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Proton therapy is a radiation technique that yields less dose in normal tissues than photon therapy. In the Netherlands, proton therapy is reimbursed if the reduced dose to normal tissues is predicted to translate into a prespecified reduction in toxicity, based on nationally approved validated models. The aim of this paper is to present the development of a national indication protocol for proton therapy (NIPP) for model-based selection of breast cancer patients and to report on first clinical experiences. A national proton therapy working group for breast cancer (PWG-BC) screened the literature for prognostic models able to estimate the individual risk of specific radiation-induced side-effects. After critical appraisal and selection of suitable models, a NIPP for breast cancer was written and subjected to comments by all stakeholders. The approved NIPP was subsequently introduced to select breast cancer patients who would benefit most from proton therapy. The model of Darby et al. (N Engl J Med 2013; 368:987–82) was the only model fulfilling the criteria prespecified by the PWG-BC. The model estimates t he relative risk of an acute coronary event (ACE) based on the mean heart dose. The absolute lifetime risk of ACE <80 years was calculated by applying this model to the Dutch absolute incidence of ACE for female and male patients, between 40 and 70 years at breast cancer radiotherapy, with/without cardiovascular risk factors. The NIPP was approved for reimbursement in January 2019. Based on a threshold value of a 2% absolute lower risk on ACE for proton therapy compared with photons, 268 breast cancer patients have been treated in the Netherlands with proton therapy between February 2019 and January 2021. The NIPP includes a model that allows the estimation of the absolute risk on ACE <80 years based on mean heart dose. In the first 2 years, 268 breast cancer patients have been treated with proton therapy in The Netherlands. • Selection protocol was determined for proton therapy for breast cancer patients. • Prediction of lifetime risk of acute coronary events based on mean heart dose. • About 3–4% of breast cancer patients are expected to benefit from proton therapy. [ABSTRACT FROM AUTHOR]

Objective: Concerns of increased time consumption and of the impact on clinical decisions may restrain doctors from shared decision making (SDM). This paper evaluates consultation length and decisions made when using an in-consult patient decision aid (PtDA).Methods: This prospective cohort study compared an unexposed cohort with a cohort exposed to SDM and a PtDA in two preference-sensitive decision situations: invasive lung cancer diagnostics and adjuvant treatment for early breast cancer. Outcome measures were consultation length and decisions made.Results: The study included 261 consultations, 115 were in the SDM-exposed cohort. Consultations were inconsiderably longer in the SDM cohort; 2 min, 11 s (p = 0.2217) for lung cancer diagnostics and 3 min, 57 s (p = 0.1128) for adjuvant breast cancer treatment. In lung cancer diagnostics, consultation length became more uniform and decisions tended to become conservative after introduction of SDM. For adjuvant breast cancer, slightly more patients in the SDM cohort chose to decline treatment.Conclusion: Shared decision making did not take significantly longer time and led to slightly more conservative decisions.Practice Implications: SDM may be implemented without considerable impact on consultation length. The impact on clinical decisions depends mainly on the clinical situation. [ABSTRACT FROM AUTHOR]

Despite substantial strides to improve cancer control in India, challenges to deliver oncology services persist. One major challenge is the provision and accessibility of adequate infrastructure. This paper offers ethnographic insight on the conceptual and material conditions that are currently shaping the delivery of oncology in Mumbai, focusing specifically on the way India's socio-economic context necessitates non-biomedical acts of voluntarism or 'seva' (selfless service). Developing the premise that hospitals are not identical clones of a biomedical model, detailed attention is paid to the way 'care' emerges through 'praxis of place' (Casey, 2003) within the cancer hospital as a multi-scalar 'heterotopic' (Street and Coleman, 2012) site. Such a perspective enables global/local tensions to come into view, together with the heterogeneous confluence of juxtaposing materialities, imaginations, social practices and values that both propels and constrains the everyday delivery of care. The paper reflects on the theoretical implications of hospital seva in Mumbai in light of social science studies of hospital ethnography and health activism and contributes important ethnographic insight into the current global health debates regarding effective implementation of cancer services in India. [ABSTRACT FROM AUTHOR]

