Dr Haffty on Radiation in Node-Positive Breast Cancer That Converts to Node Negative

Bruce G. Haffty, MD, MS, FACR, FASTRO, chair, Radiation Oncology, associate vice chancellor for Cancer Programs, Rutgers Cancer Institute of New Jersey, system director, Radiation Oncology, RWJ Barnabas Health, discusses the evolving considerations regarding the omission of regional nodal radiation therapy in patients with node-positive breast cancer who convert to node-negative status after neoadjuvant chemotherapy.

 International Congress on the Future of Breast Cancer® East

findings from the phase 3 NRG/NSABP B-51/RTOG 1304 trial

 (NCT01872975) suggested patients who initially present with positive lymph nodes and achieved node-negative status after receiving chemotherapy had similar disease-free survival outcomes irrespective of whether they received regional nodal radiation.

The low number of recurrence events observed in these patients during the study has led to a reevaluation of the necessity of radiation therapy in this specific subgroup, Haffty says. Historically, radiation therapy has been a standard component of treatment for patients with node-positive breast cancer to reduce the risk of locoregional recurrence. However, Haffty notes that the findings indicating comparable outcomes between patients who received regional nodal radiation therapy and those who did not are influencing clinical practice.

Based off these findings, many radiation oncologists, including Haffty, are now reconsidering the need for regional nodal radiation in these patients, particularly in light of the adverse effects associated with radiation therapy, he says. Despite these promising findings, Haffty acknowledges that some practitioners remain cautious and are waiting for the full publication of the study data before fully integrating this approach into their practice. Nonetheless, the trend toward omitting radiation therapy in patients who convert to node-negative status is gaining traction, as it aligns with a more personalized treatment approach that minimizes unnecessary interventions, Haffty continues.

The omission of radiation therapy in patients with node-positive disease who convert to node-negative status is becoming more common, and this evolving strategy underscores the importance of tailoring treatment plans to an individual patient's response to therapy, Haffty concludes.

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Bruce G. Haffty, MD, MS, FACR, FASTRO, discusses the use of radiation in node-positive breast cancer patients who convert to node-negative status after neoadjuvant chemotherapy.

Bruce Haffty, MD, MS, discusses the significance of technical and biological advancements in approaches to radiotherapy in breast cancer.  

Dr Haffty on Technical and Biological Advancements in Radiotherapy Within Breast Cancer

Bruce Haffty, MD, MS, chair, Radiation Oncology, associate vice chancellor for Cancer Programs, Rutgers Cancer Institute of New Jersey, system director, Radiation Oncology, RWJBarnabas Health, discusses the significance of technical and biological advancements in approaches to radiotherapy, and how they engendered the de-escalation of radiotherapy for select patients with breast cancer.

Recent technical advancements in the field of radiation oncology have allowed clinicians to more precisely target tumors and minimize the impact of treatment on surrounding tissues, Haffty begins. The development and subsequent efficacy seen with approaches such as image-guided radiation, intensity-modulated radiation, stereotactic radiation, and adaptive radiation encapsulates these improvements, he states. The ability to deliver radiation more effectively has also paved the way for biological advancements, namely the use of accelerated radiation delivery with larger doses to smaller targets, Haffty details. This progress has facilitated the integration of radiation with chemotherapy or immunotherapy, he explains.

Overall, precise approaches to radiation enabled by technical advances allowed clinicians to reduce treatment duration for select patient populations, Haffty continues. Historically, patients with breast cancer underwent 5 to 6 weeks of radiation courses, but these improvements now allow for more efficient therapeutic delivery without increasing toxicities, he states. For many patients, the duration of treatment has been condensed to 3 to 4 weeks or, in some cases, as few as 5 sessions, Haffty emphasizes.

Ongoing studies are evaluating the feasibility and efficacy of this shorter treatment course in patients who require treatment to be targeted to both the breast and lymph nodes, which also traditionally took 5 to 6 weeks, he adds. Although final results from these studies have not yet been reported, the trend toward shorter radiation periods is evident in breast cancer, Haffty states. This paradigm shift is not limited to breast cancer; similar strategies are being employed in the treatment of prostate cancer, lung cancer, and gastrointestinal cancers, Haffty concludes.

Bruce Haffty, MD, MS, discusses the significance of technical and biological advancements in approaches to radiotherapy, and how they engendered the de-escalation of radiotherapy for select patients with breast cancer.

Bruce Haffty, MD, MS, chair, Radiation Oncology, associate vice chancellor for Cancer Programs, Rutgers Cancer Institute of New Jersey, system director, Radiation Oncology, RWJBarnabas Health, discusses the rationale for launching a clinical trial to assess the feasibility of preoperative radiation boost in patients with breast cancer.

