Planning cancer control in Latin America and the Caribbean.

Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.

Does Multidisciplinary Team Management Improve Clinical Outcomes in NSCLC? A Systematic Review With Meta-Analysis.

Introduction: The implementation of multidisciplinary teams (MDTs) has been found to be effective for improving outcomes in oncology. Nevertheless, there is still a dearth of robust literature on patients with NSCLC. The aim of this study was to conduct a systematic review regarding the impact of MDTs on patient with NSCLC outcomes. Methods: Databases were systematically searched up to February 2023. Two reviewers independently performed study selection and data extraction. Risk of bias was evaluated using the Newcastle-Ottawa and certainty of evidence by the Grading of Recommendations Assessment, Development and Evaluation approach. Overall survival was the primary outcome. Secondary outcomes included mortality, length of survival, progression-free survival, time from diagnosis to treatment, complete staging, treatment received, and adherence to guidelines. A meta-analysis with a random-effect model was performed. Statistical analysis was performed with the R 3.6.2 package. Results: A total of 22 studies were included in the systematic review. Ten outcomes were identified, favoring the MDT group over the non-MDT group. Pooled analysis revealed that patients managed by MDTs had better overall survival (three studies; 38,037 participants; hazard ratio 0.60, 95% confidence interval [CI]: 0.49-0.75, I2 = 78%), shorter treatment time compared with patients in the non-MDT group (six studies; 15,235 participants; mean difference = 12.20 d, 95% CI: 10.76-13.63, I2 = 63%), and higher proportion of complete staging (four studies; 14,925 participants; risk ratio = 1.36, 95% CI: 1.17-1.57, I2 = 89%). Conclusions: This meta-analysis revealed that MDT-based patient care was associated with longer overall survival and better quality-of-care-related outcomes.

Independent radiologic review in metastatic colorectal cancer: systematic review and meta-analysis.

PURPOSE: To perform a meta-analysis addressing evaluation bias in local radiologic assessment (LRA) of lesions when compared with independent radiologic review (IRR) in randomized controlled trials (RCTs) testing chemotherapy for metastatic colorectal cancer (CRC). MATERIALS AND METHODS: MEDLINE, EMBASE, ClinicalTrials.gov, the Cochrane Library, and Web sites for major medical meetings were searched for RCTs of chemotherapy for metastatic CRC that reported response evaluation by both LRA and IRR. The risk ratios (RRs) of response in the experimental (RR(exp)) and control (RR(cont)) arms were calculated (response rate in LRA divided by response rate in IRR) for each selected study. The ratio of RR of response was calculated (RR of response of LRA divided by RR of response of IRR). The random-effects model was applied. Meta-regression was used to examine the effect of study characteristics on outcomes. RESULTS: LRA and IRR results were concordant (13 studies; 7742 patients; ratio of RR of response = 0.97; 95% confidence interval [95% CI]: 0.90, 1.04; P = .35). However, LRA overestimated tumor response independently of therapy allocation (interaction test, P = .81) both in control (RR(cont), 1.163; 95% CI: 1.086, 1.246; P < .001) and experimental (RR(exp), 1.156; 95% CI: 1.093, 1.222; P < .001) therapies. Meta-regression did not show any effect of trial characteristics on effects. CONCLUSION: LRA yields higher response rates in RCTs testing chemotherapy for metastatic CRC, although there was no sign of bias toward experimental therapy. The need for IRR to control evaluation bias must be reappraised.

Is Age-targeted full-field digital mammography screening cost-effective in emerging countries? A micro simulation model.

OBJECTIVE: The present paper estimates the cost-effectiveness of population-based breast cancer (BC) screening strategies in Brazil for women under 50 years from the perspective of the Brazilian public health system. METHODS: A Markov model, simulating the natural history of female BC sufferers in Brazil, was developed. This model compares the lifetime effects, costs, and cost-effectiveness of seven BC screening strategies in women between 40 to 49 years: (A) usual care; (B) annual screen-film mammography (SFM); (C) SFM every 2 years; (D) annual full-field digital mammography (FFDM); (E) FFDM every 2 years; and (F and G) age-targeted options, with FFDM annually until 49 years and SFM annually (or biannually) from 50 to 69 years. RESULTS: Adopting SFM every 2 years (Strategy C) was found to be slightly more costly but also more effective in terms of quality-adjusted life years (QALYs), yielding an incremental cost-effectiveness ratio (ICER) of R$ 1,509 per QALY gained. Annual SFM (Strategy B) was the next best option at an additional R$ 13,131 per QALY gained. FFDM annual screening (Strategy E) was dominated by Strategy F, the age-targeted option. For younger women, the age-based strategy had an ICER of R$ 30,520 per QALY gained. In the sensitivity analysis, the ICERs ranged from R$ 15,300 to R$ 257,899 in different regions of the country, depending on BC incidence, population age distribution, and mammography coverage. CONCLUSIONS: SFM every 2 years for all women starting between the ages of 40 and 49 would be a cost-effective strategy. Taking into account regional specificities, age-targeted FFDM is one option to improve the outcomes of BC patients in an emerging country.

Modified FLOX as first-line chemotherapy for metastatic colorectal cancer patients in the public health system in Brazil: Effectiveness and cost-utility analysis.

