Healing News

Standard adjuvant treatment for HER2-positive breast cancer patients, following primary surgery for their cancer, is Trastuzumab (Herceptin) – typically used in combination with chemotherapy. However, a new study by researchers at Fox Chase Cancer Center reports that it may be safe to treat these patients with both Trastuzumab and adjuvant radiation therapy. The study was presented at the annual meeting of the American Society for Radiation Oncology (ASTRO).

“Our study evaluated the skin toxicity and early cardiac toxicity of concurrent Trastuzumab and radiation therapy treatment in the adjuvant setting,” says Penny Anderson, M.D., radiation oncologist at Fox Chase and lead author on the study. “We found that there was an extremely low rate of acute radiation dermatitis and cardiac toxicity in patients who received this type of treatment.”

The study followed 85 breast cancer patients who received adjuvant Trastuzumab while also receiving a course of adjuvant radiation therapy, as well as 85 breast cancer patients who only received adjuvant radiation therapy. Acute dermatitis was grade 2 in 15% and grade 3 in 2% of the patients receiving concurrent treatment, likewise grade 2 and grade 3 dermatitis was observed in 14% and 2 % of patients only receiving radiation therapy – there was only one patient who developed a grade > 2. There were no differences in cardiac toxicity between the two groups.

“The results of this study show that it is safe to use both Trastuzumab and radiation therapy in an adjuvant setting, when clinically indicated,” adds Anderson. “We would like to see longer follow-up to evaluate the potential differences in late cardiac toxicity.”

Source: Diana Quattrone

Fox Chase Cancer Center

View drug information on Herceptin.

The Aeras Global TB Vaccine Foundation and the Cambodian Health Committee have announced the initiation of a study of tuberculosis prevalence in Svay Rieng Province, Cambodia, beginning this month. This is the first study conducted in partnership by the two non-profit research organizations and the first Aeras-sponsored study to be conducted in Cambodia.

“Enhancing the ability to diagnose TB in children is essential. The scientific knowledge to be gained from this trial will assist in global efforts while easing the suffering of children right now in Cambodia from this curable disease,” says Anne Goldfeld, co-founder of CHC and professor of medicine at Harvard Medical School and Harvard School of Public Health.

One out of every three people worldwide is infected with TB. In 2007 more than nine million people became sick with active TB disease and nearly 2 million people died of the disease. Co-infection with HIV and the growth of difficult-to-treat drug-resistant forms of TB have worsened the epidemic and increased calls for new TB vaccines. Cambodia is ranked by the World Health Organization as among the 22 nations with the highest burden of tuberculosis. Nearly one million Cambodians are infected with TB and 12,000 die of TB annually.

Worldwide, infants and young children are at heightened risk for TB mortality because of inadequate prevention options, difficulties in timely diagnosis, and tendency to progress more quickly to severe and disseminated forms of TB disease. Due to resource constraints and technical difficulties in diagnosing childhood TB, the incidence of TB among infants is unknown in Cambodia.

This six month cross-sectional epidemiology study will enroll up to 1,000 infants and children under five years old. The primary objective of the study is to estimate the prevalence of tuberculosis among BCG-vaccinated children over the set period of the study in two operational districts of Svay Rieng Province.

With precise estimates of TB incidence in infants and children, strategic policies and programs for preventing, diagnosing and treating childhood TB can be developed in Cambodia and other resource poor environments. Towards this goal, this study will for the first time compare the efficacy of a state-of-the art liquid culture system donated by BD (Becton, Dickinson and Company) with traditional TB culture techniques.

“Accurate diagnosis of TB is critical to getting care to children now and to efforts to develop an effective TB vaccine. The currently available TB vaccine — Bacille Calmette-GuГ©rin — provides some protection against severe forms of pediatric TB, but it does not prevent pulmonary TB, the most common form of the disease,” said R. Gordon Douglas, Jr., MD, the Executive Chairman of Aeras Global TB Vaccine Foundation. “The world deserves new, more effective TB diagnostics and TB vaccines and Aeras is pleased to be collaborating with the Cambodian Health Committee in this effort.”

