Undergraduate palliative care teaching in Swiss medical faculties: a nationwide survey and improved learning objectives.

BACKGROUND: In 2007, a first survey on undergraduate palliative care teaching in Switzerland has revealed major heterogeneity of palliative care content, allocation of hours and distribution throughout the 6 year curriculum in Swiss medical faculties. This second survey in 2012/13 has been initiated as part of the current Swiss national strategy in palliative care (2010 - 2015) to serve as a longitudinal monitoring instrument and as a basis for redefinition of palliative care learning objectives and curriculum planning in our country. METHODS: As in 2007, a questionnaire was sent to the deans of all five medical faculties in Switzerland in 2012. It consisted of eight sections: basic background information, current content and hours in dedicated palliative care blocks, current palliative care content in other courses, topics related to palliative care presented in other courses, recent attempts at improving palliative care content, palliative care content in examinations, challenges, and overall summary. Content analysis was performed and the results matched with recommendations from the EAPC for undergraduate training in palliative medicine as well as with recommendations from overseas countries. RESULTS: There is a considerable increase in palliative care content, academic teaching staff and hours in all medical faculties compared to 2007. No Swiss medical faculty reaches the range of 40 h dedicated specifically to palliative care as recommended by the EAPC. Topics, teaching methods, distribution throughout different years and compulsory attendance still differ widely. Based on these results, the official Swiss Catalogue of Learning Objectives (SCLO) was complemented with 12 new learning objectives for palliative and end of life care (2013), and a national basic script for palliative care was published (2015). CONCLUSION: Performing periodic surveys of palliative care teaching at national medical faculties has proven to be a useful tool to adapt the national teaching framework and to improve the recognition of palliative medicine as an integral part of medical training.

Prognostic factors and outcome of incompletely resected invasive thymoma following radiation therapy.

BACKGROUND: Stage III and stage IV thymomas with significant macroscopic infiltration to the neighboring structures are rarely completely resectable. It therefore remains unclear to what extent tumors must be surgically debulked to improve prognosis. PATIENTS AND METHODS: We reviewed the cases of 31 patients with incompletely resected invasive thymoma and residual macroscopic disease who were referred to postoperative irradiation. Survival and local tumor control were analyzed. All patients were treated between 1958 and 1990 with megavoltage irradiation at doses ranging from 42 to 66 Gy. The shortest follow-up time for living patients was more than 5 years. RESULTS: The overall median 5-year survival rate was 45%. Eighteen stage III patients had a 5-year survival rate of 61% and a 10-year survival rate of 57%. Thirteen patients had stage IV disease and 5- and 10-year survival rates of 23% and 8%, respectively. Univariate and multivariate analyses confirmed a worse prognosis for stage IV disease. Epithelial or spindle-cell thymoma was associated with stage IV disease. Twenty-two percent of patients with stage III disease had epithelial or spindle-cell thymoma, versus 69% of patients with stage IV disease (P = .02 for univariate and P = .05 for multivariate analysis). Initial tumor diameter greater than 10 cm correlated with poor prognosis in the univariate analysis (P = .05). However, more importantly, debulking of tumor did not significantly improve outcome when compared with patients who received biopsy only. The median survival rate of patients with stage IVa disease did not differ from that of those with stage IVb disease. Mediastinal control was achieved in 23 patients (74%). Stage IV disease did not correlate with an increase in local treatment failure after irradiation, although epithelial or spindle-cell thymoma predisposed for local treatment failure (46% v 11%; P = .04 in univariate and P = .055 in multivariate analysis). CONCLUSION: Tumor debulking leaving macroscopic residual thymoma, as opposed to biopsy alone, does not improve prognosis when followed by radiation. Radiation therapy for local tumor control is most effective in nonepithelial-predominant thymomas.

Radiotherapy for metastatic carcinomas of the kidney or melanomas: an analysis using palliative end points.

