In the Lancet:
A reasonable review of the management of cancer related pain:
Link:
Monday, June 27, 2011
Treatment of cancer pain
Meta analysis: Neoadjuvant treatment for Esophageal Cancer
In the Lancet Oncology:
A meta-analysis is updated, again suggesting that neoadjuvant treatment results in superior results over surgery alone for esophageal cancer. The comparison between chemoradiotherapy and chemotherapy was not quite significant, but there was a strong trend towards better results with chemoradiation.
Link:
Friday, June 17, 2011
secondary breast cancer after RT for HL
In the JCO this week:
An interesting article looking at the prognosis of patients developing a secondary breast cancer after RT for Hodgkin's Lymphoma, compared to sporadic disease. Perhaps not surprisingly, the cancers were detected earlier (due to more intensive screening), and was more likely to be bilateral. Additionally, there was increased risk to the other breast later in the woman's life. There was an increased risk of all cause mortality, and a non-significant increase in breast cancer specific mortality.
What this trial doesn't answer however is how patients with HL who did not recieve RT do with respect to breast cancer outcomes; therefor making it a little more difficulty to tease out the true effect of radiotherapy. That said, the finding are very consistent with the known increased risk of breast cancer induction from RT, and appropriately recommends close surveillance of these patients.
Abstract and Link:
To compare characteristics and outcomes of breast cancer in women with and without a history of radiation therapy (RT) for Hodgkin's lymphoma (HL).
Patients and MethodsWomen with breast cancer diagnosed from 1980 to 2006 after RT for HL were identified from eight North American hospitals and were matched three-to-one with patients with sporadic breast cancer by age, race, and year of breast cancer diagnosis. Information on patient, tumor and treatment characteristics, and clinical outcomes was abstracted from medical records.
ResultsA total of 253 patients with breast cancer with a history of RT for HL were matched with 741 patients with sporadic breast cancer. Median time from HL to breast cancer diagnosis was 18 years. Median age at breast cancer diagnosis was 42 years. Breast cancer after RT for HL was more likely to be detected by screening, was more likely to be diagnosed at an earlier stage, and was more likely to be bilateral at diagnosis. HL survivors had an increased risk of metachronous contralateral breast cancer (adjusted hazard ratio [HR], 4.3; 95% CI, 1.7 to 11.0) and death as a result of any cause (adjusted HR, 1.9; 95% CI, 1.1 to 3.3). Breast cancer–specific mortality was also elevated, but this difference was not statistically significant (adjusted HR, 1.6; 95% CI, 0.7 to 3.4).
ConclusionIn women with a history of RT for HL, breast cancer is diagnosed at an earlier stage, but these women are at greater risk for bilateral disease and are more likely to die as a result of causes other than breast cancer. Our findings support close follow-up for contralateral tumors in these patients and ongoing primary care to manage comorbid conditions.
"Monday, May 9, 2011
Sentinel Nodes for Endometrial Cancer
In Lancet Oncology
Results of a sentinel node lymph node biopsy in endometrial cancer are published, and they report a high NPV. Though it is buried in the paper, the sensitivity was 84%, which is a little bit lower than other SNLB series. As I count it, there were 3 patients who had a negative SLNB out of a total of 20 patients with nodal positivity, for a false negative rate of 15%.
This is a little less compelling than the more established vulvar sentinel studies, or the more recently reported cervical cancer series, but does raise some interesting possibilities. As the utility of dissection is debatable in endometrial cancer (as opposed to vuvla or cervix) - is a simple, less morbid, though admittedly less accurate means of staging "good enough?"
Link:
Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer
In the NEJM
An update to the Scandinavian randomized trial of Prostatectomy vs Watchful Waiting appears in the NEJM this week. Very useful for it's delineation of the natural history of early stage prostate cancer and the expected results with radical local therapy. Of course, it is impossible to know what the results of brachytherapy or EBRT would be in comparison to RP; nonetheless, it gives one ballpark numbers when counseling patients on their options.
Link:
Long term toxicity of WPRT for endometrial cancer (results of PORTEC 1)
In the JCO
Long term toxicity data for the PORTEC 1 trial sees manuscript publication (previously presented at ASTRO 2 years ag0). Worth a read, as the investigators find significant long term toxicity from WPRT. These results should be taken with some caveats however, as the surveys were sent out after the fact (only 351 surveys were sent out, of 714 in the full trial, and there was a 70% responsed rate for those 351). This raises the question of recall and selection bias. One can easily speculate that the patients continuing in followup were those that had complications. Additionally, one could also speculate that one is more likely to answer a QOL survey if one has significant symptoms.
