Prostatic carcinoma: limited field irradiation.

This is a retrospective study of 251 patients with histologically proven adenocarcinoma treated primarily with limited field radiotherapy techniques, under the principle direction of authors JMV and JPG, between 1968 and 1981 in San Francisco, California. All patients are followed for a minimum of 3 years; mean follow-up is 7.3 years. Routine clinical staging procedures included: H&P, digital prostate exam, cystoscopy, biopsy, blood studies including serum acid phosphatase, and imaging studies including chest X ray, IVP, bone survey or radionucleotide bone scan, and in recent years, pelvic CT scans. Twelve patients are Stage A1, 37-Stage A2, 50-Stage B, 140-Stage C1 and 12-Stage C2. Ninety percent of all cases and 85% of Stage C patients were treated with limited fields to the prostate and periprostatic volume only. Total doses were prescribed at midplane or isocenter and were generally 6500-7000 cGy, daily doses of 180-200 cGy, 5 days per week. Actuarial 5- and 10-year survival rates are: entire population-69% and 47%; Stage A1-74% and 50%; Stage A2-81% and 67%; Stage B-84% and 53%; Stage C1-63% and 42%; Stage C2-32% and 11%. The 5- and 10-year disease-free actuarial survivals are: entire population-71% and 50%; Stage A1-89% and 74%; Stage A2-82% and 69%; Stage B-71% and 52%; Stage C1-67% and 44%; Stage C2-0%. Sites of recurrence, alone or as a component of the failure pattern are: 37 (15%) local, 11 (4%) symptomatic regional recurrence (lower extremity edema, pelvic pain/sciatica, hydroureteronephrosis), and 87 (35%) distant metastasis. Seven (3%) had unknown sites of failure. Local-regional failure occurred in 42% of Stage C2 patients. Concomitant hormonal therapy has no survival impact on Stage C1 patients and poorly differentiated histology is associated with decreased determinate and disease-free survival rate of 5 years. Complications correlate with treatment technique, being more frequent with single field per day treatment plans. In patients treated with multiple fields per day or rotational plans, complications occur in less than 8% of patients and major complications have not occurred.

Nasopharyngeal carcinoma. A study examining Asian patients treated in the United States.

From 1972 to 1991, 126 Asian patients with nasopharyngeal carcinoma underwent definitive radiation therapy for locoregional disease: 86 men, 40 women. Median age was 50. All patients received external-beam irradiation with cobalt 60 or 4-18 MV x-rays. Local recurrence, regional recurrence, and distant metastases were 22%, 11%, and 23%, respectively. Local recurrence progressively increased with increasing T stage, but doses in those who recurred did not differ from the group as a whole. Regional recurrence was not associated with T or N stage or dose. Patients with N2 disease had the highest distant metastatic rate. The 5- and 10-year overall survival rates were 54% and 38%, respectively. Of age, gender, and histology, only age less than 50 was found to be favorably prognostic. No severe long-term complications were observed, and acute reactions were acceptable. Our survival results are comparable with results found both in Asia and North America. Nonetheless, altered fractionation techniques and/or other radiation modalities should be further explored to improve locoregional control.

Women's use of resources in decision-making for early-stage breast cancer: results of a community-based survey.

