Geriatric screening and comprehensive geriatric assessment during initial oncology appointments.

INTRODUCTION: Geriatric oncology underscores the significance of assessing functional age in guiding medical decisions, endeavouring to delineate practical and efficacious methodologies for evaluating functionality, adapting therapeutic regimens and attenuating the risks of treatment-related deterioration. OBJECTIVES AND METHODS: In this prospective study, we aimed to delineate the characteristics of older patients presenting for their initial oncology appointment by using geriatric screening (G8 score) and comprehensive geriatric assessment (CGA), while also assessing the feasibility of these evaluations. Secondary objectives included comparing the initial Eastern Cooperative Oncology Group (ECOG) performance status and any deviations from standard therapeutic strategies against the identified frailty in geriatric assessment. RESULTS: Most patients exhibited a G8 score ≤14 and underwent comprehensive geriatric assessment. While oncologists typically perceive patients' general conditions, CGA enables a systematic assessment, providing a comprehensive characterisation of elderly patients to inform therapeutic decisions and address identified fragilities. The CGA highlighted vulnerabilities across all primary domains. Notably, even among patients with ECOG scores of 0 and 1, the application of G8 score and CGA revealed numerous fragilities. Consistent with existing literature, these scales offered additional insights beyond ECOG evaluation alone, suggesting their potential to guide therapeutic adaptations for this demographic. CONCLUSION: Ongoing research and continuous evaluation are imperative to refine and broaden the implementation of geriatric-focused interventions.

Anthracyclines versus No Anthracyclines in the Neoadjuvant Strategy for HER2+ Breast Cancer: Real-World Evidence.

BACKGROUND AND OBJECTIVES: Deescalation strategies omitting anthracyclines (AC) have been explored in early human epidermal growth factor receptor 2-positive breast cancer (HER2+ EBC), showing similar efficacy regarding pathological complete response (pCR) and long-term outcomes as AC-containing regimens. The standard treatment for this tumor subtype is based on chemotherapy and dual HER2 blockade with trastuzumab and pertuzumab, with AC-containing regimens remaining a frequent option for these patients, even in non-high-risk cases. The primary aim of this study was to assess and compare the effectiveness of neoadjuvant regimens with and without AC used in the treatment of HER2+ EBC in the clinical practice according to the pCR achieved with each. METHODS: This retrospective multicentric study included patients with HER2+ EBC from Portuguese, Spanish, and Chilean hospitals (January 2018-December 2021). Patients receiving neoadjuvant therapy (NAT) with dual HER2 blockade (trastuzumab and pertuzumab), followed by surgery, were included. Statistical analysis used chi-squared/Fisher's exact test for associations, multivariate logistic regression for pCR, and Kaplan-Meier method for event-free survival (EFS). IBM SPSS Statistics 29.0 analyzed the data. RESULTS: The study included 371 patients from eight hospitals. Among them, 237 received sequential AC and taxane-based chemotherapy with 4 cycles of trastuzumab and pertuzumab, while 134 received 6 cycles of TCHP (docetaxel, carboplatinum, trastuzumab, and pertuzumab). The average age of the patients was 52.8 years and 52.7 years, respectively. Omitting AC from the neoadjuvant approach did not preclude achieving pCR [p = 0.246, 95% confidence interval (CI) 0.235-0.257] and was safe regardless of patient characteristics. Relapse rates were 6.8% (16 patients) in the AC group and 4.5% (6 patients) in the TCHP group. Over a median follow-up of 2.9 years, the estimated 3-year EFS was 92.5% in the AC group and 95.4% in the TCHP group (hazard ratio 0.602, 95% CI 0.234-1.547, p = 0.292, favoring TCHP). CONCLUSION: This study reports real-world evidence showing similar pCR and EFS outcomes with treatment regimens with and without AC and raises awareness of possible overtreatment and long-term toxicity in some patients with HER2+ EBC with the use of AC.

End-of-Life Antibiotherapy: Factors Associated With Prescription.

