People who did NOT respond to ACT??

Did Adriamycin, Taxol & Taxotere....then Abraxane & 38 rads.  I'm NED now.

I have been wondering about the role of radiation therapy (RT) for TNBC even if the surgery was a mastectomy.

Judy -- should we start a survey?

A number of restrospective studies seem to suggest that RT may be important:

1. J Clin Oncol. 2011 Jul 20;29(21):2852-8. Epub 2011 Jun 13.

Increased risk of locoregional recurrence for women with T1-2N0 triple-negative

breast cancer treated with modified radical mastectomy without adjuvant radiation

therapy compared with breast-conserving therapy.

Abdulkarim BS, Cuartero J, Hanson J, Deschênes J, Lesniak D, Sabri S.

Cross Cancer Institute and University of Alberta, Edmonton, Alberta, Canada.

bassam.abdulkarim@mcgill.ca

Comment in

    J Clin Oncol. 2011 Jul 20;29(21):2841-3.

PURPOSE: To evaluate the risk of locoregional recurrence (LRR) associated with locoregional treatment of women with primary breast cancer tumors negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (triple-negative breast cancer [TNBC]). 

PATIENTS AND METHODS: Patients diagnosed with TNBC were identified from a cancer  registry in a single institution (n=768). LRR-free survival was estimated using Kaplan-Meier analysis. The Cox proportional hazards regression model was used to  determine risk of LRR on the basis of locoregional management: breast-conserving  therapy (BCT; ie, lumpectomy and adjuvant radiation therapy [RT]) and modified radical mastectomy (MRM) in the TNBC population and T1-2N0 subgroup. 

RESULTS: At a median follow-up of 7.2 years, 77 patients (10%) with TNBC developed LRR. Five-year LRR-free survival was 94%, 85%, and 87% in the BCT, MRM, and MRM + RT groups, respectively (P < .001). In multivariate analysis, MRM (compared with BCT), lymphovascular invasion and lymph node positivity were associated with increased LRR. Conversely, adjuvant chemotherapy was associated with decreased risk of LRR. For patients with T1-2N0 tumors, 5-year LRR-free survival was 96% and 90% in the BCT and MRM groups, respectively (P = .027), and  MRM was the only independent prognostic factor associated with increased LRR compared with BCT (hazard ratio, 2.53; 95% CI, 1.12 to 5.75; P = .0264). 

CONCLUSION: Women with T1-2N0 TNBC treated with MRM without RT have a significant increased risk of LRR compared with those treated with BCT. Prospective studies are warranted to investigate the benefit of adjuvant RT after MRM in TNBC.

PMID: 21670451  [PubMed - indexed for MEDLINE]

2. Am J Clin Oncol. 2011 Jun;34(3):231-7.

Locoregional recurrence in patients with triple-negative breast cancer:

preliminary results of a single institution study.

Dragun AE, Pan J, Rai SN, Kruse B, Jain D.

Department of Radiation Oncology, James Graham Brown Cancer Center, University of

Louisville, Louisville, KY 40202, USA. aedrag01@louisville.edu

PURPOSE: To examine the impact of radiotherapy on breast cancer patients with triple-negative (ER-, PR-, HER2/neu-) disease. 

MATERIALS AND METHODS: A prospectively collected database of 152 triple negative  breast cancer patients was initiated in 2004. A total of 77 patients who had all  phases of their therapy (surgery, chemotherapy, and radiotherapy) at our institution with a minimum of 2-months follow-up are included. Patients with all  types of surgery (lumpectomy or mastectomy), chemotherapy (neoadjuvant or adjuvant), and radiotherapy (tangents only or comprehensive nodal irradiation) are included. Patients received radiotherapy in the setting of breast-conservation and in the postmastectomy setting for ‚â•5 cm primary tumors and/or ‚â•4 positive lymph nodes. Patients were divided into 2 groups for statistical analysis, based on whether they received radiotherapy or not. 

RESULTS: In the cohort, 53 (69%) received radiotherapy, 24 (31%) received no radiotherapy. The median follow-up was 23.2 months (range, 2.0-63.1). In the alive patients, the median follow-up time was 25.6 (range, 2.0-63.1) months. Patients who received radiotherapy were significantly more likely to be of a higher AJCC stage (P < 0.001) than patients who did not receive radiotherapy. Of  the patients who received radiotherapy, 33 (61.1%) did so for breast conservation. For the entire group, 1- and 3-year overall survivals are 90.9% and 86.3%, respectively. The 3-year actuarial locoregional relapse-free survival probability for patients who received radiation was higher than those who did not receive radiation (79.6% vs. 57.9%, P = 0.049). 

CONCLUSIONS: Despite significantly lower AJCC stage, patients with triple-negative breast cancer who do not undergo radiotherapy have a significantly higher risk of locoregional recurrence.

PMID: 20805742  [PubMed - indexed for MEDLINE]

But not universal:

1. Ann Surg Oncol. 2011 Oct;18(10):2858-65. Epub 2011 Mar 26.

The negative effect of triple-negative breast cancer on outcome after

breast-conserving therapy.

Zaky SS, Lund M, May KA, Godette KD, Beitler JJ, Holmes LR, O'Regan RM, Yu ES, Yu

DS, Landry JC.

Department of Radiation Oncology, Emory University Winship Cancer Center,

Atlanta, GA, USA.

PURPOSE: To evaluate disease failure patterns and overall survival (OS) of women  with triple-negative (TN) breast cancer who underwent breast-conserving therapy (BCT) and to understand the relationship of TN tumors with other prognostic factors.

PATIENTS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry identified 562 women diagnosed and/or treated with unilateral invasive breast cancer during 2003-2004 at three Emory hospitals. After medical record review, 193 eligible women, with all tumor types, received BCT. Primary endpoints (local, regional, and distant recurrences) and secondary endpoint (OS) were evaluated using chi-square tests and Cox proportional hazards models.

RESULTS: Of the 193 women, 33 (17.1%) had TN tumors and 160 (82.9%) had non-TN tumors. Patient characteristics were similar between the two tumor types; however, tumor grade and use of chemotherapy and hormones differed between the two groups. Median follow-up was 3.4 years; 22 patients had recurrence (12.2%), and 12 died (6.2%). Patients with TN tumors had higher local (12% versus 4% for non-TN) and distant recurrences (15% versus 4% for non-TN) rates (p = 0.01). On multivariate survival analyses, TN status [hazard ratio (HR) 1.8, 95% confidence  interval (CI) 1.13-2.93] and African American (AA) race (HR 1.9, 95%CI 1.2-3.07)  were independent predictors of inferior OS.

CONCLUSIONS: Patients with TN breast cancer showed significant increases in local and distant metastatic recurrence rates after BCT, and TN status and AA race were independent negative predictors of survival. For the future, identification of these high risk features may bring personalized medicine closer to reality.

PMID: 21442346  [PubMed - in process]

Note in this paper, 30/33 of patients with TNBC had RT.