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Consultant radiographers fly the flag at premier European breast cancer event

7 June, 2018

Author: Sairanne Wickers, University College London Hospital and Neill Roberts, Leeds Cancer Centre

Sairanne and Neill
Sairanne and Neill

Two consultant radiographers from the UK heard about the latest developments at the 11th European Breast Cancer Conference earlier this year.

Sairanne Wickers from University College London Hospital and Neill Roberts from Leeds Cancer Centre, both specialise in breast radiotherapy, and were keen to learn of the advances in the management of breast cancer patients, and how this may apply to their respective services.

The biennial event is the largest of its kind in Europe, bringing together the multidisciplinary team including pre-eminent clinicians and academics in the field.

Sairanne and Neill pick out their highlights:

Neo-adjuvant radiotherapy
In early and locally advanced breast cancer management, radiotherapy is traditionally given in the adjuvant setting (following surgery with or without upfront chemotherapy). Neo-adjuvant chemotherapy is often given to downstage large tumours in an attempt to avoid mastectomy. Dr Charlotte Coles from the University of Cambridge spoke about a new feasibility study looking at the role of radiotherapy in the neo-adjuvant setting, for patients with large tumours in whom neo-adjuvant chemotherapy may not be advised.

Eligible patients would have upfront radiotherapy followed by chemotherapy. This is an exciting new area of investigation. Speakers from France reported a number of small, single centre studies showing favourable results for the role of neo-adjuvant radiotherapy where patients are unresponsive to upfront chemotherapy.

Breast reconstruction and radiotherapy
We were fortunate to hear from our surgical colleagues who are continually developing advanced oncoplastic and reconstructive techniques to improve cosmesis, whilst optimising treatment pathways to prevent delays. We heard how PRADA, another UK based study, will take an innovative approach, looking at neo-adjuvant radiotherapy before mastectomy and reconstruction. The aim is to improve long-term cosmesis, avoid delays in radiotherapy and be more cost effective than delayed reconstruction.

Management of the axilla
Many sessions discussed and debated how to manage the pre-treatment positive axilla, particularly in patients with a complete radiological response in the breast following neo-adjuvant systemic therapy. Surgically clearing the axilla was described by many speakers as likely overtreatment, with repeat sentinel lymph node biopsy (SLNB) suggested as a method of re-staging the axilla prior to surgery.

However, we heard of false negative rates of around 26% if only one SLN is assessed post chemotherapy.  Methods of clipping the positive lymph nodes pre-treatment were discussed, to facilitate targeted SLNB and reduce the false negative rate, as well as taking two or more nodes for assessment. In summary, it was clear that management of the axilla is still an evolving and controversial area of breast cancer management.

YOUNG BOOST trial
We also heard about the initial results from large randomised control trials (RCT) and one in particular that could have implications for technique delivery of radiotherapy boosts for younger patients. The 'YOUNG BOOST' trial is a multicentre RCT from the Netherlands where four year follow-up of cosmetic outcome has demonstrated poorer cosmesis for higher doses (26Gy versus 16Gy).

There was a negative effect of photon boosts compared to electron boosts. This goes against the trend we currently see for boost delivery in the UK which is moving away from electron boosts. In the subsequent discussion, it was generally considered that the size of the boost volume has a significant impact on cosmesis, and that boost volumes should be conservative, and in light of the observed low rates of local recurrence, the indications for boost may need re-evaluation. We await longer-term follow-up to determine recurrence rates between the two dose groups.

Survivorship
There was an interesting session dedicated to the holistic support and care of this patient group. The presentations focused on the survivorship issues faced by patients, including emotional, physical and financial challenges experienced by the growing number of women surviving a breast cancer diagnosis.

Recent clinical practice guidelines from the Society of Integrative Oncology make recommendations on the role of certain complementary therapies, such as meditation and music therapy to reduce stress, acupuncture for tackling CINV, and lifestyle education and psychological support that have been shown to play a vital role in our breast cancer management pathways.

Neill commented: "The scale of the event was extremely impressive and the programme diverse. Having this opportunity allows us to keep up-to-date with current developments that have the potential to benefit our patients and to disseminate on in our academic capacity."

Sairanne added: "I would highly recommend this conference to radiographers specialising in breast cancer. 

"It was reassuring to hear from the international breast cancer community that the intricate and often complicated management decisions we face within our role are shared across Europe. Breast cancer is a complicated disease that does not have simple answers, and needs a multidisciplinary approach."

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