Sense of coherence and its context with demographics, psychological aspects, lifestyle, complementary and alternative medicine and lay aetiology.

PURPOSE: For patients with a cancer diagnosis, coping abilities are of high importance. Cancer patients with a high sense of coherence may cope better. The purpose of this study is to learn more about the correlation of sense of coherence and different aspects, such as demographics, psychological factors, lifestyle, complementary and alternative medicine (CAM) and lay aetiology. METHODS: A prospective cross-sectional study was performed in ten cancer centres in Germany. The questionnaire consisted of ten sub-items, collecting information about sense of coherence, demographics, general life satisfaction, resilience, spirituality, self-efficacy, physical activity and sports, nutrition, CAM methods and cancer causes. RESULTS: As many as 349 participants were evaluable. The mean sense of coherence score was M = 47.30. Significant associations were shown for sense of coherence and financial situation (r = 0.230, p < 0.001), level of education (r = 0.187, p < 0.001), marital status (η = 0.177, p = 0.026) and time interval since diagnosis (r = - 0.109, p = 0.045). Sense of coherence and resilience correlated on a high level, as well as spirituality, self-efficacy and general life satisfaction (r = 0.563, r = 0.432, r = 0.461, r = 0.306, p's < 0.001). CONCLUSION: Several aspects, such as demographics and psychological factors, have a great influence on the sense of coherence. To help patients to cope better, physicians should try to strengthen sense of coherence, resilience and self-efficacy and, at the same time, consider patients' individual background such as level of education, financial capacity and emotional support by family members.

[Complementary or alternative medicine in oncology : Chances or risks?] / Komplementäre oder alternative Medizin in der Onkologie : Chancen oder Risiken?

BACKGROUND: Approximately half of all cancer patients use complementary or alternative medicine. AIM: The results of the German S3 guidelines on complementary oncology are presented and placed into the context of patient consultation. MATERIAL AND METHODS: The core recommendations of the S3 guidelines are summarized including an overview of the evidence. RESULTS: Selected methods of complementary medicine can be used with the aim of improving the quality of life and reducing side effects. Comprehensive data are available for physical activity with respect to survival, quality of life and supportive therapy. For most other methods the evidence is relatively low. Therefore, weighing up the benefits and risks more frequently resulted in negative recommendations in the guidelines, especially for methods based on substances. Exceptions to this are three micronutrients (vitamins B12, D and selenium), as even in the case of a well-balanced diet, deficiency symptoms are possible. Therefore, routine measurement of the blood levels of these micronutrients is recommended. CONCLUSION: The questions from patients on what they can do by themselves should be answered respectfully and based on evidence. The benefits and risks of complementary methods must be carefully considered. To do this, regular questioning of patients on the interest in complementary methods is recommended. The decisive benefit of complementary medicine is the chance for patients to become active themselves. Therefore, all recommendations refer to the discussion with the patient, which do not formulate a therapy but are consultation recommendations: should be recommended instead of should be done.

Lay etiology concepts of cancer patients do not correlate with their usage of complementary and/or alternative medicine.

BACKGROUND: The usage of complementary and alternative medicine (CAM) is widespread among cancer patients. While reasons for and aims of using CAM have been evaluated in many studies, less is known about whether patients' concepts of how and why cancer develops has an influence on the choice of the CAM method. METHODS: We pooled the data from all studies of our working group containing questions on lay etiological concepts and CAM usage and reanalyzed them with respect to the associations between these parameters. RESULTS: The pooled dataset from 12 studies included 4792 patients. A third (1645 patients) reported using CAM. Most often used were supplements (55.9%), relaxation techniques (43.6%), and homeopathy (37.9%). Regarding perceived causes, patients most often marked stress (35.4%) followed by genes (31.9%). While all lay etiological beliefs were highly significantly associated with usage of CAM in general, there was no association between single lay etiological concepts and types of CAM used. Yet, in a network analysis, we found two associations: one comprising trauma, mistletoe, genes, and nutritional supplements, the other yoga, vitamin C, nutritional supplements, and TCM herbs. In the correlation heatmap, one cluster comprises etiological concepts of personality, immune system and trauma, and two clusters of CAM methods emerged: one comprising praying, yoga, meditation, and relaxation procedures, the other nutritional supplements, selenium, vitamins A and C. CONCLUSION: While physicians are trained to derive treatment strategies from etiological concepts, lay people choosing CAM do not follow these rules, which may point to other needs of patients addressed by CAM.