That said, this should give the practicing radiation oncologist pause when recommending WPRT if there are alternatives (VBT) or a low risk of recurrence even in the absence of adjuvant therapy.
Link and Abstract:
To determine the long-term outcome and health-related quality of life (HRQL) of patients with endometrial carcinoma (EC) treated with or without pelvic radiotherapy in the Post Operative Radiation Therapy in Endometrial Carcinoma 1 (PORTEC-1) trial.
Patients and MethodsBetween 1990 and 1997, 714 patients with stage IC grade 1 to 2 or IB grade 2 to 3 EC were randomly allocated to pelvic external-beam radiotherapy (EBRT) or no additional treatment (NAT). HRQL was evaluated with the Short Form 36-Item (SF-36) questionnaire; subscales from the European Organisation for Research and Treatment of Cancer (EORTC) PR25 module for bowel and bladder symptoms and the OV28 and CX24 modules for sexual symptoms; and demographic questions. Analysis was by intention-to-treat.
ResultsMedian follow-up was 13.3 years. The 15-year actuarial locoregional recurrence rates were 5.8% for EBRT versus 15.5% for NAT (P < .001), and 15-year overall survival was 52% versus 60% (P = .14). Of the 351 patients confirmed to be alive with correct address, 246 (70%) returned the questionnaire. Patients treated with EBRT reported significant (P < .01) and clinically relevant higher rates of urinary incontinence, diarrhea, and fecal leakage leading to more limitations in daily activities. Increased symptoms were reflected by the frequent use of incontinence materials after EBRT (day and night use, 42.9% v 15.2% for NAT; P < .001). Patients treated with EBRT reported lower scores on the SF-36 scales "physical functioning" (P = .004) and 'role-physical' (P = .003).
ConclusionEBRT for endometrial cancer is associated with long-term urinary and bowel symptoms and lower physical and role-physical functioning, even 15 years after treatment. Despite its efficacy in reducing locoregional recurrence, EBRT should be avoided in patients with low- and intermediate-risk EC.
"Sentinel Nodes in Cervical Cancer
In the JCO
Sentinel node mapping is making an appearance in all of the gynecologic cancers, most notably vulvar cancer, however two recent studies have examined the technique in cervix and endometrial cancer. The current study is in IA1-IB1 cervical lesions undergoing surgical staging and management, all of who were evaluated with a SNLB and then with a full dissection. The false negative rate was 8% (2/25), which is similar to the experience in breast. The investigators also noted that if bilateral nodes were mapped, there were no false negatives, but I would apply that with some caution as it appears to be a post hoc analysis.
While the rate false negative rate is similar to breast cancer, it remains to be seen if the clinical results will be the same as breast cancer. While this is a great step in the path towards integrating this into the management of early cervical cancer, one awaits a clinical trial in which the completion dissection is not performed, with careful follow up of the results. One must also be mindful of what we are actually accomplishing by performing less extensive dissections - while there are some adverse events associated with pelvic and PA dissections, in general they are relatively rare. The benefit of less extensive nodal sampling is much clearer in vulvar and breast cancer, where the risk of morbidity due to lymphedema is correspondingly higher.
Link and Abstract:
Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy.
Patients and MethodsAdults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes.
ResultsOne hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally.
ConclusionCombined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.
"Gem + CDDP + RT with adjuvant CDDP + Gem vs standard CTRT for cervical cancer
In the JCO:
I posted previously about this trial from Argentina when presented at ASCO 2 years ago, now the manuscript is published in the JCO. Essentially this trial asks two questions, the utility of concurrent gem with CDDP, and the utility of adjuvant chemotherapy. The overall effect is compelling in this manuscript, improved local control, DFS and OS, compared to standard CTRT with brachy, albeit at the cost of increased toxicity. I don't feel that a change in standard practice will occur in the US yet due to these results, as most US practitioners would like a confirmatory trial, preferably examining the gem question and the adjuvant chemo question separately. That said, for certain high risk patients, some of the Gynecologic Oncologists I work with have been giving adjuvant chemotherapy (CDDP based) due in part to these results.
Link and Abstract.
To determine whether addition of gemcitabine to concurrent cisplatin chemoradiotherapy and as adjuvant chemotherapy with cisplatin improves progression-free survival (PFS) at 3 years compared with current standard of care in locally advanced cervical cancer.
