Second malignancies after treatment of early-stage breast cancer: lumpectomy and radiation therapy versus mastectomy

Allogeneic hematopoietic cell transplantation in patients with a hematologic malignancy and a prior history of breast cancer

PURPOSE

To compare the outcome of allogeneic stem cell transplantation for myeloid malignancies in breast cancer survivors to a contemporaneous control group.

METHODS

Medical records of all patients with a history of breast cancer who received allogeneic stem cell transplants at a single, tertiary referral Comprehensive Cancer Center between 2002 and 2019 were reviewed. Transplant outcomes were compared to 289 control patients without a history of breast cancer from the same time period. Main outcomes included survival, disease-free survival, non-relapse mortality, relapse or progression of hematologic malignancy, and incidence of recurrent breast cancer after hematopoietic cell transplantation. Comparisons between women with a history of breast cancer and controls utilized propensity score weighting to balance patient characteristics.

RESULTS

Forty women, ages 30-74 years, with a history of breast cancer received an allogeneic hematopoietic cell transplant for a hematologic malignancy between December 2002 and February 2019. Twelve of the 40 patients are alive with a median survival of 7.4 years (range, 1.9-16.8 years). None of the patients had evidence of recurrent breast cancer prior to death or date of last contact. In multivariable Cox models, all transplant outcomes were similar between the patients and the control group with hematopoietic cell transplant comorbidity score as the most important confounding factor for adjustment in these models.

CONCLUSION

A history of treated breast cancer should not exclude patients from consideration for allogeneic hematopoietic cell transplantation.

Impact of Tobacco Smoking on Outcomes of Radiotherapy: A Narrative Review

The carcinogenic role of tobacco smoking is well recognized, but the detrimental effects of continued smoking after a cancer diagnosis have been underestimated. Radiotherapy is among the main treatment modalities for cancer. We reviewed the literature data concerning the impact of tobacco smoking on treatment outcomes in radiotherapy-managed patients with various malignancies. Most of the analyzed studies demonstrated the detrimental effect of smoking on overall survival, tumor control, quality of life, treatment toxicity, and the incidence of second primary malignancies. Healthcare professionals should use the cancer diagnosis and treatment as a teachable moment and recommend their patients to immediately cease smoking. Wherever possible, cancer patients should undergo an intensive smoking-cessation program, including behavioral and pharmacologic therapy.

Primary Lung Cancer After Treatment for Breast Cancer

Breast cancer is the most common malignancy in women and the second most common cause of cancer-related death. Due to advances in the diagnosis and treatment technologies for breast cancer, patients with breast cancer are living longer than before, resulting in an increased risk of developing subsequent malignancies, among which lung cancer is the most common. This review presents the current evidence about the risk, influencing factors and prognostic factors of developing primary lung cancer after treatment for breast cancer. The aim is to help clinicians improve their understanding, diagnosis and treatment of lung cancer after breast cancer.

Risk and Influencing Factors for Subsequent Primary Lung Cancer After Treatment of Breast Cancer: A Systematic Review and Two Meta-Analyses Based on Four Million Cases

INTRODUCTION

To compare the risk of developing lung cancer between patients with breast cancer and the general population and explore the risk factors for the development of primary lung cancer after treatment for breast cancer.

METHODS

The PubMed, EMBASE, and Web of Science databases were searched from the establishment date to October 11, 2020. Two separate meta-analyses were performed: one focused on studies reporting the risk of subsequent lung cancer after breast cancer and one focused on studies exploring the risk factors for subsequent lung cancer in patients with breast cancer. The standardized incidence ratios with 95% confidence intervals were combined to compare the risk of developing lung cancer between patients with breast cancer and the general population. The relative risks (RRs) or ORs with 95% confidence intervals were combined to assess the association of clinicopathological parameters with the risk of developing lung cancer after breast cancer. All statistical analyses were conducted by STATA 12.0.

RESULTS

A total of 15 studies involving 1,161,979 patients were eventually included in the first meta-analysis, and the pooled results indicated that female patients with breast cancer revealed a significantly higher risk of developing subsequent lung cancer (standardized incidence ratio = 1.25, p < 0.001). In addition, a total of 22 articles involving 3,090,620 patients were included in the second meta-analysis. The pooled results indicated that smoking (OR = 9.73, p < 0.001) and radiotherapy (RR = 1.40, p < 0.001) were risk factors for developing subsequent lung cancer in patients with breast cancer, and chemotherapy (RR = 0.69, p = 0.002), positive estrogen receptor status (RR = 0.93, p = 0.014) and positive progesterone receptor status (RR = 0.86, p < 0.001) were protective factors. Meanwhile, subgroup analysis based on the relative position of the breast and lung cancers (ipsilateral versus contralateral) was conducted, which indicated that radiotherapy only increased the risk of ipsilateral lung cancer in patients with breast cancer (RR = 1.27, p = 0.001).

CONCLUSIONS

Patients with breast cancer are more likely to develop lung cancer than the general population, and the risk of developing primary lung cancer after breast cancer is affected by smoking, radiotherapy, chemotherapy, estrogen receptor status and progesterone receptor status.

Contralateral breast dose with electronic compensators and conventional tangential fields - A clinical dosimetric study

Dose to the contralateral breast (CLB) from radiotherapy treatment has the potential to induce secondary breast cancer. Electronic tissue compensation (eComp) for breast cancer patients is one of the alternative methods to conventional 3D-conformal radiotherapy that eliminates the use of wedges. Several studies have investigated dose to the CLB using tangential fields involving wedges, intensity-modulated radiation therapy and volumetric modulated arc radiation therapy and various other techniques via treatment planning system calculations, Monte Carlo methods and phantoms. However, there are limited data published in assessing the actual dose received by the CLB from treatment with eComp-based tangential fields. In this study, the CLB dose for patients undergoing tangential field radiotherapy with eComp and enhanced dynamic wedged (standard) tangential fields was measured and compared to assess the CLB dose between the two methods. Measurements were conducted on a randomised trial of 40 patients, 20 of them had undergone standard planning, and the remaining 20 were treated with eComp. The mean surface dose measured with TLDs at 3cm from the medial tangential border for eComp and standard techniques was 10.04±1.37% and 10.14±2.05%, respectively for a prescription dose of 2.65Gy/fraction. The estimated dose at 1cm depth in tissue, measured with the use of perspex domes placed over the TLD at the same location, was 5.12±0.87% and 6.29±2.01% for eComp and standard, respectively. The CLB dose is dependent on the proximity of the medial tangential field edge to the contralateral breast and is patient-specific. The results of this study show that at 1cm depth, eComp technique delivers significantly less dose (p<0.05) to the CLB as compared to standard tangential fields. Furthermore, the surface dose measured for both eComp and standard are comparable indicating that the eComp-based tangential field technique does not contribute any excess dose to CLB when compared to standard tangential fields. The excess relative risk (ERR) for radiation-induced cancers for eComp was found to be 0.08, compared to 0.11 for standard tangential fields.