Introduction Most cancer patients spend their last days of life in the hospital, often receiving invasive and non-palliative interventions. These patients are particularly susceptible to infections, which are a major cause of death. The decision to use antimicrobials in a palliative context is difficult, given the lack of guidelines. Objectives To characterize patients who received antimicrobials at the end of life and analyze factors associated with their prescription decisions. Methods A retrospective analysis of patients who died in the Medical Oncology Service from January to December 2017 was done. In addition, the use of antibiotics in the last 15 days of life was considered. Clinical, therapeutic, and Eastern Corporative Oncology Group Performance Status Scale (ECOG PS) variables were analyzed using SPSS v23. Results There were a total of 116 deaths, of which 48.3% (n = 56) received antimicrobials in their last 15 days of life. The median age of the patients was 64.5 years. Most patients (55.4%) had an ECOG PS 4, of which 82.1% were stage IV tumors. The most frequent tumors were colorectal adenocarcinomas (21.3%), digestive non-colorectal (predominantly gastric or esophageal adenocarcinomas) (20.5%), and invasive breast carcinomas (16.4%). Asthenia (33.6%) and dyspnea (19.8%) were the main complaints, and most patients (55.4%) had respiratory infections. Fever was present in 51.8% of patients on antibiotics and was related to their use (p < 0.001). The use of antimicrobials is also related to higher C-reactive protein (CRP) values (p = 0.015). Conclusions The decision to institute antimicrobials at the end of life is related to clinical and analytical aspects suggestive of infection without considering the patient's general condition and the oncological disease's prognosis. Deprescription of antibiotic therapy is not yet a current clinical practice.

Tumor-infiltrating lymphocytes in early breast cancer: an exploratory analysis focused on HER2+ subtype in Portuguese patients.

Tumor-infiltrating lymphocytes (TILs) have shown prognostic value in breast cancer. This study evaluated the TILs scores in 186 Portuguese patients diagnosed with early breast cancer, with special focus on HER2 subtype. Stromal TILs were scored on the core needle biopsies, as well as in the resected specimen in HER2+ patients submitted to neoadjuvant treatment with trastuzumab and pertuzumab. TILs were higher in tumors with negative hormone receptor status and HER2 amplifications, and in triple-negative breast cancer. In HER2+ patients treated with dual anti-HER neoadjuvant therapy, the TILs score on the surgical specimen was generally lower than in the biopsy.

Neutrophile-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios as prognostic and response biomarkers for resectable locally advanced gastric cancer.

BACKGROUND: Perioperative fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) improves prognosis in locally advanced gastric cancer (LAGC). Neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte (PLR) ratios are prognostic biomarkers but not predictive factors. AIM: To assess blood ratios' (NLR, LMR and PLR) potential predictive response to FLOT and survival outcomes in resectable LAGC patients. METHODS: This was a multicentric retrospective study investigating the clinical potential of NLR, LMR, and PLR in resectable LAGC patients, treated with at least one preoperative FLOT cycle, from 12 Portuguese hospitals. Means were compared through non-parametric Mann-Whitney tests. Receiver operating characteristic curve analysis defined the cut-off values as: High PLR > 141 for progression and > 144 for mortality; high LMR > 3.56 for T stage regression (TSR). Poisson and Cox regression models the calculated relative risks/hazard ratios, using NLR, pathologic complete response, TSR, and tumor regression grade (TRG) as independent variables, and overall survival (OS) as the dependent variable. RESULTS: This study included 295 patients (mean age, 63.7 years; 59.7% males). NLR was correlated with survival time (r = 0.143, P = 0.014). PLR was associated with systemic progression during FLOT (P = 0.022) and mortality (P = 0.013), with high PLR patients having a 2.2-times higher risk of progression [95% confidence interval (CI): 0.89-5.26] and 1.5-times higher risk of mortality (95%CI: 0.92-2.55). LMR was associated with TSR, and high LMR patients had a 1.4-times higher risk of achieving TSR (95%CI: 1.01-1.99). OS benefit was found with TSR (P = 0.015) and partial/complete TRG (P < 0.001). Patients without TSR and with no evidence of pathological response had 2.1-times (95%CI: 1.14-3.96) and 2.8-times (95%CI: 1.6-5) higher risk of death. CONCLUSION: Higher NLR is correlated with longer survival time. High LMR patients have a higher risk of decreasing T stage, whereas high PLR patients have higher odds of progressing under FLOT and dying. Patients with TSR and a pathological response have better OS and lower risk of dying.

Immunotherapy in Metastatic Mucosal Melanoma with Disseminated Intravascular Coagulation: A Case of Success.

