Palliative radiotherapy for breast cancer patients with skin invasion: a multi-institutional prospective observational study

Palliative radiotherapy for breast cancer patients with skin invasion: a multi-institutional... Abstract Purpose To clarify the efficacy of palliative radiotherapy for the relief of symptoms due to skin invasion in patients with breast cancer. Materials and methods We conducted a multi-institutional prospective observational study of patients who received palliative radiotherapy for skin invasion due to a primary lesion or chest wall recurrence. Bleeding/discharge, offensive odor, pain and QOL scores were evaluated before and 1, 3 and 6 months after radiotherapy. Results Twenty-one patients were assessed. Sixteen patients (76%) received 36 Gy in 12 fractions. The mean (±1 SD) score of bleeding/discharge was 1.90 ± 0.89 before radiotherapy, 1.50 ± 0.74 at 1 month, 0.47 ± 0.58 at 3 months, and 0.82 ± 1.04 at 6 months (P = 0.001). The mean score of offensive odor was 1.21 ± 1.38 before radiotherapy, 0.71 ± 0.92 at 1 month, 0.20 ± 0.41 at 3 months, and 0.27 ± 0.62 at 6 months (P = 0.008). The mean score of pain was 2.90 ± 1.22 before radiotherapy, 3.05 ± 1.36 at 1 month, 3.29 ± 1.10 at 3 months, and 3.31 ± 1.54 at 6 months (P = 0.431). The mean total score of QOL-ACD/QOL-ACD-B was 126.2 ± 24.5 before radiotherapy, 130.3 ± 26.3 at 1 month, 136.2 ± 26.6 at 3 months, and 126.6 ± 32.8 at 6 months (P = 0.178). Conclusion Palliative radiotherapy for skin invasion in patients with breast cancer might be effective, especially for the relief of bleeding/discharge and offensive odor. breast cancer, radiotherapy, palliative radiotherapy, skin invasion Introduction Patients with advanced primary tumors of breast cancer or chest wall recurrence after mastectomy often develop symptoms associated with skin invasion, which significantly impairs the patients’ quality of life (QOL) due to bleeding/discharge, offensive odor and pain (1). Although palliative radiotherapy is recommended for patients with these symptoms (2), its efficacy has been poorly defined (3,4). This study aimed to clarify the efficacy of palliative radiotherapy for the relief of symptoms due to skin invasion in patients with breast cancer. Typically, a tangential opposed field of 4–6 MV X-rays with a tissue-equivalent bolus was used. The clinical target volume included the gross tumor volume that caused the symptoms. Dose fractionations were based on the physicians’ preference, considering patients’ performance status. Materials and methods With the approval of each institutional review board, we conducted a multi-institutional prospective observational study. The eligible patients were those who received palliative radiotherapy for skin invasion of the primary tumor or chest wall recurrence. Endpoints Bleeding/discharge, offensive odor, pain and QOL scores were evaluated before and 1, 3 and 6 months after radiotherapy. Using a 5-point scale, two observers (physician and nurse) independently assessed bleeding/discharge (0: none, 1: on contact, 2: intermittent, 3: continuous, 4: requires surgical intervention) and offensive odor (0: none, 1: subtle, 2: mild [noticeable around skin invasion], 3: moderate [noticeable around the patient], 4: severe [noticeable in the same room]). If scores differed between observers, the average scores were used. Patients rated pain on a 5-point scale ranging from 1 (severe) to 5 (no pain). Information on pain medication use (opioid agents, non-opioid agents or none) was also collected. A Japanese QOL questionnaire specifically designed for breast cancer patients (QOL questionnaire for cancer patients treated with anticancer drugs [QOL-ACD]/QOL-ACD-B) was used for QOL assessment (5,6). Adverse events were evaluated at 1, 3 and 6 months after radiotherapy based on the Common Terminology Criteria for Adverse Events version 3.0. Statistical analysis Statistical analysis was performed using SPSS version 22.0 (IBM, USA). Friedman’s test was used to compare scores of bleeding/discharge, offensive