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Postmastectomy Radiotherapy for Breast Cancer Patients with One to Three Positive Nodes?

Summary and Comment |
April 18, 2014

Postmastectomy Radiotherapy for Breast Cancer Patients with One to Three Positive Nodes?

  1. Henry Mark Kuerer, MD, PhD, FACS

This meta-analysis does not end the debate.

  1. Henry Mark Kuerer, MD, PhD, FACS

Prior meta-analyses have shown that postmastectomy radiotherapy (PMRT) reduces the risk for breast cancer mortality and recurrence in patients with node-positive disease. But whether PMRT benefits patients with only one to three positive nodes is controversial.

To address this issue, investigators performed a meta-analysis of individual data on 8135 patients with node-positive disease who were enrolled in 22 randomized trials from 1964 to 1986. Patients received PMRT to the chest wall, supraclavicular or axillary fossa (or both), and internal mammary nodes. A total of 3786 patients with documented axillary dissection were included. About 64% of patients received cyclophosphamide, methotrexate, and fluorouracil chemotherapy; 24% received tamoxifen endocrine therapy. Median follow-up was 9.4 years.

In 700 patients with axillary dissection and no positive nodes, PMRT had no significant effect on locoregional recurrence or breast cancer mortality, but it significantly increased the risk for overall mortality (rate ratio, 1.23; 2-sided P=0.03). In 1314 patients with axillary dissection and 1 to 3 positive nodes, PMRT significantly reduced locoregional recurrence (2P<0.00001), overall recurrence (RR, 0.68; 2P=0.00006), and breast cancer mortality (RR, 0.80; 2P=0.01); similar benefits were achieved in a subset of 1133 of patients who also received systemic therapy. However, the main issue here is that the 10-year rate of locoregional recurrence with systemic therapy and no PMRT (21%) was substantially higher than would be expected in the current era in patients receiving systemic therapy with one to three positive nodes (<5% for most patients; Ann Surg Oncol 2010; 17:2899 and Int J Radiat Oncol Biol Phys 2014 Apr 7).

Comment

There is no debate that postmastectomy radiotherapy should be used in patients with locally advanced breast cancer with multiple (>4) nodes with metastases because the risk for local regional recurrence remains very high. However, since the overall risk for local regional recurrence is substantially reduced in the current era — compared with trials in this meta-analysis from 30 to 50 years ago — the absolute risk for local regional recurrence without PMRT will be much smaller. Moreover, the potential long-term risks associated with the use of even modern PMRT techniques in women expected to have very high long-term survival must also be considered.

  • 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)

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Reader Comments (2)

Wilmar Briceño Phd Physician, Oncology, Venezuela

By the moments the effects of radiation therapy are favorable in the patients with positive nodes in axillary dissection . Change this form of treatment are hazardous and unethical.

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

Radiotherapy reduces death from and recurrence of breast cancer but increses death from other causes.
Cancer is an age-related disease, careful cancer treatment decision is essential for elderly patients.
RT can increase the rate of death mainly by inducing cardiac and pulmonary diseases.

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