Search

Respuesta a la carta al Editor

Objetivos: describir la frecuencia de la respuesta clínica y patológica, entre los diferentes subtipos moleculares de cáncer de mama, en pacientes que previamente recibieron quimioterapia neoadyuvante. Materiales y métodos: cohorte retrospectiva, descriptiva. Se incluyeron mujeres mayores de 18 años, con diagnóstico histológico de carcinoma invasivo de mama, en estadios IIA, IIB, IIIA, IIIB y IIIC, con clasificación por subtipos moleculares, que hubieran recibido quimioterapia neoadyuvante, atendidas en una clínica de alto nivel de complejidad localizada en Medellín (Colombia), entre el 1 de julio de 2017 y el 30 de julio de 2019. Las variables recolectadas fueron edad, estadio clínico, características histológicas, clasificación molecular y la respuesta clínica y patológica completa por subtipo molecular. Se realizó análisis descriptivo. Resultados: 255 pacientes cumplieron con los criterios de inclusión. La edad media fue de 55,2 años; los estadios clínicos con mayor prevalencia fueron IIIB (28,6 %) y IIB (26,3 %), respecto al grado histológico, los más frecuentes fueron grado 3 (48,2%) y 2 (37,3%). La frecuencia por subtipos moleculares fue: luminal A (10,2 %), luminal B HER2 negativo (39,6%), triple negativo (23,1 %), luminal B HER2 positivo (13,7 %), y HER2 puro (13,3%). La respuesta clínica completa posquimioterapia por subtipo molecular fue: luminal A (26,9 %), luminal B HER2 negativo (37,6 %), luminal B HER2 positivo (48,6 %), HER2 puro (41,2%), triple negativo (45,8%); se logró respuesta patológica completa por subtipo molecular, así: luminal A (19,2 %), luminal B HER2 negativo (32,7%), luminal B HER2 positivo (54,3 %), HER2 puro (50 %), triple negativo (42,4%). Conclusiones: en la práctica clínica, la clasificación por subtipos moleculares en cáncer de mama permite hacer una aproximación a la respuesta de la quimioterapia neoadyuvante. Se requieren estudios prospectivos en la región para determinar la capacidad predictiva de la respuesta patológica completa respecto a la sobrevida global y libre de enfermedad.

Objectives: As part of sexual and reproductive health, abortion is a woman's right in Colombia. However, not all the members of Colombian society recognize this right. The aim of this work is to understand the transformation of meanings after having to cope with voluntary termination of late pregnancy in women living in Colombia, as well as their interaction with family and friends and the health system. Material and methods: Hermeneutic research undertaken within a constructivist paradigm and analyzed from a feminist perspective using grounded theory techniques: coding, categorization and constant comparison. Nineteen semi-structured interviews were conducted among 18 women living in Colombia who underwent voluntary termination of late pregnancy defined as more than 20 weeks of gestation, accompanied by feticide and labor induction, in two Colombian cities between 2016 and 2020. Besides, two focus groups were conducted, one with some of the interviewees and another with feminist experts in order to cross-reference the information derived from the research process and delve deeper into the findings. Results: Women attached a negative and opposite meaning to voluntary termination of pregnancy, but once they found themselves in a situation that forced them to put an end to gestation, they transgressed their own meanings and those of society to find justifications to help them uphold their decision. This confrontation brought them to a place of profound and intimate reflection and led them to transform their lives. Conclusions: Meanings regarding abortion in women who undergo late pregnancy termination are usually contrary to this right in sexual and reproductive health. After the event, these meanings become transformed through a process of conscious reflection as women come face-to-face with their own meanings and those of society. [ABSTRACT FROM AUTHOR]

Objetivos: evaluar la frecuencia del parto instrumentado en Colombia y por regiones entre el 2015 y 2019. Materiales y métodos: estudio de corte transversal a partir de registros poblacionales. Se incluyeron los registros de mujeres con edad gestacional mayor a 28 semanas y parto vaginal. Muestreo consecutivo. La información se obtuvo a partir del certificado de nacido vivo del Departamento Administrativo Nacional de Estadística (DANE). Se realizó la descripción de las variables sociodemográficas y clínicas. La frecuencia del parto instrumentado fue calculada y descrita por año y departamento. Resultados: se incluyeron 3.224.218 registros de recién nacidos vivos. De estos, 1.719.405 (53,33 %) correspondieron a partos vaginales, y 1.468.726 (45,55 %) a partos por vía cesárea. La frecuencia nacional del parto instrumentado entre el 2015 y 2019 fue de 36.087 nacimientos (1,11 %); Antioquia y Bogotá, D.C. fueron los lugares con mayor ocurrencia, 16.201 (4,5 %) y 13.686 (2,52 %), respectivamente. Conclusiones: el parto vaginal instrumentado es la vía de parto con menor ocurrencia en Colombia con tendencia a la disminución. La formación en este recurso para el uso durante el trabajo de parto no debe perderse en la formación del profesional de salud, especialmente en los programas de Ginecología y Obstetricia. Se debe evaluar si el aumento en el adecuado uso de esta técnica puede disminuir la tasa de cesáreas observadas actualmente, así como describir los escenarios clínicos donde su uso es seguro para la madre y el feto. Se requieren estudios prospectivos, pues pueden permitir establecer las causas del descenso en el uso de esta herramienta obstétrica, los resultados maternos y perinatales en términos de su riesgo/beneficio.

