This document summarizes a randomized clinical trial that compared four treatment regimens for patients with early-stage Hodgkin's lymphoma. The trial investigated whether reducing the intensity of chemotherapy from 4 to 2 cycles of ABVD and reducing radiation therapy from 30Gy to 20Gy could maintain disease control while reducing toxicity. The trial found no significant differences in efficacy outcomes between treatment groups. Both 2 cycles of ABVD and 20Gy radiation were found to be non-inferior to standard treatment, with reduced acute toxicity. The study provides evidence that treatment intensity can be safely reduced for early-stage Hodgkin's lymphoma patients with favorable prognosis.
Opioid Usage Trends in Rheumatoid Arthritis_20151005_SJAJ.A. Zamora-Legoff
- Patients with rheumatoid arthritis (RA) had significantly higher rates of both any opiate use and chronic opiate use compared to non-RA patients over the study period of 2004-2014. 40% of RA patients used opiates in 2014 compared to 24% of non-RA patients.
- Chronic opiate use was substantially higher in RA patients, with 12% using chronic opiates in 2014 compared to 4% of non-RA patients. Younger RA patients aged 18-49 had the highest rates of chronic opiate use.
- RA disease characteristics did not correlate with chronic opiate use, but glucocorticoid use was associated with higher risk of chronic opiate use in RA patients.
This document summarizes the results of a study that evaluated the health care resource utilization and costs of patients with symptomatic multiple myeloma in the United Kingdom. The study found that the average total cost per treatment line was £34,296, with most costs attributed to anti-tumor drugs. The average cost per month of active treatment was £5,168. For patients receiving best supportive care after discontinuing active treatment, the average total cost was £1,444 if they progressed or £2,480 if they did not progress before death.
An evaluation of the clinical utility of a panel of variants in DPYD and ENOS...Oxford Cancer Biomarkers
This document summarizes a study evaluating the clinical utility of a genetic panel for predicting toxicities from capecitabine chemotherapy. The panel included variants in DPYD and ENOSF1 genes. The study found the panel had high sensitivity and specificity for predicting death or severe hematological toxicity. However, the panel only had moderate ability to predict risk of hand-foot syndrome. Including additional variants associated with hand-foot syndrome may help clinicians manage this side effect. Overall, the genetic panel shows promise for predicting serious adverse events from capecitabine chemotherapy.
This study compared different chemotherapy and radiotherapy regimens for patients with early unfavorable Hodgkin's lymphoma. The study found:
1) 4 cycles of ABVD chemotherapy followed by 30Gy radiotherapy was as effective as 4 cycles of BEACOPP chemotherapy followed by either 30Gy or 20Gy radiotherapy.
2) However, 4 cycles of ABVD followed by a reduced radiotherapy dose of 20Gy was inferior to the other regimens and resulted in worse patient outcomes.
3) A reduction of radiotherapy dose from 30Gy to 20Gy is only possible when combined with a more intensive chemotherapy regimen like BEACOPP, not a less intensive regimen like ABVD.
Metronomic chemotherapy involves the chronic administration of chemotherapy drugs at low, minimally toxic doses on a frequent schedule with no prolonged breaks. This strategy aims to control cancer by targeting tumor vasculature and is an attractive option in resource-limited areas due to its low cost, oral administration, and minimal side effects compared to conventional chemotherapy. Combining metronomic chemotherapy with drug repositioning and targeted therapies may lead to improved cancer control through multi-pronged effects on cancer cells, vasculature, and the immune system. However, determining the optimal biological dose and identifying surrogate markers pose challenges to realizing the full potential of this approach.
1. The study analyzed treatment patterns over time in patients receiving first-line chemotherapy for advanced or metastatic esophageal or gastric cancer based on data from 2,808 patients documented in Therapiemonitor from 2006-2013.
2. Treatment intensity increased over time, with 49.3% of patients receiving triplet chemotherapy in 2013 compared to just 10.1% in 2006. HER2 testing rates increased from 49.1% in earlier studies to 79.1% in 2012-2013, though testing was still not always performed according to guidelines.
3. Usage of fluoropyrimidine/cisplatin combinations with trastuzumab declined from 67% in 2010-2011 to 50% in 2012-2013
Medical Conferences, Pharma Conferences, Engineering Conferences, Science Conferences, Manufacturing Conferences, Social Science Conferences, Business Conferences, Scientific Conferences Malaysia, Thailand, Singapore, Hong Kong, Dubai, Turkey 2014 2015 2016
Global Research & Development Services (GRDS) is a leading academic event organizer, publishing Open Access Journals and conducting several professionally organized international conferences all over the globe annually. GRDS aims to disseminate knowledge and innovation with the help of its International Conferences and open access publications. GRDS International conferences are world-class events which provide a meaningful platform for researchers, students, academicians, institutions, entrepreneurs, industries and practitioners to create, share and disseminate knowledge and innovation and to develop long-lasting network and collaboration.
GRDS is a blend of Open Access Publications and world-wide International Conferences and Academic events. The prime mission of GRDS is to make continuous efforts in transforming the lives of people around the world through education, application of research and innovative ideas.
Global Research & Development Services (GRDS) is also active in the field of Research Funding, Research Consultancy, Training and Workshops along with International Conferences and Open Access Publications.
International Conferences 2014 – 2015
Malaysia Conferences, Thailand Conferences, Singapore Conferences, Hong Kong Conferences, Dubai Conferences, Turkey Conferences, Conference Listing, Conference Alerts
Aim: to evaluate the effi cacy and tolerability of electro-hyperthermia (ET) for the treatment of relapsed malignant glioma.
Methods: this was a retrospective observational clinical study. Patients were included in the study if they had >18 years, informed consent signed, histological diagnosis of malignant glioma, failure of previous temozolamide-based chemotherapy and radiotherapy, indication for treatment with ET.
Hyperthermia was performed with short radiofrequency waves of 13.56 MHz using a capacitive coupling technique keeping the skin surface at 26 C°. The applied power ranged between 40-150 Watts and the calculated average equivalent temperature in the tumors was above 40 C° for more than 90% of the treatment duration (20-60 minutes gradually).
Opioid Usage Trends in Rheumatoid Arthritis_20151005_SJAJ.A. Zamora-Legoff
- Patients with rheumatoid arthritis (RA) had significantly higher rates of both any opiate use and chronic opiate use compared to non-RA patients over the study period of 2004-2014. 40% of RA patients used opiates in 2014 compared to 24% of non-RA patients.
- Chronic opiate use was substantially higher in RA patients, with 12% using chronic opiates in 2014 compared to 4% of non-RA patients. Younger RA patients aged 18-49 had the highest rates of chronic opiate use.
- RA disease characteristics did not correlate with chronic opiate use, but glucocorticoid use was associated with higher risk of chronic opiate use in RA patients.
This document summarizes the results of a study that evaluated the health care resource utilization and costs of patients with symptomatic multiple myeloma in the United Kingdom. The study found that the average total cost per treatment line was £34,296, with most costs attributed to anti-tumor drugs. The average cost per month of active treatment was £5,168. For patients receiving best supportive care after discontinuing active treatment, the average total cost was £1,444 if they progressed or £2,480 if they did not progress before death.
An evaluation of the clinical utility of a panel of variants in DPYD and ENOS...Oxford Cancer Biomarkers
This document summarizes a study evaluating the clinical utility of a genetic panel for predicting toxicities from capecitabine chemotherapy. The panel included variants in DPYD and ENOSF1 genes. The study found the panel had high sensitivity and specificity for predicting death or severe hematological toxicity. However, the panel only had moderate ability to predict risk of hand-foot syndrome. Including additional variants associated with hand-foot syndrome may help clinicians manage this side effect. Overall, the genetic panel shows promise for predicting serious adverse events from capecitabine chemotherapy.
This study compared different chemotherapy and radiotherapy regimens for patients with early unfavorable Hodgkin's lymphoma. The study found:
1) 4 cycles of ABVD chemotherapy followed by 30Gy radiotherapy was as effective as 4 cycles of BEACOPP chemotherapy followed by either 30Gy or 20Gy radiotherapy.
2) However, 4 cycles of ABVD followed by a reduced radiotherapy dose of 20Gy was inferior to the other regimens and resulted in worse patient outcomes.
3) A reduction of radiotherapy dose from 30Gy to 20Gy is only possible when combined with a more intensive chemotherapy regimen like BEACOPP, not a less intensive regimen like ABVD.
Metronomic chemotherapy involves the chronic administration of chemotherapy drugs at low, minimally toxic doses on a frequent schedule with no prolonged breaks. This strategy aims to control cancer by targeting tumor vasculature and is an attractive option in resource-limited areas due to its low cost, oral administration, and minimal side effects compared to conventional chemotherapy. Combining metronomic chemotherapy with drug repositioning and targeted therapies may lead to improved cancer control through multi-pronged effects on cancer cells, vasculature, and the immune system. However, determining the optimal biological dose and identifying surrogate markers pose challenges to realizing the full potential of this approach.
1. The study analyzed treatment patterns over time in patients receiving first-line chemotherapy for advanced or metastatic esophageal or gastric cancer based on data from 2,808 patients documented in Therapiemonitor from 2006-2013.
2. Treatment intensity increased over time, with 49.3% of patients receiving triplet chemotherapy in 2013 compared to just 10.1% in 2006. HER2 testing rates increased from 49.1% in earlier studies to 79.1% in 2012-2013, though testing was still not always performed according to guidelines.
3. Usage of fluoropyrimidine/cisplatin combinations with trastuzumab declined from 67% in 2010-2011 to 50% in 2012-2013
Medical Conferences, Pharma Conferences, Engineering Conferences, Science Conferences, Manufacturing Conferences, Social Science Conferences, Business Conferences, Scientific Conferences Malaysia, Thailand, Singapore, Hong Kong, Dubai, Turkey 2014 2015 2016
Global Research & Development Services (GRDS) is a leading academic event organizer, publishing Open Access Journals and conducting several professionally organized international conferences all over the globe annually. GRDS aims to disseminate knowledge and innovation with the help of its International Conferences and open access publications. GRDS International conferences are world-class events which provide a meaningful platform for researchers, students, academicians, institutions, entrepreneurs, industries and practitioners to create, share and disseminate knowledge and innovation and to develop long-lasting network and collaboration.
