Impactos da COVID-19 nos pacientes oncológicos: uma revisão sistemática / Impacts of COVID-19 on cancer patients: a systematic review

Introdução: Com a pandemia de coronavírus os pacientes oncológicos, que estão em tratamentos, nos quais a maioria são imunossupressores, se tornaram um grupo muito suscetível a formas graves da infecção. Logo, como forma de proteção e prevenção, a realização de exames de rastreio no ambiente hospitalar foi restringida, atrasando diversos diagnósticos e comprometendo a eficácia de tratamentos. Objetivos: Analisar a produção científica acerca do tema câncer e COVID-19, a fim de contribuir com informações sobre o assunto. Métodos: Revisão sistemática da literatura nas bases de dados SciELO, LILACS e PubMed. Os descritores utilizados foram "câncer" AND "COVID-19" de acordo com o Medical Subject Headings (MeSH) e seus equivalentes para a língua portuguesa, conforme os descritores de Ciências da Saúde (DeCS). Foram incluídos artigos originais em inglês e português, sem delimitação temporal. Resultados: Foram encontrados 1.606 artigos e, após utilizar os critérios de inclusão e exclusão, nove foram incluídos para análise na revisão. Dentre os temas centrais abordados pelos estudos selecionados estão o impacto da pandemia em algumas áreas de acompanhamento do paciente oncológico, como: tratamento, telemedicina, diminuição de funcionários no atendimento ao paciente com câncer, diminuição dos ensaios clínicos, redução dos recursos financeiros e apoio psicológico a essa população. Conclusão: A pandemia afetou diretamente o modo de vida desse grupo, que sofreu com uma redução no atendimento médico e nos recursos dispostos a eles. Portanto, nota-se a necessidade de prestar um cuidado mais específico a esses pacientes em situação tão delicada durante a pandemia.

Introduction: During the coronavirus pandemic, oncological patients, who are undergoing treatments in which the majority are immunosuppressant, have become a group very susceptible to severe forms of the infection. Therefore, as a form of protection, their going to hospital environments were restricted, delaying diagnosis and compromising the effectiveness of treatments. Objectives: This study aims to analyze the scientific about the production of the theme cancer and COVID-19 in order to contribute with informations on the subject. Methods: Systematic review of literature using the SciELO, LILACS and PubMed. The following keywords were used: "cancer" AND "COVID-19" according to the Medical Subject Headings (MeSH) and their translation to the Portuguese. Studies in English and Portuguese from inception were included. Results: 1,606 studies were screened and 9 were included in the systematic review after using the inclusion and exclusion criterias. Among the central themes addressed by the selected studies are the pandemic impacts in areas of monitoring oncological patients, such as: treatment, telemedicine, reduction of employees in the care of cancer patients, reduction of clinical trials, reduction of financial resources, and psychological support to that population. Conclusion: The pandemic directly affected the way of life of this group, which suffered from a reduction in medical care and the resources available to them. Therefore, there is a need to provide more specific care to these patients in such a delicate situation during the pandemic.

A survey on the current status of clinical resources for diagnosis and treatment of breast cancer in rural hospitals of the Tohoku region in Japan.

BACKGROUND: We administered a questionnaire survey to assess the available clinical resources for the diagnosis and treatment of breast cancer and identify the issues faced by rural hospitals in the Tohoku region in Japan. METHODS: The term rural hospital was defined by the following three criteria: the facility is a certified regional cancer center and hospital, no breast specialist is on staff, and ≥ 10 breast surgeries per year have been performed. Thirty-eight rural hospitals were eligible, and each was sent a self-administered questionnaire consisting of 26 questions by mail. RESULTS: Responses were received from 29 of the 38 hospitals. Most of the hospitals had adequate facilities for diagnosis and treatment, but they needed specialists' support for ≥ 2 days per month. Approximately half of the hospitals indicated that applying resources for diagnosis and treatment of breast cancer, especially during planning of treatment and management of advanced breast cancer patients, was a burden. Interestingly, the hospitals felt that being able to provide treatment to their patients was more ideal rather than referring them to urban hospital like the prefectural cancer center and hospital providing specialized cancer treatment. CONCLUSIONS: The surveyed rural hospitals needed practical and knowledge-based support from specialists. Unfortunately, the number of specialists is currently insufficient in Tohoku. Increased number of certified physicians, clinical pathways for sharing patient's information and updated knowledge, and information and communication technology for treatment with specialists' intervention in rural hospitals may solve issues in Tohoku.

