This document summarizes the management of early breast cancer. It discusses that early breast cancer has not spread beyond the breast or lymph nodes. Management is based on clinical factors and can include lumpectomy or mastectomy for local treatment, followed by radiation and/or systemic therapies like chemotherapy. Breast conservation therapy with lumpectomy and radiation is equivalent to mastectomy in terms of survival. Sentinel lymph node biopsy can accurately stage lymph nodes and reduce morbidity compared to full axillary lymph node dissection for early breast cancer patients.

1. EARLY BREAST
CANCER:MANAGEMENT
BY: DR NITIN KUMAR
MODERATOR: DR SHAGUN MISRA

2. EARLY BREAST CANCER

3. • Breast cancer that has not spread beyond the breast or the axillary
lymph nodes. This includes ductal carcinoma in situ and stage I, stage
IIA, stage IIB, and stage IIIA breast cancers.
• T1-T3 & N0-N1 Disease.

4. MANAGEMENT
• Clinical extent – Stage
• Nodal status
• Pathological characteristic of tumor
• Receptor status
• Age of patient (menopausal status)
• Individual patient preference

5. TREATMENT OVERVIEW: EARLY STAGE BREAST CA
• Primary surgery (lumpectomy or mastectomy) to the breast and
regional nodes with or without radiation therapy (RT).
• Following definitive local treatment, adjuvant systemic therapy may
be offered, based on primary tumor characteristics such as tumor
size, grade, number of involved lymph nodes, the status of estrogen
(ER) and progesterone (PR) receptors, and expression of the human
epidermal growth factor 2 (HER2) receptor.
• Some patients with early-stage invasive breast cancer (particularly
those with HER2-positive or triple-negative disease) may be treated
with neoadjuvant therapy first, followed by surgery.

6. TREATMENT
• LOCAL THERAPY: Focuses on breast and lymph node area
Surgery
Radiotherapy
• SYSTEMIC THERAPY:
Endocrine
Chemotherapy
Targeted therapy

7. SURGERY
• The surgical management of patients with early-stage operable breast cancer
addresses both the primary tumor and regional lymphatics.
• PRIMARY TUMORS:
Complete local excision (CLE)
Mastectomy
• NODAL REGION:
Lymph node dissection
Sentinel node biopsy

8.  BREAST CONSERVATION SURGERY
• To maximise the disease control and decrease the impact of breast
cancer on quality of life.
• Demands clear local excision(CLE): clear histological margin with a rim
of normal breast tissue.
• Includes LUMPECTOMY & QUADRANTACTOMY
LUMPECTOMY: Tumor mass + narrow margin
QUADRANTACTOMY: Tumor + 2-3cm margin + overlying skin +
underlying fascia

9. RE-EXCISION AT PRIMARY SITE
• When surgical procedure is less than complete lumpectomy.
• Margins of resection unknown.
• Positive margin “ink on tumor”
• Suspicious residual microcalcification on post lumpectomy, pre-
irradiation mammogram.

10. CONTRAINDICATION OF BCS
• ABSOLUTE
RT during pregnancy (1st trimester)
Widespread disease: not incorporated in local single incision that achieve
negative margin
Diffuse suspicious microcalcification
Persistent, positive margins after “reasonable” surgical attempts

11. • RELATIVE
Tumor size greater than 5cm
Recurrence in previously conserved breast
Focally positive margins in absence of EIC
History of previous irradiation to chest
Germline mutation that predisposes to breast cancer development
Active vascular collagen disease

12.  MASTECTOMY
• In a mastectomy, all of the breast tissue underneath the skin is
removed.
• The nipple, lymph nodes, and muscle might be removed as well.
• Before removing the breast, the surgeon may do a sentinel lymph
node biopsy(SLNB).

13. Types of mastectomy include:
A total mastectomy or simple mastectomy is a surgery that removes
the whole breast with a flat skin closure. Chest muscle is not
removed.
• W S Halsted(Radical mastectomy): Breast tissue+overlying skin+pectoralis
muscle+enbloc removal of axillary LN
• D H Patey(Modified Radical Mastectomy): Pectoralis major preserved,
pectoralis minor removed
• Auchinclauss( Modified Patey’s): Both pectoralis preserved

14. A skin-sparing mastectomy removes the breast but not all of the
skin, in order to have breast reconstruction that might include flaps
and/or implants.
Nipple-sparing mastectomy preserves the nipple areola complex
(NAC) as well. Not everyone is a candidate for nipple-sparing
mastectomy.

15. Indications of Mastectomy
• Tumor of such a size relative to breast that has satisfactory cosmetic
result may not be obtained.
• Multicentric disease (>1quadrant or 2foci or more, 4cm apart)
• Diffusely positive margins not cleared with re-excision
• Prior radiation therapy to breast
• Active collagen vascular disease, particularly scleroderma
• Widespread indeterminate micro-calcification within breast
• Patients choice

16. Surgical Margins
• In a clear or negative margin (R0), no cancerous cells are found in the
tissue around the edge of the tumor.
• In an R1 positive margin, the surgeon removes all the visible tumor,
but the microscopic margins are still positive for tumor cells. Despite
best efforts this can happen.
• In an R2 positive margin, the surgeon is unable to remove all the
visible tumor or there is metastatic disease.

