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Hwang J, Chun J, Cho S, Kim JH, Cho MS, Choi SH, Kim JS. Personalized Deep Learning Model for Clinical Target Volume on Daily Cone Beam Computed Tomography in Breast Cancer Patients. Adv Radiat Oncol 2024; 9:101580. [PMID: 39258144 PMCID: PMC11381721 DOI: 10.1016/j.adro.2024.101580] [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: 10/26/2023] [Accepted: 07/17/2024] [Indexed: 09/12/2024] Open
Abstract
Purpose Herein, we developed a deep learning algorithm to improve the segmentation of the clinical target volume (CTV) on daily cone beam computed tomography (CBCT) scans in breast cancer radiation therapy. By leveraging the Intentional Deep Overfit Learning (IDOL) framework, we aimed to enhance personalized image-guided radiation therapy based on patient-specific learning. Methods and Materials We used 240 CBCT scans from 100 breast cancer patients and employed a 2-stage training approach. The first stage involved training a novel general deep learning model (Swin UNETR, UNET, and SegResNET) on 90 patients. The second stage used intentional overfitting on the remaining 10 patients for patient-specific CBCT outputs. Quantitative evaluation was conducted using the Dice Similarity Coefficient (DSC), Hausdorff Distance (HD), mean surface distance (MSD), and independent samples t test with expert contours on CBCT scans from the first to 15th fractions. Results IDOL integration significantly improved CTV segmentation, particularly with the Swin UNETR model (P values < .05). Using patient-specific data, IDOL enhanced the DSC, HD, and MSD metrics. The average DSC for the 15th fraction improved from 0.9611 to 0.9819, the average HD decreased from 4.0118 mm to 1.3935 mm, and the average MSD decreased from 0.8723 to 0.4603. Incorporating CBCT scans from the initial treatments and first to third fractions further improved results, with an average DSC of 0.9850, an average HD of 1.2707 mm, and an average MSD of 0.4076 for the 15th fraction, closely aligning with physician-drawn contours. Conclusion Compared with a general model, our patient-specific deep learning-based training algorithm significantly improved CTV segmentation accuracy of CBCT scans in patients with breast cancer. This approach, coupled with continuous deep learning training using daily CBCT scans, demonstrated enhanced CTV delineation accuracy and efficiency. Future studies should explore the adaptability of the IDOL framework to diverse deep learning models, data sets, and cancer sites.
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Affiliation(s)
- Joonil Hwang
- Department of Nuclear and Quantum Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
- Medical Image and Radiotherapy Lab (MIRLAB), Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Jaehee Chun
- OncoSoft, Seoul, Republic of Korea
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungryong Cho
- Department of Nuclear and Quantum Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
- Medical Image and Radiotherapy Lab (MIRLAB), Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Joo-Ho Kim
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Min-Seok Cho
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Seo Hee Choi
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Sung Kim
- OncoSoft, Seoul, Republic of Korea
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
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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 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] [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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Gardner LL, Thompson SJ, O'Connor JD, McMahon SJ. Modelling radiobiology. Phys Med Biol 2024; 69:18TR01. [PMID: 39159658 DOI: 10.1088/1361-6560/ad70f0] [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: 04/25/2024] [Accepted: 08/19/2024] [Indexed: 08/21/2024]
Abstract
Radiotherapy has played an essential role in cancer treatment for over a century, and remains one of the best-studied methods of cancer treatment. Because of its close links with the physical sciences, it has been the subject of extensive quantitative mathematical modelling, but a complete understanding of the mechanisms of radiotherapy has remained elusive. In part this is because of the complexity and range of scales involved in radiotherapy-from physical radiation interactions occurring over nanometres to evolution of patient responses over months and years. This review presents the current status and ongoing research in modelling radiotherapy responses across these scales, including basic physical mechanisms of DNA damage, the immediate biological responses this triggers, and genetic- and patient-level determinants of response. Finally, some of the major challenges in this field and potential avenues for future improvements are also discussed.
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Affiliation(s)
- Lydia L Gardner
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
| | - Shannon J Thompson
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
| | - John D O'Connor
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
- Ulster University School of Engineering, York Street, Belfast BT15 1AP, United Kingdom
| | - Stephen J McMahon
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
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Ba MB, Giudici F, Bellini C, Auzac G, Louvel G, Bockel S, Moukasse Y, Chaffai I, Berthelot K, Vatonne A, Conversano A, Viansone A, Larue C, Deutsch E, Michiels S, Milewski C, Rivera S. Feasibility and Safety of the "One-Week Breast Radiation Therapy" Program. Clin Oncol (R Coll Radiol) 2024; 36:e333-e341. [PMID: 38971686 DOI: 10.1016/j.clon.2024.06.045] [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] [Revised: 02/21/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024]
Abstract
AIMS FAST-Forward and UK-FAST-trials have demonstrated the safety and efficacy of five-fraction breast adjuvant radiation therapy (RT) and have become the standard of care for selected early breast cancer patients. In response to the additional burden caused by the COVID-19 pandemic, we implemented "One-Week Breast RT," an innovative program delivering five-fraction whole breast RT in a complete 5-day workflow. The primary objective of this study was to demonstrate the feasibility and safety of our program. The secondary objective was to evaluate cosmetic results. MATERIAL AND METHODS A total of 120 patients treated from February 2021 to March 2022, received whole breast RT without lymph node irradiation nor boost, with 26 Gy in five fractions over one week. Inverse planning with restricted optimization parameters offers systematic deep inspiration breath-hold aimed to provide treatment plans compliant with FAST-Forward recommendations. Toxicity and cosmetic evaluations were prospectively registered prior (pre-RT), at the end (end-RT), and 6 months after RT (6 months) based on Common Terminology Criteria for Adverse Events v. 4.03 and Harvard scale. RESULTS With a median age of 70 years (interquartile range (IQR): 66-74) and a median follow-up of 6 months (IQR: 6.01-6.25), most patients (93.3%) completed their RT in one week from baseline to the end of the treatment consultation. The most common acute toxicities (at end-RT) were skin-related: radio-dermatitis (72%), induration (35%), hyperpigmentation (8%), and breast edema (16%). The rate of radio-dermatitis decreased from end-RT to 6 months (71.7% vs 5.4%, P< 0.001). No patient experienced grade ≥3 toxicity. At 6 months, cosmetic results were generally good or excellent (94.1%). CONCLUSION This study confirms the feasibility and acute safety of the "One-Week Breast RT" in real life. Favorable toxicity profiles and good cosmetic outcomes are in line with FAST-Forward results. A prospective national cohort, aimed at decreasing treatment burden, maintaining safety, efficacy, and improving RT workflow efficiency with longer follow-up is ongoing.
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Affiliation(s)
- M B Ba
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - F Giudici
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - C Bellini
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - G Auzac
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - G Louvel
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - S Bockel
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - Y Moukasse
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - I Chaffai
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - K Berthelot
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - A Vatonne
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - A Conversano
- Gustave Roussy, Surgery Department, F-94805, Villejuif, France
| | - A Viansone
- Gustave Roussy, Medical Oncology Department, F-94805, Villejuif, France
| | - C Larue
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - E Deutsch
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France; Université Paris-Saclay, Gustave Roussy, Inserm 1030, 94805, Villejuif, France
| | - S Michiels
- Bureau de Biostatistique et d'Epidémiologie, Gustave Roussy, Oncostat U1018, Inserm, Paris-Saclay University, F-94805, Villejuif, France
| | - C Milewski
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France
| | - S Rivera
- Gustave Roussy, Radiation Therapy Department, F-94805, Villejuif, France; Université Paris-Saclay, Gustave Roussy, Inserm 1030, 94805, Villejuif, France.
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Zhang M, Zhang FX, Yang XL, Liang Q, Liu J, Zhou WB. Comparative dosimetric study of h-IMRT and VMAT plans for breast cancer after breast-conserving surgery. Transl Oncol 2024; 47:102012. [PMID: 38889521 PMCID: PMC11231535 DOI: 10.1016/j.tranon.2024.102012] [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: 11/30/2023] [Revised: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
AIM To compare the dosimetric advantages and disadvantages between hybrid intensity-modulated radiation therapy (h-IMRT) and the volumetric modulated arc therapy (VMAT) technique in hypofractionated whole-breast irradiation (HF-WBI) for early-stage breast cancer (BC). METHODS The dose distribution of h-IMRT and VMAT plans was compared in 20 breast cancer patients. This comparison included evaluation of dosimetric parameters using dose volume histograms (DVHs) for the planning target volume (PTV) and organs-at-risk (OARs). Additionally, the study examined the normal tissue complication probability (NTCP), the second cancer complication probability (SCCP) and the tumor control probability (TCP) based on different models. RESULTS Significant differences were detected between the two plans, in terms of Machine units (MUs), the control points, 95 % volume (V95 %), dose homogeneity index (DHI) and conformity index (CI). The endpoint of grade II radiation pneumonitis and cardiac death due to ischemic heart disease were assessed. In h-IMRT plan, the NTCP values were marginally lower for radiation pneumonitis and slightly higher for cardiac death compared to VMAT plan, as determined by the Lyman-Kutcher-Burman model. The Schneider model was employed to predict the SCCP for both the bilateral lungs and contralateral breast, the results demonstrate that the h-IMRT plan outperforms the VMAT plan, with statistical significance. Additionally, the LQ-Poisson model was employed to forecast the TCP of the PTV, showing that the h-IMRT plan outperformed the VMAT plan (P > 0.05). CONCLUSION The h-IMRT technique, offering superior dose coverage and better therapeutic efficacy with fewer side effects as calculated by models, is more suitable for HF-WBI compared to the VMAT technique.
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Affiliation(s)
- Min Zhang
- Xiangya Hospital, Central South University, Hunan 41000, PR China
| | - Fang-Xu Zhang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Xiao-Lei Yang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Qian Liang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Jian Liu
- Department of Otolaryngology-Head and Neck Surgery, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, PR China
| | - Wei-Bing Zhou
- Xiangya Hospital, Central South University, Hunan 41000, PR China.
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Gil-Lianes J, Tena G, Combalia M, Alejo B, Oses G, Combalia A, Iglesias P, Huguet A, Garrido S, Sola J, Malvehy J, Mollà M, Carrera C. Computational Model Based on Optical Coherence Tomography (OCT) Skin Scanning to Identify and Quantify Acute Radiation Dermatitis (ARD): A Prospective Diagnostic Study. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T752-T760. [PMID: 38964604 DOI: 10.1016/j.ad.2024.07.002] [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: 07/23/2023] [Revised: 12/19/2023] [Accepted: 03/03/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Acute radiation dermatitis (ARD) is the most widely reported radiotherapy-induced adverse event. Currently, there is no objective or reliable method to measure ARD. OBJECTIVE Our main objective was to identify and quantify the effects of radiotherapy with a computational model using optical coherence tomography (OCT) skin scanning. Secondary objectives included determining the ARD impact of different radiotherapeutic schemes and adjuvant topical therapies. METHODS We conducted a prospective, single-center case series study in a tertiary referral center of patients with breast cancer who were eligible for whole breast radiotherapy (WBRT). RESULTS A total of 39 women were included and distributed according to the radiotherapeutic schemes (15, 20, and 25 fractions). A computational model was designed to quantitatively analyze OCT findings. After radiotherapy, OCT scanning was more sensitive revealing vascularization changes in 84.6% of the patients (vs 69.2% of the patients with ARD by clinical examination). OCT quantified an increased vascularization at the end of WBRT (P<.05) and a decrease after 3 months (P=.032). Erythematous skin changes by OCT were more pronounced in the 25-fraction regime. CONCLUSION An OCT computational model allowed for the identification and quantification of vascularization changes on irradiated skin, even in the absence of clinical ARD. This may allow the design of standardized protocols for ARD beyond the skin color of the patients involved.
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Affiliation(s)
- J Gil-Lianes
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - G Tena
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - M Combalia
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - B Alejo
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - G Oses
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, España
| | - A Combalia
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - P Iglesias
- Dermatology Department, Hospital Clínic, University of Barcelona, España
| | - A Huguet
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, España
| | - S Garrido
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, España
| | - J Sola
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, España
| | - J Malvehy
- Dermatology Department, Hospital Clínic, University of Barcelona, España; IDIBAPS, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, España
| | - M Mollà
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, España
| | - C Carrera
- Dermatology Department, Hospital Clínic, University of Barcelona, España; IDIBAPS, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, España.
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Ritter AR, Prasad RN, Jhawar SR, Bazan JG, Gokun Y, Vudatala S, Diaz DA. Hypofractionated Radiation Therapy: A Cross-sectional Survey Study of US Radiation Oncologists. Am J Clin Oncol 2024; 47:434-438. [PMID: 38907597 DOI: 10.1097/coc.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
OBJECTIVES For many malignancies, hypofractionated radiotherapy (HFRT) is an accepted standard associated with decreased treatment time and costs. United States provider beliefs regarding HFRT likely impact its adoption but are poorly studied. We surveyed US-based radiation oncologists (ROs) to gauge HFRT utilization rates for prostate (PC), breast (BC), and rectal cancer (RC) and to characterize the beliefs governing these decisions. METHODS From July to October 2021, an anonymized, online survey was electronically distributed to ROs actively practicing in the United States. Demographic and practice characteristic information was collected. Questions assessing rates of offering HFRT for PC, BC, and RC and perceived limitations towards using HFRT were administered. RESULTS A total of 203 eligible respondents (72% male, 72% White, 53% nonacademic practice, 69% with 11+ years in practice) were identified. Approximately 50% offered stereotactic body radiation therapy (SBRT) for early/favorable intermediate risk PC. Although >90% of ROs offered whole-breast HFRT for early-stage BC, only 33% offered accelerated partial-breast irradiation (APBI). Overall, 41% of ROs offered short-course neoadjuvant RT for RC. The primary reported barriers to HFRT utilization were lack of data, inexperience, and referring provider concerns. CONCLUSIONS HFRT is safe, effective, and beneficial, yet underutilized-particularly prostate SBRT, APBI, and short-course RT for RC. Skills retraining and education of ROs and referring providers may increase utilization rates.