Risk of primary lung cancer after adjuvant radiotherapy in breast cancer-a large population-based study

Adjuvant radiotherapy (RT) for breast cancer (BC) has been associated with an increased risk of later radiation-induced lung cancer (LC). We examined the risk of primary LC in a population-based cohort of 52300 women treated for BC during 1992 to 2012, and 253796 age-matched women without BC. Cumulative incidence of LC was calculated by the Kaplan-Meier method, and the risk of LC after BC treatment was estimated by Cox proportional hazards regression analyses. Women with BC receiving RT had a higher cumulative incidence of LC compared to women with BC not receiving RT and women without BC. This became apparent 5 years after RT and increased with longer follow-up. Women with BC receiving RT had a Hazard ratio of 1.59 (95% confidence interval 1.37-1.84) for LC compared to women without BC. RT techniques that lower the incidental lung doses, e.g breathing adaption techniques, may lower this risk.

Canada follows the US in the rise of bilateral mastectomies for unilateral breast cancer: a 23-year population cohort study

INTRODUCTION

The use of contralateral prophylactic mastectomy (CPM) continues to grow despite the absence of evidence supporting a survival benefit. This study's objectives were to (1) describe the trends in the rates of unilateral and bilateral mastectomy (BM) in women diagnosed with unilateral breast cancer (UBC) in Ontario, Canada from 1991 to 2013, and (2) identify factors associated with BM to treat UBC.

METHODS

This retrospective cohort analysis included all women aged 18 and older diagnosed with UBC between January 1991 and December 2013. Health administrative data from the Institute for Clinical Evaluative Sciences, the Ontario Cancer Registry, and the Discharge Abstract Database were used to identify all breast cancer and mastectomy cases. Age-adjusted mastectomy rates were plotted over time. Univariable and multivariable analyses included clinically significant covariates.

RESULTS

From 1991 to 2013 there were 172,165 cases of UBC and 64,886 mastectomies (37.7%) performed in Ontario. 13.6% of the mastectomies were bilateral. BM rates increased over sixfold (from 4 to 25%) across all age groups under age 70 over a 23-year period. On multivariable analysis, younger age, higher income, rural community, earlier breast cancer stage, lobular histology, availability of reconstruction and teaching hospitals were associated with increased odds of BM.

CONCLUSIONS

This is the largest population study of breast cancer patients in Canada and shows an increasing rate of BM for UBC. The results are similar to those already described in the US and highlight the importance of continued efforts to promote efficient communication and evidence-based decision-making prior to breast surgery.

The risk for developing a secondary cancer after breast radiation therapy: Comparison of photon and proton techniques

BACKGROUND AND PURPOSE

To compare secondary malignancy risks of modern proton and photon therapy techniques for locally advanced breast cancer.

METHODS AND MATERIALS

We utilized dosimetric data from 34 [10 photon-VMAT, 10 photon-3DCRT, 14 pencil beam scanning proton (PBS)] breast cancer patients who received comprehensive nodal irradiation. Employing a model based on organ equivalent dose to account for both inhomogeneous organ dose distributions and non-linear functional dose relationships, we estimated excess absolute risk, excess relative risk, and lifetime attributable risk (LAR) for secondary malignancies. The model uses dose distribution, number of fractions, age at exposure, attained age, the linear-quadratic dose response relationship for cell survival, repopulation factor, as well as gender specific age dependencies, and initial slopes of dose response curves.

RESULTS

The LAR for carcinoma at age 70 was estimated to be up to 3.64% for esophagus with an advantage of 3DCRT over PBS and VMAT. For the ipsilateral lung, risks were lowest for PBS (up to 5.56%), followed by 3DCRT (up to 6.54%) and VMAT (up to 7.7%). For the contralateral lung, there is a clear advantage of 3DCRT and PBS techniques (risk <0.86%) over VMAT (up to 4.4%). The risk for the contralateral breast is negligible for 3DCRT and PBS but was estimated as up to 1.2% for VMAT. Risks for the thyroid are overall negligible. Independently performed comparative treatment plans on 10 patients revealed that the risk for the contralateral lung and breast using VMAT can be more than an order of magnitude higher compared to PBS. Sarcoma risks were estimated as well showing similar trends but were overall lower compared to carcinoma.

CONCLUSION

Conventional (3DCRT) techniques led to the lowest estimated risks of, thyroid and esophageal secondary cancers while PBS demonstrated a benefit for secondary lung and contralateral breast cancer risks, with the highest risks overall associated with VMAT techniques.

Potential Morbidity Reduction With Proton Radiation Therapy for Breast Cancer

Proton radiotherapy confers significant dosimetric advantages in the treatment of malignancies that arise adjacent to critical radiosensitive structures. To date, these advantages have been most prominent in the treatment of pediatric and central nervous system malignancies, although emerging data support the use of protons among other anatomical sites in which radiotherapy plays an important role. With advances in the overall treatment paradigm for breast cancer, most patients with localized disease now exhibit long-term disease control and, consequently, may manifest the late toxicities of aggressive treatment. As a result, there is increasing emphasis on the mitigation of iatrogenic morbidity, with particular attention to heart and lung exposure in those receiving adjuvant radiotherapy. Indeed, recent landmark analyses have demonstrated an increase in significant cardiac events that is linked directly to low-dose radiation to the heart. Coupled with practice-changing trials that have expanded the indications for comprehensive regional nodal irradiation, there exists significant interest in employing novel technologies to mitigate cardiac dose while improving target volume coverage. Proton radiotherapy enjoys distinct physical advantages over photon-based approaches and, in appropriately selected patients, markedly improves both target coverage and normal tissue sparing. Here, we review the dosimetric evidence that underlies the putative benefits of proton radiotherapy, and further synthesize early clinical evidence that supports the efficacy and feasibility of proton radiation in breast cancer. Landmark, prospective randomized trials are underway and will ultimately define the role for protons in the treatment of this disease.

Volume effects of radiotherapy on the risk of second primary cancers: A systematic review of clinical and epidemiological studies

As modern radiotherapy, including intensity-modulated techniques, is associated with high dose gradients to normal tissues and large low-to-moderate dose volumes, the assessment of second primary cancer (SPC) risks requires quantification of dose-volume effects. We conducted a systematic review of clinical and epidemiological studies investigating the effect of the irradiated volume or dose-volume distribution to the remaining volume at risk (RVR) on SPC incidence. We identified eighteen studies comparing SPC risks according to the irradiated volume (i.e., in most studies, the size or number of fields used), and four studies reporting risk estimates according to the dose distribution to the RVR (after whole-body dose reconstruction). An increased risk of SPCs (mainly breast and lung cancers) with extended radiotherapy was observed among patients treated for Hodgkin lymphoma or childhood cancers. However, normal tissue dose distribution was not estimated, limiting the interpretation of those results in terms of volume effects on organs at risk. Studies considering whole-body exposures quantified dose-response relationships for point dose estimates, without accounting for dose-volume distributions. Therefore, they disregarded possible tissue effects (e.g. bystander and abscopal effects, stem cell repopulation) which may play a role in the induction of SPCs. Currently, there is no clinical or epidemiological information about a possible role of high dose gradients in surrounding organs, or increasing volumes of distant tissues exposed to low doses, in the risk of SPCs. Opportunities for future research nevertheless now exist, since methods and tools for estimating individual whole-body dose-volume distributions in large patient populations have been developed.

