This guideline provides recommendations on use of postmastectomy radiation therapy (PMRT) in breast cancer treatment. Updated recommendations detail indications for PMRT in the upfront surgical setting and after neoadjuvant systemic therapy, and provide guidance on appropriate target volumes, dosing, and treatment techniques.
A multidisciplinary American Society for Radiation Oncology–ASCO–Society of Surgical Oncology task force addressed four key radiation therapy (RT) questions in patients with breast cancer who undergo mastectomy: (1) indications for PMRT after upfront surgery, (2) indications for PMRT after neoadjuvant systemic therapy followed by surgery, (3) appropriate PMRT volumes and dose-fractionation regimens, and (4) treatment techniques. Recommendations were based on a systematic review and created using a predefined consensus-building methodology for quality of evidence grading and strength of recommendation.
After upfront mastectomy, PMRT is indicated for most patients with node-positive breast cancer and select patients with node-negative disease. PMRT is also recommended after neoadjuvant systemic therapy for patients presenting with locally advanced disease and for those with residual nodal disease the time of surgery. PMRT is conditionally recommended for patients with cT1-3N1 or cT3N0 breast cancer with pathologically negative nodes after neoadjuvant systemic therapy (ypN0). When PMRT is delivered, treatment to the ipsilateral chest wall or reconstructed breast and regional lymphatics is recommended, with moderate hypofractionation preferred, but with conventional fractionation approaches acceptable in rare cases. Computed tomography–based volumetric treatment planning with 3-dimensional conformal RT is recommended, with intensity-modulated RT advised when three-dimensional conformal RT is unable to achieve treatment goals. Deep inspiration breath-hold techniques are also recommended for normal tissue sparing. For patients with skin involvement, positive superficial margins, and/or lymphovascular invasion, use of a bolus is recommended, but routine use of tissue-equivalent bolus is not recommended.Additional information is available www.asco.org/breast-cancer-guidelines.
Maybe I’m biased as chair of the VBC, but this study showed that all subtypes of SACT use were associated with markers of poorer-quality EOL care.
This study reviewed the effects of using novel agents (immunotherapy and targeted therapy) in patients at the end of life (EOL), based on the perception that these therapies may be less toxic than chemotherapy. Adjusted odds of high health service utilization and hospital death were more than twofold greater among patients receiving systemic anticancer therapy (SACT) at the EOL compared to those receiving none.
Our site participated in this study, where patients were tested for ESR1 mutations via circulating tumor DNA (ctDNA). Those who tested positive were switched to camizestrant (Cami), which demonstrated improved progression-free survival.
Vepdegestrant is an oral proteolysis-targeting chimera (PROTAC) estrogen receptor (ER) degrader that directly utilizes the ubiquitin–proteasome system. It was compared to fulvestrant in patients who had received one prior line of hormonal therapy with a CDK4/6 inhibitor. Among patients with ESR1 mutations, Vepdegestrant demonstrated a median progression-free survival (PFS) of 5.0 months versus 2.1 months with fulvestrant. In the overall population, the median PFS was 3.8 months for Vepdegestrant and 3.6 months for fulvestrant, indicating that the drug showed particular efficacy in tumors harboring ESR1 mutations.
Elinzanitant, a neurokinin-targeted therapy, has been shown to reduce vasomotor symptoms compared to placebo. These symptoms are one of the reasons some of my patients discontinue aromatase inhibitor (AI) therapy, so Elinzanitant presents a promising alternative to help manage these side effects. Additionally, Fezolinetant is already approved and available on the market.