A randomised controlled trial to evaluate both the role and the optimal fractionation of radiotherapy in the conservative management of early breast cancer

AIMS

Postoperative radiotherapy is routinely used in early breast cancer employing either 50 Gy in 25 daily fractions (long course) or 40 Gy in 15 daily fractions (short course). The role of radiotherapy and shorter fractionation regimens require validation.

MATERIALS AND METHODS

Patients with clinical stage I and II disease were randomised to receive immediate radiotherapy or delayed salvage treatment (no radiotherapy). Patients receiving radiotherapy were further randomised between long (50 Gy in 25 daily fractions) or short (40 Gy in 15 daily fractions) regimens. The primary outcome measure was time to first locoregional relapse. Reported results are at a median follow-up of 16.9 years (interquartile range 15.4-18.8).

RESULTS

In total, 707 women were recruited between 1985 and 1992: median age 59 years (range 28-80), 68% postmenopausal, median tumour size 2.0 cm (range 0.12-8.0); 271 patients have relapsed: 110 radiotherapy, 161 no radiotherapy. The site of first relapse was locoregional158 (64%) and distant 87 (36%). There was an estimated 24% reduction in the risk of any competing event (local relapse, distant relapse or death) with radiotherapy (hazard ratio = 0.76; 95% confidence interval 0.65, 0.88). The benefit of radiotherapy treatment for all competing event types was statistically significant (X(Wald)(2) = 36.04, P < 0.001). Immediate radiotherapy reduced the risk of locoregional relapse by 62% (hazard ratio = 0.38; 95% confidence interval 0.27, 0.53), consistent across prognostic subgroups. No differences were seen between either radiotherapy fractionation schedules.

CONCLUSIONS

This study confirmed better locoregional control for patients with early breast cancer receiving radiotherapy. A radiotherapy schedule of 40 Gy in 15 daily fractions is an efficient and effective regimen that is at least as good as the international conventional regimen of 50 Gy in 25 daily fractions.

A randomised controlled trial to evaluate both the role and optimal fractionation of radiotherapy in the conservative management of early breast cancer

Abstract #5125

Background: Postoperative radiotherapy is routinely used in early breast cancer using 50Gy in 25 daily fractions (Long). Both the role of radiotherapy and shorter regimens require validation.&#x2028; Methods: Patients with clinical stage 1 and 2 disease were randomised to receive immediate postoperative (RT) or delayed salvage treatment (No RT). Patients receiving RT were further randomised to Long or Short (40Gy in 15 daily fractions) regimens. The primary outcome measure was time to first relapse. Reported results are at median follow up of 16.9 years (IQR 15.4 - 18.8).&#x2028; Results: 707 women were recruited between 1985 and 1992: median age 59 years (range 28-80), 72% post menopausal, median tumour size 2.0cms (range 0.12-8.0). 271 patients have relapsed: 110 RT, 161 No RT. Site of first relapse was reported as 158 (64%) locoregional and 87 (36%) distant. Immediate RT significantly reduced the risk of relapse by 42% (HR=0.58 (95%CI: 0.45, 0.73), chi2LR=20.40, p&lt;0.001) consistent across all prognostic subgroups. Immediate RT reduced the risk of locoregional relapse by 65% (HR=0.35 (95%CI: 0.25, 0.47), (chi2LR=40.47, p&lt;0.001). No difference in relapse site, or frequency was seen between the 2 fractions. No differences were seen in overall or breast cancer specific survival.&#x2028; Discussion: With a median follow-up of 17 years, this study confirms the benefit for patients with early breast cancer receiving radiotherapy. We conclude that a radiotherapy schedule of 40 Gy in 15 daily fractions is a safe, efficient and effective regime at least as good as the international conventional regime of 50 Gy in 25 daily fractions.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5125.

