<some material deleted>
So in explanation of what I wrote over the past few days, no, I am not recommending radiotherapy for everyone post-mastectomy. I am not recommending radiotherapy for ANYONE.
I am thinking out loud. And asking for reactions to what I am reading.
And what I am reading is that (1) radiotherapy is widely recommended for preventing LOCAL recurrences after nearly all lumpectomies (Dr. Nick's recent post, plus the letter last spring in the New England Journal of Medicine from Dr. Samuel Hellman of the University of Chicago), (2) it is widely recommended for CERTAIN persons after mastectomies, to prevent local recurrences, and (3) it is now being widely considered by radiation oncologists and by some (many? a few? I don't know) medical oncologists for certain persons after mastectomies to prevent distant metastases coming from local recurrences, and thus for improving survival.
(1) Dr. Yashar Hirshaut, Breast Cancer: The Complete Guide, Revised Edition (Bantam Books, 1996):
My favorite two books in general are Dr. Hirshaut's and Dr. Love's. Each has different styles. Each has independent value. On radiation therapy after mastectomy, Dr. Hirshaut writes (and he can correct me if I take him out of context, since he is on the list):
"The radiotherapist uses radiation after a lumpectomy is performed and sometimes following a mastectomy. . . ." (p. 16.)
"After Mastectomy.
"Though radiation is not commonly used with mastectomy, sometimes when a tumor is large, or when the surgeon has not been able to get a wide enough margin around it, radiation will be used to make sure all the disease is eradicated.
"Lymph Node Treatment.
"Radiation may be used to treat the lymph nodes behind the breastbone or above the collarbone if those nodes are at high risk of containing cancer cells. For example, we would expect this to be the case if a great deal of cancer is found at the inner side of the breast or in the axilla.
[Dr. Hirshaut, I have also heard that finding a positive node higher up in the axilla may be an indication. Did I hear that wrong?]
"Extremely Large Tumors.
"When the tumor is too large to be operated on, chemotherapy is commonly used to shrink it to operable size. Then, following surgery, because of the relatively high risk of recurrence at this stage of the disease, radiation may be employed to attack any microscopic malignancy that may have escaped surgical removal. . . ." (p. 135.)
(2) Dr. Charles B. Simone, Breast Health: What You Need to Know About Disease Prevention, Diagnosis, Treatment, and Guidelines for Health Breast Care (Avery, 1995):
"If a patient has a mastectomy, should that patient receive radiation therapy? -- A patient who has a modified radical mastectomy with negative axillary nodes has less than a 10 percent chance of a recurrence on the chest wall or axillary area. However, when the lymph nodes are positive, the risk increases to 20-30 percent with the most common site of local recurrence in the chest wall as well as the lymph nodes above the collar bone (supraclavicular). The indications for having radiation treatment to the chest wall and some of the regional lymph node sites are the following:
" * Breast cancer diameters great than 5 cm.
" * Four or more positive axillary lymph nodes.
" * The breast cancer mass very close to the chest wall.
"Once a recurrence becomes evidence on the chest wall or lymph node draining sites of the breast, treatment is of little help. . . . Chemotherapy does not control these recurrences and once a recurrence is manifested, radiation therapy fails to control it in 30-60 percent of the cases. Even when radiation therapy is combined with a surgical resection or chemotherapy for the recurrence, the control rate does not improve appreciably. . . . If the breast cancer recurs in one of the lymph node regions, local treatment is not effective . . . .
"Hence, if a patient is deemed to be at high risk for a future local recurrence, the patient should be treated with radiation immediately after surgery to minimize the risk cause recurrences are difficult to eradicate."
(3) Chapter in cancer treatment handbook, Dr. Robert Parker, "Radiation Therapy for Breast Cancer ( , 1995):
" . . . [T]here has been a continuing evolution of indications for use until, currently, radiation therapy has major roles in [various situations and] as an adjuvant to mastectomy . . . .
""Radiation Therapy After Radical or Modified Radical Mastectomy.
"Although in the past many patients received local-regional radiation therapy following radical or modified radical mastectomy, such use has become controversial and infrequent (treatment of patients with metastases to axillary nodes: 50 percent in 1972 and 25 percent in 1981). In large part, this change in policy was based on the assumption that chemotherapy would be effective against distant metastases and local-regional recurrence. However, the success of chemotherapy in the prevention of chest wall and regional lymph node recurrences in 'high-risk' patients has not been documented. Consequently, in addition to systemic chemotherapy, it is prudent to irradiate the chest wall and regional lymphatics in these patients. Fletcher identified subsets of patients at risk for local-regional recurrence as a basis for elective irradiation: peripheral lymphatics and chest wall if more than 20 percent of the axillary nodes contained tumor regardless of the size or site of the primary tumor; chest wall if the primary tumor was larger than 5.0 cm, tumor involved the margins of resection, perineural or vascular spaces were extensively invaded, or when grave signs, such as fixation to the chest wall or involvement of the skin, were present; peripheral lymphatics if tumors less than 2.0 cm in greatest dimension were located centrally or medially; peripheral lymphatics if less than 20 percent of the axillary nodes contained tumor; and internal mammary nodes when primary tumors less than 2.0 cm in greatest dimension were located centrally or medially.
