Unhealthy food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium): a detailed assessment.

INTRODUCTION: The supermarket food environment is a key setting for potential public health interventions. This study assessed food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium). METHODS: A sample of 55 supermarkets across five chains and 16 Flemish municipalities was selected in 2022, about 64% in the most deprived socioeconomic areas. Healthiness indicators related to food availability (ratio of cumulative linear shelf length for healthy versus unhealthy foods), prominence (proportion of unhealthy foods at check-outs and end-of-aisle endcaps), and promotion (food marketing on food packages) were measured. RESULTS: Overall, the average ratio of healthy/unhealthy foods in supermarkets in Flanders was 0.36, meaning that for every 10m of shelf length of unhealthy foods there was 3.6m of healthy foods. There was a large variation in ratio's across supermarket chains. Of all foods available, 97.5% were ultra-processed at the check outs, while 72.2% and 58.5% were ultra-processed at the front and back end-of-aisle end-caps, respectively. Confectionery and sweet biscuits were the food categories with on average the highest number of marketing messages on pack per 10m of shelf length. CONCLUSION: Supermarket in-store food environments in Flanders were found generally unhealthy, with those located in low income areas having unhealthier in-store food environments than supermarkets located in medium and high income areas. Despite commitments of all large supermarket chains in Flanders to promote and create healthier in-store food environments, our findings indicate that currently consumers are incentivized to buy unhealthy rather than healthy food products.

Upstream Determinants of Overweight and Obesity in Europe.

PURPOSE OF REVIEW: To review the upstream determinants of overweight and obesity in Europe, including food and built environments, and political, commercial, and socioeconomic determinants. RECENT FINDINGS: Overweight and obesity affect 60% of European adults, and one in three children, and are more common in individuals with low compared to high socioeconomic position (SEP). Individuals in low SEP groups are more exposed to unhealthy built and food environments, including higher exposure to unhealthy food marketing. Industries influencing the food system have much economic power, resulting in ignoring or silencing the role of ultra-processed foods and commercial practices in weight gain. Overall, effective policies to address overweight and obesity have been insufficiently implemented by governments. To accelerate implementation, strengthened political commitment is essential. Policies must also focus on the upstream, structural, and systemic drivers of overweight and obesity; be comprehensive; and target socioeconomic inequalities in diets and physical activity.

Physical and mental health of breast cancer patients and survivors before and during successive SARS-CoV-2-infection waves.

PURPOSE: During the first SARS-CoV-2-infection wave, a deterioration in emotional well-being and increased need for mental health care were observed among patients treated or being treated for breast cancer. In this follow-up study, we assessed patient-reported quality of life (QoL), physical functioning, and psychosocial well-being during the second SARS-CoV-2-infection wave in a large, representative cohort. METHODS: This longitudinal cohort study was conducted within the prospective, multicenter UMBRELLA breast cancer cohort. To assess patient-reported QoL, physical functioning and psychosocial well-being, COVID-19-specific surveys were completed by patients during the first and second SARS-CoV-2-infection waves (April and November 2020, respectively). An identical survey was completed by a comparable reference population during the second SARS-CoV-2-infection waves. All surveys included the validated EORTC-QLQ-C30/BR23, HADS and "De Jong-Gierveld Loneliness" questionnaires. Pre-COVID-19 EORTC-QLQ-C30/BR23 and HADS outcomes were available from UMBRELLA. Response rates were 69.3% (n = 1106/1595) during the first SARS-CoV-2-infection wave and 50.9% (n = 822/1614) during the second wave. A total of 696 patients responded during both SARS-CoV-2-infection waves and were included in the analysis comparing patient-reported outcomes (PROs) during the second SARS-CoV-2-infection wave to PROs during the first wave. Moreover, PROs reported by all patients during the second SARS-CoV-2-infection wave (n = 822) were compared to PROs of a similar non-cancer reference population (n = 241) and to their pre-COVID-19 PROs. RESULTS: Patient-reported QoL, physical functioning, and psychosocial well-being of patients treated or being treated for breast cancer remained stable or improved from the first to the second SARS-CoV-2-infection wave. The proportion of emotional loneliness reduced from 37.6 to 29.9% of patients. Compared to a similar non-cancer reference population, physical, emotional, and cognitive functioning, future perspectives and symptoms of dyspnea and insomnia were worse in patients treated or being treated for breast cancer during the second SARS-CoV-2-infection wave. PROs in the second wave were similar to pre-COVID-19 PROs. CONCLUSION: Although patients scored overall worse than individuals without breast cancer, QoL, physical functioning, and psychosocial well-being did not deteriorate between the first and second wave. During the second wave, PROs were similar to pre-COVID-19 values. Overall, current findings are cautiously reassuring for future mental health of patients treated or being treated for breast cancer.

