Adequate assessment yields appropriate care-the role of geriatric assessment and management in older adults with cancer: a position paper from the ESMO/SIOG Cancer in the Elderly Working Group.

With the aging population, older adults constitute a growing proportion of the new cancer cases. Given the heterogeneous health status among older adults and their susceptibility to aging-related vulnerabilities, understanding their diversity and its implications becomes increasingly crucial for prognostication and guiding diagnostics, treatment decisions, and follow-up, as well as informing supportive care interventions. Geriatric assessment and management (GAM) refers to the comprehensive evaluation of an older individual's health status with subsequent management plans focusing on both oncologic and non-oncologic interventions. In 2019, the European Society for Medical Oncology (ESMO) and the International Society of Geriatric Oncology (SIOG) established the ESMO/SIOG Cancer in the Elderly Working Group. This position paper reflects the recommendations of the working group. Our paper summarizes the existing evidence with a focus on recent key trials and based on this, we propose several recommendations and future directions.

Nomogram for predicting survival after first-line anti-PD-1-based immunotherapy in unresectable stage IV melanoma: a multicenter international study.

BACKGROUND: The introduction of anti-programmed cell death protein 1 (PD-1) immunotherapy has revolutionized the treatment landscape for melanoma, enhancing both response rates and survival outcomes in patients with advanced stages of the disease. Despite these remarkable advances, a noteworthy subset of patients (40%-60%) does not derive advantage from this therapeutic approach. This study aims to identify key predictive factors and create a user-friendly predictive nomogram for stage IV melanoma patients receiving first-line anti-PD-1-based immunotherapy, improving treatment decisions. MATERIALS AND METHODS: In this retrospective study, we included patients with unresectable stage IV melanoma who received first-line treatment with either anti-PD-1 monotherapy or anti-PD-1 plus anti-cytotoxic T-lymphocyte associated protein 4 between 2014 and 2018. We documented clinicopathological features and blood markers upon therapy initiation. By employing the random survival forest model and backward variable selection of the Cox model, we identified variables associated with progression-free survival (PFS) after the first-line anti-PD-1-based treatment. We developed and validated a predictive nomogram for PFS utilizing the identified variables. We assessed calibration and discrimination performance metrics as part of the evaluation process. RESULTS: The study involved 719 patients, divided into a training cohort of 405 (56%) patients and a validation cohort of 314 (44%) patients. We combined findings from the random survival forest and the Cox model to create a nomogram that incorporates the following factors: lactate dehydrogenase (LDH), S100, melanoma subtype, neutrophil-to-lymphocyte ratio (NLR), body mass index, type of immune checkpoint inhibitor, and presence of liver or brain metastasis. The resultant model had a C-index of 0.67 in the training cohort and 0.66 in the validation cohort. Performance remained in different patient subgroups. Calibration analysis revealed a favorable correlation between predicted and actual PFS rates. CONCLUSIONS: We developed and validated a predictive nomogram for long-term PFS in patients with unresectable stage IV melanoma undergoing first-line anti-PD-1-based immunotherapy.

Essential cancer medicines: adding feasibility to the magnitude of clinical benefit value chain.

BACKGROUND: Cancer is a global public health problem, requiring efficient health system investments to deliver sustainable impact on population health. Access to medicines is a critical component of health systems, having a crucial role in delivering therapeutic benefits. Since 1977, the World Health Organization (WHO) has published a Model List of Essential Medicines (EML) that includes key health interventions for the prevention and control of conditions of public health relevance. Essential medicines are selected for inclusion in the EML based on the evidence of efficacy, safety, therapeutic value, and the potential to impact population health. With the rapid changes in the therapeutic landscape of cancer treatment with new medicine approvals, there is a critical need to select and prioritise specific cancer interventions based on their intrinsic value. MATERIALS AND METHODS: The European Society for Medical Oncology (ESMO) has developed a decisional methodology based on a threshold with a minimum set of technical specifications and a consensus-based procedure for decisions to select candidate cancer medicines to be submitted to the WHO for consideration for the WHO EML. RESULTS: ESMO recognises the WHO EML as an important reference guide for medicines that all countries should include in their national EMLs. Cancer medicines on the WHO EML are used in the treatment of the majority of cancers, and are recommended in the evidence-based ESMO Clinical Practice Guidelines that medical oncologists use to treat patients. ESMO's submissions to the WHO EML in 2019 and 2021 and their respective outcomes are presented in the manuscript. CONCLUSION: Due to the rising costs associated with newly available therapies, structured, reproducible, and field-tested tools to evaluate the added clinical benefit from these therapies need to be implemented in pre-selecting potential candidate medicines to be included in the WHO EML. ESMO is proud to collaborate closely with WHO on this important global public health initiative.

