Breast Refresher Flashcards
1
Q
What is the goal of radiation treatment for patients with DCIS?
A
To achieve a 50% relative risk reduction in local recurrence
This is based on findings from the EBCTCG, JNCI Monogr, 2010.
2
Q
What is the significance of the ECOG 5194 study in relation to DCIS?
A
It assessed the risk of ipsilateral breast events (IBE) in patients with DCIS over time.
3
Q
What were the two cohorts in the ECOG 5194 study? What are the recurrence rate at 20 years?
A
- Cohort 1: Low- or intermediate-grade DCIS, tumor size < 2.5 cm (17.8%, invasive 9.8%)
- Cohort 2: High-grade DCIS, tumor size < 1 cm (28.7%, invasive 15.1%)
4
Q
True or False: Age, menopausal status, and minimum negative margin width were significantly associated with IBE in the ECOG 5194 study.
A
False
Cohort and tumour size associated with recurrence
5
Q
What is the RTOG 9804 study known for?
A
It is a randomized controlled trial comparing RT versus observation after excision for good risk DCIS.
6
Q
What were the treatment arms in the RTOG 9804 study?
A
- Observation (OBS)
- Radiation Therapy (RT)
7
Q
What does the Oncotype DX breast cancer assay assess?
A
The risk of developing an IBE in women with DCIS treated with surgical excision and no radiation.
8
Q
What are the risk group percentages for ipsilateral breast events according to Oncotype DCIS?
A
- Low: 10.6%
- Intermediate: 26.7%
- High: 25.9%
9
Q
What is the DCISionRT test used for?
A
It is a prognostic and predictive test for DCIS and RT benefit.
10
Q
What is the risk threshold for the DCISionRT test?
A
Elevated Risk Group: Decision Score (DS) > 3
11
Q
What do the NCCN guidelines suggest for select patients with low-risk DCIS?
A
They may be considered suitable for APBI/PBI or omission of radiation.
12
Q
What is the benefit of RT for early-stage invasive breast cancer according to EBCTCG, Lancet, 2011?
A
RT reduces the risk of recurrence after BCS.
13
Q
What was the primary endpoint of the CALGB 9343 trial?
A
Time to local or invasive recurrence in patients over 70 with clinical stage I estrogen-positive breast cancer.
14
Q
What was the primary endpoint of the CALGB 9343 trial?
A
Time to local or regional recurrence, frequency of mastectomy for recurrence, breast cancer specific survival, time to distant metastasis, overall survival
15
Q
What were the median follow-up years for the CALGB 9343 trial?
A
12.6 years
16
Q
What was the 10-year freedom from local recurrence rate for ET + RT in the CALGB 9343 trial?
A
98% (95% CI, 96-99%)
17
Q
What was the mastectomy rate difference between ET + RT and ET alone in the CALGB 9343 trial?
A
No difference
18
Q
In the PRIME II trial, what was the patient population criteria?
A
Age 65 or older, hormone receptor-positive, node-negative, breast-conserving surgery with clear margins, negative pathological axillary staging
19
Q
What were the primary endpoints assessed in the PRIME II trial?
A
Local breast cancer recurrence, regional recurrence, breast cancer specific survival, distant recurrence as first event, overall survival
20
Q
What was the 10-year cumulative incidence of local breast cancer recurrence in the PRIME II trial for the no-radiotherapy group?
A
9.5%
21
Q
What was the 10-year cumulative incidence of local breast cancer recurrence in the PRIME II trial for the radiotherapy group?
A
0.9%
22
Q
What was the goal of the LUMINA trial?
A
Prospectively evaluate utility of luminal A subtype combined with traditional clinical pathological factors to guide RT decision-making
23
Q
What was the eligibility criteria for the LUMINA trial?
A
Women who underwent BCS for grade 1-2 tumors, treated with adjuvant endocrine therapy
24
Q
What was the primary endpoint of the LUMINA trial?
A
5-year rate of local recurrence
25
What conclusion was drawn from the LUMINA trial?
T1N0 luminal A BCS treated with endocrine therapy alone had very low rates of local recurrence at 5 years and are candidates for omission of RT
26
What was the overall and breast cancer specific survival rate at 5 years in the IDEA trial?
100%
27
What was the 5-year freedom from any recurrence in the IDEA trial?
99%
28
What is the primary endpoint of the ongoing DEBRA trial?
10-year IBTR
29
What was the age eligibility for the PRECISION trial?
50-75 years
30
What were the endpoints for the HERO trial?