GRDS is a blend of Open Access Publications and world-wide International Conferences and Academic events. The prime mission of GRDS is to make continuous efforts in transforming the lives of people around the world through education, application of research and innovative ideas.
Global Research & Development Services (GRDS) is also active in the field of Research Funding, Research Consultancy, Training and Workshops along with International Conferences and Open Access Publications.
International Conferences 2014 – 2015
Malaysia Conferences, Thailand Conferences, Singapore Conferences, Hong Kong Conferences, Dubai Conferences, Turkey Conferences, Conference Listing, Conference Alerts
Aim: to evaluate the effi cacy and tolerability of electro-hyperthermia (ET) for the treatment of relapsed malignant glioma.
Methods: this was a retrospective observational clinical study. Patients were included in the study if they had >18 years, informed consent signed, histological diagnosis of malignant glioma, failure of previous temozolamide-based chemotherapy and radiotherapy, indication for treatment with ET.
Hyperthermia was performed with short radiofrequency waves of 13.56 MHz using a capacitive coupling technique keeping the skin surface at 26 C°. The applied power ranged between 40-150 Watts and the calculated average equivalent temperature in the tumors was above 40 C° for more than 90% of the treatment duration (20-60 minutes gradually).
This meta-analysis combines data from 5 randomized controlled trials investigating adjuvant chemotherapy and chemoradiation for pancreatic cancer. It includes individual patient data from 875 patients across 4 trials, as well as previously unpublished updated follow-up data from 261 additional patients in the ESPAC1 trial. The analysis found that chemotherapy significantly reduced the risk of death, with median survival of 19 months with chemotherapy versus 13.5 months without. However, chemoradiation did not significantly reduce the risk of death compared to no adjuvant treatment, with median survivals of 15.8 months and 15.2 months respectively. Subgroup analyses suggested chemoradiation may be more effective for patients with positive resection margins, while chemotherapy was less effective for this
This study reported long-term results from RTOG 91-11, which compared three nonsurgical treatments for locally advanced larynx cancer: induction chemotherapy followed by radiation therapy (RT); concurrent cisplatin and RT; and RT alone. With a median follow-up of 10.8 years, concurrent cisplatin and RT significantly reduced the risk of laryngectomy compared to the other strategies and improved locoregional control. However, more deaths in the concurrent group were unrelated to larynx cancer, raising concerns about potential increased risk of late effects from this approach. Overall survival did not significantly differ between groups in the long-term follow-up.
Rifabutin was included in WHO guidelines for drug resistant tuberculosis treatment until 2014 but was then removed. There are concerns about cross resistance between Rifabutin and Rifampicin, but studies show that 27-30% of Rifampicin resistant isolates are still susceptible to Rifabutin. Certain rpoB gene mutations have been associated with Rifabutin susceptibility. Studies found treatment success rates of 85.7% for Rifabutin containing regimens compared to 52.4% for non-Rifabutin regimens in Rifabutin susceptible patients, though Rifabutin use was also associated with some adverse effects.
This study performed a cost-effectiveness analysis of adjuvant chemoradiotherapy for resected gastric cancer based on results from the Intergroup 0116 trial. The analysis found that the incremental cost of adding chemoradiotherapy was $20,100 and provided an additional 0.53 quality-adjusted life years, resulting in an incremental cost-effectiveness ratio of $38,400 per quality-adjusted life year gained. A probabilistic sensitivity analysis predicted a 67% likelihood that the ratio would be less than $50,000 per quality-adjusted life year, which compares favorably to other widely used cancer treatments.
1. The document analyzes changes in treatment strategies for metastatic colorectal cancer in Germany between 2005-2007 based on data from large population surveys. It finds that results from clinical trials showing increased effectiveness of new drugs like oxaliplatin and irinotecan were quickly implemented in clinical practice.
2. The treatment objective of achieving secondary resection of metastases after chemotherapy increased significantly from 18% to 27% during this period, as clinical trials showed biologicals improving resectability rates. Biologicals were used more often when secondary resection was the goal compared to other objectives.
3. A multivariate analysis found that while many factors influenced treatment choices, the objective of secondary resection and patient age had the most significant impact
This document discusses the diagnosis and treatment of drugs five years after their approval, focusing on procarbazine. It provides the following key points:
1) Procarbazine has an established role in combination chemotherapy for Hodgkin's disease since its 1969 FDA approval, but its role has not expanded beyond this and a few other applications in the past 5 years.
2) It is most effective for Hodgkin's disease when used in combination with other drugs in the MOPP regimen, achieving around an 80% complete remission rate. However, relapse remains an issue.
3) For other cancers like non-Hodgkin's lymphomas and lung cancer, procarbazine has limited effectiveness as a single
Adherence to treatment and quality of life during hepatitis C therapy:a prosp...Michel Rotily
Adherence to treatment and quality of life during hepatitis C therapy:a prospective, real-life, observational study by Patrick Marcellin, Michel Chousterman, Thierry Fontanges, Denis Ouzan, Michel Rotily, Marina Varastet,Jean-Philippe Lang, Pascal Melin and Patrice Cacoub, for the CheObs Study Group published in Liver Int 2011
Abstract—Colorectal cancer is leading cancer-related public health problem. This study was conducted to determine the effect of High-Dose-Rate intraluminal brachytherapy (HDR-BT) with or without interstitial brachytherapy during neoadjuvant chemoradiation for locally advanced rectal cancer. This randomized contrial was conducted on 28 patients attended with locally advanced rectal cancer (T3, T4 or N+) treated initially with concurrent capecitabine (800 mg/m2 twice daily for 5 days per week) and pelvic external beam radiation therapy (45Gy in 25 Fractions) after one week MRI for all patients; received intraluminal HDR-BT with 4Gy x 2 Fractions with one week interval for those had gross residual disease within 1cm of rectal wall and receiveed intraluminal and interstitial brachytherapy with 4Gy x 2 Fractions with one week interval for those had gross residual disease far from 1cm of rectal wall. All patients underwent surgery within 4-8 week after completion of neoadjuvant therapy. In the control group which were not randomized, twenty-eight patients underwent neoadjuvant chemoradiation (45Gy in 25 Fraction with concurrent capecitabine 800mg/m2 twice daily for 5 days per week) followed by surgery. It was found that in HDR-BT group pathologic complete response (pCR), pathologic partial response (pPR) and pathologic response rates (pCR+pPR) based on AJCC TNM staging for colorectal cancer were %35.7, %35.7, and %71.4 respectively. The pCR, pPR, and pRR were %25, %17, and %42 in the control group respectively. pCR, pPR, and pRR were improved with HDR-BT. However, only response rate improvement was statistically significant (p=0.031). There was no a statistically significant difference in the complications between the two groups (p > 0.05). So it can be concluded that HDR intraluminal with or without interstitial brachytherapy may be an effective method of dose escalation technique in neoadjuvant chemoradiation therapy of locally advanced rectal cancer with higher response rate and manageable side effects.
Open-label uncontrolled pilot study to evaluate complementary therapy with Ru...home
Some patients treated with Ruta graveolens 9c had a transitory improvement
in QoL, but the effectiveness of this treatment remains to be confirmed in further
studies.
The effect of long-term traditional Chinese medicine treatment on disease-fre...LucyPi1
Abstract Objective: Traditional Chinese medicine (TCM) has been extensively used as one of popular alternative therapies for several cancers. However, it remains unclear whether TCM treatment is associated with longer survival in lung cancer patients. In this study, we explored the effect of long-term TCM treatment on patients with different stages of lung cancer. Methods: All information of lung cancer patients with stage I-III disease from January 2007 to September 2015 was collected for this retrospective cohort study. Those who were treated with TCM after surgery were divided into TCM group and the others were into the non-TCM group (control group). All patients were regularly followed up by clinic appointment or phone, and all survival data were collected from databases after the last follow-up in October 2017. Results: A total of 575 patients were included in this study, with 299 patients in the TCM group and 276 in the control group. For all patients, 5-year disease-free survival (DFS) was 62.2% in TCM group and 42.1% in the control group, and 6-year DFSs were 51.8% and 35.4%, respectively (HR = 0.51, 95% CI: 0.40 to 0.66, log-rank P ≤ 0.001). For patients with stage I, 5-year DFSs were 83.7% (TCM group) and 57.5% (control group) and 6-year DFSs were 73.7% and 51.9%, respectively (HR = 0.30, 95% CI: 0.18 to 0.50, log-rank P ≤ 0.001). For patients with stage II in the TCM group and the control group, 5-year DFSs were 59.4% and 17.6% and 6-year DFSs were 44.7% and 17.6%, respectively (HR = 0.31, 95% CI: 0.19 to 0.52, log-rank P ≤ 0.001), and for patients with stage III, 5-year and 6-year DFSs in the TCM group were 18.7% and 12.5% compared with 28.4% and 20.3% in the control group (HR = 1.06, 95% CI: 0.72 to 1.56, log-rank P = 0.76). Conclusions: This study demonstrated that long-term TCM treatment as an adjuvant therapy is able to improve the DFS of postoperative stage I-III lung cancer patients, especially in patients with stage I and II disease. However, these observational findings need being validated by large sample randomized controlled trials.
