Hypofractionation in post-mastectomy breast cancer patients: seven-year follow-up

Acute and late toxicities after moderate hypo-fractionated radiation therapy to the chest wall/breast and regional lymph nodes: a retrospective observational study

BACKGROUND

Still controversial is the optimal radiotherapy (RT) schedule for high-risk patients after mastectomy or breast conserving surgery (BCS). An alternative to conventional RT schedules is hypo-fractionation (HF) (40.5 Gy or 42.67 Gy in 15-16 fractions). The present observational, retrospective study assessed acute and late toxicities after hypo-fractionation targeting the chest wall/breast and regional lymph nodes, compared with a cohort that had received conventional fractionation. The aim was to establish the safety of hypo-fractionation in wide-field irradiation.

MATERIALS AND METHODS

This study enrolled 80 patients (median age 63 years; range 34-83) who underwent either BCS (9) or mastectomy (71) as well as axillary lymph node dissection. The RT schedule was 40.05 Gy in 15 fractions over 3 weeks. A simultaneous integrated boost (SIB) (49.5 Gy in 15 fractions) was delivered to the tumour bed in 9 patients who received whole breast irradiation (WBI). Acute and late toxicities were graded according to Common Terminology Criteria for Adverse Events (CTCAE v4.02) and compared with outcomes in 51 patients after conventionally fractionated RT to the chest wall/breast and regional nodes. Median follow-up was 16 months (range 2.7-33.8 months).

RESULTS

All patients completed RT with no toxicity-related interruption. No patient developed any cardiac or pulmonary toxicity or ≥ grade 3 acute skin and oesophageal toxicity. Late G1 skin toxicity occurred in 9/75 patients who were eligible for analysis. No patient developed ≥ G2 late toxicity. The incidences of acute toxicity, skin rash and dysphagia were significantly lower after HF (p < 0.001 and 0.040, respectively). No significant differences emerged in late edema and skin toxicity.

CONCLUSIONS

The efficacy and safety of hypofractionated regimens were confirmed in real-life settings. Present evidence supports the use of HFRT as standard treatment, providing patients with the advantages of shorter treatment times and reduced healthcare costs.

Radiation Therapy for Breast Cancer in Africa

Purpose

Although radiation therapy is an effective treatment for breast cancer, it has a low rate of use in African countries. A systematic review was undertaken to investigate studies that used radiation therapy as a treatment modality for patients with breast cancer in Africa, focusing on survival outcomes, adverse effects, radiation therapy techniques, fractionation schedules, and effectiveness of radiation therapy.

Methods and Materials

We conducted a comprehensive literature search for studies that treated breast cancer with radiation therapy, using different electronic databases (PubMed, Scopus, and EBSCOhost) up to February 2023. The output was exported to a reference management system for analyses.

Results

The literature search primarily identified 3804 records from Scopus (2427), PubMed (982), and EBSCOhost (395). Based on the inclusion and exclusion criteria, 19 articles were finally included in this systematic review. Most of the studies published were conducted in North Africa (63%), followed by West Africa (21%) and Southeast Africa (16%). Most centers employed external beam radiation therapy to deliver radiation therapy to patients with breast cancer with the standard fractionation size of 50 Gy in 25 fractions. The long-term outcomes with regards to adverse effect suggests that radiation therapy was fairly tolerated among patients with breast cancer.

Conclusions

The reports provide substantial evidence that there are limited number of published studies on the use of radiation therapy for breast cancer treatment in Africa, as well as lower overall survival rate compared with developed countries. To improve breast cancer survivorship, it is necessary for government and other health care planners to provide more radiation therapy resources and implement training programs for personnels.

Efficacy and safety analysis of hypofractionated and conventional fractionated radiotherapy in postoperative breast cancer patients

OBJECTIVES

In this meta-analysis, we conducted a comparative analysis of the safety and efficacy of hypofractionated and conventional fractionated radiotherapy in individuals who had undergone surgery for breast cancer.

