Capacity building on new palliative care services.

Palliative care in cancer has always been an important issue in low and middle income countries. In many occasions most resources have been devoted to expensive treatments although palliative and supportive care approaches are very important. Turkey, as a country, has been trying to take the necessary steps to organise palliative care. The Cancer Control Department of Ministry of Health has started the National Cancer Control Program in 2008 and also prepared a Palliative Care Action Plan. Dokuz Eylul University in Turkey has also organised a multidisciplinary palliative care team to create the necessary future plans and will open the first academic program under the Department of Clinical Oncology.

Psychosexual and body image aspects of quality of life in Turkish breast cancer patients: a comparison of breast conserving treatment and mastectomy.

AIMS AND BACKGROUND: Assessing psychosexual and body image aspects of quality of life in Turkish breast cancer patients treated by either mastectomy or breast conserving treatment (BCT). METHODS: The study group consisted of 112 patients who had undergone all treatment at a single institution under the care of a multidisciplinary breast team. Following surgery, all patients underwent adjuvant radiotherapy with or without chemotherapy and hormone therapy. At the time of this study all patients were disease free with at least 2 years' follow-up. Twenty percent of the patients were premenopausal and 80% postmenopausal. The patients completed a questionnaire consisting of 42 questions related to their sexual relations and body image. RESULTS: Forty-one percent of sexually active patients had experienced a deterioration of sexual functioning after treatment. This was mainly due to loss of libido (80%), loss of interest in partner (54%), and sexual dissatisfaction (59%). Problems tended to develop early in the course of treatment. Decreased sexual desire was significantly more frequent in patients undergoing mastectomy versus BCT (80% vs 61%; P = 0.043) and in premenopausal versus postmenopausal patients (P = 0.024). Although 80% of patients were satisfied with their appearance as a whole, only 54% liked their naked bodies. There was no significant difference in body image scores between patients undergoing mastectomy or BCT apart from a general feeling of physical unattractiveness in mastectomy patients (3.4 vs 2.8; P = 0.03). CONCLUSIONS: Significant, similar psychosexual and body image problems occur in patients treated for breast cancer with either mastectomy or BCT. Problems arise early in the course of the disease and therefore detection and treatment of these problems should be addressed during the patients' initial assessment and at the start of treatment. These findings are similar to those reported on similar groups of treated women in American and European populations.

Importance of patient, tumour and treatment related factors on quality of life in head and neck cancer patients after definitive treatment.

The purpose of this study is to assess patient, tumour and treatment related factors on quality of life (QoL) outcomes of patients who received definitive or postoperative radiotherapy +/- chemotherapy for head and neck (H&N) cancer. In this cross-sectional study, 110 H&N cancer patients were evaluated in follow-up visit and were asked to fill out the European Organisation for Research and Treatment of Cancer QoL Core Questionnaire (QLQ-C-30) and H&N Module (QLQ-H&N35). Patients were also graded for their late side effects using EORTC/RTOG scoring system. The QLQ C-30 and QLQ-H&N35 mean scores were compared using ANOVA analysis for these variables: age, gender, occupation, educational status, social security status, place of residence, tumour localization, clinical stage, comorbidity, Karnofsky performance score, treatment modality and side effects. Median follow-up was 29 (4-155) months. Tumour localization was significant factor affecting physical (P = 0.03), social (P = 0.01), cognitive (P = 0.002) functioning. Treatment modality had significant impact on the physical (P = 0.02) and cognitive scores (P = 0.008). Global QoL was affected significantly by disease stage (P = 0.01) and occupation (P = 0.01). The QLQ-H&N35 scores were found significantly higher in patients with moderate/severe late morbidity. Tumour localization and the treatment modality are the most important factors affecting the QoL of H&N cancer patients treated definitively.

The effect of socioeconomic factors on quality of life after treatment in patients with head and neck cancer.

PURPOSE: To determine the effect of socioeconomic factors on quality of life (QoL) after treatment in patients with head and neck carcinoma (HNC). PATIENTS AND METHODS: The study population included 50 HNC patients seen in their control examinations after radiotherapy during a 2-month interval and who were willing to complete the Short-Form 36 QoL questionnaire. Socioeconomic, demographic, and tumor- and treatment-related factors were analyzed for their effect on physical component summary score (PCS) and mental component summary score (MCS) using the Mann-Whitney U test. RESULTS: All patients received radiotherapy, and 33 patients (66%) underwent surgery for the primary tumor and/or neck disease. Chemotherapy was given in 9 patients (18%). Mean PCS and MCS were 47.9 (range, 24.8-59.3) and 46.7 (range, 22-63.3) for the whole patient population. There was no significant factor affecting PCS. Education level of "middle school or higher," perceived economic status of "medium or higher," social security status of not being "absent or minimally covered," and unilateral type of neck surgery were found to increase MCS significantly. According to separate linear regression analyses performed for three socioeconomic variables, the most significant factor for MCS was social security status compared with education level and perceived economic status. It was the only parameter that retained its significance when all five parameters were combined in a linear regression model. CONCLUSION: This study demonstrated that educational status, perceived economic status, and social security status showed a significant effect on the QoL of HNC patients after radiotherapy. When all variables were taken into account, only "social security status" remained significant.

