Conventional centrally inserted central venous catheters (C-CVCs) are still frequently used to deliver chemotherapy in patients with hematological malignancies in resource-limited settings despite their increased risk of infection. Evidence supporting the use of peripherally inserted central catheters (PICCs) in Latin America remains limited. We therefore compared the safety and effectiveness of PICCs versus conventional centrally inserted central venous catheters (C-CVCs) in a Latin American setting. We performed a prospective cohort study including 92 adult patients with hematological malignancies who required central venous access at a single academic center in Lima, Peru, between June 2018 and March 2019. Patients received either PICCs (n=42) or C-CVCs (n=50). Outcomes included catheter-related bloodstream infection (CRBSI) incidence, catheter-related mortality, and catheter longevity. Despite differences in sex and underlying diseases between groups, PICCs were associated with a significantly lower CRBSI incidence compared with C-CVCs (3.4 vs. 14.0 per 1,000 catheter-days; adjusted incidence rate ratios [IRR] 0.38, 95% confidence intervals [CI] 0.15–0.94). Median catheter duration was longer with PICCs (43 vs. 24 days, p<0.001). PICCs were safely used in patients with severe thrombocytopenia. Thirty-day catheter-related mortality was lower in the PICC group (4.9% vs. 15.9%, p=0.01). PICCs were associated with lower CRBSI incidence, longer catheter duration, and lower catheter-related mortality. These findings support PICC implementation as a safe and effective alternative to C-CVCs in resource-constrained settings.

Background: Vascular resection and reconstruction during pancreatic surgery has become increasingly common in high-volume centers. However, the impact of intraoperative vascular events and complex venous reconstructions on severe morbidity remains understudied. Methods: We conducted a retrospective cohort study including 77 patients who underwent pancreatic resection with vascular reconstruction at a high-volume tertiary care center between January 2010 and December 2024. Perioperative factors were evaluated through univariate and multivariate analyses. Results: Intraoperative events occurred in 25 % of the patients; severe morbidity (≥ IIIb according to the Clavien–Dindo classification) was observed in 31 %, and the mortality rate was 3.9 %. Severe morbidity was significantly influenced by intraoperative events (OR=4.3, 95 % CI 1.3–14.6, p = 0.016) and type 4 venous reconstruction (OR=12.7, 95 % CI 1.5–280, p = 0.037). Despite the increasing proportion of type 3 and type 4 venous reconstructions performed over the years, the rates of severe morbidity have remained stable. A notable improvement in the R0 resection rate for pancreatic ductal adenocarcinoma was observed after 2019, with a significant shift toward more complex venous reconstructions. Conclusion: Intraoperative events and type 4 venous reconstruction significantly increase the risk of severe morbidity in pancreatic surgery. These findings underscore the importance of surgical planning, expertise in vascular procedures, and multidisciplinary care to improve outcomes.

Purpose We provide for the first time a comprehensive situational diagnosis and propose an artificial intelligence (AI)-assisted nationwide plan of implementation, attending the most urgent needs. Methods Baseline information was collected from open-source databases of the Peruvian Government. Data on cancer incidence from the Health Authorities and GLOBOCAN were collected and compared. The existing external-beam radiotherapy (EBRT) devices and brachytherapy (BT) units were identified and information on their obsolescence was additionally collected. The ten most common cancer entities with RT indication were considered for the analysis. Utilizing open-source softwares, population clusters based on density, cancer incidence, geographic distribution, existing facilities able to be implemented with radiotherapy and travel times for patients were defined. A coding for identifying the best possible locations with AI was developed, keeping the allocation of resources to the minimum possible. A projection until 2030 on required resources was additionally elaborated. Results As of 2023 eight additional EBRT and seven BT devices were needed to cover the existing demand. The artificial-intelligence algorithm yielded the regions where these resources should be primarily allocated. An increase in demand of approximately 22% is expected until 2030, which translates into additional 23 EBRT and 16 BT devices, considering the replacement of obsolete units until then. Conclusion Increased investment pace is required to cover the existing RT demand in Peru. This AI-assisted analysis might help prioritize allocation of resources. The code employed in this work will be made publicly available, so this method could be replicated in other developing economies.

Purpose: This study aimed to identify the predictive factors of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) and to evaluate the applicability of the Japanese treatment guidelines for endoscopic resection in the western population. Methods: Five hundred-one patients with pathological diagnoses of EGC were included. Univariate and multivariate analyses were conducted to identify the predictive factors of LNM. EGC patients were distributed according to the indications for endoscopic resection of the Eastern guidelines. The incidence of LNM was evaluated in each group. Results: From 501 patients with EGC, 96 (19.2%) presented LNM. In 279 patients with tumors with submucosal infiltration (T1b), 83 (30%) patients had LNM. Among 219 patients who presented tumors > 3 cm, 63 (29%) patients had LNM. Thirty-one percent of patients with ulcerated tumors presented LMN (33 out of 105). In 76 patients and 24 patients with lymphovascular and perineural invasion, the percentage of LMN was 84% and 87%, respectively. In the multivariate analysis, a tumor diameter >3 cm, submucosal invasion, lymphovascular, and perineural invasion were independent predictors of LMN in EGC. No patient with differentiated, non-ulcerated mucosal tumors presented LNM regardless of tumor size. Three of 17 patients (18%) with differentiated, ulcerated mucosal tumors and < 3 cm presented LNM. No LNM was evidenced in patients with undifferentiated mucosal tumors and < 2 cm. Conclusions: The presence of LNM in Western EGC patients was independently related to larger tumors (>3 cm), submucosal invasion, lymphovascular and perineural invasion. The Japanese absolute indications for EMR are safe in the Western population. Likewise, Western patients with differentiated, non-ulcerated mucosal tumors, and larger than 2 cm are susceptible to endoscopic resection. Patients with undifferentiated mucosal tumors smaller than 2 cm presented encouraging results and ESD could be recommended only for selected cases.

OBJECTIVE:The study aimed to describe and compare minimally invasive surgery (MIS) and open surgery for rectal cancer in Peru.MATERIAL AND METHODS:A retrospective single-center analysis was performed for all patients who underwent sphinctersparing surgery for non-metastatic rectal cancer at Instituto Nacional de Enfermedades Neoplásicas in Peru between January 2016 and December 2020. Clinical, perioperative, pathological, and survival outcomes were compared between both groups. A propensity score matching method was used to minimize bias.RESULTS:162 patients were included in the final analysis. 124 had open surgery and 38 had MIS. Patients, clinical tumour, pathological characteristics, and perioperative were similar between groups after matching. Similar circumferential resection margin (CRM) with optimal quality of the mesorectum (p=1.000) but higher number of lymph nodes resected in open surgery group (p=0.741) was described. The leakage rate was slightly higher in the MIS group (p=0.358) with 10.5%, while the postoperative hospital stay was longer in the open surgery group after matching (p=0.001; OR 95% 5.2 CI: 1.8-15.6). The estimated recurrence-free survival (RFS) and overall survival (OS) at 3 years in open surgery and MIS was 71.8% (95% CI; 0.58-0.89) and 70% (95% CI; 0.56-0.88) (p=0.431) and 77.7% (95% CI; 0.64-0.94) and 88.9% (95% CI; 0.79-0.99) (p=0.5), respectively.CONCLUSIONS:Shorter postoperative hospital stay in the minimally invasive surgery group was reported. RFS, OS, and recurrence rates were similar between both groups. This approach is for non-metastatic rectal cancer in referral centers in Peru.

