Patterns of radiotherapy practice for patients with cervical cancer (1999-2001): patterns of care study in Japan

PURPOSE: To describe the patterns of definitive radiotherapy practice for patients with uterine cervical cancer from 1999 to 2001 in Japan. METHODS AND MATERIALS: The Japanese Patterns of Care Study (JPCS) working group conducted a third extramural audit survey of 68 institutions and collected specific information on 324 cervical cancer patients treated with definitive radiotherapy. RESULTS: Almost all patients (96%) were treated with whole pelvic radiotherapy using opposing anteroposterior fields (87%). A midline block was used in 70% of the patients. Intracavitary brachytherapy (ICBT) was applied in 82% of cases. Most patients (89%) were treated with high-dose rate (HDR) ICBT. Calculation of doses to organs at risk (ICRU 38) was performed for rectum in 25% of cases and for bladder in 18% of cases. Only 3% of patients were given intravenous conscious sedation during ICBT applicator insertions. The median total biologically effective dose at point A (EBRT+ICBT) was 74 Gy(10) in cases treated with HDR-ICBT. There was no significant difference in total biologically effective dose between stages. The median overall treatment time was 47 days. Concurrent chemoradiation was applied in 17% of patients. CONCLUSIONS: This study describes the general patterns of radiotherapy practice for uterine cervical cancer in Japan. Although methods of external radiotherapy seemed to be appropriate, there was room for improvement in ICBT practice, such as pretreatment. A substantial difference in total radiotherapy dose between Japan and the United States was observed.     

Patterns of care study in Japan

BACKGROUND: The Patterns of Care Study (PCS), started in the 1970's, is a well-known study used for clinical quality assurance (QA) in radiation oncology in the United States. PCS has been introduced in Japan since 1996. METHODS: Three national PCS surveys have been performed by means of external audit to evaluate patterns of care for the patients with carcinoma of any of esophagus and cervix treated with radiation between 1992 and 1994, for those with carcinoma of any of esophagus, cervix, breast, lung and prostate between 1995 and 1997, and for those with any of the five disease sites between 1999 and 2001. In the first PCS, feasibility of the study was confirmed. In the second PCS, two-stage cluster sampling of institutions and patients was performed and national averages for the survey items were calculated as QA measures. In the third PCS, additional imaging data were collected. The Japan/USA PCS workshops were held at San Francisco in 2001 and at Tokyo in 2003. RESULTS: Significant variations in process and structure were observed according to institutional stratification. In academic institutions, external beam energy > or =6 MV for deep-seated tumors of esophagus, lung, prostate and cervix, and brachytherapy for those of cervix and esophagus were used more frequently. There was an average of less than one full-time equivalent radiation oncologist in most non-academic institutions. These variations influenced the outcomes. There were also significant differences between USA and Japan in various aspects, e.g. a difference in radiation dose of 20% for uterine cervix cancer patients. It is higher in the USA. The number of new cancer patients requiring radiation is increasing steeply (120,000 in 2000 and 170,000 in 2005). Based on PCS data, structural guidelines were published and distributed throughout Japan. CONCLUSION: PCS is useful for establishing the clinical QA for radiation oncology as well as other specialties through detailed monitoring and evaluation of their structures, processes and outcomes.     

Patterns of care study of breast-conserving therapy in Japan: comparison of the treatment process between 1995 1997 and 1999 2001 surveys

BACKGROUND: The Japan Patterns of Care Study (JPCS) conducted two national surveys to identify changes associated with the treatment process of care for patients undergoing breast-conserving therapy (BCT). Between the two national surveys, the Japanese Breast Cancer Society published its treatment guideline for BCT. METHOD: The first survey collected data on 865 patients treated between 1995 and 1997 (JPCS-1), and the second on 746 patients treated between1999 and 2001 (JPCS-2) by extramural audits. RESULTS: There was a shift to an older age distribution in JPCS-2 compared with JPCS-1. In JPCS-2, the average patient age was 53.9 compared with 51.5 in JPCS-1 (P < 0.001). There was a reduction in the extent of breast surgery and the proportion of the patients who received quadrantectomy was 57.0% in JPCS-1 and 30.3% in JPCS-2 (P < 0.001). In JPCS-2, a cast or shell for immobilization was used at a significantly higher rate of 52.9% compared with 32.6% for JPCS-1 (P < 0.001). The rate of boost irradiation was increased in JPCS-2, especially for patients with a positive surgical margin; it was significantly increased to 83.5% in JPCS-2 compared with 53.9% in JPCS-1 (P < 0.001). CONCLUSIONS: The second survey revealed a rapid change in the trend of the treatment of BCT in Japan and represented high compliance of the treatment guideline for BCT published by the Japanese Breast Cancer Society (JBCS) in 1999.     

