Multidisciplinary survey on use of feeding tubes in head and neck cancer patients undergoing chemoradiotherapy in Germany-the SUFEETUBE project.

BACKGROUND AND OBJECTIVE: Data on enteral tube feeding in head and neck cancer (HNC) patients undergoing chemoradiotherapy vary considerably between German institutions. This survey aims to investigate the management of feeding tubes in an interdisciplinary context across Germany. MATERIALS AND METHODS: Between December 2022 and May 2023, 70 participants (42 radiation oncologists, 12 medical oncologists, 14 head and neck surgeons, and 2 physicians covering several specialties) responded to our web-based survey. In addition to the type of institution (university hospital, private practice, etc.), their age, and professional experience (in years), participants were asked several questions on the indication and institutional policy for tube placement and management (prophylactic/reactive nasogastric or gastrostomy tube). All questions were mandatory single- or multiple-choice questions, while additional comments were possible by email. RESULTS: Most participants were employed at a university hospital (n = 52; 74.3%) and came from a radiation oncology background (n = 42; 60%). Fifty-four contributors (77.1%) reported that no nutritional risk screening prior to chemoradiotherapy was routinely performed, and 71.4% (n = 50) stated that no standardized protocol was used at the institution to set the indication for tube placement. Generally, policies and methods of tube feeding vary considerably between the individual institutions and specialties. However, the majority (n = 56, 80%) recommended a prophylactic percutaneous enteral gastrostomy (PEG) tube to their patients before chemoradiotherapy. Still, there was no consistent trend regarding the approach for reactive tube feeding. CONCLUSION: The policies and methods of tube feeding vary considerably between the individual institutions and specialties in Germany. In the era of individualized medicine, uniform protocols are difficult to establish. However, a baseline nutritional risk screening could simplify decision-making in clinical practice.

Cosmetic changes following surgery and accelerated partial breast irradiation using HDR interstitial brachytherapy : Evaluation by a multidisciplinary/multigender committee.

BACKGROUND: Patients with early-stage breast cancer can benefit from adjuvant accelerated partial breast irradiation (APBI) following breast-conserving surgery (BCS). This work reports on cosmetic results following APBI using multicatheter high-dose-rate interstitial brachytherapy (HDR-IBT). PATIENTS AND METHODS: Between 2006 and 2014, 114 patients received adjuvant APBI using multicatheter HDR-IBT. For each patient, two photographs were analyzed: the first was taken after surgery (baseline image) and the second at the last follow-up visit. Cosmesis was assessed by a multigender multidisciplinary team using the Harvard Breast Cosmesis Scale. Dose-volume histogram (DVH) parameters and the observed cosmetic results were investigated for potential correlations. RESULTS: The median follow-up period was 3.5 years (range 0.6-8.5 years). The final cosmetic scores were 30% excellent, 52% good, 14.5% fair, and 3.5% poor. Comparing the baseline and follow-up photographs, 59.6% of patients had the same score, 36% had a better final score, and 4.4% had a worse final score. Only lower target dose nonuniformity ratio (DNR) values (0.3 vs. 0.26; p = 0.009) were significantly associated with improved cosmetic outcome vs. same/worse cosmesis. CONCLUSION: APBI using multicatheter HDR-IBT adjuvant to BCS results in favorable final cosmesis. Deterioration in breast cosmesis occurs in less than 5% of patients. The final breast cosmetic outcome in patients treated with BCS and APBI using multicatheter HDR-IBT is influenced primarily by the cosmetic result of the surgery. A lower DNR value is significantly associated with a better cosmetic outcome.

Intensity modulated perioperative HDR brachytherapy for recurrent and/or advanced head and neck metastases.

