Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy

Omission of radiotherapy after breast conservation surgery in the postneoadjuvant setting

BACKGROUND

Breast conservation therapy (BCT) consists of breast conservation surgery (BCS) and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) can downstage tumors, broadening BCS eligibility in patients requiring mastectomy. However, tumor downstaging does not obviate need for RT. This study evaluated factors that predict RT omission after NACT and BCS.

METHODS

The National Cancer Database was queried for women with unilateral, clinical stage II-III breast cancer, treated with NACT and BCS between 2008 and 2012. Patients not receiving RT after NACT and BCS were identified. A subgroup analysis was performed eliminating patients for whom RT was recommended but not received.

RESULTS

Among 10,220 patients meeting study eligibility, 974 (9.53%) did not receive RT after BCS. Predictors of RT omission included older age, insurance status, facility type, facility region, more recent year of diagnosis, receptor status unknown, human epidermal growth factor receptor 2 status positive or unknown, and positive margins. Factors increasing the likelihood of RT receipt included cN3 disease, receptor positivity, and primary downstaging. Race, Hispanicity, education, income, comorbidities, rural versus urban setting, histology, grade, and nodal stage change were not associated with RT omission. When excluding the 314 patients for whom RT was recommended but not received, age, Medicaid insurance, facility type, facility region, receptor status unknown, human epidermal growth factor receptor 2 status unknown, and positive margins were predictors of RT omission.

CONCLUSIONS

Race, comorbidities, and socioeconomic status were not predictors of RT omission. It remains unclear whether omission of RT in some cases is due to lack of physician knowledge. Further efforts are needed to ensure that physicians and patients recognize that RT is a vital and required part of BCT, even after NACT.

Pros and cons of immediate Vicryl mesh insertion after lumpectomy

BACKGROUND

Lumpectomy is a standard surgery for breast cancer; however, it results in breast deformity, especially after radiation therapy. Wider surgical margin correlates lower local recurrence rate. However, bigger defect brings worse cosmetic outcome. The use of a simple filler for the defect is expected. We aimed to improve the cosmetic outcome by using an absorbable Vicryl mesh for breast reconstruction immediately post-lumpectomy.

METHODS

One sheet of Vicryl woven mesh was prepared for insertion, washed the cavity with natural saline, and placed into the space. The cosmetic outcome was scored for the size, shape, scar, and softness of the breast. The size, shape, color, and position of the nipple-areola complex were also scored. Adverse events were collected retrospectively.

RESULTS

From April 2008 to October 2014, 24 female patients received immediate Vicryl mesh insertion. A lumpectomy only group was recruited for cosmetic analysis. All patients received postsurgical radiotherapy. The mean cosmetic assessment score was 8.0 and 9.1 of 12 for the Vicryl mesh group and lumpectomy only group, respectively (P = 0.17). Sixteen patients had adverse events such as erythema at approximately 2 weeks post-surgery. No significant differences were shown except adverse events between two groups. No patient has had local recurrence thus far.

CONCLUSION

Immediate Vicryl mesh insertion leads to significantly increased incidence of postoperative complications and delay in commencement of adjuvant radiotherapy. Furthermore, the cosmetic outcomes are not superior to that of no reconstruction. The development of superior biomaterials is anticipated for breast reconstruction after lumpectomy.

The influence of timing of radiation therapy following breast-conserving surgery on 10-year disease-free survival

Background:

The Dutch guidelines advise to start radiation therapy (RT) within 5 weeks following breast-conserving surgery (BCS). However, much controversy exists regarding timing of RT. This study investigated its effect on 10-year disease-free survival (DFS) in a Dutch population-based cohort.

Methods:

All women diagnosed with primary invasive stage I-IIIA breast cancer in 2003 treated with BCS+RT were included. Two populations were studied. Population 1 excluded patients receiving chemotherapy before RT. Analyses were stratified for use of adjuvant systemic therapy (AST). Population 2 included patients treated with chemotherapy, and compared chemotherapy before (BCS-chemotherapy-RT) and after RT (BCS-RT-chemotherapy). DFS was estimated using multivariable Cox regression. Locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were secondary outcomes.

