Does delay in breast irradiation following conservative breast surgery in node-negative breast cancer patients have an impact on risk of recurrence?

Clinical relevance of the timing of radiotherapy after breast-conserving surgery : Results of a large, single-centre, population-based cohort study

PURPOSE

To investigate the effect of the timing of radiation therapy after breast-conserving surgery in relation to distant metastasis-free survival and disease-specific survival.

METHODS

The analysis was performed in relation to 4189 women all undergoing breast-conserving therapy (BCT). Three groups were defined with respect to lymph node status and the use of adjuvant systemic therapy (AST). Patients were categorized into time intervals: < 37 days, 37-53 days, 54-112 days and > 112 days.

RESULTS

For women without lymph node metastases and with favourable characteristics aged > 55 years, an improved treatment efficacy was noted when starting radiotherapy with a time interval of < 37 days. The same was observed for women with lymph nodes metastases receiving AST aged ≤ 50 years. Finally, for women aged > 50 years with negative lymph node status but with unfavourable characteristics and receiving AST, an improved treatment efficacy was noted when starting radiotherapy after a time interval of ≥ 37 days.

CONCLUSION

The results of our study further support the hypothesis that the timing of radiotherapy may have an impact on treatment efficacy and that further studies (preferably randomized trials) are indicated.

Quality of training in radiation oncology in Germany: where do we stand? : Results from a 2016/2017 survey performed by the working group "young DEGRO" of the German society of radiation oncology (DEGRO)

PURPOSE

To evaluate the current situation of young radiation oncologists in Germany with regard to the contents and quality of training and level of knowledge, as well as their working conditions and professional satisfaction.

METHODS

From June 2016 to February 2017, a survey was conducted by the young DEGRO (yDEGRO) using an online platform. The questionnaire consisted of 28 items examining a broad range of aspects influencing residency. There were 96 completed questionnaires RESULTS: 83% of participants stated to be very or mostly pleased with their residency training. Moderate working hours and a good colleagueship contribute to a comfortable working environment. Level of knowledge regarding the most common tumor sites (i.e. palliative indications, lung, head and neck, brain, breast, prostate) was pleasing. Radiochemotherapy embodies a cornerstone in training. Modern techniques such as intensity-modulated radiotherapy (IMRT) and stereotactic procedures are now in widespread use. Education for rare indications and center-based procedures offers room for improvement.

CONCLUSION

Radiation oncology remains an attractive and versatile specialty with favorable working conditions. Continuing surveys in future years will be a valuable measuring tool to set further priorities in order to preserve and improve quality of training.

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.

Impact of Timing of Concurrent Chemoradiation for Newly Diagnosed Glioblastoma: A Critical Review of Current Evidence

ABBREVIATIONS

EORTC/NCIC, European Organisation for Research and Treatment of Cancer/National Cancer Institute of CanadaGBM, glioblastomaOS, overall survivalPFS, progression-free survivalSEER, Surveillance, Epidemiology, and End ResultsTMZ, temozolomide.

The Effect of Timing of Concurrent Chemoradiation in Patients With Newly Diagnosed Glioblastoma

BACKGROUND

The effect of timing of initiation of concurrent radiation and chemotherapy after surgery on outcome of patients with glioblastoma (GBM) remains unclear.

OBJECTIVE

To further explore this issue, we analyzed 4 clinical trials for patients newly diagnosed with GBM receiving concurrent and adjuvant temozolomide.

METHODS

The cohort study included 198 adult patients with newly diagnosed supratentorial GBM who were enrolled from 2004 to 2010 in 4 clinical trials consisting of radiation plus temozolomide and an experimental agent. The interval to initiation of therapy was determined from the time of surgical resection. The partitioning deletion/substitution/addition algorithm was used to determine the cutoff points for timing of chemoradiation at which there was a significant difference in overall survival (OS) and progression-free survival (PFS).

RESULTS

The median wait time between surgery and initiation of concurrent chemoradiation was 29.5 days (range, 7-56 days). A short delay in chemoradiation administration (at 30-34 days) was predictive of prolonged OS (hazard ratio [HR]: 0.63, P = .03) and prolonged PFS (HR: 0.68, P = .06) compared with early initiation of concurrent chemoradiation (<30 days), after adjusting for protocol and baseline prognostic variables including extent of resection by multivariate analysis. A longer delay to chemoradiation beyond 34 days was not associated with improved OS or PFS compared with early initiation (HR: 0.94, P = .77 and HR: 0.91, P = .63, respectively).

CONCLUSION

A short delay in the start of concurrent chemoradiation is beyond the classic paradigm of 4 weeks post-resection and may be associated with prolonged OS and PFS.

Time interval from breast-conserving surgery to breast irradiation in early stage node-negative breast cancer: 17-year follow-up results and patterns of recurrence

PURPOSE

A retrospective chart review was conducted to determine whether the time interval from breast-conserving surgery to breast irradiation (surgery-radiation therapy interval) in early stage node-negative breast cancer had any detrimental effects on recurrence rates.

METHODS AND MATERIALS

There were 566 patients with T1 to T3, N0 breast cancer treated with breast-conserving surgery and breast irradiation and without adjuvant systemic treatment between 1985 and 1992. The surgery-to-radiation therapy intervals used for analysis were 0 to 8 weeks (201 patients), >8 to 12 weeks (233 patients), >12 to 16 weeks (91 patients), and >16 weeks (41 patients). Kaplan-Meier estimates of time to local recurrence, disease-free survival, distant disease-free survival, cause-specific survival, and overall survival rates were calculated.

