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Bollet MA, Racadot S, Rivera S, Arnaud A, Bourgier C. [Breast cancer radiation therapy: Current questions in 2023]. Cancer Radiother 2023; 27:524-530. [PMID: 37541797 DOI: 10.1016/j.canrad.2023.07.005] [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: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023]
Abstract
Radiation therapy is a corner stone of breast cancer treatment as it has been shown postoperatively that it improves local control and overall survival. In recent years, multidisciplinary therapeutic strategies have evolved considerably for early-stage breast cancer, both surgically and in terms of systemic treatments or radiation therapy. Each of these developments affects other treatment components and open up new questions allowing even more personalized treatments. Essentially normofractionated a few years ago, breast radiation therapy is today very largely moderately or even ultra hypofractionated. De-escalation of the surgery of the axilla has changed the indications for lymph node radiation therapy keeping similar efficacy with reduced toxicity. Indications for radiation therapy after neoadjuvant chemotherapy remain based on pre-chemotherapy staging pending the results of ongoing randomized studies. The addition of a boost to the tumor bed significantly reduces the risk of local recurrence, but the magnitude of this benefit decreases with increasing age. The main risk factors for local recurrence are young age, the associated extended ductal in situ component, hormone receptor negative and high-grade status. The results of the simultaneous integrated boost (SIB) seem similar with normo- or moderately hypofractionated radiation therapy regimen.
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Affiliation(s)
- M A Bollet
- Institut de radiothérapie Hartmann, 4, rue Kléber, 92300 Levallois-Perret, France; Institut français du sein, 15, rue Jean-Nicot, 75007 Paris, France
| | - S Racadot
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - S Rivera
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; UMR 1030, université Paris-Saclay, Gustave-Roussy, 94805 Villejuif, France.
| | - A Arnaud
- Institut du cancer Sainte-Catherine, Avignon, France
| | - C Bourgier
- Fédération universitaire d'oncologie radiothérapie de Méditerranée Occitanie, Institut du cancer de Montpellier (ICM), université de Montpellier, Inserm U1194, IRCM, Montpellier, France
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Sigaudi V, Zannetti M, Ferrara E, Manfredda I, Mones E, Loi G, Krengli M, Franco P. Ultra-Hypofractionation for Whole-Breast Irradiation in Early Breast Cancer: Interim Analysis of a Prospective Study. Biomedicines 2022; 10:biomedicines10102568. [PMID: 36289830 PMCID: PMC9599048 DOI: 10.3390/biomedicines10102568] [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: 09/14/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
We report on the early clinical outcomes of a prospective series of early breast cancer (EBC) patients treated with ultra-hypofractionated post-operative whole-breast irradiation (WBI) after breast-conserving surgery (BCS) and axillary management. Primary endpoints were patient's compliance and acute toxicity. Secondary endpoints included physician-rated cosmesis and ipsilateral breast tumour recurrence (IBTR). Acute toxicity was evaluated at the end of WBI, 3 weeks and 6 months thereafter, according to the Common Terminology Criteria for Adverse Events (v. 5.0). Patients were treated between September 2021 and May 2022. The treatment schedule for WBI consisted of either 26 Gy in 5 fractions over one week (standard approach) or 28.5 Gy in 5 fractions over 5 weeks (reserved to elders). Inverse planned intensity-modulated radiation therapy (IMRT) was used employing a static technique. A total of 70 patients were treated. Fifty-nine were treated with the 26 Gy/5 fr/1 w and 11 with the 28.5 Gy/5 fr/5 ws schedule. Median age was 67 and 70 in the two groups. Most of the patients had left-sided tumours (53.2%) in the 26 Gy/5 fr/1 w or right-sided lesions (63.6%) in the 28.5 Gy/5 fr/5 ws group. Most of the patients had a clinical T1N0 disease and a pathological pT1pN0(sn) after surgery. Ductal invasive carcinoma was the most frequent histology. Luminal A intrinsic subtyping was most frequent. Most of the patients underwent BCS and sentinel lymph node biopsy and adjuvant endocrine therapy. All patients completed the treatment program as planned. Maximum detected acute skin toxicities were grade 2 erythema (6.7%), grade 2 induration (4.4%), and grade 2 skin colour changes. No early IBTR was observed. Ultra-hypofractionated WBI provides favourable compliance and early clinical outcomes in EBC after BCS in a real-world setting.
