Effect of Delay in Initiating Radiotherapy for Patients with Early Stage Breast Cancer

Disaggregation of Asian American and Pacific Islander Women With Stage 0-II Breast Cancer Unmasks Disparities in Survival and Surgery-to-Radiation Intervals: A National Cancer Database Analysis From 2004 to 2017

PURPOSE

Aggregation of Asian Americans (AAs) with Native Hawaiians and Other Pacific Islanders (NHPIs) masks significant health disparities. We evaluated overall survival (OS) and surgery-to-radiation intervals (STRIs) among AA and NHPI women with early-stage breast cancer.

METHODS

This National Cancer Database study included women with stage 0-II breast cancer diagnosed between 2004 and 2017. STRI was defined as days from surgery to radiation. Patients were stratified by adjuvant treatment. AAs were disaggregated into geographically relevant subpopulations: East, South, and Southeast Asians. Kaplan-Meier estimates and log-rank tests assessed survival. Cox proportional hazard and linear regression were adjusted for clinical and sociodemographic factors.

RESULTS

In total, 578,927 women were included (median age 61 years, median follow-up 65 months, and 10-year OS 83%). AA and NHPI 10-year OS was 91% overall; subpopulation 10-year OS was 92% for East Asian, 90% for South Asian, 90% for Southeast Asian, and 83% for NHPI. On multivariable analysis, compared with non-Hispanic White, NHPI women had worse survival (adjusted hazard ratio [aHR] = 1.38; 95% CI, 1.09 to 1.77); all AA subpopulations had improved survival: East Asian (aHR = 0.57; 95% CI, 0.48 to 0.69), South Asian (aHR = 0.66; 95% CI, 0.51 to 0.84), and Southeast Asian (aHR = 0.78; 95% CI, 0.65 to 0.94). The AA and NHPI median STRI for was 73 days overall; the disaggregated median STRI was 68 days for East Asian, 80 days for South Asian, 77 days for Southeast Asians, and 81 days for NHPI. On adjusted analysis, compared with non-Hispanic White, Southeast Asians and NHPI had longer STRI by 6.6 (95% CI, 4.3 to 8.9) and 10.0 (95% CI, 5.8 to 14) days, respectively.

CONCLUSION

Breast cancer disparities exist among disaggregated AA and NHPI subpopulations. Data disaggregation insights may lead to interventions to overcome these disparities, such as optimizing time-to-treatment for select populations.

The Selection of Time Interval Between Surgery and Adjuvant Therapy in Early Stage Cervical Cancer

OBJECTIVES

The optimal interval between surgery and adjuvant treatment has not yet been found in cervical cancer. And whether patients with different FIGO stage should choose different interval is unknown. The purpose of this study was to evaluate whether interval has a different effect on oncologic outcome for patients with different tumor stages.

METHODS

We performed a retrospective study of 226 cervical cancer patients who were treated by surgery and adjuvant therapy from May 2005 to August 2015. All patients were divided into 2 groups according to the interval of 5 weeks. Overall survival (OS) and disease-free survival (DFS) were compared between patients with interval shorter and longer than 5 weeks in the whole group and subgroups. Recurrence patterns were also analyzed. Multivariate analysis was performed to explore clinical factors significantly associated with DFS, local recurrence-free survival and distant metastasis-free survival for patients with stage IB2-IIA.

RESULTS

For patients with stage IA2-IB1, the 5-year OS and DFS were similar between groups of short and long interval with also the comparable results of local and distant failure. For patients with IB2-IIA, both the OS and DFS in the short-interval group were higher than that in the long-interval group. Besides, the rates of local recurrence were found higher in the group of long interval compared with short interval. Multivariable analysis indicated that time interval was an independent predictor of DFS and local recurrence-free survival for patients with stage IB2-IIA.

CONCLUSIONS

In cervical cancer patients, time interval between surgery and adjuvant therapy may have different effects on the prognosis in different FIGO stages.

The impact of the interval between the induction of chemotherapy and radiotherapy on the survival of patients with nasopharyngeal carcinoma

Background

There have been no reliable scientific studies examining whether the interval between induction chemotherapy (IC) and initiating radiotherapy is associated with poor outcomes of nasopharyngeal carcinoma (NPC).

