Impact of Radiotherapy on Psychological, Financial, and Sexual Aspects in Postmastectomy Carcinoma Breast Patients: A Prospective Study and Management

A Pilot Study to Show Longitudinal Trends in Health-Related Quality of Life (HRQOL) in a Cohort of Breast Cancer Patients Under Treatment at a Tertiary Healthcare Facility in Bhubaneswar, India

Introduction

Breast cancer incidence has overtaken that of cervical cancer among women in India according to the Globacon 2020 reports. Cancer management is also being streamlined at the Center and district levels, such that comprehensive integrated management is offered to cases to optimize the best results. In breast cancer, there are two modes of surgery namely Breast Conservation Surgery(BCS) and Modified Radical Mastectomy (MRM) now over 2 decades, with recommended Chemo radiation depending on the extent of the disease. HRQOL (Health-related Quality of Life) studies have been done in these groups of patients, due to their added relevance in terms of the loss of a vital organ like the breast. EORTC 30 and BR23 are standardized and detailed tools that have been seen to estimate QOL, keeping in mind a whole array of domains that are affected by the disease.

Objective

To evaluate the "Body Image" and "Quality of life" (QOL) in operated breast cancer patients using BR -23 and EORTC - QLQ- questionnaire at 1month (after surgery) and then 3 to 4 months after surgery.

Methods

This article attempts to draw a comparison among of EORTC30 and BR 23 scores calculated for 46 breast cancer patients operated during the pandemic time in one center and consenting to repeat the measures at pre-decided three time periods during the course of management.

Results

No significant differences are noted in the mean scores for EORTC 30 and BR23 for the two types of surgeries. Visit 1 scores for both modes of surgery are over 75 and by Visit 3 become less than 55 for EORTC. BR 23 (which measures the symptoms core to Breast cancer) at all 3 visits are between 45 to 55. Friedman's test shows that the scores are not significant for age groups, the number of living children, or lifestyle factors like alcohol or tobacco chewing, though quadratic graphs depict the distinct variations in the scores at the 3 times reinforcing the need for follow-up of mental health in these subjects at intervals. The study largely brings out a strong need for repeated follow-up and counseling at regular and short intervals, post-surgery in breast cancer patients. EORTC 30 and BR 23 tools are excellent to use to essay information on the mental health of patients with breast cancer.

Sleep quality and psychological disorders in breast cancer female patients receiving radiotherapy at a tertiary oncology center in West Saudi Arabia

PURPOSE

Breast cancer is the most prevalent type of cancer among women worldwide. Many recently diagnosed and treated breast cancer patients complain about sleep disorders, depression, anxiety, stress, and fatigue. This study aimed to evaluate sleep quality among breast cancer patients and to assess its association with psychological disorders, and socio-demographic and clinical characteristics of patients.

METHODS

This cross-sectional study was conducted among women who received radiotherapy for breast cancer (stage 1-3) at King Abdul-Aziz Medical City-Jeddah from January to August 2021. Each participant completed a personal information form, the Pittsburgh Sleep Quality Index (PSQI), the Depression, Anxiety, and Stress Scale-21 (DASS-21), and the International Physical Activity Questionnaire (IPAQ). Clinical data were collected from the medical records to evaluate certain risk factors. Descriptive statistics were used for participant characteristics, and analyses of variance were used to assess associations between the qualitative variables.

RESULTS

Fifty-six women with a mean age of 50.1 years and an average of 10 months after cancer diagnosis were included. Poor sleep quality was present in 58% of respondents. Symptomatic depression, anxiety, and stress were found in 34%, 32%, and 30% of women, respectively. Poor sleep quality was associated with depression (p = 0.031), anxiety (p = 0.03), and stress (p = 0.024) and was independently associated with hot flashes. In multivariate analysis, patients with depression or with cancer for more than 6 months were less likely to have good sleep after controlling other variables (21.74 and 14.71 times, respectively).

