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Stefan MF, Herghelegiu CG, Magda SL. Accelerated Atherosclerosis and Cardiovascular Toxicity Induced by Radiotherapy in Breast Cancer. Life (Basel) 2023; 13:1631. [PMID: 37629488 PMCID: PMC10455250 DOI: 10.3390/life13081631] [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: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
The number of patients diagnosed with breast cancer and cardiovascular disease is continuously rising. Treatment options for breast cancer have greatly evolved, but radiotherapy (RT) still has a key role in it. Despite many advances in RT techniques, cardiotoxicity is one of the most important side effects. The new cardio-oncology guidelines recommend a baseline evaluation, risk stratification and follow-up of these patients. Cardiotoxicity induced by RT can be represented by almost all forms of cardiovascular disease, with atherosclerosis being the most frequent. An interdisciplinary team should manage these patients, in order to have maximum therapeutic effect and minimum cardiovascular toxicity. This review will summarize the current incidence, risk factors, mechanisms and follow-up of RT-induced cardiovascular toxicity.
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Affiliation(s)
- Miruna Florina Stefan
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
| | - Catalin Gabriel Herghelegiu
- Institutul National Pentru Sanatatea Mamei si a Copilului “Alessandrescu Rusescu”, 020395 Bucharest, Romania;
| | - Stefania Lucia Magda
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania
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de Siqueira GS, Hanna SA, de Moura LF, Miranda FA, Carvalho HDA, Marta GN. Moderately hypofractionated radiation therapy for breast cancer: A Brazilian cohort study. LANCET REGIONAL HEALTH. AMERICAS 2022; 14:100323. [PMID: 36777384 PMCID: PMC9903971 DOI: 10.1016/j.lana.2022.100323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background Results from numerous clinical trials have led to a consensus that moderately hypofractionated radiation therapy is the ideal postoperative irradiation treatment plan in patients with breast cancer (BC). However, there are specific situations such as chest wall (with or without breast reconstruction) and regional node irradiation that still face obstacles in its widespread use. There is a lack of evidence supporting the use of moderately hypofractionated irradiation from the Latin American context. This study aims to describe the profile and clinical outcomes of patients treated with moderate hypofractionation for both early-stage (Stage I and II) and locally advanced BC (Stage III) regardless of the type of surgery in a Brazilian Oncology Center. Methods All patients with non-metastatic BC who were treated with moderately hypofractionated schedules of 40Gy in 15 fractions or 42.4Gy in 16 fractions between 2010 to 2019 at Hospital Sírio-Libanês, Brazil were retrospectively analyzed. The rates of local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distance recurrence-free survival (DRFS) and overall survival (OS) were estimated. Acute and late toxicity profiles were accessed for the entire cohort. Findings A total of 670 patients were included. The median age was 57 years and the median follow-up time was 31 months. Most of the patients had stage I and II breast cancer, and 81.6% underwent breast-conserving surgery. Of the 123 women who underwent mastectomy treatment, 29% (n = 37) had immediate reconstruction with implants and 28% (n = 35) with autologous tissue. Seventy-one per cent of the patients presented luminal subtype tumour and 84.3% received adjuvant hormonal therapy. Chemotherapy was administered to almost half of the patients and all 80 patients with Her-2 positive disease received trastuzumab-based systemic therapy. One-third of patients received regional node irradiation; boost was performed in 41.1% of treatments. The 5-year LRFS, RRFS, DRFS and OS was 95.6%, 97.6%,92.2% and 95.9%, respectively. Acute and late side effects profile were mild and only 2.9% of patients developed grade 3 dermatitis. Among patients with breast implants, 11.4% had capsular contracture. Interpretation In this Brazilian institution experience, moderately hypofractionated irradiation to the breast, chest wall (with or without breast reconstruction), and regional lymph nodes was safe and with an acceptable toxicity profile. Funding None.
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Affiliation(s)
| | - Samir A. Hanna
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil
| | | | | | - Heloísa de Andrade Carvalho
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil,Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil,Latin American Cooperative Oncology Group, Porto Alegre, Brazil,Corresponding author at: Department of Radiation Oncology, Hospital Sírio, Libanês, Rua Dona Adma Jafet 91. Sao Paulo, SP. Brazil. 01308-050.