Purpose: The aim of this study is to evaluate the oncological care during the first state of national emergency due to the COVID-19 pandemic in several public cancer hospitals in Peru. Materials and Methods: A multicentric cross-sectional descriptive study was conducted by interviewing adult cancer patients diagnosed and treated between January 2019 and February 2020 from 18 hospitals. This study was carried out in September 2020, the last month of the first state of national emergency. Demographic and clinical characteristics were evaluated, including COVID-19 status and cancer treatment features. Results: A total of 1472 patients were included; the median age was 55 years (range 19-97). Most patients (85.8%, n = 1263) had solid neoplasia, 13.5% (n = 198) hematologic neoplasia, and 0.7% (n = 11) others. SARS-CoV-2 infection was confirmed in 8.6% (n = 126), 1.2% (n = 18) were probable, 1.6% (n = 24) suspected, and 88.6% (n = 1304) negative cases. Overall, 51.6% of patients (n = 759) had cancer treatment delays, 42.5% (n = 626) changed treatment delivery (endovenous to oral systemic therapy), and 12.6% (n = 185) of cases cancer therapy was discontinued. In total, 10.3% (n = 117) of patients whose disease was controlled or in remission, experienced progression of disease during the state of emergency. A total of 6.7% (n = 98) of patients died, of whom 73.5% (n = 72) died from disease progression; 18.4% (n = 18) from SARS-CoV-2 infection and 8.1% (n = 8) from undetermined causes. Patients with hematological malignancies [hazard ratio (HR): 5.11 (95% confidence interval (CI): 1.99-13.07)] and no response to therapy before the onset of the pandemic [5.01 (1.44-17.42)] had an increased risk of death among COVID-19 infected individuals, whereas advanced clinical stage [5.09 (2.37-10.95)] and discontinuation of treatment [3.66 (1.97-6.78)] were risk factors among non-COVID-19 patients. Conclusion: Our study suggests that the COVID-19 pandemic has an adverse impact on the outcomes of Peruvian cancer patients. In our cohort, cancer mortality was higher than COVID-19 disease mortality.

Abstract Purpose This study aimed to identify the clinicopathological factors associated with the presence of lymph node metastasis (LNM) in patients diagnosed with early gastric cancer (EGC) and treated with radical gastrectomy. Methods Patients who underwent radical gastrectomy for gastric cancer from January 1990 to December 2019 were identified from a prospectively compiled database.Patients with pathological diagnoses of EGC were included. Univariate and multivariate analyses were conducted to identify risk factors associated with LNM. Results From 501 patients with EGC, 96(19.2%) presented LNM.In 279 patients with tumors with submucosal infiltration(T1b), 83(30%) patients had LNM. Among 219 patients who presented tumors > 3cm, 63(29%) patients had LNM. Thirty-one percent of patients with ulcerated tumors presented LMN(33 out of 105). In 76 patients and 24 patients with lymphovascular and perineural invasion, the percentage of LMN was 84% and 87%,respectively. In the univariate analysis, tumor diameter > 3cm, undifferentiated tumors, ulcerated tumors, submucosal invasion, lymphovascular, and perineural invasion showed a significant association with the presence of LNM.In the multivariate analysis, a tumor size > 3cm, submucosal invasion, lymphovascular, and perineural invasion were independent predictors of LMN in EGC. Patients who presented differentiated tumors, without ulceration, infiltration of the mucosa, and a tumor diameter ≤ 2cm, none presented LNM. Four patients(3%) who complied with the new Japanese indications for endoscopic treatment presented LNM. Conclusions The presence of lymph node metastasis in patients with EGC was independently related to larger tumors (tumor diameter > 3cm), submucosal invasion, lymphovascular and perineural invasion.

Background: Gastric cancer (GC) is the fourth most common cause of cancer deaths around the world and the first cause of cancer deaths in Peru; however, there are no prospective trials for adjuvant chemotherapy in GC after curative gastrectomy in this country. The objective of this study was to evaluate the effectiveness of adjuvant chemotherapy in stage II-III gastric cancer patients who underwent D2 gastrectomy. Methods: We included patients with stage II-III gastric cancer who underwent radical gastrectomy and D2 dissection between 2014 and 2016 at our institution. Patients received 3-week cycles of capecitabine (1,000 mg/m(2) twice daily on days 1-14) plus oxaliplatin (130 mg/m(2) on day 1) for 6 months. Survival curves were estimated with the Kaplan-Meier method, and the Cox proportional hazards model was used to identify prognostic factors for survival. Results: In total, 173 patients were included: 100 (57.8%) patients received adjuvant chemotherapy and surgery (AChS) and 73 (42.2%) surgery alone (SA). Three-year disease-free survival (DFS) was higher in the AChS groups (69%) than in the SA group (52.6%) (p = 0.034). Regarding overall survival (OS), 31 patients (31%) died in the AChS group compared with 34 (46.6%) in the SA group (p = 0.027). In the multivariate analysis, adjuvant chemotherapy was an independent prognostic factor for DFS (HR = 0.60; 95% CI = 0.37-0.97; p = 0.036) and OS (HR = 0.58; 95% CI = 0.36-0.95; p = 0.029). ACh showed consistent benefit in DFS and OS for patients with albumin >3.5 g/dL, lymphovascular and perineural invasion, pT4, pN2-3, pathologic stage (PS) IIIA and IIIB and lymph node ratio (LNR) > 13.1. Conclusion: These data suggest that adjuvant capecitabine and oxaliplatin reduce the recurrence and mortality in patients with stage II-III gastric cancer who underwent D2 gastrectomy. PS IIIA and IIIB and LNR > 13.1 benefited more from receiving adjuvant chemotherapy and poorly cohesive gastric carcinoma did not significantly reduce the rates of survival.

BACKGROUND:Ampullary adenocarcinoma (AAC) is a rare neoplasm that accounts for only 0.2% of all gastrointestinal cancers. Its incidence rate is lower than 6 cases per million people. Different prognostic factors have been described for AAC and are associated with a wide range of survival rates. However, these studies have been exclusively conducted in patients originating from Asian, European, and North American countries.AIM:To evaluate the histopathologic predictors of overall survival (OS) in South American patients with AAC treated with curative pancreaticoduodenectomy (PD).METHODS:We analyzed retrospective data from 83 AAC patients who underwent curative (R0) PD at the National Cancer Institute of Peru between January 2010 and October 2020 to identify histopathologic predictors of OS.RESULTS:Sixty-nine percent of patients had developed intestinal-type AAC (69%), 23% had pancreatobiliary-type AAC, and 8% had other subtypes. Forty-one percent of patients were classified as Stage I, according to the AJCC 8th Edition. Recurrence occurred primarily in the liver (n = 8), peritoneum (n = 4), and lung (n = 4). Statistical analyses indicated that T3 tumour stage [hazard ratio (HR) of 6.4, 95% confidence interval (CI) of 2.5-16.3, P < 0.001], lymph node metastasis (HR: 4.5, 95%CI: 1.8-11.3, P = 0.001), and pancreatobiliary type (HR: 2.7, 95%CI: 1.2-6.2, P = 0.025) were independent predictors of OS.CONCLUSION:Extended tumour stage (T3), pancreatobiliary type, and positive lymph node metastasis represent independent predictors of a lower OS rate in South American AAC patients who underwent curative PD.

