Objective
To explore oncologists, social workers, and nurses' perceptions about the causes of their cancer patient's mental health distress.
Methods
The grounded theory (GT) method of data collection ...and analysis was used. Sixty‐one oncology health care professionals were interviewed about what they perceived to be the causes of mental health distress in their patients. Analysis involved line‐by‐line coding and was inductive, with codes and categories emerging from participants' narratives.
Results
Oncology health care professionals were sensitive in their perceptions of their patients' distress. The findings were organized into three categories, namely, disease‐related factors, social factors, and existential factors. Disease‐related themes included side effects of the disease and treatment, loss of bodily functions, and body image concerns as causing patient's mental health distress. Social‐related themes included socio‐economic stress, loneliness/lack of social support, and family‐related distress. Existential themes included dependence/fear of being a burden, death anxiety, and grief and loss.
Conclusions
Oncology health care professionals were able to name a wide range of causes of mental health distress in their patients. These findings highlight the need to have explicit conversations with patients about their mental status and to explore their understanding of their suffering. A patient‐centered approach that values the patient's conceptualization of their problem and their narrative to understanding their illness can improve the patient‐provider relationship and facilitate discussions about patient‐centered treatments.
Introduction
The best local management for breast cancer recurrence following conservative treatment for breast cancer (BC) continues to be an open question. In this study, we compared patients' ...outcome after salvage lumpectomy (SL) vs mastectomy for ipsilateral breast tumor recurrence (IBTR).
Materials and methods
Between 1987 and 2014 we identified 121 patients with pT0‐2, N0‐3, M0 BC who had BCT as their primary treatment, and subsequently had IBTR (unifocal). 47 patients underwent SL and 74 salvage mastectomy (SM) as the local treatment for their 1st recurrence.
Results
Median follow‐up was 14 years (1‐30) from first BC diagnosis. For the SL and SM cohorts, 8 and 10 patients (17%, 13.5%, P = 0.22), respectively, developed subsequent local recurrence as a 3rd event. Although in MVA, woman who underwent SL had higher chances of having a 2nd recurrence (3rd event), P = 0.020, at a median follow‐up of 14 years, 95.8% of SL patients are alive, NED, 85% are mastectomy free. 87% of patients who opted for SM are alive, NED. Having re‐irradiation following SL did not protect against 2nd breast cancer recurrence (3rd event, P = 0.42).
Conclusion
Salvage lumpectomy following IBTR, while associated with higher second LR rate than SM is not associated with inferior outcome. With survival >95% at 14 years in the SL cohort, salvage lumpectomy with or without re‐radiation, in a selected population (unifocal T), represents an acceptable treatment option for patients in order to delay time to mastectomy without reducing BC survival. Both options should be discussed prior to any surgical decision.
To assess the prevalence and dosimetric and clinical predictors of mandibular osteoradionecrosis (ORN) in patients with head and neck cancer who underwent a pretherapy dental evaluation and ...prophylactic treatment according to a uniform policy and were treated with intensity-modulated radiotherapy (IMRT).
Between 1996 and 2005, all patients with head-and-neck cancer treated with parotid gland-sparing IMRT in prospective studies underwent a dental examination and prophylactic treatment according to a uniform policy that included extractions of high-risk, periodontally involved, and nonrestorable teeth in parts of the mandible expected to receive high radiation doses, fluoride supplements, and the placement of guards aiming to reduce electron backscatter off metal teeth restorations. The IMRT plans included dose constraints for the maximal mandibular doses and reduced mean parotid gland and noninvolved oral cavity doses. A retrospective analysis of Grade 2 or worse (clinical) ORN was performed.
A total of 176 patients had a minimal follow-up of 6 months. Of these, 31 (17%) had undergone teeth extractions before RT and 13 (7%) after RT. Of the 176 patients, 75% and 50% had received >or=65 Gy and >or=70 Gy to >or=1% of the mandibular volume, respectively. Falloff across the mandible characterized the dose distributions: the average gradient (in the axial plane containing the maximal mandibular dose) was 11 Gy (range, 1-27 Gy; median, 8 Gy). At a median follow-up of 34 months, no cases of ORN had developed (95% confidence interval, 0-2%).
The use of a strict prophylactic dental care policy and IMRT resulted in no case of clinical ORN. In addition to the dosimetric advantages offered by IMRT, meticulous dental prophylactic care is likely an essential factor in reducing ORN risk.
To report interim cosmetic results and toxicity from a prospective study evaluating accelerated partial-breast irradiation (APBI) administered using a highly conformal external beam approach.
We ...enrolled breast cancer patients in an institutional review board-approved prospective study of APBI using beamlet intensity-modulated radiotherapy (IMRT) at deep-inspiration breath-hold. Patients received 38.5 Gy in 3.85 Gy fractions twice daily. Dosimetric parameters in patients who maintained acceptable cosmesis were compared with those in patients developing unacceptable cosmesis in follow-up, using t-tests.
Thirty-four patients were enrolled; 2 were excluded from analysis because of fair baseline cosmesis. With a median follow-up of 2.5 years, new unacceptable cosmesis developed in 7 patients, leading to early study closure. We compared patients with new unacceptable cosmesis with those with consistently acceptable cosmesis. Retrospective analysis demonstrated that all but one plan adhered to the dosimetric requirements of the national APBI trial. The mean proportion of a whole-breast reference volume receiving 19.25 Gy (V50) was lower in patients with acceptable cosmesis than in those with unacceptable cosmesis (34.6% vs. 46.1%; p = 0.02). The mean percentage of this reference volume receiving 38.5 Gy (V100) was also lower in patients with acceptable cosmesis (15.5% vs. 23.0%; p = 0.02).
