Is Local Radiation Necessary After Total Mastectomy for Stage IIB Triple-Negative Breast Cancer?

The necessity of total mastectomy and adjuvant radiotherapy?

My mother, who is 77 years old, underwent a right total mastectomy and axillary lymph node dissection on January 20.
The postoperative pathology report indicated triple-negative breast cancer, stage IIB T3N0M0, with a tumor size of 10 cm and a histological grade of III.
There was no lymph node metastasis, with 0 out of 13 nodes affected.
The doctor recommended chemotherapy and radiation therapy post-surgery, but due to my mother's age and the absence of lymph node metastasis, she and our family prefer not to pursue any treatment and would like to continue with monitoring instead.
The hematologist has agreed to allow my mother to return for follow-up appointments every three months.
The surgeon understands that chemotherapy can be very challenging for older patients, but given that the tumor is over 5 cm, he strongly recommends at least radiation therapy.
Currently, an appointment for localization has been scheduled for March 28.
We are still hesitant about whether to put my mother through these treatments, especially since she has already undergone a total mastectomy.
Is localized radiation therapy necessary, or is it just an option? My mother is not a strong person; she was quite traumatized by oral chemotherapy for colon cancer five years ago.
What is your advice on this matter? Thank you!

Jojo, 50~59 year old female. Ask Date: 2016/03/19

Dr. Lai Yicheng reply Oncology

Dear Ms.
Jojo,
Thank you for your letter.
I would like to respond as follows: Your mother has been diagnosed with right-sided breast cancer, T3N0M0, with a tumor size of 10 cm, grade 3, triple-negative, and stage IIB.

1.
Adjuvant chemotherapy and radiotherapy are the standard treatment modalities.
Given that your mother is 77 years old, if managed correctly, she still has a long life ahead.
Therefore, it is essential to follow the standard treatment protocols; otherwise, the risk of recurrence could be as high as 30%.
2.
Since adjuvant radiotherapy and chemotherapy are the standard treatment options, the focus should be on how to minimize the side effects of the treatment rather than on the treatment options themselves.
Thank you for your inquiry.
Sincerely,
Dr.
Lai Yi-Cheng
Department of Radiation Oncology
Changhua Hospital

Reply Date: 2016/03/19

More Info

The decision regarding the necessity of local radiation therapy after a total mastectomy for Stage IIB triple-negative breast cancer (TNBC) is a complex one that involves multiple factors, including the specific characteristics of the cancer, the patient's overall health, and the potential benefits and risks of treatment options.

In your mother's case, she has been diagnosed with Stage IIB TNBC, characterized by a tumor size of 10 cm (T3), no lymph node involvement (N0), and no distant metastasis (M0). The tumor's grade III indicates a high level of aggressiveness. Given these factors, the standard treatment protocol typically includes adjuvant chemotherapy and radiation therapy, especially for larger tumors like hers.

1. Importance of Radiation Therapy: Local radiation therapy is often recommended after mastectomy for patients with larger tumors or those with high-grade cancers. The rationale behind this recommendation is to reduce the risk of local recurrence, which can be significant in cases of larger tumors. Studies have shown that radiation therapy can decrease the likelihood of cancer returning in the chest wall and surrounding areas, particularly for patients with tumors greater than 5 cm.

2. Age and Health Considerations: While your mother's age (77 years) and previous experiences with chemotherapy may raise concerns about her ability to tolerate further treatments, it is essential to weigh these factors against the potential benefits of radiation therapy. Many older patients can successfully undergo radiation therapy with manageable side effects. The treatment is generally localized, which means it may have fewer systemic effects compared to chemotherapy.

3. Monitoring and Follow-Up: The decision to forgo radiation therapy in favor of monitoring may seem appealing, especially given your mother's previous negative experience with chemotherapy. However, without radiation, there is a higher risk of local recurrence, which could lead to more severe complications and the need for more aggressive treatments later on. Regular follow-ups every three months are crucial, but they cannot replace the preventive benefits of radiation therapy.

4. Consultation with Specialists: It is vital to have an open discussion with your mother's oncologist and radiation oncologist about the specific risks and benefits of radiation therapy in her case. They can provide insights tailored to her health status, tumor characteristics, and personal preferences. Additionally, they can discuss strategies to minimize side effects and make the treatment more tolerable.

5. Emotional and Psychological Support: Given your mother's previous experience with cancer treatment, it may also be beneficial to involve a support system, including counseling or support groups for cancer patients. This can help her cope with the emotional aspects of treatment and provide a more positive outlook.

In conclusion, while local radiation therapy after total mastectomy for Stage IIB TNBC is generally considered necessary to reduce the risk of recurrence, the final decision should be made collaboratively with her healthcare team, taking into account her overall health, preferences, and the potential benefits of the treatment. It is essential to ensure that she feels supported and informed throughout this process.

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