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Melemenidis S, Viswanathan V, Dutt S, Kapadia N, Lau B, Soto LA, Ashraf MR, Thakur B, Mutahar AZI, Skinner LB, Yu AS, Surucu M, Casey KM, Rankin EB, Horst KC, Graves EE, Loo BW, Dirbas FM. Effectiveness of FLASH vs. Conventional Dose Rate Radiotherapy in a Model of Orthotopic, Murine Breast Cancer. Cancers (Basel) 2025; 17:1095. [PMID: 40227580 PMCID: PMC11988084 DOI: 10.3390/cancers17071095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/15/2025] [Accepted: 03/17/2025] [Indexed: 04/15/2025] Open
Abstract
Introduction: Radiotherapy is effective for breast cancer treatment but often causes undesirable side effects that impair quality of life. Ultra-high dose rate radiotherapy (FLASH) has shown reduced normal tissue toxicity while achieving comparable tumor growth delay compared to conventional dose rate radiotherapy (CONV). This study evaluated whether FLASH could achieve similar tumor control as CONV with tumor eradication as the primary endpoint, in an orthotopic breast cancer model. Methods: Non-metastatic, orthotopic tumors were generated in the left fourth mammary fat pad using the Py117 mammary tumor cell line in syngeneic C57BL/6J mice. Two sequential irradiation studies were performed using FLASH (93-200 Gy/s) and CONV (0.08 Gy/s) electron beams. Single fractions of 20, 25, or 30 Gy were applied to tumors with varying abdominal wall treatment fields (~3.75 or 2.5 mm treatment margin to tumor). Results: Both FLASH and CONV demonstrated comparable efficacy. Small tumors treated with 30 Gy and larger abdominal wall treatment fields appeared to have complete eradication at 30 days but also exhibited the highest skin toxicity, limiting follow-up and preventing confirmation of eradication. Smaller abdominal wall treatment fields reduced skin toxicity and allowed for extended follow-up, which resulted in 75% tumor-free survival at 48 days. Larger tumors showed growth delay but no eradication. Conclusions: In this preclinical, non-metastatic orthotopic breast cancer model, FLASH and CONV demonstrated equivalent tumor control with single-fraction doses of 20, 25, or 30 Gy. Overall, 30 Gy achieved the highest eradication rate but also resulted in the most pronounced skin toxicity.
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Affiliation(s)
- Stavros Melemenidis
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Vignesh Viswanathan
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Suparna Dutt
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Naviya Kapadia
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Brianna Lau
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Luis A. Soto
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - M. Ramish Ashraf
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Banita Thakur
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA 94305, USA; (B.T.); (A.Z.I.M.)
| | - Adel Z. I. Mutahar
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA 94305, USA; (B.T.); (A.Z.I.M.)
| | - Lawrie B. Skinner
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Amy S. Yu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Kerriann M. Casey
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Erinn B. Rankin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Kathleen C. Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Edward E. Graves
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Billy W. Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.M.); (V.V.); (S.D.); (B.L.); (L.A.S.); (M.R.A.); (L.B.S.); (A.S.Y.); (M.S.); (E.B.R.); (K.C.H.); (E.E.G.); (B.W.L.J.)
| | - Frederick M. Dirbas
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA 94305, USA; (B.T.); (A.Z.I.M.)
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2
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Almeida ND, Pepin A, Schrand TV, Shekher R, Goulenko V, Fung-Kee-Fung S, Farrugia MK, Shah C, Singh AK. Re-Evaluating the Omission of Radiation Therapy in Low-Risk Patients With Early-Stage Breast Cancer. Clin Breast Cancer 2024; 24:563-574. [PMID: 39179441 DOI: 10.1016/j.clbc.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/06/2024] [Accepted: 07/13/2024] [Indexed: 08/26/2024]
Abstract
Traditionally, management of early-stage breast cancer has required adjuvant radiation therapy following breast conserving surgery, due to decreased local recurrence and breast cancer mortality. However, over the past decade, there has been an increasing emphasis on potential overtreatment of patients with early-stage breast cancer. This has given rise to questions of how to optimize deintensification of treatment in this cohort of patients while maintaining clinical outcomes. A multitude of studies have focused on identification of a subset of patients with invasive breast cancer who were at low risk of local recurrence based on clinicopathologic features and therefore suitable for RT omission. These studies have failed to identify a subset that does not from RT with respect to local control. Several ongoing trials are evaluating alternative approaches to deintensification while focusing on tumor biology. With regards to ductal carcinoma in situ (DCIS), the role of RT has been questioned since breast conservation was utilized. Paralleling invasive disease studies, studies have sought to use clinicopathologic features to identify low risk patients suitable for RT omission but have failed to identify a subset that does not from RT with respect to local control. Use of new assays in patients with DCIS may represent the ideal approach for risk stratification and appropriate deintensification. At this time, when considering deintensification, individualizing treatment decisions with a focus on shared decision making is paramount.
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MESH Headings
- Humans
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Female
- Radiotherapy, Adjuvant/methods
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Recurrence, Local/pathology
- Mastectomy, Segmental
- Neoplasm Staging
- Risk Assessment
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Affiliation(s)
- Neil D Almeida
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Abigail Pepin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Tyler V Schrand
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY; Department of Chemistry, Bowling Green State University, Bowling Green, OH
| | - Rohil Shekher
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Victor Goulenko
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Simon Fung-Kee-Fung
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mark K Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Meattini I, de Oliveira Franco R, Salvestrini V, Hijal T. Special issue. De-escalation of loco-regional treatment in breast cancer: Time to find the balance? Partial breast irradiation. Breast 2023; 69:401-409. [PMID: 37116401 PMCID: PMC10163674 DOI: 10.1016/j.breast.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023] Open
Abstract
Breast cancer is the most common cancer in women worldwide. Over the past few decades, remarkable progress has been made in understanding the biology and pathology of breast cancer. A personalized conservative approach has been currently adopted addressing the patient's individual risk of relapse. After postoperative whole breast irradiation for early-stage breast cancer, a rate of recurrences outside the initial tumour bed lower than 4% was observed. Thus, the highest benefits of breast irradiation seem to result from the dose delivered to the tissue neighbouring the tumour bed. Nonetheless, reducing treatment morbidity while maintaining radiation therapy's ability to decrease local recurrences is an important challenge in treating patients with radiation therapy. In this regard, strategies such as partial-breast irradiation have been developed to reduce toxicity without compromising oncologic outcomes. According to the national and international published guidelines, clinical oncologists can refer to specific dose/fractionation schedules and eligible criteria. However, there are still some areas of open questions. Breast cancer represents a multidisciplinary paradigm; it should be considered a heterogeneous disease where a "one-treatment-fits-all" approach cannot be considered an appropriate option. This is a wide overview on the main partial breast irradiation advantages, risks, timings, techniques, and available recommendations. We aim to provide practical findings to support clinical decision-making, exploring future perspectives, towards a balance for optimisation of breast cancer.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Rejane de Oliveira Franco
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Tarek Hijal
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
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Sjöström M, Fyles A, Liu FF, McCready D, Shi W, Rey-McIntyre K, Chang SL, Feng FY, Speers CW, Pierce LJ, Holmberg E, Fernö M, Malmström P, Karlsson P. Development and Validation of a Genomic Profile for the Omission of Local Adjuvant Radiation in Breast Cancer. J Clin Oncol 2023; 41:1533-1540. [PMID: 36599119 PMCID: PMC10022846 DOI: 10.1200/jco.22.00655] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/07/2022] [Accepted: 11/18/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Adjuvant radiotherapy (RT) is used for women with early-stage invasive breast cancer treated with breast-conserving surgery. However, some women with low risk of recurrence may safely be spared RT. This study aimed to identify these women using a molecular-based approach. METHODS We analyzed two randomized trials of women with node-negative invasive breast cancer to ± RT following breast-conserving surgery: SweBCG91-RT (stage I-II, no adjuvant systemic therapy) and Princess Margaret (age 50 years or older, T1-T2, adjuvant tamoxifen). Transcriptome-wide profiling was performed (Affymetrix Human Exon 1.0 ST microarray). Patients with estrogen receptor-positive/human epidermal growth factor receptor 2-negative tumors and with gene expression data were included. The SweBCG91-RT cohort was divided into training (N = 243) and validation (N = 354) cohorts. A 16-gene signature named Profile for the Omission of Local Adjuvant Radiation (POLAR) was trained to predict locoregional recurrence (LRR) using elastic net regression. POLAR was then validated in the SweBCG91-RT validation cohort and the Princess Margaret cohort (N = 132). RESULTS Patients categorized as POLAR low-risk without RT had a 10-year LRR of 6% (95% CI, 2 to 16) and 7% (0 to 27) in SweBCG91-RT and Princess Margaret cohorts, respectively. There was no significant benefit from RT in POLAR low-risk patients (hazard ratio [HR], 1.1 [0.39 to 3.4], P = .81, and HR, 1.5 [0.14 to 16], P = .74, respectively). Patients categorized as POLAR high-risk had a significant decreased risk of LRR with RT (HR, 0.43 [0.24 to 0.78], P = .0055, and HR, 0.25 [0.07 to 0.92], P = .038, respectively). An exploratory analysis testing for interaction between RT and POLAR in the combined validation cohort was performed (P = .066). CONCLUSION The novel POLAR genomic signature on the basis of LRR biology may identify patients with a low risk of LRR despite not receiving RT, and thus may be candidates for RT omission.
