The prevalence and nature of supportive care needs in lung cancer patients.

PURPOSE: In the present work, we set out to comprehensively describe the unmet supportive care and information needs of lung cancer patients. METHODS: This cross-sectional study used the Supportive Care Needs Survey Short Form 34 (34 items) and an informational needs survey (8 items). Patients with primary lung cancer in any phase of survivorship were included. Demographic data and treatment details were collected from the medical charts of participants. The unmet needs were determined overall and by domain. Univariable and multivariable regression analyses were performed to determine factors associated with greater unmet needs. RESULTS: From August 2013 to February 2014, 89 patients [44 (49%) men; median age: 71 years (range: 44-89 years)] were recruited. The mean number of unmet needs was 8 (range: 0-34), and 69 patients (78%) reported at least 1 unmet need. The need proportions by domain were 52% health system and information, 66% psychological, 58% physical, 24% patient care, and 20% sexuality. The top 2 unmet needs were "fears of the cancer spreading" [n = 44 of 84 (52%)] and "lack of energy/tiredness" [n = 42 of 88 (48%)]. On multivariable analysis, more advanced disease and higher MD Anderson Symptom Inventory scores were associated with increased unmet needs. Patients reported that the most desired information needs were those for information on managing symptoms such as fatigue (78%), shortness of breath (77%), and cough (63%). CONCLUSIONS: Unmet supportive care needs are common in lung cancer patients, with some patients experiencing a very high number of unmet needs. Further work is needed to develop resources to address those needs.

Celebrating 10 Years of Undergraduate Medical Education: A Student-Centered Evaluation of the Princess Margaret Cancer Centre--Determinants of Community Health Year 2 Program.

Between 2000 and 2011, over 170 second-year medical students participated in a Determinants of Community Health (DOCH 2) project at Princess Margaret Hospital (PMH). Students undertook community-based research projects at the hospital or with PMH community partners involving activities such as producing a literature review, writing a research proposal, obtaining ethics approval, carrying out data collection and analysis, presenting their data to classmates and supervisors, and production of a final report. An electronic survey consisting of both quantitative and qualitative questions was developed to evaluate the PMH-DOCH 2 program and was distributed to 144 past students with known email addresses. Fifty-eight students responded, a response rate of 40.3%. Data analysis indicates that an increase in oncology knowledge, awareness of the impact of determinants of health on patients, and knowledge of research procedures increased participants' satisfaction and ability to conduct research following DOCH 2. Furthermore, the PMH-DOCH 2 program enhanced the development of CanMEDS competencies through career exploration and patient interaction as well as through shadowing physicians and other allied health professionals. In addition, some students felt their PMH-DOCH 2 projects played a beneficial role during their residency matching process. The PMH-DOCH 2 research program appeared to provide a positive experience for most participants and opportunities for medical students' professional growth and development outside the confines of traditional lecture-based courses.

A pilot study examining the unmet needs of cancer survivors living with polypathology.

With improved average longevity, the issue of polypathology in the cancer population is of growing importance, because it will increasingly affect more people. The present study piloted two self-report surveys aiming to provide preliminary data on the nature of polypathology and supportive care needs (met and unmet) of cancer survivors. Survivors were recruited from outpatient clinics at the Princess Margaret Hospital in Toronto and were asked to complete and give feedback on the surveys. Of a convenience sample of 88 survivors, almost three quarters (73%) reported having polypathology, and 64% had at least 1 unmet need. Results also suggest that those with the highest number of needs were more likely to have polypathology. Our study invites further assessments with self-report surveys of the complex picture that arises when cancer is not the only disease affecting a person. It also highlights the need for innovative supportive services to address patient needs.

The relationship of changes in EORTC QLQ-C30 scores to ratings on the Subjective Significance Questionnaire in men with localized prostate cancer.

