Clinical Oncology

A Study of Medical Intervention in Routine Breast Cancer Follow-up

Q. Ghafoor, P. Sanghera, R.J. Grieve — 2010-03-01

Abstract: Aims: The incidence and prevalence of breast cancer is increasing, and survival rates continue to climb, placing increasing demands on clinic time. In the modern health service, the value of routine follow-up has been questioned, as there is a very low rate of detection of asymptomatic recurrences in such clinics. The National Institute for Health and Clinical Excellence has recommended potential discharge after the completion of adjuvant treatment. However, there is more to follow-up than the detection of recurrence. This aim of this study was to determine the level and type of intervention occurring within a dedicated hospital breast cancer follow-up clinic, taking into account recent developments in management. We also reviewed the role of community-based breast cancer follow-up as an alternative setting to the hospital.Materials and methods: All patients attending a dedicated breast cancer follow-up clinic within a hospital setting under the care of a single oncologist over a 7 month period were prospectively studied. Information regarding tumour characteristics, in addition to any form of investigation, intervention and trial recruitment, was recorded for 598 patients.Results: A breast cancer-relevant intervention was carried out in 50% of patients. Forty-seven patients (7.9%) had their breast medication changed, 81 (13.5%) were investigated for suspected recurrence and 44 (7.4%) were enrolled into a clinical trial. Fourteen (2.3%) patients were referred to another specialty; in total, 115 (19.2%) further investigations were carried out related to the disease or treatment.Conclusions: A significant number of interventions were undertaken from the clinic. A large proportion of these could be co-ordinated from primary care, if adequate guidelines are in place. However, rapid advances in breast cancer management should be considered, and cost-effectiveness needs to be studied before making strong recommendations as to where breast cancer follow-up is best managed.

Attitudes of Canadian Radiation Oncologists towards Post-lumpectomy Radiotherapy for Elderly Women with Stage I Hormone-responsive Breast Cancer

E. Warner, E. Chow, A. Fairchild, E. Franssen, L. Paszat, E. Szumacher — 2010-03-01

Abstract: Aims: Post-lumpectomy breast radiation is the standard of care for all patient subgroups. However, elderly women with stage I breast cancer on adjuvant tamoxifen therapy have a 4% risk of local recurrence after lumpectomy without adjuvant breast radiation. The purpose of this study was to explore the attitudes of Canadian radiation oncologists who treat breast cancer with respect to their use of adjuvant post-lumpectomy radiotherapy, and their willingness to implement a decision aid for this patient population.Materials and methods: The questionnaire was mailed to 141 Canadian radiation oncologists who treat breast cancer. The respondents were asked to complete an online survey consisting of four parts: (1) demographic information; (2) factors determining post-lumpectomy radiation treatment decisions; (3) hypothetical case scenarios; (4) interest in using a decision aid in their practice.Results: Among the 61 (43%) physicians who completed the survey, there was substantial response variation. After contraindications to radiotherapy, patient overall health and patient preference had the greatest influence on their decision to offer radiotherapy to this patient subgroup. Margin status and use of hormonal therapy were given less importance. For each of the case scenarios, 60–83% of physicians (depending on the case scenario) would offer the patient a choice; far fewer (12–57%) would be comfortable not irradiating. Sixty-four per cent of respondents welcomed the concept of a decision aid for this population.Conclusions: Although there is significant variation in practice patterns and attitudes among radiation oncologists regarding post-lumpectomy radiotherapy for elderly, low-risk breast cancer patients, the vast majority value patient choice and would be willing to use a decision aid designed for this population in their practice.

Factors Predicting Outcome for Advanced Gastroesophageal Cancer in Elderly Patients Receiving Palliative Chemotherapy

S.R. Lord, P.S. Hall, P. McShane, J. Brown, M.T. Seymour — 2010-03-01

Abstract: Aims: Most patients with advanced gastroesophageal cancer are elderly, but current standard regimens have emerged from trials predominantly involving patients with a median age <65 years. The aim of this study was to assess the factors influencing survival outcome for an elderly gastroesophageal cancer non-trial population.Materials and methods: We reviewed the case notes of all patients in our centre over the age of 65 years who received palliative chemotherapy for gastroesophageal cancer over a period of 3.5 years. Patients were classified as having received standard, non-standard combination or single-agent chemotherapy. After an initial univariate analysis, a multivariate analysis of the most significant prognostic factors was carried out.Results: In total, 120 patients were suitable for analysis. The median overall survival for patients receiving standard chemotherapy was 8.1 months, non-standard combination 8.3 months and single-agent fluoropyrimidines 3.9 months. Poor prognosis was predicted by two independent factors: poor performance status (hazard ratio 2.402; 95% confidence interval 1.53–3.77, P<0.001) and the presence of cancer symptoms (hazard ratio 2.235; 95% confidence interval 1.32–3.79, P=0.003).Conclusions: An assessment of the performance status and the level of symptoms is vital in this vulnerable group of patients. Prospective randomised trials to assess the benefit of chemotherapy in elderly patients with gastroesophageal cancer are required.