PURPOSE: To assess the rate and duration of response to palliative radiotherapy (RT) in patients with metastatic melanoma or renal cell carcinoma. PATIENTS AND METHODS: From 1992 to 1995, 90 patients were entered into a nonrandomized study. Goals of palliative RT were prospectively defined and subjective response was documented at the end of RT, after 2-6 weeks, and every 3 months thereafter. Most patients were treated with 5 x 4 Gy or 10 x 3 Gy. RESULTS: Relief of pain from bone lesions was observed in 26 of 40 cases, with a duration of response of 2.4 months, corresponding to 57% of the remaining lifetime. A total of 55% of patients with persistent neurologic dysfunction despite corticosteroids improved, for a duration of 2.5 months (86% of the further lifespan). Freedom from symptoms in patients treated for impending neurological complications from metastases to the brain, spine, or nerve plexus was documented for 86-100% of their lifetime. CONCLUSIONS: Despite the methodological flaws discussed, the efficacy of a short course of palliative RT for so-called radioresistant tumors is demonstrated.

Quality of life in patients cured from a carcinoma of the head and neck by radiotherapy: the importance of the target volume.

PURPOSE: To assess the health-related quality of life (QOL) of long-term survivors of carcinomas of different subsites of the head and neck following curative radiotherapy (RT). PATIENTS AND METHODS: Patients continuously free from recurrence or second primary tumors treated 1988-1994 were contacted 5.1 to 5.9 years after RT and asked to fill in the EORTC QLQ-C30 core questionnaire and the H&N cancer module. RT had been restricted to the glottis (group A; carcinomas of the vocal cord T1-2 N0), or had included bilateral neck nodes and the primary tumor outside the nasopharynx (group B; AJC Stage II to IV) or within the nasopharynx, respectively (group C; Stage II to IV). Response rate was 97% (group A; n = 41), 69% (group B; n = 26) and 71% (group C; n = 12), respectively. The groups were different with respect to age (older in group A), alcohol consumption (absent in group C) and proportion of females (more in group C). RESULTS: Patients with nasopharyngeal cancer reported the highest morbidity on the H&N module (dry mouth, sticky saliva, trismus, problems with teeth, trouble eating). However, these symptoms did not have a high impact on global QOL or function scores on the QLQ-C30 core questionnaire. Patients in group B reported a lower global QOL but less severe symptoms on the module. CONCLUSION: The high morbidity of patients treated for a nasopharyngeal cancer may be explained by the location of the target volume which included the bilateral temporo-mandibular joints and the salivary glands. These patients require appropriate care during follow-up and will probably profit most from new RT techniques with sparing of normal tissues.

Long-term morbidity of adjuvant infradiaphragmatic irradiation in patients with testicular cancer and implications for the treatment of stage I seminoma.

Long-term abdominal or urological morbidity and second malignancies in 289 surviving patients with infradiaphragmatic adjuvant radiotherapy (RT) for testicular cancer between 1950 and 1988 are analysed by retrospective chart review. After RT with single doses between 1.5 and 2.0 Gy and a total dose between 30 and 35 Gy, we did not observe any peptic ulcer nor other abdominal or urological long-term morbidity, except second tumours. The cumulative incidence of 16 second extratesticular malignancy was (in years after RT): 0.4% (4 years), 1.3% (9 years), 4.5% (14 years), 6.3% (19 years), 7.5% (24 years), 15.6% (29 years) and 23.6% (35 years). The ratio of observed to expected incidence of extratesticular malignancies did not differ significantly from unity; only the frequency of penile cancer (n = 2) was somewhat higher than expected. The cumulative risk of bilateral testicular cancer was 4.8% with no difference between patients with seminoma or non-seminomatous germ cell tumours. In a recent group of 128 patients with a stage I seminoma staged and treated between 1978 and 1988 by modern standard, there was no recurrence.

Cardiac lesions after mediastinal irradiation for Hodgkin's disease.

