Breast Cancer Reirradiation Practice Patterns: An International Survey From the Reirradiation Collaborative Group (ReCOG)

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PURPOSE: Reirradiation (reRT) for locally or regionally recurrent breast cancer is increasingly considered, but practice patterns remain heterogeneous. This study reports results from an international Reirradiation Collaborative Group (ReCOG) survey evaluating contemporary clinical reRT practices and key knowledge gaps in optimal breast reRT approaches. METHODS AND MATERIALS: Radiation oncologists, medical physicists, and dosimetrists with expertise in breast radiation therapy completed a structured ReCOG survey between February 2024 and June 2025. Respondents were asked about patient selection, factors influencing the choice between second breast-conserving therapy and mastectomy, reRT dose-fractionation schedules, planning methods, and knowledge gaps affecting clinical decision making. RESULTS: Thirty-seven respondents participated, from Europe (n = 19), North America (n = 14), and other regions (n = 4), representing 32 identifiable institutions. The most common reasons for not offering reRT included high risk of major side effects from prior radiation therapy such as fibrosis or lymphedema (40%), short relapse interval (33%), or limited life expectancy (17%). Among patients receiving reRT, fibrosis (31%), pain (17%), and arm lymphedema (14%) were reported as the most impactful toxicities on quality of life. Conventional fractionation (45-60 Gy in 1.8 to 2 Gy fractions over 23-30 fractions) was the most frequently selected regimen, followed by moderate hypofractionated schedules (40 Gy in 15 fractions). One respondent reported using twice daily dose of 40 to 50Gy in 1.25 to 1.5Gy fractions. External-beam photon techniques were the predominant modality, with intensity modulated radiation therapy/volumetric modulated arc therapy preferred, while proton therapy and brachytherapy were used selectively. Hyperthermia use was limited (n = 7). Most respondents (80%) performed plan summation when prior DICOM radiation therapy data were available, but specific methods varied. Organs of interest (OOI) dose guidance was most consistently applied for the brachial plexus, heart, lungs, and skin, although thresholds differed widely. The top 3 knowledge gaps identified were as follows: (1) long-term toxicity and oncologic outcome data, (2) standardized and validated OOI dose guidance, and (3) consensus on optimal reRT dose-fractionation schedules, and the scarcity of prospective trials. CONCLUSIONS: This ReCOG survey reveals substantial heterogeneity in breast cancer reRT practices. The identified knowledge gaps highlight the need for standardized clinical guidelines and practical clinical toolsets to support decision making in patient selection, technical planning, and OOI dose guidance to improve outcomes for patients undergoing reRT.

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