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Item Open Access Brachytherapy for cervical cancer : guidelines to facilitate quality patient management in a multidisciplinary environment(University of the Free State, 2014-10) Long, Deirdré; Friedrich-Nel, H. S.; Joubert, G.English: This study was undertaken to establish guidelines to facilitate quality patient management for cervical cancer patients, receiving high dose rate-intracavitary brachytherapy, in a multidisciplinary environment. An extensive literature search found that guidance to service providers and members of multidisciplinary teams (radiation oncologists, radiation therapists and oncology nurses) is limited to the organisational and technical aspects of high dose rate-intracavitary brachytherapy treatment delivery. The aim was thus to formulate patient-centred guidelines that could be used as a tool to guide members of multidisciplinary teams in providing quality patient management to this group of women in governmental and private brachytherapy units in South Africa. A prospective, qualitative study with a phenomenological approach was chosen as the framework for the study. The study was approved by the management of the hospital and the department and by the Ethics Committee of the Faculty of Health Sciences, University of the Free State. All participants gave written informed consent before participation. The study objectives were approached in five stages. In stage one the study utilised semi-structured, one-to-one interviews in English, Afrikaans or Sesotho in order to gain a detailed picture of a participant’s experience and perceptions of patient management while undergoing brachytherapy. In order to include the opinions of women across the age spectrum into the study, the researcher purposively recruited participants from each of the following three age groups: 30-45 years; 46-60 years and 61years and older. Each age group included at least one private and one local oncology patient. Hospitalised patients were also included in the study sample. The sample size for this study was determined by saturation of the data. Saturation was reached having interviewed twenty-eight participants. Interviews were conducted by a multilingual female social worker. An open-ended interview schedule in English, Afrikaans and Sesotho were designed by the researcher and provided the interviewer with a set of predetermined questions that guided the interviewing process. The participants had to respond to open-ended questions (with probes) at the department of Oncology, Universitas Annex, Bloemfontein after their third brachytherapy treatment. The order of questions in the interview schedule simulated the path of events that each participant had gone through at the department (from the new patient clinic up until brachytherapy treatment delivery). Interviews were audio recorded and transcribed before qualitative analysis by the researcher. Understanding and acknowledging the patient’s unmet needs were fundamental to the development of the proposed guidelines. The analysis identified shared and unique experiences amongst the 28 interviewed participants. Four themes with sub-themes were identified from the data: (1) informational needs, (2) patient disposition towards treatment, (3) psychological experience and (4) physical experience. In stage two the scope of the proposed guidelines was formulated by (1) the integration of the patient experience of stage one, together with (2) a literature search and (3) the knowledge and experience of the researcher. The proposed guidelines addressed logistical matters of the practice setting and the collective and exclusive roles and responsibilities of members of the multidisciplinary team at the new patient clinic and the brachytherapy unit of the department. The proposed guidelines were aligned with the flow of patient management in the Department of Oncology. In stage three of the research study the proposed guidelines were reviewed by members of the multidisciplinary team of the Department of Oncology who regularly interact with this group of patients. Twenty members of the multidisciplinary team working at the brachytherapy unit of the Department of Oncology, Bloemfontein, with at least a year’s experience of service delivery at the brachytherapy unit, were purposively selected to participate in the focus group interviews. Focus groups usually include six to ten participants and therefore the twenty selected participants were divided into two focus groups. Each focus group was compiled in such a way that the members were comparable regarding professional category and years of experience. Medical physicists were excluded as they are not directly involved with the management or care of patients at this unit. The two focus group interviews took place on the same day. The setting was familiar and in close vicinity for the participants. The focus group interviews were conducted in English so as to accommodate all participants. The duties of the group