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External radiotherapy for breast cancer in the elderly

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Abstract

Background

Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients.

Aims

The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population.

Materials and methods

Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost.

Discussion

The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care.

Conclusions

New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.

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Abbreviations

RT:

Radiation therapy

WBRT:

Whole-breast radiotherapy

EBCTCG:

Early Breast Cancer Trialists’ Collaborative Group

OS:

Overall survival

CGA:

Comprehensive Geriatric Assessment Numeric Rating Scale

ER:

Oestrogen receptor

NCCN:

National Comprehensive Cancer Network

EUSOMA:

European Society of Breast Cancer Specialists

APBI:

Accelerated partial breast irradiation

WBI:

Whole-breast irradiation

IMRT:

Intensity-modulated radiation therapy

VMAT:

Volumetric modulated arc therapy

HIBT:

High-intensity brachytherapy

SEER:

Surveillance epidemiology and end results

PMRT:

Postmastectomy radiotherapy

HyRT:

Hypofractionated radiotherapy

BCS:

Breast-conserving surgery

NCI:

National Cancer Institute

References

  1. SEER Cancer Statistic reviewed 1975–2004

  2. Louwman WJ, Vulto JC, Verhoeven RH et al (2007) Clinical epidemiology of breast cancer in the elderly. Eur J Cancer 43(Suppl 15):2242–2252

    Article  CAS  PubMed  Google Scholar 

  3. Singletary SE (2003) Rating the risk factors for breast cancer. Ann Surg 237:474–482

    PubMed  PubMed Central  Google Scholar 

  4. Anderson WF, Matsuno RK, Sherman ME et al (2007) Estimating age-specific breast cancer risk: a descriptive tool to identify age interaction. Cancer Causes Control 18:439–447

    Article  PubMed  Google Scholar 

  5. Anderson WF, Chen BE, Brinton LA et al (2007) Qualitative age interaction (or effect modification) suggest different cancer pathways for early-onset and late-onset breast cancer. Cancer Causes Control 18:1187–1198

    Article  PubMed  Google Scholar 

  6. Punglia RS, Hughes KS, Muss HB (2015) Management of older women with early-stage breast cancer. Am Soc Clin Oncol Educ. doi:10.14694/EdBook_AM.2015.35.48

    Google Scholar 

  7. Albrand G, Terret C (2008) Early breast cancer in the elderly: assessment and management considerations. Drugs Aging 25:35–45

    Article  CAS  PubMed  Google Scholar 

  8. Bergman L, Kluck HM, van Leeuwen FE et al (1992) The influence of age on treatment choice and survival of elderly breast cancer patients in south-eastern Netherlands: a population-based study. Eur J Cancer 28A:1475–1480

    Article  CAS  PubMed  Google Scholar 

  9. Sanguinetti A, Polistena A, Lucchini R et al (2014) Breast cancer in older women: what factors affect the treatment? Int J Surg 12(Suppl 2):S177–S180

    Article  PubMed  Google Scholar 

  10. Karuturi M, VanderWalde N, Muss H (2016) Approach and management of breast cancer in the elderly. Clin Geriatr Med 32:133–153

    Article  PubMed  Google Scholar 

  11. Carlson RW, Moench S, Hurria A et al (2008) NCCN Task Force Report: breast cancer in the older woman. J Natl Compr Cancer Netw 6(Suppl 4:S1–25):quiz S26–quiz S27

    Google Scholar 

  12. Wildiers H, Kunkler I, Biganzoli L et al (2007) Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 8:1101–1115

    Article  PubMed  Google Scholar 

  13. Biganzoli L, Wildiers H, Oakman C et al (2012) Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 13:e148–e160

    Article  PubMed  Google Scholar 

  14. Kunkler IH, Prescott RJ, Williams LJ et al (2006) When may adjuvant radiotherapy be avoided in operable breast cancer? Clin Oncol (R Coll Radiol) 18:191–199

