For breast cancer patients, much of the time after diagnosis is defined by anxious waiting: waiting for a plan, waiting for surgery, waiting for chemotherapy or radiotherapy, waiting for follow-up appointments. After surgery, breast cancer patients receiving radiotherapy typically wait a week or two while clinicians develop their treatment plan, then adjust their lives around completing three to six weeks of daily radiation therapy. Meanwhile, clinicians must coordinate care for numerous patients and attempt to schedule machines efficiently — a particular challenge in places where demand for radiotherapy outstrips available equipment.
A different approach may be possible. Some breast cancer patients are eligible to receive radiotherapy in just five consecutive days, making the process less burdensome.
Promising results
A U.K. clinical trial of 4,096 people studied patients with early breast cancer who had completed surgery. Some patients received a lower total dose of radiation spread across just five days, whereas the standard treatment at the time called for a higher total dose administered in 15 sessions over three weeks. Patients on the one-week course received a higher dose per session than those receiving the standard treatment. In addition, there were two groups of patients following the one-week course, with one group receiving a slightly lower daily dose than the other.
The phase 3 trial, called FAST-Forward, studied patients who received treatment between 2011 and 2014. Researchers followed them for five years afterward, publishing their results in 2020 in The Lancet. All the patients had breast cancer that had not spread beyond their breast or the lymph nodes in the armpit on the same side of their body.
For all three groups — two with radiotherapy spread over one week, and the one group on the traditional, longer plan — the outcomes following treatment were comparable. Recurrence of cancer in the treated breast was low — occurring in 2.3% of patients or less — and it was lowest in the group that received one week of radiotherapy at the lower daily dose. The researchers also found no difference in how long people lived after treatment. The trial team recommended that women with early breast cancer receive one week of radiotherapy as a new standard of care.
“The one-week schedule has major benefits over the three-week or five-week regimens in terms of convenience and cost for patients and for health services globally,” the U.K. researchers reported in The Lancet. “Beyond its safety and effectiveness, the 26 Gy FAST-Forward schedule is convenient and substantially less expensive for patients and for health services.”
Far-reaching potential
The Gustave Roussy cancer center in Villejuif, France, outside Paris, is already using the one-week treatment plan for women over 60 years old with localized breast cancer that does not involve lymph nodes. The oncology hospital says this type of cancer accounts for more than half of all breast cancers in France, indicating that many patients could benefit from this program.
With the help of new technology, GE HealthCare’s InstaPlan, in collaboration with RaySearch, clinicians could also consolidate the entire process, from the initial radiotherapy consultation through the full course of radiotherapy, into just five days for eligible patients. They have condensed their preparation into several hours, instead of the seven to 15 days previously required. Before treatment begins, a patient undergoes a simulation scan in the same position that treatment will be administered. Using this CT scan, clinicians prepare a treatment plan. Later that same day, the patient has her first session, which uses high-precision, image-guided radiotherapy. During treatment, the patient is coached through synchronized breathing that helps position her breasts away from her heart and lungs to minimize the radiation those organs receive. GE HealthCare is currently developing additional InstaPlan sites in Europe, with the Swiss Medical Network and North Estonia Medical Centre.
Impactful innovation
The one-week program could help clinicians see more patients and simplify scheduling. Technology assists with both coordination and treatment. With an accelerated timeline, quality assurance is especially important, as most errors during radiotherapy arise from the planning stage. GE HealthCare is developing innovations in radiation therapy aimed at decreasing the time between diagnosis and treatment, improving patient outcomes. Its Intelligent Radiation Therapy (iRT) platform (which InstaPlan is integrated into) helps care teams develop personalized and optimal treatment strategies by facilitating decision-making, improving efficiency, and streamlining workflows.
“While our arsenal of weapons to battle breast cancer is constantly increasing, and clinicians are now better equipped than ever to cure the disease, new challenges arise,” says Dr. Ilya Gipp, chief medical officer for GE HealthCare’s Oncology business. “Along with the necessity of eliminating treatment-related toxicity and resolving the financial distress caused by cancer, there is a need to reduce time toxicity.”
“Radiation therapy is a powerful, precise method of treating breast cancer,” Dr. Gipp adds. “To make it even more efficient and patient-friendly, we aim to enhance it with solutions that decrease the duration of treatment, the number of visits, and waiting times. Through these improvements, we hope to reduce the impact on the patient’s daily life, psychological and emotional toll, and the burden on caregivers.”
GE HealthCare also is investing in artificial intelligence to help clinicians automatically delineate organs at risk in CT scans, speeding up what has been a painstaking manual process to help ensure that the maximum dose of radiation goes to a tumor while minimizing the exposure to surrounding tissue. This segmentation is particularly important for patients receiving one week of radiotherapy for breast cancer, since they are receiving a higher daily dose of radiation.
Minimizing disruption
For breast cancer patients, a one-week accelerated schedule could make treatment less disruptive. Once radiotherapy begins, doctors recommend not skipping any sessions. Daily radiation therapy for three to six weeks forces people to put plans on hold and sometimes take time off work. For patients who have to travel a long way for treatment, costs for hotels and other expenses add up. Women who are caregivers to children or elderly family members have to make alternate arrangements. All of these issues are less challenging if they only have to be accommodated for five days.
Elisabeth Wikenhed, a breast cancer patient in Malmö, Sweden, received a one-week radiotherapy schedule, with a total of 26 Gy (Gray) given in five fractions across the week — 5.2 Gy during each treatment.
“My skin became sensitive and sunburned on the treated chest area about two weeks after I finished my treatment, so my medical team gave me advice and information about my recovery and how to cope with any side effects,” Wikenhed says. She notes that radiation burns have been reported to be milder with the one-week radiation treatment than with the three-week treatment.
About half of all cancer patients will receive radiation treatment, so streamlining the process could benefit many people. The one-week schedule could improve patient access in countries that have limited treatment centers providing radiotherapy. In India, for example, many private cancer centers are unaffordable for most people, and patients may have to wait up to one year to receive radiotherapy at a public hospital. Patients and their families also may struggle to pay for accommodations during treatment, so a shorter course of radiotherapy could reduce their financial burden.
For now, the new treatment plan is offered under limited circumstances. The technology required to coordinate and administer the one-week radiotherapy schedule is available only in more advanced cancer centers. The treatment plan is not offered to women with more advanced breast cancer.
In some cases, the side effects from one week of radiotherapy could be more pronounced. In the U.K. clinical trial[i], patients who received one week of radiotherapy at a higher daily dose were more likely to show changes in their breast, such as shrinkage, than those who received three weeks of treatment at a lower daily dose.
In some cases, rapid radiation therapy — also known as hypofractionated radiotherapy — is being offered for other types of cancers. It has been used to treat certain prostate, gastrointestinal, and lung cancers. High-precision imaging allows clinicians to target tumors more effectively, reducing radiation to surrounding tissue. Improvements in technology, workflow, and care coordination could help more patients benefit from this type of treatment.
