How to Understand if Radiation Can be Skipped for Breast Cancer Treatment. 2022 Guidelines

How to Understand if Radiation Can be Skipped for Breast Cancer Treatment. 2022 Guidelines

As we learn more about the different breast cancer types, subtypes, and personalized treatment options, researchers are beginning to question whether some people with breast cancer may be able to omit, or skip, radiation therapy altogether. While every situation is different, recent studies show that some groups of people with breast cancer may benefit less from radiation therapy than others. 1 Whether or not you can skip radiation therapy depends on both your age and the characteristics of your cancer.

Generally speaking, patients may consider skipping radiation if the risk of cancer recurrence without radiation therapy is low. 1 In other words, you might be able to skip radiation if there is only a small chance of your cancer coming back after having a lumpectomy or a mastectomy to remove it. In some cases, those who are 70 years
old or older may also consider skipping radiation therapy.

In this post, you’ll learn more about the types of situations where the benefits of radiation therapy for breast cancer treatment may not outweigh the risks.

First, what is radiation therapy?

Radiation therapy, sometimes called radiotherapy, is a type of cancer treatment that involves directing high-energy rays or particles at the cancer site to kill cancer cells or shrink tumors. Radiation damages cancer cells’ DNA so they can no longer grow and divide, and eventually, the cancer cells die. While radiation therapy can damage both normal cells and cancer cells, normal cells are better at repairing themselves than cancer cells and less
likely to be damaged in the long term. 2

Radiation may be delivered from a machine outside the body (known as external radiation) or from a device temporarily placed in the breast tissue where the cancer was removed (internal radiation). 2

Unlike systemic therapy (such as chemotherapy, hormonal therapy, and targeted therapy), which affects the whole body, radiation therapy is locoregional, which means it targets the cancer site specifically. It is literally “local” and “regional.” The size of the area where radiation therapy is given (called the field) depends on how far the cancer has spread and how likely the cancer is to come back in the future.

Radiation therapy is often given after surgery but can also be given before surgery. Post-operative radiation therapy can treat any remaining cancer cells present after surgery, which helps to prevent the cancer from coming back in the breast or the lymph nodes. 3,4

Radiation therapy can be given as a treatment on its own, or it may be given in addition to systemic therapies like chemotherapy or hormone therapy. 4

Types of radiation therapy include:

  • whole breast radiation therapy
  • partial breast radiation therapy
  • lymph node radiation therapy 4

Depending on the situation, radiation therapy may occur as often as five days a week for up to seven weeks. 3 Because of this time commitment and potential side effects, patients electing to receive radiation therapy may consider requesting medical leave from work.

Why might I choose to skip radiation therapy?

While radiation therapy can reduce the risk of cancer recurrence, there are associated risks. Unpleasant short-term side effects may include:

  • breast soreness or pain
  • fatigue, sometimes lasting for several weeks
  • swelling
  • skin redness or darkening, peeling, or itching (similar to a sunburn) 3

People who receive radiation of the lymph nodes in the armpit are at higher risk of developing lymphedema, a type of swelling in the hands, arms, or chest due to a buildup of lymph fluid. 3

While modern technology has reduced the risk of long-term damage, in extremely rare cases, radiation treatment can lead to:

  • nerve damage
  • development of another cancer
  • lung or heart problems
  • rib fracture 3

Radiation therapy may also impact the appearance and feel of reconstructed breasts and implants. 2

In addition to the potential effects on health or quality of life, radiation therapy increases treatment costs. 5 It’s important to weigh the costs and benefits of radiation therapy in terms of your specific type of cancer, your prognosis, and the impacts on your overall quality of life. Speaking with a radiation oncologist can help you learn more about your options.

Who may be less likely to benefit from radiation therapy?

