Hypofractionated Adjuvant Radiation Therapy Is Effective for Patients With Lymph Node-Positive Breast Cancer: A Population-Based Analysis

PURPOSE

This study evaluated long-term, population-based, breast cancer-specific outcomes in patients treated with radiation therapy (RT) to the breast/chest wall plus regional nodes using hypofractionated (HF) (40-42.5 Gy/16 fractions) versus conventionally fractionated (CF) regimens (50-50.4 Gy/25-28 fractions).

METHODS AND MATERIALS

A prospective provincial database was used to identify patients with lymph node-positive breast cancer treated with curative-intent breast/chest wall + regional nodal RT from 1998 to 2010. The effect of RT fractionation on locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) was assessed for the entire cohort and for high-risk subgroups: grade 3, ER-/HER2-, HER2+, and ≥4 positive nodes. Multivariable analysis and 2:1 case-match comparison of HF versus CF were also performed.

RESULTS

A total of 5487 patients met the inclusion criteria (4006 HF and 1481 CF). Median age was 55 years, and median follow-up was 12.7 years. On multivariable analysis, no statistically significant differences were identified in 10-year LRRFS (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.59-1.27; P = .46), DRFS (HR 0.90; 95% CI, 0.76-1.06; P = .19), or BCSS (HR 0.92; 95% CI, 0.76-1.10; P = .36) between the HF and CF cohorts. There was no statistical difference in breast cancer-specific outcomes in the high-risk subgroups. On analysis of 2962 HF cases matched to 1481 CF controls, no statistical difference was observed in LRRFS (HR 0.98; 95% CI, 0.71-1.33; P = .87), DRFS (HR 0.97; 95% CI, 0.85-1.11; P = .68), or BCSS (HR 1.00; 95% CI, 0.87-1.16; P = .92).

CONCLUSIONS

This large, population-based analysis with long-term follow-up after locoregional RT demonstrated that modest HF provides similar breast cancer-specific outcomes compared with CF. HF is an effective option for patients with stage I to III breast cancer receiving nodal RT.

Cardiac death after breast radiotherapy and the QUANTEC cardiac guidelines

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Cardiovascular risk factors predict for cardiac death after breast radiotherapy.

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Cardiovascular risk factors should be modified in breast cancer patients.

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Radiation induced cardiac death at 10-years is low if mean heart dose is <3.3 Gy.

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Radiation induced cardiac death at 10-years is low if maximum LAD dose is <45.4 Gy.

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Studies are needed to evaluate heart and LAD constraints in the CT-planning era.

Background

Breast/chest wall irradiation (RT) increases risk of cardiovascular death. International Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines state for partial heart irradiation a “V25Gy <10% will be associated with a <1% probability of cardiac mortality” in long-term follow-up after RT. We assessed whether women treated with breast/chest wall RT 10-years ago who died of cardiovascular disease (CVD) violated QUANTEC guidelines.

Materials/methods

A population-based database identified all cardiovascular deaths in women with early-stage breast cancer <80 years, treated with adjuvant breast/chest wall RT from 2002 to 2006. Ten-year rate of cardiovascular death was calculated using a Kaplan-Meier method. Patients were matched on a 2:1 basis with controls that did not die of CVD. For left-sided cases, the heart and left anterior descending (LAD) artery were retrospectively delineated. Dose-volume histograms were calculated, and heart V25Gy compared to QUANTEC guidelines.

Results

5249 eligible patients received breast/chest wall RT from 2002 to 2006: 76 (1.4% at 10-years) died of CVD by June 2015. Forty-two patients received left-sided RT (1.7% CVD death at 10-years), 34 right-sided RT (1.3% at 10-years). Heart V25Gy did not exceed 10% in any left-sided cases. No cardiac dosimetry parameter distinguished left-sided cases from controls.

Conclusions

QUANTEC guidelines were not violated in any patient that died of CVD after left-sided RT. The risk of radiation induced cardiac death at 10-years appears to be very low if MHD is <3.3 Gy and maximum LAD dose (EQD2₃ Gy) is <45.4 Gy. Further studies are needed to evaluate heart and LAD constraints in the CT-planning era.

Characterization of the nonmuscle myosin heavy chain IIB promoter: regulation by E2F

To identify DNA sequences important for the transcriptional regulation of the nonmuscle myosin heavy chain IIB (NMMHC-IIB) gene we isolated and sequenced genomic clones that contain the promoter of the gene for both human and mouse. In addition to considerable homology in the first (untranslated) exon (91%) we found 80% sequence identity in the 700 base pairs immediately upstream of the major start of transcription (+1) as well as significant homologies as far as 1500 base pairs upstream. The promoter region was characterized using luciferase reporter constructs transiently transfected into NIH3T3 cells. Consensus binding sites for several known transcription factors are present that are completely conserved between the mouse and human genes, including CRE/ATF, Sp1, CAAT, and the cell-cycle transcription factor E2F. Gel shift assays indicated that E2F can bind to its putative binding site in vitro. To test whether this site is functional we cotransfected NMMHC-IIB promoter constructs driving luciferase with a vector expressing E2F-1. The E2F-1 vector stimulated luciferase activity from an intact promoter whereas mutation of the site eliminates binding and diminishes transactivation. These data provide strong evidence that E2F or an E2F-related transcription factor is involved in the regulation of nonmuscle myosin expression.

Timing of surgery and radiotherapy in the management of metastatic spine disease: expert opinion

Background

Combined surgery and radiotherapy, in the treatment of metastatic disease of the spine, is now emerging as the gold standard of care where there is an indication for spinal stabilization and/or surgical decompression. However potential complications related to wound healing can occur with radiation delivered shortly before or after to surgery. The purpose of this study was to understand the practice of leading radiation oncologists and spine surgeons with regards to the timing of radiation (conventional and stereotactic) and surgery for the management of spinal metastases.

Methods

Questionnaires were sent to leading radiation oncologists and spine surgeons throughout North America and completed via mail, email or internet.

Results

Eighty-six responses were received from radiation oncologists and 27 from spine surgeons. A total of 58% recommended waiting either 1 or 2 weeks after radiotherapy before operating on patients with spinal metastases. With radiotherapy administered after surgery, 62% of respondents suggested either a 1 or 2 weeks interval was sufficient.

