at forty-six randomized trials involving over twenty-three thousand patients. In the group of more than eighty-five hundred women who had cancer in lymph nodes and received radiation after mastectomy, the improvement in survival was highly significant at sixteen years, with six out of one hundred more women dying from the tumor who had not received radiation compared with those who had: Early Breast Cancer Trialists’ Collaborative Group, “Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: An overview of the randomized trials,” Lancet 366 (2005), pp. 2087–2106. In Denmark, the Breast Cancer Cooperative Group studied over seventeen thousand premenopausal women like Julie Brody, who had cancer that had spread to the lymph nodes or other worrisome findings. Radiation therapy after mastectomy and chemotherapy, with a ten-year follow-up, showed that only 9 percent who received radiation had the tumor reappear on the chest wall versus 32 percent who had not received radiation. Furthermore, the disease did not come back (so-called diseasefree survival) in 48 percent of those who received radiation versus 35.4 percent of those who did not. Overall survival also was quite different—54 percent in the radiation group lived versus 45 percent without radiation. See Marie Overgaard et al., “Postoperative radiotherapy in high-risk premenopausal women with breast cancer who received adjuvant chemotherapy,” NEJM 337 (1997), pp. 949–955. These findings were in concert with the studies from British Columbia, where 50 percent of women with cancer in their lymph nodes who had not entered menopause and received radiation therapy after mastectomy were free of cancer and alive at fifteen years, versus 33 percent of women who were free of cancer if they did not receive radiation. There was also a trend toward improved overall survival of 54 percent versus 46 percent in the group not receiving radiation. At twenty years, there was an overall survival benefit of 47 percent versus 37 percent; in those with one to three positive lymph nodes, there was 7 percent absolute survival (57 percent versus 50 percent).
121 The criticism of these results came largely from surgeons, who noted that in studies done in the United States, where more lymph nodes were removed from women at the time of mastectomy, the failure rate in terms of the tumor returning at the site of the surgery was much lower than in either British Columbia or Denmark. This informed the discussion when Julie Brody’s oncologist presented her case at the clinical conference. Surgeons there, including the one who operated on Brody, argued that with a more complete operation, most of the patients with one to three positive lymph nodes would actually have been found to have four more positive nodes, and this accounted for the apparent survival benefit in this group. “Her prognosis is still quite good without the radiation, and I removed every node that needed to be removed,” her surgeon stated.
121 The debate continues. And even among expert committees, there are differences in guidelines. The National Comprehensive Cancer Network published recommendations that radiation should be “strongly considered” in women like Julie Brody with one to three positive nodes (http://www.nccn.org/professionals/physician_gls/f_guidelines.asp). But the American Society of Clinical Oncology, which includes specialists across the field of cancer treatment such as medical oncologists, radiation therapists, and surgeons, recommended radiation only in patients with four or more positive nodes. See Abram Recht et al., “Postmastectomy radiotherapy: Guidelines of the American Society of Clinical Oncology,” JCO 19 (2001), pp. 1539–1569. Similar guidelines were published in Canada: Pauline T. Truong et al., “Clinical practice guidelines for the care and treatment of breast cancer: 16. locoregional post-mastectomy radiotherapy,” CMAJ 170 (2004), pp. 1263–1273. The year that Julie was diagnosed, an editorial about radiation therapy for women