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. 2025 Jun 30;14(6):1101-1111.
doi: 10.21037/gs-2025-84. Epub 2025 Jun 26.

Postmastectomy radiotherapy indications using pathological prognostic staging in node-positive breast cancer

Juan Zhou #  1 , Lin-Feng Guo #  2 , San-Gang Wu  2 , Zhen-Yu He  3
Affiliations

Postmastectomy radiotherapy indications using pathological prognostic staging in node-positive breast cancer

Juan Zhou et al. Gland Surg. .

Abstract

Background: The role of pathological prognostic staging (PPS) on postmastectomy radiotherapy (PMRT) selection remains unclear. This study aimed to investigate the impact of PPS on PMRT selection in patients with node-positive breast cancer (BC).

Methods: We included women diagnosed with BC between 2010 and 2015 from the Surveillance, Epidemiology, and End Results database. Chi-square test, operating characteristic curve, and competing-risks analyses with the Fine and Gray model were used for statistical analyses.

Results: A total of 14,830 patients were included. Overall, 8,807 (59.4%) patients received PMRT while 6,023 (40.6%) did not. Among them, 11,767 patients (79.3%) had their stage changed, with 1,086 (7.3%) upstaged and 10,681 (72.0%) downstaged. PPS had better prognostic accuracy compared with anatomical staging (AS) (P<0.001). Regarding PPS, PMRT significantly decreased 5-year breast cancer-specific mortality in patients with stage IIIA (14.4% vs. 19.7%, P<0.001), IIIB (19.8% vs. 27.2%, P=0.003), and IIIC (38.5% vs. 45.7%, P=0.049) diseases compared with those of other stages. However, no significant effects were observed in stage IA, IB, IIA, and IIB diseases.

Conclusions: Our study highlights significant staging differences between AS and PPS in patients with node-positive BC. The high rate of downstaging observed with PPS suggests its potential to enhance risk stratification and optimize treatment strategies, especially in guiding the appropriate use of PMRT.

Keywords: Breast cancer (BC); mastectomy; radiotherapy; staging; survival.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-84/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Receiver operating characteristic analyses for comparing the prognostic abilities between the AS and PPS. AS, anatomical staging; AUC, area under the curve; PPS, pathological prognostic staging; ROC, receiver operating characteristic.
Figure 2
Figure 2
The cumulative incidence of breast cancer-specific mortality curves of the anatomical staging (A) and pathological prognostic staging (B) using competing-risks regression.
Figure 3
Figure 3
The effect of PMRT on breast cancer-specific mortality according to the breast cancer subtypes: (A) HoR+/HER2−; (B) HoR+/HER2+; (C) HoR−/HER2+; (D) HoR−/HER2−. HER2, human epidermal growth factor receptor 2; HoR, hormone receptor; PMRT, postmastectomy radiotherapy.
Figure 4
Figure 4
The effect of PMRT on breast cancer-specific mortality according to the anatomical staging. (A) IIA; (B) IIB; (C) IIIA; (D) IIIB; (E) IIIC. PMRT, postmastectomy radiotherapy.
Figure 5
Figure 5
The effect of PMRT on breast cancer-specific mortality according to the pathological prognostic staging. (A) IA; (B) IB; (C) IIA; (D) IIB; (E) IIIA; (F) IIIB; (G) IIIC. PMRT, postmastectomy radiotherapy.
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