Market concentration and the healthiness of packaged food and non-alcoholic beverage sales across the European single market.

OBJECTIVE: To assess the relationship between market concentration and diversity, as indicators of market structure, and the healthiness of food and beverage sales across Europe. DESIGN: Market share (MS) data per country were used to calculate market concentration, assessed by the four-firm concentration ratio and market diversity, and by the number of companies with ≥1 % MS and the number of companies uniquely present in one European country. The healthiness of food sales was assessed by applying the NOVA classification (level of processing). Simple and multiple linear regressions were performed to assess the relationship between market concentration, diversity and the healthiness of food and beverage sales. SETTING: The European single market. PARTICIPANTS: The twenty-seven European single market member states for which Euromonitor sales data were available at the most fine-grained Euromonitor packaged food and non-alcoholic beverage product subcategory level. RESULTS: Increased market concentration with a country and a product category fixed effect significantly predicted increased sales of ultra-processed packaged food products. There was insufficient data variability in the level of processing of non-alcoholic beverage product categories to formulate conclusions for non-alcoholic beverages. Increased market diversity in turn significantly predicted reduced country-level sales of ultra-processed products. CONCLUSIONS: The results indicated a relationship between market structure and the healthiness of packed food products sold on the European market. However, more research with detailed nutritional data is warranted to document and quantify this interaction.

Benchmarking the nutrition-related commitments and practices of major French food companies.

BACKGROUND: This study benchmarked and quantitatively assessed the transparency, specificity and comprehensiveness of nutrition-related commitments and related practices of the major companies within the French food industry. METHODS: To evaluate the nutrition-related commitments and practices across policy domains such as product reformulation, labelling, marketing, and accessibility, the 'Business Impact Assessment on Obesity and population-level nutrition' (BIA-Obesity) was applied. A total of 33 French food companies were selected using Euromonitor 2018 market share data, including major packaged food and non-alcoholic beverage manufacturers (N = 20), quick-service restaurants (N = 7), and supermarkets (N = 6). During 2019-2020 the publicly available commitments were collected for each company, scored according to the BIA-Obesity, and company representatives were provided with the opportunity to complete and verify the collected data. The following performance metrics were included to assess company practices: the median Nutri-Score of product portfolios, the proportion of products with Nutri-Score A or B, the percentage of products (not-)permitted to be marketed to children according to the World Health Organisation Europe nutrient profile model and the proportion of ultra-processed food products as determined by the NOVA-classification. In addition supermarket flyers were collected over a 6-months period to assess the healthiness of product promotions. Correlations between commitments and performance metrics were assessed applying the Spearman's rank correlation coefficient. RESULTS: Among the selected food companies, 13 companies verified and completed the publicly available data (response rate = 39%). Overall BIA-Obesity scores for company commitments varied between 2 and 74% with a median score of 28%. Scores for packaged food and non-alcoholic beverage manufacturers were higher than those for supermarkets and quick-service restaurants. The median proportion of foods with Nutri-Score A or B within product portfolios was 38% (range = 1-95%), while the median proportion of non-permitted products was 84% (range = 7-100%) and the median proportion of ultra-processed food products 63% (range = 5-100%). Stronger company commitments did not translate into better performance metrics. CONCLUSIONS: There is room for significant improvement of both company commitments and performance. Current food industry action does not meet recommended best practices. The French government is urged to regulate food industry practices to create healthier food environments.

