Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial

BACKGROUND

For women with oestrogen receptor (ER)-positive early breast cancer, treatment with tamoxifen for 5 years substantially reduces the breast cancer mortality rate throughout the first 15 years after diagnosis. We aimed to assess the further effects of continuing tamoxifen to 10 years instead of stopping at 5 years.

METHODS

In the worldwide Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) trial, 12,894 women with early breast cancer who had completed 5 years of treatment with tamoxifen were randomly allocated to continue tamoxifen to 10 years or stop at 5 years (open control). Allocation (1:1) was by central computer, using minimisation. After entry (between 1996 and 2005), yearly follow-up forms recorded any recurrence, second cancer, hospital admission, or death. We report effects on breast cancer outcomes among the 6846 women with ER-positive disease, and side-effects among all women (with positive, negative, or unknown ER status). Long-term follow-up still continues. This study is registered, number ISRCTN19652633.

FINDINGS

Among women with ER-positive disease, allocation to continue tamoxifen reduced the risk of breast cancer recurrence (617 recurrences in 3428 women allocated to continue vs 711 in 3418 controls, p=0·002), reduced breast cancer mortality (331 deaths vs 397 deaths, p=0·01), and reduced overall mortality (639 deaths vs 722 deaths, p=0·01). The reductions in adverse breast cancer outcomes appeared to be less extreme before than after year 10 (recurrence rate ratio [RR] 0·90 [95% CI 0·79–1·02] during years 5–9 and 0·75 [0·62–0·90] in later years; breast cancer mortality RR 0·97 [0·79–1·18] during years 5–9 and 0·71 [0·58–0·88] in later years). The cumulative risk of recurrence during years 5–14 was 21·4% for women allocated to continue versus 25·1% for controls; breast cancer mortality during years 5–14 was 12·2% for women allocated to continue versus 15·0% for controls (absolute mortality reduction 2·8%). Treatment allocation seemed to have no effect on breast cancer outcome among 1248 women with ER-negative disease, and an intermediate effect among 4800 women with unknown ER status. Among all 12,894 women, mortality without recurrence from causes other than breast cancer was little affected (691 deaths without recurrence in 6454 women allocated to continue versus 679 deaths in 6440 controls; RR 0·99 [0·89–1·10]; p=0·84). For the incidence (hospitalisation or death) rates of specific diseases, RRs were as follows: pulmonary embolus 1·87 (95% CI 1·13–3·07, p=0·01 [including 0·2% mortality in both treatment groups]), stroke 1·06 (0·83–1·36), ischaemic heart disease 0·76 (0·60–0·95, p=0·02), and endometrial cancer 1·74 (1·30–2·34, p=0·0002). The cumulative risk of endometrial cancer during years 5–14 was 3·1% (mortality 0·4%) for women allocated to continue versus 1·6% (mortality 0·2%) for controls (absolute mortality increase 0·2%).

INTERPRETATION

For women with ER-positive disease, continuing tamoxifen to 10 years rather than stopping at 5 years produces a further reduction in recurrence and mortality, particularly after year 10. These results, taken together with results from previous trials of 5 years of tamoxifen treatment versus none, suggest that 10 years of tamoxifen treatment can approximately halve breast cancer mortality during the second decade after diagnosis.

FUNDING

Cancer Research UK, UK Medical Research Council, AstraZeneca UK, US Army, EU-Biomed.

Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial

BACKGROUND

Oral cancer is common in men from developing countries, and is increased by tobacco and alcohol use. We aimed to assess the effect of visual screening on oral cancer mortality in a cluster-randomised controlled trial in India.

METHODS

Of the 13 clusters chosen for the study, seven were randomised to three rounds of oral visual inspection by trained health workers at 3-year intervals and six to a control group during 1996-2004, in Trivandrum district, Kerala, India. Healthy participants aged 35 years and older were eligible for the study. Screen-positive people were referred for clinical examination by doctors, biopsy, and treatment. Outcome measures were survival, case fatality, and oral cancer mortality. Oral cancer mortality in the study groups was analysed and compared by use of cluster analysis. Analysis was by intention to treat.

FINDINGS

Of the 96,517 eligible participants in the intervention group, 87,655 (91%) were screened at least once, 53,312 (55%) twice, and 29,102 (30%) three times. Of the 5145 individuals who screened positive, 3218 (63%) complied with referral. 95,356 eligible participants in the control group received standard care. 205 oral cancer cases and 77 oral cancer deaths were recorded in the intervention group compared with 158 cases and 87 deaths in the control group (mortality rate ratio 0.79 [95% CI 0.51-1.22]). 70 oral cancer deaths took place in users of tobacco or alcohol, or both, in the intervention group, compared with 85 in controls (0.66 [0.45-0.95]). The mortality rate ratio was 0.57 (0.35-0.93) in male tobacco or alcohol users and 0.78 (0.43-1.42) in female users.

