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Delay in initiating radiotherapy for breast cancer

January 23, 2017

Everyone will remember 2016. The history books will discuss the seismic political changes and we may remember what seems like a premature and cruel list of deaths amongst the famous. One death in November didn’t make the news but was of a giant of modern oncology: Umberto Veronesi. Wikipedia has Veronesi as ‘Politician’ (he was a Minister of Health in later life) but we should remember him as the man who led the first major RCT in adjuvant radiotherapy for the conserved breast. Veronesi’s work has led to thousands of women being able to safely preserve a breast affected by cancer but also to a massive workload within our radiotherapy departments. Adjuvant breast radiotherapy remains the biggest single treatment group in European radiotherapy centres.

Despite using adjuvant breast radiation routinely for 4 decades we continue to have important EBM questions about it: dose, partial breast, nodal volumes and cardiac sparing to name some of the most pressing. Despite these active concerns (all subject to ongoing / current trials) there are some fundamentals not yet fully explained and one key question is “does delay matter?” or to paraphrase “how late is too late?”

It would be unethical to make patients wait for radiotherapy to assess the effect of delay (although it might be ethical to ‘fast track’ a control group?) so data on delay to treatment remains hard to come by. Yet intuitively HCPs and patients alike dislike delay and seek to minimise it. In the UK a 31-day ‘time to treatment target’ has been established (regardless of tumour biology) to incentivise departments to treat as quickly as possible (although the incentive is more stick than carrot!)

What evidence then do we have of harm from delay and can it be measured?

The #radonc journal club this month is pleased to have Bill Mackillop from Toronto and his first author Shlok Gupta discussing their recent paper from Clinical Oncology : “The Effect of Waiting Times for Postoperative Radiotherapy on Outcomes for Women Receiving Partial Mastectomy for Breast Cancer: a Systematic Review and Meta-Analysis”

Professor Mackillop and his collaborators have been publishing, analysing and talking about radiotherapy delay for many years so we are excited to be discussing this paper.

The talk will be on Sunday 29th January at 3pm EST (8pm in the UK) for one hour

As usual the paper will be open for comment all weekend so if you can’t join for the live hour –please offer opinion or comment in the meantime either by tweeting or by posting below.

Questions will be framed along these 5 points:
T1 : What has previous research told us about delay in initiating radiotherapy?
T2 : How was this study done and what did it show?
T3 : What are the strengths of this study – and any potential weaknesses?
T4 : What are the implications of the study to practice globally (and in the context of systemic therapies)
T5 : How far can results from studies in breast cancer be extrapolated to other cancers?

Thanks to the team at Clinical Oncology for making the paper full free text for download for the duration of the journal club.

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