Partial-breast radiation is a promising alternative to whole-breast radiation to many patients with breast cancer — especially if their disease is low-risk, according to research presented at the 

2019 American Society of Clinical Oncology (ASCO) annual meeting

Administering post-lumpectomy partial-breast radiation can improve patients’ quality of life and lead to better compliance for many women, especially if it’s given in an accelerated manner. Additionally, while whole-breast radiation did have slightly better outcomes, the difference between the 2 was minimal, according to the study, which involved about 4200 women with breast cancer.

At the median follow-up of 10.2 years, the researchers found low recurrence rates, less than a percentage point off.

“The local recurrence rate was about 3.9% in the whole-breast radiation arm, and it was 4.6% in the partial-breast [arm],” said study investigator Julia White, MD, professor of radiation oncology at The Ohio State University Comprehensive Cancer Center.

White explained that if clinicians keep in mind the total overall dose, they may be able to give more radiation per day, thus shortening the course of treatment for eligible patients. In her practice and on the clinical trial, she used a regimen of 10 fractions, 10 treatments, given twice a day, 5 days a week. The treatments are typically broken up by a weekend.

“It’s done in 5 days. So, someone who lives far away can stay with a friend or family member, or maybe even a hotel, and get their radiation. That’s the idea of accelerated partial-breast radiation,” White said.

Other studies comparing whole-breast versus partial-breast radiation still use 15 to 16 treatments, and typically involve patients with low-risk, stage I disease.

“There are 2 or 3 other studies, but they all focused on the low-risk, luminal A group, [with patients whose disease was] mostly node-negative,” White said. “Our question was: Is partial-breast radiation equivalent to whole-breast radiation across the spectrum of all women who get a lumpectomy, not just the low-risk women?”

And while White and her team’s study looked at women overall, she did mention that the low-risk group had lower event rates.

“So, the difference might not be so clinically meaningful, but in subtypes or risk groups where the recurrence rates are higher, then those differences between whole-breast and partial-breast are more meaningful, clinically,” she said. “The good news is that the event rates were low altogether.”

White said that she believes partial-breast radiation would be best suited for stage I, ER-positive patients who are over the age of 50 and on endocrine therapy. “But based on our trial, it won’t replace whole-breast radiation for everybody.”

While studies like these continue to enlighten practitioners on the best way to use radiation oncology, there is still more work that needs to be done.

“I think the next step for this research is to fine-tune how we deliver radiotherapy,” White said. “There’s a learning curve to every new technology that we adapt and put into practice. It’s important for us as a specialty to continue researching what are the best methods.

Articles

Partial-breast radiation may be more convenient for patients with breast cancer, and according to recent research, the outcomes aren’t much different than patients who had whole-breast radiation.

Partial-Breast Radiation Promising for Some Breast Cancer Survivors

At the 2019 Annual ASCO meeting in Chicago, 

got the chance to speak with Martha Raymond, CEO and founder of the 

, and executive director at the GI Cancers Alliance.

We discussed where she sees growth for the GI Cancers Alliance going, as the group is now partnered with over 40 international advocacy organizations, and how her work with the Raymond Foundation continues to provide caregivers with resources on how to help the patient and themselves.

What are some new initiatives and programs from the GI Cancers Alliance?

New initiatives of the GI Cancers Alliance include a new clinical trials initiative where we provide our members with a 5-part webinar series on how we could help transform the clinical trials experience for patients. Along with that initiative, we are now voting with our members to decide where we’ll go from there after receiving all of the education from the webinar. In addition, we are looking at advocacy initiatives to possibly reach the hill, state groups, and even grassroots advocacy as another way to help amplify our collective voice.

Every day we speak to possible new members, we tell them about the work we're doing, and I think a lot of our new growth will happen in the international space. Luckily, we do represent all disease states in gastrointestinal cancers, so we're very proud of that. Even in some of the small disease states, we're able to provide them a platform to get their information out to help with education for patients and I do think internationally we will be gaining many new members very soon. 

Can you provide a brief history of the Raymond Foundation?

The Raymond Foundation was founded over 30 years ago in honor of my parent's Margaret and Patrick Raymond who both passed away with colon cancer when they were very young. Back when they were diagnosed there were no diagnostic tests, there were no screening tests and there was really only one drug available at the time, which was 5FU.

