Outcomes of high dose rate interstitial boost brachytherapy after external beam radiation therapy in head and neck cancer--an Indian (single institutional) learning experience.

PURPOSE: This study is to assess efficacy and toxicity associated with external beam radiation therapy (EBRT) and high dose rate (HDR) interstitial Iridium-192 ((192)Ir) brachytherapy for the treatment of squamous carcinoma of the oropharynx and oral cavity. METHODS AND MATERIALS: Between July 2004 and June 2006, 33 patients with oropharynx and oral cavity carcinomas were treated with (192)Ir interstitial implants after EBRT at Medical College Hospital, Kolkata. Fifteen patients had early stage disease (Stage I and II) and 18 had advanced stage disease (Stage III and IV). All received EBRT to a median dose of 50Gy (range, 46-66Gy) to the primary tumor and regional lymph nodes before brachytherapy. Node-positive patients with residual neck disease also underwent neck dissection. Brachytherapy dose (HDR) in combination with EBRT varied from 14 to 21Gy, 3-3.5Gy per fraction, two fractions daily. Locoregional control, freedom from disease, and complications were assessed. RESULTS: Followup duration was between 18 and 40 months. At the end of treatment with radiation, 79% achieved complete response (CR) (p<0.009), 21% achieved partial response (PR) and the ultimate control rate (including surgical salvage) was 100% and 78% for early and advanced disease, respectively (p<0.108). Three (9%) patients failed locally after CR. No distant metastasis was seen during followup. Grade 3 mucositis was seen in 12% cases. Transient hemorrhage occurred in 3 (9%) patients and local infection in 1 (3%) patient. Severe dysphagia was seen in 1 (3%) patient. 5/33 (15%) patients experienced xerostomia (Grade 3-4), but almost all patients had Grade 1-2 xerostomia. CONCLUSION: Oropharyngeal and oral cavity tumors can be effectively treated with (192)Ir implant boost after EBRT. Local control is excellent and complication rates are acceptable.

Awareness of palliative care among doctors of various departments in all four teaching medical colleges in a metropolitan city in Eastern India: A survey.

OBJECTIVE: To enquire about the level of awareness regarding various important aspects of palliative medicine among doctors of various departments in four Medical Colleges in Kolkata through a questionnaire. MATERIALS AND METHODS: A questionnaire was developed by few members of Indian Association of Palliative Care. It was distributed, to a convenience sample of doctors who worked at various departments in all four teaching hospitals in Kolkata. The distribution and collection of questionnaires was carried out within four months. RESULTS: The results suggested that 85% of the doctors felt that cancer was the commonest reason for the palliative care teams to be involved. Seventy four percent of the doctors mentioned that pain control was their prime job; 53% said that they are enjoying their encounter with palliative care, so far; 77% of the doctors thought breaking bad news is necessary in further decision making process; only 22% of the doctors reported the WHO ladder of pain control sequentially, 35% of the doctors believed other forms of therapies are useful in relieving pain, 35% of the doctors thought that they gave enough importance and time for pain control; 77% said that they had heard about a hospice, among them still 61% of the doctors thought that the patients should spend last days of their life at home. Thinking of the future, 92% of the doctors think that more and more people will need palliative care in the coming days. CONCLUSION: Amongst the doctors of various departments, there is a lack of training and awareness in palliative care. Almost all the doctors are interested and they are willing to have more training in pain control, breaking bad news, communication skills and terminal care.

Abnormalities by pulmonary regions studied with computer tomography and clinical correlation following local-regional radiotherapy for breast cancer.

