1. RCR breast radiotherapy consensus guidelines

2. Producing the guidelines
Draft radiotherapy guidelines
Voted at consensus meeting at RCR March 2016
48 centres represented
Agreed that a vote of 70% in favour would constitute a consensus
Final guidelines currently out for comment

3. Cardiac sparing should be standard for all left sided breast tumours
The heart should be excluded from the field
All UK centres should have availability of breath holding techniques
In left sided treatments (excluding IMC) the mean heart dose should be <2Gy in 90% of cases

4. Breast boost A boost should be considered for women under 50 years
For women over 50 consider a boost if high risk features, especially grade 3 or extensive intraductal component
Tumour bed clips should be standard of care
Photon boost using IMRT/IGRT is recommended but electron or mini-tangent boosts are acceptable alternatives

5. Safe omission of radiotherapy
Avoidance of radiotherapy should be considered in low risk tumours (T1 N0 G1-2 ER+ve HER2- ve) if willing to take minimum 5 years adjuvant endocrine therapy and mammographic followup to 10 years
Discussion around appropriate age groups. Strongest support for >70 (and over 60 in study)

6. Internal mammary node irradiation
Consider for patients with T4 disease or >4 axillary nodes
Offer if 1-3 nodes and medial tumour
Deliver using techniques that minimise heart and lung dose

7. Hypofractionation
There is no indication for using more than 15 fractions for standard adjuvant breast, chest wall or axillary radiotherapy

8. Axillary radiotherapy in sentinel node positive disease
Statement taken from recent ABS guidelines
Isolated tumour cells/micro mets: no axilla treatment
1-2 macromets: no axilla treatment required if post menopausal T1 G1-2 ER+ve HER2-ve and having breast RT
3 or more nodes: further axilla treatment (AND or RT)
Further treatment recommended if +ve node and mastectomy, T3, G3, ER-ve or HER2+ve
No consensus reached on T2, premenopausal, LVI or extranodal spread
Encourage POSNOC entry

9. Partial breast radiotherapy
Can be considered if >50 years, G1-2, <3cm, N0, ER+ve, HER2-ve
Can use external beam or multi-catheter brachytherapy
2mm minimum margins
Exclude lobular cancers