Lancet: Fewer, higher rad doses improve quality of life in breast cancer

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Hypofractionated radiotherapy regimens for the treatment of breast cancer patients does not result in increased physical side effects in the breast or detriment to body image and is equally as effective at reducing the risk of further cancer in the breast, which can lead to better quality of life for patients, according to the results of the START study published online Feb. 8 in the Lancet Oncology.

Penelope Hopwood, MD, from the Institute of Cancer Research in Sutton, England, and colleagues recruited participants for their study from the randomized START (Standardization of Breast Radiotherapy) trials. The researchers sought to determine if a lower overall dose of radiotherapy, administered in fewer, higher doses could result in improved patient perspective of quality-of-life after a follow-up period of five years.

The investigators administered radiotherapy to 2,236 participants in 13 fractions over a five-week period and 2,215 participants received 15 fractions in three weeks following primary surgery for early-stage breast cancer. Of these patients, 81 percent were included in the study after the completion of quality-of-life questionnaires and self-assessments at the five-year follow-up mark after the radiation treatment.

The self-assessment questions focused on the patients' opinions regarding their body image and radiotherapy effects on healthy tissues. The researchers found that the most frequently reported adverse effects were breast hardness (41 percent) and change in breast appearance (39 percent), at the five-year follow-up reports of moderate arm and shoulder pain or stiffness (20 percent) were noted by the authors, who said that these symptoms were present at the start of the study and were associated with the previous surgery.

Hopwood and colleagues wrote that while reported rates of adverse radiotherapy effects were found to be similar in both groups of patients, the reported rate of adverse change in skin appearance was found to be significantly lower for patients who received less overall radiotherapy.

Forty percent of the participants reported moderate or prominent concerns for at least one body image issue up to five years following treatment, with the most common concerns including feeling physically less attractive (23 percent) and dissatisfaction with their body (23 percent), according to Hopwood and colleagues.

Despite this finding, the authors wrote that the reported body image concerns did not differ between radiotherapy schedules, and breast symptoms and body image concerns generally lessened over time.

"These ratings by patients strengthen evidence in favor of hypofractionated regimens, [with the potential for] reduced adverse normal breast tissue effects reported…[and] have important implications for radiotherapy practice," concluded the authors.

In the accompanying commentary, Julie Schnur, MD, from Mount Sinai School of Medicine in New York City, wrote that these findings should make [t]he understanding and assessment of patients' experiences a top priority."

In particular, she wrote, 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 behavioral therapy.