Vol 26, No 5 (2021)
Review paper
Published online: 2021-09-23

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Should the management of radiation therapy for breast cancer be standardized? Results of a survey on current French practices in breast radiotherapy

Martin Schmitt1, Jordan Eber1, Delphine Antoni1, Georges Noël1
Rep Pract Oncol Radiother 2021;26(5):814-826.

Abstract

Background: Breast cancer is the most frequent cancer in women in France. Its management has evolved considerably in recent years with a focus on reducing iatrogenic toxicity. The radiotherapy indications are validated in multidisciplinary consultation meetings; however, questions remain outstanding, particularly regarding hypofractionated radiotherapy, partial breast irradiation, and irradiation of the internal mammary chain and axillary lymph node area.

Materials and methods: An online survey was sent to 47 heads of radiotherapy departments in France. The survey consisted of 22 questions concerning indications for irradiation of the supraclavicular, internal mammary and axillary lymph node areas; irradiation techniques and modalities; prescribed doses; and fractionation.

Results: Twenty-four out of 47 centers responded (response rate of 51%). This survey demonstrated a wide variation in the prescribed dose regimen, monoisocentric radiotherapy, and indications of irradiation of the lymph node areas.

Conclusion: This survey provides insight into the current radiotherapy practice for breast cancer in France. It shows the need to standardize practices.

