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Single-center long-term results from the randomized phase-3 TARGIT-A trial comparing intraoperative and whole-breast radiation therapy for early breast cancer. Strahlenther Onkol 2019; 195:640-647. [DOI: 10.1007/s00066-019-01438-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 11/26/2022]
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Downs-Canner S, Zabor EC, Wind T, Cobovic A, McCormick B, Morrow M, Heerdt A. Radiation Therapy After Breast-Conserving Surgery in Women 70 Years of Age and Older: How Wisely Do We Choose? Ann Surg Oncol 2019; 26:969-975. [PMID: 30737670 DOI: 10.1245/s10434-018-07151-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite data from randomized trials supporting omission of radiation therapy (RT) for women ≥ 70 years of age with T1, estrogen receptor-positive (ER+) tumors undergoing breast-conserving therapy (BCT), RT usage remains high. We reviewed our institutional experience to determine if risk factors for local recurrence or comorbidities influenced use. METHODS Women ≥ 70 years of age with T1, ER+, human epidermal growth factor receptor 2-negative (HER2-) tumors undergoing BCT in 2010-2012 were identified from a prospectively maintained database. Ten-year estimated mortality was calculated using the Suemoto index. The associations of clinicopathological features and mortality risk on receipt of RT were examined. RESULTS Overall, 323 patients with 327 cancers were identified. Median age was 75 years, median tumor size was 1 cm, and all were clinically node negative; 53.7% of patients received RT. RT usage decreased with age (73.6%, age 70-74 years; 49.5%, age 75-79 years; 33.3%, age 80-84 years; 10.7%, ≥ 85 years; p < 0.001). Within age groups, estimated mortality did not impact RT usage. On multivariable analysis, only younger age and larger tumor size were associated with RT use. Recurrence-free survival was 98% versus 93% with and without RT, respectively (p = 0.011). Those who received adjuvant radiation also had improved overall survival (92% vs. 89%), although this effect did not reach statistical significance (p = 0.051). CONCLUSION Neither the factors associated with risk of local recurrence nor the estimated risk of death in 10 years were associated with use of adjuvant radiation in a large cohort of women ≥ 70 years of age with small ER+ breast cancers treated with breast-conserving surgery.
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Affiliation(s)
- Stephanie Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tyler Wind
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Armend Cobovic
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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103
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Liu Y, Ide Y, Inuzuka M, Tazawa S, Kanada Y, Matsunaga Y, Kuwayama T, Sawada T, Akashi-Tanaka S, Nakamura S. BRCA1/BRCA2 mutations in Japanese women with ductal carcinoma in situ. Mol Genet Genomic Med 2019; 7:e493. [PMID: 30652428 PMCID: PMC6418441 DOI: 10.1002/mgg3.493] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/26/2018] [Accepted: 10/02/2018] [Indexed: 12/21/2022] Open
Abstract
Background Ductal carcinoma in situ (DCIS) is considered a component of the clinical spectrum of breast cancer even in those with BRCA1/2 mutation. The aim of this study was to report the feature of DCIS raised in Japanese women with BRCA1/2 mutations. Methods A total of 325 Japanese women with breast cancer (BC) (with or without invasive cancer) were referred for genetic counseling and underwent genetic testing for mutations in the BRCA1 and BRCA2 genes in Showa University Hospital between December 2011 and August 2016. And 49 of them who were pathologically diagnosed as DCIS were included in this study. Logistic regression models were fit to determine the associations between potential predictive factors and BRCA status. A Cox proportional hazards model is used to predictive value of parameters for Ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR). Results (a) Of 325 patients (with or without invasive cancer), 19.1% (62/325) tested positive for BRCA1/BRCA2 mutations. And 18.4% (9/49) was positive for BRCA1/BRCA2 mutations in DCIS, compared with 19.2% (53/276) in IDC (p = 1.000). Among BRCA mutations, 14.5% (9/62) had DCIS compared with nonmutations (15.2%, 40/263). Incidence of DCIS was 3.0% (1/33) of BRCA1 mutations and 27.5% (8/29) of BRCA2 mutation (p = 0.009). (b) Median age of diagnosis in BRCA mutation carriers was 39 years, compared with 46 years in noncarriers. Age, Family history (FH) of BC, FH of first or second BC and total number of relatives with BC diagnosis (DX) has significant difference between BRCA mutation carriers and noncarriers in univariate analysis. In a multivariate logistic model, total relatives with BC DX ≥ 2 (odds ratio [OR], 5.128; 95% confidence interval [CI], 1.266–20.763; p = 0.022), age at diagnosis ≤35 years (OR 0.149, 95% CI 0.023–0.954, p = 0.045) and ER+/HER2+ status (OR 5.034, 95% CI 1.092–23.210, p = 0.038) remained as independent significant predictors for BRCA mutation. Ki67 index (cut off by 14% or 30%) did not differ between BRCA mutation carriers and noncarriers (p = 0.459 and p = 0.651). (c) There was a significant difference in ER‐positive tumors among BRCA2 carriers and noncarriers (p = 0.042). Subgroup analysis showed BRCA2 carriers tend to be of higher grade (Grade 2 and 3), more frequently ER+/PR+ (p = 0.041) and lower proliferation (Ki67 index) than noncarriers, whereas differences in nuclear grade and ki67 index were not found significantly in our study. (d) BRCA mutation was not associated with an increased risk of IBTR and CBTR. Conclusion DCIS is equally as prevalent in patients who were BRCA mutation carriers as in high familial‐risk women who were noncarriers, but occurs at earlier age. BRCA2 carriers have higher incidence in DCIS than that of BRCA1 carriers, and tend to be higher grade and more frequently ER positive and lower proliferation. Total relatives with BC DX ≥2, age at diagnosis ≤35 years and ER+/HER2+ might be independent predictors for BRCA mutation in Japanese women with DCIS and patients of these risk factors should be recommended to receive genetic counseling and BRCA testing.
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Affiliation(s)
- Yan Liu
- The 3rd Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Breast Cancer Prevention and Therapy of Ministry of Education, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yoshimi Ide
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Mayuko Inuzuka
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Sakiko Tazawa
- Department of Pathology, Showa University Hospital, Tokyo, Japan
| | - Yoko Kanada
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yuki Matsunaga
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Kuwayama
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Terumasa Sawada
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Sadako Akashi-Tanaka
- Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Seigo Nakamura
- The 3rd Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Breast Cancer Prevention and Therapy of Ministry of Education, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Division of Breast Surgical Oncology, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
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Wimmer T, Ortmann O, Gerken M, Klinkhammer-Schalke M, Koelbl O, Inwald EC. Adherence to guidelines and benefit of adjuvant radiotherapy in patients with invasive breast cancer: results from a large population-based cohort study of a cancer registry. Arch Gynecol Obstet 2019; 299:1131-1140. [PMID: 30607594 DOI: 10.1007/s00404-018-5030-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 12/14/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE According to German S3 guidelines, radiotherapy (RT) is indicated in patients with invasive breast cancer after breast-conserving therapy (BCT). The aim of this analysis was to assess adherence to guidelines, long-term survival, recurrence rates, and recurrence-free survival after adjuvant RT in patients with BCT in daily clinical practice. METHODS This retrospective cohort study comprised data from the population-based clinical cancer registry of the Tumor Centre Regensburg (Bavaria, Germany). 6370 patients with non-metastatic invasive breast cancer and UICC tumor stages I, II, and III who were treated in certified breast cancer centers by BCT and diagnosed between 2003 and 2013 were included in the study. RESULTS 6184 (97.1%) breast cancer patients received guideline concordant RT and showed a 3-year overall survival (OAS) of 96.8% in contrast to 90.9% in patients without RT (5-year OAS of 93.1% vs. 79.0%, p < 0.001). In multivariable Cox regression models, better overall survival was confirmed for the RT group (HR 0.64, 95% CI 0.46-0.88, p = 0.007). The 5-year local recurrence-free survival rate (RFS) in the irradiated patients was 92.1% vs. 62.0% in the comparison group (p < 0.001). The 10-year RFS was 80.5% vs. 36.0% (p < 0.001). This difference persisted after adjusting in multivariable analysis (HR 0.20, 95% CI 0.16-0.26, p < 0.001). CONCLUSIONS This population-based analysis showed that the implementation of German guidelines in clinical routine was successful and guideline concordant adjuvant radiotherapy after BCT leads to better overall and recurrence-free survival and lower local recurrence rates.
