease) and "Complex risk assessment scale" (63% decrease), addressing knowledge gaps and simplifying risk assessment. Similarly, the "Missed fall assessment" failure mode saw an impressive 80% reduction in RPN, rectifying unclear processes and knowledge gaps. In the Fall risk precaution measures process, interventions led to noteworthy RPN reductions, such as 80% for "Unclear fall precaution measures-responsibilities" and 57% for "Missed bracelets for high risk," demonstrating successful risk mitigation. Moreover, interventions in the Patient Education process achieved significant RPN reductions (57% and 55%) for "No/improper education" and "Unuse of educational material and resources," enhancing staff education and patient awareness. The total reduction in RPNs was 62% in all failure modes in the fall assessment and management process.



Conclusion: Overall, FMEA is a valuable strategy for reducing fall risks among oncology patients, but its success depends on addressing these limitations and ensuring the thorough execution and maintenance of the identified corrective actions.

Relative dose intensity of taxane-based chemotherapy in breast cancer patients in a tertiary hospital.

INTRODUCTION: Breast cancer (BC) is the most diagnosed tumor among women worldwide. The aim of this study was to investigate the incidence and causes of low relative dose intensity (RDI) < 85% for taxane-based chemotherapy regimens used in the treatment of BC in Sultan Qaboos University Hospital (SQUH). METHODS: This was a retrospective study that included 303 BC patients, treated with taxane-based chemotherapy protocols at SQUH. RDI was calculated for each chemotherapy regimen and causes and predictors of low RDI < 85% were identified. Prophylactic and therapeutic supportive measures for certain toxicities were studied. RESULTS: 50.8% of the patients had neoadjuvant chemotherapy, 38% had adjuvant chemotherapy, and 11.2% of patients were given palliative treatment. AC-T and AC-THP were the most used regimens (40.3% and 17.2%). Mean RDI of used taxane-based chemotherapy regimens was 93.4%. Dose delays, dose reductions, and treatment discontinuation occurred in 36.6%, 14.8%, and 11.5%, respectively. Thirty-eight patients (12.5%) had low RDI < 85% which was reduced to 9.9% after the use of an alternative taxane. Age and chemotherapy intent were significant risk factors. 83.8% received primary granulocyte colony stimulating factor. CONCLUSION: An optimal RDI greater than 85% was achieved in most cases. Furthermore, prophylactic and therapeutic supportive measures were widely used.

A case report on letrozole-related maculopathy.

Letrozole is an oral aromatase inhibitor used in the treatment of hormone receptor-positive breast cancers in postmenopausal women. It acts by inhibiting the conversion of androgens to estrogen thereby lowering the estrogen synthesis in the body. We report a case of bilateral cystoid macular edema (CME) in a postmenopausal woman on letrozole for breast cancer. A 62-year-old female presented with painless gradually progressive bilateral diminution of vision for the past 6 months. Her previous ocular history is unremarkable. Her medical history is known for carcinoma of the breast for which she underwent chemotherapy followed by mastectomy, adjuvant hormonal therapy, and radiotherapy. The patient had been on letrozole for the past 4½ years. At presentation, the best corrected visual acuity in the right eye was 0.4 and 0.5 in the left eye. Fundus examination revealed significant bilateral CME. Optical coherence tomography and fundus fluorescein angiography confirmed the diagnosis. After discussing the possibility of letrozole-related maculopathy with the treating oncologist, letrozole was discontinued and the patient was reassessed. Reduction of macular edema and mild visual improvement was observed when letrozole was subsequently stopped. Although ocular side effects are rare with letrozole, a comprehensive ophthalmic evaluation is recommended for patients who present with visual disturbances for prompt intervention.

Predictors of Hypersensitivity Reactions to Platinum-Based Chemotherapy in a Tertiary Care Hospital in Oman: A case control study.

