Influence of different treatment techniques on radiation dose to the LAD coronary artery

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Myocardial perfusion imaging with 99 mTc - tetrofosmin SPECT in breast cancer patients that received postoperative radiotherapy: a case-control study

<p>Abstract</p> <p>Purpose</p> <p>To evaluate the cardiac toxicity of radiotherapy (RT) in breast cancer (BC) patients employing myocardial perfusion imaging (MPI) with Tc-99 m Tetrofosmin - single photon emission computer tomography (T-SPECT).</p> <p>Materials and methods</p> <p>We studied 46 BC female patients (28 patients with left and 18 patients with right BC) treated with postoperative RT compared to a control group of 85 age-matched females. The median time of RT to SPECT was 40 months (6-263).</p> <p>Results</p> <p>Abnormalities in the summed stress score (SSS) were found in 54% of left BC patients, 44.4% of right BC patients, and 32.9% of controls. In left BC patients there were significantly more SSS abnormalities compared to controls (4.0 ± 3.5 vs 2.6 ± 2.0, p = 0.05) and possible trend of increased abnormalities of right BC patients (3.7 ± 3.0 vs 2.6 ± 2.0, p = 0.14). Multiple regression analysis showed more abnormalities in the MPI of left BC patients compared to controls (SSS, p = 0.0001); Marginal toxicity was also noted in right BC patients (SSS, p = 0.045). No additional toxicity was found in patients that received adjuvant cardiotoxic chemotherapy. All T-SPECT abnormalities were clinically silent.</p> <p>Conclusion</p> <p>The study suggests that radiation therapy to BC patients result in MPI abnormalities but without apparent clinical consequences.</p

Split Course Hyperfractionated Accelerated Radio-Chemotherapy (SCHARC) for patients with advanced head and neck cancer: Influence of protocol deviations and hemoglobin on overall survival, a retrospective analysis

BACKGROUND: The advantage of hyperfractionated accelerated radiation therapy for advanced head and neck cancer has been reported. Furthermore, randomized trials and meta-analyses have confirmed the survival benefit of additional chemotherapy to radiotherapy. We retrospectively analyzed the efficiency and toxicity of the Regensburg standard therapy protocol "SCHARC" and the overall survival of our patients. METHODS: From 1997 to 2004, 64 patients suffering from advanced head and neck cancer (88 % stage IV, 12 % stage III) were assigned to receive the SCHARC protocol. Around half of the patients were diagnosed with oro-hypopharynx carcinoma (52 %), one third with tongue and floor of mouth tumors (29 %) and one fifth (19 %) suffered from H & N cancer at other sites. The schedule consisted of one therapy block with 30 Gy in 20 fractions over a two week period with concomitant chemotherapy (d 1–5: 20 mg/m(2)/d DDP + 750–1000 mg/m(2)/d 5FU (cont. infusion). This therapy block was repeated after a fortnight break up to a cumulative dose of 60 Gy and followed by a boost up to 70 Gy (69–70.5 Gy). All patients assigned to this scheme were included in the survival evaluation. RESULTS: Forty patients (63 %) received both radiation and chemotherapy according to the protocol. The mean follow up was 2.3 years (829 d) and the median follow up was 1.9 years (678 d), respectively. The analysis of survival revealed an estimated 3 year overall survival rate of 57 %. No patient died of complications, 52 patients (80 %) had acute grade 2–3 mucositis, and 33 patients (58 %) suffered from acute grade 3 skin toxicity. Leucopenia was no major problem (mean nadir 3.4 g/nl, no patient < 1.0 g/nl) and the mean hemoglobin value decreased from 13.2 to 10.5 g/dl. Univariate analysis of survival showed a better outcome for patients with a hemoglobin nadir >10.5 g/dl and for patients who completed the protocol. CONCLUSION: The SCHARC protocol was effective in patients diagnosed with advanced head and neck cancer. It led to long-term disease control and survival in about 50 % of the patients with significant but acceptable toxicity. Most patients were not anemic at beginning of therapy. Therefore, we could assess the influence of pre-treatment hemoglobin on survival. However, a low hemoglobin nadir was associated with poor outcome. This result suggests an influence of anemia during therapy on prognosis

