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Zhuang T, Parsons D, Desai N, Gibbard G, Keilty D, Lin MH, Cai B, Nguyen D, Chiu T, Godley A, Pompos A, Jiang S. Simulation and pre-planning omitted radiotherapy (SPORT): a feasibility study for prostate cancer. Biomed Phys Eng Express 2024; 10:025019. [PMID: 38241733 DOI: 10.1088/2057-1976/ad20aa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/19/2024] [Indexed: 01/21/2024]
Abstract
This study explored the feasibility of on-couch intensity modulated radiotherapy (IMRT) planning for prostate cancer (PCa) on a cone-beam CT (CBCT)-based online adaptive RT platform without an individualized pre-treatment plan and contours. Ten patients with PCa previously treated with image-guided IMRT (60 Gy/20 fractions) were selected. In contrast to the routine online adaptive RT workflow, a novel approach was employed in which the same preplan that was optimized on one reference patient was adapted to generate individual on-couch/initial plans for the other nine test patients using Ethos emulator. Simulation CTs of the test patients were used as simulated online CBCT (sCBCT) for emulation. Quality assessments were conducted on synthetic CTs (sCT). Dosimetric comparisons were performed between on-couch plans, on-couch plans recomputed on the sCBCT and individually optimized plans for test patients. The median value of mean absolute difference between sCT and sCBCT was 74.7 HU (range 69.5-91.5 HU). The average CTV/PTV coverage by prescription dose was 100.0%/94.7%, and normal tissue constraints were met for the nine test patients in on-couch plans on sCT. Recalculating on-couch plans on the sCBCT showed about 0.7% reduction of PTV coverage and a 0.6% increasing of hotspot, and the dose difference of the OARs was negligible (<0.5 Gy). Hence, initial IMRT plans for new patients can be generated by adapting a reference patient's preplan with online contours, which had similar qualities to the conventional approach of individually optimized plan on the simulation CT. Further study is needed to identify selection criteria for patient anatomy most amenable to this workflow.
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Affiliation(s)
- Tingliang Zhuang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Neil Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Grant Gibbard
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Dana Keilty
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Dan Nguyen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Tsuicheng Chiu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Andrew Godley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Arnold Pompos
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Steve Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
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Abdel-Razeq H, Mansour A, Edaily S, Dayyat A. Delays in Initiating Anti-Cancer Therapy for Early-Stage Breast Cancer-How Slow Can We Go? J Clin Med 2023; 12:4502. [PMID: 37445537 DOI: 10.3390/jcm12134502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
Breast cancer is the most commonly diagnosed cancer among women worldwide, and is a leading cause of cancer-related deaths. When diagnosed at an early stage, appropriate and timely treatment results in a high cure rate and better quality of life. Delays in initiating anti-cancer therapy, including surgical resection, adjuvant/neoadjuvant chemotherapy and radiation therapy are commonly encountered, even in developed health care systems. Existing comorbidities that mandate referral to other services, genetic counseling and testing that may dictate the extent and type of anti-cancer therapy and insurance coverage, are among the most commonly cited factors. However, delays can be unavoidable; for over three years, health care systems across the globe were busy dealing with the unprecedented COVID-19 pandemic. War across hot zones around the globe resulted in millions of refugees; most of them have no access to cancer care, and when/where available, there may be significant delays. Thus, cancer patients across the globe will probably continue to suffer from significant delays in diagnosis and appropriate treatment. Many retrospective reports showed significant negative impacts on different aspects of treatment outcomes and on patients' psychosocial wellbeing and productivity. In this paper, we review the available data on the impact of delays in initiating appropriate treatment on the outcomes of patients with early-stage breast cancer.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan
- Department of Internal Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Asem Mansour
- Department of Radiology, King Hussein Cancer Center, Amman 11941, Jordan
| | - Sarah Edaily
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan
| | - Abdulmajeed Dayyat
- Department of Radiation Oncology, King Hussein Cancer Center, Amman 11941, Jordan
- Department of Radiation Oncology, Dalhousie University, Halifax, NS B3H 4R2, Canada
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3
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Bonci EA, Anacleto JC, Cardoso MJ. Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures. Breast 2023; 69:265-273. [PMID: 36924556 PMCID: PMC10027565 DOI: 10.1016/j.breast.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/11/2023] [Indexed: 03/14/2023] Open
Abstract
Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.
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Affiliation(s)
- E-A Bonci
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal; Surgical Oncology Department, "Prof. Dr. Ion Chiricuta" Institute of Oncology, Cluj-Napoca, Romania; Surgical Oncology and Gynecologic Oncology Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - J Correia Anacleto
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal; Hospital CUF Cascais, Cascais, Portugal
| | - M-J Cardoso
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal; Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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Tope P, Farah E, Ali R, El-Zein M, Miller WH, Franco EL. The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses. eLife 2023; 12:81354. [PMID: 36718985 PMCID: PMC9928418 DOI: 10.7554/elife.81354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
Background The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes. Methods We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval. Results We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design. Conclusions Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer. Funding The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.