Objectives: This study aimed to estimate the prevalence and evaluate risk factors of hypersensitivity reactions (HSRs) to platinum-based compounds (PBCs) in cancer patients. PBCs play an important role in cancer therapy. However, one of the drawbacks of PBCs is the occasional occurrence of HSRs, which can lead to serious consequences. Methods: This retrospective case control study was conducted from January 2013 to December 2020 at Sultan Qaboos University Hospital, Muscat, Oman and included patients who received any PBC for the management of non-haematological cancers. Data regarding demographic characteristics and diseases and treatment details were collected from the hospital's electronic database. The data were quantitatively described and Student's t-test and Wilcoxon Mann-Whitney tests were used to detect significant differences. Results: A total of 38 cases and 148 matched controls were studied. The prevalence of HSRs to PBCs in the cohort of this study was 4.7% (95% confidence interval: 3.33-6.37%), higher with carboplatin compared with cisplatin and oxaliplatin. The female gender (P = 0.032), concomitant taxanes (P = 0.002) and concurrent radiation (P <0.001) were significant predictors of HSRs to PBCs. The majority of the reactions were of mild to moderate severity, and the rechallenge rate after HSR development was 13%. Conclusion: HSRs to PBCs impact therapy decisions and understanding the risk factors is important to improve treatment outcomes in cancer patients.

Beliefs and Perceptions About Cancer Diagnosis and Treatment-Seeking and Decision-Making Behaviors Among Omani Patients with Cancer: A Single-Center Study.

A cancer diagnosis is associated with anxiety and psychological distress. Cultural and societal factors greatly affect the complex process of coping mechanisms and decision making. Omani patients receiving cancer treatment at Sultan Qaboos University Hospital in Oman were interviewed about their perceptions regarding cancer, treatment, outcome, and decision making. Out of a total of 360 approached, 216 patients consented. The median age was 42 years. The results showed that 60.6% of patients considered cancer diagnosis as a test from God, 13.9% considered it as a result of an evil eye, 40% believed prayers treat cancer. Fifty-six percent of participants wanted to make treatment decisions themselves, while 2.3% preferred their family to make decisions. Our findings suggest that perceptions about cancer in Oman are specific and are associated with religion and sociocultural background.

Needs for Cancer Education In Oman Based on the Breast Cancer Screening Program.

Most breast cancers in Oman are diagnosed at advanced stages and therefore early detection is important. The Oman Cancer Association (OCA) initiated a mobile mammography program in 2009, but no studies have evaluated its impact. This study aimed at estimating the proportion and predictors of OCA-screened women who had repeated mammography (adherence) and the sensitivity and specificity of the program. Demographic, screening, diagnosis, and treatment data of 13,079 women screened in the OCA mammography clinic from 2009 to 2016, and medical records of all breast cancer patients seen at Royal and Sultan Qaboos University hospitals during the same period were retrieved. Logistic regression analysis was conducted to identify predictors of adherence. A total of 8278 screened women over age 42 years (median age of 50 ± 8 years) were included in the study. Only 18% of initially negative screened women were compliant with recommended subsequent screening. Predictors of adherence included age (50-69 years), family history of cancer, family history of breast cancer, and breast self-examination. The overall cancer detection rate was 4.1/1000 screened women. Positive predictive value of screening was 4.7% with a sensitivity rate of 53% and specificity of 92%. This study showed a low mammography adherence among previously screened women. The study revealed low sensitivity, high specificity, and an acceptable cancer detection rate. Future programs should focus on improving data collection of screened women, maintaining the linkage of databases of screening and treatment clinics, and developing guidelines for breast cancer screening in Oman. The recommendations based on the study results should be incorporated into future professional, patient, and public cancer education programs.

Correlation of expression of Akt1 and E2F1 and their phosphorylated forms in breast cancer patients with clinicopathological parameters.