odor, pain, and QOL-ACD/QOL-ACD-B before and 1, 3 and 6 months after radiotherapy. Endpoints with significant differences were then analyzed by the Wilcoxon signed-rank test to compare scores between two time points (before versus 1, 3 or 6 months after radiotherapy). The Wilcoxon signed-rank test was also used to compare pain medication use between each time point. Two-tailed P values less than 0.05 (Friedman’s test) and 0.016 (Wilcoxon signed-rank test) were considered significant, taking multiplicity into account using Bonferroni correction. Results A total of 25 patients were recruited from three institutions from April 2014 to September 2016. Of these, 21 patients were assessed, excluding four patients who had died or had a poor performance status at 1 month after radiotherapy. Patient characteristics are shown in Table 1. Table 1. Patient characteristics Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) ECOG, Eastern Cooperative Oncology Group. Table 1. Patient characteristics Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) ECOG, Eastern Cooperative Oncology Group. Symptom relief and QOL improvement Bleeding/discharge and offensive odor were significantly improved after radiotherapy (P = 0.001 and P = 0.008, respectively, by Friedman’s test). Comparisons by the Wilcoxon signed-rank test showed significant improvements in bleeding/discharge at 3 months (P = 0.001) and 6 months (P = 0.009), and in offensive odor at 3 months (P = 0.005) (Figs. 1 and 2). Figure 1. View largeDownload slide Box plots of bleeding/discharge scores before and after radiotherapy. Error bars indicate range. Figure 1. View largeDownload slide Box plots of bleeding/discharge scores before and after radiotherapy. Error bars indicate range. Figure 2. View largeDownload slide Box plots of offensive odor scores before and after radiotherapy. Error bars indicate range. Figure 2. View largeDownload slide Box plots of offensive odor scores before and after radiotherapy. Error bars indicate range. No significant improvements were observed in pain (P = 0.431) (Fig. 3), pain medication use (P = 0.087) (Table 2), or total scores of QOL-ACD/QOL-ACD-B (P = 0.178) (Fig. 4). Figure 3. View largeDownload slide Box plots of pain scores before and after radiotherapy. Error bars indicate range. Figure 3. View largeDownload slide Box plots of pain scores before and after radiotherapy. Error bars indicate range. Table 2. Pain medication use before and after radiotherapy (P = 0.087 by Freidman’s test) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) View Large Table 2. Pain medication use before and after radiotherapy (P = 0.087 by Freidman’s test) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) View Large Figure 4. View largeDownload slide Box plots of total scores of quality of life questionnaires for cancer patients treated with anticancer drugs (QOL-ACD) and QOL-ACD-B before and after radiotherapy. Error bars indicate range. Figure 4. View largeDownload slide Box plots of total scores of quality of life questionnaires for cancer patients treated with anticancer drugs (QOL-ACD) and QOL-ACD-B before and after radiotherapy. Error bars indicate range. Adverse events Grade 2 and 3 dermatitis was observed in one (5%) and two patients (10%), respectively. No other ≥Grade 2 adverse events were noted. Discussion To the best of our knowledge, this is the first prospective study to report on the efficacy of palliative radiotherapy for breast cancer with skin invasion. Bleeding/discharge and offensive odor significantly improved after palliative radiotherapy. Best responses were obtained at 3 months after radiotherapy for bleeding/discharge, offensive odor and QOL scores, suggesting that the re-progression of symptoms might have occurred at 6 months. As most patients received 36 Gy in 12 fractions, optimization of dose fractionation might be necessary to achieve higher rates and a longer duration of symptom relief. No improvement in pain was observed in the present study. It was surprising because it is well-known that radiotherapy