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Affiliation(s)
- Valeria Sigaudi
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
| | - Micol Zannetti
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
| | - Eleonora Ferrara
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Irene Manfredda
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Eleonora Mones
- Department of Medical Physics, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Gianfranco Loi
- Department of Medical Physics, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Marco Krengli
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
- Correspondence: ; Tel.: +39-0321-3733424
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Metz G, Snook K, Sood S, Baron-Hay S, Spillane A, Lamoury G, Carroll S. Breast Radiotherapy after Oncoplastic Surgery-A Multidisciplinary Approach. Cancers (Basel) 2022; 14:1685. [PMID: 35406457 PMCID: PMC8996843 DOI: 10.3390/cancers14071685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.
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Affiliation(s)
- Gabrielle Metz
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
| | - Kylie Snook
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Samriti Sood
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Sally Baron-Hay
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
| | - Andrew Spillane
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Gillian Lamoury
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
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Brunt AM, Haviland JS, Kirby AM, Somaiah N, Wheatley DA, Bliss JM, Yarnold JR. Five-fraction Radiotherapy for Breast Cancer: FAST-Forward to Implementation. Clin Oncol (R Coll Radiol) 2021; 33:430-439. [PMID: 34023185 DOI: 10.1016/j.clon.2021.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/10/2021] [Accepted: 04/29/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The phase 3 FAST-Forward trial reported outcomes for 26 and 27 Gy schedules delivered in 5 fractions over 1 week versus 40 Gy in 15 fractions over 3 weeks in 4000 patients. We discuss concerns raised by the radiotherapy community in relation to implementing this schedule. IPSILATERAL BREAST TUMOUR RELAPSE (IBTR) Published estimated 5-year IBTR with 95% CI after 40 Gy in 15 fractions was 2.1% (95% CI 1.4-3.1), 1.7% (1.2-1.6) after 27 Gy and 1.4% (0.2-2.2) after 26 Gy, emphatically showing non-inferiority of the 5-fraction regimens. Subgroup analyses comparing IBTR in 26 Gy versus 40 Gy show no evidence of differential effect regarding age, grade, pathological tumour size, nodal status, tumour bed boost, adjuvant chemotherapy, HER2 status and triple negative status. The number of events in these analyses is small and results should be interpreted with caution. There was only 1 IBTR event post-mastectomy. NORMAL TISSUE EFFECTS The 26 Gy schedule, on the basis of similar NTE to 40 Gy in 15 fractions, is the recommended regimen for clinical implementation. There is a low absolute rate of moderate/marked NTE, these are predominantly moderate not severe change. Subgroup analyses comparing clinician-assessed moderate or marked adverse effect for 26 Gy versus 40 Gy show no evidence of differential effects according to age, breast size, surgical deficit, tumour bed boost, or adjuvant chemotherapy. RADIOBIOLOGICAL CONSIDERATIONS The design of the FAST-Forward trial does not control for time-related effects, and the ability to interpret clinical outcomes in terms of underlying biology is limited. There could conceivably be a time-effect for tumour control. A slight reduction in α/β estimate for the late normal tissue effects of test regimens might be a chance effect, but if real could reflect fewer consequential late effects due to lower rates of moist desquamation. CONCLUSION The 26 Gy 5-fraction daily regimen for breast radiotherapy can be implemented now.
