Randomized Controlled Trial

. 2015 Jul 23;373(4):307-16.

doi: 10.1056/NEJMoa1415340.

Regional Nodal Irradiation in Early-Stage Breast Cancer

Collaborators, Affiliations

Collaborators

MA.20 Study Investigators:
Nancy Grant, Winkle Kwan, Carson Leong, Susan Balkwill, Don C Wilson, Hannah Carolan, Valeri Goutsouliak, Scott Tyldesley, Peter Lim, Lorna Weir, Christina F Aquino-Parsons, Gillian Campbell, Mira Keyes, Karen Gelmon, Ivo Olivotto, Pauline Truong, Elaine Wai, Hosam Kader, Paul A Blood, Skaria Alexander, Isabelle Roy, Jean-Pierre Guay, Pierre Del Vecchio, Marjory Jolicoeur, Francis Methot, Jose Ayllon, Sophie Lavertu, Marie-Andree Fortin, Pierre Rousseau, Isabelle Germain, Marie Larochelle-Beland, Isabelle Vallieres, Lucie Blondeau, Jacques Laverdiere, Anne Dagnault, Paul-Emile Raymond, Andre Fortin, James Butler, Mohamed A M Akra, Andrew L Cooke, Abdenour Nabid, Rachel Bujold, Olivier Ballivy, Gilles Prevot, Susan Chafe, Diane Severin, Alan Lees, Keith Tankel, Nirmal Mehta, Bassam Abdulkarim, John Oliver Amanie, Tirath Nijjar, Jonathan Greenland, Vasanth R Basrur, Darindra Gopaul, Timothy J Whelan, Ian S Dayes, Barbara Strang, Harold I Reiter, Jonathan Sussman, James R Wright, Sachi M Voruganti, Ian Hodson, William G McMillan, Mark Levine, Olga Vujovic, Michael I Lock, David D'Souza, Francisco Perera, Nancy Read, Edward Yu, Christine Lambert, Marie Duclos, Lorraine Portelance, Marc David, George Shenouda, David Melnychuk, Khalil Sultanem, Janice Giesbrecht, Richard H F Shao, Brian Findlay, Julie Bowen, Randall J Bissett, David Want, Sarwat Shehata, Ida Ackerman, Lawrence Paszat, Veronique Benk, Ewa Szumacher, May Tsao, Jean-Philippe Pignol, Eileen Rakovitch, Jacqueline Spayne, Gregory Czarnota, Anna Maria Wojcicka, Edward L Chow, Kathleen Pritchard, Joanne Meng, Jean-Michel Caudrelier, Laval J Grimard, Catherine Lochrin, Bhavani D Nair, Peter Cross, Dorianne Rheaume, Wladyslawa Cwajna, Robert D H Rutledge, Maureen Nolan, Ali El-Gayed, David P Skarsgard, Andree Lirette, Fernando Rojas, Linda Leblanc, Conrad Falkson, Margaret L Anthes, Peter Craighead, Theresa Trotter, Jack Mackinnon, Siraj Husain, Gregory McKinnon, Katherine Vallis, Lee Manchul, Woodrow A Wells, Anthony Fyles, Fei-Fei Liu, Wilfred Levin, John Cho, Gabrielle Kane, Anne Koch, David McCready, Malcolm Feigan, George Papadatos, Denise Lonergan, Helen Peres, Geoff Delaney, Judith Cox, Guy Bryant, Peter O'Brien, Jane Ludbrook, M Kumar, Boon Chua, David Blakey, Claire Phillips, Michelle Bishop, Sam Guglani, Roslyn Drummond, Maree Sexton, Margot Lehman, Jennifer Harvey, Raghu Gowda, Michael Penniment, Scott Carruthers, Margaret Latham, David Joseph, M Taylor, Nigel Spry, Peter Graham, Verity Ahern, David Parda, James Taylor, Berna Roig, Lorraine Champion, Rashmi Benda, Michael Kasper, Janaki Moni, Yadvindera Bains, Timothy Rearden, Carl Olson, Craig Schultz, Lawrence Berk, Mark Becker, Peter Leider, William Mueller, Julia White, Howard Zaren, R Lee, Vilija Avizonis, Ivy Petersen, Laura Vallow, Winston Tan, Steven Buskirk, Jane Ridings, John Bollinger, Nina Johnson, Alberto Daconceicao, William Casey, Michael Kuettel, Johnny Yap, Naoyuki Saito, David Pruitt, Salam Jafar, Linda Gemer, Dale Lakomy, James Herman, Susan Stinson, Steven Chmura, Lori Pierce, Oscar Streeter, Waylene Wang, Michelle Yao, Julie Soriano, Wingate Clapper, James Jones, James Richardson, Jeffrey Forman, Harry Kim, Tara Washington