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Kazemzadeh A, Abedi I, Amouheidari A, Shirvany A. A radiobiological comparison of hypo-fractionation versus conventional fractionation for breast cancer 3D-conformal radiation therapy. ACTA ACUST UNITED AC 2021; 26:86-92. [PMID: 34046218 DOI: 10.5603/rpor.a2021.0015] [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] [Received: 06/30/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
Background The present research was aimed to compare the toxicity and effectiveness of conventional fractionated radiotherapy versus hypo-fractionated radiotherapy in breast cancer utilizing a radiobiological model. Materials and methods Thirty-five left-sided breast cancer patients without involvement of the supraclavicular and axillary lymph nodes (with the nodal stage of N0) that had been treated with conventional or hypo-fractionated were incorporated in this study. A radiobiological model was performed to foretell normal tissue complication probability (NTCP) and tumor control probability (TCP). Results The data represented that TCP values for conventional and hypo-fractionated regimens were 99.16 ± 0.09 and 95.96 ± 0.48, respectively (p = 0.00). Moreover, the NTCP values of the lung for conventional and hypo-fractionated treatment were 0.024 versus 0.13 (p = 0.035), respectively. Also, NTCP values of the heart were equal to zero for both regimens. Conclusion In summary, hypo-fractionated regimens had comparable efficacy to conventional fraction radiation therapy in the case of dosimetry parameters for patients who had left breast cancer. But, utilizing the radiobiological model, conventional fractionated regimens presented better results compared to hypo-fractionated regimens.
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Affiliation(s)
| | - Iraj Abedi
- Medical Physics Department, Isfahan University of Medical Sciences, Isfahan, Iran
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Singh D, Saini G, Koul R, Gupta V, Abrol D, De S, Kulshrestha P, Hukku SN, Lakshmi SJ, Parikh PM, Aggarwal S. Practical consensus recommendations regarding role of postmastectomy radiation therapy. South Asian J Cancer 2020; 7:87-90. [PMID: 29721470 PMCID: PMC5909302 DOI: 10.4103/sajc.sajc_108_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The use of radiation therapy after mastectomy (PMRT) has been limited to those patients who are at significant risk of cancer recurring in the chest wall or in the nodal basins. The use of PMRT has been widely accepted for patients with four or more positive lymph nodes,[1],[2] but there is still controversy regarding the value of PMRT for those with one to three positive nodes. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.
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Affiliation(s)
- D Singh
- Department of Radiation Oncology, Max Hospital, Noida, Uttar Pradesh, India
| | - G Saini
- Department of Radiation Oncology, Max Hospital, Noida, Uttar Pradesh, India
| | - R Koul
- Department of Surgical Oncology, Sir Ganga Ram Hospital, New Delhi, India
| | - V Gupta
- Department of Surgical Oncology, BLK Super Specialty Hospital, New Delhi, India
| | - D Abrol
- Department or Radiation Oncology, Jammu Medical College, Jammu, Jammu and Kashmir, India
| | - S De
- Department of Radiation Oncology, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - P Kulshrestha
- Department of Radiation Oncology, Metro Hospital and Cancer Institute, New Delhi, India
| | - S N Hukku
- Department of Radiation Oncology, BLK Super Specialty Hospital, New Delhi, India
| | - S J Lakshmi
- Department of Radiation Oncology, Artemis Hospital, Gurugram, Haryana, India
| | - Purvish M Parikh
- Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
| | - S Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
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Kirova Y, Tallet A, Aznar MC, Loap P, Bouali A, Bourgier C. Radio-induced cardiotoxicity: From physiopathology and risk factors to adaptation of radiotherapy treatment planning and recommended cardiac follow-up. Cancer Radiother 2020; 24:576-585. [PMID: 32830054 DOI: 10.1016/j.canrad.2020.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/25/2022]
Abstract
Cancer and cardiovascular disease (CVD) are the leading cause of mortality worldwide, and breast cancer (BC) the most common malignancy affecting women worldwide. Radiotherapy is an important component of BC treatment and participates in CVD occurrence. It seems, therefore, crucial to gather both radiation oncology and cardiology medical fields to improve the follow-up quality of our BC patients. This review aims at updating our knowledge regarding cardiotoxicities risk factors, and consequently, doses constraints in case of 3D-conformal and IMRT treatment planning. Then we will develop how to reduce cardiac exposure and what kind of cardiac follow-up we could recommend to our breast cancer patients.
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Affiliation(s)
- Y Kirova
- Department of radiation oncology, institut Curie, 75005 Paris, France
| | - A Tallet
- Department of radiation oncology, institut Paoli-Calmette, Marseille, France
| | - M C Aznar
- Division of cancer sciences, faculty of biology, medicine and health, the university of Manchester, The Christie NHS Foundation Trust, Manchester, and Nuffield department of population health, university of Oxford, Oxford, UK
| | - P Loap
- Department of radiation oncology, institut Curie, 75005 Paris, France
| | - A Bouali
- Cardiology department, Lyon Sud Hospital, Hospices civils de Lyon, Lyon, France
| | - C 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.
