Clinical Oncology - Articles in Press

Survey of the Availability and Use of Advanced Radiotherapy Technology in the UK - Corrected Proof

W.P.M. Mayles, on behalf of the Radiotherapy Development Board — 2010-07-30

Abstract: Aims: To determine the availability of intensity-modulated radiotherapy (IMRT) treatment in the UK and to assess the magnitude of the shortfall in terms of patient treatments. In addition, the availability of image-guided radiotherapy (IGRT) was also reviewed.Materials and methods: A survey was carried out between July and September 2008 of the use of advanced technology in radiotherapy.Results: In total, 50 centres responded out of the 58 National Health Service centres canvassed, representing about 89% of patients treated in the UK. Forty-six centres had at least two machines capable of IMRT and 26 centres had at least one machine capable of IGRT. Thirty-two centres were carrying out forward-planned IMRT and 18 centres were carrying out the more complex inverse-planned IMRT. In all, 38 centres (76% of respondents) were offering either forward- or inverse-planned IMRT to some of their patients. All the centres with IGRT capability were using IGRT for at least some of their patients. Respondents were asked to list the total number of radical and palliative patients being treated according to the treatment site. Forty-two per cent of respondents took the option to list the total number of radical and palliative patients only. Based on these data, 10.7% of radical patients are currently being given forward-planned IMRT, mainly for breast cancer (18.6% of such patients) and 2.2% of radical patients are being given inverse-planned IMRT, mainly for prostate (7.5% of such patients) and head and neck cancer (6.7% of such patients). Whereas at present only 18 centres are able to treat with inverse-planned IMRT, 45 centres expected to be able to do so by 2010. Respondents were asked to estimate the percentage of patients who should be given IMRT for each site and this was used to estimate the shortfall in IMRT provision.Conclusions: Based on the consensus of opinion, 32% of radically treated patients should receive inverse-planned IMRT and 22% forward-planned IMRT, making a total of 55%. In fact, 2% receive inverse-planned IMRT and 11% the less complex forward-planned IMRT. Thus, with an estimated 75 948 radical treatments being carried out with megavoltage radiotherapy, the professional opinion is that 41 421 of patients would benefit from treatment with IMRT. In fact, only 9775 were so treated in 2008; a shortfall of 32 497 patients treated instead with conventional radiotherapy.

Education and Training for Intensity-modulated Radiotherapy in the UK - Corrected Proof

2010-07-23

Abstract: A growing body of evidence as to the benefits of intensity-modulated radiotherapy (IMRT) has led to the recommendation for its adoption as a treatment option for cancer patients within the UK. Routine clinical implementation of this technology has been slow. One of the causal factors was identified as being the need to improve confidence by improving the understanding and technical skills for IMRT of clinical oncology staff. This report determines and describes the additional knowledge and skills required for IMRT practice for clinical oncologists, clinical scientists (radiotherapy physicists) and radiographers, derived from reviewing evidence from other nations’ IMRT practices and adapting them to UK needs. This knowledge and skills specification can be used to inform IMRT educational curricula. Novel educational methods to maintain the required understanding and skills are also described.

The Value of Periodic Follow-up in the Detection of Recurrences after Radical Treatment in Locally Advanced Head and Neck Cancer - Corrected Proof

2010-07-22

Abstract: Aims: To determine the value of routine follow-up in detecting and salvaging recurrence after radical treatment of locally advanced head and neck squamous cell carcinoma and to identify clinical or pathological prognostic factors that predicted for survival.Materials and methods: A retrospective medical chart review was conducted at the Odette Cancer Centre between January 2000 and May 2006. Two hundred and twenty-three patients with advanced (stage III or IV) squamous cell carcinoma of the head and neck who were treated with curative intent were reviewed. Recurrences were divided into local, regional or distant recurrences. The detection method for each recurrence was categorised as self or physician detected. A self-detected recurrence arose from symptoms that led to investigations that confirmed a recurrence (even if initiated at the time of a routine visit), whereas a physician-detected recurrence was found during the routine follow-up examination and was asymptomatic.Results: There was no evidence to suggest a significant improvement in disease-free or overall survival in the physician-detected versus patient-detected groups. Regional and distant recurrences were only detected by physicians in one-fifth of cases and, overall, patients self-detected their own recurrence in two-thirds of the cases that experienced disease progression within the sample. Of the 12 clinical/pathological variables considered, only the response to treatment and perineural invasion were associated with survival.Conclusions: Current surveillance methods do not appear to improve cancer control in the stage III/IV head and neck squamous cell carcinoma population. However, technological advances and biomarker development may lead to surveillance technique enhancements. Also, post-treatment follow-up remains important for the evaluation of treatment results, emotional support and management of late complications. Among the clinical and pathological factors considered, only the treatment response and perineural invasion predicted survival.