Recurrent neck metastases following surgery and full dose adjuvant radiotherapy of squamous cell head and neck cancer remain a clinical challenge. After revision neck dissection and chemotherapy re-irradiation dosage is often limited and survival prognosis deteriorates. Here, adjuvant high-dose rate intensity modulated perioperative brachytherapy (HDR IMBT) offers a second full radiation dose with a limited volume of normal tissue radiation in the neck. In this retrospective study patients were identified who underwent revision surgery and perioperative HDR IMBT for recurrent neck metastases. Survival rates were estimated and the scarce literature on interstitial brachytherapy of the neck was reviewed. From 2006 to 2014, nine patients were treated for recurrent or palliative neck metastases using salvage surgery and HDR IMBT. Eight patients received previous surgery and external beam radiotherapy with or without chemotherapy. Two and five year overall survival was calculated to be 78 and 67 %, respectively. HDR IMBT is a salvage treatment option for selected cases in the neck following surgical revision or last-line treatment strategies. In the literature and this small cohort radiation toxicity and the risk of "carotid blow-out" seemed to be low.

Salvage high-dose-rate interventional radiotherapy (brachytherapy) for locally relapsed prostate cancer after radical prostatectomy and subsequent external irradiation.

Purpose: To report the use of high-dose-rate (HDR) interventional radiotherapy (brachytherapy, IRT) as a salvage treatment for macroscopic histologically confirmed local relapse of prostatic cancer after prostatectomy and subsequent external irradiation. Material and methods: A retrospective study of patients with prostate adenocarcinoma, treated with HDR-IRT for an isolated local relapse after prostatectomy and external irradiation at our institution (2010-2020). Treatment results and treatment related-toxicity were recorded. Clinical outcomes were analyzed. Results: Ten patients were identified. The median age was 63 years (range, 59-74 years), and the median follow-up time was 34 months (range, 10-68 months). Four patients had a biochemical relapse, and the mean time to prostate specific antigen (PSA) increase was 13 months. One-year biochemical failure-free survival (bFFS), 3-year bFFS, and 4-year bFFS were 80%, 60%, and 60%, respectively. Most of the treatment-related toxicities were grade 1-2. Two patients experienced grade 3 late genitourinary toxicity. Conclusions: HDR-IRT seems to be an effective treatment option showing acceptable toxicity for prostate cancer patients with isolated macroscopic histologically confirmed local relapse after prostatectomy and subsequent external irradiation.

Pre-treatment Emotional Distress in Patients Receiving Radiotherapy for Gynecologic Cancers.

BACKGROUND/AIM: Patients with gynecologic cancers selected for external-beam radiotherapy or brachytherapy may experience emotional distress. We aimed to identify patients who may benefit from early psycho-oncological intervention. PATIENTS AND METHODS: We investigated 10 potential risk factors of emotional distress in a retrospective series of 122 patients planned for radiotherapy of gynecologic cancers. Factors included COVID-19 pandemic, number of physical problems, age, performance status, tumor site/stage, surgery, chemotherapy, brachytherapy, and history of another tumor. p-Values <0.005 indicated significance, and p-values <0.06 trends. RESULTS: Frequencies of worry, fear, sadness, depression, nervousness, and loss of interest were 41%, 57%, 39%, 16%, 38%, and 20%, respectively. Significant associations with at least one of these symptoms were found for ≥5 physical problems and no upfront surgery. Trends were observed for chemoradiotherapy, history of another tumor, worse performance status, and younger age. CONCLUSION: The prevalence of pre-radiotherapy emotional distress was remarkable in patients with gynecologic cancers. Patients with risk factors may benefit from immediate psycho-oncological assistance.

Prevalence and Risk Factors of Emotional Distress in Patients With Prostate Cancer Assigned to External-beam Radiotherapy With or Without High-dose Rate Brachytherapy.