Background: This study aims to determine the presence of tumor deposits in the mesogastrium of patients who underwent radical D2 gastrectomy with en bloc CME. Methods: Thirteen consecutive gastric cancer patients who underwent radical gastrectomy with D2 dissection and CME at the Abdominal Surgical Department of the National Cancer Institute INEN (Lima, Peru) between March and April 2019 were prospectively incorporated. The presence of TDs was investigated and clinicopathological data were compared between positive TDs patients and negative TDs patients. Results: Thirteen patients entered the study, 10 of these patients were women, and 3 were male. The mean age of 56.3 years. Tumors were located at the middle third in 7 patients, at the distal third in 6 patients. Seven patients were diagnosed with diffuse-type and 6 patients with intestinal-type according to Lauren’s Classification. The mean tumor size was 4.51cm (range :1.9cm-8cm). Patients were staged by the AJCC TNM 8th Edition staging system, T4a (5 patients), T3 (5 patients), T1a (2 patients), and T1b (1 patient). Tumor deposits were found in 4 of 13 patients (30.7%). TDs were evidenced in locally advanced patients (pT3a and pT4a), 3 patients with lymphatic metastasis (pN1 and pN2), and in 1 patient without lymphatic metastasis (pN0). Conclusions: In the present study is demonstrated that tumor deposits are present in surgical specimens of gastric cancer patients who underwent D2 Radical Gastrectomy associated with CME, the presence of tumor deposits is not exclusive of patients with nodal metastasis. Further studies are necessary to evaluate the importance of the presence of TDs in long-term survival. Keywords: Complete mesogastrium excision (CME); Gastric Cancer; Tumor Deposit (TD).

Background Cancer patients are at higher risk of infection and severity of Coronavirus Disease-19 (COVID-19). Management of patients infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is challenging due to the scarce scientific information and treatment guidelines. In this work, we present our Institutional experience with our first 100 patients with oncological malignancies and COVID-19. Patients and methods We conducted a cross-sectional study of the first 100 patients hospitalised at the Instituto Nacional de Enfermedades Neoplasicas (Lima, Peru) who were positive for SARS-CoV-2 by reverse transcriptase (RT)-PCR during the period 30 March to 20 June. Clinicopathological variables of the oncological disease as well as risk factors, management and outcomes to COVID-19 were evaluated. Results The mean age was 43.5 years old (standard deviations: ±24.8) where 57% were male patients. In total, 44%, 37% and 19% were adult patients bearing solid tumours, adults with haematologic malignancies and paediatric patients, respectively. Hypertension was the most frequent comorbidity (23%) followed by chronic lung disease (10%). COVID-19-associated symptoms included cough (65%), fever (57%) and dyspnoea (56%). Twelve percent of patients were asymptomatic. Nosocomial infections were more frequent in paediatric patients (84.2%) than in adult patients (16.0%). Patients with uncontrolled oncological disease were most frequent (72%). Anaemia was present in 67% of patients, 68% had lymphopenia, 62% had ferritin value > 500 mcg/L, 85% had elevated lactate dehydrogenase (LDH), 83% D-dimer > 500 ng/mL and 80% C-Reactive Protein > 8 mg/L. The most common complication was acute respiratory failure (42%). Overall fatality rate was 39% where the main cause of mortality was acute respiratory distress syndrome (64.1%). Conclusion Paediatric patients had better outcomes than adult populations, and a high number of asymptomatic carriers and nosocomial infection, early diagnosis are recommended. Considering oncological treatments 30 days before COVID-19 diagnosis, our data did not reveal an increased mortality.

Abstract Purpose Solid pseudopapillary neoplasm (SPN) is an uncommon pathology with a low-grade malignancy. Surgery is the milestone treatment. Nevertheless, despite appropriate management, some patients present recurrence. Risk factors associated with recurrence are unclear. The objective was to identify the clinicopathological factors associated with recurrence in patients with SPN treated with pancreatic resection. Methods Medical records of patients treated with pancreatic resection during 2006–2020 were evaluated. Patients with histological diagnosis of SPN were included. Survival analysis was performed to identify the clinicopathological factors related to recurrence. Results Seventy-four patients were diagnosed with SPN; 70 (94.6%) patients were female, and the median age was 20 years old. The median tumor diameter was 7.9 cm. Multivisceral resection was performed in 9 (12.2%) patients. Four (5.4%) patients presented lymph node metastasis.R0 resection was achieved in all cases. Six (8%) patients presented recurrence and the liver was the most frequent recurrence site (n = 5).After a median follow-up of 40.2 months, 9 (12%) patients died. Five (6.8%) patients died of disease progression. The 1–3- and 5-year overall survival (OS) was 97.1%, 90.2% and 79.9%, respectively. The 1–3-and-5-year recurrence-free survival (RFS) was 98.4%, 89.9% and 87%, respectively. In the univariate Cox-regression analysis, age ≥ 28 years(HR = 8.61, 95% CI 1.1–73.8),tumor diameter ≥ 10 cm(HR = 9.3, 95% CI 1.12–79.6),invasion of adjacent organs (HR = 7.45, 95% CI 1.5–36.9), lymph node metastasis (pN +) (HR = 16.8, 95% CI 2.96–94.9) and, AJCC Stage III (HR = 10.1, 95% CI 1.2–90.9) were identified as predictors for recurrence. Conclusions SPN is more frequently diagnosed in young women with a good overall prognosis after an R0 surgical resection even with disease recurrence. Age ≥ 28 years, larger tumors ≥ 10 cm, invasion of adjacent organs, lymph node metastasis(pN +) and, AJCC Stage III were predictors factors of recurrence in resected SPN.

Pancreas tumors are extremely rare in pediatric and adolescent patients. Surgical resection is the mainstay of treatment; however, the data are limited with respect to morbidity and mortality. We aimed to evaluate short- and long-term outcomes of pediatric and adolescent patients who underwent surgical resection of pancreatic tumors. Patients $$\le$$ 18-year-olds who underwent resection of pancreas tumor at the National Institute of Neoplastic Diseases INEN during 2000–2020 were included. Thirty-four patients were diagnosed; 28 patients were female and 6 were male. The median age was 13.4-years-old. Histological diagnosis was solid pseudopapillary neoplasm (SPN) (n = 29, 85.3%), pancreatoblastoma (n = 3), neuroendocrine carcinoma (n = 1), and insulinoma (n = 1). No patient experienced postoperative mortality and 15 (44.1%) patients developed postoperative complications including pancreatic fistula as the most frequent. Under a median follow-up period of 33.8 (0.5–138) months, four (11.8%) patients died. Of the 29 patients with SPN, the 3- and-5-year OS rates were 100% and 83.1%, respectively. SPN was the most frequent cause of surgical treatment for pediatric and adolescent patients in the high-volume cancer center in Peru and was associated with favorable survival. Pancreaticoduodenectomy was safely performed in this patient group with acceptable morbidity and zero mortality.

