Impact of Screening Programs on Stage Migration in Breast Cancer.

INTRODUCTION: Breast cancer (BC) is the leading malignancy globally with consequent morbidity, mortality and burden on health care resources when diagnosed at an advance stage. Early-stage diagnosis is crucial to the better outcome. Screening is pivotal to early detection at an early stage. It is understood to reduce mortality, improve outcome, and is cost effective. OBJECTIVE: The objective of the study was to see the impact of screening program on Breast cancer stage in Oman. In this study we looked into the trends in stagespecific breast cancer incidence during two pre-specified time periods 2006-2010 and 2015-2017, before and after the introduction of a national screening programme in Oman. PATIENTS AND METHODS: It is a retrospective analysis, where breast cancer patient's data was retrieved from Oman national cancer Registry ministry of health Sultanate of Oman, for two pre-specified time periods 2006-2010 before the introduction of cancer screening programs and 2015-2017. The cases included were those who had confirmed histopathology diagnosis and where a composite stage, based on TNM stage, was available to be analysed and compared in these two pre-specified time periods to find out the difference between these two time periods. The statistical analysis was carried out and p values were determined. Ethical approval obtained from Royal Hospital medical ethics and scientific research committee. RESULTS: There was a 41% reduction in stage IV breast cancer from 23.01% to 13.58 %, and 86.15% increase in stage 0-1 from 6.86 % to 16.98%. (p Value<001). The stage 0 cases increased from 0% to 4.26 %. With regard to tumour size, T0-1 tumours increased from 14.16% to 26.03%, while T4 tumours decreased from 16.59% to 7.69%. There was increase in node negative breast cancer cases in Oman. The N0 increased from 28.43% to 37.64%. The diagnosis as Non-metastatic M0 disease increased from 39.77% to 60.23%, while diagnosis as metastatic M1 disease decreased from 55.32% to 44.68%. DISCUSSION AND CONCLUSIONS: The introduction of national screening programme in Oman resulted in a continued increase in localized cancers and a decline in advanced disease. Screening programmes should be evaluated continuously and systematically to ensure their targeted objectives. The causal link between stage distribution and mortality needs to be investigated further in the context of screening. Health planners, policymakers, and other stakeholders; including clinicians, educators, community members, and advocates, should be aware of the health system requirements, as well as overall costs of these approaches to breast cancer early detection, to make effective investments, plans, and policies. Key Words: Breast Cancer; Screening; Oman; Royal hospital; early detection; early stage; OCA.

COVID-19 amongst cancer patients: An experience from Oman.

OBJECTIVE: To evaluate the extent of coronavirus infection in cancer patients along with their demographics, laboratory findings and outcomes in a tertiary care setting. METHODS: The study was conducted in Muscat, Oman, from March 24 to October 23, 2020. The data was collected from the cancer registry of the Directorate-General of Non-Communicable Diseases, Ministry of Health, Oman. Data of inpatient coronavirus cases were retrieved from the electronic medical records system of the Royal Hospital, Muscat, all tertiary hospitals linked electronically to the registry and the coronavirus registry of Oman. The data of cancer patients infected with coronavirus was analysed and compared with non-cancer coronavirus-infected patients. Data was analysed using IBM SPSS 2019 v26. RESULTS: Of the 16,260 cancer patients, 77(0.47%) were infected with COVID-19 compared to 111,837(2.17%) in the national population. Mortality among cancer patients with COVID-19 was high 27(35.1%) compared to 1,147(1.03%) in the national population. Cancer patients with COVID-19 also had diabetes 15(20%), hypertension 20(26%), renal complications 15(20%) and cardiac issues 9(12%). Of the total, 32(41.6%) cancer patients with COVID-19 had received active cancer treatment within the preceding 4 weeks. CONCLUSIONS: The data on coronavirus infection outcome is emerging at a rapid pace focussing on the impact of underlying diseases, and the capacity of healthcare systems. Oncologists should customise cancer management, while cancer patients must practise social distancing, and seek prompt evaluation of suspicious symptoms.

