new england

journal of medicine
The

established in 1812

July 23, 2015

vol. 373 no. 4

Regional Nodal Irradiation in Early-Stage Breast Cancer

TimothyJ. Whelan, B.M., B.Ch., IvoA. Olivotto, M.D., WendyR. Parulekar, M.D., Ida Ackerman, M.D.,
BoonH. Chua, M.B., B.S., Ph.D., Abdenour Nabid, M.D., KatherineA. Vallis, M.B., B.S., Ph.D., JuliaR. White, M.D.,
Pierre Rousseau, M.D., Andre Fortin, M.D., LoriJ. Pierce, M.D., Lee Manchul, M.D., Susan Chafe, M.D.,
MaureenC. Nolan, M.D., Peter Craighead, M.D., Julie Bowen, M.D., DavidR. McCready, M.D.,
KathleenI. Pritchard, M.D., Karen Gelmon, M.D., Yvonne Murray, B.Sc., JudyAnneW. Chapman, Ph.D.,
BingshuE. Chen, Ph.D., and MarkN. Levine, M.D., for the MA.20 Study Investigators*

a bs t r ac t
BACKGROUND

Most women with breast cancer who undergo breast-conserving surgery receive wholebreast 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) (nodalirradiation 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.

The authors affiliations are listed in the

Appendix. Address reprint requests to Dr.
Whelan at the Juravinski Cancer Centre at
Hamilton Health Sciences, 699 Concession St., Rm. 4-204, Hamilton, ON L8V 5C2,
Canada, or at t [email protected].
*A list of the MA.20 study investigators is
provided in the Supplementary Appendix, available at NEJM.org.
N Engl J Med 2015;373:307-16.
DOI: 10.1056/NEJMoa1415340
Copyright 2015 Massachusetts Medical Society.

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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307

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any women with early-stage

breast cancer undergo breast-conserving
surgery followed by whole-breast irradiation, which reduces the rate of local recurrence.1-3 Radiotherapy to the chest wall and regional lymph nodes, termed regional nodal
irradiation, which is commonly used after mastectomy in women with node-positive breast cancer who are treated with adjuvant systemic therapy, reduces locoregional and distant recurrence
and improves overall survival.4-6 An unanswered
question is whether the addition of regional nodal
irradiation to whole-breast irradiation after breastconserving surgery has the same effect. Wholebreast irradiation may involve irradiation of the
lower axillary and internal mammary lymph
nodes.7 However, regional nodal irradiation increases the complexity of radiotherapy and may
increase the risks of pneumonitis, lymphedema,
cardiac disease, and late secondary neoplasms.
In the NCIC Clinical Trials Group MA.20 trial,
we compared whole-breast irradiation plus regional nodal irradiation with whole-breast irradiation alone in women with early-stage breast
cancer who were treated with breast-conserving
surgery and adjuvant systemic therapy.

Me thods
Patients

Eligible patients were women with invasive carcinoma of the breast who were treated with breastconserving surgery and sentinel-lymph-node biopsy or axillary-node dissection and who had positive
axillary lymph nodes or negative axillary nodes
with high-risk features. Such features were defined as a primary tumor measuring 5 cm or
more or 2 cm or more with fewer than 10 axillary
nodes removed and at least one of the following:
grade 3 histologic categorization, estrogen-receptor (ER) negativity, or lymphovascular invasion.
A level I or II axillary dissection was required for
patients with positive results on sentinel-node biopsy. All patients received adjuvant systemic therapy with chemotherapy, endocrine therapy, or both.
Patients were excluded if they had T4 tumors
(clinical evidence of direct extension to chest wall
or skin) or N23 nodes (involvement of axillary
nodes that are fixed or of internal mammary
nodes), distant metastasis, or serious nonmalignant disease (e.g., cardiovascular or pulmonary)

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that would preclude definitive radiation therapy.

