Shorter Fractionation Schedules Research Articles

Prospective Study to Compare Efficacy of Conventional Chemoradiotherapy with Hypofractionated Chemoradiotherapy in Locally Advanced Carcinoma of Oropharynx.

Chemoradiotherapy is the standard treatment for advanced Oropharyngeal squamous cell carcinoma (OPSCC). Upcoming hypofractionation has led to better compliance and non-inferior results in various sites such as breast and prostate cancer etc. This study prospectively compared a dose-intensified schedule in advanced OPSCC with standard hypofractionation. Patients with advanced stage III and IV OPSCC suitable for radical chemoradiotherapy were eligible. Patients were alternatively allocated to both the treatment arms. Arm A planned to receive 64 Gy in 25 fractions (#) with concurrent cisplatin and Arm B received standard fractionation 70 Gy in 35 # with concurrent cisplatin. All patients completed a median follow up of 6 to 18 months. The primary end point was acute toxicity (less than 3 months) and late toxicity at 1 year. Secondary end point was disease free survival and overall survival at 1 year. 44 patients in arm A and 49 patients in arm B were recruited over 18 months. 34 patients completed full-dose radiotherapy in both arms. Maximum acute toxicity in arm A in terms of skin reaction was Grade II in 47.05% cases and mucositis grade II in 67.6% cases. In arm B grade II skin toxicity was seen in 47.1% and mucositis grade II was seen in 79.4 % cases. Ryle's tube dependency was seen in 38.2 % cases in arm A and 50% in arm B. Complete response rate at 3 months was equivalent in both arms in Arm A (100%), and in Arm B (96.7%). Disease free survival (DFS), Overall survival (OS) at 3 month, 6 months, and 12 months was comparable. 64 Gy in 25 fractions with concomitant chemotherapy is tolerable in patients with equivalent results and better compliance. Shorter fractionation schedule is more acceptable and we look forward for more randomized control trials.

Does cost minimization of hypofractionated radiation therapy content all health stakeholders?

Does cost minimization of hypofractionated radiation therapy content all health stakeholders?

Impact of Total Neoadjuvant Therapy vs. Standard Chemoradiotherapy in Locally Advanced Rectal Cancer: A Systematic Review and Meta-Analysis of Randomized Trials.

Simple SummaryMultimodality therapy is the standard of care for patients with locally advanced rectal cancer (LARC). The optimal treatment sequence is, however, a matter of debate. Neoadjuvant radiotherapy with concurrent fluoropyrimidines followed by surgery and adjuvant chemotherapy has been the standard treatment for the past years. Alternative therapeutic strategies such as total neoadjuvant treatment (TNT) are gaining momentum, although results from individual clinical trials are not conclusive regarding its impact on survival. In this context, we aimed to systematically review available evidence from randomized trials comparing different sequencing strategies. The results from our meta-analysis show that TNT not only provides increased complete pathological response rates, but also improves disease-free and overall survival at 3 years compared to standard neoadjuvant chemoradiotherapy, with no substantial increase in severe adverse events. These results support the use of induction or consolidation chemotherapy before surgery in LARC and TNT as a valuable treatment strategy in these patients.Multimodality treatment is a standard of care for LARC, but the optimal sequencing of the treatment modalities remains unclear. Several randomized clinical trials (RCTs) compared total neoadjuvant treatment (TNT) vs. standard neoadjuvant chemoradiotherapy (CRT) with inconsistent results. A systematic review and meta-analysis was performed to evaluate the efficacy of TNT in terms of complete pathological response (pCR) rate, disease-free and overall survival vs. standard CRT in LARC. A systematic search was performed through MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and meeting abstracts up to May 2020. RCTs comparing CRT vs. TNT followed by surgery in LARC were eligible for the study. Study selection and data extraction were done following PRISMA guidelines by two independent reviewers. The Mantel–Haenzel method was used to obtain a fixed-effects model of pooled odds or hazard ratios for the main outcomes. Eight RCTs, including 2301 patients, met the eligibility criteria. TNT significantly improved pCR rate (OR = 1.99, 95% confidence interval (CI) 1.59–2.49; p < 0.001), 3-year disease-free-survival (DFS) (HR = 0.82, 95%CI 0.71–0.95; p = 0.01) and 3-year overall survival (OS) (hazard ratio (HR) = 0.81, p = 0.04). Grade 3–4 adverse events were not significantly different in both strategies (OR = 1.58; p = 0.14). An improved pCR rate was documented regardless of the type of radiotherapy administered (long vs. short fractionation schedules). No significant heterogeneity was found. The results of this meta-analysis show that TNT improves pCR and survival rates vs. standard preoperative CRT in patients with LARC. TNT may become a new standard of care in LARC, although longer follow-up is needed to properly assess its long-term impact on survival.

