[Demography of radiation oncology residents in France in 2008: current situation and perspectives for the next three years]. / Démographie des internes en oncologie-radiothérapie en France en 2008: état et perspectives pour les trois prochaines années.

PURPOSE: Although a recent increase in number of young radiation oncologists in training has been observed during the past decade, the general demographic evolution of radiation oncologists covers partially future needs. MATERIAL AND METHOD: During the seven past national annual courses, which were organised and supported by the Société française des jeunes radiothérapeutes oncologues (SFJRO), the Société française de radiothérapie oncologique (SFRO), the Collège national des enseignants de cancérologie (CNEC) and the Institut national du cancer (Inca), different types of surveys were realized in order to analyse demography, quality of training and motivations of French residents in radiation oncology. The latest results were collected during the last national course, which took place in March 2008. Seventy-five young French radiation oncologists ("internes des hopitaux" or residents) out of 110 participants who attended the national course and 75 questionnaires were analysed. RESULTS: Since 2002, the total number of residents increased regularly (50, 75, 103 and 109 residents respectively in 2000, 2005, 2007 and 2008). Men and women are presently 48.5% and 51.5% respectively. Qualitative analysis of practical and theoretical training was performed using a visual analogical scale from zero to 10. Scores of 56 and 61 were respectively observed. Other descriptions of local training in the different universities (clinical skills, clinical cases analysis, bibliography session...) are described. Finally, analysis of the motivations for choosing the radiation oncology speciality demonstrates common interests in both medical practice and technical aspects in oncology. Innovation, technology, imaging and research are also widely mentioned. Sixteen residents will finish their training by the end of 2008, 42 are expected in 2009 and 27 in 2010. Almost all residents believe that a postgraduate position is necessary to complete their training as assistant professor ("chefs de clinique-assistants des hôpitaux") in a university hospital or a cancer centre. Unfortunately, only 36 assistant professor positions are available in France, representing half of the need. Only 21 residents out of 104 already have a position as assistant professor. The availability of such a position remains undetermined for the rest of them. CONCLUSIONS: Despite the recent increase in the number of residents in radiation oncology in France, the need to create new assistant professor positions is crucial to assure quality of training for this both medical and technical speciality. Since 2002, the establishment of SFJRO has facilitated national links among residents, between residents and professors (CNEC), and between the French society (SFRO) and the European society (ESTRO).

Harmonization of practices between radiotherapy centres in the Nord and Pas-de-Calais regions (France): A three-year evaluation.

PURPOSE: The delineation of volumes of interest can be a source of significant interobserver variability. The purpose of this study was to improve the homogeneity of delineation between oncologist-radiotherapists in the territorial departments of Nord and Pas-de-Calais (France) through discussions of clinical cases and the adoption of common published reference documents. MATERIALS AND METHODS: All eleven radiotherapy centres in the Nord and Pas-de-Calais departments of France participated. The localizations assessed to date included prostate, head and neck, breast and brain cancers. For each localization, the junior or senior physician(s) in charge of pathology delineated the volumes of interest according to their usual practices. Validated indices, including the Dice similarity coefficient, were used to quantify the delineation differences. The anonymized results were presented at two to three annual meetings. A second delineation of the clinical cases was then carried out to quantify homogenization. An evaluation of dosimetry practices was also conducted for prostate cancer. Wilcoxon assay matched data were used. RESULTS: Our work showed either satisfactory delineation concordance after the initial assessment or improved delineation concordance. For prostate cancer, the Dice similarity coefficient values were greater than 0.6 initially in two of the three clinical cases. For head and neck cancers, a statistically significant improvement was observed for only one of the clinical target volumes. More than half of the Dice similarity coefficient values were greater than 0.6 in the first comparison. The study of clinical cases of breast cancer allowed a homogenization of the delineation of five of the six lymph node clinical target volumes. The dosimetry study of prostate cancer allowed for a homogenization of practices. CONCLUSION: This work makes it possible to harmonize the delineation practices around validated standards. An extension to the entire Hauts-de-France region is planned.

[The Oxygen effect: an old new target?]. / L'effet Oxygène, une cible ancienne toujours d'actualité ?

The Oxygen effect plays a key role in cellular response to ionizing radiations. From many years, tumour hypoxia is a limiting treatment factor. Multiple ways to interact with free radicals have been developed. The increase in tissue oxygenation has a limited impact. Radiosensitizing agents as nimorazole or gadolinium have a clinical benefit. Tirapazamine or AQ4N, bioreductive agents, are not routinely used. New agents through the HIF-1 and the endothelial cell pathways are currently being developed. Studies on the expression of endogenous markers of hypoxia could be useful tools to predict tumour response to the treatment.

[Stereotactic body radiation therapy for liver primary and metastases: the Lille experience]. / Radiothérapie stéréotaxique hépatique par CyberKnife(®) : l'expérience lilloise.

