Patterns of breast cancer radiotherapy practices among Saudi radiation oncologists

Reem K. Ujaimi

doi:10.15537/smj.2021.42.5.20200820

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Table 1

- Features of hypofractionation regimens.

Survey questions and response(s)	n (%)
The following is a reason not to hypofractionate^*
Nodal irradiation, with or without InM radiation	4 (16.7)
DCIS	3 (12.5)
Postmastectomy	2 (8.3)
InM radiation	6 (25)
Immediate reconstruction	11 (45.8)
Skin involvement	3 (12.5)
None	6 (25)
Other	2 (8.3)
Dose (Gy/F)
42.4/16	5 (20.8)
40/15	18 (75)
Other	1 (4.2)
Boost dose (Gy/F)
2.00	12 (50)
2.5	12 (50)
Organs at risk constraints
I use the exact same constraints as conventional fractionation	13 (54.2)
I change the dose parameters based on the EQD2 calculation	6 (25)
I follow a certain institutional or trial protocol	5 (20.8)

↵* Multiple responses allowed. InM: internal mammary, DCIS: ductal carcinoma in situ, EQD2: equivalent dose in 2 Gy fraction

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Table 2

- Features of postmastectomy radiotherapy.

Survey questions and response(s)	n (%)
The following is an indication for PMRT in my practice^*
T3N0	20 (83.3)
T3N1	24 (100)
T4N any	24 (100)
T1-T2N1	21 (87.5)
High-risk node negative	13 (54.2)
Other	2 (8.3)
PMRT volumes^*
Chest wall only unless its N+	14 (58.3)
Chest wall and regional nodes always	5 (20.8)
Chest wall and regional nodes for any T4	11 (45.8)
Chest wall +/- regional nodes for high-risk node negative	9 (37.5)
Bolus placement
Always, every day, removed only for skin intolerance	2 (8.3)
Always, half of the course	14 (58.3)
For T4 only, everyday	1 (4.2)
For T4 only, half of the course	6 (25)
Other	1 (4.2)
The following is an indication for scar boost after mastectomy
Close or positive margin	13 (54.2)
I boost all patients	1 (4.2)
None	5 (20.8)

↵* Multiple responses allowed PMRT: postmastectomy radiotherapy. T: tumor, N: node

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Table 3

- Features of regional nodal irradiation (RNI).

Survey questions and response(s)	n (%)
The following is an indication for RNI after BCS and ALND^*
Any N1	15 (62.5)
Macrometastatic N1	14(58.3)
N1 with high-risk features	16 (66.7)
N1 with inadequate axillary dissection	19 (79.2)
N1 with extracapsular extension	18 (75)
N2	21 (87.5)
Any T3N0	3 (12.5)
T3N0 with high-risk features	11 (45.8)
T2N0 with high-risk features	4 (16.7)
Nx	10 (41.7)
The following is an indication for RNI after MRM^*
Any N1	13 (54.2)
Macrometastatic N1	13 (54.2)
N1 with high-risk features	14 (58.3)
N1 with inadequate axillary dissection	18 (75)
N1 with extracapsular extension	17 (70.8)
N2	21 (87.5)
Any T3N0	5 (20.8)
T3N0 with high-risk features	15 (62.5)
T2N0 with high-risk features	2 (8.3)
Nx	8 (33.3)
The following is an indication for InM LN radiation^*
Radiologically positive InM node	23 (95.8)
N1 and medially located tumor	14 (58.3)
N0 and medially located tumor with certain high-risk features	3 (12.5)
When 50% or more of the axilla is positive	14 (58.3)
Whenever RNI is indicated for right-sided tumors only	1 (4.2)
Whenever RNI is indicated	2 (8.3)
The definition of adequate LN dissection is
8 or more	3 (12.5)
10 or more	20 (83.3)
15 or more	1 (4.2)

↵* Multiple responses allowed, CTV: clinical target volume, IMRT: intensity modulated radiotherapy, LN: lymph node, RTOG: Radiation Therapy Oncology Group, PTV: planning target volume, ESTRO: European Society for Radiotherapy and Oncology, InM; internal mammary, VMAT: volumetric modulated arc therapy, SC: supraclavicular, ECE: extracapsular extension, T: tumor, N: node

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Table 4

- Features of radiotherapy planning (N=24).