INTERPRETATION

: Oral visual screening can reduce mortality in high-risk individuals and has the potential of preventing at least 37,000 oral cancer deaths worldwide.

The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas

OBJECTIVES

We assessed the long-term efficacy and toxicity of conservative surgery and radiotherapy in the control of pituitary adenomas.

DESIGN

Retrospective study of patients treated at the Royal Marsden Hospital.

PATIENTS

Four hundred and eleven patients with pituitary adenomas treated with conventional external beam radiotherapy at the Royal Marsden Hospital between 1962 and 1986. Two hundred and fifty-two patients had clinically non-functioning pituitary adenomas, 131 had hormone secreting tumours and in 28 patients the secretory status was not known. Three hundred and thirty-eight patients had surgical intervention of whom only 11 had complete tumour excision. All patients received conventional fractionated external beam radiotherapy to a dose of 45-50Gy in 25-30 fractions.

MEASUREMENTS

Actuarial progression free survival and overall survival and assessment of toxicity, particularly in terms of vision, requirement for hormone replacement therapy and incidence of second tumours.

RESULTS

The actuarial progression free survival was 94% at 10 years and 88% at 20 years for all patients and 97% at 10 years and 92% at 20 years for patients with clinically non-functioning adenomas. Only secretory status was an independent prognostic factor for disease control. The 10 and 20-year survivals for all patients were 77 and 58% respectively. When compared with the normal population the relative risk of death was 1.76 (P < 0.001) and no prognostic factors for survival were identified. The morbidity of radiotherapy was low. Visual deterioration, assumed to be radiation induced, occurred in 1.5% of patients and the risk of second brain tumour was 1.9% at 20 years. Fifty per cent of patients received hormone replacement therapy by 19 years.

CONCLUSION

Conventional external beam radiotherapy as described here combined with conservative surgery is safe and effective in the control of pituitary adenomas. These results should form a baseline for comparison with new treatment strategies.

Risk of second brain tumour after conservative surgery and radiotherapy for pituitary adenoma

OBJECTIVE

To assess the risk of second brain tumour in patients with pituitary adenoma treated with conservative surgery and external beam radiotherapy.

DESIGN

Long term follow up of a cohort of patients with pituitary adenoma and comparison of tumour occurrence with population incidence rates.

SETTING

The Royal Marsden Hospital.

SUBJECTS

334 patients with pituitary adenoma treated with conservative surgery and radiotherapy (median dose 45 Gy) and followed up for 3760 person years.

MAIN OUTCOME MEASURES

Second intracranial tumour and systemic malignancy.

RESULTS

Five patients developed a second brain tumour: two had astrocytoma, two meningioma, and one meningeal sarcoma. The cumulative risk of developing a second brain tumour over the first 10 years after treatment was 1.3% (95% confidence interval 0.4% to 3.9%) and over 20 years 1.9% (0.7% to 5.0%). The relative risk of a second brain tumour compared with the incidence in the normal population was 9.38 (3.05 to 21.89). There was no excess risk of any other type of second primary malignancy.

CONCLUSIONS

There is an increased risk of second intracranial tumour in patients with pituitary adenoma treated with surgery and radiotherapy. Although radiation is likely to be the most important factor contributing to the excess risk, further study is required in a cohort of similar patients not receiving radiation.

Craniopharyngioma--a long-term results following limited surgery and radiotherapy

Between 1950 and 1986 173 patients with craniopharyngioma were treated at the Royal Marsden Hospital with external beam radiotherapy either alone or following surgery. Four patients had complete tumour excision, 21 subtotal and 78 partial resection, 14 had biopsy alone, 34 aspiration alone and 22 had no surgery directed at tumour eradication. Seventy-seven (45%) were children (aged < 16 years). The 10 and 20 year progression-free survival (PFS) rates were 83% and 79%. There were no independent prognostic factors for PFS. The 10 and 20 year survival rates were 77% and 66% at a median follow-up of 12 years. After adjustment for mortality in the normal population, age and technique of radiotherapy (which corresponded with era of treatment) were significant independent prognostic factors for survival. The risk of death (corrected for mortality from natural causes and controlling for radiotherapy technique) for age groups 16-39 and > or = 40 was 0.58 and 0.40 respectively, relative to a risk of 1.0 for the age group < 16 years. Survival and PFS were not influenced by the extent of surgical excision. Visual field defect improved after radiotherapy in 36% of patients (38/106) and visual acuity in 30% (27/91). No patient developed radiation optic neuropathy. We conclude that limited surgery and radiotherapy achieve excellent long-term tumour control and survival with low morbidity.

