Cosmetic outcome 1, 2, 3, and 4 years after intraoperative radiotherapy or external beam radiotherapy for early breast cancer: An objective assessment of patients from a randomized controlled trial

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Background: The randomized controlled TARGIT Trial was designed to determine noninferiority between the novel technique of TARGIT [intra-operative radiotherapy with Intrabeam (Carl Zeiss, Germany)] and conventional external beam radiotherapy (EBRT) in women with early breast cancer. The main outcome objective is risk of local relapse within the treated breast. We report here data from a subprotocol assessing cosmesis in 114 women over 50 years old participating in the TARGIT Trial from one center (Perth, Australia).

Methods: Frontal view digital photographs from were assessed, blind to treatment, using specialist software (BCCT.core 2.0, INESC Porto, Portugal) that produces an objective composite score based on symmetry, color, and scar. Data on patient and tumor characteristics were obtained from hospital notes. Statistical analysis was by generalized estimating equations (GEE) on all data, and logistic regression analysis at year 1 only.

Results: Photographs were taken at baseline (before surgery) and 1, 2, 3, and 4 years after initial breast-conserving surgery; none of the 114 patients had subsequent breast surgery. Median age at randomization was 62 years (IQR 56 to 68). The composite scores were dichotomized into Excellent and Good (EG), and Fair and Poor (FP). There was a nonsignificant 45% increase in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group (OR=1.45, 95%CI 0.78 – 2.69, p=0.245) after adjusting for tumour size. The results were similar when adjusted for tumor grade and age of the patient. For year 1 there was a statistically significant 2.35 fold increase in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group (OR=2.35, 95%CI 1.02 – 5.45, p=0.047) after adjusting for age of the patient, tumor size, and grade.

Conclusions: These results confirm a significantly better cosmetic outcome with TARGIT compared to EBRT in the first year after surgery.

Knowledge and perceptions regarding oral and pharyngeal carcinoma among adult dental patients

BACKGROUND

The aim of this study was to assess awareness and knowledge of oral and pharyngeal carcinoma and risk perception for developing the cancer among adult patients attending a major dental centre in Perth. Influence of socio-demographic factors on awareness, knowledge and perception was ascertained.

METHODS

A random sample of 120 potential participants over the age of 18 who attended the Oral Health Centre of Western Australia between 14 and 18 June 2010 were invited to participate in the survey. A total of 100 participants completed a face-to-face interview guided by a questionnaire.

RESULTS

Seventy-two per cent of the participants had heard of oral and pharyngeal carcinoma. Sixteen per cent knew that both smoking and drinking increased the risk of oral and pharyngeal carcinoma and 49% knew at least one sign or symptom of the cancer. Language spoken at home, education, and employment influenced cancer awareness and knowledge. Sixty-two per cent of the participants considered themselves not at risk of developing the cancer.

CONCLUSIONS

The findings suggest that knowledge concerning oral and pharyngeal carcinoma in the community may be limited and educational strategies may be required to improve such knowledge.

Abstract PD06-01: A Single Treatment with Targeted Intraoperative Radiotherapy (TARGIT) Is Similar to Several Weeks of External Beam Radiotherapy (EBRT) with Respect to Efficacy and Safety, and Has Obvious Advantages to the Patient and the Economy

Background: After breast-conserving surgery, 90% of local recurrences occur within the index quadrant despite the presence of multicentric cancers elsewhere in the breast. Thus, restriction of radiation therapy to the tumour bed during surgery might be adequate for selected patients. Materials and methods: Having safely piloted the new technique of single-dose targeted intraoperative radiotherapy (TARGIT) with Intrabeam, we launched the TARGIT-A trial on March 24, 2000. In this prospective, randomised, non-inferiority trial, women aged 45 years or older with invasive ductal breast carcinoma undergoing breast-conserving surgery were enrolled to compare TARGIT with whole breast external beam radiotherapy (EBRT). The primary outcome was local recurrence in the conserved breast with a predefined absolute non-inferiority margin of 2-5%. Analysis was by intention-to-treat.

Results: 1113 patients were randomly allocated to TARGIT and 1119 were allocated to EBRT. The Kaplan-Meier estimate of local recurrence in the conserved breast at 4 years was 1-20% (95% CI 0-53-2-71) in the TARGIT and 0-95% (0.39-2-31) in the EBRT group (difference between groups 0.25%, −1.04 to 1.54; p=0.41). The frequency of any complications and major toxicity (TARGIT 3.3% vs. EBRT 3.9% p=0·44) was similar. Radiotherapy toxicity was lower in the TARGIT group (0.5% vs. 2.1%, p=0.002). 14% of patients who received TARGIT also received EBRT as per the protocol, i.e., the remaining 86% patients could safely avoid 3-6 weeks of daily radiotherapy treatments and its obvious associated costs in economic and human terms.