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Affiliation(s)
- Parker Tope
- Division of Cancer Epidemiology, McGill UniversityMontrealCanada
| | - Eliya Farah
- Division of Cancer Epidemiology, McGill UniversityMontrealCanada
| | - Rami Ali
- Division of Cancer Epidemiology, McGill UniversityMontrealCanada
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill UniversityMontrealCanada
| | | | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill UniversityMontrealCanada
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Xie Y, Zhang Y, Xie K, Zhong X, Zheng H, Gou Q. Impact of time to initiation of postoperative radiotherapy after neoadjuvant chemotherapy on the prognosis of breast cancer: a retrospective cohort study in China. Int J Cancer 2022; 151:730-738. [PMID: 35333401 DOI: 10.1002/ijc.34003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 02/05/2023]
Abstract
The optimal time to the initiation of postoperative radiotherapy (TTR) in breast cancer patients after neoadjuvant chemotherapy (NAC) and surgery is unclear. We explored the association between TTR and outcomes among breast cancer females to determine the optimal timing for radiotherapy. We included 1022 women with breast cancer who underwent NAC and surgery between 1997 and 2019. Patients were categorized into three groups based on the TTR: <8 weeks, 8-16 weeks, and > 16 weeks. We used Cox proportional hazards models and analyzed the hazard ratios (HRs) for breast cancer-specific mortality (BCSM) and all-cause mortality (ACM). The median TTR for the cohort was 97 days. Compared to patients with TTRs of 8-16 weeks, those with TTRs <8 weeks or > 16 weeks had an increased risk of BCSM (HR, 2.59; 95% confidence interval [CI], 1.26-5.36 and HR, 2.01; 95% CI, 1.24-3.28, respectively) and ACM (HR, 2.32; 95% CI, 1.17-4.56 and HR, 1.92; 95% CI, 1.24-2.98, respectively) after adjusting for the confounders. Furthermore, at TTR of >16 weeks, each additional week of TTR was associated with a 3% increase in BCSM risk and 2% increase in ACM risk. Our findings suggest that patients who have undergone NAC and surgery show lower BCSM and ACM risks at TTR of 8-16 weeks compared with <8 weeks or > 16 weeks. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yuxin Xie
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yingjie Zhang
- Department of radiation therapy, West China Hospital, Sichuan University, Chengdu, China
| | - Keqi Xie
- Departments of Anesthesiology, Mianyang Central Hospital, Mianyang, Sichuan, China
| | - Xiaorong Zhong
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Zheng
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Molecular Diagnosis of Cancer, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qiheng Gou
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Wang M, Huang J, Chagpar AB. Factors Associated With a Delay in Postmastectomy Radiation Therapy. Am Surg 2021; 87:1484-1487. [PMID: 33775156 DOI: 10.1177/0003134820966289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While the optimal time interval between mastectomy and postmastectomy radiation therapy (PMRT) has not been well-elucidated, a delay in PMRT has been associated with increased local recurrence. We sought to determine factors associated with a delay in PMRT beyond 12 weeks in patients not undergoing adjuvant chemotherapy. METHODS Medical records of breast cancer patients who underwent mastectomy at our institution between January 2010 and December 2017 who subsequently received PMRT were retrospectively reviewed. As adjuvant chemotherapy can delay PMRT, patients receiving adjuvant chemotherapy were excluded. Factors associated with a delay in PMRT (defined as > 12 weeks from the time of mastectomy) were analyzed. RESULTS Among the 89 patients who met our inclusion criteria, the mean time from mastectomy to PMRT was 11.4 weeks. 24 patients (27.0%) had PMRT > 12 weeks after mastectomy. Factors associated with a delay in PMRT included black race (P = 0.031), younger age (P = 0.047), higher body mass index (P = 0.015), contralateral prophylactic mastectomy (P = 0.033), longer initial hospital length of stay (P = 0.001), and more complications (P = 0.025). On multivariable analysis controlling for all of these factors, only initial hospital length of stay (OR 1.63; 95% CI: 1.07-2.49; P = 0.024) was associated with a delay in PMRT. CONCLUSION Over a quarter of patients not undergoing adjuvant chemotherapy have a delay in PMRT beyond 12 weeks from the time of mastectomy. Length of initial hospital stay is the key driver in delaying PMRT.
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Affiliation(s)
- Melinda Wang
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Julian Huang
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Anees B Chagpar
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
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7
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Mandó P, Hirsch I, Waisberg F, Ostinelli A, Luca R, Pranevicene B, Ferreyra Camacho A, Enrico D, Chacon M. Appraising the quality of meta-analysis for breast cancer treatment in the adjuvant setting: A systematic review. Cancer Treat Res Commun 2021; 27:100358. [PMID: 33957603 DOI: 10.1016/j.ctarc.2021.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Breast cancer is the tumor with highest incidence in women worldwide and adjuvant treatment is extremely important to achieve disease control. Given the relevance of systematic reviews, their rigor should be warranted to avoid biased conclusions. Our objective was to investigate the methodological quality of meta-analysis of early breast cancer adjuvant treatment. MATERIAL AND METHODS Comprehensive searches were performed using electronic databases from 1/1/2007 to 11/12/2018. All studies identified as a systematic review with meta-analysis investigating the efficacy of breast cancer adjuvant treatments were included. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) version 2 tool. RESULTS Of 950 citations retrieved, 66 studies (7.0%) were deemed eligible. Methodological quality was highly variable, median AMSTAR score 8.5 (IQR 7-9.5) and range 0-16. There was a weak positive correlation between journal impact factor and AMSTAR score (r = 0.17) and citation rate and AMSTAR score (r = 0.16). Cochrane Systematic Reviews were of higher quality than reviews from other journals. Overall confidence was critically low for 61 (92.4%) studies, and the least well-reported domains were the statement of conflict of interest and funding source for the included studies (4.6%), the report of a pre-defined study protocol (15.2%), and the description of details of excluded studies (6.1%). CONCLUSIONS Our findings reinforce concerns about the design, conduction and interpretation of meta-analysis in current literature. Methodological quality should be carefully considered and journal editors, decision makers and readers in general, must follow a critical approach to this studies.