Incorporation of new drugs for treatment of metastatic colorectal cancer (mCRC) has led to a clear improvement in overall patient survival, the added cost of treatment, however, is a major concern worldwide. The cost-effectiveness of using a modified FLOX (mFLOX) regimen for treating mCRC patients was delineated. In this study, 82 consecutive mCRC patients were treated with leucovorin (LV) at 20 mg/m2 in combination with weekly bolus of 5-fluorouracil (5-FU) (500 mg/m2) for 6 consecutive weeks and oxaliplatin (85 mg/m2) at weeks 1, 3 and 5, every 8 weeks. Overall survival (OS) and toxicity were evaluated. A Markov Model with a 2-year time horizon and 2-week cycles was developed, comparing mFLOX and mFOLFOX6 in a Brazilian environment. Health outcomes were measured in quality-ajusted life years (QALYs). The median overall period of survival was 19 months, while the estimated 1-year survival was 75%. Response by RECIST was assessed in 33 patients. Partial response was observed in 39.4% of patients, while 36.3% were stable. The mFLOX regimen cost was BRL 9,000, while the mFOLFOX6 BRL 22,000 (1 EUR=2.29 BRL), leading to an incremental costed of BRL 13,000, considering a 20-week period of first-line therapy. The incremental effect of the mFOLFOX was of 0,117 QALY. The incremental cost-effectiveness ratio of mFOLFOX6 was of BRL 110,344/QALY. The sensitivity analysis detected no differences in the outcome measures. In conclusion, the mFLOX is an active regimen in mCRC patients, possibly providing a cost-effective option in public health systems.

Neurokinin-1 receptor antagonists for chemotherapy-induced nausea and vomiting: a systematic review.

BACKGROUND: The addition of neurokinin-1 receptor (NK1R) antagonists to antiemetic regimens has substantially reduced chemotherapy-induced nausea and vomiting (CINV). We sought to systematically review the overall impact of NK1R antagonists on CINV prevention. METHODS: We systematically searched the MEDLINE, EMBASE, and CENTRAL databases, and meeting proceedings for randomized controlled trials (RCTs) that evaluated NK1R antagonists plus standard antiemetic therapy for CINV prevention. Complete response (CR) to therapy was defined as the absence of emesis and the absence of rescue therapy. The endpoints were defined as CR in the overall phase (during the first 120 hours of chemotherapy), CR in the acute phase (first 24 hours), and the delayed phase (24-120 hours) after chemotherapy, nausea, and toxicity. Subgroup analyses evaluated the type of NK1R antagonist used, the emetogenic potential of the chemotherapy regimen, and prolonged use of 5-HT3 (serotonin) receptor antagonists, a class of standard antiemetic agents. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Statistical tests for heterogeneity were one-sided; statistical tests for effect estimates and publication bias were two-sided. RESULTS: Seventeen trials (8740 patients) were included in this analysis. NK1R antagonists increased the CR rate in the overall phase from 54% to 72% (OR = 0.51, 95% CI = 0.46 to 0.57, P < .001). CR and nausea were improved in all phases and subgroups. The expected side effects from NK1R antagonists did not statistically significantly differ from previous reports; however, this analysis suggests that the incidence of severe infection increased from 2% to 6% in the NK1R antagonist group (three RCTs with a total of 1480 patients; OR = 3.10; 95% CI = 1.69 to 5.67, P < .001). CONCLUSIONS: NK1R antagonists increased CINV control in the acute, delayed, and overall phases. They are effective for both moderately and highly emetogenic chemotherapy regimens. Their use might be associated with increased infection rates; however, additional appraisal of specific data from RCTs is needed.

Os motivos e as expectativas dos pacientes com dispepsia não ulcerosa frente à consulta médica / Reasons and expectations of patients with ulcer-like dyspepsia at the medical visit

O termo dispepsia refere-se a sintomas que se originam no trato gastrintestinal superior, geralmente usado para definir dor ou desconforto abdominal superior. Os critérios de Roma I para o diagnóstico de dispepsia não-ulcerosa são dor ou desconforto abdominal superior crônico ou recorrente, por um período mínimo de um mês, com sintomas presentes em mais de 25por cento do tempo, sem evidências clínicas ou laboratóriais de doença orgânica. Objetivo: avaliar os motivos que trazem os pacientes com dispepsia não-ulcerosa ao médico e identificar suas expectativas frente as possíveis abordagens terapêutica, além de avaliar alguns aspectos psicológicos dos dispépticos e sua relação com a procura dos serviços de saúde. Métodos: Este é um estudo de caso de controles; os casos constituíram-se por 45 pacientes com critérios diagnósticos de dispepsia não-ulcerosa submetidos a endoscopia digestiva alta para excluir doenças orgânicas; os controles foram compostos por 46 pacientes com diversas doenças acompanhados no ambulatório de medicina interna. Os dados foram recolhidos através da aplicação de um questionário padronizado.Resultado: No que se refere aos problemas do cotidiano (estressants ambientais), na época da aconsulta, uma proporção significativa dos casos referiu ter dois (27por cento), o que ocorreu somente em 6 por cento dos controles (OR = 5,2; IC95por cento = 1,22-25,5). Em relação aos motivos que levaram os pacientes a procurar ajuda médica, a exacerbação recente dos sintomas foi mais frequente entre os controles (OR = 0,21;IC95por cento =0,06-0,6) enquanto a "cacerofobia" foi o principal motivo entre os pacientes com dispepsia ( OR = 11,0;IC95por cento = 2,12-76,4), seguido por dúvidas com relação a diagnósticos prévios (OR = 5,5; IC95por cento = 1,03-54,5). Conclusões: A maior prevalência de estressantes ambientais e de comportamento de medo ou dúvida diagnóstica do doente dispéptico sugere a importância dos fatores psicossociais na modulação dos sintomas das doenças funcionais do tubo digestivo, podendo influenciar os objetivos da consulta médica e ter desdobramentos na abordagem terapêutica