International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationsThe influence of the boost in breast-conserving therapy on cosmetic outcome in the eortc “boost versus no boost” trial
Introduction
Over the last decade, breast-conserving therapy (BCT) has been established as the treatment of choice for patients with early-stage breast cancer 1, 2, 3, 4. However, specific details of the surgical, radiotherapeutic, and systemic adjuvant approaches are not generally agreed upon. In this paper we will concentrate on one of the controversial items of radiotherapy technique, namely the effects of giving a boost dose to the tumor bed.
The two major endpoints of BCT are good local control and good cosmetic outcome. The influence of the radiotherapy boost on both endpoints, however, is controversial. Pezner et al. 5, 6 claimed that omitting the local boost in patients with tumor-free specimen margins resulted in local control rates comparable to those of other institutions that routinely used a boost. On the other hand, the Lyon trial (7) showed that the delivery of a 10-Gy boost (given in fractions of 2.5 Gy) to the tumor area significantly reduced the risk of early local recurrence in patients with tumor-free margins from 4.5% to 3.6% at 5 years, compared to treatment of the whole breast with a dose of 50 Gy in 2.5-Gy fractions.
A similar controversy exists concerning the influence of the radiation boost on the cosmetic result after BCT. Some studies have concluded that the boost had no effect on the cosmetic outcome, in terms of the degree of breast retraction or the proportion of patients having an excellent or good cosmetic result, although patients treated with a boost may have had an increased frequency of telangiectasia 5, 7, 8. Others have demonstrated a negative effect of the boost on the global cosmetic result 9, 10, 11, 12. One factor that might determine whether or not the boost can be shown to worsen the cosmetic outcome is the time following radiotherapy at which the cosmetic result is evaluated. It is well known that the cosmetic changes progress over the first years after BCT and that the cosmetic outcome is evaluable only after at least 3 years 13, 14, 15, 16. Two of the above-mentioned studies which found no adverse effect of the boost evaluated cosmetic outcome at a median follow-up of 2 years or less (5, 7).
The European Organization for Research and Treatment of Cancer (EORTC) Phase III trial 22881/10882 for Stage I and II breast cancer was created to unequivocally answer the question of the impact of the radiation boost on local control, survival, and cosmesis. The current analysis focuses on the influence of the boost on the cosmetic outcome.
Section snippets
Trial design and treatment
From May 1989 to June 1996, 5569 early-stage breast cancer patients were entered in the “boost versus no boost” trial. Patients with T1-2 N0-1 M0 invasive breast cancer were eligible. Exclusion criteria were: age over 70 years; carcinoma in situ (CIS) without invasive tumor; residual microcalcifications on mammogram or gross residual disease in the breast after tumorectomy (unless reexcision had been performed); tumor foci in more than one quadrant; a prior history of malignant disease; or an
Patient population
An overview of the distribution of the patient, tumor, and treatment characteristics of the different patient populations is given in Table 1. The p-values in this table relate to the comparison of panel patients to the remainder of the population (“others”) and of digitizer patients to patients without any digitizer measurements available (“others”). The characteristics of the no-boost and the boost patients are reported separately for the panel and digitizer patients. There were no
Discussion
The EORTC trial 22881/10882 was launched to investigate in BCT, the influence of the boost on local control, survival, and cosmesis. In this study we have shown that the boost slightly impairs the cosmetic outcome 3 years after BCT. Because the local recurrence rate is only 3.9% so far for the overall population after a median follow-up of 3.8 years, more follow-up is needed before the influence of the boost on local control and survival can be reliably evaluated. Therefore, the answers to
Acknowledgements
The authors thank all the participating institutions for their cooperation, the panel members Jacques H. Borger, Stefan J. Brenninkmeyer, Marianne Pierart, Joop A. Van Dongen, and Erik Van Limbergen for their great effort in scoring the photographs, Ellen Bartelink for performing all the digitizer measurements, and Abram Recht for reviewing the manuscript. This work was partially supported by a grant from the European Commission (DGXII) within the framework of BIOMED I and by Grants
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2022, The LancetCitation Excerpt :We also previously reported that patient-reported cosmetic outcomes were slightly worse with a boost than with no boost, and these worse outcomes persisted at 2 years.15 These findings were similar to the adverse effects reported in a study examining a boost radiation of 16 Gy in eight fractions in women with invasive breast cancer, but not when this boost schedule was used after a whole breast dose of 45 Gy in 25 fractions.19–21 Our results on local control and toxicity associated with a tumour bed boost provide the evidence for shared treatment decision making by the patients and treating physicians, guided by the values and preferences of patients.
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Trial participants and responsible physicians: Tilburg NL (Poortmans), Utrecht NL (Struikmans), Leuven B (Van den Bogaert), Dijon F (Horiot), Paris F (Fourquet), Amsterdam NL (Borger), Heerlen NL (Jager), Nijmegen NL (Hoogenraad), Cologne D (Müller), Geneva CH (Kurtz), Nottingham GB (Morgan), Montpellier F (Dubois), Namur B (Salamon), Lausanne CH (Mirimanoff), Leiden NL (Leer), Grenoble F (Bolla), Haifa IS (Kuten), La Louviere B (Renaud), Krefeld D (Schulz), Rotterdam NL (Koper), Antwerp B (Van den Weyngaert), Brussels B (Storme), Creteil F (Calitchi), Berlin D (Budach), Düsseldorf D (Roth), Brisbane AUS (Poulsen), Pamplona ES (Dominguez), Vannes F (Monpetit), Tel Aviv IS (Kovner), Barcelona ES (Biete Sola), Madrid ES (Calvo)