Management Practices of Locally Advanced and Metastatic Urothelial Carcinoma: A Questionnaire-Based Survey among Lebanese Oncologists

Background and Objective: The outcome of locally advanced and metastatic urothelial carcinoma LA/mUC has improved over the past years with a plethora of new treatments and the approval of immune checkpoint inhibitors (ICIs), antibody-drug conjugates, and targeted agents, to identify locally advanced metastatic urothelial carcinoma’s current management practices in Lebanon and the implication of the ongoing economic crisis on the medical practice. Methods: An online questionnaire was used to survey ten Lebanese oncologists from six different hospitals, between July 5 and July 11, 2022, requesting information pertaining to their current clinical practice in the pharmacological treatment of locally advanced metastatic urothelial carcinoma. Key Findings: Cisplatin-based chemotherapy was the most frequently reported initial treatment of locally advanced metastatic urothelial carcinoma. Participants reported using immune checkpoint inhibitors in platinum-ineligible patients and those with PDL1 positive tumors. Also, they would not consider the concomitant use of immunotherapy and chemotherapy in the first-line setting. Participants believed that avelumab maintenance is effective in the absence of progression after first-line platinum-based chemotherapy;they would consider initiating it 2 - 10 weeks after completion of chemotherapy. Conclusions and Clinical Implications: After comparing with current international guidelines, this study shows that Lebanese oncologists follow international guidelines and have deep knowledge of recent clinical trials for the management of locally advanced metastatic urothelial carcinoma, regardless of economic crisis challenges.

Impact of the economic crisis and drug shortage on Lebanese cancer patients’care

BACKGROUND As a consequence of the economic crisis,the sociopolitical instability and the advent of the coronavirus disease-19 pandemic,nested challenges faced the Lebanese healthcare system.These have resulted in critical shortages of essential resources,including medications vital for oncologic patients.AIM To assess the ramifications of the ongoing economic crisis on oncology patient care focusing on our outpatient oncology department.METHODS A questionnaire was distributed during the month of February 2022 to oncology patients in Hôtel Dieu de France University Hospital in Beirut during their outpatient therapy.The primary objective was to assess the far-reaching impact of the economic crisis on patient care and the resulting psychological implications.RESULTS Among 182 interviewed patients,31.87%experienced treatment interruption mainly due to acute drug shortages.Despite 87.91%of the patients benefiting from third-party coverage,69.60%had to self-pay for their medications leading to 69.78%of patients perceiving that healthcare was more difficult to access after 2020.Psychologically,one-third of the patients exhibited symptoms of anxiety and/or depression,with 7 patients reporting suicidal ideations.Notably,37.93%of patients who interrupted cancer treatment reported a history of comorbidities,and 89.66%who altered their treatment cited financial difficulties.CONCLUSION Lebanese cancer patients face complex challenges spanning economic,healthcare,and psychological realms.Income inequalities exacerbated by the economic crisis hindered healthcare access.

Bladder Perforation during Transurethral Resection of Bladder Tumor Is Not an Innocent Accident: Literature Review Based on a Clinical Case Experience

Urothelial Carcinoma (UC) is one of the most frequent cancers worldwide. Transurethral Resection of Bladder Tumor (TURBT) is a standard treatment in the disease’s early stages, with bladder perforation being a possible and classical complication. However, extravesical tumor seeding resulting from perforation is a rare phenomenon. We hereby report the case of a 76-year-old man with a history of smoking diagnosed with high-grade T1 urothelial carcinoma. TURBT was performed and bladder perforation occurred during the procedure. Radical cystectomy after neoadjuvant chemotherapy failed to reveal an invasive tumor. However, the patient experienced peritoneal recurrence with liver metastasis 3 years following the operation. This case left physician wondering whether the bladder perforation and the resulting tumor seeding are the cause behind the late peritoneal recurrence of an early-stage urothelial carcinoma.

Dilemma of first line regimens in metastatic pancreatic adenocarcinoma

Pancreatic cancer is one of the deadliest cancers,ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer(m PC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of m PC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel(GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score(0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.

Comprehensive review into the challenges of gastrointestinal tumors in the Gulf and Levant countries

Although gastrointestinal stromal tumors(GISTs)are rare,with an incidence of 1/100000 per year,they are the most common sarcomas in the peritoneal cavity.Despite considerable progress in the diagnosis and treatment of GIST,about half of all patients are estimated to experience recurrence.With only two drugs,sunitinib and regorafenib,approved by the Food and Drug Administration,selecting treatment options after imatinib failure and coordinating multidisciplinary care remain challenging.In addition,physicians across the Middle East face some additional and unique challenges such as lack of published local data from clinical trials,national disease registries and regional scientific research,limited access to treatment,lack of standardization of care,and limited access to mutational analysis.Although global guidelines set a framework for the management of GIST,there are no standard local guidelines to guide clinical practice in a resource-limited environment.Therefore,a group of 11 experienced medical oncologists from across the Gulf and Levant region,part of the Rare Tumors Gastrointestinal Group,met over a period of one year to conduct a narrative review of the management of GIST and to describe regional challenges and gaps in patient management as an essential step to proposing local clinical practice recommendations.

Is There Any Indication for Prophylactic Brain Irradiation in the Management of Small Cell Prostate Cancer?

Small cell prostate carcinoma (SCPC) is an extremely rare pathology with an aggressive behavior, characterized by early brain metastases. We describe three cases of SCPC where brain metastases occurred despite response to chemotherapy. The benefit of prophylactic brain irradiation (PBI), as part of the management of SCPC, is discussed and compared to its indications in small cell lung cancer.

Complete Remission by Primary Chemotherapy of Advanced Non-Seminomatous Germ Cell Tumor in an Intra-Abdominal Testis

Ectopic testis predisposes to a high risk of germ cell tumor development. Treatment of advanced testicular germ cell tumor developing in an uncorrected abdominal testis is based on primary chemotherapy followed by removal of the testis along with residual masses. However, persistence of viable tumor particularly in the testis is always noted since testis penetration of chemotherapeutic agents is reduced. We report a case of complete pathological remission of a patient with advanced non-seminomatous germ cell tumor in intra-abdominal testis by primary chemotherapy alone, with a review of the literature.