PURPOSE: To examine the relationship between changes in health-related quality-of-life (HRQOL) on the EORTC Quality of Life Questionnaire (QLQ-C30), and patients' perceptions of HRQOL changes as measured by the Subjective Significance Questionnaire (SSQ). PATIENTS AND METHODS: A total of 101 patients completed the QLQ-C30 on weeks 1, 4 and 7 of radical external-beam radiation therapy (RT) for localized cancer of the prostate. Patients rated their change in physical functioning, emotional functioning, social functioning, and overall/global quality of life (QOL) by completing a seven-category SSQ at weeks 4 and 7. The association between changes in the QLQ-C30 change and the corresponding SSQ ratings were determined by calculation of mean change scores for each SSQ category and by Spearman rank correlation coefficient analysis. RESULTS: Patients' completion of the QLQ-C30 and SSQ exceeded 95%. Statistically significant changes in fatigue, pain, appetite, diarrhea, and global QOL scores were detected during RT. For patients reporting 'a little' change in global QOL on the SSQ, absolute mean QLQ-C30 change scores ranged between 0 to 15 points with 12/16 mean change scores between 2.5 and 8.5 points. In the entire study sample, correlations between SSQ patient ratings and QLQ-C30 change scores were lower than previously reported, ranging between 0.15 and 0.24 for the four different domains, but were higher when QOL scores producing ceiling effects were omitted. CONCLUSION: The SSQ and QLQ-C30 may measure related concepts that could assist in the interpretation of changes in scores and in the calibration of the QLQ-C30. However, the nature of this relationship could not be elucidated in this data set because of a lack of variance in HRQOL scores in the study sample. Further investigation should be carried out in study samples with sufficient variance to allow more robust conclusions.

More than just a pamphlet: development of an innovative computer-based education program for cancer patients.

Patients with cancer continue to lack practical information regarding their illness and report low levels of awareness and use of patient services. The challenge to educators is to find cost-effective and timely ways to deliver a complex mix of interesting and high-quality information and expertise to this large and diverse audience, while still tailoring the content to individual needs and situations. In the present article, we describe the Princess Margaret Hospital (PMH) computer-based patient education program. The program is aimed toward empowering those dealing with cancer and provides comprehensive medical information and support via an interactive Intranet web site containing information about cancer (the Oncology Interactive Education Series), library resources, Internet links, information about PMH services, and a hospital calendar of events. Preliminary evaluation results have provided valuable direction for on-going program development and suggest that the program is easy to use, informative, and enjoyable for patients, families, volunteers, and health professionals.

Squamous cell carcinoma of the oesophagus treated with radiation and 5-fluorouracil, with and without mitomycin C.

A retrospective analysis was performed of patients with squamous cell carcinoma of the oesophagus without evidence of distant metastases, who were treated with radical intent. Between 1981 and 1984, and 1989 and 1991, 98 patients were treated with radiation, 5-fluorouracil (5-FU) and mitomycin C; and between 1984 and 1989, 133 patients were treated with radiation and 5-FU without mitomycin C. Actuarial survival and local control were assessed, and prognostic factors were identified for both endpoints. The standard dose of radiation prescribed was 52 Gy to the 95% isodose in 20 fractions over 4 weeks. 5-FU was given by continuous infusion as 1 g/m2 (maximum 1.5 g)/day, for 4 days. Patients who received mitomycin C were given 10 mg/m2 (maximum 18 mg) on day 1. Survival and local relapse-free rates were estimated using the method of Kaplan and Meier, and the Cox proportional hazards model was used to evaluate possible prognostic factors, including the effect of mitomycin C administration. The median survival was 15.4 months (95% confidence interval 12.7-17.2) with 31% 2-year survival (standard error (SE) 3%), and 13% 5-year survival (SE 2%). In the multivariate analysis, lower radiation dose and younger age were the only statistically significant prognostic factors for reduced overall survival and reduced relapse-free rate respectively. There was no difference in survival (chi(2) = 0.07, 1 degree of freedom (df), P=0.79) or local relapse-free rate (chi2 = 0.39, 1 df, P = 0.53) between patients treated with or without mitomycin C. The treatment was well tolerated. Further studies are required to determine the most effective combination of radiation and chemotherapy or other radiation sensitizers for squamous cell carcinoma of the oesophagus.