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Affiliation(s)
- Theresa Wimmer
- Faculty of Medicine, University of Regensburg, Universitaetsstraße 31, 93053, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Michael Gerken
- Tumor Center-Institute for Quality Management and Health Services Research, University of Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Department for Radiotherapy, Regensburg University Medical Center Regensburg, Franz-Josef-Strauss-Allee 24, 93053, Regensburg, Germany.
| | - Oliver Koelbl
- Department for Radiotherapy, Regensburg University Medical Center Regensburg, Franz-Josef-Strauss-Allee 24, 93053, Regensburg, Germany
| | - Elisabeth C Inwald
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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Long-Term Outcomes of Immunohistochemically Defined Subtypes of Breast Cancer Less Than or Equal to 2 cm After Breast-Conserving Surgery. J Surg Res 2018; 236:288-299. [PMID: 30694768 DOI: 10.1016/j.jss.2018.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/20/2018] [Accepted: 11/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Molecular subtype predicts the prognosis of early-stage breast cancer patients. We assessed the long-term outcomes of breast cancer ≤2 cm treated with breast-conserving surgery (BCS) and stratified according to an immunohistochemically (IHC)-based subtype definition. METHODS This retrospective study was conducted from a prospectively collected database. Included patients had pT1, any N, M0 breast cancer after BCS (without anti-HER2 therapy) and available information on estrogen receptor (ER), progesterone receptor (PR), HER2 status, Ki-67 index. Five IHC-defined subtypes were identified: luminal A-like (ER and/or PR-positive/HER2-negative/Ki-67 < 20%), luminal B-like/HER2-negative (ER and/or PR-positive/HER2-negative/Ki-67 ≥ 20%), luminal B-like/HER2-positive (ER and/or PR-positive/HER2-positive/any Ki-67 value), HER2-positive/nonluminal (ER and PR-negative/HER2-positive), and triple-negative (ER and PR-negative/HER2-negative). RESULTS We analyzed 184 (65%) luminal A-like, 57 (20%) luminal B-like/HER2-negative, 17 (6%) luminal B-like/HER2-positive, 6 (2%) HER2-positive/nonluminal, and 18 (7%) triple-negative patients. Median follow-up was 112 (interquartile range 94-125) mo. The cumulative 5- and 10-y local recurrence (LR) rates were 1.5% and 4%, respectively. The cumulative 5- and 10-y distant recurrence (DR) rates were 3% and 8%, respectively. The Cox regression revealed that HER2-positive/nonluminal subtypes had the highest risk of LR (P = 0.0025). The luminal B-like/HER2-positive subtypes had the highest risk of DR (P = 0.0019). HER2 positivity carried a higher risk of DR in women with luminal breast cancer who completed 5 y of adjuvant hormonal therapy (P = 0.02). CONCLUSIONS The IHC-defined subtype impacts on the prognosis of breast cancer ≤2 cm after BCS, determining significant differences in LR and DR rates. In the pre-"anti-HER2 therapy" era, patients with HER2-positive/nonluminal or luminal B-like/HER2-positive subtype had worse long-term outcomes than those with luminal A-like subtype.
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106
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Akdeniz D, Schmidt MK, Seynaeve CM, McCool D, Giardiello D, van den Broek AJ, Hauptmann M, Steyerberg EW, Hooning MJ. Risk factors for metachronous contralateral breast cancer: A systematic review and meta-analysis. Breast 2018; 44:1-14. [PMID: 30580169 DOI: 10.1016/j.breast.2018.11.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The risk of developing metachronous contralateral breast cancer (CBC) is a recurrent topic at the outpatient clinic. We aimed to provide CBC risk estimates of published patient, pathological, and primary breast cancer (PBC) treatment-related factors. METHODS PubMed was searched for publications on factors associated with CBC risk. Meta-analyses were performed with grouping of studies by mutation status (i.e., BRCA1, BRCA2, CHEK2 c.1100delC), familial cohorts, and general population-based cohorts. RESULTS Sixty-eight papers satisfied our inclusion criteria. Strong associations with CBC were found for carrying a BRCA1 (RR = 3.7; 95%CI:2.8-4.9), BRCA2 (RR = 2.8; 95%CI:1.8-4.3) or CHEK2 c.1100delC (RR = 2.7; 95%CI:2.0-3.7) mutation. In population-based cohorts, PBC family history (RR = 1.8; 95%CI:1.2-2.6), body mass index (BMI) ≥30 kg/m2 (RR = 1.5; 95%CI:1.3-1.9), lobular PBC (RR = 1.4; 95%CI:1.1-1.8), estrogen receptor-negative PBC (RR = 1.5; 95%CI:1.0-2.3) and treatment with radiotherapy <40 years (RR = 1.4; 95%CI:1.1-1.7) was associated with increased CBC risk. Older age at PBC diagnosis (RR per decade = 0.93; 95%CI:0.88-0.98), and treatment with chemotherapy (RR = 0.7; 95%CI:0.6-0.8) or endocrine therapy (RR = 0.6; 95%CI:0.5-0.7) were associated with decreased CBC risk. CONCLUSIONS Mutation status, family history, and PBC treatment are key factors for CBC risk. Age at PBC diagnosis, BMI, lobular histology and hormone receptor status have weaker associations and should be considered in combination with key factors to accurately predict CBC risk.
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Affiliation(s)
- Delal Akdeniz
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, Netherlands; Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Marjanka K Schmidt
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Caroline M Seynaeve
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Danielle McCool
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Daniele Giardiello
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, Netherlands
| | - Alexandra J van den Broek
- Division of Molecular Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Michael Hauptmann
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands; Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, Netherlands.
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Lindsay WD, Ahern CA, Tobias JS, Berlind CG, Chinniah C, Gabriel PE, Gee JC, Simone CB. Automated data extraction and ensemble methods for predictive modeling of breast cancer outcomes after radiation therapy. Med Phys 2018; 46:1054-1063. [PMID: 30499597 DOI: 10.1002/mp.13314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The purpose of this study was to compare the effectiveness of ensemble methods (e.g., random forests) and single-model methods (e.g., logistic regression and decision trees) in predictive modeling of post-RT treatment failure and adverse events (AEs) for breast cancer patients using automatically extracted EMR data. METHODS Data from 1967 consecutive breast radiotherapy (RT) courses at one institution between 2008 and 2015 were automatically extracted from EMRs and oncology information systems using extraction software. Over 230 variables were extracted spanning the following variable segments: patient demographics, medical/surgical history, tumor characteristics, RT treatment history, and AEs tracked using CTCAEv4.0. Treatment failure was extracted algorithmically by searching posttreatment encounters for evidence of local, nodal, or distant failure. Individual models were trained using decision trees, logistic regression, random forests, and boosted decision trees to predict treatment failures and AEs. Models were fit on 75% of the data and evaluated for probability calibration and area under the ROC curve (AUC) on the remaining test set. The impact of each variable segment was assessed by retraining without the segment and measuring change in AUC (ΔAUC). RESULTS All AUC values were statistically significant (P < 0.05). Ensemble methods outperformed single-model methods across all outcomes. The best ensemble method outperformed decision trees and logistic regression by an average AUC of 0.053 and 0.034, respectively. Model probabilities were well calibrated as evidenced by calibration curves. Excluding the patient medical history variable segment led to the largest AUC reduction in all models (Average ΔAUC = -0.025), followed by RT treatment history (-0.021) and tumor information (-0.015). CONCLUSION In this largest such study in breast cancer performed to date, automatically extracted EMR data provided a basis for reliable outcome predictions across multiple statistical methods. Ensemble methods provided substantial advantages over single-model methods. Patient medical history contributed the most to prediction quality.
