Staying A-Breast: SUPREMO and INSEMA

[TheWallnerus]

---

Members don't see this ad.

No Benefit from Chest Wall Irradiation in Intermediate-Risk Breast Cancer: SABCS 2024

Study shows chest wall irradiation post-mastectomy offers no survival benefit for most intermediate-risk breast cancer patients.

www.emjreviews.com

"Based on the lack of improvement of 10-year OS with adjuvant chest wall irradiation in patients with 1-3 positive nodes or pN0 with other risk factors treated with optimal systemic therapy, Dr. Kunkler concluded, “Adjuvant chest wall irradiation should be omitted in most patients meeting eligibility criteria for SUPREMO.”

https://www.nejm.org/doi/10.1056/NEJMoa2412063

Do or should these findings change a rad onc's practice, today.

For hypothetical discussion's sake:
1) 50yo female with ER+ grade 2 2.2cm breast mass, one positive node, s/p mastectomy; apply PMRT, and if so with ENI?
2) 55yo female ER+ grade 2 1.5cm lesion, cN0, surgeon does not do SLN. With a negative SLN, ASTRO guidelines would recommend/prefer PBI. With no SLN, will you do PBI, or whole breast, and if whole breast apply any nodal RT and if so to what volumes?

 

[BobbyHeenan]

I will definitely be more inclined to omit CW radiation in someone with widely clear margins and 1 + node that had an axilla dissection.

It is probably fine to omit some of these patients that have a mastectomy and SLNB and 1/1 is +, but i guess technically they weren't on the trial due to no axilla dissection, correct? I haven't looked that closely at the trial either - how many T3N0's were carrying the weight in that trial?...a subset I already often omitted.

===

regarding hte second case...hmm, that's a tough one. We typically only omit SLNB in age 65 and up (and usually it ends up being 70+ and up), and in those ones I am comfortable with APBI as long as no LVSI. 55 is pushing it, probably would do whole breast there if no node but I don't feel strongly about that.

 

[metallica81788]

So are we just back to mutilating dissections and edema for breast now and we don't do any PMRT? What was the point of the last 30 years?
Breast might actually be the worst.

 

[madchemist89]

So are we just back to mutilating dissections and edema for breast now and we don't do any PMRT? What was the point of the last 30 years?
Breast might actually be the worst.

Probably just omitting radiation for everyone except the most locally advanced cases.

 

[ramsesthenice]

So are we just back to mutilating dissections and edema for breast now and we don't do any PMRT? What was the point of the last 30 years?
Breast might actually be the worst.

My friend, breast is definitely the worst.

As a non-breast person, this doesn't seem that surprising. With modern imaging, systemic therapy, etc., if you do a big enough surgery, you can probably omit radiation. But to Master of Llama's point, is that even what patients want? This is a win for smaller pool of people who need/want a mastectomy but doesn't seem like that much of a threat to our global breast volume. We already took care of that on our own 😉

 

[RadRadRad]

Where do we stand on omitting surgery
Weren’t their some trials with biopsy after chemo that omitted surgery?

 

[communitydoc13]

My friend, breast is definitely the worst.

As a non-breast person, this doesn't seem that surprising. With modern imaging, systemic therapy, etc., if you do a big enough surgery, you can probably omit radiation. But to Master of Llama's point, is that even what patients want? This is a win for smaller pool of people who need/want a mastectomy but doesn't seem like that much of a threat to our global breast volume. We already took care of that on our own 😉

Most breast surgeons I know are looking for ways to do nothing more than a lumpectomy on anyone (SLN bx going away (prematurely at times IMO)). None of the breast surgeons I work with likes to do an axillary dissection, much less a mastectomy.

 

[ramsesthenice]

Most breast surgeons I know are looking for ways to do nothing more than a lumpectomy on anyone (SLN bx going away (prematurely at times IMO)). None of the breast surgeons I work with likes to do an axillary dissection, much less a mastectomy.