A Prospective Study of Cosmetic Outcomes for Patients Treated with Breast Conservation and Radiation Therapy using Shorter Fractionation Schedules at Auckland Hospital, New Zealand

AimsBreast cosmesis is an important outcome for women after breast conservation. It has been shown to be correlated with better patient satisfaction, sexuality and self-esteem. This study reports the subjective and objective breast cosmesis outcomes for women treated at Auckland Hospital Radiation Oncology Department using hypofractionated radiation therapy. Materials and methodsBreast cosmesis was evaluated using a subjective questionnaire and standardised photographs before radiation, at 6 weeks, 1 year, 3 years and 5 years after radiation. Objective evaluation of the photographs and completion of questionnaires were undertaken by clinicians at the same time points. The questionnaire evaluated global cosmesis on a four-point scale – excellent (E), good (G), fair (F) and poor (P). Patient, tumour and treatment factors were evaluated to assess the impact on cosmesis. ResultsThree hundred and fifty-eight patients completed the baseline assessments and two hundred and two patients completed the 5-year assessments. Sixty-eight per cent of patients at baseline and 70% at 5 years scored their cosmesis as E/G compared with 52% and 51%, respectively, by clinician assessment. Age >50 years, separation ≤25 cm, non-diabetic, T1 tumours, node negative, quadrant of the scar, no boost and no adjuvant endocrine therapy were correlated with E/G cosmesis. On multivariate analysis at baseline, the individual breast factors that were significantly associated with a score of E/G cosmesis were breast shape (P = 0.028) and scar appearance (P = 0.001). At 5 years, breast shape (P = 0.003), nipple shape (P = 0.019) and scar appearance (P = 0.001) were found to be significant. ConclusionThis study shows that most women reported no significant change in their breast cosmesis after hypofractionated radiation treatment over 5 years and that a number of patient, tumour and treatment factors may impact on breast cosmesis.

Haemostatic radiotherapy for bleeding cancers of the upper gastrointestinal tract.

Bleeding can cause significant morbidity in patients with upper gastrointestinal malignancies. Palliative radiotherapy can palliate bleeding effectively across numerous cancer sites such as the lung and rectum. The data available regarding the role in bleeding from upper gastrointestinal cancers are limited to a single meta-analysis, a phase 2 trial, eleven retrospective cohorts and two case reports, with the majority focusing on gastric cancer. From the data available radiotherapy appears to be a well-tolerated, effective haemostatic agent that should be considered in all patients with bleeding from an upper gastrointestinal malignancy. Questions remain regarding the radiobiology of haemostasis and the optimum fractionation schedule. There is no convincing evidence that protracted higher dose regimens provide additional benefit. Commonly used fractionation schedules use 1, 5 or 10 fractions. Short fractionation schedules have been used in patients with deteriorating performance status.

