The 2022 Assisi Think Tank Meeting: White paper on optimising radiation therapy for breast cancer

The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. < 70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.

The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report

AIMS

Moderately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries.

MATERIALS AND METHODS

The study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution.

RESULTS

Data from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5-10% to 30-40%, depending on the healthcare provider.

CONCLUSION

Although a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.

TECRA Listeria Visual Immunoassay (TLVIA) for Detection of Listeria in Foods: Collaborative Study

A collaborative study involving 26 laboratories and 5 food types was performed to compare the TECRA Listeria Visual Immunoassay (TLVIA) with standard culture methods. Three foods (lettuce, ice cream, and fish fillets), under the jurisdiction of the U.S. Food and Drug Administration, and 2 foods (cooked chicken and cooked ground turkey), under the jurisdiction of the U.S. Department of Agriculture, were used to determine the effectiveness of the TLVIA. Of the 900 samples tested, 300 were inoculated with low levels (1-5 cells/25 g) of Listeria spp. and 300 were inoculated with high levels of Listeria spp. (10-50 cells/25 g). Method agreement between the conventional culture methods and TLVIA (visual) was 94.7%. Method agreement between the conventional culture methods and TLVIA (reader) was 93.6%. The colorimetric polyclonal enzyme immunoassay (TLVIA) for detection of Listeria in foods has been adopted first action by AOAC INTERNATIONAL.

Relative Effectiveness of Selenite Cystine Broth, Tetrathionate Broth, and Rappaport-Vassiliadis Medium for Recovery of Salmonella spp. from Raw Flesh, Highly Contaminated Foods, and Poultry Feed: Collaborative Study

A collaborative study was performed in 18 laboratories to validate use of Rappaport-Vassiliadis (RV) medium in the standard culture method for recovery of Salmonella spp. from raw, highly contaminated foods and poultry feed. RV medium made from its individual ingredients and incubated at 42�C was compared with selenite cystine (SC) broth incubated at 35�C and tetrathionate (TT) broth incubated at 35� and 43�C for effectiveness in recovery of Salmonella spp. Four artificially contaminated foods (oysters, frog legs, mushrooms, and shrimp) and poultry feed and one naturally contaminated food (chicken) were analyzed. The artificially contaminated foods were inoculated with single serovars of Salmonella at target levels of 0.04 colony-forming units (CFU)/g for the low level and 0.4 CFU/g for the high level. For analysis of 1125 test portions, RV medium (42�C) recovered Salmonellairom 409 test portions; TT (43�C), from 368 test portions; TT (35�C), from 310 test portions; and SC (35�C), from 334 test portions. Overall, RV medium was comparable with or better than other selective enrichments for recovery of Salmonella from the foods in this study, except mushrooms. From mushrooms, SC broth (35�C) recovered more positive test portions than did RV medium (42�C) and TT broth (43�C). The method for detection of Salmonella in raw, highly contaminated foods and

Rappaport-Vassiliadis Medium for Recovery of Salmonellaspp. from Low Microbial Load Foods: Collaborative Study

Twenty-three laboratories participated in a collaborative study to compare the relative effectiveness of Rappaport-Vassiliadis (RV) medium incubated at 42°C, selenite cystine (SC) broth (35°C), and tetrathionate (TT) broth (35 and 43°C) for recovery of Salmonella from the following foods with a low microbial load: dried egg yolk, dry active yeast, ground black pepper, guar gum, and instant nonfat dry milk. For dry active yeast, lauryl tryptose (LT) broth, incubated at 35°C, was used instead of SC broth. All of the foods were artificially inoculated with single Salmonella serovars, that had been lyophilized before inoculation, at high and low target levels of 0.4 and 0.04 colony forming units/g food, respectively. For analysis of 870 test portions, representing all of the foods except yeast, 249 Salmonella-positive test portions were detected by RV medium, 265 by TT broth (43°C), 268 by TT broth (35°C), and 269 by SC broth (35°C). For analysis of 225 test portions of yeast, 79 Salmonella-positive test portions were detected by RV medium, 79 by TT broth (43°C), 84 by TT broth (35°C), and 68 by LT broth (35°C). RV medium was comparable to, or even more effective than, the other selective enrichments for recovery of Salmonella from all of the foods except guar gum. It is recommended that RV (42°C) and TT (35°C) be used with foods that have a low microbial load, except for guar gum for which SC (35°C) and TT (35°C) are recommended.

The NeST (neoadjuvant systemic therapy in breast cancer) study - Protocol for a prospective multi-centre cohort study to assess the current utilization and short-term outcomes of neoadjuvant systemic therapies in breast cancer

INTRODUCTION

Neoadjuvant systemic therapy (NST) has several potential advantages in the treatment of breast cancer. However, there is currently considerable variation in NST use across the UK. The NeST study is a national, prospective, multicentre cohort study that will investigate current patterns of care with respect to NST in the UK.

