Carmel N Anandadas

Early prostate cancer – which treatment do men prefer and why?

Study Type – Preference (prospective cohort)
Level of Evidence 1b

Development of a patient-reported questionnaire for collecting toxicity data following prostate brachytherapy.

PURPOSE To improve a questionnaire used to collect patient-reported outcomes from patients with early stage prostate cancer treated with brachytherapy. A secondary aim was to adapt the Late Effects of Normal Tissue (LENT) subjective toxicity questionnaire for use to collect Common Terminology Criteria for Adverse Events (CTCAE) data, the current preferred platform for assessing radiation toxicity. MATERIALS AND METHODS Three hundred and seventy-seven patients were treated with permanent iodine-125 seed implant brachytherapy for early prostate cancer. Toxicity data were collected before and at nine time points post-treatment (0-36 months). Compliance rates for patients completing individual items and item-subsection correlation coefficients were calculated. A factor analysis was carried out to analyse responses to the questionnaire and identify less informative questions, which could be removed. Cronbachs α coefficient was used to measure reliability. RESULTS Two thousand one hundred and eighty-eight questionnaires were analysed. There was poor compliance for questions specifically relating to operations and bowel medication. We found that the division of the questionnaire into subsections based on anatomical site was reasonable and that certain items could be safely removed. The high mean value for Cronbachs α across all questionnaires (0.752; 95% CI: 0.726-0.779) indicated that the questionnaire was reliable. Fifteen of the 44 questions were removed from the original questionnaires. Questions on urinary incontinence severity, management of urinary and bowel incontinence, effects of reduced flow of urine and the effects of symptoms on activity of daily living and change in sexual function were required to adapt the LENT subjective questionnaire for use to collect CTCAE data. CONCLUSIONS A questionnaire, validated over 6 years to collect LENT subjective data were adapted and is a reliable approach for collecting CTCAE data after prostate brachytherapy.

Practice Change after Evaluation of an Offline Correction Protocol for Image-guided Radiotherapy in Head and Neck Cancer.

Madam d Image-guided radiotherapy is essential when verifying delivery of complex radiotherapy and is the UK standard of care for patients undergoing multi-fractionated treatments [1]. This study assessed the adequacy of planning margins and the effectiveness of an offline no action level (NAL) correction protocol in reducing geometric setup errors in patients undergoing radical radiotherapy for head and neck cancer at a single institution. Cone beam computed tomography images were fused with bone registries to obtain set-up data in the superioreinferior, anterioreposterior and lateral planes for 124 patients treated on two linear accelerators between January and December 2012. An offline NAL correction protocol with 0.3 cm tolerance was used. Population systematic (S) and random (s) errors were calculated following the initial three fractions pre-correction and for all images. Required clinical target volumeeplanning target volume (CTVePTV) margins for the whole patient population were generated using the Van Herk formula (2.5S þ 0.7s) [2]. Population set-up errors and required CTVePTVmargins for the first three fractions pre-correction and for all fractions are shown in Table 1. The offline NAL correction protocol successfully identified and reduced systematic error. Therewas no effect on random error. The CTVePTVmargins calculated suggested that the 0.3 cm margin in use at the timewas inadequate and this has now been increased to 0.4 cm in all planes. Additionally, online imaging has been introduced for the first three fractions to account for the higher error observed during this period. This practice change highlights the importance of continual assessment

Cardiac Side-effects of Breast Radiotherapy

Madam d With reference to the excellent review article on the cardiac side-effects of breast radiotherapy [1], we can confirm that relatively low mean heart doses can be achieved using careful optimisation of beam angles and simple tangential forward-planned intensity-modulated radiotherapy, without breath-hold. An audit of 121 patients treated at the Christie Hospital with left breast radiotherapy (40 Gy/15 fractions without internal mammary node irradiation) in 2015 showed a mean heart dose of 1.00 Gy (range 0.25e2.41 Gy). The mean V 2Gy was 9% (range 0e21%), the V 10Gy was 0.7% (range 0e3%). We are reviewing alternative methods for those patients with difficult anatomy where the mean heart dose is higher than average (2.5% of patients with doses greater than 2 Gy). Measurement of the mean heart dose is a convenient way to identify those patients where critical structures, such as the left anterior descending coronary artery, are receiving a higher and functionally significant radiation dose [2]. In most patients, the distal left anterior descending coronary artery is not easily seen on routine computed