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    Comparação das características clínicas, laboratoriais e dos desfechos de pacientes com leucemia linfocítica crônica acompanhados em hospitais públicos ou privados no Brasil: uma análise retrospectiva do Registro Brasileiro de Leucemia Linfocítica Crônica
    (Universidade Federal de São Paulo (UNIFESP), 2020-12-18) Pfister, Verena [UNIFESP]; Silva, Celso Arrais Rodrigues Da [UNIFESP]; Universidade Federal de São Paulo
    Introduction: Chronic lymphocytic leukemia (CLL) typically occurs in elderly patients and has a highly variable clinical course. It is important to understand the aspects that affect the outcomes of CLL in a real-world setting. In addition to biological factors, socioeconomic and health system characteristics may also influence the clinical course and outcome of CLL. Data from the Brazilian Registry of CLL was analyzed to compare clinical and treatmentrelated characteristics in patients with CLL followed in public or private institutions in Brazil. Objective: To describe the clinical and laboratory characteristics and outcomes of a series of CLL patients followed in public or private hospitals in Brazil. Methods: The Brazilian Registry of CLL started in 2004 as a prospective non-interventional data collection tool. All patients with minimum available data required on patient and disease characteristics and survival were included. Results/discussion: From January 2004 to August 2020, 3053 patients from 37 centers met eligibility criteria for this analysis: 2449 (80%) were followed at public hospitals and 604 (20%) at private institutions. The majority were male (57%), with median age of 66 years (ranging from 23 to 106). Binet stage at diagnosis was A in 1678 (58%) patients, B in 652 (23%) and C in 540 (19%). FISH for del(17p) was performed in only 486 patients (16%), while FISH for the most common aberrations [del(13q), +12, del(11q), and del(17p)] was performed in 446 patients (15%). IGHV mutational status was performed in only 214 patients (7%), and karyotype in only 173 patients (6%). Comparing public and private hospitals, we observed that patients in public hospital are older (median age 66 years vs. 63 years for private hospitals, P<0.0001), had more advanced disease at diagnosis (frequency of Binet B or C was 44% in public vs. 33% in private hospital, P<0.0001), more frequently had elevated creatinine levels (18% vs. 10%, P<0.0001). All prognostic markers were performed more often in private than in public hospitals: FISH for del17p (42% of cases vs. 10%, respectively, P<0.0001), IGHV mutational status (13% vs. 6%, respectively,P<0.0001) and karyotype (16% vs. 3%, respectively, P<0.0001). The frequency of a positive FISH for del(17p) was similar between public and private hospitals (11% vs. 9%, P=0.65), as well as the frequency of unmutated IGHV status (60% vs. 49%, P=0.12). Analyzing 1080 patients who have been treated since 2008, treatment was performed after a median time follow up of 6 months (range: 0-290) after diagnosis. First line treatment was predominantly based on chlorambucil in 43% of cases and in fludarabine in 39%. Anti-CD20 monoclonal antibody was used in only 35% of cases (rituximab in 32% and obinutuzumab in 3%). Novel agents were used in first line in only 23 patients (2%) , 19 of which in the context of a clinical trial. In public hospitals there were significantly less patients receiving fludarabine-base regimens (36% vs. 52%, P<0.0001), and regimens containing anti-CD20 monoclonal antibodies (26% vs. 75%, P<0.0001). Overall survival at 7 years was significantly worse in public than in private hospitals (68% vs. 92%, respectively, P<0.0001). After a multivariate analysis, survival in patients from public hospitals remained significantly worse than in private hospitals (hazard ratio - HR 2.88, 95% confidence interval 1.59 – 5.24), after correcting for age, Binet staging and beta2-microglobulin. Treatment free survival at 7 years was also worse in public than in private hospitals (30% vs. 48%, respectively, P<0.0001), although the difference did not remain after correcting for Binet staging and beta2-microglobulin in a multivariate analysis (HR 0.91, 95%CI 0.50- 1.66, P=0.76). Conclusion: Our data indicate that there are striking differences among patients treated in public or private hospitals in Brazil. A worse clinical condition as well as the lack of accessibility to basic laboratory tests and adequate therapies may explain the worse outcome of patients treated in public institutions in Brazil.