Impact of COVID-19 on Management and Outcomes of Oncology Patients: Results of MENA COVID-19 and Cancer Registry (MCCR).

Introduction: Despite extensive studies of the impact of COVID-19 on patients with cancer, there is a dearth of information from the Middle East and North Africa (MENA) region. Our study aimed to report pertinent MENA COVID-19 and Cancer Registry (MCCR) findings on patient management and outcomes. Methods: MCCR was adapted from the American Society of Clinical Oncology COVID-19 Registry to collect data specifically from patients with cancer and SARS-CoV-2 infection from 12 centers in eight countries including Saudi Arabia, Jordan, Lebanon, Turkey, Egypt, Algeria, United Arab Emirates, and Morocco. The Registry included data on patients and disease characteristics, treatment, and patient outcomes. Logistic regression was used to assess associations with mortality. Results: Between November 29, 2020, and June 8, 2021, data were captured on 2008 patients diagnosed with COVID-19 from the beginning of the pandemic. Median age was 56 years (16-98), 56.4% were females, and 26% were current or ex-smokers. Breast cancer (28.5%) was the leading diagnosis and 50.5% had metastatic disease. Delays of planned treatment (>14 days) occurred in 80.3% for surgery, 48.8% for radiation therapy, and 32.9% for systemic therapy. Significant reduction in the delays of all three treatment modalities occurred after June 1, 2020. All-cause mortality rates at 30 and 90 days were 17.1% and 23.4%, respectively. All-cause mortality rates at 30 days did not change significantly after June 1, 2020; however, 90-day mortality increased from 33.4% to 42.9% before and after that date (p = 0.015). Multivariable regression analysis showed the following predictors of higher 30- and 90-day mortality: age older than 70 years, having metastatic disease, disease progression, and being off chemotherapy. Conclusion: Patients with cancer in the MENA region experienced similar risks and outcome of COVID-19 as reported in other populations. Although there were fewer treatment delays after June 1, 2020, 90-day mortality increased, which may be attributed to other risk factors such as disease progression or new patients who presented with more advanced disease.

Quality of Life and Psychological Wellbeing of Colorectal Cancer Survivors in the KSA.

INTRODUCTION: Colorectal cancer (CRC) ranked first among cancers reported in males and ranked third amongst females in Saudi Arabia. CRC cancer symptoms or symptoms secondary to treatment, such as diarrhea, constipation, fatigue and loss of appetite are very common and has significant negative effects on the quality of life (QoL). METHODS: This project was a cross-sectional study of colorectal cancer survivors diagnosed between 1 January 2015 and May 2017. Assessment was performed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the colorectal cancer specific module (EORTC QLQ-CR 29) and the Hospital Anxiety and Depression Scale (HADS). Data on potential predictors of scores were also collected. RESULTS: 115 CRC patients from Middle, Eastern and Western regions of the KSA participated in the study. Participants have unexpectedly low global health score with a mean of 56.9±31.3. Physical functioning scale had the lowest score of 61.3±27.7. Regarding the generic symptoms of cancer, fatigue was the worst symptom, followed by appetite loss. Psychological wellbeing assessment utilizing HADS reveals alarming outcomes for survivors of CRC in the KSA with high proportion of participants with moderate to severe depression (55%) and a good proportion of participants with moderate to high anxiety (31%). Only 3.7% of participants reported receiving psychosocial support. DISCUSSION: Results of this project reveal an overall trend of low scores of quality of life amongst colorectal cancer patients in the KSA when compared with regional or international figures. Consistent results for psychological wellbeing were reached. We recommend routine screening for quality of life and psychological wellbeing and including the outcomes per individual patient care. Psychological support is highly needed for cancer survivors.

Hepatoid esophagogastric adenocarcinoma and tumoral heterogeneity: a case report.

Hepatoid adenocarcinoma of the stomach is an uncommon subtype of gastric cancer remarkably similar to hepatocellular carcinoma in histopathological analysis. It is also commonly associated with high serum alfa-fetoprotein and a poorer prognosis, despite the emergence of new therapeutic options. In recent years, next generation sequencing (NGS) technology has made it possible to identify and describe the genes and molecular alterations common to gastric cancer thereby contributing to the advancement of targeted therapies. A 62-year-old patient, with no prior risk factor for hepatocellular carcinoma (HCC), presented to the emergency room with dysphagia for solids, abdominal pain and weight loss of about 3 kilograms over 3 months. Histopathological analysis presented with disparities regarding HER2 and programmed death-ligand 1 (PD-L1) status in the primary and metastatic sites. We describe a case of a de novo metastatic, human epidermal growth factor receptor 2 (HER2) positive esophagogastric junction hepatoid adenocarcinoma. Although this is a rare subgroup of gastric cancer, treatment strategies were based in recent studies in immunotherapy and guided therapy, taking into consideration the molecular findings from the patient's tumor NGS analysis. Data about HER2 and PDL1 heterogeneity were also reviewed. Despite the aggressiveness and rarity of this histology, the patient had a good response to treatment.