Palliative thoracic radiotherapy near the end of life in lung cancer: A population-based analysis

ObjectivesPalliative thoracic radiotherapy (RT) can improve quality of life for patients with advanced lung cancer, but treatment can be associated with acute toxicity and symptomatic relief may take several weeks. The optimal fractionation schedule is not known. Delivery of RT near the end of life (EOL) is an emerging indicator of poor quality care. The aim of this study was to determine utilization of palliative thoracic RT in the last 4 weeks of life, and factors associated with its use, in patients with incurable lung cancer in a population-based healthcare system. Materials and methodsAll patients with lung cancer in British Columbia treated with palliative thoracic RT in 2014 and 2015 were identified. Associations between starting a course of palliative thoracic RT within 4 weeks of death and patient/treatment characteristics were assessed using univariate and multivariate logistic regression analysis. Results1676 courses of palliative thoracic RT were delivered to 1584 lung cancer patients. Median survival was 20 weeks. 12% of palliative thoracic RT courses were delivered in the last 4 weeks of life, with short fractionation schedules and simple RT planning techniques used more frequently near EOL. Of RT courses delivered in the last 4 weeks of life 89% were courses of 1 – 5 fractions, 75% were completed as prescribed and 94% involved simple 1–2 field RT techniques. Receipt of RT in the last 4 weeks of life was associated with male gender, younger age, poor performance status, metastatic disease, small cell carcinoma histology and no prior chemotherapy. ConclusionFurther study and standardization of quality indicators for palliative RT utilization near EOL is required. Whilst clarification occurs, physicians should consider the prognosis of patients with incurable lung cancer and the realistic expectation of benefit from palliative thoracic RT when considering treatment indications and fractionation schedules.

Palliative radiotherapy education in hospice and palliative medicine fellowship: A national needs assessment.

87 Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians are thought to contribute to sub-optimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. We conducted a national survey of HPM fellowship program directors and fellows to assess the need for increased PRT education in HPM fellowship. Methods: A 17-item, anonymous, electronic survey was distributed via email in May 2018 to the directors of all US Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow. A similar 19-item survey was emailed to the coordinators of these programs for distribution to enrolled fellows. Three reminder emails were sent over a one-month period. Results: Eighty-one (68%) of 120 eligible program directors and 114 (34%) of 338 eligible fellows completed the surveys. Nearly all respondents (98% of program directors and 99% of fellows) agreed that HPM physicians should be familiar with the principles of PRT and 95% of both groups agreed that this topic should be taught in HPM fellowship. Thirty percent of programs, however, lacked any PRT curriculum and 57% of programs provided only 1 or 2 hours of didactic PRT education. The minority of fellows felt confident in their ability to identify radiation oncology emergencies (43%) or to manage symptoms associated with radiotherapy toxicities (42%) and only 56% felt confident in their ability to assess which patients should be referred to radiation oncology for possible PRT. Notably, the majority of fellows reported that if they were more knowledgeable about PRT they would be more likely to consider referral to radiation oncology (78%), to collaborate with the radiation oncologists involved in their patients’ care (76%), and to advocate for shorter fractionation schedules or possible omission of radiation therapy altogether based on a patient’s prognosis or goals of care (78%). Conclusions: HPM fellowship program directors and fellows agree that that there is a need for increased education in PRT in HPM fellowship. Curricular interventions that address this need may result in more appropriate utilization of PRT.

Impact of Performance Status and Comorbidity on Palliative Radiation Treatment Tolerance and End-Of-Life Decision-Making