CONCLUSION

Poor sleep quality was present in 58% of women with breast cancer receiving radiotherapy and was significantly associated with depression, anxiety, stress, and hot flashes. Depression level and cancer duration were significant predictors of sleep quality. Early identification and proper management of psychological and sleep disorders are necessary to improve the quality of life and survival of breast cancer patients.

Care Pathway Analysis to Inform the Earliest Stages of Technology Development: Scoping Oncological Indications in Need of Innovation

OBJECTIVES

Identifying unmet needs for innovative solutions across disease contexts is challenging but important for directing funding and research efforts and informing early-stage decisions during the innovation process. Our aim was to study the merits of care pathway analysis to scope disease contexts and guide the development of innovative devices. We used oncologic surgery as a case study, for which many intraoperative imaging techniques are under development.

METHODS

Care pathway analysis is a mapping process, which produces graphical maps of clinical pathways using important outcomes and subsequent consequences. We performed care pathway analyses for glioblastoma, breast, bladder, prostate, renal, pancreatic, and oral cavity cancer. Differences between a "perfect" care pathway and the current care pathway in terms of percentage of inadequate margins, associated recurrences, quality of life, and 5-year overall survival were calculated to determine unmet needs. Data from The Netherlands Cancer Registry and literature were used.

RESULTS

Care pathway analysis showed that highest percentages of inadequate margins were found in oral cavity cancer (72.5%), glioblastoma (48.7%), and pancreatic cancer (43.9%). Inadequate margins showed the strongest increase in recurrences in cancer of oral cavity, and bladder (absolute increases of 43.5% and 41.2%, respectively). Impact on survival was largest for bladder and oral cavity cancer with positive margins.

CONCLUSIONS

Care pathway analysis provides overviews of current clinical paths in multiple indications. Disease contexts can be compared via effectiveness gaps that show the potential need for innovative solutions. This information can be used as basis for stakeholder involvement processes to prioritize care pathways in need of innovation.

Effect of Postoperative Adjuvant Radiotherapy on Quality of Life, Anxiety, and Depression in Adult Female Breast Cancer Patients

Aim: This study aims to identify anxiety and depression caused by adjuvant radiotherapy in breast cancer cases to determine the deterioration in the quality of life and investigate the effect of early treatment.

Materials and Methods: In this study, the Beck Depression Inventory, Beck Anxiety Inventory, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30) Turkish 3.0 forms were evaluated in 63 breast cancer patients before the start of radiotherapy treatment (T1) and at six weeks after the end of radiotherapy treatment (T2).

Results: A high level of anxiety was detected in 77.8% of patients, and depression was found in 25.4% of patients in T1. When depressive cases were evaluated with EORTC QLQ-C30 scores, the general health status (p = 0.043), role function (p = 0.027), emotional (p < 0.002), cognitive (p < 0.001), and social (p < 0.0001) scales were statistically lower in T1, whereas pain (p = 0.045) and insomnia (p < 0.0001) symptoms were higher in T1. Anxiety and EORTC QLQ-C30 scores in terms of emotional function (p = 0.015), social function (p < 0.003), and symptoms of insomnia (p = 0.027) were found to be statistically higher in T1 anxious cases. However, anxiety was detected in only 3% of T2 cases, and no depression was found in any of the cases. Anxiety and EORTC QLQ-C30 scores and symptom scales were evaluated in terms of role function (p < 0.0001), emotional (p = 0.041) and social scales (p = 0.014), fatigue (p = 0.028), pain (p = 0.033), insomnia (p = 0.011), and constipation (p < 0.0001); these were found to be statistically significant in T2.

Conclusion: This study revealed that early diagnosis and treatment of anxiety before initiating adjuvant radiotherapy reduces the development of long-term anxiety-related depression in the future. Therefore, it is recommended that patients be evaluated for anxiety and depression before starting adjuvant radiotherapy.

