Patient access to perioperative chemotherapy with fluorouracil, leucovorin, oxaliplatin and docetaxel in patients with resectable gastric cancer in the Netherlands

Background: The FLOT4 trial demonstrated superior survival of perioperative chemotherapy with 5-fluorouracil, oxaliplatin, and docetaxel (FLOT) compared to anthracycline triplets for resectable gastric cancer. These results were presented at the American Society of Clinical Oncology (ASCO) congress in June 2017 and published in April 2019. However, adoption of novel treatments in clinical practice often encounters delays. This study assesses the patterns of perioperative chemotherapy utilization and FLOT uptake in clinical practice within the Netherlands. Materials and methods: A retrospective cohort study was conducted with resectable gastric cancer patients (cT1–4a,XcNallcM0) between 2015–2020 from the Netherlands Cancer Registry. Descriptive statistics, Cochran-Armitage tests, Fisher's exact or unpaired T-tests, and Jonckheere-Terpstra tests were used to analyze chemotherapy trends and FLOT uptake across hospitals. Results: Among 3290 included patients, 42.9 % received neoadjuvant treatment. In 2015, 43.6 % of patients received perioperative chemotherapy versus 43.5 % in 2020 (p = 0.63). 40 out of 62 hospitals (64.5 %) adopted FLOT between the ASCO presentation and the full publication. FLOT increased from 42.9 % before publication to 86.8 % after publication (p &lt; 0.0001), while anthracycline triplet use decreased to 0.9 % (p &lt; 0.0001). Higher hospital volume was associated with fewer days to adoption (p = 0.04) but not with adoption of FLOT before publication (p = 0.14). Conclusion: Timing of FLOT adoption varied among Dutch hospitals, leading to unequal patient access to effective treatments. Establishing (inter)national guidelines on provisional treatment adjustment pending publication is crucial to reduce variation in access. Moreover, rapid publication of final trial results is imperative to reduce variation in practice and ensure fair patient treatment.</p

Adjuvant nivolumab after chemoradiotherapy and resection for patients with esophageal cancer:A real-world matched comparison of overall survival

The Checkmate-577 trial showed a significant disease-free and a non-significant overall survival benefit for nivolumab compared to placebo in esophageal or gastroesophageal junction (GEJ) cancer patients with residual disease after neoadjuvant chemoradiotherapy (nCRT) and resection. Real-world overall survival (OS) data has not yet been presented. The aim of this study was to evaluate OS of patients treated with or without adjuvant nivolumab in a nationwide real-world matched comparison.For this study, patients diagnosed with non-metastatic esophageal or GEJ cancer in 2020-2023 who had residual pathological disease after nCRT and resection were selected from the Netherlands Cancer Registry. 333 patients received treatment with adjuvant nivolumab. From the period before the introduction of nivolumab, 486 patients were selected who received nCRT and resection alone. Propensity score trimming and nearest neighbor matching were used to create two well-balanced groups of 311 patients per treatment group. Median follow-up time was 24.4 months and 31.4 months for patients treated with and without adjuvant nivolumab, respectively. The 2-year OS was 66.8% (95% confidence interval [CI]: 61.6%-72.44%) and 58.8% (95% CI: 53.5%-64.5%) for the groups with and without nivolumab, respectively (log-rank p = 0.024), hazard ratio: 0.75, 95% CI: 0.60-0.97 (p = 0.024). In conclusion, this matched real-world study showed an OS in favor of patients treated with nivolumab compared to patients without nivolumab. This represents the first report on a real-world OS benefit in this setting. As follow-up and the number of events are still limited, these analyses should be interpreted with caution and updated in the forthcoming years

Perioperative Chemotherapy for Gastro-Esophageal or Gastric Cancer:Anthracyclin Triplets versus FLOT