RESULTS

Median follow-up was 17.4 years. Patients in all 4 time intervals were similar in terms of characteristics and pathologic features. There were no statistically significant differences among the 4 time groups in local recurrence (P=.67) or disease-free survival (P=.82). The local recurrence rates at 5, 10, and 15 years were 4.9%, 11.5%, and 15.0%, respectively. The distant disease relapse rates at 5, 10, and 15 years were 10.6%, 15.4%, and 18.5%, respectively. The disease-free failure rates at 5, 10, and 15 years were 20%, 32.3%, and 39.8%, respectively. Cause-specific survival rates at 5, 10, and 15 years were 92%, 84.6%, and 79.8%, respectively. The overall survival rates at 5, 10, and 15 years were 89.3%, 79.2%, and 66.9%, respectively.

CONCLUSIONS

Surgery-radiation therapy intervals up to 16 weeks from breast-conserving surgery are not associated with any increased risk of recurrence in early stage node-negative breast cancer. There is a steady local recurrence rate of 1% per year with adjuvant radiation alone.

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.

Role of chemotherapy in breast cancer

Breast cancer represents a major health problem, with more than a million new cases and 370,000 deaths worldwide yearly. Options and understanding of how to use cytotoxic chemotherapy in both advanced and early stage breast cancer have made substantial progress in the past 10 years, with numerous landmark studies identifying clear survival benefits for newer approaches. Despite this research, the optimal approach for any individual patient cannot be determined from a literature review or decision-making algorithm alone. Treatment choices are still predominantly based on practice determined by individual or collective experience and the historic development of treatment within a locality. In many situations treatment decisions cannot be divorced from economic considerations. Blanket application of international, national or local guidelines is usually impractical or inappropriate and careful consideration of the detailed circumstances of each patient is required to make optimal use of available options. Recent research has allowed us to refine breast cancers further into prognostic groups based on a gene expression profile. Clinical trials to prove the value of this approach are currently being designed. This review discusses the evidence for various chemotherapy regimens in the adjuvant and metastatic settings, and examines the current evidence for the timing of radiotherapy in the adjuvant setting.

Timing of radiotherapy in breast-conserving therapy: a large prospective cohort study of node-negative breast cancer patients without adjuvant systemic therapy

Background:

To investigate the issue of timing of radiation therapy (RT) after lumpectomy in relation to recurrences and outcome.

Methods:

Analysis was done on 1107 breast-conserving therapies (BCT) with 1070 women, all without lymph node metastasis and without any adjuvant systemic therapy. Timing was defined as time from lumpectomy till RT. Patients were categorised into tertiles: <45 days, 45–56 days, and 57–112 days.

Results:

Local control did not show a difference between the tertiles. The distant metastasis-free survival as well as the disease-specific survival showed a decreased outcome starting the RT to early after the lumpectomy.

Conclusion:

The results of this cohort study further refines the hypothesis that timing of RT in BCT might have an impact on outcome. It suggests that a randomised trial in timing of RT in BCT seems necessary to give a definite answer.

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.

The optimal sequence of radiotherapy and chemotherapy in adjuvant treatment of breast cancer

BACKGROUND

The optimal time sequences for chemotherapy and radiation therapy after breast surgery for patients with breast cancer remains unknown. Most of published studies were done for early breast cancer patients. However, in Egypt advanced stages were the common presentation. This retrospective analysis aimed to assess the optimum sequence for our population.

METHODS

267 eligible patients planned to receive adjuvant chemotherapy [FAC] and radiotherapy. Majority of patients (87.6%) underwent modified radical mastectomy while, 12.4% had conservative surgery.We divided the patients into 3 groups according to the sequence of chemotherapy and radiotherapy. Sixty-seven patients (25.1%) received postoperative radiotherapy before chemotherapy [group A]. One hundred and fifty patients (56.2%) were treated in a sandwich scheme (group B), which means that 3 chemotherapy cycles were given prior to radiotherapy followed by 3 further chemotherapy cycles. A group of 50 patients (18.7%) was treated sequentially (group C), which means that radiotherapy was supplied after finishing the last chemotherapy cycle. Patients' characteristics are balanced between different groups.

RESULTS

Disease free survival was estimated at 2.5 years, and it was 83.5%, 82.3% and 80% for patient receiving radiation before chemotherapy [group A], sandwich [group B] and after finishing chemotherapy [group C] respectively (p > 0.5). Grade 2 pneumonitis, which necessitates treatment with steroid, was detected in 3.4% of our patients, while grade 2 radiation dermatitis was 17.6%. There are no clinical significant differences between different groups regarded pulmonary or skin toxicities.

CONCLUSION

Regarding disease free survival and treatment toxicities, in our study, we did not find any significant difference between the different radiotherapy and chemotherapy sequences.

Delays in primary surgical treatment are not associated with significant tumor size progression in breast cancer patients

OBJECTIVES

We evaluated the effect of time to surgery on tumor growth by comparing initial imaging and pathologic tumor size estimates. We also determined predictors of delay to surgery.

BACKGROUND

Preoperative work-up, coordination of reconstructive surgery, and referral to tertiary care centers can delay surgical treatment of breast cancer. Whether these delays are associated with interim tumor progression is unknown.

METHODS

We identified 818 clinically node-negative breast cancer patients at our cancer center who had undergone surgery as their first therapeutic modality for invasive breast cancer from September 2003 to December 2006. Baseline tumor size was determined by mammography and sonography; tumor size at surgery was determined from pathology reports.

RESULTS

The median time from imaging to surgery was 21 days (1-132 days). In multivariate analysis, increased time to surgery was associated with older age, total mastectomy versus breast-conserving surgery, and reconstructive surgery. The median difference from baseline mammographic tumor size to surgery was 0 cm (8.6 cm smaller to 7.3 cm larger at surgery). The median difference from baseline sonographic tumor size to surgery was 0.1 cm (7.5 cm smaller to 8.3 cm larger at surgery). Neither of these differences was significantly associated with time to surgery. Time to surgery was associated with positive lymph nodes at surgery; however, no association was found after controlling for other prognostic factors.

