Patient-specific PTV margins in radiotherapy for bladder cancer - A feasibility study using cone beam CT

Purpose

To assess the feasibility of using cone beam computed tomography (CBCT) to generate patient-specific PTV margins for bladder cancer patients treated with radiation therapy (RT).

Methods

Eleven patients underwent CT simulation and daily RT (full bladder and empty rectum). CBCT was done prior to each fraction, and the whole bladder was contoured off-line. For the first 15 CBCTs of each patient, the bladder was aligned with CT-simulation bladder (pBladder) to create an occupancy volume (OV). A 5 mm isotropic margin was added to OV (OV + 5). A measurement-based PTV (mPTV) was generated by measuring maximal displacement between pBladder and OV in six directions. OV, OV + 5, mPTV, and a standard PTV (2 cm isotropic margin) were compared for absolute and relative volume differences. Using the final 10 CBCT of each patient, the ability of each study volume to encompass the entire CBCT bladder was determined.

Results

161/165 CBCT images were of adequate quality for contouring. No daily trend in bladder volume variation was noted. The median absolute volumes (cm³) were: 221, 271, 426, 440, and 914 for pBladder, OV, OV + 5, mPTV, and standard PTV, respectively. The median ratios of the study volumes/pBladder were: 1.4 OV, 2.1 OV + 5, 2.4 mPTV, 4.1 standard PTV. OV + 5 was smaller than mPTV in 9 patients. There was considerable inter-patient variability in study volumes and no apparent association of the magnitude of margin expansion and pBladder. The bladder was encompassed in 69%, 99%, 99%, and 100% of the final 10 fractions by OV, OV + 5, mPTV, and standard PTV, respectively.

Conclusions

The use of daily CBCT to generate patient-specific PTV margins is feasible and results in a marked reduction in the irradiated volume compared to population-based margins. As daily bladder volume varied unpredictably with considerable differences between patients, these findings support the use of patient-specific PTV margin expansions for bladder radiotherapy.     

First report on the patient database for the identification of the genetic pathways involved in patients over-reacting to radiotherapy: GENEPI-II

Background

Identifying the most radiosensitive patient group would have huge clinical implications.

Methods

A tissue bank containing skin fibroblasts, whole blood, lymphocytes, plasma and lymphoblastoid cell lines from clinically radiation hypersensitive patients was established from patients in Europe and Canada. Over-reacting individuals had CTCAE3.0 severe acute side effects grade 2 or more occurring at very low radiation doses where these side effects are unexpected or grade 3-4 lasting more than 4 weeks after the end of radiotherapy and/or requiring surgical intervention at any time or severe late side effects grade 3-4.

Results

Eleven patients have been identified with a mean age of 61.6 ± 8.5 years (range 49-74). Two patients were male, 9 female. One patient had non-small cell lung cancer, 6 breast cancer, 2 head and neck cancer, one lymphoma and one meningioma. The mean follow-up time after radiotherapy was 1658 ± 1048 days (range 84-3752).

Conclusions

The establishment of an international tissue bank of the rare group of patients with extreme hypersensitivity to radiotherapy was proven to be feasible and should enable in-depth molecular studies.     

Comparison of early quality of life in patients treated with radiotherapy following mastectomy or breast conservation therapy: A prospective study

Introduction

To compare quality of life (QOL) in breast cancer patients from a developing country after breast conservation surgery (BCS) or mastectomy and adjuvant radiotherapy (RT).

Materials and methods

In a 6-month period, all consecutive early and locally advanced breast cancer patients treated with either BCS or mastectomy and treated with RT were analyzed. All patients who underwent mastectomy were treated with 45 Gray/20#/4 weeks. Patients with BCS were treated with a dose of 45-50 Gray/25#/5 weeks to whole breast followed by tumor bed boost (15 Gray/6#/6 days with suitable energy electrons). Prospective evaluation of QOL using EORTC QLQ C30 and breast cancer specific QLQ BR23 was done before starting RT (baseline), at mid-RT and at RT conclusion for all patients.

