Intensity Modulated Proton Therapy for Bilateral Breast or Chest Wall and Comprehensive Nodal Irradiation for Synchronous Bilateral Breast Cancer: Initial Clinical Experience and Dosimetric Comparison

Garda, Allison E.; Hunzeker, Ashley; Michel, Ann K; Fattahi, Sayeh; Shiraishi, S.; Remmes, Nicholas B.; Schultz, Heather; Harmsen, William S.; Shumway, Dean A.; Yan, Elizabeth; Park, Sean S.; Mutter, Robert W.; Corbin, Kimberly S.

doi:10.1016/j.adro.2022.100901

Cited by 4 publications

(7 citation statements)

References 48 publications

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“…Thus, this further advances the case that proton is heart sparing in this setting. Notably, this coronary sparing has been corroborated in other critical reports [21]. Although cardiac sparing may appear to be the most substantive dosimetric benefit with proton therapy compared with photon therapy in treating patients with bilateral breast cancer, we also found that superior dose falloff and beam shaping conferred by protons, owing to the sharp penumbra, Bragg peak, and spot positioning, can reduce the dose to other adjacent organs.…”

Section: Discussionsupporting

confidence: 86%

“…Thus, this further advances the case that proton is heart sparing in this setting. Notably, this coronary sparing has been corroborated in other critical reports [ 21 ].…”

Section: Discussionsupporting

confidence: 82%

“…Like ours, previous reports have also found that the mean heart dose can be reduced nearly 5-fold (from 9.98 Gy to 2.12 Gy), and lung dose metrics, such as V5 Gy, can be halved (from 97.9% to 39.8%) by using proton rather than photon therapy [14]. Other reports corroborate the superiority of protons over photons in the avoidance of adjacent organs at risk (OARs) when treating patients with bilateral breast cancer [18,20,21].…”

Section: Discussionmentioning

confidence: 88%

“…In addition, this study and other corroborating publications show that protons can substantially reduce the mean heart dose in bilateral breast cancer treatment to <3 Gy, which is generally considered within accepted constraints [ 14 , 18 ]. Notably, in the largest dosimetric comparative study to date, the mean heart dose was reduced from an average of 7.2 Gy to 0.7 Gy with proton versus photon for bilateral breast cancer patients [ 21 ]. This is important because the dose-cardiac risk relationship is well-defined in breast cancer [ 22 ] and validated in other disease-site studies [ 23 ], suggesting that for each additional 1 Gy mean heart dose, an approximate 7% relative increase in the risk of cardiac injury is conferred.…”

Section: Discussionmentioning

confidence: 99%

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Proton Therapy for Bilateral Breast Cancer Maximizes Normal-Tissue Sparing

Brooks

Vega

Vivers

et al. 2023

International Journal of Particle Therapy

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Purpose Treatment for bilateral breast cancer with radiation therapy is technically challenging. We evaluated the clinical and dosimetric outcomes of a small series of patients with synchronous bilateral breast cancer, including a photon dosimetric comparison, to identify optimal treatment planning approaches. Materials and Methods We reviewed a registry of patients (simultaneously) diagnosed with synchronous bilateral breast cancers who underwent postoperative definitive adjuvant proton therapy at our institution between 2012 and 2021. All patients were treated with double-scattered proton or pencil-beam scanning therapies. For comparison, intensity-modulated radiation therapy photon plans optimized for organ sparing and coverage were generated after treatment. Results Six patients were included. The median patient age was 66 years; all were female with no history of breast cancer or radiation therapy. Two (33%) patients received breast/chest wall–only treatments, 1 (17%) required breast plus level I axillary treatment to one side and breast plus regional nodal irradiation (RNI) to the other, and 3 (50%) received bilateral breast/chest plus RNI; dosimetric results are reported for each group's median. Analysis showed clinical target coverage was comparable between proton and photon techniques (V95% of 96.4% with proton, 97.8% with photon). However, protons could deliver superior organ sparing at clinically relevant dose metrics for virtually all structures: a 6.7 Gy absolute reduction in the mean heart dose (7.5 Gy with photons to 0.7 Gy with protons), a 47% to 57% relative reduction in D0.1cm3 to coronary arteries, a 54% relative reduction in lung V20 Gy, and an absolute 7.6 Gy reduction to the brachial plexus. There was also greater esophagus and spinal cord sparing. The overall survival rate was 100% at 1.5 years of median follow-up (0.5-4.9), and all patients were free of disease. For toxicity, all patients had some form of acute side effects: 66% experienced grade 2 breast/chest pain or soreness; 100% had grade 2 radiation dermatitis or skin induration; 33% had grade 2 fatigue; and 17% had grade 2 esophagitis (per the Common Terminology Criteria for Adverse Events [CTCAE] version 5.0; US National Cancer Institute, Bethesda, Maryland). Subacute toxicity (within 6 months) was observed for 17% of patients with delayed onset of grade 3 dermatitis in the setting of preexisting lupus, 17% with a delayed surgical wound complication, and 17% with grade 2 soft tissue fibrosis. No grade 4 or 5 events were observed. Conclusions Substantial dose reductions to multiple organs at risk while maintaining target coverage make proton the preferred modality for bilateral breast cancer treatment when available.

