Abstract
The treatment of breast cancer involves a multi-disciplinary approach with radiation therapy playing a key role. Breast-conserving surgery has been an option for women with early-stage breast cancer for over two decades now. Multiple randomized trials now have demonstrated the efficacy of breast-conserving surgery followed by radiation therapy. With the advancements in breast imaging and the successful campaign for early detection of breast cancer, more women today are found to have early-stage small breast cancers. Patient factors (breast size, tumor location, history of prior radiation therapy, preexisting conditions such as collagen vascular disease, age, having prosthetically augmented breasts), pathological factors (margin status, tumor size, presence of extensive intraductal component requiring multiple surgical excisions), as well as patient preference are all taken into consideration prior to surgical management of breast cancer. Whole-breast fractionated radiation therapy between 5 and 7 weeks is considered as the standard of care treatment following breast-conserving surgery. However, new radiation treatment strategies have been developed in recent years to provide alternatives to the conventional 5–7 week whole-breast radiation therapy for some patients. Accelerated partial breast radiation therapy (APBI) was introduced because the frequency of breast recurrences outside of the surgical cavity has been shown to be low. This technique allows treatments to be delivered quicker (usually 1 week, twice daily) to a limited volume. Often times, this treatment involves the use of a brachytherapy applicator to be placed into the surgical cavity following breast-conserving surgery. Accelerated hypofractionated whole-breast irradiation may be another faster way to deliver radiation therapy following breast-conserving surgery. This journal article reviews the role of radiation therapy in women with early-stage breast cancer addressing patient selection in breast-conserving therapy, a review of pertinent trials in breast-conserving therapy, as well as the different treatment techniques available to women following breast-conserving surgery.
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References
American Cancer Society (2008) Cancer facts and figures. American Cancer Society, Atlanta
Antonucci J, Wallace M, Goldstein N et al (2009) Differences in patterns of failure in patients treated with accelerated partial breast irradiation versus whole-breast irradiation: a matched-pair analysis with 10-year follow-up. Int J Radiat Oncol Biol Phys 74(2):447–452
Arthur D, Winter K, Kuske R et al (2008) A phase II trial of brachytherapy alone after lumpectomy for select breast cancer: tumor control and survival outcomes of RTOG 95–17. Int J Radiat Oncol Biol Phys 72(2):463–473
Barnett GC, Wilkinson J, Moody AM et al (2009) A randomised controlled trial of forward-planned radiotherapy (IMRT) for early breast cancer: baseline characteristics and dosimetry results. Radiother Oncol Epub (ahead of publication)
Bartelink H, Horiot JC, Poortmans P et al (2001) Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med 345(19):1378–1387
Benitez P, Keisch M, Vicini F et al (2007) Five-year results: the initial clinical trial of MammosSite balloon brachytherapy for partial breast irradiation in early-stage breast cancer. Am J Surg 194(4):456–462
Benson JR, Jotoi I, Keisch M et al (2009) Early breast cancer. Lancet 373:1463–1479
Bentzen SM, Agrawal RK, Aird EG et al (2008) The UK Standarisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 371(9618):1098–1107
Beral V, Hermon C, Reeves G et al (1995) Sudden fall in breast cancer death rates in England and Wales. Lancet 356(8965):1670–1674
Beriwal S, Coon D, Kim H et al (2008) Multicatheter hybrid breast brachytherapy: a potential alternative for patients with inadequate skin distance. Brachytherapy 7(4):301–304
Blichert-Toft M, Nielsen M, During M et al (2008) Long-term results of breast conserving surgery vs. mastectomy for early stage breast cancer: 20-year follow-up of the Danish randomized DBCG-82TM protocol. Acta Oncol 47(4):672–681
Borghero YO, Salehpuor M, McNeese MD et al (2007) Multileaf field-in-field forward-planned intensity-modulated dose compensation for whole-breast irradiation is associated with reduced contralateral breast dose: a phantom model comparison. Radiother Oncol 82(3):324–328
Brown S, McLaughlin M, Pope K et al (2009) Initial radiation experience evaluating early tolerance and toxicities in patients undergoing accelerated partial breast irradiationusing the Contura Multi-Lumen Balloon breast brachytherapy catheter. Brachytherapy 8(2):227–233
Buchholz TA (2009) Radiation therapy for early-stage breast cancer after breast-conserving surgery. N Engl J Med 360(1):63–70
Buchholz TA, Tucker SL, Erwin J et al (2001) Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breats-conservation therapy. J Clin Oncol 19(8):2240–2246
