What does "Advanced" mean in 2023? reflecting on 10 years of the ESTRO advanced Skills in modern radiotherapy course

The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective. Teaching these "advanced skills" has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.

Omission of radiation therapy after breast-conserving surgery for biologically favourable tumours in younger patients: The wrong answer to the right question

In this perspective paper, the findings of the recently published LUMINA study are critically evaluated, with an emphasis on the need for careful interpretation and a thoughtful approach in clinical practice. The LUMINA trial, which investigates the role of adjuvant endocrine therapy in low-risk breast cancer patients, is assessed for its limitations, including a highly selective patient cohort and an insufficient follow-up period. The importance of long-term data and further trials to inform clinical decisions effectively is emphasized. While the LUMINA study does not support an immediate change in practice, it is seen as a foundation for generating hypotheses to guide ongoing clinical trials. This important study has served as inspiration to develop this perspective paper, which takes into account ongoing studies and the toxicity profile of postoperative treatments in low-risk recurrence breast cancer. The need for a patient-cantered approach is stressed, considering individual wishes and desires in decision-making, despite the complexity of articulating these aspects in guidelines. A wise interpretation of available findings is essential to ensure sound clinical decision-making before broadly applying omission of radiation therapy.

CANTO skin: Evaluation of skin toxicity risk factors in patients treated for breast cancer

Skin reaction is a common toxicity during oncology management, especially followed during the radiotherapy. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients treated for an early breast cancer (BC). We evaluated 8561 patients during their overall management for a BC. We focus on specific skin toxicities: erythema, fibrosis, telangiectasia and changes of skin colour. These toxicities were assessed at the baseline defined as 0-3-6 (M0), 12 (M12), 36 (M36) and 60 (M60) months. The prevalence of toxicities of interest varied over time, so at M0, 30.4% of patients had erythema while 17.7% of patients had fibrosis. At M60, the prevalence of erythema was 2%, while fibrosis remained stable at about 19%. After adjustments, at M0, there was a significant association between the onset of cutaneous erythema and obesity, the presence of axillary dissection, the type of surgery and the tumour phenotype RH+/HER2+. Concerning fibrosis, a significant association was found, at M12, with the age of the patient, obesity, Charlson score and type of surgery. Concerning the modification of skin colour at M12, we find a link between the age of the patient, obesity, tobacco consumption and alcohol consumption. The prevention of this toxicity is a major issue for the quality of life. Our results allow us to understand the risk of developing skin toxicity in a patient, depending on her intrinsic, tumour or therapeutic characteristics and to implement adapted means of prevention and monitoring.

Recommandations francophones pour la pratique clinique concernant la prise en charge des cancers du sein de Saint-Paul-de-Vence 2022-2023

With more than 60,000 new cases of breast cancer in mainland France in 2023 and 8% of all cancer deaths, breast cancer is the leading cancer in women in terms of incidence and mortality. While the number of new cases has almost doubled in 30 years, the percentage of patients at all stages alive at 5 years (87%) and 10 years (76%) testifies to the major progress made in terms of screening, characterisation and treatment. However, this progress, rapid as it is, needs to be evaluated and integrated into an overall strategy, taking into account the characteristics of the disease (stage and biology), as well as those of the patients being treated. These are the objectives of the St Paul-de-Vence recommendations for clinical practice. We report here the summary of the votes, discussions and conclusions of the Saint-Paul-de-Vence 2022-2023 RPCs.

CANTO: Skin Toxicities Evaluation of a Multicenter Large Prospective Cohort of Irradiated Patients for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Skin damage is a common toxicity during oncology management. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients treated for an early breast cancer (BC).

MATERIALS/METHODS

CANTO (NCT01993498) is a prospective, multicentric, clinical cohort study of 11 400 patients with stage I-III BC, treated in 26 French cancer centers. In this study, we will evaluate the 8561 patients during their overall management for a BC. We are focus on specifical skin toxicities: Erythema, fibrosis, telangiectasia and skin color (CTCAE v4.0). These toxicities were assessed at 3-6 (M0), 12 (M12), 36 (M36), 60 (M60) months.

RESULTS

The prevalence of toxicities of interest varied over time, so at M0, 30.4% of patients had erythema while 17.7% of patients had fibrosis. At M12, M36 and M60, the prevalence of erythema decreased from 5.5 % to 2.5 % then to 2 %, respectively, while fibrosis remained stable at about 19 %. The prevalence of telangiectasia increased from 0.8 % to 7 % from M0 to M60. While the modification of skin color was 51.1 % at M0, and 10.6 % at M60. After adjustments, at M0, there was a statistically significant association between the onset of cutaneous erythema and obesity, the presence of axillary dissection, the type of surgery the age of the patient as well as the tumor phenotype RH+/HER2+ [OR: 0.79 [0.67; 0.93]]. Concerning fibrosis, a statistically significant association was found, at M12, with the age of the patient, obesity, tumor grade, Charlson score, type of surgery and mitotic index. Obesity and the age of the patient represent at M12 and M36 a risk significantly associated with the onset of telangiectasia. Concerning the modification of skin color at M12, we find a link between the age of the patient, obesity, tobacco consumption, tumor grade, Charlson score, type of surgery, and alcohol consumption [OR: 0.69 [0.51; 0.91]].

CONCLUSION

In this study we identified several risk factors for acute and late skin toxicity. The knowledge of its predictive factors allows a personalized management of the patient by adapting our treatments and our monitoring according to these different factors.

[Breast cancer radiation therapy: Current questions in 2023]

Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.

Insights on the carbon footprint of radiotherapy in France

The French healthcare system is responsible for 8% of the national footprint. Achieving a net zero emissions scenario will require a 4-5 fold decrease of carbon emissions in the coming years. The carbon footprint of radiation therapy has not been specifically studied to date. In this review we summarize the content of the carbon footprint dedicated session at the annual meeting of the French society of radiation oncology (SFRO). We discuss the French healthcare system carbon footprint and its major drivers and our work on the estimation of the carbon footprint of external beam radiation therapy in the French setting. We developed a dedicated methodology to estimate the carbon footprint related to radiation therapies, and describe the main drivers of emissions based on a single centre as an example, namely patient's rides, accelerators acquisition and maintenance and data storage. Based on the carbon footprint calculated in our centres, we propose mitigation strategies and an estimation of their respective potential. Our results may be extrapolated to other occidental settings by adapting emission factors (kilograms of carbon per item or euro) to other national settings. External beam radiation therapy has a major carbon footprint that may be mitigated in many ways that may impact how radiation therapy treatments are delivered, as well as the national organization of the radiotherapy sector. This needs to be taken into account when thinking about the future of radiotherapy.

[Targeted systemic treatments and locoregional radiotherapy for breast cancer: Can we expect a benefit from the potentiation of local treatment?]

