Cargando…

Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts

Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday...

Descripción completa

Detalles Bibliográficos
Autores principales: Vijayakumar, Srinivasan, Nittala, Mary R, Buddala, Vedanth, Mobit, Paul, Duggar, William N, Yang, Claus Chunli, Lirette, Seth T, Mundra, Eswar, Ahmed, Hiba Z, Berry, Scott M, Craft, Barbara S, Woods, William C, Otts, Jeremy, Rahimi, Asal, Dobbs, Thomas
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10072193/
https://www.ncbi.nlm.nih.gov/pubmed/37025715
http://dx.doi.org/10.7759/cureus.36432
_version_ 1785019331958013952
author Vijayakumar, Srinivasan
Nittala, Mary R
Buddala, Vedanth
Mobit, Paul
Duggar, William N
Yang, Claus Chunli
Lirette, Seth T
Mundra, Eswar
Ahmed, Hiba Z
Berry, Scott M
Craft, Barbara S
Woods, William C
Otts, Jeremy
Rahimi, Asal
Dobbs, Thomas
author_facet Vijayakumar, Srinivasan
Nittala, Mary R
Buddala, Vedanth
Mobit, Paul
Duggar, William N
Yang, Claus Chunli
Lirette, Seth T
Mundra, Eswar
Ahmed, Hiba Z
Berry, Scott M
Craft, Barbara S
Woods, William C
Otts, Jeremy
Rahimi, Asal
Dobbs, Thomas
author_sort Vijayakumar, Srinivasan
collection PubMed
description Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday through Friday external beam RT to the whole breast (WBRT). Recent clinical trials have shown that partial breast radiation therapy (PBRT) to the region surrounding the lumpectomy cavity with shorter courses can result in equal local control, survival, and slightly improved cosmetic outcomes. Intraoperative RT (IORT) wherein RT is administered at the time of operation for BCT to the lumpectomy cavity as a single-fraction RT is also considered PBRT. The advantage of IORT is that weeks of RT are avoided. However, the role of IORT as part of BCT has been controversial. The extreme views go from “I will not recommend to anyone” to “I can recommend to all early-stage favorable patients.” These divergent views are due to difficulty in interpreting the clinical trial results. There are two modalities of delivering IORT, namely, the use of low-energy 50 kV beams or electron beams. There are several retrospective, prospective, and two randomized clinical trials comparing IORT versus WBRT. Yet, the opinions are divided. In this paper, we try to bring clarity and consensus from a highly broad-based multidisciplinary team approach. The multidisciplinary team included breast surgeons, radiation oncologists, medical physicists, biostatisticians, public health experts, nurse practitioners, and medical oncologists. We show that there is a need to more carefully interpret and differentiate the data based on electron versus low-dose X-ray modalities; the randomized study results have to be extremely carefully dissected from biostatistical points of view; the importance of the involvement of patients and families in the decision making in a very transparent and informed manner needs to be emphasized; and the compromise some women may be willing to accept between 2-4% potential increase in local recurrence (as interpreted by some of the investigators in IORT randomized studies) versus mastectomy. We conclude that, ultimately, the choice should be that of women with detailed facts of the pros and cons of all options being presented to them from the angle of patient/family-focused care. Although the guidelines of various professional societies can be helpful, they are only guidelines. The participation of women in IORT clinical trials is still needed, and as genome-based and omics-based fine-tuning of prognostic fingerprints evolve, the current guidelines need to be revisited. Finally, the use of IORT can help rural, socioeconomically, and infrastructure-deprived populations and geographic regions as the convenience of single-fraction RT and the possibility of breast preservation are likely to encourage more women to choose BCT than mastectomy. This option can also likely lead to more women choosing to get screened for breast cancer, thus enabling the diagnosis of breast cancer at an earlier stage and improving the survival outcomes.
format Online
Article
Text
id pubmed-10072193
institution National Center for Biotechnology Information
language English
publishDate 2023
publisher Cureus
record_format MEDLINE/PubMed