Off-label despite high-level evidence: a clinical practice review of commonly used off-patent cancer medicines.

INTRODUCTION: Off-label use of medicines is generally discouraged. However, several off-patent, low-cost cancer medicines remain off-label for indications in which they are commonly used in daily practice, supported by high-level evidence based on results of phase III clinical trials. This discrepancy may generate prescription and reimbursement obstacles as well as impaired access to established therapies. METHODS: A list of cancer medicines that remain off-label in specific indications despite the presence of high-level evidence was generated and subjected to European Society for Medical Oncology (ESMO) expert peer review to assess for accountability of reasonableness. These medicines were then surveyed on approval procedures and workflow impact. The most illustrative examples of these medicines were reviewed by experts from the European Medicines Agency to ascertain the apparent robustness of the supporting phase III trial evidence from a regulatory perspective. RESULTS: A total of 47 ESMO experts reviewed 17 cancer medicines commonly used off-label in six disease groups. Overall, high levels of agreement were recorded on the off-label status and the high quality of data supporting the efficacy in the off-label indications, often achieving high ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scores. When prescribing these medicines, 51% of the reviewers had to implement a time-consuming process associated with additional workload, in the presence of litigation risks and patient anxiety. Finally, the informal regulatory expert review identified only 2 out of 18 (11%) studies with significant limitations that would be difficult to overcome in the context of a potential marketing authorisation application without additional studies. CONCLUSIONS: We highlight the common use of off-patent essential cancer medicines in indications that remain off-label despite solid supporting data as well as generate evidence on the adverse impact on patient access and clinic workflows. In the current regulatory framework, incentives to promote the extension of indications of off-patent cancer medicines are needed for all stakeholders.

Streamlining clinical research: an ESMO awareness call to improve sponsoring and monitoring of clinical trials.

BACKGROUND: During recent years, the burden of bureaucracy in clinical research has increased dramatically, adversely impacting the activity of investigators and clinical research teams. Although compliance with the Declaration of Helsinki, the guidelines for Good Clinical Practice (GCP), and other applicable regulations remains unquestionable, their overinterpretation and substitution by the internal operating procedures of sponsors and Contract Research Organizations (CROs) have increased the administrative burden. A survey conducted by the European Society for Medical Oncology (ESMO) Clinical Research Observatory (ECRO) among 940 investigators confirmed that they considered that the administrative burden in clinical research is excessive; that administrative procedures could be reduced without affecting the safety and the rights of the patients and the quality of the data; and that bureaucracy represents an obstacle for clinical research. METHODS: A panel of physicians with extensive experience in clinical research, composed by members of the ECRO and the ESMO Scientific Medical and Public Policy divisions, analyzed clinical trial procedures related to administrative workflow, pharmacovigilance, and medical care. RESULTS: The panel identified situations that generate debate between investigators and sponsors/CROs and selected real clinical scenarios that exemplify such situations. The panel discussed and proposed specific recommendations for those situations, based on GCP. CONCLUSIONS: This initiative aspires to streamline clinical research procedures and to become a platform for discussion among all clinical trial stakeholders, with the aim of promoting the sustainability of clinical research and the care of cancer patients.

A novel orchiectomy surgical procedure in donkeys ( Equus asinus africanus) with parascrotal access.

