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With the aim of improving the quality of cancer care globally, ASCO began to offer its quality improvement programs to interested international oncology practices. In this manuscript, we describe the experiences with ASCO quality initiatives in low- and middle-income countries (LMICs). The experience acquired from different practices in Latin America and Africa was reviewed and various action steps were summarized. Encountered challenges and implemented solutions to mitigate these challenges were identified to list as lessons learned for oncology practices in LMICs or low-resource settings to use in their future quality improvement initiatives and providing a proactive approach for those practices considering starting quality improvement programs. Having programs tailored to LMICs may facilitate the participation of more practices and help them take advantage of these programs to enhance patient care. The preliminary data and learning are promising and demonstrate that participation in quality improvement activities can have a positive effect. Although this early experience is encouraging, each country and resource-limited practice will have its own unique challenges as highlighted in this article. Having more practices participate will further enhance the knowledge base, build experience in addressing challenges, and enable oncology patients to reap the benefits worldwide.

Introduction The global pandemic was an emerging challenge that significantly impacted healthcare systems and the delivery of care. Prompt actions and adaptive techniques, such as the virtual clinic, were implemented to ensure the quality and continuity of the care provided. The aim of this quality improvement project was to ensure the smooth implementation and effectiveness of the virtual clinic during the COVID-19 crisis. Methods A specialized team of multidisciplinary healthcare providers was established to systematically ensure the implementation of the virtual clinic within the Department of Oncology. The team used multiple Plan-Do-Study-Act (PDSA) cycles of the quality improvement model to achieve the final goal and facilitate the transition to the virtual clinic. Results A total of 29 weekly virtual clinic sessions were conducted, covering various oncology services. From March to December 2020, 81% of the scheduled patients (3888) responded to virtual clinic calls. Physicians initiated 234 unplanned virtual clinic calls to follow up on a patient’s condition. In addition, 916 medications were shipped to patients as needed. A patient satisfaction survey in May 2020 indicated an overall satisfaction rate of 92% with the virtual clinic process. Staff satisfaction was also high (91%), and 88% of the physicians believed that the virtual clinic would continue beyond the pandemic. Conclusion Implementing the virtual clinic is achievable through following systematic steps and effectively addressing emerging challenges as required. The concept of the virtual clinic was well accepted by patients and staff.

PURPOSEThere is an urgent need to improve access to cancer therapy globally. Several independent initiatives have been undertaken to improve access to cancer medicines, and additional new initiatives are in development. Improved sharing of experiences and increased collaboration are needed to achieve substantial improvements in global access to essential oncology medicines.METHODSThe inaugural Access to Essential Cancer Medicines Stakeholder Meeting was organized by ASCO and convened at the June 2022 ASCO Annual Meeting in Chicago, IL, with two subsequent meetings, Union for International Cancer Control World Cancer Congress held in Geneva, Switzerland, in October 2022 and at the ASCO Annual Meeting in June of 2023. Invited stakeholders included representatives from cancer institutes, physicians, researchers, professional societies, the pharmaceutical industry, patient advocacy organizations, funders, cancer organizations and foundations, policy makers, and regulatory bodies. The session was moderated by ASCO. Past efforts and current and upcoming initiatives were initially discussed (2022), updates on progress were provided (2023), and broad agreement on resulting action steps was achieved with participants.RESULTSSummit participants recognized that while much work was ongoing to enhance access to cancer therapeutics globally, communication and synergy across projects and organizations could be enhanced by providing a platform for collaboration and shared expertise.CONCLUSIONThe summit resulted in new cross-stakeholder insights and planned collaboration addressing barriers to accessing cancer medications. Specific actions and timelines for implementation and reporting were established.

While multidisciplinary tumor boards (MTBs) are widely used in managing patients with cancer, their impact on patient care and outcome is not routinely measured in different settings. The authors conducted a literature review in Medline, Google Scholar, Embase, and Web of Science using the following keywords: cancer, multidisciplinary, tumor board, quality performance indicator, lung cancer, and lymphoma. Standards from various accreditation and professional organizations were reviewed to compile relevant standards for MTB. A list of quality performance indicators that can be used to improve MTBs’ performance and impact was compiled. Specific examples for non-Hodgkin lymphoma and lung cancer MTBs were presented. Guidance was provided to help MTB team members select implement the appropriate quality measures. The functions and impact of MTBs should be monitored and evaluated by a set of measures that help guide MTBs to improve their performance and provide better care to their patients.

