Radiotherapy for invasive breast cancer in North America and Europe: Results of a survey

Radiation Oncologists' Views on Adjuvant Radiotherapy for Early-Stage Breast Cancer in the Elderly: Comparisons between Japan and the United States

PURPOSE

To understand perspective on breast cancer using a survey.

MATERIALS & METHODS

Questionnaire was distributed to 304 Japanese radiation oncologists (RadOncs) (response rate: 64.1%). Result was compared with a similar US survey.

RESULTS

In a scenario with an 81-year-old patient with comorbidities, while most US RadOncs chose to tell that radiation might not be necessary, 2% of Japanese chose it. In a scenario with a healthy 65-year-old breast cancer patient with lumpectomy, while most US RadOncs chose to discuss omission of radiation, 24.5% of Japanese chose it.

CONCLUSIONS

Differences were observed on radiotherapy for older early-stage breast cancer.

Real de-escalation or escalation in disguise?

The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.

Perspectives on the role of breast cancer susceptibility gene in breast cancer

PURPOSE

Breast cancer susceptibility gene 1/2 can repair damaged DNA through homologous recombination. Besides, the local immune microenvironment of breast cancer is closely linked to the prognosis of patients. But the relationship of breast cancer susceptibility gene 1/2 expression and local immunosuppressive microenvironment in breast cancer is not clear. The aim of this study was to discuss the correlation between them.

METHODS

The fresh primary breast tumors and paired normal tissues of 156 cases of breast cancer patients as well as peripheral blood of 156 cases among them in Tianjin Medical University Cancer Institute and Hospital from January 2014 to October 2018 were collected. The association between breast cancer susceptibility gene 1/2 germline mutation and immune status of microenvironment in situ was analyzed.

RESULTS

The results indicated that the germline mutation of breast cancer susceptibility gene 1/2 was inconsistent with the breast cancer susceptibility gene 1/2 protein expression, and the proportion of immune cells in patients with negative expression of breast cancer susceptibility gene 1/2 protein was higher than patients with positive expression of breast cancer susceptibility gene 1/2 protein (p < 0.05). And the expression of programmed cell death protein 1, cytotoxic T-Lymphocyte Antigen 4, programmed death ligand-1 of CD3⁺ T cells in patients with negative expression of breast cancer susceptibility gene 1/2 protein was higher than patients with positive expression of breast cancer susceptibility gene 1/2 protein (p < 0.05). The breast cancer susceptibility gene 1 protein expression was significantly correlated with family history of breast cancer patients (p = 0.006), local lymph node metastases (p = 0.001), and TNM staging (p ≤ 0.001). The breast cancer susceptibility gene 2 protein expression was significantly related to local lymph node metastases (p ≤ 0.001), III stage rate(p = 0.003) and molecular subtyping (p ≤ 0.001). Besides, the 5 years disease free survival was worse for G1 group and pathological III stage patients than other groups and other TNM stage patients.

CONCLUSION

In short, the immune therapy may be a potential therapy method for breast cancer patients with negative expression of breast cancer susceptibility gene 1/2 protein.

A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema

BACKGROUND

Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness.

AIM

The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL).

METHODS

PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed.

RESULTS

Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRR_P] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRR_P = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRR_P = 46.8% [95% CI: 43.2-50.4]; below knee CRR_P = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRR_P = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRR_P = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRR_P = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26).

CONCLUSIONS

VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.

Radiation Boost After Adjuvant Whole Breast Radiotherapy: Does Evidence Support Practice for Close Margin and Altered Fractionation?

Adding a boost to whole breast radiation (WBI) following breast-conserving surgery (BCS) may help improve local control, but it increases the total cost of treatment and may worsen cosmetic outcomes. Therefore, it is reserved for patients whose potential benefit outweighs the risks; however, current evidence is insufficient to support comprehensive and consistent guidance on how to identify these patients, leading to a potential for significant variations in practice. The use of a boost in the setting of close margins and hypofractionated radiotherapy represents two important areas where consensus guidelines, patterns of practice, and current evidence do not seem to converge. Close margins were previously routinely re-excised, but this is no longer felt to be necessary. Because of this recent practice change, good long-term data on the local recurrence risk of close margins with or without a boost is lacking. As for hypofractionation, although there is guidance recommending that the decision to add a boost be independent from the whole-breast fractionation schedule, it appears that patterns-of-practice data may show underutilization of a boost when hypofractionation is used. The use of a boost in these two common clinical scenarios represents important areas of future study for the optimization of adjuvant breast radiation.

Local and regional recurrence following mastectomy in breast cancer patients with 1-3 positive nodes: implications for postmastectomy radiotherapy volume

PURPOSE

To determine the necessity of postmastectomy radiotherapy (PMRT) and which regions would be at risk for recurrence, we evaluated local and regional recurrence in breast cancer patients with 1-3 positive nodes and a tumor size of <5 cm.

MATERIALS AND METHODS

We retrospectively analyzed data of 133 female breast cancer patients with 1-3 positive nodes, and a tumor size of <5 cm who were treated with mastectomy followed by adjuvant systemic therapy between 2007 and 2016. The median follow-up period was 57 months (range, 12 to 115 months). Most patients (82.7%) were treated with axillary lymph node dissection. Adjuvant chemotherapy, endocrine therapy, and trastuzumab therapy were administered to 124 patients (93.2%), 112 (84.2%), and 33 (24.8%), respectively. The most common chemotherapy regimen was anthracycline and cyclophosphamide followed by taxane (71.4%).

RESULTS

Three patients (2.3%), 8 (6.0%), and 12 (9.0%) experienced local, regional, and distant failures, respectively. The 5-year cumulative risk of local recurrence, regional recurrence, distant metastasis, and disease-free survival was 3.1%, 8.0%, 11.7%, and 83.4%, respectively. There were no statistically significant clinicopathologic factors associated with local recurrence. Lymphovascular invasion (univariate p = 0.015 and multivariate p = 0.054) was associated with an increased risk of regional recurrence.

CONCLUSION

Our study showed a very low local recurrence in patients with 1-3 positive nodes and tumor size of <5 cm who were treated with mastectomy and modern adjuvant systemic treatment. The PMRT volume need to be tailored for each patient's given risk for local and regional recurrence, and possible radiation-related toxicities.