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Affiliation(s)
- Pablo Mandó
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; CEMIC, Galvan 4102, Ciudad de Buenos Aires, CP 1431, Argentina.
| | - Ian Hirsch
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Hospital General de Agudos Teodoro Álvarez, Juan Felipe Aranguren 2701, Ciudad de Buenos Aires, CP1406, Argentina
| | - Federico Waisberg
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Alexis Ostinelli
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
| | - Romina Luca
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Belen Pranevicene
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Augusto Ferreyra Camacho
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Diego Enrico
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Matías Chacon
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
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Hedden N, Xu H. Radiation therapy dose prediction for left-sided breast cancers using two-dimensional and three-dimensional deep learning models. Phys Med 2021; 83:101-107. [DOI: 10.1016/j.ejmp.2021.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/05/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022] Open
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9
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You KY, Zou WL, Ding L, Bi ZF, Yao HR. Large Tumor Size is an Indicator for the Timely Administration of Adjuvant Radiotherapy in Luminal Breast Cancer with Positive Lymph Node. Cancer Manag Res 2021; 13:1325-1332. [PMID: 33603478 PMCID: PMC7884945 DOI: 10.2147/cmar.s293470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/25/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The optimum timing of adjuvant radiotherapy for breast cancer patients who had undergone surgery remains unclear. The present study aimed to identify the clinical factors which could assist the selecting of time interval (TI) between surgery and adjuvant radiotherapy in luminal breast cancer with lymph node metastasis. Patients and Methods This retrospective study included 1054 luminal breast cancer patients with lymph node metastasis, diagnosed between May 2004 and December 2014, and treated with surgery followed by adjuvant therapy. Overall survival (OS) and disease-free survival (DFS) were compared between patients in the short and long TI groups. Multivariate analysis was performed to examine clinical factors associated with DFS. Subgroups analysis was further performed based on the significant predictors of DFS to explore the association of TI and tumor prognosis. Results For the whole group of patients, there was no difference in OS and DFS between patients with long and short TI. Multivariate analysis showed that age, N stage and tumor size were significant predictors of DFS. Subgroup analysis demonstrated that neither age nor N stage were informative in TI selection; in contrast, in patients with large tumors, a short TI was associated with better DFS than a long TI. In patients with small tumors, there was no significant association between TI and tumor prognosis. In the multivariable analysis, TI was independent predictor of DFS and local recurrence-free survival in patients with large tumors. Conclusion Large tumor size is an indicator for the timely administration of adjuvant radiotherapy in luminal breast cancer with positive lymph node.
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Affiliation(s)
- Kai-Yun You
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,RNA Biomedical Institute, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Wei-Liang Zou
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Lin Ding
- Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhuo-Fei Bi
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,RNA Biomedical Institute, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Department of Radiation Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - He-Rui Yao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,RNA Biomedical Institute, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Department of Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
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Radiotherapy challenges in COVID era. BIOMEDICAL ENGINEERING TOOLS FOR MANAGEMENT FOR PATIENTS WITH COVID-19 2021. [PMCID: PMC8192315 DOI: 10.1016/b978-0-12-824473-9.00009-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The pandemic caused by the new coronavirus (SARS-CoV-2) associated with a disease named COVID-19 by the World Health Organization that began in late 2019 in Wuhan city has become a global public health problem. Only 2 months later, the new virus affected most countries of the world, the consequence being an overload of health systems, especially Intensive Care Units. Considered a category of patients at high risk of developing severe forms of the disease, cancer patients can develop a severe form of the disease, complicated by acute respiratory distress syndrome requiring mechanical ventilation. Radiotherapy, as a treatment included in the multidisciplinary management of cancer for both curative and palliative purposes, is also affected by the COVID-19 pandemic. COVID-19-positive or -suspected patients are a special category for which the decision to postpone treatment should be made based on the particularities of tumor biology and the radiobiological effect of a gap in radiation fractions delivery. Emergencies including spinal cord compressions, tumor bleeding, and brain metastases not responsive to corticosteroid treatment, should be considered a priority but the palliative treatment should be limited from one single fraction to maximum five fractions for spinal cord compression and whole brain radiotherapy. Radiotherapy for brain metastases does not bring a benefit in terms of overall survival for patients with life expectancy of days or weeks and dexamethasone treatment is the correct choice in this situation. In all settings, the approach of radiotherapy treatment must be adapted for both scenarios of an outbreak pandemic, when general measures of social distancing and protection by specific equipment of patients and radiotherapy staff are a priority, but also for a long period of coexistence with the virus with possible new “pandemic waves.”
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11
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Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, O'Sullivan DE, Booth CM, Sullivan R, Aggarwal A. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371:m4087. [PMID: 33148535 PMCID: PMC7610021 DOI: 10.1136/bmj.m4087] [Citation(s) in RCA: 541] [Impact Index Per Article: 135.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways. DESIGN Systematic review and meta-analysis. DATA SOURCES Published studies in Medline from 1 January 2000 to 10 April 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models. RESULTS The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings. CONCLUSIONS Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.
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Affiliation(s)
- Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Will D King
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | | | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Gregory A Paulin
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | | | - Dylan E O'Sullivan
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Ajay Aggarwal
- Department of Clinical Oncology, Guy's & St Thomas' NHS Trust, London, UK
- Institute of Cancer Policy, King's College London, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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12
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Duggan C, Dvaladze A, Rositch AF, Ginsburg O, Yip CH, Horton S, Rodriguez RC, Eniu A, Mutebi M, Bourque JM, Masood S, Unger-Saldaña K, Cabanes A, Carlson RW, Gralow JR, Anderson BO. The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview. Cancer 2020; 126 Suppl 10:2339-2352. [PMID: 32348573 PMCID: PMC7482869 DOI: 10.1002/cncr.32891] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice. METHODS In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening. RESULTS Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits. CONCLUSIONS Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.