18. EQUIVALENCE OF BCT AND MASTECTOMY
• NSABP- 06
• EORTC 10801
• Veronesi et al
• DBCG-82TM Protocol
• EBCTCG Meta analysis 2005

19. NSABP-06 Compare Segmental Mastectomy and Axillary Dissection With and
Without Radiation of the Breast and Total Mastectomy and Axillary Dissection.
• To evaluate the efficacy of BCS in stage I or II
tumors (~50% each) that were 4 cm or less in
diameter.
• RT: 50Gy/25#, without boost.
• End points:
Disease free survival
Distant-disease–free survival
Overall survival

21. There is no difference in survival between women who underwent lumpectomy
followed by radiation compared to total mastectomy. Furthermore, treatment
lumpectomy and radiation reduces the recurrence of breast cancer compared to
lumpectomy alone or total mastectomy.

22. EORTC 10801 Breast conserving therapy versus
mastectomy for stage I–II breast cancer
• Stage I (15%) and II (85%)
patients, randomized to BCT vs
MRM
• BCT included RT to 50Gy/25#
with an HDR 25Gy boost to
cavity.
• Adjuvant CMF was given for 6
months to ~45% patients (age <
45 years and/or Node positive)

23. Kaplan-Meier curves for overall survival
in patients with a diagnosis of clinical
stage I or II invasive carcinoma of the
breast after breast-conserving therapy
and mastectomy
Cumulative incidence curves of malignant-
disease-related mortality, when other
causes of death are classed as competing
risks

24. • No significant difference in survival was observed. Thirteen-year
survival rates: mastectomy arm, 60.0% (95% CI 55.0%–65.0%); BCT
arm, 54.9% (95% CI 50.1%–59.8%).
• Updated EORTC 10801 trial showed no significant difference in either
the occurrence of distant metastases or overall survival between BCT
plus radiotherapy and mastectomy after a median of 22·1 years.

25. Veronesi et al: BCT vs MRM for Early Breast Cancer
• 701 patients with tumors <2 cm in diameter and without palpable
axillary nodes.
• 352 were randomly assigned to treatment - either quadrantectomy
and axillary dissection plus RT (50 Gy in 5 weeks to the breast and 10-
Gy boost) and 349 to radical (Halsted) mastectomy.
• ~25% patients were later found to be
node positive (5% N2).
• The probability of recurrence was
significantly higher with BCT than with
radical mastectomy (30 of 352 vs. 8 of
349 patients, P<0.001).

26. • After a median follow-up of 20 years, the rate of death from all causes was 41.7%in the
group that underwent breast-conserving surgery and 41.2% in the radical-mastectomy
group (P=1.0). The respective rates of death from breast cancer were 26.1 percent and
24.3 percent (P=0.8).
• Conclusion: Breast-conserving surgery is the treatment of choice for women with
relatively small breast cancers.

27. DBCG-82TM protocol Long-term results of BCS vs MRM for
EBC: 20-year follow-up
• 1983 to 1989 recruiting 1154 patients, of which 924 were
randomized. 793 were analysed; 131 excluded on account of incorrect
randomization.
• Eligibility criteria
• Primary operable breast carcinoma.
• Age < 70 years.
• Probability of satisfactory cosmetic outcome with BCS.

28. Study design and treatment modalities of patients entering the DBCG-82TM protocol.
• LOW RISK:tumour diameter of 50 mm or less, with no invasion to skin or deep fascia, and
no metastatic axillary lymph nodes.
• HIGH RISK: tumour diameter exceeding 50 mm, and/ or invasion to skin or deep fascia,
and/or involvement of axillary nodes

29. • Recurrence free survival (RFS)
according to intent to treat in 731
evaluable patients enrolled in the
DBCG-82TM protocol.
• Overall survival (OS) according to intent
to treat in 731 evaluable patients
enrolled in the DBCG-82TM protocol.

30. • The pattern of recurrences as a first event in breast conservation vs.
mastectomy did not differ significantly irrespective of site (p=0.27)
• New primaries were significantly associated to BCS while true
recurrences dominated among mastectomy treated patient.
• In conclusion, long-term data indicate that BCS in eligible patients
proves as effective as mastectomy both regarding local tumour
control, RFS and OS.

31. EBCTCG 2005 META-ANALYSIS
• Meta-analysis of prospective trials comparing mastectomy and ALND
versus BCS and ALND, total 42,000 patients in 78 trials.
RT vs no RT: 23,000
More vs less surgery: 9300
More surgery vs radiotherapy: 9300
• For axillary negative patients , the 5 year risk of an isolated local recurrence
in mastectomy patient was 5.3% compared 8.6% in BCT arm.
• For node positive patient the 5 year risk of an isolated local recurrence was
4.7% in mastectomy arm compared with 7.9% in BCT arm.
• OS (at 15 yr) of node positive patient with mastectomy was 65.6%
compared with 64.5% with BCT arm.

