IMPRESS-Norway: improving public cancer care by implementing precision medicine in Norway; inclusion rates and preliminary results.

BACKGROUND AND PURPOSE: In Norway, comprehensive molecular tumour profiling is implemented as part of the public healthcare system. A substantial number of tumours harbour potentially targetable molecular alterations. Therapy outcomes may improve if targeted treatments are matched with actionable genomic alterations. In the IMPRESS-Norway trial (NCT04817956), patients are treated with drugs outside the labelled indication based on their tumours molecular profile. PATIENTS AND METHODS: IMPRESS-Norway is a national, prospective, non-randomised, precision cancer medicine trial, offering treatment to patients with advanced-stage disease, progressing on standard treatment. Comprehensive next-generation sequencing, TruSight Oncology 500, is used for screening. Patients with tumours harbouring molecular alterations with matched targeted therapies available in IMPRESS-Norway, are offered treatment. Currently, 24 drugs are available in the study. Primary study endpoints are percentage of patients offered treatment in the trial, and disease control rate (DCR) defined as complete or partial response or stable disease in evaluable patients at 16 weeks (W16) of treatment. Secondary endpoint presented is DCR in all treated patients. RESULTS: Between April 2021 and October 2023, 1,167 patients were screened, and an actionable mutation with matching drug was identified for 358 patients. By the data cut off 186 patients have initiated treatment, 170 had a minimum follow-up time of 16 weeks, and 145 also had evaluable disease. In patients with evaluable disease, the DCR was 40% (58/145). Secondary endpoint analysis of DCR in all treated patients, showed DCR of 34% (58/170). INTERPRETATION: Precision cancer medicine demonstrates encouraging clinical effect in a subset of patients included in the IMPRESS-Norway trial.

Survival after docetaxel for metastatic castration-resistant prostate cancer in a rural health care setting.

Introduction: The aim of this study was to evaluate overall survival of men who received systemic therapy with docetaxel for metastatic castration- resistant prostate cancer (MCRPC) in rural Nordland County, Norway. Prognostic factors related to treatment and other variables were evaluated. Material and methods: Overall, 132 pa- tients were included in this retrospective study covering the years 2009-2022. Uni- and multivariate survival analyses were performed. Results: In this elderly cohort (median age 72 years), weekly low-dose docetaxel was the preferred regimen (44%). Seventy-three percent were treated in the first line. Only 11 patients (8%) were pre-exposed to docetaxel in the hormone-sensitive phase. Median survival was 14.3 months. Prognostic factors for longer survival included higher hemoglobin, lower lactate dehydrogenase, administration of docetaxel as first-line MCRPC treatment, and use of fewer prescription drugs for comorbidity. Pre-exposure to docetaxel did not play a major role, p = 0.76. Conclusions: In this rural health care setting, survival after docetaxel was shorter than reported by other groups. Blood test results were confirmed as important prognostic factors. In the present era of evolving treatment sequences, we recommend monitoring of real-world treatment results.

Sex Differences in Presentation, Treatment, and Survival in Patients Receiving Palliative (Chemo)Radiotherapy for Non-Small Cell Lung Cancer.

BACKGROUND/AIM: The aim of this study was to analyze sex differences in a real-world cohort of patients who received palliative thoracic radiotherapy or chemoradiotherapy for non-small cell lung cancer. PATIENTS AND METHODS: Retrospectively, baseline, treatment, toxicity, and survival data from a single institution were analyzed. The study included 181 patients (82 females, 99 males). RESULTS: Despite borderline significant differences in disease presentation (T and N stage), final assignment to stage II, III or IV was similar. The same was true for target volume size. Neither radiotherapy parameters nor systemic treatment approaches were significantly different. Toxicity profiles and survival were similar too. Less than 1 out of 3 patients experienced high-grade toxicity, largely esophagitis. Median survival was 8.1 (males) versus 7.8 months (females) and the corresponding 2-year survival rates were 16 and 15%, respectively (p=0.78). CONCLUSION: Relevant sex differences were not observed in this study of common radiotherapy regimes such as 10 fractions of 3 Gy or 15 fractions of 2.8 Gy, the latter often combined with carboplatin/vinorelbine chemotherapy.

Percent of remaining life on palliative radiation treatment: solely a function of fractionation?

