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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
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
Currently No Guidelines for RT
after Neoadjuvant Chemotherapy
Currently No Guidelines for RT
after Neoadjuvant Chemotherapy
Postmastectomy Radiotherapy
(Adjuvant Data)
EBCTG Meta-analysis of
PMRT trials
Absolute Benefits of PMRT (n= 8135)
Impact of Number of Involved Nodes
MDACC Retrospective
MDACC Retrospective
MDACC Retrospective
Regional Nodal Radiotherapy
for 1-3 LN+ (Adjuvant Data)
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
MA.20: 10-year Results (n=1832)
MA.20: 10-year Survival Data
MA.20: Hazard Ratios for OS
MA.20: Adverse Events
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
EORTC 22922: DFS & OS
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:
Importance of IMN coverage:
Danish Experience
Key Patient/Treatment Characteristics (median follow-up 8.9 years)
Predicting Local Regional
Recurrence after Neoadjuvant
Chemotherapy
Can Systemic Therapy Select for
Patients who Don’t Benefit from RT? NSABP Experience
MVA of Predictors for LRR after Mastectomy
(1070 patients, 128 events)
MVA of Predictors for LRR after
Lumpectomy + Breast RT
(1890 patients, 189 events)
10-Year Risk of LRR
Nomagram to Predict 10-Year Risk of LRR
Future
Alliance A11202
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
Thank You!
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