Influence of Age on the Clinical Outcome of Breast Cancer for Men and the Development of Second Primary Cancers

BACKGROUND

Low incidence of breast cancer in men (BCM) (< 1% of all breast cancers) has led to a paucity of outcome data. This study evaluated the impact of age on BCM outcomes.

METHODS

For this study, BCM patients treated between 2000 and 2011 were stratified by age (≤ 65 or > 65 years). Kaplan-Meier methods were used to compare overall survival (OS) and breast cancer-specific survival (BCSS). Competing-risk methods analyzed time to second primary cancers (SPCs), with any-cause death treated as a competing risk.

RESULTS

The study identified 152 BCM patients with a median age of 64 years (range 19-96 years). The median body mass index (BMI) was 28 kg/m². Men age 65 years or younger (n = 78, 51%) were more overweight/obese than men older than 65 years (n = 74, 49%) (89% vs 74%, respectively; P = 0.008). Both groups had similar nodal metastases rates (P = 0.4), estrogen receptor positivity (P = 1), and human epidermal growth factor receptor 2 (HER2)neu overexpression (P = 0.6). Men 65 years of age or younger were more likely to receive chemotherapy (P = 0.002). The median follow-up period was 5.8 years (range 0.1-14.4 years). The 5-year OS was 86% (95% confidence interval [CI] 80-93%), whereas the 5-year BCSS was 95% (95% CI 91-99%). The BCM patients 65 years of age and younger had better OS (P = 0.003) but not BCSS (P = 0.8). The 5-year cumulative incidence of SPC was 8.4% (95% CI 3.4-13.4%). The prior SPC rate was higher for men older than 65 years (n = 20, 31%) than for those age 65 years or younger (n = 7, 11%) (P = 0.008). This did not account for differences in life years at risk. No difference was observed in SPC cumulative incidence stratified by age (P = 0.3).

CONCLUSIONS

Men 65 years of age or younger received more chemotherapy and had improved OS, but not BCSS, compared with men older than 65 years. For all BCM, SPC is a risk, and appropriate screening may be warranted.

Staging Uveal Melanoma with Whole-Body Positron-Emission Tomography/Computed Tomography and Abdominal Ultrasound: Low Incidence of Metastatic Disease, High Incidence of Second Primary Cancers

PURPOSE:

The purpose of this study was to report the results of staging primary uveal melanoma with whole-body (18) fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) and abdominal ultrasound.

MATERIALS AND METHODS:

From January 2012, patients with uveal melanoma over 4 mm in thickness were staged with FDG PET/CT and abdominal ultrasound.

RESULTS:

Over 2 years, 108 patients with medium-to-large melanoma underwent dual imaging. According to the tumor, node, and metastasis classification, there were 75% T3, 11% T2, and 14% T1 uveal melanomas. Only, three of 108 patients (2.8%) were found to have metastatic uveal melanoma. All three had liver metastases confirmed following biopsy; one of three had additional extrahepatic widespread metastases. In these three patients, liver findings using both imaging techniques were consistent in one patient. In the second case, abdominal ultrasound missed the diagnosis of metastatic disease; however, FDG PET/CT revealed intense metabolic activity of the liver. In the third case, PET/CT missed the liver metastases; however, this was identified on abdominal ultrasound. PET/CT identified incidental second primary malignancies in 10 patients (9%). Second malignancies were found in the lung, breast, colon, thyroid, and adrenal gland. Abdominal ultrasound detected benign hepatic abnormalities in 20 patients (18%).

CONCLUSIONS:

Whole-body PET/CT and abdominal ultrasound complement each other in the staging of uveal melanoma. Benign hepatic abnormalities found using ultrasound is common. Of importance, a second asymptomatic primary malignancy associated with uveal melanoma was detected almost one in 10 patients.

Long-term risk of second malignancies in women after breast conservation therapy for ductal carcinoma in situ or early-stage breast cancer

PURPOSE

Women with ductal carcinoma in situ (DCIS) or early-stage breast cancer have an excellent prognosis, but their risk of developing second malignant neoplasms (SMNs) is not well established. We analyzed SMNs in a large cohort with long follow-up after breast conservation therapy.

METHODS

The study population comprised 755 women with DCIS (n = 135) or stage I-II breast carcinoma (n = 620). Subjects were aged 25-89 (median 55) years when they underwent breast-conserving surgery followed by radiotherapy to the entire breast (60-68Gray) between 1992 and 2001. Additional treatment included hormonal therapy and/or chemotherapy based on clinical characteristics. SMNs were grouped by site. The rate of SMNs over time was determined using the Kaplan-Meier method. To compare the probability of developing SMNs overall and for specific organs or sites, probability estimates were obtained for a 55-year-old female from the Surveillance, Epidemiology, and End Results Program (SEER).

RESULTS

Median follow-up from radiotherapy was 13.8 years. The 15-year age-adjusted probability of developing any SMN was 12.0%, close to the SEER rate of 12.1% for a non-breast malignancy. Systemic therapy and higher-dose radiotherapy (> 63 Gray) were not associated with significantly increased risks of SMNs. Compared to SEER, significantly increased risk was noted for gynecologic cancers and melanoma.

CONCLUSIONS

Most SMNs were unrelated to treatment, and the 15-year incidence was similar to that of cancer in the SEER control group-findings that should be reassuring to patients. Further risk reduction is expected from prophylactic gynecologic surgery. Continued investigations into genetic links with melanoma are warranted.

Early re-staging and molecular subtype shift surveillance of locally recurrent or metastatic breast cancer: A new PET/CT integrated precise algorithm

Recurrent breast cancer poses considerable diagnostic and therapeutic challenges for clinic. Clinical suspicion of recurrence must be first confirmed by imaging studies. Then re-biopsy of suspected recurrence and metastasis in patients with breast cancer is recommended in the practice guidelines of the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) to confirm whether the molecular subtype changes. It may change the individual treatment plan directly. Our research provided an integrated algorithm for locally recurrent or distant metastatic breast cancer, including early relapse detection and subsequently a new practical PET/CT imaging guide biopsy approach for surveilling molecular subtype shifts of the recurrent breast cancer. In our results, ¹⁸F-FDG PET/CT appears to be more sensitive and accurate than conventional imaging technologies in early detecting locally recurrent or metastatic breast cancer. PET/CT-guided percutaneous FDG-avid target biopsies offers a new integrated precise re-biopsy algorithm for pathologic confirm and surveillance of molecular subtype shifts of the recurrent breast cancer. The precise algorithm for breast cancer recurrence and metastasis can be established in one stop, opening a window of opportunity for breast cancer patients to improve precise individual therapy and prolong survival.

Association between breast cancer and the risk of colorectal cancer

BACKGROUND

The literature to date has suggested a potential increase in colorectal cancer (CRC) among patients with breast cancer.