Local excision and postoperative radiotherapy for distal rectal cancer.

PURPOSE: To assess the outcome following local excision and postoperative radiotherapy (RT) for distal rectal carcinoma. MATERIALS AND METHODS: Seventy-three patients received postoperative radiotherapy following local surgery for primary rectal carcinoma at Princess Margaret Hospital from 1983 to 1998. Selection factors for postoperative RT were patient preference, poor operative risks, and "elective" where conservative therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1--8 cm). There were 24 T1, 36 T2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tumor specimens in which margins could be adequately assessed, they were positive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. Median tumor dose was 50 Gy (range, 38--60 Gy), and 62 patients received 50 Gy in 2.5-Gy daily fractions. The tumor volume included the primary with 3--5 cm margins. No patients received adjuvant chemotherapy. Median follow-up was 48 months (range, 10--165 months). RESULTS: Overall 5-year survival and disease-free survival were 67% and 55%, respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; and 3 relapsed distantly only. For patients with T1, T2, and T3 lesions, 5-year local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-year survival rates were 76%, 58%, and 33%, respectively. The 5-year local relapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52% vs. 89%, p = 0.03, or where tumor fragmentation occurred during local excision compared to no fragmentation, 51% vs. 76%, p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoperineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86% at 5 and 10 years. The 5-year colostomy-free rate was 82%. There were 2 patients who experienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (bowel obstruction requiring surgery). CONCLUSION: The local relapse rate for patients with T1 disease was high compared to other series of local excision and postoperative RT. Patients with LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative RT.

A prospective study of factors predicting clinically occult spinal cord compression in patients with metastatic prostate carcinoma.

BACKGROUND: The objective of this study was to identify clinical parameters that predict occult subarachnoid space or spinal cord (SAS/SC) compression, as determined by magnetic resonance imaging (MRI), in patients with metastatic prostate carcinoma. METHODS: A prospective study was performed in which 68 patients with bone metastases from prostate carcinoma and a normal neurologic examination underwent MRI of the entire spine after documentation of clinical, X-ray, and bone scan parameters potentially predictive of occult SAS/SC compression. RESULTS: Occult SAS/SC compression was diagnosed in 22 patients (32%) using MRI. Nine patients (13%) had compressions at two discontinuous spinal levels. Extensive disease on bone scan, the duration of continuous hormonal therapy prior to study entry, and hemoglobin concentration were found to predict SAS/SC compression by univariate analysis. The extent of disease on bone scan and the duration of continuous hormonal therapy were independent predictors of SAS/SC compression by multivariate analysis (P = 0.02 and P = 0.04, respectively). The risk of occult SAS/SC compression increased from 32% to 44% in patients with a bone scan that showed > 20 metastases as the duration on hormones increased from 0 to 24 months. The risk in patients with fewer metastases increased from 11% to 17% over the same interval. The presence or absence of back pain was not predictive of SAS/SC compression. CONCLUSIONS: Patients who are at high risk for occult SAS/SC compression can be identified using clinical parameters and readily available diagnostic tests. These high-risk patients should undergo MRI screening with the aim of diagnosing and treating spinal cord compression before the development of neurologic deficits that may be irreversible.

Adjuvant and salvage radiation therapy after radical prostatectomy for adenocarcinoma of the prostate.