This document summarizes a study on drug utilization patterns in patients with burns over 15% of their total body surface area admitted to a tertiary hospital burn ward in Nashik, India. A total of 50 patients were included in the study, with an average burn percentage of 61.96%. The mortality rate was found to be 20% for burns under 40% TBSA, 33% for 40-60% TBSA, and 95% for over 60% TBSA. The most commonly prescribed drugs were Ringer's Lactate, gentamicin, ranitidine, metronidazole, cefoperazone + sulbactam, and ciprofloxacin. The drug utilization 90% included
This document summarizes a presentation on rare central nervous system (CNS) cancers. It discusses molecular markers in gliomas, treatment with antiangiogenic drugs like bevacizumab, and management of low-grade tumors. It also reviews studies on chemotherapy for recurrent and newly diagnosed low-grade gliomas, ongoing clinical trials, and risks of distant spread with bevacizumab treatment.
This document summarizes the results and recommendations from the 2009 Consensus Conference on antiemetics organized by ESMO and MASCC. The conference updated guidelines for preventing chemotherapy- and radiotherapy-induced nausea and vomiting. Key points:
- Chemotherapy agents were classified into four levels of emetogenic potential (high, moderate, low, minimal) based on literature review. This classification guides antiemetic treatment recommendations.
- For prevention of acute nausea/vomiting from highly emetogenic chemo like cisplatin, the addition of the NK1 receptor antagonist aprepitant to ondansetron and dexamethasone was found to significantly improve complete response rates compared to the standard regimen.
This document summarizes the long-term outcomes and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the PORTEC-1 trial. It finds that after a median follow-up of 15 years:
1) Patients who received radiotherapy had a lower locoregional recurrence rate of 5.8% compared to 15.5% for those who did not receive radiotherapy.
2) There was no significant difference in overall survival rates between the groups, which were 52% for those who received radiotherapy and 60% for those who did not.
3) Quality of life questionnaires sent to patients 11-18 years post-treatment found that those who
Association between genomic recurrence risk and well-being among breast cance...Enrique Moreno Gonzalez
Gene expression profiling (GEP) is increasingly used in the rapidly evolving field of personalized medicine. We sought to evaluate the association between GEP-assessed of breast cancer recurrence risk and patients’ well-being.
This study evaluated the performance of three pneumonia severity scores - CURB-65, CRB-65, and CURB-age - in predicting 30-day mortality in 559 adult inpatients with community-acquired pneumonia. The study found that CURB-age stratified patients into risk groups that were most closely associated with mortality outcomes. Specifically, CURB-age identified more low-risk patients who had lower mortality than CRB-65, and sorted more patients who died within 30 days into the high-risk group compared to the other scores. Analysis of receiver operating characteristics further indicated CURB-age had better ability to predict 30-day mortality compared to the other scores. The study concludes CURB-age may provide
Adjuvant interferon-alpha therapy is the only drug that has shown activity in the adjuvant systemic treatment of melanoma. It improves relapse-free survival by approximately 10% at five years and may have a small impact on overall survival. However, it is associated with considerable but reversible toxicity that requires experienced management.
This document summarizes treatment approaches for early-stage Hodgkin lymphoma. It describes the evolution from radiotherapy alone to combined modality therapy with chemotherapy and radiotherapy. Key findings include:
1) Combined modality therapy is superior to radiotherapy alone in achieving high cure rates of over 90% for early-stage disease.
2) 4 cycles of ABVD chemotherapy followed by involved-field radiotherapy is as effective as subtotal nodal radiotherapy plus chemotherapy.
3) For selected early-stage favorable disease, 2 cycles of ABVD chemotherapy and 20Gy radiotherapy may be sufficient treatment.
4) For early-stage unfavorable disease, 4 cycles of ABVD chemotherapy with 30Gy
This study assessed 602 patients with early-stage Hodgkin's lymphoma who received three cycles of ABVD chemotherapy. Patients then underwent PET scanning; those with negative scans were randomly assigned to receive radiotherapy or no further treatment. At median follow-up of 60 months, progression-free survival was 94.6% in the radiotherapy group and 90.8% in the no-further-treatment group, a difference that was not statistically significant. While the study did not demonstrate the non-inferiority of no further treatment, patients in both groups had a very good prognosis.
This meta-analysis combines data from 5 randomized controlled trials investigating adjuvant chemotherapy and chemoradiation for pancreatic cancer. It includes individual patient data from 875 patients across 4 trials, as well as previously unpublished updated follow-up data from 261 additional patients in the ESPAC1 trial. The analysis found that chemotherapy significantly reduced the risk of death, with median survival of 19 months with chemotherapy versus 13.5 months without. However, chemoradiation did not significantly reduce the risk of death compared to no adjuvant treatment, with median survivals of 15.8 months and 15.2 months respectively. Subgroup analyses suggested chemoradiation may be more effective for patients with positive resection margins, while chemotherapy was less effective for this
This study reported long-term results from RTOG 91-11, which compared three nonsurgical treatments for locally advanced larynx cancer: induction chemotherapy followed by radiation therapy (RT); concurrent cisplatin and RT; and RT alone. With a median follow-up of 10.8 years, concurrent cisplatin and RT significantly reduced the risk of laryngectomy compared to the other strategies and improved locoregional control. However, more deaths in the concurrent group were unrelated to larynx cancer, raising concerns about potential increased risk of late effects from this approach. Overall survival did not significantly differ between groups in the long-term follow-up.
Rifabutin was included in WHO guidelines for drug resistant tuberculosis treatment until 2014 but was then removed. There are concerns about cross resistance between Rifabutin and Rifampicin, but studies show that 27-30% of Rifampicin resistant isolates are still susceptible to Rifabutin. Certain rpoB gene mutations have been associated with Rifabutin susceptibility. Studies found treatment success rates of 85.7% for Rifabutin containing regimens compared to 52.4% for non-Rifabutin regimens in Rifabutin susceptible patients, though Rifabutin use was also associated with some adverse effects.
This study performed a cost-effectiveness analysis of adjuvant chemoradiotherapy for resected gastric cancer based on results from the Intergroup 0116 trial. The analysis found that the incremental cost of adding chemoradiotherapy was $20,100 and provided an additional 0.53 quality-adjusted life years, resulting in an incremental cost-effectiveness ratio of $38,400 per quality-adjusted life year gained. A probabilistic sensitivity analysis predicted a 67% likelihood that the ratio would be less than $50,000 per quality-adjusted life year, which compares favorably to other widely used cancer treatments.
1. The document analyzes changes in treatment strategies for metastatic colorectal cancer in Germany between 2005-2007 based on data from large population surveys. It finds that results from clinical trials showing increased effectiveness of new drugs like oxaliplatin and irinotecan were quickly implemented in clinical practice.
2. The treatment objective of achieving secondary resection of metastases after chemotherapy increased significantly from 18% to 27% during this period, as clinical trials showed biologicals improving resectability rates. Biologicals were used more often when secondary resection was the goal compared to other objectives.
3. A multivariate analysis found that while many factors influenced treatment choices, the objective of secondary resection and patient age had the most significant impact
This document discusses the diagnosis and treatment of drugs five years after their approval, focusing on procarbazine. It provides the following key points:
1) Procarbazine has an established role in combination chemotherapy for Hodgkin's disease since its 1969 FDA approval, but its role has not expanded beyond this and a few other applications in the past 5 years.
2) It is most effective for Hodgkin's disease when used in combination with other drugs in the MOPP regimen, achieving around an 80% complete remission rate. However, relapse remains an issue.
3) For other cancers like non-Hodgkin's lymphomas and lung cancer, procarbazine has limited effectiveness as a single
Adherence to treatment and quality of life during hepatitis C therapy:a prosp...Michel Rotily
Adherence to treatment and quality of life during hepatitis C therapy:a prospective, real-life, observational study by Patrick Marcellin, Michel Chousterman, Thierry Fontanges, Denis Ouzan, Michel Rotily, Marina Varastet,Jean-Philippe Lang, Pascal Melin and Patrice Cacoub, for the CheObs Study Group published in Liver Int 2011
Abstract—Colorectal cancer is leading cancer-related public health problem. This study was conducted to determine the effect of High-Dose-Rate intraluminal brachytherapy (HDR-BT) with or without interstitial brachytherapy during neoadjuvant chemoradiation for locally advanced rectal cancer. This randomized contrial was conducted on 28 patients attended with locally advanced rectal cancer (T3, T4 or N+) treated initially with concurrent capecitabine (800 mg/m2 twice daily for 5 days per week) and pelvic external beam radiation therapy (45Gy in 25 Fractions) after one week MRI for all patients; received intraluminal HDR-BT with 4Gy x 2 Fractions with one week interval for those had gross residual disease within 1cm of rectal wall and receiveed intraluminal and interstitial brachytherapy with 4Gy x 2 Fractions with one week interval for those had gross residual disease far from 1cm of rectal wall. All patients underwent surgery within 4-8 week after completion of neoadjuvant therapy. In the control group which were not randomized, twenty-eight patients underwent neoadjuvant chemoradiation (45Gy in 25 Fraction with concurrent capecitabine 800mg/m2 twice daily for 5 days per week) followed by surgery. It was found that in HDR-BT group pathologic complete response (pCR), pathologic partial response (pPR) and pathologic response rates (pCR+pPR) based on AJCC TNM staging for colorectal cancer were %35.7, %35.7, and %71.4 respectively. The pCR, pPR, and pRR were %25, %17, and %42 in the control group respectively. pCR, pPR, and pRR were improved with HDR-BT. However, only response rate improvement was statistically significant (p=0.031). There was no a statistically significant difference in the complications between the two groups (p > 0.05). So it can be concluded that HDR intraluminal with or without interstitial brachytherapy may be an effective method of dose escalation technique in neoadjuvant chemoradiation therapy of locally advanced rectal cancer with higher response rate and manageable side effects.
Open-label uncontrolled pilot study to evaluate complementary therapy with Ru...home
Some patients treated with Ruta graveolens 9c had a transitory improvement
in QoL, but the effectiveness of this treatment remains to be confirmed in further
studies.
