Post Mastectomy Radiation Therapy

Alyssa Mellott
RadSci 3574
Annotated Bibliography
1. Tendulkar R, Rehman S, Macklis R, et al. Impact of Postmastectomy Radiation on
Locoregional Recurrence in Breast Cancer Patients With 1-3 Positive Lymph Nodes
Treated With Modern Systemic Therapy. International Journal Of Radiation Oncology,
Biology, Physics [serial online]. August 2012;83(5):e577-e581. Available from: Academic
Search Complete, Ipswich, MA. Accessed April 11, 2014.
2. San-Gang W, Yong C, Zhen-Yu H, et al. Using the lymph nodal ratio to predict the risk
of locoregional recurrence in lymph node-positive breast cancer patients treated with
mastectomy without radiation therapy. Radiation Oncology [serial online]. July
2013;8(1):1-8. Available from: Academic Search Complete, Ipswich, MA. Accessed April
11, 2014.
3. Overgaard M, Jensen M, Mouridsen H, et al. Postoperative radiotherapy in high-risk
postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer
Cooperative Group DBCG 82c randomized trial. Lancet [serial online]. May 15,
1999;353(9165):1641-1648. Available from: Academic Search Complete, Ipswich, MA.
Accessed April 11, 2014.
For my annotated bibliography, I chose to analyze postmastectomy radiation therapy
(PMRT) in breast cancer patients. It can be highly controversial in certain situations, and it
is important to know the risks of recurrence to help determine if adjuvant treatment is
needed. The title of the first article is Impact of Postmastectomy Radiation on
Locoregional Recurrence in Breast Cancer Patients With 1-3 Positive Lymph Nodes
Treated With Modern Systemic Therapy. This article expresses the benefits of using PMRT
to prevent locoregional reoccurrence (LRR) in breast cancer patients who have positive lymph
nodes (LN+), and are treated with systemic therapy. The researchers chose a sample of 396
subjects from the population of patients with 1-3 LN+, because PMRT is especially
controversial in these situations. Of the patients studied from 2000-2007, 98 underwent PMRT
and 271 did not.1 The five-year rate of LRR was 0% with PMRT, but 8.9% without PMRT.1
The authors of the journal identified five risk factors that made LRR more probable in patients

who did not receive PMRT, the strongest predictors being extracapsular extension and grade.

Others include lymphovascular invasion and a nodal ratio greater than 25%.1
The Tendulkar article is an example of a primary research study, which means that the
investigators are looking to answer a specific research question. In this case, they are
questioning whether to treat patients with 1-3 LN+ with PMRT. To answer this question,
quantitative data is utilized. Numbers are used to assess the outcome, such as the ratio of
those who experienced LRR to those who did not. Since this study uses quantitative data,
it is considered an observational quantitative study. Defined as a further subtype, it would
be closest to a case-control study because an exposed group and unexposed group are
known at the beginning of the study. In this case, the subjects are divided into groups
depending on whether they received PMRT or not. A limitation of this type of study is that
there is no intervention, therefore it cannot show a cause and effect relationship. As for
reliability and validity, it seems that this study is very strong. I believe that the specificity
of the patients (only those with 1-3 LN+) chosen help improve validity. Also, the 0% LRR
rate with patients who received PMRT shows an indisputable reliability. There are not
many treatment outcomes that are this significant, and once again, I believe that these
researchers have covered all of the bases to provide valid and reliable results.
In my clinical practice, I will never have the power to make decisions about whether a
patient should receive PMRT, but this study has helped me shape a strong opinion on the
topic. I believe that radiation therapy should be a key treatment for breast cancer patients that
have 1-3 LN+. As stated above, it had a 0% LRR in the 98 relevant patients who received the
treatment from 2000-2007. After reviewing the study, I believe that most people in this position
should choose to have the extra radiation therapy. If a patient does have a mastectomy, I would
strongly suggest having this extra treatment to reduce the risk of LRR. If a patient with 1-3

LN+ is having doubts about having PMRT, the five LRR risk factors discussed in the journal
article are a good way to help the physician with the decision process. For example, estrogen
and progesterone receptor negative patients showed a higher correlation with LRR. These
factors can be telling, but according to this study the best decision is to always have PMRT for
1-3 LN+. I have helped treat many patients with radiation therapy after they have had a
mastectomy, and hope that this is becoming more of a trend for patients that have less than 4
LN+. It is an easy preventative step in reducing the risk for recurrence.
The title of the second article is Using the lymph nodal ratio to predict the risk of

locoregional recurrence in lymph node-positive breast cancer patients treated with

mastectomy without radiation therapy. This study is evaluating the use of axillary lymph
node ratio (LNR) versus overall involved nodes (pN stage) as a prognostic indication for
axillary lymph-node positive patients who were treated with a mastectomy but no
radiation therapy. LNR is defined as the ratio of the number of positive axillary lymph
nodes to the number of removed axillary lymph nodes.2 In relation to the previous study,
this research is also evaluating a method that can help delegate the appropriate treatment
after a mastectomy. Until recently, the pN stage has been primarily used to assess the
lymph nodes after a mastectomy, but it may not be the best determinant when it comes
PMRT. These investigators set out to assess a more specific lymph node status among
patients. A sample of 1,068 patients was retrospectively analyzed to determine the
correlation between their pN stage, LNR, overall survival (OS), and locoregional
recurrence-free survival (LRFS). Multivariate analysis showed that LNR was an
independent prognostic factor of LRFS and OS, while pN stage had no significant effect
on LFRS or OS.2 The researchers concluded that prognosis and PMRT should be decided
using LNR rather than pN stage. It was suggested the use of the LNR may minimize the