Current Trends in the Follow-up of Head and Neck Cancer Patients in the UK

A. Joshi, F. Calman, M. O'Connell, J.-P. Jeannon, P. Pracy, R. Simo — 2010-03-01

Abstract: Aims: The follow-up of patients with head and neck cancer is an essential aspect of their management. Follow-up provides support and reassurance for patients and will allow early detection of recurrence and second primary tumours. However, there is little evidence of a survival benefit from follow-up. With prolonged follow-up periods, multidisciplinary teams may be under increasing pressure to see more patients and this could have a negative effect on the time and quality of consultations given to individual patients. The aim of the present study was to analyse the current trends in the follow-up of head and neck cancer patients after treatment with curative intent in the UK.Materials and methods: A postal questionnaire was sent to all members of the British Association of Head and Neck Oncologists.Results: Three hundred and twenty-seven questionnaires were sent and 214 were returned, making a response rate of 65.4%. One hundred and ninety-eight (61%) of these were deemed appropriate for evaluation and of these 111 (56%) clinicians followed up patients for a minimum of 5 years with 25 (13%) following patients for 10 years and 44 (22%) for life. Within the set of clinicians following patients for 5 years, 24 (12%) followed up patients with salivary gland and thyroid malignancies for a longer period of time. All clinicians concurred that the reasons for follow-up are to support patients, to detect local recurrences or metastases, second primary tumours and to monitor and manage the complications of treatment.Conclusions: Most of the clinicians followed up their patients up to a minimum of 5 years, with a significant minority who followed up the patients treated for cancers of the head and neck for longer periods. More studies are needed to elucidate the rationale and evidence for follow-up and to determine the adequate period of surveillance.

Primary Radiotherapy for Carcinoma of the Retromolar Trigone: A Useful Alternative to Surgery

2010-03-01

Abstract: Aims: Squamous cell carcinoma of the retromolar trigone is uncommon. The standard initial treatment is primary surgery, which usually involves microvascular reconstruction with a composite flap. Some patients are considered unsuitable for this procedure. This retrospective study examined the outcome and toxicity for patients with squamous cell carcinoma of the retromolar trigone treated with definitive radiotherapy in a single centre.Materials and methods: Between 1991 and 2000, 43 patients were treated with definitive radiotherapy with a median dose of 50Gy in 16 fractions over 21 days. Hospital case notes and radiotherapy records were analysed.Results: The median age was 66 years (range 39–84 years). Nodal disease was evident in 13 (30.2%) patients. Twenty-one patients (51.2%) had stage I/II disease and 20 patients (48.8%) had stage III/IV disease. After a median follow-up of 59 months, 13 (30.2%) patients were alive and well, nine (20.9%) patients had died of an intercurrent illness and 21 (48.8%) had died of their disease. Five-year locoregional control was 46.5% (95% confidence interval 29.7–61.7), cause-specific survival was 45.7% (95% confidence interval 29.1–60.8) and overall survival was 30.9% (95% confidence interval 17.5–46.3). Osteoradionecrosis was documented in two patients.Discussion: This hypofractionated regimen is convenient for this patient population and produced comparable outcomes to longer fractionation schedules without an increase in late toxicity.

Radiobiological Modelling of the Therapeutic Ratio for the Addition of Synchronous Chemotherapy to Radiotherapy in Locally Advanced Squamous Cell Carcinoma of the Head and Neck