We analysed the risk of myocardial infarctions in 339 patients with Hodgkin's disease treated with radiotherapy (rt) with or without chemotherapy. A total of 112 patients underwent cardiac testing with echocardiography, rest and exercise electrocardiogram and myocardial scintigraphy. Nearly all patients have been treated with < 2.0 Gy per fraction to the anterior cardiac region. A significantly increased risk of myocardial infarctions or of sudden death has been observed (10 patients). No cardia events have been observed in 215 non-smokers without hypertension and without coronary artery disease (CAD) already present before rt. In the heart study group (112 patients), there were 6 patients with probable or proven CAD. Five of these 6 patients had known risk factors for CAD. Echocardiography showed sclerosis of the aortic and or the mitral valves in 34 patients. Of these patients, 2 had a slight and 1 a moderate aortic stenosis, 5 had a slight and 1 a moderate mitral regurgitation. Evidence for a disturbance of the diastolic function has not been observed. No patient had a clinically relevant pericardial lesion. In patients without risk factors for CAD, there is only a low risk of ischaemic cardiac events after modern mediastinal rt for Hodgkin's disease. Patients should eliminate the known risk factors. There is a high incidence of sclerosis of the mitral and or the aortic valves developing into clinically important lesions in few patients. Decision on the treatment strategy and the rt technique should also involve consideration of the cardiac risk. For routine follow-up, we recommend inclusion of an echocardiography in intervals between 3 and 4 years.

[Radiotherapy in prostatic carcinoma]. / Radiotherapie beim Prostatakarzinom.

Treatment of patients with prostate cancer has become one of the most frequent indications in radiation oncology. Reasons for this fact may be the increasing number of elderly patients, early diagnosis and urologists who are familiar with the possibility of tumor control by radiation. The treatment results and side effects of modern techniques are presented. Many questions concerning treatment policy remain unanswered. Due to the long natural history of prostate cancer we will have to endorse clinical trials and wait many years for their results.

[Radiotherapy in treatment of breast cancer]. / Die Strahlentherapie in der Behandlung des Mammakarzinoms.

Surgery and radiation therapy are the basic therapies for local tumor control in breast cancer. The role of radiation therapy has been established in a number of prospective studies during the past years. Technical advances (computerized treatment planning, linear accelerators) and knowledge of tolerance in normal tissues have practically eliminated the severe side effects of former radiation therapies. Radiation is able to prevent local recurrences in postoperative situations (breast-conserving therapies, in high-risk situations after mastectomy, after excision of chest wall recurrences). If a tumor cannot be removed or a gross tumor is left after excision, radiation will be necessary to achieve local tumor control. Radiation has an important role in palliation in metastatic disease. The current paper summarizes the role of modern radiation therapy in the treatment of breast cancer and points to problems in the referral of patients in current practice.

[Therapy of CNS metastases]. / Therapie von ZNS-Metastasen.

Brain metastases occur in 20-30% of patients with systemic cancer and represent one of the most unfavourable prognostic parameters. In the majority of cases brain metastases are multiple and are usually treated with whole brain irradiation. The treatment of single brain metastases often includes surgery, followed by whole brain radiotherapy. Although the goal of treatment of both single and brain metastases is almost always palliation and not cure, it is important that several modes of treatment are carefully compared. In comparing different treatment regimens it should be emphasised that not only duration of survival time and time until tumour recurrence are used as outcome parameters but also the quality of life. The only way in which the results of different therapies can be compared is by means of randomised trials. As long as high quality studies are not available, any definitive assessment of the relative effectiveness of radiosurgery to standard treatment for brain cannot be defined. Radiosurgery can be used to treat patients, whose metastases recur after traditional therapies. As with other definitive therapies for patients with brain metastases, highly functional patients with well-controlled systemic cancers derive the greatest benefit from treatment with radiosurgery.

[Radiotherapy as an emergency measure]. / Strahlentherapie als Notfallmassnahme.

An emergency in radiotherapy is a case calling for such urgent treatment that the usual stages of planning are abbreviated and radiation is started within a few hours. After a short summary of the biological effects of radiotherapy, we will discuss the emergency situations one has to deal with. Most frequent are those in the course of malignant disease. Yet, in the context of increasingly practised transfusion- and transplantation-techniques, the number of other emergencies is rising.

[Papillary and follicular thyroid carcinoma: long-term course in 339 patients of the Zurich University Hospital 1960 to 1988 and review]. / Papilläres und follikuläres Schilddrüsenkarzinom: Langzeitverlauf bei 339 Patienten des USZ 1960 bis 1988 und Ubersicht.

