The patients perception of her breast following radiation and limited surgery

Tumor bed volumetric changes during breast irradiation for the patients with breast cancer

Purpose

The aim of this study was to evaluate changes in breast tumor bed volume during whole breast irradiation (WBI).

Materials and Methods

From September 2011 to November 2012, thirty patients who underwent breast-conserving surgery (BCS) followed by WBI using computed tomography (CT) simulation were enrolled. Simulation CT scans were performed before WBI (CT1) and five weeks after the breast irradiation (CT2). The tumor bed was contoured based on surgical clips, seroma, and postoperative change. We retrospectively analyzed the factors associated with tumor bed volumetric change.

Results

The median tumor bed volume on CT1 and CT2 was 29.72 and 28.6 mL, respectively. The tumor bed volume increased in 9 of 30 patients (30%) and decreased in 21 of 30 patients (70%). The median percent change in tumor bed volume between initial and boost CT was -5%. Seroma status (p = 0.010) was a significant factor in tumor bed volume reduction of 5% or greater. However, patient age, body mass index, palpability, T stage, axillary lymph node dissection, and tumor location were not significant factors for tumor bed volumetric change.

Conclusion

In this study, volumetric change of tumor bed cavity was frequent. Patients with seroma after BCS had a significant volume reduction of 5% or greater in tumor bed during breast irradiation. Thus, resimulation using CT is indicated for exquisite boost treatment in breast cancer patients with seroma after surgery.

[The impact of radiation therapy on sexual function]

The aim of this study was to evaluate the impact of radiation therapy on sexual life. The analysis was based on a Pubmed literature review. The keywords used for this research were "sexual, radiation, oncology, and cancer". After a brief reminder on the anatomy and physiology, we explained the main complications of radiation oncology and their impact on sexual life. Preventive measures and therapeutic possibilities were discussed. Radiation therapy entails local, systematic and psychological after-effects. For women, vaginal stenosis and dyspareunia represent the most frequent side effects. For men, radiation therapy leads to erectile disorders for 25 to 75% of the patients. These complications have an echo often mattering on the patient quality of life of and on their sexual life post-treatment reconstruction. The knowledge of the indications and the various techniques of irradiation allow reducing its potential sexual morbidity. The information and the education of patients are essential, although often neglected. In conclusion, radiation therapy impacts in variable degrees on the sexual life of the patients. Currently, there are not enough preventive and therapeutic means. Patient information and the early screening of the sexual complications are at stake in the support of patients in the reconstruction of their sexual life.

A prospective study of breast lymphedema: frequency, symptoms, and quality of life

Although lymphedema of the arm is a well-known complication of breast and axillary surgery, breast lymphedema has received scant attention. We sought to prospectively characterize breast lymphedema's incidence, associated symptoms, clinical course, and impact on quality of life. Subjects were enrolled prospectively from a consecutive sample of patients undergoing non-mastectomy breast procedures (excisional biopsy or wide local excision ± lymph node removal) and followed for signs and symptoms of lymphedema in the operated breast. Symptoms and distress were serially assessed with 11-point linear analog scales. Breast lymphedema was diagnosed independent of symptoms, based on the distribution and degree of edema and erythema. One hundred twenty-four women were followed for a median of 11 months, and breast lymphedema was diagnosed in 38 (31%) women. Breast lymphedema was more frequent after breast surgery with axillary node removal (49%) compared to breast surgery alone (0%), p < 0.0001. Breast lymphedema involved multiple quadrants in most women and was characterized by edema in 100% and erythema in 79%. Patients with breast lymphedema were significantly more likely than women without breast lymphedema to report symptoms of breast heaviness (65% vs 22%, p < 0.0001), redness (62% vs 29%, p = 0.0006), and swelling (59% vs 22%, p < 0.0001), but symptom-associated distress was low overall. Three of 32 breast lymphedema patients with clinical follow-up developed chronic edema. Breast lymphedema occurs in approximately one-half of women who undergo breast surgery with axillary node removal. The condition is characterized by diffuse skin edema and erythema as well as self-reported symptoms with a low level of distress.

Satisfaction with a weight loss program: what matters?

