1. Hypofractionated radiotherapy for breast cancer
Preliminary results from CMC Vellore
Sham Sundar
Christian Medical College Vellore
Radiotherapy unit 1

2. Balukrishna S, Sunitha Susan Varghese, Selvamani B

3. Background
Breast cancer is the most frequent cancer among women according to the Globocan update
In India, it is the most common cancer contributing to 27% of all new cancers in women
Radiation therapy is an integral part of multi-modality management

4. Radiotherapy in breast cancer
The local cancer control and overall survival benefits of adjuvant RT for women with early breast cancer have been established by a systematic review of 17 RCT’s involving more than patients by EBCTCG
In most studies 50Gy in 25 fractions was delivered in 5 weeks
. This standard regimen is based on a historical assumption that breast cancer is less sensitive to changes in the dose per fraction than dose-limiting healthy normal tissues.

5. Rationale for hypofractionation
Radiobiologic models suggested that a larger daily dose (hypofractionation) given over a shorter time (accelerated therapy) might be just as effective
Such regimen may also be more convenient for patients and less resource- intensive than the standard schedule
breast cancer might be much more sensitive to changes in radiotherapy dose per fraction than most other cancers.
Fowler JF. The linear-quadratic for- mula and progress in fractionated radio- therapy. Br J Radiol 1989;62:
Cohen L. Radiotherapy in breast cancer I. The dose–time relationship theoretical considerations. Br J Radiol 1952; 25: 636–42. Douglas BG. Superfractionation: its rationale and anticipated benefits. Int J Radiat Oncol Biol Phys 1982; 8: 1143–53.

6. START trials
START A - 2 regimens (39 Gy and 42·9 Gy) of a 13 fraction regimen delivered over 5 weeks
START B - 40 Gy in 15 fractions over 3 weeks
5 year and 10 year results - safe and effective
Consistent with the hypothesis that breast cancer tissue and the dose- limiting normal tissues are similarly sensitive to fraction size

7. Purpose
To review the acute toxicity and feasibility of hypofractionated regimen radiotherapy in post mastectomy and post BCS in our patient population
We here report initial results for 51 patients treated at our center with the START-B type of fractionation.

8. Methods and Materials From January 2013 till July 2014
Reviewed patients who had hypo fractionated radiotherapy
This included patients with all stages of breast cancer (If metastatic, had oligo bone metastases)
Undergone BCS or mastectomy.
Had received to chest wall or whole breast, supraclavicular fossa and axilla (where indicated) followed by tumour bed boost in BCS patients.

9. Methods and Materials Conventional or conformal technique.
All these patients had weekly assessement by a radiation oncologist during radiotherapy and at 3 months after completion of radiotherapy.
The oncologist grades skin changes according to RTOG Acute Radiation Morbidity Scoring Criteria
other complaints of patients were also noted and addressed.

10. Methods and Materials Nearly 83% of patients had 3 months of follow up
Skin changes at follow up were also noted
The results were analysed using SPSS version 20

11. Results
We had 51 female breast cancer patients

12. Age
Median age 47

13. Patient characteristics
Laterality
Right
Left 21 30
Surgery
Mastectomy
BCS 37 14
Technique
Conventional
Conformal
Neoadjuvant chemotherapy
Yes No 33 18

14. Co-morbidities Diabetes - 7 patients Hypertension - 9 patients
Others - 4 patients
Will have a chart or graph here

15. End of RT assessment Pie chart
Two patients(4%) developed grade 3 dermatitis. Six patients(12%) had grade 2 and 25(50%) had grade 1 acute radiation dermatitis

16. Assessment at 3 months post RT
43 patients(83%) had 3 months follow up. Eight(15.68%) had persistent hyper pigmentation at the end of three months post RT.
11% had developed early onset of lymphedema
Will represent these as graphs

17. Chemotherapy before RT
Correlations
Chemotherapy before RT
End of RT reactions
3 months post RT changes
and taxanes
-0.15
-0.32
P - value
0.294
0.04
In these patients have a significant gap between start of adjuvant radiotherapy and surgery.

18. Correlations
Technique
End of RT reactions
3 months post RT changes
Conformal
0.14
-0.314
P - value
0.325
0.045
Use of conformal technique had decreased incidence of 3 months post RT skin changes

19. End of RT reactions - likelihood ratio
Correlations
The patients were classified as 6 groups WB
WB + SCF
WB + SCF+ Axilla CW
CW + SCF
CW + SCF + Axilla
analysis
End of RT reactions - likelihood ratio
p-value
Whole breast
8.553
0.006
axilla
4.659
0.05

20. Lymphedema likelihood ratio
Correlations
Early onset of lymphedema was seen with use of axillary irradiation, though the association was significant it was confounded by other variables.
analysis
Lymphedema likelihood ratio
p-value
Axillary RT
14.5
0.001

21. Grade III reactions
Will see skin dose, hot spot and if significant will add them here.

22. Conclusion
The safety and efficacy of hypo fractionated regimen in conserved breast has been proven by many trials
The acute skin toxicity with hypo fractionated regimen in our patient population is acceptable.
In chest wall irradiation, the acute skin toxicity is significantly lower, when compared to whole breast irradiation.

23. Correlations
Hypofractionated RT is feasible and very relevant in Indian population in terms of acute skin toxicity.
Hypofractionated regimen should be encouraged to increase throughput and for cost minimization