Troponin T-release associates with cardiac radiation doses during adjuvant left-sided breast cancer radiotherapy

Background Adjuvant radiotherapy (RT) for left-sided breast cancer increases cardiac morbidity and mortality. For the heart, no safe radiation threshold has been established. Troponin T is a sensitive marker of myocardial damage. Our aim was to evaluate the effect of left-sided breast cancer RT on serum high sensitivity troponin T (hscTnT) levels and its association with cardiac radiation doses and echocardiographic parameters. Methods A total of 58 patients with an early stage, left-sided breast cancer or ductal carcinoma in situ (DCIS) who received adjuvant breast RT without prior chemotherapy were included in this prospective, non-randomized study. Serum samples were taken before, during and after RT. An increase of hscTnT >30 % was predefined as significant. A comprehensive 2D echocardiograph and electrocardiogram (ECG) were performed before and after RT. Dose-volume histograms (DVHs) were generated for different cardiac structures. Results The hscTnT increased during RT from baseline in 12/58 patients (21 %). Patients with increased hscTnT values (group A, N = 12) had significantly higher radiation doses for the whole heart (p = 0.02) and left ventricle (p = 0.03) than patients without hscTnT increase (group B, N = 46). For the left anterior descending artery (LAD), differences between groups A and B were found in volumes receiving 15 Gy (p = 0.03) and 20 Gy (p = 0.03) Furthermore, after RT, the interventricular septum thickened (p = 0.01), and the deceleration time was prolonged (p = 0.008) more in group A than in group B. Conclusions The increase in hscTnT level during adjuvant RT was positively associated with the cardiac radiation doses for the whole heart and LV in chemotherapy-naive breast cancer patients. Whether these acute subclinical changes increase the risk of excessive long-term cardiovascular morbidity or mortality, will be addressed in the follow-up of our patients.BioMed Central open acces

Evaluating the Quality of Colorectal Cancer Care across the Interface of Healthcare Sectors

Contains fulltext : 118387.pdf (publisher's version ) (Open Access)BACKGROUND: Colorectal cancer (CRC) has a high prevalence in western countries. Diagnosis and treatment of CRC is complex and requires multidisciplinary collaboration across the interface of health care sectors. In Germany, a new nationwide established program aims to provide quality information of healthcare delivery across different sectors. Within this context, this study describes the development of a set of quality indicators charting the whole pathway of CRC-care including data specifications that are necessary to operationalize these indicators before practice testing. METHODS: Indicators were developed following a systematic 10 step modified 'RAND/UCLA Appropriateness Method' which involved a multidisciplinary panel of thirteen participants. For each indicator in the final set, data specifications relating to sources of quality information, data collection procedures, analysis and feedback were described. RESULTS: The final indicator set included 52 indicators covering diagnostic procedures (11 indicators), therapeutic management (28 indicators) and follow-up (6 indicators). In addition, 7 indicators represented patient perspectives. Primary surgical tumor resection and pre-operative radiation (rectum carcinoma only) were perceived as most useful tracer procedures initiating quality data collection. To assess the quality of CRC care across sectors, various data sources were identified: medical records, administrative inpatient and outpatient data, sickness-funds billing code systems and patient survey. CONCLUSION: In Germany, a set of 52 quality indicators, covering necessary aspects across the interfaces and pathways relevant to CRC-care has been developed. Combining different sectors and sources of health care in quality assessment is an innovative and challenging approach but reflects better the reality of the patient pathway and experience of CRC-care

PD02-02: A Decision Analysis of Contralateral Prophylactic Mastectomy in Women Undergoing Treatment for Sporadic Unilateral Breast Cancer.