PURPOSE

Satisfaction is understudied in weight loss programs. The purpose of this study was to examine the association between participant/program experiences and satisfaction with a weight loss intervention.

DESIGN

A prospective cohort design was utilized.

SETTING

The study was conducted in the Minneapolis metro area.

SAMPLE

Participants were obese employees of a managed care organization. One hundred were enrolled, and 78 had complete data available.

INTERVENTION

Treatment included telephone counseling along with a home telemonitoring scale and instructions to self-weigh daily.

MEASURES

Outcomes included overall program satisfaction and willingness to refer the program to others. Predictors included demographics, treatment group, participation in other programs, expected weight, general health, body mass index, diet quality, physical activity, body image, mental health, counseling, and self-weighing.

ANALYSIS

Quantitative predictor-outcome associations were examined using multiple logistic regressions. Qualitative satisfaction responses were analyzed using a general inductive approach.

RESULTS

Weight loss (odds ratio [OR] = 1.83, p = .008), improved diet (OR = 1.27, p = .092), increased physical activity (OR = 1.05, p = .034), and improved body image (OR = 1.38, p = .051) were independent predictors of overall satisfaction. Treatment group (OR = 14.83, p = .015) and number of counseling calls (OR = 1.49, p = .009) were predictors of willingness to refer the program. Qualitative themes indicated desire to integrate counseling on emotional issues.

CONCLUSION

Health progress explained overall satisfaction, whereas treatment characteristics explained willingness to endorse the intervention. Concentrating on these factors may improve retention. Limitations included self-reported measures.

Patterns of Surgical Treatment for Women Diagnosed with Early Breast Cancer in Queensland

BACKGROUND

Australian women with early breast cancer should be given the choice between breast-conserving surgery (BCS) or mastectomy. This is the first Australian study to report on patterns of surgical care specifically for early breast cancer at a population level.

METHODS

Two population-based routine data collections were linked to obtain surgical treatment information for breast cancer cases diagnosed in 2004 in Queensland, from which we identified 1274 cases of early female breast cancer. Logistic regression was used to assess the likelihood of female breast cancer patients having mastectomy, BCS, and axillary node dissection, after adjusting for patient and hospital demographics, tumor size, and comorbidities.

RESULTS

Three-quarters (77%) of women had BCS, 29% had a mastectomy, and 86% had dissection of the axillary lymph nodes. The likelihood of women having mastectomy was higher among women living in rural areas, those treated in public hospitals, and women who had comorbidities of anemia or heart failure. In contrast, BCS was more likely for women treated in private hospitals or hospitals with high surgical caseload. Heart failure decreased the likelihood of BCS. Having an axillary node dissection was more likely among younger women and those treated in high caseload hospitals.

CONCLUSION

The observed differentials in surgical treatment for early breast cancer patients suggest that access issues may have contributed to the decision-making process. Understanding the reasons why women with early breast cancer choose a certain treatment strategy should be a focus of future research.

Cosmetic outcome of breast conservative treatment for early stage breast cancer

PURPOSE

To evaluate the cosmetic outcome of breast conservative therapy and to examine the degree of agreement between the patients' and oncologists' ratings. We also analyze the influence of several factors on cosmesis.

METHODS AND MATERIALS

We retrospectively evaluated 145 patients with primary breast cancer treated by local excision and radiotherapy between January 2000 and May 2001. Cosmetic outcome was evaluated by doctors and patients and was scored as excellent, good, fair or poor.

RESULTS

73% of patients rated cosmesis as excellent or good while the percentage was 71% when rated by radiation oncologists. The degree of cosmesis concordance evaluated by oncologists and patients was low (kappa = 0.3). In our study the variables which significantly influence on the cosmetic outcome were concomitant adjuvant chemotherapy (p = 0.04) and radiation therapy boost, either by electron beam or brachytherapy (p = 0.013).

CONCLUSION

The cosmetic outcome of breast conserving therapy was good. There was a similar rating by the patient and radiation oncologist, but the level of concordance between patients and doctors was low. Factors that significantly influence the cosmesis appear to be concomitant adjuvant chemotherapy and radiation therapy boost.

