Kuwait Cancer Control Center Research Articles

Diet, lifestyle factors, comorbidities, and hepatocellular carcinoma risk in a middle eastern country: a case-control study

BackgroundHepatocellular Carcinoma (HCC) can be classified as one of the most common malignancies worldwide. There is scarcity of the published data on the risk factors for HCC in the Gulf Cooperation Council countries specifically Kuwait. Therefore, this case-control study sought to examine the risk factors associated with HCC in Kuwait.MethodsFifty-three histopathologically confirmed HCC cases were recruited from the Kuwait Cancer Control Center Registry. One hundred ninety-six controls (1:4 ratio) were selected from medical and/ or surgical outpatient’s clinics at all six public hospitals of Kuwait. A structured questionnaire was used to collect the data both from cases and controls through face-to-face interviews. A multivariable logistic regression model was fitted to the case-control data. Adjusted odds ratios (ORadj) and their 95% confidence intervals (CI) were computed using the parameters’ estimates of the final model and used for interpretation of the model.ResultsThe HCC cases compared with the controls were 41.6 times more likely to have had the history of non-alcoholic fatty liver disease (NAFLD) (ORadj = 41.6; 95% CI: 8.9–193.5; p < 0.001). The cases compared with the controls were more likely to have reported the history of heavy alcohol drinking (ORadj = 14.2; 95% CI: 1.2–173.4; p = 0.038). Furthermore, compared with the controls, the HCC cases tended to frequently consume milk and/or milk substitutes (≥ 3 glass/ week) (ORadj = 7.2; 95% CI: 1.2–43.4). Conversely however, there was a significant protective effect if the participants reportedly have had regularly used olive oil in their routine diet as a source of fat (ORadj = 0.17; 95% CI: 0.04–0.80) or regularly used non-steroid anti-inflammatory drugs (NSAIDs) (ORadj = 0.20; 95% CI: 0.05–0.71).ConclusionsThis study showed that heavy alcohol consumption, NAFLD history, and excessive consumption of milk/ milk substitutes were associated with a significantly increased HCC risk. Conversely however, regular use of olive oil in the diet as a source of fat or regular use of NSAIDs had a significantly protective effect against HCC risk. Adapting healthy dietary habits and preventing/ treating NAFLD may minimize the HCC risk. Future research with a larger sample size may contemplate validating the results of this study and unraveling additional risk factors contributing to HCC risk. The resultant data may help design and implement evidence-based educational programs for the prevention of HCC in this and other similar settings.

Prognostic impact of chronic lymphocytic leukemia comorbidity index in a young population: a real-world evidence study of a national gulf region cohort

In chronic lymphocytic leukaemia (CLL), comorbidities assessed by the CLL comorbidity index (CLL-CI) have been associated with outcomes in Western cohorts. We conducted a retrospective analysis of an unselected Middle Eastern cohort of newly diagnosed CLL patients seen at the Kuwait Cancer Control Center (n = 300). Compared to Western studies, these Middle Eastern patients were diagnosed at a younger age (median of 59) and had a higher comorbidity burden (69% non-low risk CLL-CI). A higher CLL-CI score was independently associated with significantly shorter event-free survival and greater risk of death. Our analysis demonstrates that CLL-CI is a valuable tool for comorbidity assessment and prognostic influence in (relatively young) Middle Eastern CLL patients.

Adolescents and Young Adults with Multiple Myeloma, Kuwait Experience

Background Multiple myeloma MM is an incurable plasma cell malignancy with a median age of 65 years at diagnosis worldwide, a small number of publications were focused on young adult Multiple myeloma MM with special characteristics and clinical outcomes. Objectives To evaluate the incidence of MM among adolescent and young adults (AYA) in Kuwait aged 40 and below. Also, to describe the clinical characteristics, high risk features and treatment outcomes at the Kuwait Cancer Control Centre (KCCC). Materials &amp; Methods We collected data retrospectively from the hematological malignancy registry at KCCC and looked at AYA patients (pts) with a confirmed diagnosis of Multiple myeloma at our center from 2015 till 2022, we looked at age of onset, gender, nationality, year of myeloma diagnosis, presence of extramedullary disease, International Staging System score (ISS score), cytogenetic aberrations, induction therapy, receipts of auto-transplant and maintenance therapy. Results From 2015 till 2022, 340 patients were diagnosed with MM in Kuwait, eleven patients were found 40 years old or younger, only one was female patients, the median age was 35 years old, around a third were Kuwaiti, 73% were non-Kuwaiti of middle eastern background, 4 patients were found to have extramedullary disease at diagnosis, with advanced stage ISS III found in 3/9 pts. One patient was found with 1Q gain and the rest of the 10 patients were with negative del17p, t (4,14), t(14,16), gain1q and t(11,14). Of note, interphase FISH cytogenetic is not done with CD138 selection. Six patients were treated with RVD induction (Lenalidomide, Bortizomib, Dexamethasone), two patients treated by CTD (Cyclophosphamide, Thalidomide, Dexamethasone), one pt treated by VCD (Bortizomib,Cyclophosphamide,Dexamethasone), one patient treated by Daratumumab RVD, and one patient treated by VTD. Overall response rate (ORR) was 90.9%, (10/11) responded patients proceeded to HDCT/ASCT and all these patients went on maintenance post-transplant, two patients were lost to follow up while 9 patients still under follow up, median follow up 33 months, one pt had a relapse after transplant. Conclusion MM is an uncommon disease among AYA in Kuwait (3.2%) of all myeloma patients, with favorable durable responses in this group of patients.