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Affiliation(s)
| | | | | | | | - Yevgeniya Gokun
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sundari Vudatala
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
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Booth S, Freeman JQ, Li JL, Huo D. Increase in Hypofractionated Radiation Therapy Among Patients with Invasive Breast Cancer or Ductal Carcinoma In Situ: Who is Left Behind? Pract Radiat Oncol 2024; 14:e305-e323. [PMID: 38685449 DOI: 10.1016/j.prro.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE We aimed to update the trend of hypofractionated whole-breast irradiation (HF-WBI) use over time in the US and examine factors associated with lack of HF-WBI adoption for patients with early-stage invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) undergoing a lumpectomy. METHODS AND MATERIALS Among patients who underwent a lumpectomy, we identified 928,034 patients with early-stage IBC and 330,964 patients with DCIS in the 2004 to 2020 National Cancer Database. We defined HF-WBI as 2.5-3.33 Gy/fraction to the breast and conventionally fractionated WBI as 1.8-2.0 Gy/fraction. We evaluated the trend of HF-WBI utilization using a generalized linear model with the log link and binomial distribution. Factors associated with HF-WBI utilization were assessed using multivariable logistic regression in patients diagnosed between 2018 and 2020. RESULTS Among patients with IBC, HF-WBI use has significantly increased from 0.7% in 2004 to 63.9% in 2020. Similarly, HF-WBI usage among patients with DCIS has also increased significantly from 0.4% in 2004 to 56.6% in 2020. Black patients with IBC were less likely than White patients to receive HF-WBI (adjusted odds ratio [AOR] 0.81; 95% CI, 0.77-0.85). Community cancer programs were less likely to administer HF-WBI to patients with IBC (AOR, 0.80; 95% CI, 0.77-0.84) and to those with DCIS (AOR, 0.87; 95% CI, 0.79-0.96) than academic/research programs. Younger age, positive nodes, larger tumor size, low volume programs, and facility location were also associated with lack of HF-WBI adoption in both patient cohorts. CONCLUSIONS HF-WBI utilization among postlumpectomy patients has significantly increased from 2004 to 2020 and can finally be considered standard of care in the US. We found substantial disparities in adoption within patient and facility subgroups. Reducing disparities in HF-WBI adoption has the potential to further alleviate health care costs while improving patients' quality of life.
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MESH Headings
- Humans
- Female
- Middle Aged
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Radiation Dose Hypofractionation
- Aged
- Adult
- Mastectomy, Segmental
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
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Affiliation(s)
- Sara Booth
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Jincong Q Freeman
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
| | - James L Li
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Pritzker School of Medicine, University of Chicago, Illinois
| | - Dezheng Huo
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Center for Clinical Cancer Genetics and Global Health, University of Chicago, Chicago, Illinois.
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9
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Gil-Lianes J, Tena G, Combalia M, Alejo B, Oses G, Combalia A, Iglesias P, Huguet A, Garrido S, Sola J, Malvehy J, Mollà M, Carrera C. Computational Model Based on Optical Coherence Tomography (OCT) Skin Scanning to Identify and Quantify Acute Radiation Dermatitis (ARD): A Prospective Diagnostic Study. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:752-760. [PMID: 38554749 DOI: 10.1016/j.ad.2024.03.017] [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: 07/23/2023] [Revised: 12/19/2023] [Accepted: 03/03/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Acute radiation dermatitis (ARD) is the most widely reported radiotherapy-induced adverse event. Currently, there is no objective or reliable method to measure ARD. OBJECTIVE Our main objective was to identify and quantify the effects of radiotherapy with a computational model using optical coherence tomography (OCT) skin scanning. Secondary objectives included determining the ARD impact of different radiotherapeutic schemes and adjuvant topical therapies. METHODS We conducted a prospective, single-center case series study in a tertiary referral center of patients with breast cancer who were eligible for whole breast radiotherapy (WBRT). RESULTS A total of 39 women were included and distributed according to the radiotherapeutic schemes (15, 20, and 25 fractions). A computational model was designed to quantitatively analyze OCT findings. After radiotherapy, OCT scanning was more sensitive revealing vascularization changes in 84.6% of the patients (vs 69.2% of the patients with ARD by clinical examination). OCT quantified an increased vascularization at the end of WBRT (P<.05) and a decrease after 3 months (P=.032). Erythematous skin changes by OCT were more pronounced in the 25-fraction regime. CONCLUSION An OCT computational model allowed for the identification and quantification of vascularization changes on irradiated skin, even in the absence of clinical ARD. This may allow the design of standardized protocols for ARD beyond the skin color of the patients involved.
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Affiliation(s)
- J Gil-Lianes
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - G Tena
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - M Combalia
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - B Alejo
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - G Oses
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - A Combalia
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - P Iglesias
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain
| | - A Huguet
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - S Garrido
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - J Sola
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - J Malvehy
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain; IDIBAPS, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, Spain
| | - M Mollà
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - C Carrera
- Dermatology Department, Hospital Clínic, University of Barcelona, Spain; IDIBAPS, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Barcelona, Spain.
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10
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O'Leary RL, Duijm LEM, Boersma LJ, van der Sangen MJC, de Munck L, Wesseling J, Schipper RJ, Voogd AC. Invasive recurrence after breast conserving treatment of ductal carcinoma in situ of the breast in the Netherlands: time trends and the association with tumour grade. Br J Cancer 2024; 131:852-859. [PMID: 38982194 PMCID: PMC11369187 DOI: 10.1038/s41416-024-02785-6] [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: 01/08/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND The first aim of this study was to examine trends in the risk of ipsilateral invasive breast cancer (iIBC) after breast-conserving surgery (BCS) of ductal carcinoma in situ (DCIS). A second aim was to analyse the association between DCIS grade and the risk of iIBC following BCS. PATIENTS AND METHODS In this population-based, retrospective cohort study, the Netherlands Cancer Registry collected information on 25,719 women with DCIS diagnosed in the period 1989-2021 who underwent BCS. Of these 19,034 received adjuvant radiotherapy (RT). Kaplan-Meier analyses and Cox regression models were used. RESULTS A total of 1135 patients experienced iIBC. Ten-year cumulative incidence rates of iIBC for patients diagnosed in the periods 1989-1998, 1999-2008 and 2009-2021 undergoing BCS without RT, were 12.6%, 9.0% and 5.0% (P < 0.001), respectively. For those undergoing BCS with RT these figures were 5.7%, 3.7% and 2.2%, respectively (P < 0.001). In the multivariable analyses, DCIS grade was not associated with the risk of iIBC. CONCLUSION Since 1989 the risk of iIBC has decreased substantially and has become even lower than the risk of invasive contralateral breast cancer. No significant association of DCIS grade with iIBC was found, stressing the need for more powerful prognostic factors to guide the treatment of DCIS.
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MESH Headings
- Humans
- Female
- Netherlands/epidemiology
- Middle Aged
- Mastectomy, Segmental
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms/epidemiology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/therapy
- Retrospective Studies
- Aged
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/pathology
- Neoplasm Grading
- Adult
- Radiotherapy, Adjuvant/statistics & numerical data
- Registries
- Aged, 80 and over
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Affiliation(s)
- Rebecca L O'Leary
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Pathology, the Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands.
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands.
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11
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Llorián-Salvador Ó, Windeler N, Martin N, Etzel L, Andrade-Navarro MA, Bernhardt D, Rost B, Borm KJ, Combs SE, Duma MN, Peeken JC. CT-based radiomics for predicting breast cancer radiotherapy side effects. Sci Rep 2024; 14:20051. [PMID: 39209947 PMCID: PMC11362146 DOI: 10.1038/s41598-024-70723-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
Skin inflammation with the potential sequel of moist epitheliolysis and edema constitute the most frequent breast radiotherapy (RT) acute side effects. The aim of this study was to compare the predictive value of tissue-derived radiomics features to the total breast volume (TBV) for the moist cells epitheliolysis as a surrogate for skin inflammation, and edema. Radiomics features were extracted from computed tomography (CT) scans of 252 breast cancer patients from two volumes of interest: TBV and glandular tissue (GT). Machine learning classifiers were trained on radiomics and clinical features, which were evaluated for both side effects. The best radiomics model was a least absolute shrinkage and selection operator (LASSO) classifier, using TBV features, predicting moist cells epitheliolysis, achieving an area under the receiver operating characteristic (AUROC) of 0.74. This was comparable to TBV breast volume (AUROC of 0.75). Combined models of radiomics and clinical features did not improve performance. Exclusion of volume-correlated features slightly reduced the predictive performance (AUROC 0.71). We could demonstrate the general propensity of planning CT-based radiomics models to predict breast RT-dependent side effects. Mammary tissue was more predictive than glandular tissue. The radiomics features performance was influenced by their high correlation to TBV volume.
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Affiliation(s)
- Óscar Llorián-Salvador
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany.
- Department of Informatics, Bioinformatics and Computational Biology-i12, Technische Universität München, Boltzmannstr. 3, 85748, Munich, Germany.
- Institute of Organismic and Molecular Evolution, Johannes Gutenberg University Mainz, Hanns-Dieter-Hüsch- Weg 15, 55128, Mainz, Germany.
| | - Nora Windeler
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Nicole Martin
- Department of Informatics, Bioinformatics and Computational Biology-i12, Technische Universität München, Boltzmannstr. 3, 85748, Munich, Germany
| | - Lucas Etzel
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 69120, Heidelberg, Germany
| | - Miguel A Andrade-Navarro
- Institute of Organismic and Molecular Evolution, Johannes Gutenberg University Mainz, Hanns-Dieter-Hüsch- Weg 15, 55128, Mainz, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 69120, Heidelberg, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum, 85764, München, Germany
| | - Burkhard Rost
- Department of Informatics, Bioinformatics and Computational Biology-i12, Technische Universität München, Boltzmannstr. 3, 85748, Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 69120, Heidelberg, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum, 85764, München, Germany
| | - Marciana N Duma
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
- Department of Radiation Oncology, Helios Clinics of Schwerin - University Campus of MSH Medical School Hamburg, Schwerin, Germany
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 69120, Heidelberg, Germany
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum, 85764, München, Germany
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12
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Bhatia RK, Lichter KE, Zaorsky NG, Mantz C. Using hypofractionation to decarbonise radiation oncology. BMJ 2024; 386:e079072. [PMID: 39164042 DOI: 10.1136/bmj-2023-079072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
Affiliation(s)
- Rohini K Bhatia
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Katie E Lichter
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Nicholas G Zaorsky
- Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
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13
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Wong JS, Uno H, Tramontano AC, Fisher L, Pellegrini CV, Abel GA, Burstein HJ, Chun YS, King TA, Schrag D, Winer E, Bellon JR, Cheney MD, Hardenbergh P, Ho A, Horst KC, Kim JN, Leonard KL, Moran MS, Park CC, Recht A, Soto DE, Shiloh RY, Stinson SF, Snyder KM, Taghian AG, Warren LE, Wright JL, Punglia RS. Hypofractionated vs Conventionally Fractionated Postmastectomy Radiation After Implant-Based Reconstruction: A Randomized Clinical Trial. JAMA Oncol 2024:2822041. [PMID: 39115975 PMCID: PMC11310844 DOI: 10.1001/jamaoncol.2024.2652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/02/2024] [Indexed: 08/10/2024]
Abstract
Importance Postmastectomy radiation therapy (PMRT) improves local-regional disease control and patient survival. Hypofractionation (HF) regimens have comparable efficacy and complication rates with improved quality of life compared with conventional fractionation (CF) schedules. However, the use of HF after mastectomy in patients undergoing breast reconstruction has not been prospectively examined. Objective To compare HF and CF PMRT outcomes after implant-based reconstruction. Design, Setting, and Participants This randomized clinical trial assessed patients 18 years or older undergoing mastectomy and immediate expander or implant reconstruction for breast cancer (Tis, TX, or T1-3) and unilateral PMRT from March 8, 2018, to November 3, 2021 (median [range] follow-up, 40.4 [15.4-63.0] months), at 16 US cancer centers or hospitals. Analyses were conducted between September and December 2023. Interventions Patients were randomized 1:1 to HF or CF PMRT. Chest wall doses were 4256 cGy for 16 fractions for HF and 5000 cGy for 25 fractions for CF. Chest wall toxic effects were defined as a grade 3 or higher adverse event. Main Outcomes and Measures The primary outcome was the change in physical well-being (PWB) domain of the Functional Assessment of Cancer Therapy-Breast (FACT-B) quality-of-life assessment tool at 6 months after starting PMRT, controlling for age. Secondary outcomes included toxic effects and cancer recurrence. Results Of 400 women (201 in the CF arm and 199 in the HF arm; median [range] age, 47 [23-79] years), 330 patients had PWB scores at baseline and at 6 months. There was no difference in the change in PWB between the study arms (estimate, 0.13; 95% CI, -0.86 to 1.11; P = .80), but there was a significant interaction between age group and study arm (P = .03 for interaction). Patients younger than 45 years had higher 6-month absolute PWB scores if treated with HF rather than CF regimens (23.6 [95% CI, 22.7-24.6] vs 22.0 [95% CI, 20.7-23.3]; P = .047) and reported being less bothered by adverse effects (mean [SD], 3.0 [0.9] in the HF arm and 2.6 [1.2] in the CF arm; P = .02) or nausea (mean [SD], 3.8 [0.4] in the HF arm and 3.6 [0.8] in the CF arm; P = .04). In the as-treated cohort, there were 23 distant (11 in the HF arm and 12 in the CF arm) and 2 local-regional (1 in the HF arm and 1 in the CF arm) recurrences. Chest wall toxic effects occurred in 39 patients (20 in the HF arm and 19 in the CF arm) at a median (IQR) of 7.2 (1.8-12.9) months. Fractionation was not associated with chest wall toxic effects on multivariate analysis (HF arm: hazard ratio, 1.02; 95% CI, 0.52-2.00; P = .95). Fewer patients undergoing HF vs CF regimens had a treatment break (5 [2.7%] vs 15 [7.7%]; P = .03) or required unpaid time off from work (17 [8.5%] vs 34 [16.9%]; P = .02). Conclusions and Relevance In this randomized clinical trial, the HF regimen did not significantly improve change in PWB compared with the CF regimen. These data add to the increasing experience with HF PMRT in patients with implant-based reconstruction. Trial Registration ClinicalTrials.gov Identifier: NCT03422003.
