13个淋巴结阳性乳腺癌的放疗.docx

13个淋巴结阳性乳腺癌的放疗.docx

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13个淋巴结阳性乳腺癌的放疗

RadiotherapyforEarlyBreastCancerand1to3PositiveNodes

ZosiaChustecka

March19,2014

GLASGOW,Scotland—Forwomenwithearlybreastcancerwhoundergomastectomyandaxillarydissection,radiotherapyisrecommendedforthosewhoarefoundtohave4ormorepositivelymphnodes,butisnotusuallygiventowomenwhoarefoundtobenode-negative.

However,forthewomenwhofallintothegrayareainbetween,whoarefoundtohave1to3positiveaxillarynodes,therehasbeeninsufficientevidencetomakearecommendationonewayoranother.

Nowtherearedatatoshowthatradiationisalsobeneficialinthisgroup.

TheresultswerepresentedMarch 19hereatthe9thEuropeanBreastCancerConference,andpublishedonlinesimultaneouslyintheLancet.

Thefindingcomesfromameta-analysisofindividualdataforatotalof8135womenparticipatinginclinicaltrialswhowerefollowedforanaverageof11years;1314ofthesewomenwerefoundtohave1to3positivenodes.

Theresultsforthissubgroupofwomenshowedthatpostmastectomyradiotherapysignificantlyreducedbothrecurrenceandbreastcancermortality,evenwhensystemictherapywasgiven.

Themeta-analysiswasconductedbytheEarlyBreastCancerTrialists'CollaborativeGroup（EBCTCG）,andpresentedatthemeetingbyPaulMcGale,PhD,seniorstatisticianattheUniversityofOxford,UnitedKingdom.

Inwomenwhohad1to3positivenodes,postmastectomyradiotherapyreducedtherecurrencerateby32%andreducedthebreastcancermortalityrateby20%.Thebenefitwassimilarwhetherwomenhadonly1positivenodeorwhethertheyhad2or3positivenodes.

"Givingradiotherapytothesewomenledtonearly12fewerrecurrencesper100womenafter10yearsand8fewerdeathsper100womenafter20years,"Dr.McGalesaidinastatement.

Theresultsfromthemeta-analysisalsoconfirmedpreviousfindingsofbenefitfromradiotherapyforwomenwith4ormorepositivenodes,andthelackofbenefitforwomenwithnode-negativedisease.

Forwomenwith4ormorepositivenodes（n =1772）,themeta-analysisshowedthatradiotherapyreducedoverallrecurrenceby21%andbreastcancermortalityby13%.Inotherwords,radiotherapyforthesewomenledto9fewerrecurrencesper100womenafter10years,and9fewerbreastcancerdeathsper100womenafter20years.

Theseresultsarestatisticallysimilartothosefoundforthesubgroupofwomenwith1to3positivenodes,commentedcoauthorCarolynTaylor,FRCR,aclinicaloncologistatOxfordUniversityHospitalsandaclinicalresearchfellowattheUniversityofOxford.Shenotedthatthewomenwithmorepositivenodeswouldbeatahigherriskforrecurrence,buttheproportionalreductioninriskwassimilartothatseeninwomenwithfewerpositivenodes.

Inthismeta-analysis,atotalof5821womenhadnode-positivedisease;ofthese,3131（54%）hadaxillarydissection（definedasremovalofaxillarylymphnodesinatleastlevels IandII）and2541（44%）hadaxillarysampling（lessextensiveaxillarysurgery）,whilefor149（2%）,theextentofaxillarysurgerywasunknown.

Themeta-analysisalsoconfirmedthattherewasnosignificantbenefitfromradiotherapyforwomenwhowerefoundtobenode-negative（n =700）."Therewasnoevidencethatradiotherapyprovidedanybenefit"inthisgroup,theresearcherswrite.

BenefitSeenRegardlessofChemotherapy

"Anotherresultfromourstudyisthattheproportionalbenefitsofradiotherapyweresimilarinwomenregardlessofwhetherornottheyhadalsoreceivedchemotherapyorhormonaltherapy,"Dr.McGalesaid.Themostcommonchemotherapyusedinthetrialswascyclophosphamide,methotrexate,andfluorouracil,andthemostcommonhormonaltherapyusedwastamoxifen

"Thisisimportantbecausemostwomentodayreceivethesetherapies.Ourresultssuggestthatwomenbeingtreatedtodayarelikelyalsotobenefitfromradiotherapyiftheyhaveanypositivelymphnodes,"headded.

Themeta-analysisincludedtrialsthatwereconductedbetween1964and1986.

"Sincethetimewhenthewomeninthesetrialswererandomized,therehavebeenadvancesinradiotherapyandalsoinbreastscreening,surgery,lymphnodestaging,andsystemictherapy,"Dr.McGalecommented."Sotheabsolutebenefitsfrompostmastectomyradiotherapytodaymaybesmallerthanthosewehavereportedhere.Buttheproportionalbenefitsfromradiotherapyarelikelytobeatleastasbig."

ThesamepointwashighlightedbyDr.Taylor."Inrecentyears,largernumbersofwomenwithjustafewpositivelymphnodeshavereceivedchemotherapy,andthetypesofchemotherapyhavechanged.Also,thevastmajorityofwomenwithhormone-sensitivetumorsarenowgivenhormonaltherapy."

Inaddition,radiotherapytechniqueshaveimprovedinthepastfewdecades,andwomentodayreceivebettercoverageoftargetareas,anddosestonormaltissuesarelikelytobelower,theresearcherspointout.