Resilience in cancer patients and how it correlates with demographics, psychological factors, and lifestyle.

BACKGROUND: Being diagnosed with cancer is challenging. Many patients wish to be actively involved in treatment and contribute to therapy, but the patients' coping abilities and desire for involvement differ. The individual level of resilience seems to play a major role. Our study aims to learn more about the associations of resilience and factors as demographics and psychological factors. METHODS: This multicentric cross-sectional study was conducted in ten oncological centers in Germany in summer 2021. The questionnaire collected information on demographics, resilience, self-efficacy, general satisfaction with life, and sense of coherence. Considered lifestyle-aspects were diet and physical activity. 416 patients were included in the analyses. RESULTS: A moderate mean resilience score was achieved (M = 69). Significant correlations in demographics were found for resilience and education (r = 0.146, p = 0.003), income (r = 0.205, p = 0.001), and time since receiving diagnosis (r = - 0.115, p = 0.021). Resilience and self-efficacy correlated on a high level (r = 0.595, p < 0.001), resilience and sense of coherence, and resilience and general satisfaction with life in a moderate way (r = 0.339, p < 0.001; r = 0.461, p = 0.001). CONCLUSIONS: Resilience portrays an important aspect in cancer treatment. Detecting patients at risk, stabilizing, or improving resilience are important to focus on and strengthen them accordingly. Possible negatively influencing factors (e.g., low self-efficacy) need to be considered. Factors affecting resilience but difficult to influence, as educational background, should be screened for. Also, the combination of low resilience and low income seems to describe a vulnerable patient group.

Cancer patients' needs for virtues and physicians' characteristics in physician-patient communication: a survey among patient representatives.

BACKGROUND: Data on patients' needs with respect to physicians' ethical behavior and virtues are important but not available in most cases. PATIENTS AND METHODS: In an iterative process together with patients' representatives, we developed a standardized questionnaire which was distributed to the representatives of the Women's Self-Help after Cancer in Germany. We started with the classical ethical virtues and clustered them to characteristics. The patients' representatives were asked to rate in different communications settings. RESULTS: One hundred eighty-six patients' representatives took part in the survey. For four communication situations (first communication on symptoms, diagnosis of cancer, choice of therapy, doubts on therapy), competence was rated as very important by 80-89% and as important by 6-7%; honesty as very important by 78-89% and as important by 5-12%; respect as very important by 66-71% and as important by 19-21%; and patience as very important by 55-68% and as important by 6-24%. Compassion was rated as less important, with only 24-31% rating it as very important and another 26-32% as important. Additional desires expressed by the participants were physicians having more time (9.1%) and a better relationship between physician and patient (7.0%). CONCLUSION: Competence, honesty, respect, and patience are important characteristics which should be focused on in communication training of medical students and physicians. In spite of compassion being rated as less important, training on compassion/empathy might help doctors to improve coping with the continuous confrontation with complications, progress, suffering, and death of their patients.

[Radiochemotherapy for invasive bladder cancer : An update]. / Radiochemotherapie beim Harnblasenkarzinom : Ein Update.

