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Elder E, Fasola C, Clavin N, Hecksher A, Trufan S, Schepel C, Donahue E, Warren Y, White RL, Hadzikadic-Gusic L. Anatomic Location of Tissue Expander Placement Is Not Associated With Delay in Adjuvant Therapy in Women With Breast Cancer. Ann Plast Surg 2023; 91:679-685. [PMID: 37856209 DOI: 10.1097/sap.0000000000003694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Tissue expanders in breast reconstruction are traditionally placed retropectoral. Increasingly, patients are undergoing prepectoral placement. The impact of this placement on the initiation of adjuvant treatment is unknown. METHODS A retrospective review was conducted to identify women diagnosed with breast cancer who underwent mastectomy followed by radiation and/or chemotherapy. Women were divided into 3 groups: prepectoral tissue expander placement, retropectoral tissue expander placement, and no immediate reconstruction. A treatment delay was defined as greater than 8 weeks between tissue expander placement and adjuvant therapy. RESULTS Of 634 women, 205 (32%) underwent tissue expander placement, and 429 (68%) did not have immediate reconstruction. Of those with tissue expanders placed, 84 (41%) had prepectoral placement, and 121 (59%) had retropectoral placement. The median time to adjuvant therapy was 49 days for the entire cohort: no reconstruction, 47 days; prepectoral, 57 days; and retropectoral, 55 days. Treatment delays were observed in 34% of women: no reconstruction, 28%; prepectoral, 51%; and retropectoral, 46% ( P < 0.001). Tissue expander placement was associated with a delay to adjuvant therapy when compared with no reconstruction ( P < 0.001). The location of the tissue expander did not impact the odds of having a delay. On multivariable analysis, having reconstruction, having postoperative infection, not undergoing chemotherapy treatment, and being a current smoker were associated with a delay to adjuvant therapy. A delay to treatment was not associated with worse survival. CONCLUSIONS Placement of a tissue expander delayed adjuvant therapy. The location of tissue expander placement, retropectoral versus prepectoral, did not impact the time to adjuvant treatment.
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Affiliation(s)
- Erin Elder
- From the Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health
| | - Carolina Fasola
- Department of Radiation Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Nicholas Clavin
- Division of Plastic Surgery, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute
| | | | - Sally Trufan
- Department of Cancer Biostatistics, Levine Cancer Institute, Charlotte, NC
| | | | - Erin Donahue
- Department of Cancer Biostatistics, Levine Cancer Institute, Charlotte, NC
| | - Yancey Warren
- From the Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health
| | - Richard L White
- From the Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health
| | - Lejla Hadzikadic-Gusic
- From the Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health
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Brunt AM, Haviland JS, Wheatley DA, Sydenham MA, Bloomfield DJ, Chan C, Cleator S, Coles CE, Donovan E, Fleming H, Glynn D, Goodman A, Griffin S, Hopwood P, Kirby AM, Kirwan CC, Nabi Z, Patel J, Sawyer E, Somaiah N, Syndikus I, Venables K, Yarnold JR, Bliss JM. One versus three weeks hypofractionated whole breast radiotherapy for early breast cancer treatment: the FAST-Forward phase III RCT. Health Technol Assess 2023; 27:1-176. [PMID: 37991196 PMCID: PMC11017153 DOI: 10.3310/wwbf1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
Background FAST-Forward aimed to identify a 5-fraction schedule of adjuvant radiotherapy delivered in 1 week that was non-inferior in terms of local cancer control and as safe as the standard 15-fraction regimen after primary surgery for early breast cancer. Published acute toxicity and 5-year results are presented here with other aspects of the trial. Design Multicentre phase III non-inferiority trial. Patients with invasive carcinoma of the breast (pT1-3pN0-1M0) after breast conservation surgery or mastectomy randomised (1 : 1 : 1) to 40 Gy in 15 fractions (3 weeks), 27 Gy or 26 Gy in 5 fractions (1 week) whole breast/chest wall (Main Trial). Primary endpoint was ipsilateral breast tumour relapse; assuming 2% 5-year incidence for 40 Gy, non-inferiority pre-defined as < 1.6% excess for 5-fraction schedules (critical hazard ratio = 1.81). Normal tissue effects were assessed independently by clinicians, patients and photographs. Sub-studies Two acute skin toxicity sub-studies were undertaken to confirm safety of the test schedules. Primary endpoint was proportion of patients with grade ≥ 3 acute breast skin toxicity at any time from the start of radiotherapy to 4 weeks after completion. Nodal Sub-Study patients had breast/chest wall plus axillary radiotherapy testing the same three schedules, reduced to the 40 and 26 Gy groups on amendment, with the primary endpoint of 5-year patient-reported arm/hand swelling. Limitations A sequential hypofractionated or simultaneous integrated boost has not been studied. Participants Ninety-seven UK centres recruited 4096 patients (1361:40 Gy, 1367:27 Gy, 1368:26 Gy) into the Main Trial from November 2011 to June 2014. The Nodal Sub-Study recruited an additional 469 patients from 50 UK centres. One hundred and ninety and 162 Main Trial patients were included in the acute toxicity sub-studies. Results Acute toxicity sub-studies evaluable patients: (1) acute grade 3 Radiation Therapy Oncology Group toxicity reported in 40 Gy/15 fractions 6/44 (13.6%); 27 Gy/5 fractions 5/51 (9.8%); 26 Gy/5 fractions 3/52 (5.8%). (2) Grade 3 common toxicity criteria for adverse effects toxicity reported for one patient. At 71-month median follow-up in the Main Trial, 79 ipsilateral breast tumour relapse events (40 Gy: 31, 27 Gy: 27, 26 Gy: 21); hazard ratios (95% confidence interval) versus 40 Gy were 27 Gy: 0.86 (0.51 to 1.44), 26 Gy: 0.67 (0.38 to 1.16). With 2.1% (1.4 to 3.1) 5-year incidence ipsilateral breast tumour relapse after 40 Gy, estimated absolute differences versus 40 Gy (non-inferiority test) were -0.3% (-1.0-0.9) for 27 Gy (p = 0.0022) and -0.7% (-1.3-0.3) for 26 Gy (p = 0.00019). Five-year prevalence of any clinician-assessed moderate/marked breast normal tissue effects was 40 Gy: 98/986 (9.9%), 27 Gy: 155/1005 (15.4%), 26 Gy: 121/1020 (11.9%). Across all clinician assessments from 1 to 5 years, odds ratios versus 40 Gy were 1.55 (1.32 to 1.83; p < 0.0001) for 27 Gy and 1.12 (0.94-1.34; p = 0.20) for 26 Gy. Patient and photographic assessments showed higher normal tissue effects risk for 27 Gy versus 40 Gy but not for 26 Gy. Nodal Sub-Study reported no arm/hand swelling in 80% and 77% in 40 Gy and 26 Gy at baseline, and 73% and 76% at 24 months. The prevalence of moderate/marked arm/hand swelling at 24 months was 10% versus 7% for 40 Gy compared with 26 Gy. Interpretation Five-year local tumour incidence and normal tissue effects prevalence show 26 Gy in 5 fractions in 1 week is a safe and effective alternative to 40 Gy in 15 fractions for patients prescribed adjuvant local radiotherapy after primary surgery for early-stage breast cancer. Future work Ten-year Main Trial follow-up is essential. Inclusion in hypofractionation meta-analysis ongoing. A future hypofractionated boost trial is strongly supported. Trial registration FAST-Forward was sponsored by The Institute of Cancer Research and was registered as ISRCTN19906132. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 09/01/47) and is published in full in Health Technology Assessment; Vol. 27, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Adrian Murray Brunt
- School of Medicine, University of Keele and University Hospitals of North Midlands, Staffordshire, UK
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Duncan A Wheatley
- Department of Oncology, Royal Cornwall Hospital NHS Trust, Truro, UK
| | - Mark A Sydenham
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - David J Bloomfield
- Sussex Cancer Centre, Brighton and Sussex University Hospitals, Brighton, UK
| | - Charlie Chan
- Women's Health Clinic, Nuffield Health Cheltenham Hospital, Cheltenham, UK
| | - Suzy Cleator
- Department of Oncology, Imperial Healthcare NHS Trust, London, UK
| | | | - Ellen Donovan
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | - Helen Fleming
- Clinical and Translational Radiotherapy Research Group, National Cancer Research Institute, London, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, UK
| | | | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Penelope Hopwood
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Anna M Kirby
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Cliona C Kirwan
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Zohal Nabi
- RTQQA, Mount Vernon Cancer Centre, Middlesex, UK
| | - Jaymini Patel
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Elinor Sawyer
- Comprehensive Cancer Centre, King's College London, London, UK
| | - Navita Somaiah
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Isabel Syndikus
- Clatterbridge Cancer Centre, Clatterbridge Hospital NHS Trust, Cheshire, UK
| | | | - John R Yarnold
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Judith M Bliss
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
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Strnad V, Krug D, Sedlmayer F, Piroth MD, Budach W, Baumann R, Feyer P, Duma MN, Haase W, Harms W, Hehr T, Fietkau R, Dunst J, Sauer R. DEGRO practical guideline for partial-breast irradiation. Strahlenther Onkol 2020; 196:749-763. [PMID: 32350554 PMCID: PMC7449998 DOI: 10.1007/s00066-020-01613-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE This consensus statement from the Breast Cancer Working Group of the German Society for Radiation Oncology (DEGRO) aims to define practical guidelines for accelerated partial-breast irradiation (APBI). METHODS Recent recommendations for relevant aspects of APBI were summarized and a panel of experts reviewed all the relevant literature. Panel members of the DEGRO experts participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for implementing APBI in clinical routine, focusing on patient selection, target definition, and treatment technique. RESULTS Appropriate patient selection, target definition for different APBI techniques, and basic rules for appropriate APBI techniques for clinical routine outside of clinical trials are described. Detailed recommendations for APBI in daily practice, including dose constraints, are given. CONCLUSION Guidelines are mandatory to assure optimal results of APBI using different techniques.
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Affiliation(s)
- V Strnad
- University Hospital Erlangen, Erlangen, Germany.
| | - D Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - F Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | - M D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - W Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - R Baumann
- St. Marien-Krankenhaus Siegen, Siegen, Germany
| | - P Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | - M N Duma
- University Hospital, Jena, Germany
| | - W Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - W Harms
- St. Claraspital Basel, Basel, Switzerland
| | - T Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - R Fietkau
- University Hospital Erlangen, Erlangen, Germany
| | - J Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Sauer
- University Hospital Erlangen, Erlangen, Germany
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Jang MG, Ko HC, Kim SJ. Effects of p-coumaric acid on microRNA expression profiles in SNU-16 human gastric cancer cells. Genes Genomics 2020; 42:817-825. [PMID: 32462517 DOI: 10.1007/s13258-020-00944-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/12/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND p-Coumaric acid (p-CA), a phenolic compound abundantly found in edible plants, was found to induce apoptosis in SNU-16 gastric cancer cells. However, the effects of p-CA on the microRNA expression pattern in SNU-16 cells have not been reported. OBJECTIVES The primary objective of this study was to investigate microRNA expression profiles in p-CA-treated SNU-16 cells. METHODS SNU-16 cells were treated with 1.5 mM p-CA for 48 h. High-throughput RNA sequencing was performed. The accuracy and validity of the RNA sequencing results were tested by real-time PCR. Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed using the differentially expressed microRNAs (DEMs). RESULTS Thirty-two DEMs were identified between p-CA-treated and control cells, 9 of which were upregulated, and 23 downregulated. GO and KEGG pathway analyses of the target genes indicated that these genes were involved in a variety of biological functions and several cancer-related pathways. The miRNA interactive network analysis identified hsa-miR-125a-5p, hsa-miR-30a-5p, and hsa-miR-7-5p as the major nodes. CONCLUSIONS Our findings indicated that p-CA exerted its anticancer effects in SNU-16 gastric cancer cells by modulating the expression of certain microRNAs, providing a better understanding of the anticancer properties of p-CA in gastric cancer cells.