The effect of long-term traditional Chinese medicine treatment on disease-fre...LucyPi1
Abstract Objective: Traditional Chinese medicine (TCM) has been extensively used as one of popular alternative therapies for several cancers. However, it remains unclear whether TCM treatment is associated with longer survival in lung cancer patients. In this study, we explored the effect of long-term TCM treatment on patients with different stages of lung cancer. Methods: All information of lung cancer patients with stage I-III disease from January 2007 to September 2015 was collected for this retrospective cohort study. Those who were treated with TCM after surgery were divided into TCM group and the others were into the non-TCM group (control group). All patients were regularly followed up by clinic appointment or phone, and all survival data were collected from databases after the last follow-up in October 2017. Results: A total of 575 patients were included in this study, with 299 patients in the TCM group and 276 in the control group. For all patients, 5-year disease-free survival (DFS) was 62.2% in TCM group and 42.1% in the control group, and 6-year DFSs were 51.8% and 35.4%, respectively (HR = 0.51, 95% CI: 0.40 to 0.66, log-rank P ≤ 0.001). For patients with stage I, 5-year DFSs were 83.7% (TCM group) and 57.5% (control group) and 6-year DFSs were 73.7% and 51.9%, respectively (HR = 0.30, 95% CI: 0.18 to 0.50, log-rank P ≤ 0.001). For patients with stage II in the TCM group and the control group, 5-year DFSs were 59.4% and 17.6% and 6-year DFSs were 44.7% and 17.6%, respectively (HR = 0.31, 95% CI: 0.19 to 0.52, log-rank P ≤ 0.001), and for patients with stage III, 5-year and 6-year DFSs in the TCM group were 18.7% and 12.5% compared with 28.4% and 20.3% in the control group (HR = 1.06, 95% CI: 0.72 to 1.56, log-rank P = 0.76). Conclusions: This study demonstrated that long-term TCM treatment as an adjuvant therapy is able to improve the DFS of postoperative stage I-III lung cancer patients, especially in patients with stage I and II disease. However, these observational findings need being validated by large sample randomized controlled trials.
This document summarizes a study on drug utilization patterns in patients with burns over 15% of their total body surface area admitted to a tertiary hospital burn ward in Nashik, India. A total of 50 patients were included in the study, with an average burn percentage of 61.96%. The mortality rate was found to be 20% for burns under 40% TBSA, 33% for 40-60% TBSA, and 95% for over 60% TBSA. The most commonly prescribed drugs were Ringer's Lactate, gentamicin, ranitidine, metronidazole, cefoperazone + sulbactam, and ciprofloxacin. The drug utilization 90% included
This document summarizes a presentation on rare central nervous system (CNS) cancers. It discusses molecular markers in gliomas, treatment with antiangiogenic drugs like bevacizumab, and management of low-grade tumors. It also reviews studies on chemotherapy for recurrent and newly diagnosed low-grade gliomas, ongoing clinical trials, and risks of distant spread with bevacizumab treatment.
This document summarizes the results and recommendations from the 2009 Consensus Conference on antiemetics organized by ESMO and MASCC. The conference updated guidelines for preventing chemotherapy- and radiotherapy-induced nausea and vomiting. Key points:
- Chemotherapy agents were classified into four levels of emetogenic potential (high, moderate, low, minimal) based on literature review. This classification guides antiemetic treatment recommendations.
- For prevention of acute nausea/vomiting from highly emetogenic chemo like cisplatin, the addition of the NK1 receptor antagonist aprepitant to ondansetron and dexamethasone was found to significantly improve complete response rates compared to the standard regimen.
This document summarizes the long-term outcomes and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the PORTEC-1 trial. It finds that after a median follow-up of 15 years:
1) Patients who received radiotherapy had a lower locoregional recurrence rate of 5.8% compared to 15.5% for those who did not receive radiotherapy.
2) There was no significant difference in overall survival rates between the groups, which were 52% for those who received radiotherapy and 60% for those who did not.
3) Quality of life questionnaires sent to patients 11-18 years post-treatment found that those who
Association between genomic recurrence risk and well-being among breast cance...Enrique Moreno Gonzalez
Gene expression profiling (GEP) is increasingly used in the rapidly evolving field of personalized medicine. We sought to evaluate the association between GEP-assessed of breast cancer recurrence risk and patients’ well-being.
This study evaluated the performance of three pneumonia severity scores - CURB-65, CRB-65, and CURB-age - in predicting 30-day mortality in 559 adult inpatients with community-acquired pneumonia. The study found that CURB-age stratified patients into risk groups that were most closely associated with mortality outcomes. Specifically, CURB-age identified more low-risk patients who had lower mortality than CRB-65, and sorted more patients who died within 30 days into the high-risk group compared to the other scores. Analysis of receiver operating characteristics further indicated CURB-age had better ability to predict 30-day mortality compared to the other scores. The study concludes CURB-age may provide
Adjuvant interferon-alpha therapy is the only drug that has shown activity in the adjuvant systemic treatment of melanoma. It improves relapse-free survival by approximately 10% at five years and may have a small impact on overall survival. However, it is associated with considerable but reversible toxicity that requires experienced management.
This document summarizes treatment approaches for early-stage Hodgkin lymphoma. It describes the evolution from radiotherapy alone to combined modality therapy with chemotherapy and radiotherapy. Key findings include:
1) Combined modality therapy is superior to radiotherapy alone in achieving high cure rates of over 90% for early-stage disease.
2) 4 cycles of ABVD chemotherapy followed by involved-field radiotherapy is as effective as subtotal nodal radiotherapy plus chemotherapy.
3) For selected early-stage favorable disease, 2 cycles of ABVD chemotherapy and 20Gy radiotherapy may be sufficient treatment.
4) For early-stage unfavorable disease, 4 cycles of ABVD chemotherapy with 30Gy
This study assessed 602 patients with early-stage Hodgkin's lymphoma who received three cycles of ABVD chemotherapy. Patients then underwent PET scanning; those with negative scans were randomly assigned to receive radiotherapy or no further treatment. At median follow-up of 60 months, progression-free survival was 94.6% in the radiotherapy group and 90.8% in the no-further-treatment group, a difference that was not statistically significant. While the study did not demonstrate the non-inferiority of no further treatment, patients in both groups had a very good prognosis.
This document describes a study protocol for a randomized phase III clinical trial comparing neoadjuvant chemoradiation followed by surgery versus surgery alone in patients with adenocarcinoma or squamous cell carcinoma of the esophagus. The trial aims to enroll 350 patients total with 175 patients in each arm. The primary objective is to compare median survival rates and quality of life between the two treatment groups. Secondary objectives include comparing pathological responses, progression-free survival, number of complete resections, treatment toxicity, and costs. The chemoradiation regimen involves weekly paclitaxel and carboplatin chemotherapy with concurrent radiation over 5 weeks. Patients will then undergo surgery and be followed up for survival and quality of life outcomes
Aggressive treatment for early lymphomasGil Lederman
1) A study of 183 patients with early stage non-Hodgkin's lymphoma treated with CHOP chemotherapy and local radiation found a 98% complete response rate and 83% 5-year survival rate.
2) The chemotherapy regimen consisted of cyclophosphamide, doxorubicin, vincristine, and prednisone, followed by radiation therapy one month after the last chemotherapy treatment.
3) The authors concluded that this combined approach of short-term CHOP chemotherapy followed by local radiation should be considered the standard of care for stages I-II non-Hodgkin's lymphoma.
This study compared short-course radiotherapy to long-course chemoradiation for patients with T3 rectal cancer. It found that long-course treatment resulted in a lower risk of local tumor recurrence, though the difference was not statistically significant. Both treatments had similar rates of distant tumor recurrence and overall survival. Long-course treatment seemed to provide a greater benefit for distal tumors, with fewer local recurrences, but again the difference was not statistically significant due to the small number of distal tumors.
This study evaluated the safety of using radiation therapy concurrently with CDK4/6 inhibitors to treat 133 patients with metastatic hormone receptor-positive breast cancer. The study found that using radiation therapy concurrently did not significantly increase adverse events grades 3 or higher, any grade toxicity, rates of dose reduction or discontinuation of CDK4/6 inhibitors. Additionally, concurrent radiation therapy did not negatively impact progression-free or overall survival rates. The results suggest radiation therapy can be safely combined with CDK4/6 inhibitors without increasing toxicity or interfering with systemic treatment.
The document discusses adjuvant radiation therapy for gallbladder carcinoma based on available literature. It summarizes several retrospective studies that found improved survival outcomes with adjuvant radiation or chemoradiation after surgical resection compared to surgery alone, especially for node-positive or advanced-stage disease. However, it notes the evidence is limited due to the rarity of the disease and lack of large randomized controlled trials. While adjuvant therapy appears logical, more research is still needed to better define its role and optimal use.
This case study evaluated the effectiveness of adding cetuximab to radiotherapy for the treatment of squamous-cell carcinoma of the head and neck. 424 patients were randomly assigned to receive radiotherapy alone or radiotherapy plus cetuximab. The study found that combining cetuximab with radiotherapy significantly increased both the duration of control of locoregional disease and overall survival rates compared to radiotherapy alone, with a 32% reduced risk of locoregional progression and a 26% reduced risk of death. Common adverse effects of cetuximab included rash and hypersensitivity reactions.
This document summarizes the use of PET-CT in staging and assessing treatment response in Hodgkin's lymphoma. It discusses that PET-CT is an important tool for initial staging, assessing response to chemotherapy, and prognostic indicator when done after partial chemotherapy. The sensitivity and specificity of PET-CT is higher than CT alone for detecting nodal and organ involvement. PET-CT may avoid the need for bone marrow biopsy in some cases. Interim PET imaging helps distinguish residual mass as viable tumor or necrosis/fibrosis. The document also reviews chemotherapy regimens like ABVD, BEACOPP and Stanford V in early and advanced Hodgkin's lymphoma.