Results

One hundred and thirteen patients had mastectomy and 142 patients underwent BCS. Reliability test (Cronbach alpha) for questionnaire filling was 0.669-0.886. At pre-RT assessment, global QOL scores in mastectomy and BCS groups were 71.1 and 71.3, respectively. There was no significant difference in pre-RT EORTC QLQ C30 functional and symptom domains between mastectomy and BCS patients. However, social function domain score was higher in patients who underwent mastectomy (83 versus 73.9; p = 0.018). In QLQ BR23 domains, body image and sexual functioning domains were similar between the two groups. However, sexual enjoyment (10.9 versus 47.6; p = 0.006) and future perspective (7.4 versus 37.1; p = 0.036) domains were significantly better in BCS arm. There was no difference between systemic side effect (BRSSE), breast symptom (BRBS) and arm symptom (BRAS) domain scores between the groups. There was no significant difference in change of QOL scores between mastectomy and BCS patients at RT completion as compared to baseline.

Conclusions

There was no significant difference in quality of life in patients with BCS versus those with mastectomy. However, patients who underwent BCS had better sexual enjoyment and future perspective scores compared with mastectomy patients. There was no significant change of QOL domain scores after RT in mastectomy and BCS patients.     

Brachytherapy versus cystectomy in solitary bladder cancer: A case control, multicentre, East-Netherlands study

Purpose

Comparing the outcome of surgery and brachytherapy-based radiotherapy in patients with solitary T1G3/T2 bladder tumour in, a retrospective case-control study, because efforts for a randomised clinical trial comparing these modalities have failed.

Materials and methods

Cystectomy group. Patients were selected using the pathological registration system (PALGA). 289 cases of TURT followed by cystectomy, indicated by a muscle - invading bladder tumour were performed in three East-Netherlands medical centres between 1991 and 2001. Out of this group 179 patients with clinical T2N0M0 bladder tumour were selected. All the consecutive files were analysed by a urologist and a radiation oncologist and 65 of those patients (mean age 63.7 years) would have been eligible for brachytherapy, based on an initial analysis: cystoscopy estimated tumour size, post-TURT pathological report, completed by CT-scan and/or, MRI-scan. A final pathological report after radical cystectomy was not considered for patients’ selection.Brachytherapy group. Patients were selected using a prospective registration study aiming at determination of our treatment results. 89 Patients (mean age 68.4 years) underwent TURT followed by a course of external beam irradiation and interstitial brachytherapy from 1983 till 2005 in the Arnhem Radiotherapy Institute.

Results

The median follow-up for the brachytherapy group was 5.7 years (range 0.2-21.4 years), for the cystectomy group was 5.05 years (range: 0.04-16.8 years). No difference in disease-specific survival (DSS) could be detected with a 5- and 10-year DSS of 71% and 66% in the brachytherapy group and 60% and 57% in the cystectomy group, respectively. Five-year overall survival (OS) was 57% in the brachytherapy group and 52% in the cystectomy group, however, the 10-year OS was better in the cystectomy than in the brachytherapy group (42% and 33%, respectively). This is caused by the significant age difference in favour of the cystectomy group. Cystectomy-free survival in the brachytherapy group was 70%.

Conclusion

Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder carcinoma. However, in a selected patient population a bladder sparing treatment, i.e. a combination of transurethral tumour resection (TURT), external beam irradiation and interstitial brachytherapy, can be applied successfully. This concerns a solitary, T1G3 or T2 bladder tumour, with a diameter < 5 cm.     

Nurse-led telephone follow-up and an educational group programme after breast cancer treatment: results of a 2 × 2 randomised controlled trial

Objective

To investigate whether frequent hospital follow-up in the first year after breast cancer treatment might partly be replaced by nurse-led telephone follow-up without deteriorating health-related quality of life (HRQoL), and whether a short educational group programme (EGP) would enhance HRQoL.

Patients and methods

A multicentre pragmatic randomised controlled trial (RCT) with a 2 × 2 factorial design was performed among 320 breast cancer patients who were treated with curative intent. Participants were randomised to follow-up care as usual (3-monthly outpatient clinic visits), nurse-led telephone follow-up, or the former strategies combined with an educational group programme. The primary outcome for both interventions was HRQoL, measured by EORTC QLQ-C30. Secondary outcomes were role and emotional functioning and feelings of control and anxiety.

