Time for Integration of Predictive Factors for Selection of Breast Cancer Patients Who Need Postoperative Radiation Therapy?

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Overtreatment and undertreatment are still major problems in the primary therapy for breast cancer. Hopefully, we will soon be able to utilize prognostic factors to identify those patients who will relapse despite treatment with the currently available standard adjuvant therapy modalities. Such patients might be spared the various types of adjuvant therapy, including radiotherapy, if the effects on local and systemic disease control are minute; novel therapeutic strategies, based on a better understanding of the reasons for treatment failure and disease relapse, will be necessary for these patients. These observations, together with the strain of health care on the economies of many countries, underline the importance of tailoring the therapy for each patient according to evidence-based medicine. The optimal way to obtain results for decision-making is traditionally done within the framework of prospective and randomized clinical trials. We do not have data from a controlled trial, but a report by Silvestrini et al. ( 1 ) in this issue of the Journal highlights and substantiates previous findings on the relationship between immunohistochemical overexpression of the p53 protein and prognosis for breast cancer patients ( 2 ). In their study ( 1 ), Silvestrini et at. have incorporated new immunohistochemical data on p53, glutathione S-transferase-π (GST-π), and BcI-2 as they relate to certain subgroups of patients who seem to benefit from postoperative radiotherapy after breast-conserving surgery. Their data ( 1 ), combined with those from previous studies (3–8), rather strongly indicate that we should be able to identify those patients who are likely to gain a major benefit from postoperative radiotherapy and those who are not. The following are risk factors for local recurrence after breast-conserving surgery (1,3–8):