PurposePrevious studies have indicated a relationship between functional status and comorbidity on overall survival when treating patients with bone and brain metastases. However, the degree to which these findings have been integrated into modern-day practice remains unknown. This study examines the impact of performance measures, including Karnofsky Performance Status (KPS) and comorbidity, on palliative radiation therapy treatment tolerance and fractionation schedule. The relationship between a shorter fractionation schedule (SFx) and pending mortality is examined. Methods and materialsThis study included patients who were treated with palliative intent to the brain or bone between January 1, 2016 and June 30, 2016. Demographic and medical characteristics collected included KPS score (stratified as good [90-100], fair [70-80], and poor (≤60]), socioeconomic status, comorbidity (binary measure using the Adult Comorbidity Evaluation-27 scale), site of metastatic disease, and treatment facility. Univariable analyses were performed using the Cox proportional hazards regression model to assess the impact of the variables on the prescribed number of fractions (binary measure, ≥10 [long fractionation schedule], and <10 [SFx]), and major treatment interruptions (MTIs; defined as missing ≥3 radiation therapy treatment days or ending treatment prematurely). ResultsA total of 145 patients were eligible for study inclusion, including 95 patients who were treated for bony metastatic disease and 50 patients for brain metastases. High comorbidity (P = .029) and both fair (P = .051) and poor (P = .065) functional status were associated with more frequent MTIs. However, high comorbidity and low KPS score were not associated with shorter treatment plans. In addition, patients with an earlier time to death were not more likely to receive an SFx (P = .871). ConclusionsLow KPS and elevated comorbidity scores predict for a poorer prognosis and more frequent MTIs; however, there was no indication that physicians incorporated this information in the fractionation scheduling.

Survival and stability of patients with urothelial cancer and spinal bone metastases after palliative radiotherapy

Abstract Background The aim of the study was to analyze survival and stability of patients with urothelial cell cancer and spinal bone metastases (SBM) after radiotherapy (RT). Furthermore, to assess the effects of RT on bone mineral density (BMD) as a local response in SBM after RT. Patients and methods Survival of 38 patients with 132 SBM from urothelial cancer, treated from January 2000 to January 2012, was calculated. Stability of irradiated thoracic and lumbar SBM was retrospectively evaluated in computed tomography (CT) scans using the validated Taneichi et al. score. Difference in BMD, measured in Hounsfield units (HU), of the SBM before and at 3 and 6 months after RT was analyzed. Results All patients died during follow-up. Overall survival (OS) after 6 months, 1 year and 2 years was 90%, 80% and 40%, respectively. Bone survival (BS) was 85%, 64% and 23% after 6 months, 1 year and 2 years, respectively. Survival from start of RT (RTS) was 42% after 6 months, 18% after 1 year and 5% after 2 years. Only 11% received bisphosphonates. Stability did not improve at 3 or 6 months after RT. BMD increased by 25.0 HU ± 49.7 SD after 3 months (p = 0.001) and by 24.2 HU ± 52.2 SD after 6 months (p = 0.037). Pain relief (&gt; 2 points on the visual analogue scale) was achieved in only 27% of patients. Conclusions Benefit from palliative RT of painful or unstable SBM is limited in these patients and they should be carefully selected for RT. Shorter fractionation schedules may be preferred and outcome may improve with concomitant bisphosphonates.

Survival and Stability of Patients with Urothelial Cancer and Spinal Bone Metastases after Palliative Radiotherapy.

BackgroundThe aim of the study was to analyze survival and stability of patients with urothelial cell cancer and spinal bone metastases (SBM) after radiotherapy (RT). Furthermore, to assess the effects of RT on bone mineral density (BMD) as a local response in SBM after RT.Patients and methodsSurvival of 38 patients with 132 SBM from urothelial cancer, treated from January 2000 to January 2012, was calculated. Stability of irradiated thoracic and lumbar SBM was retrospectively evaluated in computed tomography (CT) scans using the validated Taneichi et al. score. Difference in BMD, measured in Hounsfield units (HU), of the SBM before and at 3 and 6 months after RT was analyzed.ResultsAll patients died during follow-up. Overall survival (OS) after 6 months, 1 year and 2 years was 90%, 80% and 40%, respectively. Bone survival (BS) was 85%, 64% and 23% after 6 months, 1 year and 2 years, respectively. Survival from start of RT (RTS) was 42% after 6 months, 18% after 1 year and 5% after 2 years. Only 11% received bisphosphonates. Stability did not improve at 3 or 6 months after RT. BMD increased by 25.0 HU ± 49.7 SD after 3 months (p = 0.001) and by 24.2 HU ± 52.2 SD after 6 months (p = 0.037). Pain relief (> 2 points on the visual analogue scale) was achieved in only 27% of patients.ConclusionsBenefit from palliative RT of painful or unstable SBM is limited in these patients and they should be carefully selected for RT. Shorter fractionation schedules may be preferred and outcome may improve with concomitant bisphosphonates.

