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Breast Cancer Brachytherapy Benefits Still Unclear

By MedImaging International staff writers
Posted on 17 Jan 2012

Accelerated partial breast irradiation using brachytherapy (APBIb) for the treatment of breast cancer has been rapidly increasing over the last several years in the United States as an alternative to conventional whole-breast irradiation (WBI), according to recent research.

The study’s findings were published online December 16, 2011, in the Journal of the National Cancer Institute. Various types of APBI recurrence (external beam radiation, intraoperative radiotherapy, brachytherapy using multiple interstitial catheters, or intracavitary brachytherapy using a balloon catheter) deliver radiation to breast tissue at the highest risk of recurrence. Benefits of these techniques include decreased treatment time and less radiation to uninvolved portions of the breast and normal tissues.

Disadvantages of APBI include the potential that tumor cells in a different part of the breast will remain untreated, which could lead to increased local recurrence. Because of the potential limitations of APBI, in 2009 the American Society for Radiation Oncology (ASTRO; Fairfax, VA, USA) convened a task force of breast cancer experts to develop criteria for use of APBI off-protocol. They proposed three groups of APBI appropriateness: suitable, cautionary and unsuitable, based on patient characteristics and clinical factors.

Because of the growing popularity of APBIb specifically, Jona Hattangadi, MD, from the department of radiation oncology at the Brigham and Women’s Hospital and Harvard Medical School (both based in Boston, MA, USA) and colleagues performed a retrospective analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database of women who had received either APBIb or WBI between 2000 and 2007. In line with ASTRO guidelines, the researchers classified the 138,815 women as “suitable,” “cautionary,” or “unsuitable” for APBIb.

The investigators revealed that 3,576 of the 138,815 patients had received APBIb: 32% of whom would have been considered suitable, 29.6% cautionary, and 36.2% unsuitable. The overall use of APBIb increased from 0.4% in 2000 to 6.6% in 2007. There was a broad range of utilization patterns across the United States with specific geographic regions having higher APBIb use in spite of other patient and clinical factors. There were also considerable racial and ethnic discrepancies with respect to APBIb use. White women were more apt to get this treatment than black women among cautionary or unsuitable patients; and women living in cities were more likely to get it than those in rural areas even though it would potentially provide greater convenience for the rural women.
The authors concluded that, “the wide disparity in use of APBIb suggests that unwarranted variation--practice variation not explained by illness, patient preference, or evidence-based medicine--may be present. Future studies of APBIb use will help elucidate whether patterns change as [the ASTRO guidelines] diffuse into practice and whether the regional and temporal changes in APBIb cost, reimbursement, and insurance coverage affect utilization.”

In an accompanying editorial in the same issue, Simona F. Shaitelman, MD, from the department of radiation oncology at the University of Texas M.D. Anderson Cancer Center (Houston, USA), noted that it is encouraging that the authors discovered the fastest increase in utilization among patients classified as suitable, even if most of patients undergoing APBIb in their study were not classified as suitable. Dr. Shaitelman also commented on the authors’ suggestion that financial interests that might be fueling usage and noted that reimbursement was decreased for the procedure after the end of the period of the study. She wrote, “Moving forward, it will be useful to analyze more recent trends in the use of APBI and to document whether such changes in financial remuneration are indeed associated with the delivery of APBI.”

Dr. Shaitelman concluded that more research of the effectiveness of APBI is needed. “Although population based studies allow us to reflect on changes in patterns of practice, we are still left eagerly awaiting the results of large randomized trials that compare patients outcomes with WBI vs APBI.”

Related Links:
Brigham and Women’s Hospital
M.D. Anderson Cancer Center

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60 (!!!!! 7978.2009124756): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

61 (341.89224243164): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

62 (726.93824768066): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

63 (!!!!! 7459.8789215088): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

64 (955.82008361816): SELECT fid FROM jos_deeppockets WHERE id=294738890 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294738890 AND published='1' LIMIT 1

65 (!!!!! 3539.0853881836): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=213 ORDER BY `ordering`

66 (!!!!! 2521.9917297363): select jos_twitters.link from jos_twitters where cat=10

67 (391.96014404297): select jos_facebook.link from jos_facebook where cat=10

68 (71.048736572266): select jos_google_plus.link from jos_google_plus where cat=10

69 (279.90341186523): select jos_linkedin.link from jos_linkedin where cat=10

70 (97.036361694336): SELECT fid FROM jos_deeppockets WHERE id=294738890 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294738890 AND published='1' LIMIT 1

71 (344.03800964355): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=213 ORDER BY `ordering`

72 (!!!!! 10250.091552734): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (427.0076751709): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

74 (102.99682617188): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

75 (117.06352233887): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (50.067901611328): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (37.193298339844): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (94.175338745117): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (67.949295043945): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (42.200088500977): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (37.908554077148): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

89 (110.14938354492): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (56.028366088867): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

91 (62.942504882812): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

92 (101.80473327637): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (53.167343139648): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (52.928924560547): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (42.200088500977): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (176.90658569336): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (88.930130004883): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (61.988830566406): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (63.896179199219): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

106 (609.15946960449): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

107 (97.990036010742): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

108 (115.87142944336): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (80.108642578125): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

110 (371.93298339844): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

111 (!!!!! 6782.054901123): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

112 (!!!!! 1126.0509490967): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (!!!!! 1036.8824005127): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

114 (729.08401489258): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

115 (495.91064453125): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

116 (324.01084899902): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

117 (86.069107055664): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

118 (97.036361694336): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

119 (86.069107055664): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

120 (76.055526733398): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

121 (48.160552978516): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

122 (127.07710266113): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

123 (60.081481933594): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

124 (425.10032653809): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

125 (!!!!! 60240.983963013): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

126 (!!!!! 6628.9901733398): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738890 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738890 AND type='deeppockets_item' AND published='1' LIMIT 1

127 (!!!!! 28923.988342285): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

128 (641.1075592041): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

129 (164.98565673828): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

130 (229.83551025391): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

131 (391.00646972656): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

132 (388.14544677734): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

133 (!!!!! 2727.0317077637): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

134 (119.92454528809): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

135 (70.095062255859): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

136 (46.968460083008): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

137 (585.07919311523): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (475.88348388672): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

139 (266.07513427734): SELECT name FROM jos_deeppockets WHERE id=213

140 (39.815902709961): SELECT name FROM jos_deeppockets WHERE id=213

141 (764.13154602051): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))213((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

142 (672.81723022461): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))213((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

143 (79.154968261719): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

144 (76.055526733398): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

145 (!!!!! 12212.038040161): TRUNCATE TABLE jos_trademed_module

146 (144.00482177734): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (72.002410888672): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294738890 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

148 (498.05641174316): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (75.817108154297): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

150 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

151 (48.160552978516): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

152 (!!!!! 1185.8940124512): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

153 (92.983245849609): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

154 (71.048736572266): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

155 (51.975250244141): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738890 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738890 AND type='deeppockets_item' AND published='1' LIMIT 1

156 (567.19779968262): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=213 or channel_id is null)

157 (60.081481933594): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=213 or channel_id is null)

158 (60.081481933594): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

159 (94.175338745117): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

160 (56.028366088867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738890 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738890 AND published='1' LIMIT 1

161 (42.915344238281): select jos_twitters.link from jos_twitters where cat=10

162 (35.04753112793): select jos_facebook.link from jos_facebook where cat=10

163 (35.04753112793): select jos_google_plus.link from jos_google_plus where cat=10

164 (35.04753112793): select jos_linkedin.link from jos_linkedin where cat=10

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