Caitlin Yee

Prospective Study of Breast Radiation Dermatitis

Background Despite clear benefits of radiotherapy (RT) for breast cancer, there are numerous side effects. Radiation dermatitis has a significant impact on quality of life and can result in treatment interruptions or cessation. The purpose of this study was to prospectively follow breast radiation dermatitis and determine trends including peak toxicity. Patients and Methods Upon initiation of RT treatment, to assess skin reaction, each patient was seen weekly by the healthcare team, or contacted via telephone to assess patient‐reported symptoms. Weekly progression of radiation dermatitis was assessed using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.03. Patients were stratified for analysis of radiation dermatitis based on RT technique and dosage. Results A total of 148 patients with 2 or more skin assessments were analyzed. The majority of patients received 2‐field tangential RT (64.2%) with a dose of 5000 cGy in 25 fractions. Overall, patients experienced the most Grade 2 CTCAE toxicity (61.9%) 2 weeks after completion of RT; Grade 3 toxicity also peaked at this time (8.3%). Regardless of stratification by RT technique or by dosage of RT, Grade 2 and 3 toxicities consistently peaked at 1 or 2 weeks after RT. Conclusions Breast radiation dermatitis appears to peak approximately 2 weeks after RT. Treatment factors such as technique or dosing regimen do not appear to have a substantial effect on radiation dermatitis, but our study was limited by small sample size. This study provides additional evidence that radiation dermatitis should continue to be followed closely, especially in the 2 weeks following RT. Micro‐Abstract Radiation dermatitis is a common distressing side effect of breast radiotherapy. This study of 148 patients aimed to determine the trend of radiation dermatitis. Radiation dermatitis appears to peak at 2 weeks after radiotherapy; treatment factors such as technique or dosing regimen do not appear to have a substantial effect, but our study was limited by small sample size. Radiation dermatitis should continue to be followed closely, especially in the 2 weeks following RT.

Prevalence of pain in patients with breast cancer post-treatment: A systematic review

PURPOSEnTo evaluate the prevalence and severity of persistent pain after breast cancer treatment (PPBCT) in patients who received surgery, radiotherapy or a combination of treatments and to explore how different treatments and techniques impact pain.nnnMETHODSnMedline, Embase and Cochrane Central databases were searched for articles which evaluated the prevalence of PPBCT. Search results were limited to studies addressing chronic post-surgical pain (CPSP), persistent post-surgical pain (PPSP), post-mastectomy pain syndrome (PMPS) or radiotherapy (RT) related pain in breast cancer patients and published in the English language. The primary outcome was the incidence or severity of PPBCT. Descriptive analyses were performed.nnnRESULTSnA total of 177 studies were included in this review. Overall, pain prevalence was 29.8% amongst 3746 patients (Group 1: 30 studies) post-surgery, 27.3% post-RT (Group 2: 41 studies, nu202f=u202f15u202f019), and 21.8% amongst BC survivors who reported on the general prevalence of after receiving various combinations of BC treatment (Group 3: 106 studies, nu202f=u202f135u202f437).nnnCONCLUSIONnPPBCT remains to be a prevalent and complex clinical issue, despite a variety of different techniques and treatments. Various factors such as varying definitions of pain, inconsistent use of assessment tools and differences in methodology between studies may contribute to discrepancies in reports of PPBCT. A greater understanding of BC treatments and their impact on PPBCT may help identify potential risk factors, prevention and pain management strategies.

A retrospective review of phyllodes tumours of the breast: A single institution experience