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Affiliation(s)
- Martin Sjöström
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Anthony Fyles
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Fei-Fei Liu
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - David McCready
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Wei Shi
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | | | | | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Corey W. Speers
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Lori J. Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mårten Fernö
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Per Malmström
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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6
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Meattini I, Poortmans PMP, Marrazzo L, Desideri I, Brain E, Hamaker M, Lambertini M, Miccinesi G, Russell N, Saieva C, Strnad V, Visani L, Kaidar-Person O, Livi L. Exclusive endocrine therapy or partial breast irradiation for women aged ≥70 years with luminal A-like early stage breast cancer (NCT04134598 - EUROPA): Proof of concept of a randomized controlled trial comparing health related quality of life by patient reported outcome measures. J Geriatr Oncol 2020; 12:182-189. [PMID: 32739355 DOI: 10.1016/j.jgo.2020.07.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/21/2020] [Accepted: 07/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Postoperative radiation therapy after breast conserving surgery in the older adult population is a matter of debate; although radiation therapy was shown to benefit these patients concerning local disease control, the absolute benefit was small and potentially negligible. Partial breast irradiation has been introduced as an alternative treatment approach for low-risk patients. Older adult patients with early breast cancer constitute a unique population with regards to prognosis and potential comorbidities, thus minimizing treatment to maintain health-related quality of life (HRQoL) without compromising survival is extremely important. Estimates of the patient's risk of benefit and/or harm with treatment should be performed together with an assessment of baseline comorbidities, life expectancy, and care preferences. Published data suggest that radiation therapy or endocrine therapy alone resulted in excellent disease control in older women with early breast cancer, and that the combination of both treatments has less incremental benefit than expected. Conversely, the toxicity profile of endocrine therapy is well known, often significantly impacting long term HRQoL of these potentially frail patients. METHODS Patients older than 70 years receiving breast conserving surgery with T1N0, Luminal A-like tumors will be randomized to receive partial breast irradiation-alone or endocrine therapy-alone. The main objectives are to determine patient reported outcome measures in terms of HRQoL, as assessed by the EORTC QLQ-C30 using the global health status of patients, and to demonstrate a non-inferior local control rate between arms. Secondary endpoints are represented by individual scales from QLQ-C30 and module QLQ-BR45 scores; ELD14 questionnaire; geriatric COre DatasEt assessment; distant control rate, adverse events rates, breast cancer specific, and overall survival. DISCUSSION The EUROPA trial is a new randomized trial focused on older adults (≥70 years) affected by good prognosis primary breast cancer. Our assumption is that postoperative radiation therapy-alone avoids the long-term toxicity of endocrine therapy and favorably impacts on HRQoL in this population. In the current report we present the trial's background and methods, focusing on perspectives in the field of precision medicine. TRIAL REGISTRATION The trial is registered with ClinicalTrial.gov Identifier NCT04134598 / EUROPA trial.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Philip M P Poortmans
- Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Livia Marrazzo
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Etienne Brain
- Institut Curie, Hopital René Huguenin, Saint-Cloud, France
| | | | - Matteo Lambertini
- Breast Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Guido Miccinesi
- Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Florence, Italy
| | - Nicola Russell
- The Netherland Cancer Institute, Amsterdam, the Netherlands
| | - Calogero Saieva
- Istituto per lo Studio, la Prevenzione e la Rete Oncologica (ISPRO), Florence, Italy
| | | | - Luca Visani
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Joseph K, Vos LJ, Gabos Z, Pervez N, Chafe S, Tankel K, Warkentin H, Ghosh S, Amanie J, Powell K, Polkosnik LA, Horsman S, MacKenzie M, Sabri S, Parliament MB, Mackey J, Abdulkarim B. Skin Toxicity in Early Breast Cancer Patients Treated with Field-In-Field Breast Intensity-Modulated Radiotherapy versus Helical Inverse Breast Intensity-Modulated Radiotherapy: Results of a Phase III Randomised Controlled Trial. Clin Oncol (R Coll Radiol) 2020; 33:30-39. [PMID: 32711920 DOI: 10.1016/j.clon.2020.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/08/2020] [Accepted: 07/03/2020] [Indexed: 11/15/2022]
Abstract
AIMS Skin toxicity is a common adverse effect of breast radiotherapy. We investigated whether inverse-planned intensity-modulated radiotherapy (IMRT) would reduce the incidence of skin toxicity compared with forward field-in-field breast IMRT (FiF-IMRT) in early stage breast cancer. MATERIALS AND METHODS This phase III randomised controlled trial compared whole-breast irradiation with either FiF-IMRT or helical tomotherapy IMRT (HT-IMRT), with skin toxicity as the primary end point. Patients received 50 Gy in 25 fractions and were assessed to compare skin toxicity between treatment arms. RESULTS In total, 177 patients were available for assessment and the median follow-up was 73.1 months. Inverse IMRT achieved more homogeneous coverage than FiF-IMRT; erythema and moist desquamation were higher with FiF-IMRT compared with HT-IMRT (61% versus 34%; P < 0.001; 33% versus 11%; P < 0.001, respectively). Multivariate analysis showed large breast volume, FiF-IMRT and chemotherapy were independent factors associated with worse acute toxicity. There was no difference between treatment arms in the incidence of late toxicities. The 5-year recurrence-free survival was 96.3% for both FiF-IMRT and HT-IMRT and the 5-year overall survival was 96.3% for FiF-IMRT and 97.4% for HT-IMRT. CONCLUSIONS Our study showed significant reduction in acute skin toxicity using HT-IMRT compared with FiF-IMRT, without significant reduction in late skin toxicities. On the basis of these findings, inverse-planned IMRT could be used in routine practice for whole-breast irradiation with careful plan optimisation to achieve the required dose constraints for organs at risk.
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Affiliation(s)
- K Joseph
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - L J Vos
- Alberta Cancer Clinical Trials, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Z Gabos
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - N Pervez
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - S Chafe
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - K Tankel
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - H Warkentin
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - S Ghosh
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - J Amanie
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - K Powell
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - L-A Polkosnik
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - S Horsman
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - M MacKenzie
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - S Sabri
- Division of Experimental Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - M B Parliament
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - J Mackey
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - B Abdulkarim
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada.