10.5-year recurrence-free interval
31
What is the goal of the Canadian OCOG trial?
Compare a 5-week standard fractionation schedule of whole breast RT to a hypofractionated 3-week schedule
32
What was the primary endpoint of the Canadian OCOG trial?
10-year risk of local recurrence
33
What were the 10-year local recurrence rates for the conventional RT versus hypofractionated RT in the Canadian OCOG trial?
6.7% (50Gy) versus 6.2% (40Gy)
34
What was the primary endpoint of the START B trial?
Local-regional relapse and late normal tissue effects
35
What were the findings regarding breast shrinkage and telangiectasia in the START B trial?
Less common in the 40 Gy group
36
What was the design of the BIG 3-07/TROG 07.01 trial?
Randomized controlled trial comparing conventional fractionation to hypofractionation and boost to no boost
37
What were the eligibility criteria for the BIG 3-07/TROG 07.01 trial?
Women with completely excised non-low-risk DCIS
38
What was the sample size of the randomized controlled trial comparing fractionation methods for DCIS?
1608 women
39
What are the two types of radiotherapy compared in the study?
Conventional fractionation and hypofractionation
40
What is the definition of non-low risk in the context of this study?
Defined as >= 1 of the following: < 50 years, palpable tumor, size > 15 mm, multifocal disease, nuclear grade 2 or 3, central necrosis, comedo-histology, or a surgical margin < 10 mm
41
What was the primary endpoint of the DBCG HYPO study?
3-year grade 2-3 breast induration
42
What were the total doses and fractions for conventional RT in the DBCG HYPO study?
50 Gy in 25 daily fractions
43
What were the total doses and fractions for hypofractionated RT in the DBCG HYPO study?
40 Gy in 15 daily fractions
44
What was the median follow-up period for the DBCG HYPO study?
7.26 years
45
What was the 3-year rate of grade 2-3 induration for the 50 Gy group in the DBCG HYPO study?
11.8%
46
What was the 3-year rate of grade 2-3 induration for the 40 Gy group in the DBCG HYPO study?
9.0%
47
What was the median follow-up time for the UK FAST trial?
9.9 years
48
What was the primary endpoint of the UK FAST trial?
Changes in photographic breast appearance at baseline, 2, and 5 years after RT
49
What significant difference was observed between the 30 Gy and 50 Gy schedules in the UK FAST trial?
Significantly higher rates of change in breast appearance for 30 Gy schedule
50
What is the definition of normal tissue effects (NTE) in the context of the UK FAST trial?
Effects on normal breast tissue resulting from radiotherapy
51
What were the total doses and fractions in the FAST-Forward trial?
40 Gy total dose across 15 fractions over 3 weeks, 27 Gy total dose across 5 fractions over 1 week, 26 Gy total dose across 5 fractions over 1 week
52
What was the median age of patients in the FAST-Forward trial?
61 years
53
What was the primary endpoint of the FAST-Forward trial?
Ipsilateral breast tumor relapse (IBTR)
54
What is the recommended dose-fractionation scheme for women receiving whole breast irradiation according to the 2018 ASTRO guidelines?
Hypofractionated WBI to a dose of 4000 cGy in 15 fractions or 4250 cGy in 16 fractions
55
What were the recommendations for moderate hypofractionation and a boost for DCIS in the 2018 ASTRO guidelines?
Conditional recommendations
56
What does NCCN suggest regarding ultrahypofractionated WBRT for selected patients?
Consideration of 28.5 Gy in 5 fractions for patients over 50 years following BCS with early-stage, node-negative disease
57
What is the maximum allowed dose to the breast PTV according to FAST and FAST-Forward studies?
Dmax < 107% for FAST and Dmax < 110% for FAST-Forward
58
What historical trials provided long-term data supporting the addition of a tumor bed boost after whole breast radiotherapy?
Lyon and EORTC trials
59
What was the sample size for the Lyon trial?
2657
60
What was the sample size for the EORTC trial?
5318
61
What is the primary endpoint of the IMPORT HIGH trial?
Ipsilateral breast tumor relapse (IBTR)
## Footnote
The trial tested simultaneous integrated boost against sequential boost.
62
What was the 5-year IBTR incidence for the control group in the IMPORT HIGH trial?
1.9% (95% CI 1.2 to 3.1)
## Footnote
This is compared to 2.0% for test group 1 and 3.2% for test group 2.
63
What was the follow-up duration for the IMPORT HIGH trial?
Median follow-up was 74 months.
64
What was the significant finding regarding breast induration in the IMPORT HIGH trial?
