Exploring the latest recommendations for radiation therapy treatment of early breast cancer.

1. 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

2. Breast Cancer: Current Situation
Incidence & Mortality from Breast Cancer in UK & Wales 1971-2009
Source: National Statistics, 2010
Systemic
Local

3. 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

4. Locoregional Recurrences Following Treatment of
Earlier Stages of Breast Cancer:
ONCOLOGY 14(11):1561-1581, 2000]

5. 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.

6. Radiation Therapy is Beneficial after
BCS: EBCTCG – 2011 Meta-analysis:
Lancet. Nov 12, 2011; 378(9804): 1707–1716.

7. Radiation Therapy is Beneficial after
BCS: EBCTCG – 2011 Meta-analysis:
Lancet. Nov 12, 2011; 378(9804): 1707–1716.

8. Local Recurrence Distant Recurrence
No Radiation Therapy 25% 10%
Radiation Therapy 8% 12%
Radiation Therapy is Beneficial after
BCS: EBCTCG – 2011 Meta-analysis:
Lancet. Nov 12, 2011; 378(9804): 1707–1716.

10. 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

11. Radiation Therapy is Beneficial after
MRM: EBCTCG – 2014 Meta-analysis:
Lancet 2014; 383: 2127–35

12. Radiation Therapy is Beneficial after
MRM: EBCTCG – 2014 Meta-analysis:
Lancet 2014; 383: 2127–35

13. Radiation Therapy is Beneficial after
MRM: EBCTCG – 2014 Meta-analysis:
Lancet 2014; 383: 2127–35

14. Radiation Therapy is Beneficial after
MRM: EBCTCG – 2014 Meta-analysis:
Lancet 2014; 383: 2127–35

15. 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

16. Fraction Size, Fractionation and OAP:
Lancet Oncol 2013; 14: 1086–94

17. Fraction Size, Fractionation and OAP:
Lancet Oncol 2013; 14: 1086–94

18. Fraction Size, Fractionation and OAP:
Lancet Oncol 2013; 14: 1086–94

19.  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:

20. Partial Breast Irradiation:

21. 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.

22. Partial Breast Irradiation:
 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).
Int J Radiat Oncol Biol Phys. 2009;74(4):987.
Int J Radiat Oncol Biol Phys. 2010;78(3):799.

23. Partial Breast Irradiation:

24. 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.

25. 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.

26. mohamed.abdulla@oncologyclinic.org