Toxicité aiguë de la tomothérapie des cancers mammaires

Risk Factors Related to Acute Radiation Dermatitis in Breast Cancer Patients After Radiotherapy: A Systematic Review and Meta-Analysis

Background

Acute radiation dermatitis (ARD) is the most common acute response after adjuvant radiotherapy in breast cancer patients and negatively affects patients’ quality of life. Some studies have reported several risk factors that can predict breast cancer patients who are at a high risk of ARD. This study aimed to identify patient- and treatment-related risk factors associated with ARD.

Methods

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and WanFang literature databases were searched for studies exploring the risk factors in breast cancer patients. The pooled effect sizes, relative risks (RRs), and 95% CIs were calculated using the random-effects model. Potential heterogeneity and sensitivity analyses by study design, ARD evaluation scale, and regions were also performed.

Results

A total of 38 studies composed of 15,623 breast cancer patients were included in the analysis. Of the seven available patient-related risk factors, four factors were significantly associated with ARD: body mass index (BMI) ≥25 kg/m² (RR = 1.11, 95% CI = 1.06–1.16, I² = 57.1%), large breast volume (RR = 1.02, 95% CI = 1.01–1.03, I² = 93.2%), smoking habits (RR = 1.70, 95% CI = 1.24–2.34, I² = 50.7%), and diabetes (RR = 2.24, 95% CI = 1.53–3.27, I² = 0%). Of the seven treatment-related risk factors, we found that hypofractionated radiotherapy reduced the risk of ARD in patients with breast cancer compared with that in conventional fractionated radiotherapy (RR = 0.28, 95% CI = 0.19–0.43, I² = 84.5%). Sequential boost and bolus use was significantly associated with ARD (boost, RR = 1.91, 95% CI = 1.34–2.72, I² = 92.5%; bolus, RR = 1.94, 95% CI = 1.82–4.76, I² = 23.8%). However, chemotherapy regimen (RR = 1.17, 95% CI = 0.95–1.45, I² = 57.2%), hormone therapy (RR = 1.35, 95% CI = 0.94–1.93, I² = 77.1%), trastuzumab therapy (RR = 1.56, 95% CI = 0.18–1.76, I² = 91.9%), and nodal irradiation (RR = 1.57, 95% CI = 0.98–2.53, I² = 72.5%) were not correlated with ARD. Sensitivity analysis results showed that BMI was consistently associated with ARD, while smoking, breast volume, and boost administration were associated with ARD depending on study design, country of study, and toxicity evaluation scale used. Hypofractionation was consistently shown as protective. The differences between study design, toxicity evaluation scale, and regions might explain a little of the sources of heterogeneity.

Conclusion

The results of this systematic review and meta-analysis indicated that BMI ≥ 25 kg/m² was a significant predictor of ARD and that hypofractionation was consistently protective. Depending on country of study, study design, and toxicity scale used, breast volume, smoking habit, diabetes, and sequential boost and bolus use were also predictive of ARD.

[Tobacco and alcohol consumption in women treated for breast cancer in a department of surgical oncology: Frequent behaviours to consider]

INTRODUCTION

Tobacco and alcohol represent the two most important risk factors increasing cancer incidence and mortality, particularly among women with breast cancer. However, few researches have focused on the consumption of psychoactive substances in women treated for breast cancer. The present study describes the prevalence of tobacco and alcohol consumption and their relationships with the sociodemographic, medical and psychological variables in a population of women receiving surgery treatment for breast cancer.

METHODS

Between October 2014 and August 2015, a group of women receiving breast cancer treatment were recruited to participate to a screening and brief intervention program (SBI) for the consumption of tobacco and alcohol, adapted to the oncology context. Data on tobacco and alcohol consumption were collected using two questionnaires : the smoking status identification (NIDA) and alcohol consumption (AUDIT-C). A questionnaire for socio- demographic data and two for psychological data (Thermometer of psychological distress; ESAS), have been used. The medical data were reported by participants and verified on medical records.

RESULTS

In a total of 11 months, 120 women with breast cancer were included in this study. A large majority of patients were hospitalized for a first-time cancer (80.8%), type invasive ductal carcinoma (70.8%) and were receiving surgery as primary treatment (45%). Furthermore, 30.8% of the women reported tobacco consumption and 38.4% high-risk alcohol consumption. Regarding mental health, 40.8% presented moderate to intense levels of psychological distress. No significant relationships were found between consumption scores and sociodemographic, medical or psychological characteristics. Only the patient's age was negatively associated with tobacco consumption.

DISCUSSION

Tobacco and at-risk alcohol consumption are frequently reported behaviors during breast cancer treatment. Intervention strategies targeting risk behaviors related to addictive consumption should be implemented during the full treatment of breast cancer patients.