A. Hartley, P. Sanghera, J. Glaholm, H. Mehanna, C. McConkey, J. Fowler — 2010-03-01

Abstract: Aims: To model the therapeutic gain from the addition of synchronous chemotherapy to radiotherapy in locally advanced head and neck cancer.Materials and methods: Refinements to previous methodology, including the derivation of weighted estimates of key parameters from randomised studies and the use of the expected mucosal biologically effective dose concept, have been used to produce an evidence-based assessment of the benefit from the addition of chemotherapy when considering acute grade 3 mucositis and rates of 5-year local control.Results: For a value of α=0.3Gy−1 the additional contribution from chemotherapy to local control was estimated to be 9.3Gy10 and to grade 3 mucositis 6.4Gy10. The additional expected mucosal biologically effective dose if radiotherapy dose escalation had been used instead of chemotherapy would have been 11.6Gy10. Therefore, the mucosal sparing by using synchronous chemotherapy rather than radiotherapy dose escalation was found to be 5.2Gy10 or the equivalent dose in 2Gy fractions 4.3Gy EQD2.Conclusion: This modelling suggests a small therapeutic gain for the use of synchronous chemotherapy instead of radiotherapy dose escalation. This conclusion is dependent on the linear quadratic model and takes no account of late side-effects. This gain would be greater for agents that enhance the mucosal reaction to a lesser degree. This gain may be less when data for radiotherapy dose escalation to smaller high dose volumes using intensity-modulated radiotherapy are considered.

Radioiodine Ablation for Differentiated Thyroid Cancer—None, One Dose or Two?

G.J.G. Rees — 2010-03-01

Abstract: Patients with good prognosis differentiated thyroid cancer are at risk from over-treatment with radioiodine thyroid remnant ablation. Some with unfavourable localised disease might benefit from an elective second dose.

Should We Routinely Offer a Second Admission for Radioiodine to Patients with High-risk Differentiated Thyroid Cancer?

G.E. Gerrard, L. O'Toole, F. Roberts — 2010-03-01

Abstract: Aims: To assess whether an elective second admission for radioiodine is useful for patients with high-risk differentiated thyroid cancer (DTC).Materials and methods: A retrospective analysis was carried out on 47 high-risk DTC patients treated with a second admission for radioiodine at our centre during the 2007–2008 period.Results: In 21 patients (45%), the surgeon described an incomplete resection. Twenty-six (55%) had surgical macroscopic complete resection, but cancer cells at the margin of excision histologically. Overall, at the second admission for radioiodine, 27 patients (57%) had a normal post-treatment scan and undetectable thyroid-stimulating hormone (TSH) stimulated thyroglobulin. Twenty patients (43%) had raised stimulated thyroglobulin at second admission for radioiodine, of whom only six (13%) had abnormal uptake (>0.1%) on the post-treatment scan.Conclusions: A second admission for radioiodine could have been avoided in most patients. Instead, information from stimulated thyroglobulin and a diagnostic radioiodine scan would have been sufficient to guide further management. This study also provides interesting outcome data on incompletely resected DTC.

Is There a Role for Adjuvant Hysterectomy after Suboptimal Concurrent Chemoradiation in Cervical Carcinoma?

2010-03-01

Abstract: Aims: Failure to carry out intracavitary brachytherapy (ICBT) in cervical carcinoma results in suboptimal chemoradiation and increases the risk of recurrence. The aim of this study was to investigate the role of adjuvant hysterectomy after unsuccessful ICBT.Materials and methods: A retrospective analysis was carried out of all women referred with cervical carcinoma between January 1999 and July 2007 where ICBT insertion was unsuccessful after the initial chemoradiation. The data collected and analysed included histology, stage of disease, causes for unsuccessful ICBT insertion, the response to the initial chemoradiation, subsequent treatment, morbidity, recurrence rates and survival rates. Kaplan–Meier and Log-rank methods were used to analyse recurrence-free and overall survival rates.Results: ICBT insertion was unsuccessful in 19 of 208 (9%) patients. The causes of failure were: inability to dilate the cervix; uterine perforation; vesicovaginal fistula; patient refusal; other problems, including the presence of pyometrium, patient not fit for general anaesthetic, and narrow vagina; and consultant choice with no obvious reason. Fourteen of 19 patients (74%) received further pelvic external beam radiotherapy (EBRT) alone; five (26%) patients underwent adjuvant hysterectomy. The median follow-up for all patients was 63 months; 60 months for patients treated with adjuvant hysterectomy (range 31–68 months) and 85 months for patients treated with further EBRT. None of the patients treated with adjuvant hysterectomy developed any significant late toxicity. Seven patients (50%) treated with EBRT have relapsed compared with none in the adjuvant hysterectomy arm (P=0.068). Six patients (43%) in the EBRT arm have subsequently died of recurrent disease compared with none in the adjuvant hysterectomy arm (P=0.152).Conclusions: Adjuvant hysterectomy after unsuccessful ICBT does not seem to increase late toxicity and reduces the risk of pelvic recurrence and may improve survival. The role of adjuvant hysterectomy after suboptimal chemoradiation merits further investigation in clinical trials.

