title: Supraclavicular radiation for breast cancer does not increase the 10-year risk of stroke.
abstract: BACKGROUND
  Modern radiation techniques, which limit the radiation dose to the heart during treatment for breast cancer, have greatly reduced the risk of radiation-induced cardiac injury. However, the risk of radiation damage to the carotid artery, which is often incidentally included in the supraclavicular radiation field for breast cancer treatment, is not routinely examined, and the technique used to treat this field has not changed significantly from early radiation trials. The purpose of the current study was to compare the incidence of hospitalization for stroke among women with breast cancer treated with supraclavicular radiation with those who received radiation therapy to the breast but not the supraclavicular fossa.
  
  
  METHODS
  Data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for 5752 women who were diagnosed with American Joint Committee on Cancer (AJCC) Stage I-III nonmetastatic breast cancer between 1988 and 1997 were analyzed. Women included were age > or = 66 years, had known lymph node (LN) status, had tumors measuring < or = 5 cm, underwent breast surgery, and received adjuvant radiation therapy (with or without supraclavicular irradiation). Patients with < 5 years of follow-up were excluded because events in the first 5 years after radiation were unlikely to be radiation induced. A Cox proportional hazards model was used to compare patients with 0 positive LNs (surrogate group for no supraclavicular radiation, n = 5281) with patients with > 4 positive LNs (surrogate for supraclavicular radiation group, n = 471) for the endpoint of hospitalization for stroke. Time-to-event curves were calculated using the conditional Kaplan-Meier method.
  
  
  RESULTS
  The median follow-up for the 0 and 4+ LN cohorts were 92 months and 90 months, respectively (minimum of 60 months). The 10-year and 15-year actuarial freedom from hospitalization for stroke was 91% (0 LN) versus 89.5% (4+ LN) and 79% (0 LN) versus 81.6% (4+ LN), respectively (P = .28). Estrogen receptor status was balanced between the 2 cohorts. As expected, the 4+ cohort had more advanced tumors, higher stage, larger tumor size, and higher grade (P < .0001). In multivariate analysis including LN group, year of diagnosis, age, race, type of surgery, stage, tumor size, grade, estrogen receptor status, and Charlson comorbidity score, only increased age (hazard ratio [HR] for ages 70-74 years, 1.6; HR for ages 75-79 years, 2.1; and HR for age 80 + years, 2.7) and increasing comorbidity score were predictive of an increased risk of hospitalization for stroke.
  
  
  CONCLUSIONS
  Although patients with nonbreast malignancies treated with higher doses to the carotid arteries have been shown to have an increased risk of carotid injury, no evidence was found that radiation to the carotid delivered during supraclavicular irradiation for breast cancer increases the risk of hospitalization for stroke.
authors.affiliation: Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA. wwoodward@mdanderson.org
authors.forename: Wendy A
authors.initials: WA
authors.lastname: Woodward
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Duan
authors.forename: Gabriel N
authors.initials: GN
authors.lastname: Hortobagyi
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001940:Breast / Q000528:radiation effects; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D002339:Carotid Arteries / Q000528:radiation effects*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D009367:Neoplasm Staging; D016017:Odds Ratio; D016016:Proportional Hazards Models; D011832:Radiation Injuries / Q000453:epidemiology*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D011960:Receptors, Estrogen / Q000032:analysis; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology*; D013997:Time Factors
chemical_list: D011960:Receptors, Estrogen