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Affiliation(s)
| | | | | | | | - Chidambaram Chinniah
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Peter E Gabriel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - James C Gee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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McClelland S, Xanthopoulos EP, Mitin T. The Sin of Exclusion: Applicability of Trials Encouraging Omission of Radiation Therapy to Nonwhite Patients With Breast Cancer. J Oncol Pract 2018; 14:635-638. [PMID: 30423265 DOI: 10.1200/jop.18.00344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Shearwood McClelland
- Indiana University School of Medicine, Indianapolis, IN; University of Wisconsin School of Medicine, Madison, WI; and Oregon Health and Science University, Portland, OR
| | - Eric P Xanthopoulos
- Indiana University School of Medicine, Indianapolis, IN; University of Wisconsin School of Medicine, Madison, WI; and Oregon Health and Science University, Portland, OR
| | - Timur Mitin
- Indiana University School of Medicine, Indianapolis, IN; University of Wisconsin School of Medicine, Madison, WI; and Oregon Health and Science University, Portland, OR
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Nakada H, Inoue M, Furuya K, Watanabe H, Ikegame K, Nakayama Y, Ohmori M, Nakagomi H. Fat necrosis after breast-conserving oncoplastic surgery. Breast Cancer 2018; 26:125-130. [PMID: 30151780 DOI: 10.1007/s12282-018-0901-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fat necrosis is a subjective early as well as delayed complication, which sometimes mimics local recurrence and ruins the quality of life by pain and poor cosmetic result. While, the frequency and severity of fat necrosis are important issues that breast surgeons should explain to the patient, these data are not revealed well. METHODS A total of 1476 patients who underwent breast surgery from January 2000 to December 2012 were enrolled in the present study. We assessed fat necrosis by mammographic and physical findings and created grading criteria: Grade (G) 0, no fat necrosis; G1, no symptomatic fat necrosis (mammographic dystrophic calcification); G2, mild symptomatic necrosis (mammographic dystrophic necrosis with tumor); G3, severe symptomatic necrosis (mammographic dystrophic necrosis with pain or skin change); and G4, symptomatic necrosis requiring surgical intervention. RESULTS Of the 1476 patients enrolled, 393 (27%) underwent mastectomy, and 1083 (73%) underwent breast-conserving surgery. We achieved a high rate of breast-conserving surgery at a total rate of 73% over the study period and maximum rate of 88% in 2010, using oncoplastic procedures. We mainly adopted a pedicled fat flap (417/1083; 39%) and a free dermal fat flap (40/1083; 3.7%). Among the 626 patients who underwent partial resection with no replacement for the defect, G1-G2 fat necrosis was seen in 29/626 (4.6%). While, the incidence of fat necrosis with pedicled fat flap and free dermal fat graft was 68/417 (16%) and 40/40 (100%), respectively, showing a significant difference (p < 0.01). Furthermore, the incidence of G3-G4 fat necrosis was significantly higher with free dermal fat grafts (25%; 10/40) than with pedicled flap (2.9%; 12/417) (p < 0.01). Among pedicled flaps, the incidence of fat necrosis with inframammary adipofascial flaps was 56% (14/25) which was higher than that with lateral epidermal fat flaps (12%; 33/276) (p < 0.01), and rotation of surrounding breast tissues (8%; 21/116) (p < 0.01). The incidence of G3 fat necrosis was also high at 20% (5/25) in inframammary adipofascial flaps. CONCLUSIONS Breast-conserving oncoplastic surgery carries a risk of fat necrosis as a delayed complication. The incidence rate and severity of fat necrosis with each procedure should be assessed. We should select fat grafts with a good blood supply to replace defects of breast-conserving therapy.
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Affiliation(s)
- Haruka Nakada
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan
| | - Masayuki Inoue
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan
| | - Kazushige Furuya
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan
| | - Hideki Watanabe
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan
| | - Kou Ikegame
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan
| | - Yuko Nakayama
- First Department of Surgery, University of Yamanashi, Yamanashi, Japan
| | - Masato Ohmori
- First Department of Surgery, University of Yamanashi, Yamanashi, Japan
| | - Hiroshi Nakagomi
- Department of Breast Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, 400-8506, Japan.
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Goodman CR, Seagle BLL, Friedl TWP, Rack B, Lato K, Fink V, Cristofanilli M, Donnelly ED, Janni W, Shahabi S, Strauss JB. Association of Circulating Tumor Cell Status With Benefit of Radiotherapy and Survival in Early-Stage Breast Cancer. JAMA Oncol 2018; 4:e180163. [PMID: 29800954 DOI: 10.1001/jamaoncol.2018.0163] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance Circulating tumor cells (CTCs) represent the liquid component of solid tumors and are a surrogate marker for residual cancer burden. Although CTC status is prognostic of recurrence and death in breast cancer, its role in guiding clinical management remains unknown. Objective To determine whether CTC status is predictive of radiotherapeutic benefit in early-stage breast cancer. Design, Setting, and Participants The cohort studies in the present analysis included patients with stages pT1 to pT2 and pN0 to pN1 breast cancer and known CTC status from the National Cancer Database (NCDB) and the multicenter phase 3 SUCCESS clinical trial. Multivariable parametric accelerated failure time models were used to evaluate the association of CTC status and radiotherapy (RT) with survival outcomes. Data were collected from January 1, 2004, through December 31, 2014, from the NCDB cohort. The SUCCESS trial collected data from September 1, 2005, through September 30, 2013. The analyses were completed from November 1, 2016, through December 17, 2017. Exposure Adjuvant RT. Main Outcomes and Measures Overall survival (OS), local recurrence-free survival (LRFS), and disease-free survival (DFS). Results A total of 1697 patients from the NCDB (16 men [0.9%] and 1681 women [99.1%]; median age, 63 years; interquartile range, 53-71 years) and 1516 patients from the SUCCESS clinical trial (median age, 52 years; interquartile range, 45-60 years) were identified. Circulating tumor cells were detected in 399 patients (23.5%) in the NCDB cohort and 294 (19.4%) in the SUCCESS cohort. The association of RT with survival was dependent on CTC status within the NCDB cohort (4-year OS, 94.9% for CTC-positive RT vs 88.0% for CTC-positive non-RT vs 93.9% for CTC-negative RT vs 93.4% for CTC-negative non-RT groups; P < .001) and 5-year DFS within the SUCCESS cohort (88.0% for CTC-positive RT vs 75.2% for CTC-positive non-RT vs 92.3% for CTC-negative RT vs 88.3% for CTC-negative non-RT; P = .04). In the NCDB cohort, RT was associated with longer OS in patients with CTCs (time ratio [TR], 2.04; 95% CI, 1.55-2.67; P < .001), but not in patients without CTCs (TR, 0.80; 95% CI, 0.52-1.25; P = .33). In the SUCCESS cohort, CTC-positive patients treated with RT exhibited longer LRFS (TR, 2.73; 95% CI, 1.62-4.80; P < .001), DFS (TR, 3.03; 95% CI, 2.22-4.13; P < .001), and OS (TR, 1.83; 95% CI, 1.23-2.72; P = .003). Among patients from both cohorts who underwent breast-conserving surgery, RT was associated with longer OS in patients with CTCs (TR, 4.37; 95% CI, 2.71-7.05; P < .001) but not in patients without CTCs (TR, 0.87; 95% CI, 0.47-1.62; P = .77). Radiotherapy was not associated with OS after mastectomy in CTC-positive or CTC-negative patients. Conclusions and Relevance Treatment with RT was associated with longer LRFS, DFS, and OS in patients with early-stage breast cancer and detectable CTCs. These results are hypothesis generating; a prospective trial evaluating CTC-based management for RT after breast-conserving surgery in women with early-stage breast cancer is warranted.
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Affiliation(s)
- Chelain R Goodman
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brandon-Luke L Seagle
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Thomas W P Friedl
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
| | - Brigitte Rack
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
| | - Krisztian Lato
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
| | - Visnja Fink
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
| | - Massimo Cristofanilli
- Division of Medicine-Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Eric D Donnelly
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University Hospital Ulm, Ulm, Germany
| | - Shohreh Shahabi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan B Strauss
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Close Margins Less Than 2 mm Are Not Associated With Higher Risks of 10-Year Local Recurrence and Breast Cancer Mortality Compared With Negative Margins in Women Treated With Breast-Conserving Therapy. Int J Radiat Oncol Biol Phys 2018; 101:661-670. [DOI: 10.1016/j.ijrobp.2018.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/02/2018] [Indexed: 12/18/2022]
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112
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Shumway DA, Griffith KA, Hawley ST, Wallner LP, Ward KC, Hamilton AS, Morrow M, Katz SJ, Jagsi R. Patient views and correlates of radiotherapy omission in a population-based sample of older women with favorable-prognosis breast cancer. Cancer 2018; 124:2714-2723. [PMID: 29669187 PMCID: PMC7537366 DOI: 10.1002/cncr.31378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The omission of radiotherapy (RT) after lumpectomy is a reasonable option for many older women with favorable-prognosis breast cancer. In the current study, we sought to evaluate patient perspectives regarding decision making about RT. METHODS Women aged 65 to 79 years with AJCC 7th edition stage I and II breast cancer who were reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries were surveyed (response rate, 70%) regarding RT decisions, the rationale for omitting RT, decision-making values, and understanding of disease recurrence risk. We also surveyed their corresponding surgeons (response rate, 77%). Patient characteristics associated with the omission of RT were evaluated using multilevel, multivariable logistic regression, accounting for patient clustering within surgeons. RESULTS Of 999 patients, 135 omitted RT (14%). Older age, lower tumor grade, and having estrogen receptor-positive disease each were found to be strongly associated with omission of RT in multivariable analyses, whereas the number of comorbidities was not. Non-English speakers were more likely to omit RT (adjusted odds ratio, 5.9; 95% confidence interval, 1.4-24.5). The most commonly reported reasons for RT omission were that a physician advised the patient that it was not needed (54% of patients who omitted RT) and patient choice (41%). Risk of local disease recurrence was overestimated by all patients: by approximately 2-fold among those who omitted RT and by approximately 8-fold among those who received RT. The risk of distant disease recurrence was overestimated by approximately 3-fold on average. CONCLUSIONS To some extent, decisions regarding RT omission are appropriately influenced by patient age, tumor grade, and estrogen receptor status, but do not appear to be optimally tailored according to competing comorbidities. Many women who are candidates for RT omission overestimate their risk of disease recurrence. Cancer 2018;124:2714-2723. © 2018 American Cancer Society.
