Heather Goodare

Quality of life after breast radiotherapy

1 Hopwood P, Haviland JS, Sumo G, Mills J, Bliss JM, Yarnold JR. Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials. Lancet Oncol 2010; 11: 231–40. 2 Carling M, Goodare H, Ironside A, Millington J, Rogers C. Radiotherapy hypofractionation in early breast cancer. Lancet 2008; 372: 204–05. 3 Bartelink H, Arriagada R. Hypofractionation in radiotherapy for breast cancer. Lancet 2008; 371: 1050–52. 4 Withers HR. Radiation biology and treatment options in radiation oncology. Cancer Res 1999; 59 (suppl): 1676–84. 5 Powell S, Cooke J, Parsons C. Radiation-induced brachial plexus injury: followup of two diff erent fractionation schedules. Radiother Oncol 1990; 18: 213–20. 6 Hanley B, Staley K. Yesterday’s women: the story of R.A.G.E. London: Macmillan Cancer Support, 2006. Correspondence Quality of life after breast radiotherapy

Psychological support for patients having breast cancer surgery. Patients' consent should have been sought.

EDITOR,—It is ironic that a study in which informed consent was not sought1 should be published in the same issue as an editorial by Richard Smith calling for action on misconduct in research.2 The study falls well short of good clinical research practice, which is a requirement in trials sponsored by the pharmaceutical industry.3 The hospital ethics committee was surely at fault in allowing the research to proceed in contravention of the Nuremberg Code. In her commentary Claire Foster addresses …

Late effects of breast radiotherapy.

1 Haviland J S, Owen J R, Dewar J A, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086–94. 2 Hopwood P, Haviland J S, Sumo G,et al. Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials. Lancet Oncol 2010; 11: 231–40. 3 Carling M, Goodare H, Ironside A, Millington J, Rogers C. Quality of life after breast radiotherapy. Lancet Oncol 2010; 12: 10. 4 Moulton B, Collins P A, Burns-Cox N, Coulter A. From informed consent to informed request: do we need a new gold standard? J R Soc Med 2013; 106: 391–94. 5 Johnson A. The timing of treatment in breast cancer: gaps and delays in treatment can be harmful. Breast Cancer Res Treat 2000; 60: 201–09. For instance, in Hopwood and colleagues’ 5-year follow-up report, up to a third of women reported moderate or marked pain in the arm or shoulder over 5 years, while the 10year followup report by Haviland and colleagues makes no mention of pain, merely of shoulder stiffness. Because our personal experience of late eff ects is that they are progressive, we fi nd this odd. It is also confusing from the point of view of comparison to have diff erent descriptions of adverse events, using different vocabulary (eg, induration vs hardness, and telangiectasia vs skin problems). We find too that some post-radiotherapy effects that we ourselves have experienced are still not mentioned, notably bone necrosis (not necessarily leading to fractures, though these do occur). However, it is a step forward to have 10-year results, and since follow-up data are still being collected, and followup was still short for cardiac events, we hope that these data and other late eff ects will continue to be monitored. The publication of this Article off ers an opportunity to reassess the role of radiotherapy in the overall treatment of breast cancer. It prompts the observation that timing is crucial, especially for fast-growing tumours, and we note that the time from surgery to randomisation in these trials was remarkably long (8–9 weeks in START A and more than 7 weeks in START B). Also, randomisation did not allow for grade of tumour. Patients now expect fully informed consent to treatment, and if they so wish are given details of their pathology. Surely a one-size-fitsall approach is inappropriate for radiotherapy. Fast-growing tumours might well need swift decisions and a diff erent fractionation regimen from the slow-growing tumours. It has been convincingly suggested that diff ering protocols should be applied to diff erent tumours. Now may be the time to take stock: perhaps weekend working should be considered, and NICE might yet need to revise their guidance. Until we get serious about personal lifestyle modification and national policies to promote environmental and behavioural change, we will need blood pressure lowering medications and statins to contain the epidemic of cardiovascular disease.

Radiotherapy hypofractionation in early breast cancer.

204 www.thelancet.com Vol 372 July 19, 2008 group exposed for longer to the hazard of inadequately treated residual tumour nests. A further possibility is that, in addition to delay, patients in the 25-fraction group were more likely to be subject to interruption and pro longation of their radiotherapy treatment. In breast cancer, prolongation by more than 7 days increases the risk of local recurrence and decreases overall survival. I urge the START Trialists to publish data on the interval from surgery or the last dose of chemotherapy to the fi rst fraction of radiotherapy and on the overall time for radiotherapy in both of the START trials. These data could provide the basis for hypothesis generation: as a post-hoc subgroup analysis it will not provide conclusive results.

The problem of accessing psychotherapies for depression in the UK.

The study by Amick and colleagues confirms what many of us have been saying for decades, that talking therapy is as good as antidepressants for treating depression,1 2 and some would say, often better, and without side effects. Never mind that the research looks at cognitive behavioural therapy (CBT) only, which although helpful in some contexts tends to concentrate on the …

Cost is a barrier to patient involvement

Many thanks for your Editor’s Choice, published on my 85th birthday.1 Patient participation in medical research has improved since I was invited to be the first patient representative on The BMJ editorial board, after complaining about the flawed study of women with breast cancer attending the Bristol Cancer Help Centre.2 I was one of …