Background radiation and cancer incidence in Kerala, India-Karanagappally cohort study

The coastal belt of Karunagappally, Kerala, India, is known for high background radiation (HBR) from thorium-containing monazite sand. In coastal panchayats, median outdoor radiation levels are more than 4 mGy y-1 and, in certain locations on the coast, it is as high as 70 mGy y-1. Although HBR has been repeatedly shown to increase the frequency of chromosome aberrations in the circulating lymphocytes of exposed persons, its carcinogenic effect is still unproven. A cohort of all 385,103 residents in Karunagappally was established in the 1990's to evaluate health effects of HBR. Based on radiation level measurements, a radiation subcohort consisting of 173,067 residents was chosen. Cancer incidence in this subcohort aged 30-84 y (N = 69,958) was analyzed. Cumulative radiation dose for each individual was estimated based on outdoor and indoor dosimetry of each household, taking into account sex- and age-specific house occupancy factors. Following 69,958 residents for 10.5 years on average, 736,586 person-years of observation were accumulated and 1,379 cancer cases including 30 cases of leukemia were identified by the end of 2005. Poisson regression analysis of cohort data, stratified by sex, attained age, follow-up interval, socio-demographic factors and bidi smoking, showed no excess cancer risk from exposure to terrestrial gamma radiation. The excess relative risk of cancer excluding leukemia was estimated to be -0.13 Gy-1 (95% CI: -0.58, 0.46). In site-specific analysis, no cancer site was significantly related to cumulative radiation dose. Leukemia was not significantly related to HBR, either. Although the statistical power of the study might not be adequate due to the low dose, our cancer incidence study, together with previously reported cancer mortality studies in the HBR area of Yangjiang, China, suggests it is unlikely that estimates of risk at low doses are substantially greater than currently believed.

Cerebrovascular mortality in patients with pituitary adenoma

OBJECTIVE

To assess cerebrovascular mortality in a UK cohort of patients with pituitary adenoma known to have increased incidence of cerebrovascular accidents (CVA).

METHODS

A total of 334 patients treated at the Royal Marsden Hospital (RMH) between 1962 and 1986 with surgery and postoperative radiotherapy were followed up via the NHS Central Register (NHSCR) to identify deaths and emigrations. The causes of death were assessed by NHSCR-based death certificates and coded according to the 9th revision of ICD. Follow-up was censored at age 85, on emigration or cancellation of NHSCR. Thirteen patients could not be traced. A total of 4982 person-years was accumulated in the cohort. Expected numbers of deaths were computed from the national age-, sex- and period-specific mortality rates for England and Wales.

RESULTS

In the pituitary adenoma cohort, 128 deaths were observed compared to 80.9 expected [relative risk (RR) of death 1.58 (95% CI: 1.32-1.90)]. There were 33 cerebrovascular deaths compared with 8.04 expected (RR 4.11, 95% CI 2.84-5.75). Three deaths were from subarachnoid haemorrhage compared to 0.54 expected (RR 5.51, 95% CI 1.14-16.09). There was an increased cerebrovascular mortality in women (RR 6.93, 95% CI 4.29-10.60) compared to men (RR 2.4, 95% CI 1.24-4.20; P = 0.002) and in patients having debulking surgery (RR 5.19, 95% CI 3.50-7.42) compared to biopsy/no surgery (RR 1.33, 95% CI 0.27-3.88; P = 0.02). The RR in patients with nonsecretory tumours was 3.65 (95% CI 2.26-5.58), compared with 5.23 (95% CI 2.25-10.30) in secretory tumours (P = 0.4). The effect of age at radiotherapy was not significant (P = 0.4).

CONCLUSION

Patients with pituitary adenoma treated with surgery and radiotherapy have an increased risk of cerebrovascular mortality compared to the general population, which mirrors the increased incidence of CVA. The possible risk factors include hypopituitarism, radiotherapy and extent of surgery but none are at present proven causes. The evaluation of new treatment strategies should not only assess intermediate end-points of tumour and endocrine control but should concentrate on long-term survival with particular emphasis on CVA incidence and mortality.

Polymorphisms in DNA repair gene XRCC1 and increased genetic susceptibility to breast cancer

X-ray repair cross-complementing 1 (XRCC1) gene encodes for a scaffolding protein, which plays an important role in base excision DNA repair by bringing together DNA polymerase beta, DNA ligase III and poly(ADP-Ribose) polymerase (PARP) at the site of DNA damage. Three polymorphisms of the XRCC1 gene at codons 194, 280 and 399 leading to amino acid changes at evolutionary conserved regions are found to alter the efficiency of the resulting protein and may therefore constitute potential breast cancer risk. In the present study we sought to determine whether these genetic variants of the XRCC1 gene was associated with any increased risk of breast cancer among the South Indian women in a hospital based case control study using PCR-RFLP and DNA sequencing techniques. Our data showed a positive association between the polymorphisms of codons 194 (OR = 1.98, 95% CI = 1.13-3.48 for Trp allele) and 399 (OR = 2.14, 95% CI = 1.29-3.58 for Gln allele) and breast cancer risk. However, XRCC1 codon 280 genotype analysis showed no evidence for an association with increased risk of breast cancer. A combined analysis of the effect of XRCC1 codon 194 and 399 revealed the highest risk (OR = 3.64, 95% CI = 1.57-8.46) for carriers of the polymorphic alleles in both these codons. In conclusion, the present study suggested involvement of XRCC1 codon 194 and 399 polymorphisms in the genetic predisposition to breast cancer among South Indian women. Our preliminary results based on the analysis of functionally relevant polymorphisms in XRCC1 low penetrance gene may provide a better model that would exhibit additive effects on individual susceptibility to breast cancer.

