title: Cardiovascular death and second non-breast cancer malignancy after postmastectomy radiation and doxorubicin-based chemotherapy.
abstract: OBJECTIVE
  To assess the incidence of long-term toxicity after postmastectomy radiation and doxorubicin-based adjuvant chemotherapy.
  
  
  METHODS
  Records of 470 patients treated with mastectomy, doxorubicin-based chemotherapy, and postmastectomy radiation in five institutional prospective trials were retrospectively reviewed. Actuarial toxicity rates were compared with those of 1031 patients treated with mastectomy and doxorubicin-based chemotherapy who did not receive postmastectomy radiation. For those treated with radiation, the chest wall received a median dose of 55 Gy with Co-60 (42%) or electrons (51%). Adjuvant chemotherapy consisted of a doxorubicin-based regimen, often followed by 2 years of cyclophosphamide, methotrexate, and fluorouracil.
  
  
  RESULTS
  Median follow-up was 10 years. The overall 10-year actuarial rates of RTOG toxicity Grade >1 and >or=3 after radiation were 4% and 2%, respectively. The overall 10- and 15-year actuarial rates of second non-breast cancer malignancy were 3.8% and 7%, respectively. There was no statistical difference between the rates of non-breast cancer second malignancy in the radiated and unirradiated cohorts (3.4% vs. 4.7% 10-year actuarial rates). Increasing age and treatment with >10 cycles of chemotherapy were associated with higher rates of second malignancy (p = 0.025, p = 0.016). The 10-year actuarial rate of death from myocardial infarction (MI) was 2.4% (eight events) and 0.5% (five events) in the radiated and unirradiated groups, respectively (p = 0.058). Of the 8 irradiated patients who died of MI, 2 patients had left-sided breast cancer.
  
  
  CONCLUSIONS
  We found very low rates of serious sequelae after postmastectomy radiation, including death from myocardial infarction and non-breast cancer second malignancy. The rate of second non-breast cancer malignancy was increased among patients treated with >10 cycles of cyclophosphamide-containing chemotherapy.
authors.affiliation: Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
authors.forename: Wendy A
authors.initials: WA
authors.lastname: Woodward
authors.forename: Eric A
authors.initials: EA
authors.lastname: Strom
authors.forename: Marsha D
authors.initials: MD
authors.lastname: McNeese
authors.forename: George H
authors.initials: GH
authors.lastname: Perkins
authors.forename: Eleysia L
authors.initials: EL
authors.lastname: Outlaw
authors.forename: Gabriel N
authors.initials: GN
authors.lastname: Hortobagyi
authors.forename: Aman U
authors.initials: AU
authors.lastname: Buzdar
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy* / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D004317:Doxorubicin / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality*; D016609:Neoplasms, Second Primary / Q000209:etiology*; D011878:Radiotherapy / Q000009:adverse effects; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D013629:Tamoxifen / Q000627:therapeutic use
chemical_list: D013629:Tamoxifen; D004317:Doxorubicin