I would like to comment about Dr. Vicente Valeros response to
Dr. Padmini Iyers question regarding adjuvant
therapy for a postmenopausal woman with stage IIIA breast cancer.
Although Dr. Valeros response was quite detailed with regard
to chemotherapy, no mention was made about the role of radiation
therapy in patients with advanced breast cancer.
I am a second-year resident in radiation oncology and recently
finished a rotation on our breast cancer service. The patient Dr.
Iyer is treating should be considered for postmastectomy radiation
therapy both on the basis of her large primary tumor and the number
of involved nodes.
Recent studies by groups in Denmark (Overgaard M et al: N Engl J Med
337:949, 1997) and Canada (Ragaz J et al: N Engl J Med 337:956, 1997)
demonstrated not only increased local control with chest wall
irradiation in addition to chemotherapy but also improved survival
for patients with stage II/III breast cancer.
On the basis of these studies, we are now treating many more patients
with postmastectomy radiation therapy. We treat the chest wall and
both the axillary and supraclavicular lymph nodes.
Although this patients prognosis is poor, I think that
radiation therapy should be considered in addition to chemotherapy.
In the Danish study, chemotherapy plus radiation therapy improved
survival and local control regardless of tumor size, grade, or the
number of positive nodes.
In addition, I noticed that no mention was made of the role for
hormonal therapy, as this patient was estrogen-receptor/progesterone-receptor
PETER WHITCOPF, MD
Department of Radiation Oncology
University of Virginia
Health Sciences Center
Dr. Valero Responds:
My answer to the Oncology Rounds question dealt solely with answering
the question posed by Dr. Iyer about adjuvant therapy for a
59-year-old patient with stage IIIA breast cancer. Although I was
asked to discuss only the role of additional adjuvant chemotherapy,
including high-dose chemotherapy, in patients in this situation,
certainly I concur with Drs. Whitcopf and Ko about the role of
It is our standard of care at M.D. Anderson to give chest wall and
peripheral lymphatic irradiation, including axillary,
supraclavicular, and internal mammary lymph nodes, to these patients
at the completion of chemotherapy. It is also our standard of care to
give tamoxifen (Nolvadex), 20 mg daily for 5 years, to patients in
VICENTE VALERO, MD
Associate Professor of Medicine
The University of Texas
M.D. Anderson Cancer Center