Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?
Would your practice vary based on hormone receptor or Her2 status?
Atif Khan, Memorial Sloan Kettering Cancer Center
Added March 18, 2020
20 people found this helpful
15 people agreed with this answer
Agree with what has been posted here and copying the guidance we have issued to our breast doctors at MSKCC, where we are in the midst of the COVID-19 flare.
To improve capacity in the event of personnel shortages, we have divided patients into priority tiers.
Tier 1 (highest priority):
- Inflammatory breast cancer
- Residual node positivity after NAC
- Any patient with 4 or more positive nodes
- Extensive LVI
- Any node positive TNBC
- Any local-regional recurrence patient
Tier 2 (medium priority):
- N1a patients
- Path N0 after NAC
- LVI (NOS)
- Node negative TNBC
Tier 3 (low priority):
- DCIS
- Luminal A or B node negative patients
GENERAL PRINCIPLES FOR BREAST PATIENTS:
- Please omit radiotherapy in anyone who is a candidate for omission
- Low priority patient can be delayed by up to 20 weeks after lumpectomy without compromising control (Olivotto JCO 2009) (MAKE SURE THEY ARE ON ENDOCRINE THERAPY)
- Medium/High priority patients can be delayed by up to 8 weeks after surgery (many studies)
- Any patient eligible for APBI should receive APBI. CONSIDER SWITCHING APBI to 6 Gy x 5 (Livi schedule but modified to daily).
- FAST FORWARD: all whole breast patients eligible for this. For higher risk patients (ie Z11), may still be preferable to offer 16 fractions but this is evolving rapidly. Based on personal communication with C Coles and UK investigators, 5.2 x 5 should be okay for MOST patients. Stay below brachial plexus in your tangent plans. Do not use FAST FORWARD for nodes (yet). Boost with 1 fraction when boost indicated (5.2 x 1)
- Flat chest wall patients: PLEASE USE HYPOFRACTIONATED PMRT 16 fractions. Consider for recon patients on case by case basis (off trial).
- RNI in BCT patients: Okay to use hyofx schedule 16 fractions. Lumpectomy SIB: RTOG 1005 was 3.2 Gy x 15 fx. FOR OUR PURPOSES, USE 3 Gy x 16 fx.
Comments
Radiation Oncologist, Senior staff physician and Division Director Breast Services in the Department of Radiation Oncology, Academic Institution (Midwest)
March 19, 2020
We have developed similar recommendations for our breast patients here at the HFHS.
Wendy Woodward, University of Texas MD Anderson Cancer Center
Added March 17, 2020
4 people found this helpful
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Many centers on the leading edge of the COVID-19 curve are taking this action for luminal node negative patients based on the references posted already. Expect reduced workforce due to efforts to reserve and protect part of the workforce, workforce in quarantine, and the effect of school closings. Deferring patients now who can safely be deferred to maintain capacity for those for whom delay could have a detrimental impact is a practical decision. Consider omission and APBI for eligible patients as well. Consider scheduling the deferred simulation appointments so as not to lose these patients to follow up.
Matthew Katz, Radiation Oncology Associates PA
Added March 19, 2020
4 people found this helpful
3 people agreed with this answer
Some data suggest it's OK to start endocrine therapy and radiation can be delayed without detriment up to 20 weeks after surgery.
I feel comfortable given the current pandemic in delaying RT with endocrine therapy started now for luminal and DCIS.
Also seriously consider whether radiation is needed at all for low risk patients.
How will you prioritize new starts when the COVID-19 pandemic is over and you have a backlog of delayed patients and newly diagnosed patients to schedule?
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Debu Tripathy
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Sushil Beriwal
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This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this situation.
At the heart of this issue is the question of what are the risks of delaying adjuvant breast radiation and how do we weigh those risks against the risks of COVID-19 transmission to our patients and healthcare workers.
We have some literature to guide us on this question. A study of >6000 pts with T1-2 N0-1 breast CA (not getting chemo, ~85% N0, ~20% ER-,) from Canada showed that only intervals greater than 20 weeks (~5 months) from surgery impaired outcomes.
A similar study of 1107 patients from the Netherlands in N0 pts (~10% ER-) not getting chemo showed no difference going up to 112 days (~4 months). Data from 3 IBCSG trials (n=964, >90% N0, ~25% ER-, no chemo) also found no effect of RT delay <20 weeks (~5 months)
A SEER study
This study specifically in women ≥65 yo (n>18,000, ~7% N+, ~7% ER-), found an increased risk of LR after 6 weeks (HR 1.19). However, adjusted hazard rations for LR with varying thresholds, show the HR continuously increases with increasing time from surgery and thus using a strict 6 week cutoff may not be warranted by the data.
Taken together, there are at least 3 studies that show that in primarily favorable patients (ER+, N0), delays of 4-5 months do not compromise outcomes.
Given this, one could make an argument for delaying new starts for the most favorable breast CA patients (post-menopausal, ER+, N0) and in this scenario would start endocrine therapy for these patients prior to RT.
For the higher risk patients (node +, ER-, HER2+ not getting anti-Her2 therapy), the argument for delaying is less clear-cut, especially given the unknown duration of this pandemic and given that it will likely get worse before it gets better; though as stated above, this risk-assessment could change quickly.
There is also consideration of increasing use of hypofractionation and APBI where appropriate to minimize patient treatment visits. This may be a time to rely on the published data supporting hypofractionated PMRT and/or accelerated APBI in a broader group of patients to minimize our patients' treatment visits.