Breast cancer is the first most common cancer worldwide, and radiation therapy has a major role to play in locoregional adjuvant treatment. In recent years, we have seen the emergence of adjuvant targeted systemic therapies improving the prognosis of patients at high risk of recurrence. Practices concerning combinations of targeted therapies and locoregional radiation therapy for non-metastatic breast cancers often remain heterogeneous due to the low level of evidence and lack of validated recommendations. This literature review covers immunotherapy, CDK 4/6 inhibitors, PARP inhibitors and anti-Her2 therapies. Combining these targeted systemic therapies with radiation therapy could potentiate local treatment. The optimal therapeutic sequence and fractionation for maximum synergistic effect remain to be defined. However, while efficacy may be enhanced, radiosensitization of healthy tissue may also lead to increased toxicity. It appears possible to continue immunotherapy, trastuzumab, pertuzumab, TDM-1 or lapatinib during locoregional breast and lymph node irradiation. PARP inhibitors and CDK4/6 inhibitors are still to be suspended, due to the lack of data in the adjuvant setting and their short half-life, which does not necessitate prolonged discontinuation. As with the new antibody-drug conjugates, prospective data are needed in conjunction with adjuvant radiation therapy.

[Clinical research in private sector: Which strategic analysis?]

Clinical research in private practice has significantly increased in recent years and has become crucial for the attractiveness of centres both for patients who can access innovative treatments and molecules and for participating physicians. The responsiveness, the size and reduced number of interlocutors, flexibility, and decision-making autonomy of private practitioners are strengths in the strategic analysis of clinical research in the private sector. However, the varied medical activity allowing for broader recruitment, location of practice, and administrative time related leadership roles can become weakness in terms of quality and time dedicated to this research activity, which still relies heavily on strong individual involvement. Collaborations, which develop when clinical research in private centres is dynamic, are sources of opportunities, growth, and progress, allowing participation in various ambitious projects that can benefit patients in these facilities. Recent administrative and legislative complexities for trial integration and competition with academic structures can threaten this important clinical research activity for private practices, requiring reflection on its valorisation and promotion to ensure its sustainability.

[Real world data in radiotherapy: A data farming project by Unitrad]

The aim of the data farming project by the Unitrad group is to produce and use large quantities of structured real-life data throughout radiotherapy treatment. Starting in 2016, target real world data were selected at expert consensus conferences and regularly updated, then captured in MOSAIQ© as the patient was treated. For each partner institution, the data was then stored in a relational database, then extracted and used by researchers to create real world knowledge. This production was carried out in a multicentre, coordinated fashion. When necessary, the raw data was shared according to the research projects, in compliance with regulations. Feedack was provided at each stage, enabling the system to evolve flexibly and rapidly, using the "agile" method. This work, which is constantly evolving, has led to the creation of health data warehouses focused on data of interest in radiotherapy, and the publication of numerous academic studies. It forms part of the wider context of the exploitation of real-life data in cancerology. Unitrad data farming is a collaborative project for creating knowledge from real-life radiotherapy data, based on an active network of clinicians and researchers.

[Five-fraction radiotherapy for breast cancer]

Extreme hypofractionation in adjuvant breast radiotherapy currently generates a lot of interest. We propose here a synthesis of hypofractionation trials and present the DESTHE COL and DESTHE GR projects, encouraged by the French National Cancer Institute (INCa), which experiment care pathways in order to deploy effective strategies to de-escalate the therapeutics and to reduce sequelae after cancer treatment.

Mapping the location of local and regional recurrences according to breast cancer surgery and radiation therapy: Results from EORTC 22922/10925

The purpose of this study is to evaluate the influence of the extent of surgery and radiation therapy (RT) on the rates and sites of local (LR) and regional recurrences (RR) in the EORTC 22922/10925 trial.

PATIENTS AND METHODS

All data were extracted from the trial's individual patients' case report forms (CRF) and analysed with a median follow-up of 15.7 years. Cumulative incidence curves were produced for LR and RR accounting for competing risks: an exploratory analysis of the effect of the extent of surgical and radiation treatments on LR rate was conducted using the Fine & Gray model accounting for competing risks and adjusted for baseline patient and disease characteristics. The significance level was set at 5%, 2-sided. Frequency tables were used to describe the spatial location of LR and RR.

RESULTS

Out of 4004 patients included in the trial, 282 (7%) patients experienced LR and 165 (4.1%) RR, respectively. Cumulative incidence rate of LR at 15 years was lower after mastectomy (3.1%) compared to BCS + RT (7.3%) (F&G: HR (Hazard Ratio) = 0.421, 95%CI = 0.282-0.628, p-value < 0.0001). LR were similar up to 3 years for both mastectomy and BCS but continued to occur at a steady rate for BCS + RT, only. The spatial location of the recurrence was related to the locoregional therapy applied and the absolute gain of RT correlated to stage of disease and extent of surgery.

CONCLUSIONS

The extent of locoregional therapies impacts significantly on LR and RR rates and spatial location.

Radiation-induced lung injury after breast cancer treatment: incidence in the CANTO-RT cohort and associated clinical and dosimetric risk factors

Purpose

Radiation-induced lung injury (RILI) is strongly associated with various clinical conditions and dosimetric parameters. Former studies have led to reducing radiotherapy (RT) doses to the lung and have favored the discontinuation of tamoxifen during RT. However, the monocentric design and variability of dosimetric parameters chosen have limited further improvement. The aim of our study was to assess the incidence of RILI in current practice and to determine clinical and dosimetric risk factors associated with RILI occurrence.

Material and methods

Data from 3 out of the 10 top recruiting centers in CANTO-RT, a subset of the CANTO prospective longitudinal cohort (NCT01993498), were retrospectively analyzed for RILI occurrence. This cohort, which recruited invasive cT0-3 cN0-3 M0 breast cancer patients from 2012 to 2018, prospectively recorded the occurrence of adverse events by questionnaires and medical visits at the end of, and up to 60 months after treatment. RILI adverse events were defined in all patients by the association of clinical symptoms and compatible medical imaging.

Results

RILI was found in 38/1565 (2.4%) patients. Grade II RILI represented 15/38 events (39%) and grade III or IV 2/38 events (6%). There were no grade V events. The most frequently used technique for treatment was 3D conformational RT (96%). In univariable analyses, we confirmed the association of RILI occurrence with pulmonary medical history, absence of cardiovascular disease medical history, high pT and pN, chemotherapy use, nodal RT. All dosimetric parameters were highly correlated and had close predictive value. In the multivariable analysis adjusted for chemotherapy use and nodal involvement, pulmonary medical history (OR=3.05, p<0.01) and high V30 Gy (OR=1.06, p=0.04) remained statistically significant risk factors for RILI occurrence. V30 Gy >15% was significantly associated with RILI occurrence in a multivariable analysis (OR=3.07, p=0.03).

Conclusion

Our study confirms the pulmonary safety of breast 3D RT in CANTO-RT. Further analyses with modern radiation therapy techniques such as IMRT are needed. Our results argue in favor of a dose constraint to the ipsilateral lung using V30 Gy not exceeding 15%, especially in patients presenting pulmonary medical history. Pulmonary disease records should be taken into account for RT planning.

Pattern and risk factors of isolated local relapse among women with hormone receptor-positive and HER2-negative breast cancer and lymph node involvement: 10-year follow-up analysis of the PACS 01 and PACS 04 trials

PURPOSE

We aimed to determine the pattern of isolated local recurrences (ILR) in women with stage II-III hormone receptor-positive and human epidermal growth factor receptor 2 breast cancer (HR + /HER2-BC) after 10-year follow-up.

