Omission of adjuvant radiotherapy for older adults with early-stage breast cancer particularly in the COVID era: A literature review (on the behalf of Italian Association of Radiotherapy and Clinical Oncology)

Abstract

This review is aimed at evaluating whether radiation therapy (RT) can be omitted in older adult early-stage lowrisk breast cancer (BC) patients. The published data are particularly relevant at present, during the COVID-19 pandemic emergency, to define a treatment strategy and to prioritize essential therapy. Cochrane Database of Systematic Reviews and PubMED were systematically researched from outset through April 2020 using Mesh terms. Only randomized controlled trials (RCT), with one arm without adjuvant wholebreast irradiation (WBI), were included in the analysis. Recent literature regarding the COVID pandemic and BC RT was assessed. The reported RCTs identified a group of BC patients (pT1-2N0M0 R0, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative tumours) in which the absolute risk of local recurrence (LR) was considered low enough to omit RT. The most common risk factors were tumor diameter, nodal and receptor status. Adjuvant RT had a significant impact on LR but not on distant metastasis (DM) or death. During the COVID 19 pandemic, results from RTCs were re-considered to define treatment recommendations for BC patients. International scientific societies and radiation oncology experts suggested RT omission, whenever possible, in older adult early-stage BC patients. Adjuvant RT might be omitted in a highly selected group of older adult early-stage BC patients with favourable prognostic factors. Hypofractionated regimens should be the standard. RT omission, partial breast irradiation (PBI), and ultra-hypofractionated regimens could be considered in selected cases due to the pandemic.

Covid-19 and radiotherapy: a systematic review after 2 years of pandemic

“…HFRT should be the standard of care. Partial breast irradiation and ultra- HFRT regimens could be considered in selected cases due to the pandemic [ 117 , 119 ].…”

“…Adjuvant RT might be omitted in a highly selected group of older adult early-stage breast cancer patients with favorable prognostic factors [ 117 ].…”

Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer

“…Ultimately, the actively evolving scientific understanding of breast cancer biology is driving clinical trials that are providing radiation oncologists and women with breast cancer with the information they need to make personalized choices that both protect them from recurrences and from unwarranted treatment morbidity. In view of the evolving evidence, therapeutic strategies incorporating tumor and patient characteristics, as well as patient preferences, should be discussed in a multidisciplinary tumor board to tailor the treatment for the patient [10].…”

“…This need has prompted re-consideration of radiotherapy indications and has initiated investigations to identify any subset of low-risk women with such a negligible burden of residual locoregional disease risk following breast-conserving surgery who could be safely spared radiation therapy. In particular, much attention has been focused lately on elderly early-stage breast cancer patients with favorable prognostic factors [10].…”

Impact of COVID-19 on care of older adults with cancer: a narrative synthesis of reviews, guidelines and recommendations

“…However, the authors found no association between anticancer treatment and COVID-19, noting that adverse COVID-19 outcomes and increased mortality were associated with older adults with cancer regardless of their treatment status. Possible omission of radiotherapy was suggested by Palumbo et al [20] in select older adults with early-stage breast cancer. These authors also suggest that given the high risk for older adults with cancer, risk and benefit must be carefully weighed and suggest that delay or reduction in visits to healthcare centres may be a reasonable approach.…”