Source:
Annmarie Leadman
Aeras Global TB Vaccine Foundation

Optic nerve sheath meningiomas are rare tumors that are traditionally treated with surgery, which is typically a blinding procedure. However, researchers from Thomas Jefferson University Hospital have found that a specialized type of radiation therapy offers the same local control, with fewer adverse effects on vision. The investigators presented their data at the 51st ASTRO Annual Meeting (Abstract #2676/B-261).

Fractionated stereotactic radiotherapy is a more precise, targeted type of radiation therapy that allows an effective dose of radiation to tumor, but helps spare other structures around it. In the case of optic nerve sheath meningiomas, the eye lens and brain cells are spared, according to Robert Den, M.D., a resident in Radiation Oncology at Thomas Jefferson University Hospital.

“Fractionated stereotactic radiotherapy is beneficial because it is a non-invasive means to achieve disease control, while allowing patients to continue with their daily lives without being hindered by a major surgical procedure,” Dr. Den said.

Dr. Den and colleagues conducted a retrospective analysis of 58 patients with optic nerve sheath meningiomas who were treated with fractionated stereotactic radiotherapy between 1996 and 2006. They reviewed patient charts for technical radiotherapy information and for treatment outcomes, which included local control, visual acuity and acute and late toxicity related to treatment. The median follow-up was 70 months.

Based on MRI, the radiographic local tumor control was more than 95%. Visual acuity was stabilized or improved in 92% of patients. Four patients had worsening vision. One patient developed optic neuritis and one developed central retinal venous occlusion. There were no grade-3 or higher late complications.

“This was the largest U.S. cohort of patients with optic nerve sheath meningiomas treated with fractionated stereotactic radiotherapy,” said Dr. Den. “There is no difference in outcome and the patients’ quality of life was much better. This should be the standard of care for patients with optic nerve sheath meningiomas.”

Source: Emily Shafer

Thomas Jefferson University

Clinical researchers at Princess Margaret Hospital (PMH) have confirmed that patients with oropharyngeal squamous cell cancer (“tonsil cancer”) harbour a common type of human papilloma virus (HPV16), but also that such cancers are very sensitive to radiation. For some patients, this may mean successful treatment with radiation alone and avoiding the side effects of chemotherapy.

“This represents the power of personalized medicine. By using a relatively simple molecular test to evaluate the tumour, we can customize the treatment plan, produce an excellent outcome, and maintain the patient’s quality of life,” says principal investigator Dr. Fei-Fei Liu, PMH radiation oncologist, Head of the Division of Applied Molecular Oncology, Ontario Cancer Institute, and Dr. Mariano Elia Chair in Head & Neck Cancer Research, University Health Network.

The findings were published on November 2 in the Journal of Clinical Oncology (JCO 231670).

Dr. Liu’s team discovered that patients whose tumours tested positive for HPV16 had a much better survival, compared to patients whose tumours did not harbour HPV16. This HPV effect was independent of treatment (radiation alone, or radiation plus chemotherapy), suggesting that some HPV16 patients could be treated with radiation only. As a result, PMH now routinely tests tonsil-area tumours for HPV16 — one of the first cancer programs to do so.

The study’s finding is important because this particular type of cancer is increasing – up more than 10% in the past 20 years. The jump is likely attributed to the spread of HPV16 through sexual activity, compared with a 20% decline in other similar head-and-neck cancers over the same period because fewer people are now smoking.

Dr. Liu says the HPV vaccine currently available for teenagers targets the HPV16 strain. “Of course the goal is to prevent HPV infection in the first place, but for individuals who need treatment now, it’s a major step to know that we could provide options so that some of our patients could be spared the often-difficult side effects of chemotherapy.”

The research team analyzed tumour biopsies of 111 patients treated at PMH from 2003-2006, comparing clinical diagnosis, treatment plans, and outcomes. They found HPV16 in 60% of the samples, and determined that these patients experienced a much better survival, compared to the HPV-negative patients.