Results:

Population 1 (n=2759) showed better DFS and DMFS for a time interval of >55 than a time interval of <42 days. Patients treated with AST showed higher DFS for >55 days (hazards ratio (HR) 0.60 (95% confidence interval (CI): 0.38–0.94)) and 42–55 days (HR 0.64 (95% CI: 0.45–0.91)) than <42 days. Results were similar for DMFS, while timing did not affect LRRFS and OS. For patients without AST, timing was not associated with DFS, DMFS and LLRFS, but 10-year OS was significantly lower for 42–55 and >55 days compared to <42 days. In population 2 (n=1120), timing did not affect survival in BCS-chemotherapy-RT. In BCS-RT-chemotherapy, DMFS was higher for >55 than <42 days.

Conclusions:

Starting RT shortly after BCS seems not to be associated with a better long-term outcome. The common position that RT should start as soon as possible following surgery in order to increase treatment efficacy can be questioned.

Breast reconstruction and postmastectomy radiotherapy: complications by type and timing and other problems in radiation oncology

Breast reconstruction (BR) represents a suitable option for women who are not expected to require postmastectomy radiotherapy (PMRT). As recent evidence has led to an extension of the indications for PMRT, this has also appeared to increase the incidence of reconstructive complications. Nevertheless, in the USA at least, trends towards BR are changing. The frequency of immediate reconstruction continues to increase, even in the setting of PMRT. In immediate implant-based reconstruction, a staged approach is preferred. The failure rate of PMRT in implant patients is lower than that with expander patients. In delayed implant-based construction, tissue expansion of irradiated skin leads to a significantly increased risk of complications. In contrast, autologous tissue appears to tolerate radiation damage better than implant-based reconstructions. No significant differences have been described when complication rates of immediate autologous tissue BR with PMRT were compared with delayed autologous tissue BR following PMRT. In previously radiated patients, autologous tissue BR is preferred, and it may be safer when carried out ≥ 12 months after PMRT. Several other problems are associated with radiation delivery after BR and the clues to solve them are reviewed in this paper.

Waiting time for radiation therapy after breast-conserving surgery in early breast cancer: a retrospective analysis of local relapse and distant metastases in 615 patients

Background

Postoperative radiotherapy after breast-conserving surgery (BCS) is the standard in the management of breast cancer. The optimal timing for starting postoperative radiation therapy has not yet been well defined. In this study, we aimed to evaluate if the time interval between BCS and postoperative radiotherapy is related to the incidence of local and distant relapse in women with early node-negative breast cancer not receiving chemotherapy.

Methods

We retrospectively analyzed clinical data concerning 615 women treated from 1984 to 2010, divided into three groups according to the timing of radiotherapy: ≤60, 61–120, and >120 days. To estimate the presence of imbalanced distribution of prognostic and treatment factors among the three groups, the χ2 test or the Fisher exact test were performed. Local relapse-free survival, distant metastasis-free survival (DMFS), and disease-free survival (DFS) were estimated with the Kaplan–Meier method, and multivariate Cox regression was used to test for the independent effect of timing of RT after adjusting for known confounding factors. The median follow-up time was 65.8 months.

Results

Differences in distribution of age, type of hormone therapy, and year of diagnosis were statistically significant. At 15-year follow-up, we failed to detect a significant correlation between time interval and the risk of local relapse (p = 0.09) both at the univariate and the multivariate analysis. The DMFS and the DFS univariate analysis showed a decreased outcome when radiotherapy was started early (p = 0.041 and p = 0.046), but this was not confirmed at the multivariate analysis (p = 0.406 and p = 0.102, respectively).

Conclusions

Our results show that no correlation exists between the timing of postoperative radiotherapy and the risk of local relapse or distant metastasis development in a particular subgroup of women with node-negative early breast cancer.

Emerging agents for the prevention of treatment induced neutropenia in adult cancer patients

INTRODUCTION

The administration of myeloid growth factors is the only approved treatment for the prevention of chemotherapy induced neutropenia and febrile neutropenia. However, their specific indications and contraindications and potential side effects limit their application to only a relatively small subset of patients at the highest risk for complications, such as infection.

