Hypofractionated Radiotherapy Before or After Breast Surgery for Treatment of Patients With Non-Metastatic Breast Cancer

Anatomic Stage I Breast Cancer AJCC v8, Anatomic Stage II Breast Cancer AJCC v8, Anatomic Stage III Breast Cancer AJCC v8, Breast Carcinoma, Triple-Negative Breast Carcinoma

This phase II trial studies how well hypofractionated radiotherapy before (preoperative) or after (postoperative) breast surgery works in treating patients with different types of non-metastatic (has not spread from original tumor site) breast cancer and to determine the outcomes and side effects of this treatment. Radiation therapy is considered an integral part of breast conserving therapy. Hypofractionated radiation therapy is a radiation treatment in which the total dose of radiation is divided into large doses and treatments are given less than once a day. This has been shown to be an effective treatment for breast cancer while reducing treatment time and decreasing side effects. Preoperative radiotherapy alone or concurrently with chemotherapy has also been tested with excellent results and with minimal toxicity. Preoperative radiation of the intact tumor with a hypofractionated regimen can potentially decrease toxicity by allowing the delivery of treatment to intact breast tissue. The potential advantages of preoperative radiation therapy include the delivery of radiation in the intact breast when radiation can be more effective as more oxygen can be available in the tissue. Furthermore, complications and cosmetic results are expected to be lower in pre-operative radiotherapy before surgery, as there have been no changes in blood supply to the breast. This lends to the possibility of using lower doses of radiotherapy to patients, and potentially better cancer associated clinical outcomes for our breast cancer patients. Undergoing hypofractionated radiation therapy before or after breast surgery may be safe and effective in treating patients with different types of non-metastatic breast cancer.

PRIMARY OBJECTIVE: I. Compare the rate of grade (G)3 or higher radiation treatment related adverse events with the use of preoperative and postoperative radiation within the first 2-years for groups A-D. CORRELATIVE AND EXPLORATORY OBJECTIVES: I. Grade 3 wound complications and seroma infection between preop and postoperative radiation. II. Locoregional control with or without surgery at 2-years in group D (Her2+). III. To evaluate radiographic complete response and near complete response. IV. To estimate the 5-year locoregional control, distant recurrence, invasive disease-free survival, cause-specific survival, and overall survival. V. To evaluate patient-reported outcomes. VI. To evaluate clinical features, treatment technique, dose-volume parameters, histologic and genetic variants associated with adverse events, and fair and poor cosmetic outcomes or unplanned surgical intervention. VII. Evaluate tumor mutation signatures before and after chemotherapy, radiation, and surgery, correlate tumor mutation signatures before and after radiation with pathologic information at the time of surgery. VIII. To describe the pathologic changes seen in breast cancer patients with preoperative radiation. IX. Evaluate circulating tumor deoxyribonucleic acid (DNA), tumor infiltrating lymphocytes, neo-epitopes, and peripheral blood mononuclear before and after chemotherapy, radiation, and surgery; correlate tumor mutation signatures before and after radiation with pathologic information at the time of surgery. X. Group A-D: Determine the rate of implant/tissue expander failure after preop and postop radiation. XI. Group A-C: To determine the pathologic complete response (pCR) rate and near pathologic rate with cellularity \<10% after neoadjuvant chemotherapy and hypofractionated radiotherapy to the whole breast with nodal irradiation if indicated, based on the postsurgical specimen. XII. Group D: Determine locoregional control with the use of preoperative radiation conformal radiation. It will be determined based on the number of patients with controlled locoregional disease at 6-months. XIII. Group A-C: To determine true radiographic complete response based on post treatment positron emission tomography (PET) standardized uptake value (SUV) \<2.5 or uptake \< mediastinum. XIV. Group A-C: To determine the pathologic complete response (pCR) rate and near pathologic rate with cellularity \<10% after neoadjuvant chemotherapy and hypofractionated radiotherapy to the whole breast with nodal irradiation if indicated, based on the postsurgical specimen. XV. Group E: To determine the rates of surgery for locoregional disease after RT at 2 and 5-years. XVI. Group E: To determine the rates of persistent disease in the breast or regional lymphatics after RT at 2 and 5-years. OUTLINE: Patients with low risk and high risk estrogen receptor (ER) positive disease, triple negative disease and HER2 positive disease without complete response are randomized to 1 of 2 arms. Patients with HER2 positive, complete response disease are assigned to arm I. ARM I: Patients undergo standard of care (SOC) chemotherapy followed by breast hypofractionated radiotherapy once daily (QD) for a total of 5 fractions. Patients then undergo SOC breast surgery 10 weeks after radiation treatment. Patients also undergo computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), contrast-enhanced digital mammography (CEDM), and/or breast ultrasound (US) throughout the study. Additionally, patients undergo a biopsy and may undergo optional blood sample collection and tissue collection on study. ARM II: Patients undergo SOC chemotherapy and SOC breast surgery followed by breast hypofractionated radiotherapy QD for a total of 5 fractions. Patients also undergo CT, MRI, PET, CEDM, and/or breast US throughout the study. Additionally, patients undergo a biopsy and may undergo optional blood sample collection and tissue collection on study. After completion of study treatment, patients are followed up at 16 weeks, 6 months, 12 months, 24 months, 36 months, 48 months and at 5 years.

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