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Starling MTM, Thibodeau S, de Sousa CFPM, Restini FCF, Viani GA, Gouveia AG, Mendez LC, Marta GN, Moraes FY. Optimizing Clinical Implementation of Hypofractionation: Comprehensive Evidence Synthesis and Practical Guidelines for Low- and Middle-Income Settings. Cancers (Basel) 2024; 16:539. [PMID: 38339290 PMCID: PMC10854666 DOI: 10.3390/cancers16030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024] Open
Abstract
The global cancer burden, especially in low- and middle-income countries (LMICs), worsens existing disparities, amplified by the rising costs of advanced treatments. The shortage of radiation therapy (RT) services is a significant issue in LMICs. Extended conventional treatment regimens pose significant challenges, especially in resource-limited settings. Hypofractionated radiotherapy (HRT) and ultra-hypofractionated/stereotactic body radiation therapy (SBRT) offer promising alternatives by shortening treatment durations. This approach optimizes the utilization of radiotherapy machines, making them more effective in meeting the growing demand for cancer care. Adopting HRT/SBRT holds significant potential, especially in LMICs. This review provides the latest clinical evidence and guideline recommendations for the application of HRT/SBRT in the treatment of breast, prostate, and lung cancers. It emphasizes the critical importance of rigorous training, technology, stringent quality assurance, and safety protocols to ensure precise and secure treatments. Additionally, it addresses practical considerations for implementing these treatments in LMICs, highlighting the need for comprehensive support and collaboration to enhance patient access to advanced cancer care.
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Affiliation(s)
| | - Stephane Thibodeau
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
| | | | | | - Gustavo A. Viani
- Department of Medical Imagings, Ribeirão Preto Medical School, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto 14049-900, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Andre G. Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
- Division of Radiation Oncology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Lucas C. Mendez
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Gustavo Nader Marta
- Radiation Oncology Department, Hospital Sirio Libanês, Sao Paulo 01308-050, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Fabio Ynoe Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
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Whelan TJ, Fyles A, Parpia S, Nielsen T, Levine MN. LUMINA: Using molecular biomarkers to guide decision making for breast radiotherapy. Radiother Oncol 2024; 190:110074. [PMID: 38163484 DOI: 10.1016/j.radonc.2023.110074] [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: 12/18/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
In this opinion piece, we respond to comments about the LUMINA trial by Meattini and colleagues in the Journal. LUMINA was a prospective cohort study which evaluated the omission of radiotherapy after breast conserving surgery (BCS) in patients treated with endocrine therapy with low risk clinico-pathologic features and luminal A breast cancer. We address their areas of concern including the single cohort design that required careful patient selection, the relatively short follow-up period of 5 years, and the limited follow-up on younger patients. The Ki67 biomarker was key to defining the luminal A phenotype. We clarify the evidence supporting the Ki67 criteria used. The compliance with endocrine therapy was high and similar to other contemporary trials. Based on the results of LUMINA, and mounting evidence from other trials, we feel comfortable offering our patients the option of no radiotherapy after BCS if they fit the trial eligibility criteria from LUMINA and have decided to receive adjuvant endocrine therapy. We concur that a patient-centered approach to treatment decision making should be used to make patients aware of all available information including the results of the LUMINA trial when deciding on post-operative breast radiotherapy.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Princess Margaret Hospital, Toronto, ON, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Torsten Nielsen
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Shang Y, Zhang S, Cheng Y, Feng G, Dong Y, Li H, Fan S. Tetrabromobisphenol a exacerbates the overall radioactive hazard to zebrafish (Danio rerio). ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 316:120424. [PMID: 36272602 DOI: 10.1016/j.envpol.2022.120424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
The major health risks of dual exposure to two hazardous factors of plastics and radioactive contamination are obscure. In the present study, we systematically evaluated the combinational toxic effects of tetrabromobisphenol A (TBBPA), one of the most influential plastic ingredients, mainly from electronic wastes, and γ-irradiation in zebrafish for the first time. TBBPA (0.25 μg/mL for embryos and larvae, 300 μg/L for adults) contamination aggravated the radiation (6 Gy for embryos and larvae, 20 Gy for adults)-induced early dysplasia and aberrant angiogenesis of embryos, further impaired the locomotor vitality of irradiated larvae, and worsened the radioactive multiorganic histologic injury, neurobehavioural disturbances and dysgenesis of zebrafish adults as well as the inter-generational neurotoxicity in offspring. TBBPA exaggerated the radiative toxic effects not only by enhancing the inflammatory and apoptotic response but also by further unbalancing the endocrine system and disrupting the underlying gene expression profiles. In conclusion, TBBPA exacerbates radiation-induced injury in zebrafish, including embryos, larvae, adults and even the next generation. Our findings provide new insights into the toxicology of TBBPA and γ-irradiation, shedding light on the severity of cocontamination of MP components and radioactive substances and thereby inspiring novel remediation and rehabilitation strategies for radiation-injured aqueous organisms and radiotherapy patients.
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Affiliation(s)
- Yue Shang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Shuqin Zhang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Yajia Cheng
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Guoxing Feng
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Yinping Dong
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Hang Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China
| | - Saijun Fan
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, 238 Baidi Road, 300192, Tianjin, China.