Assessment of the Commitments and Performance of the European Food Industry to Improve Population Nutrition.

Objectives: Food companies could play an important role in improving population diets, but often escape accountability through unspecific commitments. This study evaluated nutrition-related commitments and estimated performance of the largest packaged food and non-alcoholic beverage manufacturers, supermarkets and quick-service restaurants (QSR) in Europe. Methods: To quantitatively assess companies' publicly available commitments in 2020, the "Business Impact Assessment on Obesity and Population Nutrition" was applied. The proportion of sales from ultra-processed and "unhealthy" food categories (product categories not-permitted to be marketed to children) and over time changes in the number of QSR transactions and QSR and supermarket outlets were calculated. Results: Company commitments fell short of best practice recommendations (median overall score of 21%, range: 1%-62%). Food and beverage companies generated 82% (15%-100%) and 58% (1%-100%) sales from ultra-processed and "unhealthy" products, respectively. The number of QSR outlets and transactions substantially increased in Europe since 2011, while QSR commitments to improve population nutrition remained limited. Conclusion: Whilst most companies made some nutrition-related commitments, they did not comply with best practice recommendations. A large proportion of sales was generated from ultra-processed/unhealthy products and QSR outlets increased. Government regulations are urgently needed.

Benchmarking the nutrition-related commitments and practices of major Belgian food companies.

BACKGROUND: To benchmark and quantitatively assess the transparency, specificity and comprehensiveness of nutrition-related commitments, as well as related practices of the largest Belgian food companies. METHODS: The 'Business Impact Assessment on Obesity and population-level nutrition' (BIA-Obesity) was applied to evaluate nutrition-related commitments and practices concerning product formulation, labelling, promotion and accessibility by the biggest Belgian food and non-alcoholic beverage manufacturers (n = 19), supermarkets (n = 5) and quick-service restaurants (n = 7). Publicly available commitments were collected and company representatives given the opportunity to verify and complete the information (2019-2020). Commitments were scored according to the BIA-Obesity. To assess company practices, the following indicators were calculated: median Nutri-Score of product portfolios, the proportion of products not-permitted to be marketed to children (using the World Health Organisation Regional Office for Europe nutrient profile model), the proportion of ultra-processed food products (using the NOVA-classification) and the proportion of products displaying Nutri-Score on the front-of-pack. Promotions in supermarket flyers were analysed over a one-year period and quick-service restaurant density around schools was calculated. Correlations between commitments and performance indicators were calculated applying the Spearman's rank correlation coefficient. RESULTS: Eighteen out of 31 companies participated (56%). Overall BIA-Obesity scores for commitments ranged from 2 to 75% (median = 35%) with notable variation across policy domains and food industries. The proportion of portfolios consisting of A and B Nutri-Score products ranged from 0 to 100% (median = 29%). The median proportion of products not-permitted to be marketed to children was 81% (range = 12%-100%) and the median proportion of ultra-processed foods was 75% (range = 2%-100%) across product portfolios. No significant correlations were observed between the strength of commitments and related performance indicators. CONCLUSION: Food industry actions do not meet recommended best practices. Performance indicators show large potential for improvement across policy domains and industries. Government regulations are urgently needed to improve food industry efforts and ensure that commitments translate into improved practices.

The impact of the COVID-19 pandemic on perceived access to health care and preferences for health care provision in individuals (being) treated for breast cancer.

