ASCO, ASTRO, and SSO Issue Joint Update to Guideline on Postmastectomy Radiotherapy for Women With Breast Cancer




We still don’t have a single, validated formula that can determine who needs postmastectomy radiotherapy, but we hope that the research evidence summarized in this guideline update will help doctors and patients make more informed decisions.
— Stephen B. Edge, MD

Earlier this month, ASCO, in collaboration with the American Society for Radiation Oncology (ASTRO) and the Society for Surgical Oncology (SSO), jointly issued an update to a clinical practice guideline for physicians treating women with breast cancer who have undergone a mastectomy. The update provides additional considerations for physicians to determine which patients might benefit from postmastectomy radiotherapy.

Update May Help More Informed Decisions

“We still don’t have a single, validated formula that can determine who needs postmastectomy radiotherapy, but we hope that the research evidence summarized in this guideline update will help doctors and patients make more informed decisions,” said Stephen B. Edge, MD, Co-Chair and ASCO representative on the Expert Panel that developed the guideline update. “We also hope this publication will spur more research into patient and tumor characteristics that predict risk of recurrence after mastectomy.”

The update was published by ASCO, ASTRO, and SSO in their respective journals, the Journal of Clinical Oncology,1 Practical Radiation Oncology, and Annals of Surgical Oncology.

Abram Recht, MD

Abram Recht, MD

“In an era of personalized medicine, we want to be sure that we offer the right care to the right patients. Thanks to advances in systemic therapy, fewer women need radiation therapy after a mastectomy,” said Abram Recht, MD, Co-Chair and ASCO representative on the Expert Panel that developed the guideline update. “This means we can be more selective when recommending this treatment to our patients.”

Treatment Planning

The guideline update states there is strong evidence showing that postmastectomy radiotherapy reduces the risk of breast cancer recurrence. It provides evidence-based recommendations for the use of postmastectomy radiotherapy in patients with tumors smaller than 5 cm (T1-2) and 1 to 3 positive lymph nodes; patients undergoing neoadjuvant systemic therapy; and patients with T1-2 tumors and a positive sentinel node biopsy. The Expert Panel also addressed the technical aspects of radiotherapy, such as the optimal extent of regional nodal irradiation.

Bruce G. Haffty, MD

Bruce G. Haffty, MD

“For many women, [postmastectomy radiotherapy] reduces the risk of local and regional failure, but physicians must weigh this benefit with the considerable side effects associated with this treatment,” said Bruce G. Haffty, MD, Immediate Past Chair of ASTRO’s Board of Directors. “This cooperative guideline underscores the complexity inherent in decisions related to postmastectomy radiotherapy, as well as the importance of clinical judgment in treatment planning.”

Key Recommendations

To develop this guideline update, an Expert Panel reviewed the relevant literature published between January 2001 and July 2015. This included a meta-analysis of 22 clinical trials published in 2014, which provides evidence that postmastectomy radiotherapy is highly effective at preventing local breast cancer recurrence.

Key recommendations of the guideline update follow:

  • The decision to use postmastectomy radiotherapy should involve providers from all treating disciplines as well as the patient. Doctors and patients should discuss the risks and benefits to determine the best treatment approach for the patient.
  • For women with T1-2 breast cancer and 1 to 3 positive lymph nodes, postmastectomy radiotherapy reduces the risk of recurrence and breast cancer death. However, for some patients with a low risk of recurrence, the potential complications of postmastectomy radiotherapy may outweigh the benefit.
  • When making decisions on recommending postmastectomy radiotherapy, doctors should consider patient and tumor characteristics that may diminish the benefit of postmastectomy radiotherapy or increase the risk of complications.
  • Patients with T1-2 tumors with a positive sentinel node biopsy who elect to omit axillary lymph node dissection should receive postmastectomy radiotherapy only if there is already sufficient information to justify its use without needing to know that additional axillary nodes are involved.
  • Patients with axillary nodal involvement that persists following neoadjuvant systemic therapy should receive postmastectomy radiotherapy.
  • Radiation should generally be given to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast when postmastectomy radiotherapy is used for patients with positive axillary lymph nodes.
Monica Morrow, MD, FACS

Monica Morrow, MD, FACS

“This guideline highlights the need to individualize therapy as well as identifies areas where more research is needed,” said Monica Morrow, MD, FACS, the SSO representative on the Expert Panel that developed the guideline update. “It emphasizes that we are moving beyond a simplistic one size fits all approach to more tailored therapy, which will improve benefits for patients.”

The guideline update is available at www.asco.org/pmrt-guideline.

ASCO encourages feedback on its guidelines from oncologists, practitioners, and patients through the ASCO Guidelines Wiki at www.asco.org/guidelineswiki. ■

Disclosure: Dr. Edge reported no potential conflicts of interest. Dr. Recht
has served as a consultant or advisor for CareCore and US Oncology and has received institutional research funding from Genomic Health. Dr. Morrow has received honoraria from Genomic Health. For a full list of disclosures from all authors, visit jco.org.

Reference

1. Recht A, Comen EA, Fine RE, et al: Postmastectomy radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. J Clin Oncol. September 19, 2016 (early release online).



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