Efficacy and Tolerability of Limited Field Radiotherapy with Concurrent Capecitabine in Locally Advanced Pancreatic Cancer - Corrected Proof

2010-07-22

Abstract: Aims: Patients with locally advanced pancreatic cancer (LAPC) are most commonly managed with chemotherapy or concurrent chemoradiotherapy (CRT), which may or may not include non-involved regional lymph nodes in the clinical target volume. We present our results of CRT for LAPC using capecitabine and delivering radiotherapy to a limited radiation field that excluded non-involved regional lymph nodes from the clinical target volume.Materials and methods: Thirty patients were studied. Patients received 50.4Gy external beam radiotherapy in 28 fractions, delivered to a planning target volume expanded from the primary tumour and involved nodes only. Capecitabine (500–600mg/m2) was given twice daily continuously during radiotherapy. Toxicity and efficacy data were prospectively collected.Results: Nausea, vomiting and tumour pain were the most common grade 2 toxicities. One patient developed grade 3 nausea. The median time to progression was 8.8 months, with 20% remaining progression free at 1 year. The median overall survival was 9.7 months with a 1 year survival of 30%. Of 21 patients with imaged progression, 13 (62%) progressed systemically, three (14%) had local progression, two (10%) had locoregional progression and three (14%) progressed with both local/locoregional and systemic disease.Conclusion: CRT using capecitabine and limited field radiotherapy is a well-tolerated, relatively efficacious treatment for LAPC. The low toxicity and low regional progression rates support the use of limited field radiotherapy, allowing evaluation of this regimen with other anti-cancer agents.

The Implementation of Intensity-modulated Radiotherapy in the UK - Corrected Proof

M.V. Williams, T. Cooper, R. Mackay, J. Staffurth, D. Routsis, N. Burnet — 2010-07-22

Radiotherapy in the UK lags behind that in much of Europe in terms of both the low proportion of cancer patients gaining access to treatment and the long waiting times . The technical quality of radiotherapy is also a cause for concern. The National Radiotherapy Advisory Group (NRAG) report published in May 2007 had an overall aim of developing world class radiotherapy . The NRAG technology subgroup report envisaged that within 10 years 50% of patients would be treated by four-dimensional image-guided, adaptive radiotherapy, of which intensity-modulated radiotherapy [IMRT] is a vital component . This paper summarises the work of the National Radiotherapy Implementation Group (NRIG) in supporting the implementation of IMRT.

PACS in Radiotherapy - Corrected Proof

J. Shakeshaft — 2010-07-14

Abstract: In recent years, the use of the Picture Archiving and Communications System (PACS) has become widespread in the area of diagnostic radiology for archival, review and reporting of patient data. However, the adoption of PACS within the field of radiotherapy is still very limited, despite the fact that most radiotherapy systems now use Digital Imaging and Communications in Medicine (DICOM) for both storage and communication. This paper discusses the challenges of integrating PACS into a radiotherapy department as a long-term archive of patient treatments. A possible solution based on a large English department is used as an example.

A Multicentre Timing Study of Intensity-modulated Radiotherapy Planning and Delivery - Corrected Proof

S.J. Thomas, A. Vinall, A. Poynter, D. Routsis — 2010-07-12

Abstract: Aims: The aim of the study was to measure how long the intensity-modulated radiotherapy (IMRT) process takes, both for planning and delivery, using several IMRT techniques and departments.Materials and methods: Timings were measured at three radiotherapy centres for each step of the process of outlining, planning and delivering IMRT for head and neck cancers. Times were measured for a total of 63 patients; 27 with helical tomotherapy, 37 with dynamic sliding window (26 in one centre, 11 in another) and nine with step-and-shoot.Results: The mean time to outline a patient was 108min, to produce and check the plan 7.9h, to carry out and analyse patient-specific quality assurance 1.9h. The mean treatment time (including on-treatment verification imaging where carried out), measured gate to gate, was 28min 10s for first fractions and 20min 20s for subsequent fractions.Conclusion: An analysis of subgroups showed some differences in times between techniques, and some differences between departments with the same techniques. For all four techniques, the median time from the end of outlining to the start of treatment was under 3 weeks.

Results of a Quantitative Survey to Explore Both Perceptions of the Purposes of Follow-up and Preferences for Methods of Follow-up Delivery Among Service Users, Primary Care Practitioners and Specialist Clinicians after Cancer Treatment - Corrected Proof

