- Email: [email protected]
Late effects of breast radiotherapy
Correspondence
Until we get serious about personal lifestyle modification and national policies to promote environmental and behavioural change, we will need blood pressure lowering medications and statins to contain the epidemic of cardiovascular disease. NJS was Chair of the Cholesterol Guidelines Panel, and DML-J and DG were coChairs of the Risk Assessment Work Group.
*Donald M Lloyd-Jones, David Goff, Neil J Stone [email protected] Northwestern University Feinberg School of Medicine, Chicago 60611, IL, USA (DML-J, NJS); and Colorado School of Public Health, Aurora, CO, USA (DG) 1
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Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437740.48606.d1. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437741.48606.98. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: a Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437739.71477.ee. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437738.63853.7a. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet 2013; published Nov 20. http:// dx.doi.org/10.1016/S0140-6736(13)62388-0.
Camille Van Vooren/Reporters/Science Photo Library
Late effects of breast radiotherapy We welcome the publication of the 10-year results of the START trials,1 but we have concerns about the reporting of late tissue effects. We note that the categories used in the latest report differ from those in the 5-year quality of life study,2 and find this problematic. 602
For instance, in Hopwood and colleagues’ 5-year follow-up report,2 up to a third of women reported moderate or marked pain in the arm or shoulder over 5 years, while the 10- year followup report by Haviland and colleagues1 makes no mention of pain, merely of shoulder stiffness. Because our personal experience of late effects is that they are progressive, we find this odd. It is also confusing from the point of view of comparison to have different descriptions of adverse events, using different vocabulary (eg, induration vs hardness, and telangiectasia vs skin problems). We find too that some post-radiotherapy effects that we ourselves have experienced are still not mentioned, notably bone necrosis (not necessarily leading to fractures, though these do occur).3 However, it is a step forward to have 10-year results, and since follow-up data are still being collected, and followup was still short for cardiac events,1 we hope that these data and other late effects will continue to be monitored. The publication of this Article 1 offers an opportunity to reassess the role of radiotherapy in the overall treatment of breast cancer. It prompts the observation that timing is crucial, especially for fast-growing tumours, and we note that the time from surgery to randomisation in these trials was remarkably long (8–9 weeks in START A and more than 7 weeks in START B). Also, randomisation did not allow for grade of tumour. Patients now expect fully informed consent to treatment,4 and if they so wish are given details of their pathology. Surely a one-size-fitsall approach is inappropriate for radiotherapy. Fast-growing tumours might well need swift decisions and a different fractionation regimen from the slow-growing tumours. It has been convincingly suggested that differing protocols should be applied to different tumours.5 Now may be the time to take stock: perhaps weekend working should be considered, and NICE might yet need to revise their guidance.
We declare that we have no conflicts of interest.
*Heather Goodare, Jan Millington, Pam Pond, Christina Rogers, David Bainbridge [email protected] RAGE (Radiotherapy Action Group Exposure), Southborough TN4 0NX, UK 1
2
3
4
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Haviland J S, Owen J R, Dewar J A, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086–94. Hopwood P, Haviland J S, Sumo G,et al. Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials. Lancet Oncol 2010; 11: 231–40. Carling M, Goodare H, Ironside A, Millington J, Rogers C. Quality of life after breast radiotherapy. Lancet Oncol 2010; 12: 10. Moulton B, Collins P A, Burns-Cox N, Coulter A. From informed consent to informed request: do we need a new gold standard? J R Soc Med 2013; 106: 391–94. Johnson A. The timing of treatment in breast cancer: gaps and delays in treatment can be harmful. Breast Cancer Res Treat 2000; 60: 201–09.
Department of Error Vaidya JS, Wenz F, Bulsara M, et al. Risk-adapted targeted intraoperative radiotherapy versus wholebreast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet 2014; 383: 603–13—In table 3 of this Article (published online Nov 11, 2013), in the Postpathology section of the Absolute difference column, the 90% CI for All patients should have been 0·2 to 2·6, the 90% CI for Mature cohort should have been 0·3 to 3·8, and the difference for Earliest cohort should have been 1·8%. In the Postpathology section of the Z score column, the score for Mature cohort should have been –0·429. These corrections have been made to the online version as of Feb 14, 2014, and to the printed Article. Krum H, Schlaich MP, Böhm M, et al. Percutaneous renal denervation in patients with treatment-resistant hypertension: final 3-year report of the Symplicity HTN-1 study. Lancet 2014; 383: 622–29—In this Article (published online Nov 7, 2013), Paul Sobotka should have been listed as an author. This correction has been made to the online version as of Feb 14, 2014, and to the printed Article.
www.thelancet.com Vol 383 February 15, 2014
Until we get serious about personal lifestyle modification and national policies to promote environmental and behavioural change, we will need blood pressure lowering medications and statins to contain the epidemic of cardiovascular disease. NJS was Chair of the Cholesterol Guidelines Panel, and DML-J and DG were coChairs of the Risk Assessment Work Group.