[Nomadism of patients treated by radiotherapy in Île-de-France: Does our health system have as much money to waste?] / Nomadisme des patients traités par radiothérapie en Île-de-France : notre système de santé a-t-il autant d'argent à gaspiller ?

PURPOSE: Human, material, and financial resources being limited, the organization of the care system must allow an efficient allocation of resources. The management of cancers leads to specific and repetitive care for which the reimbursement of transport costs represents a high cost. We carried out an analysis of the additional transport costs, linked to the care of patients in Île-de-France, in a center other than the radiotherapy center closest to their home. MATERIALS AND METHODS: Using data from the Île-de-France Regional Health Agency, we have created a model evaluating the additional cost linked to transport generated by the care of a radiotherapy patient far from his home. In order to take into account the uncertainties linked to the hypotheses made in the development of the model, we carried out deterministic and probabilistic sensitivity analyzes. RESULTS: In the base case, the additional annual cost related to transport was 841,176 euros in Île-de-France. The probabilistic sensitivity analysis reports a total annual additional cost of 2,817,481 euros. CONCLUSION: Our results are similar to a report from the General Inspectorate of Social Affairs published in July 2011, which then pointed to an additional cost of between 4 and 6 million euros annually. The long-term care of cancer patients from their homes contributes to a deterioration in the quality of life linked to travel times, a delay in the care of potential treatment complications, and the spread of infectious diseases, such as COVID-19, and bacteria resistant to antibiotics.

[Proton therapy in France in 2019]. / État des lieux de la protonthérapie en France en 2019.

Among over 100 proton therapy centres worldwide in operation or under construction, French proton therapy is coming to full maturity with the recent opening of the Nice (1991, upgrade in 2016) and Caen (2018) facilities next to the Orsay (1991, upgrade in 2010) centre. Proton therapy is a national priority for children and young adults in all three centres. The patient-related activity of the three French centres is coordinated via the Protonshare portal to optimise referral by type of indication and available expertise in coordination with the French society of radiation oncology SFRO and French radiotherapy centres. The centres are recognised by the French Health Care excellence initiative, promoted by the ministry of Foreign Affairs. The three centres collaborate structurally in terms of clinical research and are engaged at the international level in the participation to European databases and research initiatives. Concerted actions are now also promoted in preclinical research via the Radiotransnet network. Ongoing French developments in proton therapy are well presented in international hadron therapy meetings, including European Proton Therapy Network and Particle Therapy Cooperative Oncology Group. Proton therapy teaching in France is offered at several levels and is open to colleagues from all radiation oncology centres, so that they are fully informed, involved and trained to facility recognition of possible indications and thereby to contribute to appropriate patient referral. This close collaboration between all actors in French radiation oncology facilitates the work to demonstrate the required level of medical and scientific evidence for current and emerging indications for particle therapy. Based on that, the future might entail a possible creation of more proton therapy facilities in France.

Challenges and Opportunities to Realize "The 2030 Agenda for Sustainable Development" by the United Nations: Implications for Radiation Therapy Infrastructure in Low- and Middle-Income Countries.

PURPOSE: In 2015, the United Nations proposed "The 2030 Agenda for Sustainable Development" goals, which envision reducing premature mortality from noncommunicable diseases by one third by 2030. Because >50% of patients with cancer require radiation therapy (RT), the existing gaps in RT infrastructure in low- and middle-income countries (LMICs) and additional requirements by 2030 were examined. Cost-effective strategies to address this challenge were explored. METHODS AND MATERIALS: Public domain databases of the United Nation organizations were accessed. RT requirements for 2030 were estimated according to the International Atomic Energy Agency recommendations. To explore a feasible cost-effective solution, a teleradiotherapy network (TRTNet) was conceived with 4 to 8 primary RT centers (PRTCs) (each with 1 teletherapy unit, US$2.05 million) linked to a secondary RT center (SRTC; 2 teletherapy units and 1 brachytherapy unit, US$5.05 million). RESULTS: Of the 137 LMICs, 51 (37.3%) presently lack RT facilities. The remaining 86 LMICs have 5084 teletherapy units (gap: -7741) and thus a mean access to RT of 33%. By 2030, an additional 12,133 teletherapy units would be required for 14.2 million patients with cancer. A TRTNet linked 4 to 8 PRTCs with 1 SRTC could yield a return of investment (ROI) between -181.1% and 757.6% depending on the TRTNet configuration, 2-year survival, gross national income per capita, and employment-population ratio of the individual LMICs. Sixty-five (47.4%) of these could be expected to attain a positive ROI (7.1% to 757.6%) with a 2-year survival of 50% and a TRTNet configuration of 1 SRTC and 8 PRTCs. CONCLUSION: Optimized TRTNets through resource sharing could be a cost-effective and financially viable option to create RT infrastructure and facilitate capacity building toward realizing the 2030 Agenda for Sustainable Development goals in most LMICs. Low-income countries and some LMICs not expected to gain positive ROI should be considered for external financial assistance.