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Affiliation(s)
- Julia S. Wong
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Gregory A. Abel
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Harold J. Burstein
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yoon S. Chun
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tari A. King
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric Winer
- Yale Cancer Center, New Haven, Connecticut
| | - Jennifer R. Bellon
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - Alice Ho
- Duke University Medical Center, Durham, North Carolina
| | | | - Janice N. Kim
- Fred Hutchinson Cancer Center/UW Medicine, Seattle, Washington
| | - Kara-Lynne Leonard
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence
| | | | - Catherine C. Park
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Abram Recht
- Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Ron Y. Shiloh
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - Alphonse G. Taghian
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Boston
| | - Laura E. Warren
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Rinaa S. Punglia
- Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
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14
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Fujita M, Nagashima K, Uno T, Hashimoto H, Suzuki K, Kasai T, Yamaguchi K, Onouchi Y, Sato D, Fujisawa T, Hata A. Impact of the COVID-19 Pandemic on Hypofractionated Radiation Therapy Use for Breast Cancer in Japan: A Nationwide Study. Adv Radiat Oncol 2024; 9:101555. [PMID: 39104876 PMCID: PMC11298581 DOI: 10.1016/j.adro.2024.101555] [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: 11/06/2023] [Accepted: 06/04/2024] [Indexed: 08/07/2024] Open
Abstract
Purpose Hypofractionated radiation therapy (RT) was recommended for several cancer sites to reduce outpatient visits during the COVID-19 pandemic. This study aimed to identify the impact of the pandemic on hypofractionated RT for breast cancer in Japan. Methods and Materials The monthly number of courses for hypofractionated and conventional RTs was counted using sample data sets from the National Database of Health Insurance Claims and Specific Health Checkups of Japan, a nationwide database accumulating insurance claims data comprehensively. Changes in the number of hypofractionated and conventional RTs were estimated using an interrupted time-series analysis. Results The number of hypofractionated RT courses gradually increased before the pandemic in contrast to that of conventional RT courses, which gradually decreased. However, conventional RT remained outnumbered by hypofractionated RT throughout the observation period. After the outbreak of the pandemic, the use of hypofractionated RT significantly increased in April 2020 (1312 courses; 95% CI, 801-1823) but decreased in October 2020 (-601; 95% CI, -1111 to -92). Subgroup analysis by age and the number of beds in medical institutions revealed similar trends. Conclusions Although conventional RT for breast cancer has been gradually replaced by hypofractionated RT, it remains predominant. The use of hypofractionated RT increased briefly early in the COVID-19 pandemic; however, this increase was not sustained, unlike in other countries. Considering the benefits of hypofractionated RT for breast cancer, its use should be encouraged in Japan.
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Affiliation(s)
- Misuzu Fujita
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
- Department of Public Health, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Kengo Nagashima
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Hideyuki Hashimoto
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
| | - Kiminori Suzuki
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
| | - Tokuzo Kasai
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
| | - Kazuya Yamaguchi
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
| | - Yoshihiro Onouchi
- Department of Public Health, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Daisuke Sato
- Hospital and Health Administration, Fujita Health University Graduate School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, Japan
| | - Takehiko Fujisawa
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
| | - Akira Hata
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-ku, Chiba, Japan
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15
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Kyei KA, Anim-Sampong S, Akoe EA, Daniels J, Obeng-Mensah T, Antwi WK, Ainuson-Quampah J. Radiation-induced dermatitis among breast cancer patients undergoing adjuvant radiotherapy in Ghana. Transl Oncol 2024; 46:102028. [PMID: 38861854 PMCID: PMC11209633 DOI: 10.1016/j.tranon.2024.102028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/14/2024] [Accepted: 06/05/2024] [Indexed: 06/13/2024] Open
Abstract
The aim of the study was to investigate radiation-induced epidermal desquamation among breast cancer patients undergoing radiotherapy with 6MV linac and Co-60 teletherapy units. METHOD: Quantitative data was collected using self-administered closed ended questionnaires addressing the desquamation in relation to some patient-and treatment-related factors. The Radiation Therapy Oncology Group (RTOG) criteria for acute skin toxicity was used to grade the toxicity. Chi square and logistic regression analyses were respectively used to test statistical significance and evaluate the effects of the various factors on radiation induced epidermal desquamation RESULTS: Majority of the participants had high BMIs (overweight: 39.5 %; obese: 50 %). Patients with BMI ≥ 25 kg/m2 presented with wet desquamation (RTOG grade 2). A chi-square analysis showed a significant difference (p = 0.02) between BMI and severity of desquamation. There was no significant difference between type of treatment machine and cumulative incidence dose of desquamation (p= 0.251). The logistic regression analysis showed that patients who had undergone mastectomy (OR = 0.562) were less likely to develop wet desquamation (RTOG grade 2) on the Co-60 machine within the 20-30 Gy threshold (OR=0.981) compared to those on the linear accelerator. Patients with lower BMI (OR = 0.412,[ < 25 vs ≥30]; OR = 0.286, [25-29.9 vs ≥30]) were also less likely to develop wet desquamation compared to those with higher BMI. CONCLUSION: Radiation-induced epidermal desquamation is a common side effect of breast cancer patients undergoing radiotherapy. BMI has an effect on the severity of desquamation experienced during breast irradiation.
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Affiliation(s)
- K A Kyei
- Dept. of Radiography, University of Ghana, P. O. Box KB 143, Korle Bu, Accra, Ghana; National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana.
| | - S Anim-Sampong
- Dept. of Radiography, University of Ghana, P. O. Box KB 143, Korle Bu, Accra, Ghana
| | - E A Akoe
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - J Daniels
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - T Obeng-Mensah
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - W K Antwi
- Dept. of Radiography, University of Ghana, P. O. Box KB 143, Korle Bu, Accra, Ghana
| | - J Ainuson-Quampah
- Dept. of Radiography, University of Ghana, P. O. Box KB 143, Korle Bu, Accra, Ghana
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16
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Wu VS, Khlopin M, Chadha M, Smith-Graziani DJ, Jagsi R, McClelland S. Out-of-Pocket Cost Modeling of Adjuvant Antiestrogen and Radiation Therapy After Lumpectomy for Early-Stage Breast Cancer Across Medicaid and Medicare Plans. Int J Radiat Oncol Biol Phys 2024; 119:1379-1385. [PMID: 38432284 DOI: 10.1016/j.ijrobp.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/11/2024] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The optimal adjuvant therapy (antiestrogen therapy [ET] + radiation therapy or ET alone, or in some reports radiation therapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiation therapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency. METHODS AND MATERIALS Several radiation therapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we used the 5-fraction and 15-fraction radiation therapy and ET prescribed over a 5-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a 5-year time horizon. RESULTS Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2738.52 for ET alone, $2221.26 for 5-fraction radiation therapy alone, $2573.92 for 15-fraction radiation therapy alone, $3361.26 for combined ET+ 5-fraction radiation therapy, and $3713.92 for combined ET + 15-fraction radiation therapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1130.00 with radiation therapy alone and face an out-of-pocket of $2270.00 for ET alone and combined ET+ radiation therapy. For Medicaid beneficiaries, all treatments approved by Medicaid are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option. CONCLUSIONS This model (based on actual cost estimates per insurance plan rather than claims data), by estimating expenses within Medicare and Medicaid plans, provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced.
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Affiliation(s)
- Victoria S Wu
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Martha Khlopin
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Manjeet Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Demetria J Smith-Graziani
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Shearwood McClelland
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio; Department of Neurological Surgery, University Hospitals Cleveland Medical Center Case Western Reserve University, Cleveland, Ohio.
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17
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Wu Z, Hou L, Li C, Li X, Li Y. Hypofractionated versus Conventional Postmastectomy Irradiation for Breast Cancer: Comparison of Acute Skin Toxicity. BREAST CANCER (DOVE MEDICAL PRESS) 2024; 16:423-432. [PMID: 39099624 PMCID: PMC11297561 DOI: 10.2147/bctt.s471901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/24/2024] [Indexed: 08/06/2024]
Abstract
Purpose Breast cancer is the leading cause of cancer mortality among women. Radiotherapy can reduce recurrence and prolong survival of patients accepting breast-conserving surgery (BCS). This study aims to compare acute skin reactions in patients receiving hypofractionated versus conventional radiotherapy at a single institution and to summarize the relevant influencing factors. Methods This study analyzed 152 patients who underwent either hypofractionated or conventional whole-breast irradiation (WBI) after BCS. Acute skin toxicity was assessed according to the Radiation Therapy Oncology Group (RTOG) criteria. Predictive factors for acute skin toxicity were identified using multivariate analysis and visualized using a forest spot. Results Grade 0 reactions occurred in 75.34% vs 70.89%, grade 1 in 16.44% vs 15.19%, grade 2 in 8.22% vs 12.66%, and grade 3 in 0% vs 1.27% of patients receiving hypofractionated and conventional WBI, respectively. There was no statistically significant difference in acute skin reaction in patients treated with hypofractionated radiation compared with conventional radiation (P = 0.62). Multivariate analysis revealed that metastatic lymph nodes (P = 0.021), whole-breast planning target volume (PTV-WB) (P < 0.001), and tumor bed planning target volume (PTV-TB) (P = 0.002) were significantly correlated with higher rates of acute skin toxicity. Conclusion Hypofractionated WBI demonstrated similar acute skin adverse reactions compared to conventional WBI. These findings indicate that hypofractionated radiotherapy offers comparable tolerance, equivalent curative effect, convenience, and economic benefits, supporting its clinical promotion.
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Affiliation(s)
- Zhiyuan Wu
- Department of Radio-Oncology, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, People’s Republic of China
| | - Lili Hou
- Department of Breast Surgery, Suzhou Wuzhong People’s Hospital, Suzhou, People’s Republic of China
| | - Cheng Li
- Department of Radio-Oncology, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, People’s Republic of China
| | - Xiaohua Li
- Department of Breast Surgery, Suzhou Wuzhong People’s Hospital, Suzhou, People’s Republic of China
| | - Ying Li
- Department of Radio-Oncology, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, People’s Republic of China
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18
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Marazzi F, Masiello V, Orlandi A, Moschella F, Chiesa S, Di Leone A, Garufi G, Mazzarella C, Sanchez AM, Casa C, Bucaro A, De Lauretis F, Borghesan N, Tagliaferri L, Franceschini G, Bria E, Masetti R, Fabi A, Aristei C, Tortora G, Valentini V, Gambacorta MA. Outcomes of Radiotherapy in Oligoprogressive Breast Cancer. J Pers Med 2024; 14:805. [PMID: 39201997 PMCID: PMC11355129 DOI: 10.3390/jpm14080805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 09/03/2024] Open
Abstract
INTRODUCTION Radiotherapy (RT) shows potential for improving local control in cases of oligoprogressive metastatic breast cancer (mBC). This retrospective analysis aims to evaluate the advantages of RT in such a clinical scenario. METHODS We conducted a retrospective analysis including patients with mBC who received radiation therapy (RT) for up to three sites of oligoprogression while continuing systemic therapy. The study took place between January 2014 and December 2021. Our endpoints were progression-free survival after radiotherapy (PFS-AR), the rate of discontinuation of systemic therapy (RDT) at three months post-RT, and overall survival (OS). We used Cox regression analysis to perform multivariate analysis for PFS-AR. RESULTS Fifty-nine patients met the inclusion criteria. The PFS-AR was 13 months (95% CI 8.5-18.8 months). At three months, the RDT was 3% (two patients). A significant difference in median PFS-AR was observed between patients in the first + second-line group and those in the subsequent line group (p = 0.03). In the multivariate analysis conducted for PFS-AR, the biologically effective dose (BED) with α/β = 4 > 100 Gy emerged as the sole significant variable (p = 0.0017). The median overall survival (OS) was 24.4 months (95% CI 17-24.4 months). CONCLUSIONS This study is the first report on the outcomes of radiotherapy in a cohort of over 50 patients with oligoprogressive metastatic breast cancer (mBC). Our findings emphasize the significant relationship between PFS-AR, the number of ongoing lines of systemic therapy, and the BED of radiotherapy.
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Affiliation(s)
- Fabio Marazzi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Valeria Masiello
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Armando Orlandi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, 00168 Rome, Italy; (A.O.); (G.G.); (E.B.); (G.T.)
| | - Francesca Moschella
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Silvia Chiesa
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Alba Di Leone
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Giovanna Garufi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, 00168 Rome, Italy; (A.O.); (G.G.); (E.B.); (G.T.)
| | - Ciro Mazzarella
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Alejandro M. Sanchez
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Calogero Casa
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Angela Bucaro
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Flavia De Lauretis
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Niccolo Borghesan
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
| | - Luca Tagliaferri
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
| | - Gianluca Franceschini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Emilio Bria
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, 00168 Rome, Italy; (A.O.); (G.G.); (E.B.); (G.T.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Riccardo Masetti
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Chirurgia Senologica, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, 00168 Rome, Italy; (F.M.); (A.D.L.); (A.B.); (F.D.L.); (N.B.); (G.F.); (R.M.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alessandra Fabi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOSD di Medicina Personalizzata in Senologia, Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Direzione Scientifica, 00168 Rome, Italy;
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, 06156 Perugia, Italy;
| | - Giampaolo Tortora
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, 00168 Rome, Italy; (A.O.); (G.G.); (E.B.); (G.T.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria A. Gambacorta
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, 00168 Rome, Italy; (F.M.); (V.M.); (S.C.); (C.M.); (C.C.); (L.T.); (V.V.); (M.A.G.)