Conclusions

There appeared to be no significant difference in practice with the use of stereotactic radiotherapy though surgeons tend to accept a shorter interval in this subset of patients. We recommend that the interval between radiotherapy and surgery (and vice versa) should ideally be a minimum of 2 weeks.

Impact of the Spinal Instability Neoplastic Score on Surgical Referral Patterns and Outcomes

Background

The Spinal Instability Neoplastic Score (sins) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of sins in a population-based cohort of patients undergoing palliative spine radiotherapy (rt) and referral rates to spinal surgery pre-rt. Secondary outcomes included referral to a spine surgeon post-rt, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events.

Methods

We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student's t-test, Chi-squared, Fisher's exact, and Kaplan-Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups.

Results

We included 195 patients with a follow-up of 6.1 months. The median sins was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-rt referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-rt with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups.

Conclusion

Higher sins was associated with pre-rt referral to a spine surgeon, but most patients with high sins were not referred. Higher sins was not associated with shorter survival or worse outcome following rt.

Prospective Evaluation of the Relationship Between Mechanical Stability and Response to Palliative Radiotherapy for Symptomatic Spinal Metastases

BACKGROUND

A substantial number of patients with spinal metastases experience no treatment effect from palliative radiotherapy. Mechanical spinal instability, due to metastatic disease, could be associated with failed pain control following radiotherapy. This study investigates the relationship between the degree of spinal instability, as defined by the Spinal Instability Neoplastic Score (SINS), and response to radiotherapy in patients with symptomatic spinal metastases in a multi-institutional cohort.

METHODS AND MATERIALS

The SINS of 155 patients with painful thoracic, lumbar, or lumbosacral metastases from two tertiary hospitals was calculated using images from radiotherapy planning CT scans. Patient-reported pain response, available for 124 patients, was prospectively assessed. Pain response was categorized, according to international guidelines, as complete, partial, indeterminate, or progression of pain. The association between SINS and pain response was estimated by multivariable logistic regression analysis, correcting for predetermined clinical variables.

RESULTS

Of the 124 patients, 16 patients experienced a complete response and 65 patients experienced a partial response. Spinal Instability Neoplastic Score was associated with a complete pain response (adjusted odds-radio [ORadj] 0.78; 95% confidence interval [CI] 0.62-0.98), but not with an overall pain response (ORadj 0.94; 95% CI 0.81-1.10).

CONCLUSIONS

A lower SINS, indicating spinal stability, is associated with a complete pain response to radiotherapy. This supports the hypothesis that pain resulting from mechanical spinal instability responds less well to radiotherapy compared with pain from local tumor activity. No association could be determined between SINS and an overall pain response, which might indicate that this referral tool is not yet optimal for prediction of treatment outcome.

IMPLICATIONS FOR PRACTICE

Patients with stable painful spinal metastases, as indicated by a Spinal Instability Neoplastic Score (SINS) of 6 or lower, can effectively be treated with palliative external beam radiotherapy. The majority of patients with (impending) spinal instability, as indicated by a SINS score of 7 or higher, will achieve a (partial) response after palliative radiotherapy; however, some patients might require surgical intervention. Therefore, it is recommended to refer patients with a SINS score of 7 or higher to a spine surgeon to evaluate the need for surgical intervention.

Abstract P1-10-06: Hypofractionated nodal radiotherapy (RT) did not increase arm morbidity compared to conventional fractionated nodal RT

Purpose: Regional nodal radiation therapy (RT) can cause adverse arm symptoms and lymphedema. Hypofractionation (HF), defined as &gt;2 Gy/fraction, improves convenience but whether it increases arm morbidity is unclear. This study evaluates patient-reported arm symptoms in women treated with HF compared to conventional fractionation (CF) RT (defined as ≤2Gy/fraction).

Materials / Methods: Provincial cancer registries were used to identify subjects who received 3D, CT-planned nodal RT for pT1-3 pN0-2 M0 breast cancer from 2007-2009 in British Columbia and 2008 – 2010 in Alberta, Canada. Treatment eras were selected to enable sufficient follow-up time to develop late arm symptoms. Following research ethics approval, eligible patients were mailed an explanation letter and an externally validated, Self-reported Arm Symptom Scale (SASS) survey. The SASS included 8 questions about arm symptoms, with responses on a 5-point Likert scale regarding arm/hand problems (numbness, pain, stiffness, immobility and swelling), and 5 questions related to activities of daily living (ADL). Clinicopathologic characteristics and SASS scores were compared between HF vs. CF nodal RT cohorts using non-parametric analysis (on ordinal and scale responses) and binned chi-squared analysis (comparison for responses of 1 vs. &gt; 1).

Results: 800/1759 eligible patients returned a completed survey (45.5%). Upon detailed chart review of responders, 92 cases with recurrence or metastasis were excluded. The remaining 708 cases formed the study cohort. Of these, 406 (57%) patients received HF RT (modal dose/fractionation 40 Gy/15 fractions (fx) and 45 Gy/20 fx), and 302 (43%) received CF RT (45 Gy/25 fx, 48-50 Gy/25 fx, and 50.4 Gy/28 fx). A boost was delivered to the breast in 22% of subjects, equally by fractionation group (p=0.31).

Median time interval since RT completion was 5.67 years. The mean age at diagnosis was 59.0 in HF vs 53.8 years in CF-treated cohorts (p&lt;0.001). The mean # positive (n=3) and excised (n=12) nodes were similar between fractionation cohorts (p=0.44). Primary tumor size was marginally larger in the CF group (2.8 vs. 2.7 cm, p=0.03). 42.9% of patients were treated with partial mastectomy with no significant difference in fractionation (p=0.54). Overall, 602 (75.3%) patients received chemotherapy. A trend toward increased use of CF after chemotherapy was observed (78.8% vs. 72.7%, p=0.07).

The mean sums of responses for the arm symptoms / ADL components of the SASS were 12.5 / 7.6 vs. 13.3 / 7.9 for the HF and CF groups respectively (p=0.17 / 0.85). On analysis of individual questions, the CF group had a higher prevalence of self-reported symptoms, including shoulder stiffness (p=0.04), trouble moving the arm (p=0.02), and ability to reach overhead (p&lt;0.01). There was no difference in self-reported arm swelling between the two groups (p=0.57).

Conclusion: Hypofractionated nodal RT was not associated with an increase in patient-reported arm symptoms or disability compared to conventional fractionated nodal RT. Subjects treated with CF RT reported more disability in certain aspects of arm and shoulder function. These data support the use of shorter fractionation when the regional lymph nodes are part of the therapeutic target.

