Breast cancer and soft tissue

The meticulous work of numerous investigators has significantly advanced our understanding of the biological diversity and molecular complexity of breast cancer. Because of this expanded insight into the natural history of this disease, the surgical, radiotherapeutic, and systemic management has evolved in remarkably profound ways leading to unequivocal improvement in patient outcomes. It is perhaps the apotheosis of our enhanced understanding of the biology and natural history of breast cancer that we can now declare that we have entered the age of treatment de-escalation. The obvious benefit of de-escalation for the appropriately selected patient is that it decreases the risk of treatment-related morbidity with the result of enhanced quality of life. In addition, less intense therapy can decrease treatment time, improve convenience, and decrease the cost of therapy. Brachytherapists have led the way in this endeavor in that one of the earliest and most successful examples of therapeutic de-escalation for breast cancer has been the development of accelerated partial breast irradiation (APBI). APBI was based upon the hypothesis that smaller target volumes would allow for the possibility of reduced treatment duration and result in less normal tissue toxicity all while maintaining high levels of local control. Several well conducted randomized trials comparing post-operative WBRT to post-operative APBI ( , , , , , , ) have now been completed. More than ten thousand patients have been randomized with median follow-up ranging from five to more than ten years. The efficacy of APBI is now clearly established in that all trials have showed no clinically meaningful difference in survival, regional recurrence, or in-breast failure as compared to WBRT with the absolute difference in ipsilateral breast tumor recurrence ranging from −0.6 to 0.8%.