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.
This review of patient-reported outcomes (PRO’s) monitoring on the POLARIX trial highlights the usefulness of this technology in our practice. We may see more of these systems in place in the future as more cellular therapy becomes available in the community setting.
The QUIWI study used quizartinib, a FLT3 drug added to standard chemo induction/consolidation in FLT-negative acute myeloid leukemia (AML) patients. There was a meaningful overall survival (OS) improvement across all age and risk groups including the NPM1+ population. They purposefully used a higher dose to achieve what is felt to be off-target TKI activity in familiar pathways of KIT, PDGRF…etc.
This really feels like a first-line practice changer in PD-L1+ MTNBC—the sacituzumab govitecan/pembrolizumab combination delivering a 3.4-month progression-free survival (PFS) improvement and pushing median PFS past 11 months is quite meaningful. Mature overall survival (OS) data will be interesting to see. Remember to watch closely and consider screening for drug-induced interstitial lung disease(ILD).
ASCENT-03 shows that in first-line, PD-1/PD-L1–ineligible advanced TNBC, sacituzumab improves PFS to 9.7 vs 6.9 months and extends median duration of response (DOR) to 12.2 vs 7.2 months, with similar overall response rate (ORR) (48% vs 46%) and immature overall survival (OS) (21.5 vs 20.2 months) Grade ≥3. Adverse events (AEs) were comparable (66% vs 62%), but sacituzumab had more neutropenia and diarrhea, fewer discontinuations (4% vs 12%), and early-cycle infection-related deaths in patients without primary G-CSF. For PD-1/PD-L1–ineligible mTNBC, SG offers more durable control than chemo with manageable myelosuppression — so consider SG first-line and start G-CSF early in higher-risk patients.
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.