Results

Data of 299 patients were available for evaluation. There was no significant difference in HRQoL between nurse-led telephone and hospital follow-up at 12 months after treatment (p = 0.42; 95% confidence interval (CI) for difference: −1.93-4.64) and neither between follow-up with or without EGP (p = 0.86; 95% CI for difference: −3.59-3.00). Furthermore, no differences between the intervention groups and their corresponding control groups were found in role and emotional functioning, and feelings of control and anxiety (all p-values >0.05).

Conclusion

Replacement of most hospital follow-up visits in the first year after breast cancer treatment by nurse-led telephone follow-up does not impede patient outcomes. Hence, nurse-led telephone follow-up seems an appropriate way to reduce clinic visits and represents an accepted alternative strategy. An EGP does not unequivocally affect positive HRQoL outcomes.     

Breast radiotherapy as part of loco-regional treatments in stage IV breast cancer patients with oligometastatic disease

Background

Local treatments seem to improve metastasis progression-free survival (MPFS) and overall survival (OS) when added to systemic therapies in stage IV breast cancer.

Methods

From 1990 to 2003, we reviewed 9138 cases treated and registered in the Institut Gustave-Roussy breast cancer database. Among them, 308 had presented with stage IV disease. Eighty percent of patients (n = 239) had received a loco-regional treatment and they were categorized into two groups: loco-regional radiotherapy (LRRT) alone (Group 1; n = 147) or breast and axillary surgery ± LRRT (Group 2; n = 92).

Results

The median follow-up was 6.5 years. LRRT obtained a long-standing loco-regional clinical response in 85% of patients. The 3-year MPFS rates were 20% in Group 1 and 39% in Group 2; the 3-year OS rates were 39% and 57%, respectively. However, no significant differences in MPFS or OS were observed between the two groups when adjusted on prognostic factors.

Conclusions

Radiation therapy alone provides long-standing local control and yields MPFS and OS rates equivalent to those obtained when radiation therapy is combined with surgery, whatever the prognostic factors. Loco-regional therapies, especially radiation therapy alone, may have an important role to play in the treatment of selected patients with stage IV breast cancer.     

Validation of the QUAL-EC for assessing quality of life in patients with advanced cancer

Objective

Improving quality of life is the main goal of palliative cancer care. However, there is a lack of measures validated specifically for advanced cancer. The purpose of this study was to validate the Quality of Life at the End of Life (QUAL-E) measure in a sample of patients with advanced cancer.

Methods

Data were analysed for 464 patients with advanced cancer who were participating in a randomised controlled trial of early palliative care intervention versus routine care. Patients completed the 26-item QUAL-E, the Functional Assessment of Cancer Therapy (FACT-G) quality of life measure and measures of spiritual well-being, performance status, symptom burden, satisfaction with care and communication with health care providers. We conducted a confirmatory factor analysis on the QUAL-E to test for the hypothesised four-factor structure and examined construct validity by calculating correlations with relevant scales.

Results

A 17-item reduced version of the QUAL-E, the QUAL-E-Cancer (QUAL-EC) achieved an acceptable fit to a four-factor model. Both the full and reduced versions of the QUAL-E were internally reliable and showed good construct validity. Symptom Control was correlated with other measures of physical functioning; Relationship with Healthcare Provider was correlated with satisfaction with care and better physician and nurse communication; Preparation for End of Life was strongly associated with emotional well-being; and Life Completion was strongly associated with social and spiritual well-being.

Conclusions

Due to its good factor structure and sound psychometrics, we recommend the reduced QUAL-EC scale to assess quality of life in patients with advanced cancer.     

Consumption of animal products, olive oil and dietary fat and results from the Belgian case-control study on bladder cancer risk

Aim

The Western diet typically consists of high levels of saturated fat from animal products and has been associated with an increased risk of bladder cancer. Whilst olive oil, the predominant fat in the Mediterranean diet, has been associated with many health benefits its role in bladder cancer aetiology is still unknown. Therefore, we investigated the effect of intake of animal products, olive oil and other major dietary fats on bladder cancer risk.

Methods

Dietary data were collected from 200 cases and 386 controls participating in a Belgian case-control study on bladder cancer. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) by comparing the highest with the lowest tertiles of intake between cases and controls using unconditional logistic regression. Adjustment was made for age, sex, smoking characteristics, occupational exposures and calorie intake.