32. BREAST CONSERVATION THERAPY IS
ACCEPTABLE MODALITY OF TREATMENT IN
PLACE OF MASTECTOMY IN EARLY BREAST
CANCER

33.  NODAL REGION MANAGEMENT
AIMS
• Assessment of nodal status: For evaluation of prognosis
To determine adjuvant therapy
• Eradication of metastatic disease within axillary nodes
INCLUDES
• ALND (Axillary Lymph Node Dissection)
• SLND (Sentinel Lymph Node Dissection)

34. Axillary Lymph Node Dissection
LEVELS
• Level I – nodes located below the lower
edge of the chest muscle
• Level II – nodes located underneath the
chest muscle
• Level III – nodes located above the chest
muscle near the collarbone

35. ALND
• Dissections of level I & II has been most common axillary surgical
procedure in patients with clinically node negative breast cancer.
• Complete axillary dissection, including level III, performed in patients
with clinically positive lymph nodes.
• Level III dissection has greater morbidity, but no documented survival
benefit.

36. SENTINEL LYMPH NODE BIOPSY
• Sentinel lymph nodes (SLNs) are the first lymph nodes that cancer
cells are most likely to spread to from a primary tumor.
• Firstly tumor is localised
• Dermal injection (raise a wheal) of radiocolloid in skin overlying
tumor in 5 locations: 0.5mCi of Tc Sulphur colloid in 0.5cc. After
~1hour pt taken to OT.

37. • 5cc of dye injected typically isosulfan blue followed by massaging
5minutes. Methylene blue can also be used.
• Sub areolar injection (Sappey’s plexus) is preferred
• The combination of radioisotope and dye(‘Hot and Blue’) provide
most accurate means of localising the sentinel node.

38. EQUIVALENCE OF SLNB & ALND
• Veronesi et al. : Accuracy of SLNB
• ALMANAC : Morbidity of SLNB
• NSABP B32 : Efficacy of SLNB

39. VERONESI ET AL, 2003Randomized Comparison of Sentinel-Node
Biopsy with Routine Axillary Dissection in Breast Cancer
• Randomized trial of 516 patients with T1 tumors.
• Axillary dissection was performed in the sentinel node group if the
sentinel node contained metastases.
• The overall accuracy of the sentinel node status was 96.9% (249/257
correctly identified), the sensitivity 91.2% (83/91 patients picked up),
and the specificity 100%.
• There was less pain, less arm swelling and better arm mobility in the
patients who underwent sentinel node biopsy only, than in those who
also underwent axillary dissection.

40. ALMANAC TRIAL Axillary Lymph node Mapping vs Nodal Axillary
Clearance
• Patients randomized between
compulsory ALND vs SLNB + ALND. RT
was as per institutional protocol and
clinician discretion.

41. • Primary end points:
Arm morbidity
Quality of life
• The RR of any lymphedema and sensory loss for the SLNB vs ALND at
12 months was 0.37 (95% CI 0.23 - 0.60: 5% vs 13%) and 0.37 (95% CI
= 0.27 to 0.50: 11% vs 31%),respectively.
• Drain usage, length of hospital stay, and time to resumption of
normal day-to-day activities after surgery were statistically
significantly lower in the sentinel lymph node biopsy group (all P <
.001), and axillary operative time was reduced (P = .055).
• Patient-recorded QoL and arm functioning scores were significantly
better in the SLNB throughout (all p < .003). These benefits were seen
with no increase in anxiety levels in the sentinel lymph node biopsy
group (P > .05).

42. NSABP 32 Phase III, Randomized Trial Comparing Axillary Resection with Sentinal
Lymph Node Dissection:
• Enrolled 5611 women, of
which 3989 had negative
SLNBs.
• Mean follow up time for
SLN negative patients was
95.6 months.
• Predominantly T1 disease
and most patients
underwent BCS

43. • 8-year Kaplan-Meier
estimates for OS were 91·8%
(95% CI 90·4-93·3) in group 1
and 90·3% (88·8-91·8) in
group 2, unadjusted HR 1.2
(p=0.12)
• For DFS the HR was 1·05 (95%
CI 0·90-1·22; p=0·54) [82·4%
(80·584·4) in group 1 vs 81·5%
(79·6-83·4) in group 2].

44. • 309 deaths were reported, 140 of 1975 patients in group 1 and 169 of
2011 in group 2.
• 75 patients in Arm 1 had negative SLNBs but positive nodes on ALND.
Of these, 5 had died.
• There were eight regional-node recurrences as first events in group 1
and 14 in group 2 (p=0·22).
Conclusion: Overall survival, disease-free survival, and regional control
were statistically equivalent between groups. When the SLN is
negative, SLN surgery alone with no further ALND is an appropriate,
safe, and effective therapy for breast cancer patients with clinically
negative lymph nodes.