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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19
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Park SH, Yang YJ, Sung S, Choi Y, Yang EJ. Postoperative complications of hypofractionated and conventional fractionated radiation therapy in patients with implant-based breast reconstruction: A systematic review and meta-analysis. Breast 2024; 77:103782. [PMID: 39111201 PMCID: PMC11362802 DOI: 10.1016/j.breast.2024.103782] [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: 05/29/2024] [Revised: 07/12/2024] [Accepted: 07/23/2024] [Indexed: 09/02/2024] Open
Abstract
INTRODUCTION Post-mastectomy radiation therapy is an important component of adjuvant therapy for high-risk patients. However, radiation to reconstructed breasts can cause various complications. Recently, hypofractionated (HF) protocols have been adopted in several countries. Here, we aimed to assess the impact of HF protocols on implant-reconstructed breasts through a meta-analysis and systematic review of the currently available literature. METHODS Records published until August 2023 were systematically searched in PubMed, Cochrane Library, and EMBASE databases. Keywords included hypofractionation radiotherapy, mastectomy, and breast reconstruction. Studies that utilized HF and conventional fractionation (CF) after prosthetic reconstruction were selected. Due to the rarity of events in outcomes, Mantel-Haenszel's odds ratios were calculated using a fixed-effect model to compare the complication rates between HF and CF groups. For analysis with high heterogeneity, a random effect model was used. RESULTS Seven articles with 924 implant reconstructions, in which 506 (54.8 %) underwent HF were included. HF patients received 43.8 Gy on average, while CF patients received 51.2 Gy. Mean follow-up ranged from 10.6 to 35 months. Seven studies were included in the meta-analysis. HF groups had a significantly lower risk of capsular contracture (OR 0.25, 95 % CI 0.11-0.55), major revision surgery (OR 0.19, 95 % CI 0.05-0.80), and wound dehiscence (OR 0.24, 95 % CI 0.07-0.78) compared to CF groups. The risks of other complications were not statistically significant. CONCLUSION This study indicates that HF protocols are associated with fewer complications than CF protocols in implant-reconstructed patients. These findings suggest that the application of HF PMRT in implant-reconstructed patients with breast cancer is plausible.
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Affiliation(s)
- Seong-Hyuk Park
- Department of Plastic & Reconstructive Surgery, Institute of Innovative Digital Healthcare, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Jung Yang
- Department of Convergence Science, College of Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon, Republic of Korea
| | - Sihyun Sung
- Department of Research and Development, Seoul Medical Informatics Intelligence Lab Inc, Seoul, Republic of Korea
| | - Yelim Choi
- Department of Research and Development, Seoul Medical Informatics Intelligence Lab Inc, Seoul, Republic of Korea
| | - Eun-Jung Yang
- Department of Plastic & Reconstructive Surgery, Institute of Innovative Digital Healthcare, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Powell A, Batumalai V, Wong K, Kaadan N, Shafiq J, Delaney GP, Vinod SK. Cost-Outcome of Radiotherapy for Local Control and Overall Survival Benefits in Breast Cancer. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00291-7. [PMID: 39117508 DOI: 10.1016/j.clon.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 06/30/2024] [Accepted: 07/18/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE Radiotherapy (RT) is an integral component in the treatment of breast cancer. The aims of this study were to estimate the cost per 5-year Local Control (LC) and Overall Survival (OS) benefits of the first course of RT, based on breast cancer stage, and the potential cost savings with adoption of the FAST-Forward protocol. METHODS AND MATERIALS All RT activities for breast cancer RT July 2017-June 2020 and their associated costs were consolidated together. The average cost of treatment course was calculated (average cost per fraction X average no. of fractions). Cost per outcome was estimated based on published gains in 5-year LC and OS with optimal use of radiotherapy. RESULTS 481 patients with breast cancer were analysed. The average cost per fraction was $285 AUD (£148 GBP) for all stages. The average costs for 5-year LC and OS gain were $31,483 AUD (£16 392 GBP) and $235,435 AUD (£122 566 GBP) respectively for all stages. The estimated costs for 5-year LC outcomes were $29,675 AUD (£15 450 GBP), $34,675 AUD (£18 053 GBP) and $32,478 AUD (£16 910 GBP) for Stage I-III respectively. The estimated costs for 5-year OS were $455,909 AUD (£237 378 GBP), $532,727 AUD (£ 277 375 GBP) and $60,717 AUD (£31 614 GBP) for Stage I-III respectively. 266 patients had characteristics that made them eligible for the FAST-Forward protocol. A cost saving of $2592-3864 AUD (£1350-2012 GBP) per patient was estimated had these patients been treated with the protocol. CONCLUSIONS The cost of RT for LC outcome is similar across stages. The greatest value for OS outcome was seen in patients with Stage III breast cancer, due to the greater survival benefit with RT in these patients compared with Stage I-II breast cancer. Significant cost savings can be made by implementing the FAST-Forward protocol.
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Affiliation(s)
- A Powell
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia
| | - V Batumalai
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; GenesisCare, Sydney, Australia
| | - K Wong
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - N Kaadan
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - J Shafiq
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - G P Delaney
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - S K Vinod
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW.
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21
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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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Calvo Tudela A, García Anaya MJ, Segado Guillot S, Martin Romero N, Lorca Ocón MJ, Medina Carmona JA, Gómez‐Millán J, García Ríos I. Ultrahypofractionation in postoperative radiotherapy for breast cancer: A single-institution retrospective cohort series. Cancer Med 2024; 13:e7367. [PMID: 38970300 PMCID: PMC11226724 DOI: 10.1002/cam4.7367] [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: 10/04/2023] [Revised: 05/08/2024] [Accepted: 05/27/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The 'FAST-forward', study published in April 2020, demonstrated the effectiveness of an extremely hypofractionated radiotherapy schedule, delivering the total radiation dose in five sessions over the course of 1 week. We share our department's experience regarding patients treated with this regimen in real-world clinical settings, detailing outcomes related to short-term toxicity and efficacy. METHODS A descriptive observational study was conducted on 160 patients diagnosed with breast cancer. Between July 2020 and December 2021, patients underwent conservative surgery followed by a regimen of 26 Gy administered in five daily fractions. RESULTS The median age was 64 years (range: 43-83), with 82 patients (51.3%) treated for left-sided breast cancer, 77 patients (48.1%) for right-sided breast cancer, and 1 instance (0.6%) of bilateral breast cancer. Of these, 66 patients had pT1c (41.3%), 70.6% were infiltrative ductal carcinomas, and 11.3% were ductal carcinoma in situ. Most tumours exhibited intermediate grade (41.9%), were hormone receptor positive (81.3%), had low Ki-67 (Ki-67 < 20%; 51.9%) and were Her 2 negative (85%). The majority of surgical margins were negative (99.4%). Among the patients, 72.5% received hormonotherapy, and 23.8% received chemotherapy. Additionally, 26 patients (16.3%) received an additional tumour boost following whole breast irradiation (WHBI) of 10 Gy administered in five sessions of 2 Gy over a week. The median planning target volume (PTV) was 899 cm3 (range: 110-2509 cm3). Early toxicity was primarily grade I radiodermatitis, affecting 117 patients (73.1%). During a median follow-up of 15 months (range: 3.9-28.77), only one patient experienced a local relapse, which required mastectomy. CONCLUSIONS The implementation of this highly hypofractionated regimen in early-stage breast cancer appears feasible and demonstrates minimal early toxicity. However, a more extended follow-up duration would be required to evaluate long-term toxicity and efficacy accurately.
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Affiliation(s)
- Angel Calvo Tudela
- Department of Radiation OncologyVirgen de la Victoria University HospitalMalagaSpain
| | | | | | - Nuria Martin Romero
- Department of Radiation OncologyVirgen de la Victoria University HospitalMalagaSpain
| | | | | | - Jaime Gómez‐Millán
- Department of Radiation OncologyVirgen de la Victoria University HospitalMalagaSpain
- Malaga Biomedical Research InstituteMalagaSpain
| | - Isabel García Ríos
- Department of Radiation OncologyVirgen de la Victoria University HospitalMalagaSpain
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Eijkelboom AH, Stam MR, van den Bongard DH, Sattler MG, Bantema-Joppe EJ, Siesling S, van Maaren MC. Implementation of ultra-hypofractionated radiotherapy schedules for breast cancer during the COVID-19 pandemic in the Netherlands. Clin Transl Radiat Oncol 2024; 47:100807. [PMID: 38979479 PMCID: PMC11228630 DOI: 10.1016/j.ctro.2024.100807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 07/10/2024] Open
Abstract
Background and purpose The COVID-19 pandemic resulted in an accelerated recommendation to use five-fraction radiotherapy schedules, according to the FAST- and FAST-Forward trial. In this study, trends in the use of different radiotherapy schedules in the Netherlands were studied, as well as the likelihood of receiving five fractions. Materials and methods Data from the NABON Breast Cancer Audit-Radiotherapy and Netherlands Cancer Registry was used. Women receiving radiotherapy for their primary invasive breast cancer or DCIS between 01-01-2020 and 31-12-2021 were included. Logistic regression was used to investigate the association between patient-, tumour-, treatment-, and radiotherapy institution-related characteristics and the likelihood of receiving five fractions in tumours meeting the FAST and FAST-Forward criteria. Results Detailed information about radiotherapy treatment was available for 9,392 tumours. Shortly after the start of the COVID-19 pandemic, i.e. April 2020, 19% of the tumours being treated with radiotherapy received five fractions of 5.2 or 5.7 Gray (Gy). While only 3% of the tumours received five fractions in March 2020. The usage of five fractions increased to 26% in December 2021. Partial breast irradiation, compared to whole breast irradiation, was significantly associated with the administration of five fractions, as well as radiotherapy delivered in an academic radiotherapy institution compared to an independent institution. Conclusion The start of the COVID-19 pandemic was associated with the early use of ultra-hypofractionated radiotherapy schedules. After publication of the trials, and mainly after the recommendation by the national radiotherapy society, the implementation further increased. These schedules were not yet used in all patients meeting the eligibility criteria for the FAST- or FAST-Forward trial.
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Affiliation(s)
- Anouk H. Eijkelboom
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Boven Clarenburg 2, 3511 CV, Utrecht, the Netherlands
| | - Marcel R. Stam
- Radiotherapiegroep, Wagnerlaan 47, 6815 AD Arnhem, the Netherlands
| | | | - Margriet G.A. Sattler
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Enja J. Bantema-Joppe
- Department of Radiation Oncology, Radiotherapy Institute Friesland, Borniastraat 36, 8934 AD Leeuwarden, the Netherlands
| | - Sabine Siesling
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Boven Clarenburg 2, 3511 CV, Utrecht, the Netherlands
| | - Marissa C. van Maaren
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Boven Clarenburg 2, 3511 CV, Utrecht, the Netherlands
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Ryu H, Shin KH, Chang JH, Jang BS. A nationwide study of breast reconstruction after mastectomy in patients with breast cancer receiving postmastectomy radiotherapy: comparison of complications according to radiotherapy fractionation and reconstruction procedures. Br J Cancer 2024; 131:290-298. [PMID: 38840031 PMCID: PMC11263609 DOI: 10.1038/s41416-024-02741-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND We examined the patterns of breast reconstruction postmastectomy in breast cancer patients undergoing postmastectomy radiotherapy (PMRT) and compared complications based on radiotherapy fractionation and reconstruction procedures. METHODS Using National Health Insurance Service (NHIS) data (2015-2020), we analysed 4669 breast cancer patients with PMRT and reconstruction. Using propensity matching, cohorts for hypofractionated fractionation (HF) and conventional fractionation (CF) were created, adjusting for relevant factors and identifying grade ≥3 complications. RESULT Of 4,669 patients, 30.6% underwent HF and 69.4% CF. The use of HF has increased from 19.4% in 2015 to 41.0% in 2020. Immediate autologous (32.9%) and delayed two-stage implant reconstruction (33.9%) were common. Complication rates for immediate (N = 1286) and delayed two-stage (N = 784) reconstruction were similar between HF and CF groups (5.1% vs. 5.4%, P = 0.803, and 10.5% vs. 10.7%, P = 0.856, respectively) with median follow-ups of 2.5 and 2.6 years. HF showed no increased risk of complications across reconstruction methods. CONCLUSION A nationwide cohort study revealed no significant difference in complication rates between the HF and CF groups, indicating HF for reconstructed breasts is comparable to CF. However, consultation regarding the fractionation for reconstructed breast cancer patients may still be necessary.
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Affiliation(s)
- Hyejo Ryu
- Department of Radiation Oncology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Bum-Sup Jang
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Korea.
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.