5-year incidence of moderate or marked breast induration was 11.5% for the control group versus 10.6% for test group 1 and 15.5% for test group 2 (p=0.015).
65
What does RTOG stand for in the context of breast cancer trials?
Radiation Therapy Oncology Group.
66
What was the primary endpoint of the RTOG 1005 trial?
Ipsilateral breast recurrence.
67
What were the treatment arms in the RTOG 1005 trial?
Arm 1 Control and Arm 2 Simultaneous integrated boost.
68
What was the median follow-up time for the RTOG 1005 trial?
7.3 years.
69
What were the 5 & 7-year recurrence rates for the control vs. SIB arm in RTOG 1005?
Control: 2.0/2.2%, SIB: 1.9/2.6%.
70
What is the recommendation from ASTRO and NCCN regarding boost treatment?
Both support simultaneous integrated boost up to 48Gy with a 3-week treatment schedule.
71
What does the acronym APBI stand for?
Accelerated Partial Breast Irradiation.
72
What does the ELIOT trial compare?
Whole breast RT to intraoperative partial breast irradiation.
73
What was the primary endpoint of the ELIOT trial?
Rate of ipsilateral breast tumor recurrence (IBTR).
74
What were the 10/15-year IBTR rates for WBI and ELIOT groups?
WBI: 1.1/2.4%, ELIOT: 8.1/12.6%.
75
What is the significance of the TARGIT trial?
It compares single-dose targeted intraoperative radiotherapy vs. fractionated external beam radiotherapy.
76
What was the primary endpoint of the TARGIT trial?
Local recurrence.
77
What were the eligibility criteria for the IMPORT LOW trial?
Women 50 years s/p breast-conserving surgery with > 2 mm margins.
78
What were the primary endpoints of the IMPORT LOW trial?
Ipsilateral local relapse.
79
What was the median follow-up time for the IMPORT LOW trial?
72.2 months.
80
What were the absolute differences in local relapse for the reduced-dose and partial breast groups in the IMPORT LOW trial?
Reduced-dose: -0.73%, Partial breast group: -0.38%.
81
What does the RAPID trial compare?
External beam APBI to whole breast RT.
82
What was the eligibility criterion for the RAPID trial?
Women > 40 years with invasive and non-invasive disease treated by BCS.
83
What was the primary endpoint for the RAPID trial?
Ipsilateral breast tumor recurrence.
84
What is the primary endpoint of the RAPID trial?
Ipsilateral breast tumor recurrence (IBTR)
## Footnote
This endpoint focuses on the recurrence of cancer in the same breast after treatment.
85
What is the median follow-up duration of the RAPID trial?
8.6 years
86
What were the 8-year IBTR rates for APBI and WBI in the RAPID trial?
* APBI: 3.0% (95% CI 1.9-4.0)
* WBI: 2.8% (95% CI 1.8-3.9)
87
How did acute radiation toxicity compare between APBI and WBI patients in the RAPID trial?
Less frequent among APBI patients (p < 0.0001)
88
What was the late adverse cosmesis difference with APBI at 3, 5, and 7 years?
* 3 years: 11.3%
* 5 years: 16.5%
* 7 years: 17.7%
89
What were the eligibility criteria for NSABP B-39?
* Women > 18 years
* Early-stage breast cancer: 0, I, or II
* Negative surgical margins after lumpectomy
90
What was the primary endpoint of the NSABP B-39 trial?
Invasive and non-invasive IBTR as a first recurrence
91
What was the median follow-up for the NSABP B-39 trial?
10.2 years
92
What were the 10-year cumulative incidence rates of IBTR for WBI and APBI in NSABP B-39?
* WBI: 3.9% (95% CI 3.1-5.0)
* APBI: 4.6% (95% CI 3.7-5.7)
93
What recommendation did the NCCN guidelines make for APBI fractionation?
26-27 Gy in 5 daily fractions is an appropriate approach
94
What is the purpose of the FLORANCE trial?
Determine 5-year difference in IBTR between APBI and WBI
95
What were the 10-year cumulative incidence rates of IBTR in the FLORANCE trial?
* WBI: 2.5% (n = 6)
* APBI: 3.7% (n = 9)
96
What was the primary endpoint of the ACCEL trial?
Non-inferiority of 2-year cosmesis using the RAPID WBI arm as the control
97
What was the median follow-up duration for the ACCEL trial?
2.1 years
98
What did the ACCEL trial find regarding cosmesis?
Cosmesis was non-inferior to the WBI arm of the RAPID trial
99
What is the main focus of the RTOG 1014 trial?
