Elsevier

Clinical Oncology

Volume 18, Issue 5, June 2006, Pages 369-375
Clinical Oncology

Original Article
Intra-European Differences in the Radiotherapeutic Management of Breast Cancer: A Survey Study

https://doi.org/10.1016/j.clon.2006.02.004Get rights and content

Abstract

Aims

To document and explain self-reported practices of the radiotherapeutic management of breast cancer within different European regions.

Methods

An original survey questionnaire was developed to assess radiation oncologists' self-reported management of breast cancer. The questionnaire was distributed to physician members of the American Society for Therapeutic Radiology and Oncology and the European Society of Therapeutic Radiation Oncology. This paper presents the results of the comparative analysis of 702 responses from North America and 435 responses from Europe.

Results

Several areas of variation are identified. These include the selection criteria for post-mastectomy radiation and radiation for ductal carcinoma in situ (DCIS). Variations are also seen in the management of regional lymph nodes after lumpectomy, and radiation dose and fractionation.

Conclusions

Radiation oncologists within Europe vary in their self-reported practices for managing women with breast cancer. These differences may be rooted in deeper cultural differences and differences in the healthcare systems of different European countries. They may also reflect differences in the relative weight radiation oncologists place upon data generated within their own countries. These results support the need for co-operative group trials to provide evidence for more uniform treatment recommendations and policies.

Introduction

In recent years, Europe has moved towards economic and political integration. Nevertheless, significant cultural and social differences persist among the various regions. Such differences are so deep that they may lead to divergent medical practices, even when the biological behaviour of human disease is expected to be relatively constant.

The management of breast cancer has been the focus of considerable research and innovation over the past century. Breast cancer has evolved from a disease treated almost exclusively with radical surgery to one in which more conservative interventions have been sought and tested. Despite the wealth of evidence that has been gathered from randomised trials, areas of controversy persist.

Regional differences in breast cancer care have been shown in previous studies 1, 2, 3. Therefore, we conducted a large-scale survey of radiation oncologists in North America and Europe, in order to document and understand the nature of any variations in radiotherapeutic management of breast cancer. We have previously published papers on regional differences within North America, as well as differences between North America and Europe as a whole 4, 26. With the exception of two particularly controversial areas — surgical margin width [5] and irradiation of the internal mammary chain [6] — no data on intra-European variation have yet been presented. In this paper, we present the data gathered on the other areas of intra-European variation in the radiotherapeutic management of breast cancer, as a means by which to appreciate the effects of cultural, social, political and other differences that may affect patterns of medical care.

Section snippets

Methods

Radiation oncologists in Europe and North America were sent a postal survey questionnaire inquiring about their management of breast cancer in a variety of clinical scenarios. The methods by which the original survey questionnaire was designed, pre-tested and administered have been described in detail elsewhere 4, 5, 6. In brief, questionnaires were posted to 3401 physician members of the American Society for Therapeutic Radiology and Oncology (ASTRO) and 2680 physician members of the European

Patient Data

A total of 1137 responses were obtained: 435 from Europe and 702 from North America. The European respondents included 44 from Eastern Europe; 36 from the UK; 80 from France and Belgium; 98 from Germany, Austria and Switzerland; 47 from Italy and Greece; 50 from Spain and Portugal; and 80 from the Netherlands, Sweden, Finland and Denmark. The American respondents included 667 from the USA and 35 from Canada.1

Discussion

Overall, respondents from the different European regions in this study reported offering relatively similar treatments to their patients. Nevertheless, several differences were observed. In particular, British respondents seemed more likely to hypofractionate treatment and to recommend against radiation treatment in patients with low-grade DCIS. They were also least likely to recommend regional nodal irradiation after lumpectomy and less likely to use boost doses of radiation after whole-breast

Conclusion

This international survey study identified several areas of agreement as well as areas of disagreement that exist in the radiotherapeutic management of breast cancer. Post-mastectomy radiation in patients with T3N0 disease or one to three positive lymph nodes is controversial within several regions of Europe. Consensus has been reached within Europe on the need for post-lumpectomy radiation therapy, but there seems to be a tendency to offer hypofractionated treatment, often without boost doses,

Acknowledgments

The authors would like to thank those physicians who took the time to complete this comprehensive survey. We also thank Dr Elizabeth Ceilley, Dr Simon Powell and Laurent Grignon for their valuable help. We would like also to acknowledge the valuable effort of Lean Minnen, ESTRO Membership Coordinator. We are also grateful to Nancy Briton, Ph.D. from the Survey and Measurement Core, Dana Farber/Harvard Cancer Center for statistical advice.

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