The National Epirubicin Adjuvant Trial (NEAT) and Scottish Cancer Trials Breast Group (SCTBG) br9601 randomized phase III adjuvant early breast cancer trials: The updated definitive joint analysis

534

Background: NEAT and the SCTBG BR9601 trial address the role of Epirubicin (E) as an adjunct to CMF in adjuvant chemotherapy for women with early breast cancer (EBC). Methods: NEAT compared E (100mg/m2 x4cycles) followed by classical (c)CMF (x4cycles) with cCMF (x6cycles); BR9601 compared E (100mg/m2 × 4cycles) followed by iv dose modified CMF q3w (750:50:600 ×4cycles) with iv CMF (x8cycles). Eligibility was completely excised EBC, requiring adjuvant chemotherapy, and start of treatment <10 wks from surgery. Primary outcome measures were relapse-free-survival (RFS) and overall survival (OS). A joint efficacy analysis of NEAT (n=2,021) and BR9601 (n=370) triggered by planned 5-year median follow-up (FU) and estimated 800 RFS events and 600 deaths has 85% power to detect 5% two-sided differences. Results: In 2,391 eligible patients, characteristics were balanced across treatments: 72% node +ve; 59% <50 years old; 47% pre-menopausal; 58% tumours grade 3; 55% >2cms; 32% ER-ve, 50% ER+ve (18% NA). At a median FU of 6.2 yrs, 710 relapses or deaths without relapse and 570 deaths are observed. Despite lower than anticipated event rates in the control arm, these updated results confirm a highly significant benefit in favour of ECMF for both RFS (HR 0.75 (95%CI 0.64–0.87) p=0.0002) and OS (HR 0.74 (0.62–0.87) p=0.0004), independent of trial and prognostic factors. In 1458 NEAT patients (in whom data are available), 68% were to receive tamoxifen; chemotherapy scheduling data is available for 843, of whom 46% were declared concurrent and 54% sequential. In a non-pre-planned retrospective analysis, sequential tamoxifen shows a trend for advantage on RFS (HR 0.78 (0.59–1.02) p=0.06). We have amenorrhoea data on 598 NEAT and BR9601 pre-menopausal women, of whom 72% became amenorrhoeic by the end of chemotherapy. In this instance, developing amenorrhoea showed no advantage for RFS (HR 0.90 (0.65–1.24) or OS (HR 0.99 (0.68–1.44)). Conclusions: This updated definitive analysis adds to the Overview in respect of an anthracycline advantage and confirms ECMF as an established and effective standard adjuvant therapy for EBC.

[Table: see text]

Questioning specialists' attitudes to breast cancer follow-up in primary care

BACKGROUND

National Institute for Clinical Excellence (NICE) guidelines recommend discharging asymptomatic breast care patients 3 years after diagnosis. A role for General Practitioners (GPs) and breast care nurses is proposed, together with skills training, but it remains unclear for how long breast cancer patients should be followed up, what tests should be done, and who should be conducting the follow-up. We therefore surveyed Breast Cancer Specialists.

DESIGN

A 20-point questionnaire was sent to 562 Specialists registered in the Cancer Research Clinical Trials Unit database, with questions on case-load, perceptions of follow-up, local policy and opinions on greater primary care involvement.

RESULTS

The most commonly acknowledged purpose of follow-up was detection of treatment-related morbidity. Eighty four percent of respondents adhered to a locally developed protocol with only 9% conforming to NICE guidelines. The median follow-up was 5 years. Significant factors predicting delayed discharge were younger age (P < or = 0.0001); poorer Nottingham Prognostic Index (P = 0.003); treatment factors (P = 0.002); and patient risk factors (P = 0.003). Centres with higher case-loads (>200/year) were more likely to discharge earlier. Reduced workload was perceived as the main benefit of discharge, while lack of GP oncological experience and loss of outcome data were concerns.

CONCLUSIONS

Specialists favour a risk adjusted discharge strategy and increased oncology infrastructure in primary care.