facilitator were performed by the study promoter, while the duties of assistant facilitator during the focus group interviews were performed by the study co-promoter. The topic guide for the focus group interviews was the list of proposed guidelines. The focus group interviews were guided by the interview schedule, during which general and specific, open-ended questions were asked. After discussions by the focus group, each section was summarised in agreement with the focus group by the assistant facilitator. An opportunity was provided for the focus group members to add additional information to the proposed guidelines. The proposed guidelines proved to be clear and concise and structured and formulated in an explanatory and understandable manner that is easy to apply by all disciplines working at the new patient clinic and the brachytherapy unit. In total, six additional guidelines were proposed, twelve guidelines were amended and four guidelines were omitted. The words “shared responsibilities” were changed to collective responsibilities and the roles and responsibilities of members of the multidisciplinary team were allocated to a specific member/s. In stage four of the research study the amended guidelines were reviewed by heads or designated representatives of governmental and private brachytherapy units in South Africa. This stage was undertaken to gather their opinions and views on the applicability and feasibility of the guidelines. Electronic mail interviews in English were conducted with seven heads or designated representatives. The layout and formulation of the guidelines were accepted by all the participants as it was found to be well compartmentalised with well-defined mandates. In addition the guidelines would be practical to implement at brachytherapy units as the layout and formulation of the guidelines are logical, clear and concise. Seventeen additional guidelines were proposed, two guidelines were amended and one guideline was omitted. The feedback assisted the researcher in further refining the proposed guidelines, before the final presentation in stage five of the research. The final guidelines presented in stage five of this research study provide a framework that clearly defines the collective and exclusive roles and responsibilities of members of multidisciplinary teams for implementation at the new patient clinic and brachytherapy unit, respectively. In addition, the guidelines address the practice setting of brachytherapy units, ensuring a secure environment for the patient. Although individual unit activities may differ and resource constraints may prevent the full implementation of the guidelines, these guidelines could be implemented with some refining and focussing on what is already in practice. The researcher therefore conclude that the study aim and objectives have been achieved and that the guidelines will make a significant difference to the patient’s experience of patient management at brachytherapy units in the country.Item Open Access Connect : prognostic awareness and structured serious illness conversations in stage IV cancer patients(University of the Free State, 2020-12) Murray, G. Muller; Sherriff, A.Prognostic awareness has been shown to be a key aspect regarding a patient’s understanding of their diagnosis, the available treatment options and the likely treatment and disease outcomes. It is recognised as essential to informed decision making in the setting where there is no curative therapy available, such as in advanced cancer. Palliative care aims to deliver holistic care to both the patient and their carers by enhancing the quality of life of a patient while also considering the role and burdens of the carers and family. A patient’s prognostic awareness is critical in advance care planning and studies have shown that patients and their families wish to discuss prognosis so as to help with decision making regarding a patient’s wishes at the end of life. Advanced care planning has been shown to result in reduced ICU admission and intensive interventions at end of life, while end of life discussions resulted in earlier hospice enrolment for patients and better quality of life and reduced depression in bereaved caregivers. This study represents the first South African study to evaluate prognostic awareness in stage IV cancer patients. An interventional study was used to evaluate the baseline prognostic awareness of 40 patients with incurable cancer being treated with palliative intent and attending our oncology outpatient clinic. Patients were randomised to standard of care with the addition of a measurement of prognostic awareness vs. the same plus a structured communication intervention designed to explore patients’ understanding of their diagnosis and expected illness trajectory, concerns and wishes for end-of-life care. The baseline subjective prognostic awareness of all patients was measured using face to face interviews utilising three questions based on different timeframes to adjudge the risk