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Is Radiotherapy Always Necessary After Lumpectomy for Early Breast Cancer?

For older women with good prognoses, the answer could be no.

Patients with localized breast cancer who undergo lumpectomy generally also receive radiotherapy to prevent local recurrence. Because tamoxifen also reduces the incidence of local recurrence, two trials were designed to determine whether radiotherapy confers benefit beyond that of tamoxifen. In both studies, women underwent lumpectomy and were randomized to receive either tamoxifen alone (20 mg daily for 5 years) or tamoxifen plus radiation.

A Canadian study involved 769 women (age, 50 or older) with localized breast cancer (tumor size, 5 cm). The estimated 5-year rate of local relapse was significantly higher with tamoxifen alone than with tamoxifen plus radiation (7.7% vs. 0.6%). No significant differences were seen between groups in rates of distant relapse or overall survival. In an unplanned subgroup analysis of women with favorable characteristics (i.e., age 60 or older, tumor size 1 cm, and estrogen-receptor-positive tumor), local relapse was uncommon in both the tamoxifen-alone and tamoxifen-plus-radiation groups (1.2% vs. 0%).

A U.S. study involved 636 older women (age, 70 or older), nearly all of whom had estrogen-receptor-positive tumors that were 2 cm. As in the Canadian trial, the estimated 5-year rate of local relapse was significantly higher with tamoxifen alone than with tamoxifen plus radiation (4% vs. 1%), but rates of distant relapse and overall survival were the same in both groups.

Comment: Results from both of these studies show that radiation therapy reduces risk for local recurrence of breast cancer after lumpectomy, even in patients who receive adjuvant tamoxifen. However, the absolute benefit is only a few percentage points among older women with favorable prognoses. Thus, editorialists conclude that older women, like the women in these trials, reasonably could forego radiotherapy, as long as they understand the risks and benefits of this approach.

— Allan S. Brett, MD

Published in Journal Watch General Medicine September 24, 2004

Citation(s):

Fyles AW et al. Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med 2004 Sep 2; 351:963-70.

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Hughes KS et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004 Sep 2; 351:971-7.

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Smith IE and Ross GM. Breast radiotherapy after lumpectomy -- No longer always necessary. N Engl J Med 2004 Sep 2; 351:1021-3.

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