Choosing Wisely Philippines: ten low-value or harmful practices that should be avoided in cancer care.

The Choosing Wisely Philippines campaign is an initiative that identifies low-value or potentially harmful practices that are relevant to patients with cancer in the Philippines. The main purpose of these initiatives is to facilitate quality improvement systems and maximise patient outcomes. Of the ten practices identified, four are new recommendations, and six are modified adaptations from previous Choosing Wisely initiatives in the USA and Africa. Recommendations in the final list include interventions involving diagnosis (two practices), treatment (five practices), palliative and supportive care (two practices) and surveillance (1 practice).

Cancer clinical trials in the Philippines.

In this Commentary, we discuss disparities in resources for and access to cancer trials from the perspective of the Philippines, a lower-middle-income country in Southeast Asia, where cancer is the fourth leading cause of death. Geographic disparities play out such that academic institutions and clinical trials are centralized in the island of Luzon, particularly in the capital, Manila. These disparities are compounded by the lack of comprehensive cancer patient and clinical trial registries in the Philippines. Additionally, sociocultural considerations influence clinical trial implementation. Providers must consider the role of a patient's family in the decision to participate in clinical trials; a patient's degree of health literacy; and the economic burden of cancer care, with attention to both the direct and indirect financial toxicities associated with cancer care. Our call to action is threefold. (1) Bolster locally led trials and encourage international collaboration to improve diversity in trial participation and trials' generalizability. (2) Strengthen national trial registries to improve awareness of trials for which patients are eligible. (3) Integrate cultural competency frameworks that move beyond parachutism and parasitism in research and instead promote trust, reciprocity, and collaboration. These challenges may yet evolve, but in emphasizing these barriers, we hope to kindle further dialogue, new insights, and innovative action towards solving these disparities in cancer research, not just in the Philippines, but also in other low- and middle-income countries.

Rare variant of genetically confirmed tuberous sclerosis complex presenting with bilateral renal angiomyolipoma in Wünderlich syndrome.

A 28-year-old woman came for non-traumatic right flank pain with hypotension and right flank mass. She had multiple hyperpigmented skin papules located on the centre area of her face, and angiomas on her toes. She was anaemic and had a blood transfusion on top of aggressive fluid resuscitation. Abdominal CT showed bilaterally enlarged kidneys and fluid collection in the right perirenal space (haemorrhage). The consideration was an angiomyolipoma in spontaneous perinephric haemorrhage. We considered tuberous sclerosis complex (TSC) and did genetic testing. Results revealed mutations in the TSC2 gene, consistent with the diagnosis of TSC. No immediate surgical plans were considered at that time. She opted to be discharged against medical advice and was scheduled for a close outpatient follow-up. The patient followed up after 2 weeks, already on sirolimus 2 mg once daily. She reported improved overall well-being and a decrease in the flank mass size.

Beyond bevacizumab: a review of targeted agents in metastatic small bowel adenocarcinoma.

Small bowel cancers are rare tumors with an incidence 50-100-fold less than colorectal cancer. These tumors carry a poor prognosis. Owing to its rarity, treatment of this disease, particularly in its advanced stages, has not been optimized and is derived mainly from treatment regimens for colorectal cancer. Based on recent studies bevacizumab, an antibody directed against vascular endothelial growth factor and used in the management of metastatic CRC, has been added to treatment guidelines for metastatic small bowel adenocarcinoma. We investigate in this review the evidence behind other targeted treatments that may be beneficial in the treatment of metastatic small bowel adenocarcinoma. These are agents against EGFR, VEGFR-2, HER2, and NTRK as well as immune checkpoint inhibitors. The last class of drugs appears to hold the greatest promise based on the preponderance of evidence supporting its use. However, overall data remains sparse. Results of studies currently underway will be valuable in shedding more light on the management of this aggressive cancer.

Patterns of Biomarker Use in Cancer Treatment Among Medical Oncologists in the Philippines.