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References

  1. Binder-Foucard F, Bossard N, Delafosse P, et al. French network of cancer registries (Francim). Cancer incidence and mortality in France over the 1980-2012 period: solid tumors. Rev Epidemiol Sante Publique. 2014; 62(2): 95–108.
  2. Vaidya JS, Wenz F, Bulsara M, et al. TARGIT trialists' group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014; 383(9917): 603–613.
  3. Veronesi U, Orecchia R, Maisonneuve P, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013; 14(13): 1269–1277.
  4. Donker M, Slaets L, van Tienhoven G, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014; 15(12): 1303–1310.
  5. Belkacemi Y, Kaidar-Person O, Poortmans P, et al. Breast Working Party of the EORTC Radiation Oncology Group (ROG). Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey. Ann Oncol. 2015; 26(3): 529–535.
  6. Offersen BV, Boersma LJ, Kirkove C, et al. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer. Radiother Oncol. 2015; 114(1): 3–10.
  7. Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018; 8(3): 145–152.
  8. Podgorsak EB, Gosselin M, Kim TH, et al. A simple isocentric technique for irradiation of the breast, chest wall and peripheral lymphatics. Br J Radiol. 1984; 57(673): 57–63.
  9. Kagkiouzis J, Platoni K, Kantzou I, et al. Review of the three-field techniques in breast cancer radiotherapy. J BUON. 2017; 22(3): 599–605.
  10. Banaei A, Hashemi B, Bakhshandeh M. Comparing the monoisocentric and dual isocentric techniques in chest wall radiotherapy of mastectomy patients. J Appl Clin Med Phys. 2015; 16(1): 5069.
  11. Toulba A AF, Lkhouyaali S NM. Mono-Isocentric Technique in the Breast Cancer and Organ at Risk Tolerance. J Nucl Med Radiat Ther [Internet]. 2013. https://www.omicsonline.org/mono-isocentric-technique-in-the-breast-cancer-and-organ-at-risk-tolerance-2155-9619.S2-010.php?aid=9169 (29 Nov 2019).
  12. Zhang T, Dilworth JT, Marina O, et al. A three-field monoisocentric inverse breast treatment planning technique without half-beam blocking. J Appl Clin Med Phys. 2015; 16(5): 246–258.
  13. Gez E, Assaf N, Ashaf N, et al. Postmastectomy electron-beam chest-wall irradiation in women with breast cancer. Int J Radiat Oncol Biol Phys. 2004; 60(4): 1190–1194.
  14. Grellier Adedjouma N, Chevrier M, Fourquet A, et al. Long-Term Results of a Highly Performing Conformal Electron Therapy Technique for Chest Wall Irradiation After Mastectomy. Int J Radiat Oncol Biol Phys. 2017; 98(1): 206–214.
  15. Kirova YM, Campana F, Fournier-Bidoz N, et al. Postmastectomy electron beam chest wall irradiation in women with breast cancer: a clinical step toward conformal electron therapy. Int J Radiat Oncol Biol Phys. 2007; 69(4): 1139–1144.
  16. Feigenberg SJ, Price Mendenhall N, Benda RK, et al. Postmastectomy radiotherapy: patterns of recurrence and long-term disease control using electrons. Int J Radiat Oncol Biol Phys. 2003; 56(3): 716–725.
  17. Jackson SM. The clinical application of electron beam therapy with energies up to 10 MeV. Br J Radiol. 1970; 43(511): 431–440.
  18. Smith BD, Pan IW, Shih YCT, et al. Adoption of intensity-modulated radiation therapy for breast cancer in the United States. J Natl Cancer Inst. 2011; 103(10): 798–809.
  19. van der Laan HP, Dolsma WV, van 't Veld AA, et al. Comparison of normal tissue dose with three-dimensional conformal techniques for breast cancer irradiation including the internal mammary nodes. Int J Radiat Oncol Biol Phys. 2005; 63(5): 1522–1530.
  20. Bourgier C, Aimard L, Bodez V, et al. Adjuvant radiotherapy in the management of axillary node negative invasive breast cancer: a qualitative systematic review. Crit Rev Oncol Hematol. 2013; 86(1): 33–41.
  21. Liu H, Chen X, He Z, et al. Evaluation of 3D-CRT, IMRT and VMAT radiotherapy plans for left breast cancer based on clinical dosimetric study. Comput Med Imaging Graph. 2016; 54: 1–5.
  22. Rastogi K, Sharma S, Gupta S, et al. Dosimetric comparison of IMRT versus 3DCRT for post-mastectomy chest wall irradiation. Radiat Oncol J. 2018; 36(1): 71–78.
  23. Hong L, Hunt M, Chui C, et al. Intensity-modulated tangential beam irradiation of the intact breast. Int J Radiat Oncol Biol Phys. 1999; 44(5): 1155–1164.