METHODS

UNICANCER-PACS 01 and PACS 04 trials included 5,008 women with T1-T3 and N1-N3 to evaluate the efficacy of different anthracycline ± taxanes-containing regimens after modified mastectomy or lumpectomy plus axillary lymph node dissection. We analyzed the data from 2,932 women with HR + /HER2- BC to evaluate the cumulative incidence of ILR and describe the factors associated with ILR.

RESULTS

After a median follow-up of 9.1 years (95% CI 9.0-9.2 years), the cumulative incidence of ILR increased steadily between 1 and 10 years from 0.2% to 2.5%. The multivariable analysis showed that older age (subhazard ratios [sHR] = 0.95, 95% CI 0.92-0.99) and mastectomy (sHR = 0.39, 95% CI 0.17-0.86) were associated with lower risk of ILR, and no adjuvant endocrine therapy (sHR = 2.73, 95% CI 1.32 7-5.67) with increased risk of ILR.

CONCLUSION

In this population of high-risk patients with localized HR + /HER2- BC, the risk of ILR was low but remained constant over 10 years. Younger age at diagnosis, breast-conserving surgery, and adjuvant endocrine therapy were independent risk factors of ILR.

Abstract P1-10-12: AI-based cardiac sub-structures segmentation for safer radiotherapy planning

Purpose: Whilst radiotherapy increases cure rates in breast cancer, lung cancer, among others, it may also involve some cardiac exposure, which in turn may increase the risk of different heart diseases. The heart is a complex anatomical organ that involves many different structures making it difficult to contour cardiac sub-structures reproducibly. Contouring, especially for these cases, suffers from inter- and intra-expert variability while being time consuming. Cardiac atlases have been developed to aid in the delineation of cardiac substructures. However, these methods have many shortcomings, including the inability to overcome variations in patient anatomy. In this study, a deep learning based commercial solution for automatic OAR delineation was trained following international guidelines for heart substructures delineation and tested on an unseen cohort of lung and breast patients to evaluate its clinical acceptability.

Methods: ART-Net, a CE-marked, FDA-cleared anatomically preserving deep-learning ensemble architecture for automatic annotation of OAR was evaluated using data of 20 breast/lung patients from 2 centers. Automatic annotation of 27 different structures (Ventricles (left and right), atria (left and right), left ventricle (anterior, apical, inferior, lateral, septal), LAD coronary (mid, proximal, distal, total), circumflex coronary (distal, proximal, total), RCA (distal, mid, proximal, total), coronary sinus, left main coronary artery, ascending aorta, pulmonary arteries, vena cava inferior, vena cava superior and the heart) was performed and submitted to 2 experts across 2 centers for qualitative evaluation. Contours were scored as A/acceptable, B/acceptable after minor corrections, and C/not acceptable for clinical use. To avoid any bias, experts were blind to whether the contour were manually, or AI delineated. The DSC between automatic and manual (ground truth) contours of the heart sub-structures were evaluated and compared with interobserver variability from the literature [1,2] using average and min DSC scores.

Results: Automatic contours were generated in a mean time of 0.5s per scan slice. Out of the 27 structures, 20 were considered clinically acceptable in the qualitative study. In the inter-expert variability study, 12 structures passed the test successfully using initial acceptance criterion over an acceptable sample size and 9 other structures demonstrated performances above the minimal threshold of inter-expert variability, sometimes on smaller datasets due to lack of manual data. Overall, 16 structures were included in the final model. 13 structures were considered clinically acceptable in 100% of the cases with AI contours rated at the same level as manual contours. For the other 3 structures (coronary sinus, left main coronary artery and vena cava inferior), the performance of the AI contours was slightly below that of the manual contours (within 3.4% difference), with the least performing structure being the coronary sinus (84% for AI vs 87% manual).

Conclusion: We show first results for the evaluation of AI-based auto-contouring tool for annotation of the substructures of the heart. The results show very good clinical acceptance, highlighting the high usability of the commercial tool for cardiac cases and its clinical implementation feasibility. The use of this AI tool can facilitate and accelerate future research studies investigating relationships between substructure doses and cardiac outcomes. Future work will include improvement of the sub-structures (mid, proximal, distal) and a retrospective meta-analysis to assess heart sub-structures degree of importance in terms of toxicity.

References:

1. Lee J., et al. Development of delineation for the left anterior descending coronary artery region in left breast cancer radiotherapy: An optimized organ at risk. Radiother Oncol. 2017

2. Duane F, et al. A cardiac contouring atlas for radiotherapy. Radiother Oncol. 2017

Table 1. Quantitative and qualitative results of the evaluation.

Heart sub-structures evaluated quantitatively with mean DSC compared to a range of DSC found in international guidelines and qualitatively as A or B (i.e. considered clinically acceptable). Highlighted are all structures that met the acceptance criterion of reaching a percentage of at least 85% of A or B, or that fell within the DICE range of interobserver variability found in the literature.

Citation Format: Pierre Loap, Angela Botticella, Ludovic De Marzi, Antonin Levy, Stephanie Bolle, Stéphane COLAME, Arthus Cannard, Catherine Martineau-Huynh, Ayoub Oumani, Thais S. Roque, Nikos Paragios, Eric Deutsch, Caroline Luo, Youlia M. Kirova, Sofia Rivera. AI-based cardiac sub-structures segmentation for safer radiotherapy planning [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-10-12.

Facing points of view: Representations on adjuvant endocrine therapy of premenopausal patients after breast cancer and their healthcare providers in France. The FOR-AD study

PURPOSE

Adjuvant endocrine therapy (ET) for 5-10 years is the backbone of the therapeutic strategy in patients with hormone receptor positive (HR+) early breast cancer (BC). However, long-term adherence to adjuvant ET represents a major challenge for most patients. According to prior studies, side effects of adjuvant ET are an important reason for poor adherence. In contrast, better communication and relational bond between patients and healthcare providers (HCPs) may improve adherence. The FOR-AD (Focus on non-adherence) study aimed at better understanding the representation of adjuvant ET by patients and their HCPs, in order to improve the care process.

METHODS

Three focus groups of premenopausal women (receiving adjuvant ET for variable amount of time) and two focus groups of HCPs (including oncologists, pharmacists, and nurses) were conducted, each including around ten participants. Thematic analyses using a general inductive approach were constructed to report participants' representations.

RESULTS

Two main themes emerged across groups, and appeared of major importance. Representations on adjuvant ET were often homogenous within each group, but differed between patients and their HCPs. The relationship between both groups was considerably discussed, particularly its importance in facilitating adherence to adjuvant ET. Suggestions on improving the care process were also given, such as systematically including psychologists in follow-up care paths and having a nurse navigator follow patients under treatment with adjuvant ET.

CONCLUSION

The present qualitative exploration may help buildi future tailored interventions to improve adherence to adjuvant ET, in particular regarding the role of nurse navigators.

