radiotherapy vs. no radiotherapy after breast conserving surgery (bcs) for in-situ breast cancer....

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Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

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Page 1: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Radiotherapy vs.No Radiotherapy

after breast conserving surgery (BCS)

for in-situ breast cancer.Luc Vakaet

Page 2: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Clash of the titans

Bernard Fisher Melvin Silverstein

Page 3: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

EBCTCG: RT vs no RT for DCIS

Study Name Inclusion criteria Entry # pts Prescription Margins clear?

NSABP B-17 Lumpectomy 1985-1990 818 50 Gy to breast No

EORTC 10853 Local Excision; Age < 70

1986-1996 1010 50 Gy to breast No

Swedish DCIS Study

Quadrantectomy 1988 1046 50 Gy to breast No

Stockholm 8 Breast-Conserving Surgery

1990-1999 188 50 Gy to breast No

UK DCIS Trial Screen-Detected; Complete Local

Excision;

1990 1030 50 Gy to breast Yes

Total 4092

EBCTCG Preliminary results. Not for publication or

citation

Page 4: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Results: Isolated local recurrenceRelative risk

event total ev/tot event total ev/tot

NSABP B-17 76 413 18% 138 405 34% 54%

EORTC 10853 72 507 14% 126 503 25% 57%

Swedish BCCG 42 526 8% 114 520 22% 36%

Stockholm 8 13 95 14% 25 93 27% 51%

UK DCIS 29 522 6% 69 508 14% 41%

Totals 232 2063 11% 472 2029 23% 48%

Radiation Control

Page 5: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet
Page 6: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Preliminary results. Not for publication or

citation

EBCTCG Preliminary results. Not for publication or

citation

Page 7: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

EBCTCG Preliminary results. Not for publication or

citation

Page 8: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

EBCTCG Preliminary results. Not for publication

or citation

Page 9: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

RT prevents only clinically unimportant non-invasive recurrences?

Age

At riskLocal

recurrence Percent At riskLocal

recurrence Percent

Non-invasve 403 51 13% 411 30 7%

Invasive 403 53 13% 411 17 4%

Lumpectomy Lumpectomy + RT

NSABP B-17 JCO 1998

Page 10: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Can we select patients that would not or very little benefit from RT

• Does DCIS size matter?= > Only for DCIS > 5 cm

• Does patient age matter?= > Unnecessary for patients older than 70

• Does margin width matter?= > Margins more than 1 cm is OK

• Does differentiation matter?= > Only for patients with Grade 3

Page 11: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Margin width < 1 cm

Silverstein et al. NEJM 1999

What about theVan Nuys Prognostic Index (VNPI)?

Page 12: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Does DCIS size matter?

EBCTCG Preliminary results. Not for publication

or citation

Page 13: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Does age matter?

NSABP B-17 JCO 1998

Age

At riskLocal

recurrence Percent At riskLocal

recurrence Percent

<50 137 36 26% 137 21 15%

50-59 115 33 29% 131 12 9%

>59 151 35 23% 143 14 10%

Lumpectomy Lumpectomy + RT

Page 14: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

UKNZL DCIS Study: Always re-excision when margins are positive

Lancet 2003

Page 15: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

EORTC 10 yrs FU of local recurrence

26%54%

25%37%

13%30%37%

24%43%

18%34%35%

JCO 2006

Page 16: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

JCO 2006

Page 17: Radiotherapy vs. No Radiotherapy after breast conserving surgery (BCS) for in-situ breast cancer. Luc Vakaet

Summary of the scientific evidence

• 10.6 % (p < 0.0001) absolute gain in any recurrence by year 10. 50% relative reduction of the risk of recurrence.

• no difference in breast cancer mortality or any death by year 10.

• The gain in recurrence is statistically significant in any subgroup analysed.

• There are no prospectively verified prognostic indices for local recurrence.

• We cannot (yet) define a subgroup of patients with sufficiently low risk to exclude radiation after BCS.