A quality improvement programme in radiotherapy using workflow audits.

BACKGROUND: Evaluation of the quality of healthcare depends on measures of structures, processes and outcomes. Progress in recording data allows for better measures of processes, such as the completeness of clinical data, the performance of professional tasks and the use of checklists. OBJECTIVES: To report the results of a radiotherapy (RT) workflow audit and a subsequent online survey of user experience. METHODS: The RT workflow audit was developed in 2016 and has been undertaken twice a year at 28 facilities or units, with a total of 32 linear accelerators. Electronic patient folders were reviewed to assess the documentation of 90 task items, of which 64 were scored. The auditor came from another facility. The online survey took place in July 2020. It contained questions on the audit's process, professional value and future use. Invitations were sent by email to the 151 radiotherapist staff at the 28 units where the audit had been implemented. Responses were anonymous. RESULTS: For the RT workflow audit, scores improved from 60% in some units in 2016 to >90% in all units for at least 2 years since 2018. The number of responders to the online survey was 58, giving a responder rate of 38%. The margin of error of the results was 10%. The audit's task items were considered appropriate by 77% of responders, and feedback was reported by 78% of them. The audit was considered very or extremely valuable to their unit's service delivery by 58% of responders. Changes in the unit as a result of the audit were reported by 77% of responders. The audit was very useful or extremely useful to 75% of responders in maintaining personal professional standards. The proportion of responders who were very or extremely supportive of continuing with the audit was 77%. The comments in the online survey will be helpful for ongoing review of the RT workflow audit. CONCLUSIONS: The RT workflow audit extends the scope of accreditation audits by including measures of processes. Users of the audit evaluate its processes favourably and report that it has value both in their unit's clinical service and for their personal professional standards. The audit is effective in developing quality improvement programmes.

How to publish your work in a peer-reviewed journal: A short guide.

The basis of a manuscript is the research question, which is reported within a standard publication structure. The 'Background' section clarifies the question. The 'Methods' section describes what was done in the study. The 'Results' section describes the data observed and the analysis of these data. The 'Discussion' section describes how findings of the study relate to current knowledge and the practical implications of the results, and suggests future studies. This structure differs from that of a thesis, the aims of which are broader than reporting on a specific research question.

10-year update on chemotherapy for non-small cell lung cancer.

BACKGROUND: A 1995 meta analysis of chemotherapy in patients with advanced non-small cell carcinoma indicated clinical benefit from cisplatin based chemotherapy. Subsequent studies have aimed to increase the efficacy or decrease the toxicity of chemotherapy. PATIENT AND METHODS: Illustrative studies and meta analyses of different aspects of chemotherapy which have taken place over the last decade, are reviewed. RESULTS: The use of novel (third generation) chemotherapy agents has resulted in a further increase in patient survival. Gemcitabine was shown to be associated with an increase in progression free survival when compared to other third generation agents as well as a strong tendency to increased overall survival. An increase in survival was also shown with doublet chemotherapy regimes as compared to the use of single agents only. The use of triplet agent chemotherapy results in no further increased survival, but increased toxicity. Cisplatin is associated with increased survival over carboplatin based chemotherapy regimens when third generation agents are used, but increased nausea and vomiting. Non-platin third generation combinations give equivalent survival to platin-based regimens. CONCLUSIONS: First line chemotherapy given to patients with advanced NSCLC should be two-drug combination regimen. Non-platin containing regimens may be used as an alternative to platinum based regimens in the first line.

Cost considerations in determining the affordability of adjuvant trastuzumab in breast cancer.

The drug cost of adjuvant trastuzumab to benefit one patient with localised human epidermal growth factor receptor 2 (HER2)-positive breast cancer depends on the baseline survival rate (BLSR) of the prognostic group of the patient. This varies from ZAR13 752 900 (BLSR 90%) to ZAR4 006 100 (BLSR 60%). All treated patients are exposed to potential toxicity. The value and affordability of treatments need to be considered, as there are finite resources available in our healthcare system. All patients must have access to cost-effective treatments. However, patient selection for expensive treatments is important, as expenditure on patients where the gains are relatively small will result in resources not being available for other patients. The state, healthcare institutions and the pharmaceutical industry need to work together to optimise the benefits of treatment to patients.

Weekly gemcitabine with monthly cisplatin: effective chemotherapy for advanced non-small-cell lung cancer.