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Affiliation(s)
| | | | - Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ophira Ginsburg
- Perlmutter Cancer Center, Section for Global Health, Division of Health and Behavior, Department of Population Health, New York University Langone Health, NY, USA
| | | | - Susan Horton
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Alexandru Eniu
- Hopital Riviera Chablais, Vaud-Valais, Rennaz, Switzerland
| | - Miriam Mutebi
- Breast Surgical Oncology, Aga Khan University Hospital, Nairobi, Kenya
| | - Jean-Marc Bourque
- Department of Radiation Oncology, University of Ottawa, Ottawa, Canada
- Department of Medicine, McGill University, Montreal, Canada
| | - Shahla Masood
- University of Florida Health Jacksonville Breast Center, Jacksonville, FL, USA
| | | | | | - Robert W. Carlson
- National Comprehensive Cancer Center, Plymouth Meeting, Pennsylvania, USA
| | | | - Benjamin O Anderson
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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13
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Raphael MJ, Saskin R, Singh S. Association between waiting time for radiotherapy after surgery for early-stage breast cancer and survival outcomes in Ontario: a population-based outcomes study. ACTA ACUST UNITED AC 2020; 27:e216-e221. [PMID: 32489271 DOI: 10.3747/co.27.5629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background After surgery for early-stage breast cancer (bca), adjuvant radiotherapy (rt) decreases the risk of locoregional recurrence and death from bca. It is unclear whether delays to the initiation of adjuvant rt are associated with inferior survival outcomes. Methods This population-based retrospective cohort study included a random sample of 25% of all women with stage i or ii bca treated with adjuvant rt in Ontario between 1 September 2001 and 31 August 2002, when, because of capacity issues, wait times for radiation were abnormally long. Pathology reports were manually abstracted and deterministically linked to population-level administrative databases to obtain information about recurrence and survival outcomes. Cox proportional hazards modelling was used to evaluate the association between waiting time and survival outcomes. A composite survival outcome was used to ensure that all possible measurable harms of delay would be captured. The composite outcome, event-free survival, included locoregional recurrence, development of metastatic disease, and bca-specific mortality. Results We identified 1028 women with stage i or ii bca who were treated with breast-conserving surgery and adjuvant rt. For the 599 women who were treated with adjuvant radiation without intervening chemotherapy, a waiting time of 12 weeks or more from surgery to the start of radiation appeared to be associated with worse event-free survival after a median follow-up of 7.2 years (hazard ratio for the composite outcome: 1.44; 95% confidence interval: 0.98 to 2.11; p = 0.07). For the 429 women who received intervening adjuvant chemotherapy, a waiting time of 6 weeks or more from completion of chemotherapy to start of radiation was associated with worse event-free survival after a median follow-up of 7.4 years (hazard ratio: 1.50; 95% confidence interval: 1.00 to 2.22; p = 0.047). Conclusions Delay to the initiation of adjuvant rt after breast-conserving surgery is associated with inferior bca survival outcomes. The good prognosis for patients with early-stage bca limits the statistical power to detect an effect of delay to rt. Given that there is no plausible advantage to delay, we agree with Mackillop that time to initiation of rt should be kept "as short as reasonably achievable."
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Affiliation(s)
- M J Raphael
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON
| | | | - S Singh
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON.,ices, Toronto, ON
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14
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Yung R, Ray RM, Roth J, Johnson L, Warnick G, Anderson GL, Kroenke CH, Chlebowski RT, Simon MS, Fung C, Pan K, Wang D, Barrington WE, Reding KW. The association of delay in curative intent treatment with survival among breast cancer patients: findings from the Women's Health Initiative. Breast Cancer Res Treat 2020; 180:747-757. [PMID: 32062784 DOI: 10.1007/s10549-020-05572-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Delays in adjuvant breast cancer (BC) therapy have been shown to worsen outcomes. However, thus far studies have only evaluated delays to initial treatment, or a particular modality, such as chemotherapy, leaving uncertainty about the role of delay to subsequent therapy and the effects of cumulative delay, on outcomes. We investigated the associations of delays across treatment modalities with survival. METHODS We included 3368 women with incident stage I-III BC in the Women's Health Initiative (WHI) enrolled in fee-for-service Medicare who underwent definitive surgery. This prospective analysis characterized treatment delays by linking WHI study records to Medicare claims. Delays were defined as > 8 weeks to surgery, chemotherapy, and radiation from diagnosis or prior treatment. We used Cox proportional hazards models to estimate BC-specific mortality (BCSM) and all-cause mortality (ACM) in relation to treatment delays. RESULTS We found 21.8% of women experienced delay to at least one therapy modality. In adjusted analysis, delay to chemotherapy was associated with a higher risk of BCSM (HR = 1.71; 95% CI 1.07-2.75) and ACM (HR = 1.39; 95% CI 1.02-1.90); delay in radiation increased BCSM risk (HR = 1.49; 95% CI 1.00-2.21) but not ACM risk (HR = 1.19; 95% CI 0.99-1.42). Delays across multiple treatment modalities increased BCSM risk threefold (95% CI 1.51-6.12) and ACM risk 2.3-fold (95% CI 1.50-3.50). CONCLUSIONS A delay to a single treatment modality and delay to a greater extent an accumulation of delays were associated with higher BCSM and ACM after BC. Timely care throughout the continuum of breast cancer treatment is important for optimal outcomes.