CANTO-RT: One of the Largest Prospective Multicenter Cohort of Early Breast Cancer Patients Treated with Radiotherapy including Full DICOM RT Data

This article describes the methodology used and provides a characterization of the study population in CANTO-RT (CANcer TOxicities RadioTherapy). CANTO (NCT01993498) is a prospective clinical cohort study including patients with stage I-III BC from 26 French cancer centers. Patients matching all CANTO inclusion and exclusion criteria who received RT in one of the 10 top recruiting CANTO centers were selected. Individual full DICOM RT files were collected, pseudo-anonymized, structured and analyzed on the CANTO-RT/UNITRAD web platform. CANTO-RT included 3875 BC patients with a median follow-up of 64 months. Among the 3797 patients with unilateral RT, 3065 (80.4%) had breast-conserving surgery, and 2712 (71.5%) had sentinel node surgery. Tumor bed boost was delivered in 2658 patients (68.5%) and lymph node RT in 1356 patients (35%), including internal mammary chain in 844 patients (21.8%). Most patients (3691 (95.3%)) were treated with 3D conformal RT. Target volumes, organs at risk contours and dose/volume histograms were extracted after quality-control procedures. CANTO-RT is one of the largest early BC prospective cohorts with full individual clinical, biological, imaging and DICOM RT data available. It is a valuable resource for the identification and validation of clinical and dosimetric predictive factors of RT and multimodal treatment-related toxicities.

P09.04.B The importance of treatment tolerability for people with glioma: registry review and qualitative findings from the COBra Study

Background

Gliomas are the commonest form of primary brain tumour, accounting for 80% of malignant brain tumours. Gliomas represent a heterogeneous group of cancers with variable outcomes, traditionally graded from I to IV (least to most aggressive). The poor prognosis of some glioma patients and high symptom burden has led to a growing emphasis on their quality of survival. Maintaining cognitive function, physical function and other health-related quality of life aspects throughout the disease trajectory are key considerations, particularly for patients with aggressive forms of glioma. It is therefore important that glioma intervention studies collect data aligned with patient priorities that enables assessment of the net clinical benefit of treatments and facilitates informed decision-making. In particular, and of increasing recognition, is the importance of monitoring the incidence of adverse events during and after the course of an intervention, and understanding their impact upon patients, and patients’ own assessment of, tolerability.

Material and Methods

A trial registry review, a systematic review of the qualitative literature and semi-structured interviews with patients and caregivers were undertaken. Outcomes were extracted from these sources to formulate a longlist during the development of a core outcome set for glioma interventional trials (the COBra study).

Results

The registry review (n=91), systematic review (n=21) and semi-structured interviews (n=19) identified many important outcomes and concepts, one of which was tolerability. Tolerability, adverse events, toxicity or safety was reported to be collected as an outcome in 46 trials. Outcomes related to tolerability were identified from 7 articles included in the systematic review. Themes related to tolerability emerged from the qualitative interviews. These included tolerability of side effects of treatment; trade-offs of side effects versus potential benefits in deciding on, and willingness to, undertake further treatment; and self-directed strategies for coping.

Conclusion

There is a growing acknowledgement of the importance of treatment tolerability in the wider field of cancer research. In glioma research specifically, its significance is yet to be reflected in outcomes collected in trials. Our qualitative findings indicate tolerability is of high significance to patients and those close to them. Participants reported how their preconceptions and experience of tolerability influenced treatment decisions and treatment uptake. However, outcomes related to tolerability were collected in just over half of trials in our sample. Tolerability and items relating to the patients’ experience of adverse events should be collected and reported in trial findings to reflect patients’ priorities and enable informed treatment decisions.

Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting

We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.

Practice changing data and emerging concepts from recent radiation therapy randomised clinical trials

INTRODUCTION

Oncology treatments are constantly and rapidly evolving. We aimed at highlighting the latest radiation therapy practice changing trials and emerging concepts, through an overview of recent randomised clinical trials (RCTs).

MATERIALS AND METHODS

Requests were performed in the Medline database to identify all publications reporting radiation therapy RCTs from 2018 to 2021.

RESULTS

Recent RCTs sustained the role of newer combinatorial strategies through radioimmunotherapy for early stage or metastatic lung cancer, newer pro-apoptotic agents (e.g. debio 1143 in locoregionally advanced head and neck squamous cell carcinoma) or nanoparticles (e.g. NBTXR3 in locally advanced soft-tissue sarcoma). High-tech radiotherapy allows intensifying treatments and gaining ground in some indications through the development of stereotactic body radiotherapy for example. First randomised evidence on personalised radiation therapy through imaging-based (¹⁸FDG positron emission tomography-computed tomography for lung cancer or early stage unfavourable Hodgkin lymphoma, PMSA positron emission tomography-computed tomography or magnetic resonance imaging for high-risk prostate cancer) or biological biomarkers (PSA for prostate cancer, HPV for head and neck cancer, etc) were conducted to more tailored treatments, with more favourable outcomes. Patients' quality of life and satisfaction appeared to be increasing aims. RCTs have validated (ultra)hypofractionated schemes in many indications as for breast, prostate or rectal cancer, resulting in equivalent outcomes and toxicities, more convenient for patients and favouring shared decision making.

CONCLUSION

Radiation therapy is a dynamic field of research, and many RCTs have greatly impacted therapeutic standards over the last years. Investments in radiotherapy research should facilitate the transfer of innovation to clinic.

CANTO-RT: Skin toxicities evaluation of a multicenter large prospective cohort of irradiated patients for early-stage breast cancer

Skin damage is the most common and most important toxicity during and after radiotherapy. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients irradiated for an early breast cancer CANTO is a prospective clinical cohort study of 10 150 patients with stage I-III BC treated from 2012-2017 in 26 cancer centers. In this study, we used CANTO-RT, a sub-cohort of CANTO, including 3480 patients who received RT. We are focus on specifical skin toxicities: Erythema, fibrosis, telangiectasia, and cutaneous pigmentation The prevalence of toxicities of interest varied over time, so at M3-6, 41.1% of patients had erythema while 24.8% of patients had fibrosis. At M12 and M36, the prevalence of erythema decreased respectively while fibrosis remains stable. The prevalence of telangiectasia increases from 1% to 7.1% from M3-6 to M36. After adjustments, we showed an association between the occurrence of skin erythema and obesity; the type of surgery; the presence of axillary dissection; the use of taxane-based CT and the 3DvsIMRT irradiation technique. Regarding fibrosis, an association is found, at M3-6, with age at diagnosis, obesity, tobacco, and the use of boost. Only obesity and the type of surgery received by the patient remained statistically significant at M12 and M36. In this study we identified several risk factors for acute and late skin. The use of a boost was mainly related to the occurrence of fibrosis while the use of IMRT-type technique decreased the occurrence of skin erythema.

Favorable safety profile of moderate hypofractionated over normofractionated radiotherapy in breast cancer patients: a multicentric prospective real-life data farming analysis

Background

Moderately hypofractionated whole-breast radiotherapy (HFRT) has proven to be as safe and efficient as normofractionated radiotherapy (NFRT) in randomized trials resulting in major changes in clinical practice. Toxicity rates observed in selected clinical trial patients may differ from those observed in unselected patients with possible comorbidities and frailty in real-life. This study aimed to examine the influence of HFRT versus NFRT on acute toxicity and identify risks factors of dermatitis in real-life patients.