Survey question	Response	n (%)
I contour chest wall/breast	Always	21 (87.5)
	Never	1 (4.2)
	Only when treating with IMRT	2 (8.3)
I contour nodal CTV	Always	23 (95.8)
	Never	0 (0)
	Only when treating with IMRT	1 (4.2)
If nodal CTV was contoured^*	I adjust the field border/shielding accordingly	16 (66.7)
	I follow the standard field borders and use the contours for reference only	9 (37.5)
	I don’t contour nodal CTV anyway	0 (0)
	Other	0 (0)
My LN CTV follows	RTOG atlas	20 (83.3)
	ESTRO atlas	2 (8.3)
	Other	2 (8.3)
My LN PTV	Is 3 mm	3 (12.5)
	Is 5 mm	12 (50)
	Is equal to my CTV	2 (8.3)
	Is technique dependent, I add 3-5 mm when using IMRT but not with 3D	7 (29.2)
	Other	0.(0)
InM PTV	Is equal to my CTV	2 (8.3)
	5 mm all around	5 (20.8)
	3 mm all around	3 (12.5)
	3 or 5 mm, but trimmed from lung/heart	6 (25)
	Is technique dependent, I add 3-5 mm when using IMRT but not with 3D, and I DO NOT trim from lung or heart	5 (20.8)
	Is technique dependent, I add 3-5 mm when using IMRT but not with 3D, and I DO trim from lung or heart	3 (12.5)
	Other	0 (0)
Acceptable InM PTV coverage is	80% of prescription	7 (29.2)
	90% of prescription	8 (33.3)
	95% of prescription	4 (16.7)
	I only care about CTV coverage	4 (16.7)
Acceptable InM CTV coverage	80% of prescription	6 (25)
	90% of prescription	13 (54.2)
	95% of prescription	5 (20.8)
Technique used when treating InM^*	Modified wide tangents whenever possible	21 (87.5)
	Direct electron field matching photon tangents whenever possible	4 (16.7)
	Step and shoot IMRT	6 (25)
	VMAT	13 (54.2)
	Tomotherapy	4 (16.7)
	Other	0 (0)
RNI after axillary dissection^*	For any N1 I treat as per MA20 (small SC field encompassing axilla 3-SC)	16 (66.7)
	For N1+ ECE I treat the full axilla+SC+/-InM	14 (58.3)
	For any N1 I treat the full axilla+SC+/-InM	2 (8.3)
	For N1+ inadequate dissection I treat the full axilla+SC+/-InM	17 (70.8)
	For N2 I always treat the dissected axilla +SC+/- InM (large MA20 SC field)	13 (54.2)
	For N2 I treat the dissected axilla only in cases of inadequate dissection or extensive nodal involvement	10 (41.7)

↵* Multiple responses allowed. CTV: clinical target volume, IMRT: intensity modulated radiotherapy, LN: lymph node, RTOG: Radiation Therapy Oncology Group, PTV: planning target volume, ESTRO: European Society for Radiotherapy and Oncology, InM: internal mammary, VMAT: volumetric modulated arc therapy, RNI: regional nodal irradiation, SC: supraclavicular, ECE: extracapsular extension

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Table 5

- Features of DIBH techniques.

Survey questions and response(s)	n (%)
I use DIBH technique(s)
With 3D	11(45)
With IMRT/VMAT	1 (4.2)
With both	5 (20.8)
I do not use it	7 (29.2)
I use DIBH technique(s)^*
For all left-sided patients	10 (41.7)
When treating InM on the left side	8 (33.3)
When heart constraints are not acceptable	11(45.8)
At our department we have a protocol for screening patients who could benefit from it	2 (8.3)
I do not use it because it is not available at our center	6 (25)
Other	1 (4.2)
If you chose other above, please specify
Any side with InMN, also if liver is located high in chest and occasionally with right side SCV field if very young patient
I do not use DIBH technique(s) because^*
The accessories are not available at my center, I would love to acquire them	7 (53.8)
It takes a long time in the machine; we cannot afford it	3 (23.1)
I am satisfied with my treatment without it	5 (38.5)
No reason, just never thought of using it	1 (7.7)

↵* Multiple responses allowed. DIBH: deep inspirational breath hold, IMRT: intensity modulated radiotherapy, VMAT: volumetric modulated arc therapy, InM: internal mammary, InMN: internal mammary nodes, SCV: supraclavicular