Patterns of Practice in Radiotherapy for Breast Cancer in Korea

Adjuvant radiotherapy (RT) is a well-established treatment for breast cancer. However, there is a large degree of variation and controversy in practice patterns. A nationwide survey on the patterns of practice in breast RT was designed by the Division for Breast Cancer of the Korean Radiation Oncology Group. All board-certified members of the Korean Society for Radiation Oncology were sent a questionnaire comprising 39 questions on six domains: hypofractionated whole breast RT, accelerated partial breast RT, postmastectomy RT (PMRT), regional nodal RT, RT for ductal carcinoma in situ, and RT toxicity. Sixty-four radiation oncologists from 54 of 86 (62.8%) hospitals responded. Twenty-three respondents (35.9%) used hypofractionated whole breast RT, and the most common schedule was 43.2 Gy in 16 fractions. Only three (4.7%) used accelerated partial breast RT. Five (7.8%) used hypofractionated PMRT, and 40 (62.5%) had never used boost RT after chest wall irradiation. Indications for regional nodal RT varied; ≥pN2 (n=7) versus ≥pN1 (n=17) versus ≥pN1 with pathologic risk factors (n=40). Selection criteria for internal mammary lymph node (IMN) irradiation also varied; only four (6.3%) always treated IMN when regional nodal RT was administered and 30 (46.9%) treated IMN only if IMN involvement was identified through imaging. Thirty-one (48.4%) considered omission of whole breast RT after breast-conserving surgery for ductal carcinoma in situ based on clinical and pathologic risk factors. Fifty-two (81.3%) used heart-sparing techniques. Overall, there were wide variations in the patterns of practice in breast RT in Korea. Standard guidelines are needed, especially for regional nodal RT and omission of RT for ductal carcinoma in situ.

Hypofractionation with concomitant boost using intensity-modulated radiation therapy in early-stage breast cancer in Mexico

Aim

To evaluate whether hypofractionation with integrated boost to the tumour bed using intensity-modulated radiation therapy is an acceptable option and to determine whether this treatment compromises local control, toxicity and cosmesis.

Background

Retrospective studies have demonstrated that patients who are treated with HF and integrated boost experience adequate local control, a dosimetric benefit, decreased toxicity and acceptable cosmesis compared with conventional fractionation.

Materials and methods

A retrospective, observational and longitudinal study was conducted from January 2008 to June 2015 and included 34 patients with breast cancer (stage 0-II) who were undergoing conservative surgery.The prescribed doses were 45 Gy in 20 fractions (2.25 Gy/fraction) to the breast and 56 Gy in 20 fractions (2.8 Gy/fraction) to the tumour bed.

Results

Thirty-four patients were included. The mean follow-up was 49.29 months, and the mean age was 52 years. The mean percentage of PTV from the mammary region that received 100% of the prescribed dose was 97.89% (range 95-100), and the mean PTV percentage of the tumour bed that received 100% of the dose was 98% (95-100).The local control and the overall survival were 100%, and the cosmesis was good in 82% of the patients. Grade 1 acute toxicity was present in 16 patients (47%), and grade 1 chronic toxicity occurred in 6 cases (18%).

Conclusion

The results of the present study demonstrate that hypofractionation with integrated boost using intensity-modulated radiation therapy is an acceptable option that provides excellent local control and low toxicity.

A survey of current surgical treatment of early stage breast cancer in China

The purpose of this national survey is to explore the patterns of surgical management for early stage breast cancer patients in China. A paper questionnaire survey was sent to the representatives from 520 hospitals who attended an international symposium in Guangzhou, China, 2014. The questionnaire included demographic information, initials and most preferred approaches for breast cancer surgery. The results were presented descriptively. The response rate was 42.5%. Only 7% of hospitals with >50% rate of breast conserving surgery (BCS). Intraoperative frozen sections and additional cavity margins assessment were used at 88% and 30.9% of hospitals, respectively. For invasive carcinoma, 15% of participants defined an adequate margin as no tumor cells on the ink. Sentinel lymph node biopsy (SLNB) was routinely performed in 93.2% of hospitals. Only 16.6% of hospitals would embrace the conclusions of the American College of Surgeons Oncology Group (ACOSOG) Z0011 study and omit axillary lymph node dissection (ALND) for patients who fit the Z0011 criteria. The current patterns for the management of breast cancer patients are still lagging behind. Chinese doctors need to catch up with the updated results of the cutting-edge clinical studies and multiple measures are in need to improve this situation.

Lung cancer specialists' opinions on treatment for stage I non-small cell lung cancer: A multidisciplinary survey

PURPOSE

The current standard of care for surgically eligible stage I non-small cell lung cancer (NSCLC) is surgical resection, but emerging data suggest that stereotactic body radiation therapy (SBRT) is potentially as effective as surgery. However, specialist views of the current evidence about SBRT and how they would incorporate a randomized controlled trial (RCT) into practice is unclear. We sought to understand specialist opinions about evidence regarding treatment of stage I NSCLC and how this translates into practice and clinical trial implementation.

METHODS AND MATERIALS

We used a 28-item, web-based survey that invited all participating providers from the American Society for Radiation Oncology, American Thoracic Society Thoracic Oncology Assembly, and the International Association for the Study of Lung Cancer to share opinions regarding practice beliefs, treatment of stage I NSCLC, and a clinical trial scenario.

RESULTS

A total of 959 surveys were completed; 64% were from radiation oncologists (ROs) and 49% were from outside the United States. The majority of ROs (80%) reported that current evidence indicates that SBRT has the same or a better benefit compared with surgery for surgically eligible patients with stage I NSCLC; 28% of non-radiation oncologists (NROs) indicated the same (P < .01). Almost all ROs (94%), compared with 62% of NROs, would permit surgically eligible patients to enroll in an RCT of SBRT versus surgery (P < .01). Most ROs (82%) and NROs (87%) believed that changing practice in thoracic surgery would be somewhat difficult, very difficult, or impossible (P = .066) even if an RCT showed better survival with SBRT.

CONCLUSIONS

NROs believe that SBRT is much less effective than surgery, contrary to ROs, who believe that they are similar. Most would support an RCT, but NROs would do so less. Changes in surgical practice may be challenging even if an RCT shows better mortality and quality of life with SBRT. These results are helpful in the creation and dissemination of RCTs that are designed to understand this question.