Gary H Lyman discusses chemotherapy-induced neutropenia and the use of colony-stimulating factors to manage it. Chemotherapy often causes neutropenia, which can lead to febrile neutropenia and complications that reduce chemotherapy dose intensity. Colony-stimulating factors like G-CSF have been shown in clinical trials to reduce the risk of febrile neutropenia and allow for full dose chemotherapy. Clinical practice guidelines from organizations like EORTC and ASCO recommend using colony-stimulating factors for patients with a high risk (over 20%) of febrile neutropenia or when dose-dense chemotherapy is associated with improved survival.
34320294 jak inhibitors more than just glucocorticoids (1)EVELIN LÁZARO
This editorial discusses recent trials investigating immunomodulatory therapies for COVID-19. It finds that treatment with glucocorticoids (dexamethasone) and JAK inhibitors reduces mortality in hospitalized patients receiving supplemental oxygen or ventilation. Combining JAK inhibitors with glucocorticoids may widen the window of benefit compared to either treatment alone. The editorial concludes that anti-inflammatory therapies reduce mortality in COVID-19 patients with moderate to severe disease, and that JAK inhibitors are a particularly promising option due to their oral administration, safety profile, and potential for combination with glucocorticoids.
Small cell lung cancer (SCLC) accounts for 15-20% of lung cancers. It is an aggressive disease with rapid growth and early metastasis. The median survival is 2-4 months without treatment. Pathology shows dense sheets of small cells with scant cytoplasm and frequent mitoses. Immunohistochemistry markers include CD56, chromogranin, and synaptophysin. SCLC commonly causes paraneoplastic syndromes. Treatment involves chemotherapy with cisplatin and etoposide combined with early, accelerated thoracic radiotherapy to improve survival outcomes. Prognosis remains poor, especially in extensive stage disease.
- Renal cell carcinoma (RCC) incidence has increased in recent years, with 20-50% of localized cases progressing to metastatic cancer.
- Several risk stratification models (UISS, SSIGN, Leibovich) are used to predict survival and guide surveillance and treatment eligibility.
- Early adjuvant trials of VEGF TKIs like sunitinib and sorafenib showed minimal improvement in disease-free survival at significant cost of toxicity.
- The KEYNOTE-564 trial showed significant improvement in disease-free survival for high-risk RCC patients treated with adjuvant pembrolizumab compared to placebo.
Lenalidomide maintenance compared with placebo in responding elderlyravi jaiswal
This randomized phase III trial compared lenalidomide maintenance therapy versus placebo in elderly patients with diffuse large B-cell lymphoma (DLBCL) who achieved a response to first-line R-CHOP induction therapy. The trial found that lenalidomide maintenance led to a statistically significant improvement in progression-free survival compared to placebo, with a median PFS not reached in the lenalidomide arm versus 58.9 months in the placebo arm. There was no significant difference in overall survival between the arms. Lenalidomide maintenance was associated with more grade 3-4 adverse events compared to placebo. The benefit of lenalidomide maintenance was seen across patient subgroups.
This document summarizes several oral presentations made at the 36th Annual Conference of the Association of Radiation Oncologists of India. It includes summaries of studies on locally advanced breast cancer, locally advanced cervical cancer, laryngeal cancer, head and neck cancer, and cancer of the lip. One study found that adding paclitaxel to standard neoadjuvant chemotherapy improved outcomes for locally advanced breast cancer. Another study found that low-dose radiation prior to chemoradiation reduced tumor size and improved outcomes for cervical cancer. A third study compared outcomes and toxicities of different radiation techniques for laryngeal cancer.
Breast cancer is the commonest cancer and leading cause of cancer death in women. Triple negative breast cancers are ER, PR and Her 2 Neu negative. These tumors have high propensity for metastatic spread. The lack of expression of ER, PR and Her 2 Neu receptors makes chemotherapy only option available to treat these aggressive tumors.
Breast Cancer is the commonest cancer and leading cause of cancer death in women. In the year 2012 approximately 1,671,149
new patients were diagnosed with breast cancer and 521,907
deaths were attributed to this menace [1]. According to SEER
Cancer Registry 95% of the patients have localized disease at
initial presentation whereas 5% of patients present with metastatic disease [2]. About 20-30% of early stage patients develop
systemic disease at some point in life [3]. In Pakistan every year
approximately 90,000 women are diagnosed with breast cancer
and most of these patients have either locally advanced or metastatic disease [4]. A study conducted by Gilani et al. [5] showed
that 25-36% of Pakistani women present with disseminated disease.
Analysis of Radiation Cystitis and Radiation Proctitis Cases in Patients with...Premier Publishers
Carcinoma cervix is commonly seen in India and is mostly diagnosed at an advanced stage where radiation therapy forms the basis of its treatment. Radiation cystitis and proctitis are commonly seen in these patients and contribute to increased morbidity and mortality. The aim of our study was to analyze the factors associated with radiation cystitis and proctitis in treated patients of carcinoma cervix. A retrospective observational study. All treated patients of carcinoma cervix from 2012 to 2017 with radiation induced cystitis and proctitis attending GOPD were analyzed. Descriptive statistics applied using SPSS software (Version 16). Chi square test and Fischer t test applied for calculating significance values. 100 cases were analyzed in toto. 89% belonged to radiation proctitis group and 11% to radiation cystitis group. All patients received external beam radiotherapy either in the form of conventional (90%) or IMRT technique (10%). Prevalence of radiation proctitis and cystitis in conventional radiotherapy group was 10.4% and 1.31% respectively and in IMRT group was 6.29% and 0.69% respectively. The patients were followed up after treatment for a minimum of 6 months. 100% cystitis cases were cured. But, 15.7% of proctitis cases did not get relieved of their symptoms. Radiation proctitis was seen more in patients receiving conventional radiotherapy via LINAC accelerators as compared to IMRT technique. More patient load, lack of adequate packing methods may contribute to increased incidence of RT related complications. Further evaluation of these patients is required to suggest management protocols and also to avoid them.
Metronomic chemotherapy involves the chronic administration of low, minimally toxic doses of chemotherapy drugs on a frequent schedule with no prolonged breaks. This contrasts with conventional chemotherapy which uses maximum tolerated doses with breaks to allow for bone marrow recovery. Metronomic chemotherapy aims to target the tumor vasculature through its anti-angiogenic effects and has shown efficacy in palliative settings with less toxicity. Several drugs have been used in metronomic chemotherapy regimens with the most common being cyclophosphamide and methotrexate. Ongoing research is focused on optimizing dosing schedules and biomarkers to evaluate treatment response and resistance.
Radiosensitivity and cell age in mitotic cycle .pptxKiran Ramakrishna
1) The document discusses cell cycle analysis techniques like autoradiography using tritium-labeled thymidine and bromodeoxyuridine staining to determine what phase of the cell cycle cells are in.
2) It describes how synchronizing cells through mitotic shake-off or hydroxyurea blocking allows studying the effects of radiation at different phases, finding sensitivity is highest in M and lowest in S phase.
3) Checkpoint genes can stop the cell cycle if DNA is damaged, preventing mitosis, and their absence leads to higher radiation and cancer risks. The oxygen effect is also less for denser ionizing radiations.
This document discusses various cancer susceptibility syndromes. It begins by defining cancer susceptibility and the genetic and epigenetic factors that influence it. It then discusses several key syndromes in more detail, focusing on the genes involved, inheritance patterns, clinical features, and cancer risks. These include retinoblastoma (RB1 gene), Lynch syndrome (DNA mismatch repair genes), hereditary breast-ovarian cancer (BRCA1/2), neurofibromatosis type 1 (NF1 gene), and familial adenomatous polyposis (APC gene). It also outlines other syndromes categorized by the genes' functions in genomic integrity, proliferation, translation regulation, and angiogenesis.
Leukemia are neoplastic disorders of the hematopoietic system characterized by aberrant or arrested differentiation. There are two main types - acute and chronic leukemias. Acute leukemias are further classified as myeloid or lymphoid based on the lineage of the malignant cells. Chromosomal abnormalities are detected in the majority of acute leukemia cases and correlate with specific disease subtypes and clinical outcomes. Treatment involves induction chemotherapy followed by consolidation therapy and stem cell transplantation for eligible patients, with cure rates varying based on disease risk factors.
Craniospinal irradiation involves treating the entire brain and spinal cord to prevent spread of certain cancers. It was pioneered in the 1950s for medulloblastoma and other tumors. The target area includes the brain, spinal cord down to S2 or S3. Planning challenges include immobilizing the large target area and minimizing dose inhomogeneity at field junctions. Techniques like prone positioning, double junction fields, and IMRT aim to deliver a uniform dose while sparing organs at risk.
This document discusses pain management in cancer patients. It defines pain and describes the different types of pain. It discusses the pathophysiology of pain pathways and various scales used to assess and grade a patient's pain. It also discusses barriers to effective pain management and the WHO analgesic ladder for treating cancer pain with non-opioid and opioid medications like paracetamol, NSAIDs, tramadol, morphine, fentanyl, and methadone. Adjuvant therapies and alternative treatments are also mentioned.
1) Endometrial cancer is the most common gynecologic cancer and risk increases with factors like postmenopausal bleeding, obesity, diabetes, and unopposed estrogen use.
2) Diagnostic workup includes endometrial biopsy or D&C followed by surgical staging including TAH/BSO and lymph node assessment.
3) Treatment depends on surgical staging - low risk receives no additional treatment; intermediate receives vaginal brachytherapy; high risk receives pelvic radiation with concurrent chemotherapy based on GOG-249 trial results showing improved outcomes.
