ATLANTA—Subcutaneous administration of the anti-CD 38 monoclonal antibody daratumumab could help more patients get this emerging therapy more easily for their advanced or recently-diagnosed multiple myeloma according to research reported from the Pavo study at the 2017 American Society of Hematology annual meeting.
Study author Ajai Chari MD, Associate Professor of Medicine and Director of Clinical Research in the Multiple Myeloma Program, at Mount Sinai Hospital in New York tells the Audio Journal of Oncology “These are really exciting results. This would be extremely practice changing. Daratumumab has moved from monotherapy in advanced disease to first relapse. And now—at this year’s ASH—we have newly diagnosed [myeloma]. That’s a lot of dara[tumumab] being used globally. And to be giving a more convenient, potentially safer, form of administration is really going to be very practice changing.”
READ MORE about the Pavo study in Oncology TimesAjai Chari MONO INTERVIEW for AJO Production MASTER
Childhood Obesity—Whose Business Is It?12 Jan 2018
SOURCE: Pediatric Physical Therapy journal
ARTICLE “Trends in Attitudes and Practice Patterns of Physical Therapists in Addressing Childhood Obesity in Schools”[url=http://journals.lww.com/pedpt/pages/d…]
PLYMOUTH, New Hampshire USA—School-based physical therapists are well positioned (among a range of health care professionals and educators) to deliver guidance and training to help children cope with or avoid obesity—according to original research findings published in Pediatric Physical Therapy journal (Pediatr Phys Ther 2017;00:1–9). Author Eydie Kendall PT, PhD, PCS Assistant Professor at Plymouth State University’s Doctor of Physical Therapy Program talks about findings from her investigation of attitudes to childhood obesity among physical therapists in American schools and describes the pivotal position they occupy for providing interventions to combat this looming health threat. Sanjay Kinra MBBS MD MRCP MSc PhD FFPH, Professor of Clinical Epidemiology at the London School of Hygiene & Tropical Medicine, and Consultant Paediatrician (Childhood Obesity) at University College London adds comments from the perspective of his global research in pediatric obesity. Dylan Thompson PhD, Chair of Human Physiology and Research Director at the Department for Health, University of Bath, England, discusses his research findings about the science connecting physical activity with weight control. SOURCE: Pediatric Physical Therapy Volume 30 Number 1 (January 1st, 2018) REFERENCE: Pediatr Phys Ther 2017;00:1–9 TITLE: “Trends in attitudes and practice patterns of physical therapists in addressing childhood obesity in schools” AUTHOR: Eydie Kendall, PT, PhD, PCS, Assistant Professor, Plymouth State University Doctor of Physical Therapy Program [url=http://journals.lww.com/pedpt/pages/d…] TRANSCRIPT: Not only are there more kids who are affected by obesity, but those who are: are more obese then we seen before—even more obese. And so when you have greater levels of obesity you have many more problems with orthopedic development cardiovascular issues—that now we are starting to see not only in adulthood but we’re seeing in childhood as well. So: One of the major findings of this study is that we are really not at a consensus! We can’t agree as to whether or not it’s our role to intervene with childhood obesity as far as physical therapy within the schools. In a nutshell: what was the attitude you found among physical therapists? One of the really interesting findings is that the younger therapists—those with less experienced—tend to embrace that role in intervention in the childhood obesity more so than those older therapists who have already had clinical experience working with kids. And so it—sort of—hints that there might be some changes coming down the pike with our profession. It takes a whole team to address the issue of childhood obesity. And physical therapy is uniquely positioned to play a role—especially for those kids who are profoundly affected by the problem. The question that I aimed to the answer was: What is physical therapy’s role—and specifically for school-district physical therapy? A child spends a good part of their day—five days a week—in schools. So it’s an opportunity to influence that lifestyle for that child. And so working on being healthy and being active is a very important piece. What did you find out in your survey? Did you find that physical therapists regard it as part of the job? I think we’re all over the place. But I also think it’s (kind of) changing. When we see these kids who are profoundly overweight they’re going to have developmental impact. So the skeletal systems are not going to form because of the forces put upon them. Physical therapy looks at pathology. And then pediatric physical therapy has to have a crystal ball and predict the future based on what you are seeing at the time. And so I think we have a huge role that we can play that goes along with our typical practice because we can see what’s going on bio-mechanically with these kids, and then try to project what problems they may have as adults. So: I think the take-home message to physical therapist is that: We pretty much need to decide for ourselves what our treatment philosophy is—and what our role is—in embracing this problem. I think: maybe our focus needs to be on working with those kids who really need more help then just signing up for soccer, not drinking as much soda, and staying away from the TV. There are kids who really are in trouble. And I think we are uniquely positioned to help those kids.