Primary sarcoma of the breast

BACKGROUND AND OBJECTIVES

Primary sarcoma occurring in breast is rare and comprises 0.5-1% of all breast neoplasm. Majority of the series include both stromal and cystosarcoma phyllodes, only a few hundred cases of sarcomas other then cystosarcoma are reported.

PATIENTS AND METHODS

We carried out a retrospective analysis of 19 patients with primary sarcoma of the breast treated between 1982 and 2002.

RESULTS

Mean age of the patients was 38.6 years (12-70 years). Gradually progressive swelling was the commonest presenting feature. There were eight cases of angiosarcoma, four cases of spindle cell sarcoma, two each of pleomorphic sarcoma and stromal sarcoma, and one each of malignant fibrous histiocytoma, embryonal rhabdomyosarcoma, and sarcoma (NOS). Eight of these were high-grade (42%). Eight patients underwent either radical or modified mastectomy, three underwent wide excisions, and one underwent quadrantectomy. Ten (52.6%) patients received postoperative adjuvant radiation. Two patients received chemotherapy. After a mean follow-up time of 34.5 months (median 25 months), eight patients failed. Failure was local in five, opposite breast in one, and both local and distant in two. The disease free survival at 3-year was 39%. In univariate analysis only the margin of first surgery was found to be a significant predictor of survival (P = 0.05).

CONCLUSIONS

Primary sarcomas of the breast are aggressive tumors. Surgical treatment should consist of at least simple mastectomy. All attempts should be made to achieve a negative margin as this appears to be the only factor influencing survival in these patients.

Malignant phyllodes tumor

The study aims to evaluate the survival and prognosis of patients with malignant phyllodes tumor. Between 1982 and 1998, 37 women with malignant phyllodes tumor were treated at the Regional Cancer Center, Trivandrum. Twelve patients were recurrent. Survival was estimated using the Kaplan-Meier method. Patient, disease, and treatment factors were compared using log-rank test. The Cox-proportional hazard model was employed to identify the prognostic factors. Thirty-six patients had surgery. Twenty-five patients received postoperative radiotherapy, and 2 received chemotherapy in addition. The median follow-up was 43 months (range 1-170 months). Eight patients failed locally, and 7 of these were successfully salvaged by surgery. The 5-year overall survival was 74.2% (95% CI, 0.44 to 0.89), whereas 5-year disease-free survival was 59.6% (95% CI, 0.39 to 0.7). The margin of surgical excision was found to be the only independent prognostic factor (p=0.003). However, patients with tumor size more than 5 cm (hazard ratio 2.9) were found to have increased hazard, whereas those receiving adjuvant radiotherapy (hazard ratio 0.6), married women (hazard ratio 0.4), and those women over the age of 35 years (hazard ratio 0.7) showed a decreased hazards. Cystosarcoma phyllodes is a rare malignancy of the female breast. Surgery with adequate margins is the primary treatment. Adjuvant radiotherapy appears to improve the disease-free survival.

Radiotherapy in the treatment of solitary plasmacytoma

Solitary plasmacytoma of bone (SPB) and extramedullary plasmacytoma (EMP) are rare. High local control rates are reported with radiotherapy, although the optimal dose and extent of radiotherapy portals remains controversial. Between 1983 and 1993, 30 patients with solitary plasmacytoma were seen at the Regional Cancer Centre, Trivandrum, India. 23 patients had SPB and seven EMP. The mean age was 52 years and the male to female ratio 3.2:1. Diagnosis of SPB was confirmed by biopsy in 16 patients and tumour excision in seven. 20 patients received megavoltage radiotherapy to the bone lesion with limited margins, and one received chemotherapy. Two patients who underwent complete tumour excision received no further treatment. All seven patients with EMP received megavoltage radiotherapy, four following biopsy and three after tumour excision. Local control was achieved in all patients with SPB. Nine progressed to multiple myeloma and one developed a solitary plasmacytoma in another bone. Six patients with EMP achieved local control. Three later progressed to multiple myeloma and one had local relapse. Median time to relapse was 28 months in SPB and 30 months in EMP. 5-year overall survival rates were 82% and 57% for patients with SPB and EMP, respectively. The corresponding progression free survival rates were 55% and 50%, respectively. Age, sex, site of tumour, serum M protein and haemoglobin levels did not significantly influence progression free survival. The extent of surgery, radiotherapy dose or time to relapse were not significant prognostic factors. Radiotherapy appears to be an effective modality of treatment of solitary plasmacytoma. No dose-response relationship is observed, and high local control rates are achieved with limited portals. Progression to multiple myeloma is the commonest pattern of failure, although no prognostic factors for progression are identified. The role of chemotherapy in preventing disease progression needs further evaluation.