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8
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Gui Y, Liu X, Chen X, Yang X, Li S, Pan Q, Luo X, Chen L. A Network Meta-Analysis of Surgical Treatment in Patients With Early Breast Cancer. J Natl Cancer Inst 2020; 111:903-915. [PMID: 31187142 DOI: 10.1093/jnci/djz105] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/30/2019] [Accepted: 05/15/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In early breast cancer treatment, the preferred surgical regimen remains a topic of controversy, and conventional pairwise meta-analysis cannot provide a hierarchy based on clinical trial evidence. Therefore, a network meta-analysis was performed both for direct and indirect comparisons and to assess the survival outcomes of surgical regimens. METHODS Randomized clinical trials comparing different surgical regimens for the treatment of early breast cancer were identified. Overall survival (OS) and disease-free-survival (DFS) were analyzed using random-effects network meta-analysis on the hazard ratio (HR) scale and calculated as combined HRs and 95% confidence intervals (CIs). All statistical tests were two-sided. RESULTS The network meta-analysis compared 11 different surgical regimens that consisted of 13 and 17 direct comparisons between strategies for OS (34 trials; n = 23 587 patients) and DFS (32 trials; n = 22 552 patients), respectively. The values of surface under the cumulative ranking for OS and DFS after mastectomy (M)+radiotherapy (RT) were observed to be the largest. Breast-conserving surgery (BCS)+axillary node sampling+RT almost achieved the threshold for inferiority compared with the other surgical treatment arms and was statistically significantly associated with worse OS (HR = 0.51, 95% CI = 0.24 to 0.94; HR = 0.48, 95% CI = 0.22 to 0.92; HR = 0.51, 95% CI = 0.23 to 0.96). No statistically significant difference between BCS+sentinel lymph node biopsy (SLNB)+RT vs BCS+SLNB+intraoperative RT was observed in carrying out network meta-analysis (HR = 0.95, 95% CI = 0.64 to 1.36). CONCLUSIONS M+RT has the most favorable survival outcomes among the various surgical regimens for the treatment of early breast cancer patients. For patients who receive BCS, SNLB has more favorable outcomes than axillary node sampling. Intraoperative RT and postoperative RT have similar outcomes in patients who receive SLNB.
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9
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Franco P, De Rose F, De Santis MC, Pasinetti N, Lancellotta V, Meduri B, Meattini I. Omission of postoperative radiation after breast conserving surgery: A progressive paradigm shift towards precision medicine. Clin Transl Radiat Oncol 2020; 21:112-119. [PMID: 32090175 PMCID: PMC7025960 DOI: 10.1016/j.ctro.2020.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/02/2020] [Accepted: 02/02/2020] [Indexed: 02/06/2023] Open
Abstract
Post-operative radiotherapy is standard after breast conservation in early breast cancer. To de-escalate the treatment burden, indentifying a subset at very low risk of relapse is crucial. Clinical and pathological factors are important, but can be integrated with genomic signatures. Ongoing trials will provide evidence on patients at low risk for radiotherapy omission.
Radiation therapy is a standard therapeutic option in the post-operative setting for early breast cancer patients after breast conserving surgery, providing a substantial benefit in reducing the risk of local relapse with a consequent survival gain. Nevertheless, the reduction in the burden related to treatment is becoming crucial in modern oncology for both local and systemic therapies and investigational efforts are being put forward by radiations oncologists to identify a subset of women at very low risk to be potentially omitted from post-operative irradiation after breast conservation. Clinical factors, classical pathological parameters and new predictive scores derived from gene expression and next generation sequencing techniques are being integrated in the quest toward a reliable low-risk profile for breast cancer patients. We herein provide a comprehensive overview on the topic.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Italy.,Department of Oncology, Radiation Oncology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | | | - Nadia Pasinetti
- Radiation Oncology Department, University of Brescia and Spedali Civili, Brescia, Italy
| | - Valentina Lancellotta
- Radiation Oncology Department, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy.,Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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10
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He L, Lv Y, Song Y, Zhang B. The prognosis comparison of different molecular subtypes of breast tumors after radiotherapy and the intrinsic reasons for their distinct radiosensitivity. Cancer Manag Res 2019; 11:5765-5775. [PMID: 31303789 PMCID: PMC6612049 DOI: 10.2147/cmar.s213663] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 05/25/2019] [Indexed: 12/18/2022] Open
Abstract
Radiotherapy can increase the cell cycle arrest that promotes apoptosis, reduces the risk of tumor recurrence and has become an irreplaceable component of systematic treatment for patients with breast cancer. Substantial advances in precise radiotherapy unequivocally indicate that the benefits of radiotherapy vary depending on intrinsic subtypes of the disease; luminal A breast cancer has the highest benefit whereas human epidermal growth factor receptor 2 (HER2)-positive and triple negative breast cancer (TNBC) are affected to a lesser extent irrespective of the selection of radiotherapy strategies, such as conventional whole-breast irradiation (CWBI), accelerated partial-breast irradiation (APBI), and hypofractionated whole-breast irradiation (HWBI). The benefit disparity correlates with the differential invasiveness, malignance, and radiosensitivity of the subtypes. A combination of a number of molecular mechanisms leads to the strong radioresistant profile of HER2-positive breast cancer, and sensitization to irradiation can be induced by multiple drugs or compounds in luminal disease and TNBC. In this review, we aimed to summarize the prognostic differences between various subtypes of breast tumors after CWBI, APBI, and HWBI, the potential reasons for drug-enhanced radiosensitivity in luminal breast tumors and TNBC, and the robust radioresistance of HER2-positive cancer. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/ugTrSMuQVI8
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Affiliation(s)
- Lin He
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People's Republic of China
| | - Yang Lv
- Department of Oncology, The PLA Navy Anqing Hospital, Anqing, Anhui Province, People's Republic of China
| | - Yuhua Song
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People's Republic of China
| | - Biyuan Zhang
- Department of Radiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People's Republic of China
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11
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Wickberg Å, Liljegren G, Killander F, Lindman H, Bjöhle J, Carlberg M, Blomqvist C, Ahlgren J, Villman K. Omitting radiotherapy in women ≥ 65 years with low-risk early breast cancer after breast-conserving surgery and adjuvant endocrine therapy is safe. Eur J Surg Oncol 2018; 44:951-956. [DOI: 10.1016/j.ejso.2018.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/28/2018] [Accepted: 04/05/2018] [Indexed: 11/16/2022] Open
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12
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Study on the dose modification factor of strut adjusted volume implant (SAVI) with a 169Yb source using MCNP4C. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2018; 41:445-450. [DOI: 10.1007/s13246-018-0641-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
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13
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Improvement of consistency in delineating breast lumpectomy cavity using surgical clips. J Surg Res 2018; 221:30-34. [DOI: 10.1016/j.jss.2017.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 11/22/2022]
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14
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Mao JH, Diest PJV, Perez-Losada J, Snijders AM. Revisiting the impact of age and molecular subtype on overall survival after radiotherapy in breast cancer patients. Sci Rep 2017; 7:12587. [PMID: 28974723 PMCID: PMC5626767 DOI: 10.1038/s41598-017-12949-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/12/2017] [Indexed: 01/07/2023] Open
Abstract
Adjuvant radiotherapy (RT) in breast cancer (BC) is often used to eradicate remaining tumor cells following surgery with the goal of maximizing local control and increasing overall survival. The current study investigated the impact of age and BC molecular subtype on overall survival after RT using a meta-analysis of the METABRIC and TCGA BC patient cohorts. We found that RT significantly prolonged survival across the whole BC patient population. The survival benefit of RT was predominantly observed in stage II BC patients treated with breast conserving surgery. Patients were then stratified by age and molecular subtype to investigate survival rate associated with RT. An increase in survival for the luminal-A and basal BC molecular subtypes was observed after RT. Stratifying patients based on age revealed that increased survival was restricted to younger patients (≤60 years of age at diagnosis). There was a significant survival benefit of radiotherapy for younger patients with tumors of the luminal A and basal molecular subtypes. Patients with other breast tumor subtypes or older breast cancer patients did not seem to benefit effects of RT. Therefore, alternate local treatment strategies should be considered for older, luminal B, and HER2 driven BC patients.
