Radiation therapy timing
Radiation therapy timing - After surgery or chemotherapy (Practice Point)
In patients who have completed definitive surgery for breast cancer, commence radiation therapy as soon as possible after wound healing within 8 weeks of surgery or typically within 3-4 weeks of completion of adjuvant chemotherapy.
How this guidance was developed
This practice point was developed using an expert consensus process. A potentially relevant source recommendation, graded 'C’, was identified from the NCCP 2015 guidelines (Ireland) that recommends local breast irradiation is initiated as soon as possible following wound healing. The NCCP recommendation was used as the basis for the development of this practice point, which is consistent with eviQ recommendations.
Radiation therapy timing – Breast reconstruction (Practice Point)
For patients requiring mastectomy and radiation therapy offer breast reconstruction with the opportunity to discuss the risks and benefits of early or delayed reconstruction, taking into account different surgical techniques, reconstruction methods and patient preferences. In patients considering breast reconstruction, discuss the risk of complications and reconstructive failure in relation to the timing of radiation therapy.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process.
Radiation therapy, neoadjuvant systemic therapy and reconstruction – Sequencing (Practice Point)
The ideal sequencing of radiation therapy, neoadjuvant systemic therapy and reconstruction is unknown and therefore should be discussed by a multidisciplinary team (MDT), ideally before surgery or radiation therapy.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process based on clinical expertise and knowledge of the Australian healthcare context and based on information contained within the NCCN 2018 (USA) guidelines. It was subsequently informed by the subsequently the ESMO 2019 (Europe) guidelines which included a recommendation graded 'A' (using ESMO methods adapted from the Infectious Diseases Society of America-United States Public Health Service Grading System) based on very low level evidence/expert opinion.
Radiation therapy after neoadjuvant chemotherapy
Radiation therapy after neoadjuvant chemotherapy – Node-positive or locally advanced breast cancer (Recommendation)
For patients with locally advanced breast cancer and/or involved lymph nodes at presentation who have received neoadjuvant chemotherapy, consider post-mastectomy radiation therapy with or without nodal radiation therapy.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). Three source recommendations (for different patient populations, based on investigations of macrometastases) were merged to generate a recommendation applicable to all three patient populations. All three source recommendations were based on a systematic review conducted to September 2017: two of these recommendations used wording (‘Offer’) indicative of a strong recommendation and one used wording (‘Consider’) indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The evidence review by NICE (2018) indicates that there was not enough evidence to recommend subgroups of women in whom postmastectomy radiotherapy could be safely omitted after neoadjuvant chemotherapy. Therefore, the NICE committee agreed that the recommendations for postmastectomy radiotherapy among people who have not received neoadjuvant chemotherapy applied to this population.
Radiation therapy after neoadjuvant chemotherapy – Inflammatory breast cancer (Recommendation)
For patients with inflammatory breast cancer who have been treated with neoadjuvant chemotherapy, offer local/regional treatment with mastectomy followed by radiation therapy.
How this guidance was developed
This recommendation was adopted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to July 2008 (it was not updated in 2018) and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. Minor wording changes were made.
Radiation therapy after breast-conserving surgery
Radiation therapy after breast-conserving surgery (Recommendation)
Offer breast radiation therapy to patients with breast cancer who have had breast-conserving surgery with clear surgical margins.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted by expanding the patient population from "women" to "all patients".
Radiation therapy boost after breast-conserving surgery (Recommendation)
In patients who have undergone breast-conserving surgery and who are at high risk of local recurrence (age ≤50 years with any grade, age 51-70 years with higher grade, or a positive margin), offer radiation therapy boost following whole-breast radiation therapy.
How this guidance was developed
This recommendation was adopted from the ASTRO 2018 guidelines (US). The source recommendation was based on a systematic review of the evidence conducted to May 2016 and was graded ‘strong’ (using GRADE methods) by the source guideline authors. The source recommendation was accepted with minor stylistic changes, but with no changes to the meaning or tone of the source recommendation. This is consistent with ESMO 2019 (Europe) guidelines which recommend radiation-therapy boost in patients at higher risk of local recurrence (graded 'A') and the NICE 2018 guidelines (UK) which also indicate ‘offer an external beam boost to the tumour bed for women with invasive breast cancer and a high risk of local recurrence, following WBI therapy’ (wording (‘Offer’) indicative of a strong recommendation).
