Résumé
Objetivo: estimar o impacto orçamentário incremental da terapia-alvo para tratamento de primeira linha do melanoma avançado não cirúrgico e metastático, em comparação à dacarbazina. Métodos: análise de impacto orçamentário na perspectiva do Sistema Único de Saúde (SUS) do Brasil; a partir de dados demográficos e estimativas da incidência, foi delimitada a população no horizonte temporal de três anos (2018-2020) e estimados os custos diretos médicos; foi considerado cenário de referência o tratamento com dacarbazina, e como cenários alternativos a terapia-alvo com vemurafenibe, dabrafenibe, vemurafenibe + cobimetinibe e dabrafenibe + trametinibe; a avaliação das incertezas foi conduzida mediante análise por cenários. Resultados: o impacto orçamentário incremental variou de R$ 451.867.881,00 a R$ 768.860.968,00, representando 0,70 a 1,53% dos gastos anuais totais com medicamentos ambulatoriais no SUS; no melhor e no pior cenário, os resultados variaram de R$ 289.160.835,00 a R$ 1.107.081.926,00. Conclusão: a terapia-alvo, comparada à dacarbazina, implica impacto excessivo no orçamento, desfavorecendo eventual incorporação.
Objetivo: estimar el impacto presupuestario incremental de la terapia dirigida para tratamiento de primera línea del melanoma avanzado no quirúrgico y metastásico comparado con la dacarbazina. Métodos: análisis de impacto presupuestario, en la perspectiva del Sistema Único de Salud (SUS) de Brasil; a partir de datos demográficos y estimaciones de incidencia se delimitó la población en un horizonte temporal de tres años (2018-2020) y se estimaron los costos directos médicos. El escenario de referencia fue el tratamiento con dacarbazina y los escenarios alternativos la terapia dirigida con vemurafenib, dabrafenib, vemurafenib + cobimetinib y dabrafenib + trametinib; la evaluación de incertidumbre se llevó a cabo mediante análisis por escenarios. Resultados: el impacto presupuestario incremental varió de R$ 451.867.881,00 a R$ 768.860.968,00, representando 0,70 a 1,53% de gastos anuales totales con medicamentos de ambulatorios en el SUS; en el mejor y el peor escenario los resultados variaron de R$ 289.160.835,00 a R$ 1.107.081.926,00. Conclusión: el uso de terapia dirigida comparado a la dacarbazina implica en impacto excesivo en el presupuesto, desfavoreciendo una eventual incorporación.
Objective: to estimate the incremental budget impact of target therapy for first-line treatment of advanced non-surgical and metastatic melanoma compared to dacarbazine treatment. Methods: budget impact analysis, from the Brazilian National Health System (SUS) perspective; based on demographic data and incidence estimates, the population over a three-year time horizon (2018-2020) was delimited and the direct medical costs were estimated; the reference scenario was treatment with dacarbazine, and the alternative scenarios were target therapy with vemurafenib, dabrafenib, vemurafenib + cobimetinib and dabrafenib + trametinib; uncertainty assessment was conducted through scenario analysis. Results: the incremental budget impact ranged from R$ 451,867,881.00 to R$ 768,860,968.00, representing 0.70 to 1.53% of total SUS annual outpatient drugs expenditure; in best and worst scenario, results ranged from R$ 289,160,835.00 to R$ 1,107,081,926.00. Conclusion: the use of target therapy compared to dacarbazine implies an excessive impact on the budget, this bring unfovorable to its possible incorporation.