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Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Monica Morrow
- Breast Surgical Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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113
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Individualizing Local-Regional Therapy of Breast Cancer in the Elderly. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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114
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Corica T, Nowak AK, Saunders CM, Bulsara MK, Taylor M, Williams NR, Keshtgar M, Joseph DJ, Vaidya JS. Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial. Radiat Oncol 2018; 13:68. [PMID: 29653541 PMCID: PMC5899392 DOI: 10.1186/s13014-018-0998-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of this research was to assess agreement between four rating systems of cosmetic outcome measured in a subset of patients with early breast cancer participating in the randomised TARGIT-A trial. TARGIT-A compared risk-adapted single-dose intra-operative radiotherapy (TARGIT-IORT) to whole breast external beam radiotherapy (EBRT). Methods Patients, their Radiation Oncologist and Research Nurse completed a subjective cosmetic assessment questionnaire before radiotherapy and annually thereafter for five years. Objective data previously calculated by the validated BCCT.core software which utilizes digital photographs to score symmetry, colour and scar was also used. Agreement was assessed by the Kappa statistic and longitudinal changes were assessed by generalized estimating equations. Results Overall, an Excellent-Good (EG) cosmetic result was scored more often than a Fair-Poor (FP) result for both treatment groups across all time points, with patients who received TARGIT-IORT scoring EG more often than those who received EBRT however this was statistically significant at Year 5 only. There was modest agreement between the four rating systems with the highest Kappa score being moderate agreement which was between nurse and doctor scores at Year 1 with Kappa = 0.46 (p < 0.001), 95% CI (0.24, 0.68). Conclusion Despite similar overall findings between treatment groups and rating systems, the inter-rater agreement was only modest. This suggests that the four rating systems utilized may not necessarily be used interchangeably and it is arguable that for an outcome such as cosmetic appearance, the patient’s point of view is the most important. Trial Registration TARGIT-A ISRCTN34086741, Registered 21 July 2004, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13014-018-0998-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tammy Corica
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia. .,Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.
| | - Anna K Nowak
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia
| | | | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, 19 Mouat Street, Fremantle, WA, 6160, Australia
| | - Mandy Taylor
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Norman R Williams
- Surgical & Interventional Trials Unit, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, London, NW1 2FD, UK
| | - Mohammed Keshtgar
- Royal Free London Foundation NHS Trust, Division of Surgical Sciences, The Breast Unit, Pond Street, Hampstead, London, NW3 2QG, UK
| | - David J Joseph
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.,Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Jayant S Vaidya
- Division of Surgery & Interventional Science, University College London, London W1W 7TS, UK; Whittington Hospital, Royal Free Hospital and University College Hospital, University College London, London, NW1 2FD, UK
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115
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Franco P, Iorio GC, Bartoncini S, Airoldi M, De Sanctis C, Castellano I, Ricardi U. De-escalation of breast radiotherapy after conserving surgery in low-risk early breast cancer patients. Med Oncol 2018; 35:62. [PMID: 29616366 DOI: 10.1007/s12032-018-1121-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
The reduction in the burden related to treatment is becoming more and more important in modern oncology. Radiation therapy is a mainstay option in the postoperative setting for early breast cancer patients after breast-conserving surgery. Nowadays, different options are available to de-escalate radiotherapy in this scenario such as the use of hypofractionated whole-breast radiation, the selective delivery of the boost dose to the lumpectomy cavity, the introduction of accelerated partial breast irradiation and the omission of treatment in appropriately selected patients with low-risk features. We herein provide a review article on this topic.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Giuseppe Carlo Iorio
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Sara Bartoncini
- Department of Oncology, Radiation Oncology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Mario Airoldi
- Department of Medical Sciences, Pathology Unit, University of Turin, Turin, Italy
| | - Corrado De Sanctis
- Department of Gynecology and Obstetrics, Breast Unit, AOU Città della Salute e della Scienza, Turin, Italy
| | - Isabella Castellano
- Department of Oncology, Medical Oncology 2, AOU Città della Salute e della Scienza, Turin, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
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116
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Huang XZ, Chen Y, Chen WJ, Zhang X, Wu CC, Zhang CY, Sun SS, Wu J. Effect of radiotherapy after breast-conserving surgery in older patients with early breast cancer and breast ductal carcinoma in situ: a meta-analysis. Oncotarget 2018; 8:28215-28225. [PMID: 28415667 PMCID: PMC5438644 DOI: 10.18632/oncotarget.15998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 02/28/2017] [Indexed: 01/06/2023] Open
Abstract
Background There are no consistent agreements on whether radiotherapy after breast-conserving surgery (BCS) could provide local control and survival benefit for older patients with early breast cancer or breast ductal carcinoma in situ (DCIS). The present study aimed to evaluate the efficacy of radiotherapy after BCS in older patients with early breast cancer or DCIS. Results Radiotherapy could reduce the risk of local relapse in older patients with early breast cancer. The 5-year AR of local relapse was 2.2% and 6.2% for radiotherapy and non-radiotherapy group, respectively, with low 5-year ARD of 4.0% and high NNT of 25. The 10-year AR of local relapse was 5.3% and 10.5% for radiotherapy and non-radiotherapy group, respectively, with the 10-year ARD of 5.2% and NNT of 20. However, radiotherapy could not improve survival benefits, including overall survival, cancer-specific survival, breast-cancer-specific survival, and distant relapse. Moreover, radiotherapy could reduce the risk of ipsilateral breast events in older patients with DCIS. Materials and Methods PubMed and Embase database were searched for relevant studies. Hazard ratios (HRs), risk ratios (RRs), absolute risk (AR), absolute risk difference (ARD), and number needed to treat (NNT) were used as effect measures to evaluate the efficacy of radiotherapy in older patients. Conclusions Our study indicates that radiotherapy could slightly reduce the risk of local relapse in older patients with favorable early breast cancer. However, radiotherapy cannot translate into significant survival benefits.
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Affiliation(s)
- Xuan-Zhang Huang
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - You Chen
- The Wenzhou Dental Hospital, Wenzhou City 325027, P.R. China
| | - Wen-Jun Chen
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - Xi Zhang
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - Cong-Cong Wu
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - Chao-Ying Zhang
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - Shuang-Shuang Sun
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
| | - Jian Wu
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou City 325027, P.R. China
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117
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Julian TB, Mamounas EP. Partial Breast Irradiation: Continuing the Retreat from Halstedian Breast Cancer Management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/10463356.2006.11884348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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118
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Horton JK, Jagsi R, Woodward WA, Ho A. Breast Cancer Biology: Clinical Implications for Breast Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 100:23-37. [PMID: 29254776 DOI: 10.1016/j.ijrobp.2017.08.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 12/18/2022]
Abstract
Historically, prognosis and treatment decision making for breast cancer patients have been dictated by the anatomic extent of tumor spread. However, in recent years, "breast cancer" has proven to be a collection of unique phenotypes with distinct prognoses, patterns of failure, and treatment responses. Recent advances in biologically based assays and targeted therapies designed to exploit these unique phenotypes have profoundly altered systemic therapy practice patterns and treatment outcomes. Data associating locoregional outcomes with tumor biology are emerging. However, the likelihood of obtaining level I evidence for fundamental radiation therapy questions within each of the specific subtypes in the immediate future is low. As such, this review aims to summarize the existing data and provide practical context for the incorporation of breast tumor biology into clinical practice.