2010-07-09

Abstract: Aims: To ascertain perceptions of reasons for follow-up after cancer treatment among service users (patients and carers), primary care practitioners and specialist clinicians (doctors and specialist nurses) and to identify levels of preference for different models of follow-up and the effect of an individual’s experience on preferred models.Materials and methods: A national survey designed to meet the needs of each key respondent group was carried out after a structured literature review, an extensive consultation process and a pilot scheme. Respondents were asked to assess their degree of preference for 10 pre-selected indications for follow-up. Eight models of follow-up were also identified and respondents were asked to state their experience and preference for each type. The questionnaire was distributed nationally via the 34 cancer networks in England and was available both online and in hard copy (postal). The uptake for the electronic format was in the main by primary care practitioners and specialist clinicians. Service users preferred the paper (postal) format. The survey was also publicised through the primary care and patient partnership forums at a Cancer Network Development event.Results: In total, 2928 responses were received, comprising service users (21% of the sample), primary care practitioners (32%) and specialist clinicians (47%). Eighty-six per cent of responses were received from the 10 strategic health authorities in England, with the remaining 14% from Scotland, Wales and The Isle of Man. The responses from Scotland, Wales and the Isle of Man generally occurred where they interfaced with English cancer networks or had been engaged through word of mouth by colleagues. Among all respondents the main aims of cancer follow-up were considered to be: (1) to monitor for early complications after treatment; (2) to detect recurrences early; (3) to detect late effects of treatment. The most commonly experienced method of follow-up among all respondent groups was outpatient review with a doctor. This was considered to be the most preferred follow-up option among service users (86%). The least preferred option among service users was postal follow-up (32%). Primary care practitioners and specialist clinicians were more likely than service users to have experienced alternative methods of follow-up, such as telephone follow-up, self-triggered referral and non-specialist follow-up. These models were highly rated by those who had experience of them.Conclusions: There was a reasonable level of consensus between service users, primary care practitioners and specialist clinicians as to the reasons for follow-up. Service users seemed to have higher expectations of follow-up, particularly in relation to detecting recurrences early. As respondents were more likely to prefer a method of follow-up delivery that they had experienced than one they had not; there could be resistance to change from established methods to new methods without adequate explanation. This suggests that the communication of new methods could be critical to their successful introduction.

Guidelines for Adjuvant Therapy in Colorectal Cancer. Are They Useful? And to Whom? - Corrected Proof

J. Cassidy — 2010-07-02

In the last two decades or so we have witnessed an explosion of guidelines dealing with almost every aspect of medical care. I suspect that many doctors have guideline burnout and are disinterested by them and simply file these away without ever looking at them. This has not been helped by what seems to be contradictory statements from various guideline developers on the same topics. It is also not really possible to declare what is right and wrong in each guideline, because the differences are often due to variation in development methodologies. At least in the UK guidelines have until now been malleable, so local circumstances (including clinicians’ preferences) come to bear in the process of implementation. A lot of this is done in the name of clinical freedom. So the guidelines get watered down and do not form guidance as such.

Substantial Improvement in UK Cervical Cancer Survival with Chemoradiotherapy: Results of a Royal College of Radiologists’ Audit - Corrected Proof

C.L. Vale, J.F. Tierney, S.E. Davidson, K.J. Drinkwater, P. Symonds — 2010-07-01

Abstract: Aims: To compare survival and late complications between patients treated with chemoradiotherapy and radiotherapy for locally advanced cervix cancer.Materials and methods: A Royal College of Radiologists’ audit of patients treated with radiotherapy in UK cancer centres in 2001–2002. Survival, recurrence and late complications were assessed for patients grouped according to radical treatment received (radiotherapy, chemoradiotherapy, postoperative radiotherapy or chemoradiotherapy) and non-radical treatment. Late complication rates were assessed using the Franco-Italian glossary.Results: Data were analysed for 1243 patients from 42 UK centres. Overall 5-year survival was 56% (any radical treatment); 44% (radical radiotherapy); 55% (chemoradiotherapy) and 71% (surgery with postoperative radiotherapy). Overall survival at 5 years was 59% (stage IB), 44% (stage IIB) and 24% (stage IIIB) for women treated with radiotherapy, and 65% (stage IB), 61% (stage IIB) and 44% (stage IIIB) for those receiving chemoradiotherapy. Cox regression showed that survival was significantly better for patients receiving chemoradiotherapy (hazard ratio=0.77, 95% confidence interval 0.60–0.98; P=0.037) compared with those receiving radiotherapy taking age, stage, pelvic node involvement and treatment delay into account. The grade 3/4 late complication rate was 8% (radiotherapy) and 10% (chemoradiotherapy). Although complications continued to develop up to 7 years after treatment for those receiving chemoradiotherapy, there was no apparent increase in overall late complications compared with radiotherapy alone when other factors were taken into account (hazard ratio=0.94, 95% confidence interval 0.71–1.245; P=0.667).Discussion: The addition of chemotherapy to radiotherapy seems to have improved survival compared with radiotherapy alone for women treated in 2001–2002, without an apparent rise in late treatment complications.

Failure to Irradiate the Whole Bone after Surgery for Skeletal Metastasis may Predispose to Second Metastasis Formation - Corrected Proof

C. Esler, R. Ashford — 2010-07-01

Sir — Long bone internal fixation is a frequently used surgical procedure for stabilising pathological fractures secondary to metastatic bone disease. Postoperative external beam radiotherapy is used despite little clinical evidence to support its use. Radiation fields vary between oncologists. We present two cases that we feel demonstrate why the whole bone should be irradiated .

