Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials

Early Breast Cancer Trialists' Collaborative Group

Tomado de The Lancet, Early Online Publication, 

Summary

Background

Postmastectomy radiotherapy was shown in previous meta-analyses to reduce the risks of both recurrence and breast cancer mortality in all women with node-positive disease considered together. However, the benefit in women with only one to three positive lymph nodes is uncertain. We aimed to assess the effect of radiotherapy in these women after mastectomy and axillary dissection.

Methods

We did a meta-analysis of individual data for 8135 women randomly assigned to treatment groups during 1964—86 in 22 trials of radiotherapy to the chest wall and regional lymph nodes after mastectomy and axillary surgery versus the same surgery but no radiotherapy. Follow-up lasted 10 years for recurrence and to Jan 1, 2009, for mortality. Analyses were stratified by trial, individual follow-up year, age at entry, and pathological nodal status.

Findings

3786 women had axillary dissection to at least level II and had zero, one to three, or four or more positive nodes. All were in trials in which radiotherapy included the chest wall, supraclavicular or axillary fossa (or both), and internal mammary chain. For 700 women with axillary dissection and no positive nodes, radiotherapy had no significant effect on locoregional recurrence (two-sided significance level [2p]>0·1), overall recurrence (rate ratio [RR], irradiated vs not, 1·06, 95% CI 0·76—1·48, 2p>0·1), or breast cancer mortality (RR 1·18, 95% CI 0·89—1·55, 2p>0·1). For 1314 women with axillary dissection and one to three positive nodes, radiotherapy reduced locoregional recurrence (2p<0 0="" 1133="" 1314="" 1772="" 2p="0·04).</div" 95="" again="" and="" axillary="" both="" breast="" cancer="" ci="" cyclophosphamide="" dissection="" fluorouracil="" for="" four="" given="" groups="" in="" locoregional="" methotrexate="" more="" mortality="" nodes="" of="" or="" overall="" p="" positive="" radiotherapy="" recurrence="" reduced="" systemic="" tamoxifen="" them="" therapy="" these="" trial="" trials="" was="" were="" which="" with="" women="">

Interpretation

After mastectomy and axillary dissection, radiotherapy reduced both recurrence and breast cancer mortality in the women with one to three positive lymph nodes in these trials even when systemic therapy was given. For today's women, who in many countries are at lower risk of recurrence, absolute gains might be smaller but proportional gains might be larger because of more effective radiotherapy.

Funding

Cancer Research UK, British Heart Foundation, UK Medical Research Council.

ONCOURG®: GUÍA PRÁCTICA DE ACTUACIÓN EN URGENCIAS ONCOLÓGICAS PARA ESPECIALISTAS INTERNOS RESIDENTES Y MÉDICOS DE ATENCIÓN PRIMARIA

El Dr. Muñoz Carmona edita una guía de Urgencias para tratar casos de cáncer

El manual de Oncología ofrece las claves para mejorar la asistencia a enfermos que sufren tumores y está dirigido a los médicos de Atención Primaria y a los MIR

 Un manual claro y conciso dirigido a médicos de familia y residentes para tratar a los enfermos con cáncer que acuden a Urgencias por problemas relacionados con esta grave enfermedad o causados por tratamientos agresivos como la quimioterapia o la radioterapia. Ésta es la meta que el doctor sevillano David Muñoz, especialista en Oncología Radioterápica, ha plasmado en Manual de Urgencias para Especialistas Internos Residentes y Médicos Internos Residentes de Oncología.

"La atención al paciente oncológico en Urgencias por médicos no especialistas en Oncología hace que a menudo sea compleja", comenta el doctor Muñoz, que trabaja en el Hospital Juan Ramón Jiménez (Huelva). Los enfermos con cáncer requieren una atención integral, de modo que es necesario que el profesional que los atiende en Urgencias conozca el manejo de fármacos y diagnósticos.

Se estima que el 10% de los pacientes que acuden a Urgencias son enfermos de cáncer. Los tumores de pulmón, mama y colon son los que llevan a estos enfermos hasta Urgencias, con mayor frecuencia. El gran desconocimiento de la patología oncológica en Urgencias hace que el índice de ingresos aumente de manera significativa en el hospital incrementando así los costes sanitarios. De modo que "resulta fundamental el conocimiento de las urgencias oncológicas por los médicos que van a atender a estos pacientes de manera urgente", añade el especialista. Mediante el nuevo manual médico, "pretendemos actualizar para los profesionales el manejo del dolor, ya que nuestros pacientes utilizan fármacos considerados tabú por la población general y, a veces, por médicos con desconocimiento en su uso".

Del mismo modo, esta guía para médicos de familia y residentes aborda los problemas neurológicos y neuropsiquiátricos que presentan estos enfermos, y los síntomas cardiorrespiratorios, digestivos, metabólicos, etcétera que se producen en el contexto de la enfermedad, tanto por la evolución de la misma como la producida por la alta toxicidad que a veces genera la quimioterapia o la radioterapia.

El dolor, que precisa un ajuste de analgésicos, problemas respiratorios como infecciones o neumonías y las alteraciones causadas por efectos secundarios de tratamientos agresivos son los problemas más habituales que llevan a los enfermos con cáncer hasta Urgencias. La supervivencia del paciente diagnosticado de cáncer a los cinco años ronda el 57% para los hombres y el 44% de las mujeres. "Esto no hace más que resaltar la importancia de la actualización de los conocimientos en la asistencia a estos enfermos en la Atención Primaria y la medicina de Urgencias", concluye.

Palliative Radiotherapy Trials for Bone Metastases: A Systematic Review

Foto David Muñoz Carmona©
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Purpose The objective is to update previous meta-analyses with a systematic review of randomized palliative radiotherapy (RT) trials comparing single fractions (SFs) versus multiple fractions (MFs). Methods The analysis includes all published reports from randomized trials comparing SF or MF schedules for the treatment of painful bone metastases with localized RT. A systematic review was performed using the random-effects model with Review Manager version 4.1 (Cochrane Collab- oration, Oxford, UK). The odds ratio and 95% CI were calculated for each trial and presented in a forest plot. Results A total of 16 randomized trials from 1986 onward were identified. For intention-to-treat patients, the overall response (OR) rates for pain were similar for SF at 1,468 (58%) of 2,513 patients and MF RT at 1,466 (59%) of 2,487 patients. The complete response (CR) rates for pain were 23% (545 of 2,375 patients) for SF and 24% (558 of 2,351 patients) for MF RT. No significant differences were found in response rates. Trends showing an increased risk for SF RT arm patients in terms of pathological fractures and spinal cord compressions were observed, but neither were statistically significant (P 􏰀 .75 and P 􏰀 .13, respectively). The likelihood of re-treatment was 2.5-fold higher (95% CI, 1.76 to 3.56) in SF RT arm patients (P 􏰁 .00001). Repeated analysis of these end points, excluding dropout patients, did not alter the conclusions. Generally, no significant differences with respect to acute toxicities were observed between the arms. Conclusion No significant differences in the arms were observed for overall and CR rates in both intention-to-treat and assessable patients. However, a significantly higher re-treatment rate with SFs was evident. J Clin Oncol 25:1423-1436. © 2007 by American Society of Clinical Oncology