Hypofractionation for breast cancer

[Gfunk6]

So how extensively do you guys use hypofractionation for breast cancer? And, if you do use it, do you stick with Whelan (42.6 Gy in 16 fx) or START (41.6 Gy in 13 fx)?

When I was in training, we were quite restrictive in our use of Whelan hypofractionation and declined to use it in the following situations:

Age < 50
Anything other than luminal A receptor status (ER/PR+, HER2 -)
If pt was to undergo chemotherapy
Grade III disease
L breast cancer
Inclusion of SCV, axillary LNs, or IMNs
If boost was given

As an attending, I've become more inclusive and only restrict the use of Whelan hypofractionation in Grade III disease, if regional LNs are included, or if patient is getting chemo. For L sided cancers, I use an Active Breathing Coordinator with tight constraints on L lung and bilateral ventricles. If boost is required, I generally go for the standard 10 Gy in 5 fractions.

I'm curious if you are more or less inclusive in your own practices.

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[medgator]

So how extensively do you guys use hypofractionation for breast cancer? And, if you do use it, do you stick with Whelan (42.6 Gy in 16 fx) or START (41.6 Gy in 13 fx)?

When I was in training, we were quite restrictive in our use of Whelan hypofractionation and declined to use it in the following situations:

Age < 50
Anything other than luminal A receptor status (ER/PR+, HER2 -)
If pt was to undergo chemotherapy
Grade III disease
L breast cancer
Inclusion of SCV, axillary LNs, or IMNs
If boost was given

As an attending, I've become more inclusive and only restrict the use of Whelan hypofractionation in Grade III disease, if regional LNs are included, or if patient is getting chemo. For L sided cancers, I use an Active Breathing Coordinator with tight constraints on L lung and bilateral ventricles. If boost is required, I generally go for the standard 10 Gy in 5 fractions.

I'm curious if you are more or less inclusive in your own practices.

You're referring to the START A trial. I actually trained with using START B (40 Gy at 2.67/Fx) with or without a boost (10 Gy/5 Fx) depending on the patient. I think from a pure longevity of data standpoint, Whelan's trial has more long-term F/U than either START trial.

I stick with Whelan's criteria unless there are extenuating circumstances (like the pt will end up forgoing Tx altogether and isn't a candidate for APBI which I do offer in practice using the SAVI catheter). One area where I'm a bit more liberal is when it comes to DCIS

I recently had a 56 y.o F with G2 DCIS pt who had a number of co-morbidities (painful OA, debilitating MS) who had hoped for APBI but had too small of a lumpectomy cavity. She wasn't going to tolerate ~6 weeks of XRT. I treated her using hypoFx with a boost and felt somewhat comfortable doing it based on data from canada.

http://www.ncbi.nlm.nih.gov/pubmed/20400190
http://www.ncbi.nlm.nih.gov/pubmed/20803608

 

[Palex80]

I offer hypofractionation based on the START B trial (39.9 / 2.66) for node-negative, non G3 patients over the age of 60. I still have some concerns over long term cosmetic effects of hypofractionation, that's why I don't offer it to younger patients.
I don't offer hypofractionation, when the radiation therapy plan turns out with several hotspots in the breast, which can't be wedged out. So mainly patients with bigger breasts are excluded.

As far as boost is concerned, I give it also in hypofrationated manner (i know, that's not evidence based), 4-5 x 2.66 Gy.


So far, my (little) experience with short follow-up has been good. Not much of acute toxicity and no severe late toxicity so far.

 

[deleted4401]

The acute toxicity anecdotally seems to be less in my limited experience. I do it on patients that fit Whelan criteria. If patient needs a boost, I do standard fx. I was doing on DCIS, but my practice said since it wasn't delineated well by the Red Journal guidelines, I'd have to make a special consent for it, so I've stopped until guidelines and NCCN start recommending it.

In my opinion, there is no reason not to use it. It works. Follow up is good. It's cheaper. Both START and Canadian are legitimate. Boost is up to doc, and it makes sense to do it in this case, I just don't...

 

[OTN]

I don't use hypofractionation much.

In my experience the cosmetic outcome with hypofractionation has been inferior to standard fractionation, with greater retraction of the treated breast.

 

[medgator]

I don't use hypofractionation much.

In my experience the cosmetic outcome with hypofractionation has been inferior to standard fractionation, with greater retraction of the treated breast.

The results of START B suggests the opposite

http://www.ncbi.nlm.nih.gov/pubmed/18355913

 

[Gfunk6]

The results of START B suggests the opposite

http://www.ncbi.nlm.nih.gov/pubmed/18355913

No difference in cosmesis after 10 year follow-up on Whelan's trial.

 

[deleted4401]

2 years of experience not enough to judge cosmesis for me but evidence suggests good outcomes. Gotta be really tough on constraints, max dose of 105% I think, which is tough to obtain.

 

[OTN]

2 years of experience not enough to judge cosmesis for me but evidence suggests good outcomes. Gotta be really tough on constraints, max dose of 105% I think, which is tough to obtain.

THIS I think is the biggest issue. With the size of most of my patients here in Texas, trying to dose adequately while keeping these constraints isn't easy.

 

[seper]

when you guys evaluate Dmax on Whelan protcol (must be <107%), do you use the maximum point dose, dose to 1 cc, 2 cc or something else?

 

[Gfunk6]

when you guys evaluate Dmax on Whelan protcol (must be <107%), do you use the maximum point dose, dose to 1 cc, 2 cc or something else?

Generally I use dose to 1 cc.

 

[deleted4401]

Point dose for max, not sure what Whelan suggested

 

[RadRadRad]

ASTRO white paper has recs. think they say something like no 107% at central axis, but then go on to recommend that 3D planning be done.

 

[seper]

thanks
I found that max point dose < 107% is very difficult to achieve.
Hotspot is usually not at the central axis.