Vanessa da Costa Miranda

Análise do atraso no diagnóstico e tratamento do câncer de mama em um hospital público

BACKGROUND: To identify potential delays in the management of patients with breast cancer examined at a public hospital, from time of suspicion until diagnosis and beginning of treatment. METHODS: Retrospective study which analyzed data related to time elapsed in different intervals between suspicion, diagnosis and onset of systemic cancer-directed treatments, of consecutive breast cancer patients cared for at the medical oncology clinic of the Mario Covas Hospital during 2006. RESULTS: Sixty-eight women, with a mean age of 56.3 years (standard deviation: 12.2 years), were included. Of all the intervals, the longest delay occurred between the mammographic suspicion of cancer and performance of biopsy (median of 72 days, range: 4 - 1095 days); this was significantly longer (P<0.001) than in the other intervals analyzed. Furthermore, this interval in particular, was significantly longer in patients with advanced stage breast cancer when compared to those at the initial stage (P=0.014). CONCLUSION: Breast cancer patients treated in a public hospital in Brazil suffer delays, especially during the diagnosis of their disease. Minimizing the time between mammography and biopsy of suspicious lesions appears to be the most crintical step to correct this situation.

Adverse drug reactions and drug interactions as causes of hospital admission in oncology

CONTEXT Although several studies have evaluated the frequency of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) in general medicine, few studies have looked at the epidemiology of adverse drug events (ADEs) in oncology. OBJECTIVES We sought to investigate how many hospital admissions in oncology are related to a DDI or an ADR. METHODS All cancer patients admitted to an oncology ward during an eight-month period had their charts retrospectively evaluated for reasons of hospitalization, using a 4-point scale (definitely, probably, possibly, or unlikely associated) to classify admissions by their probability of being associated with either a DDI or an ADR. RESULTS From September 2007 to May 2008, there were 550 hospital admissions and 458 were eligible. Among unplanned admissions (n=298), 39 (13.0%, 95% confidence interval [CI] 9.4%-17.4%) were considered to be associated with an ADE, 33 (11.0%, 95% CI 7.7%-15.2%) with an ADR, and six (2.0%, 95% CI 0.7%-4.3%) with a DDI. The most common DDIs involved warfarin, captopril, and anti-inflammatory agents, and the most frequent ADR was neutropenic fever post-chemotherapy. Most patients were discharged completely recovered, but two patients died. CONCLUSION Approximately one in 10 unplanned hospitalizations of cancer patients is associated with an ADE. Prospective and population-based studies are warranted to evaluate their magnitude in oncology.

Effectiveness of guaraná (Paullinia cupana) for postradiation fatigue and depression: Results of a pilot double-blind randomized study

CONTEXT AND OBJECTIVE Guaraná (Paullinia cupana) has been used medicinally for centuries. The aim of this study is evaluate the effectiveness of guaraná in the treatment of postradiation depression and fatigue. DESIGN AND SETTING This study had a double-blind randomized design with crossover between experimental arms, at Faculdade de Medicina da Fundação do ABC. METHODS We conducted a randomized double-blind crossover trial with 36 patients with breast cancer undergoing adjuvant radiation therapy. We randomized patients to either guaraná 75 mg daily p.o. or to placebo. Patients were switched to the other experimental arm at the middle of the radiation treatment, which consisted of 28 daily fractions of 180 cGy. Evaluations were conducted at the beginning, at the middle, and at the end of radiation therapy. RESULTS We were unable to show any statistically significant differences between the guaraná and the placebo-treated group with any of the measured scores. Also, within the same group, we did not see any statistically significant associations during either the guaraná- or placebo-treated periods with any of the aforementioned measures. CONCLUSIONS We were unable to show that patients with breast cancer undergoing radiation therapy derive any advantage with guaraná over placebo for both fatigue and depressive symptoms.

Prevalence of the burnout syndrome among Brazilian medical oncologists

INTRODUCTION Burnout syndrome which is prevalent among oncologists is characterized by three aspects: emotional exhaustion, depersonalization and low personal accomplishment. The purpose was to evaluate prevalence of the burnout syndrome among Brazilian medical oncologists and the variables that correlate with its presence. METHODS A survey was conducted with members of the Brazilian Society of Medical Oncology (SBOC) who received three questionnaires (general, Maslach burnout questionnaire and an opinion survey) mailed to all 458 members. RESULTS Response rate was of 22.3%. According to the criteria proposed by Grunfeld, which consider burnout present when at least one of the aspects is severely abnormal, prevalence of this syndrome was 68.6% (95% confidence interval, CI: 58.68% to 77.45%). By multivariate analysis having a hobby/physical activity, a religious affiliation, older age, living with a companion and rating vacation time as sufficient were correlated significantly and independently with burnout syndrome. CONCLUSIONS The burnout syndrome is prevalent among Brazilian oncologists. Oncologists having sufficient personal and social resources to engage in a hobby, physical activity, have enough vacation time and religious activities are at lower risk of developing burnout.