The management of histologically unverified presumed cerebral gliomas with radiotherapy

PURPOSE

To define the natural history, and prognostic factors of patients with histologically unverified presumed gliomas diagnosed on CT or MR imaging, and treated with external beam radiotherapy.

METHODS AND MATERIALS

Retrospective review of 111 adults with histologically unverified presumed cerebral glioma treated with radiotherapy between 1974 and 1990. Using CT or MRI criteria alone 41 were presumed low grade, 63 high grade gliomas and 7 were unclassified. Survival results were compared to a cohort of 82 adults with histologically verified low grade gliomas treated over the same period with surgery and radiotherapy.

RESULTS

The 5 year survival probability of the whole cohort was 31%. Age, performance status, and the degree of contrast enhancement were independent prognostic factors for survival. Patients with presumed low grade glioma had a 5 year survival of 41% compared to 52% for patients with verified low grade glioma. After correction for prognostic factors no significant difference was found in the survival between patients with verified and unverified low grade tumors. One of 15 cases with subsequent histology, obtained at autopsy or salvage surgery, had nonglial pathology.

CONCLUSION

Patients diagnosed on the basis of clinical features and imaging as having presumed glioma have similar natural history and clinical behavior after treatment with radiotherapy to those with histologically confirmed gliomas. However, the results should not be taken as justification for avoiding biopsy. A proportion of patients may have nonglial pathology and new more effective treatment strategies for patients with glial tumors can only evolve on the basis of full diagnostic information including pathology.

Radiotherapy for the treatment of recurrent craniopharyngioma

Twenty-five patients with craniopharyngioma received radiotherapy at the time of recurrence. The 10-year progression free survival and survival from the time of recurrence were 72% and 77% respectively. Nineteen patients underwent surgery prior to radiotherapy (6 partial excision, 4 decompression and 9 cyst aspiration). The extent of resection at the time of recurrence did not influence the outcome. Apart from pituitary failure there was no serious morbidity associated with this approach. The results of radiotherapy at recurrence are similar to those of conservative surgery and radiotherapy at the time of presentation. It suggests that radiotherapy remains an effective treatment modality at the time of recurrence of craniopharyngioma and it may therefore be delayed in situations where immediate radiation is not advisable. However, the high recurrence rate in incompletely excised craniopharyngioma, together with the potential risk of additional morbidity and mortality from undiagnosed progressive tumour and salvage surgery, would argue for a policy of radiotherapy as part of the initial treatment of incompletely excised craniopharyngioma.

Role of xenobiotic metabolizing gene polymorphisms in breast cancer susceptibility and treatment outcome

Metabolic activation and inactivation of potential genotoxic agents occur by Phase I and Phase II enzymes in multiple interactions. An expanding body of literature demonstrates that ethnic differences in breast cancer incidence may be partly caused by host genetic factors particularly genetic polymorphisms of these carcinogen-metabolizing enzymes. The present case-control study aimed at identification of such low penetrance breast cancer susceptibility genes in 224 Indian women and to investigate the potential effects of their polymorphisms on sporadic breast cancer risk. The main objective of the study was to evaluate the effects of genetic polymorphisms of the xenobiotic metabolizing genes CYP1A1, GSTM1 and GSTT1 on breast cancer risk by PCR-RFLP and DNA sequencing. Our results showed a significant association between CYP1A1 m1, m2 polymorphisms and breast cancer risk; however there was a lack of association between GSTM1 null deletion and breast cancer. The associations of CYP1A1, GSTM1 and GSTT1 genotypes with breast cancer risk were more pronounced among the pre-menopausal patients. Combined genotype analysis revealed the CYP1A1 m2 ValVal-GSTM1 homozygous null deletion genotype combinations to be associated with the highest risk of breast cancer (OR=10.3, 95% CI=1.2-86.1). Correlations with clinicopathological factors and treatment outcome were also analyzed for predicting disease free survival by univariate and multivariate analysis. Significant differences in disease free survival between the wild and polymorphic genotypes were observed only for CYP1A1 m2, GSTT1 genotypes. Our results based on the analysis of functionally relevant polymorphisms in these low penetrance genes may provide a better model that would exhibit additive effects on individual susceptibility to breast cancer. Such genotype analysis resulting in a high-risk profile holds considerable promise for individualizing screening and therapeutic intervention in breast cancer. Hence, the present study may provide strong supportive evidence for genetic interactions in the etiology of breast cancer.

