Use of Adjuvant Radiation Therapy for Breast Cancer: A Misunderstanding

I would like to comment about Dr. Vicente Valero’s response to Dr. Padmini Iyer’s question regarding adjuvant therapy for a postmenopausal woman with stage IIIA breast cancer. Although Dr. Valero’s 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

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 patient’s 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 positive.

PETER WHITCOPF, MD
Department of Radiation OncologyUniversity of Virginia Health Sciences CenterCharlottesville, Virginia

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 radiation therapy.

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 this situation.

VICENTE VALERO, MD
Associate Internist/Associate Professor of MedicineThe University of Texas M.D. Anderson Cancer CenterHouston, Texas