Abstract
Background. Although nodal status is the major determinant of risk of locoregional relapse (LRR),
other factors also contribute, and these assume a greater significance for those with
node-negative breast cancer. Previous reviews of post-mastectomy radiotherapy have
included studies using radiotherapy techniques or doses no longer considered clinically
appropriate. Objectives. To determine the effectiveness of post-mastectomy radiotherapy in women with node-negative
breast cancer with particular reference to those patient and tumour factors which
contribute to an increased risk of LRR. Methods. A systematic literature review was conducted. Trials using inadequate or orthovoltage
radiotherapy were excluded. Data linking potential risk factors, either individually
or in combination, to the occurrence of LRR were handled qualitatively. Data from
randomised trials of post-mastectomy radiotherapy were included in a meta-analysis.
Results. Baseline risk of LRR is increased in the presence of lymphovascular invasion, a
grade 3 tumour, tumours greater than 2 cm or a close resection margin and in patients who are pre-menopausal or aged less
than 50. Those with no risk factors have a baseline risk of LRR of approximately 5%
or less rising to a risk of 15% or more for those with two or more risk factors. In
the meta-analysis of three randomised trials of mastectomy and axillary clearance
(667 patients), the addition of radiotherapy resulted in an 83% reduction in the risk
of LRR (P < 0.00001) and in a 14% improvement in survival (P = 0.16). Conclusion. The use of post-mastectomy radiotherapy for women with node-negative breast cancer
requires re-evaluation. Radiotherapy should be considered for those with two or more
risk factors.
Keywords
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References
- Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007.Ann Oncol. 2007; 18: 1133-1144
- Postmastectomy radiotherapy: guidelines of the American Society of Clinical Oncology.J Clin Oncol. 2001; 19: 1539-1569
- Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy.Can Med Assoc J. 2004; 170: 1263-1273
- Overview of randomised trials of postoperative adjuvant radiotherapy in breast cancer.Cancer Treat Rep. 1987; 71: 15-29
- Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials.Lancet. 2005; 366: 2087-2106
- Postmastectomy radiation therapy: who needs it?.J Clin Oncol. 2004; 22: 4237-4239
- Tables of equivalent dose in 2 Gy fractions: a simple application of the linear–quadratic equation.Int J Radiat Oncol Biol Phys. 1995; 31: 371-378
Joiner MC, van der Kogel AJ. The linear–quadratic approach to fractionation and calculation of iso-effect relationships. In: Basic clinical radiobiology. 2nd ed. London: Arnold; 1997.
- Improved methodology for analysing local and distant recurrence.J Clin Oncol. 1990; 8: 548-555
- Survival effects of postmastectomy adjuvant radiation therapy using biologically equivalent doses: a clinical perspective.J Nat Cancer Inst. 2006; 98: 26-38
- Overview of randomised trials in high risk breast cancer patients treated with adjuvant systemic therapy with or without postmastectomy irradiation.Semin Radiat Oncol. 1999; 9: 292-299
- Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis.J Clin Oncol. 2000; 18: 1220-1229
- Postoperative radiotherapy in breast cancer – long-term results from the Oslo study.Int J Radiat Oncol Biol Phys. 1986; 12: 727-732
- The value of radiotherapy after modified radical mastectomy. 10-year results of the Heidelberg study.Dtsch Med Wochenschr. 1983; 108: 325-330
- The total incidence of loco-regional recurrence in a randomised trial of breast cancer TNM stage II. The South Sweden Breast Cancer Trial.Acta Oncol. 1993; 32: 641-646
- Radiotherapy and tamoxifen after mastectomy in postmenopausal women – 20 year follow-up of the South Sweden Breast Cancer Group randomised trial SSBCG II:I.Eur J Cancer. 2007; 43: 2100-2108
- Adequate locoregional treatment for early breast cancer may prevent secondary dissemination.J Clin Oncol. 1995; 13: 2869-2878
- Adjuvant postoperative radiotherapy, chemotherapy, and immunotherapy in stage III breast cancer.Cancer. 1987; 60: 936-942
- Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy.New Engl J Med. 1997; 337: 949-955
- Postoperative radiotherapy in high-risk postmenopausal breast cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial.Lancet. 1999; 353: 1641-1648
- Adjuvant radiation therapy versus surgery alone in operable breast cancer: long term follow-up of a randomised clinical trial.Radiother Oncol. 1993; 26: 100-104
- Tumour to fascia margin as a factor in local recurrence after modified radical mastectomy.Surg Gynecol Obst. 1988; 166: 523-526
- Axillary lymph node status, but not tumour size, predicts locoregional recurrence and overall survival after mastectomy for breast cancer.Ann Surg. 2003; 5: 732-739
- Locoregional recurrence after mastectomy: incidence and outcomes.J Am Coll Surg. 2006; 203: 469-474
- Using loco-regional recurrence as an indictor of the quality of breast cancer treatment.Eur J Cancer. 2004; 40: 487-493
- Loco-regional recurrences after mastectomy in breast cancer: prognostic factors and implications for postoperative irradiation.Radiother Oncol. 1999; 50: 267-275
- Locoregional recurrence rates and prognostic factors for failure in node-negative patients treated with mastectomy: implications for postmastectomy radiation.Int J Radiat Oncol Biol Phys. 2005; 62: 1035-1039
- Radiotherapy of the chest wall following mastectomy for early-stage breast cancer: impact on local recurrence and overall survival.Int J Radiat Oncol Biol Phys. 2000; 48: 967-975
- Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation.J Clin Oncol. 2000; 18: 2817-2827
- Differences in risk factors for local and distant recurrence after breast-conserving therapy or mastectomy for stage I and II breast cancer: pooled results of two large European randomised trials.J Clin Oncol. 2001; 19: 1688-1697
- Risk factors for locoregional recurrence among breast cancer patients: results from International Breast Cancer Study Group trials I through VII.J Clin Oncol. 2003; 21: 1205-1213
- The role of the number of uninvolved lymph nodes in predicting locoregional recurrence in breast cancer.J Clin Oncol. 2007; 25: 2019-2026
Yau TK, Chang TY, Soong S, et al. Postmastectomy locoregional recurrence in Hong Kong: low risk patients without radiotherapy have more failures than intermediate risk patients with radiotherapy. Presented at 30th San Antonio Breast Cancer Symposium; 2007 [Abstract 4094].
