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Delayed 2nd procedure intraoperative radiotherapy for breast cancer vs Whole breast radiotherapy

Just published – the first in the series of papers describing long-term outcomes of the TARGIT-A trial.

Conventional adjuvant radiotherapy for breast cancer given daily for several weeks is onerous and expensive. Some patients may be obliged to choose a mastectomy instead, and some may forgo radiotherapy altogether. In late 1990s, we proposed to test whether radiotherapy could be safely limited to the tumour bed.

There were two trials that tested this hypothesis:

In the randomised trial of immediate TARGIT-IORT vs EBRT, 2298 patients who had been diagnosed with breast cancer by needle biopsy were enrolled. They were randomly allocated to receive to receive TARGIT-IORT immediately during their lumpectomy under the same anaesthetic, or conventional post-operative radiotherapy over several weeks. Its previously published initial results showed that TARGIT-IORT was as effective as EBRT, and the manuscript describing its long-term outcomes is currently under review.

In this randomised trial of delayed TARGIT-IORT vs EBRT, 1153 patients who had already had a lumpectomy for breast cancer were enrolled. They were randomly allocated to receive EBRT or delayed TARGIT-IORT given as a second procedure by reopening the lumpectomy wound. This paper describes the long-term outcomes of this trial of delayed IORT. https://jamanetwork.com/journals/jamaoncology/article-abstract/2763397

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Articles Presentations

Neoadjuvant chemotherapy for breast cancer – A rethink

In January 2018, a paper was published in the British Medical Journal with the following key messages: https://www.bmj.com/content/360/bmj.j5913

Key messages

  • Neoadjuvant chemotherapy is being increasingly used for breast cancer despite higher rates of local recurrence and no evidence of survival benefit, mainly because of the immediate and dramatic pathological responses seen with newer drugs
  • The increased pathological response of the primary tumour does not translate into a survival benefit even when given in the adjuvant setting, challenging the paradigm of “window of opportunity” studies
  • We must acknowledge that neoadjuvant chemotherapy may not be beneficial to patients
  • We should consider reducing the widespread use of neoadjuvant chemotherapy

The full paper can be accessed at http://discovery.ucl.ac.uk/10041365/  and along with discussions at Rethinking neoadjuvant chemotherapy for breast cancer – full text and subsequent discussion

Discussed at the British Association of Surgical Oncologists- BASO-ACS – NCRI 2018 conference, Glasgow, UK, 4 November 2018

Here is a Tweetorial 
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Articles

BMJ: Rethinking neoadjuvant chemotherapy for breast cancer

Full text download [download id=”1774″]

http://www.bmj.com/content/360/bmj.j5913
Key Messages
  • Neoadjuvant chemotherapy is being increasingly used for breast cancer despite higher rates of local recurrence and no evidence of survival benefit, mainly because of the immediate and dramatic pathological responses seen with newer drugs
  • The increased pathological response of the primary tumour does not translate into a survival benefit even when given in the adjuvant setting, challenging the paradigm of “window of opportunity” studies
  • We must acknowledge that neoadjuvant chemotherapy may not be beneficial to patients
  • We should consider reducing the widespread use of neoadjuvant chemotherapy
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Articles

TARGIT IORT on BBC Inside Health, July 2016

 

BBC Inside Health programme 5 and 6 July 2016

Intrabeam |TARGIT IORT discussion starts at 12:14 min

http://www.bbc.co.uk/programmes/b07j537l

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Presentations Targeted Intraoperative Radiotherapy for Breast Cancer

Intrabeam | TARGIT IORT, ASTRO 2016

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Articles

Intrabeam TARGIT IORT for breast cancer – NICE approval 2017

NICE Recommendation of Intrabeam TARGIT IORT for breast cancer

NICE tweet about their recommendation of Intrabeam for breast cancer

British Medical Journal: NICE recommends controlled intrabeam use for breast cancer after three year delay [download id=”1490″]

BreastCancerNow: Intrabeam TARGIT IORT gives better quality of life

Daily Mirror: Thousands of women with early breast cancer should receive radiotherapy with surgery

DailyMail: Blast of radiation you get DURING operation for breast cancer could spare patients weeks of gruelling treatment

ActionRadiotherapy

LiveWire: Intrabeam TARGIT IORT effective”

Swindon Advertiser: GWH cancer project will save 120 women trip to Oxford each year

BBC Wiltshire coverage of Intrabeam TARGIT IORT

PharmaTimes: NICE backs targeted breast cancer therapy

Indian Express about Intrabeam TARGIT IORT

Twitter

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Articles

Goa Cancer Society Oration, 18 October 2017

[download id=”1408″]

Click to see the video of Goa Cancer Society Oration, 2016

A comprehensive paper on TARGIT-A trial can be found at Intrabeam | TARGIT IORT

Detailed previous literature is at TARGIT IORT with Intrabeam

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Articles Targeted Intraoperative Radiotherapy for Breast Cancer

Further evidence -16 publications – supporting use of TARGIT IORT using Intrabeam in routine clinical practice

In the last 18 months further evidence has emerged supporting the use of TARGIT IORT for breast cancer.

