Sarah Darby

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials.

Summary Background After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk. Methods We undertook a meta-analysis of individual patient data for 10 801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease. Findings Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7–17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6–6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2–17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8–5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (≥20%), intermediate (10–19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1–12·5), 1·1% (–2·0 to 4·2), and 0·1% (–7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5–27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8–15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease. Interpretation After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made. Funding Cancer Research UK, British Heart Foundation, and UK Medical Research Council.Breast-conserving surgery can excise all detected macroscopic tumor tissue in women with early-stage breast cancer. However, the presence of microscopic tumor foci in the conserved breast of these women, if untreated, may lead to locoregional recurrence and/or life-threatening distant recurrence. Radiotherapy in the conserved breast after surgery may reduce rates of recurrence and breast cancer death more among some groups of women than in others. This meta-analysis assessed the extent to which the absolute reduction by radiotherapy in 10-year risk of first recurrence differs among women with different prognostic and other characteristics and relates the absolute reduction in the 15-year risk of breast cancer death to the absolute reduction in the 10-year recurrence risk. 92 Obstetrical and Gynecological Survey

Making it Obvious: Designing Feedback into Energy Consumption

The process of giving feedback on consumption motivates consumers to save energy through reduced waste, yet the body of evidence testifying to this is rarely acted upon in any systematic way. The paper reviews the literature on the effectiveness of three types of feedback to domestic consumers: direct feedback in the home, indirect feedback via billing and ‘inadvertent’ feedback (a by-product of technical, household or social changes). The lessons learned on the importance of clear, immediate and user-specific information are then applied in a survey of the opportunities for better feedback to consumers in terms of technology, design and location of meters and display panels, energy billing and services such as audits and advice programmes.

CANCER NEAR POTENTIAL SITES OF NUCLEAR INSTALLATIONS

Mortality and census data for 400 districts of England and Wales were analysed with respect to existing sites of nuclear power stations and sites where the construction of such installations had been considered or had occurred at a later date (potential sites). Excess mortality due to leukaemia and Hodgkins disease in young people who lived near potential sites was similar to that in young people who lived near existing sites. Areas near existing and potential sites might share unrecognised risk factors other than environmental radiation pollution.

Load management at home: advantages and drawbacks of some ‘active demand side' options

The Supergen HiDEF (Highly Distributed Energy Future) project explores possibilities for decentralising five features of energy systems: resources, control, network infrastructure, participation and policy. This paper addresses issues of decentralised resources and participation (markets and commercial arrangements). It outlines some practicalities of an ‘active demand side’, supported by a brief overview of social and behavioural aspects of electricity use. Examples are derived from the international literature on behavioural aspects of energy use and residential load management programmes. Four potential active demand options are analysed in outline, in relation to customer involvement and likely enabling technologies. They are: overall demand reduction, static tariffs for peak reduction, dynamic tariffs for load management with variable supply, and continuous load-balancing through dynamic demand. Each of these can offer something to the utility; but what might it offer the customer, and what issues might it raise? The paper proposes development of a framework for evaluating ‘active demand’ options in terms of what they offer to small-scale end-users, to assist with planning for low-carbon energy transitions.

Conditions of energy efficient behaviour—a comparative study between Sweden and the UK

The main aim of this study is to compare how specific conditions in certain countries (in this case, the UK and Sweden) can stimulate or oblige householders to be more energy efficient, or can obstruct this. European goals for energy and emission reductions now constitute the main frame for long-term energy policy changes, but national governments develop and implement policy in contrasting ways and in different contexts. Important aspects are: geographical context, degree of liberalisation of electricity and gas industry, structure and composition of energy systems, metering and billing infrastructure, and the nature of electrical load problems. The following conditions are described and compared in this paper: (1) regulation to control residential consumption and emissions; (2) energy systems; (3) electricity pricing; (4) the role of utilities and other agents in residential demand reduction; (5) quality of feedback on energy use to the householder; and (6) customer behaviour and perceptions of energy use. The analysis is carried out with a view to ecological, economic and social aspects of energy systems. The comparison shows the significance of factors that are sometimes overlooked when considering the potential for demand reduction and load management, and produces some lessons and questions that are widely applicable.