PURPOSEAnaplastic lymphoma kinase (ALK) gene alterations are potent oncogenic drivers in non–small-cell lung cancer (NSCLC). Tyrosine kinase inhibitors targeting the ALK pathway are effective in treating ALK-positive NSCLC. Around 5% of Asian and White patients with NSCLC have ALK-positive tumors, but ALK rearrangement prevalence data in the Middle East and North Africa (MENA) region are limited.METHODSIn this noninterventional epidemiology study, histologically confirmed nonsquamous NSCLC samples retained for < 5 years in tissue banks at six centers in MENA were retrospectively analyzed for ALK rearrangement using the VENTANA immunohistochemistry (IHC) method. Patient characteristics obtained were analyzed for association with ALK rearrangement. Concordance between IHC and Vysis fluorescence in situ hybridization (FISH) ALK detection methods was assessed in a subset of samples.RESULTSFour hundred forty-eight tissue samples were analyzed using IHC: 137 (30.6%) in Lebanon, 104 (23.2%) in Saudi Arabia, 97 (21.7%) in Egypt, 80 (17.9%) in the United Arab Emirates, and 30 (6.7%) in Morocco. On the basis of IHC, the prevalence was 8.7% (95% CI, 6.3 to 11.7) for ALK-positivity and 91.3% (95% CI, 88.3 to 93.7) for ALK-negativity. On the basis of FISH (n = 148), the prevalence was 5.4% positivity and 81.8% negativity (12.8% nonevaluable). Concordance between IHC and FISH (n = 129) was 98.4% (95% CI, 94.2 to 99.8) for negative agreement and 98.5% (95% CI, 94.5 to 99.8) for overall agreement. Univariate analysis showed that ALK rearrangement was significantly associated with epidermal growth factor receptor wild-type status (P = .03) but was not significantly associated with sex, race, smoking history, or histologic subtype.CONCLUSIONOur findings suggest that ALK rearrangements are more prevalent in MENA than other geographic regions. High concordance was found between FISH and IHC. Except for epidermal growth factor receptor wild-type status, no clinicopathologic characteristics were associated with ALK-positive NSCLC.

PURPOSEAs frontline workers facing the COVID-19 pandemic, healthcare providers should be well-prepared to fight the disease and prevent harm to their patients and themselves. Our study aimed to evaluate the knowledge, attitude, and practice of oncologists in response to the COVID-19 pandemic and its impact on them.METHODSA cross-sectional study was conducted using a validated questionnaire disseminated to oncologists by SurveyMonkey. The tool had 42 questions that captured participants’ knowledge, attitude, and practice; their experiences; and the pandemic’s impact on various aspects of their lives. Participants from Middle East and North African countries, Brazil, and the Philippines completed the electronic survey between April 24 and May 15, 2020.RESULTSOf the 1,010 physicians who participated in the study, 54.75% were male and 64.95% were medical or clinical oncologists. The level of knowledge regarding the prevention and transmission of the virus was good in 52% of participants. The majority (92%) were worried about contracting the virus either extremely (30%) or mildly (62%), and 84.85% were worried about transmitting the virus to their families. Approximately 76.93% reported they would take the COVID 19 vaccine once available, with oncologists practicing in Brazil having the highest odds ratio of intention to receive the COVID-19 vaccine (odds ratio, 11.8, 95% CI, 5.96 to 23.38, P < .001). Participants reported a negative impact of the pandemic on relations with coworkers (15.84%), relations with family (27.84%), their emotional and mental well-being (48.51%), research productivity (34.26%), and financial income (52.28%).CONCLUSIONThe COVID-19 pandemic has adverse effects on various personal and professional aspects of oncologists’ lives. Interventions should be implemented to mitigate the negative impact and prepare oncologists to manage future crises with more efficiency and resilience.

Background: Tyrosine kinase inhibitors (TKIs) are the standard of care for resectable and metastatic non-small-cell lung cancer (NSCLC) harbouring epidermal growth factor receptor (EGFR) mutations (EGFRm). We describe the real-world practice of EGFRm testing, prevalence, treatment and outcomes in EGFRm stage III NSCLC from a multi-country, observational study. Methods: The KINDLE study retrospectively captured diagnostic information, treatments and survival outcomes in patients with stage III NSCLC from January 2013 to December 2017. Baseline characteristics and treatments were described and real-world outcomes from initial therapy were analysed using Kaplan–Meier methods. Results: A total of 3151 patients were enrolled across three regions: Asia ( n = 1874), Middle East and North Africa (MENA) ( n = 1046) and Latin America (LA) ( n = 231). Of these, 1114 patients (35%) were tested for EGFRm (46% in Asia, 17% in MENA and 32% in LA) and EGFRm was detected in 32% of tested patients (34.3% in Asia, 20.0% in MENA and 28.4% in LA). In a multi-variate analysis, overall EGFRm patients treated with EGFR-TKI monotherapy as initial treatment, without any irradiation, had twice the risk of dying (hazard ratio: 1.983, 95% confidence interval: 1.079–3.643; p = 0.027) versus any other treatment. Finally, unresectable patients with EGFRm NSCLC who received concurrent chemoradiotherapy (cCRT) as initial therapy had longer overall survival (OS) compared with their counterparts who only received TKI monotherapy without any irradiation (48 months versus 24 months; p

Abstract Background Colorectal cancer (CRC) is the most diagnosed cancer among males and third among females in Saudi Arabia, with up to two-third diagnosed at advanced stage. The objective of our study was to estimate CRC survival and determine prognostic factors. Methods Ministry of National Guard- Health Affairs (MNG-HA) registry data was utilized to identify patients diagnosed with CRC between 2009 and 2017. Cases were followed until December 30th, 2017 to assess their one-, three-, and five-year CRC-specific survivals. Kaplan-Meier method and Cox proportional hazard models were used to assess survival from CRC. Results A total of 1012 CRC patients were diagnosed during 2009–2017. Nearly, one-fourth of the patients presented with rectal tumor, 42.89% with left colon and 33.41% of the cases were diagnosed at distant metastasis stage. The overall one-, three-, and five-year survival were 83, 65 and 52.0%, respectively. The five-year survival was 79.85% for localized stage, 63.25% for regional stage and 20.31% for distant metastasis. Multivariate analyses showed that age, diagnosis period, stage, nationality, basis of diagnosis, morphology and location of tumor were associated with survival. Conclusions Findings reveal poor survival compared to Surveillance, Epidemiology, and End Results (SEER) population. Diagnoses at late stage and no surgical and/or perioperative chemotherapy were associated with increased risk of death. Population-based screening in this population should be considered.

