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Zangouri V, Roshanshad A, Ranjbar A, Izadi M, Rajaeifar S, Goodarzi A, Nasrollahi H. Outcomes and complications of intraoperative radiotherapy versus external beam radiotherapy for early breast cancer. Cancer Rep (Hoboken) 2024; 7:e1950. [PMID: 38205671 PMCID: PMC10849931 DOI: 10.1002/cnr2.1950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/19/2023] [Accepted: 11/12/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is an alternative for external beam radiotherapy (EBRT) for early stage breast cancer (BC). Herein, we compared outcomes, postoperative and post-radiation complications of IORT and EBRT. METHODS We conducted a cohort study to compare complications of IORT and EBRT in patients. A checklist of the complications of IORT and EBRT, was used to assess and post-radiation complications and outcomes. RESULTS Overall, 264 women (121 in IORT and 143 in EBRT group) with a mean (SD) age of 55 ± 8.6 years analyzed in this study. The IORT group (quadrantectomy + SLNB + IORT) had more severe post-operative pain compared to the EBRT group (quadrantectomy + SLNB) (OR = 1.929, 95% CI: 1.116-3.332). Other postoperative complications, including edema, erythema, seroma, hematoma, and wound complications were not significantly different between the IORT and EBRT groups. EBRT was associated with higher rates post-radiation complications, including erythema (95.8% vs. 21.5%), skin dryness (30.8% vs. 12.4%), pruritus (26.6% vs. 17.4%), hyperpigmentation (48.3% vs. 9.9%), and telangiectasia (1.4% vs. 0.8%). Multivariate analysis showed that erythema, skin dryness and pruritus, and hyperpigmentation were more severe in the EBRT group, while breast induration was higher in the IORT group (OR = 4.109, 95% CI: 2.242-7.531). Excellent, good, and fair cosmetic outcome was seen in 11.2%, 72%, and 16.8% of the patients in the EBRT group and 29.8%, 63.6%, and 6.6% in the IORT group, respectively, suggesting that the cosmetic outcome was significantly better in the IORT group (P < .001). There wasn't statistically significant difference in recurrence-free survival and overall survival rates between two groups of patients who received either IORT or EBRT (P = .953, P = .56). CONCLUSION IORT is considered to have lower post-radiation complications and better cosmetic outcomes in breast cancer patients. Therefore, IORT might be used as the treatment of choice in eligible patients.
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Affiliation(s)
- Vahid Zangouri
- Surgical Oncology Division, General Surgery DepartmentShiraz University of Medical SciencesShirazIran
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
| | - Amirhossein Roshanshad
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- Poostchi Ophthalmology Research CenterShiraz University of Medical SciencesShirazIran
| | - Aliyeh Ranjbar
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mahsa Izadi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Sara Rajaeifar
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Ali Goodarzi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Hamid Nasrollahi
- Radiation Oncology, Radio‐Oncology Department, School of MedicineShiraz University of Medical SciencesShirazIran
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Turkheimer LM, Petroni GR, Berger AC, Schroen AT, Brenin DR, Lazar M, Libby B, Janowski EM, Showalter TN, Showalter SL. Novel Form of Breast Intraoperative Radiation Therapy with CT-Guided High-Dose-Rate Brachytherapy: Interim Results of a Prospective Phase-II Clinical Trial. J Am Coll Surg 2024; 238:10-20. [PMID: 37870228 DOI: 10.1097/xcs.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Precision breast intraoperative radiation therapy (PB-IORT) is a novel method of IORT that uses customized CT-based treatment plans and high-dose-rate (HDR) brachytherapy. We conducted a phase-II multi-institution trial to evaluate the efficacy of PB-IORT. STUDY DESIGN Between 2015 and 2022, 3 centers enrolled women aged 45 years and older with invasive or in situ carcinoma measuring 3 cm or smaller and N0 status (n = 358). Breast-conserving surgery was performed, and a multilumen balloon catheter was placed in the lumpectomy bed. CT images were used to create customized HDR brachytherapy plans that delivered 12.5 Gy to the tumor bed. The primary outcome assessed was the 5-year rate of index quadrant tumor recurrence. An interim analysis was conducted after one-third of eligible participants completed 5 years of follow-up. This trial is registered with clinicaltrials.gov (NCT02400658). RESULTS The cohort comprised 153 participants with a median age of 64 years and median follow-up time of 5.9 years. The estimated 5-year index quadrant tumor recurrence rate and overall survival were 5.08% (95% CI 2.23 to 9.68) and 95.1%, respectively. Locoregional (ipsilateral breast and axilla) and distant recurrence rates were each 1.96%. Seven deaths occurred during the first 5 years of follow-up, with only 1 attributable to breast cancer. Overall, 68.6% of patients experienced any adverse effects, and 4 cases of breast-related severe toxicities were observed. CONCLUSIONS This study presents the results of a planned interim analysis of a phase-II trial investigating PB-IORT and demonstrates the efficacy and safety of single-fraction, CT-based, HDR brachytherapy after breast-conserving surgery. These findings provide valuable insights into the use of PB-IORT as a treatment modality.
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Affiliation(s)
- Lena M Turkheimer
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Gina R Petroni
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA (Petroni)
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Berger)
| | - Anneke T Schroen
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - David R Brenin
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Melissa Lazar
- Department of Surgery, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA (Lazar)
| | - Bruce Libby
- Radiation Oncology, Moffitt Cancer Center, Tampa, FL (Libby)
| | - Einsley M Janowski
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy N Showalter
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Shayna L Showalter
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
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Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Bhimani F, McEvoy M, Gupta A, Pastoriza J, Shihabi A, Basavatia A, Tomé WA, Fox J, Mehta K, Feldman S. Case Report: Bilateral targeted intraoperative radiotherapy: a safe and effective alternative for synchronous bilateral breast cancer. Front Oncol 2023; 13:1276766. [PMID: 37941541 PMCID: PMC10628514 DOI: 10.3389/fonc.2023.1276766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023] Open
Abstract
Background The incidence of bilateral breast cancer (BBC) ranges from 1.4% to 11.8%. BBC irradiation is a challenge in current clinical practice due to the large target volume that must be irradiated while minimizing the dose to critical organs. Supine or prone breast techniques can be used, with the latter providing better organ sparing; both, however, result in lengthy treatment times. The use of Intra-operative radiotherapy (IORT) in breast cancer patients who choose breast conservation has been highlighted in previous studies, but there is a scarcity of literature analyzing the utility and applicability of IORT in BBC. This case series aims to highlight the applicability of administering bilateral IORT in patients with BBC. Case reports Five patients with bilateral early-stage breast cancer (or DCIS) were treated with breast-conserving surgery followed by bilateral IORT. Of the 10 breast cancers, 8 were diagnosed as either DCIS or IDC, while the other 2 were diagnosed as invasive lobular carcinoma and invasive carcinoma, respectively. During surgery, all patients received bilateral IORT. Furthermore, 1 patient received external beam radiation therapy after her final pathology revealed grade 3 DCIS. The IORT procedure was well tolerated by all five patients, and all patients received aromatase inhibitors as adjuvant therapy. Additionally, none of these patients showed evidence of disease after a 36-month median follow-up. Conclusion Our findings demonstrate the successful use of IORT for BCS in patients with BBC. Furthermore, none of the patients in our study experienced any complications, suggesting the feasibility of the use of IORT in BBC. Considering the benefits of improved patient compliance and a reduced number of multiple visits, IORT may serve as an excellent patient-centered alternative for BBC. Future studies are recommended to reinforce the applicability of IORT in patients with BBC.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Areej Shihabi
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Amar Basavatia
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
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Liu J, Shi X, Niu Z, Qian C. Comparative efficacy of intraoperative radiotherapy and external boost irradiation in early-stage breast cancer: a systematic review and meta-analysis. PeerJ 2023; 11:e15949. [PMID: 37744215 PMCID: PMC10512934 DOI: 10.7717/peerj.15949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023] Open
Abstract
External boost radiotherapy (EBRT) and intraoperative radiotherapy (IORT) are shown to be effective in patients with early-stage breast cancer. However, the difference between IORT and EBRT for patients' prognosis remains to be elucidated. The purpose of this meta-analysis is to investigate differences in local recurrence (LR), distant metastases, disease free survival (DFS), and overall survival (OS) between these two therapies. We searched the Cochrane Library, PubMed, Web of Science and Embase, from inception to Jan 10th, 2022. We used The Cochrane risk-of-bias assessment tool to assess the risk of bias of the included studies, and the STATA15.0 tool was used for the meta-analyses. Eight studies were ultimately included. Meta-analysis demonstrated that there was an inconsistent finding in the long-term risk of LR between the two radiotherapies, and there was no significant difference in short-term risk of LR, the metastasis rate, DFS, and OS IORT would be more convenient, less time-consuming, less costly, and more effective at reducing side effects and toxicity. However, these benefits must be balanced against the potential for increased risk of LR in the long term.
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Affiliation(s)
- Jiaxin Liu
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Xiaowei Shi
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Zhenbo Niu
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
| | - Cheng Qian
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
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6
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Squeo GC, Meneveau MO, Varhegyi NE, Lattimore CM, Janowski E, Showalter TN, Showalter SL. Factors Associated With Cosmetic Outcomes After Treatment With a Novel Form of Breast Intraoperative Radiation Therapy. J Surg Res 2023; 283:514-522. [PMID: 36436288 DOI: 10.1016/j.jss.2022.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 09/07/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Precision breast intraoperative radiation therapy (PB-IORT) incorporates computed tomography-guided treatment planning and high dose rate brachytherapy to deliver a single dose of highly conformal radiational therapy. The purpose of this study is to determine factors associated with poor cosmetic outcomes after treatment with PB-IORT. METHODS The study included all consecutive participants enrolled in an ongoing phase II clinical trial that had completed a minimum of 12 mo of follow-up. A poor cosmetic outcome was defined as scoring "fair" or "poor" on the Harvard Cosmesis evaluation, or "some" or "very much" on any of the three general cosmesis categories. Statistical analysis was performed utilizing R. RESULTS The final cohort included 201 participants, of which 181 (90%) had an overall good/excellent cosmetic outcome. Group 1 consisted of 162 (81%) participants who reported only excellent/good cosmetic outcomes. Group 2 consisted of 39 (19%) participants who reported some aspect of a poor cosmetic outcome. On multivariable analysis, participants with ductal carcinoma in situ were significantly more likely to experience a poor cosmetic outcome (odds ratio 2.45, 95% confidence interval 1.03-5.82, P = 0.04), and those who received subsequent whole breast irradiation were also more likely to have a poor cosmetic outcome (odds ratio 10.20, 95% confidence interval CI 1.04-99.95, P = 0.04). CONCLUSIONS Patients with need for further radiation after PB-IORT are at increased risk for a poor cosmetic outcome. Larger balloon volume and distance between the skin do not have deleterious effects on cosmetic outcomes.
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Affiliation(s)
- Gabriella C Squeo
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Max O Meneveau
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Nikole E Varhegyi
- University of Virginia School of Medicine, Department of Public Health Sciences, Charlottesville, Virginia
| | - Courtney M Lattimore
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Einsley Janowski
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Timothy N Showalter
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Shayna L Showalter
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia.