Background: This study analyzed the percent of remaining life (PRL) on treatment in patients irradiated for bone metastases. Bone metastases were treated together with other target volumes, if indicated, e.g. a 10-fraction treatment course that included brain and bone metastases. PRL was determined by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. Materials and methods: Different baseline parameters were assessed for association with dichotomized PRL (< 5% vs. ≥ 5%). The retrospective study included 219 patients (287 courses of palliative radiotherapy). After univariate analyses, multi-nominal logistic regression was employed. Results: PRL on treatment ranged from 1-23%. Single-fraction radiotherapy resulted in < 5% PRL on treatment in all cases. All courses with 10 fractions resulted in at least 5% PRL on treatment. Significant associations were found between various baseline parameters and PRL category. With fractionation included in the regression model, 3 parameters retained significant p-values: Karnofsky performance status (KPS), none-bone target volume and fractionation (all with p < 0.001). If analyzed without fractionation, none-bone target volume (p < 0.001), hemoglobin (p < 0.001), KPS (p = 0.01), lack of additional systemic treatment (p = 0.01), and hypercalcemia (p = 0.04) were significant. Conclusions: Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS < 70 and those treated for additional target types during the same course are at high risk of spending a larger proportion of their remaining life on treatment.

The LabPS score: Inexpensive, Fast, and Site-agnostic Survival Prediction.

OBJECTIVES: To provide a widely applicable, blood-biomarker-based and performance-status-based prognostic model, which predicts the survival of patients undergoing palliative non-brain radiotherapy. This model has already been examined in a cohort of patients treated for brain metastases and performed well. METHODS: This was a retrospective single-institution analysis of 375 patients, managed with non-ablative radiotherapy to extracranial targets, such as bone, lung, or lymph nodes. Survival was stratified by LabPS score, a model including serum hemoglobin, platelets, albumin, C-reactive protein, lactate dehydrogenase, and performance status. Zero, 0.5, or 1 point was assigned and the final point sum calculated. A higher point sum indicates shorter survival. RESULTS: The LabPS score predicted overall survival very well (median 0.6 to 26.5 mo, 3-month rate 0% to 100%, 1-year rate 0% to 89%), P =0.0001. However, the group with the poorest prognosis (4.5 points) was very small. Most patients with comparably short survival or radiotherapy administered in the last month of life had a lower point sum. Additional prognostic factors, such as liver metastases, opioid analgesic use, and/or corticosteroid medication, were identified. CONCLUSIONS: If busy clinicians prefer a general prognostic model rather than a panel of separate diagnosis-specific/target-specific scores, they may consider validating the LabPS score in their own practice. In resource-constrained settings, inexpensive standard blood tests may be preferable over imaging-derived prognostic information. Just like other available scores, the LabPS cannot identify all patients with very short survival.

Palliative appropriateness criteria: external validation of a new method to evaluate the suitability of palliative radiotherapy fractionation.

BACKGROUND: Recently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life (PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. The purpose of the present study was to validate this novel metric. PATIENTS AND METHODS: The retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The methods were identical to those employed in the score development study. The score was calculated by assigning 1 point each to several factors identified in the original study and using the online calculator provided by the PAC developers. RESULTS: Median survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses. PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk (p < 0.001). The original and present study were not perfectly concordant regarding number and type of baseline parameters that should be included when calculating the PAC score. CONCLUSION: This study supports the dual strategy of PRL and risk of early death calculation, with results stratified for fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding the underlying components of the score, because the original and validation study were only partially aligned.

Prognostic Factors and Independent Validation of a Risk Stratification Model in Octogenarian Patients Irradiated for Brain Metastases.

BACKGROUND/AIM: This study aimed at validation of a prognostic model, originally developed by Rades et al., in an age-restricted, particularly vulnerable subgroup of patients with brain metastases, because international variations in clinical practice and survival outcomes may impact on the performance of survival prediction tools. PATIENTS AND METHODS: Retrospectively, data from a single institution were analyzed. The study included 50 patients managed with palliative whole-brain radiotherapy. The Rades et al. score was assigned and the resulting 3 prognostic strata compared. RESULTS: The 3-month survival rates for the 3 strata were 0, 35, and 41%, respectively (p<0.001 pooled over all strata, log-rank test for Kaplan-Meier curves). However, the prognostic impact of extracranial metastases suggested by Rades et al., together with the performance status and number of brain metastases in their study of 94 patients, was absent. In contrast, cancer type (better survival for breast and melanoma) and lack of steroid treatment were significant in the present study. CONCLUSION: The original Rades et al. score is a useful prognostic model in our validation database. However, additional factors, such as primary cancer type and need to prescribe corticosteroids, appear to play a role and might therefore be considered when performing future large-scale studies.

