The Use of Hormone Therapy Alone Versus Hormone Therapy and Radiation Therapy for Breast Cancer in Elderly Women: A Population-Based Study.

PURPOSE: The Cancer and Leukemia Group B (CALGB) 9343 trial randomized elderly women with estrogen receptor-positive, stage 1 breast cancer to receive either hormone therapy (HT) or HT and radiation therapy (HT-RT) after lumpectomy and showed no difference in survival. After this publication, a practice guideline made HT alone a standard treatment option in British Columbia. The subsequent population-based pattern of practice was studied. METHODS AND MATERIALS: All women aged 70 to 79 years, referred after lumpectomy from 1999 to 2009, with stage 1, estrogen receptor-positive breast cancer were identified. The use of adjuvant HT or HT-RT was evaluated in 2 eras: before (1999-2003) and after (2005-2009) the CALGB publication. The proportion receiving each treatment in these eras was determined. Kaplan-Meier analyses with Cox regression were used for survival endpoints. The Fine and Gray method was used with non-breast cancer death as a competing risk for event-free survival. The Charlson score was used to quantify comorbidity. Adherence was defined as dispensation of 80% of prescribed HT. RESULTS: HT-RT was used in 91% of patients before (n=319) and 89% of patients after (n=403) the CALGB publication (P=.4). In the HT-alone group, the rate of HT adherence was 75% at 1 year and 55% at 4 years. The 10-year locoregional recurrence-free survival rate was 98% with HT-RT and 90% with HT alone (P=.01), whereas the 10-year breast cancer-specific survival rate was 96% with HT-RT and 95% with HT alone (P=.2). Patients with grade 3 histology or lymphovascular invasion were more likely to have low event-free survival. On multivariate analysis, treatment type did not predict overall survival (P=.3). CONCLUSIONS: Our patient outcomes closely matched those of the CALGB trial, suggesting that its results are generalizable to a population of elderly breast cancer patients with typical HT adherence. The CALGB trial results, as well as the resulting practice guideline, did not change the use of adjuvant HT-RT in our population-based cancer program.

Time for full inclusion of community actions in the response to AIDS.

INTRODUCTION: Community action, including activism, advocacy and service delivery, has been crucially important in the global response to AIDS from the beginning of the epidemic and remains one of its defining features. This indispensable contribution has been increasingly acknowledged in strategic planning documents from UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria, the World Bank, the World Health Organization and other organizations. A growing body of literature demonstrates that community-based services can have measurable impact, serve populations that are not accessing public health services and reach people at scale. DISCUSSION: Recognition of the powerful potential role of community has not translated into full incorporation of community responses in programme planning or financing, and communities are still not fully understood as true assets within overall systems for health. The diverse community contributions remain seriously underappreciated and under-resourced in national responses. CONCLUSIONS: It is time for a paradigm shift in how we think about, plan and finance community-based responses to HIV in order to achieve improved impact and move toward ending the epidemic. We must utilize the unique strengths of communities in creating resilient and sustainable systems for health. There are several priorities for immediate attention, including agreement on the need to nurture truly comprehensive systems for health that include public, private and community activities; re-examination of donor and national funding processes to ensure community is strategically included; improvement of data systems to capture the full spectrum of health services; and improved accountability frameworks for overall health systems. Health planning and financing approaches run by governments and donors should institutionalize consideration of how public, community and private health services can strategically contribute to meeting service needs and accomplishing public health targets.

Identification of patients at very low risk of local recurrence after breast-conserving surgery.

