The first Middle East and North Africa expert consensus recommendations for the management of advanced colorectal cancer.

Colorectal cancer (CRC) is ranked as the third most prevalent and the second deadliest cancer worldwide. In the Middle East and North Africa (MENA) region, the number of CRC cases increased over the past decades and will nearly double by 2030. The lack of clear MENA guidelines for the management of patients with CRC represents a step backwards in the fight against this burden. Therefore a panel of 24 MENA experts in the field of gastrointestinal oncology developed, using a Delphi process, the first consensus recommendations for the management of patients with advanced CRC. Forty-seven different statements were formulated in the areas of epidemiology, screening, biomarkers and treatment. These recommendations will guide, standardize and unify the management of this cancer in the MENA region.

Nivolumab as Second-Line Therapy Improves Survival in Patients with Unresectable Hepatocellular Carcinoma.

BACKGROUND: Limited data exists for the efficacy and outcomes of nivolumab as a second-line treatment for unresectable hepatocellular carcinoma (uHCC). We aimed to assess the efficacy and safety of nivolumab in patients with uHCC who experienced disease progression during sorafenib treatment. METHODS: In this retrospective, observational, multicenter study, adult Child-Turcotte-Pugh A/7B patients with uHCC who tolerated sorafenib therapy but showed disease progression switched to second-line intravenous nivolumab (n = 42). A similar number of consecutive, unselected patients who were maintained on sorafenib therapy, regardless of tumoral response or progression, served as historical controls (n = 38). The primary endpoint was overall survival (OS, defined as the time from starting sorafenib in either group up to death due to any cause) and analyzed by intention-to-treat. RESULTS: The mean age of the overall cohort was 72.4 ± 10.1 years, of whom 87.5% were males and 58.8% had underlying viral etiology. Patients in the two cohorts were similar, except those who received nivolumab had more co-morbidities (70.0% vs. 15.4%), ECOG-2 status (21.4% vs. 15.8%), BCLC stage C (81.0% vs. 47.4%), and extravascular invasion (54.4% vs. 21.8%) (p < 0.05 for all). More patients in the nivolumab arm were Child-Turcotte-Pugh B (35.7% vs. 21.1%, p = 0.15). Median OS was 22.2 months (95% CI: 8.9-49.8) on second-line nivolumab and 11.0 months (95% CI: 3.6-18.4) on sorafenib alone (HR 1.93; 95% CI: 1.1-3.3, p = 0.014). Median OS after starting nivolumab was 10.2 months, and time-to-progression was 4.9 months (95% CI: 3.2-6.3). CONCLUSION: Nivolumab is an effective second-line treatment option in patients with uHCC who progress on sorafenib, with significantly improved OS. These early real-life data offer encouraging results, similar to those shown in Phase I/IIa clinical trials. Further investigations are warranted for the use of nivolumab as a monotherapy.

Cardiac Morbidity and Mortality in Patients with Sarcoma: A Population-Based Study.

Background: Soft tissue sarcoma (STS) is a rare malignancy that affects soft tissues. It encompasses various subtypes and requires different treatment strategies. Doxorubicin is a commonly used anthracycline in the management of localized and metastatic STS. However, high doses of doxorubicin are associated with cardiotoxicity, which can significantly impact patients' long-term outcomes. This study aimed to evaluate doxorubicin's effect on cardiac function in patients with sarcoma and to correlate the frequency of cardiotoxicity with potential risk factors. Methods: A retrospective analysis was conducted on patients with sarcoma who were treated with doxorubicin between 2016 and 2022 at King Abdulaziz Medical City in Saudi Arabia. Patient demographic information, comorbidities, cardiac measurements, laboratory values, systemic therapy, and treatment outcomes were collected from electronic medical records. A statistical analysis was performed to assess the association between cardiotoxicity and various factors. Results: A total of 133 patients were included in the study, with a median age of 30 years. Cardiotoxicity was observed in 9% of the patients. Female patients had a significantly higher risk of developing cardiotoxicity. Patients with a higher Eastern Cooperative Oncology Group (ECOG) performance status and lower troponin I levels also had an increased risk of cardiotoxicity. However, there was no significant association between cardiotoxicity and the number of chemotherapy cycles, total cumulative dose of doxorubicin, or history of radiation. Furthermore, patients with cardiotoxicity had a higher risk of mortality. The overall survival of the patients was 18 months. Conclusion: Doxorubicin-associated cardiotoxicity is a concern for patients with sarcoma. Female patients and patients with a higher ECOG performance status are at an increased risk of developing cardiotoxicity. Careful monitoring and risk assessment are crucial for mitigating the adverse effects of doxorubicin treatment in patients with sarcoma. Future studies are warranted to validate these findings and explore preventive strategies for doxorubicin-induced cardiotoxicity in patients with sarcoma.

