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Jagsi R, Griffith KA, Harris EE, Wright JL, Recht A, Taghian AG, Lee L, Moran MS, Small W, Johnstone C, Rahimi A, Freedman G, Muzaffar M, Haffty B, Horst K, Powell SN, Sharp J, Sabel M, Schott A, El-Tamer M. Omission of Radiotherapy After Breast-Conserving Surgery for Women With Breast Cancer With Low Clinical and Genomic Risk: 5-Year Outcomes of IDEA. J Clin Oncol 2024; 42:390-398. [PMID: 38060195 DOI: 10.1200/jco.23.02270] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Multiple studies have shown a low risk of ipsilateral breast events (IBEs) or other recurrences for selected patients age 65-70 years or older with stage I breast cancers treated with breast-conserving surgery (BCS) and endocrine therapy (ET) without adjuvant radiotherapy. We sought to evaluate whether younger postmenopausal patients could also be successfully treated without radiation therapy, adding a genomic assay to classic selection factors. METHODS Postmenopausal patients age 50-69 years with pT1N0 unifocal invasive breast cancer with margins ≥2 mm after BCS whose tumors were estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor 2-negative with Oncotype DX 21-gene recurrence score ≤18 were prospectively enrolled in a single-arm trial of radiotherapy omission if they consented to take at least 5 years of ET. The primary end point was the rate of locoregional recurrence 5 years after BCS. RESULTS Between June 2015 and October 2018, 200 eligible patients were enrolled. Among the 186 patients with clinical follow-up of at least 56 months, overall and breast cancer-specific survival rates at 5 years were both 100%. The 5-year freedom from any recurrence was 99% (95% CI, 96 to 100). Crude rates of IBEs for the entire follow-up period for patients age 50-59 years and age 60-69 years were 3.3% (2/60) and 3.6% (5/140), respectively; crude rates of overall recurrence were 5.0% (3/60) and 3.6% (5/140), respectively. CONCLUSION This trial achieved a very low risk of recurrence using a genomic assay in combination with classic clinical and biologic features for treatment selection, including postmenopausal patients younger than 60 years. Long-term follow-up of this trial and others will help determine whether the option of avoiding initial radiotherapy can be offered to a broader group of women than current guidelines recommend.
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Affiliation(s)
- Reshma Jagsi
- Emory University, Atlanta, GA
- University of Michigan, Ann Arbor, MI
| | | | | | | | - Abram Recht
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | | | | | - Asal Rahimi
- University of Texas, Southwestern, Dallas, TX
| | | | | | - Bruce Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Hennequin C, Belkacémi Y, Bourgier C, Cowen D, Cutuli B, Fourquet A, Hannoun-Lévi JM, Pasquier D, Racadot S, Rivera S. Radiotherapy of breast cancer. Cancer Radiother 2021; 26:221-230. [PMID: 34955414 DOI: 10.1016/j.canrad.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Adjuvant radiotherapy is an essential component of the treatment of breast cancer. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. A boost dose over the tumour bed is required if the patient is younger than 50 years-old. Partial breast irradiation could be routinely proposed as an alternative to whole breast irradiation, but only in selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neoadjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra- and infraclavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Hypofractionation regimens (42.5Gy in 16 fractions, or 41,6Gy en 13 or 40Gy en 15) are equivalent to conventional irradiation and must prescribe after tumorectomy in selected patients. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with or after radiotherapy.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Y Belkacémi
- Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - C Bourgier
- Institut du cancer Montpellier (ICM), 34000 Montpellier, France
| | - D Cowen
- Hôpital La Timone, AP-HM, 13000 Marseille, France
| | - B Cutuli
- Polyclinique Courlancy, 51000 Reims, France
| | - A Fourquet
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - J-M Hannoun-Lévi
- Centre Antoine-Lacassagne, 33, avenue Valombrose, 06000 Nice, France
| | - D Pasquier
- Centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - S Racadot
- Centre Léon-Bérard, 69000 Lyon, France
| | - S Rivera
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