PURPOSE: To evaluate the outcome of adjuvant and salvage radiotherapy (RT) after radical prostatectomy (RP) for clinically localized prostate cancer using conventional clinical end-points, and the biochemical relapse-free rate (bRFR). METHODS: Between 1987 and 1994, 113 node negative, hormonally naïve men received RT 1 month to 12 years after RP. Adjuvant RT was given for positive resection margins and/or pT3 disease. Salvage RT was given for a persistently elevated prostatic specific antigen (PSA), a rising PSA, or palpable recurrence post RP. Clinical and biochemical endpoints determined outcome. Log-rank testing and the Cox proportional hazards model identified factors predictive for biochemical relapse free rate. RESULTS: Median follow-up after RT was 3.7 years (range 0.2-9 years). Five-year clinical local control was 95% for patients with no palpable evidence of disease and 59% for those with palpable recurrence (P < 0.0001). 5-year bRFR was 81% for adjuvant RT, 19% for salvage of biochemical recurrence, 0% for patients with palpable disease (P < 0.0001). Improved bRFR for adjuvant and salvage RT was predicted by a Gleason score < 7 vs. 7 vs. > 7 (hazard ratio 1.53; 95% CI 0.99-2.35) and an undetectable pre-RT PSA vs. PSA < 2.0 ng/ml vs. PSA > 2.0 ng/ml (hazard ratio 3.81; 95% CI 2.47-5.87). Seminal vesicle involvement was not a statistically significant independent predictor of bRFR. CONCLUSIONS: The most favourable bRFR was observed for adjuvant therapy. Salvage was most successful with a pre-RT PSA < 2.0 ng/ml, or Gleason score < 7. Few patients with a pre-RT PSA > 2.0 ng/ml were salvaged, and none with palpable recurrence. These patients require investigation of alternative salvage strategies.

Can assessment of psychosocial orientation assist continuing education program development in psychosocial oncology?

BACKGROUND: A pilot study was designed to aid in the development of a formal, interdisciplinary curriculum in psychosocial oncology for front-line health care professionals. METHOD: A 190-item questionnaire was distributed to psychosocial (PP) and non-psychosocial (NPP) oncology professionals attending a psychosocial skills workshop. A 38-item attitudinal survey of psychosocial orientation was used in an attempt to identify unperceived needs of the learners. RESULTS: Of the 150 questionnaires distributed, 104 (69%) were completed and returned. Overall scores for satisfaction with the workshop were high, and significantly higher in the PP group. No interdisciplinary difference existed in the preferred learning formats for future events, and both groups preferred interactive, experiential forums for developing skills relevant to patient management. The two groups' perceived learning needs differed. NPPs wanted to focus on skills such as communication, counseling, crisis intervention, palliative care, and coping with life-threatening illness. The attitudinal survey results demonstrated a significant difference between the psychosocial orientations of PPs and NPPs and suggested that NPPs would benefit from: 1) information to correct misconceptions about patients' psychosocial needs and experiences, 2) demonstrations of how to overcome contextual barriers to the delivery of psychosocial care. CONCLUSIONS: Front-line oncology professionals in many disciplines are interested in continuing education in psychosocial oncology. The attitudinal survey provided insight into unperceived learning needs that can help in designing future curricula. Its value as a tool to measure impact of these programs is worthy of future study.

The impact of irregularly rising prostate-specific antigen and "impending failure" on the apparent outcome of localized prostate cancer following radiotherapy.

