Although survival and cancer recurrence rates were similar, this approach, known as hypofractionation, appears to be just as effective in controlling cancer while reducing treatment side effects, improving patient convenience, and potentially saving money for both patients and healthcare systems, says the lead author of the study, Lee Shing Fung, MBBS, a radiation oncologist at the National University Cancer Institute in Singapore.
Radiation Treatment After Breast Cancer Surgery
Doctors often recommend radiation treatment after breast cancer surgery to help eliminate any cancer cells that may remain in the breast. This has been the standard of care for most patients with breast cancer since the 1970s, according to the study authors.
The new research compared so-called “modern” hypofractionation, delivered in 13 to 16 sessions, with “traditional” methods, which usually require 25 to 28 sessions. The study also looked at ultra-hypofractionation. “Ultra-hypofractionation is even shorter, typically completed in five sessions, and is designed for selected early-stage breast cancer patients,” explains Dr. Fung.
The traditional regimen typically lasts 5 to 6.5 weeks, while the modern version commonly occurs over approximately 3 to 4 weeks, says Meena S. Moran, MD, a professor of therapeutic radiology and the chief of breast radiation oncology at the Yale School of Medicine in New Haven, Connecticut.
Fewer Weeks of Radiation at Higher Doses Versus the Conventional Schedule: Which Is Better?
Even though the practice of giving higher doses of radiation for fewer weeks is becoming more common, there’s been no comprehensive comparison of the overall benefit, frequency, and severity of potential side effects, aesthetic consequences, and implications for quality of life versus the traditional course of radiation therapy, the study authors wrote.
To bridge that gap, researchers searched databases and found 35 randomized controlled trials conducted between 1986 and 2023 that included more than 20,000 patients. All had undergone breast-conserving therapy or mastectomy and had either the traditional or modern course of radiation therapy.
After pooling the data, the researchers found that the modern regimen reduced the risk of skin redness and peeling (called acute radiation dermatitis) by 46 percent in breast-conserving therapy patients and by 32 percent in mastectomy patients, compared with the traditional regimen.
In the trials that looked only at women who had breast conserving treatment like a lumpectomy rather than mastectomy, these differences were not statistically significant.
Fewer weeks of radiation at higher doses were also associated with improved overall appearance of the breast and quality of life compared with the conventional regimen.
The data for ultra-hypofractionation was less conclusive, but its safety and effectiveness seem to be similar up to at least five years of follow-up, wrote the authors.
Shorter Radiation Regimens Have the Same Outcomes as Longer Ones, but With Fewer Downsides
“This meta-analysis, which pooled data from all the published studies, suggests that these shorter regimens are as effective in preventing cancer recurrence and are also associated with less toxicity,” says Dr. Moran.
Potential side effects such as skin redness and peeling, hyperpigmentation, and breast shrinkage are the same for both the modern and traditional treatment, but occur less frequently in the modern treatment, she says.
“There should be no drawbacks (of the higher doses), unless the patients are having post-mastectomy radiation and/or regional nodal radiation after having undergone reconstruction. In these patients, the data for these shorter fractionation/higher daily dose schedules are limited,” says Moran.
Next Steps for Putting the Findings Into Practice
To fully integrate these shorter radiation protocols into standard practice, more long-term studies are needed, especially for ultra-hypofractionation, to confirm its safety and effectiveness beyond five years, says Fung.
“Clinically, our findings support that moderate hypofractionation should be offered to most patients, and ultra-hypofractionation should be considered for selected early-stage patients,” he says.
Moran agrees, saying, “If a patient is being told they are going to receive (conventional fractionation), they should discuss the rationale for using the longer fractionation schedule with their prescribing physician.”
For these changes to become widespread, updates to clinical guidelines, training for healthcare providers, and adjustments to healthcare policies, especially around reimbursement, are essential, says Fung.