Patients and methods

In this retrospective study, we included a total of 239 local advanced NPC patients who underwent concurrent chemoradiotherapy and IC. Based on the interval between IC and intensity-modulated radiation therapy (IMRT), the patients were classified into three groups as follows: Group A (≤7 vs >7 days), Group B (≤14 vs >14 days), and Group C (≤ 21 vs >21 days). Univariate and multivariate regression analyses were performed to determine the prognostic factors of survival outcomes. The differences between the two groups were compared by the log-rank test.

Results

The median IC-IMRT interval was 9 days (range, 1–76 days). The median follow-up time was 40 months (range, 4–58 months). The IC-IMRT interval including Group A, Group B, and Group C was not significantly associated with overall survival (OS), distant metastasis-free survival (DMFS), locoregional relapse-free survival (LRFS), or disease-free survival (DFS). Multivariate analysis showed that the tumor stage was the independent significant predictor for OS, DMFS, LRFS, and DFS. But it appears that there was a trend toward improvement in the outcome of ≤7 days group in OS from the Kaplan–Meier curves.

Conclusion

It is also feasible to postpone radiotherapy for 1–3 weeks if patients were unable to receive treatment immediately due to chemotherapy complications such as bone marrow suppression. However, we suggest that patients should start IMRT as soon as possible after IC.

Timing and Delays in Breast Cancer Evaluation and Treatment

BACKGROUND

Even small delays in the treatment of breast cancer are a frequently expressed concern of patients. Knowledge about this subject is important for clinicians to counsel patients appropriately and realistically, while also optimizing care. Although data and quality measures regarding time to chemotherapy and radiotherapy have been present for some time, data regarding surgical care are more recent and no standard exists. This review was written to discuss our current knowledge about the relationship of treatment times to outcomes.

METHODS

The published medical literature addressing delays and optimal times to treatment was reviewed in the context of our current time-dependent standards for chemotherapy and radiotherapy. The surgical literature and the lack of a time-dependent surgical standard also were discussed, suggesting a possible standard.

RESULTS

Risk factors for delay are numerous, and tumor doubling times are both difficult to determine and unhelpful to assess the impact of longer treatment times on outcomes. Evaluation components also have a time cost and are inextricable from the patient's workup. Although the published literature has lack of uniformity, optimal times to each modality are strongly suggested by emerging data, supporting the current quality measures. Times to surgery, chemotherapy, and radiotherapy all have a measurable impact on outcomes, including disease-free survival, disease-specific survival, and overall survival.

CONCLUSIONS

Delays have less of an impact than often thought but have a measurable impact on outcomes. Optimal times from diagnosis are < 90 days for surgery, < 120 days for chemotherapy, and, where chemotherapy is administered, < 365 days for radiotherapy.

Impact of time interval between radical hysterectomy with pelvic node dissection and initial adjuvant therapy on oncological outcomes of early stage cervical cancer

Objective

To determine the impact of time interval (TI) from radical hysterectomy with pelvic node dissection (RHND) to adjuvant therapy on oncological outcomes in cervical cancer.

Methods

The study included 110 stage IA2–IB1 cervical cancer patients who underwent RHND and adjuvant therapy. The patients were divided into 2 groups based on the cut-off points of TI of 4 and 6 weeks, respectively. The associations of TI and clinicopathologic factors with oncological outcomes were evaluated using Cox proportional-hazards regression.

Results

The median TI was 4.5 weeks. There were no statistical differences in 5-year recurrence-free survival (RFS) (89.2% vs. 81.0%, and 83.2% vs. 100.0%) or 5-year overall survival (OS) rates (90.9% vs. 97.2%, and 93.2% vs. 100.0%) between patients according to TI (≤4 vs. >4, and ≤6 vs. >6 weeks, respectively). Deep stromal invasion (p=0.037), and parametrial involvement (PI) (p=0.002) were identified as independent prognostic factors for RFS, together with the interaction between TI and squamous cell carcinoma histology (p<0.001). In patients with squamous cell carcinoma, a TI longer than 4 weeks was significantly associated with a worse RFS (hazard ratio [HR]=15.8; 95% confidence interval [CI]=1.4–173.9; p=0.024). Univariate analysis showed that only tumor size (p=0.023), and PI (p=0.003) were significantly associated with OS.

