HJAR Mar/Apr 2026

40 MAR / APR 2026 I  HEALTHCARE JOURNAL OF ARKANSAS DIALOGUE COLUMN ONCOLOGY lymphedema and the very small, but not zero, risks of cardiac complications and sec- ond malignancies. In the postmastectomy setting, there have been some recent advances in knowledge regarding when radiation can be safely omitted and on reducing toxicity. Since the early 1990s, the common indications for radiation after mastectomy were primary tumor size greater than five centimeters and four or more positive lymph nodes. In 2014, the Early Breast Cancer Trialists’ Col- laborative Group (EBCTCG) meta-analy- sis 1 showed that even women with a single positive lymph node had a breast cancer- specific mortality advantage with adjuvant radiation. Most of the women involved in the trials used for the analysis were treated be- tween 1964 and 1986, raising the question of whether modern surgical techniques, radia- tion techniques, and later systemic therapy regimens would still make this a valid stan- dard. The waters were further muddied as neoadjuvant chemotherapy became more prominent and surgical de-escalation of the armpit became standard. There have been several retrospective analyses and small institutional trials in- volving whether women with one to three A COMMON MODALITY in treatment for breast cancer is external beam radiation therapy, given after an appropriate level of surgery, typically divided by mastectomy or lumpectomy. The importance of postmastec- tomy radiation in appropriately selected pa- tients has been demonstrated in a multitude of trials since the 1970s, showing improve- ments in not just local control but also overall survival. Despite this, there are many toxici- ties associated with chest wall radiation, rais- ing the question of whether there are certain situations in which it can be safely omitted. Balancing Benefit and Toxicity in Chest Wall Radiation Radiation to the chest wall can cause sev- eral different skin toxicities: acutely in the form of a reaction resembling thermal burns, and chronically in the form of scarring and loss of plasticity, whichmakes reconstruction difficult. There have been improvements on this front over the years, with the develop- ment of modern techniques such as hypo- fractionation, intensity modulated radiation therapy (IMRT), and the elimination of bo- lus from most patients, but the skin effects are still present. Radiation to the chest wall can also raise concerns of increased risk of lymph nodes truly need postmastectomy radiation therapy, some in favor and some opposed, but only recently have large, ran- domized controlled trials started to show data on the subject. One trial in particular, Selective Use of Postoperative Radiotherapy aftEr MastectO- my (SUPREMO), enrolled over 1,600 patients between 2006 and 2010 and had enrollment criteria of including either N1 disease (one to three lymph nodes) or T3 disease (primary tumor greater than five centimeters), along with a few other high-risk features. If a sentinel node biopsy was found to be positive, the patients then underwent an arm- pit dissection with at least eight to 10 lymph nodes. Patients were then randomized to either postmastectomy radiation or obser- vation. Preliminary results were presented at the 2024 San Antonio Breast Conference and the final manuscript was published in the New England Journal of Medicine in No- vember 2025. 2 Among evaluable patients, a total of 29 had a chest wall recurrence — nine (1.1%) in the irradiation group and 20 (2.5%) in the group without irradiation, but there was no difference in overall survival or disease-free survival at 10 years. There was no difference REFINING THE ROLE OF Chest Wall Radiation AFTER MASTECTOMY