title: Factors of influence on acute skin toxicity of breast cancer patients treated with standard three-dimensional conformal radiotherapy (3D-CRT) after breast conserving surgery (BCS).
abstract: OBJECTIVE
  Standard 3D-CRT after BCS may cause skin toxicity with a wide range of intensity including acute effects like erythema or late effects. In order to reduce these side effects it is mandatory to identify potential factors of influence in breast cancer patients undergoing standard three-dimensional conformal radiation therapy (3D-CRT) of the breast and modern systemic therapy.
  
  
  METHODS
  Between 2006 and 2010 a total of 211 breast cancer patients (median age 52,4 years, range 24-77) after BCS consecutively treated in our institution with 3D-CRT (50 Gy whole breast photon radiotherapy followed by 16 Gy electron boost to the tumorbed) were evaluated with special focus on documented skin toxicity at the end of the 50 Gy-course. Standardized photodocumentation of the treated breast was done in each patient lying on the linac table with arms elevated. Skin toxicity was documented according to the common toxicity criteria (CTC)-score. Potential influencing factors were classified in three groups: patient-specific (smoking, age, breast size, body mass index = BMI, allergies), tumor-specific (tumorsize) and treatment-specific factors (antihormonal therapy with tamoxifen or aromatase inhibitors, chemotherapy). Uni- and multivariate statistical analyses were done using IBM SPSS version 19.
  
  
  RESULTS
  After 50 Gy 3D-CRT to the whole breast 28.9% of all 211 patients had no erythema, 62.2% showed erythema grade 1 (G1) and 8.5% erythema grade 2. None of the patients had grade 3/4 (G3/4) erythema.In univariate analyses a significant influence or trend on the development of acute skin toxicities (erythema G0 versus G1 versus G2) was observed for larger breast volumes (p=0,004), smoking during radiation therapy (p=0,064) and absence of allergies (p=0,014) as well as larger tumorsize (p=0,009) and antihormonal therapy (p=0.005).Neither patient age, BMI nor choice of chemotherapy showed any significant effect on higher grade toxicity. In the multivariate analysis, factors associated with higher grade skin toxicity were larger breast target volume (p=0,003), smoking (p=0,034) and absence of allergies (p=0,002).
  
  
  CONCLUSIONS
  Patients treated in this study showed less objectively documented skin toxicity after 50 Gy 3D-CRT compared to similar patient cohorts. Factors associated with higher grade skin toxicity were smoking during 3D-CRT, absence of allergies and larger breast volumes.
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, 68167, Mannheim, Germany. uta.kraus-tiefenbacher@umm.de
authors.forename: Uta
authors.initials: U
authors.lastname: Kraus-Tiefenbacher
authors.forename: Andreas
authors.initials: A
authors.lastname: Sfintizky
authors.forename: Grit
authors.initials: G
authors.lastname: Welzel
authors.forename: Anna
authors.initials: A
authors.lastname: Simeonova
authors.forename: Elena
authors.initials: E
authors.lastname: Sperk
authors.forename: Kerstin
authors.initials: K
authors.lastname: Siebenlist
authors.forename: Sabine
authors.initials: S
authors.lastname: Mai
authors.forename: Frederik
authors.initials: F
authors.lastname: Wenz
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D018275:Carcinoma, Lobular / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D015412:Mastectomy, Segmental; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011379:Prognosis; D011855:Radiodermatitis / Q000175:diagnosis / Q000209:etiology*; D020266:Radiotherapy, Conformal / Q000009:adverse effects*; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D055815:Young Adult