An article published Online First in The Lancet Oncology reports that radiotherapy for breast cancer patients given as a lower overall dose in fewer higher doses (hypofractionated) compared with the international standard treatment, does not seem to increase adverse symptoms. Also, according to the self-reported experience of patients, it does not result in worse body image. These results add to the evidence that shorter hypofractionated radiotherapy schedules do not cause more side effects in the breast. Furthermore, they are equally effective at reducing the risk of further cancer in the breast, and thus provide better quality of life for patients.
Quality of life in patients with breast cancer has been studied at length. But, there is little information about the patients’ perspective of quality of life after radiotherapy, particularly the effects of radiotherapy on adverse skin changes and body image.
Penelope Hopwood and colleagues from The Institute of Cancer Research, UK and the Royal Marsden NHS Foundation Trust, UK, investigated to provide more evidence. They examined the patients’ experience of adverse breast, arm, and shoulder symptoms. They analysed functional outcomes and body image after different radiotherapy regimens, up to five years after treatment.
A total of 2,208 women given radiotherapy after primary surgery for early-stage breast cancer were recruited from the START (Standardisation of Breast Radiotherapy) Trials. The START trials compared the international standard dose of radiotherapy (50 Gy delivered in 25 fractions over 5 weeks) with alternative schedules based on fewer but higher doses. In Trial A, doses of 39 Gy and 41.6 Gy were given in 13 fractions over 5 weeks and in Trial B, 40 Gy was given in 15 fractions over 3 weeks. Results showed that radiotherapy delivered as a lower overall dose in fewer larger doses gives similar tumour control and the potential for fewer adverse side effects than the international schedule. The women completed quality-of-life questionnaires and self-assessments of body image and radiotherapy effects on healthy tissues at regular intervals for five years after treatment.
The most frequently reported adverse effects over five years were breast hardness (41 percent) and change in breast appearance (39 percent). Also, up to a third of patients experienced arm and shoulder pain. The five-year rate of moderate or marked shoulder stiffness was about 20 percent. On the other hand, many arm and shoulder symptoms were present at the start of the study and were associated with previous surgery.
The only symptom to differ significantly between the radiotherapy schedules was undesirable change in skin appearance after radiotherapy. But the overall pattern for all adverse effects was similar. There were lower or similar rates for the schedules with a higher dose compared with the international standard treatment.
Researchers found that up to five years following treatment, 40 percent of women reported moderate or striking concerns for at least one body-image item. The most widespread concerns were feeling physically less attractive (23 percent) and dissatisfaction with body (23 percent). However, the reported body image concerns were similar between radiotherapy schedules.
The authors explain: “Considerable morbidity still arises due to effects on normal [healthy] tissues of treatment for early breast cancer, and patients’ self-assessments are important to ascertain the extent and duration of these effects.”
They comment: “These ratings by patients…strengthen evidence in favour of hypofractionated regimens, [with the potential for] reduced adverse normal breast tissue effects reported…[and] have important implications for radiotherapy practice.”
In an associated note, Julie Schnur from Mount Sinai School of Medicine, New York, USA says that these findings should make: “The understanding and assessment of patients’ experiences a top priority.” She says they particularly highlight the necessity for the development of a scale designed to assess breast body image rather than just overall body image. There is further need for broader interventions to improve body image such as cognitive and behavioural therapy.
“Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomized Standardisation of Breast Radiotherapy (START) trials”
Penelope Hopwood, Joanne S Haviland, Georges Sumo, Judith Mills, Judith M Bliss, John R Yarnold, on behalf of the START Trial Management Group
DOI: 10.1016/S1470-2045(09)70382-1
Written by Stephanie Brunner (B.A.)