{"entity":{"id":"idea-pu-five-fraction-breast-default","kind":"idea","name":"One week of breast radiotherapy in five treatments as the default after surgery","aka":[],"tldr":"A trial of 4,000 people showed that five treatments over one week control breast cancer as well as three weeks, and England's national guideline has offered it as standard since 2023 when the lymph nodes are not treated. In United States hospitals, ten treatments or fewer were used for 11.4 per cent of women with early breast cancer after breast-conserving surgery in 2020 and 2021.","summary":"The evidence. FAST-Forward randomised 4,000 patients between 40 Gy in 15 fractions over three weeks and 26 or 27 Gy in five fractions over one week. Estimated five-year recurrence in the treated breast was 2.1 per cent after 40 Gy, 1.7 per cent after 27 Gy and 1.4 per cent after 26 Gy, which its authors describe as \"emphatically showing non-inferiority of the 5-fraction regimens\", and 26 Gy had normal-tissue effects similar to the three-week course. Subgroup analyses by age, grade, size, nodal status, boost, chemotherapy, HER2 status and triple-negative status found no evidence of a different effect, with the caveat that the event numbers were small.\n\nThe guideline. NICE NG101 recommendation 1.13.13 (2023) reads: \"Offer 26 Gy in 5 fractions over 1 week for people with invasive breast cancer having partial-breast, whole-breast or chest-wall radiotherapy, without regional lymph node irradiation, after breast-conserving surgery or mastectomy.\" The committee recommends considering 40 Gy in 15 fractions for some groups, for example where a diagnosis increases sensitivity to radiotherapy, after implant-based reconstruction, or with a high body mass index or fibromyalgia, and offering it when the lymph nodes are treated. It noted that the five-fraction course had a higher incidence of some clinician-assessed effects at five years, mainly firmer breasts, which it judged not clinically significant apart from swelling.\n\nThe measured gap. In the United States National Cancer Database, among 528,553 women with early-stage breast cancer treated with breast-conserving surgery and radiotherapy, schedules of ten or fewer fractions rose from 4.8 per cent in 2015 to 2019 to 11.4 per cent in 2020 to 2021, with a median cost of 2,289 dollars against 5,032 for longer courses; the longer courses remained the majority. The earlier shift to three-week courses was itself slow: among eligible women in the same database, moderate hypofractionation rose from 26.2 per cent in 2012 to 67.0 per cent in 2016. When a large commercial insurer stopped paying for the longer course in eligible women, use of the shorter one rose by 4.2 percentage points among those covered, and by 8.5 points among self-insured patients indirectly exposed to the policy. NICE noted in 2023 that English centres varied between the two schedules; OnCo did not find a published national audit of the proportion now treated in five fractions.","asOf":"2026-10-20","links":[{"label":"Brunt et al., Five-fraction radiotherapy for breast cancer: FAST-Forward to implementation (Clinical Oncology 2021)","url":"https://doi.org/10.1016/j.clon.2021.04.016"},{"label":"NICE guideline NG101, Early and locally advanced breast cancer: recommendations 1.13.2 (breath-hold, 2018) and 1.13.13 (26 Gy in 5 fractions, 2023)","url":"https://www.nice.org.uk/guidance/ng101/chapter/Recommendations"},{"label":"McDougall et al., COVID-19 as a catalyst for ultra-hypofractionated radiotherapy in early breast cancer: trends, predictors, and estimated cost savings (Clinical Breast Cancer 2026)","url":"https://doi.org/10.1016/j.clbc.2026.06.004"},{"label":"Woodward et al., Trends in use of hypofractionated whole breast radiation in breast cancer: an analysis of the National Cancer Database (International Journal of Radiation Oncology, Biology, Physics 2021)","url":"https://doi.org/10.1016/j.ijrobp.2020.09.004"},{"label":"Parikh et al., Association of utilization management policy with uptake of hypofractionated radiotherapy among patients with early-stage breast cancer (JAMA Oncology 