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Affiliation(s)
- A M Brunt
- David Weatherall Building, School of Medicine, University of Keele, Keele, UK; Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK.
| | - J S Haviland
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - A M Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, UK; Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
| | - N Somaiah
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK; Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, UK
| | - D A Wheatley
- Sunrise Centre, Royal Cornwall Hospital, Truro, UK
| | - J M Bliss
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - J R Yarnold
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
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Marta GN, Coles C, Kaidar-Person O, Meattini I, Hijal T, Zissiadis Y, Pignol JP, Ramiah D, Ho AY, Cheng SHC, Sancho G, Offersen BV, Poortmans P. The use of moderately hypofractionated post-operative radiation therapy for breast cancer in clinical practice: A critical review. Crit Rev Oncol Hematol 2020; 156:103090. [PMID: 33091800 PMCID: PMC7448956 DOI: 10.1016/j.critrevonc.2020.103090] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/14/2022] Open
Abstract
Post-operative radiation therapy (RT) reduces loco-regional recurrence rates and mortality in most patients with non-metastatic breast cancer. The aim of this critical review is to provide an overview of the applicability of moderately hypofractionated RT for breast cancer patients, focusing on factors influencing clinical decision-making. An international group of radiation oncologists agreed to assess, integrate, and interpret the existing evidence into a practical report to guide clinicians in their daily management of breast cancer patients. We conclude that moderately hypofractionated RT to the breast, chest wall (with/without breast reconstruction), and regional lymph nodes is at least as safe and effective as conventionally fractionated regimens and could be considered as the treatment option for the vast majority of the patients.For those who are still concerned about its generalised application, we recommend participating in ongoing trials comparing moderately hypofractionated RT to conventionally fractionated RT for breast cancer patients in some clinical circumstances.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology - Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiology and Oncology - Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Charlotte Coles
- Department of Oncology, University of Cambridge, Cambridge, UK.
| | - Orit Kaidar-Person
- Breast Cancer Radiation Unit, Radiation Oncology Institute, Sheba Medical Center, Ramat Gan, Israel.
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy.
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montréal, Quebec, Canada.
| | - Yvonne Zissiadis
- Department of Radiation Oncology, Genesis Cancer Care, Wembley, Western Australia, Australia.
| | | | - Duvern Ramiah
- Department of Radiation Oncology, Donald Gordon Medical Centre, Johannesburg, South Africa.
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - Skye Hung-Chun Cheng
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
| | - Gemma Sancho
- Department of Radiation Oncology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium.
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Eldredge-Hindy H, Gaskins J, Dragun A, Roberts TL, Riley EC, McMasters KM, Ajkay N. Patient-Reported Outcomes and Cosmesis After Once-Weekly Hypofractionated Breast Irradiation in Medically Underserved Patients. Int J Radiat Oncol Biol Phys 2020; 107:934-942. [PMID: 32387804 DOI: 10.1016/j.ijrobp.2020.04.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate patient-reported outcomes (PROs) and cosmesis from a phase 2 trial of once-weekly hypofractionated breast irradiation (WH-WBI) after breast-conserving surgery (BCS). METHODS AND MATERIALS Patients had stage 0-II breast cancer treated with BCS and negative margins. WH-WBI was 28.5 to 30 Gy in 5 weekly fractions of 5.7 to 6 Gy delivered with or without a boost. PROs were collected for 3 years after treatment using the Breast Cancer Treatment Outcome Scale (BCTOS) and European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life Questionnaire (QLQ-BR23). Physicians rated cosmetic outcome with the Global Cosmesis Score. Longitudinal growth models were used to assess changes in BCTOS across time, and baseline values and changes between time points were correlated with patient and treatment factors. RESULTS From 2011 to 2015, 158 women received WH-WBI, and 148 were eligible for analysis after a median follow-up of 39.3 months. Adverse changes (P < .001) in global BCTOS score and breast pain and arm function subscores were observed 6 months after radiation therapy, followed by improvement to near-baseline values at years 1 and 3. Adverse changes in BCTOS cosmetic subscore were also detected at 6 months (P < .001), with no significant improvement at 1 (P = .385) and 3 (P = .644) years. No effect was detected for longitudinal changes in BCTOS scoring for age, body mass index, diabetes, smoking, breast volume, tumor size, seroma volume, dosimetric factors, dose, boost, or systemic therapy. Physician-rated cosmesis at 3 years was excellent/good in 89% and fair/poor in 11%. CONCLUSIONS WH-WBI was associated with transient worsening in arm function and breast pain but persistent adverse changes in cosmetic PROs that were typically mild or moderate in severity. Physician-rated cosmetic outcomes were acceptable.
