title: The incidence of breast cancer following mantle field radiation therapy as a function of dose and technique.
abstract: BACKGROUND
  There is an increased incidence of breast cancer following mantle field radiation therapy for Hodgkin's disease (HD). We reviewed the experience at the Mallinckrodt Institute of Radiology (MIR) for radiation factors related to the development of breast cancer after mantle field radiation therapy for HD.
  
  
  METHODS
  The radiation therapy records of 152 women treated with mantle field irradiation for HD at MIR between 1966-1985 were reviewed for the development of breast cancer and treatment-related factors. All patients had a minimum of 5 years of follow-up. The treatment era (1966-1974 vs. 1975-1985), stage of HD, mediastinal dose, axillary dose, maximum dose from the anterior field (anterior d(max) dose), the anterior-posterior:posterior-anterior (AP:PA) ratio, age at the time of treatment, length of follow-up, and history of splenectomy were analyzed as possible contributing factors for the development of breast cancer. The observed number of breast cancers was compared to the expected number based on age-adjusted incidences from the Connecticut Tumor Registry.
  
  
  RESULTS
  Ten breast cancers occurred in the population. Eight involved an upper outer quadrant. In a multivariate analysis, the development of breast cancer was significantly associated with axillary dose. Patients in the early treatment era were at an increased risk for the development of breast cancer due to high anterior d(max) and breast doses from weighting the fields anteriorly on a low energy linear accelerator. The use of current radiation therapy techniques was not related to an increased risk of breast cancer with a median follow-up of 13 years.
  
  
  CONCLUSIONS
  A high dose to the axilla and the anterior d(max) point is significantly associated with the development of breast cancer after mantle field irradiation for HD. Efforts to protect the breast from high doses will likely lessen the increased risk of breast cancer in women treated with radiation therapy for HD.
authors.affiliation: Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
authors.forename: A
authors.initials: A
authors.lastname: Tinger
authors.forename: T H
authors.initials: TH
authors.lastname: Wasserman
authors.forename: E E
authors.initials: EE
authors.lastname: Klein
authors.forename: E A
authors.initials: EA
authors.lastname: Miller
authors.forename: T
authors.initials: T
authors.lastname: Roberts
authors.forename: J V
authors.initials: JV
authors.lastname: Piephoff
authors.forename: N A
authors.initials: NA
authors.lastname: Kucik
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006689:Hodgkin Disease / Q000532:radiotherapy*; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D015999:Multivariate Analysis; D009381:Neoplasms, Radiation-Induced / Q000453:epidemiology*; D016609:Neoplasms, Second Primary / Q000453:epidemiology*; D011878:Radiotherapy / Q000379:methods; D011879:Radiotherapy Dosage