METHODS

We performed a systematic review of the literature and included 37 retrospective cohort studies and 8 case-control studies. The primary aim was to determine the prevalence of CRC. Secondary aims included analysis of adenomatous polyps and analysis of CRC prevalence by age. We calculated pooled prevalence rates and odds ratios (ORs) using random effects models with 95% confidence intervals (CI).

RESULTS

We identified 1,055,917 individuals with breast cancer among whom 9097 cases of CRC were detected. The pooled event rate for CRC was 0.7% (95% CI, 0.6%-0.9%; I²=97%). Four case-control studies reported prevalence of CRC (N=17,873 patients with breast cancer and 70,366 controls), including 46 cases of CRC in the patients with breast cancer, and 272 CRC in the controls (OR, 1.2; 95% CI, 0.4%-3.7%; P = .7). Six studies reported prevalence of advanced adenomas in patients with breast cancer (N=1087) compared with controls (N=1356) with 62 cases of advanced adenomas in patients compared with 47 in the controls (OR, 1.5; 95% CI, 0.97-2.2; P = .07). In patients with breast cancer <50 years old (4 studies, N=64,706), the pooled OR was increased (OR, 2.5; 95% CI, 1.7-3.5; P =.001). In 3 studies of women <45 years old (N=92,594), the risk was increased (OR, 2.3; 95% CI, 1.7-2.6; P < .001).

CONCLUSIONS

Patients with breast cancer should not undergo CRC screening at intervals different from the general population. In patients with breast cancer <50 years old, CRC screening should be considered at age 45 years.

Gynecological Cancer as a Second Malignancy in Patients With Breast Cancer

Purpose

The aim of this study was to determine the incidence and risk factors for gynecological cancer as second malignancy (SM) after treatment of breast cancer (BC).

Methods and Materials

Between January 1985 and December 2007, a total of 2756 patients with BC were analyzed for gynecological cancers as an SM. Analysis was carried out for patient-, disease-, and treatment-related characteristics. The Cox proportional hazards regression model was used to estimate the relative risk of gynecologic malignancies.

Results

The median age at BC diagnosis was 49 years and median follow-up of 14 years. In total, 25 cases of gynecological cancer were noted with an incidence of 0.9%. We observed 9 ovarian and endometrium (0.3%) as well as 7 uterine cervix (0.25%) cancers. Family history of BC was the most significant risk factor for SM (relative risk, 7.4; 95% confidence interval, 3.03–18.28; P<0.001). Women with a family history of BC had a higher incidence of endometrial (12%) and ovarian (16%) cancer compared with those who have no family history (0.1%, P = 0.003). Statistically significant higher incidence of endometrial cancer was seen in patients undergoing hormonal therapy (0.4%) as compared with those who are not undergoing hormonal therapy (0.1%, P = 0.001). Most of the endometrial (88.9%) and cervical (71%) cancers were detected at an early stage but ovarian cancers (66.6%) in advanced stage. Chemotherapy and radiotherapy did not increase the risk of gynecological SM.

Conclusions

Women with BC are at risk of developing a second primary gynecological malignancy particularly of endometrium and ovary. Family history of BC was a high risk factor for gynecologic SM. These patients should be followed up for its early detection.

Risk of second primary cancer associated with pre-diagnostic smoking, alcohol, and obesity in women with keratinocyte carcinoma

Keratinocyte carcinoma (KC), which includes basal-cell carcinoma (BCC) and squamous-cell cancer (SCC), has been associated with an increased risk of second primary cancers (SPCs), although the reason for this increase is unknown. We assessed the effects of smoking, alcohol, and obesity prior to the diagnosis of KC on the development of SPCs, as these are well-established risk factors for multiple cancers and may also contribute to the increased risk of SPCs among those with KC. A total of 15,628 women with self-reported KC were identified in the Nurses' Health Study. Incident SPCs were assessed throughout the follow-up until June 2012. Cox proportional hazards models were used to calculate the hazard ratios (HRs) of SPC associated with pre-diagnostic smoking, alcohol and body mass index (BMI). We also compared these risk estimates to those for first cancers in all cohort participants. During 193,695 person-years of follow-up, we recorded 2839 SPC cases. Compared with never smokers, current smokers had a significantly elevated risk for SPC overall and specifically for lung, colorectal, and bladder cancers. We also found a positive association between higher BMI and risk for SPC overall as well as for endometrial and bladder SPCs. Women with KC who consumed alcohol ≥30g/day had a marginally higher risk of SPC compared to non-drinkers. The associations between incident SPC risk among KC cases and smoking, alcohol, and obesity appeared similar to the associations between these risk factors and the incident first primary cancers in the whole cohort. Only in the heavy smoking (≥25 cigarettes/day) category was the HR for SPC after KC (2.34; 95% CI 1.98-2.76) slightly higher than that for the first cancer in the overall cohort (HR 1.86; 95% CI 1.75-1.98, P_{heterogeneity}=0.01). In conclusion, pre-diagnostic smoking, alcohol and obesity prior to KC diagnosis were associated with risk of SPCs.

Estimating Second Malignancy Risk in Intensity-Modulated Radiotherapy and Volumetric-Modulated Arc Therapy using a Mechanistic Radiobiological Model in Radiotherapy for Carcinoma of Left Breast

Objectives

The aim of this study is to estimate second cancer risk (SCR) in intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) using a mechanistic radiobiological model. The model also takes into account patient age at exposure and the gender-specific correction factors of SCR.

Materials and Methods

Fifty IMRT and VMAT plans were selected for the study. Monte Carlo-based dose calculation engine was used for dose calculation. Appropriate model parameters were taken from the literature for the mechanistic model to calculate excess absolute risk (EAR), lifetime attributable risk, integral dose and relative risk (RR) for lungs, contralateral breast, heart, and spinal cord.

Results

The mean monitor unit (MU) in IMRT and VMAT plans were 751.1 ± 133.3 and 1004.8 ± 180, respectively, for IMRT and VMAT. The mean EAR values with age correction were 44.6 ± 11.9, 11.2 ± 6.4, 5.4 ± 4.0, 1.4 ± 0.5, and 0.3 ± 0.2 for left lung, right lung, contralateral breast, heart, and spinal cord, respectively, for the IMRT treatments and 54.6 ± 20.6, 30.2 ± 12.0, 13.8 ± 8.6, 1.6 ± 0.6, and 0.9 ± 0.5 for the VMAT treatments in units of 10,000 PY. The RR of 6.7% and 9.1%, respectively, for IMRT and VMAT found in our study using computational models is in close comparison with the value reported in a large epidemiological breast cancer study.

Conclusions

VMAT plans had a higher risk of developing second malignancy in lung, contralateral breast, heart, and cord compared to IMRT plans. However, the increase in risk was found to be marginal compared to IMRT. Incorporating the age correction factor decreased the risk of contralateral breast SCR. No strong correlation was found between EAR and MU.