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Affiliation(s)
- Janet K Horton
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alice Ho
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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119
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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120
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Donnelly ED, Neuschler E, Henley C, Helenowski I, Hansen N, Khan SA, Bethke K, Gutiontov S, Nesbit E, Hayes J, Strauss JB. Development of a nomogram to predict the clinical impact of a postexcision preirradiation mammogram. Breast J 2017; 24:620-623. [PMID: 29286191 DOI: 10.1111/tbj.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
Abstract
We aimed to better quantify the impact of a postexcision preirradiation mammogram (PPM), first by identifying factors associated with abnormal results and then incorporating these findings into a nomogram. Beginning February 2011, our institution made a practice change to obtain a PPM on all patients with any calcifications identified. A total of 530 patients underwent a PPM. Suspicious abnormalities were reported in 61 patients (11.5%), with the PPM leading to a change in management in 47 instances (8.9%). A nomogram was created based on patient and tumor characteristics to identify patients most likely to have an abnormal PPM.
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Affiliation(s)
- Eric D Donnelly
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Erin Neuschler
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher Henley
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Irene Helenowski
- Department of Preventive Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nora Hansen
- Department of Surgical Oncology - Breast Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Seema A Khan
- Department of Surgical Oncology - Breast Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin Bethke
- Department of Surgical Oncology - Breast Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stanley Gutiontov
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eric Nesbit
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Hayes
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan B Strauss
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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121
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Accelerated partial breast irradiation for elderly women with early breast cancer: A compromise between whole breast irradiation and omission of radiotherapy. Brachytherapy 2017; 16:929-934. [DOI: 10.1016/j.brachy.2017.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 11/18/2022]
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122
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Shea B, Boyan WP, Kamrani K, Lepis G, Dupree D, Chang S, Goldfarb M, Kohli M. Let us cut to the core: is core biopsy enough for subcentimeter breast cancer? J Surg Res 2017; 216:30-34. [PMID: 28807211 DOI: 10.1016/j.jss.2017.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/20/2017] [Accepted: 04/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast conservation therapy has become a preferred method of treating early-stage breast cancer. As care continues to evolve, certain lesions allowed less invasive treatment options. A simplified explanation of early breast cancer care is detection, biopsy, surgery, and adjuvant therapy. The authors look to challenge that algorithm for a specific type of disease. METHODS A retrospective review was performed to identify all subcentimeter breast cancer that underwent surgery after core biopsy. These cases (n = 115) were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found on final pathology, potentially rendering the surgical resection an unneeded procedure. RESULTS The authors found that 17 of 115 patients (14.8%) who underwent biopsy for subcentimeter breast cancer had no residual disease found on final surgical resection. Although the subsets were small, the largest core needle resulted in negative pathology two of three times, while the smallest gauge, never resulted in negative resection at time of surgery. CONCLUSIONS Nearly, fifteen percent of patients were found to have no residual disease on final surgical pathology. These results were obtained when the radiologist was simply trying to get tissue diagnosis. The authors postulate that this percentage could be even higher if protocols were initiated to biopsy these small lesions with larger core biopsies and possibly alleviate the need for formal surgery in these specific, small lesion.
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Affiliation(s)
- Brian Shea
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
| | - William P Boyan
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey.
| | - Kambiz Kamrani
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
| | - Grace Lepis
- School of Medicine, St George's University, The Lime, Grenada, West Indies
| | - David Dupree
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
| | - Sumy Chang
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
| | - Michael Goldfarb
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
| | - Manpreet Kohli
- Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey
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Sjöström M, Lundstedt D, Hartman L, Holmberg E, Killander F, Kovács A, Malmström P, Niméus E, Werner Rönnerman E, Fernö M, Karlsson P. Response to Radiotherapy After Breast-Conserving Surgery in Different Breast Cancer Subtypes in the Swedish Breast Cancer Group 91 Radiotherapy Randomized Clinical Trial. J Clin Oncol 2017; 35:3222-3229. [PMID: 28759347 DOI: 10.1200/jco.2017.72.7263] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate the effect of adjuvant radiotherapy (RT) after breast conservation surgery in different breast cancer subtypes in a large, randomized clinical trial with long-term follow-up. Patients and Methods Tumor tissue was collected from 1,003 patients with node-negative, stage I and II breast cancer who were randomly assigned in the Swedish Breast Cancer Group 91 Radiotherapy trial between 1991 and 1997 to breast conservation surgery with or without RT. Systemic adjuvant treatment was sparsely used (8%). Subtyping was performed with immunohistochemistry and in situ hybridization on tissue microarrays for 958 tumors. Results RT reduced the cumulative incidence of ipsilateral breast tumor recurrence (IBTR) as a first event within 10 years for luminal A-like tumors (19% v 9%; P = .001), luminal B-like tumors (24% v 8%; P < .001), and triple-negative tumors (21% v 6%; P = .08), but not for human epidermal growth factor receptor 2-positive (luminal and nonluminal) tumors (15% v 19%; P = .6); however, evidence of an overall difference in RT effect between subtypes was weak ( P = .21). RT reduced the rate of death from breast cancer (BCD) for triple-negative tumors (hazard ratio, 0.35; P = .06), but not for other subtypes. Death from any cause was not improved by RT in any subtype. A hypothesized clinical low-risk group did not have a low risk of IBTR without RT, and RT reduced the rate of IBTR as a first event after 10 years (20% v 6%; P = .008), but had no effect on BCD or death from any cause. Conclusion Subtype was not predictive of response to RT, although, in our study, human epidermal growth factor receptor 2-positive tumors seemed to be most radioresistant, whereas triple-negative tumors had the largest effect on BCD. The effect of RT in the presumed low-risk luminal A-like tumors was excellent.
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Affiliation(s)
- Martin Sjöström
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Dan Lundstedt
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Linda Hartman
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Erik Holmberg
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Fredrika Killander
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Anikó Kovács
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Per Malmström
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Emma Niméus
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Elisabeth Werner Rönnerman
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Mårten Fernö
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
| | - Per Karlsson
- Martin Sjöström, Linda Hartman, Fredrika Killander, Per Malmström, Emma Niméus, and Mårten Fernö, Lund University; Martin Sjöström, Fredrika Killander, Per Malmström, and Emma Niméus, Skåne University Hospital, Lund; Dan Lundstedt, Anikó Kovács, Elisabeth Werner Rönnerman and Per Karlsson, Sahlgrenska University Hospital; Dan Lundstedt, Erik Holmberg, and Per Karlsson, University of Gothenburg; and Erik Holmberg, Regional Cancer Center West, Gothenburg, Sweden
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Zingarello A, Mazouni C, Rivera S, Mokdad-Adi M, Pistilli B. Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer. Breast 2017; 35:162-168. [PMID: 28755621 DOI: 10.1016/j.breast.2017.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/03/2017] [Accepted: 07/17/2017] [Indexed: 12/01/2022] Open
Abstract
The rate of local recurrences, after breast-conserving surgery or mastectomy for hormone receptor-positive (HR+) breast cancer, has dramatically changed in last decades, due to advances in surgical and radiation techniques and a more extensive use of adjuvant systemic treatments. However, the occurrence of local recurrences remains a major predictor for distant metastasis and is responsible for increased cancer-specific death. It has been estimated that 1 in 4 HR+ and HR-ipsilateral breast recurrences leads to widespread metastatic disease, with an annual mortality rate of 10% in the first 5 years. Nevertheless, very few studies have been conducted to evaluate the optimal care of purely HR+ local relapses of breast cancer, after surgical removal. In this review we have highlighted the available knowledge on prognostic assessment and systemic treatment for women experiencing local relapses of HR+ breast cancers, underlying unsolved questions and controversial clinical aspects.
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Affiliation(s)
- Anna Zingarello
- Gustave Roussy, Université Paris-Saclay, Department of Medical Oncology, Villejuif, F-94805, France; Department of Medical Oncology, U.O. Oncologia Medica 2, IRCCS AOU San Martino - IST, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | - Chafika Mazouni
- Gustave Roussy, Université Paris-Saclay, Department of Surgery, Villejuif, F-94805, France
| | - Sofia Rivera
- Gustave Roussy, Université Paris-Saclay, Department of Radiation Therapy, Villejuif, F-94805, France
| | - Meriem Mokdad-Adi
- Gustave Roussy, Université Paris-Saclay, Department of Medical Oncology, Villejuif, F-94805, France
| | - Barbara Pistilli
- Gustave Roussy, Université Paris-Saclay, Department of Medical Oncology, Villejuif, F-94805, France.
