Clinical Practice Recommendations and Practice Points

This clinical guideline is intended for all members of the multidisciplinary team responsible for the care of a woman with early breast cancer. Ideally, the recommendations regarding the use of different fractionation schedules should be considered prior to breast surgery.

Recommendations and practice points should be considered in the context of clinical judgement for each patient. Considerations should include the absolute benefits and harms of treatments, other treatments in use, patient preferences and quality of life issues. These factors should be discussed with the patient and their family or supporters, tailored to their preferences for information and decision-making involvement.

Patients

Recommendations		Grade	References
1	In selected patients* with early breast cancer who require post-operative whole breast radiotherapy, hypofractionated radiotherapy is a suitable alternative to conventionally fractionated radiotherapy, and should be offered where appropriate. *Patients: Women aged 50 years or older with pathological stage T1-2, node-negative (N0), non-metastatic (M0) disease who have undergone breast conserving surgery, with clear surgical margins	A	Haviland 2013¹⁰ (START A and B) Spooner 2012¹¹ UK FAST trial 2011¹² Whelan 2010⁶ (Canadian trial) Owen 2006⁷ (RMH/GOC trial)
2	For women outside the above criteria with early breast cancer who require post-operative whole breast radiotherapy, hypofractionated radiotherapy could be considered as an alternative to conventionally fractionated radiotherapy. Note: there is insufficient evidence to make a recommendation for or against the use of hypofractionated radiotherapy for men with breast cancer.	C	Haviland 2013¹⁰ (START A and B) Spooner 2012¹¹ UK FAST trial 2011¹² Whelan 2010⁶ (Canadian trial) Owen 2006⁷ (RMH/GOC trial)
Practice point
a	Recent evidence indicates that tumour grade does not need to be taken into account when considering the use of hypofractionated radiotherapy		Whelan 2010⁶ Bane 2014¹⁴ Haviland 2013¹⁰ Herbert 2012¹⁵

Optimal Schedules

Recommendation	Grade	References
3	For women not receiving a tumour bed boost, recommended hypofractionated schedules for whole breast radiotherapy based on current evidence are: 40 Gy in 15 fractions given at the rate of one fraction per day, 5 fractions per week over 21 days; or 42.5 Gy in 16 fractions given at the rate of one fraction per day, 5 fractions per week over 22 days	A	Haviland 2013¹⁰ (START B) Canadian^6,13 Spooner 2012¹¹
Practice point
b	For women in whom a tumour bed boost is indicated, specific evidence-based dose-fractionation schedules for use with tumour bed boost have not been defined, but the following boost doses are considered acceptable: 10 Gy in 5 fractions	Haviland 2013 (START B) ¹⁰

Recommendation

Grade

References

For women not receiving a tumour bed boost, recommended hypofractionated schedules for whole breast radiotherapy based on current evidence are:

40 Gy in 15 fractions given at the rate of one fraction per day, 5 fractions per week over 21 days; or
42.5 Gy in 16 fractions given at the rate of one fraction per day, 5 fractions per week over 22 days

Haviland 2013¹⁰

(START B)

Canadian^6,13

Spooner 2012¹¹

Practice point

For women in whom a tumour bed boost is indicated, specific evidence-based dose-fractionation schedules for use with tumour bed boost have not been defined, but the following boost doses are considered acceptable:

10 Gy in 5 fractions

Haviland 2013 (START B) ¹⁰

Adverse Events And Toxicity

Recommendation	Grade	References
4	When selecting an appropriate radiotherapy schedule consideration should be given to the possibility of adverse events including acute reactions and late effects, noting that cosmetic outcomes are equivalent with the recommended optimal schedules for hypofractionated radiotherapy versus a conventionally fractionated radiotherapy schedule.	B	Haviland 2013¹⁰ (START A and B) Spooner 2012¹¹ UK FAST trial 2011¹² Whelan 2010⁶ (Canadian trial) Owen 2006⁷ (RMH/GOC trial)
Practice Point
c	As cardiac effects from radiation therapy may take up to 20 years to develop, heart sparing protocols should be adopted irrespective of the dose fractionation regimen used. Particular consideration should be given to these effects when prescribing hypofractionated radiation therapy to the left breast, especially in women with pre-existing heart disease..	Haviland 2013¹⁰ (START A and B)

Recommendation

Grade

References

When selecting an appropriate radiotherapy schedule consideration should be given to the possibility of adverse events including acute reactions and late effects, noting that cosmetic outcomes are equivalent with the recommended optimal schedules for hypofractionated radiotherapy versus a conventionally fractionated radiotherapy schedule.

Haviland 2013¹⁰ (START A and B)

Spooner 2012¹¹

UK FAST trial 2011¹²

Whelan 2010⁶ (Canadian trial)

Owen 2006⁷ (RMH/GOC trial)

Practice Point

As cardiac effects from radiation therapy may take up to 20 years to develop, heart sparing protocols should be adopted irrespective of the dose fractionation regimen used. Particular consideration should be given to these effects when prescribing hypofractionated radiation therapy to the left breast, especially in women with pre-existing heart disease..

Haviland 2013¹⁰ (START A and B)

Clinical Practice Recommendations and Practice Points