METHODS AND ANALYSIS

Phase 1 - a national practice questionnaire (NPQ) to survey current practice.Phase 2 - a multi-centre prospective cohort study of breast cancer patients, undergoing NST.Women undergoing NST as their MDT recommended primary breast cancer treatment between December 2017 and May 2018 will be included. The breast surgery and oncological professional associations and the trainee research collaborative networks will encourage participation by all breast cancer centres.Patient demographics, radiological, oncological, surgical and pathological data will be collected, including complications and the need for further intervention/treatment. Data will be collated to establish current practice in the UK, regarding NST usage and variability of access and provision of these therapies. Prospective data on 600 patients from ~50 centres are anticipated.Trial registration: ISRCTN11160072.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this study, as per the online Health Research Authority decision tool. The information obtained will provide valuable insights to help patients make informed decisions about their treatment. These data should establish current practice in the UK concerning NST, inform future service delivery as well as identifying further research questions.This protocol will be disseminated through the Mammary Fold Academic Research Collaborative (MFAC), the Reconstructive Surgery Trials Network and the Association of Breast Surgery. Participating units will have access to their own data and collective results will be presented at relevant conferences and published in appropriate peer-reviewed journals, as well as being made accessible to relevant patient groups.

The Assisi Think Tank Meeting Survey of post-mastectomy radiation therapy in ductal carcinoma in situ: Suggestions for routine practice

BACKGROUND

Risk factors for local recurrence after mastectomy in ductal carcinoma in situ (DCIS) emerged as a grey area during the second "Assisi Think Tank Meeting" (ATTM) on Breast Cancer.

AIM

To review practice patterns of post-mastectomy radiation therapy (PMRT) in DCIS, identify risk factors for recurrence and select suitable candidates for PMRT.

METHODS

A questionnaire concerning DCIS management, focusing on PMRT, was distributed online via SurveyMonkey.

RESULTS

142 responses were received from 15 countries. The majority worked in academic institutions, had 5-20 years work-experience and irradiated <5 DCIS patients/year. PMRT was more given if: surgical margins <1 mm, high-grade, multicentricity, young age, tumour size >5 cm, skin- or nipple- sparing mastectomy. Moderate hypofractionation was the most common schedule, except after immediate breast reconstruction (57% conventional fractionation).

CONCLUSIONS

The present survey highlighted risk factors for PMRT administration, which should be further evaluated.

Abstract ES4-1: Partial breast irradiation: Efficacy and patient selection

Partial breast irradiation is an attractive option for patients and clinicians as a smaller region of the breast is irradiated in (usually) a shorter time period compared with whole breast radiation therapy (RT). The hypothesis for this approach is that a smaller irradiated volume is likely to translate into decreased toxicity, whilst maintaining good local control and survival (efficacy).

This educational lecture will examine in detail the efficacy of the four “modern” large, randomised partial breast RT trials that have been published in the last 5 years. These include the ELIOT, Targit-A, GEC-ESTRO and IMPORT LOW studies1-4.

In addition, the eligibility criteria and baseline characteristics of recruited patients will be considered for each trial in the context of ipsilateral breast tumour relapse rates. Current national and international guidelines regarding patient selection for partial breast RT will also be discussed.

References:

1.Veronesi U et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013 Dec;14(13):1269-77.

2.Vaidya JS et al; TARGIT trialists' group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014 Feb 15;383(9917):603-13.

3.Strnad V et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016 Jan 16;387(10015):229-38.

4.Coles CE et al; IMPORT Trialists. Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet. 2017 Sep 9;390(10099):1048-1060.

Citation Format: Coles C. Partial breast irradiation: Efficacy and patient selection [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES4-1.

Mentoring for newly appointed consultant psychiatrists

The south-west Mentoring Scheme has developed in the context of a general and increasing concern for the health and morale of senior doctors (British Medical Association (BMA), 2000). Their problems are now well described (Allen, 1999; Ghodseet al, 2000), but there is little evidence of effective intervention. The aspirations of the National Service Framework and the NHS Plan will come to nothing if there are not sufficient trained and experienced staff to implement them, and senior staff are increasingly looking forward to early retirement rather than the continued satisfactions of working within the NHS. Recruitment and retention of consultant psychiatrists is the most problematic of all medical specialities, with 14% of posts empty or occupied by locums (Sainsbury Centre for Mental Health, 2000). There is a clear need to find ways of preventing work-related ill health, stress and burn-out among practitioners (Roberts, 1997; Department of Health, 1999: p 115), and to sustain their creative and productive engagement in health care. A demotivated profession cannot be expected to deliver an effective service (McBride & Metcalf, 1995; Appletonet al, 1998) and policy is not a substitute for personnel.