Citation Format: Leong N, Truong P, Tankel K, Kwan W, Weir L, Olivotto I. Hypofractionated nodal radiotherapy (RT) did not increase arm morbidity compared to conventional fractionated nodal RT [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-06.

Population-based analysis of the impact and generalizability of the NSABP-B24 study on endocrine therapy for patients with ductal carcinoma in situ of the breast

BACKGROUND

In 1999, the National Surgical Adjuvant Breast and Bowel Project (NSABP)-B24 trial demonstrated that tamoxifen reduced relapse risk in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) and radiotherapy (RT). In 2002, Allred's subgroup analysis showed that tamoxifen mainly benefitted estrogen receptor (ER)-positive disease. This study evaluates the impact and generalizability of these trial findings at the population level.

PATIENTS AND METHODS

From 1989 to 2009, 2061 women with DCIS underwent BCS + RT in British Columbia. The following cohorts were analyzed: (1) pre-NSABP-B24 era (1989-1998, N = 417); (2) post-NSABP-B24 era (2000-2009, N = 1548). Cohort 2 was further divided into pre- and post-Allred eras.

RESULTS

Endocrine therapy (ET) was used in 404/2061 (20%) patients. Median age of patients treated with compared with without ET, was 53 versus 57 years, (P < 0.0005). One of 417 (0.2%) versus 399/1548 (26%) patients took ET before versus after NSABP-B24. Among the post-Allred era cohort treated with ET (N = 227), tumors were ER-positive in 65%, ER-negative in 1%, and ER-unknown in 33%; whereas of those treated without ET (N = 801), ER was positive in 43%, negative in 15%, and unknown in 42% (P < 0.0005). On multivariable analysis of the post-NSABP-B24 era, ET was associated with improved event-free survival (EFS) (hazard ratio 0.6; P = 0.02); 5-year EFS were 96.9% with ET versus 94.5% without ET.

CONCLUSIONS

ET use in DCIS patients treated with BCS + RT increased significantly after the NSABP-B24 study. ER+ disease and younger age were associated with increased ET use. ET was associated with improved EFS, confirming the generalizability of trial data at a population level.

Should women younger than 40 years of age with invasive breast cancer have a mastectomy? 15-year outcomes in a population-based cohort

PURPOSE

Optimal local management for young women with early-stage breast cancer remains controversial. This study examined 15-year outcomes among women younger than 40 years treated with breast-conserving surgery plus whole-breast radiation therapy (BCT) compared with those treated with modified radical mastectomy (MRM).

METHODS AND MATERIALS

Women aged 20 to 39 years with early-stage breast cancer diagnosed between 1989 and 2003 were identified in a population-based database. Primary outcomes of breast cancer-specific survival (BCSS), overall survival (OS) and secondary outcomes of local relapse-free survival (LRFS), locoregional relapse-free survival (LRRFS), and distant relapse-free survival (DRFS) were calculated using Kaplan-Meier methods and compared between BCT and MRM cohorts using log-rank tests. A planned subgroup analysis was performed on patients considered "ideal" for BCT (ie, T1N0, negative margins and no extensive ductal carcinoma in situ) and in whom local therapy may have the largest impact on survival because of low systemic risk.

RESULTS

965 patients were identified; 616 had BCT and 349 had MRM. The median follow-up time was 14.4 years (range, 8.4-23.3 years). Overall, 15-year rates of BCSS (76.0% vs 74.1%, P=.62), OS (74.2% vs 73.0%, P=.75), LRFS (85.4% vs 86.5%, P=.95), LRRFS (82.2% vs 81.6%, P=.61), and DRFS (74.4% vs 71.6%, P=.40) were similar between the BCT and MRM cohorts. In the "ideal" for BCT subgroup, there were 219 BCT and 67 MRM patients with a median follow-up time of 15.5 years. The 15-year BCSS (86.1% vs 82.9%, P=.57), OS (82.6% vs 82.9%, P=.89), LRFS (86.2% vs 84.2%, P=.50), LRRFS (83.1% vs 78.3%, P=.24), and DRFS (84.8% vs 79.1%, P=.17) were similar in the BCT and MRM cohorts.

CONCLUSIONS

This population-based analysis with long-term follow-up confirmed that women younger than 40 years treated with BCT had similar 15-year outcomes compared with MRM. Young age alone is not a contraindication to BCT.

Secondary sarcoma of bone post-prostate brachytherapy: A case report

Malignancies associated with brachytherapy for prostate cancer are largely unreported in the literature. We report a case of post-brachytherapy osteogenic sarcoma in the pelvis 6 years after permanent (125)I implant for intermediate-risk prostate cancer. The patient was treated with neoadjuvant chemotherapy, limb-sparing surgical resection and postoperative radiation therapy for unexpected positive margins.

Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases

BACKGROUND

The Spinal Instability Neoplastic Score (SINS) categorizes tumor related spinal instability. It has the potential to streamline the referral of patients with established or potential spinal instability to a spine surgeon. This study aims to define the inter- and intra-observer reliability and validity of SINS among radiation oncologists.

METHODS

Thirty-three radiation oncologists, across ten international sites, rated 30 neoplastic spinal disease cases. For each case, the total SINS (0-18 points), three clinical categories (stable: 0-6 points, potentially unstable: 7-12 points, and unstable: 13-18 points), and a binary scale ('stable': 0-6 points and 'current or possible instability'; surgical consultation recommended: 7-18 points) were recorded. Evaluation was repeated 6-8 weeks later. Inter-observer agreement and intra-observer reproducibility were calculated by means of the kappa statistic and translated into levels of agreement (slight, fair, moderate, substantial, and excellent). Validity was determined by comparing the ratings against a spinal surgeon's consensus standard.

RESULTS

Radiation oncologists demonstrated substantial (κ=0.76) inter-observer and excellent (κ=0.80) intra-observer reliability when using the SINS binary scale ('stable' versus 'current or possible instability'). Validity of the binary scale was also excellent (κ=0.85) compared with the gold standard. None of the unstable cases was rated as stable by the radiation oncologists ensuring all were appropriately recommended for surgical consultation.

CONCLUSIONS

Among radiation oncologists SINS is a highly reliable, reproducible, and valid assessment tool to address a key question in tumor related spinal disease: Is the spine 'stable' or is there 'current or possible instability' that warrants surgical assessment?