Cabioglu N, Hunt KK, Buchholz TA et al (2005) Improving local control with breast-conserving therapy: a 27-year single-institution experience. Cancer 104(1):20–29
Cady B, Stone MD, Schuler JG et al (1996) The new era in breast cancer: invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening. Arch Surg 131(3):201–308
Cady B (2007) Local therapy and survival in breast cancer (comment to editor). N Engl J Med 357(10):1051
Clarke DH, Le MG, Sarrazin D et al (1985) Analysis of local-regional relapses in patients with early breast cancer treated by excision and radiotherapy: experience of the Institut Gustave-Roussy. Int J Radiat Oncol Biol Phys 11(1):137–145
Clarke M, Collins R, Darby S et al (2005) Effects of radiotherapy and of differences in the extent of surgery for earl breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366(9503):2087–2106
Delouche G, Bachelot F, Premont M et al (1987) Conservation treatment of early stage breast cancer: long term results and complications. Int J Oncol Biol Phys 13(1):29–34
Dickler A (2009) Xoft Axxent electronic brachytherapy: a new device for delivering brachytherapy to the breast. Nat Clin Pract Oncol 6(3):138–142
Dickler A, Seif N, Kirk M et al (2009) A dosimetric comparison of MammoSite and ClearPath high-dose-rate brachytherapy devices. Brachytherapy 8(1):14–18
Fisher B, Anderson S (1994) Conservative surgery for the management of invasive and noninvasive carcinoma of the breast: NSABP trials. National Surgical Adjuvant Breast and Bowel Project. World J Surg 18(1):63–69
Fisher B, Anderson S, Bryant J et al (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347(16):1233–1241
Fisher B, Dignam J, Bryant J et al (1996) Five versus more than five years of tamoxifen therapy for breast cancer patients with negative lymph nodes and estrogen receptor-postive tumors. J Natl Cancer Inst 88(21):1529–1542
Fisher B, Stewart JA (2007) Local therapy and survival in breast cancer (comment to editor). N Engl J Med 356(10):1051
Fisher BJ, Bryant J, Dignam J et al (2002) Tamoxifen, radiation therapy, or both for the prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol 20(20):4141–4149
Fowble B, Solin LJ, Schultz DJ et al (1989) Frequency, sites of relapse, and outsome of regional node failures following conservative surgery and radiation for early breast cancer. Int J Radiat Oncol Biol Phys 17(4):703–710
Fowble BL, Schultz DJ, Overmoyer B et al (1994) The influence of young on outcome in early stage breast cancer. Int J Radiat Oncol Biol Phys 30(1):23–33
Fyles AW, McCready DR, Manchul LA et al (2004) Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med 351(10):963–970
Goyal S, Khan AJ, Vicini F, et al (2009) Factors associated with optimal cosmetic results at 36 months in patients treated with accelerated partial breast irradiation (APBI) on the American Society of Breast Surgeons (ASBrS) MammoSite ® Breast Brachytherapy Registry Trial. Ann Surg Oncol [Epub ahead of print]
Harris JS, Neill CJ, Rosser PF (2008) A comprehensive clinical 3-dimensional dosimetric analysis of forward planned IMRT and conventional wedge planned wedged techniques for intact breast radiotherapy. Med Dosim 33(1):62–70
Holland R, Connolly JL, Gelman R et al (1990) The presence of extensive intraductal component component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol 8(1):113–118
Holli K, Saaristo R, Isalo J et al (2001) Lumpectomy with or without postopertive radiotherapy for breast cancer with favorable prognostic features: results of a randomized study. Br J Cancer 84(2):164–169
Hughes KS, Schnaper LA, Berry D et al (2004) Lupectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 351(10):971–977
Keisch M, Vicini F, Kuske R et al (2003) Initial clinical experience with the Mammo Site breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 55(2):289–293
Keynes G (1954) Carcinoma of the breast, the unorthodox view. Proc Cardiff Med Soc 40
Kumle M (2008) Declining breast cancer incidence with decreased HRT use. Lancet 372(9639):608–610
Kurtz JM, Spitalier JM, Amalric R et al (1988) Mammary recurrences in women younger than forty. Int J Radiat Biol Phys 15(2):271–271
Mehta K, Haffty BG (1996) Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy. Int J Radiat Oncol Biol Phys 35(4):679–685
Morrow M, Harris JR (2007) Practice guidelines for breast-conserving therapy in the management of invasive breast cancer. J Am Coll Surg 205:362–372
Murley R (1986) Breast cancer: Keynes and conservatism. Br J Clin Pract 40:49–58
Nelson J, Beitsch P, Vicini F et al (2009) Four-year clinical update from the American Society of Breast Surgeons MammoSite brachytherapy trial. Am J Surg 198(1):83–91
NIH Office of the Director: NIH Concensus Statement (2000) 4: 17
Nixon AJ, Neuberg D, Hayes DF et al (1994) Relationship of patient’s age to pathologic features of the tumor and prognosis for patient’s with stage I or II breast cancer. J Clin Oncol 12(5):888–894
Overgaard M, Hansen PS, Overgaard J et al (1997) Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med 337(14):945–955
