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Randomized Controlled Trial
. 2015 Jul 23;373(4):307-16.
doi: 10.1056/NEJMoa1415340.

Regional Nodal Irradiation in Early-Stage Breast Cancer

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Free PMC article
Randomized Controlled Trial

Regional Nodal Irradiation in Early-Stage Breast Cancer

Timothy J Whelan et al. N Engl J Med. .
Free PMC article

Abstract

Background: 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.

Methods: We randomly assigned women with node-positive or high-risk node-negative breast cancer who were treated with breast-conserving surgery and adjuvant systemic therapy to undergo either whole-breast irradiation plus regional nodal irradiation (including internal mammary, supraclavicular, and axillary lymph nodes) (nodal-irradiation group) or whole-breast irradiation alone (control group). The primary outcome was overall survival. Secondary outcomes were disease-free survival, isolated locoregional disease-free survival, and distant disease-free survival.

Results: Between March 2000 and February 2007, a total of 1832 women were assigned to the nodal-irradiation group or the control group (916 women in each group). The median follow-up was 9.5 years. At the 10-year follow-up, there was no significant between-group difference in survival, with a rate of 82.8% in the nodal-irradiation group and 81.8% in the control group (hazard ratio, 0.91; 95% confidence interval [CI], 0.72 to 1.13; P=0.38). The rates of disease-free survival were 82.0% in the nodal-irradiation group and 77.0% in the control group (hazard ratio, 0.76; 95% CI, 0.61 to 0.94; P=0.01). Patients in the nodal-irradiation group had higher rates of grade 2 or greater acute pneumonitis (1.2% vs. 0.2%, P=0.01) and lymphedema (8.4% vs. 4.5%, P=0.001).

Conclusions: Among women with node-positive or high-risk node-negative breast cancer, the addition of regional nodal irradiation to whole-breast irradiation did not improve overall survival but reduced the rate of breast-cancer recurrence. (Funded by the Canadian Cancer Society Research Institute and others; MA.20 ClinicalTrials.gov number, NCT00005957.).

Figures

Figure 1
Figure 1. 10-Year Kaplan–Meier Estimates of Survival
Shown are rates of overall survival (Panel A), disease-free survival (Panel B), isolated locoregional disease-free survival (Panel C), and distant disease-free survival (Panel D) among patients who underwent whole-breast irradiation plus regional nodal irradiation (WBI + RNI) and those who underwent whole-breast irradiation alone (WBI, control group).
Figure 2
Figure 2. Disease-free Survival at 10 Years, According to Subgroup
Shown are hazard ratios and rates of disease-free survival among patients who underwent whole-breast irradiation plus regional nodal irradiation (WBI+RNI) and those who underwent whole-breast irradiation alone (WBI, control group). The dashed vertical line at 0.76 in dicates the overall hazard ratio estimate. Hazard ratios are shown on a logarithmic scale. DFS denotes disease-free survival, ER estrogen receptor, and PR progesterone receptor.

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