Melanoma prognosis in the United States: Identifying barriers for improved care.

BACKGROUND: Despite improvements in melanoma mortality, disparities in melanoma survival persist. We evaluated possible sociodemographic and health care-based predictors of differences in melanoma survival in the United States by using the melanoma mortality-to-incidence ratio (MIR). METHODS: State-based MIRs were calculated by using US cancer statistics data from 1999 to 2014. Pearson correlations and linear regressions were used to determine associations between MIR and dermatologist density, primary care provider density, number of physicians by state, number of National Cancer Institute-designated cancer centers, health care spending per capita, average household income, racial/ethnic makeup of the population, percentage of uninsured individuals, and percentage with a bachelor's degree. RESULTS: The mean overall MIR was 0.15 ± 0.04; only Alaska was an outlier (0.24). No state MIRs increased significantly over time; MIR decreased for most states. Multivariable analysis revealed that states with more active physicians (P = .02) and a higher percentage non-Hispanic whites (P = .004) had higher MIRs (poorer survival). Significant Pearson correlations were seen between MIR and melanoma incidence (r = -0.72, P < .001), melanoma mortality (r = 0.38, P < .001), dermatologist density (r = 0.32, P < .001), and National Cancer Institute-designated cancer center count (r = -0.12, P = .001). CONCLUSIONS: Melanoma survival is improved in higher-incidence areas and areas with higher dermatologist density. These findings highlight areas of poorer melanoma survival and the need for local studies evaluating disparities in melanoma survival.

Are State-Sponsored New Radiation Therapy Facilities Economically Viable in Low- and Middle-Income Countries?

PURPOSE: The economic viability of establishing a state-funded radiation therapy (RT) infrastructure in low- and middle-income countries (LMICs) in accordance with the World Bank definition has been assessed through computation of a return on investment (ROI). METHODS AND MATERIALS: Of the 139 LMICs, 100 were evaluated according to their RT facilities, gross national income (GNI) per capita, and employment/population ratio. The assumption was an investment of US$5 million for a basic RT center able to treat 1000 patients annually. The national breakeven points and percentage of ROI (%ROI) were calculated according to the GNI per capita and patient survival rates of 10% to 50% at 2 years. It was assumed that 50% of these patients would be of working age and that, if employed and able to work after treatment, they would contribute to the country's GNI for at least 2 years. The cumulative GNI after attaining the breakeven point until the end of the 15-year lifespan of the teletherapy unit was calculated to estimate the %ROI. The recurring and overhead costs were assumed to vary from 5.5% to 15% of the capital investment. RESULTS: The %ROI was dependent on the GNI per capita, employment/population ratio and 2-year patient survival (all P<.001). Accordingly, none of the low-income countries would attain an ROI. If 50% of the patients survived for 2 years, the %ROI in the lower-middle and upper-middle income countries could range from 0% to 159.9% and 11.2% to 844.7%, respectively. Patient user fees to offset recurring and overhead costs could vary from "nil" to US$750, depending on state subsidies. CONCLUSIONS: Countries with a greater GNI per capita, higher employment/population ratio, and better survival could achieve a faster breakeven point, resulting in a higher %ROI. Additional factors such as user fees have also been considered. These can be tailored to the patient's ability to pay to cover the recurring costs. Certain pragmatic steps that could be undertaken to address these issues are discussed in the present study.