Improving public cancer care by implementing precision medicine in Norway: IMPRESS-Norway.

BACKGROUND: Matching treatment based on tumour molecular characteristics has revolutionized the treatment of some cancers and has given hope to many patients. Although personalized cancer care is an old concept, renewed attention has arisen due to recent advancements in cancer diagnostics including access to high-throughput sequencing of tumour tissue. Targeted therapies interfering with cancer specific pathways have been developed and approved for subgroups of patients. These drugs might just as well be efficient in other diagnostic subgroups, not investigated in pharma-led clinical studies, but their potential use on new indications is never explored due to limited number of patients. METHODS: In this national, investigator-initiated, prospective, open-label, non-randomized combined basket- and umbrella-trial, patients are enrolled in multiple parallel cohorts. Each cohort is defined by the patient's tumour type, molecular profile of the tumour, and study drug. Treatment outcome in each cohort is monitored by using a Simon two-stage-like 'admissible' monitoring plan to identify evidence of clinical activity. All drugs available in IMPRESS-Norway have regulatory approval and are funded by pharmaceutical companies. Molecular diagnostics are funded by the public health care system. DISCUSSION: Precision oncology means to stratify treatment based on specific patient characteristics and the molecular profile of the tumor. Use of targeted drugs is currently restricted to specific biomarker-defined subgroups of patients according to their market authorization. However, other cancer patients might also benefit of treatment with these drugs if the same biomarker is present. The emerging technologies in molecular diagnostics are now being implemented in Norway and it is publicly reimbursed, thus more cancer patients will have a more comprehensive genomic profiling of their tumour. Patients with actionable genomic alterations in their tumour may have the possibility to try precision cancer drugs through IMPRESS-Norway, if standard treatment is no longer an option, and the drugs are available in the study. This might benefit some patients. In addition, it is a good example of a public-private collaboration to establish a national infrastructure for precision oncology. Trial registrations EudraCT: 2020-004414-35, registered 02/19/2021; ClinicalTrial.gov: NCT04817956, registered 03/26/2021.

Established Serum Biomarkers Are Prognostic Factors in Patients With Oligometastatic Cancer and Brain Involvement.

BACKGROUND/AIM: This study was designed to evaluate the prognostic impact of the previously validated LabBM score (serum lactate dehydrogenase, C-reactive protein, albumin, hemoglobin, platelets) in a new setting, namely patients with a limited number of brain metastases, arbitrarily defined as max. 4 brain lesions, from common tumor types such as lung and breast cancer. A total of 5 metastatic lesions overall were allowed to comply with current definitions of oligometastatic cancer. PATIENTS AND METHODS: For this retrospective single-institution analysis, 101 patients were identified from a previously described, prospectively maintained database. RESULTS: Twenty-one patients (21%) had extracranial metastases. Non-small cell and small cell lung cancer were the prevailing tumor types (78%). Forty-nine patients (49%) had normal blood test results (LabBM score 0 points). Their median survival (23 months) was significantly longer than that of patients with higher LabBM score. In multivariate analysis, LabBM score, performance status and single brain metastasis were associated with significantly better survival. Limited extracranial metastases did not impair prognosis. Patients with LabBM score 0 had a 5-year survival rate of 27% after surgery (n=24) and 39% after stereotactic radiotherapy (n=13), respectively (p=0.3). CONCLUSION: Blood biomarkers can be regarded as surrogate of the metastatic burden in the body, which is not always detectable by imaging methods. In contrast to circulating tumor cells and other emerging markers, the LabBM score is inexpensive. Patients with LabBM score >0 had a 2.8-fold increased risk of death. The score might be helpful in predicting survival improvement provided by ablative local treatment of oligometastases.

Feasibility and efficacy of early docetaxel plus androgen deprivation therapy for metastatic hormone-sensitive prostate cancer in a rural health care setting.