Effectiveness of repeat breast-conserving surgery and partial breast re-irradiation
100
What were the findings regarding second IBTR in the RTOG 1014 trial?
5% second IBTR (all DCIS)
101
What are the conclusions regarding early-stage disease management?
Moving toward less radiation treatment with shorter, hypofractionated courses
102
What considerations should be made before utilizing genomic signatures to omit RT?
Consider individualized risk
103
What is the trend in radiation treatment for early-stage breast cancer?
Moving toward less radiation treatment utilizing shorter, increasingly hypofractionated, and less expensive courses of therapy and smaller treatment volumes.
104
What should be considered before utilizing genomic signatures to omit RT?
Individualized risk, particularly in specific populations not well represented in studies, and shared decision-making.
105
What was the focus of the British Columbia Study?
Ipsilateral CW, SCV, axilla, and bilateral IMN RT at 37.5Gy in 16 fractions vs. NO RT.
106
What were the results of the British Columbia Study regarding isolated local recurrence at 20 years?
Isolated LR R20: 26% vs. 10%.
107
What are the overall survival rates at 20 years from the British Columbia Study for patients with 1-3 positive nodes?
OS20: 37% vs. 47% for >4 positive nodes.
108
What was the aim of the Danish 82b and c Studies?
Ipsilateral CW, SCV, axilla, and ipsilateral 1-4th IC IMN RT at 50Gy in 25 fractions vs. NO RT.
109
What were the results of the Danish studies regarding isolated local recurrence at 10 years?
Isolated LRR10: 26% vs. 5%.
110
What are frequently cited limitations in breast cancer studies?
* Outdated systemic therapy, both in type and timing relative to PMRT
* Median number of nodes did not meet criteria for completion axillary dissection.
111
What factors should be estimated to assess the risk of recurrence?
* Age
* Grade
* LVI
* Surgical margins
* Tumor size
* Extent of N+, nodal ratio, ECE
* Systemic therapy response
* Tumor biology
112
In the EORTC 22922 trial, what were the control and nodal irradiation groups?
* Control Group: Whole breast or chest wall RT alone (50Gy in 25 fractions)
* Nodal Irradiation Group: Whole breast or chest wall RT plus regional nodal irradiation (50Gy in 25 fractions).
113
What were the primary and secondary endpoints of the EORTC 22922 trial?
* Primary endpoint: Overall survival
* Secondary endpoints: Disease-free survival, survival free from distant disease, death from breast cancer.
114
What were the outcomes of the NCIC-CTG MA.20 trial regarding overall survival?
OS10: 82.8% RNI vs. 81.8% control.
115
What were the significant findings in the NCIC-CTG MA.20 trial?
Significant improvements in DFS, local regional DFS, and distant DFS.
116
What were the primary and secondary endpoints of the KROG 08-06 trial?
* Primary endpoint: 7-year DFS
* Secondary endpoints: rates of overall survival, breast cancer mortality, local recurrence.
117
What was the median follow-up time in the KROG 08-06 trial?
8.4 years.
118
True or False: N0 patients benefit from PMRT according to the Oxford overview.
False.
119
What is the minimum number of nodes required for the SUPREMO trial eligibility?
Minimum 10 nodes if N+ or minimum of 4 nodes if N0.
120
What is the endpoint for the SUPREMO trial?
Overall survival (OS10).
121
What was the follow-up duration for the Danish studies regarding isolated local recurrence?
10 years.
122
Fill in the blank: The British Columbia Study was conducted from _______ to _______.
1979 to 1986.
123
What was the median follow-up period in the KROG 08-06 study?
8.4 years
124
What was the primary endpoint of the study?
7-year DFS
125
List the secondary endpoints of the study.
* Rates of overall survival
* Breast cancer mortality
* Local recurrence
* Regional recurrence
* Distant metastasis-free survival
* Acute/late adverse events
126
What was the improvement in 7-year DFS in the IMN vs non-IMN-RT cohort?
2.4% improvement (NS, p=0.22)
127
In subgroup analysis, which tumors showed significant DFS improvements?
Mediocentral tumors
128
What was the breast cancer-specific mortality rate in the IMN group?
10.2% vs 4.9% (HR=0.41, p=0.04)
129
What was the distant metastasis-free survival rate in the IMN group?
82.3% vs 91.8% (HR=0.44, p=0.01)
130
True or False: There was a significant difference in overall survival rates between IMN and non-IMN groups.
False (88.5% vs 93.2%, HR=0.51, p=0.08)
131
What adverse event was reported more frequently in the IMN-RT group?
