Postoperative radiotherapy in breast cancer--long-term results from the Oslo study

Mortality patterns over 34 years of breast cancer patients in a clinical trial of post-operative radiotherapy

Between January 1949 and June 1955 a clinical trial was held in which patients with operable breast carcinoma were subjected to a radical mastectomy and then randomised to either have immediate post-operative radiotherapy (radiated group) or delayed radiotherapy on recurrence (watched group). Data relating to the 1461 patients entered in the trial have been analysed to investigate the late effects of treatment, if any, over a period of 34 years. A logrank comparison of the survival patterns of the radiated and watched groups, considering all deaths, during the first 15 years of follow-up did not show any statistically significant difference (P = 0.37). However, after 15 years there was a significantly increased mortality in the radiated group (P = 0.0025). The relative risk after 15 years for the radiated group relative to the watched group was 1.43 with a 95% confidence interval of 1.13 to 1.81. Taking the series as a whole, this increased mortality was attributable to deaths from cardiovascular disease (excluding cerebrovascular disease). There was no evidence that the increased mortality due to cardiovascular disease was significantly different between patients who had a left- or right-sided tumour. There was also no significant difference between the watched and radiated group from mortality due to breast cancer or other malignancies. The data analysed here relate to patients treated 40 years ago. Neither the type of surgery nor the techniques and quality of radiation are used any longer. Furthermore, an artificial radiation menopause has also fallen into disuse. Data should be prospectively gathered from more recent trials, to see if there is any hazard in the very long term from present day methods of treatment. These should include patients treated by lesser forms of surgery, supervoltage therapy, adjuvant hormone and/or chemotherapy.

Breast cancer: the role of postoperative radiotherapy

Although the role of radiotherapy in breast cancer is controversial, there are clearly defined indications for its use. The probability of local relapse can be determined by careful evaluation of the histological features of the primary tumour, the absolute number of involved axillary nodes and the type and and extent of the surgery performed. Using these data, patients can be divided into a relatively low risk group who probably do not require radiotherapy and a group at significant risk of relapse who, even with adjuvant systemic therapy, are likely to benefit from postoperative radiotherapy. Despite the often-repeated view to the contrary, radiotherapy is more effective in the locoregional control of breast cancer if given postoperatively than if withheld until tumour relapse occurs. Radiotherapy at the time of relapse provides long-term control in only 40-55% of patients. This results in significant morbidity from uncontrolled local disease in the one-third of patients who survive 5 years and the one-quarter of patients who survive 10 years from the time of local relapse. This paper outlines the rationale and indications for the use of radiotherapy in improving locoregional control in breast cancer.

Long-term follow-up of sickness periods in breast cancer patients primarily treated with surgery and radiotherapy or surgery only

Morbidity as assessed by the number of sicklisted days was studied in 500 breast cancer patients. All patients were part of a randomized trial going on between 1971 and 1976 to evaluate the clinical effect of pre- and postoperative radiotherapy versus surgery only. Data on the number of sicklisted days and various forms of retirement from 1971 to 1984 was obtained by cooperation with the Swedish National Social Insurance Office. It was shown that the number of sicklisted days did not differ significantly between the study groups when the initial sickperiod--that is the time for operation, adjuvant radiotherapy and immediate recovery--was deducted from the total number of sicklisted days. The same result was also obtained when the time on disability pension was added. Our results do thus not support the hypothesis that adjuvant radiotherapy increases morbidity in breast cancer patients.

Does adjuvant radiotherapy have a role in the postmastectomy management of patients with operable breast cancer--revisited

About 2 decades ago, "routine" adjunctive postmastectomy radiotherapy, especially for axillary node-positive patients, was the norm and uncriticized standard against which adequate treatment was measured in most centers. With the advent of cyclic, aggressive, multi-agent chemotherapy and anti-hormones used as adjuvants, especially within the last decade, there has been tremendous reduction in patients referred to the radiation oncologist for consideration of adjunctive postmastectomy radiotherapy. This presentation will attempt to define a role for radiotherapy in at least selected subsets of patients who undergo modified radical mastectomy, based upon published series in the literature. Breast cancer is a protean disease and deserves a multidisciplinary approach to evaluation and treatment. "Routine" adjunctive postmastectomy radiotherapy for all patients with operable breast cancer obviously is not indicated, but there appear to be groups of patients who benefit from radiotherapy, both from the standpoint of disease-free survival and improved quality of life, and . . . in very narrow subsets, absolute survival. In some of these subsets the benefit clinically may be greater than that resulting from chemotherapy or anti-hormone therapy, although, because of sample size, falling short of statistical verification. In response to the posed question, while this remains a controversial issue, there appears to be a role for selective adjunctive postmastectomy radiotherapy in specific subsets of patients, and physicians administering adjunctive breast cancer therapy with sweeping applications of chemotherapy or anti-hormones alone do not appear to be offering their patients optimal therapy.