Affiliation

¹ From the Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, ON (T.J.W., M.N.L.), Tom Baker Cancer Centre, Calgary, AB (I.A.O., P.C.), BC Cancer Agency-Vancouver Island Centre, Victoria, BC (I.A.O.), Queen's University and NCIC Clinical Trials Group, Kingston, ON (W.R.P., Y.M., J.-A.W.C., B.E.C.), University of Toronto and Sunnybrook Odette Cancer Centre, Toronto (I.A., K.I.P.), Centre Universitaire de Sherbrooke at Fleurimont Hospital, Sherbrooke, QC (A.N.), Université de Montréal, Montreal (P.R.), Laval University and L'Hôtel-Dieu de Québec, Quebec, QC (A.F.), Princess Margaret Hospital, Toronto (L.M., D.R.M.), Cross Cancer Institute, Edmonton, AB (S.C.), Nova Scotia Cancer Centre, Halifax (M.C.N), Northeastern Ontario Regional Cancer Centre, Sudbury (J.B.), and BC Cancer Agency-Vancouver Centre, Vancouver, BC (K.G.) - all in Canada; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia (B.H.C.); Cancer Research UK-Medical Research Council Oxford Institute for Radiation Oncology, Oxford, United Kingdom (K.A.V.); Ohio State University Wexner Medical Center, Columbus (J.R.W.); and the University of Michigan Comprehensive Cancer Center, Ann Arbor (L.J.P.).

PMID: 26200977
PMCID: PMC4556358
DOI: 10.1056/NEJMoa1415340

Randomized Controlled Trial

Regional Nodal Irradiation in Early-Stage Breast Cancer

Timothy J Whelan et al. N Engl J Med. 2015.

. 2015 Jul 23;373(4):307-16.

doi: 10.1056/NEJMoa1415340.

Collaborators

MA.20 Study Investigators:
Nancy Grant, Winkle Kwan, Carson Leong, Susan Balkwill, Don C Wilson, Hannah Carolan, Valeri Goutsouliak, Scott Tyldesley, Peter Lim, Lorna Weir, Christina F Aquino-Parsons, Gillian Campbell, Mira Keyes, Karen Gelmon, Ivo Olivotto, Pauline Truong, Elaine Wai, Hosam Kader, Paul A Blood, Skaria Alexander, Isabelle Roy, Jean-Pierre Guay, Pierre Del Vecchio, Marjory Jolicoeur, Francis Methot, Jose Ayllon, Sophie Lavertu, Marie-Andree Fortin, Pierre Rousseau, Isabelle Germain, Marie Larochelle-Beland, Isabelle Vallieres, Lucie Blondeau, Jacques Laverdiere, Anne Dagnault, Paul-Emile Raymond, Andre Fortin, James Butler, Mohamed A M Akra, Andrew L Cooke, Abdenour Nabid, Rachel Bujold, Olivier Ballivy, Gilles Prevot, Susan Chafe, Diane Severin, Alan Lees, Keith Tankel, Nirmal Mehta, Bassam Abdulkarim, John Oliver Amanie, Tirath Nijjar, Jonathan Greenland, Vasanth R Basrur, Darindra Gopaul, Timothy J Whelan, Ian S Dayes, Barbara Strang, Harold I Reiter, Jonathan Sussman, James R Wright, Sachi M Voruganti, Ian Hodson, William G McMillan, Mark Levine, Olga Vujovic, Michael I Lock, David D'Souza, Francisco Perera, Nancy Read, Edward Yu, Christine Lambert, Marie Duclos, Lorraine Portelance, Marc David, George Shenouda, David Melnychuk, Khalil Sultanem, Janice Giesbrecht, Richard H F Shao, Brian Findlay, Julie Bowen, Randall J Bissett, David Want, Sarwat Shehata, Ida Ackerman, Lawrence Paszat, Veronique Benk, Ewa Szumacher, May Tsao, Jean-Philippe Pignol, Eileen Rakovitch, Jacqueline Spayne, Gregory Czarnota, Anna Maria Wojcicka, Edward L Chow, Kathleen Pritchard, Joanne Meng, Jean-Michel Caudrelier, Laval J Grimard, Catherine Lochrin, Bhavani D Nair, Peter Cross, Dorianne Rheaume, Wladyslawa Cwajna, Robert D H Rutledge, Maureen Nolan, Ali El-Gayed, David P Skarsgard, Andree Lirette, Fernando Rojas, Linda Leblanc, Conrad Falkson, Margaret L Anthes, Peter Craighead, Theresa Trotter, Jack Mackinnon, Siraj Husain, Gregory McKinnon, Katherine Vallis, Lee Manchul, Woodrow A Wells, Anthony Fyles, Fei-Fei Liu, Wilfred Levin, John Cho, Gabrielle Kane, Anne Koch, David McCready, Malcolm Feigan, George Papadatos, Denise Lonergan, Helen Peres, Geoff Delaney, Judith Cox, Guy Bryant, Peter O'Brien, Jane Ludbrook, M Kumar, Boon Chua, David Blakey, Claire Phillips, Michelle Bishop, Sam Guglani, Roslyn Drummond, Maree Sexton, Margot Lehman, Jennifer Harvey, Raghu Gowda, Michael Penniment, Scott Carruthers, Margaret Latham, David Joseph, M Taylor, Nigel Spry, Peter Graham, Verity Ahern, David Parda, James Taylor, Berna Roig, Lorraine Champion, Rashmi Benda, Michael Kasper, Janaki Moni, Yadvindera Bains, Timothy Rearden, Carl Olson, Craig Schultz, Lawrence Berk, Mark Becker, Peter Leider, William Mueller, Julia White, Howard Zaren, R Lee, Vilija Avizonis, Ivy Petersen, Laura Vallow, Winston Tan, Steven Buskirk, Jane Ridings, John Bollinger, Nina Johnson, Alberto Daconceicao, William Casey, Michael Kuettel, Johnny Yap, Naoyuki Saito, David Pruitt, Salam Jafar, Linda Gemer, Dale Lakomy, James Herman, Susan Stinson, Steven Chmura, Lori Pierce, Oscar Streeter, Waylene Wang, Michelle Yao, Julie Soriano, Wingate Clapper, James Jones, James Richardson, Jeffrey Forman, Harry Kim, Tara Washington