BACKGROUND/AIM: Upcoming radiotherapy for prostate cancer may lead to emotional distress. This study aimed to identify the prevalence and risk factors in a retrospective cohort of 102 patients. PATIENTS AND METHODS: Thirteen characteristics were evaluated for six emotional problems. To account for multiple comparisons, Bonferroni correction was used; p-values <0.0038 were significant (alpha level <0.05). RESULTS: Prevalence of worry, fears, sadness, depression, nervousness, and loss of interest in usual activities was 25%, 27%, 11%, 11%, 18%, and 5%, respectively. A greater number of physical problems was significantly associated with worry (p=0.0037) and fears (p<0.0001) and showed trends regarding sadness (p=0.011) and depression (p=0.011). Trends were also found for associations between younger age and worry (p=0.021), advanced primary tumor stage and fears (p=0.025), patient's history of another malignancy and nervousness (p=0.035), and between external-beam radiotherapy alone and fears (p=0.042) or nervousness (p=0.037). CONCLUSION: Although the prevalence of emotional distress was comparably low, patients with risk factors may benefit from early psychological support.

Comparison of Two Cisplatin Regimens for Chemoradiation in Patients With Squamous-cell Carcinoma of the Head and Neck.

BACKGROUND/AIM: Many patients with squamous-cell carcinoma of the head and neck receive cisplatin-based chemoradiation. This retrospective study compared two chemoradiation programs to help identify the optimal cisplatin-regimen. PATIENTS AND METHODS: Forty-one patients assigned to chemoradiation with two cycles of 20 mg/m2/days(d)1-5 were compared to 78 patients assigned to chemoradiation with two cycles of 25 mg/m2/d1-4. Groups were compared for toxicity, loco-regional control (LRC), and survival. RESULTS: Both treatments were associated with similar rates of oral mucositis, radiation dermatitis, xerostomia, nausea, decreased renal function, and hematotoxicity. The cisplatin-regimen had no significant impact on LRC (p=0.41) or survival (p=0.85). Survival was significantly worse with radiotherapy interruptions (>1 week) or discontinuation (p<0.001) and administration of <80% of the planned cisplatin dose (p<0.001). CONCLUSION: Both cisplatin-regimens did not differ significantly regarding toxicities, LRC, and survival. It is important to avoid interruption or discontinuation of radiotherapy and to administer ≥80% of planned cisplatin.

Salvage Perioperative Interstitial High-Dose-Rate Interventional Radiotherapy (Brachytherapy) for Local Recurrences of the Chest Wall Following Mastectomy and Previous External Irradiation.

(1) Background: To investigate the technical feasibility, safety, and efficacy of interstitial perioperative high-dose-rate interventional radiotherapy (HDR-IRT, brachytherapy) as a local salvage treatment combined with surgery for local chest wall recurrences following mastectomy and subsequent external beam radiation treatment (EBRT). (2) Methods: A retrospective analysis of 56 patients treated with interstitial HDR-IRT in combination with local surgery of a chest wall recurrence of breast cancer after previous treatment with mastectomy and EBRT from 2008 to 2020. (3) Results: Local recurrence following HDR-IRT was encountered in seven (12.5%) patients. The 1-year local recurrence-free survival (RFS), 3-year RFS, and 5-year RFS were 91%, 82%, and 82%, respectively. The 1-year overall survival (OS), 3-year OS, and 5-year OS was 85.5%, 58%, and 30%, respectively. Acute grade 1-2 radiation dermatitis was observed in 22 (39.3%) patients. Late ≥grade 3 toxicities were encountered in five (8.9%) patients. (4) Conclusions: Salvage perioperative interstitial high-dose-rate interventional radiotherapy (brachytherapy) combined with surgery seems to be an effective interdisciplinary management with acceptable treatment-related toxicity for local recurrences of the chest wall following mastectomy and previous external irradiation.

A New Prognostic Instrument for Predicting the Probability of Completion of Cisplatin during Chemoradiation for Head and Neck Cancer.