PURPOSE: To identify clinical and pathological factors that identify groups of women with stage I breast cancer with a 5-year risk of local recurrence (LR) ≤1.5% after breast-conserving therapy (BCS) plus whole-breast radiation therapy (RT). METHODS AND MATERIALS: Study subjects were 5974 patients ≥50 years of age whose cancer was diagnosed between 1989 and 2006, and were referred with pT1 pN0 invasive breast cancer treated with BCS and RT. Cases of 5- and 10-year LR were examined using Kaplan-Meier methods. Recursive partitioning analysis was performed in patients treated with and without endocrine therapy to identify combinations of factors associated with a 5-year LR risk ≤1.5%. RESULTS: The median follow-up was 8.61 years. Median age was 63 years of age (range, 50 to 91). Overall 5-year LR was 1.5% (95% confidence interval [CI], 1.2%-1.9%) and 10-year LR was 3.4% (95% CI, 2.8%-4.0%). Of 2830 patients treated with endocrine therapy, patient subsets identified with 5-year LR ≤1.5% included patients with grade 1 histology (n=1038; LR, 0.2%; 95% CI, 0%-0.5%) or grade 2 histology plus ≥60 years of age (n=843; LR, 0.5%; 95% CI, 0%-1.0%). Ten-year LR for these groups were 0.8% (95% CI, 0.1%-1.6%) and 0.9% (95% CI, 0.2%-1.6%), respectively. Of 3144 patients treated without endocrine therapy, patients with grade 1 histology plus clear margins had 5-year LR ≤1.5% (n=821; LR, 0.6%; 95% CI, 0.1%-1.2%). Ten-year LR for this group was 2.2% (95% CI, 1.0%-3.4%). CONCLUSIONS: Histologic grade, age, margin status, and use of endocrine therapy identified 45% of a population-based cohort of female patients over age 50 with stage I breast cancer with a 5-year LR risk ≤1.5% after BCS plus RT. Prospective study is needed to evaluate the safety of omitting RT in patients with such a low risk of LR.

Local recurrence in women with stage I breast cancer: declining rates over time in a large, population-based cohort.

PURPOSE: To evaluate whether local recurrence (LR) risk has changed over time among women with stage I breast cancer treated with breast-conserving therapy. METHODS AND MATERIALS: Subjects were 5974 women aged ≥50 years diagnosis with pT1N0 breast cancer from 1989 to 2006, treated with breast-conserving surgery and radiation therapy. Clinicopathologic characteristics, treatment, and LR outcomes were compared among 4 cohorts stratified by year of diagnosis: 1989 to 1993 (n=1077), 1994 to 1998 (n=1633), 1999 to 2002 (n=1622), and 2003 to 2006 (n=1642). Multivariable analysis was performed, with year of diagnosis as a continuous variable. RESULTS: Median follow-up time was 8.6 years. Among patients diagnosed in 1989 to 1993, 1994 to 1998, 1999 to 2002, and 2003 to 2006, the proportions of grade 1 tumors increased (16% vs 29% vs 40% vs 39%, respectively, P<.001). Surgical margin clearance rates increased from 82% to 93% to 95% and 88%, respectively (P<.001). Over time, the proportions of unknown estrogen receptor (ER) status decreased (29% vs 10% vs 1.2% vs 0.5%, respectively, P<.001), whereas ER-positive tumors increased (56% vs 77% vs 86% vs 86%, respectively, P<.001). Hormone therapy use increased (23% vs 23% vs 62% vs 73%, respectively, P<.001), and chemotherapy use increased (2% vs 5% vs 10% vs 13%, respectively, P<.001). The 5-year cumulative incidence rates of LR over the 4 time periods were 2.8% vs 1.7% vs 0.9% vs 0.8%, respectively (Gray's test, P<.001). On competing risk multivariable analysis, year of diagnosis was significantly associated with decreased LR (hazard ratio, 0.92 per year, P=.0003). Relative to grade 1 histology, grades 2, 3, and unknown were associated with increased LR. Hormone therapy use was associated with reduced LR. CONCLUSION: Significant changes in the multimodality management of stage I breast cancer have occurred over the past 2 decades. More favorable-risk tumors were diagnosed, and margin clearance and systemic therapy use increased. These changes contributed to the observed declining LR rates among patients treated with breast-conserving therapy.

Survivors of breast cancer: patient perspectives on survivorship care planning.