Smile InTM Totems in Radiotherapy: Patients’ Satisfaction with Limited Equipment and COVID-19

Background: We report a mono-institutional experience regarding patient-perceived quality regarding the Chieti Radiotherapy Department, through RAMSI (Radiotherapy Amica Mia—SmileINTM(SI)—My Friend RadiotherapySI) project, in critical scenarios of limited equipment and COVID-19. Material and methods: Patient-reported experience measures (PREMs) were assessed as follows: Patient-centric welcome perception (PCWP), Comfort, Professional skills and Punctuality. Patients could give anonymous feedback using HappyOrNot technology through four totems located in strategic areas within the center. An internal benchmark was obtained using the feedback received after a preliminary observation period. The SI Experience Index was collected, analyzed and compared. Weekly and monthly reports were generated. Results: From February 2019 to February 2022, 8924 patients accessed the department; 17,464 daily treatments were recorded and 5830 points of feedback were collected: 896, 1267, 1125 and 2542 for PCWP, Comfort, Professional skills and Punctuality, respectively. A LINAC decommissioning period was analyzed, with decreases in the SI-Index score and Smile-IN approved percentage and an improvement after this period. Additionally, the COVID-19 pandemic was analyzed with a mild evaluations decrease for PREM’s Welcome, Comfort and Punctuality (Δ-value: −9%, −3% and −4%, respectively), while Professional skills were always optimal. Conclusion: The RAMSI project was effective for assessing treatment quality perception, allowing for improving clinical procedures with corrective actions. The RAMSI project is ongoing.

Evaluating Thresholds to Adopt Hypofractionated Preoperative Radiotherapy as Standard of Care in Sarcoma

Introduction

Data supporting hypofractionated preoperative radiation therapy (RT) for patients with extremity and trunk soft tissue sarcoma (STS) are currently limited to phase II single-institution studies. We sought to understand the type and thresholds of clinical evidence required for experts to adopt hypofractionated RT as a standard-of-care option for patients with STS.

Methods

An electronic survey was distributed to multidisciplinary sarcoma experts. The survey queried whether data from a theoretical, multi-institutional, phase II study of 5-fraction preoperative RT could change practice. Using endpoints from RTOG 0630 as a reference, the survey also queried thresholds for acceptable local control, wound complication, and late toxicity for the study protocol to be accepted as a standard-of-care option. Responses were logged from 8/27/2020 to 9/8/2020 and summarized graphically.

Results

The survey response rate was 55.3% (47/85). Local control is the most important clinical outcome for sarcoma specialists when evaluating whether an RT regimen should be considered standard of care. 17% (8/47) of providers require randomized phase III evidence to consider hypofractionated preoperative RT as a standard-of-care option, whereas 10.6% (5/47) of providers already view this as a standard-of-care option. Of providers willing to change practice based on phase II data, most (78%, 29/37) would accept local control rates equivalent to or less than those in RTOG 0630, as long as the rate was higher than 85%. However, 51.3% (19/37) would require wound complication rates superior to those reported in RTOG 0630, and 46% (17/37) of respondents would accept late toxicity rates inferior to RTOG 0630.

Conclusion

Consensus building is needed among clinicians regarding the type and threshold of evidence needed to evaluate hypofractionated RT as a standard-of-care option. A collaborative consortium-based approach may be the most pragmatic means for developing consensus protocols and pooling data to gradually introduce hypofractionated preoperative RT into routine practice.

Patients' Satisfaction by SmileInTM Totems in Radiotherapy: A Two-Year Mono-Institutional Experience

