- Email: [email protected]
Tailoring Locoregional Radiotherapy Use After Neoadjuvant Chemotherapy: Time for a Definitive Answer
contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29:1564-1569.
breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575.
17. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive
Tailoring Locoregional Radiotherapy Use After Neoadjuvant Chemotherapy: Time for a Definitive Answer Eleftherios P. Mamounas, MD, MPH For patients with early-stage breast cancer who undergo surgery as their initial treatment, there is abundant information on rates and predictors of locoregional recurrence (LRR), with or without adjuvant systemic therapy.1-4 This information has been useful for making decisions regarding whether to use locoregional radiotherapy (XRT) following mastectomy or add regional nodal XRT following breastconserving surgery. In patients with node-positive disease treated with mastectomy, the use of chest wall and regional XRT significantly reduces the risk of LRR and death5-9; however, for patients with negative axillary nodes, the absolute reduction in LLR from postmastectomy XRT is small, and no significant improvement in overall survival has been observed.5-9 For patients treated with breast-conserving surgery, the addition of postlumpectomy breast XRT has been shown to significantly reduce rates of breast cancer recurrence and breast cancerespecific mortality.10 The effect of adding regional nodal XRT to breast XRT was not formally tested until recently. On the basis of extrapolation of results from the postmastectomy XRT trials, most clinicians would recommend adding regional nodal XRT to breast XRT for patients with 4 or more positive nodes. However, recent results from the National Cancer Institute of Canada MA.20 trial demonstrated that in patients with 1-3 positive nodes (or high-risk node-negative disease) who have undergone lumpectomy, adding regional nodal XRT to breast XRT significantly reduces LRR and significantly prolongs disease-free survival and distant disease-free survival, with a non-significant trend toward prolonging overall survival.11 Based on the above evidence, for patients with early-stage breast cancer who undergo surgery first, chest wall + regional nodal XRT is commonly prescribed after mastectomy for patients with positive axillary nodes, and regional nodal XRT in addition to breast XRT is rapidly gaining momentum
222
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
as the treatment of choice for patients with node-positive disease who are treated with lumpectomy. During the past decade, neoadjuvant chemotherapy has become the gold standard for the treatment of patients with locally advanced breast cancer and a reasonable alternative to adjuvant chemotherapy for patients with large operable breast tumors. In randomized clinical trials, neoadjuvant chemotherapy has been found to be as effective as adjuvant chemotherapy in prolonging disease-free and overall survival, and it has some potential clinical advantages, such as the conversion of mastectomy candidates to candidates for breast-conserving surgery and the improvement in cosmesis by reducing the extent of lumpectomy in patients with initially large tumors who are already candidates for breast-conserving surgery. In addition, the consistent observation that pathologic complete response to neoadjuvant chemotherapy is associated with excellent long-term outcomes has brought forward the hypothesis that neoadjuvant chemotherapy can be used to both reduce the extent of surgery in the axilla by downstaging involved axillary nodes and reduce the extent of (or need for) locoregional XRT by down-staging primary tumors and involved axillary nodes. However, in contrast to the abundant information on LRR rates for patients treated with surgery first followed by adjuvant systemic therapy, there is limited information on the rates and predictors of LRR in patients who receive neoadjuvant chemotherapy. There are 2 reasons for this paucity of data regarding LRR after neoadjuvant chemotherapy. First, considerably fewer patients with operable breast cancer are being treated with neoadjuvant versus adjuvant chemotherapy. Second, by the time neoadjuvant chemotherapy became established as an alternative to adjuvant chemotherapy, the role of locoregional XRT in patients with positive nodes at presentation was well established. Thus, most available neoadjuvant chemotherapy databases include patients who, at the discretion of the treating physician, were treated with postoperative XRT (because they either had pathologically positive nodes at surgery or were presumed to be node-positive before neoadjuvant chemotherapy). As a result, there is considerable debate over how best to use locoregional XRT in patients who have received neoadjuvant chemotherapy and, more specifically, in those