Many head and neck cancer patients assigned to definitive or adjuvant chemoradiation treatment do not complete the concurrent cisplatin dose. We determined corresponding risk factors and developed a prognostic instrument to help identify these patients. Ten pre-treatment characteristics were retrospectively analyzed in 154 patients with head and neck cancer who were treated via chemoradiation with cisplatin. These pre-treatment characteristics included age, sex, Karnofsky performance score, tumor site, primary tumor stage, nodal stage, histologic grade, upfront surgery, human papilloma virus status, and history of smoking. The characteristics significantly associated with the completion of cisplatin-based treatment, the receipt of ≥80% cisplatin, or showing a strong trend of association after multivariate analyses were used for the prognostic instrument. For each characteristic, 0 points were assigned for worse outcomes, and 1 point was assigned for better outcomes. Patients' scores were calculated by adding these points. Age ≤ 60 years and a Karnofsky performance score of 90-100 were significantly associated with both endpoints after multivariate analysis, and male gender showed a trend for association with the receipt of ≥80% cisplatin. Patient scores were 0, 1, 2, and 3 points. The corresponding rates of completion of cisplatin-based treatment were 14%, 41%, 62%, and 72%, respectively (p = 0.004). The rates of receipt of ≥80% cisplatin were 29%, 54%, 72%, and 94%, respectively (p < 0.001). This new prognostic instrument helps to predict whether head and neck cancer patients scheduled for chemoradiation will receive cisplatin as planned.

Chemoradiation with Cisplatin vs. Carboplatin for Squamous Cell Carcinoma of the Head and Neck (SCCHN).

Cisplatin is the standard for the chemoradiation of squamous cell carcinoma of the head and neck (HNSCC). Many patients cannot receive cisplatin due to impaired renal function. This study investigated carboplatin as an alternative option. In total, 131 patients assigned to two courses of cisplatin (20 mg/m2/d1--5 or 25 mg/m2/d1-4) were matched to 45 patients not suitable for cisplatin and receiving carboplatin (AUC 1.0/d1-5 or AUC 1.5/d1-4). The endpoints included loco-regional control (LRC), metastases-free survival (MFS), overall survival (OS), toxicities, and the completion of chemotherapy. The patients in the carboplatin group were significantly older and had more G3 tumors. Otherwise, the baseline characteristics were balanced. The LRC rates at 2 and 3 years were 77% and 76% in the cisplatin group vs. 69% and 65% in the carboplatin group (p = 0.21). The MFS rates were 83% and 78% vs. 78% and 74% (p = 0.34) and the OS rates 83% and 79% vs. 83% and 75% (p = 0.64), respectively. The outcomes were not significantly different in the subgroups receiving definitive or adjuvant chemoradiation. No significant differences were found regarding toxicities. Non-significantly more patients in the carboplatin group completed their chemotherapy (78% vs. 66%, p = 0.15). Carboplatin was associated with similar outcomes and toxicities as cisplatin, although these patients had worse renal function, more aggressive tumors, and were older. Given the limitations of this study, carboplatin appears an option for patients not suitable for cisplatin.

First Results of Concurrent Chemoradiation with Two Courses of 5 × 25 mg/m2 Cisplatin for Locally Advanced Head and Neck Cancer.

Many patients with squamous cell carcinoma of the head and neck (SCCHN) receive cisplatin-based chemoradiation. Cisplatin 100 mg/m2 every three weeks is toxic and alternative cisplatin regimens are desired. Two courses of 20 mg/m2/day 1-5 (cumulative 200 mg/m2) were shown to be similarly effective and better tolerated than 100 mg/m2 every three weeks. Previous studies suggested that cumulative doses >200 mg/m2 may further improve outcomes. In this study, 10 patients (group A) receiving two courses of 25 mg/m2/day 1-5 (cumulative 250 mg/m2) in 2022 were retrospectively matched and compared to 98 patients (group B) receiving two courses of 20 mg/m2/day 1-5 or 25 mg/m2/day 1-4 (cumulative 200 mg/m2). Follow-up was limited to 12 months to avoid bias. Group A achieved non-significantly better 12-month loco-regional control (100% vs. 83%, p = 0.27) and metastases-free survival (100% vs. 88%, p = 0.38), and similar overall survival (89% vs. 88%, p = 0.90). No significant differences were found regarding toxicities, completion of chemotherapy, and interruption of radiotherapy. Given the limitations of this study, chemoradiation with two courses of 25 mg/m2/day 1-5 appears an option for carefully selected patients as a personalized treatment approach. Longer follow-up and a larger sample size are needed to properly define its role.