Background: Patient’s satisfaction is recognized as an indicator to monitor quality in healthcare services. Patient-reported experience measures (PREMs) may contribute to create a benchmark of hospital performance by assessing quality and safety in cancer care. Methods: The areas of interest assessed were: patient-centric welcome perception (PCWP), punctuality, professionalism and comfort using the Lean Six Sigma (LSS) methodology. The RAMSI (Radioterapia Amica Mia SmileIN^{TM (SI)} My Friend Radiotherapy^SI), project provided for the placement of SI totems with four push buttons using HappyOrNot technology in a high-volume radiation oncology (RO) department. The SI technology was implemented in the RO department of the Fondazione Policlinico Universitario A. Gemelli IRCCS. SI totems were installed in different areas of the department. The SI Experience Index was collected, analyzed and compared. Weekly and monthly reports were created showing hourly, daily and overall trends. Results: From October 2017 to November 2019, a total of 42,755 votes were recorded: 8687, 10,431, 18,628 and 5009 feedback items were obtained for PCWP, professionalism, punctuality, and comfort, respectively. All areas obtained a SI-approved rate ≥ 8.0. Conclusions: The implementation of the RAMSI system proved to be doable according to the large amount of feedback items collected in a high-volume clinical department. The application of the LSS methodology led to specific corrective actions such as modification of the call-in-clinic system during operations planning. In order to provide healthcare optimization, a multicentric and multispecialty network should be defined in order to set up a benchmark.

A Grateful Disposition Promotes the Well-Being of Women with Breast Cancer Through Adaptive Coping

Introduction

Gratitude has been studied as a disposition that reflects the extent to which people appreciate what they have in life knowing that it has not been given to them forever. Being grateful has been found to promote quality of life, which is why it may be used to cope in difficult times including during breast cancer diagnosis and treatment.

Methods

Dispositional gratitude was examined in relation to the well-being of women with breast cancer. In the current study, 119 women with breast cancer completed questionnaires that measured gratitude, well-being, coping styles, depression, and anxiety.

Results

Correlational analyses found that dispositional gratitude was positively correlated with well-being (p < 0.001) and was negatively correlated with depression (p < 0.05) and anxiety (p < 0.05). Gratitude was also positively correlated with the use of task-oriented (p < 0.05) and socially oriented coping (p < 0.01) techniques. Analyses of mediation using PROCESS found that the use of task-oriented and socially oriented coping mediated relationships between gratitude and well-being, between gratitude and anxiety, and between gratitude and depression.

Conclusion

In terms of application, the present results suggest that among women who have breast cancer, increasing dispositional gratitude may increase adaptive coping, which in turn will increase their well-being.

Novel imaging techniques for intraoperative margin assessment in surgical oncology: A systematic review

Inadequate margins continue to occur frequently in patients who undergo surgical resection of a tumor, suggesting that current intraoperative methods are not sufficiently reliable in determining the margin status. This clinical demand has inspired the development of many novel imaging techniques that could help surgeons with intraoperative margin assessment. This systematic review provides an overview of novel imaging techniques for intraoperative margin assessment in surgical oncology, and reports on their technical properties, feasibility in clinical practice and diagnostic accuracy. PubMed, Embase, Web of Science and the Cochrane library were systematically searched (2013‐2018) for studies reporting on imaging techniques for intraoperative margin assessment. Patient and study characteristics, technical properties, feasibility characteristics and diagnostic accuracy were extracted. This systematic review identified 134 studies that investigated and developed 16 groups of techniques for intraoperative margin assessment: fluorescence, advanced microscopy, ultrasound, specimen radiography, optical coherence tomography, magnetic resonance imaging, elastic scattering spectroscopy, bio‐impedance, X‐ray computed tomography, mass spectrometry, Raman spectroscopy, nuclear medicine imaging, terahertz imaging, photoacoustic imaging, hyperspectral imaging and pH measurement. Most studies were in early developmental stages (IDEAL 1 or 2a, n = 98); high‐quality stage 2b and 3 studies were rare. None of the techniques was found to be clearly superior in demonstrating high feasibility as well as high diagnostic accuracy. In conclusion, the field of imaging techniques for intraoperative margin assessment is highly evolving. This review provides a unique overview of the opportunities and limitations of the currently available imaging techniques.

What's new?

