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Nakamura M, Fujisawa T, Oyoshi H, Zhou Y, Fukushi K, Hirata H, Tomizawa K, Motegi A, Hojo H, Wakabayashi M, Kano K, Ohno R, Nakamura A, Yamaguchi M, Zenda S. Acute toxicity of hypofractionated radiotherapy for Japanese breast cancer patients after surgery: a single center prospective observational study (HyPORT-BC). Breast Cancer 2024; 31:1176-1181. [PMID: 39115636 DOI: 10.1007/s12282-024-01626-x] [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: 05/21/2024] [Accepted: 08/05/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND This single center prospective observational study was conducted to evaluate the acute toxicity of hypo-fractionated radiotherapy for Japanese breast cancer patients after surgery. METHODS This study recruited patients who were scheduled for moderately hypo-fractionated radiotherapy including supraclavicular lymph node area (Cohort M) or ultra-hypo-fractionated radiotherapy for the conserved breast (Cohort U) as postoperative treatment for breast cancer. Radiotherapy plans were generated using automated planning system. Irradiation of 42.5 Gy/16 fractions (Cohort M) or 26 Gy/5 fractions (Cohort U) was delivered, and boost irradiation of 10 Gy/5 fractions was added as needed. The primary endpoint was the proportion of grade ≥ 2 acute adverse events within 90 days. The toxicities were evaluated using CTCAE ver 5.0. RESULTS Between January 2023 and December 2023, 123 patients (81 in Cohort M and 42 in Cohort U) were enrolled. All the included patients were Japanese and completed their planned radiotherapy and were also able to be evaluated for acute adverse events. Grade 1/2/3-5 acute adverse events were observed in 67/12/0 for Cohort M and 31/4/0 for Cohort U. The proportion of grade ≥ 2 acute adverse events within 90 days was 15% (95% confidence interval 8-24%) for Cohort M and 10% (95% confidence interval 3-23%) for Cohort U. CONCLUSIONS The proportion of acute toxicity of hypo-fractionated radiotherapy for Japanese breast cancer patients after surgery was shown to be acceptable in this study.
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Affiliation(s)
- Masaki Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Takeshi Fujisawa
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hidekazu Oyoshi
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuzheng Zhou
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Keiko Fukushi
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hidenari Hirata
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Kento Tomizawa
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hidehiro Hojo
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masashi Wakabayashi
- Clinical Research Support Office Biostatistics Section, National Cancer Center Hospital East, Chiba, Japan
| | - Kazuto Kano
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Risa Ohno
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Azusa Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masayuki Yamaguchi
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Radiology, National Cancer Center Hospital East, Chiba, Japan
| | - Sadamoto Zenda
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Anderson BM. Stay on the Trail: It's Safer Than Bushwhacking. Int J Radiat Oncol Biol Phys 2024; 120:316-317. [PMID: 39244349 DOI: 10.1016/j.ijrobp.2024.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/27/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Bethany M Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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3
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Lee SF, Kennedy SKF, Caini S, Wong HCY, Yip PL, Poortmans PM, Meattini I, Kaidar-Person O, Recht A, Hijal T, Torres MA, Cao JQ, Corbin KS, Choi JI, Koh WY, Kwan JYY, Karam I, Chan AW, Chow E, Marta GN. Randomised controlled trials on radiation dose fractionation in breast cancer: systematic review and meta-analysis with emphasis on side effects and cosmesis. BMJ 2024; 386:e079089. [PMID: 39260879 PMCID: PMC11388113 DOI: 10.1136/bmj-2023-079089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVE To provide a comprehensive assessment of various fractionation schemes in radiation therapy for breast cancer, with a focus on side effects, cosmesis, quality of life, risks of recurrence, and survival outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to 23 October 2023). STUDY SELECTION Included studies were randomised controlled trials focusing on conventional fractionation (CF; daily fractions of 1.8-2 Gy, reaching a total dose of 50-50.4 Gy over 5-6 weeks), moderate hypofractionation (MHF; fraction sizes of 2.65-3.3 Gy for 13-16 fractions over 3-5 weeks), and/or ultra-hypofractionation (UHF; schedule of only 5 fractions). DATA EXTRACTION Two independent investigators screened studies and extracted data. Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's tool and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach, respectively. DATA SYNTHESIS Pooled risk ratios (RRs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity was analysed using Cochran's Q test and I2 statistic. Network meta-analysis was used to integrate all available evidence. MAIN OUTCOME MEASURES The pre-specified primary outcome was grade ≥2 acute radiation dermatitis and late radiation therapy related side effects; secondary outcomes included cosmesis, quality of life, recurrence, and survival metrics. RESULTS From 1754 studies, 59 articles representing 35 trials (20 237 patients) were assessed; 21.6% of outcomes showed low risk of bias, whereas 78.4% had some concerns or high risk, particularly in outcome measurement (47.4%). The RR for grade ≥2 acute radiation dermatitis for MHF compared with CF was 0.54 (95% CI 0.49 to 0.61; P<0.001) and 0.68 (0.49 to 0.93; P=0.02) following breast conserving therapy and mastectomy, respectively. Hyperpigmentation and grade ≥2 breast shrinkage were less frequent after MHF than after CF, with RRs of 0.77 (0.62 to 0.95; P=0.02) and 0.92 (0.85 to 0.99; P=0.03), respectively, in the combined breast conserving therapy and mastectomy population. However, in the breast conserving therapy only trials, these differences in hyperpigmentation (RR 0.79, 0.60 to 1.03; P=0.08) and breast shrinkage (0.94, 0.83 to 1.07; P=0.35) were not statistically significant. The RR for grade ≥2 acute radiation dermatitis for UHF compared with MHF was 0.85 (0.47 to 1.55; P=0.60) for breast conserving therapy and mastectomy patients combined. MHF was associated with improved cosmesis and quality of life compared with CF, whereas data on UHF were less conclusive. Survival and recurrence outcomes were similar between UHF, MHF, and CF. CONCLUSIONS MHF shows improved safety profile, cosmesis, and quality of life compared with CF while maintaining equivalent oncological outcomes. Fewer randomised controlled trials have compared UHF with other fractionation schedules, but its safety and oncological effectiveness seem to be similar with short term follow-up. Given the advantages of reduced treatment time, enhanced convenience for patients, and potential cost effectiveness, MHF and UHF should be considered as preferred options over CF in appropriate clinical settings, with further research needed to solidify these findings. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023460249.
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Affiliation(s)
- Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Samantha K F Kennedy
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPO), Florence, Italy
| | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Hospital Authority, Hong Kong
| | - Pui Lam Yip
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- GROW-School for Oncology and Reproductive (Maastro), Maastricht University, Maastricht, Netherlands
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Mylin A Torres
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey Q Cao
- Section of Radiation Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wee Yao Koh
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jennifer Y Y Kwan
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Irene Karam
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Adrian W Chan
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Edward Chow
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil
- Latin America Cooperative Oncology Group, Porto Alegre, Brazil
- Postgraduate Program, Department of Radiology and Oncology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Yadav BS, Dey T. Hypofractionation for Regional Nodal Irradiation in Breast Cancer: Best of Both the Worlds. Clin Breast Cancer 2024; 24:399-410. [PMID: 38614852 DOI: 10.1016/j.clbc.2024.03.007] [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: 11/27/2023] [Revised: 03/03/2024] [Accepted: 03/09/2024] [Indexed: 04/15/2024]
Abstract
Locoregional radiotherapy play an important role in controlling the disease after surgery in patients with breast cancer. Radiotherapy schedules vary from conventional fraction to hypofractionation. The purpose of this review is to get an insight into the data on regional nodal irradiation (RNI) with hypofractionation in patients with breast cancer. This systematic review was constructed in accordance with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) framework. Electronic databases such as PubMed, Cochrane and EMBASE were searched from January 1, 2023 to March 31, 2023 to identify studies published in English language on hypofractionated RNI in post mastectomy patients. The search was carried out with the National Library of Medicine's Medical Subject Heading (MeSH) terms like "regional nodal irradiation," "hypofractionated" and "hypofractionation in breast cancer" with different Boolean operators (and/or). A manual search of reference lists of included articles was also performed to make sure there were no additional cases unidentified from the primary search. Studies deemed potentially eligible were identified and assessed by same independent reviewers to confirm eligibility. RNI data are mainly from a randomized study from Beijing and pooled data from START trials. There are also data from retrospective and single institutional studies and a few phase II studies with limited number of patients using different dose fractionations and techniques of radiotherapy. Doses used in these trials ranged from 26-47.7 Gy in 5-19 fractions over 1-4 weeks. Grade ≥ 2 pulmonary fibrosis and lymphedema rate ranged from 2%-7.9% and 3%-19.8% respectively. Grade ≥ 2 shoulder dysfunction and brachial plexopathy ranged from 0.2%-28% and 0%-< 1%, respectively. Late effects with a dose range of 26-40 Gy delivered in 5 to 15 fractions over 1-3 weeks were less/similar to conventional fraction. Current data showed lower/similar rates of toxicity with hypofractionated RNI compared with conventional fractionation RNI. Doses of 26 Gy to 40 Gy delivered in 5 to 15 fractions over 1-3 weeks are safe for RNI. With limited data, ultra-hypofractionation 26 Gy/5 fractions/1 week also seems to be safe. However, long-term outcome is awaited and many trials are going on to address its efficacy and safety.