Background: Diagnosis of COVID-19 infection in cancer patients is critical to co-manage their underlying disease and infection appropriately. Our study aimed at evaluating the sensitivity and specificity of screening patients with cancer for COVID-19 infection. Methods: All oncology patients receiving care at Department of Oncology at King Abdulaziz Medical City in Riyadh were screened using the acute respiratory infection (ARI) survey. Nasopharyngeal and throat swap for polymerase chain reaction (PCR) testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was performed on patients who have high ARI score (i.e. ≥ 4), or any patient requiring elective/emergency hospitalization, undergoing a procedure as well as screening asymptomatic patients receiving chemotherapy between April 1st and July 30, 2020. Institutional Review Board approval was obtained. Descriptive and inferential analyses were done and sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated considering the COVID-19 PCR as the gold standard. Results: During the study period, a total of 473 patients were included with a median age was 56 years (14–104), 51% were female, 73% had solid tumors, and 66% received treatment within the last 3 months. These patients underwent 688 PCR tests along with ARI survey screening. Testing was done in the outpatient, inpatient, and emergency department setting in 41%, 40% and 19% of the patients, respectively. Majority of tests were screening of asymptomatic patients and only 23% were tested for suspected infections with ARI ≥ 4. A total of 54 patients (8%) had positive PCR for COVID-19 infection. The prevalence of infection varied from month to month ranging from 1.09% in April up to 19.70% in June and correlated with the average daily and active case load at a national level. The diagnostic yield of the ARI score also correlated with infection burden nationally. The PPV and NPV of the ARI as a screening tool was 18.24% (0–31.8) and 95.6% (86.36–98.86%) with the PPN fluctuating considerably in parallel with the prevalence of COVID-19 result. Similarly, the sensitivity and specificity of the ARI were 55.77% (0–70.59) and 79.4 (69.19–92), respectively. Conclusion: The yield of screening asymptomatic patients with cancer varies based on the community burden of COVID-19 infection. As universal screening can cause delays to patient care, it should be tailored based on the individual patient risks and infection burden in the region.

Background: The COVID-19 pandemic has a tangible impact on the health care systems globallyand is represented by interruption of the usual services in many health facilities and exposingvulnerable patients to significant risks.Objectives: We aimed to evaluate this pandemic’s impact on Iraq’s cancer care.Materials and methods: We conducted an exploratory study using a validated web-basedquestionnaire of 51 items. The questionnaire collected information on the capacity and servicesoffered at the Iraqi cancer centers, the magnitude of care disruption, reasons for the disruption,challenges faced, patient harm estimation, and the interventions implemented during the pandemic.Results: 18 cancer centers from 11 Iraqi governorates took part between 21st April and 8th May2020. These centers were serving around 18,867 new patients per year. Most of them (72.2%)were facing challenges in delivering their care during the pandemic. Although 44.4% of the centersreduced their services as part of a pre-emptive strategy, other reported reasons included lack ofpersonal protective equipment (22.2%), an overwhelmed system (11.1%), and a restricted approachto medications (11.1%). Missing at least one therapy cycle by > 10% of the patients was reportedin 38.9% of the centers. Participants have reported that their patients were exposed to potentialharm from interruption of cancer-specific care (44.4%) and non-cancer-related care (33.3%).Conclusion: The negative impact of the COVID-19 pandemic on cancer care in Iraq is evident.Additional research to estimate such an effect at the patients’ level and the required measures tocounteract this problem is vital.

Abstract Background The use of complementary and alternative medicine (CAM) is common among cancer patients and it may reflect the individual and societal beliefs on cancer therapy. Our study aimed to evaluate the trends of CAM use among patients with cancer between 2006 and 2018. Methods We included 2 Cohorts of patients with cancer who were recruited for Cohort 1 between 2006 and 2008 and for Cohort 2 between 2016 and 2018. The study is a cross-sectional study obtaining demographic and clinical information and inquiring about the types of CAM used, the reasons to use them and the perceived benefits. We compared the changes in the patterns of CAM use and other variables between the two cohorts. Results A total of 1416 patients were included in the study, with 464 patients in Cohort 1 and 952 patients in Cohort 2. Patients in Cohort 2 used less CAM (78.9%) than Cohort 1 (96.8%). Cohort 1 was more likely to use CAM to treat cancer compared to Cohort 2 (84.4% vs. 73%, respectively, p