Results

There was a statistically significant inverse association between olive oil intake and bladder cancer consistent with a linear dose-response relationship: middle versus the lowest tertile (OR: 0.62; 95% CI: 0.39-0.99) and the highest versus the lowest tertile (OR: 0.47; 95% CI: 0.28-0.78; p-trend = 0.002). We also observed borderline statistically significant increased odds of bladder cancer for the highest versus the lowest intake of cheese (OR: 1.53; 95% CI: 0.95-2.46; p-trend = 0.08). No potential associations were detected for any other source or type of dietary fat.

Conclusion

We observed evidence for a protective effect by olive oil and a possible increased risk of bladder cancer associated with a high intake of cheese. Our results require further investigation and confirmation by other studies.     

Effects of exercise intervention in breast cancer patients: is mobile health (mHealth) with pedometer more effective than conventional program using brochure?

Purpose

To investigate and compare the effects of mobile health (mHealth) and pedometer with conventional exercise program using a brochure on physical function and quality of life (QOL).

Methods

The study was a prospective, quasi-randomized multicenter trial where 356 patients whose cancer treatment had been terminated were enrolled. All patients were instructed to perform a 12-week regimen of aerobic and resistance exercise. The mHealth group received a pedometer and a newly developed smartphone application to provide information and monitor the prescribed exercises. Those in the conventional group received an exercise brochure. Physical measurements were conducted at baseline, 6 weeks, and 12 weeks. Self-reported physical activity (international physical activity questionnaire-short form), general QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30), and breast cancer-specific QOL (Quality of Life Questionnaire Breast Cancer Module 23) were assessed at baseline and 12 weeks. A user satisfaction survey was assessed in the mHealth group.

Results

Basic characteristics were not different between the two groups except for age and previous radiotherapy. Physical function, physical activity, and QOL scores were significantly improved regardless of the intervention method, and changes were not significantly different between the two groups. Additionally, the mean Likert scale response for overall satisfaction with the service was 4.27/5 in the mHealth group.

Conclusions

Overall, both the mHealth coupled with pedometer and conventional exercise education using a brochure were effective in improving physical function, physical activity, and QOL. This study provides a basis of mHealth research in breast cancer patients for progressing further developing field, although superiority of the mHealth over the conventional program was not definitely evident.

     

Incidental findings on brain Magnetic Resonance Imaging in long-term survivors of breast cancer treated with adjuvant chemotherapy

Purpose

Incidental brain findings defined as previously undetected abnormalities of potential clinical relevance that are unexpectedly discovered at brain imaging and are unrelated to the purpose of the examination are common in the general population. Because it is unclear whether the prevalence of incidental findings in breast cancer patients treated with chemotherapy is different to that in the general population, we compared the prevalence in breast cancer survivors treated with chemotherapy to that in a population-based sample of women without a history of any cancer.

Patients and methods

Structural brain MRI (1.5T) was performed in 191 female CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil) chemotherapy-exposed breast cancer survivors. A reference group of 1590 women without a history of cancer was sampled from a population-based cohort study. All participants were aged 50 to 80 years. Five trained reviewers recorded the brain abnormalities. Two experienced neuro-radiologists reviewed the incidental findings.

Results

The cancer survivors had completed chemotherapy on average 21 years before. Of the 191 subjects, 2.6% had an aneurysm and 3.7% had a meningioma. The prevalence of meningiomas and aneurysms was not different between the groups. The prevalence of pituitary macro adenomas in the breast cancer survivors (1.6%) was higher than that in the reference group (0.1%) (OR = 23.7; 95% CI 2.3-245.8).

Conclusion

Contrary to commonly held opinions, we did not observe an increased prevalence of meningiomas in cancer survivors. Breast cancer survivors previously treated with chemotherapy are more likely to develop pituitary adenomas than persons without a history of cancer and chemotherapy treatment.     

Multiinstitutional study on target volume delineation variation in breast radiotherapy in the presence of guidelines

Purpose

This study aims to determine magnitude, causes and consequences of post-operative breast tumour target volume delineation variation among radiation oncologists in the presence of guidelines.

Materials and methods

Excision cavities, CTVs and PTVs of eight breast cancer patients were delineated on CT scans by 13 Dutch radiation oncologists (observers) from 12 Dutch institutes participating in the international Young Boost Trial. Delineated volumes and conformity indices were determined. CTV delineation variation (SD) was determined for anatomically relevant regions. Non-parametric statistics were performed to establish effects of observers, patient characteristics and regions on delineation variation.

