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Transcript of Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC...
![Page 1: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/1.jpg)
Radiation Therapy in Breast Cancer
MOTP Seminar January 2009
Jacqueline Spayne MD PhD FRCPC
Department of Radiation Oncology
Odette Cancer Centre
![Page 2: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/2.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 3: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/3.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
Breast conserving therapy
Post-mastectomy
Radiation target volumes
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 4: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/4.jpg)
Adjuvant radiation following
breast conserving surgery (BCS)
in early breast cancer (EBC)
• 6 (important) RCTs of mastectomy vs lumpectomy + XRT
– Equivalent OS and acceptable LC
![Page 5: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/5.jpg)
From CCO Guidelines, see:http://www.cancercare.on.ca/pdf/full1_2.pdf
![Page 6: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/6.jpg)
Adjuvant radiation following BCS in EBC
• 4 RCTs of Lumpectomy +/- XRT
![Page 7: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/7.jpg)
From CCO Guidelines, see:
http://www.cancercare.on.ca/pdf/full1_2.pdf
Adjuvant radiation following BCS in EBC
![Page 8: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/8.jpg)
Adjuvant radiation following BCS in EBC
Meta-analyses• EBCTCG Lancet 2000/Cochrane2002
- 40 trials – 1950s-1980s (inc some mastectomy)
- 10yr LRR reduced from 27% to 9%
- 5% absolute breast cancer mortality benefit
- No OS benefit with increased non-BC deaths
• Vinh-Hung JNCI 2004
- 15 trials (BCS only)
- IBT recurrence RR 3.00 with no RT
- 8.6% mortality benefit with RT
![Page 9: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/9.jpg)
Post-mastectomy RadiationRCTs of mastectomy +/- XRT
Danish premenopausal (Overgaard NEJM 97)
10y LRR 10y OS
CMF 32% 45%
CMF+RT 9% 54%
Danish post-menopausal (Overgaard Lancet 99)
10y LRR 10y OS
Tam 35% 36%
Tam+RT 8% 45%
![Page 10: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/10.jpg)
Post-mastectomy RadiationBC Trial – 20yr update (Ragaz JNCI 2005)
318 Premenopausal N+, CMF chemo
LRR-free Survival
![Page 11: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/11.jpg)
Postmastectomy RadiationBC Trial – 20yr update (Ragaz JNCI 2005)
318 Premenopausal N+, CMF chemo
Overall Survival
![Page 12: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/12.jpg)
Post-mastectomy Radiation Meta-analysis
EBCTCG Lancet 2005
![Page 13: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/13.jpg)
Post-mastectomy Radiation Meta-analysis Gebski et al JNCI 2006
![Page 14: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/14.jpg)
Post-mastectomy Radiation Meta-analysis Gebski et al JNCI 2006
![Page 15: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/15.jpg)
Post-mastectomy Radiation Indications
• Node positive
• T3, T4
• Other risk factors
– Grade 3
– +LVI
– Positive margins
![Page 16: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/16.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
Breast conserving therapy
Post-mastectomy
Radiation target volumes
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 17: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/17.jpg)
Adjuvant radiation in Breast Cancer
– Target Volumes• RT-geekspeak – GTV, CTV, PTV• Post BCS
– Breast, underlying chest wall
• Post-mastectomy– Chest wall
• N2 disease– Supra-clavicular fossa– ?Axilla, IMN
![Page 18: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/18.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
Breast conserving therapy
Post-mastectomy
Radiation target volumes
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 19: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/19.jpg)
Radiation in Breast Cancer - Toxicity• Breast tangents alone – RT well tolerated
• Acute - common
– Skin
– Fatigue
• Sub-acute – very rare
– Pneumonitis
• Late – very rare
– Lung
– Cardiac
– 2nd malignancies
• Except - Pigmentation, fibrosis, telangiectasia – up to 30% depends on technique
![Page 20: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/20.jpg)
Radiation in Breast Cancer - Toxicity
• Additional late toxicity of nodal irradiation
• Lymphedema
• BC trial – 9% vs 3%; Danish trials – 14% vs 3%
• Pneumonitis
• BC trial – 1 patient (0.6%)
• Impaired shoulder ROM
• Danish trials – 16% vs 2%
![Page 21: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/21.jpg)
Radiation in Breast Cancer - Toxicity• Additional late toxicity of nodal irradiation cont’d
• Asymptomatic lung fibrosis
• Danish trial – 60% vs ?0%
• Chronic pulmonary symptoms – ??
• Neurological
• Danish trial - paresthesia/hyperesthesia 21% vs 7%
• slight decreased strength – 14% vs 2%
![Page 22: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/22.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation for 1-3 LN+
• Radiation of IMC nodes
• 3 vs 4 field for supraclavicular fossa
• Patient selection after neo-adjuvant chemo
![Page 23: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/23.jpg)
Can adjuvant RT be omitted in some patients?
• Canadian trial (Fyles NEJM 2004)
769 pts, >50y, T1/2N0, clear margins, on Tam
5y LR 5yDFS 5y OS
All pts – no RT 7.7% 84% 93%
All pts - + RT 0.6%* 91%* 93% (NS)
T1 ER+ - no RT 5.9%
T1 ER+ - + RT 0.4%*
>60y, T</=1cm, ER+ - no RT 1.2% (Unplanned analysis)
>60y, T</=1cm, ER+ - +RT 0% NS
![Page 24: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/24.jpg)
Can adjuvant RT be omitted in some patients?