is effective for pain relief in the various palliative settings (7–10). In our study, few patients reported severe pain, and only 14% of patients took opioid agents before radiotherapy. The fact that pain was not the dominant symptom in our cohort might make it difficult to show the efficacy of radiotherapy on pain relief. In addition, no improvement in QOL scores was observed, suggesting that tumor progression outside the radiation field might have affected the QOL, irrespective of improvements in skin invasion symptoms. We used 5-point scales that we defined by ourselves to assess bleeding/discharge and offensive odor. Our scales may be easy to apply. On the other hand, it is a limitation of our study that symptoms were evaluated using non-validated scales. The lack of validated scales, which hinders clinical research on palliative therapy for skin invasion, is an important issue that needs to be addressed in the future. Nonetheless, our findings provide new insights into palliative therapy for skin invasion, as strong evidence is not yet available. In conclusion, palliative radiotherapy for skin invasion in patients with breast cancer might be effective, especially for the relief of bleeding/discharge and offensive odor. Presentation A part of this report was presented at the 59th Annual Meeting of the American Society of Therapeutic Radiology and Oncology in San Diego, CA, USA, on 24–27 September 2017. Conflict of interest statement None declared. References 1 Fracchia AA , Evans JF , Eisenberg BL . Stage III carcinoma of the breast. A detailed analysis . Ann Surg 1980 ; 192 : 705 – 10 . Google Scholar CrossRef Search ADS PubMed 2 Cardoso F , Costa A , Norton L , et al. . ESO-ESMO 2nd international consensus guidelines for advanced breast cancer (ABC2)dagger . Ann Oncol 2014 ; 25 : 1871 – 88 . Google Scholar CrossRef Search ADS PubMed 3 Yoshioka S , Hojou S , Toyoda Y , et al. . Three cases of breast cancer with skin metastasis after mastectomy treated by radiotherapy . Gan to Kagaku Ryoho 2010 ; 37 : 2766 – 8 . Google Scholar PubMed 4 Ozeki J , Enomoto K , Sakurai K , Amano S . A case of the breast cancer metastases to skin treated with local radiotherapy was effective . Gan to Kagaku Ryoho 2010 ; 37 : 2763 – 5 . Google Scholar PubMed 5 Kurihara M , Shimizu H , Tsuboi K , et al. . Development of quality of life questionnaire in Japan: quality of life assessment of cancer patients receiving chemotherapy . Psychooncology 1999 ; 8 : 355 – 63 . Google Scholar CrossRef Search ADS PubMed 6 Otsuka S , Watanabe N , Sasaki Y , Shimojima R . Postoperative courses of breast reconstruction using inferior adipofascial tissue repair . Breast Cancer 2015 ; 22 : 570 – 7 . Google Scholar CrossRef Search ADS PubMed 7 Ashby M . The role of radiotherapy in palliative care . J Pain Symptom Manage 1991 ; 6 : 380 – 8 . Google Scholar CrossRef Search ADS PubMed 8 Chow E , Zeng L , Salvo N , Dennis K , Tsao M , Lutz S . Update on the systematic review of palliative radiotherapy trials for bone metastases . Clin Oncol (R Coll Radiol) 2012 ; 24 : 112 – 24 . Google Scholar CrossRef Search ADS PubMed 9 Cameron MG , Kersten C , Guren MG , Fossa SD , Vistad I . Palliative pelvic radiotherapy of symptomatic incurable prostate cancer – a systematic review . Radiother Oncol 2014 ; 110 : 55 – 60 . Google Scholar CrossRef Search ADS PubMed 10 Fairchild A , Harris K , Barnes E , et al. . Palliative thoracic radiotherapy for lung cancer: a systematic review . J Clin Oncol 2008 ; 26 : 4001 – 11 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Japanese Journal of Clinical Oncology Oxford University Press

Palliative radiotherapy for breast cancer patients with skin invasion: a multi-institutional prospective observational study

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Abstract

