- Email: [email protected]
Outcomes of 3D Conformal Planning of Whole Breast Radiotherapy Following Breast Conserving Surgery
Abstracts / Clinical Oncology 29 (2017) e95ee104 z
The Royal Marsden NHS Foundation Trust, London, UK Guy’s and St Thomas’ NHS Foundation Trust, London, UK jj Velindre NHS Trust, Cardiff, UK x
Purpose: Oncotype DX is a 21 gene panel developed to predict the risk of tumour recurrence in patients with oestrogen receptor (ER) positive, HER2 negative breast cancer. NICE has recommended its use for patients at intermediate risk of recurrence, where this information would help clinicians to assess the potential benefit of chemotherapy versus endocrine therapy alone. Our aim was to see how oncologists are interpreting Oncotype DX tests in their clinical practice. Methods: Data on patient and tumour characteristics (size, grade, ER/PR/ HER2/nodal status), Oncotype DX recurrence score, treatment options offered and treatment outcomes were collected from 11 UK cancer centres. Results: Of the 358 patients tested, 185 (52%) were in the low risk category (recurrence score <18), 129 (36%) were intermediate risk (score 18e30) and 42 (12%) were high risk (31). Chemotherapy was recommended for 4 patients in the low risk group, and was discussed/offered to a further 10. Chemotherapy was recommended for all high risk patients. For patients with intermediate Oncotype scores, chemotherapy was recommended for 46 patients (44.2%), the option of chemotherapy was discussed/offered to 16 (15.4%) and 42 (40.4%) were not offered chemotherapy. Overall, 90 patients (25.1%) received chemotherapy. Where oncologists recommended chemotherapy to patients (n ¼ 94), 85.1% of patients went on to receive chemotherapy. Where oncologists had offered or discussed chemotherapy as an option (n ¼ 26), 34.6% of patients went on to receive it. The most common regimens were FEC756 (45%), EC6 (18%) and EC4 (13%), with 12% of patients receiving third generation chemotherapy (FEC/T or EC/taxane); other regimens included AC4, TC4 and weekly paclitaxel. Conclusion: Over half of patients tested had low risk Oncotype scores. The majority (74.9%) of patients tested did not receive chemotherapy. The widest variation in clinical practice was observed in interpreting intermediate risk Oncotype results, and in the chemotherapy regimens offered.
Outcomes of 3D Conformal Planning of Whole Breast Radiotherapy Following Breast Conserving Surgery R. De Paiva, F. Mark, O. Fraser, S. Dubey Plymouth Hospital NHS Trust, Plymouth, UK Purpose: 3D conformal radiotherapy planning using the field in field (FiF) technique has been in use in our department since 2009 to deliver whole breast radiotherapy following breast conservation surgery (BCS). This retrospective study assessed the rates of ipsilateral breast cancer recurrence and dosimetric data with the FiF technique. Methods: Patients treated with conformal whole breast radiotherapy following BCS between January 2010 and December 2011 were identified from the local radiotherapy database and hospital records were accessed to record the relevant information. For conformal radiotherapy, whole breast and high risk CTV were defined together with respective PTVs with a margin of 5 mm. The heart and lung volumes were also defined on the planning system. Results: 219 patients were included in the study. The mean follow-up period was 67.8 months. The mean age of patients was 59.3 years. The tumour margin was clear by >2 mm in 75.1% of cases. The adjuvant hormonal treatment was received by 77.1% and chemotherapy by 32.9% of patients. All patients received conformal FiF breast radiotherapy to a dose of 40 Gy in 15 fractions over 3 weeks. The median number of radiotherapy treatment fields was 4. The mean whole breast PTV (PTVWB) covered by the 90% isodose was 94.97% with a mean Dmax dose of 106.6%. The mean heart dose for left-sided treatment was 1.19 Gy. The mean ipsilateral lung volume covered by 12 Gy was 9.7%. The ipsilateral breast cancer recurrence was detected in 7 patients (3.19%). On multivariate Cox regression analysis, HER2 status, T stage, age and dose covering PTVWB were statistically associated with increased risk of ipsilateral breast relapse. Conclusion: The conformal whole breast radiotherapy enables optimisation of radiotherapy doses to target volume and organs at risk without affecting local control rates.