Social Distress among Cancer Patients: Differential Effects of Risk Factors and Attenuating Role of Culturally Specific Social Support.

Introduction: We investigated the association between social distress or toxicity and patients' clinical conditions, demographic characteristics, and social support and networks, and whether this association differs along the distribution of patients' distress levels. This study included 156 patients treated at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods: We used the previously validated Social Toxicity Assessment Tool in Cancer (STAT-C) to assess cancer patients' distress. We analyzed distress level, the outcome variable of interest, and covariates to show distribution and identify associations. We then used logistic quantile regression for bounded outcomes to assess the association between social distress or toxicity and patients' clinical conditions, demographic characteristics, and social support and network. As an extension, we examined the interaction between disease status and social support, focusing on the moderating role of social support in attenuating the impact of disease status on social distress. Results: The median age of the patients was 51.2 (SD = 21.4, range 22 to 89), with 48.1% being older than 50 years. Of the 156 cancer patients analyzed, 82 (52.6%) were classified as burdened, and 50% of those with uncontrolled disease status were socially distressed. However, there were more socially distressed patients diagnosed within a year and patients undergoing treatment. There was a greater number of patients who shared their diagnosis with family, colleagues, and neighbors with social distress. The odds of suffering from social distress were higher in younger patients (50 years or younger) than in older patients. Social distress was lower in patients who underwent combined chemotherapy, surgery, and radiation compared with patients who received a single treatment regimen (OR = 0.65, CI, -0.820 to -0.036, p = 0.033). The odds of social distress were 67% higher in patients diagnosed within one year than in patients diagnosed more than one year prior (OR = 1.664, CI, 0.100-0.918, p = 0.015). Patients with uncontrolled disease conditions who shared their diagnosis and treatment with social networks were 48% less likely to experience social distress. Thus, sharing cancer diagnoses with social networks has a statistically significant moderating effect by attenuating the impact of disease status on social distress. Conclusion: Understanding the risk factors for social distress may be important for cancer management. Additionally, identifying the moderating role that patients' sharing of cancer diagnoses in social networks plays in attenuating the impact of disease status on social distress may provide healthcare providers with valuable insights for holistic culture-specific care.

Antibiotic Exposure Concurrently with Anti-PD1 Blockade Therapy Reduces Overall Survival in Patients with Child-Pugh Class A Advanced Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide with a poor prognosis. Treatment with immune checkpoint inhibitors (ICIs) has improved overall survival in patients with HCC. However, not all patients benefit from the treatment. In this study, 59 patients with HCC were enrolled from two medical centers in Saudi Arabia, with 34% using antibiotics concurrently with their Nivolumab (anti-PD1 blockade). The impact of antibiotic use on the clinical outcomes of patients with HCC undergoing treatment with anti-PD1 blockade was examined. The patients' overall survival (OS) was 5 months (95% CI: 3.2, 6.7) compared to 10 months (95% CI: 0, 22.2) (p = 0.08). Notably, patients with Child-Pugh A cirrhosis receiving anti-PD1 blockade treatment without concurrent antibiotic use showed a significantly longer median OS reaching 22 months (95% CI: 6.5, 37.4) compared to those who were given antibiotics with a median OS of 6 months (95% CI: 2.7, 9.2) (p = 0.02). This difference in overall survival was particularly found in Child-Pugh class A patients receiving anti-PD1 blockade. These findings suggest that antibiotic use may negatively affect survival outcomes in HCC patients undergoing anti-PD1 blockade, potentially due to antibiotic-induced alterations to the gut microbiome impacting the anti-PD1 blockade response. This study suggests the need for careful consideration when prescribing antibiotics to patients with HCC receiving anti-PD1 blockade.