Abstract Purpose To clarify the efficacy of palliative radiotherapy for the relief of symptoms due to skin invasion in patients with breast cancer. Materials and methods We conducted a multi-institutional prospective observational study of patients who received palliative radiotherapy for skin invasion due to a primary lesion or chest wall recurrence. Bleeding/discharge, offensive odor, pain and QOL scores were evaluated before and 1, 3 and 6 months after radiotherapy. Results Twenty-one patients were assessed. Sixteen patients (76%) received 36 Gy in 12 fractions. The mean (±1 SD) score of bleeding/discharge was 1.90 ± 0.89 before radiotherapy, 1.50 ± 0.74 at 1 month, 0.47 ± 0.58 at 3 months, and 0.82 ± 1.04 at 6 months (P = 0.001). The mean score of offensive odor was 1.21 ± 1.38 before radiotherapy, 0.71 ± 0.92 at 1 month, 0.20 ± 0.41 at 3 months, and 0.27 ± 0.62 at 6 months (P = 0.008). The mean score of pain was 2.90 ± 1.22 before radiotherapy, 3.05 ± 1.36 at 1 month, 3.29 ± 1.10 at 3 months, and 3.31 ± 1.54 at 6 months (P = 0.431). The mean total score of QOL-ACD/QOL-ACD-B was 126.2 ± 24.5 before radiotherapy, 130.3 ± 26.3 at 1 month, 136.2 ± 26.6 at 3 months, and 126.6 ± 32.8 at 6 months (P = 0.178). Conclusion Palliative radiotherapy for skin invasion in patients with breast cancer might be effective, especially for the relief of bleeding/discharge and offensive odor. breast cancer, radiotherapy, palliative radiotherapy, skin invasion Introduction Patients with advanced primary tumors of breast cancer or chest wall recurrence after mastectomy often develop symptoms associated with skin invasion, which significantly impairs the patients’ quality of life (QOL) due to bleeding/discharge, offensive odor and pain (1). Although palliative radiotherapy is recommended for patients with these symptoms (2), its efficacy has been poorly defined (3,4). This study aimed to clarify the efficacy of palliative radiotherapy for the relief of symptoms due to skin invasion in patients with breast cancer. Typically, a tangential opposed field of 4–6 MV X-rays with a tissue-equivalent bolus was used. The clinical target volume included the gross tumor volume that caused the symptoms. Dose fractionations were based on the physicians’ preference, considering patients’ performance status. Materials and methods With the approval of each institutional review board, we conducted a multi-institutional prospective observational study. The eligible patients were those who received palliative radiotherapy for skin invasion of the primary tumor or chest wall recurrence. Endpoints Bleeding/discharge, offensive odor, pain and QOL scores were evaluated before and 1, 3 and 6 months after radiotherapy. Using a 5-point scale, two observers (physician and nurse) independently assessed bleeding/discharge (0: none, 1: on contact, 2: intermittent, 3: continuous, 4: requires surgical intervention) and offensive odor (0: none, 1: subtle, 2: mild [noticeable around skin invasion], 3: moderate [noticeable around the patient], 4: severe [noticeable in the same room]). If scores differed between observers, the average scores were used. Patients rated pain on a 5-point scale ranging from 1 (severe) to 5 (no pain). Information on pain medication use (opioid agents, non-opioid agents or none) was also collected. A Japanese QOL questionnaire specifically designed for breast cancer patients (QOL questionnaire for cancer patients treated with anticancer drugs [QOL-ACD]/QOL-ACD-B) was used for QOL assessment (5,6). Adverse events were evaluated at 1, 3 and 6 months after radiotherapy based on the Common Terminology Criteria for Adverse Events version 3.0. Statistical analysis Statistical analysis was performed using SPSS version 22.0 (IBM, USA). Friedman’s test was used to compare scores of bleeding/discharge, offensive odor, pain, and QOL-ACD/QOL-ACD-B before and 1, 3 and 6 months after radiotherapy. Endpoints with significant differences were then analyzed by the Wilcoxon signed-rank test to compare scores between two time points (before versus 1, 3 or 6 months after radiotherapy). The Wilcoxon signed-rank test was also used to compare pain medication use between each time point. Two-tailed P values less than 0.05 (Friedman’s test) and 0.016 (Wilcoxon signed-rank test) were