CONCLUSIONS

Modest time intervals from imaging to surgery are not significantly associated with change in tumor size; thus, patients may undergo preoperative work-up without experiencing significant disease progression.

Long-term results of a randomized trial on the sequencing of radiotherapy and chemotherapy in breast cancer

OBJECTIVE

A prospective, phase III randomized study was undertaken to compare the outcomes of 2 different radiotherapy and chemotherapy sequences in conservatively treated patients with breast cancer.

METHODS

Between January 1997 and November 2002, 206 patients operated of quadrantectomy and axillary dissection for breast cancer, candidates to receive adjuvant CMF chemotherapy (cyclophosphamide, methotrexate, and fluorouracil) were assigned to concurrent or sequential radiation treatment by using a balanced randomization method. Before randomization patients were stratified by tumor diameter, age, and lymph node status. The primary end point was the freedom from breast recurrence, and secondary end points were overall and disease-free survival. Overall outcomes were analyzed according to the intention-to-treat principle.

RESULTS

All 206 patients enrolled and randomized in the trial were analyzed. The median follow-up was 111 months, with no patient lost for follow-up. No difference in 10-years breast recurrence-free, disease-free, metastasis-free, and overall survival rates was observed in the 2 treatment sequence groups. The Hazard Ratios, calculated for each prognostic factor, showed no difference in all outcomes between the 2 treatment sequences.

CONCLUSIONS

No influence of the treatment sequence on long-term outcomes was observed in this trial. This finding suggests that to avoid an increased risk of distant recurrence or an excessive toxicity, radiation therapy may be delayed until after the end of the more, recently used, anthracycline-based chemotherapy without increasing the risk of breast recurrences, thus allowing the delivery of full-dose chemotherapy in patients at risk for systemic disease spread.

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.

A phase II study of radiotherapy and concurrent paclitaxel chemotherapy in breast-conserving treatment for node-positive breast cancer

PURPOSE

Administering adjuvant chemotherapy before breast radiotherapy decreases the risk of systemic recurrence, but delays in radiotherapy could yield higher local failure. We assessed the feasibility and efficacy of placing radiotherapy earlier in the breast-conserving treatment course for lymph node-positive breast cancer.

METHODS AND MATERIALS

Between June 2000 and December 2004, 44 women with node-positive Stage II and III breast cancer were entered into this trial. Breast-conserving surgery and 4 cycles of doxorubicin (60 mg/m(2))/cyclophosphamide (600 mg/m(2)) were followed by 4 cycles of paclitaxel (175 mg/m(2)) delivered every 3 weeks. Radiotherapy was concurrent with the first 2 cycles of paclitaxel. The breast received 39.6 Gy in 22 fractions with a tumor bed boost of 14 Gy in 7 fractions. Regional lymphatics were included when indicated. Functional lung volume was assessed by use of the diffusing capacity for carbon monoxide as a proxy. Breast cosmesis was evaluated with the Harvard criteria.

RESULTS

The 5-year actuarial rate of disease-free survival is 88%, and overall survival is 93%. There have been no local failures. Median follow-up is 75 months. No cases of radiation pneumonitis developed. There was no significant change in the diffusing capacity for carbon monoxide either immediately after radiotherapy (p = 0.51) or with extended follow-up (p = 0.63). Volume of irradiated breast tissue correlated with acute cosmesis, and acute Grade 3 skin toxicity developed in 2 patients. Late cosmesis was not adversely affected.

CONCLUSIONS

Concurrent paclitaxel chemotherapy and radiotherapy after breast-conserving surgery shortened total treatment time, provided excellent local control, and was well tolerated.

Anthracycline and concurrent radiotherapy as adjuvant treatment of operable breast cancer: a retrospective cohort study in a single institution

Background

Concurrent chemoradiotherapy (CCRT) after breast surgery was investigated by few authors and remains controversial, because of concerns of toxicity with taxanes/anthracyclines and radiation. This treatment is not standard and is more commonly used for locally advanced breast cancer. The aim of our study was to evaluate the efficacy and safety of the concomitant use of anthracycline with radiotherapy (RT).

Findings

Four hundred women having operable breast cancer, treated by adjuvant chemotherapy (CT) and RT in concomitant way between January 2001 and December 2003, were included in this retrospective cohort study. The study compares 2 adjuvant treatments using CCRT, the first with anthracycline (group A) and the second with CMF (group B). The CT treatment was repeated every 21 days for 6 courses and the total delivered dose of RT was 50 Gy, divided as 2 Gy daily fractions. Locoregional recurrence free (LRFS), event free (EFS), and overall survivals (OS) were estimated by the Kaplan-Meier method. The log-rank test was used to compare survival events. Multivariate Cox-regression was used to evaluate the relationship between patient characteristics, treatment and survival.

