1. Radiotherapy Protocols Bristol protocol version 12

2. Dose Prescription 40Gy in 15 fractions daily for the majority of patients Other dose schedules to be used at discretion of clinician and patient after discussion include: – 45Gy in 20 fractions daily. – 50Gy in 25 fractions daily

3. CHEST WALL (POST MASTECTOMY) Radiotherapy to the chest wall is indicated if the: Tumour extends to the excision margin. 4 or more lymph nodes are involved on histological examination. Margin >1mm. Skin involvement. Tumour >5cm diameter. Multi-focal grade 3, T2N0 and grade 3 histology and/or lymphovascular invasion. N1 patients can also be considered If in the opinion of the Breast MDT the patient is deemed suitable for this

4. CHEST WALL (POST MASTECTOMY) Dose Prescription 40Gy in 15 fractions daily. 45Gy in 20 fractions daily. 50Gy in 25 fractions daily – the preferred dose for a reconstructed breast ???

5. SUPRACLAVICULAR FOSSA and AXILLA Radiotherapy to the supraclavicular fossa only is indicated when: 1-3 positive lymph nodes after a level II axillary clearance and a minimum of 10 lymph nodes retrieved if other poor prognostic factors (e.g. T3 and/or grade 3 tumour). 4 or more positive lymph nodes after a level II axillary clearance and a minimum of 10 lymph nodes retrieved. After neo-adjuvant chemotherapy if considered high risk

6. There are no absolute indications for radiotherapy to the supraclavicular fossa and axilla but it can be considered in the following situations: No axillary surgery has been carried out (with the exception of DCIS and very good prognosis invasive carcinoma ). Palpable/+ve axillary lymph node prior to neo-adjuvant chemotherapy in patients who have had axillary sampling and no pathological complete response after neo-adjuvant chemotherapy. Sentinel node biopsy or sampling of lymph nodes is positive for axillary metastases and axillary dissection is not undertaken or the patient declines axillary clearance. Extensive extra-capsular spread. A high node positive count and/or if a high proportion of retrieved nodes are involved.