BACKGROUND: The standard treatment for muscle-invasive bladder cancer is radical cystectomy with pelvic lymphadenectomy. Primary organ-preservation by means of multimodal therapy, however, can be a viable alternative to radical surgery. OBJECTIVES: The concept and results of multimodal therapy, consisting of initial transurethral resection of the bladder tumor (TUR-B), followed by simultaneous radiochemotherapy (RCT), are presented. MATERIALS AND METHODS: Evaluation of retrospective cohorts and prospective therapy optimization studies on organ-preservation treatment regimens. Comparative meta-analyses comparing cystectomy with multimodal treatment are presented. RESULTS: Complete TUR-B, including bladder mapping and tumor biopsy, should precede simultaneous RCT. Radiosensitization should be cisplatin-based or consist of a combination of 5­fluorouracil and mitomycin C. Complete response rates after TUR-B plus RCT are generated in 60-90% of patients along with 5­year survival rates of 40-75% and preservation of the bladder in approximately 80% of surviving patients. CONCLUSIONS: Multimodal therapy by means of TUR-B followed by simultaneous RCT is a viable alternative to radical cystectomy for patients with muscle-invasive urinary bladder carcinoma. Patients with early tumors (cT2/3N0) are particularly suitable in whom initial TUR-B leads to complete tumor resection (R0).

Use of complementary and alternative medicine by patients with cancer: a cross-sectional study at different points of cancer care.

Complementary and alternative medicine (CAM) is widely used by cancer patients. In order to learn more on the usage of CAM, its reasons and motifs as well as sources of information along the trajectory of treatment, we decided to evaluate the prevalence and predictors for the use of CAM by cancer patients while being under active treatment with chemo- or radiotherapy or in aftercare. We distributed a standardized questionnaire among patients attending a department of radio-oncology, an ambulance for oncology and offices of general practitioners (GPs). Five hundred and six patients took part. Most attributed cancer to stress and trauma (23.7 and 16.4 %) or genes (20.8 %). Forty-four percentage reported knowing a physician with competence in CAM, and in all settings, most patients named the GP. Fifty-one percentage admitted using CAM, 35 % informed the oncologist about using CAM, 56 % informed the GP, and 26 % did not inform any physician. Most often used CAM was vitamin D (17 %) and selenium (16 %). Most important goals were to strengthen the immune system (59 %) and become active (52 %). Most patients were satisfied with the CAM methods they used. Yet, with some methods, dissatisfaction was up to 30 %. The GP has an important function concerning CAM in oncology as most patients believe the GP to have best knowledge in CAM. In order to integrate complementary medicine into evidence-based medicine, physicians should be trained on how to communicate on CAM with the patient and with each other. Explaining cancer and cancer therapies in a way lay persons are able to understand may be helpful. Physicians should actively address patients' needs of involvement not only in decision making, but also actively in the therapy.

Prostate cancer patients' report on communication about endocrine therapy and its association with adherence.

BACKGROUND: Endocrine therapy is a mainstay of prostate cancer therapy. Given that few data exist on patient physician communication with regard to this field of therapy and adherence, we conducted a survey of patient members of a German support organization. PATIENTS AND METHODS: We developed a structured questionnaire that was tested in a pilot version and then programmed as an online questionnaire. RESULTS: The questionnaire was completed by 694 patients. While 58 % of participants rated the information they received as comprehensive, 42 % did not. Fifty-one percentage stated that they were informed of side effects in detail, and 35 % received information on supportive treatments available in the event of side effects. Patients with higher education more often reported receiving information on side effects (p = 0.036) as well as alternatives for treatment (p = 0.001). Only 13 % stated that their questions were answered in detail, with 43 % receiving no answers or only non-detailed answers. Additional information was sought by 82 %, mostly from the Internet (67 %) and patient support groups (66 %). Seventy-six percentage experienced side effects that imposed limitations on their daily activities. Of those patients with side effects, 60 % reported that their physicians did not react to their complaints. There is a significant association between side effects in general and depression in particular and non-adherence (p < 0.01 and p = 0.002, respectively). In contrast, better information on side effects is associated with better adherence (p < 0001). CONCLUSION: In order to improve adherence, detailed information on side effects and comprehensive supportive care is most important. Physicians should not rely on written information but should rather mainly engage in direct communication.

A lecture program on complementary and alternative medicine for cancer patients--evaluation of the pilot phase.