METHODS

This study involved a systematic and independent review of relevant research articles published in reputable databases such as PubMed, Embase, Cochrane Library, and Web of Science. Two investigators conducted the review, which included studies published up to January 3, 2023. The quality of the eligible studies was evaluated and data were extracted using Review Manager software 5.4 (RevMan 5.4) to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The analysis comprised 35 studies and encompassed a collective sample of 18,246 individuals diagnosed with breast cancer. We did not find a statistically significant disparity in efficacy between conventional fractionated (CF) radiotherapy and hypofractionated (HF) radiotherapy regarding local recurrence (LR; OR = 0.91, 95% CI: 0.76-1.09, P = 0.30), disease-free survival (DFS; OR = 1.20, 95% CI: 1.01-1.42, P = 0.03), and overall survival (OS; OR = 1.08, 95% CI: 0.93-1.26, P = 0.28). Concerning safety, there was no significant difference between the HF and CF regimens in terms of breast pain, breast atrophy, lymphedema, pneumonia, pulmonary fibrosis, telangiectasia, and cardiotoxicity. However, the HF regimen resulted in lower skin toxicity (OR = 0.43, 95% CI: 0.33-0.55, P < 0.01) and improved patient fatigue outcomes (OR = 0.73, 95% CI: 0.60 - 0.88, P < 0.01).

CONCLUSIONS

Although there is no substantial difference in LR, DFS, OS, or many other side effects between the HF and CF regimens, the HF regimen reduces skin toxicity and relieves patient fatigue. If these two issues need to be addressed in clinical situations, the HF regimen may be a superior alternative to conventional radiotherapy in postoperative breast cancer patients.

Long-term treatment results of conventional and hypofractionation radiotherapy in postmastectomy cancer breast patients: A retrospective study from rural cancer center of Maharashtra, India

AIM

This study aims to evaluate the long-term treatment outcome of conventional and hypofractionation radiotherapy in postmastectomy cancer breast patients.

MATERIAL AND METHODS

A total of 140 postmastectomy breast cancer patients were included in this retrospective study, who were treated from 2012 to 2014 with chemotherapy and various fractionation radiotherapy schedules. Radiotherapy treatment records for study group-I received radiotherapy 4256 cGy in 16 fractions over 3½ weeks, group-II patients received 4005 cGy in 15 fractions over 3 weeks, and conventional radiotherapy group-III received 5000 cGy in 25 fractions over 5 weeks.

RESULTS

The median follow-up of patients from all groups was 60 months (range 9 to 111 months). There were 39 cases with disease failure, 13 (26%) in group I (42.56 Gy), 16 (40%) in group II (40.05 Gy), and 10 (20%) in group III (50 Gy). There were 4 locoregional recurrences (LRRs), two isolated, and 11 distant failures in group I, 3 LRRs (1 isolated LRR) and 15 distant failures in group II, and only one LRR and 9 distant failures in group III. The disease-free survival (DFS) were 74%, 60%, and 80%, respectively, in groups I, II, and III (P =0.044).

CONCLUSION

The long-term results of this study show that hypofractionation radiotherapy in postmastectomy cases is well tolerated and acute and late side effects are also comparable to conventional fractionation. In our study, locoregional and distant failure seems slightly higher with hypofractionation schedules than in other studies, highlighting the need for more studies with long-term follow-up in postmastectomy patients.

Moderately hypofractionated post-operative radiation therapy for breast cancer: preferences amongst radiation oncologists from countries in Latin America and the Caribbean

Background

The safety and effectiveness of moderately hypofractionated post-operative radiation therapy for breast cancer were demonstrated by several trials. This study aimed to evaluate the current patterns of practice and prescription preference about moderately hypofractionated post-operative radiation therapy to assess possible aspects that affect the decision-making process regarding the use of fractionation in breast cancer patients in Latin America and the Caribbean (LAC). We also aimed to identify factors that can restrain the utilization of moderately hypofractionated post-operative radiation therapy for breast cancer.

Materials an methods

Radiation oncologists from LAC were invited to contribute to this study. A 38-question survey was used to evaluate their opinions.

Results

A total of 173 radiation oncologists from 13 countries answered the questionnaire. The majority of respondents (84.9%) preferred moderately hypofractionated post-operative radiation therapy as their first choice in cases of whole breast irradiation. Whole breast plus regional nodal irradiation, post-mastectomy (chest wall and regional nodal irradiation) without reconstruction, and post-mastectomy (chest wall and regional node irradiation) with reconstruction hypofractionated post-operative radiation therapy was preferred by 72.2% 71.1%, and 53.7% of respondents, respectively. Breast cancer stage, and flap-based breast reconstruction were the factors associated with absolute contraindications for the use of hypofractionated schedules.

Conclusion

Even though moderately hypofractionated post-operative radiation therapy for breast cancer is considered a new standard to the vast majority of the patients, its unrestricted application in clinical practice across LAC still faces reluctance.