45. ALND AFTER POSITIVE SLNB?
• ACOSOG Z0011 (2011)
• IBCSG 23-01 (2013)
• AMAROS (2014)
• OTOASOR (2017)

46. ACOSOG Z0011 Guiliano et al, 2011 (updated 2017)
• Upto T2N0 (target sample size: 1900)
• SLNB followed by randomization to ALND
(445) or no ALND (446).
• Eligibility: < 2 nodes +ve on SLNB
• ALND: Level I+II, > 10 nodes
• RT: Opposed tangents, SCF field not
allowed.
• PRIMARY ENDPOINT: Overall endpoint
• SECONDARY ENDPOINT: Surgical
morbidities & Disease free survival

47. • 97% patients in both groups received systemic chemotherapy (most
common: Anthracycline + taxane)
• 90% patients received adjuvant RT in both groups.
SLND 86.3%
ALND 83.6%
SLND 80.2%
ALND 78.2%

48. • Conclusion
For patients with EBC who had limited SLN positivity, omission of
ALND did not result in inferior survival.

49. IBCSG 23-01 ALND vs no ALND in Sentinel Node micrometastases.
Galimberti et al, 2013
• cT2N0 patients >1 micrometastatic (< 2mm) deposits on SLNB.
PRIMARY ENDPOINT: Disease
free survival
• Median age: 53 years
• 90% patients had BCS
• 98% received adjuvant RT
• 96% received adjuvant systemic
therapy

50. 5-year DFS without ALND was
noninferior to ALND (HR 0·78, 95% CI
0·55–1·11; non-inferiority
p=0·0042).
5-year OS without ALND was
noninferior; HR for non-inferiority was
<1.25 (pre-defined objective) for all
subgroup analyses by T size, ER
status, grade and type of surgery.
Conclusion: Axillary dissection could be avoided in patients with early breast cancer and
limited sentinel-node involvement, thus eliminating complications of axillary surgery with no
adverse effect on survival.

51. AMAROS Radiotherapy Or Surgery, a randomised, multicentre, open-label, phase 3
non-inferiority trial
• N = 4823, upto T2N0
• PRIMARY ENDPOINT: 5 year axillary
recurrence
• SECONDARY ENDPOINTS:
Axillary RFS
Disease Free Survival
Overall Survival
Shoulder mobility
Lymphedema
 Quality of Life
• Receptor status not recorded, systemic
treatment as per physican.
• RT included Axilla levels I-III + SCF.

52. • Median follow up (SLNB+): 10 years
• Axillary recurrence
- 7/744 with ALND vs 11/681 with RT (0.43% vs 1.82%)
- Study was not powered to detect a difference this small.
• OS: 81.4% with RT vs 84.6% with ALND (NS)
• DFS also similar.
• Lymphedema significantly more in ALND arm, but not to extent
defined in protocol (10% increase in circumference). Shoulder
mobility, QoL were also similar.

53. Conclusion:
Comparable disease control, with lesser morbidity in the RT arm.

54. OTOASOR Optimal Treatment of Axilla Surgery or Radiotherapy (after +ve
SLNB)
• N = 526; T < 3cm, cN0 (Triple test)
• RT: WB + Axilla (1-3) + SCF; 50Gy/25#
• 83% ER+ve, 12% Her2+ve; 83% BCS
• pT2/3 57% vs 40% in ALND vs RNI
• Mean F/U: 97 months (Range 54 – 134)
• PRIMARY ENDPOINT: Axillary control
• SECONDARY ENDPOINT:
OS
DFS
• OS: 78% vs 85% (NS)
• DFS: 72% vs 77% (NS)

55. SUMMARY
• In selected patients of Early Breast Cancer, axillary dissection may be
omitted despite a positive SLNB.1
Upto T2 disease
Micrometastases/1-2 positive sentinel nodes
Upfront surgery
• Locoregional RT and systemic therapy form an integral component of
management for these patients.

56. ROLE OF RT IN BCS
• NSABP-06 (1985, updated 2002)
• Veronesi et al (1993, updated 2001)
• EBCTCG Meta-analysis (2011)

57. Selected randomized trials of BCS±RT in
early-stage breast cancer

58. NSABP B06 Mastectomy vs Lumpectomy + RT (20 year update,
Fisher et al 2002)
• Initiated in 1976.
• N = 2163, Stage I and II disease
• 3 arms: MRM (713) v Lumpectomy (719) v Lumpectomy + WBI (731)
• The cumulative incidence of an IBTR 20 years after surgery was 14.3%
in PORT and 39.2% among those who underwent lumpectomy only (p
<.001).
• The benefit of radiation therapy was independent of nodal status.

59. • Slightly better cancer specific survival, though not statistically
significant.
• For the patients treated with lumpectomy
alone, IBTR rates were ~ 40% in nodes
negative patients and 50% for N+ve.
• For patients treated with lumpectomy +
RT, the corresponding rates were 10% for
N0 and 5% for N+ve.
• There was no difference between the
treatment groups for OS, DFS and DDFS.
20 YEAR MASTECTOMY LUMPECTOMY LUMPECTOMY+R
T
OS 47% 46% 46%
DFS 35% 35% 36%

60. • IBRT
Significantly poorer with RT
• Overall Survival 82.4% in Surgery
+ RT
76.9% in Surgery alone p = 0.326

61. EBCTCG Meta-analysis 2011 Effect on RT after BCS
• Evaluated 10801 women treated with BCS in randomized trials that
examined RT vs no RT following Breast conservation.
• All the trials demonstrated a significant decrease in the incidence of
IBTR with addition of radiation.
• Node –ve: 29% → 10%
• Node +ve: 47% → 13%
(Rate of IBTR at 10 year)
• The magnitude of the benefit was greatest in in studies which
included stage I and II breast cancers.

