Radiation Therapy After Mastectomy: Long-Term Results

radiation therapist with linear accelerator cancer treatment

What You Need to Know: After mastectomy and axillary dissection, radiotherapy (RT) reduces both recurrence and breast cancer mortality among women with one to three positive lymph nodes, even when systemic therapy is given.

Background: Radiation therapy after breast removal (mastectomy) for breast cancer has been shown to reduce the risk of recurrence and death from the disease for women with cancer spread to regional lymph nodes. However, the benefit among women who have only one to three positive nodes remains uncertain.

The Study: The authors did a meta–analysis (study of a collection of studies), using individual data for 8135 women randomly assigned to treatment groups (during 1964–86 in 22 trials) of radiotherapy to the chest wall and regional lymph nodes after mastectomy and axillary surgery versus the same surgery but no radiotherapy.

  • Follow–up lasted 10 years for recurrence and to Jan 1, 2009, for mortality.
  • Analyses were stratified by trial, individual follow–up year, age at entry, and pathological nodal status.

Results:

  • 3786 women had axillary dissection to at least level II and had zero, one to three, or four or more positive nodes.
  • All were in trials in which radiotherapy included the chest wall, supraclavicular (above the collarbone) or axilla (underarm area), or both, and internal mammary chain (nodes alongside the sternum, or breast bone.
  • For 700 women with axillary dissection and no positive nodes, radiotherapy had no significant effect on locoregional recurrence (, overall recurrence, or breast cancer mortality.
  • For 1314 women with axillary dissection and one to three positive nodes, radiotherapy reduced locoregional recurrence (2p<0.00001), overall recurrence (RR 0.68, 95% CI 0.57–0.82, 2p=0.00006), and breast cancer mortality (RR 0.80, 95% CI 0.67–0.95, 2p=0.01).

For today’s women, who in many countries are at lower risk of recurrence, absolute gains might be smaller but proportional gains might be larger because of more effective radiotherapy. This study adds to the evidence pointing to the value of radiation therapy for women found to have node involvement after surgery. I’m Dr. Michael Hunter, and I am proud to help individuals with cancer.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomized trials. The Lancet, 03/25/2014

Radiation Cuts Risk of Recurrence for Breast DCIS

DCIS solid

Take-Home Pearl: Radiation therapy (following breast-conserving surgery) for ductal carcinoma in situ (DCIS) reduces the risk of an in-breast (local) recurrence by about half.

The European Organization for the Research and Treatment of Cancer (EORTC) study included patients with DCIS, randomized to either postoperative (adjuvant, or “in addition to”) radiation therapy (N-507) or no additional treatment (N=503). Patients were under 70 years of age, and had DCIS 5cm or smaller. The radiation therapy dose was 50 Gy in 25 treatments over a 5-week period, targeting the whole breast. The use of tamoxifen (“anti-estrogen”) therapy was not specified in the protocol. Margins were deemed negative if they were at least 1mm. Between 1986 and 1996, 1010 women entered the study. Only 5% of the patients who received radiation therapy got a boost (extra radiation to the primary DCIS area).

Results: The median follow-up time was 15.8 years. The 15-year chances of being free of an in-breast recurrence were: 1) No radiation group 69%; radiation therapy group 82%. Type of recurrence were roughly divided evenly between DCIS and invasive cancer. Radiation therapy reduced the risk of local relapse by half. A multivariate analysis showed the following features increased the risk of recurrence: age under 40; detection by clinical exam (and not simply by mammograms); solid or cribriform growth pattern; and involved or close margins.

My Take: Adjuvant radiation therapy following breast conserving surgery for DCIS reduces the risk of an in-breast recurrence significantly. No subgroup could be identified for which radiation therapy did not provide benefit. Given a lack of increase in the high long-term survival rates (98% or so in the literature), the use of radiation therapy should be based on patient preference, overall health status, and life expectancy. Finally, local recurrence rates can be even lower than what was seen in the EORTC trial: To wit, our local recurrence rates at Evergreen Hospital (Kirkland, WA, USA) are 2% at 12 year median follow-up. Perhaps this excellent outcome is due, at least in part, to a demand for good margins, the routine use of adjuvant tamoxifen and whole breast radiation therapy. I’m Dr. Michael Hunter.

Reference: Donker M, et al. J Clinical Oncology 2013;31 (November 10): 4054-4059.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Are Protons Better Than Photons for Prostate Radiation Treatment?

English: Depth dose of electrons, x rays or pr...
English: Depth dose of electrons, x rays or protons entering human tissue for the purpose of cancer treatment (Photo credit: Wikipedia)

Massachusetts General Hospital, University of Pennsylvania (USA), and several other proton centers are participating in a clinical trial that may help to settle a long-running debate: Is proton beam therapy (PBT) ore effective and safe than intensity-modulated radiation therapy (IMRT) for prostate cancer?

