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Omit RT for patients age 65 years and over (or younger patients with relevant co-morbidities) who have invasive breast cancers that are up to 30 mm with clear margins, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative, and node negative who are planned for treatment with endocrine therapy.
Deliver RT in 5 fractions only for all patients requiring RT who have node-negative tumors that do not require a boost. Options include 28-30 Gy in once-weekly fractions over 5 weeks or 26 Gy in 5 daily fractions over 1 week, as per the FAST and FAST Forward trials, respectively.
To reduce fractions and/or complexity, omit boost RT in the vast majority of patients. Exceptions are in patients =40 years old and those older than 40 years who have significant risk factors for local relapse.
Consider omitting nodal RT in post-menopausal women who require whole-breast RT following sentinel lymph node biopsy and primary surgery for T1, ER positive, HER2 negative, grade 1-2 tumors with 1-2 macrometastases.
Use moderate hypofractionation for all breast/chest wall and nodal RT (eg, 40 Gy in 15 fractions over 3 weeks).
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