Uptake of the Congenital Muscular Torticollis Guidelines
Survey findings about the effectiveness of a recently-introduced clinical practice guideline for congenital muscular torticollis therapy are reported in Pediatric Physical Therapy journal by Sandra Kaplan PT DPT PhD, Director, Post Professional Education at the Stuart D. Cook MD Guild and the Department of Rehabilitation and Movement Science at Rutgers, The State University of New Jersey. (“Uptake of the Congenital Muscular Torticollis Clinical Practice Guideline Into Pediatric Practice”)
Pediatr Phys Ther 2017;00:1–7
Research Demonstrates Effectiveness of PT Guideline
A case series of two children with benign paroxysmal positional vertigo (BPPV) is reported in Pediatric Physical Therapy journal by Jennifer L. Fay, PT, DPT, NCS, Neurologic Clinical Specialist, Vestibular Rehabiliation at New York University’s Langone Medical Center in New York City, who demonstrates the successful implementation of the Dix-Hallpike test and therapeutic correction of the condition. (Pediatr Phys Ther 2016;00:1–6)
Prostate Genomics—Which Patients Will Die?20 Apr 2017
MILAN, Italy—Genomic profiling could help reduce the risk of over-treatment in primary prostate cancer (PC) by identifying patients and healthy individuals whose genes put them at greatest risk of developing dangerous disseminated disease said Norman J Maitland PhD, Professor of Molecular Biology and Director of the Cancer Research Unit at York University, UK. He was speaking at the 2016 European Multidisciplinary Meeting on Urological Cancers (EMUC).
He interpreted data from several recent studies—investigating the influence gene mutations had on prostate tumor development—that infer gene arrays could soon distinguish patients with dangerous tumors from those whose disease does not need aggressive management.
He discusses his findings n the Audio Journal of Oncology Interview with Peter Goodwin: “We don’t know which [patients] are going to die of prostate cancer and which ones can be left untreated for the rest of their lives,” he said. “Genetics is one tool to allow us to understand that.”Norman Maitland AJO PRODUCTION Master
MILAN, Italy—The first choice of therapy for patients with metastatic kidney cancer who have failed VEGF therapy has changed according to experts at the 2016 European Multidisciplinary Meeting on Urological Cancers (EMUC) who assessed phase 3 study data on two different agents—each of which showed clinically meaningful improvements to outcomes.
“There is a new treatment algorithm for individuals who have failed VEGF-targeted therapy,” said Thomas Powles, MBBS MRCP MD, Director of Barts Cancer Centre at St Bartholemews Hospital in London, UK.
“Both the ESMO and EAU guidelines are [now] supporting nivolumab and cabozantinib rather than—[as] previously—supporting axitinib and everolimus.”
He based his comments on observations from the METEOR and CheckMate 025 studies which found that therapy with cabozantinib or nivolumab improved overall survival compared to everolimus.
Peter Goodwin discusses the details of the METEOR findings with him.Thomas Powles 1 EMUC PRODUCTION Master
Karim Touijer, MD MPh, Sidney Kimmel Center for Prostate & Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York.
MILAN, Italy—Patients with node-positive prostate cancer being treated with prostatectomy could derive benefit from early multimodality therapy combining androgen deprivation therapy (ADT) with radiotherapy (RT)—on top of surgery—if they have pathological features indicating high risk, according to findings reported at the European Multidisciplinary Meeting on Urological Cancers (EMUC).
Combining ADT with RT soon after prostatectomy improved overall survival as much as 40 per cent in the highest-risk patients according to analysis of data from studies conducted at three institutions—Memorial Sloan-Kettering Cancer Center in New York, the Mayo Clinic in Rochester MN and San Raffaele Hospital in Milan.
