Fatigue and radiotherapy: (B) experience in patients 9 months following treatment.

Little is known regarding the prevalence and course of fatigue in cancer patients after treatment has ended and no recurrence found. The present study examines fatigue in disease-free cancer patients after being treated with radiotherapy (n = 154). The following questions are addressed. First, how do patients describe their fatigue 9 months after radiotherapy and is this different from fatigue in a nonselective sample from the general population (n = 139)? Secondly, to what degree is fatigue in patients associated with sociodemographic, medical, physical and psychological factors? Finally, is it possible to predict which patients will suffer from fatigue 9 months after radiotherapy? Results indicated that fatigue in disease-free cancer patients did not differ significantly from fatigue in the general population. However, for 34% of the patients, fatigue following treatment was worse than anticipated, 39% listed fatigue as one of the three symptoms causing them most distress, 26% of patients worried about their fatigue and patients' overall quality of life was negatively related to fatigue (r = -0.46). Fatigue in disease-free patients was significantly associated with: gender, physical distress, pain rating, sleep quality, functional disability, psychological distress and depression, but not with medical (diagnosis, prognosis, co-morbidity) or treatment-related (target area, total radiation dose, fractionation) variables. The degree of fatigue, functional disability and pain before radiotherapy were the best predictors of fatigue at 9-month follow-up, explaining 30%, 3% and 4% of the variance respectively. These findings are in line with the associations found with fatigue during treatment as reported in the preceding paper in this issue. The significant associations between fatigue and both psychological and physical variables demonstrate the complex aetiology of this symptom in patients and point out the necessity of a multidisciplinary approach for its treatment.

Feasibility of escalating daily doses of cisplatin in combination with accelerated radiotherapy in non-small cell lung cancer.

The aim of this study was to determine whether it is feasible to reduce the overall treatment time from 7 to 4 weeks in patients with non-small cell lung cancer (NSCLC) receiving radiotherapy with cisplatin. This follows an EORTC phase III randomised trial (08844) in which cisplatin given before each radiation dose resulted in improved local control and survival, but which had a relatively long treatment period of 7 weeks [Schaake-Koning et al., N Engl J Med 1992, 326, 524-530]. 38 patients with confirmed NSCLC (2 stage I, 1 stage II, 18 stage IIIA, 17 stage IIIB) received a total tumour dose of 55 Gy/20 fractions/26 days, from January 1992 to March 1994. Daily fractions of 2 Gy (5 times/week) were given to the macroscopic tumour and the non-involved adjacent lymph node areas. During the same session, a dose of 0.75 Gy was given to the macroscopic tumour (simultaneous boost). Cisplatin 6 mg/m2 was administered 1-2 h before each fraction, in an escalating total dose, during week 1 in 3 patients, during weeks 1 and 2 in 6 patients, during weeks 1, 2 and 3 in 5 patients and during the whole treatment in 24 patients. 38 patients were evaluable for acute side-effects (WHO). Maximal therapy-related toxicity (WHO) was grade 3 (nausea/vomiting in 2 patients, oesophagitis in 3 patients, dyspnoea in 3 patients, cough in 1 patient). Late side-effects were evaluated in 34 patients. There was grade 2 oesophagitis in 2 patients; grade 3 toxicity in 8 patients (tiredness in 3 patients, dyspnoea in 3 patients, oesophagitis in 2 patients); grade 4 toxicity in 4 patients (dyspnoea in 3 patients, cough in 1 patient). Pulmonary fibrosis grade 3 occurred in 4 and grade 4 in 6 patients. One patient developed a severe (grade 3) radiation pneumonitis. The low incidence of acute and late side-effects with this treatment, combining daily administration of 6 mg cisplatin with radical radiotherapy using a simultaneous boost technique, indicates that escalation of the radiation dose seems feasible.

Feasibility of curative radiotherapy with a concomitant boost technique in 33 patients with non-small cell lung cancer (NSCLC)

Thirty-three patients with an inoperable NSCLC were treated with a dose of 60 Gy/20 fractions/25 days, using a concomitant boost technique. A dose of 40 Gy/2 Gy/25 days was given to the tumor area and a part (15 patients) or the whole (18 patients) mediastinum. During each session a simultaneous boost to the tumor of 1 Gy was administered. Moderate acute oesophageal toxicity was observed in 7/33 patients (22%). One out of 33 patients developed serious late oesophageal toxicity. A correlation between the oesophageal toxicity, absorbed oesophageal dose of irradiation and length of the elective field was observed. Five out of 33 patients developed subacute radiation pneumonitis grade 2 or 3. In selected patients with inoperable NSCLC radiotherapy, with a dose of 60 Gy/20 fractions/25 days, using a concomitant technique is feasible.

