Health-related quality of life in men with localized prostate cancer treated with radiotherapy: validation of an abbreviated version of the Expanded Prostate Cancer Index Composite for Clinical Practice in Spain.

BACKGROUND: Health-related quality of life (HRQoL) is greatly affected by prostate cancer (PCa) and associated treatments. This study aimed to measure the impact of radiotherapy on HRQoL and to further validate the Spanish version of the 16-item Expanded Prostate Cancer Index Composite (EPIC-16) in routine clinical practice. METHODS: An observational, non-interventional, multicenter study was conducted in Spain with localized PCa patients initiating treatment with external beam radiotherapy (EBRT) or brachytherapy (BQT). Changes from baseline in EPIC-16, University of California-Los Angeles Prostate Cancer Index (UCLA-PCI), and patient-perceived health status were longitudinally assessed at end of radiotherapy (V2) and 90 days thereafter (V3). Psychometric evaluations of the Spanish EPIC-16 were conducted. RESULTS: Of 516 patients enrolled, 495 were included in the analysis (EBRT, n = 361; BQT, n = 134). At baseline, mean (standard deviation [SD]) EPIC-16 global scores were 11.9 (7.5) and 10.3 (7.7) for EBRT and BQT patients, respectively; scores increased, i.e., HRQoL worsened, from baseline, by mean (SD) of 6.8 (7.6) at V2 and 2.4 (7.4) at V3 for EBRT and 4.2 (7.6) and 3.9 (8.2) for BQT patients. Changes in Spanish EPIC-16 domains correlated well with urinary, bowel, and sexual UCLA-PCI domains. EPIC-16 showed good internal consistency (Cronbach's alpha = .84), reliability, and construct validity. CONCLUSION: The Spanish EPIC-16 questionnaire demonstrated sensitivity, strong discriminative properties and reliability, and validity for use in clinical practice. EPIC-16 scores worsened after radiotherapy in different HRQoL domains; however, a strong tendency towards recovery was seen at the 3-month follow-up visit.

Clinical Applications of Molecular Biomarkers in Prostate Cancer.

There is clinically relevant molecular heterogeneity in prostate cancer (PCa), but this biological diversity has had only a minimal impact on clinical practice. Treatment outcomes in patients with localised PCa are often highly variable, even among patients stratified to the same risk group or disease state based on standard clinical and pathological parameters. In recent years, the development of gene panels has provided valuable data on the differential expression of genes in patients with PCa. Nevertheless, there is an urgent need to identify and validate prognostic and predictive biomarkers that can be applied across clinical scenarios, ranging from localised disease to metastatic castration-resistant PCa. The availability of such tools would allow for precision medicine to finally reach PCa patients. In this review, we evaluate current data on molecular biomarkers for PCa, with an emphasis on the biomarkers and gene panels with the most robust evidence to support their application in routine clinical practice.

Long term control stereotactic body radiotherapy (SBRT) for oligometastatic colorectal cancer: a single center study.

BACKGROUND: To evaluate survival after stereotactic body radiotherapy (SBRT) as radical treatment for metastases of colorectal cancer (CRC) and to identify prognostic factors after treatment. METHODS: Patients with metastatic CRC treated with SBRT on metastatic lesions were retrospectively analyzed between February 2012 and August 2016 at the General University Hospital of Valencia. The follow-up was carried out until July 15, 2018. The data have been collected in a database. Patients may have received prior systemic therapy and/or resection of metastatic disease. Endpoints were timed from end of SBRT and included overall survival (OS) and progression-free survival (PFS). Univariate and multivariate analysis using Cox proportional hazard modeling was used to identify prognostic factors. RESULTS: A total of 49 patients were identified. Before SBRT, 77.5% of the patients have received systemic therapy and 65.2% surgery for metastatic disease. Of metastatic lesions treated with SBRT 53.1% were located in the lung, 30.6% in the liver and 16.3% in other locations. Median survival were: PFS after treatment with SBRT was 9.9 months (95% CI: 4.64-15.1) and the median OS was 28.9 months (95% CI: 19.0-38.7). No relapses were observed in 20% of the patients after SBRT. The treatment was well tolerated and no patient had grade 3 or 4 adverse effects. Right colon [HR 16.53 (95% CI: 3.11-87.87), P value 0.001] and higher tumor stage (III-IV) [HR 12.30 (95% CI: 2.10-71.92), P value 0.005] showed a lower OS in a multivariate analysis. CONCLUSIONS: SBRT for oligometastatic disease is an effective option for patients with advanced CRC, with encorauging survival outcomes. However, a definitive validation in large randomized studies is required.