difference between clinical judgment and the real status of the lymph nodes that arises due
to differing physician practices.2
This is a primary research study due to the fact that the investigators are looking to
answer a specific research question. In this case, the research question is whether to use
pN staging or LNR in determining prognosis and whether to move forward with adjuvant
radiation therapy after a mastectomy. To answer this question, quantitative data is once
again utilized. For example, the percentages of LFRS and OS helped determine the results
and conclusions for this research. This article could be considered an observational study,
but it is also a methodological study design. This type of study compares a new measure to
an existing standard, and is becoming more prevalent in the medical field. In this study, we
are considering the use LNR over pN staging in this research. I believe that this study has
a high validity and reliability. As the previous study discussed there are many factors that
should go into the decision of whether to have PMRT, but this study is just evaluating
lymph node staging as an indication. Theyre research question is very specific and clear,
and I believe this helps the accuracy of the findings. The investigators also used a very
large sample, and this should help to solidify the reliability of the study.
There are many things to look at when deciding whether a patient should have
radiation therapy following a mastectomy. For the patient, this is a crucial decision that
will affect their future, and it can mean life or death. I believe that physicians should be
using the most accurate information to predict prognosis and prescribe additional or
preventative treatment. I believe that LNR alone or LNR in addition to pN staging should
be a new factor that physicians look at when making these decisions. It seems that the
decision of whether to follow up with radiation therapy is very dependant on the
physician. I think that the more factors we have to predict OS and LRFS, the better. It is

even important to consider the risk factors that have smaller correlations, because this can
make a difference down the road for breast cancer patients. The details are important, and
the patient should be treated according to their specific situation.
The title of my third article is Postoperative radiotherapy in high-risk postmenopausal
breast-cancer patients given adjuvant tamoxifen. The researchers that conducted this
study decided to focus on post-menopausal women. They state that post mastectomy
radiotherapy is associated with a lower locoregional recurrence rate and improved diseasefree and overall survival when combined with chemotherapy in premenopausal high-risk
breast-cancer patients.3 Though the previous revelation was well known at the time, postmenopausal women have a distinctive hormonal makeup and many other factors that
differentiate them from younger women. Therefore, it is beneficial for PMRT to be
analyzed separately in this population. More specifically, this research involved high-risk,
post-menopausal patients who were also given adjuvant tamoxifen. The question is
whether adding PMRT to this chemo regimen is beneficial. In this study, 1,375 subjects
from the given population were randomly assigned tamoxifen alone or tamoxifen plus
radiation therapy following a mastectomy. LRR, distant metastasis, and overall survival
were all assessed. The findings showed that patients who only received tamoxifen had
significantly higher LRR, more recurrence overall, and worse OS. One of the main
controversial points at this time was long-term survival of post-menopausal women who
were treated with PMRT. Previous studies had shown that PMRT had no effect on longterm survival for this population, but this study shows different results. According to the
investigators, the estimated overall survival after 10 years was 45% for radiotherapy plus
tamoxifen, and 36% for patients treated with tamoxifen alone.3 Once again, this study
shows that a slightly more aggressive strategy following a mastectomy can have a positive

impact on prognosis, while a conservative treatment can potentially cause problems in the
long run.
This study is considered a primary research study, and the research question is whether
PMRT and tamoxifen is better than tamoxifen alone in high-risk, post-menopausal women
following a mastectomy. It is utilizing quantitative data to back up its findings. For
example, the investigators state that LRR occurred 8% of the radiotherapy plus tamoxifen
group versus 53% of the tamoxifen only group.3 Unlike the previous studies, this is a true
experimental quantitative study because the researchers used intervention and random
assignment. More specifically, it is a randomized clinical trial, and uses prospective data
(which can often be more beneficial than retrospective data). These are the only types of
studies that can show cause and effect, and they have one of the highest levels of evidence.
Therefore, these findings are considered very strong in the world of study designs.
Overall, the study seems to be valid and highly reliable. The fact that it is randomized
clinical trial automatically makes it more valid, and the clarity of the findings make it hard
to refute the reliability of the study.
After an in depth review of this article, it seems that PMRT is again the safe way to go.
Simply put, the benefits of receiving PMRT outweigh the risks in most cases. It is amazing
how many indications can go into postmastectomy treatment decisions. They should all be
considered, especially if the physician is considering a more conservative treatment. To
conclude, I believe that physicians should be considering the LNR after a mastectomy. It is
important to consider the ratio of positive axillary lymph nodes to the number of axillary
nodes removed in the decision making process. Additionally, patients with 1-3 LN+, and
high-risk, post-menopausal women should have PMRT. It is much easier to treat the
disease right after surgery, rather than trying a salvage treatment for recurrence.