Other exclusion criteria are provided in the Supplementary Appendix, available with the full text
of this article at NEJM.org.
Potentially eligible patients underwent chest
radiography and liver-function testing. A bone
scan and abdominal ultrasonography or computed
tomography (CT) were performed if abnormal results were identified. Written informed consent
was obtained from patients before randomization.
The study protocol was approved by the institutional review board at each participating center
and is available at NEJM.org.
Randomization and Treatment Regimens

Before randomization, patients were stratified according to the number of axillary nodes that were
removed (<10 or 10), the number of positive axillary nodes (0, 1 to 3, or >3), the type of chemotherapy (anthracycline-containing, other, or none),
hormonal therapy (yes or no), and treatment center. With the use of a centralized minimization
procedure, the NCIC Clinical Trials Group office
in Kingston, Ontario, randomly assigned patients
to undergo either whole-breast irradiation plus
regional nodal irradiation (nodal-irradiation group)
or whole-breast irradiation alone (control group).8
For patients in the control group who were
assigned to undergo whole-breast irradiation
alone, the breast was treated with a pair of opposed fields tangentially arranged across the
chest. A dose of 50 Gy in 25 fractions was prescribed. Other radiotherapy planning details are
provided in the Supplementary Appendix.
For patients in the nodal-irradiation group,
the intention was to treat the breast at risk and
the ipsilateral internal mammary lymph nodes in
the upper three intercostal spaces, along with
the supraclavicular and axillary lymph nodes. Two
techniques for irradiation of the internal mammary lymph nodes were permitted: a modified
wide-tangent technique and a technique involving
a separate internal-mammary-node field plus tangents. For the modified wide-tangent technique,
the upper tangent fields were widened to include
the internal mammary nodes and narrowed inferiorly to reduce the dose to the underlying lung
and heart. For the technique involving a separate
internal-mammary-node field, a mixed electron
and photon field was angled to match the tangent
fields. CT planning was recommended, with the

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Nodal Irr adiation in Early-Stage Breast Cancer

internal mammary node volume defined as 1 cm

around internal mammary vessels in the first three
intercostal spaces to be covered by at least the 80%
isodose. Wedges, compensators, or intensity-modulated radiation therapy were permitted to ensure
a uniform dose throughout the target volume.
Dose correction for the different densities of tissues irradiated (e.g., lung) was permissible.
The supraclavicular and level III axillary nodes
were treated with a nondivergent anterior field to
include the head of the clavicle medially and the
coracoid process laterally. The inferior border was
matched to the superior field of the breast tangents, and the superior border included the supraclavicular fossa. For patients who had fewer than
10 axillary nodes removed or more than 3 positive axillary nodes, the lateral aspect of the field
was extended laterally to include the level I and II
axillary lymph nodes, and it was recommended
that a nondivergent posterior field should match
the anterior field or that a smaller patch field be
used to cover the axilla. Patients were treated with
4 to 18 MV in the supine position with the arm
abducted.
The dose to the breast and internal mammary
node fields was 50 Gy in 25 fractions. The dose
to the anterior supraclavicular and axillary field
was 50 Gy in 25 fractions prescribed at a depth
of 3 cm. For patients who were treated with anterior and posterior fields, a dose of 45 Gy in 25
fractions was prescribed at midseparation at the
center of the fields. Treatment beam images were
obtained to confirm adequate coverage. Boost radiation of 10 to 16 Gy in 5 to 8 fractions to the
tumor bed with the use of external-beam radiation or brachytherapy was permitted in the two
study groups according to the institutions policy
(e.g., for close margins of excision or a young age).
We used a quality-assurance program that included a review of radiation plans before treatment
for the first 25 patients who underwent randomization at each participating center and after treatment for all other patients. (Details are provided
in the Supplementary Appendix.)
Adjuvant chemotherapy according to institutional practice was delivered before radiation.
Endocrine therapy with tamoxifen or an aromatase inhibitor was administered either concurrently with or after radiotherapy. After June 2005,
trastuzumab was recommended for patients
with human epidermal growth factor receptor
2 (HER2)positive disease.