Sujets)
Humains , Coûts et analyse des coûts/tendances , Dacarbazine/administration et posologie , Dacarbazine/usage thérapeutique , Thérapie moléculaire ciblée/méthodes , Thérapie moléculaire ciblée/tendances , Mélanome/traitement médicamenteux , Mélanome/épidémiologie , Tumeurs cutanées/traitement médicamenteux , Système de Santé Unifié , Santé publique/tendances , Coûts des soins de santé/tendances , Métastase tumorale/traitement médicamenteux , Antinéoplasiques/économieRésumé
ABSTRACT Background Glioma, the most common primary malignant brain tumor in adults, is highly aggressive and associated with a poor prognosis. The objectives of this study were to evaluate the association of genetic polymorphisms related to angiogenesis and apoptosis with gliomas, as well as comorbidities, lifestyle, clinical profile, survival and response to treatment (temozolomide [TMZ] and radiotherapy [RT]) in patients with the disease. Methods In a total of 303 individuals, genotypes were performed by real-time PCR, and clinical data, lifestyle and comorbidities were obtained from medical records and questionnaires. The significance level was set at 5%. Results Smoking, alcohol consumption, systemic arterial hypertension, diabetes mellitus and body mass index prevailed among patients, compared to controls (p < 0.05). The heterozygous genotype rs1468727 (T/C) and the homozygous genotype rs2010963 (G/G) (p > 0.05) were observed in both groups. Lifestyle and comorbidities showed independent risk factors for the disease (p < 0.0001, p = 0.0069, p = 0.0394, respectively). Patients with low-grade gliomas had a survival rate of 80.0 ± 1.7% in three years. For the combination of TMZ+RT, survival was 78.7 ± 7.6% in 20 months, compared to TMZ only (21.9 ± 5.1%, p = 0.8711). Conclusions Genetic variants were not associated with gliomas. Specific lifestyle habits and comorbidities stood out as independent risk factors for the disease. Low-grade gliomas showed an increase in patient survival with TMZ+RT treatment.
RESUMO Introdução Glioma, tumor cerebral maligno, é altamente agressivo e associado a mau prognóstico. Os objetivos deste estudo foram avaliar a associação de polimorfismos genéticos relacionados a angiogênese e apoptose em pacientes com glioma, bem como suas comorbidades, hábitos de vida, perfil clínico, sobrevida e resposta ao tratamento (temozolomida [TMZ] e radioterapia [RT]). Métodos 303 indivíduos foram genotipados por PCR em tempo real, e foram coletados dados clínicos, hábitos de vida e comorbidades. Admitiu-se nível de significância para valor p < 0,05. Resultados Tabagismo, elitismo, hipertensão arterial sistêmica, diabetes mellitus e índice de massa corporal prevaleceram entre os pacientes, comprados aos controles (p < 0,05). O genótipo heterozigoto rs1468727 (T/C) e homozigoto rs2010963 (G/G) (p > 0,05) foram observados em ambos os grupos. Tabagismo, elitismo, hipertensão arterial sistêmica, diabetes mellitus e índice de massa corporal apresentaram fatores de risco independentes para a doença (p < 0.0001, p = 0.0069, p = 0.0394, respectivamente). Os pacientes com gliomas de baixo grau apresentaram sobrevida de 80,0 ± 1,7% em três anos. Para a combinação de RT e TMZ, a sobrevida foi de 78,7±7,6% em 20 meses, em comparação com TMZ (21,9 ± 5,1%, p = 0,8711). Conclusões As variantes genéticas não estiveram associadas aos gliomas. Hábitos de vida e comorbidades específicas destacaram-se como fatores de risco independentes para a doença. O tratamento com TMZ + RT mostrou aumento na sobrevida dos pacientes.
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Humains , Mâle , Femelle , Nourrisson , Enfant d'âge préscolaire , Enfant , Adolescent , Adulte , Adulte d'âge moyen , Sujet âgé , Sujet âgé de 80 ans ou plus , Jeune adulte , Polymorphisme génétique/génétique , Tumeurs du cerveau/génétique , Apoptose/génétique , Gliome/génétique , Tumeurs du cerveau/anatomopathologie , Tumeurs du cerveau/thérapie , Association thérapeutique , Antinéoplasiques alcoylants/administration et posologie , Dacarbazine/administration et posologie , Dacarbazine/analogues et dérivés , Estimation de Kaplan-Meier , Réaction de polymérisation en chaine en temps réel , Témozolomide , Génotype , Gliome/anatomopathologie , Gliome/thérapie , Mode de vie , Néovascularisation pathologiqueRésumé
Background: Recent trials show that > 90% of patients with early stage Hodgkin`s Lymphoma (ESHL) can be cured, especially when using the ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) chemotherapeutic (CT) protocol. The use of radiotherapy (RT) is variable and can be selected according to the presence of specific risk factors, including PET-CT, as recently reported. Aim: To report the experience in the treatment of ESHL. Material and Methods: Retrospective and descriptive analysis of patients with ESHL treated at the Red de Salud UC-Christus between 2011-2015. Results: Twenty-two patients were treated. In 73%, the tumor was of nodular sclerosis histologic type. Most patients (95%) were in stage II, and 78% had a favorable prognosis according to the Deutsche Hodgkin Studiengruppe (GHSG) criteria. All patients were stratified using PET-CT and treated using the ABVD CT protocol, for 4-6 cycles. Only 5 patients received RT. There was no change of conduct after interim-PET-CT results. Ninety one percent of patients achieved complete response and there were two cases of refractory disease. Both cases underwent hematopoietic stem cell transplantation. After 17 months of median follow-up, 91% of patients are relapse-free, and only one patient died (5%). Conclusions: ABVD offers excellent results for ESHL patients. The benefit of PET-CT should be evaluated with prospective protocols, aiming to select patients needing RT or to reduce the number of CT cycles.