Modifying radical radiotherapy in high grade gliomas; shortening the treatment time through acceleration

PURPOSE

To evaluate the efficacy and toxicity of accelerated radiotherapy in patients with primary high grade glioma, where acceleration is used as a means of delivering a shortened course of radical radiotherapy.

PATIENTS AND METHODS

Two-hundred and eleven patients with primary high grade glioma were treated at the Royal Marsden NHS Trust between 1987 and 1997 with accelerated radiotherapy (55 Gy in 34 fractions twice daily), to planning target volume (PTV) defined as enhancing tumour and a 3 cm margin. All had histologically confirmed high grade glioma (53 anaplastic astrocytoma, 137 glioblastoma multiforme, 4 gliosarcoma, 5 gemistocytic astrocytoma, 12 high grade astrocytoma not otherwise specified). The mean Karnofsky performance status (KPS) was 90 and median age was 54 years (range 19-77).

RESULTS

Of 211 patients entered, 201 were able to complete radiotherapy; 39 patients (19%) had deterioration in KPS during radiotherapy and this was transient in 11. Median survival of 211 patients was 10 months with 1 year, 2 year, and 3 year survival probabilities of 38%, 14%, and 8% respectively. Age and extent of excision were independent prognostic factors for survival. Previous comparison to matched cohort receiving 60 Gy in 30 daily fractions did not demonstrate significant survival difference.

CONCLUSION

Accelerated radiotherapy is a feasible treatment approach for patients with high grade glioma. The survival and functional outcome are comparable to conventional radiotherapy and the treatment is without serious acute toxicity. While acceleration of conventional dose irradiation could be tested in randomised studies, it is unlikely this approach would result in a clinically meaningful survival benefit. Accelerated radiotherapy therefore remains one of the ways of delivering radical irradiation in patients with high grade glioma. However, it adds complexity to what is a palliative treatment regimen and the rationale and advisability should be re-examined, particularly in terms of impact on quality of life, true patient preference, and health economic considerations.

Craniopharyngioma: improving outcome by early recognition and treatment of acute complications

PURPOSE

To assess the frequency, mode of presentation, treatment, and outcome of acute complications in patients with craniopharyngioma around the time of radiotherapy.

METHODS AND MATERIALS

A review was made of 188 patients with craniopharyngioma treated with conservative surgery and external beam radiotherapy at the Royal Marsden Hospital between 1950 and 1992.

RESULTS

Twenty six (14%) (95% confidence interval: 9-19%) patients with craniopharyngioma developed acute deterioration immediately before, during and 2 months after radiotherapy with visual deterioration (19 patients), hydrocephalus (7 patients), and global deficit (7 patients). Cystic enlargement with or without hydrocephalus was the most common cause of deterioration. No patient or disease characteristics were predictive of deterioration on univariate or multivariate analysis. Eighteen patients had surgical intervention at the time of deterioration and survived the immediate period. Six of seven patients who did not have surgical intervention died. All patients who survived the postcomplication period completed the full course of external beam radiotherapy. The 10-year progression-free survival of 162 patients without deterioration was 86%, and of 18 patients with acute deterioration who recovered after surgery, 77%.

CONCLUSION

Patients with craniopharyngioma develop acute deterioration around the time of radiotherapy owing to cystic enlargement and/or hydrocephalus which does not represent tumor progression. Early recognition and appropriate surgical treatment followed by conventional full-dose radiotherapy are associated with good long-term outcome.

Survival in patients with recurrent glioma as a measure of treatment efficacy: prognostic factors following nitrosourea chemotherapy

The assessment of efficacy of treatment in patients with recurrent glioma is notoriously difficult, and survival is the most objective endpoint. Between 1970 and 1992, a cohort of 211 patients with recurrent glioma received nitrosourea-based chemotherapy at the time of disease progression. The median survival from the start of chemotherapy was 7 months, with 30% 1-year and 10% 2-year survival probabilities. One-year survival was 22% in 147 patients with recurrent high-grade astrocytoma, 41% in 37 patients with low-grade astrocytoma and 45% in 24 patients with oligodendroglioma. Age, histological grade and Karnofsky performance status (KPS) at recurrence were independent prognostic factors for survival on multivariate analysis. Based on patients' age, tumour grade and KPS, it was possible to define three distinct prognostic groups with 1-year survival probabilities of 60, 21 and 17% (P < 0.005). Response to chemotherapy was difficult to assess but correlated with prognostic subgroup, with highest response rate (46%) in the most favourable group and lowest (13%) in the poor prognostic group. In patients with recurrent glioma, patient and tumour parameters are the major determinants of outcome which are identical to prognostic factors at the time of primary diagnosis. They can be used to provide prognostic information for the individual patient, and to stratify patients particularly in trials assessing the efficacy of novel treatments.