Discussion: For selected patients with early breast cancer, a single-dose targeted intraoperative radiotherapy should be considered as an alternative to whole breast EBRT delivered over several weeks. It could save time, effort, and money for the patient and the healthcare system, which is particularly relevant in the present times of healthcare reform. NB the main trial results have been presented in ASCO 2010 and published in the Lancet Online First.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD06-01.

Safety and efficacy of targeted intraoperative radiotherapy (TARGIT) for early breast cancer: First report of a randomized controlled trial at 10-years maximum follow-up

LBA517

Background: After breast conserving surgery, 90% of local recurrences (LR) occur within the index quadrant. Hence, restricting the radiation therapy to the immediate area around the tumour bed after removal of the primary tumour may be adequate (Vaidya JS, et al. Br Cancer.1996;74:820-4)

Methods: Having safely piloted a new technique of partial breast irradiation (Vaidya JS, Baum M, Tobias JS et al Ann Oncol 2001;12:1075-80) we launched the TARGIT-A trial in March 2000 comparing TARGIT vs. standard whole breast external beam radiotherapy (EBRT) after breast conserving surgery in patients ≥45 years with invasive duct carcinoma. LR was the primary outcome measure (core protocol: www.thelancet.com/protocol-reviews/99PRT-47 ). Trial accrual from 31 international centers is complete (n=2232), with 80% power to detect a difference in relapse rate of 2.5% - the non-inferiority margin.

Results: Median age was 63 (IQR 57-69), median tumor size 13mm (IQR 9-18mm), lymph nodes 17%+ve. Median follow-up is 24.6 months (max 10 years). Wound breakdown or delayed healing were reported in 28 of the TARGIT group and 20 in the EBRT group (p=0.24). RTOG grade 3 toxicity (nil grade 4) was seen in 6 vs. 21 (p=0.004) respectively. Overall local toxicity was equivalent (34/1092 TARGIT v. 41/1096 EBRT, p=0.42). The Kaplan-Meier estimate of LR in the breast, was 0.31% (CI 0.08-1.26) for TARGIT versus 0.29% for EBRT (CI 0.07-1.16) at 24 months.

Conclusions: In the TARGIT group, the radiotherapy toxicity was significantly lower than in the EBRT group, while the increase in wound complications was not statistically significant. This analysis suggests that at a median follow-up of 24 months the local control with TARGIT is comparable to EBRT. Longer term follow-up is essential and accrual in similar studies is encouraged.

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Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years

OBJECTIVE

To investigate the association of the method of hysterectomy for benign reasons with morbidity outcomes in Western Australia after taking other demographic, social and health-related factors into account.

DESIGN

Population-based retrospective observational study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy for benign reasons.

METHOD

Logistic and zero-truncated negative binomial regression analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Relative odds of experiencing complications during the hysterectomy admission or readmission and relative length of stay in hospital by type of hysterectomy.

RESULTS

There were 78,577 hysterectomies performed for benign reasons from 1981 to 2003. Procedure-related haemorrhage (2.4%) was the most commonly recorded complication, followed by genitourinary disorders (1.9%), infection (1.6%) and urinary tract infections (1.6%). Vaginal hysterectomy was associated with reduced odds of infection and haemorrhage compared with abdominal procedures during the hysterectomy admission. Readmission rates increased from 5.4% in 1981-84 to 7.2% in 2000-03 as average length of stay decreased by 53% over the same time period. Women who underwent laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies had increased odds of readmission for haemorrhage and genitourinary disorders compared with abdominal hysterectomy. Young age, increasing number of co-morbid conditions and having a complication at hysterectomy admission were also associated with increased odds of readmission.

CONCLUSION

These findings identify women at risk of readmission following hysterectomy and highlight an opportunity to modify early discharge and patient follow-up practices to reduce this risk.

Acute decompression illness and serum s100beta levels: a prospective observational pilot study

BACKGROUND

S100beta, a calcium binding protein associated with astroglial cells and other tissues has been shown to be raised in the serum of patients with a number of neurological pathologies. As there are no published data on serum S100beta determinations in recreational divers affected by decompression illness (DCI) this pilot study determines whether S100beta is a possible biochemical marker of DCI worthy of further investigation.

METHODS

Venous blood samples were drawn from patients diagnosed with, and treated for acute DCI at a hyperbaric facility and analysed for serum S100beta concentration and Creatine Kinase (CK) activity. Samples were taken at initial presentation, and again following final treatment.

RESULTS

Twenty one patients were included in the study. Neither S100beta, nor CK levels were significantly raised above population normal limits.

CONCLUSION

S100beta is not a clinically useful serum marker of acute DCI.