2020)","url":"https://doi.org/10.1001/jamaoncol.2020.0449"}],"tags":["protocol-upgrade","upgrade:proven-unevenly-used","evidence:strong","breast"],"related":["idea-acc-hypofractionation-default-lmic","idea-cost-hypofractionation-payment","idea-pu-prostate-hypofractionation-default","idea-pu-washing-and-deodorant-during-radiotherapy"],"cancers":["breast-cancer","breast-hr-positive"],"sections":["radiation"],"technologies":["hypofractionated-radiotherapy","radiotherapy-access-gap"],"targets":[],"drugs":[],"companies":[],"institutions":["nice"],"pathways":[],"terms":["hypofractionation","post-mastectomy-radiotherapy"],"trials":["fast-forward","fast-trial","start-a","start-b"],"people":[],"bottlenecks":["b-knowledge-diffusion","b-incentive-misalignment","b-surgery-radiation-innovation"],"keyPapers":["paper-murray-brunt-lancet","paper-haviland-lancet-oncol"],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Adopting 26 Gy in five fractions as the written default for eligible breast and chest-wall radiotherapy, with exceptions recorded, raises its use above 80 per cent of eligible patients within a year with no change in recurrence or patient-reported breast effects at five years compared with the preceding cohort.","rationale":"The trial is large and mature, a national guideline recommends it, it saves the patient ten trips and the department two-thirds of the machine time, and the claims and registry data that measure practice show that most eligible women in at least one large health system still receive a longer course.","test":"A per-centre audit of fraction numbers in eligible patients against the guideline, published by centre, with five-year recurrence and patient-reported breast outcomes collected through the registry.","maturity":"being-tested-at-scale","actor":"clinic","cost":"small","horizonYears":2},"route":"/ideas/idea-pu-five-fraction-breast-default/","neighbours":{"idea":[{"id":"idea-pu-prostate-hypofractionation-default","kind":"idea","name":"Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy","route":"/ideas/idea-pu-prostate-hypofractionation-default/"},{"id":"idea-acc-hypofractionation-default-lmic","kind":"idea","name":"Make one-week radiotherapy the default in overloaded systems","route":"/ideas/idea-acc-hypofractionation-default-lmic/"},{"id":"idea-prev-omit-radiotherapy-low-risk-breast-default","kind":"idea","name":"Make skipping radiotherapy the default for very low-risk breast cancer","route":"/ideas/idea-prev-omit-radiotherapy-low-risk-breast-default/"},{"id":"idea-cost-hypofractionation-payment","kind":"idea","name":"Pay for a course of radiotherapy, not for each fraction","route":"/ideas/idea-cost-hypofractionation-payment/"},{"id":"idea-acc-single-fraction-palliative-radiotherapy-default","kind":"idea","name":"Single-fraction radiotherapy as the default for painful bone metastases","route":"/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/"},{"id":"idea-pu-washing-and-deodorant-during-radiotherapy","kind":"idea","name":"Tell people having radiotherapy that they can wash the treated skin and use deodorant","route":"/ideas/idea-pu-washing-and-deodorant-during-radiotherapy/"}],"cancer":[{"id":"breast-cancer","kind":"cancer","name":"Breast cancer (all types)","route":"/cancers/breast-cancer/"},{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"hypofractionated-radiotherapy","kind":"technology","name":"Hypofractionated radiotherapy","route":"/technologies/hypofractionated-radiotherapy/"},{"id":"radiotherapy-access-gap","kind":"technology","name":"Radiotherapy access and the global machine gap","route":"/technologies/radiotherapy-access-gap/"}],"institution":[{"id":"nice","kind":"institution","name":"National Institute for Health and Care Excellence","route":"/institutions/nice/"}],"term":[{"id":"hypofractionation","kind":"term","name":"Hypofractionation (fewer, larger radiotherapy doses)","route":"/terms/hypofractionation/"},{"id":"post-mastectomy-radiotherapy","kind":"term","name":"Radiotherapy after mastectomy","route":"/terms/post-mastectomy-radiotherapy/"}],"trial":[{"id":"fast-trial","kind":"trial","name":"FAST (5-fraction whole-breast radiotherapy)","route":"/trials/fast-trial/"},{"id":"fast-forward","kind":"trial","name":"FAST-Forward","route":"/trials/fast-forward/"},{"id":"start-a","kind":"trial","name":"START-A (UK Standardisation of Breast Radiotherapy, trial A)","route":"/trials/start-a/"},{"id":"start-b","kind":"trial","name":"START-B (UK Standardisation of Breast Radiotherapy)","route":"/trials/start-b/"}],"bottleneck":[{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"}],"paper":[{"id":"paper-murray-brunt-lancet","kind":"paper","name":"Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial","route":"/key-papers/paper-murray-brunt-lancet/"},{"id":"paper-haviland-lancet-oncol","kind":"paper","name":"The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials","route":"/key-papers/paper-haviland-lancet-oncol/"}]}}