"Postmastectomy radiation therapy should be measured by its effectiveness in reducing tumor regrowth on the chest wall or in the peripheral lymphatics. In prospective randomized studies from Oslo and Stockholm, evidence was provided that local-regional recurrences can be reduced. Survival benefit in these studies was small. however, in the Oslo II study, 47 patients with central or medial primary tumors had a 20 percent survival advantage. Likewise, a report from Institut Gustave Roussy indicated a survival benefit for patients with central or medial primary tumors when the internal mammary nodes were irradiated or resected.
"Some authorities advocate withholding irradiation of the chest wall and regional lymphatics until local regional recurrences appear in that minority of patients reflecting high-risk factors. However, such gross recurrences are controlled in only about half of these patients, and the clinical consequences of tumors progressing on the chest wall . .. are very morbid.
"Inasmuch as patients receiving postmastectomy radiation therapy also are at high risk for distant metastases, chemotherapy is likely to be used. Although CMF and chest wall irradiation are tolerated when used concurrently, consecutive administration, usually with initial chemotherapy, especially when doxorubicin is included, has been the most frequent program."
(4) Chapter in cancer treatment handbook, Drs. Charles Haskell, Robert Parker, and Susan Love, "Treatment of Breast Cancer by Stage of Disease and Special Problems" ( , 1995):
"The treatment of breast cancer is in a state of flux, and recommendations must be made in the context of the results of current therapeutic research. . . . Some experienced physicians, including the authors of this chapter, may disagree about the management of individual patients. One should remember that each patient is unique, with a distinct socioeconomic background and psychological background, spectrum of associated organ dysfunctions, and stage of disease. The tumor is also distinctive . . . . The experienced physician will individualize therapy when it is appropriate; nevertheless, it is useful to have a generalized approach to treatment as a point of reference. This chapter will briefly sketch such an approach. It draws heavily on practice guidelines developed for the University of California at Los Angeles (UCLA) Breast Center. . . .
"Stages I and II
"A generalized approach to local control, developed by physicians in the UCLA Breast Center is summarized in Figure 32-1
<figure omitted>
"Figure 32-1: " . . . Radiation therapy is also used after total mastectomy for the following groups of patients: T greater than 5.0 cm; extranodal extension of disease; more than four positive nodes or extensive lymphatic invasion. . . .
"Local Control with Radiation Therapy. . . . After a total mastectomy with lymph node dissection, radiation therapy is also recommended for women with T3 lesions, extranodal extension of tumor, extensive lymphatic invasion within the tumor, and four or more positive lymph nodes.
[Discussion of timing of chemotherapy and radiation therapy omitted, as well as discussion of chemotherapy choices.]
"Stages IIIA and IIIB
" . . . Combined-modality therapy is clearly needed for both of these
groups of patients, although the optimal program is uncertain. . . . the
approach used at UCLA Breast Center is summarized in Figure 32-3.
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ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ IIIA and IIIB
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ 3-4 cycles FAC
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ Reevaluate
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ /ΚΚΚΚΚΚ |ΚΚΚΚΚΚ \
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ Ghostectomy LumpectomyΚΚ Mastectomy
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |ΚΚΚΚΚΚ |ΚΚΚΚΚΚΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ [some steps omitted]ΚΚΚΚΚΚΚ /
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |ΚΚΚΚΚΚ |ΚΚΚΚΚΚΚΚΚΚ /
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ Adjuvant Systemic Therapy
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |ΚΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ |ΚΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ ABMTΚΚΚ 3 cycles FAC
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ \ΚΚΚΚΚΚ |
ΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚΚ XRT [radiation therapy]
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". . . [W]e generally treat patients who have locally advanced breast cancer with three or four cycles of doxorubicin-based chemotherapy . . . . This is followed by surgical resection if possible . . . and postoperative radiation therapy. If the preoperative chemotherapy is effective in reducing the size of the primary tumor, two or three additional cycles of chemotherapy are given after completion of radiation therapy." [Note: this description contradicts the sequence of the last two steps shown in the Figure but, as they say in the discussion under stage I and II, the proper sequencing is open to debate -- even between their text and their figure, apparently!] (pp. 375-379.)
(5) Joan Swirsky & Barbara Balaban, The Breast Cancer Handbook: Taking Control After You've Found a Lump (Harper Perrenial, 1994) (they are a clinical nurse specialist and a social worker):
"Radiation can also be given in conjunction with a mastectomy. . . . Radiation can be given after a mastectomy, either before or after chemotherapy to women who have had large tumors or many positive nodes." (pp. 113-114.)
<snip>
John