Follow-up and Outcomes

Patients were followed according to a prescribed

schedule (see the Supplementary Appendix). Adverse events were assessed with the use of the
National Cancer Institute Common Toxicity Criteria, version 2. Data with respect to quality of
life, which was assessed with the use of the
European Organization for Research and Treatment of Cancer Quality of Life Questionnaire
(EORTC QLQ-C30) and cosmetic and arm-function modules that were developed for the trial,
are not included in this report.
The primary outcome was overall survival,
which was defined as the time from randomization to death from any cause. Prespecified secondary outcomes were disease-free survival, isolated locoregional disease-free survival, distant
disease-free survival, and toxicity. Disease-free
survival was defined as the time from randomization to the time of a first recurrence in the
ipsilateral breast or in nodal or distant sites, a
contralateral breast cancer, or death from breast
cancer. Isolated locoregional disease-free survival
was defined as the time from randomization to
the time of a first recurrence in the ipsilateral
breast or in axillary, supraclavicular, or internal
mammary nodes without evidence of distant disease for 1 month. Distant disease-free survival was
defined as the time from randomization to the
time of a recurrence at a distant site (e.g., bone,
liver, lung, or central nervous system) or death
from breast cancer.
Statistical Analysis

The study was designed to detect a hazard ratio

of 0.73 for overall survival, which corresponded
to an improvement of 5 percentage points (from
80% to 85%) in 5-year survival. We determined
that 312 deaths among 1832 patients would provide a power of 80% to detect this hazard ratio,
using a two-sided alpha level of 0.05 and assuming a 4-year accrual period with 3 years of follow-up. A planned interim analysis was performed
after the occurrence of 170 deaths and was presented at the 2011 Annual Meeting of the American Society of Clinical Oncology.9
The final analysis was performed in the intention-to-treat population. We used the Kaplan
Meier method to describe the survival experiences
of patients in the two study groups. Details with
respect to data censoring are provided in the Supplementary Appendix. Stratified log-rank tests

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309

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Table 1. Characteristics of the Patients at Baseline.*

WBI
(N=916)

WBI+RNI
(N=916)

Median age (range) yr

53 (2684)

54 (2984)

Patients who underwent initial sentinellymph-node biopsy no. (%)

357 (39.0)

360 (39.3)

Characteristic

No. of axillary nodes removed

Median (interquartile range)

12 (816)

12 (916)

19 no. (%)

303 (33.1)

294 (32.1)

10 no. (%)

612 (66.8)

622 (67.9)

No. of positive axillary nodes no. (%)

0

89 (9.7)

88 (9.6)

447 (48.8)

460 (50.2)

233 (25.4)

209 (22.8)

100 (10.9)

109 (11.9)

>3

47 (5.1)

50 (5.5)

2 cm

501 (54.7)

459 (50.1)

2.15 cm

409 (44.7)

443 (48.4)

6 (0.7)

13 (1.4)

Positive

682 (74.5)

685 (74.8)

Negative

234 (25.5)

231 (25.2)

Positive

549 (59.9)

553 (60.4)

Negative

365 (39.8)

360 (39.3)

Anthracycline without taxane

540 (59.0)

554 (60.5)

Anthracycline with taxane

Tumor size no. (%)

>5 cm
Estrogen-receptor status no. (%)

Progesterone-receptor status no. (%)

Adjuvant chemotherapy no. (%)

244 (26.6)

230 (25.1)

Other

45 (4.9)

47 (5.1)

No chemotherapy

87 (9.5)

85 (9.3)

Aromatase inhibitor

529 (57.8)

521 (56.9)

Tamoxifen

167 (18.2)

172 (18.8)

No endocrine therapy

220 (24.0)

223 (24.3)

Boost irradiation no. (%)

317 (34.6)

294 (32.1)

Adjuvant endocrine therapy no. (%)

* There were no significant differences between the groups at baseline.