Estimated Risk of Radiation Induced Contra Lateral Breast Cancer Following Chest Wall Irradiation by Conformal Wedge Field and Forward Intensity Modulated Radiotherapy Technique for Post-Mastectomy Breast Cancer Patients

Background:

Epidemiological studies have indicated an increasing incidence of radiation induced secondary cancer (SC) in breast cancer patients after radiotherapy (RT), most commonly in the contra-lateral breast (CLB). The present study was conducted to estimate the SC risk in the CLB following 3D conformal radiotherapy techniques (3DCRT) including wedge field and forward intensity modulated radiotherapy (fIMRT) based on the organ equivalent dose (OED).

Material and Methods:

RT plans treating the chest wall with conformal wedge field and fIMRT plans were created for 30 breast cancer patients. The risks of radiation induced cancer were estimated for the CLB using dose-response models: a linear model, a linear-plateau model and a bell-shaped model with full dose response accounting for fractionated RT on the basis of OED.

Results:

The plans were found to be ranked quite differently according to the choice of model; calculations based on a linear dose response model fIMRT predict statistically significant lower risk compared to the enhanced dynamic wedge (EDW) technique (p-0.0089) and a non-significant difference between fIMRT and physical wedge (PW) techniques (p-0.054). The widely used plateau dose response model based estimation showed significantly lower SC risk associated with fIMRT technique compared to both wedge field techniques (fIMRT vs EDW p-0.013, fIMRT vs PW p-0.04). The full dose response model showed a non-significant difference between all three techniques in the view of second CLB cancer. Finally the bell shaped model predicted interestingly that PW is associated with significantly higher risk compared to both fIMRT and EDW techniques (fIMRT vs PW p-0.0003, EDW vs PW p-0.0032).

Conclusion:

In conclusion, the SC risk estimations of the CLB revealed that there is a clear relation between risk associated with wedge field and fIMRT technique depending on the choice of model selected for risk comparison.

Imaging in the evaluation and follow-up of early and advanced breast cancer: When, why, and how often?

Imaging in the evaluation and follow-up of patients with early or advanced breast cancer is an important aspect of cancer care. The role of imaging in breast cancer depends on the goal and should only be performed to guide clinical decisions. Imaging is valuable if a finding will change the course of treatment and improve outcomes, whether this is disease-free survival, overall survival or quality-of-life. In the last decade, imaging is often overused in oncology and contributes to rising healthcare costs. In this context, we review the data that supports the appropriate use of imaging for breast cancer patients. We will discuss: 1) the optimal use of staging imaging in both early (Stage 0-II) and locally advanced (Stage III) breast cancer, 2) the role of surveillance imaging to detect recurrent disease in Stage 0-III breast cancer and 3) how patients with metastatic breast cancer should be followed with advanced imaging.

Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone

We observed the outcomes of chemotherapy with radiotherapy (CR) or radiotherapy (RT) alone for cancer patients of larynx, breast, blood and brain origins through complete blood count (CBC). Following were more depressed in CR patients: mean corpuscular hemoglobin-MCH & lymphocytes-LYM, hematocrit, mean corpuscular hemoglobin concentration-MCHC, hemoglobin-HB and red blood cells-RBC. In RT patients, following were more depressed: LYM, MCH and MCHC. Overall, in all cancer patients, the lymphocytes were depressed 52%. There existed a significant difference between white blood cells and RBC in both CR and RT patients. A significant moderate negative correlation is found in HB with the dose range 30-78 (Gray) given to the CR cancer patients. More number of CBC parameters affected in patients treated with CR and RT; but in less percentage as compared to patients who treated with RT alone. The cancer patients suffered from anemia along with immune modulations from the treatments.

Risk of Second Non-Breast Primary Cancer in Male and Female Breast Cancer Patients: A Population-Based Cohort Study

Female breast cancer patients have an increased risk of developing subsequent malignant diseases, but this issue is rarely discussed in regards to male breast cancer patients. Thus, we conducted a national survey that included 100,915 female and 578 male breast cancer patients to investigate the risk of second primary malignancy (SPM). During a follow-up period that included 529,782 person-years, 3,153 cases of SPM developed. Compared with the general population, the standardized incidence ratio (SIR) of SPM in breast cancer patients was 1.51 [95% confidence interval (CI): 1.46-1.56]. The observed risk was significantly higher in male patients (SIR 2.17, 95% CI 1.70-2.73) and in patients whose age at breast cancer diagnosis was 40 years or younger (SIR 3.39, 95% CI 2.80-4.07), comparing to age-matched general population. Compared with the overall female population, the SIRs of female breast cancer patients with uterine (SIR: 2.66, 95% CI: 2.37-2.98), thyroid (SIR: 2.30, 95% CI: 2.02-2.62), and bone and soft tissue (SIR: 2.16, 95% CI: 1.56-2.91) cancers were significantly increased. Male breast cancer patients also displayed significantly higher SIRs for thyroid (SIR: 13.2, 95% CI: 1.60-47.69), skin (SIR: 8.24, 95% CI: 3.02-17.94) and head and neck (SIR: 4.41, 95% CI: 2.35-7.54) cancers. Among breast cancer patients, risk factors significantly associated with SPM included male gender, older age, chemotherapy treatment and comorbidity with liver cirrhosis. From our analysis, we concluded that the risk of SPM was significantly higher for both male and female breast cancer patients compared with the general population, suggesting that more intensive surveillance may be needed, especially in high-risk patients.

Hereditary breast and ovarian cancer syndrome: considering the complexities

HBOC is the most common and well-described hereditary breast cancer syndrome and is often at the center of professional recommendations, accreditation standards, and insurance company coverage policies. A person’s BRCA gene mutation status may alter their decisions about surgical treatment, eligibility for a clinical trial, and their approach to cancer risk reduction and screening. The potential for knowledge gained from undergoing BRCA gene testing is great, but there are limitations and pitfalls of which patients should be aware before providing informed consent, including the possibility of uncertain or uninformative results, potential for psychological distress, and effect on family members. As such, it is important for clinicians across the health care spectrum to be able to appropriately identify patients at risk of having HBOC, understand the effect that this diagnosis has on their patients with and without cancer, and be able to identify resources to support their patients throughout genetic testing process.

Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis

OBJECTIVE

To examine whether contralateral prophylactic mastectomy (CPM) is associated with improved survival, incidence of contralateral breast cancer (CBC), and recurrence in patients with unilateral breast cancer (UBC).

BACKGROUND

Despite conflicting data, CPM rates continue to increase. Here we present the first meta-analysis to assess post-CPM outcomes in women with UBC.

METHODS

We searched 5 databases and retrieved papers' bibliographies for relevant studies published through March 2012. Fixed- and random-effects meta-analyses were conducted on the basis of tests of study heterogeneity. We examined potential confounding via stratification and meta-regression. We report pooled relative risks (RRs) and risk differences (RDs) with 95% confidence intervals (CIs) at 2-tailed P < 0.05 significance.

