International expert consensus on radiotherapy of early breast cancer
Authors: R. Arriagada
Journal: Annals of Oncology (2007)

Goldhirsch A. et al. [1.Goldhirsch A. Wood W.C. Gelber R.D. et al.Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007.Ann Oncol. 2007; 18: 1133-1144Abstract Full Text Full Text PDF PubMed Scopus (832) Google Scholar] recently published the highlights of the 10th St Gallen expert consensus on the primary therapy for early breast cancer. I would like to comment on two aspects of the radiotherapy management. Regarding endocrine therapy for premenopausal patients, the authors wrote that ovarian radiation was overwhelmingly rejected. This strong contraindication, however, was not supported in the text by any medical reference. In our experience [2.Arriagada R. Lê M.G. Spielmann M. et al.Randomized trial of adjuvant ovarian suppression in 926 premenopausal patients with early breast cancer treated with adjuvant chemotherapy.Ann Oncol. 2005; 16: 389-396Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar], ovarian irradiation has been equally effective than gonadotropin-releasing hormone analogues, and with certainly a significant lower cost (four sessions of external radiotherapy) when a definitive ovarian suppression is to be reached. It would be good to know if the experts feared haematological toxicity or the induction of second malignancies and whether these hypotheses have indeed a strong scientific support. The second issue is the indication of post-mastectomy radiotherapy. It is finally recommended for patients with four or more positive lymph nodes (N+), and considered doubtful for those with one to three N+. Even without waiting for the publication of the related Early Breast Cancer Trialists' Collaborative Group meta-analysis results, we, however, have evidence that the treatment is also effective and beneficial in the latter group of patients, as recent results of the Danish randomised trials [3.Overgaard M. Nielsen H.N. Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DCBC 82 b&c randomized trials.Radiother Oncol. 2007; 82: 247-253Abstract Full Text Full Text PDF PubMed Scopus (361) Google Scholar] and the Institut Gustave-Roussy breast cancer database [4.Arriagada R. Lê M.G. Number of positive axillary lymph nodes and post-mastectomy radiotherapy effect in breast cancer patients.Radiother Oncol. 2007; 84: 102-103Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] have shown. It is also curious that the panel recommended the irradiation of supraclavicular lymph nodes for positive axilla, but even did not mention the internal mammary chain (IMC) issue. The treatments of these two lymph node areas have been almost always combined in the available randomised evidence. Thus, what are the reasons to separate these volumes in the treatment recommendation? If the IMC irradiation was considered dangerous regarding the cardiac hazards, this should have been mentioned at least in the text. This treatment approach has been recently evaluated by an European Organisation for Research and Treatment of Cancer trial including >4000 patients and long-term results will be available only in several years. I personally feel that these kinds of recommendations apparently not based on sound science could be dangerous, as they are sometimes and in some places followed worldwide without further discussion.