Patterns, costs and cost-effectiveness of care in a trial of chemotherapy for advanced non-small cell lung cancer

In a recently published randomised trial of chemotherapy versus palliative care in advanced non-small cell lung cancer (the MIC2 trial), chemotherapy was shown to prolong survival without compromising quality of life. The study presented here examines patterns of care and their associated costs within a representative subgroup of patients from the MIC2 trial. The study consisted of 116 patients from the South Birmingham Health Authority area. The total health service cost for each patient from entry to trial to death or last follow-up was calculated by combining the resources used with their associated unit costs. The mean cost for patients with complete data on the chemotherapy arm was 6999 pounds sterling (standard deviation (S.D.) 4194 pounds sterling) compared to 4076 pounds sterling (S.D. 3078 pounds sterling) for those with complete data on the palliative care arm. Non-parametric bootstrapping gave a difference between treatment arms in mean cost of 2924 pounds sterling(95% CI 1234 pounds sterling - 4323 pounds sterling). With a difference in mean survival of 2.4 months, this translates to an incremental cost-effectiveness ratio of 14,620 pounds sterling per life year gained. Chemotherapy was found to be more costly than standard palliative care, mainly due to the increased number of hospital in-patient days.

Delay and survival in bladder cancer

OBJECTIVE

To assess in detail and evaluate the effect on survival of delays in the diagnosis and treatment of cancer (which might lead to a worse prognosis), dividing the delay from onset of symptoms to first treatment into several components, comprising patient delay, general practitioner (GP) delay, and two or more periods of hospital delay.

PATIENTS AND METHODS

Data were prospectively collected on 1537 new cases of urothelial cancer in the West Midlands from 1 January 1991 to 30 June 1992. Death information was obtained from the West Midlands Cancer Intelligence Unit and censored at 31 July 2000. The influence of delay times on survival was explored.

RESULTS

The median delay from onset of symptoms to GP referral was 14 days (Delay 1), from GP referral to first hospital attendance was 28 days (Delay 2), and from first hospital attendance to first transurethral resection of bladder tumour was 20 days (Delay 3). The median hospital delay (Delay 2 + 3) was 68 days and the median total delay (Delay 1 + 2 + 3) was 110 days. Patients with a shorter Delay 1 had a lower tumour stage and a 5% better 5-year survival. Patients with a shorter hospital delay had worse survival; total delay had no effect on survival.

CONCLUSIONS

There was significantly better survival for patients referred to hospital within 14 days of the onset of symptoms. The relationship between delay and survival in bladder cancer is complex. Hospital delays may be influenced more by comorbidity than by the characteristics of the tumour. However, the adverse effects of delay seem to be most pronounced for patients with pT1 tumours.

Long-term risk of salvage cystectomy after radiotherapy for muscle-invasive bladder cancer

OBJECTIVES

To establish the long-term outcome for muscle-invasive transitional cell carcinoma of the bladder treated by radiotherapy with or without neoadjuvant cisplatin.

METHODS

159 patients with T2-T4a NX M0 bladder cancer were entered into a prospective randomized trial between June 1984 and June 1988. Follow-up was by 3-monthly cystoscopy in the first year, 6-monthly the next 2 years and yearly thereafter. Salvage surgery was performed at the discretion of the participating clinician.

RESULTS

Minimum follow-up was 9 (median 11) years, at which time 29 patients (18%) remain alive. Median survival was 24 months with no difference between the treatment groups (chi(2) = 0.08, p = 0.77). Overall cystectomy rate was 24% (radiotherapy alone 20%, combined therapy 28%; p = 0.24). Median time to cystectomy from primary treatment was 12 months; range 56 days to 10 years. The risk of cystectomy was 11, 10 and 7% for the first, second and third years after radiotherapy respectively, and 8% in total after the third year. The proportion of patients alive in each successive year who had required a cystectomy was between 20 and 30% for 5 of the first 8 years after treatment.

CONCLUSIONS

Salvage cystectomy is necessary in a quarter of patients after radiotherapy and this can be needed up to 10 years after treatment. During this time, multiple invasive procedures are likely to be performed, resulting in significant patient morbidity and cost. Patients should be fully counselled about the need for prolonged surveillance and the persisting risk of salvage surgery when deciding between primary cystectomy and radiotherapy.

Occupational urothelial tumours: a regional case-control study

OBJECTIVE

To investigate the role of occupational exposures in the risk of developing urothelial cancer.