Consideration of patient and disease characteristics in selecting radiation regimens for treatment of bone metastases

PurposeRadiation therapy is one of the mainstays of treatment for painful bone metastases; however, the optimal fractionation and dosing of radiation for a given patient and disease characteristics are still subject to debate. Methods and materialsWe retrospectively examined 475 patients who received radiation for bone metastases at our institution from 2009 through 2014 and evaluated survival outcomes based on parameters of their first treatment course and patient demographics. Kaplan-Meier analysis was used to analyze factors associated with overall survival (OS). A recursive partition analysis (RPA) was used to generate a decision tree of patient characteristics resulting in significant differences in survival. A Cox model was used to verify the RPA and evaluate the significance of biologically equivalent dose (BED) along with other factors. ResultsIn our cohort, median age was 62 years and median Karnofsky performance status (KPS) was 70. Survival time by primary tumor type: breast (median, 35.9 months), prostate (12.8 months), other (median, 11.0 months), lung (median, 5.3 months), and gastrointestinal (median, 4.0 months) (P < .0001). Primary tumor type and KPS significantly affected survival, whereas age was also significant for survival in certain primary tumor types. Pain control was not found to be significantly affected by primary tumor type (P = .72) or BED (P = .14). ConclusionOur data demonstrate that selection of radiation fractionation schedules should take into account primary tumor type, KPS, and age, and we have generated an RPA model including these factors to help guide decision making. We also found that shorter fractionation schedules are as effective as longer fractionation schedules for pain control, regardless of primary tumor type.

Comparison of Three Short Fractionation Schedules for Exclusive High-Dose Rate Brachytherapy in Intermediate-Risk Endometrial Carcinoma

Comparison of Three Short Fractionation Schedules for Exclusive High-Dose Rate Brachytherapy in Intermediate-Risk Endometrial Carcinoma

Safety considerations for IGRT: Executive summary

Radiation therapy is an effective cancer treatment that is constantly being transformed by technological innovation. Dedicated devices for fraction-by-fraction imaging and guidance within the treatment room have enabled image guided radiation therapy (IGRT) allowing clinicians to pursue highly conformal dose distributions, higher dose prescriptions, and shorter fractionation schedules. Capitalizing on IGRT-enabled accuracy and precision requires a strong link between IGRT practices and planning target volume (PTV) design. This is clearly central to high quality, safe radiation therapy. Failure to properly apply IGRT methods or to coordinate their use with an appropriate PTV margin can result in a treatment that is ‘precisely wrong’. The white paper summarized in this executive summary recommends foundational elements and specific activities to maximize the safety and effectiveness of IGRT.

A Population-Based Study of the Fractionation of Postlumpectomy Breast Radiation Therapy

The optimal fractionation schedule of post lumpectomy radiation therapy remains controversial. The objective of this study was to describe the fractionation of post-lumpectomy radiation therapy (RT) in Ontario, before and after the seminal Ontario Clinical Oncology Group (OCOG) trial, which showed the equivalence of 16- and 25-fraction schedules. This was a retrospective cohort study conducted by linking electronic treatment records to a population-based cancer registry. The study population included all patients who underwent lumpectomy for invasive breast cancer in Ontario, Canada, between 1984 and 2008. Over the study period, 41,747 breast cancer patients received post lumpectomy radiation therapy to the breast only. Both 16- and 25-fraction schedules were commonly used throughout the study period. In the early 1980s, shorter fractionation schedules were used in >80% of cases. Between 1985 and 1995, the proportion of patients treated with shorter fractionation decreased to 48%. After completion of the OCOG trial, shorter fractionation schemes were once again widely adopted across Ontario, and are currently used in about 71% of cases; however, large intercenter variations in fractionation persisted. The use of shorter schedules of post lumpectomy RT in Ontario increased after completion of the OCOG trial, but the trial had a less normative effect on practice than expected.

