Persons treated for breast cancer often experience raised levels of anxiety and depression [1- 3]. However a recent review has found that an increased prevalence at 5 years post diagnosis was confirmed for depression but not for anxiety . The focus on depression and anxiety has tended to ignore some pressing additional psychological needs of patients with cancer. The strongest priority as rated by patients with breast cancer, recently found that 62% wished to speak with their clinician, at the out-patient clinic, about their fears of cancerrecurrence (FCR) . The number of articles that document fears of recurrence is increasing and there has been an extensive review to show associations with anxiety and depression . It is clear that FCR is a stable construct that is aversive to the individual at high levels. To reduce extensive FCR that has developed, through specialist intervention, is complex and resource intensive [7-9]. A preventive approach is therefore indicated.
The Concerns About Recurrence Questionnaire (CAR- Q) has been investigated as a possible brief scale for FCR . It has been constructed as a 5 item scale that questions the respondent about frequency, intrusiveness and degrees of distress. An item of risk perception is also included. There is a translation into Danish as well as English there- fore promoting a cross-cultural dimension. The authors used classical test theory (CTT) in addition to single par- ameter models (Item Response Models, IRT) to estimate difficulty (referred to also as ‘location’ or ‘severity’ across the latent construct). The CAR-Q was developed specific- ally for breast cancer. Our group has considered bringing together a scale that will function well across numerous cancer sites. This would save substantial effort and also en- able comparisons across sites. The CAR-Q is perhaps the closest to what we would regard as a scale that has been studied in some detail psychometrically. There are some satisfactory features of this scale and the work by the origi- nators is carefully reported. Their IRT results on further in- spection do show some extensive local dependence issues which they do state in their 2015 article will need address- ing and some items rewording. They state that CAR-Q-4 (the 4 item version) perhaps is the most reliable but admit that the 4 item English version did not fit the Rasch model and did not report the fit for the Danish sample saying that ‘ modelling ’ was not possible with the 4-item scale. Was this a convergence problem? This is not elucidated. The model- ling also was rejected for this Danish 3 item version. Our interpretation suggests that there are some unsatisfactory psychometric qualities to this scale. Furthermore, no brief FCR scale has adopted the more flexible two parameter graded response model IRT approach. The advantage of this later approach is that both item discrimination (slope) as well as difficulty/severity (location) are estimated simultaneously.
FCR which can be reinforced through positive or negative consequences. The attendance by the patient to their radiotherapy treatment session may sensitize these patients and raise associated anxiety about cancer risk, success of treatment and possible recurrence. The experience of the patient who expresses these cues or concerns and then not have them attended to by the clinician, may as a consequence, reinforce psychological avoidance by the patient to subsume the emotional experience. Alternatively, the experience may simply provide an indicator to the patient that these issues are not regarded as important and are better discarded if possible. The longer term
Among 111 TNBC patients, 70 patients received PORT and 41 did not receive PORT. The mean age of patients at diagnosis was 63 ± 7 years (range 28–81 years). The patients presented with T1, T2, T3, and T4 were 32, 42, 24, and 13 patients, respectively. Thirty patients presented with axillary node- negative disease, 24 with one to three positive axillary nodes, and 58 with four or more axillary node metastasis. The American Joint Committee on Cancer staging distribution was 18, 17, and 76 patients as stage I, II, and III, respectively. The majority of patients were diagnosed with invasive duct carcinoma (94/111). Forty-three patients had Grade III disease and 68/111 patients had GI or GII disease. Sixty-seven patients had MRM performed and 44/111 had BCT. Fifty-one patients received neoadjuvant chemotherapy, 48 received adjuvant chemotherapy, and 12 patients did not receive any systemic treatment. Common neoadjuvant/adjuvant chemotherapy regimens were docetaxel/doxorubicin/cyclophosphamide and paclitaxel/carboplatin.