PURPOSE: To examine the impact of irregularly rising prostate-specific antigen (PSA) and "impending" biochemical failure on the apparent rate of biochemical relapse following radiotherapy for localized prostate cancer. METHODS AND MATERIALS: We analyzed the outcome of 572 patients with T1/T2 prostate cancer treated with radiotherapy alone at the Princess Margaret Hospital (median follow-up, 4.21 years). Biochemical outcomes were analyzed using 2 different definitions of failure: (1) the American Society for Therapeutic Radiology and Oncology (ASTRO) definition, and (2) a modified definition that included 2 consecutive rises in PSA, with a minimum rise of 1.5 ng/mL above the nadir, or a nadir value of greater than 4 ng/mL. Patients were defined as having "impending failure" when the last 2 PSA measurements taken demonstrated 2 consecutive rises. RESULTS: Two-hundred and thirty patients (40%) met the ASTRO definition of failure; 258 patients (48%) failed by the modified definition (p = 0.001). Five-year biochemical relapse-free rate (bNED) rate was 55% using the ASTRO definition, and 49% using the modified definition. This difference in 5-year bNED was greatest for patients with high-risk disease (ASTRO definition 30% vs. modified definition 15%). Twenty-four of the 38 additional cases identified as biochemical failures by the modified definition had irregularly rising PSA levels; 14 were "impending failures." These additional 38 patients had a median PSA elevation 5.4 ng/mL above the nadir, and a high risk of subsequent clinical failure (4-year clinical failure-free rate of 63%). The ASTRO definition had a sensitivity of 87% and specificity of 74% for predicting clinical relapse. The modified definition had a sensitivity of 95% and a specificity of 70%. CONCLUSION: A definition of biochemical failure that includes an absolute allowable rise in PSA above the nadir can identify patients with rising PSA who are at substantial risk of clinical relapse, but who are not defined as biochemical failures by the ASTRO definition. This is particularly true for patients with high-risk disease. The use of a uniform definition of biochemical failure is crucial to ensure that differences in apparent outcome are not due to differences in the definition of relapse. Currently, the ASTRO definition should remain the standard. Large cohort studies with long follow-up can be utilized to optimize the definition of biochemical failure following radiotherapy for prostate cancer.

Staying up-to-date through distance education: the radiation therapy perspective.

BACKGROUND: Distance education (DE) courses are offered to medical radiation technologists (therapy) [MRT(T)] in Canada for professional development (PD). METHODS: A survey of 300 therapists was conducted to identify potential participants and factors that can influence DE participation and learning. RESULTS: The motivation to take PD is intrinsic, for personal growth and fulfillment, rather than to satisfy employment or provincial requirements. There is interest in DE because of its accessibility. Work constraints appear to be more restrictive than domestic ones and little support for PD is perceived from the cancer centers. CONCLUSIONS: These findings raise implications for professional development in cancer centers that are broader than the original objective of optimizing course design.

A province-wide needs assessment of oncology health care professionals in psychosocial oncology.

BACKGROUND: Oncology professionals still lack the knowledge and skills to provide effective psychosocial care. Continuing education (CE) aimed at addressing this lack may improve the provision of psychosocial care to patients and their families. METHODS: The authors conducted a province-wide cross-sectional mail survey of oncology health care professionals [oncologists (MDs), nurses (RNs) and radiation therapists (RTs)] and assessed psychosocial orientation, self-assessed knowledge, and motivation to learn about psychosocial oncology. In addition, they sought factors that might influence professionals' willingness to attend CE programs. RESULTS: In total, 241 surveys were completed and returned. Psychosocial orientation was highest in the RN subgroup. MDs rated their knowledge to deal with specific psychosocial issues higher than did RNs and RTs, while their motivation to learn more about providing psychosocial care was significantly lower. Seventy-three percent of respondents indicated that they would like CE in psychosocial oncology. Self-reported motivation to learn was the most significant factor associated with this interest. CONCLUSION: These findings raise questions about perceived learning needs and aided in the development of an interprofessional curriculum in psychosocial oncology.

Effect of radiation on skin expansion and skin flap viability in pigs.