Patterns of care study in Japan: analysis of patients subjected to mastectomy followed by radiotherapy

BACKGROUND: Two prospective studies reported in 1997 demonstrated that postoperative radiotherapy after mastectomy was not only associated with a higher loco-regional control rate but also with a higher overall survival rate. The purpose of this study is to clarify the processes of care for patients undergoing mastectomy and postoperative radiotherapy in Japan. METHODS: A national survey carried out in 1998-2000, involving 79 Japanese institutions by two-stage cluster sampling of institutions and patients, disclosed that 1124 patients with breast cancer had been treated between 1995 and 1997. Mastectomy followed by radiotherapy was performed on 258 patients. RESULTS: The compliance rates for pre-treatment evaluation, including history, physical examination and mammography, averaged approximately 50% (24-81%). The chest wall was irradiated in only 19% of the patients and regional node irradiation was carried out for 70-86%. Radiation treatment planning with the aid of computed tomography was done in only 29% of patients (university hospitals or cancer centers, 39%; other hospitals, 17%; P = 0.001). Hormonal therapy was administered to 56% of the patients who showed no endocrine responsiveness. Non-intensive chemotherapy, which did not include the use of anthracycline or taxol, was used in 55% of the patients who received chemotherapy. CONCLUSIONS: There is room for improvement regarding some aspects of radiotherapy and adjuvant systemic therapies. Especially in the field of radiotherapy, significant differences were found among the treatment techniques employed in various institutions.     

Patterns of care study for postmastectomy radiotherapy in Japan: its role in monitoring the patterns of changes in practice

BACKGROUND: Three prospective randomized clinical trials (RCT) in the 1990s demonstrated the survival benefit of postmastectomy radiotherapy (PMRT) for patients with locally advanced breast cancer. The present study was performed to evaluate whether the Patterns of Care Study (PCS) fulfills a role in monitoring the patterns of changes in clinical practices in Japan. METHODS: The first survey (JPCS-1) involved 79 Japanese facilities by two-stage cluster sampling of facilities and patients, and was carried out during 1998-2000. JPCS-1 included 1124 patients with breast cancer who were treated between 1995 and 1997. The second survey (JPCS-2) was carried out during 2001-2003, involving 827 patients who were treated between 1999 and 2001 in 76 facilities. RESULTS: Patients with adverse risk factors, including pathologically axillary positive nodes (> or =4) and/or advanced primary disease (pT3-4) accounted for 57% of the patients who received PMRT in JPCS-1 and 72% of those in JPCS-2 (P = 0.039). The multiple radiotherapy target volume including the chest wall and regional lymph nodes was applied in 18% of the patients in JPCS-1 and 44% of those in JPCS-2 (P < 0.001). However, the dose distribution was calculated in only 42% of the patients in both surveys (P = 0.467). CONCLUSIONS: The eligibility and the target volume for PMRT were influenced by the outcome of RCT, but the quality of radiotherapy did not improve sufficiently. The PCS survey is useful to monitor the changes in patterns of clinical practice and can clarify some problems with radiotherapy techniques.     