who present with clinically or pathologically involved axillary nodes before neoadjuvant chemotherapy and are then found to have pathologically negative axillary nodes at surgery. An article by Le Scodan and colleagues12 represents yet another attempt to compare outcomes of patients treated with neoadjuvant chemotherapy according to whether they also received postmastectomy XRT. The authors included 134 patients who were treated with neoadjuvant chemotherapy and were found to have pathologically node-negative disease at surgery. The main limitation of this retrospective analysis, as outlined above, is that the use of postmastectomy XRT was at the discretion of the treating physician. Thus, not surprisingly, patients with worse prognostic factors at presentation and/or after neoadjuvant chemotherapy were more likely to receive postmastectomy radiotherapy. Despite that, outcomes were similar between patients who did or did not receive postmastectomy XRT; however, because of the relatively small number of patients included in the comparison (78 with XRT and 56 without), the study was clearly underpowered to detect small differences in outcomes due to the addition of XRT. So where do the results of this study (and similar ones) leave us currently regarding the use of postmastectomy XRT in patients with negative nodes after neoadjuvant chemotherapy? It is generally agreed that the only way that one can definitively establish the case for or against postmastectomy XRT in patients with histologically node-negative disease after neoadjuvant chemotherapy is through a prospective randomized clinical trial; however, to facilitate acceptance of randomization into such a clinical trial, it is important to obtain information on the rates and patterns of locoregional failure from cohorts of patients who received neoadjuvant chemotherapy without postmastectomy XRT. Ideally, the allocation to not receive postmastectomy XRT should be mandated for all patients in the cohort rather than be left to the discretion of the treating physician. Until the late 1990s, none of the National Surgical Adjuvant Breast and Bowel Project (NSABP) adjuvant and neoadjuvant breast cancer clinical trials permitted chest wall or regional nodal XRT after mastectomy or regional nodal XRT after breast-conserving surgery. Up until that time, there was no convincing evidence that XRT to those areas significantly improved overall survival, but it was shown to increase morbidity. Data from 2 NSABP neoadjuvant trials (B-18 and B-27) provide us with the opportunity to examine the rates and patterns of LRR in patients treated with neoadjuvant chemotherapy as well as to identify independent predictors of LRR in this setting. The results of a combined analysis of these 2 trials, which included over 3000 patients, clearly demonstrated that in addition to age and clinical factors (such as clinical tumor size and clinical nodal status) assessed
before neoadjuvant chemotherapy, pathologic response in the breast and pathologic axillary nodal status have a major impact on the rates and patterns of LRR.13 The results further suggest that pathologic complete response in the breast with negative axillary nodes minimizes the effects of age, clinical tumor size, and clinical nodal status on the rates of LRR. Since clinical nodal status is a strong surrogate for pathologic nodal status, these results indicate that in patients treated with neoadjuvant chemotherapy, rates of LRR in those who have positive nodes before neoadjuvant chemotherapy can be lowered if the nodes become pathologically node-negative after neoadjuvant chemotherapy (particularly if there is also a pathologic complete response in the breast). Thus, patients who have positive axillary nodes at presentation (who would be candidates for postmastectomy chest wall + regional nodal XRT or postlumpectomy breast + regional nodal XRT) appear to have low rates of LRR if they become pathologically nodenegative after neoadjuvant chemotherapy. These results provide a launching pad for a randomized clinical trial that will seek to demonstrate whether the use of XRT (chest wall + regional nodal XRT for mastectomy patients and breast + regional nodal XRT for lumpectomy patients) would significantly improve outcomes in patients who present with histologically confirmed involved axillary nodes before neoadjuvant chemotherapy but are found to have histologically negative axillary nodes at surgery. Such a randomized clinical trial is currently under development by the NSABP and the Radiation Therapy Oncology Group. The results of this trial have the potential to produce a major paradigm shift in the locoregional management of earlystage breast cancer, assuming that they demonstrate that the addition of XRT does not significantly improve outcomes in this originally high-risk group of patients. It is time to move forward in order to answer this important clinical question.