Radiation therapy after breast-conserving surgery – Older women (Recommendation)
Discuss the benefits and risks of omitting radiation therapy after breast-conserving surgery in women over 70 years of age with very low risk of local recurrence and who are suitable and willing to take endocrine therapy for five years.
How this guidance was developed
This recommendation was adapted from two source recommendations from the NICE 2018 guidelines (UK). The source recommendations were based on a systematic review of the evidence conducted to September 2017 and used wording (‘Consider’) indicative of a conditional recommendation and wording ('Discuss') indicative of the need for shared-decision making (using GRADE methods). The source recommendations were merged and simplified, and the threshold age changed from >65 years to >70 years to reflect the findings of the CALGB 9343 trial in the US and the use of this age in the NCCN (US) guidelines as a result of this study. The recommendation was considered probably generalisable to men, but the lack of certainty resulted in no change to the patient population.
Partial breast irradiation – Considerations (Recommendations)
In patients with breast cancer (excluding lobular type) who have undergone breast-conserving surgery with clear surgical margins and who have a very low risk of local recurrence, partial breast irradiation can be considered if patients are suitable and willing to take adjuvant endocrine therapy for five years.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Consider’) indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted by including a link to a validated predictive tool rather than providing a definition of 'very low risk of local recurrence' within the recommendation. The recommendation was also made gender neutral, and less directive by replacing "consider" with "can be considered".
This recommendation is supported by a more recent recommendation in ESMO 2019 (Europe) clinical practice guidelines, graded ‘C’ (using ESMO methods adapted from the Infectious Diseases Society of America-United States Public Health Service Grading System).
Hypofractionated radiation therapy after breast-conserving surgery (Recommendation)
Offer a hypofractionated course of radiation therapy to women with breast cancer who have undergone breast-conserving surgery with clear surgical margins and who require post-operative whole breast radiation therapy.
How this guidance was developed
This recommendation was initially adapted from the CA 2015 guidelines (Australia). Two source recommendations were merged and adapted to use language applicable to the Australian health care context. Both source recommendations were based on a systematic review conducted to November 2013: one was graded 'A' and the other 'B' (using NHMRC methods) by the source guideline authors. This initial rewording was in alignment with ASTRO (2011) which recommended HF-WBI for women ≥50 years old, T1-2 N0, no chemotherapy and ±7% dose homogeneity in the central axis.
This original wording also aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 5. However, the ASTRO guidelines were updated in 2018 and currently recommend HF-WBI for patients of any age, at any stage (provided intent is to treat the whole breast), and any chemotherapy [and volume of breast tissue receiving >105% pf the prescription dose should be minimised regardless of dose fractionation). The relevant recommendations are based on a systematic review of the evidence conducted to May 2016 and the various elements were graded ‘strong’ or ‘conditional’ (using GRADE methods) by the source guideline authors.
Radiation therapy after mastectomy
Radiation therapy to the chest wall after mastectomy #1 (Recommendation)
For patients with breast cancer who have undergone a mastectomy and have at least four positive lymph nodes and a T3 or T4 tumour or involved surgical margins, offer adjuvant radiation therapy to the chest wall.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation is based on a systematic review of the evidence conducted to September 2017 and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted by narrowing the population to ‘patients who have undergone a mastectomy and have at least four positive nodes and a T3 or T4 tumour or involved surgical margins’ as there is clear evidence in patients with locally advanced disease.
Radiation therapy to the chest wall after mastectomy #2 (Recommendation)
For patients with breast cancer who have undergone a mastectomy and have macrometastases in 1-3 lymph nodes, consider adjuvant radiation therapy to the chest wall.
How this guidance was developed
This recommendation was adapted from the NICE 2018 guidelines (UK). The source recommendation is based on a systematic review of the evidence conducted to September 2017 and used wording (‘Offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was adapted by narrowing the population to ‘patients who have undergone a mastectomy and have macrometastases in 1-3 lymph nodes’, and by changing the wording from ‘offer’ to ‘consider’ as radiation therapy is not conventionally offered to patients with a single positive node.
This recommendation is also informed by the ASCO/ASTRO/SSO focused guideline update on postmastectomy radiotherapy 2016 which notes that, although the panel unanimously agreed that available evidence shows that postmastectomy radiation therapy reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential (lung, cardiac) toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment.