*Donald M Lloyd-Jones, David Goff, Neil J Stone [email protected] Northwestern University Feinberg School of Medicine, Chicago 60611, IL, USA (DML-J, NJS); and Colorado School of Public Health, Aurora, CO, USA (DG) 1
2
3
4
5
Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437740.48606.d1. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437741.48606.98. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: a Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437739.71477.ee. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013; published online Nov 12. DOI:10.1161/01.cir.0000437738.63853.7a. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet 2013; published Nov 20. http:// dx.doi.org/10.1016/S0140-6736(13)62388-0.
Camille Van Vooren/Reporters/Science Photo Library
Late effects of breast radiotherapy We welcome the publication of the 10-year results of the START trials,1 but we have concerns about the reporting of late tissue effects. We note that the categories used in the latest report differ from those in the 5-year quality of life study,2 and find this problematic. 602
For instance, in Hopwood and colleagues’ 5-year follow-up report,2 up to a third of women reported moderate or marked pain in the arm or shoulder over 5 years, while the 10- year followup report by Haviland and colleagues1 makes no mention of pain, merely of shoulder stiffness. Because our personal experience of late effects is that they are progressive, we find this odd. It is also confusing from the point of view of comparison to have different descriptions of adverse events, using different vocabulary (eg, induration vs hardness, and telangiectasia vs skin problems). We find too that some post-radiotherapy effects that we ourselves have experienced are still not mentioned, notably bone necrosis (not necessarily leading to fractures, though these do occur).3 However, it is a step forward to have 10-year results, and since follow-up data are still being collected, and followup was still short for cardiac events,1 we hope that these data and other late effects will continue to be monitored. The publication of this Article 1 offers an opportunity to reassess the role of radiotherapy in the overall treatment of breast cancer. It prompts the observation that timing is crucial, especially for fast-growing tumours, and we note that the time from surgery to randomisation in these trials was remarkably long (8–9 weeks in START A and more than 7 weeks in START B). Also, randomisation did not allow for grade of tumour. Patients now expect fully informed consent to treatment,4 and if they so wish are given details of their pathology. Surely a one-size-fitsall approach is inappropriate for radiotherapy. Fast-growing tumours might well need swift decisions and a different fractionation regimen from the slow-growing tumours. It has been convincingly suggested that differing protocols should be applied to different tumours.5 Now may be the time to take stock: perhaps weekend working should be considered, and NICE might yet need to revise their guidance.
We declare that we have no conflicts of interest.
*Heather Goodare, Jan Millington, Pam Pond, Christina Rogers, David Bainbridge [email protected] RAGE (Radiotherapy Action Group Exposure), Southborough TN4 0NX, UK 1
2
3
4
5
Haviland J S, Owen J R, Dewar J A, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086–94. Hopwood P, Haviland J S, Sumo G,et al. Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials. Lancet Oncol 2010; 11: 231–40. Carling M, Goodare H, Ironside A, Millington J, Rogers C. Quality of life after breast radiotherapy. Lancet Oncol 2010; 12: 10. Moulton B, Collins P A, Burns-Cox N, Coulter A. From informed consent to informed request: do we need a new gold standard? J R Soc Med 2013; 106: 391–94. Johnson A. The timing of treatment in breast cancer: gaps and delays in treatment can be harmful. Breast Cancer Res Treat 2000; 60: 201–09.
Department of Error Vaidya JS, Wenz F, Bulsara M, et al. Risk-adapted targeted intraoperative radiotherapy versus wholebreast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet 2014; 383: 603–13—In table 3 of this Article (published online Nov 11, 2013), in the Postpathology section of the Absolute difference column, the 90% CI for All patients should have been 0·2 to 2·6, the 90% CI for Mature cohort should have been 0·3 to 3·8, and the difference for Earliest cohort should have been 1·8%. In the Postpathology section of the Z score column, the score for Mature cohort should have been –0·429. These corrections have been made to the online version as of Feb 14, 2014, and to the printed Article. Krum H, Schlaich MP, Böhm M, et al. Percutaneous renal denervation in patients with treatment-resistant hypertension: final 3-year report of the Symplicity HTN-1 study. Lancet 2014; 383: 622–29—In this Article (published online Nov 7, 2013), Paul Sobotka should have been listed as an author. This correction has been made to the online version as of Feb 14, 2014, and to the printed Article.
www.thelancet.com Vol 383 February 15, 2014