AIM/BACKGROUND: The aim of this study was to evaluate the feasibility and efficacy, in terms of overall survival, of intensified upfront systemic therapy in patients with metastatic hormone-sensitive prostate cancer who lived in rural Nordland County, Norway. PATIENTS AND METHODS: Overall 117 patients were included in this retrospective study. Three cohorts were created: early docetaxel and androgen deprivation therapy (ADT; the CHAARTED regimen; n = 37), ADT only during the same time period (2014-2020; n = 33), and ADT only in the years 2009-2014 (n = 47). RESULTS: Four patients (11%) did not complete 6 cycles of docetaxel, one of these due to early progression of cancer. During follow-up, 8 patients (22%) progressed to castration-resistant disease (mCRPC), compared to 24 (73%) with ADT only and 35 (75%) in the historical cohort, p = 0.000001. Such progression occurred within 12 months in 3 patients (8%) treated with docetaxel and 9 patients (27%) treated with ADT only during the same time period, p = 0.05. Median survival was 56 months (95% CI: 40-72 months), compared to 30 months in both other cohorts. 3-year survival rates were 79%, 38% and 37%, respectively (p = 0.016). In multivariate analysis, the CHAARTED regimen was associated with significantly improved survival. CONCLUSION: In this rural health care setting, early docetaxel was feasible and effective in reducing progression to mCRPC and prolonging survival. Median survival was very close to the 58 months reported in the CHAARTED trial.

Ipilimumab in a real-world population: A prospective Phase IV trial with long-term follow-up.

Ipilimumab was the first treatment that improved survival in advanced melanoma. Efficacy and toxicity in a real-world setting may differ from clinical trials, due to more liberal eligibility criteria and less intensive monitoring. Moreover, high costs and lack of biomarkers have raised cost-benefit concerns about ipilimumab in national healthcare systems and limited its use. Here, we report the prospective, interventional study, Ipi4 (NCT02068196), which aimed to investigate the toxicity and efficacy of ipilimumab in a real-world population with advanced melanoma. This national, multicentre, phase IV trial included 151 patients. Patients received ipilimumab 3 mg/kg intravenously and were followed for at least 5 years or until death. Treatment interruption or cessation occurred in 38%, most frequently due to disease progression (19%). Treatment-associated grade 3 to 4 toxicity was observed in 28% of patients, and immune-related toxicity in 56%. The overall response rate was 9%. Median overall survival was 12.1 months (95% CI: 8.3-15.9); and progression-free survival 2.7 months (95% CI: 2.6-2.8). After 5 years, 20% of patients were alive. In a landmark analysis from 6 months, improved survival was associated with objective response (HR 0.16, P = .001) and stable disease (HR 0.49, P = .005) compared to progressive disease. Poor performance status, elevated lactate dehydrogenase and C-reactive protein were identified as biomarkers. This prospective trial represents the longest reported follow-up of a real-world melanoma population treated with ipilimumab. Results indicate safety and efficacy comparable to phase III trials and suggest that the use of ipilimumab can be based on current cost-benefit estimates.

The LabBM score is an excellent survival prediction tool in patients undergoing palliative radiotherapy.

BACKGROUND AND AIM: The prognostic assessment of patients referred for palliative radiotherapy can be conducted by site-specific scores. A quick assessment that would cover the whole spectrum could simplify the working day of clinicians who are not specialists for a particular disease site. This study evaluated a promising score, the LabBM (validated for brain metastases), in patients treated for other indications. MATERIALS AND METHODS: The LabBM score was calculated in 375 patients by assigning 1 point each for C-reactive protein and lactate dehydrogenase above the upper limit of normal, and 0.5 points each for hemoglobin, platelets and albumin below the lower limit of normal. Uni- and multivariate analyses were performed. RESULTS: Median overall survival gradually decreased with increasing point sum (range 25.1-1.1 months). When grouped according to the original three-tiered model, excellent discrimination was found. Patients with 0-1 points had a median survival of 15.7 months. Those with 1.5-2 points had a median survival of 5.8 months. Finally, those with 2.5-3.5 points had a median survival of 3.2 months (all p-values ≤ 0.001). CONCLUSION: The LabBM score, which is derived from inexpensive blood tests and easy to use, stratified patients into three very distinct prognostic groups and deserves further validation.

Recursive Partitioning Analysis of Systemic Therapy after Radiotherapy in Patients with Brain Metastases.