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Vaidya JS, Bulsara M, Wenz F, Sperk E, Massarut S, Alvarado M, Williams NR, Brew-Graves C, Bernstein M, Holmes D, Vinante L, Pigorsch S, Lundgren S, Uhl V, Joseph D, Tobias JS. The TARGIT-A Randomized Trial: TARGIT-IORT Versus Whole Breast Radiation Therapy: Long-Term Local Control and Survival. Int J Radiat Oncol Biol Phys 2023; 115:77-82. [PMID: 35998867 DOI: 10.1016/j.ijrobp.2022.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- University Medical Centre Freiburg, University of Frieberg, Frieberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | | | | | | | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, California
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of RadioOncology and Radiotherapy, Technical University of Munich, Munich, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
| | - Valery Uhl
- Radiation Oncology, Summit Medical Center, Oakland, California
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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Vaidya JS, Vaidya UJ, Baum M, Bulsara MK, Joseph D, Tobias JS. Global adoption of single-shot targeted intraoperative radiotherapy (TARGIT-IORT) for breast cancer—better for patients, better for healthcare systems. Front Oncol 2022; 12:786515. [PMID: 36033486 PMCID: PMC9406153 DOI: 10.3389/fonc.2022.786515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/28/2022] [Indexed: 12/30/2022] Open
Abstract
Micro abstractTargeted intraoperative radiotherapy (TARGIT-IORT) is delivered immediately after lumpectomy for breast cancer. We estimated its impact. At least 44,752 patients with breast cancer were treated with TARGIT-IORT in 260 centres in 35 countries, saving >20 million miles of travel and preventing ~2,000 non–breast cancer deaths. The TARGIT-IORT website (https://targit.org.uk/travel) provides maps and tools to find the nearest centre offering TARGIT-IORT and travel savings.BackgroundTargeted intraoperative radiotherapy (TARGIT-IORT) delivers radiotherapy targeted to the fresh tumour bed exposed immediately after lumpectomy for breast cancer. TARGIT-A trial found TARGIT-IORT to be as effective as whole-breast radiotherapy, with significantly fewer deaths from non–breast cancer causes. This paper documents its worldwide impact and provides interactive tools for clinicians and patients.MethodCentres using TARGIT-IORT provided the date of the first case and the total number of patients. We plotted these data on a customised Google Map. An interactive web-based tool provided directions to the closest centre. Using the data from the TARGIT-A trial, we estimated the total savings in travel miles, carbon footprint, and the number of non–breast cancer deaths that might be prevented.ResultsData from 242 (93%) of the 260 centres treating patients from 35 countries were available. From the first patient treated in 1998 to early 2020, at least 44,752 women with breast cancer have been treated with TARGIT-IORT. The TARGIT-IORT website (https://targit.org.uk/travel) displays the Google Map of centres with number of cases and an interactive tool for patients to find the nearest centre offering TARGIT-IORT and their travel savings. Scaling up to the already treated patients, >20 million miles of travel would have been saved and about 2,000 deaths prevented.ConclusionOne can ascertain the number of patients treated with a novel treatment. These data show how widely TARGIT-IORT has now been adopted and gives an indication of its beneficial worldwide impact on a large number of women with breast cancer.
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Affiliation(s)
- Jayant Sharad Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- *Correspondence: Jayant Sharad Vaidya, ;
| | - Uma Jayant Vaidya
- Medical Sciences Division Brasenose College, University of Oxford, Oxford, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Kishor Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S. Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Evaluation of breast cosmetic changes with a computer-software; the breast cancer conservative treatment cosmetic results (BCCT. core) in hypofractionated whole breast irradiation after breast-conserving surgery-supplementary analysis of multicenter single-arm confirmatory trial: JCOG0906. Breast Cancer 2022; 29:1042-1049. [PMID: 35861936 DOI: 10.1007/s12282-022-01384-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 06/26/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND A good cosmetic outcome has been defined as an important endpoint in breast-conserving therapy (BCT). Various evaluation methods have been studied, but the optimal method has yet to be identified. The present supplementary analysis of JCOG0906 focused on comparing evaluation methods for breast cosmetic outcomes following hypofractionated whole breast irradiation (HFWBI) to examine whether a computer-software (the Breast Cancer Conservative Treatment cosmetic results [BCCT. core])-based program evaluation (CE) can be used for Asian women in clinical trials of BCT. METHODS Of 306 women, 292 underwent institutional evaluation (IE) for breast cosmetic outcomes before (pre) and 3 years after (post) HFWBI using a 4-point scale (excellent/good/fair/poor), and they were evaluated by CE and a central panel evaluation (PE) on the same scale using 292 pairs of pre/post-HFWBI photographs. PE was performed twice by consensus of the same two experts with a 3-year interval. CE was assessed individually by two radiation oncologists, an expert and a non-expert. Intra-observer variability and inter-observer variability were calculated using the kappa (k) and weighted kappa (wk) statistics. RESULTS The agreement between the first and second PE using pre/post-HFWBI photographs was moderate (k = 0.60, wk = 0.64. k = 0.53, wk = 0.60). The agreement between the expert and non-expert on CE was substantial (k = 0.72, wk = 0.76. k = 0.72, wk = 0.77). The inter-observer variability of CE was smaller than the intra-observer variability of PE. CONCLUSION CE with BCCT. core was considered a reproducible and an appropriate evaluation method for Asian women in clinical trials of BCT, when breast cosmetic changes were compared between pre/post therapy.
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11
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He L, Zhou J, Qi Y, He D, Yuan C, Chang H, Wang Q, Li G, Shao Q. Comparison of the Oncological Efficacy Between Intraoperative Radiotherapy With Whole-Breast Irradiation for Early Breast Cancer: A Meta-Analysis. Front Oncol 2022; 11:759903. [PMID: 34976808 PMCID: PMC8718609 DOI: 10.3389/fonc.2021.759903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/29/2021] [Indexed: 01/09/2023] Open
Abstract
Background Intraoperative radiotherapy (IORT) and whole-breast irradiation (WBI) are both effective radiotherapeutic interventions for early breast cancer patients undergoing breast-conserving surgery; however, an issue on whether which one can entail the better prognosis is still controversial. Our study aimed to investigate the 5-year oncological efficacy of the IORT cohort and the WBI cohort, respectively, and compare the oncological efficacy between the cohorts. Materials and Methods We conducted a computerized retrieval to identify English published articles between 2000 and 2021 in the PubMed, the Web of Science, the Cochrane Library, and APA PsycInfo databases. Screening, data extraction, and quality assessment were performed in duplicate. Results A total of 38 studies were eligible, with 30,225 analyzed participants. A non-comparative binary meta-analysis was performed to calculate the weighted average 5-year local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) in the two cohorts, respectively. The LRFS, DMFS, and OS (without restriction on the 5-year outcomes) between the two cohorts were further investigated by a comparative binary meta-analysis. The weighted average 5-year LRFS, DMFS, and OS in the IORT cohort were 96.3, 96.6, and 94.1%, respectively, and in the WBI cohort were 98.0, 94.9, and 94.9%, respectively. Our pooled results indicated that the LRFS in the IORT cohort was significantly lower than that in the WBI cohort (pooled odds ratio [OR] = 2.36; 95% confidential interval [CI], 1.66–3.36). Nevertheless, the comparisons of DMFS (pooled OR = 1.00; 95% CI, 0.76–1.31), and OS (pooled OR = 0.95; 95% CI, 0.79–1.14) between the IORT cohort with the WBI cohort were both not statistically significant. Conclusions Despite the drastically high 5-year oncological efficacy in both cohorts, the LRFS in the IORT cohort is significantly poorer than that in the WBI cohort, and DMFS and OS do not differ between cohorts.
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Affiliation(s)
- Lin He
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China.,Cancer Center, Faculty of Health Sciences, University of Macau, Macau, Macau SAR, China
| | - Jiejing Zhou
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Yuhong Qi
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Dongjie He
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Canliang Yuan
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Hao Chang
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Qiming Wang
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Gaiyan Li
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Qiuju Shao
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
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12
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Leonardi MC, Kouloura A, Rojas DP, Zaffaroni M, Intra M, Veronesi P, Morra A, Gerardi MA, Fodor CI, Zerella MA, Camarda AM, Cattani F, Luraschi R, Viola A, Riva G, Miglietta E, Orecchia R, Dicuonzo S, Jereczek-Fossa BA. The POLO (Partially Omitted Lobe) approach to safely treat in-breast recurrence after intraoperative radiotherapy with electrons. Br J Radiol 2021; 95:20210405. [PMID: 34919420 DOI: 10.1259/bjr.20210405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study is to evaluate feasibility of salvage 4-week hypofractionated whole breast radiotherapy (WBRT) in patients with in-breast recurrence after receiving intraoperative radiotherapy with electrons (IOERT) for primary breast cancer (BC). METHODS BC patients who had repeated quadrantectomy underwent modified WBRT with intensity-modulated radiotherapy using Helical Tomotherapy to underdose the IOERT region. This approach, called POLO (Partially Omitted Lobe), excluded the IOERT volume from receiving the full prescription dose. RESULTS Nine patients were treated with this approach, receiving 45 Gy in 20 fractions. A simultaneous integrated boost of 2.5 Gy in 20 fractions was delivered in 6/9 patients. Dose constraints and planning objectives were reported. No severe toxicity was reported while local control and overall survival were 100%. CONCLUSION The POLO approach is technically feasible and capable to achieve a significant reduction of radiation dose delivered to the previous treated IOERT area. ADVANCES IN KNOWLEDGE The study demonstrates the technical and dosimetric feasibility of conservative salvage whole breast radiotherapy, while sparing the area already treated with IORT, in patients with in-breast recurrence.
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Affiliation(s)
| | - Andriana Kouloura
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Maria Camarda
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Viola
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Giulia Riva
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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13
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Hickey BE, Lehman M. Partial breast irradiation versus whole breast radiotherapy for early breast cancer. Cochrane Database Syst Rev 2021; 8:CD007077. [PMID: 34459500 PMCID: PMC8406917 DOI: 10.1002/14651858.cd007077.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)). OBJECTIVES To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer. SEARCH METHODS On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible. DATA COLLECTION AND ANALYSIS Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis. MAIN RESULTS We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence). AUTHORS' CONCLUSIONS It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.
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Affiliation(s)
- Brigid E Hickey
- Radiation Oncology Raymond Terrace, Princess Alexandra Hospital, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Margot Lehman
- School of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
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14
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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15
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Single-dose intraoperative radiotherapy during lumpectomy for breast cancer: an innovative patient-centred treatment. Br J Cancer 2021; 124:1469-1474. [PMID: 33531693 PMCID: PMC7851812 DOI: 10.1038/s41416-020-01233-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/04/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022] Open
Abstract
In the randomised TARGIT-A trial, risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy was non-inferior to whole-breast external beam radiotherapy, for local recurrence. In the long-term, no difference was found in any breast cancer outcome, whereas there were fewer deaths from non-breast-cancer causes. TARGIT-IORT should be included in pre-operative consultations with eligible patients.