AREAS COVERED

A computerized systematic literature search was performed through Medline, Google Scholar, Cochrane Library, the Pharmaprojects database and the clinicaltrials.gov website. The shortcomings of the existing treatment approach are reviewed, along with a synopsis of the characteristics of novel agents that protect bone marrow progenitors from the cytotoxic effects of antineoplastic treatment that may be used in the future as a stand-alone preventive strategy or as an adjunct to growth factors.

EXPERT OPINION

There is an abundance of agents undergoing evaluation for the prevention of treatment-induced neutropenia. The appropriate selection of patients, the optimization of the use of existing agents and the increasing competition from biosimilars which likely ensure future decreases in healthcare costs are essential for growth factors to retain their dominant position in this setting.

True Local Recurrences after Breast Conserving Surgery have Poor Prognosis in Patients with Early Breast Cancer

Background:

This study was aimed at investigating clinical and histopathologic features of ipsilateral breast tumor recurrences (IBTR) and their effects on survival after breast conservation therapy.

Methods:

1,400 patients who were treated between 1998 and 2007 and had breast-conserving surgery (BCS) for early breast cancer (cT1-2/N0-1/M0) were evaluated. Demographic and pathologic parameters, radiologic data, treatment, and follow-up related features of the patients were recorded.

Results:

53 patients (3.8%) had IBTR after BCS within a median follow-up of 70 months. The mean age was 45.7 years (range, 27-87 years), and 22 patients (41.5%) were younger than 40 years. 33 patients (62.3%) had true recurrence (TR) and 20 were classified as new primary (NP). The median time to recurrence was shorter in TR group than in NP group (37.0 (6-216) and 47.5 (11-192) months respectively; p = 0.338). Progesterone receptor positivity was significantly higher in the NP group (p = 0.005). The overall 5-year survival rate in the NP group (95.0%) was significantly higher than that of the TR group (74.7%, p < 0.033). Multivariate analysis showed that younger age (<40 years), large tumor size (>20 mm), high grade tumor and triple-negative molecular phenotype along with developing TR negatively affected overall survival (hazard ratios were 4.2 (CI 0.98-22.76), 4.6 (CI 1.07-13.03), 4.0 (CI 0.68-46.10), 6.5 (CI 0.03-0.68), and 6.5 (CI 0.02- 0.80) respectively, p < 0.05).

Conclusions:

Most of the local recurrences after BCS in our study were true recurrences, which resulted in a poorer outcome as compared to new primary tumors. Moreover, younger age (<40), large tumor size (>2 cm), high grade, triple negative phenotype, and having true recurrence were identified as independent prognostic factors with a negative impact on overall survival in this dataset of patients with recurrent breast cancer. In conjunction with a more intensive follow-up program, the role of adjuvant therapy strategies should be explored further in young patients with large and high-risk tumors to reduce the risk of TR.

QuickStart radiotherapy: an inter-professional approach to expedite radiotherapy treatment in early breast cancer

Background and purpose

This study aims to develop an expedited radiotherapy (RT) process and evaluate its time savings in women requiring whole breast RT.

Material and methods

An inter-professional RT team streamlined the computed tomography (CT) simulation and treatment pathway for a ‘QuickStart’ process. Target delineation was performed by an advanced practice radiation therapist and approved by the radiation oncologist (RO) for planning. Automated breast planning software was used for treatment planning and standard quality checks were performed. To assess time savings, the initial 25 QuickStart patients were matched with women who underwent whole breast simulation on the same day (±3 days), treated using the conventional process.

Results

A total of 73 post-lumpectomy women were treated through the QuickStart process; the median consent-to-RT was 2 days (range: 0–13) and the mean CT simulation-to-RT treatment was 2 hours and 42 minutes (SD 0:30). In the subgroup analysis, QuickStart patients saved an average of 11 days from CT simulation-to-RT and had shorter median wait-times for both surgery/chemotherapy-to-RT (60 versus 38 days;p=0·002) and consultation-to-RT (7 versus 20 days;p&lt;0·001).

Conclusions

Through inter-professional team efforts and the application of automated planning software, we have achieved a process that significantly decreases patient wait-times while maintaining the quality of whole breast RT.

