An examination of nationwide trends in accelerated partial breast irradiation - The replacement of breast brachytherapy with intraoperative radiotherapy and external beam radiation

PURPOSE

To examine recent modality utilization trends in accelerated partial breast irradiation (APBI) in the National Cancer Database (NCDB) based on the American Society for Radiation Oncology (ASTRO) guidelines.

MATERIALS AND METHODS

A total of 58,194 patients treated with APBI were identified. Patients were segregated by APBI modality (brachytherapy, external beam radiotherapy [EBRT], and intraoperative radiotherapy ([IORT]). These patients were then further classified by suitability to receive APBI based on ASTRO guidelines. Temporal trends in utilization were evaluated using linear regression. Logistic regression was applied to study factors contributing to APBI modality choice and treatment within the ASTRO suitability groups.

RESULTS

Patients treated with brachytherapy, EBRT, and IORT comprised 70.5%, 17.5%, and 12.0% of patients treated with APBI. From 2008 to 2017, total APBI cases remained relatively stable (-54.1 cases/year, p = 0.161) while brachytherapy cases decreased by 258.7 cases/year (p < 0.001). EBRT and IORT increased by 51.5 cases/year (p = 0.019) and 153.1 cases/year (p < 0.001), respectively. 40.0% of patients treated with APBI were classified as "suitable", which increased from 2010 to 2017 from 35.3% to 45.3% (slope = 1.51%/year, r² = 0.61, p = 0.022). In comparison, 36.0% (36.1% in 2010 to 33.1% in 2017) of patients were classified as "cautionary" (slope = -0.33%/year, r² = 0.63, p = 0.019) and 23.9% (28.6% in 2010 to 21.6% in 2017) of patients were classified as "unsuitable" (slope = -1.18%/year, r² = 0.67, p = 0.012).

CONCLUSIONS

While overall APBI utilization has remained stable since 2008, this has been accompanied by a decline in brachytherapy and a rise in IORT. The causes of these trends should be the topic of future research.

Intraoperative radiation therapy for breast cancer patients: current perspectives

Accelerated partial breast irradiation (APBI) provides an attractive alternative to whole breast irradiation (WBI) through normal tissue radiation exposure and reduced treatment duration. Intraoperative radiation therapy (IORT) is a form of APBI with the shortest time interval, as it delivers the entirety of a planned radiation course at the time of breast surgery. However, faster is not always better, and IORT has been met with healthy skepticism. Patients treated with IORT have an increased compliance and overall satisfaction when compared to patients treated with WBI. However, early randomized trial results demonstrated an increased rate of recurrence after IORT, slowing its widespread adoption. Despite these controversies, IORT utilization is increasing nationally and several novel developments are aimed at continuing to minimize the risk of recurrence and treatment-related toxicity while maximizing the patient experience.

Accelerated partial breast irradiation: a review and evaluation of indications for treatment

Accelerated partial breast irradiation (APBI) represents a well-studied treatment modality for the delivery of adjuvant radiation therapy following breast-conserving surgery. Interstitial APBI represents the APBI technique with the longest follow-up to date; data from randomized trials and matched pair analyses demonstrate equivalent local control to traditional whole-breast irradiation with comparable rates of toxicity and improved cosmesis. While less mature, prospective data support the efficacy and safety of applicator-based brachytherapy with new multilumen applicators offering the potential for improved outcomes. External beam APBI represents a noninvasive technique; however, concerns regarding toxicity with this technique have emerged though newer techniques may mitigate these concerns. Multiple guidelines have been published based on traditional clinical and pathologic criteria to help physicians offer APBI to appropriately selected patients.

Techniques for intraoperative radiation therapy for early-stage breast carcinoma

ABSTRACT 

Intraoperative radiation therapy (IORT) is a method of accelerated partial breast irradiation developed to replace other longer courses of radiotherapy with a single radiation session administered at the time of breast-conserving surgery. The purpose of this review is to summarize the advantages and disadvantages of breast IORT techniques that are currently available, as well to consider potential alternative techniques for breast IORT or ultra-short course breast radiotherapy. Furthermore, we highlight the published outcomes for the IORT treatment approaches including: electron therapy, superficial photon therapy and other techniques. Potential future directions of IORT are explored including novel IORT techniques utilizing intraoperative brachytherapy with in-room imaging and rapid treatment planning.

First international consensus guidelines for breast cancer in young women (BCY1)

The 1st International Consensus Conference for Breast Cancer in Young Women (BCY1) took place in November 2012, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for management of breast cancer in young women were developed and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).