Adverse healthcare experiences are correlated with increased time to diagnosis in women with vulvar inflammatory dermatoses: a retrospective cohort survey

This retrospective cohort survey of over 300 women examined diagnostic delay in vulvar dermatoses compared with nonvulvar control conditions (e.g. psoriasis or atopic dermatitis). Adverse healthcare experiences (e.g. uncertainty of which provider to consult, embarrassment in talking to providers) occurred more often for participants with vulvar disease and were significantly correlated with increased time to diagnosis in this group, which was not the case in control conditions. The findings suggest opportunities to improve care for people with vulvar disease.

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.

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.

Genital Self-Image, Sexual Function, and Quality of Life Among Individuals with Vulvar and Non-Vulvar Inflammatory Dermatoses

Vulvar inflammatory dermatoses (VID; e.g., lichen sclerosus, lichen planus, vulvar dermatitis) can significantly impact sexual function. Both vulvar and non-vulvar inflammatory dermatoses (NVID; i.e., skin conditions not impacting vulvar skin, such as non-genital psoriasis and eczema/dermatitis) have yet to be fully characterized with regard to impact on genital self-image. A 20-min web-based survey was distributed September-November 2020 through social media ads, support groups, and online research recruitment services. Individuals in the USA over age 18 who were assigned female at birth and self-reported having been diagnosed with an inflammatory dermatosis were eligible. The primary outcome was the Female Genital Self-Image Scale (FGSIS). Secondary outcomes included the Female Sexual Function Index (FSFI), the Skindex-16 (a skin-related quality of life measure), the PROMIS Global-10 (assessing global physical/mental health), and sexual behavior histories. Participants (n = 348) reported mean age of 43.1 ± 15.5 (range = 19-81). Nearly one-third (n = 101; 29.0%) reported VID, 173 (50%) had NVID, and 74 (21%) experienced both vulvar and non-vulvar symptoms; they were analyzed as part of the VID group. The mean FGSIS score among participants with VID was 16.9 ± 4.1 and was significantly (p < .01) lower than that of participants with NVID (M = 21.2 ± 4.3), indicating lower genital self-image. Mental health (as measured by PROMIS-Global 10) was also impaired in VID. Rates of sexual dysfunction were high in both groups (> 60%). Findings suggest that in VID, lower genital self-image is correlated with poorer sexual function, quality of life, and global physical and mental health. Additional recommendations for VID management are proposed.

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.

Hydrocolloid dressing versus conventional wound care after dermatologic surgery

Background

Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries.

Objective

To examine whether a one-time HCD application after dermatologic surgery results in greater patient satisfaction and improved postoperative outcomes compared with conventional daily dressings (CDD).

Methods

We examined patients who underwent Mohs or standard surgical excision with linear closure followed by HCD. The patients additionally had a history of excisional surgery with CDD in the past 5 years. A modified version of the validated Bluebelle Wound Healing Questionnaire was administered.

Results

The survey response rate was 74.4% (64/86). Compared with CDD, HCD rated higher in comfort, convenience, scar appearance, and simplicity of wound care instructions (P < .0001). Nearly all patients (96.8%) preferred HCD over CDD.

Limitations

Variability in time from prior dermatologic surgery may introduce recall bias. Prior surgeries involving CDD were sometimes performed by a different surgeon, which could introduce other confounding factors.

Conclusions

A simplified wound care regimen involving HCD can potentially lead to increased comfort, convenience, simplicity, and a subjective improvement in scar appearance, though additional studies are needed.

"Worse Than Disappointing": Prediagnostic Health Care Challenges of Women With Inflammatory Vulvar Dermatoses

OBJECTIVE

The purpose of this study was to investigate challenges women face before inflammatory vulvar dermatosis diagnosis to guide interventions for improving time to diagnosis and health care experiences.

MATERIALS AND METHODS

The present analysis was part of a larger study exploring sexual health and quality of life of women with vulvar and nonvulvar inflammatory dermatoses, evaluated via a 20-minute web-based survey. One open-response item asked participants to "briefly describe any challenges you faced with regards to health care or health care providers in the time when you were seeking a diagnosis"; this item informed the present study. Eligible participants were women older than 18 years, living in the United States, with diagnosis of an inflammatory vulvar dermatosis persisting at least 1 month. Participants (n = 118) had a mean age of 46.55 ± 15.35 years, and 64% (n = 75) had lichen sclerosus.

RESULTS

Provider-based challenges consisted of insensitive communication and ascribing physical symptoms to mental health issues, self-harm, or other factors. System-based challenges included confusing referral networks, limited specialist access, and widespread lack of provider education. Personal challenges for participants seeking care included feelings of embarrassment and reduced health care efficacy. Challenges led to emotional response and impact for participants, characterized by negative (e.g., distrust in the medical system) or positive (e.g., self-advocacy efforts, strong social media communities) outcomes.

CONCLUSIONS

Findings provide unique insights into the challenges women experience before inflammatory vulvar dermatosis diagnosis. This study creates new knowledge exploring the diagnostic journey accompanying inflammatory vulvar dermatoses and contributes practically to clinical and research needs of this understudied population.