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Affiliation(s)
- Mi Gyeong Jang
- Department of Biology, Jeju National University, 102 Jejudaehak-ro, Jeju-si, Jeju Special Self-Governing Province, 63243, Republic of Korea
- Biotech Regional Innovation Center, Jeju National University, 102 Jejudaehak-ro, Jeju- si, Jeju Special Self-Governing Province, 63243, Republic of Korea
| | - Hee Chul Ko
- Biotech Regional Innovation Center, Jeju National University, 102 Jejudaehak-ro, Jeju- si, Jeju Special Self-Governing Province, 63243, Republic of Korea
| | - Se-Jae Kim
- Department of Biology, Jeju National University, 102 Jejudaehak-ro, Jeju-si, Jeju Special Self-Governing Province, 63243, Republic of Korea.
- Biotech Regional Innovation Center, Jeju National University, 102 Jejudaehak-ro, Jeju- si, Jeju Special Self-Governing Province, 63243, Republic of Korea.
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Hunter AJ, Hendrikse AS. Estimation of the effects of radiotherapy treatment delays on tumour responses: A review. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2020. [DOI: 10.4102/sajo.v4i0.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Han X, Zhao J, Ruddy KJ, Lin CC, Sineshaw HM, Jemal A. The impact of dependent coverage expansion under the Affordable Care Act on time to breast cancer treatment among young women. PLoS One 2018; 13:e0198771. [PMID: 29897976 PMCID: PMC5999229 DOI: 10.1371/journal.pone.0198771] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/24/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer. METHODS A total of 7,176 patients diagnosed with early stage breast cancer in 2007-2009 (pre-ACA) and 2011-2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19-25 (targeted by the policy) considered as the intervention group, and patients aged 26-34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation. RESULTS Compared with the control group of patients aged 26-34, young patients aged 19-25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort. CONCLUSIONS AND RELEVANCE No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.
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Affiliation(s)
- Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- * E-mail:
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Kathryn J. Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Chun Chieh Lin
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
| | - Helmneh M. Sineshaw
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
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Strnad V, Major T, Polgar C, Lotter M, Guinot JL, Gutierrez-Miguelez C, Galalae R, Van Limbergen E, Guix B, Niehoff P, Lössl K, Hannoun-Levi JM. ESTRO-ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated Partial Breast Irradiation alone or as boost - GEC-ESTRO Breast Cancer Working Group practical recommendations. Radiother Oncol 2018; 128:411-420. [PMID: 29691075 DOI: 10.1016/j.radonc.2018.04.009] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/06/2018] [Accepted: 04/06/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE This consensus statement from the Breast Cancer Working Group of Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) aims at generating practical guidelines for multi-catheter image-guided brachytherapy in the conservative management of breast cancer patients used for either Accelerated Partial Breast Irradiation (APBI) or for a breast boost. METHODS Recent advances in techniques of multi-catheter brachytherapy were summarized and all the relevant literature was reviewed by a panel of experts. Panel members of the GEC-ESTRO experts participated in a series of conferences, supplemented their clinical experience, were surveyed to determine their current practices and patterns, performed a literature review, and formulated recommendations for implementing APBI with multi-catheter brachytherapy, focusing on treatment planning issues, catheter insertion, dosimetry and quality assurance. This document was reviewed and approved by the full panel, the GEC-ESTRO executive board and by the ACROP (Advisory Committee on Radiation Oncology Practice). RESULTS Three-dimensional (3D) treatment planning, catheter insertion techniques, dosimetry and methods of quality assurance for APBI and boost with multi-catheter image-guided brachytherapy after breast conserving surgery are described. Detailed recommendations for daily practice including dose constraints are given. CONCLUSIONS Recent standards and guidelines for the use of APBI with different multi-catheter image-guided brachytherapy techniques have been defined. Different techniques are used to insert the catheters. Guidelines are mandatory to assure precise catheter insertion for coverage of the target volume and to guarantee high-quality dosimetry. The same rules apply for brachytherapy based boost irradiation for breast cancer after whole breast irradiation as well as for partial breast re-irradiation.