We've come a long way in these 30 years with new treatment protocols for patients and I'm very proud to say that looking back where we were 30 years ago to where we are now, and I know there are more strides we still need to make to help patients but again, just in my lifetime there were no resources there to help patients, not even cancer patients in general, much less colon cancer patients and now there are. So, we are looking forward to new growth to continue to help the caregiver and the patient. 

What are the new cancer caregiver initiatives?

We're very proud at the Raymond Foundation to have launched the first cancer caregiver action plan. It’s really a road map for cancer caregivers for all disease states to let them know that basically they're not alone and to let them know the tools they might use to help themselves, because as we all know, being a caregiver is difficult. They want to be strong for the patient, but at the same time they have to take care of their own needs, which is very difficult for caregivers.

What we provide is information both on our website and in a downloadable form so caregivers will have a tool kit, an actual guide, to help them. Let them know they're not alone, let them hear stories of what they've experienced so they might learn lessons from other caregivers and we're excited as we continue the launch of our action plan that will go into in-depth programming for newly diagnosed patients all the way through palliative care all the way through a hospice care situation. So, I think we will provide caregivers and patients a road map throughout the whole care continuum.

Could you expand on the Cancer Caregiver Action plan?

Our cancer caregiver action plan is available for free, it is on our website on 

 and also available in print copies, so if individuals want to take the actual copy to their oncologist office and share it with a patient, or even share it in support groups, they can do so.

We've learned a lot that caregivers are taking the plan and they're sharing it, they're learning from it, and one of the wonderful parts I think of the care plan is that it provides a journal as well. Allowing caregivers to journal their experience and keep notes about the care continuum with the patient.     

At the 2019 Annual ASCO meeting in Chicago, Oncology Nursing News got the chance to speak with Martha Raymond, CEO and founder of the Raymond Foundation, and executive director at the GI Cancers Alliance.

The Raymond Foundation Is Dedicated to Helping Patients and Caregivers

By the year 2024 there will be 11 million cancer survivors in the United States, and the majority of them will be over the age of 65. This will put these survivors at greater risk of developing new chronic conditions, according to Kelly Kenzik, PhD, MS, assistant professor in the division of hematology and oncology, and associate scientist at the O'Neil Comprehensive Cancer Center at University of Alabama at Birmingham.

At the 2019 ASCO Annual Meeting Kenzik presented research on how this greater risk is creating a larger burden on not just the individual, but providers and care systems as well. 

 got the chance to sit down with Kenzik and discuss the findings of this research and its implications.

How can a further study of the cumulative burden of chronic health conditions (CHCs) inform healthcare delivery in these patients?

We've done this in the childhood cancer survivor population, and we wanted to see if we could do this in an older adult population because the burden actually represents not just developing the condition, but how frequently you're now engaging with the healthcare system over time. So, getting diagnosed with diabetes and how many recurrent events are showing up after that over a 1-year, 5-year, 10-year period is both informative to the patient side for survivorship care planning, and to the health system, to know what to expect for a cancer survivor who then develops diabetes after their diagnosis.

What were the methods and findings of this study?

For this study, we used SEER-Medicare data, which is a large national cancer research database, combined with Medicare administrative claims. We used this to identify 300,082 breast, prostate, colon, and non-Hodgkin lymphoma survivors all over the age of 65. What we then wanted to see was what new conditions developed after their cancer diagnosis, so we looked at 109 different conditions grouped into 10 organ-system categories. We worked with St. Jude co-authors to kind of see if we could mimic some of the childhood cancer survivor study to see what this looks like in an older adult population.

In doing this, we looked at all of these 109 conditions and looked at the nuance at morbidity, which were the new existing conditions that developed after cancer. We then looked at the recurrent events and classified them as chronic or classified conditions then looking at the burden, so whether they were showing up in inpatient visit or an outpatient visit over a 1-, 5-, and 10-year period for all of these, and largely we saw that cardiovascular conditions were our most common condition that created the most burden on patients and the system. We also saw that musculoskeletal diseases were very prominent as well. The conditions that showed hospitalizations were some of those we associated with aging. For instance, large weight loss, fluid, and electrolyte imbalances were putting people in the hospital.

