Innovations et recherche en radiothérapie en France

Significant advances in radiation therapy have recently been observed. Important technological advances allow for greater precision in defining target volumes and organs at risk, which will certainly impact the risk/benefit ratio for cancer care, particularly in the new setting of therapeutic associations using new drugs. Despite the major role of radiation therapy in the multidisciplinary management of several cancers, pharmaceutical industry support for radiation therapy trials that do not involve drugs remains nil. Thus, grant applications for radiotherapy studies are mainly oriented towards institutional clinical research. At the same time, research in radiation therapy has changed considerably. In France, since the beginning of the year 2000, the Cancer Institute (INCa) has considered radiation oncology modernisation as one of the health priorities. In their programs, substantial grants have been allocated to the evaluation of innovative techniques, including financial issues and their potential generalisation throughout the country. Funding for clinical research programs has also been allocated to significant projects that will impact future clinical practice. In this article, we aim to describe the various plans for restructuring radiation therapy in France, and make an inventory of the innovative projects in clinical and technology research that involve public and private institutions.     

Réponses post-traumatiques et dissociation en oncologie

Résumé: Depuis quelques années, létude de la prévalence du syndrome de stress post-traumatique chez des patients atteints de cancer rencontre un intérêt croissant. Ce trouble psychiatrique, responsable dune souffrance émotionnelle significative et de perturbations du fonctionnement psychosocial, semble pourtant encore largement ignoré dans la pratique clinique. Or, il existe de nombreux arguments qui suggèrent un rôle central de processus post-traumatiques dans ladaptation faisant suite au diagnostic, aux traitements et à lévolution du cancer. Une telle révision des concepts fondamentaux pourrait avoir des conséquences majeures non seulement sur notre compréhension de ladaptation psychologique au cancer, mais aussi sur les modalités dinterventions thérapeutiques les plus appropriées dans ce contexte très spécifique et, dès lors, sur la qualité de vie des malades et de leur entourage. Dans cet article, nous nous attelerons principalement à démontrer la présence de manifestations «subsyndromales» de stress post-traumatique chez des patients cancéreux et nous accorderons une place importante aux symptômes dissociatifs éventuellement présents dans cette population de malades. Des hypothèses seront formulées quant aux liens potentiels qui unissent diagnostic de cancer, dissociation et tableaux cliniques posttraumatiques. En particulier, lidée classique selon laquelle la dissociation aiguë constituerait un mécanisme adaptatif est remise en question et une conceptualisation alternative propose de comprendre ce tableau comme le résultat dune altération brutale des réseaux de mémoire autobiographique. Enfin, la littérature relative au traitement psychologique du syndrome de stress post-traumatique se trouve, elle aussi, confrontée à dimportantes difficultés dans la démonstration de lefficacité des modèles actuels. Cette observation ne peut manquer de soulever de multiples questions quant à ladéquation des concepts fondateurs à lorigine de ces modèles. Nous évoquerons à cet égard les éléments qui plaident pour une prééminence des processus émotionnels dans la genèse des réponses psychologiques observées.     

Management et souffrance des soignants en oncohématologie

The suffering of caregivers is often observed in haematology and oncology teams. A major Programme Hospitalier de Recherche Clinique was conducted in the north-west of France. Every oncology and haematology ward was contacted. On 64 wards we got 574 questionnaires within 53 different centres. Four major causes of aetiology have been identified, linked to the caregiver, to the speciality of oncohaematology, to the workload and to the organisation and team management. Our group (Afsos) has shown a relationship between participative management and quality of life at work of caregivers. This participative management is now mandatory in France for teams caring for palliative patients (measure 13a of HAS accreditation visit). The perspectives of the results are discussed.     

Critères de prise en charge en médecine physique et de réadaptation et pathologies cancéreuses

Introduction

Physical medicine and rehabilitation (PMR) cares are limited in practice in France. The complexity of treatments and their potential effects on disability, life expectancy, constitute some chronic factors of the cancer diseases. This chronic evolution is more and more indication of PMR interventions to limit deficiency or disability.

Objectives

To present the PMR modalities at different situations of the cancer diseases evolutions.

Methodology

This paper reports the orientation in our outpatient unit, the modalities for cares in PMR, the role of PMR doctors and the different technological or competent needs for cancer patients with deficiency or disability.

Discussion

A new and important reflexion with information, studies and acquired experiences are necessary. Organization of cares, institutions and cooperation must be developed in this specific domain of the rehabilitation for cancer patients with disability.     

Intelligence artificielle et radiothérapie : quelles bases et quelles perspectives ?