References 1. Recht A, Gray R, Davidson NE. Locoregional failure 10 years after mastectomy and adjuvant chemotherapy with or without tamoxifen without irradiation: experience of the Eastern Cooperative Oncology Group. J Clin Oncol. 1999; 17:1689-1700. 2. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation. J Clin Oncol. 2000;18:2817-2827. 3. Wallgren A, Bonetti M, Gelber RD, et al; International Breast Cancer Study Group Trials I through VII. Risk factors for locoregional recurrence among breast cancer patients: results from International Breast Cancer Study Group trials I through VII. J Clin Oncol. 2003;21:1205-1213.
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
223
4. Taghian A, Jeong JH, Mamounas E, et al. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. J Clin Oncol. 2004;22:4247-4254. 5. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. Early Breast Cancer Trialists’ Collaborative Group. N Engl J Med. 1995;333:1444-1455. 6. Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet. 2000;355:1757-1770. 7. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337:956-962. 8. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997; 337:949-955.
Laughter, the Best Medicine Dara Insley, BS Before we begin, I need to clarify my credentials. I’m not an expert on the physical and psychological effects of laughter and humor (my degree is in Sociology), but I like to laugh. My sense of humor has been described as giddy, joyful, silly, crazy, nutty, giggly, quirky, and even wicked. All of these types of humor helped me during my battle with breast cancer. In fact, that’s what I hope to get across in this article: making fun of cancer and its treatments can cause an “upward spiral” effect on patients, doctors, and others around us, even if they aren’t fully on board with trying to find the humor in cancer. (Please note: I honor all feelings associated with cancer, but this piece focuses on humor.) In December 2009, I was diagnosed with mucinous carcinoma in my right breast, with axillary lymph node involvement. I had chemotherapy until April 2010, underwent a double mastectomy in May 2010, had my upper lymph nodes surgically removed in June 2010, and underwent radiation therapy (under the watchful eyes of Dr. Thomas Buchholz) during August and September 2010. Posttherapy I am taking tamoxifen, as most breast mucinous carcinomas are “hormonally positive.” I was 39 at diagnosis, and no, I wasn’t doing my
224
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
9. Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353:1641-1648. 10. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707-1716. 11. Whelan TJ, Olivotto I, Ackerman I, et al. NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer (abstract LBA1003). J Clin Oncol. 2011:29. 12. Le Scodan R, Selz J, Stevens D, et al. Radiotherapy for stage II and stage III breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy. Int J Radiat Oncol Biol Phys. 2012;82:e1-e7. 13. Mamounas E, Anderson S, Dignam J, et al. Predictors of locoregional recurrence following neoadjuvant chemotherapy: results from combined analysis of NSABP B-18 and B-27. J Clin Oncol. In press.
breast self-exams, and I have no family history of breast cancer. While I was receiving chemotherapy, I sat down one day at my computer and started searching for “cancer jokes.” I found a few corny, silly, not-true jokes, but I wanted some true, firsthand funny stories from people about when and where they laughed at (or in the face of) cancer. I found nothing, so rolling around this idea that we can make fun of it all, I decided to create my own website where people can read and share cancer jokes. Not just breast cancer jokes, and not just for adults, either. Kids get cancer, too. The sites are www.canswear.net for grown-ups and www.canshare.net for the young ones. Here’s a sampling of jokes from the canswear.net website: If you get a chemotherapy port put in, just tell everyone it’s a microchip, like for your pet. Or, if you want to make your surgeon laugh, write this on the surgical site: “Please handle with care. Contents are biohazardous materials!!” My tip for doctors: Start giving out toys or stickers to grown-ups for being “good patients.” Then, it would be fun to go to the doctor. And, last but not least, after I lost my hair from the chemotherapy, I was standing in line at a dollar store one day when a woman asked me, “Do you have cancer or are you making a statement?” I was so shocked, I just said, “Cancer,” but instead of an apology she proceeded to tell me
breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575.
17. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive
Tailoring Locoregional Radiotherapy Use After Neoadjuvant Chemotherapy: Time for a Definitive Answer Eleftherios P. Mamounas, MD, MPH For patients with early-stage breast cancer who undergo surgery as their initial treatment, there is abundant information on rates and predictors of locoregional recurrence (LRR), with or without adjuvant systemic therapy.1-4 This information has been useful for making decisions regarding whether to use locoregional radiotherapy (XRT) following mastectomy or add regional nodal XRT following breastconserving surgery. In patients with node-positive disease treated with mastectomy, the use of chest wall and regional XRT significantly reduces the risk of LRR and death5-9; however, for patients with negative axillary nodes, the absolute reduction in LLR from postmastectomy XRT is small, and no significant improvement in overall survival has been observed.5-9 For patients treated with breast-conserving surgery, the addition of postlumpectomy breast XRT has been shown to significantly reduce rates of breast cancer recurrence and breast cancerespecific mortality.10 The effect of adding regional nodal XRT to breast XRT was not formally tested until recently. On the basis of extrapolation of results from the postmastectomy XRT trials, most clinicians would recommend adding regional nodal XRT to breast XRT for patients with 4 or more positive nodes. However, recent results from the National Cancer Institute of Canada MA.20 trial demonstrated that in patients with 1-3 positive nodes (or high-risk node-negative disease) who have undergone lumpectomy, adding regional nodal XRT to breast XRT significantly reduces LRR and significantly prolongs disease-free survival and distant disease-free survival, with a non-significant trend toward prolonging overall survival.11 Based on the above evidence, for patients with early-stage breast cancer who undergo surgery first, chest wall + regional nodal XRT is commonly prescribed after mastectomy for patients with positive axillary nodes, and regional nodal XRT in addition to breast XRT is rapidly gaining momentum
222
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
as the treatment of choice for patients with node-positive disease who are treated with lumpectomy. During the past decade, neoadjuvant chemotherapy has become the gold standard for the treatment of patients with locally advanced breast cancer and a reasonable alternative to adjuvant chemotherapy for patients with large operable breast tumors. In randomized clinical trials, neoadjuvant chemotherapy has been found to be as effective as adjuvant chemotherapy in prolonging disease-free and overall survival, and it has some potential clinical advantages, such as the conversion of mastectomy candidates to candidates for breast-conserving surgery and the improvement in cosmesis by reducing the extent of lumpectomy in patients with initially large tumors who are already candidates for breast-conserving surgery. In addition, the consistent observation that pathologic complete response to neoadjuvant chemotherapy is associated with excellent long-term outcomes has brought forward the hypothesis that neoadjuvant chemotherapy can be used to both reduce the extent of surgery in the axilla by downstaging involved axillary nodes and reduce the extent of (or need for) locoregional XRT by down-staging primary tumors and involved axillary nodes. However, in contrast to the abundant information on LRR rates for patients treated with surgery first followed by adjuvant systemic therapy, there is limited information on the rates and predictors of LRR in patients who receive neoadjuvant chemotherapy. There are 2 reasons for this paucity of data regarding LRR after neoadjuvant chemotherapy. First, considerably fewer patients with operable breast cancer are being treated with neoadjuvant versus adjuvant chemotherapy. Second, by the time neoadjuvant chemotherapy became established as an alternative to adjuvant chemotherapy, the role of locoregional XRT in patients with positive nodes at presentation was well established. Thus, most available neoadjuvant chemotherapy databases include patients who, at the discretion of the treating physician, were treated with postoperative XRT (because they either had pathologically positive nodes at surgery or were presumed to be node-positive before neoadjuvant chemotherapy). As a result, there is considerable debate over how best to use locoregional XRT in patients who have received neoadjuvant chemotherapy and, more specifically, in those