[Status report of Hungarian radiotherapy based on treatment data, available infrastucture, and human resources]. / A magyar sugárterápia helyzete a betegellátási adatok, a rendelkezésre álló infrastruktúra és emberi eroforrás tükrében.

The purpose of the study is to report the status of Hungarian radiotherapy (RT) based on the assessment of treatment data in years 2012 to 2014, available infrastructure, and RT staffing. Between December 2014 and January 2015, a RT questionnaire including 3 parts (1. treatment data; 2. infrastructure; 3. staffing) was sent out to all Hungarian RT centers (n=12). All RT centers responded to all questions of the survey. 1. Treatment data: In 2014, 33,162 patients were treated with RT: 31,678 (95.5%) with teletherapy, and 1484 (4.5%) with brachytherapy (BT). Between 2012 and 2014, the number of patients treated with radiotherapy increased with 6.6%, but the number of BT patients decreased by 11%. Forty-two percent of all patients were treated in the two centers of the capital: 9235 patients (28%) at the National Institute of Oncology (NIO), and 4812 (14%) at the Municipial Oncoradiology Center (MOC). Out of the patients treated on megavoltage RT units (n=22,239), only 901 (4%) were treated with intensity-modulated RT (IMRT), and 2018 (9%) with image-guided RT (IGRT). In 2014, 52% of all BT treatments were performed in Budapest: NIO - 539 patients (36%); MOC - 239 patients (16%); and BT was not available in 3 RT centers. Prostate I-125 seed implants and interstitial breast BT was utilized in one, prostate HDR BT in two, and head&neck implants in three centers. 2. Infrastructure: Including ongoing development projects funded by the European Union, by the end of year 2015, 39 megavoltage teletherapy units, and 12 HDR BT units will be in use in 13 available Hungarian RT centers. 3. Staffing: Actually, 92 radiation oncologists (RO), 29 RT residents, 61 medical physicists, and 229 radiation therapy technologists are working in 12 RT centers. There are 23 vacant positions (including 11 RO positions) available at the Hungarian RT centers. According to the professional minimal requirements and WHO guidelines, the implementation of 11 new linear accelerators, and 1 BT units are needed in Hungary. Further resources for the development and upgrade of RT infrastructure and capacity should be allocated to RT centers in Budapest. Brachytherapy and modern teletherapy (e.g. IMRT and IGRT) are underutilized in Hungary compared to other European countries. Implementation of continuous education and practical training programs in leading Hungarian and international RT centers are suggested in an effort to a wider implementation of modern RT techniques in Hungarian RT centers.

[Current situation and perspectives of proton therapy]. / État des lieux et perspectives de la protonthérapie.

Proton beam therapy is indicated as a treatment for some rare tumours and paediatric tumours because the technique allows a good local control with minimal toxicity; the growing number of centres that use proton beam therapy is associated with an increase of dosimetric and clinical data for other malignant tumours as well. This paper reviews potential indications of proton beam therapy. A systematic review on Medline was performed with the following keywords proton beam therapy, cancer, heavy particle, charged particle. No phase III trial has been published using proton beam therapy in comparison with the best photon therapy, but numerous retrospective and dosimetric studies have revealed an advantage of proton beam therapy compared to photons, above all in tumours next to parallel organs at risk (thoracic and abdominal tumours). This could be accompanied with a better safety profile and/or a better tumoural control; numerous phase 0, I, II, III and IV studies are ongoing to examine these hypotheses in more common cancers. Use of proton beam therapy is growing for common cancers within clinical trials but some indications could be applied sooner since in silico analysis showed major advantages with this technique.

Radiation therapy infrastructure and human resources in low- and middle-income countries: present status and projections for 2020.