• CALGB C9343 (Hughes NEJM 2004)
636 pts, >70y, T1N0, clear margins, ER+, on Tamoxifen
5y LRR 5y OS
No RT 4% 86%
+RT 1%* 87%
![Page 25: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/25.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation for 1-3 LN+
• Radiation of IMC nodes
• 3 vs 4 field for supraclavicular fossa
• Patient selection after neo-adjuvant chemo
![Page 26: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/26.jpg)
Radiation Protocols
• Standard adjuvant treatment – 50Gy in 25 fractions
• Canadian hypofractionation trial (Whelan JNCI 2002)
4250/16 equivalent to 5000/25 to breast only in selected pts
• EORTC boost trial (Bartelink NEJM 2001)
50/25 50/25+16/8boost
LR all pts 7.3% 4.3%*
</=40y 19.5% 10.2%*
41-50 9.5% 5.8%*
>50 4.1% 3%NS
![Page 27: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/27.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation for 1-3 LN+
• Radiation of IMC nodes
• 3 vs 4 field for supraclavicular fossa
• Patient selection after neo-adjuvant chemo
![Page 28: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/28.jpg)
Partial Breast Radiation
• Techniques
– Intra-operative (Mammosite)– Catheter HDR– Seeds– External beam
• Short-term follow-up only• Remains experimental
![Page 29: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/29.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation for 1-3 LN+
• Nodal radiation fields
• Patient selection after neo-adjuvant chemo
![Page 30: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/30.jpg)
Nodal irradiation with 1-3 +ve nodes• Post-lumpectomy – no
– Consider if:
– <4-6 (?) nodes dissected
– Other bad prognostic features (eg large T, LVI, young, ECE)
– MA20 trial - closed
• Post-mastectomy
– Guidelines equivocal
– Meta-analysis supports chest-wall radiation for N1
![Page 31: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/31.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation for 1-3 LN+
• Nodal radiation fields
• Patient selection after neo-adjuvant chemo
![Page 32: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/32.jpg)
Nodal radiation fields• Radiation of IMC chains
– Most trials included IMC
– Practice variable
– Usually only include with IQ tumours and/or N+++
– Techniques variable – risk of increased toxicity
• Addition of posterior SC (deep axillary) field
– Inadequate axillary clearance
– ??ECE
– Toxicity risk
![Page 33: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/33.jpg)
Adjuvant RT in Breast Cancer - Controversies
• Omission of radiation in selected patients
• RT protocols - Fractionation & boost
• Partial breast radiation
• Nodal radiation
– Indications: N1 vs N2; post BCS vs post-mastectomy
– Target nodes: axilla, SCF, IMC
• Patient selection after neo-adjuvant chemo
![Page 34: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/34.jpg)
Adjuvant Radiation after Neoadjuvant Chemo
• No randomized data
• MDACC 6 neoadjuvant chemo trials
542 patients chemo, mast’y, + RTvs
134 patients chemo, mast’y, no RT
Huang et al JCO 2004
![Page 35: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/35.jpg)
Adjuvant Radiation after Neoadjuvant Chemo
Huang et al JCO 2004
![Page 36: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/36.jpg)
Adjuvant Radiation after Neoadjuvant ChemoCause-Specific Survival – Stage 3B
Huang et al JCO 2004
![Page 37: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/37.jpg)
Adjuvant Radiation after Neoadjuvant Chemo…….even after pCR
McGuire et al in press
![Page 38: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/38.jpg)
Adjuvant Radiation after Neoadjuvant Chemo…….even after pCR
McGuire et al in press
![Page 39: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/39.jpg)
Adjuvant Radiation after Neoadjuvant Chemo
• Policy
– All LABC patients offered adjuvant
radiation
– Chest wall + regional lymph nodes
![Page 40: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/40.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
Breast conserving therapy
Post-mastectomy
Radiation target volumes
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 41: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/41.jpg)
Salvage Radiation for Breast Cancer
• Can have dramatic responses
• Huang et al IJROBP 200238 inoperable patients after anthracycline
regimen
![Page 42: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/42.jpg)
Salvage Radiation for Breast Cancer
38 patients inoperable after chemo
Loco-regional radiation
32 had mastectomy
6 year follow-up5 LRR alone
21 distant mets3 both
9 disease free
Huang et al IJROBP 2002
![Page 43: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/43.jpg)
Neoadjuvant Radiation for Breast Cancer
• TRIAL– Neoadjuvant concurrent chemoradiation in LABC
![Page 44: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/44.jpg)
Radiation Treatment in Breast Cancer
• Adjuvant Radiotherapy
Breast conserving therapy
Post-mastectomy
Radiation target volumes
• Toxicities
• Controversies
• Salvage Radiation
• RT for recurrence & metastases
![Page 45: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/45.jpg)
Radiation for Recurrence & Metastases• Recurrence
– In-breast → mastectomy
– Chestwall → consider radiation
depends on previous treatment, time interval, prognosis, other treatment options etc
• Metastases
– Whole other topic!!!!
![Page 46: Radiation Therapy in Breast Cancer MOTP Seminar January 2009 Jacqueline Spayne MD PhD FRCPC Department of Radiation Oncology Odette Cancer Centre.](https://reader037.fdocuments.in/reader037/viewer/2022102923/551b36bd55034607418b6695/html5/thumbnails/46.jpg)
QUESTIONS……..