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Affiliation(s)
- Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Germany.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology Budapest, Hungary
| | - Csaba Polgar
- Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Michael Lotter
- Department of Radiation Oncology, University Hospital Erlangen, Germany
| | - Jose-Luis Guinot
- Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | | | - Razvan Galalae
- Department of Radiation Therapy, Evangelische Kliniken, Gelsenkirchen, Germany
| | - Erik Van Limbergen
- Department of Radiotherapy, University Hospital Gasthuisberg, Leuven, Belgium
| | - Benjamin Guix
- IMOR Foundation, Medical Institute for Radiotherapy and Oncology, Barcelona, Spain
| | - Peter Niehoff
- Department of Radiation Therapy, Sana Hospital Offenbach, Germany
| | - Kristina Lössl
- Department of Radiation Oncology, University Hospital Bern, Inselspital, Switzerland
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Kim HJ, Kim JS, Chie EK, Noh DY, Bang YJ, Ha SW. The Sequencing of Chemotherapy and Radiotherapy in Breast Cancer Patients after Mastectomy. TUMORI JOURNAL 2018; 96:28-33. [DOI: 10.1177/030089161009600105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The purpose of the study was to retrospectively evaluate the outcome according to the sequencing of radiotherapy and chemotherapy after mastectomy in high-risk patients with breast cancer. Methods From January 1986 through September 2000, 275 women with stage I-IIIB breast cancer were treated with chemotherapy and radiotherapy after mastectomy. The patients were divided into four groups. Chemotherapy was given first in 116 patients (CTRT), concurrent chemoradiotherapy in 77 (CCRT), sandwich therapy in 65 (SAND), and radiotherapy first in 17 (RTCT). Prognostic factors such as age, primary tumor size and nodal status were not statistically different among the four groups. There was a higher proportion of patients with close or positive margins in CCRT and RTCT groups than in the CTRT and SAND groups (22/77, 5/17 vs 3/116, 2/65, P <0.001). Results Median follow-up was 145 months (range, 10–210). Five-year overall and disease-free survival were 69.4% and 56.1%, respectively. Survival outcomes were not statistically different among the four groups (5-year overall/disease-free survival, 68.0%/63.0%, 71.3%/60.8%, 65.0%/48.1%, 81.9%/58.8%, in CTRT, CCRT, SAND, and RTCT, respectively) (P = 0.3422/P = 0.6333). The incidence of local-regional recurrence was not different in the early radiotherapy group (CCRT/RTCT, 11%/12%) and delayed radiotherapy group (CTRT/SAND, 7%/8%). Conclusions This study suggests that in these high-risk breast cancer patients after mastectomy, delay in the start of radiotherapy does not increase local-regional recurrence, and the final survival outcomes are not affected by the sequencing of chemotherapy and radiotherapy.
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Affiliation(s)
- Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-young Noh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yung-jue Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Whan Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University, Seoul, Korea
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Karlsson P, Cole BF, Price KN, Gelber RD, Coates AS, Goldhirsch A, Castiglione M, Colleoni M, Gruber G. Timing of Radiation Therapy and Chemotherapy After Breast-Conserving Surgery for Node-Positive Breast Cancer: Long-Term Results From International Breast Cancer Study Group Trials VI and VII. Int J Radiat Oncol Biol Phys 2017; 96:273-279. [PMID: 27598802 DOI: 10.1016/j.ijrobp.2016.06.2448] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/24/2016] [Accepted: 06/16/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To update the previous report from 2 randomized clinical trials, now with a median follow-up of 16 years, to analyze the effect of radiation therapy timing on local failure and disease-free survival. PATIENTS AND METHODS From July 1986 to April 1993, International Breast Cancer Study Group trial VI randomly assigned 1475 pre-/perimenopausal women with node-positive breast cancer to receive 3 or 6 cycles of initial chemotherapy (CT). International Breast Cancer Study Group trial VII randomly assigned 1212 postmenopausal women with node-positive breast cancer to receive tamoxifen for 5 years, or tamoxifen for 5 years with 3 early cycles of initial CT. For patients who received breast-conserving surgery (BCS), radiation therapy (RT) was delayed until initial CT was completed; 4 or 7 months after BCS for trial VI and 2 or 4 months for trial VII. We compared RT timing groups among 433 patients on trial VI and 285 patients on trial VII who received BCS plus RT. Endpoints were local failure, regional/distant failure, and disease-free survival (DFS). RESULTS Among pre-/perimenopausal patients there were no significant differences in disease-related outcomes. The 15-year DFS was 48.2% in the group allocated 3 months initial CT and 44.9% in the group allocated 6 months initial CT (hazard ratio [HR] 1.12; 95% confidence interval [CI] 0.87-1.45). Among postmenopausal patients, the 15-year DFS was 46.1% in the no-initial-CT group and 43.3% in the group allocated 3 months initial CT (HR 1.11; 95% CI 0.82-1.51). Corresponding HRs for local failures were 0.94 (95% CI 0.61-1.46) in trial VI and 1.51 (95% CI 0.77-2.97) in trial VII. For regional/distant failures, the respective HRs were 1.15 (95% CI 0.80-1.63) and 1.08 (95% CI 0.69-1.68). CONCLUSIONS This study confirms that, after more than 15 years of follow-up, it is reasonable to delay radiation therapy until after the completion of standard CT.
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Affiliation(s)
- Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Bernard F Cole
- Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont
| | - Karen N Price
- International Breast Cancer Study Group Statistical Center, Frontier Science and Technology Research Foundation, Boston, Massachusetts
| | - Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Frontier Science and Technology Research Foundation, Harvard T. F. Chan School of Public Health, Boston, Massachusetts
| | - Alan S Coates
- International Breast Cancer Study Group and University of Sydney, Sydney, Australia
| | - Aron Goldhirsch
- Senior Consultant Breast Cancer, European Institute of Oncology and International Breast Cancer Study Group, Milan, Italy
| | | | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology and International Breast Cancer Study Group, Milan, Italy
| | - Günther Gruber
- Institute of Radiotherapy, Klinik Hirslanden, Zürich, Switzerland
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Gupta S, King W, Korzeniowski M, Wallace D, Mackillop W. The Effect of Waiting Times for Postoperative Radiotherapy on Outcomes for Women Receiving Partial Mastectomy for Breast Cancer: a Systematic Review and Meta-Analysis. Clin Oncol (R Coll Radiol) 2016; 28:739-749. [DOI: 10.1016/j.clon.2016.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 05/26/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
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Caponio R, Ciliberti MP, Graziano G, Necchia R, Scognamillo G, Pascali A, Bonaduce S, Milella A, Matichecchia G, Cristofaro C, Di Fatta D, Tamborra P, Lioce M. 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. Eur J Med Res 2016; 21:32. [PMID: 27514645 PMCID: PMC4982229 DOI: 10.1186/s40001-016-0226-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 01/25/2016] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Raffaella Caponio
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy.