considered significant, taking multiplicity into account using Bonferroni correction. Results A total of 25 patients were recruited from three institutions from April 2014 to September 2016. Of these, 21 patients were assessed, excluding four patients who had died or had a poor performance status at 1 month after radiotherapy. Patient characteristics are shown in Table 1. Table 1. Patient characteristics Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) ECOG, Eastern Cooperative Oncology Group. Table 1. Patient characteristics Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) Factor Number of patients Median age (range) 53 (42–85) years Median duration from the onset of breast cancer (range) 36 (2–170) months ECOG performance status 0–1 18 (86%) 2 2 (10%) 3 1 (5%) Dose fractionation 36 Gy in 12 fractions 16 (76%) 30 Gy in 10 fractions 2 (10%) 39 Gy in 13 fractions 1 (5%) 50 Gy in 20 fractions 1 (5%) 60 Gy in 30 fractions 1 (5%) Concurrent systemic therapy Chemotherapy 3 (14%) Hormone therapy 6 (29%) Supportive care 12 (57%) Pain medication Opioid agents 3 (14%) Non-opioid agents 8 (38%) None 10 (48%) ECOG, Eastern Cooperative Oncology Group. Symptom relief and QOL improvement Bleeding/discharge and offensive odor were significantly improved after radiotherapy (P = 0.001 and P = 0.008, respectively, by Friedman’s test). Comparisons by the Wilcoxon signed-rank test showed significant improvements in bleeding/discharge at 3 months (P = 0.001) and 6 months (P = 0.009), and in offensive odor at 3 months (P = 0.005) (Figs. 1 and 2). Figure 1. View largeDownload slide Box plots of bleeding/discharge scores before and after radiotherapy. Error bars indicate range. Figure 1. View largeDownload slide Box plots of bleeding/discharge scores before and after radiotherapy. Error bars indicate range. Figure 2. View largeDownload slide Box plots of offensive odor scores before and after radiotherapy. Error bars indicate range. Figure 2. View largeDownload slide Box plots of offensive odor scores before and after radiotherapy. Error bars indicate range. No significant improvements were observed in pain (P = 0.431) (Fig. 3), pain medication use (P = 0.087) (Table 2), or total scores of QOL-ACD/QOL-ACD-B (P = 0.178) (Fig. 4). Figure 3. View largeDownload slide Box plots of pain scores before and after radiotherapy. Error bars indicate range. Figure 3. View largeDownload slide Box plots of pain scores before and after radiotherapy. Error bars indicate range. Table 2. Pain medication use before and after radiotherapy (P = 0.087 by Freidman’s test) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) View Large Table 2. Pain medication use before and after radiotherapy (P = 0.087 by Freidman’s test) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) Number of patients assessed Opioid agents Non-opioid agents None Before radiotherapy 21 3 (14%) 8 (38%) 10 (48%) 1 Month after radiotherapy 19 3 (16%) 3 (16%) 13 (68%) 3 Months after radiotherapy 16 1 (6%) 1 (6%) 14 (88%) 6 Months after radiotherapy 15 4 (27%) 2 (13%) 9 (60%) View Large Figure 4. View largeDownload slide Box plots of total scores of quality of life questionnaires for cancer patients treated with anticancer drugs (QOL-ACD) and QOL-ACD-B before and after radiotherapy. Error bars indicate range. Figure 4. View largeDownload slide Box plots of total scores of quality of life questionnaires for cancer patients treated with anticancer drugs (QOL-ACD) and QOL-ACD-B before and after radiotherapy. Error bars indicate range. Adverse events Grade 2 and 3 dermatitis was observed in one (5%) and two patients (10%), respectively. No other ≥Grade 2 adverse events were noted. Discussion To the best of our knowledge, this is the first prospective study to report on the efficacy of palliative radiotherapy for breast cancer with skin invasion. Bleeding/discharge and offensive odor significantly improved after palliative radiotherapy. Best responses were obtained at 3 months after radiotherapy for bleeding/discharge, offensive odor and QOL scores, suggesting that