Health-related quality of life in survivors of stage I-II breast cancer: randomized trial of post-operative conventional radiotherapy and hypofractionated tomotherapy

BackgroundHealth-related quality of life (HRQOL) assessment is a key component of clinical oncology trials. However, few breast cancer trials comparing adjuvant conventional radiotherapy (CR) and hypofractionated tomotherapy (TT) have investigated HRQOL. We compared HRQOL in stage I-II breast cancer patients who were randomized to receive either CR or TT. Tomotherapy uses an integrated computed tomography scanner to improve treatment accuracy, aiming to reduce the adverse effects of radiotherapy.MethodsA total of 121 stage I–II breast cancer patients who had undergone breast conserving surgery (BCS) or mastectomy (MA) were randomly assigned to receive either CR or TT. CR patients received 25 × 2 Gy over 5 weeks, and BCS patients also received a sequential boost of 8 × 2 Gy over 2 weeks. TT patients received 15 × 2.8 Gy over 3 weeks, and BCS patients also received a simultaneous integrated boost of 15 × 0.6 Gy over 3 weeks. Patients completed the EORTC QLQ-C30 and BR23 questionnaires. The mean score (± standard error) was calculated at baseline, the end of radiotherapy, and at 3 months and 1, 2, and 3 years post-radiotherapy. Data were analyzed by the 'intention-to-treat' principle.ResultsOn the last day of radiotherapy, patients in both treatment arms had decreased global health status and functioning scores; increased fatigue (clinically meaningful in both treatment arms), nausea and vomiting, and constipation; decreased arm symptoms; clinically meaningful increased breast symptoms in CR patients and systemic side effects in TT patients; and slightly decreased body image and future perspective.At 3 months post-radiotherapy, TT patients had a clinically significant increase in role- and social-functioning scores and a clinically significant decrease in fatigue. The post-radiotherapy physical-, cognitive- and emotional-functioning scores improved faster in TT patients than CR patients. TT patients also had a better long-term recovery from fatigue than CR patients. ANOVA with the Bonferroni correction did not show any significant differences between groups in HRQOL scores.ConclusionsTT patients had a better improvement in global health status and role- and cognitive-functioning, and a faster recovery from fatigue, than CR patients. These results suggest that a shorter fractionation schedule may reduce the adverse effects of treatment.

Shorter fractionation schedules in breast cancer radiotherapy: Clinical and economic implications