Measurement of body composition in cancer patients using CT planning scan at the third lumbar vertebra / Medición de la composición corporal en pacientes oncológicos mediante la TC de planificación a nivel de la tercera vértebra lumbar

Objective: the main objective was to assess body composition in terms of skeletal muscle index (SMI), myosteatosis, visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and intermuscular adipose tissue (IMAT) as an adjunct of information provided by radiotherapy CT planning scan. Material and methods: a sample of 49 patients with lung and digestive cancers underwent a CT scan for radiotherapy treatment, which included measurements at the L3 region. Images were analyzed with a radiotherapy contouring software, using different Hounsfield Unit (HU) settings. Cross-sectional areas (cm2) were automatically computed by summing tissue pixels and multiplying by pixel surface area. Low SMI (cm2/m2) and muscle density (HU) were determined according to the recently established cut-off points. Results: the prevalence of low SMI was detected in 46.94% of patients, being present in 8 women, 4 men with BMI < 25 kg/m2, and 11 men with BMI = 25 kg/m2. The average mean skeletal attenuation of total skeletal muscle area was 29.02 (± 8.66) HU, and myosteatosis was present in 13 women (81.25%) and 31 men (93.94%). Mean SAT was 131.92 (± 76.80) cm2, mean VAT was 133.19 (± 85.28) cm2, and mean IMAT was 11.29 (± 12.86) cm2. Conclusion: skeletal muscle abnormalities are frequently present in cancer patients and a low SMI may also exist even in the presence of overweight. As CT scans are an important tool at any radiation oncology department, they could also be used to offer highly sensitive and specific information about body composition, as well as to detect early malnutrition before starting radiotherapy treatment

Objetivo: evaluar la composición corporal mediante el índice de músculo esquelético (IME), el tejido adiposo visceral (TAV), el tejido adiposo subcutáneo (TAS) y el tejido adiposo intermuscular (TAIM) o la densidad muscular (DM) en pacientes oncológicos antes de iniciar el tratamiento con radioterapia mediante cortes de TAC. Materiales y métodos: se estudiaron 49 pacientes con cáncer de pulmón y del aparato digestivo sometidos a tomografía computarizada con cortes en L3 para la determinación del tratamiento con radioterapia. El tejido adiposo y muscular se cuantificó mediante distintas Unidades Hounsfield (UH) (-29 a +150 para masa muscular, -190 a -30 para TAIM/TAS y -150 a -50 para TAV). Resultados: la prevalencia de un IME bajo se detectó en el 46,94% de los pacientes, estando presente en 8 mujeres, 6 de ellas con un IMC = 25 kg/m². Según la distribución masculina, se identificaron 4 hombres con IMC < 25 kg/m² y 11 hombres con = 25 kg/m². La DM media fue de 29,02 (± 8,66) UH y la mioesteatosis estuvo presente en 13 mujeres (81,25%) y 31 hombres (93,94%). La media del TAS fue de 131,92 (± 76,80) cm², la del TAV de 133,19 (± 85,28) cm² y la del TAIM de 11,29 (± 12,86) cm². Conclusión: las anormalidades del músculo esquelético y la masa grasa son muy frecuentes en los pacientes con cáncer, pudiendo existir un bajo IME incluso en presencia de sobrepeso u obesidad. Teniendo en cuenta que la TAC es una herramienta importante en cualquier departamento de radioterapia, también podría utilizarse para ofrecer información sensible y específica sobre la composición corporal, así como para detectar la malnutrición precoz

Measurement of body composition in cancer patients using CT planning scan at the third lumbar vertebra.