Cosmetic outcome of breast conserving therapy after sentinel node biopsy versus axillary lymph node dissection

INTRODUCTION

Next to locoregional control, good cosmetic outcome is one of the main goals of breast conserving treatment (BCT) for breast cancer surgery. Factors affecting cosmetic outcome are well known. The sentinel node (SN) procedure avoids lymphedema in the breast, which might influence cosmetic outcome. The aim of this study was to evaluate the cosmetic outcome of BCT after the SN procedure compared to that after axillary lymph node dissection (ALND).

METHODS

The subjects were 20 patients who underwent ALND and 20 patients who underwent the SN procedure. After a minimum follow-up period of 43 months, we photographed each patient. Fifteen healthy women served as control subjects. We used the percentage breast retraction assessment index (pBRA=BRA/reference length x 100) to compare cosmetic outcome.

RESULTS

The median pBRAs of the ALND group and SN group (14.3 and 6.71, respectively) significantly differed ( p=0.001). The pBRA of the SN group was comparable to the pBRA (6.1) of the control group ( p=0.317).

CONCLUSION

Cosmetic outcome of BCT after the SN procedure was superior compared to the cosmetic outcome after ALND. This is an important additional reason to implement the SN procedure in routine daily practice.

Pain and quality of life after surgery for breast cancer

BACKGROUND

In breast cancer (BC) patients, conservative surgery (CS) followed by irradiation or immediate breast reconstruction (IBR) after modified radical mastectomy (MRM) has been proposed in the attempt to avoid the negative impact of MRM on feminine body image. Regardless of the type of operation, BC patients may feel pain even without recurrent disease with poor adjustment in terms of quality of life (QL).

METHODS

We adopted a questionnaire comprising the short form of the McGill Pain questionnaire, and a previously validated questionnaire able to identify four subscales exploring physical well-being, physical autonomy, relational life and psychological well-being. The questionnaire was mailed in 1999 to a consecutive series of 757 (CS: 481 cases; MRM + IBR with skin expander: 93 cases; MRM: 183 cases) disease-free patients treated for BC between March 1995 and March 1998.

RESULTS

The final analysis assessed the data relating to 529 patients who underwent axillary dissection. Pain was reported by 39.7% of women with higher incidence in patients who underwent CS than in those who underwent MRM +/- IBR, but this difference did not reach statistical significance (p = 0.07). The only statistically significant difference (p < 0.05) between the surgical groups was the pain appearance that occurred earlier in the CS patients and later in the MRM + IBR patients. No other differences were observed. The women with pain had significantly worse QL scores on all of the subscales than those without.

CONCLUSION

Pain after surgery for BC distress almost one-third of patients, regardless of the type of treatment, and had a negative effect on patients' QL. The different surgical procedures may marginally influence the quantitative characteristics of pain.

Breast conservation rates-barriers between tertiary care and community practice

PURPOSE

Low rates of breast conservation therapy (BCT) are reported in the southern United States. We evaluated the influence on BCT rates of opening a radiotherapy (RT) clinic at a community hospital in North Carolina. Before opening, RT was available 5 miles away at a tertiary care center.

METHODS AND MATERIALS

A review of the pathology database of the community hospital identified patients who underwent definitive surgery for invasive breast malignancy or ductal carcinoma in situ between 1994 and 1995, and 1997 and 1998, before and after the opening of the RT clinic in 1996. From these data, the mode of therapy, mastectomy or BCT, was determined. The results were compared using logistic regression analysis. Surgical and RT physician staffing were unchanged throughout the study period.

RESULTS

A total of 586 patients was evaluated. The BCT rate at the community hospital for 1994-1995 and 1997-1998 was 29% and 44%, respectively. On both univariate and multivariate logistic regression analysis, the era of treatment was statistically significant in its impact on the procedure performed (p <0.001).

CONCLUSION

The use of BCT increased at a community hospital after the opening of an on-site RT facility, even though RT was available 5 miles away previously.

Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements

This study was undertaken to examine the feasibility of breast volume estimation as a predictor of cosmetic outcome. We looked at the cosmetic result of conservative surgery related to the percentage of breast tissue removed. The breast tissue excised was calculated by comparing the breast volume, calculated from the mammogram, and the specimen volume. A total of 24 patients were recalled to a special clinic and were assessed for their cosmetic result by the clinician, independent observer and the patient. The assessment was based on a scale of 1 to 4 (poor to excellent). Our results show that if less than 20% of the breast was removed, all assessors felt that the cosmetic result was at least fair. If more than 20% of the breast was removed, the cosmetic score was poor as assessed by the clinician and independent observer. When excision of greater than 20% of breast tissue is anticipated, then a breast reconstruction procedure should be considered, if cosmetic outcome is to be enhanced.

Hyperbaric oxygen therapy for late sequelae in women receiving radiation after breast-conserving surgery

PURPOSE

Persisting symptomatology after breast-conserving surgery and radiation is frequently reported. In most cases, symptoms in the breast resolve without further treatment. In some instances, however, pain, erythema, and edema can persist for years and can impact the patient's quality of life. Hyperbaric oxygen therapy was shown to be effective as treatment for late radiation sequelae. The objective of this study was to assess the efficacy of hyperbaric oxygen therapy in symptomatic patients after breast cancer treatment.

PATIENTS AND METHODS

Forty-four patients with persisting symptomatology after breast-conservation therapy were prospectively observed. Thirty-two women received hyperbaric oxygen therapy in a multiplace chamber for a median of 25 sessions (range, 7-60). One hundred percent oxygen was delivered at 240 kPa for 90-min sessions, 5 times per week. Twelve control patients received no further treatment. Changes throughout the irradiated breast tissue were scored prior to and after hyperbaric oxygen therapy using modified LENT-SOMA criteria.

RESULTS

Hyperbaric oxygen therapy patients showed a significant reduction of pain, edema, and erythema scores as compared to untreated controls (p < 0.001). Fibrosis and telangiectasia, however, were not significantly affected by hyperbaric oxygen therapy. Seven of 32 women were free of symptoms after hyperbaric oxygen therapy, whereas all 12 patients in the control group had persisting complaints.

CONCLUSIONS

Hyperbaric oxygen therapy should be considered as a treatment option for patients with persisting symptomatology following breast-conserving therapy.

Magnetic resonance imaging (MRI) controlled outcome of side effects caused by ionizing radiation, treated with 780 nm-diode laser -- preliminary results

BACKGROUND AND OBJECTIVE

Ionizing radiation therapy by way of various beams such as electron, photon and neutron is an established method in tumor treatment. The side effects caused by this treatment such as ulcer, painful mastitis and delay of wound healing are well known, too. Biomodulation by low level laser therapy (LLLT) has become popular as a therapeutic modality for the acceleration of wound healing and the treatment of inflammation. Evidence for this kind of application, however, is not fully understood yet. This study intends to demonstrate the response of biomodulative laser treatment on the side effects caused by ionizing radiation by means of magnetic resonance imaging (MRI).

STUDY DESIGN/PATIENTS AND METHODS

Six female patients suffering from painful mastitis after breast ionizing irradiation and one man suffering from radiogenic ulcer were treated with lambda=780 nm diode laser irradiation at a fluence rate of 5 J/cm2. LLLT was performed for a period of 4-6 weeks (mean sessions: 25 per patient, range 19-35). The tissue response was determined by means of MRI after laser treatment in comparison to MRI prior to the beginning of the LLLT.

RESULTS

All patients showed complete clinical remission. The time-dependent contrast enhancement curve obtained by the evaluation of MR images demonstrated a significant decrease of enhancement features typical for inflammation in the affected area.

CONCLUSION

Biomodulation by LLLT seems to be a promising treatment modality for side effects induced by ionizing radiation.

Quality-of-life assessment in health care research and practice

This article reviews the different ways in which quality-of-life assessment has been applied to and has affected health care research and practice. A schema that describes the steps involved in the ongoing challenge of improving health outcomes is used to structure the review. The role of quality-of-life assessment is addressed with regard to: the identification of health problems, the evaluation of new treatments, the formulation of treatment guidelines and health policies, the delivery of optimal care in practice, and the assessment of outcomes in the wider community. The benefit of quality-of-life assessment has been demonstrated in a number of these areas (e.g., in identifying problems and evaluating treatments). Its role in other applications (e.g., in clinical practice to assess patients' needs) shows great promise and requires additional evaluation.

