Plenary Session Included Findings on Partial- vs Whole-breast Techniques and Patient Beliefs about Radiotherapy


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When the dates were picked for the 54th Annual Meeting of the American Society for Radiation Oncology (ASTRO), no one could have anticipated that the meeting would coincide with Hurricane Sandy’s devastation of parts of the northeast. As the storm approached on Monday and Boston shut down its transit system, ASTRO attendees had to evacuate the convention center by 2:00 PM. Thus, the Plenary Session scheduled for Monday afternoon was delivered to video cameras and tape recorders instead of to a live audience. Happily, Boston was largely spared and the ASTRO Annual Meeting reopened on Tuesday.

In addition to our more in-depth coverage of ASTRO presentations, we have compiled brief reports of a few further meeting highlights here, including two presentations from the Plenary Session.

Mistaken Beliefs about Radiotherapy

Many patients with terminal lung cancer reported mistaken beliefs about their expectations for palliative radiation therapy in a study reported by the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) at the Plenary Session.1 Only 36% of patients correctly stated that radiation therapy was not at all likely to cure their disease.

CanCORS was a population-based and health system–based prospective cohort study that enrolled 5,013 patients with newly diagnosed lung cancer in 5 geographic regions, at 10 Veterans Administration sites and 5 large health maintenance organizations from 2003 to 2005. Patients older than age 21 with stage “wet” IIIB or IV lung cancer who received or were scheduled to have radiation therapy were interviewed about 4 months after diagnosis. The investigators analyzed responses to various questions that began: “After talking with your doctors about radiation therapy, how likely did you think it was that radiation would …?”

Responses to surveys from 384 patients were analyzed. Median survival was 11.5 months. Most patients were optimistic that radiation therapy could help them. More than three-quarters (78%) of patients believed that radiation was very likely or somewhat likely to help them live longer, and about two-thirds (67%) believed that radiation was very likely or somewhat likely to help them with problems from lung cancer. Also, 66% believed that radiation therapy was very likely or somewhat likely to have side effects or complications. The authors were concerned, however, that 64% did not understand that radiation therapy was not at all likely to cure their cancer.

These results suggest that physicians need to be more proactive in having conversations about expectations of radiation therapy with patients who have incurable lung cancer. Several studies have shown that it is difficult for physicians to have end-of-life discussions with patients, but other studies show that being honest with patients about the risks and benefits of therapy actually empowers them to make decisions that are right for them, explained lead author of this study, Aileen B. Chen, MD, a radiation oncologist at Dana-Farber Cancer Institute in Boston.

“To help patients make informed decisions about radiation treatments near the end of life, health-care providers need to improve communication with patients and understanding about the goals and limitations of palliative radiotherapy. While palliative radiotherapy can be very effective at relieving symptoms from cancer, overly intensive care can reduce patients’ quality of life and lead to significant time and financial burdens for patients and their families.”

Long-term Cardiac Safety of Breast Irradiation

Patients with breast cancer who were treated with radiation did not have a higher risk of cardiovascular mortality compared to those treated with modified radical mastectomy, according to the first study to document comprehensive cardiac outcomes 25 years after treatment.2 The study was reported by Charles B. Simone, II, MD, a radiation oncologist at the Hospital of the University of Pennsylvania in Philadelphia.

The investigation focused on long-term outcomes in 247 patients with stage I and II breast cancer who were enrolled in an NCI breast-conservation trial from 1979 to 1987. Twenty-five years following treatment, 102 patients were alive. Fifty of these patients participated in this study; 26 underwent breast-conserving therapy plus radiotherapy, and 24 had modified radical mastectomy.

Evaluations included a detailed cardiac history, exam, cardiac laboratory tests, and 3T cardiac MRI to assess anatomic and functional abnormalities, as well as a CT angiogram to evaluate coronary stenosis and determine whether patients had a high coronary arterial calcium score for atherosclerosis. For all parameters assessed, no higher risk of adverse cardiovascular outcomes was found in patients who underwent breast irradiation.

This is good news, since these findings were in women treated with older radiation techniques. “Over the past 2 decades, radiation has become more precise and safer with modern techniques. We are pleased to find that patients with early-stage breast cancer treated with modern radiation therapy treatment planning techniques do not have an increased risk of long-term cardiac toxicity and that breast-conservation therapy with radiation therapy should remain a standard treatment option,” Dr. Simone commented.

