Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Recht, Abram; Comen, Elizabeth; Fine, Richard E.; Fleming, Gini F.; Hardenbergh, Patricia H.; Ho, Alice Y.; Hudis, Clifford A.; Hwang, E. Shelley; Kirshner, Jeffrey J.; Morrow, Monica; Salerno, Kilian E.; Sledge, George W.; Solin, Lawrence J.; Spears, Patricia A.; Whelan, Timothy J.; Somerfield, Mark R.; Edge, Stephen B.

doi:10.1245/s10434-016-5558-8

Cited by 126 publications

(90 citation statements)

References 72 publications

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“…Current guidelines 7 recommend strong consideration of PMRT to the chest wall and regional lymph nodes for patients who undergo mastectomy with 1 to 3 positive nodes, but whether micrometastases contribute to the positive node count is uncertain. 23 In our study, we found no difference in LRR with or without PMRT by Kaplan-Meier estimation (p = 0.4).…”

Section: Discussionmentioning

confidence: 99%

“…More importantly, the vast majority of patients did not receive PMRT, and rates of LRR in this group were less than 5%, far lower than the rates of LRR in the no-radiotherapy arms of the clinical trials that suggested a benefit for PMRT in patients with 1–3 nodal metastases. 7,24 The 10-year results of the MA.20 and EORTC trials showed decreased LRR and improved disease-free survival with comprehensive nodal irradiation in patients with T1–T3, node-positive or ‘high-risk’ node-negative disease. The majority of patients underwent breast conservation, and micrometastases were not analyzed separately; the improvement in locoregional control was attributed in part to a decrease in internal mammary recurrences.…”

Section: Discussionmentioning

confidence: 99%

“…Randomized trials demonstrated equivalent locoregional control when comparing SLNB alone to axillary dissection (ALND) in patients with micrometastases, but included small numbers of patients treated with mastectomy, and varying adjuvant treatments. 4–6 Current guidelines 7 recommend consideration of PMRT for patients with metastases in 1–3 axillary nodes based on trials demonstrating benefit in patients with nodal macrometastases. The impact of micrometastases or isolated tumor cells on locoregional recurrence, and hence whether they should be included in node counts when determining the need for PMRT, is not well studied.…”

Section: Introductionmentioning

confidence: 99%

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Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer

et al. 2017

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Background Randomized trials demonstrate equivalent locoregional control with sentinel node biopsy (SLNB) or axillary dissection (ALND) for T1–2, micrometastatic breast cancer, but include few mastectomy patients. Consensus is lacking on indications for post-mastectomy radiotherapy (PMRT) in this population. Herein we evaluate locoregional recurrence (LRR) in an unselected, modern cohort of T1–2 breast cancer patients with micrometastases or isolated tumor cells (N0i+/N1mi) having mastectomy. Methods We identified patients with T1–2N0i+/N1mi breast cancer treated with mastectomy from 1/2006–12/2011. Recurrent, bilateral, and neoadjuvant cases were excluded. The primary outcome of interest was LRR. Results 352 patients, 211 (60%) with ITCs and 141 (40%) with micrometastases, were identified. 162 (46%) had SLNB alone and 1 node was positive in 295 (84%) cases. 31 (9%) had PMRT. 95% had systemic therapy. At median 6 years follow-up, the overall crude LRR rate was 2.8% (n=9), with no axillary recurrences, and the crude LRR rate was 3.9% among those who had SNB alone. Those with LRR had median age 55yrs, median tumor size 1.7cm, and ductal histology; the majority were high-grade (89%), estrogen receptor positive (78%), with 1 positive node (89%). There was no association between LRR and receipt of PMRT (p=0.4), SNB vs ALND (p=0.2), or number of positive nodes (p=0.7) by the log-rank test. Conclusions LRR was infrequent among T1–2N0i+/N1mi patients treated with mastectomy without PMRT, with no axillary failures, suggesting that PMRT or nodal radiotherapy are not routinely indicated in this population.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer

et al. 2017

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“…To our knowledge, this is the first automated treatment planning tool designed for PMRT, which uses tangential fields to irradiate the chest wall matched with an oblique en face beam to irradiate the SCV lymph nodes. Although some clinics may also include the internal mammary chain (IMC) lymph nodes in such treatment, this remains an area of controversy . Treatment of the IMC increases the dose delivered to the heart and the risk of heart disease .…”