INTRODUCTION: Objective: the main objective was to assess body composition in terms of skeletal muscle index (SMI), myosteatosis, visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and intermuscular adipose tissue (IMAT) as an adjunct of information provided by radiotherapy CT planning scan. Material and methods: a sample of 49 patients with lung and digestive cancers underwent a CT scan for radiotherapy treatment, which included measurements at the L3 region. Images were analyzed with a radiotherapy contouring software, using different Hounsfield Unit (HU) settings. Cross-sectional areas (cm2) were automatically computed by summing tissue pixels and multiplying by pixel surface area. Low SMI (cm2/m2) and muscle density (HU) were determined according to the recently established cut-off points. Results: the prevalence of low SMI was detected in 46.94% of patients, being present in 8 women, 4 men with BMI < 25 kg/m2, and 11 men with BMI ≥ 25 kg/m2. The average mean skeletal attenuation of total skeletal muscle area was 29.02 (± 8.66) HU, and myosteatosis was present in 13 women (81.25%) and 31 men (93.94%). Mean SAT was 131.92 (± 76.80) cm2, mean VAT was 133.19 (± 85.28) cm2, and mean IMAT was 11.29 (± 12.86) cm2. Conclusion: skeletal muscle abnormalities are frequently present in cancer patients and a low SMI may also exist even in the presence of overweight. As CT scans are an important tool at any radiation oncology department, they could also be used to offer highly sensitive and specific information about body composition, as well as to detect early malnutrition before starting radiotherapy treatment.

INTRODUCCIÓN: Objetivo: evaluar la composición corporal mediante el índice de músculo esquelético (IME), el tejido adiposo visceral (TAV), el tejido adiposo subcutáneo (TAS) y el tejido adiposo intermuscular (TAIM) o la densidad muscular (DM) en pacientes oncológicos antes de iniciar el tratamiento con radioterapia mediante cortes de TAC. Materiales y métodos: se estudiaron 49 pacientes con cáncer de pulmón y del aparato digestivo sometidos a tomografía computarizada con cortes en L3 para la determinación del tratamiento con radioterapia. El tejido adiposo y muscular se cuantificó mediante distintas Unidades Hounsfield (UH) (-29 a +150 para masa muscular, -190 a -30 para TAIM/TAS y -150 a -50 para TAV). Resultados: la prevalencia de un IME bajo se detectó en el 46,94% de los pacientes, estando presente en 8 mujeres, 6 de ellas con un IMC ≥ 25 kg/m². Según la distribución masculina, se identificaron 4 hombres con IMC < 25 kg/m² y 11 hombres con ≥ 25 kg/m². La DM media fue de 29,02 (± 8,66) UH y la mioesteatosis estuvo presente en 13 mujeres (81,25%) y 31 hombres (93,94%). La media del TAS fue de 131,92 (± 76,80) cm², la del TAV de 133,19 (± 85,28) cm² y la del TAIM de 11,29 (± 12,86) cm². Conclusión: las anormalidades del músculo esquelético y la masa grasa son muy frecuentes en los pacientes con cáncer, pudiendo existir un bajo IME incluso en presencia de sobrepeso u obesidad. Teniendo en cuenta que la TAC es una herramienta importante en cualquier departamento de radioterapia, también podría utilizarse para ofrecer información sensible y específica sobre la composición corporal, así como para detectar la malnutrición precoz.

Diagnosis of pre-sarcopenia from a single selectional crosscut at C3 region, using CT scans before radiotherapy / Diagnóstico de pre-sarcopenia mediante un único corte axial en C3 utilizando el TC de planificación de radioterapia

Purpose: the main purpose of this study was to diagnose pre-sarcopenia in cancer patients who had lack of computed tomography (CT) abdominal images, with a newly discovered method based on cervical images. Material and methods: a sample of 37 patients with either lung cancer or a cancer that affected the upper digestive system underwent radiotherapy computed simulation which included measurements at C3 and L3 regions. Skeletal muscle mass (SMM) and skeletal muscle index (SMI) were determined by Hounsfield units and compared in both regions. Pre-sarcopenia was identified according to the cut-points currently established: ≤ 41 cm2/m2 in females, ≤ 43 cm2/m2 in males with a BMI ≤ 25 kg/m2, and ≤ 53 cm2/m2 in males with a BMI > 25 kg/m2. Results: the correlation of SMM and SMI between the C3 and L3 regions was R2 = 0.876 and R2 = 0.805, respectively. Moreover, there was a positive association (86.49%) in terms of the diagnosis of pre-sarcopenia according to both regions. In total, eleven pre-sarcopenic patients (29.37%) were identified; three of them being overweight (27.27%) and two of them being obese (18.18%). Conclusion: a single sectional cross at the level of C3 can be used for the diagnosis of pre-sarcopenia. This new method avoids unnecessary irradiation, saves hospital costs and detects malnutrition before starting radiotherapy treatment in cancer patients who have lack of CT abdominal imaging