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Affiliation(s)
- Jian-Hua Mao
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, California, USA.
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jesus Perez-Losada
- Instituto de Biología Molecular y Celular del Cáncer (CIC-IBMCC), Universidad de Salamanca/CSIC, Salamanca, 37007, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, 37007, Spain
| | - Antoine M Snijders
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, California, USA.
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15
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Abbott AM, Valente SA, Loftus L, Tendulkar RD, Greif JM, Bethke KP, Donnelly ED, Lottich C, Ross DL, Friedman NB, Bedi CG, Joh JE, Kelemen P, Hoefer RA, Kang SK, Ruffer J, Police A, Fyles A, Graves GM, Willey SC, Tousimis EA, Small W, Lyons J, Grobmyer S, Laronga C. A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter? Am J Surg 2017; 214:629-633. [PMID: 28918848 DOI: 10.1016/j.amjsurg.2017.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.
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Affiliation(s)
| | | | - L Loftus
- Moffitt Cancer Center, Tampa, USA
| | | | - J M Greif
- Alta Bates Summit Medical Center, Oakland, CA, USA
| | | | | | - C Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - D L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | - C G Bedi
- Mercy Medical Center, Baltimore, MD, USA
| | - J E Joh
- Mercy Medical Center, Baltimore, MD, USA
| | - P Kelemen
- Ashikari Breast Center, Dobbs Ferry, NY, USA
| | - R A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - S K Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - J Ruffer
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - A Police
- University of California Irvine Medical Center, Irvine, CA, USA
| | - A Fyles
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - G M Graves
- Sutter Cancer Center, Sacramento, CA, USA
| | - S C Willey
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - E A Tousimis
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - W Small
- Loyola University, Maywood, IL, USA
| | - J Lyons
- The Cleveland Clinic, Cleveland, OH, USA
| | - S Grobmyer
- The Cleveland Clinic, Cleveland, OH, USA
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16
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Silverstein MJ, Epstein MS, Lin K, Chen P, Khan S, Snyder L, Guerra LE, De Leon C, Mackintosh R, Coleman C, Lopez J, Kim B. Intraoperative Radiation Using Low-Kilovoltage X-Rays for Early Breast Cancer: A Single Site Trial. Ann Surg Oncol 2017; 24:3082-3087. [DOI: 10.1245/s10434-017-5934-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/25/2022]
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17
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Kuperman VY, Spradlin GS, Kordomenos J. Effect of applicator rotation on dose distribution in accelerated partial breast irradiation. Biomed Phys Eng Express 2017. [DOI: 10.1088/2057-1976/aa62ae] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Risk factors and state-of-the-art indications for boost irradiation in invasive breast carcinoma. Brachytherapy 2017; 16:552-564. [DOI: 10.1016/j.brachy.2017.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 12/14/2022]
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Margenthaler JA, Ollila DW. Breast Conservation Therapy Versus Mastectomy: Shared Decision-Making Strategies and Overcoming Decisional Conflicts in Your Patients. Ann Surg Oncol 2016; 23:3133-7. [DOI: 10.1245/s10434-016-5369-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Indexed: 11/18/2022]
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20
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Epstein M, Silverstein M, Lin K, Kim B, Khan S, De Leon C, Guerra L, Snyder L, Coleman C, Lopez J, Mackintosh R, Chen P. Acute and Chronic Complications in Breast Cancer Patients Treated with Intraoperative Radiation Therapy. Ann Surg Oncol 2016; 23:3304-9. [PMID: 27334211 DOI: 10.1245/s10434-016-5316-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intraoperative radiation therapy (IORT) permits the delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the complications associated with this modality of treatment using the Xoft(®) Axxent Electronic Brachytherapy (Axxent) System. METHODS A total of 702 patients who received IORT using the Xoft(®) Axxent System at Hoag Memorial Hospital Presbyterian between June 2010-February 2016 were accrued in an IORT data registry study. The prospective and retrospective protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months. RESULTS Acute complications were observed in 21 % of patients and included hematomas that required drainage, seromas requiring drainage more than 3 times, infections treated with antibiotics or surgery, necrosis requiring surgery, and erythema. Chronic complications were observed in 13 % of patients and included seromas, fibrosis, and hyperpigmentation. The majority of acute and chronic problems from IORT were mild. If grade I erythema, fibrosis, and hyperpigmentation were removed, only 32 of 702 (4.6 %) had significant complications. Our complication rates were comparable to those of the TARGIT trial. CONCLUSIONS IORT is a modality that safely delivers radiation therapy to patients diagnosed with breast cancer. This technique allows women who cannot (or decline to) undergo whole breast radiation to consider breast-conserving therapy rather than mastectomy.
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Affiliation(s)
- Melinda Epstein
- Hoag Institute for Research and Education, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.
| | - Melvin Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.,Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Kevin Lin
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Brian Kim
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.,Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Cristina De Leon
- Hoag Institute for Research and Education, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | | | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Colleen Coleman
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - January Lopez
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Ralph Mackintosh
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Peter Chen
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
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Choi M, Small W, Emami B. Routine use of preoperative breast MRI for patients considered for intraoperative radiotherapy. J Thorac Dis 2016; 8:765-8. [PMID: 27162648 DOI: 10.21037/jtd.2016.03.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This editorial comments on the study by Tallet et al. which reported on the incidence of ipsilateral second breast cancers (BC) detected by preoperative magnetic resonance imaging (MRI) in patients being considered for intraoperative radiotherapy (IORT). Any second BC was detected in 7% of patients; an ipsilateral BC was detected in 4% of patients, precluding them from IORT. The authors comment that in view of detection of a substantial rate of ipsilateral BCs by preoperative MRI, this exam should be used routinely for staging patients being considered for IORT.
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Affiliation(s)
- Mehee Choi
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Bahman Emami
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
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Muñoz GH, Hany RP, Cosson A, Gonzalez C, Rasquií JH, Rodriguez I, Ghaleb J, Gonzalez E, Benitez MM, Hurtado W, Sanchez N, Figuera C. Intraoperative Radiation Therapy (INTRABEAM) Experience at the Mastology Unit Leopoldo Aguerrevere Clinic. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/jct.2015.610101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Diffusion of accelerated partial breast radiotherapy in the United States: physician-level and patient-level analyses. Med Care 2014; 52:969-74. [PMID: 25185635 DOI: 10.1097/mlr.0000000000000215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate diffusion of brachytherapy-based accelerated partial breast radiotherapy (RT) in the United States, a new breast cancer treatment requiring 5 days twice daily, rather than daily treatment for 6-7 weeks. It has limited long-term effectiveness data compared with standard whole breast RT. DATA AND METHODS We used 2005-2008 Medicare claims for female Medicare beneficiaries receiving RT after breast-conserving surgery merged with physician and area-based data (n=74,254 patient-subjects; n=1901 physicians), applying logistic regression to estimate: (1) proportion of patients for whom the radiation oncologist used brachytherapy-based accelerated RT, and (2) probability a patient received brachytherapy-based accelerated RT, clustering on physician. RESULTS Use of accelerated partial breast RT increased over time (8% in 2005 to 17% in 2008). Physician-level analysis indicates rural physicians were less likely to perform accelerated RT [odds ratio (OR): 0.35-0.49; P<0.002)]; as were those licensed 20+years [OR: 0.54; 95% confidence interval (CI), 0.39-0.74]. Overall, 11.7% of patients received accelerated RT. Treatment post 2005 was associated with increasing odds of receiving accelerated RT (P<0.0001). Older age was associated with lower odds of receiving accelerated RT (reference, 66-69 years old, OR: 0.90, P<0.006), as was black (OR: 0.73;95% CI, 0.63-0.85) or other race (OR: 0.80; 95% CI, 0.65-1.00), living in rural areas (OR: 0.8; P<0.0001), or seeing an older physician [20+years postgraduation (OR: 0.7; 95% CI, 0.5-0.9)]. Patients living in counties with more hospitals with advanced RT facilities were more likely to undergo accelerated RT (OR: 1.4; 95% CI, 1.1-1.8). DISCUSSION This new technology appears to be in the early phase of diffusion across the United States and is more rapidly being taken up in younger, white patients living in urban and suburban areas with availability of advanced RT facilities. Rural and older patient populations are not tending to undergo the treatment.