Assessment of treatment-related thyroid dysfunction in patients with head and neck cancer.

OBJECTIVE: To assess thyroid dysfunction in head and neck cancer patients who have received external beam radiotherapy according to radiotherapy fields and dose, tumor site and other local or systemic treatments retrospectively and prospectively and propose a follow-up schedule. MATERIAL AND METHODS: A total of 378 patients was classified into two groups. Group I (n = 345) consisted of surgically treated 153 laryngeal, 80 nasopharyngeal and 112 oral cavity/oropharyngeal carcinoma patients; these patients were evaluated retrospectively for treatment-related thyroid dysfunction using their data files. Group II included 33 patients with head and neck cancer who were evaluated prospectively. Thyroid function tests were performed at the beginning of the radiotherapy and every three months after the radiotherapy course, and thyroid dysfunction regarding surgery, radiotherapy and chemotherapy was evaluated. RESULTS: In Group I, the median follow-up for 153 operated laryngeal carcinoma patients was 44 months. Four (2.6%) of them were found to have clinically apparent hypothyroidism. After a median follow-up of 36 months, none of the 80 nasopharyngeal carcinoma patients showed signs of hypothyroidism. Clinically apparent hypothyroidism was detected in only 1 (0.8%) of the oral cavity/oropharyngeal carcinoma patients after a median follow-up of 25 months. In Group II, 1 (3%) patient was found to have thyroid dysfunction postoperatively prior to radiotherapy. At the time of analysis, 29 (87.8%) patients were euthyroidic, 2 (6.1%) patients had subclinical and 2 (6.1%) patients had clinical hypothyroidism. All patients with thyroid dysfunction have had combined surgery and radiotherapy, and none of the patients treated with radical radiotherapy has experienced hypothyroidism. CONCLUSIONS: Even after a short follow-up, the incidence of thyroid dysfunction was 12.2% in head and neck cancer patients treated with combined surgery and radiotherapy. We recommend thyroid function tests in these patients prior to and once every 3-6 months after the radiotherapy course.

The variability of applicator position among high dose rate intracavitary brachytherapy applications in cervical cancer patients treated with ring & tandem applicators.

OBJECTIVE: To evaluate the interindividual and intraindividual applicator position variability in high dose rate ring and tandem intracavitary brachytherapy applications in locally advanced cervical cancer. PATIENTS AND METHODS: Eight patients with locally advanced cervical cancer formed the study population. They had been treated in Dokuz Eylül University Department of Radiation Oncology between the years 2000 and 2005 with high dose rate intracavitary brachytherapy using ring and tandem applicators. The 3-dimensional geometric variation of the applicator center in craniocaudal, mediolateral and anteroposterior directions was determined on the basis of bony reference points in 24 pairs of orthogonal films obtained in the conventional simulator. Then the following evaluations were performed: 1) the applicator position variability in all applications (interindividual variability), 2) the intraindividual applicator position variability relative to the first application, 3) the intraindividual applicator position variability relative to the average of three applications. Among the potential factors that might influence the reproducibility of ring and tandem applications, age, stage, the period between external radiotherapy and brachytherapy were evaluated by univariate analysis. RESULTS: Standard deviation of interindividual applicator variability was 3.83 mm in craniocaudal, 0.39 mm in mediolateral and 2.86 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the first application was 1.91 mm in craniocaudal, 0.4 mm in mediolateral, and 4.26 mm in anteroposterior directions. The standard deviation of intraindividual variability relative to the average of three applications was 0.95 mm in craniocaudal, 1.86 mm in mediolateral, and 1.24 mm in anteroposterior directions. According to univariate analysis, no factor influenced applicator position variability. CONCLUSIONS: In order to extract definitive conclusions about factors that affect positional reproducibility of ring and tandem applicators, studies are needed that include larger numbers of patients.

Training logbook for radiotherapy.

