Updated Guidelines for Postmastectomy Radiation May Affect More Women Who Have Breast ReconstructionRead Now
For many women who are diagnosed with breast cancer, postmastectomy radiation therapy (PMRT) is a critical part of treatment. It kills residual cancer cells, reduces the likelihood of recurrence and increases survival. Clinical guidelines revised this month now recommend PMRT for more breast cancer patients, especially those with smaller tumors and limited lymph node involvement.Based on research evidence developed between 2001 and 2015, three cancer organizations, The American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology have jointly revised their guidelines to broaden the scope of patients who would benefit from PMRT. As a result, more women may have radiation. While radiation therapy has proven benefits, it may also cause side effects (see May 23, 2016 blog). It also limits subsequent options for breast reconstruction and has a greater likelihood of reconstructive complications and/or failure.
The new guidelines focus on a group of women in the PMRT “gray zone”-- those with tumors smaller than 5 centimeters, and not more than 3 positive lymph nodes. The panel found “strong evidence” that PMRT reduces the risk of breast cancer recurrence and breast cancer death in these patients. Currently, the debate about PMRT has been most controversial for this group; while some doctors recommend PMRT for these women, others do not.
The revised guidelines recommend that:
• the PMRT decision should include the patient and all physicians involved in her treatment.
· the potential complications of PMRT may outweigh the benefit for some patients who have a low risk of recurrence. Doctors and patients should weigh the benefits and risks of PRMT to determine the best treatment approach for the patient.
• physicians should consider patient and tumor characteristics that may diminish the benefit of PMRT or increase the risk of complications.
• patients with T1-2 tumors with a positive sentinel node biopsy who elect to omit axillary lymph node dissection should receive PMRT only if there is already sufficient information to justify its use without needing to know that additional axillary nodes are involved.
• Patients with axillary nodal involvement that persists following neoadjuvant systemic therapy should receive PMRT.
This recommended change continues the move away from a one-size-fits-all treatment approach. It contributes to the trend towards individualizing therapy, by underscoring the importance of weighing the benefit and risk of PMRT for individual patients. The risks of PMRT, for example, may outweigh the benefits for a 65-year-old woman with estrogen-receptor positive breast cancer and a very small involvement in a single lymph node, while PMRT would be advised for a 40-year-old with triple-negative breast cancer and multiple lymph nodes involved.
Reference: Annals of Surgical Oncology