King Hussein Cancer Center Research Articles

The clinical value of peripheral immune cell counts in pancreatic cancer.

Elevated neutrophil-lymphocyte ratio (NLR) is linked to poor overall survival (OS) in pancreatic cancer. We aim to investigate the association of the various hematologic markers, in particular NLR among others, with distant metastases, a common feature in pancreatic cancer. Clinical data from 355 pancreatic cancer patients managed at King Hussein Cancer Center (Amman-Jordan) have been reviewed. We examined the relationship between absolute neutrophil count (ANC), absolute lymphocyte count (ALC), absolute eosinophilic count (AEC), absolute monocytic count (AMC), NLR, monocyte to lymphocyte ratio (MLR) and platelet to lymphocyte ratio (PLR) with the presence of baseline distant metastases and OS. Receiver Operating Characteristic (ROC) curve analysis was plotted to identify the NLR optimum cutoff value indicative of its association with distant metastases. On univariate and multivariate analyses patients whom on presentation had high NLR (≥3.3) showed more baseline distant metastases compared to patients with low NLR (<3.3), (p-value: <0.0001 and <0.0001, respectively). Patients with high baseline ANC (≥5500/μL), AMC (≥600/μL), MLR (≥0.3) had more baseline distant metastases in comparison to patients with lower values (p-value: 0.02, 0.001, and <0.0001, respectively). High ANC, NLR, MLR, and PLR and low ALC were associated with poorer OS, (p-value: <0.0001, <0.0001, <0.0001, 0.04, and 0.01, respectively). This study presents additional evidence of the association of some of the hematologic markers; in particular ANC, NLR, AMC, and MLR, with baseline distant metastases and poor outcome in pancreatic cancer. Whether these immune phenomena can help in identifying patients at higher risk for the subsequent development of distant metastases is unknown.

Syndromic osteosarcoma, does it carry a poor prognosis? King Hussein Cancer Center experience. A case series report with literature review

Osteosarcoma is a tumor derived from mesenchymal cells. Osteosarcoma mainly affects children of 10-14 years old, usually of primary aetiology. Some genetic disorders have been shown to increase osteosarcoma incidence. The aim of our study was to investigate the association of osteosarcoma with syndromic features and the potential effects in the prognosis of osteosarcoma. A case series report of six cases with different syndromes was reported in this study and we have retrospectively evaluated the prognosis of the cases. Data was collected from January 2003 till December 2011 at King Hussein Cancer Center in Jordan. A total of 69 patients were diagnosed to have osteosarcoma during the studied period, 6 of them having associated syndromes, constituting 8.7% of all cases. The syndromes identified were Rothmund-Thomson Syndrome, Osteogenesis Imperfecta, Diamond-Blackfan Anemia, Osteopoikilosis, and Cockayne Syndrome. From the 63 non-syndromic patients follow up was lost in 14 of them. Among the remaining 49 patients, 34 (69.3%) were alive and 15 (30.6%) died, while among the syndromic patients one was lost for follow up, only one remained alive (20%), and 4 died (80%). The statistical analysis indicated that syndromic patients presented a poorer prognosis than non-syndromic patients since an association with a higher mortality rate was observed (p

Syndromic osteosarcoma, does it carry a poor prognosis? King Hussein Cancer Center experience. A case series report with literature review

Syndromic osteosarcoma, does it carry a poor prognosis? King Hussein Cancer Center experience. A case series report with literature review

Gaining Palliative Medicine Subspecialty Recognition and Fellowship Accreditation in Jordan

ContextPalliative medicine (PM) has gained subspecialty recognition in many countries during the past two decades. Jordan is one of the first Arab countries to gain accreditation for the specialty. ObjectivesTo outline the process undertaken by leaders in palliative care in Jordan to have PM recognized as a subspecialty and the development of a two-year fellowship training program. To contextualize the Jordanian experience with the experience from other countries and assess the need for PM specialty programs in Jordan. MethodsA thorough review of all documentations, letters, correspondence, and proposals exchanged between the palliative care department at King Hussein Cancer Center and the Jordanian Medical Council from 2011 to 2017. An assessment of the number of certified physicians and fellowship posts required to meet the current palliative care needs in Jordan, using population-based need for palliative care. ResultsThe process of gaining subspecialty status for PM in Jordan was complex, lengthy, and dependent on the collaboration of many officials and health sector organizations working together on a national strategy to achieve it. Ultimately, PM was recognized as a subspecialty in 2017, a two-year fellowship program was accredited by the Jordanian Medical Council in 2018, with a recognized subspecialty board examination, which can be accessed by many medical and surgical specialties. It is estimated that 185–235 full-time equivalent palliative care specialist physicians are needed to meet the demand of patients in Jordan. ConclusionKey factors enabling accreditation to happen in Jordan were strong leadership, persistence, collaboration with major stakeholders, and seeking out opportunities to promote the specialty. Our experience and lessons learnt are transferable to other countries and may prove beneficial to others aiming to gain subspecialty recognition for PM.