Methods of determining the relationship of the mandibular canal and third molars: a survey of Australian oral and maxillofacial surgeons

BACKGROUND

Surgical extraction of third molars is one of the most common oral and maxillofacial surgical procedures performed and may have a number of associated complications. One of these complications is inferior alveolar nerve (IAN) dysaesthesia or impairment of sensory perception (including paraesthesia and/or anaesthesia). Previous studies assume that most clinicians use various combinations of nine radiologic criteria on panoramic radiographs as indicators of the relationship and, therefore, predictors of the risk of postoperative dysaesthesia. Our study assessed both the current radiologic modalities and assessment criteria used by Australian oral and maxillofacial surgeons when determining the proximity of mandibular canal to third molars.

METHODS

A survey of all surgeon members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZOMS) practising in Australia was undertaken.

RESULTS

Of the 105 questionnaires sent to surgeons, 72 responses (68 per cent) were returned. All surgeons reported using the panoramic radiograph but only 25 per cent considered it sufficiently accurate in determining the relationship between the mandibular canal (MC) and the third molar root, while 61 per cent of surgeons use CT for this purpose but the average frequency of use was very low (five per cent). This study also revealed that the nine radiologic criteria on a panoramic radiograph are used to varying extents by Australian surgeons. Nearly all surgeons use 'change in MC direction' and 'MC narrowing' to determine and close relationship. Thirty-one per cent used superimposition of the MC and the root of the third molar alone and 24 per cent used appearance of contact of the root with the MC alone in the absence of any other radiologic criteria to indicate close or intimate relationship.

CONCLUSION

Further research is required to determine the accuracy and observer agreement or reliability of using the nine panoramic characteristics, to determine this relationship and whether the presurgical determination of proximity and position (buccal or lingual) of the canal utilizing CT has any usefulness in determining the surgical protocol or affect on postoperative morbidity.

Incidence and risk factors for injury in non-elite Australian Football

This paper identifies the risk and protective factors for injury in non-elite Australian Football. Five hundred and thirty five non-elite Australian footballers completed a baseline questionnaire at the commencement of the 1997 preseason. Participants were telephoned each month during the 1997 and 1998 playing seasons to provide details of their exposure at training and games and any injury experiences in the previous four weeks. The incidence of injury in this study was 24 injuries per 1000 player hours. The risk factors for injury were identified as: not wearing sports-specific football boots (IRR 1.40, 95% CI 1.03-1.90); an existing back pathology (IRR 1.29, 95% CI 1.10-1.51); excessive foot pronation (IRR 1.29, 95% CI 1.07-1.56); and extroverted behaviour (IRR 1.01, 95% CI 1.00-1.03). Cooling down after training (IRR 0.95, 95% CI 0.90-0.99) and not being injured in the previous 12 months (IRR 0.73, 95% CI 0.61-0.88) were found to be protective against injury. This study found that there was a high risk of injury associated with playing Australian Football at a community level. Further research is required to gain an understanding of the mechanisms by which the identified risk factors influence injury risk in community level Australian Football.

Outcomes of myringoplasty in Australian Aboriginal children and factors associated with success: a prospective case series

The objective of this study was to assess the outcomes of myringoplasties in Aboriginal children and to identify factors associated with a successful outcome with the use of prospective case series from primary health care clinics and hospitals in four rural and remote regions of Western Australia. All 58 Aboriginal children, aged 5-15 years, who underwent 78 myringoplasties between 1 January 2000 and 30 June 2001 were included in the study. Complete postoperative (post-op) follow-up was achieved following 78% of myringoplasties. The main outcome measures were (a) success, i.e. an intact tympanic membrane and normal hearing six or more months post-op in the operated ear, (b) closure of the perforation, (c) Post-op hearing improvement. Forty-nine per cent of myringoplasties were successful, 72% resulted in closure or reduction in the size of the perforation and 51% resulted in hearing improvement. After controlling for age, sex, clustering and number of previous myringoplasties, no association was observed between success or hearing improvement and perforation size, or the presence of serous aural discharge at the time of surgery. Myringoplasty resulted in hearing improvement and/or perforation closure in a significant proportion of children. Thus, primary school-aged Aboriginal children in whom conservative management of chronic suppurative otitis media has been unsuccessful should have access to myringoplasty because of the positive impact on their socialization, language and learning that results from improved hearing.

Association of domestic exposure to volatile organic compounds with asthma in young children

AIM

To investigate the association between domestic exposure to volatile organic compounds (VOCs) and asthma in young children.

METHODS

A population based case-control study was conducted in Perth, Western Australia in children aged between 6 months and 3 years. Cases (n = 88) were children recruited at Princess Margaret Hospital accident and emergency department and discharged with asthma as the primary diagnosis; 104 controls consisted of children from the same age group without an asthma diagnosis identified through the Health Department of Western Australia. Information regarding the health status of the study children and characteristics of the home was collected using a standardised questionnaire. Exposure to VOCs, average temperature and relative humidity were measured in winter and summer in the living room of each participating household.