BACKGROUNDnPhyllodes tumours are rare and histologically diverse, posing challenges in prognosis and treatment. Due to their rarity, they have seldom been studied.nnnPURPOSEnThe purpose was to investigate clinical practices in the management of phyllodes tumours, as well as patient outcomes to contribute to the limited body of knowledge surrounding these tumours.nnnMETHODSnA retrospective review was conducted on all patients with phyllodes tumours at a single institution. Descriptive analyses were conducted on demographic, disease and treatment (breast-conserving surgery, mastectomy, surgical re-excision, adjuvant/palliative radiation, palliative chemotherapy) information. Overall and disease-free survivals were analyzed, and the cumulative incidence of recurrence and metastases was compared.nnnRESULTSn79 patients with phyllodes tumours of the breast were included in the study. Tumours were classified as malignant, borderline, or benign in 67.1%, 21.5%, and 11.4% of patients, respectively. There were no statistically significant differences in overall or disease-free survival between patients with benign, borderline or malignant disease. Only patients with malignant disease developed recurrence or metastases. Those with malignant disease who received mastectomies had a lower 10-year cumulative incidence of recurrence; however this was not statistically significant (pxa0=xa00.69). All patients had negative surgical margins due to a re-excision or mastectomy following margin-positive breast conserving surgery. Of all risk factors assessed, necrosis was significantly associated with increased incidence of recurrence (local or distant) in patients with malignant disease (pxa0=xa00.03).nnnCONCLUSIONnThe presence of tumour necrosis is a significant negative prognostic factor. Breast-conserving surgery may be adequate in providing local control, given negative surgical margins.

Treatment Outcomes in Male Breast Cancer: A Retrospective Analysis of 161 Patients

AIMSnMale breast cancer is a rare disease with limited evidence-based guidelines for treatment. This study aimed to identify demographic, pathological and clinical factors associated with its prognosis.nnnMATERIALS AND METHODSnA retrospective review of 161 male breast cancer patients diagnosed at a single institution from 1987 to June 2017 was conducted. Patient demographics, disease characteristics, treatment and outcome were extracted and included in competing-risk analysis and the univariate Cox proportional hazard model for univariate analysis. Factors with Pxa0<xa00.10 were included in multivariable analysis.nnnRESULTSnThe mean age at diagnosis was 67 years (standard deviationxa0=xa011.2) and the median follow-up duration was 5.3 years (range 0-25 years). There were 48 deaths, including 23 cancer-specific deaths. The actuarial median survival was 19.9 years. In multivariable analysis, factors associated with overall survival were size of tumours (hazard ratio 2.0; 95% confidence interval 1.4-2.7, Pxa0<xa00.0001) and diagnosis of metastatic disease (hazard ratio 8.7; 95% confidence interval 1.9-40.6; Pxa0=xa00.006). Of 138 patients without metastases at diagnoses, 11 had local-regional recurrence and 26 had distant metastases. In the multivariable model for local-regional recurrence, a more recent year of diagnosis was associated with reduced risk (hazard ratio 0.9, 95% confidence interval 0.8-1.0, Pxa0=xa00.008), whereas more positive lymph nodes was associated with higher risk (hazard ratio 2.2, 95% confidence interval 1.2-4.0, Pxa0=xa00.01). A higher risk of metastases was associated with more positive lymph nodes (hazard ratio 1.9; 95% confidence interval 1.1-3.3; Pxa0=xa00.03) and tumour size (hazard ratio 1.8; 95% confidence interval 1.1-2.9; Pxa0=xa00.01). A higher risk of any recurrence or metastases was associated with the number of positive nodes (hazard ratio 1.9; 95% confidence interval 1.2-3.0; Pxa0=xa00.005) and tumour size (hazard ratio 1.6; 95% confidence interval 1.1-2.2; Pxa0=xa00.01).nnnCONCLUSIONnIn general, tumour size and more positive lymph nodes were associated with worse prognosis. Larger powered studies are needed to identify prognostic factors with smaller effect sizes.

Early Local Recurrence in a Patient With Encapsulated Papillary Carcinoma of the Breast

Encapsulated papillary carcinoma (EPC) of the breast is a rare form of papillary carcinoma with a very good prognosis. EPC, otherwise known as intracystic or encysted papillary carcinoma, is treated as in situ disease in the absence of clear invasion. Lumpectomy alone has generally been considered sufficient treatment for these patients. The use of adjuvant radiotherapy and endocrine therapy remains a matter of debate in reported studies. We present the case of a 51-year-old woman who had undergone lumpectomy with clear margins for pure EPC who declined adjuvant treatment; however, multifocal disease recurred < 16 months after the initial surgery. This unexpected outcome suggests that some forms of EPC could be more aggressive, although, to date, no prognostic biomarkers are available to predict the risk of recurrence. More studies are needed to help identify those patients with EPC that requires more aggressive management than surgery alone.