RESULTS

Of 93 studies reviewed, 14 were included in meta-analyses. Compared with nonrecipients, CPM recipients had higher rates of overall survival [OS; RR = 1.09 (95% CI: 1.06, 1.11)] and lower rates of breast cancer-specific mortality [BCM; RR = 0.69 (95% CI: 0.56, 0.85)] but saw no absolute reduction in risk of metachronous CBC (MCBC). Among patients with elevated familial/genetic risk (FGR, ie, BRCA carrier status and/or family history of breast cancer), both relative and absolute risks of MCBC were significantly decreased among CPM recipients [RR = 0.04 (95% CI: 0.02, 0.09); RD = -24.0% (95% CI: -35.6%, -12.4%)], but there was no improvement in OS or BCM.

CONCLUSIONS

CPM is associated with decreased MCBC incidence but not improved survival among patients with elevated FGR. The superior outcomes observed when comparing CPM recipients with nonrecipients in the general population are likely not attributable to a CPM-derived decrease in MCBC incidence. UBC patients without known FGR should not be advised to undergo CPM.

Tobacco use in the oncology setting: advancing clinical practice and research

Although tobacco is a well-established causal agent for many human cancers, less emphasis has been placed on translating this evidence by evaluating the effects of continued tobacco use after a cancer diagnosis. A broad assessment of the effects of continued tobacco use demonstrates that tobacco increases cancer treatment toxicity, recurrence, second primary tumors, and mortality in patients with cancer. Few studies report the potential benefits of cessation after a cancer diagnosis, but data suggest improved treatment outcomes in patients with cancer who quit smoking. Improving tobacco cessation treatment efficacy and access to cessation support has been sparsely researched in the oncology setting compared with the general population; however, patients with cancer are receptive to standard evidence-based tobacco cessation guidelines. Several studies demonstrate moderate tobacco cessation success in patients with cancer using the general principles of evidence-based tobacco cessation support. Several systems-level issues and research efforts are needed to standardize tobacco use definitions, increase access to tobacco cessation support, improve tobacco cessation efficacy, understand the time-dependent effects of tobacco and cessation on cancer biology, and realize the potential benefits of tobacco cessation for patients with cancer.

The biological and clinical effects of smoking by patients with cancer and strategies to implement evidence-based tobacco cessation support

Tobacco use is an established risk factor for the development of several cancers; however, far less work has been done to understand the effects of continued smoking on cancer treatment outcomes, and structured tobacco cessation efforts are not well incorporated into the standard care for patients with cancer. In this Review we discuss the known biological effects of smoking on cancer cell biology and emphasise the clinical effects of continued smoking in patients with cancer treated with chemotherapy or radiotherapy. Although evidence supports the need for inclusion of dedicated tobacco cessation efforts for patients with cancer, clinicians should consider the methods used to provide evidence-based tobacco cessation support and the available resources to deliver and maintain consistent tobacco cessation support. We also address the variables to consider in the design and implementation of a sustainable tobacco cessation programme.

Future directions for the early detection of recurrent breast cancer

The main goal of follow-up care after breast cancer treatment is the early detection of disease recurrence. In this review, we emphasize the multidisciplinary approach to this continuity of care from surgery, medical oncology, and radiology. Challenges within each setting are briefly addressed as a means of discussion for the future directions of an effective and efficient surveillance plan of post-treatment breast cancer care.

Second cancer risk after 3D-CRT, IMRT and VMAT for breast cancer

PURPOSE

Second cancer risk after breast conserving therapy is becoming more important due to improved long term survival rates. In this study, we estimate the risks for developing a solid second cancer after radiotherapy of breast cancer using the concept of organ equivalent dose (OED).

MATERIALS AND METHODS

Computer-tomography scans of 10 representative breast cancer patients were selected for this study. Three-dimensional conformal radiotherapy (3D-CRT), tangential intensity modulated radiotherapy (t-IMRT), multibeam intensity modulated radiotherapy (m-IMRT), and volumetric modulated arc therapy (VMAT) were planned to deliver a total dose of 50 Gy in 2 Gy fractions. Differential dose volume histograms (dDVHs) were created and the OEDs calculated. Second cancer risks of ipsilateral, contralateral lung and contralateral breast cancer were estimated using linear, linear-exponential and plateau models for second cancer risk.

RESULTS

Compared to 3D-CRT, cumulative excess absolute risks (EAR) for t-IMRT, m-IMRT and VMAT were increased by 2 ± 15%, 131 ± 85%, 123 ± 66% for the linear-exponential risk model, 9 ± 22%, 82 ± 96%, 71 ± 82% for the linear and 3 ± 14%, 123 ± 78%, 113 ± 61% for the plateau model, respectively.

CONCLUSION

Second cancer risk after 3D-CRT or t-IMRT is lower than for m-IMRT or VMAT by about 34% for the linear model and 50% for the linear-exponential and plateau models, respectively.

Reducing tobacco-related cancer incidence and mortality: summary of an institute of medicine workshop

Tobacco use remains a serious and persistent national problem. Recognizing that progress in combating cancer will never be fully achieved without addressing the tobacco problem, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop exploring current issues in tobacco control, tobacco cessation, and implications for cancer patients. Workshop participants discussed potential policy, outreach, and treatment strategies to reduce tobacco-related cancer incidence and mortality, and highlighted a number of potential high-value action items to improve tobacco control policy, research, and advocacy.

Risk of second primary cancer after breast cancer treatment

Technological advances in both diagnosis and treatment of breast cancer lead to early detection and better treatment management. Consequently, the population of long-term survivors is on the rise. The risk of developing second cancers among breast cancer survivors was shown to be higher than that for the general population. The aim of this work was to review the literature on the risk of second primary cancer (SPC) after breast irradiation. Pubmed search of population-based studies on SPC after breast irradiation was conducted and the findings (in terms of Standardised Incidence Ratio) were collated and discussed. Several studies confirmed the link between breast tumour irradiation and risk of SPC, showing a small, but valid risk. There are, however, confounding factors that can either underestimate or overestimate risks: misclassification of tumour status, genetic inheritance, smoking, environmental factors, and the lack of accurate data in cancer registries. While isolating these potential triggers might be difficult, this approach would allow better discernability between radiotherapy-related risks and those generated by other factors. It is also important to evaluate the current status of treatment-related late effects and to lower such risks by minimising the dose delivered to normal tissues.

International guidelines for management of metastatic breast cancer (MBC) from the European School of Oncology (ESO)-MBC Task Force: Surveillance, staging, and evaluation of patients with early-stage and metastatic breast cancer

In clinical practice, the surveillance and follow-up of patients with breast cancer (BC) is quite variable. At the 7th European Breast Cancer Conference, the ESO-MBC Task Force convened a series of lectures, followed by open debate, on the use of physical examination, imaging, and laboratory tests in patients with early-stage BC, and for restaging evaluations and follow-up among patients with MBC. Based on the available data, the Task Force recommends against intensive, routine radiologic or blood-based surveillance (with the exception of mammography) in patients with early-stage BC. As systemic therapies for MBC continue to improve, this question might be re-visited in the context of a carefully controlled clinical trial in specific BC subtypes. For patients with MBC, response to therapy should generally be assessed 2-3 months after initiation of treatment, and thereafter every 2-4 months for endocrine therapy or every 2-4 cycles for chemotherapy, depending on the dynamics of the disease, the location and extent of metastatic involvement, and type of treatment. Additional testing should be performed irrespective of the planned intervals if progression of disease is suspected (e.g. in the case of specific symptoms). Use of tumor markers is not recommended for surveillance of early-stage patients, but may be helpful in monitoring response to therapy in patients with metastatic disease. However, change in tumor markers alone should not be used for decision-making. Moving forward, enhanced efforts to document quality of life over time should be made in order to more fully evaluate the risk/benefit ratio of available options.