Conclusion

Delay in administering adjuvant therapy more than 4 weeks after RHND in early stage squamous cell cervical cancer results in poorer RFS.

Timing of Radiation Therapy and Chemotherapy After Breast-Conserving Surgery for Node-Positive Breast Cancer: Long-Term Results From International Breast Cancer Study Group Trials VI and VII

PURPOSE

To update the previous report from 2 randomized clinical trials, now with a median follow-up of 16 years, to analyze the effect of radiation therapy timing on local failure and disease-free survival.

PATIENTS AND METHODS

From July 1986 to April 1993, International Breast Cancer Study Group trial VI randomly assigned 1475 pre-/perimenopausal women with node-positive breast cancer to receive 3 or 6 cycles of initial chemotherapy (CT). International Breast Cancer Study Group trial VII randomly assigned 1212 postmenopausal women with node-positive breast cancer to receive tamoxifen for 5 years, or tamoxifen for 5 years with 3 early cycles of initial CT. For patients who received breast-conserving surgery (BCS), radiation therapy (RT) was delayed until initial CT was completed; 4 or 7 months after BCS for trial VI and 2 or 4 months for trial VII. We compared RT timing groups among 433 patients on trial VI and 285 patients on trial VII who received BCS plus RT. Endpoints were local failure, regional/distant failure, and disease-free survival (DFS).

RESULTS

Among pre-/perimenopausal patients there were no significant differences in disease-related outcomes. The 15-year DFS was 48.2% in the group allocated 3 months initial CT and 44.9% in the group allocated 6 months initial CT (hazard ratio [HR] 1.12; 95% confidence interval [CI] 0.87-1.45). Among postmenopausal patients, the 15-year DFS was 46.1% in the no-initial-CT group and 43.3% in the group allocated 3 months initial CT (HR 1.11; 95% CI 0.82-1.51). Corresponding HRs for local failures were 0.94 (95% CI 0.61-1.46) in trial VI and 1.51 (95% CI 0.77-2.97) in trial VII. For regional/distant failures, the respective HRs were 1.15 (95% CI 0.80-1.63) and 1.08 (95% CI 0.69-1.68).

CONCLUSIONS

This study confirms that, after more than 15 years of follow-up, it is reasonable to delay radiation therapy until after the completion of standard CT.

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.

Wait times for breast surgical operations, 2003-2011: a report from the National Cancer Data Base

BACKGROUND

Few large-scale multicenter studies have examined wait times for breast surgery and no benchmarks exist.

METHODS

Using the National Cancer Data Base, we analyzed time from diagnosis to first surgery for 819,175 non-neoadjuvant AJCC stage 0-III breast cancer patients treated from 2003 to 2011. Chi-square tests and logistic regression models were used to examine factors associated with delays to surgery and adjuvant chemotherapy.

RESULTS

Seventy percent of patients underwent an initial lumpectomy (LP), 22% a mastectomy (MA), and 8% a mastectomy with reconstruction (MR). The median time from diagnosis to first surgery significantly increased by approximately 1 week for all three procedures over the study period. In a multivariate analysis, the following variables were independent predictors of a longer wait time to first surgery: increasing age, black or Hispanic race, Medicaid or no insurance, low-education communities and metropolitan areas, increasing comorbidities, stage 0 and grade 1 disease, academic/research facilities, high-volume facilities, and facilities located in the New England, Mid-Atlantic, and Pacific regions. In 2010-2011, patients who waited >30 days for surgery were 1.36 times more likely (OR = 1.36, 95% CI 1.30-1.43) to experience a delay to adjuvant chemotherapy >60 days compared with patients who were surgically treated within 30 days of diagnosis.

