San Antonio Breast Cancer Symposium - ANCO On-Line · San Antonio Breast Cancer Symposium-Radiation...
Transcript of San Antonio Breast Cancer Symposium - ANCO On-Line · San Antonio Breast Cancer Symposium-Radiation...
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SanAntonioBreastCancerSymposium
-RadiationTherapyUpdates-
TracySherertz,MDUCSFRadiationOncology
RadiotherapyAbstracts
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Impactofradiotherapyoncomplicationsandpatient-reportedsatisfactionwithbreastreconstruction:Findingsfromthe
prospectivemulticenterMROCstudy
*OralPresentation*
Jagsi R,Momoh AO,QiJ,HamillJB,Billig J,KimHM,Pusic AL,WilkinsEGUniversityofMichigan,AnnArbor,MI;MemorialSloanKetteringCancer
Center,NewYork,NY
ImpactofRTonReconstructionOutcomes
• Prospective,multicentercohortstudy(MastectomyReconstructionOutcomesConsortium,MROC,fundedbyNCI)
• 11institutions,2012-15• Responsesfrom553radiatedand1461non-radiatedpts whoreceived
differentapproachestoreconstruction
• Primaryvariablesofinterestwere– developmentofanybreastcomplications(e.g.hematoma,woundinfection)
byoneyearpost-reconstruction– satisfactionmeasuredwiththevalidatedBREAST-Qinstrument.
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ImpactofRTonReconstructionOutcomes
• Mixed-effectsregressionmodelsassessedimpactofreconstructiontypeandRTontheoutcomesofinterest
• Covariateadjustmentincluded:• reconstructiontiming• age• extentofdisease• bilateralvs unilateraltreatment• chemotherapyreceipt• nodalmanagement• BMI• smoking
Jagsi etalSABCS2016
• diabetes• race• ethnicity• education• employment• income• maritalstatus• hospitalsite
• Medianage:49
• Bilateralmastectomyreceivedby45.6%ofradiatedand53.3%ofnon-radiatedpts (p=0.002)
• Autologousreconstructionmorecommonlyreceivedbyradiatedpts (38.3%vs25.1%,p<0.001)
• Immediatereconstructionwaslesscommoninradiatedpts (82.6%vs 95.6%,p<0.001)
• Byoneyear,atleastonecomplicationoccurredin– 28.8%ofradiatedpts (30.8%ofimplantpts and25.5%ofautologouspts)– 22.3%ofnon-radiatedpts (20.4%ofimplantpts and28.1%ofautologouspts)
• At2yrs,acomplicationhadoccurredin34.1%of331radiatedpts vs 22.5%of946non-radiatedpts
ImpactofRTonReconstructionOutcomes:Results
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• Onmultivariableanalysis,predictorsofcomplicationsat1year:– immediatereconstruction– bilateraltreatment– higherBMI
• RTeffectdifferedbyreconstructiontype– RTwasassociatedwith2.1(95%CI=1.45,3.10)timeshigheroddsof
complicationinimplantpts– Nodifferenceinautologouspts (OR=1.3,95%CI=0.76,2.09)
ImpactofRTonReconstructionOutcomes:Results
Jagsi etalSABCS2016
• RTeffectonpatientoutcomesalsodifferedbyreconstructiontypes
• Inimplant pts,adjustedmeanBREAST-Qsatisfactionwithbreastscoresweresignificantlylowerinradiatedpts thaninnon-radiatedpts (51.5vs.58.0at1year,p<.001;48.9vs.59.8at2years,p<.001)
• Whilesatisfactioninautologous pts didnotdifferbyradiation(61.3inradiatedvs.63.5innon-radiatedat1year;62.8vs.65.8at2years)
ImpactofRTonReconstructionOutcomes:Results
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• Conclusions:– Inthelargestprospectivemulticenterstudyofoutcomesofbreastreconstructionto
date,autologousreconstructionappearstoyieldsuperiorpatient-reportedoutcomesandlowerriskofcomplicationsthanimplant-basedapproachesamongpatientsreceivingPMRT
• Validatescommonperceptionthatpatientsatisfactionisimprovedwithautologousvs implant-basedreconstruction
ImpactofRTonReconstructionOutcomes
Jagsi etalSABCS2016
AretherepatientswithT1-T2,node-negativebreastcancerwhoareathighriskforlocoregional recurrence?
Mamtani A,Patil S,Stempel M,MorrowMBreastService,MemorialSloanKetteringCancerCenter,NewYork,NY
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T1-T2N0patientsathighriskforlocoregional recurrence?