"Wewillhavetowaitforresultsfromnewtrialstoobservedirectlythelong-termeffectsofmodernradiotherapyinwomenwhoaregivenmodernchemotherapyandhormonaltherapy,"Dr.Taylorsaid.

"However,itislikelythatthepercentagereductionsindiseaserecurrenceandbreastcancermortalityfromtoday'sradiotherapywillbeatleastasbigasthebenefitsseenhere,"Dr.Taylorcommented.

BestGuideCurrentlyAvailable?

Untilthenewtrialsarecompleted,thesedatafromthemeta-analysis"mightbethebestguidethatiscurrentlyavailabletohelpestimatethelikelyabsolutebenefitsfromradiotherapyinwomentoday,"theauthorswrite.

InaninterviewwithMedscapeMedicalNews,Dr.Tayloremphasizedthatthenewfindingwasforwomenwith1to3positivenodes,asubgroupforwhichtherehadbeenlittleinformationaboutpreviously.Theresultsfromthemeta-analysisshowthattheproportionalreductioninbothbreastcancerrecurrenceandmortalitydidnotvaryaccordingtowhetherornotthewomenreceivedchemotherapyand/orhormonaltherapy,andalsoitdidnotvaryaccordingtothenumberofnodesthatwerepositive."Sothesedataarelikelytoapplytowomenbeingtreatedtoday,"shesaid.

"Whatwillbedifferentistheabsoluteriskreduction,becausewomentodaygetbetterdetectionwithscreeningandbettertreatmentwithchemotherapyandlocaltargetedagents,sotheirabsoluterisksofrecurrencearelikelytobemuchlessthanwasseeninthewomenparticipatinginthesetrials,"sheexplained."Butwecanapplythoseproportionalbenefitstoworkouttheabsolutegainsforwomenwhoarebeingconsideredforpostmastectomyradiotherapy,"sheadded.

Whenaskedwhetherpostmastectomyradiotherapyshouldnowberecommendedforallwomenwith1to3positivenodes,Dr.Tayloremphasizedtheneedtoassesseachpatientindividually.

Thebenefitthatanindividualwomanwillgetwilldependonwhatherriskforrecurrenceisintheabsenceofradiotherapy,shesaid."So,forexample,forawomanwith3positivenodesandalargehigh-gradetumor,herriskofrecurrenceishighandshewouldbelikelybenefitfromradiotherapy.Butforawomanwith1positivenodeandalowerriskofrecurrence,Iasaclinicianwouldneedtoworkoutherriskofrecurrenceintheabsenceofradiotherapy,andthenIwouldusetheproportionalreductioninriskfromthisstudytoworkouthergainfromradiotherapy,becauseasaclinicianIamalwaysbalancinguptherisksofthetreatmentversusthebenefits."

Eachclinicianwouldneedtosimilarlyweightheriskandbenefitforthepatientthatisfacingthem,shesaid,buttheresultsfromthismeta-analysiswouldsuggestthatmostwomenwith1to3positivenodeswouldbenefitfromradiotherapy.

Lancet.PublishedonlineMarch19,2014.Abstract

9thEuropeanBreastCancerConference（EBCC-9）:

Abstracto-202.PresentedMarch19,2014

Effectofradiotherapyaftermastectomyandaxillarysurgeryon10-yearrecurrenceand20-yearbreastcancermortality:

meta-analysisofindividualpatientdatafor8135womenin22randomisedtrials.

Lancet.2014Mar19.pii:

S0140-6736（14）60488-8.doi:

10.1016/S0140-6736（14）60488-8.[Epubaheadofprint]

EbctcgEarlyBreastCancerTrialists'CollaborativeGroup.

BACKGROUND:

Postmastectomyradiotherapywasshowninpreviousmeta-analysesto

reducetherisksofbothrecurrenceandbreastcancermortalityinallwomenwith

node-positivediseaseconsideredtogether.However,thebenefitinwomenwith

onlyonetothreepositivelymphnodesisuncertain.Weaimedtoassessthe

effectofradiotherapyinthesewomenaftermastectomyandaxillarydissection.

METHODS:

Wedidameta-analysisofindividualdatafor8135womenrandomly

assignedtotreatmentgroupsduring1964-86in22trialsofradiotherapytothe

chestwallandregionallymphnodesaftermastectomyandaxillarysurgeryversus

thesamesurgerybutnoradiotherapy.Follow-uplasted10yearsforrecurrence

andtoJan1,2009,formortality.Analyseswerestratifiedbytrial,individual

follow-upyear,ageatentry,andpathologicalnodalstatus.

FINDINGS:

3786womenhadaxillarydissectiontoatleastlevelIIandhadzero,

onetothree,orfourormorepositivenodes.Allwereintrialsinwhich

radiotherapyincludedthechestwall,supraclavicularoraxillaryfossa（or

both）,andinternalmammarychain.For700womenwithaxillarydissectionandno

positivenodes,radiotherapyhadnosignificanteffectonlocoregionalrecurrence

（two-sidedsignificancelevel[2p]>0·1）,overallrecurrence（rateratio[RR],

irradiatedvsnot,1·06,95%CI0·76-1·48,2p>0·1）,orbreastcancermortality

（RR1·18,95%CI0·89-1·55,2p>0·1）.For1314womenwithaxillarydissectionand

onetothreepositivenodes,radiotherapyreducedlocoregionalrecurrence

（2p<0·00001）,overallrecurrence（RR0·68,95%CI