Postoperative radiotherapy for non-small-cell lung cancer: results of the 1999-2001 patterns of care study nationwide process survey in Japan

To investigate the practice process of postoperative radiation therapy for non-small-cell lung cancer (NSCLC) in Japan. Between April 2002 and March 2004, the Patterns of Care Study conducted an extramural audit survey for 76 of 556 institutions using a stratified two-stage cluster sampling. Data on treatment process of 627 patients with NSCLC who received radiation therapy were collected. Ninety-nine (16%) patients received postoperative radiation therapy between 1999 and 2001 (median age, 65 years). Pathological stage was stage I in 8%, II in 17%, IIIA in 44%, and IIIB in 20%. The median field size was 9 cmx11 cm, and median total dose was 50 Gy. Photon energies of 6 MV or higher were used for 64 patients, whereas a cobalt-60 unit was used for five patients. Three-dimensional conformal treatment was used infrequently. Institutional stratification influenced several radiotherapy parameters such as photon energy and planning target volume. Smaller non-academic institutions provided worse quality of care. The study confirmed continuing variation in the practice of radiotherapy according to stratified institutions. Outdated equipment such as Cobalt-60 units was used, especially in non-academic institutions treating only a small number of patients per year.     

The Cambridge post-mastectomy radiotherapy (C-PMRT) index: A practical tool for patient selection

Background and purpose

Post mastectomy radiotherapy (PMRT) reduces loco-regional recurrence (LRR) and has been associated with survival benefit. It is recommended for patients with T3/T4 tumours and/or ?4 positive lymph nodes (LN). The role of PMRT in 1–3 positive LN and LN negative patients is contentious. The C-PMRT index has been designed for selecting PMRT patients, using independent prognostic factors for LRR. This study reports a 10 year experience using this index.

Materials and methods

The C-PMRT index was constructed using the following prognostic factors (a) number of positive LN/lymphovascular invasion, (b) tumour size (c) margin status and (d) tumour grade. Patients were categorised as high (H) risk, intermediate (I) risk and low (L) risk. PMRT was recommended for H and I risk patients. The LRR, distant metastasis and overall survival (OS) rates were measured from the day of mastectomy.

Results

From 1999 to 2009, 898 invasive breast cancers in 883 patients were treated by mastectomy (H: 323, I: 231 and L: 344). At a median follow up of 5.2 years, 4.7% (42/898) developed LRR. The 5-year actuarial LRR rates were 6%, 2% and 2% for the H, I and L risk groups, respectively. 1.6% (14/898) developed isolated LRR (H risk n = 4, I risk group n = 0 and L risk n = 10). The 5-year actuarial overall survival rates were 67%, 77% and 90% for H, I and L risk groups, respectively.

Conclusion

Based on published literature, one would have expected a higher LRR rate in the I risk group without adjuvant RT. We hypothesise that the I risk group LRR rates have been reduced to that of the L risk group by the addition of RT. Apart from LN status and tumour size, other prognostic factors should also be considered in selecting patients for PMRT. This pragmatic tool requires further validation.     

Paediatric medulloblastoma: Patterns of care and radiotherapy quality assurance in Australia

The purpose of this study was to document how children in Australia with medulloblastoma are being treated and to evaluate the quality of radiotherapy (RT) delivered. The Radiotherapy Database of the Australian and New Zealand Children’s Haematology and Oncology Group was used to identify 46 children with medulloblastoma younger than the age of 15 years treated with radical intent by craniospinal irradiation between 1997 and 1999 inclusively. Twenty‐six patients had completely resected disease without evidence of disease spread. Of these, 16 patients received a craniospinal RT dose of <25 Gy in addition to chemotherapy. RT treatment immobilization methods varied, as did planning methods. RT dose to critical structures was recorded on treatment plans for only 15% of patients. The average systematic error in shield placement at the posterior orbit was 5.2 mm, and two‐thirds of patients were ‘overshielded’ at this site. Adequate coverage of the distal end of the thecal sac was achieved in fewer than 50% of on‐treatment verification films for 21 of 45 patients. With a reduction in RT dose to the craniospinal axis for paediatric medulloblastoma, greater attention is needed for patient immobilization, documentation of RT dose to critical structures and the placement and reproducibility of shielding.     