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125
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Fiorentino A, Mazzola R, Giaj Levra N, Fersino S, Ricchetti F, Di Paola G, Gori S, Massocco A, Alongi F. Comorbidities and intensity-modulated radiotherapy with simultaneous integrated boost in elderly breast cancer patients. Aging Clin Exp Res 2017; 30:533-538. [DOI: 10.1007/s40520-017-0802-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/14/2017] [Indexed: 12/11/2022]
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126
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Snider JW, Mutaf Y, Nichols E, Hall A, Vadnais P, Regine WF, Feigenberg SJ. Projected Improvements in Accelerated Partial Breast Irradiation Using a Novel Breast Stereotactic Radiotherapy Device: A Dosimetric Analysis. Technol Cancer Res Treat 2017; 16:1031-1037. [PMID: 28705082 PMCID: PMC5762064 DOI: 10.1177/1533034617718961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Accelerated partial breast irradiation has caused higher than expected rates of poor cosmesis. At our institution, a novel breast stereotactic radiotherapy device has demonstrated dosimetric distributions similar to those in brachytherapy. This study analyzed comparative dose distributions achieved with the device and intensity-modulated radiation therapy accelerated partial breast irradiation. Nine patients underwent computed tomography simulation in the prone position using device-specific immobilization on an institutional review board–approved protocol. Accelerated partial breast irradiation target volumes (planning target volume_10mm) were created per the National Surgical Adjuvant Breast and Bowel Project B-39 protocol. Additional breast stereotactic radiotherapy volumes using smaller margins (planning target volume_3mm) were created based on improved immobilization. Intensity-modulated radiation therapy and breast stereotactic radiotherapy accelerated partial breast irradiation plans were separately generated for appropriate volumes. Plans were evaluated based on established dosimetric surrogates of poor cosmetic outcomes. Wilcoxon rank sum tests were utilized to contrast volumes of critical structures receiving a percentage of total dose (Vx). The breast stereotactic radiotherapy device consistently reduced dose to all normal structures with equivalent target coverage. The ipsilateral breast V20-100 was significantly reduced (P < .05) using planning target volume_10mm, with substantial further reductions when targeting planning target volume_3mm. Doses to the chest wall, ipsilateral lung, and breast skin were also significantly lessened. The breast stereotactic radiotherapy device’s uniform dosimetric improvements over intensity-modulated accelerated partial breast irradiation in this series indicate a potential to improve outcomes. Clinical trials investigating this benefit have begun accrual.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Yildirim Mutaf
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea Hall
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Patrick Vadnais
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Peppercorn J, Jimenez R. Breaking Up Is Hard to Do: Omission of Radiation Therapy for Select Women Aged >70 Years With Breast Cancer. Int J Radiat Oncol Biol Phys 2017; 98:918-921. [DOI: 10.1016/j.ijrobp.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 10/19/2022]
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128
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Breast cancer electron intraoperative radiotherapy: assessment of preoperative selection factors from a retrospective analysis of 758 patients and review of literature. Breast Cancer Res Treat 2017; 165:261-271. [DOI: 10.1007/s10549-017-4321-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/29/2017] [Indexed: 11/25/2022]
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129
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130
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White J. New Approaches for Tailoring the Use of Radiotherapy in Early-Stage Breast Cancer. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0240-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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131
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Risk factors and state-of-the-art indications for boost irradiation in invasive breast carcinoma. Brachytherapy 2017; 16:552-564. [DOI: 10.1016/j.brachy.2017.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 12/14/2022]
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132
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Tamoxifen with radiotherapy compared with Tamoxifen alone in elderly women with early-stage breast cancer treated with breast conserving surgery: A systematic review and meta-analysis. Radiother Oncol 2017; 123:1-9. [DOI: 10.1016/j.radonc.2017.02.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/13/2017] [Accepted: 02/23/2017] [Indexed: 12/23/2022]
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133
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Matuschek C, Bölke E, Haussmann J, Mohrmann S, Nestle-Krämling C, Gerber PA, Corradini S, Orth K, Kammers K, Budach W. The benefit of adjuvant radiotherapy after breast conserving surgery in older patients with low risk breast cancer- a meta-analysis of randomized trials. Radiat Oncol 2017; 12:60. [PMID: 28335784 PMCID: PMC5364687 DOI: 10.1186/s13014-017-0796-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/05/2017] [Indexed: 11/12/2022] Open
Abstract
PURPOSE/OBJECTIVE(S) It is currently unclear whether patients with low risk breast cancer receiving adjuvant endocrine therapy need adjuvant radiation therapy after breast conserving surgery. The data of randomized trials are available. MATERIALS/METHODS In a database search 5 randomized trials including in total 3766 mostly elderly patients with early stage breast cancer treated either with adjuvant endocrine therapy or with endocrine therapy and additional whole breast radiation after breast conserving surgery were identified. Published hazard ratios for time to local recurrence were the basis of our meta-analysis. Meta-analysis of the effect sizes on local recurrence was performed using a random effects model based on parameter estimates of log hazard ratios in Cox models and their standard errors. Furthermore, overall survival was examined. RESULTS Adjuvant hormone therapy alone in mostly older patients with low risk breast cancer resulted in significantly shorter time to local relapse compared to radiation therapy combined with hormone therapy (Hazard Ratio: 6.8, 95% CI: 4.23-10.93, p < 0.0001) . There was no significant difference for overall survival. CONCLUSION Additional radiation therapy to hormone therapy did improve local relapse in breast cancer patients but did not show significant impact on overall survival.
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Affiliation(s)
- Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
- Klinik für Strahlentherapie und Radiologische Onkologie, Heinrich Heine Universität, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Svjetlana Mohrmann
- Department of Gynecologic and Obtresic, Heinrich Heine University, Dusseldorf, Germany
| | | | - Peter Arne Gerber
- Department of Dermatology, Medical Faculty Heinrich Heine University, Dusseldorf, Germany
| | | | - Klaus Orth
- Department of General, Visceral and Thoracic Surgery, Harzkliniken Goslar, Goslar, Germany
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
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134
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Bellon JR. Editorial: Regional Nodal Irradiation in the Anti-HER2 Era. J Natl Cancer Inst 2017; 109:3071271. [DOI: 10.1093/jnci/djx011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/13/2022] Open
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Abstract
OBJECTIVE When given in conjunction with surgery for treating cancer, radiation therapy may result in impaired wound healing, which, in turn, could cause skin ulcers. In this study, bilayer and monolayer autologous skin substitutes were used to treat an irradiated wound. MATERIALS AND METHODS A single dose of 30 Gy of linear electron beam radiation was applied to the hind limb of nude mice before creating the skin lesion (area of 78.6 mm). Monolayer tissue-engineered skin substitutes (MTESSs) were prepared by entrapping cultured keratinocytes in fibrin matrix, and bilayer tissue-engineered skin substitutes (BTESSs) were prepared by entrapping keratinocytes and fibroblasts in separate layers. Bilayer tissue-engineered skin substitute and MTESS were implanted to the wound area. Gross appearance and wound area were analyzed to evaluate wound healing efficiency. Skin regeneration and morphological appearance were observed via histological and electron microscopy. Protein expressions of transforming growth factor β1 (TGF-β1), platelet-derived growth factor BB (PDGF-BB), and vascular endothelial growth factor (VEGF) in skin regeneration were evaluated by immunohistochemistry (IHC). RESULTS Macroscopic observation revealed that at day 13, treatments with BTESS completely healed the irradiated wound, whereas wound sizes of 1.1 ± 0.05 and 6.8 ± 0.14 mm were measured in the MTESS-treated and untreated control groups, respectively. Hematoxylin-eosin (H&E) analysis showed formation of compact and organized epidermal and dermal layers in the BTESS-treated group, as compared with MTESS-treated and untreated control groups. Ultrastructural analysis indicates maturation of skin in BTESS-treated wound evidenced by formation of intermediate filament bundles in the dermal layer and low intercellular space in the epidermal layer. Expressions of TGF-β1, PDGF-BB, and VEGF were also higher in BTESS-treated wounds, compared with MTESS-treated wounds. CONCLUSIONS These results indicate that BTESS is the preferred treatment for irradiated wound ulcers.