Propósito: el propósito de este estudio fue diagnosticar la presarcopenia en pacientes con cáncer que no disponen de imágenes por tomografía computarizada (TC) a nivel abdominal mediante un método novedoso basado en cortes a nivel cervical. Material y métodos: se analizaron y se compararon mediante unidades la masa muscular y la masa muscular esquelética en 37 pacientes con cáncer de pulmón y neoplasias del aparato digestivo superior que incluían cortes en la TC de planificación a nivel de C3 y L3. La presarcopenia se identificó de acuerdo con los puntos de corte establecidos actualmente: ≤ 41 cm2/m2 para mujeres, ≤ 43 cm2/m2 en hombres con un IMC ≤ 25 kg/m2 y ≤ 53 cm2/m2 en hombres con IMC > 25 kg/m2. Resultados: la correlación de la masa muscular y el índice musculoesquelético entre las regiones C3 y L3 fue R2 = 0.876 y R2 = 0.805, respectivamente. Además, hubo una asociación positiva (86,49%) en términos del diagnóstico de presarcopenia según ambas regiones. En total, se identificaron once pacientes con presarcopenia (29,37%); tres de ellos con sobrepeso (27,27%) y dos con obesidad (18,18%). Conclusión: un solo corte transversal a nivel de la vértebra C3 puede diagnosticar la presarcopenia. Este nuevo método evita la irradiación innecesaria, ahorra costos hospitalarios y detecta la desnutrición antes de iniciar el tratamiento de radioterapia en pacientes con cáncer que no disponen de imágenes a nivel abdominal

Diagnosis of pre-sarcopenia from a single selectional crosscut at C3 region, using CT scans before radiotherapy.

INTRODUCTION: Purpose: the main purpose of this study was to diagnose pre-sarcopenia in cancer patients who had lack of computed tomography (CT) abdominal images, with a newly discovered method based on cervical images. Material and methods: a sample of 37 patients with either lung cancer or a cancer that affected the upper digestive system underwent radiotherapy computed simulation which included measurements at C3 and L3 regions. Skeletal muscle mass (SMM) and skeletal muscle index (SMI) were determined by Hounsfield units and compared in both regions. Pre-sarcopenia was identified according to the cut-points currently established: ≤ 41 cm2/m2 in females, ≤ 43 cm2/m2 in males with a BMI ≤ 25 kg/m2, and ≤ 53 cm2/m2 in males with a BMI > 25 kg/m2. Results: the correlation of SMM and SMI between the C3 and L3 regions was R2 = 0.876 and R2 = 0.805, respectively. Moreover, there was a positive association (86.49%) in terms of the diagnosis of pre-sarcopenia according to both regions. In total, eleven pre-sarcopenic patients (29.37%) were identified; three of them being overweight (27.27%) and two of them being obese (18.18%). Conclusion: a single sectional cross at the level of C3 can be used for the diagnosis of pre-sarcopenia. This new method avoids unnecessary irradiation, saves hospital costs and detects malnutrition before starting radiotherapy treatment in cancer patients who have lack of CT abdominal imaging.

INTRODUCCIÓN: Propósito: el propósito de este estudio fue diagnosticar la presarcopenia en pacientes con cáncer que no disponen de imágenes por tomografía computarizada (TC) a nivel abdominal mediante un método novedoso basado en cortes a nivel cervical. Material y métodos: se analizaron y se compararon mediante unidades la masa muscular y la masa muscular esquelética en 37 pacientes con cáncer de pulmón y neoplasias del aparato digestivo superior que incluían cortes en la TC de planificación a nivel de C3 y L3. La presarcopenia se identificó de acuerdo con los puntos de corte establecidos actualmente: ≤ 41 cm2/m2 para mujeres, ≤ 43 cm2/m2 en hombres con un IMC ≤ 25 kg/m2 y ≤ 53 cm2/m2 en hombres con IMC > 25 kg/m2. Resultados: la correlación de la masa muscular y el índice musculoesquelético entre las regiones C3 y L3 fue R2 = 0.876 y R2 = 0.805, respectivamente. Además, hubo una asociación positiva (86,49%) en términos del diagnóstico de presarcopenia según ambas regiones. En total, se identificaron once pacientes con presarcopenia (29,37%); tres de ellos con sobrepeso (27,27%) y dos con obesidad (18,18%). Conclusión: un solo corte transversal a nivel de la vértebra C3 puede diagnosticar la presarcopenia. Este nuevo método evita la irradiación innecesaria, ahorra costos hospitalarios y detecta la desnutrición antes de iniciar el tratamiento de radioterapia en pacientes con cáncer que no disponen de imágenes a nivel abdominal.