Peru is a South American nation with a growing and aging population of 31 million people with a life expectancy at birth of 76.7 years. The country is divided into 25 regions, 79% of the population is urban, and Lima, the capital, concentrates more than a third of the population.1Instituto Nacional de Estadística e InformáticaPerú: perfil sociodemográfico. Informe nacional. Censos Nacionales 2017. Lima 2018.https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdfDate accessed: December 1, 2019Google Scholar Although Peru is an upper-middle-income country, health expenditure represents only 5.1% of the gross domestic product, which is lower than the average of Latin America and the Caribbean (LATAM) (8.56%).2The World BankData. 2019.https://data.worldbank.org/indicator/NY.GDP.MKTP.CDDate accessed: December 1, 2019Google Scholar Out-of-pocket health expenditure is 30.9%.3Falconi DP, Bernabé E. Determinants of catastrophic healthcare expenditure in Peru [e-pub ahead of print]. Int J Health Econ Manag. https://doi.org/10.1007/s10754-018-9245-0. Accessed February 28, 2020.Google Scholar Peru has a comprehensive National Cancer Plan and two population-based cancer registries in Lima and Arequipa. The Peruvian health care system is fragmented into public and private sectors, leading to considerable disparities. The public sector is further divided into a subsidized regimen and a contributory regimen. Within the subsidized regimen, the provision of health services is covered by Seguro Integral de Salud (SIS) in the network of establishments, hospitals, and institutes of the Ministry of Health (MOH), including the Peruvian National Cancer Institute (INEN) and the two regional cancer institutes. The contributory regimen corresponds to the social security system (EsSalud) that provides services in its own establishments for the salaried population and their families. The private sector is composed of multiple private insurers, private clinics, and medical centers and offers services for the population with capacity to pay. Overall, SIS and the social security cover 44% and 25% of the population, respectively, whereas only 5% of the population has a private insurance.1Instituto Nacional de Estadística e InformáticaPerú: perfil sociodemográfico. Informe nacional. Censos Nacionales 2017. Lima 2018.https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdfDate accessed: December 1, 2019Google Scholar However, this general overview covers marked national variation. The rural population is affiliated to SIS and the social security in 76% and 6%, respectively. In contrast, whereas 10% of Lima’s population has a private insurance, those affiliated to this type of insurance do not reach 5% in 21 of 25 regions.4Instituto Nacional de Estadística e InformáticaPoblación afiliada a algún seguro de salud. Sobre la base de los Censos Nacionales 2017. Lima 2018.https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1587/libro01.pdfDate accessed: December 27, 2019Google Scholar Recently, the government made a great step toward universal health insurance, as it authorized the affiliation of all persons without any health insurance who reside in Peruvian territories to SIS, regardless of their socioeconomic status.5Decreto de urgencia Nº 017-2019: Decreto de urgencia que establece medidas para la cobertura universal de saludLima, Peru: Diario Oficial El Peruano; 2019.https://cdn.www.gob.pe/uploads/document/file/431389/1831446-1.pdfDate accessed: March 1, 2020Google Scholar Lung cancer is the sixth most common cancer and the second cause of cancer deaths in Peru. According to Globocan statistics, 3210 new cases and 2844 deaths were projected in 2018, with standardized incidence and mortality rates of 9.5 and 8.9, respectively, and a mortality-incidence ratio of 0.93. Lung cancer incidence in Peru is lower than the LATAM average.6Ferlay J. EM LF Colombet M. et al.Cancer today Lyon, France: International Agency for Research on Cancer; 2018.https://gco.iarc.fr/todayDate accessed: December 1, 2019Google Scholar A nationwide health information system (REUNIS-MINSA) now provides visual data on several diseases, including lung cancer mortality rates by regions, showing significant differences across the board and ranging from 2.7 to 17.5 per 100,000 inhabitants (Fig. 1). The regions with the highest mortality are Callao, Lima, and Arequipa,7Ministerio de Salud, REUNISRepositorio único nacional de información en salud. Lima 2015.https://www.minsa.gob.pe/reunis/Date accessed: December 14, 2019Google Scholar and this distribution has been maintained since 2005.8Flores C.J. Torres-Roman J.S. Mas L. et al.Spatio-temporal distribution of lung cancer mortality rate in Peru: 2005-2014.J Clin Oncol. 2017; 35e20081Crossref Google Scholar According to the Metropolitan Lima Cancer Registry (2010–2012),9Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades NeoplásicasRegistro de cáncer de Lima metropolitana. Incidencia y mortalidad 2010–2012. Lima, Peru; 2016.http://www.inen.sld.pe/portal/documentos/pdf/banners_2014/2016/Registro%20de%20C%C3%A1ncer%20Lima%20Metropolitana%202010%20-%202012_02092016.pdfDate accessed: December 13, 2019Google Scholar lung cancer has a standardized incidence rate of 11.2 (13.3 in males and 9.6 in females) and a standardized mortality rate of 9.2 (11.0 in males and 7.8 in females). Most cases (75%) occurred in people older than 60 years. Lung cancer in patients younger than 40 years represents 4.3% of all cases as presented in a recent series.10Galvez-Nino M, Ruiz R, Pinto JA. Lung Cancer in the Young [e-pub ahead of print]. Lung. https://doi.org/10.1007/s00408-019-00294-5. Accessed February 28, 2020.Google Scholar Data from Metropolitan Lima Cancer Registry indicate as well that from 1968 to 2012, lung cancer incidence has decreased in men and increased in women (Fig. 2),9Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades NeoplásicasRegistro de cáncer de Lima metropolitana. Incidencia y mortalidad 2010–2012. Lima, Peru; 2016.http://www.inen.sld.pe/portal/documentos/pdf/banners_2014/2016/Registro%20de%20C%C3%A1ncer%20Lima%20Metropolitana%202010%20-%202012_02092016.pdfDate accessed: December 13, 2019Google Scholar although the absolute number of cases is increasing because of population growth and aging. Data on mortality, corresponding to a shorter period (1990–2012), indicate a nonsteady decrease for men and an increase for women. In Lima, standardized lung cancer incidence varies greatly among districts, ranging from 6.34 to 35.97 in the male population and from 5.47 to 21.66 in the female population. When comparing two periods, 2004 to 200511Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades NeoplásicasRegistro de cáncer de Lima metropolitana. Incidencia y mortalidad 2004–2005. Lima2014.http://www.inen.sld.pe/portal/documentos/pdf/banners_2014/Febrero/25022014_Libro_RCLM_CD.pdfDate accessed: December 13, 2019Google Scholar versus 2010 to 2012,9Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades NeoplásicasRegistro de cáncer de Lima metropolitana. Incidencia y mortalidad 2010–2012. Lima, Peru; 2016.http://www.inen.sld.pe/portal/documentos/pdf/banners_2014/2016/Registro%20de%20C%C3%A1ncer%20Lima%20Metropolitana%202010%20-%202012_02092016.pdfDate accessed: December 13, 2019Google Scholar it was found that incidence has increased, especially in women; four and eight of 49 districts entered the highest tier of incidence in men and women, respectively (Fig. 3).Figure 3Incidence rate per districts in Lima. Reprinted with permission from Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades Neoplásicas.9Departamento de Epidemiología y Estadística del Cáncer. Instituto Nacional de Enfermedades NeoplásicasRegistro de cáncer de Lima metropolitana. Incidencia y mortalidad 2010–2012. Lima, Peru; 2016.http://www.inen.sld.pe/portal/documentos/pdf/banners_2014/2016/Registro%20de%20C%C3%A1ncer%20Lima%20Metropolitana%202010%20-%202012_02092016.pdfDate accessed: December 13, 2019Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) The prevalence of tobacco use in adults in Peru has more than halved from 27% in 200012Pinillos L. Quesquén M. Bautista F. Poquioma E. Tabaquismo: un problema de salud pública en el Perú.Rev Peruana Med Exp Salud Publ. 2005; 22: 64-70Google Scholar to 13.3% in 2010—19.7% in men and 7.8% in women.13Organización Panamericana de la Salud. Informe sobre Control del Tabaco en la Región de las Américas. A 10 años del Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco. Washington, DC: Organización Panamericana de la Salud; 2016. https://iris.paho.org/bitstream/handle/10665.2/28380/9789275318867_spa.pdf?sequence=1&isAllowed=y. Accessed December 2, 2019.Google Scholar This is lower than the current prevalence of smokers in the LATAM region, which has also decreased from 28% in 2000 to 17.4% in 2015.14Organización Panamericana de la SaludDisminuye el consumo de tabaco, pero se debe hacer más para proteger a las personas y reducir las muertes por enfermedades cardíacas que generan fumar y la exposición a su humo.https://www.paho.org/per/index.php?option=com_content&view=article&id=4044:disminuye-el-consumo-de-tabaco-pero-se-debe-hacer-mas-para-proteger-a-las-personas-y-reducir-las-muertes-por-enfermedades-cardiacas-que-generan-fumar-y-la-exposicion-a-su-humo&Itemid=1062Date accessed: December 2, 2019Google Scholar Likewise, current cigarette and tobacco smoking among youth (aged 13–15 y) has decreased from 19.4% in 2007 to 9.7% in 2014.15World Health Organization Regional Office for South-East Asia Global Youth Tobacco Survey (GYTS) 2014: Indonesia Factsheet. WHO Regional Office for South-East Asia, 2015https://apps.who.int/iris/handle/10665/205147Date accessed: March 2, 2020Google Scholar These results suggest that tobacco control policies as outlined in the following are having a progressive impact. Peru ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) in November 2004,16Organización Mundial de la Salud Convenio Marco de la OMS para el Control del Tabaco. OMS, Geneva, Switzerland2003https://goo.gl/P3O9LzDate accessed: March 2, 2020Google Scholar,17Decreto Supremo Nº 054-2004-RE: Decreto Supremo que ratifica el “Convenio marco de la OMS para el control de Tabaco” Diario Oficial El Peruano, Lima, Peru2004https://es.scribd.com/document/362228977/Decreto-Supremo-054-2004-REDate accessed: March 1, 2020Google Scholar and enforced it in 2005. Significant progress has been made in adhering to the framework through the endorsement of laws guaranteeing a 100% smoke-free public environment and regulating tobacco advertising, packaging, and labeling.18Ley 29571: Código de Protección y Defensa del Consumidor Diario Oficial El Peruano, Lima, Peru2010https://www.indecopi.gob.pe/documents/20195/177451/CodigoDProteccionyDefensaDelConsumidor%5B1%5D.pdf/934ea9ef-fcc9-48b8-9679-3e8e2493354eDate accessed: March 1, 2020Google Scholar, 19Resolución Ministerial N° 469-2011-MINSA: "Normativa Gráfica para el uso y aplicación de las advertencias sanitarias en envases, publicidad de cigarrillos y de otros productos hechos con tabaco" Diario Oficial El Peruano, Lima, Peru2011https://www.gob.pe/institucion/minsa/normas-legales/243544-469-2011-minsaDate accessed: March 1, 2020Google Scholar, 20Ley 29517: Ley que modifica la ley Nº 28705 Ley general para la Prevención y Control de los Riesgos del Consumo del tabaco, para adecuarse al Convenio Marco de la Organización Mundial de la Salud OMS para el Control del tabaco, N° 29517 Diario Oficial El Peruano, Lima, Peru2010https://www.gob.pe/institucion/minsa/normas-legales/245512-29517Date accessed: March 1, 2020Google Scholar In Peru, tobacco advertising within 500 m from a health or education establishment is banned. The amount of nicotine, tar, and monoxide must be disclosed in the cigarette packages, and 50% of both sides of the packages must include graphic and text warnings, which are rotated every 12 months. In addition, the use of the terms “light” or “soft” is prohibited. Importantly, retail sale or sale in packages less than five cigarettes and selling to people under 18 years old is illegal. Nevertheless, there are pending commitments to fully implement the WHO FCTC, to integrate smoking control programs and strategies into a National Tobacco Control Plan, which is still nonexistent, to develop a tobacco cessation program, to take action to avoid interference from the tobacco industry, and to increase taxation further to reduce tobacco demand. In 2018, the tax per pack of cigarettes was increased to 61%, which is the highest recorded in the country.21Decreto Supremo Nº 112-2016-EF: Modifican el Literal B del Nuevo Apéndice IV del Texto Único Ordenado de la Ley del Impuesto General a las Ventas e Impuesto Selectivo al Consumo Diario Oficial El Peruano, Lima, Peru2016https://busquedas.elperuano.pe/normaslegales/modifican-el-literal-b-del-nuevo-apendice-iv-del-texto-unico-decreto-supremo-n-112-2016-ef-1376337-2/Date accessed: March 1, 2020Google Scholar,22Decreto Supremo Nº 092-2018-EF: Modifican el Literal B del Nuevo Apéndice IV del Texto Único Ordenado de la Ley del Impuesto General a las Ventas e Impuesto Selectivo al Consumo Diario Oficial El Peruano, Lima, Peru2018https://busquedas.elperuano.pe/normaslegales/modifican-el-literal-b-del-nuevo-apendice-iv-del-texto-unico-decreto-supremo-n-092-2018-ef-1646369-3/Date accessed: March 1, 2020Google Scholar However, the recommendation of the WHO FCTC is 75%. Under the leadership of the MOH, a multisectoral approach has been used to formulate and implement tobacco control actions. For its part, the Ministry of Education has established prevention programs in the school curriculum to prevent the start of tobacco consumption. Local governments carry out marketing inspections and ensure smoke-free environments. It is worth emphasizing the role of the civil society through Comisión Nacional Permanente de Lucha Antitabáquica, an institution with international support that since 1988 has been promoting and advocating for public policies regarding tobacco control, educating human resources, and verifying compliance with the law. The prevalence of smokers among Peruvian patients with lung cancer in recent series has been reported to range between 20%23Ruiz R. Nino M.G. Perez K.R. et al.16–25 Epidemiology of advanced lung cancer in Peru.J Thorac Oncol. 2019; (P2:14(10):S875)Abstract Full Text Full Text PDF Google Scholar and 42%,24Gutierrez JM, Ruiz R, Araujo J, et al. Características epidemiológicas y sobrevida en pacientes con Cáncer de Pulmón en la Clínica Oncosalud-AUNA 2011-2014. Carcinos, in press.Google Scholar which is very low when compared with what is reported by international series (75%–95%),25Pesch B. Kendzia B. Gustavsson P. et al.Cigarette smoking and lung cancer—relative risk estimates for the major histological types from a pooled analysis of case–control studies.Int J Cancer. 2012; 131: 1210-1219Crossref PubMed Scopus (286) Google Scholar indicating that risk factors beyond tobacco must be considered. In rural areas in Peru, crop residues (1.4%), dung (1.8%), and particularly wood (17.3%) are the most used fuels for cooking.1Instituto Nacional de Estadística e InformáticaPerú: perfil sociodemográfico. Informe nacional. Censos Nacionales 2017. Lima 2018.https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdfDate accessed: December 1, 2019Google Scholar In-house exposure to these fumes increases the risk of respiratory diseases in children (risk ratio [RR] = 2.3, 95% confidence interval [CI], 1.04–5.18) and adult women (RR = 3.2, 95% CI, 1.00–5.59) and of lung cancer also in women (RR = 1.9, 95% CI, 1.1–3.5).26Desai M.A. Mehta S. Smith K.R. Indoor Smoke From Solid Fuels: Assessing the Environmental Burden of Disease at National and Local Levels. World Health Organization, Geneva2004Google Scholar,27Viegi G. Simoni M. Scognamiglio A. et al.Indoor air pollution and airway disease.Int J Tuberc Lung Dis. 2004; 8: 1401-1415PubMed Google Scholar In the country, in 2017, 1,757,409 families (21.3%) cooked by burning biomass as fuel.1Instituto Nacional de Estadística e InformáticaPerú: perfil sociodemográfico. Informe nacional. Censos Nacionales 2017. Lima 2018.https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1539/libro.pdfDate accessed: December 1, 2019Google Scholar To address this issue, the government has developed the National Program of Improved Kitchens28Cooperación Técnico Alemana. Proyecto Energía, Desarrollo y Vida (ENDEV-PERÚ). Manual de capacitación para instalador de cocina mejorada familiar Cooperación Técnica Alemana - GTZ, Lima, Peru2008http://www3.vivienda.gob.pe/dnc/archivos/Estudios_Normalizacion/Manuales_guias/manual-de-cocina-mejorada.pdfDate accessed: March 1, 2020Google Scholar that enhances the cleanliness of the interior environments through efficient combustion and appropriate dimensions of the holes and the chimney. In addition, pollution by particles in environmental air, which reaches a value of 50 μg/m3 in Lima29Gonzales G.F. Zevallos A. Gonzales-Castañeda C. et al.Contaminación ambiental, variabilidad climática y cambio climático: una revisión del impacto en la salud de la población peruana.Rev Peru Med Exp Salud Publica. 2014; 31: 547-556Crossref PubMed Google Scholar (far greater than the WHO recommendation of 10 μg/m3), has been estimated to cause more than 600 cases of lung cancer in Peru yearly.30Zolezzi A. Salud y medio ambiente en el Perú actual.Acta Med Peru. 2017; 34: 79-81Crossref Google Scholar In Peru, there is no population screening test for lung cancer; however, the National Cancer Plan includes the diagnosis and staging of patients with presumptive diagnosis of lung cancer. On a private level, there is an isolated effort using low-dose tomography for high-risk individuals. The implementation of a national low-dose tomography screening program is unfeasible at the moment owing to limitations in funding, infrastructure, expertise, and health system response. Late lung cancer diagnosis is the most common presentation. According to a study from INEN, 9.2% and 85.5% of patients with lung cancer from 2010 to 2014 were diagnosed at stages III and IV, respectively.31Ruiz R. Nino M.G. Cruz Z.M. et al.Epidemiology and survival of lung cancer in a Latin American cohort.J Clin Oncol. 2019; 37e13101Crossref Google Scholar In contrast, in a recent publication from a private center, 20% of patients were diagnosed at stage III and 64% at stage IV during the same period of time.24Gutierrez JM, Ruiz R, Araujo J, et al. Características epidemiológicas y sobrevida en pacientes con Cáncer de Pulmón en la Clínica Oncosalud-AUNA 2011-2014. Carcinos, in press.Google Scholar Regarding pathologic diagnosis, adenocarcinoma is by far the most frequent subtype, accounting for 72% of all lung cancer cases.31Ruiz R. Nino M.G. Cruz Z.M. et al.Epidemiology and survival of lung cancer in a Latin American cohort.J Clin Oncol. 2019; 37e13101Crossref Google Scholar In Peru, there are few laboratories that perform molecular diagnosis, most of them in the private sector. Within the public sector, the detection of EGFR mutations by polymerase chain reaction, ALK rearrangements by fluorescence in situ hybridization, and the assessment of programmed death-ligand 1 by immunohistochemistry are covered through the subsidized and contributory regimens but available only at INEN and at the two higher complexity hospitals of the social security. At INEN, 16% and 36% of the samples for EGFR and ALK assessment, respectively, are insufficient. Liquid biopsy and next-generation sequencing are available only in the private sector. The predominant targetable alteration in Peruvian patients with lung cancer is the EGFR mutation representing between 32% and 39% of cases.24Gutierrez JM, Ruiz R, Araujo J, et al. Características epidemiológicas y sobrevida en pacientes con Cáncer de Pulmón en la Clínica Oncosalud-AUNA 2011-2014. Carcinos, in press.Google Scholar,32Mas L. Piscocha C. Landa J. et al.Prevalence of EGFR mutations in the Peruvian population: study in a large cohort of patients with NSCLC.J Clin Oncol. 2017; 35e13076Crossref Google Scholar, 33Galvez-Nino M. Ruiz R. Roque K. et al.P2. 05 Real World data on epidermal growth factor receptor tyrosine kinase inhibitors use in advanced non-small cell lung cancer from a Latin American cohort.J Thorac Oncol. 2019; 14: S1187Abstract Full Text Full Text PDF Google Scholar, 34Mas L. de la Torre J.G. Barletta C. Estado mutacional de los exones. 2011;2;19y 21 de EGFR en adenocarcinoma de pulmón: Estudio en 122 pacientes peruanos y revisión de la evidencia de eficacia del inhibidor tirosina kinasa erlotinib.Carcinos. 2011; 1: 52-61Google Scholar These rates, which are the highest reported for the LATAM region, may be explained to some extent by the important Asian ancestry.35Pinto J.A. Mas L.A. Gomez H.L. High epidermal growth factor receptor mutation rates in Peruvian patients with non–small-cell lung cancer: is it a matter of Asian ancestry?.J Glob Oncol. 2017; 3: 429-430Crossref PubMed Scopus (4) Google Scholar ALK rearrangements have been detected in around 10% of cases.24Gutierrez JM, Ruiz R, Araujo J, et al. Características epidemiológicas y sobrevida en pacientes con Cáncer de Pulmón en la Clínica Oncosalud-AUNA 2011-2014. Carcinos, in press.Google Scholar,36Arrieta O. Cardona A.F. Bramuglia G. et al.Molecular epidemiology of ALK rearrangements in advanced lung adenocarcinoma in Latin America.Oncology. 2019; 96: 207-216Crossref PubMed Scopus (13) Google Scholar A small targeted panel performed in 113 patients with lung cancer found mutations in KRAS and BRAF in 15.9% and 1.8% of patients, respectively (unpublished data). The Peruvian Society of Cardiothoracic and Vascular Surgery is composed of 120 active members as of today, with 10 of them being women. Approximately, a quarter of all these specialists are mainly advocated to the Thoracic Surgery subspecialty, and very few have training in Thoracic Surgical Oncology. These specialists are concentrated in Lima and in three regions of Peru (La Libertad, Arequipa, and Lambayeque). Only one center in the country provides specialized training in Thoracic Surgical Oncology. This shortage of specialists results in cardiothoracic surgeons also performing operations for the treatment of cancer and in prolonged waiting times for operation in the public sector. Video-assisted thoracic operation for performing lobectomy is available in highly specialized centers, mostly in Lima, at which thoracic oncology surgeons are available. The equipment for performing video-assisted thoracic operation is available nationwide; however, the scarcity of specialists is the limiting factor for the widespread use of this procedure. Therefore, open thoracotomy is still the most common surgical approach, especially in public centers. Robot-assisted thoracic operation for thoracic malignancies is not available in Peru. At INEN, stages I and II are eligible for primary operation. Patients with stage III receive multidisciplinary care, including chemoradiation and, very occasionally, operation. Thoracic operation for advanced cases with oligometastatic presentation is performed in selected cases, according to what is recommended by multidisciplinary tumor boards. Radiotherapy (RT) is key in the management of early, locally advanced, and metastatic lung cancer. Currently, there are 104 radiation oncologists, 100 radiotherapists, and 40 physicists in Peru. According to the National Institute on Nuclear Energy (IPEN),37Instituto Peruano de Energía Nuclear.https://www.ipen.gob.pe/Date accessed: December 2, 2019Google Scholar 28 centers have RT services and are distributed over six of 25 regions in Peru (Lima, La Libertad, Lambayeque, Arequipa, Junín, and Cusco), with 15 of them located in Lima. Equipment available is limited to 32 high-energy linear accelerators and five cobalt machines; that is 1 U for every 1,031,250 inhabitants. In Lima, the ratio is 1 U for every 504,411 inhabitants, whereas in the rest of the country, there is one machine for every 1,628,333 inhabitants. In all cases, the availability of RT units falls short of the recommended International Atomic Energy Agency ratio of one machine for every 200,000 to 250,000 inhabitants. Approximately 100 more units are needed to close this gap. In the public sector, waiting times for treatment are prolonged. Lima concentrates the six RT centers with capacity to perform special techniques such as intensity-modulated radiation therapy, volumetric modulated arc therapy, stereotactic body radiation therapy, and radiosurgery for the treatment of lung cancer; the two electronic intraoperative contact RT machines and the two CT simulators are able to perform 4-dimensional simulation. All of them but INEN are private. Regarding brachytherapy, there are 11 high dose rate brachytherapy machines37Instituto Peruano de Energía Nuclear.https://www.ipen.gob.pe/Date accessed: December 2, 2019Google Scholar, and only two centers, located in Lima, have experience in performing endobronchial brachytherapy. There is no access to Cyberknife units, tomotherapy, or proton therapy, but a Gammaknife equipment belonging to the private sector is available. In Peru, the regulatory approval of new therapies is given by the General Head of Medicines, Supplies and Drugs (DIGEMID) of the Peruvian MOH. Time from FDA approval to regulatory approval in Peru is becoming shorter (Table 1). However, the regulatory approval of new drugs does not imply access to the subsidized regimen, which additionally depends on their incorporation to the Peruvian Essential Medicine List, on the basis of safety, efficacy, and cost-effectivity. For the previous years, this list has included mainly cytotoxic drugs and no biologicals or targeted therapy. It was not until 2017 that erlotinib was included in this list. To overcome this limitation, the MOH authorized its public institutions to acquire and use drugs not included in the Peruvian Essential Medicine List, on the condition that they undergo evaluation by institutional committees and health-technology assessment (HTA) by DIGEMID. However, the implementation of HTA continues to face significant challenges concerned with the fragmentation of the health care system and shortage of resources for a timely evaluation. For this reason, INEN and the MOH in a concerted effort have established the normative mechanisms to enable access to selected high-cost drugs, on the condition that they are present on institutional guidelines.38Resolución Ministerial N° 116-2018-MINSA: Aprobar la Directiva Administrativa N° 249-MINSA/2018/DIGEMID "Gestión del Sistema Integrado de Suministro Público de Productos Farmacéuticos, Dispositivos Médicos y Productos Sanitarios - SISMED" Diario Oficial El Peruano, Lima, Peru2018https://www.gob.pe/institucion/minsa/normas-legales/187637-116-2018-minsaDate accessed: March 1, 2020Google Scholar Currently, the scope of this directive is restricted to INEN but is projected to have national reach.Table 1Time to Drug Regulatory Approval and AccessDrug/IndicationFDA ApprovalNational Regulatory ApprovalAccess for the Subsidized RegimenUse Authorization at INENErlotinib2004200820172017Afatinib20132014NoNoOsimertinib/T790M EGFR mutation20152018No2019Osimertinib/EGFR mutation first line20182019NoNoCrizotinib/ALK mutation20112012NoNoAlectinib20152017No2019Pembrolizumab20152016No2019Nivolumab20152015NoNoAtezolizumab20162017NoNoFDA, Food and Drug Administration; INEN, the Peruvian National Cancer Institute. Open table in a new tab FDA, Food and Drug Administration; INEN, the Peruvian National Cancer Institute. For its part, within the contributory regimen, HTA is performed by its own health-technology agency Instituto de Evaluación de Tecnologías Sanitarias e Investigación, allowing access to selected innovative drugs, most of which provide overall survival or quality of life benefit. Importantly, its methodological and evaluation documents are published online and are accessible to patients and other stakeholders.39ESSALUD, Instituto de Evaluación de Tecnologías en Salud e Investigación Lima.http://www.essalud.gob.pe/ietsi/Date accessed: December 20, 2019Google Scholar The scenario is very different for private institutions, where only regulatory approval is needed for using a drug. However, increasingly, private insurers are also establishing HTA to regulate the use of high-cost medications. A summary of drugs available in Peru is shown in Table 1. Regarding results of systemic therapies, a group of researchers from INEN recently presented real-world data on 55 patients with EGFR mutated lung cancer treated with erlotinib at any line of treatment from 2015 to 2018 and found an overall response rate (ORR) of 65.9% and an unexpectedly prolonged progression-free survival (PFS) of 18 months.33Galvez-Nino M. Ruiz R. Roque K. et al.P2. 05 Real World data on epidermal growth factor receptor tyrosine kinase inhibitors use in advanced non-small cell lung cancer from a Latin American cohort.J Thorac Oncol. 2019; 14: S1187Abstract Full Text Full Text PDF Google Scholar Results from another institution could not confirm these results; with follow-up time of 32.4 months, ORR was 73.6% and median PFS and median overall survival were 12 and 24 months, respectively (unpublished data). Results of immunotherapy use at any line have also been evaluated in a cohort of 68 patients. Although ORR was 38% and PFS was 5.5 m, duration of response was 18.6 months (unpublished data). Lung cancer in Peru is a growing public health problem with characteristics that differ from what occurs in the LATAM region and the world. It is a disease that occurs predominantly in nonsmokers, with a high incidence of adenocarcinoma and EGFR and ALK mutations, the cause of which is not well elucidated yet.

