Almost all women get radiation therapy after lumpectomy. Lumpectomy plus radiation has been shown to be as effective as mastectomy without radiation for many women. Radiation isn't routinely given after mastectomy, but some women do benefit from it. Still, the study reviewed here found that some women who would benefit from radiation after mastectomy aren't getting radiation.
Doctors sometimes use "T" to talk about the size of a cancer. T1 and T2 breast cancers are smaller and T3 and T4 cancers are larger. Breast cancers that are T3 or T4 and/or have two or more lymph nodes involved may benefit the most from radiation after mastectomy.
The researchers in this study surveyed 2,260 women diagnosed with breast cancer that hadn't spread to parts of the body away from the breast. Of the 1,627 women who filled out the survey, more than 79% had lumpectomy; 93.3% of these women had radiation after lumpectomy. The other 20% of the women had mastectomy and 60.2% of these women had radiation after mastectomy.
Since radiation therapy isn't given routinely after mastectomy, it seems to make sense that 39.8% of the women who had mastectomy didn't get radiation. To see if any women who didn't get radiation after mastectomy might have benefited from it, the researchers looked at how many women diagnosed with cancer likely to respond to radiation actually got radiation. These cancers were classified as "strong indication for radiation."
The researchers expected that nearly all of the "strong indication for radiation" cancers would have been treated with radiation.
So it seems that some women who could benefit from radiation therapy after mastectomy aren't getting those benefits.
But if the breast cancer surgeon was very involved in treatment planning, radiation was more likely to be given if indicated. Women who said they really didn't want to have radiation were the most likely not to get radiation.
If you've been diagnosed with breast cancer, you and your doctor will consider the specifics of the cancer, your unique situation, your surgical options, and your treatment options after surgery when creating your treatment plan. If you choose lumpectomy, it's very likely that radiation will be recommended after surgery. If you choose mastectomy, you might want to ask your doctor if you would benefit from radiation, especially if the cancer is large or has spread to more than one lymph node.
Using the most complete and accurate information, you and your doctor can develop a treatment plan that makes the most sense for you. You can learn more about radiation after breast cancer surgery in the Breastcancer.org Radiation Therapy section.
Even among breast cancer patients likely to derive a similar clinical benefit from radiation, those who undergo mastectomy are less likely to receive radiation than those who have breast-conserving surgery, researchers found.
In the subgroup of women with strong indications for radiation, 95.4% of those who had breast-conserving surgery received radiation, compared with 77.6% of women who underwent mastectomy (P<0.001), according to Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, and colleagues.
Among patients with weaker indications for radiation, the rate was still significantly higher following breast-conserving surgery (80% versus 47.5%, P<0.001), the researchers reported online in the Journal of Clinical Oncology.
Because radiation yields a similar reduction in the risk of recurrence when appropriately used with the two surgical approaches, the researchers said the findings suggest "that a substantial minority of patients with breast cancer remained undertreated."
Having a surgeon who was very much involved with the patient's decision on radiation more than doubled the likelihood of getting the treatment, regardless of surgery type (OR 2.33, 95% CI 1.80 to 3.02).
Thus, Jagsi and colleagues wrote, "educational efforts targeting both surgeons and medical oncologists may be important in improving rates of radiotherapy receipt in this population, as may be the development of tailored decision aids that encourage communication between patients and providers."
Previous studies have identified underutilization of radiation among patients with breast cancer, the researchers wrote, but they were mostly based on registry data, which could be incomplete.
Jagsi and colleagues surveyed 2,260 women with nonmetastatic breast cancer identified through Surveillance, Epidemiology, and End Results (SEER) registries from Detroit and Los Angeles. The survey results were merged with the SEER data.
The response rate to the survey was 72% among those approached.
Most of the women (79.1%) opted for breast-conserving surgery, with the rest undergoing mastectomy.
The overall rate of receipt (or planned receipt) of adjuvant radiation was higher following breast-conserving surgery (93.3% versus 60.2%).
All women who had breast-conserving surgery were considered to have indications for radiation.
Women who had mastectomy were considered possible candidates for radiation if they had any number of positive lymph nodes or T3 or T4 tumors.
Weak indications for radiation among women undergoing breast-conserving surgery included age above 70 accompanied by stage I disease, as well as estrogen-positive tumors. All other women were deemed to have strong indications for radiation.
For women undergoing mastectomy, weak indications for radiation included T1 or T2 disease with one nodal metastasis only or T3 disease with no positive lymph nodes.
Strong indications included at least two positive lymph nodes with any stage of disease, T4 disease, or T3 disease with one nodal metastasis.
Rates of receipt for adjuvant radiation were consistently lower among women undergoing mastectomy, regardless of the strength of indication, after adjustment for age, comorbidity, geographic site, ethnicity, and education.
About half of the survey respondents reported that their surgeon was very involved in their decision to undergo radiation or not, and these patients were significantly more likely to approve it (86.5% versus 74.7%, P<0.001).
As expected, patient-reported desire to avoid radiation was associated with lower rates of receipt (OR 0.35, 95% CI 0.27 to 0.44).
Jagsi and colleagues acknowledged that the findings might not be generalizable to women living in other geographic areas.
The study was additionally limited, they noted, because patient-reported data may be subject to bias, the sample size might not have enough statistical power to detect more modest differences, and selection bias could have affected the results.
The study was funded by the National Cancer Institute, the American Cancer Society, the California Department of Public Health, and the CDC.
The authors reported no conflicts of interest.
Primary source: Journal of Clinical Oncology Source reference: Jagsi R, et al "Patterns and correlates of adjuvant radiotherapy receipt after lumpectomy and after mastectomy for breast cancer" J Clin Oncol 2010; DOI: 10.1200/JCO.2009.26.8433.
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