CONCLUSIONS

Facility and socioeconomic factors are most strongly associated with longer wait times for breast operations, and delays to surgery are associated with delays to adjuvant chemotherapy initiation.

Impact of bilateral versus unilateral mastectomy on short term outcomes and adjuvant therapy, 2003-2010: a report from the National Cancer Data Base

BACKGROUND

Rates of bilateral mastectomy (BM) have increased, but the impact on length of stay (LOS), readmission rate, 30-day mortality, and time to adjuvant therapy is unknown.

METHODS

Using the National Cancer Data Base, we selected 390,712 non-neoadjuvant AJCC stage 0-III breast cancer patients who underwent either unilateral mastectomy (UM) or BM from 2003 to 2010 with and without reconstruction. We used chi-square and logistic regression models for the analysis.

RESULTS

A total of 315,278 patients (81 %) had UM, and 75,437 (19 %) had BM; 97,031 (25 %) underwent reconstruction. The number of median days from diagnosis to UM increased from 19 days in 2003 to 28 days in 2010, and for BM, increased from 21 to 31 days (p < 0.001). BM was independently associated with a longer time to surgery when adjusting for patient, facility, and tumor factors and reconstruction (OR 1.11; 95 % CI 1.07-1.15; p < 0.001). Reconstructed patients were twice as likely to have a longer time to surgery (OR 2.07; 95 % CI 2.01-2.14; p < 0.001). The median LOS was 1 day (range 0-184 days) for UM versus 2 (range 0-182) for BM (p < 0.001); 30-day mortality and readmission rates were not different between BM and UM. The median number of days from diagnosis to definitive chemotherapy, hormonal therapy, and radiation therapy was significantly greater in the BM group.

CONCLUSIONS

Delays to surgical and adjuvant treatment are significantly longer for BM irrespective of reconstruction, and these delays have increased over the study period. These findings can be used by clinicians to counsel patients on BM.

Timing of radiotherapy following breast-conserving surgery: outcome of 1393 patients at a single institution

BACKGROUND

The role of postoperative radiotherapy in breast-conserving therapy is undisputed. However, optimal timing of adjuvant radiotherapy is an issue of ongoing debate. This retrospective clinical cohort study was performed to investigate the impact of a delay in surgery-radiotherapy intervals on local control and overall survival.

PATIENTS AND METHODS

Data from an unselected cohort of 1393 patients treated at a single institution over a 17-year period (1990-2006) were analyzed. Patients were assigned to two groups (CT+/CT-) according to chemotherapy status. A delay in the initiation of radiotherapy was defined as > 7 weeks (CT- group) and > 24 weeks (CT+ group).

RESULTS

The 10-year regional recurrence-free survival for the CT- and CT+ groups were 95.6 and 86.0 %, respectively. A significant increase in the median surgery-radiotherapy interval was observed over time (CT- patients: median of 5 weeks in 1990-1992 to a median of 6 weeks in 2005-2006; CT+ patients: median of 5 weeks in 1990-1992 to a median of 21 weeks in 2005-2006). There was no association between a delay in radiotherapy and an increased local recurrence rate (CT- group: p = 0.990 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.644 for intervals 0-15 weeks vs. ≥ 24 weeks) or decreased overall survival (CT- group: p = 0.386 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.305 for intervals 0-15 weeks vs. ≥ 24 weeks).

CONCLUSION

In the present cohort, a delay of radiotherapy was not associated with decreased local control or overall survival in the two groups (CT-/CT+). However, in the absence of randomized evidence, delays in the initiation of radiotherapy should be avoided.

From a Waiting List to a Priority List: A Computerized Model for an Easy-to-Manage and Automatically Updated Priority List in the Booking of Patients Waiting for Radiotherapy

Aims and background

Waiting time for radiotherapy is a major problem in clinical practice. We developed a model to create a priority list of patients waiting for radiotherapy according to clinical criteria, where booking of patients is not on a “first-come, first-served” basis and where prioritization has not been left up to individual discretion.