Affiliation

¹ From the Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, ON (T.J.W., M.N.L.), Tom Baker Cancer Centre, Calgary, AB (I.A.O., P.C.), BC Cancer Agency-Vancouver Island Centre, Victoria, BC (I.A.O.), Queen's University and NCIC Clinical Trials Group, Kingston, ON (W.R.P., Y.M., J.-A.W.C., B.E.C.), University of Toronto and Sunnybrook Odette Cancer Centre, Toronto (I.A., K.I.P.), Centre Universitaire de Sherbrooke at Fleurimont Hospital, Sherbrooke, QC (A.N.), Université de Montréal, Montreal (P.R.), Laval University and L'Hôtel-Dieu de Québec, Quebec, QC (A.F.), Princess Margaret Hospital, Toronto (L.M., D.R.M.), Cross Cancer Institute, Edmonton, AB (S.C.), Nova Scotia Cancer Centre, Halifax (M.C.N), Northeastern Ontario Regional Cancer Centre, Sudbury (J.B.), and BC Cancer Agency-Vancouver Centre, Vancouver, BC (K.G.) - all in Canada; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia (B.H.C.); Cancer Research UK-Medical Research Council Oxford Institute for Radiation Oncology, Oxford, United Kingdom (K.A.V.); Ohio State University Wexner Medical Center, Columbus (J.R.W.); and the University of Michigan Comprehensive Cancer Center, Ann Arbor (L.J.P.).

PMID: 26200977
PMCID: PMC4556358
DOI: 10.1056/NEJMoa1415340

Abstract

Background: Most women with breast cancer who undergo breast-conserving surgery receive whole-breast irradiation. We examined whether the addition of regional nodal irradiation to whole-breast irradiation improved outcomes.

Methods: We randomly assigned women with node-positive or high-risk node-negative breast cancer who were treated with breast-conserving surgery and adjuvant systemic therapy to undergo either whole-breast irradiation plus regional nodal irradiation (including internal mammary, supraclavicular, and axillary lymph nodes) (nodal-irradiation group) or whole-breast irradiation alone (control group). The primary outcome was overall survival. Secondary outcomes were disease-free survival, isolated locoregional disease-free survival, and distant disease-free survival.