PURPOSE: Several factors affect how medical oncologists in the Philippines use biomarkers in real-world practice. This study describes patterns of biomarker testing for the management of breast, colorectal, and lung cancers among medical oncologists in the Philippines. METHODS: A cross-sectional survey was performed among practicing medical oncologists in the Philippines from November to December 2019. The questionnaire determined the ideal and practical use of biomarkers as perceived by the respondents. Responses were summarized. Associations between biomarker use across select conditions were determined. RESULTS: A total of 127 respondents (38% of medical oncologists in the Philippines) participated in this study. In actual practice, 97% of the respondents requested estrogen receptor/progesterone receptor testing, and 93% requested human epidermal growth factor receptor 2 testing. For colorectal cancer, the respondents would use KRAS and mismatch repair/microsatellite instability, but 59.84% had never used BRAF. For lung cancer, 97.64% of respondents would test for epidermal growth factor receptor (EGFR), 88.19% would test for PD-L1, 80.31% for anaplastic lymphoma kinase, 58.27% for ROS1, and 33.07% for BRAF. In actual practice, EGFR was the most frequently ordered test (67.72%), while 44.80% of medical oncologists had never used ROS1. The most common reason for testing was adherence to international guidelines (96%). The most commonly cited barrier to biomarker use was patients' financial constraints (94.49%). Overall, the respondents' use of biomarkers was not significantly associated with institutional affiliation, the number of patients they saw monthly, and the availability of biomarker tests in their areas of practice. CONCLUSION: Medical oncologists in the Philippines would use biomarkers in treating breast, colorectal, and lung cancers if these were clinically indicated and if cost were not a factor. Financial difficulty experienced by patients was the most commonly cited barrier to biomarker use.

Medical oncology care amidst the COVID-19 pandemic at the National University Hospital in the Philippines.

COVID-19 has abruptly and radically changed the landscape of cancer care delivery throughout the world, including the Philippines. The Philippine General Hospital is the academic hospital of the University of the Philippines. Its cancer centre is a primary referral centre that takes care of Filipinos-many resource-constrained-that are burdened by malignancy. As the global pandemic challenges healthcare delivery, centres are forced to rethink how to care for their patients. This paper discusses how a national, academic, referral cancer institute in a low-middle income country is trying to meet the challenges of COVID-19.

Treatment Outcomes of Patients With Colorectal Cancer Enrolled in a Comprehensive Benefits Program of the National Insurance System in the Philippines: Data From the Pilot Site.

PURPOSE: Cancer treatment causes significant financial burden, especially in developing countries such as the Philippines. This led the Philippine Department of Health to create the Z-Package colorectal cancer benefit program, an insurance system specifically designed to treat Filipinos with colorectal cancers with early to locally advanced-stage disease. The main goal of this program is to optimize treatment outcomes for this curable disease without causing financial toxicity. MATERIALS AND METHODS: Three-year data on patients enrolled in the Z-Package colorectal cancer benefit program from 2016 to 2018 were reviewed by the University of the Philippines, Philippine General Hospital Colorectal Polyp and Cancer Study Group. RESULTS: A total of 251 patients were enrolled in the Z-package colorectal cancer benefit program from 2016 to 2018. Mean age was 57 years old and a majority of patients (66%) were male. A majority of patients had rectal cancer (78%) and were diagnosed with stage III disease (82%). A majority (75%) were compliant to their treatment plans and clinic follow-up. Specifically, compliance to the prescribed surgery, chemotherapy, and/or radiation treatment were 90%, 77%, and 96%, respectively. Recurrence, morbidity, and mortality rates of enrolled patients in the Z-Package program from 2016 to 2018 were 17%, 22%, and 19%, respectively. Morbidities were mostly chemotherapy related (8%). Finally, patients in this program had a 2- and 3-year survival probability of 74% and 70%, respectively, which are comparable with data from more developed nations. CONCLUSION: Results of this study include real-world data that show that when the highest standards of patient care are provided through a multidisciplinary team, patients' overall survival is also maximized.