INTRODUCTION:The Mortality-Incidence Ratio complement [1 - MIR] is an indicator validated in various populations to estimate five-year cancer survival, but its validity remains unreported in Peru. This study aims to determine if the MIR correlates directly with five-year survival in patients diagnosed with the ten most common types of cancer in metropolitan Lima.MATERIALS AND METHODS:The Metropolitan Lima Cancer Registry (RCLM in Spanish) for 2004-2005 was used to determine the number of new cases and the number of deaths of the following cancers: breast, stomach, prostate, thyroid, lung, colon, cervical, and liver cancers, as well as non-Hodgkin's lymphoma and leukaemia. To determine the five-year survival, the five-year vital status of cases recorded was verified in the National Registry of Identification and Civil Status (RENIEC in Spanish). A linear regression model was used to assess the correlation between [1 - MIR] and total observed five-year survival for the selected cancers.RESULTS:Observed and estimated five-year survival determined by [1 - MIR] for each neoplasia were thyroid (66.7%, 86.7%), breast (69.6%; 68%), prostate (64.3%, 63.8%) and cervical (50.1%, 58.5%), respectively. Pearson's r coefficient for the correlation between [MIR - 1] and observed survival was = 0.9839. Using the coefficient of determination, it was found that [1 - MIR] (X) captures the 96.82% of observed survival (Y).CONCLUSION:The Mortality-Incidence Ratio complement [1 - MIR] is an appropriate tool for approximating observed five-year survival for the ten types of cancers studied. This study demonstrates the validity of this model for predicting five-year survival in cancer patients in metropolitan Lima.

