Professional Statements and Societal Positions Guidelines
Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.
In response to requests, input was received from 2 physician specialty societies and 3 academic medical centers (3 reviewers) while this policy was under review in 2011. There was a near-uniform consensus in responses that whole-breast and lung intensity-modulated radiotherapy (IMRT) is appropriate in select individuals with breast and lung cancer. Respondents noted IMRT might reduce the risk of cardiac, pulmonary, or spinal cord exposure to radiation in some cancers such as those involving the left breast or large cancers of the lung. Respondents also indicated whole-breast IMRT might reduce skin reactions and potentially improve cosmetic outcomes. Partial-breast IMRT was not supported by respondents, and the response was mixed on the value of chest wall IMRT postmastectomy.
In response to requests, input was received from 1 physician specialty society and 2 academic medical centers (3 reviewers) while this policy was under review in 2010. Input suggested that IMRT is used in select individuals with breast cancer (e.g., some cancers involving the left breast) and lung cancer (e.g., some large cancers).
Practice Guidelines and Position Statements
National Comprehensive Cancer Network
Current NCCN guidelines (v.4.2020) for breast cancer indicate the importance of individualizing RT planning and delivery. CT based treatment planning is encouraged to delineate target volumes and adjacent organs at risk. Improved target dose homogeneity and sparing of normal tissues can be accomplished utilizing various "compensators such as wedges, forward planning using segments, and IMRT." Respiratory control techniques including deep inspiration breath-hold and prone positioning may be used to try to further reduce dose in adjacent normal tissues, such as the heart and lung. The guideline states that "the panel recommends whole breast irradiation to include breast tissue in entirety. CT-based treatment planning is recommended to limit irradiation exposure of the heart and lungs, and to assure adequate coverage of the breast and lumpectomy site." The guidelines indicate chest wall and regional lymph node irradiation may be appropriate postmastectomy in select individuals but IMRT is not mentioned as a technique for irradiation in these circumstances.
Current NCCN guidelines (v.5.2020) for non-small-cell lung cancer indicate that "More advanced technologies are appropriate when needed to deliver curative RT safely. These technologies include (but are not limited to) IMRT/VMAT [volumetric modulated arc therapy]; Nonrandomized comparisons of using advanced technologies versus older techniques demonstrate reduced toxicity and improved survival."
Current NCCN guidelines (v.3.2020) for small-cell lung cancer indicate that "Use of more advanced technologies is appropriate when needed to deliver adequate tumor doses while respecting normal tissue dose constraints." IMRT is included in the technologies listed. The guidelines also states that "IMRT is preferred over 3D conformal external-beam RT on the basis of reduced toxicity in the setting of concurrent chemotherapy/RT."
American Society for Radiation Oncology
In 2018, the American Society for Radiation Oncology published evidence-based guidelines on whole-breast irradiation with or without low axilla inclusion. The guidance recommended a "preferred" radiation dosage of "4000 cGy [centigray] in 15 fractions or 4250 cGy in 16 fractions".
In 2018, the American Society for Radiation Oncology has also published evidence-based guidelines on RT for lung cancer. The guidelines recommended "moderately hypofractionated palliative thoracic radiation therapy" with chemotherapy as palliative care for stage III and IV incurable non-small-cell lung cancer.
American Society of Clinical Oncology/American Society for Radiation Oncology/Society of Surgical Oncology
In 2016, the American Society of Clinical Oncology (ASCO), American Society for Radiation Oncology, and the Society of Surgical Oncology developed a focused update of a prior ASCO guideline related to the use of post mastectomy RT. The Expert Panel unanimously agreed that "available evidence shows that post mastectomy RT reduces the risk of locoregional failure, any recurrence, and breast cancer mortality for individuals with T1-2 breast cancer with 1 to 3 positive axillary nodes. However, some subsets of these individuals are likely to have such a low risk of locoregional failure that the absolute benefit of post mastectomy RT is outweighed by its potential toxicities." Additionally, the guideline noted that "the decision to recommend post mastectomy RT requires a great deal of clinical judgment."