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ShokriShokri F, Mozdarani H, Omrani MD. Rel-A/PACER/miR 7 Axis May Play a Role in Radiotherapy Treatment in Breast Cancer Patients. IRANIAN BIOMEDICAL JOURNAL 2023; 27:173-82. [PMID: 37507347 PMCID: PMC10507291 DOI: 10.61186/ibj.3901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/06/2023] [Indexed: 12/17/2023]
Abstract
Background Radiotherapy has become the standard form of treatment for breast cancer (BC). Radioresistance is an issue that limits the effectiveness of radiotherapy (RT). Therefore, predictive biomarkers are needed to choose the appropriate RT for the patient. Activation of the proinflammatory transcription factor, nuclear factor-kappa B (NF-κB), is a frequently noted pathway in BC. Investigating the relationship between RT and alterations in gene expression involved in the immune pathway can help better control the disease. This research investigated the impact of RT on the expression levels of Rel-A, PACER, and miR-7 within the NF-κB signaling pathway. Methods Blood samples (n = 15) were obtained from BC patients during four different time intervals: 72 hours prior to initiating RT, as well as one, two, and four weeks following RT completion. Samples were also collected from 20 healthy women who had no immune or cancer-related diseases. Blood RNA was extracted, and complementary DNA was synthesized. Gene expression level was determined using R real-time polymerase chain reaction (RT-PCR). Results There was a significant difference in the expression level of Rel-A between patients and normal individual blood samples (p < 0.05). After four weeks of RT, qRT-PCR revealed a significant downregulation of miR-7 and upregulation of Rel-A and PACER in BC patients. Also, there was a significant association between Rel-A expression and monocyte numbers during RT (p < 0.001). Conclusion The expression level of PACER, miR-7 and Rel-A, changed after RT; therefore, these genes could be used as diagnostic and therapeutic RT markers in BC.
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Affiliation(s)
- Fazlollah ShokriShokri
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran;
| | - Hossein Mozdarani
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran;
| | - Mir Davood Omrani
- Urogenital Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Zafar MR, Sharma A, Sunder SS, Karthikeyan B, Nagahama M, Atia A, Bahuva R, Pokharel S, Iyer V, Kattel S, Sharma UC. Left atrial appendage volume as a prognostic Indicator of long-term mortality in Cancer survivors treated with thoracic radiation. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:2. [PMID: 36641509 PMCID: PMC9840329 DOI: 10.1186/s40959-023-00155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/09/2023] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cancer survivors with prior chest radiation therapy (CXRT) frequently present with atrial fibrillation, heart failure, and have higher overall long-term mortality. There are no data examining the utility of left atrial (LA) and LA appendage (LAA) volume-indices to predict clinical outcomes in these patients. OBJECTIVES We examined the prognostic value of cardiac phase-dependent 3-D volume-rendered cardiac computerized tomography (CT)-derived LA and LAA volume-indices to predict mortality and major adverse cardiac events (MACE) in cancer survivors treated with thoracic irradiation. METHOD We screened 625 consecutive patients with severe aortic stenosis who had undergone transcatheter aortic valve replacement from 2012 to 2017. Based on the gated cardiac CT image quality, we included 184 patients (CXRT:43, non-CXRT:141) for further analysis. We utilized multiplane-3D-reconstructed cardiac CT images to calculate LA and LAA volume-indices, and examined the prognostic role of CCT-derived LA and LAA volume-indices in predicting the all-cause mortality, cardiovascular (CV) mortality, and MACE. We used multivariate cox-proportional hazard analysis to identify the clinical predictors of survival. RESULTS Overall, the CXRT group had significantly elevated LAA volume-index compared to non-CXRT group (CXRT:11.2 ± 8.9 ml/m2; non-CXRT:8.6 ± 4.5 ml/m2, p = 0.03). On multivariate cox-proportional hazard analysis, the elevated LAA volume and LAA volume-index were the strongest predictors of reduced survival in CXRT group compared to non-CXRT group (LAA volume: RR = 1.03,95% CI 1.0-1.01, p = 0.01; and LAA volume index: RR = 1.05, 95% CI 1.0-1.01, p = 0.03). LAA volume > 21.9 ml was associated with increased mortality. In contrast, LA volume was not a significant predictor of mortality. CONCLUSION We describe a novel technique to assess LA and LAA volume using 3-D volume-rendered cardiac CT. This study shows enlarged LAA volume rather than LA volume carries a poor prognosis in cancer-survivors treated with prior CXRT. Compared to conventionally reported markers, LAA volume of > 21.9 ml was incremental to that of other risk factors.