This document summarizes various benign, premalignant, and malignant lesions of the penis. It discusses the etiology, diagnosis, staging, and management of penile carcinoma. The main types of penile carcinoma are squamous cell carcinoma (>95%) and mesenchymal tumors (<3%). Risk factors include phimosis, number of sexual partners, and HPV infection. Diagnosis involves physical exam, imaging, and histology. Treatment options depend on the location, size, stage, and grade of the tumor, and may include surgery, radiation therapy, chemotherapy, or a combination. Surgery ranges from circumcision to penectomy, while radiation includes brachytherapy and external beam radiation therapy. Prognosis depends on
This document discusses the management of bladder carcinoma. It covers diagnosis through cystoscopy and imaging. Staging is described using the TNM system. Treatment options are provided for non-muscle invasive bladder cancer including transurethral resection and intravesical therapies. Muscle invasive bladder cancer treatment involves radical cystectomy with urinary diversion or bladder preservation approaches using chemoradiation. Adjuvant therapies and management of metastatic disease is also outlined. Complications of treatment and approaches to radiotherapy are summarized.
This document summarizes the management of prostate carcinoma. It discusses clinical features, risk stratification, treatment options including active surveillance, radical prostatectomy, radiation techniques, adjuvant and salvage radiation therapy, brachytherapy, and androgen deprivation therapy. Treatment is tailored based on risk factors, tumor characteristics, and patient factors. Image-guided radiation therapy helps ensure accurate targeting of the prostate. Dose escalation and addition of hormones improves outcomes for intermediate- and high-risk disease.
This document provides guidelines for the management of prostate carcinoma. It discusses risk stratification, treatment options including active surveillance, radiation therapy techniques, brachytherapy, adjuvant radiation, androgen deprivation therapy, and follow-up schedules. Treatment is tailored based on risk level (very low, low, intermediate, high, very high risk) and life expectancy. Image-guided radiation therapy allows for daily adjustment of patient positioning and beam targeting. Androgen deprivation therapy is an important part of treatment for intermediate to very high risk disease. Follow-up involves monitoring PSA levels at regular intervals post-treatment.
1) Accelerated partial breast irradiation (APBI) delivers radiation to only the portion of the breast surrounding the tumor site after breast-conserving surgery, shortening treatment time compared to whole breast irradiation (WBI).
2) Several phase III trials have found APBI to have local control rates comparable to WBI with reduced toxicity, though some trials found slightly higher recurrence rates with APBI.
3) Toxicity and cosmetic outcomes vary by technique, with brachytherapy generally showing better results than external beam techniques.
This document summarizes several landmark trials in breast cancer treatment. It describes trials evaluating chemoprevention using tamoxifen and raloxifene, surgery including lumpectomy versus mastectomy, sentinel node biopsy versus axillary dissection, and the role of radiation therapy. Key findings include that lumpectomy with radiation was found to have similar survival as mastectomy, sentinel node biopsy reduced arm morbidity compared to axillary dissection, and radiation therapy after lumpectomy lowered the risk of recurrence in early-stage breast cancer patients.
This document discusses management of oral cavity cancer. It covers the incidence, risk factors, patterns of spread, staging, and treatment approaches for oral cavity cancer. The main treatment approaches are surgery, radiotherapy including external beam radiotherapy and brachytherapy, and concurrent chemoradiotherapy. Surgery involves excision of the primary tumor with margins and neck dissection. Reconstruction options after surgery include skin grafts, regional flaps, and free flaps. Brachytherapy is used as monotherapy or with external beam radiotherapy for early stage tumors. Selection criteria for brachytherapy include early stage disease localized to the organ of origin.
The document discusses management of oropharyngeal cancers. The oropharynx includes areas like the base of the tongue, soft palate, tonsils and posterior pharyngeal walls. Oropharyngeal cancers commonly spread to cervical lymph nodes in levels II, III and IV. Risk factors include age, gender, smoking, alcohol and HPV infection. Treatment may involve surgery, radiation therapy or chemotherapy depending on the stage of cancer. Imaging tests like CT, MRI and PET scans are used to stage the cancer and detect metastases.
This document discusses guidelines for cancer screening and the National Cancer Control Programme in India. It provides screening guidelines for several common cancers, including breast, cervical, colorectal, lung and prostate cancer. Screening aims to detect cancer before symptoms appear using tests such as blood tests, medical imaging or stool tests. Early detection can improve health outcomes. The National Cancer Control Programme also aims to increase awareness and improve access to screening and treatment services across India.
Dr. Kiran Kumar discusses the management of pituitary tumors. Pituitary tumors are most commonly found in adults aged 30-60 years and can cause hormonal issues or mass effect symptoms. Diagnostic evaluation involves blood tests, MRI imaging, and visual field testing. Treatment options include observation for small asymptomatic tumors, medication to control hormone levels, surgery to remove the tumor, and radiation therapy as an adjuvant treatment or for inoperable tumors. The goals of treatment are to remove the tumor, control hypersecretion, and preserve pituitary function without injury to surrounding structures.
1) Endometrial cancer is the most common gynecologic cancer in developed countries, with a lifetime risk of 1 in 35 women. It occurs most often in postmenopausal women.
2) Diagnosis involves endometrial biopsy or dilation and curettage to obtain tissue samples. Staging involves total abdominal hysterectomy and bilateral salpingo-oophorectomy.
3) For low-risk early-stage disease, no additional treatment is typically needed. For high-risk early-stage disease, adjuvant pelvic radiation with or without chemotherapy is recommended based on trials such as PORTEC-3.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
This document provides information on the management of soft tissue sarcoma. It discusses the clinical presentation, patterns of spread, imaging, histology, grading, staging, prognostic factors and management of soft tissue sarcomas. The key points are:
1) Soft tissue sarcomas most commonly present as painless swellings in the extremities and can invade locally along fascial planes. Imaging like MRI is important for assessing tumor extent.
2) Histologically, the most common subtypes are undifferentiated pleomorphic sarcoma and liposarcoma. Grading systems consider tumor differentiation, mitosis and necrosis.
3) Staging is based on tumor size, depth, nodal status and metastasis
This document discusses various benign, premalignant, and malignant lesions of the penis. It covers the etiology, risk factors, diagnosis, staging, and management options for penile cancer including surgery, radiotherapy, and chemotherapy. The main types of penile cancer are squamous cell carcinoma (>95%) and mesenchymal tumors (<3%). Surgical options range from circumcision to partial or total penectomy. Radiotherapy can be delivered via brachytherapy or external beam radiation. Management depends on tumor stage, size, histology, and patient preferences regarding organ preservation.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Travel Clinic Cardiff: Health Advice for International Travelers
Journal club hd 10 trial dr kiran
1. Reduced Treatment Intensity in Patients
with Early-Stage Hodgkin’s Lymphoma
Andreas, M.D., Annette Ph.D., Hans, M.D.,et al.
DR Kiran Kumar BR
2. BACKGROUND
Whether it is possible to reduce the intensity of
treatment in early (stage I or II) Hodgkin’s lymphoma
with a favorable prognosis remains unclear.
Therefore they conducted a multicenter, randomized
trial comparing four treatment groups consisting of a
combination chemotherapy regimen of two different
intensities followed by involved-field radiation
therapy at two different dose levels.
3. INTRODUCTION
Radiation therapy was the original mainstay of treatment for patients who had
early-stage Hodgkin’s lymphoma with a favorable prognosis.
With the use of such techniques as extended-field radiation therapy and total
lymphoid irradiation, more than 80% of patients with localized disease
became long-term survivors.
However, the relapse rate with radiation therapy alone ranged from 20 to
40%,and extended-field radiation therapy and total lymphoid irradiation
were associated with the occurrence of secondary solid tumors.
The integration of a chemotherapy regimen consisting of doxorubicin,
bleomycin, vinblastine, and dacarbazine (ABVD) with radiation therapy
resulted in greater efficacy and allowed the radiation field and dose to be
reduced, leading to widespread use of the combined approaches in patients
with early-stage Hodgkin’s lymphoma and a favorable prognosis.
Four cycles of ABVD followed by 30 Gy of involved-field radiation therapy is
now regarded as the standard of care by many groups.11-14 The use of
chemotherapy alone has been considered as a potential alternative approach
but remains controversial.
4. Whether the number of treatment cycles and the radiation dose
can be reduced in patients with early-stage Hodgkin’s
lymphoma and a favorable prognosis remains unclear.
In an attempt to reduce the toxic effects of treatment while
retaining full control of the cancer, the German Hodgkin Study
Group (GHSG) in 1998 initiated a prospective, randomized,
multicenter study (HD10) in which four cycles of ABVD
chemotherapy were compared with two cycles of ABVD, and
30 Gy of involved-field radiation therapy was compared with
20 Gy of involved-field radiation therapy in patients receiving
either of the two chemotherapy regimens.
5. PATIENTS AND METHODS:
Newly diagnosed Hodgkin’s lymphoma in clinical stage I or II, as
confirmed on histologic examination, with no clinical risk
factors.
Patients were eligible if they were between 16 and 75 years of
age, had not been treated previously for Hodgkin’s lymphoma,
and were free of concurrent disease.
Study Design:
HD10 was a multicenter, randomized study of four different
treatment regimens in patients with early-stage Hodgkin’s
lymphoma and a favorable diagnosis.
6. Chemotherapy
ABVD was administered on days 1 and 15 in monthly cycles:
Doxorubicin, 25 mg/m2
Bleomycin, 10 mg/m2
Vinblastine, 6 mg/m2
Dacarbazine, 375mg/m2
If the TC< 2500 /cu mm or the platelet count <80,000/cu mm
on a day when chemotherapy, treatment was postponed until
normal levels were achieved.
GCSF was given if clinically indicated.
7. Radiation therapy
Before treatment, all sites of disease were defined and
documented by the treating medical oncologist and
radiation oncologist.
A central panel of experts in radiation oncology then planned
involved- field radiation therapy as defined in the study
protocol according to treatment group and, if necessary,
revised the initial staging.
The recommended interval between completion of the ABVD
regimen and the start of radiation therapy was 4 to 6 weeks.
Patients received either 30 Gy or 20 Gy of involved-field
radiation therapy in single fractions of 1.8 to 2.0 Gy
administered five times weekly.
8.
9. End Points
• Primary end point : Freedom from treatment
failure.
• Secondary end points : Overall survival,
progression-free survival, complete response,
and treatment toxicity.