Utilisation of Radiotherapy in Rural and Urban Areas in British Columbia Compared with Evidence-based Estimates of Radiotherapy Needs for Patients with Breast, Prostate and Lung Cancer - Corrected Proof

S. Tyldesley, C. McGahan — 2010-07-01

Abstract: Aims: To compare the existing model estimates of the appropriate rates of radiotherapy for lung, breast and prostate cancers with actual radiotherapy rates in rural, semi-urban and urban areas, and in areas with short and long drive distances to cancer clinics in British Columbia.Materials and methods: : All registered cases of lung, breast and prostate cancer diagnosed in British Columbia between 1997 and 2007 were identified. The proportion of cancers treated within 1 (RT1Y) and 5 years (RT5Y) of diagnosis were calculated according to rural, semi-urban and urban area, and areas associated with short and long drive distances to cancer clinics in British Columbia.Results: RT1Y for lung, breast and prostate in urban and rural areas were 47/45%, 57/46% and 31/30%, and for short and long drive times were 47/44%, 56/50% and 31/31% compared with model estimates for initial radiotherapy needs of 41–45%, 57–61% and 32–37%, respectively. RT5Y for lung, breast and prostate in urban and rural areas were 52/47%, 59/48% and 42/39%, and for short and long drive times were 51/47%, 57/50% and 42/42% compared with model estimates for overall radiotherapy needs of 66–83%, 57–61% and 60–61%, respectively.Conclusions: Radiotherapy rates vary between and within urban and rural areas in British Columbia. Radiotherapy rates for breast and lung cancer patients are higher, and closer to model estimates of need, in urban areas and short drive time areas. Radiotherapy rates do not vary with drive time or rural versus urban classification for patients with prostate cancer.

Validation of Recursive Partitioning Analysis Classification in Patients with Brain Metastases from Non-small Cell Lung Cancer Treated with Short-course Accelerated Radiotherapy - Corrected Proof

2010-06-30

Abstract: Aims: To study various prognostic factors affecting outcome and to validate Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class in non-small cell lung cancer (NSCLC) with brain metastases treated with short-course accelerated radiotherapy (SCAR).Materials and methods: The case records of 100 patients with NSCLC consecutively treated at Tata Memorial Hospital from August 2006 to August 2009 were studied for various patient, tumour and treatment-related prognostic factors. Patients received whole-brain radiotherapy to a dose of 20Gy/five fractions over 1 week (n=90) or 30Gy/10 fractions over 2 weeks (n=10). The Kaplan–Meier estimate was used for survival analysis in SPSS v15.Results: The median overall survival was 4.0 months (range 0.5–30.0 months). The 6-, 12-, 18- and 24-month survival rates were 35.8, 18.0, 9.3 and 6.2%, respectively. Of the various prognostic factors, RPA class (II versus III, P value=0.023), Karnofsky performance score (<70 versus ≥70, P value=0.039) and the use of systemic therapy (yes versus no, P value=0.00) emerged as significant on univariate analysis. RPA classification effectively separated the patient population into prognostically distinct subgroups. The median overall survival for RPA class II and RPA class III was 6 and 4 months, respectively. The use of systemic therapy prolonged overall survival by 6 months (3 months versus 9 months).Conclusion: The SCAR regimen is an effective and resource-sparing palliative strategy for brain metastases in NSCLC. The results validate the usefulness of RPA classification in this specific subset of patients treated with SCAR.

Prognostic Significance of Age in the Radical Treatment of Oesophageal Cancer with Surgery or Chemoradiotherapy: a Prospective Observational Cohort Study - Corrected Proof

2010-06-30

Abstract: Aims: To compare the outcomes of stage-directed surgical therapy and chemoradiotherapy (CRT) for oesophageal cancer and to determine if a significant age–treatment interaction exists to guide therapy.Materials and methods: Five hundred and eight consecutive patients with oesophageal cancer suitable for radical treatment based on radiological stage and performance status were studied (275 surgery; 93 surgery alone, 131 neoadjuvant chemotherapy, 51 neoadjuvant CRT and 233 definitive CRT). The primary measure of outcome was survival.Results: Thirty-day mortality rates and 2-year survival after surgery and CRT in patients <70 years were 2.4 and 57.5%, respectively, compared with 0 (P=0.207) and 47.3% (P=0.011), respectively. Thirty-day mortality rates and 2-year survival after surgery and CRT in patients ≥70 years were 7.0 and 45.1%, respectively, compared with 0 (P=0.029) and 46.3% (P=0.992), respectively. Multivariate analysis including only surgical patients in the model revealed three factors to be independently and significantly associated with survival; endoscopic ultrasound (EUS) T stage (P=0.033), EUS lymph node metastasis count (≥2 versus 0: hazard ratio 1.67, 95% confidence interval 1.06–2.92, P=0.026), and age ≥70 years (hazard ratio 1.51, 95% confidence interval 1.05–2.16, P=0.025).Conclusion: Overall survival for patients treated with surgery was strongly age dependent around the age of 70 years, and patients ≥70 years with oesophageal cancer should be aware that outcomes after CRT are similar to those after surgery.