Clinicopathological Features and Outcomes of Gastrointestinal Stromal Tumours in Oman: A multi-centre study.

OBJECTIVES: This study aimed to report the clinicopathological features, management and long-term outcomes of patients with gastrointestinal stromal tumours (GISTs) in Oman. METHODS: This retrospective study was conducted on patients treated for GIST between January 2003 and December 2017 at three tertiary referral centres in Muscat, Oman. All patients with confirmed histopathological diagnoses of GIST and followed-up at the centres during this period were included. Relevant information was retrieved from hospital records until April 2019. RESULTS: A total of 44 patients were included in the study. The median age was 55.5 years and 56.8% were female. The most common primary site of disease was the stomach (63.6%) followed by the jejunum/ileum (18.2%). Two patients (4.5%) had c-Kit-negative, discovered on GIST-1-positive disease. A total of 24 patients (54.5%) presented with localised disease and eight (33.3%) were classified as being at high risk of relapse. Patients with metastatic disease received imatinib in a palliative setting, whereas those with completely resected disease in the intermediate and high-risk groups were treated with adjuvant imatinib. Of the six patients (13.6%) with progressive metastatic disease, of which four had mutations on exon 11 and one on exon 9, while one had wild-type disease. Overall, rates of progression-free survival and overall survival (OS) at 100 months were 77.4% and 80.4%, respectively. Rates of OS for patients with localised and metastatic disease were 89.9% and 80.2%, respectively. CONCLUSION: The presenting features and outcomes of patients with GISTs in Oman were comparable to those reported in the regional and international literature.

The Need for Regulatory Reforms in the Use of Opioids for Pain Management and Palliative Care in the Middle East.

Palliative Care (PC) is an evolving oncology subspecialty in the Middle East (ME). Justified opioid use is an integral part of palliative care. Often, morphine consumption is taken as a quality indicator of palliative care services, but is it a reliable indicator to reflect the status of palliative care in current Middle East setting? We need to understand that data on morphine consumption, represent the amount distributed of morphine per person in a country and does not refer the actual justified amount utilization of opioids. In addition, the currently used consumption data is not reflective of product and dosage employed. It includes opioid use in other conditions like post-operative pain, traumatic pain, and drug abuse as well. The population and cancer incidence is highly variable amongst countries. The opioid consumption reported at present in Oman is very low 0.5474 mg/person. The opioid prescription must have an appropriate validated policy, well administered and enforced effectively. The policy must be balanced in such a way to eliminate the barriers of availability on one hand, and limit the probability of abuse on the other. Ideally there should be a national empowered competent control authority which should estimate the needs, license, distribute, monitor and report opioid use. There is an additional need to train health care workers in adequate pain assessment, effective pain management, and validated opioid prescribing practices. The issues in the Middle Eastern (ME) countries are erratic and undependable cancer data, limited palliative care programs, non-effective or no palliative care/pain management policies, and almost non-existent prescription policies of controlled drugs. There is an urgent and essential need to work for comprehensive and integrated palliative care programs encompassing the subspecialties. It must include and care for local perspectives of psychological, social, spiritual, and religious issues in PC in addition to pain management. There remains a need for health education for population, advocacy for policy makers, and a political will at the appropriate levels to meet these challenges.

Breast cancer in a patient with Kindlers syndrome.