“It is the patients who are supposed—technically—to have the worst mortality from the disease that have the best survival when they receive the treatment,” said co-investigator Karim Touijer MD MPh, Attending Physician at the Department of Urology in the Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan-Kettering Cancer Center in New York City.
He said that while the most common approach to node-positive disease after prostatectomy was observation—followed by treatment only if there was progression—his analysis suggested a potential net benefit from combining RT and ADT in patients who had additional risk factors on top of nodal spread.
He said studies were urgently needed to confirm any benefit since the natural history of patients with nodal disease after radical prostatectomy indicated that even—without further treatment—30 per cent of all patients were free from recurrence by 10 years. And this figure rose to 45 per cent among patients with only one or two nodes.
Pathological features can discriminate the 80 per cent of patients with nodal disease who had favorable characteristics and would be candidates for observation, he said. But it was important to identify those at the high risk because they could benefit from a multimodality approach, he said.
In his research from the three institutions patients with node-positive prostate cancer were divided into three groups after prostatectomy—those who had additional treatment with external beam RT, those who received the same RT combined with ADT, and patients assigned to no further treatment until relapse.
“We looked at a combined data set of nearly 1400 patients [who] received one of three strategies: Observed until they failed biochemically then treatment started, or: Automatically received hormonal therapy for life, or: Received the combination of hormonal and radiation therapy,” he said, adding that patients who received the combination of ADT and external beam RT started with the worst disease yet had the best overall survival.
Local Treatment Benefit
Touijer said they concluded there was great value in local control of the disease, despite the belief that if a patient had lymph-node metastases after radical prostatectomy the disease was already distant and systemic.
“What this data shows us is that maybe some patients are like that but not all of them, and not the majority, [and] that if we still focus—with all the treatments that we have available—to control the disease locally and regionally we can improve survival,” he said.
Not all Nodal Disease the Same
And analysis of the National Cancer Database (including 70 percent of all patients treated at US cancer centers) had given “external validation of these findings”.
“Close to 5 000 patients were treated by observation followed by treatment after failure, radiation alone, hormonal therapy alone, or a combination of hormonal and radiation therapy,” he said, noting that subcategories of patients with nodal disease clearly needed different treatment since there was a wide spectrum of risk and patients with the worst pathological features benefited the most from combining surgery, ADT and RT.
“We did statistical risk groups based on Gleason grade, clinical stage, invasion of the seminal vesicles, T4 disease, positive surgical margins—all the elements which have been shown to be predictive in most prostate cancers in many series. And the worse these features are the better the separation and the advantage in overall survival if we added radiation and hormone therapy,” he said.
The three-institutional data set revealed no difference in overall survival between patients who were observed and those treated with lifetime ADT.
“When we tried to look in detail at cancer-specific survival we saw that there was an advantage to androgen deprivation therapy. But when we looked at death from other causes—not cancer causes—we saw that there was [also] a detriment,” he said.
Node-positive patients assigned after prostatectomy to RT alone lived longer than patients allocated to ADT alone.
“The assumption is that thorough surgery followed by radiation therapy is controlling the source of the disease and seems to make a difference in terms of survival. [But] the combination of both [ADT and RT] seems to give the best result.”
But Touijer repeated that prospective clinical trials were needed to remove potentially confounding variables in these retrospective data, warning that these therapies could also have deleterious effects.
“One always has to balance the risk and benefit. But in terms of survival it looks like multimodality therapy has a clear advantage,” he said.
“A prudent way forward is for surgeons to reach out to radiation therapists and medical oncologists when they are dealing with patients [who] have lymph node metastases after radical prostatectomy and happen to have a Gleason 8, 9 or 10, pathological stage T3b or T4, positive surgical margins, and a higher nodal count and really carefully look at the value a multimodality approach for these patients—because it may alter their survival.”
Karim Touijer EMUC AJO PRODUCTION Master
MILAN, Italy—Genomic testing combined with clinical assessment could be the best way to identify patients with prostate cancer who can benefit from early radiotherapy after prostatectomy, according to a study in The Lancet Oncology reported at the European Multidisciplinary Meeting on Urological Cancers (EMUC).
