Breast: Whole-breast hypofractionation

Why E is correct

Since 2023 NICE NG101 recommends offering 26 Gy in 5 fractions over 1 week for whole-breast radiotherapy without regional lymph node irradiation after breast-conserving surgery. This follows FAST-Forward, in which 26 Gy in 5 fractions over 1 week was non-inferior to 40 Gy in 15 fractions over 3 weeks for ipsilateral breast tumour relapse (5-year 1.4% versus 2.1%) with similar normal tissue effects. 40 Gy in 15 fractions, established by START B, remains a schedule NICE says to consider for people with a diagnosis that increases sensitivity to radiotherapy, implant-based reconstruction, or another reason to prefer three weeks.

And why the others are not

• AIncorrect. 60 Gy in 30 fractions overtreats the whole breast and is not an adjuvant whole-breast schedule.
• BIncorrect as the standard. 40 Gy in 15 fractions over 3 weeks is the START B schedule; NICE now lists it as a schedule to consider in specific circumstances such as increased radiotherapy sensitivity or implant-based reconstruction, none of which applies here.
• CIncorrect. 50 Gy in 25 fractions is the historical conventional schedule that hypofractionation has replaced.
• DIncorrect. A tumour-bed boost is for those at high risk of local recurrence; this node-negative grade 2 patient does not warrant one, and the 50 Gy base is outdated.

Source NICE NG101 — Early and locally advanced breast cancer: radiotherapy recommendations — National Institute for Health and Care Excellence. Early and locally advanced breast cancer: diagnosis and management. NICE guideline NG101. Published 18 July 2018, last updated 14 April 2025.