1
|
Marta GN, Coles C, Kaidar-Person O, Meattini I, Hijal T, Zissiadis Y, Pignol JP, Ramiah D, Ho AY, Cheng SHC, Sancho G, Offersen BV, Poortmans P. The use of moderately hypofractionated post-operative radiation therapy for breast cancer in clinical practice: A critical review. Crit Rev Oncol Hematol 2020; 156:103090. [PMID: 33091800 PMCID: PMC7448956 DOI: 10.1016/j.critrevonc.2020.103090] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/14/2022] Open
Abstract
Post-operative radiation therapy (RT) reduces loco-regional recurrence rates and mortality in most patients with non-metastatic breast cancer. The aim of this critical review is to provide an overview of the applicability of moderately hypofractionated RT for breast cancer patients, focusing on factors influencing clinical decision-making. An international group of radiation oncologists agreed to assess, integrate, and interpret the existing evidence into a practical report to guide clinicians in their daily management of breast cancer patients. We conclude that moderately hypofractionated RT to the breast, chest wall (with/without breast reconstruction), and regional lymph nodes is at least as safe and effective as conventionally fractionated regimens and could be considered as the treatment option for the vast majority of the patients.For those who are still concerned about its generalised application, we recommend participating in ongoing trials comparing moderately hypofractionated RT to conventionally fractionated RT for breast cancer patients in some clinical circumstances.
Collapse
Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology - Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiology and Oncology - Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Charlotte Coles
- Department of Oncology, University of Cambridge, Cambridge, UK.
| | - Orit Kaidar-Person
- Breast Cancer Radiation Unit, Radiation Oncology Institute, Sheba Medical Center, Ramat Gan, Israel.
| | - Icro Meattini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy.
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montréal, Quebec, Canada.
| | - Yvonne Zissiadis
- Department of Radiation Oncology, Genesis Cancer Care, Wembley, Western Australia, Australia.
| | | | - Duvern Ramiah
- Department of Radiation Oncology, Donald Gordon Medical Centre, Johannesburg, South Africa.
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - Skye Hung-Chun Cheng
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
| | - Gemma Sancho
- Department of Radiation Oncology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium.
| |
Collapse
|
2
|
Miranda FA, Vieira MTL, Moraes FYD, Marta GN, Carvalho HDA, Hanna SA. Cosmesis in patients with breast neoplasia submitted to the hypofractionated radiotherapy with of intensity-modulated beam. ACTA ACUST UNITED AC 2019; 64:1023-1030. [PMID: 30570055 DOI: 10.1590/1806-9282.64.11.1023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/05/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the cosmetic satisfaction of patients diagnosed with breast cancer submitted to the hypofractionated radiotherapy with IMRT (hIMRT) technique and its correlation with dosimetric data of the radiotherapy planning. METHODS The retrospective cohort study that assessed women with a diagnosis of malignant breast neoplasia submitted to the conservative treatment or radical mastectomy and treated with hIMRT. In the period between August 2007 to December 2014, in a philanthropic / private institution, 170 records were selected. The cosmetic assessment was carried out by means of the Harvard/RTOG/NSABP scale with one-year minimum range after treatment. The collected dosimetric data were: breast / chest wall volume, volume that received 95% (V95%) and 107% (V107%) of the prescribed dose. RESULTS The volume of the treated breasts ranged from 169 to 2.103 ml (median = 702; IQR: 535 to 914 ml). Median V95% was 86.7% (54.6-96.6%; IQR: 80.0% to 90.6%); eight (5.7%) patients had V95% higher than 95%. Median V107% was 0% (0%-16.3%; IQR: 0.0% to 0.3% and 13); 9.3% patients had V107% higher than 2%. One hundred and thirty-three (78.2%) patients responded to the cosmetic assessment: 99 (74.4%) considered the cosmetic results excellent. Significant associations between cosmetic assessment and breast volume (p=0.875), V95% (p=0.294) e V107% (p=0.301) were not found. CONCLUSION The cosmetic results showed favorable when using hIMRT, and the lack of correlation with usual the dosimetric data illustrates the capacity of hIMRT to minimize the heterogeneity of the dose in this endpoint, even in voluminous breasts.