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16
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Casey DL, Gupta GP, Ollila DW. The Role of Intraoperative Radiation in Early-stage Breast Cancer. Clin Breast Cancer 2021; 21:103-111. [PMID: 34030857 DOI: 10.1016/j.clbc.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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17
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Mi Y, Lv P, Wang F, Li L, Zhu M, Wang Y, Zhang Y, Liu L, Cao Q, Dong M, Shi Y, Fan R, Li J, Gu Y, Zuo X. Targeted Intraoperative Radiotherapy Is Non-inferior to Conventional External Beam Radiotherapy in Chinese Patients With Breast Cancer: A Propensity Score Matching Study. Front Oncol 2020; 10:550327. [PMID: 33134162 PMCID: PMC7578338 DOI: 10.3389/fonc.2020.550327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/07/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To investigate the efficacy of targeted intraoperative radiotherapy (TARGIT) vs. conventional external beam radiotherapy (EBRT) in Chinese patients with breast cancer. Methods: We retrospectively analyzed breast cancer patients who underwent breast-conserving surgery (BCS) at our hospital between April 2009 and October 2017. Patients were divided into TARGIT group and EBRT group according to different radiotherapy methods. TARGIT was performed with low-energy X-rays emitted by the Intrabeam system to deliver a single dose of 20 Gy to the applicator surface. Propensity score matching was performed at 1:1. The Kaplan-Meier method was used to calculate the locoregional recurrence (LR), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) of the two groups, and the log-rank test was run to analyse between-group difference before and after matching. Results: A total of 281 patients were included, with a median follow-up of 43 months. Of them, 82 were included in the TARGIT group and 199 in the EBRT group. Using the risk-adapted approach, 6.1% of patients received supplemental EBRT in the TARGIT group. The 5-year LR rate was 3.2% in the TARGIT group and 3.1% in the EBRT group (P = 0.694), the 5-year DMFS rates were 100 and 96.7%, respectively (P = 0.157); the 5-year DFS rates were 96.8 and 94.2% (P = 0.604); and the 5-year OS rates were 97.6 and 97.8% (P = 0.862). After matching which eliminated interference from imbalanced baseline factors, 128 matched patients were analyzed by the Kaplan-Meier method. The 5-year LR rate was 2.3% in the TARGIT group and 1.6% in the EBRT group; the 5-year DMFS rates were 100 and 98.4%, respectively; the 5-year DFS rates were 97.7 and 98.4%; and the 5-year OS rates were 98.4 and 98.4% (P = 0.659, 0.313, 0.659, 0.987). There was no significant difference in efficacy between TARGIT group and EBRT group. Conclusion: TARGIT and EBRT have similar 5-year outcomes in selected Chinese breast cancer patients undergoing BCS, and it can be used as an effective alternative to standard therapy, with substantial benefits to patients. The results need to be further confirmed by extending the follow-up time.
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Affiliation(s)
- Yin Mi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengwei Lv
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingzhi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanyan Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingying Zhang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lele Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinchen Cao
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meilian Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yonggang Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingruo Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanting Gu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Zuo
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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18
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger HL, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph DJ, Tobias JS. Long term survival and local control outcomes from single dose targeted intraoperative radiotherapy during lumpectomy (TARGIT-IORT) for early breast cancer: TARGIT-A randomised clinical trial. BMJ 2020; 370:m2836. [PMID: 32816842 PMCID: PMC7500441 DOI: 10.1136/bmj.m2836] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether risk adapted intraoperative radiotherapy, delivered as a single dose during lumpectomy, can effectively replace postoperative whole breast external beam radiotherapy for early breast cancer. DESIGN Prospective, open label, randomised controlled clinical trial. SETTING 32 centres in 10 countries in the United Kingdom, Europe, Australia, the United States, and Canada. PARTICIPANTS 2298 women aged 45 years and older with invasive ductal carcinoma up to 3.5 cm in size, cN0-N1, eligible for breast conservation and randomised before lumpectomy (1:1 ratio, blocks stratified by centre) to either risk adapted targeted intraoperative radiotherapy (TARGIT-IORT) or external beam radiotherapy (EBRT). INTERVENTIONS Random allocation was to the EBRT arm, which consisted of a standard daily fractionated course (three to six weeks) of whole breast radiotherapy, or the TARGIT-IORT arm. TARGIT-IORT was given immediately after lumpectomy under the same anaesthetic and was the only radiotherapy for most patients (around 80%). TARGIT-IORT was supplemented by EBRT when postoperative histopathology found unsuspected higher risk factors (around 20% of patients). MAIN OUTCOME MEASURES Non-inferiority with a margin of 2.5% for the absolute difference between the five year local recurrence rates of the two arms, and long term survival outcomes. RESULTS Between 24 March 2000 and 25 June 2012, 1140 patients were randomised to TARGIT-IORT and 1158 to EBRT. TARGIT-IORT was non-inferior to EBRT: the local recurrence risk at five year complete follow-up was 2.11% for TARGIT-IORT compared with 0.95% for EBRT (difference 1.16%, 90% confidence interval 0.32 to 1.99). In the first five years, 13 additional local recurrences were reported (24/1140 v 11/1158) but 14 fewer deaths (42/1140 v 56/1158) for TARGIT-IORT compared with EBRT. With long term follow-up (median 8.6 years, maximum 18.90 years, interquartile range 7.0-10.6) no statistically significant difference was found for local recurrence-free survival (hazard ratio 1.13, 95% confidence interval 0.91 to 1.41, P=0.28), mastectomy-free survival (0.96, 0.78 to 1.19, P=0.74), distant disease-free survival (0.88, 0.69 to 1.12, P=0.30), overall survival (0.82, 0.63 to 1.05, P=0.13), and breast cancer mortality (1.12, 0.78 to 1.60, P=0.54). Mortality from other causes was significantly lower (0.59, 0.40 to 0.86, P=0.005). CONCLUSION For patients with early breast cancer who met our trial selection criteria, risk adapted immediate single dose TARGIT-IORT during lumpectomy was an effective alternative to EBRT, with comparable long term efficacy for cancer control and lower non-breast cancer mortality. TARGIT-IORT should be discussed with eligible patients when breast conserving surgery is planned. TRIAL REGISTRATION ISRCTN34086741, NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik L Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynaecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, The Ludwig Maximilian University of Munich, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden Hospital, Charité, Medical University of Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
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19
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No Difference in Overall Survival and Non-Breast Cancer Deaths after Partial Breast Radiotherapy Compared to Whole Breast Radiotherapy-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2020; 12:cancers12082309. [PMID: 32824414 PMCID: PMC7464494 DOI: 10.3390/cancers12082309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 01/20/2023] Open
Abstract
Purpose/objective: Adjuvant radiotherapy after breast conserving surgery is the standard approach in early stage breast cancer. However, the extent of breast tissue that has to be targeted with radiation has not been determined yet. Traditionally, the whole breast was covered by two opposing tangential beams. Several randomized trials have tested partial breast irradiation (PBI) compared to whole breast irradiation (WBI) using different radiation techniques. There is evidence from randomized trials that PBI might result in lower mortality rates compared to WBI. We aimed to reassess this question using current data from randomized trials. Material/methods: We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect sizes for overall survival (OS), breast cancer-specific survival (BCSS), and non-breast cancer death (NBCD) as investigated endpoints. Analysis of subgroups using different radiation techniques was intended. We used hazard ratios (HR) and risk differences (RD) to estimate pooled effect sizes. Statistical analysis was performed using the inverse variance heterogeneity model. Results: We identified eleven studies randomizing between PBI and WBI. We did not find significant differences in OS (n = 14,070; HR = 1.02; CI-95%: 0.89–1.16; p = 0.810, and n = 15,203; RD = −0.001; CI-95%: −0.008–0.006; p = 0.785) and BCSS (n = 15,203; RD = 0.001; CI-95%: −0.002–0.005; p = 0.463). PBI also did not result in a significant decrease of NBCD (n = 15,203; RD = −0.003; CI-95%: −0.010–0.003; p = 0.349). A subgroup analysis by radiation technique also did not point to any detectable differences. Conclusion: In contrast to a previous assessment of mortality, we could not find a detrimental effect of WBI on OS or NBCD. A longer follow-up might be necessary to fully assess the long-term mortality effects of PBI compared to WBI.
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20
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Lohmander F, Lagergren J, Johansson H, Roy PG, Frisell J, Brandberg Y. Quality of life and patient satisfaction after implant-based breast reconstruction with or without acellular dermal matrix: randomized clinical trial. BJS Open 2020; 4:811-820. [PMID: 32762012 PMCID: PMC7528522 DOI: 10.1002/bjs5.50324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 06/15/2020] [Indexed: 11/22/2022] Open
Abstract
Background Acellular dermal matrix (ADM) in implant‐based breast reconstructions (IBBRs) aims to improve cosmetic outcomes. Six‐month data are presented from a randomized trial evaluating whether IBBR with ADM provides higher health‐related quality of life (HRQoL) and patient‐reported cosmetic outcomes compared with conventional IBBR without ADM. Methods In this multicentre open‐label RCT, women with breast cancer planned for mastectomy with immediate IBBR in four centres in Sweden and one in the UK were allocated randomly (1 : 1) to IBBR with or without ADM. HRQoL, a secondary endpoint, was measured as patient‐reported outcome measures (PROMs) using three validated instruments (EORTC‐QLQC30, QLQ‐BR23, QLQ‐BRR26) at baseline and 6 months. Results Between 24 April 2014 and 10 May 2017, 135 women were enrolled, of whom 64 with and 65 without ADM were included in the final analysis. At 6 months after surgery, patient‐reported HRQoL, measured with generic QLQ‐C30 or breast cancer‐specific QLQ‐BR23, was similar between the groups. For patient‐reported cosmetic outcomes, two subscale items, cosmetic outcome (8·66, 95 per cent c.i. 0·46 to 16·86; P = 0·041) and problems finding a well‐fitting bra (−13·21, −25·54 to −0·89; P = 0·038), yielded higher scores in favour of ADM, corresponding to a small to moderate clinical difference. None of the other 27 domains measured showed any significant differences between the groups. Conclusion IBBR with ADM was not superior in terms of higher levels of HRQoL compared with IBBR without ADM. Although two subscale items of patient‐reported cosmetic outcomes favoured ADM, the majority of cosmetic items showed no significant difference between treatments at 6 months. Registration number: NCT02061527 (
www.clinicaltrials.gov).
