Low rectal cancer treatment strategies: a cohort study assessing watch and wait.

PURPOSE: Treatment strategies for low rectal cancer have been evolving toward achieving less treatment morbidity with the same oncological success-we aimed to assess the results of the new watch and wait (W&W) strategy in our cohort. METHODS: A tertiary care cohort study was conducted. New patients with rectal adenocarcinoma up to 6 cm from the anal margin, cM0, locally staged higher than cT1N0, evaluated between November 2014 and October 2018, were included. All 93 patients received neoadjuvant radiotherapy ± chemotherapy. Re-evaluation was planned 8-12 weeks after the end of treatment. Patients showing clinical complete response (cCR) were given the choice of either to proceed to surgery or to enter W&W. RESULTS: Of the 93 patients, 82.8% were re-evaluated and 20.8% had cCR. Patients in clinical stages II/III were significantly less likely to achieve cCR than those in stage I (p = 0.017). After a mean follow-up of 17.44 months, there were 4 regrowths in the 16 patients under W&W, all submitted to R0 surgery, ypN0; there were no deaths or local recurrences; one patient with regrowth had distant recurrence. Sixty patients underwent direct surgery after a mean follow-up of 16.23 months; 3 patients had local and distant recurrences; 7 others had only distant recurrences; there were 8 deaths. There were no statistically significant differences between patients under W&W and patients who underwent direct surgery regarding local or distant recurrences, or death (p > 0.9; p = 0.44; p = 0.19, respectively). CONCLUSION: The W&W strategy for low rectal cancer achieved the same oncological outcomes as the traditional strategy while sparing some patients from surgery.

[Breast Cancer: Value-Based Healthcare, Costs and Financing]. / Cancro de Mama: Valor em Saúde, Custos e Financiamento.

INTRODUCTION: Breast cancer is the second most common oncological disease worldwide. To analyse the new disease specific funding programme (breast cancer) implemented at the Francisco Gentil Portuguese Institute of Oncology, Lisbon Center (Instituto Português de Oncologia de Lisboa Francisco Gentil), the actual costs of the patients were examined using activity-based costing as a costing methodology. This study addresses the following question: "How much does it cost to treat breast cancer per 'patient-month' compared to the monthly fixed 'funding envelope'?". MATERIALS AND METHODS: The study cohort consisted of 807 patients, corresponding to all the patients eligible for the new disease specific funding programme and who were enrolled during the first year of implementation. Activity-based costing was used to calculate the total real costs per stage of disease and per 'patient-month' as well as the deviation from the monthly fixed 'funding envelope'. RESULTS: The total costs were 6.6 M€, whereas the total funding was 5.2 M€ for a total of 5648 'patient-months'. In 2014, the balance difference between the funding obtained and the actual costs was -1.4 €M for the cohort of 807 patients. DISCUSSION: The extreme cases of differences in cost per 'patient-month' compared to the monthly fixed 'funding envelope' were (i) stage 0/Tis, with higher funding at 415.23 € per 'patient-month', and (ii) stage IIIC, with lower funding at 1062.79 € per 'patient-month'. CONCLUSION: The 'patient-month' cost, regardless of disease stage was 1170.29 €. The median deviation per 'patient-month' was negative (241.21 €) compared to the monthly fixed 'funding envelope' of 929.08 € in the first year. Establishing activity-based costing - funding models will be crucial for the future sustainability of the healthcare sector.

Introdução: O cancro de mama é a segunda doença oncológica mais comum no mundo. Com o propósito de estudar o novo financiamento por patologia ­ cancro de mama ­ implementado no Instituto Português de Oncologia de Lisboa Francisco Gentil, foram analisados os custos reais dos doentes, através da metodologia de custeio activity based costing. Pretendeu-se dar resposta à pergunta de investigação: "Quanto custa tratar o cancro de mama por 'mês*doente' face ao 'envelope financeiro' fixo mensal?". Material e Métodos: O universo foi constituído por 807 doentes correspondendo a todos os doentes elegíveis no novo programa de financiamento por patologia e entrados ao longo do primeiro ano de implementação. Através do activity based costing foram apurados os custos reais totais por estádio da doença e por 'mês*doente' e o desvio relativamente ao 'envelope financeiro' fixo mensal. Resultados: Total de custos (6,6 M€), total de financiamento (5,2 M€) para um total de 5648 'meses*doente'. Em 2014, o saldo entre o financiamento obtido e os custos reais, foi negativo em 1,4 M€ para o universo de 807 doentes. Discussão: As situações extremas em termos de custos por 'mês*doente' face ao 'envelope financeiro' mensal fixo foram: (i) o estádio 0/TIS com financiamento superior em 415,23 € por 'mês*doente'; (ii) o estádio IIIC com um financiamento inferior em 1062,79 € por 'mês*doente'. Conclusão: O custo 'mês*doente', independentemente do estádio da doença, foi de 1170,29 €. O desvio médio 'mês*doente' foi negativo (241,21 €) face ao 'envelope financeiro' mensal fixo de 929,08 € no primeiro ano. Estabelecer modelos de financiamento com base no activity based costing será crucial para a sustentabilidade futura do sector da saúde.

Rectal cancer management in elderly patients: experience of a single Portuguese institution.

BACKGROUND: The incidence of rectal cancer increases with age, and older patients are more likely to have other chronic conditions that can affect outcome and tolerability of treatment. OBJECTIVE: The incidence of rectal cancer increases with age, and older patients are more likely to have other chronic conditions that can affect outcome and tolerability of treatment. METHODS: 59 patients aged 75 years and older with stage II-III rectal cancer who were treated during a 3-year period were included in the study. Comorbidities were assessed using the Charlson Comorbidity Index (CCI) and the patients were divided into 2 groups based on their CCI scores: Fit (score of 0-1 points) and Vulnerable (score of greater than or = 2). Primary endpoint was survival at 1 and 3 years. RESULTS: The sample included 43 patients (72.9%) in the Fit group and 16 patients (27.1%) in the Vulnerable group. The most common comorbidities were myocardial infarction, diabetes, and chronic lung disease. One-year survival the same between the groups (P = .330), but 3-year survival was lower in the Vulnerable group patients (83.7% vs 56.3%, respectively; P = .040). The rates of neoadjuvant chemo- and radiotherapy use and low anterior resection performance were the same between the groups. Colostomy closure was achieved more frequently in the Fit group compared with the Vulnerable group (83.3% vs 55.6%; P = .083). There was no difference in mean disease-free survival, grade 3-4 toxicity, and dose reduction between the groups. CONCLUSIONS: Comorbidity assessment should always be included in standard oncological management of elderly patients. Fit patients can be managed with standard treatment and may bene¦t from a conventional, more aggressive approach in their therapy.