breast radiation in the era of neoadjuvant chemotherapy · 5/3/2016 · • postmastectomy...
TRANSCRIPT
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Breast Radiation in the Era of
Neoadjuvant Chemotherapy
Breast Cancer Management 2016
Eileen Connolly M.D., Ph.D.
Assistant Professor of Radiation Oncology
May 3rd, 2016
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Learning Objectives
• Postmastectomy Radiotherapy (Adjuvant Data) o Evidence For
o Against
• Regional Nodal Radiotherapy for 1-3 LN+ (Adjuvant Data) o MA.20
o EORTC 22922
o Danish Experience (+/- IMN)
• Predicting Local Regional Recurrence after Neoadjuvant Chemotherapy o NSABP Experience
• Future
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Currently No Guidelines for RT
after Neoadjuvant Chemotherapy
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Currently No Guidelines for RT
after Neoadjuvant Chemotherapy
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Postmastectomy Radiotherapy
(Adjuvant Data)
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EBCTG Meta-analysis of
PMRT trials
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Absolute Benefits of PMRT (n= 8135)
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Impact of Number of Involved Nodes
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MDACC Retrospective
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MDACC Retrospective
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MDACC Retrospective
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Regional Nodal Radiotherapy
for 1-3 LN+ (Adjuvant Data)
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MA.20
• pN+ or high risk node negative
(T2N0 & G3 or ER- or LVSI)
• BCS + ALND + systemic tx
• 85% 1-3 LN+
• 91% chem (86% A or 26% T)
• 76% Endocrine Tx
• RNI = IMNs, SCV, ICV ± axilla
R
a
n
d
o
m
i
z
e
d
2000-2007
N=1,832
Breast only
Breast + RNI
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MA.20: 10-year Results (n=1832)
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MA.20: 10-year Survival Data
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MA.20: Hazard Ratios for OS
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MA.20: Adverse Events
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EORTC 22922
• BCS or MTX + ALND
• Medial/central N± or lateral N+
• BCS = 76%, MTX = 24%
• pN0 = 44%, pN1 43%
• Chemo 25%
• Endocrine Tx 30%
• Chemo + Endocrine Tx 30%
• RNI = IMNs, SCV, ICV ± axilla
R
a
n
d
o
m
i
z
e
d
1996-2004
N=4004
Breast or CW only
Breast or CW + RNI
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EORTC 22922: DFS & OS
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Summary • Adjuvant RT clearly indicated ≥4 LN+
• 1-3 LN+ there is a DFS benefit and reduction in LRR o With modern treatment no increased risk of cardiac toxicity
o ?? Need for IMN treatment
• Why did MA 2.0 and EORTC show OS benefit? o Studies were underpowered:
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Importance of IMN coverage:
Danish Experience
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Key Patient/Treatment Characteristics (median follow-up 8.9 years)
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Predicting Local Regional
Recurrence after Neoadjuvant
Chemotherapy
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Can Systemic Therapy Select for
Patients who Don’t Benefit from RT? NSABP Experience
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MVA of Predictors for LRR after Mastectomy
(1070 patients, 128 events)
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MVA of Predictors for LRR after
Lumpectomy + Breast RT
(1890 patients, 189 events)
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10-Year Risk of LRR
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Nomagram to Predict 10-Year Risk of LRR
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Future
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Alliance A11202
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Conclusions
• Lack of randomized evidence demonstrating benefits of
RT or safety of omission of PMRT in patients after NAC.
• Ongoing NSABP and Alliance trials will address many of
the issues
• Outside of trial recommendations based on patients
highest clinical or pathologic stage o If clinically N+ after NAC adjuvant RT recommended
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Thank You!