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Affiliation(s)
- Harriet Eldredge-Hindy
- Department of Radiation Oncology, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
| | - Anthony Dragun
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Cooper University Health Care, Camden, New Jersey
| | - Teresa L Roberts
- Department of Radiation Oncology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Elizabeth C Riley
- Department of Medicine, Division of Medical Oncology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kelly M McMasters
- Department of Surgical Oncology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Nicolas Ajkay
- Department of Surgical Oncology, University of Louisville School of Medicine, Louisville, Kentucky
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Montero-Luis A, Aristei C, Meattini I, Arenas M, Boersma L, Bourgier C, Coles C, Cutuli B, Falcinelli L, Kaidar-Person O, Leonardi MC, Offersen B, Marazzi F, Rivera S, Tagliaferri L, Tombolini V, Vidali C, Valentini V, Poortmans P. The Assisi Think Tank Meeting Survey of post-mastectomy radiation therapy in ductal carcinoma in situ: Suggestions for routine practice. Crit Rev Oncol Hematol 2019; 138:207-213. [PMID: 31092377 DOI: 10.1016/j.critrevonc.2019.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/11/2019] [Accepted: 04/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Risk factors for local recurrence after mastectomy in ductal carcinoma in situ (DCIS) emerged as a grey area during the second "Assisi Think Tank Meeting" (ATTM) on Breast Cancer. AIM To review practice patterns of post-mastectomy radiation therapy (PMRT) in DCIS, identify risk factors for recurrence and select suitable candidates for PMRT. METHODS A questionnaire concerning DCIS management, focusing on PMRT, was distributed online via SurveyMonkey. RESULTS 142 responses were received from 15 countries. The majority worked in academic institutions, had 5-20 years work-experience and irradiated <5 DCIS patients/year. PMRT was more given if: surgical margins <1 mm, high-grade, multicentricity, young age, tumour size >5 cm, skin- or nipple- sparing mastectomy. Moderate hypofractionation was the most common schedule, except after immediate breast reconstruction (57% conventional fractionation). CONCLUSIONS The present survey highlighted risk factors for PMRT administration, which should be further evaluated.
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Affiliation(s)
- A Montero-Luis
- Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain.
| | - C Aristei
- Radiation Oncology, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - I Meattini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - M Arenas
- Radiation Oncology, University Hospital Sant Joan, Reus, Spain
| | - L Boersma
- Radiation Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhøek Huis, Amsterdam, Netherlands
| | - C Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, Univ Montpellier, Montpellier, France
| | - C Coles
- Radiation Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - B Cutuli
- Radiation Oncology, Institut du Cancer Courlancy, Reims, France
| | - L Falcinelli
- Radiation Oncology, Perugia General Hospital, Italy
| | - O Kaidar-Person
- Radiation Oncology Unit, Oncology Institute, Rambam Medical Center, Haifa, Israel
| | - M C Leonardi
- Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - B Offersen
- Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - F Marazzi
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - S Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - L Tagliaferri
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - V Tombolini
- Radiation Oncology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - C Vidali
- Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - V Valentini
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - P Poortmans
- Radiation Oncology, Institut Curie, Department of Radiation Oncology; Paris Sciences & Lettres - PSL University; Paris, France
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8
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The Assisi Think Tank Meeting and Survey of post MAstectomy Radiation Therapy after breast reconstruction: The ATTM-SMART report. Eur J Surg Oncol 2018; 44:436-443. [DOI: 10.1016/j.ejso.2018.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/11/2017] [Accepted: 01/02/2018] [Indexed: 11/23/2022] Open
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9