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Affiliation(s)
- Meer R. Zafar
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Ashutosh Sharma
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- grid.425214.40000 0000 9963 6690Department of Medicine at the Icahn School of Medicine, Mount Sinai Health System, New York, NY USA
| | - Sunitha Shyam Sunder
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Badri Karthikeyan
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Makoto Nagahama
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- grid.415875.a0000 0004 0368 6175Division of Cardiology, Lehigh Valley Health Network, Allentown, PA USA
| | - Andrew Atia
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Ronak Bahuva
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Saraswati Pokharel
- grid.240614.50000 0001 2181 8635Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Centre, Buffalo, NY USA
| | - Vijay Iyer
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Sharma Kattel
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- grid.47100.320000000419368710Department of Medicine, Division of Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Umesh C. Sharma
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacob’s School of Medicine and Biomedical Sciences, Buffalo, NY USA
- Advanced Cardiovascular Imaging, Division of Cardiovascular Medicine, 875 Ellicott Street, Buffalo, New York, 14203 USA
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Poortmans PM, Struikmans H, De Brouwer P, Weltens C, Fortpied C, Kirkove C, Budach V, Peignaux-Casasnovas K, van der Leij F, Vonk E, Valli M, van Tienhoven G, Weidner N, Noel G, Guckenberger M, Koiter E, van Limbergen E, Engelen A, Fourquet A, Bartelink H. Side Effects 15 Years after Lymph Node Irradiation in Breast Cancer: Randomized EORTC Trial 22922/10925. J Natl Cancer Inst 2021; 113:1360-1368. [PMID: 34320651 DOI: 10.1093/jnci/djab113] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/25/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Uncertainty about the benefit/risk ratio of regional lymph node irradiation led to varying clinical protocols. We investigated long-term late side effects after internal mammary and medial supraclavicular (IM-MS) lymph node irradiation to improve shared decision-making. METHODS The multicentre EORTC trial (ClinicalTrials.gov, NCT00002851) randomized stage I-III breast cancer patients with involved axillary nodes and/or a medially located primary tumor. We analyzed late side effects, both longitudinally at every follow-up and cross-sectionally at 5-year intervals. All statistical tests were 2-sided. RESULTS Between 1996 and 2004, 46 departments from 13 countries accrued 4004 patients. Median follow-up was 15.7 years. Longitudinal follow-up data showed cumulative incidence rates at 15 years of 2.9% (95% confidence interval [CI] = 2.2%-3.8%) vs. 5.7% (95% CI = 4.7%-6.9%) (P<.001) for lung fibrosis, of 1.1% (95% CI = 0.7%-1.7%) vs. 1.9% (95% CI = 1.3%-2.6%) (P=.07) for cardiac fibrosis, and of 9.4% (95% CI = 8.0%-10.8%) vs. 11.1% (95% CI = 9.6%-12.7%) (P=.04) for any cardiac disease, when treated without or with IM-MS lymph node irradiation. There was no evidence for differences between left- and right-sided breast cancer (Wald chi-square test of treatment by breast side interaction, P=.33 and P=.35, for cardiac fibrosis and for any cardiac disease, respectively). The cumulative incidence probabilities of cross-sectionally reported side effects with a score of 2 or greater at 15 years were 0.1% (95% CI = 0.0%-0.5%) vs. 0.8% (95% CI = 0.4%-1.4%) for pulmonary (P=.02), 1.8% (95% CI = 1.1%-2.8%) vs. 2.6% (95% CI = 1.8%-3.7%) for cardiac (P=.15), and 0.0% (95% CI not evaluated) vs. 0.1% (95% CI = 0.0%-0.4%) for oesophageal (P=.16), respectively. No difference was observed in the incidence of second malignancies, contralateral breast cancer or cardiovascular deaths. CONCLUSIONS The incidence of late pulmonary side effects was statistically significantly higher after IM-MS lymph node irradiation, as were some of the cardiac events, without a difference between left- and right-sided treatments. Absolute rates and differences were very low, without increased non-breast cancer related mortality, even before introducing heart-sparing techniques.
