Breast
PMRT target volume, not PMRT itself, is what SUPREMO actually tested.
SUPREMO
ForPost-mastectomy breast, node-negative high-risk or 1-3 positive nodes
TL;DREditorial critique: chest-wall-only RT cut 10yr CW recurrence 1.1% vs 2.5% (HR 0.45) but RNI was prohibited.
The RT-relevant number is buried in SUPREMO's supplement: node-positive LRR 3.3% vs 4.8%, HR 0.51 (0.27-0.96), significant even with chest-wall-only fields and RNI prohibited. With supraclavicular coverage in 12% and IMN in under 2%, this trial never tested comprehensive PMRT, so it cannot settle the elective nodal decision.
In a post-mastectomy patient with 1-3 positive nodes staged by SLNB alone, this argues SUPREMO does not license PMRT omission; it says nothing about node-negative pts without adverse features, where EBCTCG also found no benefit.
The supplement carries the number the headline drops: node-positive LRR 3.3% vs 4.8%, HR 0.51 (0.27-0.96), achieved even with RNI prohibited, supraclavicular coverage in 12% and IMN in under 2%. SUPREMO therefore constrains chest-wall-only treatment, not the elective nodal volume decision.
Axillary staging gates how far SUPREMO travels: only 14% had SLNB alone, and roughly 30% of SLNB pts with 1-3 positive nodes harbour further nodes at completion ALND. Choosing ALND to justify skipping PMRT trades a 8% five-year lymphedema risk with SLNB alone for 25% with ALND alone.
Also covered Jul 7
9 details
ASO Perspectives editorial in Annals of Surgical Oncology, not new trial data. Two radiation oncologists re-read SUPREMO against the PMRT and RNI evidence base. PMRT after neoadjuvant therapy is explicitly out of scope.
The central claim is that SUPREMO tested chest wall alone, not PMRT: RNI was prohibited, supraclavicular nodes were covered in 12% of PMRT-arm pts (n=97), and internal mammary irradiation occurred in fewer than 2% across both arms. Non-UK centres could give RNI in the observation arm, and 12 control pts received supraclavicular RNI.
Only 25% were truly node-negative and would not be offered PMRT under current guidelines; the majority had N1 disease (1-3 nodes). 65% were hormone-receptor positive, TNBC was 10%, and only 14% had SLNB alone with the majority undergoing ALND.
SUPREMO's 10-year chest-wall recurrence fell from 2.5% to 1.1% (HR 0.45) with no gain in overall LRR, DFS or OS. The supplement carries the signal the headline drops: LRR 4.8% to 3.3%, HR 0.51 (95% CI 0.27-0.96) in node-positive pts, not in node-negative.
| Approach | 5yr lymphedema risk |
|---|---|
| SLNB alone | 8% |
| SLNB + RNI | 11% |
| ALND alone | 25% |
| ALND + RNI | 30% |
EBCTCG 2014 found PMRT cut 10-year LRR by 17.9% and 20-year breast cancer mortality by 8% in 1-3 node-positive women, persisting with a single positive node, with no node-negative benefit. MA-20 and EORTC 22922 both showed RNI benefit in 1-3 node-positive disease despite near-universal ALND, and a later EBCTCG RNI meta-analysis showed gains at 15 years including in contemporary systemic-therapy trials.
This is a single-perspective editorial from two radiation oncologists, so the framing selects evidence favouring comprehensive RNI, and the reader gets no independent re-analysis of SUPREMO's data. Its strongest number, the node-positive LRR HR 0.51, comes from a supplementary subgroup the trial did not power for.
The authors leave the genuinely open questions to trials in progress: MA.39 (Tailor-RT) for RNI omission at low recurrence score, T-Rex for RNI omission in hormone-sensitive disease with one to two macrometastatic SLNs. They also note the surgical corollary, that ALND should not be chosen to earn a PMRT omission, since ALND is the dominant lymphedema driver.
Editorial, no new data; contests the omission reading of SUPREMO on field design and population grounds, aligning with ASTRO 2025 and NCCN rather than the trial's public messaging.
- RNI omission in 1-3 node-positive pts staged by SLNB alone
- Whether low Oncotype score permits comprehensive RNI omission
- PMRT effect in triple-negative disease after mastectomy