The Trial: Prostate Advanced Radiation Technologies Investigating Quality of Life (PARTIQoL) is the first large Phase III randomized clinical trial to directly compare PBT against IMRT. It is a 5 year trial that opened in July 2012, and is still accruing patients.

The Modalities: PBT and IMRT are advanced technologies capable of delivering higher doses of radiation more directly to the prostate, as compared to older technologies. These higher doses can lead to higher cancer control rates. By reducing the dose to surrounding normal structures (such as the bladder, rectum, and small intestines), side effects may be reduced as well. Unlike IMRT, Proton Beam Therapy delivers radiation using a more focused beam to the target, with less of a low-dose bath in the pelvis and (theoretically) no exit dose beyond the tumor. In theory, PBT may cause fewer side effects than does IMRT.

What Do We Know Now? The few studies comparing protons with IMRT are few in number, and have been retrospective (or backward looking, potentially introducing significant bias). A 2012 study in the Journal of the American Medical Association (JAMA) found that patients treated with PBT had improved unitary function in the short-term. But the study is flawed: It relied on physician billing codes, rather than patient reports. Earlier this year, Dr. Efstathiou and colleagues described patient-reported outcomes following PBT, IMRT, or 3-D conformal radiation therapy. PBT caused fewer gastrointestinal side effects and urinary problems, but by 2 years, outcomes were similar to IMRT.

Costs? According to the 2012 JNCI study, median Medicare reimbursement for PBT is $32.428, compared with $18,575 for IMRT.

My Take: Proton Beam Therapy has an established role for pediatric malignancies (and uveal melanomas). Hopefully, we will learn whether it has an advantage over IMRT with this important clinical trial. For now, either IMRT or PBT are appropriate radiotherapeutic approaches for localized prostate cancer. You may be a candidate for surgery, active surveillance, or radioactive seed implant, depending on your cancer risk, medical condition, age, life expectancy, and personal preferences. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

References: http://clinicaltrials.gov/ct2/show/NCT01617161; Efstathiou JA et al. British Journal of Cancer 108 (6) 1225-1230; Sheets NC et al. JAMA 2012; 307(15):1611-1620; Journal of the National Cancer Institute 2013 Jan 2; 105(1):25-32.

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

older senior elderly woman doctor

Summary: Adding radiation therapy to tamoxifen after lumpectomy was associated with modestly lower risk ofr local and regional recurrence, but no survival advantage.

The Study: CALGB 9343 was a trial designed to evaluate lumpectomy plus tamoxifen with or without breast radiation therapy. Patients were at least 70 years old, had Stage I disease, and tumors that were hormone receptor positive. The trial was conducted from 1994 to 1999.

Results: At a median follow-up 12.6 years, the benefit of whole breast radiation therapy was statistically significant: At 10 years, 98% of patients who received tamoxifen plus radiation therapy were free from local-regional recurrences, compared with 90% of those who received only tamoxifen. However, mastectomy rates, distant metastases, overall survival, and risk of second primary cancers or death from other causes did not differ when comparing the two groups.

My Take: The current US National Comprehensive Cancer Network Guidelines state that radiation therapy after lumpectomy can be omitted in women 70 or older who have estrogen receptor-positive, node-negative breast cancers that are less than 2cm in size, and who receive adjuvant endocrine therapy. I agree, but I would offer radiation therapy to those women who want to optimize local control, who have few medical co-morbidities, and a high probability of surviving at least 10 years. And I would also in general be more aggressive with more advanced stage disease. I’m Dr. Michael Hunter, and I thank you for letting me share my thoughts.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minutes, available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Hughes KS et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: Long-term follow-up of CALGB 9343.J Clin Oncol 2013 Jul 1; 31:2382.

Axillary Radiotherapy for Breast Cancer: Can It Control the Nodes?

Breast tangential fields breath hold

“If radiation therapy is deemed necessary, you can radiate the axilla [underarm area] at the same time and achieve similar local control as full lymph node dissection in the axilla.”

– Emiel J. Rutgers, MD, PhD

It appears that radiation therapy to the axilla may replace axillary node dissection for local cancer control for selected patients with involvement of sentinel nodes. The European Organization for the Research and Treatment of Cancer (EORTC) AMAROS trial was recently presented.

Background: For patients with cancer in a sentinel node, it is often important to treat the regional lymph nodes, as recurrence there increases the risk of death. In the USA, many patients with a positive (involved) sentinel node with go on to additional surgery to reduce the chance of a return of cancer to the node area.