Quality of life determinants in women with breast cancer undergoing treatment with curative intent

BACKGROUND

The diagnosis of breast cancer and its subsequent treatment has significant impact on the woman's physical functioning, mental health and her well-being, and thereby causes substantial disruption to quality of life (QOL). Factors like patient education, spousal support and employment status, financial stability etc., have been found to influence QOL in the breast cancer patient. The present study attempts to identify the determinants of QOL in a cohort of Indian breast cancer patients.

PATIENTS AND METHODS

Functional Assessment of Cancer Therapy-Breast (FACT-B) Version 4 Malayalam was used to assess quality of life in 502 breast cancer patients undergoing treatment with curative intent. The data on social, demographic, disease, treatment, and follow-up were collected from case records. Data was analysed using Analysis of Variance (ANOVA) and multinomial logistic regression.

RESULTS

The mean age of the patients was 47.7 years with 44.6% of the women being pre-menopausal. The FACT-B mean score was 90.6 (Standard Deviation [SD] = 18.4). The mean scores of the subscales were - Physical well-being 19.6 (SD = 4.7), Social well-being 19.9 (SD = 5.3), Emotional well-being 14 (SD = 4.9), Functional well-being 13.0 (SD = 5.7), and the Breast subscale 23.8 (SD = 4.4). Younger women (< 45 years), women having unmarried children, nodal and/or metastatic disease, and those currently undergoing active treatment showed significantly poorer QOL scores in the univariate analysis. However multivariate analysis indicated that the religion, stage, pain, spouse education, nodal status, and distance travelled to reach the treatment centre as indicative of patient QOL.

CONCLUSION

QOL derangements are common in breast cancer patients necessitating the provisions for patient access to psychosocial services. However, because of the huge patient load, a screening process to identify those meriting intervention over the general population would be a viable solution.

Spinal cord compression in prostate cancer: treatment outcome and prognostic factors

BACKGROUND AND PURPOSE

Spinal cord compression (SCC) is an important complication of metastatic prostate cancer. We have analysed patients treated at the Royal Marsden Hospital to assess treatment outcome and prognostic factors in this patients group.

MATERIALS AND METHODS

We performed retrospective analysis of 69 patients with spinal cord compression and prostate cancer treated at the Royal Marsden Hospital.

RESULTS

At presentation 40 (58%) patients were non-ambulant and 52% were catheterised. Diagnosis was established by myelography in 42% and magnetic resonance imaging (MRI) in 47% of patients. MRI detected significantly more patients with multiple sites of compression (51 versus 7%, P < 0.001). SCC was present at the initial diagnosis of prostatic cancer in 13 patients and 17 patients had received no hormone treatment prior to diagnosis. Following treatment 36 (52%) patients had a functional improvement of motor power with 25/40 (63%) non-ambulant patients becoming ambulant. Seventy-seven percent of patients who had eventual improvement had some improvement in power within 7 days. On multivariate analysis a single level of compression, no previous hormone therapy and a young age (<65 years) predicted for better outcome. When these factors were included an increased radiation dose (>30 Gy) or the addition of surgery did not improve the functional outcome. Following initial recovery; there was a 45% risk of developing a further episode of cord compression at the same or new site by 2 years with a median time to progression of 236 days (range 47-1215 days). The median survival was 115 days (range 5-2016 days) with 25% of patients surviving for 2 years. Patients with no prior hormone therapy had a median survival of 627 days (range 46-1516 days). Other predictors of improved survival on multivariate analysis were a single site of compression and a haemoglobin over 12 g.

CONCLUSIONS

Treatment of SCC in prostate cancer results in improved motor function in the majority of patients. Long-term survival is possible, especially in good performance status patients with no prior hormone treatment. Survivors remain at high risk of subsequent neurological relapse. An early improvement in motor power is a strong predictor of subsequent functional improvement. MRI detects additional sites of asymptomatic SCC which makes it the investigation of choice.

Selective avoidance of lymphatic radiotherapy in the conservative management of early breast cancer

In view of the morbidity and potential mortality associated with routine post-operative lymph node radiotherapy in women with early stage breast cancer, an attempt has been made to select patients in whom radiotherapy can be withheld. Three hundred and forty-seven consecutive patients treated wide local excision plus or minus axillary surgery have been evaluated. Only 20% were subsequently given radiotherapy to regional nodes. Relapse in the axilla, the supraclavicular fossa or at both these sites have occurred in 16 patients so far, 12 of whom were successfully treated. Systemic relapse was seen in eight of these patients occurring with one exception before or within 3 months of node relapse. Only four have persisting symptoms as a result of nodal relapse. So far, a policy involving selective lymphatic radiotherapy in women treated for early breast cancer appears justified.