Abstract Colorectal cancer (CRC) is the most common cancer in males and third in females in Saudi Arabia, with the majority (66%) diagnosed at a late stage. We evaluated the effect of marital status on stage at diagnosis and CRC survival. We hypothesized that married patients would be more likely to present at an early stage and have higher survival than unmarried patients. The Ministry of National Guard-Health Affairs (MNG-HA) cancer registry was used to identify patients diagnosed with CRC from 2009 to 2017. A competing risk analysis was performed to assess the 5-year CRC-specific survival, adjusting for potential confounders. The Kaplan–Meier method and the Cox regressions were used to assess survival. Two-thirds (76.50%) of the 936 CRC patients were married, 11.64% were unmarried, and 11.86% had an unknown marital status. With multiple imputation-based analysis, the multivariate analysis indicated that unmarried patients were 52% more likely to present at an advanced stage [adjusted odds ratio (aOR) 1.52; 95% CI 1.33–1.73], and had a 30% higher risk of death due to CRC compared to the married patients (aHR 1.30; CI 1.17, 1.44). Future CRC screening and survivorship programs should assess the needs of the vulnerable unmarried population. Interventions supporting the early detection of CRC in this population may be beneficial in the long term and lead to improved cancer outcomes.

Introduction: Due to the complex nature of cancer cases, it is imperative that the involved healthcare providers coordinate the patients care plan in union to reach the best possible outcome in the smoothest and fastest manner. This is what multidisciplinary tumor board (MTB) meetings strive to achieve. Conducting regular MTB meetings requires significant investment of time and finances. It is thus vital to assess the empirical benefits of such practice. Methods: A meta-analysis was conducted to evaluate the literature regarding the impact of MTB meetings on patient 5-year survival. Relevant studies were identified by searching Ovid MEDLINE and Embase databases from January 1995 to July 2019. Studies were included if they assessed 5-year survival in cases discussed in MTB meetings and used a comparison group and/or a pretest and posttest design. Results: Five articles met the study's inclusion criteria. Quality of studies was affected by selection bias and the use of historic cohorts. The results showed significantly improved 5-year survival in the MTB group compared with the non-MTB groups (odds ratio for 5-year death rate of 0.59, CI 0.45–0.78, p < 0.001). Conclusion: This meta-analysis showed that cancer MTB meetings have a significant impact on patients’ 5-year survival. This could be because of several reasons, such as less time to treatment initiation, better adherence to guidelines, higher numbers of investigational imaging, lesser surgical complications, and recurrence rates. Future prospective studies are needed to further delineate reasons for improvement of outcome to enhance the benefits of this approach.

PURPOSEIn response to the COVID-19 pandemic, the ASCO launched a Global Webinar Series to address various aspects of cancer care during the pandemic. Here we present the lessons learned and recommendations that have emerged from these webinars.METHODSFifteen international health care experts from different global regions and oncology disciplines participated in one of the six 1-hour webinars to discuss the latest data, share their experiences, and provide recommendations to manage cancer care during the COVID-19 pandemic. These sessions include didactic presentations followed by a moderated discussion and questions from the audience. All recommendations have been transcribed, categorized, and reviewed by the experts, who have also approved the consensus recommendations.RESULTSThe summary recommendations are divided into different categories, including risk minimization; care prioritization of patients; health care team management; virtual care; management of patients with cancer undergoing surgical, radiation, and systemic therapy; clinical research; and recovery plans. The recommendations emphasize the protection of patients and health care teams from infections, delivery of timely and appropriate care, reduction of harm from the interruption of care, and preparation to handle a surge of new COVID-19 cases, complications, or comorbidities thereof.CONCLUSIONThe recommendations from the ASCO Global Webinar Series may guide practicing oncologists to manage their patients during the ongoing pandemic and help organizations recover from the crisis. Implementation of these recommendations may improve understanding of how COVID-19 has affected cancer care and increase readiness to manage the current and any future outbreaks effectively.

PURPOSE ASCO developed the Quality Oncology Practice Initiative (QOPI) to ensure patient safety in oncology outpatient services. We evaluated the impact of participation in QOPI certification on patient care at our institution. METHODS To participate in QOPI, we created a multidisciplinary team, and we chose the required modules and began QOPI participation per program requirement. In the initial round, we scored lower than the required score of 75% to be eligible for QOPI certification. We then implemented multiple measures and interventions, and we conducted multiple Plan, Do, Study, Act cycles (PSDA) cycles to achieve our goal. RESULTS Our score in the initial round was 68%; in the second round, our score remained low at 65%; in the third round, we exceeded the target score by achieving 93%. We completed the certification process with a site visit. In October 2018, we became the first QOPI-certified center in the Middle East and Asia. CONCLUSION We learned many lessons during our journey toward QOPI certification. Essential elements of success included timely assembly of the right multidisciplinary team and clear communication between team members within the institution and with the ASCO QOPI team.