Radiation pneumonitis (6.1% vs 3.2%, p=0.06)
132
What was the design of the DBCG IMN study?
Prospective population-based cohort study
133
What percentage of patients in the DBCG IMN study had pN2-3 disease?
40%
134
How were patients allocated to receive IMN-RT in the DBCG IMN study?
Based on cancer laterality
135
What was the observed overall survival improvement at 15-year follow-up in the IMN-RT group?
4.7% improvement
136
Did IMN-RT decrease the risk of distant recurrence and death from breast cancer?
Yes
137
What were the key outcomes measured in the EORTC 22922 study?
* 15-year OS
* 15-year BCSM
138
What was the 15-year overall survival rate in the EORTC 22922 study?
73.1% vs 70.9% (p=0.36)
139
What was the 10-year disease-free survival rate in the NCIC-CTG MA.20 study?
77.0% vs 82.0% (p=0.01)
140
What is the primary outcome of the EBCTCG meta-analysis?
* Recurrence at any site
* Breast cancer mortality
* Non-breast cancer mortality
* All-cause mortality
141
How does RNI impact disease-free survival in pN1 patients?
Improves disease-free survival and breast cancer mortality
142
What was the design of the Chinese Trial comparing PMRT schedules?
Randomized phase III non-inferiority study
143
What were the primary and secondary endpoints of the Chinese Trial?
Primary Endpoint: 5-year locoregional recurrence
Secondary Endpoint: Acute and late toxicities
144
What were the 5-year cumulative incidence rates of locoregional recurrence in the hypofractionated and conventional groups?
8.3% (hypofractionated) vs 8.1% (conventional)
145
Fill in the blank: The median follow-up period in the FABREC study was _______.
40.4 months
146
What was observed regarding lymphedema rates after ALND compared to ART in the AMAROS study?
Lymphedema was observed significantly more often after ALND (44.2%) than after ART (28.6%)
147
What was the goal of the RT-CHARM study?
To evaluate whether the reconstruction complication rate at 24 months post RT is non-inferior with hypofractionation
148
What was the primary endpoint of the FAST Forward Nodal Sub-Study?
Patient-assessed arm swelling at 5 years
149
What were the baseline and 24-month arm swelling percentages for the 40Gy group in the FAST Forward Nodal Sub-Study?
80% baseline vs 77% at 24 months
150
What were the moderate/marked arm/hand swelling percentages at 24 months for the 40Gy and 26Gy groups?
10% for 40Gy vs 7% for 26Gy
151
What was the primary endpoint of the RHEAL study?
Arm lymphedema
152
What are the NCCN guidelines for regional node dose?
45-50.4 Gy at 1.8-2 Gy/fx; alternatives include 40 Gy at 2.67 Gy/fx or 42.5 Gy at 2.66 Gy/fx
153
True or False: There is a growing body of data supporting the safety and efficacy of hypofractionation in the postmastectomy reconstruction setting.
True
154
What does persistent nodal disease after neoadjuvant systemic therapy indicate?
Systemic therapy resistance and predictive of additional non-sentinel lymph nodes
155
What was the primary endpoint of the NSABP B-51 trial?
Invasive breast cancer recurrence free interval (IBC-RFI)
156
What does 5-year follow-up data suggest about regional nodal irradiation in patients who become pathologically node negative after neoadjuvant therapy?
Limited benefit to regional nodal irradiation
157
What were the 10-year cumulative incident rates of locoregional recurrence (LRR) for low, intermediate, and high recurrence scores?
* RS low: 3.3% * RS intermediate: 7.2% * RS high: 12.2%
158
In the SWOG S8814 trial, what was the median follow-up period?
8.7 years
159
What were the 10-year locoregional recurrence rates for patients with a mastectomy and no radiotherapy based on the recurrence score?
* 7.7% for low * 16.8% for intermediate/high
160
What was the primary endpoint of the MA.39/TAILOR RT study?
Recurrence free interval at 10 years
161
What is the endpoint of the RADCOMP study?
10-year risk of major cardiac events
162
What does the DBCG Proton Trial focus on?
Randomizing breast cancer patients based on elevated mean heart dose or high lung dose
163
What are the conclusions regarding neoadjuvant and adjuvant systemic therapies for breast cancer?
They shift the therapeutic ratio of local therapy prompting de-escalation of both surgery and radiation therapy
164
Fill in the blank: For patients that require PMRT/RNI, the focus is on increasingly ________ and less toxic approaches to treatment.
hypofractionated