of death from cancer as described by Helft et al during two consecutive outpatient visits. Objective prognosis was determined using survival curves relevant to the specific cancer type and stage and discussed with the oncologist, while subjective prognosis was evaluated at both visits using the three questions which evaluated the patient’s perceived level of risk of dying from their disease over one year, five years and beyond five years. Thus, the unstructured approach used with half the patients consisted of the standard of care with the addition of three questions to determine prognostic awareness followed by an open ended, patient directed prognostic discussion of questions and views the patient may have had following the prognostic questions, these patients comprised the control group. In contrast with the interventional group, the same standard of clinical care and three questions to determine prognostic awareness was followed by a physician directed guided serious illness conversation administered in the standardised format as described by Bernacki et al. By comparing the objective prognosis with the patient’s subjective prognosis, patients were grouped as having high, low or poor prognostic awareness in each of the three timeframes. Data was analysed to evaluate the change from baseline values. There was a high level of willingness to participate in the study and discuss prognosis with a >95% participation rate. Results indicated that at baseline most patients had low to poor prognostic awareness with the majority significantly overestimating their prognosis. More patients in the interventional group had high PA both at baseline and at the second visit while there was a greater increase in high PA within the control group with the unstructured approach to discussing prognosis. The difference in baseline PA may be a confounding factor to parallel comparison of the groups. In evaluating for change in prognostic awareness within the control and intervention groups, both groups showed a trend towards increased prognostic awareness, however statistical analysis of the interventional and standard of care groups for the 1 year (p = 0.52 and p = 0.6), five year (p = 0.84 and p = 0.26) and open timeframe ( p = 0.84 and p = 0.38) did not reach statistical significance. Thus, the addition of a structured guided prognostic discussion compared to an unstructured approach was not shown to be superior in this study. At baseline the percentage of patients in the population as a whole with high prognostic awareness was 20%, 25% and 35% for the three timeframes. In contrast after a single application of the interventions used in our study, a trend for improved prognostic awareness from baseline in the population was evident with high prognostic awareness measured in 22.5%, 37.5% and 52.5% of patients for the three timeframes. It may be that the inclusion of a formal evaluation of prognostic awareness in itself results in a trend towards improved prognostic awareness, this study did not provide evidence that following such an evaluation the administration of a structured prognostic discussion yielded superior results to an unstructured discussion on prognosis. Further study in South African patients may advance the role and utility of high prognostic awareness in patients, families and caregivers faced with incurable illness.Item Open Access Outcomes of patients receiving radical radiation with concurrent chemotherapy for vulva cancer at Universitas Hospital Oncology Department, Free State, South Africa(University of the Free State, 2019) Fourie, C.; Sherriff, A.Introduction and aim: Although cancer of the vulva is relatively rare in the developed world, incidence is increasing worldwide. In South Africa, increased incidence is accompanied by a decrease in age at diagnosis. Whereas patients in developed countries are often operable at presentation and undergo surgery, limited resources and the extent of presenting disease in our setting lead to an approach aiming for cure with primary radiotherapy and concurrent chemotherapy in many instances. Even with curable disease, the morbidity and mortality in these patients are high. This study aimed to measure survival outcomes in this group of patients. Methods: This is a retrospective, descriptive cohort study of vulva carcinoma patients receiving radical treatment from 2006 to 2010. We collected demographic, treatment and follow-up data, and date of death where available. Results: A total of 55 patients presented in the trial period, of which 30 met the inclusion criteria. The study population had a mean age 50 years, and 52% were HIV positive, of which 17% were on HAART. Of the HIV positive participants, most had a CD4 count above 400. Most patients had stage 3, moderately differentiated disease. The mean radiation dose received was 66.3 Gy, and nearly all patients completed concurrent chemotherapy. Adequate follow up data was only available for 7 participants, and date of death was only available for four. Survival