Donkeys are a public health concern in the Northeast region of Brazil, with thousands of stray animals. Orchiectomy is an important population control measure; however, the long postoperative period with daily treatment of open wounds in the scrotum makes it difficult to perform a large number of castrations in sheltering centers. We evaluate a novel surgical procedure for orchiectomy in donkeys using parascrotal access. Twelve donkeys were used, divided into two groups: I - submitted to orchiectomy through parascrotal surgical access (novel procedure), and II - submitted to orchiectomy through scrotal access (conventional). Postoperative evaluations consisted of a macroscopic evaluation of the surgical wound (bleeding and intensity of edema), hematological parameters, and peritoneal fluid, which occurred in both groups at the moments (M): M0 - before the surgical procedure. The others moments occurred after surgery: M12 (twelve hours); M24 (twenty-four hours); M48 (forty-eight hours); M72 (seventy-two hours); M8D (eight days); and M16D (sixteen days). The surgical techniques did not generate an important systemic inflammatory response to the point detected by the leukogram, fibrinogen dosage, and peritoneal fluid. The parascrotal technique required long surgery but promoted less bleeding, less edema, and faster healing. The techniques used did not promote sufficient systemic inflammation to alter the number of leukocytes and the fibrinogen concentration; however, evaluation of the peritoneal fluid proved to be important for evaluating inflammatory processes involving the scrotum and inguinal canal. We describe a novel surgical procedure for orchiectomy in Donkeys using a parascrotal access that promoted less risk of bleeding, shorter period of edema, and healing time, but required longer surgery time.

The impact of COVID-19 on oncology professionals-one year on: lessons learned from the ESMO Resilience Task Force survey series.

BACKGROUND: COVID-19 has had a significant impact on the well-being and job performance of oncology professionals globally. The European Society for Medical Oncology (ESMO) Resilience Task Force collaboration set out to investigate and monitor well-being since COVID-19 in relation to work, lifestyle and support factors in oncology professionals 1 year on since the start of the pandemic. METHODS: An online, anonymous survey was conducted in February/March 2021 (Survey III). Key outcome variables included risk of poor well-being or distress (expanded Well-Being Index), feeling burnout (single item from expanded Well-Being Index), and job performance since COVID-19. Longitudinal analysis of responses to the series of three surveys since COVID-19 was carried out, and responses to job demands and resources questions were interrogated. SPSS V.26.0/V.27.0 and GraphPad Prism V9.0 were used for statistical analyses. RESULTS: Responses from 1269 participants from 104 countries were analysed in Survey III: 55% (n = 699/1269) female, 54% (n = 686/1269) >40 years, and 69% (n = 852/1230) of white ethnicity. There continues to be an increased risk of poor well-being or distress (n = 464/1169, 40%) and feeling burnout (n = 660/1169, 57%) compared with Survey I (25% and 38% respectively, P < 0.0001), despite improved job performance. Compared with the initial period of the pandemic, more participants report feeling overwhelmed with workload (45% versus 29%, P < 0.0001). There remain concerns about the negative impact of the pandemic on career development/training (43%), job security (37%). and international fellowship opportunities (76%). Alarmingly, 25% (n = 266/1086) are considering changing their future career with 38% (n = 100/266) contemplating leaving the profession. CONCLUSION: Oncology professionals continue to face increased job demands. There is now significant concern regarding potential attrition in the oncology workforce. National and international stakeholders must act immediately and work closely with oncology professionals to draw up future-proof recovery plans.

Undernutrition risk and nutritional screening implementation in hospitals: Barriers and time trends (2019-2020).

BACKGROUND & AIMS: Undernutrition screening is the starting point for high-quality nutrition care. In Portugal, the systematic nutritional risk assessment became mandatory for every inpatient in hospitals of the National Health System in 2019. The aims of this study were to describe the country's nutritional risk prevalence of hospitalized patients, and the experience of implementing a systematic undernutrition screening method, including time trends, barriers, and facilitators. METHODS: This research was carried out in Portuguese Public Hospitals (n = 49) and included both the analysis of data from health information systems between January 2019 and December 2020 and from an online survey. The performance indicators are described for 38 hospitals that use the SClinico electronic health records software provided by the Ministry of Health. The Nutritional Risk Screening 2002 (NRS 2002) was applied to adult patients and the STRONGkids to paediatric patients. In order to assess barriers and facilitators the online survey was applied to all public hospitals (n = 49), including Hospital Centres and Local Health Units. RESULTS: In 2020, 25.5% of the screened patients were nutritionally at risk. There was a significant increase in the proportion of patients screened from the pre- (10.6 ± 1.9%) to the post-adaptation period of the electronic health record (23.3 ± 4.8%, July-December 2019, and 25.4 ± 2.2%, January-June 2020) (p < 0.001). Data from 41 Hospital Centres and Local Health Units (84%) were obtained from the online survey. The major barriers identified were the lack of human resources (89.7%) and equipment (41.0%), as well as insufficient knowledge about the role of undernutrition screening (35.9%). The most-reported facilitators were the integration of undernutrition screening to electronic health records (22.2%) and good multidisciplinary articulation (36.1%). CONCLUSION: The high prevalence of nutritional risk justifies the mandatory nutritional screening, which leads to the improvement of the quality of hospital care. However, local and national efforts are warranted to adapt nutritional screening policies to local conditions and to increase and improve its implementation.