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Affiliation(s)
- Budhi Singh Yadav
- Department of Radiotherapy & Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
| | - Treshita Dey
- Department of Radiotherapy & Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Mahata A, Chakraborty S, Mandal S, Achari RB, Bhattacharyya T, Mallick I, Arunsingh M, Chatterjee S. Quality Assurance in Radiotherapy (RT)-Specific Trials: Indian Scenario. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00211-5. [PMID: 38897901 DOI: 10.1016/j.clon.2024.05.016] [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: 04/25/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
AIMS There is evidence that proper radiotherapy trial quality assurance (RTTQA) translates into improved outcomes for patients. However, the practice of RTTQA is heterogeneous and implemented in a diverse manner across trials. In this paper, we review the RTTQA report for randomised trials (RCT) conducted in India and present our experience with RTTQA for various clinical trials and highlight the key achievements and challenges. MATERIALS AND METHODS Search was performed using the keywords and the variations thereof for "radiotherapy" and author affiliations from India, its states and major metropolitan cities. Pubmed search filters were used to restrict results to RCT published in the past 5 years (2019-2024). Reporting of RTTQA procedures from publications and protocols was documented along with the protocol-specified dosimetric goals. We also evaluated a few clinical trials performed in the Department of Radiation Oncology at Tata Medical Center. The different RTTQA procedures and results for four representative clinical trials have been described. RESULTS A formal RTTQA process was reported by only one out of 24 randomised controlled trials and formal dosimetric goals were pre-specified by 9 of 13 trials where IMRT was used as treatment. RTTQA requirements were tailored for each clinical trial at Tata Medical Center. For the HYPORT trial, the RTTQA process focused on ensuring the matchline doses were homogenous. HYPORT B trial commissioned the use of a simultaneous integrated boost technique which emphasised conformal avoidance of dose spillage to contralateral breast and lung. HYPORT Adjuvant and PROPARA trials are multicentre clinical trials. While HYPORT Adjuvant focussed on ensuring that the dose delivery met the predefined constraints, segmentation of the target volume was important for the PROPARA trial. CONCLUSION We demonstrate different RTTQA procedures required for representative clinical trials and highlight key challenges encountered.
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Affiliation(s)
- A Mahata
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - S Chakraborty
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India.