e99
Changes in Ejection Fraction (EF) Following Sequential Anthracycline and Trastuzumab in Patients with HER2D Early Breast Cancer (EBC) e Is There a Need for Two Echocardiograms Pre-trastuzumab? S. Fernando *, L. Okonta *, I. Sandri *, A. Wardley y, H. Mitchell y, A.M. Conway y * Guy’s and St Thomas’ NHS Foundation Trust, London, UK y The Christie Hospital, Christie NHS Foundation Trust, Manchester, UK
Purpose: NCRI [1] guidelines state that echocardiograms should be done on HER2þ breast cancer patients pre-anthracycline chemotherapy, pre-trastuzumab and on the 6th and 12th cycles of trastuzumab. A previous UKBCM [2] audit from the Christie NHS Foundation Trust showed that there was no change between EF pre-anthracycline and pre-trastuzumab. The recommendation was to omit one echocardiogram in younger patients with no cardiac co-morbidities. We decided to conduct a similar audit at Guy’s and St Thomas’ NHS Foundation Trust. Methods: Retrospective data were collected over a 2 year period (May 2014 to 2016) from our chemotherapy database. HER2þ EBC patients having adjuvant/neoadjuvant chemotherapy with an anthracycline followed by trastuzumab were selected. Echocardiogram reports were retrieved preanthracycline and then pre-trastuzumab. Results: Sixty-nine patients were identified. There was a decrease in EF 10% in only two patients, both under 50 years of age. Patient 1: no cardiovascular co-morbidities. EF decreased from 64% to 54% between anthracycline and trastuzumab. Ramipril 1.25 mg was started. The EF at the end of 18 cycles of treatment was 56%. Patient 2: History of palpitations. The first EF was 76%. Subsequent echocardiograms showed stable EFs of 55e65%. No treatment was given. Eighteen patients had cardiovascular co-morbidities, of whom two were over 65 years. Only three patients overall were over 65 years. None of these patients had a decrease in EF at these time points. Conclusion: Our results support those from the Christie. Most patients do not require two echocardiograms pre-trastuzumab. Even though there was a decrease in EF 10% in two patients, the resulting EF was still >50% and the patients were asymptomatic. This supports a change in practice with only high risk patients having more frequent echocardiograms. References [1] Jones AL, et al. Management of cardiac health in trastuzumab-treated patients with breast cancer: updated United Kingdom National Cancer Research Institute recommendations for monitoring. Br J Cancer 2009;100(5):684e692. [2] Wardley A, Mitchell H, Conway AM, et al. Cardiac monitoring and cardiac events in patients receiving adjuvant trastuzumab treatment. The Christie NHS Foundation Trust. Poster session presented at the 3rd Annual UK Breast Cancer Group, 20e21 November 2015, London, UK.
Clinical Benefit from Vinorelbine after Prior Treatment with Eribulin: a Single-centre Experience T. Irfan, A. Okines, K. Khabra, A. Ring, M. Parton, S. Johnson, N. Turner The Royal Marsden NHS Foundation Trust, London, UK
Purpose: The EMBRACE trial demonstrated that eribulin, a microtubule inhibitor, improved survival for previously treated advanced breast cancer (ABC) compared with chemotherapy of physician’s choice, which was vinorelbine, a vinca alkaloid microtubule inhibitor, in 25% [1]. Vinorelbine is now commonly used as a 3rd line treatment after eribulin, but its efficacy in this setting is unknown. Methods: A retrospective analysis of all patients who received vinorelbine after prior eribulin for ABC between 2011 and 2015. Data collected included patient demographics, histopathology, treatment duration and responses. The primary end point was progression-free survival (PFS) from the date of first vinorelbine. Secondary end points included radiological response rate (RR), clinical benefit rate (partial response or stable disease) and overall survival (OS). Results: 38 patients were identified, all female, 25/38 (65.8%) were ER positive/ HER2 negative, 6 (15.8%) HER2 positive and 7 (18.4%) triple negative. The median number of chemotherapy lines for ABC prior to eribulin was 2 (range 0e4). 15 patients (39.5%) received 1 line of chemotherapy between eribulin and vinorelbine. Patients received a median of 3 cycles of vinorelbine (range
