Rashdan, Sawsan

e13635 Background: Melanoma is an aggressive skin malignancy with rising global incidence, for which checkpoint inhibitors (CPI) and BRAF-targeted therapies are standard of care in advanced disease. However, access to molecular diagnostics and CPI remains limited in conflict-affected regions such as Syria. Real-world data describing melanoma management in this setting are scarce. Methods: We conducted a retrospective study of all patients diagnosed with melanoma between 2022 and 2024 at Al-Bairouni University Hospital (ABUH), Syria’s primary oncology referral center. Demographic and clinical characteristics were analyzed for the entire cohort, and patients with advanced disease were evaluated for molecular testing and treatment patterns. Semi-structured interviews were conducted in a mixed advanced cancer subset (N = 35) to explore barriers to immunotherapy access. Results: Among 115 patients with melanoma, the median age at diagnosis was 57 years (IQR 44.5–67), and 54.7% were male. At presentation, 18.3% had stage I disease, 1.7% stage II, 2.6% stage III, and 40.9% stage IV disease; staging was unavailable in 36.5%. Among patients with advanced melanoma (n = 47), BRAF testing was performed in 17 (36.2%), with targeted therapy administered to 5/16 BRAF-positive patients. Only 7/47 patients (14.9%) received CPI, primarily as monotherapy. In the qualitative subset (predominantly lung cancer), five major barriers to immunotherapy access emerged: financial toxicity (n = 22), limited drug availability (n = 9), limited patient awareness (n = 8), geographic/logistical challenges (n = 5), and system delays (n = 4). Conclusions: Despite a substantial burden of advanced melanoma, access to molecular testing, targeted therapy and CPI in Syria remains limited. Qualitative findings highlight financial and structural barriers as primary drivers of limited access, underscoring the need for improved drug availability, diagnostic infrastructure, and patient education in conflict-affected settings.

1557 Background: Immunotherapy is now a standard-of-care treatment for lung cancer across most stages. Access to immunotherapy and molecular diagnostic tests in conflict-affected countries such as Syria remains poorly described. As the principal cancer center in Syria, Al-Bairouni University Hospital (ABUH) provides care for nearly three-quarters of all cancer cases nationally. We conducted this study to evaluate access to immunotherapy and molecular diagnostic services at ABUH. Methods: A mixed-methods study was performed between 2022 and 2024 at ABUH. This study included a retrospective cohort of all patients diagnosed with lung adenocarcinoma. Quantitative data included disease stage at diagnosis, molecular testing rates, and immunotherapy utilization. In addition, a qualitative patient survey was thematically analyzed to explore barriers to treatment access in a separate cohort of patients with mixed tumor types. Results: Among 2,920 patients diagnosed with lung cancer, 1,393 (47.7%) had lung adenocarcinoma. The median age at diagnosis was 61 years; 79.7% of patients were male. Smoking history was as follows: Current 792 (56.9%), Former 268 (19.2%), never smoked 318 (22.8%) At presentation, 3 patients (0.2%) had stage I disease, 40 (2.9%) stage II, 174 (12.5%) stage III, and 778 (55.8%) stage IV disease, staging was unknown for the rest of the patients. EGFR mutation testing was performed by ABUH for 226/1393 patients (16.2%) only, with positive results identified in 124 cases (8.9%). PD-L1 testing was conducted by ABUH in only 32/1393 patients (2.3%) and was positive in 23 (1.65%). Of all patients with lung adenocarcinoma, only 5 patients (0.6%) with stage IV disease received immunotherapy. All were treated with nivolumab. Thematic analysis of qualitative data (35 patients) revealed that high treatment costs and limited drug availability are the primary barriers to accessing immunotherapy. Conclusions: This study represents the first evaluation of access to immunotherapy for patients with lung cancer in Syria. Even at ABUH, the country's main cancer center, access to immunotherapy and molecular testing remains markedly limited. International collaboration is necessary to expand diagnostic infrastructure, standardize data reporting, and enhance financial protection mechanisms. These are critical steps toward achieving better cancer care in Syria.

PURPOSE Immune checkpoint inhibitors (ICIs) have significantly improved outcomes in various malignancies. However, the high cost of these therapies limits access for much of the global population. This systematic review aims to evaluate the efficacy of low-dose ICIs compared with standard doses in different malignancies, addressing financial and access barriers in global cancer care. METHODS We conducted a systematic review of studies comparing the efficacy of low-dose versus standard-dose ICI regimens in advanced solid tumors. A comprehensive search was performed across multiple electronic databases, including retrospective and prospective studies. Excluded were animal studies, editorials, conference papers, book chapters, and other immunotherapy modalities. Outcomes assessed included overall survival (OS), progression-free survival, and objective response rate. Results were summarized descriptively due to study heterogeneity. RESULTS From 1,010 screened articles, four studies with 435 Asian patients were included, covering a variety of solid tumors. All included studies were with a low quality of evidence and a high risk of bias due to retrospective design. Two studies used weight-based dosing (pembrolizumab <2 mg/kg and nivolumab <2.15 mg/kg), showing similar OS to standard dosing in non–small cell lung cancer (NSCLC) and renal cell carcinoma, respectively. Flat dose regimens in two studies (nivolumab 20 mg or 100 mg once every 3 weeks and pembrolizumab 100 mg once every 3 weeks) also demonstrated comparable OS in NSCLC. CONCLUSION Low-dose ICIs may offer equivalent clinical benefits to standard dosing, potentially reducing costs and expanding access in developing countries. Although awaiting more representative randomized clinical trials, weight-based ICI regimens could be a viable alternative in low- and middle-income countries.