Recommendations for standardized pathological characterization of residual disease for neoadjuvant clinical trials of breast cancer by the BIG-NABCG collaboration

Neoadjuvant systemic therapy (NAST) provides the unique opportunity to assess response to treatment after months rather than years of follow-up. However, significant variability exists in methods of pathologic assessment of response to NAST, and thus its interpretation for subsequent clinical decisions. Our international multidisciplinary working group was convened by the Breast International Group-North American Breast Cancer Group (BIG-NABCG) collaboration and tasked to recommend practical methods for standardized evaluation of the post-NAST surgical breast cancer specimen for clinical trials that promote accurate and reliable designation of pathologic complete response (pCR) and meaningful characterization of residual disease. Recommendations include multidisciplinary communication; clinical marking of the tumor site (clips); and radiologic, photographic, or pictorial imaging of the sliced specimen, to map the tissue sections and reconcile macroscopic and microscopic findings. The information required to define pCR (ypT0/is ypN0 or ypT0 yp N0), residual ypT and ypN stage using the current AJCC/UICC system, and the Residual Cancer Burden system were recommended for quantification of residual disease in clinical trials.

What is the quality of economic evaluations of non-drug therapies? A systematic review and critical appraisal of economic evaluations of radiotherapy for cancer

BACKGROUND

Breast, cervical and colorectal cancers are the three most frequent cancers in women, while lung, prostate and colorectal cancers are the most frequent in men. Much attention has been given to the economic evaluation of pharmaceuticals for treatment of cancer by the National Institute for Health and Care Excellence (NICE) in the UK and similar authorities internationally, while economic analysis developed for other types of anti-cancer interventions, including radiotherapy and surgery, are less common.

OBJECTIVES

Our objective was to review methods used in published cost-effectiveness studies evaluating radiotherapy for breast, cervical, colorectal, head and neck and prostate cancer, and to compare the economic evaluation methods applied with those defined in the guidelines used by the NICE technology appraisal programme.

METHODS

A systematic search of seven databases (MEDLINE, EMBASE, CDSR, NHSEED, HTA, DARE, EconLit) as well as research registers, the NICE website and conference proceedings was conducted in July 2012. Only economic evaluations of radiotherapy interventions in individuals diagnosed with cancer that included quality-adjusted life-years (QALYs) or life-years (LYs) were included. Included studies were appraised on the basis of satisfying essential, preferred and UK-specific methods requirements, building on the NICE Reference Case for economic evaluations and on other methods guidelines.

RESULTS

A total of 29 studies satisfied the inclusion criteria (breast 14, colorectal 2, prostate 10, cervical 0, head and neck 3). Only two studies were conducted in the UK (13 in the USA). Among essential methods criteria, the main issue was that only three (10%) of the studies used clinical-effectiveness estimates identified through systematic review of the literature. Similarly, only eight (28%) studies sourced health-related quality-of-life data directly from patients with the condition of interest. Other essential criteria (e.g. clear description of comparators, patient group indication and appropriate time horizon) were generally fulfilled, while most of the UK-specific requirements were not met.

CONCLUSION

Based on this review there is a dearth of up-to-date, robust evidence on the cost effectiveness of radiotherapy in cancer suitable to support decision making in the UK. Studies selected did not fully satisfy essential method standards currently recommended by NICE.

Abstract P3-08-09: Is it me or is it hot in here? Hot flushes (or flashes): An unmet need. UK NCRI breast clinical studies group working party on symptom management (vasomotor)

Hot Flushes or Flashes are a serious problem. They impact significantly on daily life and sleep quality, affecting employment, relationships and quality of life. The only effective treatment for hot flushes is oestrogen which is contraindicated in 75% of breast cancer patients. An estimated 550,000 people now live in the UK with a diagnosis of breast cancer and up to 70% women experience disabling hot flushes which can continue for years after treatment. Studies have shown that up to 50% of patients stop taking their life-saving antioestrogen drugs before 5 years1 quite probably due to unacceptable side-effects

On the initiative of the patient advocate members of the NCRI Breast Clinical Studies Group, a Working Party on Symptom Management has been established. Members of the group have a particular interest in hot flushes and include representatives from patients, oncology, psychology, gynaecology, acupuncture and the voluntary not-for-profit sector

The Working Party audited current UK clinical practice for hot flushes in cancer with a short questionnaire circulated to the UK Breast Intergroup mailing list (about 800 breast cancer health professionals) and to the Breast Cancer Care Nursing Network (about 850 clinical nurse specialists/breast care nurses). The full results of the questionnaire will be presented

Briefly, a small number of people were prescribed hormone replacement therapy or Progesterone (Megestrol acatate), more Clonidine and Gabapentin and many selective serotonin reuptake inhibitors (SSRIs). Although SSRIs have some effect in reducing the intensity of hot flushes, they have significant side effects including sexual dysfunction, in a group of women, many of whom are already suffering sexual problems due to anti-oestrogen drugs or premature menopause. In addition, available treatments (both pharmacological and non-pharmacological) varied across the UK.