Abstract P4-16-01: Accelerated hypofractionated whole breast radiotherapy for localized breast cancer: the effect of a boost on patient reported long-term cosmetic outcome

PURPOSE: Equivalent long-term local control and cosmetic outcomes between conventional and accelerated, hypofractionated whole breast radiotherapy (AWBRT) for early-stage breast cancer have been demonstrated. However, there is uncertainty about the long-term cosmetic outcome of a boost to the tumor bed following AWBRT (AWBRT+B). The primary outcome of this study was to evaluate the cosmetic effect of a boost using a patient reported questionnaire. The cosmetic subscale in the questionnaire was used to compare the appearance of the treated versus non treated breast between the boost and non-boost groups.

MATERIALS AND METHODS: Between 2000 and 2005, 4392 women 75 years and under with unilateral early-stage breast cancer received AWBRT alone or AWBRT+B. Random samples of 800 women treated with AWBRT alone and 800 women treated with AWBRT+B were identified from the 3960 women still alive at least 5 years after treatment without contralateral disease. The women were contacted by mail to complete a questionnaire based on the Breast Cancer Treatment Outcomes Scale (22 questions regarding cosmetic, pain and functional outcomes). Cochrane-Armitage (CA) trend test and Wilcoxon Rank-sum (WR) were used to compare baseline patient and treatment variables to long-term cosmetic outcomes between the two treatment groups.

RESULTS: 312 women (154 received AWBRT alone and 158 received AWBRT+B) completed the questionnaire. The median (range) age of respondents was 57 (40–75) years in the AWBRT alone group and 52 (32–75) years in the AWBRT+B group (p &lt; 0.001). The median (range) follow-up time after radiotherapy treatment was 8.7 (5.5–11.5) years in the AWBRT alone group and 7.8 (5.5–11.5) years in the AWBRT+B group (p &lt; 0.001). Boost doses ranged between 7.5 Gy in 3 fractions to 16 Gy in 8 fractions. The most commonly used boost regimen was 10 Gy in 4 fractions (70% of respondents). Women treated with AWBRT+B also had higher T stage, higher grade, were more likely to have had chemotherapy and trended towards having an increased number of positive nodes compared to the AWBRT alone group. Current weight, ER status, and use of hormonal therapy were similar between both groups.

When comparing the overall appearance of the treated to untreated breast, there was no significant difference between the women who received AWBRT alone and those who received AWBRT+B (42% stating no or slight difference vs. 41%) (p = 0.87 CA). Focusing on the cosmetic subscale in the questionnaire, the average summed score for the AWBRT alone group was slightly worse to the score for the AWBRT+B group (2.3 vs. 2.1, p = 0.02 WR). On the functional subscale, the average summed score for the AWBRT alone group was worse than the AWBRT+B group (1.8 versus 1.5, p &lt; 0.001 WR). On the pain subscale, the average summed score for the AWBRT alone group was better than the AWBRT+B group (1.6 versus 2.0, p &lt; 0.0001 WR). However, when the pain subscale was only applied to the area around the scar, the two groups were similar (2.0 for AWBRT alone and 2.0 for AWBRT+B, p = 0.71).

CONCLUSION: Similar to conventionally fractionated WBRT, patients who receive a boost after AWBRT self-report long-term slightly worse cosmetic and pain outcomes compared AWBRT alone.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-01.

Does the intent to irradiate the internal mammary nodes impact survival in women with breast cancer? A population-based analysis in British Columbia

PURPOSE

To determine the value of the intent to include internal mammary nodes (IMNs) in the radiation therapy (RT) volume for patients receiving adjuvant locoregional (breast or chest wall plus axillary and supraclavicular fossa) RT for breast cancer.

METHODS AND MATERIALS

2413 women with node-positive or T3/4N0 invasive breast cancer, treated with locoregional RT from 2001 to 2006, were identified in a prospectively maintained, population-based database. Intent to include IMNs in RT volume was determined through review of patient charts and RT plans. Distant relapse free survival (D-RFS), breast cancer-specific survival (BCSS), and overall survival (OS) were compared between the two groups. Prespecified pN1 subgroup analyses were performed.

RESULTS

The median follow-up time was 6.2 years. Forty-one percent of study participants received IMN RT. The 5-year D-RFS for IMN inclusion and exclusion groups were 82% vs. 82% (p = 0.82), BCSS was 87% vs. 87% (p = 0.81), and OS was 85% vs. 83% (p = 0.06). In the pN1 subgroup, D-RFS was 90% vs. 88% (p = 0.31), BCSS was 94% vs. 92% (p = 0.18), and OS was 91% vs. 88% (p = 0.01). After potential confounding variables were controlled for, women who received IMN RT did not have significantly different D-RFS (hazard ratio [HR] = 1.02 (95% confidence interval [CI], 0.84-1.24; p = 0.85), BCSS (HR = 0.98 (95% CI, 0.79-1.22; p = 0.88), or OS (HR = 0.95; 95% CI, 0.78-1.15; p = 0.57). In the pN1 subgroup, IMN RT was associated with trends for improved survival that were not statistically significant: D-RFS (HR = 0.87; 95% CI, 0.63-1.22; p = 0.42), BCSS (HR = 0.85; 95% CI, 0.57-1.25; p = 0.39), and OS (HR = 0.78; 95% CI, 0.56-1.09; p = 0.14).

CONCLUSIONS

After a median follow-up time of 6.2 years, although intentional IMN RT was not associated with a significant improvement in survival, this population-based study suggests that IMN RT may contribute to improved outcomes in selected patients with N1 disease.

Promoting consultation recording practice in oncology: Identification of critical implementation factors and determination of patient benefit

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Background: The objectives of this implementation study were to 1) identify and address the evidentiary, contextual, and facilitative mechanisms that serve to retard or promote the transfer and uptake of consultation recording use in oncology practice, and 2) follow patients during the first few days following receipt of the consultation recording to document, from the patient’s perspective, the benefits realized from listening to the recording.

Methods: Nine medical and 9 radiation oncologists from cancer centers in three Canadian cities (Calgary, Vancouver, Winnipeg) recorded their primary treatment consultations for 228 patients newly diagnosed with prostate or breast cancer. The Digital Recording Use Semi-Structured Interview (DRUSSI) was conducted at two days post-consultation and at 1-week post-consultation. Each oncologist was given a feedback letter summarizing the consultation recording benefits reported by their patients.