Materials and methods

Prospective data from breast cancer patients, treated with locoregional radiotherapy were collected between November 2015 and February 2020 in 3 comprehensive cancer centers. Through a systematic data-farming strategy, acute toxicity evaluation forms (CTCAEv4.0) were prospectively completed and extracted electronically. The results from each center were then anonymously merged into a single database for analysis. A Chi-2 test was used to compare HFRT and NFRT. Furthermore, risk factors of dermatitis were identified in a sub-study (622 patients) by multivariate logistic regression analysis.

Results

In total, 3518 T0-4 N0-3 mostly M0 (85.8%) breast cancer patients with a median age of 60.7 (24–96 years old) were analyzed. Acute grade 2–3 dermatitis, grade 1–3 breast oedema, and grade 1–2 hyperpigmentation were less frequent with HFRT versus NFRT: respectively 8.9% versus 35.1% (Chi-2 = 373.7; p < 0.001), 29.0% versus 37.0% (Chi-2 = 23.1; p < 0.001) and 27.0% versus 55.8% (Chi-2 = 279.2; p < 0.001). Fewer patients experienced pain with HFRT versus NFRT: 33.4% versus 53.7% respectively (Chi-2 = 137.1; p < 0.001). Factors such as high BMI (OR = 2.30 [95% CI, 1.28–4.26], p < 0.01), large breast size (OR = 1.88 [95% CI, 1.07–3.28], p < 0.01) and lumpectomy over mastectomy (OR = 0.52 [95% CI, 0.27–0.97], p < 0.05) were associated with greater risk factors of grade 2–3 dermatitis in multivariate analysis regardless of NFRT or HFRT.

Conclusion

The results of this study suggests that breast HFRT may be a better option even for patients with a high BMI or large breast size. Acute toxicity was low to mild, and lower with HFRT compared to NFRT. Results from real-life data were robust, and support the use of HFRT beyond randomized study populations. Long-term real-life data awaits further investigation.

Abstract P4-11-07: Improfib: Impact of radiotherapy on fatigue in breast cancer survivors

Background Fatigue is a common and disabling symptom experienced by patients (pts) after breast cancer (BC) treatment, significantly impacting their quality of life. However, this complex and multidimensional symptom often remains poorly managed. Previous studies identified some treatment-related factors associated with increased risk of developing severe and persistent fatigue. A better understanding of the relationship between treatment modalities and fatigue may help prevention and management strategies.Multimodal BC treatment often includes radiotherapy (RT) to the breast and/or nodal areas. RT modalities are now increasingly personalized. While an association between receipt of RT and fatigue after BC was previously suggested, large-scale data analyzing the impact of distinct RT modalities on fatigue are lacking.Our aim was to assess the impact of RT modalities on fatigue one year after treatment among patients with early-stage BC. Methods CANcer TOxicity (CANTO; NCT01993498) is a large multicentric nationwide prospective cohort of patients with stage I-III BC diagnosed from June 2012 to February 2017. The present analysis was performed in CANTO-RT, a sub-cohort of CANTO including 3875 patients who received RT in one of the 10 top recruiting CANTO centers. Among those patients, we selected 3797 patients who received unilateral RT.Our primary outcome was severe global fatigue 1 year after RT completion, defined by EORTC QLQ-C30 score ≥ 40/100. Secondary outcomes included severe physical, emotional and cognitive dimensions of fatigue (EORTC QLQ-FA12). The following RT-related variables were used as independent variables: Technique (3D vs IMRT), type of fractionation: Normofractionation (NF) vs Hypofractionation (HF), Boost to tumor bed (Yes vs No), Nodal RT (Yes vs No) and internal mammary chain (IMC) RT (Yes vs No). Multivariable logistic regression models assessed associations between RT-related variables and fatigue, adjusting for clinical, tumor, and BC treatment-related covariates collected at BC diagnosis. Results Our analytic cohort included 3797 patients. Among them, 2348 patients were postmenopausal (63%), 2030 received chemotherapy (52%), and 3068 endocrine therapy (81%). The prevalence of severe global fatigue 1 year after treatment was 33.3%. In addition, 33.1%, 20.4%, and 12.9% of patients reported severe physical, emotional and cognitive fatigue, respectively. Conformal 3D RT was delivered in 3635 patients (96%) mostly NF (2Gy/fraction) (n=2707; 93%). The majority of patients (n=2600; 68%) received a boost. Nodal RT was delivered in 1317 patients (35%) including 819 patients (22%) with IMC RT. After correction for age, BMI, comorbidities, income, smoke behavior, anxiety, depression, receipt of chemo and endocrine therapy, there was a significant relationship between specific RT modalities and severe global fatigue. Specifically, receipt of IMC RT (adjusted OR vs. no 1.57 [95% CI 1.10-2.25; p=0.0134]) and NF RT (adjusted OR vs. HF 1.77 [95% CI 1.01-3.11; p=0.048]) were associated with increased odds of severe global fatigue.In addition, there was a significant association between NF RT (adjusted OR vs. HF 1.75 [95% CI 1.01-3.07; p=0.049]) and an increased likelihood of severe physical fatigue, whereas none of the investigated RT modalities seemed to be associated with emotional and cognitive fatigue dimensions. Conclusions More than one third of patients in this RT-treated cohort reported severe fatigue 1 year after treatment. We found a significant association between RT modalities, such as IMC RT and NF, and increased likelihood of severe global fatigue. NF was also associated with physical fatigue. Our data add to the current understanding of treatment-related factors that can impact fatigue after BC, and inform personalized interventions to improve prevention and management of this disabling symptom.

Citation Format: Youssef Ghannam, Antonio Di Meglio, Thomas Sarrade, Alexandra Jacquet, Sibille Everhard, Youlia Kirova, Karine Peigneaux, Philippe Guilbert, Claire Chara-Brunaud, Julien Blanchecotte, Gilles Crehange, David Pasquier, Séverine Racadot, Céline Bourgier, Julien Geffrelot, Ahmed Benyoucef, Francois Paris, Guillaume Auzac, Inès Vaz-Luis, Sofia Rivera. Improfib: Impact of radiotherapy on fatigue in breast cancer survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-07.

Abstract P3-19-01: CANTO RT: The largest prospective multicenter cohort of early breast cancer patients treated with radiotherapy including full DICOM RT data