Patterns of pretreatment diagnostic assessment and staging for patients with cervical cancer (1999-2001): patterns of care study in Japan

OBJECTIVE: To evaluate the patterns of pretreatment diagnostic assessment in uterine cervical cancer patients treated with definitive radiotherapy in Japan. METHODS: The Japanese Patterns of Care Study working group conducted a second extramural audit survey of 68 institutions and collected specific information on 631 patients with cervical cancer. All patients were treated with radiotherapy in 1999-2001. Of these, 324 patients treated without surgery were the subjects of this study. RESULTS: International Federation of Gynecology and Obstetrics-prescribed diagnostic procedures were performed at moderate rates in our study cohort. The performance rates of chest X-ray, intravenous urography, cystoscopy, and proctoscopy were 74, 54, 53, and 33%, respectively. Cross sectional imaging studies were frequently performed. Pelvic CT, abdominal CT, and pelvic MRI were performed in 88, 80, and 76%, respectively. Lymphangiography (1%) and surgical evaluation (1%) were rarely done. Only one patient underwent PET scans in this survey period. CONCLUSIONS: This study demonstrated the patterns of pretreatment diagnostic assessment in cervical cancer patients treated with definitive radiotherapy in Japan.     

Postoperative radiotherapy for uterine cervical cancer: results of the 1995-1997 patterns of care process survey in Japan

OBJECTIVE: To determine the average national practice of postoperative radiotherapy for uterine cervical cancer in Japan. METHODS: The Japanese Patterns of Care Study (PCS) reviewed the process of care employed for 455 uterine cervical cancer patients who were treated with surgery followed by postoperative radiotherapy (RT) during 1995-1997. Cases with missing data were excluded from calculations of percentage and significance for each of the surveyed items. RESULTS: According to FIGO stages, 198 patients (45%) were in stage I, 52 patients (12%) were in stage IIA, 146 patients (33%) were in stage IIB and 46 patients (10%) were in stage III/IVA. The most common surgical procedure among the patients was radical hysterectomy (73%). Three hundred and seventy patients (82%) were treated with external beam RT (ERT) alone, and 74 patients (17%) were treated with a combination of ERT and intracavitary RT (ICRT). A midline block was used for the pelvic field in 63 patients (14%). Only seven patients (2%) were treated with extended field ERT. Pelvic ERT was most often performed using AP-PA opposed fields for 431 patients (97%). A majority of the patients (312 patients, 70%) were treated with a total dose of 45.0-50.4 Gy for ERT. Chemotherapy (CT) was administered to 178 patients (40%), neoadjuvant preoperative CT was administered to 80 patients (22%) and concurrent CT with postoperative RT was administered to 29 patients (8%). CONCLUSION: This PCS established the national practice average of postoperative RT for uterine cervical cancer. Follow-up studies need to be conducted to determine whether the observed differences in treatment processes affect outcomes.     

Patterns of Care Study quantitative evaluation of the quality of radiotherapy in Japan

BACKGROUND: Quality assurance (QA) of clinical practice is important for any medical specialty. Programs based on the Patterns of Care Study (PCS) have been developed to compare the quality of radiotherapeutic care at individual institutions, with the national average representing the process and outcome of radiotherapy. The feasibility of these programs was analyzed. METHODS: Calculation programs for the national average and standard score were developed to evaluate quantitatively the process and outcome of radiotherapy at individual institutions as well as at the national level. The programs were used to evaluate the quality of radiotherapy for 561 esophageal carcinoma patients surveyed in the Japanese PCS. RESULTS: As a representative example of QA measurement, the national average for the 5-year survival rate for these patients in the nonsurgery group was 5%. The regional averages for those in academic and nonacademic institutions were 9% and 1%, respectively (P = 0.0142), showing a significant difference between these two institutional strata. The standard score compared with the national average for institution No.105, for example, was 16.3 (P < 0.0001), with the positive value indicating that the outcome at this institution was significantly higher than the national average. The corresponding figure compared with the regional average was -0.3 (P = 0.7391), with the negative value indicating the outcome is not superior to the regional average of academic institutions. CONCLUSIONS: These programs make it possible to compare quantitatively the quality of radiation therapy at individual institutions with the national and regional averages. They should also be useful for nationwide QA projects in radiation oncology as well as in other medical specialities.     

Patterns of care in radiotherapy of breast cancer in Austria 1985: data acquisition and comparison with data of US-PCS 1983.