While surgical resection is critical in the treatment of primary solid tumors, resection at tumor margins remains problematic, with inadequately resected margins facilitating tumor recurrence. In this systematic review, the authors collected information on novel imaging techniques applied to the intraoperative assessment of tumor margins across cancer types. A total of 16 groups of techniques were identified, with many in early stages of clinical application. Following comparison, no single technique was clearly superior in clinical feasibility or diagnostic accuracy. The review highlights the evolving nature of imaging techniques for intraoperative margin assessment and identifies opportunities and limitations in the field.

Keeping abreast about ashwagandha in breast cancer

ETHNOPHARMACOLOGICAL RELEVANCE

Ashwagandha has been used as an ayurvedic medicine in the form of 'Rasayana' (as a tonic) even before 3000 BCE in India. As per Ayurveda, it has long been used traditionally for the treatment of inflammation, weakness, impotence, pulmonary tuberculosis. This plant is also beneficial in lumbago and leucorrhea in the female. In the recent past, Withania has shown its anti-cancerous activity in various experimental models. In addition, Withania also possesses many other properties such as anti-oxidant, anti-stress, adaptogenic, and regenerative which will eventually be beneficial and safe in treating cancer patients.

AIM OF THE STUDY

This review aims to provide experimental evidence along with a deeper insight into molecular mechanisms of Ashwagandha (Withania somnifera (L.) Dunal) through which it acts as a chemotherapeutic agent against different types of breast cancer.

MATERIALS AND METHODS

Literature searches with the help of electronic online databases (Elsevier, Google Scholar, Scopus, Springer Link, ScienceDirect, ResearchGate, PubMed) were carried out. The timeline for collection of data for the review article was from 2000 to 2019. The plant name was validated from The Plant List (2013). Version 1.1. Published on http://www.theplantlist.org/(accessed 21st March 2020).

RESULTS

Various forms of Withania somnifera were used and several in vitro, in vivo, and clinical studies were reported by researchers. They found ashwagandha to exhibit anti-apoptotic, anti-metastatic, anti-invasive and anti-inflammatory properties and gave the evidence that ashwagandha has a capability for averting and treating breast cancer.

CONCLUSION

Various in vitro and in vivo studies suggested Ashwagandha may possess a potential for treating breast cancer, especially ER/PR positive breast cancer and triple-negative breast cancer. A clinical trial has also been conducted in the past that suggested its potential in refining quality of life in breast cancer patients. Studies directed towards molecular pathways have helped in unravelling the key mechanisms of ashwagandha. Future research should be directed towards translational studies involving breast cancer patients. These will reinforce the ancient power of our Ayurvedic medicine.

Autotaxin and Breast Cancer: Towards Overcoming Treatment Barriers and Sequelae

After a decade of intense preclinical investigations, the first in-class autotaxin inhibitor, GLPG1690, has entered Phase III clinical trials for idiopathic pulmonary fibrosis. In the intervening time, a deeper understanding of the role of the autotaxin–lysophosphatidate (LPA)–lipid phosphate phosphatase axis in breast cancer progression and treatment resistance has emerged. Concordantly, appreciation of the tumor microenvironment and chronic inflammation in cancer biology has matured. The role of LPA as a central mediator behind these concepts has been exemplified within the breast cancer field. In this review, we will summarize current challenges in breast cancer therapy and delineate how blocking LPA signaling could provide novel adjuvant therapeutic options for overcoming therapy resistance and adverse side effects, including radiation-induced fibrosis. The advent of autotaxin inhibitors in clinical practice could herald their applications as adjuvant therapies to improve the therapeutic indexes of existing treatments for breast and other cancers.

Health-related quality of life in Asian patients with breast cancer: a systematic review

OBJECTIVE

To summarise the evidence on determinants of health-related quality of life (HRQL) in Asian patients with breast cancer.

DESIGN

Systematic review conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and registered with PROSPERO (CRD42015032468).