The majority (95%) of respondents to our questionnaire agreed or strongly agreed that treatment and management of hot flushes is an unmet need. The questionnaire also demonstrated inequality of access to treatment in the UK.

An exploration of the US National Cancer Institute and UK clinical trials databases revealed very few studies working in this area. 21 studies in the UK, Europe and the USA since 2006. Most trials investigate non pharmacological approaches and combinations and new versions of existing approaches.

There are no agreed guidelines for managing hot flushes after breast cancer, which may limit the access and availability of appropriate interventions. It is clear from our survey that clinicians are left making individual decisions based on personal experience and availability of local services, which has led to a patchy and inequitable position on the management of this troubling problem. There is a need for research to understand the physiology of flushing and to develop and test new interventions to address this intractable problem, which continues to be a cause of considerable distress to many women after breast cancer.

1. Makubate B et al Cohort study of adherence to adjuvant endocrine therapy, breast cancer recurrence and mortality.Br J Cancer. 2013;108:1515-24.

This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 10/34/01). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-09.

Breast-feeding initiation time and neonatal mortality risk among newborns in South India

OBJECTIVE

To examine the association between breast-feeding initiation time and neonatal mortality in India, where breast-feeding initiation varies widely from region to region.

STUDY DESIGN

Data were collected as part of a community-based, randomized, placebo-controlled trial of the impact of vitamin A supplementation in rural villages of Tamil Nadu, India. Multivariate binomial regression analysis was used to estimate the association between neonatal mortality and breast-feeding initiation time (<12 h, 12 to 24 h, >24 h) among infants surviving a minimum of 48 h.

RESULT

Among 10 464 newborns, 82.1% were first breast-fed before 12 h, 13.8% were breast-fed between 12 and 24 h, and 4.1% were breast-fed after 24 h. After adjusting for birth weight, gestational age and other covariates, late initiators (>24 h) were at ∼78% higher risk of death (relative risk=1.78 (95% confidence interval (CI)=1.03 to 3.10)). There was no difference in mortality risk when comparing babies fed in the first 12 h compared with the second 1  h after birth.

CONCLUSION

Late (>24 h) initiation of breast-feeding is associated with a higher risk of neonatal mortality in Tamil Nadu. Emphasis on breast-feeding promotion programs in low-resource settings of India where early initiation is low could significantly reduce neonatal mortality.

Concurrent weekly cisplatin chemotherapy and radiotherapy in a haemodialysis patient with locally advanced cervix cancer

AIMS

Concurrent cisplatin chemo-radiotherapy improves outcome in cervical carcinoma. In haemodialysis patients, cisplatin is potentially hazardous. We report the treatment of a haemodialysis patient with cervix cancer using cisplatin-based chemo-radiation. Mathematical modelling using toxicity data from a range of cisplatin dosages and schedules reported in published studies was undertaken.

MATERIALS AND METHODS

The patient was treated using weekly cisplatin chemotherapy 25mg/m(2). The serum platinum levels were measured. Correlations between reported toxicity and platinum levels for a variety of cisplatin schedules in published studies were evaluated.

RESULTS

Treatment was completed with no interruptions and minimum acute toxicity. The platinum levels rose progressively. The elimination half-life was prolonged at 6.6-7.5 days. The percentage extraction varied between 7.7 and 41.0%. The cumulative cisplatin dose correlated with neurotoxicity (P=0.002). Myelotoxicity correlated with the peak cisplatin level in the first 15 days of treatment (P=0.01). With an elimination half-life of 7.5 days, 35 mg/m(2) weekly is predicted to have the same risk of myelotoxicity and neurotoxicity as 40 mg/m(2) weekly in a patient with normal renal function.

CONCLUSIONS

Weekly cisplatin chemotherapy 25mg/m(2) can be delivered safely in a haemodialysis patient. Dialysis is effective in eliminating platinum even if carried out more than 3h after infusion, but it should commence as soon as possible after cisplatin infusion, as the incidence of myelotoxicity is related to the peak platinum level.