PURPOSE: In Austria, a Patterns of Care Study (PCS) has been conducted to evaluate the standards of practice for breast cancer patients. The year 1985 was selected in order to establish a base data set. MATERIALS AND METHODS: At all nine radiation therapy facilities active in patient treatment in 1985, ten patients charts were randomly selected and reviewed. Evaluation of the radiotherapeutic standards was the principal purpose, however, surgical and histopathological parameters were also considered. RESULTS: Results of the Austrian PCS (including 90 patients) were compared with the "1983 Patterns of Care Process Survey for Definitive Breast Irradiation" performed in 1983 in the U.S. (including 191 patients). Documentation of pathologic tumour size (83% vs. 73%), histologic tumour subtype (99% vs. 97%) and microscopic margin analysis (60% vs. 51%) showed comparable results. Technical equipment was obviously quite different in the two countries, cobalt therapy was used in 25% in the US-PCS compared to 71% in the Austrian PCS. A clear difference also was obtained concerning the use of wedges for tangential breast/thoracic wall fields (64% vs. 21%) and the frequency of portal films (93% vs. 26%). CONCLUSIONS: Comparing both PCS studies, we found overall many similarities. Differences could be obtained in the quality level of radiation treatment, as for example use of wedges for tangential fields and the number of portal films. In a next step, a further Austrian PCS is planned to compare the Austrian base data from 1985 with quality standards from 1993 and 2001.     

Radical external beam radiotherapy for prostate cancer in Japan: results of the 1999-2001 patterns of care process survey

BACKGROUND: The Patterns of Care Study evaluated standards of practice for patients with clinically localized prostate cancer treated with radiotherapy in Japan. This study examined the influence of institutional stratification on care for patients receiving radical external beam radiotherapy. METHODS: A national survey of 66 institutions was conducted using two-stage cluster sampling, and detailed information was accumulated on 283 patients who received radiotherapy between 1999 and 2001. RESULTS: In A (academic) and B (non-academic) institutions, more than 80% of patients had intermediate or unfavorable risk disease. Although there were no significant differences in disease characteristics between A and B institutions, institutional stratification significantly affected radiotherapy practice patterns, such as the use of a CT-based treatment planning (A1: 91.5%, B: 77.1%; P = 0.0007) and the use of conformal therapy (A: 56.4%, B: 24.1%; P < 0.0001). CT-based treatment planning and conformal therapy significantly influenced total radiation dose (P < 0.0001 for each). Hormonal therapy was commonly used in both A and B institutions (A: 89.0%, B: 90.7%). Many patients with a favorable prognosis (A: 62.5%, B: 91.7%) received hormonal therapy, and most patients with unfavorable risk disease (A: 93.6%, B: 91.6%) also received hormonal therapy. CONCLUSION: During the period 1999-2001, the majority of prostate cancer patients treated in Japan with radical external beam radiotherapy had advanced diseases. Institutional stratification significantly affected radiotherapy practice patterns, with the notable exception that radiotherapy was commonly combined with hormonal therapy regardless of the institutional stratification and individual risk.     

Patterns of radiotherapy practice for patients with squamous carcinoma of the uterine cervix: patterns of care study

