Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy : Analysis of 205 cases

Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure

Background

Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach.

Summary

In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly.

Key Messages

The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.

Cost-effectiveness analysis of advanced radiotherapy techniques for post-mastectomy breast cancer patients

Background

Prior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT).

Methods

Using a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER).

Results

For the patient cohort, STD-VMAT has an ICER of $32,617/QALY relative to SOC; TOMO is dominated by STD-VMAT; IMRT has an ICER of $19,081/QALY relative to STD-VMAT; NC-VMAT, MA-VMAT, MIXED are dominated by IMRT; IMPT has an ICER of $151,741/QALY relative to IMRT. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of $100,000/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY.

Conclusion

Advanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of $100,000/QALY, and IMRT might be a cost-effective option for PMRT patients.

Comparing hypofractionated to conventional fractionated radiotherapy in postmastectomy breast cancer: a meta-analysis and systematic review

Purpose

To compare the efficacy and toxicity of hypofractionated radiotherapy versus conventional fractionated radiotherapy in postmastectomy breast cancer using meta-analysis.

Methods

The PubMed, EMbase, Cochrane Library, Google Scholar, Wan Fang and CNKI databases were searched to identify controlled clinical trials comparing hypofractionated radiotherapy versus conventional fractionated radiotherapy in postmastectomy breast cancer. Overall survival (OS) was the primary endpoint, and disease-free survival (DFS), locoregional recurrence (LRR), distant metastasis (DM), acute skin toxicity, acute lung toxicity, late skin toxicity, lymphedema,, shoulder restriction, and late cardiac related toxicity were the secondary endpoints.

Results

Twenty-five controlled clinical trials involving 3871 postmastectomy breast cancer patients were included in this meta-analysis according to the selection criteria. The meta-analysis revealed that there were no significant differences in OS (OR = 1.08, 95% CI = 0.87~1.33, P = 0.49), DFS (OR = 1.13, 95% CI = 0.91~1.40, P = 0.28), LRR (OR = 1.01, 95% CI = 0.76~1.33, P = 0.96), DM (OR = 1.16, 95% CI = 0.85~1.58, P = 0.34), acute skin toxicity (OR = 0.94, 95% CI = 0.67~1.32, P = 0.72), acute lung toxicity (OR = 0.94, 95% CI = 0.74~1.20, P = 0.62), late skin toxicity (OR = 0.98, 95% CI = 0.75~1.27, P = 0.88), lymphedema (OR = 0.99, 95% CI = 0.77~1.28, P = 0.94), shoulder restriction (OR = 0.75, 95% CI = 0.43~1.31, P = 0.31), or late cardiac related toxicity (OR = 1.17, 95% CI = 0.82~1.65, P = 0.39) between the two groups.

Conclusions

The results of this study show that compared to conventional fractionated radiotherapy, hypofractionated radiotherapy is not significantly different with respect to efficacy or toxicity in postmastectomy breast cancer. Additional large randomized clinical trials are needed to further confirm this conclusion.

Hypofractionated radiotherapy for elderly breast cancer patients: from early stages disease to local palliation for unresectable disease

There is a lack of clear guidelines on optimal radiotherapy dose regimen for elderly breast cancer patients. This review summarizes the current evidence on role of hypofractionated radiotherapy in elderly breast cancer. Also, suggestions have been provided on the best fractionation approaches based on current evidence. Hypofractionated radiotherapy is feasible and well tolerated in elderly breast cancer patients with both early and locally advanced disease. Ultra-hypofractionated regimen seem appropriate for palliation of unresectable primary breast disease and could become a safe approach for adjuvant treatments. Hypofractionated radiotherapy should be considered for treatment of elderly breast cancer for curative intent, as well as for palliation.