Cosmetic Outcomes for Partial- vs Whole-breast Irradiation

Accelerated partial-breast irradiation with three-dimensional (3D) external-beam radiation therapy for patients with breast cancer who have had breast-conserving surgery can result in a worse cosmetic outcome compared with whole-breast irradiation, according to interim safety results of the phase III RAPID trial presented at the Plenary Session.3

Accelerated partial-breast irradiation may be offered to women following breast-conserving surgery as part of their treatment, explained lead author Timothy Whelan, MD, Juravinski Cancer Centre, Hamilton, Ontario, Canada. “Our study supports earlier phase II trial research, finding that accelerated partial-breast irradiation using 3D conformal radiation therapy can increase the risk of moderate radiation side effects, which may affect cosmetic outcome for some patients. Additional research on [3D conformal radiotherapy–based accelerated partial-breast irradiation] is needed before offering it to women as a standard option,” he stated.

At a median follow-up of 2.5 years, nurses found that 32% of 850 patients had adverse cosmesis compared with 19% of patients treated with whole-breast irradiation. Oncologists and patients had similar assessments in the rate of observed adverse cosmesis with accelerated partial-breast irradiation vs whole-breast irradiation.

The rates of late grade 1 and 2 radiation toxicities were higher in women treated with accelerated partial-breast irradiation vs whole-breast irradiation. Grade 3 and 4 toxicities were rare in both treatment groups.

Stereotactic Body Radiation Therapy for Inoperable Stage I NSCLC

A preliminary study found that the safety and efficacy of stereotactic body radiation therapy compared favorably to historical results with conventional radiation therapy in patients with inoperable stage I non–small cell lung cancer (NSCLC).4 In 100 patients treated from June 2004 to November 2008 at 15 institutions in Japan, 3-year overall survival was 59.9%, and toxicity was mild.

Three-year progression-free survival was 49.8%, local progression–free survival was 52.8%, and event-free survival was 46.8%. The rates of grade 3 adverse events included dyspnea in 10% of patients, hypoxia in 8%, pneumonitis in 7%, chest pain in 2%, and cough in 1%. Only 2% of patients reported grade 4 adverse events (dyspnea and hypoxia), and no grade 5 adverse events were seen.

“[Stereotactic body radiation therapy] can be delivered in a shorter window of time with lower rates of toxicity than conventional radiation therapy. In this study, [stereotactic body radiation therapy] for patients with inoperable stage I lung cancer was highly effective and showed mild toxicity. This treatment should replace conventional radiotherapy as standard treatment for this population of patients,” stated lead author Yasushi Nagata, MD, Department of Radiation Oncology at Hiroshima University in Hiroshima, Japan, as study coordinator of the Japan Clinical Oncology Group (JCOG) 0403 trial. ■

Disclosure:Drs. Chen, Whelan, Simone, and Nagata reported no potential conflicts of interest.

References

1. Chen AB, Cronin A, Weeks J, et al: Patient beliefs about palliative radiation therapy (RT) in incurable lung cancer. 54th ASTRO Annual Meeting. Abstract 1. Presented October 29, 2012.

2. Simone CB, Sibley C, Dan TD, et al: Cardiac toxicity is not increased 25 years after treatment of early-stage breast carcinoma with mastectomy or breast conservation therapy from the National Cancer Institute randomized trial. 54th ASTRO Annual Meeting. Abstract 87. Presented October 29, 2012.

3. Whelan T, Olivotta I, Parpia S, et al: Interim toxicity results from RAPID: A randomized trial of accelerated partial breast irradiation (APBI) using 3-D conformal external beam radiation therapy (3-D CRT). 54th ASTRO Annual Meeting. Abstract LBA2. Presented October 29, 2012.

4. Nagata Y, Hiraoka M, Shibata T, et al: Stereotactic body radiation for T1N0M0 non-small cell lung cancer. First report for inoperable population of a phase II trial by Japan Clinical Oncology Group. 54th ASTRO Annual Meeting. Abstract 115. Presented October 29, 2012.



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