Patients' preference for radiotherapy fractionation schedule in the palliation of symptomatic unresectable lung cancer.

The palliative radiotherapeutic management of unresectable non-small-cell lung cancer is controversial, with various fractionation (Fx) schedules available. We aimed to determine patient's choice of Fx schedule after involvement in a decision-making process using a decision board. A decision board outlining the various advantages and disadvantages apparent in the Medical Research Council study of Fx schedules (17 Gy in two fractions vs 39 Gy in 13 fractions) was discussed with patients who met Medical Research Council eligibility criteria. Patients were then asked to indicate their preferred Fx schedules, reasons and their level of satisfaction with being involved in the decision-making process. Radiation oncologists (RO) could prescribe radiotherapy schedules irrespective of patients' preferences. Of 92 patients enrolled, 55% chose the longer schedule. English-speaking patients were significantly more likely to choose the longer schedule (P = 0.02, 95% confidence interval: 1.2-7.6). Longer Fx was chosen because of longer survival (90%) and better local control (12%). Shorter Fx was chosen for shorter overall treatment duration (80%), cost (61%) and better symptom control (20%). In all, 56% of patients choosing the shorter schedule had their treatment altered by the treating RO, whereas only 4% of patients choosing longer Fx had their treatment altered (P < 0.001). Despite this, all (100%) patients were satisfied with being involved in the decision-making process. The decision board was useful in aiding decision-making, with both Fx schedules being acceptable to patients. Interestingly, despite the longer average survival associated with longer Fx, nearly half of the patients believed that this was not as important as a shorter duration of treatment and lower cost. Despite patients' preferences, there were significant alterations of preferred schedules because of RO's own biases.

Does the implementation of radiation oncology outpatient infection control measures adversely affect patient satisfaction with doctor-patient interaction?

INTRODUCTION: There are worldwide concerns of an impending avian influenza outbreak, with nations formulating infection control strategies to prepare for such an event. Little evidence exists for how infection control measures impact on the provision of cancer services, or how patient experience would be affected. Our aim was to compare patient satisfaction with doctor-patient interaction, during and following a period of infection control measures. METHODS: We measured patient satisfaction using a validated 29-question instrument for two weeks during the implementation of strict infection control measures as a result of the severe acute respiratory syndrome outbreak (T1), and compared results with a two-week period after measures had been lifted (T2). RESULTS: A total of 296 patients were surveyed, 149 at T1 and 147 at T2. Most patients indicated overall satisfaction, with 92.3 percent and 86.9 percent satisfied at T1 and T2, respectively (p-value is not significant). Mean satisfaction index was 3.02 and 3.04 out of 4 at T1 and T2, respectively (p-value is not significant). However, the responses for several individual questions did differ significantly between time points. At T1 more patients indicated satisfaction for understanding the doctor's plans (p-value is 0.001), while at T2, more patients indicated satisfaction for being told how to care for their condition (p-value is 0.04). CONCLUSION: The study demonstrated high patient satisfaction at both time points. Similar levels of satisfaction despite infection control measures may be due to patients being more tolerant of problems in doctor-patient interactions during the outbreak due to media campaigns. This research may facilitate those healthcare services planning to minimise the impact of infection control measures on patient care.

Phase II study of the American Brachytherapy Society guidelines for the use of high-dose rate brachytherapy in the treatment of cervical carcinoma: is 45-50.4 Gy radiochemotherapy plus 31.8 Gy in six fractions high-dose rate brachytherapy tolerable?

In 2000, the American Brachytherapy Society (ABS) published incompletely evaluated guidelines for curative chemoradiation and high-dose rate (HDR) brachytherapy for cervical cancer: our aim was to assess guideline tolerability in an Asian population. From 2000, all stage I-IVA cervical carcinoma patients were treated following ABS guidelines. Early disease (FIGO stage I/II <4 cm) received 45 Gy whole-pelvis external-beam radiation (EBRT) at 1.8 Gy/fraction, while advanced-stage disease received 50.4 Gy: no central shielding was used. All patients were planned to receive chemotherapy during EBRT, cisplatin 40 mg/m(2) weekly. All patients received 31.8-Gy HDR brachytherapy (six fractions of 5.3 Gy/fraction) to point A via three-channel applicators. Radiotherapy was completed within 8 weeks. Toxicity scoring used Common Toxicity Criteria. Nineteen of 21 (90.4%) patients (8 early, 13 advanced stage) received planned radiation, and 85.7% received planned chemotherapy. Median follow-up was 24 months (range 9-50 months). Three-year overall survival (S) was 79.1% and disease-free survival (DFS) was 64.8%. S/DFS for early and advanced stage was 85.7%/85.7% and 73.3%/47.1%, respectively. Complete response (CR) was achieved by 85.7% of patients, partial response 14.3%. For those in CR, there were no local failures. Acute cystitis occurred in 23.8%, proctitis 4.8%, and gastroenteritis 47.6%. Late cystitis occurred in 9.5%, gastroenteritis 4.8%, and genitourinary fistula (in the presence of progressive disease) 4.8%. No grade 3/4 treatment-related toxicity occurred. The ABS guidelines were well tolerated and efficacious in our study, although longer follow-up is required. Further studies are warranted to validate safety and efficacy of the recommendations.

Patient satisfaction with doctor-patient interaction in a radiotherapy centre during the severe acute respiratory syndrome outbreak.

