Articles Posted in Radiation Therapy

A preliminary report shows that surgery that spares the breast in patients with a certain kind of early-stage breast cancer has better survival rates than mastectomy.

The study findings, reported Consumer Affairs, “defy the conventional belief that the two treatment interventions offer equal survival, and show the need to revisit some standards of breast cancer practice in the modern era, …”

Breast-conserving therapy (BCT), according to a paper presented at the Breast Cancer Symposium earlier this month, involved lumpectomy plus radiation for patients with early-stage, hormone receptor-positive breast cancer. Lumpectomy is the removal of only the mass with the tumor, not the whole breast (mastectomy). Hormone receptor-positive breast cancer (HR+) is when the cells have receptors for either estrogen or progesterone, which invites growth. Hormone receptor status is a primary factor in how a patient’s breast cancer is treated.

A couple of weeks ago, we wrote about urologists who, according to clinical guidelines, use too much radiation to treat prostate cancer pain. Here’s some related have-you-no-shame prostate cancer news brought to you by your local urologist.

According to a study in the New England Journal of Medicine, (NEJM) an awful lot of urologists are making decisions about treatment for their prostate cancer patients based on whether or not they own intensity-modulated radiation therapy (IMRT) facilities. One-third of men whose doctors own such equipment get that therapy for about $35,000 per treatment course. But before they were financially invested in radiation equipment, the same doctors prescribed that therapy for only 13 of 100 of their patients.

As discussed in Bloomberg, prostate cancer is the most common tumor diagnosed in the U.S.; nearly 240,000 men will get a diagnosis of prostate cancer this year. As we’ve blogged often (here and here), a diagnosis of prostate cancer presents a complicated scenario; the range of appropriate treatment moves from watchful waiting (no intervention unless and until the pathology changes in certain ways) to hormone therapy to surgery, chemotherapy and radiation. As Businessweek summarizes, “While only about 12%, or 29,270 men, will die from it this year, all will have to decide how, and whether, they want to treat the cancer.”

Although radiation can be a vital diagnostic tool and a life-saving cancer treatment, its dangers are well-documented (see our backgrounder on radiation overdose injuries).

A recent study published in the Journal of the American Medical Association (JAMA) suggests that doctors might be using radiation therapy too often for patients with advanced-stage prostate cancer. That puts them at risk of normal cell damage, skin irritation, diarrhea, bleeding and other problems. It also adds to the cost of their treatment.

Radiation therapy is prescribed to treat pain in patients whose prostate cancer has spread to their bones. This intervention is not for improving chances of survival in these advanced-stage cases, only to address severe pain. Radiation treatment of 10 sessions or more is recommended only in fewer than 10% of cases, and only if the patient’s cancer also might have spread to nearby soft tissue.

Old habits die hard, and in this regard the medical profession is no different from any other. Researchers at the Yale School of Medicine were surprised, though, at the results of their study showing that despite the fact that radiation has limited benefit for some older women with breast cancer, the treatment is still being prescribed.

A large clinical trial conducted by the National Cancer Institute (NCI) concluded that radiation for some women older than 70 with early stage, low-risk breast cancer offered limited benefit. So significant was the 2004 NCI trial that breast cancer treatment guidelines were changed to place radiation therapy in the “optional” category for these patients.

But the Yale researchers found that in the years following implementation of the new guidelines, there has been minimal change in the clinical care of older women with breast cancer. Their report was published in the March Journal of Clinical Oncology along with an editorial echoing our feeling that the perpetual motion treatment machine needs to be overhauled.

A new study might add to the perception that U.S. medical care is uncontrollably expensive thanks in part to unnecessary tests. “Screening by Chest Radiograph and Lung Cancer Mortality” concludes that people who have an annual chest X-ray do not have a significantly lower mortality rate than people who don’t.

The study, whose lung data are part of a larger investigation into cancers of the prostate, colon/rectum and ovaries, examined people who were given either annual chest X-rays (chest radiography) or standard medical care without screening. In the 13 years’ of the study, 1,696 lung cancers were detected in chest radiograph group and 1,620 lung cancers in the control group. The radiograph group reported 1,213 lung cancer deaths, and 1,230 in the control group.

The results weren’t really a surprise; researchers said the study confirmed expectations rather than setting new ones.

