Radiation Therapy For The Whole Breast

Publication Date: March 1, 2018
Last Updated: March 14, 2022

Recommendations for patients receiving WBI without additional fields to cover the regional lymph nodes

Overall Statement

For women with invasive breast cancer receiving WBI with or without inclusion of the low axilla, the preferred dose-fractionation scheme is HF-WBI to a dose of 4000 cGy in 15 fractions or 4250 cGy in 16 fractions. (Strong, High)
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Grade, margins, and ER/PR/HER2 status and biology

The decision to offer HF-WBI should be independent of tumor grade. (Strong, High)
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The decision to offer HF-WBI may be independent of hormone receptor status, HER2 receptor status, and margin status. (Conditional, Moderate)
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Normal tissue exposure

The decision to offer hypofractionation should be independent of breast cancer laterality. (Strong, Moderate)
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Systemic therapy receipt

The decision to offer HF-WBI should be independent of chemotherapy received prior to radiation and trastuzumab or endocrine therapy received prior to or during radiation. (Strong, Moderate)
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Age

There is no evidence indicating deleterious effects of HF-WBI compared with CF-WBI in either younger or older patients, and thus HF-WBI may be used regardless of age. (Conditional, Moderate)
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Stage (including DCIS vs invasive disease)

HF-WBI may be used as an alternative to CF-WBI in patients with DCIS. (Conditional, Moderate)
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Histology

CF-WBI may be preferred over HF-WBI when treating primary breast cancers with rare histologies that are most commonly treated with CF when arising in other parts of the body. (Conditional, Low)
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Breast size and dose homogeneity

The decision to offer HF-WBI should be independent of breast size (including central axis separation) provided that dose-homogeneity goals, as outlined in KQ4, can be achieved. (Strong, Moderate)
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Collagen vascular disease and other relative contraindications to radiation

In patients with breast augmentation, either HF-WBI or CF-WBI may be used. (Conditional, Low)
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In patients with collagen vascular disease, if the patient and her physician opt for WBI, then either HF-WBI or CF-WBI may be used. (Conditional, Low)
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When should patients receive a tumor bed boost in conjunction with WBI?

Age, grade, margins, and biology for invasive disease

A tumor bed boost is recommended for patients with invasive breast cancer who meet any of the following criteria: age ≤50 years with any grade, age 51 to 70 years with high grade, or a positive margin. (Strong, Moderate)
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Omitting a tumor bed boost is suggested in patients with invasive breast cancer who meet the following criteria: age >70 years with hormone receptor-positive tumors of low or intermediate grade resected with widely negative (≥2 mm) margins. (Conditional, Moderate)
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For patients with invasive breast cancer not meeting criteria articulated in KQ2A or KQ2B, individualized decision-making is suggested because the decision in these cases is highly sensitive to patient preferences and values regarding the modest expected disease control benefit and the modest increase in treatment-related burden and toxicity associated with boost radiation therapy. (Conditional, Moderate)
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Age, grade, and margins for DCIS

A tumor bed boost may be used for patients with DCIS who meet any of the following criteria: age ≤50 years, high grade, or close (<2 mm) or positive margins. (Conditional, Moderate)
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A tumor bed boost may be omitted in patients with DCIS who, if age >50 years, meet the following criteria: screen detected, total size ≤2.5 cm, low to intermediate nuclear grade, and widely negative surgical margins (≥3 mm). (Conditional, Moderate)
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For patients with DCIS not meeting criteria articulated in KQ2D or KQ2E, individualized decision-making is suggested as the decision in these cases is highly sensitive to patient preferences and values regarding the modest expected disease control benefit and the modest increase in treatment-related burden and toxicity. (Conditional, Moderate)
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Dose-fractionation used for WBI

The decision to use a tumor bed boost is recommended to be based on the clinical indications for a boost and be independent of the whole breast fractionation scheme. (Strong, High)
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Ability to limit dose to critical normal tissues, including heart and whole breast volume

Physicians may reduce the boost dose or omit the boost for patients believed to be at higher risk for normal tissue toxicity from a boost because of a large boost volume relative to breast volume or inclusion of critical normal tissue in the boost radiated volume. (Conditional, Low)
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What is/are preferred dose-fractionation scheme(s) for a tumor bed boost?