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Affiliation(s)
- Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium.,University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peter De Brouwer
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven faculty of medicine, Leuven, Belgium
| | - Catherine Fortpied
- European Organisation for Research and Treatment of Cancer (EORTC), Headquarters, Brussels, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Volker Budach
- Department of Radiation Oncology, Charité-Universitaetsmedizin Berlin, corporate member of Free University Berlin, Humboldt-University Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Georges Noel
- Department of Radiation Oncology, Centre Paul Strauss, Strasbourg, France
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Erik van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven faculty of medicine, Leuven, Belgium
| | - Antoine Engelen
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Poortmans PM, Weltens C, Fortpied C, Kirkove C, Peignaux-Casasnovas K, Budach V, van der Leij F, Vonk E, Weidner N, Rivera S, van Tienhoven G, Fourquet A, Noel G, Valli M, Guckenberger M, Koiter E, Racadot S, Abdah-Bortnyak R, Van Limbergen EF, Engelen A, De Brouwer P, Struikmans H, Bartelink H. Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial. Lancet Oncol 2020; 21:1602-1610. [PMID: 33152277 DOI: 10.1016/s1470-2045(20)30472-1] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND 10-year results from several studies showed improved disease-free survival and distant metastasis-free survival, reduced breast cancer-related mortality, and variable effects on overall survival with the addition of partial or comprehensive regional lymph node irradiation after surgery in patients with breast cancer. We present the scheduled 15-year analysis of the European Organisation for Research and Treatment of Cancer (EORTC) 22922/10925 trial, which aims to investigate the impact on overall survival of elective internal mammary and medial supraclavicular (IM-MS) irradiation. METHODS EORTC 22922/10925, a randomised, phase 3 trial done across 46 radiation oncology departments from 13 countries, included women up to 75 years of age with unilateral, histologically confirmed, stage I-III breast adenocarcinoma with involved axillary nodes or a central or medially located primary tumour. Surgery consisted of mastectomy or breast-conserving surgery and axillary staging. Patients were randomly assigned (1:1) centrally using minimisation to receive IM-MS irradiation at 50 Gy in 25 fractions (IM-MS irradiation group) or no IM-MS irradiation (control group). Stratification was done for institution, menopausal status, site of the primary tumour within the breast, type of breast and axillary surgery, and pathological T and N stage. Patients and investigators were not masked to treatment allocation. The primary endpoint was overall survival analysed according to the intention-to-treat principle. Secondary endpoints were disease-free survival, distant metastasis-free survival, breast cancer mortality, any breast cancer recurrence, and cause of death. Follow-up is ongoing for 20 years after randomisation. This study is registered with ClinicalTrials.gov, NCT00002851. FINDINGS Between Aug 5, 1996, and Jan 13, 2004, we enrolled 4004 patients, of whom 2002 were randomly assigned to the IM-MS irradiation group and 2002 to the no IM-MS irradiation group. At a median follow-up of 15·7 years (IQR 14·0-17·6), 554 (27·7%) patients in the IM-MS irradiation group and 569 (28·4%) patients in the control group had died. Overall survival was 73·1% (95% CI 71·0-75·2) in the IM-MS irradiation group and 70·9% (68·6-72·9) in the control group (HR 0·95 [95% CI 0·84-1·06], p=0·36). Any breast cancer recurrence (24·5% [95% CI 22·5-26·6] vs 27·1% [25·1-29·2]; HR 0·87 [95% CI 0·77-0·98], p=0·024) and breast cancer mortality (16·0% [14·3-17·7] vs 19·8% [18·0-21·7]; 0·81 [0·70-0·94], p=0·0055) were lower in the IM-MS irradiation group than in the control group. No significant differences in the IM-MS irradiation group versus the control group were seen for disease-free survival (60·8% [95% CI 58·4-63·2] vs 59·9% [57·5-62·2]; HR 0·93 [95% CI 0·84-1·03], p=0·18), or distant metastasis-free survival (70·0% [67·7-72·2] vs 68·2% [65·9-70·3]; 0·93 [0·83-1·04], p=0·18). Causes of death between groups were similar. INTERPRETATION The 15-year results show a significant reduction of breast cancer mortality and any breast cancer recurrence by IM-MS irradiation in stage I-III breast cancer. However, this is not converted to improved overall survival. FUNDING US National Cancer Institute, Ligue Nationale contre le Cancer, and KWF Kankerbestrijding.