spelling pubmed-100721932023-04-05 Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts Vijayakumar, Srinivasan Nittala, Mary R Buddala, Vedanth Mobit, Paul Duggar, William N Yang, Claus Chunli Lirette, Seth T Mundra, Eswar Ahmed, Hiba Z Berry, Scott M Craft, Barbara S Woods, William C Otts, Jeremy Rahimi, Asal Dobbs, Thomas Cureus Radiation Oncology Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday through Friday external beam RT to the whole breast (WBRT). Recent clinical trials have shown that partial breast radiation therapy (PBRT) to the region surrounding the lumpectomy cavity with shorter courses can result in equal local control, survival, and slightly improved cosmetic outcomes. Intraoperative RT (IORT) wherein RT is administered at the time of operation for BCT to the lumpectomy cavity as a single-fraction RT is also considered PBRT. The advantage of IORT is that weeks of RT are avoided. However, the role of IORT as part of BCT has been controversial. The extreme views go from “I will not recommend to anyone” to “I can recommend to all early-stage favorable patients.” These divergent views are due to difficulty in interpreting the clinical trial results. There are two modalities of delivering IORT, namely, the use of low-energy 50 kV beams or electron beams. There are several retrospective, prospective, and two randomized clinical trials comparing IORT versus WBRT. Yet, the opinions are divided. In this paper, we try to bring clarity and consensus from a highly broad-based multidisciplinary team approach. The multidisciplinary team included breast surgeons, radiation oncologists, medical physicists, biostatisticians, public health experts, nurse practitioners, and medical oncologists. We show that there is a need to more carefully interpret and differentiate the data based on electron versus low-dose X-ray modalities; the randomized study results have to be extremely carefully dissected from biostatistical points of view; the importance of the involvement of patients and families in the decision making in a very transparent and informed manner needs to be emphasized; and the compromise some women may be willing to accept between 2-4% potential increase in local recurrence (as interpreted by some of the investigators in IORT randomized studies) versus mastectomy. We conclude that, ultimately, the choice should be that of women with detailed facts of the pros and cons of all options being presented to them from the angle of patient/family-focused care. Although the guidelines of various professional societies can be helpful, they are only guidelines. The participation of women in IORT clinical trials is still needed, and as genome-based and omics-based fine-tuning of prognostic fingerprints evolve, the current guidelines need to be revisited. Finally, the use of IORT can help rural, socioeconomically, and infrastructure-deprived populations and geographic regions as the convenience of single-fraction RT and the possibility of breast preservation are likely to encourage more women to choose BCT than mastectomy. This option can also likely lead to more women choosing to get screened for breast cancer, thus enabling the diagnosis of breast cancer at an earlier stage and improving the survival outcomes. Cureus 2023-03-20 /pmc/articles/PMC10072193/ /pubmed/37025715 http://dx.doi.org/10.7759/cureus.36432 Text en Copyright © 2023, Vijayakumar et al. https://creativecommons.org/licenses/by/3.0/This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Radiation Oncology
Vijayakumar, Srinivasan
Nittala, Mary R
Buddala, Vedanth
Mobit, Paul
Duggar, William N
Yang, Claus Chunli
Lirette, Seth T
Mundra, Eswar
Ahmed, Hiba Z
Berry, Scott M
Craft, Barbara S
Woods, William C
Otts, Jeremy
Rahimi, Asal
Dobbs, Thomas
Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title_full Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title_fullStr Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title_full_unstemmed Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title_short Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts
title_sort real world and public health perspectives of intraoperative radiotherapy in early-stage breast cancer: a multidisciplinary analysis beyond the statistical facts
topic Radiation Oncology
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10072193/
https://www.ncbi.nlm.nih.gov/pubmed/37025715
http://dx.doi.org/10.7759/cureus.36432
work_keys_str_mv AT vijayakumarsrinivasan realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT nittalamaryr realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT buddalavedanth realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT mobitpaul realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT duggarwilliamn realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT yangclauschunli realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT lirettesetht realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT mundraeswar realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT ahmedhibaz realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT berryscottm realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT craftbarbaras realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT woodswilliamc realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT ottsjeremy realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT rahimiasal realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts
AT dobbsthomas realworldandpublichealthperspectivesofintraoperativeradiotherapyinearlystagebreastcanceramultidisciplinaryanalysisbeyondthestatisticalfacts