13个淋巴结阳性乳腺癌的放疗.docx
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13个淋巴结阳性乳腺癌的放疗.docx
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13个淋巴结阳性乳腺癌的放疗
RadiotherapyforEarlyBreastCancerand1to3PositiveNodes
ZosiaChustecka
March19,2014
GLASGOW,Scotland—Forwomenwithearlybreastcancerwhoundergomastectomyandaxillarydissection,radiotherapyisrecommendedforthosewhoarefoundtohave4ormorepositivelymphnodes,butisnotusuallygiventowomenwhoarefoundtobenode-negative.
However,forthewomenwhofallintothegrayareainbetween,whoarefoundtohave1to3positiveaxillarynodes,therehasbeeninsufficientevidencetomakearecommendationonewayoranother.
Nowtherearedatatoshowthatradiationisalsobeneficialinthisgroup.
TheresultswerepresentedMarch 19hereatthe9thEuropeanBreastCancerConference,andpublishedonlinesimultaneouslyintheLancet.
Thefindingcomesfromameta-analysisofindividualdataforatotalof8135womenparticipatinginclinicaltrialswhowerefollowedforanaverageof11years;1314ofthesewomenwerefoundtohave1to3positivenodes.
Theresultsforthissubgroupofwomenshowedthatpostmastectomyradiotherapysignificantlyreducedbothrecurrenceandbreastcancermortality,evenwhensystemictherapywasgiven.
Themeta-analysiswasconductedbytheEarlyBreastCancerTrialists'CollaborativeGroup(EBCTCG),andpresentedatthemeetingbyPaulMcGale,PhD,seniorstatisticianattheUniversityofOxford,UnitedKingdom.
Inwomenwhohad1to3positivenodes,postmastectomyradiotherapyreducedtherecurrencerateby32%andreducedthebreastcancermortalityrateby20%.Thebenefitwassimilarwhetherwomenhadonly1positivenodeorwhethertheyhad2or3positivenodes.
"Givingradiotherapytothesewomenledtonearly12fewerrecurrencesper100womenafter10yearsand8fewerdeathsper100womenafter20years,"Dr.McGalesaidinastatement.
Theresultsfromthemeta-analysisalsoconfirmedpreviousfindingsofbenefitfromradiotherapyforwomenwith4ormorepositivenodes,andthelackofbenefitforwomenwithnode-negativedisease.
Forwomenwith4ormorepositivenodes(n =1772),themeta-analysisshowedthatradiotherapyreducedoverallrecurrenceby21%andbreastcancermortalityby13%.Inotherwords,radiotherapyforthesewomenledto9fewerrecurrencesper100womenafter10years,and9fewerbreastcancerdeathsper100womenafter20years.
Theseresultsarestatisticallysimilartothosefoundforthesubgroupofwomenwith1to3positivenodes,commentedcoauthorCarolynTaylor,FRCR,aclinicaloncologistatOxfordUniversityHospitalsandaclinicalresearchfellowattheUniversityofOxford.Shenotedthatthewomenwithmorepositivenodeswouldbeatahigherriskforrecurrence,buttheproportionalreductioninriskwassimilartothatseeninwomenwithfewerpositivenodes.
Inthismeta-analysis,atotalof5821womenhadnode-positivedisease;ofthese,3131(54%)hadaxillarydissection(definedasremovalofaxillarylymphnodesinatleastlevels IandII)and2541(44%)hadaxillarysampling(lessextensiveaxillarysurgery),whilefor149(2%),theextentofaxillarysurgerywasunknown.
Themeta-analysisalsoconfirmedthattherewasnosignificantbenefitfromradiotherapyforwomenwhowerefoundtobenode-negative(n =700)."Therewasnoevidencethatradiotherapyprovidedanybenefit"inthisgroup,theresearcherswrite.
BenefitSeenRegardlessofChemotherapy
"Anotherresultfromourstudyisthattheproportionalbenefitsofradiotherapyweresimilarinwomenregardlessofwhetherornottheyhadalsoreceivedchemotherapyorhormonaltherapy,"Dr.McGalesaid.Themostcommonchemotherapyusedinthetrialswascyclophosphamide,methotrexate,andfluorouracil,andthemostcommonhormonaltherapyusedwastamoxifen
"Thisisimportantbecausemostwomentodayreceivethesetherapies.Ourresultssuggestthatwomenbeingtreatedtodayarelikelyalsotobenefitfromradiotherapyiftheyhaveanypositivelymphnodes,"headded.
Themeta-analysisincludedtrialsthatwereconductedbetween1964and1986.
"Sincethetimewhenthewomeninthesetrialswererandomized,therehavebeenadvancesinradiotherapyandalsoinbreastscreening,surgery,lymphnodestaging,andsystemictherapy,"Dr.McGalecommented."Sotheabsolutebenefitsfrompostmastectomyradiotherapytodaymaybesmallerthanthosewehavereportedhere.Buttheproportionalbenefitsfromradiotherapyarelikelytobeatleastasbig."
ThesamepointwashighlightedbyDr.Taylor."Inrecentyears,largernumbersofwomenwithjustafewpositivelymphnodeshavereceivedchemotherapy,andthetypesofchemotherapyhavechanged.Also,thevastmajorityofwomenwithhormone-sensitivetumorsarenowgivenhormonaltherapy."
Inaddition,radiotherapytechniqueshaveimprovedinthepastfewdecades,andwomentodayreceivebettercoverageoftargetareas,anddosestonormaltissuesarelikelytobelower,theresearcherspointout.