Objectives: To describe the frequency of clinical and pathological response in different molecular subtypes of breast cancer, in patients receiving prior neoadjuvant chemotherapy. Materials and methods: Descriptive retrospective cohort. The study population consisted of women 18 years of age and older with a histological diagnosis of invasive breast cancer stages IIA, IIB, IIIA, IIIB and IIIC, with a classification by molecular subtypes, who had received prior neoadjuvant chemotherapy, seen at a high complexity clinic in Medellin (Colombia), between July 1, 2017, and July 30, 2019. We measured age clinical stage, histological characteristics, molecular classification, and complete clinical and pathological responses by molecular subtype. A descriptive analysis was conducted. Results: Overall, 255 patients met the inclusion criteria. Mean age was 55.2 years; the clinical stages with the highest prevalence were IIIB (28.6 %) and IIB (26.3 %), and the most frequent by histologic grading were grades 3 (48.2 %) and 2 (37.3 %). Frequency by molecular types was as follows: luminal A (10.2 %), HER2-negative luminal B (39.6 %), triple-negative (23.1%), HER2-positive luminal B (13.7 %), and pure HER2 (13.3 %). Complete clinical response following chemotherapy, by molecular type, was as follows: luminal A (26.9 %), HER2-negative luminal B (37.6 %), HER2-positive luminal B (48.6 %), pure HER2 (41.2 %), triple-negative (45.8 %). Complete pathological response by molecular subtype was achieved in the luminal A (19.2 %), HER2-negative luminal B (32.7 %), HER2-positive luminal B (54.3 %), pure HER2 (50 %) and triple-negative (42.4 %) subtypes. Conclusions: In clinical practice, breast cancer classification by molecular subtypes is a means to approach the assess the to neoadjuvant chemotherapy. Se requieren estudios prospectivos en la región para determinar la capacidad predictiva de la respuesta patológica completa respecto a la sobrevida global y libre de enfermedad. [ABSTRACT FROM AUTHOR]

Objectives: To describe how the frequency of cesarean section has evolved in Colombia since 1998, both in overall terms as well as discriminated according to the legal standing of the healthcare providers (IPSs) where delivery takes place, and to estimate the size of the association between the legal standing of the institutions and the performance of cesarean sections between 2015 and 2017. Material and methods: A cross-sectional cohort study that describes the frequency of cesarean deliveries between 1998 and 2020, plus an analytical component to estimate the association between the legal nature and the route of delivery between 2015 and 2017, based on the birth records of the Colombian National Statistics Administrative Department (DANE). Proportions of cesarean sections and their increase by institution type are presented. The prevalence ratio was used as an estimator of this association. Results: In 1998, the proportion of cesarean deliveries was 25.7 %; it increased to 46.4 % by 2015 and then dropped to 44.6 % by 2020. After 1998, the proportion of cesarean sections in public hospitals increased from 26.2 % to 42.9 % by 2014, while in private providers it increased from 45.0 % to 57.7 % by 2013. The prevalence ratio of cesarean sections in private versus public institutions was 1.57 (95 % CI: 1.56-1.57). Conclusions: After a long period of sustained growth, there is now a reduction in the proportion of cesarean sections in the country. In public health care institutions, these procedures increased in greater proportion during most of the study period, while in private healthcare providers they are carried out at a higher frequency in all subgroups of women. It will be necessary to evaluate in the future, using more robust methodologies, whether the decrease in the frequency of cesarean section is a real or secular trend. [ABSTRACT FROM AUTHOR]