Makes sense. That is the way things were headed even 10 years ago when I was in training. Totally spit balling here, but I'd say < 5% of the breast cases that get presented in our chart rounds are post-mastectomy. Doesn't seem like something we see too much of.

 

[medgator]

Makes sense. That is the way things were headed even 10 years ago when I was in training. Totally spit balling here, but I'd say < 5% of the breast cases that get presented in our chart rounds are post-mastectomy. Doesn't seem like something we see too much of.

They're getting MRIs when appropriate etc? I think that number is probably higher than 5% around me and that's a function of the disease extent not surgeon/pt preference

 

[OTN]

These results are not surprising and will not change my practice. LVSI remains the key negative prognostic factor that pushes me towards adjuvant CW RT.

 

[TheWallnerus]

More direct question: for a patient who fits within EORTC 22922, EBCTCG 2014, and SUPREMO—and given that SUPREMO conclusions conflict with EORTC 22922/EBCTCG (and stipulating EORTC 22922/EBCTCG results were called practice-changing when they were published)—will we see current rad onc practice change? Do EORTC 22922 and EBCTCG become partially or wholly invalidated by SUPREMO... or can all three results peacefully and logically co-exist.

Will Larry Marks think differently about this, in other words.

 

[Palex80]

No Benefit from Chest Wall Irradiation in Intermediate-Risk Breast Cancer: SABCS 2024

Study shows chest wall irradiation post-mastectomy offers no survival benefit for most intermediate-risk breast cancer patients.

www.emjreviews.com

"Based on the lack of improvement of 10-year OS with adjuvant chest wall irradiation in patients with 1-3 positive nodes or pN0 with other risk factors treated with optimal systemic therapy, Dr. Kunkler concluded, “Adjuvant chest wall irradiation should be omitted in most patients meeting eligibility criteria for SUPREMO.”

https://www.nejm.org/doi/10.1056/NEJMoa2412063

Do or should these findings change a rad onc's practice, today.

For hypothetical discussion's sake:
1) 50yo female with ER+ grade 2 2.2cm breast mass, one positive node, s/p mastectomy; apply PMRT, and if so with ENI?
2) 55yo female ER+ grade 2 1.5cm lesion, cN0, surgeon does not do SLN. With a negative SLN, ASTRO guidelines would recommend/prefer PBI. With no SLN, will you do PBI, or whole breast, and if whole breast apply any nodal RT and if so to what volumes?

The data is tricky to interpret.

Bear in mind for SUPREMO that:

1. The study was statistically underpowered to show any benefit of RT, observed death events were less than expected (The trialsts assumed a 7% ! OS benefit with RT). Also, far too many stages/histologies wege eligible.
2. RNI was not given to all patients, it was left to the discretion of the physicians and we do not know how many got it.
3. Patients with pN+ received axillary surgery. Few patients will get axillary clearance for a positive SLN these days. We do not know however how many positive nodes that patient may have. For SUPREMO you had to have axillary dissection and still only 1-3 nodes to qualify.

 

[TheWallnerus]

FWIW Recht and a few other names have given some opinions (not all of them understandable tbh) on SUPREMO:

theMednet

But oh to be a breast cancer expert...

The data is tricky to interpret.

 

[Palex80]

Makes sense. That is the way things were headed even 10 years ago when I was in training. Totally spit balling here, but I'd say < 5% of the breast cases that get presented in our chart rounds are post-mastectomy. Doesn't seem like something we see too much of.

We see more, probably 15% and we treat >200 BC patients overall per year.

Mainly:
- multicentric tumors or tumors with extensive DCIS
- young patients with family history/BRCA carriers
- young patients with small breasts who want a reconstruction anyhow
- patients who don’t want „to mess around“ and "have it all off" (some opt for bilateral mastectomy)

 

[Tigerstang]

Most breast surgeons I know are looking for ways to do nothing more than a lumpectomy on anyone (SLN bx going away (prematurely at times IMO)). None of the breast surgeons I work with likes to do an axillary dissection, much less a mastectomy.