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Affiliation(s)
- F Lohmander
- Department of Breast and Endocrine Surgery, Section of Breast Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Lagergren
- Department of Surgery, Breast Centre, Capio St Görans Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - H Johansson
- Department of Oncology-Pathology, Cancer Centre, Karolinska Institutet, Stockholm, Sweden
| | - P G Roy
- Department of Breast Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Y Brandberg
- Department of Oncology-Pathology, Cancer Centre, Karolinska Institutet, Stockholm, Sweden
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21
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Vaidya JS, Bulsara M, Saunders C, Flyger H, Tobias JS, Corica T, Massarut S, Wenz F, Pigorsch S, Alvarado M, Douek M, Eiermann W, Brew-Graves C, Williams N, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Baum M, Joseph D. Effect of Delayed Targeted Intraoperative Radiotherapy vs Whole-Breast Radiotherapy on Local Recurrence and Survival: Long-term Results From the TARGIT-A Randomized Clinical Trial in Early Breast Cancer. JAMA Oncol 2020; 6:e200249. [PMID: 32239210 PMCID: PMC7348682 DOI: 10.1001/jamaoncol.2020.0249] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Conventional adjuvant radiotherapy for breast cancer given daily for several weeks is onerous and expensive. Some patients may be obliged to choose a mastectomy instead, and some may forgo radiotherapy altogether. We proposed a clinical trial to test whether radiotherapy could be safely limited to the tumor bed. Objective To determine whether delayed second-procedure targeted intraoperative radiotherapy (TARGIT-IORT) is noninferior to whole-breast external beam radiotherapy (EBRT) in terms of local control. Design, Setting, and Participants In this prospective, randomized (1:1 ratio) noninferiority trial, 1153 patients aged 45 years or older with invasive ductal breast carcinoma smaller than 3.5 cm treated with breast conservation were enrolled from 28 centers in 9 countries. Data were locked in on July 3, 2019. Interventions The TARGIT-A trial was started in March 2000; patients were randomized after needle biopsy to receive TARGIT-IORT immediately after lumpectomy under the same anesthetic vs EBRT and results have been shown to be noninferior. A parallel study, described in this article, was initiated in 2004; patients who had their cancer excised were randomly allocated using separate randomization tables to receive EBRT or delayed TARGIT-IORT given as a second procedure by reopening the lumpectomy wound. Main Outcomes and Measures A noninferiority margin for local recurrence rate of 2.5% at 5 years, and long-term survival outcomes. Results Overall, 581 women (mean [SD] age, 63 [7] years) were randomized to delayed TARGIT-IORT and 572 patients (mean [SD] age, 63 [8] years) were randomized to EBRT. Sixty patients (5%) had tumors larger than 2 cm, or had positive nodes and only 32 (2.7%) were younger than 50 years. Delayed TARGIT-IORT was not noninferior to EBRT. The local recurrence rates at 5-year complete follow-up were: delayed TARGIT-IORT vs EBRT (23/581 [3.96%] vs 6/572 [1.05%], respectively; difference, 2.91%; upper 90% CI, 4.4%). With long-term follow-up (median [IQR], 9.0 [7.5-10.5] years), there was no statistically significant difference in local recurrence-free survival (HR, 0.75; 95% CI, 0.57-1.003; P = .052), mastectomy-free survival (HR, 0.88; 95% CI, 0.65-1.18; P = .38), distant disease-free survival (HR, 1.00; 95% CI, 0.72-1.39; P = .98), or overall survival (HR, 0.96; 95% CI, 0.68-1.35; P = .80). Conclusions and Relevance These long-term data show that despite an increase in the number of local recurrences with delayed TARGIT-IORT, there was no statistically significant decrease in mastectomy-free survival, distant disease-free survival, or overall survival. Trial Registration ISRCTN34086741, ClinicalTrials.gov Identifier: NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Department of Biostatistics, University of Notre Dame, Fremantle, West Australia, Australia
| | - Christobel Saunders
- University of Western Australia School of Surgery, West Australia, Australia
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Frederik Wenz
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steffi Pigorsch
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | | | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Wolfgang Eiermann
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Norman Williams
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, United Kingdom
| | - Elena Sperk
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, United Kingdom
| | - Marc Sütterlin
- University Medical Center Mannheim, Department of Gynecology and Obstetrics, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- Helen Rey Breast Cancer Foundation, John Wayne Cancer Institute, University of Southern California, Los Angeles
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- University Hospital, Department of Radiation Oncology, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre Toronto, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, New York
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, United Kingdom
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
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22
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Wickberg Å, Liljegren G, Ahlgren J, Karlsson L, With A, Johansson B. Intraoperative high dose rate brachytherapy during breast-conserving surgery: A Prospective Pilot Study. Scand J Surg 2020; 110:312-321. [PMID: 32228155 DOI: 10.1177/1457496920903975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate feasibility, quality of life, toxicity, and cosmetic outcome for intraoperative breast cancer brachytherapy after breast-conserving surgery using high dose rate brachytherapy. METHODS AND MATERIALS Fifty-two consecutive women, ⩾50 years old, diagnosed with a unifocal non-lobular breast cancer ⩽3 cm, N0, underwent breast-conserving surgery and sentinel node biopsy. Twenty-five women received intraoperative brachytherapy pre-pathology at primary surgery and the others post-pathology, during a second procedure. An applicator, connected to a high dose rate afterloader, was used. Two of the women were excluded due to metastases found per-operatively at a frozen section from the sentinel node. Quality of life was evaluated using two validated health questionnaires. Treatment toxicity was documented according to the LENT-SOMA scale by two oncologists. The cosmetic result was evaluated using the validated freely available software BCCT.core 2.0. RESULTS The clinical procedure worked out well logistically. Seven women received supplementary external radiotherapy due to insufficient margins and, in one case, poor adaptation of the breast parenchyma to the applicator. No serious adverse effects from irradiation were registered. The results from the health questionnaires showed no major differences compared with reference groups from the Swedish population. Only two women were registered as having a "poor" cosmetic result while a majority of the women had a "good" outcome. CONCLUSION This pilot study shows that intraoperative brachytherapy is a feasible procedure and encourages further trials evaluating its role in treatment of early breast cancer.
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Affiliation(s)
- Å Wickberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - G Liljegren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Ahlgren
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - L Karlsson
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - A With
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - B Johansson
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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23
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Lemanski C, Bourgier C, Draghici R, Thezenas S, Morel A, Rouanet P, Colombo PE, Mourregot A, Delmond L, Fenoglietto P, Ailleres N, Azria D, Gutowski M. Intraoperative partial irradiation for highly selected patients with breast cancer: Results of the INTRAOBS prospective study. Cancer Radiother 2020; 24:114-119. [PMID: 32171675 DOI: 10.1016/j.canrad.2020.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/20/2019] [Accepted: 01/10/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate our long-term experience on one-day breast intraoperative radiotherapy (IORT) given as sole radiation treatment to selected patients with breast cancer. METHODS AND MATERIALS Inclusion criteria of INTRAOBS study (prospective observational study) were: ER+ T1N0 unifocal ductal carcinoma; absence of lymphovascular invasion or of extensive intraductal component (Scarff-Bloom-Richardson grade III and HER2+++ excluded). Two different linacs were used (20Gy/1 fraction): one dedicated electron linac (<October 2011), and afterwards a mobile linac (50kV photons). The primary endpoint was the local recurrence rate (=ipsilateral breast cancer recurrences number). Secondary endpoints were recurrence-free survival (RFS), overall and specific survival, cosmetic results, and patient satisfaction. RESULTS Of the present pre-planned analysis for the first 200 patients (median age: 68 years; range, 59-87 years) who received IORT between January 2010 and October 2014 (median follow-up of 53.4 months). A total of 193 patients were still alive. The local recurrence rate was 2.5% (n=5). The 1- and 5-year local RFS rates were 100% and 95.2%, respectively. At 12 months post-surgery, satisfaction about IORT was excellent for 86.9% of patients. Cosmetic results were considered by patients and physicians as good or very good in 89.4% and 97.3% of cases, respectively. CONCLUSIONS IORT for selected patients with breast cancer shows low recurrence rates, good cosmetic outcomes and excellent satisfaction.
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Affiliation(s)
- Claire Lemanski
- Fédération universitaire d'oncologie radiothérapie, ICM, Institut régional du cancer Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France
| | - Celine Bourgier
- Fédération universitaire d'oncologie radiothérapie, ICM, Institut régional du cancer Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France; IRCM, Institut de recherche en cancérologie de Montpellier, Inserm U1194, université Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France
| | - Roxanna Draghici
- Fédération universitaire d'oncologie radiothérapie, ICM, Institut régional du cancer Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France
| | - Simon Thezenas
- Biometrics unit, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Aurélie Morel
- Radiophysics Unit, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Philippe Rouanet
- Department of Surgical and Reconstructive Oncology, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Pierre-Emmanuel Colombo
- Department of Surgical and Reconstructive Oncology, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Anne Mourregot
- Department of Surgical and Reconstructive Oncology, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Laure Delmond
- Department of Surgical and Reconstructive Oncology, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Pascal Fenoglietto
- Radiophysics Unit, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - Norbert Ailleres
- Radiophysics Unit, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
| | - David Azria
- Fédération universitaire d'oncologie radiothérapie, ICM, Institut régional du cancer Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France; IRCM, Institut de recherche en cancérologie de Montpellier, Inserm U1194, université Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France.
| | - Marian Gutowski
- Department of Surgical and Reconstructive Oncology, ICM-Val d'Aurelle, université Montpellier, Montpellier, France
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24
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Tagliaferri L, Lancellotta V, Zinicola T, Gentileschi S, Sollena P, Garganese G, Guinot JL, Rembielak A, Soror T, Autorino R, Cammelli S, Gambacorta MA, Aristei C, Valentini V, Kovacs G. Cosmetic assessment in brachytherapy (interventional radiotherapy) for breast cancer: A multidisciplinary review. Brachytherapy 2019; 18:635-644. [PMID: 31171462 DOI: 10.1016/j.brachy.2019.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE This review was to focus on breast brachytherapy cosmetic assessment methods state of the art and to define the advantages and disadvantages related to. METHODS AND MATERIALS We conducted a literature review of the major experience on breast brachytherapy cosmetic assessment methods in several databases (PubMed, Scopus, and Google Scholar databases). To identify the relevant works, a task force screened citations at title and abstract level to identify potentially relevant paper. An expert board reviewed and approved the text. The assessment systems were classified into three main groups: (1) the Oncological Toxicity Scales, (2) the Independent Patients Perspective Measures, (3) the Patient-Related Outcome Measures. Each cosmetic assessment method was evaluated following six parameters: (1) anatomical site, (2) advantages, (3) disadvantages, (4) subjective/objective, (5) quantitative/qualitative, (6) computers or pictures needs. RESULTS Eleven assessment methods were selected. Three methods were classified as Oncological Toxicity Scale, six in the Independent Patients Perspective Measures classification, and two as Patient-Related Outcome Measures. Six methods are subjective, while eight are objective. Four systems are classified as quantitative, four as qualitative while three both. Five systems need informatics support. Moreover, each method was discussed individually reporting the main characteristics and peculiarities. CONCLUSIONS Cosmesis is one major end point for the patient who has a malignancy of low lethal potential. In modern personalized medicine, there is a need for standardized cosmetic outcome assessments to analyze and compare the results of treatments. No gold standard methods currently exist. The result of this review is to summarize the various cosmesis methods, defining the strengths and weaknesses of each one and giving a line in research and clinical practice.