parameters could thus not be calculated for this cohort. Conclusion: Compared to departmental numbers from 2016 and 2017, the size of our cohort was small, which gives the impression that the incidence of vulva carcinoma is increasing. We concluded that our population is not comparable to international populations, which prompts interest in finding individualized treatment. However, more studies are needed to investigate survival of these patients receiving definitive radiotherapy with concurrent chemotherapy.Item Open Access Plasmablastic lymphoma in HIV positive patients in the Free State Province of South Africa(University of the Free State, 2017) Jordaan, Jacoline; Sherriff, A.; Goedhals, J.2.1 Methods: The patient sample of this study consisted of all HIV-positive patients that were diagnosed with PBL in the period between 2005 and 2013 in the Free State Province of South Africa and who were treated by the Department of Oncology at the Universitas Hospital Complex. The study design is a retrospective study with descriptive and analytical components aimed at analysing the patient profile and the performance of a range of treatment regimes. 2.2 Results: Fifty nine patients from one institution were evaluated after all exclusions. The mean age at diagnosis with PBL was 39,1 years with the gender distribution favouring males. Forty one point eight percent of patients presented with a performance status of ECOG 1. The amount of patients diagnosed with HIV prior the diagnosis of PBL was 59,3%. A third of patients were on HAART prior to diagnosis of PBL and 37% of patients were documented to be started on HAART with diagnosis of PBL. The median CD4 value on diagnosis of PBL was 108,5. The most popular extra nodal site was the oral cavity. According to our statistics only 38 of our patients received some form of treatment for their PBL, 21 patients were either too critical or lost to follow up to start treatment. Thirty seven patients received chemotherapy. Radiation therapy was part of the treatment for 12 of the patients. The median follow up time was 2,3 months. Progression free survival at 3 months for our study population was 90,8% (95%CI 83,1%-98,5%). The overall survival of patients according to treatment modality at 3 months calculated as follows: HAART prior to PBL (n=14) 71,43%, HAART with PBL (n=12) 91,66%, No HAART (n=9) 55,56%, patients receiving chemotherapy as treatment modality (n=27) 92,59%. 2.3 Conclusions: The importance of improved management of HIV is highlighted by the results of the study. If better control over HIV and a patient’s general immunity can be achieved, more intensive chemotherapy regimes can be employed. Therefore, HAART is the mainstay and most important factor of the treatment of PBL. By starting HIV positive patients on HAART at an earlier stage in the disease (despite the CD4 value) might help in the survival of PBL patients or play a role in preventing PBL.Item Open Access Protocol for anal carcinoma: a retrospective review at the Department of Oncology Universitas Academic Hospital Bloemfontein(University of the Free State, 2021) Buthelezi, Thandeka Nompumelelo; Sherriff, A.Background: Anal carcinoma is an uncommon cancer worldwide. Standard therapy is chemoradiation as it is not only curative but also has the advantage of organ preservation. In our department we see mostly locally advanced carcinomas as opposed to the early stage disease investigated in international articles. The standard dose for chemoradiation is 55-59 Gy. We have given up to 70Gy in locally advanced disease. Objectives: We aimed to assess whether the higher dose of up to 66-70 Gy, given in our department to locally advanced disease is improving survival and has a comparable side effect profile to the standard radiation dose. Method: As will be explained later, only patients that were from the Free State and treated in our department from 2001 to 2010 were included in the study sample. Clinical records were used to obtain data. The total number of participants were 28. Only patients that received chemoradiation or radiation only were included. The data analysed were: local demographics, local control, acute and late toxicity, colostomy free survival and progression free survival with correlation to the total radiation dose received .Numerical variables were summarised using medians and interquartile ranges. Categorical variables were summarised using frequencies and percentages. Results: Males made up 57,1% of the participants and females 42,9%. The mean age was 45 with the youngest being 21 years old. Twelve of the participants had HIV infection. Ninety one percent of the patients had squamous cell carcinoma. All presented with locally advanced disease. Five patients defaulted post radiation. Participants that received split course radiation were 86%, 7% received continuous radiation to a total dose of 50,4 Gy,3,6% 38 Gy and 3,6% 3740cGy . The highest radiation dose received was 60 Gy. On follow-up 12 (43%) had a complete response 