In the 2 groups (A+B) (n = 400; 249 in group A and 151 in group B), the median follow-up period was 74.5 months. At 5 years, the isolated LRFS was significantly higher in group A compared to group B (98.7% vs 95.3%; hazard ratio [HR] = 0.258; 95% CI, 0.067 to 0.997; log-rank P = .034). In addition, the use of anthracycline regimens was associated with a higher rate of 5 years EFS (80.4% vs 75.1%; HR = 0.665; 95% CI, 0.455 to 1.016; log-rank P = .057). The 5 years OS was 83.2% and 79.2% in the anthracycline and CMF groups, respectively (HR = 0.708; 95% CI, 0.455 to 1.128; log-rank P = .143). Multivariate analysis confirmed the positive effect of anthracycline regimens on LRFS (HR = 0.347; 95% CI, 0.114 to 1.053; log-rank P = .062), EFS (HR = 0.539; 95% CI, 0.344 to 0.846; P = 0.012), and OS (HR = 0.63; 95% CI, 0.401 to 0.991; P = .046). LRFS, EFS and OS were significantly higher in the anthracycline group where the patients (n = 288) received more than 1 cycle of concurrent CT (P = .038, P = .026 and P = .038, respectively). LRFS and EFS were significantly higher in the anthracycline group within the BCT subgroup (P = .049 and P = .04, respectively). There were more hematologic, and more grade 2/3/4 skin toxicity in the anthracycline group.

Conclusions

After mastectomy or BCT, the adjuvant treatment based on anthracycline and concurrent RT reduced breast cancer relapse rate, and significantly improved LRFS, EFS and OS in the patients receiving more than 1 cycle of concurrent CT. There were more hematologic and non hematologic toxicities in the anthracycline group.

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.

Concurrent chemoradiotherapy in adjuvant treatment of breast cancer

BACKGROUND

The optimal sequencing of chemotherapy and radiotherapy after breast surgery was largely studied but remains controversial. Concurrent chemo-radiotherapy is a valuable method for adjuvant treatment of breast cancer which is under ongoing research program in our hospital. We are evaluating the feasibility of the concomitant use of chemotherapy retrospectively.

METHODS

Two hundred forty four women having breast cancer were investigated in a retrospective study. All patients were either treated by radical surgery or breast conservative surgery. The study compares two adjuvant treatments associating concomitant chemotherapy and radiotherapy. In the first group (group A) the patients were treated by chemotherapy and radiotherapy in concomitant way using anthracycline (n = 110). In the second group (group B) the patients were treated by chemotherapy and radiotherapy in concomitant way using CMF treatment (n = 134). Chemotherapy was administered in six cycles, one each 3 weeks. Radiotherapy delivered a radiation dose of 50 Gy on the whole breast (or on the external wall) and/or on the lymphatic region. The Kaplan-Meier method was used to estimate the rates of disease free survival, loco-regional recurrence-free survival and overall survival. The Pearson Khi2 test was used to analyse the homogeneity between the two groups. The log-rank test was used to evaluate the differences between the two groups A and B.

RESULTS

After 76.4 months median follow-up (65.3 months mean follow up), only one patient relapsed to loco-regional breast cancer when the treatment was based on anthracycline. However, 8 patients relapsed to loco-regional breast cancer when the treatment was based on CMF. In the anthracycline group, the disease free survival after 5 years, was 80.4% compared to 76.4% in the CMF group (Log-rank test: p = 0.136). The overall survival after 5 years was 82.5% and 81.1% in the anthracycline and CMF groups respectively (Log-rank test: p = 0.428). The loco-regional free survival at 5 years was equal to 98.6% in group A and 94% in group B (Log-rank test: p = 0,033). The rate of grade II and grade III anaemia was 13.9% and 6.7% in anthracycline group and CMF group respectively (Khi2-test: p = 0.009). The rate of grade II and grade III skin dermatitis toxicity was 4.5% in the group A and 0% in the group B (Khi2-test: p = 0.013).

CONCLUSION

From the 5 years retrospective investigation we showed similar disease free survival and overall survival in the two concurrent chemo-radiotherapy treatments based on anthracycline and CMF. However in the loco-regional breast cancer the treatment based on anthracycline was significantly better than that of the treatment based on CMF. There was more haematological and skin dermatitis toxicity in the anthracycline group.

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.

Radiotherapy timing in 4,820 patients with breast cancer: university of florence experience

PURPOSE

To analyze the relationship between a delay in radiotherapy (RT) after breast-conserving surgery and ipsilateral breast recurrence (BR).

METHODS AND MATERIALS

We included in our analysis 4,820 breast cancer patients who had undergone postoperative RT at the University of Florence. The patients were categorized into four groups according to the interval between surgery and RT (T1, <60 days; T2, 61-120 days; T3, 121-180 days; and T4, >180 days).

RESULTS

On multivariate analysis, the timing of RT did not reach statistical significance in patients who received only postoperative RT (n = 1,935) or RT and hormonal therapy (HT) (n = 1,684) or RT, chemotherapy (CHT), and HT (n = 529). In the postoperative RT-only group, age at presentation, surgical margin status, and a boost to the tumor bed were independent prognostic factors for BR. In the RT plus HT group, age at presentation and boost emerged as independent prognostic factors for BR (p = 0.006 and p = 0.049, respectively). Finally, in the RT, CHT, and HT group, only multifocality was an independent BR predictor (p = 0.01). Only in the group of patients treated with RT and CHT (n = 672) did multivariate analysis with stepwise selection show RT timing as an independent prognostic factor (hazard ratio, 1.59; 95% confidence interval, 1.01-2.52; p = 0.045). Analyzing this group of patients, we found that most patients included had worse prognostic factors and had received CHT consisting of cyclophosphamide, methotrexate, and 5-fluorouracil before undergoing RT.

CONCLUSION

The results of our study have shown that the timing of RT itself does not affect local recurrence, which is mainly related to prognostic factors. Thus, the "waiting list" should be thought of as a "programming list," with patients scheduled for RT according to their prognostic factors.

Sequencing chemotherapy and radiotherapy in locoregional advanced breast cancer patients after mastectomy - a retrospective analysis

BACKGROUND

Combined chemo- and radiotherapy are established in breast cancer treatment. Chemotherapy is recommended prior to radiotherapy but decisive data on the optimal sequence are rare. This retrospective analysis aimed to assess the role of sequencing in patients after mastectomy because of advanced locoregional disease.