RESULTS

Cases were exposed to significantly higher VOC levels (microg/m3) than controls (p<0.01). Most of the individual VOCs appeared to be significant risk factors for asthma with the highest odds ratios for benzene followed by ethylbenzene and toluene. For every 10 unit increase in the concentration of toluene and benzene (microg/m3) the risk of having asthma increased by almost two and three times, respectively.

CONCLUSIONS

Domestic exposure to VOCs at levels below currently accepted recommendations may increase the risk of childhood asthma. Measurement of total VOCs may underestimate the risks associated with individual compounds.

Mortality and cancer incidence in a cohort of meatworkers

AIMS

To determine the risk of all cause mortality, cause specific mortality, and incident cancer in meatworkers.

METHODS

In a retrospective cohort study, a list of members of a meatworkers union in Australia was matched with the national death and cancer registries. Standardised mortality ratios (SMR) and standardised incidence ratios (SIR) were calculated using Australian population rates. Exposure to animal viruses, animal blood, animal faeces, and plastic pyrolysis products was assigned according to job title. A nested case control analysis examined the risk of mortality and cancer incidence by each exposure.

RESULTS

There were approximately 20 000 subjects available for analysis. Male workers had increased risk of mortality from all causes (SMR 116, 95% CI 105 to 128) and from injury (SMR 131, 95% CI 108 to 157). Risk of incident lung cancer in males was non-significantly increased (SIR 164, 95% CI 97 to 259) and males had a raised risk of head and neck cancer (SIR 188, 95% CI 103 to 315). There were no significant associations with specific exposures.

CONCLUSIONS

Compared to the general Australian population, meatworkers have increased risk of death from all causes, death from injury, and incident lung and head and neck cancer. Analysis by occupational exposures did not disclose any strong evidence of specific occupational risk factors, although this analysis was limited by small numbers of some outcomes and exposure assessment which was based on job titles only.

Subcutaneous glucose sensor values closely parallel blood glucose during insulin-induced hypoglycaemia

AIMS

To assess the accuracy of the Minimed continuous glucose monitoring system (CGMS) in estimating blood glucose concentration during a controlled reduction in blood glucose.

RESEARCH DESIGN AND METHODS

We studied nine adolescent diabetics (age 14 +/- 1.5 years) wearing the CGMS during hyperinsulinaemic hypoglycaemic clamp studies. The glucose values obtained by the CGMS were compared with the venous blood samples taken during the studies and measured at the bedside using a glucose oxidase technique.

RESULTS

Blood glucose was lowered from euglycaemia to a mean of 2.8 mmol/l over 120 min and maintained at that level for a further 40 min. A total of 429 paired glucose measurements were available for analysis. Analysis using weighted Deming regression and t-tests revealed small differences between the methods, with blood glucose levels slightly higher than interstitial fluid levels. The mean difference across all values was 0.13 mmol/l. The observed difference was greatest at blood glucose values < 3.3 mmol/l.

CONCLUSIONS

This study suggests that during a fall in systemic glucose the subcutaneous glucose sensor provides an accurate reflection of blood glucose. However, a small difference is apparent at blood glucose values < 3.3 mmol/l.

Preparing a new generation anaesthetic machine for patients susceptible to malignant hyperthermia

Anaesthetic machines are prepared for use with patients who are susceptible to malignant hyperpyrexia (MH) by flushing with oxygen at 10 l/min for ten minutes to reduce the anaesthetic concentration to 1 part per million (ppm) or less. Anaesthetic workstations are now often used in place of traditional machines. Workstations have greater internal complexity, and it is not known if they can be made safe for susceptible patients by flushing with oxygen. We used a high sensitivity infrared gas analyser to measure the washout of isoflurane from five Datex-Ohmeda workstations. Measurements were then repeated with a patient breathing circuit. Isoflurane washout occurred in an exponential manner. The time to reach a concentration of 1 ppm at the fresh gas outlet was 17 +/- 7 minutes, and all machines had reached less than 2 ppm by ten minutes. The washout of isoflurane from the machine and patient breathing circuit was much slower than from the machine alone, with a concentration less than 2 ppm reached only after 30 minutes. We conclude that the Datex-Ohmeda workstation can be prepared for use in MH susceptible patients by flushing with oxygen at 10 l/min for ten minutes. Flushing of the patient breathing system is not straightforward, and we recommend using a clean T-piece circuit. If the circle system and ventilator are required for anaesthesia, we suggest using new breathing hoses, rebreathing bag and soda lime cartridge, and ventilating an artificial lung for 30 minutes with a fresh gas flow rate of 10 l/min and tidal volume of 1 litre.