Introduction: Insulinomas are rare functional pancreatic tumors with good prognosis when small and benign but dismal results if larger or harbor malignant features. Objective: Analyze clinical features, treatment and clinical outcomes of insulinomas treated in the period 1992 - 2017 at The National Cancer Institute (INEN) of Peru. Methods: All patients with biochemical / histopathological criteria for insulinoma were included and retrospectively analyzed. Results: Fourteen patients were included, [9 women (64.3%); mean age 41.1 ± 17.1 years (range, 11–74)]. Thirteen patients (92.9%) had sporadic tumors. Twelve (85.7%) had solitary tumors. Eleven (78.6%) had fasting hypoglycemia. Mean glucose nadir was 32.4 ± 9.8 mg/dL with a median insulin value of 42 uU/mL (range,14.6–285). The lesion was identified by CT or MRI before surgery in twelve patients. Four (28.6%) were found in the tail and four in the pancreas body. Mean size of lesion 3.75 cm (range; 1.2–14 cm). Nine (64.3%) patients were treated with enucleation and seven of them with laparoscopy (77.8%). No mortality recorded. Two patients had clinically significant pancreatic fistula (ISGPF type B). Three patients (21.4%) had malignant insulinomas, two of them developed metastatic disease after 94 and 156 months and surgery + chemotherapy was offered. Surgery alone achieved curability in twelve (85.7%) patients. Median follow up: 62 months (range; 0-215), overall survival:142 months (range; 60-264). Conclusion: Minimal Invasive surgery became the standard treatment for most patients with insulinoma with high curability rate since 2000. Malignant insulinomas may have favorable long-term outcomes with multimodality treatment.