Current study: The study was designed to compare axillary dissection with radiation therapy to the axilla 12 years ago. The AMAROS study included 4,806 patients, with tumors up to 5cm and no palpable nodes. About 30% had a positive axillary node on sentinel node removal. At a median follow-up of 6.1 years, the risk of a recurrence in the axilla was 0.5% in the surgery group, and 1% in the radiation therapy group. Disease-free survival rates were similar, as were the overall survival chances.

The rates of lymphedema (arm swelling) were higher for surgery than radiation therapy at various intervals: At 1 year, surgery 40% and radiation therapy 22%; at 3 years, 30% (surgery) and 17% (radiation), and at 5 years 28% (surgery) versus 14% (radiation).

My take: This study illustrates that in the sentinel node era, less can be more. For patients with an involved sentinel node, radiation therapy (including to the axilla) appears reasonably safe and offers a high chance of local control. This (and other) studies will likely change the standard of care for selected patients. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you. 

Primary Brain Cancer: Any Progress?

brain tumor glioma coronal

In spite of advances in imaging and treatment, life expectancy for patients with primary tumors of the brain remain low at about 15 to 18 months. So are we making progress? Today, we hear from Dr. Steven Brem, the Chief of Neurosurgery at the Hospital of the University of Pennsylvania (Philadelphia, Pennsylvania, USA).

Is survival improving? Patients with malignant gliomas are living longer than ever before and they have better quality of life. Overall survival used to be 9 months, and it now averages 15 to 18 months. While not spectacular, the trend is unmistakable. And we now have a subgroup of perhaps 20% of patients who are living over 3 years, with an occasional very long-term survival. The combination of temozolomide chemotherapy and radiation therapy as been a major advance. And the use of bevacizumab [which starves a tumor of its blood supply] for recurrent glioblastomas is changing the neuro-oncology landscape. This is because we previously didn’t think such large molecules would be able to cross the blood-brain barrier and be effective. In addition, it shows us that targeted therapies will likely have a greater role in the future.

Current research: Several lines of research are being pursued. A better understanding of the genes (cancer genomics) will allow for breakthroughs in management. Immunotherapies are being pursued (currently for glioblastoma multiforme, or GBM). In addition, the neural pathways of the brain are being mapped, with the findings translating to the operating room. Using advanced mathematical modeling, surgeons can visualize what was formerly invisible to the eye, and even invisible under the microscope – the brain’s “wiring diagram.” Eventually, surgery will be tailored to the region of the tumor boundary, reducing the risk of neurologic complications such as cognitive impairment, paralysis, language deficits, and others. As glioblastoma cells follow white fiber matter paths, we should be able to better predict tumor growth and strategically plan therapy using newer mathematical models that provide a roadmap for each tumor. We also are pursuing the causes of malignant brain tumors.

My take: We will see improvement in survival rates among those with malignant brain tumors. Over the next 10 years, we should make more progress than we have over the last 30 to 40 years, given a better understanding of genomics, better neuroimaging, and better treatment.

The ASCO Post, June 25, 2013

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you. 

Lymphedema: Estimating the Risk for Patients with Breast Cancer

Breast cancer awareness
Breast cancer awareness (Photo credit: AslanMedia)

The development of breast cancer-related lymphedema is tied closely to how many nodes are removed by surgery. Radiation therapy and chemotherapy can also increase risk. A recent study from Korea (published in (check out the length of the this name!) International Journal of Radiation Oncology Biology Physics, 2013) attempted to estimate the risk of lympededema based on combinations of these treatment factors.

The Study: The authors looked at 772 patients with breast cancer. All had primary surgery with axillary node dissection from 2004 to 2009. The study looked back at these patients (retrospective analysis). Adjuvant chemotherapy was given to 677 patients. Of the 675 who got radiation therapy, 35% had a component directed at the nodes above the collarbone (supraclavicular nodes).

Results: Half of patients were followed beyond 5.1 years. The 5 year cumulative chance of getting edema was 17%. Of these 76% developed it in the first 2 years after surgery. Fully 91% of those who got it did so within 3 years.

Risk factors included number of nodes removed by the surgeon, chemotherapy use, and whether the nodes above the collarbone were treated with radiation therapy. The total number of risk factors correlated well with the incidence of lymphedema. Patients with 0 to 1 risk factors had a 5 year risk of only 3%, while those with 2 or 3 risk factors had a risk of 19% and 38%, respectively.

My take: The bad news? Any lymph node removal introduces risk. The good news? If a patient had 10 of fewer nodes removed, and no other risk factors, the 5 year risk dropped to 1.4%. For those who had fewer than 10 nodes removed but got chemotherapy, the risk was 3.8%. Fortunately today, many patients who have a limited node sampling of only 1 to 3 nodes (to help establish prognosis for invasive breast cancer) have a very low risk of significant lymphedema. The so-called sentinel node procedure has truly improved the surgical management for many patients with early breast cancer. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minutes. Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. All can be found at the Apple Ibooks store. Thank you.