Tyrosine Kinase Inhibitors for Radioactive Iodine Refractory Differentiated Thyroid Cancer.

Patients with differentiated thyroid cancer usually present with early-stage disease and undergo surgery followed by adjuvant radioactive iodine ablation, resulting in excellent clinical outcomes and prognosis. However, a minority of patients relapse with metastatic disease, and eventually develop radioactive iodine refractory disease (RAIR). In the past there were limited and ineffective options for systemic therapy for RAIR, but over the last ten to fifteen years the emergence of tyrosine kinase inhibitors (TKIs) has provided important new avenues of treatment for these patients, that are the focus of this review. Currently, Lenvatinib and Sorafenib, multitargeted TKIs, represent the standard first-line systemic treatment options for RAIR thyroid carcinoma, while Cabozantinib is the standard second-line treatment option. Furthermore, targeted therapies for patients with specific targetable molecular abnormalities include Latrectinib or Entrectinib for patients with NTRK gene fusions and Selpercatinib or Pralsetinib for patients with RET gene fusions. Dabrafenib plus Trametinib currently only have tumor agnostic approval in the USA for patients with BRAF V600E mutations, including thyroid cancer. Redifferentiation therapy is an area of active research, with promising initial results, while immunotherapy studies with checkpoint inhibitors in combination with tyrosine kinase inhibitors are underway.

Human Development Index and its association with staff spiritual care provision: a Middle Eastern oncology study.

BACKGROUND: Although staff spiritual care provision plays a key role in patient-centered care, there is insufficient information on international variance in attitudes toward spiritual care and its actual provision. METHODS: A cross-sectional survey of the attitudes of Middle Eastern oncology physicians and nurses toward eight examples of staff provision of spiritual care: two questionnaire items concerned prayer, while six items related to applied information gathering, such as spiritual history taking, referrals, and encouraging patients in their spirituality. In addition, respondents reported on spiritual care provision for their last three advanced cancer patients. RESULTS: Seven hundred seventy responses were received from 14 countries (25% from countries with very high Human Development Index (HDI), 41% high, 29% medium, 5% low). Over 63% of respondents positively viewed the six applied information gathering items, while significantly more, over 76%, did so among respondents from very high HDI countries (p value range, p < 0.001 to p = 0.01). Even though only 42-45% overall were positively inclined toward praying with patients, respondents in lower HDI countries expressed more positive views (p < 0.001). In interaction analysis, HDI proved to be the single strongest factor associated with five of eight spiritual care examples (p < 0.001 for all). Significantly, the Middle Eastern respondents in our study actually provided actual spiritual care to 47% of their most recent advanced cancer patients, compared to only 27% in a parallel American study, with the key difference identified being HDI. CONCLUSIONS: A country's development level is a key factor influencing attitudes toward spiritual care and its actual provision. Respondents from lower ranking HDI countries proved relatively more likely to provide spiritual care and to have positive attitudes toward praying with patients. In contrast, respondents from countries with higher HDI levels had relatively more positive attitudes toward spiritual care interventions that involved gathering information applicable to patient care.

Training for awareness of one's own spirituality: A key factor in overcoming barriers to the provision of spiritual care to advanced cancer patients by doctors and nurses.

OBJECTIVE: When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist. We aimed to study these barriers in a new cultural context and analyzed a new subgroup with "unrealized potential" for improved spiritual care provision: those who are positively inclined toward spiritual care yet do not themselves provide it. METHOD: We distributed the Religion and Spirituality in Cancer Care Study via the Middle East Cancer Consortium to physicians and nurses caring for advanced cancer patients. Survey items included how often spiritual care should be provided, how often respondents themselves provide it, and perceived barriers to spiritual care provision.ResultWe had 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern countries. The results showed that 82% of respondents think staff should provide spiritual care at least occasionally, but 44% provide spiritual care less often than they think they should. In multivariable analysis of respondents who valued spiritual care yet did not themselves provide it to their most recent patients, predictors included low personal sense of being spiritual (p < 0.001) and not having received training (p = 0.02; only 22% received training). How "developed" a country is negatively predicted spiritual care provision (p < 0.001). Self-perceived barriers were quite similar across cultures.Significance of resultsDespite relatively high levels of spiritual care provision, we see a gap between desirability and actual provision. Seeing oneself as not spiritual or only slightly spiritual is a key factor demonstrably associated with not providing spiritual care. Efforts to increase spiritual care provision should target those in favor of spiritual care provision, promoting training that helps participants consider their own spirituality and the role that it plays in their personal and professional lives.