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Humains , Mâle , Femelle , Adulte , Maladie de Hodgkin/traitement médicamenteux , Protocoles de polychimiothérapie antinéoplasique/usage thérapeutique , Pronostic , Vinblastine/administration et posologie , Bléomycine/administration et posologie , Induction de rémission , Protocoles de polychimiothérapie antinéoplasique/administration et posologie , Doxorubicine/administration et posologie , Études rétrospectives , Résultat thérapeutique , Survie sans rechute , Dacarbazine/administration et posologieSujets)
Animaux , Humains , Souris , Antinéoplasiques/usage thérapeutique , Protéines tumorales/antagonistes et inhibiteurs , Tumeurs/traitement médicamenteux , Poly(ADP-ribose) polymerases/antagonistes et inhibiteurs , Antinéoplasiques/pharmacologie , Essais cliniques comme sujet , Réparation de l'ADN/effets des médicaments et des substances chimiques , ADN tumoral/effets des médicaments et des substances chimiques , ADN tumoral/métabolisme , Dacarbazine/administration et posologie , Dacarbazine/analogues et dérivés , Dacarbazine/pharmacologie , Systèmes de délivrance de médicaments , Conception de médicament , Résistance aux médicaments antinéoplasiques , Tests de criblage d'agents antitumoraux , Synergie des médicaments , Souris knockout , Protéines tumorales/physiologie , Tumeurs/enzymologie , Poly(ADP-ribose) polymerases/composition chimique , Poly(ADP-ribose) polymerases/déficit , Poly(ADP-ribose) polymerases/génétique , Poly(ADP-ribose) polymerases/physiologie , Radiotolérance/effets des médicaments et des substances chimiquesRésumé
This study was performed to validate the effectiveness and safety of concurrent chemoradiotherapy and adjuvant therapy with temozolomide for newly diagnosed glioblastoma multiforme as a standard treatment protocol. Between 2004 and 2011, patients newly diagnosed with glioblastoma who were treated with temozolomide during concurrent chemoradiotherapy and adjuvant chemotherapy were included from a single institution and analyzed retrospectively. The primary endpoint was overall survival, and the secondary endpoints were progression-free survival, response, and safety. A total of 71 patients were enrolled in this study. The response rate was 41% (29/71), and the tumor control rate was 80% (57/71). In the 67 patients who completed the concurrent chemoradiotherapy with temozolomide, the median overall survival was 19 months and the 1- and 2-yr overall survival rates were 78.3% and 41.7%, respectively. The median progression free survival was 9 months, and the 1- and 2-yr progression free survival rates were 33.8% and 14.3%, respectively. The mean duration of survival after progression of disease in salvage treatment group was 11.9 (1.3-53.2) months. Concurrent chemoradiotherapy with temozolomide resulted in grade 3 or 4 hematologic toxic effects in 2.8% of the patients. The current protocol of temozolomide during and after radiation therapy is both effective and safe and is still appropriate as the standard protocol for treatment of glioblastoma. An active salvage treatment might be required for a better prognosis.