Purpose: In this paper, we describe the methodology used, and provide a first characterization of the study population and radiotherapy (RT) data in CANTO-RT (CANcer TOxicities Radiotherapy), the largest available multicenter prospective cohort of early breast cancer (BC) patients treated with RT that aims to identify predictors of development, and persistence of long-term toxicities. Methods: CANTO (NCT01993498) is a French prospective clinical cohort study of 10 150 patients with stage I-III BC from 26 cancer centers. Patients matching all CANTO inclusion and exclusion criteria, who received RT and were still in follow up, in the 10 top recruiting CANTO centers, with a minimum follow up of 3 years, were selected for CANTO-RT. Eligible patients had breast/chest wall +/- lymph node RT with curative intent. Individual full DICOM RT files (CT, RT Structure, RT Dose, RT Plan) were collected, anonymized, structured and analyzed on the CANTO-RT/UNITRAD web platform using AQUILAB Share Place™ and Analytics Dose module. Characteristics of the patients and tumors (including TNM, histology, HER2, estrogen and progesterone receptor) were recorded at baseline. Characteristics of the treatments, skin, lung, cardiovascular, neurological, musculoskeletal toxicities (CTCAE v4.0), QOL (BR23, QLQC30), cosmetic, and oncological outcomes were assessed at diagnosis (baseline), 3-6 (M0), 12 (M12), 36 (M36) and 60 (M60) months after completion of primary surgery, chemotherapy or radiotherapy whichever came last together, with blood, plasma and serum tests. Results: CANTO-RT enrolled 3875 BC patients between June 2012 and February 2017 with a median follow-up of 64 months :1947 (50.2%) left side, 1850 (47.8%) right side and 78 (2%) bilateral BC. The vast majority of patients had hormone receptor-positive tumors 3321 (85.7%) and 553 (14.3%) had human epidermal growth factor 2 (HER2) positive tumors; 2586 (66.7%) had stage pT1 and 2525 (65.2%) pN0 disease; 2087 (53.8%) neoadjuvant or adjuvant chemotherapy, 477 (12.3%) adjuvant trastuzumab and 3138 (81%) adjuvant endocrine therapy. Among 3797 patients with unilateral RT, 3065 (80.4%) had breast conserving surgery, 747 (19.6%) total mastectomy; 2712 (71.5%) sentinel node and 1080 (28.5%) axillary dissection. Tumor bed boost was delivered in 2658 patients (68.5%) and lymph node RT in 1356 patients (35%) including internal mammary chain in 844 patients (21.8%). Most patients 3691 (95.3%) were treated with 3D conformal RT and 184 (4.7%) with intensity-modulated RT. Normofractionated RT (2Gy/fraction) was mostly used (69.9%). Clinical target (breast, chest wall, lymph nodes) and contoured organs at risk (heart, left anterior descending coronary, lung, spinal cord, esophagus, thyroid, brachial plexus, contralateral breast, humeral head) contours and dose/volume histograms were automatically extracted after quality control procedure excluding corrupted files and inconsistencies 36 (1%) (Table 1). Conclusion: CANTO-RT is the largest early breast cancer prospective cohort with full individual clinical and DICOM RT data available. CANTO-RT is a valuable resource, open for collaborative projects, for identification and validation of clinical and dosimetric predictive factors of RT related toxicities. Further long term follow up is ongoing.

Table 1.Baseline characteristics of the CANTO RT breast cancer patients.CharacteristicsBreast Cancer Patients [N(%) or Mean (range)]Age at enrolmentMean (range), years56.5 (23.3-85.8)Tumour size (pT)T037 (1)T12586 (66.7)T21058 (27.3)T3177 (4.6)Missing17 (0.4)Nodal status (pN)02525 (65.2)11035 (26.7)2223 (5.8)379 (2)Missing13 (0.3)Tumour histologyInfiltrating Ductal3011 (77.7)Lobular473 (12.2)Others (including mixed)381 (9.8)Missing10 (0.3)Hormone Receptors positiveNegative541 (14)Positive3321 (85.7)Missing13 (0.3)HER2Negative3305 (85.3)Positive553 (14.3)Missing17 (0.4)Type of chemotherapyNo chemotherapy1788 (46.1)Neoadjuvant chemotherapy450 (11.6)Adjuvant chemotherapy1629 (42)Peri-adjuvant chemotherapy (neo + adjuvant)8 (0.2)Hormonal therapyNo730 (18.8)Yes3138 (81)Missing7 (0.2)Herceptin treatmentNo or Not applicable3378 (87.2)Yes477 (12.3)Missing20 (0.5)Type of breast surgerylumpectomy3113 (80.3)Mastectomy734 (18.9)Right lumpectomy and Left mastectomy13 (0.3)Right mastectomy and Left lumpectomy9 (0.2)None6 (0.2)Type of lymph node surgerySentinel node2746 (70.9)Axillary dissection1086 (28)Right sentinel node, Left axillary dissection20 (0.5)Right axillary dissection, left sentinel node12 (0.3)None11 (0.3)Radiation therapyRight Side1850 (47.8)Left Side1947 (50.2)Bilateral78 (2.0)Patients with boostNo or Not applicable1217 (31.4)Yes2658 (68.6)Lymph node levels treatedNone2519 (65)Yes1356 (35)Level 1284 (20.9)Level 2340 (25.1)Level 31072 (79.1)Level 41348 (99.4)Internal mammary chain844 (62.2)Irradiation techniques3D3691 (95.3)IMRT184 (4.7)Fractionation regimensNormofractionation 25-fractions2707 (69.9)Hypofractionation 15-16 fractions166 (4.3)Hypofractionation and Partial breast irradiation51 (1.3)Unspecified fractionation - CTV breast or chest wall not delineated951 (24.5)

Citation Format: Thomas Sarrade, Rodrigue Allodji, Youssef Ghannam, Guillaume Auzac, Sibille Everhard, Ophélie Querel, Youlia Kirova, Karine Peignaux, Philippe Guilbert, Claire Charra-Brunaud, Julien Blanchecotte, Rezart Belshi, David Pasquier, Séverine Racadot, Céline Bourgier, Sandrine Ducornet, David Gibon, Fabrice André, Florent De Vathaire, Sofia Rivera. CANTO RT: The largest prospective multicenter cohort of early breast cancer patients treated with radiotherapy including full DICOM RT data [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-01.

Abstract P4-09-05: Focus on non-adherence: A qualitative exploration of perceptions associated to adjuvant endocrine therapy (ET) in premenopausal patients with breast cancer and their health care providers (HCP)

Background and Objectives: Despite the proven benefits on reducing time to recurrence and improving survival, recent studies indicate that only half or less of patients with early stage breast cancer (BC) complete their recommended full-course of adjuvant ET. Findings suggested that adherence therefore remains a challenge for both patients and professionals, with differences in representations that remain poorly understood. The main objective of this study is to investigate BC patient’s perceptions about ET. Secondary objectives are: (1): to capture potential gaps between their perceptions and the representations of their HCP (2): to explore preferences in patients regarding programs aimed to improve adherence to ET. Methods We conducted separately focus groups with patients and HCP to capture a multilevel framework regarding non-adherence. Inclusion criteria for patients’ focus groups were: non metastatic hormone-receptor positive (HR+) BC; ≥18 years old; premenopausal at time of diagnosis; receiving ET for at least 2 months; for HCP criteria were: to be a medical oncologist, radiation oncologist, pharmacist or nurse; with at least 5 years of experience on BC. The discussion schedule was non-directive and included: introduction remarks and three key- questions linked to our objectives as well as follow-up questions to facilitate the discourse. Discussions were audio recorded, anonymized and transcribed verbatim. We used a thematic analysis approach to identify patterns and themes. Results: Twenty-eight patients (median age=45 yrs) and 17 professionals (11 women, median professional experience with BC =9.5 yrs) participated. Major themes emerging among participants are showed in Table 1. Important differences between HCP and patients with BC were analyzed regarding their representations towards adherence and communication.Conclusions: Dissatisfaction concerning ET medical monitoring and communication is shared by patients and professionals. The HCP reported a lack of communication skills to support patients struggling with ET adherence. Strikingly, the major barrier to ET reported by patients is related to the employment and the lack of adaptation to sequelae of ET. This barrier is not reported by professionals and appears a critical challenge to face. The suggestions made by patients during the focus groups offer promising perspectives regarding support programs to improve adherence.