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Henson KE, McGale P, Darby SC, Parkin M, Wang Y, Taylor CW. Cardiac mortality after radiotherapy, chemotherapy and endocrine therapy for breast cancer: Cohort study of 2 million women from 57 cancer registries in 22 countries. Int J Cancer 2020; 147:1437-1449. [PMID: 32022260 PMCID: PMC7496256 DOI: 10.1002/ijc.32908] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 01/13/2023]
Abstract
Comparisons of patients receiving different cancer treatments reflect the effects of both treatment and patient selection. In breast cancer, however, if radiotherapy decisions are unrelated to laterality, comparisons of left-sided and right-sided cancers can demonstrate the causal effects of higher-versus-lower cardiac radiation dose. Cardiac mortality was analysed using individual patient data for 1,934,248 women with breast cancer in 22 countries. The median date of diagnosis was 1996 and the interquartile range was 1987-2002. A total of 1,018,505 women were recorded as irradiated, 223,077 as receiving chemotherapy, 317,619 as receiving endocrine therapy and 55,264 died of cardiac disease. Analyses were stratified by time since breast cancer diagnosis, age at diagnosis, calendar year of diagnosis and country. Patient-selection effects were evident for all three treatments. For radiotherapy, there was also evidence of selection according to laterality in women irradiated 1990 or later. In patients irradiated before 1990, there was no such selection and cardiac mortality was higher in left-sided than right-sided cancer (rate ratio [RR]: 1.13, 95% confidence interval 1.09-1.17). Left-versus-right cardiac mortality RRs were greater among younger women (1.46, 1.19, 1.20, 1.09 and 1.08 after cancer diagnoses at ages <40, 40-49, 50-59, 60-69 and 70+ years, 2ptrend =0.003). Left-versus-right RRs also increased with time since cancer diagnosis (1.03, 1.11, 1.19 and 1.21 during 0-4, 5-14, 15-24 and 25+ years, 2ptrend =0.002) while for women who also received chemotherapy, the left-versus-right RR was 1.42 (95% confidence interval 1.13-1.77), compared to 1.10 (1.05-1.16) for women who did not (2pdifference = 0.03). These results show that the relative increase in cardiac mortality from cardiac exposure during breast cancer radiotherapy given in the past was greater in younger women, lasted into the third decade after exposure and was greater when chemotherapy was also given.
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Affiliation(s)
- Katherine E. Henson
- Nuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
| | - Paul McGale
- National Cancer Registration and Analysis Service, Public Health EnglandLondonUnited Kingdom
| | - Sarah C. Darby
- National Cancer Registration and Analysis Service, Public Health EnglandLondonUnited Kingdom
| | - Max Parkin
- National Cancer Registration and Analysis Service, Public Health EnglandLondonUnited Kingdom
| | - Yaochen Wang
- National Cancer Registration and Analysis Service, Public Health EnglandLondonUnited Kingdom
| | - Carolyn W. Taylor
- National Cancer Registration and Analysis Service, Public Health EnglandLondonUnited Kingdom
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Batumalai V, Delaney GP, Descallar J, Gabriel G, Wong K, Shafiq J, Barton M. Variation in the use of radiotherapy fractionation for breast cancer: Survival outcome and cost implications. Radiother Oncol 2020; 152:70-77. [PMID: 32721419 PMCID: PMC7382346 DOI: 10.1016/j.radonc.2020.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 11/30/2022]
Abstract
We evaluated the use of hypofractionation in breast radiotherapy in an Australian population-based cohort. Hypofractionation appears underused for breast radiotherapy in Australia over time. Variation in practice were observed by patient, tumour, sociodemographic and geographical factors. This study highlights that evidence-based practice will translate to reduced health care treatment costs.
Background and purpose Substantial variation in the adoption of hypofractionation for breast radiation therapy has been observed, despite the availability of consensus guidelines. This study aimed to investigate the variation in radiation therapy fractionation in breast cancer patients in New South Wales (NSW), Australia, and to estimate survival outcome and cost implications. Materials and methods This is a population-based cohort of patients who received radiation therapy for breast cancer (2009–2013), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. Survival outcome was estimated using multivariable Cox proportional hazards model. Cost per treatment and potential cost saving associated with evidence-based fractionation was estimated. Results A total of 10,482 patients were available for analysis, divided into 3 cohorts (breast alone: N = 7000; breast + nodes: N = 1119; all chestwall: N = 2363). In multivariable analysis, increasing age, laterality (right), year of treatment (2013), early stage, lower socioeconomic status, and regional area of residence were independent predictors of hypofractionation for breast alone radiation therapy. For the breast + nodes and chest wall cohorts, common factors that predicted the use of hypofractionation were increasing age. In multivariable survival analysis, there was no difference between the fractionation regimens at 5 years. Estimated radiation therapy cost of this cohort approximated $52.1 million, compared with $38.5 million had these patients been treated with evidence-based fractionation. This demonstrated a potential saving of $13.6 million. Conclusion Hypofractionation appears underused for breast radiation therapy in NSW over time. This study highlights that evidence-based practice will translate to reduced health care treatment costs.