Outcomes and toxicity following post-operative hypofractionated radiotherapy to the regional nodes and the breast or the chest wall in locally advanced breast cancer

OBJECTIVES

We aimed to analyze the impact of a 3-week schedule of HypoFractionated (HF) radiotherapy (RT) after axillary dissection and breast surgery, in terms of safety and efficacy in patients with locally advanced breast cancer (BC).

METHODS

Eligible patients were females with Stage IIA - IIIC BC who underwent axillary dissection and breast surgery, either quadrantectomy or mastectomy. HF RT was delivered in 15 or 16 fractions for a total dose of 40.05 Gy or 42.56 Gy, respectively, to the clavicular nodal region along with the whole breast (HF WBRT) or the chest wall (HF PMRT), according to the type of surgery. Locoregional recurrence (LRR), distant metastases-free survival (DMFS), overall survival (OS) and acute and late treatment-related toxicities were estimated.

RESULTS

57 patients with a median age of 60 years (32-85) were retrospectively analyzed. 34 (60%) of patients underwent breast conservative surgery in the form of quadrantectomy and 23 (40%) were offered radical mastectomy. All patients underwent hypofractionated regional nodal irradiation (HF RNI). 34 (60%) of them underwent HF WBRT, while 23 (40%) received HF PMRT.At a median follow-up of 80 months (30-113), the 7-year LRR-free survival was 93% (95% CI, 74%-95%). The same features for DMFS and OS were 76% (95% CI, 52%-78%) and 67% (95% CI, 50%-80%), respectively. Only one (2%) patient experienced G3 acute skin toxicity. No grade ≥2 late toxicity was observed.

CONCLUSION

Our study shows that HF RNI with HF RT to the whole breast or the chest wall after breast surgery is safe and effective in patients with locally advanced BC. Longer follow-up is needed to strengthen further analyses on late toxicity and clinical outcomes.

ADVANCES IN KNOWLEDGE

This paper adds to the evidence that post-operative RNI with WBRT or PMRT can be safely and effectively delivered with 3-week HF regimen. Locally advanced BC patients can be offered HF RT to the regional nodes and the breast or the chest wall regardless the type of surgery.

Feasibility, Tolerance, and Quality of Life for Hypofractionation Versus Conventional Fractionation for Post-mastectomy Radiotherapy in Indian Patients

Introduction: The international standard for post-operative radiotherapy for breast cancer delivers hypofractionated radiotherapy. However, many centers in India still follow the longer conventional schedule probably because of paucity of large prospective trials in Indian patients on the same and apprehension regarding tolerance of high dose per fraction in the said population. We aimed to test the feasibility of hypofractionation in our setting and compared the toxicities and the quality of life in patients receiving conventional and hypofractionated radiotherapy.

Materials and methods: Eighty histopathologically proven women of non-metastatic carcinoma breast who underwent modified radical mastectomy were assigned to receive 50 Gray/25 fractions/five weeks or 40 Gray/15 fractions/three weeks. Patients were assessed for the following toxicities - radiation dermatitis, radiation pneumonitis, dysphagia, skin fibrosis, lymphedema, shoulder stiffness, and brachial plexopathy, during radiation and at treatment completion and then at first, third, and sixth-month follow-up. Health-related quality of life was assessed using the European Organisation for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) and breast cancer-specific quality of life questionnaire (QLQ-BR23) at treatment completion and then at first, third, and sixth-month follow-up.

Results and conclusion: We had a mean follow-up of 12.78 months. All the assessed toxicities and quality of life scores were comparable between the two arms at all time points of evaluation (p>0.05); 40 Gray in 15 fractions over three weeks is feasible and as safe as the five-week schedule with comparable quality of life. Hypofractionation can be practiced as a routine for post-mastectomy breast cancer patients as this shorter radiotherapy schedule is convenient and cheaper for the patients with no compromise on normal tissue toxicity or quality of life.

Ten-year outcomes of hypofractionated postmastectomy radiation therapy of 26 Gy in 6 fractions

PURPOSE

To investigate the efficacy and long-term side effects of hypofractionated postmastectomy radiation therapy (HFRT-PM) of 26 Gy in 6 fractions over 5 weeks.

MATERIALS & METHODS

We retrospectively reviewed characteristics and outcomes of patients with stage I-III breast cancer treated with HFRT-PM between 2000-2009. Treatment provided four fractions of 4 Gy (day (d)1, d3, d15, d17) then two fractions of 5 Gy (d29, d31) over 5 weeks. The treatment techniques were applied by using 3D conformal radiotherapy of chest wall with regional nodal volume if required.