The Changing Aetiology of Head and Neck Cancer: the Role of Human Papillomavirus - Corrected Proof

M. Evans, N.G. Powell — 2010-06-28

Abstract: Human papillomavirus (HPV) is associated with the development of a subset of head and neck cancers arising in the oropharynx, which includes the tonsils, base of tongue and soft palate. HPV-associated oropharyngeal cancer (OPC) seems to be rapidly increasing in incidence in many countries, including the USA, Sweden and Greece, and is known to affect younger patients who are less likely to have been exposed to the carcinogenic effects of tobacco and alcohol than their HPV-negative counterparts. There is accumulating evidence from prospective studies that HPV-positive OPC responds better to treatment, including chemotherapy and radiotherapy, than HPV-negative OPC, and that patients with HPV-positive disease have excellent long-term survival rates. To date, patients with HPV-positive and HPV-negative OPC are managed according to common treatment protocols; this may no longer be appropriate in an age when the delivery of targeted treatment, tailored to individual tumour and patient characteristics, is becoming a reality. This review summarises our current understanding of HPV-positive OPC, drawing parallels from the role of HPV in the development of cervical cancer. We also consider how knowledge of tumour HPV status may affect the future management and prevention of OPC and discuss the need for future collaborative trials in this important group of patients.

Split-course Hypofractionated Palliative Radiotherapy for Patients with Head and Neck Squamous Cell Carcinoma — a Worthwhile Treatment Schedule in the UK? - Corrected Proof

R.A. Pearson, R.H. Bannister-Young, D. Ivison, C.G. Kelly, S. Chatterjee — 2010-06-28

Sir — The standard radical schedule for non-surgical treatment of head and neck squamous cell carcinoma is 70Gy in 2Gy fractions over 7 weeks or equivalent (65Gy in 30 fractions) with or without concurrent chemotherapy. A significant minority of patients have poor performance status with multiple co-morbidities rendering them unfit to tolerate potential toxicities associated with the above regimen. In the last few years, several studies have looked at the role of hypofractionated palliative radiotherapy schedules. Some studies have used daily treatments lasting about 3 weeks ; others have explored split-course regimens .

The Efficacy of Preventing Neutropenic Sepsis in Patients with Testicular Germ Cell Tumours: Results of Two Consecutive Audits - Corrected Proof

E.M. Teoh, D.P. Dearnaley, A. Horwich, N. Van As, U. Riley, R.A. Huddart — 2010-06-28

Sir — Patients with testicular germ cell tumours are at high risk of chemotherapy-induced neutropenia and febrile neutropenia/neutropenic sepsis (FN/NS). Published data have shown a reduction in the rates of neutropenia, sepsis, hospitalisation and all-cause mortality with prophylactic levofloxacin use in patients undergoing chemotherapy .

Chemoradiotherapy for Cervical Cancer — Do Questions Remain? - Corrected Proof

L.T. Tan — 2010-06-28

The introduction of chemoradiotherapy into routine clinical practice for locally advanced carcinoma of the cervix is one of the success stories of the National Health Service (NHS). In February 1999, the US National Cancer Institute issued a rare clinical alert stating that ‘strong consideration should be given to adding chemotherapy to radiation therapy in the treatment of cervical cancer’. This was in advance of the publication of five randomised phase III trials showing that platinum-based chemotherapy, when given concurrently with radiotherapy, significantly improves survival. A questionnaire survey of UK practice is a noun, practise is a verb in 2000 showed that 96% of respondents (46 of 48 oncologists representing 46 UK centres) had begun using chemoradiotherapy for the treatment of cervical cancer less than 1 year after the issue of the National Cancer Institute alert. This encouraging finding suggests that rapid implementation of effective treatments is possible in the NHS, despite the resource constraints.

Improving Survival with Thoracic Radiotherapy in Patients with Small Cell Lung Cancer. The CONVERT and the REST Trials - Corrected Proof

C. Faivre-Finn, F. Blackhall, M. Snee, S. Harden, P. Hulse, P. Lorigan — 2010-06-25

Clinical trials testing systemic therapies in small cell lung cancer (SCLC) have been associated with disappointing results in the last two decades, and so the standard chemotherapy treatment remains platinum and etoposide chemotherapy . On a more optimistic note, major advances have been made since the 1980s with radiotherapy in this disease. These advances include improvements in radiotherapy techniques, the use of prophylactic cranial irradiation (PCI) for all stages of SCLC and improved understanding in the combination of chemotherapy and radiotherapy . The standard of care in good performance status limited-stage SCLC is early concurrent chemoradiotherapy, with the best survival results being achieved with twice daily radiation . As a result of the implementation of the best standard of care, the 5 year survival of limited-stage SCLC patients has increased from less than 10% with chemotherapy alone to 25% with early concurrent chemoradiotherapy . In extensive-stage disease, chemotherapy is the standard of care. Thoracic radiotherapy is generally given to alleviate symptoms, whereas PCI in extensive-stage SCLC patients who respond to chemotherapy was recently proven to double survival at 1 year .