Results: Between March 2000 and February 2007, a total of 1832 women were assigned to the nodal-irradiation group or the control group (916 women in each group). The median follow-up was 9.5 years. At the 10-year follow-up, there was no significant between-group difference in survival, with a rate of 82.8% in the nodal-irradiation group and 81.8% in the control group (hazard ratio, 0.91; 95% confidence interval [CI], 0.72 to 1.13; P=0.38). The rates of disease-free survival were 82.0% in the nodal-irradiation group and 77.0% in the control group (hazard ratio, 0.76; 95% CI, 0.61 to 0.94; P=0.01). Patients in the nodal-irradiation group had higher rates of grade 2 or greater acute pneumonitis (1.2% vs. 0.2%, P=0.01) and lymphedema (8.4% vs. 4.5%, P=0.001).

Conclusions: Among women with node-positive or high-risk node-negative breast cancer, the addition of regional nodal irradiation to whole-breast irradiation did not improve overall survival but reduced the rate of breast-cancer recurrence. (Funded by the Canadian Cancer Society Research Institute and others; MA.20 ClinicalTrials.gov number, NCT00005957.).

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Figures

**Figure 1. 10-Year Kaplan–Meier Estimates of Survival**
Shown are rates of overall survival (Panel A), disease-free survival (Panel B), isolated locoregional disease-free survival (Panel C), and distant disease-free survival (Panel D) among patients who underwent whole-breast irradiation plus regional nodal irradiation (WBI + RNI) and those who underwent whole-breast irradiation alone (WBI, control group).

**Figure 2. Disease-free Survival at 10 Years, According to Subgroup**
Shown are hazard ratios and rates of disease-free survival among patients who underwent whole-breast irradiation plus regional nodal irradiation (WBI+RNI) and those who underwent whole-breast irradiation alone (WBI, control group). The dashed vertical line at 0.76 in dicates the overall hazard ratio estimate. Hazard ratios are shown on a logarithmic scale. DFS denotes disease-free survival, ER estrogen receptor, and PR progesterone receptor.

See this image and copyright information in PMC

Comment in

Nodal Irradiation after Breast-Cancer Surgery in the Era of Effective Adjuvant Therapy.
Burstein HJ, Morrow M. Burstein HJ, et al. N Engl J Med. 2015 Jul 23;373(4):379-81. doi: 10.1056/NEJMe1503608. N Engl J Med. 2015. PMID: 26200984 No abstract available.
Extra radiation to lymph nodes reduces breast cancer recurrence, studies show.
Mayor S. Mayor S. BMJ. 2015 Jul 22;351:h4012. doi: 10.1136/bmj.h4012. BMJ. 2015. PMID: 26206999 No abstract available.
Breast cancer: rational use of regional nodal irradiation needed.
Killock D. Killock D. Nat Rev Clin Oncol. 2015 Sep;12(9):501. doi: 10.1038/nrclinonc.2015.136. Epub 2015 Aug 4. Nat Rev Clin Oncol. 2015. PMID: 26241938 No abstract available.
[Regional nodal irradiation in early-stage breast cancer with 0-3 positive nodes].
Krug D. Krug D. Strahlenther Onkol. 2015 Nov;191(11):889-91. doi: 10.1007/s00066-015-0897-0. Strahlenther Onkol. 2015. PMID: 26374451 German. No abstract available.
Regional Nodal Irradiation in Early-Stage Breast Cancer.
Whelan TJ, Olivotto IA, Levine MN. Whelan TJ, et al. N Engl J Med. 2015 Nov 5;373(19):1878-9. doi: 10.1056/NEJMc1510505. N Engl J Med. 2015. PMID: 26535517 No abstract available.
Regional Nodal Irradiation in Early-Stage Breast Cancer.
Hindié E, Groheux D. Hindié E, et al. N Engl J Med. 2015 Nov 5;373(19):1877-8. doi: 10.1056/NEJMc1510505. N Engl J Med. 2015. PMID: 26535518 No abstract available.
Proton Therapy for Breast Cancer: Getting to the Heart of the Matter.
MacDonald SM. MacDonald SM. Int J Radiat Oncol Biol Phys. 2016 May 1;95(1):46-48. doi: 10.1016/j.ijrobp.2015.11.035. Int J Radiat Oncol Biol Phys. 2016. PMID: 27084624 No abstract available.

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Regional Nodal Irradiation in Early-Stage Breast Cancer

Collaborators

Affiliation

Regional Nodal Irradiation in Early-Stage Breast Cancer

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