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Lichter KE, Charbonneau K, Lewy JR, Bloom JR, Shenker R, Sabbagh A, Chino J, Rodrigues A, Hearn J, Grover S, Sheu RD, Witztum A, Qureshi MM, Yom SS, Anand C, Thiel CL, Mohamad O. Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation. Lancet Oncol 2024; 25:790-801. [PMID: 38821084 DOI: 10.1016/s1470-2045(24)00148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND The health-care industry is a substantial contributor to global greenhouse gas emissions, yet the specific environmental impact of radiotherapy, a cornerstone of cancer treatment, remains under-explored. We aimed to quantify the emissions associated with the delivery of radiotherapy in the USA and propose a framework for reducing the environmental impact of oncology care. METHODS In this multi-institutional retrospective analysis and simulation study, we conducted a lifecycle assessment of external beam radiotherapy (EBRT) for ten anatomical disease sites, adhering to the International Organization for Standardization's standards ISO 14040 and ISO 14044. We analysed retrospective data from Jan 1, 2017, to Oct 1, 2023, encompassing patient and staff travel, medical supplies, and equipment and building energy use associated with the use of EBRT at four academic institutions in the USA. The primary objective was to measure the environmental impacts across ten categories: greenhouse gases (expressed as kg of carbon dioxide equivalents [CO2e]), ozone depletion, smog formation, acidification, eutrophication, carcinogenic and non-carcinogenic potential, respiratory effects, fossil fuel depletion, and ecotoxicity. Human health effects secondary to these environmental impacts were also estimated as disability-adjusted life years. We also assessed the potential benefits of hypofractionated regimens for breast and genitourinary (ie, prostate and bladder) cancers on US greenhouse gas emissions using an analytic model based on the 2014 US National Cancer Database for fractionation patterns and patient commute distances. FINDINGS We estimated that the mean greenhouse gas emissions associated with a standard 25-fraction EBRT course were 4310 kg CO2e (SD 2910), which corresponded to 0·0035 disability-adjusted life years per treatment course. Transit and building energy usage accounted for 25·73% (1110 kg CO2e) and 73·95% of (3190 kg CO2e) of total greenhouse gas emissions, respectively, whereas supplies contributed only 0·32% (14 kg CO2e). Across the other environmental impact categories, most of the environmental impact also stemmed from patient transit and energy use within facilities, with little environmental impact contributed by supplies used. Hypofractionated treatment simulations suggested a substantial reduction in greenhouse gas emissions-by up to 42% for breast and 77% for genitourinary cancer-and environmental impacts more broadly. INTERPRETATION This comprehensive lifecycle assessment of EBRT delineates the environmental and secondary health impacts of radiotherapy, and underscores the urgent need for sustainable practices in oncology. The findings serve as a reference for future decarbonisation efforts in cancer care and show the potential environmental benefits of modifying treatment protocols (when clinical equipoise exists). They also highlight strategic opportunities to mitigate the ecological footprint in an era of escalating climate change and increasing cancer prevalence. FUNDING Mount Zion Health Fund.
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Affiliation(s)
- Katie E Lichter
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA.
| | - Kiley Charbonneau
- Loyola University Chicago-Stritch School of Medicine Maywood, IL, USA
| | | | - Julie R Bloom
- Department of Radiation Oncology, Mount Sinai Hospital, New York, NY, USA
| | - Rachel Shenker
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Ali Sabbagh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Junzo Chino
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Anna Rodrigues
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC, USA
| | - Jason Hearn
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ren-Dih Sheu
- Department of Radiation Oncology, Mount Sinai Hospital, New York, NY, USA
| | - Alon Witztum
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Muhammad Mustafa Qureshi
- Department of Radiation Oncology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Chirjiv Anand
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Cassandra L Thiel
- Department of Population Health, New York University Grossman School of Medicine and New York University Langone Health, New York, NY, USA
| | - Osama Mohamad
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Washington I, Palm RF, White J, Rosenberg SA, Ataya D. The Role of MRI in Breast Cancer and Breast Conservation Therapy. Cancers (Basel) 2024; 16:2122. [PMID: 38893241 PMCID: PMC11171236 DOI: 10.3390/cancers16112122] [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: 04/22/2024] [Revised: 05/19/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Contrast-enhanced breast MRI has an established role in aiding in the detection, evaluation, and management of breast cancer. This article discusses MRI sequences, the clinical utility of MRI, and how MRI has been evaluated for use in breast radiotherapy treatment planning. We highlight the contribution of MRI in the decision-making regarding selecting appropriate candidates for breast conservation therapy and review the emerging role of MRI-guided breast radiotherapy.
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Affiliation(s)
- Iman Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Russell F. Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Julia White
- Department of Radiation Oncology, The University of Kansas Medical Center, 4001 Rainbow Blvd, Kansas City, KS 66160, USA;
| | - Stephen A. Rosenberg
- Department of Radiation Therapy, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Dana Ataya
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 10920 N. McKinley Drive, Tampa, FL 33612, USA;
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27
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Huang EY, Ho MW, Wang YM. Dosimetric Correlation of Acute Radiation Dermatitis in Patients With Breast Cancer Undergoing Hypofractionated Proton Beam Therapy Using Pencil Beam Scanning. J Breast Cancer 2024; 27:187-200. [PMID: 38769685 PMCID: PMC11221205 DOI: 10.4048/jbc.2024.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/24/2024] [Accepted: 03/31/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE Pencil-beam scanning (PBS) is a modern delivery technique used in proton beam therapy (PBT) to reduce normal tissue reactions. No dosimetric correlation between dermatitis and PBS has been reported for breast cancer. The current study aimed to investigate the factors associated with grade 2 or higher dermatitis in patients with breast cancer undergoing PBT using PBS. METHODS The medical data of 42 patients with breast cancer who underwent adjuvant radiotherapy between December 2019 and September 2023 were reviewed. All patients received hypofractionated radiotherapy (HFRT), either 26 Gy (relative biological effectiveness [RBE])/five fractions or 40.05 or 43.5 Gy (RBE)/15 fractions, for the whole breast/chest wall with or without nodal irradiation. The duration of acute radiation dermatitis was defined as within 90 days from the start of radiotherapy. The Kaplan-Meier method and Cox proportional hazards model were used for univariate and multivariate analyses of the actuarial rates of grade 2-3 dermatitis. RESULTS Twenty-two (52.4%) and 20 (47.6%) patients were diagnosed with grade 1 and 2 dermatitis, respectively. Multivariate analysis revealed a clinical target volume (CTV) ≥ of 320 cc (p = 0.035) and a skin dose of D10cc ≥ 38.3 Gy (RBE) (p = 0.009) as independent factors of grade 2 dermatitis. The 10-week cumulative grade 2 dermatitis rates were 88.2%, 39.4%, and 8.3% (p < 0.001) for patients with both high, either high, and neither high CTV and D10cc, respectively. CONCLUSION To the best of our knowledge, this is the first study on dosimetric correlations for dermatitis in patients with breast cancer who underwent hypofractionated PBT using PBS. In the era of HFRT, skin dose modulation using PBS may reduce the incidence of dermatitis.
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Affiliation(s)
- Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Meng Wei Ho
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.
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Oppong R, Yeboah D, Owusu-Ansah M, Salifu SP. Radiation Therapy for Breast Cancer in Africa. Adv Radiat Oncol 2024; 9:101488. [PMID: 38681886 PMCID: PMC11043849 DOI: 10.1016/j.adro.2024.101488] [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: 06/02/2023] [Accepted: 02/15/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Although radiation therapy is an effective treatment for breast cancer, it has a low rate of use in African countries. A systematic review was undertaken to investigate studies that used radiation therapy as a treatment modality for patients with breast cancer in Africa, focusing on survival outcomes, adverse effects, radiation therapy techniques, fractionation schedules, and effectiveness of radiation therapy. Methods and Materials We conducted a comprehensive literature search for studies that treated breast cancer with radiation therapy, using different electronic databases (PubMed, Scopus, and EBSCOhost) up to February 2023. The output was exported to a reference management system for analyses. Results The literature search primarily identified 3804 records from Scopus (2427), PubMed (982), and EBSCOhost (395). Based on the inclusion and exclusion criteria, 19 articles were finally included in this systematic review. Most of the studies published were conducted in North Africa (63%), followed by West Africa (21%) and Southeast Africa (16%). Most centers employed external beam radiation therapy to deliver radiation therapy to patients with breast cancer with the standard fractionation size of 50 Gy in 25 fractions. The long-term outcomes with regards to adverse effect suggests that radiation therapy was fairly tolerated among patients with breast cancer. Conclusions The reports provide substantial evidence that there are limited number of published studies on the use of radiation therapy for breast cancer treatment in Africa, as well as lower overall survival rate compared with developed countries. To improve breast cancer survivorship, it is necessary for government and other health care planners to provide more radiation therapy resources and implement training programs for personnels.
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Affiliation(s)
- Rita Oppong
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - David Yeboah
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | | | - Samson Pandam Salifu
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
- Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
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Sun Y, Saulsberry L, Liao C, Hedeker D, Huo D. Geographic and Physician-Level Variation in the Use of Hypofractionated Radiation Therapy for Breast Cancer in the U.S.: A Cross-Classified Multilevel Analysis. Adv Radiat Oncol 2024; 9:101487. [PMID: 38725638 PMCID: PMC11078635 DOI: 10.1016/j.adro.2024.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose We aimed to assess geographic and physician-level variation for hypofractionated whole-breast irradiation (HF-WBI) use for early-stage breast cancer patients in the United States. We further evaluated the association between HF-WBI use and demographic factors after accounting for these variations. Methods and Materials We performed a retrospective study of early-stage breast cancer patients using private employer-sponsored insurance claims from 2008 to 2017. Patients were clustered according to geographic level and by radiation oncologist. Bayesian cross-classified multilevel logistic models were used to examine the geographic heterogeneity and variation of radiation oncologists simultaneously. Intracluster correlation coefficient (ICC) and median odds ratios (MOR) were calculated to quantify the variation at different levels. We also used the cross-classified model to identify patient demographic factors associated with receiving HF-WBI. Results The study included 79,747 women (74.0%) who received conventionally fractionated whole-breast irradiation (CF-WBI) and 27,999 women (26.0%) who underwent HF-WBI. HF-WBI adoption increased significantly across time (2008-2017). The variation in HF-WBI utilization was attributed mostly to physician-level variability (MOR = 2.59). The variability of HF-WBI utilization across core-based statistical areas (CBSAs) (MOR = 1.55) was found to be the strongest among all geographic classifications. After accounting for variability in both CBSAs and radiation oncologists, age, receiving chemotherapy, and several community-level factors, including distance from home to facility, community education level, and racial composition, were found to be associated with HF-WBI utilization. Conclusion This study demonstrated geographic and physician-level heterogeneity in the use of HF-WBI among early-stage breast cancer patients. HF-WBI utilization was also found to be associated with patient and community-level characteristics. Given observed physician-level variability, intervention through continuing medical education could help doctors to better understand the advantages of HF-WBI and promote the adoption of HF-WBI in the U.S. Influence of physician-level characteristics on HF-WBI utilization merits further study.
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Affiliation(s)
- Yijia Sun
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Chuanhong Liao
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Donald Hedeker
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
| | - Dezheng Huo
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
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Flores-Balcázar CH, Urías-Arce DM. Evaluation of Tumor Control and Normal Tissue Complication Probabilities in Patients Receiving Comprehensive Nodal Irradiation for Left-Sided Breast Cancer. Curr Oncol 2024; 31:3189-3198. [PMID: 38920725 PMCID: PMC11202494 DOI: 10.3390/curroncol31060241] [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: 04/02/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Women with left-sided breast cancer receiving adjuvant radiotherapy have increased incidence of cardiac mortality due to ischemic heart disease; to date, no threshold dose for late cardiac/pulmonary morbidity or mortality has been established. We investigated the likelihood of cardiac death and radiation pneumonitis in women with left-sided breast cancer who received comprehensive lymph node irradiation. The differences in dosimetric parameters between free-breathing (FB) and deep inspiration breath hold (DIBH) techniques were also addressed. Based on NTCP calculations, the probability of cardiac death was significantly reduced with the DIBH compared to the FB technique (p < 0.001). The risk of radiation pneumonitis was not clinically significant. There was no difference in coverage between FB and DIBH plans. Doses to healthy structures were significantly lower in DIBH plan than in FB plan for V20, V30, and ipsilateral total lung volume. Inspiratory gating reduces the dose absorbed by the heart without compromising the target range, thus reducing the likelihood of cardiac death.
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Affiliation(s)
- Christian H. Flores-Balcázar
- Radiotherapy and Medical Physics Service, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Radiotherapy Service, Instituto Nacional de Cancerología, Mexico City 14080, Mexico;
| | - Dulce M. Urías-Arce
- Radiotherapy Service, Instituto Nacional de Cancerología, Mexico City 14080, Mexico;
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31
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Jin K, Luo J, Yu X, Guo X. Hypofractionated radiotherapy with simultaneous tumor bed boost (Hi-RISE) in breast cancer patients receiving upfront breast-conserving surgery: study protocol for a phase III randomized controlled trial. Radiat Oncol 2024; 19:62. [PMID: 38802888 PMCID: PMC11131299 DOI: 10.1186/s13014-024-02449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The effectiveness and safety of moderately hypofractionated radiotherapy (HFRT) in patients undergoing breast-conserving surgery (BCS) has been demonstrated in several pivotal randomized trials. However, the feasibility of applying simultaneous integrated boost (SIB) to the tumor bed and regional node irradiation (RNI) using modern radiotherapy techniques with HFRT needs further evaluation. METHODS This prospective, multi-center, randomized controlled, non-inferiority phase III trial aims to determine the non-inferiority of HFRT combined with SIB (HFRTsib) compared with conventional fractionated radiotherapy with sequential boost (CFRTseq) in terms of five-year locoregional control rate in breast cancer patients undergoing upfront BCS. A total of 2904 participants will be recruited and randomized in a 1:1 ratio into the HFRTsib and CFRTseq groups. All patients will receive whole breast irradiation, and those with positive axillary nodes will receive additional RNI, including internal mammary irradiation. The prescribed dose for the HFRTsib group will be 40 Gy in 15 fractions, combined with a SIB of 48 Gy in 15 fractions to the tumor bed. The CFRTseq group will receive 50 Gy in 25 fractions, with a sequential boost of 10 Gy in 5 fractions to the tumor bed. DISCUSSION This trial intends to assess the effectiveness and safety of SIB combined with HFRT in early breast cancer patients following BCS. The primary endpoint is locoregional control, and the results of this trial are expected to offer crucial evidence for utilizing HFRT in breast cancer patients after BCS. TRIAL REGISTRATION This trial was registered at ClincalTrials.gov (NCT04025164) on July 18, 2019.
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Affiliation(s)
- Kairui Jin
- Department of Radiation Oncology, Department of Oncology, Shanghai Medical College, Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, Shanghai, 200032, China
| | - Jurui Luo
- Department of Radiation Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xiaoli Yu
- Department of Radiation Oncology, Department of Oncology, Shanghai Medical College, Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, Shanghai, 200032, China.
| | - Xiaomao Guo
- Department of Radiation Oncology, Department of Oncology, Shanghai Medical College, Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, 270 DongAn Road, Shanghai, 200032, China.