The data for this study originates from a time when cancer follow-up was organised in specialised hospital departments. Given the median time of 11 months to CR and of 32 months to SPC, patients were most likely actively followed at the time of CR and SPC. We demon- strated increasing activity in general practice prior to a subsequent cancer event, which could indicate that pa- tients found the GP more accessible despite direct access to specialised hospital departments. This is in line with a study by Grunfeld et al. , who reported that most breast cancer recurrences were detected as interval events and that women presented first in general prac- tice despite hospital-based follow-up. Furthermore, studies in gynaecological cancers [42–44], malignant melanoma  and colorectal cancers  found be- tween 42 and 72% of CRs to be diagnosed as interval events outside scheduled follow-up visits and to be symptomatic at diagnosis. Gilbert et al.  found 67% of lung CRs to be detected by the GP. This indicates involvement of general practice and supports that the increased contact rates in general practice found in the present study were related to detection of CR and SPC.
can be in direct contact with the vaginal incision and cause implantation metastasis, which is one of the possible ways of direct implantation me- tastasis in laparoscopic surgeries. The biological characteristics of tumor cells in which invasive and metastatic characteristics are the most im- portant for the metastasis and recurrence of tu- mors; (11, 12) are growth autonomy, transplant ability, dedifferentiation, invasion, and metasta- sis. The first step of the implantation and metas- tasis of cervical cancer cells is the exfoliation of cancer cells from the primary site. The next step, performed in our study, is to look for changes in the expression of E-cadherin, MMP-2, VEGF-C and CD44v6 in cancer cells exfoliated from the vaginal stump and literature show (13-15) that these are closely related to cancer cell invasion and metastasis. Furthermore, it also confirms the significance of the vaginal stump ligation in reducing cervical cancer cells implantation and the recurrence of cervical cancer from the cyto- kine level.
allow simulation of phenomena which involve transitions of heterogeneous individuals between states over time. During each discrete three-month time increment—or cycle—each of a series of hypothetical individuals may be in only one state at a time. Within a state, individuals may experience a series of probabilistic events which determine whether they will remain in their current state during the next cycle or transition to a new state. In our model, a series of simulated patients starts each cycle in one of five states: no known recurrence, recurrence curatively treated, recurrence palliatively treated, deceased due to cancer, or deceased due to other causes (See state transition diagram in Figure 2). Three months is used as a cycle length since this represents the shortest recommended inter-visit inter- val among published recommendations for post-surgical surveillance in CRC patients [12,15,16,40]. Note that only surveillance testing of asymptomatic patients occurs based on discrete time steps. Natural history events are mea- sured in continuous time so that simulated patients will reach the point of detectability (D i ), the point of unresect-
The patients who underwent ipsilateral MRND or bilateral MRND have the same N stage. The surgical extent of lat- eral neck compartment is not reflected in TNM stage. However, meticulous preoperative evaluation of contralat- eral LN is needed to avoid residual or persistent disease during postoperative follow-up. The factors that associ- ated with contralateral LN metastasis were male gender, more than 2 cm size of main tumor, multifocality, bilater- ality, and ETE. Recurrence in N1b PTC patients is pre- dicted by central neck LN ratio > 0.44, lateral neck LN ratio > 0.29, and multifocality of tumors. We suggest that patients with these factors should receive short-term follow-up using image modalities like US and CT.
Considering that most predictors of recurrence (clinico- pathological features and tumor specific characteristics) are highly correlated, we aimed to develop a comprehen- sive model to predict recurrence which would preclude associational factors. In addition, considering that BC re- currence during early stages and late stages of the disease course significantly affects patients’ quality of life, we hy- pothesized that predictors of recurrence may differ for early recurrence and late recurrence. Thus, in order to an- swer the question whether or not predictors of early re- currence (defined as earlier than 5 years) are different from those of late recurrence (later than 5 years), we fur- ther developed two other models based on time of recur- rence using advanced statistical modeling.
In the present study we also have investigated the prognostic impact of RABEX-5 mRNA in a previously described cohort of 180 surgically resected prostate cancer patients [12-14]. To confirm the representativeness of the prostate cancer in present study, we analyzed established prognostic predictors of prostate cancer patient survival. The data showed a significant impact of well-known clin- ical pathological prognostic parameters, such as seminal vesicle invasion, and Gleason score. Assessment of biochemical recurrence free survival in prostate cancer revealed that the high expression level of RABEX-5 mRNA was correlated with adverse biochemical recurrence free survival of prostate cancer patients. Since variables ob- served to have a prognostic influence by univariate analysis may covariate, the expression of RABEX-5 mRNA and those clinicalopathological parameters that were significant in univariate analysis were further examined in multivariate analysis. Multivariate analysis revealed that RABEX-5 mRNA expression was an independent predictor of bio- chemical recurrence free survival. Our data demonstrate a marked increase in RABEX-5 mRNA expression in tumors compared to noncancerous tissue, with a significant and independent relationship between high RABEX-5 mRNA expressing tumors and reduced postoperative overall sur- vival. It seems convincing that the high RABEX-5 mRNA expression conferred a very unfavorable prognosis in our
Sorlie and colleagues  reanalyzed their Norway/ Stanford dataset, including 84 tissue samples from their previously published work [71,79] and 38 additional tumor samples from patients with locally advanced breast cancer treated with preoperative chemotherapy. The first gene list and the list used for the reanalyzed report had approximately 200 genes in common, and tumors could be classified in the five main gene clusters as previously described. In addition, Sorlier and colleagues attempted to validate their findings in two independent datasets reported by Van’t Veer and colleagues  and by West and colleagues . Ninety-seven tumors from the van’t Veer and colleagues’ study could be classified into the five subtypes, and these different breast cancer types were associated with prognosis. Patients with the luminal-A subtype had the best survival rates, while the worst survival rates were associated with the basal and HER-2 subtypes. However, van’t Veer and colleagues based their analysis on 461 genes (out of 24,480). The dataset from West and colleagues, generated on an Affymetrix platform, could also be classified into the previously described subtypes after selecting 242 genes out of a total of 7129 genes.