METHODS

A total of 212 eligible patients had a stage III breast cancer and had adjuvant chemotherapy and radiotherapy after mastectomy and axillary dissection between 1996 and 2004. According to concerted multi-modality treatment strategies 86 patients were treated sequentially (chemotherapy followed by radiotherapy) (SEQgroup), 70 patients had a sandwich treatment (SW-group) and 56 patients had simultaneous chemoradiation (SIM-group) during that time period. Radiotherapy comprised the thoracic wall and/or regional lymph nodes. The total dose was 45-50.4 Gray. As simultaneous chemoradiation CMF was given in 95.4% of patients while in sequential or sandwich application in 86% and 87.1% of patients an anthracycline-based chemotherapy was given.

RESULTS

Concerning the parameters nodal involvement, lymphovascular invasion, extracapsular spread and extension of the irradiated region the three treatment groups were significantly imbalanced. The other parameters, e.g. age, pathological tumor stage, grading and receptor status were homogeneously distributed. Looking on those two groups with an equally effective chemotherapy (EC, FEC), the SEQ- and SW-group, the sole imbalance was the extension of LVI (57.1 vs. 25.6%, p < 0.0001).5-year overall- and disease free survival were 53.2%/56%, 38.1%/32% and 64.2%/50%, for the sequential, sandwich and simultaneous regime, respectively, which differed significantly in the univariate analysis (p = 0.04 and p = 0.03, log-rank test). Also the 5-year locoregional or distant recurrence free survival showed no significant differences according to the sequence of chemo- and radiotherapy. In the multivariate analyses the sequence had no independent impact on overall survival (p = 0.2) or disease free survival (p = 0.4). The toxicity, whether acute nor late, showed no significant differences in the three groups. The grade III/IV acute side effects were 3.6%, 0% and 3.5% for the SIM-, SW- and SEQ-group. By tendency the SIM regime had more late side effects.

CONCLUSION

No clear advantage can be stated for any radio- and chemotherapy sequence in breast cancer therapy so far. This could be confirmed in our retrospective analysis in high-risk patients after mastectomy. The sequential approach is recommended according to current guidelines considering a lower toxicity.

Mastectomy with immediate expander-implant reconstruction, adjuvant chemotherapy, and radiation for stage II-III breast cancer: treatment intervals and clinical outcomes

PURPOSE

To determine intervals between surgery and adjuvant chemotherapy and radiation in patients treated with mastectomy with immediate expander-implant reconstruction, and to evaluate locoregional and distant control and overall survival in these patients.

METHODS AND MATERIALS

Between May 1996 and March 2004, 104 patients with Stage II-III breast cancer were routinely treated at our institution under the following algorithm: (1) definitive mastectomy with axillary lymph node dissection and immediate tissue expander placement, (2) tissue expansion during chemotherapy, (3) exchange of tissue expander for permanent implant, (4) radiation. Patient, disease, and treatment characteristics and clinical outcomes were retrospectively evaluated.

RESULTS

Median age was 45 years. Twenty-six percent of patients were Stage II and 74% Stage III. All received adjuvant chemotherapy. Estrogen receptor staining was positive in 77%, and 78% received hormone therapy. Radiation was delivered to the chest wall with daily 0.5-cm bolus and to the supraclavicular fossa. Median dose was 5,040 cGy. Median interval from surgery to chemotherapy was 5 weeks, from completion of chemotherapy to exchange 4 weeks, and from exchange to radiation 4 weeks. Median interval from completion of chemotherapy to start of radiation was 8 weeks. Median follow-up was 64 months from date of mastectomy. The 5-year rate for locoregional disease control was 100%, for distant metastasis-free survival 90%, and for overall survival 96%.

CONCLUSIONS

Mastectomy with immediate expander-implant reconstruction, adjuvant chemotherapy, and radiation results in a median interval of 8 weeks from completion of chemotherapy to initiation of radiation and seems to be associated with acceptable 5-year locoregional control, distant metastasis-free survival, and overall survival.

The effect of timing of radiotherapy after breast-conserving surgery in patients with positive or close resection margins, young age, and node-negative disease, with long term follow-up

PURPOSE

The aim of this study was to determine the effect of timing of radiotherapy after conservative breast surgery on local recurrence in women with positive resection margins and young age, treated without systemic therapy.

METHODS AND MATERIALS

A total of 568 patients with T1 and T2, N0 breast cancer were treated with breast-conserving surgery and breast irradiation, between January 1, 1985, and December 31, 1992, at the London Regional Cancer Centre. 63 patients (11.1%) had positive/close resection margins (< 2 mm) and 48 patients (8.4%) were age < or = 40 years. For patients with positive resection margins, the time intervals from breast surgery to breast irradiation used for analysis were, 0 to 8 weeks, > 8 to 12 weeks and > 12 weeks. For patients < or = 40 years, the intervals used for analysis were 0 to 8 weeks and > 8 weeks.

RESULTS

Median follow up was 11.2 years. For patients < or = 40 years, local recurrence rate at 5 and 10 years was 17.2% and 19.8% respectively. Four patients (17.4%) treated in the 0-week to 8-week interval and 7 patients (28.0%) treated in the > 8 week interval had local recurrences. For patients < or = 40 years with positive resection margins, the local recurrence rate was 25.0%. For patients with positive resection margins, 5-year and 10-year local recurrence rates were as follows: 0 to 8 weeks, 0% and 10.5% respectively; > 8 to 12 weeks, 10.3% and 10.3% respectively; and > 12 weeks, 13.3% and 20.0% respectively.