BACKGROUND: The majority of women with stage I/II breast cancer may choose between mastectomy and breast-conserving therapy (BCT). A survey was designed to examine the resources women used in making this decision. METHODS: From 1990 to 1994, 261 patients were diagnosed with or treated for stage I/II breast cancer at Washington Hospital (Fremont, CA). One-hundred seventy-six surviving patients received a questionnaire asking them to anonymously rank various medical and nonmedical persons, audio and visual materials, and decision criteria on a 5-point scale with regard to their influence on that individual's choice to undergo BCT or mastectomy. The BCT and mastectomy groups were similar demographically; approximately 50% were college-educated. Statistical significance of the difference in means between groups was assessed with the t test. The response rate to the survey was 65%. RESULTS: The average survey ranking was > 1.0 for the following: surgeon (4.5), primary care physician (2.8), spouse (2.4), radiation oncologist (1.7), medical oncologist (1.5), American Cancer Society brochure (1.4), and children (1.2). The ranking of children (p = 0.08), friends (p = 0.08), parents (p = 0.09), and spouse (p = 0.13) was higher in the mastectomy group; the ranking of the radiation oncologist (p = 0.001) and ACS brochure (p = 0.03) was higher in the BCT group. The majority of patients consulted only with the surgeon (96%), primary care physician (64%), and spouse (55% overall, 75% among married patients) before making a treatment choice. Decision criteria were ranked as follows: chance for cure (4.5), physician recommendation (3.7), potential side effects (1.7), cosmetic appearance (1.3), sexual attractiveness (1.1), treatment convenience (1.0), and desire to avoid mastectomy (1.5). Desire to avoid mastectomy was higher in the BCT group (p < 0.0001); ranking of chance for cure was higher in the mastectomy group (p = 0.12). Overall satisfaction was higher in the BCT group; 87% of these patients were "very satisfied" with their decision versus 68% for the mastectomy group (p = 0.005). Review of the admitting records for 125 patients treated with mastectomy indicated that 46% had clear medical or personal contra-indications to BCT, but that the remainder might have benefitted from specialty consultation. CONCLUSIONS: The surgeon's recommendation and the patient's perception of chance for cure were the most influential factors affecting treatment decision. There was a limited use of specialty consultation or written and audiovisual materials in this educated patient population. The survey results suggest potential areas of intervention to improve rates of BCT, namely use of up-front multidisciplinary evaluation, further education of primary care physicians, and greater attention to concerns of family members.

The results of radical prostatectomy at a community hospital during the prostate specific antigen era.

BACKGROUND: The use of radical prostatectomy in the treatment of prostate cancer has increased with the advent of prostate specific antigen (PSA) screening. Few series have examined the relapse rates after prostatectomy relative to pre-treatment prognostic factors, such as preoperative PSA and Gleason scores. The characteristics and outcome of patients diagnosed with prostate cancer and treated with radical prostatectomy at community hospitals in the prostate specific antigen era have not been described in detail. METHODS: The tumor registry records were obtained for all patients diagnosed with prostate cancer and treated with radical prostatectomy at Washington Hospital, Fremont, CA, from 1990 through 1993. The clinical and pathologic characteristics, including the original pathology report, for the 100 patients were reviewed by a single physician. Relapse was defined by the persistence or appearance of a PSA value greater than 0.2 ng/mL (Hybritech, Inc., San Diego, CA) following surgery or by clinical evidence of recurrent disease. Crude and actuarial probabilities of relapse were analyzed relative to pre-treatment PSA values, Gleason score, pathologic stage, and surgical margin status. The median follow-up time was 2.5 years. RESULTS: The pT-classification distribution of the 100 cases was as follows: T1, 4%; T2A, 14%; T2B, 11%; T2C, 49%; T3A, 8%; T3B, 2%; T3C, 6%; and N+, 6%. Pretreatment PSA values were less than or equal to 4 ng/mL for 10 patients, greater than 4 to 10 ng/mL for 38 patients, greater than 10 to 20 ng/mL for 27 patients, and greater than 20 ng/mL for 13 patients. The value was unknown for 12 patients. The Gleason score was less than or equal to 5 for 40%, 6 for 17%, 7 for 31%, and 8 to 10 for 12%. Positive surgical margins were noted in 30% of the patients. The actuarial probability of overall survival and freedom from relapse for the entire group of patients at 3 years was 95% and 73%, respectively. Pre-treatment PSA values greater than 20 ng/mL, Gleason score greater than or equal to 7, and pT3 classification were significant predictors of relapse in univariate analysis. Preoperative PSA greater than 20 ng/mL and Gleason score were significant prognostic factors in multivariate analysis. Pathologic margin status was not a significant predictor of relapse in this experience. CONCLUSIONS: Short-term relapse rates are high among those patients with preoperative PSA values greater then 20 ng/mL or Gleason scores greater than or equal to 7. Overall results of radical prostatectomy at this community hospital were similar to those reported at referral centers.