| | - S Mandal
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - R B Achari
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - T Bhattacharyya
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - I Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - M Arunsingh
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - S Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
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Ratosa I, Montero A, Ciervide R, Alvarez B, García-Aranda M, Valero J, Chen-Zhao X, Lopez M, Zucca D, Hernando O, Sánchez E, de la Casa MA, Alonso R, Fernandez-Leton P, Rubio C. Ultra-hypofractionated one-week locoregional radiotherapy for patients with early breast cancer: Acute toxicity results. Clin Transl Radiat Oncol 2024; 46:100764. [PMID: 38516338 PMCID: PMC10955656 DOI: 10.1016/j.ctro.2024.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Purpose Moderate hypofractionated radiotherapy is the standard of care for all patients with breast cancer, irrespective of stage or prior treatments. While extreme hypofractionation is accepted for early-stage tumours, its application in irradiating locoregional lymph nodes remains controversial. Materials and methods A prospective registry analysis from July 2020 to September 2023 included 276 patients with early-stage breast cancer treated with one-week ultra-hypofractionation (UHF) at 26 Gy in 5 fractions on the whole breast (58.3 %) or thoracic wall (41.7 %) and ipsilateral regional lymph nodes and simultaneous integrated boost (58.3 %). Primary endpoint was assessment of acute adverse events (AEs). Secondarily, onset of early-delayed toxicity was assessed. A minimum 6-month follow-up was required for assessing potential treatment-related early-delayed complications. Acute or late complications attributable to treatment were assessed at inclusion using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 criteria. Results With a median follow-up of 19 months (range 1-49 months), 159 (57.6 %) patients reported AEs, predominantly grade (G) 1 (n = 139, 50.4 %) and G2 (n = 20, 7.8 %). Skin acute toxicity was common (G1/2: 134, G3: 14), while breast oedema occurred in 10 patients (G1: 9, G2: 1), and 15.9 % reported breast pain (G1: 42, G2: 2). Ipsilateral arm oedema was observed in 1.8 % patients. For patients with a follow-up beyond 6 months (n = 213), 23.4 % patients reported G1/G2 skin AEs, 8.8 % had G1/G2 breast/chest wall oedema, and 8.9 % experienced arm lymphedema. There were no cases of brachial plexopathy or G3 toxicity in this group of patients. Conclusions One-week UHF adjuvant locoregional radiation is well-tolerated, displaying low-toxicity profiles comparable to other studies using similar irradiation schedules.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain
| | - Raquel Ciervide
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Beatriz Alvarez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | | | - Xin Chen-Zhao
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Mercedes Lopez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Daniel Zucca
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Rosa Alonso
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Carmen Rubio
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
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Giridhar P, Pradhan S, Pujari L, Singh P, Shinghal A, Khandelwal C, Mukherjee C, Tripathi M, Shukla V, M V M, Choudary Z, Gupta A. Is FAST FORWARD the Way Forward in Radiotherapy for Locally Advanced Breast Cancer - Learnings From the COVID Pandemic. Clin Breast Cancer 2024; 24:e116-e125. [PMID: 38105131 DOI: 10.1016/j.clbc.2023.11.003] [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: 07/07/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Low middle-income countries (LMICs), including India, have paucity of external beam radiotherapy (RT) machines leading to prolonged wait times for RT. Delay in delivery of RT has been shown to adversely affect outcomes in locally advanced breast cancer (LABC). With the availability of results of multiple randomized controlled trials, hypofractionated RT delivered over 3 to 4 weeks became the standard of care in breast cancer RT. METHODS We conducted a retrospective audit of 172 LABC patients treated with ultrahypofractionated adjuvant RT (radiotherapy completed in 1 week) during the COVID pandemic. Log rank and Cox-regression model used for univariate and multi-variate analyses. RESULTS No patient developed grade 3 esophagitis. Grade 2 esophagitis requiring short term narcotic analgesics was seen in 12 (6.9%) patients. Grade 2 or higher toxicity peaked between 2 and 3 weeks after RT. The estimated 2 and 3- year recurrence free survival (RFS) for the cohort is 87.1 % and 81.4 %, respectively. The estimated 2 and 3-year overall survival for the cohort is 95% and 91.3%. On multivariate analysis, presence of extra-nodal extension was found to be an independent factor associated with worse RFS (P = .028). CONCLUSIONS FAST FORWARD protocol RT in LABC appears well tolerated.