• Indicationsforpost-mastectomyradiotherapy(PMRT)inT1-T2,nodenegative(N0)breastcancerpts with“high-risk”featuresarecontroversialbasedonlackofconsensusastowhatconstitutes“high-risk”,andvariableresultsofsmallretrospectivestudies
• EORTC22922andMA20trialsreportedimproved10-yeardisease-freesurvivalwithnodalirradiationincludedhigh-riskN0patientsbutthesepatientswerenotanalyzedseparatelyanddidnotreceivemodernsystemictherapy
• Question:Whatisthelong-termlocoregional controlinT1-T2N0patientswithhigh-riskfeaturesundergoingmastectomyinthecontemporaryera?
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T1-T2N0patientsathighriskforlocoregional recurrence?
• Methods:Retrospectivelyreviewedpts withT1-T2N0breastcancerwith≥1high-riskfeaturetreatedwithmastectomyfrom2006-2011– High-riskfeaturesweredefinedas
• age<40years• multifocal/multicentric disease• lymphovascular invasion(LVI)• medialorcentraltumorlocation
• PrimaryoutcomeofinterestwasLRR
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T1-T2N0patientsathighriskforlocoregional recurrence?
• 672pts– 187(28%)had1riskfactor:
• 21(3%)wereage<40years• 132(20%)weremultifocal/multicentric• 34(5%)hadLVI
– 449(67%)patientshad≥2high-riskfeatures
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-PMRTwasreceivedby15(2%)pts(excluded)
T1-T2N0patientsathighriskforlocoregional recurrence?
• SLNbx alonein98%pts• Median4LNsretrieved(range1-15).• Adjuvantsystemictherapyreceivedby86%pts• Medianf/u5.6years
– LRRratewas4.7%(n=31)– Majority(55%)ofeventsinvolvingthechestwall– IncreasingtumorsizewasassociatedwithLRR(HR1.70,95%CI1.26–2.29,p=0.006)– Age,histology,grade,subtype,LVI,multifocality/multicentricity,andtumorlocation
werenot(allp>0.05)
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-AlthoughLRRincreasedfrom3.8% to9.4%with1vs.≥4high-riskfeatures,acomparisonof1vs.2vs.3vs.≥4riskfactorswasnotsignificantbyKaplan-Meierestimation(p=0.54).
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T1-T2N0patientsathighriskforlocoregional recurrence?
• Conclusions:– AlowLRRrateof4.7%wasseeninthislargeunselectedcohortofT1-T2N0
cancerswith"high-risk"featurestreatedbymastectomyandsystemictherapywithoutPMRT
– Whileincreasingtumorsizewaspredictive,otherfeaturesdidnotconferahigherriskofLRReitherindependentlyortogether,anddonotbythemselvesmandatetheuseofPMRTinthispopulation.
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Hypofractionated nodalradiotherapy(RT)didnotincreasearmmorbiditycomparedtoconventionalfractionatednodalRT
LeongN,TruongP,Tankel K,KwanW,WeirL,Olivotto ISaskatchewanCancerAgencyAllanBlairCancerCentre,Regina,SK,Canada;BCCancerAgencyVancouverIslandCentre,Victoria,BC,Canada;AlbertaHealthServicesTomBakerCancerCentre,
Calgary,AB,Canada;BCCancerAgencyFraserValleyCentre,Surrey,BC,Canada;BCCancerAgencyVancouverCentre,Vancouver,BC,Canada;AlbertaHealthServices
CrossCancerInstitute,Edmonton,AB,Canada
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Hypofractionated RNI
• Regionalnodalirradiationcancontributetoadversearmsymptomsandlymphedema
• Hypofractionation (HF),definedas>2Gy/fraction,improvesconveniencebutwhetheritincreasesarmmorbidityisunclear
• Canadianstudyevaluatespatient-reportedarmsymptomsinwomentreatedwithHFcomparedtoconventionalfractionation(CF)RT(definedas≤2Gy/fraction)
LeongetalSABCS2016
Hypofractionated RNI
• Pts whoreceived3DCTnodalRTforpT1-3pN0-2M0breastcancerfrom2007-2009inBritishColumbiaand2008– 2010inAlberta,Canada
• Patientsmailedanexplanationletterandanexternallyvalidated,Self-reportedArmSymptomScale(SASS)survey
• TheSASSincluded8questionsaboutarmsymptoms,withresponsesona5-pointLikert scaleregardingarm/handproblems(numbness,pain,stiffness,immobilityandswelling),and5questionsrelatedtoactivitiesofdailyliving(ADL)
• Clinicopathologic characteristicsandSASSscoreswerecomparedbetweenHFvs.CFnodalRTcohorts
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Hypofractionated RNI
• 708pts (non-metastatic,non-recurrent)• 406(57%)patientsreceivedHFRT- 40Gy/15fx and45Gy/20fx• 302(43%)receivedCFRT- 45Gy/25fx,48-50Gy/25fx,and50.4Gy/28fx• Boostdeliveredin22%ofsubjectsinbothgroups• MediantimeintervalsinceRTcompletion:5.67years• Meanageatdiagnosis:59.0inHFvs 53.8yearsinCF cohorts(p<0.001)• Mean#positive(n=3)andexcised(n=12)LNssimilarbetweencohorts(p=0.44)• PrimarytumorsizewasmarginallylargerintheCFgroup(2.8vs.2.7cm,p=0.03)• 42.9%ofpatientsweretreatedwithpartialmastectomywithnosignificant
differenceinfractionation(p=0.54)• Overall,602(75.3%)patientsreceivedchemotherapy• AtrendtowardincreaseduseofCFafterchemotherapywasobserved(78.8%vs.