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Affiliation(s)
- Luca Tagliaferri
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia
| | - Valentina Lancellotta
- Department of Surgery and Biomedical Sciences, Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italia
| | - Tiziano Zinicola
- Università Cattolica del Sacro Cuore, Istituto di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia.
| | - Stefano Gentileschi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Chirurgia Plastica e Ricostruttiva, Centro di Trattamento Chirurgico del Linfedema, Roma, Italia
| | - Pietro Sollena
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Dermatologia, Roma, Italia
| | - Giorgia Garganese
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna e del Bambino, Roma, Italia
| | - José L Guinot
- Department of Radiation Oncology, Foundation Instituto Valenciano de Oncologia (I.V.O.), València, Spain
| | - Agata Rembielak
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester and Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Tamer Soror
- Department of Clinical Radiation Oncology, Ernst von Bergmann Medical Center, Academic Teaching Hospital of Humboldt University Berlin (Charité), Berlin, Germany; National Cancer Institute (NCI), Radiation Oncology Department, Cairo University, Cairo, Egypt
| | - Rosa Autorino
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia
| | - Silvia Cammelli
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italia
| | - Maria A Gambacorta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia; Università Cattolica del Sacro Cuore, Istituto di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia
| | - Cynthia Aristei
- Department of Surgery and Biomedical Sciences, Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italia
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia; Università Cattolica del Sacro Cuore, Istituto di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italia
| | - György Kovacs
- Interdisciplinary Brachytherapy Unit, UKSH CL, Lübeck, Germany
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Single-center long-term results from the randomized phase-3 TARGIT-A trial comparing intraoperative and whole-breast radiation therapy for early breast cancer. Strahlenther Onkol 2019; 195:640-647. [DOI: 10.1007/s00066-019-01438-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 11/26/2022]
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Corica T, Saunders CM, Bulsara MK, Taylor M, Joseph DJ, Nowak AK. Patient preferences for adjuvant radiotherapy in early breast cancer are strongly influenced by treatment received through random assignment. Eur J Cancer Care (Engl) 2019; 28:e12985. [PMID: 30637839 PMCID: PMC6590655 DOI: 10.1111/ecc.12985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 10/23/2018] [Accepted: 12/07/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE TARGIT-A randomised women with early breast cancer to receive external beam radiotherapy (EBRT) or intraoperative radiotherapy (TARGIT-IORT). This study aimed to identify what extra risk of recurrence patients would accept for perceived benefits and risks of different radiotherapy treatments. METHODS Patient preferences were determined by self-rated trade-off questionnaires in two studies: Stage (1) 209 TARGIT-A participants (TARGIT-IORTn = 108, EBRTn = 101); Stage (2) 123 non-trial patients yet to receive radiotherapy (pre-treatment group), with 85 also surveyed post-radiotherapy. Patients traded-off risks of local recurrence in preference selection between TARGIT-IORT and EBRT. RESULTS TARGIT-IORT patients were more accepting of IORT than EBRT patients with 60% accepting the highest increased risk presented (4%-6%) compared to 12% of EBRT patients, and 2% not accepting IORT at all compared to 43% of EBRT patients. Pre-treatment patients were more accepting of IORT than post-treatment patients with 23% accepting the highest increased risk presented compared to 15% of post-treatment patients, and 15% not accepting IORT at all compared to 41% of pre-treatment patients. CONCLUSIONS Breast cancer patients yet to receive radiotherapy accept a higher recurrence risk than the actual risk found in TARGIT-A. Measured patient preferences are highly influenced by experience of treatment received. This finding challenges the validity of post-treatment preference studies.
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Affiliation(s)
- Tammy Corica
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Christobel M Saunders
- School of Medicine, Division of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Mandy Taylor
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David J Joseph
- School of Medicine, Division of Surgery, University of Western Australia, Perth, Western Australia, Australia.,Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Anna K Nowak
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Winters ZE, Bernaudo L. Evaluating the current evidence to support therapeutic mammoplasty or breast-conserving surgery as an alternative to mastectomy in the treatment of multifocal and multicentric breast cancers. Gland Surg 2018; 7:525-535. [PMID: 30687626 DOI: 10.21037/gs.2018.07.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The oncological safety of treating multiple ipsilateral breast cancers (MIBCs) with types of breast conserving surgery (BCS) compared to mastectomy remains uncertain. This is predicated on the absence of any randomised controlled trials or high-quality protocol defined prospective cohort studies. A single recently published systematic review by the first author, reports its summarised results in this review. Fundamentally the important question is the evaluation of clinical safety following BCS compared to mastectomy for treating MIBC, which is reported in only six studies. Consequently, current evidence doesn't support the latest St Gallen consensus suggesting the possibility of using BCS to treat all MIBC. There is minimal comparative outcomes data on multicentric (MC) cancers compared to multifocal (MF) cancers comparing BCS or mastectomy. There is also poor evidence of clinical outcomes following therapeutic mammoplasty (TM) for MIBC compared to mastectomy. The potential recommendation of two potential radiotherapy boosts to separate lumpectomy sites following BCS for MC cancers remains a novel treatment concept whose feasibility will be evaluated in the forthcoming NIHR funded randomised feasibility trial called MIAMI. This is a world first attempt to assess the feasibility of a randomised trial design alongside the on-going Alliance registry study (ACOSOG, American College of Surgeons Oncology Group Z11102) in the USA, in which there is no comparative evaluation of mastectomy outcomes. The MIAMI trial aims to assess the clinical safety of multiple lumpectomies combined with TM compared to the standard of mastectomy in MIBC stratified by MF or MC cancers. There is limited evidence on the impacts of inter-tumoral heterogeneity relating to breast cancer subtypes in relation to individualised treatments and recommendations for types of breast surgery. Recent studies have highlighted the potential contributions of stromal epigenetic changes that are currently poorly understood regarding their contributions to either clinical unifocal or MF cancers.
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Affiliation(s)
- Zoe Ellen Winters
- Breast Cancer Surgery, Patient-Centred and Clinical Outcomes Research Group, Surgical and Interventional Trials Unit, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
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Corica T, Nowak AK, Saunders CM, Bulsara MK, Taylor M, Williams NR, Keshtgar M, Joseph DJ, Vaidya JS. Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial. Radiat Oncol 2018; 13:68. [PMID: 29653541 PMCID: PMC5899392 DOI: 10.1186/s13014-018-0998-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of this research was to assess agreement between four rating systems of cosmetic outcome measured in a subset of patients with early breast cancer participating in the randomised TARGIT-A trial. TARGIT-A compared risk-adapted single-dose intra-operative radiotherapy (TARGIT-IORT) to whole breast external beam radiotherapy (EBRT). Methods Patients, their Radiation Oncologist and Research Nurse completed a subjective cosmetic assessment questionnaire before radiotherapy and annually thereafter for five years. Objective data previously calculated by the validated BCCT.core software which utilizes digital photographs to score symmetry, colour and scar was also used. Agreement was assessed by the Kappa statistic and longitudinal changes were assessed by generalized estimating equations. Results Overall, an Excellent-Good (EG) cosmetic result was scored more often than a Fair-Poor (FP) result for both treatment groups across all time points, with patients who received TARGIT-IORT scoring EG more often than those who received EBRT however this was statistically significant at Year 5 only. There was modest agreement between the four rating systems with the highest Kappa score being moderate agreement which was between nurse and doctor scores at Year 1 with Kappa = 0.46 (p < 0.001), 95% CI (0.24, 0.68). Conclusion Despite similar overall findings between treatment groups and rating systems, the inter-rater agreement was only modest. This suggests that the four rating systems utilized may not necessarily be used interchangeably and it is arguable that for an outcome such as cosmetic appearance, the patient’s point of view is the most important. Trial Registration TARGIT-A ISRCTN34086741, Registered 21 July 2004, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13014-018-0998-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tammy Corica
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia. .,Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.
| | - Anna K Nowak
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia
| | | | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, 19 Mouat Street, Fremantle, WA, 6160, Australia
| | - Mandy Taylor
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Norman R Williams
- Surgical & Interventional Trials Unit, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, London, NW1 2FD, UK
| | - Mohammed Keshtgar
- Royal Free London Foundation NHS Trust, Division of Surgical Sciences, The Breast Unit, Pond Street, Hampstead, London, NW3 2QG, UK
| | - David J Joseph
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.,Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Jayant S Vaidya
- Division of Surgery & Interventional Science, University College London, London W1W 7TS, UK; Whittington Hospital, Royal Free Hospital and University College Hospital, University College London, London, NW1 2FD, UK
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Coles CE, Haviland JS, Kirby AM, Titley J, Wilcox M, Bliss JM, Yarnold JR. Targeted radiotherapy for early breast cancer - Authors' reply. Lancet 2018; 391:27-28. [PMID: 29323651 DOI: 10.1016/s0140-6736(17)33317-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK.
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Anna M Kirby
- Department of Radiotherapy and Imaging, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Jenny Titley
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - John R Yarnold
- Department of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
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Harris EER, Small W. Intraoperative Radiotherapy for Breast Cancer. Front Oncol 2017; 7:317. [PMID: 29312887 PMCID: PMC5743678 DOI: 10.3389/fonc.2017.00317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/06/2017] [Indexed: 01/15/2023] Open
Abstract
Intraoperative radiotherapy (IORT) for early stage breast cancer is a technique for partial breast irradiation. There are several technologies in clinical use to perform breast IORT. Regardless of technique, IORT generally refers to the delivery of a single dose of radiation to the periphery of the tumor bed in the immediate intraoperative time frame, although some protocols have performed IORT as a second procedure. There are two large prospective randomized trials establishing the safety and efficacy of breast IORT in early stage breast cancer patients with sufficient follow-up time on thousands of women. The advantages of IORT for partial breast irradiation include: direct visualization of the target tissue ensuring treatment of the high-risk tissue and eliminating the risk of marginal miss; the use of a single dose coordinated with the necessary surgical excision thereby reducing omission of radiation and the selection of mastectomy for women without access to a radiotherapy facility or unable to undergo several weeks of daily radiation; favorable toxicity profiles; patient convenience and cost savings; radiobiological and tumor microenvironment conditions which lead to enhanced tumor control. The main disadvantage of IORT is the lack of final pathologic information on the tumor size, histology, margins, and nodal status. When unexpected findings on final pathology such as positive margins or positive sentinel nodes predict a higher risk of local or regional recurrence, additional whole breast radiation may be indicated, thereby reducing some of the convenience and low-toxicity advantages of sole IORT. However, IORT as a tumor bed boost has also been studied and appears to be safe with acceptable toxicity. IORT has potential efficacy advantages related to overall survival related to reduced cardiopulmonary radiation doses. It may also be very useful in specific situations, such as prior to oncoplastic reconstruction to improve accuracy of adjuvant radiation delivery, or when used as a boost in higher risk patients to improve tumor control. Ongoing international clinical trials are studying these uses and follow-up data are accumulating on completed studies.
