Oncology Frontier: For those women who do not hit all of those markers and radiotherapy is opted， what should be taken into consideration?

　　《肿瘤瞭望》：没有完全符合以上低复发标准的患者放疗时应该注意什么？

　　Dr. Ollivotto: If the patient is not interested in breast saving or breast conservation and she will soon have the breast off， mastectomy is the simplest thing to do. If she is interested in breast conservation and when we survey women in north America about 80% given a choice elect breast conserving surgery but there is still about 20% who elect not to. One of the big factors that drives women to say “no thanks I do not want it”， is the time and inconvenience. Historically and in the United States， radiation treatment is given over a 5， 6， 6.5 week interval. It is not necessary. There have been studies that we have done in Canada and the UK demonstrating that a 3 week course of daily visits to the cancer center is perfectly adequate. Access， time， and inconvenience is one thing women need to consider. The next thing is the size and shape of the breast. The goal of the breast conserving surgery is to leave the breast that looks pretty normal compared to the other side. If the tumor is large， then you have to chop out too much of the breast and it leaves a disfigured appearance and you may have not achieved as much as you could. Size， relative to the size of the breast would be the next consideration and then in giving radiation， therapy mostly is well tolerated but there are small groups of patients， people with diseases such as lupus， systemic lupus erythematosus， scleroderma， autoimmune diseases， Crest syndrome， who may have an increased risk of developing fibrosis in association with radial therapy， xerodermapigmentosum， ataxia telangiectasia， and some of these types of rare genetic or autoimmune conditions that increase fibrosis. Those people should have not it. People who have previous radiation in a curative sense， like for Hodgkin’s disease， where we give radiation to the mediastinum， have already had half the breast treated and adding radiation to those patients， they may be better served by mastectomy. Assuming they do not have any of these relative to absolute contraindications to radiation therapy， then you would think about discussing with them the risk of other side effects. In my view and experience， there are patients who develop more fibrosis and scarring with the 3 types of treatment. Those in particular are people with very large breasts where technically we do not get as very homogenous a dose. Number 2， people who have a problem after the surgery， either a lot of swelling of the breast after the excision and infection or a big hematoma， those people have a higher risk of fibrosis and complications from the radiation. They might be better served by the more extended American type fractionation over 6.5 weeks so the choice of technique is important. Using techniques that improve the homogeneity of the breast， there is something called field in field techniques that are much better than wedge and radiation therapy which is a historical way of treating. Having access and developing the skills to use more modern radiation planning that improves the homogeneity of the breast， improves the outcome. Those would be some of the considerations.

　　Ollivotto教授：如果患者对保乳治疗不感兴趣，就会选择切除乳房，乳房切除术就比较简单了。我们调查了北美的乳腺癌患者，约有80%的患者选择保乳治疗，不过仍有20%的患者不选保乳手术，其原因是不方便、治疗时间太长。在美国，放疗曾每次进行5周、6周或6.5周。实际上，这完全没有必要。我们在加拿大及英国所开展的研究表明，为期三周的连续放疗就已足够了。进行放疗的途径、时间以及是否方便均是乳腺癌患者放疗时需要考虑的问题。还需要考虑乳房的大小及形态。保乳手术治疗的目的是保留乳房并使其看起来与对侧乳房一样正常。如果肿瘤较大，则需要切除很多乳腺组织，则乳房外观会非常难看，这很难让患者满意。除形态外还要考虑乳房的大小。放疗一般耐受性较好，但可能会增加一小部分患者（如伴有狼疮、全身性红斑狼疮、硬皮病、自身免疫性疾病、Crest综合征、着色性干皮病、共济失调毛细血管扩张症以及一些罕见的遗传性或自身免疫性疾病者）发生乳腺纤维化的风险。因此，伴有上述疾病的患者不能进行放疗。曾因霍奇金病等疾病接受纵膈放疗的患者，其一半的胸部已经放疗过了，对她们最好行乳房切除术。如果患者没有放疗的相对或绝对禁忌证，则应告知其他放疗副作用。以我的经验来看，有三种类型患者放疗后更容易出现纤维化和疤痕。第一种是乳房较大者，对这些患者而言，我们的技术无法使放疗剂量在乳房均匀分布。第2种是术后出现感染、肿胀或血肿的患者，其发生放疗纤维化或其他并发症的风险比较高。这些患者最好采取6.5周美国分馏放疗，即放疗技术的选择很重要。与过去楔形板放疗相比，乳房野中野适形放疗能改善乳房均匀性。患者有机会用这些先进放疗技术治疗以改善乳房均匀性，则可提高放疗效果。这也是应该考虑的因素。