METHODS

According to the PRISMA guidelines, databases of MEDLINE (PubMed), Embase and PsycINFO were systematically searched using the following terms and synonyms: breast cancer, quality of life and Asia. Articles reporting on HRQL using EORTC-QLQ-C30, EORTC-QLQ-BR23, FACT-G and FACT-B questionnaires in Asian patients with breast cancer were eligible for inclusion. The methodological quality of each article was assessed using the quality assessment scale for cross-sectional studies or the Newcastle-Ottawa Quality Assessment Scale for cohort studies.

RESULTS

Fifty-seven articles were selected for this qualitative synthesis, of which 43 (75%) were cross-sectional and 14 (25%) were longitudinal studies. Over 75 different determinants of HRQL were studied with either the EORTC or FACT questionnaires. Patients with comorbidities, treated with chemotherapy, with less social support and with more unmet needs have poorer HRQL. HRQL improves over time. Discordant results in studies were found in the association of age, marital status, household income, type of surgery, radiotherapy and hormone therapy and unmet sexuality needs with poor global health status or overall well-being.

CONCLUSIONS

In Asia, patients with breast cancer, in particular those with other comorbidities and those treated with chemotherapy, with less social support and with more unmet needs, have poorer HRQL. Appropriate social support and meeting the needs of patients may improve patients' HRQL.

Relationship between time elapsed since completion of radiotherapy and quality of life of patients with breast cancer

BACKGROUND

To investigate the relationship between time elapsed since completion of radiotherapy (RT) and quality of life (QOL) of patients with breast cancer.

METHODS

A total of 300 patients with breast cancer were treated at the First Affiliated Hospital of Anhui Medical University between January 2013 and April 2016. Of these, 212 patients were included in the study. Patients were divided into 4 groups based on the time elapsed since completion of RT. The generic cancer questionnaire, EORTC QLQ-30, and the breast cancer-specific questionnaire, QLQ-BR23, were used to assess the QOL.

RESULTS

Analysis of time elapsed since completion of RT and QOL revealed changes in the scores for role function with passage of time; the third year's scores were the highest. Pain symptoms during the 3rd and 4th years after RT were lower than those during the 1st and 2nd years after RT; scores for financial difficulties fluctuated with passage of time; perception of own body scores improved within first 3 years; sexual activity and enjoyment of sexual activity showed a significant decrease during the 2nd to 4th year post RT. Scores pertaining to concerns about future state of health showed a significant increase during the 2nd to 4th year after RT, while breast symptoms score showed fluctuations with passage of time.

CONCLUSIONS

Social function, pain symptoms, and concerns about future state of health tended to improve with passage of time after RT. Other scales showed no correlation with time elapsed since completion of RT.

Oncology Section EDGE Task Force on Cancer: A systematic review of patient-reported measures for sexual dysfunction

BACKGROUND

Sexual dysfunction is an important and infrequently addressed issue in patients with cancer.

PURPOSE

To identify self-report measures for assessing sexual dysfunction and to evaluate their psychometric properties and relevance to patients with cancer.

METHODS

Multiple electronic databases (CINAHL, Medline, PsycInfo) were reviewed using specific search terms to locate articles that identify self-report measures assessing sexual dysfunction. From the 1118 articles reviewed, 21 measures were selected for analysis. Each measure was independently reviewed and rated by two reviewers using the Cancer EDGE Task Force Outcome Measure Rating Form. Any discrepancies between reviewers were discussed and an overall recommendation for each measure was made using the 4-point Cancer EDGE Task Force Rating Scale.

RESULTS

Based on the psychometric properties and relevance to patients with cancers, we highly recommend the following four measures: Sexual Function - Vaginal Changes Questionnaire; International Index of Erectile Function; Erection Hardness Score; Sexual Health Inventory for Men (aka International Index of Erectile Function-5). We recommend one measure, the Sexual Interest and Desire Inventory. We are unable to recommend eight measures based on limited psychometric information and/or clinical utility. Finally, we do not recommend an additional eight measures.

CONCLUSIONS

Five of the 21 sexual dysfunction measures demonstrated satisfactory psychometric properties and application to the cancer population and are thereby recommended for clinical use in patients with cancer.