Estimated Doses to the Heart, Lungs and Oesophagus and Risks From Typical UK Radiotherapy for Early Breast Cancer During 2015-2023.

PURPOSE: Breast cancer radiotherapy can increase the risks of heart disease, lung cancer and oesophageal cancer. At present, the best dosimetric predictors of these risks are mean doses to the whole heart, lungs and oesophagus, respectively. We aimed to estimate typical doses to these organs and resulting risks from UK breast cancer radiotherapy. METHODS: A systematic review and meta-analysis was conducted of planned or delivered mean doses to the whole heart, lungs or oesophagus from UK breast cancer radiotherapy in studies published during 2015-2023. Average mean doses were summarised for combinations of laterality and clinical targets. Heart disease and lung cancer mortality risks were then estimated using established models. RESULTS: For whole heart, thirteen studies reported 2893 doses. Average mean doses were higher in left than in right-sided radiotherapy and increased with extent of clinical targets. For left-sided radiotherapy, average mean heart doses were: 2.0 Gy (range 1.2-8.0 Gy) breast/chest wall, 2.7 Gy (range 0.6-5.6 Gy) breast/chest wall with either axilla or supraclavicular nodes and 2.9 Gy (range 1.3-4.7 Gy) breast/chest wall with nodes including internal mammary. For right-sided radiotherapy, average mean heart doses were: 1.0 Gy (range 0.3-1.0 Gy) breast/chest wall and 1.2 Gy (range 1.0-1.4 Gy) breast/chest wall with either axilla or supraclavicular nodes. There were no whole heart dose estimates from right internal mammary radiotherapy. For whole lung, six studies reported 2230 doses. Average mean lung doses increased with extent of targets irradiated: 2.6 Gy (range 1.4-3.0 Gy) breast/chest wall, 3.0 Gy (range 0.9-5.1 Gy) breast/chest wall with either axilla or supraclavicular nodes and 7.1 Gy (range 6.7-10.0 Gy) breast/chest wall with nodes including internal mammary. For whole oesophagus, two studies reported 76 doses. Average mean oesophagus doses increased with extent of targets irradiated: 1.4 Gy (range 1.0-2.0 Gy) breast/chest wall with either axilla or supraclavicular nodes and 5.8 Gy (range 1.9-10.0 Gy) breast/chest wall with nodes including internal mammary. CONCLUSIONS: The typical doses to these organs may be combined with dose-response relationships to estimate radiation risks. Estimated 30-year absolute lung cancer mortality risks from modern UK breast cancer radiotherapy for patients irradiated when aged 50 years were 2-6% for long-term continuing smokers, and <1% for non-smokers. Estimated 30-year mortality risks for heart disease were <1%.

International Variation in Criteria for Internal Mammary Chain Radiotherapy.

AIMS: Evidence has emerged that internal mammary chain (IMC) radiotherapy reduces breast cancer mortality, leading to changes in treatment guidelines. This study investigated current IMC radiotherapy criteria and the percentages of patients irradiated for breast cancer in England who fulfilled them. MATERIALS AND METHODS: A systematic search was undertaken for national guidelines published in English during 2013-2018 presenting criteria for 'consideration of' or 'recommendation for' IMC radiotherapy. Patient and tumour variables were collected for patients who received breast cancer radiotherapy in England during 2012-2016. The percentages of patients fulfilling criteria stipulated in each set of guidelines were calculated. RESULTS: In total, 111 729 women were recorded as receiving adjuvant breast cancer radiotherapy in England during 2012-2016 and full data were available on 48 095 of them. Percentages of patients fulfilling IMC radiotherapy criteria in various national guidelines were: UK Royal College of Radiologists 13% (6035/48 095), UK National Institute for Health and Care Excellence 18% (8816/48 095), Germany 32% (15 646/48 095), Ireland 56% (26 846/48 095) and USA 59% (28 373/48 095). Differences between countries occurred because in Ireland and the USA, treatment may be considered in some node-negative patients, whereas in the UK, treatment is considered if at least four axillary nodes are involved or for high-risk patients with one to three positive nodes. In Germany, treatment may be considered for all node-positive patients. CONCLUSIONS: There is substantial variability between countries in criteria for consideration of IMC radiotherapy, despite guidelines being based on the same evidence. This will probably lead to large variations in practice and resource needs worldwide.

Factors associated with intentional and unintentional non-adherence to adjuvant endocrine therapy following breast cancer.