“We hope these findings will help other cancer programs manage their patients,” says Dr. Brian O’Sullivan, Leader of the Head and Neck Program at Princess Margaret Hospital, Associate Director of the Radiation Medicine Program at PMH, and Bartley-Smith/Wharton Chair in Radiation Oncology.

This study was funded by the Ontario Institute for Cancer Research, Canadian Institutes of Health Research, and The Princess Margaret Hospital Foundation.

Source: Jane Finlayson

University Health Network

Radiation oncologists at Rush University Medical Center are intent on finding ways to avoid damage to the critically important hippocampus and limbic circuit of the brain when cranial radiation is required to treat existing or potential metastatic cancers.

The goal is to spare these areas, which are responsible for short-term memory, as well as emotions, motivation, and a range of executive functions, such as planning and decision-making.

Cranial radiation is used to destroy tumors that have spread to the brain, which happens in 20 to 25 percent of all cancer patients. It is also used prophylactically to prevent the development of overt intracranial metastases in patients diagnosed with small-cell lung carcinoma.

But there is a downside to the treatment. Because the hippocampus and the limbic area are irradiated along with the rest of the brain, the treatment often causes memory lapses, difficulty with executive planning, and poor fine motor control. The consequences can be devastating for patients, whose quality of life is deeply affected.

In a review of records for 107 patients with 700 lesions, the team of radiation oncologists at Rush found that metastases had occurred in the hippocampus in only 0.8 percent of the cases, and in the limbic circuit in fewer than 3 percent of cases.

That finding emboldened them to determine whether it might be possible to deliver cranial radiation to the brain, but not to these particular areas – eliminating metastases or potential metastases with radiation but sparing the hippocampus and the limbic areas, where metastases were unlikely to occur.

In their feasibility study, the researchers were able to show that the hippocampus and limbic circuit can be largely spared using advanced equipment that targets the radiation to specific areas.

Their results are being presented in a poster session at the annual meeting of the American Society for Radiation Oncology, which is being held November 1-5 in Chicago.

“We have shown that it is possible to reduce the dose of radiation to this area, while treating the rest of the brain, where the cancer is located, at full dose,” said Dr. Arnold Herskovic, principal investigator of the study.

The feasibility study was done using a TomoTherapy Hi-Art System, which enables the treatment of tumors with image-guided radiation therapy.

The researchers expect to start a clinical trial of the new procedure soon to determine whether in fact it can both prevent or treat brain metastases and minimize long-term neurocognitive consequences.

Other researchers at Rush involved in the study were Dr. James Marsh, Dr. Ben Gielda, Julius Turnian, PhD, and Dr. Ross Abrams, chair of radiation oncology.

Source: Sharon Butler

Rush University Medical Center

Stereotactic radiosurgery (SRS), a radiation therapy procedure pioneered at the University of Pittsburgh Cancer Institute (UPCI) that precisely delivers a large dose of radiation to tumors, effectively controls pain in patients with cancer that has spread to the spine, according to researchers from UPCI. The results of the research were presented this week during the American Society for Radiation Oncology (ASTRO) annual meeting in Chicago, being held November 1 – 5, 2009.

The study, led by Dwight E. Heron, M.D., associate professor and vice-chairman of the Department of Radiation Oncology at the University of Pittsburgh School of Medicine, compared the effectiveness of single and multi-session treatments of SRS in controlling patients’ pain. According to Dr. Heron, cancers can frequently spread to the bone and the spine is the site most commonly involved, which can be extremely painful. “Conventional radiation therapy is not always effective in alleviating bone pain resulting from spread of cancer to the spine. In patients who have previously received radiation, few options for effective treatment exist,” Dr. Heron said.

The study reviewed the outcomes of 228 patients treated with SRS at UPCI and Georgetown University Medical Center (GUMC). Patients at UPCI received a single treatment of SRS while patients at GUMC generally received three treatment sessions.