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Affiliation(s)
- Prashanth Giridhar
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India.
| | - Satyajit Pradhan
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Lincoln Pujari
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Prarabdh Singh
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Abhishek Shinghal
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Chaturbhaj Khandelwal
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Chandrima Mukherjee
- Department of Radiation Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Mayank Tripathi
- Department of Surgical Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Varun Shukla
- Department of Nuclear Medicine, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Manikandan M V
- Department of Nuclear Medicine, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Zacchariah Choudary
- Department of Onco-pathology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Anuj Gupta
- Department of Medical Oncology, MPMMCC/ HBCH, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
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Starling MTM, Thibodeau S, de Sousa CFPM, Restini FCF, Viani GA, Gouveia AG, Mendez LC, Marta GN, Moraes FY. Optimizing Clinical Implementation of Hypofractionation: Comprehensive Evidence Synthesis and Practical Guidelines for Low- and Middle-Income Settings. Cancers (Basel) 2024; 16:539. [PMID: 38339290 PMCID: PMC10854666 DOI: 10.3390/cancers16030539] [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: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024] Open
Abstract
The global cancer burden, especially in low- and middle-income countries (LMICs), worsens existing disparities, amplified by the rising costs of advanced treatments. The shortage of radiation therapy (RT) services is a significant issue in LMICs. Extended conventional treatment regimens pose significant challenges, especially in resource-limited settings. Hypofractionated radiotherapy (HRT) and ultra-hypofractionated/stereotactic body radiation therapy (SBRT) offer promising alternatives by shortening treatment durations. This approach optimizes the utilization of radiotherapy machines, making them more effective in meeting the growing demand for cancer care. Adopting HRT/SBRT holds significant potential, especially in LMICs. This review provides the latest clinical evidence and guideline recommendations for the application of HRT/SBRT in the treatment of breast, prostate, and lung cancers. It emphasizes the critical importance of rigorous training, technology, stringent quality assurance, and safety protocols to ensure precise and secure treatments. Additionally, it addresses practical considerations for implementing these treatments in LMICs, highlighting the need for comprehensive support and collaboration to enhance patient access to advanced cancer care.
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Affiliation(s)
| | - Stephane Thibodeau
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
| | | | | | - Gustavo A. Viani
- Department of Medical Imagings, Ribeirão Preto Medical School, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto 14049-900, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Andre G. Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
- Division of Radiation Oncology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Lucas C. Mendez
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Gustavo Nader Marta
- Radiation Oncology Department, Hospital Sirio Libanês, Sao Paulo 01308-050, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Fabio Ynoe Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
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9
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Sauvage LM, Loap P, Vu-Bezin J, Cao K, Kissel M, Bringer S, Maraadji S, Fourquet A, Kirova Y. Large scale experience of two ultrahypofractionated 5 fractions regimes after breast conserving surgery from a single centre. Acta Oncol 2023; 62:1791-1797. [PMID: 37824092 DOI: 10.1080/0284186x.2023.2267170] [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: 07/28/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Ultra-hypofractionation breast radiotherapy is a safe alternative to moderate hypofractionation. This study reports the results of two ultrahypofractionated regimens used in clinical practice in a high-volume radiotherapy center in terms of efficacy and of tolerance. METHODS we included all patients treated in an adjuvant setting with five fractions after breast conserving surgery (BCS), for a histologically-confirmed invasive or in situ breast carcinoma. Radiotherapy regimens after BCS were either a 5-week schedule with 5 weekly fractions of 5,7 Gy or a one-week schedule with 5 daily fractions of 5,2 Gy. Adverse events were recorded and local-relapse free survival (LRFS), locoregional-relapse free survival (LRRFS), metastasis-free survival (MFS), for breast-cancer specific survival (BCSS) and overall survival (OS) were evaluated. RESULTS Between December 2014 and December 2022, 396 patients (400 breasts) were treated with ultrahypofractionated radiotherapy. Five-year LRFS was 98.8% (95% confidence interval: 97.1%-100%), and 5-year OS was 96.0% (95%CI: 92.6-99.5%). Age was statistically associated with OS in univariate analysis (HR: 1.16, 95%CI: 1.04-1.42, p = .01). Four patients (1.0%) experienced acute grade 3 radiation-induced adverse events, and 8 patients (2.3%) acute grade 2 toxicities. Twenty-three patients (5.8%) experienced late toxicity, all of them being graded as grade 1. The use of the 5.7 Gy-weekly-fraction regimen and the delivery of a tumor bed boost were significantly associated with acute radiodermatitis (p < .01; p = .02; respectively) and late fibrosis (p < .01; p = .049; respectively). CONCLUSIONS ultrahypofractionated radiotherapy was associated with an excellent tumor control rate in our 'real-life' cohort with low-risk breast cancer patients. However, delivery of a tumor bed boost and using weekly 5.7-Gy fractions were associated with an increased risk of acute and late cutaneous toxicities.