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Affiliation(s)
- Philip M Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium.
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium; Department of Oncology, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Catherine Fortpied
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy Cancer Centre, Villejuif, France
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Georges Noel
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg-Europe, Strasbourg, France
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Severine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | - Erik F Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium; Department of Oncology, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Antoine Engelen
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, Netherlands
| | - Peter De Brouwer
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
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Nikbakht R, Bahrampour A. Determining factors influencing survival of breast cancer by fuzzy logistic regression model. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:135. [PMID: 29387122 PMCID: PMC5767811 DOI: 10.4103/jrms.jrms_405_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 09/02/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
Background Fuzzy logistic regression model can be used for determining influential factors of disease. This study explores the important factors of actual predictive survival factors of breast cancer's patients. Materials and Methods We used breast cancer data which collected by cancer registry of Kerman University of Medical Sciences during the period of 2000-2007. The variables such as morphology, grade, age, and treatments (surgery, radiotherapy, and chemotherapy) were applied in the fuzzy logistic regression model. Performance of model was determined in terms of mean degree of membership (MDM). Results The study results showed that almost 41% of patients were in neoplasm and malignant group and more than two-third of them were still alive after 5-year follow-up. Based on the fuzzy logistic model, the most important factors influencing survival were chemotherapy, morphology, and radiotherapy, respectively. Furthermore, the MDM criteria show that the fuzzy logistic regression have a good fit on the data (MDM = 0.86). Conclusion Fuzzy logistic regression model showed that chemotherapy is more important than radiotherapy in survival of patients with breast cancer. In addition, another ability of this model is calculating possibilistic odds of survival in cancer patients. The results of this study can be applied in clinical research. Furthermore, there are few studies which applied the fuzzy logistic models. Furthermore, we recommend using this model in various research areas.
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Affiliation(s)
- Roya Nikbakht
- Department of Biostatistics and Epidemiology, Modeling in Health Research Center, Faculty of Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Abbas Bahrampour
- Department of Biostatistics and Epidemiology, Modeling in Health Research Center, Faculty of Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Marks LB, Zagar TM, Kaidar-Person O. Reassessing the Time Course for Radiation-Induced Cardiac Mortality in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:303-305. [PMID: 28068237 DOI: 10.1016/j.ijrobp.2016.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/17/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina.
