Mastectomy patients with small tumors, fewer lymph nodes involved, benefit from the therapy, cancer experts agree
New guidelines issued by three leading cancer organizations suggest that more breast cancer patients should consider radiation therapy after a mastectomy.
Overall, the guidelines say there’s enough evidence to show radiation treatment after a mastectomy decreases the risk of breast cancer recurrence, and that even women with smaller tumors and three or fewer lymph nodes involved can benefit from the therapy.
“The new guidelines say there is clear evidence that the benefit of [post-mastectomy radiation therapy] extends to women with limited lymph node involvement,” said Dr. Stephen Edge. He is vice president for health care outcomes and policy at Roswell Park Cancer Institute in Buffalo, N.Y. Edge was co-chair of the panel that developed the new guidelines.
One radiation treatment expert welcomed the updated recommendations.
“The guideline is timely,” said Dr. Janna Andrews, an attending physician in radiation medicine at Norwell Health Cancer Institute, in Lake Success, N.Y. “The field of post-mastectomy radiation is changing. It’s always up for discussion now as to who needs [post-mastectomy radiation therapy].”
The new guidelines help clarify what used to be a gray area, Andrews explained. “In the past, if a woman had a small tumor, less than 5 centimeters, and not more than three or four positive lymph nodes, many doctors would say she does not need [post-mastectomy radiation therapy],” she said.
The guidelines don’t offer a single formula for which patients need radiation therapy, Edge noted. But they do focus on the group of women for whom there is the most debate about the value of radiation.
“There is a great deal of controversy about whether women with one, two or three lymph nodes [with cancer] have sufficient risk to warrant radiation,” he said. “For women with four or more lymph nodes involved, everyone would recommend radiation.”
The guidelines also strongly support input from all specialists who treat breast cancer in making the decision about radiation treatment. That typically includes the surgeon, radiation physician and an oncologist.
Doctors need to weigh the risks and benefits, Edge added. Side effects can include redness of the skin, swelling and skin breakdown severe enough to compromise future breast reconstruction, he explained.
Edge said that doctors need to consider patients individually. For instance, he explained, ”a woman 65 who has microscopic involvement in a single lymph node and an estrogen-receptor positive cancer would be very different from a 38-year-old who has three lymph nodes involved and so-called triple-negative breast cancer.” The younger woman, he said, would typically be advised to get radiation.
The older woman, because her risk is lower, should have a discussion with her doctor to decide if the benefit outweighs the risk, Edge noted.
Andrews said that one take-home message for patients is to expect the surgeon to have consulted with the radiation oncologist and others on her team. If a woman’s doctor tells her she does not need radiation after a mastectomy, the woman should be told why and she should ask if the radiation oncologist weighed in on the decision.
Edge was a panel representative from the American Society of Clinical Oncology, which created the guidelines along with the American Society for Radiation Oncology and the Society of Surgical Oncology.
All three groups published the guidelines online this week in their respective journals: theJournal of Clinical Oncology, Practical Radiation Oncology and the Annals of Surgical Oncology.
To learn more about radiation in breast cancer treatment, visit BreastCancer.org.
SOURCES: Stephen Edge, M.D., vice president, healthcare outcomes and policy, Roswell Park Cancer Institute, Buffalo, N.Y.; Janna Andrews, M.D., attending physician, radiation medicine, Northwell Health Cancer Institute, Lake Success, N.Y., and assistant clinical professor, Hofstra-Northwell School of Medicine, Hempstead, N.Y.; Sept. 19, 2016, Journal of Clinical Oncology; Practical Radiation Oncology; Annals of Surgical Oncology, online
Last Updated: Sep 21, 2016
Copyright © 2016 HealthDay. All rights reserved.
The story addresses new guidelines from the American Society of Clinical Oncology, the American Society for Radiation Oncology and the Society of Surgical Oncology, which say that that some breast cancer patients who would have been unlikely to receive radiation therapy in the past may benefit from radiation treatment. Specifically, the guidance (and the story) focuses on cases in which the patient has had a mastectomy, had small tumors, and in which few lymph nodes are involved.
To fully appreciate these new guidelines, patients and healthcare providers need some basic information that they can use to evaluate the costs and benefits of radiation therapy: How much does it reduce risk of cancer recurrence? How much would it cost? How strong is the evidence behind these guidelines? To varying degrees, the story falls short on these fronts.
Breast cancer is the most common cancer among women in the United States. According to the CDC, more than 230,000 women (and more than 2,000 men) were diagnosed with breast cancer in 2013 alone. New recommendations related to breast cancer treatment, particularly when coming from three professional organizations, are significant — if for no other reason than because so many people are likely to be affected.
Cost is not addressed in the story. That’s problematic because, as the American Cancer Society notes, “treating cancer with radiation can cost a lot.” According to an August 2015 paper in the Journal of Oncology Practice, radiation therapy for breast cancer can cost anywhere from $7,300 to $10,300. That’s a lot of money, and worth noting.
Benefits aren’t quantified in the story. In fact, benefits are barely discussed in the story. The story simply notes “the guidelines say there’s enough evidence to show radiation treatment after a mastectomy decreases the risk of breast cancer recurrence.” But how much does it decrease the risk of breast cancer recurrence? If the benefits aren’t clearly defined, it’s virtually impossible to determine if the costs and risks outweigh them. Granted, the decreased risk of recurrence likely varies widely based on the patient and type of cancer (a point the story makes). But the story would have been much stronger if it had tried to offer more detail on benefits for readers.
The story does address the need to “weigh the risks and benefits.” The story notes: “Side effects can include redness of the skin, swelling and skin breakdown severe enough to compromise future breast reconstruction.” Those are important points, and we’re glad the story made them.
We wish the story had also discussed that there can also be more serious health effects from radiation, including the possibility of increased risk of a second cancer. Also, surgical complications may be increased in patients who require radiation therapy.
The story tells readers which three organizations issued the guidelines, but it doesn’t tell readers why. The story refers to “enough evidence” and “clear evidence,” but doesn’t tell researchers what that evidence is or where it comes from. Was there one big study on this subject? Three? Nine? Is the guidance based on observational data? Does it stem from decades of observation? The story doesn’t tell us.
No disease mongering here.
The story cites two experts: One who was involved in crafting the guidelines, and one who was not. More input from independent sources would have made the story stronger, but this is sufficient to merit a Satisfactory rating.
The story essentially compares getting radiation therapy to not getting radiation therapy (but, as noted above, doesn’t really offer much detail on the benefits of radiation therapy).
Depending on the circumstances, patients who receive post-mastectomy radiation may also be treated with chemotherapy, and we wished that had been discussed, too, since the combination can potentially increase health risks.
The story doesn’t address availability. However, since it is referring to an existing form of therapy that is widely used, we’ll rate this as not applicable.
The story does a good job here, explaining that “the new guidelines help clarify what used to be a gray area,” and noting that whether to pursue radiation treatment would still need be to determined on a case-by-case basis by a patient and her (or his) healthcare provider.
Since the story includes input from an independent source, it clearly goes beyond what is found in any release related to the new guidelines.