Relationship between Symptom Burden and HRQOL among Kuwaiti Women Recently Diagnosed with Breast Cancer: A Cross-Sectional Study.

Breast cancer is a life-threatening chronic condition associated with distress and psychological symptoms. Breast cancer also leads to ongoing ambiguity around the symptom burden of the disease and its treatment over the long-term, which impacts health-related quality of life (HRQOL). The factors influenced HRQOL of Kuwaiti women with breast cancer is unclear and not well understood. The purpose of the study was to explore the relationships between the symptom burden and HRQOL of Kuwaiti women diagnosis with breast cancer within their first year. This cross-sectional correlational study surveyed 100 Kuwaiti women diagnosed with breast cancer within the previous year at the Kuwait Cancer Control Center Hospital (KCCC). The study collected data using a combination of five questionnaires: The Memorial Symptom Assessment-Short Form Scale (MSAS-SF), the Medical Outcomes Study Social Support Survey (MOS-SSS), the Functional Assessment of Cancer Therapy-General (FACT-G), and demographic/clinical questionnaire. The 100 Kuwaiti women in the study experienced moderate symptom burden (M = 2.35, SD = 0.28), which is significantly negatively associated with HRQOL. The most prevalent symptoms the women reported were pain, difficulty sleeping, lack of energy, and hair loss. Symptom burden was significantly negatively associated with HRQOL. The findings of this study suggest the need for more training for clinicians to diagnose and treat common symptoms. Improved screening tools and psychosocial interventions also need to be developed. Future research should focus on longitudinal data and qualitative methods to gain a more comprehensive understanding of Kuwaiti women's experiences with breast cancer.

Evaluation of the CLL-IPI and IPS-E Prognostic Indices in a Young Middle Eastern Population with Chronic Lymphocytic Leukemia: A Retrospective Analysis at the Kuwait Cancer Control Center

Introduction: The Chronic Lymphocytic Leukemia International Prognostic Index (CLL-IPI) is a powerful prognostic tool validated in multiple Western populations. However, its utility in the young Middle Eastern population is unknown. Methodology: We conducted a retrospective analysis of 152 unselected patients with chronic lymphocytic leukemia (CLL) diagnosed between 2008 and 2022 at the Kuwait Cancer Control Center, which serves as the sole cancer center in Kuwait. The evaluation of the CLL-IPI was based on the assessment of event-free survival (EFS) across the entire cohort. Subsequently, we compared the CLL-IPI with the International Prognostic Score for Early-stage patients (IPS-E) in order to predict the time to first treatment specifically within the subgroup of patients diagnosed with early-stage disease. Results: The median age of the study cohort was 59.9 years (IQR, 53.1–68.8). The 5-year EFS rates for the low, intermediate, and high/very high-risk categories were approximately 82%, 34%, and 23%, respectively, p < 0.001 (C-statistic = 0.67). On multivariate analysis, advanced stage and unmated IGHV status were independent prognostic factors of EFS. In those with early-stage disease, cumulative 5-year treatment incidence rates for the low, intermediate, and high/very high-risk categories based on the CLL-IPI score were approximately 8%, 55%, and 55%, respectively, p = 0.001 (C-statistic = 0.70). However, based on the IPS-E score, the cumulative 5-year treatment incidence rates for the low, intermediate, and high-risk categories were approximately 0%, 10%, and 60%, respectively, p < 0.001 (C-statistic = 0.73). Conclusions: The CLL-IPI and the IPS-E are valid stratification tool in our young Middle Eastern population.