Clinical and Cancer-Related Predictors for Venous Thromboembolism in Cancer Patients Presenting to the Emergency Department.

The accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests. We sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE. We retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1,2016. Cancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37-5.60], p<0.001), presentation within 6months of the cancer diagnosis (OR 1.92 [95% CI 1.62-2.28], p<0.001), active cancer (OR 1.35 [95% CI 1.10-1.65], p=0.003), advanced stage (OR 1.40 [95% CI 1.01-1.94], p=0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32-2.27], p<0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort. Cancer risk group, presentation within 6months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED.

Frequency of Mismatch Repair Protein (MMRP) Deficiency among Young Jordanians Diagnosed with Colorectal Carcinoma (CRC).

Purpose Microsatellite instability (MSI) caused by mismatch repair protein (MMRP) deficiency is detected in 15% of sporadic colorectal cancers (CRCs). Our aim is to investigate the frequency of MMRP deficiency in young CRC patients, using immunohistochemical analysis. Methods This study targeted cases of CRC at King Hussein Cancer Center from 2004 until 2012 in patients 45 years of age or younger at the time of diagnosis. Clinicopathological data was obtained from 155 patients' records. Immunohistochemistry for MLH1, MSH2, PMS2, and MSH6 proteins was performed on paraffin-embedded tissue containing carcinoma. Results The median age of patient at diagnosis was 38 years. A total of 29 (19%) cases showed deficient MMRP(dMMRP)expression. Loss of expression of PMS2 was seen in 17 cases, 12 cases of which showed loss of MLH1 expression. Loss of expression of MSH6 was seen in 10 cases, 9 of which showed loss of MSH2 expression. One case (3.4%) showed loss of all four MMR proteins, and another case (3.4%) showed loss of PMS2/MLH1 and MSH6. There was a significant association between abnormal MMR protein expression and tumor location proximal to splenic flexure (p value 0.000), pathologic features suggestive of microsatellite instability (p value 0.000), P53 negativity (p value 0.000), and stage (p value 0.02). Patients with dMMRP CRC appeared to have a significantly better overall survival compared to patients with proficient MMRP(pMMRP)(p value 0.02). Loss of MSH2/MSH6 was significantly associated with positive family history of cancer (p value = 0.020). Conclusions The prevalence of dMMRP tumors in this age group appears to be similar to international literature. dMMRP tumors tends to be associated with earlier stages and better outcomes compared to pMMRP cases. dMMRP can serve as a biomarker for better prognosis. These results are of value in directing the clinical management of young patients with CRC.

Breast Cancer Care in Jordan.

Breast cancer is the most common malignancy in Jordan and the third leading cause of cancer death after lung and colorectal cancers. Although the incidence of breast cancer in Jordan is lower than that in industrialized nations, the number of new cases has been significantly increasing, and women present with breast cancer at a younger age and with more advanced disease than women in Western countries. Jordan is a medium-income country with limited resources and a young population structure. Therefore, breast cancer poses a particularly challenging burden on the country’s health care system. Despite ongoing endeavors to improve breast cancer care at both public and private levels, more work is needed to achieve downstaging of the disease and improve access, awareness, and participation in early detection. Multimodality treatment facilities and supportive care are available; however, the quality of care varies widely according to where the patient is treated, and most treatment facilities remain located centrally, thus, creating access difficulties. The King Hussein Cancer Center, the only comprehensive cancer center in Jordan, has changed the practice of oncology in the country via implementation of a multidisciplinary approach to treatment, monitoring of treatment outcomes, and investments in ongoing cancer research. However, there remains no national system for ensuring provision of high-quality cancer care nationwide. Here, we review the epidemiology of breast cancer and the current status of breast cancer care in Jordan, we compare our treatment outcomes with international ones, and we highlight challenges and improvement opportunities.