INTRODUCTION: Survivors of breast cancer (SBC) constitute the largest population of cancer survivors. Needs for survivorship care may vary according to life stage and urban/rural place of residence. This study was conducted to better understand patient preferences for survivorship care plans (SCP). METHODS: Patients were identified through cancer agency electronic records and invited to participate by mail. Sessions were stratified by age and rural/urban place of residence. Participants were asked about preferences for content and format of SCP. Focus groups were conducted using a semi-structured format with interviews being taped, transcribed, cross-checked for accuracy, and analyzed independently, using constant comparative methods. RESULTS: Preferred SCP key elements included treatment summary, information on nutrition/exercise, expected side effects, signs and symptoms of recurrence, recommended follow-up schedule, information sent to primary care physician, and updates on changes. SBC emphasized preference for individualized content depending upon physical and psychosocial effects. No difference was observed between preferred SCP content among patients residing in urban/rural areas. Rural participants preferred electronic formats for ongoing information bulletins and communication with health care providers. DISCUSSION/CONCLUSIONS: SBC from all age groups identify common preferences for key SCP elements with individualized content reflecting the wide variation observed among physical and psychosocial effects of breast cancer. Patterns of key psychological, social, and physical effects observed at different life stages may help SCP customization. IMPLICATIONS FOR CANCER SURVIVORS: Results provide direction for designing key content and format of SCP and also provide information about elements of care planning that should be customized to individual patient needs.

Quantification of masticatory muscle atrophy after high-dose radiotherapy.

PURPOSE: To determine the rate of change in the cross-sectional area of the masticatory muscles after radiotherapy. METHODS AND MATERIALS: Eligible patients had undergone unilateral radiotherapy between 1993 and 2000 and had a baseline CT scan, a comparable follow-up CT scan a minimum of 1 year later, and no recurrence of cancer. Fourteen patients had their CT series scanned into digital image files. Two anatomically selected CT slices were bisected by the midline sagittal plane and stored under randomly assigned file names. Three observers measured the masseter and medial pterygoid areas on two occasions. RESULTS: The intraobserver reliability of the muscle area measurements was 96.3% for the masseter and 97.1% for the medial pterygoid. The interobserver reliability of the muscle area measurements was 96.7% for the masseter and 96.3% for the medial pterygoid. On the treated side, the muscles received a median dose of 56 Gy (range 47-63) in 2.0-0.4-Gy fractions. With a median follow-up of 2.9 years (range 1-7.6), mixed-effects regression analysis demonstrated a significant area of reduction of -0.17 cm(2)/y (p = 0.0001) for the masseter and -0.13 cm(2)/y (p = 0.001) for the medial pterygoid. The controlled rate of muscle atrophy was 3.9%/y (95% confidence interval 1.4-6.4) for the masseter and 2.3%/y (95% confidence interval -0.6 to 5.1) for the medial pterygoid. CONCLUSION: Standard therapeutic radiation doses appear to cause significant masticatory muscle atrophy.

Ferruginous foreign body: a clinical simulant of melanoma with distinctive histologic features.

A 53-year-old man reported a pigmented lesion on his forearm that he had first become aware of approximately 30 years previously. More recently, the lesion had become symptomatic and was excised because of concern of melanoma; however, during tissue processing, an embedded metallic object was found. Histologic examination of the tissue surrounding the site of the metallic object confirmed an inner zone of iron deposition with a distinctive histologic appearance indistinguishable from rust, associated with a foreign body reaction. Surrounding this was an outer zone of siderophages with the more usual histologic appearance. Chemical analysis of the foreign body confirmed its ferruginous nature. On subsequent questioning, the patient informed us that he had worked with heavy equipment in a mine at the time that he had first noticed the lesion.

What do parents of children with learning disabilities, ADHD, and related disorders deal with?

Children with learning disabilities, attention deficit/hyperactivity disorder (ADHD), and related disorders puzzle parents because of their many abilities and disabilities. It can also be difficult to understand how much of their behavior is the nature of the condition and how much is oppositional. It is all too easy for parents to "catch" a child's feelings of inadequacy and then feel bad as a parent. Parenting approaches that include clear, concise instructions; structure without rigidity; nurturing a child's gifts and interests; and constant approval of positive behavior help parents feel better and help children feel safe. It takes time for both children and parents to embrace the concept that being different does not mean being inferior and, in fact, can be a good thing. Parents need to be nurtured and praised to help them nurture and praise their children. Most parents use almost every resource they have to help their children flourish, and still, they worry they are not doing a good enough job. Usually they are!