Partial breast radiation for early-stage breast cancer

Radiodermatitis and Fibrosis in the Context of Breast Radiation Therapy: A Critical Review

Simple Summary

Skin toxicity is the main complication during irradiation in the management of early-stage breast cancer. In some cases, it may cause treatment to stop. These toxicities may be acute (mainly radiodermatitis) and/or late (mainly fibrosis). Their understandings, their mechanisms of occurrence, as well as their management is indispensable in order to improve the management of these patients. Through this study we propose to provide a clear picture of these toxicities in relation to the modalities of radiotherapy, advances in their quantification, and management to help practitioners improve their knowledge and clinical practices on this topic.

Abstract

Background: Radiation therapy has been progressively improved in order to maintain a satisfactory tumour response, while reducing toxicity. We will review the incidence of radiodermatitis and fibrosis according to the various radiation and fractionation techniques. We will then focus on the various methods used to manage, prevent, and quantify this toxicity. Method: More than 1753 articles were identified using the various search terms. We selected 53 articles to answer the questions addressed in this study according to criteria set in advance. Result: The literature reports lower acute toxicity with IMRT compared to 3DCRT, but no significant differences in terms of late toxicities. Partial breast irradiation appears to be less effective in terms of local control with a higher rate of late toxicity. Intra operative radiation therapy appears to provide good results in terms of both local control and late toxicity. The hypofractionation has equivalent efficacy and safety to the normofractionated regimen, but with lower rates of radiodermatitis and fibrosis. The adddition of a boost, particularly a sequential boost, increases the risk of fibrosis and radiodermatitis during treatment. Conclusion: The development of IMRT has significantly reduced acute toxicity and has improved tolerability during treatment. Modified fractionation has reduced treatment time, as well as adverse effects.

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REFLEXIONS ABOUT NEW STRATEGIES OF RADIOTHERAPY FOR EARLY BREAST CANCER: Radiotherapy (RT) remains a major treatment element in early breast cancer, with a major impact on local control and survival. For ductal carcinoma in situ (DCIS), RT reduces local recurrence (LR) rates by 50 to 60 % after conservative surgery (both in situ and invasive). This was confirmed by four randomized trials and one meta-analysis. For infiltrating breast cancers (IBC), RT also reduces LR rates by 65 to 75 % after conservative surgery. Boost allows an additional reduction of LR. RT is efficient in all age categories, but hypofractionated schemes are particularly adapted to elderly women. Partial breast irrradiation techniques are very much heterogeneous and lack follow-up. They should be used in LR low-risk patients only and in the frame of controlled studies. Locoregional RT for high-risk patients (especially in pN+) remains essential to reduce the locoregional recurrence rate and to increase survival, as confirmed in several meta-analyses. Four studies showed a survival benefit (2-3 %), thanks to internal mammary chain irradiation in LR high-risk patients. Moreover, axillary RT seems to be a likely valuable alternative to axillary dissection in case of sentinel node invasion. Finally, with the modern techniques and dosimetric optimization, RT toxicity was reduced, or even cancelled, arousing hope for a better increased benefit for the patients in the future.

Racial disparities in travel time to radiotherapy facilities in the Atlanta metropolitan area

Low-income women with breast cancer who rely on public transportation may have difficulty in completing recommended radiation therapy due to inadequate access to radiation facilities. Using a geographic information system (GIS) and network analysis we quantified spatial accessibility to radiation treatment facilities in the Atlanta, Georgia metropolitan area. We built a transportation network model that included all bus and rail routes and stops, system transfers and walk and wait times experienced by public transportation system travelers. We also built a private transportation network to model travel times by automobile. We calculated travel times to radiation therapy facilities via public and private transportation from a population-weighted center of each census tract located within the study area. We broadly grouped the tracts by low, medium and high household access to a private vehicle and by race. Facility service areas were created using the network model to map the extent of areal coverage at specified travel times (30, 45 and 60 min) for both public and private modes of transportation. The median public transportation travel time to the nearest radiotherapy facility was 56 min vs. approximately 8 min by private vehicle. We found that majority black census tracts had longer public transportation travel times than white tracts across all categories of vehicle access and that 39% of women in the study area had longer than 1 h of public transportation travel time to the nearest facility. In addition, service area analyses identified locations where the travel time barriers are the greatest. Spatial inaccessibility, especially for women who must use public transportation, is one of the barriers they face in receiving optimal treatment.

[Radiotherapy for breast cancer: which strategy in 2012?]

Postoperative radiotherapy remains essential in breast cancer in 2012. After conserving surgery, it reduces local recurrence risks from 50 to 70%, both for ductal carcinoma in situ and invasive cancers. This was confirmed in several randomized trials and three meta-analyses. The boost increases local control in invasive cancers, but its role should be better defined in ductal carcinoma in situ. Among the latter, there is no clearly identified subgroup for which radiotherapy could be avoided. Local recurrence risk factors are now well-identified both for ductal carcinoma in situ and invasive cancers, with an inclusion, for the latter, of new molecular subgroups. After mastectomy, radiotherapy reduces local recurrence rates from 60 to 70%, especially among patients with axillary nodal involvement, with, in parallel, a 7 to 9% increased survival rate. In order to reduce the waiting list and to avoid under treatment, especially in the elderly, several hypofractionated radiotherapy schemes have been developed for several years. Three randomized trials confirmed similar results to classical radiotherapy. For ten years, several techniques of partial breast irradiation have been developed, with various doses and treated volumes. The optimal indications should be defined according to the new international guidelines.