A population perspective to mitigating risk for second primary breast cancer

SUMMARY There are more than 2 million breast cancer survivors in the USA. Approximately 5–10% of survivors will develop a second, metachronous breast cancer within 10 years’ time; a risk two- to six-times higher than that in the general population. Women who develop metachronous cancer are more likely to die from the disease compared with women with unilateral cancer. Risk factors for metachronous cancer include BRCA mutation status, young age, family history and tumor phenotype, while adjuvant chemotherapy and endocrine therapy may attenuate the risk. Surveillance guidelines recommend annual mammography, but MRI is not currently indicated for most women. An increasing number of women are choosing prophylactic contralateral mastectomy, although it is not likely to be beneficial for most women. Improved strategies are needed for identifying survivors at an increased risk in order to help guide clinical decisions regarding follow-up care. This review presents an overview of the burden and risk factors for metachronous breast cancer and discusses challenges and opportunities for a population approach to mitigating risk and adverse outcomes from these cancers.

Other primary malignancies in breast cancer patients treated with breast conserving surgery and radiation therapy

BACKGROUND

Our purpose was to examine the incidence and impact on survival of other primary malignancies (OPM) outside of the breast in breast cancer patients and to identify risk factors associated with OPM.

METHODS

Patients with stage 0-III breast cancer treated with breast conserving therapy at our center from 1979 to 2007 were included. Risk factors were compared between patients with/without OPM. Logistic regression was used to identify factors that were associated with OPM. Standardized incidence ratios (SIRs) were calculated.

RESULTS

Among 4,198 patients in this study, 276 (6.6 %) developed an OPM after breast cancer treatment. Patients with OPM were older and had a higher proportion of stage 0/I disease and contralateral breast cancer compared with those without OPM. In a multivariate analysis, older patients, those with contralateral breast cancer, and those who did not receive chemotherapy or hormone therapy were more likely to develop OPM after breast cancer. Patients without OPM had better overall survival. The SIR for all OPM sites combined after a first primary breast cancer was 2.91 (95 % confidence interval: 2.57-3.24). Significantly elevated risks were seen for numerous cancer sites, with SIRs ranging from 1.84 for lung cancer to 5.69 for ovarian cancer.

CONCLUSIONS

Our study shows that breast cancer patients have an increased risk of developing OPM over the general population. The use of systemic therapy was not associated with increased risk of OPM. In addition to screening for a contralateral breast cancer and recurrences, breast cancer survivors should undergo screening for other malignancies.

Predicting the risk of secondary lung malignancies associated with whole-breast radiation therapy

PURPOSE

The risk of secondary lung malignancy (SLM) is a significant concern for women treated with whole-breast radiation therapy after breast-conserving surgery for early-stage breast cancer. In this study, a biologically based secondary malignancy model was used to quantify the risk of secondary lung malignancies (SLMs) associated with several common methods of delivering whole-breast radiation therapy (RT).

METHODS AND MATERIALS

Both supine and prone computed tomography simulations of 15 women with early breast cancer were used to generate standard fractionated and hypofractionated whole-breast RT treatment plans for each patient. Dose-volume histograms (DVHs) of the ipsilateral breast and lung were calculated for each patient on each plan. A model of spontaneous and radiation-induced carcinogenesis was used to determine the relative risks of SLMs for the different treatment techniques.

RESULTS

A higher risk of SLMs was predicted for supine breast irradiation when compared with prone breast irradiation for both the standard fractionation and hypofractionation schedules (relative risk [RR] = 2.59, 95% confidence interval (CI) = 2.30-2.88, and RR = 2.68, 95% CI = 2.39-2.98, respectively). No difference in risk of SLMs was noted between standard fractionation and hypofractionation schedules in either the supine position (RR = 1.05, 95% CI = 0.97-1.14) or the prone position (RR = 1.01, 95% CI = 0.88-1.15).

CONCLUSIONS

Compared with supine whole-breast irradiation, prone breast irradiation is associated with a significantly lower predicted risk of secondary lung malignancy. In this modeling study, fractionation schedule did not have an impact on the risk of SLMs in women treated with whole-breast RT for early breast cancer.

Can the risk of secondary cancer induction after breast conserving therapy be reduced using intraoperative radiotherapy (IORT) with low-energy x-rays?

BACKGROUND

Radiation induced secondary cancers are a rare but severe late effect after breast conserving therapy. Intraoperative radiotherapy (IORT) is increasingly used during breast conserving surgery. The purpose of this analysis was to estimate secondary cancer risks after IORT compared to other modalities of breast radiotherapy (APBI - accelerated partial breast irradiation, EBRT - external beam radiotherapy).

METHODS

Computer-tomography scans of an anthropomorphic phantom were acquired with an INTRABEAM IORT applicator (diameter 4 cm) in the outer quadrant of the breast and transferred via DICOM to the treatment planning system. Ipsilateral breast, contralateral breast, ipsilateral lung, contralateral lung, spine and heart were contoured. An INTRABEAM source (50 kV) was defined with the tip of the drift tube at the center of the spherical applicator. A dose of 20 Gy at 0 mm depth from the applicator surface was prescribed for IORT and 34 Gy (5 days × 2 × 3.4 Gy) at 10 mm depth for APBI. For EBRT a total dose of 50 Gy in 2 Gy fractions was planned using two tangential fields with wedges. The mean and maximal doses, DVHs and volumes receiving more than 0.1 Gy and 4 Gy of organs at risk (OAR) were calculated and compared. The life time risk for secondary cancers was estimated according to NCRP report 116.

RESULTS

IORT delivered the lowest maximal doses to contralateral breast (< 0.3 Gy), ipsilateral (1.8 Gy) and contralateral lung (< 0.3 Gy), heart (1 Gy) and spine (< 0.3 Gy). In comparison, maximal doses for APBI were 2-5 times higher. EBRT delivered a maximal dose of 10.4 Gy to the contralateral breast and 53 Gy to the ipsilateral lung. OAR volumes receiving more than 4 Gy were 0% for IORT, < 2% for APBI and up to 10% for EBRT (ipsilateral lung). The estimated risk for secondary cancer in the respective OAR is considerably lower after IORT and/or APBI as compared to EBRT.

CONCLUSIONS

The calculations for maximal doses and volumes of OAR suggest that the risk of secondary cancer induction after IORT is lower than compared to APBI and EBRT.

