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PURPOSE: To assess the cosmetic impact of breast conserving surgery (BCS), whole breast irradiation (WBI) fractionation and tumour bed boost (TBB) use in a phase III trial for women with ductal carcinoma in situ (DCIS) of the breast. MATERIALS AND METHODS: Baseline and 3-year cosmesis were assessed using the European Organization for Research and Treatment of Cancer (EORTC) Cosmetic Rating System and digital images in a randomised trial of non-low risk DCIS treated with postoperative WBI +/- TBB. Baseline cosmesis was assessed for four geographic clusters of treating centres. Cosmetic failure was a global score of fair or poor. Cosmetic deterioration was a score change from excellent or good at baseline to fair or poor at three years. Odds ratios for cosmetic deterioration by WBI dose-fractionation and TBB use were calculated for both scoring systems. RESULTS: 1608 women were enrolled from 11 countries between 2007 and 2014. 85-90% had excellent or good baseline cosmesis independent of geography or assessment method. TBB (16 Gy in 8 fractions) was associated with a >2-fold risk of cosmetic deterioration (p < 0.001). Hypofractionated WBI (42.5 Gy in 16 fractions) achieved statistically similar 3-year cosmesis compared to conventional WBI (50 Gy in 25 fractions) (p ≥ 0.18). The adverse impact of a TBB was not significantly associated with WBI fractionation (interaction p ≥ 0.30). CONCLUSIONS: Cosmetic failure from BCS was similar across international jurisdictions. A TBB of 16 Gy increased the rate of cosmetic deterioration. Hypofractionated WBI achieved similar 3-year cosmesis as conventional WBI in women treated with BCS for DCIS.

Background: Patient-reported outcome (PRO) measures have been used widely to screen for depression, anxiety, and symptoms in cancer patients. Computer-based applications that collect patients' responses and transfer them to the treating health professional in real time have the potential to improve patient well-being and cancer outcomes. Objective: This study will test the feasibility and acceptability of a newly developed eHealth system which facilitates PRO data capture from cancer patients, data linkage and retrieval to support clinical decisions and patient self-management, and data retrieval to support ongoing evaluation and innovative research. Methods: The eHealth system is being developed in consultation with 3 overarching content-specific expert advisory groups convened for this project: the clinical advisory group, technical advisory group, and evaluation advisory group. The following work has already been completed during this phase of the study: the Patient-Reported Outcome Measures for Personalized Treatment and Care (PROMPT-Care) eHealth system was developed, patient-reported outcomes were selected (distress, symptoms, unmet needs), algorithms to inform intervention thresholds for clinical and self-management were determined, clinician PRO feedback summary and longitudinal reports were designed, and patient self-management resources were collated. PROsaiq, a custom information technology system, will transfer PRO data in real time into the hospital-based oncology information system to support clinical decision making. The PROMPT-Care system feasibility and acceptability will be assessed through patients completing PROMPT-Care assessments, participating in face-to-face cognitive interviews, and completing evaluation surveys and telephone interviews and oncology staff participating in telephone interviews. Results: Over the course of 3 months, the system will be pilot-tested with up to 50 patients receiving treatment or follow-up care and 6 oncology staf

Setup error in breast radiotherapy (RT) measured with 3-dimensional cone-beam computed tomography (CBCT) is becoming more common. The purpose of this study is to review the literature relating to the magnitude of setup error in breast RT measured with CBCT. The different methods of image registration between CBCT and planning computed tomography (CT) scan were also explored. A literature search, not limited by date, was conducted using Medline and Google Scholar with the following key words: breast cancer, RT, setup error, and CBCT. This review includes studies that reported on systematic and random errors, and the methods used when registering CBCT scans with planning CT scan. A total of 11 relevant studies were identified for inclusion in this review. The average magnitude of error is generally less than 5 mm across a number of studies reviewed. The common registration methods used when registering CBCT scans with planning CT scan are based on bony anatomy, soft tissue, and surgical clips. No clear relationships between the setup errors detected and methods of registration were observed from this review. Further studies are needed to assess the benefit of CBCT over electronic portal image, as CBCT remains unproven to be of wide benefit in breast RT.

