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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.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 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 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 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.