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Section: Discussionsupporting

confidence: 86%

“…Thus, this further advances the case that proton is heart sparing in this setting. Notably, this coronary sparing has been corroborated in other critical reports [ 21 ].…”

Section: Discussionsupporting

confidence: 82%

Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

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Proton Therapy for Bilateral Breast Cancer Maximizes Normal-Tissue Sparing

Brooks

Vega

Vivers

et al. 2023

International Journal of Particle Therapy

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“…No patients developed grade 3 or 4 radiation pneumonitis [ 21 ]. Other reports of proton therapy for breast cancer support this finding [ 27 , 28 ].…”

Section: Rationale For Proton Therapysupporting

confidence: 59%

The Potential of Proton Therapy for Locally Advanced Breast Cancer: Clinical and Technical Considerations

2023

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Proton therapy is a promising therapeutic modality with unique physical properties that allow for abrupt dose fall-off distal to the target of interest, thereby sparing nearby organs at risk. A number of studies have identified the utility of proton radiation in mitigating treatment related sequelae for patients with locally advanced breast cancers. Thus, in the following review, we highlight clinical and technical considerations for proton radiotherapy delivery in patients with locally advanced breast cancer.

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Proton Therapy in Breast Cancer: A Review of Potential Approaches for Patient Selection

Wu,

Chen,

Cao

et al. 2024

Technol Cancer Res Treat

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Proton radiotherapy may be a compelling technical option for the treatment of breast cancer due to its unique physical property known as the “Bragg peak.” This feature offers distinct advantages, promising superior dose conformity within the tumor area and reduced radiation exposure to surrounding healthy tissues, enhancing the potential for better treatment outcomes. However, proton therapy is accompanied by inherent challenges, primarily higher costs and limited accessibility when compared to well-developed photon irradiation. Thus, in clinical practice, it is important for radiation oncologists to carefully select patients before recommendation of proton therapy to ensure the transformation of dosimetric benefits into tangible clinical benefits. Yet, the optimal indications for proton therapy in breast cancer patients remain uncertain. While there is no widely recognized methodology for patient selection, numerous attempts have been made in this direction. In this review, we intended to present an inspiring summarization and discussion about the current practices and exploration on the approaches of this treatment decision-making process in terms of treatment-related side-effects, tumor control, and cost-efficiency, including the normal tissue complication probability (NTCP) model, the tumor control probability (TCP) model, genomic biomarkers, cost-effectiveness analyses (CEAs), and so on. Additionally, we conducted an evaluation of the eligibility criteria in ongoing randomized controlled trials and analyzed their reference value in patient selection. We evaluated the pros and cons of various potential patient selection approaches and proposed possible directions for further optimization and exploration. In summary, while proton therapy holds significant promise in breast cancer treatment, its integration into clinical practice calls for a thoughtful, evidence-driven strategy. By continuously refining the patient selection criteria, we can harness the full potential of proton radiotherapy while ensuring maximum benefit for breast cancer patients.

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Intensity Modulated Proton Therapy for Bilateral Breast or Chest Wall and Comprehensive Nodal Irradiation for Synchronous Bilateral Breast Cancer: Initial Clinical Experience and Dosimetric Comparison

Abstract: Intensity modulated proton therapy (IMPT) for bilateral breast/chest wall and comprehensive nodal irradiation for synchronous bilateral breast cancer: initial clinical experience and dosimetric comparison, Advances in Radiation Oncology (2022), doi:

Cited by 4 publications

References 48 publications

Proton Therapy for Bilateral Breast Cancer Maximizes Normal-Tissue Sparing

Proton Therapy for Bilateral Breast Cancer Maximizes Normal-Tissue Sparing

The Potential of Proton Therapy for Locally Advanced Breast Cancer: Clinical and Technical Considerations

Proton Therapy in Breast Cancer: A Review of Potential Approaches for Patient Selection

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