Comparing the Quality of Life of Caregivers for Patients with Hematologic and Solid Malignancies in Kuwait: A Cross-Sectional Study

Cancer incidence is escalating globally, and the Middle East, including Kuwait, is no exception. This study delves into a comparative analysis of the Quality of Life (QOL) experienced by caregivers for patients with hematologic and solid malignancies in Kuwait. The prevalence of cancer in Kuwait is rising, becoming the second leading cause of death after cardiovascular diseases. Colorectal and breast cancer are predominant forms, with an increased occurrence in females. Notably, haematological malignancies, rooted partly in consanguineous marriages, exhibit a distinct prevalence pattern, accounting for a significant proportion of deaths. Kuwait has made substantial investments in bone marrow transplantation programs to address this issue. To understand the impact of caregiving on the QOL of individuals supporting cancer patients, a cross-sectional study was conducted. Caregivers were recruited from the Kuwait Cancer Control Centre outpatient clinics between February 25 and March 25, 2020. Caregivers’ QOL was assessed using the Caregiver Quality of Life Cancer Index (CQoLC) through face-to-face interviews. The study aimed to determine if caregivers were adequately informed before their patients’ discharge and analyse reasons for non-participation. Previous research on caregiver QOL has predominantly focused on Western societies, while this study addresses the Kuwaiti context. The expectation is that findings will contrast with Western studies due to unique cultural and societal dynamics, where women play a pivotal role in caregiving. While males may experience reduced QOL due to work-home time constraints, female caregivers in Arab countries tend to be efficient, albeit with potential skill deficiencies. The study enrolled 117 caregivers, with 65 supporting patients with solid malignancies and 52 caring for hematologic malignancy patients. The demographic characteristics of caregivers were analysed, revealing trends related to age, gender, marital status, employment, education, and living arrangements. Caregivers of solid malignancy patients displayed higher levels of burden compared to hematologic malignancy caregivers, with emotional strain, worry, and sadness being significant factors. While there was a notable refusal rate among potential participants, the study’s insights are valuable. To enhance the QOL of caregivers, especially those supporting outpatient cases, targeted interventions such as palliative care and training programs are crucial. The economic burden on caregivers necessitates policies addressing financial support. The findings of this study contribute to the ongoing efforts to improve the QOL of caregivers in Kuwait, thereby alleviating the multifaceted challenges posed by cancer and its care. This research underscores the importance of tailoring interventions to the specific cultural, social, and economic context of Kuwait to optimize caregiver well-being and patient outcomes.

Chronic Lymphocytic Leukemia Treatment: Single Center Experience

Background: Chronic lymphocytic leukemia (CLL) is relatively uncommon in the Middle East, with a younger age at diagnosis and different clinical characteristics compared to the West. There is little research on CLL in this region. This study aims to evaluate widely used prognostic markers and examine treatment outcomes of CLL patients in the Kuwait Cancer Control Center (KCCC), the only cancer center in Kuwait. Methods: This is a retrospective analysis of unselected 141 CLL patients receiving treatment in the KCCC. Diagnostic and treatment guidelines in our center were in accordance with the International Workshop on CLL criteria. Results: The median age of those patients at diagnosis was 58 years (IQR, 51-65), with 60% of patients under the age of 60. The male to female ratio in this group was 3.3:1. Median absolute lymphocyte count was 51x109/L (IQR, 51-65), and the median hemoglobin and platelet count were 11.8 g/dL (IQR, 10.1-13.8) and 170x109/L (IQR, 129-222). FISH analysis was performed in 118 patients, of which 9% (11) demonstrated del17p. Del13q and trisomy 21 were detected in 31% (36) and 26% (31) patients, respectively. IGHV mutational status was determined in 80 patients, 25% (20) were mutated, and 75% (60) were unmutated. When it comes to treatment, 47% (65) of patients were on FCR regimen, while 11% (15) and 12% (16) were receiving BR and CR, respectively. Approximately 15% (21) of patients in our study were on a BTKi. In 105 patients, the median progression-free survival (PFS) was 44.2 months [95% CI: 36-61.5], with a PFS rate of 48% and 32% at 25 and 50 months, respectively. In 121 patients with no history of progression or treatment in our study cohort, 41.5% and 21% progressed or received treatment at 25 and 50 months, respectively, with a median time to first progression or treatment around 37.6 months [95% CI: 29.1-49.5]. Examining 103 patients with prior history of progression or treatment, 34% and 13% progressed again or required a second course of treatment at 25 and 50 months, respectively, with a median time to second progression or treatment around 65.5 months [95% CI: 40.5-NA]. Those receiving chemoimmunotherapy exhibited a higher median PFS of 93 months [95% CI: 83-NA] compared to those receiving a BTKi with a median PFS of 42 months [95% CI: NA-NA]. However, the difference was not statistically significant (p=0.34). IGHV mutation status was significantly associated with OS (p=0.044) but not PFS (p=0.28). Those with unmutated IGHV had an inferior outcome compared to their mutated counterparts with OS rates at 50 months, around 15% and 25%, respectively, PFS rates were also lower in the unmutated compared to a mutated group, 21% vs. 31% at 50 months, respectively, and PFS medians around 49 [95% CI: 36.4-NA] and 94.5 [95% CI: 94.5-NA], respectively. Multivariate cox regression analysis on OS was not significant (p=0.160). None of the individual treatment regimens were significant predictors of OS compared to the reference (BR), except FCR. Treatment with FCR was associated with a hazard ratio of 0.11 (p = 0.011). Unmutated IGHV status, presence of del17p, and age greater than 60 were all associated with greater hazard ratios, but none were significant predictors of OS. Conclusion: Our CLL treatment group is younger. Unmutated IGHV was associated with a poor prognosis, consistent with the literature. However, treatment with BTKis was not associated with superior outcomes compared to CIT; however, this study is not powered to detect a difference between the two arms. Those receiving FCR had the best survival outcome compared to those receiving other therapies. Keywords: Chronic Lymphocytic Leukemia, Treatment Outcomes, Kuwait, Middle East Funding Agency: Kuwait Foundation for the Advancement of Science, Grant number: PR1713MM03 Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Predicting Stage Progression in Binet Stage a Chronic Lymphocytic Leukemia