In the absence of strong risk factors for local recurrence, such as those enumerated in KQ3B, 1000 cGy in 4 to 5 fractions is suggested as the standard tumor bed boost dose-fractionation, regardless of whole breast dose-fractionation, stage, or histology. (Conditional, Moderate)
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Particularly in the presence of strong risk factor(s) for local recurrence, such as the single risk factor of positive margins or a combination of risk factors such as young age and close margins, a higher radiation boost dose of 1400 to 1600 cGy in 7 to 8 fractions or 1250 cGy in 5 fractions may also be used. (Conditional, Low)
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What are preferred techniques for WBI treatment planning?

Dose homogeneity

The volume of breast tissue receiving greater than 105% of the prescription dose should be minimized. To achieve this, 3-dimensional conformal treatment planning with a “field-in-field” technique is recommended as the initial treatment planning approach. (Strong, Moderate)
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Target delineation and coverage

The tumor bed should be contoured with a goal of achieving coverage of the tumor bed with at least 95% of the prescription dose. The whole breast volume may be contoured or defined clinically, with a goal of covering at least 95% of the whole breast volume with 95% of the whole breast prescription dose. Treatment plans should be individualized after consideration of many factors, including tumor characteristics, patient anatomy, and comorbidities. (Strong, Moderate)
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Cardiac delineation and avoidance

The heart should be contoured on the treatment planning computed tomography scan in accordance with Radiation Therapy Oncology Group guidelines. Tangent beams should be delineated to minimize the dose to the heart. The mean heart dose should be as low as reasonably achievable. Deep inspiration breath hold, prone positioning, and/or heart blocks are recommended to minimize heart dose. Judicious tailoring of the whole breast dose coverage may be used to minimize the dose to the heart, provided that the tumor bed is remote from this region of the breast. (Strong, High)
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Normal tissue doses

Treatment techniques should also minimize dose to the contralateral breast, lung, and other normal tissues. (Strong, High)
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Patient positioning and position verification/image guidance

Patients should be positioned considering the reproducibility of the breast for treatment. Skin folds should be unfolded to the extent possible. For patients with a large breast size, prone positioning may be used to further minimize dose to normal tissues. Regardless of the positioning method, care should be taken to ensure that the contralateral breast is not in the treatment fields. (Strong, High)
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When designing the frequency and type of imaging, imaging of the treatment beam ports may be used to minimize dose to normal tissues such as the heart. For patients with significant daily positioning variations, daily imaging may be used. Doses are lowest with kilovoltage (kV) planar techniques but the appropriate imaging method depends on the localization needs for the patient. (Conditional, Low)
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What are preferred techniques for tumor bed boost treatment planning?

Technique/modality

When a tumor bed boost is to be administered, external beam treatment is recommended with a radiation modality that will minimize high radiation dose to nontarget tissue. (Strong, Moderate)
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To facilitate immobilization and minimize normal tissue exposure, resimulation for boost planning may be used to allow for repositioning or in patients with large seromas at the time of whole breast treatment planning. (Conditional, Low)
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At this time, evidence is strongest in support of sequential administration of the boost after whole breast treatment; therefore, outside the context of trials, sequential boost is currently recommended. (Conditional, Moderate)
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Target delineation and coverage

3-dimensional treatment planning should include delineation of the tumor bed, as noted in KQ4B. For boost treatment, conformal blocking with an adequate margin surrounding the tumor bed or boost PTV should be used, after consideration of factors such as risk of recurrence and the ability to spare normal tissues given the patient’s anatomy. (Strong, Moderate)
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Cardiac avoidance and normal tissue doses

Caution should be taken to minimize dose to critical normal tissues, including the heart, and to minimize the volume of ipsilateral breast included in the boost field. (Strong, Moderate)
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Patient positioning and position verification/image guidance

With supine positioning for boost treatment, no additional immobilization is recommended. Daily imaging may be used in patients at risk for less reproducible setup. (Conditional, Low)
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Recommendation Grading

Overview

Title

Radiation Therapy For The Whole Breast

Authoring Organization

Publication Month/Year

March 1, 2018

Last Updated Month/Year

December 5, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This Executive Summary introduces the guideline and its recommendations about Radiation therapy for the whole breast.

Target Patient Population

Patients with breast cancer

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D001941 - Breast Diseases, D001943 - Breast Neoplasms, D018787 - Radiation Oncology, D011827 - Radiation

Keywords

breast cancer, radiation therapy, Adjuvant Radiation Therapy, oncology, Breast Cancer

Source Citation

Practical Radiation Oncology (2018) 8, 145-152

Methodology

Number of Source Documents
121
Literature Search Start Date
January 1, 2009
Literature Search End Date
January 1, 2016