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Abstract
Objective. To understand decision making concerning adoption and nonadoption of accelerated partial breast radiotherapy (RT) prior to long-term randomized trial evidence. Methods. A total of 36 radiation oncologists and surgeons were recruited through purposive and snowball sampling strategies from September 2010 through January 2013. Semistructured phone interviews were conducted and audio-recorded and lasted 20–45 minutes. Qualitative analysis was conducted using a framework approach, iteratively exploring key concepts and emerging issues raised by subjects. Interviews were transcribed and imported into Atlas.ti v6. Transcripts were independently coded by 3 researchers shortly after each interview, followed by consensus development on each coded transcript. Barriers and facilitators of adoption, practice patterns, and informational/educational sources concerning accelerated partial breast RT were all assessed to determine major themes. Results. Nearly half of physicians were surgeons (47%), and half were radiation oncologists (53%), with 61% overall in urban settings. Twenty-nine of the 36 physicians interviewed used brachytherapy-based partial breast RT. Five major factors were involved in physicians’ decisions to adopt accelerated partial breast RT: facilitators encouraging adoption (e.g., enthusiastic colleagues and patient convenience), financial and prestige incentives, pressures to adopt (e.g., potential declines in referrals), judgment concerning acceptable level of scientific evidence, and barriers (e.g., not having appropriate machinery or referral mechanism in place). If technology was adopted, clinical guideline adherence varied. Conclusions. Technology adoption is based on financial and social pressures, along with often-limited scientific evidence and what seems “best” for patients. For technology adoption and diffusion to be rational and evidence-based, we must encourage appropriate financial payment models to curb use outside of research studies and promote development of additional treatment registries until sufficient evidence is gathered.
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Affiliation(s)
- Heather Taffet Gold
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Kimberly Pitrelli
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Mary Katherine Hayes
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Madhuvanti Mahadeo Murphy
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
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Smith SL, Truong PT, Lu L, Lesperance M, Olivotto IA. Identification of patients at very low risk of local recurrence after breast-conserving surgery. Int J Radiat Oncol Biol Phys 2014; 89:556-62. [PMID: 24929165 DOI: 10.1016/j.ijrobp.2014.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 02/24/2014] [Accepted: 03/11/2014] [Indexed: 01/23/2023]
Abstract
PURPOSE To identify clinical and pathological factors that identify groups of women with stage I breast cancer with a 5-year risk of local recurrence (LR) ≤1.5% after breast-conserving therapy (BCS) plus whole-breast radiation therapy (RT). METHODS AND MATERIALS Study subjects were 5974 patients ≥50 years of age whose cancer was diagnosed between 1989 and 2006, and were referred with pT1 pN0 invasive breast cancer treated with BCS and RT. Cases of 5- and 10-year LR were examined using Kaplan-Meier methods. Recursive partitioning analysis was performed in patients treated with and without endocrine therapy to identify combinations of factors associated with a 5-year LR risk ≤1.5%. RESULTS The median follow-up was 8.61 years. Median age was 63 years of age (range, 50 to 91). Overall 5-year LR was 1.5% (95% confidence interval [CI], 1.2%-1.9%) and 10-year LR was 3.4% (95% CI, 2.8%-4.0%). Of 2830 patients treated with endocrine therapy, patient subsets identified with 5-year LR ≤1.5% included patients with grade 1 histology (n=1038; LR, 0.2%; 95% CI, 0%-0.5%) or grade 2 histology plus ≥60 years of age (n=843; LR, 0.5%; 95% CI, 0%-1.0%). Ten-year LR for these groups were 0.8% (95% CI, 0.1%-1.6%) and 0.9% (95% CI, 0.2%-1.6%), respectively. Of 3144 patients treated without endocrine therapy, patients with grade 1 histology plus clear margins had 5-year LR ≤1.5% (n=821; LR, 0.6%; 95% CI, 0.1%-1.2%). Ten-year LR for this group was 2.2% (95% CI, 1.0%-3.4%). CONCLUSIONS Histologic grade, age, margin status, and use of endocrine therapy identified 45% of a population-based cohort of female patients over age 50 with stage I breast cancer with a 5-year LR risk ≤1.5% after BCS plus RT. Prospective study is needed to evaluate the safety of omitting RT in patients with such a low risk of LR.
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Affiliation(s)
- Sally L Smith
- Radiation Therapy Program and Breast Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver Island Centre, University of British Columbia, Victoria, British Columbia, Canada.
| | - Pauline T Truong
- Radiation Therapy Program and Breast Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver Island Centre, University of British Columbia, Victoria, British Columbia, Canada
| | - Linghong Lu
- Department of Mathematics and Statistics, University of Victoria, Victoria, British Columbia, Canada
| | - Mary Lesperance
- Department of Mathematics and Statistics, University of Victoria, Victoria, British Columbia, Canada
| | - Ivo A Olivotto
- Division of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Macdonald SM, Taghian AG. Partial–breast irradiation: towards a replacement for whole–breast irradiation? Expert Rev Anticancer Ther 2014; 7:123-34. [PMID: 17288524 DOI: 10.1586/14737140.7.2.123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Largely thanks to all of the investigators and patients who have participated in randomized breast-conservation trials, many women facing a diagnosis of breast cancer today can conserve their breast with the help of adjuvant radiation therapy. A standard course of radiation consists of 5-7 weeks of daily radiation treatments delivered to the whole breast. The success of this treatment has led investigators to attempt to determine whether the same control can be achieved while decreasing the volume of breast tissue irradiated, thus allowing treatment to be delivered in a shorter period of time. This approach could alleviate time and logistical problems faced by patients during their course of treatment as well as improving overall cost-effectiveness. It can also allow complete avoidance of the adjacent heart and lung tissue in the radiation treatment portal. Partial-breast irradiation (the delivery of radiation to the resection cavity, plus a safety margin) delivered in just hours or days, is currently under investigation. Although relatively new, its use is growing rapidly and many institutional and cooperative group trials are quickly enlisting patients, while physicians are gaining experience in a variety of partial-breast irradiation techniques.
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Affiliation(s)
- Shannon M Macdonald
- Harvard Medical School, Massachusetts General Hospital, Department of Radiation Oncology, Boston, MA 02114, USA.
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Tinterri C, Gatzemeier W, Costa A, Gentilini MA, Zanini V, Regolo L, Pedrazzoli C, Rondini E, Amanti C, Gentile G, Taffurelli M, Fenaroli P, Tondini C, Sacchetto G, Sismondi P, Murgo R, Orlandi M, Cianchetti E, Andreoli C. Breast-conservative surgery with and without radiotherapy in patients aged 55-75 years with early-stage breast cancer: a prospective, randomized, multicenter trial analysis after 108 months of median follow-up. Ann Surg Oncol 2013; 21:408-15. [PMID: 24197757 DOI: 10.1245/s10434-013-3233-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Breast-conserving therapy (BCT), including postoperative whole breast irradiation (WBI), is generally accepted as the treatment of choice for most patients with early-stage breast cancer. The question whether WBI is mandatory in all patients remains one of the most controversial issues in BCT. To answer this question, a randomized, prospective, multicentre study was launched in January 2001. Primary endpoints of the study were to assess the cumulative incidence of in-breast-recurrences (IBR) and overall survival (OAS) after conservative surgery (BCS) with or without WBI. METHODS From January 2001 until December 2005, 749 patients with unifocal infiltrating breast cancer up to 25 mm, 0-3 positive axillary lymph nodes, no extensive intraductal component or lymphvascular invasion from 11 centres in Italy, were randomly assigned to BCS+WBI (arm 1:373 patients) or BCS alone (arm 2:376 patients). Treatment arms were well balanced in terms of baseline characteristics. Systemic adjuvant therapy was administered according to the institutional policies. Kaplan-Meier method was used for survival analysis and log-rank test to evaluate the difference between the two arms. RESULTS (Last analysis 31.12.2012): After median follow-up of 108 months, 12 (3.4%) IBR were observed in arm 1 and 16 (4.4%) in arm 2. OAS was 81.4% in arm 1 and 83.7% in arm 2. There was no statistically significant difference regarding IBR and death in the two treatment groups. CONCLUSIONS These data are promising and suggest that WBI after BCS can be omitted in selected patients with early stage breast cancer without exposing them to an increased risk of local recurrence and death. Longer follow-up is needed to further consolidate these results.
