title: Breast cancer laterality does not influence survival in a large modern cohort: implications for radiation-related cardiac mortality.
abstract: OBJECTIVE
  Radiation therapy for left-sided breast cancer has been associated with an elevated risk of cardiac mortality, based on studies predating treatment planning based on computed tomography. This study assessed the impact of tumor laterality on overall survival (OS) in a large cohort treated with modern techniques, to indirectly determine whether left-sided treatment remains associated with increased cardiac mortality.
  
  
  METHODS
  Patients treated for breast cancer with breast conserving surgery and adjuvant external beam radiation therapy were identified in the National Cancer Database, and OS was compared based on tumor laterality using Kaplan-Meier analysis. Separate analyses were performed for noninvasive and invasive carcinoma and for breast-only and breast plus regional nodal radiation therapy. Multivariate regression analysis of OS was performed with demographic, pathologic, and treatment variables as covariates to adjust for factors associated with breast cancer-specific survival.
  
  
  RESULTS
  We identified 344,831 patients whose cancer was diagnosed from 1998 to 2006 with a median follow-up time of 6.04 years (range, 0-14.17 years). Clinical, tumor, and treatment characteristics were similar between laterality groups. Regional nodal radiation was used in 14.2% of invasive cancers. No OS difference was noted based on tumor laterality for patients treated with breast-only (hazard ratio [HR] 0.984, P=.132) and breast plus regional nodal radiation therapy (HR 1.001, P=.957). In multivariate analysis including potential confounders, OS was identical between left and right sided cancers (HR 1.002, P=.874). No significant OS difference by laterality was observed when analyses were restricted to patients with at least 10 years of follow-up (n=27,725), both in patients treated with breast-only (HR 0.955, P=.368) and breast plus regional nodal radiation therapy (HR 0.859, P=.155).
  
  
  CONCLUSIONS
  Radiation therapy for left-sided breast cancer does not appear to increase the risk of death in this national database relative to right-sided tumors. Consequently, radiation therapy-induced cardiac disease may be less prominent than previously demonstrated.
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut. Electronic address: charles.rutter@yale.edu.
authors.forename: Charles E
authors.initials: CE
authors.lastname: Rutter
authors.affiliation: Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Anees B
authors.initials: AB
authors.lastname: Chagpar
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Suzanne B
authors.initials: SB
authors.lastname: Evans
mesh_terms: D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000628:therapy; D002423:Cause of Death; D017024:Chemotherapy, Adjuvant; D005260:Female; D006321:Heart / Q000528:radiation effects*; D006801:Humans; D015182:Lymphatic Irradiation; D015412:Mastectomy, Segmental; D008875:Middle Aged; D011832:Radiation Injuries / Q000401:mortality*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects / Q000401:mortality; D012044:Regression Analysis; D016019:Survival Analysis