PURPOSEThe COVID-19 pandemic affected health care systems globally and resulted in the interruption of usual care in many health care facilities, exposing vulnerable patients with cancer to significant risks. Our study aimed to evaluate the impact of this pandemic on cancer care worldwide.METHODSWe conducted a cross-sectional study using a validated web-based questionnaire of 51 items. The questionnaire obtained information on the capacity and services offered at these centers, magnitude of disruption of care, reasons for disruption, challenges faced, interventions implemented, and the estimation of patient harm during the pandemic.RESULTSA total of 356 centers from 54 countries across six continents participated between April 21 and May 8, 2020. These centers serve 716,979 new patients with cancer a year. Most of them (88.2%) reported facing challenges in delivering care during the pandemic. Although 55.34% reduced services as part of a preemptive strategy, other common reasons included an overwhelmed system (19.94%), lack of personal protective equipment (19.10%), staff shortage (17.98%), and restricted access to medications (9.83%). Missing at least one cycle of therapy by > 10% of patients was reported in 46.31% of the centers. Participants reported patient exposure to harm from interruption of cancer-specific care (36.52%) and noncancer-related care (39.04%), with some centers estimating that up to 80% of their patients were exposed to harm.CONCLUSIONThe detrimental impact of the COVID-19 pandemic on cancer care is widespread, with varying magnitude among centers worldwide. Additional research to assess this impact at the patient level is required.

PURPOSEProgrammed death-ligand 1 (PD-L1) is a marker for checkpoint inhibitor use in the management of solid tumors, especially in non–small-cell lung cancer (NSCLC). Our study was aimed at determining the patterns of PD-L1 expression and cluster of differentiation 8 (CD8) immunostains in patients with NSCLC in the Arab population.METHODSArchival tumor tissue from patients with a confirmed diagnosis of NSCLC were obtained and stained for PD-L1 with antibody 22C3, using immunohistochemistry staining and giving the tumor proportion score (TPS) as a percentage from 0%-100% of stained tumor cells. Tumors were categorized into negative expressers (TPS < 1%), low positive (TPS, 1%-49%), and high positive (TPS, 50%-100%). Correlation of expression with clinical and pathologic features, including CD8-positive (CD8+) lymphocyte density, was also analyzed.RESULTSTwo hundred patients with NSCLC were included in the study from 6 centers in Saudi Arabia and Algeria. Median age was 65 years (28-93 years), and the majority were men (75%) with stage 4 NSCLC (64%). The TPS was high in 37 patients (18%), low in 60 patients (30%), and negative in 103 patients (52%). In a univariate analysis, the following were significant predictors of any PD-L1 expression (> 1%): male sex, being Saudi national patients, high expression of CD8+, and presence of tumor-infiltrating lymphocytes. In the multivariate analysis, only high expression of CD8+ cells (≥ 2+) was significant, with an odds ratio of 4.4 (95% CI, 1.5 to 12.9; P = .003)CONCLUSIONPD-L1 expression in our population is similar to the published literature and correlated with the density of CD8+ cells. Validation of the predictive value of this marker in our population and identifying easier and reliable methods to test for it are warranted.

BackgroundBurnout (BO) is a recognized challenge among the oncology workforce. It affects both genders with a higher frequency among women. This study examined the factors contributing to the development of burnout among female oncologists from the Middle East and North Africa (MENA).MethodsAn online cross-sectional survey was distributed to oncology professionals from different countries in the MENA region. The validated Maslach Burnout Inventory (MBI) of emotional exhaustion (EE), Depersonalization (DE), and Personal Achievement (PA) plus questions about demography/work-related factors and attitudes toward oncology were included. Data were analyzed to measure BO prevalence and related factors.ResultsBetween 10 February and 15 March 2020, 545 responses were submitted by female oncologists. The responses pre-dated the COVID-19 pandemic emergence in the region. BO prevalence was 71% among female professionals. Women aged 25% on administrative work daily. Nearly half of the respondents (49%) expressed a recurring thought of quitting oncology and 70% had no burnout support or education. Inability to deliver optimal care was reported as distressing for career development in 82%. Factors significantly influencing the BO risk were identified. Marital status, having children, academia and years in practice did not impact the risk of BO among female oncologists from MENA.ConclusionFemale oncologists from the Middle East and North Africa (MENA) were found to have a high prevalence of BO. In this cohort, the majority of women oncology workers were young and in their early to mid-career stages. Burnout was linked to being younger, practicing in North African nations, having a heavy administrative load, and having persistent thoughts of quitting. Practicing a hobby and engaging in oncology communication, on the other hand, reduced the chance of BO. Burnout support and education, specifically for oncology women, is required.

Background: Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease. Methods: Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members. Results: The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region. Conclusion: The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

Introduction: Cancer care is a major challenge to health care and for optimal outcomes, health systems need to align policy across many areas of public life. The recognition that even the wealthiest nations can fail optimum outcomes indicates a need for increased efficiency in cancer control programs. Fundamental to this is the efficient direction of resources––a process that can be optimized through economic measures. This article contains expert recommendations on how decision makers can implement pharmacoeconomic principles at national level in developing countries. Methods: A multidisciplinary panel of 10 experts was formed of oncologists, clinical pharmacists, health economists, and chronic disease control and public health experts from different countries and health-care sectors. The panel developed consensus recommendations for different stakeholders using a framework analysis method. Results: Recommendations were categorized as national level, hospital level, industry level, and public-community level to support decision makers in implementing pharmacoeconomic principles in a systematic way. The recommendations included having proper well-structured, data-driven processes with a specific role for each stakeholder. We proposed required structures and processes in such a way that they can be customized based on individual country plans. Conclusion: The expert panel recommendations will serve as a guide to relevant stakeholders at a national level. Adaptation of these recommendations to each setting is important to accommodate the situation and needs of each country.

