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