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Affiliation(s)
- Eleanor E R Harris
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, IL, United States
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Azria D, Lapierre A, Gourgou S, De Ruysscher D, Colinge J, Lambin P, Brengues M, Ward T, Bentzen SM, Thierens H, Rancati T, Talbot CJ, Vega A, Kerns SL, Andreassen CN, Chang-Claude J, West CML, Gill CM, Rosenstein BS. Data-Based Radiation Oncology: Design of Clinical Trials in the Toxicity Biomarkers Era. Front Oncol 2017; 7:83. [PMID: 28497027 PMCID: PMC5406456 DOI: 10.3389/fonc.2017.00083] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/13/2017] [Indexed: 12/15/2022] Open
Abstract
The ability to stratify patients using a set of biomarkers, which predict that toxicity risk would allow for radiotherapy (RT) modulation and serve as a valuable tool for precision medicine and personalized RT. For patients presenting with tumors with a low risk of recurrence, modifying RT schedules to avoid toxicity would be clinically advantageous. Indeed, for the patient at low risk of developing radiation-associated toxicity, use of a hypofractionated protocol could be proposed leading to treatment time reduction and a cost-utility advantage. Conversely, for patients predicted to be at high risk for toxicity, either a more conformal form or a new technique of RT, or a multidisciplinary approach employing surgery could be included in the trial design to avoid or mitigate RT when the potential toxicity risk may be higher than the risk of disease recurrence. In addition, for patients at high risk of recurrence and low risk of toxicity, dose escalation, such as a greater boost dose, or irradiation field extensions could be considered to improve local control without severe toxicities, providing enhanced clinical benefit. In cases of high risk of toxicity, tumor control should be prioritized. In this review, toxicity biomarkers with sufficient evidence for clinical testing are presented. In addition, clinical trial designs and predictive models are described for different clinical situations.
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Affiliation(s)
- David Azria
- Department of Radiation Oncology, Radiobiology Unit, Biometric and Bio-informatic Divisions, Montpellier Cancer Institute (ICM), IRCM, INSERM U1194, Montpellier, France
| | - Ariane Lapierre
- Department of Radiation Oncology, Radiobiology Unit, Biometric and Bio-informatic Divisions, Montpellier Cancer Institute (ICM), IRCM, INSERM U1194, Montpellier, France
| | - Sophie Gourgou
- Department of Radiation Oncology, Radiobiology Unit, Biometric and Bio-informatic Divisions, Montpellier Cancer Institute (ICM), IRCM, INSERM U1194, Montpellier, France
| | - Dirk De Ruysscher
- Department of Radiation Oncology, Maastricht University Medical Centre, MAASTRO Clinic, Maastricht, Netherlands
- Radiation Oncology, KU Leuven, Leuven, Belgium
| | - Jacques Colinge
- Department of Radiation Oncology, Radiobiology Unit, Biometric and Bio-informatic Divisions, Montpellier Cancer Institute (ICM), IRCM, INSERM U1194, Montpellier, France
| | - Philippe Lambin
- Department of Radiation Oncology, Maastricht University Medical Centre, MAASTRO Clinic, Maastricht, Netherlands
| | - Muriel Brengues
- Department of Radiation Oncology, Radiobiology Unit, Biometric and Bio-informatic Divisions, Montpellier Cancer Institute (ICM), IRCM, INSERM U1194, Montpellier, France
| | - Tim Ward
- Patient Advocate, Manchester, UK
| | - Søren M. Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hubert Thierens
- Department of Basic Medical Sciences, Ghent University, Ghent, Belgium
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Ana Vega
- Fundacion Publica Galega de Medicina Xenomica-SERGAS, Grupo de Medicina Xenomica-USC, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Sarah L. Kerns
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharine M. L. West
- Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital NHS Trust, Manchester, UK
| | - Corey M. Gill
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barry S. Rosenstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Akhtari M, Abboud M, Szeja S, Pino R, Lewis GD, Bass BL, Miltenburg DM, Butler EB, Teh BS. Clinical outcomes, toxicity, and cosmesis in breast cancer patients with close skin spacing treated with accelerated partial breast irradiation (APBI) using multi-lumen/catheter applicators. J Contemp Brachytherapy 2016; 8:497-504. [PMID: 28115955 PMCID: PMC5241383 DOI: 10.5114/jcb.2016.64830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/07/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) using a single-lumen device is associated with better cosmetic outcomes if the spacing between the applicator and skin is > 7 mm. However, there are no reports addressing the late toxicity and clinical outcomes in patients treated with single-entry multi-lumen/catheter applicators who had close skin spacing (7 mm or less). We undertook this study to report clinical outcome, acute and late toxicity as well as cosmesis of early stage breast cancer patients with close skin spacing treated with APBI using multi-lumen or multi-catheter devices. MATERIAL AND METHODS This is a retrospective study of all breast cancer patients who had undergone APBI using single-entry multi-lumen/catheter devices in a single institution between 2008 to 2012. The study was limited to those with ≤ 7 mm spacing between the device and skin. RESULTS We identified 37 patients and 38 lesions with skin spacing of ≤ 7 mm. Seven lesions (18%) had spacing of ≤ 3 mm. Median follow-up was 47.5 months. There was one case of ipsilateral breast recurrence and one ipsilateral axillary recurrence. Based on RTOG criteria, 22 treated lesions experienced grade 1 and 9 lesions experienced grade 2 toxicity. Twenty-one lesions experienced late grade 1 toxicity. One patient had to undergo mastectomy due to mastitis. Twenty-four treated breasts showed excellent and 11 had good cosmetic outcome. Overall cosmesis trended towards a significant correlation with skin spacing. However, all patients with ≤ 3 mm skin spacing experienced acute and late toxicities. CONCLUSIONS Accelerated partial breast irradiation can be safely performed in patients with skin spacing of ≤ 7 mm using single-entry multi-lumen/catheter applicators with excellent cosmetic outcomes and an acceptable toxicity profile. However, skin spacing of ≤ 3 mm is associated with acute and late toxicity and should be avoided if possible.
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Affiliation(s)
- Mani Akhtari
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Mirna Abboud
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Sean Szeja
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Ramiro Pino
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Gary D. Lewis
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Barbara L. Bass
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | | | - E. Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
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TGF-β1 Is Present at High Levels in Wound Fluid from Breast Cancer Patients Immediately Post-Surgery, and Is Not Increased by Intraoperative Radiation Therapy (IORT). PLoS One 2016; 11:e0162221. [PMID: 27589056 PMCID: PMC5010202 DOI: 10.1371/journal.pone.0162221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/18/2016] [Indexed: 12/13/2022] Open
Abstract
In patients with low-risk breast cancer, intraoperative radiotherapy (IORT) during breast-conserving surgery is a novel and convenient treatment option for delivering a single high dose of irradiation directly to the tumour bed. However, edema and fibrosis can develop after surgery and radiotherapy, which can subsequently impair quality of life. TGF- β is a strong inducer of the extracellular matrix component hyaluronan (HA). TGF-β expression and HA metabolism can be modulated by irradiation experimentally, and are involved in edema and fibrosis. We therefore hypothesized that IORT may regulate these factors.Wound fluid (WF) draining from breast lumpectomy sites was collected and levels of TGF-β1 and HA were determined by ELISA. Proliferation and marker expression was analyzed in primary lymphatic endothelial cells (LECs) treated with recombinant TGF-β or WF. Our results show that IORT does not change TGF-β1 or HA levels in wound fluid draining from breast lumpectomy sites, and does not lead to accumulation of sHA oligosaccharides. Nevertheless, concentrations of TGF-β1 were high in WF from patients regardless of IORT, at concentrations well above those associated with fibrosis and the suppression of LEC identity. Consistently, we found that TGF-β in WF is active and inhibits LEC proliferation. Furthermore, all three TGF-β isoforms inhibited LEC proliferation and suppressed LEC marker expression at pathophysiologically relevant concentrations. Given that TGF-β contributes to edema and plays a role in the regulation of LEC identity, we suggest that inhibition of TGF-β directly after surgery might prevent the development of side effects such as edema and fibrosis.
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Cosmesis and Breast-Related Quality of Life Outcomes After Intraoperative Radiation Therapy for Early Breast Cancer: A Substudy of the TARGIT-A Trial. Int J Radiat Oncol Biol Phys 2016; 96:55-64. [DOI: 10.1016/j.ijrobp.2016.04.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/05/2016] [Accepted: 04/17/2016] [Indexed: 11/20/2022]
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Health Technol Assess 2016; 20:1-188. [PMID: 27689969 DOI: 10.3310/hta20730] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Based on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed - the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies. OBJECTIVE To compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks. DESIGN The TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurred before initial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurred after initial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world. SETTING Thirty-three centres in 11 countries. PARTICIPANTS Women who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size. INTERVENTIONS TARGIT within a risk-adapted approach and whole-breast EBRT. MAIN OUTCOME MEASURES The primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality. RESULTS In total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan-Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%; p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%; p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%; p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%; p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%; p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%; p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%; p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8-9.1 million each year. This does not include environmental, patient and societal costs. LIMITATIONS The number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years. CONCLUSIONS For patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT. FUTURE WORK The analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684. FUNDING University College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, University of Western Australia, Perth, WA, Australia
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Stephen Morris
- Health Economics Group, Department of Biomedical Engineering, University College London, London, UK
| | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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Single dose IOERT versus whole breast irradiation : Cosmetic results in breast-conserving therapy. Strahlenther Onkol 2016; 192:705-13. [PMID: 27538776 DOI: 10.1007/s00066-016-1029-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Scarce data are available about the cosmetic result of single dose intraoperative electron radiotherapy (IOERT) in breast-conserving radiotherapy. METHODS AND MATERIALS We included 71 breast cancer patients. Breast-conserving surgery and sentinel node procedure had started almost 3 years earlier. Subsequently, 26 patients were treated with IOERT and 45 patients received postoperative whole breast irradiation (WBI). For both groups we determined seven dimensionless asymmetry features. We compared the subjectively and the objectively derived cosmetic scores with each other. RESULTS For four asymmetry features we noted significantly smaller differences for patients treated with IOERT when compared to those treated with WBI: relative breast contour difference, relative breast area difference and relative breast overlap difference. After correcting for excision volume a significant difference was noticed also for relative lower breast contour. For the IOERT group the cosmetic scores "excellent or good" as determined by each patient and one physician were 88 and 96 %, respectively. When the overall cosmetic scores for patients treated with IOERT and WBI were compared to those of the objectively derived scores, there was a fair level of agreement. CONCLUSION For patients treated with IOERT we noted less asymmetry and high rates of "good or excellent" subjectively derived cosmetic scores. The level of agreement between the subjectively and the objectively derived cosmetic scores was limited. Due to the small sample size and the design of the study no definitive conclusions can be drawn.