A major challenge in value-based health care is the lack of standardized health outcomes measurements, hindering optimal monitoring and comparison of the quality of health care across different settings globally. The International Consortium for Health Outcomes Measurement (ICHOM) assembled a multidisciplinary international working group, comprised of 26 health care providers and patient advocates, to develop a standard set of value-based patient-centered outcomes for breast cancer (BC). The working group convened via 8 teleconferences and completed a follow-up survey after each meeting. A modified 2-round Delphi method was used to achieve consensus on the outcomes and case-mix variables to be included. Patient focus group meetings (8 early or metastatic BC patients) and online anonymized surveys of 1225 multinational BC patients and survivors were also conducted to obtain patients' input. The standard set encompasses survival and cancer control, and disutility of care (eg, acute treatment complications) outcomes, to be collected through administrative data and/or clinical records. A combination of multiple patient-reported outcomes measurement (PROM) tools is recommended to capture long-term degree of health outcomes. Selected case-mix factors were recommended to be collected at baseline. The ICHOM will endeavor to achieve wide buy-in of this set and facilitate its implementation in routine clinical practice in various settings and institutions worldwide.

AimsThe aim of this study was to estimate the population-based local control (LC) and overall survival (OS) benefits of radiotherapy for selected cancers if the whole cancer population in Australia were treated according to evidence-based guidelines. These estimates were based on the published radiotherapy utilisation (RTU) models used for estimating demand of radiotherapy services nationally and internationally. MethodsBenefits were defined as the LC and OS proportional gains from radiotherapy over no radiotherapy and from post-operative radiotherapy over surgery alone. CRT benefits were the proportional gains from concurrent radiotherapy and chemotherapy over radiotherapy alone. The RTU models for breast, gastro-intestinal (oesophagus, stomach, colorectal, gall bladder, pancreas), haematological (leukaemia, lymphoma, myeloma), lung, melanoma, unknown primary and ‘other’ (anus, non-melanoma skin cancer, soft tissue sarcoma) cancers were extended to incorporate benefit estimates of radiotherapy alone (RT alone) and of radiotherapy with concurrent chemotherapy (CRT). Literature review (1990-2015) was conducted to identify benefit estimates of individual radiotherapy indications and summed to estimate the population-based gains for these outcomes. Model robustness was tested through univariate and multivariate sensitivity analyses.ResultsFor the RT alone model, the lowest 5-year LC benefit estimates (benefit %, 95% Confidence Interval) were for leukaemia (1%, 0.2%-1%) and oesophageal cancer (1%, 0.5%-1%), the highest for breast cancer (15%, 12.9%-16.8%). The lowest and highest for 5-year OS benefit were: oesophageal cancer (0.1%, 0.06%-0.13%) and lymphoma (6.5%, 5.9%-7.1%). For the CRT model, lowest and highest LC benefits were for: ‘other’ cancers (1%, 0.2%-1.3%) and rectal cancer (6%, 2.5%-9.4%). 5-year OS benefit ranges were: ‘other’ cancers (0.2%, -0.1%-0.4%) and oesophageal cancer (2%, 1.7%-2.7%). 2-year OS benefits (RT only + CRT) were estimated for lung cancer