Background: Chemotherapy-induced febrile neutropenia (FN) is a major cause of morbidity and mortality in cancer patients if not treated promptly. As we were facing considerable delays in the management of chemotherapy-induced febrile neutropenic patients in the Emergency Department (ED), we initiated an improvement project aiming for “door-to-antibiotic time” of 60 minutes or less for all patients with fever and suspected chemotherapy-induced neutropenia. Methods: A multidisciplinary team was established to work on the project. We used quality improvement tools for mapping the existing patient flow processes of patients with FN in the ED. Several proposed change ideas have been tested using the Model for Improvement. These change ideas include improving the triaging process, creating an electronic “chemotherapy alert caution” and order sets for physicians, and using the hot-line by nurses to call the pharmacy to expedite the process of preparation of antibiotics. Outcome and process measures were collected weekly and they were discussed thoroughly and analyzed by the team. Run charts were used to monitor the progress. Results: After six Plan-Do-Study-Act cycles, all process measures improved and ultimately the “door-to-antibiotic time” was achieved by reducing it from 255 minutes to 49 minutes. During project testing and implementation, the nursing staff skills improvement and education were taken into consideration as a balancing measure. Conclusion: In a six-month period, the project led to a timely administration of antibiotics for patients with FN in the ED. This improvement was sustained for more than two years after the project initiation.

Background: Druggable molecular targets are very important in the management of non-small-cell lung cancer (NSCLC). The purpose of our study is to determine the pattern of testing and mutation prevalence in the Middle East and North Africa population. Patients and Methods: Data of consecutive patients with nonsquamous NSCLC were collected from 10 centers in five countries; Saudi Arabia, UAE, Qatar, Lebanon, and Algeria. Statistical analysis was performed to delineate the prevalence of druggable targets and other relevant information. Results: Five hundred and sixty-six patients were included in the study. Majority were males (78.1%) with a median age of 61 years (22–89), 50% were current or ex-smokers and 370 patients (65.4%) were Stage IV. The epidermal growth factor receptor (EGFR) testing was performed on 164 patients of all stages. EGFR mutation was detected in 30 out of 96 patients (31.3%) with metastatic disease and in 12 out of 68 patients (17.6%) with Stage I to III. Female sex (39.5% vs. 22% males, P = 0.032), Stage IV (31.2% vs. 17.6% in Stage I to III, P = 0.049), and positive immunohistochemical-TTF1 (31.4% vs. 8.7% negative, P = 0.026) were predictors of mutation on univariate analysis. The multivariate analysis showed that patients with stage IV have three times higher positivity than lower stages (odds ratio = 3.495, P = 0.036). Anaplastic lymphoma kinase fusion was present in seven out of 89 patients (7.8%) of all stages, and only three out of 52 patients (5.8%) with metastatic disease. The reasons for not performing the tests in all of the 370 patients with metastatic disease were: physicians do not know where and how to send the test (62.3%), lack of funding to perform the test (11.1%), insufficient tissue (10.1%), and other reasons (16.6%). Conclusions: Only a small fraction of patients with NSCLC are tested for druggable targets and the prevalence of EGFR mutation is prevalence higher than the Western population. Overcoming the challenges of testing requires systematic plans to address education and resource allocation.

Background: Family involvement is essential in providing patient-centered care. It is very challenging to adapt into the health-care system. Our project aims at implementing a culturally tailored communication model to systematically involve a family in patient care. Materials and Methods: A multidisciplinary team was established to implement our previously developed communication model. We used rapid plan–do–study–act (PDSA) cycles of improvement to test the set of interventions to incorporate learned lessons into the project activities. The communication model was implemented in stages starting from the emergency department (ED) and expanding to different hospital units. Result: Fifteen PDSA cycles were conducted in the ED, intensive care unit, and inpatient wards. A clear algorithm on how to appoint the most responsible family members was developed and points of communication with the family were identified. Educational materials were developed for patients and families in addition to staff education about the program. There was a strong acceptance of the concept from families and staff, and the process is being implemented into our electronic health records. Conclusion: Our communication model was well accepted by patients, their families, and our staff. The plan is to automate the process for sustainability by making it an integral component of the electronic medical records and to introduce it throughout our system.

Background: Family involvement is a critical component of patient-centered care that impacts the quality of care and patient outcome. Our aim was to develop a patient- and family-based communication model suitable for societies with extended families. Methods: A multidisciplinary team was formed to conduct a situational analysis and review the patterns of family involvement in our patient population. Patient complaints were reviewed also to identify gaps in communication with families. The team proposed a model to facilitate the involvement of the family in the patient's care through the improvement of communication. Results: A communication model was developed keeping the patient in the center of communication but involving the family through identifying the most responsible family member. To assure structured measurable contact, mandatory points of communication were defined. The model streamlines communication with the family but maintaining the patients’ rights and autonomy. Conclusion: Our proposed model of communication takes into account the importance of communication with the family in a structured way. The team believes that it is going to be accepted by patients who will be explored in the pilot implementation stage as the next future step.

