Shorter Radiation Schedule Seems As Effective As Standard Schedule After Breast Reconstruction
Women who received radiation on a shorter, or hypofractionated, schedule after implant breast reconstruction after mastectomy had the same risk of recurrence (the cancer coming back) as women who received radiation on a traditional schedule, according to a study. The shorter course also improved their quality of life, both physically and financially.
The research was presented on Oct. 1, 2023, at the American Society for Radiation Oncology (ASTRO) annual meeting. Read the abstract of “Patient-Reported Toxicity Results from the FABREC Study: A multicenter Randomized Trial of Hypofractionated vs. Conventionally-Fractionated Postmastectomy Radiation Therapy after Implant-Based Reconstruction.”
What is hypofractionated radiation?
A traditional external whole-breast radiation schedule includes about 25 treatments — one treatment five days a week for five to seven weeks. But that time commitment can be challenging for people, so doctors developed a shorter radiation therapy schedule, known as accelerated or hypofractionated. This schedule involves fewer treatments with higher doses of radiation during each treatment. It allows people to receive about the same radiation dose in a three- to five-week schedule.
Both the National Comprehensive Cancer Network (NCCN) and ASTRO say that a hypofractionated schedule should be the standard of care for whole-breast radiation therapy.
Doctors measure radiation doses in Gray. People on traditional radiation therapy schedules receive 45 to 50 Gray in a five- to seven-week period — 1.8 to 2 Gray during each treatment. In a hypofractionated schedule, people get 40 Gray in 15 treatments or 42.5 Gray in 16 treatments.
Listen to the episode of The Breastcancer.org Podcast featuring Dr. Chirag Shah explaining hypofractionated radiation.
About the study
The study, called Radiation Fractionation on Patient Outcomes After Breast REConstruction (FABREC), included 400 women diagnosed with stage 0 to stage III breast cancer between March 2018 and November 2021 at 16 treatment centers in the United States. The women were aged 23 to 79. All the women had mastectomy followed by immediate placement of either an implant or a tissue expander.
All the women were scheduled to receive radiation after reconstruction. Before radiation started, the women were split into two groups:
201 women received radiation on a traditional schedule of 25 treatments over five weeks, receiving a total of 50 Gray
199 women received radiation on a hypofractionated scheduled of 16 treatments over three weeks, receiving a total of 42.56 Gray
A majority of the women received chemotherapy before mastectomy, and some received hormonal therapy before mastectomy.
The women completed questionnaires about their quality of life before they joined the study, and six, 12, and 18 months after radiation started. Six months after radiation started, the women also completed a survey asking about financial issues.
The researchers included information from 385 women in the final analysis.
Follow-up time ranged from 6.9 months to 54.4 months, with half of the women being followed for more than 31.8 months. During follow-up:
16 women, eight in each treatment group, had a metastatic recurrence, meaning the breast cancer came back in a part of the body away from the breast
two women, one in each treatment group, had a local recurrence, meaning the breast cancer came back in the chest, breast, armpit, or skin near the original cancer
Six months after radiation started, physical well-being scores were about the same in both treatment groups.
Women who received radiation on a hypofractionated schedule were less likely to take breaks from treatment and the breaks they took were shorter:
2.7% of women in the hypofractionated treatment group took a treatment break
7.7% of women in traditional treatment group took a treatment break
treatment breaks averaged 2.8 days in the hypofractionated treatment group
treatment breaks averaged 3.3 days in the traditional treatment group
Both of these differences were statistically significant, which means they were likely due to the difference in treatment schedules and not just because of chance.
Women in the hypofractionated treatment group also had to take less unpaid time off work:
women in the hypofractionated treatment group needed 73.7 hours of unpaid time off
women in the traditional treatment group needed 125.8 hours of unpaid time off
The radiation schedule wasn’t linked to a higher risk of side effects. Rates of severe side effects (grade 3 or higher) were similar between the two treatment groups, about 8.5%. Still, women younger than 45 in the hypofractionated treatment group said they were less bothered by side effects compared to women younger than 45 in the traditional treatment group.
Certain things were linked to a higher risk of side effects, including:
having an infection in the breast area after mastectomy or reconstruction
having a tissue expander rather than an implant
receiving hormonal therapy before surgery
having more lymph nodes removed
“Both the accelerated and standard courses of treatment were equally effective at preventing the cancer from returning and had the same level of side effects, senior study author Rinaa Punglia, MD, MPH, FASTRO, associate professor of radiation oncology at Dana-Farber Brigham Cancer Center, said in a statement. “But with shortening the treatment from five weeks to three, patients experienced fewer treatment disruptions, a lower financial burden, and other meaningful improvements to their lives.
“Our trial results suggest that hypofractionation can safely be used in this setting without compromising efficacy or increasing side effects,” Dr. Punglia continued. “Reducing the requirement to three weeks of radiation therapy would be a significant improvement in the quality of our patients’ lives.”
What this means for you
This study suggests that a hypofractionated radiation schedule after mastectomy and implant reconstruction offers the same protection against recurrence as a traditional schedule and is likely more convenient and cost-effective for many women.
Still, there are a few things to keep in mind when considering the results:
The study included only women who had reconstruction with implants or tissue expanders. Women who had breast reconstruction using their own tissue – called autologous or flap reconstruction – were not included. So it’s unclear if a shorter radiation schedule is as effective as a traditional schedule after flap reconstruction.
Follow-up time was relatively short. The longest time any of the women in the study were followed was about 4.5 years. A 2021 Danish study found that some estrogen receptor-positive breast cancers recurred up to 32 years after diagnosis. So while the effectiveness of the shorter radiation schedule seemed the same as the traditional schedule, longer follow-up time may show differences.
Women who had tissue expanders placed, rather than an implant, and women who had more lymph nodes removed were more likely to have more side effects.
It’s also important to know that radiation can cause the skin over an implant to become tighter, tougher, and more rigid. Radiation also can increase your risk of complications with an implant, including an infection. Because of these factors, many plastic surgeons recommend having radiation before having breast reconstruction.
It makes sense to talk about your reconstruction and radiation options with both your radiation oncologist and your plastic surgeon so you can decide on a treatment schedule that makes the most sense for your unique situation.
— Last updated on November 15, 2023 at 6:58 PM