The variability in clinical course among patients with chronic lymphocytic leukemia (CLL) and the lack of consensus regarding follow-up and treatment strategies necessitate a prognostic model to determine patients at high risk of treatment initiation for prompt medical attention. Our study involved 121 participants diagnosed with Binet stage A CLL. Their demographic and clinical characteristics were retrospectively analyzed to determine their risk category according to the international prognostic scoring index for the early stage-CLL (IPS-E) model and evaluate the applicability of this prognostic approach in our young cohort from the Kuwait Cancer Control Center. Our cohort had a median age of 59 years and was predominantly male (70.2%). During the study period, 27 cases demonstrated progression to the first treatment. According to the IPS-E risk model, 17 cases were deemed low risk, 48 were intermediate risk, and 56 were high-risk. Of 121 tests to determine IGHV status, 60 patients have mutated IGHV. Multivariate Cox regression analysis revealed that patients with palpable lymph nodes and unmutated IGHV status confer a significantly higher risk of initiating treatment (hazards ratio of 3.12 and 3.36, respectively). In contrast, absolute lymphocyte count (ALC) was not statistically significant. A beta 2 microglobulin level >3.5 may also contribute toward progression to treatment through a higher disease burden. Based on the IPS-E model, high-risk patients fared worse compared to low- and intermediate-risk patients. However, the clinical impact of distinguishing the two latter risk groups may not be as significant. Although cases of CLL are relatively common, their clinical behavior regarding initiating the first treatment remains elusive. Nevertheless, the IPS-E risk model remains valuable in directing medical attention toward high-risk patients for optimal follow-up and treatment.

CML-415 Treatment Free Remission (TFR) in Chronic Myeloid Leukemia-Chronic Phase (CML-CP), Kuwait Experience

CML is one of the successful stories in oncology. Treatment of CML has evolved and goals of therapy have changed over the years. Treatment free remission (TFR) is becoming an attractive goal in CML patients (pts) especially in younger population. To evaluate the trend of TFR in CML treated pts in Kuwait. Retrospective analysis of CML pts treated in Kuwait Cancer Control Center (KCCC) who had a trial of TFR. Data were collected from the charts and electronic medical records. Pts who stopped tyrosine kinase inhibitor (TKI) due to intolerance or pregnancy were included if they were in deep molecular remission (DMR) (3MR4.0) regardless of the duration of therapy. A total of 42 pts was eligible for TFR. Most of our pts were treated with imatinib (93%). All patients achieved optimal milestones, however pts who stopped treatment in DMR due to intolerance or pregnancy were included. Most of our pts were young with a median age of 38 yrs and had a low risk Sokal/ELTS score. Our cohort of pts had a long duration of TKI exposure (103 mons) and DMR (70 mons). At a median follow up of 50 mons, TFR rate was 74%. As shown in table 2, 10 pts (24%) lost TFR and were able to regain DMR upon re-starting TKI. All of them were treated with imatinib. Successful TFR rates are high among pts treated in Kuwait. This is largely due to a longer duration of therapy and higher percentage of pts with low risk Sokal/ELTS score.

Implementation of the Distress Assessment and Response Tool at the Kuwait Cancer Control Centre

