A Review of Treatment for Breast Cancer-Related Lymphedema: Paradigms for Clinical Practice.

OBJECTIVES: Breast cancer-related lymphedema (BCRL) represents a major complication of breast cancer treatment, impacting the quality of life for breast cancer survivors that develop it. The purpose of this review is to evaluate the literature surrounding BCRL treatment modalities to guide clinicians regarding risk-stratified treatment options. METHODS: A review of studies over a 10-year period (January 2006 to February 2016) was performed. Noninvasive strategies evaluated included compression therapy, manual lymphatic drainage, and complex decongestive therapy (CDT). Invasive modalities evaluated included liposuction and lymphatic bypass/lymph node transfer (LNT). Our search yielded 149 initial results with 45 studies included. RESULTS: A number of prospective studies have found that CDT is associated with volume reduction in the affected limb as well as improved quality of life, particularly in patients with early stage BCRL. With regards to invasive treatment options, data support that lymphatic bypass and LNT are associated with symptomatic and physiologic improvements, particularly in patients with more advanced BCRL. In addition, a small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe BCRL. CONCLUSIONS: CDT is an effective treatment modality for early stage BCRL. For more advanced BCRL, LNT has demonstrated efficacy. Further study is required with respect to comparing BCRL treatment modalities.

Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience.

OBJECTIVES: In order to demonstrate the impact of multidisciplinary care in the community oncology setting, we evaluated treatment decisions after the initiation of a dedicated prostate and genitourinary (GU) multidisciplinary clinic (MDC). METHODS: In March 2010, a GU MDC was created at William Beaumont Hospital with the goal of providing patients with a comprehensive multidisciplinary evaluation and consensus treatment recommendations in a single visit. Urologists, radiation, and medical oncologists along with ancillary support staff participated in this comprehensive initial evaluation. The impact of this experience on patient treatment decisions was analyzed. RESULTS: During the first year, a total of 182 patients were seen. Compared with previous years, low-risk MDC patients more frequently chose external beam radiation therapy (41.1% vs. 26.6%, P=0.02), and active surveillance (14.3% vs. 6.1%, P=0.02) and less frequently prostatectomy (30.4% vs. 44.0%, P=0.03). Similar increases in external beam were seen in intermediate and high-risk patients. Increased use of hormonal therapy was found in high-risk patients compared with the years before the initiation of the MDC (76.2% vs. 51.1%, P=0.03). Increased adherence to National Comprehensive Cancer Network (NCCN) guidelines was seen with intermediate-risk patients (89.8% vs. 75.9%, P=0.01), whereas nonsignificant increases were seen in low-risk (100% vs. 98.9%, P=0.43) and high-risk patients (100% vs. 94.2%, P=0.26). CONCLUSIONS: The establishment of a GU MDC improved the quality of care for cancer patients as demonstrated by improved adherence to National Comprehensive Cancer Network guidelines, and a broadening of treatment choices made available.

Use of intensity modulated radiation therapy to reduce acute and chronic toxicities of breast cancer patients treated with traditional and accelerated whole breast irradiation.

PURPOSE: The purpose of this analysis was to examine the impact of applying intensity modulated radiation therapy (IMRT) on toxicity with traditional and accelerated whole breast irradiation (AWBI). METHODS AND MATERIALS: A total of 335 patients with stage 0-IIB breast cancer were treated with either a conventional wedge technique (S-WBI, n = 87), IMRT (I-WBI, n = 93), or AWBI with IMRT (I-AWBI, n = 155). S-WBI and I-WBI patients received a median dose of 45 Gy to the breast with a median 16-Gy tumor bed boost for a cumulative median dose of 61 Gy. I-AWBI patients received a median dose of 42.56 Gy via an accelerated IMRT plan, without a boost. Acute and chronic toxicities were assessed using Common Toxicity Criteria v.3.0. RESULTS: Median follow-up was 11.0, 9.1, and 1.1 years for S-WBI, I-WBI, and I-AWBI patients, respectively. When comparing patients of all breast sizes, I-WBI showed decreased incidences of grade 2+ acute radiation dermatitis and induration compared with I-AWBI (1% vs 23%, P < .001/0% vs 5%; P = .05 ) and S-WBI (1% vs 12%, P = .007/0% vs 6%; P = .02). I-WBI also had lower rates of chronic edema compared with S-WBI patients (3% vs 13%, P = .03). In larger breasted patients, I-WBI was associated with reduced acute toxicities compared with S-WBI with regard to grade 2 + dermatitis and edema (0% vs 19%, P = .02/7% vs 24%, P = .06). No differences were seen between I-WBI and I-AWBI with IMRT techniques with the exception of increased acute radiation dermatitis in I-AWBI patients (0% vs 38%, P < .001). CONCLUSIONS: This analysis confirms previous data which have demonstrated that RT with IMRT is associated with reduced toxicities compared with conventional techniques. In larger breasted women, with the exception of acute skin reactions, I-AWBI showed comparable rates of toxicities compared with I-WBI. These data support the use of IMRT to expand the role of AWBI and the currently accruing Radiation Therapy Oncology Group 1005 trial.

Percentage of positive biopsy cores: a better risk stratification model for prostate cancer?

PURPOSE: To assess the prognostic value of the percentage of positive biopsy cores (PPC) and perineural invasion in predicting the clinical outcomes after radiotherapy (RT) for prostate cancer and to explore the possibilities to improve on existing risk-stratification models. METHODS AND MATERIALS: Between 1993 and 2004, 1,056 patients with clinical Stage T1c-T3N0M0 prostate cancer, who had four or more biopsy cores sampled and complete biopsy core data available, were treated with external beam RT, with or without a high-dose-rate brachytherapy boost at William Beaumont Hospital. The median follow-up was 7.6 years. Multivariate Cox regression analysis was performed with PPC, Gleason score, pretreatment prostate-specific antigen, T stage, PNI, radiation dose, androgen deprivation, age, prostate-specific antigen frequency, and follow-up duration. A new risk stratification (PPC classification) was empirically devised to incorporate PPC and replace the T stage. RESULTS: On multivariate Cox regression analysis, the PPC was an independent predictor of distant metastasis, cause-specific survival, and overall survival (all p < .05). A PPC >50% was associated with significantly greater distant metastasis (hazard ratio, 4.01; 95% confidence interval, 1.86-8.61), and its independent predictive value remained significant with or without androgen deprivation therapy (all p < .05). In contrast, PNI and T stage were only predictive for locoregional recurrence. Combining the PPC (≤50% vs. >50%) with National Comprehensive Cancer Network risk stratification demonstrated added prognostic value of distant metastasis for the intermediate-risk (hazard ratio, 5.44; 95% confidence interval, 1.78-16.6) and high-risk (hazard ratio, 4.39; 95% confidence interval, 1.70-11.3) groups, regardless of the use of androgen deprivation and high-dose RT (all p < .05). The proposed PPC classification appears to provide improved stratification of the clinical outcomes relative to the National Comprehensive Cancer Network classification. CONCLUSIONS: The PPC is an independent and powerful predictor of clinical outcomes of prostate cancer after RT. A risk model replacing T stage with the PPC to reduce subjectivity demonstrated potentially improved stratification.