Mucosal melanoma accounts for 1% of all melanomas. It is more aggressive than cutaneous melanoma, and local excision provides the best disease-free survival. The vast majority of patients eventually develop metastases, with a metastatic pattern independent of the primary tumor site. While studies show that BRAF and KIT inhibitors have a role in the management of these patients, the actual treatment focus is on immunotherapy. Herein is described the case of a 79-year-old woman with metastatic mucosal melanoma and bone marrow infiltration causing disseminated intravascular coagulation, who was treated with an immunotherapy combination (anti-CTLA-4 and anti-PD-1 antibodies), achieving complete disease remission. This is the third case of melanoma with disseminated intravascular coagulation at presentation and the second case treated with immunotherapy in the literature, but the only one achieving disease remission.

How shall we treat locally advanced triple negative breast cancer?

Triple negative breast cancer (TNBC) has been shown to respond to neoadjuvant chemotherapy (NACT). It has been established that achieving pathological complete response (pCR) for certain aggressive subtypes of breast cancer, including HER-2 (over-expressed) and TNBC, provides an important surrogate marker for predicting long-term clinical response and survival outcomes. How to increase the number of patients that achieve pCR remains challenging. Platinum-based NACT seems to be part of the solution and capecitabine, an active drug in metastatic breast cancer, but not a standard one in earlier stages may have found its place in the adjuvant setting. In the near future immunotherapy can play a role in early TNBC.

Itinerários terapêuticos da população trans em um município do nordeste brasileiro / Therapeutic Itineraries of the Transgender in a Northeastern Brazilian City / Itinerarios terapéuticos de la población transexual en una ciudad del noreste de Brasil

Resumo O artigo apresenta resultados de pesquisa qualitativa sobre os itinerários terapêuticos da população trans no município de Timon - Maranhão a partir da realização de entrevistas individuais e semiestruturadas com oito pessoas trans (dois homens e seis mulheres). A análise dos dados foi realizada com base no referencial teórico da hermenêutica de Paul Ricoeur. A partir das narrativas dos participantes da pesquisa, foram reconhecidas três unidades de significado: "a construção do ser-trans", "o acesso à saúde da população trans" e, também, "itinerários terapêuticos (trans)formados". Os itinerários mencionados não apresentaram vínculos formais entre os serviços, nem tampouco garantia de acesso e continuidade do cuidado.

Abstract A qualitative research was carried out on the therapeutic itineraries followed by the trans population in the municipality of Timon - Maranhão, through individual and semistructured interviews with eight trans people (two men and six women). Data analysis was performed based on the theoretical framework of Paul Ricoeur's hermeneutics. From the narratives of the research participants, three units of meaning were recognized: "the construction of the being-trans", "the access to health of the trans population" and, also, "therapeutic (trans) formed itineraries". The mentioned itineraries did not present formal links between the services, nor guarantee access and continuity of care.

Resumen Se realizó una investigación cualitativa sobre los itinerarios terapéuticos de la población trans en el municipio de Timón - Maranhão, a través de entrevistas individuales y semiestructuradas a ocho personas trans (dos hombres y seis mujeres). El análisis de los datos se realizó con base en el marco teórico de la hermenéutica de Paul Ricoeur. A partir de las narrativas de los participantes de la investigación, se reconocieron tres unidades de significado: "la construcción del ser-trans", "el acceso a la salud de la población trans" y, también, "itinerarios terapéuticos (trans) formados". Los itinerarios mencionados no presentaban vínculos formales entre los servicios, ni garantizaban el acceso y la continuidad de la atención.

Mentores em educação médica: adquirindo competências, promovendo a inclusão e combatendo o Burnout / Mentors in medical education: acquiring skills, promoting inclusion and fighting Burnout