10. Statistical Analysis
Proof of the noninferiority of the less intensive treatment, as compared with
the standard treatment of four cycles of ABVD plus 30 Gy of involved-
field radiation therapy, with respect to freedom from treatment failure at 5
years was the goal for both chemotherapy and radiation therapy. The
noninferiority margin was defined as 7% in the study protocol. This led to
the following two hypotheses: for chemotherapy, the 5-year rate of freedom
from treatment failure in the two pooled groups assigned to two cycles of
ABVD would be less than 7% below the rate in the two pooled groups
assigned to four cycles, and for radiation therapy, the 5-year rate of
freedom from treatment failure in the two pooled groups assigned to 20 Gy
of involved-field radiation therapy would be less than 7% below the rate in
the two pooled groups assigned to 30 Gy. Survival rates for the four groups
were compared with the use of the Kaplan–Meier method as well as
stratified Cox regression analyses for hazard ratios (i.e., the chemotherapy
comparison was stratified according to the radiation therapy assignment
and vice versa), whereas outcomes and toxicity rates were compared with
the use of Fisher’s exact test. Tests of the hypotheses were performed
according to the intention-to-treat principle and also on the basis of the
treatment actually received. Subgroup analyses were not prespecified in the
statistical-analysis plan, but we performed post hoc sensitivity analyses that
excluded patients with nodular lymphocyte- predominant Hodgkin’s
lymphoma.
11. Statistical Analysis
In addition, to estimate the combined effect of reduced
chemotherapy and reduced radiation therapy, we compared
group 1, which received the most intensive therapy, with group
4, which received the least intensive therapy. To detect a
possible influence of prognostic factors or interactions
between the effects of chemotherapy and those of radiation
therapy, multivariate Cox regression analyses were specified in
the protocol and performed as sensitivity analyses on the same
data sets for comparing the two chemotherapy regimens and
the two radiation therapy regimens.
13. Adverse Events
Toxicity of Treatment
Acute toxicity during chemotherapy was more frequent in patients who
received four cycles of ABVD than in those who received two
cycles (Table 2). Overall, 51.7% of the patients who received four
cycles of ABVD had at least one instance of severe toxicity (grade
III or IV) as compared with 33.2% of those who received two cycles
(P<0.001). The most frequent events were hair loss (in 28.1% of
patients receiving four cycles vs. 15.2% of those receiving two
cycles) and hematologic toxic effects (24.0% vs. 15.0%). Infections
were also more common with four cycles of ABVD than with two
cycles (5.1% vs. 1.7%). Treatment-related deaths occurred in six
patients treated with four cycles of ABVD (two died from
pulmonary fibrosis, two from sepsis, one from pneumonia, and one
from an unspecified cause) and in one patient treated with two
cycles (from pulmonary fibrosis). Severe toxicity (grade III or IV)
was observed more often among the patients treated with 30 Gy of
involved-field radiation therapy than among those who received 20
Gy (8.7% vs. 2.9%, P<0.001).
14. Secondary Neoplasia
Over a median follow-up period of 7.5 years (90
months), secondary cancers were diagnosed in a
total of 55 patients (4.6%): 38 solid tumors, 15 cases
of non-Hodgkin’s lymphoma, and 2 cases of
acute myeloid leukemia. There were no significant
differences in the occurrence of secondary cancers
among the four treatment groups (P = 0.59),
the pooled chemotherapy groups (P = 0.89), or the
pooled radiation therapy groups (P = 0.34).
Deaths
A total of 57 patients (4.8%) died during the follow-
up period. The most frequent causes of death
were secondary neoplasia (in 11), Hodgkin’s lymphoma
(in 10), cardiovascular events (in 9), toxicity
of primary therapy (in 7), and toxicity of salvage
therapy (in 5, all after having received two
cycles of ABVD). No difference in mortality was
noted among the four groups or between the combined
chemotherapy groups and the combined
radiation therapy groups
15.
16.
17. Disease Control and Survival
Final treatment outcomes were as follows: 1150 of 1190 patients
(96.6%) had a complete remission, 8 (0.7%) had a partial remission,
and 8 (0.7%) did not have a response (2 had no change and 6 had
progression of disease during treatment). (Response criteria are
described in the Supplementary Appendix.) For 24 patients (2.0%),
the treatment outcome was unclear. The relapse rate was 6.0% (71
of 1190 patients). No significant differences were seen in rates of
remission, progression, or relapse among the four treatment groups
or between the combined chemotherapy groups and the combined
radiation therapy groups. The rates of freedom from treatment
failure in the whole intention-to-treat analysis set of 1190 patients
were estimated to be 92.0% (95% confidence interval [CI], 90.2 to
93.5) at 5 years and 87.1% (95% CI, 84.5 to 89.3) at 8 years. The
overall survival rates for all 1190 patients were estimated to be
96.8% (95% CI, 95.7 to 97.7) at 5 years and 94.5% (95% CI, 92.8 to
95.8) at 8 years (Table 3). For the same patients, the rate of
progression- free survival was estimated to be 92.4% (95% CI, 90.6
to 93.8) at 5 years and 87.6% (95% CI, 85.0 to 89.7) at 8 years.
18. Chemotherapy Comparison
In the intention-to-treat analysis, the median observation time for the primary
end point, freedom from treatment failure, was identical in the two
chemotherapy groups (79 months). The rate of freedom from treatment
failure at 5 years was 93.0% with four cycles of ABVD (95% CI, 90.5 to
94.8) and 91.1% with two cycles (95% CI, 88.3 to 93.2) (Table 3). On the
basis of the stratified Cox regression analysis, the hazard ratio for treatment
failure with two cycles of ABVD as compared with four cycles was 1.17
(95% CI, 0.82 to 1.67). The 5-year estimated group difference (two cycles
vs. four cycles) was −1.9 percentage points (95% CI, −5.2 to 1.4). The
sensitivity analysis, based on treatment received per protocol, showed a 5-
year estimated group difference of −2.3 percentage points (95% CI, −5.6 to
2.9). On the basis of these results, the predefined 7% inferiority of two
cycles of ABVD plus radiation therapy can be excluded for the primary end
point, freedom from treatment failure. The intention-to-treat analysis
showed no significant differences between the two chemotherapy groups
for the secondary end points of overall survival (P = 0.93; hazard ratio for
death, 1.02 [95% CI, 0.61 to 1.72]) and progression-free survival (P = 0.28;
hazard ratio for progression, relapse, or death from any cause, 1.22 [95%
CI, 0.85 to 1.77]).
19. Radiation therapy Comparison
In the intention-to-treat analysis of radiation therapy, the median
observation time for the primary end point, freedom from treatment
failure, was similar in the two groups: 77 months with 20 Gy and 80
months with 30 Gy. The rate of freedom from treatment failure at 5
years was 93.4% (95%−3.6 to 2.6). The sensitivity analysis based on
therapy received showed a 5-year estimated group difference of −0.2
percentage points (95% CI, −3.3 to 2.8). Thus, the predefined 7%
inferiority of chemotherapy plus 20 Gy of radiation therapy can be
excluded for the primary end point (freedom from treatment failure).
The intention-to-treat analysis showed no significant differences
between the radiation therapy groups for the secondary end points of
overall survival (P = 0.61; hazard ratio for death, 0.86 [95% CI, 0.49
to 1.53]) and progression- free survival (P = 0.98; hazard ratio for
progression, relapse, or death from any cause, 1.01 [95% CI, 0.68 to
1.48]). Overall, the rates of freedom from treatment failure might
appear to be higher than those in a pure intention-to-treat analysis,
since patients who dropped out before radiation therapy were
excluded from this analysis. However, this was unlikely to affect
between group comparisons.
20. Prespecified Regression Analyses
Prespecified factors included in the multivariate model were
age above 50 years (P<0.001) and infradiaphragmatic
disease (P = 0.24), whereas male sex (P = 0.32), systemic
symptoms (P = 0.75), and a low albumin level (P = 0.54)
were excluded. In the multivariate model including age,
infradiaphragmatic involvement, and randomization group,
no significant interaction was detected between the effects
of the number of chemotherapy cycles and the radiation
therapy dose.
Comparison of Groups 1 and 4
As shown in Figure 2, no significant difference in the rate of
freedom from treatment failure was seen between groups 1
and 4 according to the stratified log-rank test (P = 0.79).
The 5-year estimate for the group difference was −1.6
percentage points (95% CI, −6.3 to 3.1), which is better
than the noninferiority margin of −7 percentage points.
21. Discussion
The aim of the HD10 study was to determine whether fewer cycles of chemotherapy
and lower doses of radiation therapy could be delivered while maintaining high
rates of disease control in patients with early Hodgkin’s lymphoma and a favorable
prognosis who were undergoing combined- approach treatment programs. No
difference in efficacy was noted between the two-cycle ABVD regimen and the
four-cycle regimen when each was combined with involved-field radiation therapy.
This was true for the primary end point, freedom from treatment failure at 5 years,
as well as for all other efficacy end points, such as response, overall survival, and
progression-free survival. The results were robust with longer followup (8 years).
No differences were seen between the intention-to-treat and the per-protocol
analyses. With regard to radiation therapy, the rate of freedom from treatment
failure at 5 years was 93.4% (95% CI, 91.0 to 95.2) with 30 Gy of involved- field
radiation therapy and 92.9% (95% CI, 90.4 to 94.8) with 20 Gy. The results
presented here show noninferiority for both fewer cycles of chemotherapy and a
lower dose of radiation, on the basis of a noninferiority margin of 7 percentage
points. However, confidence intervals were rather wide for differences in freedom
from treatment failure and hazard ratios. Although the 5-year estimate for the
group difference between the most intensive treatment and the least intensive
treatment in this study was only 1.6 percentage points, a potential difference of
6.3 percentage points in favor of the more intensive treatment cannot be excluded
and must be weighed against the reductions in acute and late toxicity, lower costs
of treatment, and better quality of life associated with shorter and less intense
treatment.