Additional details regarding the baseline characteristics of the patients are
provided in Table S1 in the Supplementary Appendix. WBI denotes wholebreast irradiation alone (control group), and WBI+RNI whole-breast irradiation plus regional nodal irradiation.
A total of 35 patients in WBI group and 33 patients in the WBI+RNI group underwent only sentinel-lymph-node biopsy.
Other types of chemotherapy included cyclophosphamide, methotrexate, and
fluorouracil (CMF).
Endocrine therapy was initiated after radiation therapy in some patients.
In these patients, an aromatase inhibitor was used alone or after previous receipt of tamoxifen.
Boost irradiation was delivered after WBI or WBI+RNI.

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that were adjusted for the stratification factors

excluding the study center were used to compare
the study groups. Likelihood ratio tests of treatment according to covariate interactions were used
to examine the heterogeneity of the treatment
effect according to prespecified subgroups of the
four stratification factors, status with respect to
ER positivity and progesterone-receptor (PR) positivity, and tumor location. In a post hoc analysis,
we estimated the rate of death from breast cancer by using the cumulative incidence function
and Grays test for competing risks for the between-group comparison. The corresponding hazard ratio was estimated with the use of the Fine
Gray model. In a similar manner, we conducted
a sensitivity analysis for isolated locoregional and
distant disease-free survival after adjustment for
competing risks.
All patients who underwent irradiation were
included in the safety analysis, according to the
treatment they received. Fishers exact test was
used to compare toxic effects in the two groups.
A P value of less than 0.05 was considered to indicate statistical significance, with no adjustment
for multiple testing. All analyses were conducted
with the use of SAS software, version 9.2 (SAS
Institute).

R e sult s
Between March 2000 and February 2007, a total
of 1832 patients were enrolled, with 916 assigned
to each study group. Among patients in the control group who were assigned to receive wholebreast irradiation, 5 received whole-breast and
regional nodal irradiation and 3 received no radiation. Among patients in the nodal-irradiation
group, 19 received whole-breast irradiation alone
and 9 received no radiation. Thirty-five patients
(1.9%) withdrew consent, and 37 (2.0%) were lost
to follow-up (Fig. S1 in the Supplementary Appendix). The median follow-up at the time of this
analysis was 9.5 years.
The characteristics of the patients at baseline
were similar in the two study groups (Table1).
Most patients (99%) had tumors that were categorized as either T1 (measuring 2 cm) or T2
(measuring >2 cm but 5 cm), had one to three
positive axillary nodes (85%), and had ER-positive disease (75%). Most of the patients received
combination chemotherapy (91%) with an anthracycline (86%) or with a taxane (26%), along with

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Nodal Irr adiation in Early-Stage Breast Cancer

endocrine therapy (76%). A modified wide-tangent

approach was used in 80% of patients in the
nodal-irradiation group.

Table 2. Disease Recurrence or Death.

Event

Mortality

The data for recurrences and deaths are provided

in Table2. There was no significant betweengroup difference in overall survival, with 10-year
rates of survival of 82.8% in the nodal-irradiation group and 81.8% in the control group (hazard ratio for death in the nodal-irradiation group
as compared with the control group, 0.91; 95%
confidence interval [CI], 0.72 to 1.13; P=0.38)
(Fig.1A). In a prespecified subgroup analysis, patients with ER-negative disease in the nodal-irradiation group had a higher 10-year rate of overall
survival than did patients in the control group
(81.3% vs. 73.9%), a difference that approached
statistical significance (hazard ratio, 0.69; 95% CI,
0.47 to 1.00; P=0.05). The test for interaction was
0.08 (Fig. S2 in the Supplementary Appendix).
No significant difference was detected in
breast-cancer mortality, with 10-year rates of
10.3% in the nodal-irradiation group and 12.3%
in the control group (hazard ratio, 0.80; 95% CI,
0.61 to 1.05; P=0.11) (Fig. S3 in the Supplementary Appendix). The causes of nonbreast-cancer
deaths were similar in the two groups (Table2).
Recurrence

