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Top Line: Should adjuvant radiation and chemo be given concurrently for breast cancer? 
The Study: Your knee-jerk reaction is probably “no.” They’re typically sequenced. Several trials have compared sequenced versus concurrent regimens and show mixed results. SECRAB was a large randomized trial in the UK of nearly 2300 women receiving both adjuvant chemo and adjuvant radiation. To put this trial in perspective, it was running in parallel with the START trials from 1998 to 2004. So regimens weren’t that standardized, but the majority of patients did receive 40 Gy in 15 fractions. Chemo mainly consisted of CMF, with 45% receiving an anthracycline. Over half had breast conservation and just under two-thirds were lymph node positive. Concurrent therapy significantly reduced the rate of local failure at 5 (5 → 3%) and 10 (7 n→ 5%) years. It also reduced the rate of locoregional failure, but not distant failure or any survival outcomes. The local failure benefit was particularly evident in the patients who received anthracyclines. As expected, concurrent therapy significantly increased moderate to severe skin toxicity (15→ 24%). However, among the patients who received the now standard hypofractionated regimen, there was no increase in skin toxicity. But wait, couldn’t radiation interfere with the administration of chemo? No, it was mainly chemo toxicity that interfered with the administration of radiation.
TBL: Concurrent CMF-based chemo and radiation improves local control for breast cancer, but unfortunately we’re left in the dark on how this translates to modern dose-dense and taxane-containing regimens. | Fernando, Radiother Oncol 2019


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