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Aristei C, Perrucci E, Alì E, Marazzi F, Masiello V, Saldi S, Ingrosso G. Personalization in Modern Radiation Oncology: Methods, Results and Pitfalls. Personalized Interventions and Breast Cancer. Front Oncol 2021; 11:616042. [PMID: 33816246 PMCID: PMC8012886 DOI: 10.3389/fonc.2021.616042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/02/2021] [Indexed: 12/31/2022] Open
Abstract
Breast cancer, the most frequent malignancy in women worldwide, is a heterogeneous group of diseases, characterized by distinct molecular aberrations. In precision medicine, radiation oncology for breast cancer aims at tailoring treatment according to tumor biology and each patient’s clinical features and genetics. Although systemic therapies are personalized according to molecular sub-type [i.e. endocrine therapy for receptor-positive disease and anti-human epidermal growth factor receptor 2 (HER2) therapy for HER2-positive disease] and multi-gene assays, personalized radiation therapy has yet to be adopted in the clinical setting. Currently, attempts are being made to identify prognostic and/or predictive factors, biomarkers, signatures that could lead to personalized treatment in order to select appropriate patients who might, or might not, benefit from radiation therapy or whose radiation therapy might be escalated or de-escalated in dosages and volumes. This overview focuses on what has been achieved to date in personalized post-operative radiation therapy and individual patient radiosensitivity assessments by means of tumor sub-types and genetics.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | | | - Emanuele Alì
- Radiation Oncology Section, University of Perugia, Perugia, Italy
| | - Fabio Marazzi
- Radiation Oncology Department, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Valeria Masiello
- Radiation Oncology Department, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Simonetta Saldi
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
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2
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Obeng-Gyasi S, Coles CE, Jones J, Sacks R, Lightowlers S, Bliss JM, Brunt AM, Haviland JS, Kirby AM, Kalinsky K. When the World Throws You a Curve Ball: Lessons Learned in Breast Cancer Management. Am Soc Clin Oncol Educ Book 2021; 41:1-11. [PMID: 33956493 DOI: 10.1200/edbk_320691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the care of patients with operable breast cancer, there has been a shift toward increasing use of neoadjuvant therapy. There are benefits to neoadjuvant therapy, such as monitoring for response, as well as an increased rate of breast conservation and reduction of potential morbidity associated with breast surgery, including axillary management. Among patients with highly proliferative tumors, such as HER2-positive or triple-negative breast cancer, those with residual disease are at higher risk of recurrence, which informs the recommended systemic therapy in the adjuvant setting. For instance, in patients with residual disease after neoadjuvant chemotherapy and HER2-targeted therapy, there is a role for adjuvant trastuzumab emtansine for those with residual disease at the time of surgery. The same holds true regarding the role of adjuvant capecitabine in patients with residual disease after neoadjuvant chemotherapy. With the added complexities of treating patients in the era of the COVID-19 outbreak, additional considerations are critical, including initiation of surgery within an appropriate time from completion of neoadjuvant therapy. National consensus guidelines on time to surgery must be developed to improve measurement and comparison across systems. In addition, there is emerging radiation treatment management research addressing a number of factors, including hypofractionation, role of proton beam therapy, safe omission of radiotherapy, and preoperative radiotherapy with or without drug combination. In this article, the multidisciplinary approach of treating patients with operable breast cancer is highlighted, with updates and future considerations described.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jade Jones
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Ruth Sacks
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sara Lightowlers
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - A Murray Brunt
- School of Medicine, University of Keele, Keele, United Kingdom
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden National Health Service Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Kevin Kalinsky
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Piccart MJ, Hilbers FS, Bliss JM, Caballero C, Frank ES, Renault P, Naït Kaoudjt R, Schumacher E, Spears PA, Regan MM, Gelber RD, Davidson NE, Norton L, Winer EP. Road Map to Safe and Well-Designed De-escalation Trials of Systemic Adjuvant Therapy for Solid Tumors. J Clin Oncol 2020; 38:4120-4129. [PMID: 33052755 DOI: 10.1200/jco.20.01382] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 02/11/2024] Open
Abstract
An important challenge in the field of cancer is finding the balance between delivering effective treatments and avoiding adverse effects and financial toxicity caused by innovative, yet expensive, drugs. To address this, several treatment de-escalation trials have been conducted, but only a few of these have provided clear answers. A few trials had poor accrual or had design flaws that led to conflicting results. Members of the Breast International Group (BIG) and North American Breast Cancer Group (NABCG) believe the way forward is to understand the lessons from these trials and listen more carefully to what truly matters to our patients. We reviewed several adjuvant trials of different cancer types and developed a road map for improving the design and implementation of future de-escalation trials. The road map incorporates patients' insights obtained through focused group discussions across the BIG-NABCG networks. Considerations for the development of de-escalation trials for systemic adjuvant treatment, including noninferiority trial design, choice of end points, and prioritization of a patient's perspectives, are presented in this consensus article.