Sujets)
Adolescent , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Femelle , Humains , Mâle , Adulte d'âge moyen , Jeune adulte , Antinéoplasiques alcoylants/administration et posologie , Tumeurs du cerveau/diagnostic , Chimioradiothérapie adjuvante/méthodes , Comorbidité , Dacarbazine/administration et posologie , Glioblastome/diagnostic , Hémopathies/mortalité , Études longitudinales , Prévalence , Radiothérapie conformationnelle/mortalité , République de Corée/épidémiologie , Facteurs de risque , Taux de survie , Résultat thérapeutiqueRésumé
INTRODUÇÃO: A significância prognóstica do marcador imunológico CD 20 no linfoma de Hodgkin clássico (LHc) ainda é incerta, particularmente no que se refere à refratariedade ao tratamento inicial. OBJETIVOS: Avaliar a influência da positividade do marcador CD 20 na refratariedade do LHc ao tratamento poliquimioterápico inicial, com o esquema doxorubicina 25 mg/m², bleomicina 10 mg/m², vinblastina 6 mg/m² e dacarbazina 375 mg/m² (ABVD), no Ceará, Brasil. MATERIAL E MÉTODOS: Estudo analítico incluindo 97 pacientes com diagnóstico de LHc firmado entre janeiro de 2000 e dezembro de 2004. A análise foi realizada avaliando variáveis demográficas, clínicas e laboratoriais. RESULTADOS: Foi evidenciada uma positividade do CD 20 em 38,1 por cento dos pacientes. Na análise bivariada, CD 20 positivo (razão de chance [RC] = 4,02; intervalo de confiança [IC] = 1,09 - 8,54; p = 0,02), a presença de sintomas B (RC = 4,02; IC = 1,18-17,51; p = 0,01) e a elevação da desidrogenase lática (mediana não-refratários 248,5 [200,5 - 389,5]; mediana refratários 356 [208,5 - 545]; p = 0,03) apresentaram relação de pior prognóstico quanto à refratariedade. Na regressão logística, o CD 20 positivo (RC ajustada = 3,6; IC = 0,99 - 13,09; p = 0,05) e a presença de sintomas B (RC ajustada = 5,41; IC = 1,16 - 25,34; p = 0,03) continuaram apresentando pior prognóstico. DISCUSSÃO: Esses dados coincidem com a literatura, em que a positividade do marcador CD 20 está relacionada com pior resposta ao tratamento com ABVD. CONCLUSÃO: Os nossos dados indicam que o tratamento com ABVD não é completamente adequado para a abordagem terapêutica inicial deste subgrupo de pacientes e novas pesquisas precisam ser realizadas no sentido de aperfeiçoar o tratamento destes pacientes.
INTRODUCTION: The prognostic value of CD20 antigen expression in classical Hodgkin lymphoma (cHL) is uncertain, particularly regarding the refractoriness to first-line treatment. OBJECTIVES: To assess the influence of CD20 positiveness on the refractoriness of cHL to first-line chemotherapy with ABVD protocol in Ceará State, Brazil. MATERIAL AND METHODS: Analytical study including 97 patients diagnosed with cHL between January/2000 and December/2004. The analysis was performed evaluating demographic, clinical and laboratory variables. RESULTS: CD20 antigen expression was positive in 38.1 percent of the patients. In the bivariate analysis, CD20 antigen expression (OR = 4.02; CI = 1.09 - 8.54; p = 0.02), the presence of B-symptoms (OR = 4.02; CI = 1.18-17.51; p = 0.01) and an elevated lactate dehydrogenase level (median not refractory 248.5 [200.5 - 389.5]; median refractory 356 [208.5-545]; p = 0.03) showed worse prognosis as to refractoriness. In the logistic regression analysis, the presence of CD 20 (OR = 3.6; CI = 0.99-13.09; p = 0.05) and B-symptoms (OR = 5.41; CI = 1.16-25.34; p = 0.03) continued to show worse prognosis. DISCUSSION: These findings coincide with literature data indicating that CD 20 antigen expression is associated with low response to treatment with ABVD. CONCLUSION: Our data show that the treatment with ABVD is not totally appropriate for the initial therapeutic approach in this subgroup of patients and that further studies are required to optimize their treatment.