Results: Sixty-nine percent of patients listened to at least a portion of the recording within the first week following the consultation. Consultation recording favourableness ratings were high: 93.6% rated the intervention between 75–100 on a 100-point scale. Four main areas of benefit were reported: 1) Anxiety reduction; 2) Enhanced retention of information; 3) Better informed decision making; and 4) Improved communication with family members. Eight fundamental components of successful transfer and uptake of consultation recording practice were identified.

Conclusions: Implementation research and additional randomized trials are needed to facilitate the transfer and uptake of consultation recording use so that far more patients and significant others may realize the associated benefits.

Age over 80 years is not associated with increased hemorrhagic transformation after stroke thrombolysis

Thrombolysis trials have recruited few patients aged ≥80 years, which has led to uncertainty about the likely risk-to-benefit profile in the elderly. Leukoaraiosis (LA) has been associated with hemorrhagic transformation (HT) and increases with advanced age. We tested whether there were any independent associations between age, LA and HT. Consecutive patients treated with intravenous (IV) tissue plasminogen activator (tPA) were identified from a prospective database. LA on baseline CT scans was assessed by two independent raters using the modified Van Swieten Score (mVSS) (maximum score 8, severe >4). HT was assessed on routine 24 hour to 48 hour CT /MRI scans using the European Cooperative Acute Stroke Study criteria for hemorrhagic infarct (HI) or parenchymal hematoma (PH) and judged symptomatic by the treating neurologist as per Safe Implementation of Thrombolysis in Stroke criteria. There were 206 patients treated with IV tPA (mean age: 71.0 years; range: 24-92 years), of whom 65/206 (32%) were aged ≥80 years. Overall, HT occurred in 41/206 patients (20%), HI in 31, PH1 in four (one symptomatic) and PH2 in six (three symptomatic). Age was not associated with HT (any HT: odds ratio [OR]=1.01; 95% confidence interval [CI]=0.5-2.08; p=0.99; PH: OR=0.53; 95% CI=0.12-2.3; p=0.51). There was one patient with PH1 and one patient with PH2 in 65 patients ≥80 years, both asymptomatic. LA was present in 112/208 (54%), and severe in 16.5%. LA increased with age (p<0.001) but was not associated with PH (any LA: OR=0.83; 95% CI=0.25-2.8; p=0.99; severe LA: OR=0.54, 95% CI=0.09-3.5; p=0.99). Age ≥80 years or LA did not increase the risk of HT (including PH) after thrombolysis, although LA increased with age. Neither factor should exclude otherwise eligible patients from tPA treatment.

Impact of internal mammary node inclusion in the radiation treatment volume on the outcomes of patients with breast cancer treated with locoregional radiation after six years of follow-up

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Background: There is ongoing controversy about radiotherapy (RT) to internal mammary nodes (IMNs). Proponents of IMN RT cite the survival benefit seen in postmastectomy RT trials that included IMNs. However, others point out that benefit cannot be definitively attributed to IMN inclusion, as other lymph node regions were included in the RT arms. The issue is important, as IMN RT potentially increases cardiac and respiratory morbidity.

Methods: 2,413 women referred to a provincial RT program with newly diagnosed node positive, or T3/4N0 non-M1 invasive breast cancer, treated with a complete course of locoregional RT from 2001 to 2006, were retrospectively identified in a provincial database. IMN RT inclusion versus exclusion was determined through review of patient charts and RT treatment plans. Breast cancer-specific survival (BCSS), relapse-free survival (RFS), and overall survival (OS) were compared between the two groups using univariate and multivariable analyses.

Results: Analyses were performed at a median follow-up of 6.2 years. 41.4% of the subjects received IMN RT. The 5-year BCSS for the IMN inclusion and exclusion group was 84.8% versus 82.9%, respectively (HR 0.93 [95% CI 0.76, 1.14]; p=.51); the 5-year RFS was 87.4% versus 86.9% (HR 0.993 [0.83, 1.19]; p=0.94); and the 5-year OS was 84.8% versus 82.9% (HR 0.84 [0.70, 1.01]; p=0.06). After controlling for potentially confounding variables, there was no significant difference in BCSS (HR 0.96 [0.78, 1.18], p=0.88), RFS (HR 1.02 [0.84, 1.22], p=0.87), or OS (HR 0.91 [0.76, 1.10]; p=0.35).

Conclusions: After a median follow-up of 6.2 years, this population-based study shows no benefit from including IMNs in the locoregional RT volume after adjusting for other prognostic and treatment variables.

Abstract P4-11-03: The Impact of Fractionation on Local Relapse for Patients with Grade 3 Breast Cancer

Background: Several randomized trials have demonstrated that hypofractionated (HF) and conventionally fractionated (CF) radiotherapy (RT) provide equivalent local control following breast conserving surgery (BCS). However, an update of the Canadian trial suggested that patients with grade 3 disease had an increased risk of local relapse after HF. The risk of local relapse following HF or CF according to grade was investigated among a population-based cohort from British Columbia, Canada. Materials and methods: Female patients diagnosed between 1990 and 2000 with T1-T2N0M0 breast cancer treated with lumpectomy, axillary dissection and RT with at least 6 nodes removed and RT delivered to the breast were identified. Whole breast RT prescriptions were distributed in two groups : HF (typically 42.5 to 44 Gy in 16 fractions), and CF (45Gy to 50 Gy in 25 fractions). The 45 Gy prescription was followed by a boost to the biopsy cavity regardless of the margin status. Patients with close or positive margins received a boost (typically 7.5 to 10Gy in 3 to 4 fractions, or 10 to 20Gy in 5 to 10 fractions). Baseline demographic (age, year of diagnosis), tumour (grade, histology, size, lymphatic vascular space invasion (LVI), presence of extensive DCIS) and treatment factors (margin status, hormonal or chemotherapy use, RT fractionation group, and RT boost use) were abstracted. Cumulative rates of local relapse were estimated using a competing risk approach (distant relapses or death were competing risks) and compared across groups using Gray's test. Factors significant on univariate analysis were included with fractionation group in a multivariate (Fine and Gray) model among grade 3 patients. Results: The cohort consisted of 1,335 patients diagnosed with grade 3 breast cancers: 252 received CF and 1083 patients received HF. The fractionation groups were well balanced for most of the aforementioned factors except median age (56 years for CF vs 52 years for HF (P&lt;0.01), and use of systemic therapy (hormones alone: 26% vs 19%; chemotherapy alone: 27%vs 33%; and chemo+hormone therapy: 8% vs 10% (p=0.04) for HF compared to CF). The 10-year cumulative incidence rate of local relapse in patients with grade 3 breast cancers was 6.9% for the HF group and 6.2 % for the CF group (p=0.99). A Fine and Gray multivariate competing risk model showed that age under 40 years (p=0.02), positive margins (p=0.05) and negative ER status (p=0.01) were associated with an increased risk of local relapse, but fractionation group was not (Hazard ratio=0.95, p=0.88).