MATERIALS AND METHODS

Occupational histories, obtained using a self-administered questionnaire, for 803 patients with urothelial cancer (first diagnosed 1991-93) were compared with similar information for 2135 matched controls. Relative risks (RRs) were estimated using conditional logistic regression. Comparisons were also made with historical regional employment information available from the 1971 census.

RESULTS

There were many statistically significant positive associations for urothelial cancer risks and ever being employed in specified occupations (with or without statistical adjustment for smoking status in 1991). Smoking-adjusted RRs of > 2.0 were obtained for seven occupations; manufacture of fire lighters/ patent fuels (RR 4.30, 95% confidence interval 0.78-23.79), rodent extermination (3.71, 1.20-11.48), manufacture of dyestuffs (2.61, 0.98-7.00), leather work (2.51, 1.44-4.35), cable manufacturing industry (2.46, 1.20-5.04), textile printing and dyeing (2.32, 0.98-5.45), and sewage works (2.19, 1.16-4.11). Analyses of the occupations followed in 1971 (thus allowing for 20-year latency) indicated an elevated RR for workers in the plastics industry (5.22, 1.57-17.36).

CONCLUSIONS

The historical legacy of exposure to aromatic amines in the rubber, cable-making, dyestuffs and other industries remains. An important proportion of patients presenting with urothelial tumours are likely to have had occupational exposure to urothelial carcinogens. A review of occupational exposures in the contemporaneous plastic, textile and leather industries is warranted.

Slow N-acetylation genotype is a susceptibility factor in occupational and smoking related bladder cancer

Bladder cancer is a common multifactorial disease and is known to be associated with occupational exposure to arylamines. Smoking is also a recognised contributory environmental cause. Occupational bladder cancer has previously been associated with slow acetylation by N-acetyltransferase (NAT) in humans in phenotyping studies, but more recently there has been some controversy regarding this issue. NAT is an enzymic activity involved in the metabolism of arylamines, and its 'classical' polymorphism is due to multiple alleles at the NAT2 locus. A genotyping approach has been used to investigate NAT2 type in a population of 189 Caucasian bladder cancer patients attending a clinic at a hospital in Birmingham. Genomic DNA was prepared from a blood sample donated by each of the patients and was used in the polymerase chain reaction with primers specific for all NAT2 alleles. Restriction fragment length polymorphism analysis was used to determine which alleles were present. Results have been compared to those from an age-matched non-malignant Caucasian control population (59 individuals) from the same region. Occupational and smoking history was determined by questionnaire and a significant excess of genotypic slow acetylators is found in those groups of bladder cancer patients exposed to arylamines as a result of their occupation or who are cigarette smokers. A higher proportion of slow acetylators is also found in those bladder cancer patients without identified exposure to arylamines when compared to the non-malignant controls. Slow NAT genotype is therefore a contributory risk factor in bladder carcinogenesis which acts through influencing individual response to environmental carcinogens.

Treatment preferences of urologists in Great Britain and Ireland in the management of prostate cancer

A questionnaire was sent to all full-time British and Irish urologists (n = 278) on the management of prostate cancer and was answered by 229 (82%). The questions included 3 specific clinical situations, namely the management of incidental disease, the timing of treatment for metastatic disease and the mode of hormonal manipulation used for advanced disease. It was found that 79% of urologists preferred a deferred treatment policy for incidental disease in the over-75 age group. Radical prostatectomy was advocated by 10% of those questioned for patients in the under-60 age group. Radiotherapy was the mainstay of treatment for incidental disease in the poorer prognosis groups of incidental disease, namely younger patients with more aggressive tumours. Most urologists treated patients with asymptomatic metastatic disease at the time of diagnosis, with 18% entering patients into the Medical Research Council trial comparing immediate with deferred therapy. Orchiectomy was advocated by 57% of urologists as their first-line treatment for patients where hormonal manipulation was indicated. Consequently orchiectomy should remain the "gold standard" in comparative phase III trials in advanced prostate cancer.