Many mastectomy patients with locally advanced breast cancer do not get postop radiation

Breast cancer patients who undergo a mastectomy should receive subsequent radiation treatment if their cancer has spread to four or more nearby lymph nodes, however, according to a new study, only 65 percent of these women are getting the recommended postmastectomy radiation therapy (PMRT). The researchers looked at nearly 57,000 cases of breast cancer, and their study has been published as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication this spring.

Several studies¹ have found that PMRT reduces the risk of breast cancer recurrence and improves survival in patients whose cancer is "locally advanced" with a pathologic stage of N2 or N3 using the American Joint Committee on Cancer (AJCC) staging system. The AJCC defines N2 cancer primarily as having spread to between four and nine axillary, or underarm, lymph nodes but no other organs, and N3 disease involves 10 or more axillary lymph nodes.2

"My colleagues and I were quite startled by the finding that a third of patients with N2/N3 disease did not receive PMRT, which is the standard of care," said lead author Quyen D. Chu, MD, MBA, FACS, professor of surgery at Louisiana State University (LSU) Health Sciences Center, Shreveport.

Since 2000, the National Cancer Institute and the American Society of Clinical Oncology have recommended PMRT, in addition to chemotherapy, for most breast cancer patients who opt for breast removal and have a high risk of tumor recurrence in the chest area. This risk group includes women with four or more positive (cancerous) lymph nodes.

For this study, the investigators evaluated compliance with the treatment guidelines using the National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society. NCDB captures an estimated 70 percent of newly diagnosed cancer cases in the United States from approximately 1,500 cancer programs accredited by the CoC.

From 2.72 million breast cancer cases diagnosed between 1998 and 2011 and listed in the database, 56,990 files of women with N2 or N3 cancer were found. The researchers evaluated these de-identified files to determine factors linked to receipt of PMRT.

Dr. Chu and colleagues found those patients' socioeconomic characteristics such as race or ethnicity, income or education level, health insurance status, residential location, or comorbidity (coexisting illness) did not influence whether women with N2 or N3 breast cancer received PMRT. Likewise, neither did the geographic region of the treatment facility nor its type of cancer program (community cancer program, larger comprehensive community cancer program, academic cancer research program, or other type). However, most study patients were white, had private insurance, had a high income and educational level, and lived in a large metropolitan area.

According to statistical analyses, only three factors independently predicted a higher likelihood that patients would receive PMRT: receipt of chemotherapy, readmission to the hospital within the first month after breast removal, and being alive 30 days after the operation.