“A certain sub-population of patients would benefit from having early postoperative radiotherapy, and the genomic test will hopefully help identify that subset,” said one of the investigators Jeffrey Karnes MD, a urologic oncologist at the Mayo Clinic in Rochester MN.
Under senior author Felix Feng MD, from the University of California in San Francisco, the study reported on the use of genomic classifiers to help therapy decision-making in patients being treated with prostatectomy.
Since around half of all patients do not have recurrences after radical prostatectomy Karnes said the study was needed to help identify those with aggressive prostate cancers who do—and who could therefore benefit from early postoperative radiotherapy.
“We identified four risk factors—stage T3b or 4, lymph-node invasion, Gleason score 8, 9 or 10 and high genomic risk. Patients benefited from adjuvant radiotherapy if they had at least two of those risk factors,” he said.
The study assessed the use of a combination of clinical factors and genomic classifiers in the Post-Operative Radiation Therapy Outcomes Score (PORTOS).
Patients with high PORTOS had marked reductions of metastasis over ten years from adding radiotherapy to their prostatectomy.
Among the 39 patients with high PORTOS (out of an overall cohort of 197) only five percent of the 20 men who had radiotherapy had metastases by ten years postoperatively compared with 63 percent of the 19 patients who did not have radiotherapy.
Not all patients
However, the benefit of radiotherapy was not seen in the 157 patients who had low PORTOS among whom the metastasis rate by ten years was nearly doubled in those who had radiotherapy—57 percent, as compared with 31 percent among patients having no adjuvant therapy.
The study concluded that treatment with postoperative radiotherapy should now be considered in patients with high PORTOS but that the use of PORTOS as a predictive tool still needed to be investigated further in additional independent cohorts.
Karim Touijer MD MPh, from the Sidney Kimmel Center for Prostate and Urologic Cancers, at the Memorial Sloan-Kettering Cancer Center in New York, said that including genomic classifiers gave “good discrimination in selecting patients” and he described Karnes’ data as “a great signal” to be subjected to careful statistical analysis—mainly decision curve analysis—which he considered would be “of great value” to help optimize the use of adjuvant radiation therapy by integrating clinical and genomic features.
Quoting the new data Karnes made a strong case for the combined use of genomic classifiers from tumor specimens together with clinical features for predicting prostate cancer response to radiotherapy.
In the genomic research he said the original aim had been “to better prognosticate patients who had high-risk prostate cancer” by quantifying the risk of metastasis at five years and at ten years. But the technique had proved to have predictive value too.
He explained that the standard clinical criteria had not been sufficient to decide on post-surgical radiotherapy.
“At the end of the day we [were] still left with this dilemma: Do we actually give radiation early—maybe [with] the consequence that the patient may not recover fully—versus waiting for PSA progression?”
Karnes noted that by incorporating genomic classifiers into an overall predictive assessment it was now clear that there were some men for whom the earlier radiation was given the better. And he said this had already affected his practice.
“In my practice [for patients with clinical risk factors] I reflexively get a genomic test. If it’s high I immediately refer that patient for radiotherapy,” he said.
More evidence came from another study Karnes was involved with led by Ashley Evan Ross, MD, PhD, Assistant Professor of Urology, Oncology and Pathology at the James Buchanan Brady Urological Institute at Johns Hopkins Hospital in Baltimore MD, which allocated four groups of patients on the basis of PSA levels to be treated with adjuvant radiotherapy, early salvage radiotherapy, salvage radiotherapy or no radiotherapy at all.
“We did show that the higher the genomic score the more separation in the curves. When the genomic score was low the metastasis rate at 10 years didn’t differ that much. The higher the genomic score the more separation. Patients benefit from early or adjuvant radiotherapy the higher the genomic complexity,” said Karnes.
The study concluded, however, that any decision about the timing and the need for additional local therapy after surgery was “nuanced and requires providers and patients to balance risks of morbidity with the improved oncological outcomes.”
While patients at high risk were candidates for clinical trials, adjuvant treatment could safely be avoided by men who are found to have low-risk when assessed by combined clinical and genomic scoring.
“It does improve what we call the “area under the curve.” By using our usual clinical-pathologic parameters, adding genomic information does allow us to prognosticate or rightfully assign therapy better,” Karnes said, noting that the higher the PORTOS the more likely the benefit of incorporating “multi-modal therapy” including post-operative radiation.