Recent research findings suggest that some patients with a low risk of the cancer returning after surgery may experience less benefit from radiation therapy. While radiation therapy can help to reduce the risk of cancer recurrence, studies show that, for some groups of people, it may not improve their chances of survival. 1,5

Because breast cancer does not look the same for everyone, whether radiotherapy may be beneficial to you depends on many individual factors, including what type of cancer you have:

Ductal Carcinoma In Situ (DCIS)

Recent studies demonstrate that receiving whole-breast radiation therapy after breast-conserving surgery (also known as a lumpectomy) may reduce the risk of cancer recurrence for patients with DCIS, even for patients with a low risk of recurrence. Based on this evidence, The National Comprehensive Cancer Network (NCCN) 2022 guidelines panel
recommends breast-conserving surgery followed by whole-breast radiation therapy for patients with DCIS. 5

However, based on more limited evidence, the guidelines state that patients with DCIS may consider breast-conserving surgery alone (without radiation therapy) if both the patient and the doctor agree that there is a low risk that the cancer will return. 5

The panel notes that the risks of radiation may outweigh the benefits if:

  • you have negative margins
  • your tumor is positive for the estrogen receptor
  • you agree to receive endocrine (hormonal) therapy following surgery 5

Non-metastatic, invasive breast cancer

For patients with non-metastatic, invasive breast cancer, recent studies indicate that receiving whole-breast radiation therapy after breast-conserving surgery can reduce the risk of the cancer returning and can benefit the chances of survival.5

However, for adults 70 years or older with ER-positive tumors, whole-breast radiation may reduce the risk of cancer recurrence but may not affect their chances of survival.5 Therefore, for these patients, the reduction in the risk of cancer recurrence alone may not be enough to warrant the risks of receiving radiation therapy.

The National Comprehensive Cancer Network (NCCN) 2022 guidelines panel recommends that patients may consider receiving breast-conservation surgery only (without radiation) if you:

  • have negative margins
  • are 70 years or older
  • have negative lymph nodes
  • have estrogen receptor-positive, T1 breast cancer
  • commit to five years of endocrine (hormonal) therapy 5

For patients who undergo a mastectomy, the NCNN guidelines state that, unless you are a high-risk patient, post-mastectomy radiation therapy is not recommended for those who:

  • have negative nodes
  • have tumors 5 cm or smaller
  • have clear margins 5

For patients who received systemic therapy before a mastectomy, the NCNN guidelines state that patients can skip radiation therapy if:

  • they had node-negative disease at the time of diagnosis
  • their axilla was assessed by sentinel lymph node biopsy or axillary node dissection 5

Metastatic breast cancer

While radiation therapy is not the main form of treatment for metastatic breast cancer, it may be used as an alternative to surgery, to treat pain or discomfort caused by the cancer, 6 or to target specific places in the body where the cancer has spread. 3 If you have metastatic breast cancer, talk to your doctor about whether skipping radiation therapy may be an
option.

Special Considerations

Previous radiation therapy

If you have previously received radiation therapy to the same area of the body for another medical concern, you will likely not receive radiation again. Exceptions include if a significant amount of time has passed since the previous treatment or if the treatment areas (fields) do not overlap.

Active lupus or scleroderma

Radiation therapy may put people who have active lupus or scleroderma at risk for skin necrosis, or death of the skin. While this is rare, it is a serious side effect. If you have either of these conditions, consult with a radiation oncologist to learn more about your options.

Summary

The decision to skip radiation treatment should be shared between you and your medical team. While radiation can help reduce the risk that cancer will return, it doesn’t always improve the chances of survival. 1,5 If your cancer has a low risk of returning, skipping radiation therapy may be an option. 1 Discussing your unique situation with your doctor can help you decide whether the benefits of radiation therapy are worth the risk.

References

1 Allen SG, Speers C, Jagsi R. Tailoring the omission of radiotherapy for early-stage breast cancer based on Tumor Biology. Seminars in Radiation Oncology. 2022;32(3):198-206. doi:10.1016/j.semradonc.2022.01.006

2 Radiation Therapy. Breastcancer.org. https://www.breastcancer.org/treatment/radiation-therapy. Published July 27, 2022. Accessed August 29, 2022.

3 Radiation for Breast Cancer. American Cancer Society.
https://www.cancer.org/cancer/breast-cancer/treatment/radiation-for-breast-cancer.html. Published October 27, 2021. Accessed August 29, 2022.

4 NCNN Guidelines for Patients: Invasive Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/patients/guidelines/content/PDF/breast-invasive-
patient.pdf. Published 2022. Accessed August 29, 2022.

5 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/loginReturnURL=https://www.nccn.org/professionalsphysician_gls/pdf/breast.pdf. Published June 2022. Accessed August 29, 2022.

6 NCNN Guidelines for Patients: Metastatic Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/patients/guidelines/content/PDF/stage_iv_breast-
patient.pdf. Published 2022. Accessed August 29, 2022.