Postmastectomy Radiation Therapy: An ASTRO-ASCO-SSO Clinical Practice Guideline

Abstract

ASCO Guidelines provide recommendations with comprehensive review and analyses of the relevant literature for each recommendation, following the guideline development process as outlined in the ASCO Guidelines Methodology Manual . ASCO Guidelines follow the ASCO Conflict of Interest Policy for Clinical Practice Guidelines . Clinical Practice Guidelines and other guidance (“Guidance”) provided by ASCO is not a comprehensive or definitive guide to treatment options. It is intended for voluntary use by clinicians and should be used in conjunction with independent professional judgment. Guidance may not be applicable to all patients, interventions, diseases or stages of diseases. Guidance is based on review and analysis of relevant literature, and is not intended as a statement of the standard of care. ASCO does not endorse third-party drugs, devices, services, or therapies and assumes no responsibility for any harm arising from or related to the use of this information. See complete ASCO and ASTRO disclaimers in Appendix 1 (online only) for more. PURPOSE This guideline provides recommendations on use of postmastectomy radiation therapy (PMRT) in breast cancer treatment. Updated recommendations detail indications for PMRT in the upfront surgical setting and after neoadjuvant systemic therapy, and provide guidance on appropriate target volumes, dosing, and treatment techniques. METHODS A multidisciplinary American Society for Radiation Oncology–ASCO–Society of Surgical Oncology task force addressed four key radiation therapy (RT) questions in patients with breast cancer who undergo mastectomy: (1) indications for PMRT after upfront surgery, (2) indications for PMRT after neoadjuvant systemic therapy followed by surgery, (3) appropriate PMRT volumes and dose-fractionation regimens, and (4) treatment techniques. Recommendations were based on a systematic review and created using a predefined consensus-building methodology for quality of evidence grading and strength of recommendation. RECOMMENDATIONS After upfront mastectomy, PMRT is indicated for most patients with node-positive breast cancer and select patients with node-negative disease. PMRT is also recommended after neoadjuvant systemic therapy for patients presenting with locally advanced disease and for those with residual nodal disease at the time of surgery. PMRT is conditionally recommended for patients with cT1-3N1 or cT3N0 breast cancer with pathologically negative nodes after neoadjuvant systemic therapy (ypN0). When PMRT is delivered, treatment to the ipsilateral chest wall or reconstructed breast and regional lymphatics is recommended, with moderate hypofractionation preferred, but with conventional fractionation approaches acceptable in rare cases. Computed tomography–based volumetric treatment planning with 3-dimensional conformal RT is recommended, with intensity-modulated RT advised when three-dimensional conformal RT is unable to achieve treatment goals. Deep inspiration breath-hold techniques are also recommended for normal tissue sparing. For patients with skin involvement, positive superficial margins, and/or lymphovascular invasion, use of a bolus is recommended, but routine use of tissue-equivalent bolus is not recommended. Additional information is available at www.asco.org/breast-cancer-guidelines .