BACKGROUND: Adjuvant local-regional radiotherapy (RT) is commonly recommended for breast cancer patients. Postoperative adjuvant RT for breast cancer is associated with pulmonary side effects. This study was undertaken to measure the RT-induced pulmonary radiological changes with computer tomography (CT) scan using a CT-adapted modification of the Arriagada classification system, and to correlate these changes to RT techniques, pulmonary complications, and pulmonary function. The aim of the study is to study pulmonary radiological abnormalities with CT following different RT techniques for breast cancer, and their correlation to pulmonary complications and reduction in forced vital capacity (FVC). MATERIALS AND METHODS: CT scans of the lungs were performed prior to and 4 months following RT in 53 breast cancer patients treated with local-regional RT. The radiological abnormalities were analyzed with a CT-adapted modification of a classification system originally proposed by Arriagada. The patients were monitored for RT-induced pulmonary complications. FVC was measured prior to and 6 months following RT. Statistical analysis used were that increasing CT scores were correlated with pulmonary complications (P < 0.001). The correlation between density grade (0-3, 4-9) and pulmonary complications (no complication vs slight/severe) was tested using Chi-square exact test for trend (2-sided). In addition, correlation between CT scores and FVC was done. RESULTS: Increasing CT scores were correlated with pulmonary complications (P < 0.001). The mean reduction of FVC for patients scoring 4-9 (-220 ml) was larger than for patients scoring 0-3 (-15 ml) (Spearson correlation coefficient significant at 0.01 level 2 tailed). But the mean reduction of FVC with greater volume of lung irradiated was not statistically different than lesser volume of lung irradiated (P > 0.05). CONCLUSIONS: Radiological abnormalities detected on CT images and scored with a modification of Arriagada's classification system can be used as an objective endpoint for pulmonary side effects in postmastectomy RT.

Effect of bladder distension on dosimetry of organs at risk in computer tomography based planning of high-dose-rate intracavitary brachytherapy for cervical cancer.

PURPOSE: Distension and shape of urinary bladder may vary during intracavitary brachytherapy (ICBT) for cervical cancer, significantly affecting doses to bladder, rectum, sigmoid colon and small intestine and consequently late radiation toxicities. This study is to evaluate the effects of different fixed volume bladder distention on dosimetry, assessed by three dimensional image based planning, in different organs at risk during the treatment of cervical cancer with ICBT. MATERIAL AND METHODS: Forty seven cervical cancer patients (stage IB to IVA) were qualified for ICBT following external beam radiotherapy. Urinary bladder was distended with different volumes of normal saline instilled by a Foley's catheter. Planning CT scans were performed after insertion of applicators and three dimensional treatment planning was done on Brachyvision(®) treatment planning system (Varian Medical Systems, Palo Alto, CA). Dose volume histograms were analyzed. Bladder, rectum, sigmoid colon and small intestine doses were collected for individual plans and compared, based on the amount of bladder filling. RESULTS: Mean dose to the bladder significantly decreased with increased bladder filling. However, doses to the small volumes (0.1 cc, 1 cc, 2 cc) which are relevant for brachytherapy, did not change significantly with bladder filling for bladder, rectum or sigmoid colon. Nevertheless, all dose values of small intestine are decreased significantly with bladder filling. CONCLUSIONS: Bladder distension has no significant effect on doses received during brachytherapy by relevant volumes of bladder, rectum and sigmoid colon except intestine where values are decreased with bladder distension. A larger study with clinical correlation of late toxicities is essential for proper evaluation of this strategy.

Fatigue in breast cancer patients on adjuvant treatment: course and prevalence.

INTRODUCTION: Fatigue is a major complain in breast cancer patients and survivors. Patterns and degree varies with schedule and type of the treatment. Different co-factors may aggravate fatigue. Multimodal approach is helpful in managing fatigue. AIM: To quantify prevalence, course and degree of fatigue in breast cancer patients on adjuvant treatment and effectiveness of different management approach. MATERIALS AND METHODS: One Hundred and ten post-mastectomy breast cancer patients (Stage I to Stage III) were assessed. Patients on chemotherapy were assessed one week before, day after chemotherapy and two weeks later in every cycle. Patients on External Beam Radiation Therapy (EBRT) were assessed one week before and every week during radiation. Assessment was continued on second and fourth week of follow up. Functional Assessment of Chronic Illness Therapy - Fatigue subscale (FACIT-F) was used for assessment. Significant cofactors were also searched for. RESULTS: Eighty four percent patients experienced fatigue. Fatigue was more prevalent during chemotherapy (91%) than EBRT (77%). Patients on Chemotherapy exhibit peak fatigue day after Chemotherapy and decreased level until the next cycle. Significant increase of fatigue was seen only in first cycle. Patient on EBRT had gradually increased fatigue during the course of treatment. Lower degree of fatigue was present in post treatment period. Anemia was a significant cofactor causing fatigue (P < 0.05). Blood Transfusion improved fatigue scores. CONCLUSION: Fatigue increases during chemotherapy and or EBRT. Different intervention strategies are needed to address the issue.