Overall, we started to see this pattern emerge and saw how each cancer had their own specific set up, so we were able to target down and see which conditions showed up for each.

Why did some cancer survivors have more overall burden than others?

What we did start to see was that if you look at overall numbers often times they would look similar, but once you started to break down the individual disease groupings you can see that colorectal patients were having all of their GI issues popping up and those may put you in the hospital quicker than having a diabetes issue that can be resolved by having an outpatient visit.

So, depending on what the nuance at morbidity was some of those were more severe in putting people in an inpatient setting more so than an outpatient setting. For example, colorectal cancer is primarily treated with surgeries which can result in longer-term issues for GI-related conditions.

Are there any next steps for this research?

An important aspect to this research is paralleling this with the cost of care, what is the cost to the patient for these types of visits and what is the cost to the system. We want to know what the financial burden of this is and what are the best care pathways we can send people down to reduce the burden on the patient and the system.

With more people surviving long after their cancer diagnosis, there is also a heightened risk of developing chronic health conditions.

Examining Chronic Health Conditions in Cancer Survivors

In a recent study comparing outcomes between breast cancer survivors who received whole-breast radiation to those who received partial-breast radiation, researchers found that there were not drastic differences between the two, explained Julia White, MD, head of breast radiation oncology at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. 

After a follow-up of about 10 years, 3.9% of patients who had whole-breast radiation had local recurrences, compared to 4.6% of patients who had partial-breast radiation. Additionally, White mentioned that there were lower recurrence rates for low-risk patients, so they may be even better candidates for partial-breast radiation. 

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There is not a major difference in outcomes between whole-breast and partial-breast radiation for some patients with breast cancer.

Whole-Breast Versus Partial-Breast Radiation

The treatment of gastrointestinal (GI) cancers is a team sport, and oncology nurses are key players, explained Craig Lustig, MPA, the associate director for the Ruesch Center for the Cure of Gastrointestinal Cancers. 

The director of our center often talks about that cancer is a team sport. That's not meant to be flippant, it's a reality [because], in particular patients with GI cancer need to be evaluated, first and foremost, by a number of different providers, potentially to really best understand the disease and then develop the best approach. 

I think then on the flip side, as the patient is going through treatment, the providers, the nurses, and, and maybe technicians, folks who you're interacting with on a day-to-day basis are incredibly valuable. They can provide information and tools to help you through that treatment experience. We know that many of the diseases and the GI cancers can be a very a heavy burden on the individual, on their functioning. So, the nurses that you may encounter in the clinic or in the infusion area can give you advice and tools because they have seen so many patients who are dealing with these things. 

The other thing that's important is that treatments evolve, so the side effects, let's say for more common chemotherapy agents, we know are different than the newer immunotherapy agents. Understanding those differences is the kind of thing that a nurse who is really educated in that area can help you through. The guidance they're going to give you is about how you can best tolerate those treatments, and ultimately get the maximum benefit from them. 

The treatment of gastrointestinal cancers is a team sport, and nurses are key players.

GI Cancer Treatment Is a Team Sport

Gut microbiome may impact immunotherapy response in patients with cancer, according to Ryan Weight, DO, MD, assistant professor of medicine-medical oncology at the University of Colorado School of Medicine.

Weight, who presented research on the topic at the 2019 ASCO Annual Meeting, recently sat down with 

 to discuss the importance of a healthy microbiota, and what patients can do to improve it.

: What do we know about the role of the microbiome in maintaining balance in the immune system? 

 We're learning more about the microbiome everyday through ongoing studies. We are starting to gain an understanding of its importance and its role within the response to immunotherapy and immune checkpoint blockade agents. From the data that is available, we understand that data suggests a diverse microbiome within the gut can improve response to immune checkpoint blockade across various tumor types. 

What is some of the research that supports that? 

There are a number of basic science studies and preclinical work that has been performed. Many of these studies that have been published to-date are on mouse models which have looked at the fecal microbiota of mice and their response to implanted tumors within the mice. 