Breast Cancer (BC) has associated risk factors and genetic factors like BRCA1, and BRCA2. Many benign and malignant disease processes are found concurrently with BC and believed to be additional risk factors like gall bladder stones (cholelithiasis), hypertension, diabetes mellitus, cerebrovascular lesions, arthritis, spine and spinal cord degenerative lesions, infertility, depression, sleep disturbances, obesity, autoimmune diseases (SLE), and thyroid diseases. There are some malignant disease associations like synchronous or metachronous ovarian, colonic and endometrial tumours with Breast cancer. Kindler Syndrome (KS) is a rare autosomal recessive genetic disorder manifesting as generalized dermatoses, described in 1954 by Theresa Kindler. KS is associated with acral skin blistering inducible by trauma, mucosal inflammation, photosensitivity, progressive pigmentation, telangiectasia, and skin atrophy (Poikiloderma). Repeated and progressive inflammation and subsequent fibrosis leads to ectropion, esophageal, anal, urethral, and vaginal stenosis and dryness. About 100 cases of Kindler syndrome have been reported in literature so far some from Arab World as well. Pathobiology of Kindler syndrome is not well understood. There are defects in KIND1 gene on chromosome 20. This gene expresses itself in basal keratinocytes, where it encodes a protein, called Kindlin 1. We report the second only case of Kindler's syndrome having breast cancer. These very very rare combinations have diagnostic issues, management restrictions, prognostic and follow up implications.

Are we prepared to implement a Lean philosophy within cancer-care service in Oman?

Lean, as it applies to business, has come to signify simplicity, swift response, and efficiency. The concept is to do more with less; namely, to use resources in the most productive way possible through the elimination of all types of waste. The Lean approach can be applied to any field, including healthcare, in which the exponential growth of costs is widespread. Hospitals began experimenting with Lean healthcare in 1990s.  Equal accessibility to healthcare is consistent with the tenets of social justice and a society's duty to ensure basic healthcare to everyone. However, the gap between a state's constitutional responsibility and resource availability is widening, creating a need for an evolution in healthcare provision based on relevance, objectivity, and impartiality. Health-services providers must juggle limited resources to ensure even-handed healthcare availability to all in the era of cost explosion.

High Occurrence of Non-Clear Cell Renal Cell Carcinoma in Oman.

It is conventionally accepted that renal cell carcinoma (RCC) occurs in older patients and the clear cell type is the most common histology. However, ethnic variations exist and this study was carried out to determine the epidemiological pattern of RCC in Oman. Ninety RCC patients who presented to a tertiary care center in the Sultanate of Oman from 2010 to 2014 were studied. The main findings were that the median age of presentation was low, more patients presented with localized stage, and there was a higher incidence of non-clear (especially papillary) histology. Data from other Gulf countries and possible reasons for the different profile are discussed.

Utilization of systemic palliative chemotherapy at the end of life: a local experience.

OBJECTIVE: To evaluate attitude towards using systemic chemotherapy near the end of life for cancer patients. METHODS: This retrospective study comprised data of all patients who died with cancer at the Medical Oncology Department of the National Oncology Centre, Muscat, Oman, from January 2009 to December 2011. The records were retrieved from the electronic patient record system of ALSHIFA, Royal Hospital. Demographic data, chemotherapy at end of life, performance status, 'do not resuscitate' status, hospitalisation, and chemotherapy toxicity were analysed. RESULTS: The mean age of the 261 patients in the study was 52.3 +/- 14.52 years. Ninety-two (35%) patients did not receive chemotherapy in the last 3 months of their lives. Chemotherapy administered at end of life was 169 (65%), 126 (48%), and 75 (29%) in last 3 months, one month and 2 weeks of life. Those who received more than 3 lines of chemotherapy were 66 (36%). CONCLUSIONS: The end-of-life use of chemotherapy should always be carefully discussed. The patient's right to information should be honoured. The transition from active to best supportive care should be carefully guided.

Age at diagnosis of female breast cancer in Oman: Issues and implications.