Frequency of Screening Magnetic Resonance Imaging to Detect Occult Spinal Cord Compromise and to Prevent Neurological Deficit in Metastatic Castration-resistant Prostate Cancer

2010-03-01

Abstract: Aims: Neurological deficit from malignant spinal cord compression (SCC) is a major complication of metastatic castration-resistant prostate cancer (CRPC). The aims of the present study were to determine the incidence of neurological deficit in metastatic prostate cancer patients and to determine the optimal frequency of screening magnetic resonance imaging (MRI) spine required to detect clinically occult radiological SCC (rSCC).Materials and methods: A retrospective analysis of the clinical data of 130 consecutive patients with CRPC, with no functional neurological deficit, who had screening MRI spine from January 2001 to May 2005, was undertaken. Patients found to have rSCC received radiotherapy. All patients were followed-up to document the incidence of neurological deficit.Results: Thirty-seven (28.4%) patients had rSCC on MRI. The proportion of patients free from neurological deficit at 3, 6, 12, 18 and 24 months was 94, 80, 59 and 43%, respectively, in patients who had rSCC on initial MRI and 97.5, 89, 75 and 63%, respectively, in patients who had no rSCC. A high prostate-specific antigen (PSA) level at initial MRI (P = 0.035) and a short PSA doubling time < 3 months (P = 0.009) significantly predicted for neurological deficit on univariate analysis, whereas back pain (P = 0.059), although an important predictive factor, did not attain statistical significance. On multivariate analysis, only rapid PSA doubling time (<3 months) independently predicted for future neurological deficit (P = 0.042).Conclusion: MRI spine can be used to detect asymptomatic rSCC in patients with CRPC and serial estimations are required to maintain a low incidence of clinical SCC. If serial screening MRI spine is used to detect rSCC in 90% of patients before the development of neurological signs, the optimum frequency depends on the subset of patients studied. The results of our study suggest that the optimum frequency would be every 4–6 months for patients with previous SCC, rapid or high PSA or back pain and annually for asymptomatic patients.

Radiotherapy Demand and Activity in England and Australia

D.R. Wigg — 2010-03-01

Sir — I read with interest the review by Williams and Drinkwater on radiotherapy in England in 2007. There are many similarities between this report and the review of Australian facilities between 1986 and 1999 . Of particular interest is the low ‘access rates’ of 37% rather than 50%. This is very similar to the Australian results in which the proportion of newly diagnosed patients with invasive non-skin cancers treated with megavoltage therapy was described for each state and for Australia as a whole.

Synchronous Ovarian Cancer in a Patient with Pleomorphic Lobular Breast Cancer: A Therapeutic Dilemma

O. Dizdar, C. Arslan, K. Altundag — 2010-03-01

Sir — A 49-year-old premenopausal female patient presented with a breast lump and abdominal distention. Her personal history was unremarkable and a family history revealed ovarian cancer in her aunt and thyroid cancer in her brother. On physical examination, a 4cm mass in her right breast and an axillary fixed lymphadenopathy of 2cm were palpated and ascites was detected. Biopsy from the breast lump showed pleomorphic lobular carcinoma, grade 3, oestrogen receptor and progesterone receptor were both positive with HER2 overexpression immunohistochemically. Abdominal computed tomography revealed peritoneal carcinomatosis, ascites and a 15mm left ovarian cyst. A chest X-ray and a bone scan were normal. Diagnostic paracentesis was carried out to rule out a second intra-abdominal malignancy and showed malignant epithelial cells that were oestrogen receptor negative, progesterone receptor negative and HER2 negative, suggesting ovarian cancer morphology. Debulking surgery, including hysterectomy and bilateral salphingo-oopherectomy, was carried out. Pathology revealed serous papillary carcinoma of the ovary. Surgical stage was IIIC. Chemotherapy with paclitaxel and carboplatin was commenced. After six cycles of chemotherapy, the size of the breast lump and axillary lymphadenopathies remained stable. The patient underwent lumpectomy and axillary dissection for breast cancer. Pathology showed a T2N2 tumour (stage IIIA). She received radiotherapy to the breast and axilla, four cycles of adjuvant doxorubicin and cyclophosphamide, and subsequently trastuzumab and hormonal treatment with letrozole. At follow-up, she has been receiving letrozole treatment for 2 years without any signs of recurrence.

Meetings' Notices

2010-03-01