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Affiliation(s)
- Vikneswary Batumalai
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia.
| | - Geoff P Delaney
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - Joseph Descallar
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Gabriel Gabriel
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Karen Wong
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Jesmin Shafiq
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Michael Barton
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
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Koulis TA, Nichol AM, Truong PT, Speers C, Gondara L, Tyldesley S, Lohrisch C, Weir L, Olson RA. Hypofractionated Adjuvant Radiation Therapy Is Effective for Patients With Lymph Node-Positive Breast Cancer: A Population-Based Analysis. Int J Radiat Oncol Biol Phys 2020; 108:1150-1158. [PMID: 32721421 DOI: 10.1016/j.ijrobp.2020.07.2313] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/16/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This study evaluated long-term, population-based, breast cancer-specific outcomes in patients treated with radiation therapy (RT) to the breast/chest wall plus regional nodes using hypofractionated (HF) (40-42.5 Gy/16 fractions) versus conventionally fractionated (CF) regimens (50-50.4 Gy/25-28 fractions). METHODS AND MATERIALS A prospective provincial database was used to identify patients with lymph node-positive breast cancer treated with curative-intent breast/chest wall + regional nodal RT from 1998 to 2010. The effect of RT fractionation on locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) was assessed for the entire cohort and for high-risk subgroups: grade 3, ER-/HER2-, HER2+, and ≥4 positive nodes. Multivariable analysis and 2:1 case-match comparison of HF versus CF were also performed. RESULTS A total of 5487 patients met the inclusion criteria (4006 HF and 1481 CF). Median age was 55 years, and median follow-up was 12.7 years. On multivariable analysis, no statistically significant differences were identified in 10-year LRRFS (hazard ratio [HR] 0.87; 95% confidence interval [CI], 0.59-1.27; P = .46), DRFS (HR 0.90; 95% CI, 0.76-1.06; P = .19), or BCSS (HR 0.92; 95% CI, 0.76-1.10; P = .36) between the HF and CF cohorts. There was no statistical difference in breast cancer-specific outcomes in the high-risk subgroups. On analysis of 2962 HF cases matched to 1481 CF controls, no statistical difference was observed in LRRFS (HR 0.98; 95% CI, 0.71-1.33; P = .87), DRFS (HR 0.97; 95% CI, 0.85-1.11; P = .68), or BCSS (HR 1.00; 95% CI, 0.87-1.16; P = .92). CONCLUSIONS This large, population-based analysis with long-term follow-up after locoregional RT demonstrated that modest HF provides similar breast cancer-specific outcomes compared with CF. HF is an effective option for patients with stage I to III breast cancer receiving nodal RT.
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Affiliation(s)
- Theodora A Koulis
- University of British Columbia, British Columbia, Canada; BC Cancer, Kelowna, British Columbia, Canada.
| | - Alan M Nichol
- University of British Columbia, British Columbia, Canada; BC Cancer Vancouver, Vancouver, British Columbia, Canada
| | - Pauline T Truong
- University of British Columbia, British Columbia, Canada; BC Cancer Victoria, Victoria, British Columbia, Canada
| | | | | | - Scott Tyldesley
- University of British Columbia, British Columbia, Canada; BC Cancer Vancouver, Vancouver, British Columbia, Canada
| | - Caroline Lohrisch
- University of British Columbia, British Columbia, Canada; BC Cancer Vancouver, Vancouver, British Columbia, Canada
| | - Lorna Weir
- University of British Columbia, British Columbia, Canada; BC Cancer Vancouver, Vancouver, British Columbia, Canada
| | - Robert A Olson
- University of British Columbia, British Columbia, Canada; BC Cancer Prince George, Prince George, British Columbia, Canada
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Moran MS, Truong PT. Hypofractionated radiation treatment for breast cancer: The time is now. Breast J 2020; 26:47-54. [PMID: 31944484 DOI: 10.1111/tbj.13724] [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: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 11/28/2022]
Abstract
While there is now Level I data with long-term follow-up supporting the routine use of hypofractionated (HF) whole-breast radiation therapy (WBRT) after breast-conserving surgery, its adoption has been slow and variable. This article will review the literature supporting the efficacy and safety of hypofractionated radiation for breast cancer, discuss the radiobiological rationale specific to breast tumors, and make an argument for justifying the routine adoption of shorter, HF-WBRT courses when delivering breast radiation. Data using HF with regional nodal irradiation and in the post-mastectomy setting will also be reviewed. The aim is to provide an in-depth understanding of the use of hypofractionated radiation therapy for breast cancer, its applicability, and topics warranting future research.