Abstract Changes in the nature and structure of healthcare pathways have implications for healthcare professionals' jurisdictional boundaries. The introduction of treatment focused BRCA1 and 2 genetic testing (TFGT) for newly diagnosed patients with breast cancer offers a contemporary example of pathway change brought about by technological advancements in gene testing and clinical evidence, and reflects the cultural shift towards genomics. Forming part of an ethnographically informed study of patient and practitioner experiences of TFGT at a UK teaching hospital, this paper focuses on the impact of a proposal to pilot a mainstreamed TFGT pathway on healthcare professionals' negotiations of professional jurisdiction. Based upon semi-structured interviews (n = 19) with breast surgeons, medical oncologists and members of the genetics team, alongside observations of breast multidisciplinary team meetings, during the time leading up to the implementation of the pilot, we describe how clinicians responded to the anticipated changes associated with mainstreaming. Interviews suggest that mainstreaming the breast cancer pathway, and the associated jurisdictional reconfigurations, had advocates as well as detractors. Medical oncologists championed the plans, viewing this adaptation in care provision and their professional role as a logical next step. Breast surgeons, however, regarded mainstreaming as an unfeasible expansion of their workload and questioned the relevance of TFGT to their clinical practice. The genetics team, who introduced the pilot, appeared cautiously optimistic about the potential changes. Drawing on sociological understandings of the negotiation of professional jurisdictions our work contributes a timely, micro-level examination of the responses among clinicians as they worked to renegotiate professional boundaries in response to the innovative application of treatment-focused BRCA testing in cancer care – a local and dynamic process which we refer to as an 'oncogenetic taskscape in the making'. Highlights • A micro-level examination of clinicians' work assembling an 'oncogenetic taskscape'. • Mainstreaming genomic testing requires changes to professional jurisdictions. • Technology's clinical relevance informs clinicians' acceptance of mainstreaming. • Clinical implementation of new technology requires inter-professional collaboration. [ABSTRACT FROM AUTHOR]

The term "locally advanced breast cancer" (LABC) encompasses a heterogeneous group of breast neoplasms that represent an extremely variable percentage of newly diagnosed breast cancers (4-90%, depending of world regions). These cancers may have different clinical and biological characteristics that can be managed by primary surgery or neoadjuvant integrated treatments. In this paper we review the updated guidelines and discuss most recently reported evidence related to LABC multidisciplinary workout, in order to maximize results of combined systemic therapies, modern surgical procedures and radiotherapy. [ABSTRACT FROM AUTHOR]

Breast cancer is one of the most perilous diseases that annually attack thousands of women. Physicians usually monitor the breast tumor changes during the course of a chemotherapy treatment. Computer programs may help physicians to predict the pathological response in order to adjust the medical treatment to produce the intended effects. This paper proposes a method for quantifying and visualizing the changes of breast tumors of cases undergoing medical treatment through strain tensors. The proposed method determines the displacement fields between each follow-up mammogram and its baseline. To compute the displacement fields, we evaluated the performance of eight robust and recent optical flow methods through landmark-based error and statistical analysis. Since, there is no ground truth to evaluate the optical flow methods when they are applied to mammograms, we propose to aggregate the best optical flow methods using ordered weighted averaging operators. The aggregated optical flow methods using the ‘as many as possible’ operator yields the smallest landmark-based error among three aggregation approaches analyzed with the proposed algorithm. The resulting optical flow is then used to estimate the strain tensors. The proposed method provides a good quantification and visualization for breast tumor changes and that helps physicians to plan treatment for their patients. [ABSTRACT FROM AUTHOR]

Surgery associated with radiation therapy is the standard treatment for early breast cancer. This paper reviews the new evidence on local control and survival, the indications of lymph-node irradiation, and the long-term results of large prospective trials. New shorter fractionation schemes allow a reduction in the constraints of daily treatment courses over several weeks, and recent technical improvements in treatment delivery will improve cancer outcomes in terms of local control, decreased toxicity and long-term sequelae. Research should focus on identifying molecular markers for radiation sensitivity while designing specific, targeted modulators of the radiation response in early breast cancer. [ABSTRACT FROM AUTHOR]