The rate of disease-free survival was higher in the

nodal-irradiation group than in the control group,
with 10-year rates of 82.0% and 77.0%, respectively (hazard ratio, 0.76; 95% CI, 0.61 to 0.94;
P=0.01) (Fig.1B). In prespecified subgroup analyses, the treatment effects were greater for patients with ER-negative or PR-negative tumors than
for those with hormone receptorpositive tumors
(Fig.2). There were no major treatment differences according to other factors.
The 10-year rates of isolated locoregional disease-free survival were 95.2% in the nodal-irradiation group and 92.2% in the control group
(hazard ratio, 0.59; 95% CI, 0.39 to 0.88; P=0.009)
(Fig.1C). The treatment effect was associated
mainly with a reduction in the rate of regional
recurrence (Table2). The majority of regional
treatment failures included the axillary nodes (in
63% of patients) or the supraclavicular nodes (in
27%). The rates of distant disease-free survival at
10 years were 86.3% in the nodal-irradiation group
and 82.4% in the control group (hazard ratio,

WBI
(N=916)

WBI+RNI
(N=916)

no. of patients with event (%)

Isolated locoregional recurrence

62 (6.8)

39 (4.3)

Local (in breast) only

38 (4.1)

33 (3.6)

Regional only

23 (2.5)*

Local and regional

Distant recurrence
First or concurrent with locoregional
recurrence
After locoregional recurrence
Any recurrence or contralateral breast cancer
Any recurrence
Contralateral breast cancer

5 (0.5)

1 (0.1)*

1 (0.1)

151 (16.5)

118 (12.9)

118 (12.9)

100 (10.9)

33 (3.6)

18 (2.0)

195 (21.3)

154 (16.8)

175 (19.1)

134 (14.6)

20 (2.2)

20 (2.2)

168 (18.3)

155 (16.9)

Breast cancer

113 (12.3)

93 (10.2)

Other cancer

26 (2.8)

32 (3.5)

Cardiovascular cause

11 (1.2)

11 (1.2)

Other cause

12 (1.3)

8 (0.9)

6 (0.7)

11 (1.2)

Death

Unknown

* Included among regional recurrences were 14 involving axillary nodes, 8 involving supraclavicular nodes, 1 involving infraclavicular nodes, and 1 involving multiple sites. The 10-year cumulative rate of regional recurrence was
2.7%.
Included among regional recurrences were 5 involving axillary nodes and 1 involving multiple sites. The 10-year cumulative rate of regional recurrence was
0.7%.

0.76; 95% CI, 0.60 to 0.97; P=0.03) (Fig.1D). The

improvements in isolated locoregional and distant
disease-free survival in the nodal-irradiation group
were similar when the study groups were compared with the use of competing-risks analyses
(Fig. S4 and S5 in the Supplementary Appendix).
Adverse Events

Table3 summarizes selected potential radiationrelated adverse events of grade 2 or higher. Grade
4 toxic effects were rare, and no grade 5 events
were reported. For acute events (those occurring
3 months after the completion of radiation), significant increases in the rates of radiation dermatitis and pneumonitis were reported in the nodalirradiation group. For delayed events (those
occurring >3 months after the completion of radiation), there were significant increases in the
rates of lymphedema, telangiectasia of the skin,
and subcutaneous fibrosis in the nodal-irradia-

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311

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n e w e ng l a n d j o u r na l

A Overall Survival

of

m e dic i n e

B Disease-free Survival

100

100
WBI+RNI

WBI+RNI
80

WBI

Percentage

Percentage

80
60
40

Hazard ratio, 0.91 (95% CI, 0.721.13)

P=0.38

20
0

WBI

60
40

Hazard ratio, 0.76 (95% CI, 0.610.94)

P=0.01

20
0

10

Years
No. at Risk
879
890

828
841

773
806

602
635

317
331

C Isolated Locoregional Disease-free Survival

10

Hazard ratio, 0.59 (95% CI, 0.390.88)

P=0.009

764
800

710
758

553
592

279
297

WBI+RNI

80

60

20

833
861

100

WBI

40

916
915

D Distant Disease-free Survival

80

Percentage

WBI
WBI+RNI

WBI+RNI

100

WBI

60
40

Hazard ratio, 0.76 (95% CI, 0.600.97)