Collapse
Affiliation(s)
| | | | - Fabio Ynoe de Moraes
- Radiation Medicine Program, Princess Margaret Hospital University of Toronto, Toronto, Ontario, Canada
| | - Gustavo Nader Marta
- Radiation Oncologist of Hospital Sírio-Libanês - SP and Instituto do Câncer do Estado de São Paulo, São Paulo (SP), Brasil
| | - Heloísa de Andrade Carvalho
- Radiation Oncologist of Hospital Sírio-Libanês - SP and Instituto de Radiologia (InRad) - SP, São Paulo (SP), Brasil
| | | |
Collapse
|
3
|
Ciammella P, Podgornii A, Galeandro M, Micera R, Ramundo D, Palmieri T, Cagni E, Iotti C. Toxicity and cosmetic outcome of hypofractionated whole-breast radiotherapy: predictive clinical and dosimetric factors. Radiat Oncol 2014; 9:97. [PMID: 24762173 PMCID: PMC4029983 DOI: 10.1186/1748-717x-9-97] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 03/09/2014] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Patrizia Ciammella
- Radiation Oncology Unit, Department of Advanced Technology, Arcispedale Santa Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico, Viale Risorgimento 80, 42123 Reggio Emilia Italy.
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Affiliation(s)
- David Azria
- Department of Radiation Oncology and INSERM U896, Institut du Cancer Montpellier, 34298 Montpellier, France.
| | - Claire Lemanski
- Department of Radiation Oncology and INSERM U896, Institut du Cancer Montpellier, 34298 Montpellier, France
| |
Collapse
|
5
|
Soledad Torres C, Juan Carlos Acevedo B, Bernardita Aguirre D, Nuvia Aliaga M, Luis Cereceda G, Bruno Dagnino U, Jorge Gutiérrez C, Álvaro Ibarra V, Hernando Paredes F, José Miguel RV, Verónica Robert M, Antonio Sola V, Ricardo Schwartz J. Estado del arte el diagnóstico y tratamiento del cáncer de mama. REVISTA MÉDICA CLÍNICA LAS CONDES 2013. [DOI: 10.1016/s0716-8640(13)70199-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
6
|
Appelt A, Vogelius I, Bentzen S. Modern Hypofractionation Schedules for Tangential Whole Breast Irradiation Decrease the Fraction Size-corrected Dose to the Heart. Clin Oncol (R Coll Radiol) 2013; 25:147-52. [DOI: 10.1016/j.clon.2012.07.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/28/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
|
7
|
The impact of dose heterogeneity on late normal tissue complication risk after hypofractionated whole breast radiotherapy. Radiother Oncol 2012; 104:143-7. [PMID: 22809586 DOI: 10.1016/j.radonc.2012.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 06/08/2012] [Accepted: 06/17/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE Linear quadratic models predict that hypofractionation increases the biological effect of physical dose inhomogeneity. The clinical significance of this effect was tested retrospectively in a trial of adjuvant breast hypofractionation. METHODS The UK FAST trial randomised 915 women after breast conservation surgery between standard fractionation and two dose levels of a 5-fraction regimen delivering 5.7 or 6.0 Gy fractions in 5 weeks, using 3D dosimetry. Logistic regression tested for association between the absolute volumes receiving different isodose level >100% of prescribed dose (hotspots) and the risk of change in 2-year photographic breast appearance. The strength of this association was compared between control and hypofractionated groups. RESULTS Three hundred and ninety datasets from 11 participating centres were available for analysis. At 2 years post-randomisation, 81 (20.8%) had mild change and 24 (6.2%) had marked change in photographic breast appearance. After adjusting for breast size and surgical deficit, there was no statistically significant association between the risk of 2-year change in breast appearance and dose inhomogeneity in either the control or hypofractionated schedules, according to the various definitions of hotspots analysed. The magnitude of the effect of dosimetry on 2-year change in breast appearance did not vary significantly between control and hypofractionated schedules for any of the dosimetry parameters (p>0.05 for all heterogeneity tests). CONCLUSION Dose inhomogeneity had no greater impact on the risk of 2-year change in photographic breast appearance after hypofractionated breast radiotherapy than after standard fractionation.
Collapse
|
8
|
Yarnold J, Bentzen SM, Coles C, Haviland J. Hypofractionated whole-breast radiotherapy for women with early breast cancer: myths and realities. Int J Radiat Oncol Biol Phys 2011; 79:1-9. [PMID: 20950960 DOI: 10.1016/j.ijrobp.2010.08.035] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 08/09/2010] [Accepted: 08/17/2010] [Indexed: 11/30/2022]
Affiliation(s)
- John Yarnold
- Section of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital, Sutton, United Kingdom.
| | | | | | | |
Collapse
|
9
|
Abstract
Published results of randomised trials involving >7000 women confirm the safety and efficacy of hypofractionated schedules of adjuvant radiotherapy for women with early breast cancer using fraction sizes between 2 and 3 Gy assuming appropriate downward adjustments to total dose. Unnecessary concerns relating to heart tolerance, suboptimal dose distribution and duration of follow up need not discourage the routine adoption of 15- or 16-fraction schedules in women treated by breast conservation surgery for early breast cancer. Regardless of fractionation regimen, dose escalation to the index quadrant in high risk subgroups will result in a greater relative increase in late adverse effects than tumour control, a therapeutic disadvantage that can only be overcome by exploiting a marked dose-volume effect. A 15-fraction schedule of whole breast radiotherapy is unlikely to represent the lower limits of hypofractionation, and the preliminary results of a 5-fraction regimen are encouraging.