The Association Between Use of Hypofractionation and Treatment Completion Among Recipients of Radiation Therapy Post-Mastectomy

PURPOSE

Although there is some evidence to support the use of hypofractionated (HF) radiation therapy (RT) postmastectomy, it is not currently the standard of care. RT noncompletion and delayed completion have been shown to lead to inferior outcomes. This study assesses the association between the choice of an HF versus conventionally fractionated regimen and completion.

METHODS AND MATERIALS

RT orders placed in 2016 and 2017 for patients with a national health plan, along with the associated claims, were extracted. Each order was assigned a target date for timely completion, as well as a date 30 days after the target, which was used to assess delayed completion. Univariate analyses and logistic regressions were conducted to test for an association between regimen and completion. A Poisson regression was used to examine the association between regimen and length of treatment delay among patients completing RT.

RESULTS

Of the 743 orders meeting inclusion criteria, 56 (7.5%) were for HF. Unadjusted analyses found that the timely and delayed completion rates were significantly (P < .001) higher for patients receiving HF. The adjusted odds ratios (HF order versus CF order) were 3.96 (95% confidence interval, 2.23-7.01) for timely completion and 2.64 (95% confidence interval, 1.43-5.15) for completion within 30 days of the target. Among completers, an order for HF was significantly (P < .001) associated with less delay.

CONCLUSIONS

When an HF regimen was ordered, patients were more likely to complete therapy without a delay, to complete therapy overall, and, if experiencing a delay, to experience a shorter delay.

Challenges Facing Radiation Oncologists in The Management of Older Cancer Patients: Consensus of The International Geriatric Radiotherapy Group

The management of older cancer patients remains difficult because of data paucity. Radiation oncologists need to identify potential issues which could affect treatment of those patients. A workshop was organized in Barcelona among international radiation oncologists with special interest in the management of older cancer patients on April 22, 2018. The following consensus was reached: 1. Older cancer patients often faced unconscious discriminating bias from cancer specialists and institutions because of their chronological age. 2. Advances in radiotherapy techniques have allowed patients with multiple co-morbidities precluding surgery or systemic therapy to achieve potential cure in early disease stages. 3. The lack of biomarkers for frailty remains an impediment to future research. 4. Access to healthcare insurance and daily transportation remains an issue in many countries; 5. Hypofractionation, brachytherapy, or stereotactic techniques may be ideally suited for older cancer patients to minimize transportation issues and to improve tolerance to radiotherapy. 6. Patients with locally advanced disease who are mentally and physically fit should receive combined therapy for potential cure. 7. The role of systemic therapy alone or combined with radiotherapy for frail patients needs to be defined in future clinical trials because of targeted agents or immunotherapy may be less toxic compared to conventional chemotherapy.

Hypofractionated Whole-Breast Irradiation With or Without Boost in Elderly Patients: Clinical Evaluation of an Italian Experience

PURPOSE

To examine local control, disease-free survival (DFS), and toxicity in elderly (≥ 65 years) breast cancer patients treated with hypofractionated radiotherapy (hypo-RT) with or without a boost to the tumor bed.

PATIENTS AND METHODS

The study was conducted on 752 patients treated from April 2009 to February 2017. Patients received 42.4 Gy in 16 daily fractions (2.65 Gy per fraction). A boost was only administered in cases of grade 3 primary tumor and close or positive margins. Acute and late toxicity was prospectively assessed during and after hypo-RT, based on the Radiation Therapy Oncology Group scale. DFS and local recurrence-free survival were estimated by the Kaplan-Meier method for cumulative probability. Log-rank tests were used to identify differences by subtype. Cox proportional hazard models were used to investigate the impact of various factors on the risk of disease progression.