Abstract Background: This report describes the implementation of a comprehensive distress screening program at the Kuwait Cancer Control Center (KCCC), the first such initiative in the Middle East. A Kuwait-adapted version of the Distress Assessment and Response Tool (K-DART) was used in this screening program. Methods: Paper-based K-DART surveys were piloted in the lymphoma clinic at KCCC in July 2013, followed by gradual hospital-wide expansion. K-DART included patient-reported outcome measures to assess cancer-related physical and emotional symptoms and practical problems. English and Arabic translations of these measures were used. Trained nurses administered K-DART and followed up with the oncologist for patients with moderate-to-high levels of distress. Descriptive data are reported for prevalence of distress, psychosocial oncology program (PSOP) referral rates, and patient and staff satisfaction with K-DART. Results: A total of 1,153 K-DART surveys were completed by 618 patients in the pilot lymphoma clinic, with screening rates increasing from 33.5% to 75.3% over the first 12 months of implementation. Among all K-DART completers, 85/618 (13.8%) were referred to PSOP, whereas only 1/955 (0.1%) of K-DART noncompleters were referred to PSOP. After hospital-wide expansion of screening, a total of 2,017 patients completed K-DART in the first year of implementation. Both patients and physicians reported high satisfaction with K-DART, which was reported to enhance patient–physician communication and improve clinical care. Conclusion: Implementation of K-DART in a Middle Eastern country is feasible and facilitates a more comprehensive approach to cancer care, contributing to the successful establishment of a PSOP at the KCCC.

PB2068: RETROSPECTIVE ANALYSIS OF HAIRY CELL LEUKEMIA (HCL) PATIENTS (PTS) TREATED WITH DIFFERENT MODALITIES AS FIRST LINE: REAL-LIFE EXPERIENCE OVER 20 YEARS IN KUWAIT.

Background: Introduction: Hairy cell leukaemia (HCL) is a rare chronic lymphoproliferative disorder Aims: We retrospectively analysed all HCL cases diagnosed and treated at the Department of Hematology at Kuwait Cancer Control Center over a 20 year period. Methods: Baseline parameters collected included patient and disease demographics including bone marrow findings, as well as treatment protocols, and complications arising from treatment or relapse. Overall survival (OS) and progression free-survival (PFS) were calculated using a Kaplan-Meier analysis. Results: Forty-one patients with a median age of 51 (range 31–78) years were enrolled in the study over the time period 1994-2020. Diagnosis was established according to the WHO criteria for HCL. Clinical characteristics are shown in Table 1. Almost one third of the pts were Kuwaiti which reflects the demographic distribution of the country’s population. All pts were male (n=40) except for 1 pt. Treatment was initiated in 39 pts. In first-line, 28 pts were treated with cladribine (2CDA) alone, five received 2CDA in combination with rituximab, and four received interferon. The overall response rate (ORR) was 87.8%. In pts who received 2CDA-based therapy, the ORR was 97%. After a median follow-up of 92 months (3-266), median OS was not reached and median PFS was 7.7 years (95% CI, 5yrs-NR) (Figure 1). Sixteen pts (39%) had disease progression and were retreated mostly with 2CDA. Therapy was well tolerated with no reported treatment-related mortality. Febrile neutropenia was 22%. Image:Summary/Conclusion: This is the first report of HCL characteristics and outcomes from Kuwait. HCL pts have outcomes that are comparable to those in the published literature.

Organs dosimetry in targeted radionuclide therapy

The objective of this study is to assess the patients' effective and organ dose during theranostic applications in Kuwait. In total, eighteen adults' patients were conducted nuclear medicine procedures with 177Lu Dotatate for theranostic purpose in Kuwait Cancer control center (KCCC), Kuwait. Medium energy collimator (MEC) (208 keV Scatter 26% better than 113 keV Scatter 60%) was utilized to obtain scans in definite time intervals ranged from one to 2 h (before voiding), 6:00, 24:00, 48:00, 72:00 h. Patients, tissue and organ radiation doses were computed utilizing OLINDA/EXM Software. The average radiation effective dose (in mSv/MBq) for bladder, liver, and both kidneys (left & right), were 0.36, 0.08, 0.61 & 0.60. The range of the effective dose was from 0.55 mSv to 7.7 mSv. The acquired scans using 177Lu were delivered diagnostic findings. The patients’ effective dose is lower compared to the previous studies. Variation is attributed to the departmental protocol and administered activity. The values of the mean organ dose were comparable and lower than previously published studies. Different organs have different level of doses, which may affected by the presence of the metastatic tumors in the entire organ.

Radiobiological risks in terms of effective dose and organ dose from 18F-FDG whole-body PET/CT procedures.

IntroductionIntegrated Positron Emission Tomography (PET) with Computerized tomography (CT) (PET/CT) are widely used to diagnose, stage and track human diseases during whole body scanning. Multi-modality imaging is an interesting area of research that aims at acquiring united morphological-functional image information for accurate diagnosing and staging of the disease. However, PET/CT procedure accompanied with high radiation dose from CT and administered radioactivity. The aim of the present study was to estimate the patients’ dose from 18F-fluorodeoxyglucose imaging (18F-FDG) hybrid PET/CT whole body scan.Materials and methodsRADAR (Radiation Dose Assessment Resource) software was used to estimate the effective dose for 156 patients (110 (70.5%)) males and 46 (39.5%) female) examined using Discovery PET/CT 710, GE Medical Systems installed at Kuwait Cancer Control Center (KCCC).ResultsThe effective dose results presented in this PET/CT study ranged from (1.56–9.94 mSv). The effective dose was calculated to be 3.88 mSv in females and 3.71 mSv in males. The overall breast (female), lung, liver, kidney and thyroid were 7.4, 7.2, 5.2, 4, 3 and 2.9, respectively.For females, the body mass index (BMI) was 28.49 kg/m2 and for males it was 26.50 kg/m2 which showed overweight values for both genders. Conclusions: The findings indicate that the effective dose of 18F-FDG in both male and female patients was not substantially different. The study suggested that the risk–benefit proportions of any 18F-FDG whole body PET/CT scan should be clarified and carefully weighed. Patient’s doses are lower compared with previous studies.