62. • Reduced the 15-year risk of breast cancer death from 25.2% to 21.4%
(absolute reduction 3.8%, 1.6 – 6.0, 2p=0.00005).
• After breast-conserving surgery, radiotherapy to the conserved breast
halves the rate at which the disease recurs and reduces the breast
cancer death rate by about a sixth.

63. SUMMARY: PORT
• BCS
All patients
With lumpectomy boost
• Mastectomy
>T3 &/or N+
Close Margins
• Positive margins
All Patients

64. HYPOFRACTIONATION IN CA BREAST
RADIOBIOLOGY
• Traditionally tumor is assumed to be relatively
less responsive to fraction size with a high α/β.
• However, several studies have now been
reported that suggest α/β for breast is much
lower (~3).
Therefore a modest increase in fraction size should
achieve a greater cell kill, which could translate
into better tumor control.
This is in contrast to most other tumors, where the
high α/β makes the required increase in fraction
size prohibitively high.

65. START TRIALS A & B
• Designed to assess the impact of larger fraction size on treatment
outcomes (oncological and toxicity).
• Upto pT3aN1, BCS or MRM with clear margins (> 1mm)
START A START B
3 different RT regimens while keeping
OTT same (5 weeks)
2 RT regimens with OTT as per daily
treatment.
50Gy/25# @2Gy/# over 5 weeks
41.6Gy/13# @3.2Gy/# over 5 weeks
39Gy/13# @3Gy/# over 5 weeks
50Gy/25# @2Gy/# over 5 weeks
40Gy/15# @2.67Gy/# over 3 weeks

66. START A EFS OS LRR
50GY 86.4% 88.9% 7.4%
41.6GY 88% 88.7% 6.3%
39GY 89.3% 89.3% 8.8%
START B EFS OS LRR
50GY 85.9% 89% 5.5%
40GY 88.4% 92% 4.3%

67. START A: DFS SIMILAR IN ALL
ARMS
START B: DFS BETTER WITH
40GY

68. START A
SHRINKAGE 50GY 34.2%
41.6GY 31.4%
39GY 30.0%
INDURATION 50GY 27.1%
41.6GY 28.2%
39GY 21.6%
ARM EDEMA 50GY 16.3%
41.6GY 22.5%
39GY 8.2%
START B
SHRINKAGE 50GY 31.2%
40GY 26.2%
INDURATION 50GY 17.4%
40GY 14.3%
ARM EDEMA 50GY 13.7%
40GY 4.7%

69. Hypofractionation in breast cancer Whelan et al
(2010)
• INCLUSION CRITERIA
Invasive Breast Ca ( upto T2), BCS, Margins clear, N0, separation > 25cm
Stratified by T size (T1/T2), Age (50 years), systemic therapy, centre
• TREATMENT ARM
Control group: 50.0 Gy in 25 fractions over 35 days (n = 612)
Trial group: 42.5 Gy in 16 fractions over 22 days (n = 622)
• No Nodal irradiation/Boost
• 80% Stage I, 70% ER+
• 40% received tamoxifen, 10% chemotherapy

70. RESULTS
• Risk of local recurrence at 10years
6.7% in standard irradiation arm
6.2% in hypo fractionated regimen
• Cosmetic outcomes at 10 years
71.3% good or excellent in control group
69.8% good or excellent in hypofractionated group
• Late toxicity and cosmesis was similar in both arms at both 5 and 10
years
CONCLUSION:
Hypofractionated whole breast irradiation was not inferior to standard
fractionation treatment in T1-2N0 with clear margins.

71. Extreme Hypofractionation UK FAST CRUKE/04/015
• 3 dose fraction regimens:
50 Gy/25# @ 2Gy/#, 5 days a week x 5 weeks (n = 302)
30 Gy/5# @ 6Gy/#, once a week x 5 weeks (n = 308)
28.5 Gy/5# @ 5.7Gy/#, once a week x 5 weeks (n = 903)
• EBC; pT < 3cm, N0, upfront BCS.
• Median F/U: 10 years
• CF and 28.5/5 arms were comparable in terms of late effets, but 30Gy/5#
resulted in significantly worse lymphedema, breast hardness and
telangiectasia.
• 10yr local relapse rate (all patients): 1.3% (total 10 events only)

72. EXTREME HYPOFRACTIONATION
• Patient convenience, combined with the radiobiology of breast
tumors and logistics makes hypofractionation an attractive prospect.
• Several other retrospective, Phase 1 and 2 studies have been
reported with encouraging results.
• Under evaluation; not a part of standard practice yet.
Long term oncological outcome results awaited.

73. FAST Forward Phase 3, randomised, non-inferiority trial
ELIGIBILITY
• Patients aged at least 18 years
• Invasive carcinoma of the breast (pT1–3, pN0–1, M0)
• Had breast conservation surgery or mastectomy (reconstruction
allowed)
• Concurrent endocrine therapy or trastuzumab, or both, were
permitted but not concurrent chemotherapy.