An outpatient radiotherapy department assessed how precautions implemented during the severe acute respiratory syndrome (SARS) outbreak affected patient satisfaction with doctor-patient interaction and explored variables potentially influencing satisfaction. The information obtained would help prepare us for future infectious disease outbreaks. Outpatients seen during the outbreak completed a validated questionnaire assessing satisfaction with doctor-patient interaction. Additional items assessed included patients' perception of SARS measures and patient demographics. Of 149 patients, 97% had heard of SARS, 92% believed SARS precautions necessary, and 54% believed contracting SARS was possible despite the precautions. Patients were satisfied with doctors wearing masks (97%), temperature checks (97%), and patients wearing masks (96%). Despite the high satisfaction levels with SARS precautions, 24% believed it had adversely affected doctor-patient interaction. With regards to doctor-patient interaction, 94% of patients were satisfied. Patients were most satisfied with the 'information exchange' domain (mean score 3.23 out of 4) compared to other domains (P < 0.0001, 100.00% confidence) and were less satisfied with the 'empathy' domain compared to other domains (P < 0.0001, 100.00% confidence). Patients were most satisfied with understanding their treatment plan (100%), doctor being honest (97%) and being understood (96%). Patients were least satisfied with information about caring for their illness (61%), that the visit could be better (59%), and the doctor showing more interest (58%). On multivariate analysis, patients who were less satisfied with SARS measures were significantly less satisfied with doctor-patient interaction (P = 0.0001). Dissatisfaction with SARS measures was associated with significant dissatisfaction for questions in all domains. Older age and non-breast cancer patients were also less satisfied with doctor-patient interaction. Most (94%) of patients were satisfied with doctor-patient interaction, despite implementation of infectious disease prevention measures. However, patients who were dissatisfied with the SARS precautions had poorer satisfaction. In particular, physician empathy appeared to be most adversely affected. The results have relevance to any radiotherapy department preparing contingency plans in the event of infectious disease outbreaks.

Introducing the Intergroup 0116 protocol of adjuvant chemo-radiotherapy in gastric cancer into clinical practice.

AIMS: The results of techniques from a well-conducted clinical trial are often difficult to reproduce when implemented in community oncology practice. The U.S. Intergroup 0116 protocol of adjuvant chemo-radiotherapy in gastric cancer presented in mid-2000 produced a survival advantage over surgery alone. The current study aims to determine the adherence with protocol design and delivery of radiation therapy (radiotherapy) in the initial 20 patients managed with the Intergroup 0116 protocol at The National University Hospital, Singapore. MATERIALS AND METHODS: A formal quality assurance audit was performed on clinical features, radiotherapy treatment charts and simulation films of the first 20 patients treated with the Intergroup 0116 protocol from July 2000 to September 2001. Specific details were audited for their consistency with described protocol in domains of eligibility criteria, radiotherapy prescription, target volume coverage and adherence to dose-limiting normal tissue tolerances. Compliance and toxicity with the protocol was assessed by audit of delivered radiotherapy dose, treatment interruptions, inpatient admissions and weight loss during radiotherapy. RESULTS: The 20 audited patients were appropriately selected on the basis of eligibility criteria of Intergroup 0116 protocol. There was only one minor variation of radiotherapy target volume coverage resulting from marginal coverage of the porta hepatis region. Adherence to the protocol was satisfactory, with 19 patients completing the radiotherapy protocol as planned and only one major variation in treatment delivery resulting from gastrointestinal toxicity. One major and one minor variation in normal tissue-dose constraints occurred on the heart and spinal cord, respectively. Compliance with treatment delivery was good, with only one patient failing to complete the prescribed radiotherapy dose owing to toxicity, although seven patients required treatment interruption. CONCLUSION: This audit showed good compliance with radiotherapy design and delivery. A formal medical quality assurance audit may provide a useful tool to assess complex new protocols introduced into routine departmental practice.

Hiding in the bunker: Challenges for a radiation oncology department operating in the Severe Acute Respiratory Syndrome outbreak.

In February 2003, one woman returned from Hong Kong to Singapore with a previously undescribed atypical pneumonia. Two months later, Singapore is facing its greatest ever threat to its population's health and the country's economy. The government has taken strong action to break the chain of infection of Severe Acute Respiratory Syndrome (SARS). As a radiation oncology department in Singapore, we have faced challenges in keeping staff and patients safe while continuing to provide a service to our patients. In this article, we outline the measures taken to curb SARS in Singapore and discuss the implications for Australasian radiation oncology departments.

The rate of breast-conserving surgery in early breast cancer: an audit of surgical practice at St Vincent's campus, NSW in 1990 and 1994.

An audit was undertaken to document the use of breast-conserving surgery (BCS) in the management of early breast cancer (EBC) at St Vincent's campus during two time periods, the calendar years 1990 and 1994. The medical records of all women diagnosed with a new primary breast cancer at St Vincent's Public and Private Hospitals initially treated during 1990 and 1994 were reviewed to document patient, tumour and treatment characteristics. Comparisons were made with data on BCS in EBC from the Australian medical literature. A total of 228 patients was managed with a definitive surgical procedure in the years 1990 and 1994. There were no major differences in the manner of presentation, the tumour subtypes or the treatment techniques between the two years. There was an apparent increase in the number of tumours < 2 cm managed in 1994 but no major difference in the use of BCS. The BCS rates for the two years were 33 and 36%, respectively. There were wide variations in the rate of BCS between surgeons, and for the same surgeon, between the two calendar years. These data from a major teaching hospital serving a largely non-mammographically screened population would suggest that BCS rates for EBC are lower than expected. The data on BCS rates for EBC in Australia are limited and the optimal rate of BCS in current practice is unknown.