INTRODUCTION: Female breast cancer (BC) is the most frequent malignancy diagnosed globally, about 23% of the diagnosed cancers. BC incidence varies geographically, highest in Western Europe and lowest in Africa. BC in females is strongly correlated to age, the highest incidence rate amongst older women reinforcing the importance of hormonal status. BC in young females has an aggressive phenotype. There is a shared observation amongst practicing oncologists that BC in Middle East and the developing world presents at an earlier age. AIM AND OBJECTIVE: The aims of this study are to evaluate the age at presentation of female BC in Oman, and to compare our data with international and regional published data. It discusses the impact of young age Breast Cancer. MATERIALS AND METHODS: All diagnosed female BC cases registered from 1996-2010 all over the country, were retrieved from the National Cancer Registry, Ministry of Health. BC cases were analyzed with respect to age at presentation. The data were compared with regional and international data. RESULTS: A total of 14,109 cancer cases were recorded during the period of study. BC was the leading malignancy as 1,294 cases (9.1%). Female BC patients were 1,230; denoting 19.2% of all female cancers. 53.5% of female BC presented below 50 years of age. Male BC constituted 5% of total, with 67% of male BC occurring over 50 years of age. Compared with data from Oman, the highest rates in UK and other Western countries are above 50 years of age. These rates are four to 10 times higher than local in different age groups. Interestingly, these rates increase with increasing age in UK from 40-45 to up to 85+, keep on increasing and go up to four times higher with higher age. This phenomenon, of increasing incidence rates with age, is not observed in our local population. DISCUSSION: BC is significantly correlated to age as reported from Western population. BC is reported at a younger age from developing and Arab World, which need to be further studied and validated. This phenomenon of BC in younger age may have significant implications and effects ranging from screening, diagnosis, management, prognosis, and cost of treatment. CONCLUSION: The impact on young women diagnosed with BC is enormous, ranging from psychosocial to healthcare services and economics. There is a need to study it further in depth in developing World.

Be a true listener, rather than a good conversationalist.

Oncology patient care is an ever evolving field both as a science and a clinical art. We evaluate, diagnose, and treat cancer patients daily. We break the bad and the good news to them. We are the hope on which their life and dreams hang on. We, as practitioners, have to assess each patient as an intelligent observer. We have to devise our strategy to break heartbreaking news to them in a tailored and personalized fashion according to the physical, psychological, emotional, and social status of the patient. The process has to be gentle, perceptive, pragmatic, yet truthful. These need to be reasonably good observational, listening, comprehending, and delivering potentials; which are sharpened by experience and skills.

Aromatase inhibitors--a viable option for recurrent granulosa cell tumour of ovary: overview and case report.

Granulosa cell tumour of the ovary in adults is a rare tumour of low malignant potential affecting middle aged peri or post menopausal patients. These tumours are often diagnosed at an early stage, due to their hormonally active nature. They, however, have unique distinguishing histologic features and behaviour of frequent and late local or systemic relapses. The diagnosis can be challenging with unusual presentations. There is high association of endometrial carcinoma. Surgery is the mainstay of management in early low risk disease, while radiotherapy and systemic platinum based chemotherapy are employed in higher stage with poor prognostic indices. Survival is good in early stage disease. Recurrent, progressive, and treatment refractory disease is not infrequent and poses management challenge. Endocrine manipulation and hormone treatment are employed in few cases with equivocal results, as reported in literature. We present a case of recurrent and treatment refractory GCT in a postmenopausal patient, managed by aromatase inhibitor Anastrozole with reasonable efficacy.

Chemotherapy-induced neutropenic necrotizing enterocolitis: a review.

Neutropenia is a common toxicity of systemic cytotoxic therapy. Neutropenic enterocolitis (NE) is a rare occurrence but can be fatal, subsequent to neutropenia. The exact incidence and frequency is difficult to establish, but is usually underestimated. It is often missed but has recently been appreciated with increasing frequency in solid tumours. NE was initially reported with taxenes but now an increasing number of chemotherapeutic drugs are implicated. NE incidence is expected to increase with the use of dose dense regimens, myeloablative cytotoxic protocols, tissue transplants, and emerging newer molecules. The usual presentation is often non-specific and often over shadowed by the symptomatology of primary malignant disease and toxicity symptoms of chemotherapy. The basis of diagnosis is clinical, radiological (ultra sound/CT scan), per operative findings, and eventually post mortem. Treatment options of this highly fatal phenomenon varies from conservative to early surgical intervention. NE is expected to be diagnosed with increasing frequency. The factors leading to it are mucosal injury, caecal distension with resultant ischaemia, cytotoxic drugs, and microbiological agents. A high index of clinical suspicion and an early diagnosis is paramount for better outcome. Irrespective of management employed, conservative or upfront surgical intervention, it has a poor out come with high mortality. A clinical suspicion, early diagnosis, and prompt management are the key to a better result. There is need to identify people at high risk by prognostic factors, large scale studies, and formulating consensus management guidelines. At present individualized risk assessment based strategy is advocated.