“Both arms of the study successfully proved that SRS is a safe and effective form of treatment for patients with cancer that has spread to their bones, even in patients who had previously received radiation to the spine,” said Dr. Heron. “Interestingly, patients who received only one treatment experienced faster onset of pain relief but those who received three treatments experienced relief for longer periods of time. Additionally, patients who received three treatments had less need for re-treatment and greater survival rates.”

This study was funded by Accuray, Inc.

Source: Courtney McCrimmon

University of Pittsburgh Schools of the Health Sciences

An article published Online First and in a future edition of The Lancet reports that when on-demand radiographs are dictated by the patient’s clinical status, the number of radiographs carried out is a third less, without compromising patient care or safety. Current guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. The article is the work of Dr Gilles Hejblum, Institut National de la SantГ© et de la Recherche MГ©dicale, Paris, France, and colleagues.

A total of twenty-one intensive care units at eighteen hospitals in France were included in this randomised study. They were assigned to either a routine or an on-demand strategy for chest radiographs during the first of two treatment periods. In the second period, units then switched to the alternative strategy. Each treatment period lasted for the time taken for enrolment and study of twenty consecutive patients per intensive care unit. Patients were monitored until discharge from the unit or for up to 30 days of mechanical ventilation, whichever happened first. Units enrolled 967 patients. But 118 were excluded because they had been receiving mechanical ventilation for less than two days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation.

The results indicated that 424 patients had 4,607 routine chest radiographs. The average per patient-day of mechanical ventilation was 1.09. A total of 425 patients had 3,148 on-demand chest radiographs (with a mean of 0.75). This corresponded to a reduction of 32 percent with the on-demand strategy. Significantly, no change was recorded between the routine and on-demand strategies in any secondary outcome measures such as days of mechanical ventilation, length of stay in the intensive care unit, or mortality. But the authors caution that numbers of radiographs are not the only factor to consider. They explain: “Opinions from medical personnel participating in the study about the routine versus on-demand strategies were not recorded before, during, and after the study. This information is potentially important – for example, the physicians’ workloads are increased by individual assessment of every patient early in the morning to decide whether a chest radiograph is necessary instead of ordering systematic morning chest radiographs for all mechanically ventilated patients. Such considerations could restrict implementation of the on-demand strategy in daily practice.”

But they write in conclusion: “Results from our study strongly support the adoption of an on-demand strategy in preference to a routine strategy to decrease the number of chest radiographs done in mechanically ventilated adult patients without a reduction in patient safety. In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice.”

In a complementary comment, Dr Mark D Siegel, and Dr Ami N Rubinowitz, Yale School of Medicine, New Haven, CT, USA, remark: “Hejblum and colleagues have provided persuasive evidence that routine daily chest radiographs are unnecessary in most intubated mechanically ventilated patients, and can be safely replaced by an on-demand approach, reserving studies for clinical indications. Whether an on-demand strategy is appropriate for individual intensive care units needs to be decided locally. In our view, an on-demand strategy should be adopted only if: skilled clinicians are available to promptly identify patients requiring chest radiography; images can be made and interpreted efficiently; abnormalities can be acted on throughout the day. If these conditions are met, an on-demand strategy would seem justified and might lead to cost savings, decreased radiation exposure, and a greater diagnostic and therapeutic yield from the radiography.”

“Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study”
Gilles Hejblum, Ludivine Chalumeau-Lemoine, Vincent Ioos, Pierre-Yves Boëlle, Laurence Salomon, Tabassome Simon, Jean-François Vibert, Bertrand Guidet
DOI: 10.1016/S0140-6736(09)61459-8
The Lancet

Stephanie Brunner (B.A.)

An article published Online First and in a future edition of The Lancet reports that when on-demand radiographs are dictated by the patient’s clinical status, the number of radiographs carried out is a third less, without compromising patient care or safety. Current guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. The article is the work of Dr Gilles Hejblum, Institut National de la SantГ© et de la Recherche MГ©dicale, Paris, France, and colleagues.