Some of the more interesting work that has been published is that if you perform a fecal microbiota transplant from a patient, say with melanoma, who had a response to their immune checkpoint blockade, if you take the feces from that patient and you transplant it, at least in a mouse model, also with melanoma, you can increase the response rate to immune checkpoint blockade in that mouse model through a fecal microbiota transplant. 

Through some of that basic science and translational clinical work, we're beginning to understand the importance of both the diversity and the immune-specific role of the fecal microbiota in response to immune checkpoint blockade. 

What is the role of diet in maintaining a diverse microbiome? 

Even more recently, there has been a couple of studies that have come out that have found that agents that manipulate the gut microbiota can influence response to immune checkpoint blockades. Now these, keep in mind, are not large, randomized clinical trials, but they are some retrospective studies that have looked at response to immune checkpoint blockade based on the oral intake of the patients who have been receiving those agents. Some of the things that have been highlighted over the past couple of years have been things like probiotics, high-fiber diets, and antibiotics. All 3 of those have been shown to influence, at least retrospectively, the outcomes in patients receiving immune checkpoint blockade. 

For example, there is a suggestion that antibiotics can reduce the diversity of the gut microbiome. Probiotics can also reduce the diversity of the gut microbiome, which may lead to a diminished response to immune checkpoint blockade. That's what these studies are suggesting. It needs to be bore out in large, randomized clinical trials, but it's an interesting thing to think about in our patients who are receiving these agents. 

In addition to that, there is a suggestion that a high fiber diet can improve gut diversity, and therefore potentially improve the likelihood of response to immune checkpoint blockade. Again, more study is needed, but these are some interesting topics that are beginning to be looked at. 

Patients with cancer who are receiving immunotherapy may have improved responses if they have a healthy and diverse gut microbiome.

Gut Microbiome Can Impact Immunotherapy Response

Health-related quality of life (QOL) is becoming an increasingly important endpoint in cancer clinical trials, explained Giuseppe Lombardi, MD, PhD, a medical oncologist at the Veneto Institute of Oncology in Padua, Italy.

It is important that clinicians can offer patients not only the chance of improved survival, but also to live well in the meantime. This is especially true for patients with glioblastoma, who can have decreased neurologic or physical functioning. To ensure this, cancer treatment centers should assemble multidisciplinary teams that involve psychosocial supports, therapists, and more.

Health-related quality of life (QOL) is becoming an increasingly important endpoint in cancer clinical trials.

Quality of Life Is an Important Endpoint in Cancer Trials

While self-reported family cancer history is vital to screen individuals for hereditary cancer risk, its documentation tends to be lacking, according to recent research conducted at The University of Texas MD Anderson Cancer Center.

Researchers analyzed the electronic health records of more than 47,000 patients being treated at MD Anderson, and found that only 20.9% provided information on the 3 key aspects of family cancer history: the relationship to the family member with cancer, what kind of cancer they had, and the age that their family member was diagnosed.

“Family history is one of the key indicators of hereditary cancers. What we have found, and what the Office of Public Health and Genomics at the CDC has been propagating, is that there is a very large number of people within the population who do suffer from these hereditary cancer syndromes but may not know about it,” said study author Mala Pande, PhD, MPH, MBBS, assistant professor in the Department of Gastroenterology, Hepatology, and Nutrition at MD Anderson, in an interview with 

: How has family cancer history documentation by healthcare providers been suboptimal? 

 When we started looking at family history to increase ascertainment of high-risk cases, we were interested in seeing the quality of the family history that's been captured in the electronic health records at our institution. The literature has shown that there are a lot of barriers in collection of family history. ASCO had actually put out an expert statement in 2014 providing guidelines for what the minimum adequate family history really is that oncology providers should be getting. But due to various constraints, it just isn't as it should be. 

We found that even though about half of the people seen at MD Anderson over a period of 1 year had provided a cancer family history for 1 or more family members, there were gaps. The biggest gap was that even though patients are able to say, "Hey, my mother was affected, or my aunt was affected," they usually don't provide the age of diagnosis of family members. 

When you really look at the utility of family cancer history, it is to run a risk assessment to see if genetic testing or genetic referral is required for the patient. If you don't have a complete family history, it's not possible to run an accurate risk assessment. It really makes it important to have a good family history captured in the electronic health record. 