Predictors of Acute Radiation Dermatitis and Esophagitis in African American Patients Receiving Whole Breast Radiotherapy

PURPOSE/OBJECTIVES

Adjuvant whole breast radiotherapy following breast conserving surgery is standard of care in the management of early stage breast cancer. Two of the most common acute toxicities of breast radiotherapy are radiation esophagitis (RE) and radiation dermatitis (RD). African Americans are at higher risk for experiencing treatment-related toxicity and are often under-represented in clinical trials.

METHODS

An institutional database was developed to include all African American patients with history of breast cancer or DCIS undergoing adjuvant radiotherapy at a single institution from 2013-2019. Records were reviewed to identify patient age, BMI, radiation dose, prone vs supine position, inclusion of boost, and inclusion of regional nodal irradiation (RNI). Radiation treatment plans were reviewed to identify breast size as well as dosimetric parameters to the breast and esophagus. Medical records were reviewed to identify which patients were prescribed silvadene or mylanta-lidocaine during or immediately following their course of radiotherapy which was used as a surrogate for Grade 2 or higher dermatitis (G2RD) and esophagitis (G2RE), respectively.

RESULTS

272 patients were included in the final analysis. On univariable analysis, morbidly obese patients were more likely to develop G2RD while hypofractionated radiotherapy was associated with lower rates of G2RD. On multivariable analysis, increasing breast volume was associated with higher rates of G2RD. For the subset of patients receiving RNI, 19% of patients experienced G2RE with the best predictor on multivariable analysis being D_mean to the esophagus.

CONCLUSION

Radiation dermatitis and esophagitis are common toxicities in African American patients undergoing adjuvant breast radiotherapy. Breast size, irrespective of patient's BMI, was associated with worse rate of dermatitis. Prone position and hypofractionated radiation reduced rates of G2RD. D_mean to the esophagus was the dosimetric parameter best correlating with G2RE. These results may be used to help select patients are at higher risk for G2 or higher toxicity during radiotherapy.

Correlation between toxicity and dosimetric parameters for adjuvant intensity modulated radiation therapy of breast cancer: a prospective study

ORCID: 0000–0001-6019–7309. In the treatment of breast cancer, intensity-modulated radiation therapy (IMRT) reportedly reduces the high-dose irradiation of at-risk organs and decreases the frequency of adverse events (AEs). Comparisons with conventional radiotherapy have shown that IMRT is associated with lower frequencies of acute and late-onset AEs. Here, we extended a prospective, observational, single-center study of the safety of IMRT to a second investigating center. Patients scheduled for adjuvant IMRT after partial or total mastectomy were given a dose of 50 Gy (25 fractions of 2 Gy over 5 weeks), with a simultaneous integrated boost in patients having undergone conservative surgery. 300 patients were included in the study, and 288 were analyzed. The median follow-up period was 2.1 years. The 2-year disease-free survival rate [95% CI] was 93.4% [89.2–96.0%]. Most AEs were mild. The most common AEs were skin-related—mainly radiodermatitis [in 266 patients (92.4%)] and hyperpigmentation (in 178 (61.8%)). 35% and 6% of the patients presented with grade 2 acute skin and esophageal toxicity, respectively. Only 4 patients presented with a grade 3 event (radiodermatitis). Smoking (odds ratio) [95% CI] = 2.10 [1.14–3.87]; p = 0.017), no prior chemotherapy (0.52 [0.27–0.98]; p = 0.044), and D98% for subclavicular skin (1.030 [1.001–1.061]; p = 0.045) were associated with grade ≥ 2 acute AEs. In a univariate analysis, the mean dose, (p < 0.0001), D2% (p < 0.0001), D50% (p = 0.037), D95% (p = 0.0005), D98% (p = 0.0007), V30Gy (p < 0.0001), and V45Gy (p = 0.0001) were significantly associated with grade ≥ 1 acute esophageal AEs. In a multivariate analysis, D95% for the skin (p < 0.001), D98% for the subclavicular skin and low D95% for the internal mammary lymph nodes were associated with grade ≥ 1 medium-term AEs. The safety profile of adjuvant IMRT after partial or total mastectomy is influenced by dosimetric parameters.

Trial registration: ClinicalTrials.gov NCT02281149.

Prospective Study of Intensity-Modulated Radiation Therapy for Locally Advanced Breast Cancer

Simple Summary

Tomotherapy is a modern intensity-modulated radiotherapy technique, whose aim is to reduce the high doses delivered to organs at risk. Thus, we conducted a prospective study evaluating the early and medium-term toxicities, the patient’s quality of life, and the aesthetic outcomes (evaluated by both physicians and patients) of tomotherapy for breast cancer. We wanted to show that this treatment is very well tolerated, with low-grade acute toxicities, and has only a moderate impact on patients’ quality of life and aesthetic outcome, in order to support its larger use in this very frequent situation.

