De-escalation of breast radiotherapy after conserving surgery in low-risk early breast cancer patients

Abstract

The reduction in the burden related to treatment is becoming more and more important in modern oncology. Radiation therapy is a mainstay option in the postoperative setting for early breast cancer patients after breast-conserving surgery. Nowadays, different options are available to de-escalate radiotherapy in this scenario such as the use of hypofractionated whole-breast radiation, the selective delivery of the boost dose to the lumpectomy cavity, the introduction of accelerated partial breast irradiation and the omission of treatment in appropriately selected patients with low-risk features. We herein provide a review article on this topic.

Breast size impact on adjuvant radiotherapy adverse effects and dose parameters in treatment planning

“… 34 , 35 , 36 , 37 Moreover, shorter treatment schedules are a cost-effective approach for both the patient and healthcare providers. 38 The advantages of a hypofractionated schedule over conventional fractionation, e.g . convenience, a less acute pain, fatigue, and dermatitis, were recently confirmed with prospectively collected physician-assessed data and patient-reported outcome measures in a large comparative analysis by Jagsi et al .…”

“… 7 , 12 , 22 , 24 , 26 , 34 , 37 Clinical reports are confirming the long-term safety and feasibility of moderately hypofractionated schedules also in women with large breasts. 11 , 17 , 32 , 36 , 38 , 42 , 80 , 81 Most of the investigators attributed higher toxicity rates in BC radiotherapy to dose inhomogeneity and a higher percentage of hot spots, irrespective of breast volume. 7 , 12 , 17 , 31 V105–107 % of the prescribed dose (PD) was significantly related to increased desquamation, dermatitis, oedema, and pain 12 ; and V105 % PD 82 , 83 or V110 % PD 83 to long-term breast pain.…”

“…In order to de-escalate radiotherapy, selected patients will be treated routinely with the moderate HF or accelerated partial breast irradiation techniques (treating only the tumour bed with a safety margin) in the near future, as emerging data confirm a similar 5-year cumulative incidence of loco-regional and distant relapse compared to WBRT. 38 , 92 , 93 In a 5-year assessment, patients treated with partial radiotherapy approaches self-reported less moderate or marked skin (p = 0.051) or overall breast appearance change (p < 0.0001) compared to the WBRT group. 88 APBI using interstitial brachytherapy was able to significantly reduce acute G3 skin toxicity (7 % in WBRT group vs .…”

Suggestions for Radiation Oncologists during the COVID-19 Pandemic

“…When whole breast radiotherapy is indicated, 5 fractions can be used for node-negative patients not requiring a boost (28-30 Gy in once weekly fractions over 5 weeks as per FAST trial or 26 Gy in 5 daily fractions in 1 week as per FAST Forward trial). Boost dose to the tumor bed should be omitted unless for young patients (≤40 years) and/or for those having high-risk factors for local recurrence [15]. Nodal radiotherapy can be omitted for postmenopausal women after breast conservation in case of 1-2 macrometastases at sentinel lymph node biopsy and low-risk features (size ≤ 2 cm, G1-G1, estrogen receptor-positive and HER2negative disease) [13].…”

Controversial issues in radiotherapy after breast-conserving surgery for early breast cancer in older patients: a systematic review

“…Currently, there are lots of options for de-escalating the side effects of RT, such as hypofractionated radiation, the selective delivery of a boost dose to the lumpectomy cavity, and the introduction of accelerated partial breast irradiation, including brachytherapy [ 35 ]. Breast irradiation on the prone board with meticulous positioning and suitable photon energy can be used to prevent acute dermatitis and reduce the dose to organs at risk [ 36 ].…”