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.

Dermatographism with vulvar symptoms

Dermatographism (DG) is characterized by a localized, inducible, wheal-and-flare response along the distribution of mechanical pressure. We report an illustrative case of DG with vulvar symptoms (DG-VS) and review the literature on this rarely recognized but easily treated etiology of vulvar complaints. A 35-year-old woman presented with a 1-year history of vulvar pruritus unresponsive to antifungal, antibacterial, and steroid treatments. A prior punch biopsy was nondiagnostic. Vulvar examination revealed normal architecture and no cutaneous abnormalities. She was markedly dermatographic with a scratch test. DG-VS was diagnosed. The patient achieved complete symptomatic control on low-dose hydroxyzine. She maintains excellent control at 3.5 years. In the literature, a typical patient with DG-VS is of reproductive age, with several years’ history of vulvar symptoms (itching, burning, pain, or swelling) and repeated empiric treatment for infectious/inflammatory etiologies. Exacerbation with sexual activity, menstruation, or wearing tight clothing is characteristic and supports the role of mechanical pressure in inducing focal symptoms. Dermatologic changes to the vulvar skin are rarely noted. DG-VS is diagnosed based on clinical findings, symptom patterns, and a positive scratch test and is treated with antihistamines. DG-VS remains absent from current vulvar disease guidelines. In the complex world of vulvar pain and itch, an etiology so easily screened for and readily treated warrants consideration.

"You have to be clean:" a qualitative study of pubic hair grooming behaviours among women living in Italy

The majority of pubic hair and genital self-image research describes women living in the USA, UK and Australia. This may leave attitudes and behaviours across other cultures and geographic regions ambiguous. The purpose of this study was to describe pubic hair removal attitudes and behaviours among reproductive-age women living in Italy. Individual interviews were conducted with 46 women aged 18-45 years between June and July 2017, living in Florence, Italy and currently utilising the Italian healthcare system. Pubic hair removal was popular among participants. Women mainly removed pubic hair by waxing. Sexual partners influenced removal, as did cultural norms and the desire for cleanliness. Most participants indicated pubic hair removal onset during adolescence, often upon puberty. However, most participants had never discussed removal complications with providers. Pubic hair removal often related to a more positive genital self-image because of social norms surrounding hairlessness. Removal among this sample appears to differ from the literature in other contexts, with women living in Italy engaging in more frequent and earlier waxing. Findings offer opportunities for clinicians to proactively address safe pubic hair practices and women's genital concerns during consultations.

[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.

0817 Abnormal REM Sleep Atonia Control In Patients With Chronic Post-traumatic Stress Disorder

Introduction

Post-traumatic stress disorder (PTSD) is characterized by persistent mental and emotional stress following one or more significant physical or psychological traumatic incidents earlier in life. Vivid recall of the events, including traumatic nightmares, and prominent sleep disturbance are usual in PTSD. Previous studies have suggested that PTSD may share some clinical features with idiopathic REM sleep behavior disorder (iRBD) including altered REM sleep without atonia (RSWA) levels. Our group has previously found evidence for altered RSWA control in patients with psychiatric disease, including a pilot sample of PTSD patients with iRBD. We aimed to comparatively analyze RSWA levels between patients with PTSD, PTSD and RBD (PTSD+RBD), iRBD, and controls.

Methods

We selected 18 PTSD, 18 PTSD+RBD, 15 iRBD, and 51 healthy control patients matched for age and sex from the Mayo Clinic Center for Sleep Medicine’s polysomnography database for RSWA quantification. RSWA amounts in the submentalis (SM) and anterior tibialis (AT) were quantitatively analyzed as a percentage of REM sleep duration, in accordance with previously published methods. Non-parametric analyses were performed to compare RSWA, patient demographics, and PSG data across groups. Significance was set at p &lt; 0.016.

Results

Patients with PTSD had significantly higher RSWA than controls in all RSWA density measures (p &lt; 0.016 for all). All measures of RSWA, excluding average SM duration, were significantly greater in PTSD+RBD patients compared with controls (p &lt; 0.016 for all). Within the PTSD group, patients on antidepressants did not have significantly higher RSWA in any of the measures. PTSD+RBD patients had significantly higher SM Phasic, AT Any, SM+AT Any, and Tonic RSWA measures than PTSD patients (p &lt; 0.016 for all).

Conclusion

PTSD patients have significantly higher RSWA than controls, with PTSD+RBD patients having higher RSWA levels than PTSD patients. These data provide the first evidence for abnormal RSWA control in patients with chronic PTSD. This provides evidence of a unique biology in PTSD that could imply a future risk for neurodegenerative disease in PTSD similar to RBD patients. Further prospective studying will need to be performed on patients with PTSD to understand the unique biology.

