Не знаю, что делать..

[Кошка Мурка]

100% иногда вредит, просто она может тебя послушать и не сделать радиацию :-)

- главное, чтобы она приняла решение, послушав специалистов, а не доморощеных "знатоков" вроде тебя.

[Шмоль]

Господа доктора, созрел довольно дурацкий вопрос, но я его все равно задам. Когда делают радиацию, бейсикли облучают опухоль со всех сторон, так? Если Звизда в ремиссии, это значит, что у нее больше, слава Богу, нет опухолей, так? Что ей собираютца облучать? :v:

[Инквизитор]

Господа доктора, созрел довольно дурацкий вопрос, но я его все равно задам. Когда делают радиацию, бейсикли облучают опухоль со всех сторон, так? Если Звизда в ремиссии, это значит, что у нее больше, слава Богу, нет опухолей, так? Что ей собираютца облучать? :в:

Организьм... Область шеи и средостения... Самое херовое осложнение (не хочу пугать, но неизлечимое) - радиоционный плексит плечевого сплетения, радиоционная мыелопатия (поражение спинного мозга), легочной радиоционный фиброз, радиационный перикардит... И это не считая раков не относящихся к лимфоме. Я конкретный противник радиации в данном конкретном случае. Может быть я не прав, но как считаю - так и говорю...

П.С.: Жирик, можешь кидать тухлыми помидорами, но я высказался только полностью изучив все детали, а не базируясь на эмоциональном отношении к раку в целом...

[Шмоль]

Организьм... Область шеи и средостения... Самое херовое осложнение (не хочу пугать, но неизлечимое) - радиоционный плексит плечевого сплетения, радиоционная мыелопатия (поражение спинного мозга), легочной радиоционный фиброз, радиационный перикардит... И это не считая раков не относящихся к лимфоме. Я конкретный противник радиации в данном конкретном случае. Может быть я не прав, но как считаю - так и говорю...

П.С.: Жирик, можешь кидать тухлыми помидорами, но я высказался только полностью изучив все детали, а не базируясь на эмоциональном отношении к раку в целом...

Cпасибо, Инквизитор! :34:

[Vrag]

Значить так. Предлагаю всем заинтересованным лицам внимательно прочитать то что я буду тут сегодня печатать и постать. К модераторам просьба не удалять ссылки и цитаты.

[Vrag]

Малышка, [uptodate] это на мой взгляд хороший источник информации но он ни в коем случае не заменяет [peer reviewed journal publications] а уж тем более [treatment guidelines].

Я давал ссылки на [treatment guidelines prepared by the National Comprehensive Cancer Network]. К сожалению без регистрации их не откроешь. Я могу [pdf file] послать по электронной почте если кто-то хочет почитать.

[Vrag]

[I want to emphasize that the use of radiation therapy in Hodgkin’s disease following complete response to chemotherapy (particularly for stage I-II) is a controversial issue. The NCCN panel favors its use, particularly for bulky disease (as defined in my post 3347, this definition of bulky disease is based on the definition used in clinical trials and in the NCCN guidelines). However, chemotherapy alone is recognized as a reasonable alternative by the panel. This is shown in the treatment algorithm on page 7 of the pdf file of the NCCN guidelines. This issue is also addressed in the discussion section of guidelines.]

[Yesterday, Inquisitor expressed the opinion of one of his colleagues, who apparently would not favor the use of radiotherapy in zvizdyusha’s case. There are other experts in this field who would agree with this recommendation. I will paste here an editorial published very recently in the Journal of the National Cancer Institute] (статья опубликована 2 недели назад)

[Vrag]

[Logo DL. Late Effects From Radiation Therapy: The Hits Just Keep on Coming. J Natl Cancer Inst Volume 101, Number 13 Pp. 904-905, July 1, 2009

Correspondence to: Dan L. Longo, MD, National Institute on Aging, 251 Bayview Blvd, Ste 100, Rm 04C224, Baltimore, MD 21224-6825 (e-mail: [email protected]).

There can be little doubt by now that if radiation therapy use in Hodgkin's disease were a drug regulated by the US Food and Drug Administration (FDA), it would have been taken off the market. Can you imagine the response to a drug company's argument? "Even though we don't have any long-term follow-up data, we are pretty sure that reducing the dose of the drug by one third is going to eliminate the late fatal and life-threatening side effects. We are giving the drug completely differently these days. Trust us on this." It seems highly unlikely that such an argument would influence the FDA's decision making, doesn't it?

However, precisely that argument seems to be influencing the persistent use of radiation therapy plus chemotherapy in Hodgkin's disease when equally effective treatment that omits radiation therapy altogether, namely chemotherapy alone, is available. The practice defies logical explanation. Like Samuel Johnson's comment on second marriages, it seems to reflect a triumph of hope over experience.

To add to the already overwhelming evidence that the use of radiation therapy in Hodgkin's disease is shortsighted, De Bruin et al. (1), reporting for Flora van Leeuwen's group at the Netherlands Cancer Institute, have quantified yet another late side effect from the use of radiation therapy. They examined the incidence of strokes and transient ischemic attacks (TIAs) among 2201 patients who had been treated with radiation therapy, combined modality therapy, or chemotherapy for Hodgkin's disease, and who had survived at least 5 years. The subjects had a median follow-up of 17 years, a long time by usual standards but still not long enough that one can be sure that all events that are likely to occur have occurred. Patients remain at risk. The median time to first stroke was 17.4 years and the median age at first stroke was 52 years. Forty-five percent of the cerebrovascular events occurred in patients younger than 50 years of age.]