Evaluation of the Impact of Smoking and Alcohol Consumption on Toxicity and Outcomes of Chemoradiation for Head and Neck Cancer.

BACKGROUND/AIM: Smoking and alcohol abuse may impair outcomes of chemoradiation for squamous cell head and neck cancer (SCCHN). Potential associations with toxicity, loco-regional control (LRC), and overall survival (OS) were investigated. PATIENTS AND METHODS: Ninety-six patients were retrospectively analyzed for impacts of pre-radiotherapy (pre-RT) smoking history, smoking during radiotherapy, and pre-RT alcohol abuse on toxicity, LRC, and OS. RESULTS: A trend was found for associations between pre-RT smoking history and grade ≥2 dermatitis. Smoking during radiotherapy was significantly associated with grade ≥3 mucositis and showed trends regarding grade ≥2 mucositis and dermatitis. On univariate analyses, smoking during radiotherapy was negatively associated with LRC and OS, pre-RT alcohol abuse with OS, and >40 pack years with LRC and OS. In multivariate analyses, smoking during radiotherapy remained significant for decreased OS, and pack years showed a trend. CONCLUSION: Smoking during radiotherapy was an independent predictor of OS and associated with increased toxicity. Thus, it is important to stop smoking prior to the start of radiotherapy.

Emotional Distress in Head-and-neck Cancer Patients Scheduled for Chemoradiation or Radiotherapy Alone.

BACKGROUND/AIM: Radiotherapy for head-and-neck cancer is often associated with significant toxicities, which may cause emotional distress. We evaluated prevalence and risk factors for pre-treatment emotional problems in patients irradiated for head-and-neck cancer. PATIENTS AND METHODS: Twelve characteristics were retrospectively investigated in 213 patients for associations with emotional problems (worry, fear, sadness, depression, nervousness, loss of interest). After Bonferroni adjustment, p-values <0.0042 were regarded significant. RESULTS: At least one emotional problem was reported by 131 patients (61.5%). Specific prevalence for emotional problems ranged between 10% and 44%. Physical complaints showed significant associations with all six emotional problems (p<0.0001) and female sex with sadness (p=0.0013). Trends were found for associations between female sex and fear (p=0.0097), history of another tumor and sadness (p=0.043), worse performance status and nervousness (p=0.012), and cancer site (oropharynx/oral cavity) and nervousness (p=0.063). CONCLUSION: More than 60% of patients reported emotional distress prior to radiotherapy for head-and-neck cancer. Patients with risk factors likely require near-term psycho-oncological assistance.

Salvage High-Dose-Rate Interventional Radiotherapy (Brachytherapy) Combined with Surgery for Regionally Relapsed Head and Neck Cancers.

(1) Background: to report on the use of high-dose-rate (HDR) interventional radiotherapy (brachytherapy, IRT) as a salvage treatment for patients with regionally relapsed head and neck cancers. (2) Methods: A retrospective study of 60 patients treated with HDR-IRT for loco-regionally relapsed head and neck cancers at our institution (2016-2020). Treatment procedure, results, and related toxicities were collected. Local and overall survival outcomes were analyzed. (3) Results: The median follow-up was 22.4 months. Twenty-nine (48.3%) patients had locoregional recurrences with a median time of 28.9 months. The local-recurrence free-survival was 88.1% and 37.3% at 3 years and 5 years. At the last follow-up, 21 patients were alive and the median time to death was 24 months. The overall survival was 39.2% and 16.6% at 3 years and 5 years. Collectively, there were 28 events of grade ≥ 3 late toxicities recorded in 21 patients (35%). (4) Conclusions: Salvage HDR-IRT combined with surgery offers a second-line curative treatment option for regionally relapsed head and neck cancers with acceptable outcomes and toxicities.