Permanent seed implant brachytherapy in low-risk prostate cancer: Preoperative planning with 145 Gy versus real-time intraoperative planning with 160 Gy.

AIM: The present retrospective study was to compare toxicity and survival outcomes in a group of low-risk PCa patients treated with either the preoperative planning technique (145 Gy) or the real-time IoP technique (160 Gy). BACKGROUND: The two most common permanent seed implantation techniques are preoperative planning (PP) with 145 Gy and real-time intraoperative planning (IoP) with 160 Gy. Although IoP has largely replaced PP at many centres in recent years, few studies have directly compared these two techniques. MATERIALS AND METHODS: Retrospective study of 408 patients with low-risk PCa treated with permanent seed implant brachytherapy at our institution between October 2003 and December 2014. Of these, 187 patients were treated with PP at a dose of 145 Gy while 221 received real-time IoP with 160 Gy. RESULTS: At a median follow up of 90 months, 5- and 8-year rates of biochemical relapse-free survival (BRFS) were 94.8% and 86% with the IoP technique versus 90.8% and 83.9%, respectively, with PP. The maximum dose to the urethra was <217 Gy with both techniques. Despite the higher dose, IoP did not cause any significant increase in toxicity (p = 0.11). CONCLUSIONS: The present study shows that real-time intraoperative brachytherapy at a dose of 160 Gy yield better biochemical control than preoperative planning at 145 Gy. In addition, urinary toxicity did not increase, despite the dose escalation, probably because the dose constraints to the urethra were met despite the increased dose escalation. These findings support the use of real-time IoP.

Evaluation of acute skin toxicity in breast radiotherapy with a new quantitative approach.

BACKGROUND AND PURPOSE: Current criteria to evaluate acute radiodermatitis are highly subjective so quantification of physiological parameters is needed. We describe a non-invasive method of assessing skin microcirculation in breast cancer patients treated with hypofractionated radiotherapy and correlate them with the CTCAE scale. METHODS: Prospective study of 63 patients where blood flow was measured with real-time laser Doppler flowmetry (LDF) at baseline, weekly, and 3-months post-radiotherapy. Skin toxicity was assessed with the microcirculation index (MCI), a novel index based on blood flow parameters obtained via LDF. RESULTS: MCI was positively correlated (R=0.647; p<0.001) with the dose. Changes in MCI from baseline to the end of radiotherapy and at 3-months post-radiotherapy were significant (p<0.001). All CTCAE groups experienced a significant increase in MCI values from baseline to end of radiotherapy (p<0.001 for CTCAE grades 0 and 1; and p=0.028 for the grade 2 group). Significant differences in MCI values were observed among CTCAE groups at the end of radiotherapy (p=0.016). CONCLUSIONS: LDF is an accurate and objective measure of changes in blood flow. The comparison with the CTCAE shows the limitations of this subjective way of classifying patients. LDF is the first step for future studies of radiodermatitis treatments and prevention.

Corrigendum to "Uroncor consensus statement: Management of biochemical recurrence after radical radiotherapy for prostate cancer: From biochemical failure to castration resistance". [Rep. Pract. Oncol. Radiother. 20 (2015) 259-272].

[This corrects the article DOI: 10.1016/j.rpor.2015.04.003.].

Three linked nomograms for predicting biochemical failure in prostate cancer treated with radiotherapy plus androgen deprivation therapy.