72.7%,p=0.07)
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Hypofractionated RNI
• Results:– CFgrouphadahigherprevalenceofself-reportedsymptoms,includingshoulder
stiffness(p=0.04),troublemovingthearm(p=0.02),andabilitytoreachoverhead(p<0.01)
– Nodifferenceinself-reportedarmswellingbetweenthetwogroups(p=0.57)
• Conclusions:– Hypofractionated nodalRTwasnotassociatedwithanincreaseinpatient-reportedarm
symptomsordisabilitycomparedtoconventionalfractionatednodalRT.– SubjectstreatedwithCFRTreportedmoredisabilityincertainaspectsofarmand
shoulderfunction– Thesedatasupporttheuseofshorterfractionationwhentheregionallymphnodesare
partofthetherapeutictarget
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Theuseofhypofractionated radiotherapyforthetreatmentofwomenwithearlybreastcancerintheBrazilianpublichealthsystemmayincreaseaccesstotreatment:Costeffectiveness
andbudgetimpactanalyses
AndradeTRdM,Nazário ACP,FonsecaMCMFederalUniversityofSãoPaulo,SãoPaulo,Brazil
Costeffectivenessofhypofractionated RTinBrazil
• OBJECTIVES:– Toevaluatethecosteffectivenessandeconomicimpactofincreasingtheuseofhypofractionated RTforthe
treatmentofwomenolderthan50years,withearlybreastcancer(stagesIandII)withintheBrazilianNationalHealthSystem(SUS)
• METHODS:– Authorsbuilta‘cost-effectiveness’MarkovmodelinExcelwhichquantifiesthecostandtheamountof
photonbeamslinearacceleratortimeusedforthetreatmentofpatientsusinghypofractionated(2.67Gy/fraction)orconventional(2Gy/fraction) over5yr period
• Effectivenessmeasuredas#hourssavedusinghypofractionated vs conventionalRT– CostsconsideredincludedRTplanning,physicsQA,andtheuseoflinearaccelerator
• Authorsdeterminedthe#ofwomen>50yo withStage1-2breastCAtreatedwithadjuvantRTin2013and2014,andthenprojectedthesepopulationsto2016to2020.
• Authorsconsideredayearlyincreaseof20%intheadoptionofhypofractionated RTfortheyears2016to2019(201620%;201740%;201860%;201980%and202090%)
• Thetreatmentfractiontimewassetas15minutes
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Costeffectivenessofhypofractionated RTinBrazil
• RESULTS:– Useofhypofractionated RTat5yearswasabletodecreasethenumberofhoursof
treatment(-21,835hours)andthetotalcostoftreatment(-$11,790,229.64)
• Annualincrementalimpactwouldbeof-$243,202.65,-$490,294.13,-$741,085.61,-$995,388.73and-$1,127,712.81providing3,378,6.810,10,294,13,826and15,664freehoursofthelinearacceleratorfortheyears2016,2017,2018,2019and2020,respectively
• The“linac-free”hoursmayallow613,1,380,2,306,3,392and4,010additionalpatientstohaveaccesstobreastCAtreatmentduring2016to2020respectively.
