When can women with early-stage breast cancer skip radiation after lumpectomy?

When can women with early-stage breast cancer skip radiation after lumpectomy?

Emerging research may allow more women with early-stage breast cancer to safely skip radiation therapy.

Women with early-stage breast cancer often choose a lumpectomy, which removes only the cancerous tissue and a thin portion of the surrounding healthy cells rather than the entire breast. Current cancer guidelines for most women under age 65 recommend lumpectomy with radiation therapy, which targets stray cancer cells that may cause breast cancer to return or spread to other parts of the body.

A new study presented at the 2022 annual meeting of the American Society of Clinical Oncology could eventually expand the option to skip radiation for some 55-year-old women. However, limitations in necessary tests could hinder this approach from spreading, according to a Harvard expert.

Reduced risk of breast cancer recurrence

Landmark 2004 ResearchReinforced by subsequent studies, cancer experts helped develop guidelines that identify women with early-stage breast cancer who can safely discard radiation after lumpectomy.

In general, this option is offered to women 65 years of age or older with small, non-aggressive cell tumors that have not spread to the lymph nodes. Medically, this is described as a T1N0 tumor, grade 1-2. Tumors must be estrogen receptor positive, which means that estrogen helps promote their growth. They must also have an adequate margin of normal tissue surrounding the cut tumor to ensure that all of the cancer has been removed. Instead, women who decide to skip radiation receive drugs known as endocrine therapy for five years. This prevents cancer cells from using hormones such as estrogen to grow and spread.

“This has been the standard of care for a long time in women 65 years of age or older. Now the debate is whether we can also omit radiation for a larger group of breast cancer patients. For example, can we take this approach in patients younger than 65 years old? If patients are chosen carefully?” says Dr. Nadine Tong, director of the Cancer Risk Prevention and Breast Cancer Prevention Program at Beth Israel Deaconess Medical Center.

What does the new evidence suggest?

New evidence suggests that younger women who have tumor features similar to those described above may also be able to forgo radiation without increasing the odds of recurrence. Instead, they will undergo endocrine therapy for five years.

The study included 500 women aged 55 and over With early-stage breast cancer similar to the established criteria for skipping radiation during treatment. It also allowed women to score if the margin of natural breast tissue removed was very thin (only 1 millimeter or larger). The analysis used an additional test on cancer cells removed during a lumpectomy to ensure that they were slow growing.

Over an average follow-up of five years, the study revealed that the rate of breast cancer recurrence in the same breast was 2.3% in women who skipped radiation after a lumpectomy and took endocrine blockers instead — the same rate expected with radiation use, which Dr. Tong says It is impressive. “Most recurrences will occur within five years. If they are reproducible, the results could point to a new set of criteria for radiation avoidance.”

Promising results, but there are still huge obstacles

The results of the study are preliminary, and more rigorous research is needed to confirm its findings. There is an additional barrier that makes it difficult to translate these trial results into clinical practice: The reliability of the test used in the study to show that the cancers were slow-growing – called Ki67 – varies, and many hospitals do not routinely use it to evaluate breast tumors.

“It will help evaluate the results of other studies that omitted radiation to feel confident that we have identified additional patients with invasive breast cancer for whom radiation can be safely omitted,” Dr. Tong says. “Some of these studies use molecular testing to assess features of breast cancer, and we are awaiting results from these trials as well.”

Questions to ask your cancer team

For women with early-stage breast cancer who want to know if radiation is necessary after lumpectomy surgery, Dr. Tong suggests asking the oncology team the following questions:

  • Does my type of tumor meet the criteria for avoiding radiation therapy? If not, then why? “I think many radiation oncologists don’t usually ask that question,” Dr. Tong says.
  • What is the probability that the tumor will come back if I receive radiation or not? If you have the choice, Dr. Tong says, it’s important to understand the difference in the odds of recurrence or treatment.
  • Will I need to take medication instead of being exposed to radiation? If so, for how long and what are the possible side effects?
  • What are the possible side effects if I undergo radiation? She explains, “Radiation can cause redness, like breast burning, and the treated breast can shrink a little over time. Ask about short- and long-term side effects.”

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