Results

Even in the presence of delineation guidelines considerable delineation variation is present (0.24 < SD < 1.22 cm). Presence of clips or seroma reduced interobserver variation (0.24 < SD < 0.62 cm). Region-specific analysis showed distinct regions of higher variability per patient. This could not always be ascribed to anatomical features, suggesting interobserver variation is not solely due to lack of image quality.

Conclusions

In this study, interobserver delineation variation in breast tumour target volume delineation is larger than, e.g. setup inaccuracies and results from limited reliable visual guidance as well as interpretation differences between observers, despite guidelines. Reduction of delineation variation is essential in view of current developments in planning techniques, particularly for External Partial Breast Irradiation.     

Secondary radiation doses of intensity-modulated radiotherapy and proton beam therapy in patients with lung and liver cancer

Purpose

To compare the secondary radiation doses following intensity-modulated radiotherapy (IMRT) and proton beam therapy (PBT) in patients with lung and liver cancer.

Methods and materials

IMRT and PBT were planned for three lung cancer and three liver cancer patients. The treatment beams were delivered to phantoms and the corresponding secondary doses during irradiation were measured at various points 20-50 cm from the beam isocenter using ion chamber and CR-39 detectors for IMRT and PBT, respectively.

Results

The secondary dose per Gy (i.e., a treatment dose of 1 Gy) from PBT for lung and liver cancer, measured 20-50 cm from the isocenter, ranged from 0.17 to 0.086 mGy. The secondary dose per Gy from IMRT, however, ranged between 5.8 and 1.0 mGy, indicating that PBT is associated with a smaller dose of secondary radiation than IMRT. The internal neutron dose per Gy from PBT for lung and liver cancer, 20-50 cm from the isocenter, ranged from 0.03 to 0.008 mGy.

Conclusions

The secondary dose from PBT is less than or compatible to the secondary dose from conventional IMRT. The internal neutron dose generated by the interaction between protons and body material is generally much less than the external neutron dose from the treatment head.     

The value of routine physical examination in the follow up of women with a history of early breast cancer

Purpose

Routine physical examination is recommended in follow up guidelines for women with a history of breast cancer. The objective of this paper is to assess the contribution of routine physical examination in addition to mammography in the early diagnosis of breast cancer recurrences.

Patients and methods

The medical follow-up documents of 669 patients were reviewed. 127 contra-lateral breast cancers (CBCs) and 58 loco-regional recurrences (LRRs) in 163 patients were included. The additional contribution of routine physical examination over mammography was evaluated with the proportions of CBCs or LRRs detected by physical examination alone. χ² tests were used to compare the difference of contribution of physical examination among subgroups.

Results

Seven (6%) out of 127 CBCs and 13 (22%) out of 58 LRRs were detected by routine physical examination alone. Six LRRs (17%; 6/35) were in patients after breast conserving surgery and seven LRRs (30%; 7/23) in patients after mastectomy. There was a trend that the contribution of physical examination is higher in women under 60 years of age in the detection of CBCs (9%; 5/57) and LRRs (28%, 8/29) than in women over 60 years of age (CBCs:3%; 2/70 and LRRs:17%, 5/29; χ² = 3.090, P = 0.079).

Conclusions

Twenty-two percent of loco regional breast cancer recurrences would have been detected later without physical examination. Routine physical examination may be most valuable for women with a history of breast cancer younger than 60 years at follow-up visit.     

Reducing inequalities in lung cancer incidence through smoking policies

Introduction

Lower social class has higher lung cancer incidence, largely attributable to higher smoking prevalence among the lower social classes. We assessed the magnitude and time dimension of potential impact of targeted interventions on smoking on socioeconomic inequalities in lung cancer.

Methods

Using population dynamic modelling, we projected lung cancer incidence up to 2050 in lowest and highest socioeconomic groups under two intervention scenarios (annual 10% increase in cigarette prices and health advertisement) and compared this to a scenario of no intervention. For the analysis we retrieved smoking prevalence data from the General Household Survey of England and Wales between 1980 and 2006 and cancer incidence data from the national cancer registry.