The Royal Marsden NHS Foundation Trust, London, UK Guy’s and St Thomas’ NHS Foundation Trust, London, UK jj Velindre NHS Trust, Cardiff, UK x
Purpose: Oncotype DX is a 21 gene panel developed to predict the risk of tumour recurrence in patients with oestrogen receptor (ER) positive, HER2 negative breast cancer. NICE has recommended its use for patients at intermediate risk of recurrence, where this information would help clinicians to assess the potential benefit of chemotherapy versus endocrine therapy alone. Our aim was to see how oncologists are interpreting Oncotype DX tests in their clinical practice. Methods: Data on patient and tumour characteristics (size, grade, ER/PR/ HER2/nodal status), Oncotype DX recurrence score, treatment options offered and treatment outcomes were collected from 11 UK cancer centres. Results: Of the 358 patients tested, 185 (52%) were in the low risk category (recurrence score <18), 129 (36%) were intermediate risk (score 18e30) and 42 (12%) were high risk (31). Chemotherapy was recommended for 4 patients in the low risk group, and was discussed/offered to a further 10. Chemotherapy was recommended for all high risk patients. For patients with intermediate Oncotype scores, chemotherapy was recommended for 46 patients (44.2%), the option of chemotherapy was discussed/offered to 16 (15.4%) and 42 (40.4%) were not offered chemotherapy. Overall, 90 patients (25.1%) received chemotherapy. Where oncologists recommended chemotherapy to patients (n ¼ 94), 85.1% of patients went on to receive chemotherapy. Where oncologists had offered or discussed chemotherapy as an option (n ¼ 26), 34.6% of patients went on to receive it. The most common regimens were FEC756 (45%), EC6 (18%) and EC4 (13%), with 12% of patients receiving third generation chemotherapy (FEC/T or EC/taxane); other regimens included AC4, TC4 and weekly paclitaxel. Conclusion: Over half of patients tested had low risk Oncotype scores. The majority (74.9%) of patients tested did not receive chemotherapy. The widest variation in clinical practice was observed in interpreting intermediate risk Oncotype results, and in the chemotherapy regimens offered.
Outcomes of 3D Conformal Planning of Whole Breast Radiotherapy Following Breast Conserving Surgery R. De Paiva, F. Mark, O. Fraser, S. Dubey Plymouth Hospital NHS Trust, Plymouth, UK Purpose: 3D conformal radiotherapy planning using the field in field (FiF) technique has been in use in our department since 2009 to deliver whole breast radiotherapy following breast conservation surgery (BCS). This retrospective study assessed the rates of ipsilateral breast cancer recurrence and dosimetric data with the FiF technique. Methods: Patients treated with conformal whole breast radiotherapy following BCS between January 2010 and December 2011 were identified from the local radiotherapy database and hospital records were accessed to record the relevant information. For conformal radiotherapy, whole breast and high risk CTV were defined together with respective PTVs with a margin of 5 mm. The heart and lung volumes were also defined on the planning system. Results: 219 patients were included in the study. The mean follow-up period was 67.8 months. The mean age of patients was 59.3 years. The tumour margin was clear by >2 mm in 75.1% of cases. The adjuvant hormonal treatment was received by 77.1% and chemotherapy by 32.9% of patients. All patients received conformal FiF breast radiotherapy to a dose of 40 Gy in 15 fractions over 3 weeks. The median number of radiotherapy treatment fields was 4. The mean whole breast PTV (PTVWB) covered by the 90% isodose was 94.97% with a mean Dmax dose of 106.6%. The mean heart dose for left-sided treatment was 1.19 Gy. The mean ipsilateral lung volume covered by 12 Gy was 9.7%. The ipsilateral breast cancer recurrence was detected in 7 patients (3.19%). On multivariate Cox regression analysis, HER2 status, T stage, age and dose covering PTVWB were statistically associated with increased risk of ipsilateral breast relapse. Conclusion: The conformal whole breast radiotherapy enables optimisation of radiotherapy doses to target volume and organs at risk without affecting local control rates.