PURPOSE: The aim of this study was to examine the efficacy of a regimen of initial gemcitabine followed by cisplatin in patients with advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Fifty-three patients (36 men and 17 women; age range, 35 to 74 years) were enrolled. Patients had bidimensionally measurable disease. Gemcitabine (phase-specific agent) was administered on days 1, 8, and 15 at a dose of 1,000 mg/m2. Cisplatin (cycle-specific agent) was administered on day 15 (100 mg/m2). Chemotherapy was administered in 28-day cycles. RESULTS: Of 53 patients enrolled, 50 were assessable for response. The overall response rate was 52%. There were two complete responses (4%) and 24 partial responses (48%). The median survival duration was 13 months and the 1-year survival rate was 61%. The regimen was generally well tolerated. World Health Organization (WHO) grade 3 and 4 neutropenia occurred in 38.8% and 19.2% of patients, respectively. Grade 3 and 4 thrombocytopenia occurred in 13.3% and 7.7% of patients, respectively. Most patients experienced mild nausea and vomiting. Few patients had hair loss and oral toxicity was mild. Relatively few patients required dose modifications for any of the three weekly doses of chemotherapy. For the first two cycles of chemotherapy, the dose-intensity per infusion was 947 mg/m2 for gemcitabine and 85 mg/m2 for cisplatin. CONCLUSION: This regimen of gemcitabine and cisplatin was effective, with high response and survival rates and few dosage modifications during its administration. Prospective randomized studies with other cisplatin-based combination chemotherapy regimens are indicated.

Efficacy and safety profile of gemcitabine in non-small-cell lung cancer: a phase II study.

PURPOSE: The aim of this study was to evaluate the efficacy and toxicity of gemcitabine at higher doses than had been used previously in patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Eighty-four patients (65 men, 19 women; age range, 35 to 75 years; mean age, 59 years) with locally advanced or metastatic pathologically documented NSCLC were enrolled. Patients had bidimensionally measurable disease, as defined by computed tomographic (CT) scan or chest x-ray. A total of 28.6% had previously been surgically treated, while 9.5% had received radiotherapy. Fifty-three patients commenced at a dose of 1,000 mg/m2, and 31 at a dose of 1,250 mg/m2. Patients were to receive two dose escalations of 25%, provided that overall toxicity was no worse than World Health Organization (WHO) grade 1 or WHO grade 0 for platelets. Responding patients were reviewed and validated by a blinded oncology review board (ORB) of experts not involved with the study. Of the original 84 patients enrolled, 76 were assessable. RESULTS: The overall response rate was 20% (95% confidence interval [CI], 11.6% to 30.8%). There were two complete responses (3%) and 13 partial responses (17%). Hematologic toxicity was negligible. WHO grade 3 WBC toxicity occurred in 0.9% of doses and WHO grade 4 in 0.1%. WHO grade 3 and 4 thrombocytopenia occurred in 0.1% and 0.1% of all doses, respectively. Nonhematologic toxicity was minor and easily controlled. Common side effects included peripheral edema, asthenia, and transient malaise. CONCLUSION: The single-agent efficacy of gemcitabine is equivalent to other agents commonly used to treat NSCLC. Gemcitabine has an unusually mild side effect profile for such an active agent. The nausea and vomiting experienced with gemcitabine are mild and generally well controlled with standard antiemetics; 5-HT3 receptor antagonists are typically not required. The use of gemcitabine does not cause significant alopecia, and hematologic toxicity is modest and unlikely to require hospitalization. Gemcitabine may have a role as monotherapy in patients with inoperable NSCLC.

A prospective randomised study in limited disease small cell carcinoma--doxorubicin and vincristine plus either cyclophosphamide or etoposide.

