IMRT for Breast Cancer Treatment: A New Standard?

Megan Comer

4/24/17
1. Buwenge M, Cammelli S, Ammendolia I, et al. Intensity modulated radiation therapy for

breast cancer: current perspectives. Breast Cancer: Targets and Therapies. 2017; 9: 121-126.

https://www.dovepress.com/intensity-modulated-radiation-therapy-for-breast-cancer-current-

perspe-peer-reviewed-fulltext-article-BCTT Accessed April 21, 2017.

The article “Intensity modulated radiation therapy for breast cancer: current perspectives”

is a systematic review of research conducted from 1990 to 2016 on the database PubMed1. A

systematic review takes data from multiple studies and critically analyzes it to answer a

research question. This review specifically analyzed the effects of intensity modulated

radiation therapy (IMRT) in breast cancer treatment, and sought to answer if patients

benefited in a long-term sense from IMRT versus whole breast radiation therapy (WBRT).

Ten articles reported data from five randomized controlled trials (RCT) found on the

PubMed website that matched criteria set up by the authors1. The studies used were all

randomized trials, had a primary endpoint of reduction of adverse events such as cosmesis

problems and quality of life, and were all prospective studies1. Overall, the review found that

the use of IMRT can reduce toxicity in certain patients, but more research needs to be done to

find what patients are good candidates for this treatment modality1.

The review is valid, both internally and externally. The point of the study was to review

WBRT to IMRT, specifically differences in the long-term side effects of patients, rates of

recurrence, quality of life. Using statistical analysis, the study accomplished this comparison.

The review uses five RCTs, but only three of which specifically compare IMRT and standard

WBRT with the same patient set-up and target dose goals. One study compares prone and

supine IMRT breast treatment, and the other compares IMRT accelerated partial breast

irradiation (APBI). These two differing studies of the five make it hard to determine if the
effects come specifically from the IMRT treatment, or from some other factors. This

decreases the external validity of the study. It would be more valid if the review had used

only RCTs that compared IMRT to WBRT specifically. This study is reliable, because if it

were to be done again, the same results would be yielded. This systemic review could be

better if more RCT were compared, but this may not realistically be possible if more RCTs

are not available for review.

This review concludes that IMRT cannot yet be considered for standard treatment

technique, because there was no impact on patients QoL. But, it should be considered for

patients with factors such as large breasts, post-op complications, or hot-spot volumes when

planned with WBRT1. These results will change daily clinical practice, however. Different

radiation therapy options will be available for women who have irregular breast shapes and

sizes that previously would have had to deal with increased toxicity and associated skin

effects. Dosimetrists will need to have expanding knowledge to be able to plan these

different treatment techniques, and therapists will need to know what patients are under an

IMRT protocol, as their set up techniques may vary from normal WBRT. Based on the

systematic review conducted by Buwenge M, Cammelli S, Ammendolia I, et al., IMRT is

able to reduce toxicity and associated skin effects for selected patients, but is not essential for

all breast cancer patients.

2. Erpolat OP, Akmansu M, Dinc SC, Akkan K, Bora H. The evaluation of the feasibility of

carotid sparing intensity modulated radiation therapy technique for comprehensive breast

irradiation. Physica Medica. 2017; 36: 60-65.

http://www.sciencedirect.com/science/article/pii/S112017971730008X. Published March 22,

2017. Accessed April 21, 2017.

 “The evaluation of the feasibility of carotid sparing intensity modulated radiation therapy

technique for comprehensive breast irradiation” is a planning study comparing three-

dimensional conformal radiation therapy (3DCRT) and carotid-sparing IMRT. It compares

both the virtual dosimetric plans and feasibility of CS-IMRT versus 3DCRT planning, using

ten patients that met criteria such as having histologically proven left breast cancer, who

underwent breast-conserving surgery with axillary dissection, with at least one risk factor for

atherosclerosis2. When comparing the 3DCRT with the CS-IMRT plans, researchers found

better homogeneity index and CI were obtained, with better target coverage and controlled

dose to the carotid arteries and other critical structures2. Decreasing dose to the carotid

arteries is important for long-term survival and the quality of life of breast cancer patients,

especially those with obesity, hypertension, diabetes mellitus, and other risk factors for

vascular stenosis2. Overall, this study concludes that it is reasonable to designate the carotid

arteries as a dose-limiting structure, and perform CS-IMRT on high-risk patient populations.

This research is both reliable and valid. The restraints placed on the dosimetric plans are

reproducible, and would yield similar results in patients outside of the study, if the same

dosimetric techniques were used to plan the treatment. This study is valid, both internally and

externally. It set out to investigate CS-IMRT and the feasibility of using it to spare dose to

the carotid arteries for patients with risk factors for atherosclerosis, which is exactly what it

did. The results of this study are externally valid specifically for patients with left sided

breast cancer, who had breast-conserving surgery and have risk factors for atherosclerosis.