The Full Report of the TARGIT-A trial was published in the HTA Journals in September 2016.
This contains several additional analyses including a) subgroup analysis as per tumour and patient characteristics b) formal health economic analysis c) analysis of the earliest cohort of patients with a median follow up of 5 years had the same results as the main trial, viz. – that TARGIT and EBRT had similar breast cancer control and non-breast-cancer deaths were fewer with TARGIT.

HTA Journals 18 June 2016
Full report of TARGIT-A trial comparing Intrabeam TARGIT IORT vs traditional radiotherapy over several weeks for early breast cancer

An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. Health Technology Assessment 2016;20(73) — PDF download —

The publications from 2015-16, after the main results of the TARGIT-A trial were published as well as the initial publications (listed at the end of file)
are available in the file:
[download id=”1365″]

To read, right-click this Download link to the pdf file, and save the file on your computer.
Then open using Acrobat Reader.
If you cannot see the Bookmarks pane,
click on View profile, then show/hide – navigation panes and then click on Bookmarks.
Now you should see all the 16 bookmarks and navigate through the 16 papers.

To read the list of 66 selected initial original publications please see [download id=”1361″]
The front page of this website has links to the full text PDFs of important publications http://www.targit.org.uk

The list is also shown below:

Further evidence supporting adoption TARGIT IORT in routine clinical practice:
16 publications in major journals the last 18 months from USA, Europe and Australia

1. BMC Cancer Nov 2014
French Study of 12,025 patients: Over 50% of patients having breast conservation are suitable for TARGIT IORT

2. Breast Surg Mar-Apr 2015
Intraoperative radiotherapy of the breast for early-stage breast cancer: ready for primetime

3. Br J Surgery May 2015
Intraoperative radiotherapy in early breast cancer

4. Ecancermedicalscience Mar 2015
Is IORT ready for roll-out? [Yes]

5. Red Journal Jun 2015
Pride, Prejudice, or Science: Attitudes Towards the Results of the TARGIT-A Trial of Targeted Intraoperative Radiation Therapy for Breast Cancer

Red Journal Aug 2015- Editorial by the Red Journal
“…..Many careers have been built around fractionated radiation therapy for breast cancer, and it comprises a substantial proportion of the practice of the average contemporary radiation oncologist. Depending on your perspective, intraoperative radiation therapy is thus either a very serious threat or a quantum leap forward.”

6. Breast Care 15 July 2015
Accelerated Partial Breast Irradiation in Clinical Practice

7. American J Surg Oct 2016
IORT with its low rate of LR and wound complications may be a reasonable alternative to whole breast irradiation for early-stage breast cancer, regardless of age.

8. Chapter in “Short Course Breast Radiotherapy” 1 Jan 2016
A Risk-Adapted Approach to Breast Radiation Using Targeted Intraoperative Radiotherapy (TARGIT)

9. Oncogene 15 Feb 2016
Radiotherapy-induced miR-223 prevents relapse of breast cancer by targeting the EGF pathway.

10. Oncology 15 April 2016
[Low] Frequency of Whole-Breast Radiation Therapy Following Intraoperative Radiation Therapy Due to Criteria Identified by Lumpectomy

11. Lancet 23 April 2016
A meta-analysis of GEC-ESTRO + TARGIT-A trials show Partial Breast Irradiation (PBI) has similar breast cancer control as Whole Breast Irradiation (WBI), and fewer deaths from other causes.

12. Red Journal 30 April 2016
Better Quality of Life with TARGIT

13. Lancet 7 May 2016:
Intraoperative radiation therapy for breast cancer: a patient’s view

14. Annals of Surgical Oncology 9 May 2016
TARGIT-R (Retrospective): North American Experience [of nearly 1000 patients] with Intraoperative Radiation Using Low-Kilovoltage X-Rays [Intrabeam] for Breast Cancer

15. BMJ Open 10 May 2016
TARGIT IORT radiotherapy during lumpectomy for breast cancer could save millions of travel miles & tonnes of CO2. …plus free up thousands of hours for women with early stage breast cancer, every year. 
Video Abstract
Full paper
Press release by the BMJ

16. Red Journal 13 May 2016
Mortality reduction with Partial Breast Irradiation: A meta-analysis of randomised controlled trials

An estimated 20,000 patients have already been treated with Intrabeam TARGIT IORT
Worldwide Adoption of Intrabeam TARGIT IORT

Categories
Articles Targeted Intraoperative Radiotherapy for Breast Cancer

Reduced mortality with targeted radiation for early breast cancer

“Our meta-analysis of 5-year data from published randomized trials of partial breast irradiation (PBI, alone or within a risk-adapted approach) vs. whole breast irradiation (WBI) for invasive breast cancer treated with lumpectomy, found no difference in breast cancer mortality (n=4489,difference 0.000%(95%CI -0.7 to +0.7),p=0.972). PBI was better than WBI for non-breast cancer mortality (n=4231,difference 1.1% (95%CI -2.1% to -0.2%),p=0.023), and total mortality (difference 1.3% (95%CI -2.5% – 0.0%),p=0.05), leading to a 25% relative risk reduction.”

