Breast Neoplasms: Feyer P

Sautter-Bihl ML, Souchon R, Budach W, Sedlmayer F, Feyer P, Harms W, Haase W, Dunst J, Wenz F, Sauer R. · Municipal Hospital Karlsruhe, Karlsruhe, Germany. · Strahlenther Onkol. · Pubmed #19016032 No free full text.

Abstract: BACKGROUND AND PURPOSE: The aim of the present paper is to update the practical guidelines for radiotherapy of breast cancer published in 2006 by the breast cancer expert panel of the German Society for Radiooncology (DEGRO). These recommendations were complementing the S3 guidelines of the German Cancer Society (DKG) elaborated in 2004. The present DEGRO recommendations are based on a revision of the DKG guidelines provided by an interdisciplinary panel and published in February 2008. METHODS: The DEGRO expert panel (authors of the present manuscript) performed a comprehensive survey of the literature. Data from lately published meta-analyses, recent randomized trials and guidelines of international breast cancer societies, yielding new aspects compared to 2006, provided the basis for defining recommendations referring to the criteria of evidence-based medicine. In addition to the more general statements of the DKG, this paper emphasizes specific radiooncologic issues relating to radiotherapy after mastectomy (PMRT), locally advanced disease, irradiation of the lymphatic pathways, and sequencing of local and systemic treatment. Technique, targeting, and dose are described in detail. RESULTS: PMRT significantly reduces local recurrence rates in patients with T3/T4 tumors and/or positive axillary lymph nodes (12.9% with and 40.6% without PMRT in patients with four or more positive nodes). The more local control is improved, the more substantially it translates into increased survival. In node-positive women the absolute reduction in 15-year breast cancer mortality is 5.4%. Data referring to the benefit of lymphatic irradiation are conflicting. However, radiotherapy of the supraclavicular area is recommended when four or more nodes are positive and otherwise considered individually. Evidence concerning timing and sequencing of local and systemic treatment is sparse; therefore, treatment decisions should depend on the dominating risk of recurrence. CONCLUSION: There is common consensus that PMRT is mandatory for patients with T3/T4 tumors and/or four or more positive axillary nodes and should be considered for patients with one to three involved nodes. Irradiation of the lymphatic pathways and the optimal time point for onset of radiotherapy are still under debate.

Sautter-Bihl ML, Budach W, Dunst J, Feyer P, Haase W, Harms W, Sedlmayer F, Souchon R, Wenz F, Sauer R, Anonymous00109, Anonymous00110. · Municipal Hospital Karlsruhe, Germany. · Strahlenther Onkol. · Pubmed #18040609 No free full text.

Abstract: BACKGROUND: The present paper is an update of the practical guidelines for radiotherapy of breast cancer published in 2006 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) [34]. These recommendations have been elaborated on the basis of the S3 guidelines of the German Cancer Society that were revised in March 2007 by an interdisciplinary panel [18]. METHODS: The DEGRO expert panel performed a comprehensive survey of the literature, comprising lately published meta-analyses, data from recent randomized trials and guidelines of international breast cancer societies, referring to the criteria of evidence- based medicine [25]. In addition to the more general statements of the German Cancer Society, this paper emphasizes specific radiotherapeutic aspects. It is focused on radiotherapy after breast-conserving surgery. Technique, targeting, and dose are described in detail. RESULTS: Postoperative radiotherapy significantly reduces rates of local recurrence. The more pronounced the achieved reduction is, the more substantially it translates into improved survival. Four prevented local recurrences result in one avoided breast cancer death. This effect is independent of age. An additional boost provides a further absolute risk reduction for local recurrence irrespective of age. Women > 50 years have a hazard ratio of 0.59 in favor of the boost. For DCIS, local recurrence was 2.4% per patient year even in a subgroup with favorable prognostic factors leading to premature closure of the respective study due to ethical reasons. For partial-breast irradiation as a sole method of radiotherapy, results are not yet mature enough to allow definite conclusions. CONCLUSION: After breast-conserving surgery, whole-breast irradiation remains the gold standard of treatment. The indication for boost irradiation should no longer be restricted to women <or= 50 years. Partial-breast irradiation is still an experimental treatment and therefore discouraged outside controlled clinical trials. Omission of radiotherapy after breast-conserving surgery of DCIS should be restricted to individual exceptions.