Safety and tolerability of regorafenib: a real-life experience.

Regorafenib has been approved among the treatment options for patients with advanced stage colorectal cancer (CRC), hepatocellular carcinoma (HCC), and gastrointestinal stromal tumors (GIST). In this study, we aim to report the real-life experience of the safety and tolerability regorafenib in our institution. We conducted a retrospective chart review of 43 patients who received regorafenib in Kuwait Cancer Control Center (KCCC) from 2016 to the end of 2019. Data collected include diagnosis, patient demographics, performance status, number of previous lines of treatment, number of treatment cycles, side effects, best-tolerated dose, and treatment discontinuation due to intolerability. Univariate analysis with Pearson chi-square test were conducted to study co-relation between discontinuation rates and several factors. We had available data for 43 patients (23 males and 20 females). Of the patients, 83.7% had an ECOG performance status of 0 or 1. Seventy-three percent were diagnosed with metastatic CRC, 21% were diagnosed with HCC and 6% were diagnosed with GIST tumors. Half of the patients received 3 lines or more of treatment prior to regorafenib. The median number of cycles received was 3.7 with 11.6% of patients still on active treatment at the time of analysis. The most reported grade 3 and above side effects included rash (41.9%), fatigue (39.6 %), hypertension (25.6%), mucositis (21.9%), hand-foot syndrome (2.3%), and hyperbilirubinemia (4.6%). The best-tolerated dose was 80 mg and that was achieved in 44.2% of patients. The recommended dose of 160 mg could only be achieved in 20.9% of patients. The treatment was discontinued because of intolerability in 25.6% of patients. The discontinuation rates in those with ages 60 years and above versus below 60 years were 91% and 68%, respectively. In our cohort, the best-tolerated dose of regorafenib was 80 mg. Toxicity and intolerability of regorafenib lead to treatment discontinuation in nearly a quarter of patients. Patient age may influence tolerance and adherence to regorafenib.

Tumour Size and Age in Early Versus Advanced Breast Cancer in Kuwait

Background: In the Middle East, Kuwait in particular, the rate of incidence of breast cancer has increased in the past recent years. The objective of this study was to obtain information about the relationship between tumour size and age in early vs. late stage breast cancer in Kuwaiti female patients. Method: A total of 259 files of Kuwaiti women with breast cancer in 2012 were obtained from the Kuwait Cancer Control Center Registry (KCCC). Data were obtained was evaluated and divided into different prognostic variables including patient characteristics, tumour size, tumour grade, TNM, laterality, and treatments. Results: The results showed that the mean age at diagnosis was 54± 11.2. The mean tumour size was 3.4± 2.1 cm. The most frequent stage observed throughout the study, according to TNM staging, was T2N0M0. One hundred and thirty cases were diagnosed as an early stage while sixty-eight cases were diagnosed as a late stage. Conclusion: Larger tumour size, high lymph node involvement and negative ER/PR receptors were observed more in the older age group compared with other studies. An early-stage disease can present with large tumour size >3 cm and late-stage disease can present with small tumour size. More studies are required to find the aetiologies. Women should be encouraged to do screening programs.

Radiotherapy in localized gastric cancer management: To be or not to be?