Self-perceptions of women after early breast cancer surgery

AIMS

To discover satisfaction with treatment decision and the late influences of surgery for early breast cancer on the lives and self-perceptions of women.

METHODS

A two-part mail survey was returned by 90 women aged 2.8-7.6 years after breast-conserving treatment (BCT) and by 56 women aged 3.0-8.0 years after modified radical mastectomy (MRM).

RESULTS

Approximately one-third of all patients felt the information and time before the treatment decision was inadequate. Most women in both treatment groups had participated in treatment decision-making. When the surgeon alone had made the choice it did not affect satisfaction with the treatment result. Few patients regretted the treatment modality chosen. The majority of patients felt no discomfort in their treated breast, but a quarter of all the women suffered from rib pain. Fifteen of 52 sexually active women reported of reduced breast pleasure sensation in their resected breast. The women in both treatment groups were asked to score a summary satisfaction index (SSI) on a scale of 0-10 for seven different areas of life: cosmesis, function, work, home, recreation/sports, social life and sexuality. SSI was used as a measure of quality of life. There was a difference in all these categories between BCT and MRM groups, the former giving significantly higher values. Post-menopausal women tended to be more-satisfied than younger women and women over 70 years showed no difference in satisfaction between the two treatment modalities. Treatment of early breast cancer caused little morbidity in the long run. After MRM slightly more local symptoms were reported.

CONCLUSIONS

Most women treated with breast-conserving surgery esteemed their life normal or close to normal, giving us a reason to favour BCT when suitable. For women over 70 years old mastectomy remains a viable alternative.

Factors influencing cosmetic results after conservation therapy for breast cancer

PURPOSE

Host, tumor, and treatment-related factors influencing cosmetic outcome are analyzed for patients receiving breast conservation treatment.

METHODS AND MATERIALS

Four-hundred and fifty-eight patients with evaluable records for cosmesis evaluation, a subset of 701 patients treated for invasive breast cancer with conservation technique between 1969 and 1990, were prospectively analyzed. In 243 patients, cosmetic evaluation was not adequately recorded. Cosmesis evaluation was carried out from 3.7 months to 22.3 years, median of 4.4 years. By pathologic stage, tumors were 62% T1N0, 14% T1N1, 15%, T2N0, and 9% T2N1. The majority of patients were treated with 4-6 MV photons. Cosmetic evaluation was rated by both patient and physician every 4-6 months. A logistic regression analysis was completed using a stepwise logistic regression. P-values of 0.05 or less were considered significant. Excellent cosmetic scores were used in all statistical analyses unless otherwise specified.

RESULTS

At most recent follow-up, 87% of patients and 81% of physicians scored their cosmetic outcome as excellent or good. Eighty-two percent of physician and patient evaluations agreed with excellent-good vs. fair-poor rating categories. Analysis demonstrated a lower proportion of excellent cosmetic scores when related to patient age > 60 years (p = 0.001), postmenopausal status (p = 0.02), black race (p = 0.0034), and T2 tumor size (p = 0.05). Surgical factors of importance were: volume of resection > 100 cm3 (p = 0.0001), scar orientation compliance with the National Surgical Adjuvant Breast Project (NSABP) guidelines (p = 0.0034), and > 20 cm2 skin resected (p = 0.0452). Extent of axillary surgery did not significantly affect breast cosmesis. Radiation factors affecting cosmesis included treatment volume (tangential breast fields only vs. three or more fields) (p = 0.034), whole breast dose in excess of 50 Gy (p = 0.0243), and total dose to tumor site > 65 Gy (p = 0.06), as well as optimum dose distribution with compensating filters (p = 0.002). Daily fraction size of 1.8 Gy vs. 2.0 Gy, boost vs. no boost, type of boost (brachytherapy vs. electrons), total radiation dose, and use of bolus were not significant factors. Use of concomitant chemotherapy with irradiation impaired excellent cosmetic outcome (p = 0.02). Use of sequential chemotherapy or adjuvant tamoxifen did not appear to diminish excellent cosmetic outcomes (p = 0.31). Logistic regression for excellent cosmetic outcome analysis was completed for age, tumor size, menopausal status, race, type of surgery, volume of breast tissue resected, scar orientations, whole breast radiation dose, total radiation dose, number of radiation fields treated, and use of adjuvant chemotherapy. Significant independent factors for excellent cosmetic outcome were: volume of tissue resected (p = 0.0001), type of surgery (p = 0.0001), breast radiation dose (p = 0.005), race (p = 0.002), and age (p = 0.007).