Souchon R, Budach W, Dunst J, Feyer P, Haase W, Harms W, Sautter Bihl ML, Wenz F, Sauer R, Anonymous00094. · No affiliation provided · Strahlenther Onkol. · Pubmed #16896587 No free full text.

This publication has no abstract.

Hoeller U, Borgmann K, Feyer P, Souchon R, Anonymous00209. · Klinik für Strahlentherapie, Radioonkologie und Nuklearmedizin, Vivantes Klinikum Neukölln, Berlin. · Strahlenther Onkol. · Pubmed #17896084 No free full text.

Abstract: BACKGROUND: Tamoxifen (TAM) is well established in the adjuvant therapy of breast cancer. However, the timing of TAM therapy, concurrent or after radiotherapy, is controversial. METHOD: Literature is reviewed with respect to experimental and clinical data on interaction of TAM and radiation on tumor control and radiation side effects. RESULTS: In vitro data support the concept of antagonistic effects of concurrent TAM and radiation on tumor cells, but in animal models a synergistic effect was seen. Considering the modulation of TAM effects by estrogen and growth factor receptors, two-dimensional systems may not be suitable for studying the interaction of TAM and radiation. From a clinical perspective, a tumor-protective effect of TAM therapy concurrent with radiation was not evident. However, prospective studies addressing this question adequately are not available at the time. CONCLUSION: Although some studies indicate an enhancement of lung and subcutaneous fibrosis after TAM therapy, the side effects are mild and at this point do not seem to warrant withholding TAM.

Sauer R, Sautter-Bihl ML, Budach W, Feyer P, Harms W, Souchan R, Wollwiener D, Kreienberg R, Wenz F. · Department of Radiation Oncology, University of Erlangen, Erlangen, Germany. · Cancer. · Pubmed #17647249 links to  free full text

Abstract: BACKGROUND: Breast-conserving surgery followed by whole-breast radiotherapy (WBRT) has become the standard treatment for the majority of patients with early breast cancer. Whereas the indications for systemic adjuvant treatment have continuously expanded, there is a tendency to restrict postoperative radiotherapy to accelerated partial breast irradiation (APBI) instead of WBRT. METHODS: The different techniques of APBI are described and their respective advantages or potential drawbacks outlined. Moreover, the results described in the literature are briefly reviewed as a basis for the consensus statements and recommendations of the German Society of Radiation Oncology, the German Society of Senology, and the Working Group for Gynecological Oncology of the German Cancer Society. RESULTS: The methods mainly used for APBI are: interstitial radiotherapy with multicatheter technique, intraoperative radiotherapy (IORT) using either electrons produced by linear accelerators or 50 kV x-rays (Intrabeam), the balloon-catheter technique (MammoSite), or 3D conformal external beam radiotherapy. These techniques have marked differences in dose distribution and homogeneity. The published range of local recurrence rates varies between 0% to 37%, the median follow-up from 8 to 72 months. CONCLUSIONS: To date, follow-up times mostly do not yet permit a definite judgment concerning the long-term effectiveness and side effects of APBI. The relevant societies in Germany support randomized clinical studies comparing APBI with WBRT in a well-defined subset of low-risk patients. However, the authors expressly discourage the routine use of APBI outside clinical trials. Until definite results show that APBI neither impairs therapeutic outcome nor cosmetic results, WBRT remains the gold standard in the treatment of early breast cancer.

Borgmann K, Hoeller U, Nowack S, Bernhard M, Röper B, Brackrock S, Petersen C, Szymczak S, Ziegler A, Feyer P, Alberti W, Dikomey E. · Clinic for Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. · Int J Radiat Oncol Biol Phys. · Pubmed #18406889 No free full text.

Abstract: PURPOSE: We tested whether the chromosomal radiosensitivity of in vitro irradiated lymphocytes could be used to predict the risk of acute reactions after radiotherapy. METHODS AND MATERIALS: Two prospective studies were performed: study A with 51 patients included different tumor sites and study B included 87 breast cancer patients. Acute reaction was assessed using the Radiation Therapy Oncology Group score. In both studies, patients were treated with curative radiotherapy, and the mean tumor dose applied was 55 Gy (40-65) +/- boost with 11 Gy (6-31) in study A and 50.4 Gy +/- boost with 10 Gy in study B. Individual radiosensitivity was determined with lymphocytes irradiated in vitro with X-ray doses of either 3 or 6 Gy and scoring the number of chromosomal deletions. RESULTS: Acute reactions displayed a typical spectrum with 57% in study A and 53% in study B showing an acute reaction of Grade 2-3. Individual radiosensitivity in both studies was characterized by a substantial variation and the fraction of patients with Grade 2-3 reaction was found to increase with increasing individual radiosensitivity measured at 6 Gy (study A, p = 0.238; study B, p = 0.023). For study B, this fraction increased with breast volume, and the impact of individual radiosensitivity on acute reaction was especially pronounced (p = 0.00025) for lower breast volume. No such clear association with acute reaction was observed when individual radiosensitivity was assessed at 3 Gy. CONCLUSION: Individual radiosensitivity determined at 6 Gy seems to be a good predictor for risk of acute effects after curative radiotherapy.