Patients and MethodsEligible chemotherapy- and radiotherapy-naive patients with stage IIB to IVA disease and Karnofsky performance score ≥ 70 were randomly assigned to arm A (cisplatin 40 mg/m2 and gemcitabine 125 mg/m2 weekly for 6 weeks with concurrent external-beam radiotherapy [XRT] 50.4 Gy in 28 fractions, followed by brachytherapy [BCT] 30 to 35 Gy in 96 hours, and then two adjuvant 21-day cycles of cisplatin, 50 mg/m2 on day 1, plus gemcitabine, 1,000 mg/m2 on days 1 and 8) or to arm B (cisplatin and concurrent XRT followed by BCT only; dosing same as for arm A).
ResultsBetween May 2002 and March 2004, 515 patients were enrolled (arm A, n = 259; arm B, n = 256). PFS at 3 years was significantly improved in arm A versus arm B (74.4% v 65.0%, respectively; P = .029), as were overall PFS (log-rank P = .0227; hazard ratio [HR], 0.68; 95% CI, 0.49 to 0.95), overall survival (log-rank P = .0224; HR, 0.68; 95% CI, 0.49 to 0.95), and time to progressive disease (log-rank P = .0012; HR, 0.54; 95% CI, 0.37 to 0.79). Grade 3 and 4 toxicities were more frequent in arm A than in arm B (86.5% v 46.3%, respectively; P < .001), including two deaths possibly related to treatment toxicity in arm A.
ConclusionGemcitabine plus cisplatin chemoradiotherapy followed by BCT and adjuvant gemcitabine/cisplatin chemotherapy improved survival outcomes with increased but clinically manageable toxicity when compared with standard treatment.
"JCO long term follow up of Tamoxifen
In the JCO:
A very interesting article on the long term benefits of tamoxifen for breast cancer patients, emphasizing the curative nature of adjuvant hormone modulation in breast cancer patients. Also of interest is the reduction in CV events with longer term tamoxifen and the stability of the endometrial cancer risk at ~1.5% for both.
Link and Abstract:
The Cancer Research UK 'Over 50s' trial compared 5 and 2 years of tamoxifen in women with early breast cancer. Results are reported after median follow-up of 10 years.
Patients and MethodsBetween 1987 and 1997, 3,449 patients age 50 to 81 years with operable breast cancer who had been taking 20 mg of tamoxifen for 2 years were randomly assigned to either stop or continue for an additional 3 years, if they were alive and recurrence free. Data on recurrences, new tumors, deaths, and cardiovascular events were obtained (April 2010).
ResultsThere were 1,103 recurrences, 755 deaths as a result of breast cancer, 621 cardiovascular (CV) events, and 236 deaths as a result of CV events. Fifteen years after starting treatment, for every 100 women who received tamoxifen for 5 years, 5.8 fewer experienced recurrence, compared with those who received tamoxifen for 2 years. The risk of contralateral breast cancer was significantly reduced (hazard ratio, 0.70; 95% CI, 0.48 to 1.00). Among women age 50 to 59 years, there was a 35% reduction in CV events (P = .005) and 59% reduction in death as a result of a CV event (P = .02); in older women, the effect was much smaller and not statistically significant.
ConclusionTaking tamoxifen for the recommended 5 years reduces the risk of recurrence or contralateral breast cancer 15 years after starting treatment. It also lowers the risk of CV disease and death as a result of a CV event, particularly among those age 50 to 59 years. Women should therefore be encouraged to complete the full course. Although aromatase inhibitors improve disease-free survival, tamoxifen remains a cheap and highly effective alternative, particularly in developing countries.
"Monday, May 2, 2011
3mo, 6 mo or no ADT for locally advance prostate cancer
Lancet Oncology this month:
The TROG investigators have published 10 year results of their no ADT, 3mo ADT, vs 6mo ADT, 3 armed randomized trial. The results show that while there are some benefits to 3mo ADT (such as decreased PSA recurrences, and improved DFS), but the larger benefits (distant metastases and overall survival) only became significant with 6 month. Of note, the majority of these patients were high risk, so the EORTC trial would already suggest that even 6months treatment doesn't give the full benefit, but, nonetheless, it does appear that even a few more months add benefit.
Thursday, April 21, 2011
NEJM: Potential health effects of the Fukushima disaster
NEJM this week has a good review of the nature and potential health effects of the reactor disaster in Fukushima. Definitely worth a read, and has some interesting comparisons to the Chernobyl disaster as well as Three Mile Island.
