Photons, electrons, protons and ions, administered in a few sessions and in an extremely targeted way against tumors. Technologies that allow you to follow the movements of your breath with millimeter precision, and imaging to adapt the treatment to the tumor’s response. Thus radiotherapy is also becoming more and more “precise”. And it is combined in a personalized way with other treatments: for example with immunotherapy, to make the tumor more “recognizable” by the immune system.
In the future, radiotherapy could even be “flash”, i.e. delivered in a very short time: a fraction of a second instead of a few minutes, as happens today. Some of these innovations are already a reality for many cancers, while others will probably arrive in a few years. Indeed, there are many avenues opened up by research in the field of radiotherapy, including for breast cancer, as emerged from the XXXII National Congress of the Italian Association of Radiotherapy and Clinical Oncology (Airo), which was held last week in Bologna.
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Radiation therapy for breast cancer: high precision to reduce side effects
In the treatment of breast cancer, radiotherapy plays a very important role. “In most cases, it’s done after surgery, to get rid of any remaining cancer cells,” she tells Breast Health. Marco KrengliDirector of Radiotherapy at the Maggiore University Hospital of Charity of Novara and president-elect of Airo: “A fundamental aspect for us, therefore, is to avoid hitting the surrounding healthy tissue. On the one hand, we now have high-precision machinery, from In another we use technologies that combine the radiation beam with the movements of the chest during breathing and which allow us to reduce the amount of radiation that can reach other organs, such as the heart and lung, to very low levels”.
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High intensity rays against metastases
Increasingly, radiotherapy also plays a role in oligometastatic patients, i.e. patients with less than 5 metastases, usually of small dimensions. “In general, the identification of oligometastatic patients, i.e. those who have developed a limited number of distant metastases and who today we consider curable with the aim of healing, is one of the most innovative concepts in the oncological field”, continues Krengli.
In the case of oligometastases in the bones, brain area or lymph nodes in deep locations, for example, treatment with radiosurgery – or stereotactic therapy, which delivers a very high dose of radiation – often allows them to be eradicated. This may make it possible to reduce or postpone treatment with chemotherapy, hormone therapy and drugs with a molecular target, so much so that clinical studies are underway in patients with oligometastatic prostate cancer to validate the advantage of the use of radiotherapy. Furthermore, a recent meta-analysis of 42 clinical trials has highlighted an advantage in both overall and disease-free survival for those receiving local treatment.
“It is a strategy that also lends itself quite well to the oligometastases of breast cancer, but a lot depends on the biology of the tumor: the patients who benefit the most are those with a slow-growing and non-aggressive disease”.
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Beyond the curative intent, metastases that develop in particularly difficult or delicate locations, for example in the orbital and periorbital area, can be treated with photon-based radiotherapy, says the expert. In selected cases, then, hadrontherapy may also be indicated, a type of radiotherapy that uses protons and carbon ions (particles called hadrons in complex). It must be said, however, that this treatment has been included in the new LEA (Essential Levels of Assistance, which establish reimbursement) only for some specific tumours. Studies are currently underway to extend its use to other neoplasms, including breast cancer, for example with the aim of further reducing the possible risks for the heart.
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Again, one of the lines of research concerns the combination of radiotherapy with immunotherapy, in order to make tumors more sensitive to the latter treatment. With regard to breast cancer in particular, however, to date we do not have sufficient evidence of the effectiveness of the combination strategy. “It is a very fascinating prospect. The premises and the rationale are there – says Krengli – but we have not yet confirmed it and it is therefore necessary to conduct other studies”.
Same dose, fewer sessions
Still looking to the future, a change that could instead come in the next few years is hypofractionation with 5 radiotherapy sessions. “It means administering the same radiation dose in less time: in just one week instead of two or three, as is the norm now”, explains the doctor. In past years, patients were treated in 30 sessions, i.e. for six weeks.
Today in Italy, as in general in European countries, the standard provides for 15 sessions, except in the United Kingdom, where the 5-session standard has established itself. With what advantages? “Hypofractionation – replies Krengli – has really improved the patients’ quality of life. Just think of those who live far from radiotherapy centres. It is not the only aspect to consider: during treatment, in fact, other pharmacological therapies are interrupted for reduce the risk of toxicity, so hypofractionation makes it possible to shorten this stop period. Finally, fewer sessions guarantee greater adherence to radiotherapy”.
Studies show that administering the same dose of radiation in 5 or 15 sessions has the same effects 5 years after treatment, also from an aesthetic point of view. However, confirmation is expected 10 years later. “Progress in our field may appear slower than in other disciplines – he concludes – but in reality, technological innovations and new knowledge on tumor biology have marked – and continue to mark – enormous progress”.