Background: Challenges related to access to cancer medications is an increasing global problem that has far-reaching impact on patients and healthcare systems. In this article, we are enlisting suggested solutions at the hospital or practice level to maximize the access to these important treatment modalities. Methods: An expert panel of practicing oncologists, clinical pharmacists, and health economists convened using a framework approach. The panelists identified individuals and entities that impact the use of cancer therapeutics and how they can improve the utilization and access to them. They enlisted the potential actions that hospital management and staff can take to enhance access to cancer therapeutics, then they grouped them into specific categories. Results: List of potential strategies and related action items were compiled into different categories including hospital leadership, drug evaluation entities, pharmacy, physicians, patients and families, and other parties. Recommendations included various actions to be considered by each group to achieve set goals. Conclusion: Our expert panel recommend multiple strategies and approaches to reduce the cost of cancer medications and improve patients’ access to them. These recommendations can be adapted by the decision-makers and staff of the hospitals to their own settings and the current circumstances.

Background: Although erlotinib is widely used in the management of non-small cell lung cancer (NSCLC), no prior studies were conducted in Middle Eastern population. Our study aims at evaluating erlotinib prospectively in this population. Patients and Methods: This open-label, prospective, single-arm, multicenter Phase IV clinical trial of erlotinib as single agent evaluated safety and efficacy of Erlotinib in Middle Eastern patients with advanced NSCLC. Results: A total of 56 patients were enrolled in five sites in Saudi Arabia. Majority of patients were males (60%) with median age of 57 years (34–80), Stage IV (98%), and adenocarcinoma (84%). Eastern Cooperative Oncology Group performance Status III (41.1%). Epidermal growth factor receptor (EGFR) mutations were present in 24 patients out of 36 patients tested (67%). The most common reported adverse events (AEs) were rash 36 (64%), diarrhea 29 (52%), fatigue 10 (18%), and anorexia 5 (9%). Grade 4 or 5 AEs were not observed. Complete response was achieved in 2 (3.6%) and overall disease control was 60.8%. Median overall survival (OS) was significantly longer in patients with EGFR mutation than wild type (20 vs. 3 months, P = 0.002). Progression-free survival was 10 months and significantly longer in patients with EGFR mutation than wild type (16 vs. 6 months, P = 0.037). Patients with unknown EGFR status had PSF and OS better than wild-type patients and worse than patients with EGFR mutation. Cox regression analysis showed that older age (P = 0.029, HR 1.064), EGFR wild type (P = 0.014, hazard ratio [HR]: 8.497), and receiving radiation (P = 0.033, HR 6.433) significantly increase risk of death for patients receiving erlotinib. Conclusion: Erlotinib has efficacy and safety profile in Middle Eastern population similar to the reported literature. The empiric use of erlotinib in patients with unknown EGFR status in our patient population is warranted due to high prevalence of the mutation. However, it should not be used in confirmed wild-type disease.

Purpose: As the burden of cancer on the population and the health care system continues to increase with more complicated treatment options, the need for multidisciplinary teams to be as efficient as possible becomes more vital. Our study aimed to evaluate the consistency of GI Tumor Board (GI TB) recommendations with international guidelines, the adherence of physicians involved in patient care to TB recommendations, and the impact on the management of patients. Methods: A prospective cohort study was conducted from January to June 2016 at our institution, which is a major tertiary hospital that provides comprehensive cancer care. All cases presented at the GI TB during this period were included. Data regarding adherence to National Comprehensive Cancer Network guidelines, adherence to TB recommendations, and changes made to the management of patients were collected weekly from the GI TB in a data collection form. Results: Of the 104 patients included, 57 (55%) were males and the median age was 58 (16 to 85) years. Colorectal cancer was the most common diagnosis, in 65 patients (63%). Nearly one-half of cases (45%) were stage IV cancers. Starting new treatment was recommended for 72 patients (69%). Further investigations were requested for 15 patients (14%). For imaging, 24 recommendations (23%) were made. Adherence to National Comprehensive Cancer Network guidelines was observed in 97% of total recommendations. New findings were found in pathology (11%), radiology (13%), and staging (4%). Management plans were changed in 37 cases (36%). Over a 3-month period after presentation to the GI TB, most of the recommendations (87%) were performed. Conclusion: A multidisciplinary tumor board enhances the adherence to guidelines and has an impact on patient management in approximately one-third of patients. Among physicians, adherence to recommendations of the TB was high.

Abstract Background A significant proportion of cancer patients use complementary and alternative medicine (CAM) along with conventional therapies (CT), whereas a smaller proportion delay or defer CT in favor of CAM. Previous studies exploring CAM use among cancer patients in the Middle East region have shown discrepant results. This study investigates the prevalence and pattern of CAM use by Saudi cancer patients. It also discusses the possible benefits and harm related to CAM use by cancer patients, and it explores the beliefs patients hold and their transparency with health care providers regarding their CAM use. Methods A cross-sectional study was conducted in oncology wards and outpatient clinics by using face-to-face interviews with the participants. Results A total of 156 patients with a median age of 50 years (18–84) participated in the study. The prevalence of CAM use was 69.9%; the most prominent types of CAM were those of a religious nature, such as supplication (95.4%), Quran recitation (88.1%), consuming Zamzam water (84.4%), and water upon which the Quran has been read (63.3%). Drinking camel milk was reported by 24.1% of CAM users, whereas camel urine was consumed by 15.7%. A variety of reasons were given for CAM use: 75% reported that they were using CAM to treat cancer, enhance mood (18.3%),control pain (11.9%), enhance the immune system (11%),increase physical fitness (6.4%), and improve appetite (4.6%). Thirty percent of CAM users had discussed the issue with their doctors; only 7.7% had done so with their nurses. Conclusions The use of CAM, including camel products, is highly prevalent among cancer patients in the Middle East, but these patients do not necessarily divulge their CAM use to their treating physicians and nurses. Although CAM use can be beneficial, some can be very harmful, especially for cancer patients. Association is known between camel products and brucellosis and Middle East respiratory syndrome coronavirus (MERS-CoV). Both can lead to tremendous morbidity in immune-compromised patients. Doctor–patient communication regarding CAM use is of paramount importance in cancer care.

