Do you always use a bolus when treating with postmastectomy radiotherapy?

It's important to note that today's PMRT patient (with her skin-sparing surgery and her tissue expanders and her small primary with just two nodes) is not the typical neglected/advanced ulcerated mess of yesteryear. I reserve bolus only for patients with high-risk for skin involvement (inflammatory ...

Despite dogmatic teachings (of which there are many, including the options in the poll), I was not convinced that there was any oncologic need for bolus use in PMRT in the absence of skin involvement, regardless of presence or absence of reconstruction. Recent publications and presentations have onl...

I am not aware of any high-quality evidence to define the optimal bolusing schedule. There is considerable variation in use of bolus from center to center. In our practice, we use 3 mm on bolus on the chest wall fields every other day for the first 2 weeks of treatment (i.e. we bolus 5 of 10 fractio...

Vargo and Beriwal, PMID 26383675

The above reference shows sites of chest wall relapse after mastectomy and this is the rationale for us to use bolus until a grade 2 reaction develops.

For inflammatory cancer or skin involvement, we try to use bolus for the entire course, if feasible.

Do we need to reassess our targets? Why do we treat the chest wall? Most recurrences are in the skin or subcutaneous tissue. I always presumed that this was due to lymphatic invasion. Measurement of skin dose results in such variation that one should really think about the role or omission of bolus.