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Affiliation(s)
- C Tinterri
- Breast Unit, Istituto Clinico Humanitas, Rozzano, Milan, Italy,
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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
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Blamey RW, Bates T, Chetty U, Duffy SW, Ellis IO, George D, Mallon E, Mitchell MJ, Monypenny I, Morgan DAL, Macmillan RD, Patnick J, Pinder SE. Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial. Eur J Cancer 2013; 49:2294-302. [PMID: 23523089 DOI: 10.1016/j.ejca.2013.02.031] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/31/2013] [Accepted: 02/25/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of local recurrence (LR) after conservative surgery for early breast cancer without adjuvant therapy is unacceptably high even with favourable tumours. The aim of this study was to examine the effect of adjuvant therapies in tumours with excellent prognostic features. METHODS Patients with primary invasive breast cancer <2 cm diameter, grade 1 or good prognosis special type, and node negative, treated by wide local excision (WLE) with clear margins were randomised into a 2 × 2 clinical trial of factorial design with or without radiotherapy and with or without tamoxifen. Trial entry was allowed to either comparison or both. FINDINGS The actuarial breast cancer specific survival in 1135 randomised patients at 10 years was 96%. Analysis by intention to treat showed that LR after WLE was reduced in patients randomised to radiotherapy (RT) (HR 0.37, CI 0.22-0.61 p<0.001) and to tamoxifen (HR 0.33, CI 0.15 - 0.70 p<0.004). Actuarial analysis of patients entered into the four-way randomisation showed that LR after WLE alone was 1.9% per annum (PA) versus 0.7% with RT alone and 0.8% with tamoxifen alone. No patient randomised to both adjuvant treatments developed LR. Analysis by treatment received showed LR at 2.2%PA for surgery alone versus 0.8% for either adjuvant radiotherapy or tamoxifen and 0.2% for both treatments. CONCLUSIONS Even in these patients with tumours of excellent prognosis, LR after conservative surgery without adjuvant therapy was still very high. This was reduced to a similar extent by either radiotherapy or tamoxifen but to a greater extent by the receipt of both treatments.
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Affiliation(s)
- R W Blamey
- Nottingham City Hospital, Hucknall Rd., Nottingham NG5 1PB, United Kingdom
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Langlands FE, Horgan K, Dodwell DD, Smith L. Breast cancer subtypes: response to radiotherapy and potential radiosensitisation. Br J Radiol 2013; 86:20120601. [PMID: 23392193 DOI: 10.1259/bjr.20120601] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Radiotherapy (RT) is of critical importance in the locoregional management of early breast cancer. Over 50% of patients receive RT at some time during the treatment of their disease, equating to over 500 000 patients worldwide receiving RT each year. Unfortunately, not all patients derive therapeutic benefit and some breast cancers are resistant to treatment, as evidenced by distant metastatic spread and local recurrence. Prediction of individual responses to RT may allow a stratified approach to this treatment permitting those patients with radioresistant tumours to receive higher doses of RT (total and/or tumour cavity boost doses) and/or radiosensitising agents to optimise treatment. Also, for those patients unlikely to respond at all, it would prevent harmful side effects occurring for no therapeutic gain. More selective targeting would better direct National Health Service resources, ease the burden on heavily used treatment RT machines and reduce the economic cost of cancer treatment. Unfortunately, there are no robust and validated biomarkers for predicting RT outcome. We review the available literature to determine whether classification of breast cancers according to their molecular profile may be used to predict successful response to, or increased morbidity from, RT. Class-specific biomarkers for targeting by radiosensitising agents are also discussed.
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Affiliation(s)
- F E Langlands
- Section of Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, Leeds University, Leeds, UK
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Tamaki K, Tamaki N, Kamada Y, Uehara K, Ohuchi N, Miyashita M, Ishida T, Sasano H. Clinical significance following breast conservation therapy with or without irradiation in breast cancer patients. Jpn J Clin Oncol 2013; 43:251-7. [PMID: 23277499 DOI: 10.1093/jjco/hys214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We retrospectively examined the clinical outcome of irradiated versus non-irradiated groups of Japanese breast cancer patients according to their clinical and histopathological characteristics following breast-conserving therapy. METHODS We retrospectively evaluated a total of 1197 Japanese female breast cancer patients (598 irradiated and 599 non-irradiated) who received breast-conserving therapy. The median age of the patients was 54 years (range: 24-99 years). We retrospectively examined the local recurrence-free survival rates in those with or without post-operative irradiation according to age, surgical margin status and histopathological characteristics including histological grade, estrogen receptor expression and HER2 status. RESULTS Local recurrence-free survival rates in the irradiated group were significantly higher than those in the non-irradiated group, especially in surgical margin-positive [hazard ratio (HR): 0.334, 95% confidence interval: 0.14-0.79, P = 0.001], estrogen receptor-positive (HR: 0.249, 95% confidence interval: 0.11-0.54, P < 0.001), HER2-negative (HR: 0.382, 95% confidence interval: 0.21-0.69, P = 0.001) and non-triple-negative (HR: 0.382, 95% confidence interval: 0.21-0.69, P = 0.001) breast cancer patients. CONCLUSION The results indicated that irradiation after breast-conserving therapy is strongly recommended in Japanese breast cancer patients, especially those with surgically positive margins, estrogen receptor-positive tumors and HER2-negative invasive breast cancers.
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Affiliation(s)
- Kentaro Tamaki
- Department of Breast Surgery, Nahanishi Clinic, 2-1-9 Akamine, Naha, Okinawa, Japan.
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32
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Gold HT, Hayes MK. Cost effectiveness of new breast cancer radiotherapy technologies in diverse populations. Breast Cancer Res Treat 2012; 136:221-9. [DOI: 10.1007/s10549-012-2242-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 09/03/2012] [Indexed: 11/28/2022]
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Wilson M, Korourian S, Boneti C, Adkins L, Badgwell B, Lee J, Suzanne Klimberg V. Long-Term Results of Excision Followed by Radiofrequency Ablation as the Sole Means of Local Therapy for Breast Cancer. Ann Surg Oncol 2012; 19:3192-8. [DOI: 10.1245/s10434-012-2476-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Indexed: 12/24/2022]
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Albert JM, Pan IW, Shih YCT, Jiang J, Buchholz TA, Giordano SH, Smith BD. Effectiveness of radiation for prevention of mastectomy in older breast cancer patients treated with conservative surgery. Cancer 2012; 118:4642-51. [PMID: 22890779 DOI: 10.1002/cncr.27457] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 01/10/2012] [Accepted: 01/12/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND A recent clinical trial concluded that radiation therapy (RT) does not lower the risk of mastectomy and, thus, may be omitted in older women with stage I, estrogen receptor (ER)-positive breast cancer who undergo conservative surgery (CS). However, it is not known whether this finding applies to patients outside of clinical trials. Accordingly, we used the Surveillance, Epidemiology, and End Results-Medicare observational cohort to determine the effect of RT on the risk of mastectomy among older women with stage I, ER-positive breast cancer. METHODS The authors identified 7403 women ages 70 to 79 years who underwent CS between 1992 and 2002. Claims were used to determine RT status and to identify women who underwent mastectomy subsequent to initial treatment. The Kaplan-Meier method was used to estimate the risk of subsequent mastectomy, and Cox regression analysis was used to determine the effect of RT adjusted for clinical-pathologic covariates. RESULTS At a median follow-up of 7.3 years, the risk of subsequent mastectomy within 10 years of diagnosis was 3.2% for patients who received RT versus 6.3% for patients who did not receive RT (P < .001). In adjusted analyses, RT was associated with a lower risk of mastectomy (hazard ratio, 0.33; 95% confidence interval, 0.22-0.48; P < .001). RT provided no benefit for patients ages 75 to 79 years without high-grade tumors who had a pathologic lymph node assessment (P = .80); however, for all other subgroups, RT was associated with an absolute reduction in risk of mastectomy that ranged from 4.3% to 9.8% at 10 years. CONCLUSIONS Outside of a clinical trial, the receipt of RT after CS was associated with a greater likelihood of ultimate breast preservation for most older women with early breast cancer.