Results

By 2050, the model projected that lung cancer incidence inequality would almost double (Incidence Rate Ratio (IRR) = 4.2 in 2050 vs. 2.5 in 2005) in men and slightly decrease (IRR = 2.4 in 2050 vs. 2.7 in 2005) in women compared to what was observed in 2005. If annual increase in cigarette price targeting the lowest socioeconomic group was implemented, socioeconomic inequality in lung cancer incidence in 2050 might be largely reduced (IRR = 1.5 and 1.4 among men and women, respectively). If in addition to annual price increase (targeted to the lowest socioeconomic group) health advertisement was implemented and successfully reduced smoking prevalence in the highest socioeconomic group, the lung cancer gap between the socioeconomic groups would be reduced by 78% and 58% in men and women by 2050.

Conclusion

Even under the best scenarios, inequality in lung cancer was not fully eliminated within 45 years period. Though the process is lengthy, rigorous interventions may reduce the expected widening of the future inequalities in lung cancer. Modelling exercise such as ours relies heavily on the quality of the input data and the assumptions, thus caution is needed in interpretation of our findings and should consider all the assumptions taken in the analysis.     

The role of ipsilateral breast radiotherapy in management of occult primary breast cancer presenting as axillary lymphadenopathy

Aim

To assess the role of ipsilateral breast radiotherapy (IBR) in women with occult primary breast cancer presenting with axillary metastases (OPBC).

Methods

Patients with axillary nodal metastases and histological diagnosis of breast cancer without palpable, mammographic or ultrasonographic evidence of a breast primary were identified from a prospectively maintained single institution database. Imaging, surgery, radiotherapy, recurrence and survival data were collected. Patients whose breast cancer primary was detected on MRI (but occult on clinical examination and other imaging) were excluded from the analyses of IBR and outcome, but were included in other exploratory analyses.

Results

Fifty-five patients were included between 1975 and 2009. Median follow up was 68 months. Twenty patients had breast magnetic resonance imaging (MRI) in addition to other imaging. A primary breast cancer was detected in 7 of these 20. 48/55 patients had no detectable breast primary. 35/48 patients (73%) were treated with radiotherapy to the conserved breast, and 13/48 (27%) with observation. Patients who had IBR had better 5 year local recurrence free survival (LRFS) (84% versus 34%, p < 0.001), and relapse free survival (RFS) (64% versus 34%, p = 0.05), but no difference in overall survival (OS) (84% versus 85%, p = 0.2). There was no difference in 5 year LRFS (80% versus 90%: p = 0.3) between patients who received radiation of 50 Gy in 25 fractions versus ?60 Gy.

Conclusion

Patients with OPBC should be managed with IBR and breast conservation, or mastectomy. Our data suggest it is not necessary to irradiate the breast to more than 50 Gy in 25 fractions.     

Effects of a 4-Week Multimodal Rehabilitation Program on Quality of Life,Cardiopulmonary Function,and Fatigue in Breast Cancer Patients

Purpose

This study examines the effects of a rehabilitation program on quality of life (QoL), cardiopulmonary function, and fatigue in breast cancer patients. The program included aerobic exercises as well as stretching and strengthening exercises.

Methods

Breast cancer patients (n=62) who had completed chemotherapy were randomly assigned to an early exercise group (EEG; n=32) or a delayed exercise group (DEG; n=30). The EEG underwent 4 weeks of a multimodal rehabilitation program for 80 min/day, 5 times/wk for 4 weeks. The DEG completed the same program during the next 4 weeks. The European Organization for Research and Treatment of Cancer-Core Quality of Life Questionnaire (EORTC QLQ-C30), EORTC Breast Cancer-Specific Quality of Life Questionnaire (EORTC QLQ-BR23), predicted maximal volume of oxygen consumption (VO₂max), and fatigue severity scale (FSS) were used for assessment at baseline, and at 2, 4, 6, and 8 weeks.

Results

After 8 weeks, statistically significant differences were apparent in global health, physical, role, and emotional functions, and cancer-related symptoms such as fatigue and pain, nausea, and dyspnea on the EORTC QLQ-C30; cancer-related symptoms involving the arm and breast on the EORTC QLQ-BR23; the predicted VO₂max; muscular strength; and FSS (p<0.050), according to time, between the two groups.