[Vrag]

продолжение [In the entire group, about 20% of the strokes were fatal, and 7% of the population is projected to die from stroke at 30 years of follow-up. That projection is actually a bit of an underestimate of the risk because only one person among the 187 who received chemotherapy alone had a stroke (three strokes would have been expected in an age-matched population not treated for Hodgkin's disease), that stroke was not fatal, and none had TIAs. Thus, 87 of the 88 documented ischemic events and all the fatal events were in Hodgkin's disease survivors who had received radiation therapy. Among those who received radiation to the neck and/or mediastinum, the risk of a cerebrovascular event was increased 2.5-fold compared with an age-matched control group that had received no radiation therapy.

A remarkable feature of the study is the detailed medical documentation and nearly complete follow-up of the patients. Most of the cerebrovascular events were embolic, and the emboli originated in the heart in one in four cases. This result implies that coronary artery disease was an important predisposing factor in addition to carotid artery disease. Hull et al. (2) have also noted that radiation therapy can damage the aortic valve, which can then become a nidus for clotting.

The study has a weakness. The relationship of stroke to radiation doses and fractions was not examined. Thus, it was not possible to evaluate the assumption that lower doses produce less risk.

However, other data suggest that dose of radiation may influence time to first stroke. Bowers et al. (3) found that children with Hodgkin's disease whose treatment included radiation therapy had a relative risk of 4.3 for developing a stroke compared with a sibling control group, and the median time after treatment for strokes to occur was 17.5 years. These results are similar to those of De Bruin et al. in adults. By contrast, when the Netherlands Cancer Institute group measured stroke risk among head and neck cancer patients who generally received 60–70 Gy of radiation, rather than the 36–40 Gy used in patients with Hodgkin's disease, the relative risk was about 5.6 but the time to first stroke was only 10.9 years (4). It was proposed that the time to develop a cerebrovascular complication is affected both by dose of radiation and by age at the time of exposure (1). Patients with preexisting atherosclerotic vessels may develop embolic complications in a shorter time.

The results of the study by De Bruin et al. (1) emphasize that physicians following patients who received mantle-field radiation therapy that included the cervical region should aggressively manage modifiable risk factors for atherosclerosis including hypercholesterolemia, hypertension, and smoking. Agents that influence vascular stiffness are in development (5); therefore, stroke prevention in patients who have received cervical radiation therapy may be a useful measure for the role of vascular stiffness in subsequent embolic events.

These results also should make an impact on the physician's choice of primary treatment. What does the balance sheet look like? If you are treated with radiation therapy, you are accepting a risk of 1% per year of developing a second malignancy and that risk does not appear to decrease even 30 years after treatment (6). If you are a woman younger than 30 years old who is being treated with mantle-field radiation therapy, your risk of developing breast cancer within 25 years is more than one in three, comparable in fact with the risk associated with some genetic forms of the disease (7). You are also accepting a threefold increased risk of a fatal myocardial infarction as well as a risk for myocardial infarctions that are not immediately fatal (8). And now, it appears you are accepting a 2.5- to 3-fold increased risk of an ischemic cerebrovascular event, one in five of which will kill you (1). Those are the fatal risks. In addition, there are other nuisance risks like dental carries, dry mouth, dysgeusia, transverse myelitis, hypothyroidism, and others that are not necessarily fatal but require some compensatory action on the part of the patient that affects quality of life variably (9).

Now, what about the advantages? For head and neck cancer, the advantages to using radiation therapy as a component of treatment are well defined and clear. For breast-conserving approaches to breast cancer treatment, the advantages are well defined and clear. For Hodgkin's disease, the advantage of using radiation therapy is not clear at all. Indeed, it could be and has been argued that there are none (10).

With a risk to benefit ratio for the use of radiation therapy that is approaching infinity, it remains a puzzle that the vast majority of patients with Hodgkin's disease are treated with combined modality therapy today. Noncurative courses of chemotherapy are combined with noncurative courses of radiation therapy in most cases. Why? Certainly lower doses and shorter courses of chemotherapy produce less acute toxicity and that is good. No convincing data have defined more than anecdotal late fatal toxicities associated with adriamycin, bleomycin, vinblastine, and dacarbazine chemotherapy, so fewer cycles are unlikely to make any substantial impact there. It is hoped that lower doses of radiation therapy will reduce the risk of late fatal toxicities from radiation therapy, but long-term follow-up data documenting that hope do not yet exist. One should keep in mind the fundamental radiobiology research showing that the risk of inducing cancer has a bell-shaped relationship to dose in the laboratory (11). If we do not know where we are on that bell-shaped curve, it is not completely clear that moving to a lower dose will actually lower the risk. So it seems that the political pressure to keep using radiation therapy has allowed hope to triumph over experience in our exercise of clinical judgment.

Maybe lowering the dose of radiation therapy will actually reduce the incidence of late effects. We can certainly hope it is true, but until it is proven to be true, it cannot be assumed to be true. No therapy is effective until it has been proven effective, and no therapy is safe until it has been proven to be safe. Unfortunately, given the lifelong increased risks of late effects that have been documented from the use of radiation therapy, we simply cannot keep exposing patients to risk without clear benefit while we wait for safety data to be produced. With an alternative therapy at hand that is just as effective and has been proven to be safe with 25-year follow-up data (12), it is simply unjustified to keep using a toxic modality for the next 10–20 years while safety data are collected and analyzed.
]

[Vrag]

[NOTES

The author reports no conflicts of interest.

REFERENCES

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