BACKGROUND: Nomograms were established to predict biochemical recurrence (BCR) after radiotherapy (RT) with a low weight of the characteristic variables of RT and androgen deprivation therapy (ADT). Our aim is to provide a new stratified tool for predicting BCR at 4 and 7 years in patients treated using RT with radical intent. MATERIALS AND METHODS: A retrospective, nonrandomized analysis was performed on 5044 prostate cancer (PCa) patients with median age 70 years, who received RT-with or without ADT-between November 1992 and May 2007. Median follow-up was 5.5 years. BCR was defined as a rise in serum prostate-specific antigen (PSA) of 2 ng/ml over the post-treatment PSA nadir. Univariate association between predictor variables and BCR was assessed by the log-rank test, and three linked nomograms were created for multivariate prognosis of BCR-free survival. Each nomogram corresponds to a category of the Gleason score-either 6,7, or 8-10-and all of them were created from a single proportional hazards regression model stratified also by months of ADT (0, 1-6, 7-12, 13-24, 25-36, 36-60). The performance of this model was analyzed by calibration, discrimination, and clinical utility. RESULTS: Initial PSA, clinical stage, and RT dose were significant variables (p < 0.01). The model showed a good calibration. The concordance probability was 0.779, improving those obtained with other nomograms (0.587, 0.571, 0.554) in the database. Survival curves showed best clinical utility in a comparison with National Comprehensive Cancer Network (NCCN) risk groups. CONCLUSION: For each Gleason score category, the nomogram provides information on the benefit of adding ADT to a specific RT dose.

Uroncor consensus statement: Management of biochemical recurrence after radical radiotherapy for prostate cancer: From biochemical failure to castration resistance.

Management of patients who experience biochemical failure after radical radiotherapy with or without hormonal therapy is highly challenging. The clinician must not only choose the type of treatment, but also the timing and optimal sequence of treatment administration. When biochemical failure occurs, numerous treatment scenarios are possible, thus making it more difficult to select the optimal approach. Moreover, rapid and ongoing advances in treatment options require that physicians make decisions that could impact both survival and quality of life. The aim of the present consensus statement, developed by the Urological Tumour Working Group (URONCOR) of the Spanish Society of Radiation Oncology (SEOR), is to provide cancer specialists with the latest, evidence-based information needed to make the best decisions for the patient under all possible treatment scenarios. The structure of this consensus statement follows the typical development of disease progression after biochemical failure, with the most appropriate treatment recommendations given for each stage. The consensus statement is organized into three separate chapters, as follows: biochemical failure with or without local recurrence and/or metastasis; progression after salvage therapy; and treatment of castration-resistant patients.

Fractionated stereotactic radiotherapy plus bevacizumab after response to bevacizumab plus irinotecan as a rescue treatment for high-grade gliomas.

AIM: To evaluate the possibility of implementing a new scheme of rescue treatment after relapse or progression of high-grade glioma (HGG) treated at the first-line with bevacizumab and irinotecan (BVZ+CPT11), evaluating the response and toxicity of associating BVZ and fractionated stereotactic radiotherapy (BVZ+FSRT). MATERIALS AND METHODS: We retrospectively analysed data from 59 patients with relapse of HGG. Nine patients with HGG relapse after treatment using the Stupp protocol that were treated with BVZ+CPT11 for progression between July 2007 and August 2012, after which the response was assessed according to the Revised Assessment in Neuro-Oncology (RANO) criteria. BVZ was administered at a dose of 10 mg/kg and FSRT up to a prescribed dose of 30 Gy, 500 cGy per fraction, three days a week. The median follow-up was 38 months. RESULTS: The treatment was well-tolerated by all patients. The response after nuclear magnetic resonance imaging (MRI) at 3-6 months was progression in two patients, stable disease in four, and three patients had a partial response. The median overall survival (OS) from diagnosis until death or the last control was 36.8 months. The median progression-free survival (PFS) was 10.8 months. The results from tumour sub-group analysis indicated that the PFS was not statistically significant although it seemed that it was higher in grade-III. The OS was higher in grade-III gliomas. CONCLUSIONS: The combination of BVZ+FSRT as a second-line HGG relapse rescue treatment is well-tolerated and seems to offer promising results. We believe that multi-centre prospective studies are needed to determine the long-term efficacy and toxicity of this therapeutic approach.

Guidelines for equipment and staffing of radiotherapy facilities in the European countries: final results of the ESTRO-HERO survey.