Isolated local-regional recurrence following mastectomy for adenocarcinoma of the breast treated with radiation therapy alone or combined with surgery and/or chemotherapy

The results of radiation therapy alone or combined with surgery and/or chemotherapy are reported for 47 patients who presented with local and/or regional recurrence without evidence of distant metastases following initial management of adenocarcinoma of the breast with radical or modified radical mastectomy (43) or simple mastectomy (4). Patients were treated between October 1964 and March 1983 at the University of Florida; all have a 2-year minimum follow-up and 42/47 (89%) have had follow-up for greater than or equal to 5 years. The overall actuarial local-regional control rates were 80% at 2 years, 68% at 5 years, and 61% at 10 years. The 5-year actuarial local-regional control rates by site and extent of disease were as follows: single chest wall nodule, 92%; multiple chest wall nodules, 49%; regional lymph nodes, 66%; and multiple sites, 64%. The 5- and 10-year actuarial determinate disease-free survival rates for all patients were 41 and 17%, respectively. The 5- and 10-year actuarial survival rates for all patients were 50 and 34%, respectively.

Long-term effect of internal mammary chain treatment. Results of a multivariate analysis of 1195 patients with operable breast cancer and positive axillary nodes

A multivariate analysis on 1195 patients with operable breast cancer and histologically positive axillary nodes treated by mastectomy and complete axillary dissection at the Institut Gustave-Roussy between 1958 and 1978 suggests a beneficial effect of treatment of the internal mammary chain (IMC) on the risks of death and distant metastasis for the patients with medial tumors. For these patients, surgical IMC dissection and post-operative irradiation have similar effects on both the risk of death and of distant metastasis. For the patients with lateral tumors, no beneficial effect of the treatment of the IMC on these two risks was observed. Postoperative irradiation to the IMC, axilla, chest wall and supraclavicular nodes significantly decreases the risk of locoregional recurrences independent of the tumor site and surgical management of the lymph nodes.

Three-dimensional internal mammary lymphoscintigraphy: implications for radiation therapy treatment planning for breast carcinoma

Conservative surgery combined with radiation therapy for the treatment of early breast carcinoma has been shown to achieve both a high rate of local tumor control and good cosmetic results with a minimum of complications. Whether the internal mammary lymph nodes (IMNs) should be included in the treatment volume is a topic of considerable controversy. Radionuclide internal mammary node lymphoscintigraphy (IMN-LS) can locate these nodes in three dimensions. We have analyzed the results of IMN-LS in 167 patients imaged at the Dana-Farber Cancer Institute and treated at the Joint Center for Radiation Therapy between 1977 and 1980. The location of the IMNs was found variable from patient to patient. At least one IMN was not included within tangential fields arbitrarily arranged to have a medial entrance point 3.0 cm across the midline in 17% of evaluable patients. However, 48% and 66% of patients had IMNs that could be adequately treated with fields positioned only 1.0 cm or 2.0 cm across midline, respectively. We conclude that when treatment of the IMNs is warranted, IMN-LS not only assures their complete coverage in the majority of patients but also may help reduce the amount of heart and lung irradiated.

The role of computed tomography in the evaluation of post-mastectomy locally recurrent breast cancer

The rate of post mastectomy local-regional recurrence of breast cancer has remained in the range of 10-30% for decades. The traditional treatment, external beam radiation therapy, is successful in eradicating local disease in most cases, but re-recurrences are seen in about 50% of patients. Since 1982, 33 patients with such recurrences have undergone evaluation with computed tomography (CT) at our institution as part of their diagnostic work-up. In 22/33 (67%), CT revealed unsuspected disease, and in 10 of these patients the radiation treatment plan had to be altered. These results, similar to three other published series, strongly suggest that CT is a necessary part of the work-up of patients with post-mastectomy local-regional recurrences. The significance of these findings with respect to the cause of post mastectomy local-regional failures is further discussed.