| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
EDITORIALS |
From the Department of Radiation Oncology, Brigham & Women’s Hospital, Boston, Massachusetts.
Correspondence: Address correspondence to: Jay R. Harris, MD, Brigham & Women’s Hospital, Department of Radiation Oncology, 75 Francis St., L2, Boston, MA 02115; Fax: 617-632-2290; E-mail: jharris{at}lroc.harvard.edu
The use of breast-conserving therapy was conceived as a careful integration of surgery and radiotherapy to maximize cosmetic outcomes without sacrificing survival relative to mastectomy for early-stage breast cancer.1–8 Therefore, risks of untoward side effects must be minimized while maintaining adequate levels of local control. Over time, surgical and radiation oncologists have made refinements in the techniques of both surgery and radiotherapy to further optimize this balance. This balance is especially critical given the significant impact of local control on overall survival seen in preliminary data from the 2000 update of the Early Breast Cancer Trialists’ Collaborative Group overview (Overview Steering Committee, personal communication, September 2000).
In this issue of the Annals of Surgical Oncology, Meric et al. share the M. D. Anderson Cancer Center experience regarding long-term complications associated with breast conserving surgery (BCS) and radiotherapy (RT) using modern techniques.9 In their study, 294 patients treated between 1990 and 1992 were prospectively monitored for treatment-related complications. Tumors had been surgically removed with grossly normal tissue margins, and if surgical margins were microscopically positive, a re-excision was performed. Axillary lymph node dissection included level I and II nodes with identification but not stripping of the axillary vein. With a median follow-up of 89 months, (range, 13–126 months), arm edema was noted in 13.6% of patients, with 4.5% having grade 2 or higher morbidity. Risk of arm edema was significantly associated with having received lumpectomy plus axillary lymph node dissection versus lumpectomy alone (P = .05).
These findings are in concordance with previous studies that have shown the incidence of axillary edema to vary with the extent of axillary surgery and the use of nodal irradiation. A study from the Joint Center for Radiation Therapy (JCRT) reported that the risk of arm edema at 6 years was 37% with a full dissection compared with 8% with lower level dissection only (P = .03).10 In this study, arm edema occurred in 72% of patients who underwent full dissection and received full axillary irradiation. In patients at risk for nodal recurrence after axillary dissection (generally those with four or more positive axillary nodes), the nodal radiation field can include the full axilla (lateral border about halfway through the humeral head) or just the axillary apex (lateral border at the lateral edge of the coracoid process). Although no prospective trial of full axillary versus axillary apex-only radiation has been performed, it is anticipated that the risk of arm edema would be smaller with the more limited field. Currently, the decision of whether to treat the full axilla or just the axillary apex is made only after careful review of the operative note and consultation with the surgical oncologist who performed the axillary dissection. Special attention is paid to the number of positive nodes, total number of nodes removed, proximity of the surgery to the axillary vein, and presence of extracapsular extension. Ideally, the decision regarding the use and extent of axillary nodal irradiation should be a shared responsibility of the surgical and radiation oncologist.
Meric et al. found a negative association between the use of a radiation boost to the primary site and cosmetic outcome, with more breast fibrosis in those patients who had received a boost (P = .041).9 In their study, overall 25% of patients had grade 1 breast thickening or fibrosis, and 4% had grade 2 or higher morbidity. These results correspond to those found at the JCRT in a study of 1159 patients treated between 1970 and 1985 with breast RT to 45–46 Gy and a boost to the primary site of 16–18 Gy (median follow-up of 107 months for patients treated before 1982 and 67 months for those treated in or after 1982).11 In this study, excellent (describing no identifiable effects of treatment) cosmetic outcome was achieved in approximately 75% of patients and acceptable results (good, describing minimal but identifiable effects of treatment, or excellent) in nearly all patients. In particular, 95% of patients treated after 1982 with an implant and 97% of those treated with an electron boost (P = not significant) had excellent or good cosmetic results. The importance of the boost in RT after BCS has been established by the randomized "boost vs. no boost" European Organization for Research and Treatment of Cancer trial of 5318 patients, where the addition of the boost decreased the rate of local recurrence by 41%.12 Patients 40 years of age and younger benefitted the most in this study, with a 54% reduction in local recurrence. However, use of the boost was associated with a small negative impact on cosmetic outcome 3 years after initial therapy.13,14 Nevertheless, given the potential implications of local recurrence on distant disease,15 the importance of the boost in terms of reducing local recurrence, we believe, outweighs its untoward effects on cosmetic outcome in the majority of patients.
Finally, Meric et al. did not note any second malignancies or cardiac events in their patient population.9 However, large patient numbers and longer follow-up times may be required to see these rare but serious very late sequelae of RT. In a study of 1624 patients treated with BCS and RT at the JCRT, 3 (0.18%) women developed sarcomas in the treatment field at 72, 107, and 110 months after initial treatment.16 Moreover, studies with large numbers of patients using data from registries and from meta-analyses indicate that follow-up periods of greater than 10 years are required to detect a difference in number of deaths because of myocardial infarctions and other possible adverse effects on overall survival.17–19
In conclusion, the use of BCS and RT requires a fine balance with respect to minimizing local recurrence while optimizing cosmetic outcomes. This balance is best achieved with combined input from both radiation and surgical oncologists, highlighting the importance of a multidisciplinary approach for the breast cancer patient. This thoughtful and detailed study from M. D. Anderson provides further evidence of the long-term safety of BCS and RT and suggests practical ways to further improve this balance. Integrating the timing of systemic treatment, which can affect both local control20 and cosmetic outcome,2,3,21–23 makes achieving this balance even more challenging.
Received for publication May 13, 2002. Accepted for publication May 16, 2002.
REFERENCES
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