Radiation therapy to the chest wall after mastectomy #3 (Recommendation)
For patients with breast cancer who have undergone a mastectomy and have lymph node-negative T3 or T4 cancer, consider adjuvant radiation therapy to the chest wall.
How this guidance was developed
This recommendation was adopted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Consider’) indicative of a conditional recommendation (using GRADE methods) by the source guideline authors. The source recommendation was accepted with minor stylistic changes, but with no changes to the meaning or tone of the source recommendation.
Radiation therapy after mastectomy – Patients at low risk of recurrence (Recommendation)
For patients with breast cancer who have undergone mastectomy and who are at low risk of local recurrence (e.g. most people who have lymph node-negative breast cancer), do not offer radiation therapy to the chest wall.
How this guidance was developed
This recommendation was adopted from the NICE 2018 guidelines (UK). The source recommendation was based on a systematic review of the evidence conducted to September 2017 and used wording (‘Do not offer’) indicative of a strong recommendation (using GRADE methods) by the source guideline authors. The source recommendation was accepted with minor stylistic changes, but with no changes to the meaning or tone of the source recommendation.
Radiation therapy of nodal regions
Radiation therapy of nodal basins #1 (Practice Point)
For patients with 4 or more nodes involved, offer radiation of the nodal basins in addition to the chest wall or whole breast.
How this guidance was developed
The extent of nodal irradiation is an area of ongoing debate and research (ACS/ASTRO/SSO 2016 Focused guideline update on postmastectomy radiotherapy).
This practice point was developed using an expert consensus process. A potentially relevant ‘moderate’ (using ASCO methods) source recommendation was identified from the ASCO/ASTRO/SSO 2016 guidelines (US) that provided guidance regarding radiation therapy of the nodal regions. This recommendation was not adopted or adapted because it was considered too detailed.
Radiation therapy of nodal basins #2 (Practice Point)
For patients with 1-3 lymph nodes involved, consider radiation of the nodal basins in addition to the chest wall or whole breast.
How this guidance was developed
The extent of nodal irradiation is an area of ongoing debate and research (ACS/ASTRO/SSO 2016 Focused guideline update on postmastectomy radiotherapy).
This practice point was developed using an expert consensus process. A potentially relevant ‘moderate’ (using ASCO methods) source recommendation was identified from the ASCO/ASTRO/SSO 2016 guidelines (US) that provided guidance regarding radiation therapy of the nodal regions. This recommendation was not adopted or adapted because it was considered too detailed.
Radiation therapy of the internal mammary lymph node chain (Practice Point)
For patients where involvement of the internal mammary lymph nodes is identified during sentinel node biopsy or an 18F-FDG PET study, consider radiation to the internal mammary lymph node chain.
How this guidance was developed
The extent of nodal irradiation is an area of ongoing debate and research (ACS/ASTRO/SSO 2016 Focused guideline update on postmastectomy radiotherapy).
This practice point was developed using an expert consensus process. A potentially relevant ‘moderate’ (using ASCO methods) source recommendation was identified from the ASCO/ASTRO/SSO 2016 guidelines (US) that provided guidance regarding radiation therapy of the nodal regions. This recommendation was not adopted or adapted because it was considered too detailed.
Radiation therapy and adverse effects
Radiation therapy and adverse effects (Recommendation)
In patients undergoing radiation therapy use techniques that minimise the dose to the lung and heart, including deep inspiratory breath-holding for left-sided cancer.
How this guidance was developed
This recommendation was adopted from a source recommendation from the NICE 2018 guideline (UK). The source recommendation is based on a systematic review of the evidence conducted to September 2017 and used wording (‘Use’) indicative of a strong recommendation (using GRADE methods).
Radiation therapy – Patients with p53 mutations (Practice Point)
Wherever possible avoid radiation therapy in patients with p53 genetic mutations.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care due to the increased risk of radiation-induced malignancy in these patients. This practice point was developed using an expert consensus process.
Radiation therapy considerations – Pregnant women (Practice Point)
In pregnant women with breast cancer with a high risk of recurrence, the multidisciplinary team should consider the risks and benefits of radiation therapy to the woman and the fetus, and these should be discussed with the woman.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process.
Radiation therapy timing – Pregnant women (Practice Point)
In pregnant women with breast cancer with a low to intermediate risk of recurrence, delay radiation therapy until after delivery of the baby.
How this guidance was developed
No evidence-based source recommendation was identified for this topic, which was considered an important aspect of care. This practice point was developed using an expert consensus process.