Accelerated partial irradiation for breast cancer: systematic review and meta-analysis of 8653 women in eight randomized trials

BACKGROUND AND PURPOSE

Accelerated partial breast irradiation (APBI) is the strategy that allows adjuvant treatment delivery in a shorter period of time in smaller volumes. This study was undertaken to assess the effectiveness and outcomes of APBI in breast cancer compared with whole-breast irradiation (WBI).

MATERIAL AND METHODS

Systematic review and meta-analysis of randomized controlled trials of WBI versus APBI. Two authors independently selected and assessed the studies regarding eligibility criteria.

RESULTS

Eight studies were selected. A total of 8653 patients were randomly assigned for WBI versus APBI. Six studies reported local recurrence outcomes. Two studies were matched in 5 years and only one study for different time of follow-up. Meta-analysis of two trials assessing 1407 participants showed significant difference in the WBI versus APBI group regarding the 5-year local recurrence rate (HR=4.54, 95% CI: 1.78-11.61, p=0.002). Significant difference in favor of WBI for different follow-up times was also found. No differences in nodal recurrence, systemic recurrence, overall survival and mortality rates were observed.

CONCLUSIONS

APBI is associated with higher local recurrence compared to WBI without compromising other clinical outcomes.

Intraoperative radiotherapy for breast cancer

Intra-operative radiotherapy (IORT) as a treatment for breast cancer is a relatively new technique that is designed to be a replacement for whole breast external beam radiotherapy (EBRT) in selected women suitable for breast-conserving therapy. This article reviews twelve reasons for the use of the technique, with a particular emphasis on targeted intra-operative radiotherapy (TARGIT) which uses X-rays generated from a portable device within the operating theatre immediately after the breast tumour (and surrounding margin of healthy tissue) has been removed. The delivery of a single fraction of radiotherapy directly to the tumour bed at the time of surgery, with the capability of adding EBRT at a later date if required (risk-adaptive technique) is discussed in light of recent results from a large multinational randomised controlled trial comparing TARGIT with EBRT. The technique avoids irradiation of normal tissues such as skin, heart, lungs, ribs and spine, and has been shown to improve cosmetic outcome when compared with EBRT. Beneficial aspects to both institutional and societal economics are discussed, together with evidence demonstrating excellent patient satisfaction and quality of life. There is a discussion of the published evidence regarding the use of IORT twice in the same breast (for new primary cancers) and in patients who would never be considered for EBRT because of their special circumstances (such as the frail, the elderly, or those with collagen vascular disease). Finally, there is a discussion of the role of the TARGIT Academy in developing and sustaining high standards in the use of the technique.

Interval between hysterectomy and start of radiation treatment is predictive of recurrence in patients with endometrial carcinoma

PURPOSE

Adjuvant radiation therapy (RT) has been shown to improve local control in patients with endometrial carcinoma. We analyzed the impact of the time interval between hysterectomy and RT initiation in patients with endometrial carcinoma.

METHODS AND MATERIALS

In this institutional review board-approved study, we identified 308 patients with endometrial carcinoma who received adjuvant RT after hysterectomy. All patients had undergone hysterectomy, oophorectomy, and pelvic and para-aortic lymph node evaluation from 1988 to 2010. Patients' demographics, pathologic features, and treatments were compared. The time interval between hysterectomy and the start of RT was calculated. The effects of time interval on recurrence-free (RFS), disease-specific (DSS), and overall survival (OS) were calculated. Following univariate analysis, multivariate modeling was performed.

RESULTS

The median age and follow-up for the study cohort was 65 years and 72 months, respectively. Eighty-five percent of the patients had endometrioid carcinoma. RT was delivered with high-dose-rate brachytherapy alone (29%), pelvic RT alone (20%), or both (51%). Median time interval to start RT was 42 days (range, 21-130 days). A total of 269 patients (74%) started their RT <9 weeks after undergoing hysterectomy (group 1) and 26% started ≥ 9 weeks after surgery (group 2). There were a total of 43 recurrences. Tumor recurrence was significantly associated with treatment delay of ≥ 9 weeks, with 5-year RFS of 90% for group 1 compared to only 39% for group 2 (P<.001). On multivariate analysis, RT delay of ≥ 9 weeks (P<.001), presence of lymphovascular space involvement (P=.001), and higher International Federation of Gynecology and Obstetrics grade (P=.012) were independent predictors of recurrence. In addition, RT delay of ≥ 9 weeks was an independent significant predictor for worse DSS and OS (P=.001 and P=.01, respectively).

