Adjuvant Radiotherapy in Older Women with Early Breast Cancer: Benefits Questioned

Summary and Comment |
June 17, 2013

Adjuvant Radiotherapy in Older Women with Early Breast Cancer: Benefits Questioned

  1. Henry Mark Kuerer, MD, PhD, FACSAU1256

Adding irradiation to tamoxifen after lumpectomy was associated with modestly lower risk for local-regional recurrence but no survival advantage.

  1. Henry Mark Kuerer, MD, PhD, FACSAU1256

Although radiotherapy (RT) after lumpectomy lowers risk for ipsilateral recurrence, not all women may experience substantial benefits from RT. CALGB 9343, a randomized trial conducted from 1994 to 1999, was designed to evaluate lumpectomy plus tamoxifen with or without breast irradiation in women aged ≥70 with stage I, estrogen receptor–positive breast cancer. This report documents long-term follow-up in 636 participants.

At median follow-up of 12.6 years, the benefit of whole-breast RT was statistically significant (hazard ratio, 0.18; P<0.001), yet modest with respect to local-regional recurrence: At 10 years, 98% of patients who received tamoxifen plus RT were free from local-regional recurrences, compared with 90% of those who received only tamoxifen. Mastectomy rates, distant metastases, disease-specific and overall survival, and risk for second primary cancers and death from other causes did not differ significantly between groups. Ten-year overall survival was 67% in women who received tamoxifen plus RT and 66% in those who received only tamoxifen.

Comment

These results are critical to acknowledge in an increasingly cost-conscious era where overuse of expensive therapies with well-known potential risks has become less acceptable. Many clinicians also suspect that, given today's enhanced selection of patients based on better breast imaging, improved pathologic margin control, and use of aromatase inhibitors, recurrences in older patients who do not receive radiotherapy may be even lower than in these study participants. Furthermore, other points must be considered. A 70-year-old woman with early-stage breast cancer and few or no medical comorbidities has a high probability of surviving ≥10 years (see prognosis calculator). In patients with severe comorbidities (and therefore more relevant competing risks for death), multidisciplinary treatments must be individualized.

The initial results of CALGB 9343 at 5-year median follow-up were published in 2004 (N Engl J Med 2004; 351:971). To what extent did those early findings influence clinical practice patterns? An analysis of Medicare data from 2001 through 2007 in a sample of 12,925 women who fulfilled the CALGB 9343 inclusion criteria showed that 79% received adjuvant RT before the study's publication compared with 75% after publication (J Clin Oncol 2012; 30:1601). The current National Comprehensive Cancer Network Guidelines state that RT after lumpectomy can be omitted in women aged ≥70 who have estrogen receptor–positive, node-negative cancers <2 cm in size and who receive adjuvant endocrine therapy. Whether the more-mature CALGB 9343 data will have a greater impact on practice patterns will be of interest.

Editor Disclosures at Time of Publication

  • Disclosures for Henry Mark Kuerer, MD, PhD, FACS at time of publication Consultant / Advisory board Bayer Pharma AG Speaker's bureau AstraZeneca Grant / research support Susan G. Komen Foundation Leadership positions in professional societies Alliance for Clinical Trials in Oncology (Chair, Education Committee)

Citation(s):

Reader Comments (4)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Among older patients with small , fully resected breast cancer and substantial comorbid cardiopulmonary conditions risk of RT may be high. A 70-year-old woman with emphysema , heart faillure, a successfull lumpectomy in the left breast and RT with cardiopulmonary toxicity.MAKE the RIGHT CHOICE!

JOHNNY QUIJADA Physician, Oncology, PRIVATE

This work CALGB does not emphasize Grade III . Lymphovascular invasion. Oncotype Score high and of course not made for RE NEGATIVE., Or Her +
What we do in this group if we find any patient with one or more of these factors
I think that should be given careful Rt

dongiovanni Physician, Oncology, community hospital

Breast radiotherapy must be accuretly discussed with the patient >70 submitting exactely the data of CALGB 9343 and reassuring that the locoregional follow up will be accurate. In our practice in a similar setting 70-80% of informed patients refute RT.
Radiotherapists specifically should be stressed to consider such patient-oriented treatment
Dottor Vincenzo Dongiovanni
Turin

rbthorn@comcast.net Physician, Obstetrics/Gynecology, Retired

First: Please restore CALGB to words. Second: How many of the women receiving lumpectomy developed Pulmonary embolus while on Tamoxifen?

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