A prospective randomised study was undertaken in patients with limited disease small cell carcinoma of the lung (SCCL), which compared doxorubicin, 50 mg/m2, and vincristine, 2 mg i.v. (intravenously) on day 1, with either cyclophosphamide, 800 mg/m2 on day 1 (CAV) or etoposide, 60 mg/m2 i.v. on day 1 and 120 mg/m2 orally on days 2-5 (AVE). Responding patients were to receive six cycles of chemotherapy at 3 weekly intervals followed after 2 weeks by mediastinal irradiation. Response rates and toxicity were evaluated by the chi square or Fisher's exact test and survival by the logrank test. 81 patients were entered into the study, 38 of whom received CAV and 43 received AVE. In the patients treated with CAV and AVE, the overall response rate was 61% (confidence limit (CL), 45-71%) and 74% (CL, 61-87%) respectively, the complete response rate was 32% (CL, 17-47%) and 51% (CL, 36-66%), respectively (P = 0.07) and the median survival was 12 and 14.5 months, respectively (P = 0.15). In the patients treated with CAV and AVE, the incidence of grade 3 and 4 leucopenia was 29% (CL, 15-43%) and 9% (CL, 0-18%), respectively (P = 0.025). No patient developed doxorubicin cardiomyopathy. These findings support the role of etoposide in first line chemotherapy for SCCL. AVE is among the more efficacious regimens for SCCL and also has a relatively low toxicity.

Prospective study of etoposide scheduling in combination chemotherapy for limited disease small cell lung carcinoma.

78 patients with limited disease small cell lung carcinoma (SCLC) were entered into a prospective randomised study of two combination regimens (AVE-5 and AVE-1) that differed only in the scheduling of etoposide. Patients in the AVE-5 arm received etoposide intravenously 60 mg/m2 on day 1 and orally 120 mg/m2 on days 2-5 of each cycle. Patients in the AVE-1 arm received etoposide 300 mg/m2 intravenously on day 1. Patients in both arms received doxorubicin and vincristine on day 1 of each cycle. The complete (53% vs. 26%) and the overall (75% vs. 52%) response rates were significantly higher in the AVE-5 arm. Median survival was also increased from 11 to 14 months in this arm. Toxicity was low and similar in both groups. The daily administration of etoposide in low toxicity combination therapy for SCLC is important. This can be conveniently achieved by using etoposide orally.

Weekly gemcitabine and monthly cisplatin for advanced non-small cell lung carcinoma.

Most chemotherapy for non-small cell lung cancer (NSCLC) currently includes combination chemotherapy based on cisplatin. Gemcitabine is a nucleoside analog with demonstrated activity against NSCLC, yet it has low toxicity. This phase II study was designed to examine the efficacy of a combination chemotherapy regimen consisting of gemcitabine followed by cisplatin. The patient population comprised 53 patients with pathologically confirmed locally advanced or metastatic NSCLC. Gemcitabine 1,000 mg/m2 was administered on days 1, 8, and 15 and cisplatin 100 mg/m2 was given on day 15. Chemotherapy was administered every 28 days. Of the 50 patients evaluable for response, there were two complete responses (4%) and 24 partial responses (48%). The median duration of response was 8.5 months, median survival was 13 months, and the 1-year survival rate was 61%. The regimen was generally well tolerated. World Health Organization grade 3 leukopenia occurred in 28.8% of patients, while grade 3 and 4 neutropenia occurred in 38.8% and 19.2% of patients, respectively. Grade 3 and 4 thrombocytopenia was seen in 13.3% and 7.7% of patients, and grade 3 and 4 anemia occurred in 11.5% and 1.9% of patients, respectively. Alopecia and oral toxicity was mild, although most patients experienced mild nausea and vomiting. Relatively few patients required dose modifications for any of the three weekly doses of chemotherapy. We conclude that the combination of gemcitabine and cisplatin is an effective regimen for NSCLC, resulting in high response and survival rates. Additional prospective randomized studies with other cisplatin-based combination chemotherapy regimens are warranted.

Gemcitabine in the treatment of elderly patients with advanced non-small cell lung cancer.

Gemcitabine is active against non-small cell lung cancer (NSCLC), with single-agent response rates of 20% or more in previously untreated patients. Its mild toxicity profile suggests that it should be well tolerated by older patients. To assess the impact of age on the efficacy and tolerance of gemcitabine, the results of four phase II trials of single-agent gemcitabine for the treatment of NSCLC were analyzed retrospectively. Starting doses for gemcitabine ranged from 800 to 1,250 mg/m2/wk, and in all studies gemcitabine was administered weekly for 3 weeks followed by a 1-week rest period. Response rates, toxicity, and dose delivery were compared for two age groups, less than 65 years (255 patients) or > or = 65 years (105 patients). The pretreatment characteristics for both patient groups were well balanced. Overall response rates were 16% and 24% for the younger and older patients, respectively (P = .072). Median survival and 1-year survival rates were 8.1 months and 27% and 9.1 months and 36%, respectively, for patients aged less than 65 years and > or = 65 years. Hematologic and nonhematologic toxicities were similar for both age groups. The number of cycles associated with dose reductions or dose omissions and the mean number of treatment cycles administered were also similar. In summary, gemcitabine is active and well tolerated in elderly patients with NSCLC, and is a promising new alternative for the treatment of this patient population.