Central Nervous System Tumors in Adolescents and Young Adults: An Epidemiological Study from Jordan

Background: The adolescent and young adult (AYA) age group lacks targeted epidemiologic studies that assess the prevalence and outcome of tumors. We aim to provide deep analysis of the epidemiology of central nervous system (CNS) tumors in AYA in Jordan. Methodology: This is a retrospective study for all CNS tumors in the AYA group patients diagnosed and managed at King Hussein Cancer Center in 2007–2016. A patient list was retrieved from the Center’s Cancer Registry, and clinicopathologic data were reviewed individually from the patients’ records. Results: A total of 370 cases of primary CNS tumors were retrieved, with a median age of 28.5 years. Males outnumbered females; 57.6 and 42.4%, respectively. Most tumors occurred in the cerebrum (62.2%, n = 230), the frontal lobe was the most commonly affected (29%). Glioma was the most common histologic category (58.9%, n = 218), with high-grade tumors, including glioblastoma and anaplastic astrocytoma, prevailing. Embryonal tumors comprised the second most common group (16.8%, n = 62). Medulloblastoma was the prototype of embryonal tumors (91.9%; n = 57). Glioma tended to affect the older age group than embryonal tumors (p value = 0.002). On last available follow-up, 29.5% were lost to follow-up, 36% were alive, and 34.6% were deceased. The median overall survival (OS) for all tumors was 47.6 months. Embryonal tumors had a better outcome than glioma (median OS 76.3 vs. 30.3 months, respectively; p value = 0.001). Conclusions: High-grade glioma affecting the cerebrum was the most common tumor among AYA age group and was associated with a less favorable outcome compared to embryonal tumors. More research is needed to address this special age group.

Automatic body segmentation for accelerated rendering of digitally reconstructed radiograph images

Abstract The rendering of digitally reconstructed radiograph (DRR) images involves creating a digital reconstruction of an image made by a three-dimensional (3D) imaging system, such as a computed tomography (CT) scan, to produce a new two-dimensional (2D) image that emulates a medical X-ray scan. Acceleration of DRR generation has been the focus of much research in recent years, especially for medical applications that are designed to work on different imaging systems such as 2D/3D medical image registration. In this study, we succeeded in reducing the DRR generation time by using an automatic body segmentation approach on the CT volume. The proposed automatic body segmentation methodology consists of several steps that are carried out sequentially, starting with the use of fractional order Darwinian particle swarm optimization to generate a binary mask for all CT volume slices and ending with the use of a watershed transform to obtain the parameters required to identify the human body or part thereof as a confirmed region of interest (ROI). In our experiment, nearly half of the CT volume was identified as a non-ROI by the proposed approach. The approach also achieved an acceleration in the DRR generation process because the time complexity rate is reduced from O ( N 3 ) to O ( M 3 ) , where M ≈ 1 2 N . That is to say, the DRR generation process was accelerated from 9.3 s when using the original (512 × 512 × 350) CT volume to 4.9 s when using the automated segmented CT volume, which involved the applications of the traditional ray-casting projection technique. The proposed methodology was applied by using a computer with an Intel® Core™ i7-7500 U processor, 8 GB RAM and 2.70 GHz processing speed. We used the two most commonly employed measurements, i.e., the dice similarity coefficient (DSC) and the Tanimoto coefficient (TC) to evaluate the segmentation results for the tested datasets. The results were also compared with ground truth images drawn by a specialist at the King Hussein Cancer Center in Jordan. The comparison of the automated segmented volume and its ground truth showed that the proposed methodology obtained 99.50% accuracy based on the DSC and 99.03% based on TC.