An accumulating body of level I evidence from randomised trials of adjuvant radiotherapy in early breast cancer supports the safety and efficacy of giving a lower total dose in fewer larger fractions (hypofractionation) than the historical standard of 50 Gy in 25 fractions of 2.0 Gy over 5 weeks. 1 Bentzen S.M. Agrawal R.K. Aird E.G. et al. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet. 2008; 371: 1098-1107 Abstract Full Text Full Text PDF PubMed Scopus (861) Google Scholar , 2 Bentzen S.M. Agrawal R.K. Aird E.G. et al. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol. 2008; 9: 331-341 Abstract Full Text Full Text PDF PubMed Scopus (809) Google Scholar , 3 Owen J.R. Ashton A. Bliss J.M. et al. Effect of radiotherapy fraction size on tumour control in patients with early-stage breast cancer after local tumour excision: long-term results of a randomised trial. Lancet Oncol. 2006; 7: 467-471 Abstract Full Text Full Text PDF PubMed Scopus (457) Google Scholar , 4 Whelan T. MacKenzie R. Julian J. et al. Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node-negative breast cancer. J Natl Cancer Inst. 2002; 94: 1143-1150 Crossref PubMed Scopus (554) Google Scholar The published phase 3 trials relate to patients prescribed whole breast radiotherapy, but the principle is being extended to trials evaluating partial breast irradiation restricted to the tumour bed. 5 Orecchia R. Ciocca M. Lazzari R. et al. Intraoperative radiation therapy with electrons (ELIOT) in early-stage breast cancer. Breast. 2003; 12: 483-490 Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar , 6 Vaidya JS, Baum M, Tobias JS, Houghton J. Lancet. Targeted intraoperative radiotherapy; 1999. <http://www.thelancet.com/journals/lancet/misc/protocol/99PRT-47>. Google Scholar , 7 Strnad V, Polgar C. On behalf of the European Brachytherapy Breast Cancer GEC-ESTRO Working Group. GEC-ESTRO APBI Trial: interstitial brachytherapy alone versus external beam radiation therapy after breast conserving surgery for low risk invasive carcinoma and low risk duct carcinoma in-situ (DCIS) of the female breast; 2006. <http://www.apbi.uni-erlangen.de/outline/outline.html>. Google Scholar , 8 Wolmark N, Curran WJ. Trial protocol March 13, 2007. On behalf of NSABP and RTOG of the American College of Radiology (ACR). NSABP Protocol B-39. RTOG Protocol 0413. A randomized phase III study of conventional whole breast irradiation versus partial breast irradiation for women with stage 0, I, or II breast cancer. National surgical adjuvant breast and bowel project (NSABP); 2007. p. 1–132. Google Scholar , 9 OCOG. Ontario Clinical Oncology Group (OCOG), Canadian Institutes of Health Research (CIHR), Canadian Breast Cancer Research Alliance. RAPID: Randomized Trial of Accelerated Partial Breast Irradiation; 2008. <http://clinicaltrials.gov/ct2/show/NCT00282035>. Google Scholar , 10 Yarnold J, Coles C. Trial Protocol, version 4, 19.02.2008. On behalf of the IMPORT LOW Trial Management Group: Intesity Modulated and Partial Organ Radiotherapy. Randomised trial testing intensity modulated and partial organ radiotherapy following breast conservation surgery for early breast cancer. Sutton, Surrey, UK: The Institute of Cancer Research: Royal Cancer Hospital; 2008. p. 1–74. Google Scholar , 11 http://www.irmatrial.it/. Google Scholar Interest in hypofractionation is based not only on the practical advantages to patients and health services of fewer hospital visits, but also on two postulated clinical benefits. The first is that breast cancer is more sensitive to fraction size than formerly thought, so that fewer larger fractions maintain current levels of anti-tumour effect without increasing late adverse effects. The second is that shorter overall treatment times (accelerated hypofractionation) may be more effective in patients with rapidly proliferating tumours.

Whole-breast radiotherapy with shorter fractionation schedules following breast-conserving surgery: short-term morbidity and preliminary outcomes

The success of whole-breast radiotherapy with shorter fractionation schedules following BCS has rarely been evaluated in Japanese women. Here we present the short-term morbidity and preliminary outcomes of the shorter fractionation regimen initiated at the Kawasaki Medical School Hospital in 2003. Between January 2003 and December 2005, 248 patients (251 breasts) with breast cancer underwent short-course RT following BCS. The whole breast was irradiated with a total dose of 42.5-47.8 Gy in 16-20 fractions. Patients with positive margins received additional boost irradiation to the tumor bed of 10-13.3 Gy in 4-5 fractions using 4-11 MeV electrons. Adjuvant therapy was administered in 217 cases. The median follow-up time was 26 months. The actuarial 4 year overall, cause specific, and disease-free survival rates were 96.7, 98.6, and 94.9%, respectively. Local recurrence was observed in one patient and distant metastases in four. The 4 year local control rate was 99.0%. A total of 221 patients developed radiation dermatitis (207 patients with grade 1, 14 patients with grade 2). The incidence of grade 2 dermatitis correlated with patient age. Radiation pneumonitis was observed in 15 patients (nine patients with grade 1, six with grade 2), two of whom developed BOOP. No difference was found in age, irradiated breast site, or use of boost irradiation, chemotherapy, and tamoxifen between those with and without pneumonitis. The short fractionation regimen results in acceptable short-term morbidity. With limited follow-up, the incidence of recurrence in the treated breast was low.