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Affiliation(s)
- Rachel Yung
- Seattle Cancer Care Alliance, Breast Oncology, Seattle, WA, USA.,Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Roberta M Ray
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joshua Roth
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa Johnson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Greg Warnick
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Garnet L Anderson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Candyce H Kroenke
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Rowan T Chlebowski
- Hematology and Medical Oncology, Harbor-UCLA Medical Center, Los Angeles, WA, USA
| | - Michael S Simon
- Department of Oncology, Karmanos Cancer Institute at Wayne State University, Detroit, MI, USA
| | - Chunkit Fung
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Kathy Pan
- Hematology and Medical Oncology, Harbor-UCLA Medical Center, Los Angeles, WA, USA.,Division of Oncology, Kaiser Permanente Southern California, Torrance, CA, USA
| | - Di Wang
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Wendy E Barrington
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,School of Nursing, University of Washington, Seattle, WA, USA
| | - Kerryn W Reding
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,School of Nursing, University of Washington, Seattle, WA, USA.
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15
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Li Y, Chen M, Pardini B, Dragomir MP, Lucci A, Calin GA. The role of radiotherapy in metaplastic breast cancer: a propensity score-matched analysis of the SEER database. J Transl Med 2019; 17:318. [PMID: 31547814 PMCID: PMC6757394 DOI: 10.1186/s12967-019-2069-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/17/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Only few studies, with small patient cohorts, have evaluated the effect of radiotherapy (RT) for metaplastic breast cancer (MBC). Hence, it is important to investigate the role of RT in MBC survival using a large population-database. METHODS A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) from 1973 to 2015 was performed. We compared MBC patients with or without RT for overall survival (OS) and breast cancer-specific survival (BCSS) using univariate and multivariate Cox proportional hazard regressions before and after propensity score matching (PSM). RESULTS From a total of 2267 patients diagnosed with MBC between 1998 and 2015, 1086 (47.9%) received RT. In the multivariate analysis before PSM, RT provided a better OS (HR 0.73; 95% CI 0.61-0.88; p = 0.001) and BCSS (HR 0.71; 95% CI 0.58-0.88; p = 0.002). Multivariate analyses after PSM (n = 1066) confirmed that patients receiving RT (n = 506) survived longer than those without RT (OS, HR 0.64; 95% CI 0.51-0.80; p < 0.001 and BCSS, HR 0.64; 95% CI 0.50-0.83; p = 0.001). A longer OS was observed when RT was given to older patients (p = 0.001) and in case of large tumor size (p = 0.002). Intriguingly, patients with N0 stage showed better OS after RT (HR 0.69, P = 0.012). CONCLUSIONS Our findings support the beneficial effect of RT for MBC patients. In particular, older patients or with large tumor size have a greater survival benefit from RT. In conclusion, we have assessed the importance of the use of RT in MBC as survival factor and this could lead to the development of guidelines for this rare sub-type of tumors.
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Affiliation(s)
- Yongfeng Li
- Department of Breast Surgery, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Science; Cancer Hospital of the University of Chinese Academy of Sciences; Zhejiang Cancer Hospital, Hangzhou, 310022 Zhejiang People’s Republic of China
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, South Campus Research Building 4, 1901 East Road, Houston, TX 77054 USA
| | - Meng Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, South Campus Research Building 4, 1901 East Road, Houston, TX 77054 USA
| | - Barbara Pardini
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, South Campus Research Building 4, 1901 East Road, Houston, TX 77054 USA
- Italian Institute for Genomic Medicine, Turin, Italy
| | - Mihnea P. Dragomir
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, South Campus Research Building 4, 1901 East Road, Houston, TX 77054 USA
- Department of Surgery, Fundeni Clinical Hospital, 22328 Bucharest, Romania
- The Research Center for Functional Genomics, Biomedicine and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj Napoca, Romania
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX 77030 USA
| | - George A. Calin
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, South Campus Research Building 4, 1901 East Road, Houston, TX 77054 USA
- Center for RNA Interference and Non-coding RNAs, The University of Texas MD Anderson Cancer Center, Houston, TX 77054 USA
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16
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Borm KJ, Schönknecht C, Nestler A, Oechsner M, Waschulzik B, Combs SE, Münch S, Niemeyer M, Duma MN. Outcomes of immediate oncoplastic surgery and adjuvant radiotherapy in breast cancer patients. BMC Cancer 2019; 19:907. [PMID: 31510973 PMCID: PMC6739964 DOI: 10.1186/s12885-019-6104-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oncoplastic surgery techniques lead to a rearrangement of the breast tissue and impede target definition during adjuvant radiotherapy (RT). The aim of this study was to assess local control rates after immediate oncoplastic surgery and adjuvant RT. METHODS This study comprises 965 patients who underwent breast-conserving therapy and adjuvant RT between 01/2000 and 12/2005. 288 patients received immediate oncoplastic surgery (ONC) and 677 patients breast-conserving surgery only (NONC). All patients were treated with adjuvant external tangential-beam RT (total dose: 50/50.4 Gy; fraction dose 1.8/2.0 Gy). An additional boost dose of 10-16 Gy to the primary tumor bed was given in 900 cases (93.3%). Local control rates (LCR), Progression free survival (PFS) and overall survival (OS) were assessed retrospectively after a median follow-up period of 67 (Q25-Q75: 51-84) months. RESULTS No significant difference was found between ONC and NONC in regard to LCR (5-yr: ONC 96.8% vs. NONC 95.3%; p = 0.25). This held also true for PFS (5-yr: ONC 92.1% vs. NONC 89.3%; p = 0.09) and OS (5-yr: ONC 96.0% vs. NONC 94.8%; p = 0.53). On univariate analyses G2-3 (p = 0.04), a younger age (p = 0.01), T-stage (p < 0.01) lymph node involvement (p < 0.01) as well as triple negative tumors (p < 0.01) were identified as risk factors for local recurrence. In a propensity score stratified Cox-regression model no significant impact of oncoplastic surgery on local control rate was found (HR: 2.05, 95% CI [0.93; 4.51], p = 0.08). CONCLUSION Immediate oncoplastic surgery seems not to affect the effectiveness of adjuvant whole breast RT on local control rates in breast cancer patients.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Christine Schönknecht
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andrea Nestler
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Oberschleißheim, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Niemeyer
- Department of Obstetrics and Gynecology, Technical University Munich, Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany. .,Department of Radiation Oncology, University Hospital Jena, Bachstraße 18, 07743, Jena, Germany.