CONCLUSION

Patients < or = 40 years have an increased local recurrence rate which occurs early. Patients with positive resection margins have higher local recurrence rates that become apparent when breast irradiation is delayed.

Delay in initiating adjuvant radiotherapy following breast conservation surgery and its impact on survival

PURPOSE

Delays in the diagnosis of breast cancer are associated with advanced stage and poor survival, but the importance of the time interval between lumpectomy and initiation of radiation therapy (RT) has not been well studied. We investigated factors that influence the time interval between lumpectomy and RT, and the association between that interval and survival.

PATIENTS AND METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database on women aged 65 years and older, diagnosed with Stages I-II breast cancer, between 1991 and 1999. Among patients who did not receive chemotherapy, we studied factors associated with the time interval between lumpectomy and the initiation of RT, and the association of delay with survival, using linear regression and Cox proportional hazards modeling.

RESULTS

Among 24,833 women with who underwent lumpectomy, 13,907 (56%) underwent RT. Among those receiving RT, 97% started treatment within 3 months; older age, black race, advanced stage, more comorbidities, and being unmarried were associated with longer time intervals between surgery and RT. There was no benefit to earlier initiation of RT; however, delays >3 months were associated with higher overall mortality (hazard ratio, 1.92; 95% confidence interval, 1.64-2.24) and cancer-specific mortality (hazard ratio, 3.84; 95% confidence interval 3.01-4.91).

CONCLUSIONS

Reassuringly, early initiation of RT was not associated with survival. Although delays of >3 months are uncommon, they are associated with poor survival. Whether this association is causal or due to confounding factors, such as poor health behaviors, is unknown; until it is better understood, efforts should be made to initiate RT in a timely fashion.

Timing of radiotherapy and survival benefit in breast cancer

PURPOSE

To look at the optimum timing of radiotherapy in breast-conserving therapy (BCT) in relation to outcome in breast cancer.

METHODS

We analyzed 1473 BCT on 1446 breast cancer patients from our prospective cohort, stage I or II, node-negative, and without adjuvant systemic therapy. Timing was defined as time from lumpectomy till radiotherapy. Patients were categorized into three timing tertiles: 1-36 days, 37-53 days, and 54-112 days.

RESULTS

The 10-year local relapse-free survival rates did not show significant differences between the three groups. The 10-year Distant Metastasis-Free Survival (DMFS) was 78.9% for the first tertile, versus 86.1% (HR 0.6; P = 0.009) for the second, and 90.7% (HR 0.3; P < 0.001) for the third. The 10-year Disease-specific Survival (DSS) was 83.8% for the first tertile, versus 90.6% (HR 0.5; P = 0.007) for the second, and 97.2% (HR 02; P < 0.001) for the third. Also in multivariate Cox regression analysis the second (HR 0.6; P = 0.053) and the third tertile (HR 0.3; P = 0.002) had significantly better DSS.

CONCLUSION

Timing of radiotherapy in BCT for breast cancer seems to be highly important in relation to survival. This study shows a 40-70% relative survival benefit with timing after 36 days.

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.

Radiation Therapy for Breast Cancer

Over the past five decades, radiotherapy (RT) has become an integral part in the combined modality management of breast cancer. Although its significant effect on local control has been long demonstrated, only recently has adjuvant RT been shown to have a significant effect on breast cancer mortality and overall survival. This article summarizes the adjuvant role of RT after mastectomy and lumpectomy, as well as the rationale and techniques for partial-breast irradiation.

Eleven-year follow-up results in the delay of breast irradiation after conservative breast surgery in node-negative breast cancer patients

PURPOSE

This retrospective review was conducted to determine if delay in the start of radiotherapy after conservative breast surgery had any detrimental effect on local recurrence or disease-free survival in node-negative breast cancer patients.

METHODS AND MATERIALS

A total of 568 patients with T1 and T2, N0 breast cancer were treated with breast-conserving surgery and breast irradiation, without adjuvant systemic therapy, between January 1, 1985 and December 31, 1992 at the London Regional Cancer Centre. The time intervals from definitive breast surgery to breast irradiation used for analysis were 0 to 8 weeks (201 patients), greater than 8 to 12 weeks (235 patients), greater than 12 to 16 weeks (91 patients), and greater than 16 weeks (41 patients). Kaplan-Meier estimates of time to local-recurrence and disease-free survival rates were calculated.

RESULTS

Median follow-up was 11.2 years. Patients in all 4 time intervals were similar in terms of age and pathologic features. No statistically significant difference was seen between the 4 groups in local recurrence or disease-free survival with surgery radiotherapy interval (p = 0.521 and p = 0.222, respectively). The overall local-recurrence rate at 5 and 10 years was 4.6% and 11.3%, respectively. The overall disease-free survival at 5 and 10 years was 79.6% and 67.0%, respectively.

CONCLUSION

This retrospective study suggests that delay in the start of breast irradiation of up to 16 weeks from definitive surgery does not increase the risk of recurrence in node-negative breast cancer patients. The certainty of these results is limited by the retrospective nature of this analysis.

Examining time intervals between diagnosis and treatment in the management of patients with limited stage small cell lung cancer

OBJECTIVE

To examine time intervals between diagnosis and treatment of limited stage small cell lung cancer (L-SCLC) and to evaluate its effect on clinical outcomes.

MATERIALS AND METHODS

Data on 166 patients with L-SCLC referred to a regional cancer center between January 1991 and December 1999 were analyzed. The time intervals studied were defined as: interval A, first abnormal chest x-ray to pathologic diagnosis: interval B, diagnosis to first oncology consultation; interval C, oncology consultation to first day of thoracic radiotherapy (RT); interval D, oncology consultation to first day of chemotherapy; and interval E, first day of chemo to first day of RT. Cox proportional hazards models were used to examine associations between the time intervals and thoracic relapse (TR) and overall survival (OS) outcomes. Logistic regression analysis was used to model associations between time and complete response (CR) rates.