RESULTS

Among the 752 patients treated, 41 (5.5%) experienced disease progression, including 7 (17.1%) exclusively local recurrences; 1 (2.4%) local and nodal recurrence; 1 (2.4%) local and nodal recurrence plus metastasis; 7 (17.1%) nodal recurrences plus metastases; and 25 (61%) exclusively distant metastases. The 5-year DFS, local recurrence-free survival, breast cancer-specific survival, and overall survival rates were 91.8% (95% confidence interval [CI], 88.6-94.2), 98.0% (95% CI, 96.1-99.1), 98.2% (95% CI, 96.5-99.1), and 87.5% (95% CI, 83.8-90.5), respectively. On univariate analysis, the administration of a boost, disease grade (grades 1 and 2 vs. 3), and molecular subtype (triple negative or human epidermal growth factor receptor 2 [HER2] positive, or luminal B vs. luminal A) significantly affected disease progression (P < .01). These findings were confirmed by multivariate analysis.

CONCLUSION

Hypo-RT is effective and well tolerated in the elderly population, and the routine use of a boost for patients over 65 years is not justified. Further studies on the boost issue are strongly advocated.

The long-term outcome of adjuvant hypofractionated radiotherapy and conventional fractionated radiotherapy after breast-conserving surgery for early breast cancer: a prospective analysis of 107 cases

Background

This study aimed to evaluate the long-term outcomes of hypofractionated and conventional fractionated radiotherapy after breast-conserving surgery in patients with early-stage breast cancer. In addition, cosmetic and delayed toxic effects in the breast were also investigated.

Methods

A total of 107 female patients were recruited and randomly classified into the hypofractionated radiotherapy (HF) group (53 participants) and the conventional fractioned radiotherapy (CF) group (54 participants). The HF group was subjected to the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 42.56 Gy/16 fractions + tumor bed boost at 7.98 Gy/3 fractions. The CF group received the following treatments: whole-breast irradiation (± irradiation of the infra-supraclavicular region) at 50 Gy/25 fractions + tumor bed boost at 10 Gy/5 fractions.

Results

The 10-year local recurrence (LR) rate, tumor-specific survival rate, disease-free survival rate, and overall survival rate of the HF and CF groups were 9.6% vs. 7.9% (P=0.712); 88.1% vs. 90.1% (P=0.738); 81.1% vs. 82.9% (P=0.792); and 86.5% vs. 88.5% (P=0.748), respectively. The 10-year rates of patients with good or excellent cosmetic results in the HF and CF groups were 72.7% vs. 67.4% (P=0.581), respectively. The 10-year rates of patients with delayed toxicity-free effects in the skin and the rates of patients with toxicity-free subcutaneous tissues in the HF and CF groups were 70.5% vs. 65.2% (P=0.595) and 52.3% vs. 47.8% (P=0.673), respectively.

Conclusions

Hypofractionated and CF showed comparable long-term efficacy, cosmetic effects, and delayed toxic effects. Hence, HF may be used as an alternative to conventional fractionated radiotherapy.

External radiotherapy for breast cancer in the elderly

BACKGROUND

Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients.

AIMS

The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population.

MATERIALS AND METHODS

Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost.

DISCUSSION

The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care.

CONCLUSIONS

New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.

Retrospective Analysis of Efficacy and Toxicity of Hypo-fractionated Radiotherapy in Breast Carcinoma

INTRODUCTION

The conventional dose fractionation of adjuvant radiotherapy (RT) to whole breast is 45-50 Gy in 25 fractions as 1.8-2.0-Gy per fraction. Lumpectomy cavity with a 1.5-2-cm margin receieves additional 10- 16 Gy doseas boost. Alternative dose fraction schedules used in various randomised trials have established the role of hypofractionated radiotherapy (HRT) in early breast cancer. HRT allows time and cost saving thus better patient compliance. However the efficacy and toxicity of HRT in locally advanced breast cancer is still under evaluation.

AIM

To study the toxicity and efficacy of Hypofractionated Radiotherapy (HRT) as compared to Conventional Radiotherapy (CRT) in breast cancer at our centre.

MATERIALS AND METHODS

A retrospective analysis of breast cancer patients treated between October 2012- September 2014 with adjuvant radiation therapy as CRT or HRT. The data of these patients was retrieved and analysed regarding demographic profile, stage at presentation, pathological type, extent of surgery, chemotherapy, efficacy and toxicity of HRT. The toxicity assessment was done as per RTOG toxicity criteria. The data were analysed using SPSS software version 20.0.