The medical community is waking up to an enormous problem with radiation – mainly X-rays and CT scans – used to diagnose disease and injury. Patients are getting too much radiation, and the excess itself causes injuries, many years down the road, in a big uptick in the risk of cancer.

Even a “routine” CT scan of the abdomen, ordered thousands of times every day in the United States for patients with belly pain, carries a large risk of downstream cancer, just from that single scan.

Dr. Rebecca Smith-Bindman, MD, of the University of California San Francisco, estimates a 20-year-old woman who undergoes a CT scan of the abdomen and pelvis has a one in 250 chance over her lifetime of getting cancer just from that single dose of radiation. This number was in a talk she gave recently at UCSF, as reported by her colleague Bob Wachter, MD, a patient safety expert at UCSF.

A physician who gave nearly 100 veterans with prostate cancer incorrect doses of radiation has been sanctioned by the Nuclear Regulatory Commission (NRC). The errors involved the incorrect placement of iodine-125 seeds in patients to treat prostate cancer.

Out of 116 such brachytherapy procedures performed at the facility between 2002 and 2008, the VA reported that 97 were carried out incorrectly. The NRC investigation found that Dr. Gary Kao, a radiation oncologist at the VA Medical Center in Philadelphia, took part in 91 of the 97 incorrect procedures. In several cases, the incorrect doses were caused by Kao having implanted the seeds in nearby organs or surrounding tissue.

As a result, the NRC ruled that Kao cannot take part in agency-related activities without undergoing more training. The NRC also issued a separate order requiring Gregory Desobry, a medical physicist who worked at the same facility, to notify the agency if he accepts employment in that capacity involving NRC-regulated activities within 20 days of beginning such work. Last year, the NRC fined the Philadelphia VA hospital $227,500 over the incidents.

Many women with early breast cancer do not need to have their armpit lymph nodes removed, according to a new study. Currently, this painful procedure has long been routine, as physicians believed it would prolong women’s lives by keeping the cancer from spreading or coming back. However, the study shows that removing the cancerous lymph nodes is unnecessary when women receive chemotherapy and radiation, which wipes out most of the disease in the nodes.

The study indicates that for about 20% of women (40,000 women a year in the U.S.), the removal of the cancerous lymph nodes doesn’t (a) alter the treatment plan for the patient; (b) improve survival rates; or (c) make the cancer less likely to recur. And it has a downside, since it can cause complications like infection and lymphedema, a chronic swelling in the arm.

Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. However, they warn that change may come slowly because the notion that the nodes must be removed is very deeply ingrained.

Why do patients who need focused, precise doses of radiation get walloped with huge overdoses that cause serious and even fatal injuries? A deadly combination of non-user-friendly radiation equipment, incompatible software when machines from different manufacturers are cobbled together, user error by the technicians administering the radiation, and lax regulation by federal authorities: All these are major issues in the ongoing expose by the New York Times of malpractice issues in radiation therapy.

In the latest installment, the team led by reporter Walt Bogdanich focuses on linear accelerators, machines that originally were intended to give broad-beam radiation doses to large swaths of the body, but now are increasingly modified to deliver what are supposed to be precise, focused radiation beams. The therapy is called stereotactic radiosurgery, and it allows hospitals who lack the more expensive competitor device, gamma knife surgery, to compete for radiation therapy business when the patient needs a very focused, intense dose to sensitive tissue — such as a nerve deep in the brain.

But without proper setup, and without an easy way to see when the machine’s beam has not been focused properly, tragedies can happen, as the reporters document.

The Food and Drug Administration has canceled its policy of giving rubber-stamp approval to marketing of powerful new radiation therapy equipment like linear accelerators. From now on, the manufacturer of the machine is going to have to prove the equipment has proper safety checks to prevent dangerous overdoses of radiation to patients.

The New York Times ran a series in January 2010 that exposed some horrific tragedies that occurred, particularly when hospitals rushed into operation new and complicated equipment without thorough safety checks and training of technicians. The series also showed that the equipment often lacked simple fail-safe devices such as a way of preventing the machine from delivering a walloping overdose of radiation even if one had been inadvertently programmed by a technician.

But since the FDA only has power over manufacturers and not over hospitals themselves, it still will be possible for poorly trained technicians to cause errors that hurt patients by either delivering overdoses or underdoses of radiation.

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