International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: breastLong-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system
Introduction
The data on clinical outcome after breast-conserving therapy (BCT) in women with early-stage breast cancer underline its potential curability. Surgical removal of the tumor followed by radiotherapy (RT) with or without chemotherapy is a common treatment protocol. Studies of BCT show a relatively low recurrence rate with limited long-term morbidity and a high level of patient satisfaction with the cosmetic outcome 1, 2, 3.
Thus, longer patient survival results in a greater chance for long-term radiation sequelae to increase in incidence and severity (4). Symptomatic long-term radiation sequelae are a burden on the quality of life of our patients.
For external beam RT, it has been sufficiently proved that the probability of late side effects depends on, among other factors, the fractionation, interfraction interval, total dose, and volume irradiated, as well as individual patient factors 5, 6, 7.
Clinical experience and previous studies have revealed a heterogeneous spectrum of late toxicity such as pain, breast edema, fibrosis, telangiectasia, arm edema, atrophy, ulcer, pulmonary fibrosis, rib fractures, and others 8, 9, 10, 11. However, monitoring radiation-induced late effects in daily practice and clinical trials has not been standardized, and only long-term follow-up data can determine the ultimate risk. The European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group proposed the late effects of normal tissue-subjective, objective, management, and analytic (LENT-SOMA) scales to allow the quantification of late effects on normal tissue and therefore minimize the risk of overlooking an unacceptable incidence of late morbidity 12, 13.
Within the past years, LENT-SOMA scales of different anatomic sites have been used successfully to detect and analyze radiation-relevant late toxicity after treatment of benign (14) and malignant 15, 16, 17 diseases.
The aim of this retrospective study was to present the status quo of long-term toxicity in 590 cured women who underwent BCT up to 19 years previously (median follow-up 96 months, range 51–222). A direct comparison of the results of our three subpopulations was not appropriate because of different follow-up intervals, RT protocols, and patient numbers. Treatment-related morbidity was classified using the LENT-SOMA criteria. Patients and physicians graded the cosmetic outcome.
Section snippets
Patients
Between 1983 and 1995, 2943 women with early-stage breast cancer were irradiated after BCT (lumpectomy) at the University Hospital of Hamburg.
Women were accepted for BCT if they fulfilled the following criteria: pathologic Stage I (pT1pN0 M0) or Stage II (pT2pN0M0, pT1pN1M0, or pT2pN0cM0) disease and compatibility between tumor size and remaining breast to allow an acceptable cosmetic result.
Of the 2943 patients, 1923 (65%) were eligible for the study (alive with known address); 577 (20%) had
Results
Patient and treatment characteristics are shown in Table 1. The median age at treatment was 54 years (range 27–82). The median time between RT and the last follow-up visit was 8 years (range 5–19).
Discussion
In general, the clinical experience that has been accumulated over decades may not be able to predict with certainty what will be the outcome of long-term toxicity. The importance of knowledge on the tolerance of normal tissue to irradiation by radiation oncologists cannot be overemphasized.
One rationale for this study was to assess the late morbidity in patients who were treated with BCT >5 years ago. Long-term sequelae with a median follow-up of 8 years (range 4–19) after BCT were evaluated
Conclusion
Our data reveal that subjective and objective long-term late effects in women after BCT are not infrequent; however, they are mainly asymptomatic with minor effects on daily life. The LENT-SOMA breast module is a useful tool in monitoring late toxicity. It should be used in a prospective setting in both clinical practice and forthcoming studies to allow actuarial risk estimates and better comparability of data for definitive conclusions.
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