Outcome of Oncology Patients Infected With Coronavirus.

PURPOSE: This study investigated the features of oncology patients with confirmed Middle East respiratory syndrome (MERS) at the Ministry of National Guard Health Affairs-Riyadh during the outbreak of June 2015 to determine the clinical course and outcome of affected patients. METHODS: The patients' demographic information, cancer history, treatment pattern, information about MERS-coronavirus (CoV) infection, history of travel, clinical symptoms, test results, and outcome were collected and analyzed as part of a quality improvement project to improve the care and safety of our patients. Only patients with confirmed infection were included. RESULTS: A total of 19 patients were identified, with a median age of 66 years (range, 16-88 years), and 12 patients (63%) were males. The most common underlying disease was hematologic malignancies (47.4%), followed by colorectal cancer (21%) and lung cancer (15.8%). Hypertension and diabetes mellitus were the most common comorbidities (57.9% and 52.6%, respectively). Infection was diagnosed by nasopharyngeal swab in all patients. All patients contracted the infection during their hospitalization for other reasons. Sixteen patients (80%) were admitted to the intensive care unit; 13 patients (81%) had acute respiratory distress syndrome, 11 were intubated (68.75%), 9 had acute renal injury (56.25%), and 3 required dialysis (18.75%). Only 3 patients (15.8%) with early-stage cancers survived. Patients with hematologic malignancies and advanced solid tumors had a 100% case fatality rate. The majority of the causes of death were due to multi-organ failure and septic shock. CONCLUSION: MERS-CoV infection resulted in a high case fatality rate in patients with malignancy. Therefore, it is critical to implement effective primary preventive measures to avoid exposure of patients with cancer to the virus.

Managing Oncology Services During a Major Coronavirus Outbreak: Lessons From the Saudi Arabia Experience.

Outbreaks of infectious etiology, particularly those caused by a novel virus that has no known treatment or vaccine, may result in the interruption of medical care provided to patients with cancer and put them at risk for undertreatment in addition to the risk of being exposed to infection, a life-threatening event among patients with cancer. This article describes the approach used to manage patients with cancer during a large-scale Middle East respiratory syndrome-coronavirus hospital outbreak in Saudi Arabia to ensure continuity of care and minimize harm from treatment interruption or acquiring infection. The approach taken toward managing this high-risk situation (COVID-19) could be easily adopted by health care organizations and would be helpful to ensure readiness for the occurrence of future outbreaks of different infectious etiologies like those recent episodes of new coronavirus.

Improving adherence to lung cancer guidelines: a quality improvement project that uses chart review, audit and feedback approach.

INTRODUCTION: The implementation of evidence-based clinical practice guidelines is one of the most effective interventions for improving quality of care. A gap between guidelines and clinical practice often exists, which may result in patients not receiving appropriate care. This project aimed at improving adherence to lung cancer guidelines at our institution. METHOD: The records of patients with lung cancer were evaluated for adherence to guidelines by using an auditing tool that was developed to capture pertinent information. The study team collected data about the following variables: compliance with documentation of pathological diagnosis, documentation of disease stage prior to treatment initiation, presentation at thoracic tumour board within 30 days of diagnosis, management course, and management of end of life in terms of early 'no code' initiation, stopping chemotherapy and referral to palliative care prior to 2 weeks of death. Annual audits were performed from 2012 to 2015. Education and discussion with team members to address the deviations were the main interventions to improve adherence. RESULTS: The baseline measurements were taken in 2012 (49 patients). Histological subtype identification improved from 94% to 100%. Presentation of new cases at the tumour board improved from 35% to 82%. Testing for epidermal growth factor receptor mutation for non-squamous cell lung cancer improved from 77% to 100%. The staging was documented in 100% of the cases. CONCLUSION: Running audits to monitor adherence to guidelines and discussions with the team have a positive effect on providing consistent evidence-based care for patients with lung cancer.

Maximizing response: a case report of salvage chemotherapy after immune checkpoint inhibition in a patient with previous chemo-refractory metastatic esophageal carcinoma.

Esophageal carcinoma is an aggressive malignancy and outcomes remain poor. Immune checkpoint inhibitors are a standard-of-care in the third-line and beyond settings, although benefit is modest. Herein, we report the case of a patient who achieved a partial response to salvage chemotherapy following treatment with an immune checkpoint inhibitor despite having chemo-refractory disease. A 41-year-old male, with a history of Crohn's disease, was diagnosed with Her2-positive metastatic esophageal adenocarcinoma to lungs and lymph nodes. The patient received multiple lines of systemic therapy including: first-line modified DCF (docetaxel/cisplatin/5-fluorouracil) with trastuzumab, second-line trastuzumab/afatinib on a clinical study, third-line carboplatin/irinotecan/ramucirumab and fourth-line treatment with a Her2 antibody-drug conjugate, DS-8201A, on a phase I study. While the patient was not a candidate for clinical trials evaluating immune checkpoint inhibitors due to his history of Crohn's disease, the latter was well controlled. Thus, the patient commenced pembrolizumab as fifth-line of treatment 2 years since diagnosis. After 3 cycles of therapy, the patient developed grade 3 immune-related colitis and treatment was discontinued. The patient maintained a good performance status and commenced a sixth-line of carboplatin/irinotecan/ramucirumab. Subsequent imaging demonstrated a partial response which was maintained over a 6-month period. This case demonstrates a response to previously administered chemotherapy following immune checkpoint inhibitor therapy, despite prior progression on this chemotherapy regimen. To our knowledge, this has not been previously reported in esophagogastric carcinoma (EGC). Post-immune checkpoint inhibitor chemotherapy may be a feasible treatment strategy. Research is needed to evaluate the role of post-immune checkpoint inhibitor chemotherapy in patients with metastatic EGC.