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Affiliation(s)
- Meena S Moran
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Pauline T Truong
- Department of Radiation Oncology, BC Cancer, University of British Columbia, Vancouver, BC, Canada
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Tovanabutra C, Katanyoo K, Uber P, Chomprasert K, Sukauichai S. Comparison of Treatment Outcome between Hypofractionated Radiotherapy and Conventional Radiotherapy in Postmastectomy Breast Cancer. Asian Pac J Cancer Prev 2020; 21:119-125. [PMID: 31983173 PMCID: PMC7294031 DOI: 10.31557/apjcp.2020.21.1.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Indexed: 11/25/2022] Open
Abstract
Objective: The aim of this study was to compare Conventional fractionated radiotherapy (CFRT) and Hypofractionated radiotherapy (HFRT) in terms of treatment outcomes, such as in 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity. Materials and Methods: We retrospectively analyzed the data obtained from 462 breast cancer patients who received complete adjuvant radiotherapy treatment between January 2012 and December 2014. One hundred twenty eight patients received CFRT 2 Gy daily fractions at a total dose of 48-60 Gy (group 1), while 334 patients received HFRT 2.65-2.67 Gy daily for 15-19 fractions at a total dose of 39.7-47.8 Gy 9 (grup 2). Treatment outcome such as 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity were measured and compared between two groups. Results: Median follow-up was 65.7 months (ranging from 45.1 to 95.2 months). Five-year loco-regional recurrence free survival rate was 96.1% in both CFRT and HFRT groups (p=0.993). Five-year disease-free survival rate of CFRT group was higher (68.8%), but this difference was not significant (HFRT =63.5%) (p=0.396). These were complied with 5-year overall survival rate (71.9% and 64.7%, p=0.385). Five-year distant metastatic free survival rate was 85.9% in CFRT group and 79.6% in HFRT group (p=0.169). No difference was observed between two groups in terms of toxicities, including changes in chest wall appearance, skin fib rosis, brachial plexopathy, arm edema, pulmonary fibrosis, and cardiovascular events. Conclusion: The treatment outcomes of hypofractionated radiotherapy in the postmastectomy breast cancer patients is comparable to the outcomes of conventional treatment at the Chonburi Cancer Hospital as previously reported from other studies, and HFRT can be implemented in resource-limited settings.
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Affiliation(s)
| | - Kanyarat Katanyoo
- Department of Radiology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pichet Uber
- Radiation Oncology section, Chonburi Cancer Hospital, Chonburi, Thailand
| | | | - Sitthi Sukauichai
- Medical Oncology section, Chonburi Cancer Hospital, Chonburi, Thailand
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Zhao S, Liu Y, Huang F, Chen X, Cao X, Yu J. The long-term outcome of adjuvant hypofractionated radiotherapy and conventional fractionated radiotherapy after breast-conserving surgery for early breast cancer: a prospective analysis of 107 cases. J Thorac Dis 2017; 9:3840-3850. [PMID: 29268393 DOI: 10.21037/jtd.2017.09.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to evaluate the long-term outcomes of hypofractionated and conventional fractionated radiotherapy after breast-conserving surgery in patients with early-stage breast cancer. In addition, cosmetic and delayed toxic effects in the breast were also investigated. Methods A total of 107 female patients were recruited and randomly classified into the hypofractionated radiotherapy (HF) group (53 participants) and the conventional fractioned radiotherapy (CF) group (54 participants). The HF group was subjected to the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 42.56 Gy/16 fractions + tumor bed boost at 7.98 Gy/3 fractions. The CF group received the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 50 Gy/25 fractions + tumor bed boost at 10 Gy/5 fractions. Results The 10-year local recurrence (LR) rate, tumor-specific survival rate, disease-free survival rate, and overall survival rate of the HF and CF groups were 9.6% vs. 7.9% (P=0.712); 88.1% vs. 90.1% (P=0.738); 81.1% vs. 82.9% (P=0.792); and 86.5% vs. 88.5% (P=0.748), respectively. The 10-year rates of patients with good or excellent cosmetic results in the HF and CF groups were 72.7% vs. 67.4% (P=0.581), respectively. The 10-year rates of patients with delayed toxicity-free effects in the skin and the rates of patients with toxicity-free subcutaneous tissues in the HF and CF groups were 70.5% vs. 65.2% (P=0.595) and 52.3% vs. 47.8% (P=0.673), respectively. Conclusions Hypofractionated and CF showed comparable long-term efficacy, cosmetic effects, and delayed toxic effects. Hence, HF may be used as an alternative to conventional fractionated radiotherapy.