Egyptian Society of Liver Cancer Recommendation Guidelines for the Management of Hepatocellular Carcinoma.

Globally, hepatocellular carcinoma (HCC) is the fourth most common cause of death from cancer. The prevalence of this pathology, which has been on the rise in the last 30 years, has been predicted to continue increasing. HCC is the most common cause of cancer-related morbidity and mortality in Egypt and is also the most common cancer in males. Chronic liver diseases, including chronic hepatitis C, which is a primary health concern in Egypt, are considered major risk factors for HCC. However, HCC surveillance is recommended for patients with chronic hepatitis B virus (HBV) and liver cirrhosis; those above 40 with HBV but without cirrhosis; individuals with hepatitis D co-infection or a family history of HCC; and Nonalcoholic fatty liver disease (NAFLD) patients exhibiting significant fibrosis or cirrhosis. Several international guidelines aid physicians in the management of HCC. However, the availability and cost of diagnostic modalities and treatment options vary from one country to another. Therefore, the current guidelines aim to standardize the management of HCC in Egypt. The recommendations presented in this report represent the current management strategy at HCC treatment centers in Egypt. Recommendations were developed by an expert panel consisting of hepatologists, oncologists, gastroenterologists, surgeons, pathologists, and radiologists working under the umbrella of the Egyptian Society of Liver Cancer. The recommendations, which are based on the currently available local diagnostic aids and treatments in the country, include recommendations for future prospects.

Developing, Implementing, and Validating a Social Toxicity Assessment Tool of Cancer.

PURPOSE: The social impact of cancer on patients and their family is well known. Yet, unlike with physical and financial toxicities, no validated tools are available to measure this impact. This study aimed at developing, validating, and implementing a novel social toxicity assessment tool for patients with cancer diagnosis (STAT-C). METHODS: Questions were generated through multiple steps including focus groups of patients, their families, and oncology care professionals. These steps along with relevant literature resulted in the development of an initial 20-item questionnaire. Content validity and relevance of the tool were assessed using Content Validity Index for individual items and Content Validity Index for the entire scale. Following expert examination, the constructed STAT-C tool consisted of 14 items grouped into three domains-social relations, social activities, and economic impact. Based on the total possible score for the survey in 150 patients for all the items, three levels of a socioeconomic toxicity were determined-severe social toxicity, mild social toxicity, and no social toxicity. RESULTS: The 14 items were marked as relevant, and the Content Validity Index for individual items ranged between 0.80 and 1.00. An overall average Content Validity Index for the entire scale of 0.87 showed high content validity of the constructed tool. Exploratory factor analysis revealed retention of 13 items of the constructed STAT-C Tool, which loaded across three factors that mapped groupings into measures of social relations, social activities, and economic impact domains. CONCLUSION: Our study revealed that STAT-C is a valid, reliable tool, and well captures and measures unique and pertinent social toxicity constructs for Arabic-speaking patients. The tool should enable oncology professionals to deliver better patient-centered care as a component of a comprehensive approach.

Reducing Futile Acute Care Services for Terminally Ill Patients With Cancer: The Dignity Project.

