Balancing Local Control With Long-Term Cosmesis in Re-Irradiation

In the management of patients with locoregionally advanced breast cancer, the clinical mandate often shifts toward prioritizing local control, sometimes at the expense of long-term cosmesis. However, for survivors, the chronic sequelae of aggressive retreatment, particularly debilitating skin changes and fibrosis, can profoundly impact quality of life years after the final fraction is delivered.

During the 2026 American College of Radiation Oncology (ACRO) Summit, CancerNetwork® sat down with J. Isabelle Choi, MD, to discuss the nuances of mitigating treatment-related morbidity. In this interview, Choi outlined her institutional standards for dose fractionation, the critical "subtle" differences between 1.8 Gy and 2.0 Gy daily schedules, and the multidisciplinary supportive care interventions, ranging from prophylactic pharmacotherapy to long-term physical therapy, required to stay ahead of late-term tissue damage.

Choi is an associate attending radiation oncologist at Memorial Sloan Kettering Cancer Center

Transcript:

[In terms of dose fractionation during treatment planning], in the re-irradiation setting, I use 1.8 Gy per day, once daily fractionation. I have not used a BID, or twice daily fractionation. I know that’s something that is being used in some other institutions, but that’s the standard, at least at our institution. That’s in contrast also to using 2 Gy per day. It’s a subtle difference, but just a way in terms of fractionation to hopefully mitigate some of the chronic byproduct changes. In addition, I work closely with my patients to provide a lot of preventative measures as soon as they’re finished with treatment, to try to get ahead or prevent some of the fibrosis from occurring. For the skin, those are things like long term skincare moisturizer to allow for improved healing there. I also asked my patients to begin massage as soon as the acute inflammation has healed to the area once daily for even several years, because the fibrosis can continue to develop over a long period of time. I’ll also have them work closely with physical therapy and occupational therapy to maintain the range of motion and help to prevent fibrosis. Finally, if they’re motivated, I’ll also speak with them about [doing a] prophylactic course of pentoxifylline and vitamin E, which has been shown on some studies to reduce long term fibrosis after breast radiation.