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Affiliation(s)
- Shuhong Zhao
- Department of Radiation, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Yi Liu
- Department of Oncology, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Fengxian Huang
- Department of Radiation, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Xin Chen
- Department of Radiation, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Ximing Cao
- Department of Radiation, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Jiao Yu
- Department of Radiation, Shaanxi Provincial People's Hospital, Xi'an 710068, China
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12
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Hypofractionated Nodal Radiation Therapy for Breast Cancer Was Not Associated With Increased Patient-Reported Arm or Brachial Plexopathy Symptoms. Int J Radiat Oncol Biol Phys 2017; 99:1166-1172. [PMID: 29165285 DOI: 10.1016/j.ijrobp.2017.07.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/15/2017] [Accepted: 07/28/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine whether nodal radiation therapy (RT) for breast cancer using modest hypofractionation (HF) with 2.25 to 2.5 Gy per fraction (fx) was associated with increased patient-reported arm symptoms, compared with conventional fractionation (CF) ≤2 Gy/fx. METHODS AND MATERIALS Two cancer registries were used to identify subjects who received computed tomography-planned nodal RT for pT1-3, pN0-2, M0 breast cancer, from 2007 to 2010 at 2 cancer institutions. After ethics approval, patients were mailed an explanatory letter and the Self-reported Arm Symptom Scale, a validated instrument with 8 questions about arm symptoms and 5 related to activities of daily living. Clinicopathologic characteristics and Self-reported Arm Symptom Scale scores were compared between HF/CF cohorts using nonparametric analysis, χ2 analysis, and multivariate ordinal regression. RESULTS Of 1759 patients, 800 (45.5%) returned a completed survey. A total of 708 eligible cases formed the study cohort. Of these, 406 (57%) received HFRT (40 Gy/16 fx, 45 Gy/20 fx), and 302 (43%) received CFRT (45-50 Gy/25 fx, 50.4 Gy/28 fx). Median time interval after RT was 5.7 years. Forty-three percent and 75% of patients received breast-conserving surgery and chemotherapy, respectively. Twenty-two percent received breast boost RT, independent of fractionation. Median age at diagnosis was 59 years (HF) and 53 years (CF) (P<.001). The mean numbers of excised (n=12) and involved (n=3) nodes were similar between fractionation cohorts (P=.44), as were the mean sums of responses in arm symptoms (P=.17) and activities of daily living (P=.85). Patients receiving HF reported lower rates of shoulder stiffness (P=.04), trouble moving the arm (P=.02), and difficulty reaching overhead (P<.01) compared with the CF cohort. There was no difference in self-reported arm swelling or symptoms related to brachial plexopathy. CONCLUSIONS Nodal RT with hypofractionation was not associated with increased patient-reported arm symptoms or functional deficits compared with CF. Subjects treated with CF reported more disability in certain aspects of arm/shoulder function. These data support shorter fractionation utilization when regional nodes are within the therapeutic target.
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Radiation dose to the left anterior descending coronary artery during interstitial pulsed-dose-rate brachytherapy used as a boost in breast cancer patients undergoing organ-sparing treatment. J Contemp Brachytherapy 2017; 9:7-13. [PMID: 28344598 PMCID: PMC5346609 DOI: 10.5114/jcb.2017.66043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/11/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose To assess dose received by the left anterior descending (LAD) coronary artery during interstitial pulsed-dose-rate brachytherapy (PDR-BT) boost for left-sided breast cancer patients undergoing organ-sparing treatment. Material and methods Thirty consecutive pT1-3N0-1M0 breast cancer patients boosted between 2014 and 2015 with 10 Gy/10 pulses/hour PDR-BT following a computed tomography (CT) simulation with the multi-catheter implant were included. The most common localization of primary tumor were upper quadrants. Patients were implanted with rigid tubes following breast conserving surgery and whole breast external beam irradiation (40 Gy/15 or 50 Gy/25 fractions). Computed tomography scans were retrospectively reviewed and LADs were contoured without and with margin of 5 mm (LAD5mm). Standard treatment plan encompassed tumor bed determined by the surgical clips with margin of 2 cm. Dosimetric parameters were extracted from the dose-volume histograms. Results The mean D90 and V100 were 10.3 Gy (range: 6.6-13.3), and 42.0 cc (range: 15.3-109.3), respectively. The median dose non-uniformity ratio (DNR) was 0.50 (range: 0.27-0.82). The mean doses to LAD and LAD5mm were 1.0 Gy and 0.96 Gy, and maximal doses were 1.57 Gy and 1.99 Gy, respectively. Dose to the 0.1 cc of the LAD and LAD5mm were 1.42 Gy and 1.85 Gy (range: 0.01-4.98 Gy and 0.1-6.89 Gy), respectively. Conclusions Interstitial multi-catheter PDR-BT used as a boost for left-sided breast cancer is generally associated with low dose to the LAD. However, higher dose in individual cases may require alternative approaches.
