Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ

Publication Date: November 14, 2023
Last Updated: November 16, 2023

Indications for PBI as an alternative to WBI

Early-stage invasive breast cancer is defined as an invasive lesion ≤3 cm with 0-3 positive lymph nodes.
PBI is recommended for patients with early-stage invasive breast cancer with all of the following factors:
grade 1-2 disease (S, H )
620
ER-positive histology (S, H )
620
age 40-49 years
(S, M )
620
age ≥50 years (S, H )
620
tumor size ≤2 cm (S, M )
620
PBI is conditionally recommended for patients with early-stage invasive breast cancer with the following factors:
  • grade 3 disease or
  • ER-negative histology or
  • size >2 - ≤3 cm
(C, L )
Implementation remark: PBI may not be appropriate when multiple of these factors are present, given the possibility of a higher recurrence risk.
620
PBI is conditionally not recommended for patients with early-stage invasive breast cancer with any of the following factors:
  • HER2-positive tumors not receiving anti-HER2 therapy
  • lymphovascular invasion
  • lobular histology
(C, CC)
Implementation remark: Given low patient numbers accrued to RCTs, higher risk of recurrence with PBI is possible.
620
PBI is not recommended for patients with early-stage invasive breast cancer with any of the following factors:
  • positive lymph nodes
  • positive surgical margins
  • known germline BRCA1/2 mutation
  • age <40 years
(S, CC)
620
PBI is recommended for patients with DCIS with all of the following factors:
  • low-to-intermediate grade
  • age ≥40 years
  • size ≤2cm
(S, CC)
Implementation remark: While represented in the RCTs, there was a lack of subgroup analyses for pathologic and clinical features of patients treated with DCIS.
620
PBI is conditionally recommended for patients with DCIS with the following factors:
  • high grade or
  • size >2 - ≤3 cm
(C, CC)
Implementation remark: PBI may not be appropriate when both of these factors are present, given the possibility of a higher recurrence risk.
620
PBI is not recommended for patients with DCIS with any of the following factors:
  • positive surgical margins
  • known germline BRCA1/2 mutation
  • age <40 years
(S, CC)
620

Appropriate PBI techniques with respect to rates of IBR

For patients with early-stage invasive breast cancer or DCIS receiving PBI, 3-D CRT is recommended. (S, H )
620
For patients with early-stage invasive breast cancer or DCIS receiving PBI, IMRT is recommended. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS receiving PBI, multicatheter brachytherapy is recommended. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS receiving PBI, single-entry catheter brachytherapy is conditionally recommended. (C, M )
620
For patients with early-stage invasive breast cancer receiving PBI, electron IORT is not recommended, unless part of a clinical trial or multi-institutional registry. (S, M )
Implementation remark: For patients considered for electron IORT, the characteristics in KQ1 do not apply.
620
For patients with early-stage invasive breast cancer receiving PBI, kV IORT alone (without WBI) is not recommended, unless part of a clinical trial or multi-institutional registry. (S, L )
Implementation remarks: For patients considered for kV IORT, the characteristics in KQ1 do not apply. WBI following kV IORT may be needed for patients with higher risk features.
620

Appropriate PBI dose-fractionation regimens

For patients with early-stage invasive breast cancer or DCIS receiving external beam PBI, 3000 cGy in 5 once daily fractions delivered on nonconsecutive days within 2 weeks is recommended. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS receiving external beam PBI, 4005 cGy in 15 once daily fractions over 3 weeks is recommended. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS receiving PBI with HDR brachytherapy, 3010 cGy in 7 fractions, 3200 cGy in 8 fractions, 3400 cGy in 10 fractions delivered twice daily or 5000 cGy with 160-180 cGy/hour PDR is recommended. (S, M )
Implementation remark: Single-entry PBI trials used 3400 cGy in 10 fractions delivered twice daily.
620

Appropriate PBI techniques with respect to toxicity and cosmesis

Only techniques of PBI which received a strong strength of recommendation in favor of usage in the "Appropriate PBI techniques with respect to rates of IBR" section were evaluated in in this section.
For patients with early-stage invasive breast cancer or DCIS eligible for PBI, once daily external beam PBI is recommended, based on fewer late toxicities, and improved cosmesis. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS eligible for PBI, twice daily external beam PBI to a dose of 3850 cGy in 10 fractions is not recommended, based on poorer cosmetic outcomes. (S, M )
620
For patients with early-stage invasive breast cancer or DCIS eligible for PBI, multicatheter brachytherapy is recommended, based on cosmetic outcomes. (S, M )
620
For patients with early-stage invasive breast cancer eligible for PBI with an intended dose of 4005 cGy in 15 fractions, PBI is recommended over WBI, due to fewer late toxicities and improved cosmesis. (S, M )
620

Additional

Figure 1. Adjuvant Radiation Therapy Treatment Options for Early-Stage Invasive Breast Cancer or DCIS

Link to External Image Unavailable

Table 6. PBI target volumes and planning parameters*

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Recommendation Grading

Abbreviations

  • DCTS: Ductal Carcinoma In Situ
  • HDR: High-dose Rate
  • HER2: Human Epidermal Growth Factor Receptor 2
  • IBR: Ipsilateral Breast Recurrence
  • IMRI: Intensity Modulated Radiation Therapy
  • IORT: Intraoperative Radiation Therapy
  • KQ: Key Question
  • PBI: Partial Breast Irradiation
  • WBI: Whole Breast Irradiation
  • kV: Kilovoltage

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ

Authoring Organization

Publication Month/Year

November 14, 2023

Last Updated Month/Year

November 20, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ.

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant, radiology technologist

Scope

Management

Diseases/Conditions (MeSH)

D001943 - Breast Neoplasms, D000071960 - Breast Carcinoma In Situ, D018270 - Carcinoma, Ductal, Breast

Keywords

breast cancer, invasive breast cancer, early stage breast cancer, ductal carcinoma, breast irradiation

Source Citation

Simona F. Shaitelman, Bethany M. Anderson, Douglas W. Arthur, Jose G. Bazan, Jennifer R. Bellon, Lisa Bradfield, Charlotte E. Coles, Naamit K. Gerber, Madeera Kathpal, Leonard Kim, Christine Laronga, Icro Meattini, Elizabeth M. Nichols, Lori J. Pierce, Matthew M. Poppe, Patricia A. Spears, Shaveta Vinayak, Timothy Whelan, Janice A. Lyons, Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline, Practical Radiation Oncology, 2023, ISSN 1879-8500, https://doi.org/10.1016/j.prro.2023.11.001

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement