Do you consider omitting adjuvant radiation therapy in an older patient with node positive TNBC who achieve pCR to neoadjuvant chemotherapy?

It depends on what surgery the patient has received.

If lumpectomy plus SLNB, I would not omit unless there is absolute contraindications, intolerance to radiation therapy. PRIME II, CALGB 9343, and this meta-analysis provided evidence that post lumpectomy radiation therapy can be omitted in women > 65 yr, ER+, LN- breast cancer. There is no trial to support omitting radiation therapy in LN+, TNBC.

If mastectomy plus SLNB, if clinical stage III, retrospective data suggest that postoperative RT improves local control even with pCR to neoadjuvant chemotherapy [Huang EH et al. JCO 2004, McGuire SE et al. Int J Radiat Oncol Biol Phys 2007]. Therefore, if tolerance is not a concern, it is still very reasonable to recommend RT.

I assume you mean lymph node irradiation. This is very clearly dependent on age. Based on retrospective studies which included virtually no patients over 70, I probably would not. There is absolutely no data to show survival in this age group with an average risk of competing causes of death of 4% per year. The McGuire study was small and the median was near 50 and benefit was seen only in stage 3 and not all patients received taxanes or that matter may be appropriate for adjuvant therapy. The same can be said of the Huang study. The complications of completing radiation or surgery to the axilla in this age of patients are not inconsiderable. Regarding breast irradiation, I have no opinion and wish we had trials in the elderly.

We must hav...