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17
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Kim KH, Yeo SM, Cheong IY, Kim Y, Jeon BJ, Hwang JH. Early Rehabilitation after Total Mastectomy and Immediate Reconstruction with Tissue Expander Insertion in Breast Cancer Patients: A Retrospective Case-control Study. J Breast Cancer 2019; 22:472-483. [PMID: 31598346 PMCID: PMC6769388 DOI: 10.4048/jbc.2019.22.e40] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 08/26/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose To prevent surgical site complications, many plastic surgeons use the so-called “conventional protocol,” which immobilizes the shoulder and upper arm for 1 month after reconstruction. In an effort to improve the shoulder mobility of patients who received immediate breast reconstruction with tissue expander insertion (TEI), we introduced an early rehabilitation protocol with a short-term immobilization period of 2 weeks. This study aims to compare this early rehabilitation exercise program with the conventional protocol and to determine factors affecting shoulder mobility and quality of life of patients after immediate breast reconstruction. Methods A total of 115 patients with breast cancer who underwent reconstructive surgery were retrospectively reviewed. For patients who underwent reconstruction before January 2017, the conventional protocol was followed with immobilization of their shoulder for over 4 weeks. Patients who underwent reconstruction after January 2017 were educated to undergo a self-exercise program after a short-term immobilization period of 2 weeks. We compared shoulder mobility, pain, quality of life, and complications at postoperative 1 and 2 months between the groups. Results Patients who received early rehabilitation showed greater shoulder flexion and abduction range at postoperative 1 month than those who received the conventional protocol. This increased shoulder abduction range continued until postoperative 2 months. There were no significant surgical site problems in both groups during the 2 months of follow-up. Conclusion To enhance the recovery of shoulder mobility, early rehabilitation with a shorter immobilization period should be recommended to patients with breast cancer undergoing reconstruction surgery with TEI. Trial Registration ClinicalTrials.gov Identifier: NCT03541161
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Affiliation(s)
- Kyou Hyun Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul, Korea
| | - Seung Mi Yeo
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul, Korea
| | - In Yae Cheong
- Department of Physical and Rehabilitation Medicine, National Rehabilitation Center, Seoul, Korea
| | - Yoon Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul, Korea
| | - Byung Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Seoul, Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Seoul, Korea
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18
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Christiansen RL, Gornitzka J, Andersen P, Nielsen M, Johnsen L, Bertelsen AS, Zukauskaite R, Johansen J, Hansen CR. Awareness and surveillance of radiation treatment schedules reduces head and neck overall treatment time. Tech Innov Patient Support Radiat Oncol 2019; 9:26-30. [PMID: 32095592 PMCID: PMC7033770 DOI: 10.1016/j.tipsro.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 12/21/2018] [Accepted: 01/15/2019] [Indexed: 11/03/2022] Open
Abstract
Overall treatment time for HNC treatment was reduced according to DAHANCA guidelines. Sufficient accelerator capacity alone did not sufficiently minimize treatment time. Surveillance of treatment calendars reduced breaches to 3% (6fx/wk) and 13% (5 fx/wk). Radiobiological efficacy was increased by 1.3 Gy (6 fx/wk) and 2.0 Gy (5 fx/wk). Surveillance of treatment calendars presented minimal financial costs.
Background and purpose Overall treatment time (OTT) is essential for local tumour control and survival in radiotherapy of head and neck cancer (HNC). National radiotherapy guidelines of the Danish Head and Neck Cancer Group (DAHANCA) recommend a maximum OTT of 41 days for moderately accelerated radiation treatment (6 fractions/week) and 48 days for conventional treatment (5 fractions/week). The purpose of this study was to evaluate the effect of surveillance of the radiotherapy course length and treatment gaps in HNC patients to reduce OTT. Methods The study included 2011 patients with HNC undergoing radical radiation treatment with 66–68 Gy in 33–34 fractions in 2003–2017 at Odense University Hospital. In February 2016, a systematic weekly review by two radiation therapists of all planned treatment courses was introduced to check OTT of individual patients to portend likely breaks or treatment prolongations. Schedules that violated the OTT guidelines were conferred with the responsible radiation oncologist, and treatment rescheduled by treating twice daily to catch up with a delay. Results The mean length of accelerated treatment courses was reduced from a maximum of 40.9 days in 2007 to 38.3 days in 2017 and from 50.3 days to 45.9 days for conventional courses. The percentage of individual treatment courses that violated the recommended OTT was reduced to 3% of the accelerated treatments and 13% for the conventional treatments. Conclusion Continuous surveillance of treatment schedules of HNC patients by a brief weekly survey reduced treatment course duration to an extent that was radiobiologically and clinically meaningful.