Abstract

The objective of this study was to evaluate the acute and medium-term toxicities, the quality of life, and aesthetic results of patients with breast cancer (BC) treated with tomotherapy. This was a prospective study, including patients with BC treated by tomotherapy. Radiation therapy delivered 50 Gy in 25 fractions to the breast or chest wall and to lymph node areas, with a simultaneous integrated boost at a dose of 60 Gy at the tumor bed in cases of breast conservative surgery. We included 288 patients, 168 and 120 treated with breast-conserving surgery and mastectomy respectively. Two hundred sixty patients (90.3%) received lymph node irradiation. Median follow-up was 25 months (6–48). Acute dermatitis was observed in 278 patients (96.5%), mostly grade 1 (59.7%). The aesthetic aspect of the breast at one year was reported as “good” or “excellent” in 84.6% of patients. The patients’ quality of life improved over time, especially those treated with chemotherapy. The two-year overall survival and disease-free survival were 97.8% (95% confidence interval (CI): 94.1–99.2%), and 93.4% (95% CI: 89.2–96.0%) respectively. Tomotherapy for locally advanced BC has acceptable toxicity, supporting its use in this indication; however, longer follow-up is needed to assess long-term outcomes.

The impact of smoking on adjuvant breast cancer radiation treatment: A systematic review

BACKGROUND

The influence of cigarette smoking on cancer risk has been well-studied. Similarly, exposure to ionizing radiation from radiotherapy (RT) can produce detrimental effects on an individual's health. In patients administered RT, there has been an observed relationship in other primary carcinomas. The purpose of this systematic review was to summarize the influence of cigarette smoking on outcomes post adjuvant RT in breast cancer patients.

METHODS

OVID Medline, Cochrane and Embase were searched and 1893 articles were identified. A total of 71 articles were included in the review. Study type, published year and sample size, age, systemic therapies, RT techniques and treatment side effects were collected if available.

RESULTS

The review found 198 different outcomes which fell into 7 categories and similar outcomes were recorded. 40% of skin reaction outcomes, 50% of cardiovascular outcomes, 71% of reconstruction outcomes, 29% of pulmonary function outcomes, 33% of mortality outcomes and 42% of secondary recurrence outcomes reported significant differences between smokers and non-smokers. None of the articles reported non-smokers to have a higher risk than smokers.

CONCLUSION

Cigarette smoking can pose a higher risk of post-treatment complications that can influence an individual's quality of life, survival rate and/or recurrence risk. This review further assessed the impact of smoking on various patient outcomes and side-effects in the adjuvant breast RT setting. The information provided in this review suggest that smoking cessation programs would help educate patients to understand their risks of being a current or former smoker when undergoing RT.

Intensity-modulated radiation therapy with simultaneous integrated boost for locally advanced breast cancer: a prospective study on toxicity and quality of life

Radiotherapy after breast conserving surgery and mastectomy with node positive disease has been shown to reduce risk of recurrence and mortality in the treatment of breast cancer. Intensity-modulated radiation therapy (IMRT) after conservative surgery offers several advantages over conventional RT including improved acute and late toxicity and quality of life (QoL). We undertook this study to prospectively evaluate acute (≤90 days after last dose of radiotherapy) and long-term (>90 days) cutaneous, esophageal, and fibrosis toxicity and QoL in breast cancer patients treated by adjuvant IMRT after breast surgery. We included patients with complex volumes for which 3D RT does not allow a good coverage of target volumes and sparing organs at risk. We report here an interim analysis with a median follow-up of 13.1 months (range, 6.5–25.9 months). Most of the acute toxicity was cutaneous (95.9%) and oesophageal (59.6%), and mostly grade 1 and 2. Medium-term cutaneous toxicity rate was 25.6%, and mostly grade 1. Medium-term esophageal toxicity was rare (1.8%). In this series acute oesophageal toxicity was found to be associated with dosimetric factors. QoL was well preserved throughout the study, and aesthetic outcomes were good. Based on these data, tomotherapy may be a favorable alternative to other techniques in patients needing a complex irradiation of the breast and lymph node volumes.

Skin toxicity after chest wall/breast plus level III-IV lymph nodes treatment with helical tomotherapy

INTRODUCTION

To evaluate the incidence of toxicity in breast cancer with helical tomotherapy (HT).

MATERIALS AND METHODS

51 patients with breast cancer were assigned to postoperative radiotherapy by means of HT to the chest wall/breast plus draining nodes. During HT treatment, toxicity was monitored and were assessed using the Common Terminology Criteria for Adverse Events 4.0 scale.

RESULTS

Acute skin G3 toxicity observed in 1.9% cases. No acute or late G4 toxicity was observed. At a median follow-up of 21 months 2 patients have late G1 toxicity.

CONCLUSIONS

HT was associated with a low incidence of low-grade skin toxicity.