Survival rates, tumor control and complications in 339 patients with follicular or papillary carcinoma of the thyroid treated at the clinics of radio-oncology and nuclear medicine during the period 1960-1988 were analyzed. Operable tumors were treated by subtotal thyroidectomy or various modes of uni- or bilateral subtotal resection combined with eradication of remaining thyroid tissue with iodine 131 or percutaneous irradiation, the latter limited in the seventies to patients with local or regional tumor extension. Further 131I was administered when iodine-incorporating tissue was detected. Mortality due to tumor was under 5% in patients younger than 40, 2-20% in older patients with tumor stages T1-3 N0-1 M0 or T2-3 N0 M0, 53 to 74% in various groups T4 N0-2 M0 and over 40, and more than 85% in patients over 40 with distant metastasis. When the total activity of 131I was limited to 1 Ci (37 Gbq), an increased incidence of leukemias or cancer of the bladder was not observed. These observations are discussed and compared with data from published reports. A scheme for treatment and follow-up is presented.

[Long-term results following radioiodine treatment of patients with metastasizing follicular and papillary thyroid carcinoma]. / Langzeitergebnisse nach Radiojodbehandlung von Patienten mit metastasiertem follikulärem und papillärem Schilddrüsenkarzinom.

From 1963 to 1988, 94 patients with mediastinal and/or distant metastasis of follicular or papillary thyroid cancer have been treated in our department by subtotal or near total thyroidectomy, 131-iodine ablation of the thyroid recurrent thyroid hormone and 131-iodine applications. Patients with locally advanced tumours had also percutaneous irradiation. Some patients had also surgical excision and percutaneous irradiation of the metastasis. Rates of complete and permanent remissions were: 53% (all pap.), 7% (all foll.), 75% (lung and/or mediastinal metastasis), 100% (miliary or micronodular lung metastasis and small mediastinal nodes), 6% (bone metastasis). Tumor specific survival rates were: 95% and 90% 10 and 20 years in patients less than 40 years old at the beginning of the treatment, 65% (5 years), 40% (10 years), 25% (15 years) and 18% (20 years) in patients at least 40 years old. Serious complications due to radioiodine were observed in three patients (one acute leukemia, one macroscopic haematuria with irradiation cystitis and one cancer of the bladder). Furthermore five patients suffered from grade III/IV thrombocytopenia: these patients had also multiple bone metastasis and percutaneous irradiation of various bone regions.

Volumetric staging (VS) is superior to TNM and AJCC staging in predicting outcome of head and neck cancer treated with IMRT.

The UICC classification (TNM) represents the validated standard tool to describe tumor extent and includes prognostic information on the probability of disease control. The American Joint Committee on Cancer (AJCC) stage grouping is based on the evaluation of treatment and outcome. Gross tumor volume (GTV) might be more relevant than pure description (TNM) or stage grouping as prognostic factor for local control in head and neck cancer (HNC). Based on the observation of GTV-correlated outcome in our initial HNC patient cohort treated with IMRT, we tested the hypothesis that the GTV is the most reliable predictive tool in HNC outcome. A GTV based volumetric staging system (VS) was introduced, using two volumetric cut-off values (15 and 70 cm3). VS, TNM, and AJCC stages were assessed and correlated with outcome following primary radiation in 172 HNC patients. Analyses were based on Kaplan-Meier survival curves. VS proved to be superior to the TNM/AJCC in predicting outcome. In addition, VS enabled to stratify high- and low-risk patients in advanced TN stages. GTV represented the most important prognostic indicator in HNC treated with IMRT and is recommended to be considered for therapeutic decisions and estimation of outcome.

IMRT using simultaneously integrated boost (SIB) in head and neck cancer patients.