- Can a subgroup of node-negative breast carcinoma patients with T1–2 tumour who may benefit from postmastectomy radiotherapy be identified?.Int J Radiat Oncol Biol Phys. 2007; 68: 1024-1029
- Low locoregional recurrence rate among node-negative breast cancer patients with tumours 5 cm or larger treated by mastectomy, with or without adjuvant systemic therapy and without radiotherapy: results from five National Surgical Adjuvant Breast and Bowel Project randomised clinical trials.J Clin Oncol. 2006; 24: 3927-3932
- Low local recurrence rate without postmastectomy radiation in node-negative breast cancer patients with tumours 5 cm and larger.Int J Radiat Oncol Biol Phys. 2006; 66: 358-364
- Post-mastectomy radiotherapy in pT3N0M0 breast cancer: is it needed?.Radiother Oncol. 1999; 52: 213-217
- Clinical outcomes of post-operative locoregional radiotherapy in pre-menopausal and post-menopausal Chinese women with breast cancer.Radiother Oncol. 2000; 54: 201-208
- The role of postoperative radiotherapy in node negative breast cancer patients with pT3–T4 disease.Eur J Surg Oncol. 2007; 33: 285-293
- A positive margin is not always an indication for radiotherapy after mastectomy in early breast cancer.Int J Radiat Oncol Biol Phys. 2004; 58: 797-804
- Lymphovascular invasion is associated with reduced locoregional control and survival in women with node-negative breast cancer treated with mastectomy and systemic therapy.J Am Coll Surg. 2005; 200: 912-921
- A close or positive margin after mastectomy is not an indication for chest wall irradiation except in women aged fifty or younger.Int J Radiat Oncol Biol Phys. 1998; 41: 599-605
- Local recurrence and the deep resection margin in carcinoma of the breast.Surg Gynecol Obst. 1986; 163: 513-517
- Morbidity and mortality of ischaemic heart disease in high-risk breast cancer patients after adjuvant post-mastectomy systemic treatment with or without radiotherapy: analysis of DBCG 82b and 82c randomised trials.Lancet. 1999; 354: 1425-1430
- Adjuvant radiotherapy for breast cancer: effects of longer follow-up.Radiother Oncol. 2004; 72: 35-43
- Meta-analysis of the literature or of individual patient data: is there a difference?.Lancet. 1993; 341: 418-422
- Loco-regional recurrence after mastectomy in high-risk breast cancer – risk and prognosis. An analysis of patients from the DBCG 82 b&c randomisation trials.Radiother Oncol. 2006; 79: 147-155
Early Breast Cancer Trialists’ Collaborative Group. Chemotherapy and hormonal therapy for early breast cancer: effects of recurrence and 15-year survival in an overview of the randomised trials. Lancet 2005;365:1687–717.
- Effect of breast cancer radiotherapy and cigarette smoking on risk of second primary lung cancer.J Clin Oncol. 2008; 26: 392-398
- Risk of cardiac death after adjuvant radiotherapy for breast cancer.J Natl Cancer Inst. 2005; 97: 419-424
- The influence of pathologic tumour characteristics on locoregional recurrence rates following mastectomy.Int J Radiat Oncol Biol Phys. 2001; 50: 735-742
Wilson CB, Haba Y, Wishart GC. The identification of patients for post-mastectomy radiotherapy using the Cambridge index: audit of a prospective series. Presented at 30th San Antonio Breast Cancer Symposium; 2007 [Abstract 4093].
- Elucidating the role of chest wall irradiation in ‘intermediate-risk’ breast cancer: the MRC/EORTC SUPREMO trial.Clin Oncol. 2008; 20: 31-34
Available from: http://www.asco.org/ASCO/Abstracts+%26+Virtual+Meeting/Speaker?&spk=Darby%2C+Sarah+%5Bfau%5D.
Article info
Publication history
Published online: November 10, 2008
Accepted:
September 24,
2008
Received in revised form:
September 15,
2008
Received:
June 19,
2008
Footnotes
☆Funding sources. Dr. N.P. Rowell is employed by Maidstone & Tunbridge Wells NHS Trust. There are no additional sources of funding.
Identification
Copyright
© 2008 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