Radiotherapy in Italy after Conservative Treatment of Early Breast Cancer. A Survey by the Italian Society of Radiation Oncology (AIRO)

Aims and Background

The aim of surveys on clinical practice is to stimulate discussion and optimize practice. In this paper the current Italian radiotherapy practice after breast-conserving surgery for early breast cancer is described and adherence to national and international guidelines is assessed. Furthermore, results are compared with an earlier survey in northern Italy and international reports.

Study Design

A multiple-choice questionnaire sent to all 138 Italian radiation oncology centers.

Results

48% of centers responded. Most performed breast-conserving surgery when tumor size was ≤3 cm. All centers routinely performed axillary dissection; 45 carried out sentinel node biopsy followed by axillary dissection when the sentinel node was positive. Most centers re-excised when resection margins were positive. The median interval between surgery and radiotherapy, when chemotherapy was not administered, was 60 days. Adjuvant chemotherapy was preferably administered before radiotherapy. Regional lymph nodes were never irradiated in 10 centers; in all others irradiation depended on the number of positive lymph nodes and/or involvement of axillary fat and/or tumor location in medial quadrants. All centers used standard fractionation; hypofractionated schemes were available in 6. Most centers used 4–6 MV photons. In 59 centers the boost dose of 10 Gy could be increased if margins were not negative. All centers ensured patient setup reproducibility. Treatment planning was computerized in 59 centers. The irradiation dose was prescribed at the ICRU point in 56 centers and portal films were made in 54 centers. Intraoperative radiotherapy was used in 4 centers: for partial breast irradiation in 1 and for boost administration in 3 centers.

Conclusions

Although the quality of radiotherapy delivery has improved in Italy in recent years, approaches that do not conform to international standards persist.

Comparison of Radiotherapeutic Management of Operated Breast Cancer in 1999 and in 2006: A Sampling Survey on the Southeast Coast of China

Aims

To obtain a better understanding of the changes in radiotherapeutic management of breast cancer patients in the more developed areas of China over the past decade.

Methods

Four academic radiation therapy departments located on the Southeast Coast of China were selected for the study. The survey was conducted on female breast cancer patients who received radiotherapy in 1999 and 2006. The questionnaires were designed to determine the purposes of radiotherapy and to address the postoperative radiotherapy techniques used. The data for these two years were analyzed and compared.

Results

The percentage of breast-conserving treatment increased from 3% in 1999 to 13% in 2006, but the percentage of patients treated with postmastectomy radiotherapy dropped from 69% in 1999 to 66% in 2006 (P <0.05). As regards the changes in techniques from 1999 to 2006, the use of special immobilization devices, treatment planning systems, and CT simulations increased from 46% to 80%, 23% to 70%, and 0% to 14%, respectively (P <0.01). From 1999 to 2006, irradiation of the chest wall following mastectomy increased from 67% to 90%, but for internal mammary irradiation it decreased from 76% to 30% and for the axilla, from 69% to 37% (P <0.01). There were no obvious differences between 1999 and 2006 on the field design, boost treatment on the tumor bed, or dose prescription.

Conclusions

Breast-conserving treatment was performed more frequently in China in 2006 than in 1999, but postmastectomy radiotherapy did not change a great deal and it was still an essential option. Although the international treatment guidelines have been accepted and implemented by physicians in recent years, prompt improvement in the quality of breast cancer radiotherapy is needed.

The value of FATS expression in predicting sensitivity to radiotherapy in breast cancer

Purpose

The fragile-site associated tumor suppressor (FATS) is a newly identified tumor suppressor involved in radiation-induced tumorigenesis. The purpose of this study was to characterize FATS expression in breast cancers about radiotherapy benefit, patient characteristics, and prognosis.

Results

The expression of FATS mRNA was silent or downregulated in 95.2% of breast cancer samples compared with paired normal controls (P < .0001). Negative status of FATS was correlated with higher nuclear grade (P = .01) and shorter disease-free survival (DFS) of breast cancer (P = .036). In a multivariate analysis, FATS expression showed favorable prognostic value for DFS (odds ratio, 0.532; 95% confidence interval, 0.299 to 0.947; (P = .032). Furthermore, improved survival time was seen in FATS-positive patients receiving radiotherapy (P = .006). The results of multivariate analysis revealed independent prognostic value of FATS expression in predicting longer DFS (odds ratio, 0.377; 95% confidence interval, 0.176 to 0.809; P = 0.012) for patients receiving adjuvant radiotherapy. In support of this, reduction of FATS expression in breast cancer cell lines, FATS positive group significantly sensitized than Knock-down of FATS group.

Materials and Methods

Tissue samples from 156 breast cancer patients and 42 controls in tumor bank were studied. FATS gene expression was evaluated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). FATS function was examined in breast cancer cell lines using siRNA knock-downs and colony forming assays after irradiation.

Conclusions

FATS status is a biomarker in breast cancer to identify individuals likely to benefit from radiotherapy.

Outcomes and utilization of postmastectomy radiotherapy for T3N0 breast cancers

BACKGROUND

The role of postmastectomy radiotherapy (PMRT) for women with pT3N0M0 breast cancer is controversial. We sought to determine the benefit of PMRT in this cohort using the National Cancer Database (NCDB).

METHODS

We analyzed women with pT3N0M0 breast cancer who received mastectomy with or without PMRT between 2004 and 2012. We excluded men, women ≤18 years, neoadjuvant or unknown radiation or chemotherapy status, unknown estrogen or progesterone receptor status, unknown surgical margin status, histology other than invasive ductal or lobular carcinoma, and if death occurred <3 months after diagnosis. A total of 4291 patients was included for analysis. Chi-squared analysis was used to compare patient characteristics. Univariate (UVA) and multivariate (MVA) Cox proportional hazards modeling was used to identify factors associated with survival. Propensity score matching was performed to address confounding variables. Survival analysis was performed using Kaplan-Meier and shared frailty models.