Introdução: A medicina baseada em evidências incorporou de forma definitiva a ciência à arte do ato médico, exigindo de cada ator envolvido neste cenário intermináveis horas debruçadas sobre as fontes de saber documentadas. Entretanto, se a incorporação destes saberes teóricos não for aliada ao desenvolvimento de competências específicas e de uma praxe reflexiva, humanística e em constante atualização, capaz de acompanhar as dinâmicas transformações impostas pela celeridade do conhecimento científico atual, essa ciência pode não só não ser resolutiva como culminar em intervenções iatrogênicas. Neste buscar por competências específicas, assumem papel relevante as horas dispendidas enquanto graduando em medicina nos serviços de atenção primária e hospitalares disponíveis, onde, via de regra, o graduando está em contato direto e sobre a orientação e/ou supervisão de um médico que, na grande maioria das vezes, não tem ligação formal com à atividade docente. Este encontro e construção do relacionamento trabalho/ensino/aprendizagem é feito de forma intuitiva e pode se tornar mais produtivo dependendo de vários fatores. Objetivos: Procurou-se discutir vários aspectos relacionados a essa construção, mais especificamente acerca dos saberes experienciais desse agente educacional, o médico clínico, analisando um dos modelos modernos de relacionamento aluno-mestre ao longo da graduação, o mentoring, para introduzirmos uma discussão de como a exposição a um programa formal pode moldar e contribuir para a construção do pool de saberes experenciais em educação que, em última análise, darão ou não a capacidade a este médico, sem relação formal com atividade docente, a condição necessária para poder educar com eficiência, especialmente quando ele se depara, por circunstâncias do trabalho assistencial, com a responsabilidade de participar de forma impactante na formação das novas gerações de médicos. Método: Trata-se de revisão sistemática realizada nas bases Scielo e Pubmed sobre o tema apresentado, para a qual se utilizou a combinação de diferentes descritores. Resultados: Evidência robusta de literatura, com forte nível de evidência, nos mostra o impacto positivo dos programas formais de mentoring na redução do burnout e na inclusão de minorias no ambiente acadêmico das faculdades médicas. Relacionamos os textos sobre formação de competências docentes específicas, descritas como saberes experiências que, sob a ótica de Maurice Tardiff, são obtidas com a prática em serviço e por meio da exposição à atividade docente dos alunos, atuando como mentores de alunos mais novos em um programa de mentoria formal. Utilizamos esta relação para propor a importância de se utilizar este efeito positivo do programa na mudança de perfil dos futuros médicos em relação ao comprometimento com formação de novas gerações de médicos. Conclusão. Os programas atuais de mentoring formais focam principalmente na redução do burnout e, para tal, são montados. Esta dissertação propõe uma mudança de paradigma, ao propor que os programas sejam constituídos com o objetivo principal de implementar saberes experienciais em docência informal para os alunos participantes, mediante a exposição deles a atividades como mentores de alunos mais jovens. Por meio dos saberes experienciais obtidos como mentores formaríamos futuros médicos supervisores mais comprometidos com a educação médica e com a formação das futuras gerações

Introduction: Evidence-based medicine has definitively incorporated science into the art of medical practice, requiring every actor involved in this scenario to spend endless hours on documented sources of knowledge. However, if the incorporation of these theoretical knowledge is not linked to the development of specific competences and a reflexive, humanistic and constantly updating praxis capable of accompanying the dynamic transformations imposed by the celerity of current scientific knowledge, this science may not only not be resolutive but culminate in iatrogenic interventions. In this search for specific competences, the hours spent while graduating in medicine in the primary and hospital services available assume a relevant role, where, as a rule, the graduate is in direct contact and on the guidance and/or supervision of a doctor who, in the majority of the time, has no formal connection with the teaching activity. This encounter and construction of the work/teaching/learning relationship is done intuitively and can become more productive depending on several factors. Aims: The objective was to discuss several aspects related to this construction, specifically about the experiential knowledge of these educational agents, clinical physicians, analyzing one of the modern models of student-teacher relationship throughout the graduation, called mentoring, to introduce a discussion on how the exposure to a formal program can shape and contribute to the construction of the pool of expertise in education that will ultimately or not provide the ability of these physicians, without formal relation to teaching. This condition is necessary to enable them to be educated effectively, especially when, due to circumstances of care work, they are faced with the responsibility of participating in an impactful way in the formation of the new generations of doctors. Method: It is a systematic review carried out in the databases Scielo and Pubmed on the presented theme, for which the combination of different descriptors was used. Results: Robust literature evidence shows the positive impact of formal mentoring programs on reducing burnout and on the inclusion of minorities in the academic setting of medical colleges. The texts on training of specific teacher competences were listed. These competencies were described as experiential knowledge that, from the perspective of Maurice Tardiff, are obtained through the practice in service and through exposure to the teaching activity of the students, acting as mentors of younger students in a formal mentoring program. This list was used to propose the importance of using this positive effect of the program in changing the profile of future physicians in relation to the commitment with the formation of new generations of physicians. Conclusion: The current formal mentoring programs focus primarily on reducing burnout and they are set up to do so. This dissertation proposes a paradigm shift by proposing that the programs be constituted with the main objective of implementing experiential knowledge in informal teaching for the participating students by exposing them to activities as mentors of younger students. Through the experiential knowledge gained as mentors future medical supervisors more committed to medical education and to the training of future generations would be formed