The purpose of this study was to determine the impact of magnetic resonance imaging (MRI) geometric distortions when using MRI for target delineation and planning for whole-breast, intensity-modulated radiotherapy (IMRT). Residual system distortions and combined systematic and patient-induced distortions are considered. This retrospective study investigated 18 patients who underwent whole-breast external beam radiotherapy, where both CT and MRIs were acquired for treatment planning. Distortion phantoms were imaged on two MRI systems, dedicated to radiotherapy planning (a wide, closed-bore 3T and an open-bore 1T). Patient scans were acquired on the 3T system. To simulate MRI-based planning, distortion maps representing residual system distortions were generated via deformable registration between phantom CT and MRIs. Patient CT images and structures were altered to match the residual system distortion measured by the phantoms on each scanner. The patient CTs were also registered to the corresponding patient MRI scans, to assess patient and residual system effects. Tangential IMRT plans were generated and optimized on each resulting CT dataset, then propagated to the original patient CT space. The resulting dose distributions were then evaluated with respect to the standard clinically acceptable DVH and visual assessment criteria. Maximum residual systematic distortion was measured to be 7.9 mm (95% < 4.7 mm) and 11.9 mm (95% < 4.6 mm) for the 3T and 1T scanners, respectively, which did not result in clinically unacceptable plans. Eight of the plans accounting for patient and systematic distortions were deemed clinically unacceptable when assessed on the original CT. For these plans, the mean difference in PTV V95 (volume receiving 95% prescription dose) was 0.13 ± 2.51% and -0.73 ± 1.93% for right- and left-sided patients, respectively. Residual system distortions alone had minimal impact on the dosimetry for the two scanners investigated. The combination of MRI syst

This study investigates breast magnetic resonance imaging (MRI) image quality for 3 different breast radiotherapy positions (prone, supine flat and supine inclined) and associated choice of breast coils. Supine breast MRI has comparable image quality to prone breast MRI for the purposes of radiotherapy delineation for T2-weighted sequences.

Introduction Detailed, published surveys specific to Australian breast radiotherapy practice were last conducted in 2002. More recent international surveys specific to breast radiotherapy practice include a European survey conducted in 2008/2009 and a Spanish survey conducted in 2009. Radiotherapy techniques continue to evolve, and the utilisation of new techniques, such as intensity-modulated radiation therapy (IMRT), is increasing. This survey aimed to determine current breast radiotherapy practices across Australia. Method An online survey was completed by 50 of the 69 Australian radiation therapy treatment centres. Results Supine tangential beam whole breast irradiation remains the standard of care for breast radiotherapy in Australia. A growing number of institutions are exploring prone positioning and IMRT utilisation. This survey demonstrated a wide variation in the benchmarks used to limit and report organ at risk doses, prescribed dose regimen, and post-mastectomy bolus practices. This survey also indicated, when compared with international literature, that there may be less interest in or uptake of external beam partial breast irradiation, prone positioning, simultaneous integrated boost and breath hold techniques. These are areas where further review and research may be warranted to ensure Australian patients are receiving the best care possible based on the best evidence available. Conclusion This survey provides insight into the current radiotherapy practice for breast cancer in Australia.

Background and purpose A rapid learning approach has been proposed to extract and apply knowledge from routine care data rather than solely relying on clinical trial evidence. To validate this in practice we deployed a previously developed decision support system (DSS) in a typical, busy clinic for non-small cell lung cancer (NSCLC) patients. Material and methods Gender, age, performance status, lung function, lymph node status, tumor volume and survival were extracted without review from clinical data sources for lung cancer patients. With these data the DSS was tested to predict overall survival. Results 3919 lung cancer patients were identified with 159 eligible for inclusion, due to ineligible histology or stage, non-radical dose, missing tumor volume or survival. The DSS successfully identified a good prognosis group and a medium/poor prognosis group (2 year OS 69% vs. 27/30%, p < 0.001). Stage was less discriminatory (2 year OS 47% for stage I-II vs. 36% for stage IIIA-IIIB, p = 0.12) with most good prognosis patients having higher stage disease. The DSS predicted a large absolute overall survival benefit (∼40%) for a radical dose compared to a non-radical dose in patients with a good prognosis, while no survival benefit of radical radiotherapy was predicted for patients with a poor prognosis. Conclusions A rapid learning environment is possible with the quality of clinical data sufficient to validate a DSS. It uses patient and tumor features to identify prognostic groups in whom therapy can be individualized based on predicted outcomes. Especially the survival benefit of a radical versus non-radical dose predicted by the DSS for various prognostic groups has clinical relevance, but needs to be prospectively validated.