Trends and variations in postmastectomy radiation therapy for breast cancer in patients with 1 to 3 positive lymph nodes: A National Cancer Data Base analysis

Ohri, Nisha; Sittig, M.P.; Tsai, C. Jillian; Hwang, Eun Sil Shelley; Mittendorf, Elizabeth A.; Shi, Wei; Zhang, Zhigang; Ho, Alice Y.

doi:10.1002/cncr.31080

Cited by 19 publications

(7 citation statements)

References 28 publications

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“…Compared to previous population-based analyses showing between 30.3% and 40.5% of patients with N1 disease (1-3 positive lymph nodes) receiving PMRT by 2012 [5,6], in our study, 64.7% of such patients were recommended for PMRT. This con rms the trend of an increasing number of patients with N1 disease being considered for PMRT and it is in keeping with national clinical guidelines [7][8][9].…”

Section: Discussioncontrasting

confidence: 84%

“…This highlights some interesting geographical variation, which merits further investigation. A similar US-based study found that density of radiation oncology practices was associated with receipt of PMRT in patients with N1 stage breast cancer [5]. Results of the Selective Use of Post Mastectomy Radiotherapy (SUPREMO) trial are awaited and are likely to reduce the variation in practice of PMRT use in intermediate-risk breast cancer (de ned as pT1-2N1; pT3N0; or pT2N0 if also grade III or with lymphovascular invasion) [14].…”

Section: Discussionmentioning

confidence: 99%

“…As a result, the indications for PMRT in women with breast cancer are widening. Population-based data from the US shows that use of PMRT in patients with 1-3 positive lymph nodes increased signi cantly between 2003 and 2012 [5,6]. Several national treatment guidelines now recommend that radiotherapy be considered for all patients with node-positive disease after mastectomy [7][8][9].…”

Section: Introductionmentioning

confidence: 99%

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Patterns of Post-Mastectomy Radiotherapy in Immediate Breast Reconstruction – Results from the iBRA-2 Cohort Study

Rattay

Trickey

O’Connell

et al. 2021

Preprint

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PurposeLong-term data indicates that post-mastectomy radiotherapy (PMRT) is associated with improved overall survival in all node-positive breast cancer patients. Immediate breast reconstruction (IBR) remains controversial in the context of planned PMRT, but rates of IBR are increasing. The aim of this study was to examine current practice of PMRT in patients undergoing mastectomy +/- IBR.MethodsData were collected from 2,526 patients enrolled in the iBRA-2 prospective cohort study undergoing mastectomy +/- IBR between 1st July and 31st December 2016, recruited consecutively at 71 centres across the United Kingdom, Ireland, and five international centres.ResultsOf a total of 2,590 breast procedures included in the analysis, 696 were implant-based, 105 pedicled flap and 230 free-flap reconstruction. 31.4% of implant-based, 34.3% of pedicled, and 32.5% of free-flap reconstructions were recommended for PMRT. PMRT recommendation by cancer stage was 21% for T1-2 N0, 65% for T1-2 N1, and 89% for Tany N2 and T3 Nany disease. On multivariate analysis, patients undergoing IBR were no less likely to be recommended for PMRT than patients having mastectomy only. However, patients in Northern Ireland/Ireland, the North of England, and Scotland were less likely to be recommended for PMRT.ConclusionAlthough IBR was more likely to be performed for lower stage cancers and younger patients with fewer co-morbidities, patients undergoing IBR were no less likely to be recommended for PMRT, irrespective of reconstruction technique. This study also highlighted regional variation in PMRT practice within the UK which merits further investigation.

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Section: Discussioncontrasting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Patterns of Post-Mastectomy Radiotherapy in Immediate Breast Reconstruction – Results from the iBRA-2 Cohort Study

Rattay

Trickey

O’Connell

et al. 2021

Preprint

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“…6 showing that RLNR rates increased from 19.1% in 2003 to 30.3% for patients with 1-3 positive LNs after mastectomy. 9 The trade-offs of RLNR are increased risks of radiation pneumonitis and BCRL. [10][11][12] Therefore, individualizing treatment decisions regarding axillary surgery (ALND v SLNB), with or without RLNR, is a crucial part of clinical decision making impacting all disciplines.…”

Section: Introductionmentioning

confidence: 99%

Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer–Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial

Naoum

Roberts

Brunelle

et al. 2020

JCO

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PURPOSE To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer–related lymphedema (BCRL) rates in patients with breast cancer. PATIENTS AND METHODS From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival. RESULTS The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively). CONCLUSION Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used.

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“…Fortunately, more recent studies have demonstrated that PMRT following immediate breast reconstruction has acceptable aesthetic outcomes and complication rates, possibly due to improvements in radiation and surgical techniques (Billig et al, 2017; Ho et al, 2017; Mirzabeigi et al, 2013; Shammas et al, 2019). As a result, the use of immediate breast reconstruction has risen, despite concurrent increased use of PMRT and RNI (Ohri et al, 2018; Surgeons ASoP, 2018).…”

Section: Introductionmentioning

confidence: 99%

Comparing complications in irradiated and non‐irradiated free‐flaps in patients with bilateral immediate breast reconstruction and unilateral post‐mastectomy radiotherapy

Khetpal

Heller

et al. 2021

Microsurgery

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Background Numerous studies have evaluated the effect of post‐mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free‐flaps are compared to non‐irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. Methods Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free‐flaps were compared to those on the contralateral non‐irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free‐flaps. Results Seventy‐three women were included. There was no significant difference between complication rates for the irradiated and non‐irradiated free‐flaps (39.7% vs. 38.4%, p = .78), although irradiated free‐flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free‐flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32–10.97; p = .01). Conclusions PMRT may contribute to free‐flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.

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Trends and variations in postmastectomy radiation therapy for breast cancer in patients with 1 to 3 positive lymph nodes: A National Cancer Data Base analysis

Abstract: The receipt of PMRT by patients with breast cancer who have 1 to 3 positive lymph nodes has increased over time, with wide variability in practice patterns in the United States. Cancer 2018;124:482-90. © 2017 American Cancer Society.

Cited by 19 publications

References 28 publications

Patterns of Post-Mastectomy Radiotherapy in Immediate Breast Reconstruction – Results from the iBRA-2 Cohort Study

Patterns of Post-Mastectomy Radiotherapy in Immediate Breast Reconstruction – Results from the iBRA-2 Cohort Study

Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer–Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial

Comparing complications in irradiated and non‐irradiated free‐flaps in patients with bilateral immediate breast reconstruction and unilateral post‐mastectomy radiotherapy

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