Neoadjuvant chemotherapy with six cycles of carboplatin and paclitaxel in advanced ovarian cancer patients unsuitable for primary surgery: Safety and effectiveness

OBJECTIVE Three cycles of neoadjuvant chemotherapy (NACT) followed by interval debulking (ID) surgery is an alternative for patients with advanced ovarian cancer unresectable disease. This study aimed to determine the efficacy and safety of six cycles of NACT followed by cytoreduction. METHODS Retrospective analysis of all patients with advanced epithelial ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma treated with platinum based NACT between January 2008 and February 2012. RESULTS Eighty-two patients underwent NACT; 78% and 18.2% had extensive stage IIIC or IV disease at diagnosis, respectively. Their median age was 60 years (41-82). On histology, serous adenocarcinoma was found in 90.2%. Patients did not receive chemotherapy after debulking surgery. 35.4% suffered grade 3/4 toxicity; the most commonly observed toxicities were hematologic and nausea. After NACT, 23.1% experienced clinical complete response, 57.4% partial response, and 12.1% disease progression. Complete resection of all macroscopic and microscopic disease (R0) was performed in 63.7%. Surgical complications were uncommon; however, four (6.2%) patients needed a second procedure due to operative complications and 18 (27.3%) needed blood transfusion after debulking. Over a median follow-up period of 19.2 months, median overall survival and chemotherapy-free interval were 37.5 months (confidence interval not reached) and 16 months, respectively. CONCLUSION Six cycles of neoadjuvant carboplatin and paclitaxel was safe and effective and did not increase perioperative or postoperative complications in patients with stage IIIC/IV disease who were unsuitable for optimal PDS. The overall survival of this cohort was higher than that of those treated with ID surgery.

O conhecimento do diagnóstico de câncer não leva à depressão em pacientes sob cuidados paliativos

OBJECTIVE: Characterize the profile of patients under palliative care at this institution and evaluate the prevalence of depression in these patients. METHODS: Sixty two cancer patients under palliative care, who had answered three questionnaires: one regarding their demographic characteristics, another to evaluate their quality of life and the Becks depression inventory were surveyed. RESULTS: Of these patients, 68% presented with some degree of depression. Most of them were aware of their diagnosis (87.1%), did not talk to their physicians on other subjects but their disease (81.18%), were satisfied with their treatment (93.33%) and with the support they received (95.70%). Pain, fatigue, weakness and sleep disturbances were the most frequently reported symptoms. There was a significant correlation between presence of depression and not knowing the diagnosis (p=0.008), being admitted to the hospital (p=0.0019) and not having ever received oncologic treatment. CONCLUSION: Patients under palliative care at this institution, despite being satisfied with the treatment, reported poor communication with their physicians and presented with a high rate of depression. Awareness of their diagnosis and having received prior oncologic treatment (p=0.07) correlated significantly and inversely with having depression.

Oncologic Concerns regarding Laparoscopic Cytoreductive Surgery in Patients with Advanced Ovarian Cancer Submitted to Neoadjuvant Chemotherapy

Background: Presently, the use of laparoscopy in advanced ovarian cancer (AOC) is extremely controversial. In the era of neoadjuvant chemotherapy (NACT), endoscopic debulking surgery could be a reasonable alternative for selected patients with primarily unresectable disease. Objectives: To evaluate the feasibility as well as the operative and oncologic safety of laparoscopic debulking surgery in patients with AOC submitted to NACT. Methods: This is a pilot observational study on initially unresectable, high-grade serous ovarian cancer treated with a sequence of 6 cycles of carboplatin and paclitaxel followed by debulking surgery performed by laparoscopy (group 1) or laparotomy (group 2). The inclusion criteria were clinical complete response, CA-125 normalization, imaging without disease in critical areas, and optimal cytoreduction. Results: From January 2011 to March 2014, 21 patients were included. Ten women underwent laparoscopy and 11 laparotomy. No epidemiological or oncologic differences were observed between the groups. No surgery-related casualties, intraoperative complications, conversion to laparotomy, or excessive blood loss or transfusion was detected in the laparoscopic procedures. The mean time of operation was 292 min. The length of hospital stay averaged 3.6 days. Two women in group 1 developed relevant complications. After a mean follow-up of 20 months, the recurrence rates were similar, i.e. 80% in group 1 versus 88% in group 2. Although statistical significance was not reached, the mortality related to cancer was considerably higher (20 vs. 0%; p = 0.086) and the mean chemotherapy-free interval was markedly shorter in group 1 (13.3 vs. 20.5 months; p = 0.288). Conclusion: Laparoscopic optimal debulking surgery after NACT is feasible and effective in selected patients. Nevertheless, laparoscopy was substantially associated with inferior oncologic results. Endoscopic cytoreduction in AOC should be cautiously suggested until larger prospective trials confirm the observed results.