PURPOSE: To determine the impact of research findings and evolving technology on the patterns of radiotherapy practice for patients with carcinoma of the uterine cervix. METHODS AND MATERIALS: Sixty-two radiation therapy facilities participated in the study after having been selected from a random sample, proportionally stratified according to practice type, of all United States facilities. Each facility submitted a list of patients treated during 1992-1994 with radiation for squamous carcinoma of the cervix. Cases for review were randomly selected from each institution after excluding those of patients who had distant metastases or initial hysterectomy. A total of 471 patients' records were reviewed in the treating institutions to obtain information about patients' characteristics, diagnostic evaluation, tumor extent, treatment approach, and radiotherapy techniques. RESULTS: Of the 61 facilities that treated eligible cases of intact cervical cancer during the 3-year survey period, 35 (57%) treated fewer than three eligible patients per year. Thirty-four (83%) of 41 non-academic facilities vs. 1 (5%) of 20 academic facilities treated fewer than three patients per year. FIGO stages were I, II, III, and IV in 32%, 40%, 24%, and 3% of patients, respectively. Computed tomography (CT) was the most common method of lymph node evaluation, but surgical evaluation, which was performed in 76 (16%) patients, had increased from previous surveys. Fields were designed using a dedicated simulator in 95% of patients; a dedicated CT unit was used for treatment planning in 119 (30%) cases. External beam irradiation was most often given using a four-field technique at 180 cGy per day on a 10-20 MV linear accelerator. The average daily fraction size had decreased from previous surveys, and 13% of patients were treated with daily doses of 170 cGy or less. Most patients were treated with a combination of external beam and low dose-rate (LDR) intracavitary irradiation. Of 425 patients who had treatment with curative intent that included brachytherapy, 362 (85%) had LDR brachytherapy, 45 (11%) had high dose-rate (HDR) brachytherapy, 3 had a combination of HDR and LDR, and 15 had incomplete information about the brachytherapy dose-rate. Forty-six (23%) of 197 patients with Stages I-IIA disease were treated with radiation followed by extrafascial hysterectomy. Of 111 patients treated with curative intent for Stage III-IV disease, 72 (65%) had a combination of external beam and intracavitary radiation therapy, 22 (20%) had external beam plus interstitial brachytherapy, and 17 (15%) were treated with external beam irradiation only. For patients who completed treatment with curative intent and did not have adjuvant hysterectomy or HDR brachytherapy, the median total dose at point A was 82.5 Gy. For all patients who completed treatment with radiation alone, the median total duration of treatment was 63 days; more than 70 days were taken to complete treatment in 33% of cases. Twenty-nine percent of patients received chemotherapy, usually concurrent with their radiation therapy. Only 27% of these patients were on investigational protocols. CONCLUSIONS: Greater participation in well-designed prospective trials might help clinicians address important clinical questions and reduce current inconsistencies in the use of adjuvant treatments. Radiation oncologists should take steps to avoid unnecessary treatment protraction and to improve patient compliance. Future studies will be needed to determine whether the small number of cases being treated in most nonacademic facilities will influence the outcome for patients with invasive cervical carcinoma.     

Patterns of radiotherapy practice for patients with carcinoma of the uterine cervix: a patterns of care study

PURPOSE: To determine the influence of research findings and evolving technology on the practice of radiotherapy in patients with carcinoma of the cervix. METHODS AND MATERIALS: Radiation oncology facilities were randomly selected from two strata: those that treated <500 and those that treated >/=500 new cancer patients annually. Patient records were randomly selected from lists of eligible patients treated between 1996 and 1999 at each institution. A total of 442 patient records were reviewed at 59 facilities (55 with eligible patients). National estimates were made using weights that reflected the relative contribution of each institution and of each patient within the sampled institutions. Most estimates were based on the 383 patients who had received their initial therapy at a surveyed facility (excluding the 59 patients who were referred for brachytherapy only after initial treatment at another facility). The estimates of brachytherapy practice were based on the 408 patients who had received their brachytherapy at a surveyed facility. The data were compared with those obtained from a similar 1992-1994 survey. RESULTS: Overall, 40.5%, 25.4%, and 33.9% of patients had Stage IA-IIA, IIB, or IIIA-IVA disease, respectively. CT was the most common method of nodal evaluation, with surgical evaluation performed in only 12% of patients. Of the 55 facilities with eligible patients, 32 had treated <==8 eligible patients during the 4-year study period. We estimated that 27.5% of patients were treated at facilities that treated <==2 patients with intact cervical cancer annually; 43% were treated at facilities that treated <500 new patients annually. Patients treated at small facilities were significantly more likely to have received a total dose to Point A of <80 Gy, to have had their treatment protracted to >70 days, and to have undergone adjuvant hysterectomy or chemotherapy. In large facilities, radiotherapy was less likely to be protracted to >70 days in the 1996-1999 survey than in the 1992-1994 survey (p < 0.0001); however, in small facilities, treatment was more likely to be protracted than in the earlier survey (p = 0.06), contributing to increasing disparities between the treatments given in large and small facilities. Overall, 92.4% of patients treated with nonpalliative intent were treated with brachytherapy. Of the patients who received brachytherapy, 16.4% had at least part of their brachytherapy delivered at a high dose rate; this was not significantly greater than the proportion treated with high-dose-rate brachytherapy in the 1992-1994 survey (9.1%; p = 0.3). The proportion of patients receiving chemotherapy as part of their initial treatment in 1996-1999 (34.6%) was not significantly different statistically from that in 1992-1994 (25.6%; p = 0.3). However, in 1999, 63% of patients had received chemotherapy compared with 19%, 28%, and 26% in 1996, 1997, and 1998, respectively. The details and confirmation of chemotherapy administration were rarely documented in the radiation oncology clinic notes and hospital records. CONCLUSION: The sharp increase in the use of chemotherapy in 1999 suggested rapid application of the results from randomized trials. However, considerable heterogeneity in practice patterns remains, particularly in the use of brachytherapy. The practice at small facilities appears to differ significantly from that at larger facilities in several respects, with a statistically significantly larger proportion of treatments at small facilities failing to meet current guidelines for optimal treatment.     