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Picot J, Copley V, Colquitt JL, Kalita N, Hartwell D, Bryant J. The INTRABEAM® Photon Radiotherapy System for the adjuvant treatment of early breast cancer: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-190. [PMID: 26323045 DOI: 10.3310/hta19690] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Initial treatment for early breast cancer is usually either breast-conserving surgery (BCS) or mastectomy. After BCS, whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A potential alternative to post-operative WB-EBRT is intraoperative radiation therapy delivered by the INTRABEAM(®) Photon Radiotherapy System (Carl Zeiss, Oberkochen, Germany) to the tissue adjacent to the resection cavity at the time of surgery. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of INTRABEAM for the adjuvant treatment of early breast cancer during surgical removal of the tumour. DATA SOURCES Electronic bibliographic databases, including MEDLINE, EMBASE and The Cochrane Library, were searched from inception to March 2014 for English-language articles. Bibliographies of articles, systematic reviews, clinical guidelines and the manufacturer's submission were also searched. The advisory group was contacted to identify additional evidence. METHODS Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were conducted. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to full texts of retrieved papers by one reviewer and checked by a second reviewer. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, and differences in opinion were resolved through discussion at each stage. Clinical effectiveness studies were included if they were carried out in patients with early operable breast cancer. The intervention was the INTRABEAM system, which was compared with WB-EBRT, and study designs were randomised controlled trials (RCTs). Controlled clinical trials could be considered if data from available RCTs were incomplete (e.g. absence of data on outcomes of interest). A cost-utility decision-analytic model was developed to estimate the costs, benefits and cost-effectiveness of INTRABEAM compared with WB-EBRT for early operable breast cancer. RESULTS One non-inferiority RCT, TARGeted Intraoperative radioTherapy Alone (TARGIT-A), met the inclusion criteria for the review. The review found that local recurrence was slightly higher following INTRABEAM than WB-EBRT, but the difference did not exceed the 2.5% non-inferiority margin providing INTRABEAM was given at the same time as BCS. Overall survival was similar with both treatments. Statistically significant differences in complications were found for the occurrence of wound seroma requiring more than three aspirations (more frequent in the INTRABEAM group) and for a Radiation Therapy Oncology Group toxicity score of grade 3 or 4 (less frequent in the INTRABEAM group). Cost-effectiveness base-case analysis indicates that INTRABEAM is less expensive but also less effective than WB-EBRT because it is associated with lower total costs but fewer total quality-adjusted life-years gained. However, sensitivity analyses identified four model parameters that can cause a switch in the treatment option that is considered cost-effective. LIMITATIONS The base-case result from the model is subject to uncertainty because the disease progression parameters are largely drawn from the single available RCT. The RCT median follow-up of 2 years 5 months may be inadequate, particularly as the number of participants with local recurrence is low. The model is particularly sensitive to this parameter. CONCLUSIONS AND IMPLICATIONS A significant investment in INTRABEAM equipment and staff training (clinical and non-clinical) would be required to make this technology available across the NHS. Longer-term follow-up data from the TARGIT-A trial and analysis of registry data are required as results are currently based on a small number of events and economic modelling results are uncertain. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006720. FUNDING The National Institute for Health Research Health Technology Assessment programme. Note that the economic model associated with this document is protected by intellectual property rights, which are owned by the University of Southampton. Anyone wishing to modify, adapt, translate, reverse engineer, decompile, dismantle or create derivative work based on the economic model must first seek the agreement of the property owners.
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Affiliation(s)
- Jo Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Vicky Copley
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jill L Colquitt
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Neelam Kalita
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Debbie Hartwell
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jackie Bryant
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Valente SA, Tendulkar RD, Cherian S, O'Rourke C, Greif JM, Bailey L, Uhl V, Bethke KP, Donnelly ED, Rudolph R, Pederson A, Summer T, Lottich SC, Ross DL, Laronga C, Loftus L, Abbott AM, Kelemen P, Hermanto U, Friedman NB, Bedi GC, Joh JE, Thompson WA, Hoefer RA, Wilson JP, Kang SK, Rosen B, Ruffer J, Bravo L, Police A, Escallon JM, Fyles AW, McCready DR, Graves GM, Rohatgi N, Eaker JA, Graves J, Willey SC, Tousimis EA, Collins BT, Shaw CM, Riley L, Deb N, Kelly T, Andolino DL, Boisvert ME, Lyons J, Small W, Grobmyer SR. TARGIT-R (Retrospective): North American Experience with Intraoperative Radiation Using Low-Kilovoltage X-Rays for Breast Cancer. Ann Surg Oncol 2016; 23:2809-15. [PMID: 27160524 DOI: 10.1245/s10434-016-5240-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Single-dose intraoperative radiotherapy (IORT) is an emerging treatment for women with early stage breast cancer. The objective of this study was to define the frequency of IORT use, patient selection, and outcomes of patients treated in North America. METHODS A multi-institutional retrospective registry was created, and 19 institutions using low-kilovoltage IORT for the treatment of breast cancer entered data on patients treated at their institution before July 31, 2013. Patient selection, IORT treatment details, complications, and recurrences were analyzed. RESULTS From 2007 to July 31, 2013, a total of 935 women were identified and treated with lumpectomy and IORT. A total of 822 patients had at least 6 months' follow-up documented and were included in the analysis. The number of IORT cases performed increased significantly over time (p < 0.001). The median patient age was 66.8 years. Most patients had disease that was <2 cm in size (90 %) and was estrogen positive (91 %); most patients had invasive ductal cancer (68 %). Of those who had a sentinel lymph node procedure performed, 89 % had negative sentinel lymph nodes. The types of IORT performed were primary IORT in 79 %, secondary IORT in 7 %, or planned boost in 14 %. Complications were low. At a median follow-up of 23.3 months, crude in-breast recurrence was 2.3 % for all patients treated. CONCLUSIONS IORT use for the treatment of breast cancer is significantly increasing in North America, and physicians are selecting low-risk patients for this treatment option. Low complication and local recurrence rates support IORT as a treatment option for selected women with early stage breast cancer.
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Affiliation(s)
| | | | | | | | | | | | - Valery Uhl
- Summit Medical Center, Emeryville, CA, USA
| | | | | | - Ray Rudolph
- Memorial University Medical Center, Savannah, GA, USA
| | | | | | - S Chace Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - Darrel L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | | | | | | | | | | | | | | | | | - Richard A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - Jason P Wilson
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - Song K Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - Barry Rosen
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - James Ruffer
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - Luis Bravo
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - Alice Police
- University of California Irvine Medical Center, Irvine, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lee Riley
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nimisha Deb
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Tricia Kelly
- St. Luke's University Health Network, Bethlehem, PA, USA
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Falco M, Masojć B, Rolla M, Czekała A, Pietruszewska J, Rubik-Leszczyńska A, Lewocki M, Łukowiak M, Kram A. Risk factors for seroma evacuation in breast cancer patients treated with intraoperative radiotherapy. Rep Pract Oncol Radiother 2016; 21:225-31. [PMID: 27601955 PMCID: PMC5002024 DOI: 10.1016/j.rpor.2016.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Novel techniques in oncology provide new treatment opportunities but also introduce different patterns of side effects. Intraoperative radiotherapy (IORT) allows a shortened overall treatment time for early breast cancer either combined with whole breast radiotherapy (WBRT), or alone. Although the early side effects of IORT are well known, data on clinically important late side effects, which require medical intervention, are scarce. AIM In this study, we analyze risk factors for seroma evacuation more than 6 months after IORT. MATERIALS AND METHODS We evaluated 120 patients with a mean follow-up of 27.8 months (range: 7-52 months). Fifty-one patients received IORT only and 69 were additionally treated with WBRT. RESULTS Seroma evacuation was performed 6-38 months after IORT. Two (3.9%) events were observed in the IORT group and 14 (20%) in the IORT + WBRT group. Univariate (Kaplan-Meier) analysis showed that addition of WBRT to IORT increased the risk of seroma evacuation [hazard ratio = 5.5, 95% confidence interval: 2.0-14.7, P = 0.011]. In a multivariate analysis (Cox proportional hazards regression), WBRT and axillary lymph node dissection were significant risk factors for seroma evacuation (model P value = 0.0025). CONCLUSIONS WBRT applied after IORT is associated with increased risk of seroma evacuation, which might be considered as a late side effect.
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Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Rolla
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Agnieszka Czekała
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Jolanta Pietruszewska
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | | | - Mirosław Lewocki
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Łukowiak
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Andrzej Kram
- Pathology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
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Cardoso MJ, Cardoso JS, Oliveira HP, Gouveia P. The breast cancer conservative treatment. Cosmetic results - BCCT.core - Software for objective assessment of esthetic outcome in breast cancer conservative treatment: A narrative review. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2016; 126:154-159. [PMID: 26707372 DOI: 10.1016/j.cmpb.2015.11.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 11/06/2015] [Accepted: 11/12/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Cosmetic outcome of breast cancer conservative treatment (BCCT) remains without a standard evaluation method. Subjective methods, in spite of their low reproducibility, continue to be the most frequently used. Objective methods, although more reproducible, seem unable to translate all the subtleties involved in cosmetic outcome. The breast cancer conservative treatment cosmetic results (BCCT.core) software was developed in 2007 to try to overcome these pitfalls. The software is a semi-automatic objective tool that evaluates asymmetry, color differences and scar visibility using patient's digital pictures. The purpose of this work is to review the use of the BCCT.core software since its availability in 2007 and to put forward future developments. METHODS All the online requests for BCCT.core use were registered from June 2007 to December 2014. For each request the department, city and country as well as user intention (clinical use/research or both) were questioned. A literature search was performed in Medline, Google Scholar and ISI Web of Knowledge for all publications using and citing "BCCT.core". RESULTS During this period 102 centers have requested the software essentially for clinical use. The BCCT.core software was used in 19 full published papers and in 29 conference abstracts. CONCLUSIONS The BCCT.core is a user friendly semi-automatic method for the objective evaluation of BCCT. The number of online requests and publications have been steadily increasing turning this computer program into the most frequently used tool for the objective cosmetic evaluation of BCCT.