CONCLUSIONS

Delay in administering adjuvant RT after hysterectomy was associated with worse survival endpoints. Our data suggest that shorter time interval between hysterectomy and start of RT may be beneficial.

Factors associated with wait times across the breast cancer treatment pathway in Ontario

BACKGROUND

Longer times from diagnosis to breast cancer treatment are associated with poorer prognosis. This study examined factors associated with wait times by phase in the breast cancer treatment pathway.

METHODS

There were 1760 women eligible for the study, aged 50-69 diagnosed in Ontario with invasive breast cancer from 1995-2003. Multivariate logistic regression examined factors associated with greater than median wait times for each phase of the treatment pathway; from diagnosis to definitive surgery; from final surgery to radiotherapy without chemotherapy and from final surgery to chemotherapy.

RESULTS

The median wait times were 17 days (Inter Quartile Range (IQR) = 0-31) from diagnosis to definitive surgery, 44 days (IQR = 34-56) from final surgery to postoperative chemotherapy and 75 days (IQR = 57-97) from final surgery to postoperative radiotherapy. Diagnosis during 2000-2003 compared to 1995-1999 was associated with significantly longer wait times for each phase of the treatment pathway. Higher income quintile was associated with longer wait time from diagnosis to surgery (OR = 1.47, 95% CI = 1.05-2.06) and shorter wait times from final surgery to radiotherapy (OR = 0.60, 95% CI = 0.37-0.96). Greater stage at diagnosis was associated with shorter wait times from diagnosis to definitive surgery (stage III vs I: OR = 0.49, 95% CI = 0.34-0.71).

CONCLUSIONS

While diagnosis during the latter part of the study period was associated with significantly longer wait times for all phases of the treatment pathway, there were variations in the associations of stage and income quintile with wait times by treatment phase. Continued assessment of factors associated with wait times across the breast cancer treatment pathway is important, as they indicate areas to be targeted for quality improvement with the ultimate goal of improving prognosis.

Preoperative delays in the US Medicare population with breast cancer

PURPOSE

Although no specific delay threshold after diagnosis of breast cancer has been demonstrated to affect outcome, delays can cause anxiety, and surgical waiting time has been suggested as a quality measure. This study was performed to determine the interval from presentation to surgery in Medicare patients with nonmetastatic invasive breast cancer who did not receive neoadjuvant chemotherapy and factors associated with a longer time to surgery.

METHODS

Medicare claims linked to Surveillance, Epidemiology, and End Results data were reviewed for factors associated with delay between the first physician claim for a breast problem and first therapeutic surgery.

RESULTS

Between 1992 and 2005, 72,586 Medicare patients with breast cancer had a median interval (delay) between first physician visit and surgery of 29 days, increasing from 21 days in 1992 to 32 days in 2005. Women (29 days v 24 days for men; P < .001), younger patients (29 days; P < .001), blacks and Hispanics (each 37 days; P < .001), patients in the northeast (33 days; P < .001), and patients in large metropolitan areas (32 days; P < .001) had longer delays. Patients having breast conservation and mastectomies had adjusted median delays of 28 and 30 days, respectively, with simultaneous reconstruction adding 12 days. Preoperative components, including imaging modalities, biopsy type, and clinician visits, were also each associated with a specific additional delay.

CONCLUSION

Waiting times for breast cancer surgery have increased in Medicare patients, and measurable delays are associated with demographics and preoperative evaluation components. If such increases continue, periodic assessment may be required to rule out detrimental effects on outcomes.

Use and timeliness of radiation therapy after breast-conserving surgery in low-income women with early-stage breast cancer

PURPOSE

To characterize overall receipt and timeliness of radiation therapy (RT) following breast-conserving surgery among Medicaid-insured patients.

METHOD

State cancer registry data linked with Medicaid claims from 2003 to 2009 were analyzed. Multivariate logistic and Cox proportional hazards regressions were employed.

RESULTS

Overall, 81% of patients received guideline-recommended RT. Significant variation in timing of RT initiation was documented. Having fewer comorbitidies and receiving chemotherapy were correlated with higher odds of RT initiation within 1 year.