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Affiliation(s)
- Jeffrey M Albert
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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A Multi-Institutional Study of Feasibility, Implementation, and Early Clinical Results With Noninvasive Breast Brachytherapy for Tumor Bed Boost. Int J Radiat Oncol Biol Phys 2012; 83:1374-80. [DOI: 10.1016/j.ijrobp.2011.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 09/29/2011] [Accepted: 10/04/2011] [Indexed: 11/18/2022]
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Abstract
In the last four decades breast-conserving surgery followed by whole breast irradiation has become the standard of care for the treatment of early-stage (0-I-II) breast carcinoma. With the advent of breast-screening, incidence of breast carcinomas with more favorable prognostic characteristics has increased significantly. This change in the prognostic profile of newly diagnosed breast cancers opened a new horizon for clinical research seeking for individual risk-adapted protocols of breast cancer radiotherapy. Several groups have been tested the efficacy of accelerated (partial or whole) breast irradiation, which has become the new treatment paradigm in the radiotherapy of early-stage breast cancers. Furthermore, others have attempted to identify subgroups of patients for whom radiotherapy after breast-conserving surgery could be safely omitted. Recently molecular gene expression assays have emerged as promising prognostic and predictive markers for local recurrence. This article reviews the results of these studies focusing on individual risk-adapted radiotherapy after breast-conserving surgery for patients with early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Országos Onkológiai Intézet Budapest Ráth Gy. u. 7-9. 1122.
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37
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Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
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Tuttle TM, Jarosek S, Habermann EB, Yee D, Yuan J, Virnig BA. Omission of radiation therapy after breast-conserving surgery in the United States: a population-based analysis of clinicopathologic factors. Cancer 2011; 118:2004-13. [PMID: 21952948 DOI: 10.1002/cncr.26505] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 07/12/2011] [Accepted: 07/18/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Radiation therapy (RT) after breast-conserving surgery (BCS) is associated with a significant reduction in ipsilateral breast tumor recurrence and breast cancer mortality rates in patients with early stage breast cancer. The authors of this report sought to determine which patients with breast cancer do not receive RT after BCS in the United States. METHODS The Surveillance, Epidemiology, and End Results registry was used to determine the rates of RT after BCS for women with stage I through III breast cancer in the United States from 1992 through 2007. A multivariate analysis was performed to identify independent predictors of omission of RT. RESULTS In total, 294,254 patients with invasive, nonmetastatic breast cancer were identified who underwent surgery from 1992 through 2007. Most patients (57%) underwent BCS; among those, 21.1% did not receive RT after BCS. The omission of RT increased significantly from 1992 (15.5%) to 2007 (25%). The receipt of RT also decreased significantly for patients with increased cancer stage, age <55 years, high-grade tumors, large tumors, positive or untested lymph node status, African American or Hispanic race, and negative or unknown estrogen receptor status. Significant geographic variation was observed in the rates of RT after BCS. CONCLUSIONS The omission of RT after BCS was more common in recent years, especially among women who had an increased risk of breast cancer recurrence. This trend represents a serious health care concern because of the potential increased risk of local recurrence and breast cancer mortality.
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Affiliation(s)
- Todd M Tuttle
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Murthy KK, Sivakumar SS, Davis CA, Ravichandran R, El Ghamrawy K. Optimization of dose distribution with multi-leaf collimator using field-in-field technique for parallel opposing tangential beams of breast cancers. J Med Phys 2011; 33:60-3. [PMID: 19893692 PMCID: PMC2772025 DOI: 10.4103/0971-6203.41194] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Accepted: 04/24/2008] [Indexed: 11/24/2022] Open
Abstract
3 Dimensional Conformal Radiotherapy (3D-CRT) planning software helps in displaying the 3D dose distribution at different levels in the planned target volume (PTV). Physical or dynamic wedges are commonly applied to obtain homogeneous dose distribution in the PTV. Despite all these planning efforts, there are about 10% increased dose hot spots encountered in final plans. To overcome the effect of formation of hot spots, a manual forward planning method has been used. In this method, two more beams with multi-leaf collimator (MLC) of different weights are added in addition to medial and lateral wedged tangent beams. Fifteen patient treatment plans were taken up to check and compare the validity of using additional MLC fields to achieve better homogeneity in dose distributions. The resultant dose distributions with and without presence of MLC were compared objectively. The dose volume histogram (DVH) of each plan for the PTV was evaluated. The 3D dose distributions and homogeneity index (HI) values were compared. The 3D dose maximum values were reduced by 4% to 7%, and hot spots assumed point size. Optimizations of 3D-CRT plans with MLC fields improved the homogeneity and conformability of dose distribution in the PTV. This paper outlines a method of obtaining optimal 3D dose distribution within the PTV in the 3D-CRT planning of breast cases.
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Affiliation(s)
- K Krishna Murthy
- Department of Radiotherapy, National Oncology Center, The Royal Hospital, Muscat, Sultanate of Oman
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Lin R, Tripuraneni P. Radiation therapy in early-stage invasive breast cancer. Indian J Surg Oncol 2011; 2:101-11. [PMID: 22693401 DOI: 10.1007/s13193-011-0048-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 01/06/2010] [Indexed: 10/18/2022] Open
Abstract
The treatment of breast cancer involves a multi-disciplinary approach with radiation therapy playing a key role. Breast-conserving surgery has been an option for women with early-stage breast cancer for over two decades now. Multiple randomized trials now have demonstrated the efficacy of breast-conserving surgery followed by radiation therapy. With the advancements in breast imaging and the successful campaign for early detection of breast cancer, more women today are found to have early-stage small breast cancers. Patient factors (breast size, tumor location, history of prior radiation therapy, preexisting conditions such as collagen vascular disease, age, having prosthetically augmented breasts), pathological factors (margin status, tumor size, presence of extensive intraductal component requiring multiple surgical excisions), as well as patient preference are all taken into consideration prior to surgical management of breast cancer. Whole-breast fractionated radiation therapy between 5 and 7 weeks is considered as the standard of care treatment following breast-conserving surgery. However, new radiation treatment strategies have been developed in recent years to provide alternatives to the conventional 5-7 week whole-breast radiation therapy for some patients. Accelerated partial breast radiation therapy (APBI) was introduced because the frequency of breast recurrences outside of the surgical cavity has been shown to be low. This technique allows treatments to be delivered quicker (usually 1 week, twice daily) to a limited volume. Often times, this treatment involves the use of a brachytherapy applicator to be placed into the surgical cavity following breast-conserving surgery. Accelerated hypofractionated whole-breast irradiation may be another faster way to deliver radiation therapy following breast-conserving surgery. This journal article reviews the role of radiation therapy in women with early-stage breast cancer addressing patient selection in breast-conserving therapy, a review of pertinent trials in breast-conserving therapy, as well as the different treatment techniques available to women following breast-conserving surgery.