Support

 

Contextualising challenges of reproduction and motherhood in Florence, Italy: a qualitative study

Objectives: This study sought to understand attitudes, behaviours and expectations regarding reproductive planning, infertility and motherhood among women living in Italy.Methods: Researchers conducted 55 in-depth interviews among 46 reproductive-aged women living in or around Florence, Italy, currently using the Italian health care system, and nine Italian health care professionals. Researchers used an expanded grounded theory approach to understand women's reproductive experiences, with the social-ecological model serving as a conceptual lens for data analyses.Results: Fertility care inadequacy and financial instability impacted participants' attitudes towards reproduction. Women's shifting roles and reduced marital salience prompted decisions to delay or forgo childbearing. For pregnant women and women with children, perceived postpartum challenges included employment discrimination, childrearing costs and variable paternal support. Some participants discussed increased parental responsibility sharing, but many noted lingering expectations that women prioritise motherhood above other pursuits.Conclusion: Findings provide insight into Italian women's reproductive attitudes and behaviours and the declining fertility rate in the current economic and social environment. Practical recommendations for policy and socio-cultural interventions should address reproductive barriers such as affordable childcare, improved fertility assistance, maternal employment protection, and better utilization of existing support structures.

[Prophylactic nodal radiotherapy for breast cancer]

Adjuvant radiotherapy is a key treatment in early-stage breast cancer. The meta-analysis by the Early Breast Cancer Trialist's Collaborative Group (EBCTCG) has demonstrated a decreased risk of locoregional relapse and death after whole-breast radiotherapy. Prophylactic lymph nodes irradiation in breast cancer has also proven to be beneficial in several therapeutic trials. At a time when three-dimensional conformal radiotherapy has become the standard procedure and with the development of intensity-modulated radiation therapy, defining nodal volumes is essential and practices should be harmonized to assess and compare the efficiency and toxicity of radiotherapy. Furthermore, the indication of lymph nodes irradiation has to take into account the risk/benefit balance as expanding the irradiated volume can increase radio-induced toxicity. Selection of patients receiving this treatment is essential. The aim of this update is to define nodal volumes, to precise the indications of their irradiation and to present the expected benefits as well as the potential side effects.

'It's just a very personal thing': contraceptive influences and decision making among women living in Italy

Objective: The purpose of the study was to assess contraceptive knowledge, perceptions and experiences among reproductive-aged women in Italy. Methods: As part of a larger mixed-methods study, researchers conducted 46 interviews (June-July 2017) with English-speaking women aged 18-45 living in or near Florence, Italy, who were using the Italian health care system. Researchers used grounded theory to explore women's contraceptive decision making and use. HyperRESEARCH software was used to aid data organisation and analysis. Researchers used a comparative method to contextualise data and identify emergent themes. Results: Participants illuminated knowledge gaps and misinformation about the efficacy and long-term health effects of hormonal contraceptive methods. Family, friends and health care providers influenced their contraceptive choices. Local family planning clinics (consultori) were cited as primary sources of contraceptive information, resources and access. Conclusion: Misinformation may contribute to the underuse of effective hormonal contraception in Italy. The study findings can inform practical recommendations to improve the dissemination of contraceptive information. Improved messaging strategies could address contraceptive concerns (e.g., hormonal effects) and knowledge gaps, which may improve hormonal contraceptive uptake.

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.

Partial versus whole breast irradiation: Side effects, patient satisfaction and costs

PURPOSE

Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs.

MATERIALS AND METHODS

Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy.

RESULTS

When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions.

CONCLUSION

In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.

Birth mode, breastfeeding and childhood infectious morbidity in the Yucatec Maya

OBJECTIVES

Cesarean delivery is linked to breastfeeding complications and child morbidity. These outcomes may disproportionately affect Latin American indigenous populations that are experiencing rising cesarean delivery rates, but often inhabit environments that exacerbate postnatal morbidity risks. We therefore assess relationships between birth mode, infant feeding practices, and childhood infectious morbidity in a modernizing Yucatec Maya community, where prolonged breastfeeding is the norm. We predicted that under these conditions, cesarean delivery would increase risk of childhood infectious morbidity, but prolonged breastfeeding postcesarean would mitigate morbidity risk.

METHODS

Using a longitudinal child health dataset (n = 88 children aged 0-60 months, 24% cesarean-delivered, 2290 observations total), we compare gastrointestinal infectious (GI) and respiratory infectious (RI) morbidity rates by birth mode. We model associations between cesarean delivery and breastfeeding duration, formula feeding and child nutritional status, then model GI and RI as a function of birth mode, child age, and feeding practices.

RESULTS

Cesarean delivery was associated with longer breastfeeding durations and higher child weight-for-age, but not with formula feeding, GI, or RI. Adolescent motherhood and RI were risk factors for GI; formula feeding and GI were risk factors for RI. Regional housing materials protected against GI; breastfeeding protected against RI and mitigated the effect of formula feeding.

CONCLUSIONS

We find no direct link between birth mode and child infectious morbidity. Yucatec Maya mothers practice prolonged breastfeeding, especially postcesarean, and in conjunction with formula feeding. This practice protects against childhood RI, but not GI, perhaps because GI is more susceptible to maternal and household factors.