In my neck of the woods, they are doing mastectomy's like their going out a style. Everyone gets immediate recon, too. Run up that bill!

 

[madchemist89]

In my neck of the woods, they are doing mastectomy's like their going out a style. Everyone gets immediate recon, too. Run up that bill!

Same here. The plastic surgeons love mastectomies.

 

[communitydoc13]

In my neck of the woods, they are doing mastectomy's like their going out a style. Everyone gets immediate recon, too. Run up that bill!

Insane given the average age of a breast cancer patient. Also, no need for mastectomy for even a level 2 oncoplastic procedure with bilateral reduction mammoplasty/mastopexy. Retains natural breast tissue and preferable to an implant for life style IMO.

I've had issues with one surgeon basically doing level 2 oncoplastics on everyone. Most women will have a good cosmetic outcome with lumpectomy alone IMO.

You're not in Miami or SoCal?

 

[madchemist89]

Insane given the average age of a breast cancer patient. Also, no need for mastectomy for even a level 2 oncoplastic procedure with bilateral reduction mammoplasty/mastopexy. Retains natural breast tissue and preferable to an implant for life style IMO.

I've had issues with one surgeon basically doing level 2 oncoplastics on everyone. Most women will have a good cosmetic outcome with lumpectomy alone IMO.

You're not in Miami or SoCal?

This is a problem with general surgeons in the community doing breast cancer surgery in my experience.

 

[BobbyHeenan]

I am so thankful to have a very thoughtful and skilled breast surgeon. She does oncoplastic reconstructions/mastopexies selectively but delineates cavities really well when she does so, so leaving us options for apbi or boost if needed. She takes great measure to avoid axilla dissections at all costs and is very pro radiation - especially about older patients getting APBI and using radiation when there is an axilla sterilization question versus more surgery.

 

[TheWallnerus]

She takes great measure to avoid axilla dissections at all costs and is very pro radiation - especially about older patients getting APBI

For breast cancer patients getting RT in America of all the different techniques/volumes given a plurality should be getting PBI.

 

[BobbyHeenan]

For breast cancer patients getting RT in America of all the different techniques/volumes given a plurality should be getting PBI.

Agree. And she is on board and understands the issues we have when they re arrange all this tissue and I need a target.

 

[evilbooyaa]

Who is still getting ax dissections nowadays? Sure, if Ax dissection and 1-3 nodes positive, maybe PMRT isn't always necessary the way EORTC/EBCTCG meta-analyses taught us historically.

However, a trial that is underpowered for an endpoint that shows no difference does not mean there is no difference. It means money was spent and no conclusion can be made.

So, no, probably won't change my practice. But the # of patients I see with mastectomy and ALND in the past year I can probably count on 1-2 hands....

 

[Mandelin Rain]

Who is still getting ax dissections nowadays? Sure, if Ax dissection and 1-3 nodes positive, maybe PMRT isn't always necessary the way EORTC/EBCTCG meta-analyses taught us historically.

However, a trial that is underpowered for an endpoint that shows no difference does not mean there is no difference. It means money was spent and no conclusion can be made.

So, no, probably won't change my practice. But the # of patients I see with mastectomy and ALND in the past year I can probably count on 1-2 hands....

100% this.

 

[BobbyHeenan]

Who is still getting ax dissections nowadays? Sure, if Ax dissection and 1-3 nodes positive, maybe PMRT isn't always necessary the way EORTC/EBCTCG meta-analyses taught us historically.

However, a trial that is underpowered for an endpoint that shows no difference does not mean there is no difference. It means money was spent and no conclusion can be made.

So, no, probably won't change my practice. But the # of patients I see with mastectomy and ALND in the past year I can probably count on 1-2 hands....

It is only the ER+ clinical up front node +'s that I see getting ax dissection anymore. Not a huge number of patients. They are very selective about which patients get full dissections after neoadj chemo and it is exceedingly rare in my neck of the woods. They usually just removed the up front + nodes that were clipped and maybe a few others.

 

[drowsy12]