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[Hypofractionated whole breast irradiation (WBRT): Results and indications]. Cancer Radiother 2016; 20:567-71. [PMID: 27614516 DOI: 10.1016/j.canrad.2016.07.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 11/22/2022]
Abstract
Breast irradiation after breast-conserving surgery is essential for maximizing local control and overall survival. The increase of breast cancer (BC) incidence, constraints of classical five weeks (w) radiation regimens and scarcity of radiotherapy units have led to test short hypofractionated WBRT schemes. One pilot study and three prospective randomized trials have tested various hypofractionated regimens of WBRT. About 7000 patients were included and follow-up ranged from 5 to 12 years. The conclusion of these trials is similar, showing local control and toxicity equivalent to these of the standard regimens. Three schemes are now clearly validated: 42.5Gy/16fr/3w, 40Gy/15fr/3w, or 42Gy/13fr/5w. However, the majority of included patients had favorable prognostic factors, were treated to the breast only and the boost dose, when indicated, was delivered with a standard fractionation. Therefore, we recommend the regimens preferentially in patients treated to the breast only, and without nodal involvement. These studies did not evaluate the addition of a boost dose with a hypofractionated scheme. If a boost is to be given, a standard fractionation should be used. Particular care should be taken to avoid heterogeneities leading to high fraction doses to organs at risk (lung and heart).
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Deshmukh S, Sharan K, Fernandes DJ, Srinivasa VM, Yathiraj PH, Singh A, Reddy A. A Study on Dosimetric Outcomes and Acute Toxicity of Post Mastectomy Adjuvant Hypofractionated Radiotherapy for Breast Cancer. J Clin Diagn Res 2016; 10:XC05-XC08. [PMID: 27630936 DOI: 10.7860/jcdr/2016/20477.8146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 05/24/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Hypofractionated External Beam Radiotherapy (HFRT) is a relatively new adjuvant Radiotherapy (RT) schedule for breast cancers following breast conservation surgery and less commonly, following mastectomy. Here we report our experience on normal tissue exposure and acute toxicity of HFRT after mastectomy. AIM To assess the dosimetric outcomes and acute toxicity profile of adjuvant HFRT following mastectomy for breast cancer. MATERIALS AND MATERIALS This prospective observational study considered consecutive patients planned for adjuvant HFRT (42.5 Gy in 16 sessions delivered over 3 weeks) to the chest wall with/without regional nodes between October 2014 and June 2015. The dosimetric parameters including dose homogeneity to the target volume and exposure to heart and lung were analyzed. Acute haematological and dermatological toxicity was recorded until upto three months after completion of RT. RESULTS Among the 56 patients treated with HFRT, the mean age was 49 years (range: 28-69 years). Pathologically positive nodes and ≥pT3 primary was observed in 44 (78.6%) and 12 (21.4%) patients, respectively. Majority (87.5%) received prior adjunct chemotherapy. RT to the supraclavicular fossa was delivered for 39 (69.6%) patients. The mean V90 and V95 to the Planning Target Volume (PTV) were 95% (± 3.3%) and 93% (± 4%), respectively. The maximum dose received was on average 47.7 Gy (112%; range: 46.2-48.5 Gy). The mean lung dose was 10.2 Gy (± 3.5 Gy) and V20 was 20.9% (± 6%). The mean V25 to heart was 6.6% (± 4.8%) for left sided and 0% for right sided tumours (p=0.001). Acute skin toxicity peaked at completion of RT and was tolerable (grade 0, I, II and III reactions were 75%, 16% and 1.8%, respectively). No patient had ≥ grade III haematological toxicity, and treatment was not interrupted for any patient. CONCLUSION Adjuvant HFRT could be planned while meeting the dose constraints to normal tissues in all patients and was well tolerated, with mild to moderate acute adverse effects that did not warrant any therapeutic intervention or treatment interruption.