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Costeffectivenessofhypofractionated RTinBrazil
• CONCLUSIONS:– Consideringtheconditionsproposedinthismodel,increasinguseof
hypofractionation totreatwomenolderthan50yearsisexpectedtoincreasethesystemefficiency,savemoneyandimproveaccesstotreatmentformorepatients
Manyhealthcaresystemsinterestedintheseanalysestoencouragepolicychange
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OngoingRadiotherapyTrials
NRGoncology/NSABPB-51/RTOG1304:AphaseIIIsuperiorityclinicaltrialdesignedtodetermineifchestwallandregionalnodalradiotherapy(CWRNRT)post
mastectomy(Mx)ortheadditionofRNRTtobreastRTpostbreast-conservingsurgery(BCS)willreduceinvasivecancereventsinpatients(pts)withpositiveaxillary(Ax)nodesandconverttoypN0afterneoadjuvant chemotherapy(NC)
Mamounas EP,Bandos H,WhiteJR,JulianTB,KhanAJ,Shaitelman SF,TorresMA,Vicini FA,Ganz PA,McCloskeySA,PaikS,GuptaN,LiXA,DiCostanzoDJ,Curran,Jr WJ,Wolmark NNRGOncology/NSABP(NSABPLegacyTrialsAreNowPartoftheNRGOncologyPortfolio),Pittsburgh,PA;UFHealth
CancerCenteratOrlandoHealth,Orlando,FL;UniversityofPittsburgh,Pittsburgh,PA;NRGOncology/RTOG,Philadelphia,PA;OhioStateUniversity,Columbus,OH;AlleghenyHealthNetworkCancerInstitute,Pittsburgh,PA;RutgersCancerInstituteofNewJersey,NewBrunswick,NJ;UniversityofTexasMDAndersonCancerCenter,Houston,TX;Winship CancerInstituteEmoryUniversity,Atlanta,GA;St.JosephMercyOakland,Pontiac,MI;
UniversityofCaliforniaatLosAngeles,LosAngeles,CA;SeveranceBiomedicalSci Inst andYonsei Univ CollegeofMedicine,Seoul,Korea;MedicalCollegeofWisconsin,Milwaukee,WI;TheOhioStateUniversityWexner MedicalCenter,Columbus,OH
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• DecisionsontheuseofRNIaregenerallybasedonthepathologicalnodalstatusatthetimeofsurgicalstaging
• Neoadjuvant chemohasbeenshowntodown-sizelargeprimarytumorsanddown-stageinvolvedaxillarynodes
NSABP51
• Severalrandomizedandnon-randomizedstudieshaveshownthatachievingapathCRinthebreastandLNsleadstoimprovedlocalregionalcontrol
[datafromNSABP18and27]
• PhaseIIIrandomizedpost-neoadjuvant chemotherapytrialevaluatesifCWRNRTpostMx orwholebreastirradiation(WBI)withRNRTafterBCSsignificantlyreducestheinvasivebreastcancerrecurrence-freeinterval(IBC-RFI)rateinptspresentingwithpositiveAxnodesthatarepathologicallynegativeafterNC.– SecondaryaimsareOS,LRRFI,DRFI,andsecondprimarycancer,aswellas
comparingRTeffectoncosmesis inreconstructedMx pts.
• CorrelativesciencestudiesexamineRTeffectbytumorsubtype,molecularoutcomepredictorsforresidualdiseasepts,andpredictorsforthedegreeofreductioninloco-regionalrecurrence.
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NSABP51
• 1636pts tobeenrolledover5yrs withdefinitiveanalysisat7.5yr
• Accrualasof6/13/16is356
Arandomizedtrialof15fractionvs 25fractionpencilbeamscanningprotonradiotherapyaftermastectomyinpatients
requiringregionalnodalirradiation
MutterRW,ParkSS,Hieken TJ,VargasCE,Mei-YinPC,KathrynRJ,HectorVR,KimberlyCS,ElizabethYS,DanielVWMayoClinic,Rochester,MN
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Hypofractionated ProtonPMRT
• Background:– Pencilbeamscanningprotontherapyisattractiveduetopotentialtoreducethedosetotheheartandlungscomparedwithtraditionalphotontechniqueswhileimprovingconformality andlimitingskindosecomparedwithpassivelyscannedprotontherapy
– Theoptimaldoseandfractionationforpencil-beamscanningprotontherapyremainsunknown
Hypofractionated ProtonPMRT
• TrialDesign:– multi-centeropenlabelphaseIIrandomizedcontrolledtrialto
determinethesafetyof15fractionvs 25fractionpencilbeamscanningprotonradiotherapyaftermastectomyinpatientsrequiringRNI
– Patients≥18yearswithprimary,non-inflammatoryinvasivebreastcancerwhohaveundergonemastectomywithorwithoutimmediatereconstructionandchestwallandregionalnodalirradiationplanned
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Hypofractionated ProtonPMRT
• Aims:– Determinewhetherthe24monthcomplicationrate(definedasgrade3or
greaterlateadverseevents,andunplannedsurgicalinterventioninpatientswhoundergomastectomywithreconstruction)of15fractionchestwallandregionalnodepencilbeamscanningprotonradiotherapyisacceptablerelativetoa25fractionregimen
• Statisticalmethods:Thestudyisdesignedasanon-inferiority/superioritydesign
• Accrual:ThestudyopenedinJune2016.Fiveofaplannedeighty-twopatientshavebeenaccruedtodate
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