CONCLUSION

Although RT use in Medicaid-insured women appears to have improved since earlier studies, documented delays in RT are troublesome and warrant further investigation.

A case-match study comparing unilateral with synchronous bilateral breast cancer outcomes

PURPOSE

There is controversy about whether patients with synchronous bilateral breast cancer (SBBC) have similar or worse outcomes compared with patients with unilateral breast cancer. The purpose of this study was to determine whether survival outcomes for patients with SBBC can be estimated from the characteristics of their individual cancers.

PATIENTS AND METHODS

Patients had invasive breast cancer, without metastases or inflammatory disease, diagnosed in British Columbia between 1989 and 2000. There were 207 cases with SBBC (diagnosed ≤ 2 months apart) and 15,497 with unilateral breast cancer. By using 10-year breast cancer-specific survival (BCSS) estimates, the higher-risk cancer of each SBBC case was determined and matched with three breast cancers from the unilateral cohort to select 621 high-risk matches. The priority sequence of matching the prognostic and predictive variables was positive lymph node number, primary tumor size, age, grade, lymphovascular invasion, estrogen receptor status, local therapy used, margin status, treating clinic, diagnosis year, and type of systemic therapy used.

RESULTS

With a median follow-up of 10.2 years, the overall 10-year BCSS was significantly higher for the unilateral cohort (81%; 95% CI, 81% to 82%) than for the SBBC cases (71%; 95% CI, 63% to 77%). The SBBC cases had significantly higher mean age and stage at presentation. The 10-year BCSS was 74% (95% CI, 69% to 77%) for the high-risk matches.

CONCLUSION

BCSS was not significantly different between the SBBC cases and their high-risk matches.

Optimal sequence of implied modalities in the adjuvant setting of breast cancer treatment: an update on issues to consider

The adjuvant setting of early breast cancer treatment is an evolving field where different modalities must be combined to improve outcomes; moreover, quality of life of breast cancer survivors emerges as a new important parameter to consider, thus implying a better understanding of toxicities of these modalities. We have conducted a review focusing on the latest literature of the past 3 years, trying to evaluate the existing data on the maximum acceptable delay of radiotherapy when given as sole adjuvant treatment after surgery and the optimal sequence of all these modalities with respect to each other. It becomes evident radiotherapy should be given as soon as possible and within a time frame of 6-20 weeks. Chemotherapy is given before radiotherapy and hormone therapy. However, radiotherapy should be started within 7 months after surgery in these cases. Hormone therapy with tamoxifen might be given safely concomitantly or sequentially with radiotherapy although solid data are still lacking. The concurrent administration of letrozole and radiotherapy seems to be safe, whereas data on trastuzumab can imply only that it is safe to use concurrently with radiotherapy. Randomized comparisons of hormone therapy and trastuzumab administration with radiotherapy need to be performed.

Timing of radiotherapy and outcome in patients receiving adjuvant endocrine therapy

PURPOSE

To evaluate the association between the interval from breast-conserving surgery (BCS) to radiotherapy (RT) and the clinical outcome among patients treated with adjuvant endocrine therapy.

PATIENTS AND METHODS

Patient information was obtained from three International Breast Cancer Study Group trials. The analysis was restricted to 964 patients treated with BCS and adjuvant endocrine therapy. The patients were divided into two groups according to the median number of days between BCS and RT and into four groups according to the quartile of time between BCS and RT. The endpoints were the interval to local recurrence, disease-free survival, and overall survival. Proportional hazards regression analysis was used to perform comparisons after adjustment for baseline factors.

RESULTS

The median interval between BCS and RT was 77 days. RT timing was significantly associated with age, menopausal status, and estrogen receptor status. After adjustment for these factors, no significant effect of a RT delay ≤20 weeks was found. The adjusted hazard ratio for RT within 77 days vs. after 77 days was 0.94 (95% confidence interval [CI], 0.47-1.87) for the interval to local recurrence, 1.05 (95% CI, 0.82-1.34) for disease-free survival, and 1.07 (95% CI, 0.77-1.49) for overall survival. For the interval to local recurrence the adjusted hazard ratio for ≤48, 49-77, and 78-112 days was 0.90 (95% CI, 0.34-2.37), 0.86 (95% CI, 0.33-2.25), and 0.89 (95% CI, 0.33-2.41), respectively, relative to ≥113 days.