Delivery of Brachytherapy for Cervical Cancer: Organisational and Technical Advice to Facilitate High-quality Care - Corrected Proof

2010-06-25

Abstract: Aims: Brachytherapy is a standard therapy for cervical cancer; it allows for the delivery of a high dose of radiation to the tumour while sparing the surrounding healthy tissues. With this document, the Brachytherapy Cervical Cancer Expert Working Group (BCCEWG) aimed to provide advice on organisational and technical aspects of the delivery of brachytherapy services in Ontario, Canada.Materials and methods: We sought technical documents, practice guidelines and standards through an environmental scan of internet resources, an iterative search of the literature on MEDLINE and EMBASE, and a search of reference lists of included documents.Results: We identified 20 guidance documents authored by 10 organisations; 11 documents were identified through the environmental scan, five through the literature search and four from reference lists. The recommendations included in this document were developed by the BCCEWG through the selection and review of the evidence and informal consensus.Conclusions: These organisational recommendations aim to set the stage for high-quality delivery of brachytherapy for cervical cancer services in the province of Ontario, Canada. They address the characteristics of the practice setting, including facilities, equipment, delivery suite, imaging technologies, treatment planning and dosimetry; the practice team, including team members, roles, training, team caseload/volumes and qualifications; and the quality assurance domain, including documentation, audit, safety and quality control.

Survival in Patients with Non-small Cell Lung Cancer and Brain Metastases and QUARTZ in Practice - Corrected Proof

K.L. Bradley, M.T. Lwin, V.M. Laurence — 2010-06-21

Sir — The QUARTZ (Quality of Life after Radiotherapy and Steroids) trial is a prospective randomised controlled trial seeking to answer the question of whether optimal supportive care including dexamethasone is as effective as optimal supportive care and whole brain radiotherapy (WBRT) in terms of patient-assessed quality-adjusted life years in non-small cell lung cancer (NSCLC) with inoperable brain metastases. Overall survival is a secondary end point. An inclusion criterion for this trial is ‘clinician/patient uncertainty of the role of WBRT’.

Late Complications from Chemoradiotherapy for Cervical Cancer: Reflections from Cervical Cancer Survivors 10 Years after the National Cancer Institute Alert - Corrected Proof

C. Vale, A. Nightingale, N. Spera, A. Whelan, B. Hanley, J.F. Tierney — 2010-06-17

Around 10 years ago, the US National Cancer Institute issued an unprecedented clinical alert stating that chemoradiotherapy should be considered for women with cervical cancer instead of radiotherapy alone . This was based on the results of five randomised trials, each of which showed a benefit of chemoradiotherapy on survival. Since that recommendation, cisplatin-based chemoradiotherapy has become the standard of care in many countries for women with high-risk early stage and locally advanced cervical cancer. However, a number of important questions remained and there were concerns among the clinical community regarding the late effects of chemoradiotherapy, which anecdotally seemed to be worse than with radiotherapy alone .

Heterogeneity of Metabolic Response to Systemic Therapy in Metastatic Breast Cancer Patients - Corrected Proof

2010-06-16

Abstract: Aim: The aim of this retrospective study was to describe the intra-individual heterogeneity of the 18F-labelled fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) response among lesions in bone-dominant metastatic breast cancer patients treated with systemic therapies.Patients and methods: The metabolic response was analysed by comparing PET/CT scans carried out before and during a new treatment phase (n=46) in 25 bone-dominant metastatic breast cancer patients. Patients presented both bone and extra-bone metastases in 48% treatment phases. The metabolic response was analysed according to European Organization for Research and Treatment of Cancer (EORTC) criteria. A heterogeneous response was defined as the coexistence of responding and non-responding lesions within the same patient.Results: The lesion-based response analysis showed a heterogeneous metabolic response in 48% of treatment phases. In the subset with both bone and extra-bone metastases (n=20), PET/CT showed discordant responses between bone and extra-bone metastases in 6/20 (30%) treatment phases. Considering all the cases included in the study, the time to progression (TTP) was longer in cases with a metabolic response compared with the cases with a metabolic non-response (P=0.02). In cases with a PET/CT non-response, TTP seemed to be lower in those with a homogeneous non-response compared with those with a heterogeneous metabolic response (P=0.07).Conclusion: Whole-body FDG-PET allows frequent heterogeneous responses after systemic therapy to be identified in bone-dominant metastatic breast cancer patients.

UK Fourth National Colorectal Cancer Consensus Meeting 2009 - Corrected Proof

2010-06-11

Healthcare professionals and patient groups took part in the 4th UK Colorectal Cancer (CRC) Consensus Meeting, held on 3 November 2009 at the Royal College of Physicians in London, to discuss important clinical questions, such as the use of molecular prognostic markers, and a range of difficult ethical issues, including clinical futility, the role of the National Institute for Health and Clinical Excellence (NICE), commissioning, funding and access to treatment.

Ductal Variant of Adenocarcinoma Prostate Responding to Docetaxel — a Case Report - Corrected Proof

C. Paterson, P.D. Correa, J.M. Russell — 2010-06-09

Sir — Ductal carcinoma is an unusual variant of adenocarcinoma of the prostate with poorly understood natural history. Equally, treatment is not well defined. Docetaxel and prednisolone is standard first-line treatment in men with hormone refractory metastatic prostate cancer . A search of published studies failed to find any reports of metastatic ductal cancer treated successfully with docetaxel . We therefore report a case of a 62-year-old man with metastatic ductal prostate cancer who responded to this regimen.