| | - Maria Paola Ciliberti
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Giusi Graziano
- Direzione Scientifica, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Rocco Necchia
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Giovanni Scognamillo
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Antonio Pascali
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Sabino Bonaduce
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Anna Milella
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Gabriele Matichecchia
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Cristian Cristofaro
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Davide Di Fatta
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
| | - Pasquale Tamborra
- U.O. Fisica Sanitaria, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Marco Lioce
- U.O. Radioterapia, National Cancer Research Centre Istituto Tumori "Giovanni Paolo II", Via O. Flacco, 65, Bari, Italy
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Coles CE, Brunt AM, Wheatley D, Mukesh MB, Yarnold JR. Breast radiotherapy: less is more? Clin Oncol (R Coll Radiol) 2012. [PMID: 23183306 DOI: 10.1016/j.clon.2012.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A 3 week schedule of whole breast radiotherapy is firmly established in the UK and is becoming more accepted internationally, especially as accelerated partial breast radiotherapy regimens become more common. It seems that a 3 week schedule is unlikely to be the lower limit of whole breast hypofractionation and the partial breast may even be adequately treated with just a single treatment. It is, however, essential that these hypotheses are rigorously tested within well-designed trials to ensure the highest quality of radiotherapy. This overview will address the rationale for hypofractionation in breast cancer, discuss past trials and outline the design of current studies.
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Affiliation(s)
- C E Coles
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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13
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Schroeder TM, Liem B, Sampath S, Thompson WR, Longhurst J, Royce M. Early breast cancer with positive margins: excellent local control with an upfront brachytherapy boost. Breast Cancer Res Treat 2012; 134:719-25. [DOI: 10.1007/s10549-012-2087-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
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Wheeler SB, Wu Y, Meyer AM, Carpenter WR, Richardson LC, Smith JL, Lewis MA, Weiner BJ. Use and timeliness of radiation therapy after breast-conserving surgery in low-income women with early-stage breast cancer. Cancer Invest 2012; 30:258-67. [PMID: 22489864 DOI: 10.3109/07357907.2012.658937] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To characterize overall receipt and timeliness of radiation therapy (RT) following breast-conserving surgery among Medicaid-insured patients. METHOD State cancer registry data linked with Medicaid claims from 2003 to 2009 were analyzed. Multivariate logistic and Cox proportional hazards regressions were employed. RESULTS Overall, 81% of patients received guideline-recommended RT. Significant variation in timing of RT initiation was documented. Having fewer comorbitidies and receiving chemotherapy were correlated with higher odds of RT initiation within 1 year. CONCLUSION Although RT use in Medicaid-insured women appears to have improved since earlier studies, documented delays in RT are troublesome and warrant further investigation.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health. Stephanie
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15
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Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients. Breast Cancer Res Treat 2012; 133:333-45. [PMID: 22270934 DOI: 10.1007/s10549-012-1955-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 01/09/2012] [Indexed: 10/14/2022]
Abstract
Observed racial/ethnic disparities in the process and outcomes of breast cancer care may be explained, in part, by structural/organizational characteristics of health care systems. We examined the role of surgical facility characteristics and distance to care in explaining racial/ethnic variation in timing of initiation of guideline-recommended radiation therapy (RT) after breast conserving surgery (BCS). We used Surveillance Epidemiology and End Results-Medicare data to identify women ages 65 and older diagnosed with stages I-III breast cancer and treated with BCS in 1994-2002. We used stepwise multivariate logistic regression to examine the interactive effects of race/ethnicity and facility profit status, teaching status, size, and institutional affiliations, and distance to nearest RT on timing of RT initiation, controlling for known covariates. Among 38,574 eligible women who received BCS, 39% received RT within 2 months, 52% received RT within 6 months, and 57% received RT within 12 months post-diagnosis, with significant variation by race/ethnicity. In multivariate models, women attending smaller surgical facilities and those with on-site radiation had higher odds of RT at each time interval, and women attending governmental facilities had lower odds of RT at each time interval (P < 0.05). Increasing distance between patients' residence and nearest RT provider was associated with lower overall odds of RT, particularly among Hispanic women (P < 0.05). In fully adjusted models including race-by-distance interaction terms, racial/ethnic disparities disappeared in RT initiation within 6 and 12 months. Racial/ethnic disparities in timing of RT for breast cancer can be partially explained by structural/organizational health system characteristics. Identifying modifiable system-level factors associated with quality cancer care may help us target policy interventions that can reduce disparities in outcomes.
