Change in the use of fractionation in radiotherapy used for early breast cancer at the start of the COVID-19 pandemic: A population-based cohort study of older women in England and Wales

Background: Adjuvant radiotherapy is recommended for patients with early breast cancer (EBC) receiving breast-conserving surgery (BCS) and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, the Royal College of Radiologists published guidance recommending the use of five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens for eligible patients based on randomised controlled trial-based evidence demonstrating non-inferiority compared with standard moderate-HFRT. We evaluated the uptake of this recommendation by NHS services in England and Wales as part of the National Audit of Breast Cancer in Older Patients.Methods: Women aged ≥50 years undergoing surgery for EBC from Jan-2019 to Jul-2020 were identified from the Rapid Cancer Registration Dataset for England and Wales Cancer Network data, linked to routine national hospital and radiotherapy datasets.Results: Among 35,561 women having surgery for EBC, 71% received post-operative radiotherapy. Receipt of 26 Gray in five fractions (26Gy5F) increased from 12% in Mar-2020 to 70% in Apr-2020. Regional variation in the use of 26Gy5F during Apr-Jul 2020 was similar by age, ranging from 49-87% among older women. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities, initial BCS. Of radiotherapy to the breast/chest wall, 85% was 26Gy5F; 23% if radiotherapy included regional nodes.Conclusions: There was a striking increase in use of 26Gy5F regimens for EBC, among women (≥50 years), within a month of recommendations in guidance published at the start of the COVID-19 pandemic in England and Wales. This work includes patient data collated by the National Disease Registration Service. Background: Adjuvant radiotherapy is recommended for patients with early breast cancer (EBC) receiving breast-conserving surgery (BCS) and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, the Royal College of Radiologists published guidance recommending the use of five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens for eligible patients based on randomised controlled trial-based evidence demonstrating non-inferiority compared with standard moderate-HFRT. We evaluated the uptake of this recommendation by NHS services in England and Wales as part of the National Audit of Breast Cancer in Older Patients. Methods: Women aged ≥50 years undergoing surgery for EBC from Jan-2019 to Jul-2020 were identified from the Rapid Cancer Registration Dataset for England and Wales Cancer Network data, linked to routine national hospital and radiotherapy datasets. Results: Among 35,561 women having surgery for EBC, 71% received post-operative radiotherapy. Receipt of 26 Gray in five fractions (26Gy5F) increased from 12% in Mar-2020 to 70% in Apr-2020. Regional variation in the use of 26Gy5F during Apr-Jul 2020 was similar by age, ranging from 49-87% among older women. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities, initial BCS. Of radiotherapy to the breast/chest wall, 85% was 26Gy5F; 23% if radiotherapy included regional nodes. Conclusions: There was a striking increase in use of 26Gy5F regimens for EBC, among women (≥50 years), within a month of recommendations in guidance published at the start of the COVID-19 pandemic in England and Wales. This work includes patient data collated by the National Disease Registration Service.