Temporal and spatial toxicogenetic damage in estuarine catfish Cathorops spixii from a marine protected area with evidence of anthropogenic influences.

Taking action to contribute to the preservation of the natural coastal environment, which maintains a diversity of life, is important in today's world. In estuarine ecosystems that are included in marine protected areas (MPA), it is important to conduct biomonitoring over time to monitor the effects of xenobiotics on bioindicator species such as the catfish Cathorops spixii. This study aims to evaluate the toxicogenetic signals in C. spixii from a MPA (Cananéia-Iguape region, Brazilian coast). These genotoxic signals are demonstrated by the presence of micronuclei (MN) and abnormalities in erythrocytes (AE). This study also takes into account the environmental differences signaled by the water's properties (temperature, salinity, pH, DO, dissolved nutrients, and particulate material) over time (2009, 2014, 2017, and 2018). The results show that in the northern region of the estuary, and mainly in 2009, the water properties reveal the influence of the river in the form of the lowest levels of salinity and pH and the highest levels of nutrients. The most significant levels of suspended particulate material and chlorophyll-a are found in the southern region of the estuary, mainly in 2017 and 2018. In general, the C. spixii from the northern region had better well-being than catfish from the more preserved (southern) region. The data on MN and AE show evidence of toxicogenetic damage occurring over time and clastogenic/aneugenic effects mainly in fish sampled in 2018. The presence of a new AE, first recorded in C. spixii sampled in 2018, and named here as double bubbled, is another indicator of toxicogenetic effects. Finally, although the southern region of the estuary has better abiotic properties and conditions for primary production, the obtained toxicogenetic data for C. spixii reinforces the need for - and encourages the implementation of - monitoring actions in this marine protected area using bioindicator species of contamination.

The concerns of oncology professionals during the COVID-19 pandemic: results from the ESMO Resilience Task Force survey II.

BACKGROUND: The COVID-19 pandemic has resulted in significant changes to professional and personal lives of oncology professionals globally. The European Society for Medical Oncology (ESMO) Resilience Task Force collaboration aimed to provide contemporaneous reports on the impact of COVID-19 on the lived experiences and well-being in oncology. METHODS: This online anonymous survey (July-August 2020) is the second of a series of global surveys launched during the course of the pandemic. Longitudinal key outcome measures including well-being/distress (expanded Well-being Index-9 items), burnout (1 item from expanded Well-being Index), and job performance since COVID-19 were tracked. RESULTS: A total of 942 participants from 99 countries were included for final analysis: 58% (n = 544) from Europe, 52% (n = 485) female, 43% (n = 409) ≤40 years old, and 36% (n = 343) of non-white ethnicity. In July/August 2020, 60% (n = 525) continued to report a change in professional duties compared with the pre-COVID-19 era. The proportion of participants at risk of poor well-being (33%, n = 310) and who reported feeling burnout (49%, n = 460) had increased significantly compared with April/May 2020 (25% and 38%, respectively; P < 0.001), despite improved job performance since COVID-19 (34% versus 51%; P < 0.001). Of those who had been tested for COVID-19, 8% (n = 39/484) tested positive; 18% (n = 7/39) felt they had not been given adequate time to recover before return to work. Since the pandemic, 39% (n = 353/908) had expressed concerns that COVID-19 would have a negative impact on their career development or training and 40% (n = 366/917) felt that their job security had been compromised. More than two-thirds (n = 608/879) revealed that COVID-19 has changed their outlook on their work-personal life balance. CONCLUSION: The COVID-19 pandemic continues to impact the well-being of oncology professionals globally, with significantly more in distress and feeling burnout compared with the first wave. Collective efforts from both national and international communities addressing support and coping strategies will be crucial as we recover from the COVID-19 crisis. In particular, an action plan should also be devised to tackle concerns raised regarding the negative impact of COVID-19 on career development, training, and job security.