About half of all patients with cancer use complementary or alternative medicine (CAM). In 2013, we started a lecture program for patients, followed by evidence-based recommendations on counseling on CAM. These recommendations have been published before by this working group. The aim of the program is to provide scientific facts on the most often used CAM methods in standardized presentations which help patients discuss the topic with their oncologists and support shared decision making. The article presents the evaluation of the pilot phase. Participants received a standardized questionnaire before the start of the lecture. The questionnaire comprises four parts: demographic data, data concerning experience with CAM, satisfaction with the lecture, and needs for further information on CAM. In 2013, seven lectures on CAM were given in cooperation with regional branches of the German Cancer Society in several German states. Four hundred sixty patients and relatives took part (75% females and 16% males). Forty-eight percent formerly had used CAM. Most often named sources of information on CAM were print media (48%) and the Internet (37%). Most participants rated additional written information valuable. About one third would like to have an individual consultation concerning CAM. A standardized presentation of evidence on CAM methods most often used, together with recommendations on the self-management of symptoms, is highly appreciated. The concept of a highly interactive lecture comprising is feasible and if presented in lay terminology, adequate. In order to give additional support on the topic, written information should be provided as the first step.

Attitudes of members of the German Society for Palliative Medicine toward complementary and alternative medicine for cancer patients.

BACKGROUND: A high proportion of cancer patients use complementary and alternative medicine (CAM). In oncology, risks of CAM are side effects and interactions. OBJECTIVE: Our aim was to conduct a survey on professionals in palliative care regarding attitudes toward CAM. DESIGN AND SUBJECTS: An internet-based survey with a standardized questionnaire was sent to all members of the German Society for Palliative Care. MEASUREMENTS: The questionnaire collected data on attitude toward CAM and experiences. RESULTS: Six hundred and ninety questionnaires (19 %) were returned (49 % physicians, 35 % nurses, 3 % psychologists). Acceptance of CAM is high (92 % for complementary and 54 % for alternative medicine). Most participants had already been asked on CAM by patients (95 %) and relatives (89 %). Forty-four percent already had used complementary methods and 5 % alternative methods. Only 21 % think themselves adequately informed. Seventy-four percent would use complementary methods in a patient with advanced tumor, and 62 % would use alternative therapy in patients if there was no other therapy. Even from those who are skeptical 45 % would treat a patient with alternative methods. CONCLUSIONS: In order to inform patients on CAM and to further patients' autonomy, evidence on benefits and harms of CAM must be provided. As awareness of risks from CAM is low and critical appraisal especially of alternative medicine missing, but interest on information on CAM is high, experts should provide evidence-based recommendations for CAM in palliative care to members of different professions. This could be done by a curriculum focusing on the most often used CAM methods.

Integrating cancer patients' perspectives into treatment decisions and treatment evaluation using patient-reported outcomes--a concept paper.

Patient-reported outcomes are an important tool in clinical research. In the setting of cancer treatments, benefit of therapy is essentially characterised by improvement of survival as well as quality of life (QoL). A standardised instrument to assess QoL is the standardised QoL questionnaire of the European Organisation for Research and Treatment (EORTC QLQ-C30 questionnaire). QoL instruments provide data on different aspects (domains) of the framework of QoL. Using these questionnaires in studies provides data on how a treatment affects QoL in a group of patients. The goal of our concept is to individualise QoL and to use validated instruments in order to integrate patients' perspectives and aims into treatment assessment, planning and control. We propose to use the domains of the EORTC QLQ-C30 and to ask the patient to determine which objectives besides survival are relevant for him and should be achieved by treatment. These individual goals can be used in a process of shared decision-making to choose and monitor treatment. In clinical studies, this approach would allow to recruit more patients who would most probably benefit from the therapy. In addition, supportive data could be gathered in correlation to treatment goals and actual benefits.

Attitude of employees of a university clinic to complementary and alternative medicine in oncology.

