Altered fractionation in radiation therapy for breast cancer in the elderly: are we moving forward?

Radiotherapy is a pivotal treatment for treating breast cancer. However, its role in the management of elderly patients is still under debate. Some authors suggest be avoided after surgery for early stage, some others advocate its adoption. For breast cancer treatment different schedules are used both for whole and partial breast irradiation, in adjuvant as well as definitive setting. Which one is better for elderly patients is a controversial topic. Numerous studies focused on both moderate or extreme hypofractionated irradiation have been published. However, only few addressed the topic on elderly patient population. The data on hypofractionated radiotherapy showed that for whole breast, locoregional and post-mastectomy treatment, this approach is a valid option reporting similar efficacy and toxicity to the standard fractionation. Also accelerated partial breast irradiation for patients with favourable early stage disease represents a viable option allowing for de-escalation by targeting radiation dose to the part of breast tissue at highest recurrence risk. Undoubtedly, for frail and elderly patients a short course of radiotherapy could increase their adherence and the quality of life. In the same manner, the preoperative approach has been applied for both whole and partial breast irradiation, allowing for more precise target delineation compared to the post-surgical one, eventually leading to a smaller treatment volume, to less geographical missing and possibly to a lower radiation-induced toxicity. Some more long-term results could make us more confident in prescribing adjuvant or preoperative partial breast irradiation. These approaches could be the most appropriate treatment for elderly patients, potentially preserving quality of life and increasing the tolerability to the irradiation.