Radiation therapy for early breast cancer bgicc 2015

Updates in Radiation Therapy

of Early Breast Cancer.Mohamed Abdulla M.D.

Prof. of Clinical Oncology - NEMROCK

Kasr Al-Aini School of Medicine.

Cairo University

BGICC – 7th

Friday; 16/01/2015

Fairmont Hotel and Tower

Breast Cancer: Current Situation

Incidence & Mortality from Breast Cancer in UK & Wales 1971-2009

Source: National Statistics, 2010

Systemic

Local

The Link Between Local Control and

Distant Dissemination in Breast

Cancer:

Local recurrences and distant metastases are partially

independent events. LR does not herald DM.

Local recurrence increased the risk of distant spread in:

1. Young women (< 35 Years) at presentation.

2. Peritumoral lymphatic invasion.

3. Local recurrence at the first 2 years.

J Natl Cancer Inst. 1995 Jan 4;87(1):19-27.

Int. J. Radiation Oncology Biol. Phys., Vol.

43, No. 1, pp. 11–24, 1999

Locoregional Recurrences Following Treatment of

Earlier Stages of Breast Cancer:

ONCOLOGY 14(11):1561-1581, 2000]

Radiation Therapy is Beneficial after

BCS: EBCTCG – 2011 Meta-analysis:

Lancet. Nov 12, 2011; 378(9804): 1707–1716.

17 Randomized Trials N +ve & N –ve = 10801 Patients

1 death due to breast cancer can be avoided for every 4

recurrences prevented.



Lancet. Nov 12, 2011; 378(9804): 1707–1716.

Local Recurrence Distant Recurrence

No Radiation Therapy 25% 10%

Radiation Therapy 8% 12%



Lancet. Nov 12, 2011; 378(9804): 1707–1716.

Can we omit adjuvant radiation therapy

following BCS in low risk patients?

BASO II Trial:

• < 2 cm

• HR+

• G 1

• N0

• Wide Excision.

Results:

• No adjuvant 1.8% LR annually & can be by either RTH or TAM.

• Adjuvant RTH + TAM No LR.

PRIME II Trial:

• >65 years old

• < 3 cm

• N0

• G3 or LVI

• HR+ TAM

Results:

• 5 y IBTR: 0.6% & 2.7% (p 0.004).

• No significant difference in regional, contralateral, or distant recurrences

• Death is not linked to breast cancer in the majority.

EJC SUPPLEMENTS 8 (2010) 1– 36 San Antonio Breast Cancer Symposium Dec. 11, 2013


MRM: EBCTCG – 2014 Meta-analysis:

Lancet 2014; 383: 2127–35

Radiation Therapy is Beneficial after MRM: EBCTCG – 2014 Meta-analysis:

Lancet 2014; 383: 2127–35


MRM: EBCTCG – 2014 Meta-analysis:

Lancet 2014; 383: 2127–35

Lessons Learned Over Years:

PORTH

Breast Conserving

Surgery

Yes

All Patients

No

> 70 Years

N0

Stage I

Endocrine Therapy

Modified Radical

Mastectomy

1. T4 any N

2. T3N+

3. +ve margins Invasive Disease.

4. Any T + > 4 +ve Nodes

Extention:

1. T1-2 N+ (1-3)

2. T3N0

3. DCIS at margins.

4. TNBC (N0)

Following Neoadjuvant Therapy for

Locally Advanced

Disease

Eur J Cancer. 1995;31A(10):1574.

Int J Radiat Oncol Biol Phys. 2006;65(4):1149.

UpTodate.com. Dec. 2014

Fraction Size, Fractionation and OAP:

Lancet Oncol 2013; 14: 1086–94

CONCLUSIONS:

• 40 Gy/15 Fractions/3 weeks: is the most accepted.

• Questions waiting for answer:

1. Efficacy & Toxicity in patients with large breast size.

2. Efficacy & Toxicity in patients with more advanced tumors.

3. Tolerability with chemotherapy and monoclonal

antibodies.

• Radiation Therapy Boost:

o Routine following BCS and conventional WBRT.

o Most beneficial in young women and high risk factors.

o Following HF radiation therapy…?

Fraction Size, Fractionation and OAP:

Partial Breast Irradiation:


Results:

• OAS and distant metastases risk are not significantly

different.

• Worse cosmotic outcome.

• Higher incidence of subsequent mastectomy.

• Higher incidence of postoperative infectious and non-

infectious complications on using APBI

(Brachytherapy).

Breast J. 2010;16(3):245.

J Clin Oncol. 2013;31(32):4038.

JAMA. 2012 May;307(17):1827-37.


More Trials are Needed for:

1. Multicentric breast cancer.

2. Pathological involvement of lymph nodes.

3. T > 3 cm.

4. LVI.

5. Breast cancer during pregnancy.

Less Optimal Candidates:

1. DCIS and Invasive Lobular Carcinoma.

2. HR-.

3. HER 2 Neu positive breast cancer.

4. Hereditary Breast Cancer (BRACA1/2).



Intra-Operative Radiation Therapy:

> 45 Years & Unifocal Disease

TARGIT - A ELIOT

• +++ IBTR.

• + Breast Cancer Specific

Mortality.

• ≠ OAS.

• --- G 3-4 Skin Complications.

• High Risk Groups:

1. G 3.

2. ER –

3. TNBC

Lancet. 2014;383(9917):603.

Lancet Oncol. 2013 Dec;14(13):1269-77. Epub 2013 Nov 11.

Take Home Message

Radiation therapy treatment is still playing a major role in

therapeutic plan of early breast cancer following BCS in nearly

most of patients and upon indication following MRM.

Significant improvement in local control and cancer specific

survival over extended periods of time.

Hypofractionated protocol (START-B) is the recommended one.

Tumor Bed Boost should be adopted following BCT.

APBI and IORT should be taken with caution and needs more

validation.

The impact of molecular intrinsic subtypes and genomic

alterations upon determining the benefit of radiation therapy is

ongoing.

[email protected]

Radiation therapy for early breast cancer bgicc 2015

Health & Medicine

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