BACKGROUND: Cancer patients often use complementary and alternative medicine (CAM), yet discussion with the oncologist is often missing and oncologists lack knowledge in CAM. PATIENTS AND METHODS: In order to learn more about the attitude of professionals in oncology toward CAM, a survey was conducted on employees of a German university clinic using a structured questionnaire. RESULTS: In total, 547 employees took part in the survey. One-third would definitely use CAM on cancer patients. Female employees are more interested in CAM than males (80% versus 20%; P = 0.001); physicians are less interested than nurses (57% versus 72%; P = 0.008). 2.5% of physicians and 9% of nurses are convinced that CAM is as effective as conventional therapy in cancer. Fifty-two percent of physicians and 12% of nurses agree that adverse effects due to CAM may be possible. Seventy-three percent did not consider themselves adequately informed on CAM for their professional work. CONCLUSIONS: As a substantial part of participants would use CAM on cancer patients and most are interested in but not trained on this topic, there is a need for training of professionals from different professions working in oncology.

Patients with advanced cancer and their usage of complementary and alternative medicine.

PURPOSE: A total of 40 % of cancer patients use complementary and alternative medicine (CAM), and patients with advanced cancer use CAM more often than others. The aim of our study was to gather data on CAM use and reasons to use CAM of patients with advanced cancer being admitted for residential palliative care and their relatives. METHODS: Structured interviews were carried out with 25 patients and 25 relatives of those patients, respectively, of a German comprehensive cancer center based on a standardized questionnaire of the working group Prevention and Integrative Oncology of the German Cancer Society. RESULTS: Median age of patients was 64.5 years (relatives: 53.5); 15 patients were male and 10 were female (relatives: 7 and 18). In total, 40 % of all patients used some CAM method at the time of the study, supplements and prayer being the most frequent method. Main reasons for using CAM were to sustain one's own strength (52 % for patients and 72 % for relatives) and to be able to do something by oneself (36 and 40 %). Sources of information were television/radio (48 and 28 %) and family/friends (40 and 48 %). Relatives also use the Internet (40 %). CONCLUSIONS: Also for patients in palliative care and their relatives, CAM is important. Reasons for using CAM are similar for patients with less advanced cancer. As most patients do not discuss using CAM with their physician, side effects and interactions of biologically based treatments may be dangerous. The desire of patients to act autonomously should be encouraged. Yet, physicians should ensure safe administration of complementary methods by including CAM in their communication with the patient and the family.

Counseling cancer patients on complementary and alternative medicine. Background, theory, and implementation of nationwide counseling facilities.

BACKGROUND AND PURPOSE: Complementary and alternative medicine (CAM) is of high relevance in oncology. Only a minority of professionals feel competent in CAM. Our aim was to provide a strategy for establishing evidence-based counseling on CAM in oncology in the German health system. METHODS: We performed a systematic search of the literature on patient counseling concerning CAM. Of 811 articles identified in this search 51 met our inclusion criteria. Data from these articles were analyzed and adapted to the needs of German patients by a group of experts of the DEGRO ("Deutschen Gesellschaft für Radioonkologie") and the German Cancer Society. In the next step a strategy about how to integrate evidence-based counseling on CAM at cancer centers and oncological institutions was developed. RESULTS: First, evidence-based recommendations on CAM counseling were derived. The core of our strategy combines two levels of information provision: level 1 will be oncologists, radiotherapists and other specialists and level 2 oncological CAM experts. The latter group will serve as trainers and backup for complicated or advanced questions and for individual counseling of patients with complex needs. Professionals in level 1 will be offered special training. CONCLUSION: Evidence-based counseling on CAM is not only possible but also mandatory in order to meet patient information needs. Our proposal would allow for integrated counseling available at all oncological institutions and guarantee a high quality. Furthermore, provision of information on two different levels allows the effective use of resources (manpower and financing).

Biochemical relapse of prostate cancer. Evidence after radical surgery.