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K E R, Krishnan M. Surface dose measurement and comparison between TLD and OSLD during modified re constructive mastectomy irradiation. Biomed Phys Eng Express 2024; 10:045025. [PMID: 38714180 DOI: 10.1088/2057-1976/ad47fd] [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: 12/13/2023] [Accepted: 05/07/2024] [Indexed: 05/09/2024]
Abstract
Radiotherapy (RT) is one of the major treatment modalities among surgery and chemotherapy for carcinoma breast. The surface dose study of modified reconstructive constructive Mastectomy (MRM) breast is important due to the heterogeneity in the body contour and the conventional treatment angle to save the lungs and heart from the radiation. These angular entries of radiation beam cause an unpredictable dose deposition on the body surface, which has to be monitored. Thermoluminescent dosimeter (TLD) or optically stimulated luminescent dosimeter (nano OSLD) are commonly preferable dosimeters for this purpose. The surface dose response of TLD and nano OSLD during MRM irradiation has been compared with the predicted dose from the treatment planning system (TPS). The study monitored 100 MRM patients by employing a total 500 dosimeters consisting of TLD (n = 250) and nano OSLD (n = 250), during irradiation from an Elekta Versa HD 6 MV Linear accelerator. The study observed a variance of 3.9% in the dose measurements for TLD and 3.2% for nano OSLD from the planned surface dose, with a median percentage dose of 44.02 for nano OSLD and 40.30 for TLD (p value 0.01). There was no discernible evidence of variation in dose measurements attributable to differences in field size or from patient to patient. Additionally, no variation was observed in dose measurements when comparing the placement of the dosimeter from central to off-centre positions. In comparison, a minor difference in dose measurements were noted between TLD and nano OSLD, The study's outcomes support the applicability of both TLD and nano OSLD as effective dosimeters during MRM breast irradiation for surface dose evaluation.
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Affiliation(s)
- Ratheesh K E
- Department of Medical Physics, Centre for Interdisciplinary Research, D. Y. Patil Education Society (Deemed to be University), Kolhapur, Maharashtra, India
| | - Mayakannan Krishnan
- Department of Medical Physics, Centre for Interdisciplinary Research, D. Y. Patil Education Society (Deemed to be University), Kolhapur, Maharashtra, India
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Szymanski K, Chun Fat S, Brazio PS. Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges. Ann Plast Surg 2024; 92:S315-S319. [PMID: 38689412 DOI: 10.1097/sap.0000000000003817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease. METHODS A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy. RESULTS Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms. CONCLUSIONS The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.
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Affiliation(s)
| | - Shelby Chun Fat
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Philip S Brazio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Díaz-Gavela AA, Cerro Peñalver ED, Sanchez-Garcia S, Pardo-Perez E, Thuissard-Vasallo IJ, Andreu-Vázquez C, Molina López MY, Pena Huertas M, Guerrero-Gómez LL, Sanz-Rosa D, Lorenzo FC. Hypofractionated whole breast IMRT with HDR brachytherapy boost in early-stage breast cancer: Long-term results from a single-center. Brachytherapy 2024; 23:342-354. [PMID: 38522961 DOI: 10.1016/j.brachy.2024.02.009] [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: 10/20/2023] [Revised: 02/18/2024] [Accepted: 02/24/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION/OBJECTIVES The addition of a boost to the lumpectomy bed after whole-breast (WB) radiotherapy plays a key role in the treatment of patients with breast cancer (BC). The clinical benefits of a boost with high-dose-rate brachytherapy (HDR-BT) after conventional fractionation is supported by a large body of evidence. However, few studies have described its outcomes after a hypofractionated scheme. MATERIALS AND METHODS We included all patients treated with adjuvant WB-IMRT in 15 sessions followed by a single-session HDR-BT boost with local anesthesia on an outpatient basis. RESULTS Between 2009 and 2017, 638 patients with early-stage BC were treated according to the aforementioned protocol after breast-conserving surgery. Median follow-up was 6 years (4-11). Despite the low incidence of side effects and their slightness, we did identify an impact of breast volume on the risk of acute radiodermatitis, fibrosis, pain and edema. However, we did not identify any relationship between the volume in cubic centimeters of the BT-implant with acute or long-term side effects. 2.2% patients had an actual local relapse, 2.4% a 2nd primary in the same breast and 2.39% were diagnosed with contralateral BC. Event-free survival at 11 years was 85.5% with an overall survival of 95.7%. CONCLUSION Adjuvant hypofractionated whole-breast IMRT followed by a single dose HDR-BT boost has a low incidence of acute and chronic toxicity and excellent oncological outcomes. However, it may be worthwhile to intensify self-care protocols and surveillance in women with large breasts who may be at increased risk of side effects.
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Affiliation(s)
- Ana Aurora Díaz-Gavela
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain.
| | - Elia Del Cerro Peñalver
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain
| | | | - Eduardo Pardo-Perez
- Radiophysics Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain
| | - Israel John Thuissard-Vasallo
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - Cristina Andreu-Vázquez
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - Marina Pena Huertas
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - David Sanz-Rosa
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - Felipe Counago Lorenzo
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain; Present address: Department of Radiation Oncology, San Francisco de Asís Hospital, Madrid, Spain; Department of Radiation Oncology, La Milagrosa Hospital, Madrid, Spain
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Stenger-Weisser A, Unterkirhere O, Glanzmann C, Streller T, Logaritsch P, Studer G. Early and Intermediate Treatment Outcome After Postoperative External Beam Accelerated Partial Breast Irradiation in Patients With Early-Stage Breast Cancer. Pract Radiat Oncol 2024; 14:216-224. [PMID: 37925101 DOI: 10.1016/j.prro.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE To prospectively evaluate early and intermediate outcome after accelerated partial breast irradiation (APBI) in patients early-with stage breast cancer. METHODS AND MATERIALS Inclusion criteria were defined according to the APBI American Society for Radiation Oncology's ASTRO Evidence-Based Consensus Statement. The prescribed dose was 26 to 28 Gy in 5 fractions on 5 consecutive days. Regular follow-up visits with objective and subjective evaluation of treatment tolerance were performed after 0 and 2 weeks, 6 months, and at annual intervals. RESULTS Between February 2017 and January 2020, 175 patients with breast conserving surgery met the inclusion criteria for APBI. Mean age was 65.7 years (range, 46-88). Thirteen percent of patients received a diagnosis with carcinoma in situ, 55%, 35%, and 37% with T1a/b/c, and 10% with T2 stages, respectively. The mean volume of planning target volume (PTV) was 119 cc (range, 45-465), the ratio of mean PTV: whole breast volume ratio was 21% (7%-53%). Mean follow-up was 42 months (median, 45, range, 0-67). Acute toxicity after 2 weeks was low with 69%, 26%, and 5% grade 0, 1, and 2. In addition, 1-, 2-, 3-, 4-, and 5-year follow-up data were available from 146, 134, 107, 73, and 25 patients. Patient-reported cosmetic outcomes were assessed excellent or good in 97.9%, 98.5%, 98.1%, 98.6%, and 100%. Regarding grade 2 toxicities, as by now 3%, 2%, 2%, 0%, and 0% G2 fibrosis, 1%, 1%, 0%, 0%, and 0% G2 atrophy, no G2 skin telangiectasia or breast edema occurred. So far, none of the patients have experienced G3 toxicity or higher. The remaining patients had grade 0 or 1 toxicity only. Five ipsilateral breast recurrences (1 marginally to PTV, 4 out-of-field) and 5 distant recurrences were recorded by March 2023. The 4-year in-breast recurrence rate was 2.5%. Eight patients died, with 2 of them from disease. For all patients, the 4-year overall, cancer specific and disease-free survival rates were 97.1%, 99.4%, and 95.3%, respectively. CONCLUSIONS We showed high early- and intermediate-term treatment tolerance and disease control of APBI using 26 to 28 Gy in five fractions in one week in carefully selected patients with early breast cancer. APBI is highly appreciated by patients and efficient, as an additional advantage for busy centers.
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Affiliation(s)
| | - Olga Unterkirhere
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland
| | | | - Tino Streller
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland
| | | | - Gabriela Studer
- Radiation Oncology, Cantonal Teaching Hospital Lucerne, Luzern, Switzerland; Faculty of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
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Ali D, Piffoux M. Methodological guide for assessing the carbon footprint of external beam radiotherapy: A single-center study with quantified mitigation strategies. Clin Transl Radiat Oncol 2024; 46:100768. [PMID: 38633470 PMCID: PMC11021844 DOI: 10.1016/j.ctro.2024.100768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/19/2024] [Accepted: 03/23/2024] [Indexed: 04/19/2024] Open
Abstract
Background and purposes Data on the carbon footprint of external beam radiotherapy (EBRT) are scarce. Reliable and exhaustive data, including a detailed carbon inventory, are needed to determine effective mitigation strategies. Materials and methods This study proposes a methodology for calculating the carbon footprint of EBRT and applies it to a single center. Mitigation strategies are derived from the carbon inventory, and their potential reductions are quantified whenever possible. Results The average emission per treatment and fraction delivered was 489 kg CO₂eq and 27 kg CO₂eq, respectively. Patient transportation (43 %) and the construction and maintenance of linear accelerators (LINACs) and scanners (17 %) represented the most significant components. Electricity, the only energy source used, accounted for only 2 % of emissions.Derived mitigation strategies include a data deletion policy (reducing emissions in 30 years by 12.5 %), geographical appropriateness (-12.2 %), transportation mode appropriateness (-9.3 %), hypofractionation (-5.9 %), decrease in manufacturers' carbon footprint (-5.2 %), and an increase in machine durability (-3.5 %). Conclusion Our findings indicate that a significant reduction in the carbon footprint of a radiotherapy unit can be achieved without compromising the quality of care.This study provides a methodology and a starting point for comparison and proposes and quantifies mitigation strategies, paving the way for others to follow.
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Affiliation(s)
- David Ali
- Centre de Radiothérapie et de Traitement des Tumeurs, Versailles, France
| | - Max Piffoux
- Département d’Oncologie Médicale, Hospices Civils de Lyon, CITOHL, Lyon, France
- Direction de la Recherche Clinique et de l’Innovation, Centre Léon Bérard, Lyon, France
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Yoshimura M, Yamauchi C, Sanuki N, Hamamoto Y, Hirata K, Kawamori J, Kawamura M, Ogita M, Yamamoto Y, Iwata H, Saji S. The Japanese breast cancer society clinical practice guidelines for radiation treatment of breast cancer, 2022 edition. Breast Cancer 2024; 31:347-357. [PMID: 38578563 PMCID: PMC11045565 DOI: 10.1007/s12282-024-01568-4] [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: 11/13/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
The Breast Cancer Clinical Practice Guidelines, organized by the Japanese Breast Cancer Society (JBCS), were published in 2022. We present the English version of the Radiation Therapy (RT) section of the guidelines. The JBCS formed a task force to update the 2018 version of the JBCS Clinical Practice Guidelines. The Background Questions (BQs) contain the standard treatments for breast cancer in clinical practice, whereas the Clinical Questions (CQs) address daily clinical questions that remain controversial. Future Research Questions (FRQs) explore the subjects that are considered important issues, despite there being insufficient data for inclusion as CQs. The task force selected the 12 BQs, 8 CQs, and 6 FRQs for the RT section. For each CQ, systematic literature reviews and meta-analyses were conducted according to the Minds Manual for Guideline Development 2020, version 3.0. The recommendations, strength of recommendation, and strength of evidence for each CQ were determined based on systematic reviews and meta-analyses, and finalized by voting at the recommendation decision meeting.
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Affiliation(s)
- Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara‑cho, Sakyo‑ku, Kyoto, 606‑8507, Japan.
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Moriyama, Japan
| | - Naoko Sanuki
- Department of Radiology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Yasushi Hamamoto
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Kimiko Hirata
- Department of Radiation Oncology, Kyoto City Hospital, Kyoto, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mami Ogita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Yamamoto
- Department of Breast and Endocrine Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
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Howard K, Norris S, Salisbury A, Pearce A, Hay L, Stapleton B, Lean C, Last A, Kwedza R, White K, Rushton S. Women's Preferences for Hypofractionated Radiation Therapy for Treatment of Early-Stage Breast Cancer: A Discrete Choice Experiment. Int J Radiat Oncol Biol Phys 2024; 119:172-184. [PMID: 38110105 DOI: 10.1016/j.ijrobp.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 10/19/2023] [Accepted: 11/11/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The primary treatment recommended for early-stage breast cancer is breast conserving surgery followed by external beam radiation therapy of the whole breast. Previously, radiation therapy for early-stage breast cancer was given using more fractions over longer durations. Guidelines support treatments with fewer fractions over a shorter time (hypofractionated radiation therapy). This study aimed to understand women's preferences for different features of treatments for early-stage breast cancer. METHODS AND MATERIALS A discrete choice experiment with 12 choice tasks was conducted, describing the treatments by extent of surgery, duration of radiation treatment, need to relocate for treatment, local side effects, changes in breast appearance, costs, and difficulty with daily activities during and after treatment. Participants were women with breast cancer and from the general population. Mixed logit analyses were conducted and trade-offs between attributes estimated. RESULTS Four hundred twenty respondents completed the discrete choice experiment. The relative importance of attributes varied by respondent characteristics; the most influential attribute for younger women was type of surgery (breast conserving surgery). Type of surgery did not influence older women's preferences. Shorter treatment duration, avoiding relocation, fewer local side effects, and less difficulty with daily activities all positively influenced treatment preference. Younger women were willing to accept 32 to 40 days of radiation treatment before a treatment that included mastectomy was potentially acceptable. CONCLUSIONS Attributes of treatment such as duration, need for relocation, side effects, and effects on normal daily activities during and after treatment significantly influenced women's preference for treatment, including surgery. Our findings have the potential for real impact for patients and services including supporting one-on-one clinical discussions, supporting program and patient resource development, and informing service funding, organization, and delivery.