The identification of markers for the prediction of breast cancer has been widely investigated, specifically for the identification of biomarkers for early breast cancer diagnosis. The evaluation of ER, progesterone receptor (PgR), Ki67, and human epidermal growth factor (HER2) is common in clinical practice for prognostic purposes and treatment decisions. However, laboratory variability in Ki67 scoring is well known and therefore this bio- marker is not ideal for clinical decision making . Other markers, such as B-cell lymphoma 2, androgen re- ceptor, epidermal growth factor, phosphatase and tensin homolog, and PIK3CA, have been investigated for their prognostic value in breast cancer. Tumors with muta- tions in PIK3CA have been shown to be associated with lower recurrence and mortality rates in the late time period [13,14]. Liu and colleagues  analyzed predic- tors of late relapse in early-stage ER-positive breast can- cer, in which differences in the primary tumor tissue in patients with distant relapses occurring early (less than 3 years) versus late (after 7 years) have been compared. A set of genes was identified that were prognostic specif- ically for early relapse (CALM1, CALM2, CALM3, SRC, CDK1, and MAPK1), but they also identified genes that appear to predict late relapse (ESR1, ESR2, EGFR, BCL2, and AR). High expression levels of BCL2 have also been shown to be a good predictor of late breast cancer recur- rence in a subset of 73 patients with primary breast
Current Canadian guidelines recommend repeat transurethral resection of bladder tumour (TURBT) at 4-6 weeks, prior to the initiation of intravesical Bacillus Calmette-Guerin (BCG). 4 Repeat resection requires further operating room resources and adds further cost and risk of complications to the patient. This recommendation is based on data from major cancer centers in non-universal health care systems, which report rates of recurrence and upstaging on repeat TUR to be 45-76% and 29-40%, respectively. 3,5,6 However, minimal Canadian data is available and these landmark studies were performed approximately two decades ago. Therefore, we aimed to determine the contemporary rate of
A total of 1,734 men were identified during the study period undergoing treatment with either RP (n = 722) or RT (n = 1,012). Table 1 presents the demographic and pathologic features of these men by disease recurrence status. As expected, pathologic factors (PSA, Gleason and stage were highly associated with recurrence. Several differences between men undergoing RP or RT were identified (data not shown). Men treated with RT were older (15% vs. 1% over age 75, p<0.001) had higher Charlson Comorbidity scores (p<0.001) and were more likely to have been diagnosed with DM prior to diagnosis (p<0.001). Men receiving RT had higher pretreatment PSA values compared to the RP group (35% ≥ 10 ng/mL vs. 19%, p<0.001). The median follow-up time was 41 months (range 1 – 121 months). Recurrence was observed in 281 men (16%). Cumulative recurrence was similar following RT (15%) and surgery (17%). Recurrence events occurred in 7%, 14% and 33% of low, intermediate and high risk cases (as defined by the National Comprehensive Cancer Network (NCCN ® )), 24 respectively.
