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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.
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.
The 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.
The 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.
One trial page, one roadmap page and one idea page on OnCo cite this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing pages listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
One trial page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
Shares National Institute for Health and Care Excellence, Knowledge reaches practice too slowly, Breast cancer (all types), HR-positive / HER2-negative breast cancer and the tags protocol-upgrade, upgrade:proven-unevenly-used, breast.
Shares Knowledge reaches practice too slowly, Breast cancer (all types) and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares Knowledge reaches practice too slowly, Surgery and radiotherapy cure most, get least and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares Knowledge reaches practice too slowly and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares Knowledge reaches practice too slowly and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares Knowledge reaches practice too slowly and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares HR-positive / HER2-negative breast cancer and the tags protocol-upgrade, upgrade:proven-unevenly-used.
Shares HR-positive / HER2-negative breast cancer and the tags protocol-upgrade, upgrade:proven-unevenly-used.
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