RESULTS

Of the 4291 women analyzed, 2030 (47%) received PMRT. On MVA, PMRT (HR 0.72, p < 0.001), chemotherapy (HR 0.51, p < 0.001), and hormone therapy (HR 0.63, p < 0.001) were associated with improved overall survival (OS). After propensity score matching, a matched cohort of 2800 women was analyzed. At 5 years, OS was 83.7% and 79.8% with and without PMRT, respectively (p < 0.001). This difference in OS benefit increased with time. At 10 years, OS was 67.4% and 59.2% with and without PMRT, respectively.

CONCLUSIONS

PMRT was associated with improved OS in women with pT3N0M0 breast cancer, which strongly suggests PMRT may provide a survival advantage and should be considered.

Breast interest group faculty of radiation oncology: Australian and New Zealand patterns of practice survey on breast radiotherapy

INTRODUCTION

This patterns of practice study was conducted on behalf of the RANZCR Breast Interest Group in order to document current radiotherapy practices for breast cancer in Australia and New Zealand. The survey identifies variations and highlights potential contentious aspects of radiotherapy management of breast cancer.

METHODS

A fifty-eight question survey was disseminated via the Survey Monkey digital platform to 388 Radiation Oncologists in Australia and New Zealand.

RESULTS

In total, 156 responses were received and collated. Areas of notable consensus among respondents included hypofractionation (77.3% of respondents would 'always' or 'sometimes' consider hypofractionation in the management of ductal carcinoma in-situ and 99.3% in early invasive breast cancer); margin status in early breast cancer (73.8% believe a clear inked margin is sufficient and does not require further surgery) and use of bolus in post-mastectomy radiotherapy (PMRT) (91.1% of participants use bolus in PMRT). Areas with a wider degree of variability amongst respondents included regional nodal irradiation and components of radiotherapy planning and delivery (examples include the technique used for delivery of boost and frequency of bolus application for PMRT).

CONCLUSION

The results of these patterns of practice survey informs radiation oncologists in Australia and New Zealand of the current clinical practices being implemented by their peers. The survey identifies areas of consensus and contention, the latter of which may lead to a development of research trials and/or educational activities to address these areas of uncertainty.

Longitudinal analysis of patient-reported outcomes and cosmesis in a randomized trial of conventionally fractionated versus hypofractionated whole-breast irradiation

BACKGROUND

The authors compared longitudinal patient-reported outcomes and physician-rated cosmesis with conventionally fractionated whole-breast irradiation (CF-WBI) versus hypofractionated whole-breast irradiation (HF-WBI) within the context of a randomized trial.

METHODS

From 2011 to 2014, a total of 287 women with American Joint Committee on Cancer stage 0 to stage II breast cancer were randomized to receive CF-WBI (at a dose of 50 grays in 25 fractions plus a tumor bed boost) or HF-WBI (at a dose of 42.56 grays in 16 fractions plus a tumor bed boost) after breast-conserving surgery. Patient-reported outcomes were assessed using the Breast Cancer Treatment Outcome Scale (BCTOS), the Functional Assessment of Cancer Therapy-Breast, and the Body Image Scale and were recorded at baseline and 0.5, 1, 2, and 3 years after radiotherapy. Physician-rated cosmesis was assessed at the same time points. Outcomes by treatment arm were compared at each time point using a 2-sided Student t test. Multivariable mixed effects growth curve models assessed the effects of treatment arm and time on longitudinal outcomes.

RESULTS

Of the 287 patients enrolled, 149 were randomized to CF-WBI and 138 were randomized to HF-WBI. At 2 years, the Functional Assessment of Cancer Therapy-Breast Trial Outcome Index score was found to be modestly better in the HF-WBI arm (mean 79.6 vs 75.9 for CF-WBI; P = .02). In multivariable mixed effects models, treatment arm was not found to be associated with longitudinal outcomes after adjusting for time and baseline outcome measures (P≥.14). The linear effect of time was significant for BCTOS measures of functional status (P = .001, improved with time) and breast pain (P = .002, improved with time).

CONCLUSIONS

In this randomized trial, longitudinal outcomes did not appear to differ by treatment arm. Patient-reported functional and pain outcomes improved over time. These findings are relevant when counseling patients regarding decisions concerning radiotherapy. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2886-2894. © 2016 American Cancer Society.

Unintended irradiation of internal mammary chain - Is that enough?

AIM

To evaluate the unintentional coverage of the internal mammary chain (IMC) with tangential fields irradiation to the breast, and its relation with the type of surgery employed.

BACKGROUND

The dose distribution in regions adjacent to the treatment targets (mammary gland or chest wall), with incidental irradiation of the IMC, could translate into clinical benefit, due to the proximity of these regions.

MATERIALS AND METHODS

One hundred and twelve consecutive conformal radiotherapy plans were correlating the average dose to the IMC with the type of surgery employed, the extent of disease and the irradiation techniques.

RESULTS

The mean doses to IMC after modified radical mastectomy (MRM), modified radical mastectomy with immediate reconstruction (MRM + R), and breast conservative surgery (BCS) were 30.34 Gy, 30.26 Gy, and 18.67 Gy, respectively. Significant differences were identified between patients who underwent MRM or MRM + R over BCS (p = 0.01 and 0.003, respectively), but not between MRM and MRM + R (p = 0.88). Mean doses to IMC were greater in patients with T3-T4 tumors when compared with more initial stages (≤T2) (p = 0.0096). The lymph node involvement also correlated with higher average doses to IMC (node positive: 26.1 Gy × node negative: 17.8 Gy, p = 0.0017).

CONCLUSIONS

The moderate dose level to the IMC in the unintentional irradiation scenario seems to be insufficient to treat the subclinical disease, although it could have an impact in patients undergoing mastectomy.

Radiotherapy of the Lymphatic Pathways in Early Breast Cancer

International guidelines reveal substantial differences regarding indications for regional nodal irradiation (RNI). Recently, several randomized studies provided new insights and these are discussed here. Patients with 1-3 positive nodes seem to profit from RNI compared to whole-breast (WBI) or chest-wall irradiation (CWI) alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and 1 meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel nodes or microscopic metastases on prognosis are equivocal. Recent data suggest that the current restrictive use of RNI should be scrutinized, as the hazard-benefit relation appears to shift towards an improvement of outcome.

Regional Nodal Irradiation in Early-Stage Breast Cancer

BACKGROUND

Most women with breast cancer who undergo breast-conserving surgery receive whole-breast irradiation. We examined whether the addition of regional nodal irradiation to whole-breast irradiation improved outcomes.

