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For women with one to three involved nodes or a larger node-negative tumour, radiotherapy to the chest wall after mastectomy did not help them live longer. It roughly halved the small chance of the cancer returning on the chest wall, from one in forty to one in ninety.
SUPREMO is the trial the postmastectomy radiotherapy question needed, because the meta-analysis that established the practice pooled trials run between 1964 and 1986, before modern systemic therapy. It randomised patients with intermediate-risk disease after mastectomy, an axillary procedure and systemic therapy to chest-wall irradiation of 40 to 50 Gy or to none; the intention-to-treat population was 1,607.
At a median 9.6 years, ten-year overall survival was 81.4 percent with irradiation and 81.9 percent without (hazard ratio for death 1.04, 95 percent confidence interval 0.82 to 1.30, p=0.80). Twenty-nine patients had a chest-wall recurrence, nine (1.1 percent) with irradiation and twenty (2.5 percent) without, a hazard ratio of 0.45 (0.20 to 0.99). Disease-free survival was 76.2 against 75.5 percent (hazard ratio 0.97, 0.79 to 1.18) and distant metastasis-free survival 78.2 against 79.2 percent (1.06, 0.86 to 1.31).
The limits are worth stating because they are being argued over. SUPREMO tested chest-wall irradiation alone, not comprehensive regional nodal irradiation including the internal mammary chain, so it does not speak to the nodal question that MA.20 and EORTC 22922 answered. Its sample size was cut and its eligibility widened during a long accrual, and the population skews to the lower end of intermediate risk. Commentators have made both cases from the same paper: that postmastectomy radiotherapy can be safely omitted in this group, and that the trial does not resemble the way radiotherapy is now delivered.
In England, NICE NG101 recommendation 1.13.10 offers postmastectomy radiotherapy for node-positive macrometastatic disease or involved margins and 1.13.12 says not to offer it to people at low risk of local recurrence; the guideline predates this trial.
Numbers are from the trial as recorded here; see the source links in the table below. This is orientation, not medical advice: ask your team how closely the trial population matches you.
1,607 randomised.
nine patients · twenty patients
Source| Endpoint | Arm | n | Value | HR (95% CI) | p | Source |
|---|---|---|---|---|---|---|
| Overall survival at 10 yearsprimary | Chest-wall irradiation | 808 | 81.4% | 1.04 (0.82 to 1.3) | 0.80 | link |
| No chest-wall irradiation | 799 | 81.9% | ||||
| Chest-wall recurrence | Chest-wall irradiation | 808 | 1.1% | 0.45 (0.2 to 0.99) | - | link |
| No chest-wall irradiation | 799 | 2.5% | ||||
| Disease-free survival at 10 years | Chest-wall irradiation | 808 | 76.2% | 0.97 (0.79 to 1.18) | - | link |
| No chest-wall irradiation | 799 | 75.5% |
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Radiotherapy after mastectomy, Hypofractionated radiotherapy, HER2-positive breast cancer, Breast cancer (all types).
Shares Breast reconstruction, Mastectomy, HER2-positive breast cancer, Breast cancer (all types).
Shares Radiotherapy after mastectomy, HER2-positive breast cancer, Breast cancer (all types), Triple-negative breast cancer (TNBC).