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Affiliation(s)
| | | | - Judith M Bliss
- The Institute of Cancer Research, Clinical Trials & Statistics Unit, London, United Kingdom
| | | | - Elizabeth S Frank
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
| | | | | | | | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Meredith M Regan
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Harvard TH Chan School of Public Health, Boston, MA
- Frontier Science and Technology Research Foundation, Boston, MA
| | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, Department of Medicine, New York, NY
| | - Eric P Winer
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
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Arenas M, Selek U, Kaidar-Person O, Perrucci E, Montero Luis A, Boersma L, Coles C, Offersen B, Meattini I, Bölükbaşı Y, Leonardi MC, Pfeffer R, Cutuli B, Vidali C, Franco P, Kouloulias V, Masiello V, Rivera S, Bourgier C, Ciabattoni A, Lancellotta V, Trigo L, Valentini V, Poortmans P, Aristei C. The 2018 assisi think tank meeting on breast cancer: International expert panel white paper. Crit Rev Oncol Hematol 2020; 151:102967. [PMID: 32450277 DOI: 10.1016/j.critrevonc.2020.102967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 01/13/2023] Open
Abstract
We report on the second Assisi Think Tank Meeting (ATTM) on breast cancer which was held under the auspices of the European Society for RadioTherapy & Oncology (ESTRO). In discussing in-depth current evidence and practice it was designed to identify grey areas in diverse forms of the disease. It aimed at addressing uncertainties and proposing future trials to improve patient care. Before the meeting, three key topics were selected: 1) primary systemic therapy, mastectomy, breast reconstruction and post-mastectomy radiation therapy, 2) therapeutic options in ductal carcinoma in situ, and 3) therapy de-escalation in early stage breast cancer. Clinical practice in these areas was investigated by means of an online questionnaire. The time lapse period between the survey and the meeting was used to review the literature and on-going clinical trials. At the ATTM both were discussed in depth and research protocols were proposed.
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Affiliation(s)
| | - Ugur Selek
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | - Orit Kaidar-Person
- Radiation Oncology, Oncology Institute, Rambam Medical Center, Haifa, Israel
| | | | | | - Liesbeth Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Charlotte Coles
- Radiation Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Icro Meattini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Yasemin Bölükbaşı
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | | | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centres, Tel Aviv, Israel
| | - Bruno Cutuli
- Radiation Oncology, Institut du Cancer Courlancy, Reims, France
| | - Cristiana Vidali
- Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Pierfrancesco Franco
- Radiation Oncology, Department of Oncology, University of Turin School of Medicine, Turin, Italy
| | - Vassilis Kouloulias
- Radiation Oncology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, Athens, Greece
| | - Valeria Masiello
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, University Montpellier, Montpellier, France
| | | | - Valentina Lancellotta
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lurdes Trigo
- Radiation Oncology, Instituto Portugues de Oncologia Francisco Martins Porto E.P.E, Porto, Portugal
| | - Vincenzo Valentini
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Philip Poortmans
- Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp - University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Cynthia Aristei
- Radiation Oncology, University of Perugia and Perugia General Hospital, Perugia, Italy.
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Chua BH. Individualised target volume selection and dose prescription after conservative surgery, mastectomy and reconstruction. Breast 2019; 48 Suppl 1:S69-S75. [PMID: 31839165 DOI: 10.1016/s0960-9776(19)31128-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Progress in radiotherapy (RT) for early breast cancer, driven by advances in radiobiology and radiation techniques is enabling individualised target volume and dose-fractionation according to recurrence risk. Conventionally fractionated WBI (CF-WBI) has been justified on the basis that it spares dose-limiting late-responding normal tissues more than breast cancer. However, randomised clinical trials (RCTs) testing hypofractionated WBI (HF-WBI) showed equivalent tumour control, improved acute toxicity and similar late toxicity between selected HF-WBI schedules and CF-WBI. RCTs showed that tumour bed boost (TBB) after WBI improved local control but increased breast fibrosis compared to no TBB. RCT comparing sequential TBB and simultaneous integrated TBB using dose intensity modulation showed similar toxicity. Partial breast irradiation (PBI) limits target volume to the tumour bed, which permits safe treatment acceleration. RCTs showed that PBI resulted in low local relapse rates but in some RCTs, higher rates of late toxicity and adverse cosmetic outcome than WBI. Given heterogeneity of PBI techniques, target volumes and dose-fractionation schedules used in RCTs, interpretation of results to distinguish whether outcome variations are caused by target volume or dose-fractionation effect is challenging. RCTs demonstrating efficacy of post-mastectomy RT (PMRT) included the chest wall and regional nodes but did not distinguish relative contributions of nodal target sub-volumes. In patients with smaller axillary tumour burden, IMC irradiation is controversial. RCTs were not powered for comparison between CF-PMRT and HF-PMRT. No increase in arm or shoulder dysfunction with HF-PMRT was observed. No RCT data exist on HF-PMRT in patients with breast reconstruction.
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Affiliation(s)
- Boon H Chua
- Faculty of Medicine, University of New South Wales, UNSW Sydney, NSW, Australia; Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.