RESULTS

454 patients were identified, with a median follow-up of 10.6 years (range 0.5-22.9). Regional nodal irradiation was made in 84.1 % of patients. At 10 years, the cumulative incidence of locoregional relapse was 15.1 %. In multivariate analysis, regional lymph nodes involvement (≥ 4 nodes) was associated with worse locoregional control (HR 1.68; [95% CI 1.06-2.67], p = 0.03) and overall survival (HR 2.16; [95% CI 1.59-2.95], p < 0.001). The toxicities were acceptable. The incidence of cardiac disorders (3.3 %), and symptomatic lung fibrosis (1.5 %) was low during follow-up. At 10 years, the cumulative rate of arm lymphedema was 9.5 % and considered severe in 20 patients (4.4 %).

CONCLUSION

The long-term results of this study show that HFRT-PM of 26 Gy in 6 fractions over 5 weeks seems safes but locoregional recurrence seems slightly higher than those observed in the literature, highlighting that long-term follow-up is needed and the need of randomized trials for hypofractionated radiotherapy therapy in postmastectomy situation.

Hypofractionated Postmastectomy Radiation Therapy

Purpose

To provide an overview of the major randomized trials that support the use of hypofractionated post-mastectomy radiation therapy for locally advanced breast cancer patients.

Methods and Materials

PubMed was systematically reviewed for publications reporting use of of hypofractionated radiation therapy in patients requiring post-mastectomy radiation.

Results

Standard fractionation, which is typically delivered over 5 to 7 weeks, is considered the standard of care in setting of post-mastectomy radiation therapy (PMRT). Modern data has helped to establish hypofractionated whole breast irradiation, which consists of a 3- to 4-week regimen, as a new standard of care for early-stage breast cancer. Hypofractionated whole breast irradiation has also laid the groundwork for the exploration of a hypofractionated approach in the setting of hypofractionated post-mastectomy radiation therapy.

Conclusions

While standard fractionation remains the most commonly utilized regimen for PMRT, recently published trials support the safety and efficacy of a hypofractionated approach. Ongoing trials are further investigating the use of hypofractionated PMRT.

The use of moderately hypofractionated post-operative radiation therapy for breast cancer in clinical practice: A critical review

Post-operative radiation therapy (RT) reduces loco-regional recurrence rates and mortality in most patients with non-metastatic breast cancer. The aim of this critical review is to provide an overview of the applicability of moderately hypofractionated RT for breast cancer patients, focusing on factors influencing clinical decision-making. An international group of radiation oncologists agreed to assess, integrate, and interpret the existing evidence into a practical report to guide clinicians in their daily management of breast cancer patients. We conclude that moderately hypofractionated RT to the breast, chest wall (with/without breast reconstruction), and regional lymph nodes is at least as safe and effective as conventionally fractionated regimens and could be considered as the treatment option for the vast majority of the patients.For those who are still concerned about its generalised application, we recommend participating in ongoing trials comparing moderately hypofractionated RT to conventionally fractionated RT for breast cancer patients in some clinical circumstances.

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.

Comparison of Treatment Outcome between Hypofractionated Radiotherapy and Conventional Radiotherapy in Postmastectomy Breast Cancer

Objective:

The aim of this study was to compare Conventional fractionated radiotherapy (CFRT) and Hypofractionated radiotherapy (HFRT) in terms of treatment outcomes, such as in 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity.

Materials and Methods:

We retrospectively analyzed the data obtained from 462 breast cancer patients who received complete adjuvant radiotherapy treatment between January 2012 and December 2014. One hundred twenty eight patients received CFRT 2 Gy daily fractions at a total dose of 48-60 Gy (group 1), while 334 patients received HFRT 2.65-2.67 Gy daily for 15-19 fractions at a total dose of 39.7-47.8 Gy 9 (grup 2). Treatment outcome such as 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity were measured and compared between two groups.

Results:

Median follow-up was 65.7 months (ranging from 45.1 to 95.2 months). Five-year loco-regional recurrence free survival rate was 96.1% in both CFRT and HFRT groups (p=0.993). Five-year disease-free survival rate of CFRT group was higher (68.8%), but this difference was not significant (HFRT =63.5%) (p=0.396). These were complied with 5-year overall survival rate (71.9% and 64.7%, p=0.385). Five-year distant metastatic free survival rate was 85.9% in CFRT group and 79.6% in HFRT group (p=0.169). No difference was observed between two groups in terms of toxicities, including changes in chest wall appearance, skin fib rosis, brachial plexopathy, arm edema, pulmonary fibrosis, and cardiovascular events.