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Lazzari G, Terlizzi A, Della Vittoria Scarpati G, Perri F, De Chiara V, Turi B, Silvano G. Predictive parameters in hypofractionated whole-breast 3D conformal radiotherapy according to the Ontario Canadian trial. Onco Targets Ther 2017; 10:1835-1842. [PMID: 28392704 PMCID: PMC5373827 DOI: 10.2147/ott.s127833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
AIM To evaluate the possible role of dosimetric parameters according Normal Tissue Complication Probability (NTCP) model as predictive of late toxicity and cosmesis in hypofractionated whole-breast three-dimensional conformal radiotherapy. PATIENTS AND METHODS A retrospective analysis on 215 consecutive early breast cancer patients treated with breast conserving surgery and adjuvant hypofractionated whole-breast radiotherapy (according the Ontario Canadian trial), with a 6 years median follow-up was conducted. To assess the impact of 10%-20% dose hotspots on different percent values of planning target volume (PTV) of the breast, we retrospectively employed the NTCP model of Lyman. PTV breast (PTVbr), V110 were identified. For statistical analysis the χ2 and paired t-test were used to find a correlation between late skin and subcutaneous toxicity and cosmetic outcome with dosimetrical parameters Multivariate analysis was performed with the aim to assess independently the impact of dosimetric and clinical parameters on late toxicity and cosmesis using Pearson's covariance. RESULTS Late skin toxicity was recorded in 47/215 (22%); and G3 toxicity occurred in 11 patients (5%). Cosmesis with excellent-good score was found in 172 patients (80%) while fair-poor score was found in 43 patients (20%). In univariate χ2 analysis the V110 >10% of the PTV breast significantly correlated with higher toxicity (P<0.005, OR 9.60 [CI 3.89-23.72]). Cosmesis related to V110 >10% and PTV breast volume over 1,300 cc was significant at multivariate analysis (P<0.005, OR 6.07 [CI 2.36-15.59]). CONCLUSION To safely use one of the most important whole-breast hypofractionated radiotherapy schedules, we found some predictive paramaters on the basis of NTCP model by Lyman. These parameters may be useful in selection of elegible patients.
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Affiliation(s)
| | | | | | | | - Vincenzo De Chiara
- Radiation Therapy Unit, Saints Giovanni Di Dio and Ruggi di Aragona, University of Salerno, Taranto, Italy
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10
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Sharma RA, Plummer R, Stock JK, Greenhalgh TA, Ataman O, Kelly S, Clay R, Adams RA, Baird RD, Billingham L, Brown SR, Buckland S, Bulbeck H, Chalmers AJ, Clack G, Cranston AN, Damstrup L, Ferraldeschi R, Forster MD, Golec J, Hagan RM, Hall E, Hanauske AR, Harrington KJ, Haswell T, Hawkins MA, Illidge T, Jones H, Kennedy AS, McDonald F, Melcher T, O'Connor JPB, Pollard JR, Saunders MP, Sebag-Montefiore D, Smitt M, Staffurth J, Stratford IJ, Wedge SR. Clinical development of new drug-radiotherapy combinations. Nat Rev Clin Oncol 2016; 13:627-42. [PMID: 27245279 DOI: 10.1038/nrclinonc.2016.79] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In countries with the best cancer outcomes, approximately 60% of patients receive radiotherapy as part of their treatment, which is one of the most cost-effective cancer treatments. Notably, around 40% of cancer cures include the use of radiotherapy, either as a single modality or combined with other treatments. Radiotherapy can provide enormous benefit to patients with cancer. In the past decade, significant technical advances, such as image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic radiotherapy, and proton therapy enable higher doses of radiotherapy to be delivered to the tumour with significantly lower doses to normal surrounding tissues. However, apart from the combination of traditional cytotoxic chemotherapy with radiotherapy, little progress has been made in identifying and defining optimal targeted therapy and radiotherapy combinations to improve the efficacy of cancer treatment. The National Cancer Research Institute Clinical and Translational Radiotherapy Research Working Group (CTRad) formed a Joint Working Group with representatives from academia, industry, patient groups and regulatory bodies to address this lack of progress and to publish recommendations for future clinical research. Herein, we highlight the Working Group's consensus recommendations to increase the number of novel drugs being successfully registered in combination with radiotherapy to improve clinical outcomes for patients with cancer.