BACKGROUND: Histiocytic disease is a diverse disease, characterized by multisystem involvement, diagnosis and management can be challenging. Guidelines are important tool to provide evidence-based management; however, guidelines for management of adult histiocytic disease are scarce. METHODOLOGY: A multidisciplinary team from Saudi Arabia developed guidelines to manage the adult histiocytic disease with an intention to provide standard of care for diagnosis and management of the most frequently encountered subtypes of adult histiocytic disease in the region. RESULTS: Detailed guidelines to different categories of histiocytic disease were finalized after review of many international guidelines and extensive literature review. CONCLUSION: Local guidelines for adults histiocytic disease was developed and can be shared with different hematology centers.

BACKGROUND: While lung cancer is the leading cancer cause of death, it is largely preventable. Furthermore, early diagnosis enhances the chance of cure. Therefore, we developed guidelines for lung cancer prevention and early detection. METHODS: A multidisciplinary team of experts in lung cancer representing different health-care sectors was assembled based on the National Cancer Center request and in coordination with the Saudi Lung Cancer Association of Saudi Thoracic Society. The team reviewed various reliable international guidelines and the data and experience in the Kingdom and formulated guidelines that address the primary and secondary prevention approaches in lung cancer, including tobacco control, early diagnosis, and lung cancer screening. RESULTS: The team developed guidelines to assist healthcare professionals in the Kingdom manage the different aspects of lung cancer prevention. Primary prevention through tobacco control: the recommendations encourage all healthcare professionals in all practice settings to screen their patients for smoking and to provide counseling and if needed referral to smoking cessation programs for current smokers. For early diagnosis of patients with symptoms suspicions of lung cancer, it is expected standard of care to investigate, work up, and refer the patients appropriately. Mass screening of patients at high risk for developing lung cancer: the recommendations listed the program requirements, eligible patients, and algorithm to manage findings. However, the team does not recommend that national screening program be mandated or implemented for lung cancer at this stage until more data and studies provide stronger evidence to justify adopting a national program. CONCLUSIONS: Physicians can play an important role in preventing lung cancer by tobacco control and also detect lung cancer at earlier presentation. However, national mass screening programs require further study.

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.

Background: The risk of getting cancer before full life expectancy and mortalities per year are on the rise in Saudi Arabia. Yet, evidence of economic burden of cancer in the country remains largely unknown. In order to provide evidence, we attempted to estimate the economic burden in terms of indirect cost associated with premature cancer deaths among the active or potentially economically active population aged 15–60 years in Saudi Arabia. Method: Within the framework of the World Health Organization guide of identifying the economic consequences of disease and injury, our method employs cost-of-illness approach. This approach is based on a macroeconomic model that estimates the indirect cost of cancer in terms of total non-health gross domestic product resource loss associated with a disease. We used epidemiological, health system, and macroeconomic data for our estimation. We discounted the net loss at 3% and computed an extension of the loss with a finite and stable upper limit proxied by non-health gross domestic product per capita. We carried out separate analyses for male and female. We conducted sensitivity analyses to account for uncertainties of epidemiological and economic factors on the robustness of the estimated economic burden. We varied the proportion of total cancer deaths, discount rate, and value of health expenditure per capita by ±20%. We further determined which of these factors or parameters had the greatest uncertainty or variation on the net present value total non-health gross domestic product resource loss per Capita. Results: Our results indicate the indirect cost associated with cancer deaths among Saudi population aged 15–60 years to be Int$ 2.57 billion of which Int$ 1.46 billion (57%) was accounted for by females. The total indirect loss of cancer deaths increased by 8% to Int$ 2.77 billion when the loss is allowed to grow with a finite and stable upper limit proxied by non-health gross domestic product per capita over the discounted years of life lost per a death among female and male respectively. Much of the uncertainty in the determination of the value of the loss was accounted for by the proportion of total cancer deaths and discount rate, while health expenditure per capita was responsible for the least variability. Conclusion: Our findings reveal evidence of indirect cost associated with cancer premature deaths in Saudi Arabia. In order to develop cancer control actions, the results of this study can inform health system policymakers not only of the extent of the enormous economic burden but also drawing attention to epidemiological and economic factors that explain the variability of the burden.

Summary: Targeting epidermal growth factor receptor (EGFR) is an important treatment option for non-small cell lung cancer (NSCLC).These targeted therapies have been studied extensively in NSCLC in first line and subsequent lines, including maintenance in empiric fashion or in patients with tumors harboring the EGFR mutations.In this manuscript, we will review in details the evolutions of these targeted therapy in the management of NSCLC. Keywords: EGFR, lung cancer, inhibitors