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Affiliation(s)
- Kirsten Howard
- Menzies Centre for Health Policy and Economics; School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
| | | | | | - Alison Pearce
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Liz Hay
- NSW Ministry of Health, St Leonards, New South Wales, Australia
| | | | - Cynthia Lean
- Cancer Institute NSW, St Leonards, New South Wales, Australia
| | - Andrew Last
- School of Clinical Medicine, Rural Clinical Campus, UNSW Medicine & Health, Port Macquarie, New South Wales, Australia
| | - Ru Kwedza
- Cancer Institute NSW, St Leonards, New South Wales, Australia
| | - Kahren White
- Cancer Institute NSW, St Leonards, New South Wales, Australia
| | - Shelley Rushton
- Cancer Institute NSW, St Leonards, New South Wales, Australia
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Kim E, Yoo JS, Kim YJ, Joo J, Oh ES, Chung Y, Chung SH, Kim TH. Toxicity Evaluation of Dose-Escalation in Hypofractionated Regional Nodal Irradiation for Breast Cancer: A Retrospective Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00513-3. [PMID: 38631540 DOI: 10.1016/j.ijrobp.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Regional nodal irradiation (RNI) to the axilla and supraclavicular area presents distinct toxicities, such as lymphedema and shoulder stiffness, compared with whole-breast irradiation. There is insufficient evidence on the safety of dose-escalation in hypofractionated RNI. We aimed to evaluate and compare toxicity rates in patients with breast cancer who received hypofractionated RNI with and without dose-escalation. METHODS AND MATERIALS We retrospectively analyzed 381 patients with breast cancer treated with hypofractionated RNI between March 2015 and February 2017. Patients received either the standard-dose to the regional nodal area (43.2 Gy/16 fx; 48.7 Gy3.5 equivalent dose [EQD2], 2 Gy equivalent dose with α/β= 3.5 Gy) or dose-escalation with a median dose of 54.8 Gy3.5 EQD2 (range, 51.7-60.9 Gy3.5 EQD2), depending on clinical and pathologic nodal stage. Toxicity rates of lymphedema and shoulder stiffness were assessed, and statistical analyses were conducted to identify associated factors. RESULTS The median follow-up time was 32.3 months (5.7-47.0 months). After radiation therapy, 71 (18.6%) patients developed lymphedema, and 48 (12.6%) developed shoulder stiffness. Patients who received dose-escalation exhibited significantly higher rates of lymphedema (32.1% vs 14.8%; odds ratio, 2.72, P = .0004) and shoulder stiffness (23.8% vs 9.4%; odds ratio, 2.01, P = .0205) compared with the standard-dose group. Moreover, dose-escalation showed a tendency to increase the severity of lymphedema and shoulder stiffness. CONCLUSIONS Patients who received dose-escalation in hypofractionated RNI face a higher risk of developing lymphedema and shoulder stiffness compared with those who received standard-dose hypofractionated RNI. Therefore, it is crucial to implement close and frequent monitoring for early detection, along with timely rehabilitation interventions for these patients.
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Affiliation(s)
- Euidam Kim
- Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.
| | - Yeon-Joo Kim
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.
| | - Jungnam Joo
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Eun Sang Oh
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Yoonsun Chung
- Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
| | - Seung Hyun Chung
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Tae Hyun Kim
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
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Roohani S, Wiltink LM, Kaul D, Spałek MJ, Haas RL. Update on Dosing and Fractionation for Neoadjuvant Radiotherapy for Localized Soft Tissue Sarcoma. Curr Treat Options Oncol 2024; 25:543-555. [PMID: 38478330 PMCID: PMC10997691 DOI: 10.1007/s11864-024-01188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 04/06/2024]
Abstract
OPINION STATEMENT Neoadjuvant radiotherapy (RT) over 5-6 weeks with daily doses of 1.8-2.0 Gy to a total dose of 50-50.4 Gy is standard of care for localized high-grade soft tissue sarcomas (STS) of the extremities and trunk wall. One exception is myxoid liposarcomas where the phase II DOREMY trial applying a preoperative dose of 36 Gy in 2 Gy fractions (3-4 weeks treatment) has achieved excellent local control rates of 100% after a median follow-up of 25 months.Hypofractionated preoperative RT has been investigated in a number of phase II single-arm studies suggesting that daily doses of 2.75-8 Gy over 1-3 weeks can achieve similar oncological outcomes to conventional neoadjuvant RT. Prospective data with direct head-to-head comparison to conventional neoadjuvant RT investigating oncological outcomes and toxicity profiles is eagerly awaited.For the entire group of retroperitoneal sarcomas, RT is not the standard of care. The randomized multi-center STRASS trial did not find a benefit in abdominal recurrence-free survival by the addition of preoperative RT. However, for the largest histological subgroup of well-differentiated and grades I and II dedifferentiated liposarcomas, the STRASS trial and the post-hoc propensity-matched STREXIT analysis have identified a possible benefit in survival by preoperative RT. These patients deserve to be informed about the pros and cons of preoperative RT while the longer follow-up data from the STRASS trial is awaited.
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Affiliation(s)
- Siyer Roohani
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- BIH Charité Junior Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- German Cancer Consortium (DKTK), Partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Lisette M Wiltink
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Cancer Consortium (DKTK), Partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mateusz Jacek Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rick L Haas
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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Lo Faro L, Fogliata A, Franceschini D, Spoto R, Dominici L, Bertolini A, Stefanini S, Vernier V, Ilieva MB, Scorsetti M. Adjuvant Hypofractionated Whole Breast Irradiation (WBI) vs. Accelerated Partial Breast Irradiation (APBI) in Postmenopausal Women with Early Stage Breast Cancer: 5Years Update of the HYPAB Trial. Clin Breast Cancer 2024; 24:253-260. [PMID: 38220538 DOI: 10.1016/j.clbc.2023.12.012] [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: 10/12/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/16/2024]
Abstract
Therapeutical strategies in breast cancer are continuously updating. Recent researches assessed the possibility of irradiating only the surgical bed in selected patients (Partial Breast Irradiation, PBI). In 2014 we designed a study to evaluate toxicity and cosmesis of APBI using Volumetric Modulated Arc Therapy-Rapid Arc compared with hypofractionated whole breast irradiation (WBI). We present here the 5-years updated data. HYPAB was a single-institution randomized trial that recruited 172 patients from 2015 to 2018. Patients underwent conserving surgery and were randomized to either adjuvant WBI (40.5Gy/15 fractions with simultaneous boost to 48 Gy to tumoral bed) or APBI (30Gy/5 fractions), both delivered with VMAT-RA technique. Clinical evaluation was performed during the first visit, once a week during radiotherapy and during follow up. Cosmesis was assessed using the Harvard Scale for Breast Cosmesis. At the time of the analysis 161 patients were eligible, 53% in the WBI and 47% in the APBI group, with a median follow-up of 67 months. Most common late skin toxicities were G1 fibrosis (32%) and oedema (28%) and were higher in the WBI group; no G3 toxicities were observed. Cosmesis was rated poor in only 6 cases. 147 patients had no evidence of disease at the last follow-up, and no patients died of the disease. Mature results confirm the safety and efficacy of APBI in selected early stage breast cancer patients. Late toxicity is improved in the APBI arm at the cost of a slight increase in local relapse. Further studies are ongoing to better elucidate the use of APBI as a de-escalation approach.
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Affiliation(s)
- L Lo Faro
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy.
| | - A Fogliata
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - D Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - R Spoto
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - L Dominici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - A Bertolini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - S Stefanini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - V Vernier
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - M B Ilieva
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - M Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
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Nichols EM, Bentzen SM, Milburn M, Kesmodel SB, Bellavance E, Becker SJ, Mutaf Y, Tkaczuk K, Rosenblatt P, Feigenberg SJ. A Prospective Trial of Single-Fraction Radiation to the Tumor Bed with a Novel Breast-Specific Stereotactic Radiation Therapy Device: The GammaPod. Adv Radiat Oncol 2024; 9:101398. [PMID: 38778822 PMCID: PMC11110030 DOI: 10.1016/j.adro.2023.101398] [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: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 05/25/2024] Open
Abstract
Purpose Radiation therapy for early-stage breast cancer is typically delivered in a hypofractionated regimen to the whole breast followed by a tumor bed boost. This results in a treatment course of approximately 4 weeks. In this study, the tumor bed boost was delivered in a single fraction as part of a safety and feasibility study for FDA clearance of the device. Methods and Materials Eligible women with early-stage breast cancer underwent lumpectomy followed by radiation therapy. Patients underwent breast immobilization using a system specific to the GammaPod followed by CT simulation, boost treatment planning, and boost treatment delivery all in a single treatment day. Patients then started whole-breast radiation therapy within 1 week of the boost treatment. Patients and treatments were assessed for safety and feasibility. Acute toxicities were recorded. Results A single-fraction boost of 8 Gy was delivered to the tumor bed before a course of whole-breast radiation. The GammaPod treatment was successfully delivered to 14 of 17 enrolled patients. Acute toxicities from all radiation therapy, inclusive of the boost and whole-breast radiation, were limited to grade 1 events. Conclusions The GammaPod device successfully delivered a single-fraction boost treatment to the tumor bed with no change in expected acute toxicities. The results of this study led to FDA clearance of the device through the Investigational Device Exemption process at the FDA. The GammaPod is in clinical use at 4e institutions nationally and internationally, with additional sites pending in 2023.
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Affiliation(s)
- Elizabeth M. Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Søren M. Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Steven J. Feigenberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Kang NK, Sung SY, Kim SH, Jeon YW, Suh YJ, Lee JH. Hypofractionated Partial Breast Irradiation With Intensity-Modulated Radiotherapy in Early Breast Cancer or Carcinoma In Situ: An Investigational Short-Term Analysis. J Breast Cancer 2024; 27:79-90. [PMID: 38529590 PMCID: PMC11065498 DOI: 10.4048/jbc.2023.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024] Open
Abstract
PURPOSE This study aimed to analyze the treatment outcomes and adverse effects of moderately hypofractionated partial breast irradiation (PBI) in patients with early breast cancer. METHODS In total, 473 patients with early breast cancer or carcinoma in situ were diagnosed with Tis or T1N0 disease and underwent PBI following breast-conserving surgery. All histologic tumor types, close surgical margins within 1 mm of the tumor, and multifocal tumors were included in this study. A radiation dose of 50 Gy in 20 fractions was delivered over 4 weeks using intensity-modulated radiotherapy technique. Dosimetric data, recurrence patterns, survival outcomes, and adverse events were retrospectively analyzed. RESULTS During a median follow-up of 28.9 months, seven patients (1.5%) experienced ipsilateral breast tumor recurrence (IBTR). Two patients had regional recurrence, four patients developed contralateral breast cancer, and no distant metastases were observed. The locoregional recurrence rate in the ipsilateral breast was 1.8%. Two deaths occurred during the follow-up period, but were not attributed to breast cancer. The 2-year disease-free survival and 2-year overall survival rates were was 94.0% and 99.8%, respectively. Acute adverse events occurred in 131 patients (27.1%), and were distributed among all grades, with only two patients (0.4%) experiencing grade 3 events. Late adverse events were noted in 16 patients (3.4%), and were distributed among all grades, including grade 3 events in four patients (0.8%). No grade 4 or 5 events were observed. CONCLUSION Hypofractionated PBI demonstrated favorable IBTR rates in patients with early breast cancer, with low incidence of acute and late toxicities in the short-term analysis.
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Affiliation(s)
- Nam Kyu Kang
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ye Won Jeon
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Jin Suh
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Schaverien MV, Singh P, Smith BD, Qiao W, Akay CL, Bloom ES, Chavez-MacGregor M, Chu CK, Clemens MW, Colen JS, Ehlers RA, Hwang RF, Joyner MM, Largo RD, Mericli AF, Mitchell MP, Shuck JW, Tamirisa N, Tripathy D, Villa MT, Woodward WA, Zacharia R, Kuerer HM, Hoffman KE. Premastectomy Radiotherapy and Immediate Breast Reconstruction: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e245217. [PMID: 38578640 PMCID: PMC10998161 DOI: 10.1001/jamanetworkopen.2024.5217] [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] [Received: 12/26/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Importance Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). Objective To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. Design, Setting, and Participants This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. Intervention This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. Main Outcome and Measures The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Results Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. Conclusions and Relevance This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). Trial Registration ClinicalTrials.gov Identifier: NCT02912312.
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Affiliation(s)
- Mark V. Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Puneet Singh
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Smith
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Catherine L. Akay
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth S. Bloom
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mariana Chavez-MacGregor
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Carrie K. Chu
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark W. Clemens
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Jessica S. Colen
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Richard A. Ehlers
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rosa F. Hwang
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa M. Joyner
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rene D. Largo
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexander F. Mericli
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa P. Mitchell
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - John W. Shuck
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Nina Tamirisa
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark T. Villa
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Wendy A. Woodward
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rensi Zacharia
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Henry M. Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Karen E. Hoffman
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Guadagnolo BA, Baldini EH. Are We Ready for Life in the Fast Lane? A Critical Review of Preoperative Hypofractionated Radiotherapy for Localized Soft Tissue Sarcoma. Semin Radiat Oncol 2024; 34:180-194. [PMID: 38508783 DOI: 10.1016/j.semradonc.2023.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
This critical review aims to summarize the relevant published data regarding hypofractionation regimens for preoperative radiation therapy (RT) prior to surgery for soft tissue sarcoma (STS) of the extremity or superficial trunk. We identified peer-reviewed publications using a PubMed search on the MeSH headings of "soft tissue sarcoma" AND "hypofractionated radiation therapy." To obtain complication data on similar anatomical radiotherapeutic scenarios we also searched "hypofractionated radiation therapy" AND "melanoma" as well as "hypofractionated radiation therapy" AND "breast cancer." We then used reference lists from relevant articles to obtain additional pertinent publications. We also incorporated relevant abstracts presented at international sarcoma meetings and relevant clinical trials as listed on the ClinicalTrials.gov website. Detailed data are presented and contextualized for ultra-hypofractionated and moderately hypofractionated regimens with respect to local control, wound complications, and amputation rates. Comparative data are also presented for late toxicities including: fibrosis, joint limitation, edema, skin integrity, and bone fracture or necrosis. These data are compared to a standard regimen of 50 Gy in 25 daily fractions delivered over 5 weeks. This analysis supports the continued use of a standard regimen for preoperative RT for STS of 25 × 2 Gy over 5 weeks without concurrent chemotherapy. Use of concurrent chemotherapy with preoperative RT for STS should be reserved for well-designed clinical trials. A randomized trial of ultra-hypofractionated and moderately hypofractionated pre op RT for STS is warranted, but it is critical for the primary endpoint (or co-primary endpoint) to be late toxicity to: bone, soft tissue, joint, and skin.
