Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial

Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at l...

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Published inThe Lancet (British edition) Vol. 390; no. 10099; pp. 1048 - 1060
Main Authors Coles, Charlotte E, Griffin, Clare L, Kirby, Anna M, Titley, Jenny, Agrawal, Rajiv K, Alhasso, Abdulla, Bhattacharya, Indrani S, Brunt, Adrian M, Ciurlionis, Laura, Chan, Charlie, Donovan, Ellen M, Emson, Marie A, Harnett, Adrian N, Haviland, Joanne S, Hopwood, Penelope, Jefford, Monica L, Kaggwa, Ronald, Sawyer, Elinor J, Syndikus, Isabel, Tsang, Yat M, Wheatley, Duncan A, Wilcox, Maggie, Yarnold, John R, Bliss, Judith M, Al Sarakbi, Wail, Barber, Sarah, Barnett, Gillian, Bliss, Peter, Dewar, John, Eaton, David, Ebbs, Stephen, Ellis, Ian, Evans, Philip, Harris, Emma, James, Hayley, Kirwan, Cliona, Kirk, Julie, Mayles, Helen, McIntyre, Anne, Mills, Judith, Poynter, Andrew, Provenzano, Elena, Rawlings, Christine, Sculpher, Mark, Sumo, Georges, Sydenham, Mark, Tutt, Andrew, Twyman, Nicola, Venables, Karen, Winship, Anna, Winstanley, John, Wishart, Gordon, Thompson, Alastair
Format Journal Article
LanguageEnglish
Published England Elsevier Ltd 09.09.2017
Elsevier Limited
Elsevier
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Abstract Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy. IMPORT LOW is a multicentre, randomised, controlled, phase 3, non-inferiority trial done in 30 radiotherapy centres in the UK. Women aged 50 years or older who had undergone breast-conserving surgery for unifocal invasive ductal adenocarcinoma of grade 1–3, with a tumour size of 3 cm or less (pT1–2), none to three positive axillary nodes (pN0–1), and minimum microscopic margins of non-cancerous tissue of 2 mm or more, were recruited. Patients were randomly assigned (1:1:1) to receive 40 Gy whole-breast radiotherapy (control), 36 Gy whole-breast radiotherapy and 40 Gy to the partial breast (reduced-dose group), or 40 Gy to the partial breast only (partial-breast group) in 15 daily treatment fractions. Computer-generated random permuted blocks (mixed sizes of six and nine) were used to assign patients to groups, stratifying patients by radiotherapy treatment centre. Patients and clinicians were not masked to treatment allocation. Field-in-field intensity-modulated radiotherapy was delivered using standard tangential beams that were simply reduced in length for the partial-breast group. The primary endpoint was ipsilateral local relapse (80% power to exclude a 2·5% increase [non-inferiority margin] at 5 years for each experimental group; non-inferiority was shown if the upper limit of the two-sided 95% CI for the local relapse hazard ratio [HR] was less than 2·03), analysed by intention to treat. Safety analyses were done in all patients for whom data was available (ie, a modified intention-to-treat population). This study is registered in the ISRCTN registry, number ISRCTN12852634. Between May 3, 2007, and Oct 5, 2010, 2018 women were recruited. Two women withdrew consent for use of their data in the analysis. 674 patients were analysed in the whole-breast radiotherapy (control) group, 673 in the reduced-dose group, and 669 in the partial-breast group. Median follow-up was 72·2 months (IQR 61·7–83·2), and 5-year estimates of local relapse cumulative incidence were 1·1% (95% CI 0·5–2·3) of patients in the control group, 0·2% (0·02–1·2) in the reduced-dose group, and 0·5% (0·2–1·4) in the partial-breast group. Estimated 5-year absolute differences in local relapse compared with the control group were −0·73% (−0·99 to 0·22) for the reduced-dose and −0·38% (−0·84 to 0·90) for the partial-breast groups. Non-inferiority can be claimed for both reduced-dose and partial-breast radiotherapy, and was confirmed by the test against the critical HR being more than 2·03 (p=0·003 for the reduced-dose group and p=0·016 for the partial-breast group, compared with the whole-breast radiotherapy group). Photographic, patient, and clinical assessments recorded similar adverse effects after reduced-dose or partial-breast radiotherapy, including two patient domains achieving statistically significantly lower adverse effects (change in breast appearance [p=0·007 for partial-breast] and breast harder or firmer [p=0·002 for reduced-dose and p<0·0001 for partial-breast]) compared with whole-breast radiotherapy. We showed non-inferiority of partial-breast and reduced-dose radiotherapy compared with the standard whole-breast radiotherapy in terms of local relapse in a cohort of patients with early breast cancer, and equivalent or fewer late normal-tissue adverse effects were seen. This simple radiotherapy technique is implementable in radiotherapy centres worldwide. Cancer Research UK.