CONCLUSIONS

Satisfactory cosmesis was recorded in 81% of patients. Impaired cosmetic results are more likely with improper orientation of tylectomy and axillary incisions, larger volume of breast resection, radiation dose to the entire breast in excess of 50.0 Gy, and concurrent administration of chemotherapy. Careful selection of treatment procedures for specific patients/tumors and refinement in surgical/irradiation techniques will enhance the cosmetic results in breast conservation therapy.

Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 1. Comparison of patients' ratings, observers' ratings, and objective assessments

The cosmetic and functional results of breast conserving therapy were evaluated in a sample of 76 patients with early stage breast cancer, treated by wide local excision, axillary dissection and postoperative radiotherapy between 1975 and 1985. A comparison was made between patients' ratings, independent ratings by two observers (an oncology nurse and a radiation oncologist) and objective measurements. In approximately 40% of the cases, moderate to large differences in the appearance of the treated versus the untreated breast were reported by patients and clinical observers alike. When evaluated on an individual level, the observers' ratings showed relatively high inter-rater agreement (kappa = 0.64), but low levels of concordance were found between the patients' and observers' ratings (kappa < 0.10). Approximately half of the patients reported limited arm or shoulder function, generally mild in nature. Compared to the patients', the observers' ratings of arm edema were significantly lower, indicating 20% mild and 5% more severe swelling. Objective measures of cosmesis and function correlated moderately with the observers' and patients' ratings. Both cosmetic and functional results were found to be significantly related to time elapsed since treatment, with patients treated longer ago exhibiting more problems. The cosmetic and functional outcomes were not related to the patients' age. The results suggest that the patients' opinion can provide important additional information in the evaluation of cosmetic and functional results of breast conserving treatment.

Lactation following conservation surgery and radiotherapy for breast cancer

A 38-year-old woman with early stage invasive breast cancer was treated with wide excision of the tumor, axillary lymph node dissection, and breast irradiation. Three years later, she gave birth to a normal baby. She attempted breast feeding and had full lactation from the untreated breast. The irradiated breast underwent only minor changes during pregnancy and postpartum but produced small amounts of colostrum and milk for 2 weeks postpartum. There are only a few reports of lactation after breast irradiation. These cases are reviewed, and possible factors affecting breast function after radiotherapy are discussed. Because of scant information available regarding its safety for the infant, nursing from the irradiated breast is not recommended.

Treatment of early breast cancer with conservation of the breast. A review

This paper reviews the current status of conservative treatment for early breast cancer. While the first patients were treated with such techniques more than 60 years ago, it is during the last decade that randomized trials have confirmed that such treatment is comparable to mastectomy in preventing breast cancer death. Radiotherapy to the breast after local tumour excision is important to prevent local breast relapse, but it is not clear whether it has any influence on the risk of distant metastases. Several questions remain to be answered. While most investigators agree that the breast should receive a radiation dose of about 50 Gy in 5 weeks, there is no general agreement about the need for a tumour bed booster dose. Considering patients with tumour infiltration at the surgical resection line for whom it is not possible for cosmetic reasons to perform re-resection, it is not clear whether an acceptable local control rate can be achieved through application of a high booster dose in the tumour bed. More trials are needed to show whether certain patients with small invasive carcinomas should be treated with wide local excision without radiotherapy. The need for radiotherapy after local excision for small intraductal (ductal carcinoma in situ) cancers is being addressed in ongoing trials.