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Affiliation(s)
- Ricky A Sharma
- UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Martin D Forster
- UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK
| | - Julian Golec
- Vertex Pharmaceuticals (Europe) Ltd, Abingdon, UK
| | | | - Emma Hall
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | - Kevin J Harrington
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | | | | | | | | | - Fiona McDonald
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | | | | | | | | | | | - John Staffurth
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
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Hickey BE, James ML, Lehman M, Hider PN, Jeffery M, Francis DP, See AM. Fraction size in radiation therapy for breast conservation in early breast cancer. Cochrane Database Syst Rev 2016; 7:CD003860. [PMID: 27425588 PMCID: PMC6457862 DOI: 10.1002/14651858.cd003860.pub4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an update of a Cochrane Review first published in 2008 and updated in 2009. OBJECTIVES To assess the effect of altered radiation fraction size for women with early breast cancer who have had breast conserving surgery. SEARCH METHODS We searched the Cochrane Breast Cancer Specialised Register (23 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Jan 1996 to May 2015), EMBASE (Jan 1980 to May 2015), the WHO International Clinical Trials Registry Platform (ICTRP) search portal (June 2010 to May 2015) and ClinicalTrials.gov (16 April 2015), reference lists of articles and relevant conference proceedings. No language or publication constraints were applied. SELECTION CRITERIA Randomised controlled trials of altered fraction size versus conventional fractionation for radiation therapy in women with early breast cancer who had undergone breast conserving surgery. DATA COLLECTION AND ANALYSIS Two authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors. MAIN RESULTS We studied 8228 women in nine studies. Eight out of nine studies were at low or unclear risk of bias. Altered fraction size (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not have a clinically meaningful effect on: local recurrence-free survival (Hazard Ratio (HR) 0.94, 95% CI 0.77 to 1.15, 7095 women, four studies, high-quality evidence), cosmetic outcome (Risk ratio (RR) 0.90, 95% CI 0.81 to 1.01, 2103 women, four studies, high-quality evidence) or overall survival (HR 0.91, 95% CI 0.80 to 1.03, 5685 women, three studies, high-quality evidence). Acute radiation skin toxicity (RR 0.32, 95% CI 0.22 to 0.45, 357 women, two studies) was reduced with altered fraction size. Late radiation subcutaneous toxicity did not differ with altered fraction size (RR 0.93, 95% CI 0.83 to 1.05, 5130 women, four studies, high-quality evidence). Breast cancer-specific survival (HR 0.91, 95% CI 0.78 to 1.06, 5685 women, three studies, high quality evidence) and relapse-free survival (HR 0.93, 95% CI 0.82 to 1.05, 5685 women, three studies, moderate-quality evidence) did not differ with altered fraction size. We found no data for mastectomy rate. Altered fraction size was associated with less patient-reported (P < 0.001) and physician-reported (P = 0.009) fatigue at six months (287 women, one study). We found no difference in the issue of altered fractionation for patient-reported outcomes of: physical well-being (P = 0.46), functional well-being (P = 0.38), emotional well-being (P = 0.58), social well-being (P = 0.32), breast cancer concerns (P = 0.94; 287 women, one study). We found no data with respect to costs. AUTHORS' CONCLUSIONS We found that using altered fraction size regimens (greater than 2 Gy per fraction) does not have a clinically meaningful effect on local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance, late toxicity or patient-reported quality-of-life measures for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins.
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Affiliation(s)
- Brigid E Hickey
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
- The University of QueenslandSchool of MedicineBrisbaneAustralia
| | - Melissa L James
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | - Margot Lehman
- The University of QueenslandSchool of MedicineBrisbaneAustralia
- Princess Alexandra HospitalRadiation Oncology UnitGround Floor, Outpatients FIpswich Road, WoollangabbaBrisbaneQueenslandAustralia4102
| | - Phil N Hider
- University of Otago, ChristchurchDepartment of Population HealthPO Box 4345ChristchurchNew Zealand8140
| | - Mark Jeffery
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | - Daniel P Francis
- Queensland University of TechnologySchool of Public Health and Social WorkVictoria Park RoadBrisbaneQueenslandAustralia4059
| | - Adrienne M See
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
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Barry PN, Dragun AE. Once-weekly hypofractionated breast irradiation: fool's gold or diamond in the rough? J Comp Eff Res 2016; 4:147-56. [PMID: 25825843 DOI: 10.2217/cer.14.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Daily conventionally fractionated breast irradiation over 5-7 weeks is costly and inconvenient. Its use is associated with disparities in both the delivery of quality care and outcomes for vulnerable populations. Alternatively, daily hypofractionated breast irradiation delivered over 3 weeks exhibits equal efficacy and toxicity profiles. Today, a new generation of accelerated radiotherapy for breast cancer has emerged. Once-weekly hypofractionated breast irradiation has been tested in pilot and large randomized studies and the initial data appear promising. As the data mature, this new approach has implications for cost-efficacy and provision of radiotherapy services. The purpose of this review is to explore the evolution of once-weekly hypofractionated breast irradiation including our ongoing institutional clinical trial at the University of Louisville.