Criticality Analysis of Medical Equipment: A Case Study at King Hussein Cancer Center (KHCC) Amman-Jordan

Proper maintenance management of medical equipment is of prime importance to the health sector as otherwise this would result in poor treatment, longer waiting times and patients suffering as well as draining, the normally limited, financial resources of most public medical institutions. King Hussein Cancer Center (KHCC), Amman-Jordan is a unique medical institution where treatment of different types of cancer is provided and where equipment unavailability is considered a risky event which may result in life-threatening complications. This is especially true for critical treatment equipment. Criticality analysis was performed on a representative sample of medical equipment at KHCC in order to assess and improve the effectiveness of current maintenance management policy. A sample of twenty-one medical devices was selected for this study. Past failure and maintenance data, in addition to relevant financial information, were collected for these devices and compiled into criticality ranks. In order to take account of the special nature of these equipment medical criticality (in terms of risk score) values were also calculated based on relevant tables of the American Society for Healthcare Engineering (ASHE). Overall criticality ranking of medical equipment was then determined based on equipment cost, ASHE risk score, reliability and maintenance cost. The present results have revealed major flaws within the purchase and maintenance policies at KHCC. For example, some extremely expensive devices with extremely high-cost maintenance contracts were revealed to exhibit low reliability values and suffer from repeated failures. These were within patient-sensitive equipment cancer treatment devices. The results also have shown that under "less than optimum" maintenance practice, the ASHE risk score may be a misleading measure of equipment criticality. This was shown by comparing the obtained overall equipment criticality to their ASHE risk score where high level of discrepancy was present between the two measures.

Health- Related Quality of Life Among Jordanian Adolescent Cancer Patients Receiving Active Treatment.

Aims:The aim of this study was to evaluate quality of life among adolescents diagnosed with malignancies and currently undergoing treatment in the age group of 13-18 years old. Method:The study used a descriptive cross-sectional design. Participants were recruited from the pediatric oncology department at King Hussein Cancer Center in Jordan. The Arabic version of self-report (adolescent 13-18) pediatric quality of life inventory (PedsQLTM ) 4.0 Generic Core Scale was used. Results:Eighty patients were enrolled in the study. The total score of PedsQL 4.0 generic core was 62.0 (SD=16.5). The highest score was for social functioning (mean=85.4, SD=18.4) and the lowest score was school functioning (mean=39.5, SD=28.4). Females had significantly higher scores for health-related quality of life (HRQOL) in school functioning. Type of tumor did not affect HRQOL. Outpatient participants had significantly higher scores for HRQOL in all domains, except in school functioning where inpatients had a significantly higher score. Conclusion:To the best of our knowledge, this is the first study to reveal the HRQOL scores for Jordanian adolescents with cancer. Addressing the special needs in such a unique age group is essential when planning a comprehensive care plan for a better quality of life.

ES20.04 Tobacco Control Integration in Cancer Care: The Jordan Experience

Tobacco Control Integration in Cancer Care: The Jordan Experience Tobacco control is an integral component of any action plan that aims to reduce cancer incidence and mortality. Efforts at King Hussein Cancer Center, the only comprehensive cancer center in Jordan and the region, started 10 years ago. We sought to address the tobacco epidemic in Jordan on multiple fronts. In Jordan, tobacco prevalence exceeds 60%. About 50% of patients presenting with a cancer diagnosis are smokers. Integrating tobacco control in general and tobacco dependence treatment in patients suffering from cancer is pivotal. Smoking in patients with cancer has been shown to impact cancer treatment, increase complications from cancer treatment, increase cancer recurrence, increase the odds of development of secondary malignancies and eventually decrease overall long-term survival. Throughout the last 10 years our tobacco dependence treatment program grew in services and scope. The program addressed three major components required for tobacco control in cancer patients: First, patient-centered clinical tobacco dependence treatment service. Second, tobacco dependence treatment training and education for health-care providers. Third, research that addresses tobacco dependence in cancer patients. Our program provides 6 smoking cessation clinics every week dedicated mainly to our cancer patients. We have managed to address training needs for our staff by establishing a tobacco treatment specialist training program, the first ever to be accredited by The Council for Tobacco Treatment Training Programs outside the USA. We studied outcomes of our treatment program and developed means to improve referral to smoking cessation clinics as well as improve the abstinence of our patients. In addition, we studied knowledge, attitude and perception of our health care providers working at our institution; a step especially important in a country where significant numbers of health care providers are smokers. Finally, we studied the impact of our tobacco dependence treatment program on the survival of our patients. Understanding the impact of smoking cessation on short-term survival of patients with cancer (2 years) highlights the importance of integrating such programs as part of the acute treatment phase of these patients. Cancer registry and smoking cessation clinic data for cancer patients diagnosed between 2012 and 2016 were analyzed. Approximately 19% of cancer patients were seen at the smoking cessation clinic. In a sub-sample of 2,387 patients, a significant two-year survival advantage was observed for smokers who had visited the smoking cessation clinic and confirmed that they had not smoked on at least two of their 3, 6 or 12-month follow-up visits (HR 2.8, 95% confidence interval [CI] = 1.7–4.5) relative to those who never went to the smoking cessation clinic. Those at the smoking cessation clinic who were abstinent at only one follow-up point also exhibited a survival advantage (non-abstainers at the smoking cessation had comparable survival to those who were not seen at the clinic). In conclusion, tobacco control in patients with cancer has an important role in the outcome and survival of these patients and must be integrated in their short and long-term plan of care. Cessation, cancer, Tobacco