| | - Timothy M Zagar
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Orit Kaidar-Person
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
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Ahmed SH, Moussa Sherif DE, Fouad Y, Kelany M, Abdel-Rahman O. Principles of a risk evaluation and mitigation strategy (REMS) for breast cancer patients receiving potentially cardiotoxic adjuvant treatments. Expert Opin Drug Saf 2016; 15:911-23. [DOI: 10.1517/14740338.2016.1170115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Locoregional Treatment in Early Stage Breast Cancer: More Evidence and Yet More Questions? Clin Oncol (R Coll Radiol) 2015; 27:689-91. [PMID: 26545707 DOI: 10.1016/j.clon.2015.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/09/2015] [Indexed: 11/22/2022]
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Poortmans PM, Collette S, Kirkove C, Van Limbergen E, Budach V, Struikmans H, Collette L, Fourquet A, Maingon P, Valli M, De Winter K, Marnitz S, Barillot I, Scandolaro L, Vonk E, Rodenhuis C, Marsiglia H, Weidner N, van Tienhoven G, Glanzmann C, Kuten A, Arriagada R, Bartelink H, Van den Bogaert W. Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer. N Engl J Med 2015. [PMID: 26200978 DOI: 10.1056/nejmoa1415369] [Citation(s) in RCA: 714] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown. METHODS We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracic-wall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer. RESULTS Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median follow-up of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest. CONCLUSIONS In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).
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Affiliation(s)
- Philip M Poortmans
- From the Department of Radiation Oncology, Radboud University Medical Center, Nijmegen (P.M.P.), Department of Radiation Oncology, Institute Verbeeten, Tilburg (P.M.P., K.D.W.), Department of Radiation Oncology, Medisch Centrum Haaglanden, The Hague (H.S.), Department of Radiation Oncology, University Medical Center Utrecht, Utrecht (H.S., C.R.), Department of Radiation Oncology, Institute for Radiation Oncology Radiotherapeutisch Instituut Stedendriehoek en Omstreken, Deventer (E.V.), Department of Radiation Oncology, Academic Medical Center (G.T.), and Department of Radiation Oncology, the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (H.B.), Amsterdam - all in the Netherlands; European Organization for Research and Treatment of Cancer (EORTC) Headquarters (S.C., L.C.) and Department of Radiation Oncology, University Hospital Saint-Luc, Université Catholique de Louvain (C.K.), Brussels, and Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven (E.V.L., W.V.B.) - all in Belgium; Department of Radiation Oncology, Charité University Medicine Berlin, Berlin (V.B., S.M.), and Department of Radiation Oncology, University Hospital, Tübingen (N.W.) - both in Germany; Department of Radiation Oncology, Institut Curie, Paris (A.F.), Department of Radiation Oncology, Centre Georges-François Leclerc, Dijon (P.M., I.B.), Department of Radiation Oncology, Université François Rabelais, Tours (I.B.), and Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif (H.M.) - all in France; Department of Radiation Oncology, Ospedale Regionale di Bellinzona e Valli, Bellinzona (M.V.), and Department of Radiation Oncology, University Hospital Zurich (C.G.) - both in Switzerland; Department of Radiation Oncology, Sant'Anna Hospital, Como, Italy (M.V., L.S.); Department of Radiation Oncology, Rambam Medical Center, Haifa, Israel (A.K.); and Grupo Oncológico Cooperativo Chileno de Investigación, Santiago, Chile (R.A.)