The study base was patients registered with a BC diagnosis according to the International Classification of Diseases, 10th revision (ICD-10) (code: C67*) in the DaBlaCa-data during 2012–2014 with tumor stage > Ta and curatively intended radical treatment. We included patients deceased by the time of data extraction in October 2016, as we only had informa- tion on recurrence status on the deceased. Patients were eli- gible if registered in the DNPR with a cystectomy procedure code or more than 15 fractions of radiotherapy. Patients were excluded if registered in the CAR with a previous cancer (except for nonmelanoma skin cancer) or registered in the CAR or the DNPR with distant metastasis within 90 days of cystectomy or the first day of radiotherapy (ICD-10 codes: C78, C79, CxxxM, or distant tumor stage based on the TNM classification). 25 Furthermore, patients were excluded
radiologist-defined severity of normal tissue damage with CT texture features . In an additional study, they demonstrated the ability to differentiate patients with and without clinical radiation pneumonitis by measurements of dose-dependent texture change between pre- and post-radiotherapy CT images . To the best of our knowledge, these are the only papers present in the literature measuring CT texture for benign radiation induced lung injury. Our previous work presented in Chapters 3 evaluated quantitative CT image texture analysis for early prediction of recurrence after SABR [13, 14]. We have shown that second-order texture features based on grey-level co-occurrence matrices (GLCM) calculated within manually delineated ground-glass opacity (GGO) regions can predict recurrence within 6 months post-SABR. The regions of GGO refer to hazy regions of increased attenuation in the lung within which vascular regions can still be visualized, and these regions typically surround the consolidative mass. Texture features within these regions showed 2-fold cross-validation (CV) errors of 23–30% and areas under the receiver operating characteristic curve (AUC) of 0.78–0.81 . As seen in Figure 4-1, patients with benign injury tended to have a smooth GGO appearance compared to a variegated appearance in patients with recurrence.
circles of hell that punish human deception such as fraud and betrayal. Like McCarthy, Dante represents that humans‟ innate violence and lust as derived from animal impulses, so he tolerates sins of this nature more so than calculated transgressions. For example, in Canto 19, Dante punishes Pope Nicholas III in The Eighth Circle of Hell for fraud by burying his head facedown in a hole with flames burning the soles of his feet, because he committed simony, which is the exchange of payment for holy offices of the church. Without sympathy, a heated Dante inquires of the pope, “Pray tell / me now; how much treasure did our Lord require / of Saint Peter before He gave the keys into this charge?” (19.80-83). This emphasizes his spite for the pope‟s sin of personal greed and deliberate corruption beneath the facade of serving God. When Dante adds, “Thou art / rightly punished…for your avarice / afflicts the world, trampling on the good and exalting / the wicked,” he expresses his ideas about justice (19.86-93). Unlike Dante‟s personal experience of unwarranted exile, the poet‟s imagined world creates a moral justice system wherein punishments more appropriately match the crimes as he sees fit. This alternative justice system establishes Dante‟s moral standards while expressing a critique of church corruption. While the La Divina Commedia in its entirety is an allegory of a spiritual journey toward salvation, the Inferno creates a world to illustrate and reject sin, specifically. By creating a new world from his tour of hell, Dante expresses some of the worst fears of the standard, medieval idea of hell, but he maintains his individual, poetic voice. By inclusion of his idols, Virgil and Beatrice, as moral guides and accessible literary and papal figures, Dante demonstrates his moral justice system.
Patients with hormone receptor-positive breast cancer remain at risk of recurrence for as long as they survive. For that reason, many investigators have explored the benefit of extended therapy beyond the standard treat- ment of 5 years. Recently, several studies showed that extended tamoxifen reduces late recurrence risk by one third compared with no further hormonal therapy beyond 5 years [5, 9]. Extended use of aromatase inhibi- tors has also been shown to reduce the risk of late relapse by nearly 50 % compared with no further treat- ment [10, 11]. However, prolonged endocrine therapy leads to adverse events (such as hot flashes, sexual dys- function, uterine bleeding, or osteoporosis) in approxi- mately half of patients who take it. Therefore, treating only patients with a clear chance of recurrence but not those unlikely to develop late recurrence is a reasonable practice. The question is: Which patient has risk of late relapse and will benefit from extended hormonal therapy?
Literature was retrieved through the PubMed, Web of Science, EMBASE database, and the Cochrane Database of Systematic Reviews (updated to August-1, 2015) using the following keywords: (i) “neuraxial anesthesia,” “epidural anesthesia,” “spinal anesthesia,” “regional anesthesia,”“anesthetic technique,” or “general anesthesia,” and (ii) “recurrence,” “metastasis,” “survival,” or “prognosis,” and (iii) “neoplasm,”“cancer,” or“carcinoma”. Only studies published in English were included. Both abstracts and full text papers were eligible. We did not define the minimum number of patients to be included for this meta-analysis. Three hundred and eighteen papers were screened out by this strategy. After reviewing their titles, we identified 97 papers for further consideration. And after reading their abstracts, we finally reviewed 47 potentially eligible papers by full text reading. The study flowchart is shown in Figure 1.