Effectiveness of the AJCC 8th edition staging system for selecting patients with T1–2N1 breast cancer for post-mastectomy radiotherapy: a joint analysis of 1986 patients from two institutions

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Abstract

Background

The role of post-mastectomy radiotherapy (PMRT) in the treatment of patients with T1–2N1 breast cancer is controversial. This study’s purpose was to evaluate the risk of recurrence of T1–2N1 breast cancer and the efficacy of PMRT in low-, medium- and high-risk groups of patients.

Methods

Post-mastectomy patients with T1–2N1 breast cancer were restaged according to the American Joint Committee on Cancer Staging Manual, 8th edition (AJCC 8th ed.) staging system. Recurrence scores were generated using prognostic factors identified for loco-regional recurrence and distant metastasis in patients without PMRT, and three risk groups were identified. Rates of loco-regional recurrence and distant metastasis were calculated with a competing risk model and compared using Gray’s test. Disease-free survival and overall survival were calculated using the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazards regression model was used for the multivariate analysis.

Results

Data from 1986 patients (1521without PMRT; 465 with PMRT) were analyzed. Patients without PMRT were stratified into low-, intermediate- and high-risk groups by age, tumor location, AJCC 8th ed. stage, number of positive nodes and lympho-vascular invasion. The 5-year loco-regional recurrence rate and distant metastasis rates for the three risk groups were significant at 2.5, 5.4 and 16.2% ( p < 0.001) respectively, and 4.9, 8.4 and 18.6% ( p < 0.001) respectively. In the high-risk group, loco-regional recurrence ( p < 0.001), and distant metastasis ( p = 0.044) were significantly reduced, and disease free survival ( p = 0.004), and overall survival ( p = 0.029) were significantly improved after PMRT. In the low- and intermediate-risk groups, PMRT had no significant effect on loco-regional recurrence ( p = 0.268), distant metastasis ( p = 0.252), disease free survival ( p = 0.608) or overall survival ( p = 0.986).

Conclusion

Our results showed no benefits of PMRT in the low-risk group, and thus, omitting PMRT radiotherapy in this population could be considered.

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Most cited references 22

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Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial.

M. Overgaard, P Hansen, J Overgaard … (1997)

Irradiation after mastectomy can reduce locoregional recurrences in women with breast cancer, but whether it prolongs survival remains controversial. We conducted a randomized trial of radiotherapy after mastectomy in high-risk premenopausal women, all of whom also received adjuvant systemic chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (CMF). A total of 1708 women who had undergone mastectomy for pathological stage II or III breast cancer were randomly assigned to receive eight cycles of CMF plus irradiation of the chest wall and regional lymph nodes (852 women) or nine cycles of CMF alone (856 women). The median length of follow-up was 114 months. The end points were locoregional recurrence, distant metastases, disease-free survival, and overall survival. The frequency of locoregional recurrence alone or with distant metastases was 9 percent among the women who received radiotherapy plus CMF and 32 percent among those who received CMF alone (P<0.001). The probability of survival free of disease after 10 years was 48 percent among the women assigned to radiotherapy plus CMF and 34 percent among those treated only with CMF (P<0.001). Overall survival at 10 years was 54 percent among those given radiotherapy and CMF and 45 percent among those who received CMF alone (P<0.001). Multivariate analysis demonstrated that irradiation after mastectomy significantly improved disease-free survival and overall survival, irrespective of tumor size, the number of positive nodes, or the histopathological grade. The addition of postoperative irradiation to mastectomy and adjuvant chemotherapy reduces locoregional recurrences and prolongs survival in high-risk premenopausal women with breast cancer.

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Regional Nodal Irradiation in Early-Stage Breast Cancer.

Timothy J Whelan, Ivo A Olivotto, Wendy R Parulekar … (2015)

Most women with breast cancer who undergo breast-conserving surgery receive whole-breast irradiation. We examined whether the addition of regional nodal irradiation to whole-breast irradiation improved outcomes.

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Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial.

