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Recommendation
Hypofractionated radiation therapy after breast-conserving surgery
Offer a hypofractionated course of radiation therapy to women with breast cancer who have undergone breast-conserving surgery with clear surgical margins and who require post-operative whole breast radiation therapy.
In selected patients* with early breast cancer who require post-operative whole breast radiotherapy, hypofractionated radiotherapy is a suitable alternative to conventionally fractionated radiotherapy and should be offered where appropriate.
*Patients: Women aged 50 years or older with pathological stage T1-2, node-negative (N0), non-metastatic (M0) disease who have undergone breast conserving surgery, with clear surgical margins.)
When selecting an appropriate radiotherapy schedule consideration should be given to the possibility of adverse events including acute reactions and late effects, noting that cosmetic outcomes are equivalent with the recommended optimal schedules for hypofractionated radiotherapy versus a conventionally fractionated radiotherapy schedule
Grade, margins, and ER/PR/HER2 status and biology Statement KQ1B. The decision to offer HF-WBI should be independent of tumor grade (Recommendation strength: Strong; Quality of evidence: High; Consensus: 100%)
Statement KQ1C. The decision to offer HF-WBI may be independent of hormone receptor status, HER2 receptor status, and margin status. (Recommendation strength: Conditional; Quality of evidence: Moderate; Consensus: 100%)
Statement KQ1D. The decision to offer hypofractionation should be independent of breast cancer laterality. (Recommendation strength: Strong; Quality of evidence: Moderate; Consensus: 100%) Systemic therapy receipt
Statement KQ1E. The decision to offer HF-WBI should be independent of chemotherapy received prior to radiation and trastuzumab or endocrine therapy received prior to or during radiation. (Recommendation strength: Strong; Quality of evidence: Moderate; Consensus: 92%)
Statement KQ1F. There is no evidence indicating deleterious effects of HF-WBI compared with CF-WBI in either younger or older patients, and thus HF-WBI may be used regardless of age. (Recommendation strength: Conditional; Quality of evidence: Moderate; Consensus: 93%)
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation(s) but care should be taken in its application
A strong recommendation indicated the task force was confident the benefits of the intervention clearly outweighed the harms, or vice versa, and “all or almost all informed people would make the recommended choice
Conditional recommendations were made when the risks and benefits were even or uncertain and “most informed people would choose the recommended course of action, but a substantial number would not,” suggesting a strong role for shared decision-making
Appropriate to offer a shorter, more intense course of radiotherapy (hypofractionated radiotherapy) as an alternative to conventional radiotherapy for patients with early breast cancer who: are aged 50 years and over; have a cancer at an early pathological stage T1-2, N0, M0); and have undergone breast conserving surgery with clear surgical margins
How this guidance was developed
This recommendation was initially adapted from the CA 2015 guidelines (Australia). Two source recommendations were merged and adapted to use language applicable to the Australian health care context. Both source recommendations were based on a systematic review conducted to November 2013: one was graded 'A' and the other 'B' (using NHMRC methods) by the source guideline authors. This initial rewording was in alignment with ASTRO (2011) which recommended HF-WBI for women ≥50 years old, T1-2 N0, no chemotherapy and ±7% dose homogeneity in the central axis.
This original wording also aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 5.
However, the ASTRO guidelines were updated in 2018 and currently recommend HF-WBI for patients of any age, at any stage (provided intent is to treat the whole breast), and any chemotherapy [and volume of breast tissue receiving >105% pf the prescription dose should be minimised regardless of dose fractionation). The relevant recommendations are based on a systematic review of the evidence conducted to May 2016 and the various elements were graded ‘strong’ or ‘conditional’ (using GRADE methods) by the source guideline authors.
Related guidance by topic
Hypofractionated radiation therapy after breast-conserving surgery
Recommendation
Offer a hypofractionated course of radiation therapy to women with breast cancer who have undergone breast-conserving surgery with clear surgical margins and who require post-operative whole breast radiation therapy.
Principles in action
Safe and quality care
This recommendation was initially adapted from the CA 2015 guidelines (Australia). Two source recommendations were merged and adapted to use language applicable to the Australian health care context. Both source recommendations were based on a systematic review conducted to November 2013: one was graded 'A' and the other 'B' (using NHMRC methods) by the source guideline authors. This initial rewording was in alignment with ASTRO (2011) which recommended HF-WBI for women ≥50 years old, T1-2 N0, no chemotherapy and ±7% dose homogeneity in the central axis.
This original wording also aligns with the 2017 Cancer Australia Statement – Influencing best practice in breast cancer: Practice 5.
However, the ASTRO guidelines were updated in 2018 and currently recommend HF-WBI for patients of any age, at any stage (provided intent is to treat the whole breast), and any chemotherapy [and volume of breast tissue receiving >105% pf the prescription dose should be minimised regardless of dose fractionation). The relevant recommendations are based on a systematic review of the evidence conducted to May 2016 and the various elements were graded ‘strong’ or ‘conditional’ (using GRADE methods) by the source guideline authors.
Related guidance by topic
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