Fatigue in cancer patients.

In this paper an overview is presented on what is currently known of fatigue in cancer. Fatigue is considered to be a multi-dimensional concept, that should be measured as such. However, fatigue has been assessed mostly by single items in general symptom checklists. The few specific instruments that have been used in cancer patient populations are discussed. The majority of cancer patients, about 70%, report feelings of fatigue during radio- or chemotherapy. Follow-up results show that, at least for some diagnoses, patients remain fatigued long after treatment has ended. Somatic and psychological mechanisms that have been proposed to explain fatigue are discussed. It is argued that the significance of the results obtained on fatigue as a symptom in cancer depends on comparison with other patient and non-patient populations. Also the occurrence of a response-shift has to be considered, leading to under reporting of fatigue. Finally, possible interventions to decrease feelings of fatigue are presented.

Feasibility of transposition of the ovaries in the surgical and radiotherapeutical treatment of cervical cancer.

Ovaries are seldom subject to metastases and therefore their preservation is possible in radical cervical cancer surgery. However, with postoperative radiotherapy they cannot be preserved unless they are placed outside the radiation field. The practicality of this transposition was analysed in a series of 126 patients with cervical cancer. The ovaries were transposed intraperitoneally in a lateral and cranial direction in 44 of the 64 women under the age of 50 years. In 16 of these 44 women, only one ovary could be preserved and transposed. A critical analysis was performed of the ovaries' new location by plotting their position, marked by 2 clips each, in a single pelvis. In 68% of the women at least one ovary was placed outside the radiation field. However, because of scattered radiation, i.e. 5% of the total radiation dose at a distance of 4 cm outside the radiation field, a substantial loss of ovarian function may occur. In 32% of the women at least one ovary received less than this 5%. Optimal transposition may be achieved after extension of the abdominal incision. However, this will be unnecessary in most cases, since postoperative radiotherapy will be indicated in only approximately 15% of the women.

Radiotherapy with multiple fractions per day in pancreatic and bile duct cancer.

Twenty patients with pancreatic and bile duct cancer have been treated with external radiotherapy with multiple fractions per day (MFD). All patients had localized disease only. Sixteen patients have been treated with a split-course technique, to a dose of 60 to 70 Gy in 7-8 weeks, four patients had a continuous series of 44 Gy in 19 days. The mean survival was 7.9 months for patients with a pancreatic cancer. Four out of nine patients with pancreatic cancer in whom the tumour was evaluable showed a tumour regression, one out of nine reached a partial remission. The mean survival in the responders was 9.5 months. All patients with pancreatic cancer died of their tumour. Four out of eight patients with bile duct cancer died of their tumour, the mean survival was 10 months. Four patients with bile duct cancer are still alive (10+, 10+, 10+, 11+ months). No serious acute toxicity was seen. Six patients showed gastrointestinal toxicity at 1.5 to 9 months after the end of treatment. All of them could be treated in a conservative way. From the results obtained in this feasibility study, radiotherapy with MFD in pancreatic and bile duct cancer appears to achieve similar tumour response as conventionally fractionated radiotherapy and the observed toxicity of MFD can be considered as acceptable. MFD might be a more appropriate treatment scheme for combination with chemotherapy and radiosensitizers.

Primary non-Hodgkin's lymphoma of the central nervous system. Results of radiotherapy in 15 cases.

Primary non-Hodgkin's lymphoma (NHL) of the central nervous system is a rare disease. The number of cases reported in the literature does not exceed 200. The current series comprises 15 cases of primary NHL of the CNS. In 12 cases material for pathology was obtained at surgery. In the other three cases the diagnosis was established by cytologic examination of the cerebrospinal fluid (CSF). The type of lymphoma was predominantly the diffuse lymphocytic type. All the patients received irradiation on the whole brain by means of two opposite lateral fields. The administered total doses were 40 Gy in four weeks in ten cases, 50 to 60 Gy in 5 to 6 weeks in four cases and 30 Gy in three weeks in one case. All but three patients are dead although initially a good tumor response was obtained as confirmed in most of the cases by CT scan. The mean survival of the dead patients was 14.5 months. No relationship was found between the administered dose and the relapse-free time. In six cases (40%) evidence of seeding was observed. Because of the poor results obtained with irradiation either of only the tumor bearing area or whole brain and because of the high risk of seeding through the CSF, the irradiation of the entire CNS is recommended in patients with primary NHL of the brain.