  24. Lisbona A, Averbeck D, Supiot S, et al. Radiothérapie conformationnelle avec modulation d’intensité (RCMI) guidée par l’image : impact de l’augmentation du volume irradié à faible dose ? Cancer/Radiothérapie. 2010; 14(6-7): 563–570.
  25. Fenoglietto. Impact de la modulation d’intensité dans l’irradiation des aires ganglionnaires du cancer du sein. 2015. https://app.dimensions.ai/details/publication/pub.1026824672 (5 Déc 2019).
  26. Hall E, Wuu CS. Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys. 2003; 56(1): 83–88.
  27. Purdy JA. Dose to normal tissues outside the radiation therapy patient's treated volume: a review of different radiation therapy techniques. Health Phys. 2008; 95(5): 666–676.
  28. Xu XG, Bednarz B, Paganetti H. A review of dosimetry studies on external-beam radiation treatment with respect to second cancer induction. Phys Med Biol. 2008; 53(13): R193–R241.
  29. Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881-10882 trial. J Clin Oncol. 2007; 25(22): 3259–3265.
  30. Vrieling C, van Werkhoven E, Maingon P, et al. European Organisation for Research and Treatment of Cancer, Radiation Oncology and Breast Cancer Groups. Prognostic Factors for Local Control in Breast Cancer After Long-term Follow-up in the EORTC Boost vs No Boost Trial: A Randomized Clinical Trial. JAMA Oncol. 2017; 3(1): 42–48.
  31. Kindts I, Verhoeven K, Laenen A, et al. A comparison of a brachytherapy and an external beam radiotherapy boost in breast-conserving therapy for breast cancer: local and any recurrences. Strahlenther Onkol. 2019; 195(4): 310–317.
  32. Vass S, Bairati I. A cosmetic evaluation of breast cancer treatment: a randomized study of radiotherapy boost technique. Int J Radiat Oncol Biol Phys. 2005; 62(5): 1274–1282.
  33. Renoult F, Marchal C, Brunaud C, et al. [Safety and efficacy of whole breast irradiation with a concomitant boost: analysis of 121 cases treated at the Institute of Cancerology of Lorraine]. Cancer Radiother. 2014; 18(3): 165–170.
  34. Guerrero M, Li XA, Earl MA, et al. Simultaneous integrated boost for breast cancer using IMRT: a radiobiological and treatment planning study. Int J Radiat Oncol Biol Phys. 2004; 59(5): 1513–1522.
  35. Van Parijs H, Miedema G, Vinh-Hung V, et al. Short course radiotherapy with simultaneous integrated boost for stage I-II breast cancer, early toxicities of a randomized clinical trial. Radiat Oncol. 2012; 7: 80.
  36. Lee HH, Chen CH, Luo KH, et al. Five-year survival outcomes of intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) using forward IMRT or Tomotherapy for breast cancer. Sci Rep. 2020; 10(1): 4342.
  37. Dundas KL, Pogson EM, Batumalai V, et al. Australian survey on current practices for breast radiotherapy. J Med Imaging Radiat Oncol. 2015; 59(6): 736–742.
  38. Sanders ME, Scroggins T, Ampil FL, et al. Accelerated partial breast irradiation in early-stage breast cancer. J Clin Oncol. 2007; 25(8): 996–1002.
  39. Livi L, Meattini I, Marrazzo L, et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 2015; 51(4): 451–463.
  40. Coles CE, Griffin CL, Kirby AM, et al. IMPORT Trialists. Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet. 2017; 390(10099): 1048–1060.
  41. Senkus E, Kyriakides S, Ohno S, et al. ESMO Guidelines Committee. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015; 26 Suppl 5: v8–30.
  42. Strnad V, Hannoun-Levi JM, Guinot JL, et al. Working Group Breast Cancer of GEC-ESTRO. Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol. 2015; 115(3): 342–348.
  43. Belkacémi Y, Fourquet A, Cutuli B, et al. French Expert Review Board of Nice/Saint-Paul de Vence. Radiotherapy for invasive breast cancer: guidelines for clinical practice from the French expert review board of Nice/Saint-Paul de Vence. Crit Rev Oncol Hematol. 2011; 79(2): 91–102.
  44. Hennequin C, Barillot I, Azria D, et al. [Radiotherapy of breast cancer]. Cancer Radiother. 2016; 20(Suppl): S139–S146.
  45. Gradishar WJ, Anderson BO, Abraham J, et al. Breast Cancer, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2020; 18(4): 452–478.
  46. van Deurzen CHM, de Boer M, Monninkhof EM, et al. Non-sentinel lymph node metastases associated with isolated breast cancer cells in the sentinel node. J Natl Cancer Inst. 2008; 100(22): 1574–1580.