PURPOSE: To evaluate perceived access to health care and preferences for health care provision among patients (being) treated for breast cancer during the COVID-19 pandemic. METHODS: Longitudinal study within the prospective, multicenter UMBRELLA cohort of patients (being) treated for breast cancer. All cohort participants enrolled in UMBRELLA between October 2013 and November 2020 were sent a COVID-19-specific survey during the first and second wave of the COVID-19 pandemic, i.e., April 2020 and November 2020, respectively. RESULTS: In total, 1106 (69.3%) and 822 (50.9%) cohort participants completed the survey in the first and second wave, respectively. The proportion of patients experiencing that their treatment or follow-up care was affected due to COVID-19 decreased from 28.4% (n = 198) in April 2020 to 14.8% (n = 103) in November 2020. Throughout the pandemic, one or more hospital consultations were postponed in 10.0% (n = 82) of all patients and changed into a teleconsultation in 23.1% (n = 190). The proportion of patients who experienced a higher threshold to contact their general practitioner due to COVID-19 decreased from 29.9% (n = 204) in the first wave to 20.8% (n = 145) in the second wave. In-person consultations remained most preferred in 35.2% (n = 289) of all patients. Nearly half of all patients (48.3%, n = 396) indicated that telehealth would be a useful alternative for in-person consultations in future. CONCLUSION: Perceived access to health care has improved substantially throughout the pandemic. Digital care is well received by patients (being) treated for breast cancer.

The nature of food promotions over one year in circulars from leading Belgian supermarket chains.

BACKGROUND: To examine the proportion of healthier and less healthy food promotions in circulars of major Belgian supermarket chains. METHODS: Food promotions were collected from all circulars over 1 year from the five largest Belgian supermarket chains. Foods promoted were classified according to the World Health Organization Europe nutrient profile model categories and the level and purpose of processing as per the NOVA classification. In addition, promotional characters (i.e. cartoons, licensed characters, celebrities) and premium offers within the promotions were analysed. RESULTS: In total, 15,271 food promotions were analyzed. The most frequently promoted foods in circulars were processed meat, poultry and fish (11.8%); fresh and frozen fruit, vegetables and legumes (9.5%); soft drinks and sweetened beverages (9.0%); fresh and frozen meat, poultry, fish and eggs (8.6%); cakes, sweet biscuits and pastries (8.1%); ready-made and convenience foods (8.0%); chocolate and sugar confectionery; energy bars and sweet toppings (7.7%) and cheeses (5.7%). About 52.2% of food promotions across all circulars were for ultra-processed foods, with considerable variation across chains (42.9-61.6%). Promotional characters and premium offers were found within 5.3 and 19.5% of promotions respectively. For all chains, circular covers were healthier compared to entire circulars, with a lower proportion of ultra-processed foods and a higher proportion of fresh fruit and vegetables promoted. CONCLUSIONS: Food promotions in circulars were most frequently for ultra-processed foods, with considerable variation across chains. Circular covers were healthier than entire circulars. Policies to reduce less healthy food promotions could contribute to improving the healthiness of supermarket food purchases.

A detailed mapping of the food industry in the European single market: similarities and differences in market structure across countries and sectors.

BACKGROUND: Food environments are influenced by food industries (packaged food and non-alcoholic beverage manufacturers; supermarkets and quick service restaurants). An important source of this influence is the significant market power held by a limited number of food companies. Market structure analysis, as part of a broader market power research agenda, has received limited attention from the public health community. The aim of this study was to analyse similarities and differences in market structure across countries and industries in the European Single Market. METHODS: The companies with the largest market share at the national level for each industry were identified from Euromonitor sales data in 2017/18. The market structure was assessed by the following metrics: the number of global brand owners with ≥1% market share per country, the number of companies unique for one European Single Market member state, the most sold packaged food and non-alcoholic beverage categories, the number of quick-service restaurants and supermarkets per 1000 inhabitants and market concentration by means of the Herfindahl-Hirschman Index (HHI) and the four firm concentration ratio (CR4). CR4-values > 40% and HHI-values > 2000 indicate concentrated markets with limited competition. RESULTS: The leading packaged food and non-alcoholic beverage manufacturers and the most sold food and beverage product categories were similar across countries in Europe. The observed levels of concentration were however different. Average CR4-values ranged from 21 to 72% among packaged food product markets and 60 to 76% for non-alcoholic beverage product markets. Average CR4-values for quick service restaurants and supermarkets were 50 and 60%, respectively. Across European countries the same leading quick-service restaurants were identified, while this was not the case for supermarkets. CONCLUSIONS: This study forms an important basis to understand key aspects of market structure of the European food industry, observing clear differences between food industries and European Single Market member states. This has potential implications for the implementation of food environment policies at different levels of jurisdiction.