M. Overgaard, M. B. Jensen, J Overgaard … (1999)

Postmastectomy radiotherapy is associated with a lower locoregional recurrence rate and improved disease-free and overall survival when combined with chemotherapy in premenopausal high-risk breast-cancer patients. However, whether the same benefits apply also in postmenopausal women treated with adjuvant tamoxifen for similar high-risk cancer is unclear. In a randomised trial among postmenopausal women who had undergone mastectomy, we compared adjuvant tamoxifen alone with tamoxifen plus postoperative radiotherapy. Between 1982 and 1990, postmenopausal women with high-risk breast cancer (stage II or III) were randomly assigned adjuvant tamoxifen (30 mg daily for 1 year) alone (689) or with postoperative radiotherapy to the chest wall and regional lymph nodes (686). Median follow-up was 123 months. The endpoints were first site of recurrence (locoregional recurrence, distant metastases, or both), and disease-free and overall survival. Locoregional recurrence occurred in 52 (8%) of the radiotherapy plus tamoxifen group and 242 (35%) of the tamoxifen only group (p<0.001). In total there were 321 (47%) and 411 (60%) recurrences, respectively. Disease-free survival was 36% in the radiotherapy plus tamoxifen group and 24% in the tamoxifen alone group (p<0.001). Overall survival was also higher in the radiotherapy group (385 vs 434 deaths; survival 45 vs 36% at 10 years, p=0.03). Postoperative radiotherapy decreased the risk of locoregional recurrence and was associated with improved survival in high-risk postmenopausal breast-cancer patients after mastectomy and limited axillary dissection, with 1 year of adjuvant tamoxifen treatment. Improved survival in high-risk breast cancer can best be achieved by a strategy of both locoregional and systemic tumour control.

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Author and article information

Contributors

Yujing Zhang: zhangyj@sysucc.org.cn

Yexiong Li:

ORCID: http://orcid.org/0000-0003-0985-235X

yexiong@yahoo.com

Journal

Journal ID (nlm-ta): BMC Cancer

Journal ID (iso-abbrev): BMC Cancer

Title: BMC Cancer

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2407

Publication date (Electronic): 24 August 2020

Publication date PMC-release: 24 August 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 792

Affiliations

[1 ]GRID grid.506261.6, ISNI 0000 0001 0706 7839, State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, , Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), ; Beijing, 100021 P. R. China

[2 ]Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong province 510060 P. R. China

[3 ]GRID grid.417009.b, ISNI 0000 0004 1758 4591, Department of Radiation Oncology, , The Third Affiliated Hospital of Guangzhou Medical University, ; Guangzhou, 510150 Guangzhou province P. R. China

Author information

Yexiong Li http://orcid.org/0000-0003-0985-235X

Article

Publisher ID: 7267

DOI: 10.1186/s12885-020-07267-5

PMC ID: 7446222

PubMed ID: 32838753

SO-VID: c951c9fc-1f81-49b8-8ca2-7021425defaa

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Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 3 April 2020

Date accepted : 6 August 2020

Funding

Funded by: the National Key Projects of Research and Development of China

Award ID: 2016YFC0904600

Funded by: the National Natural Science Foundation of China

Award ID: 81972860

Funded by: the Medical Scientific Research Foundation of Guangdong Province of China

Award ID: B2020065

Funded by: the Capital Characteristic Clinic Project

Award ID: Z171100001017116

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ScienceOpen disciplines: Oncology & Radiotherapy

Keywords: breast neoplasm,post-mastectomy radiotherapy,one to three positive nodes,ajcc 8th edition staging system

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ScienceOpen disciplines: Oncology & Radiotherapy

Keywords: breast neoplasm, post-mastectomy radiotherapy, one to three positive nodes, ajcc 8th edition staging system

Effectiveness of the AJCC 8th edition staging system for selecting patients with T1–2N1 breast cancer for post-mastectomy radiotherapy: a joint analysis of 1986 patients from two institutions

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Karger: Oncology

Most cited references 22

Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial.

Regional Nodal Irradiation in Early-Stage Breast Cancer.

Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial.

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