A Systematic Review of Heart Dose in Breast Radiotherapy

Abstract Radiotherapy (RT) for breast cancer improves survival, but poses risk to the heart, resulting from a linear relationship between RT dose and heart disease. This review presents studies worldwide reporting heart doses from whole breast RT after 2014 to update a previous systematic review (Taylor et al, Int J Radiat Oncol Biol Phys, 2015) in order to determine patterns of current heart dosimetry among varying RT regimens. Studies published between January 2014 and September 2017 were included if they reported whole heart dose based on whole breast RT technique or treatment position and had a sample size of ≥ 20 patients. Studies reporting brachytherapy, proton RT only, or boost to tumor bed were excluded. Among 99 studies, whole heart dose was reported by 231 regimens. The mean heart dose for left‐sided breast cancer, reported by 84 studies (196 regimens), was 3.6 Gy, compared with a review of those previously reported (5.4 Gy). Regimens employing breathing control in any position had a significantly lower mean heart dose (1.7 Gy) compared with regimens without breathing control (4.5 Gy) (P < .0001). The mean heart dose varied significantly between continents (P < .0001), with heterogeneity reported among countries within Europe (P = .04) although not within other continents. On average, the mean heart dose steadily decreased between 2014 (4.6 Gy) and 2017 (2.6 Gy) (P = .003). Other heart dose parameters including the mean dose to the left anterior descending artery were reported by 80 left‐sided regimens, and the mean left anterior descending artery dose was 12.4 Gy.

Radiation-induced Skin Toxicity in Breast Cancer Patients: A Systematic Review of Randomized Trials

Abstract Radiation dermatitis is a common side effect of radiotherapy. Radiation dermatitis has been investigated for decades, and many approaches have been proposed to limit its incidence and severity. The purpose of the present systematic review was to summarize the approaches and findings of studies testing various methods for management of radiation dermatitis in breast cancer patients. Medline, Cochrane, and Embase were searched for studies pertaining to radiation‐induced skin toxicity in breast cancer patients. The search results were limited to randomized trials of external beam radiotherapy conducted in humans and reported in the English language. The primary outcome was the incidence or severity of radiation dermatitis. Descriptive statistical analyses were performed. A total of 96 studies were included in the present review. These evaluated the effect of different radiotherapy techniques, topical treatments, supplements, skin care regimens, and treatments on radiation dermatitis. Few topical agents and oral supplements demonstrated their effectiveness across the randomized trials; however, various radiotherapy techniques, such as intensity‐modulated radiotherapy, hypofractionated radiotherapy, accelerated partial breast irradiation, simultaneous integrated boost, and prone positioning consistently demonstrated decreased rates of radiation dermatitis, despite the limited number of studies in which they were evaluated.

A pilot study with palonosetron in the prophylaxis of radiation-induced nausea and vomiting

BACKGROUNDnPalonosetron is an effective antiemetic in chemotherapy-induced nausea and vomiting (CINV), but has yet to be studied in the radiation setting. The purpose of the present study was to investigate the efficacy and safety of palonosetron in the prophylaxis of radiation-induced nausea and vomiting (RINV).nnnMETHODSnPatients without existing nausea and vomiting undergoing palliative radiotherapy to sites with emetic risk were prescribed palonosetron 0.5 mg orally before the start of radiation treatment, and every other day until completion of treatment. Patients were followed up in acute (day 1 of treatment to day 1 after treatment) and delayed phases (days 2-10 after treatment). The primary endpoint was control of vomiting. Complete control was defined as no use of rescue medication and no episodes of nausea or vomiting. Secondary endpoints included control of nausea and quality of life (QOL). QOL was assessed with the Functional Living Index-Emesis and the European Organisation for Research and Treatment of Cancer QOL Questionnaire-Core 15 Palliative (C15-PAL).nnnRESULTSnIn all evaluable patients (n=75), complete control of vomiting was 93.3% in the acute phase and 93.2% in the delayed phase. Complete control of nausea was 74.7% in the acute phase and 74.0% in the delayed phase.nnnCONCLUSIONSnResults suggest improved control in RINV compared to historical reports with first generation serotonin receptor antagonists (RA). A randomized study will be needed to confirm this finding.