(Ex-)breast cancer patients with (pre-existing) symptoms of anxiety and/or depression experience higher barriers to contact health care providers during the COVID-19 pandemic.

PURPOSE: To identify factors associated with (perceived) access to health care among (ex-)breast cancer patients during the COVID-19 pandemic. METHODS: Cross-sectional study within a large prospective, multicenter cohort of (ex-)breast cancer patients, i.e., UMBRELLA. All participants enrolled in the UMBRELLA cohort between October 2013 and April 2020 were sent a COVID-19-specific survey, including the Hospital Anxiety and Depression Scale (HADS) questionnaire. RESULTS: In total, 1051 (66.0%) participants completed the survey. During COVID-19, 284 (27.0%) participants reported clinically relevant increased levels of anxiety and/or depression, i.e., total HADS score ≥ 12. Participants with anxiety and/or depression reported statistically significant higher barriers to contact their general practitioner (47.5% vs. 25.0%, resp.) and breast cancer physicians (26.8% vs. 11.2%, resp.) compared to participants without these symptoms. In addition, a higher proportion of participants with anxiety and/or depression reported that their current treatment or (after)care was affected by COVID-19 compared to those without these symptoms (32.7% vs. 20.5%, resp.). Factors independently associated with symptoms of anxiety and/or depression during COVID-19 were pre-existent anxiety (OR 6.1, 95% CI 4.1-9.2) or depression (OR 6.0, 95% CI 3.5-10.2). CONCLUSION: During the COVID-19 pandemic, (ex-)breast cancer patients with symptoms of anxiety and/or depression experience higher barriers to contact health care providers. Also, they more often report that their health care was affected by COVID-19. Risk factors for anxiety and/or depression during COVID-19 are pre-existent symptoms of anxiety or depression. Extra attention-including mental health support-is needed for this group.

Impact of the COVID-19 Pandemic on Patient-Reported Outcomes of Breast Cancer Patients and Survivors.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic (officially declared on the March 11, 2020), and the resulting measures, are impacting daily life and medical management of breast cancer patients and survivors. We evaluated to what extent these changes have affected quality of life, physical, and psychosocial well-being of patients previously or currently being treated for breast cancer. METHODS: This study was conducted within a prospective, multicenter cohort of breast cancer patients and survivors (Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion). Shortly after the implementation of COVID-19 measures, an extra survey was sent to 1595 participants, including the validated European Organization for Research and Treatment of Cancer (EORTC) core (C30) and breast cancer-specific (BR23) Quality of Life Questionnaire (EORTC QLQ-C30/BR23) and Hospital Anxiety and Depression Scale (HADS) questionnaire. Patient-reported outcomes (PROs) were compared with the most recent PROs collected within UMBRELLA pre-COVID-19. The impact of COVID-19 on PROs was assessed using mixed model analysis, adjusting for potential confounders. RESULTS: 1051 patients and survivors (65.9%) completed the survey; 31.1% (n = 327) reported a higher threshold to contact their general practitioner amid the COVID-19 pandemic. A statistically significant deterioration in emotional functioning was observed (mean = 82.6 [SD = 18.7] to 77.9 [SD = 17.3]; P < .001), and 505 (48.0%, 95% confidence interval [CI] = 45.0% to 51.1%) patients and survivors reported moderate to severe loneliness. Small improvements were observed in quality of life and physical, social, and role functioning. In the subgroup of 51 patients under active treatment, social functioning strongly deteriorated (77.3 [95% CI = 69.4 to 85.2] to 61.3 [95% CI = 52.6 to 70.1]; P = .002). CONCLUSION: During the COVID-19 pandemic, breast cancer patients and survivors were less likely to contact physicians and experienced a deterioration in their emotional functioning. Patients undergoing active treatment reported a substantial drop in social functioning. One in 2 reported loneliness that was moderate or severe. Online interventions supporting mental health and social interaction are needed during times of social distancing and lockdowns.