"Wewillhavetowaitforresultsfromnewtrialstoobservedirectlythelong-termeffectsofmodernradiotherapyinwomenwhoaregivenmodernchemotherapyandhormonaltherapy,"Dr.Taylorsaid.
"However,itislikelythatthepercentagereductionsindiseaserecurrenceandbreastcancermortalityfromtoday'sradiotherapywillbeatleastasbigasthebenefitsseenhere,"Dr.Taylorcommented.
BestGuideCurrentlyAvailable?
Untilthenewtrialsarecompleted,thesedatafromthemeta-analysis"mightbethebestguidethatiscurrentlyavailabletohelpestimatethelikelyabsolutebenefitsfromradiotherapyinwomentoday,"theauthorswrite.
InaninterviewwithMedscapeMedicalNews,Dr.Tayloremphasizedthatthenewfindingwasforwomenwith1to3positivenodes,asubgroupforwhichtherehadbeenlittleinformationaboutpreviously.Theresultsfromthemeta-analysisshowthattheproportionalreductioninbothbreastcancerrecurrenceandmortalitydidnotvaryaccordingtowhetherornotthewomenreceivedchemotherapyand/orhormonaltherapy,andalsoitdidnotvaryaccordingtothenumberofnodesthatwerepositive."Sothesedataarelikelytoapplytowomenbeingtreatedtoday,"shesaid.
"Whatwillbedifferentistheabsoluteriskreduction,becausewomentodaygetbetterdetectionwithscreeningandbettertreatmentwithchemotherapyandlocaltargetedagents,sotheirabsoluterisksofrecurrencearelikelytobemuchlessthanwasseeninthewomenparticipatinginthesetrials,"sheexplained."Butwecanapplythoseproportionalbenefitstoworkouttheabsolutegainsforwomenwhoarebeingconsideredforpostmastectomyradiotherapy,"sheadded.
Whenaskedwhetherpostmastectomyradiotherapyshouldnowberecommendedforallwomenwith1to3positivenodes,Dr.Tayloremphasizedtheneedtoassesseachpatientindividually.
Thebenefitthatanindividualwomanwillgetwilldependonwhatherriskforrecurrenceisintheabsenceofradiotherapy,shesaid."So,forexample,forawomanwith3positivenodesandalargehigh-gradetumor,herriskofrecurrenceishighandshewouldbelikelybenefitfromradiotherapy.Butforawomanwith1positivenodeandalowerriskofrecurrence,Iasaclinicianwouldneedtoworkoutherriskofrecurrenceintheabsenceofradiotherapy,andthenIwouldusetheproportionalreductioninriskfromthisstudytoworkouthergainfromradiotherapy,becauseasaclinicianIamalwaysbalancinguptherisksofthetreatmentversusthebenefits."
Eachclinicianwouldneedtosimilarlyweightheriskandbenefitforthepatientthatisfacingthem,shesaid,buttheresultsfromthismeta-analysiswouldsuggestthatmostwomenwith1to3positivenodeswouldbenefitfromradiotherapy.
Lancet.PublishedonlineMarch19,2014.Abstract
9thEuropeanBreastCancerConference(EBCC-9):
Abstracto-202.PresentedMarch19,2014
Effectofradiotherapyaftermastectomyandaxillarysurgeryon10-yearrecurrenceand20-yearbreastcancermortality:
meta-analysisofindividualpatientdatafor8135womenin22randomisedtrials.
Lancet.2014Mar19.pii:
S0140-6736(14)60488-8.doi:
10.1016/S0140-6736(14)60488-8.[Epubaheadofprint]
EbctcgEarlyBreastCancerTrialists'CollaborativeGroup.
BACKGROUND:
Postmastectomyradiotherapywasshowninpreviousmeta-analysesto
reducetherisksofbothrecurrenceandbreastcancermortalityinallwomenwith
node-positivediseaseconsideredtogether.However,thebenefitinwomenwith
onlyonetothreepositivelymphnodesisuncertain.Weaimedtoassessthe
effectofradiotherapyinthesewomenaftermastectomyandaxillarydissection.
METHODS:
Wedidameta-analysisofindividualdatafor8135womenrandomly
assignedtotreatmentgroupsduring1964-86in22trialsofradiotherapytothe
chestwallandregionallymphnodesaftermastectomyandaxillarysurgeryversus
thesamesurgerybutnoradiotherapy.Follow-uplasted10yearsforrecurrence
andtoJan1,2009,formortality.Analyseswerestratifiedbytrial,individual
follow-upyear,ageatentry,andpathologicalnodalstatus.
FINDINGS:
3786womenhadaxillarydissectiontoatleastlevelIIandhadzero,
onetothree,orfourormorepositivenodes.Allwereintrialsinwhich
radiotherapyincludedthechestwall,supraclavicularoraxillaryfossa(or
both),andinternalmammarychain.For700womenwithaxillarydissectionandno
positivenodes,radiotherapyhadnosignificanteffectonlocoregionalrecurrence
(two-sidedsignificancelevel[2p]>0·1),overallrecurrence(rateratio[RR],
irradiatedvsnot,1·06,95%CI0·76-1·48,2p>0·1),orbreastcancermortality
(RR1·18,95%CI0·89-1·55,2p>0·1).For1314womenwithaxillarydissectionand
onetothreepositivenodes,radiotherapyreducedlocoregionalrecurrence
(2p<0·00001),overallrecurrence(RR0·68,95%CI
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