e99
Changes in Ejection Fraction (EF) Following Sequential Anthracycline and Trastuzumab in Patients with HER2D Early Breast Cancer (EBC) e Is There a Need for Two Echocardiograms Pre-trastuzumab? S. Fernando *, L. Okonta *, I. Sandri *, A. Wardley y, H. Mitchell y, A.M. Conway y * Guy’s and St Thomas’ NHS Foundation Trust, London, UK y The Christie Hospital, Christie NHS Foundation Trust, Manchester, UK
Purpose: NCRI [1] guidelines state that echocardiograms should be done on HER2þ breast cancer patients pre-anthracycline chemotherapy, pre-trastuzumab and on the 6th and 12th cycles of trastuzumab. A previous UKBCM [2] audit from the Christie NHS Foundation Trust showed that there was no change between EF pre-anthracycline and pre-trastuzumab. The recommendation was to omit one echocardiogram in younger patients with no cardiac co-morbidities. We decided to conduct a similar audit at Guy’s and St Thomas’ NHS Foundation Trust. Methods: Retrospective data were collected over a 2 year period (May 2014 to 2016) from our chemotherapy database. HER2þ EBC patients having adjuvant/neoadjuvant chemotherapy with an anthracycline followed by trastuzumab were selected. Echocardiogram reports were retrieved preanthracycline and then pre-trastuzumab. Results: Sixty-nine patients were identified. There was a decrease in EF 10% in only two patients, both under 50 years of age. Patient 1: no cardiovascular co-morbidities. EF decreased from 64% to 54% between anthracycline and trastuzumab. Ramipril 1.25 mg was started. The EF at the end of 18 cycles of treatment was 56%. Patient 2: History of palpitations. The first EF was 76%. Subsequent echocardiograms showed stable EFs of 55e65%. No treatment was given. Eighteen patients had cardiovascular co-morbidities, of whom two were over 65 years. Only three patients overall were over 65 years. None of these patients had a decrease in EF at these time points. Conclusion: Our results support those from the Christie. Most patients do not require two echocardiograms pre-trastuzumab. Even though there was a decrease in EF 10% in two patients, the resulting EF was still >50% and the patients were asymptomatic. This supports a change in practice with only high risk patients having more frequent echocardiograms. References [1] Jones AL, et al. Management of cardiac health in trastuzumab-treated patients with breast cancer: updated United Kingdom National Cancer Research Institute recommendations for monitoring. Br J Cancer 2009;100(5):684e692. [2] Wardley A, Mitchell H, Conway AM, et al. Cardiac monitoring and cardiac events in patients receiving adjuvant trastuzumab treatment. The Christie NHS Foundation Trust. Poster session presented at the 3rd Annual UK Breast Cancer Group, 20e21 November 2015, London, UK.
Clinical Benefit from Vinorelbine after Prior Treatment with Eribulin: a Single-centre Experience T. Irfan, A. Okines, K. Khabra, A. Ring, M. Parton, S. Johnson, N. Turner The Royal Marsden NHS Foundation Trust, London, UK
Purpose: The EMBRACE trial demonstrated that eribulin, a microtubule inhibitor, improved survival for previously treated advanced breast cancer (ABC) compared with chemotherapy of physician’s choice, which was vinorelbine, a vinca alkaloid microtubule inhibitor, in 25% [1]. Vinorelbine is now commonly used as a 3rd line treatment after eribulin, but its efficacy in this setting is unknown. Methods: A retrospective analysis of all patients who received vinorelbine after prior eribulin for ABC between 2011 and 2015. Data collected included patient demographics, histopathology, treatment duration and responses. The primary end point was progression-free survival (PFS) from the date of first vinorelbine. Secondary end points included radiological response rate (RR), clinical benefit rate (partial response or stable disease) and overall survival (OS). Results: 38 patients were identified, all female, 25/38 (65.8%) were ER positive/ HER2 negative, 6 (15.8%) HER2 positive and 7 (18.4%) triple negative. The median number of chemotherapy lines for ABC prior to eribulin was 2 (range 0e4). 15 patients (39.5%) received 1 line of chemotherapy between eribulin and vinorelbine. Patients received a median of 3 cycles of vinorelbine (range