ročník 11,2003 č.4

Radiotherapy-chemotherapy integration in breast-conservation therapy

Petruzelka L., Kubes J., Betlachová L., Engelová D.

Institute for Radiation Oncology, Prague, Czech Republic

Radiation therapy has clearly been established as an effective treatment modality in breast-conserving therapy, as adjuvant therapy in the post mastectomy setting, in the management of locoregional recurrence of disease, and as tool in the palliation of patients with metastatic disease.
Breast-conserving surgery followed by radiation therapy to the intact breast is an acceptable, but the preferred, standard of care for majority of women with early-stage invasive breast cancer. Criteria for breast conserving therapy are as follows
1. tumours up to 3 cm,
2. satisfactory cosmetic results anticipated,
3. postoperative whole breast radiotherapy technically feasible,
4. medically fit for surgery,
5. clear histological margins at primary excision or re-excision,
6. able to attend for regular clinical and mammographic follow up.

For patients with invasive breast cancer, omission of irradiation results in high local relapse rate. A potential alternative to whole-breast irradiation is focused to the tumour bed employing brachytherapy or using conformal radiation techniques. For patients with invasive carcinoma the alternatives to whole-breast irradiation should only be recommended in the context of prospective trials.
The majority of patients undergoing breast - conserving surgery followed by radiotherapy to the intact breast for invasive breast carcinoma will receive some form of systemic therapy, either cytotoxic therapy and/or adjuvant hormonal treatment. Clinicians are now commonly faced with the necessity of combining systemic therapy and radiation in patients after surgery. The optimal sequencing of radiation (RT) with chemotherapy (CT) remains unresolved. The options for combining RT and CT are
1. CT first followed by RT;
2. RT first followed by CT;
3. RT and CT simultaneously; or
4. CT, then RT, and then more CT (commonly referred to as sandwich therapy).

The major goal in sequencing is to obtain the highest rate of survival; however, additional important goals are to maintain a low rate of local recurrence and a low rate of complications. Decisions regarding the timing of CT and RT are individualized, depending on risk factors for systemic and/or local disease. In patients where chemotherapy is being considered, initiation of chemotherapy prior to radiation currently appears preferable.