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Affiliation(s)
- Parul N Barry
- Department of Radiation Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, KY, USA
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van Heijst TCF, Philippens MEP, Charaghvandi RK, den Hartogh MD, Lagendijk JJW, Desirée van den Bongard HJG, van Asselen B. Quantification of intra-fraction motion in breast radiotherapy using supine magnetic resonance imaging. Phys Med Biol 2016; 61:1352-70. [DOI: 10.1088/0031-9155/61/3/1352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Hypofractionated Whole-Breast Radiotherapy and Concomitant Boost after Breast Conservation in Elderly Patients. TUMORI JOURNAL 2015; 102:196-202. [DOI: 10.5301/tj.5000402] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2015] [Indexed: 01/06/2023]
Abstract
Aims To report the 5- and 10-year results of accelerated hypofractionated whole-breast radiotherapy (WBRT) with concomitant boost to the tumor bed in 83 consecutive patients with early breast cancer aged >70 years. Methods All patients were treated with breast conservation and hypofractionated WBRT. The prescription dose to the whole breast was 45 Gy (2.25 Gy/20 fractions) with an additional daily concomitant boost of 0.25 Gy to the surgical cavity (2.5 Gy/20 fractions up to 50 Gy). The maximum detected toxicity was scored according to the Common Terminology Criteria for Adverse Events, version 3.0. We considered as skin toxicity: erythema, edema, desquamation, ulceration, hemorrhage, necrosis, telangiectasia, fibrosis-induration, hyperpigmentation, retraction and atrophy. Cosmetic results were assessed as set by the Harvard criteria. Results With a median follow-up of 60 months (range 36-88), no local recurrence was observed. The maximum detected acute skin toxicity was G0 in 57% of patients, G1 in 40% and G2 in 3%. Late skin and subcutaneous toxicity was generally mild with no ≥G3 events. The cosmetic results were excellent in 69% of patients, good in 22%, fair in 5%, and poor in 4%. Conclusions The present results support the use of hypofractionation employing a concomitant boost to the lumpectomy cavity in women aged >70 years. This is a convenient treatment option for both this type of population and health-care providers.
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Rovea P, Fozza A, Franco P, De Colle C, Cannizzaro A, Di Dio A, De Monte F, Rosmino C, Filippi AR, Ragona R, Ricardi U. Once-Weekly Hypofractionated Whole-Breast Radiotherapy After Breast-Conserving Surgery in Older Patients: A Potential Alternative Treatment Schedule to Daily 3-Week Hypofractionation. Clin Breast Cancer 2015; 15:270-6. [DOI: 10.1016/j.clbc.2014.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 12/30/2014] [Accepted: 12/31/2014] [Indexed: 01/02/2023]
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Zhou ZR, Mei X, Chen XX, Yang ZZ, Hou J, Zhang L, Yu XL, Guo XM. Systematic review and meta-analysis comparing hypofractionated with conventional fraction radiotherapy in treatment of early breast cancer. Surg Oncol 2015; 24:200-11. [PMID: 26116397 DOI: 10.1016/j.suronc.2015.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 06/08/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this meta-analysis is to evaluate the efficacy and safety of altered radiation fraction size on outcomes for early breast cancer patients. METHODS A search of MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library and ClinicalTrials.gov was conducted. Quality of the randomized controlled trials (RCTs) or non-RCTs were evaluated according to Cochrane's risk of bias tool or Methodological Index for non-Randomized Studies (MINORS). Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated. Subgroup analysis was applied according to different fraction dose and sensitivity analysis was performed according to RCTs or non-RCTs. RESULTS 23 studies were included in this systematic review. Meta-analysis demonstrated hypofractionation radiotherapy (HFRT) was associated with decreased grade 2/3 acute skin reactions compared with conventional fraction RT (CFRT), either 2.5-3.0 Gy per fraction or 5.0-6.5 Gy per fraction. HFRT with 2.5-3.0 Gy per fraction significantly decreased moderate/marked photographic changes in breast appearance compared with CFRT [RR = 0.80, 95% CI (0.70, 0.91), P = 0.001], while HFRT with more than 3.0 Gy per fraction significantly increased moderate/marked photographic changes [RR = 1.21, 95% CI (1.06, 1.38), P = 0.004]. In addition HFRT cost one-third lower than CFRT. Regarding to local regional recurrence, distant metastasis, overall survival, disease free survival, excellent/good cosmetic comes, symptomatic radiation pneumonitis, ischemic heart disease and symptomatic rib fracture, there was no significant difference between two arms. CONCLUSIONS Based on available evidence, HFRT with 2.5-3.0 Gy per fraction should be the better choice for treatment of early breast cancer patients.