Section: Discussionmentioning

confidence: 99%

Automated treatment planning of postmastectomy radiotherapy

et al. 2019

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Purpose Breast cancer is the most common cancer in women globally and radiation therapy is a cornerstone of its treatment. However, there is an enormous shortage of radiotherapy staff, especially in low‐ and middle‐income countries. This shortage could be ameliorated through increased automation in the radiation treatment planning process, which may reduce the workload on radiotherapy staff and improve efficiency in preparing radiotherapy treatments for patients. To this end, we sought to create an automated treatment planning tool for postmastectomy radiotherapy (PMRT). Methods Algorithms to automate every step of PMRT planning were developed and integrated into a commercial treatment planning system. The only required inputs for automated PMRT planning are a planning computed tomography scan, a plan directive, and selection of the inferior border of the tangential fields. With no other human input, the planning tool automatically creates a treatment plan and presents it for review. The major automated steps are (a) segmentation of relevant structures (targets, normal tissues, and other planning structures), (b) setup of the beams (tangential fields matched with a supraclavicular field), and (c) optimization of the dose distribution by using a mix of high‐ and low‐energy photon beams and field‐in‐field modulation for the tangential fields. This automated PMRT planning tool was tested with ten computed tomography scans of patients with breast cancer who had received irradiation of the left chest wall. These plans were assessed quantitatively using their dose distributions and were reviewed by two physicians who rated them on a three‐tiered scale: use as is, minor changes, or major changes. The accuracy of the automated segmentation of the heart and ipsilateral lung was also assessed. Finally, a plan quality verification tool was tested to alert the user to any possible deviations in the quality of the automatically created treatment plans. Results The automatically created PMRT plans met the acceptable dose objectives, including target coverage, maximum plan dose, and dose to organs at risk, for all but one patient for whom the heart objectives were exceeded. Physicians accepted 50% of the treatment plans as is and required only minor changes for the remaining 50%, which included the one patient whose plan had a high heart dose. Furthermore, the automatically segmented contours of the heart and ipsilateral lung agreed well with manually edited contours. Finally, the automated plan quality verification tool detected 92% of the changes requested by physicians in this review. Conclusions We developed a new tool for automatically planning PMRT for breast cancer, including irradiation of the chest wall and ipsilateral lymph nodes (supraclavicular and level III axillary). In this initial testing, we found that the plans created by this tool are clinically viable, and the tool can alert the user to possible deviations in plan quality. The next step is to subject this tool to prospective testing, in which automatically p...

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“…A key question is whether spending variation is appropriate or inappropriate. Appropriate spending variation may be driven by unobservable patient preferences, such as when there is choice between breast‐conserving surgery and mastectomy, or clinical uncertainty, such as at the end‐of‐life when there is the least evidence to guide decision‐making . Other clinical factors, such as whether patients have a BRCA mutation or whether the cancer disease progresses/recurs soon after initial diagnosis, are unobservable in our data and may also lead to appropriate differences in cancer treatment.…”

Section: Discussionmentioning

confidence: 99%

What drives variation in spending for breast cancer patients within geographic regions?

Sinaiko

Chien

Hassett

et al. 2018

Health Services Research

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Objective To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. Data Source Surveillance, Epidemiology, and End Results (SEER)‐Medicare database from 2009‐2013. Study Design The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient‐level and physician‐level variance in spending. Services associated with high spending physicians were estimated using linear regression. Data Extraction Method A total of 20 818 women with a breast cancer diagnosis in 2010‐2011. Principal Findings We observed substantial between‐patient and between‐provider variation in spending following diagnosis and at the end‐of‐life. Immediately following diagnosis, 48% of between‐patient and 31% of between‐physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end‐of‐life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days. Conclusions Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient‐doctor discussions.

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Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Cited by 126 publications

References 72 publications

Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer

Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer

Automated treatment planning of postmastectomy radiotherapy

What drives variation in spending for breast cancer patients within geographic regions?

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