Moderate hypofractionation was adopted internationally in the 1970’s and 1980’s as a solution for scarce resource for breast radiation therapy (RT). This was based on the theoretical Ellis isoeffect formula and was introduced without testing in clinical trials with a lack of RT quality assurance [1]. Unfortunately, this resulted in many patients with breast cancer suffering serious late normal tissue toxicity, including brachial plexopathy following nodal RT. It became apparent that a vital component in hypofractionation is reduction of total dose as the dose per fraction is increased and several randomised trials based on the linear-quadratic formula ensued [1].
This presentation will review the current evidence for moderately hypofractionated breast RT [2-4] and highlight on-going Danish and French trials that will add to this evidence. It will then discuss 5-fraction (5F) RT [5] and describe the FAST-Forward nodal sub-study design (interim results have been submitted as a late-breaking abstract to ESTRO 2022). On-going recruiting 5F breast and nodal RT randomised trials in Canada and India will also be covered. Finally, current guidelines and consensus statements for breast nodal RT will be presented [6-7].
References
1. Yarnold J, Bentzen SM, Coles C, Haviland J. Hypofractionated whole-breast radiotherapy for women with early breast cancer: myths and realities. Int J Radiat Oncol Biol Phys 2011; 79(1): 1-9.
2. Haviland JS, Mannino M, Griffin C, et al. Late normal tissue effects in the arm and shoulder following lymphatic radiotherapy: Results from the UK START (Standardisation of Breast Radiotherapy) trials. Radiother Oncol 2018; 126(1): 155-62.
3. 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): 352-60.
4. Coles C, Griffin C, Kirby A, et al. Abstract GS4-05: Dose escalated simultaneous integrated boost radiotherapy for women treated by breast conservation surgery for early breast cancer: 3-year adverse effects in the IMPORT HIGH trial (CRUK/06/003). Cancer Research 2019; 79(4 Supplement): GS4-05-GS4-.
5. Murray Brunt A, Haviland JS, Wheatley DA, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet 2020; 395(10237): 1613-26.
6. Lewis P, Brunt AM, Coles C, Griffin S, Locke I, Roques T; Breast Radiotherapy Consensus Working Group. Clin Oncol (R Coll Radiol). Moving Forward Fast with FAST-Forward. Clin Oncol (R Coll Radiol) 2021 Jul;33(7):427-429
7. Meattini I, Becherini C, Boersma L, Kaidar-Person O, Nader Marta O, Montero A, Offersen BV, Aznar MC, Belka C, Brunt AM, Dicuonzo S, Franco P, Krause M, MacKenzie M, Marinko M, Marrazzo L, Ratosa I, Scholten A, Senkus E, Stobart H, Poortmans P and Coles CE. European Society for Radiotherapy and Oncology (ESTRO) Advisory Committee in Radiation Oncology Practice (ACROP) consensus recommendations on patient selection and dose/fractionation for external beam radiation therapy in early breast cancer. Lancet Oncol. 2022 Jan;23(1):e21-e31.