Objectives: To assess the frequency of instrumented delivery in Colombia and by regions between 2015 and 2019. Material and methods: Cross-sectional study based on population registries. Records of women with a gestational age of more than 28 weeks and vaginal delivery were included. Consecutive sampling was used. The information was taken from live birth certificates of the National Statistics Department (DANE). Sociodemographic and clinical variables were described. The frequency of instrumented deliveries was calculated and described by year and by department. Results: Overall, 3,224,218 live birth records were included. Of these 1,719,405 (53.33 %) were vaginal deliveries and 1,468,726 (45.55 %) were cesarean births. At a national level, the frequency of instrumented deliveries between 2015 and 2019 was 36,087 births (1.11 %); Antioquia and Bogotá, D.C. were the places with the highest occurrence, with 16,201 (4.5 %) and 13,686 (2.52 %), respectively. Conclusions: The occurrence of instrumented vaginal delivery in Colombia is the lowest and tends to diminish. Training of healthcare professionals in this approach during labor must not be abandoned, particularly in Obstetrics and Gynecology particularly in Obstetrics and Gynecology training programs. Further studies should be conducted to determine whether the increased adequate use of this technique could contribute to a lower rate of cesarean sections, and also to describe the clinical setting in which its use is safe for both the mother and the fetus. Prospective studies are required to identify the causes leading to the lower use of this obstetric tool as well as the risks and benefits in terms of maternal and perinatal outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To understand the meaning of the experiences of breast cancer patients undergoing diagnostic and treatment processes., Material and Methods: A descriptive qualitative study based on the hermeneutic-interpretative scientific paradigm and grounded in a phenomenological epistemological framework. The study included women aged 18 years or older diagnosed with breast cancer and treated at a university clinic in Bogotá, who were given a semi-structured interview. Procedure: Semi-structured interviews were conducted based on pre-established categories. Aspects evaluated: Knowledge about current breast cancer screening and detection patterns, current utilization patterns of healthcare services, and perceived healthcare needs., Results: Regarding Current knowledge patterns on breast cancer screening and detection, patients demonstrated limited awareness. Concerning Current utilization patterns of healthcare services, there were noted dissatisfactions with the administrative process. Regarding Perceived healthcare needs, a feeling of abandonment was identified, stemming from a lack of continuity in the care process. Additionally, two emergent categories were identified: trust in the healthcare system and predisposition to feelings of guilt due to a lack of knowledge about the disease., Conclusions: A comprehensive care process is needed that addresses the real medical needs of patients, beyond administrative concerns, and is focused on the quality of the doctor-patient relationship across the entire multidisciplinary team.

Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. Materials and Methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80 %, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus drafted five recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, onestage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations. [ABSTRACT FROM AUTHOR]

Background Primary screening with Human Papilloma Virus (HPV) testing was introduced in Colombia in 2014 for individuals between 30 and 65 years of age. When the result is positive, cytology triage is performed for colposcopy referral. The convenience of initiating HPV-DNA testing for screening at 25 years of age is currently a subject of discussion. Therefore, the objective of this health technology assessment (HTA) is to analyze the available evidence regarding safety, efficacy, cost-effectiveness, values and preferences, ethical dilemmas and considerations pertaining to the implementation of the HPV-DNA test as a cervical screening strategy in women under 30 years of age in the Colombian context. Domains to be assessed Clinical efficacy and safety 1. Cumulative rate of cervical intraepithelial neoplasia (CIN) grade 2 or high-er after 2 screening rounds. 2. Cumulative rates of invasive cancer of the uterine cervix after 2 screening rounds. 3. Safety: referral to colposcopy. Cost-effectiveness Cost-effectiveness for Colombia. Other domains considered Ethical considerations associated with cervical screening in women under 30 years of age. Organizational and individual considerations. Barriers and facilitators pertaining to the implementation of cervical screening in women under 30 years of age in the Colombian context. Methods Clinical efficacy and safety assessment A systematic literature search of systematic reviews and clinical trials was conducted in MEDLINE, Embase and CENTR AL. The body of evidence was rated using the GRADE approach. An interdisciplinary team was then convened to create a working group to review the retrieved evidence. This led to the discussion and construction of the conclusions following the guidelines of a formal consensus in accordance with the RAND/UCLA methodology. Economic study Systematic literature research of studies that had assessed cost-effectiveness for Colombia. Results Out of the 7,659 references retrieved, 8 studies were included. Clinical outcomes An integrative analysis of 5 randomized clinical trials that met the inclusion critera was performed. Compared with cytology, primary HPV-DNA testing in women under 30 years of age could be associated with a lower frequency of CIN2+ lesions during the first screening round (RR: 1.57; CI 95 %: 1.20 to 2.04; low evidence certainty), and a lower incidence of CIN2+ (RR: 0.67; CI 95 %: 0.48 to 0.92; low evidence certainty). Moreover, it is associated with a lower frequency of invasive carcinoma at the end of follow-up (RR: 0.19; CI 95 %: 0.07 to 0.53; high evidence certainty). Economic results From the financial point of view, the use of HPV- DNA testing plus cytology-based triage starting at 25 years of age is perhaps the most cost-effective option for Colombia (incremental cost-effectiveness ratio, COP 8,820,980 in 2013). Other implications Two studies suggest that barriers to implementation attributable to intermediation, public unrest and geographic considerations could be overcome with the use of new screening technologies or strategies. It is important to consider administration and service provision alternatives in order to overcome some acceptability and access barriers. Any cervical screening program must take into consideration ethical principles of nonmaleficence, beneficence, autonomy and equity. Future studies should focus on analyzing new screening techniques with emphasis on the population under 30 years of age. Conclusions The use of HPV-DNA testing as a screening strategy in women under 30 years of age is a potentially efficacious and cost-effective intervention for Colombia. Future studies should focus on analyzing new screening technologies, with emphasis on the population under 30 years of age. [ABSTRACT FROM AUTHOR]