Abstract Background: The intent of contralateral prophylactic mastectomy (CPM) is to improve survival after a diagnosis of unilateral breast cancer by reducing the risk of contralateral breast cancer (CBC). CPM rates are rising among women with sporadic breast cancer, despite limited evidence that its benefits outweigh its harms. Although CPM is highly effective in reducing a woman's risk of CBC, the competing mortality risk from a patient's index breast cancer may offset its benefits. Furthermore, any examination of CPM needs to consider quality of life effects. Methods: We developed a Markov decision analytic model to estimate the effect of CPM in women with newly diagnosed unilateral breast cancer. The primary outcomes examined were gains in life expectancy (LE) and quality-adjusted life expectancy (QALE) for CPM compared with no CPM in 18 hypothetical cohorts of 45-year old women. Data from the British Columbia Cancer Agency (BCCA) was used to generate AJCC stage and molecular subtype-specific estimates of the risk of developing distant metastases from an index breast cancer. A correction factor was applied to account for the omission of relevant systemic therapy (including trastuzamab) in some women in the BCCA cohort. Additional model parameters, including utilities (quality of life weights) for breast cancer and CPM health states, were identified from the published medical literature. LE and QALE estimates were not discounted in the base case. Univariate sensitivity analysis was used to examine the impact of plausible variation in the key model parameters on model results. Results: CPM improved LE in all cohorts (range: 0.06 - 0.54 years, Table 1). AJCC stage had more effect on LE than molecular subtype (stage I mean, 0.43 years, stage III mean, 0.11 years). However, after adjusting for quality of life, a strategy of no CPM was favored in all cohorts. Univariate sensitivity analysis demonstrated that the only model parameter that influenced the outcome of QALE was the utility for health after CPM. In the base case the utility after CPM was 0.81 (compared to 0.85 for No CPM). The preferred strategy did not change from No CPM to CPM unless the utility after CPM exceeded 0.83. Model results were otherwise stable across the ranges of the key parameters examined, including the risk of distant metastases resulting from a patient's index breast cancer by stage and subtype, duration of survival with metastatic breast cancer, and the risk of CBC. Conclusions: The primary drivers of survival after unilateral breast cancer are stage at diagnosis and molecular subtype. Our model demonstrates that CPM confers modest additional LE gains, even in women with early-stage, favorable-subtype breast cancer. Furthermore, this modest benefit is negated if one assumes a small reduction in quality of life due to CPM. The decision to pursue CPM as part of treatment of unilateral breast cancer should include consideration of both patient specific breast cancer characteristics and individual preferences. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-02.</jats:p

The incidence and functional consequences of RT-associated cardiac perfusion defects

PURPOSE: Radiation therapy (RT) for left-sided breast cancer has been associated with cardiac dysfunction. We herein assess the temporal nature and volume dependence of RT-induced left ventricular perfusion defects and whether these perfusion defects are related to changes in cardiac wall motion or alterations in ejection fraction. METHODS: From 1998 to 2001, 114 patients were enrolled onto an IRB-approved prospective clinical study to assess changes in regional and global cardiac function after RT for left-sided breast cancer. Patients were imaged 30 to 60 minutes after injection of technetium 99m sestamibi or tetrofosmin. Post-RT perfusion scans were compared with the pre-RT studies to assess for RT-induced perfusion defects as well as functional changes in wall motion and ejection fraction. Two-tailed Fisher's exact test and the Cochran-Armitage test for linear trends were used for statistical analysis. RESULTS: The incidence of new perfusion defects 6, 12, 18, and 24 months after RT was 27%, 29%, 38%, and 42%, respectively. New defects occurred in approximately 10% to 20% and 50% to 60% of patients with less than 5%, and greater than 5%, of their left ventricle included within the RT fields, respectively (p = 0.33 to 0.00008). The rates of wall motion abnormalities in patients with and without perfusion defects were 12% to 40% versus 0% to 9%, respectively; p values were 0.007 to 0.16, depending on the post-RT interval. CONCLUSIONS: Radiation therapy causes volume-dependent perfusion defects in approximately 40% of patients within 2 years of RT. These perfusion defects are associated with corresponding wall-motion abnormalities. Additional study is necessary to better define the long-term functional consequences of RT-induced perfusion defects