    Article  CAS  Google Scholar 

  15. Sautter-Bihl ML, Sedlmayer F, Budach W et al (2012) When are breast cancer patients old enough for the quitclaim of local control? Strahlenther Onkol 188:1069–1073

    Article  CAS  PubMed  Google Scholar 

  16. Hughes KS, Schnaper LA, Bellon JR et al (2013) Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol 31:2382–2387

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Pötter R, Gnant M, Kwasny W et al (2007) Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer. Int J Radiat Oncol Biol Phys 68:334–340

    Article  PubMed  Google Scholar 

  18. 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 351:963–970

    Article  CAS  PubMed  Google Scholar 

  19. Truong PT, Bernstein V, Lesperance M et al (2006) Radiotherapy omission after breast-conserving surgery is associated with reduced breast cancer-specific survival in elderly women with breast cancer. Am J Surg 191:749–755

    Article  PubMed  Google Scholar 

  20. Kunkler IH, Williams LJ, Jack WJ et al (2015) Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomized controlled trial. Lancet Oncol 16:266–273

    Article  PubMed  Google Scholar 

  21. Livi L, Paiar F, Meldolesi E et al (2005) The management of elderly patients with T1–T2 breast cancer treated with or without radiotherapy. Eur J Surg Oncol 31:473–478

    Article  CAS  PubMed  Google Scholar 

  22. Albert JM, Liu DD, Shen Y et al (2012) Nomogram to predict the benefit of radiation for older patients with breast cancer treated with conservative surgery. J Clin Oncol 30:2837–2843

    Article  PubMed  PubMed Central  Google Scholar 

  23. Rutter CE, Lester-Coll NH, Mancini BR et al (2015) The evolving role of adjuvant radiotherapy for elderly women with early-stage breast cancer. Cancer 121:2331–2340

    Article  CAS  PubMed  Google Scholar 

  24. NCCN (2016) Clinical Practice Guidelines in Oncology™. Breast Cancer. http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf, Version 1

  25. Bartelink H, Horiot JC, Poortmans PM et al (2007) 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 25:3259–3265

    Article  PubMed  Google Scholar 

  26. Kindts I, Laenen A, Peeters S et al (2016) Evaluation of a breast cancer nomogram to predict ipsilateral breast relapse after breast-conserving therapy. Radiother Oncol 119:45–51. doi:10.1016/j.radonc.2016.01.023

    Article  PubMed  Google Scholar 

  27. Smith BD, Arthur DW, Buchholz TA et al (2009) Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). J Am Coll Surg 209:269–277

    Article  PubMed  Google Scholar 

  28. Polgár C, Van Limbergen E, Pötter R (2009) Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the GroupeEuropéen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence. Radiother Oncol 2010:264–273

    Google Scholar 

  29. Vaidya JS, Joseph DJ, Tobias JS et al (2010) Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 376:91–102

    Article  PubMed  Google Scholar 

  30. Vaidya JS, Wenz F, Bulsara M et al (2014) 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 383:603–613

    Article  PubMed  Google Scholar 

  31. Genebes C, Chand ME, Gal J et al (2014) Accelerated partial breast irradiation in the elderly: 5-year results of high-dose rate multi-catheter brachytherapy. Radiat Oncol 16:115

    Article  Google Scholar 

  32. Hannoun-Levi JM, Gourgou-Bourgade S, Belkacemi Y et al (2013) GERICO-03 phase II trial of accelerated and partial breast irradiation in elderly women: feasibility, reproducibility, and impact on functional status. Brachytherapy 12:285–292

    Article  PubMed  Google Scholar 

  33. Jagsi R, Ben-David MA, Moran JM et al (2010) Unacceptable cosmesis in a protocol investigating intensity-modulated radiotherapy with active breathing control for accelerated partial-breast irradiation. Int J Radiat Oncol Biol Phys 76:16