BACKGROUND AND PURPOSE: In planning to meet evidence based needs for radiotherapy, guidelines for the provision of capital and human resources are central if access, quality and safety are not to be compromised. A component of the ESTRO-HERO (Health Economics in Radiation Oncology) project is to document the current availability and content of guidelines for radiotherapy in Europe. MATERIALS AND METHODS: An 84 part questionnaire was distributed to the European countries through their national scientific and professional radiotherapy societies with 30 items relating to the availability of guidelines for equipment and staffing and selected operational issues. Twenty-nine countries provided full or partial evaluable responses. RESULTS: The availability of guidelines across Europe is far from uniform. The metrics used for capital and human resources are variable. There seem to have been no major changes in the availability or specifics of guidelines over the ten-year period since the QUARTS study with the exception of the recent expansion of RTT staffing models. Where comparison is possible it appears that staffing for radiation oncologists, medical physicists and particularly RTTs tend to exceed guidelines suggesting developments in clinical radiotherapy are moving faster than guideline updating. CONCLUSION: The efficient provision of safe, high quality radiotherapy services would benefit from the availability of well-structured guidelines for capital and human resources, based on agreed upon metrics, which could be linked to detailed estimates of need.

Tumor bed segmentation: first step for partial breast irradiation.

INTRODUCTION: In breast IMRT simultaneous integrated boost (SIB) treatment and accelerated partial breast irradiation (APBI), proper delineation of the tumor bed is necessary. Conservative oncoplastic surgery causes changes in peritumoral breast tissue that complicates locating the site of the tumor. Nevertheless, there are still centers that do not use surgical clips to delineate the site. This study aims to show how the lack of clips affects the techniques of SIB and APBI in terms of dose distribution and safety margins in the tumor bed. MATERIALS AND METHODS: On 30 patients, the defining of the tumor bed obtained from the pre-surgery CT scan to that outlined on the basis of clips on the post-surgery CT was compared. Tumor bed deviation from the original tumor site was quantified. In addition, the margins to the original tumor site necessary to guarantee the coverage of the tumor bed were calculated. RESULTS: Variations were detected in the distances between geometric centers of the PTV (minimum 0.5-maximum 3 cm). The maximum margin necessary to include the entire tumor bed was 4.5 cm. Lesions located in the upper outer quadrant required the widest margins. If margins are not added, the tumor bed volume defined with clips will be underdosed. CONCLUSIONS: The definition of the tumor bed based on studies before surgery does not have the necessary accuracy. Clips need to be placed in the surgical bed to identify the changes occurring after the restorative mammoplasty. Without clips, SIB and APBI are not safe.

Practice patterns in the management of prostate cancer in Spain: results from a national survey among radiation oncologists in 2009.

INTRODUCTION: Little is known of practice patterns on advanced prostate cancer (PC) in Spain. The study objectives were to investigate practice patterns in the management of PC and to determine the adherence to the 2007 Spanish guidelines for the management of PC. MATERIALS AND METHODS: An epidemiological, cross-sectional study was undertaken. Study-specific questionnaires were distributed to all centers with radiation oncology (RO) facilities delivering megavoltage radiation therapy (RT) in Spain (n = 108). A questionnaire evaluated diagnostic and treatment approaches to PC in low-risk and high-risk cases. And a 12-item questionnaire was used to assess guidelines adherence. RESULTS: Responses were obtained from 102 centers (94.0 % response rate). In the high-risk scenario, the majority of clinicians (99.0 %) chose combined modality treatment with RT and androgen deprivation (AD) and 93.0 % recommended long-term AD. External-beam RT (EBRT) doses ranging 72-76 Gy were used in 59.5 % of centers and >76 Gy was employed in 40.5 %. In the low-risk scenario, EBRT was chosen by 59.6 %, brachytherapy by 39.4 %, and active surveillance by 1 %. The consensus was high (score 5 + 4 ≥ 90 %) on 8/12 questions assessing adherence to guidelines, being high specifically on items related to RT technique, RT dose, combination of HT and RT in intermediate/high-risk patients, and prognostic factors. CONCLUSIONS: This is the largest survey to date of Spanish RO departments dealing with PC. The study results therefore likely provide a highly reliable picture of clinical practice in Spain in this century and show how this practice is influenced by clinical evidence from randomized trials and consensus conferences.

Patterns of care for brachytherapy in Europe: updated results for Spain.