Background: The FLOT4-AIO trial (2019) showed improved survival with perioperative fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) compared to anthracyclin triplets in gastric cancer treatment. It is unclear whether these results extend to real-world scenarios in the Netherlands. This study aimed to compare outcomes of perioperative FLOT to anthracyclin triplets in a real-world Dutch gastric cancer population. Methods:Patients diagnosed with resectable (cT2-4a/cTxN0-3/NxM0) gastric or gastro-esophageal junction carcinoma between 2015–2021 who received neoadjuvant FLOT or anthracyclin triplets were selected from the Netherlands Cancer Registry. The primary outcome was overall survival (OS), analyzed through multivariable Cox regression. Secondary outcomes included pathological complete response (pCR), neoadjuvant chemotherapy cycle completion, surgical resection rates, and adjuvant therapy. Results: Adjusted OS showed no significant survival benefit (HR = 0.88, 95% CI 0.77–1.01, p = 0.07), even though the median OS was numerically improved by 8 months with FLOT compared to anthracyclin triplets (48.1 vs. 39.9 months, p = 0.16). FLOT patients were more likely to undergo diagnostic staging laparoscopies (74.2% vs. 44.1%, p &lt; 0.001), had higher rates of completing neoadjuvant chemotherapy (OR = 1.35, 95% CI 1.09–1.68, p = 0.007), receiving adjuvant therapy (OR = 1.34, 95% CI 1.08–1.66, p = 0.08), and achieving pCR (OR = 1.52, 95% CI 1.05–2.20, p = 0.03). No significant differences were observed in (radical) resection rates. Conclusion(s): Real-world data showed no significant OS improvement for FLOT-treated patients compared to anthracyclin triplets, despite more staging laparoscopies. However, FLOT patients demonstrated higher rates of neoadjuvant therapy completion, proceeding to adjuvant therapy, and increased pCR rates. Therefore, we recommend the continued use of neoadjuvant FLOT therapy in the current clinical setting.</p

Real-world outcomes of the CROSS regimen in patients with resectable esophageal or gastro-esophageal junction adenocarcinoma:a nationwide cohort study in the Netherlands

BACKGROUND: Recent studies in patients with resectable adenocarcinoma of the esophagus or gastroesophageal junction (GEJ)-Neo-AEGIS and ESOPEC-have explored the comparison of neoadjuvant chemoradiotherapy (nCRT) with chemotherapy, with conflicting results. To contextualize the findings from these studies using nCRT as a comparator, we aimed to investigate contemporary real-world outcomes of nCRT in patients with adenocarcinoma of the esophagus or GEJ.METHODS: From the Netherlands Cancer Registry, patients were selected who were diagnosed between 1 January 2015 and 31 December 2022 with a resectable (cT1N+M0 or cT2-4aNanyM0) esophageal, GEJ or gastric cardia adenocarcinoma and started treatment with nCRT according to the CROSS regimen, that is 5 weekly cycles of carboplatin (AUC 2 mg/mL per minute) and paclitaxel (50 mg/m2) combined with concurrent radiotherapy (41.4 Gy in 23 fractions of 1.8 Gy). Pathologic complete response (pCR) according to Mandard was the primary outcome of this study and defined as complete tumor regression of the primary tumor (Mandard grade I) irrespective of residual nodal involvement.FINDINGS: Of the 4765 included patients, 4170 (87.5%) completed the full CROSS regimen of radiotherapy and chemotherapy. A pCR was observed in 704 (20.5%) of 3439 patients who underwent surgical resection within 16 weeks after completing the CROSS regimen. In the complete study population, the median overall survival (OS) was 33.7 months (95% CI 32.0-35.6), with a 3-year OS rate of 48.1%.INTERPRETATION: Although survival rates in real-world settings are often lower compared to clinical trials, in our real-world cohort the 3-year OS was only 2.6% lower compared to that reported for the group that underwent nCRT in ESOPEC. These real-world results underscore the potential of the CROSS regimen in daily clinical practice.FUNDING: None.</p

Perioperative Chemotherapy for Gastro-Esophageal or Gastric Cancer:Anthracyclin Triplets versus FLOT

Background: The FLOT4-AIO trial (2019) showed improved survival with perioperative fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) compared to anthracyclin triplets in gastric cancer treatment. It is unclear whether these results extend to real-world scenarios in the Netherlands. This study aimed to compare outcomes of perioperative FLOT to anthracyclin triplets in a real-world Dutch gastric cancer population. Methods:Patients diagnosed with resectable (cT2-4a/cTxN0-3/NxM0) gastric or gastro-esophageal junction carcinoma between 2015–2021 who received neoadjuvant FLOT or anthracyclin triplets were selected from the Netherlands Cancer Registry. The primary outcome was overall survival (OS), analyzed through multivariable Cox regression. Secondary outcomes included pathological complete response (pCR), neoadjuvant chemotherapy cycle completion, surgical resection rates, and adjuvant therapy. Results: Adjusted OS showed no significant survival benefit (HR = 0.88, 95% CI 0.77–1.01, p = 0.07), even though the median OS was numerically improved by 8 months with FLOT compared to anthracyclin triplets (48.1 vs. 39.9 months, p = 0.16). FLOT patients were more likely to undergo diagnostic staging laparoscopies (74.2% vs. 44.1%, p &lt; 0.001), had higher rates of completing neoadjuvant chemotherapy (OR = 1.35, 95% CI 1.09–1.68, p = 0.007), receiving adjuvant therapy (OR = 1.34, 95% CI 1.08–1.66, p = 0.08), and achieving pCR (OR = 1.52, 95% CI 1.05–2.20, p = 0.03). No significant differences were observed in (radical) resection rates. Conclusion(s): Real-world data showed no significant OS improvement for FLOT-treated patients compared to anthracyclin triplets, despite more staging laparoscopies. However, FLOT patients demonstrated higher rates of neoadjuvant therapy completion, proceeding to adjuvant therapy, and increased pCR rates. Therefore, we recommend the continued use of neoadjuvant FLOT therapy in the current clinical setting.</p

