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In 1999, the Claudius-Regaud Institute of Toulouse, France, specialized in oncology, set up a workshop in order to assess the quality of its patients medical records. A retrospective evaluation was performed on a 100-chart-sample drawn from all the charts in the institution. Results show that the medical records are subdivised into three parts: medical care, nursing care and imaging. Some of the explored charts show a lack of data, and a certain inconsistency in the charts' organization and in the structure of information was reported. Patient's record is a key to communication between the different care providers in oncology. To improve its quality, efforts will have to be done in restructuring the charts, creating guidelines and training the different caregivers.

The development of non-invasive head fixation systems, allowing 3D determination of the target coordinates, has lead to the increased use of fractionated stereotactic irradiation. These systems have been checked for accuracy and the mean precision of repositioning has been evaluated to +/- 1 mm. With the mean geometrical accuracy set at +/- 1 mm, a 2 mm safety margin is usually added to the clinical target volume in order to define the planning target volume. Quality assurance procedures must conform to the required precision of the technique while remaining realistic in day-to-day use relative to planned conventional treatments. Biologically different from single dose irradiation, the fractionated stereotactic irradiation completes the range of techniques used in the treatment of intra-cerebral lesions.

Squamous cell carcinomas of the oral cavity were treated in 157 patients by surgery as first-line (104) or salvage (53) treatment. Postoperative irradiation delivered either for locally advanced tumors (stade III-IV) or for unfavorable histological data (nodal or surgical margins involvement). The retrospective study with a mean time of follow-up of 2.5 years shows a loco-regional control rate of 75% statistically influenced by histological nodal status (p < 0.01). Cumulative and cause specific survival rates at 5 years are 41.1% and 57.2% respectively. T stage was found to be a prognostic factor of survival (p < 0.01) as bone involvement (p < 0.05). Surgical margins are influent on local control and survival only in absence of radiation.

Purpose: Between November 1988 and May 1992, 14 patients were enrolled in a pilot study to evaluate the feasibility and results of hyperfractionated reirradiation for the treatment of head and neck recurrences or of second primary tumors developed in a previously irradiated volume., Materials and Methods: All patients underwent a surgical resection for the treatment of their recurrence or second cancer. Reirradiation was proposed because of positive margins and/or lymph node metastasis with extra-capsular spread. The planned reirradiation dose was 60 Gy over 5 weeks, with two daily fractions of 1.2 Gy delivered 6-8 hours apart., Results: Of the 14 patients, 10 received the reirradiation scheduled dose (ie, 60 Gy). All patients experienced an acute mucositis that never led to disruption of the treatment. Ten patients died 3 to 41 months after reirradiation (mean: 14 months), three were disease-free 48 to 71 months after reirradiation and one was alive with local progressive disease 74 months after reirradiation. The overall local control rate within the reirradiated volume was 43%. The 24- and 36-month overall survival rates were 50 and 35%, respectively. Overall, 13 late complications were noted: four were grade 1, seven were grade 2, and two were grade 3. Three patients still alive in September 1993 and whose initial files were available were enrolled in an additional study to assess from dose-volume histograms the cumulative doses delivered by the two irradiations., Conclusion: Despite poor local control, reirradiation using a hyperfractionation schedule with high dose level is feasible in terms of acute and late toxicity.

At the present time, the current improvement of technical and dosimetric aspects of radiation oncology has to be evaluated in terms of potential benefit for the patient and the society. For this last point of view, specially designed economic analyses must be performed in order to justify the number of resources involved by these technical improvements. If the question is how the current technical procedures could reduce the risk of undesirable side-effects, the response cannot be immediately drawn from the literature. This paper emphasizes the possibility to evaluate the role of side-effects as endpoints of economic analyses when using special models in medical decision making such as Markov's. Only few oncologic situations are reliable to properly analyze the relationship between sophisticated radiation techniques and the incidence of post-radiation complications. These situations should be selected when prospective economic analyses are planned in the field of radiation therapy.

Purpose: Financial costs from "Z" procedures were evaluated and compared with the amount of direct costs that are needed for the annual activity of a radiation oncology department., Materials and Methods: The various components, particularly staff earnings that are estimated for each procedure according to their category and working time, were cumulated for calculation of direct loads., Results: Comparisons between direct expenses and the total amount of Z procedures led to the following results: the global cost is the same; at analysis of therapeutic procedures, however, this apparent similarity masks some very significant gaps; valorization of Z procedures is much lower than that of the corresponding real loads, especially when therapeutic procedures are quite different from techniques that are considered as "standard"; these differences do not apply to all the components of radiation therapy procedures. In particular, medical steps would be uniformly underestimated, while irradiation per se is overestimated., Conclusion: The authors suggest modifications of the general objectives and items of the nomenclature of radiotherapy and brachytherapy procedures.