74. • RANDOMISATION: 3 ARMS
40 Gy in 15 fractions of 2·67 Gy
27 Gy in five fractions of 5·4 Gy
26 Gy in five fractions of 5·2 Gy
A sequential tumour bed radiotherapy boost to the conserved breast was
allowed (10 Gy or 16 Gy in 2-Gy fractions).
• ENDPONTS
PRIMARY:Ipsilateral breast tumour relapse
SECONDARY: late normal tissue effects
• Median follow-up of 71·5 months

75. RESULTS
• 5-year incidence of ipsilateral
breast tumour relapse
40Gy: 2.1%(1.4 to 3.1%)
27Gy: 1·7% (1·2 to 2·6)
26Gy: 1·4% (0·9 to 2·2)

76. CONCLUSION
26 Gy in five fractions over 1 week is non-inferior to the standard of 40
Gy in 15 fractions over 3 weeks for local tumour control, and is as safe
in terms of normal tissue effects up to 5 years for patients prescribed
adjuvant local radiotherapy after primary surgery for early-stage breast
cancer.

77. Whole Breast Irradiation (WBI) ASTRO
• All patients receiving WBI should be offered hypofractionated
schedules irrespective of age, stage, use of systemic therapy, invasive
or DCIS, with or without reconstruction.
• Rare histologies should still be treated with conventional
fractionation.
• Lumpectomy boost may be omitted in patients aged >70 years, ER+ve
and upto Grade II if clear margins are obtained.

78. ROLE OF BOOST IN EBC
• Rationale: 65%-80% of breast recurrences after BCS + RT occur
around the primary tumor site.
• As early as 1987 Clark et al noted in 1,504 patients a greater
incidence of failures at 10 years of 17% in those to whom no boost
was delivered, compared with 11% in those who received a cavity
boost of 5 to 15 Gy (p = .03).

79. EORTC 22881-10882 Bartelink et al, 2001; updt 2007, 2015
• 5,318 patients with BCS followed by whole-breast RT (50 Gy).
• 2661 patients (16Gy boost) vs 2657 patients (no boost).
RESULTS
• With a median follow-up of 17.2 years
20 year OS: 59.7% (Boost) vs 61.1% (No boost)
20 year IBTR: 12% (Boost) vs 16.4% (No boost)
20 year Severe fibrosis: 5.2% (Boost) vs 1.8% (No boost)
• Local recurrence was 10.2% vs 6.2% for the no boost and the boost group,
respectively (p = 0.0001).
• Largest benefit was observed in age ≤ 40 yrs (23.9% to 13%).

80. • Cumulative incidence of recurrence of tumor in the ipsilateral breast
after whole-breast irradiation to 50 Gy, with or without an additional
dose to the tumor bed, according to age.

81. RT DOSES NCCN GUIDELINES 1.2016
Conventional fractionation:
• 45 - 50Gy/25# @ 1.8 – 2 Gy/#, 5 fractions per week.
Hypofractionation:
• 40 - 42.5 Gy/15-16# @ 2.66 Gy/#, 5 fractions per week.
Tumor bed boost:
• 10 – 16 Gy @ 2 Gy per fraction.
• Role of boost in modern era of hypofractionated schedules uncertain.
• Improved local control; no benefit in DFS/OS.

82. REGIONAL NODE IRRADIATION
• INDICATIONS OF RT TO IMN
Positive axillary lymph nodes with central and medial lesions
Stage III disease
Positive sentinel lymph nodes in IM chain
SLN +ve in axilla with drainage to IM on lymphoscintigraphy

83. • INDICATION OF RT TO AXILLA
Node positive with extensive extra capsular extension
Sentinel lymph node positive with no dissection
Inadequate axillary dissection
High risk with no dissection

84. • INDICATION OF RT TO SCF
ABSOLUTE
cN2/3 disease
pN2 or pN3 disease (> 4 positive lymph nodes after axillary dissection
RELATIVE
1-3 positive lymph nodes
Positive sentinel lymph node with no axillary dissection

85. PARTIAL BREAST IRRADIATION
• Most local relapses occur in the vicinity of the original tumor bed.
• The reason for considering BCT is the disfiguring nature of
mastectomy. However the late toxicity caused by adjuvant whole
breast RT often offsets the advantage of limited surgery.
• Partial-breast radiotherapy using modern methods of radiotherapy
planning and treatment can offer good disease control while
minimizing the risk of late complications.

86. PBI TECHNIQUES
Interstitial catheters Intracavitary
(Mammosite)
IORT 3D Conformal
DOSE 34 Gy in 10# 5 days 34 Gy in 10# 5 days 18 - 21 Gy Single
fraction
38.5 Gy/10# 5 days
TARGET 1.5 cm margin
around cavity
1 cm around WLE
cavity
Visual by surgeon
and oncologist
2.5cm margin
around cavity
PROS Flexibility in
planning
Ease of placement
and planning
Single dose
Spares skin
Standard RT
machines,
Non invasive
CONS Operator
Dependent
High cost,
Fewer dwell
positions
RT before HPE
known,
Specialised
centres only
Larger fields and
more normal
tissue.