Biases in study design, implementation, and data analysis that distort the appraisal of clinical benefit and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scoring.

BACKGROUND: The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated, widely used tool developed to score the clinical benefit from cancer medicines reported in clinical trials. ESMO-MCBS scores assume valid research methodologies and quality trial implementation. Studies incorporating flawed design, implementation, or data analysis may generate outcomes that exaggerate true benefit and are not generalisable. Failure to either indicate or penalise studies with bias undermines the intention and diminishes the integrity of ESMO-MCBS scores. This review aimed to evaluate the adequacy of the ESMO-MCBS to address bias generated by flawed design, implementation, or data analysis and identify shortcomings in need of amendment. METHODS: As part of a refinement of the ESMO-MCBS, we reviewed trial design, implementation, and data analysis issues that could bias the results. For each issue of concern, we reviewed the ESMO-MCBS v1.1 approach against standards derived from Helsinki guidelines for ethical human research and guidelines from the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, the Food and Drugs Administration, the European Medicines Agency, and European Network for Health Technology Assessment. RESULTS: Six design, two implementation, and two data analysis and interpretation issues were evaluated and in three, the ESMO-MCBS provided adequate protections. Seven shortcomings in the ability of the ESMO-MCBS to identify and address bias were identified. These related to (i) evaluation of the control arm, (ii) crossover issues, (iii) criteria for non-inferiority, (iv) substandard post-progression treatment, (v) post hoc subgroup findings based on biomarkers, (vi) informative censoring, and (vii) publication bias against quality-of-life data. CONCLUSION: Interpretation of the ESMO-MCBS scores requires critical appraisal of trials to understand caveats in trial design, implementation, and data analysis that may have biased results and conclusions. These will be addressed in future iterations of the ESMO-MCBS.

The impact of COVID-19 on oncology professionals: results of the ESMO Resilience Task Force survey collaboration.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) pandemic on well-being has the potential for serious negative consequences on work, home life, and patient care. The European Society for Medical Oncology (ESMO) Resilience Task Force collaboration set out to investigate well-being in oncology over time since COVID-19. METHODS: Two online anonymous surveys were conducted (survey I: April/May 2020; survey II: July/August 2020). Statistical analyses were performed to examine group differences, associations, and predictors of key outcomes: (i) well-being/distress [expanded Well-being Index (eWBI; 9 items)]; (ii) burnout (1 item from eWBI); (iii) job performance since COVID-19 (JP-CV; 2 items). RESULTS: Responses from survey I (1520 participants from 101 countries) indicate that COVID-19 is impacting oncology professionals; in particular, 25% of participants indicated being at risk of distress (poor well-being, eWBI ≥ 4), 38% reported feeling burnout, and 66% reported not being able to perform their job compared with the pre-COVID-19 period. Higher JP-CV was associated with better well-being and not feeling burnout (P < 0.01). Differences were seen in well-being and JP-CV between countries (P < 0.001) and were related to country COVID-19 crude mortality rate (P < 0.05). Consistent predictors of well-being, burnout, and JP-CV were psychological resilience and changes to work hours. In survey II, among 272 participants who completed both surveys, while JP-CV improved (38% versus 54%, P < 0.001), eWBI scores ≥4 and burnout rates were significantly higher compared with survey I (22% versus 31%, P = 0.01; and 35% versus 49%, P = 0.001, respectively), suggesting well-being and burnout have worsened over a 3-month period during the COVID-19 pandemic. CONCLUSION: In the first and largest global survey series, COVID-19 is impacting well-being and job performance of oncology professionals. JP-CV has improved but risk of distress and burnout has increased over time. Urgent measures to address well-being and improve resilience are essential.

Acute effect of passive cycle-ergometry and functional electrical stimulation on nitrosative stress and inflammatory cytokines in mechanically ventilated critically ill patients: a randomized controlled trial.