BACKGROUND: The aim of this study was to investigate, whether ultrasensitive PSA assays can help to find a lower cut-off value for biochemical recurrence of prostate cancer after resection. MATERIALS AND METHODS: This was a retrospective analysis of the patient files of 113 men with prostate cancer who underwent surgery. The mean follow-up time was 26 months. PSA measurements were performed with the ultra sensitive Immulite assay (DPC, USA), with an analytical sensitivity of 0.001 ng PSA/ml. Patients with baseline PSA levels > 0.1 ng/ml after surgery were excluded. Different cut-off levels for PSA were applied on the values and PSA doubling-times calculated. RESULTS: Maximum PSA 0.01 ng/ml, 0.05 ng/ml, 0.1 ng/ml, 0.2 ng/ml and > 0.4 ng/ml were reached by 87%, 61%, 50%, 42% and 20% of patients, respectively. From a cut-off point of 0.1 ng/ml the chance of further progression to PSA levels of 0.2 ng/ml and 0.4 ng/ml was 75% and 40%, respectively. The PSA doubling time was 2.1 months in patients with PSA values > 0.4, 15 months for patients below 0.4 ng/ml and 22.4 months for patients whose PSA never exceeded 0.1 ng/ml. CONCLUSION: PSA cut-off values below 0.4 ng/ml lack sufficient clinical significance. However, patients with PSA values > 0.1 ng/ml should be monitored thoroughly and at shorter intervals, as further increase, i.e. tumour progression, is very likely to occur.

[The value of magnetic resonance tomography (MRI) with reference to economic aspects of radiotherapy planning of vertebral metastases. A cost benefit analysis]. / Die Wertigkeit der Magnetresonanztomographie (MRT) unter ökonomischen Aspekten bei der Bestrahlungsplanung von Wirbelkörpermetastasen. Eine Kosten-Nutzen-Analyse.

Is magnetic resonance imaging (MRI) based target volume definition for treatment planning of vertebral metastasis effective under economic considerations. From 1994 to 1999, a total of 137 patients with bone metastases affecting the vertebral column underwent MRI of the cervical, thoracic, or lumbar spine for the treatment planning of palliative radiation therapy. The following radiation treatment consisted in a irradiation of the affected vertebral region up to a total dose of 30-40 Gy. The cost calculation for radiotherapy and magnetic resonance tomography was done using the common tariff model (EBM) of the German Health Insurances. In 73% of patients (101 patients), magnetic resonance imaging resulted in marked corrections of the irradiation fields which would have resulted in the necessity of treatment for recurrence in the case of treatment planning without MRI. Consequently, the higher cost of MRI of 345.00 DEM (176,40 EUR) lead to a saving of 497.00 DEM (254,11 EUR) compared to a recurrence treatment of 10 fractions and of 1,428.00 DEM (730,12 EUR) compared to 20 fractions. The transport expenses for the second treatment could be saved as well. Even under economic considerations MRI is effective.

Late effects of radiotherapy on oral mucosa in humans.

In order to gain further understanding of the late effects of radiotherapy on oral mucosa, we analysed the histomorphological alterations, the cell populations in the subepithelial tissue, and the endothelial expression pattern of different adhesion molecules. Biopsies were taken from patients before irradiation, directly after 60 Gy, and 6-12 months after radiotherapy. Besides the histomorphological evaluation of the vessels, the endothelial expression of ICAM-1, VCAM-1 and E-selectin was determined as well as the distribution of LFA-1-, Mac-1-, VLA-4-, RM3/1-, 27E10- and 25F9-bearing cells in the subepithelial tissue. The expression of ICAM-1 was downregulated after radiotherapy, whereas the percentage of LFA-1- and VLA-4-bearing cells increased. VCAM-1 remained at low levels. The subepithelial infiltration was still dominated by RM3/1-positive macrophages. The number of vessels decreased, while the lumen of the remaining vessels increased. In conclusion, the late effects of radiotherapy are characterized by a decreased number of blood vessels and by significantly different expression patterns of the adhesion molecules studied, and of integrins and macrophage subpopulations, compared to the conditions before irradiation and directly after irradiation with 60 Gy.

Increase of RM3/1-positive macrophages in radiation-induced oral mucositis.