Combined cisplatin and gemcitabine for non-small cell lung cancer: influence of scheduling on toxicity and drug delivery.

The scheduling of cytotoxic chemotherapy has important bearing on the toxicity and ability to deliver chemotherapy at or close to full dose. We report new data on the influence of different schedules of cisplatin and gemcitabine on toxicity and drug delivery in phase II studies of non-small cell lung cancer. Patients in six phase II studies had standard entry criteria for advanced non-small cell lung cancer. Whereas gemcitabine was given on days 1, 8, and 15 of a 28-day cycle in all these studies, the scheduling of cisplatin varied and was given either on day 1, day 2, day 15 (in two studies), or days 1, 8, and 15 (in two studies). The protocol dose per infusion for gemcitabine was 1,000 mg/m2 (five studies) and 1,500 mg/m2 (one study); for cisplatin, it was 100 mg/m2 when given once per cycle and 30 mg/m2 when given on days 1, 8, and 15. Similar dose reduction schedules were implemented in the event of grade 3 or higher drug toxicity for all studies except for the day 1 cisplatin study, in which the dose was omitted for grade 2 thrombocytopenia. Nonhematologic toxicity was very low. Hematologic toxicity was moderate, and in patients who developed grade 3 or 4 toxicity, there was no hemorrhage from thrombocytopenia and neutropenic sepsis was rare. The incidence of grade 3 or 4 thrombocytopenia with the day 1, day 2, day 15 (two studies combined), and days 1, 8, and 15 (two studies combined) cisplatin regimens was 50%, 52%, 26%, and 38%. The incidence of grade 3 or 4 neutropenia with these four regimens was 51%, 37%, 56%, and 49%, respectively. Although the hematologic toxicity might appear relatively similar, it represents the toxicity at the administered rather than the intended (protocol) dose, because drug delivery was reduced or omitted in the event of grade 3 or 4 toxicity. Differences between the schedules are revealed by analysis of the actual dosages delivered. The median dosage of gemcitabine per scheduled infusion was statistically higher with the day 15 cisplatin regimens (combined) compared with any of the other regimens treating at 1,000 mg/m2 (P < .003, z-score). The dose with the day 1, day 2, day 15, and days 1, 8, and 15 cisplatin regimens was 664, 829, 889, and 774 mg/m2, respectively. Both the percentages of cycles in which gemcitabine infusions were given at full dose and in which there were no omissions of gemcitabine infusions (including infusions with dose reductions) were statistically higher in the day 15 cisplatin regimen than with any of the other regimens (P < .0001, chi-square test). The percentage of cycles containing full-dose gemcitabine with the day 1, day 2, day 15, and days 1, 8, and 15 cisplatin regimens was 24%, 44%, 75%, and 46%, respectively. The percentage of cycles in which there were no omissions of gemcitabine infusions for the four regimens above was 32%, 55%, 83%, and 72%, respectively. Apart from the once-weekly regimen (days 1, 8, and 15) in which the protocol gemcitabine dose was 1,250 mg/m2, the day 15 cisplatin schedule allowed for the highest median concentration of gemcitabine. More importantly, the day 15 cisplatin schedule provided the longest duration of gemcitabine exposure, which is particularly important for its activity as gemcitabine is a phase-specific agent. The day 15 cisplatin schedule is associated with the best dose intensity and the longest median duration of exposure to gemcitabine, and best meets the goal of administering both agents at full doses in combination.

Modeling tumor and treated lung volume influences in the irradiation of non-small-cell lung cancer patients.