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Bhattacharya IS, Bliss JM. Clinical Trials From the Other Side: Lessons Learned by a Clinician Venturing Into a Clinical Trials Unit. Clin Oncol (R Coll Radiol) 2019; 31:420-423. [PMID: 32778327 DOI: 10.1016/j.clon.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/08/2019] [Accepted: 03/25/2019] [Indexed: 11/19/2022]
Affiliation(s)
- I S Bhattacharya
- The Institute of Cancer Research Clinical Trials and Statistics Unit, London, UK.
| | - J M Bliss
- The Institute of Cancer Research Clinical Trials and Statistics Unit, London, UK
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7
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Dong Y, Zhang WW, Wang J, Sun JY, He ZY, Wu SG. The 21-gene recurrence score and effects of adjuvant radiotherapy after breast conserving surgery in early-stage breast cancer. Future Oncol 2019; 15:1629-1639. [PMID: 30864836 DOI: 10.2217/fon-2018-0967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aim: To investigate the associations with the 21-gene recurrence score (RS) and effect of adjuvant radiotherapy (RT) for early-stage breast cancer after breast conserving surgery. Methods: We included 13,246 patients in the SEER database. Results: Patients with a higher RS were independently related to nonreceipt of RT (p < 0.001). In both the traditional and Trial Assigning Individualized Options for Treatment (TAILORx) RS cut-offs, the receipt of RT was not related to better breast cancer-specific survival in low- and high-risk RS groups, but was independently related to better breast cancer-specific survival in intermediate-risk RS group before (p = 0.029) and after (p = 0.001) propensity score matching. Conclusion: The 21-gene-RS may impact the decision-making of adjuvant RT in early-stage breast cancer after breast conserving surgery. The survival benefit of adjuvant RT may be limited to patients with intermediate-risk RS.
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Affiliation(s)
- Yong Dong
- Department of Oncology, Dongguan Third People's Hospital, Affiliated Dongguan Shilong People's Hospital of Southern Medical University, Dongguan 523326, PR China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
| | - Jun Wang
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, PR China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
| | - San-Gang Wu
- Department of Radiation Oncology, Cancer Hospital, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, PR China
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Thompson MK, Poortmans P, Chalmers AJ, Faivre-Finn C, Hall E, Huddart RA, Lievens Y, Sebag-Montefiore D, Coles CE. Practice-changing radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie? Br J Cancer 2018; 119:389-407. [PMID: 30061587 PMCID: PMC6117262 DOI: 10.1038/s41416-018-0201-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 12/18/2022] Open
Abstract
As we mark 150 years since the birth of Marie Curie, we reflect on the global advances made in radiation oncology and the current status of radiation therapy (RT) research. Large-scale international RT clinical trials have been fundamental in driving evidence-based change and have served to improve cancer management and to reduce side effects. Radiation therapy trials have also improved practice by increasing quality assurance and consistency in treatment protocols across multiple centres. This review summarises some of the key RT practice-changing clinical trials over the last two decades, in four common cancer sites for which RT is a crucial component of curative treatment: breast, lung, urological and lower gastro-intestinal cancer. We highlight the global inequality in access to RT, and the work of international organisations, such as the International Atomic Energy Agency (IAEA), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the United Kingdom National Cancer Research Institute Clinical and Translational Radiotherapy Research Working Group (CTRad), that aim to improve access to RT and facilitate radiation research. We discuss some emerging RT technologies including proton beam therapy and magnetic resonance linear accelerators and predict likely future directions in clinical RT research.
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Affiliation(s)
- Mareike K Thompson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Anthony J Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, G61 1QH, UK
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester; The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, London, SM2 5NG, UK
| | - Robert A Huddart
- Section of Radiotherapy and Imaging, The Institute of Cancer Research, London, SM2 5NG, UK
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, C. Heymanslaan, 9000, Ghent, Belgium
| | - David Sebag-Montefiore
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds; Leeds Cancer Centre, St James's University Hospitals, Leeds, LS9 7TF, UK
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, CB2 0QQ, UK.
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Franco P, Iorio GC, Bartoncini S, Airoldi M, De Sanctis C, Castellano I, Ricardi U. De-escalation of breast radiotherapy after conserving surgery in low-risk early breast cancer patients. Med Oncol 2018; 35:62. [PMID: 29616366 DOI: 10.1007/s12032-018-1121-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
The reduction in the burden related to treatment is becoming more and more important in modern oncology. Radiation therapy is a mainstay option in the postoperative setting for early breast cancer patients after breast-conserving surgery. Nowadays, different options are available to de-escalate radiotherapy in this scenario such as the use of hypofractionated whole-breast radiation, the selective delivery of the boost dose to the lumpectomy cavity, the introduction of accelerated partial breast irradiation and the omission of treatment in appropriately selected patients with low-risk features. We herein provide a review article on this topic.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Giuseppe Carlo Iorio
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Sara Bartoncini
- Department of Oncology, Radiation Oncology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Mario Airoldi
- Department of Medical Sciences, Pathology Unit, University of Turin, Turin, Italy
| | - Corrado De Sanctis
- Department of Gynecology and Obstetrics, Breast Unit, AOU Città della Salute e della Scienza, Turin, Italy
| | - Isabella Castellano
- Department of Oncology, Medical Oncology 2, AOU Città della Salute e della Scienza, Turin, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
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