Conclusion:

The treatment outcomes of hypofractionated radiotherapy in the postmastectomy breast cancer patients is comparable to the outcomes of conventional treatment at the Chonburi Cancer Hospital as previously reported from other studies, and HFRT can be implemented in resource-limited settings.

Conventional versus hypofractionated postmastectomy radiotherapy: a report on long-term outcomes and late toxicity

Objective

We evaluated the long-term outcomes and late toxicity of conventional fractionated (CF) and hypofractionated (HF) postmastectomy radiotherapy (PMRT) in terms of locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), overall survival (OS), and late toxicity.

Methods

A cohort of 1640 of breast cancer patients receiving PMRT between January 2004 and December 2014 were enrolled. Nine hundred eighty patients were treated with HF-PMRT: 2.65 Gy/fraction to a total of 42.4–53 Gy and 660 patients were treated with CF-PMRT: 2 Gy/fraction to a total of 50–60 Gy.

Results

The median follow-up time was 71.8 months (range 41.5–115.9 months). No significant difference was found in the rates of 5-year LRRFS, DFS, and OS of HF-PMRT vs CF-PMRT; 96% vs. 94% (p = 0.373), 70% vs. 72% (p = 0.849), and 73% vs. 74% (p = 0.463), respectively. We identified a cohort of 937 eligible breast cancer patients who could receive late toxicities assessment. With a median follow-up time of this patient cohort of 106.3 months (range 76–134 months), there was a significant higher incidence of grade 2 or more late skin (4% vs 1%) and subcutaneous (7% vs 2%) toxicity in patients treated with HF-PMRT vs CF-PMRT. Patients who received additional radiation boost were significantly higher in the HF-PMRT group. Grade 2 or more late RTOG/EORTC lung toxicity was significant lesser in HF-PMRT vs CF-PMRT (9% vs 16%). Grade 1 brachial plexopathy was also significant lesser in HF-PMRT vs CF-PMRT (2% vs 8%). Heart toxicity and lymphedema were similar in both groups.

Conclusions

HF-PMRT is feasible to deliver with comparable long-term efficacy to CF-PMRT. HF-PMRT had higher grade 2 or more skin and subcutaneous toxicity but less lung and brachial plexus toxicity.

Trends and Patterns of Utilization of Hypofractionated Postmastectomy Radiotherapy: A National Cancer Database Analysis

BACKGROUND

The acceptance of hypofractionated radiotherapy in treating breast cancer in the breast conservation therapy setting has stimulated interest in hypofractionated postmastectomy radiotherapy (PMRT). We assessed national trends and patterns of utilization of hypofractionated PMRT.

PATIENTS AND METHODS

Women 18 years of age or older with breast cancer treated with mastectomy and PMRT to the chest wall with or without regional lymph nodes from 2004 to 2014 were identified from the National Cancer Database. A standard fractionation cohort was defined as patients receiving 180 to 200 cGy per fraction to a total dose of 4500 to 7000 cGy over 5 to 7 weeks, and a hypofractionation cohort was defined as those receiving 250 to 400 cGy per fraction to a total dose of 3000 to 6000 cGy over 2 to 5 weeks. Multivariable logistic regression was used to determine factors associated with hypofractionated PMRT use.

RESULTS

We identified 113,981 patients who met study criteria. Overall, hypofractionated PMRT use was low (1.1%) although utilization increased over time (P ≤ .001). Older age, greater comorbidity, further distance from treatment facility, treatment at academic facilities, less extensive disease, and recent treatment year were statistically significant predictors of hypofractionation use compared with standard fractionation. Conversely, breast reconstruction and receipt of chemotherapy were negative predictors.

CONCLUSION

Because of the absence of high-level evidence to support its use, hypofractionated PMRT was uncommonly utilized in the United States from 2004 to 2014, although a small increase in use was noted over time. Findings from this study might be useful in designing future studies, and might serve as a baseline for evaluation of future changes in practice patterns.

A Comparative Study of Hypofractionated and Conventional Radiotherapy in Postmastectomy Breast Cancer Patients

Objective

The aim of this study was to compare toxicity and locoregional control of short duration hypofractionated (HF) radiotherapy (RT) with conventional RT in breast cancer patients.

