Redesign of radiotherapy for prostate cancer: a proposal for universal healthcare systems.

Aim: This study was designed to recommend strategies to improve prostate patients' access to radiotherapy treatment in the Brazilian Unified Health System, along with a cost-tool to support radiotherapy care pathways' lead times and costs. Methods: Data was collected prospectively from patients with prostate cancer receiving radiotherapy in two Brazilian centers to provide data to apply design thinking and process reengineering techniques. The current status of the radiotherapy pathway was determined and the length of time taken for in-hospital activities was measured using data exported from ARIA®. Interviews with patients were used to estimate their waiting periods. This provided the data used to provide recommended strategies and the cost tool based on time-driven activity-based costing. The strategies were classified according to priority. Results: Data from 47 patients were analyzed. The mean interval from diagnosis to start of radiotherapy was 349 days (SD581), and the mean interval from seeking medical attention to starting treatment was 635 days (SD629). Twelve strategies affecting in-hospital processes and 11 impacting patients' care pathways and experiences are recommended, mostly focused on system improvement opportunities. A time-driven activity-based costing monitoring using data extracted from ARIA was coded and can be used by centers as a cost assessment guide. Conclusion: This study uses reengineering and design techniques to introduce priority strategies to allow more efficient and patient-centered radiotherapy.

Impacts of post-radiotherapy lymphocyte count on progression-free and overall survival in patients with stage III lung cancer.

BACKGROUND: We evaluated the impact of thoracic radiation in patients with non-small cell lung cancer (NSCLC), considering the depletion of total lymphocytes, use or not of chemotherapy, and radiation doses in healthy lung tissue. METHODS: Patients with stage III NSCLC, ECOG 0 to 2, receiving radiotherapy with or without chemotherapy were prospectively evaluated. All patients should be treated with three-dimensional radiotherapy and received biologically effective doses (BED10α/ß 10) of 48 to 80 Gy. Peripheral blood lymphocyte total counts were measured at the start of radiotherapy and at 2, 6 and 12 months after radiotherapy. Along with lymphocytes, PTV and doses of 5 Gy and 20 Gy in healthy lung tissue were also evaluated as potential factors influencing overall survival (OS) and progression-free survival (PFS). RESULTS: A total of 46 patients were prospectively evaluated from April 2016 to August 2019, with a median follow-up of 13 months (interquartile range, 1-39 months). The median of OS of all cohort was 22,8 months (IC 95% 17,6-28,1) and the median PFS was 19,5 months (IC 95%: 14,7-24,2). Most patients received concurrent or neoadjuvant chemotherapy (43; 93.4%). No patient received adjuvant immunotherapy. The lower the lymphocyte loss at 6 months after radiotherapy (every 100 lymphocytes/mcL), the greater the chance of PFS (HR, 0.44; 95%CI, 0.25-0.77; P = 0.004) and OS (HR, 0.83; 95%CI, 0.70-0.98; P = 0.025; P = 0.025). BED was a protective factor for both PFS (HR, 0.52; 95%CI 0.33-0.83; P = 0.0006) and OS (HR, 0.73; 95%CI 0.54-0.97; P = 0.029). CONCLUSIONS: Our results suggest that lymphocyte depletion after radiotherapy reduces tumor control and survival in patients with stage III lung cancer. Radiation doses equal or higher than 60 Gy (BED10 72 Gy) improve PFS and OS, but they negatively affect lymphocyte counts for months, which reduces survival and the potential of immunotherapy. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Thoracic irradiation for locally advanced lung cancer depletes T lymphocytes for months. Patients whose lymphocyte loss is lower have better overall survival and progression-free survival. WHAT THIS STUDY ADDS: It is necessary to protect the lymphocyte population, as well as other organs at risk. New forms of irradiation for large fields are needed. Furthermore, could immunotherapy before chemo-radiotherapy, with a greater number of lymphocytes, bring an even better result?

Alterações ultrassonográficas na medida da gordura abdominal, visceral e perirrenal em pacientes com síndrome metabólica / Ultrasound measurement of abdominal, visceral and perirrenal fatin patients with metabolic syndrome

A ultrassonografia tem sido proposta como uma técnica não invasiva para a avaliação de gordura intra-abdominal. O objetivo deste trabalho foi avaliar as alterações ultrassonográficas na medida da gordura abdominal, visceral e perirrenal de pacientes com síndrome metabólica. Métodos: Estudo descritivo do tipo série de casos, constituído de 35 pacientes com pelo menos três critérios para síndrome metabólica. Um médico radiologista determinou a medida das gorduras abdominal, visceral e perirrenal, utilizando técnica padrão. As variáveis como idade, sexo, cor da pele e índice de massa corporal foram coletadas diretamente com os pacientes. Resultados: Predominou a faixa etária entre 46 e 60 anos (62,8%), cor branca (71,4%), sexo feminino (71,4%). A obesidade superou as outras medidas antropométricas (71,4%). Das medidas ultrassonográficas, prevaleceram as menores medidas feitas, porém, nas três aferições as faixas de medidas maiores ficaram concentradas em obesos: espessura subcutânea 4-7 cm (22,8%), espessura visceral 12-17 cm (31,4%), espessura perirrenal 15-24 mm (25,7%). Dos critérios para síndrome metabólica, os mais encontrados foram: aumento da circunferência abdominal e pressão arterial elevada. Conclusão: A ultrassonografia demonstrou ser um método confiável na medida da gordura subcutânea e visceral para correlação de fatores de risco para o desenvolvimento de comorbidades cardíacas e endocrinológicas.

Ultrasound has been proposed as a noninvasive technique for evaluation of intra-abdominal fat. The aim of this study was to evaluate the changes in ultrasonographic measurements of abdominal, visceral and perirrenal fat of patients with metabolic syndrome. Methods: This is a descriptive case series, consisting of 35 patients with at least three criteria for metabolic syndrome. A radiologist determined the extent of abdominal, visceral, and perirrenal fat using a standard technique. Variables such as age, gender, skin color and body mass index were collected directly from patients. Results: Age group between 46 and 60 years (62.8%), whites (71.4%), and females (71.4%) predominated. Obesity surpassed the other anthropometric measures (71.4%). Of the ultrasonographic measures, the smallest measurements taken prevailed, but at the three measurements, the ranges of the greatest measures were concentrated in the obese: subcutaneous thickness 4-7 cm (22.8%), visceral thickness 12-17 cm (31.4%), perirrenal thickness 15-24 mm (25.7%). Of the criteria for metabolic syndrome, the most frequent were abdominal obesity and high blood pressure. Conclusion: Ultrasound proved to be a reliable method for measurement of subcutaneous and visceral fat for correlation of risk factors for the development of endocrine and cardiac co-morbidities.