PatientsN=28Major themesSub-themes•Representations on ET : a multidimensional burden1.Side effects and management2.Benefit/risk balance 3.Seeking information on ET•Professional life1.Work reintegration2.Lack of empathy of coworkers3.Career change•Psychological adjustment to ET1.Daily struggling2.Self-image modifications3.Feelings of loneliness•Relations to health care providers1.Communication: negative and positive aspects2.Shared decision-making 3.Advice on follow-up careHCP (N=17)•Representations on ET : a therapeutic weapon1.Side effects 2.Impact on body image 3.Finding solutions regarding ET side effects•Discourse to patients1.Negotiating the adherence to treatment 2.Beliefs on patients’ suggestibility 3.Communication techniques•Emotional experience: negative impact of prescribing ET1.Emotional fatigue2.Guilt 3.Desire on having psychologists to handle the patients’ emotions•Difficulties related to the healthcare system1.Lack of time 2.Lack of training

Citation Format: Léonor Maria Fasse, Nicolas Roche, Diane Boinon, Gwenn Menvielle, Agnes Dumas, Sofia Rivera, Margarida Matias, Antonio Di-Meglio, Suzette Delaloge, Ines Vaz-Luis, Barbara Pistilli. Focus on non-adherence: A qualitative exploration of perceptions associated to adjuvant endocrine therapy (ET) in premenopausal patients with breast cancer and their health care providers (HCP) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-09-05.

Radiotherapy of breast cancer

Adjuvant radiotherapy is an essential component of the treatment of breast cancer. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. A boost dose over the tumour bed is required if the patient is younger than 50 years-old. Partial breast irradiation could be routinely proposed as an alternative to whole breast irradiation, but only in selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neoadjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra- and infraclavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Hypofractionation regimens (42.5Gy in 16 fractions, or 41,6Gy en 13 or 40Gy en 15) are equivalent to conventional irradiation and must prescribe after tumorectomy in selected patients. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with or after radiotherapy.

Quality assurance program and early toxicities in the phase III BONBIS randomized trial evaluating the role of a localized radiation boost in ductal carcinoma in situ

PURPOSE

To describe the quality assurance (QA) program and early toxicities in the phase III randomized trial BONBIS (NCT00907868) on the role of a localized radiation boost in ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

From November 2008 to July 2014, 2004 patients were randomized in arm A (only whole breast radiotherapy, WBRT) and arm B (WBRT + boost). The QA program involved 44 participant centers that performed the dummy run (DR). Compliance and uniformity of clinical target volume (CTV) delineations, and dose prescription and delivery according to the BONBIS trial radiotherapy guidelines were analyzed. Acute toxicities (during and up to 3 months after radiotherapy completion, NCI-CTCAE v3.0 classification) were evaluated in 1929 patients.

RESULTS

The differences in whole breast CTV (CTV1) and planning target volume (PTV1) were ≤10%, and the differences in boost CTV (CTV2) and PTV (PTV2) were ≥20% compared with the reference DR values; 95% of the prescribed dose encompassed 98.7% and 100% of the median CTV1 and CTV2. Grade ≥2 breast erythema (38.3% vs. 22.4% of grade 2 and 5.4% vs. 2.1% of grade 3, p < 0.001), grade ≥2 dermatitis (2.8% vs. 0.7%, p < 0.001), and grade 2 hyperpigmentation (6.9% vs. 3.6%, p = 0.005) were more frequent in arm B than arm A. No acute lung or cardiac toxicity was observed. Smoking history, large breast size, and large breast CTV were strong predictive factors of grade ≥2 acute skin toxicities.

CONCLUSIONS

The QA program showed deviations in breast and tumor bed delineation. The boost significantly increased acute skin toxicities.

Longitudinal COVID-19 Surveillance and Characterization in the Workplace with Public Health and Diagnostic Endpoints

Public health practices and high vaccination rates currently represent the primary interventions for managing the spread of coronavirus disease 2019 (COVID-19). We initiated a clinical study based on frequent, longitudinal workplace disease surveillance to control severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission among employees and their household members. We hypothesized that the study would reduce the economic burden and loss of productivity of both individuals and small businesses resulting from standard isolation methods, while providing new insights into virus-host dynamics. Study participants (27 employees and 27 household members) consented to provide frequent nasal or oral swab samples that were analyzed by reverse transcription-quantitative PCR (RT-qPCR) for SARS-CoV-2 RNA. Two study participants were found to be infected by SARS-CoV-2 during the study. One subject, a household member, was SARS-CoV-2 RNA positive for at least 71 days and had quantifiable serum virus-specific antibody concentrations for over 1 year. One unrelated employee became positive for SARS-CoV-2 RNA over the course of the study but remained asymptomatic, with low associated viral RNA copy numbers, no detectable serum IgM and IgG concentrations, and IgA concentrations that decayed rapidly (half-life: 1.3 days). A COVID-19 infection model was used to predict that without surveillance intervention, up to 7 employees (95% confidence interval [CI] = 3 to 10) would have become infected, with at most 1 of them requiring hospitalization. Our scalable and transferable surveillance plan met its primary objectives and represents a powerful example of an innovative public health initiative dovetailed with scientific discovery. IMPORTANCE The rapid spread of SARS-CoV-2 and the associated COVID-19 has precipitated a global pandemic heavily challenging our social behavior, economy, and health care infrastructure. In the absence of widespread, worldwide access to safe and effective vaccines and therapeutics, public health measures represent a key intervention for curbing the devastating impacts from the pandemic. We are conducting an ongoing clinical study based on frequent, longitudinal workplace disease surveillance to control SARS-CoV-2 transmission among employees and their household members. Our study was successful in surveying the viral and immune response dynamics in two participants with unusual infections: one remained positive for SARS-CoV-2 for 71 days, while the other was asymptomatic, with low associated viral RNA copy numbers. A COVID-19 infection model was used to predict that without surveillance intervention, up to 7 employees would have become infected, with at most 1 of them requiring hospitalization, underscoring the importance of our program.

Systematic Screening of COVID-19 Disease Based on Chest CT and RT-PCR for Cancer Patients Undergoing Radiation Therapy in a Coronavirus French Hotspot

PURPOSE

Patients with cancer are presumed to be more vulnerable to COVID-19. We evaluated a screening strategy combining chest computed tomography (CT) and reverse-transcription polymerase chain reaction (RT-PCR) for patients treated with radiation therapy at our cancer center located in a COVID-19 French hotspot during the first wave of the pandemic.

METHODS AND MATERIALS

Chest CT images were proposed during radiation therapy CT simulation. Images were reviewed by an expert radiologist according to the COVID-19 Reporting and Data System classification. Nasal swabs with RT-PCR assay were initially proposed in cases of suspicious imaging or clinical context and were eventually integrated into the systematic screening. A dedicated radiation therapy workflow was proposed for COVID-19 patients to limit the risk of contamination.