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Affiliation(s)
- Ray Lin
- Department of Radiation Oncology, Scripps Clinic and Scripps Green Hospital, La Jolla, CA USA
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Long-Term Clinical and Cosmetic Outcomes After Breast Conservation Treatment for Women With Early-Stage Breast Carcinoma According to the Type of Breast Boost. Int J Radiat Oncol Biol Phys 2011; 79:1048-54. [DOI: 10.1016/j.ijrobp.2009.12.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 12/07/2009] [Accepted: 12/14/2009] [Indexed: 11/23/2022]
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Tang SSK, Gui GPH. A Review of the Oncologic and Surgical Management of Breast Cancer in the Augmented Breast: Diagnostic, Surgical and Surveillance Challenges. Ann Surg Oncol 2011; 18:2173-81. [DOI: 10.1245/s10434-011-1578-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Indexed: 11/18/2022]
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Wilder RB, Curcio LD, Khanijou RK, Eisner ME, Kakkis JL, Chittenden L, Agustin J, Lizarde J, Mesa AV, Macedo JC, Ravera J, Tokita KM. Preliminary Results in 173 Breast Cancer Patients Treated with Post-Lumpectomy MammoSite Single-Lumen Brachytherapy or Multi-Catheter Brachytherapy. Breast J 2010; 16:581-6. [DOI: 10.1111/j.1524-4741.2010.00977.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wilder RB, Curcio LD, Khanijou RK, Eisner ME, Kakkis JL, Chittenden L, Agustin J, Lizarde J, Mesa AV, Macedo JC, Ravera J, Tokita KM. Results With Accelerated Partial Breast Irradiation in Terms of Estrogen Receptor, Progesterone Receptor, and Human Growth Factor Receptor 2 Status. Int J Radiat Oncol Biol Phys 2010; 78:799-803. [DOI: 10.1016/j.ijrobp.2009.08.081] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2009] [Revised: 08/01/2009] [Accepted: 08/24/2009] [Indexed: 10/19/2022]
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Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol 2010; 5:90. [PMID: 20920346 PMCID: PMC2958971 DOI: 10.1186/1748-717x-5-90] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/04/2010] [Indexed: 01/08/2023] Open
Abstract
Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. However, its utilization has not been maximized because of logistics issues associated with the protracted treatment involved with the radiation treatment. Accelerated Partial Breast Irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. Hence because of the small volume of irradiation a higher dose can be delivered in a shorter period of time. There has been growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include Mammosite, Axxent electronic brachytherapy and Contura, Hybrid brachytherapy devices include SAVI and ClearPath. This paper reviews the different techniques, identifying the weaknesses and strength of each approach and proposes a direction for future research and development. It is evident that APBI will play a role in the management of a selected group of early breast cancer. However, the relative role of the different techniques is yet to be clearly identified.
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Affiliation(s)
- Christopher F Njeh
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Mark W Saunders
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Christian M Langton
- Physics, Faculty of Science and Technology, Queensland University of Technology, Brisbane, Australia
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Accelerated partial breast irradiation with interstitial implants: risk factors associated with increased local recurrence. Int J Radiat Oncol Biol Phys 2010; 80:1458-63. [PMID: 20675064 DOI: 10.1016/j.ijrobp.2010.04.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 04/13/2010] [Accepted: 04/14/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE To analyze patient, disease, and treatment-related factors regarding their impact on local control after interstitial multicatheter accelerated partial breast irradiation (APBI). METHODS AND MATERIALS Between November 2000 and April 2005, 274 patients with early breast cancer were recruited for the German-Austrian APBI Phase II trial (ClinicalTrials.gov identifier: NCT00392184). In all, 64% (175/274) of the patients received pulsed-dose-rate (PDR) brachytherapy and 36% (99/274) received high-dose-rate (HDR) brachytherapy. Prescribed reference dose for HDR brachytherapy was 32 Gy in eight fractions of 4 Gy, twice daily. Prescribed reference dose in PDR brachytherapy was 49.8 Gy in 83 consecutive fractions of 0.6 Gy each hour. Total treatment time was 3 to 4 days. RESULTS The median follow-up time was 64 months (range, 9-110). The actuarial 5-year local recurrence free survival rate (5-year LRFS) was 97.7%. Comparing patients with an age <50 years (49/274) vs. ≥50 years (225/274), the 5-year LRFS resulted in 92.5% and 98.9% (exact p = 0.030; 99% confidence interval, 0.029-0.032), respectively. Antihormonal treatment (AHT) was not applied in 9% (24/274) of the study population. The 5-year LRFS was 99% and 84.9% (exact p = 0.0087; 99% confidence interval, 0.0079-0.0094) in favor of the patients who received AHT. Lobular histology (45/274) was not associated with worse local control compared with all other histologies (229/274). The 5-year LRFS rates were 97.6% and 97.8%, respectively. CONCLUSIONS Local control at 5 years is excellent and comparable to therapeutic successes reported from corresponding whole-breast irradiation trials. Our data indicate that patients <50 years of age ought to be excluded from APBI protocols, and that patients with hormone-sensitive breast cancer should definitely receive adjuvant AHT when interstitial multicatheter APBI is performed. Lobular histology need not be an exclusion criterion for future APBI trials.
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Preliminary results with accelerated partial breast irradiation in high-risk breast cancer patients. Brachytherapy 2010; 9:171-7. [DOI: 10.1016/j.brachy.2009.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/19/2009] [Accepted: 08/20/2009] [Indexed: 11/22/2022]
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Winzer KJ, Sauerbrei W, Braun M, Liersch T, Dunst J, Guski H, Schumacher M. Radiation therapy and tamoxifen after breast-conserving surgery: updated results of a 2 x 2 randomised clinical trial in patients with low risk of recurrence. Eur J Cancer 2010; 46:95-101. [PMID: 19879131 DOI: 10.1016/j.ejca.2009.10.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 09/29/2009] [Accepted: 02/10/2009] [Indexed: 10/20/2022]
Abstract
To study the role of radiotherapy and tamoxifen after breast-conserving surgery (BCS) in patients with a favourable prognosis, a clinical trial was initiated by the German Breast Cancer Study Group (GBSG-V). Between 1991 and 1998, 361 patients (pT 1pN0M0, aged 45-75 years, receptor positive, grades I and II) were randomised to radiotherapy (yes/no) and tamoxifen for 2 years (yes/no) in a 2 x 2-factorial design; the exclusion of seven centres (14 patients) left 347 patients for the analysis. First results after a median follow-up of 5.9 years were published. Herein we present updated results after a median follow-up of about 10 years. Hundred and eleven events concerning event-free survival (EFS) have been observed. Since a strong interactive effect between radiotherapy and tamoxifen has been established, the results are presented in terms of the treatment effects for all four treatment groups separately. Mainly due to the presence of local recurrences, the event rate was much higher in the group with BCS only than in the other three groups. No significant difference could be established between the four treatment groups for distant disease-free survival rates (DDFS). Updated results give further evidence that even in patients with a favourable prognosis, the avoidance of radiotherapy and tamoxifen after BCS increases the rate of local recurrences substantially. Rates are about three times higher in the BCS only group. For the two outcomes EFS and DDFS, no important difference could be seen between the three groups with an additional treatment. However, because of the limited sample size with corresponding low power the strength of evidence for such a comparison is weak.
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Affiliation(s)
- K-J Winzer
- Interdisciplinary Breast Cancer, Charité Universitätsmedizin, Berlin, Germany
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De Jean P, Beaulieu L, Fenster A. Three-dimensional ultrasound system for guided breast brachytherapy. Med Phys 2009; 36:5099-106. [DOI: 10.1118/1.3243865] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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