PURPOSE: The purpose of this study was to identify factors associated with the initiation or continuation of systemic treatment after brain irradiation. The outcome of interest was a utilization rate of at least 75%, given that active extracranial disease is common in patients with brain metastases. If left untreated, extracranial disease limits survival, regardless of successful local treatment of the brain metastases. In this context, systemic therapy has been shown to improve survival, e.g., after whole-brain radiotherapy. PATIENTS AND METHODS: The study included 185 patients with active extracranial disease, 60% of whom received systemic therapy. RESULTS: Survival from the start of brain irradiation was longest in patients who received additional immune checkpoint inhibitors, endocrine treatment, or anti-HER-2 drugs. After uni- and multivariate analyses, Eastern Cooperative Oncology Group performance status (PS) was selected as the first prediction criterion in the recursive partitioning analysis (RPA) decision tree analysis. RPA was successful for patients with PS 0-1, but patients with PS 2 had lower treatment utilization rates (maximum 60-70%, with a disease-dependent impact of age and LabBM score [blood test results]). The highest utilization rates were observed in (1) patients with PS 0 and (2) those with breast cancer, small-cell lung cancer, or lung adenocarcinoma with PS 1. CONCLUSIONS: These results inform the multidisciplinary discussion and treatment planning for the common scenario of simultaneous intra- and extracranial metastases.

Is there a seasonal variation of survival after systemic chemotherapy for metastatic castration-resistant prostate cancer in a rural part of North Norway?

The winter darkness or polar night induces endocrine and metabolic mechanisms, which might reduce the efficacy of cancer treatment and thus contribute to shorter survival. Moreover, season-and weather-related treatment delays and irregularities might also cause reduced efficacy of anti-cancer drugs. Therefore, this study evaluated the prognostic impact of timing of chemotherapy (start during winter darkness or outside of this season), in terms of overall survival, in patients with metastatic castration-resistant prostate cancer (MCRPC) who received oncology care at the Nordland hospital Bodø. The study included 111 patients treated with first-line docetaxel chemotherapy for MCRPC. Twenty patients (18%) started their treatment during winter darkness (arbitrarily defined as ±4 weeks around 21 December). In unadjusted univariate analysis, survival was shorter in this group (median 10.2 vs. 18.9 months, p = 0.055). However, not all baseline parameters were equally distributed between the two groups. In multivariable-adjusted Cox regression analysis accounting for several confounding variables, only one factor was statistically significant: pre-chemotherapy serum lactate dehydrogenase level (a surrogate marker of disease burden). Thus, the present results suggest that seasonal variation is not a major contributor to the diverging survival outcomes observed after docetaxel chemotherapy.

Management of Patients With Metastatic Renal Cell Cancer and Bone Metastases.

BACKGROUND/AIM: Previous research has suggested that patients with metastatic renal cell cancer (mRCC) and bone metastases have a poorer prognosis compared to their counterparts with no skeletal involvement. Therefore, we analyzed the management and outcomes of such patients in our center. PATIENTS AND METHODS: We performed a retrospective study of 35 consecutive patients who received systemic treatment, largely targeted therapy, for mRCC with bone metastases. RESULTS: The median overall survival was 25 months from the time of diagnosis of mRCC. The 5-year survival rate was 16%. Survival from diagnosis of mRCC was significantly worse in patients with bone metastases present at the start of first-line systemic therapy (median 13 months) compared to delayed metastases diagnosed later during the course of disease (46 months, p=0.01). Few patients (29%) were able to receive more than two lines of systemic therapy. Bone-only metastases were uncommon (11%). CONCLUSION: Most patients with mRCC and bone metastases have limited overall survival.

Independent External Validation of a Score Predicting Survival After Radiotherapy for Bone Metastases and Expansion to Patients Treated With Single Fraction Radiotherapy.

BACKGROUND: Recently a prognostic score that predicts 12-month survival in patients treated with fractionated radiotherapy for painful bone metastases has been developed. Fractionated radiotherapy might cause unnecessary burden for patients with limited survival, thus estimation of survival is clinically relevant. The purpose of the present study was independent external validation of the new score and, in addition, its application in patients who received single fraction irradiation, a convenient option currently endorsed in several guidelines. METHODS: We conducted a retrospective analysis of 270 patients, including 24% who had received single fraction irradiation. The three-tiered score was assigned as described in the development study, and included age, performance status and primary tumor type. Additional prognostic factors not studied in the development cohort, such as the Glasgow prognostic score (GPS) and presence of liver metastases, were included in this validation study. RESULTS: The three-tiered score was valid in this independent cohort (12-month survival rates were 7%, 30% and 71%, respectively, P = 0.0001). Its performance and validity were also confirmed in the single fraction radiotherapy group. Three additional prognostic factors were significant in the multivariate analysis and may therefore contribute to decision making. CONCLUSIONS: Irrespective of fractionation, the score based on age, performance status and primary tumor type provides a readily available estimate of 12-month survival.