Six-Year Experience (2013-2018) With College of American Pathologists Programs at King Hussein Cancer Center in Jordan

Abstract Objectives Proficiency testing (PT) includes interlaboratory comparisons that are organized regularly to assess the performance of individual laboratories for specific tests or measurements and it is used to monitor laboratories’ continuing performance. Background The College of American Pathologists (CAP) requires laboratories to participate in PT programs and to perform the investigation and root cause analysis for unsatisfactory PT results, which is valuable to improve the laboratory performance. Methods The data were extracted from the CAP PT results of the laboratory from 2013 to 2018 in the areas of Biochemistry, Immunology, Hematology, Microbiology, Anatomic Pathology and Cytology, and Blood Bank. The data were PT scores and consisted of values between 0 and 100, representing the percentage of correct response for each analyte. Results There were 211 analytes (502 event) in 2018, 215 analytes (547 event) in 2017, 204 analytes (531 event) in 2016, 210 analytes (519 event) in 2015, 228 analytes (443 event) in 2014, and 158 analytes (528 event) in 2013 that were covered by CAP PT surveys in different laboratory areas. Over the 6 years of experience, there were 57 (1.86%) unsatisfactory results for all PT events. It was seen that the rates of unsatisfactory results in that period were gradually decreased with each year of experience, which was 1.1% (2018), 1.6% (2017), 1.9% (2016), 1.5% (2015), 2.4% (2014), and 2.6% (2013). The top 3 reasons for unacceptable results were random error, analytical error, and procedural error, which accounted for 21.0% random error (2013 (9%), 2014 (4%), 2015, 2016, 2017, &amp; 2018 (2%)), 19.3% analytical error (2013 (2%), 2014 (5%), 2015 (5%), 2016 (3.5%), 2017 (2%), &amp; 2018 (1.8%)), and 17.5% procedural error (2013 (4%), 2014 (4%), 2015 (0%), 2016 (2%), 2017 (5%), &amp; 2018 (3.5%)). Conclusion The proficiency testing performance showed a trend of improvement from 2013 to 2018, which contributed to the improvement of laboratory performance and declining the unacceptable results that affected positively on patient test performance.

Molecular correlates of cerebellar mutism syndrome in medulloblastoma.

Cerebellar mutism syndrome (CMS) is a common complication following resection of posterior fossa tumors, most commonly after surgery for medulloblastoma. Medulloblastoma subgroups have historically been treated as a single entity when assessing CMS risk; however, recent studies highlighting their clinical heterogeneity suggest the need for subgroup-specific analysis. Here, we examine a large international multicenter cohort of molecularly characterized medulloblastoma patients to assess predictors of CMS. We assembled a cohort of 370 molecularly characterized medulloblastoma subjects with available neuroimaging from 5 sites globally, including Great Ormond Street Hospital, Christian Medical College and Hospital, the Hospital for Sick Children, King Hussein Cancer Center, and Lucile Packard Children's Hospital. Age at diagnosis, sex, tumor volume, and CMS development were assessed in addition to molecular subgroup. Overall, 23.8% of patients developed CMS. CMS patients were younger (mean difference -2.05 years ± 0.50, P = 0.0218) and had larger tumors (mean difference 10.25 cm3 ± 4.60, P = 0.0010) that were more often midline (odds ratio [OR] = 5.72, P < 0.0001). In a multivariable analysis adjusting for age, sex, midline location, and tumor volume, Wingless (adjusted OR = 4.91, P = 0.0063), Group 3 (adjusted OR = 5.56, P = 0.0022), and Group 4 (adjusted OR = 8.57 P = 9.1 × 10-5) tumors were found to be independently associated with higher risk of CMS compared with sonic hedgehog tumors. Medulloblastoma subgroup is a very strong predictor of CMS development, independent of tumor volume and midline location. These findings have significant implications for management of both the tumor and CMS.

