More Virtues of One-Stop Radiotherapy for Breast Cancer

Liam Davenport

May 10, 2016

Treating breast cancer patients with single-dose targeted intraoperative radiotherapy (TARGIT) at the time of surgery substantially reduces the burden on patients' lives and on the environment in comparison with traditional radiotherapy, an analysis by UK researchers indicates.

Compared with use of fractionated external-beam radiotherapy (EBRT), TARGIT slashed mean distance traveled per patient by almost 80%, report Jayant S. Vaidya, MD, a surgical oncologist at University College London, United Kingdom, and colleagues.

Moreover, in an innovative examination of the environmental impact of cancer therapy, they found that the carbon dioxide emissions associated with TARGIT, which has been called one-stop radiotherapy, were around a quarter of those associated with use of EBRT.

Lead author Nathan J. Coombs, MD, a breast surgeon at the Great Western Hospitals National Health Service (NHS) Foundation Trust, Swindon, United Kingdom, told Medscape Medical News that the study shows that the environmental and social impact of cancer treatments should be taken into account when considering their overall value.

"No one really has ever considered the true impact of travel, and I'm not just talking about radiotherapy, because often patients who require chemotherapy are required to return to hospital on a frequent basis," he said.

Dr Coombs added: "There's an increasing push by the government to centralize resources in big centers of excellence, which may have advantages in some regards, but all that does is increase the traffic burden and the hassle for patients without necessarily improving their standard of care."

The current analysis, published online May 9 in BMJ Open, informs the wider debate over the use of TARGIT, which has been ongoing since the first data from the TARGIT-A trial were presented in 2012.

As reported by Medscape Medical News and published in the Lancet, 5-year data from the TARGIT-A trial demonstrated that targeted intraoperative radiotherapy was not inferior to whole-breast radiotherapy in terms of local recurrence and led to significantly fewer non–breast cancer deaths.

TARGIT has been employed in the United States and many countries in Europe and is offered through the NHS in Australia. However, it has been the subject of a bitter war of words between two camps of radiation oncologists, which has been characterized as a "clash of titans."

Anthony Zietman, MD, editor in chief of the International Journal of Radiation Oncology, Biology, Physics (known as the Red Journal) and radiation oncologist at Harvard Medical School, in Boston, Massachusetts, has said that the treatment has led to "polar opposite views."

Last year, in an editor's comment in the journal, he wrote: "Many careers have been built around fractionated radiation therapy for breast cancer, and it comprises a substantial proportion of the practice of the average contemporary radiation oncologist. Depending on your perspective, intraoperative radiation therapy is thus either a very serious threat or a quantum leap forward."

Tackling the doubts over the safety of TARGIT, Dr Vaidya pointed to a recent letter published in the Lancet in which he showed in combined analysis of the TARGIT-A and GEC-ESTRO trials that there was no significant difference in local recurrence between TARGIT and EBRT, a significant reduction in non–breast cancer mortality, and a trend for improved overall survival.

As for the personal attacks he has received, Dr Vaidya quoted former UK Prime Minister Margaret Thatcher: "I always cheer up immensely if an attack is particularly wounding because I think, well, if they attack one personally, it means they have not a single [scientific/evidence-based] argument left."

For Dr Coombs, the key to successful use of TARGIT is the appropriate selection of patients.

"We've tried to limit it to patients who are of a better prognosis group ― in other words, slightly smaller, slower-growing tumors," he said.

Dr Coombs said that the treatment is "as safe, if not better," than EBRT.

Patients balance convenience and risk, he added. "A lot of these ladies say: 'Look, I don't want the problem and hassle of daily travel. It's too much of an impact and an imposition on my family, and I'm prepared to accept a possible, slightly higher but nonsignificant risk of local recurrence against the convenience and the ability to get on with life immediately.' "

The current study emerged after Dr Vaidya was encouraged by his daughter Uma, who is a coauthor of the study, to consider the environmental impact of patient journeys. Independently, Dr Coombs became concerned over the social burden experienced by his patients in traveling to and from his local radiotherapy center in Oxford.

To investigate, the team examined data on 485 patients from six UK hospitals participating in the TARGIT-A trial. In this trial, patients who were to undergo lumpectomy were randomly assigned to TARGIT (n = 249) or EBRT (n = 236) before surgery. In addition, the current analysis included 22 patients who were treated at two additional UK centers with TARGIT after completion of the TARGIT-A trial.

The patients' postal codes, as well as Google Maps, were used to calculate the shortest driving distance between home and the radiotherapy center as well as the travel time. It was assumed that EBRT patients would make a total of 17 round-trips: one for consent, one for radiotherapy planning, and 15 for each of 15 fractions of radiotherapy they would undergo.

Carbon dioxide emissions were calculated on the basis of assumed fuel economy for a medium-sized family car with mileage of 40 miles per gallon. For a a diesel car, total carbon dioxide production was calculated to be 299 grams per mile, and for a nondiesel car, 272 grams per mile.

Patients receiving TARGIT traveled substantially fewer miles than those receiving EBRT: 21,681 miles (34,892 km) vs 92,591 miles (149,011 km). There was a significant difference in mean distance driven per patient: 87.1 miles (140.2 km) vs 392.3 miles (631.3 km) (P < .0001).

The researchers estimate that the total carbon dioxide emissions were 35.825 tons (32.5 metric tons), of which 81% were contributed by EBRT patients and 19% by TARGIT patients. Again, the difference in mean carbon dioxide emissions per patient was significantly lower with TARGIT than with EBRT, at 24.7 kg vs 111.4 kg (P < .0001).

The mean travel time required to undergo radiotherapy was 3.0 hours for TARGIT patients vs 14.0 hours for EBRT patients. In determing these data, consideration was not given to the amount of time spent in traffic jams, seeking a parking space, waiting at the clinic to receive radiotherapy, and undergoing radiotherapy.

With regard to the two treatment centers not included in the TARGIT-A trial, the researchers estimate that TARGIT saved, on average, 753 miles (1212 km) of travel. This equated to approximately 30.9 hours of travel time saved per patient at one center and 18.5 hours at the other.

In addition to noting the "quite profound" impact on patients' lives of traveling back and forth for EBRT, Dr Coombs said that the costs associated with the treatment need to be taken into account.

"But it's not just the direct costs. You've also got to think about the indirect costs, such as the fuel costs for the patient," he said.

"Then you've got the loss of earnings, which obviously have an impact, especially for a lot of people in their late 50s, early 60s, who will still be working. So you're losing several hours each day in loss of income," he added.

The TARGIT-A trial was supported by University College London Hospitals (UCLH)/UCL Comprehensive Biomedical Research Centre, UCLH Charities, the National Institute for Health Research Health Technology Assessment Programme, Ninewells Cancer Campaign, the National Health and Medical Research Council, and the German Federal Ministry of Education and Research. Multiple authors have financial ties to Carl Zeiss AG, a manufacturer of devices used in targeted intraoperative radiotherapy.

BMJ Open. Published online May 9, 2016. Full text

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