AbstractList Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy. IMPORT LOW is a multicentre, randomised, controlled, phase 3, non-inferiority trial done in 30 radiotherapy centres in the UK. Women aged 50 years or older who had undergone breast-conserving surgery for unifocal invasive ductal adenocarcinoma of grade 1-3, with a tumour size of 3 cm or less (pT1-2), none to three positive axillary nodes (pN0-1), and minimum microscopic margins of non-cancerous tissue of 2 mm or more, were recruited. Patients were randomly assigned (1:1:1) to receive 40 Gy whole-breast radiotherapy (control), 36 Gy whole-breast radiotherapy and 40 Gy to the partial breast (reduced-dose group), or 40 Gy to the partial breast only (partial-breast group) in 15 daily treatment fractions. Computer-generated random permuted blocks (mixed sizes of six and nine) were used to assign patients to groups, stratifying patients by radiotherapy treatment centre. Patients and clinicians were not masked to treatment allocation. Field-in-field intensity-modulated radiotherapy was delivered using standard tangential beams that were simply reduced in length for the partial-breast group. The primary endpoint was ipsilateral local relapse (80% power to exclude a 2·5% increase [non-inferiority margin] at 5 years for each experimental group; non-inferiority was shown if the upper limit of the two-sided 95% CI for the local relapse hazard ratio [HR] was less than 2·03), analysed by intention to treat. Safety analyses were done in all patients for whom data was available (ie, a modified intention-to-treat population). This study is registered in the ISRCTN registry, number ISRCTN12852634. Between May 3, 2007, and Oct 5, 2010, 2018 women were recruited. Two women withdrew consent for use of their data in the analysis. 674 patients were analysed in the whole-breast radiotherapy (control) group, 673 in the reduced-dose group, and 669 in the partial-breast group. Median follow-up was 72·2 months (IQR 61·7-83·2), and 5-year estimates of local relapse cumulative incidence were 1·1% (95% CI 0·5-2·3) of patients in the control group, 0·2% (0·02-1·2) in the reduced-dose group, and 0·5% (0·2-1·4) in the partial-breast group. Estimated 5-year absolute differences in local relapse compared with the control group were -0·73% (-0·99 to 0·22) for the reduced-dose and -0·38% (-0·84 to 0·90) for the partial-breast groups. Non-inferiority can be claimed for both reduced-dose and partial-breast radiotherapy, and was confirmed by the test against the critical HR being more than 2·03 (p=0·003 for the reduced-dose group and p=0·016 for the partial-breast group, compared with the whole-breast radiotherapy group). Photographic, patient, and clinical assessments recorded similar adverse effects after reduced-dose or partial-breast radiotherapy, including two patient domains achieving statistically significantly lower adverse effects (change in breast appearance [p=0·007 for partial-breast] and breast harder or firmer [p=0·002 for reduced-dose and p<0·0001 for partial-breast]) compared with whole-breast radiotherapy. We showed non-inferiority of partial-breast and reduced-dose radiotherapy compared with the standard whole-breast radiotherapy in terms of local relapse in a cohort of patients with early breast cancer, and equivalent or fewer late normal-tissue adverse effects were seen. This simple radiotherapy technique is implementable in radiotherapy centres worldwide. Cancer Research UK.
Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy. IMPORT LOW is a multicentre, randomised, controlled, phase 3, non-inferiority trial done in 30 radiotherapy centres in the UK. Women aged 50 years or older who had undergone breast-conserving surgery for unifocal invasive ductal adenocarcinoma of grade 1–3, with a tumour size of 3 cm or less (pT1–2), none to three positive axillary nodes (pN0–1), and minimum microscopic margins of non-cancerous tissue of 2 mm or more, were recruited. Patients were randomly assigned (1:1:1) to receive 40 Gy whole-breast radiotherapy (control), 36 Gy whole-breast radiotherapy and 40 Gy to the partial breast (reduced-dose group), or 40 Gy to the partial breast only (partial-breast group) in 15 daily treatment fractions. Computer-generated random permuted blocks (mixed sizes of six and nine) were used to assign patients to groups, stratifying patients by radiotherapy treatment centre. Patients and clinicians were not masked to treatment allocation. Field-in-field intensity-modulated radiotherapy was delivered using standard tangential beams that were simply reduced in length for the partial-breast group. The primary endpoint was ipsilateral local relapse (80% power to exclude a 2·5% increase [non-inferiority margin] at 5 years for each experimental group; non-inferiority was shown if the upper limit of the two-sided 95% CI for the local relapse hazard ratio [HR] was less than 2·03), analysed by intention to treat. Safety analyses were done in all patients for whom data was available (ie, a modified intention-to-treat population). This study is registered in the ISRCTN registry, number ISRCTN12852634. Between May 3, 2007, and Oct 5, 2010, 2018 women were recruited. Two women withdrew consent for use of their data in the analysis. 674 patients were analysed in the whole-breast radiotherapy (control) group, 673 in the reduced-dose group, and 669 in the partial-breast group. Median follow-up was 72·2 months (IQR 61·7–83·2), and 5-year estimates of local relapse cumulative incidence were 1·1% (95% CI 0·5–2·3) of patients in the control group, 0·2% (0·02–1·2) in the reduced-dose group, and 0·5% (0·2–1·4) in the partial-breast group. Estimated 5-year absolute differences in local relapse compared with the control group were −0·73% (−0·99 to 0·22) for the reduced-dose and −0·38% (−0·84 to 0·90) for the partial-breast groups. Non-inferiority can be claimed for both reduced-dose and partial-breast radiotherapy, and was confirmed by the test against the critical HR being more than 2·03 (p=0·003 for the reduced-dose group and p=0·016 for the partial-breast group, compared with the whole-breast radiotherapy group). Photographic, patient, and clinical assessments recorded similar adverse effects after reduced-dose or partial-breast radiotherapy, including two patient domains achieving statistically significantly lower adverse effects (change in breast appearance [p=0·007 for partial-breast] and breast harder or firmer [p=0·002 for reduced-dose and p<0·0001 for partial-breast]) compared with whole-breast radiotherapy. We showed non-inferiority of partial-breast and reduced-dose radiotherapy compared with the standard whole-breast radiotherapy in terms of local relapse in a cohort of patients with early breast cancer, and equivalent or fewer late normal-tissue adverse effects were seen. This simple radiotherapy technique is implementable in radiotherapy centres worldwide. Cancer Research UK.
A comprehensive literature search using PubMed and MEDLINE was done before the trial opened to identify all previous pathological and clinical breast radiotherapy studies investigating patterns of recurrence within the ipsilateral breast, and also to identify results of previous partial-breast radiotherapy studies.