RESULTS

From March 18, 2020 to May 1, 2020, 480 patients were screened by chest CT, and 313 patients had both chest CT and RT-PCR (65%). The cumulative incidence of COVID-19 was 5.4% (95% confidence interval [CI], 3.6-7.8; 26 of 480 patients). Diagnosis of COVID-19 was made before radiation therapy for 22 patients (84.6%) and during RT for 4 patients (15.3%). Chest CT directly aided the diagnosis of 7 cases in which the initial RT-PCR was negative or not feasible, out of a total of 480 patients (1.5%) and 517 chest CT acquisitions. Four patients with COVID-19 at the time of the chest CT screening had a false negative CT. Sensitivity and specificity of chest CT screening in patients with both RT-PCR and chest CT testing were estimated at 0.82 (95% CI, 0.60-0.95) and 0.98 (95% CI, 0.96-0.99), respectively. Adaptation of the radiation therapy treatment was made for all patients, with 7 postponed treatments (median: 5 days; interquartile range, 1.5-14.8).

CONCLUSIONS

The benefit of systematic use of chest CT screening during CT simulation for patients undergoing radiation therapy during the COVID-19 pandemic seemed limited.

Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial

BACKGROUND

10-year results from several studies showed improved disease-free survival and distant metastasis-free survival, reduced breast cancer-related mortality, and variable effects on overall survival with the addition of partial or comprehensive regional lymph node irradiation after surgery in patients with breast cancer. We present the scheduled 15-year analysis of the European Organisation for Research and Treatment of Cancer (EORTC) 22922/10925 trial, which aims to investigate the impact on overall survival of elective internal mammary and medial supraclavicular (IM-MS) irradiation.

METHODS

EORTC 22922/10925, a randomised, phase 3 trial done across 46 radiation oncology departments from 13 countries, included women up to 75 years of age with unilateral, histologically confirmed, stage I-III breast adenocarcinoma with involved axillary nodes or a central or medially located primary tumour. Surgery consisted of mastectomy or breast-conserving surgery and axillary staging. Patients were randomly assigned (1:1) centrally using minimisation to receive IM-MS irradiation at 50 Gy in 25 fractions (IM-MS irradiation group) or no IM-MS irradiation (control group). Stratification was done for institution, menopausal status, site of the primary tumour within the breast, type of breast and axillary surgery, and pathological T and N stage. Patients and investigators were not masked to treatment allocation. The primary endpoint was overall survival analysed according to the intention-to-treat principle. Secondary endpoints were disease-free survival, distant metastasis-free survival, breast cancer mortality, any breast cancer recurrence, and cause of death. Follow-up is ongoing for 20 years after randomisation. This study is registered with ClinicalTrials.gov, NCT00002851.

FINDINGS

Between Aug 5, 1996, and Jan 13, 2004, we enrolled 4004 patients, of whom 2002 were randomly assigned to the IM-MS irradiation group and 2002 to the no IM-MS irradiation group. At a median follow-up of 15·7 years (IQR 14·0-17·6), 554 (27·7%) patients in the IM-MS irradiation group and 569 (28·4%) patients in the control group had died. Overall survival was 73·1% (95% CI 71·0-75·2) in the IM-MS irradiation group and 70·9% (68·6-72·9) in the control group (HR 0·95 [95% CI 0·84-1·06], p=0·36). Any breast cancer recurrence (24·5% [95% CI 22·5-26·6] vs 27·1% [25·1-29·2]; HR 0·87 [95% CI 0·77-0·98], p=0·024) and breast cancer mortality (16·0% [14·3-17·7] vs 19·8% [18·0-21·7]; 0·81 [0·70-0·94], p=0·0055) were lower in the IM-MS irradiation group than in the control group. No significant differences in the IM-MS irradiation group versus the control group were seen for disease-free survival (60·8% [95% CI 58·4-63·2] vs 59·9% [57·5-62·2]; HR 0·93 [95% CI 0·84-1·03], p=0·18), or distant metastasis-free survival (70·0% [67·7-72·2] vs 68·2% [65·9-70·3]; 0·93 [0·83-1·04], p=0·18). Causes of death between groups were similar.

INTERPRETATION

The 15-year results show a significant reduction of breast cancer mortality and any breast cancer recurrence by IM-MS irradiation in stage I-III breast cancer. However, this is not converted to improved overall survival.

FUNDING

US National Cancer Institute, Ligue Nationale contre le Cancer, and KWF Kankerbestrijding.

[Postoperative radiotherapy after immediate breast reconstruction]

Immediate breast reconstruction versus delayed breast reconstruction improves quality of life of breast cancer patients undergoing total mastectomy without impacting oncologic outcomes. Two types of immediate reconstruction are possible, implant-based reconstruction or autologous reconstruction. These reconstructions interpose a tissue in the operating bed, which modifies target volume definition compared to a wall without reconstruction Post mastectomy radiotherapy increases the rate of postoperative complications for both surgical procedures. Recent guidelines were published about target volume definition in the post mastectomy setting after implant-based reconstruction. Guidelines about target volume definition after autologous reconstruction are still awaited. The aim of our work is to present the different surgical procedures for immediate breast reconstruction, their complications, and the definition of the postmastectomy target volume.

[Retrospective study on the intensification of hypofractionated radiotherapy: The organizational change]

Objectif de l’étude

Le processus de réalisation de la radiothérapie externe est une chaine d’étapes dans laquelle chacune d’entre elles est réalisée seulement si la précédente a été complétée. Le développement des pratiques d’hypofractionnement ces dernières années a tendance à augmenter la charge de travail des étapes de préparation à une irradiation et à diminuer le nombre de séances par patient. Cette étude rétrospective vise à analyser l’évolution de ces pratiques dans un centre de lutte contre le cancer et d’en apprécier les enjeux organisationnels.

Matériel et méthodes

L’ensemble des données de gestion des dossiers de radiothérapie ont été extraites du système d’information de radiothérapie. Les séances de radiothérapie ont été identifiées par patient et par code CIM (Classification internationale des maladies). Le taux de remplissage des appareils de traitement a été calculé avec les données réelles du département de radiothérapie.

Résultats

De 2015 à 2019, une augmentation du nombre de scanographies (+16 %), du nombre de patients pris en charge (+11,6 %) et du volume d’heures disponibles pour les traitements (+12 %) ont été observées. Aussi, une diminution du nombre total de séances de radiothérapie (−5 %), de la moyenne de séances réalisées par séquence de traitement (−19 %), du taux de remplissage des appareils (−7 %) et de la moyenne de séances réalisées par patients traités des tumeurs malignes des bronches et du poumon (−38 %), des organes digestifs (−37 %), secondaires (−19 %) du sein (−15 %) et de la prostate (−15 %) ont été observées. Le nombre de séances administrées par séquence de traitement entre 2015 et 2019 a diminué significativement pour les patients des classes d’âge [20–69 ans] (p < 0,001) et [> 70 ans] (p < 0,001).

Conclusion

Un paradoxe apparait entre l’augmentation du nombre total de patients pris en charge et la diminution du taux de remplissage des appareils de traitement. Ce transfert de charge de travail a un impact sur la qualité et la sécurité des soins et sur les stratégies d’organisation et d’investissement. Il a également un impact économique lié au modèle de remboursement basé sur la tarification à la séance. Une réorganisation des services de radiothérapie s’avère inéluctable.