Moreover, in 1, of 2, patients of START-A and in of 2, patients of START-B, change in breast appearance was assessed by photographs taken at baseline, and then at 2 and 5 years with scores on 3-point graded scales. The physician assessments of normal tissue effects in START-A and B were scored on a 4-point scale none, a little, quite a bit, or very much. The same authors reported variations between centers in the practice used to complete the yearly reports forms, which could equally have led to underreporting of physician assessment of normal tissue effects. We can hypothesize that the palpation of the irradiated breast is more sensitive than photographic evaluation in detecting a mild degree of fibrosis.
Another reason for the different outcomes from our study as compared to the results of the randomized trials could be the fractionation used in our CG 1. This reduced dose per fraction could have impacted on the incidence of late toxicity in the CG. In fact, in the CG the boost was delivered with a direct electron beam, while in the MARA-1 trial it was with tangential photon beams. The latter irradiation modality could have probably caused delivery of boost dose to a larger volume. Finally, the finding of a higher rate of fibrosis in MARA-1 patients could be associated to the concomitant boost while CG patients had a sequential boost.
It is therefore difficult to weigh the boost timing as the reason for the recorded differences in terms of late toxicity. Table 3 shows a clear imbalance in terms of adjuvant pharmacological treatments. This figure may have played a role in the different late toxicity rates recorded in the two groups. However, it should be emphasized that the significant impact of RT was confirmed on multivariate analysis, in which both chemotherapy and hormone therapy were included.
Despite the higher rate of late subcutaneous toxicity in the MARA-1 group, the significant differences were limited only to the lower grades G1—G2 , whereas the absence of G3—G4 could be attributed to the IMRT technique. In fact, several studies have confirmed the role of IMRT in BC in terms of improvement of dosimetric parameters, higher homogeneity in dose distribution, and reduced severity of acute toxicity. In contrast, the year results of the Canadian randomized trial comparing IMRT with traditional RT did not show significantly different results in terms of late toxicity.
Our study also showed a significant difference in terms of 5-year locoregional control However, this result should be considered with caution considering the different inclusion criteria between the two groups. In fact, Table 2 shows a clear imbalance of prognostic factors in favor of MARA-1 group in terms of tumor grading and nodal stage.
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For these reasons, we did not compare the differences in terms of disease-free and overall survival. Assessing late toxicity by clinical examination, a higher incidence of subcutaneous side effects was recorded in patients undergoing AHF. Therefore, the results of our study are not enough to question the safety of hypofractionated regimens in this setting, which have been tested in large randomized controlled trials and have become the clinical standard in many centers.
However, we believe that in patients with multiple risk factors for late toxicity larger PTV volume, diabetes, tobacco smoking , caution should be taken during and after treatment also considering the demonstrated correlation between acute and late effects. The results from some trials 20 , 21 that completed enrollment some years ago and pending publication could clarify some unanswered questions regarding this issue.
National Center for Biotechnology Information , U. Breast Cancer Dove Med Press. Published online Oct 3.
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Abstract Aim To compare late toxicity after postoperative hypofractionated radiotherapy RT and standard fractionated RT in patients with early-stage breast carcinoma. Results Median follow-up was 52 months range: 3— months.
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Conclusion In this retrospective analysis, postoperative accelerated-hypofractionated RT for early-stage-breast carcinoma was associated with higher incidence of subcutaneous side effects. Keywords: breast cancer, radiotherapy, hypofractionation, retrospective study. Endpoints The primary endpoint was to evaluate late cutaneous and subcutaneous toxicity. Eligibility Patients at low risk of recurrence were eligible for the study. Treatment planning All patients had computed tomography scans for treatment planning.
Open in a separate window. Figure 1. Example of the used IMRT technique forward-planned. Follow-up All patients underwent clinical examinations every 6 months and bilateral mammography every 12 months. Ethical issues All patients signed a written informed consent to treatment. Table 3 Treatment characteristics.