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Affiliation(s)
- Shivaprasad Deshmukh
- Resident, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Krishna Sharan
- Associate Professor, Departmentof Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Donald Jerard Fernandes
- Professor and Head, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | | | | | - Anshul Singh
- Assistant Professor, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Anusha Reddy
- Senior Resident, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
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Evans SB, Yu JB. Hypofractionated radiation therapy versus conventionally fractionated radiation therapy for early-stage breast cancer: how do we choose? Future Oncol 2016; 11:2105-7. [PMID: 26235175 DOI: 10.2217/fon.15.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Suzanne B Evans
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA.,Cancer Outcomes, Public Policy, & Effectiveness Research (COPPER) Center at Yale, New Haven, CT, USA
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA.,Cancer Outcomes, Public Policy, & Effectiveness Research (COPPER) Center at Yale, New Haven, CT, USA
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Koulis TA, Phan T, Olivotto IA. Hypofractionated whole breast radiotherapy: current perspectives. BREAST CANCER-TARGETS AND THERAPY 2015; 7:363-70. [PMID: 26604820 PMCID: PMC4629948 DOI: 10.2147/bctt.s81710] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adjuvant radiotherapy (RT) is an important part of breast cancer management but the dose and fractionation schedules used are variable. A total of 50 Gy in 25 daily fractions delivered over 5 weeks is often considered the “standard” adjuvant RT prescription. Hypofractionated regimes such as 42.5 Gy in 16 daily fractions or 40 Gy in 15 daily fractions following breast-conserving surgery have proven to be equally effective and achieve similar or better cosmetic and normal tissue outcomes for both invasive and in situ diseases and when treating the regional nodes. Hypofractionation is more convenient for patients and less costly. However, certain patients at higher risk of RT late effects may benefit from a less intense, even more extended fractionation schedule. This review describes the indications for whole breast hypofractionated adjuvant RT for patients with breast cancer following breast-conserving surgery and proposes that hypofractionation should be the new “standard” for adjuvant breast cancer RT.
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Affiliation(s)
- Theodora A Koulis
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Tien Phan
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Ivo A Olivotto
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
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Leung HWC, Chan ALF, Muo CH. Late cardiac morbidity of adjuvant radiotherapy for early breast cancer - A population-based study. J Cardiol 2015; 67:567-71. [PMID: 26359709 DOI: 10.1016/j.jjcc.2015.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/02/2015] [Accepted: 07/07/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of this study was to assess the long-term cardiac morbidity and mortality after breast irradiation using contemporary irradiation techniques. METHODS We used the Catastrophic Illness dataset from the National Health Insurance Research Database to explore the possible association between late cardiotoxicity and women with early breast cancer treated with breast conservation therapy from 2000 to 2010. The Cox proportional-hazards model was used to compare breast cancer patients who received adjuvant radiotherapy versus without adjuvant radiotherapy for the end points with the following primary diagnoses (International Classification of Diseases, 9th Revision codes): ischemic heart disease (410-414, 36.0, 36.1), valvular heart disease (394-397, 424, 35), congestive heart failure (428, 402.01, 402.11, 402.91), and conduction abnormalities (426, 37.7-37.8, 37.94-37.99). RESULTS Three hundred and thirty patients received adjuvant radiotherapy and 4802 patients did not receive radiotherapy. Median follow-up was 3.5 years. There was no difference in overall morbidity and mortality from any cardiac cause (p=0.13) in breast cancer patients who received adjuvant radiotherapy versus without radiotherapy by using modern radiotherapy techniques. CONCLUSION There were no significant differences in cardiac morbidity and mortality after radiotherapy for breast cancer with a 9-year follow-up period in our population.
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Affiliation(s)
- Henry W C Leung
- Department of Radiation Therapy, China Medical University-An Nan Hospital, Tainan, Taiwan
| | - Agnes L F Chan
- Department of Pharmacy, China Medical University-An-Nan Hospital, Tainan, Taiwan.
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
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Nitsche M, Dunst J, Carl UM, Hermann RM. Emerging Role of Hypofractionated Radiotherapy with Simultaneous Integrated Boost in Modern Radiotherapy of Breast Cancer. Breast Care (Basel) 2015; 10:320-4. [PMID: 26688679 DOI: 10.1159/000436951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Hypofractionated radiotherapy for breast cancer is becoming increasingly important. The scientific background of this development as well as the introduction of the simultaneous integrated boost to the primary tumor region in this context are discussed here.
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Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Juergen Dunst
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Ulrich M Carl
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany
| | - Robert M Hermann
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Abteilung Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Germany
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