Impact of Severe Acute Respiratory Syndrome on Patient Access to Palliative Radiation Therapy

This study evaluated the impact of the severe acute respiratory syndrome (SARS) epidemic on access and utilization of palliative radiation therapy (RT) at a single institution using a retrospective chart review. A total of 649 patients seen between January and May 2002 and between January and May 2003 were evaluated. Treatment characteristics and waiting times were recorded. March 20 to May 30, 2003, was defined as the peak period of incidence and was compared with the same period in 2002. During the SARS epidemic, there was a 21% decrease in the number of patient consultations and a 15% reduction in the number of patients treated with RT. There was no significant change in the tumor type or reason for referral. Short fractionation schedules were employed for 35% of treated patients compared with 34% in 2002. Patient waiting times between referral and treatment decreased during the period of interest, from 16 days to 8 days (P = 0.021). This study demonstrates a reduction in palliative RT services that is similar in magnitude to decreases observed in other essential cancer services during the SARS epidemic. Use of single-fraction RT and delayed follow-up visits may help to minimize hospital transfers and visits in the event of future infectious disease outbreaks.

How do waiting times affect radiation dose fractionation schedules?

The purpose of the present paper was to evaluate the changing patterns of dose prescription at the Queensland Radium Institute from 1995 to 1998 inclusive. Data were analysed from the treatment files collected on each patient and these were compared with data on delay time. There has been an increased use of shorter fractionation schedules in the period studied. Paradoxically, radical treatments have become longer. The average number of fractions for all patients was 17.4 and for palliative treatments it was 7.4. The monthly delay varied from 0 to 22 working days and the average was 7 working days. When fraction number was compared to treatment delay, there was a negative linear correlation (R = -0.25). The correlation was stronger (R = -0.467) when palliative treatments were compared, indicating that clinicians were more prepared to alter palliative treatments in the presence of a treatment delay than curative ones.

Radiation therapy in T1–T2 glottic carcinoma: influence of various treatment parameters on local control/complications

Purpose: To evaluate the influence of various treatment parameters on local control as well as complications in T1 and T2 glottic carcinomas. Methods and Materials: Between 1975 and 1989, 676 patients with early glottic carcinoma (460 T1 and 216 T2) received curative radiation with three different treatment regimens, as follows: Regimen 1—50 Gy/15 Fr/3 weeks (3.33 Gy/daily) for 192 patients; Regimen 2—60–62.5 Gy/24–25 Fr/5 weeks (2.5 Gy/daily) for 352 patients; and Regimen 3—55–60 Gy/25–30 Fr/5–6 weeks (2–2.25 Gy/daily) for 132 patients. Results: The local control at 10 years was 82% and 57% for T1 and T2 lesions respectively ( p = 0.0). For the T1N0M0 group, field size had significant impact on local control with both univariate ( p = 0.05) and multivariate ( p = 0.03) analysis. For T2N0M0, group field size ( p = 0.03) as well as registration year ( p = 0.016) were significant in univariate analysis whereas only field size remained significant on multivariate analysis. Persistent radiation edema was noted in 146 (22%) patients and was significantly worse with larger field size ( p = 0.000) but not related to different treatment regimens. Conclusion: The shorter fractionation schedule had comparable local control, without increased complications in comparison to the protracted schedule and is best suited for a busy department.