11(39%) had residual disease. Majority (75%) already had colostomies prior to starting treatment, three never required one. Conclusion: The primary end point was not met as none of the patients received the dose we were aiming to assess due to exclusion criteria. Observations made with regards to demographics and side effect profile were in keeping with published literature. PFS and OS were less due to the majority of the patients having poor prognostic features and poor patient follow up. The majority of the patients were treated with radiation doses lower than 55 Gy which is the recommended minimum for locally advanced disease.Item Open Access Rectal and bladder radiation dose during curative radiotherapy for cervix cancer at Universitas Hospital Oncology.(University of the Free State, 2017) Piek, P. C.; Sherriff, A.Introduction and aim. Cervical carcinoma is a huge burden on the South African population and health care system. Treatment of this disease has improved dramatically with the advent of 3D imaging capabilities combined with brachytherapy to deliver dose to the tumor and limit dose to organs at risk specifically the bladder and rectum. Recent guidelines give recommendations for dose limitations of these organs at risk, specific for a volume of 0.1cc, 1cc and 2cc. Our departmental dose prescription method for brachytherapy is unique by dose limitation to the rectum for each brachytherapy. The aim of this study was to determine the total dose of combined external beam radiotherapy(EBRT) and brachytherapy to the rectum and bladder for 0.1cc,1cc and 2cc and compare the outcome to international findings. Methods. 57 patients that completed definitive radiotherapy for cervical cancer were retrospectively reviewed. All patients received EBRT 50Gy in 2Gy daily fractions with brachytherapy 4-5 doses. The dose normalised to the rectum point receiving the highest dose. The combined dose of EBRT and brachytherapy was converted to bio-equivalent dose in 2Gy fractions (EQD2) for each of the volumes of the rectum and bladder. Results. Mean EQD2 dose to the rectum 0.1cc: 63.8(3.3); 1cc: 60.4(2.2); 2cc: 58.9(1.8). Mean doses to the rectum was lower than described in the literature with no patient receiving more than the dose cutoff for 2cc(70Gy). Mean doses to the bladder 0.1cc: 87.4(18.5); 1cc:75,5(11.9) and 2cc: 71,6(10.0). These doses are also lower as described in the literature however two patients received dose higher that the advised cutoff to 2cc of 90Gy. This could have been avoided for one of the patients if the correct method of dose determination was followed. Conclusion. As expected the current dose prescription method yields safe doses to the rectum. The bladder dose is a concern even though only two patients exceeded the tolerance and it could have been avoided. High variation in the bladder dose among patients suggests an opportunity for dose optimisation techniques. These findings should be correlated with clinical outcomes of toxicity.Item Open Access A retrospective study to evaluate local control and freedom from biochemical failure in Prostate cancer treated with Hypo-fractionated split course 3D conformal radiotherapy at Universitas Academic Hospital, Bloemfontein, South Africa(University of the Free State, 2020-06) Mthombeni, Joseph M.; Vorster, KarinBackground: Prostate cancer is the most common malignancy in men and the second most common cause of death for men in South Africa and universally. Three-dimensional conformal radiotherapy (3DCRT) is a safe and efficacious method to deliver radiation for prostate malignancy patients in all risk groups with acceptable toxicity rates and adequate biochemical control. AIM: To describe local control and freedom from biochemical failure in Prostate cancer patients treated with Hypo-fractionated split course external beam radiotherapy in a specified population for a given period. Methods: A retrospective descriptive cohort was conducted. Files of 142 patients with locally confined prostate adenocarcinoma who was treated at the Universitas Annex Hospital between 2003-2013 were reviewed. Data collected included demographics, risk factors, recurrence risk stratification, Gleason score, TNM staging, and PSA levels. Results: The prevalence of disease control was 108/142=76.1% at the end of the study period (60 months). The median age of the study participants was 68 years. Of the study participants, 40.14 % were white, 54.23% were black, and 5.63% were other races. At a median follow up of 5 years, all low-risk patients that participated in this study had disease control (local and biochemical), intermediate and high-risk patients with disease control were 12.68% and 59.15% respectively. The 34(23.9%) patients that had progression of the disease, 2.11% (3) and 21.83% (31) were intermediate and high risk, respectively. Conclusion: Hypo-fractionated split course 3DCRT in patients with localized prostate cancer has a significant locoregional disease control and freedom from biochemical failure.