Tumor Response After Neoadjuvant Magnetic Resonance Guided Single Ablative Dose Partial Breast Irradiation.

PURPOSE: To assess the pathologic and radiologic response in patients with low-risk breast cancer treated with magnetic resonance (MR) guided neoadjuvant partial breast irradiation (NA-PBI) and to evaluate toxicity and patient-reported outcomes (PROs). METHODS AND MATERIALS: For this single-arm prospective trial, women with unifocal, non-lobular tumors with a maximum diameter of 20 mm (age, 50-70 years) or 30 mm (age, ≥70 years) and tumor-negative sentinel node(s) were eligible. Patients were treated with a single ablative dose of NA-PBI followed by breast-conserving surgery after an interval of 6 to 8 months. Target volumes were defined on radiation therapy planning computed tomography scan and additional magnetic resonance imaging. Prescribed doses to gross tumor volume and clinical target volume (gross tumor volume plus 20 mm margin) were 20 Gy and 15 Gy, respectively. Primary outcome was pathologic complete response (pCR). Secondary outcomes were radiologic response (on magnetic resonance imaging), toxicity (Common Terminology Criteria for Adverse Events), PROs (European Organisation for Research and Treatment of Cancer QLQ-BR23, Hospital Anxiety and Depression Scale), and cosmesis (assessed by patient, radiation oncologist, and BCCT.core software). RESULTS: Thirty-six patients were treated with NA-PBI, and pCR was reported in 15 patients (42%; 95% confidence interval, 26%-59%). Radiologic complete response was observed in 15 patients, 10 of whom had pCR (positive predictive value, 67%; 95% confidence interval, 39%-87%). After a median follow-up of 21 months (range, 12-41), all patients experienced grade 1 fibrosis in the treated breast volume. Transient grade 2 and 3 toxicity was observed in 31% and 3% of patients, respectively. Local recurrences were absent. No deterioration in PROs or cosmetic results was observed. CONCLUSIONS: NA-PBI has the potential to induce pCR in a substantial proportion of patients, with acceptable toxicity. This treatment seems a feasible alternative to standard postoperative irradiation and could even result in postponement or omission of surgery if pCR can be accurately predicted in selected low-risk patients.

Which patients with ES-SCLC are most likely to benefit from more aggressive radiotherapy: A secondary analysis of the Phase III CREST trial.

INTRODUCTION: In ES-SCLC patients with residual intrathoracic disease after first-line chemotherapy, the addition of thoracic radiotherapy reduces the risk of intrathoracic recurrence, and improves 2-year survival. To identify patient subgroups for future trials investigating higher dose (extra)thoracic radiotherapy, we investigated the prognostic importance of number and sites of metastases in patients included in the CREST trial. MATERIALS/ METHODS: Additional data on sites and numbers of metastases were collected from individual records of 260 patients from the top 9 recruiting centers in the randomized CREST trial (53% of 495 study patients), which compared thoracic radiotherapy (TRT) to no TRT in ES-SCLC patients after any response to chemotherapy. All patients received prophylactic cranial irradiation. RESULTS: The clinical characteristics and outcomes of the 260 patients analyzed here did not differ significantly from that of the other 235 patients included in the CREST trial, except that fewer patients had a WHO=0 performance status (24% vs 45%), and a higher proportion had WHO=2 (15% vs 5%; p<0.0001). No distant metastases were recorded in 5%, 39% had metastases confined to one organ, 34% to two, and 22% to three or more organ sites. Metastases were present in the liver (47%), bone (40%), lung (28%), extrathoracic (non-supraclavicular) lymph nodes (19%), supraclavicular nodes (18%), adrenals (17%) and other sites (12%). The OS (p=0.02) and PFS (p=0.04) were significantly better in patients with 2 or fewer metastases, with OS significantly worse if liver (p=0.03) and/or bone metastases (p=0.04) were present. DISCUSSION: This analysis of patients recruited from the top 9 accruing centers in the CREST trial suggests that future studies evaluating more intensive thoracic and extra-thoracic radiotherapy in ES-SCLC should focus on patients with fewer than 3 distant metastases.