The aim of the present study was to investigate the effect of radiation treatment both on skin tissue expansion with the chronic inflation of subcutaneous expanders and on skin flap viability in surgically delayed and expanded skin in the pig. One flank in each of six pigs (initially weighing 17 +/- 1.8 kg) was randomly assigned for radiation treatment, and the contralateral flank served as a nonirradiated control. Three mirror-image, 8 x 10 cm, rectangular templates were marked on each flank; these templates were randomly assigned to the construction of a delayed skin flap (group A), a skin flap raised on expanded skin (group B), or a skin flap raised on expanded skin with a capsulectomy before flap surgery (group C). Radiation treatment was performed using sequential radiation with three fractions per week (810 cGy/fraction) for 2 weeks, with a total dose of 4,860 cGy. Twelve weeks after radiation treatment, skin expanders (8 x 10 cm) were installed subcutaneously in the locations assigned for skin expansion. Skin expansion by the inflation of subcutaneous skin expanders with saline twice weekly was started 8 weeks later and lasted for 3 weeks. Two weeks after surgical delay and the last skin expansion, 8 x 20 cm skin flaps were raised on the locations assigned for delayed skin flaps, expanded skin flaps, and expanded skin flaps with a capsulectomy. Skin flap viability was assessed 24 hours later using a fluorescein dye-staining technique. Skin expansion by the inflation of subcutaneous expanders with saline was slower (p < 0.05) in the radiated skin (39 +/- 6 ml/filling) than in the nonirradiated control skin (51 +/- 6 ml/filling). Radiation reduced the overall area of expanded skin by 23 percent (p < 0.05) compared with the control. Radiation treatment also reduced skin viability by 36 percent (p < 0.05) in the delayed skin flaps, 27 percent (p = 0.10) in the expanded skin flaps, and 36 percent (p < 0.05) in the expanded skin flaps with a capsulectomy when compared with their contralateral, nonirradiated controls. There were no significant differences in skin viability among these three types of skin flaps within the radiated and nonirradiated groups. Taken together, these observations indicate that radiation treatment reduced the effectiveness of the surgical delay procedure, the amount of subcutaneous skin expansion (by an increase in skin area), and skin flap viability. However, a capsulectomy alone did not affect the viability of skin flaps raised on expanded skin.

The accountability of clinical education: its definition and assessment.

BACKGROUND: Medical education is not exempt from increasing societal expectations of accountability. Competition for financial resources requires medical educators to demonstrate cost-effective educational practice; health care practitioners, the products of medical education programmes, must meet increasing standards of professionalism; the culture of evidence-based medicine demands an evaluation of the effect educational programmes have on health care and service delivery. Educators cannot demonstrate that graduates possess the required attributes, or that their programmes have the desired impact on health care without appropriate assessment tools and measures of outcome. OBJECTIVE: To determine to what extent currently available assessment approaches can measure potentially relevant medical education outcomes addressing practitioner performance, health care delivery and population health, in order to highlight areas in need of research and development. METHODS: Illustrative publications about desirable professional behaviour were synthesized to obtain examples of required competencies and health outcomes. A MEDLINE search for available assessment tools and measures of health outcome was performed. RESULTS: There are extensive tools for assessing clinical skills and knowledge. Some work has been done on the use of professional judgement for assessing professional behaviours; scholarship; and multiprofessional team working; but much more is needed. Very little literature exists on assessing group attributes of professionals, such as clinical governance, evidence-based practice and workforce allocation, and even less on examining individual patient or population health indices. CONCLUSIONS: The challenge facing medical educators is to develop new tools, many of which will rely on professional judgement, for assessing these broader competencies and outcomes.

Urethral carcinoma in women: results of treatment with primary radiotherapy.