What were your findings and key takeaways? 

The key takeaways from this research were that family cancer history is sub-optimal, as we found from our data analysis. The biggest gap is in capturing the age of diagnosis for the family members who are affected by cancer. 

Some of the things that we are looking at doing are to improve the way the family history is captured. There is no standardized way, even in the electronic health record. It's a custom-designed questionnaire that goes out to our patients in advance of their visit so they can have the time to complete all the required information. Family history being as important as it is, the surgeon general has actually created a tool that can be used by patients to collect family health history. There's even a family cancer history collection they tied in with Thanksgiving where patients are encouraged to both document and collect their family history, as well as share it with all of their relatives and take it to their providers to be able to make the whole process simpler and easier. 

What are the clinical implications of this research, and what should nurses take away from it? 

For nurses, the key takeaway would be to ensure that the family history is as complete as possible. What we're doing in our electronic health records is trying to provide prompts for the patients to finish as much as possible, but then similarly, if those gaps can be addressed when patients are reviewed in clinic by the nurses. The best person to report on the family history is the patient themselves. If they can do it in advance, then they are more likely to have more complete information and more complete details of their family history. 

The first level of improving the data quality is the patients themselves. But there is a second level, which is the nurses and the providers. They have to also make sure that they realize the importance of family history, and the importance of completing the family history, because our goal cannot be achieved unless that is done, our goal being (to make) this process automated. [We want to] run risk assessment in the background of the electronic health record so that patients who are at high risk can be flagged and receive the genetic counseling or the genetics referral that can help address where they are at an increased genetic risk. 

While self-reported family cancer history is vital to screen individuals for hereditary cancer risk, its documentation tends to be lacking.

Family Cancer History Reporting Needs Improvement

The role of the oncology nurse is vital when it comes to treating patients with head and neck cancer, explained Michael G. Moore, MD, director of head and neck surgery at Indiana University Health and president of the 

The nurses' role is critical. They're the ones who are literally right beside the patient the whole way through, not only with regard to talking to them about their treatment and administering it, but really supporting them along the way. Many people outside of just the physician take care of people, and nurses are one of the primary groups of people that really help support people, hold their hands, and also really provide them with the second-to-second and minute-to-minute advice and support along the way of their treatment. 

Nurses are there for patients every step of the way.

Oncology Nurses Are Key in Head and Neck Cancer Care

Shared decision making between providers, patients, and their caregivers will be crucial moving forward in the 

. As treatment options, toxicities, tolerability, and prognoses change over time, the focus of care is likely to change, too, explained Noopur Raje, MD, the director of the Center for Multiple Myeloma as Massachusetts General Hospital.

According to a recent study Raje was involved in, patients are very dependent on their healthcare providers at the time of diagnosis. While there are fewer options in the frontline setting, they tend to want treatment soon, and favor efficacy over toxicity.

Then, in the later settings, patients have more choices, and they tend to go over toxicities more with their providers, weighing out the pros and cons of their options.

We looked at patients through different stages. We looked at patients at the time of diagnosis, and what we found was that at the time of diagnosis patients were fairly dependent on their healthcare providers. They were "go go go" and wanted to get the treatment done. There were not a lot of options, and I think that is pretty straightforward when you think about multiple myeloma. When it comes to newly diagnosed patients, we know we give them a triplet and we don't necessarily talk about toxicity as much because you want that efficacy. You want them to feel better. That's something that actually did pan out in this study.

When it comes to second-, third-, fourth-line treatment, there was a little bit of a difference. The difference here was that there was a lot more discussion on toxicity and there were a lot more choices. That's pretty much what we see in the field as well. You put not just patients but 5 myeloma experts in a room, you're not going to get the same uniform answer of this is how I would treat my patients. I think we saw that in this patient-related outcomes study. We saw that they did focus a little more on toxicity and they were given more choices as opposed to the frontline setting.

We do see differences and I think these differences are largely because of the fact that we do have choices. If we just had the one drug, we would not have this discussion. But the good news is that in myeloma we have multiple different treatment options that we can offer, and patients are engaging in that kind of a conversation.

In different stages of multiple myeloma treatment, patients' priorities may change.

ASCO Annual Meeting