A total of twenty-one intensive care units at eighteen hospitals in France were included in this randomised study. They were assigned to either a routine or an on-demand strategy for chest radiographs during the first of two treatment periods. In the second period, units then switched to the alternative strategy. Each treatment period lasted for the time taken for enrolment and study of twenty consecutive patients per intensive care unit. Patients were monitored until discharge from the unit or for up to 30 days of mechanical ventilation, whichever happened first. Units enrolled 967 patients. But 118 were excluded because they had been receiving mechanical ventilation for less than two days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation.

The results indicated that 424 patients had 4,607 routine chest radiographs. The average per patient-day of mechanical ventilation was 1.09. A total of 425 patients had 3,148 on-demand chest radiographs (with a mean of 0.75). This corresponded to a reduction of 32 percent with the on-demand strategy. Significantly, no change was recorded between the routine and on-demand strategies in any secondary outcome measures such as days of mechanical ventilation, length of stay in the intensive care unit, or mortality. But the authors caution that numbers of radiographs are not the only factor to consider. They explain: “Opinions from medical personnel participating in the study about the routine versus on-demand strategies were not recorded before, during, and after the study. This information is potentially important – for example, the physicians’ workloads are increased by individual assessment of every patient early in the morning to decide whether a chest radiograph is necessary instead of ordering systematic morning chest radiographs for all mechanically ventilated patients. Such considerations could restrict implementation of the on-demand strategy in daily practice.”

But they write in conclusion: “Results from our study strongly support the adoption of an on-demand strategy in preference to a routine strategy to decrease the number of chest radiographs done in mechanically ventilated adult patients without a reduction in patient safety. In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice.”

In a complementary comment, Dr Mark D Siegel, and Dr Ami N Rubinowitz, Yale School of Medicine, New Haven, CT, USA, remark: “Hejblum and colleagues have provided persuasive evidence that routine daily chest radiographs are unnecessary in most intubated mechanically ventilated patients, and can be safely replaced by an on-demand approach, reserving studies for clinical indications. Whether an on-demand strategy is appropriate for individual intensive care units needs to be decided locally. In our view, an on-demand strategy should be adopted only if: skilled clinicians are available to promptly identify patients requiring chest radiography; images can be made and interpreted efficiently; abnormalities can be acted on throughout the day. If these conditions are met, an on-demand strategy would seem justified and might lead to cost savings, decreased radiation exposure, and a greater diagnostic and therapeutic yield from the radiography.”

“Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study”
Gilles Hejblum, Ludivine Chalumeau-Lemoine, Vincent Ioos, Pierre-Yves Boëlle, Laurence Salomon, Tabassome Simon, Jean-François Vibert, Bertrand Guidet
DOI: 10.1016/S0140-6736(09)61459-8
The Lancet

Stephanie Brunner (B.A.)

Emergency radiology, high resolution computed tomography (HRCT) and magnetic resonance (MR) fluoroscopy will be highlighted as fields of imaging in which the UK is playing a key role, at a special session, “UK Presents” at the Radiological Society of North America’s Annual Meeting in Chicago on Monday 30 November 2009.

The session is moderated by Professor Andy Adam, President of the Royal College of Radiologists (RCR), with three key speakers:

- Dr Tony Nicholson, Dean for Clinical Radiology at the RCR, on “The development of emergency radiology”;

- Professor David Hansell, Director of Radiology at Royal Brompton Hospital, London, on “HRCT of the lungs: a treasure trove of silver insights”;

- Professor David Lomas, Professor of Clinical MRI at Addenbrooke’s Hospital, Cambridge, on “MR fluoroscopy: from red goggles to earplugs”.

Professor Adam said, “Britons invented or co-invented ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), and have played a major role in the clinical development of modern diagnostic and interventional radiology. The ‘UK Presents’ session is particularly appropriate in view of the very close links between British and American radiology. There are many similarities in the practice of our specialty on the two sides of the Atlantic but, in science as in life, there are also sufficient differences for us to have things to teach each other.”

Speaking on his lecture, Dr Nicholson said, “Radiology has always had a role to play in the diagnosis of the emergency patient. However, the tools used have become increasingly sophisticated and accurate, and it is now doubtful whether any emergency patient does not benefit from imaging. The most remarkable development is the way in which radiologists now use these tools to treat patients, particularly those with life threatening conditions. It used to be said that some patient were too unstable for a CT scan but this no longer needs to be true and it can be argued that the more unstable the patient the greater the benefit of imaging”.