BACKGROUND AND PURPOSE: Urethral carcinoma in women is uncommon. This study was undertaken to evaluate the role of radiotherapy in the treatment of these tumors. MATERIALS AND METHODS: The hospital records of 34 women with primary urethral carcinoma were retrospectively reviewed. There were 15 squamous cell carcinomas, 13 transitional cell carcinomas, and six adenocarcinomas. The primary tumor was >4cm in size in eight patients, involved the proximal urethra in 19 and extended to adjacent organs in 22. Inguinal or iliac lymphadenopathy was present in nine patients. There were eight TNM stage I/II tumors, 11 stage III tumors and 15 stage IV tumors. Radiotherapy was administered only to the primary tumor in 15 patients, and to the primary tumor and regional lymph nodes in the remaining 19 patients. Brachytherapy with or without external radiation was used to treat the primary tumor in 20 patients. RESULTS: Tumor recurred in 21 patients. The 7-year actuarial overall and cause-specific survivals were 41 and 45%, respectively. Large primary tumor bulk and treatment with external beam radiation alone (no brachytherapy) were independent adverse prognostic factors for local tumor recurrence. Brachytherapy reduced the risk of local recurrence by a factor of 4.2. The beneficial effect of brachytherapy was most prominently seen in patients with bulky primary disease. Large tumor size was the only independent adverse predictor of overall disease recurrence and death from cancer. CONCLUSIONS: Radiotherapy is an effective treatment for carcinoma of the female urethra and preserves normal anatomy and function. Brachytherapy improves local tumor control, possibly as a result of the higher radiation dose that can safely be delivered.

Magnetic resonance imaging (MRI) for localization of the prostatic apex: comparison to computed tomography (CT) and urethrography.

BACKGROUND AND PURPOSE: It is necessary to include the entire prostate in the high dose treatment volume when planning radical radiation for patients with prostate cancer. We prospectively compared magnetic resonance imaging (MRI) to computed tomography (CT) and urethrography as means of localizing the prostatic apex. MATERIALS AND METHODS: Thirty patients with clinically localized prostate cancer had a sagittal T2-weighted MRI scan and a conventional axial CT scan performed in the treatment position prior to the start of radiotherapy. Twenty of these patients had a static retrograde urethrogram performed at simulation. The position of the MRI and CT apices were localized independently by two radiation oncologists. In addition, the MRI apex was localized independently by a diagnostic radiologist. The urethrogram apex, defined as the tip of the urethral contrast cone, was easily identified and was therefore localized by only one observer. RESULTS: There was good interobserver agreement in the position of the MRI apex. Interobserver agreement was significantly better with MRI than with CT. There were no systematic differences in the position of the MRI and CT apices. However, the MRI apex was located significantly above and behind the urethrogram apex. There was poor correlation between MRI and CT and between MRI and urethrogram in the height of the apex above the ischial tuberosities. There was 83% agreement between MRI and CT and 80% agreement between MRI and urethrogram in the identification of patients with a low-lying apex. The apex, as determined by MRI, was <2 cm above the ischial tuberosities and therefore potentially under-treated in 17% of the patients. CONCLUSIONS: MRI is superior to CT and urethrography for localization of the prostatic apex. All patients undergoing radiotherapy for prostate cancer should have localization of the apex using MRI or a technique of equal precision to assure adequate dose delivery to the entire prostate and to minimize the unnecessary irradiation of normal tissues.

Treatment of locally recurrent rectal carcinoma--results and prognostic factors.