Evaluation of the 3-day recall period for the Functional Life Index- Emesis (FLIE)

BACKGROUNDnNausea and vomiting are commonly experienced by cancer patients, and can be assessed by the Functional Life Index-Emesis (FLIE) instrument which employs a three-day recall period. However, it is unknown whether patients responses to the FLIE better correlate with the average or the worst symptom severity of the recall period, or the severity of an individual day.nnnMETHODSnPatients receiving emetogenic radiotherapy for painful bone metastases who were enrolled in one of three trials for anti-emetic medications (ondansetron, aprepitant/granisetron, or palonosetron) completed the FLIE at baseline, and days 3, 5, 7, or 10 during treatment and follow-up. The concordance correlation coefficient (rc) was calculated between FLIE overall nausea and vomiting and daily nausea, vomiting, and quality of life (QoL) using the average responses of the 3-day recall period and with each of the three days responses.nnnRESULTSnResponses from eighty-nine patients who experienced nausea or vomiting were analysed. The highest concordance for FLIE nausea was with the 3-day average [during treatment: rc =0.698, 95% confidence interval (CI): 0.495, 0.829; follow-up: rc =0.821, 95% CI: 0.711, 0.892]. FLIE vomiting had the highest concordance with worst day vomiting (during treatment, rc =0.310, 95% CI: 0.194, 0.417) or two day-prior vomiting (follow-up, rc =0.902, 95% CI: 0.832, 0.944). FLIE nausea and vomiting had inconsistent concordances with daily assessments of QoL.nnnCONCLUSIONSnResponses to the FLIE questionnaire are most representative of average nausea severity. Larger cohorts to validate these findings are warranted to address the lack of power in this present study and to confirm the wording and justification of a three-day recall period for the FLIE.

Predictors of dyspnea in patients with advanced cancer

BACKGROUNDnMore than 70% of patients with advanced cancer experience dyspnea. Dyspnea is predictive of shorter survival and interferes with quality of life (QOL). The present study aimed to identify predictors of the presence and severity of dyspnea in advanced cancer patients.nnnMETHODSnA prospective database collected from patients attending a palliative radiotherapy clinic was analyzed for patient demographics, Edmonton Symptom Assessment System (ESAS) scores, Patient-Reported Functional Status (PRFS), history of smoking and respiratory conditions, pulse oximetry readings, and primary cancer site. Using the ESAS shortness of breath item, dyspnea was classified as mild [1-3], moderate [4-6] or severe [7-10]. Logistic regression analysis and generalized estimating equations (GEEs) were used to identify predictors of the severity of dyspnea and presence of moderate/severe dyspnea (ESAS ≥4) at patients first visit and over time, respectively.nnnRESULTSnA total of 252 patients with dyspnea data were included (median age 71.3 years, 61.5% male, 44.4% had dyspnea) in a demographic analysis. Multivariable analysis showed liver metastases (P=0.01, OR =2.04), a history of respiratory conditions (P=0.03, OR =2.09) and PRFS ≥3 (P=0.03, OR =1.75) were predictive of the severity of dyspnea at the first visit. Analyzed over time, liver metastases (P=0.02, OR =1.80), lymph node metastases (P=0.02, OR =1.79), a history of respiratory conditions (P=0.006, OR =2.50) and pulse oximetry <90 (P=0.003, OR =3.32) were predictive of greater severity of dyspnea symptoms. Patients with multiple radiation treatments in the thorax region were less likely to have severe dyspnea symptoms over time (P=0.01, OR =0.32). Lung metastases (P=0.04, OR =2.03), a history of respiratory conditions (P=0.01, OR =2.60) and PRFS ≥3 (P=0.009, OR =2.30) were predictive of moderate/severe dyspnea at the first visit. Over time, lymph node metastases (P=0.003, OR =2.51), a history of respiratory conditions (P=0.04, OR =2.37) and pulse oximetry <90 (P=0.0004, OR =5.15) were predictive of moderate/severe dyspnea.nnnCONCLUSIONSnLiver, lung and lymph node metastases, a history of respiratory conditions, pulse oximetry <90 and PRFS ≥3 were predictive of the severity of dyspnea and moderate/severe dyspnea. Physicians should be aware of predictive factors that could lead to dyspnea to promote early intervention for improved patient care and the creation of screening tools for clinical practice.