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Affiliation(s)
- Rasmus Lübeck Christiansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janne Gornitzka
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Pia Andersen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Morten Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Lars Johnsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | | | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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19
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Boyages J, Baker L. Evolution of radiotherapy techniques in breast conservation treatment. Gland Surg 2018; 7:576-595. [PMID: 30687630 PMCID: PMC6323255 DOI: 10.21037/gs.2018.11.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 11/29/2018] [Indexed: 01/17/2023]
Abstract
Radiation therapy (RT) is an important component of breast cancer treatment that reduces local recurrence and improves survival after breast conservation. Breast conservation rates have increased significantly since the late 1980s and techniques have improved with greater awareness of the impact of radiation on the heart. An overview of randomized controlled trials of breast conservation using standard whole breast irradiation, whole breast hypofractionation, accelerated partial breast irradiation (APBI) and intraoperative radiation are reviewed. Selection criteria for breast conservation and the utility of adding a boost dose to the primary tumor site are reviewed. Modern dose constraints are documented and 10 different radiation techniques from the 1980s through to modern volumetric modulated arc therapy (VMAT) are compared for a patient where the breast and internal mammary nodes are treated. A radiation boost reduces the risk of a recurrence for most, but not all patients. Short courses of RT over 3-4 weeks are generally as effective as longer courses. Short-term follow-up of trials of APBI show promise for selected good prognosis subgroups. The role of intraoperative radiation remains controversial. In the last 30 years, there have been significant advances in radiation techniques. Modern radiotherapy equipment and techniques will reduce complications and improve survival rates.
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Affiliation(s)
- John Boyages
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Radiation Oncology Associates and Genesis Cancer Care Pty Ltd., Macquarie University Hospital, Sydney, Australia
| | - Lesley Baker
- Radiation Oncology Associates and Genesis Cancer Care Pty Ltd., Macquarie University Hospital, Sydney, Australia
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20
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Reichert A, Jacobs R. The impact of waiting time on patient outcomes: Evidence from early intervention in psychosis services in England. HEALTH ECONOMICS 2018; 27:1772-1787. [PMID: 30014544 PMCID: PMC6221005 DOI: 10.1002/hec.3800] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 05/16/2018] [Accepted: 06/15/2018] [Indexed: 05/25/2023]
Abstract
Recently, new emphasis was put on reducing waiting times in mental health services as there is an ongoing concern that longer waiting time for treatment leads to poorer health outcomes. However, little is known about delays within the mental health service system and its impact on patients. We explore the impact of waiting times on patient outcomes in the context of early intervention in psychosis (EIP) services in England from April 2012 to March 2015. We use the Mental Health Services Data Set and the routine outcome measure the Health of the Nation Outcome Scale. In a generalised linear regression model, we control for baseline outcomes, previous service use, and treatment intensity to account for possible endogeneity in waiting time. We find that longer waiting time is significantly associated with a deterioration in patient outcomes 12 months after acceptance for treatment for patients that are still in EIP care. Effects are strongest for waiting times longer than 3 months, and effect sizes are small to moderate. Patients with shorter treatment periods are not affected. The results suggest that policies should aim to reduce excessively long waits in order to improve outcomes for patients waiting for treatment for psychosis.
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21
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Flores-Balcázar CH, Flores-Luna L, Villarreal-Garza C, Mota-García A, Bargalló-Rocha E. Impact of Delayed Adjuvant Radiotherapy in the Survival of Women with Breast Cancer. Cureus 2018; 10:e3071. [PMID: 30510860 PMCID: PMC6267615 DOI: 10.7759/cureus.3071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective Our objective was to determine whether a delay in adjuvant radiotherapy is related to a decrease in relapse-free survival and disease-specific survival of women with operable breast cancer. Methods Data on 1000 patients diagnosed with breast cancer were recorded. The cohort was divided into five groups according to the timing of radiotherapy: ≤30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and >120 days. The relapse-free survival and disease-specific survival were also calculated in relation to the number of patients. Results This study found no statistical difference for delays in adjuvant radiotherapy in patients with early breast cancer, but we noted a statistical decrease in disease-specific survival in patients with locally advanced breast cancer receiving radiotherapy after a delay of at least 60 days. Conclusion Waiting times for radiotherapy should be as short as reasonably achievable, given the specific risk factors in the individual patient.
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22
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Zhang WW, Wu SG, Sun JY, Li FY, He ZY. Long-term survival effect of the interval between mastectomy and radiotherapy in locally advanced breast cancer. Cancer Manag Res 2018; 10:2047-2054. [PMID: 30038520 PMCID: PMC6053260 DOI: 10.2147/cmar.s163863] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction The timing of postmastectomy radiotherapy (PMRT) may influence locoregional recurrence and survival outcomes. In this study, we assessed the long-term survival effect of the interval between surgery and PMRT in locally advanced breast cancer treated with mastectomy and adjuvant chemotherapy. Methods In this retrospective study, we included women with locally advanced breast cancer who underwent adjuvant chemotherapy and PMRT after mastectomy between 1999 and 2007. Based on the interval between surgery and PMRT, the patients were classified into three groups: Group 1 (≤4 vs >4 months), Group 2 (≤5 vs >5 months), and Group 3 (≤6 vs >6 months). Univariate and multivariate regression analyses were performed to determine the prognostic factors of survival outcomes. Results A total of 340 women were included in this study, and the median follow-up duration was 79.8 months. The median surgery–PMRT interval was 5 months. The surgery–PMRT interval including Group 1, Group 2, and Group 3 was not significantly associated with locoregional recurrence-free survival, distant metastasis-free survival, disease-free survival, and overall survival. In addition, in the subgroup analysis of the effect of surgery–PMRT interval on survival outcomes according to various clinicopathologic factors, the surgery–PMRT interval was also not associated with survival outcomes in different age groups, tumor stage, and breast cancer subtypes. Conclusion Our findings suggest that the delay in the start of PMRT in locally advanced breast cancer does not increase the likelihood of locoregional recurrence, distant metastasis, and death.