Thursday, March 10, 2011
Carbo vs RT for stage I seminoma
In JCO this week:
the Carbo vs RT trial from the MRC and EORTC is updated with 5 year results - the short of it is that there is no difference in disease control, and a reduction in the rate of contralateral GCT.
Link and abstract:
Initial results of a randomized trial comparing carboplatin with radiotherapy (RT) as adjuvant treatment for stage I seminoma found carboplatin had a noninferior relapse-free rate (RFR) and had reduced contralateral germ cell tumors (GCTs) in the short-term. Updated results with a median follow-up of 6.5 years are now reported.
Patients and Methods
Random assignment was between RT and one infusion of carboplatin dosed at 7 x (glomerular filtration rate + 25) on the basis of EDTA (n = 357) and 90% of this dose if determined on the basis of creatinine clearance (n = 202). The trial was powered to exclude a doubling in RFRs assuming a 96-97% 2-year RFR after radiotherapy (hazard ratio [HR], approximately 2.0).
Results
Overall, 1,447 patients were randomly assigned in a 3-to-5 ratio (carboplatin, n = 573; RT, n = 904). RFRs at 5 years were 94.7% for carboplatin and 96.0% for RT (RT-C 90% CI, 0.7% to 3.5%; HR, 1.25; 90% CI, 0.83 to 1.89). One death as a result of seminoma (in RT arm) occurred. Patients receiving at least 99% of the 7 x AUC dose had a 5-year RFR of 96.1% (95% CI, 93.4% to 97.7%) compared with 92.6% (95% CI, 88.0% to 95.5%) in those who received lower doses (HR, 0.51; 95% CI, 0.24 to 1.07; P = .08). There was a clear reduction in the rate of contralateral GCTs (carboplatin, n = 2; RT, n = 15; HR, 0.22; 95% CI, 0.05 to 0.95; P = .03), and elevated pretreatment follicle-stimulating hormone (FSH) levels (> 12 IU/L) was a strong predictor (HR, 8.57; 95% CI, 1.82 to 40.38).
Conclusion
These updated results confirm the noninferiority of single dose carboplatin (at 7 x AUC dose) versus RT in terms of RFR and establish a statistically significant reduction in the medium term of risk of second GCT produced by this treatment.
"Kyphoplasty for Malignant Compression Fractures
An interesting arcticle in the Lancet Oncology reporting a randomized trial on using kyphoplasty for malignant compression fractures.
What they show is that kyphoplasty pretty safe and effective, and I am encouraged by the fact that the interventional radiology literature on these sorts of maneuvers is improving with prospective and randomized evaluations of care. What it doesn't show is that it should replace RT in these situations, as the control arm was simply whatever care the treating physicians wished to deliver. The authors do skirt the subject of the downsides of RT in their discussion, suggesting that this could be a replacement, but I would view that with significant skepticism. I would instead look at these as complimentary treatments, as there is no doubt that kyphoplasty holds the promise of much more rapid pain relief, and RT actually treats the tumor responsible for the fracture in the first place.
Tuesday, February 8, 2011
Boswellia serrata acts on cerebral edema in patients irradiated for brain tumors
In Cancer this week:
An interesting randomized trial looking at the use of Boswelliaserrata (an extract of Indian Frankincense) on cerebral edema, for patients undergoing radiation therapy for brain tumors (metastatic or primary). It is a modest trial with only 22pts in each arm, but they were able to demonstrate a significant decrease in T2 signal volume with the extract vs placebo. This did not however translate into a reduction in the use of steroids, nor in any clinically relevant endpoint. Of course, confirmation will be needed before this is ready for prime time, but this study is an intriguing demonstration of a novel approach at limiting steroid use.
Link and Abstract.
Abstract
BACKGROUND:
Patients irradiated for brain tumors often suffer from cerebral edema and are usually treated with dexamethasone, which has various side effects. To investigate the activity of Boswelliaserrata (BS) in radiotherapy-related edema, we conducted a prospective, randomized, placebo-controlled, double-blind, pilot trial.
METHODS:
Forty-four patients with primary or secondary malignant cerebral tumors were randomly assigned to radiotherapy plus either BS 4200 mg/day or placebo. The volume of cerebral edema in the T2-weighted magnetic resonance imaging (MRI) sequence was analyzed as a primary endpoint. Secondary endpoints were toxicity, cognitive function, quality of life, and the need for antiedematous (dexamethasone) medication. Blood samples were taken to analyze the serum concentration of boswellic acids (AKBA and KBA).