PURPOSE: To assess the local control and survival in patients who received pelvic irradiation for locally recurrent rectal carcinoma. METHODS AND MATERIALS: The records of 519 patients with locally recurrent rectal carcinoma treated principally with external-beam radiation therapy between 1975 to 1985 at a single institute were retrospectively reviewed. These included 326 patients who relapsed locally following previous abdominoperineal resection, 151 after previous low anterior resection, and 42 after previous local excision or electrocoagulation for the primary. No patients had received adjuvant radiation therapy or chemotherapy for the primary disease. Concurrent extrapelvic distant metastases were found in 164 (32%) patients at local recurrence and, in the remaining 355, the relapse was confined to the pelvis. There were 290 men and 229 women whose age ranged from 23 to 91 years (median = 65). Median time from initial surgery to radiation therapy for local recurrence was 18 months (3-138 months). Radiation therapy was given with varying dose-fractionation schedules, total doses ranging from 4.4 to 65.0 Gy (median = 30 Gy) over 1 to 92 days (median = 22 days). For 214 patients who received a total dose > or = 35 Gy, radiation therapy was given in 1.8 to 2.5 Gy daily fractions. RESULTS: The median survival was 14 months and the median time to local disease progression was 5 months from date of pelvic irradiation. The 5-year survival was 5%, and the pelvic disease progression-free rate was 7%. Twelve patients remained alive and free of disease at 5 years after pelvic irradiation. Upon multivariate analysis, overall survival was positively correlated with ECOG performance status (p = 0.0001), absence of extrapelvic metastases (p = 0.0001), long intervals from initial surgery to radiation therapy for local recurrence (p = 0.0001), total radiation dose (p = 0.0001), and absence of obstructive uropathy (p = 0.0013). Pelvic disease progression-free rates were positively correlated with ECOG performance status (p = 0.0001), total radiation dose (p = 0.0001), and previous conservative surgery for the primary (p = 0.02). CONCLUSIONS: Survival is poor for patients who develop local recurrence following previous surgery for rectal carcinoma. Pelvic radiation therapy provides only short-term palliation, and future efforts should be directed to the use of effective adjuvant therapy for patients with rectal carcinoma who are at high risk of local recurrence.

Issues in the implementation of cancer staging in Canada.

All sectors of the cancer control community in Canada agree that cancer staging is useful, and that stage should be assigned to every new case. At present, however, staging is not always recorded in the patient's records and treatment patterns and outcomes are rarely reported in terms of stage. This paper discusses what needs to be done to promote the use of staging in Canada. It is concluded that multifaceted programs of interventional continuing education (CE), tailored to meet the needs of the particular institution, offer the best prospect of success but the necessary organizational structure and information systems have to be put into place in advance. Implementation programs should be based on a thorough evaluation of the particular needs of the institution or community, and should be evaluated carefully in a few institutions before an attempt is made to disseminate them more widely. We recommend a phased approach to implementation which will first target institutions that already have the necessary infrastructure, i.e., provincial cancer centres. Demonstration of the feasibility and value of staging in that setting is seen as a means of promoting the adoption of staging in other institutions.

Improvement in total positioning error for lateral prostatic fields using a soft immobilization device.

PURPOSE: To prospectively measure the total positioning error present in lateral pelvic fields of patients undergoing prostatic irradiation, and to evaluate the effect of a rigid table insert and soft immobilization on the magnitude of the measured error. MATERIALS AND METHODS: Sixty-one consecutive patients receiving radical prostatic irradiation with a four field technique underwent a total of 234 lateral portal films during the first, third, fifth and seventh week of treatment. The position of the isocentre was compared to the isocentre on the corresponding simulator films and the magnitude and direction of deviations recorded. The patients were divided in to three cohorts of 15 patients, 15 patients and 31 patients. The first cohort was treated on a standard treatment couch, the second cohort treated with the table top stiffened using a 1 cm polycarbonate insert, and the third cohort treated with a soft immobilization device supporting the lower legs, and the polycarbonate insert. RESULTS: There was no difference in the mean deviation of the vector of the isocentre displacement in the y and z directions identified at any of the four times when measurements were taken during therapy between the cohorts treated with or without the polycarbonate insert, but without immobilization. The overall mean deviation for these first two cohorts of patients was 3.9 mm. The positioning of patients treated with immobilization was compared to those treated without, and the immobilized patients had a significantly improved overall mean deviation of 2.6 mm (P = 0.002). This was a result of improvement in both the random and systematic components of the total error. In addition, the proportion of errors greater than 5 mm was reduced from 17% of set-ups to 8% of set-ups. The time during the course of treatment when the measurement was taken had no effect on positioning error for any of the treatment groups. CONCLUSION: Stiffening the treatment couch with a 1 cm thick polycarbonate insert had no effect on reducing total positioning error, but immobilization with an inexpensive and non-customized foam rubber leg support reduced total positioning error in a statistically significant way.