Breast cancer is the leading cancer worldwide among women. Traditional clinicopathological prognostic and predictive markers need refining to improve clinical outcomes. This study explored the association between traditional clinicopathological factors and the expression of Akt1 and E2F1 transduction proteins and their phosphorylated forms in breast cancer, to determine their value as novel biomarkers and potential therapeutic targets. Tumor tissues from 94 female breast cancer patients were examined for immunophenotypic expression of total Akt1, pAkt1 (Serine 473), pAkt1 (Threonine 308), total E2F1, pE2F1 (Thr433) and pE2F1 (Ser337). The expression of pAkt1 (Ser473) was significantly associated with ER/PR positive status and total E2F1 with older age (> 50), lymph node involvement and HER2 positivity. There was a significant association between triple negative cancers and total and pAkt1 (Thr308). pAkt1 (Ser473) showed an inverse relationship with Luminal B cancers and pE2F1 (Thr433) showed an inverse association with triple negative cancers. Higher expression of pE2F1 (Ser337) was associated with better OS. Both pAkt1 (Ser473 and Thr308) proteins showed significant association with poorer patient outcomes. E2F1 (Ser337) showed a significant positive correlation with response to chemotherapy. The study suggests that a pAkt1-/pE2F1+ phenotype could indicate an opportunity to minimize chemotherapeutic options in older women; conversely a pAkt1+/pE2F1- phenotype could prompt a more aggressive regimen. Further exploration of this phenotype in younger women with breast cancer and triple-negative breast cancers is warranted.

Complications and Management of Totally Implantable Central Venous Access Ports in Cancer Patients at a University Hospital in Oman.

OBJECTIVES: Totally implantable central venous access ports (port-a-caths) are increasingly used for the safe administration of chemotherapy; however, their use is associated with complications. This study reviews patterns of complications, reasons for premature removal and the duration of the use of port-a-caths in patients receiving cancer treatment at Sultan Qaboos University Hospital (SQUH) and compares the infection rate with the literature and the researchers' experiences. METHODS: This retrospective follow-up study included patients who had received cancer treatment through a port-a-cath and were admitted to SQUH between January 2007 and April 2019. Demographic features, underlying diagnosis, clinical stage, treatment, duration of use and the cause of premature removal of the port-a-cath were recorded. RESULTS: A total of 516 port-a-caths were inserted in 482 cancer patients. The majority of devices were implanted by interventional radiologists (n = 459; 89.0%) and the right internal jugular vein was most frequently accessed (n = 396; 76.7%). The mean indwelling time of a port-a-cath was 288 days (range: 3-1,872 days) for patients with complications and 550 days (range: 7-3,123 days) for patients without complications. Port-a-cath-related infection was the main complication (n = 63; 12.2%). Patient age, gender, treatment intent, underlying diagnosis, clinical stage, chemotherapy regimen, number of treatment courses, operator implanting the port, the type of micro-organism isolated from the port-a-cath and body mass index were significant factors affecting catheter indwelling time (P <0.05). On multivariate analysis, however, none of the factors was found to be significant. CONCLUSION: Infection was the most common complication necessitating port-a-cath removal. The infection rate was much lower than the researchers' previous experience and compares favorably with several published reports.

Knowledge of symptoms, time to presentation and barriers to medical help-seeking among Omani women diagnosed with breast cancer: a cross-sectional study.

OBJECTIVE: To identify knowledge of breast cancer (BC) symptoms, time taken to consult a doctor and factors contributing to delays in medical help-seeking. DESIGN: A cross-sectional study of Omani women diagnosed with BC. SETTING: The two main teaching hospitals in Oman: Royal Hospital and Sultan Qaboos University Hospital. PARTICIPANTS: Adult Omani women recently diagnosed with BC. TOOLS: The Breast Module of the Cancer Awareness Measure and the International Cancer Benchmarking Partnership questionnaire were used to collect data. RESULTS: A total of 300 women with BC participated (response rate: 91.0%). The mean age at diagnosis was 43.0±12.50 years and 33.5% were diagnosed at stage III or IV. Although most women (74.4%) recognised breast/armpit lumps to be a symptom of BC, less than half identified other symptoms, including breast/armpit pain (44.0%), changes in the position of the nipple (36.2%), redness (31.7%), fatigue (26.3%), weight loss (23.4%) and loss of appetite (20.8%). While most (91.6%) were aware that BC could be cured if detected early, only 66.4% sought medical help within a month of developing symptoms. Initial responses to symptoms included informing husbands (40.2%) or family members (36.5%). Barriers to seeking medical help included feeling scared (68.9%) and worried about what the doctor might find (62.8%). Highly educated women were more likely to recognise the following as BC symptoms: changes in nipple position (OR: 0.16, 95% CI 0.03 to 0.81), breast pain (OR: 0.10, 95% CI 0.01 to 0.86) and unexplained weight loss (OR: 0.18, 95% CI 0.04 to 0.88) (all p<0.05). CONCLUSIONS: Although many Omani women with BC were aware of the importance of early diagnosis, most demonstrated inadequate knowledge of symptoms, did not prioritise seeking medical help and reported emotional barriers to help-seeking. More educational measures are needed to improve symptom recognition and address help-seeking barriers to minimise delays in diagnosis.