AIM: To develop a structured logbook for trainees in the medical specialty of radiotherapy with Europe that records the increasing experience throughout their training period. MATERIAL AND METHODS: A working party appointed by the European Board of Radiotherapy developed a draft version of a European logbook for trainees in radiotherapy. For development, the update European Core Curriculum for Radiotherapists (Radiation Oncologists) was taken into consideration. The logbook is composed of six sections: (1) biodata of the trainee, (2) scientific training documentation, (3) clinical training documentation, (4) record of formal presentations by the trainee, (5) publications, (6) training courses. Decisions were made to suggest that the clinical section of the logbook should: (a) only collect data that was essential for the purposes of appraisal, assessment and regulation, (b) be as user friendly as possible, (c) concentrate on quality of the data and not volume. The logbook was tested by trainees in several European training departments and adapted according to their suggestions. A final draft of the logbook was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002. RESULTS: The European training logbook for radiotherapy was endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002. CONCLUSION: Keeping a training logbook is an essential feature of the record of training for all EU trainees who wish to retain an opportunity to spend part of their training time in another country of the Union, important for someone who seeks an appointment as a specialist in another country within a few years of achieving specialist accreditation, and good professional practice for all other trainees. The European training logbook for radiotherapy is a robust instrument that allows the systematic collection of the information that needs to be recorded to monitor the professional development of European trainees in Radiation Oncology.

Depression and anxiety levels in woman under follow-up for breast cancer: relationship to coping with cancer and quality of life.

AIM: The relation of anxiety and depression levels with characteristics of coping with the disease and quality of life were evaluated in women under follow-up for breast cancer. MATERIALS AND METHODS: Patients who had presented to the breast cancer polyclinics for follow-up were evaluated. The Beck Depression and the State-Trait Anxiety inventories were used in the evaluation of depression and anxiety levels. In order to evaluate their power to cope with cancer, the patients were questioned for a social support network. EORTC QLQ-C30 and QLQ-BR23 questionnaires were applied for quality of life evaluations. RESULTS: There were 23 (19%) patients with depression; 3 (2.5%) with grade I anxiety, 94 (77%) grade II, and 23 (19%) grade III anxiety, respectively. Depression and anxiety levels were affected by the following parameters: being unaccompanied by spouse for hospital follow-ups (P < 0.0001); request to get help by a psychologist (P = 0.02); presence of a person to share their problems (P < 0.0001); and using an alternative treatment (P = 0.04). In the quality of life evaluations, difficulty in sleeping, emotional status, fatigue, and body appearance were related with both depression and anxiety (P < 0.05 for all), whereas physical function (P = 0.002), role performance (P = 0.005), cognitive condition (P < 0.0001), social position (P < 0.0001), pain (P < 0.0001), general health (P < 0.0001), treatment methods (P = 0.001), future anxiety (P < 0.0001), and arm symptoms (P = 0.001) were negatively affected in patients with depression. CONCLUSION: High depression and anxiety levels in patients under follow-up for breast cancer influence the coping with cancer and quality of life adversely.

The impact of treatment center on the outcome of patients with laryngeal cancer treated with surgery and radiotherapy.

For laryngeal cancer, surgical excision of the primary tumor should be undertaken with the aim of achieving tumor-free margins. Adequate pathological assessment of the specimen and the competency of the treatment center play a crucial role in achieving cure. The present study aimed to analyze the significance of place of surgery on the outcome of patients with laryngeal cancer who underwent surgical operation in other centers and were subsequently referred to Doküz Eylul University Head and Neck Tumour Group (DEHNTG) for postoperative irradiation. Patients were divided into three groups according to their place of surgery. The first group (Group I) consisted of patients who had their surgical operation at DEUH. Patients in the second group (Group II) were referred from centers with oncological surgical experience. The third group (Group III) consisted of patients referred from hospitals with no surgical teams experienced in head and neck cancer treatment. The clinical and pathological features of patients in these three groups were analyzed to assess the impact of place of surgery on clinical outcome as well as the prognostic factors for survival. The study population consisted of 253 patients who were treated between 1991 and 2006 with locally advanced laryngeal cancer according to the protocol of DEHNTG. The median follow-up was 48 (3-181) months. The 5 years overall, loco-regional disease-free and distant disease-free survivals were 66, 88 and 91%, respectively. When patients' clinical and histopathological features were analyzed for the impact of place of surgery, surgical margin positivity rates were found to be higher in Group III (P = 0.032), although the other two groups had more advanced clinical and pathological N stage disease (P = 0.012, P = 0.001). In multivariate analysis, older age (P < 0.0001), presence of perinodal invasion (P = 0.012), time interval between surgery and radiotherapy longer than 6 weeks (P = 0.003) and tumor grade (P = 0.049) were the most significant factors. For loco-regional failure-free survival, advanced clinical stage (P = 0.002), place of surgery (P = 0.031) and presence of clinical subglottic invasion (P = 0.029) were shown to be important prognostic factors. For distant metastasis-free survival, only pathological (+) lymph node status (P = 0.046) was a significant factor in multivariate analysis. The significance of place of surgery as well as other well-known prognostic factors underlines the importance of an experienced multidisciplinary treatment team if best results are to be obtained for the patient.