  47. de Boer M, van Deurzen CHM, van Dijck JA, et al. Micrometastases or isolated tumor cells and the outcome of breast cancer. N Engl J Med. 2009; 361(7): 653–663.
  48. Hansen NM, Grube B, Ye X, et al. Impact of micrometastases in the sentinel node of patients with invasive breast cancer. J Clin Oncol. 2009; 27(28): 4679–4684.
  49. Galimberti V, Cole BF, Viale G, et al. International Breast Cancer Study Group Trial 23-01, International Breast Cancer Study Group Trial 23-01 investigators. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013; 14(4): 297–305.
  50. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010; 11(10): 927–933.
  51. Giuliano AE, Ballman KV, McCall L, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017; 318(10): 918–926.
  52. Solá M, Alberro JA, Fraile M, et al. Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol. 2013; 20(1): 120–127.
  53. Poortmans P, Weltens C, Fortpied C, et al. Internal mammary and medial supraclavicular lymph node chain irradiation in stage I–III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial. Lancet Oncol. 2020; 21(12): 1602–1610.
  54. Whelan TJ, Olivotto IA, Parulekar WR, et al. MA.20 Study Investigators. Regional Nodal Irradiation in Early-Stage Breast Cancer. N Engl J Med. 2015; 373(4): 307–316.
  55. Thorsen LB, Offersen BV, Danø H, et al. DBCG-IMN: A Population-Based Cohort Study on the Effect of Internal Mammary Node Irradiation in Early Node-Positive Breast Cancer. J Clin Oncol. 2016; 34(4): 314–320.
  56. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013; 368(11): 987–998.
  57. Hennequin C, Fourquet A. [Controversy about internal mammary chain irradiation in breast cancer]. Cancer Radiother. 2014; 18(5-6): 351–355.
  58. Hennequin C, Bossard N, Servagi-Vernat S, et al. Ten-year survival results of a randomized trial of irradiation of internal mammary nodes after mastectomy. Int J Radiat Oncol Biol Phys. 2013; 86(5): 860–866.
  59. Rahimy E, Hong JC, Gross CP, et al. Increased Number of Beam Angles Is Associated With Higher Cardiac Dose in Adjuvant Fixed Gantry Intensity Modulated Radiation Therapy of Left-Sided Breast Cancer. Int J Radiat Oncol Biol Phys. 2017; 99(5): 1137–1145.
  60. Dess RT, Liss AL, Griffith KA, et al. Ischemic Cardiac Events Following Treatment of the Internal Mammary Nodal Region Using Contemporary Radiation Planning Techniques. Int J Radiat Oncol Biol Phys. 2017; 99(5): 1146–1153.
  61. Drost L, Yee C, Lam H, et al. A Systematic Review of Heart Dose in Breast Radiotherapy. Clin Breast Cancer. 2018; 18(5): e819–e824.
  62. Cardoso F, Kyriakides S, Ohno S, et al. ESMO Guidelines Committee. Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019; 30(10): 1674.
  63. Krasin M, McCall A, King S, et al. Evaluation of a standard breast tangent technique: a dose-volume analysis of tangential irradiation using three-dimensional tools. Int J Radiat Oncol Biol Phys. 2000; 47(2): 327–333.
  64. Aristei C, Chionne F, Marsella A, et al. Evaluation of level I and II axillary nodes included in the standard breast tangential fields and calculation of the administered dose: results of a prospective study. Int J Radiat Oncol Biol Phys. 2001; 51(1): 69–73.
  65. Alço G, Iğdem SI, Ercan T, et al. Coverage of axillary lymph nodes with high tangential fields in breast radiotherapy. Br J Radiol. 2010; 83(996): 1072–1076.
  66. Orecchia R, Huscher A, Leonardi MC, et al. Irradiation with standard tangential breast fields in patients treated with conservative surgery and sentinel node biopsy: using a three-dimensional tool to evaluate the first level coverage of the axillary nodes. Br J Radiol. 2005; 78(925): 51–54.
  67. Reed DR, Lindsley SK, Mann GN, et al. Axillary lymph node dose with tangential breast irradiation. Int J Radiat Oncol Biol Phys. 2005; 61(2): 358–364.
  68. Reznik J, Cicchetti MG, Degaspe B, et al. Analysis of axillary coverage during tangential radiation therapy to the breast. Int J Radiat Oncol Biol Phys. 2005; 61(1): 163–168.
  69. Jephcott CR, Tyldesley S, Swift CL. Regional radiotherapy to axilla and supraclavicular fossa for adjuvant breast treatment: a comparison of four techniques. Int J Radiat Oncol Biol Phys. 2004; 60(1): 103–110.