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Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, Knowling MA, Coppin CML, Weir L, Gelmon K, Le N, Durand R, Coldman AJ, Manji M. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 2005; 97:116-26. [PMID: 15657341 DOI: 10.1093/jnci/djh297] [Citation(s) in RCA: 707] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The British Columbia randomized radiation trial was designed to determine the survival impact of locoregional radiation therapy in premenopausal patients with lymph node-positive breast cancer treated by modified radical mastectomy and adjuvant chemotherapy. Three hundred eighteen patients were assigned to receive no further therapy or radiation therapy (37.5 Gy in 16 fractions). Previous analysis at the 15-year follow-up showed that radiation therapy was associated with a statistically significant improvement in breast cancer survival but that improvement in overall survival was of only borderline statistical significance. We report the analysis of data from the 20-year follow-up. METHODS Survival was analyzed by the Kaplan-Meier method. Relative risk estimates were calculated by the Wald test from the proportional hazards regression model. All statistical tests were two-sided. RESULTS At the 20 year follow up (median follow up for live patients: 249 months) chemotherapy and radiation therapy, compared with chemotherapy alone, were associated with a statistically significant improvement in all end points analyzed, including survival free of isolated locoregional recurrences (74% versus 90%, respectively; relative risk [RR] = 0.36, 95% confidence interval [CI] = 0.18 to 0.71; P = .002), systemic relapse-free survival (31% versus 48%; RR = 0.66, 95% CI = 0.49 to 0.88; P = .004), breast cancer-free survival (48% versus 30%; RR = 0.63, 95% CI = 0.47 to 0.83; P = .001), event-free survival (35% versus 25%; RR = 0.70, 95% CI = 0.54 to 0.92; P = .009), breast cancer-specific survival (53% versus 38%; RR = 0.67, 95% CI = 0.49 to 0.90; P = .008), and, in contrast to the 15-year follow-up results, overall survival (47% versus 37%; RR = 0.73, 95% CI = 0.55 to 0.98; P = .03). Long-term toxicities, including cardiac deaths (1.8% versus 0.6%), were minimal for both arms. CONCLUSION For patients with high-risk breast cancer treated with modified radical mastectomy, treatment with radiation therapy (schedule of 16 fractions) and adjuvant chemotherapy leads to better survival outcomes than chemotherapy alone, and it is well tolerated, with acceptable long-term toxicity.
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Affiliation(s)
- Joseph Ragaz
- McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave., Montreal, PQ, Canada H3A 1A1.
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Pendlebury SC, Ivanov O, Renwick S, Stevens GN. Long-term review of a breast conservation series and patterns of care over 18 years. ANZ J Surg 2003; 73:577-83. [PMID: 12887521 DOI: 10.1046/j.1445-2197.2003.t01-1-02704.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multiple randomized trials of breast conservation compared with mastectomy in early breast cancer have validated equivalence of survival. Overwhelmingly the standard management of breast conservation includes surgical removal of the tumour, axillary dissection, postoperative breast irradiation, and adjuvant systemic therapy as appropriate. The outcomes are reviewed of 832 women with early breast cancer treated by local resection and irradiation at Royal Prince Alfred Hospital over an 18 year period, with particular emphasis on the changing patterns of practice. METHODS Between September 1978 and May 1996, 832 women with early stage breast cancer were treated with conservative surgery and radiation therapy. The changes in patient, tumour and treatment factors were analysed over this time period. The outcomes of local recurrence and survival were recorded. Trends in patterns of these variables were evaluated by dividing the 18 years accrual period into three consecutive periods (1978-1983, n = 28; 1984-1990, n = 392; 1991-1996, n = 412). RESULTS At a median follow up of 76 months, the 5 and 10 year actuarial local recurrence rates were 4% and 6%, respectively. Half of the local recurrences were at the primary site. Young age, extensive intraduct carcinoma, oestrogen receptor (ER) status and extranodal spread were predictive of local recurrence on multivariate analysis. The 5 and 10 year overall survival rates were 88% and 73%, respectively. Actuarial 5 year local recurrence (4%, 6%, 2%) and survival (96%, 88%, 92%) rates varied little across the three time intervals. There was an increase in median age from 46 to 56 years over the accrual period, with no change in median primary tumour size (1.5 cm). There were significant histopathological improvements in reporting margin status and ER status. Surgically, the median number of axillary lymph nodes retrieved (14) did not alter significantly. With respect to adjuvant therapies, irradiation of lymph nodes regions decreased over time. The proportion of patients receiving adjuvant hormones or chemotherapy increased significantly (18%, 35%, 54%). CONCLUSIONS The low local recurrence rate and high survival are consistent with published literature for early breast cancer. Changes in practice during the accrual period included improvements in histopathological reporting, a reduction in irradiation of lymph node regions, and an increase in the use of systemic therapy. These changes parallel international recommendations regarding the optimal management of early breast cancer.
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Affiliation(s)
- Susan C Pendlebury
- Sydney Breast Cancer Institute and Department of Radiation Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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Affiliation(s)
- K Pritchard
- Department of Medicine, University of Toronto, Ontario, Canada
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