Endometrial Surveillance in Tamoxifen and Letrozole Treated Breast Cancer Patients.

BACKGROUND:  Our study aimed to assess the risk of endometrial pathologies after tamoxifen and aromatase inhibitors (AIs) adjuvant treatment for female breast cancer patients treated at Sultan Qaboos University Hospital in Oman. MATERIALS AND METHODS: A total of 457 patients diagnosed with estrogen positive breast cancer between January 2011 and December 2018 were screened. Two hundred and four patients met the inclusion criteria, and their detailed clinicopathological and endometrial surveillance data were collected from their electronic health records. RESULTS:  All patients underwent endometrial assessment during tamoxifen or letrozole therapy. The mean diagnostic age of breast cancer patients is 43.6 years, ranging from 27-84 years. Eighty-three percent of those patients are premenopausal, and 17% are postmenopausal. The mean tamoxifen use duration was 33 months. The majority of patients, 123 (60.3%), have had tamoxifen for three years or less, 47 (23.1%) for 3-5 years, and only 22 (10.8%) were on tamoxifen for more than five years. Increased endometrial thickness was reported in 8% of the premenopausal and 14% of the postmenopausal group. Other endometrial pathologies that were detected are inactive endometrium three (1.47%), atrophic endometrium three (1.47%), serous carcinoma one (0.50%), endometrial cancer two (0.98%), and chronic endometritis one (0.50%), which were not significantly associated with tamoxifen or letrozole therapy duration. Two patients have developed endometrial cancer, and both are postmenopausal and > 60 years old. CONCLUSIONS:  Tamoxifen and letrozole did not increase the risk of endometrial cancer in premenopausal patients. Breast Cancer (BC) patients on tamoxifen or letrozole might need a pre-treatment endometrial evaluation and explanation of alarming symptoms to guide further endometrial surveillance.

Outcomes of Women with Non-Metastatic Triple-Negative Breast Cancer in Oman: A single-centre experience.

OBJECTIVES: Triple-negative breast cancer (TNBC) is one of the most aggressive and heterogeneous variants of breast cancer. However, little is known regarding the prevalence and outcome of this entity in the Middle East. This study aimed to evaluate the outcomes of TNBC patients at a university hospital in Oman. METHODS: This retrospective study took place at the Sultan Qaboos University Hospital, Muscat, Oman, in May 2017. All patients diagnosed with non-metastatic TNBC between December 2000 and December 2015 were included. The patients' electronic medical records were reviewed to identify their clinical and pathological characteristics as well as survival outcomes. RESULTS: A total of 79 patients were diagnosed with non-metastatic TNBC during the study period. The median age was 46 years, with approximately one-third of patients (31.6%) under 40 years of age. Almost half had an advanced tumour size (49.4%) or node-positive disease (48.1%) at presentation and only 16.6% demonstrated a complete pathological response (pCR) to neoadjuvant chemotherapy. The median survival for all patients was not reached within the study period; however, the median overall survival for stage III patients was 44.6 months. The five-year overall survival for all patients was 64%, increasing to 100% and 72% for patients with stage I and II, respectively, and dropping to 47% for those with stage III disease. CONCLUSION: The findings of this study indicate that the majority of women with TNBC in Oman present at an advanced stage; moreover, such women have low rates of pCR to neoadjuvant chemotherapy and poor five-year survival.