P=0.03

20
0

10

Years

10

743
781

579
617

304
318

Years

No. at Risk
WBI
WBI+RNI

No. at Risk
916
916

Percentage

WBI
WBI+RNI

Years

No. at Risk
916
915

836
863

769
806

720
764

563
602

288
307

WBI
WBI+RNI

916
916

851
871

793
823

Figure 1. 10-Year KaplanMeier 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).

tion group. No increases in rates of brachial neuropathy, cardiac disease, or secondary cancers
were observed in the nodal-irradiation group, but
the period of follow-up was not sufficiently long
to rule out a difference in the rate of secondary
cancers.

Discussion
In this study, we evaluated the addition of regional nodal irradiation to whole-breast irradiation in patients treated with breast-conserving
surgery and adjuvant systemic therapy. No improvement was detected with respect to the primary outcome of overall survival. Most of the
study patients had no more than three positive
lymph nodes. It is likely that patients with more
312

n engl j med 373;4

than three nodes were routinely treated off trial

with regional nodal irradiation, which would potentially decrease the probability of detecting a
significant effect on overall survival in this trial.10
In addition, since the majority of patients were
treated with contemporary multiagent chemotherapy containing anthracyclines or taxanes and endocrine therapy, the baseline risk of death and
the power to detect a between-group improvement
in overall survival were probably further reduced.
On the other hand, the addition of regional
nodal irradiation to whole-breast irradiation significantly increased relative disease-free survival
by 24%, which was an absolute improvement of
5 percentage points at 10 years. The benefit reflected reductions in both isolated locoregional
and distant recurrences. The relative reduction

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Nodal Irr adiation in Early-Stage Breast Cancer

Subgroup

WBI WBI+RNI
no. of patients

All patients
Positive nodes
0
1
23
>3
Nodes removed
<10
10
ER status
Negative
Positive
PR status
Negative
Positive
Tumor location
Medial
Central
Lateral

WBI WBI+RNI

Hazard Ratio (95% CI)

no. of patients with events

WBI WBI+RNI

P Value for
Interaction

10-yr DFS (%)

916

916

195

154

0.76 (0.610.94)

77.0

82.0

89
447
333
47

88
460
318
50

23
76
80
16

13
68
60
13

0.55 (0.281.09)
0.85 (0.611.18)
0.74 (0.531.04)
0.71 (0.341.48)

72.4
80.9
67.6
60.3

83.7
83.5
74.8
69.8

303
612

294
622

63
132

55
99

0.88 (0.621.27)
0.70 (0.540.90)

74.0
74.2

76.6
81.2

234
682

231
685

78
117

48
106

0.56 (0.390.81)
0.88 (0.681.15)

61.6
78.6

76.2
80.8

365
549

360
553

91
104

55
98

0.57 (0.410.80)
0.91 (0.691.20)

70.5
76.7

81.9
78.5

136
202
578

125
227
564

34
39
122

20
37
97

0.60 (0.351.05)
0.83 (0.531.30)
0.77 (0.591.01)

72.5
78.7
73.0

82.3
82.0
78.4

0.65

0.29

0.04

0.03

0.63

0.25

0.50

WBI+RNI Better

1.0

2.0

4.0

WBI Better

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 indicates 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.

of 40% in the rate of locoregional recurrence that

was associated with regional nodal irradiation
was anticipated on the basis of reported trials of
postmastectomy radiotherapy. The relative reduction of 24% in the rate of distant recurrences
with regional nodal irradiation was probably due
to the reduction in regional nodal recurrence and
possibly to the reduction of subclinical regional
nodal disease.11,12
In patients with breast cancer, distant metastasis typically leads to death. However, we did not
observe an improvement in overall survival at 10
years. In the recent meta-analysis by the Early
Breast Cancer Trialists Collaborative Group of
postmastectomy radiotherapy in node-positive
patients, for every 1.5 recurrences (either locoregional or distant) that were prevented during the
first 10 years after radiation, one breast-cancer
death was prevented at 20 years.13
The observed effects on overall and distant
recurrence are consistent with the results of the
EORTC 22922-10925 trial, in which patients with
node-positive breast cancer or node-negative disease with central or medial tumors were randomly