Patients with breast cancer who undergo a lumpectomy typically receive whole breast radiation therapy following the procedure, Haffty begins. This involves administering whole breast radiation followed by an additional radiation boost to the specific area where the lumpectomy was performed, Haffty adds. Studies conducted years ago confirmed the effectiveness of this approach and demonstrated that the boost is beneficial, he states.

One compelling reason for administering the boost before surgery rather than after is that a preoperative boost likely targets a smaller area, Haffty explains. Postoperative changes, including the surgical site and biopsy cavity, can affect the treatment area, Haffty expands. Delivering the boost before surgery allows for an increased focus on a smaller area, potentially leading to better cosmetic outcomes from treating less surrounding tissue, he says. This investigation, findings from which were presented at the 2023 ASTRO Annual Meeting, was also rooted in the possibility that preoperative radiation may stimulate an immune response within the tumor, Haffty notes. While ongoing research is needed in this area, preoperative radiation is an intriguing concept that could offer additional benefits.

Moreover, in the postoperative setting, oncoplastic surgery along with lumpectomy involves multiple surgical procedures on the breast, he continues. Determining the precise location for the boost can be challenging under these circumstances, making the preoperative boost atheoretically advantageous option, Haffty notes.

In the long term, the hope is that targeting smaller areas with a preoperative boost may lead to improved cosmetic results and fewer adverse effects, he continues. The primary aim of the study was to establish the safety of this approach regarding wound healing and to confirm that the preoperative boost does not introduce any surgery-related complications, Haffty says. Addressing these concerns is crucial to encourage acceptance of the preoperative boost among surgeons and patients alike, he concludes.

Bruce Haffty, MD, MS, discusses the rationale for launching a clinical trial to assess the feasibility of preoperative radiation boost in patients with breast cancer.


Dr Haffty on the Rationale for Investigating Preoperative Radiation Boosts in Breast Cancer

Bruce Haffty, MD, MS, chair, Radiation Oncology, associate vice chancellor, Cancer Programs, Rutgers Cancer Institute of New Jersey, system director, Radiation Oncology, RWJBarnabas Health, discusses the feasibility of utilizing preoperative radiation boost in patients with breast cancer based on initial results from a phase 2 trial (NCT04871516).

The prospective trial was launched to assess the safety and efficacy of delivering radiation boost prior to breast-conserving surgery, Haffty begins. This approach could allow for more accurate targeting of the high radiation dose of the tumor that may spare more normal breast tissue. Investigators also hypothesized that wound complication rates with this approach would be non-inferior to that of standard conventional lumpectomy, postoperative whole breast radiation, and a postoperative boost.

The study enrolled 55 women diagnosed with non-metastatic, node-negative breast cancer or DCIS who were eligible for breast-conserving therapy (BCT), Haffty states. Patients received pre-operative radiation in the form of a boost with a total dose of 1332 cGy delivered in 4 fractions, followed by lumpectomy and subsequent adjuvant hypofractionated whole breast radiation totaling 3663 cGy delivered in 11 fractions.

Of the 48 eligible patients, a single patient (2%) experienced grade 3 wound dehiscence necessitating surgical revision, with no other grade 3 adverse effects reported. Three patients (6%) experienced grade 2 wound infections necessitating antibiotics. Cosmetic assessment at initial follow-up, which was available for 45 patients, indicated very good or excellent outcomes in 39 patients (87%), with no instances of poor cosmetic outcomes. Furthermore, both patients and surgeons had a favorable view of this approach, Haffty emphasizes.

These results demonstrate that administration of a pre-operative radiation boost prior to lumpectomy followed by whole breast radiation is safe and feasible compared with the standard of care, Haffty states. A subsequent expansion cohort is currently enrolling patients to evaluate longer-term cosmetic results, and a panel of immunologic markers is being employed to assess the immune response to the preoperative boost, Haffty concludes.

Bruce Haffty, MD, MS, discusses the feasibility of utilizing preoperative radiation boost in patients with breast cancer based on initial results from a phase 2 trial.

Bruce Haffty, MD, MS

Articles

Dr Haffty on Radiation in Node-Positive Breast Cancer That Converts to Node Negative

Dr Haffty on Technical and Biological Advancements in Radiotherapy Within Breast Cancer

Dr Haffty on the Rationale for Investigating Preoperative Radiation Boosts in Breast Cancer

Dr Haffty on the Feasibility of Preoperative Radiation Boost in Breast Cancer