Objective: The Cancer Genome Atlas research program (TCGA) developed the molecular classification for endometrial cancer with prognostic and therapeutic utility, which was replaced by the ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) classification by consensus and international guidelines due to its high cost. This article aims to present national recommendations from an expert consensus that allows unification and implementation of the molecular classification for women with endometrial cancer nationwide, with a rational use of resources and technology. Methods: Consensus of 36 experts in clinical oncology, oncological gynecology, pathology, and genetics, with clinical practice in the national territory. The leader group performed a literature review and structuring of questions rated 1 to 9 points. A modified nominal group technique was used. There was a face-to-face meeting with master presentations, deliberative dialogue, and Google Forms (Google LLC, Mountain View, CA, USA) questionnaire voting with analysis and discussion of responses. The non-consensual responses led to a second round of voting. The final manuscript was finally prepared and revised. Results: Seven recommendations were formulated integrating the panelist responses based on evidence, but adjusted to the Colombian context and reality. Recommendation 1. The molecular classification is recommended in all the endometrial cancers using the immunohistochemistry markers as subrogated results from the molecular profile initially proposed in the TCGA classification. Recommendation 2. The sequential test strategy is recommended, starting with the immunohistochemistry markers (p53, MLH1, MSH 2, MSH6, PMS2) simultaneously in all the patients, defining to request POLE (DNA polymerase epsilon) (if available) according to the risk classification based on the surgical piece. Recommendation 3. It is recommended, that the gynecologist oncologist should be the one to request the POLE (if available) according to the final pathology report. This test must be requested for all endometrial cancers stage I-II, except in low risk (stage IA low grade endometrioid histology without linfovascular invasion normal p53) and, stages III-IV without residual disease, without affecting the request of subrogated immunohistochemistry molecular markers upon histology. The consensus proposes that the POLE is requested after the immunohistochemistry and according to the categories in the risk classification established by the 2020 ESGO/ESTRO/ESP guidelines. Recommendation 4. It is recommended to perform immunohistochemistry for hormonal receptors for all women with endometrial cancer and the HER2 in patients with p53abn, simultaneously with the others immunohistochemistry markers. Recommendation 5. It is recommended to perform the immunohistochemistry markers (p53, MLH1, MSH2, MSH6 y PMS2) in an initial endometrial biopsy or curettage when the specimen is adequate and available. In case the initial immunohistochemistry is inconclusive, or there are histological discrepancies between the initial and definitive pathology, it is recommended to repeat the molecular profile in the surgical pathology. The immunohistochemistry markers must be reported in the pathology report according to the CAP (College of American Pathologists) recommendations, independently of the type of sample. Recommendation 6. It is recommended to perform MLH1 promoter methylation testing in patients who exhibit loss of expression of MLH1 in immunohistochemistry whether it is accompanied or not with loss of expression of PMS2. All the patients with deficient MMR (mismatch repair), should be sent for genetic counseling to rule out Lynch syndrome. Recommendation 7. It is recommended to consider the molecular classification in addition to the classical histopathological criteria when making adjuvant judgments, as incorporated by the classification of prognostic groups of the 2020 ESGO/ESTRO/ESP guidelines. Conclusions: It is necessary to implement the molecular classification of endometrial cancer in clinical practice in accordance to the Colombian context, due to its prognostic and probably predictive value. This will enable the characterization of the Colombian population in order to offer individualized guided treatments. This is an academic and nonregulatory document.