Razão entre linfonodos positivos e dissecados como fator prognóstico em câncer de cólon

BACKGROUND: To evaluate the prognostic value of the ratio between positive and total dissected lymph nodes in patients with colon cancer who underwent primary tumor surgical resection. METHODS: Retrospective chart review of consecutive patients with colon cancer treated at hospitals affiliated to the ABC Foundation School of Medicine, Santo Andre. Demographic data were collected as well as information on colon cancer, treatment and clinical outcomes. RESULTS: One hundred and six patients were included. Mean age was 62.82 ± 11.6 years and most were men (53.8%). Median number of lymph nodes dissected per patient was 11.5 (3 45 lymph nodes) and 58.5% had more than 10 dissected lymph nodes. The median follow-up was 25.05 ± 15.21 months (2 64 months). In univariate analysis for overall survival, lymph node ratio (p=0.044), tumor stage (p=0.001) and tumor recurrence (p=0.058) were considered significant. In multivariate analysis only tumor stage was significantly associated with overall survival (p=0.001). CONCLUSION: In this limited retrospective series, the ratio between positive and dissected lymph nodes was not independently associated with overall survival among patients with colon cancer, when considered together with the pathological stage. Larger and prospective studies are warranted to define the impact of such ratio on the overall survival of colon cancer patients.

O uso da internet como meio auxiliar para o tratamento do excesso de peso

A obesidade e a forma mais comum de ma-nutricao e sua prevalencia vem aumentando muito, inclusive no Brasil. A internet, apesar de ainda pouco explorada, pode ser util no tratamento da obesidade como ferramenta na utilizacao de tecnicas comportamentais. O objetivo deste trabalho foi avaliar o uso da internet no tratamento da obesidade em uma amostra de adultos da cidade de Lagoa dos tres Cantos, RS, onde 58,6% dos habitantes tinha IMC acima de 25kg/m2. Os individuos com excesso de peso (n= 532) foram submetidos a um programa de emagrecimento via internet com dieta hipocalorica e auxilio de tecnicas comportamentais. Foi observada diminuicao do peso medio em relacao ao inicial aos 2o, 5o, 8o e 13o meses, respectivamente: 354 individuos (66,6%) perderam mais do que 5%, sendo que 106 (20%) perderam mais do que 10% do peso inicial. Estes resultados demonstram que o acompanhamento pela internet pode ser util no combate ao excesso de peso e obesidade.

Carboplatin-based chemoradiotherapy in advanced cervical cancer: an alternative to cisplatin-based regimen?

OBJECTIVE To evaluate the results of treatment with cisplatin or carboplatin concomitant with radiotherapy (RT) in cases of locally advanced cervical cancer (CC). METHODS This study is a retrospective analysis of medical records of 184 patients with cervical cancer stage IIB-IVA who were treated at Instituto do Câncer do Estado de São Paulo from May 2008 to December 2012. All patients received complete pelvic region external-beam RT with weekly cisplatin (cis-RT, 40mg/m(2); n=159) or carboplatin (carbo-RT, AUC 2; n=25), followed by high-dose-rate intracavitary brachytherapy (HDR-ICBT). Primary endpoint was progression free survival; secondary endpoints were overall survival and overall response rate, which includes complete and partial responses. RESULTS Five or more chemotherapy cycles were administered to 87.3% and 84% of the cis-RT- and carbo-RT- treated patients, respectively (p=0.749). Estimated 3-years progression free survival was 59% in the cis-RT group vs 40% in the carbo-RT group (p=0.249). Estimated 3-years overall survival was 70% in the cis-RT group vs 68% in the carbo-RT group (p=0.298). Overall response rate (95.3% cis-RT vs 95.4% carbo-RT; p=0.911) and grade ≥3 toxic effects (8.5% cis-RT vs 11.8% carbo-RT; p=0.757) were similar. In multivariate analysis, only the overall response rate was a significant predictor of survival. CONCLUSIONS Patients with advanced cervical cancer who are treated with carbo-RT have similar 3-years overall survival, progression free survival, overall response rate, and toxic effects when compared to cis-RT-treated patients. Carbo-RT may be an alternative treatment in patients that cannot receive cisplatin.