Improving risk prediction for pancreatic cancer in symptomatic patients: a Saudi Arabian study.

BACKGROUND: Imaging tests used in our center are usually inadequate to confirm the high risk for pancreatic cancer. We aimed to use a combination of potential predictors including imaging tests to quantify the risk of pancreatic cancer and evaluate its utility. METHODS: This was a retrospective cohort study of patients who were suspected as having pancreatic cancer and underwent biopsy examination of pancreatic mass at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 1, 2013, and December 31, 2016. We retrieved data on demographics, clinical history, imaging tests, and final pancreatic diagnosis from medical records. RESULTS: Of the 206 who underwent pancreatic biopsies, the mean age was 63.6 years; 54.4% were male. Of all the biopsies, 57.8% were malignant and 42.2% were benign masses. Nine factors contributed significantly to the risk of pancreatic cancer and were noted: older age (adjusted odds ratio [aOR] =1.048; P=0.010), male gender (aOR =4.670; P=0.008), weight loss (aOR =14.810; P=0.001), abdominal pain (aOR =7.053; P=0.0.001), blood clots (aOR =20.787; P=0.014), pancreatitis (aOR =4.473; P=0.021), jaundice (aOR =7.446; P=0.003), persistent fatigue (aOR =22.015; P=0.015), and abnormal imaging tests (aOR =67.124; P=0.001). The model yielded powerful calibration (P=0.953), excellent predictive utility (area under the receiver operating characteristic curve 96.3%; 95% CI =94.1, 98.6), with optimism-corrected area under the curve bootstrap resampling of 94.9%. An optimal cut-off risk probability of 0.513 yielded a sensitivity of 94% and specificity of 84.7% for risk classification. CONCLUSION: The study developed and validated a risk model for quantifying the risk of pancreatic cancer. Nine characteristics were associated with increased risk of pancreatic cancer. This risk assessment model is feasible and highly sensitive and could be useful to improve screening performance and the decision-making process in clinical settings in Saudi Arabia.

Saudi lung cancer management guidelines 2017.

BACKGROUND: Lung cancer management is getting more complex due to the rapid advances in all aspects of diagnostic and therapeutic options. Developing guidelines is critical to help practitioners provide standard of care. METHODS: The Saudi Lung Cancer Guidelines Committee (SLCGC) multidisciplinary members from different specialties and from various regions and healthcare sectors of the country reviewed and updated all lung cancer guidelines with appropriate labeling of level of evidence. Supporting documents to help healthcare professionals were developed. RESULTS: Detailed lung cancer management guidelines were finalized with appropriate resources for systemic therapy and short reviews highlighting important issues. Stage based disease management recommendation were included. A summary explanation for complex topics were included in addition to tables of approved systemic therapy. CONCLUSION: A multidisciplinary lung cancer guidelines was developed and will be disseminated across the country.

Clinical Presentation, Risk Factors, and Treatment Modalities of Hepatocellular Carcinoma: A Single Tertiary Care Center Experience.

Objective. To investigate the risk factors, clinical characteristics, treatment modalities, and outcomes in Saudi patients with HCC and propose points for early detection of the disease. Methods. Patients were stratified according to underlying risk factors for the development of HCC. Barcelona Clinic Liver Cancer (BCLC) was used for cancer staging. Treatment was classified into surgical resection/liver transplantation; locoregional ablation therapy; transarterial embolization; systemic chemotherapy; and best supportive care. Results. A total of 235 patients were included. Males had higher tumor size and incidence of portal vein thrombosis. Viral hepatitis was a risk factor in 75.7%. The most common BCLC stages were B (34.5%) and A (33.6%), and the most common radiological presentation was a single nodule of less than 5 cm. Metastases were present in 13.2%. Overall, 77 patients (32.8%) underwent a potentially curative treatment as the initial therapy. The most commonly utilized treatment modality was chemoembolization with 113 sessions in 71 patients. The overall median survival was 15.97 ± 27.18 months. Conclusion. HCC in Saudi Arabia is associated with high prevalence of HCV. Potentially curative therapies were underutilized in our patients. Cancer stage BCLC-B was the most frequent (34.5%) followed by BCLC-A (33.6%). The overall median survival was shorter than other studies.