assigned to undergo regional nodal irradiation

that included the medial supraclavicular and internal mammary nodes or no regional nodal irradiation after breast-conserving surgery or mastectomy.14 At a median follow-up of 10.9 years,
regional nodal irradiation was associated with
improvements in disease-free and distant diseasefree survival. In our study, it is not clear which
sites of nodal irradiation (internal mammary, supraclavicular, level III axillary, or all three) led to
improvements in disease-free survival. All areas
are at risk for residual disease after surgery, but
the EORTC trial suggests that irradiation of the
internal mammary nodes is important.
Although subgroup analyses were prespecified,
they were generally not adequately powered to
assess the benefit of treatment in different subgroups. Furthermore, the P values of the subgroup analyses were not adjusted for multiple
testing.15 Patients with ER-negative or PR-negative
tumors appeared to benefit more from regional
nodal irradiation than those with ER-positive or
PR-positive tumors. Although this effect was not
observed in previous trials of postmastectomy

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313

314
38
19
NA

Skin

Subcutaneous tissue

Second cancer

NA

NA

Grade 4

Grade 2

93 (10.0)

19 (2.0)

40 (4.3)

14 (1.5)

3 (0.3)

17 (1.8)

42 (4.5)

4 (0.4)

372 (40.1)

2 (0.2)

40 (4.3)

169 (18.2)

NA

34

51

21

16

65

397

11

46

154

no. of patients with event (%)

Total

NA

11

10

45

16

Grade 3

NA

Grade 4

WBI+RNI (N=893)

98 (11.0)

37 (4.1)

62 (6.9)

21 (2.4)

4 (0.4)

22 (2.5)

75 (8.4)

8 (0.9)

442 (49.5)

11 (1.2)

53 (5.9)

170 (19.0)

Total

0.54

0.01

0.02

0.23

0.72

0.42

0.001

0.26

<0.001

0.01

0.14

0.67

P Value

of

23

13

Grade 3

WBI (N=927)

n e w e ng l a n d j o u r na l

* Adverse events were graded according to the National Cancer Institute Common Toxicity Criteria, version 2.0. Events were considered to be acute if they occurred within 3 months after the completion of radiation and delayed if they occurred more than 3 months after completion. NA denotes not applicable.
P values were calculated by means of Fishers exact test for the between-group comparison of the proportion of patients with an adverse event of grade 2 or higher.
Listed are events that were attributed to radiation.
Grade 2 events were radiographic changes requiring the use of glucocorticoids or diuretics; grade 3 events were radiographic changes and those requiring the use of oxygen.
Cardiac events included left ventricular failure, cardiac ischemia or infarction, supraventricular arrhythmia, and pericardial effusion.
Grade 2 events were moderate lymphedema requiring compression; grade 3 events were severe lymphedema limiting function.
** Neuropathy includes both sensory and motor events.
One patient was reported to have transient grade 4 motor neuropathy in the ipsilateral arm.
Included in this category are two patients with pulmonary fibrosis in the WBI+RNI group.
Included in this category are late radiation changes such as atrophy or telangiectasia.
Excluded from this category are skin and contralateral breast cancers.

2
12

16

Joint

38

Lymphedema

Neuropathy**

Pneumonitis or fibrosis

349

Cardiac

Delayed

Radiation dermatitis

35

Pneumonitis

156

Pain

Grade 2

Fatigue

Acute

Adverse Event

Table 3. Adverse Events of Grade 2 or Higher.*

The

m e dic i n e

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Nodal Irr adiation in Early-Stage Breast Cancer