PURPOSE: The CyberKnife(®) system is a recent radiation therapy technique that allows treatment of liver lesions with real-time tracking. Because of its high precision, the dose administered to the tumor can be increased. We report Oscar-Lambret Cancer Centre experience in the treatment of primary and secondary liver lesions. PATIENTS AND METHODS: It is a retrospective study analyzing all the patients who have been treated for their liver lesions since July 2007. A hundred and twenty patients have been treated: 42 for hepatocellular carcinoma, 72 for liver metastases and six for cholangiocarcinoma. Gold seeds need to be implanted before the treatment and are used as markers to follow the movement of the lesion due to respiration. On average, the treatment is administered in three to four sessions over 12 days. A total dose of 40 to 45 Gy at the 80% isodose is delivered. Local control and overall survival analysis with Log-rank is performed for each type of lesion. RESULTS: Treatment tolerance is good. The most common toxicities are of digestive type, pain and asthenia. Six gastro-duodenal ulcers and two radiation-induced liver disease (RILD) were observed. At a median follow-up of 15 months, the local control rate is respectively of 80.4% and 72.5% at 1 and 2 years. Overall survival is 84.6 and 58.3% at 1 and 2 years. The local control is significantly better for the hepatocellular carcinoma and overall survival is significantly better for liver metastases (P<0.05). The local control rate and overall survival at 1 year for cholangiocarcinoma is 100%. CONCLUSION: CyberKnife(®) is a promising technique, well tolerated, with tumoral local control rates comparable to other techniques. Its advantage is that it is very minimally invasive delivered as an outpatient procedure in a frail population of patient (disease, age).

[Which follow-up program after radiotherapy?]. / Quel programme de surveillance après radiothérapie ?

Patients' follow-up after treatment represents a growing part of the radiation oncologist activity. Treatment effectiveness and morbidity are essential criteria to evaluate the quality of a clinical practice. Morbidity and mortality reviews and feedback experience meetings have been made mandatory. Post-treatment follow-up has to be explicitly and formally organized. In the present article, we review the existing recommendations and consider several examples regarding frequently encountered cancers.

Results and special considerations when treating elderly patients with CyberKnife®: a review of 345 cases.

The relatively recent introduction of CyberKnife® in the field of radiotherapy has prompted the question of accessibility and usefulness of this technique for seniors. From June 2007 to June 2009, we treated 345 patients of all ages with CyberKnife as part of a single-center study. Median age was 61 years (range, 8-86 years). Ninety-eight patients were over 70 and 17 were older than 80. The treatment could not be completed with 2% (2/98) patients over 70 vs. 3.6% (9/247) among the younger (ns). Physiologic or psychologic problems in maintaining position for a long time were not more frequent among those over 70. The same was true with those over 80. Patients over 70 years old are able to tolerate CyberKnife treatment as efficiently as their younger counterparts. Elderly patients should not be restricted from access to CyberKnife radiosurgery with curative intent.

Cancer-associated hypercalcaemia in squamous-cell malignancies: a survival and prognostic factor analysis.

The aim of this study is to analyse survival and prognostic factors in patients diagnosed with squamous cell carcinoma (SCC) presenting a first episode of cancer-associated hypercalcaemia (CAH). Retrospectively, the authors reviewed data from 220 patients with biopsy proven SCC who presented a first episode of CAH. They were treated in a single centre between 1995 and 2007. The survival analyses were done using the Kaplan-Meier method and Cox analysis. The primary endpoint was the overall survival from the date of hypercalcaemia episode. Median age was 55 years. Median survival was 64 days (1-197). Three independent prognostic factors were identified: brain metastasis (hazard ratio (HR)=2.58 CI (1.03-6.45)), corrected calcaemia>3 mmol/l (HR=1.45 CI (1.05-2.01)) and hypoalbuminaemia (HR=1.48 CI (1.07-2.04)). Using these factors, the authors performed a bedside prognostic score. In conclusion, median survival in patients diagnosed with SCC and CAH is extremely poor. The bedside prognostic score that the authors developed can help to anticipate patients' prognosis and adapt the treatment. This score needs to be validated on an independent cohort.

[Therapeutic index in radiotherapy and patient information]. / Le service médical rendu en radiothérapie: indice thérapeutique et information du patient.

In oncology, the ratio between cure and morbidity (therapeutic index) is at the heart of treatment. Every radiotherapy needs to optimize the benefice-risk issue defining the optimal medical care. In order to go from global knowledge (evidence-based medicine) to individualized decision, the principle of patients' information will have always to be respected. In fine, it will be the patient, guided by his/her physician, to take decision on treatment.

[Sarcomas in irradiated fields: Recent data]. / Sarcomes en territoire irradié : actualités.

We reviewed the literature data on sarcomas in irradiated fields: incidence, risk factors, prognosis and therapeutic strategy. We discuss more specifically the key-role of p53 mutations and the potential consequences of new radiotherapy techniques.

Stereotactic radiotherapy of hepatocellular carcinoma: preliminary results.