Conservative surgery and radiotherapy in the treatment of spinal cord astrocytoma

Spinal cord astrocytomas are rare neoplasms, and optimal treatment guidelines are undefined, 23 patients with spinal cord astrocytomas were treated between 1984 and 1993 with conservative surgery and postoperative radiotherapy. The mean age was 31 years. Twelve patients were male and eleven female. All patients presented with neurologic deficit. Cervical cord was involved in five patients, cervicothoracic in four, thoracic in eight and thoracolumbar in six. Five patients had intramedullary cysts. Fifteen patients had low grade tumors and six high grade. Surgery was near total excision in three patients, partial excision in ten and biopsy in ten patients. All patients received postoperative radiotherapy to a median dose of 45 Gy in 25 fractions over 5 weeks. The median followup was 51 months (range 7-143 months). At 6 months post radiotherapy, twelve patients had improvement of neurologic status, nine had stable status, and two deteriorated. The actuarial overall survival was 55% at 5 years and 39% at 10 years. The actuarial progression free survival probability was 75% at 5 years and 55% at 10 years. Five patients had local failure and two failed at distant sites. Twelve patients died, six due to progressive disease, five due to complications of paraplegia and one patient of unrelated causes. Tumor grade was a significant prognostic factor for overall survival. 5 year overall survival was 79% for low grade tumors. No patient with high grade tumor survived more than 2 years and the median survival was 10 months. Low grade, female sex and presence of intramedullary cysts were associated with significantly improved progression free survival. Conservative surgery followed by radiotherapy appears to have a role in achieving tumor control and neurologic recovery in patients with low grade astrocytomas of the spinal cord. Treatment results of high grade tumors remain poor and new therapeutic strategies need to be studied.

Anthropometric factors and breast cancer risk among urban and rural women in South India: a multicentric case-control study

Breast cancer (BC) incidence in India is approximately twice as high in urban women than in rural women, among whom we investigated the role of anthropometric factors and body size. The study was conducted at the Regional Cancer Centre, Trivandrum, and in three cancer hospitals in Chennai during 2002-2005. Histologically confirmed cases (n=1866) and age-matched controls (n=1873) were selected. Anthropometric factors were measured in standard ways. Information on body size at different periods of life was obtained using pictograms. Odds ratios (OR) of BC were estimated through logistic regression modelling. Proportion of women with body mass index (BMI)>25.0 kg/m(2), waist size >85 cm and hip size >100 cm was significantly higher among urban than rural women. Risk was increased for waist size >85 cm (pre-menopausal: OR=1.24, 95% CI: 0.96-1.62; post-menopausal: 1.61, 95% CI: 1.22-2.12) and hip size >100 cm (pre-menopausal: OR=1.47, 95% CI: 1.05-2.06; post-menopausal 2.42, 95% CI: 1.72-3.41). Large body size at age 10 (OR=1.75, 95% CI: 1.01-3.03) and increased BMI (OR=1.33, 95% CI: 1.05-1.69 for 25.0-29.9 kg/m(2) and OR=1.56, 95% CI: 1.03-2.35 for 30+ kg/m(2)) were associated with pre-menopausal BC risk. Our data support the hypotheses that increased anthropometric factors are risk factors of BC in India.

Haematological toxicity of cranio-spinal irradiation

BACKGROUND

To assess the frequency and severity of myelosuppression due to cranio-spinal irradiation either alone or in combination with chemotherapy and to identify patients at high risk of haematological toxicity who may require supportive therapy.

MATERIALS AND METHODS

Between 1965 and 1994, 210 patients received cranio-spinal axis (CSA) radiotherapy as a component of treatment for primary CNS tumours at the Royal Marsden Hospital. Full blood counts (FBC) were obtained before, during and after radiotherapy in 200 patients. Haematological toxicity was graded according to the WHO criteria and duration was measured from the onset of grades 3 and 4 toxicity until recovery to grade 2.

RESULTS

Sixty-six (33%) patients developed grades 3 and 4 haematological toxicity. Nadir occurred during radiotherapy and was most frequent during the second week of spinal radiotherapy. Low haemoglobin and white cell counts prior to radiotherapy increased the likelihood of myelosuppression. Nine patients had febrile episodes requiring antibiotic therapy. Treatment was interrupted in 49 patients but treatment time was extended beyond 12 weeks in only 17 (8%) patients of which nine were due to haematological toxicity. Chemotherapy (vincristine) during radiotherapy did not impact on haematological toxicity. Age and prior chemotherapy were independent predictive factors for haematological toxicity. The relative risk of leukopaenia in children compared to adults was 7.9 (95% CI 3.4-18.6%). Patients who received prior chemotherapy had a relative risk of toxicity of 6.1 (95% CI 2.9-12.8%).

CONCLUSION

One-third of patients undergoing CSA radiotherapy develop grades 3 and 4 haematological toxicity. The risk is higher in children and in patients who receive chemotherapy prior to radiation. There was no treatment-related mortality and only nine of 200 patients (9/60 of those with toxicity) required supportive treatment for neutropaenic sepsis. The low incidence severe haematological toxicity does not warrant routine use of haemopoietic growth factors during CSA irradiation and future studies should target high risk subgroups.