Hypofractionated Radiotherapy as Adjuvant Treatment in Early Breast Cancer. A Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Adjuvant radiotherapy after breast-conserving surgery is indicated in the vast majority of breast cancer patients. Conventionally fractionated radiotherapy with 50 Gy in 25 fractions was considered standard of care for several decades. The recently publishes long-term results of randomized trials that have tested different moderately hypofractionated radiotherapy schedules that may change clinical practice. Patients and Methods: A Pubmed search was carried out to identify the relevant publications on hypofractionated radiotherapy in breast cancer. In total, 4 randomized controlled trials representing the results of 7,095 patients with 10 years of follow-up were identified. A meta-analysis on the primary end point ipsilateral breast cancer recurrence and a review of the toxicity data were performed. Results: Moderately hypofractionated radiotherapy using schedules such as 40 Gy in 15 fractions administered within 3 weeks are as efficient and safe as conventionally fractionated radiotherapy for most breast cancer patients who need adjuvant radiotherapy after breast-conserving surgery. In patients aged < 40 years, after neoadjuvant chemotherapy, and if regional lymph node radiotherapy is indicated, further data are needed. Conclusion: Moderately hypofractionated radiotherapy can be recommended as standard treatment after breast-conserving surgery in the majority of breast cancer patients.

Pulsed-dose-rate peri-operative brachytherapy as an interstitial boost in organ-sparing treatment of breast cancer

“…Indications and modalities of radiotherapy boost in hypofractionated schedules have not been fully determined. The boost dose was used in 43-75% of patients enrolled in three out of four randomized trials of hypofractionated radiotherapy as a part of BCT in early breast cancer patients [23]. …”

Acute and late adverse effects of breast cancer radiation: Two hypo-fractionation protocols

“…[8] Hypofractionated schedule radiotherapy as an accepted protocol for breast alone is supported by evidence from large randomized trials, meta-analyses, and systematic reviews. [9,10] However, the use of hypofractionated radiotherapy to both breast and regional lymph nodes is still controversial. This is because there is a concern about the benefits and the concerns regarding late effects of normal tissues.…”

“…Although 39 Gy in 13 fractions was associated with less episodes of acute and late effects compared to conventionally schedule, there was a slightly increased ipsilateral recurrence in two trials (START Pilot and START A). [9] Many questions are still not answered about the hypofractionated radiotherapy. Should it be considered as the standard protocol for all patients?…”

Postmastectomy Hypo Fractionated Radiotherapy: May be a Breakthrough in Breast Cancer Management

“…Fears that hypo fractionated radiotherapy could result in an unacceptable high rate of late radiation-induced toxicity were not confirmed in most of these trials as The late toxicities in the START trials may not have been assessed with the optimal methods, but can be considered as sufficient to exclude that relevant toxicities were not present as well as a detailed evaluation of these studies indicates that not all tested hypo fractionated regimens are equally suitable for clinical use, however 39 Gy in 13 fractions appeared to be associated with less acute and late toxicity compared to conventional fractionated regimen , also it is noted that slightly increased ipsilateral breast cancer recurrences was observed in both START trials [12][13][14][15]. Budach et al reported in his review that none of the patients in the hypo fractionated trials received neoadjuvant chemotherapy and the use of hypo fractionated radiotherapy after neo adjuvant chemotherapy is safe for the patients or not, is formally unknown, so, it is not generally recommended in this situation.…”