Management of Hypocalcaemia in the Oncology Clinics - Corrected Proof

G. Gerrard, S. Rodda, J. Anderson — 2010-06-07

Sir — Thyroid cancer patients are at risk of developing hypocalcaemia after surgery due to the removal of the parathyroid glands or after temporary or permanent devascularisation of the parathyroids. Temporary devascularisation often recovers within a few years of surgery.

Optimising Recruitment Rates to Radiotherapy Clinical Trials for Patients with Non-small Cell Lung Cancer and Brain Metastases - Corrected Proof

O. Ferguson, J. Fuller, C. Faivre-Finn, N. Bayman — 2010-06-07

Sir — The median survival for patients with brain metastases who receive palliative whole brain radiotherapy (WBRT) is 2–7 months . The uncertainty surrounding the role of WBRT in the palliation of brain metastases is well documented and the need for clinical trials to address this issue was highlighted in the Royal College consensus statement 10 years ago . It is estimated that 25 000 patients with lung cancer develop brain metastases each year in the UK. Two National Cancer Research Network (NCRN) multicentre randomised controlled trials aiming to optimise the treatment of brain metastases with WBRT in patients with non-small cell lung cancer (NSCLC), QUARTZ (NCT00403065) and TACTIC (NCT00554775), were opened for accrual in 2007/2008 . However, despite the support of most radiotherapy centres in the UK, recruitment rates have been slow, with only 145 patients enrolled to QUARTZ and 63 to TACTIC by March 2010.

The Registration of Diagnostic versus Planning Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Radiotherapy Planning for Non-small Cell Lung Cancer - Corrected Proof

2010-06-07

Abstract: Aims: Radiotherapy for non-small cell lung cancer (NSCLC) increasingly utilises fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) fusion. However, it is unknown whether a PET/CT scan conducted in the treatment position results in more accurate registration to the radiotherapy planning CT (rCT) than a diagnostic PET/CT scan. The aim of this study was to compare the accuracy of registration of the CT components of the planning PET/CT scan (pCT) and diagnostic PET/CT scan (dCT) scan with the rCT.Materials and methods: Ten patients with stage I–III NSCLC underwent an rCT immediately followed by a planning PET/CT scan, both carried out with arms placed above the head and immobilisation in the treatment position. All previously underwent a diagnostic FDG PET/CT, which was carried out with the arms above the head, but without custom immobilisation. dCT and pCT were registered to the rCT using a rigid body mutual information algorithm. Four observers identified 12 anatomical points on each scan and differences in their absolute location were analysed.Results: At the carina, the mean absolute error (MAE) for pCT–rCT compared with dCT–rCT was 4.37 versus 5.73mm (P=0.028). However, there was no significant difference in the root mean squared error (RMSE) for that point. There were no significant differences in MAE or RMSE for all other anatomical points. The MAE for all points was 4.11 versus 4.15mm (P=NS) and RMSE was 4.40 versus 4.48mm for pCT–rCT compared with dCT–rCT (P=NS).Conclusions: There is an average of 4mm of misregistration when registering the CT components of PET/CT scans to the rCT for NSCLC. Using a rigid registration technique, the registration of a diagnostic PET/CT is as good as the registration of a planning PET/CT.

Radiation Myelopathy after 36Gy in 12 Fractions Palliative Chest Radiotherapy for Squamous Cell Cancer of the Lung: Case Report and Review of Published Studies - Corrected Proof

C. Harrington, M. James, C. Wynne — 2010-06-07

Abstract: A 55 year old man was treated with 36 Gy in 12 fractions palliative chest irradiation for squamous cell carcinoma of the lung. This was followed by 3 cycles of cisplatin and gemcitabine. Five months later he developed clinical and imaging findings consistent with radiation myelopathy. The maximum spinal cord dose was 38.9 Gy. The possible contributions of portal imaging and gemcitabine are discussed and the literature reviewed.

Three Years of Erlotinib in Routine Practice for Non-small Cell Lung Cancer in South East Scotland - Corrected Proof

2010-06-04

Abstract: We present a review of 111 patients who were treated over an initial 3-year period with erlotinib. The median treatment time was 68 days and 59% of patients had stopped treatment within the first 3 months. However, 20 patients were on erlotinib for more than 12 months. Performance status and smoking history were the significant prognostic factors. The overall 3-year survival in patients who had never smoked was 26%.

A Patient Advocate’s View on Accrual Issues to Lung Radiotherapy Trials in the UK - Corrected Proof

D. Ardron — 2010-06-03

Sir — I would like to say thank you on behalf of patients and carers affected by lung cancer for the continued involvement of cancer research centres in radiotherapy research studies. There are more than 70 centres registered to take part in the Medical Research Council QUARTZ trial for example . The trial has now recruited over a 100 patients, but there is a need, underlined by the Clinical Trials Awards and Advisory Committee and the Independent Data Monitoring Committee, to increase accrual rates to ensure that the trial continues and that the question is answered. This need is mirrored in the National Cancer Research Network TACTIC and CONVERT trials, also radiotherapy trials in the field of lung cancer, but also accruing relatively slowly.

