Originally published as JCO Early Release 10.1200/JCO.2008.19.1981 on October 14 2008

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In Reply:

Jean-Philippe Pignol, Ivo Olivotto, Eileen Rakovitch

Sunnybrook Health Sciences Centre, British Columbia Cancer Agency, Vancouver Island Centre, Vancouver, British Columbia, Canada

Bölke et al conclude that breast intensity-modulated radiation therapy (IMRT) is not justified to improve tangent pair RT for patients with early-stage breast cancer. This conclusion is based on retrospective, single-institution studies, generally with ill-defined mechanisms for collecting acute toxicity information. They elect to ignore the randomized clinical trial data presented and discussed in our original report. This raises the issue of how important it is to use blind assessment to prospectively, systematically assess acute toxicity. To reiterate, the lower rates of acute skin toxicity with conventional radiotherapy reported by some other authors have come mainly from single-center studies in which the oncologist usually assessed the degree of skin reaction while the patient was still under treatment. Such evaluations would under-represent the patient's experience because the maximum skin toxicity generally occurs a week or more after the end of the radiotherapy.^1,2 In our multicenter randomized trial, skin toxicity was captured by trained clinical research assistants, who assessed skin toxicity at return visits 1, 2, 4, and 6 weeks after the end of RT. Both the patients and the clinical research assistants were blinded to the treatment arm. In the last week of treatment, 20.9% of the patients who received standard radiotherapy presented moist desquamation, compared with 48% of patients for whom postradiotherapy assessments were included. Bölke et al describe the 35% reduction in acute skin toxicity provided by breast IMRT as a "poor result." Regardless of the absolute rates of acute toxicity, this does not negate the statistical and clinical beneficial effect of IMRT. Also, patients might think differently. In our study, the occurrence of moist desquamation was significantly associated with the occurrence of grade 2 or 3 pain and with a reduction in health-related quality of life. Finally, the purpose of breast IMRT is not to increase local control, but to improve the homogeneity of the prescribed radiation dose, which reduces acute skin toxicity. So, waiting for "long-term follow-up of 10 years" is not necessary before implementing the technique.

We agree that long-term cosmetic results are important and could reinforce the findings of the trial. Such data already exist.⁴ We do agree with Bölke et al that other techniques, including partial breast irradiation or hypofractionation,^3,5 could also reduce the acute skin toxicity of breast RT. However because a large number of women still receive whole breast radiotherapy with extended fractionation, the data from our randomized clinical trial should be used to improve the quality of life of such patients now.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

published online ahead of print atwww.jco.org on October 13, 2008

REFERENCES

1. Pignol JP, Olivotto IA, Rakovitch E, et al: A multicenter randomized trial of breast-intensity modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 26:2085-2092, 2008[Abstract/Free Full Text]

2. Fisher J, Scott C, Stevens R, et al: Randomized phase III study comparing best supportive care to Biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97-13. Int J Radiat Oncol Biol Phys 48:1307-1310, 2000[Medline]

3. Whelan T, MacKenzie R, Julian J, et al: Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node-negative breast cancer. J Natl Cancer Inst 94:1143-1150, 2002[Abstract/Free Full Text]

4. Donovan E, Bleakley N, Denholm E, et al: Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol 82:254-264, 2007[CrossRef][Medline]

5. Vicini FA, Kestin L, Chen P, et al: Limited-field radiation therapy in the management of early stage breast cancer. J Natl Canc Inst 95:1205-1211, 2003[Abstract/Free Full Text]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pignol, J.-P. Articles by Rakovitch, E. Search for Related Content PubMed Articles by Pignol, J.-P. Articles by Rakovitch, E. Related Articles Related Correspondence Social Bookmarking                            What's this?