Methods

The system is based on an algorithm that assigns to each patient a personal code (priority code, PC) that can be used as a continuous variable to have a priority list. PCpatient = D0patient + PWTsubgroup of treatment. Palliative treatments were categorized according to the clinical urgency. Radical treatments were stratified by primary tumors, by the setting of treatment (preoperative, curative, postoperative) and by the main prognostic factors. Each subgroup of patients has a “priority waiting time” (PWT subgroup of treatment). Calculation of the PC starts from a differentiated date according to clinical scenario [Reference date (D0)], which is taken from the clinical history of the patient.

Results

Patients are differentiated according to clinical criteria and according to time elapsed from diagnosis. The priority list can be automatically updated day by day. Delays in patient referral or imaging availability are minimized.

Conclusions

The model represents a tool for an objective and automatic prioritization of the patients who are waiting for radiotherapy.

Radiation treatment waiting times for breast cancer patients in Manitoba, 2001 and 2005

INTRODUCTION

Our study examined the wait time from ready-to-treat to radiation therapy for cohorts of breast cancer patients requiring adjuvant radiation therapy in 2001 and in 2005 after the implementation of strategies to reduce wait times for radiation treatment. We also examined the overall time from diagnosis to radiation treatment and whether distance from the cancer treatment centre or month of referral had an effect on wait times.

METHODS

This population-based retrospective study looked at representative samples of women newly diagnosed with breast cancer in 2001 and 2005. Patients who required radiation treatment to the breast or chest wall were followed from first contact to the start of radiation treatment.

RESULTS

Time from ready-to-treat to first radiation treatment was significantly reduced for patients in 2005 as compared with 2001, regardless of whether chemotherapy was administered before radiation treatment. Time from diagnosis to radiation treatment was not different by year for those who received radiation only. Time from diagnosis to chemotherapy was significantly longer in 2005. No effect of month of diagnosis on wait times was observed.

INTERPRETATION

A significant improvement in the median wait time from ready-to-treat to first radiation treatment was noted from 2001 to 2005. This improvement may be attributable to measures taken to reduce such waits. However, we observed an increase in the median time from diagnosis to referral and from referral to consultation with medical or radiation oncology (or both), so that the overall time from diagnosis to radiation treatment was not different. Although specific intervals related to radiation treatment delivery were improved, the entire trajectory of breast cancer care experienced by patients needs to be considered.

Interval between breast-conserving surgery and start of radiation therapy in early-stage breast cancer is not predictive of local recurrence: a single-institution experience

BACKGROUND

The aim of this study was to evaluate if the interval between breast-conserving surgery and the start of radiotherapy has an effect on local relapse risk.

MATERIALS AND METHODS

Between January 2000 and December 2006 a total of 387 patients with T1-2N0+ breast cancer were treated with breast-conserving surgery and radiotherapy, with and without hormone therapy and chemotherapy. Adjuvant radiotherapy was administered to a total dose of 60 to 66 Gy in 30 to 33 fractions. The time intervals between breast-conserving surgery and the start of radiotherapy were < 60, 61 to 120, 121 to 180 and > 180 days. The Kaplan-Meier method was used to calculate local relapse-free survival rates, and the Cox regression method was used to identify predictive factors of local relapse. Evaluated variables were age, tumor location, tumor histologic type, tumor size, surgical margin status, axillary node status, estrogen receptors, tumor grading, adjuvant therapy, adjuvant chemotherapy, radiation therapy, boost dose, and interval between breast-preserving surgery and start of radiation therapy.

RESULTS

Five-year local relapse-free survival rates were 97.3% ± 1.5% for patients who did not receive chemotherapy and 94.5% ± 1.9% for patients who received chemotherapy (P = .71). There was no significant difference in local relapse among the 4 interval groups (P = .9). Multivariate Cox regression analysis showed that intervals between breast-conserving surgery and radiotherapy were not associated with higher local relapse risk.

CONCLUSION

In our study a delay in administering radiotherapy after breast-conserving surgery was not associated with an increased risk of local relapse. Taking into account contrasting results of many published studies, a larger evaluation of this issue is warranted.

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.