We conducted a retrospective study of 34 patients treated by radical neck dissection followed by radiotherapy for one or several cervical adenopathies without a primary tumor. Mean follow-up was 48 months. During follow-up, 6 patients developed a presumed primary tumor, and 11 patients presented with recurrent lymph nodes. We found no statistically significant predictive factor, as to either clinical characteristics or the histological nature of the adenopathies. On the other hand, the number of metastatic lymph nodes found on the surgical specimen was correlated with the risk of lymph node recurrence. Among the prognostic factors with an unfavorable effect on survival, the dimensions of the adenopathy, its fixed characteristic and its TNM status, were identified. In this series, the appearance of a primary tumor did not seem to worsen the prognosis. On the other hand, the appearance of lymph node recurrence predicted poorer survival rates. The results are discussed and compared with those found in the literature.

Palliative treatment of head and neck cancers needs an initial evaluation based upon clinical symptoms and tumoral behaviour. Local recurrences are the most frequent presentation of tumoral failures. The therapeutic management of these local recurrences requires a mixture of unspecific and specific oncologic procedures. Radiotherapy and chemotherapy are frequently used in those circumstances in order to reduce the tumoral volume and to facilitate the effectiveness of unspecific treatments. Management of metastatic disease is often impaired by the moderate efficiency of chemotherapy while this treatment leads to marked side effects. Basically, the best therapeutic choice depends on the expected positive balance between the improvement of symptoms and the level of treatment-related side effects. However, daily clinical approach is a better way to care these patients than predefined rigid protocols.

The authors present a retrospective analysis dealing with the cost of therapeutic procedures achieved in the department of radiotherapy of the Centre Claudius-Regaud. This analysis was performed according to the actual cost of the different components of each treatment including the human costs. For this last purpose, serial countings of time spent by each category of employees were performed and then translated into financial terms. Results show a large discrepancy between the costs of therapeutic procedures. These differences are mainly related to the purpose of therapeutic plan, dealing with the most expensive procedures dealing with the developmental treatments. This study provides a tool that can be used by medical and/or administrative managers of radiation oncology departments when changes or innovations in therapeutic procedures. This cost accounting analysis is compared to the French administrative procedures used to pay the health care services and to determine the level of hospital resources.

To increase geometric treatment accuracy in radiation therapy, we used a novel digitized method and original image processing. The radiographic films that are conventionally used for verifying each beam during the treatment were digitized by a Kodak digital system and then an original image enhancement was applied. For the evaluation of our technique, a clinical trial with two tests was used. The trial involved four readers doing 80 reading. The enhanced films were judged to be of higher quality than the non enhanced films (p = 0.001) and were read more accurately (p < or = 0.001). This automatic enhancement of digitized captured portal images can be easily integrated into the busy routine of a radiotherapy department.

In order to enhance radiation effects in the treatment of unresectable Head and Neck squamous cell carcinoma, we initiated a phase I-II study in February 1991 with concomitant radiation and cisplatin in the treatment of resectable Head and Neck squamous cell carcinoma. The first patient was treated in a palliative intend for a cervical recurrence (cutaneous metastatic lymphangitis) of laryngeal cancer. The seven other patients had a Stage IV M0, previously untreated, oropharyngeal carcinoma. Standard external radiation was carried out up to a total dose of 60 Gy/6 weeks (7 MeV electron beam) for the 1st patient and 72 Gy/8 weeks (Co60 beam) for the 7 other patients. Cisplatin was given during the entire radiation treatment, by continuous infusion, 5 days a week, at doses of 4 mg/m2/d for the 1st patient, 5 mg/m2/d for the two following patients and 6 mg/m2/d for the last five patients. One patient with a poor initial performance status (three in the WHO scale) stopped his treatment on the 6th week due to a grade 3 mucositis with deglutition pneumonia. He died 2 months later with progressive carcinoma. For one other patient, treatment was discontinued for 1 week after 48 Gy, due to a grade 3 mucositis. The other patients completed the planned protocol without any interruption. Mucositis (grade 3 in two cases, grade 2 in four cases), dermitis (grade 3 in two cases, grade 2 in four cases) and neutropenia (grade 2 in two cases) were the most frequent acute toxicity. Of the seven patients treated with a curative intend, six are free of disease at 6 to 28 months after completion of treatment. A pharmacokinetic study showed a total platinum accumulation. The mean value at the end of treatment reached 1157 ng/ml. Only one patient experienced an accumulation of the ultrafilterable platinum (137 ng/ml at the end of treatment).

We describe a retrospective and comparative assessment of the medical care of breast cancer among women in a French comprehensive cancer center, the Centre Claudius Regaud. There was no significant difference for the clinical results between two cohorts of women, treated in 1975 and 1985 respectively, for equivalent stages of disease. The overall increase in survival resulted mainly from early diagnosis. Locoregional treatment cost and conservative treatment cost, from official Social Security costs, did not increase between the two periods. However, a high risk of metastasis risk during the first treatment, or recurrence during the follow-up, resulted in differences in cost-effectiveness between 1975 and 1985. Although these results must be interpreted with caution, this analysis raises strategic questions about the suitability of some medical practices, particularly in the care of evolutive neoplasm.