Global celebrities' effect on health awareness among Jordanians: A study using the case of Angelina Jolie

Celebrities' health decisions have long been associated with heightened awareness and health trend changes. This is the first study conducted in an Arab population investigating the impact of international celebrity news on local communities using the case of Angelia Jolie's (AJ) prophylactic mastectomy and oophorectomy surgeries. The objective was to measure the effect of publicized medical information on cancer genetic testing knowledge, attitudes, and practices (KAP). This is a cross-sectional study using a semi-structured, self-administered questionnaire for clinic visitors at the King Hussein Cancer Center (KHCC). We had predominantly female (n=262, 66.3%) and healthy participants (n=248, 66.5%). Approximately 80.7% (n=330) recognized AJ, the actress, and of these, 71% (n=232) were aware of her recent diagnosis and prophylactic surgeries. Males reported a higher knowledge score (p<.001). However, females had more initiative to seek information (18.3% vs. 10.1%; p=.04). People aware of Angelina's prophylactic procedures were inclined to seek information regarding cancer genetics (20.8% vs. 9.6% p=.003). Breast and ovarian cancer patients were more likely than other cancer patients to encourage family members to undergo prophylactic surgery in case of BRCA1/2 mutations (39.2% vs. 17.1% p=.03). Ninety-three percent of the sample lacked knowledge regarding the availability of cancer genetic testing in Jordan. Results highlight a clear effect of celebrity medical news on our population, as well as openness to consider genetic testing as an early detection tool for women with a family history of breast and/or ovarian cancer. Generalization of these results to the population of Jordan requires further studies.

Smoking cessation care can translate to lower hazard of death in the short-run in cancer patients - a retrospective cohort study to demonstrate the value of smoking cessation services within the treatment phase of cancer

BackgroundSmoking cessation is a key step towards improving cancer care and outcomes. However, smoking cessation interventions are underprovided in oncology settings. Within Jordan’s only comprehensive oncology center, we sought to evaluate receipt of care at a smoking cessation clinic and the effect of assisted abstinence through the smoking cessation clinic on short-term (two-year) survival after a cancer diagnosis.MethodsWe employed a retrospective cohort study design. Cancer registry and smoking cessation clinic data for adult Jordanian cancer patients diagnosed between 2009 and 2016, who also were cigarette smokers, and who received full treatment at King Hussein Cancer Center, were analyzed. Specifically, descriptive statistics of patients who visited the smoking cessation clinic were generated, and short-term (two-year) hazard of death of patients based on whether or not smoking cessation clinic-assisted abstinence occurred, were evaluated.ResultsThere were 3403 patients who met our inclusion criteria. Approximately 21% of cancer patients were seen at the smoking cessation clinic, and significant demographic and clinical disparities in who was being seen [at the smoking cessation clinic] existed. In 2387 patients with available survival data, smokers who never went to the smoking cessation clinic (or were seen only once, or seen a year or more from diagnosis) had a hazard of death 2.8 times higher than smokers who had visited the smoking cessation clinic and who also confirmed they had not smoked on atleast two of their 3-, 6- or 12-month follow-up visits (95% confidence interval [CI] = 1.7–4.6). Non-abstainers at the smoking cessation clinic exhibited a similar disadvantage (HR 2.7, 95% CI 1.4–5.0).ConclusionsAlthough evidence-based smoking cessation interventions increase the likelihood of abstinence and can lower the short-term hazard of death during cancer treatment, there is a deprioritization of smoking cessation interventions during cancer care, as indicated by low proportions of patients seen at the smoking cessation clinic. Our findings emphasize the importance of promoting interventions to avail smoking cessation interventions in oncology settings within the cancer treatment phase.

Hematologic markers of distant metastases in gastric cancer.