Although there were no data yet on overall survival Karnes said there was a balance to be weighed against the risk of adverse side-effects of adjuvant radiotherapy in any individual patient.
But he was optimistic about the future of genomically-guided therapy decision-making in prostate cancer.
“We’re seeing genomics utilized in the entire prostate cancer spectrum from very localized disease to metastatic castration-resistant disease,” he said. “The higher the genomic complexity the more likely the patient is to benefit from early salvage or adjuvant radiotherapy.”
161124 Jeff Karnes AJO PRODUCTION Master
April 15, 2017
Active Surveillance for Renal Cell Cancer
MILAN, Italy—Criteria for withholding aggressive therapies early in the course of renal cell cancer were updated at the 2016 European Multidisciplinary Meeting on Urological Cancers (EMUC) by Phillip M Pierorazio MD, Assistant Professor of Urology and Oncology at Johns Hopkins University, Baltimore MD.
“In clinically localized small masses—four centimeters or smaller—the first-line option is non-surgical management—active surveillance—for many patients,” he said, and he went on to discuss the latest evidence on minimizing the risk of unnecessary treatment emerging from his group’s registry of patients with renal tumors.
While there has been much encouraging news about new treatments for advanced and resistant renal cancer there was need to reassure many patients that they do not need to treat early stages of the disease urgently, Pierorazio said. Most patients could take time to allow teams to gather the clinical data needed to make considered decisions based on risk/benefit assessment.
Many Tumors Not Dangerous
“What we try to impart is that most small renal masses are not dangerous. In fact upwards of 20 to 30 percent are benign. The majority of the cancers are low-grade indolent tumors or not dangerous cancers,” he said.
He recognized that some patients particularly wanted to avoid surgery and—for them—an active surveillance management strategy was viewed as a completely safe option—at least in the short term.
Pierorazio said there were penalties for proceeding with active therapy.
“No kidney surgery is without risk. The kidney is a very vascular organ. It gets a quarter of the body’s blood-flow per minute. So temporarily stopping blood-flow, removing tumors [and] reconstructing kidneys subjects patients to risks that they may not necessarily need.”
During surveillance, however, there were triggers for intervention, he said.
“We image every six months for two years then annually thereafter. Historically the biggest trigger for intervention has been a growth rate of greater than half a centimeter per year. But that’s probably not the right trigger.”
He highlighted, instead, the importance of overall tumor size, pointing out that a marked upswing of risk that a patient will have a serious cancer—from below one percent to the order of two to three percent—typically began at around a diameter of four centimeters. So he regarded monitoring tumor size as a key factor in decision-making.
When he was asked about outcomes following active surveillance as compared with more aggressive approaches he said that in his group’s registry study of patients with early renal cancer only two out of 500 patients died of kidney cancer, both of whom had up-front surgery.
“None of the patients in the active surveillance cohort has developed metastatic disease or died of kidney cancer. 30 per cent of them “progressed”—meaning their tumors grew, but only about 15 percent of them crossed over into intervention,” he said.
Best Candidates for Active Surveillance?
“We know that tumors of less than two centimeters are really indolent,” said Pierorazio. “We do not miss a window of opportunity for treatment or cure if we allow them to grow and keep an eye on them, and most of them will not grow or change.”
Although teams have traditionally regarded older patients who have comorbidities as candidates for active surveillance there was, in fact, another distinct group. “Any patient with a small tumor is certainly eligible for active surveillance,” he said.
“Active surveillance is a safe option for all patients with clinical T1A tumors—four centimeters or less. It really should be our first-line management for patients who are older with co-morbidities, but it can be considered first-line management for any patient with a tumor less than two centimeters.”
Audio Journal of Oncology
AMSTERDAM—Women diagnosed with ductal carcinoma in situ (DCIS) of the breast were found to live longer than women in the general population according to a study from the Netherlands reported at the 2017 European Cancer Congress (ECCO).
Full Interview Transcript
LOTTE ELSHOF speaks with Peter Goodwin at the European Cancer Congress, ECCO 2017 in AMSTERDAM
YOU WERE LOOKING AT CAUSE SPECIFIC MORTALITY IN PATIENTS WITH DCIS, WHAT WERE YOU TRYING TO DO IN THIS STUKDY?