Early mobilization is beneficial for critically ill patients because it reduces muscle weakness acquired in intensive care units. The objective of this study was to assess the effect of functional electrical stimulation (FES) and passive cycle ergometry (PCE) on the nitrous stress and inflammatory cytometry in critically ill patients. This was a controlled, randomized, open clinical trial carried out in a 16-bed intensive care unit. The patients were randomized into four groups: Control group (n=10), did not undergo any therapeutic intervention during the study; PCE group (n=9), lower-limb PCE for 30 cycles/min for 20 min; FES group (n=9), electrical stimulation of quadriceps muscle for 20 min; and FES with PCE group (n=7), patients underwent PCE and FES, with their order determined randomly. The serum levels of nitric oxide, tumor necrosis factor alpha, interferon gamma, and interleukins 6 and 10 were analyzed before and after the intervention. There were no differences in clinical or demographic characteristics between the groups. The results revealed reduced nitric oxide concentrations one hour after using PCE (P<0.001) and FES (P<0.05), thereby indicating that these therapies may reduce cellular nitrosative stress when applied separately. Tumor necrosis factor alpha levels were reduced after the PCE intervention (P=0.049). PCE and FES reduced nitric oxide levels, demonstrating beneficial effects on the reduction of nitrosative stress. PCE was the only treatment that reduced the tumor necrosis factor alpha concentration.

Adherence to a Mediterranean Dietary Pattern and Functional Parameters: A Cross-Sectional Study in an Older Population.

OBJECTIVES: In older adults, diet and physical activity are among the most important behaviours that influence health. The Mediterranean Dietary Pattern has been related to longevity and can benefit physical function in older adults. The present study aims to quantify the association of adherence to a Mediterranean Dietary Pattern with physical functioning through by handgrip strength, as well as, with sedentary behaviour based on sitting time, in a sample of older adults. METHODS: A cross-sectional study was conducted in 1,491 older adults ≥ 65 years old. The adherence or non-adherence to a Mediterranean Dietary Pattern was assessed using the previously validated and translated 14 item questionnaire, the PREDIMED (Prevención com Dieta Mediterránea). Handgrip strength was measured with a Jamar Dynamometer. Sitting time per day was used as an indicator of sedentary behaviour. Multinomial logistic regressions were performed to quantify the association of adherence to a Mediterranean Dietary Pattern with handgrip strength and sitting time. RESULTS: Compared to participants who adhered to a Mediterranean Dietary Pattern, those who did not adhere to this diet have a significantly higher adjusted odds ratio for low handgrip strength [adjusted odds ratio: 1.50; 95% confidence interval: 1.09-2.05], as well as for longer sitting time [adjusted odds ratio: 1.43; 95% confidence interval: 1.04-1.96]. CONCLUSION: In older adults, the non-adherence to a Mediterranean Dietary Pattern was associated with both lower values of handgrip strength and longer sitting time.

Nutritional and Functional Indicators and Their Association With Mortality Among Older Adults With Alzheimer's Disease.

This study investigated how different nutritional and functional status indicators are associated with mortality in patients with Alzheimer's disease (AD). A prospective cohort study was conducted among 79 community-dwelling older adults with AD. Follow-up was 60 months. Undernutrition status was evaluated by Mini Nutritional Assessment (MNA), body mass index, mid-arm muscle circumference (MAMC), calf circumference, and phase angle. Functional status was assessed by handgrip strength, and usual gait speed. Twenty-two participants died (27.8%). Results show that undernutrition (hazard ratio [HR] 5.69, 95% confidence interval [CI] 2.21-14.61), weight loss (HR 3.82, 95% CI 1.37-10.63), underweight (HR 3.24, 95% CI 1.18-8.82), low MAMC (HR 4.54, 95% CI 1.65-12.48), calf circumference ≤ 31 (HR 4.27, 95% CI 1.63-11.16), low HGS (HR 3.11, 95% CI 1.18-8.17), and low gait speed (HR 4.73, 95% CI 1.68-13.27) were all associated with mortality. In conclusion, a poor nutritional and functional status was associated with a higher risk of mortality, regardless of sex, age, marital status, education, and cognitive function.