    Article  Google Scholar 

  34. Bourgier C, Acevedo-Henao C, Dunant A et al (2012) Higher toxicity with 42 Gy in 10 fractions as a total dose for 3D-conformal accelerated partial breast irradiation: results from a dose escalation phase II trial. Radiat Oncol 7:141

    Article  PubMed  PubMed Central  Google Scholar 

  35. Livi L, Meattini I, Marrazzo L et al (2015) 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 51:451–463

    Article  PubMed  Google Scholar 

  36. Riou O, Fenoglietto P, Bourgier C et al (2015) Feasibility of accelerated partial breast irradiation with volumetric-modulated arc therapy in elderly and frail patients. Radiat Oncol 10:209. doi:10.1186/s13014-015-0516-3

    Article  PubMed  PubMed Central  Google Scholar 

  37. Smith BD, Haffty BG, Smith GL et al (2008) Use of post-mastectomy radiotherapy in older women. Int J Radiat Oncol Biol Phys 71:98–106

    Article  PubMed  Google Scholar 

  38. Kunkler IH, Canney P, van Tienhoven G et al (2008) MRC/EORTC (BIG 2-04) SUPREMO Trial Management Group. Elucidating the role of chest wall irradiation in “intermediate-risk” breast cancer: the MRC/EORTC SUPREMO trial. Clin Oncol (R Coll Radiol) 20:31–34

    Article  CAS  Google Scholar 

  39. EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C et al (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: metanalysis of individual patient data for 8135 women in 22 randomised trials. Lancet 383:2127–2135

    Article  Google Scholar 

  40. Whelan TJ, Pignol JP, Levine MN et al (2010) Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 362:513–520

    Article  CAS  PubMed  Google Scholar 

  41. Doré M, Cutuli B, Cellier P et al (2015) Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy: analysis of 205 cases. Radiat Oncol 4:161

    Article  Google Scholar 

  42. Whelan T, Kim D, Sussman J (2008) Clinical experience using hypofractionated radiation schedules in breast cancer. Sem Radiat Oncol 18:257–264

    Article  Google Scholar 

  43. START Trialists’ Group, Bentzen SM, Agrawal RK et al (2008) The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol 9:331–341

    Article  Google Scholar 

  44. START Trialists’ Group, Bentzen SM, Agrawal RK et al (2008) The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 371:1098–1107

    Article  Google Scholar 

  45. Smith BD, Bentzen SM, Correa CR et al (2011) Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys 81:59–68

    Article  PubMed  Google Scholar 

  46. Yarnold J, Haviland J (2010) Hypofrcationated adjuvant whole breast radiotherapy: progress and prospects. Acta Oncol 49:1288–1292

    Article  PubMed  Google Scholar 

  47. Pinnarò P, Soriani A, Landoni V et al (2010) Accelerated hypofractionated radiotherapy as adjuvant regimen after conserving surgery for early breast cancer. Interim report of toxicity after a minimum follow up of 3 years. J Exper Clin Cancer Res 29:1–9

    Article  Google Scholar 

  48. Herbert C, Nichol A, Olivotto I et al (2012) The impact of hypofractionated whole breast radiotherapy on local relapse in patients with grade 3 early breast cancer: a population-based cohort study. Int J Radiat Oncol Biol Phys 82:2086–2092

    Article  PubMed  Google Scholar 

  49. Fowler JF (1984) The first James Kirk memorial lecture. What next in fractionated radiotherapy? Br J Cancer Suppl 6:285–300

    CAS  PubMed  PubMed Central  Google Scholar 

  50. Khan A, Haffty BG (2010) Hypofractionation in adjuvant breast radiotherapy. Breast 19:168–171

    Article  PubMed  Google Scholar 

  51. Baillet F, Housset M, Maylin C et al (1990) The use of a specific hypofractionated radiation therapy regimen versus classical fractionation in the treatment of breast cancer: a randomized study of 230 patients. Int J Radiat Oncol Biol Phys 19:1131–1133