A qualitative and quantitative study of self-reported positive characteristics of individuals with ADHD

Research in Attention-deficit/hyperactivity disorder (ADHD) has had a clear focus on treatment and the dysfunction in specific situation associated with the condition. However, self-report, observational and anecdotal evidence indicates that there are also positive aspects associated with ADHD. Research on the potential positive features in individuals with an ADHD diagnosis is still limited, especially studies with larger representative samples. Here we performed qualitative research to identify positive aspects and strengths associated with ADHD in a large convenience sample from the Dutch organization for people with ADHD, dyslexia and dyscalculia. We sent out open-ended questionnaires to the members of the organization, asking what they consider to be positive aspects of their ADHD. From the responses of individuals with ADHD (n = 206), we extracted 116 codes, which were assigned to thirteen subthemes, which in turn led to five themes. These themes were: Creativity, Being dynamic, Flexibility, Socio-affective skills, and Higher-order cognitive skills. Core symptoms of ADHD such as impulsivity and hyperactivity were also considered positive aspects of ADHD by a minority of participants. After showing our results to a group of additional individuals with ADHD (focus group) they confirmed the identified positive aspects of ADHD. They also helped us with the interpretation of our findings and mentioned certain positive aspects to be a consequence of living with ADHD (being open minded and being honest). In conclusion, experiencing positive aspects seems to be common in ADHD as almost all participants reported positive aspect of ADHD, these aspects cover many different domains. Awareness about ADHD's strengths might help individuals with ADHD and their environment to better cope with, accept or embrace their diagnosis and for example make educational or occupational choices that fit them well. To incorporate these positive aspects in the understanding of ADHD, future research should focus on quantifying strengths in ADHD, and on investigating the link between these aspects and clinical characteristics and how this new knowledge can be implemented in psychoeducation and find its way to education and occupational settings

Hospital variation in treatment for synchronous metastatic esophageal and gastric cancer:A nationwide population-based study in the Netherlands

Care for metastatic esophageal (EC) or gastric cancer (GC) includes a large variety of treatment modalities. Data on treatment variation across centers are unknown. This study investigated treatment variation across hospitals and its effect on overall survival (OS) in the Netherlands by conducting a nationwide retrospective cohort study with population-based data from the Netherlands Cancer Registry. Patients diagnosed with synchronous metastatic EC/GC between 2015 and 2022 were included. Multilevel logistic regression assessed treatment patterns according to hospital of diagnosis. OS was analyzed using Cox regression analysis after categorizing hospitals into tertiles based on their adjusted odds (low/medium/high) for systemic treatment (chemotherapy, targeted therapy, and immunotherapy). Among 8406 EC and 3871 GC patients, the proportion receiving systemic treatment varied substantially: 19.8%-69.6% for EC and 15.8%-81.3% for GC across hospitals. Hospital of diagnosis was significantly associated with the adjusted probability of receiving systemic treatment (p &lt; .0001). Ten out of 78 EC (12.8%) and 7 out of 73 (9.6%) GC hospitals had significantly lower systemic treatment probabilities. EC patients with OS ≥4 months diagnosed at hospitals with lower probabilities had significantly worse OS compared to high-probability hospitals (hazard ratios [HR] 0.87 [0.79-0.95] p = .002). GC patients from low-probability hospitals had significantly worse OS than from medium- (HR 0.86 [0.76-0.96], p = .011) or high-probability hospitals (HR 0.73 [0.64-0.82], p &lt; .0001). In conclusion, this study showed substantial hospital variation in treatment for metastatic EC and GC. Hospital of diagnosis was not only associated with the probability of receiving systemic treatment but also OS. This reflects the challenge of ensuring equal healthcare access.</p

Real-world outcomes of the CROSS regimen in patients with resectable esophageal or gastro-esophageal junction adenocarcinoma: a nationwide cohort study in the Netherlands