who present with clinically or pathologically involved axillary nodes before neoadjuvant chemotherapy and are then found to have pathologically negative axillary nodes at surgery. An article by Le Scodan and colleagues12 represents yet another attempt to compare outcomes of patients treated with neoadjuvant chemotherapy according to whether they also received postmastectomy XRT. The authors included 134 patients who were treated with neoadjuvant chemotherapy and were found to have pathologically node-negative disease at surgery. The main limitation of this retrospective analysis, as outlined above, is that the use of postmastectomy XRT was at the discretion of the treating physician. Thus, not surprisingly, patients with worse prognostic factors at presentation and/or after neoadjuvant chemotherapy were more likely to receive postmastectomy radiotherapy. Despite that, outcomes were similar between patients who did or did not receive postmastectomy XRT; however, because of the relatively small number of patients included in the comparison (78 with XRT and 56 without), the study was clearly underpowered to detect small differences in outcomes due to the addition of XRT. So where do the results of this study (and similar ones) leave us currently regarding the use of postmastectomy XRT in patients with negative nodes after neoadjuvant chemotherapy? It is generally agreed that the only way that one can definitively establish the case for or against postmastectomy XRT in patients with histologically node-negative disease after neoadjuvant chemotherapy is through a prospective randomized clinical trial; however, to facilitate acceptance of randomization into such a clinical trial, it is important to obtain information on the rates and patterns of locoregional failure from cohorts of patients who received neoadjuvant chemotherapy without postmastectomy XRT. Ideally, the allocation to not receive postmastectomy XRT should be mandated for all patients in the cohort rather than be left to the discretion of the treating physician. Until the late 1990s, none of the National Surgical Adjuvant Breast and Bowel Project (NSABP) adjuvant and neoadjuvant breast cancer clinical trials permitted chest wall or regional nodal XRT after mastectomy or regional nodal XRT after breast-conserving surgery. Up until that time, there was no convincing evidence that XRT to those areas significantly improved overall survival, but it was shown to increase morbidity. Data from 2 NSABP neoadjuvant trials (B-18 and B-27) provide us with the opportunity to examine the rates and patterns of LRR in patients treated with neoadjuvant chemotherapy as well as to identify independent predictors of LRR in this setting. The results of a combined analysis of these 2 trials, which included over 3000 patients, clearly demonstrated that in addition to age and clinical factors (such as clinical tumor size and clinical nodal status) assessed
before neoadjuvant chemotherapy, pathologic response in the breast and pathologic axillary nodal status have a major impact on the rates and patterns of LRR.13 The results further suggest that pathologic complete response in the breast with negative axillary nodes minimizes the effects of age, clinical tumor size, and clinical nodal status on the rates of LRR. Since clinical nodal status is a strong surrogate for pathologic nodal status, these results indicate that in patients treated with neoadjuvant chemotherapy, rates of LRR in those who have positive nodes before neoadjuvant chemotherapy can be lowered if the nodes become pathologically node-negative after neoadjuvant chemotherapy (particularly if there is also a pathologic complete response in the breast). Thus, patients who have positive axillary nodes at presentation (who would be candidates for postmastectomy chest wall + regional nodal XRT or postlumpectomy breast + regional nodal XRT) appear to have low rates of LRR if they become pathologically nodenegative after neoadjuvant chemotherapy. These results provide a launching pad for a randomized clinical trial that will seek to demonstrate whether the use of XRT (chest wall + regional nodal XRT for mastectomy patients and breast + regional nodal XRT for lumpectomy patients) would significantly improve outcomes in patients who present with histologically confirmed involved axillary nodes before neoadjuvant chemotherapy but are found to have histologically negative axillary nodes at surgery. Such a randomized clinical trial is currently under development by the NSABP and the Radiation Therapy Oncology Group. The results of this trial have the potential to produce a major paradigm shift in the locoregional management of earlystage breast cancer, assuming that they demonstrate that the addition of XRT does not significantly improve outcomes in this originally high-risk group of patients. It is time to move forward in order to answer this important clinical question.