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Affiliation(s)
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Jeremi Vu-Bezin
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Kim Cao
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Manon Kissel
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Solène Bringer
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Safia Maraadji
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
- University of Versailles St Quentin, Paris, France
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10
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Unterkirhere O, Stenger-Weisser A, Kaever A, Hoeng L, Jeller D, Logaritsch P, Glanzmann C, Studer G. Single-Institution Prospective Evaluation of Moderately Hypofractionated Whole-Breast Radiation Therapy With Simultaneous Integrated Boost With or Without Lymphatic Drainage Irradiation After Breast-Conserving Surgery. Adv Radiat Oncol 2023; 8:101270. [PMID: 38047219 PMCID: PMC10692289 DOI: 10.1016/j.adro.2023.101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose We report treatment outcomes for patients who received adjuvant moderate hypofractionated whole-breast radiation therapy with simultaneous integrated boost (SIB-mhWBRT) after breast-conserving surgery. Methods and Materials SIB-mhWBRT for patients with breast cancer was introduced in our department in July 2017. This prospective evaluation includes 424 consecutive patients treated with SIB-mhWBRT for stage I-III invasive breast cancer (n = 391) and/or ductal carcinoma in situ (n = 33) until December 2021. SIB-mhWBRT was applied with 40 Gy in 15 daily fractions over 3 weeks according to the START B trial, with an SIB dose to the tumor bed of 48 Gy according to Radiation Therapy Oncology Group 1005/UK-IMPORT-HIGH, delivered as 3-dinemsional conformal radiation therapy (RT; n = 402), intensity modulated RT (n = 4), or volumetric modulated arc therapy (n = 18). The mean patient age was 60 years (range, 27-88). Since May 2018, patients with indications for lymphatic pathway RT were included (n = 62). Baseline parameters and follow-up data were recorded and reported, including objective assessment of treatment-related outcomes and subjective patient-reported outcome measures (PROMs). Results Mean/median follow-up was 29/33 months (range, 2-60). Acute toxicity grade 0, 1, 2, and 3 was observed in 25.0%, 61.4%, 13.3%, and 0%, respectively, at the completion of RT. Data of 281, 266, 243, 172, and 58 patients were available for 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Grade 2 late effects were identified in 8.5%, 6.0%, 4.9%, 2.2%, and 10.2% and grade 3 in 2.8%, 1.1%, 1.2%, 0%, and 0% of patients at 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Medical treatment of breast edema was the only grade 3 late effect observed. PROM cosmesis results were evaluated as excellent-good, fair, and poor in 97.2%, 2.5%, and 0.4%; 96.5%, 3.1%, and 0.4%; 97.4%, 2.2%, and 0.4%; 97.5%, 2.5%, and 0%; and 96.5%, 3.5%, and 0.0% at 6 months and 1, 2, 3, and 4 years post-RT, respectively. For all patients, the 3-year overall, cancer-specific, and disease-free survival rates were 98.2%, 99.1%, and 95.9%, respectively. Three-year risk of any locoregional recurrence was 0.6%. No mortality or relapse was observed in patients with ductal carcinoma in situ. Conclusions SIB-mhWBRT demonstrated very favorable side effect profiles and cosmesis/PROMs. Three-year results demonstrate excellent locoregional control. This short-term regimen offers substantial patient comfort and improves institutional efficacy.