BACKGROUND: Preliminary very encouraging clinical results of intensity modulated radiation therapy (IMRT) in Head Neck Cancer (HNC) are available from several large centers. Tumor control rates seem to be kept at least at the level of conventional three-dimensional radiation therapy; the benefit of normal tissue preservation with IMRT is proven for salivary function. There is still only limited experience with IMRT using simultaneously integrated boost (SIB-IMRT) in the head and neck region in terms of normal tissue response.The aim of this work was (1) to establish tumor response in HNC patients treated with SIB-IMRT, and (2) to assess tissue tolerance following different SIB-IMRT schedules. RESULTS: Between 1/2002 and 12/2004, 115 HNC patients have been curatively treated with IMRT. 70% received definitive IMRT (dIMRT), 30% were postoperatively irradiated. In 78% concomitant chemotherapy was given. SIB radiation schedules with 5-6 x 2 Gy/week to 60-70 Gy, 5 x 2.2 Gy/week to 66-68.2 Gy (according to the RTOG protocol H-0022), or 5 x 2.11 Gy/week to 69.6 Gy were used. After mean 18 months (10-44), 77% of patients were alive with no disease. Actuarial 2-year local, nodal, and distant disease free survival was 77%, 87%, and 78%, respectively. 10% were alive with disease, 10% died of disease. 20/21 locoregional failures occurred inside the high dose area. Mean tumor volume was significantly larger in locally failed (63 cc) vs controlled tumors (32 cc, p <0.01), and in definitive (43 cc) vs postoperative IMRT (25 cc, p <0.05); the locoregional failure rate was twofold higher in definitively irradiated patients. Acute reactions were mild to moderate and limited to the boost area, the persisting grade 3/4 late toxicity rate was low with 6%. The two grade 4 reactions (dysphagia, laryngeal fibrosis) were observed following the SIB schedule with 2.2 Gy per session. CONCLUSION: SIB-IMRT in HNC using 2.0, 2.11 or 2.2 Gy per session is highly effective and safe with respect to tumor response and tolerance. SIB with 2.2 Gy is not recommended for large tumors involving laryngeal structures.

[Radiation resistance: a concept in need of review or a stubborn problem for radio-oncology?]. / Strahlenresistenz: revisionsbedürftiger Begriff oder hartnäckiges Problem der Radio-Onkologie?

Many tumors are considered to be radio-resistant. Reviewing recent literature on clinical results, this notion of radio resistance needs to be revised. With new technics and improved dosimetry it has become possible to control locally even well differentiated carcinomas and achieve clear survival benefits. Three examples illustrate the importance of radiation therapy of prostatic cancer as a well established procedure. It would seem that radiation therapy in colorectal tumors of certain stages is becoming part of initial treatment. A case is made out for meningeoma, where surgery undoubtedly remains the first approach; after incomplete removal or in locally inoperable patients, radiation therapy may be of value.

[Nuclear medical methods for the detection of coronary disease]. / Nuklearmedizinische Methoden zur Erfassung koronarer Herzkrankheiten.

Three developments in recent years have speeded the advance of nuclear cardiology: gamma cameras have become available, computers have been introduced into nuclear medicine, and radionuclides such as Tc99m and Tl201 have become easily obtainable for imaging purposes. The imaging of the myocard with Tl201 has its established place in cardiology. Sensitivities of about 90% and specificities of about 80-90% make Tl201 exercise tests a powerful tool for detection of coronary artery disease (CAD) in a preselected population. Ejection fraction can be measured at rest and during exercise where an absent increase during physical stress is clearly abnormal (and also not necessarily specific for CAD). Sensitivities of 80-90% and specificities around 90% for detection of CAD seem possible. Wall motion abnormalities again can be brought out during exercise and serve to localize impaired ventricle function. Tc99m-pyrophosphate studies seem to have some implications to prognosis if myocardial accumulation persists. Only preliminary reports are thus far available for these two studies.

[Radio-oncology--advances and integration of the last few years]. / Radio-Onkologie--Fortschritte und Integration der letzten Jahre.

Progress in radiation oncology can be ascribed to better staging (diagnostic procedures such as CT and MRI), improved pathological classification, innovations in treatment planning (CT, computerized planning systems, patient fixation) and modern accelerators. These various contributions are demonstrated in detail taking radiation therapy of prostate cancer as an example. The importance of these (largely technological) advances is discussed, together with ways of balancing the technical and human aspects.