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Affiliation(s)
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana Farber/Brigham Women's Hospital, Boston, MA
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Grzywacz VP, Lehrberg AV, Quinn TJ, Zureick AH, Sarvepalli N, Oliver LN, Dekhne NS, Dilworth JT. Breast Conserving Therapy for Patients With Prior Cosmetic Implant-Based Breast Augmentation: Outcomes and Comparison Against a Matched Cohort. Clin Breast Cancer 2024; 24:227-236. [PMID: 38185608 DOI: 10.1016/j.clbc.2023.12.003] [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: 08/18/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Controversy exists regarding potential increased toxic effects in patients with cosmetic implant-based augmentation (CIBA) who receive radiation therapy. We evaluated acute and chronic toxic effects associated with radiation therapy in women with prior CIBA treated with whole-breast irradiation (WBI) as part of breast conserving therapy (BCT) and compared these results against a cohort of patients without prior breast augmentation who received similar therapy. METHODS A retrospective review was performed to identify patients with a prior history of CIBA who subsequently underwent BCT with WBI. The control group consisted of consecutively treated patients without prior CIBA who also underwent BCT with WBI. Analyses included a comparison of baseline and treatment-associated factors between the augmentation and control groups, evaluation of toxic effects between both groups, and multivariable analysis of factors associated with the receipt of additional surgery following radiation. RESULTS Thirty-six patients with prior CIBA and 135 consecutively treated patients without CIBA were identified. Patients with prior CIBA were treated from 2006 through 2019, and patients without CIBA were treated from 2016 through 2019, though treatment characteristics and median follow-up time were similar between the two groups. Patients with prior CIBA were significantly less likely to experience acute moist desquamation (0% vs. 18%; P = .005). There were otherwise no statistically significant differences in acute (≤ 6 months) or chronic (> 6 months) toxic effects between the two groups. Rates of excellent/good chronic cosmetic outcome were 89% for the CIBA group and 97% in the control group (P = .094). On multivariable analysis, patients without prior CIBA (OR = 0.04; CI = 0.01-0.13; P < .001) and patients treated with moderately hypofractionated irradiation (OR = 0.08; CI = 0.02-0.23; P < .001) were significantly less likely to undergo additional surgery following receipt of WBI. Two patients experienced implant loss following radiation therapy. CONCLUSIONS WBI as part of BCT in patients with prior implant-based breast augmentation appears safe and is associated with favorable cosmetic outcomes. There was an increased need for additional surgery in patients with prior CIBA, but rates of acute and chronic toxic effects appeared similar to those in nonaugmented patients.
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Affiliation(s)
- Vincent P Grzywacz
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Anna V Lehrberg
- Department of Surgery, Henry Ford Cancer Center, Detroit, MI
| | - Thomas J Quinn
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Andrew H Zureick
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Neha Sarvepalli
- Comprehensive Breast Care Center, William Beaumont University Hospital, Royal Oak, MI
| | - Lauren N Oliver
- Department of Plastic and Reconstructive Surgery, William Beaumont University Hospital, Royal Oak, MI
| | - Nayana S Dekhne
- Comprehensive Breast Care Center, William Beaumont University Hospital, Royal Oak, MI
| | - Joshua T Dilworth
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI.
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Laughlin BS, Corbin KS, Toesca DAS, Thorpe CS, Golafshar MA, Pockaj B, Cronin P, McGee LA, Halyard MY, Mutter RW, Keole SR, Park SS, Shumway DA, Vern-Gross TZ, Vallow L, Wong WW, DeWees TA, Vargas CE. Physician- and Patient-Reported Outcomes of the MC1635 Phase 3 Trial of Ultrahypofractionated Versus Moderately Hypofractionated Adjuvant Radiation Therapy After Breast-Conserving Surgery. Int J Radiat Oncol Biol Phys 2024; 118:1049-1059. [PMID: 37914139 DOI: 10.1016/j.ijrobp.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/21/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Our aim was to report physician- and patient-reported outcomes of patients with localized breast cancer treated with moderate versus ultrahypofractionated whole breast irradiation (WBI) after breast-conserving surgery (BCS). METHODS AND MATERIALS Between February 2018 and February 2020, patients with localized breast cancer (pT0-3 pN0-1 M0) were offered participation in a phase 3 randomized clinical trial assessing adjuvant moderate hypofractionation (MHF) to 40 Gy in 15 fractions versus ultrahypofractionation (UHF) to 25 Gy in 5 fractions after BCS, with an optional simultaneously integrated boost. Toxicities, cosmesis, and quality of life were assessed at baseline, end of treatment (EOT), and 3 months, 1 year, 2 years, and 3 years from irradiation using validated metric tools. RESULTS One hundred seven patients were randomized to MHF (n = 54) or UHF (n = 53) adjuvant WBI. The median follow-up was 42.8 months. Grade 2 radiation dermatitis was experienced by 4 patients (7.4%) in the MHF arm and 2 patients (3.7%) in the UHF arm at EOT (P = .726). No grade 3 or higher toxicities were observed. Deterioration of cosmesis by physician assessment was observed in 2 (6.7%) patients treated in the UHF arm and 1 (1.9%) patient treated in the MHF arm at EOT (P = .534), whereas at 3 months, only 1 (1.8%) patient treated in the MHF arm demonstrated deterioration of cosmesis (P = .315). At EOT, 91% and 94% of patients reported excellent/good cosmesis among those treated with MHF and UHF regimens, respectively (P = .550). At 3 months, more patients within the MHF arm reported excellent/good cosmesis compared with those in the UHF arm (100% vs 91%; P = .030). However, the difference in patient-reported cosmesis disappeared at the 1-, 2-, and 3-year time points. CONCLUSIONS UHF WBI showed similar treatment-related late toxicities and similar provider-scored cosmesis compared with MHF radiation in patients treated adjuvantly after BCS.
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Affiliation(s)
| | | | | | - Cameron S Thorpe
- Department of Radiation Oncology, Sanford Health, Fargo, North Dakota
| | - Michael A Golafshar
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Barbara Pockaj
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Patricia Cronin
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Laura Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Todd A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
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Talapatra K, Chitkara G, Murali-Nanavati S, Gupte A, Bardeskar NS, Behal S, Shaikh M, Atluri P. Practice of Tumor Bed Boost in Patients after Oncoplastic Breast-Conserving Surgery. Indian J Surg Oncol 2024; 15:63-70. [PMID: 38511033 PMCID: PMC10948658 DOI: 10.1007/s13193-023-01824-7] [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: 07/17/2023] [Accepted: 09/26/2023] [Indexed: 03/22/2024] Open
Abstract
The practice of boost to the tumor bed after treatment with oncoplastic breast-conserving surgery (BCS) remains variable. Using a survey, the present study evaluated the current practice of tumor bed boost administered in women after oncoplastic BCS. Actively practicing radiation oncologists across India were sent a questionnaire on the practice of adjuvant whole-breast radiotherapy and tumor bed boost after oncoplastic BCS via email and encouraged to participate. Of the 54 radiation oncologists who participated, most (98.1%) used a linear accelerator for radiotherapy. Hypofractionation was preferred by 59.26%, standard fractionation by 7.41%, and the remaining selected the fractionation strategy based on various patient factors. In addition, 83.33% participants reported that they always planned tumor boost, 51.85% preferred photons for the boost, and 75.93% administered sequential boost. The most common dose for the boost was 12.5 Gy in five fractions (40.74%). Most participants (77.78%) revealed that they used a combination of methods for identifying the tumor bed. With respect to clip placement, most surgeons (96%) at the participants' centers placed ≥ 4 clips at the tumor site, with both the base and margins being preferred by surgeons (81.48%) for placement. Finally, 12.96% participants revealed that the surgeons always involved them during surgical planning, whereas 7.4% participants reported that they always included the surgeons during radiotherapy planning, suggesting that radiation oncologists and oncoplastic surgeons do not involve each other during surgical and radiotherapy planning, possibly leading to suboptimal treatment. This may be attributed to the absence of guidelines regarding boost practices after oncoplastic BCS.
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Affiliation(s)
- Kaustav Talapatra
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Garvit Chitkara
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Sridevi Murali-Nanavati
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Ajinkya Gupte
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Nikhil S. Bardeskar
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Shruti Behal
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Muzammil Shaikh
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
| | - Pooja Atluri
- Nanavati Max Institute of Cancer Care, Nanavati Max Super Speciality Hospital, Mumbai, 400056 India
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Patel TA, Jain B, Cho HL, Corti C, Vapiwala N, Chino F, Leeman JE, Dee EC. Second Malignancy Probabilities in Patients With Breast Cancer Treated With Conventional Versus Hypofractionated External Beam Radiation Therapy in the Adjuvant Setting. Clin Oncol (R Coll Radiol) 2024; 36:183-192. [PMID: 38184401 PMCID: PMC11380110 DOI: 10.1016/j.clon.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/12/2023] [Accepted: 12/05/2023] [Indexed: 01/08/2024]
Abstract
AIMS For women with breast cancer, seminal studies have shown that adjuvant hypofractionated external beam radiation therapy (hEBRT) maintains similar outcomes and may reduce overall costs compared with conventionally fractionated external beam radiation therapy (cEBRT). However, it is unclear whether hEBRT may be associated with differential risk of development of radiation-induced second malignancies compared with cEBRT. Because the occurrence of second malignancies is small, large databases may improve our understanding of the relative risk of second malignancies between hEBRT and cEBRT. MATERIALS AND METHODS Using the National Cancer Database, we carried out a retrospective cohort analysis of women diagnosed with non-metastatic, stage 0-III breast cancer from 2004 to 2017. All patients had a lumpectomy or mastectomy and a follow-up time of at least 60 months after diagnosis. The probability of second malignancies in women receiving adjuvant cEBRT or hEBRT was compared using multivariable logistic regression adjusting for sociodemographic, geographical, clinical and treatment factors, allowing for relative (but not absolute) comparison of second malignancy risk. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up time were also conducted. RESULTS Of the 125 228 women in our study, 115 576 (92.3%) received cEBRT and 9652 (7.71%) received hEBRT. The median age of the cohort was 60 (interquartile range 51-68) years at diagnosis and the median follow-up time was 99.61 (interquartile range 77.5-128.49) months. Upon adjusting for sociodemographic and clinical factors, patients who received hEBRT had no difference in relative risk than patients who received cEBRT (odds ratio 0.937, 95% confidence interval 0.869-1.010, P = 0.091). In analyses stratified by year of diagnosis, and stratified by length of follow-up, there was no difference in second malignancy probability between patients who completed hEBRT and patients who completed cEBRT. CONCLUSIONS In this analysis of over 120 000 women with non-metastatic breast cancer, hEBRT was not associated with different odds of developing second malignancies compared with cEBRT. Our findings may inform patient counselling in the choice of radiation regimens for breast cancer and further support the safety of hypofractionated regimens for breast cancer.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - B Jain
- Stanford School of Medicine, Stanford, CA, USA
| | - H L Cho
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Corti
- Breast Oncology Program, Dana-Farber Cancer Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology (DIPO), University of Milan, Milan, Italy
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E C Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Lan HR, Chen M, Yao SY, Chen JX, Jin KT. Novel immunotherapies for breast cancer: Focus on 2023 findings. Int Immunopharmacol 2024; 128:111549. [PMID: 38266449 DOI: 10.1016/j.intimp.2024.111549] [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: 11/07/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
Immunotherapy has emerged as a revolutionary approach in cancer therapy, and recent advancements hold significant promise for breast cancer (BCa) management. Employing the patient's immune system to combat BCa has become a focal point in immunotherapeutic investigations. Strategies such as immune checkpoint inhibitors (ICIs), adoptive cell transfer (ACT), and targeting the tumor microenvironment (TME) have disclosed encouraging clinical outcomes. ICIs, particularly programmed cell death protein 1 (PD-1)/PD-L1 inhibitors, exhibit efficacy in specific BCa subtypes, including triple-negative BCa (TNBC) and human epidermal growth factor receptor 2 (HER2)-positive cancers. ACT approaches, including tumor-infiltrating lymphocytes (TILs) and chimeric antigen receptor (CAR) T-cell therapy, showed promising clinical outcomes in enhancing tumor recognition and elimination. Targeting the TME through immune agonists and oncolytic viruses signifies a burgeoning field of research. While challenges persist in patient selection, resistance mechanisms, and combination therapy optimization, these novel immunotherapies hold transformative potential for BCa treatment. Continued research and clinical trials are imperative to refine and implement these innovative approaches, paving the way for improved outcomes and revolutionizing the management of BCa. This review provides a concise overview of the latest immunotherapies (2023 studies) in BCa, highlighting their potential and current status.
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Affiliation(s)
- Huan-Rong Lan
- Department of Surgical Oncology, Hangzhou Cancer Hospital, Hangzhou, Zhejiang 310002, China
| | - Min Chen
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, China
| | - Shi-Ya Yao
- Department of Gastrointestinal, Colorectal and Anal Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang 310006, China
| | - Jun-Xia Chen
- Department of Gynecology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, China.
| | - Ke-Tao Jin
- Department of Gastrointestinal, Colorectal and Anal Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang 310006, China.
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