Stereotactic radiotherapy (SRT) offers a treatment option for hepatocellular carcinoma (HCC) patients that are not eligible for surgery, embolization, chemotherapy, or radiofrequency ablation. We have evaluated the feasibility, tolerance and toxicity of SRT for 25 HCC patients who were not eligible for these other modalities. The patients (6 women and 19 men) were treated with CyberKnife stereotactic radiotherapy using respiratory motion tracking. All patients had liver cirrhosis with an Eastern Cooperative Oncology Group (ECOG) performance score of less than 2 and pre-treatment Child scores ranging from A5 to B9. A total dose of 45 Gy in three fractions of 15 Gy each was prescribed to the 80% isodose line (95% of the PTV received 45 Gy) and delivered to the target volume over 10 to 12 days. Overall the treatment was well tolerated with two Grade 3 acute toxicities and no acute Grade 4 toxicities. Late toxicity was minimal with all observed late toxicities occurring within the first six months of follow-up. Three hepatic recurrences at a distance from the target and one metastasis were observed. The actuarial 1- and 2-year local control rate was 95% (95% CI: 69-95%). At a median overall follow-up of 12,7 months (range, 1-24 months), six of the twenty-five (24%) patients have died. Overall actuarial survival at 1- and 2-years was 79% (95% CI: 52-92%) and 52% (95% CI: 19-78%), respectively. Our results suggest promising therapeutic efficacy and good clinical tolerance to CyberKnife SRT treatment for HCC patients not eligible for other treatment modalities.

[Delineation variation of lung cancer in conformal radiotherapy among radiation oncology residents after an educational course: a prospective study]. / Variabilité inter-radiothérapeutes de la délinéation tumorale en oncologie thoracique : exemples d'intercomparaison de délinéations et impact de la formation.

PURPOSE: During the French national course of radiotherapy, delineation stations were at disposition for the residents. A comparative study of delineation and doses prescribed for a clinical case of lung carcinoma is reported before and after the completion of a theoretical education. METHODS: For this comparative study, 120 residents divided in 30 groups, have delineated the case before and after a lecture of radio-anatomy and a presentation of volumes and doses. The software Artiview (Aquilab SAS) was used to calculate the volume ratio (VR), common volume (CV), additional volume (AV), kappa (K) and overlap (OV) between the different volumes of interest. The expansion margins and the prescribed doses were noticed. A comparative study by a test of Student for paired series was performed. RESULTS: The GTV was 89.1cm(3) for the expert. It was 103.4 cm(3) (59.9-215.2 cm(3)) before versus 99.5 cm(3) (39.7-202.3 cm(3)) after the teaching intervention for participants. For GTV, comparison index were respectively before and after the intervention 1.16 cm(3) (0.7-2.4 cm(3)) and 1.1 cm(3)(0.5-2.3 cm(3)) for the VR (p=0.53), 78.4 cm(3) (58.9-91.8 cm(3)) and 76.4 cm(3) (40.2-92.1cm(3)) for the CV (p=0.27), 28.8 cm(3) (7.1-62 cm(3)) and 27.8 cm(3) (9.1-59.6 cm(3)) for the AV (p=0.7). OV and K were respectively 0.58 and 0.73 cm(3) before and after education. The median margin prescribed to obtain CTV from GTV was 6mm (5-10mm), no change was noticed after the course. The expert prescribed a 6mm margin. The median margin prescribed by the participants to obtain PTV from CTV was 7 mm (3-15 mm) before the course and 5mm (3-15 mm) afterwards, versus 5mm for the expert. The dose prescribed by the expert was 66 Gy on PTV. The dose was 66.2 Gy (60-70 Gy) before and 66.5 Gy (64-70 Gy) after course for residents. CONCLUSION: No significant volume modification was found after the educational course. We noticed however an adaptation of the margins and a tendency to increase the prescribed dose as well as a reduction of the delineated volume. Good quality of the initial delineation could explain the absence of significant progress after education.

Prevalence and causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study.

BACKGROUND: Burnout syndrome occurs frequently amongst oncology healthcare workers. It has a detrimental effect on the patient-physician relationship. Little is known about the prevalence and causes of burnout amongst junior doctors in oncology. METHODS: An anonymous questionnaire was sent out to every medical or radiation oncology or haematology resident in France (n=340). It included: demographical data, burnout level (Maslach Burnout Inventory), sources of stress, sense of equity at work, sources of support, and general health questions. Validated scales were used when available. Two reminder e-mails were sent to increase the response rate. RESULTS: Questionnaires were despatched during Spring 2009. The response rate was 60% (204/340). Emotional exhaustion (EE) and Depersonalisation (DP), the major components of burnout, were reported, respectively, by 26% (n=53) and 35% (n=72) of the residents. Burnout prevalence was 44% (n=89), defined as a severely abnormal level of either EE or DP. Eighteen percent of the residents (n=36) had severely abnormal levels of both EE and DP. The burnout level was not significantly different between the three specialties, but was higher amongst residents who do not feel adequately rewarded for their work (p<0.001). Burnout was associated with a lower perception of one's general health status (p<0.001) and the desire to quit Medicine or to change specialty (p<0.001). CONCLUSION: The burnout level is high amongst oncology residents. It probably discourages vocations for oncology. Interventions are needed and could include support groups, more intense coaching by senior physicians, training programmes on 'breaking bad news' and teaching of stress management skills.