87. UK IMPORT LOW trial a multicentre, randomised,
controlled, phase 3, non-inferiority trial
• 3 arms
Whole Breast RT 40 Gy/15# (n = 674)
Whole Breast RT 36 Gy/15# + Tumor Bed 40 Gy/15# (n = 673)
Tumor Bed (partial breast) 40 Gy/15# (n = 669)
• Inclusion
Age > 50 years, Size < 3cm
Upto 3 +ve nodes
Margins > 2mm
• Median F/U: 72.2 months

88. • Primary end point: IBTR
• Secondary end points:
Location of relapse
Time to relapse
DFS, OS
CBTR
• Patient characteristics
90 % Grade 1 or 2
96% Node negative, 93% LVI absent
95% ER +ve, 81% PR +ve, 96% Her2 –ve

89. • LOCAL RELAPSE
WBI: 1%
Reduced dose: < 1%
PBI: 1%
• Most late effects were lower with
reduced dose and PBI, though the
number was statistically significant
only for breast appearance.
• Breast shrinkage, induration, shoulder stiffness, skin appearance
arm edema were all statistically similar.

90. ACCELERATED PARTIAL BREAST IRRADIATION
• BCT involves Surgery → RT to whole breast and a lumpectomy boost.
However, this in its conventional form requires a protracted
treatment course (> 4 weeks).
• PBI already offers the opportunity to deliver RT to smaller volumes; it
is an attractive notion to compress the duration of RT. This is further
enabled by the reduction in target volume which can allow better
sparing of OARs.
• Logistics and patient convenience.

91. • TECHNIQUES
Interstitial brachytherapy
External beam conformal partial breast irradiation
Intraoperative single dose irradiation
Balloon brachytherapy
• CONSTRAINTS
Uninvolved normal breast: Ideally < 60% of the whole breast reference
volume should receive ≥ 50% of prescribed dose and < 35% of the whole
breast reference volume should receive the prescribed dose.
Contralateral breast: Contralateral breast reference volume, contoured using
the same methods described for the ipsilateral breast volume, should receive
< 3% of the prescribed dose to any point.

92. Ipsilateral lung: V30% < 15%, contralateral lung: V5% < 15%
HEART:
-Right breast: V5% < 5% of the heart volume.
- Left breast: V5% < 40%.
Thyroid: Maximum point dose of 3% of the prescribed dose

93. • DOSE FRACTIONATION
Brachytherapy - 34 Gy @ 3.4 Gy/#
For APBI by EBRT - 38.5 Gy/3.85 Gy/#
2# per day, > 6 hrs apart x 5 days

94. SYSTEMIC THERAPY
• CHEMOTHERAPY
• HORMONAL THERAPY
• TARGETED THERAPY

95. EBCTCG Meta-analysis Comparisons between different
polychemotherapy regimens for EBC
• 123 trials, >1,00,000 patients
• Comparisons:
Any taxane + anthracycline based regimen vs the same, or more, non-taxane
chemotherapy (n=44000).
 One anthracycline based regimen vs another (n=7000) or vs CMF (n=18000).
Polychemotherapy vs no chemotherapy (n=32000).

96. • For CMF v no chemotherapy, RRs:
Distant recurrence: 0.66 (SE 0.05)
Any recurrence: 0.70 (SE 0.04)
Breast cancer mortality: 0.76 (SE 0.05) - Overall mortality: 0.84 (SE 0.05)
Absolute mortality improvement: 4.7% at 10 years (30.7% → 26%)
• For any anthracycline-based regimen v no chemotherapy, RRs:
Distant recurrence 0.69 (SE 0.04)
Any recurrence: 0.73 (SE 0.03) - Breast cancer mortality: 0.79 (SE 0.04)
Overall mortality: 0.84 (SE 0.03)
Absolute mortality improvement: 5% at 10 years (39.6% → 34.6%)

97. • For higher anthracycline dosage vs CMF, RRs:
Any recurrence: 0.89 for recurrence (SE 0.04)
Breast Cancer mortality: 0.80 (SE 0.05)
Overall mortality: 0.84 (SE 0.04)
Absolute mortality improvement: 3.9% at 10 years (27.1% → 23.2%)
• In contrast, standard dose 4AC was found equivalent to CMF in these
parameters.
• Taxane + anthracycline based regimen vs the same, or more, non-taxane
chemotherapy: RRs
Distant recurrence: 0.87 (SE 0.03)
Any recurrence: 0.86 (SE 0.02)
Breast Cancer Mortality: 0.87 (SE 0.03) - Overall mortality: 0.89 (SE 0.03)
Absolute mortality improvement: 3.2% at 8 years (26.7% → 23.5%)

98. CHEMOTHERAPY
• Preferred for HER2 –ve
Dose dense AC → Paclitaxel every 2 weeks.
Dose dense AC → weekly Paclitaxel.
TC (docetaxel and cyclophosphamide) - AC → Docetaxel or TAC every 3 weeks
For TNBC with residual disease after Taxane + anthracycline + alkylating
agent: Adjuvant Capecitabine

99. • Preferred for HER2 +ve:
AC → TH(pacli + Trastu) + Pertuzumab
TCH (docetaxel/carboplatin/trastuzumab) + Pertuzumab
If residual disease after neoadjuvant therapy with above: Adjuvant Ado-
trastuzumab emtansine (T-DM1) x 1 year

100. • Nearly all patients with EBC require chemotherapy.
• Only a small subset with favourable disease characteristics may safely
omit it.(T1aN0, ER/PR +ve: May omit)
• Standard of care regimens include an anthracycline (unless contra-
indicated) with or without taxane.
• Her2 directed therapy is recommended for all patients with Her2+ve
disease.