PURPOSE: Patients with terminal diseases frequently undergo interventions that are futile and may be detrimental to their quality of life. We conducted a quality improvement project aimed to reduce the utilization of futile acute care services (ACSs) for patients with cancer treated with a palliative intent. METHODS: A multidisciplinary team reviewed the records of terminally ill patients with cancer who died between November 2017 and May 2018, during their admission at our institution. The review aimed to assess the magnitude of improper utilization of ACSs and admission to the intensive care unit (ICU). Lack of timely documentation of the goals of care (GOCs) was the main reason for this problem. We defined timely documentation as the availability of electronic documentation of patients' GOC before the need for ACSs. Interventions were implemented to improve the process; postintervention data were captured and compared with the baseline data. RESULTS: After the delivery of staff education and the implementation of mandatory documentation of the GOCs in the healthcare electronic record system, the timely documentation of the GOCs for patients with a palliative intent increased significantly from 59% at baseline to 83% in the postintervention phase. The impact of this intervention led to a decrease in admissions to the ICU from 26% to 12% and an estimated annual cost saving of $777,600 in US dollars. CONCLUSION: Our interventions resulted in improved documentation of the GOCs and decrease in the utilization of ACSs including ICU admissions and the associated cost.

Enhancing the performance of gastrointestinal tumour board by improving documentation.

Tumour board contributes to providing better patient care by using a multidisciplinary team approach. In the efforts of evaluating the performance of the gastrointestinal tumour board at our institution, it was difficult to assess past performance due to lack of proper use of standardised documentation tool. This project aimed at improving adherence to the documentation tool and its recommendations in order to obtain performance measures for the tumour board. A multidisciplinary team and a plan were developed to improve documentation. Four rapid improvement cycles, Plan-Do-Study-Act (PDSA) cycles, were conducted. The first cycle focused on updating the case discussion summary form (CDSF) based on experts' input and previous identified deficiencies to enhance documentation and improve performance. The second PDSA cycle aimed at incorporating the CDSF into the electronic medical records system and assessing its functionality. The third cycle was to orient and train staff on using the form and launching it. The fourth PDSA cycle aimed at assessing the ability to obtain tumour board performance measures. Adherence to completion of the CDSF improved from 82% (baseline) to 94% after the fourth PDSA cycle. Over 104 consecutive cases discussed in the tumour board between January and July 2016 and 76 cases discussed in 2015, results were as follows: adherence to National Comprehensive Cancer Network guidelines in 2016 was observed in 141 (95%) recommendations, while it was observed in 90 (92%) recommendations in 2015. Changes in the management plans were observed in 37 (36%) cases in 2016 and in 6 (8%) cases in 2015. Regarding tumour board recommendations, 87% were done within 3 months of tumour board discussion in 2016, while 69% were done in 2015. Implementing electronic standardised documentation tool improved communication among the team and enabled getting accurate data about performance measures of the tumour board with positive impact on healthcare process and outcomes.

Impact of GI Tumor Board on Patient Management and Adherence to Guidelines.

PURPOSE: As the burden of cancer on the population and the health care system continues to increase with more complicated treatment options, the need for multidisciplinary teams to be as efficient as possible becomes more vital. Our study aimed to evaluate the consistency of GI Tumor Board (GI TB) recommendations with international guidelines, the adherence of physicians involved in patient care to TB recommendations, and the impact on the management of patients. METHODS: A prospective cohort study was conducted from January to June 2016 at our institution, which is a major tertiary hospital that provides comprehensive cancer care. All cases presented at the GI TB during this period were included. Data regarding adherence to National Comprehensive Cancer Network guidelines, adherence to TB recommendations, and changes made to the management of patients were collected weekly from the GI TB in a data collection form. RESULTS: Of the 104 patients included, 57 (55%) were males and the median age was 58 (16 to 85) years. Colorectal cancer was the most common diagnosis, in 65 patients (63%). Nearly one-half of cases (45%) were stage IV cancers. Starting new treatment was recommended for 72 patients (69%). Further investigations were requested for 15 patients (14%). For imaging, 24 recommendations (23%) were made. Adherence to National Comprehensive Cancer Network guidelines was observed in 97% of total recommendations. New findings were found in pathology (11%), radiology (13%), and staging (4%). Management plans were changed in 37 cases (36%). Over a 3-month period after presentation to the GI TB, most of the recommendations (87%) were performed. CONCLUSION: A multidisciplinary tumor board enhances the adherence to guidelines and has an impact on patient management in approximately one-third of patients. Among physicians, adherence to recommendations of the TB was high.