Communication and integration: a qualitative analysis of perspectives among Middle Eastern oncology healthcare professionals on the integration of complementary medicine in supportive cancer care.

CONTEXT AND OBJECTIVES: The use of complementary and traditional medicine (CTM ) in Middle Eastern countries is widespread, including among patients with cancer. Perspectives of oncology healthcare professionals (HCPs) in this region regarding the integration of CTM within conventional supportive cancer care were explored. METHODS: An 11-item questionnaire with an open-ended question asking respondents to comment about the integration of CTM within supportive cancer care was sent to Middle Eastern oncology HCPs, using snowball sampling methodology. The narratives provided were examined using thematic analysis. RESULTS: A total of 339 oncology HCPs completed and returned the study tool (80.3 % response rate ), of which 178 from 15 Middle Eastern countries responded to the open-ended question. The majority of respondents are in favor of the integration of CTM within supportive cancer care, though ideas on how this should be implemented varied. Thematic analysis identified multifactorial barriers to integration, which focused on HCPs' perspectives (e.g., a lack of knowledge and training; a skeptical approach to CTM), attitudes of patients and caregivers (e.g., unrealistic expectations regarding the outcomes of CTM treatments) and HCP-patient communication. In order to overcome these barriers, respondents suggested education and training programs for oncology HCPs which would focus on improving patients' quality-of-life-related outcomes. CONCLUSIONS: Middle Eastern oncology HCPs support the integration of CTM within supportive cancer care, while recognizing the need for education and training in this field. A better understanding of CTM would provide the knowledge and skills which would promote a non-judgmental, evidence-based approach, fostering better communication with patients.

Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle Eastern oncology health care professionals.

BACKGROUND: The authors assessed the use of herbal medicine by Middle Eastern patients with cancer, as reported by their oncology health care professionals (HCPs). Herbal products identified by the study HCPs were evaluated for potential negative effects. METHODS: Oncology HCPs from 16 Middle Eastern countries received a 17-item questionnaire asking them to list 5 herbal products in use by their patients with cancer. A literature search (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database) was conducted to identify safety-related concerns associated with the products listed. RESULTS: A total of 339 HCPs completed the study questionnaire (response rate of 80.3%), identifying 44 herbal and 3 nonherbal nutritional supplements. Safety-related concerns were associated with 29 products, including herb-drug interactions with altered pharmacodynamics (15 herbs), direct toxic effects (18 herbs), and increased in vitro response of cancer cells to chemotherapy (7 herbs). CONCLUSIONS: Herbal medicine use, which is prevalent in Middle Eastern countries, has several potentially negative effects that include direct toxic effects, negative interactions with anticancer drugs, and increased chemosensitivity of cancer cells, requiring a reduction in dose-density. Oncology HCPs working in countries in which herbal medicine use is prevalent need to better understand the implications of this practice. The presence of integrative physicians with training in complementary and traditional medicine can help patients and their HCPs reach an informed decision regarding the safety and effective use of these products.

Integration of complementary medicine in supportive cancer care: survey of health-care providers' perspectives from 16 countries in the Middle East.

INTRODUCTION: In this multinational Middle-Eastern study, we assessed health-care providers' (HCPs) perspectives on their patients' use of complementary and traditional medicine (CTM) and identified the leading barriers to CTM integration in supportive cancer care. METHODS: A 17-item questionnaire was developed and administered to HCPs attending palliative medicine workshops conducted across the Middle East by the Middle East Cancer Consortium. RESULTS: 339 HCPs from 16 countries across the Middle East completed the questionnaire (80.3 % response rate). Respondents perceived their patients' reasons for CTM use primarily in the context of cancer cure (63 %) and quality of life (QOL) improvement (57 %). Expectation regarding CTM's role in cancer cure/survival was more pronounced in Turkey, Jordan, the Palestinian Authority, and the Persian Gulf area. In contrast, the expectation that CTM would improve QOL was more emphasized in Israel. A mid-position between the cure/survival and QOL poles was observed in Cyprus, Lebanon, and the North African countries. Leading barriers to CTM integration in supportive cancer care included oncologists' skepticism and a gap between patients' expectations and HCP's objectives. Respondents' leading recommendation to HCPs was to communicate integrative care emphasizing well-being and improved functioning in accordance with their patients' health beliefs. CONCLUSION: CTM integration in supportive cancer care can be facilitated by implementing a platform for Middle Eastern clinical collaborations. HCPs' expectations and experiences with CTM have been positive in the oncology setting. These data need to be corroborated with information of patients' expectations on the provision of CTM over all phases of the oncology treatment.