Late effects of breast radiotherapy.

1 Haviland J S, Owen J R, Dewar J A, et al. 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. Lancet Oncol 2013; 14: 1086–94. 2 Hopwood P, Haviland J S, Sumo G,et al. Comparison of patient-reported breast, arm, and shoulder symptoms and body image after radiotherapy for early breast cancer: 5-year follow-up in the randomised Standardisation of Breast Radiotherapy (START) trials. Lancet Oncol 2010; 11: 231–40. 3 Carling M, Goodare H, Ironside A, Millington J, Rogers C. Quality of life after breast radiotherapy. Lancet Oncol 2010; 12: 10. 4 Moulton B, Collins P A, Burns-Cox N, Coulter A. From informed consent to informed request: do we need a new gold standard? J R Soc Med 2013; 106: 391–94. 5 Johnson A. The timing of treatment in breast cancer: gaps and delays in treatment can be harmful. Breast Cancer Res Treat 2000; 60: 201–09. For instance, in Hopwood and colleagues’ 5-year follow-up report, up to a third of women reported moderate or marked pain in the arm or shoulder over 5 years, while the 10year followup report by Haviland and colleagues makes no mention of pain, merely of shoulder stiffness. Because our personal experience of late eff ects is that they are progressive, we fi nd this odd. It is also confusing from the point of view of comparison to have diff erent descriptions of adverse events, using different vocabulary (eg, induration vs hardness, and telangiectasia vs skin problems). We find too that some post-radiotherapy effects that we ourselves have experienced are still not mentioned, notably bone necrosis (not necessarily leading to fractures, though these do occur). However, it is a step forward to have 10-year results, and since follow-up data are still being collected, and followup was still short for cardiac events, we hope that these data and other late eff ects will continue to be monitored. The publication of this Article off ers an opportunity to reassess the role of radiotherapy in the overall treatment of breast cancer. It prompts the observation that timing is crucial, especially for fast-growing tumours, and we note that the time from surgery to randomisation in these trials was remarkably long (8–9 weeks in START A and more than 7 weeks in START B). Also, randomisation did not allow for grade of tumour. Patients now expect fully informed consent to treatment, and if they so wish are given details of their pathology. Surely a one-size-fitsall approach is inappropriate for radiotherapy. Fast-growing tumours might well need swift decisions and a diff erent fractionation regimen from the slow-growing tumours. It has been convincingly suggested that diff ering protocols should be applied to diff erent tumours. Now may be the time to take stock: perhaps weekend working should be considered, and NICE might yet need to revise their guidance. Until we get serious about personal lifestyle modification and national policies to promote environmental and behavioural change, we will need blood pressure lowering medications and statins to contain the epidemic of cardiovascular disease.