MBBS in Georgia is worth it
Increase its use in breast conservation radiation therapy
Increased dose of radiation is commonly, but not generally, used for breast conservation techniques.
The potential downsides to using a boost include:
- Increased complexity of treatment
- Increased duration of treatment
- Increased travel, social / employment relocations
- Increased complications
- Worse cosmos and / or increased chest discomfort
- Increased difficulty in detecting recurrences.
- Lengthening the gap or increasing the delay in chemotherapy, if indicated
The potential benefits of a boost are as follows:
- Reduced local failure rates
- Reduced local failure resulting in improved survival
- Maximizing cosmesis by reducing the dose to a larger breast volume
None of the potential benefits have been clearly demonstrated in a controlled manner, however, there are good theoretical reasons that a boost would improve local control. Holland's seminal paper using the radiologic-pathologic correlation of mastectomy specimens while finding residual foci beyond the limits of cosmetically acceptable resection margins also found most of the residual tumor relatively close to the index mass. There is a well-known dose-response relationship in breast cancer control. Kurtz reported a doubling in the long-term recurrence rate when the dose to the tumor bed was less than 75 Gy or when the dose was delivered at less than 75 Gy, 8 Gy per week from 15% to 30% using Telesesium after lumpectomy. Treating the whole breast at doses above 50 to 54 Gy in 5 weeks is associated with a significantly worse cosmesis, hence the usual use of a boost. However, no controlled comparisons have been published yet. Beadle reported a 50% increase in poor cosmesis rates when a boost was applied. Borger has shown that the risk of fibrosis quadruples with every 100 cm3 increase in the boost volume. Accurate localization of the tumor bed for boost delivery is difficult in the absence of radio-opaque clips (occasionally used by our referral base). The use of electrons to deliver the boost has been reported to decrease cosmetic outcome compared to I192 due to telangiectasia, although this is controversial with other reports, showing superior results with electrons compared to those in St. George and St. Wollongong. The latter avoids hospital stays. There is at least one other randomized multicenter study to test the value of a boost from the EORTC in Europe. Results are still available.
Comparisons: Patients are randomized to chemotherapy (none, AC, non-AC) and within the non-AC arm in terms of timing (before, sandwich, simultaneously) by radiotherapy. The treatment is randomized - Boost (45Gy 25 # + 16Gy 8 #) or no Boost (50Gy 25 #).
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