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Radiation De-Escalation in Older Women with Early-Stage ER+/HER2- Invasive Breast Cancer
Ton Wang1,2, Drew Neish3, Samantha Thomas3,4
1Department of Surgery, Duke University Medical Center, Durham, NC, USA. ton.wang@duke.edu.
Background:
National recommendations since 2004 have allowed for omission of post-lumpectomy radiotherapy for patients ≥70 years old with early-stage estrogen receptor positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer. Rates of omission in the era of abbreviated radiotherapy regimens are unknown. This study aimed (1) to determine contemporary trends in post-lumpectomy radiotherapy omission, (2) to determine trends in use of partial-breast (PB), ultra-hypofractionated (UHF), moderately hypofractionated (MHF), and conventionally fractionated (CF) radiotherapy regimens, and (3) to identify targetable factors to de-escalate radiotherapy in patients eligible for omission.
Methods:
A retrospective cohort analysis was performed using the National Cancer Database. The study identified patients ≥70 years old with pT1, cN0 pNX-0, cM0 ER+/HER2- breast cancer who underwent lumpectomy from 2012 to 2021. Radiotherapy treatment strategies based on number of fractions received were evaluated and compared using multivariable analysis.
Results:
The study included 121,160 patients: 51.0 % with no radiotherapy, 8.4 % with PB, 4.1 % with UHF, 30.2 % with MHF, and 6.3 % with CF radiotherapy. Radiotherapy omission decreased from 53.7 % to 46.8 % between 2012 and 2021. Whereas MHF radiotherapy doubled from 16.4 % to 32.9 %, CF radiotherapy decreased from 17.1 % to 2.0 %. A minority of patients received PB or UHF radiotherapy, although the rate of UHF increased from 4.6 % to 7.7 % between 2020 and 2021. Treatment at academic/research or Integrated Network Cancer Program facilities and higher-volume hospitals was associated with increased likelihood of treatment with abbreviated radiotherapy regimens.
Conclusions:
Despite efforts to promote treatment de-escalation, rates for omission of post-lumpectomy radiotherapy have decreased over time. To avoid overtreatment, patients who are eligible for omission but opt to receive radiotherapy should be considered for PB or UHF radiotherapy regimens.