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Affiliation(s)
- Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, People's Republic of China,
| | - San-Gang Wu
- Department of Radiation Oncology, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, People's Republic of China,
| | - Feng-Yan Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, People's Republic of China,
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, People's Republic of China,
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23
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Layne TM, Aminawung JA, Soulos PR, Nunez-Smith M, Nunez MA, Jones BA, Wang KH, Gross CP. Quality Of Breast Cancer Care In The US Territories: Insights From Medicare. Health Aff (Millwood) 2018; 37:421-428. [PMID: 29505365 DOI: 10.1377/hlthaff.2017.1045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The quality of breast cancer care among Medicare beneficiaries in the US territories-where federal spending for health care is lower than in the continental US-is unknown. We compared female Medicare beneficiaries who were residents of the US territories and had surgical treatment for breast cancer in 2008-14 to those in the continental US in terms of receipt of recommended breast cancer care (diagnostic needle biopsy and adjuvant radiation therapy [RT] following breast-conserving surgery) and the timeliness (time from needle biopsy to surgery and from surgery to adjuvant RT) of that care. Residents of the US territories were less likely to receive recommended care (24 percent lower odds of receiving diagnostic needle biopsy and 34 percent lower odds of receiving adjuvant RT) and to receive timely care (45 percent lower odds of receiving surgery and 82 percent lower odds of receiving adjuvant RT, both within three months). Further research is needed to identify barriers to the provision of adequate and timely breast cancer care in this unique population.
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Affiliation(s)
- Tracy M Layne
- Tracy M. Layne ( ) is a postdoctoral fellow in the Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, in Bethesda, Maryland
| | - Jenerius A Aminawung
- Jenerius A. Aminawung is a research associate in the Department of Internal Medicine, Yale School of Medicine, in New Haven, Connecticut
| | - Pamela R Soulos
- Pamela R. Soulos is a program manager and data analyst in the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center and a research associate in the Department of Internal Medicine, both at the Yale School of Medicine
| | - Marcella Nunez-Smith
- Marcella Nunez-Smith is an associate professor of medicine in the Department of Internal Medicine and director of the Equity Research and Innovation Center, both at the Yale School of Medicine
| | - Maxine A Nunez
- Maxine A. Nunez is a professor of nursing at the University of the Virgin Islands School of Nursing, in Saint Thomas, and principal investigator, Eastern Caribbean Health Outcomes Research Network, at the Yale Transdisciplinary Collaborative Center in the Yale School of Medicine
| | - Beth A Jones
- Beth A. Jones is a research scientist and lecturer in epidemiology in the Chronic Disease Epidemiology Department, Yale School of Public Health, in New Haven
| | - Karen H Wang
- Karen H. Wang is an instructor in the Department of Internal Medicine, Yale School of Medicine
| | - Cary P Gross
- Cary P. Gross is a professor of medicine in the Department of Internal Medicine, director of COPPER Center, and director of the National Clinician Scholars Program, all at the Yale School of Medicine
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24
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van Maaren MC, Bretveld RW, Jobsen JJ, Veenstra RK, Groothuis-Oudshoorn CG, Struikmans H, Maduro JH, Strobbe LJ, Poortmans PM, Siesling S. The influence of timing of radiation therapy following breast-conserving surgery on 10-year disease-free survival. Br J Cancer 2017; 117:179-188. [PMID: 28588320 PMCID: PMC5520509 DOI: 10.1038/bjc.2017.159] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/28/2017] [Accepted: 05/11/2017] [Indexed: 11/13/2022] Open
Abstract
Background: The Dutch guidelines advise to start radiation therapy (RT) within 5 weeks following breast-conserving surgery (BCS). However, much controversy exists regarding timing of RT. This study investigated its effect on 10-year disease-free survival (DFS) in a Dutch population-based cohort. Methods: All women diagnosed with primary invasive stage I-IIIA breast cancer in 2003 treated with BCS+RT were included. Two populations were studied. Population 1 excluded patients receiving chemotherapy before RT. Analyses were stratified for use of adjuvant systemic therapy (AST). Population 2 included patients treated with chemotherapy, and compared chemotherapy before (BCS-chemotherapy-RT) and after RT (BCS-RT-chemotherapy). DFS was estimated using multivariable Cox regression. Locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were secondary outcomes. Results: Population 1 (n=2759) showed better DFS and DMFS for a time interval of >55 than a time interval of <42 days. Patients treated with AST showed higher DFS for >55 days (hazards ratio (HR) 0.60 (95% confidence interval (CI): 0.38–0.94)) and 42–55 days (HR 0.64 (95% CI: 0.45–0.91)) than <42 days. Results were similar for DMFS, while timing did not affect LRRFS and OS. For patients without AST, timing was not associated with DFS, DMFS and LLRFS, but 10-year OS was significantly lower for 42–55 and >55 days compared to <42 days. In population 2 (n=1120), timing did not affect survival in BCS-chemotherapy-RT. In BCS-RT-chemotherapy, DMFS was higher for >55 than <42 days. Conclusions: Starting RT shortly after BCS seems not to be associated with a better long-term outcome. The common position that RT should start as soon as possible following surgery in order to increase treatment efficacy can be questioned.
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Affiliation(s)
- Marissa C van Maaren
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands.,Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
| | - Reini W Bretveld
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands
| | - Jan J Jobsen
- Department of Radiation Oncology, Medical Spectrum Twente, PO Box 217, Enschede 7500 AE, The Netherlands
| | - Renske K Veenstra
- Department of Operations, Medical Research Data Management B.V., PO Box 90, Deventer 7400 AB, The Netherlands
| | - Catharina Gm Groothuis-Oudshoorn
- Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
| | - Hendrik Struikmans
- Department of Radiation Oncology, Haaglanden Medical Center, PO Box 432, The Hague 2501 CK, The Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, The Netherlands
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, PO Box 30001, Groningen 9700 RB, The Netherlands
| | - Luc Ja Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, PO Box 9015, Nijmegen 6500 GS, The Netherlands
| | - Philip Mp Poortmans
- Department of Radiation Oncology, Institut Curie, 26 Rue d'Ulm, Paris 75005, France
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands.,Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
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