Biological Planning of Radiation Dose Based on In Vivo Dosimetry for Postoperative Vaginal-Cuff HDR Interventional Radiotherapy (Brachytherapy).

(1) Background: Postoperative vaginal-cuff HDR interventional radiotherapy (brachytherapy) is a standard treatment in early-stage endometrial cancer. This study reports the effect of in vivo dosimetry-based biological planning for two different fractionation schedules on the treatment-related toxicities. (2) Methods: 121 patients were treated. Group A (82) received 21 Gy in three fractions. Group B (39) received 20 Gy in four fractions. The dose was prescribed at a 5 mm depth or to the applicator surface according to the distance between the applicator and the rectum. In vivo dosimetry measured the dose of the rectum and/or urinary bladder. With a high measured dose, the dose prescription was changed from a 5 mm depth to the applicator surface. (3) Results: The median age was 66 years with 58.8 months mean follow-up. The dose prescription was changed in 20.7% of group A and in 41% of group B. Most toxicities were grade 1-2. Acute urinary toxicities were significantly higher in group A. The rates of acute and late urinary toxicities were significantly higher with a mean bladder dose/fraction of >2.5 Gy and a total bladder dose of >7.5 Gy. One patient had a vaginal recurrence. (4) Conclusions: Both schedules have excellent local control and acceptable rates of toxicities. Using in vivo dosimetry-based biological planning yielded an acceptable dose to the bladder and rectum.

Palliative treatment with high-dose-rate endobronchial interventional radiotherapy (Brachytherapy) for lung cancer patients.

PURPOSE: to report on the use of high-dose-rate (HDR) endobronchial interventional radiotherapy (brachytherapy, EBIRT) for palliation of symptoms in patients with lung cancer. PATIENTS AND METHODS: retrospective review of lung cancer patients treated with HDR-EBIRT at our institution (1995-2017). Treatment results and treatment related toxicity were recorded. Clinical response was subjectively evaluated within 3 months after treatment. Overall survival (OS) was analyzed. RESULTS: 347 patients were identified. The median age was 69 years and the median follow-up time was 13.4 months. Most patients received external beam radiation therapy during the primary treatment. Within 3 months, 87.7% of the patients had complete or major response of their presenting symptoms. OS was 55.2% at 1 year, 18.3% at 2 years. Patients who had complete or major response had a longer median survival than other patients (13 versus 7 months, p = 0.03). Chronic bronchitis was found in 26.8%, while 7.8% of the patients died due to uncontrollable hemoptysis. CONCLUSION: HDR-EBIRT is a safe and effective treatment option for the palliative treatment of lung cancer patients. HDR-EBIRT is most suitable as a re-irradiation technique. Further clinical studies are needed to validate its role.

Quality Assurance in Modern Gynecological HDR-Brachytherapy (Interventional Radiotherapy): Clinical Considerations and Comments.

The use of brachytherapy (interventional radiotherapy) in the treatment of gynecological cancers is a crucial element in both definitive and adjuvant settings. The recent developments in high-dose rate remote afterloaders, modern applicators, treatment-planning software, image guidance, and dose monitoring systems have led to improvement in the local control rates and in some cases improved the survival rates. The development of these highly advanced and complicated treatment modalities has been accompanied by challenges, which have made the existence of quality assurance protocols a must to ensure the integrity of the treatment process. Quality assurance aims at standardizing the technical and clinical procedures involved in the treatment of patients, which could eventually decrease the source of uncertainties whether technical (source/equipment related) or clinical. This commentary review sheds light (from a clinical point of view) on some potential sources of uncertainties associated with the use of modern brachytherapy in the treatment of gynecological cancers.

