Hypofractionated radiation therapy for breast cancer: Preferences amongst radiation oncologists in Europe – Results from an international survey

Abstract

Background and purpose: We aimed to assess the prescription preference about hypofractionated radiation therapy (HFRT) for breast cancer (BC) patients amongst radiation oncologists (ROs) practicing in Europe and to identify restraints on HFRT utilisation. Materials and methods: An online survey was circulated amongst ROs in Europe through personal, RO and BC societies' networks, from October 2019 to March 2020. The statistical analyses included descriptive statistics, chi-squared testing, and logistic regression analysis. Results: We received 412 responses from 44 countries. HFRT was chosen as the preferred schedule for whole breast irradiation (WBI) by 54.7% and for WBI with regional nodes irradiation (RNI) by 28.7% of the responding ROs. In the case of postmastectomy RT with or without reconstruction, HFRT was preferred by 21.1% and 29.6%, respectively. Overall, 69.2% of the responding ROs selected at least one factor influencing the decision to utilise HFRT, the most frequent of which included age (51.4%), RNI (46.9%), internal mammary lymph nodes irradiation (39.7%), BC stage (33.5%) and implant-based breast reconstruction (31.6%). ROs working in academic centres (odds ratio, (OR), 1.7; 95% confidence interval, (CI); 1.1-2.6, p = 0.019), practicing in Western Europe (OR, 4.2; 95%CI; 2.7-6.6, p < 0.0005) and/or dedicating >50% of clinical time to BC patients (OR, 2.5; 95%CI; 1.5-4.2, p = 0.001) more likely preferred HFRT. Conclusion: Although HFRT is recognised as a new standard, its implementation in routine RT clinical practice across Europe varies for numerous reasons. Better dissemination of evidence-based recommendations is advised to improve the level of awareness about this clinical indication.

Impact of guideline changes on adoption of hypofractionation and breast cancer patient characteristics in the randomized controlled HYPOSIB trial

“…However, the degree of adoption depended on the studied timeframe and patient characteristics. Two clinical publications and one recent European survey that studied the impact of treatment setting (academic/hospital-associated vs. non-academic/free-standing practice) confirm our finding that adoption is more pronounced at academic facilities [ 16 , 17 , 19 ]. Interestingly, there was no visible impact of chemotherapy use on the choice of HF seq , despite other data suggesting that the adoption of hypofractionation is slower in this subgroup [ 16 ].…”

“…Major points of concern voiced by participants were increased side effects, an impaired toxicity profile, and insufficient data, which stands in stark contrast to the published literature [ 22 ]. Lower reimbursement rates may further hamper implementation of hypofractionated radiotherapy for breast cancer, as stated by 19.9% of participants in the mentioned survey [ 21 ] as well as by 9.2% of participants in a recent European survey [ 19 ]. It is interesting to note that in our analysis, NF SIB was the most commonly used fractionation regimen in the standard arm despite the relatively low quality of evidence from mostly dosimetric and cohort studies [ 23 – 29 ].…”

Selection criteria for early breast cancer patients in the DBCG proton trial – The randomised phase III trial strategy

“…To ease the use of the patient selection criteria in daily clinical practice, the DBCG Radiotherapy Committee decided to choose integer numbers as dose thresholds that were independent of 40 Gy in 15 fractions or 50 Gy in 25 fractions [34] . This implies that the 4 Gy mean heart dose threshold is 10% of prescription dose for 40 Gy treatments and 8% of prescription dose for 50 Gy treatments.…”

Mobilising stakeholders to improve access to state-of-the-art radiotherapy in low- and middle-income countries

“…The reduced overall time spent in the clinic effectively protects oncology patients and radiotherapy staff from infection. It has been shown in various studies that the hypofractionated treatment outcomes are comparable to the conventional fractionated schemes with isoeffective sparing of healthy tissues [ 35 ]. All these improvements can be introduced in the African/LMIC context without undermining the importance of the precision in the treatment delivery.…”