Breast Cancer: A Lifestyle Medicine Approach.

Breast cancer is the most common female cancer diagnosis in the United States (excluding skin cancers), and the second leading cause of female cancer death. This article highlights the role that lifestyle plays in primary breast cancer prevention, breast cancer treatment, and tertiary breast cancer prevention. Current data regarding the benefits of a predominantly plant-based diet in combination with physical activity and maintenance of a healthy body weight will be reviewed. The evidenced-based patient-focused recommendations developed by the World Cancer Research Fund/American Institute for Cancer Research will be discussed in the context of an overall lifestyle strategy. It is our hope that this publication empowers clinicians to provide patients with personalized cancer-protective lifestyle prescriptions.

Breast Reconstruction and Radiation Therapy.

PURPOSE: The optimal approach to the integration of postmastectomy reconstruction and radiation therapy is not well-established. This review will summarize current literature pertaining to the most common types of reconstruction in the setting of postmastectomy radiation therapy (PMRT). DATA SOURCES: Literature from PubMed was reviewed from 2000 to 2016. STUDY SELECTION: Studies were selected with relevance to "postmastectomy breast reconstruction," "breast reconstruction," and "breast reconstructive methods and PMRT." Surgical outcomes, patient satisfaction, and cost-effectiveness were examined. DATA EXTRACTION: Data from publications was extracted, summarized, and converted to a table. RESULTS OF DATA SYNTHESIS: Implant-based techniques are on the rise, in the setting of PMRT. Implant-based methods are more affordable in the short term and result in immediate breast-mound formation compared to autologous methods. When compared to implant-based reconstruction with PMRT, autologous reconstruction with PMRT results in better quality of life (QoL) and sensory recovery as well as fewer complications and failures. Among autologous flaps, deep inferior epigastric perforator flaps are considered superior to transverse rectus abdominal muscle (TRAM) pedicled flaps and may be more suitable for PMRT. Latissimus dorsi and muscle-sparing free TRAM flaps are also viable options. In delayed autologous, which may be advantageous for high-risk patients, the optimal timing to delay surgery after radiation therapy is unknown. Reconstruction with a 2-stage tissue expander-implant technique offers good to excellent cosmetic outcomes in the setting of PMRT, although there may be complications in this 2-stage process. CONCLUSION: Surgical, cosmetic, quality of life, and life expectancy must be taken into account when selecting the way to integrate breast reconstruction and PMRT.

Personalizing Radiation Treatment Delivery in the Management of Breast Cancer.

Long-term data establishes the efficacy of radiotherapy in the adjuvant management of breast cancer. New dose and fractionation schemas have evolved and are available, each with unique risks and rewards. Current efforts are ongoing to tailor radiotherapy to the unique biology of breast cancer. In this review, we discuss our efforts to personalize radiotherapy dosing using genomic data and the implications for future clinical trials. We also explore immune mechanisms that may contribute to a tumor's unique radiation sensitivity or resistance.

Histologic heterogeneity of triple negative breast cancer: A National Cancer Centre Database analysis.

BACKGROUND: Triple negative breast cancer (TNBC) is an aggressive disease, but recent studies have identified heterogeneity in patient outcomes. However, the utility of histologic subtyping in TNBC has not yet been well-characterised. This study utilises data from the National Cancer Center Database (NCDB) to complete the largest series to date investigating the prognostic importance of histology within TNBC. METHODS: A total of 729,920 patients (pts) with invasive ductal carcinoma (IDC), metaplastic breast carcinoma (MBC), medullary breast carcinoma (MedBC), adenoid cystic carcinoma (ACC), invasive lobular carcinoma (ILC) or apocrine breast carcinoma (ABC) treated between 2004 and 2012 were identified in the NCDB. Of these, 89,222 pts with TNBC that received surgery were analysed. Kaplan-Meier analysis, log-rank testing and multivariate Cox proportional hazards regression were utilised with overall survival (OS) as the primary outcome. RESULTS: MBC (74.1%), MedBC (60.6%), ACC (75.7%), ABC (50.1%) and ILC (1.8%) had significantly different proportions of triple negativity when compared to IDC (14.0%, p < 0.001). TNBC predicted an inferior OS in IDC (p < 0.001) and ILC (p < 0.001). Lumpectomy and radiation (RT) were more common in MedBC (51.7%) and ACC (51.5%) and less common in MBC (33.1%) and ILC (25.4%), when compared to IDC (42.5%, p < 0.001). TNBC patients with MBC (HR 1.39, p < 0.001), MedBC (HR 0.42, p < 0.001) and ACC (HR 0.32, p = 0.003) differed significantly in OS when compared to IDC. CONCLUSION(S): Our results indicate that histologic heterogeneity in TNBC significantly informs patient outcomes and thus, has the potential to aid in the development of optimum personalised treatments.