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Humains , Mâle , Femelle , Enfant d'âge préscolaire , Enfant , Adolescent , Adulte , Adulte d'âge moyen , Maladie de Hodgkin/diagnostic , Maladie de Hodgkin/traitement médicamenteux , Protocoles de polychimiothérapie antinéoplasique/usage thérapeutique , Bléomycine/administration et posologie , Dacarbazine/administration et posologie , Doxorubicine/administration et posologie , Marqueurs biologiques tumoraux , Pronostic , Études prospectives , Études rétrospectives , Vinblastine/administration et posologieRésumé
Background: Hodgkin lymphoma is a highly curable disease. Aim: To evaluate the clinical characteristics and the treatment results of Hodgkin lymphoma patients of the National Cancer Program in Chile. Patients and methods: Prospective assessment of 682 patients treated in 18 adult cancer centers. Progression free survival (PFS) and overall survival (OS) were calculated. Median follow up was 127, 95, 87, 72 and 50 months for C-MOPP, radiotherapy (RT), C-MOPP/ABV, NOVP and ABVD, respectively. Results: Median age was 37 years (15-84). Nodular sclerosis and mixed cellularity were equally expressed. Advanced stages (III & IV) were present at diagnosis in 61 percent of cases. Age over 40 was an adverse prognostic factor (p <0.001). The rate of PFS at 5 and 10 years for early stages was 73 percent and 66 percent with RT, 80 percent and 74 percent with C-MOPP+RT, 73 percent and 71 percent with C-MOPP/ABV, 59 percent and 59 percent with NOVP+RT, and 81 percent with ABVD+RT, at 5 years, being significantly lower for NOVP (p =0.02). The rate of OS at 5 and 10 years for advanced stages was 82 percent and 70 percent with RT, 82 percent and 76 percent with C-MOPP+RT, 82 percent and 80 percent with C-MOPP/ABV, 68 percent and 60 percent with NOVP, and 85 percent with ABVD at 5 years, also significantly lower for NOVP (p =0.04). For advanced stages, the rate of PFS at 5 and 10 years was 49 percent and 43 percent with C-MOPP, 69 percent and 62 percent with C-MOPP/ABVD or C-MOPP/ABV, and 71 percent at 5 years with ABVD, significantly lower for C-MOPP (p =0.01). The rate of OS at 5 and 10 years was 52 percent and 46 percent with C-MOPP, 70 percent and 63 percent with C-MOPP/ABVD or C-MOPP/ABV and 76 percent with ABVD at 5 years, significantly lower for C-MOPP (p =0.0002). Conclusions: Age over 40 years was an adverse prognostic factor. C-MOPP/ABVD, C-MOPP/ABV and ABVD had comparable results and reached a high tumor control and overall survival in both early...
Sujets)
Adolescent , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Femelle , Humains , Mâle , Adulte d'âge moyen , Protocoles de polychimiothérapie antinéoplasique/usage thérapeutique , Maladie de Hodgkin/traitement médicamenteux , Programmes nationaux de santé , Protocoles de polychimiothérapie antinéoplasique/administration et posologie , Bléomycine/administration et posologie , Loi du khi-deux , Chili , Cyclophosphamide/administration et posologie , Dacarbazine/administration et posologie , Survie sans rechute , Doxorubicine/administration et posologie , Études de suivi , Maladie de Hodgkin/radiothérapie , Mitoxantrone/administration et posologie , Prednisolone/administration et posologie , Prednisone/administration et posologie , Procarbazine/administration et posologie , Études prospectives , Résultat thérapeutique , Vinblastine/administration et posologie , Vincristine/administration et posologieRésumé
Intracraneal manifestations of Hodgkin's Disease (HD) are extremely rare, with an estimated incidence rate of approximately 0.5%. They can be classified as: 1) treatment-related leucoencephalopathy, 2) central nervous system infections, 3) paraneoplasic syndromes and 4) intracraneal lymphomas, which could be sub-classified into intraparenchymal or intradural masses. We describe a case of a 40 year-old male with mixed cellularity type HD who developed neurological manifestations as relapsed disease. Magnetic resonance imaging suggested leptomeningeal metastases and atypical cells were found in cerebrospinal fluid. The patient died from progressive disease refractory to third line chemotherapy. There are less than 50 similar cases reported in the literature. We review the clinical features and differential diagnosis of leptomeningeal metastases in Hodgkin's disease.