The price of robustness; impact of worst-case optimization on organ-at-risk dose and complication probability in intensity-modulated proton therapy for oropharyngeal cancer patients.

PURPOSE: To quantify the impact of the degree of robustness against setup errors and range errors on organ-at-risk (OAR) dose and normal tissue complication probabilities (NTCPs) in intensity-modulated proton therapy for oropharyngeal cancer patients. MATERIAL AND METHODS: For 20 oropharyngeal cases (10 unilateral and 10 bilateral), robust treatment plans were generated using 'minimax' worst-case optimization. We varied the robustness against setup errors ('setup robustness') from 1 to 7mm and the robustness against range errors ('range robustness') from 1% to 7% (+1mm). We evaluated OAR doses and NTCP-values for xerostomia, dysphagia and larynx edema. RESULTS: Varying the degree of setup robustness was found to have a considerably larger impact than varying the range robustness. Increasing setup robustness from 1mm to 3, 5, and 7mm resulted in average NTCP-values to increase by 1.9, 4.4 and 7.5 percentage point, whereas they increased by only 0.4, 0.8 and 1.2 percentage point when increasing range robustness from 1% to 3%, 5% and 7%. The degree of setup robustness was observed to have a clinically significant impact in bilateral cases in particular. CONCLUSIONS: For oropharyngeal cancer patients, minimizing setup errors should be given a higher priority than minimizing range errors.

Post-lumpectomy CT-guided tumor bed delineation for breast boost and partial breast irradiation: Can additional pre- and postoperative imaging reduce interobserver variability?

For breast boost radiotherapy or accelerated partial breast irradiation, the tumor bed (TB) is delineated by the radiation oncologist on a planning computed tomography (CT) scan. The aim of the present study was to investigate whether the interobserver variability (IOV) of the TB delineation is reduced by providing the radiation oncologist with additional magnetic resonance imaging (MRI) or CT scans. A total of 14 T1-T2 breast cancer patients underwent a standard planning CT in the supine treatment position following lumpectomy, as well as additional pre- and postoperative imaging in the same position. Post-lumpectomy TBs were independently delineated by four breast radiation oncologists on standard postoperative CT and on CT registered to an additional imaging modality. The additional imaging modalities used were postoperative MRI, preoperative contrast-enhanced (CE)-CT and preoperative CE-MRI. A cavity visualization score (CVS) was assigned to each standard postoperative CT by each observer. In addition, the conformity index (CI), volume and distance between centers of mass (dCOM) of the TB delineations were calculated. On CT, the median CI was 0.57, with a median volume of 22 cm3 and dCOM of 5.1 mm. The addition of postoperative MRI increased the median TB volume significantly to 28 cm3 (P<0.001), while the CI (P=0.176) and dCOM (P=0.110) were not affected. The addition of preoperative CT or MRI increased the TB volume to 26 and 25 cm3, respectively (both P<0.001), while the CI increased to 0.58 and 0.59 (both P<0.001) and the dCOM decreased to 4.7 mm (P=0.004) and 4.6 mm (P=0.001), respectively. In patients with CVS≤3, the median CI was 0.40 on CT, which was significantly increased by all additional imaging modalities, up to 0.52, and was accompanied by a median volume increase up to 6 cm3. In conclusion, the addition of postoperative MRI, preoperative CE-CT or preoperative CE-MRI did not result in a considerable reduction in the IOV in postoperative CT-guided TB delineation, while target volumes marginally increased. The value of additional imaging may be dependent on CVS.