The purpose of this study was to describe the distribution patterns of various leukocyte subpopulations in the oral mucosa during the course of radiotherapy and to determine whether there are dose-dependent alterations, or any correlation between the clinical stages and the population density of specific leukocytes. The distribution and density of various leukocytes in oral mucosa in 13 head and neck cancer patients were immunohistochemically analysed before radiotherapy at 30 and 60 Gy and compared with the clinical degree of oral mucositis. Antibodies were used which characterized different subtypes of macrophages (27E10, 25F9, RM3/1) and recognized epitopes of granulocytes (CD15) and T cells (CD3, CD4, CD8). The study showed that whereas macrophages reactive with RM3/1 increased significantly at 30 Gy (p<0.01) and showed a further increase at 60 Gy (p<0.01), no significant alterations could be detected in the density of macrophages which stained positively for 27E10 or 25F9. Moreover, the percentage of macrophages reactive with RM3/1 showed a non-linear correlation with the clinical mucositis score (p<0.05). No significant alterations were detected in the percentage of T cells and granulocytes, compared with the values before radiotherapy. In conclusion, radiation-induced mucositis is characterized by features of an intermediate stage of an inflammatory response, suggesting active involvement of down-regulatory macrophages in its pathogenesis.

Fast neutron irradiation in advanced pre-irradiated head and neck tumors.

AIMS AND BACKGROUND: Radiotherapy with fast neutrons offers radiobiological advantages in the treatment of hypoxic and slowly proliferating tumors. Tumors recurring in pre-irradiated areas of the head and neck usually exhibit a low radiation sensitivity that seems to promise little success for a repeated irradiation with photons. In such a situation, radiotherapy with fast neutrons may offer an alternative treatment option. To evaluate the question, the Muenster patients were retrospectively analyzed. METHODS: During the period July 1986 to January 1994, 26 patients with local-regional recurrences of pre-irradiated head and neck tumors were treated with fast neutrons at our department. RESULTS: Median survival calculated by the Kaplan-Meier method was 7.4 months. The 1-year survival probability was 29.3% and the 2-year survival probability 5.9%. The objective tumor remission (complete + partial) was 50%. A subjective improvement of symptoms was reported by 42.3% of all patients. CONCLUSIONS: Despite relatively unfavorable survival rates produced by the therapy, good remission rates and thereby a good palliative effect can be attained with a short treatment time and tolerable side effects.

Dosimetric analysis at ICRU reference points in HDR-brachytherapy of cervical carcinoma.

In vivo dosimetry in bladder and rectum as well as determining doses on suggested reference points following the ICRU report 38 contribute to quality assurance in HDR-brachytherapy of cervical carcinoma, especially to minimize side effects. In order to gain information regarding the radiation exposure at ICRU reference points in rectum, bladder, ureter and regional lymph nodes those were calculated (digitalisation) by means of orthogonal radiographs of 11 applications in patients with cervical carcinoma, who received primary radiotherapy. In addition, the doses at the ICRU rectum reference point was compared to the results of in vivo measurements in the rectum. The in vivo measurements were by factor 1.5 below the doses determined for the ICRU rectum reference point (4.05 +/- 0.68 Gy versus 6.11 +/- 1.63 Gy). Reasons for this were: calibration errors, non-orthogonal radiographs, movement of applicator and probe in the time span between X-ray and application, missing connection of probe and anterior rectal wall. The standard deviation of calculations at ICRU reference points was on average +/- 30%. Possible reasons for the relatively large standard deviation were difficulties in defining the points, identifying them on radiographs and the different locations of the applicators. Although 3 D CT, US or MR based treatment planning using dose volume histogram analysis is more and more established, this simple procedure of marking and digitising the ICRU reference points lengthened treatment planning only by 5 to 10 minutes. The advantages of in vivo dosimetry are easy practicability and the possibility to determine rectum doses during radiation. The advantages of computer-aided planning at ICRU reference points are that calculations are available before radiation and that they can still be taken into account for treatment planning. Both methods should be applied in HDR-brachytherapy of cervical carcinoma.