High neutrophil-lymphocyte ratio (NLR) is associated with poor overall survival (OS) in gastric cancer. This study evaluates whether NLR, in addition to other parameters including absolute neutrophil count (ANC), absolute lymphocyte count (ALC), absolute eosinophil count (AEC), absolute monocyte count (AMC), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) are associated with distant metastases, a common and poor prognostic feature of gastric cancer. Clinical data from 502 gastric cancer patients treated at King Hussein Cancer Center (Amman, Jordan) have been retrospectively reviewed. We examined the association between ANC, ALC, AEC, AMC, NLR, MLR and PLR with the baseline distant metastases and OS. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal NLR cutoff value for association with distant metastases. Univariate and multivariate analyses showed that patients with high baseline NLR (≥3.9) had more distant metastases on presentation than patients with low NLR (<3.9), (P value: 0.0001 and 0.0005, respectively). Furthermore, patients with high baseline ANC (≥6,015/µL), AEC (≥215/µL), PLR (≥0.15) had more distant metastases in comparison to patients with low baseline ANC (<6,015/µL), AEC (<215/µL), PLR (<0.15) (P value: 0.024, 0.001, and 0.001, respectively). High ANC, NLR, MLR and PLR are associated with poor OS (P value: 0.046, 0.0003, 0.027, and <0.0001, respectively). High ANC, AEC, NLR, and PLR are associated with distant metastases on presentation in gastric cancer. In the era of cancer immunotherapy, whether these immune phenomena predict the response of gastric cancer to immunotherapy is unknown.

A Hospital-based Pharmacy Internship Program in Jordan

Objective. To develop a hospital-based pharmacy internship program in a comprehensive cancer care center in Jordan and review its outcomes over a 10-year period.Methods. King Hussein Cancer Center developed a two-year internship program for pharmacy students in Jordanian universities. The program included training in operational and clinical settings during the academic year and school holidays. In addition, the students completed rotation-related assignments and met weekly with the program director. During the rotations and at the end of the program, interns were asked to assess their level of satisfaction with the program and to comment on its content and structure. Results. From a pilot phase with only three interns and a simple training structure, the two-year internship program has become more structured now training six interns annually. During the first 10 years of the program, 51 students from four universities in Jordan enrolled in the program, with six current interns, 34 graduates, and 11 withdrawals. Graduates reported improved academic performance and satisfaction with the program's structure and the skills obtained. Their main challenge was time management during the academic year. Conclusion. A hospital-based pharmacy internship program is feasible and sustainable. Participation in the program improves interns' academic performance and clinical and professional skills, despite the challenges of highly demanding conditions on both the hospital and the students.

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan.

PurposeThe quality assurance (QA) chart rounds are multidisciplinary meetings to review radiation therapy (RT) treatment plans. This study focus on describing the changes in RT management based on QA round reviews in a single institution.Materials and MethodsAfter 9 full years of implementation, a retrospective review of all patients whose charts passed through departmental QA chart rounds from 2007 to 2015. The reviewed cases were presented for RT plan review; subcategorized based on decision in QA rounds into: approved, minor modifications or major modifications. Major modification defined as any substantial change which required patient re-simulation orre-planning prior to commencement of RT. Minor modification included treatment plan changes which didn’t necessarily require RT re-planning. ResultsOverall 7,149 RT treatment plans for different anatomical sites were reviewed at QA rounds. From these treatment plans, 6,654 (93%) were approved, 144 (2%) required minor modifications, while 351 (5%) required major modifications. Major modification included changes in: selected RT dose (96/351, 27%), target volume definition (127/351, 36%), organs-at-risk contouring (10/351, 3%), dose volume objectives/constraints criteria (90/351, 26%), and intent of treatment (28/351, 8%). The RT plans which required major modification according to the tumor subtype were as follows: head and neck (104/904, 12%), thoracic (12/199, 6%), gastrointestinal (33/687,5%), skin (5/106, 5%), genitourinary (16/359, 4%), breast (104/2387, 4%), central nervous system (36/846, 4%), sarcoma (11/277, 4%), pediatric (7/251, 3%), lymphoma (10/423, 2%), gynecological tumors (2/359, 1%), and others (11/351, 3%).ConclusionMulti-disciplinary standardized QA chart rounds provide a comprehensive and an influential method on RT plans and/ or treatment decisions.

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan

ContextChemotherapy use in the last month of life is an indicator of poor quality of end-of-life care. ObjectivesWe assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use. MethodsWe conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators. ResultsAmong the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life. ConclusionsA sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.