Confirmatory Analysis of QUARTZ Study Results: Survival Prolongation After Whole-brain Radiotherapy.

BACKGROUND/AIM: The aim of this study was to analyze the survival of patients with brain metastases treated with best supportive care or additional whole-brain radiotherapy (WBRT), in order to confirm results from the prospective randomized QUARTZ study, which suggested prolonged survival after WBRT (5 fractions of 4 Gy) if favorable prognostic factors were present (age younger than 60 years, graded prognostic assessment score 2.5-3 points). PATIENTS AND METHODS: We performed a retrospective single institution analysis of 76 patients with favorable prognosis. In contrast to the QUARTZ trial, inclusion was not limited to patients with non-small cell lung cancer (NSCLC). Furthermore, a cohort treated with higher total doses of WBRT was included (10 fractions of 3 Gy). RESULTS: All patients were younger than 60 years or had a graded prognostic assessment score of 2.5-3. The median survival was significantly shorter after best supportive care (1.2 months; 3.2 months after WBRT with 5 fractions of 4 Gy and 3.9 months after 10 fractions of 3 Gy). Also, in multivariate analyses, survival was significantly better after WBRT. Further favorable prognostic factors included better performance status, no or limited extracranial metastases and primary tumor other than gastrointestinal. CONCLUSION: In line with the QUARTZ trial results, WBRT prolonged survival in patients with favorable prognostic features.

Feasibility and efficacy of sequential systemic therapy for metastatic castration-resistant prostate cancer in a rural health care setting.

Aim: The aim of this study was to evaluate the feasibility and efficacy, in terms of overall survival, of sequential systemic therapy in patients with metastatic castration-resistant prostate cancer (MCRPC) who lived in Nordland County, Norway, a large region with a challenging geography, yet only one department of oncology located in the main city, Bodø.Patients and methods: Overall 77 patients who had received at least 2 lines of treatment were included in this retrospective study.Results: Management included docetaxel in 69 patients (90%), often prescribed in first line. Only 12 patients (16%) started their treatment with a sequence of two endocrine drugs (enzalutamide or abiraterone acetate). Thirty-two patients (42%) were not eligible for treatment beyond second line, while 31 (40%) received 3 lines, and 14 (18%) more than 3 lines (for example cabazitaxel or Ra-223). Distance to the department of oncology did not predict for treatment with more than 2 lines. Only two factors were statistically significant: age <75 years and not initiating treatment with two lines of endocrine drugs. Survival increased with increasing number of lines of treatment. None of the five individual drugs available to these patients was significantly associated with survival.Conclusions: There was no indication toward under-treatment with systemic therapy among patients from the distant regions. Sequential treatment was feasible and survival increased with each additional line.

Management of patients with metastatic prostate cancer (mPC) in a rural part of North Norway with a scattered population: does living near the department of oncology translate into a different pattern of care and survival?

The goal of the Norwegian Ministry of Health and Care Services is to offer an equal health-care service with the same outcomes wherever people are living within the country. The aim of this study was to evaluate whether this was true for patients diagnosed with metastatic prostate cancer (mPC) and living in Nordland County, a region with a challenging geography and climate and having, several small and remote communities and only 1 department of oncology. The latter is located in the main city, Bodø. We also compared a subgroup living in communities having lower average annual income (less than NOK 240,000 (equivalent to USD 28,600)) with patients living in Bodø (NOK 285,000 (USD 33,900)). Overall 288 patients were included and stratified into 3 subgroups (favourable distance and income, unfavourable distance and income, and unfavourable distance and favourable income). No statistically significant differences were observed regarding patient characteristics. There was no indication towards under-treatment among patients from the distant regions or the lower income region. Given that disparities were not observed, it was not surprising to see comparable survival outcomes (p=0.35). In conclusion, these results suggest that the health-care system in Nordland County successfully delivers state-of-the-art oncology care to patients with mPC.