Collapse
Affiliation(s)
- John Yarnold
- Institute of Cancer Research & Royal Marsden Hospital, Sutton, UK.
| | | |
Collapse
|
10
|
Are Three Weeks of Whole-Breast Radiotherapy as Good as Five Weeks in Early Breast Cancer? - 10 Year Follow-Up in the Canadian Trial of Hypofractionated Radiation Therapy. ACTA ACUST UNITED AC 2010; 5:272-274. [PMID: 22590449 DOI: 10.1159/000319790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Whole breast irradiation (WBI) is considered standard of care among both patients having undergone breast-conserving therapy for invasive breast carcinoma and selected cases post mastectomy. Since the introduction of WBI, clinical trials have been conducted to define the optimal dose, schedule and length of WBI aiming to increase efficacy while reducing toxicity. In the paper discussed in this issue's journal club, Whelan et al. present the latest in a series of randomized clinical trials on hypofractionated radiotherapy.
Collapse
|
11
|
Carling M, Goodare H, Ironside A, Millington J, Rogers C. Quality of life after breast radiotherapy. Lancet Oncol 2010; 11:612; author reply 612-3. [PMID: 20610321 DOI: 10.1016/s1470-2045(10)70121-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
12
|
Arriagada R. Nuevas estrategias en radioterapia para cáncer de mama. Medwave 2010. [DOI: 10.5867/medwave.2010.05.4517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
13
|
Schneider U, Besserer J, Mack A. Hypofractionated radiotherapy has the potential for second cancer reduction. Theor Biol Med Model 2010; 7:4. [PMID: 20149259 PMCID: PMC2829001 DOI: 10.1186/1742-4682-7-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 02/11/2010] [Indexed: 11/10/2022] Open
Abstract
Background and Purpose A model for carcinoma and sarcoma induction was used to study the dependence of carcinogenesis after radiotherapy on fractionation. Materials and methods A cancer induction model for radiotherapy doses including fractionation was used to model carcinoma and sarcoma induction after a radiation treatment. For different fractionation schemes the dose response relationships were obtained. Tumor induction was studied as a function of dose per fraction. Results If it is assumed that the tumor is treated up to the same biologically equivalent dose it was found that large dose fractions could decrease second cancer induction. The risk decreases approximately linear with increasing fraction size and is more pronounced for sarcoma induction. Carcinoma induction decreases by around 10% per 1 Gy increase in fraction dose. Sarcoma risk is decreased by about 15% per 1 Gy increase in fractionation. It is also found that tissue which is irradiated using large dose fractions to dose levels lower than 10% of the target dose potentially develop less sarcomas when compared to tissues irradiated to all dose levels. This is not observed for carcinoma induction. Conclusions It was found that carcinoma as well as sarcoma risk decreases with increasing fractionation dose. The reduction of sarcoma risk is even more pronounced than carcinoma risk. Hypofractionation is potentially beneficial with regard to second cancer induction.
Collapse
Affiliation(s)
- Uwe Schneider
- Radiotherapy Hirslanden AG, Institute for Radiotherapy, Rain 34, Aarau, Switzerland.
| | | | | |
Collapse
|
14
|
Sola A. Revisión de la literatura sobre radioterapia en el cáncer de mama temprano. Medwave 2010. [DOI: 10.5867/medwave.2010.01.4331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
15
|
OECI Workshop on late side-effects of cancer treatments. Eur J Cancer 2009; 45:354-9. [DOI: 10.1016/j.ejca.2008.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/08/2008] [Indexed: 11/24/2022]
|
16
|
Carling M, Goodare H, Ironside A, Millington J, Rogers C. Radiotherapy hypofractionation in early breast cancer. Lancet 2008; 372:204-5; author reply 205. [PMID: 18640452 DOI: 10.1016/s0140-6736(08)61067-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Williams M. Radiotherapy hypofractionation in early breast cancer. Lancet 2008; 372:203-4; author reply 205. [PMID: 18640449 DOI: 10.1016/s0140-6736(08)61065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|