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death

Summary Background After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk. Methods We undertook a meta-analysis of individual patient data for 10 801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease. Findings Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7–17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6–6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2–17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8–5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (≥20%), intermediate (10–19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1–12·5), 1·1% (–2·0 to 4·2), and 0·1% (–7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5–27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8–15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease. Interpretation After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made. Funding Cancer Research UK, British Heart Foundation, and UK Medical Research Council.Breast-conserving surgery can excise all detected macroscopic tumor tissue in women with early-stage breast cancer. However, the presence of microscopic tumor foci in the conserved breast of these women, if untreated, may lead to locoregional recurrence and/or life-threatening distant recurrence. Radiotherapy in the conserved breast after surgery may reduce rates of recurrence and breast cancer death more among some groups of women than in others. This meta-analysis assessed the extent to which the absolute reduction by radiotherapy in 10-year risk of first recurrence differs among women with different prognostic and other characteristics and relates the absolute reduction in the 15-year risk of breast cancer death to the absolute reduction in the 10-year recurrence risk. 92 Obstetrical and Gynecological Survey

Smart technology in the home: time for more clarity

ABSTRACT The idea of the smart home has been around for decades but smart homes (under most definitions) are extremely rare, although digital technology and automated appliances are commonplace in the more affluent regions of the world. This commentary argues that there are inherent difficulties with expectations for smart homes and with making them viable; and with definitions and roles of ‘users’ in smart systems. It considers what a smart home might be and the problems that smart homes might address, identifying two types of narrative in the smart-energy literature. One centres on the highly automated dwelling with integrated appliances, emphasizing state-of-the-art technology, convenience and, in some sense, efficiency. The second narrative type focuses more on system-level issues such as peak demand, ancillary services and the spread of microgeneration, and on selective applications of information and communication technology (ICT) to address these. Both raise questions about the identity of users, nature of control, boundaries of the home and ecological impact.

Breakthroughs in research and treatment of early breast cancer: an overview of the last three decades.

Breast cancer has become curable for the majority of women in Western Europe and North America. Advances have been made in imaging diagnostics as well as the implementation of nationwide screening programmes. Nowadays, we talk about prevention as well as treatment. Pathology has moved from pure morphology (tumour type, grade and stage) to biological characterisation of the tumour. Treatment has changed considerably through a better understanding of the disease; from a local disease predominated by extensive and mutilating surgical techniques to a point where breast cancer has come into its own as a systemic disease with equal “rights” to local as well as systemic treatment. This paradigm shift has led to a multidisciplinary approach of the understanding and treatment of breast cancer. Molecular classification has changed the understanding of breast cancer and will be the basis for an even more individualised treatment. New (biological) agents will help to further tailor treatment to response or resistance. While systemic treatment has been increased in number and duration surgical/local strategies have been reduced to minimum. Evidence-based medicine has helped to improve and standardise treatment of breast cancer. This review summarises the 10th Biedenkopf meeting that was held to review the advances in breast cancer understanding and treatment.

People and Communities in Energy Security

This book builds from a basic premise that energy security can be understood and approached in multiple different ways. In this chapter, the focus is on examining how people and communities reconfigure debates about energy security, in particular by bringing to light alternative, sometimes conflictive, understandings of both the problem and its potential solutions. Central to our approach is the concept of framing, which has been defined as, ‘the different ways of understanding or representing a social, technological or natural system and its relevant environment … this includes the ways system elements are bounded, characterized and prioritized, and meanings and normative values attached to each’ (Leach et al., 2010: xiii, emphasis in original).

The role of smart meters in carbon management

Metering has not traditionally been a topic to set pulses racing. However, interest in this highly specialized function has grown rapidly over the past decade, among engineers, utility and information and communication technology professionals, and economists. As an indicator, attendance at the annual European conference on metering, billing and customer relations grew from just over 100 in 1999 to almost 7000 in 2012. The main single reason for this has been the advent of ‘smart metering’. ‘Smart’ is the term normally used to describe a digital meter that measures consumption at regular intervals and has two-way communications capability. That basic definition covers a range of functional and technical specifications, however. For example, a smart electricity meter may be able to measure microgeneration and electricity exports as well as consumption. It may act as a communications hub within a building, allowing for remote control of appliances. Also, a smart water meter may be set up to send out alerts when the daily flow rises dramatically and indicates a leak. Much of the significance of smart meters, though, comes from their association with the development of smart grids: distribution networks that are overlaid with IT networks and contain sensors at critical points. Smart grids are intended to enable improved system efficiency, easy detection of faults, better informed and more careful end-users, and intelligent deployment of smalland medium-scale renewable electricity generation. Although gas, water and heat networks can also be ‘smarted’, most smart grid research and investment relates to electricity systems, where the timing of consumption and generation is critical and the challenges are greatest. A widely used definition of smart grids describes them as: “...electricity networks that can intelligently integrate the behavior and actions of all users connected to [them] – generators, consumers and those that do both – in order to efficiently deliver sustainable, economic and secure electricity supplies” [101]. The first smart meters originated during the 1970s, in response to the need to avoid building more ‘peaking plants’, which only generated electricity for very short periods each year, at high cost. If users could be persuaded to shift usage away from peak times in response to time-varying pricing, the argument went, generating assets could be managed more tightly and everyone would benefit. For this to work effectively, customers would need to be metered at frequent, regular, intervals