e16511 Background: Gastric adenocarcinoma still have dismal outcome in spite of the progress made in systemic treatment in last 2 decades. In localized disease, treatment outcome still suboptimal, with up to 88% suffer from recurrence/metastasis. Hence, improvement in radical initial treatment is mandatory. Recent trials showed survival benefit of adding radiotherapy (preoperative or adjuvant) with favorable toxicity profile when using current advances radiation techniques. Methods: We retrospectively analyzed impact of radiotherapy in management of localized gastric cancer in Kuwait. 87 adult patients with newly diagnosed gastric cancers were treated and followed up at Kuwait Cancer Control Center (KCCC) between 2009-2015, 12 were excluded due to inoperability. 13 patients were excluded as they had early disease and underwent only surgery. Finally, 62 patients were submitted in study 48 patient received radiotherapy (RT group) as part of treatment (44 postoperative, 3 postoperative after induction Chemotherapy, 1 preoperative). 14 patients did not receive radiotherapy (NRT group); five received perioperative chemotherapy, nine received postoperative chemotherapy). Survival analysis was done using Kaplan-Meier, and comparison was done according to clinicopathological features. Results: The median age at diagnosis was 55 (range 25-70). Men represented 65.5%. Asian were 17 patients and Caucasian were 70 patients. 68.9% were nonsmoker while 31% were smoker. Median follow up was 45 months (1-89). 2 year Overall survival in the NRT group was 50% while in RT group was 79.1%. 3 year OAS was 42.8% and 64.5% in NRT group and RT group respectively. Median overall survival for NRT group was 82 months. While for the RT group median survival was not reached at time of analysis with p value (0.025). 2 year DFS in NRT group was 50% while in RT group was 66.6%. 3 year DFS was 42.8% and 54.1% in NRT group and RT group respectively. Median DFS not reached in both groups p value (0.04). On correlation of prognostic clinicopathological features with benefits of adding radiotherapy it was noticed that high grade, positive margins statistically benefit more from local radiotherapy and had better local control. Distal tumours behave badly whether received radiotherapy or not. Interestingly benefit of adding radiotherapy was not significantly affected by nodal status. Conclusions: Radiotherapy should be part of management in postoperative locally advanced gastric cancer especially with high grade tumours and positive margins. However still ongoing trials to clear the role of radiotherapy in preoperative setting.

Implications of the 21-gene recurrence score assay (Oncotype DX) on adjuvant treatment decisions in ER-positive early-stage breast cancer patients: experience of Kuwait Cancer Control Center

BackgroundThe Oncotype DX is a quantitative assay of the expression of 16 tumor-related genes and 5 reference genes that predicts the potential of adjuvant chemotherapy benefit in estrogen receptor (ER)-positive early breast cancer patients. The study aims to evaluate the impact of Oncotype DX as a tool for adjuvant treatment decision of ER-positive, HER2-negative, N0/N1 early-stage breast cancer patients and to determine which clinicopathological criteria derived the greatest advantage.ResultsA hundred patients at a median age of 50 years were included. TNM stage distribution was 34, 63, and 3 patients for stages I, II, and IIIA respectively. Fifty-four patients had luminal A and 46 had luminal B tumors. The recurrence score (RS) results were low, intermediate, and high risk in 54, 34, and 12 patients respectively. Before the test results, adjuvant chemoendocrine therapy (CET) was recommended for 46 patients while 54 were advised for endocrine therapy (ET). After getting the test results, 25 patients received CET (1, 12, and12 patients in the low-, intermediate-, and high-risk groups respectively) and 75 received ET. Treatment change was documented in 37 patients (8 patients from ET to CET and 29 from CET to ET; p = 0.001, McNemar test). Treatment change was significant among patients ≤ 50 years, luminal B tumors, stage II and IIIA disease, and node-positive disease.ConclusionOncotype DX testing resulted in significant changes in the adjuvant treatment decisions in ER-positive, HER2-negative early breast cancer particularly in the case of young, luminal B, N1, and stage II–IIIA disease.

Childhood leukaemia incidence and trends in a Middle Eastern country during 1980–2014: a population-based study

This retrospective cohort study examines the trends in childhood leukaemia age-standardized incidence rates (ASIRs) (per million person-years) using cases which were diagnosed at age 0-19years from 1980 to 2014 and recorded in the Kuwait Cancer Control Center (KCCC) registry. Childhood leukaemia age-specific incidence rates overall and by sub-cohorts defined by age (0-4, 5-9, 10-14, and 15-19years), sex (male, female) and nationality (Kuwaiti, non-Kuwaiti) were computed and age-standardized. Joinpoint regression models were used to evaluate trends in childhood leukaemia ASIRs. Average annual percent change (AAPC) and its 95% confidence interval (CI) were used to interpret the observed trends. During the study period, 1077 childhood leukaemia cases of 32.3 million person-years were diagnosed. From 1980 to 2014, the average annual childhood leukaemia ASIR was 53.1 (95% CI 20.9, 85.2). Overall childhood leukaemia ASIRs significantly decreased on average by 6.8% per year (AAPC = -6.8; 95% CI -12.1, -1.1; p = 0.02) from 1980 to 1993, but a marginally significant increase in ASIRs from 1993 to 2014 was recorded (AAPC = 2.5; 95% CI -0.5, 5.5; p = 0.10). During the entire period, childhood leukaemia ASIRs trends significantly (p < 0.05) increased among 6 of 16 sub-cohorts, which was more pronounced among females and 10-14-year-old children. Overall, ASIRs significantly increased from 1993 to 2014, which specifically seems to be driven by an increase in ASIRs among females and 10-14-year-old children. These increasing trends underscore the potential involvement of a range of exposures. Future studies on unravelling such factors may help develop preventive measures to minimize childhood leukaemia risk in this and similar settings in the region.

