Public Release: 

A lower overall radiotherapy dose given in fewer, larger daily doses can result in better quality of life for patients with breast cancer

Lancet

Radiotherapy for breast cancer patients given as a lower overall dose in fewer higher doses (hypofractionated), does not seem to increase adverse symptoms or result in worse body image compared with the international standard treatment, according to the self-reported experience of patients. These results add to the evidence that shorter hypofractionated radiotherapy schedules do not cause more side effects in the breast, are equally effective at reducing the risk of further cancer in the breast, and thus provide better quality of life for patients. These are the conclusions of an Article published Online First in The Lancet Oncology.

Quality of life has been extensively studied in patients with breast cancer. But, little is known about the patients' perspective of quality of life after radiotherapy, particularly the effects of radiotherapy on adverse skin changes and body image.

To provide more evidence, Penelope Hopwood and colleagues from The Institute of Cancer Research, UK and the Royal Marsden NHS Foundation Trust, UK examined the patients' experience of adverse breast, arm, and shoulder symptoms and functional outcomes and body image after different radiotherapy regimens up to 5 years after treatment.

2208 women given radiotherapy after primary surgery for early-stage breast cancer recruited from the START (Standardisation of Breast Radiotherapy) Trials* completed quality-of-life questionnaires and self-assessments of body image and radiotherapy effects on healthy tissues at regular intervals for 5 years after treatment.

Over 5 years, the most frequently reported adverse effects were breast hardness (41%) and change in breast appearance (39%). In addition, up to a third of patients experienced arm and shoulder pain, while the 5-year rate of moderate or marked shoulder stiffness was about 20%. However, many arm and shoulder symptoms were present at the start of the study and were associated with previous surgery.

Adverse change in skin appearance after radiotherapy was the only symptom to differ significantly between the radiotherapy schedules, but the overall pattern for all adverse effects was similar, with lower or similar rates for the schedules with a higher daily dose compared with the international standard treatment.

The team found that 40% of women reported moderate or striking concerns for at least one body-image item up to 5 years following treatment. The most common concerns were feeling physically less attractive (23%) and dissatisfaction with body (23%). However, reported body image concerns did not differ between radiotherapy schedules.

The authors point out that: "Considerable morbidity still arises due to effects on normal [healthy] tissues of treatment for early breast cancer, and patients' self-assessments are important to ascertain the extent and duration of these effects."

They add that: "These ratings by patients...strengthen evidence in favour of hypofractionated regimens, [with the potential for] reduced adverse normal breast tissue effects reported...[and] have important implications for radiotherapy practice."

In an accompanying Comment, Julie Schnur from Mount Sinai School of Medicine, New York, USA says that these findings should make: "The understanding and assessment of patients' experiences a top priority." In particular, she says, they highlight the need for the development of a scale designed to assess breast body image rather than just overall body image, and broader interventions to improve body image such as cognitive and behavioural therapy.

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Dr Penelope Hopwood, Cancer Research UK's Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK. Please contact via the ICR press office. T) +44 (0) 207 153 5106 E) jane.bunce@icr.ac.uk

Professor Julie Schnur, Mount Sinai School of Medicine, New York, USA. T) +1 212 241 9200 (Ian Michaels, Press Secretary) E) Julie.schnur@mssm.edu

For full Article and Comment see: http://press.thelancet.com/tlohopwood.pdf

Notes to Editors:

* The START trials compared the international standard dose of radiotherapy (50 Gy delivered in 25 fractions over 5 weeks) with alternative schedules based on fewer but higher doses. In Trial A, doses of 39 Gy and 41.6 Gy were given in 13 fractions over 5 weeks and in Trial B, 40 Gy was given in 15 fractions over 3 weeks. Results showed that radiotherapy delivered as a lower overall dose in fewer larger doses gives similar tumour control and the potential for fewer adverse side effects than the international schedule.

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