More studies would need to be done to generalize the use of CS-IMRT, such as to right sided

breast cancer patients, or those without known risks for heart disease. This study also has a
 cohort of n=10. An increase in the number of patients analyzed would make the data found

more significant, and would improve the quality of the study overall.

Using CS-IMRT in a clinical setting would differ greatly from 3DCRT. Many patients fit

the criteria set forth by this study, meaning a clinic would likely have patients who would

need CS-IMRT. This would increase the workload on dosimetrists and physicists, as the

carotid arteries would have to be contoured, and inverse-planning techniques used, rather

than the forward planning techniques that are used with 3DCRT. Since there is no long-term

data regarding the effects of a decrease in carotid artery dose, the next step in this trial would

be implementing CS-IMRT, and then following up with patients over the course of the

following years. The actual implementation of CS-IMRT over the course of the next few

years could change routine breast treatment, as margins will become smaller and set-ups will

need to be more accurate. In short, the use of CS-IMRT is a new technique for reducing

cardiotoxicities in left-breast cancer patients, especially those with risk for atherosclerosis,

which can eventually be implemented after more long-term studies have been done.

3. Jo IY, Kim SW, Son SH. Dosimetric evaluation of the skin-sparing effects of 3-

dimensional conformal radiotherapy and intensity-modulated radiotherapy for left breast

cancer. Oncotarget Open Access Impact Journal. 2017; 8(2): 3059-3063.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356864/. Published January 10, 2017.

“Dosimetric evaluation of the skin-sparing effects of 3-dimensional conformal

radiotherapy and intensity-modulated radiotherapy for left breast cancer” is a dosimetric

evaluation of the use of IMRT in left-sided breast cancer patients, and its effect on skin sparing

and target volume coverage. 20 patients who received whole breast radiation therapy (WBRT)
were enrolled in the study, and an IMRT plan was created for each, and then the two plans were

statistically compared to look at the skin toxicity levels in each. Their analysis found that the

skin-sparing effect was higher in the IMRT plans than the 3D-CRT, with the mean dose to the

skin being higher in the 3D-CRT plans3. The study also found improved target volume coverage

using IMRT, which is meaningful because this was achieved while also lowering the skin dose3.

This study is reliable, and would be easily recreated. The study initially used 20 patients

who had left-breast cancer. A 3D-CRT plan was created using field-in-field technique in addition

to two parallel-opposed tangential fields, and then a separate IMRT plan was created using seven

fields, which are both standard treatment plans that allow for reproducibility3. The dosimetric

evaluation that was done is internally valid, as it uses correct statistical analyzing techniques, a

Wilcoxon signed-rank test, to measure what the study set out to measure, which was evaluating

skin sparing effects of 3D-CRT plans versus IMRT plans in left sided breast patients. This study

has external validity as well, because it can be generalized beyond the study itself. The

dosimetric parameters set up in the study can easily be applied to right-sided breast cancer

patients, and all types of left-sided cancer patients, because the initial twenty patients were

randomly selected from an institution’s patient pool, with the only criteria being that they had

left-sided breast cancer. This random selection increases the validity of the study and its ability

to be generalized outside of this study. An increase in the number of patients could increase this

validity even more, as a wider variety of patients would have treatment plans calculated on them,

giving the study an even greater representation of the general population.

Since this study found an overall decrease in skin dose, organ at risk dose, and an

increase in target volume coverage when using IMRT versus 3D-CRT, it supports the

implementation of IMRT of left-sided breast cancer, and possibly all types of breast cancer, into
everyday practice. This would significantly change the dosimetric planning of breast treatments,

and would require dosimetrists, physicists, and doctors to make changes to their normal planning

routines. It would require treatment centers to have multi-leaf collimation on their machines, and

extra quality assurance work would have to be done for these plans. As a therapist, the set-ups

for the IMRT breast treatment may be different than WBRT, as margins will be smaller. This

may require longer appointment times, as more imaging will most likely need to be done to

ensure the patient is in the proper position. Overall, the implementation of IMRT breast

treatments would increase work-load for the cancer treatment center, but decrease skin toxicity

and radiation-related dermatitis for the patient.

 References

1. Buwenge M, Cammelli S, Ammendolia I, et al. Intensity modulated radiation therapy for

breast cancer: current perspectives. Breast Cancer: Targets and Therapies. 2017; 9: 121-126.

https://www.dovepress.com/intensity-modulated-radiation-therapy-for-breast-cancer-current-

perspe-peer-reviewed-fulltext-article-BCTT Accessed April 21, 2017.

2. Erpolat OP, Akmansu M, Dinc SC, Akkan K, Bora H. The evaluation of the feasibility of

carotid sparing intensity modulated radiation therapy technique for comprehensive breast

irradiation. Physica Medica. 2017; 36: 60-65.

3. Jo IY, Kim SW, Son SH. Dosimetric evaluation of the skin-sparing effects of 3-dimensional

conformal radiotherapy and intensity-modulated radiotherapy for left breast cancer. Oncotarget

Open Access Impact Journal. 2017; 8(2): 3059-3063.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356864/. Published January 10, 2017.