New ASTRO Guidelines Recommend Hypofractionated Breast Irradiation


“An expert panel convened by the American Society for Radiation Oncology (ASTRO) released a set of recommendations regarding fractionation for whole-breast irradiation (WBI) in women with breast cancer. The guideline includes recommendations for standard practice, factors that should influence fractionation decision making, and issues surrounding tumor bed boost, among other issues.

” ‘Breast cancer is the most common malignancy treated with radiation therapy in the United States, and WBI is the most common radiotherapeutic approach for breast cancer,’ wrote authors led by Benjamin D. Smith, MD, of MD Anderson Cancer Center in Houston. The standard of care for WBI has involved conventional fractionation (CF), with daily doses of 180 to 200 cGy up to approximately 4,500 to 5,000 cGy; research in the 1990s and 2000s looked into whether moderate hypofractionation (HF) with daily doses of 265 to 330 cGy could offer similar outcomes.”

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Young Breast Cancer Patients Undergoing Breast Conserving Surgery See Improved Prognosis


“A new analysis indicates that breast cancer prognoses have improved over time in young women treated with breast conserving surgery. The analysis included 1331 patients younger than 40 years treated with breast conserving surgery and whole breast radiotherapy in a single cancer centre in Italy between 1997 and 2010.

“Breast cancer recurrences and deaths significantly decreased over time. A dramatic improvement in prognosis was observed after 2005, when the use of several new diagnostic and  were implemented in routine clinical practice.”

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Guidelines Establish Minimum Negative Margins in DCIS


“Three medical organizations including the American Society of Clinical Oncology (ASCO) have issued a guideline on margins in breast conserving surgery for patients with ductal carcinoma in situ (DCIS). The new recommendations are published online ahead of print in the Journal of Clinical Oncology.

“The panel of experts from ASCO, the Society of Surgical Oncology (SSO), and the American Society for Radiation Oncology (ASTRO) recommend the use of 2-mm margins as a standard in breast conserving surgery for DCIS treated with whole-breast irradiation. Margins of 2 mm are ‘associated with low rates of ipsilateral breast tumor recurrence and has the potential to decrease re-excision rates, improve cosmetic outcome, and decrease health care costs,’ wrote Monica Morrow, MD, of the department of surgery at the Memorial Sloan Kettering Cancer Center in New York, and coauthors. ‘Clinical judgment should be used in determining the need for further surgery in patients with negative margins less than 2 mm. Margins more widely clear than 2 mm do not further reduce the rates of recurrence of cancer in the breast and their routine use is not supported by evidence.’ ”

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Full Dose Radiotherapy to Whole Breast May Not Be Needed in Early Breast Cancer

“Radiotherapy to the whole breast is standard treatment after breast-conserving surgery for women with early breast cancer, even those who have a low risk of the disease returning in the breast (local relapse). However, whole breast radiotherapy can cause changes in the appearance of the breast, which may also be firmer and tender to the touch, resulting in psychological distress.

” ‘So we considered it important to set up a trial to answer the question: is full dose radiotherapy to whole breast needed in patients with low risk early breast cancer?’ Dr Charlotte Coles, MD, Consultant Clinical Oncologist at Cambridge University Hospitals NHS Trust, Cambridge, UK, told the 10th European Breast Cancer Conference (EBCC-10) today (Wednesday). One group of women received standard full dose radiotherapy to the whole breast. A second group received standard full dose to breast tissue closest to where the lump appears and a slightly lower dose further away. A third group received standard full dose radiotherapy to breast tissue closest to where the lump appears but no radiotherapy dose apart from this.”

Accelerated Partial Breast Irradiation (APBI) Using Multicatheter Brachytherapy After Breast Conserving Surgery Is as Effective as Whole Breast Irradiation (WBI) for Low-Risk Patients

“For some early stage breast cancer patients, accelerated partial breast irradiation (APBI) using multicatheter brachytherapy following breast conserving surgery may be an excellent treatment option, as it has now been proven to be as effective as the current standard treatment – whole breast irradiation (WBI) – in local control, disease-free and overall survival rates, according to research presented today at the American Society for Radiation Oncology’s (ASTRO’s) 57th Annual Meeting.

“Breast cancer patients often receive radiation therapy (RT) after breast-conserving surgery to help lower the chance that the cancer will recur or metastasize in the nearby lymph nodes. WBI using external beam radiation is a longstanding standard RT for breast cancer patients, during which the entire breast and often the surrounding chest area receives radiation for several weeks, followed by an extra boost of radiation to the area where the cancer was removed. Many women in the U.S. who are eligible for breast conserving surgery still choose to undergo mastectomy in the hopes that it will make subsequent WBI unnecessary, due largely to the long-duration of WBI and/or because of fears concerning the potential side effects of radiation to surrounding organs.”

Hypofractionation of Breast Radiotherapy Associated With Reduced Acute Toxicity

“In an analysis reported in JAMA Oncology, Jagsi et al found that hypofractionation of whole-breast radiotherapy was associated with reduced acute toxicity compared with conventional fractionation.