We looked at patients treated for DCIS – a potential precursor lesion to invasive breast cancer and we assessed cause specific mortality. So we looked at DCIS patients and during follow up see if they had died from what cause they had died and then we compared mortality with mortality in the general population. We wanted to look at [whether] DCIS patients had increased risk of dying.
WHY DID YOU WANT TO LOOK AT DCIS?
DCIS is a potential precursor to invasive breast cancer. So some DCIS lesions will progress into invasive breast cancer and invasive breast cancer can metastasise and then cause death so it’s an important thing to look at the outcomes of DCIS and there are a lot of uncertainties and anxiety associated with DCIS because many patients diagnosed with DCIS think they are diagnosed with breast cancer. But it’s not breast cancer, yet.
TELL ME WHAT YOU DID IN THE STUDY?
We looked at patients diagnosed with DCIS between 1989 and 2004 and we looked at the causes of death in this population and we compared these observed death numbers with the expected number of deaths.
QUITE A BIG GROUP?
Yes. Almost 10 000 women with DCIS
WHAT DID YOU FIND?
We found that DCIS patients older than 50 at diagnosis were at lower risk of dying compared to the general population. And—it may sound a bit counter-intuitive—but we think it is because these patients are mostly screen-detected so they go to the population-based screening program for breast cancer and these patients are likely to be more health conscious.
DETAILS—A THREE TIMES HIGHER RISK?
We saw that DCIS patients had lower risk of dying despite their increased risk of dying from breast cancer. So if you compare the risk of dying from breast cancer to the general population we see that they have an increased risk. But then if we look at absolute numbers—the risk a woman [actually] had—then the risk is very low. So after ten years 2.5 per cent of the women died from breast cancer but compared to the general population this is only slightly increased risk.
AND YOU ALSO MENTIONED THAT THE RISK OF DEATH FROM BREAST CANCER WAS INDEPENDENT OF TREATMENT?
Yes we found that no matter what treatment the risk of mortality was so low. So we compared women treated with breast conserving therapy alone, breast conserving therapy with radiotherapy, and mastectomy and we saw no differences in breast cancer mortality.
PRACTICAL MESSAGES FOR DOCS?
This study provides accurate risk estimates—relative risks and absolute risks— which are important information to the patient. And I think these patients should be told they have a precursor lesion of invasive breast cancer but not yet invasive breast cancer and it should provide reassurance.
WHAT DOES THIS IMPLY FOR LOOKING FOR DCIS BECAUSE MANY WOMEN GET WORRIED BY THE DIAGNOSIS?
Yes. It’s a very worrying diagnosis. It’s associated with a lot of anxiety and confusion. It means that we sometimes find lesions that we would have rather not detected but because of screening we will find those lesions and the screening program also has a lot of benefits. So it’s not that we say that we don’t need to screen but there are always harms against benefits and some DCIS detection would be beneficial.
YOU DON’T WANT TO COMMIT YOURSELF WHETHER IT’S BETTER TO HAVE KNOWLEDGE OF YOUR DCIS?
No. We cannot conclude that. We need more studies. More prospective studies and also we need to wait for the prospective studies on active surveillance of DCIS because at this moment we don’t have this information.
WHAT IS THE TAKE HOME MESSAGE FOR CANCER CLINICIANS?
Accurately explain the diagnosis of DCIS. Tell the patient what it is. And these women with screen-detected DCIS can be reassured that they have the same life expectancy as other women.
Women With DCIS Live Longer Than General Population
By Peter M Goodwin
AMSTERDAM—Women diagnosed with ductal carcinoma in situ (DCIS) of the breast were found to live longer than women in the general population according to a study from the Netherlands reported at the 2017 European Cancer Congress (ECCO).
“It may sound a bit counter-intuitive—but we found that DCIS patients older than 50 at diagnosis were at lower risk of dying compared to the general population,” said Lotte Elshof, MD PhD Student Associate of the Departments of Surgery, Epidemiology and Molecular Pathology at the Netherlands Cancer Institute in Amsterdam.
“We think it is because these patients are mostly screen-detected so they go to the population-based screening program for breast cancer and are likely to be more health conscious,” she said.
