Editor's Note: From August 2-4, 2024, the 7th Oncology Precision Diagnosis and Treatment Conference and the 10th Breast Cancer Individualized Treatment Conference (COMB), organized by the China Cancer Foundation and Beijing Breast Disease Prevention Society, was grandly held in Beijing. The conference gathered the latest advancements in individualized precision treatment for breast cancer in China and provided insights into the precise implementation of postoperative radiotherapy for breast cancer. At the event, Oncology Frontier invited Dr. Yanxia Zhao from Union Hospital, Tongji Hospital of Huazhong University of Science and Technology, to interpret the standards for exempting radiotherapy post-surgery, analyze the advantages of hypofractionated radiotherapy, and share tips on managing radiotherapy-related complications.Oncology Frontier: In breast-conserving therapy for breast cancer patients, which patients are suitable for postoperative radiotherapy, and in what situations can radiotherapy be exempted? Could you elaborate on the relevant indications and exemption criteria?
Dr. Yanxia Zhao: The vast majority of breast cancer patients require radiotherapy after breast-conserving surgery, as radiotherapy can reduce the risk of local recurrence by approximately two-thirds, translating into a 15-year survival benefit. The decision to use radiotherapy primarily considers the 5-year and 10-year local recurrence rates. If the 5-year local recurrence rate is less than 5% and the 10-year local recurrence rate is less than 10%, a small number of patients may be exempt from radiotherapy. Based on existing evidence from evidence-based medicine, patients over 70 years of age, hormone receptor-positive (HR+), T1N0, and able to adhere to long-term endocrine therapy, may be considered for radiotherapy exemption by comprehensively evaluating their local recurrence risk and overall survival conditions.
When considering radiotherapy exemption, patient-specific factors must be carefully evaluated. First, patient compliance is critical. If a patient has poor compliance with endocrine therapy, such as irregular use or discontinuation, their risk of local recurrence increases. Second, histological grade is important. Even if a patient is HR+/HER2-, T1N0, a grade 3 histology would indicate a high risk of recurrence. Third, the patient’s life expectancy should be considered. With significantly extended survival times for breast cancer patients, some 70-year-old patients with early-stage breast cancer may have a very young biological age and a long expected survival time. Therefore, we would re-evaluate the biological age of the patient and might not easily exempt radiotherapy for those in particularly good physical condition. Overall, these factors guide our decision on whether to administer or exempt radiotherapy post-surgery.
Oncology Frontier: Hypofractionated radiotherapy is gaining more attention in postoperative treatment for breast cancer. What are the advantages of this radiotherapy method compared to traditional radiotherapy, and what issues should be noted in clinical practice?
Dr. Yanxia Zhao: Compared to traditional fractionated radiotherapy, hypofractionated radiotherapy involves a lower total radiation dose, fewer treatment sessions, but a higher dose per session. The efficacy of hypofractionated radiotherapy is comparable to traditional radiotherapy, and the short-term and long-term side effects are non-inferior, which has increasingly garnered attention. The most notable advantage of hypofractionated radiotherapy is that it shortens the duration of treatment, reduces the cost of radiotherapy, and conserves medical resources, which is why it is increasingly promoted in Western countries.
In practical applications, the indications for hypofractionated radiotherapy need to be considered carefully. For very low-risk patients after breast-conserving surgery, partial breast hypofractionated radiotherapy may be used. For intermediate-risk patients, hypofractionated radiotherapy should cover the entire breast area, with an additional boost to the tumor bed. For high-risk patients with lymph node metastasis, comprehensive treatment including whole-breast radiotherapy, a local boost, and irradiation of the lymphatic drainage areas is typically required, and these patients are not suitable for hypofractionated radiotherapy.
Oncology Frontier: Postoperative radiotherapy for breast cancer can lead to complications such as skin reactions and lymphedema. How do you prevent and manage these complications in clinical practice, and what are some effective strategies?
Dr. Yanxia Zhao: Managing complications from postoperative adjuvant radiotherapy is a very practical concern. Take skin reactions, for example. First, it is important to establish a protective mindset. Both doctors and patients should prioritize skin protection from the start of radiotherapy, paying attention to avoiding friction, particularly in areas where the arm may rub against the armpit. Patients should choose loose, soft clothing, preferably made of cotton or silk, and avoid wearing bras. They should also limit excessive physical activity to reduce friction. Second, it is essential to maintain an appropriate skin temperature during radiotherapy, avoiding overheating or overcooling, and preventing sweating or moisture buildup. Third, prophylactic medications like triethanolamine can be used to prevent radiation-induced dermatitis. Since many patients rest outside the hospital during radiotherapy, it is crucial to ensure they are fully aware of potential skin reactions early in their treatment. In our daily practice, we often create a small group chat for patients undergoing radiotherapy, where doctors and patients who have already undergone treatment can provide support to those who are currently receiving or about to receive radiotherapy. I believe that paying attention to these details and addressing radiotherapy-related skin reactions is essential, and these are some of the experiences we’ve gathered in our daily work.
In addition to the impact on the skin, the implementation of radiotherapy plans must also consider the potential effects on the heart and lungs. Managing adverse reactions in patients is not something clinical doctors can achieve alone; it requires the collaboration of physicists, technicians, and clinical doctors from other departments to determine the target area, dosage, and comprehensive management strategies. Through such multidisciplinary management, the vast majority of patients’ radiotherapy reactions can be well controlled.
Dr. Yanxia Zhao
Ph.D., Chief Physician, Associate Professor, Master’s Supervisor Deputy Director, Department of Breast Oncology, Union Hospital, Tongji Hospital of Huazhong University of Science and Technology Secretary of the Oncology Center Party Branch, Deputy Director of the Department of Breast Oncology Member of the Breast Cancer Expert Committee, Chinese Society of Clinical Oncology (CSCO) Member of the Patient Education Committee, Chinese Society of Clinical Oncology (CSCO) Young Expert, Breast Cancer Committee, Chinese Anti-Cancer Association Member, Breast Cancer Subcommittee, Oncology Branch, Chinese Medical Doctor Association Executive Member, Breast Cancer Subcommittee, China Health Promotion Foundation Member, Tumor Heterogeneity and Individualized Therapy Committee, Chinese Anti-Cancer Association