Anaplastic large cell lymphoma of scrotal skin.

Cutaneous T cell lymphoma (CTCL) is an uncommon diverse group of lympho-proliferative disorders involving the skin. They vary considerably in clinical presentation, microscopic features and immunophenotyping. The diagnosis is challenging, zealous, and often not easy. CD30+ve anaplastic large cell lymphoma is extremely rare. Its clinical spectrum varies from a solitary unifocal skin lesion of excellent prognosis to a multi focal systemic disease having a poor out come. The diagnosis is quite cumbersome, and often difficult. The differential diagnosis include from benign skin lesions to secondary cutaneous involvement by lymphoma. A correct diagnosis is integral with a complete metastatic/staging work up to avoid over treatment. The treatment options depend on extent of disease involvement and include surgical excision, surveillance, local radiotherapy, and systemic chemotherapy. The prognosis is good with unifocal local disease. We present here a very rare case of CD30+ ALCL of scrotal skin, in a middle aged male patient.

Nasopharyngeal carcinoma presented as cavernous sinus tumour.

A 32 year Libyan male presented with the complaints of headache and diplopia. He was diagnosed with a cavernous sinus meningioma on the basis of MRI findings but no initial biopsy was taken. Depending on the radiologic diagnosis the patient was treated with gamma knife surgery twice, abroad. During follow up he developed left ear deafness and left cervical lymph adenopathy. An ENT evaluation with biopsy from the nasopharynx and cervical lymph node was taken. The histopathologic diagnosis of the resected tumour showed a nasopharyngeal carcinoma with cervical lymph node metastasis (poorly differentiated lympho-epithelial carcinoma). The cavernous sinus tumour which was initially treated as a meningioma was in fact metastasis from the nasopharyngeal carcinoma, making this an interesting and rare occurrence.

Synchronous and metachronous malignant tumours expect the unexpected.

OBJECTIVE: To evaluate occurrence of synchronous and metachronous malignant tumours, to find tumour types, age group, and relationship to treatment received. METHODS: Previously diagnosed 1st primary tumour cases experiencing a synchronous or metachronous tumour, seen at AOI from February 2003 to August 2009 (78 months) were included. The cases were analyzed for morphology/histology of 1st primary tumour, age and gender of patient, treatment received for first tumour, time interval between the 1st and 2nd primary tumour, morphology/histology of second tumour, and the treatment conferred for 2nd tumour. RESULTS: The 2nd synchronous and metachronous tumours were 46/4025 (1.14%), in 18 males and 28 females (M:F 1:1.6). The age range was 16-75 years (median 43 years). The follow up time was 24-150 months. The time to 2nd primary tumour was 2-132 months. The 1st primary tumours were breast, ovary, GIT and urinary bladder. The patients received surgery, radiotherapy, chemotherapy, and hormonal therapy alone or as multi-modality treatment for the 1st tumours. The frequent 2nd tumours were breast, ovary and Gastro Intestinal tumours. CONCLUSION: It is imperative that patients with a primary malignant tumour should be thoroughly, closely, and regularly followed. Genetic counseling, risk estimation, cancer screening and chemoprevention must be emphasized. Every subsequent occurring tumour should be biopsied. The effect of 1st tumour on the 2nd or vice versa are still not fully understood and need exploration. The 2nd primary tumour is usually more aggressive, treatment resistant, and metastasizes early requiring a more aggressive treatment strategy.