Short delay in initiation of radiotherapy may not affect outcome of patients with glioblastoma: a secondary analysis from the radiation therapy oncology group database

PURPOSE

To analyze the Radiation Therapy Oncology Group (RTOG) database of patients with glioblastoma and appraise whether outcome was influenced by time to initiation of radiation therapy (RT).

PATIENTS AND METHODS

From 1974 through 2003, adult patients with histologically confirmed supratentorial glioblastoma were enrolled onto 16 RTOG studies. Of 3,052 enrolled patients, 197 patients (6%) were either initially rendered ineligible or had insufficient chronologic data, leaving a cohort of 2,855 patients for the present analysis. We selected four patient groups based on the interval from surgery to the start of RT: <or= 2 weeks, 2 to 3 weeks, 3 to 4 weeks, more than 4 weeks to the protocol eligibility limit of 6 weeks. Survival times were estimated by the Kaplan-Meier method. Multivariate analysis incorporated variables of time interval, recursive partitioning analysis (RPA) class, and treatment regimen.

RESULTS

No decrement in survival could be identified with increasing time to initiation of RT. Among our four temporal groupings, median survival time was unexpectedly and significantly greater in the group with the longest interval (> 4 weeks) than in those with the shortest delay (<or= 2 weeks): respectively, 12.5 months versus 9.2 months (P < .0001). On multivariate analysis, with overall survival as the end point, time interval more than 4 weeks and lower RPA class were both significant predictors of improved outcome. Treatment regimen was not a significant factor.

CONCLUSION

There is no evident reduction in survival by delaying initiation of RT within the relatively narrow constraint of 6 weeks. An unanticipated yet significantly superior outcome was identified for patients for whom RT was delayed beyond 4 weeks from surgery.

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

PURPOSE

To determine the interval from breast-conserving surgery (BCS) to radiation therapy (RT) that affects local control or survival.

PATIENTS AND METHODS

The 10-year Kaplan-Meier (KM) local recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: < or = 4 (n = 83), greater than 4 to 8 (n = 2,288; reference group); greater than 8 to 12 (n = 2,606); greater than 12 to 16 (n = 961); greater than 16 to 20 (n = 358); and greater than 20 weeks (n = 132). Cox proportional hazards models and matching were used to control for confounding variables.

RESULTS

The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P = .15), DRFS (HR, 1.86; P = .02) and BCSS (HR, 2.15; P = .009) were inferior for women with BCS-to-RT intervals greater than 20 weeks compared with those greater than 4 to 8 weeks. The matched analysis yielded similar results.

CONCLUSION

Outcomes were statistically similar for BCS-to-RT intervals up to 20 weeks, but they were inferior for intervals beyond 20 weeks. Time can be reasonably allowed for the breast to heal and for patients to consider treatment options, but RT should start within 20 weeks of BCS.

Radiotherapy treatment delays and their influence on tumour control achieved by various fractionation schedules

There is often a considerable delay from initial tumour diagnosis to the start of radiotherapy treatment. This paper extends the calculations of a previous paper on the effects of delays before the initiation of radiotherapy treatment to include results from a variety of practical fractionation regimes for three different types of tumour: squamous cell carcinoma (head and neck), breast and prostate. The linear quadratic model of radiation effect, logarithmic tumour growth (coupled with delay times where relevant) and the Poisson model for tumour control probability (TCP) are used to calculate the change in TCP for delays between diagnosis and treatment. Within the limitations of radiobiological modelling, these data can be used to tentatively assess the interactions between delays, dose fractionation and TCP. The results show that delays in the start of radiotherapy treatment do have an adverse effect on tumour control for fast-growing tumours. For example, calculations predict a reduction in local tumour control of up to 1.5% per week's delay for head and neck cancers treated following surgery. In addition, there may be a variety of fractionation regimes that will yield very similar clinical results for each tumour type. It is shown theoretically that, for the tumour types considered here, it is possible to increase the dose per fraction and decrease the number of fractions while maintaining or increasing TCP relative to standard 2 Gy fractionation regimes, although there may be some advantage to using hyperfractionated regimes for head and neck cancers in order to reduce normal tissue effects.