RESULTS

The median time duration of intervals A to E were 20, 12, 63.5, 15, and 48 days, respectively. When time was analyzed as a continuous variable, no statistically significant association between the interval lengths and outcomes studied was observed. Dichotomizing each interval using the median value as cut-off revealed that interval A >20 days was significantly associated with improved CR (odds ratio = 3.573; P = 0.027) whereas interval B >12 days was associated with a trend toward lower CR (odds ratio = 0.348; P = 0.073).

CONCLUSIONS

Short median times from first abnormal chest x-ray to diagnosis and from diagnosis to oncology consultation indicate that L-SCLC patients were diagnosed and referred promptly in the community setting. OS and TR appeared independent of the time intervals analyzed. Individual variations in disease presentation and tumor biology may explain the observed associations between early pathologic diagnosis and inferior CR rates.

Délais et retards à la radiothérapie : réflexion à propos de trois types de tumeurs

In the following review of the literature, the reasons and consequences of a tendency to the increase of the delay between the diagnosis and the first irradiation session will be studied. The duration of the delay varies according to the protocol of treatment, which itself depends on the tumour. Moreover, all types of radiotherapy are concerned by the increase in delay. A retrospective study enables to determine for a given series of similar tumours and treatments the mean duration of delay and find the excessive duration. The increase of delay phenomenon exists in different countries. We know that before irradiation the tumour grows according to its biological characteristics and the TNM initial determination will no longer be true. On the other hand, effective treatments such as chemotherapy and hormone therapy are increasingly used alone, before or in combination with radiotherapy. Consequently, the classical timing of radiation therapy could be modified often delayed. It is difficult to consider that successive treatments are a real increase of delay and compare its results with previous data from radiotherapy alone. We will study its impact in three types of tumours, including tumours of head and neck, of the breast and prostate, which are the most widely reported. The consequences of prolonged delay are not easily evaluated: one of the more important parameters is the possible modification of the stage of tumour. This phenomenon is not restricted to the studied types of tumours. We will try to find possible ways of reducing abnormal delays before irradiation.

A phase III randomized study on the sequencing of radiotherapy and chemotherapy in the conservative management of early-stage breast cancer

PURPOSE

To compare two different timings of radiation treatment in patients with breast cancer who underwent conservative surgery and were candidates to receive adjuvant cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy.

METHODS AND MATERIALS

A total of 206 patients who had quadrantectomy and axillary dissection for breast cancer and were planned to receive adjuvant CMF chemotherapy were randomized to concurrent or sequential radiotherapy. Radiotherapy was delivered only to the whole breast through tangential fields to a dose of 50 Gy in 20 fractions over 4 weeks, followed by an electron boost of 10-15 Gy in 4-6 fractions to the tumor bed.

RESULTS

No differences in 5-year breast recurrence-free, metastasis-free, disease-free, and overall survival were observed in the two treatment groups. All patients completed the planned radiotherapy. No evidence of an increased risk of toxicity was observed between the two arms. No difference in radiotherapy and in the chemotherapy dose intensity was observed in the two groups.

CONCLUSIONS

In patients with negative surgical margins receiving adjuvant chemotherapy, radiotherapy can be delayed to up to 7 months. Concurrent administration of CMF chemotherapy and radiotherapy is safe and might be reserved for patients at high risk of local recurrence, such as those with positive surgical margins or larger tumor diameters.

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.

Non-homogeneous Markov Processes for Biomedical Data Analysis

Some time ago, the Markov processes were introduced in biomedical sciences in order to study disease history events. Homogeneous and Non-homogeneous Markov processes are an important field of research into stochastic processes, especially when exact transition times are unknown and interval-censored observations are present in the analysis. Non-homogeneous Markov process should be used when the homogeneous assumption is too strong. However these sorts of models increase the complexity of the analysis and standard software is limited. In this paper, some methods for fitting non-homogeneous Markov models are reviewed and an algorithm is proposed for biomedical data analysis. The method has been applied to analyse breast cancer data. Specific software for this purpose has been implemented.

Predictors of local recurrence after breast-conservation therapy

Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.

Sequencing of chemotherapy and radiation therapy in early-stage breast cancer: updated results of a prospective randomized trial

PURPOSE

The optimal integration of chemotherapy with radiation (RT) for patients with early-stage breast cancer remains uncertain. We present the long-term results of a prospective randomized trial to address this question.

PATIENTS AND METHODS

Two hundred forty-four patients were randomly assigned after conservative breast surgery to receive 12 weeks of cyclophosphamide, doxorubicin, methotrexate, fluorouracil, and prednisone (CAMFP) before RT (CT-first) or after RT (RT-first). Median follow-up for surviving patients was 135 months.

RESULTS

There were no significant differences between the CT-first and RT-first arms in time to any event, distant metastasis, or death. Sites of first failure were also not significantly different.

CONCLUSION

Among breast cancer patients treated with conservative surgery, there is no advantage to giving RT before adjuvant chemotherapy. However, this study does not have enough statistical power to rule out a clinically important survival benefit for either sequence.

A population-based study of the impact of delaying radiotherapy after conservative surgery for breast cancer

BACKGROUND

Practice guidelines have set a maximum waiting time to radiation therapy for breast cancer. We evaluated if delaying radiotherapy resulted in worse outcomes in a large cohort of women with node-negative breast cancer.