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16
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Breast cancer care compared with clinical Guidelines: an observational study in France. BMC Public Health 2011; 11:45. [PMID: 21251274 PMCID: PMC3037311 DOI: 10.1186/1471-2458-11-45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 01/20/2011] [Indexed: 11/18/2022] Open
Abstract
Background Great variability in breast cancer (BC) treatment practices according to patient, tumour or organisation of care characteristics has been reported but the relation between these factors is not well known. In two French regions, we measured compliance with Clinical Practice Guidelines for non-metastatic BC care management and identified factors associated with non-compliance at clinical and organisational levels. Methods Eligible patients had invasive unilateral BC without distant metastases and at least two contacts with one of the two regional healthcare systems (2003-2004) in the first year after diagnosis. Medical data were collected from patient medical records in all public and private hospitals (99 hospitals). The care process was defined by 20 criteria: clinical decisions for treatment and therapeutic procedures. Each criterion was classified according to level of compliance ("Compliant", "Justifiable" and "Not Compliant") and factors of non-compliance were identified (mixed effect logistic regression). Results 926 women were included. Non-compliance with clinical decisions for treatment was associated with older patient age (OR 2.1; 95%CI: 1.3-3.6) and region (OR 3.0; 95%CI: 1.2-7.4). Non-compliance with clinical decisions for radiotherapy was associated with lymph node involvement or the presence of peritumoural vascular invasion (OR 1.5; 95%CI: 1.01-2.3) and non-compliance with overall treatment (clinical decisions for treatment + therapeutic procedures) was associated with the presence of positive lymph nodes (OR 2.0; 95%CI: 1.2-3.3), grade III versus grade I (OR 2.9; 95%CI: 1.4-6.2), and one region of care versus another (OR 3.5; 95%CI: 1.7-7.1). Finally, heterogeneity of compliance in overall treatment sequence was identified between local cancer units (p < 0.05). Conclusion This study provides interesting insights into factors of non-compliance in non-metastatic BC management and could lead to quality care improvements.
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Yarnold J, Bentzen SM, Coles C, Haviland J. Hypofractionated whole-breast radiotherapy for women with early breast cancer: myths and realities. Int J Radiat Oncol Biol Phys 2011; 79:1-9. [PMID: 20950960 DOI: 10.1016/j.ijrobp.2010.08.035] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 08/09/2010] [Accepted: 08/17/2010] [Indexed: 11/30/2022]
Affiliation(s)
- John Yarnold
- Section of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital, Sutton, United Kingdom.
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18
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Timing of radiotherapy and outcome in patients receiving adjuvant endocrine therapy. Int J Radiat Oncol Biol Phys 2010; 80:398-402. [PMID: 20729007 DOI: 10.1016/j.ijrobp.2010.02.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 02/03/2010] [Accepted: 02/11/2010] [Indexed: 11/24/2022]
Abstract
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.
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Yarnold J, Haviland J. Pushing the limits of hypofractionation for adjuvant whole breast radiotherapy. Breast 2010; 19:176-9. [DOI: 10.1016/j.breast.2010.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Tsoutsou PG, Koukourakis MI, Azria D, Belkacémi Y. Optimal timing for adjuvant radiation therapy in breast cancer. Crit Rev Oncol Hematol 2009; 71:102-16. [DOI: 10.1016/j.critrevonc.2008.09.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 08/11/2008] [Accepted: 09/01/2008] [Indexed: 10/21/2022] Open
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21
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Olivotto IA, Lesperance ML, Truong PT, Nichol A, Berrang T, Tyldesley S, Germain F, Speers C, Wai E, Holloway C, Kwan W, Kennecke H. Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy. J Clin Oncol 2008; 27:16-23. [PMID: 19018080 DOI: 10.1200/jco.2008.18.1891] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the interval from breast-conserving surgery (BCS) to radiation therapy (RT) that affects local control or survival. PATIENTS AND METHODS The 10-year Kaplan-Meier (KM) local recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: < or = 4 (n = 83), greater than 4 to 8 (n = 2,288; reference group); greater than 8 to 12 (n = 2,606); greater than 12 to 16 (n = 961); greater than 16 to 20 (n = 358); and greater than 20 weeks (n = 132). Cox proportional hazards models and matching were used to control for confounding variables. RESULTS The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P = .15), DRFS (HR, 1.86; P = .02) and BCSS (HR, 2.15; P = .009) were inferior for women with BCS-to-RT intervals greater than 20 weeks compared with those greater than 4 to 8 weeks. The matched analysis yielded similar results. CONCLUSION Outcomes were statistically similar for BCS-to-RT intervals up to 20 weeks, but they were inferior for intervals beyond 20 weeks. Time can be reasonably allowed for the breast to heal and for patients to consider treatment options, but RT should start within 20 weeks of BCS.
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Affiliation(s)
- Ivo A Olivotto
- BC Cancer Agency-Vancouver Island Centre, Victoria, British Columbia, Canada.
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Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ. The relationship between waiting time for radiotherapy and clinical outcomes: A systematic review of the literature. Radiother Oncol 2008; 87:3-16. [PMID: 18160158 DOI: 10.1016/j.radonc.2007.11.016] [Citation(s) in RCA: 271] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 11/13/2007] [Accepted: 11/14/2007] [Indexed: 10/22/2022]
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Cèfaro GA, Genovesi D, Marchese R, Di Tommaso M, Di Febo F, Ballone E, Di Nicola M. The effect of delaying adjuvant radiation treatment after conservative surgery for early breast cancer. Breast J 2007; 13:575-80. [PMID: 17983399 DOI: 10.1111/j.1524-4741.2007.00511.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We examined the effect of delaying radiation treatment after conservative surgery on the risk of breast cancer local recurrence (LR). From January 1997 to December 2001, 969 women with early-stage breast cancer were treated at the Radiation Oncology Department in Chieti. We analyzed 802 of them who underwent conservative surgery followed by whole-breast radiotherapy. The patients were divided into two groups: women who did not receive chemotherapy and women who received chemotherapy. The time intervals from surgery to breast irradiation used for the analysis were <16 or more weeks for no-chemotherapy-treated women, and <25 and 25 or more weeks for chemotherapy-treated women. The relationship between LR and factors such as age, tumor size, margin status, and surgery-radiotherapy time interval was evaluated. The 8-year LR risk was estimated using the Kaplan-Meier method. LR was observed in 33 (4.1%) of the 802 patients. The overall 8-year LR risk was 6.5% (+/-1.51). In the no-chemotherapy group, the risk of LR was associated with a younger age and a positive margin status. In the chemotherapy group LR was associated with a younger age and a tumor size >3 cm. Surgery-radiotherapy interval was not associated with LR in both groups of patients. Delay in the start of radiotherapy does not increase the risk of LR in patients with early breast cancer treated or not treated with chemotherapy.