Frequency of whole breast radiation therapy after intraoperative radiation therapy due to criteria identified by lumpectomy.

PURPOSE: For selected early breast cancers, intraoperative radiation therapy (IORT) at the time of lumpectomy can be an efficient alternative to fractionated whole breast radiation therapy (WBRT). However, some patients are later recommended WBRT after IORT due to surgical pathologic findings. To understand risk factor identification rates triggering WBRT recommendation, we analyzed adverse prognostic features based on multiple international criteria for suitability for accelerated partial breast irradiation. METHODS AND MATERIALS: We performed a single-institution retrospective review of all 200 nonrecurrent invasive breast carcinomas that received IORT in 20 Gy to the tumor cavity using a 50 kV photon applicator between January 2011 and December 2015. IORT eligibility was based on the 2009 accelerated partial breast irradiation Consensus Statement from the American Society for Radiation Oncology (ASTRO). IORT was offered as the sole radiation modality to patients meeting 0-1 "cautionary" and no "unsuitable" criteria before lumpectomy. WBRT was recommended after IORT when 2+ cautionary and/or 1+ unsuitable criteria were met after accounting for resection pathology. We recalculated WBRT recommendation rates using initial and reresection margins for ASTRO consensus, Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology recommendations, and TARGeted Intraoperative radioTherapy vs. Postoperative Radiotherapy trial "prepathology" stratum protocol. RESULTS: Depending on the selection criteria chosen, rates of WBRT recommendation can vary from 4.5% to 33%. CONCLUSIONS: WBRT recommendation rates of 30-33% after lumpectomy and IORT are observed when the WBRT indication is a single ASTRO cautionary/unsuitable, Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology intermediate/high-risk criterion, or TARGeted Intraoperative radioTherapy vs. postoperative radiotherapy trial protocol recommendation. Alternatively, allowing for re-excision to clear margins and accepting one ASTRO cautionary factor lowered the rate of WBRT recommendation to 9.5%.

Dynamic contrast-enhanced MRI for automatic detection of foci of residual or recurrent disease after prostatectomy.

PURPOSE: This study aimed to develop an automated procedure for identifying suspicious foci of residual/recurrent disease in the prostate bed using dynamic contrast-enhanced-MRI (DCE-MRI) in prostate cancer patients after prostatectomy. MATERIALS AND METHODS: Data of 22 patients presenting for salvage radiotherapy (RT) with an identified gross tumor volume (GTV) in the prostate bed were analyzed retrospectively. An unsupervised pattern recognition method was used to analyze DCE-MRI curves from the prostate bed. Data were represented as a product of a number of signal-vs.-time patterns and their weights. The temporal pattern, characterized by fast wash-in and gradual wash-out, was considered the "tumor" pattern. The corresponding weights were thresholded based on the number (1, 1.5, 2, 2.5) of standard deviations away from the mean, denoted as DCE1.0, …, DCE2.5, and displayed on the T2-weighted MRI. The resultant four volumes were compared with the GTV and maximum pre-RT prostate-specific antigen (PSA) level. Pharmacokinetic modeling was also carried out. RESULTS: Principal component analysis determined 2-4 significant patterns in patients' DCE-MRI. Analysis and display of the identified suspicious foci was performed in commercial software (MIM Corporation, Cleveland, OH, USA). In general, DCE1.0/DCE1.5 highlighted larger areas than GTV. DCE2.0 and GTV were significantly correlated (r = 0.60, p < 0.05). DCE2.0/DCA2.5 were also significantly correlated with PSA (r = 0.52, 0.67, p < 0.05). Ktrans for DCE2.5 was statistically higher than the GTV's Ktrans (p < 0.05), indicating that the automatic volume better captures areas of malignancy. CONCLUSION: A software tool was developed for identification and visualization of the suspicious foci in DCE-MRI from post-prostatectomy patients and was integrated into the treatment planning system.

Close to Home: Employment Outcomes for Recent Radiation Oncology Graduates.