OBJECTIVE: The aim of this follow-up pattern of care study was to evaluate current clinical practices, staffing and equipment, and to compare these results to a study performed 5 years previously. MATERIALS AND METHODS: This descriptive, pattern of care study was carried out via an online questionnaire. The survey was sent to a total of 95 cancer care centres in Spain. RESULTS: Seventy-three centres (76.8%) responded to the survey. More than half (57.5%) of responding centres offered brachytherapy (BT). A mean of 120 patients/centre were treated by BT in 2007. The most common localisations were the endometrium (29.6% of cases), prostate (29.6%), cervix uteri (14.6%), breast (12.6%), head and neck (3.6%) and vagina (2.5%). Other sites accounted for less than 2% of cases each. Most centres that offered BT (33/40 = 82.5%) were equipped with a dedicated BT operating room. The most commonly reported dosimetric method was CT dosimetry (31 of 40 centres = 77.5%), followed by plain film (30/40 = 75%), ultrasound (26/40 = 65%), MRI (8/40 = 20%), in vivo (7/40 = 17.5%) and PET-CT (5/40 = 12.5%) dosimetry. CONCLUSION: The three most common treatment sites (gynaecological, breast and prostate) remain unchanged from 2002, with prostate treatments showing large increase. Advanced dosimetric techniques (MRI, PET-CT and CT-dosimetry) continue to gain adherents. Some centres treat small numbers of patients, a finding that deserves more attention in terms of cost and quality of care. Although BT remains strong in Spain, it could be further strengthened by making modern dosimetric techniques and treatments more widely available.

Evidence-based consensus recommendations to improve the quality of life in prostate cancer treatment.

INTRODUCTION: Prostate cancer (PC) is one of the tumours with the highest incidence in recent years. PC therapies have several adverse effects. A panel consensus recommendation has been made to prevent or ameliorate complications in PC treatment to improve quality of life. MATERIAL AND METHODS: Fifteen specialists have met to analyse the different toxicities associated with PC treatment. Each medical specialist performed a National Library of Medicine PubMed search citations searching about these secondary effects and his specialty from 1999 to 2009 to propose measures for their prevention/amelioration. RESULTS: Surgery is associated with incontinence and impotence. Radiotherapy can produce acute, late urological and gastrointestinal toxicity. Brachytherapy can produce acute urinary retention. Chemotherapy is associated with haematotoxicity, peripheral neuropathy and diarrhoea, and hormone therapy can produce osteoporosis, metabolic syndrome, cognitive and muscular alterations, cardiotoxicity, etc. CONCLUSIONS: Improvement in surgical techniques and technology (IMRT/IGRT) can prevent surgical and radiotherapeutic toxicity, respectively. Brachytherapy toxicity can be prevented with precise techniques to preserve the urethra. Chemotherapy toxicity can be prevented with personalized schedules of treatment and close follow-up of iatrogenia and hormone therapy toxicity can be prevented with close follow-up of possible secondary effects.

Brachytherapy in the United Kingdom and Spain: a subset analysis of a European pattern of care survey.

PURPOSE: The aim of this pattern of care survey was to provide an overview of brachytherapy resources and practices in the United Kingdom (UK) and Spain and to identify differences that may be relevant to health-care delivery and planning. METHODS AND MATERIALS: Both countries formed part of a larger survey of European radiation oncology centres carried out in 2002. The present study includes only data from centres that perform brachytherapy and completed the questionnaire. RESULTS: Between 1997 and 2002, the number of hospitals offering brachytherapy increased by 10.2% in the UK and 21.4% in Spain. The mean number of radiotherapy patients per centre was significantly higher in the UK (2811 patients) than in Spain (1203). Gynaecological tumours accounted for most procedures (59.7% in Spain and 60.8% in the UK), followed by prostate cancer in the UK (16.7%) and breast cancer in Spain (15.5%). Significantly more procedures for breast cancer were performed in Spain (19.7 patients/centre) than in the UK (0.4 patients/centre). A significantly higher percentage of radiation oncologists in Spain performed brachytherapy, dedicating more time to brachytherapy-related work (22.2 h/week) than their colleagues in the UK (6.7 h/week). CONCLUSIONS: Brachytherapy resources and patterns of care are similar in both countries, although several notable differences exist. Radiation oncologists in Spain dedicate significantly more time to brachytherapy. Compared to the UK, brachytherapy is used more frequently in Spain as a boost in breast cancer treatments. Both countries perform more brachytherapy procedures for prostate cancer than the European average.