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Affiliation(s)
- Giampiero Ausili Cèfaro
- Department of Radiation Oncology, G. d'Annunzio University, Via dei Vestini, I-66013 Chieti, Italy
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Jack RH, Davies EA, Robinson D, Sainsbury R, Møller H. Radiotherapy waiting times for women with breast cancer: a population-based cohort study. BMC Cancer 2007; 7:71. [PMID: 17472746 PMCID: PMC1868745 DOI: 10.1186/1471-2407-7-71] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 05/01/2007] [Indexed: 01/07/2023] Open
Abstract
Background Waiting times for cancer patients are a national priority in the UK. Previous studies have shown variation between cancer networks in the time between diagnosis and start of radiotherapy for all cancer patients. Studies of the relationship between delay in receiving treatment and survival of breast cancer patients have been inconsistent. This study aimed to examine factors associated with waiting times for radiotherapy for breast cancer patients. Methods 35,354 women resident in South East England and diagnosed with breast cancer between 1992 and 2001 who received radiotherapy within six months of diagnosis were identified from the Thames Cancer Registry. Time to radiotherapy was measured from either the date of diagnosis or the start of the previous treatment, whichever was shorter. Unadjusted and adjusted logistic regression models were fitted to examine whether patients received radiotherapy within 60 days of their diagnosis or previous treatment. Results The adjusted proportions of patients receiving radiotherapy within 60 days varied significantly between different cancer networks (range: 43% to 81%), and decreased from 68% in 1992 to 33% in 2001. After adjustment there was no association between deprivation of area of residence, age or stage and radiotherapy wait. Median time waited to radiotherapy increased over the study period whether measured from the start of chemotherapy, hormone therapy, surgery or the date of diagnosis. Conclusion This study covered a period of time before the investment following the Cancer Plan of 2000. Results are consistent with other findings suggesting variation between cancer networks and increasing waits over time. Further studies should examine different methods of measuring waiting time, the causes and consequences of waits for radiotherapy and the effect of current initiatives and investments.
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Affiliation(s)
- Ruth H Jack
- King's College London, Thames Cancer Registry, 1Floor Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - Elizabeth A Davies
- King's College London, Thames Cancer Registry, 1Floor Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - David Robinson
- King's College London, Thames Cancer Registry, 1Floor Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - Richard Sainsbury
- University College London, Department of Surgery, The Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK
| | - Henrik Møller
- King's College London, Thames Cancer Registry, 1Floor Capital House, 42 Weston Street, London, SE1 3QD, UK
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Hershman DL, Wang X, McBride R, Jacobson JS, Grann VR, Neugut AI. Delay in initiating adjuvant radiotherapy following breast conservation surgery and its impact on survival. Int J Radiat Oncol Biol Phys 2006; 65:1353-60. [PMID: 16765531 DOI: 10.1016/j.ijrobp.2006.03.048] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 03/12/2006] [Accepted: 03/14/2006] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Dawn L Hershman
- Department of Medicine and the Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, New York, NY 10032, USA.
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26
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Burstein HJ, Bellon JR, Galper S, Lu HM, Kuter I, Taghian AG, Wong J, Gelman R, Bunnell CA, Parker LM, Garber JE, Winer EP, Harris JR, Powell SN. Prospective evaluation of concurrent paclitaxel and radiation therapy after adjuvant doxorubicin and cyclophosphamide chemotherapy for Stage II or III breast cancer. Int J Radiat Oncol Biol Phys 2006; 64:496-504. [PMID: 16243442 DOI: 10.1016/j.ijrobp.2005.07.975] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Revised: 06/23/2005] [Accepted: 07/01/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the safety and feasibility of concurrent radiation therapy and paclitaxel-based adjuvant chemotherapy, given either weekly or every 3 weeks, after adjuvant doxorubicin and cyclophosphamide (AC). METHODS AND MATERIALS After definitive breast surgery and AC chemotherapy, 40 patients with operable Stage II or III breast cancer received protocol-based treatment with concurrent paclitaxel and radiation therapy. Paclitaxel was evaluated on 2 schedules, with treatment given either weeklyx12 weeks (60 mg/m2), or every 3 weeksx4 cycles (135-175 mg/m2). Radiation fields and schedules were determined by the patient's surgery and pathology. The tolerability of concurrent therapy was evaluated in cohorts of 8 patients as a phase I study. RESULTS Weekly paclitaxel treatment at 60 mg/m2 per week with concurrent radiation led to dose-limiting toxicity in 4 of 16 patients (25%), including 3 who developed pneumonitis (either Grade 2 [1 patient] or Grade 3 [2 patients]) requiring steroids. Efforts to eliminate this toxicity in combination with weekly paclitaxel through treatment scheduling and CT-based radiotherapy simulation were not successful. By contrast, dose-limiting toxicity was not encountered among patients receiving concurrent radiation with paclitaxel given every 3 weeks at 135-175 mg/m2. However, Grade 2 radiation pneumonitis not requiring steroid therapy was seen in 2 of 24 patients (8%) treated in such a fashion. Excessive radiation dermatitis was not observed with either paclitaxel schedule. CONCLUSIONS Concurrent treatment with weekly paclitaxel and radiation therapy is not feasible after adjuvant AC chemotherapy for early-stage breast cancer. Concurrent treatment using a less frequent paclitaxel dosing schedule may be possible, but caution is warranted in light of the apparent possibility of pulmonary injury.