RESULTS

A total of 100 patients with carcinoma breast who received radiotherapy over two years were analysed. Age ranged from 18-90 years, mean 49.15 ± 12.7 years. Fifty-five patients were post-menopausal, predominant clinical feature was painless lump in the breast (98%). Early stage (Stage I and II) constituted 41%, locally advanced disease in 59%. Modified radical mastectomy was done in 75%, breast conserving surgery in 25%. A 56 patients received HRT and 44 were treated with CRT. The most common acute toxicity was skin grade I. An 18% patients in HRT arm and 30% patients in conventional arm developed grade II skin toxicity (p=0.23). Dysphagia grade I was seen in 10% cases in CRT arm and 12% in HRT arm. The median follow-up period was 11.3 months with 2 loco-regional failures in each arm.

CONCLUSION

HRT seems to be equally efficacious and no more toxic than CRT in carcinoma breast even in unselected sub-group of patients.

[Hypofractionated whole breast irradiation (WBRT): Results and indications]

Breast irradiation after breast-conserving surgery is essential for maximizing local control and overall survival. The increase of breast cancer (BC) incidence, constraints of classical five weeks (w) radiation regimens and scarcity of radiotherapy units have led to test short hypofractionated WBRT schemes. One pilot study and three prospective randomized trials have tested various hypofractionated regimens of WBRT. About 7000 patients were included and follow-up ranged from 5 to 12 years. The conclusion of these trials is similar, showing local control and toxicity equivalent to these of the standard regimens. Three schemes are now clearly validated: 42.5Gy/16fr/3w, 40Gy/15fr/3w, or 42Gy/13fr/5w. However, the majority of included patients had favorable prognostic factors, were treated to the breast only and the boost dose, when indicated, was delivered with a standard fractionation. Therefore, we recommend the regimens preferentially in patients treated to the breast only, and without nodal involvement. These studies did not evaluate the addition of a boost dose with a hypofractionated scheme. If a boost is to be given, a standard fractionation should be used. Particular care should be taken to avoid heterogeneities leading to high fraction doses to organs at risk (lung and heart).

Clinicopathologic Features and Long-Term Outcomes of Elderly Breast Cancer Patients: Experiences at a Single Institution in Korea

PURPOSE

The purpose of this study was to assess the tumor characteristics and long-term clinical outcomes of adjuvant treatments after surgery with a curative aim for patients with breast cancer who are 65 years and older.

MATERIALS AND METHODS

Patients with breast cancer who underwent curative surgery from 2000 to 2009 were analyzed (n=4,388). Tumor characteristics and survival outcome were compared by dividing the patients into two age groups (< 65 and ≥ 65 years old). The Kaplan-Meier method was used for comparison of survival rates by log-rank test, and a Cox regression model was used to examine the effect of variables.

RESULTS

Among 4,388 patients with invasive breast cancer, 317 patients (7.2%) were 65 years or older and the median age of all patients was 47 years (range, 18 to 91 years). Tumor characteristics were similar between the two age groups, but the older patients were treated less often with adjuvant treatments. During a median follow-up period of 122 months, recurrence-free survival (RFS) was equivalent for patients 65 years and older compared to younger patients, but significantly worse in overall survival (OS) and breast cancer-specific survival (BCSS) (5-year OS, 94.3% vs. 90.5%; p < 0.001 and 5-year BCSS, 94.7% vs. 91.8%; p=0.031). In the multivariate model, age ≥ 65 years old was identified as an independent risk factor for OS and RFS.

CONCLUSION

Elderly breast cancer appeared to have worse outcomes with very low prevalence in Korea, despite similar tumor characteristics. More active adjuvant therapies would have a role for aggressive subtypes for fit, elderly patients.