The hypofractionated schedule and parameters commonly used for external beam APBI and prescribed by the ongoing national trial may be suboptimal, at least when highly conformal techniques such as IMRT with management of breathing motion are used. The V50 and V100 of the breast reference volume seem correlated with cosmetic outcome, and stricter limits may be appropriate in this setting.
To determine the effect of continuous positive airway pressure (CPAP) on tumor motion, lung volume, and dose to critical organs in patients receiving stereotactic body radiation therapy (SBRT) for ...lung tumors.
After institutional review board approval in December 2013, patients with primary or secondary lung tumors referred for SBRT underwent 4-dimensional computed tomographic simulation twice: with free breathing and with CPAP. Tumor excursion was calculated by subtracting the vector of the greatest dimension of the gross tumor volume (GTV) from the internal target volume (ITV). Volumetric and dosimetric determinations were compared with the Wilcoxon signed-rank test. CPAP was used during treatment if judged beneficial.
CPAP was tolerated well in 10 of the 11 patients enrolled. Ten patients with 18 lesions were evaluated. The use of CPAP decreased tumor excursion by 0.5 ± 0.8 cm, 0.4 ± 0.7 cm, and 0.6 ± 0.8 cm in the superior-inferior, right-left, and anterior-posterior planes, respectively (P ≤ .02). Relative to free breathing, the mean ITV reduction was 27% (95% confidence interval CI 16%-39%, P<.001). CPAP significantly augmented lung volume, with a mean absolute increase of 915 ± 432 cm(3) and a relative increase of 32% (95% CI 21%-42%, P=.003), contributing to a 22% relative reduction (95% CI 13%-32%, P=.001) in mean lung dose. The use of CPAP was also associated with a relative reduction in mean heart dose by 29% (95% CI 23%-36%, P=.001).
In this pilot study, CPAP significantly reduced lung tumor motion compared with free breathing. The smaller ITV, the planning target volume (PTV), and the increase in total lung volume associated with CPAP contributed to a reduction in lung and heart dose. CPAP was well tolerated, reproducible, and simple to implement in the treatment room and should be evaluated further as a novel strategy for motion management in radiation therapy.
Background
A wide range of surgical techniques has been described for breast conservation treatment (Oncoplasty) based on breast size and shape, as well as tumor size and location. However, there is ...a lack of standardization regarding the indications for oncoplastic reconstruction. This study aims to identify the presurgical parameters associated with poor cosmetic outcomes post-breast conserving treatment. We hope this preoperative model can assist in evaluating whether there is a need for oncoplastic intervention.
Methods
The study group involved 136-adult females (age 35–77) who previously undergone breast conserving surgery and radiation, without oncoplastic intervention between 2007 and 2017. Patient demographics, medical and physical parameters were collected, and each patient filled Breast-Q
TM
-questionnaire and six angles’ photographs were taken. Patients’ photographs were evaluated by 15 board-certified plastic surgeons. Both univariate and multivariate logistic regression analysis was performed to identify potential confounders for poor outcome in each of the experts' and patients’ average-grades.
Results
Our analysis identified several variables correlated with poor surgical outcome: high BMI, high chest-wall-circumference, high breast-width and larger volume-removed. The general-aesthetic-result as evaluated by our experts was favorably influenced by an upper lateral quadrant tumor while the breast shape was negatively influenced by a lower medial quadrant tumor. Interestingly, no correlation was found between the patients' and panel's evaluations, nor did we find any clinically significant parameter related to the patients' reported well-being.
Conclusion
Patients with high BMI, high chest-wall-circumference, large breast-width and larger inferomedial tumors could benefit from early plastic surgery evaluation and intervention. Patient’s psychosocial well-being as well as sexual well-being are independent from positive surgical outcome evaluated by plastic surgeons.
Level of Evidence III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors
www.springer.com/00266
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Radiation-induced dermatitis is commonly seen during radiotherapy for breast cancer. Melatonin-based creams have shown a protective effect against ultraviolet-induced erythema and a radioprotective ...effect in rats.
To evaluate the efficacy of melatonin-containing cream in minimizing acute radiation dermatitis.
In this phase II, prospective, randomized, placebo-controlled double-blind study, patients who underwent breast-conserving surgery for stage 0-2 breast cancer were randomly allocated to melatonin emulsion (26 women) or placebo (21 women) for twice daily use during radiation treatment and 2 weeks following the end of radiotherapy. All women received 50 Gy whole breast radiation therapy with 2 Gy/fx using computed tomography-based 3D planning. Patients were examined and completed a detailed questionnaire weekly and 2 weeks following the end of treatment.
The occurrence of grade 1/2 acute radiation dermatitis was significantly lower (59% vs. 90%, P = 0.038) in the melatonin group. Women older than 50 had significantly less dermatitis than younger patients (56% vs. 100%, P = 0.021). The maximal radiation dermatitis in the study group was grade 2 in 15% of the treated patients.
Patients treated with melatonin-containing emulsion experienced significantly reduced radiation dermatitis compared to patients receiving placebo.
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