METHODS

We selected a random sample of cases among women diagnosed with localized breast cancer in five regions of Québec, Canada, between 1988 and 1994. Only women with pathologically (n = 926) or clinically (n = 136) negative axillary nodes, and stage 1 or 2 disease treated with conservative surgery and radiotherapy were eligible. Information was obtained by chart review, queries to physicians and linkage with administrative databases. Outcomes were estimated by Kaplan-Meier method and Cox proportional hazards analysis. Median follow-up was 7.1 years (range: 0.9-11.8).

RESULTS

Median delay to radiotherapy was 12.4 weeks in those who received chemotherapy and 8.4 weeks in others. Overall survival at 7 years was 85.6%. Local relapse-free and distant disease-free survivals were 77.6 and 76.2%. There was no significant difference in survival according to delay to radiotherapy in crude or multivariate analysis adjusting for several prognostic factors, including systemic treatment. The risk of local failure conditional on survival in women who received radiotherapy more than 12 weeks after surgery was increased (hazard ratio: 1.75, 95% confidence interval: 1.00, 3.08, p-value = 0.052).

CONCLUSIONS

Although longer waiting time to radiotherapy may compromise local control, it does not influence survival at 7 years when other predictors of outcomes are taken into account. Well controlled studies are needed to confirm and better characterize this relationship.

[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.

Trends in postoperative radiotherapy delay and the effect on survival in breast cancer patients treated with conservation surgery

The adequate timing of adjuvant radiotherapy (RT) in breast cancer has become a subject of increasing interest in recent years. A population-based study was undertaken to determine the influence of demographic and clinical factors on the postoperative RT delay in patients treated with breast-conserving surgery (BCS) and to assess the impact of delay on survival. In total, 7800 breast cancer patients treated with BCS and adjuvant RT between 1986 and 1998 in Yorkshire were included in the study. The median interval between surgery and the start of RT (S–RT interval) was 8 weeks (7 weeks for chemotherapy negative and 11 for chemotherapy positive patients). This interval increased substantially over time from 5 weeks during 1986–1988, irrespective of patients' chemotherapy status, to 10 and 17 weeks among chemotherapy negative and chemotherapy positive patients, respectively, in 1997–1998. The S–RT interval was also significantly influenced by travel time to RT centre, year and at which RT centre patient had the treatment (P<0.001). Overall, 5-year survival was 82%. Patients with S–RT intervals longer than 9 weeks had a trend towards an increased relative risk of death. This reached a statistical significance at 20–26 weeks (RR 1.49, 95% CI (1.16–1.92)). The findings of our study suggest that delaying the initiation of RT for 20–26 weeks after surgery is associated with decreased survival in patients treated with conservation surgery.

Sequential audits of unacceptable delays in radiation therapy in Australia and New Zealand

Delays in accessing radiation treatment are of concern in Australia and New Zealand, both in terms of the proportion of patients who are actually able to access care, and in the timeliness of starting treatment. For those who are able to access treatment, one in three patients experience an unacceptable delay in starting treatment, and only one in four patients starts radiotherapy within standard good practice times. During the year 2002, more than 15 000 Australians who potentially could have benefited from radiotherapy, did not receive this treatment. For those who were able to access radiotherapy treatment, worsening delays were experienced in Australia, with greater than 40% of patients receiving curative treatment, 30% receiving palliative treatment, and 56% receiving emergency treatment starting outside of standard good practice times. Delays of up to 151 days were experienced in Australia. In Australia, delays in implementing recommendations to improve the infrastructure are resulting in a declining service for cancer patients. In New Zealand, the situation, in general, is improving, although there needs to be an ongoing commitment to grow the service according to the population needs. Urgent implementation of strategic planning is required.

Irradiation et chimiothérapie concomitante après chirurgie pour cancer du sein

In breast cancer, radiation therapy improves local control rate and survival. When chemotherapy and radiation are indicated the sequencing of the two treatments is still controversial. Several studies have suggested that adjuvant radiotherapy could be safely delayed until adjuvant chemotherapy was completed. Other studies, most of them retrospective, pointed out that a delay in the initiation of radiotherapy to give chemotherapy first, will result in a increased rate of local recurrence. Concomitant administration of the two treatments is an alternative. Pilot studies have suggested the feasibility of simultaneous administration using selected regimen as CMF or FNC. A randomized phase III trials has been conducted to compare sequential treatment with chemotherapy first and radiation versus concomitant treatments. Preliminary results of this study are presented.

Infrastructure of radiotherapy in Spain: a minimal standard of radiotherapy resources

PURPOSE

To assess the state of our specialty, the Spanish Society of Radiotherapy and Oncology ordered a survey of all Spanish services of radiation oncology.

METHODS AND MATERIALS

In June 1999, the Society ordered an analysis of the state of radiation oncology. It created a survey that was sent to all radiotherapy units in Spain. A database was created in which 230 variables were analyzed.

RESULTS

Eighty-four centers were analyzed, and 157 external beam irradiation, megavoltage units were counted, of which 67 were cobalt units and 90 were linear accelerators. The cobalt units worked an average of 11.4 h daily and the linear accelerators 11.6 h. The number of patients/unit/y was 472 for the cobalt units and 442 for the linear accelerators. The number of patients by physician and year was 179. Each center received a mean of 958 new patients annually. The average between the reception and start of treatment was 25.52 days (maximum 60), and it was estimated that only 38.1% of cancers were irradiated. The number of radiation oncologists working was 392. Spain has a deficit of 297 radiation oncologists.

CONCLUSION

There is a need for 44 MV units and for the replacement of 67 cobalt units. The present lack of units has had an impact on palliative treatment, which has resulted in pharmacy costs. As long as these instrumental deficiencies are not solved, waiting lists will continue to be inherent to the system. There are also important staff deficiencies, in that about 297 radiation oncologists would be needed to cover the needs.