History of the randomized evidence on early breast cancer overall survival:

Radiation vs no radiationafter mastectomy

L. Vakaet

2006

The effect of RT on the chance of locoregional recurrence after mastectomy

(node positive patients)

Lancet 2005

Materials and methods (1/2)• Only evidence from randomized clinical

trials (EBCTCG)

• All patients, in both arms, received mastectomy

• Only comparison is RT versus no RT

• First graph endpoint = locoregional recurrence

Materials and methods• All other graphs endpoint = Overall Survival • Overall survival = Death after breast cancer

relapse (breast cancer mortality) + Other deaths (non-breast cancer mortality)

• All evidence (the good and the bad), no selection of only the « good » results (cfr only 5 yrs of tamoxifen!)

• First studies started in the 1950’s! Randomization by envelope.

Overall SurvivalFirst RT vs no RT meta-analysis

Cuzick et al. Ca Tr Rep 1987, 3400 pts

Follow-up after 10 years (1400 pts)

Combined graph

Second RT vs no RT meta-analysis Cuzick JCO 1994; (3362 pts)

Survival with or without RT EBCTCG Lancet 2000 (5240 pts)

Survival with or without RT EBCTCG Lancet 2000 (5240 pts)

EBCTCG Oxford 2000

Jan Van de Steene

Gebski et al. 2006

Quality counts, also in RT (biologically equivalent dose)

Gebski et al. 2006

An early example of treatment of breast cancer by irradiation (1908)

Patient positioning

Isocenter lines and fieldborders

Simulation radiograph

PLUNC isodoses in breast cancer

Treatment techniques overview R&O 2002

EBCTCG Lancet 2005;(9933 pts)

EBCTCG Oxford 2006(6020 node positive pts)

Indications for radiation treatment after mastectomy

• Poorly differentiated tumors

• T3 – T4 lesions

• Node positive patients:– 1 to 3 nodes positive: OS gain of 3% at 20

years (NNT = 33)– 4 or more nodes positive: OS gain of >8% at

20 years (NNT = 12)

• No importance: age and ER status.