Kevin Hughes, MD
As the treatment of patients with breast cancer transitions toward doing less while achieving more durable results, radiation therapy may be replaced entirely by medications, explains Kevin Hughes, MD. Additionally, radiation therapy may not be the answer in patients with breast cancer over the age of 70.
In an interview with OncLive
, Hughes, associate professor of Surgery, Harvard Medical School, discusses the pros and cons of radiation therapy in elderly patients, as well as luminal A patients, and the overall changing role of the therapy in the field.
OncLive: What is the role of radiation therapy in elderly patients undergoing breast conserving surgery?
: We're looking at breast conservation in women over the age of 70. When we looked at this within the CALGB Cancer and Leukemia Group B Protocol 9343, we took women 70 and above with stage I breast cancer who were estrogen receptor (ER)-positive and randomized them to radiation versus no radiation. We found that there was a small decrease in the rate of recurrence with radiation, which was not unexpected, but there was very little other benefit. The decrease in breast recurrence was about 7% at 10 years, which is a very minimal decrease.
Overall, what we feel is that radiation is not necessary in women who are 70 and above who are ER-positive and are clinical stage I. Even though we have identified that, we have found that the community continues to radiate them. We need to move away from the approach of radiating every breast cancer that comes in the door and begin to stop radiating women over the age of 70 with early breast cancer.
We also need to extend that to younger women, when we look at luminal A cancers. Women over 50 may not need radiation either, and there are ongoing trials. The PRECISION trial is one where women 50 to 75 clinical stage I ER-positive will be treated without radiation, and I think that is the future.
Are there quality of life issues that occur in elderly patients treated with the radiation therapy?
Radiation therapy is very well tolerated. Despite the fact that it's well tolerated, it's a major inconvenience for older women. Whether they have to come in every day for 6 weeks, whether they have to come in every day for 4 weeks, or for 2 weeks, it is still inconvenient. That adds to the stress of their lives, and they often don't have people who can bring them back and forth for treatment or they often don't have the resources or support network. This is a major problem.
For those who live far from radiation therapy centers, often, they can't get the radiation at all. In the past, this has been dealt with by doing mastectomies that were totally unnecessary. Now that we recognize that the radiation is not required, it's better that they not get a mastectomy and save their breast and have the minimal in-breast recurrence risk that we're concerned about.
Overall, radiation is not a dangerous thing to do, it's not a detrimental thing to do, but if you don't need it, then any level of risk is too much.
What should the approach to these elderly patients be in the future?
Breast cancer care over the last few decades has been an approach to doing less and less to get the same level of care. We've gone from radical mastectomy, to simple mastectomy, to sentinel node biopsy. We've gone from chemotherapy for everybody, to chemotherapy for those who are genomic testing appropriate, and this constant drop in treatment has been extremely effective at doing less and getting the same outcome.
We need to do the same with radiation. Radiation has some benefit for older women, but not enough to make it worthwhile. It has some benefit for women who are younger, who have luminal A cancers or very low-grade cancers, but probably not enough to make it worthwhile. Now, we have to start looking at when we can pull back on radiation. We cannot just go from 6 weeks to 4 weeks, or just go from whole breast to partial breast, but when can we just avoid radiation all together, and that's the future.
Will there continue to be a role for radiation in other breast cancer subtype, such as HER2-positive and triple-negative?
We know that triple-negative breast cancers are extremely aggressive. We know that HER2-positive cancers seem to be aggressive as well, and these patients seem to benefit from radiation. This is not a statement that all radiation is bad, by any means. There are patients who need it, and those at the highest risk certainly do, and I would currently put the triple-negative and HER2-positive patients into that category.