22. One of the key objectives in the treatment of Hodgkin’s lymphoma is to
reduce the intensity of first-line therapy as much as possible while
maintaining tumor control. This is most relevant for early disease
with a favorable prognosis, which accounts for about 30% of all
cases of Hodgkin’s lymphoma,1 since overall survival rates are
compromised by late treatment-related mortality.4-8 In the HD10
study, two cycles of ABVD as well as 20 Gy of radiation resulted in
reduced rates of acute toxicity. Overall, 51.7% of patients treated
with four cycles of ABVD had grade III or IV toxicity, as compared
with 33.2% of those receiving two cycles (P<0.001). The rates of
acute toxicity (grade III or IV) were also higher among patients
treated with 30 Gy of involved-field radiation therapy than among
those receiving 20 Gy (8.7% vs. 2.9%, P<0.001). Although there
were numerical differences between the radiation therapy groups
with respect to secondary cancers (24 [4.1%] vs. 31 [5.4%]), these
findings were not significant and might have been due to chance.
Clearly, longer
23. follow-up is needed to identify differences in longterm toxicity, such as
secondary neoplasia and severe organ damage, among different
treatment approaches. Given that many of the late, fatal
complications of radiation therapy do not emerge until the second
decade after treatment, our data cannot speak to the effect of
treatment on overall survival.
Since radiation therapy is associated with the development of
secondary solid tumors 5 to 25 years after initial treatment,4-8 some
groups advocate the use of chemotherapy alone for patients with
early-stage Hodgkin’s lymphoma. Usually, six cycles of ABVD are
given, and there has been some controversy on this issue.15-19 For
this group of patients, combined-approach treatment programs have
provided superior tumor control when compared directly with
chemotherapy alone in some studies20-24 but not in others.15,19
Currently, combined- approach treatment programs are widely used
as the treatment of choice in early-stage Hodgkin’s lymphoma, and
our study suggests that a shorter chemotherapy regimen with a lower
radiation dose preserves a high level of disease control. With an
overall survival rate of 95.1% at 8 years, some patients may still be
overtreated.
24. However, the established clinical risk factors, which are based
on measures such as the International Prognostic Score,25
currently do not allow identification of patients who can be
cured with even less treatment. The use of positron-
emission tomography (PET) might help to discriminate
between patients at low risk and those at high risk, both
early in the course of chemotherapy26 and after its
completion.27 The potential effect of PET in patients with
Hodgkin’s lymphoma has also been suggested in a number
of retrospective, nonrandomized studies.28-30 Several
ongoing trials are evaluating the role of PET in identifying
patients with early Hodgkin’s lymphoma and a favorable
prognosis who might not need additional radiation therapy
after two cycles of ABVD (the German Hodgkin Study
Group Hodgkin Disease 16 [the current GHSG HD16] trial
[ClinicalTrials.gov number, NCT00736320]) or after three
cycles of ABVD (the European Organization for Research
and Treatment of Cancer [EORTC H10F] trial
[ClinicalTrials.gov number, NCT00433433] and others).
25. Summary:
HD10 trial showed that in patients with early-
stage Hodgkin’s lymphoma and a favorable
prognosis, treatment with two cycles of ABVD
followed by 20 Gy of involved-field radiation
therapy is as effective as, and less toxic than,
four cycles of ABVD followed by 30 Gy of
involved-field radiation therapy.
26.
27.
28. Long-Term Side Effects
This evaluation showed that after 10 years of follow-up,
No significant difference was observed between the two study groups
with respect to other late toxic effects or performance status.
A total of 191 second cancers were diagnosed in the nodal-irradiation
group and 222 were diagnosed in the control group.
At 10 years Nodal irradiation Control group
pulmonary fibrosis 4.4% 1.7% P<0.001
cardiac fibrosis 1.2% 0.6% P = 006
cardiac disease 6.5% 5.6%, P = 0.25
29. Disease-free Survival and Distant Disease-free Survival:
At the time of the final analysis,
Recurrence of disease in the regional nodes in 139 patients,
local recurrences had developed in 219 patients, and
distant disease had developed in 711 patients.
At 10 years Nodal irradiation Control group
Disease-free
survival
72.1% 69.1%
Distant disease-free
survival
78.0% 75.0%
Rate of any first
recurrence
19.4% 22.9%
30.
31. Overall Survival and Breast-Cancer
Mortality
In total, 382 patients who underwent regional nodal irradiation and 429
patients who did not undergo regional nodal irradiation died. In both
groups, the main cause of death was breast cancer.
At 10 years Nodal irradiation Control group
Overall Survival 82.3% 80.7% (P-0.06)
Rate of death from
breast cancer
12.5% 14.4 (p-0.02)
32.
33. Discussion:
At a median follow-up of 10.9 years, study showed that
irradiation of the internal mammary and medial
supraclavicular lymph nodes (regional nodal irradiation)
was associated with a small but significant benefit with
respect to the rates of disease-free survival, distant
disease free survival, and death from breast cancer.
Overall survival at 10 years exceeded 80%, and the main
cause of death remained breast cancer (67.8% in the
nodal-irradiation group vs. 72.3% in the control group).
34. The recently published meta-analysis of the Early Breast Cancer
Trialists’ Collaborative Group included individual data on 8135
women from 22 trials who were treated with mastectomy and
axillary surgery and were randomly assigned to undergo or not
undergo locoregional irradiation.
In patients who had involved axillary nodes after axillary dissection,
locoregional irradiation was associated with significantly lower rates
of regional and overall recurrences and death from breast cancer.
This benefit was independent of the number of involved axillary nodes
(the decrease in the rate of any recurrence was 11.5% among women
with one to three involved axillary nodes vs. 8.8% among women
with four positive nodes, and the corresponding decrease in the rate
of death from breast cancer was 7.9% vs. 9.3%.
In patients with one to three involved nodes, the absolute benefit was
the same with or without systemic therapy.
35. A previous Early Breast Cancer Trialists’ Collaborative Group
meta-analysis, which included individual patient data on
10,801 women in 17 randomized trials, showed a similar
benefit associated with postoperative irradiation after breast-
conserving surgery
Despite this evidence in favor of postoperative irradiation in the
multimodal treatment of most patients after BCS and for all
patients with node-positive breast cancer after mastectomy,
neither the individual randomized trials nor the meta-analyses
provided valuable information on the effect of irradiation of
the respective nodal target volumes.
36. The role of radiation directed to the internal mammary nodes was
questioned, particularly since its use was associated with radiation-
associated cardiac death, which was probably attributable to
outdated radiation techniques.
It remains undefined whether this risk is significantly lowered by
advances in radiation techniques.
The interpretation of these results is complex in the light of current
developments, including a greater proportion of screen-detected
cancers, the increasing use of adjuvant systemic therapy, and
improving radiation-therapy techniques.
The benefit of regional-node irradiation was also seen in patients with
medially or centrally located primary tumors without axillary nodal
involvement.
37. These results are similar to those of the National Cancer Institute
of Canada Clinical Trials Group MA.20 trial. That study,
which involved 1832 patients with node-positive or high-risk
node-negative disease after breast-conserving therapy, showed
that regional nodal irradiation was associated with improved
disease-free survival and distant disease-free survival.
The results of the study by Hennequin et al. showed a lack of
benefit of regional nodal irradiation; however, that study was
smaller than this study and the patients had a poorer outcome
(a 10% lower rate of overall survival at the 5-year follow-up
and a 20% lower rate of overall survival at the 10-year follow-
up).
38. Our study found a low rate of heart disease and death from
heart disease after 10.9 years of follow- up, as has been
reported before.
However, Darby et al. found a dose-dependent increased
risk of late ischemic heart disease associated with
radiotherapy for cancer of the left breast. Cardiac disease
after radiation therapy might have onset early after
treatment.
The radiation therapy techniques used in our trial, guided by
a thorough quality-assurance program, minimized the
radiation dose to the heart, possibly to a clinically less
relevant level, Nevertheless, additional follow-up is
required to assess late cardiac complications.
39. As compared with the previous 3-year morbidity report, They found
only a slight increase in the risk of pulmonary fibrosis. These results
are consistent with the results of studies of late pulmonary disease
after radiation therapy for breast cancer.
The low frequency of lymphedema (10.5% in the control group and
12.0% in the nodal-irradiation group) is probably due to the fact that
the operated part of the axilla was not irradiated unless adverse risk
factors were present.
Overall, only 7.4% of patients in the control group and 8.3% in the
nodal-irradiation group underwent irradiation to the axilla. They
recognize the limitations of our study, which was initiated in the
early 1990s to investigate whether elective regional nodal irradiation
would improve long-term overall survival.
40. Since the regional nodes are functionally interconnected, it was decided to
include the medial supraclavicular nodes, thereby in fact randomizing
between complete nodal treatment (axillary surgery and irradiation of non
dissected nodes) and axillary surgery alone.
Therefore, this study cannot determine whether internal mammary irradiation
or medial supraclavicular irradiation contributed more to the outcome.
However, the recent results from the Danish population-based study in which
patients with left-sided node-positive breast cancer underwent only medial
supraclavicular irradiation, whereas patients with right-sided node-positive
breast cancer underwent both internal mammary and medial supraclavicular
irradiation, support the role of including the internal mammary chain in the
success of regional nodal radiation therapy.
When this trial was designed, adjuvant systemic therapy was not as variable as
it is today and molecular subtypes were not yet described.
41. Summary:
We found that regional nodal irradiation was beneficial to
women with early-stage breast cancer.
It improved the rates of disease-free and distant disease-free
survival and reduced the rate of death from breast cancer
among patients with involved axillary nodes, a medially or
centrally located primary tumor, or both.
Improvement in the rate of overall survival was not confirmed
with 10 years of follow-up. Acute side effects were modest,
and the rate of death from causes other than breast cancer
was not increased.
Post-treatment follow-up for a median of 20 years is ongoing.