MRI and CT imaging for preoperative target volume delineation in breast-conserving therapy.

BACKGROUND: Accurate tumor bed delineation after breast-conserving surgery is important. However, consistency among observers on standard postoperative radiotherapy planning CT is low and volumes can be large due to seroma formation. A preoperative delineation of the tumor might be more consistent. Therefore, the purpose of this study was to determine the consistency of preoperative target volume delineation on CT and MRI for breast-conserving radiotherapy. METHODS: Tumors were delineated on preoperative contrast-enhanced (CE) CT and newly developed 3D CE-MR images, by four breast radiation oncologists. Clinical target volumes (CTVs) were created by addition of a 1.5 cm margin around the tumor, excluding skin and chest wall. Consistency in target volume delineation was expressed by the interobserver variability. Therefore, the conformity index (CI), center of mass distance (dCOM) and volumes were calculated. Tumor characteristics on CT and MRI were scored by an experienced breast radiologist. RESULTS: Preoperative tumor delineation resulted in a high interobserver agreement with a high median CI for the CTV, for both CT (0.80) and MRI (0.84). The tumor was missed on CT in 2/14 patients (14%). Leaving these 2 patients out of the analysis, CI was higher on MRI compared to CT for the GTV (p<0.001) while not for the CTV (CT (0.82) versus MRI (0.84), p=0.123). The dCOM did not differ between CT and MRI. The median CTV was 48 cm3 (range 28-137 cm3) on CT and 59 cm3 (range 30-153 cm3) on MRI (p<0.001). Tumor shapes and margins were rated as more irregular and spiculated on CE-MRI. CONCLUSIONS: This study showed that preoperative target volume delineation resulted in small target volumes with a high consistency among observers. MRI appeared to be necessary for tumor detection and the visualization of irregularities and spiculations. Regarding the tumor delineation itself, no clinically relevant differences in interobserver variability were observed. These results will be used to study the potential for future MRI-guided and neoadjuvant radiotherapy. TRIAL REGISTRATION: International Clinical Trials Registry Platform NTR3198.

Improving target delineation on 4-dimensional CT scans in stage I NSCLC using a deformable registration tool.

INTRODUCTION: Correct target definition is crucial in stereotactic radiotherapy for lung tumors. We evaluated use of deformable registration (DR) for target contouring on 4-dimensional (4D) CT scans. MATERIALS AND METHODS: Three clinicians contoured gross tumor volume (GTV) in an end-inspiration phase of 4DCT of 6 patients on two occasions. Two clinicians contoured GTVs in all phases of 4DCT and on maximum intensity projections (MIP). The initial GTV was auto-propagated to 9 other phases using a B-spline algorithm (VelocityAI). Internal target volumes (ITVs) generated were (i) ITV(10manual) encompassing all physician-contoured GTVs, (ii) ITV-MIP(optimized) from MIP after review of individual 4DCT phases, (iii) ITV(10deformed) encompassing auto-propagated GTVs using DR, and (iv) ITV(10deformed-optimized), from an ITV(10deformed) target that was modified to form a 'clinically optimal' ITV. Volume-overlaps were scored using Dice's Similarity Coefficients (DSCs). RESULTS: Intra-clinician GTV reproducibility was greater than inter-clinician reproducibility (mean DSC 0.93 vs. 0.88, p<0.0004). In five of 6 patients, ITV-MIP(optimized) differed from the ITV(10deformed-optimized). In all patients, the DSC between ITV(10deformed-optimized) and ITV(10deformed) was higher than that between ITV(10deformed-optimized) and ITV-MIP(optimized) (p<0.02 T-test). CONCLUSION: ITVs created in stage I tumors using DR were closer to 'clinically optimal' ITVs than was the case with a MIP-modified approach.