Conclusions: There was no evidence that hypofractionation was inferior to conventional fractionation for breast conserving therapy in patients with T1-T2 N0, grade 3 breast cancer in a population-based series.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-03.

Predictors of distress and quality of life in patients undergoing cancer therapy: impact of treatment type and decisional role

PURPOSE

The purpose of this secondary investigation was to examine the impact of the type of treatment received and the perceived role in treatment decision making in predicting distress and cancer-specific quality of life in patients newly diagnosed with breast or prostate cancer.

METHOD

Participants included 1057 newly diagnosed breast and prostate cancer patients from four Canadian cancer centers who partook in a randomized controlled trial examining the utility of providing patients with an audio-recording of their treatment planning consultation. A MANCOVA was performed to predict distress and cancer-specific quality of life at 12 weeks post-consultation based on control variables (patient age, education, residence, tumor size (breast sample), gleason score (prostate sample), and receipt of an initial treatment consultation recording), predictor variables (treatment type--chemotherapy, hormone therapy, radiation therapy; decisional role--active, collaborative, passive), and interactions between these predictors.

RESULTS

Women who received chemotherapy and reported having played a more passive role in treatment decision making had significantly greater distress and lower cancer-specific quality of life at 12-week post-consultation. There were no statistically significant predictors of these outcomes identified for men with prostate cancer.

CONCLUSION

Receipt of chemotherapy places women with breast cancer at risk for distress and reduced quality of life, but only for the subset of women who report playing a passive role in treatment decision making. Prospective, longitudinal studies are needed to confirm the present findings and to explicate the antecedents, composition, and consequences of the 'passive' decisional role during the treatment phase of the cancer trajectory.

Behind closed doors: systematic analysis of breast cancer consultation communication and predictors of satisfaction with communication

OBJECTIVE

The purpose of this investigation was to explicate the content of primary adjuvant treatment consultations in breast oncology and examine the predictive relationships between patient and oncologist consultation factors and patient satisfaction with communication.

METHODS

The recorded consultations of 172 newly diagnosed breast cancer patients from four Canadian cancer centers were randomly drawn from a larger subset of 481 recordings and examined by three coders using the Medical Interaction Process System (MIPS); a system that categorizes the content and mode of each distinct utterance. The MIPS findings, independent observer ratings of patient and oncologist affective behavior, and derived consultation ratios of patient centeredness, patient directedness, and psychosocial focus, were used to predict patient satisfaction with communication post-consultation and at 12-weeks post-consultation.

RESULTS

Biomedical content categories were predominant in the consultations, accounting for 88% of all utterances, followed by administrative (6%) and psychosocial (6%) utterances. Post-consultation satisfaction with communication was significantly higher for older patients, those with smaller primary tumors and those with longer consultations. Smaller tumor, lack of patient assertiveness during the treatment consultation and having the consultation with a radiation rather than medical oncologist were significantly predictive of greater satisfaction at 12-weeks post-consultation.

CONCLUSIONS

Adjuvant treatment consultations are characterized by a high degree of information-giving by the physician, a predominance of biomedical discussion and relatively minimal time addressing patients' psychosocial concerns. Controlled trials are needed to further identify and address the contextual features of these consultations that enhance patient satisfaction.

Professionalization as a governance strategy for synthetic biology

This article considers professionalization as a governance strategy for synthetic biology, reporting on social science interviews done with scientists, science journal editors, members of science advisory boards and authors of nongovernmental policy reports on synthetic biology. After summarizing their observations about the potential advantages and disadvantages of the professionalization of synthetic biology, we analyze professionalization as a strategy that overcomes dichotomies found in the current debates about synthetic biology governance, specifically "top down" versus "bottom up" governance and scientific fact versus public values. Professionalization combines community and state, fact and value. Like all governance options, professionalization has limitations, particularly regarding war and peace. It is best conceptualized as potentially part of a wider range of governance mechanisms working in concert: a "web of prevention".

The Concept of Truth Regime

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Psychosocial barriers to active surveillance for the management of early prostate cancer and a strategy for increased acceptance

OBJECTIVES

To review the psychosocial needs of men undergoing active surveillance (AS, the monitoring of early prostate cancer, with curative intervention only if the disease significantly progresses) for prostate cancer, and barriers to its uptake.

METHODS

The introduction of screening for prostate-specific antigen (PSA) has led to more men diagnosed with early and nonlife-threatening forms of prostate cancer; about half of men diagnosed as a result of PSA testing have cancers that would never cause symptoms if left untreated and yet up to 90% of such men receive curative therapy, then living with the toxicity of treatment but with no benefit. Thus AS is increasingly being promoted, but if such a strategy is to succeed, the psychosocial barriers that discourage men from adopting AS must be addressed. We reviewed and assessed reports on this topic, published in English since 1994.

RESULTS

There is relatively little research on AS, as most published reports refer to watchful waiting (which is a palliative management approach). Men with prostate cancer generally have lower levels of psychological disturbance than for other cancers, but the psychosocial issues identified include anxiety in response to no intervention, uncertainty related to loss of control, and lack of patient education and support, particularly around the time of initial treatment planning. Approaches that were identified to improve uptake of AS include increased education and improved communication, interventions to reduce anxiety and uncertainty, and the empowerment of patients by the development of a sense of control and meaning. Physicians attitudes are influential and the education of physicians about AS as an appropriate option is to be encouraged. Peer-support groups were also identified as being of particular value.

CONCLUSIONS

There are several strategies that should be developed if AS is to become more widely adopted. Increased education and good communication can alleviate anxiety and uncertainty, as can interventions for cognitive re-framing. Inviting patients to become active participants in their management might enhance the patients' sense of control, and the involvement of peer-support groups might be beneficial.