Trends in the practice of radiotherapy for localized prostate cancer in Japan: a preliminary patterns of care study report

BACKGROUND: This is the first study to examine the characteristics and changes of the patterns of radiotherapy for prostate cancer in Japan. METHODS: The Japanese Patterns of Care Study (PCS) conducted a random survey of 84 institutions nationwide. Detailed information was collected on prostate cancer patients without distant metastases, who received radiotherapy during 1996-1998 and 1999-2001. RESULTS: The patients were divided into three groups: The Fresh Group (n = 338) was treated with radical radiotherapy with photon beams; the Surgery Group (n = 115) was treated after prostatectomy; and the Hormone-Refractory Group (n = 117) was treated after progression from hormonal therapy. In the Fresh Group, there was a decline in the fraction of patients with T3-4 tumors, from 65.2% in 1996-1998 to 43.9% in 1999-2001. In 1999-2001, a higher median dose of 69 Gy was irradiated as compared to 65 Gy in 1996-1998. In particular, the fraction of the patients treated with doses >or=70 Gy increased from 16.4% to 46.3%. In the Surgery Group, the percentage of clinical T3-4 tumors before prostatectomy decreased from 71.4% in 1996-1998 to 16.2% in 1999-2001. The median radiation dose of 60 Gy did not change, but the 1999-2001 results showed a decrease in the use of doses <60 Gy. In the Hormone-Refractory Group, the median dose increased from 60 Gy in 1996-1998 to 67 Gy in 1999-2001. CONCLUSION: These data suggest that radiation doses for prostate cancer in Japan have increased dramatically within a short period of time.     

External breast prostheses in post-mastectomy care: women's qualitative accounts

GALLAGHER P., BUCKMASTER A., O’CARROLL S., KIERNAN G. & GERAGHTY J. (2009) European Journal of Cancer Care 19 , 61–71
External breast prostheses in post‐mastectomy care: women's qualitative accounts A good‐quality external breast prosthesis and prosthesis‐fitting service is an integral part of the recovery process post‐mastectomy. However, this is an area of care that has minimal information or research available. The aim of this research was to investigate women's experience of the provision, fitting, supply and use of breast prostheses in Ireland. To ascertain women's own personal and subjective experiences, five focus groups with 47 women recruited through national cancer advocacy/support organizations and four Follow‐up Breast Clinics throughout Ireland were conducted. As a result, five main themes emerged: (1) The fitting experience – Fitting? (2) Post‐mastectomy products – Having? (3) Cost – Affording? (4) Information – Knowing? and (5) Adaptation – Accepting? The emerging themes pinpointed the impact of the fitting experience, fitting environment and the qualities of a prosthesis fitter on a woman's experience in obtaining a first or replacement breast prosthesis; the importance of the physical characteristics of the prosthesis and mastectomy bras; cost, affordability and entitlements; a lack of and perceived difficulty in getting information; and the myriad of personal and social impacts of a breast prosthesis for the woman. These findings are integral for the development of standards of practice in the fitting and supply of external breast prostheses in post‐mastectomy care.