METHODS

We randomly assigned women with node-positive or high-risk node-negative breast cancer who were treated with breast-conserving surgery and adjuvant systemic therapy to undergo either whole-breast irradiation plus regional nodal irradiation (including internal mammary, supraclavicular, and axillary lymph nodes) (nodal-irradiation group) or whole-breast irradiation alone (control group). The primary outcome was overall survival. Secondary outcomes were disease-free survival, isolated locoregional disease-free survival, and distant disease-free survival.

RESULTS

Between March 2000 and February 2007, a total of 1832 women were assigned to the nodal-irradiation group or the control group (916 women in each group). The median follow-up was 9.5 years. At the 10-year follow-up, there was no significant between-group difference in survival, with a rate of 82.8% in the nodal-irradiation group and 81.8% in the control group (hazard ratio, 0.91; 95% confidence interval [CI], 0.72 to 1.13; P=0.38). The rates of disease-free survival were 82.0% in the nodal-irradiation group and 77.0% in the control group (hazard ratio, 0.76; 95% CI, 0.61 to 0.94; P=0.01). Patients in the nodal-irradiation group had higher rates of grade 2 or greater acute pneumonitis (1.2% vs. 0.2%, P=0.01) and lymphedema (8.4% vs. 4.5%, P=0.001).

CONCLUSIONS

Among women with node-positive or high-risk node-negative breast cancer, the addition of regional nodal irradiation to whole-breast irradiation did not improve overall survival but reduced the rate of breast-cancer recurrence. (Funded by the Canadian Cancer Society Research Institute and others; MA.20 ClinicalTrials.gov number, NCT00005957.).

Postmastectomy radiation therapy in T3 node-negative breast cancer

BACKGROUND

In the absence of lymph node involvement, tumor size is arguably the most important prognostic factor for women with breast cancer. Radiation therapy use in the T3 node-negative population is controversial. We investigated the use of postmastectomy radiation therapy (PMRT) in women with T3 node-negative breast cancer.

METHODS

A retrospective cohort study was conducted by identifying women with T3 node-negative breast cancer from the 1988-2009 Surveillance, Epidemiology and End Results database. Our primary outcome was breast cancer-specific survival. Survival curves were generated using the Kaplan-Meier method. Cox proportional hazard ratios (HRs) and propensity score analysis were used to evaluate the impact on survival.

RESULTS

We identified 2874 patients with T3 node-negative breast cancer and 961 (33%) received PMRT and 1913 (67%) did not. Statistically significant differences were seen in adjuvant radiation therapy use based on patient age, marital status, tumor grade, tumor size, and receptor status (P < 0.05 for all). Overall survival was lower in the PMRT group in unadjusted analysis (crude HR, 0.718; 95% confidence interval [CI], 0.614-0.840); however, adjusted HRs demonstrated no difference in overall survival (adjusted HR, 0.898; 95% CI, 0.765-1.054). Unadjusted analysis of breast cancer-specific survival demonstrated no difference between those who received PMRT and those who did not (crude HR, 0.834; 95% CI, 0.682-1.021). Propensity score analysis demonstrated no difference in breast cancer-specific survival based on PMRT use (adjusted HR, 0.939; 95% CI, 0.762-1.157).

CONCLUSIONS

Analysis of the Surveillance, Epidemiology and End Results database suggests that receipt of PMRT is not clinically beneficial in T3 node-negative breast cancer.

Acute Toxicity From Breast Cancer Radiation Using Helical Tomotherapy With a Simultaneous Integrated Boost

PURPOSE

To evaluate 2 simultaneous integrated boost treatment planning techniques using helical tomotherapy for breast conserving therapy with regard to acute skin toxicity and dosimetry.

METHODS

Thirty-two patients were studied. The original approach was for 16 patients and incorporated a directional block of the ipsilateral lung and breast. An additional 16 patients were planned for using a modified approach that incorporates a full block of the ipsilateral lung exclusive of 4 cm around the breast. Dose-volume histograms of targets and critical structures were evaluated. Skin toxicity monitoring was performed throughout treatment and follow-up using the Common Terminology Criteria for Adverse Events.

RESULTS

Treatment was well tolerated with patients receiving a median dose of 59.36 Gy. Of the 16 patients in both groups, 8 had grade 2 erythema immediately after radiation. On 3-week follow-up, 10 and 7 patients in the original and modified groups showed grade 1 erythema. On 3- and 6-month follow-up, both groups had minimal erythema, with all patients having either grade 0 or 1 symptoms. No grade 2 or 3 toxicities were reported. Mean treatment time was 7.5 and 10.4 minutes using the original and modified methods. Adequate dose coverage was achieved using both methods (V95 = 99.5% and 98%). Mean dose to the heart was 10.5 and 1.8 Gy, respectively (P < .01). For right-sided tumors, the original and modified plans yielded a mean of 8.8 and 1.1 Gy (P < .01) versus 11.7 and 2.4 Gy for left-sided tumors (P < .01). The mean dose to the ipsilateral lung was also significantly lower in the modified plans (11.8 vs. 5.0 Gy, P < .01).

CONCLUSIONS

Tomotherapy is capable of delivering homogeneous treatment plans to the whole breast and lumpectomy cavity using simultaneous integrated boost treatment. Using the treatment methods described herein, extremely low doses to critical structures can be achieved without compromising acute skin toxicity.

Metastatic Tumor Volume and Extranodal Tumor Extension: Clinical Significance in Patients With Stage II Breast Cancer

CONTEXT

Lymph node status and the number of lymph node (LN) positive for cancer cells are the most important prognostic factors in breast cancer. Extranodal tumor extension (ENTE) has been used as a histopathologic feature to classify patients into high risk versus low risk for local recurrence. However, in the current era of early detection and systemic therapy, the prognostic significance of ENTE is not as well defined in patients with 1 to 3 LNs positive for cancer.

OBJECTIVE

To determine whether the amount of tumor burden in an axillary dissection or the presence of ENTE provides any additional information regarding patient outcome in patents with 1 to 3 positive LN results.

DESIGN

Clinical and pathologic factors were identified for 456 patients with breast cancer at the University of Texas MD Anderson Cancer Center, Houston, who had pT1 tumors and 1 to 3 LNs positive for cancer and were treated by mastectomy, with or without postmastectomy radiotherapy, between 1978 and 2007.