    Article  CAS  PubMed  Google Scholar 

  52. START Trialists’ Group, Bentzen SM, Agrawal RK et al (2008) The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol 9:331–341. doi:10.1016/S1470-2045(08)70077-9

    Article  Google Scholar 

  53. Owen JR, Ashton A, Bliss JM et al (2006) Effect of radiotherapy fraction size on tumour control in patients with early-stage breast cancer after local tumour excision: long-term results of a randomized trial. Lancet Oncol 7:467–471

    Article  PubMed  Google Scholar 

  54. Whelan T, MacKenzie R, Julian J et al (2002) Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node-negative breast cancer. J Natl Cancer Inst 94:1143–1150

    Article  PubMed  Google Scholar 

  55. Kirova YM, Campana F, Savignoni A et al (2009) Breast-conserving treatment in the elderly: long-term results of adjuvant hypofractionated and normofractionated radiotherapy. Int J Radiat Oncol Biol Phys 75:76–81

    Article  PubMed  Google Scholar 

  56. Ortholan C, Hannoun-Lévi JM, Ferrero JM et al (2005) Long-term results of adjuvant hypofractionated radiotherapy for breast cancer in elderly patients. Int J Radiat Oncol Biol Phys 61:154–162

    Article  PubMed  Google Scholar 

  57. FAST Trialists group, Agrawal RK, Alhasso A et al (2011) First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). Radiother Oncol 100:93–100

    Article  Google Scholar 

  58. Thavarajah N, Menjak I, Trudeau M et al (2015) Towards an optimal multidisciplinary approach to breast cancer treatment for older women. Can Oncol Nurs J 25:384–408

    Article  PubMed  Google Scholar 

  59. Van de Water W, Bastiaannet E, Scholten AN et al (2014) Breast-conserving surgery with or without radiotherapy in older breast patients with early stage breast cancer: a systematic review and meta-analysis. Ann Surg Oncol 21:786

    Article  PubMed  Google Scholar 

  60. Poortmans P, Marsiglia H, De Las Heras M et al (2013) Clinical and technological transition in breast cancer. Rep Pract Oncol Radiother 18:345–352

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. European Medical Imaging, Radiation Oncology, Fondazione Muto-onlus, Via Taverna Rossa, 169, 80020, Casavatore, Naples, Italy

    Francesca Maria Giugliano & Matteo Muto

  2. Division of Radiation Oncology, Istituto Nazionale per lo studio e la cura dei tumori “Fondazione Giovanni Pascale”, IRCCS, Via Mariano Semmola, 80131, Naples, Italy

    Sara Falivene, Rossella Di Franco & Paolo Muto

  3. Department of Breast Cancer, Istituto Nazionale per lo Studio e la Cura dei Tumori “Fondazione Giovanni Pascale”, IRCCS, Via Mariano Semmola, 80131, Naples, Italy

    Emanuela Esposito & Massimiliano D’Aiuto

Authors
  1. Francesca Maria Giugliano
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  2. Sara Falivene
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  3. Emanuela Esposito
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  4. Rossella Di Franco
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  5. Matteo Muto
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  6. Massimiliano D’Aiuto
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Correspondence to Emanuela Esposito.

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Conflict of interests

The authors declare that they have no conflict of interest.

Ethical approval

For this type of study, formal consent is not required. The study does not require approval by ethics committee.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent to the radiation therapy procedure and to the processing of own personal data was obtained from each individual study participant. In accordance with Italian Drug Agency (AIFA) guidelines, observational studies using retrospective data or materials do not require formal approval by the local ethics committee.

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Giugliano, F.M., Falivene, S., Esposito, E. et al. External radiotherapy for breast cancer in the elderly. Aging Clin Exp Res 29 (Suppl 1), 149–157 (2017). https://doi.org/10.1007/s40520-016-0655-x

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