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Affiliation(s)
- Olga Unterkirhere
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Laura Hoeng
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | - David Jeller
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Gabriela Studer
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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11
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Belkacemi Y, Biston MC, Benchekroun N, Benider A, Chargari C, Debbi K, Doré M, El Kacimi H, Flandin I, Lalya I, Samlali H, Sellal N, Supiot S. Limited applicability and implementation of the international oncology treatments guidelines in low- and middle-income countries, an example from the Mediterranean area borders. Cancer Radiother 2023; 27:666-675. [PMID: 37550156 DOI: 10.1016/j.canrad.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 08/09/2023]
Abstract
The quality of cancer care in the modern era is based on a precise diagnosis and personalized therapy according to patients and their disease based on validated guidelines with a high level of evidence. During cancer patients' management, the objective is first to make an accurate diagnosis and then offer the best treatment, validated beforehand in a multidisciplinary board meeting, with the best benefit/risk ratio. In the context of many low- and middle-income countries, the limited available means do not allow an adequate offer, resulting in non-optimal patients' care. In addition, in many low- and middle-income countries, priority can be given to other types of disease than cancer, which may considerably reduce allocation of specific resources to cancer care. Thus, the limited availability of systemic therapy, radiotherapy machines, brachytherapy and technological development may come up against another difficulty, that of geographical distribution of the means in the countries or a lack of expertise due to insufficient training programs. For all these reasons, the implementation of the guidelines established in Western countries could be impossible for many low- and middle-income countries which, moreover, have to face a completely different epidemiology of cancers compared to developed countries. In this work, we will discuss through a few examples of common cancers on both borders of the Mediterranean area, the applicability of the guidelines and the limits of their implementation for optimal cancer care.
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Affiliation(s)
- Y Belkacemi
- Department of Radiation Oncology and Henri-Mondor Breast Center, centre hospitalier universitaire Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Inserm U955, i-Biot Team, IMRB, university of Paris-Est Crétil, Créteil, France.
| | - M-C Biston
- Centre Léon-Bérard and Creatis, CNRS UMR 5225, Inserm U1044, Insa-Lyon, université Lyon 1, Villeurbanne, France
| | - N Benchekroun
- Department of Radiation Oncology, centre Mohamed-VI, université de Casablanca, Casablanca, Morocco
| | - A Benider
- Department of Radiation Oncology, centre Mohamed-VI, université de Casablanca, Casablanca, Morocco
| | - C Chargari
- Department of Radiation Oncology, groupe hospitalier Pitié-Salpêtrière, AP-HP, Sorbonne Université Paris VI, Paris, France
| | - K Debbi
- Department of Radiation Oncology and Henri-Mondor Breast Center, centre hospitalier universitaire Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Inserm U955, i-Biot Team, IMRB, university of Paris-Est Crétil, Créteil, France
| | - M Doré
- Department of Radiation Oncology, Institute de cancérologie de l'Ouest (ICO) centre René-Gauducheau, Saint-Herblain, France
| | - H El Kacimi
- Department of Radiation Oncology, Institut d'oncologie de Rabat, Rabat, Morocco
| | - I Flandin
- Department of Radiation Oncology, centre hospitalier universitaire de Grenoble, Grenoble, France
| | - I Lalya
- Department of Radiation Oncology, hôpital militaire Mohamed-V, Rabat, Morocco
| | - H Samlali
- Department of Radiation Oncology, clinique d'oncologie le Littoral, Casablanca, Morocco
| | - N Sellal
- Department of Radiation Oncology, hôpital universitaire Mohmed-VI, université Abdelmalek-Essadi, Tanger, Morocco
| | - S Supiot
- Department of Radiation Oncology, Institute de cancérologie de l'Ouest (ICO) centre René-Gauducheau, Saint-Herblain, France; Université de Nantes, Nantes, France
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12
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Dzhugashvili M, Veldeman L, Kirby AM. The role of the radiation therapy breast boost in the 2020s. Breast 2023; 69:299-305. [PMID: 36958070 PMCID: PMC10068257 DOI: 10.1016/j.breast.2023.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Given that most local relapses of breast cancer occur proximal to the original location of the primary, the delivery of additional radiation dose to breast tissue that contained the original primary cancer (known as a "boost") has been a standard of care for some decades. In the context of falling relapse rates, however, it is an appropriate time to re-evaluate the role of the boost. This article reviews the evolution of the radiotherapy boost in breast cancer, discussing who to boost and how to boost in the 2020s, and arguing that, in both cases, less is more.
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Affiliation(s)
| | - L Veldeman
- Ghent University/Ghent University Hospital, Ghent, Belgium.
| | - A M Kirby
- Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, UK.
