Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy : Analysis of 205 cases

Abstract

BackgroundSeveral randomized trials and meta-analyses confirmed a wide benefit of radiotherapy (RT), both after breast conserving surgery (BCS) and mastectomy. However, many elderly women don't receive RT. Hypofractionated (HF) RT allows « simplified » and more accessible treatments with equivalent results to classic RT in three large randomized trials. However, there are few available data on HF-RT for nodal irradiation, as well as for the boost.MethodsWe evaluated patients treated for IBC by HF-RT between 2004 and 2012 in two regional cancer centres. We used an original scheme delivering 45 Gy in 15 fractions three times a week, both after BCS or mastectomy, with or without nodal irradiation. After BCS, a 9 Gy boost in 3 fractions was delivered. Local, regional and distant recurrences were assessed, as well as acute and late cutaneous, cardiac or pulmonary toxicities.Results205 patients were analysed, 116 after BCS (57 %) and 89 after mastectomy (43 %). Median age was 81 years (range: 52-91); 44 % had axillary nodal involvement (pN+). The Nottingham Prognostic Index (NPI) scored 0, 1, 2 and 3 in 10 %, 27 %, 44 % and 19 % of the cases. A nodal HF-RT was delivered in 65 patients (32 %) and boost in 98 patients (84 % of BCS) by 9 Gy/3 fr scheme. Fifty (24 %) patients underwent chemotherapy and 156 (75 %) hormonal treatment.With a 49-month median follow-up, 3/116 (2.6 %) patients and 4/89 (4.5 %) had local recurrence (LR) after BCS and mastectomy, respectively. The overall 5-year LR rate was 4.4 %. In univariate and multivariate analysis, LR risk factors were: high NPI (HR 5.46; p = 0.028), and triple negative tumour (HR 9.78; p = 0.006). Only 8 (4.5 %) patients had grade III skin toxicity; 29 (14 %) late fibrosis and 16 (8 %) telangiectasia. No pulmonary or cardiac toxicity was observed.ConclusionOur HF-RT scheme (with or without nodal irradiation) confirms in elderly patients the data from randomized trials, both after BCS or mastectomy. Toxicity seems very acceptable but requires a longer follow-up. A larger evaluation is still ongoing in several other centres in France.

Comparing hypofractionated to conventional fractionated radiotherapy in postmastectomy breast cancer: a meta-analysis and systematic review

“…This meta-analysis indicated that HFRT and CFRT were equally effective with respect to overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and distant metastasis (DM) after breast mastectomy. In recent small retrospective cohort studies, HF PMRT was shown to be effective with acceptable toxicity [38][39][40][41]. In a recent phase 2 trial [42], 67 women with clinical stage II to IIIa breast cancer who received a HF PMRT regimen of 36.6 Gy over 11 fractions to the chest wall and the draining regional lymph nodes with a scar boost of 4 fractions of 3.33 Gy revealed that after a median follow-up of 32 months, patients with isolated ipsilateral chest wall tumor recurrences were 3.0%, the 3-year estimated overall survival was 92.0% (95% CI, 78.9~97.1), the 3year estimated local recurrence-free survival was 89.2% (95% CI, 74.8~95.6), the 3-year estimated distant recurrence-free survival was 90.3% (95% CI, 79.7~95.6), and low toxicity was reported.…”

Cost-effectiveness analysis of advanced radiotherapy techniques for post-mastectomy breast cancer patients

“…Multiple studies [39][40][41] have shown that hypo-fractionated PMRT is safe and effective and can provide similar tumor control rate as standard 25 fractions radiotherapy for carefully selected post-mastectomy patients. It is also much more convenient for the patients and caregivers and can significantly cut treatment costs [41,42].…”

Clinicopathologic Features and Long-Term Outcomes of Elderly Breast Cancer Patients: Experiences at a Single Institution in Korea

“…Several randomized trials confirmed the effectiveness of adjuvant chemotherapy and radiotherapy in improving survival for older women with early-stage breast cancer [19-21]. Under treatment of elderly breast cancer was demonstrated in several studies and typically resulted in worse clinical outcome [14,18].…”