Artificial intelligence is a highly polysemic term. In computer science, with the objective of being able to solve totally new problems in new contexts, artificial intelligence includes connectionism (neural networks) for learning and logics for reasoning. Artificial intelligence algorithms mimic tasks normally requiring human intelligence, like deduction, induction, and abduction. All apply to radiation oncology. Combined with radiomics, neural networks have obtained good results in image classification, natural language processing, phenotyping based on electronic health records, and adaptive radiation therapy. General adversial networks have been tested to generate synthetic data. Logics based systems have been developed for providing formal domain ontologies, supporting clinical decision and checking consistency of the systems. Artificial intelligence must integrate both deep learning and logic approaches to perform complex tasks and go beyond the so-called narrow artificial intelligence that is tailored to perform some highly specialized task. Combined together with mechanistic models, artificial intelligence has the potential to provide new tools such as digital twins for precision oncology.     

Doses dans les organes à risque en radiothérapie conformationnelle et en radiothérapie en conditions stéréotaxiques : os et moelle osseuse

In patients undergoing external radiation therapy, bone marrow and cortical bone structures are all often neglected as organs at risk. Still, from increased febrile neutropenia risk in patients undergoing chemoradiation for a pelvic tumour to increased risk of vertebral fracture when undergoing hypofractioned stereotactic radiotherapy of a spinal metastasis, adverse effects are frequent and sometimes serious. This literature review first defines the rules for contouring these structures, then the dose constraints currently recommended. This article focuses first on conventional irradiation or intensity modulation radiotherapy considering classical fractionation. Secondly, it focuses on stereotactic radiotherapy. The considered organs will be haematopoietic structures, and bone cortical structures. Current recommendations are summarised in a table.     

Le cancer du sein en adjuvant : quelles caractéristiques cliniques et histopathologiques en 2007?

To refine available epidemiological data in early breast cancer, a national and retrospective study analyzed 1,934 cases listed between May and July 2007 by 88 French centers. More than one third of patients had less than 50 years old (26%) or more than 74 (15%). The anatomopathological tumors' characteristics were as following: ≤ 2 cm in 62% of cases, lymphatic invasion in 35% of cases, positive hormone receptors in 85% of cases, and SBR grade III in 18% of cases. The assessment of HER2 status, performed in 1,899 cases (98%), showed at least 12.1% of early stage HER2 positive tumors. HER2 overexpression was higher before 50 years old (15.9 versus 11.5% between 50 and 70 years, and 10.0% if ≥ 70 years old), for the largest tumors (pT2/3/4: 15.9%, ≤ 1 cm: 11.4%, between 1 and 2 cm: 9.0%) or for a high SBR grade (III: 24.7%, II: 12.1%, I: 3.5%). This study allowed to emphasize the prevalence of HER2 overexpression in elderly patients and for small size tumors.     

Évolution de la curiethérapie en France et perspectives

During the last decade, the organization of brachytherapy in France moved to 62 units in 173 radiotherapy centres in 2009. More than 7500 patients were treated in 2009, quite exclusively with curative intent, for 80% in public or associated hospitals. The techniques improved to high tech 3D dosimetry and optimization of the dose distribution. Brachytherapy, despite representing only 5% of the treatments by irradiation, is a reference treatment for several tumors.     

Biologie moléculaire et prise en charge des cancers colorectaux

In current clinical practice, increasing number of situations make necessary the use of molecular biology tests to help clinicians in charge of patients with colorectal cancer (CRC) in their therapeutic decisions: indication of adjuvant chemotherapy after colorectal surgery, treatment choice in case of unresectable metastatic CRC. Advances in pharmacogenetics allowed a better characterization of inherited causes of CRC and to identify prognostic and predictive factors for different treatments. The purpose of this article is to present the recent advances in the use of molecular biology in case of suspected Lynch syndrome and indication of anti-EGFR antibodies.     

Glioblastomes: aspects moléculaires et prise en charge actuelle

Glioblastomas are the kind of malignant gliomas found most frequently in adults. In nearly all glioblastomas there is activation of the receptor tyrosine-kinase pathway and deactivation of the p53 and retinoblastoma tumor suppressor pathways. The methylation status of the MGMT gene promoter is the most importantmolecular prognostic factor and may predict chemosensitivity to alkylating agents. As in other cancers, cancer stem cells have been identified in glioblastomas, where they could be important therapeutic target. Management of glioblastomas involves surgery, radiotherapy and chemotherapy. Concomitant chemoradiotherapy according to Stupp’s regimen is the most important recent therapeutic advance. However, the benefit of chemotherapy for inoperable tumors or in the elderly population remains to be determined. The impact of targeted therapies as part of first line treatment is under evaluation.     

Radiothérapie des oligométastases : principaux essais en cours et à venir en France

Stereotactic radiotherapy of oligometastases, mono- or hypofractionated, represents a fundamental change in the practice of the specialty as it was developed for a century. Despite the great heterogeneity of sites, techniques, and doses, most studies found a high local control rate, around 70 to 90% at 2 years, and reduced toxicity, around 5% of grade 3 at 2 years. Four main phase II and III trials are underway in France. Future research concerns the association of stereotactic radiotherapy with immunotherapy or different conventional chemotherapy protocols, the identification of the best clinical presentations, and optimization of fractionation and biological dose for poor prognosis localizations.