PURPOSE: The proposal of a hypothetical model in patients treated by irradiation for non-small-cell lung cancer show the dependence of local tumor control and patient cure rates on the volume of tumor and irradiated lung tissue. RESULTS: The local tumor control rates from conventional doses of irradiation decreases and the metastases rate increases with the tumor volume. Dose escalation will increase the potential cure rates (product of the local control and the freedom from metastases rates). Any potential gain will, however, be modified by the effect of irradiation on normal lung. Studies indicate that this is dependent on the volume of lung irradiated above a threshold dose. CONCLUSION: A clinically significant and measurable increase in cure rates from dose escalation may be seen in smaller tumors. This is unlikely to occur in larger tumors, although dose escalation to a restricted volume combined with effective systemic chemotherapy is one of the options that may be explored. The relevance of modeling and future studies of tumor and normal tissue volume effects, will increase from the widespread usage of the dose-volume histogram.

The effect of irradiation on lung function and perfusion in patients with lung cancer.

PURPOSE: To prospectively study the changes in lung function in patients with lung carcinoma treated with relatively high doses of irradiation. METHODS AND MATERIALS: Lung function was assessed prior to and at 6 and 12 months following radiation therapy by a clinical dyspnea score, formal pulmonary function tests (lung volume spirometry and diffusion capacity) as well as an ipsilateral hemithorax lung perfusion scan. Changes in dyspnea score were evaluated by the chi-square and the Fishers exact test. Changes in formal lung function tests were compared with the t-test for dependent data and correlations with the t-test for independent data. Fifty-one patients were entered into the study. There were 42 evaluable patients at 6 months after irradiation and 22 evaluable patients at 12 months after irradiation. RESULTS: A worsening of dyspnea score from 1 to 2, which is clinically acceptable, occurred in 50% or more of patients. However, a dyspnea score of 3, which is a serious complication, developed in only 5% of patients. The diffusion capacity (DLCO) decreased by 14% at 6 months and 12% at 12 months) (p < 0.0001). The forced vital capacity and total lung capacity decreased between 6% and 8% at 6 months and 12 months, which was statistically significant. The forced expiratory volume in 1 s decreased between 2 and 3% at 6 month and 12 months, which was not statistically significant. The ipsilateral hemithorax perfusion decreased by 17 and 20% at 6 and 12 months (p < 0.0001). There was no correlation between the initial hemithorax perfusion, or its decrease at follow up and the decrease in DLCO. CONCLUSION: Lung irradiation results in some loss of lung function in patients with lung cancer with a projected survival of 6 months or more. The pretreatment DLCO assessment should be useful in predicting clinical tolerance to irradiation.

Radical irradiation of T2 grade III and T3 bladder cancer--tumor response and prognosis.

A retrospective review was undertaken of the records of 69 patients treated by radical irradiation between 1972 and 1977 for T2 Grade III and T3 bladder cancer. Twenty-six of the patients were treated to a tumor dose of 54 Gy in 2 Gy fractions using five daily fractions per week and 24 of the patients were treated to a tumor dose of 48.6 Gy in 3.47 Gy fractions given tri-weekly. The tumor response and its relationship to patient five year survival with bladder conservation was determined. Tumor response was assessed on the basis of the documented gross cystoscopic findings between 6 and 12 months after radiotherapy. This could be done in 63 of the 69 patients. The complete response rate was 43%. The five year survival rate with bladder conservation for all the patients in the study was 24%; for those with a complete response at cystoscopy, 54%; and for those failing to achieve a complete response, 5.8%. A statistically significant improvement in survival with bladder conservation for patients with complete response was found in both subgroups of uniformly treated patients. A 17% incidence of severe late gastrointestinal tract complications was noted in the subgroup of patients treated with large radiation fractions. These results confirm the prognostic value of the tumor response at cystoscopy after radical radiotherapy, expand the total dose or TDF range over which it has been observed and document its occurrence with an unconventional radiation fractionation schedule.

Radical radiation and oral and intra-vesical misonidazole for bladder cancer.

Patients with T2 grade 3 and T3 bladder cancer were entered into studies to evaluate the efficacy of 40 Gy in 2 Gy fractions (5/week) to the whole pelvis followed by 12 Gy in 6 Gy fractions (1/week) to a coned down volume plus oral and intravesical misonidazole (MISO). In a pilot study of 22 patients the complete response rate at cystoscopy at 6 months was 73% and the 5-year survival rate (life-table) with and without bladder preservation was 48% and 54% respectively. The 5-year bowel major complication rate (life-table method) was 8%. These results are statistically significantly improved over that seen in a series of historical controls. A prospective randomized trial has been completed comparing the above regimen with 40 Gy to the whole pelvis followed by 20 Gy to the coned down volume in 2 Gy fractions (5/week). Fifty-eight patients were entered and 53 are evaluable. The complete response rate at cystoscopy at 6 months is 69% (18/26) in the patients treated with MISO and 63% (17/27) in those treated without MISO. As this is an important prognostic indicator, it is unlikely that there will be an advantage in either group and this is supported by the initial follow-up data. The complete response rate at cystoscopy at 6 months is higher in both arms of this study than in the historical series.