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Ten Wolde B, Kuiper M, de Wilt JHW, Strobbe LJA. Postoperative Complications After Breast Cancer Surgery are Not Related to Age. Ann Surg Oncol 2017; 24:1861-1867. [PMID: 28168385 DOI: 10.1245/s10434-016-5726-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Consensus about surgical treatment options for breast cancer in elderly patients remains elusive due to exclusion from clinical trials. Fear of complications due to increased age often is an important factor in the choice of treatment and might result in different treatment of the older patient. METHODS A total of 1258 female patients who underwent breast cancer surgery for primary diagnosed breast cancer in 2010-2014 were included. Incidence of postoperative complications (POCs) was compared between the younger (18-70 years, N = 1008) and older (≥71 years, N = 250) patients. Multivariate logistic regression was performed to identify the correlation between age and POCs. RESULTS POCs developed in 25.9% of the younger and 31.6% of the older patients (p = 0.042). In multivariable logistic regression analysis of the overall study population, age was no risk factor for POC (odds ratio 0.950, 95% confidence interval 0.640-1.410, p = 0.798). More extensive surgery (mastectomy and/or axillary lymph node dissection compared with single lumpectomy) and increased body mass index increased the odds of developing a POC. Analyses of the ≥71-year group separately revealed only type of surgery to be of influence. CONCLUSIONS Fear of increased risk of complications in the older patient is unjustified. Neither increased age nor high American Society of Anesthesiologists classification are predictors for developing POC. Type of surgery is the most important determinant. Choosing mastectomy while breast-conserving surgery is suitable should be discouraged, particularly in the older patient.
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Affiliation(s)
- Britt Ten Wolde
- Department of Surgery, Radboudumc and Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
| | - Michelle Kuiper
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Luc J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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137
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Ali AA, Xiao H, Tawk R, Campbell E, Semykina A, Montero AJ, Diaby V. Comparison of health utility weights among elderly patients receiving breast-conserving surgery plus hormonal therapy with or without radiotherapy. Curr Med Res Opin 2017; 33:391-400. [PMID: 27819160 PMCID: PMC5344798 DOI: 10.1080/03007995.2016.1257983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/02/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The selection of the most appropriate treatment combinations requires the balancing of benefits and harms of these treatment options as well as the patients' preferences for the resulting outcomes. OBJECTIVE This research aimed at estimating and comparing the utility weights between elderly women with early stage hormone receptor positive (HR+) breast cancer receiving a combination of radiotherapy and hormonal therapy after breast conserving surgery (BCS) and those receiving a combination of BCS and hormonal therapy. METHODS The Surveillance, Epidemiology, and End Results (SEER) linked with Medicare Health Outcomes Survey (MHOS) was used as the data source. Health utility weights were derived from the VR-12 health-related quality of life instrument using a mapping algorithm. Descriptive statistics of the sample were provided. Two sample t-tests were performed to determine potential differences in mean health utility weights between the two groups after propensity score matching. RESULTS The average age at diagnosis was 72 vs. 76 years for the treated and the untreated groups, respectively. The results showed an inverse relationship between the receipt of radiotherapy and age. Patients who received radiotherapy had, on average, a higher health utility weight (0.70; SD = 0.123) compared with those who did not receive radiotherapy (0.676; SD = 0.130). Only treated patients who had more than two comorbid conditions had significantly higher health utility weights compared with patients who were not treated. CONCLUSIONS The mean health utility weights estimated for the radiotherapy and no radiotherapy groups can be used to inform a comparative cost-effectiveness analysis of the treatment options. However, the results of this study may not be generalizable to those who are outside a managed care plan because MHOS data is collected on managed care beneficiaries.
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Affiliation(s)
- Askal Ayalew Ali
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | - Hong Xiao
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Rima Tawk
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | - Ellen Campbell
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | | | | | - Vakaramoko Diaby
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
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Shah C, Banda B, Chandra R, Vicini F. Minimizing toxicity in breast irradiation. Expert Rev Anticancer Ther 2017; 17:187-189. [PMID: 28110574 DOI: 10.1080/14737140.2017.1285231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chirag Shah
- a Department of Radiation Oncology , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Bhanu Banda
- a Department of Radiation Oncology , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA.,b Northeast Ohio Medical University , Rootstown , OH , USA
| | - Rohit Chandra
- a Department of Radiation Oncology , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA.,b Northeast Ohio Medical University , Rootstown , OH , USA
| | - Frank Vicini
- c 21st Century Oncology, Michigan Healthcare Professionals , Farmington Hills , MI , USA
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139
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Lakhanpal R, Jensen K, Shadbolt B, Sullivan L. Omission of whole breast irradiation for postmenopausal women with early breast cancer. Hippokratia 2017. [DOI: 10.1002/14651858.cd012469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Katrin Jensen
- Heidelberg University Hospital; Institute of Medical Biometry and Informatics; Im Neuenheimer Feld 305 Heidelberg Germany 69120
| | - Bruce Shadbolt
- The Canberra Hospital; Centre for Advances in Epidemiology and IT; Yamba Drive Canberra ACT Australia 2605
| | - Lisa Sullivan
- The Canberra Hospital; Department of Radiation Oncology; Yamba Drive Canberra ACT Australia 2605
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Hirata K, Yoshimura M, Inoue M, Yamauchi C, Ogura M, Toi M, Suzuki E, Takeuchi M, Takada M, Hiraoka M. Regional recurrence in breast cancer patients with one to three positive axillary lymph nodes treated with breast-conserving surgery and whole breast irradiation. JOURNAL OF RADIATION RESEARCH 2017; 58:79-85. [PMID: 27422931 PMCID: PMC5321183 DOI: 10.1093/jrr/rrw071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/22/2016] [Accepted: 05/20/2016] [Indexed: 06/06/2023]
Abstract
Radiotherapy with breast-conserving therapy plays a crucial role in the treatment of early breast cancer. However, optimal radiotherapy targets have been controversial. We therefore evaluated regional recurrence in breast cancer patients with one to three positive lymph nodes (LNs) treated with breast-conserving surgery (BCS) followed by whole-breast irradiation (WBI). From 1993 to 2010, 121 breast cancer patients with one to three positive LNs who underwent BCS followed by WBI were analyzed. All patients underwent radiotherapy with two tangential fields to the whole breast. To evaluate the radiation dose to the axillary LNs, we contoured axillary LNs area and evaluated the dose-volumetric parameters. The median follow-up time was 112.4 months (range, 15.6-248.1 months). The 5-year overall survival and disease-free survival rates were 95.6% and 86.6%, respectively. The 5-year regional recurrence-free rate (RRFR) was 97.4%. During follow-up, six patients had regional recurrence. The pathological T stage was the factor best associated with the 5-year RRFR using the log-rank test, with 100.0% in the pT1 cohort versus 94.7% in the pT2-4 cohort (P < 0.01). The radiation dose to the axillary LNs did not contribute to the RRFR. In conclusion, while the pathological T stage was the prognostic factor best associated with regional recurrence, few regional recurrences were observed in early breast cancer patients with one to three LNs treated with BCS followed by WBI. Unintentional radiation doses to the axillary LNs using standard WBI were not related to the RRFR after axillary dissection.
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Affiliation(s)
- Kimiko Hirata
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Minoru Inoue
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Masakazu Ogura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Masakazu Toi
- Department of Breast Surgery, Kyoto University Hospital, 54 Shogoin-Kawaracho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Eiji Suzuki
- Department of Breast Surgery, Kyoto University Hospital, 54 Shogoin-Kawaracho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Megumi Takeuchi
- Department of Breast Surgery, Kyoto University Hospital, 54 Shogoin-Kawaracho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Masahiro Takada
- Department of Breast Surgery, Kyoto University Hospital, 54 Shogoin-Kawaracho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
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141
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Dominici LS, Morrow M, Mittendorf E, Bellon J, King TA. Trends and controversies in multidisciplinary care of the patient with breast cancer. Curr Probl Surg 2016; 53:559-595. [PMID: 28160790 PMCID: PMC5298793 DOI: 10.1067/j.cpsurg.2016.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Laura S Dominici
- Surgical Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Monica Morrow
- Department of Surgery, Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jennifer Bellon
- Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Tari A King
- Surgical Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.
