Implementation of External Beam Five-Fraction Adjuvant Breast Irradiation in a US Center

SIMPLE SUMMARY: Radiation therapy to the whole breast is standard of care following breast-conserving surgery for early breast cancer. Previously this treatment was delivered daily over 3–5 weeks. Clinical trials of shorter treatment protocols completing radiation in five treatments have been completed showing similar outcomes to longer protocols; however, there remains a lack of international consensus as to which patients are best treated with shorter regimens. Here we describe how we developed a consensus in our department for using a five-fraction regimen, using a survey of physicians and a review of the most relevant literature. ABSTRACT: Five-fraction adjuvant whole breast radiation has been shown to be a safe and effective alternative to longer fractionation regimens. Given the lack of international consensus on patient selection for the protocol, we developed a consensus protocol to guide patient selection and facilitate safe and efficient five-fraction radiation in our radiation medicine department. In developing the directive, we surveyed departmental physicians about their choice of adjuvant breast regimen for various clinical scenarios. Patient travel burden was the factor most strongly impacting radiation oncologists’ decision-making when considering prescribing a five-fraction course of adjuvant breast radiation; the length of clinical trial follow-up data and acute and late normal tissue effects also impacted it, along with personal clinical experience and experience of dosimetry and physics personnel. Relative value unit (RVU) reimbursement and financial toxicity to the patient were reported to be less important in decision-making. Physicians were most comfortable using five-fraction radiation in women >50 years of age with low-risk cancer and for patients unable to attend for longer treatment courses. Eight months after implementation, the protocol accounts for 4.7% of breast irradiation delivered in our department.