Chemoradiotherapy with or without Induction Chemotherapy for Locally Advanced Pancreatic Cancer: a UK Multi-institutional Experience - Corrected Proof

2010-06-02

Abstract: Aims: The optimal management for patients with unresectable locally advanced adenocarcinoma of the pancreas (LAPC) is unclear. The aim of this study was to determine the outcome of patients treated with chemoradiotherapy (CRT) with or without induction chemotherapy.Materials and methods: We conducted a multi-centre retrospective analysis of 48 patients with biopsy‑proven LAPC treated with CRT in four regional oncology centres in the UK between March 2000 and October 2007. The prescribed radiotherapy dose was 4500–5040cGy in 25–28 fractions and was given concurrent with gemcitabine (n=37), gemcitabine/cisplatin (n=9), 5-fluorouracil (n=1) or capecitabine (n=1).Results: Four patients (8.3%) did not complete the intended treatment due to CRT‑related toxicities. The disease control rate (Objective response rate (ORR) and stable disease (SD)) was 81.3%. The median overall survival was 17 months (range 5–66 months). In subgroup analysis, a trend towards improved survival was seen in patients who completed the intended treatment (17.1 months vs 11.0 months, P=0.06) and in patients undergoing surgery (27 months vs 16 months, P=0.023).Conclusions: This is the largest reported series from the UK focussing on patients who received CRT for pancreas cancer. It shows that it is possible to deliver pancreatic CRT with acceptable toxicity. Induction chemotherapy followed by gemcitabine-based CRT shows promising activity and should be evaluated in phase III studies.

Geometrical Analysis of Radiotherapy Target Volume Delineation: a Systematic Review of Reported Comparison Methods - Corrected Proof

G.G. Hanna, A.R. Hounsell, J.M. O’Sullivan — 2010-05-31

Abstract: Radiotherapy target volume definition is a critical step in the radiotherapy treatment planning process for all tumour sites. New technology may improve the identification of tumour from normal tissue for the purposes of target volume definition. In assessing the proffered benefits of new technologies, rigorous methods of comparison are necessary. A review of published studies was conducted using PubMed (National Library of Medicine) between 1 January 1995 and 1 January 2009 using predefined search terms. The frequency of usage of the various methods of geometrical comparison (simple volume assessment, centre of mass analysis, concordance index and volume edge analysis) was recorded. Sixty-three studies were identified, across a range of primary tumour sites. The most common method of target volume analysis was simple volume measurement; this was described in 84% of the papers analysed. The concordance index type analysis was described in 30%, the centre of mass analysis in 9.5% and the volume edge analysis in 4.8%. In reporting geometrical differences between target volumes no standard exists. However, to optimally describe geometrical changes in target volumes, simple volume change and a measure of positional change should be assessed.

Radiotherapy Research Priorities for the UK - Corrected Proof

2010-04-05

Radiotherapy research in the UK has become a priority among the major research funders who are partners of the National Cancer Research Institute (NCRI). The thrust of the new initiative from the NCRI is to maximise the opportunities for high-quality radiotherapy research in the UK by bringing together information from four overlapping domains, namely cancer biology, new systemic therapies, high-quality radiotherapy and relevant biomarkers and imaging, into an integrated programme that will allow new radiotherapy approaches to be tested in phase I, II and III clinical trials. This is being co-ordinated and led by the NCRI Clinical and Translational Radiotherapy Research Working Group (CTRRWG).

Pain after Palliative Radiotherapy for Spine Metastases - Corrected Proof

O. Zaikova, S.D. Fosså, U. Kongsgaard, S. Kvaløy, K.-E. Giercksky, S. Skjeldal — 2010-04-05

Abstract: Aims: The purpose of the study was to evaluate the response to palliative radiotherapy in patients with painful spinal metastatic disease (SMD).Materials and methods: Three hundred and fifty-five patients admitted to the Norwegian Radium Hospital for radiotherapy for painful SMD were included in a prospective study and were followed up 2 months later. The Brief Pain Inventory was used to assess pain. Analgesic consumption was recalculated into the daily oral morphine-equivalent dose. The radiotherapy-related response rates were calculated using the criteria of the International Bone Metastases Consensus Group (IBMCG), taking into account the use of concomitant analgesics. The response to radiotherapy was assessed as complete or partial and non-response as stable pain, pain progression or ‘other’.Results: Brief Pain Inventory forms were obtained at follow-up from 229 of the 355 patients. Two months after radiotherapy, the median self-reported worst pain decreased significantly, but the median oral morphine-equivalent dose increased from 40 to 60mg (P<0.001). Forty-three per cent of the patients reported pain relief, but a radiotherapy-related response was found in 37% of the patients. Overall correspondence between the patients' self-reported changes in pain experience and the IBMCG-based response categories was obtained in 63% of the patients.Conclusions: The radiotherapy-related response rates in our study were lower than those reported previously in patients with bone metastases in general, which possibly indicates the presence of more complex pathophysiological mechanisms of pain in SMD.