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Adulte , Humains , Mâle , Maladie de Hodgkin/anatomopathologie , Tumeurs des méninges/secondaire , Ponction-biopsie à l'aiguille , Bléomycine/administration et posologie , Cyclophosphamide/administration et posologie , Cisplatine/administration et posologie , Cytarabine/administration et posologie , Diagnostic différentiel , Dacarbazine/administration et posologie , Maladie de Hodgkin/liquide cérébrospinal , Maladie de Hodgkin/traitement médicamenteux , Doxorubicine/administration et posologie , Étoposide/administration et posologie , Issue fatale , Leucoencéphalopathie multifocale progressive/induit chimiquement , Leucoencéphalopathie multifocale progressive/anatomopathologie , Imagerie par résonance magnétique , Tumeurs des méninges/liquide cérébrospinal , Prednisone/administration et posologie , Procarbazine/administration et posologie , Protocoles de polychimiothérapie antinéoplasique/administration et posologie , Protocoles de polychimiothérapie antinéoplasique/usage thérapeutique , Récidive , Syndromes paranéoplasiques/anatomopathologie , Vinblastine/administration et posologie , Vincristine/administration et posologieRésumé
Numerous studies have demonstrated the clinical activity of temozolomide, a second-generation alkylating agent, against malignant brain tumors, however, its activity has not been reported in an Asian population. This study analyzed the efficacy and toxicity of temozolomide in 25 adult patients with recurrent or progressive malignant gliomas after surgery and standard radiation therapy with or without chemotherapy, enrolled in our institution since July 2000. Sixteen patients had glioblastoma multiforme (GBM), six with anaplastic astrocytoma, and three with anaplastic oligodendroglioma. Of the 25 patients, 3 (12%) achieved a complete response (CR), 8 (32%) achieved a partial response (PR), 6 (24%) had stable disease (SD), and 8 (32%) had progressive disease (PD). Two patients achieved a CR, 4 patients achieved a PR, 3 patients had SD and 7 patients had PD in GBM, and 1 patient achieved a CR, 4 patients achieved a PR, 3 patients had SD, 1 patient had PD in the non-GBM patients. Median progression free survival was 8 weeks in GBM and 22 weeks in the non-GBM patients. The median overall survival of each group was 17 weeks and 28 weeks. Temozolomide demonstrated moderate activity in recurrent and progressive malignant gliomas without serious toxicity.
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Adulte d'âge moyen , Mâle , Humains , Femelle , Adulte , Adolescent , Vomissement/induit chimiquement , Résultat thérapeutique , Analyse de survie , Récidive tumorale locale , Nausée/induit chimiquement , Imagerie par résonance magnétique , Maladies du foie/induit chimiquement , Leucopénie/induit chimiquement , Gliome/traitement médicamenteux , Calendrier d'administration des médicaments , Dacarbazine/administration et posologie , Association thérapeutique , Tumeurs du cerveau/traitement médicamenteux , Encéphale/effets des médicaments et des substances chimiques , Antinéoplasiques alcoylants/administration et posologie , Administration par voie oraleRésumé
Physicochemical, Microbial and Pharmacological studies on Fe(III)-Dacarbazine complex have been done in solid and aqueous phase. On the basis of elemental analysis, polarographic studies, amperometric titrations and IR spectral studies the probable formula for the complex has been worked out to be 1:1, Fe(III)-Dacarbazine. The metal ligand interaction has been studied using polarographic method at 25 +/- 1 degrees C and at ionic strength of mu = 1.0 (KCl). Microbial studies on the complex was done against various pathogenic bacteria viz. Pseudomonas mangiferae, Staphylococcus aureus, Salmonella typhi and Vibrio cholarae and fungi i.e. Trichothecium and Chrysosporium sp. using Raper's method. Mouse sarcoma cell line 180 and Balb/C mice were used for the anticancer screening of solid complex in vitro and in vivo respectively. The observed polarographic data, on lingane treatment revealed the formation of single (1:1) (M:L) complex with Fe(III) and dacarbazine ligands. The results of amperometric titrations of Fe(III) with dacarbazine in IM KCl supporting electrolyte pH 7.0 +/- 0.1 supported the above findings the IR data speaks of the complex formation between the metal and the dacarbazine ligand through the two nitrogen one each of primary amide and trizo groups. The results of microbial and pharmacological studies with the M:Drug complex revealed that the anticancer activity of the drug metal complex is nearly doubled as compared to the pure drug. As such Fe(III) dacarbazine complex may be recommended to the therapeutic experts for its possible use as more potent anticancer drug.