RESULTS:
Compared with baseline and if measured immediately after the end of radiotherapy and BS/placebo treatment, a reduction of cerebral edema of >75% was found in 60% of patients receiving BS and in 26% of patients receiving placebo (P = .023). These findings may be based on an additional antitumor effect. There were no severe adverse events in either group. In the BS group, 6 patients reported minor gastrointestinal discomfort. BS did not have a significant impact on quality of life or cognitive function. The dexamethasone dose during radiotherapy in both groups was not statistically different. Boswellic acids could be detected in patients' serum.
CONCLUSIONS:
BS significantly reduced cerebral edema measured by MRI in the study population. BS could potentially be steroid-sparing for patients receiving brain irradiation. Our findings will need to be further validated in larger studies. Cancer 2011. © 2011 American Cancer Society.
Lancet: TAX 324 update
In the Lancet this week:
An update of TAX 324 is published confirming long term benefit for PFS and OS for TPF vs PF induction chemotherapy for locally advanced head and neck cancer. Clearly I think this confirms that this is the best induction regimen, however, wether induction chemotherapy is truly the best strategy remains uncertain (versus optimal up front concurrent chemo-radiotherapy), and further randomized work will be needed to establish this as the standard of care.
link
Collins Law and Estimating a Tumors Age before diagnosis
In Oncology last week:
An interesting article from Larry Marks - which gets at a question often heard in the clinic: "How long have I had this?" Marks uses a variation on Collins Law (well described in the paper) to estimate how long a tumor may have existed from the development of the first clonogen to the time of detection based on local recurrence rates after a curative resection, and finds that some tumors may have existed for many years prior to detection (3-6 years for the sites studied).
Now obviously there are huge assumptions: first that growth rates are similar before and after a curative surgery, and it excludes tumors which may have been treated more aggressively, and recurred distantly. Therefore, one can really only apply this to low grade cancers that are likely to fail locally only. Nonetheless, it's an interesting thought experiment.
Link (requires free membership to login)
How Long Have I Got? Estimating Typical, Best-Case, and Worst-Case Scenarios for Patients Starting First-Line Chemotherapy for Metastatic Breast Cancer: A Systematic Review of Recent Randomized Trials [REVIEW ARTICLE]
In the JCO:
A relatively simple way to approach estimating a patient's long term prognosis with metastatic breast cancer is put forward in the JCO this week. I liked this as it is simple, in a way that hopefully will be useful to patients when considering their prognosis, going beyond the simple median survivals that immediately come to mind. Of course, one has to take into account that these are based on published clinical trials, which tend to attract and accrue the most motivated and healthy of patients.
Link and Abstract.
To estimate scenarios for survival for women with metastatic breast cancer (MBC) who are starting chemotherapy.
Patients and Methods
We sought randomized, first-line chemotherapy trials for MBC published from 1999 to 2009. We recorded median progression-free survival (PFS) and median overall survival (OS) and extracted the following percentiles (represented scenario) from each OS curve: 90th (worst-case), 75th (lower-typical), 25th (upper-typical), and 10th (best-case). We also estimated these scenarios for each OS curve by multiplying its median by four simple multiples: 0.25 (worst-case), 0.5 (lower-typical), 2 (upper-typical), and 3 (best-case). Estimates were deemed accurate if they were within 0.75 to 1.33 times the actual value.
Results
From 36 trials (13,083 women), the mean for median PFS was 7.6 months (interquartile range [IQR], 6.0 to 9.0 months), the mean for median OS was 21.7 months (IQR,18.2 to 24.0 months), and the mean for the ratio of median OS to median PFS was 3.0 (IQR, 2.4 to 3.5). The mean for each OS scenario was worst-case, 6.3 months (IQR, 4.8 to 7.5 months); lower-typical, 11.9 months (IQR, 9.9 to 13.2 months); upper-typical, 36.2 months (IQR, 31.1 to 41.3 months); and best-case, 55.8 months (IQR, 47.5 to 60.2 months). Simple multiples of the median gave accurate estimates of the worst-case scenario in 73% of OS curves, lower-typical in 97%, upper-typical in 95%, and best-case in 96%. OS was longer in trials with higher proportions of estrogen receptor–positive tumors (P = .001) and in trials of trastuzumab-treated human epidermal growth factor receptor 2–positive tumors (P = .001).
