Breast cancer is the most frequent tumor in women in our country. According to data from the Spanish Network of Cancer Registries (REDECAN) the incidence last year was 34,750 new cases, which represents an increase compared to the previous year (33,375). However, due to all the therapeutic advances, survival from breast cancer has improved.
Advances in surgery, radiotherapy, systemic treatments and genetic analysis have allowed the survival rate for breast cancer to be around 90%. Recently, a study called PRIME II and published by the magazine ‘New England Journal of Medicine‘ assured that receiving radiotherapy after suffering from breast cancer in patients over 65 years of age did not increase the survival rate and it was better to “ignore it”. The coordinator of the Spanish Group of Radiotherapy Oncology for Breast Cancer (GEORM) of the Spanish Society of Radiation Oncology (SEOR), Dr. Arancha Eraso, qualifies the study data in an interview with OKSALUD.
QUESTION.- Is radiotherapy an essential curative treatment for breast tumors?
ANSWER.- Without a doubt, yes. Surgery, radiotherapy and systemic treatments are the three pillars on which breast cancer treatment rests, and are responsible for survival rates now around 90%.
Q.- Can radiotherapy be applied to all breast tumors?
R.- About 85% of patients with breast cancer will receive radiological treatment throughout the development of their disease. It has been shown to be effective both in combating the disease locally and in survival in all age groups.
Q.- Is radiotherapy recommended regardless of the patient’s age?
patient? Have you improved technically?
R.- Definitely. Pivotal studies demonstrate the benefit of radiotherapy after surgical treatment, that is, what we call adjuvant radiotherapy in all age groups. With a proven benefit in local control and survival. The breast cancer standard has changed towards hypofractionated radiotherapy schemes, that is, shorter and highly precise schemes. In many patients with a good prognosis, one week of treatment is sufficient. Oncology seeks treatment personalization and precision, adapting it to each woman with breast cancer. Thus, in recent decades, the individualization of breast cancer treatment has been governed by “less is more.”
Q.- How do you apply “less is more” in the treatment of patients with breast cancer?
R.- This is “less surgery”, almost completely abandoning removal of the entire breast, having demonstrated the superiority of conservative surgery followed by radiotherapy over mastectomy; “less is more” in chemotherapy and systemic treatments, allowing many women to avoid many of the undesirable adverse effects thanks to the use of genetic tests to identify different levels of risk and “less is more” in radiotherapy, allowing to reduce the intensity of the treatments , from the obsolete irradiation schemes for five or six weeks to the current three or even treatments in a single week, of five days, in patients with low-risk early cancers. And “less is more” in partial breast irradiation volume. We no longer have to irradiate the entire mammary gland, it is enough to irradiate the tumor bed with a margin.
Q.- What do you think of what the PRIME II study published in the “New England Journal of Medicine” exposes about the use of radiotherapy in early-stage breast cancer in patients over 65 years of age, which states that it does not improve the survival rates?
R.- This is a randomized phase 3 study, which is the highest level of study to decide treatments. The main objective is to evaluate the local control of the tumor in a group of 1326 patients with early breast cancer, over 65 years of age. In addition, they had a favorable prognosis as they were small tumors (less than 3cm), without axillary involvement, subjected to conservative surgery and with antihormonal treatment. What was randomized was whether or not to receive radiotherapy. The results after 10 years of follow-up are resounding; local control in those patients who received radiotherapy was significantly better in all age groups.
Local failure without radiotherapy is 9.5%, compared to 0.9% of those who did receive radiotherapy, with which the benefit of radiotherapy is clear. Even in those with low expression of hormone receptors, the benefit is even greater with a local failure rate of 19% in non-radiated patients compared to 0% in those who received radiation. What comes together is that radiotherapy reduces the risk of local failure, meaning that it is a treatment that reduces the possibility of patients suffering a recurrence of cancer in the same breast.
Something that has a direct impact on improving the quality of life of patients and that would imply avoiding new surgeries, new treatments and, above all, reducing the emotional burden of facing the disease again. In addition, sometimes, the recurrence has a worse prognosis, it can be more aggressive or have a more extensive disease.
Q.- Do you agree with what these researchers say that radiotherapy can be safely excluded when treating people over 65 with early-stage breast cancer?
R.- No, I’m not agree. The fact that in this study they did not find differences in overall survival between those who receive and do not receive radiotherapy is not at all synonymous with the fact that it is an omissible treatment. “The absence of evidence is not evidence of absence”, is a classic precept in Medicine that should not be ignored even at this time. In addition, from GEORM-SEOR we want to highlight and highlight a parameter of notable importance, which is quality of life, and in this regard, it is worth noting that, despite the fact that in the article all patients receive at least between 15 and 25 sessions Today, it is no longer debatable that, thanks to current knowledge and irradiation techniques, no patient with these characteristics should receive more than 5 radiotherapy sessions in a single week in any case.
Q.- Why do you think radiotherapy is given this negative nuance in this news about the PRIME II study? What are you looking to achieve?
R.- I do not know, I suppose that due to an erroneous interpretation of personalized oncology and ignorance of current radiotherapy, which with technological advances has increased precision and is a treatment with minimal side effects. As I mentioned before, thanks to the use of genetic tests, we can adjust the duration and intensity of treatments for the elderly. We do very short treatment schemes of about 15 sessions compared to the six weeks that were done before.
Q.- Have you received older patients who do not want to undergo radiotherapy due to this news? How do you think the damage caused by this type of information can be combated?
R.- No, until today no one has asked not to undergo treatment, they trust multidisciplinary teams. I don’t know if any patient will mention it in the future. I consider it very important that the information transmitted in the media be contrasted and everything related to the studies is well explained so that it does not lead to confusion for patients, and in this case, to “ignore” a treatment that has demonstrated its efficacy both locally and in survival at all ages.
