Nodal Response to Neoadjuvant Chemotherapy Predicts Receipt of Radiation Therapy after Breast Cancer Diagnosis.


BACKGROUND:Pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) is associated with improved overall survival (OS) in breast-cancer patients, but it is unclear how post-NACT response influences radiotherapy administration in patients presenting with node-positive disease. We sought to determine whether nodal pCR is associated with likelihood of receiving nodal radiation and whether radiotherapy among patients experiencing nodal pCR is associated with improved OS. METHODS:cN1 female breast cancer patients diagnosed 2010-2015 who were ypN0 (i.e., nodal pCR, n=12,341) or ypN1 (i.e., residual disease, n=13,668) post-NACT were identified in the National Cancer Database. Multivariate logistic regression was used to identify factors associated with receiving radiotherapy. Cox proportional hazards modeling was used to estimate the association between radiotherapy and adjusted OS. RESULTS:26,009 patients were included. 43.9% (n=5,423) of ypN0 and 55.3% (n=7,556) of ypN1 patients received nodal radiation. Rates of nodal radiation remained the same over time among ypN0 patients (trend test p=0.29) but increased among ypN1 patients from 49% in 2010 to 59% in 2015 (trend test p<0.001). After adjusting for covariates, nodal pCR (vs no stage change) was associated with decreased likelihood of nodal radiation after mastectomy (∼20% decrease) and lumpectomy (∼30% decrease, both p<0.01). After mastectomy, nodal (vs no) radiation conferred no significant survival benefit in ypN0 patients but approached significance for ypN1 patients (hazard ratio [HR] 0.83, 95% CI 0.69-0.99, p=0.04, overall p-value=0.11). After lumpectomy, nodal radiation was associated with improved adjusted OS for ypN0 (HR 0.38, 95% CI 0.22-0.66) and ypN1 patients (HR 0.44, 95% CI 0.30-0.66, both p<0.001), but this improvement was not significantly greater than that associated with breast-only radiation. CONCLUSIONS:ypN0 patients were less likely to receive nodal radiation than ypN1 patients, suggesting that selective omission already occurs and, in the context of limited survival data, could potentially be appropriate for select patients.





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Publication Info

Fayanju, Oluwadamilola M, Yi Ren, Gita Suneja, Samantha M Thomas, Rachel A Greenup, Jennifer K Plichta, Laura H Rosenberger, Jeremy Force, et al. (2019). Nodal Response to Neoadjuvant Chemotherapy Predicts Receipt of Radiation Therapy after Breast Cancer Diagnosis. International journal of radiation oncology, biology, physics. 10.1016/j.ijrobp.2019.10.039 Retrieved from

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Samantha Thomas

Biostatistician, Principal

Samantha is the manager of the Duke Cancer Institute (DCI) Biostatistics Shared Resource. Collaboratively, she primarily works with physicians in DCI, specifically in research of Endocrine Neoplasia and Breast Cancer. She is also the director of the Biostatistics, Epidemiology, Research, and Design Methods (BERD) Core Training and Internship Program (BCTIP). Her professional experience involves study design, analysis, and reporting of clinical trials and observational studies. Her specific areas of interest include training of collaborative biostatisticians, modeling of non-linear associations, and application of partitioning analyses to identify homogeneous patient groups.


Jennifer K Plichta

Associate Professor of Surgery

Dr. Jennifer Plichta is an Associate Professor of Surgery & Population Health Sciences at Duke University. She serves as the Director of the Breast Risk Assessment Clinic in the Duke Cancer Institute, where she cares for patients with breast cancer, benign breast problems, and those with an increased risk of breast cancer. Her clinical interests include establishing routine breast cancer risk assessment for women and creating personalized management strategies for those found to be “high risk”.


Dr. Plichta’s research focuses of identifying and managing women with risk factors for breast cancer, including those with genetic mutations, such as BRCA, those with abnormal breast biopsies, and those with a family history of breast cancer. She is also studying metastatic breast cancer and how breast cancer staging can be used to improve patient care and education. 


However, her dedication to breast cancer extends beyond her clinical and research interests. She also enjoys educating the community about breast cancer and helping to raise money for breast cancer research and education. She is the creator and primary coordinator of Duke’s free, annual breast education day for the community, “What’s best for breasts?”.


Laura Horst Rosenberger

Associate Professor of Surgery

Dr. Laura Rosenberger is an Associate Professor of Surgery, where she has a high-volume breast surgical oncology practice and enjoys all aspects of an academic career. She has clinical expertise and research interest in rare breast cancers, including sarcomas and a specific focus on phyllodes tumors. Dr. Rosenberger is the founding and coordinating Principal Investigator of multiple, multi-institutional studies, including a funded prospective germline testing study, and an actively accruing rare breast tumor registry with tissue biorepository. She has authored, or co-authored, over 75 peer-reviewed publications, and serves on multiple national committees including a member of the National Comprehensive Cancer Network, or NCCN, Breast Cancer Panel.  


Terry Hyslop

Adjunct Professor in the Department of Biostatistics & Bioinformatics

Eun-Sil Shelley Hwang

Mary and Deryl Hart Distinguished Professor of Surgery, in the School of Medicine

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