Neoadjuvant Chemotherapy Alters Neuropilin-1, PlGF, and SNAI1 Expression Levels and Predicts Breast Cancer Patients Response.

Circulating proteins hold a potential benefit as biomarkers for precision medicine. Previously, we showed that systemic levels of neuropilin-1 (NRP-1) and its associated molecules correlated with poor-prognosis breast cancer. To further identify the role of NRP-1 and its interacting molecules in correspondence with patients' response to neoadjuvant chemotherapy (NAC), we conducted a comparative study on blood and tissue samples collected from a cohort of locally advanced breast cancer patients, before and after neoadjuvant chemotherapy (NAC). From a panel of tested proteins and genes, we found that the levels of plasma NRP-1, placenta growth factor (PlGF) and immune cell expression of the transcription factor SNAI1 before and after NAC were significantly different. Paired t-test analysis of 22 locally advanced breast cancer patients showed that plasma NRP-1 levels were increased significantly (p = 0.018) post-NAC in patients with pathological partial response (pPR). Kaplan-Meier analysis indicated that patients who received NAC cycles and their excised tumors remained with high levels of NRP-1 had a lower overall survival compared with patients whose tissue NRP-1 decreased post-NAC (log-rank p = 0.049). In vitro validation of the former result showed an increase in the secreted and cellular NRP-1 levels in resistant MDA-MB-231 cells to the most common NAC regimen Adriyamicin/cyclophosphamide+Paclitaxel (AC+PAC). In addition, NRP-1 knockdown in MDA-MB-231 cells sensitized the cells to AC and more profoundly to PAC treatment and the cells sensitivity was proportional to the expressed levels of NRP-1. Unlike NRP-1, circulating PlGF was significantly increased (p = 0.014) in patients with a pathological complete response (pCR). SNAI1 expression in immune cells showed a significant increase (p = 0.018) in patients with pCR, consistent with its posited protective role. We conclude that increased plasma and tissue NRP-1 post-NAC correlate with pPR and shorter overall survival, respectively. These observations support the need to consider anti-NRP-1 as a potential targeted therapy for breast cancer patients who are identified with high NRP-1 levels. Meanwhile, the increase in both PlGF and SNAI1 in pCR patients potentially suggests their antitumorigenic role in breast cancer that paves the way for further mechanistic investigation to validate their role as potential predictive markers for pCR in breast cancer.

Knowledge and Attitudes Towards Clinical Trial Participation in Oman: A cross-sectional study.

OBJECTIVES: Clinical trials are prospective studies on human subjects designed to answer various clinical questions. However, only a limited number of clinical trials have been conducted in Oman. This study aimed to assess the knowledge and attitudes of Omani patients and their relatives towards participating in clinical trials. METHODS: This cross-sectional study was conducted between October 2015 and March 2016 among 174 patients and relatives attending the Haematology and Oncology Outpatient Clinics and Day Care Unit of the Sultan Qaboos University Hospital, Muscat, Oman. A self-administered questionnaire was designed to elicit participants' knowledge of and attitudes towards participation in clinical trials. RESULTS: A total of 100 patients and relatives agreed to take part in the study (response rate: 57.5%). The male-to-female ratio was 1:1.2. Only 31.3% of the studied population knew what clinical trials were and only 6.5% had themselves previously participated in a clinical trial. The majority agreed or strongly agreed that they would participate in clinical trials related to their own condition (59.2%). Overall, 89.7% expected to be informed about potential clinical trials by their treating physicians. CONCLUSION: Omanis had a low level of knowledge of clinical trials and a very low rate of previous participation in such trials, despite a moderate level of interest. Patients should therefore be educated and informed of ongoing clinical trials in order to improve participation rates for clinical trials conducted in Oman.

Optimal Management of Leptomeningeal Carcinomatosis in Breast Cancer Patients-A Systematic Review.