Background: Recent studies in patients with resectable adenocarcinoma of the esophagus or gastroesophageal junction (GEJ)—Neo-AEGIS and ESOPEC—have explored the comparison of neoadjuvant chemoradiotherapy (nCRT) with chemotherapy, with conflicting results. To contextualize the findings from these studies using nCRT as a comparator, we aimed to investigate contemporary real-world outcomes of nCRT in patients with adenocarcinoma of the esophagus or GEJ. Methods: From the Netherlands Cancer Registry, patients were selected who were diagnosed between 1 January 2015 and 31 December 2022 with a resectable (cT1N+M0 or cT2-4aNanyM0) esophageal, GEJ or gastric cardia adenocarcinoma and started treatment with nCRT according to the CROSS regimen, that is 5 weekly cycles of carboplatin (AUC 2 mg/mL per minute) and paclitaxel (50 mg/m2) combined with concurrent radiotherapy (41.4 Gy in 23 fractions of 1.8 Gy). Pathologic complete response (pCR) according to Mandard was the primary outcome of this study and defined as complete tumor regression of the primary tumor (Mandard grade I) irrespective of residual nodal involvement. Findings: Of the 4765 included patients, 4170 (87.5%) completed the full CROSS regimen of radiotherapy and chemotherapy. A pCR was observed in 704 (20.5%) of 3439 patients who underwent surgical resection within 16 weeks after completing the CROSS regimen. In the complete study population, the median overall survival (OS) was 33.7 months (95% CI 32.0–35.6), with a 3-year OS rate of 48.1%. Interpretation: Although survival rates in real-world settings are often lower compared to clinical trials, in our real-world cohort the 3-year OS was only 2.6% lower compared to that reported for the group that underwent nCRT in ESOPEC. These real-world results underscore the potential of the CROSS regimen in daily clinical practice. Funding: None

Mechanical properties of 3D printed concrete: a RILEM 304-ADC interlaboratory study – compressive strength and modulus of elasticity

Traditional construction techniques, such as in-situ casting and pre-cast concrete methods, have well-established testing protocols for assessing compressive strength and modulus of elasticity, including specific procedures for sample preparation and curing. In contrast, 3D concrete printing currently lacks standardized testing protocols, potentially contributing to the inconsistent results reported in previous studies. To address this issue, RILEM TC 304-ADC initiated a comprehensive interlaboratory study on the mechanical properties of 3D printed concrete. This study involves 30 laboratories worldwide, contributing 34 sets of data, with some laboratories testing more than one mix design. The compressive strength and modulus of elasticity were determined under three distinct conditions: Default, where each laboratory printed according to their standard procedure followed by water bath curing; Deviation 1, which involved creating a cold joint by increasing the time interval between printing layers; and Deviation 2, where the standard printing process was used, but the specimens were cured under conditions different from water bath. Some tests were conducted at two different scales based on specimen size—“mortar-scale” and “concrete-scale”—to investigate the size effect on compressive strength. Since the mix design remained identical for both scales, the only variable was the specimen size. This paper reports on the findings from the interlaboratory study, followed by a detailed investigation into the influencing parameters such as extraction location, cold joints, number of interlayers, and curing conditions on the mechanical properties of the printed concrete. As this study includes results from laboratories worldwide, its contribution to the development of relevant standardized testing protocols is critical

Mechanical properties of 3D printed concrete:a RILEM TC 304-ADC interlaboratory study — flexural and tensile strength

This paper discusses the flexural and tensile strength properties of 3D printed concrete, based on the results of a RILEM TC 304-ADC interlaboratory study on mechanical properties. These properties are determined using different testing techniques, including 3- and 4-point flexural tests, splitting tests, and uniaxial tension tests, on specimens extracted from large 3D printed elements in accordance with a prescribed study plan. The relationship between compressive and flexural or tensile strengths, cast or printed samples, different types of tests, and different loading orientations, are analysed to understand the influence of 3D printing. As expected, the strength can reduce significantly when the main tensile stress is acting perpendicular to the interface between layers. The role of deviations from the standard study procedure, in terms of the time interval between the placing of subsequent layers, or the adoption of a different curing strategy, are also assessed. While the increased time interval significantly impacts the strength in the critical direction, the use of variable curing conditions does not seem to have a clear-cut effect on the strength ratios of the printed to cast specimens. Additionally, the paper looks at the variability in the results for the printed specimens, in order to emphasize the need for multiple replicates for obtaining a proper result. An extensive insight into the aspects affecting the variability is presented in the paper. Finally, with the limited dataset available for specimens tested at a larger scale, it is difficult to arrive at a clear understanding of the role of specimen size (i.e., greater number of layers)