Feyer P, Kleeberg UR, Steingräber M, Günther W, Behrens M. · Radioonkologie und Radiotherapie, Vivantes Klinikum Berlin Neukoelln, Berlin, Germany. · Support Care Cancer. · Pubmed #18322707 No free full text.

Abstract: STUDY OBJECTIVES: The aims of the study were to examine the frequency of side effects and fatigue in ambulatory cancer patients and to analyse how these symptoms are reflected in patient satisfaction. SETTING: Private practices (N = 41) and day hospitals (N = 8) in Germany took part in the study. PARTICIPANTS: The respondents were 4,538 patients with cancer (response rate: 82%). The diagnoses were: 25% breast cancer, 21% colorectal cancer, 11% lymphomas and 12% haematological malignancies; mean age 63.5 years; 57% female. MEASUREMENTS: The 2004 PASQOC questionnaire contained 63 problem-oriented items which covered patient satisfaction for 15 dimensions of care. One item specifically assessed the prevalence of 17 different side effects. A score reflecting the severity of fatigue (fatigue index) was computed from three additional questions. For statistical analysis of patient satisfaction, the problem frequency was computed for each item. RESULTS: The most frequent single side effects were fatigue (60%), hair loss (54%), nausea (51%), sleep disturbance (42%), weight loss (36%), diarrhoea (32%) and mouth ulcerations (31%). The mean number of side effects was 5 per patient (range 0 to 17). The fatigue index revealed that 42% of subjects complained of moderate and 28% of severe fatigue. Both the total number of side effects and the fatigue score were negatively associated with patient satisfaction. CONCLUSIONS: Side effects and especially fatigue are frequent problems in cancer patients and are related to the patients' assessment of cancer care. Routine symptom assessment may identify patients who require more comprehensive supportive care.

Kleeberg UR, Feyer P, Günther W, Behrens M. · Hämatologisch-onkologische Praxis Altona (HOPA), Hamburg, Germany. · Support Care Cancer. · Pubmed #18204867 No free full text.

Abstract: STUDY OBJECTIVES: To examine how outpatient cancer patients assess their cancer care in private oncology practices and day hospitals, and to identify the extent to which staff meet the expectations of their patients. SETTING: Private practices (n = 41) and day hospitals (n = 8) in Germany, including 16 "repeater" practices who had already participated in the 2002 Patient Satisfaction and Quality in Oncological Care (PASQOC) survey. PARTICIPANTS: n = 4,615 patients with cancer. Diagnoses: 25% breast cancer, 21% colorectal cancer, 12% haematologic malignancies, 11% lymphomas; mean age 63.5 years; 57% female; n = 1,639 patients from repeater practices. MEASUREMENTS: The 2004 PASQOC questionnaire contained 63 problem-oriented items which covered 15 different dimensions of care. Practice staff invited their patients to participate and surveys were mailed to all sampled patients. For statistical analysis, the problem frequency (PF) was calculated for each item. RESULTS: Of 5,600 patients who received the questionnaire, 4,615 replied (response rate: 82%). The best results were obtained for the dimensions "further support in daily life" (3% PF), "nurses" (5% PF), and "physician-patient-relationship" (8% PF). Potential for improvement was most pronounced for "handling of side effects" (39% PF), "partnership and shared decision making" (30% PF), "side effects" (30% PF) and "communication with other patients" (26% PF). Considerable differences in PFs between practices were observed. Mean results from the 16 repeater practices revealed only few changes compared to the 2002 PASQOC survey, although some practices had greatly improved their performance. CONCLUSIONS: The PASQOC questionnaire identified strengths and weaknesses of outpatient care for cancer patients. By providing a comparison with other practices, PASQOC can help staff of individual practices to improve their performance.