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Wang L, Sun M, Yang S, Chen Y, Li T. Intraoperative Radiotherapy Is Not a Better Alternative to Whole Breast Radiotherapy as a Therapeutic Option for Early-Stage Breast Cancer. Front Oncol 2021; 11:737982. [PMID: 34976796 PMCID: PMC8716392 DOI: 10.3389/fonc.2021.737982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Intraoperative radiotherapy (IORT) in early-stage breast cancer has been studied over the years. However, it has not been demonstrated whether IORT is more suitable as a therapeutic option for early-stage breast cancer than whole breast radiotherapy (WBRT). Therefore, we performed a meta-analysis to compare the efficacy and safety of IORT to those of WBRT as therapeutic options for early-stage breast cancer patients receiving breast-conserving surgery (INPLASY2020120008). Methods PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. Computerized and manual searches were adopted to identify eligible randomized control trials from online databases. Risk ratio (RR) and 95% confidence intervals (CI) were calculated by random-effect models to assess the relative risk. Potential publication bias was quantified by Begg’s and Egger’s tests. Results Based on our inclusion criteria, 10 randomized control trials involving 5,698 patients were included in this meta-analysis. This meta-analysis showed that the IORT group was associated with a higher local recurrence risk (RR = 2.111, 95% CI, 1.130–3.943, p = 0.0191), especially in the long-term follow-up subgroup or published after 2020 subgroup or Caucasian subgroup (RR = 2.404, 95% CI, 1.183–4.885, p = 0.0154). Subgroup analysis showed that the IORT group had a higher recurrence risk than the WBRT group in the polycentric randomized controlled trial subgroup (RR = 1.213, 95% CI, 1.030–1.428, p = 0.0204). Pooled analysis showed that there was no statistically significant difference in overall survival, recurrence-free survival, distant metastasis-free survival, and cancer-specific survival between IORT and WBRT groups. Additionally, the risk of skin toxicity was reduced, but the incidences of fat toxicity, edema, and scar calcification were significantly increased in the patients who underwent IORT in comparison to those who underwent WBRT. Conclusion This meta-analysis revealed that IORT was not a better alternative to WBRT. More large-scale and well-designed clinical trials with longer follow-up periods are encouraged to further investigate the value of IORT. Systematic Review Registration https://inplasy.com/inplasy-2020-12-0008/.
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Affiliation(s)
- Linwei Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Shuailong Yang
- Department of Radiation and Medical Oncology, The Central Hospital of Wuhan, Wuhan, China
| | - Yuanyuan Chen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi’an, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
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Choi JI, Fox J, Bakst R, Hasan S, Press RH, Chhabra AM, Yeh B, Simone CB, Cahlon O. Proton Therapy for Partial Breast Irradiation: Rationale and Considerations. J Pers Med 2021; 11:289. [PMID: 33918662 PMCID: PMC8069416 DOI: 10.3390/jpm11040289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
In an era of continued advancements in personalized medicine for the treatment of breast cancer, select patients with early stage breast cancer may be uniquely poised to benefit from partial breast irradiation (PBI) delivered with proton therapy. PBI presents an opportunity to improve quality of life during treatment with a significantly shorter treatment duration. By targeting less non-target breast tissue, excess radiation exposure and resulting toxicities are also reduced. Proton therapy represents a precision radiotherapy technology that builds on these advantages by further limiting the normal tissue exposure to unnecessary radiation dose not only to uninvolved breast tissue but also the underlying thoracic organs including the heart and lungs. Herein, we present a concise review of the rationale for the use of proton therapy for PBI, evidence available to date, and practical considerations in the implementation and use of proton therapy for this indication.
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Affiliation(s)
- J. Isabelle Choi
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Jana Fox
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Richard Bakst
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shaakir Hasan
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Robert H. Press
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Brian Yeh
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Charles B. Simone
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
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Diagnosis of ductal carcinoma in situ in an era of de-escalation of therapy. Mod Pathol 2021; 34:1-7. [PMID: 32908254 DOI: 10.1038/s41379-020-00665-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/13/2020] [Accepted: 08/13/2020] [Indexed: 12/21/2022]
Abstract
Concerns about overdiagnosis and overtreatment have led to interest in de-escalating treatment for ductal carcinoma in situ (DCIS). This article reviews the epidemiology, natural history, and current treatment options for DCIS and discusses ongoing efforts to further de-escalate treatment for these patients.
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