Conclusion
Simple multiples of an OS curve's median can accurately estimate typical (half to double the median), best-case (triple the median), and worst-case (one quarter of the median) scenarios for survival.
"MDS in Atomic Bomb survivors
In the JCO:
Fortunately there are very few populations in which the late effects of single instance low dose whole body radiation can be studied. Fortunately also, the Japanese and US government have been very helpful in performing large scale studies of the long term effects of the two bombs dropped. While a fair amount of the secondary cancer risk has been published, from the data presented in JCO this week, MDS is clearly another risk that should be monitored for.
Links and Abstract:
The risk of myelodysplastic syndromes (MDS) has not been fully investigated among people exposed to ionizing radiation. We investigate MDS risk and radiation dose-response in Japanese atomic bomb survivors.
Patients and Methods
We conducted a retrospective cohort study by using two databases of Nagasaki atomic bomb survivors: 64,026 people with known exposure distance in the database of Nagasaki University Atomic-Bomb Disease Institute (ABDI) and 22,245 people with estimated radiation dose in the Radiation Effects Research Foundation Life Span Study (LSS). Patients with MDS diagnosed from 1985 to 2004 were identified by record linkage between the cohorts and the Nagasaki Prefecture Cancer Registry. Cox and Poisson regression models were used to estimate relationships between exposure distance or dose and MDS risk.
Results
There were 151 patients with MDS in the ABDI cohort and 47 patients with MDS in the LSS cohort. MDS rate increased inversely with exposure distance, with an excess relative risk (ERR) decay per km of 1.2 (95% CI, 0.4 to 3.0; P < .001) for ABDI. MDS risk also showed a significant linear response to exposure dose level (P < .001) with an ERR per Gy of 4.3 (95% CI, 1.6 to 9.5; P < .001). After adjustment for sex, attained age, and birth year, the MDS risk was significantly greater in those exposed when young.
Conclusion
A significant linear radiation dose-response for MDS exists in atomic bomb survivors 40 to 60 years after radiation exposure. Clinicians should perform careful long-term follow-up of irradiated people to detect MDS as early as possible.
"Results of the SPIRIT trial (Surgery vs Brachy) for Prostate
In the JCO:
Few disease sites would benefit from a randomized trial more than prostate cancer would, though we can't seem to accrue anything except for varying lengths of hormonal treatment and different postoperative strategies. The SPIRIT trial valiantly tried to correct this issue, however unfortunately failed to accrue. Fortunately, at lease some data from this attempt is published in JCO this week, and the QOL in urinary and sexual domains favor brachytherapy. Link and abstract below.
The American College of Surgeons Oncology Group phase III Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial comparing radical prostatectomy (RP) and brachytherapy (BT) closed after 2 years due to poor accrual. We report health-related quality of life (HRQOL) at a mean of 5.3 years for 168 trial-eligible men who either chose or were randomly assigned to RP or BT following a multidisciplinary educational session.
Patients and Methods
After initial lack of accrual, a multidisciplinary educational session was introduced for eligible patients. In all, 263 men attended 47 sessions. Of those, 34 consented to random assignment, 62 chose RP, and 94 chose BT. Five years later, these 190 men underwent HRQOL evaluation by using the cancer-specific 50-item Expanded Prostate Cancer Index Composite, the Short Form 12 Physical Component Score, and Short Form 12 Mental Component Score. Response rate was 88.4%. The Wilcoxon rank sum test was used to compare summary scores between the two interventions.
Results
Of 168 survey responders, 60.7% had BT (9.5% randomly assigned) and 39.3% had RP (9.5% randomly assigned). Median age was 61.4 years for BT and 59.4 for RP (P = .05). Median follow-up was 5.2 years (range, 3.2 to 6.5 years). For BT versus RP, there was no difference in bowel or hormonal domains, but men treated with BT scored better in urinary (91.8 v 88.1; P = .02) and sexual (52.5 v 39.2; P = .001) domains, and in patient satisfaction (93.6 v 76.9; P < .001).
Conclusion
Although treatment allocation was random in only 19%, all patients received identical information in a multidisciplinary setting before selecting RP, BT, or random assignment. HRQOL evaluated 3.2 to 6.5 years after treatment showed an advantage for BT in urinary and sexual domains and in patient satisfaction.
"Wednesday, February 2, 2011
Lancet Oncology: Urorad and IMRT
A very blunt interview with Anthony Zeitman is published in Lancet Oncology, blasting the Urorad business model.
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