Consider a Single Intraoperative Fraction for Patients Eligible for Hypofractionated Regimens?

Without a doubt, Eblan et al have provided an excellent review of the literature on use of hypofractionated whole breast irradiation (HF-WBI) regimens-discussing their rationale, associated controversies, available results, and ongoing research-in the context of conservative curative management of breast cancers.[1] The large randomized trials are well documented and described, with the authors highlighting differences in selection criteria that may sometimes explain the variations in reported outcomes. Overall, there is convincing evidence that, with a properly selected cohort of patients, HF-WBI will provide the same level of benefit as conventional WBI. Potential limitations and/or uncertainties surrounding equivalence of these two therapies are well outlined, namely the question of whether HF-WBI is appropriate in younger patients and those with regional–nodal spread. However, for higher-risk patients, it seems rather obvious that the local-regional prognosis does not rely only upon radiotherapy modalities, and that customized oncological management based upon individual clinical and biological risk factors should be taken into consideration to enable selection of the most appropriate combination and sequence of drugs, hormones, surgery, and radiotherapy.

My main regret about the article comes from the too-strict limitation of the discussion to current issues, as if whole-breast radiotherapy should remain forever a target volume for patients in this setting. A large proportion (over half, if not more) of the patients enrolled in the trials described by Eblan and colleagues could have been suitable candidates for partial irradiation of the breast: those with small solitary tumors (< 2 cm), postmenopausal women, patients who had undergone tumorectomy and had free margins, women with negative sentinel nodes, and those who were estrogen receptor (ER)- and progesterone receptor (PR)-positive. Moreover, among the most hypofractionated regimens, intraoperative radiotherapy (IORT) with a single fraction of 23 Gy cannot be surpassed in terms of brevity of the procedure, cost reduction, and patient satisfaction! Large series, including several randomized trials,[2,3] have shown such regimens to be equivalent to treatment with conventional radiotherapy over a 5- to 6-week period. As demonstrated in this review, the incidence of late radiation damage does not differ between patients treated with HP-WBI vs conventionally fractionated (CF)-WBI. Since skin and subcutaneous connective tissue are not irradiated during IORT, the late cosmetic results should even be markedly improved, as already suggested by the available results with IORT at 10 years.

Customized more aggressive treatments should be given to patients with the worst prognosis. For most of the other breast patients, shorter and often milder treatment, although resulting in less fame for the researchers, is also a humble victory in our daily struggle against cancer.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Eblan MJ, VanderWalde NA, Zeman EM, Jones E. Hypofractionation for breast cancer: lessons learned from our neighbors to the north and across the pond. Oncology (Williston Park). 2014;28:538-46.

2. 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;1269-77.

3. Vaidya JS, Wenz F, Bulsara M, et al, on behalf of the 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;383:603-13.