Author Ciurlionis, Laura
Ebbs, Stephen
Winstanley, John
Barber, Sarah
Sculpher, Mark
Venables, Karen
Syndikus, Isabel
Mills, Judith
Barnett, Gillian
Provenzano, Elena
James, Hayley
Poynter, Andrew
Griffin, Clare L
Evans, Philip
Harnett, Adrian N
Harris, Emma
Kirk, Julie
Wheatley, Duncan A
Bliss, Peter
Sydenham, Mark
Wishart, Gordon
Winship, Anna
Hopwood, Penelope
Jefford, Monica L
Kaggwa, Ronald
Yarnold, John R
Eaton, David
Emson, Marie A
Haviland, Joanne S
Mayles, Helen
Rawlings, Christine
Agrawal, Rajiv K
Tsang, Yat M
Kirwan, Cliona
Kirby, Anna M
Twyman, Nicola
Dewar, John
Thompson, Alastair
Tutt, Andrew
Brunt, Adrian M
Ellis, Ian
Wilcox, Maggie
Al Sarakbi, Wail
Donovan, Ellen M
McIntyre, Anne
Bliss, Judith M
Sumo, Georges
Chan, Charlie
Bhattacharya, Indrani S
Alhasso, Abdulla
Sawyer, Elinor J
Coles, Charlotte E
Titley, Jenny
AuthorAffiliation e Department of Oncology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
f Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
b Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
a Department of Oncology, University of Cambridge, Cambridge, UK
c Department of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
h Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
p Department of Oncology, Royal Cornwall Hospitals NHS Trust, Truro, UK
g Cancer Centre, University Hospitals of North Midlands and Keele University, Stoke-on-Trent, UK
j Department of Health and Medical Sciences, University of Surrey, Guildford, UK
m Department of Research Oncology, King's College London, London, UK
n Cancer Centre, The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
l Patient Advocate, London, UK
o Department of Radiotherapy, Mount Vernon Cancer Centre Northwood, Northwood, UK
i Depar
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BackLink https://www.ncbi.nlm.nih.gov/pubmed/28779963$$D View this record in MEDLINE/PubMed
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ContentType Journal Article
Contributor Ebbs, Stephen
Winstanley, John
Barber, Sarah
Sculpher, Mark
Mayles, Helen
Venables, Karen
Rawlings, Christine
Mills, Judith
Barnett, Gillian
Provenzano, Elena
James, Hayley
Kirwan, Cliona
Poynter, Andrew
Twyman, Nicola
Dewar, John
Evans, Philip
Thompson, Alastair
Harris, Emma
Tutt, Andrew
Kirk, Julie
Ellis, Ian
Al Sarakbi, Wail
Bliss, Peter
Sydenham, Mark
Wishart, Gordon
McIntyre, Anne
Winship, Anna
Sumo, Georges
Eaton, David
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2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license 2017
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Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
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Snippet Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and...
A comprehensive literature search using PubMed and MEDLINE was done before the trial opened to identify all previous pathological and clinical breast...
SourceID pubmedcentral
proquest
crossref
pubmed
elsevier
SourceType Open Access Repository
Aggregation Database
Index Database
Publisher
StartPage 1048
SubjectTerms Breast - pathology
Breast cancer
Breast Neoplasms - pathology
Breast Neoplasms - radiotherapy
Breast Neoplasms - surgery
Cancer
Cancer therapies
Carcinoma, Ductal - pathology
Carcinoma, Ductal - radiotherapy
Carcinoma, Ductal - surgery
Clinical trials
Evidence-based medicine
Female
Humans
Mastectomy
Mastectomy, Segmental - methods
Metastasis
Middle Aged
Neoplasm Recurrence, Local - prevention & control
Neoplasm Staging
Patients
Radiation therapy
Radiotherapy Dosage
Surgery
Survival analysis
Treatment Outcome
Tumors
United Kingdom
Title Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial
URI https://dx.doi.org/10.1016/S0140-6736(17)31145-5
https://www.ncbi.nlm.nih.gov/pubmed/28779963
https://www.proquest.com/docview/1937767688/abstract/
https://pubmed.ncbi.nlm.nih.gov/PMC5594247
Volume 390
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