Standardized audiotape versus recorded consultation to enhance informed consent to a clinical trial in breast oncology

BACKGROUND

The purpose of this study was to systematically compare two audiotape formats for the delivery of information relevant to informed consent to participate in a clinical trial in breast oncology, and to establish the feasibility of adding a consultation recording protocol to a clinical treatment trial.

METHOD

Participants were 69 women with newly diagnosed breast cancer and 21 oncologists from 5 Canadian cancer centers. Patients were block randomized to one of three groups: 1. standardized audiotape; 2. consultation audiotape; or 3. both audiotapes. Patients received their tapes immediately following the clinical trial consultation. Patient outcomes included perception of being informed about clinical trials, knowledge of information relevant to providing informed consent to a clinical trial, and satisfaction with communication during the consultation.

RESULTS

The consultation audiotapes contained less trial-related information than the standardized audiotape but there were no differences in clinical trial knowledge or perception of being informed across the intervention groups. Patients expressed a marginally significant preference for consultation audiotapes over standardized audiotapes.

CONCLUSIONS

Patients tended to prefer receiving an audiotape of their own consultation over a standardized audiotape. The majority of oncologists considered the audiotape intervention feasible but were less enthusiastic about being involved in a larger study given the accrual challenges that arose when trying to "piggy-back" one randomized controlled trial on an existing clinical trial.

Consistency in seroma contouring for partial breast radiotherapy: Impact of guidelines

PURPOSE

Inconsistencies in contouring target structures can undermine the precision of conformal radiation therapy (RT) planning and compromise the validity of clinical trial results. This study evaluated the impact of guidelines on consistency in target volume contouring for partial breast RT planning.

METHODS AND MATERIALS

Guidelines for target volume definition for partial breast radiation therapy (PBRT) planning were developed by members of the steering committee for a pilot trial of PBRT using conformal external beam planning. In phase 1, delineation of the breast seroma in 5 early-stage breast cancer patients was independently performed by a "trained" cohort of four radiation oncologists who were provided with these guidelines and an "untrained" cohort of four radiation oncologists who contoured without guidelines. Using automated planning software, the seroma target volume (STV) was expanded into a clinical target volume (CTV) and planning target volume (PTV) for each oncologist. Means and standard deviations were calculated, and two-tailed t tests were used to assess differences between the "trained" and "untrained" cohorts. In phase 2, all eight radiation oncologists were provided with the same contouring guidelines, and were asked to delineate the seroma in five new cases. Data were again analyzed to evaluate consistency between the two cohorts.

RESULTS

The "untrained" cohort contoured larger seroma volumes and had larger CTVs and PTVs compared with the "trained" cohort in three of five cases. When seroma contouring was performed after review of contouring guidelines, the differences in the STVs, CTVs, and PTVs were no longer statistically significant.

CONCLUSION

Guidelines can improve consistency among radiation oncologists performing target volume delineation for PBRT planning.

Adjuvant axillary radiotherapy for breast cancer: Is CT planning with nodal contouring better than traditional planning?

606

Background: Historically, adjuvant radiotherapy planning for breast cancer has been based on clinical mark-up then subsequently bony landmarks. The objective of this study is to investigate whether individualized CT-based nodal contour guided planning of axillary fields in breast cancer improves nodal coverage and minimizes dose to normal tissues. There have been no previous studies addressing this issue. Methods: Thirty 4-field radiotherapy plans were selected as ‘traditional’ plans: 15 without nodal contours (traditional field placement) and 15 with radiation oncologists’ nodal contours. The following structures were contoured on each patient CT, regardless of previously contoured structures: level I, level II/III, supraclavicular(SCV)/infraclavicular(ICV) lymph nodes, ipsilateral brachial plexus and lung. Dose volume histograms (DVHs) of the listed contoured structures were obtained for the 30 original plans. All 30 patients were then re-planned with the same anterior dose prescription as the original plan (4000cGy/16 fractions (#) or 4500cGy/25#) but adjusted depth of midplane dose prescription based on nodal depth; MLC blocking was adjusted to the ‘study’ nodal contours. DVHs of the contoured structures for the new nodal-based plans were compared with the DVHs of the original plans, using two-tailed paired t-tests. Results: Volume receiving 90% dose (V90) was significantly improved for SCV nodes: original plan 84.67% vs nodal plan 95.76%(p=0.0005). V90 were similar for level I and level II/III nodes, but hot spots in these nodal groups were significantly hotter in the original vs nodal plan: mean hot spot for level I 120.8% vs 116.3%(p=0.0008), mean hot spot for level II/III 118.1% vs 113.2% (p=0.000003). Dose to 90% of the brachial plexus (D90) was significantly higher in the original vs nodal plan: 79.92% vs 40.92%(p=0.0028). V20 lung were not significantly different. Mean total body dose was significantly higher in the original vs nodal plan 831.8cGy vs 677.7cGy (p=0.0015). Conclusions: CT-based nodal contour guided planning significantly improves coverage of the nodes, particularly supraclavicular nodes, while markedly reducing the dose to critical normal structures, such as brachial plexus.

No significant financial relationships to disclose.

The Global Public Health Intelligence Network and early warning outbreak detection: a Canadian contribution to global public health

The recent SARS epidemic has renewed widespread concerns about the global transmission of infectious diseases. In this commentary, we explore novel approaches to global infectious disease surveillance through a focus on an important Canadian contribution to the area--the Global Public Health Intelligence Network (GPHIN). GPHIN is a cutting-edge initiative that draws on the capacity of the Internet and newly available 24/7 global news coverage of health events to create a unique form of early warning outbreak detection. This commentary outlines the operation and development of GPHIN and compares it to ProMED-mail, another Internet-based approach to global health surveillance. We argue that GPHIN has created an important shift in the relationship of public health and news information. By exiting the pyramid of official reporting, GPHIN has created a new monitoring technique that has disrupted national boundaries of outbreak notification, while creating new possibilities for global outbreak response. By incorporating news within the emerging apparatus of global infectious disease surveillance, GPHIN has effectively responded to the global media's challenge to official country reporting of outbreak and enhanced the effectiveness and credibility of international public health.