The effect of delaying adjuvant radiation treatment after conservative surgery for early breast cancer

We examined the effect of delaying radiation treatment after conservative surgery on the risk of breast cancer local recurrence (LR). From January 1997 to December 2001, 969 women with early-stage breast cancer were treated at the Radiation Oncology Department in Chieti. We analyzed 802 of them who underwent conservative surgery followed by whole-breast radiotherapy. The patients were divided into two groups: women who did not receive chemotherapy and women who received chemotherapy. The time intervals from surgery to breast irradiation used for the analysis were <16 or more weeks for no-chemotherapy-treated women, and <25 and 25 or more weeks for chemotherapy-treated women. The relationship between LR and factors such as age, tumor size, margin status, and surgery-radiotherapy time interval was evaluated. The 8-year LR risk was estimated using the Kaplan-Meier method. LR was observed in 33 (4.1%) of the 802 patients. The overall 8-year LR risk was 6.5% (+/-1.51). In the no-chemotherapy group, the risk of LR was associated with a younger age and a positive margin status. In the chemotherapy group LR was associated with a younger age and a tumor size >3 cm. Surgery-radiotherapy interval was not associated with LR in both groups of patients. Delay in the start of radiotherapy does not increase the risk of LR in patients with early breast cancer treated or not treated with chemotherapy.

Is There a Detrimental Effect of Waiting for Radiotherapy for Patients With Localized Prostate Cancer?

OBJECTIVE

To evaluate a possible deleterious effect of waiting time to radiotherapy on the biochemical relapse (BR) of patients with localized prostate cancer.

PATIENTS AND METHODS

Patients included in this retrospective study had localized prostate adenocarcinoma treated with external-beam irradiation alone. Waiting time was defined as the interval between the first consultation and the first radiation treatment. BR was defined as 3 consecutive rises of prostatic specific antigen (PSA). Patients were split into 3 groups of waiting time: group A were treated within 40 days; group B waited 41 to 80 days; group C waited >80 days to receive radiotherapy. The effect of waiting on BR was estimated by the Kaplan-Meier method. Multivariate Cox proportional hazards modeling was adjusted for known prognostic factors.

RESULTS

There were 289 patients who participated in the analysis. Median follow-up time was 6.1 year. Overall BR rate was 44% at 5 years. The median waiting time increased over the study period from 26 days in 1992 to 123 days in 2000. In adjusted multivariate analysis there was a nonsignificant higher risk of BR with waiting for 41 to 80 days (hazard ratio [HR] = 0.8; 95% confidence interval [CI] = 0.3-1.6) and for >80 days (HR = 0.6; 95% CI = 0.2-1.5) when compared with patients treated within 40 days after consultation.

CONCLUSION

Delaying the start of radiotherapy showed little effect on the rate of BR in the group of 288 prostate cancer patients analyzed in this study.

Delaying Radiotherapy for the Delivery of Adjuvant Chemotherapy in the Combined Modality Treatment of Early Breast Cancer: Is It Disadvantageous and Could Combined Treatment be the Answer?

Women with early stage breast cancer are increasingly being treated with both adjuvant chemotherapy and radiotherapy. The optimal sequence of these two treatment modalities is yet to be defined. It remains controversial whether delaying radiotherapy in order to deliver chemotherapy compromises local disease control and survival. Consequently, clinical practice in the UK is divided, with a number of different combination schedules being used in an effort to bring forward the start of radiotherapy. In practice, however, any benefit in local control must be balanced against a potential increase in toxicity. A review of the current literature on the effect of radiotherapy delay is presented, together with data on the toxicity of combined chemo-radiotherapy schedules and recent data from clinical trials designed to determine the optimal sequencing of chemotherapy and radiotherapy.

Influence of the time between surgery and radiotherapy on local recurrence in patients with lymph node-positive, early-stage, invasive breast carcinoma undergoing breast-conserving surgery: results of the French Adjuvant Study Group

BACKGROUND

Radiotherapy (RT) after breast-conserving surgery (BCS) has produced significant reductions in ipsilateral breast carcinoma (BC) recurrence. It was shown previously that a delay in the initiation of RT resulted in a higher local recurrence (LR) rate. In the current retrospective analysis, the authors investigated whether the RT-adjuvant therapy sequence modified local-disease-free survival (L-DFS) after BCS in patients with early-stage, lymph node-positive BC.