References 1. Recht A, Gray R, Davidson NE. Locoregional failure 10 years after mastectomy and adjuvant chemotherapy with or without tamoxifen without irradiation: experience of the Eastern Cooperative Oncology Group. J Clin Oncol. 1999; 17:1689-1700. 2. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation. J Clin Oncol. 2000;18:2817-2827. 3. Wallgren A, Bonetti M, Gelber RD, et al; International Breast Cancer Study Group Trials I through VII. Risk factors for locoregional recurrence among breast cancer patients: results from International Breast Cancer Study Group trials I through VII. J Clin Oncol. 2003;21:1205-1213.
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
223
4. Taghian A, Jeong JH, Mamounas E, et al. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. J Clin Oncol. 2004;22:4247-4254. 5. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. Early Breast Cancer Trialists’ Collaborative Group. N Engl J Med. 1995;333:1444-1455. 6. Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet. 2000;355:1757-1770. 7. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337:956-962. 8. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997; 337:949-955.
Laughter, the Best Medicine Dara Insley, BS Before we begin, I need to clarify my credentials. I’m not an expert on the physical and psychological effects of laughter and humor (my degree is in Sociology), but I like to laugh. My sense of humor has been described as giddy, joyful, silly, crazy, nutty, giggly, quirky, and even wicked. All of these types of humor helped me during my battle with breast cancer. In fact, that’s what I hope to get across in this article: making fun of cancer and its treatments can cause an “upward spiral” effect on patients, doctors, and others around us, even if they aren’t fully on board with trying to find the humor in cancer. (Please note: I honor all feelings associated with cancer, but this piece focuses on humor.) In December 2009, I was diagnosed with mucinous carcinoma in my right breast, with axillary lymph node involvement. I had chemotherapy until April 2010, underwent a double mastectomy in May 2010, had my upper lymph nodes surgically removed in June 2010, and underwent radiation therapy (under the watchful eyes of Dr. Thomas Buchholz) during August and September 2010. Posttherapy I am taking tamoxifen, as most breast mucinous carcinomas are “hormonally positive.” I was 39 at diagnosis, and no, I wasn’t doing my
224
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
9. Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353:1641-1648. 10. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707-1716. 11. Whelan TJ, Olivotto I, Ackerman I, et al. NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer (abstract LBA1003). J Clin Oncol. 2011:29. 12. Le Scodan R, Selz J, Stevens D, et al. Radiotherapy for stage II and stage III breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy. Int J Radiat Oncol Biol Phys. 2012;82:e1-e7. 13. Mamounas E, Anderson S, Dignam J, et al. Predictors of locoregional recurrence following neoadjuvant chemotherapy: results from combined analysis of NSABP B-18 and B-27. J Clin Oncol. In press.
breast self-exams, and I have no family history of breast cancer. While I was receiving chemotherapy, I sat down one day at my computer and started searching for “cancer jokes.” I found a few corny, silly, not-true jokes, but I wanted some true, firsthand funny stories from people about when and where they laughed at (or in the face of) cancer. I found nothing, so rolling around this idea that we can make fun of it all, I decided to create my own website where people can read and share cancer jokes. Not just breast cancer jokes, and not just for adults, either. Kids get cancer, too. The sites are www.canswear.net for grown-ups and www.canshare.net for the young ones. Here’s a sampling of jokes from the canswear.net website: If you get a chemotherapy port put in, just tell everyone it’s a microchip, like for your pet. Or, if you want to make your surgeon laugh, write this on the surgical site: “Please handle with care. Contents are biohazardous materials!!” My tip for doctors: Start giving out toys or stickers to grown-ups for being “good patients.” Then, it would be fun to go to the doctor. And, last but not least, after I lost my hair from the chemotherapy, I was standing in line at a dollar store one day when a woman asked me, “Do you have cancer or are you making a statement?” I was so shocked, I just said, “Cancer,” but instead of an apology she proceeded to tell me