RESULTS

Of the 456 patients, 257 (56.4%), 141 (31.6%), and 58 (12.7%) patients had 1, 2, or 3 positive LN results, respectively. Extranodal tumor extension was present in 99 patients (21.7%) and was absent in the remaining 357 cases (78.3%). Seventy-six patients (16.7%) received radiation therapy. Patients had both worse overall survival time and disease-free survival when ENTE was present, regardless of the amount, as long as the treatment era was not included in the multivariate analysis (pre-2000 versus post-2000). However, ENTE was no longer significant on multivariate analysis when the year of treatment was taken into account.

CONCLUSIONS

The number of positive LNs remains an important predictor of survival in patients with 1 to 3 positive LN results, but the prognostic significance of ENTE in this cohort of patients has diminished over time.

Adoption of hypofractionated radiation therapy for breast cancer after publication of randomized trials

PURPOSE

Large randomized trials have established the noninferiority of shorter courses of "hypofractionated" radiation therapy (RT) to the whole breast compared to conventional courses using smaller daily doses in the adjuvant treatment of selected breast cancer patients undergoing lumpectomy. Hypofractionation is more convenient and less costly. Therefore, we sought to determine uptake of hypofractionated breast RT over time.

METHODS AND MATERIALS

In the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified 16,096 women with node-negative breast cancer and 4269 with ductal carcinoma in situ (DCIS) who received lumpectomy followed by more than 12 fractions of RT between 2004 and 2010. Based on Medicare claims, we determined the number of RT treatments given and grouped patients into those receiving hypofractionation (13-24) or those receiving conventional fractionation (≥25). We also determined RT technique (intensity modulated RT or not) using Medicare claims. We evaluated patterns and correlates of hypofractionation receipt using bivariate and multivariable analyses.

RESULTS

Hypofractionation use was similar in patients with DCIS and those with invasive disease. Overall, the use of hypofractionation increased from 3.8% in 2006 to 5.4% in 2007, to 9.4% in 2008, and to 13.6% in 2009 and 2010. Multivariable analysis showed increased use of hypofractionation in recent years and in patients with older age, smaller tumors, increased comorbidity, higher regional education, and Western SEER regions. However, even in patients over the age of 80, the hypofractionation rate in 2009 to 2010 was only 25%. Use of intensity modulated RT (IMRT) also increased over time (from 9.4% in 2004 to 22.7% in 2009-2010) and did not vary significantly between patients receiving hypofractionation and those receiving traditional fractionation.

CONCLUSIONS

Hypofractionation use increased among low-risk older US breast cancer patients with publication and maturation of evidence from randomized trials, but overall use of this cost-saving approach remained low. This contrasts with the more rapid rate of adoption of IMRT in the same time period, a costly innovation supported by less strong evidence of benefit.

Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey

BACKGROUND

Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI.

METHODS

A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014.

RESULTS

A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI.

CONCLUSION

The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

Postmastectomy radiation therapy for T3N0: a SEER analysis

BACKGROUND

There is conflicting evidence regarding the benefit of postmastectomy radiation therapy (PMRT) for pathologic stage T3N0M0 breast cancers. We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate the benefit of PMRT in this patient population.

METHODS

We queried the SEER database for T3N0M0 breast cancer patients diagnosed from 2000 to 2010 who underwent modified radical mastectomy. We excluded males, patients with unknown radiation timing/type, other primary tumors, and survival <6 months. A total of 2525 patients were included in the analysis. We performed univariate and multivariate statistical analysis using chi-square tests, log-rank tests, and Cox proportional hazards regression. The primary endpoints were overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Of the 2525 patients identified, 1063 received PMRT. The median follow-up was 56 months (range, 6-131 months). On univariate analysis, PMRT improved OS (76.5% vs 61.8%, P<.01) and CSS (85.0% vs 82.4%, P<.01) at 8 years. The use of PMRT remained significant on multivariate analysis: PMRT improved OS (hazard ratio 0.63, P<.001) and CSS (hazard ratio 0.77, P = .045). Low tumor grade (P<.01) and marital status of "married" (P = .01) also was a predictor of improved CSS on multivariate analysis.

CONCLUSIONS

PMRT was associated with significant improvements in both CSS and OS in patients with T3N0M0 breast cancers treated with modified radical mastectomy from 2000 to 2010. PMRT should be strongly considered in T3N0M0 patients. Postmastectomy radiation therapy is associated with significant improvements in overall and cause-specific survival in patients with T3N0M0 breast cancers treated with modified radical mastectomy from 2000 to 2010 in the SEER database. Postmastectomy radiation therapy should be strongly considered for patients who have T3N0M0 tumors.

Toxicity and cosmetic outcome of hypofractionated whole-breast radiotherapy: predictive clinical and dosimetric factors

Purpose

The objective of this study is to evaluate toxicity and cosmetic outcome in breast cancer patients treated with adjuvant hypo fractionated radiotherapy to the whole breast, and to identify the risk factors for toxicity.

Methods and materials

Two hundred twelve women with early breast cancer underwent conserving surgery were enrolled in the study. The patients received 40.05 Gy in 15 daily fractions, 2.67 Gy per fraction. The boost to the tumor bed was administered with a total dose of 9 Gy in 3 consecutive fractions in 55 women. Physician-rated acute and late toxicity and cosmetic outcome (both subjective and objective) were prospectively assessed during and after radiotherapy.

Results

In our population study the mean age was 63 with the 17% (36 pts) of the women younger than 50 years.

The median follow-up was 34 months. By the end of RT, 35 patients out of 212 (16%) no acute toxicity, according to the RTOG criteria, while 145 (68%) and 31 patients (15%) developed grade 1 and grade 2 acute skin toxicity, respectively.

Late skin toxicity evaluation was available for all 212 patients with a minimum follow up of 8 months. The distribution of toxicity was: 39 pts (18%) with grade 1 and 2 pts (1%) with grade 2. No worse late skin toxicity was observed.