The incidence of leptomeningeal carcinomatosis in breast cancer patients (LC-BC) is increasing. Despite significantly affecting patient quality of life (QoL) and overall survival (OS), little is known about its optimal management. A systematic review of treatment strategies for LC-BC was performed. EMBASE, Ovid Medline, Pubmed, and the Cochrane Central Register of Controlled Trials were searched from 1946 to 2015 for trials reporting on treatments for LC-BC. All treatment modalities and study types were considered. The outcome measures of interest included OS, time to neurologic progression (TTNP), QoL, and treatment toxicity. Of 718 unique citations, 173 studies met the prespecified eligibility criteria. Most were not specific to LC-BC patients. Of 4 identified randomized controlled trials (RCTs), 1 was specific to LC-BC patients and compared systemic therapy and involved-field radiotherapy with or without intrathecal (IT) methotrexate (35 patients), and the remaining 3 had compared different IT chemotherapy regimens (58 of 157 with LC-BC). Of the remaining studies, 19 were nonrandomized interventional studies (225 LC-BC patients), 148 were observational studies (3230 LC-BC patients), and 2 systematic reviews. Minimal prospective data were available on OS, TTNP, QoL, and toxicity. Owing to study heterogeneity, meta-analyses of the endpoint data could not be performed. Limited high-quality evidence exists regarding optimal treatment of LC-BC. The identified studies were heterogeneous and often methodologically poor. The only RCT that specifically assessed the role of IT chemotherapy showed no benefit, and, if anything, harm. Further prospective, tumor-specific trials with improved interstudy methodologic consistency and transparently reported data on OS, TTNP, QoL, and toxicity are urgently needed.

Palliative systemic therapy for advanced non-small cell lung cancer: Investigating disparities between patients who are treated versus those who are not.

BACKGROUND: Palliative systemic therapy (ST) in advanced non-small cell lung cancer (NSCLC) is associated with improved overall survival (OS) and quality of life, yet many patients remain untreated. We explored differences between patients who did and did not receive palliative ST in order to gain evidence to support and advocate for the untreated. METHODS: We performed a retrospective analysis of newly diagnosed patients with advanced, incurable NSCLC seen as outpatients at our institution between 2009 and 2012. Demographics, treatment, and survival data were collected. RESULTS: 528 patients were seen: 291 (55%) received palliative ST, while 237 (45%) received none. Demographics were as follows: Median age 67, 55% male, 50% ECOG performance status (PS) 0-1, 48% with weight loss. Untreated patients were older (median 71 vs. 64, p<0.01), less fit (PS 0-1 in 27% vs. 69%, p<0.01), and more likely to have lost weight (57% vs. 41%, p<0.01). Reasons for no treatment included poor PS (67%) and patient choice (23%). Median OS was shorter amongst untreated patients (3.9 vs. 10.7 months, HR 1.80 [95% CI 1.4-2.3], p<0.01). In multivariate analysis, not receiving ST was associated with shorter OS. CONCLUSION: Unsurprisingly, untreated patients had poorer prognostic features and worse OS. However, it is concerning that, despite being seen in an active academic center, nearly half of all referred patients with advanced NSCLC received no anti-cancer treatment. Current research primarily seeks to improve outcomes in treated patients with good PS. This review suggests that this is an inappropriate allocation of research effort. Our research should be more equitably split between good and poor performance patient groups if we are to improve the survival of all patients with advanced NSCLC. Potential strategies include more rapid diagnosis prior to functional decline, and the development of therapies effective and tolerated in a sicker population.

Invasive Pleomorphic Lobular Carcinoma of the Breast: Pathologic, Clinical, and Therapeutic Considerations.

Pleomorphic lobular carcinoma is an uncommon form of breast cancer and a subtype of invasive lobular carcinoma. It has unique histopathologic features that translate to a more aggressive phenotype with an associated poor prognosis. Unlike classical invasive lobular carcinoma, it can lose estrogen and progesterone receptor expression and demonstrate HER-2/neu amplification. It remains to be determined, however, whether the pleomorphic histology independently predicts a worse outcome or whether other known associated negative prognostic factors such as larger tumor size, increased metastatic disease, and associated worse molecular subtypes commonly present in pleomorphic carcinoma account for the poor prognosis. Here we present an updated review of the unique pathologic and clinical features of pleomorphic lobular carcinoma needed to guide management for women with this subtype of cancer.