T he role of postmastectomy adjuvant radiation in the treatment of operable breast carcinoma remains controversial. Although multiple prospective randomized trials have demonstrated the ability of radiation to decrease the incidence of locoregional recurrence, the absence of a decrease in distant metastases or a significant improvement in survival in the majority of these studies has raised doubts regarding the overall efficacy of the treatment. 1 An additional challenge to postmastectomy radiation has been the development of effective adjuvant chemotherapy or combined chemotherapy and endocrine therapy for the treatment of micrometastatic disease. 2 In axillary lymph node positive patients, some of these regimens [3][4][5][6][7] have also demonstrated a modest decrease in the incidence of locoregional recurrence after mastectomy, whereas others have demonstrated minimal or no benefit. 3,[8][9][10][11] The use of dose-intense regimens with autologous bone marrow support in patients with 10 or more positive axillary lymph nodes has not diminished the risk of a locoregional recurrence in these high risk patients. 12 This finding has prompted the routine use of postmastectomy radiation in patients with 10 or more positive axillary lymph nodes in the two ongoing prospective randomized trials evaluating high dose chemotherapy with autologous bone marrow transplantation. These inconsistent results of the impact of chemotherapy on local control have further confounded the issue of postmastectomy radiation.
Critics of the postmastectomy radiation randomized trials have cited the lack of a consistent randomization process and inadequate stratification, unequal patient distribution among the treatment arms, and inadequate radiation in terms of total dose and/or the regions treated. However, the most important criticism is that these trials have included many low risk patients for whom the benefit of postmastectomy radiation would be minimal in terms of both the prevention of a locoregional recurrence and an improvement in survival.Patients who appear to be at greatest risk for a locoregional recurrence See reply to counterpoint on pages 1067-8 and after mastectomy are those with primary tumors Β’5 cm and/or 4 or referenced original article on pages 1138-49, more positive axillary nodes. 8,13 -19 The incidence of isolated locoregiothis issue.
nal recurrence in these women when they also receive adjuvant chemotherapy is approximately 20 -30%.