The findings she reported were associated with the on-going randomized, non-inferiority phase III “LORD” trial being conducted in the Netherlands by the BOOG (Borstkanker Onderzoek Groep) team under principal investigator Jelle Wesseling MD PhD, Consultant Breast Pathologist at the Netherlands Cancer Institute in Amsterdam looking at “management of low grade ductal carcinoma in situ: active surveillance or not?” https://www.boogstudycenter.nl/studie/276/lord.html
Elshof explained that they looked at patients being treated for DCIS because it was a potential precursor lesion to invasive breast cancer.
“If [patients] had died we assessed cause-specific mortality [to] see from what cause they had died. And then we compared [their] mortality with mortality in the general population,” she said.
The study found that patients with DCIS had lower risk of dying of all causes combined compared to the general population and “seem to represent a generally healthy subgroup.”
Also, their absolute risk of breast cancer death was low—3.9 percent at 15 years—and the risk of dying from breast cancer among women treated for DCIS alone was only slightly higher than that in the general population.
The suggestion was that “a history of primary DCIS has no negative effect on overall survival.”
The study looked at 9,799 women treated for DCIS in the Netherlands from 1989 to 2004. 1,429 deaths occurred over a median follow-up of 10 years of which 368 were due to cardiovascular disease (4 percent of the total population) and 284 deaths were due to breast cancer (3 percent).
These data revealed an overall risk of dying of all causes that was significantly lower combined compared to the general population.
“There are a lot of uncertainties and anxiety associated with DCIS because many patients think they are diagnosed with breast cancer. Some DCIS lesions will progress into invasive breast cancer and can metastasize and then cause death. So it’s an important to look at the outcomes,” Elshof said.
Breast Cancer-Specific Risk
Although the study confirmed that patients with DCIS were at increased risk of dying from breast cancer they still had a lower risk of dying overall despite this.
“If we look at absolute numbers the risk is very low,” she said. “After ten years 2.5 percent of the women died from breast cancer—but compared to the general population this is only a slightly increased risk.”
Intriguingly the study also found that the risk of dying from breast cancer was independent of the type of treatment patients received.
“We found that no matter what treatment, the risk of mortality was low. We compared women treated with breast conserving therapy alone, breast conserving therapy with radiotherapy, and mastectomy. And we saw no differences in breast cancer mortality,” she said.
When she was asked what was the practical message for cancer clinicians she said the study provided accurate estimates of relative and absolute risk which she regarded as important information for the patient.
“These patients should be told they have a precursor lesion of invasive breast cancer but not yet invasive breast cancer. And it should provide reassurance,” she said.
“[DCIS is] a very worrying diagnosis. It’s associated with a lot of anxiety and confusion. It means that we sometimes find lesions that we would have rather not detected. But because of screening we find those lesions and the screening program also has a lot of benefits. So it’s not that we say we don’t need to screen but [that] there are always harms against benefits. And some DCIS detection would be beneficial,” said Elshof.
She concluded that doctors could now accurately explain the diagnosis of DCIS, and tell patients what it is and reassure them they have the same life expectancy as other women.
Philip Poortmans MD PhD, President-elect of ECCO and head of the Radiation Oncology Department at Radboud University Medical Center in Nijmegen, in The Netherlands said that although ductal carcinoma in situ should be considered as being clearly different from breast cancer treatments had side-effects.
“This research provides reassurance for women with DCIS because it shows that they are as likely to be alive ten years after the diagnosis as people in the general population who did not have DCIS. This is also reassuring with regards to the potential risks of side-effects,” he said.
“However, we have to recognize that in one fifth of patients who die, the cause is breast cancer—which is likely to result from progression of the DCIS they were diagnosed with. Therefore, we are eagerly waiting results of further research to identify factors—including age, as clearly shown in this study—that contribute to the risk for recurrence and progression from DCIS for each individual patient.”
Poortmans thought it was remarkable that the increased risk of dying from breast cancer was completely offset by a lower risk of dying from other causes compared to women in the general population.
“This might be explained by the generally better health and socioeconomic status of women who regularly participate in breast cancer screening. This could also be tested in the on-going research,” he said.
Elshof INTERVIEW Production MASTER
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