PURPOSE: To characterize the practice type and location of radiation oncology (RO) residents graduating in 2013. METHODS AND MATERIALS: Graduates completing RO residency in 2013 were identified, and for each, postgraduate practice setting (academic vs private practice) and location were identified. Characteristics of the graduates, including details regarding their institutions of medical school and residency education, were collected and analyzed. RESULTS: Data were obtained from 146 of the 154 RO graduates from the class of 2013. Employment data were available for 142 graduates. Approximately one-third of graduates were employed in the same state as residency (36.6%), approximately two-thirds (62.0%) in the same region as residency, and nearly three-fourths (73.9%) in the same region as medical school or residency completion. Of the 66 graduates (46.5%) working in academics, 40.9% were at the same institution where they completed residency. Most trainees (82.4%) attended medical schools with RO residency programs. CONCLUSIONS: Although personal factors may attract students to train in a particular area, the location of medical school and residency experiences may influence RO graduate practice location choice. Trends in the geographic distribution of graduating radiation oncologists can help identify and better understand disparities in access to RO care. Steps to improve access to RO care may include interventions at the medical student or resident level, such as targeting students at medical schools without associated residency programs and greater resident exposure to underserved areas.

Feasibility and Initial Dosimetric Findings for a Randomized Trial Using Dose-Painted Multiparametric Magnetic Resonance Imaging-Defined Targets in Prostate Cancer.

PURPOSE: To compare dosimetric characteristics with multiparametric magnetic resonance imaging-identified imaging tumor volume (gross tumor volume, GTV), prostate clinical target volume and planning target volume, and organs at risk (OARs) for 2 treatment techniques representing 2 arms of an institutional phase 3 randomized trial of hypofractionated external beam image guided highly targeted radiation therapy. METHODS AND MATERIALS: Group 1 (n=20) patients were treated before the trial inception with the standard dose prescription. Each patient had an additional treatment plan generated per the experimental arm. A total of 40 treatment plans were compared (20 plans for each technique). Group 2 (n=15) consists of patients currently accrued to the hypofractionated external beam image guided highly targeted radiation therapy trial. Plans were created as per the treatment arm, with additional plans for 5 of the group 2 experimental arm with a 3-mm expansion in the imaging GTV. RESULTS: For all plans in both patient groups, planning target volume coverage ranged from 95% to 100%; GTV coverage of 89.3 Gy for the experimental treatment plans ranged from 95.2% to 99.8%. For both groups 1 and 2, the percent volumes of rectum/anus and bladder receiving 40 Gy, 65 Gy, and 80 Gy were smaller in the experimental plans than in the standard plans. The percent volume at 1 Gy per fraction and 1.625 Gy per fraction were compared between the standard and the experimental arms, and these were found to be equivalent. CONCLUSIONS: The dose per fraction to the OARs can be made equal even when giving a large simultaneous integrated boost to the GTV. The data suggest that a GTV margin may be added without significant dose effects on the OARs.

Leptomeningeal failure of retinoblastoma.

Leptomeningeal (LM) failure of retinoblastoma (Rb) has not previously been reported. Upon review of our institutional experience of external beam radiotherapy (EBRT) for Rb, we found three LM failures. We sought to better define the clinical parameters of this type of recurrence. All children with LM failure had Reese-Ellsworth stage Vb eyes. Otherwise, no variables were significantly associated with LM failure. We theorize that this phenomenon is a function of the late-stage eyes for which EBRT is being reserved in the modern era.

The modern role of radiation therapy in treating advanced-stage retinoblastoma: long-term outcomes and racial differences.

PURPOSE/OBJECTIVE(S): To evaluate the effects of various patient characteristics and radiation therapy treatment variables on outcomes in advanced-stage retinoblastoma. METHODS AND MATERIALS: This was a retrospective review of 41 eyes of 30 patients treated with external beam radiation therapy between June 1, 1992, and March 31, 2012, with a median follow-up time of 133 months (11 years). Outcome measures included overall survival, progression-free survival, local control, eye preservation rate, and toxicity. RESULTS: Over 90% of the eyes were stage V. Definitive external beam radiation therapy (EBRT) was delivered in 43.9% of eyes, adjuvant EBRT in 22% of eyes, and second-line/salvage EBRT in 34.1% of eyes. A relative lens sparing (RLS) technique was used in 68.3% of eyes and modified lens sparing (MLS) in 24.4% of eyes. Three eyes were treated with other techniques. Doses ≥45 Gy were used in 68.3% of eyes. Chemotherapy was a component of treatment in 53.7% of eyes. The 10-year overall survival was 87.7%, progression-free survival was 80.5%, and local control was 87.8%. White patients had significantly better overall survival than did African-American patients in univariate analysis (hazard ratio 0.09; 95% confidence interval 0.01-0.84; P=.035). Toxicity was seen in 68.3% of eyes, including 24.3% with isolated acute dermatitis. CONCLUSIONS: External beam radiation therapy continues to be an effective treatment modality for advanced retinoblastoma, achieving excellent long-term local control and survival with low rates of treatment-related toxicity and secondary malignancy.