Radical irradiation and misonidazole in the treatment of T2 grade III and T3 bladder cancer.

The results of 2 pilot studies using a new radiation fractionation schedule plus misonidazole (MISO) in the radical radiotherapy of T2 Grade III and T3 carcinoma of the bladder are presented. Forty Gy in 20 daily fractions of 2 Gy was administered to the whole pelvis over 4 weeks followed by 12 Gy in 2 weekly fractions of 6 Gy. These last 2 doses were given after MISO administration. In an initial pilot study (Pilot Study I) MISO was administered orally only. The first two patients received MISO at a dose of 4.5g/m2 orally with each radiation fraction, after which the dose was reduced to 3.0g/m2 because of drug toxicity. In the second pilot study (Pilot Study II) MISO was administered orally at a dose of 3.0g/m2 and intravesically at a dose of 1.0g to 22 patients. The complete response rate at cystoscopy at 6 months in the latter group of patients is 73%, which is significantly better than that of 43% obtained in a retrospective study of historical controls. There have been no late radiation complications in any of the patients nor any MISO toxicity apart from nausea in the patients receiving 3.0g/m2 orally with or without the intravesical MISO.

Radical irradiation and misonidazole for T2 grade III and T3 bladder cancer: 2 year follow-up.

Patients with T2 grade III and T3 bladder cancer were treated in a Phase II trial of radical irradiation plus Misonidazole (MISO). Forty Gy in 2 Gy fractions (5 per week) to the whole pelvis were followed by 12 Gy in 6 Gy fractions (1 per week) plus oral and intravesical MISO to a coned down volume. Twenty-two patients were treated and the results compared with historical controls. The cystoscopic complete tumor response between 6 and 12 months post therapy were 73 and 43%, respectively. The patient two year survival was 81 and 51%, respectively, and the patient 2 year survival with bladder preservation was 61 and 48%, respectively--4 patients in the MISO study having undergone salvage cystectomy. Complications that may be radiation related in the MISO study are wound sepsis after salvage cystectomy in 2 patients, rectal stenosis requiring colostomy 16 months after salvage cystectomy in 1 patient and the development of a contracted bladder in 1 patient with a history of prior extensive endoscopic therapy. No misonidazole neurotoxicity seen. These findings are being further evaluated in a prospective randomized trial.

Lung cancer in patients with borderline lung functions--zonal lung perfusion scans at presentation and lung function after high dose irradiation.

We prospectively studied patients with lung carcinoma and borderline lung functions (forced expired volume [FEV1] of less than 1500 ml or a dyspnoea score of 2 [7] at presentation), who were treated with high dose irradiation. Patients were divided into those with suprahilar and hilar tumours. Lung perfusion was assessed in upper, middle and lower zones for each lung at presentation. The ipsi-lateral upper and middle zone were regarded as at risk from irradiation in patients with suprahilar tumors and the whole ipsi-lateral lung in patients with hilar tumors. Lung function was measured at presentation (18 patients) at 4-6 month follow up (16 evaluable patients = group 1) and again at 10-12 month follow up (10 evaluable patients = group 2). A worsening of the dyspnoea score (3 in group 1 and 2 in group 2) occurred only in patients with a greater than 10% decrease in transfer factor irrespective of the change in FEV1. A statistically significant correlation was found between decreased transfer factor at follow up and the perfusion in the lung zones regarded as at risk from irradiation at presentation (Spearman's rank correlation). There was no correlation between perfusion and changes in the FEV1. Patients in whom lung perfusion was less than 35% in the zones at risk tended not to have decreased transfer factor at follow up. These findings indicate that worsening in the patients' dyspnoea score after irradiation is dependent on decreased transfer factor rather than FEV1 and that patients with borderline lung functions may be treated with irradiation if the perfusion in the zones at risk from radiation is less than 35%.