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13
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Brunt AM, Haviland JS. Hypofractionation: The standard for external beam breast irradiation. Breast 2023; 69:410-416. [PMID: 37120889 PMCID: PMC10172745 DOI: 10.1016/j.breast.2023.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023] Open
Abstract
This overview provides the historical perspective of external beam breast hypofractionation over the last 50 years. It highlights the serious harm suffered by patients with breast cancer in the 1970's and 1980's because of new hypofractionation regimens based on a theoretical radiobiology model being adopted into clinical practice to solve a resource issue without testing within clinical trials and without the essential radiotherapy quality assurance. It then describes the high-quality clinical trials comparing 3-week with 5-week standard of care regimens that were initiated based on a strong scientific rationale for hypofractionation in breast cancer. Today, there are still challenges with universal implementation of the results of these moderate hypofractionation studies, but there is now a substantial body of evidence to support 3-week breast radiotherapy with several large randomised trials still to report. The limit of breast hypofractionation is then explored and randomised trials investigating 1-week radiotherapy are described. This approach is now standard of care in many countries for whole or partial breast radiotherapy and chest wall radiotherapy without immediate reconstruction. It also has the advantage of reducing burden of treatment for patients and providing cost-effective care. Further research is needed to establish the safety and efficacy of 1-week breast locoregional radiotherapy and following immediate breast reconstruction. In addition, clinical studies are required to determine how a tumour bed boost for patients with breast cancer at higher risk of relapse can be incorporated simultaneously into a 1-week radiotherapy schedule. As such, the breast hypofractionation story is still unfolding.
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Affiliation(s)
- Adrian Murray Brunt
- David Weatherall Building, School of Medicine, University of Keele, Keele, Staffordshire, ST5 5BG, UK; Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, Sutton, London, UK.
| | - Joanne Susan Haviland
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, Sutton, London, UK.
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14
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Shah C, Fleming-Hall E, Asha W. Update on Accelerated Whole Breast Irradiation. Clin Breast Cancer 2023; 23:237-240. [PMID: 36792457 DOI: 10.1016/j.clbc.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
Since the advent of breast conservation, adjuvant radiation therapy (RT) has been standard of care following breast conserving surgery (BCS). Radiation therapy following BCS has traditionally been whole breast irradiation (WBI); studies comparing breast conservation to mastectomy utilized standard fractionation WBI, which delivers treatment daily over 5 to 7 weeks (1.8-2 Gy/fraction) and was the standard for decades. More recently, multiple randomized trials have compared standard fractionation WBI to moderately hypofractionated WBI (2.66 Gy/fraction, 15-16 fractions), which allows for completion of treatment in 3 to 4 weeks. Results have demonstrated no difference in local control between these two approaches with comparable toxicity and cosmetic outcomes with long-term follow-up. As such, moderately hypofractionated WBI represents the standard of care approach for most patients with early-stage breast cancer following BCS at this time. In the past few years, ultra-hypofractionated WBI (5.2-5.7 Gy/fraction, 5 fractions) has emerged with promising outcomes; 5-year outcomes from the FAST-Forward randomized trial demonstrated noninferiority between ultra-hypofractionated WBI and moderately hypofractionated WBI. Moving forward, long-term outcomes from ultra-hypofractionated WBI studies are expected, as well as the potential for incorporating moderately hypofractionated regimens into patients requiring regional nodal irradiation following BCS. Finally, the advent of ultra-short regimens may allow clinicians to re-evaluate treatment de-intensification in early-stage breast cancer to consider radiation therapy alone following BCS in lieu of endocrine therapy.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Erica Fleming-Hall
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Wafa Asha
- Department of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan
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15
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Crockett C, Lorimer C. OncoFlash - Research Updates in a Flash! (November edition). Clin Oncol (R Coll Radiol) 2022; 34:692-694. [PMID: 36229100 DOI: 10.1016/j.clon.2022.09.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- C Crockett
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK.
| | - C Lorimer
- University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
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16
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Coles CE, Chatterjee S, Jagsi R, Kirby AM. Breast radiotherapy for ductal carcinoma in situ: could less be more? Lancet 2022; 400:408-410. [PMID: 35933995 DOI: 10.1016/s0140-6736(22)01381-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 10/16/2022]
Affiliation(s)
- Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK.
| | | | - Reshma Jagsi
- Department of Radiation Oncology and Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
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