Introducción: La medicina basada en evidencias incorporó de forma definitiva la ciencia al arte del acto médico, exigiendo de cada individuo involucrado en este contexto, interminables horas debruzadas sobre las fuentes de saber documentadas. Sin embargo, si la incorporación de estos saberes teóricos no se alía al desarrollo de competencias específicas y a una praxis reflexiva, humanística y en constante actualización, capaz de acompañar las dinámicas transformaciones impuestas por la celeridad del conocimiento científico actual, esa ciencia puede no solo ser resolutiva, sino, culminar en intervenciones iatrogénicas. En esta búsqueda por competencias específicas, asumen papel relevante las horas que el graduando de medicina destina a los servicios de atención primaria y hospitalarias, donde, rutineramente, él está en contacto directo con el paciente y bajo la orientación y/o supervisión de un médico que, en la mayor de las veces, no tiene ligación formal con la actividad docente. Este encuentro y construcción de la relación trabajo/enseñanza/aprendizaje se realiza de forma intuitiva, pudiendo llegar a ser más productivo dependiendo de varios factores. Objetivos: Se intentó discutir varios aspectos relacionados a esa construcción, más específicamente acerca de los saberes de experiencias de este agente educacional, el médico clínico, analizando uno de los modelos modernos de relacionamiento alumno-maestro a lo largo de la graduación, el mentoring, para introducir una discusión de cómo la exposición a un programa formal pode moldar y contribuir a la construcción del pool de saberes de experiencias en educación que, en último análisis, harán o no capaz a este médico, sin relación formal con actividad docente, condición necesaria para poder educar con eficiencia, especialmente cuando se depara, debido a las circunstancias del trabajo asistencial, con la responsabilidad de participar de forma impactante en la formación de las nuevas generaciones de médicos. Método: Se trata de una revisión sistemática realizada en las bases Scielo y Pubmed sobre el tema presentado, utilizándose la combinación de diferentes descriptores. Resultados: Evidencia robusta de literatura, con fuerte nivel de evidencia, nos muestra el impacto positivo de los programas formales de mentoring en la reducción del burnout y en la inclusión de minorías en el ambiente académico de las facultades médicas. Relacionamos los textos sobre formación de competencias docentes específicas, descritas como saberes de experiencias que, en la óptica de Maurice Tardiff, se obtienen con la práctica en servicio y a través de la exposición a la actividad docente de los alumnos, actuando como mentores de alumnos más nuevos en un programa de tutoría formal. Utilizamos esta relación para proponer la importancia de utilizar este efecto positivo del programa en el cambio del perfil de los futuros médicos en relación al compromiso con la formación de nuevas generaciones de médicos. Conclusión. Los programas actuales de mentoring formales enfocan principalmente en la reducción del burnout y para eso se montan. Esta disertación propone un cambio de paradigma, al proponer que los programas se construyan con el objetivo principal de implementar saberes de experiencias en docencia informal para los alumnos participantes, mediante su incorporación a las actividades como mentores de alumnos más jóvenes. A través de los saberes de experiencias obtenidos como mentores formaríamos futuros médicos supervisores más comprometidos con la educación médica y con la formación de futuras generaciones

Looking Beyond Tobacco and Alcohol: The Role of Lifestyle and Other Environmental Risk Factors for Laryngeal Cancer

Laryngeal cancer incidence in São Paulo, Brazil, is one of the highest in the world. OBJECTIVE: This hospitalbasedcase-control study was designed to investigate exposure-disease relationship between larynx cancer andsmoking and drinking history, diet, occupational exposures and other characteristics. MATERIAL ANDMETHODS: The study was conducted in 3 metropolitan areas in Brazil: São Paulo (South-east), Curitiba (South)and Goiânia (Central-west). We have analyzed information on demographics, occupational history, environmental exposures, tobacco smoking and alcoholdrinking habits obtained from interviews with 194 cases and 804 controls (non-cancer inpatients) matched on 5-year age group, gender, hospital catchments area, and trimester of admission. RESULTS: Tobacco and alcohol consumption were the most important factors for prediction of laryngeal cancer. Other important riskfactors were indoor exposure to wood stove fumes (RR=2.6), woodworking (RR=1.9), family history of cancer(RR=2.1), and high consumption of coffee and “chimarrão”(a kind of maté tea ). There was a protective effect for the consumption of citric fruits and forcarotene-rich vegetables. CONCLUSION: regionally specific lifestyle (“chimarrão”, high consumption of woodworking, and family history of cancer may be responsible for a substantial proportion of incidentlaryngeal cancer cases.