Peto R, Boreham J, Clarke M et al (2000) UK and USA breast cancer deaths down 25% in year 2000 at ages 29–69 years. Lancet 355(9217):1822
Pierce LJ, Butler JB, Martel MK et al (2002) Postmastectomy radiotherapy of the chest wal: dosimetric comparision of common techniques. Int J Radiat Oncol Biol Phys 52(5):1220–1230
Pierce LJ, Levin AM, Rebbeck TR et al (2006) Ten-year multi-institutional results of breast-conserving surgery and radiotherapy in BRCA 1/2-associated stage I/II breast cancer. J Clin Oncol 24(16):2437–2443
Poggi MM, Danforth DN, Sciuto LC et al (2003) Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer 98(4):697–702
Poortmans PM, Collette L, Bartelink H et al (2008) The addition of a boost dose on the primary tumour bed after lumpectomy in breast conserving treatment for breast cancer. A summary of the results of the EORTC 22881–10882:boost versus no boost trial. Cancer Radiothér 12(6–7):565–570
Poortsman PM, Collette L, Horiot JC et al (2009) Impact of boost dose of 10 Gy vesus 26 Gy in patients with early stage breast cancer after a microscopically incomplete lumpectomy: 10-year results of the randomised EORTC boost trial. Radiother Oncol 90(1):80–85
Porter P (2008) Westernizing womens’ risks? Breast cancer in lower-income countries. N Engl J Med 358(3):213–216
Puglia RS, Morrow M, Harris JR (2007) Local therapy and survival in breast cancer. N Engl J Med 357(10):1051–1052, author reply
Punglia RS, Morrow M, Winer EP et al (2007) Local therapy and breast cancer. N Engl J Med 356(23):2399–2405
Ragaz J, Olivotto IA, Spinelli JJ et al (2005) Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst 97(2):116–126
Recht A, Pierce SM, Abner A et al (1991) Regional nodal failure after conservative surgery and radiotherapy for early-stage breast cancer. J Clin Oncol 9(6):988–996
Rutqvist LE, Cedermark B, Glas U et al (1992) Randomized trial of adjuvant tamoxifen in node negative postmenopausal breast cancer. Acta Oncol 31(2):265–270
Sarrazin D, Le MG, Arriagada R et al (1989) Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol 14(3):177–184
Scanderbeg J, Yashar C, Rice R et al (2009) Clinical implementation of a new brachytherapy device for partial breast irradiation. Radiother Oncol 90(1):36–42
Schlembach PJ, Buchholz TA, Ross MI et al (2001) Relationship of sentinel and axillary level I and II lymph nodes to tangential fields used in breast irradiation. Int J Radiat Oncol Biol Phys 51(3):671–678
Singletary SE (2002) Surgical margins in patients with early stage breast cancer treated with breast conservation therapy. Am J Surg 184:383–393
Smith BD, Arthur DW, Buchholz TA et al (2009) Accelerated partial breast consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 74(4):987–1001
Smith BD, Gross CP, Smith GL et al (2006) Effectiveness of radiation therapy for older women with early breast cancer. J Natl Cancer Inst 98(10):681–690
Streeter O, Vicini F, Keisch M et al (2003) MammoSite ® radiation therapy system. Breast 12(6):491–496
Taghian AG, Powel SN (1999) The role of radiation therapy for primary breast cancer. Surg Clin North Am 79(5):1091–1115
van Dongen JA, Bartelink H, Fentiman IS et al (1992) Randomized clinical trial to assess the value of breast conserving therapy in stage I and II breast cancer, EORTC 10801 trial. J Natl Cancer Inst Monogr: 15–18
Veronesi U, Cascinelli N, Mariani L et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347(16):1227–1232
Vicini F, Baglan K, Kestin L et al (2001) Accelerated treatment of breast cancer. J Clin Oncol 19(7):1993–2001
Vicini F, Remouchamps V, Wallace M et al (2003) Ongoing clinical experience utilizing 3-D conformal external beam radiotherapy to deliver partial-breast irradiation in patients with early-stage breast cancer treated with breast-conserving surgery. Int J Radiat Oncol Biol Phys 57(5):1247–1253
Vicini FA, Recht A, Abner A et al (1992) Recurrence in breast following conservative surgery and radiation therapy for early-stage breast cancer. J Natl Cancer Inst Monogr (11): 33–39
Vinh-Hung V, Verschraegen C (2004) Breast-conserving therapy with or without radiotherapy:pooled analysis for risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 96(2):115–121
Whelan T, MacKenzie R, Julian J et al (2002) Randomized trial of breast irradiation schedules after lumpectomy in womenwith lymph node-negative breast cancer. J Natl Cancer Inst 94(15):1143–1150
White J, Halberg F, Rabinovitch R et al (2008) American College of Radiology Appropriateness Criteria® on conservation surgery and radiation: stages I and II breast carcinoma. J Am Coll Radiol 5(6):701–713
Yarnold J, Ashton A, Bliss J et al (2005) Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long-term results of a randomised trail. Radiother Oncol 75(1):9–17
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Lin, R., Tripuraneni, P. Radiation Therapy in Early-Stage Invasive Breast Cancer. Indian J Surg Oncol 2, 101–111 (2011). https://doi.org/10.1007/s13193-011-0048-8
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DOI: https://doi.org/10.1007/s13193-011-0048-8