Risk Factors for Sleep Disturbances in Patients Scheduled for Radiotherapy of Head-and-Neck Cancer.

BACKGROUND/AIM: Many patients with head-and-neck cancer are scheduled for irradiation. This study was performed to determine the frequency of and risk factors for pre-radiotherapy sleep disturbances in these patients. PATIENTS AND METHODS: A total of 103 patients with head-and-neck cancer scheduled for radiotherapy were included in this retrospective study. Eighteen characteristics were evaluated including timing of start of radiotherapy relative to COVID-19 pandemic; age; gender; Karnofsky performance score; Charlson comorbidity index; history of another malignancy; family history of malignancy; distress score; number of emotional, physical or practical problems; request for psychological support; tumor site and stage; upfront surgery; planned chemotherapy; and brachytherapy boost. RESULTS: The frequency of pre-radiotherapy sleep disturbances was 42.7%. This was significantly associated with age ≤63 years (p=0.049), Karnofsky performance score ≤80 (p=0.002), Charlson comorbidity index ≥3 (p=0.005), history of another malignancy (p=0.012), emotional (p=0.001) or physical (p<0.001) problems, and request for psychological support (p=0.002). CONCLUSION: Sleep disturbances were frequent in patients assigned to radiotherapy of head-and-neck cancer. Recognizing risk factors for sleep disturbance helps identify patients requiring psychological support.

Sleep Disorders Prior to Adjuvant Radiation Therapy for Gynecological Malignancies.

BACKGROUND/AIM: Many patients with gynecological malignancies receive postoperative radiotherapy, which can lead to fear and sleep disorders. We aimed to identify the prevalence of and risk factors for sleep disorders. PATIENTS AND METHODS: Sixty-two patients assigned to radiotherapy for gynecological malignancies were retrospectively evaluated. Seventeen characteristics were analyzed for associations with pre-radiotherapy sleep disorders including age, Karnofsky performance score, Charlson comorbidity index, history of additional malignancy, family history of gynecological cancer, distress score, emotional, physical or practical problems, tumor site/stage; chemotherapy, treatment volume, brachytherapy, and the COVID-19 pandemic. RESULTS: The prevalence of pre-radiotherapy sleep disorders was 46.8%. Sleep disorders were significantly associated with Charlson comorbidity index ≥3 (p=0.012), greater number of physical problems (p<0.0001), and advanced primary tumor stage (p=0.005). A trend was found for greater number of emotional problems (p=0.075). CONCLUSION: Pre-radiotherapy sleep disorders are common in patients with gynecological malignancies, particularly in those with specific risk factors. Patients should be offered early psychological support.

kOBCS©: a novel software calculator program of the Objective Breast Cosmesis Scale (OBCS).

PURPOSE: The Objective Breast Cosmesis Scale (OBCS) is an objective method that documents the aesthetic changes in breast cancer patients. This work evaluates the kOBCS© software (http://www.kobcs.info) which simplifies the estimation of the OBCS values. METHODS: Five schematic drawings were photographed and imported into the kOBCS©. Thirty photos of breast cancer patients were imported into kOBCS©; 20 users (experts and non-experts) evaluated the photographs on two different settings. Subjective evaluation was performed using the Harvard breast cosmesis scale. RESULTS: There was a highly significant correlation between the OBCS values based on hand measurements and the values estimated by kOBCS© (r = 0.997, P < 0.001). Agreement among the users using the kOBCS© was strong with high statistical significance (ICC = 0.846, P < 0.001, 95% CI 0.774-0.910, Cronbach's alpha = 0.991). Results of the subjective analyses and mean OBCS values as estimated by kOBCS© correlated significantly (r = 0.961, P < 0.001). CONCLUSIONS: The kOBCS© is a reliable and reproducible easy-to-use software for reporting breast cosmesis following breast-conserving therapy.