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Affiliation(s)
- Maria João Cardoso
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal; INESC TEC, Porto, Portugal.
| | | | | | - Pedro Gouveia
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal; INESC TEC, Porto, Portugal
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Harris EE, Small W, Holmes D, Grobmyer S, Pavord D, Rice JS, Alvarado M. In Regard to Hepel and Wazer. Int J Radiat Oncol Biol Phys 2015; 92:955-957. [DOI: 10.1016/j.ijrobp.2015.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/28/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
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Zhang L, Zhou Z, Mei X, Yang Z, Ma J, Chen X, Wang J, Liu G, Yu X, Guo X. Intraoperative Radiotherapy Versus Whole-Breast External Beam Radiotherapy in Early-Stage Breast Cancer: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1143. [PMID: 26166124 PMCID: PMC4504561 DOI: 10.1097/md.0000000000001143] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/28/2015] [Accepted: 06/12/2015] [Indexed: 11/26/2022] Open
Abstract
There has not been a clear answer about the efficacy of intraoperative radiotherapy (IORT) for women with early-stage breast cancer.The aim of this meta-analysis was to summarize the available evidence comparing the efficacy and safety of IORT with those of whole-breast external beam radiotherapy (EBRT) for women with early-stage breast cancer.MEDLINE, EMBASE, the Web of Science, and the Cochrane Library were searched up to October 2014. Two authors independently conducted the literature selection and data extraction.Studies that compared IORT with whole-breast EBRT were included in the systematic review. IORT was defined as a single dose of irradiation to the tumor bed during breast-conserving surgery rather than whole-breast irradiation.Qualities of RCTs were evaluated according to the PEDro scale. Qualities of non-RCTs were evaluated according to the Methodological Index for Non-Randomized Studies (MINORS). The risk ratios (RRs) of ipsilateral breast tumor recurrence, overall mortality, breast cancer mortality, non-breast cancer mortality, and distant metastasis were pooled using a random-effects model.Four studies with 5415 patients were included in this meta-analysis, including 2 randomized controlled trials (RCTs) and 2 non-RCTs. Ipsilateral breast tumor recurrence was significantly higher in patients with IORT compared to those with whole-breast EBRT (RR 2.83, 95% CI 1.23-6.51), but with significant heterogeneity (I = 58.5%, P = 0.065). Comparing IORT with whole-breast EBRT, the pooled RRs for overall mortality, breast cancer mortality, non-breast cancer mortality, and distant metastasis were 0.88 (95% CI: 0.66-1.17), 1.20 (95% CI: 0.77-1.86), 0.76 (95% CI: 0.44-1.31), and 0.95 (95% CI: 0.61-1.49), respectively.IORT had a significantly higher risk of ipsilateral breast tumor recurrence than whole-breast EBRT. Overall mortality did not differ significantly. IORT should be used in conjunction with the prudent selection of suitable patients. It is imperative to identify women with a low risk of local recurrence.
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Affiliation(s)
- Li Zhang
- From the Department of Radiation Oncology (LZ, ZZ, XM, ZY, JM, XC, JW, XY, XG); Department of Breast Surgery (GL), Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Cosmetic Outcome Assessment following Breast-Conserving Therapy: A Comparison between BCCT.core Software and Panel Evaluation. Int J Breast Cancer 2014; 2014:716860. [PMID: 25328712 PMCID: PMC4190270 DOI: 10.1155/2014/716860] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/09/2014] [Indexed: 11/18/2022] Open
Abstract
Purpose. Over recent decades, no consensus has yet been reached on the optimal approach to cosmetic evaluation following breast-conserving therapy (BCT). The present study compared the strengths and weaknesses of the BCCT.core software with a 10-member panel from various backgrounds. Methods. Digital photographs of 109 consecutive patients after BCT were evaluated for 7 items by a panel consisting of 2 breast surgeons, 2 residents, 2 laypersons, and 4 plastic surgeons. All photographs were objectively evaluated using the BCCT.core software (version 20), and an overall cosmetic outcome score was reached using a four-point Likert scale. Results. Based on the mean BCCT.core software score, 41% of all patients had fair or poor overall cosmetic results (10% poor), compared with 51% (14% poor) obtained with panel evaluation. Mean overall BCCT.core score and mean overall panel score substantially agreed (weighted kappa: 0.68). By contrast, analysis of the evaluation of scar tissue revealed large discrepancies between the BCCT.core software and the panel. The analysis of subgroups formed from different combinations of the panel members still showed substantial agreement with the BCCT.core software (range 0.64-0.69), independent of personal background. Conclusions. Although the analysis of scar tissue by the software shows room for improvement, the BCCT.core represents a valid and efficient alternative to panel evaluation.
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Intraoperative radiotherapy for breast cancer: the lasting effects of a fleeting treatment. Int J Breast Cancer 2014; 2014:214325. [PMID: 25180098 PMCID: PMC4142745 DOI: 10.1155/2014/214325] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 07/20/2014] [Indexed: 11/24/2022] Open
Abstract
In well-selected patients who choose to pursue breast conservation therapy (BCT) for early-stage breast cancer, partial breast irradiation (PBI) delivered externally or intraoperatively, may be a viable alternative to conventional whole breast irradiation. Two large, contemporary randomized trials have demonstrated breast intraoperative radiotherapy (IORT) to be noninferior to whole breast external beam radiotherapy (EBRT) when assessing for ipsilateral breast tumor recurrence in select patients. Additionally, IORT and other PBI techniques are likely to be more widely adopted in the future because they improve patient convenience by offering an accelerated course of treatment. Coupled with these novel techniques for breast radiotherapy (RT) are distinct toxicity profiles and unique cosmetic alterations that differ from conventional breast EBRT and have the potential to impact disease surveillance and patient satisfaction. This paper will review the level-one evidence for treatment efficacy as well as important secondary endpoints like RT toxicity, breast cosmesis, quality of life, patient satisfaction, and surveillance mammography following BCT with IORT.
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Williams NR, Pigott KH, Brew-Graves C, Keshtgar MRS. Intraoperative radiotherapy for breast cancer. Gland Surg 2014; 3:109-19. [PMID: 25083504 PMCID: PMC4115764 DOI: 10.3978/j.issn.2227-684x.2014.03.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/19/2014] [Indexed: 12/19/2022]
Abstract
Intra-operative radiotherapy (IORT) as a treatment for breast cancer is a relatively new technique that is designed to be a replacement for whole breast external beam radiotherapy (EBRT) in selected women suitable for breast-conserving therapy. This article reviews twelve reasons for the use of the technique, with a particular emphasis on targeted intra-operative radiotherapy (TARGIT) which uses X-rays generated from a portable device within the operating theatre immediately after the breast tumour (and surrounding margin of healthy tissue) has been removed. The delivery of a single fraction of radiotherapy directly to the tumour bed at the time of surgery, with the capability of adding EBRT at a later date if required (risk-adaptive technique) is discussed in light of recent results from a large multinational randomised controlled trial comparing TARGIT with EBRT. The technique avoids irradiation of normal tissues such as skin, heart, lungs, ribs and spine, and has been shown to improve cosmetic outcome when compared with EBRT. Beneficial aspects to both institutional and societal economics are discussed, together with evidence demonstrating excellent patient satisfaction and quality of life. There is a discussion of the published evidence regarding the use of IORT twice in the same breast (for new primary cancers) and in patients who would never be considered for EBRT because of their special circumstances (such as the frail, the elderly, or those with collagen vascular disease). Finally, there is a discussion of the role of the TARGIT Academy in developing and sustaining high standards in the use of the technique.
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Corica T, Joseph D, Saunders C, Bulsara M, Nowak AK. Intraoperative radiotherapy for early breast cancer: do health professionals choose convenience or risk? Radiat Oncol 2014; 9:33. [PMID: 24461031 PMCID: PMC3907143 DOI: 10.1186/1748-717x-9-33] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/20/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The randomized TARGIT trial comparing experimental intra-operative radiotherapy (IORT) to up to 7 weeks of daily conventional external beam radiotherapy (EBRT) recruited participants in Western Australia between 2003 and 2012. We aimed to understand preferences for this evolving radiotherapy treatment for early breast cancer (EBC) in health professionals, and how they changed over time and in response to emerging data. Preferences for single dose IORT or EBRT for EBC were elicited in 2004 and 2011, together with factors that may be associated with these preferences. METHODS Western Australian health professionals working with breast cancer patients were invited to complete a validated, self-administered questionnaire. The questionnaire used hypothetical scenarios and trade-off methodology to determine the maximum increase in risk of local recurrence health professionals were willing to accept in order to have a single dose of IORT in the place of EBRT if they were faced with this decision themselves. RESULTS Health professional characteristics were similar across the two time points although 2011 included a higher number of nurse (49% vs. 36%) and allied health (10% vs. 4%) participants and a lower number of radiation therapists (17% vs. 32% ) compared to 2004.Health professional preferences varied, with 7.5% and 3% judging IORT unacceptable at any risk, 18% and 21% judging IORT acceptable only if offering an equivalent risk, 56% and 59% judging IORT acceptable with a low maximum increase in risk (1-3%) and 19% and 17% judging a high maximum increase in risk acceptable (4-5%), in 2004 and 2011 respectively. A significantly greater number of nurses accepted IORT as a treatment option in 2011. CONCLUSIONS Most Western Australian health professionals working with breast cancer patients are willing to accept an increase in risk of local recurrence in order to replace EBRT with IORT in a hypothetical setting. This finding was consistent over two time points spanning 7 years despite the duration of clinical experience with IORT and the publication of the early clinical results of IORT in 2010. These results need to be compared with preferences elicited from patient groups, and further investigation into the impact of personal preferences on health professionals' advice to patients is warranted.
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Affiliation(s)
- Tammy Corica
- University of Western Australia PhD Candidate, School of Medicine and Pharmacology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
| | - David Joseph
- School of Surgery, University of Western Australia, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
| | - Christobel Saunders
- School of Surgery, University of Western Australia, MBDP M507, Crawley, WA 6009, Australia
| | - Max Bulsara
- Institute of Health and Research, University of Notre Dame, 19 Mouat Street, P.O Box 1225, Fremantle, WA 6959, Australia
| | - Anna K Nowak
- School of Medicine and Pharmacology, University of Western Australia, MBDP M503, Crawley, WA 6009, Australia
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Alvarado MD, Conolly J, Park C, Sakata T, Mohan AJ, Harrison BL, Hayes M, Esserman LJ, Ozanne EM. Patient preferences regarding intraoperative versus external beam radiotherapy following breast-conserving surgery. Breast Cancer Res Treat 2013; 143:135-40. [PMID: 24292868 DOI: 10.1007/s10549-013-2782-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 01/09/2023]
Abstract
The TARGIT-A Trial is an international randomized, prospective trial comparing intraoperative radiotherapy (IORT) for equivalence to external beam radiotherapy (EBRT) following lumpectomy for invasive breast cancer in selected low-risk patients; early results suggest that outcomes are similar. In addition to effectiveness data and cost considerations, the preferences of patients should help inform practice. This study was undertaken to explore and quantify preference in choosing between IORT and the current standard, EBRT. Eligible subjects were current or past candidates for breast-conserving surgery and radiation being seen at the University of California, San Francisco Breast Care Center. A trade-off technique varying the risk of local recurrence for IORT was used to quantify any additional accepted risk that these patients would accept to receive either treatment. Patients were first presented with a slideshow comparing EBRT with the experimental IORT option before being asked their preferences given hypothetical 10-year local recurrence risks. Patients were then given a questionnaire on demographic, social and clinical factors. Data from 81 patients were analyzed. The median additional accepted risk to have IORT was 2.3 % (-9 to 39 %), mean 3.2 %. Only 7 patients chose to accept additional risk for EBRT; 22 accepted IORT at no additional risk; and the remaining 52 chose IORT with some additional risk. Patients weigh trade-offs of risks and benefits when presented with medical treatment choices. Our results show that the majority of breast cancer patients will accept a small increment of local risk for a simpler delivery of radiation. Further studies that incorporate outcome and side effect data from the TARGIT-A trial clarify the expected consequences of a local recurrence, and include an expanded range of radiation options that could help guide clinical decision making in this area.
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Affiliation(s)
- Michael D Alvarado
- Department of Surgery, UCSF Comprehensive Cancer Center, University of California, Box 1710, 1600 Divisadero, San Francisco, CA, 94143-1710, USA,
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