CONCLUSION

A RT delay of ≤20 weeks was significantly associated with baseline factors such as age, menopausal status, and estrogen-receptor status. After adjustment for these factors, the timing of RT was not significantly associated with the interval to local recurrence, disease-free survival, or overall survival.

Histotype predicts the curative potential of radiotherapy: the example of ovarian cancers

BACKGROUND

To explore the influence of ovarian cancer histotype on the effectiveness of adjuvant radiotherapy (RT).

METHODS

A review of a population-based experience included all referred women with no reported macroscopic residuum following primary surgery who underwent adjuvant platin-based chemotherapy (CT), with or without sequential RT, and for whom it was possible to assign histotype according to the contemporary criteria.

RESULTS

Seven hundred and three subjects were eligible, of these 351 received RT. For those with apparent stage I and II tumors, the cohort with clear cell (C), endometrioid (E), and mucinous (M) disease who additionally received RT exhibited a 40% reduction in disease-specific mortality and a 43% reduction in overall mortality.

CONCLUSIONS

The curability of those with stage I and II C-, E-, and M-type ovarian carcinomas was enhanced by RT-containing adjuvant therapy. This benefit did not extend to those with stage III or serous tumors. These findings necessitate reassessments of the role of RT and of the nonselective surgical and CT approaches that have characterized ovarian cancer care.

Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis

OBJECTIVES

To determine if the length of interval between breast conserving surgery and start of radiotherapy affects local recurrence and to identify factors that might be associated with delay in older women with breast cancer.

DESIGN

Retrospective cohort analysis with Cox proportional hazards models to study the association between time to radiotherapy and local recurrence, and propensity score and instrumental variable analyses to confirm findings. Logistic regression investigated factors associated with later start of radiotherapy.

SETTING

Linked database (Surveillance, Epidemiology, and End Results Program-Medicare) in the United States

PARTICIPANTS

18 050 women aged over 65 with stage 0-II breast cancer diagnosed in 1991-2002 who received breast conserving surgery and radiotherapy but not chemotherapy.

MAIN OUTCOME MEASURE

Local recurrence.

RESULTS

Median time from surgery to start of radiotherapy was 34 days, with 29.9% (n=5389) of women starting radiotherapy after six weeks. Just over 4% (n=734) of the cohort experienced a local recurrence. After adjustment for clinical and sociodemographic factors, intervals over six weeks were associated with increased likelihood of local recurrence (hazard ratio 1.19, 95% confidence interval 1.01 to 1.39, P=0.033). When the interval was modelled continuously (assessing accumulation of risk by day), the effect was statistically stronger (hazard ratio 1.005 per day, 1.002 to 1.008, P=0.004). Propensity score and instrumental variable analysis confirmed these findings. Instrumental variable analysis showed that intervals over six weeks were associated with a 0.96% increase in recurrence at five years (P=0.026). In multivariable analysis, starting radiotherapy after six weeks was significantly associated with positive nodes, comorbidity, history of low income, Hispanic ethnicity, non-white race, later year of diagnosis, and residence outside the southern states of the US.

CONCLUSIONS

There is a continuous relation between the interval from breast conserving surgery to radiotherapy and local recurrence in older women with breast cancer, suggesting that starting radiotherapy as soon as possible could minimise the risk of local recurrence. There are considerable disparities in time to starting radiotherapy after breast conserving surgery. Regions of the US known to have increased rates of breast conserving surgery had longer intervals before radiotherapy, suggesting limitations in capacity. Given the known negative impact of local recurrence on survival, mechanisms to ameliorate disparities and policies regarding waiting times for treatment might be warranted.

Adenocarcinoma of a neovagina constructed according to the Baldwin-Mori technique

The Authors describe a case of cancerization of a neovagina constructed according to the Baldwin-Mori technique, occurring 39 years after the initial operation. Description of the clinical case is followed by a number of anatomo-pathological considerations. The risk of cancerization and the adverse events associated with this type of neovagina militate against the use of autologous transplant operations in neovagina construction.