PURPOSE: Radiation therapy, a key component of cancer management, is required in more than half of new cancer patients, particularly in low- and middle-income countries (LMICs). The projected rise in cancer incidence over the next decades in LMICs will result in an increasing demand for radiation therapy services. Considering the present cancer incidence and that projected for 2020 (as listed in GLOBOCAN), we evaluated the current and anticipated needs for radiation therapy infrastructure and staffing by 2020 for each of the LMICs. METHODS AND MATERIALS: Based on World Bank classification, 139 countries fall in the category of LMICs. Details of teletherapy, radiation oncologists, medical physicists, and radiation therapy technologists were available for 84 LMICs from the International Atomic Energy Agency-Directory of Radiotherapy Centres (IAEA-DIRAC) database. Present requirements and those for 2020 were estimated according to recommendations from the IAEA and European Society for Radiotherapy & Oncology (ESTRO-QUARTS). RESULTS: Only 4 of the 139 LMICs have the requisite number of teletherapy units, and 55 (39.5%) have no radiation therapy facilities at present. Patient access to radiation therapy in the remaining 80 LMICs ranges from 2.3% to 98.8% (median: 36.7%). By 2020, these 84 LMICs would additionally need 9169 teletherapy units, 12,149 radiation oncologists, 9915 medical physicists, and 29,140 radiation therapy technologists. Moreover, de novo radiation therapy facilities would have to be considered for those with no services. CONCLUSIONS: Twelve pragmatic steps are proposed for consideration at national and international levels to narrow the gap in radiation therapy access. Multipronged and coordinated action from all national and international stakeholders is required to develop realistic strategies to curb this impending global crisis.

[Location of radiotherapy centers: an exploratory geographic analysis for Belgium]. / Localisation des centres de radiothérapie : une analyse géographique exploratoire pour la Belgique.

PURPOSE: The distance between the patient's home and a radiotherapy department may represent a hurdle for the patient and influence treatment choice. Therefore, it is necessary to check whether the geographical distribution of radiotherapy centers is in accordance with cancer incidence, taking also into account the cost of travelling to the radiotherapy department. The objective of this study is double; first, to map the current locations of radiotherapy centers across the country and second, to evaluate the observed spatial disparities with appropriate tools. MATERIALS AND METHODS: A model of operational research (P-median) is used to suggest the optimal locations and allocations and to compare them with the current situation. This is an exploratory study with simple inputs. It helps to better understand the current geographical distribution of radiotherapy centers in Belgium as well as its possible limitations. RESULTS-CONCLUSION: It appears that the current situation is on the average acceptable in terms of accessibility to the service and that the method presents huge potentialities for decision making so as to yield a spatial system that is both efficient and equitable.

Colorectal cancer in Mexico: should a middle income country invest in screening or in treatment?

Mexico, like many other middle-income countries, is experiencing a demographic and epidemiological transition resulting in an older population suffering from chronic diseases. At the present time, cancer is the second cause of death in the country. Until recently, cervical carcinoma was the most frequent type of cancer in the country, however, the incidence of breast, prostate and colon cancers is growing. The demand for health care and health expenditure represented by cancer treatment challenges the limited resources the country has, particularly as patients seek treatment in advanced stages of the disease. Interestingly enough, these types of cancers could be detected in the early stages with rather simple screening procedures. The purpose of this paper is to describe the Mexican health system, and the impact of its fragmentation on access to medicines. Focusing on colorectal cancer (CRC), we describe its epidemiology, screening procedures and the inequities in health care access for these patients.

Colorectal cancer management in Poland: current improvements and future challenges.

Colorectal cancer (CRC) is the second most commonly identified malignant neoplasm diagnosed in men (12% of total cancers) and women (11%) in Poland, while CRC mortality is second in men (10.1%) and third in women (11.2%). The main reasons for increasing incidence and mortality are an aging population and an increase in environmental and lifestyle factors which may lead to cancer. In Poland there is a lack of historical (regularly published and accessible) data on cancer morbidity and survival rates. The Oncology Centre published cancer data for the first time in February 2009 the 2006, which, also for the first time, embraced the entire country. Oncology data collection in Poland is based on a network of 16 Regional Cancer Registries reporting to the Polish National Cancer Registry in Warsaw. An additional source of oncology data is the National Health Fund and the Central Statistical Office. The National Cancer Programme (2005) provides funding at ca 780 million euro, which includes amongst others the Early CRC Detection Programme to promote a free screening colonoscopy. Oncology services in Poland are funded almost entirely by public resources--the national budget as sustained by tax revenues (Ministry of Health) and the National Health Fund as sustained by the obligatory public health insurance contribution. Oncology expenditure covered by the national budget (Ministry of Health) and the National Cancer Programme in 2006 amounted to 44.8 million euro and 105.2 million euro, respectively. All these preventive, curative and organizational efforts have significantly improved access to efficient therapies (including radiotherapy) and diagnostic procedures in recent years in Poland, although, clearly, a lot remains to be done.