Mathematical modeling constitutes an emerging area of oncological research aiming to predict spatial and temporal evolution of tumors, by describing many different phenomena which occur at different scales. Among these, modeling at the macroscopic scale has a great potential of application, when diagnostic imaging evaluation is used to identify the metabolic tumor volume undergoing proliferation. With breast carcinoma one of the most common cancer occurrences, the personal involvement for the patient and the cost for the national health system vary considerably with the adopted treatment. When a neoadjuvant (volume reducing) drug therapy is a direct option, the choice of drug may dictate the physical burden and the surgical strategy for subsequent lumpectomy/mastectomy. This paper employs a mass transfer modeling approach in order to gain deeper insight into breast carcinoma proliferation and therapy at the tissue scale. The aim is to develop a predictive, quantitative method for each given patient. Model flexibility is demonstrated, to facilitate model replication for large patient cohorts. The proposed procedure may serve as a basis for a decision support system for surgeons and towards personalized treatment optimization of breast tumors. [ABSTRACT FROM AUTHOR]

This paper examines how to apply a spatial approach (relational and geographical) to care pathways for their better integration within their territories. Based on the case study of a senology department of a French Cancer Diagnosis, Treatment and Research Centre, we apply a mixed research methodology using qualitative data (synthesis documents, meeting minutes, in-depth interviews) and quantitative data relating to the mobility and geographical location of a cohort of 1798 patients treated in this centre. Our results show the inseparable nature of the relational dimension and the geographical approach to move towards greater integration of breast cancer care pathways. This inseparability is constructed from the proposal of a method for mapping the integrated care pathways in their territories. This method, applied to our case study, allows us to identify four main categories of pathways for the cohort of patients studied. • Cancer care pathways extend beyond the boundaries of care facilities. • Their integration in their territory is analyzed in a disorganized manner. • We study a cohort of patients of a French senology service. • We construct a spatial approach (relational and geographical) of their pathway. • The application of this methodology identify several forms of integrated care pathways. [ABSTRACT FROM AUTHOR]

Variety, complexity and uncertainty in the therapy outcomes of cancer illness make the treatment recommendation (TR) in oncology a "monumentally difficult task". Previous studies have distinguished unilateral and bilateral formats of treatment recommendations, accordingly to whether, or to what extent, the patient's perspective is included in the consideration of therapeutic options. Others have also shown how the oncologists' presentation of therapeutic options varied accordingly to the severity of the diagnosis and the availability of alternatives. Yet, no study has systemically dentified and compared components of treatment recommendation in oncology on a common set of patients and clinicians. This paper analyzes how different options in breast cancer treatments - radiotherapy, hormone therapy and chemotherapy - are presented and discussed in a set of 12 first post-surgical breast cancer visits carried out by two oncologists of high experience and seniority in two Italian hospitals. Treatment recommendation sequences involving these three option types were analyzed using the methods of conversation analysis. They were also coded for the mention of side effects and treatment burden, and for whether consent to the recommendation was invited, or expressed by the patient. Results show that radiotherapy is presented as presupposed as an extension of surgery and is not further discussed, and hormone therapy is delivered as good news and as not implying any health or lifestyle burdens. Treatment burdens were raised in the much more extensive discussions of chemotherapy, which were also accompanied by a higher chance that the patient was asked for consent to therapy. Implications are drawn as regards the extent to which clinical practice meets theory in communication protocols available in oncology, and how to consider the doctor-patient partnership and the concept of shared decision-making in such an encounter. • Oncologists deliver recommendation for different cancer treatments in different ways. • Radiotherapy is presented as presupposed, hormonetherapy is delivered as good news. • Oncologists anticipate the patient's burden only in chemotherapy. • There is a gap between protocols and communication practices in oncology. • Consent -gaining process needs be followed across time and settings. [ABSTRACT FROM AUTHOR]