Hematology/Oncology Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 09, 2018

In This Article

Whole Breast Irradiation

American Society for Radiation Oncology

For women with invasive breast cancer receiving whole breast irradiation (WBI) with or without inclusion of the low axilla, the preferred dose-fractionation scheme is hypofractionated WBI to a dose of 4000 cGy in 15 fractions or 4250 cGy in 16 fractions.

When planning, the volume of breast tissue receiving >105% of the prescription dose should be minimized and the tumor bed contoured with a goal of coverage with at least 95% of the prescription dose. Dose to the heart, contralateral breast, lung, and other normal tissues should be minimized.

The decision to offer hypofractionated WBI (HF-WBI) should be independent of tumor grade.

The decision to offer HF-WBI may be independent of hormone receptor status, HER2 receptor status, and margin status.

The decision to offer hypofractionation should be independent of breast cancer laterality.

The decision to offer HF-WBI should be independent of chemotherapy received prior to radiation and trastuzumab or endocrine therapy received prior to or during radiation.

There is no evidence indicating deleterious effects of HF-WBI compared with conventionally fractionated WBI (CF-WBI) in either younger or older patients, and thus HF-WBI may be used regardless of age.

HF-WBI may be used as an alternative to CF-WBI in patients with ductal carcinoma in situ (DCIS).

A tumor bed boost is recommended for patients with invasive breast cancer who meet any of the following criteria: age ≤50 years with any grade, age 51 to 70 years with high grade, or a positive margin.

Omitting a tumor bed boost is suggested in patients with invasive breast cancer who meet the following criteria: age >70 years with hormone receptor-positive tumors of low or intermediate grade resected with widely negative (≥2 mm) margins.

Tumor bed boost may be used for patients with DCIS who meet any of the following criteria: age ≤50 years, high grade, or close (<2 mm) or positive margins.

A tumor bed boost may be omitted in patients with DCIS who, if age >50 years, meet the following criteria: screen detected, total size ≤2.5 cm, low to intermediate nuclear grade, and widely negative surgical margins (≥3 mm).

In the absence of strong risk factors for local recurrence, such as those enumerated in KQ3B, 1000 cGy in 4 to 5 fractions is suggested as the standard tumor bed boost dose-fractionation, regardless of whole breast dose-fractionation, stage, or histology.

Particularly in the presence of strong risk factor(s) for local recurrence, such as the single risk factor of positive margins or a combination of risk factors such as young age and close margins, a higher radiation boost dose of 1400 to 1600 cGy in 7 to 8 fractions or 1250 cGy in 5 fractions may also be used.


  • Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018 mar 12. https://www.ncbi.nlm.nih.gov/pubmed/29545124


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