Late subcutaneous grade 0-1 toxicity was recorded in 208 patients (98%) and grade 2 toxicity in 3 patients (2%), while grade 3 was observed in 1 patient only. At last follow up, a subjective and objective good or excellent cosmetic outcome was reported in 93% and 92% of the women, respectively. At univariate and multivariate analysis, the late skin toxicity was correlated with the additional boost delivery (p=0.007 and p=0.023). Regarding the late subcutaneous tissue, a correlation with diabetes was found (p=0.0283).

Conclusion

These results confirm the feasibility and safety of the hypofractionated radiotherapy in patients with early breast cancer. In our population the boost administration was resulted to be a significant adverse prognostic factor for acute and late toxicity. Long-term follow up is need to confirm this finding.

DEGRO practical guidelines: radiotherapy of breast cancer III--radiotherapy of the lymphatic pathways

AIM

The purpose of this work is to update the practical guidelines for adjuvant radiotherapy of the regional lymphatics of breast cancer published in 2008 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO).

METHODS

A comprehensive survey of the literature concerning regional nodal irradiation (RNI) was performed using the following search terms: "breast cancer", "radiotherapy", "regional node irradiation". Recent randomized trials were analyzed for outcome as well as for differences in target definition. Field arrangements in the different studies were reproduced and superimposed on CT slices with individually contoured node areas. Moreover, data from recently published meta-analyses and guidelines of international breast cancer societies, yielding new aspects compared to 2008, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the German interdisciplinary S3 guidelines updated in 2012, this paper addresses indications, targeting, and techniques of radiotherapy of the lymphatic pathways after surgery for breast cancer.

RESULTS

International guidelines reveal substantial differences regarding indications for RNI. Patients with 1-3 positive nodes seem to profit from RNI compared to whole breast (WBI) or chest wall irradiation alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular, and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and one meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection (ALND), while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel node (SN) or microscopic metastases on prognosis are conflicting.

CONCLUSION

Recent data suggest that the current restrictive use of RNI should be scrutinized because the risk-benefit relationship appears to shift towards an improvement of outcome.

The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study

PURPOSE/OBJECTIVE

Lymphedema after breast cancer treatment can be an irreversible condition with a negative impact on quality of life. The goal of this study was to identify radiation therapy-related risk factors for lymphedema.

METHODS AND MATERIALS

From 2005 to 2012, we prospectively performed arm volume measurements on 1476 breast cancer patients at our institution using a Perometer. Treating each breast individually, 1099 of 1501 patients (73%) received radiation therapy. Arm measurements were performed preoperatively and postoperatively. Lymphedema was defined as ≥10% arm volume increase occurring >3 months postoperatively. Univariate and multivariate Cox proportional hazard models were used to evaluate risk factors for lymphedema.

RESULTS

At a median follow-up time of 25.4 months (range, 3.4-82.6 months), the 2-year cumulative incidence of lymphedema was 6.8%. Cumulative incidence by radiation therapy type was as follows: 3.0% no radiation therapy, 3.1% breast or chest wall alone, 21.9% supraclavicular (SC), and 21.1% SC and posterior axillary boost (PAB). On multivariate analysis, the hazard ratio for regional lymph node radiation (RLNR) (SC ± PAB) was 1.7 (P=.025) compared with breast/chest wall radiation alone. There was no difference in lymphedema risk between SC and SC + PAB (P=.96). Other independent risk factors included early postoperative swelling (P<.0001), higher body mass index (P<.0001), greater number of lymph nodes dissected (P=.018), and axillary lymph node dissection (P=.0001).

CONCLUSIONS

In a large cohort of breast cancer patients prospectively screened for lymphedema, RLNR significantly increased the risk of lymphedema compared with breast/chest wall radiation alone. When considering use of RLNR, clinicians should weigh the potential benefit of RLNR for control of disease against the increased risk of lymphedema.

Shortened radiation therapy schedules for early-stage breast cancer: a review of hypofractionated whole-breast irradiation and accelerated partial breast irradiation

Breast-conserving therapy consisting of segmental mastectomy followed by whole-breast irradiation (WBI) has become widely accepted as an alternative to mastectomy as a treatment for women with early-stage breast cancer. WBI is typically delivered over the course of 5-6 weeks to the whole breast. Hypofractionated whole-breast irradiation and accelerated partial breast irradiation have developed as alternative radiation techniques for select patients with favorable early-stage breast cancer. These radiation regimens allow for greater patient convenience and the potential for decreased health care costs. We review here the scientific rationale behind delivering a shorter course of radiation therapy using these distinct treatment regimens in this setting as well as an overview of the published data and pending trials comparing these alternative treatment regimens to WBI.

Progress and controversies: radiation therapy for invasive breast cancer

Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast-conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research.

Intensity-modulated adjuvant whole breast radiation delivered with static angle tomotherapy (TomoDirect): a prospective case series

PURPOSE

To report the 2-year outcomes of whole breast intensity-modulated radiotherapy (IMRT) after conserving surgery for early breast cancer (EBC) delivered with static angle tomotherapy (TomoDirect) (TD).

METHODS

A prospective cohort of 120 EBC patients underwent whole breast IMRT with TD between 2010 and 2012. Radiation was delivered to a conventionally fractionated whole breast total dose of 50 Gy with TD, followed by a sequential conventionally fractionated tumor bed boost dose of 10-16 Gy with helical tomotherapy (HT). Clinical endpoints include acute and late toxicity, cosmesis, quality of life and local control.

RESULTS

Median follow-up was 24 months (range 12-36 months); maximum detected acute skin toxicity was G0 22 %; G1 63 %; G2 12 % and G3 3 %. Predictors of acute dermatitis were as follows: volume of the whole breast minus boost volume receiving 105, 110 and 115 % of prescription dose, whole breast and boost volume, breast thickness and soft tissue thickness. Late skin toxicity was mild with no >G2 events. Cosmesis was good/excellent in 91.7 % of patients and fair/poor in 8.3 %. Quality of life was preserved over time, but for fatigue, transiently increased.

CONCLUSION

Adjuvant whole breast IMRT delivered sequentially with both TD and HT provides consistent clinical results. An observed unintended excessive dose outside the tumor bed might increase acute toxicity and eventually affect long-term clinical endpoints. The incorporation of the boost dose within the whole breast phase employing a simultaneous integrated boost (SIB) approach might mitigate this issue.