Improving physician's hand over among oncology staff using standardized communication tool.

Cancer patients are frequently admitted to hospital for many reasons. During their hospitalization they are handled by different physicians and other care providers. Maintaining good communication among physicians is essential to assure patient safety and the delivery of quality patient care. Several incidents of miscommunication issues have been reported due to lack of a standardized communication tool for patients' hand over among physicians at our oncology department. Hence, this improvement project aims at assessing the impact of using a standardized communication tool on improving patients' hand over and quality of patient care. A quality improvement team has been formed to address the issue of cancer patients' hand over. We adopted specific hand over tool to be used by physicians. This tool was developed based on well-known and validated communication tool called ISBAR - Identify, Situation, Background, Assessment and Recommendation, which contains pertinent information about the patient's condition. The form should be shared at a specific point in time during the handover process. We monitored the compliance of physician's with this tool over 16 weeks embedded by four 'purposive' and 'sequential' Plan-Do-Study-Act (PDSA) cycles; where each PDSA cycle was developed based on the challenges faced and lessons learned in each step and the result of the previous PDSA cycle. Physicians compliance rate of using the tool had improved significantly from 45% (baseline) to 100% after the fourth PDSA cycle. Other process measure was measuring acknowledgment of hand over receipt email at two checkpoints at 8:00 - 9:00 a.m. and 4:00 - 5:00 p.m. The project showed that using a standardized handover form as a daily communication method between physicians is a useful idea and feasible to improve cancer patients handover with positive impact on many aspects of healthcare process and outcomes.

Saudi oncology society and Saudi urology association combined clinical management guidelines for renal cell carcinoma.

In this report, updated guidelines for the evaluation, medical and surgical management of renal cell carcinoma are presented. They are categorized according the stage of the disease using the tumor node metastasis staging system 7(th) edition. The recommendations are presented with supporting evidence level.

Saudi oncology society and Saudi urology association combined clinical management guidelines for prostate cancer.

In this report, updated guidelines for the evaluation, medical, and surgical management of prostate cancer are presented. They are categorized according the stage of the disease using the tumor node metastasis staging system 7(th) edition. The recommendations are presented with supporting evidence level.

Pancreatic cancer in Saudi patients treated at tertiary institution. Ten years retrospective study.

OBJECTIVES: To describe presentation, management, and outcome, and determine prognostic factors for pancreatic cancer patients. METHODS: A retrospective review of patients diagnosed with pancreatic cancer at King Abdulaziz Medical City, Riyadh, Saudi Arabia during the period from January 2000 to December 2010. Descriptive statistics were conducted on the collected data and survival was estimated using the Kaplan Meier estimate. Univariate and multiple regression analyses were carried out. RESULTS: The medical records of 179 patients were reviewed. The patients' median age was 63 years ranging from 15-96 years, and 116 (64.8%) of them were male. The one-year survival rate was 39% and the 5-year survival was 10%. The median overall survival (OS) was 6.9 months. Age at diagnosis, grade, T stage, N stage, M stage, TNM stage group, and the combined stage group (stage III/IV versus others), site of distant metastasis, carcinoembryonic antigen (CEA), carbohydrate antigen 19-9, surgery and chemotherapy were significant predictors for OS on an univariate Cox proportional hazards regression analysis. A multiple regression model including all the significant predictors was conducted. Age at the time of diagnosis and M stage were significant variables. CONCLUSION: Our patients present at a younger age and have better 5-year survival compared with the United States Surveillance Epidemiology and End Results data, which deserves further evaluation. Age and disease stage were identified as independent prognostic factors for survival in this patient population.