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Adverse Cosmesis with Accelerated Partial-Breast Irradiation

Summary and Comment |
November 20, 2013

Adverse Cosmesis with Accelerated Partial-Breast Irradiation

  1. Henry Mark Kuerer, MD, PhD, FACS

Poor or fair cosmetic scores were more common with 3D external-beam APBI than with longer-fractionation whole-breast irradiation.

  1. Henry Mark Kuerer, MD, PhD, FACS

Accelerated partial-breast irradiation (APBI) delivers a much shorter course of radiotherapy than whole-breast irradiation (WBI; ≤1 week and 3–6 weeks, respectively). To compare cosmetic and toxicity results in patients who received WBI versus one type of APBI — 3D external beam conformal irradiation (3DI) delivered to the initial tumor bed — after breast-conserving surgery, investigators conducted an international, randomized, noninferiority trial (RAPID) involving 2135 women (age, >40) with invasive (nonlobular) or in situ breast cancers ≤3 cm in size.

Patients received either 3DI (38.5 Gy in 10 fractions twice daily) or WBI (42.5 Gy in 16 daily fractions or 50 Gy in 25 daily fractions, with boost irradiation in 21% of patients). Cosmesis was assessed at 3 and 5 years by patients and nurses and by physicians reviewing digital photographs. Adverse cosmesis was defined as fair or poor on a scale of excellent, good, fair, or poor.

Adverse cosmesis was more common with 3DI versus WBI at 3 years, as assessed by patients (26% vs. 18%; P=0.0022), nurses (29% vs. 17%; P<0.001), and physicians (35% vs. 17%; P<0.001), as well as at 5 years, as assessed by patients (32% vs. 21%; P=0.032) and nurses (19% vs. 13%; P<0.001). Grade 3 toxicities were rare in both the 3DI and WBI groups (1.4% vs. 0%), but grade 1 and 2 toxicities were more common with 3DI (P<0.001); fat necrosis was more common with 3DI (3.0% vs. 0.9%; P<0.01).

Comment

Three different evaluation methods provided concordant evidence that adverse cosmesis at 3 and 5 years was higher with 3D external beam accelerated partial-breast irradiation than with whole-breast irradiation. It is important to note that nearly 70% of patients randomized to the shorter course of radiotherapy reported good or excellent cosmetic results. Nevertheless, the trial adds to the information that clinicians should convey to patients during the informed-consent process. As noted by editorialists, these results do not apply to brachytherapy, which was not tested in this trial. Brachytherapy would likely have a less dramatic effect on cosmesis than external beam radiotherapy because it exposes a smaller volume of normal breast tissue to radiation, albeit in larger doses per fraction, and because it has a steeper dose fall-off. A similar randomized trial (NSABP B-39) is expected to add data on cosmetic and toxicity parameters and to assess tumor recurrence (Ann Surg 2004; 239:338).

  • Disclosures for Henry Mark Kuerer, MD, PhD, FACS at time of publication Consultant / Advisory board Bayer Pharma AG Speaker's bureau AstraZeneca Grant / research support Susan G. Komen Foundation Leadership positions in professional societies Alliance for Clinical Trials in Oncology (Chair, Education Committee)

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