101. HORMONAL THERAPY

102. • Selective Estrogen Receptor Modulator (SERM)
Tamoxifen,Tormemifene,Raloxifene
• Aromatase Inhibitor
1st Gen: Aminoglutethimide
2nd Gen: Formestane, fadrozole
3rd Gen: Exemestane, letrozole, anastrazole
• Pure Estrogen Receptor Antagonists (SERD)
Fulvestrant
• Ovarian ablation
RT, oophorectomy
• Ovarian suppression
GnRH analogs: Leuprolide, Goserelin, Triptorelin

103. EBCTCG Meta-analysis: Effect of Tamoxifen
• 55 trials, ~ 35,000 patients.
• For patients with ER+ve disease (n = 18000):
Reductions RECURRENCE MORTALITY
1 YEAR 21% ± 5% 14% ± 5%
2 YEAR 28% ± 3% 18% ± 4%
5 YEAR 50% ± 4% 28% ± 5%
• Patients with ER+ve disease should receive 5 years of adjuvant tamoxifen.

104. • For patients with ER poor disease (n = 8000):
REDUCTIONS RECURRENCE MORTALITY
1 YEAR 6% ± 8% 6% ± 8%
2 YEAR 13% ± 5% 7% ± 5%
5 YEAR 6% ± 11% -3% ± 11%

105. EBCTCG Metaanalysis: AI v Tamoxifen in EBC
• 31920 ER+ve, post-menopausal patients in RCTs.
• Comparisons:
5 years AI vs 5 years Tamoxifen
5 years AI vs 2-3 years Tamoxifen + AI to complete 5 years
5 years Tamoxifen vs 2-3 years Tamoxifen + AI to complete 5 years
• 5 years AI v 5 years Tamoxifen, at 10 years (n = 9885)
Recurrence: 22.7% vs 19.1% (3.6% gain)
Breast Cancer Mortality: 12.1% vs 14.2% (2.1% gain)
Overall mortality: 24% vs 21.3% (2.7% gain)

106. • 5 years AI v switch at 2-3 years, at 7 years (n = 12779)
Recurrence: 22.7% vs 19.1% (3.6% gain)
Breast Cancer Mortality: 12.1% vs 14.2% (2.1% gain)
Overall mortality: 24% vs 21.3% (2.7% gain)
• In Post-menopausal ER+ve women, AIs reduce 10 year relative
mortality by 15% compared to tamoxifen.

107. ADVERSE EFFECTS
• Menopausal symptoms:
50% - 60% ( N.B. 40% - 50% in placebo)
Vaginal dryness and discharge
Osteopenia > osteoporosis
• Depression:
Maybe seen in as high as 10% of patients.
No randomized comparisons available

108. • Ocular toxicity:
Keratopathy, maculopathy & cataract
Reported with high doses
• Thromboembolism:
Severe thromboembolism seen in ~ 1% patients in the preventive setting.
Risk up to 10 times that experienced by healthy women
Complication more common in elderly patients with metastatic breast cancer
and who are receiving CCT
• Carcinogenesis:
Increased risk of endometrial cancers (hazard rate of 1.7 per 1000 – NSABP B
14 data)
Mostly low grade & stage I tumors.

109. • OTHERS:
Hepatomas
Clear cell sarcomas of ovary

110. OPTIMAL DURATION OF HT
• At least 2 large randomized studies (ATLAS and aTTom) have
demonstrated that 5 more years of adjuvant hormonal therapy
reduces the risk of recurrence, breast cancer specific and overall
mortality. (total 10 years)
• They do so at the cost of increased toxicity:
Doubled rates of 2nd malignancy, specifically endometrial cancer
VTE events
Ischemic heart disease

111. SUMMARY: ENDOCRINE THERAPY
• All patients with ER+ve/PR+ve disease should receive adjuvant hormonal
therapy.
Pre-menopausal: Tamoxifen
Post-Menopausal: AI
• Duration: 5 years minimum; strong consideration should be given to
completing 10 years
• For high risk pre-menopausal patients (i.e. N+ve, Her2+ve, age < 40y, large
high grade tumors), to consider adding Ovarian Suppression to
AI/Tamoxifen

112. TARGETED THERAPY
• Her2: Trastuzumab, Pertuzumab, Ado-trastuzumab emtansine (T-
DM1), Lapatinib
• CDKi: Palbociclib, Ribociclib, Abemaciclib
• Anti Her2 therapy generally incorporated with Neoadjuvant or
adjuvant systemic therapy for 1 year
Trastuzumab
Trastuzumab + Pertuzumab
TDM-1
• Lapatinib and CDK4/6 inhibitors not recommended in the setting of
curative treatment