Figure 2. Actuarial grade 1 late subcutaneous toxicity-free survival vs treatment technique. Figure 3. Actuarial grade 2 late subcutaneous toxicity-free survival vs treatment technique.
Table 4 Univariate analysis of late skin toxicity. Table 5 HRs of G1 and G2 late skin toxicity estimates from Cox proportional-hazards regression models. Table 6 Univariate analysis of late subcutaneous toxicity. Table 7 HRs of G1 and G2 late subcutaneous toxicity estimates from Cox proportional-hazards regression models. Discussion We started this trial was in to evaluate late toxicity using an AHF regimen prior to the publication of several randomized studies. Footnotes Disclosure The authors report no conflicts of interest in this work.
References 1. Poortmans P. Evidence-based radiation oncology. Breast cancer. Radio-ther Oncol. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and year survival: an overview of the randomized trials. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer.
N Engl J Med. Radiother Oncol. The delivery of intensity modulated radiotherapy to the breast using multiple static fields. Fletcher GH. Hypofractionation: lessons from complications. Effect of radiotherapy fraction size on tumour control in patients with early-stage breast cancer after local tumour excision: long-term results of a randomised trial.
Lancet Oncol. The UK Standardisation of Breast Radiotherapy START trials of radiotherapy hypofractionation for treatment of early breast cancer: year follow-up results of two randomised controlled trials. Long-term results of hypofractionated radiation therapy for breast cancer. Differences in the acute toxic effects of breast radiotherapy by fractionation schedule: comparative analysis of physician-assessed and patient-reported outcomes in a large multicenter cohort. JAMA Oncol, published online. Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long-term results of a randomised trial.
Intensity modulated radiation therapy for breast cancer: current perspectives.
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Breast Cancer. Forward planned intensity modulated radiotherapy IMRT for whole breast postoperative radiotherapy. Is it useful? J Appl Clin Med Phys. Intensity-modulated radiotherapy results in significant decrease in clinical toxicities compared with conventional wedge-based breast radiotherapy. Long-term outcomes of IMRT for breast cancer: a single-institution cohort analysis.
Our support includes providing much-needed supplies and equipment, capacity building for staff and holding free annual medical camps open to the Maasai population in the area. The volunteer doctors came from our partner Oasis Health, Kenya-wide private health facility, and were flown to the Mara courtesy of Safarilink who once again supported our efforts with provision of free or reduced rate flights. A total of patients, of whom were women or girls, were given free consultation, treatment and medication including but not limited to counselling on family planning, how to protect themselves from common ailments and lifestyle illnesses, voluntary counselling and testing for HIV and diabetes, and screening for prostate cancer.
Those who had wounds, skin, chest and ear infections, stomach ulcers, arthritis, cold and coughs also received free consultations and treatment. In Loisaba Conservancy, the Community Liaison Officer has been visiting Ewaso Dispensary every Monday with the Clinical Heath Officer who attend to patients, as well as restocking the dispensary with medication provided by the government from Doldol.
Continued support to the 15 Community Health Workers at Ewaso with funding stipends and regular training. Ewaso dispensary Community Health Worker refresher training took place from 9th — 13th November The objectives of the refresher training was to:. Anti-FGM training was also carried out from the 8th — 11th December , with an Alternate Right of Passage Ceremony conducted on the 11th where 67 girls graduated.
The training included parents, youths and local leaders, and 22 boys attended the Ceremony in support.
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Through The Nature Conservancy, Loisaba has also been supporting Community Health Africa Trust, which conducts monthly outreach services to our neighbouring community conservancies. The Awards, now in their 15th year, took place on April at a special ceremony during the WTTC Global Summit in Seville, Spain, to celebrate inspirational, world-changing tourism initiatives from around the globe. Shanga is a social enterprise based in Arusha that trains and employs people with disabilities to produce high quality handmade craft items - glass blowing, beading and other activities.