e16096 Background: Modulation of immune system has demonstrated tumor response in Gastric Cancer. Tumor infiltrating lymphocytes and microsatellite instability are predictive biomarkers for response to anti-PD-L1 drugs in different malignancies, however, studies confirming it in gastric cancer are lacking. We evaluate the role of infiltrating CD8 lymphocytes over clinicopathological features including clinical stage, H. pylori presence, microsatellite instability and survival in Gastric Cancer. Methods: Frozen and paraffin samples of Gastric Cancer were prospectively collected from 100 patients who were referred to surgery. H. pylori genes (UreA and HspA) were evaluated through qPCR in frozen samples and CD8, PMS2, MLH1, MSH6 and MSH2 stains were evaluated through IHC in tissue microarrays from paraffin samples. CD8 stained slides was scanned and automatized counts was performed by BX63 Olympus in 5HPF (stained cells/ total cells x100). Data were collected from medical and pathology reports and statistical analysis was performed by R. Results: Median age was 66 years and 55% were male, most tumors were HG-3 (43%), diffuse subtype Lauren classification (37%) and pathology stage III (46%), the most frequent location was the antrum (63%). UreA or HspA genes of H. pylori were present in 79%. Microsatellite instability was found in 30%. Median CD8 TIL count were 0.045% and higher values was associated to grade (p = 0.007), stage (p = 0.022) and syncronous Atrophic Gastritis (p = 0.025). CD8 TIL count had a trend to be associated with microsatellite instability (p = 0.13). CD8 TIL count was not associated to UreA (p = 0.54) nor HspA (p = 0.52) levels. Survival analysis found that gender (p = 0.047), grade (p = 0.047) and stage (p = 0.022) were associated with longer OS. CD8 TIL had a trend (p = 0.065), and microsatellite instability (p = 0.34) had no association with OS. Conclusions: Tumor-infiltrating CD8 lymphocytes could influence clinicopathological features including survival in gastric cancer. This study was supported by the CIENCIACTIVA-CONCYTEC, under the contract #197-2015-and 204-2015, FONDECYT.