METHODS

Among 7 French Adjuvant Study Group trials, 1831 patients were assessable, including 475 patients who received RT directly after BCS (95 patients received no adjuvant therapy, and 380 patients received hormone therapy), 567 patients who received RT after the third chemotherapy (CT) cycle (250 patients received 1-3 courses, and 317 patients received 4-6 courses), and 789 patients received RT after the sixth CT cycle. In the 1356 patients who received CT, the regimens consisted of fluorouracil 500 mg/m(2); epirubicin 50 mg/m(2), 75 mg/m(2), or 100 mg/m(2); and cyclophosphamide 500 mg/m(2) in 83.5% of patients.

RESULTS

After a median follow-up of 102 months, 214 patients (11.7%) developed LR. The 9-year L-DFS rates were 92.0%, 81.5%, and 87.4%, respectively (P < 0.0001). It was worse in patients who received 1-3 CT cycles (P = 0.02). Patients who received hormone therapy were less likely to develop LR (P = 0.02). In the multivariate analysis, the timing of RT was not associated with a higher rate of LR, whereas tumor size > 2 cm and no hormone therapy were prognostic factors.

CONCLUSIONS

In the study population, there was no increase in the risk of LR when RT was delayed to deliver adjuvant CT. Prognostic factors were tumor size, and hormone therapy. The number of CT courses could modified this risk.

2003 survey of Canadian radiation oncology residents

PURPOSE

Radiation oncology's popularity as a career in Canada has surged in the past 5 years. Consequently, resident numbers in Canadian radiation oncology residencies are at all-time highs. This study aimed to survey Canadian radiation oncology residents about their opinions of their specialty and training experiences.

METHODS AND MATERIALS

Residents of Canadian radiation oncology residencies that enroll trainees through the Canadian Resident Matching Service were identified from a national database. Residents were mailed an anonymous survey.

RESULTS

Eight of 101 (7.9%) potential respondents were foreign funded. Fifty-two of 101 (51.5%) residents responded. A strong record of graduating its residents was the most important factor residents considered when choosing programs. Satisfaction with their program was expressed by 92.3% of respondents, and 94.3% expressed satisfaction with their specialty. Respondents planning to practice in Canada totaled 80.8%, and 76.9% plan to have academic careers. Respondents identified job availability and receiving adequate teaching from preceptors during residency as their most important concerns.

CONCLUSIONS

Though most respondents are satisfied with their programs and specialty, job availability and adequate teaching are concerns. In the future, limited time and resources and the continued popularity of radiation oncology as a career will magnify the challenge of training competent radiation oncologists in Canada.

[Delays and treatment interruptions: difficulties in administering radiotherapy in an ideal time-period]

Prescribed total radiation dose should be administered within in a specific time-frame and delays in commencing treatment and/or unplanned interruptions in radiation delivery are unacceptable because, in certain cancer sites, treatment-time prolongation can have a deleterious effect on local tumour control, and on patient outcomes. The present review evaluated the causes of initial treatment delays as well as interruptions in the scheduled radiotherapy. The literature search highlighted a significant concern in avoiding treatment-time prolongation in head and neck, cervix, breast and lung cancer. Among the causes involved in delay in radiotherapy commencement factors such as waiting lists, lack of material and human resources, and an increase complexity in planning, simulation and verification are highlighted. Most authors recommend radiotherapy commencement as soon as possible in radical (exclusive irradiation with active tumour present) and palliative situations with a maximum delay of no more than 6 to 8 weeks in the case of adjuvant radiotherapy (post-resection) programs. Interruptions during the course of treatment include: planned unit maintenance and servicing, acute patient toxicity or unexpected malfunction of linear accelerators; this last feature has the most deleterious effect on patients as well as radiotherapy practitioners. Interruptions that impact on the programmed time-course for radiotherapy needs to be compensated-for so as assure the biological equivalence in treatment efficacy with respect to cancer site and stage.