  70. Hernandez V, Arenas M, Müller K, et al. An optimized posterior axillary boost technique in radiation therapy to supraclavicular and axillary lymph nodes: a comparative study. Med Dosim. 2013; 38(4): 413–417.
  71. Rivera S, Louvel G, Campo ER, et al. Radiothérapie axillaire prophylactique des cancers du sein. Cancer/Radiothérapie. 2015; 19(4): 253–260.
  72. van der Laan HP, Hurkmans CW, Kuten A, et al. EORTC-ROG Breast Working Party. Current technological clinical practice in breast radiotherapy; results of a survey in EORTC-Radiation Oncology Group affiliated institutions. Radiother Oncol. 2010; 94(3): 280–285.
  73. Haviland JS, Owen JR, Dewar JA, et al. START Trialists' Group, START Trialists' Group, START Trialists' Group. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet. 2008; 371(9618): 1098–1107.
  74. Nattinger AB, Gottlieb MS, Veum J, et al. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med. 1992; 326(17): 1102–1107.
  75. Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localized breast cancer. N Engl J Med. 1992; 326(17): 1097–1101.
  76. Lazovich DA, White E, Thomas DB, et al. Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cancer. JAMA. 1991; 266(24): 3433–3438.
  77. Zubizarreta E, Van Dyk J, Lievens Y. Analysis of Global Radiotherapy Needs and Costs by Geographic Region and Income Level. Clin Oncol (R Coll Radiol). 2017; 29(2): 84–92.
  78. Ratosa I, Chirilă ME, Steinacher M, et al. Hypofractionated radiation therapy for breast cancer: Preferences amongst radiation oncologists in Europe - Results from an international survey. Radiother Oncol. 2021; 155: 17–26.
  79. Park HJ, Oh DoH, Shin KH, et al. Division for Breast Cancer, Korean Radiation Oncology Group. Patterns of Practice in Radiotherapy for Breast Cancer in Korea. J Breast Cancer. 2018; 21(3): 244–250.
  80. Wang SL, Fang H, Song YW, et al. Hypofractionated versus conventional fractionated postmastectomy radiotherapy for patients with high-risk breast cancer: a randomised, non-inferiority, open-label, phase 3 trial. Lancet Oncol. 2019; 20(3): 352–360.
  81. Balic M, Thomssen C, Würstlein R, et al. St. Gallen/Vienna 2019: A Brief Summary of the Consensus Discussion on the Optimal Primary Breast Cancer Treatment. Breast Care (Basel). 2019; 14(2): 103–110.
  82. Coles CE, Aristei C, Bliss J, et al. International Guidelines on Radiation Therapy for Breast Cancer During the COVID-19 Pandemic. Clin Oncol (R Coll Radiol). 2020; 32(5): 279–281.
  83. Braunstein LZ, Gillespie EF, Hong L, et al. Breast Radiation Therapy Under COVID-19 Pandemic Resource Constraints-Approaches to Defer or Shorten Treatment From a Comprehensive Cancer Center in the United States. Adv Radiat Oncol. 2020; 5(4): 582–588.
  84. Romestaing P, Lehingue Y, Carrie C, et al. Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France. J Clin Oncol. 1997; 15(3): 963–968.
  85. Yarnold J, Ashton A, Bliss J, et al. Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long-term results of a randomised trial. Radiother Oncol. 2005; 75(1): 9–17.
  86. Bentzen SM, Agrawal RK, Aird EG, et al. START Trialists' Group. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol. 2008; 9(4): 331–341.
  87. Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010; 362(6): 513–520.
  88. Cottu P. et al. Attitudes diagnostiques et thérapeutiques, protocoles de traitement 2019–2020 [Internet]. https://www.gustaveroussy.fr/sites/default/files/referentiel-remagus-cancer-du-sein-gustave-roussy-institut-curie-2019-2021.pdf.
  89. Robson et al. Guidelines for radiotherapy in early breast cancer. Merseyside and cheshire cancer network, warrington (2010) [Internet]. https://www.cmcanceralliance.nhs.uk/application/files/2815/4815/5651/CNG_Guidelines_for_Radiotherapy_in_Early_Breast_Cancer_April_17.doc (19 Nov 2020).
  90. Recht A, Edge SB, Solin LJ, et al. American Society of Clinical Oncology. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001; 19(5): 1539–1569.
  91. Goldhirsch A, Winer EP, Coates AS, et al. Panel members. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol. 2013; 24(9): 2206–2223.
  92. Cancers du sein — Recommandations et outils d’aide à la pratique [Internet]. https://www.e-cancer.fr/Professionnels-de-sante/Recommandations-et-outils-d-aide-a-la-pratique/Cancers-du-sein#toc-recommandations-de-prise-en-charge-sp-cialis-e (19 Nov 2020).