e15521 Background: Helicobacter pylori (HP) infection is one of the most common infections worldwide and is a risk factor for gastric cancer (GC) development. This study was conducted to determinate the prevalence rate of HP as well as presence of vacA and cagA in gastric cancer samples from Peruvian patients. Methods: GC samples were prospectively collected from patients who went to surgery between April 2015 and November 2016. Three types of gastric samples were obtained from each patient: tumoral area (T), proximal healthy (P) and distal healthy tissue (D) samples. HP status through H&E was analyzed by a pathologist. DNA was extracted from tissue, and detection of colonization (ureA and hspA) and virulence genes (vacA and cagA) of HP was performed through quantitative PCR (qPCR). Results: A total of 183 patients were studied with a mean age of 64 years and 51.9% were men. 52.2% had a primary from antrum, 47.8% was HG 3 and 60% were diffuse. Presence of HP through H&E was found in 58.4% (n=107/183). Positive HP cases through qPCR were determinate with positivity of at least one ureA/hspA gene and was found in 89.6% (n=164/183). HP detection rate and its concentration were higher in D (ureA: 62.8%, n=115, [703.58±245.47pg]; hspA: 73.8%, n=135, [42.77±10.17pg]) than P (ureA: 59.0%, n=108, [539.69±121.32pg]; hspA: 71.0%, n=130, [31.90±8.64pg]) and T (ureA: 49.7%, n=91, [296.32±164.98pg]; hspA: 70.5%, n=129, [4.6±1.33pg]) (p<.001). Antrum location was associated to higher level of hspA expression (p=0.047). Neither histology (p=0.45) nor HG (p=0.2) was associated to level of hspA expression. qPCR detected HP in 75% (n=57/76) of cases without evidence of HP by pathology evaluation (H&E) (ICC: 0.77 vs 0.58). cagA virulence gene was detected in 95.8% (n=159/166) while vacAm allele in 85.5% (n=142/166) and vacAs allele in 96.8% (n=160/166). vacA+cagA- combination was found in 0.6% (n=1/166), vacA+cagA+ cases in 95.8% (n=159/166) and vacA-cagA- cases in 3.6% (n=3/166). Conclusions: Our results show a significant presence of HP in Peruvian gastric cancer patients and combination of vacA+/-cagA+/- virulence genes had particular patterns.