“The study involved data on physician-assessed toxic effects and patient-reported outcomes in 2,309 patients who received adjuvant whole-breast radiotherapy after lumpectomy for unilateral breast cancer at Michigan Radiation Oncology Quality Consortium sites from October 2011 through June 2014. Patients had to have a comprehensive physician toxicity evaluation within 1 week of completing radiotherapy and at least 1 weekly evaluation during treatment.”

Partial Breast Irradiation Sufficient in Early Disease

“Accelerated partial breast irradiation (APBI) was shown to be just as effective and safe as whole breast irradiation (WBI), according to the results of a randomized phase III clinical trial conducted in Italy. There was no difference between APBI, delivered as intensity-modulated radiation therapy (IMRT), and WBI after a 5-year median follow-up. APBI also resulted in significantly better safety and cosmetic outcomes for patients. The results were presented by the study’s principal investigator, Lorenzo Livi, MD, of the radiotherapy-oncology unit at Florence University Hospital in Florence, Italy, at the 2014 San Antonio Breast Cancer Symposium (SABCS), held December 9–13 in San Antonio, Texas.

“The mean time to ipsilateral breast tumor recurrence (IBTR) was 2.9 years. There was no statistically significant difference in the 5-year IBTR rate (1.4% and 1.5% in the WBI and APBI arms, respectively; P = .86) or the 5-year overall survival rate (96.6% and 99.4% in the WBI and APBI arms, respectively; P = .057). Because of the low IBTR rate, a longer follow-up is still needed.

“ ‘Our results showed a very low recurrence rate [for APBI] and no differences in terms of distant metastases and overall survival rate. Partial breast [irradiation] certainly will be an effective option for treatment in selected breast cancer patients,’ Livi told Cancer Network via e-mail.”

Shorter, Cheaper Radiation Treatment Not given to Most Breast Cancer Patients

“In 2011, expert guidelines endorsed shorter whole breast radiation for early-stage breast cancer patients. However, a new study finds that this less costly treatment has not reached many patients who meet guidelines to receive it.

“The study – led by Dr. Justin E. Bekelman, of the University of Pennsylvania Perelman School of Medicine in Philadelphia – is published in JAMA and is released to coincide with the San Antonio Breast Cancer Symposium.

“The researchers explain that breast conservation therapy is the most common treatment for early-stage breast cancer, with whole breast irradiation (WBI) recommended for most women after surgery, as it reduces recurrence and improves overall survival.

“Conventional WBI has been the ‘mainstay’ of treatment in the US and consists of 5-7 weeks of daily radiation treatments. However, hypofractionated WBI is a shorter alternative to conventional WBI, consisting of fewer higher-dose treatments over 3 weeks.

” ‘Hypofractionated WBI increases convenience, reduces treatment burden and lowers health care costs,’ note the authors, ‘while offering similar cancer control and cosmesis (cosmetic outcomes) to conventional WBI.’ They also note that patients naturally prefer shorter radiation treatments.”

Analysis Shows Increased Use of HF-WBI for Patients with Early-Stage Breast Cancer

The gist: A recent study looked at who receives two different types of whole-breast radiation treatment for early-stage breast cancer. It found increased use of hypofractionaed whole-breast irradiation (HF-WBI) from 2004-2011, and found that, depending on where they live or where they’re treated, some women are more likely to receive HF-WBI than conventionally fractionated whole-breast irradiation (CF-WBI). HF-WBI and CF-WBI have similar survival rates, but HF-WBI has a shorter treatment course, a lower total dose, and a lower number of daily fractions.

“The use of hypofractionated whole-breast irradiation (HF-WBI) for patients with early-stage breast cancer increased 17.4 percent from 2004 to 2011, and patients are more likely to receive HF-WBI compared to conventionally fractionated whole-breast irradiation (CF-WBI) when they are treated at an academic center or live ≥50 miles away from a cancer center, according to a study published in the December 1, 2014 issue of the International Journal of Radiation Oncology • Biology • Physics (Red Journal), the official scientific journal of the American Society for Radiation Oncology (ASTRO).

“An analysis of randomized trials demonstrated that patients with early-stage breast cancer who are treated with breast-conserving surgery and adjuvant whole-breast irradiation have improved survival and a lower risk of tumor recurrence compared to patients who are not treated with radiation therapy. Patients are commonly treated with CF-WBI; however, several recent randomized trials have confirmed that patients treated with HF-WBI have similar disease-free and overall survival rates as those treated with CF-WBI. CF-WBI delivers a total dose of 45-50 Gy in 25-28 daily fractions of 1.8-2.0 Gy over five to six weeks, while HF-WBI uses a shorter treatment course and a lower total dose and number of fractions, delivering a total dose of 39-42.5 Gy in 13-16 daily fractions of 2.5-3.2 Gy over three to five weeks.”