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Kunkler I. The Evolving Role of Whole Breast Hypofractionation in Older Patients With Early Breast Cancer. Semin Radiat Oncol 2022; 32:155-158. [DOI: 10.1016/j.semradonc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gu L, Dai W, Fu R, Lu H, Shen J, Shi Y, Zhang M, Jiang K, Wu F. Comparing Hypofractionated With Conventional Fractionated Radiotherapy After Breast-Conserving Surgery for Early Breast Cancer: A Meta-Analysis of Randomized Controlled Trials. Front Oncol 2021; 11:753209. [PMID: 34660318 PMCID: PMC8518530 DOI: 10.3389/fonc.2021.753209] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/30/2022] Open
Abstract
Background The purpose of this meta-analysis was to compare the safety and efficacy between hypofractionated and conventional fractionation radiotherapy in patients with early-stage breast cancer after breast-conserving surgery. Methods We conducted a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Library to identify relevant randomized controlled trials (RCTs) published before February 2021. At the same time, the hazard ratio (HR), risk ratio (RR), and 95% confidence interval (CI) were calculated to evaluate local recurrence (LR), relapse-free survival (RFS), overall survival (OS), adverse events, and cosmetic outcomes. Results A total of 14 articles were included in this meta-analysis. Four thousand eight hundred and sixty-nine patients were randomly assigned to the control group to receive conventional radiotherapy (CFRT); 6,072 patients were randomly assigned to the experimental group and treated with hypofractionated radiotherapy (HFRT). The results showed that there was no statistical difference between HFRT and CFRT in LR (HR = 0.99, 95%CI = 0.97-1.02, p = 0.476), RFS (HR = 0.99, 95%CI = 0.97-1.02, p = 0.485), OS (HR = 1.00, 95%CI = 0.97-1.03, p = 0.879), and cosmetic outcomes (RR = 1.03, 95%CI = 0.95-1.12, p = 0.53). In addition, HFRT showed fewer severe adverse reactions such as acute skin toxicity, induration, breast atrophy, and pain. Conclusion Our results suggest that there is no statistical difference between HFRT and CFRT in terms of LR, RFS, OS, and cosmetic outcomes. HFRT reduces the risk of developing toxicity reactions compared to CFRT. HFRT may be a better option for patients with early breast cancer after breast-conserving surgery.
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Affiliation(s)
- Lihu Gu
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Wei Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Rongrong Fu
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hongfeng Lu
- Department of Breast Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Jingyi Shen
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Yetan Shi
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Mengting Zhang
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Ke Jiang
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Feng Wu
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
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Meattini I, Poortmans PM, Aznar MC, Becherini C, Bonzano E, Cardinale D, Lenihan DJ, Marrazzo L, Curigliano G, Livi L. Association of Breast Cancer Irradiation With Cardiac Toxic Effects: A Narrative Review. JAMA Oncol 2021; 7:924-932. [PMID: 33662107 DOI: 10.1001/jamaoncol.2020.7468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE To promptly recognize and manage cardiovascular (CV) risk factors before, during, and after cancer treatment, decreasing the risk of cancer therapy-related cardiac dysfunction is crucial. After recent advances in breast cancer treatment, mortality rates from cancer have decreased, and the prevalence of survivors with a potentially higher CV disease risk has increased. Cardiovascular risks might be associated with the multimodal approach, including systemic therapies and breast radiotherapy (RT). OBSERVATIONS The heart disease risk seems to be higher in patients with tumors in the left breast, when other classic CV risk factors are present, and when adjunctive anthracycline-based chemotherapy is administered, suggesting a synergistic association. Respiratory control as well as modern RT techniques and their possible further refinement may decrease the prevalence and severity of radiation-induced heart disease. Several pharmacological cardioprevention strategies for decreasing cardiac toxic effects have been identified in several guidelines. However, further research is needed to ascertain the feasibility of these strategies in routine practice. CONCLUSIONS AND RELEVANCE This review found that evidence-based recommendations are lacking on the modalities for and intensity of heart disease screening, surveillance of patients after RT, and treatment of these patients. A multidisciplinary and multimodal approach is crucial to guide optimal management.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Matteo Polyclinic Foundation, Pavia, Italy
- PhD School in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Livia Marrazzo
- Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Moderate hypofractionation remains the standard of care for whole-breast radiotherapy in breast cancer: Considerations regarding FAST and FAST-Forward. Strahlenther Onkol 2021; 197:269-280. [PMID: 33507331 PMCID: PMC7841378 DOI: 10.1007/s00066-020-01744-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/31/2020] [Indexed: 12/27/2022]
Abstract
Moderate hypofractionation is the standard of care for adjuvant whole-breast radiotherapy after breast-conserving surgery for breast cancer. Recently, 10-year results from the FAST and 5‑year results from the FAST-Forward trial evaluating adjuvant whole-breast radiotherapy in 5 fractions over 5 weeks or 1 week have been published. This article summarizes recent data for moderate hypofractionation and results from the FAST and FAST-Forward trial on ultra-hypofractionation. While the FAST trial was not powered for comparison of local recurrence rates, FAST-Forward demonstrated non-inferiority for two ultra-hypofractionated regimens in terms of local control. In both trials, the higher-dose experimental arms resulted in elevated rates of late toxicity. For the lower dose experimental arms of 28.5 Gy over 5 weeks and 26 Gy over 1 week, moderate or marked late effects were similar in the majority of documented items compared to the respective standard arms, but significantly worse in some subdomains. The difference between the standard arm and the 26 Gy of the FAST-Forward trial concerning moderate or marked late effects increased with longer follow-up in disadvantage of the experimental arm for most items. For now, moderate hypofractionation with 40–42.5 Gy over 15–16 fractions remains the standard of care for the majority of patients with breast cancer who undergo whole-breast radiotherapy without regional nodal irradiation after breast-conserving surgery.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA
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Goldberg M, Whelan TJ. Accelerated Partial Breast Irradiation (APBI): Where Are We Now? CURRENT BREAST CANCER REPORTS 2020; 12:275-284. [PMID: 33101597 PMCID: PMC7568840 DOI: 10.1007/s12609-020-00384-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 01/26/2023]
Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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