In the figure below, PBI means Partial Breast Irradiation i.e., radiation only to the area near the tumour rather than the whole breast (Whole Breast Irradiation WBI).
The red diamond shows the overall effect from several trials with over 4000 patients. If the diamond sits on the vertical line, it means there is no effect – and if it is on the left it means that treatment is better for the patient.
So PBI (using TARGIT IORT as a single shot radiation at the time of lumpectomy for breast cancer, for example) reduces mortality, possibly by avoiding irradiation of vital organs, while maintaining cancer control.

Meta-analysis shows lower mortality with partial breast irradiation compared with whole breast irradiation for early breast cancer

Full paper can be accessed at:
www.sciencedirect.com/science/article/pii/S0360301616302000
http://www.redjournal.org/article/S0360-3016(16)30200-0/pdf

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Articles

Media coverage of after BMJ press release about environmental and social benefit of TARGIT IORT for breast cancer

BMJ Blog

British Medical Journal – BMJ – May 10, 2016

More Virtues of One-Stop Radiotherapy for Breast Cancer

Medscape – May 10, 2016

Treating breast cancer patients with single-dose targeted intraoperative radiotherapy (TARGIT) at the time of surgery substantially reduces the burden on patients’ lives and on the environment in comparison with traditional radiotherapy, an analysis by …

Intra-operative Radiation For Breast Cancer Better For Patients and Environment

MedicalResearch.com (blog) – May 9, 2016

Prof. Vaidya: TARGIT-A randomised clinical trial (ISRCTN34086741) compared giving TARGIT IORT during lumpectomy vs. traditional EBRT given …

Targeted radiotherapy during surgery cuts breast cancer patients’ travel – study

BT.com – ‎May 9, 2016‎

Giving breast cancer patients a targeted dose of radiotherapy during surgery would save them millions of miles travelling to and from hospital appointments, according to a study. The procedure, which is widely available in other countries but not on …

Radiotherapy during breast cancer surgery cuts cost and time

OnMedica – ‎May 10, 2016

Giving patients undergoing surgery for early-stage breast cancer a single, targeted intraoperative dose of radiotherapy saves women hundreds of miles and many hours of travel, costs and fuel and has the potential to cut the UK’s carbon dioxide (CO2) …

Radiotherapy during surgery could save millions of travel miles and tons of CO2

Medical Xpress – ‎May 9, 2016‎

One targeted dose of radiotherapy given during surgery to remove early stage breast cancer could save millions of travel miles, enough CO2 emissions for a 100 hectare forest, and free up thousands of hours of women’s time, concludes research published …

Radiotherapy technique ‘cuts patient travel times’

World First Travel Insurance – May 10, 2016

Breast cancer sufferers could save themselves unnecessary long journeys if Britain adopted a radiotherapyprocedure already used by several other countries, a report claims. Patients waste “unnecessary” journeys averaging out at 100 miles and nearly …

Targeted radiotherapy during surgery cuts breast cancer patients’ travel – study

Daily Mail – By Press Association  – May 9th 2016, 11:14:58 pm

Giving breast cancer patients a targeted dose of radiotherapy during surgery would save them millions of miles travelling to and from hospital appointments, …

 

Breast cancer find reduces radiotherapy: Single high-powered shot given during surgery could help 20,000 patients avoid weeks of daily treatment 

Daily Mail – Health By Ben Spencer, Health Correspondent- May 9th 2016, 10:58:39 pm

High powered intrabeam radiotherapy, delivered during surgery while a patient is still under anaesthetic, takes as little as 20 minutes (file photo).

Radiotherapy during surgery could save millions of travel miles and tons of CO2

EurekAlert (press release) – ‎May 9, 2016‎

One targeted dose of radiotherapy given during surgery to remove early stage breast cancer could save millions of travel miles, enough CO2 emissions for a 100 hectare forest, and free up thousands of hours of women’s time, concludes research published …

Targeted radiotherapy during surgery cuts breast cancer patients’ travel – study

South Wales Guardian – ‎May 9, 2016‎

Under current standard treatment for breast cancer, the cancerous tissue is cut out in a procedure known as a lumpectomy and patients then undergo a course of daily radiotherapy lasting three to six weeks. But under an alternative form of treatment ..