Presentation and Outcomes of Hepatocellular Carcinoma in the Arabian Peninsula: A Review of a Single Institution Experience in the Sorafenib Era.

There is a growing evidence showing that there are geographic differences in hepatocellular carcinoma (HCC). Little is known about the characteristics of hepatocellular carcinoma in the Arabian Peninsula. The present study examines the presentation and outcomes of HCC in a single institution. A retrospective chart review of patients presented with advanced-stage HCC to Kuwait Cancer Control Center (KCCC) between 2008 and 2018 was conducted. Data collected included patients demographics, HCC risk factors, performance status, Child-Pugh score, pick up of sorafenib, and survival. About 111 cases were analyzed. The mean age of the cohort was 61.8 ± 11.4 years and 94 patients (84.7%) were males. HCV and diabetes were the most common risk factors for HCC and presented in 60 patients (54.1%) and 45 patients (40.5%), respectively. About 78 (70.3%) patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1 at presentation. Only 29 (26.1%) patients presented with Child-Pugh class A, while 42 (40.4%) patients received sorafenib. The median overall survival was only 3 months. In our cohort, HCV and diabetes were the main risk factors for HCC. The majority of patients was not amenable to sorafenib treatment and carries a very poor prognosis.

Profile of Myeloproliferative Neoplasms in Kuwait: Population-Based Study

Introduction Myeloproliferative neoplasms (MPNs) are a group of hematopoietic disorders of stem-cell origin, characterized by mutations that disrupt hematopoietic signal-transduction pathways. The Middle East lacks an MPN registry representative of the disease in our area. Here we report on the epidemiology of these neoplasms in our area, including phenotype, clinical features and relevant outcomes. Methods This population-based study reports various demographic characteristics and clinical attributes of all suspected and confirmed MPN patients from all over Kuwait referred to the research hematology lab at Kuwait University &amp; cytogenetic lab in Kuwait Cancer Control Centre (KCCC) during the period from 2007 to 2018. Molecular determination of the patients' driver mutation status currently relies on ARMS-PCR. Confirming a diagnosis follows the WHO criteria, and its refinements, for the diagnosis of MPNs. Data entry and analysis was performed using SPSS (v.22) software. Results Most patients are ≥ 40 years old (79.8%), with a median age of 55 years. Gender distribution is almost equal, with ethnic categorization as Kuwaiti and Non-Kuwaiti showing a similar pattern. ET is the most common diagnosis (40.1%), followed by PRV (32.3%). JAK2 V617F mutation is reported positive in 89.7% of cases, followed by CALR in 8.0% of MPNs. The incidence of MPNs ranged from 0.5 to 2.1 per 100,000 in 2007 through 2018. The lowest rate was recorded in 2007 (0.511) and the highest was observed in 2011 and 2016 (2.417 and 2.101, respectively). The increase in 2011 is likely due to the introduction of a more sensitive technique using ARMS-PCR for the diagnosis of MPNs, whereas the increase in 2017 may be explained by the publication of WHO 2016 modified criteria. Moreover, throughout the years, the distribution of MPNs in different age groups showed similar pattern, with the highest incidence in patients aged ≥ 60. Driver mutations can fit with a general increase in incidence from 2007-2017, which may be attributed to increased awareness among treating physicians asking suspected cases to screen for MPNs using molecular techniques.One hundred and twenty-four (18.5%) cases were documented to have a prior history of thrombosis, with roughly equal distribution between arterial and venous sites. A large proportion (89.5%) of the thrombotic events occurred in those who are ≥ 40 years old, with most events being associated with ET (34.7%) and PRV (33.1%). Almost one-third of cases of thrombosis were associated with undetermined MPN diagnosis. Participating patients were categorized as either low or high risk for thrombotic events, with the latter being defined as age ≥ 55 years and the presence of a previous thrombotic event. The results demonstrate that a total of 46 cases were defined as high risk, most of them being associated with ET (20 cases) and PRV (19 cases). A statistically significant association was reported between gender and site of occurrence of thrombotic events, with males having more arterial thromboses, and females were documented to have more venous thromboses. Conclusion JAK2 V617F driver mutation is the most common positive finding in the participating patients. Roughly one-fifth of the participants encountered thrombotic events, and the site of thrombosis is associated with gender, demonstrating statistical significance. These results should warrant a more thorough evaluation of MPNs in Kuwait to provide a better understanding of its epidemiology. This can be achieved through optimized documentation of patients' data, and testing for additional novel driver mutations and transformation; as well as encourage physicians in primary care centers to refer suspected cases for molecular diagnosis. Disclosures No relevant conflicts of interest to declare.