the re-progression of symptoms might have occurred at 6 months. As most patients received 36 Gy in 12 fractions, optimization of dose fractionation might be necessary to achieve higher rates and a longer duration of symptom relief. No improvement in pain was observed in the present study. It was surprising because it is well-known that radiotherapy is effective for pain relief in the various palliative settings (7–10). In our study, few patients reported severe pain, and only 14% of patients took opioid agents before radiotherapy. The fact that pain was not the dominant symptom in our cohort might make it difficult to show the efficacy of radiotherapy on pain relief. In addition, no improvement in QOL scores was observed, suggesting that tumor progression outside the radiation field might have affected the QOL, irrespective of improvements in skin invasion symptoms. We used 5-point scales that we defined by ourselves to assess bleeding/discharge and offensive odor. Our scales may be easy to apply. On the other hand, it is a limitation of our study that symptoms were evaluated using non-validated scales. The lack of validated scales, which hinders clinical research on palliative therapy for skin invasion, is an important issue that needs to be addressed in the future. Nonetheless, our findings provide new insights into palliative therapy for skin invasion, as strong evidence is not yet available. In conclusion, palliative radiotherapy for skin invasion in patients with breast cancer might be effective, especially for the relief of bleeding/discharge and offensive odor. Presentation A part of this report was presented at the 59th Annual Meeting of the American Society of Therapeutic Radiology and Oncology in San Diego, CA, USA, on 24–27 September 2017. Conflict of interest statement None declared. References 1 Fracchia AA , Evans JF , Eisenberg BL . Stage III carcinoma of the breast. A detailed analysis . Ann Surg 1980 ; 192 : 705 – 10 . Google Scholar CrossRef Search ADS PubMed 2 Cardoso F , Costa A , Norton L , et al. . ESO-ESMO 2nd international consensus guidelines for advanced breast cancer (ABC2)dagger . Ann Oncol 2014 ; 25 : 1871 – 88 . Google Scholar CrossRef Search ADS PubMed 3 Yoshioka S , Hojou S , Toyoda Y , et al. . Three cases of breast cancer with skin metastasis after mastectomy treated by radiotherapy . Gan to Kagaku Ryoho 2010 ; 37 : 2766 – 8 . Google Scholar PubMed 4 Ozeki J , Enomoto K , Sakurai K , Amano S . A case of the breast cancer metastases to skin treated with local radiotherapy was effective . Gan to Kagaku Ryoho 2010 ; 37 : 2763 – 5 . Google Scholar PubMed 5 Kurihara M , Shimizu H , Tsuboi K , et al. . Development of quality of life questionnaire in Japan: quality of life assessment of cancer patients receiving chemotherapy . Psychooncology 1999 ; 8 : 355 – 63 . Google Scholar CrossRef Search ADS PubMed 6 Otsuka S , Watanabe N , Sasaki Y , Shimojima R . Postoperative courses of breast reconstruction using inferior adipofascial tissue repair . Breast Cancer 2015 ; 22 : 570 – 7 . Google Scholar CrossRef Search ADS PubMed 7 Ashby M . The role of radiotherapy in palliative care . J Pain Symptom Manage 1991 ; 6 : 380 – 8 . Google Scholar CrossRef Search ADS PubMed 8 Chow E , Zeng L , Salvo N , Dennis K , Tsao M , Lutz S . Update on the systematic review of palliative radiotherapy trials for bone metastases . Clin Oncol (R Coll Radiol) 2012 ; 24 : 112 – 24 . Google Scholar CrossRef Search ADS PubMed 9 Cameron MG , Kersten C , Guren MG , Fossa SD , Vistad I . Palliative pelvic radiotherapy of symptomatic incurable prostate cancer – a systematic review . Radiother Oncol 2014 ; 110 : 55 – 60 . Google Scholar CrossRef Search ADS PubMed 10 Fairchild A , Harris K , Barnes E , et al. . Palliative thoracic radiotherapy for lung cancer: a systematic review . J Clin Oncol 2008 ; 26 : 4001 – 11 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Japanese Journal of Clinical OncologyOxford University Press

Published: Apr 19, 2018

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