For certain stages of many cancers, including breast and lung, randomized controlled trials (RCTs) have shown that postoperative radiotherapy (RT) improves outcomes for operable individuals. Adding radiation to chemotherapy also improves outcomes for those with inoperable lung tumors that have not metastasized beyond regional lymph nodes.
Radiation therapy may be administered externally (i.e., a beam of radiation is directed into the body) or internally (i.e., a radioactive source is placed inside the body, near a tumor). External radiotherapy (RT) techniques include "conventional" or 2-dimensional (2D) RT, 3-dimensional (3D) conformal RT, and intensity-modulated radiation therapy (IMRT).
Conventional External-Beam Radiotherapy
Methods to plan and deliver RT have evolved that permit more precise targeting of tumors with complex geometries. Conventional 2D treatment planning utilizes X-ray films to guide and position radiation beams. Bony landmarks bones visualized on X-ray are used to locate a tumor and direct the radiation beams. The radiation is typically of uniform intensity.
Three-Dimensional Conformal Radiotherapy
Radiation treatment planning has evolved to use 3D images, usually from computed tomography (CT) scans, to more precisely delineate the boundaries of the tumor and to discriminate tumor tissue from adjacent normal tissue and nearby organs at risk for radiation damage. Three-dimensional conformal RT (3D-CRT) involves initially scanning the individual in the position that will be used for the radiation treatment. The tumor target and surrounding normal organs are then outlined in 3D on the scan. Computer software assists in determining the orientation of radiation beams and the amount of radiation the tumor and normal tissues receive to ensure coverage of the entire tumor in order to minimize radiation exposure for at risk normal tissue and nearby organs. Other imaging techniques and devices such as multi leaf collimators (MLCs) may be used to "shape" the radiation beams. Methods have also been developed to position the individual and the radiation portal reproducibly for each fraction and to immobilize the individual, thus maintaining consistent beam axes across treatment sessions.
Intensity-modulated radiotherapy is the more recent development in external radiation. Treatment planning and delivery are more complex, time-consuming, and labor-intensive for IMRT than for 3D-CRT. Similar to 3D-CRT, the tumor and surrounding normal organs are outlined in 3D by a scan and multiple radiation beams are positioned around the individual for radiation delivery. In IMRT, radiation beams are divided into a grid-like pattern, separating a single beam into many smaller "beamlets". Specialized computer software allows for "inverse" treatment planning. The radiation oncologist delineates the target on each slice of a CT scan and specifies the target's prescribed radiation dose, acceptable limits of dose heterogeneity within the target volume, adjacent normal tissue volumes to avoid, and acceptable dose limits within the normal tissues. Based on these parameters and a digitally reconstructed radiographic image of the tumor, surrounding tissues, and organs at risk, computer software optimizes the location, shape, and intensities of the beam ports to achieve the treatment plan's goals.
Increased conformality may permit escalated tumor doses without increasing normal tissue toxicity and is proposed to improve local tumor control, with decreased exposure to surrounding, normal tissues, potentially reducing acute and late radiation toxicities. Better dose homogeneity within the target may also improve local tumor control by avoiding under dosing within the tumor and may decrease toxicity by avoiding overdosing.
Summary of Evidence
For individuals who have breast cancer who receive IMRT, the evidence includes systematic reviews, randomized controlled trials (RCTs), and nonrandomized comparative studies. Relevant outcomes are overall survival (OS), disease-specific survival, locoregional control, quality of life, and treatment-related morbidity. There is modest evidence from RCTs for a decrease in acute skin toxicity with IMRT compared with 2-dimensional (2D) RT for whole-breast irradiation, and dosimetry studies have demonstrated that IMRT reduces inhomogeneity of radiation dose, thus potentially providing a mechanism for reduced skin toxicity. However, because whole-breast RT is now delivered by 3-dimensional (3D) conformal RT (3D-CRT), these comparative data are of limited value. Studies comparing IMRT with 3D-CRT include one (1) RCT comparing IMRT with deep inspiration breath hold (DIBH) to 3D-CRT, two (2) additional RCTs comparing IMRT to 3D-CRT in women who had undergone breast-conserving surgery (with one (1) RCT evaluating simultaneous vs. sequential boost therapy), two (2) nonrandomized comparative studies on whole-breast IMRT, and a few studies on chest wall IMRT. These studies suggest that IMRT requires less radiation exposure to nontarget areas and may improve upon, or provide similar improvement in, clinical outcomes. The available studies on chest wall IMRT for postmastectomy breast cancer individuals have focused on treatment planning and techniques. However, when dose-planning studies have indicated that RT will lead to unacceptably high radiation doses, the studies suggest IMRT will lead to improved outcomes. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have lung cancer who receive IMRT, the evidence includes one (1) RCT that focused on esophageal adverse events and multiple nonrandomized, retrospective, comparative studies. Relevant outcomes are OS, disease-specific survival, locoregional control, quality of life, and treatment-related morbidity. Dosimetry studies have shown that IMRT can reduce radiation exposure to critical surrounding structures, especially in large lung tumors. Based on nonrandomized comparative studies, IMRT appears to produce survival outcomes comparable to those of 3D-CRT, while reducing toxicity. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.