Therapy-related myeloid malignancies in myeloma

Therapy related myeloid malignancies are an increasingly recognized treatment complication in patients undergoing therapy for multiple myeloma. The main predisposing factors are the alkylating agents, topoisomerase II inhibitors and radiotherapy, but recently questions have been raised regarding the immunomodulatory agent lenalidomide. Little is known about the new antimyeloma agents in the context of therapy related myeloid malignancies. The duration of treatment and the time from diagnosis are the main contributing factors in alkylating induced myeloid malignancies which occur 5–10 years after treatment, chromosome 5 and 7 abnormalities being the characteristic finding. High dose therapy (HDT) does not seem to be a major contributing factor per se in multiple myeloma. In a number of large published series, all the factors related with therapy-induced myelodysplasia were defined prior to HDT. Topoisomerase II inhibitors induce mainly acute leukemias which invariably correlate with dysregulation of the MLL gene. Radiotherapy causes therapy related myelodysplasia if applied in bone marrow producing areas, especially if combined with chemotherapy. Therapy related myeloid malignancies generally herald a poor prognosis. Karyotypic abnormalities seem to be the main prognostic factor. In all cases the risk for therapy related myeloid malignancies drops sharply by 10 years after the treatment.

The impact of age on outcome in early-stage breast cancer

Multiple studies have shown that breast-conserving therapy (BCT) and mastectomy have equivalent outcomes for large populations of women with early-stage breast cancer. For individual treatment decisions, however, it is important to appreciate the heterogeneity of disease. Recent molecular studies have suggested that "breast cancer" includes biologically distinct classes of disease; although these molecular distinctions are important, other patient-related factors also affect outcome and influence prognosis. One of the most important of these patient factors is the age of the patient at diagnosis. Numerous studies have shown very different breast cancer outcomes based on patient age; younger women typically have more aggressive tumors that are more likely to recur both locoregionally and distantly, and older women more commonly have less aggressive disease. The overall disease-specific outcomes, techniques, and doses for adjuvant radiation therapy and toxicity of treatments should be discussed within the context of age because breast cancer is a very different disease based on this factor. Arguments can be made that more aggressive locoregional therapy is warranted in populations of young women with breast cancer and perhaps less aggressive therapy in the elderly.

Second malignancies in breast cancer patients following radiotherapy: a study in Florence, Italy

INTRODUCTION

Patients diagnosed with breast cancer are often treated with surgery followed by radiation therapy. In this paper, we evaluate the effect that radiotherapy may have had on the subsequent risk of second malignancies, including the possible influences of age at treatment and menopausal status.

METHODS

In order to evaluate the long-term consequences of radiotherapy, a cohort study was conducted based on clinical records for 5,248 women treated for breast cancer in Florence (Italy), with continuous follow-up from 1965 to 1994. The Cox proportional hazards model for ungrouped survival data was used to estimate the relative risk for second cancer after radiotherapy.

RESULTS

This study indicated an increased relative risk of all second cancers combined following radiotherapy (1.22, 95% CI: 0.88 to 1.69). The increased relative risk appeared five or more years after radiotherapy and appeared to be highest amongst women treated after the menopause (1.61, 95% CI: 1.13 to 2.29). Increased relative risks were observed specifically for leukaemia (8.13, 95% CI: 0.96 to 69.1) and other solid cancers (1.84, 95% CI: 1.06 to 3.16), excluding contralateral breast cancer. For contralateral breast cancer, no raised relative risk was observed during the period more than five years after radiotherapy.

CONCLUSIONS

The study indicated a raised risk of second malignancies associated with radiotherapy for breast cancer, particularly for women treated after the menopause.

Doses to internal organs for various breast radiation techniques--implications on the risk of secondary cancers and cardiomyopathy

Background

Breast cancers are more frequently diagnosed at an early stage and currently have improved long term outcomes. Late normal tissue complications induced by adjuvant radiotherapy like secondary cancers or cardiomyopathy must now be avoided at all cost. Several new breast radiotherapy techniques have been developed and this work aims at comparing the scatter doses of internal organs for those techniques.

Methods

A CT-scan of a typical early stage left breast cancer patient was used to describe a realistic anthropomorphic phantom in the MCNP Monte Carlo code. Dose tally detectors were placed in breasts, the heart, the ipsilateral lung, and the spleen. Five irradiation techniques were simulated: whole breast radiotherapy 50 Gy in 25 fractions using physical wedge or breast IMRT, 3D-CRT partial breast radiotherapy 38.5 Gy in 10 fractions, HDR brachytherapy delivering 34 Gy in 10 treatments, or Permanent Breast ¹⁰³Pd Seed Implant delivering 90 Gy.

Results

For external beam radiotherapy the wedge compensation technique yielded the largest doses to internal organs like the spleen or the heart, respectively 2,300 mSv and 2.7 Gy. Smaller scatter dose are induced using breast IMRT, respectively 810 mSv and 1.1 Gy, or 3D-CRT partial breast irradiation, respectively 130 mSv and 0.7 Gy. Dose to the lung is also smaller for IMRT and 3D-CRT compared to the wedge technique. For multicatheter HDR brachytherapy a large dose is delivered to the heart, 3.6 Gy, the spleen receives 1,171 mSv and the lung receives 2,471 mSv. These values are 44% higher in case of a balloon catheter. In contrast, breast seeds implant is associated with low dose to most internal organs.

Conclusions

The present data support the use of breast IMRT or virtual wedge technique instead of physical wedges for whole breast radiotherapy. Regarding partial breast irradiation techniques, low energy source brachytherapy and external beam 3D-CRT appear safer than ¹⁹²Ir HDR techniques.

Rates of second malignancies after definitive local treatment for ductal carcinoma in situ of the breast

PURPOSE

We analyzed the risk of second malignancies developing in patients with ductal carcinoma in situ (DCIS) undergoing surgery and radiotherapy (S+RT) vs. surgery alone.

METHODS AND MATERIALS

The S+RT cohort consisted of 256 women treated with breast-conserving therapy at William Beaumont Hospital. The surgery alone cohort consisted of 2,788 women with DCIS in the regional Surveillance, Epidemiology, and End Results database treated during the same time period. A matched-pair analysis was performed in which each S+RT patient was randomly matched with 8 surgery alone patients (total of 2,048 patients). Matching criteria included age±2 years. The rates of second malignancies were analyzed overall and as contralateral breast vs. non-breast cancers and by organ system.

RESULTS

Median follow-up was 13.7 years for the S+RT cohort and 13.3 years for the surgery alone cohort. The overall 10-/15-year rates of second malignancies among the S+RT and surgery alone cohorts were 14.2%/24.2% and 16.4%/22.6%, respectively (p=0.668). The 15-year second contralateral breast cancer rate was 14.2% in the S+RT cohort and 10.3% in the surgery alone cohort (p=0.439). The 15-year risk of a second non-breast malignancy was 14.2% for the S+RT cohort and 13.4% for the surgery alone cohort (p=0.660). When analyzed by organ system, the 10- and 15-year rates of second malignancies did not differ between the S+RT and surgery alone cohorts for pulmonary, gastrointestinal, central nervous system, gynecologic, genitourinary, lymphoid, sarcomatoid, head and neck, or unknown primary tumors.

CONCLUSIONS

Compared with surgery alone, S+RT is not associated with an overall increased risk of second malignancies in women with DCIS.