Adherence to adjuvant endocrine therapy (AET) following breast cancer is known to be suboptimal despite its known efficacy in reducing recurrence and mortality. This study aims to investigate factors associated with non-adherence and inform the development of interventions to support women and promote adherence. A questionnaire survey to measure level of adherence, side effects experienced, beliefs about medicine, support received and socio-demographic details was sent to 292 women 2-4 years post breast cancer diagnosis. Differences between non-adherers and adherers to AET were explored, and factors associated with intentional and unintentional non-adherence are reported. Approximately one quarter of respondents, 46 (22%), were non-adherers, comprising 29 (14%) intentional non-adherers and 17 (8%) unintentional non-adherers. Factors significantly associated with intentional non-adherence were the presence of side effects (p < .03), greater concerns about AET (p < .001) and a lower perceived necessity to take AET (p < .001). Half of the sample (105/211) reported that side effects had a moderate or high impact on their quality of life. Factors associated with unintentional non-adherence were younger age (<65) (p < .001), post-secondary education (p = .046) and paid employment (p = .031). There are distinct differences between intentional non-adherence and unintentional non-adherence. Differentiation between the two types of non-adherence may help tailor support and advice interventions.

Retrospective study of management of uterine sarcomas at Oxford 1990-1998: role of adjuvant treatment.

We report a retrospective study of 47 consecutive patients with uterine sarcoma treated at the Churchill Hospital in Oxford between 1990-1998. The mainstay of treatment was surgery with adjuvant chemotherapy and radiotherapy reserved for selected patients with early stage disease. Overall 1 and 2 year survival was 49% and 30% respectively compared with 73% and 55% in the group who received adjuvant chemotherapy/radiotherapy. Median survival was 11 months for the group as a whole compared to 32.9 months in the adjuvant therapy group. This is a retrospective review with small numbers and considerable selection bias, however, given the poor survival of patients with this disease, adjuvant treatment should be considered in future trials of patients with uterine sarcoma.

The risk of treatment. A study of rheumatoid arthritis patients' attitudes.

Despite its importance, there is no well-validated method of measuring patients' concept of 'acceptable' risk of medical treatment. Numerical methods give widely varying results depending on the methodology. We have attempted to assess 'acceptable' risk using relative comparisons. We administered a questionnaire to 67 patients with rheumatoid arthritis (RA). In general, patients' estimate of acceptable risk was less than the actual risk of treatment. Some illogical choices were made, showing poor understanding by patients of the concepts of risk and risk:benefit ratio. Patients appeared willing to accept higher levels of risk from procedures than from drug treatment. Willingness to accept risk in exchange for successful treatment of their RA did not correlate with disease severity, age, willingness to take non-medical risks or family responsibilities.

Skin care during radiotherapy: a survey of UK practice.

A postal survey of skin care during radiotherapy throughout UK centres has shown considerable variability in practice between units. No scientific study has established the value of many of the treatments advocated and suggestions for a more rational approach to the care of irradiated skin are made. In particular, the continued use of common topical applications for the management of dry and moist desquamation is questioned.

Fatal primary mediastinal non-seminomatous germ cell tumour initially diagnosed as malignant mesothelioma.

A patient with a missed diagnosis of a primary mediastinal germ cell tumour is reported. The initial diagnosis of malignant mesothelioma was not compatible with the clinical course. The true diagnosis was reached after the patient had completed a course of palliative irradiation following the development of superior vena cava obstruction. He succumbed to a massive haemoptysis before chemotherapy could begin.

Adolescent risk-taking: an analysis of problem behaviors in problem children.

In this study adolescent risk-taking is explored from several theoretical positions: Jessor's problem-behavior perspective, risk-taking as normal and adaptive, adolescent egocentrism, and a decision-making perspective. Adolescents (ages 11-17) referred to mental health clinics (N = 80) completed a risk involvement and perception questionnaire, the Jesness Personality Inventory, and a measure of adolescent egocentrism. For purposes of concurrent validity, a diagnosis was completed by the subject's clinic therapist. As predicted, both Benefit and Risk Perception were significantly correlated with Involvement (in opposite directions), supportive of a decision-making perspective. A configuration of social maladjustment personality correlates in conjunction with a diagnosis of Conduct Disorder showed a strong, positive correlation with Involvement, supporting a problem-behavior perspective. Egocentrism measures were not significantly related to Risk Involvement or Risk and Benefit Perceptions. Adolescent risk-taking is argued to be a multidimensional phenomenon involving personality correlates and cognitive aspects of decision-making.

Pre-hospital care of the multiple injured casualty.

Theatre nurses often forget that the multi-traumatised patient has undergone untold horror and pain before his or her arrival in the operating theatre. Brian Lavery, area training officer with the Scottish Ambulance Service, talks about the para-medics role in the pre-hospital care of these patients.