Professor Hansell said, “High-resolution CT has been responsible for changes in both the accuracy of diagnosis of, and our understanding of the behaviour of, diffuse lung diseases.
It also provides information about the prognosis of individual patients and helps to stratify groups of patients enrolled in clinical trials. I aim to contrast the speed with which we have derived knowledge from high-resolution CT, with the more sedate rate at which advances were made, using chest radiography, in the last century. I will also discuss the increasingly complex, but complementary, relationship between pathology and radiology in the challenging area of diffuse lung disease diagnosis.”

Professor Lomas said, “X-ray based fluoroscopy enabled a new generation of imaging diagnostics and interventions during the 20th Century that revolutionised medicine. Improvements in health, therapeutics, life expectancy and patient expectations mean that in the 21st century, as the use of X-ray CT has replaced many of the roles of X-ray fluoroscopy based tests, concern has increased regarding the adverse effects of radiation exposure. The obvious alternative, providing the flexibility and versatility required, is magnetic resonance imaging but it remains unclear whether MRI will rise to the challenges or if the technology will be sufficiently competitive with volumetric CT.”

Source
The Royal College of Radiologists

What do patients want from their radiation oncologists? The most significant preference is that more than one-third of female cancer patients (37 percent) prefer to have their hands held by their radiation oncologists during important office visits, compared to 12 percent of men, according to a randomized study presented November 4, 2009, at the 51st Annual Meeting of the American Society for Radiation Oncology (ASTRO).

Another significant finding is that almost three-quarters of the patients (72 percent) preferred to be called by their first name, even among elderly patients. There is a greater preference for this among females than males (76 percent to 66 percent), and white patients compared to blacks (74 percent to 56 percent). The study also shows that while 95 percent of all patients want their oncologist to be honest with them about their chances of cure and expected survival, there is a significantly increased preference for honesty among prostate cancer patients versus lung cancer patients (97 to 91 percent).

“In oncology, a strong physician-patient relationship is essential because the patient’s interactions with their doctor can help the patient confidently make life or death decisions, such as what cancer treatment is best for them,” Ajay Bhatnagar, M.D., lead author of the study, a radiation oncologist at Cancer Treatment Services International in Casa Grande, Ariz., and Adjunct Assistant Professor of Radiation Oncology at the University of Pittsburgh Cancer Institute in Pittsburgh said. “Oncologists can use these results to provide greater patient satisfaction for their patients, and therefore significantly improve patient care.”

The study sought to find out what cancer patients wanted from their patient-doctor relationship and whether their physicians would be able to change their behaviors to satisfy their patients’ preferences if they had knowledge of these preferences. The prospective randomized trial took place between June 2006 and March 2008 and involved 508 patients, who underwent radiation for breast, prostate or lung cancer. Patients answered a survey about their preferences of their radiation oncologist, with a variety of questions focusing on the patient-doctor relationship. The survey was given at three time periods: prior to initial consultation, midpoint of radiation treatment, and at completion of radiation therapy.

The patients were randomized into two groups, based on whether their oncologist reviewed their initial patient preference survey responses (experimental group) or did not (control group). At time of completion, the patient also completed a satisfaction survey.

In addition to other findings, nearly three-quarters of all patients (70 percent) are neutral about their radiation oncologist wearing a white coat or professional clothing. The study also shows that 95 percent of high school graduates show a greater preference for having their radiation treatment described in everyday language by their radiation oncologists, compared to 91 percent of college graduates and 84 percent of post-graduate patients.

For more information on radiation for cancer, visit rtanswers.

The abstract, “What Do Patients Want From Their Radiation Oncologist? Final Results From A Prospective Randomized Trial,” will be presented at a scientific session at 11:00 a.m. on Wednesday, November 4, 2009.

Source
American Society for Radiation Oncology (ASTRO)