Patterns of care for lung cancer in radiation oncology departments of Turkey.

PURPOSE: To determine the patterns of care for lung cancer in Turkish radiation oncology centers. METHODS AND MATERIALS: Questionnaire forms from 21 of 24 (87.5%) centers that responded were evaluated. RESULTS: The most frequent histology was non-small cell lung cancer (NSCLC) (81%). The most common postoperative radiotherapy (RT) indications were close/(+) surgical margins (95%) and presence of pN2 disease (91%). The most common indications for postoperative chemotherapy (CHT) were ">/= IB" disease (19%) and the presence of pN2 disease (19%). In Stage IIIA potentially resectable NSCLC, the most frequent treatment approach was neoadjuvant concomitant chemoradiotherapy (CHRT) (57%). In Stage IIIA unresectable and Stage IIIB disease, the most frequent approach was definitive concomitant CHRT (91%). In limited SCLC, the most common treatment approach was concomitant CHRT with cisplatin+etoposide for cycles 1-3, completion of CHT to cycles 4-6, and finally prophylactic cranial irradiation in patients with complete response (71%). Six cycles of cisplatin + etoposide CHT and palliative thoracic RT, when required, was the most commonly used treatment (81%) in extensive SCLC. Sixty-two percent of centers did not have endobronchial brachytherapy (EBB) facilities. CONCLUSION: There is great variation in diagnostic testing, treatment strategies, indications for postoperative RT and CHT, RT features, and EBB availability for LC cases. To establish standards, national guidelines should be prepared using a multidisciplinary approach.

Turkish people's knowledge of cancer and attitudes toward prevention and treatment.

BACKGROUND: The basic level of cancer knowledge of the population is as important in controlling cancer as diagnostic tools, screening, and new approaches to prevention, early diagnosis, and treatment. METHODS: A questionnaire consisting of 24 questions was given to 630 healthy Turkish people to determine their basic knowledge and attitudes regarding cancer. RESULTS: The majority of respondents (78%) were found to have little knowledge of cancer despite the fact that the average level of education of the sample was superior to that of the general population. Educational level was the major predictive factor influencing the basic knowledge and attitudes of the respondents. CONCLUSION: The overall education of the public as well as the basic level of knowledge of cancer must be improved in cooperation with oncology societies and media in order to overcome the cancer burden in Turkey.

Experience of the Izmir Pediatric Oncology Group on Neuroblastoma: IPOG-NBL-92 Protocol.

This multicentric study aimed to bring neuroblastoma patients together under IPOG-NBL-92 protocol and evaluate the results within the period between 1992 and 2001 in Izmir. Sixty-seven neuroblastoma patients from 4 pediatric oncology centers in Izmir were included in the study. IPOG-NBL-92 protocol modified from German Pediatric Oncology (GPO)-NB-90 protocol was applied: Patients in stage 1 received only surgery, while surgery plus 4 chemotherapy courses (cisplatin, vincristine, ifosfamide) were given in stage 2 and surgery plus 6 chemotherapy courses (cisplatin, vincristine, ifosfamide, epirubicin, cyclophosphamide) were given in stages 3 and 4 patients. In patients who were kept in complete remission (CR), a maintenance therapy of one year was applied. Radiotherapy was given to the primary site following induction chemotherapy plus surgery in stages 3 and 4 patients with partial remission (PR). The stages of the patients were as follows: 5% in stage 1, 39% in stage 3, 49% in stage 4, and 7% in stage 4S. Primary tumor site was abdomen in 88% of cases. CR rates were as 100% in stage 1, 76% in stage 3, 35% in stage 4, and 75% in stage 4S. Relapse was observed in 32% of patients in a median of 19 months. The median follow-up time for survivors was 33 (17-102) months. Five-year OS rate was 31% and the EFS rate was 30% in all patients. Five-year overall and event-free survival rates were 63 and 30% in stage 3, but 6 and 5%, respectively, in stage 4 patients. Univariate analysis established that the age, stage, primary tumor site, and high LDH and NSE levels conferred a significant difference. The IPOG-NBL-92 protocol has proved to be satisfactory with tolerable toxicity and reasonable CR and survival rates. However, more effective treatments suitable to Turkey's social and economic conditions are urgently needed for children over 1 year of age with advanced neuroblastoma.