radiotherapy,16 it supports the hypothesis that further research on the molecular characterization
of the primary tumor may identify patients who
are more likely to benefit from regional nodal
irradiation.17,18 Since the number of node-negative
patients in our trial was relatively small, the application of our results to node-negative patients
is unclear. In addition, at the time of our study,
the size of nodal metastasis was not routinely
measured, so it is difficult to generalize our findings to patients with micrometastases.
Our study was an international effort involving more than 1800 patients from Canada, the
United States, and Australia. Adherence to treatment was high, and relatively few patients were
lost to follow-up. The trial was conducted with
contemporary CT radiotherapy planning to optimize the quality and safety of treatment and with
a rigorous radiotherapy quality-assurance process,
including pretreatment reviews of radiation plans,
to confirm technical protocol compliance. These
approaches potentially contributed to the limited
radiation-related toxicity that was observed. At a
median follow-up of nearly 10 years, there were
no increases in cardiac morbidity and mortality
or in rates of death from other causes associated
with regional nodal irradiation. We observed a
near doubling (absolute increase, 4 percentage
points) in the rate of lymphedema among patients who were treated with regional nodal irradiation, a finding that was consistent with that
of previous trials of locoregional therapy.4,19 The
rate of acute radiation pneumonitis was also significantly higher in the nodal-irradiation group
(absolute increase, 1 percentage point), although
the condition was uncommon in the two groups.
It remains too early to assess the influence of
the additional radiotherapy on heart disease and
second cancers.
When we designed our trial, there was no plan
to adjust the P value for multiple comparisons of
secondary outcomes in the event that the primary
outcome was not significant. Inferences on the
observed treatment effects for secondary outcomes

in our analysis may be less robust because of the

issue of multiple testing.20
Axillary dissection occurred in 96% of patients
in our trial. Increasingly, sentinel-lymph-node biopsy without axillary dissection is being performed in patients with sentinel-nodepositive
disease on the basis of the results of the American College of Surgeons Oncology Group Z0011
trial.21 In the absence of a randomized trial evaluating the addition of regional nodal irradiation
to whole-breast irradiation in patients with positive results on sentinel-lymph-node biopsy without axillary dissection, we feel that it is reasonable to speculate that the results of our study
may be applicable to such patients, since many
of the cancer-containing axillary nodes are removed. In addition, in the Z0011 trial, the recurrence rates were similar regardless of whether
an axillary dissection was performed.
In conclusion, the addition of regional nodal
irradiation to whole-breast irradiation after breastconserving surgery in women with node-positive
or high-risk node-negative breast cancer did not
improve overall survival but did reduce breastcancer recurrence. Our findings indicate the importance of basing treatment decisions on a careful discussion of the potential benefits and risks
with each patient.
Supported by grants from the Canadian Cancer Society Research Institute to the NCIC Clinical Trials Group (021039 and
015469), the Canadian Breast Cancer Research Initiative
(010415), and the U.S. National Cancer Institute (CA077202,
CA32102, and CA27057) and the Cancer Council of Victoria,
New South Wales, Queensland, and South Australia (288720).
Dr. Whelan is a recipient of a Canada Research Chair.
Dr. Whelan reports receiving fees for serving on an advisory
board from Genomic Health and testing reagents for another
study from NanoString Technologies; and Dr. Pritchard, receiving fees for serving on advisory boards from AstraZeneca, Pfizer,
Roche, Amgen, Novartis, GlaxoSmithKline, and Eisai, consulting fees from Pfizer and Novartis, lecture fees from Novartis,
and grant support from AstraZeneca, Pfizer, Roche, Novartis,
and Eisai. No other potential conflict of interest relevant to this
article was reported.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank the women with breast cancer who participated in
this trial; and acknowledge Dr. Veronique Benk, a coinvestigator
in the trial, who died during the conduct of the study.

Appendix
The authors affiliations are as follows: 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 AgencyVancouver Island Centre, Victoria, BC
(I.A.O.), Queens 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.), Universit de Montral, Montreal (P.R.), Laval University and LHtel-Dieu de Qubec, 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 AgencyVancouver Centre, Vancouver, BC (K.G.) all in

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315

Nodal Irr adiation in Early-Stage Breast Cancer

Canada; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia (B.H.C.); Cancer Research UKMedical 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.).

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