Conclusion

The results of our study suggest that a supervised multimodal rehabilitation program may improve the physical symptoms, QoL, and fatigue in patients with breast cancer.     

Symptoms 10-17 years after breast cancer radiotherapy data from the randomised SWEBCG91-RT trial

Background

Postoperative radiotherapy decreases the risk for local recurrence and improves overall survival in women with breast cancer. We have limited information on radiotherapy-induced symptoms 10-17 years after therapy.

Material and methods

Between 1991 and 1997, women with lymph node-negative breast cancer were randomised in a Swedish multi-institutional trial to breast conserving surgery with or without postoperative radiotherapy. In 2007, 10-17 years after randomisation, the group included 422 recurrence-free women. We collected data with a study-specific questionnaire on eight pre-selected symptom groups.

Results

For six symptom groups (oedema in breast or arm, erysipelas, heart symptoms, lung symptoms, rib fractures, and decreased shoulder mobility) we found similar occurrence in both groups. Excess occurrence after radiotherapy was observed for pain in the breast or in the skin, reported to occur “occasionally” by 38.1% of survivors having undergone radiotherapy and surgery versus 24.0% of those with surgery alone (absolute difference 14.1%; p = 0.004) and at least once a week by 10.3% of the radiotherapy group versus 1.7% (absolute difference 8.6%; p = 0.001). Daily life and analgesic use did not differ between the groups.

Conclusions

Ten to 17 years after postoperative radiotherapy 1 in 12 women had weekly pain that could be attributed to radiotherapy. The symptoms did not significantly affect daily life and thus the reduced risk for local recurrence seems to outweigh the risk for long-term symptoms for most women.     

Breast reconstruction following mastectomy for invasive breast cancer by free flaps from the abdomen is oncologically safe

Aims

To report the long-term results of oncological safety of breast reconstruction by autologous tissue following mastectomy for invasive breast cancer.

Methods

One-hundred-fifty-six consecutive patients with invasive breast cancer treated with mastectomy and reconstruction by autologous tissue were reviewed throughout (from 1987 to 2003 with median follow up time of 66 months).

Results

Median patient age was 45.9 years (range 26–68). The 157 observed tumors had mean diameter of 25 ± 19 mm, 70 of them were poorly differentiated, and 137 were invasive ductal carcinoma. Multifocal disease was present in 44 patients. Breast reconstruction was carried out only by autologous tissue (free flaps were used in 95% and free TRAM flap transfer was the most common reconstructive procedure). There was only one local recurrence as first site of recurrence, thus yielding a local recurrence rate of 0.6%.

Conclusions

Breast reconstruction by autologous tissue following mastectomy for invasive breast cancer is an oncologically safe procedure.     

Randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphoedema after radiotherapy for cancer

Background

A non-randomised phase II study suggested a therapeutic effect of hyperbaric oxygen (HBO) therapy on arm lymphoedema following adjuvant radiotherapy for early breast cancer, justifying further investigation in a randomised trial.

Methods

Fifty-eight patients with ?15% increase in arm volume after supraclavicular ± axillary radiotherapy (axillary surgery in 52/58 patients) were randomised in a 2:1 ratio to HBO (n = 38) or to best standard care (n = 20). The HBO group breathed 100% oxygen at 2.4 atmospheres absolute for 100 min on 30 occasions over 6 weeks. Primary endpoint was ipsilateral limb volume expressed as a percentage of contralateral limb volume. Secondary endpoints included fractional removal rate of radioisotopic tracer from the arm, extracellular water content, patient self-assessments and UK SF-36 Health Survey Questionnaire.

Findings

Of 53/58 (91.4%) patients with baseline assessments, 46 had 12-month assessments (86.8%). Median volume of ipsilateral limb (relative to contralateral) at baseline was 133.5% (IQR 126.0-152.3%) in the control group, and 135.5% (IQR 126.5-146.0%) in the treatment group. Twelve months after baseline the median (IQR) volume of the ipsilateral limb was 131.2% (IQR 122.7-151.5%) in the control group and 133.5% (IQR 122.3-144.9%) in the treatment group. Results for the secondary endpoints were similar between randomised groups.

Interpretation

No evidence has been found of a beneficial effect of HBO in the treatment of arm lymphoedema following primary surgery and adjuvant radiotherapy for early breast cancer.