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Affiliation(s)
- Harold J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, and Harvard Medical School, Boston, MA 02115, USA.
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Schlienger M. Délais et retards à la radiothérapie : réflexion à propos de trois types de tumeurs. Cancer Radiother 2005; 9:590-601. [PMID: 16168693 DOI: 10.1016/j.canrad.2005.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Revised: 06/18/2005] [Accepted: 07/07/2005] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- M Schlienger
- Service de radiothérapie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
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Hébert-Croteau N, Freeman CR, Latreille J, Rivard M, Brisson J. A population-based study of the impact of delaying radiotherapy after conservative surgery for breast cancer. Breast Cancer Res Treat 2005; 88:187-96. [PMID: 15564801 DOI: 10.1007/s10549-004-0594-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Nicole Hébert-Croteau
- Direction des systèmes de soins et services, Institut national de santé publique du Québec, Canada.
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Hébert-Croteau N, Freeman C, Latreille J, Brisson J. Delay of Radiation Therapy and Outcomes of Breast Cancer. J Clin Oncol 2004; 22:1342-3; author reply 1343-4. [PMID: 15051786 DOI: 10.1200/jco.2004.99.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hannoun-Levi JM, Courdi A, Marsiglia H, Namer M, Gerard JP. Breast Cancer in Elderly Women: is Partial Breast Irradiation a Good Alternative? Breast Cancer Res Treat 2003; 81:243-51. [PMID: 14620919 DOI: 10.1023/a:1026166518203] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Approximately half of all breast cancer occurs after age 65. Several aspects for the treatment of early breast cancer may be influenced by patient age, including postoperative radiation therapy (RT), in order to prevent the risk of local recurrence (LR). Postoperative adjuvant RT, improving the chances of local control, is not always completed because of comorbidity-associated factors. Does an alternative exist between a 5-week radiotherapy regime and no irradiation after breast conservative surgery without burdening the overall therapeutic management? METHODS The authors review the literature regarding age-specific issues in the irradiation of breast cancer and the potential role of a partial breast irradiation (PBI) to prevent LR in the ipsilateral breast. RESULTS Phase II and III trials have been analyzed for feasibility, efficacy and toxicity. PBI may be delivered with low or high dose rate brachytherapy and intra operative, or external beam radiation therapy. PBI satisfies the control quality criteria. The majority of the teams provide PBI recurrence rates lower than 5% (0-4.4%) with a median follow-up varying between 8 and 72 months, associated with cosmetic results comparable to those achieved with conventional external beam. CONCLUSIONS Breast cancer in elderly women represents a medical and economical problem. The recommended conservative treatment includes RT for 50 Gy over 5 weeks. Some subgroups of patients did not receive radiotherapy because of comorbidity-associated factors or more favorable tumor biology. PBI seems to be an acceptable alternative to adjuvant RT over 5 weeks and no irradiation. The evaluation of toxicity and efficacy, especially in terms of local control, is necessary and large multicentric phase III trials comparing the two irradiation approaches are needed, including quality of life, economic considerations and longer follow-up.
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Affiliation(s)
- J M Hannoun-Levi
- Department of Radiation Oncology, Center Antoine Lacassagne, Nice, France.
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Abstract
Radiation therapy represents a very important part of breast conservative treatment. The classic schedule consists in delivering a total dose of 50 Gy in 25 fractions on 5 weeks, sometimes associated with a 10 to 16 Gy boost. For elderly women with difficulties to move or for younger women having professional activity or with young children in charge, a 5 to 6 weeks radiation therapy with long and frequent transportations is sometimes difficult to achieve. The aim of partial breast irradiation (PBI) is to prevent, in a short period (5 to 8 days) and less transportations, the risk of local recurrence into the tumor bed. Different techniques have been described, using either interstitial brachytherapy (low or high dose rate) or intra-operative radiation therapy (IORT photons or electrons) or external beam radiation therapy. Phase II PBI trials using interstitial brachytherapy showed a local control rate of 0 to 4% with a follow-up of 20 to 75 months. The rate of good/excellent cosmetic results is 67 to 100%. Results analysis of trials using very new PBI techniques (MammoSite), IORT) remains more difficult. If phase III randomized trials could confirm that PBI achieved, for selected patients, local controls equivalent to those obtain with whole breast irradiation, PBI could improve quality of life during radiation therapy, and maybe contribute to have a cost effective breast cancer conservative treatment.
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Recht A. Integration of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. Clin Breast Cancer 2003; 4:104-13. [PMID: 12864938 DOI: 10.3816/cbc.2003.n.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is no consensus on the optimal combination of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. This article reviews prospective and retrospective studies that shed light on this topic. Patients with positive, close, or unknown microscopic margins appear to benefit from relatively early initiation of radiation therapy, whereas those with wider tumor-free margin widths do not. For patients at high risk of distant failure (such as those with = 4 positive axillary nodes), chemotherapy may be more effective when it begins before radiation therapy rather than after. Regimens of concurrent radiation therapy and chemotherapy tend to have higher acute and subacute complication rates than sequential regimens, but the actual rates vary substantially with the exact details of the overall treatment program. There are no data on the impact of the timing of tamoxifen administration on the effectiveness of radiation therapy. Tamoxifen does not appear to increase complication rates relative to the use of radiation therapy alone. Thus, the best way of giving combined-modality therapy is uncertain. Further retrospective and prospective studies to investigate the issues discussed herein should be performed.
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Affiliation(s)
- Abram Recht
- Department of Radiation Oncology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA,USA.
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