title: Patterns of Local-Regional Management Following Neoadjuvant Chemotherapy in Breast Cancer: Results From ACOSOG Z1071 (Alliance).
abstract: OBJECTIVE
  American College of Surgeons Oncology Group Z1071 was a prospective trial evaluating the false negative rate of sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) in breast cancer patients with initial node-positive disease. Radiation therapy (RT) decisions were made at the discretion of treating physicians, providing an opportunity to evaluate variability in practice patterns following NAC.
  
  
  METHODS
  Of 756 patients enrolled from July 2009 to June 2011, 685 met all eligibility requirements. Surgical approach, RT, and radiation field design were analyzed based on presenting clinical and pathologic factors.
  
  
  RESULTS
  Of 401 node-positive patients, mastectomy was performed in 148 (36.9%), mastectomy with immediate reconstruction in 107 (26.7%), and breast-conserving surgery (BCS) in 146 patients (36.4%). Of the 284 pathologically node-negative patients, mastectomy was performed in 84 (29.6%), mastectomy with immediate reconstruction in 69 (24.3%), and BCS in 131 patients (46.1%). Bilateral mastectomy rates were higher in women undergoing reconstruction than in those without (66.5% vs 32.2%, respectively, P<.0001). Use of internal mammary RT was low (7.8%-11.2%) and did not differ between surgical approaches. Supraclavicular RT rate ranged from 46.6% to 52.2% and did not differ between surgical approaches but was omitted in 193 or 408 node-positive patients (47.3%). Rate of axillary RT was more frequent in patients who remained node-positive (P=.002). However, 22% of patients who converted to node-negative still received axillary RT. Post-mastectomy RT was more frequently omitted after reconstruction than mastectomy (23.9% vs 12.1%, respectively, P=.002) and was omitted in 19 of 107 patients (17.8%) with residual node-positive disease in the reconstruction group.
  
  
  CONCLUSIONS
  Most clinically node-positive patients treated with NAC undergoing mastectomy receive RT. RT is less common in patients undergoing reconstruction. There is wide variability in RT fields. These practice patterns conflict with expert recommendations and ongoing trial guidelines. There is a significant need for greater uniformity and guidelines regarding RT following NAC.
authors: Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey. Electronic address: hafftybg@cinj.rutgers.edu.
authors: Bruce G
authors: BG
authors: Haffty
authors: Alliance Statistics and Data Center, Duke University, Durham, North Carolina.
authors: Linda M
authors: LM
authors: McCall
authors: Weill Medical College of Cornell University, New York, New York.
authors: Karla V
authors: KV
authors: Ballman
authors: Mayo Clinic, Jacksonville, Florida.
authors: Sarah
authors: S
authors: McLaughlin
authors: University of Michigan, Ann Arbor, Michigan.
authors: Reshma
authors: R
authors: Jagsi
authors: University of North Carolina, Chapel Hill, North Carolina.
authors: David W
authors: DW
authors: Ollila
authors: Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, Texas.
authors: Kelly K
authors: KK
authors: Hunt
authors: MD Anderson Cancer Center, Houston, Texas.
authors: Thomas A
authors: TA
authors: Buchholz
authors: Mayo Clinic, Rochester, Minnesota.
authors: Judy C
authors: JC
authors: Boughey
mesh_terms: D001365:Axilla; D001943:Breast Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D015182:Lymphatic Irradiation / Q000706:statistics & numerical data; D016462:Mammaplasty / Q000706:statistics & numerical data*; D008408:Mastectomy / Q000706:statistics & numerical data*; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D020360:Neoadjuvant Therapy; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011446:Prospective Studies; D021701:Sentinel Lymph Node Biopsy