Presentation on theme: "Evidence for adjuvant radiation therapy benefiting breast cancer patients with 1 to 3 positive lymph nodes treated with a modified radical mastectomy and."— Presentation transcript:
1 Evidence for adjuvant radiation therapy benefiting breast cancer patients with 1 to 3 positive lymph nodes treated with a modified radical mastectomy and systemic therapyShaheenah Dawood, Ana M. Gonzalez-Angulo, Wendy Woodward, Funda Meric-Bernstam, Kelly Hunt, Aman U. Buzdar,Gabriel N. Hortobagyi, Thomas A. BuchholzThe University of Texas M. D. Anderson Cancer CenterDepartments of Breast Medical Oncology, Surgical Oncology and Radiation OncologyDubai Hospital, U.A.E, Department of Medical OncologyDepartments of Breast Medical Oncology, and Quantitative Sciences(Abstract number :507
2 DisclosureI have no relevant relationships to disclose.
3 Postmastectomy Radiation Oxford: Mastectomy +/- XRT Trials Breast Recurrence Breast Ca DeathsLN - DiseaseLocal Recurrence2/3 reductionBreast Ca Survivalnone in LN-5% for LN+8% vs. 3%28% vs. 31%LN + Disease29% vs. 8%60%vs. 55%
4 There is current consensus that postmastectomy radiation therapy is indicated for patients whose tumors are either > 5cm and/or >= 4 positive lymph nodes.Whether adjuvant radiation therapy should be used for patients with early stage breast cancer with tumors < 5cm and up to 3 positive axillary lymph nodes treated with mastectomy and systemic therapy is controversial.
5 AimThus the purpose of this retrospective study was to determine if adjuvant radiation therapy had an impact on survival for patients with early stage breast cancer with up to 3 positive axillary lymph nodes treated with surgery and systemic therapy
6 Methodology Stage I and II Breast Cancer Mastectomy + no RadiationSegmental Resection + Radiation
7 MethodologyDatabase : M.D Anderson Breast Cancer Management Systems DatabaseInclusion criteria :Female patientsDiagnosed between 1980 and 2007SurgeryT1/T2 N0 or T1/T2/N1Tumors <5 cmNodes <4Exclusion criteria :Male patientsMore than one primaryHormone receptor positive who did not receive hormone treatmentMastectomy and radiation therapySegmental resection and no radiation
8 Outcome Measures Follow-up cut-off was 30th December 2008. Local-Regional Disease Free Survival (LRDFS): Calculated from the date of diagnosis to the date of first locoregional metastases or last follow-up.Distant Disease Free Survival (DDFS): Calculated from the date of diagnosis to the date of first distant metastases or last follow-up.
9 Statistical AnalysisKaplan-Meier method used to calculate outcome and segmental resection with radiation patients were compared to those with mastectomy without radiation using two-sided log rank tests.Cox proportional hazards was used adjusting for differences in patient and tumor characteristics between the two groups.
11 Neoadjvuant chemotherapy No Yes Mastectomy(No Radiation)Segmental(Radiation)P valueNeoadjvuant chemotherapy No Yes1239 (78.17%)346 (21.83%)1627 (75.5%)528 (24.5%)0.0564Anthracycline No Yes141 (9.02%)1423 (90.98%)155 (7.29%)1972 (92.71%)0.0561Taxane No Yes716 (45.78%)848 (54.22%)919 (43.21%)1208 (56.79%)0.1198
12 Results Number Total no. analyzed 3740 Deaths 767 (18.1%) Median follow-up54 months ( months)Median OS161 months(95% CI months)5-year DDFS78%(95% CI 76%-79%)5-year LRDFS88%(95% CI 87%-90%)
13 Multivariate Analysis of LRDFS Whole CohortHRLower95% CIUpperP-ValueMastectomy vs. Segmental1.260.951.680.11Models adjusted for age, grade, hormone receptor status, HER2 status,menopausal status, race, neoadjuvant chemo, anthracycline use, taxane use,and lymphovascular invasion
14 LRDFS Among LN Negative Groups T1N0 (N=1191)T2N0 (N=997)5- Year EstimatesSegmental : 92%Mastectomy: 91%P=0.935- Year EstimatesSegmental : 91%Mastectomy: 89%P=0.99
15 LRDFS Among LN Positive Groups T1N1 (N=876)T1N2 (N=676)5- Year EstimatesSegmental : 91%Mastectomy: 90%P=0.655- Year EstimatesSegmental : 91%Mastectomy: 87%P=0.009
16 Adjusted Hazard Ratios for LRDFS among various subgroups Favors MastectomyForrest Plot For Sub-GroupsFavors SegmentalWhole CohortT1N0T1N0T2N0T2N0T1N1T1N1T2N1T2N1No Neoadjuvant group (HR = 2.62 , 95% CI , P =Hazard Ratios LDFS
17 Multivariate Analysis for DDFS Whole CohortHRLower95% CIUpperP-ValueMastectomy vs. Segmental1.381.131.700.0018Models adjusted for age, grade, hormone receptor status, HER2 status,menopausal status, race, neoadjuvant chemo, anthracycline use, taxane use,and lymphovascular invasion
18 DDFS Among LN Negative Groups T1N0 (N=1191)T2N0 (N=997)5- Year EstimatesSegmental : 87%Mastectomy: 86%P=0.115- Year EstimatesSegmental : 85%Mastectomy: 80%P=0.38
19 DDFS Among LN Positive Groups T1N1(N=876)T2N1(N=676)5- Year EstimatesSegmental : 90%Mastectomy: 85%P=0.0045- Year EstimatesSegmental : 77%Mastectomy: 68%P=0.0177
20 Adjusted Hazard Ratios for DDFS among various subgroups Favors MastectomyFavors SegmentalT1N0T2N0T1N1T2N1HR = 1.71 , 95% CI , P =0.007No Neoadjuvant group (HR = 1.54, 95% CI , P =0.061)
21 ConclusionsPatients with tumors <5 cm and 1 to 3 positive lymph have an increase risk of loco-regional and distant disease recurrence when radiation is not used as a component of their local-regional treatment.The benefit of radiation appears to be most pronounced for patients with T2N1 disease with the benefit still unclear for those with T1N1 disease.
22 Limitations We acknowledge the following limitations: Retrospective nature of the studyComparing women who underwent segmental resection with radiation to a comparable cohort who underwent mastectomy to assess the benefit of post mastectomy radiation may not be ideal.However the results of our study are hypothesis generating and will need to be confirmed in prospective randomized clinical trials.
23 Acknowledgement Mentors Dr. Thomas A. Buchholz Dr. Ana M. Gonzalez-AnguloDr. Mona Al RhukhaimiDr. Farid Khalifa