Methods

A total of 100 postmastectomy breast cancer patients were randomized for adjuvant RT in control group (comprising fifty patients who received the standard conventional dose of 50 Gy in 25 fractions with 2 Gy per fraction) and study group (comprising fifty patients who received HF RT with dose of 42.72 Gy in 16 fractions with 2.67 Gy per fraction). All patients were treated on linear accelerator with 3-dimensional conformal RT technique. Outcome was analyzed in terms of toxicity, tolerability, and locoregional control.

Results

In the present study, at a median follow-up of 20 months, almost similar results were seen in both the groups in terms of toxicity, tolerability, and locoregional control. Adjuvant postmastectomy HF RT was found to be well tolerated with mild-to-moderate side effects that neither reached statistical significance nor warranted any treatment interruption/hospitalization.

Conclusions

HF postmastectomy RT is comparable to conventional RT without evidence of higher adverse effects or inferior locoregional tumor control and has an added advantage of increased compliance because of short duration; hence, it can help in accommodating more breast cancer patients in a calendar year, ultimately resulting in decreased waiting list, increased turnover, and reduced cost of treatment.

A Retrospective Analysis of Toxicity and Efficacy for 2 Hypofractionated Irradiation Schedules Versus a Conventional One for Post-Mastectomy Adjuvant Radiotherapy in Breast Cancer

INTRODUCTION

The aim of this analysis was a retrospective evaluation of the efficacy and toxicity of 2 hypofractionated irradiation schedules compared to conventional therapy in post-mastectomy patients.

METHODS

3 irradiation schedules were analyzed: 48.30 Gy in 21 fractions (group A, n = 60), 42.56 Gy in 16 fractions (group B, n = 27) and 50 Gy in 25 fractions (group C, n = 30) of the front chest wall. All groups were also treated with a supraclavicular field, with 39.10 Gy in 17 fractions (group A), 37.24 Gy in 14 fractions (group B) or 45 Gy in 25 fractions (group C).

RESULTS

No local recurrences were noted in any group during 36 months of follow-up. Acute skin toxicity presented in all groups, with 58.3%, 70.4% and 60% of grade I; 35%, 25.9% and 40% of grade II; 6.7%, 3.7% and 0% of grade III being seen in groups A, B and C, respectively. Late skin toxicity was noted only as grade I in 16.7%, 25.9% and 26.7% of groups A, B and C, respectively. No significant difference was noted among all groups for either acute or late skin toxicity, or for radio-pneumonitis (chi² test, p > 0.05).

CONCLUSION

All schedules were equally effective with equivalent toxicity. A prospective randomized study is needed to confirm our results.

Systematic review and meta-analysis comparing hypofractionated with conventional fraction radiotherapy in treatment of early breast cancer

BACKGROUND

The purpose of this meta-analysis is to evaluate the efficacy and safety of altered radiation fraction size on outcomes for early breast cancer patients.

METHODS

A search of MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library and ClinicalTrials.gov was conducted. Quality of the randomized controlled trials (RCTs) or non-RCTs were evaluated according to Cochrane's risk of bias tool or Methodological Index for non-Randomized Studies (MINORS). Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated. Subgroup analysis was applied according to different fraction dose and sensitivity analysis was performed according to RCTs or non-RCTs.

RESULTS

23 studies were included in this systematic review. Meta-analysis demonstrated hypofractionation radiotherapy (HFRT) was associated with decreased grade 2/3 acute skin reactions compared with conventional fraction RT (CFRT), either 2.5-3.0 Gy per fraction or 5.0-6.5 Gy per fraction. HFRT with 2.5-3.0 Gy per fraction significantly decreased moderate/marked photographic changes in breast appearance compared with CFRT [RR = 0.80, 95% CI (0.70, 0.91), P = 0.001], while HFRT with more than 3.0 Gy per fraction significantly increased moderate/marked photographic changes [RR = 1.21, 95% CI (1.06, 1.38), P = 0.004]. In addition HFRT cost one-third lower than CFRT. Regarding to local regional recurrence, distant metastasis, overall survival, disease free survival, excellent/good cosmetic comes, symptomatic radiation pneumonitis, ischemic heart disease and symptomatic rib fracture, there was no significant difference between two arms.

CONCLUSIONS

Based on available evidence, HFRT with 2.5-3.0 Gy per fraction should be the better choice for treatment of early breast cancer patients.