Nassar El Assaad

Background: Leiomyosarcomas are an aggressive soft-tissue sarcoma that arise from smooth muscle, have a high metastatic potential and account for 10–20% of soft-tissue sarcomas. Despite decades of research, the first-line treatment remains unresolved due to the absence of direct comparative trials, heterogeneous study designs, and trade-offs between efficacy and toxicity. This systematic review evaluates the optimal therapeutic systemic chemotherapy regimens in the first-line setting, specifically gemcitabine- and doxorubicin-based regimens, including associated toxicities. Methods: A systematic search in MEDLINE (Ovid), Embase (Ovid), and Cochrane Library (Wiley) identified studies of first-line gemcitabine- or doxorubicin-based chemotherapy for leiomyosarcoma. The review protocol was registered in PROSPERO (CRD420261280028). Of the 3092 articles screened, 11 articles were eligible for inclusion, comprising results from 1225 patients. Eligible studies were in English and included ≥10 patients with advanced/metastatic leiomyosarcoma reporting on LMS-specific outcomes and no prior systemic therapy. This qualitative systematic review synthesizes prospective and retrospective evidence without quantitative meta-analysis. Results: The review included two phase 3 trials, six phase 2 trials, one phase 1b trial, and two retrospective studies. While there was no direct comparison in this setting, doxorubicin-based combinations consistently reported higher objective response rates, progression-free survival, and overall survival. The most favorable outcomes were observed in the LMS04 trial with doxorubicin plus trabectedin followed by surgery and trabectedin maintenance, yielding a median progression-free survival of 12 months, overall survival of 33 months, and objective response rate of 36%. This regimen also had the highest grade 3–4 toxicity. Conclusions: Doxorubicin-based regimens remain the most active first-line option for leiomyosarcoma, although treatment practices remain heterogeneous.

PURPOSE: Lebanon's ongoing economic collapse has severely disrupted the health care system, particularly access to essential cancer therapies. Small cell lung cancer (SCLC) is an aggressive malignancy with limited treatment options and poor prognosis. Immune checkpoint inhibitors (ICIs) have provided modest survival benefits in extensive-stage SCLC (ES-SCLC), but access in resource-limited settings is highly vulnerable to financial instability. In October 2022, Lebanon officially withdrew public subsidies for ICIs, threatening equitable cancer care. This study evaluates the impact of the Ministry of Public Health subsidy withdrawal on access to ICIs and associated outcomes in patients with ES-SCLC. MATERIALS AND METHODS: A mixed-methods study was conducted at Hôtel-Dieu de France (HDF) University Hospital in Beirut. The qualitative component involved a semi-structured interview with the HDF pharmacy to characterize operational challenges. The quantitative component was a retrospective cohort study of patients diagnosed with ES-SCLC from 2019 to 2024. Data included demographics, treatment access, and survival. Analyses included bivariate statistics, Kaplan-Meier survival analysis, and Cox proportional hazards regression. RESULTS: The interview identified financial hardship and drug shortages as major barriers. Among 71 patients, 75% did not receive guideline-concordant optimal treatment. Access to ICIs was significantly associated with method of payment (χ ² = 13.8, P = .037) and public insurance coverage (χ ² = 8.6, P = .035). Survival was higher among patients receiving optimal treatment ( P = .021), male patients ( P = .004), and those treated before subsidy withdrawal ( P = .037). In multivariable Cox regression, male gender, optimal treatment, and public insurance were independently associated with improved survival. CONCLUSION: The withdrawal of public subsidies amid Lebanon's economic crisis critically disrupted access to ICIs and contributed to poorer outcomes. Robust financial protection mechanisms are urgently needed to sustain equitable cancer care.