Predictive factors for supraclavicular lymph node recurrence in N1 breast cancer patients

BACKGROUND

The purpose of this study was to identify predictive factors for supraclavicular lymph node recurrence (SCLR) in N1 breast cancer patients and define a high-risk subgroup who might benefit from supraclavicular nodal radiotherapy (RT).

MATERIALS AND METHODS

From January 1995 to December 2009, 113 breast cancer patients with 1 to 3 positive axillary lymph nodes were enrolled in this study. All patients underwent breast-conserving surgery (BCS) or modified radical mastectomy (MRM). RT was given to all patients who received BCS. Among the patients given MRM, those with breast tumors >5 cm in size received RT. Regional nodal irradiation was not applied. Systemic chemotherapy was given to 105 patients (92.9%). Patient data were retrospectively reviewed and analyzed to identify predictive factors for SCLR.

RESULTS

The median follow-up duration was 6.5 years, with 5- and 10-year actuarial SCLR rates of 9.3% and 11.2%, respectively. Factors associated with SCLR on univariate analysis included histologic grade, number of dissected axillary lymph nodes, lymphovascular invasion, extracapsular extension (ECE), and adjuvant chemotherapy. On multivariate analysis, histologic grade and ECE remained significant. The patient group with grade 3 and ECE had a significantly higher rate of SCLR compared with the remainder (5-year SCLR rate; 71.4% vs. 4.0%, p<0.001).

CONCLUSIONS

Histologic grade and ECE status are significant predictive factors for SCLR. Supraclavicular nodal RT is necessary in N1 breast cancer patients featuring histologic grade 3 and ECE.

Postmastectomy radiation therapy: an overview for the practicing surgeon

Locoregional control of breast cancer is the shared domain and responsibility of surgeons and radiation oncologists. Because surgeons are often the first providers to discuss locoregional control and recurrence risks with patients and because they serve in a key gatekeeping role as referring providers for radiation therapy, a sophisticated understanding of the evidence regarding radiotherapy in breast cancer management is essential for the practicing surgeon. This paper synthesizes the complex and evolving evidence regarding the role of radiation therapy after mastectomy. Although substantial evidence indicates that radiation therapy can reduce the risk of locoregional failure after mastectomy (with a relative reduction of risk of approximately two-thirds), debate persists regarding the specific subgroups who have sufficient risks of residual microscopic locoregional disease after mastectomy to warrant treatment with radiation. This paper reviews the evidence available to guide appropriate referral and patient decision making, with special attention to areas of controversy, including patients with limited nodal disease, those with large tumors but negative nodes, node-negative patients with high risk features, patients who have received systemic chemotherapy in the neoadjuvant setting, and patients who may wish to integrate radiation therapy with breast reconstruction surgery.

Breast reconstruction and post-mastectomy radiation practice

PURPOSE

The goal of this study was to explore the perspectives and practice of radiation oncologists who treat breast cancer patients who have had breast reconstruction.

METHODS

In 2010, an original electronic survey was sent to all physician members of the American Society of Radiation Oncology, National Cancer Research Institute-Breast Cancer Studies Group in the United Kingdom, Thai Society of Therapeutic Radiology and Oncology, Swiss Society of Radiation Oncology, and Turkish Radiation Oncology Society. We identified factors associated with radiation oncologists who treat breast cancer patients with reconstruction performed prior to radiation and obtained information regarding radiation management of the breast reconstruction.

RESULTS

358 radiation oncologists responded, and 60% of the physicians were from the United States. While 64% of participants agree or strongly agree that breast image affects a woman's quality of life during radiation, 57% feel that reconstruction challenges their ability to deliver effective breast radiation. Compared with other countries, treatment within the United States was associated with a high reconstruction rate (>/= 50% of mastectomy patients) prior to radiation (p < 0.05). Delayed-immediate reconstruction with a temporary tissue expander was more common in the United States than in other countries (52% vs. 23%, p = 0.01). Among physicians who treat patients with tissue expanders, the majority (60%) prefer a moderately inflated implant with 150-250 cc of fluid rather than a completely deflated (13%) or inflated expander (28%) during radiation. Among radiation oncologists who treat reconstructions, 49% never use bolus and 40% never boost a breast reconstruction. United States physicians were more likely than physicians from other countries to boost or bolus the reconstruction irrespective of the type of reconstruction seen in their clinic patients (p < 0.01).

CONCLUSIONS

Great variation in practice is evident from our study of radiation treatment for breast cancer patients with reconstruction. Further research on the impact and delivery of radiation to a reconstructed breast may validate some of the observed practices, highlight the variability in treatment practice, and help create a treatment consensus.

Locoregional recurrence of pT3N0M0 breast cancer after mastectomy is not higher than that of pT1-2N0M0: an analysis for radiotherapy

The purpose of this study was to investigate the value of post-operative radiotherapy in the treatment of pT3N0M0 breast cancer after mastectomy. We analyzed the clinical data of 1390 patients with pT1-3N0M0 breast cancer who were admitted and treated from 1998 to 2007 at the Sun Yat-sen University Cancer Center. All patients underwent mastectomy and did not receive radiotherapy. The locoregional recurrence-free survival, distant metastasis-free survival and overall survival of different T stages of breast cancer were compared. The median follow-up duration was 72 months. The 10-year locoregional recurrence-free survival patients with pT1N0, pT2N0 and pT3N0 breast cancers were 95.3, 91.9 and 93.6%, respectively (χ(2) = 2.550, P = 0.279). The 10-year distant metastasis-free survival rates of patients with pT1N0, pT2N0 and pT3N0 breast cancers were 88.1%, 81.0% and 78.4%, respectively (χ(2) = 8.254, P = 0.016). The 10-year overall survival rates of patients with pT1N0, pT2N0 and pT3N0 breast cancers were 91.9%, 83.5% and 73.0%, respectively (χ(2) = 12.403, P = 0.002). Univariate analyses failed to identify any prognostic factors for locoregional recurrence in pT3N0 patients. Multivariate analysis showed that the T stage had no effect on locoregional recurrence. The locoregional recurrence rate in patients with pT3N0M0 breast cancer who underwent mastectomy and did not receive postoperative radiotherapy was not higher than that in patients with pT1-2N0M0 breast cancer who received the same treatment, suggesting that routine adjuvant post-operative radiotherapy should not be recommended in this patient population.