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142
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Snider JW, Mutaf Y, Nichols E, Hall A, Vadnais P, Regine WF, Feigenberg SJ. Dosimetric Improvements with a Novel Breast Stereotactic Radiotherapy Device for Delivery of Preoperative Partial-Breast Irradiation. Oncology 2016; 92:21-30. [PMID: 27898429 DOI: 10.1159/000449388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/12/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Partial-breast irradiation (PBI) with external-beam radiotherapy has produced higher than expected rates of fair-to-poor cosmesis. Worsened outcomes have been correlated with larger volumes of breast tissue exposed to radiation. A novel breast-specific stereotactic radiotherapy (BSRT) device (BSRTD) has been developed at our institution and has shown promise in delivering highly conformal dose distributions. We compared normal tissue sparing with this device with that achieved with intensity-modulated radiation therapy (IMRT)-PBI. METHODS Fifteen women previously treated with breast conservation therapy were enrolled on an institutional review board-approved protocol. Each of them underwent CT simulation in the prone position using the BSRTD-specific immobilization system. Simulated postoperative and preoperative treatment volumes were generated based on surgical bed/clip position. Blinded planners generated IMRT-PBI plans and BSRT plans for each set of volumes. These plans were compared based on clinically validated markers for cosmetic outcome and toxicity using a Wilcoxon rank-sum test. RESULTS The BSRT plans consistently reduced the volumes receiving each of several dose levels (Vx) to breast tissue, the chest wall, the lung, the heart, and the skin in both preoperative and postoperative settings (p < 0.05). Preoperative BSRT yielded particularly dramatic improvements. CONCLUSION The novel BSRTD has demonstrated significant dosimetric benefits over IMRT-PBI. Further investigation is currently proceeding through initial clinical trials.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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143
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Surgical and Locoregional Treatment of DCIS and Early-Invasive Breast Cancer. Clin Obstet Gynecol 2016; 59:733-742. [PMID: 27749366 DOI: 10.1097/grf.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical and radiation therapy for DCIS and early stage 1 and 2 invasive breast cancer is detailed and described.
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144
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Tann AW, Hatch SS, Joyner MM, Wiederhold LR, Swanson TA. Accelerated partial breast irradiation: Past, present, and future. World J Clin Oncol 2016; 7:370-379. [PMID: 27777879 PMCID: PMC5056328 DOI: 10.5306/wjco.v7.i5.370] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/01/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.
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145
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Lakhanpal R, Sestak I, Shadbolt B, Bennett GM, Brown M, Phillips T, Zhang Y, Bullman A, Rezo A. IHC4 score plus clinical treatment score predicts locoregional recurrence in early breast cancer. Breast 2016; 29:147-52. [DOI: 10.1016/j.breast.2016.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/18/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022] Open
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146
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Aumont M. [What is the role of intraoperative radiotherapy in breast cancer treatment?]. Cancer Radiother 2016; 20:583-6. [PMID: 27614504 DOI: 10.1016/j.canrad.2016.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
Abstract
Breast-conserving surgery followed by whole breast postoperative irradiation is considered to be the current standard treatment for patients with early stage breast cancer. It allows an excellent local tumour control with 6% of local recurrence. Over the last years, partial breast radiotherapy has been developed to reduce treatment volume and duration. Intraoperative radiotherapy is one of the techniques. It offers an excellent delineation of the tumour bed and high normal tissue sparing. This purpose of this review is to describe the different intraoperative radiotherapy techniques available, to assess their potential clinical efficiency and tolerance, the recommendations for new practice with a selected population of patients and for future research.
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Affiliation(s)
- M Aumont
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44085 Saint-Herblain, France.
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147
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Killander F, Karlsson P, Anderson H, Mattsson J, Holmberg E, Lundstedt D, Holmberg L, Malmström P. No breast cancer subgroup can be spared postoperative radiotherapy after breast-conserving surgery. Fifteen-year results from the Swedish Breast Cancer Group randomised trial, SweBCG 91 RT. Eur J Cancer 2016; 67:57-65. [PMID: 27614164 DOI: 10.1016/j.ejca.2016.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an established treatment for women with T1-2N0 breast cancers. Since subgroups of patients have low ipsilateral breast tumour recurrence (IBTR) rates, it is important to study whether RT is necessary for all patients. PATIENTS AND METHODS A total of 1187 women with primary T1-2N0M0 breast cancer were randomised, after standardised sector resection, to postoperative whole breast RT or no local treatment. Adjuvant systemic therapy was offered to patients with stage II cancers. Patients were followed with clinical examinations and annual mammography for 10 years and thereafter referred to the Swedish mammography screening program. RESULTS After 15 years of follow-up, a higher cumulative incidence of IBTR was observed in control patients, 23.9%, versus irradiated patients, 11.5%, P<0.001. Recurrence-free survival was inferior, 51.7% versus 60.4%, P=0.0013. The main effect of RT was seen during the first 5 years. However, overall survival was not significantly lower 68.4% versus 71.1%, P=0.68, nor was breast cancer-specific mortality significantly higher. CONCLUSIONS RT after BCS significantly reduced the incidence of IBTR at 15 years of follow-up. We were unable to identify subgroups which could be spared RT. Breast cancer mortality was not significantly reduced after RT. Good predictive markers for radiation sensitivity and improved adjuvant systemic therapy are needed to omit RT after BCS.
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Affiliation(s)
- F Killander
- Department of Clinical Sciences, Oncology, Lund University, Lund, Sweden; Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden.
| | - P Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden
| | - H Anderson
- Department of Clinical Sciences, Cancer Epidemiology, Lund, Sweden
| | - J Mattsson
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - E Holmberg
- Regional Oncologic Centre, Sahlgrenska University Hospital, Göteborg, Sweden
| | - D Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden
| | - L Holmberg
- Regional Oncologic Centre, Uppsala University Hospital, Uppsala, Sweden; King's College London, Faculty of Life Sciences and Medicine, Division of Cancer Studies, London, UK
| | - P Malmström
- Department of Clinical Sciences, Oncology, Lund University, Lund, Sweden; Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden
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148
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van der Leij F, van Werkhoven E, Bosma S, Linn SC, Rutgers EJ, van de Vijver MJ, Bartelink H, Elkhuizen PHM, Scholten A. Low risk of recurrence in elderly patients treated with breast conserving therapy in a single institute. Breast 2016; 30:19-25. [PMID: 27587341 DOI: 10.1016/j.breast.2016.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To guide decision making in preventing over- or under-treatment in older breast cancer patients who have undergone breast conserving surgery, we analyzed prognostic factors and risk of recurrence in a consecutive series of patients ≥ 65 years old with breast cancer and identified subgroups that may benefit or not from more intensive treatment. METHODS Patients ≥65 years of age with breast cancer (pT1-2/pN0-2) treated with breast conserving surgery and postoperative radiation therapy at the Netherlands Cancer Institute (NKI) between 1980 and 2008 were identified. Endpoints were locoregional recurrence (LRR), distant metastasis (DM) and overall survival (OS). Multivariable analyses were performed using Cox proportional hazards models. RESULTS 1922 patients with a median age of 70 years were analyzed. The 5- and 10- years LRR rates were 2% and 3% respectively. In multivariable analysis there was no significant factor influencing LRR risk. Patients with low risk tumors (node negative patients with T1 and ER positive, grade 1 or 2) had lower risk of DM (HR 0.26) and better OS (HR 0.65) compared to patients with higher risk tumors (grade 3 and/or node positive). CONCLUSION In elderly breast cancer patients the risk of LRR and DM is low. In patients with less favorable characteristics the risk of LRR is equally low, with a higher risk to develop DM and worse OS. Treatment in the low risk group may be minimized, while for the higher risk group adjuvant treatment could be intensified.
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Affiliation(s)
- Femke van der Leij
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Statistics Department, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Sophie Bosma
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; Department of Pathology, University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Emiel J Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marc J van de Vijver
- Department of Pathology, Academical Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Astrid Scholten
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Health Technol Assess 2016; 20:1-188. [PMID: 27689969 DOI: 10.3310/hta20730] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Based on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed - the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies. OBJECTIVE To compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks. DESIGN The TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurred before initial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurred after initial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world. SETTING Thirty-three centres in 11 countries. PARTICIPANTS Women who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size. INTERVENTIONS TARGIT within a risk-adapted approach and whole-breast EBRT. MAIN OUTCOME MEASURES The primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality. RESULTS In total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan-Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%; p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%; p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%; p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%; p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%; p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%; p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%; p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8-9.1 million each year. This does not include environmental, patient and societal costs. LIMITATIONS The number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years. CONCLUSIONS For patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT. FUTURE WORK The analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684. FUNDING University College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, University of Western Australia, Perth, WA, Australia
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Stephen Morris
- Health Economics Group, Department of Biomedical Engineering, University College London, London, UK
| | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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Shah C, Tendulkar R, Smile T, Nanavati A, Manyam B, Balagamwala E, Pham Y, Takiar R, Wobb J, Khan A, Arthur D, Wazer D, Vicini F. Adjuvant Radiotherapy in Early-Stage Breast Cancer: Evidence-Based Options. Ann Surg Oncol 2016; 23:3880-3890. [DOI: 10.1245/s10434-016-5503-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Indexed: 01/22/2023]
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