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Affiliation(s)
- Zhi-Rui Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Xin Mei
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Xing-Xing Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Zhao-Zhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Jing Hou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Li Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Xiao-Li Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China.
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China.
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Ciammella P, Podgornii A, Galeandro M, Micera R, Ramundo D, Palmieri T, Cagni E, Iotti C. Toxicity and cosmetic outcome of hypofractionated whole-breast radiotherapy: predictive clinical and dosimetric factors. Radiat Oncol 2014; 9:97. [PMID: 24762173 PMCID: PMC4029983 DOI: 10.1186/1748-717x-9-97] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 03/09/2014] [Indexed: 11/25/2022] Open
Abstract
Purpose The objective of this study is to evaluate toxicity and cosmetic outcome in breast cancer patients treated with adjuvant hypo fractionated radiotherapy to the whole breast, and to identify the risk factors for toxicity. Methods and materials Two hundred twelve women with early breast cancer underwent conserving surgery were enrolled in the study. The patients received 40.05 Gy in 15 daily fractions, 2.67 Gy per fraction. The boost to the tumor bed was administered with a total dose of 9 Gy in 3 consecutive fractions in 55 women. Physician-rated acute and late toxicity and cosmetic outcome (both subjective and objective) were prospectively assessed during and after radiotherapy. Results In our population study the mean age was 63 with the 17% (36 pts) of the women younger than 50 years. The median follow-up was 34 months. By the end of RT, 35 patients out of 212 (16%) no acute toxicity, according to the RTOG criteria, while 145 (68%) and 31 patients (15%) developed grade 1 and grade 2 acute skin toxicity, respectively. Late skin toxicity evaluation was available for all 212 patients with a minimum follow up of 8 months. The distribution of toxicity was: 39 pts (18%) with grade 1 and 2 pts (1%) with grade 2. No worse late skin toxicity was observed. Late subcutaneous grade 0-1 toxicity was recorded in 208 patients (98%) and grade 2 toxicity in 3 patients (2%), while grade 3 was observed in 1 patient only. At last follow up, a subjective and objective good or excellent cosmetic outcome was reported in 93% and 92% of the women, respectively. At univariate and multivariate analysis, the late skin toxicity was correlated with the additional boost delivery (p=0.007 and p=0.023). Regarding the late subcutaneous tissue, a correlation with diabetes was found (p=0.0283). Conclusion These results confirm the feasibility and safety of the hypofractionated radiotherapy in patients with early breast cancer. In our population the boost administration was resulted to be a significant adverse prognostic factor for acute and late toxicity. Long-term follow up is need to confirm this finding.
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Affiliation(s)
- Patrizia Ciammella
- Radiation Oncology Unit, Department of Advanced Technology, Arcispedale Santa Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico, Viale Risorgimento 80, 42123 Reggio Emilia Italy.
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The use of radiotherapy for early breast cancer in woman at different ages. Clin Transl Oncol 2014; 16:680-5. [DOI: 10.1007/s12094-014-1164-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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