The Value of FDG Positron Emission Tomography in the Management of Patients with Breast Cancer

Increasing experience with positron emission tomography (PET) scanning in breast cancer patients is revealing a significant role for this imaging modality. This report summarizes the experience of 2-[F18]fluoro-2-deoxy-D-glucose (FDG) PET scanning in 165 breast cancer patients from the BC Cancer Agency, British Columbia, Canada, and reviews the literature on this topic. Using the database at PETSCAN Vancouver, we identified imaged patients with a diagnosis of breast cancer. We then conducted a retrospective review of these patients' BC Cancer Agency charts to extract demographic and follow-up information. Between November 2000 and March 2003 we identified 165 patients with histologically confirmed breast cancer who had undergone PET scanning, were registered at the BC Cancer Agency, and had follow-up information. The median patient age was 52 years. The sensitivity of PET in detecting axillary metastases was 28%, and the specificity was 86%. At diagnosis, 5% of patients were diagnosed with distant metastases. In patients undergoing PET scanning because of suspected recurrence, the sensitivity and specificity for detecting recurrence were 89% and 88%, respectively. Distant metastases were demonstrated in 30% of patients who were thought only to have local-regional recurrence. The results suggest that there are two clinical situations in which PET appears to be particularly valuable. The first is in the evaluation of patients who are suspected of having a tumor recurrence. The other is in identifying patients with multifocal or distant sites of malignancy who otherwise appear to have an isolated, potentially curable, local-regional recurrence.

Evolving Treatment Strategies for Inflammatory Breast Cancer: A Population-Based Survival Analysis

Purpose

To determine if mastectomy (Mx) use, chemotherapy (CT) intensity, or treatment sequence of CT, radiation therapy (RT), and Mx have improved outcome for inflammatory breast cancer (IBC).

Patients and Methods

A retrospective analysis of 485 patients with IBC diagnosed in British Columbia between 1980 and 2000 analyzed locoregional relapse-free survival (LRFS) and breast cancer–specific survival (BCSS) by treatment intent and treatment received. Curative intent was defined as delivery of more than four cycles of anthracycline-based CT plus locoregional RT in patients without distant metastases.

Results

Median follow-up among survivors was 6.5 years. Median BCSS was 1.0 and 3.2 years for patients with distant metastases at diagnosis or those who were curatively treated, respectively. Among patients treated curatively (n = 308), there were no significant differences in LRFS or BCSS with timing of Mx before or after CT/RT, time between diagnosis and RT, or the sequence of RT and CT. Patients receiving more intensive CT had improved 10-year BCSS compared with standard CT (43.7% v 26.3%; P = .04). Ten-year LRFS for patients having Mx after CT, Mx before CT, and without Mx was 62.8%, 58.6%, and 34.4%, respectively (P = .0001); the corresponding 10-year BCSS was 36.9%, 19.9%, and 22.5%, respectively (P = .005). On multivariate analysis, Mx was associated with improved LRFS (P = .04). Independent prognostic factors for BCSS were menopausal status (P = .02), estrogen receptor status (P = .02), and CT type (P = .05).

Conclusion

This retrospective analysis suggested that mastectomy, in conjunction with CT and RT, seemed to enhance locoregional control, whereas modern CT regimens seemed to improve BCSS.

Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial

BACKGROUND

The British Columbia randomized radiation trial was designed to determine the survival impact of locoregional radiation therapy in premenopausal patients with lymph node-positive breast cancer treated by modified radical mastectomy and adjuvant chemotherapy. Three hundred eighteen patients were assigned to receive no further therapy or radiation therapy (37.5 Gy in 16 fractions). Previous analysis at the 15-year follow-up showed that radiation therapy was associated with a statistically significant improvement in breast cancer survival but that improvement in overall survival was of only borderline statistical significance. We report the analysis of data from the 20-year follow-up.

METHODS

Survival was analyzed by the Kaplan-Meier method. Relative risk estimates were calculated by the Wald test from the proportional hazards regression model. All statistical tests were two-sided.

RESULTS

At the 20 year follow up (median follow up for live patients: 249 months) chemotherapy and radiation therapy, compared with chemotherapy alone, were associated with a statistically significant improvement in all end points analyzed, including survival free of isolated locoregional recurrences (74% versus 90%, respectively; relative risk [RR] = 0.36, 95% confidence interval [CI] = 0.18 to 0.71; P = .002), systemic relapse-free survival (31% versus 48%; RR = 0.66, 95% CI = 0.49 to 0.88; P = .004), breast cancer-free survival (48% versus 30%; RR = 0.63, 95% CI = 0.47 to 0.83; P = .001), event-free survival (35% versus 25%; RR = 0.70, 95% CI = 0.54 to 0.92; P = .009), breast cancer-specific survival (53% versus 38%; RR = 0.67, 95% CI = 0.49 to 0.90; P = .008), and, in contrast to the 15-year follow-up results, overall survival (47% versus 37%; RR = 0.73, 95% CI = 0.55 to 0.98; P = .03). Long-term toxicities, including cardiac deaths (1.8% versus 0.6%), were minimal for both arms.

CONCLUSION

For patients with high-risk breast cancer treated with modified radical mastectomy, treatment with radiation therapy (schedule of 16 fractions) and adjuvant chemotherapy leads to better survival outcomes than chemotherapy alone, and it is well tolerated, with acceptable long-term toxicity.

The problem of evidence-based medicine: directions for social science

Evidence-based medicine (EBM) is arguably the most important contemporary initiative committed to reshaping biomedical reason and practice. The move to establish scientific research as a fundamental ground of medical decision making has met with an enthusiastic reception within academic medicine, but has also generated considerable controversy. EBM and the broader forms of evidence-based decision making it has occasioned raise provocative questions about the relation of scientific knowledge to social action across a variety of domains. Social science inquiry about EBM has not yet reached the scale one might expect, given the breadth and significance of the phenomenon. This paper contributes reflections, critique and analysis aimed at helping to build a more robust social science investigation of EBM. The paper begins with a "diagnostics" of the existing social science literature on EBM, emphasizing the possibilities and limitations of its two central organizing analytic perspectives: political economy and humanism. We further explore emerging trends in the literature including a turn to original empirical investigation and the embrace of "newer" theoretical resources such as postmodern critique. We argue for the need to move the social inquiry of EBM beyond concerns about rationalization and the potential erasure of the patient and, to this end, suggest new avenues of exploration. The latter include analysis of clinical epidemiology and clinical reason as the discursive preconditions of EBM, the role of the patient as a site for the production of evidence, and the textually mediated character of EBM.