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Retrospective translational cohort within phase 3 SWOG S8814, which enrolled 1989-1995. RT use was not randomized: it was expected after BCS and left to physician discretion after mastectomy. Reported under REMARK guidelines.

Postmenopausal, ER/PR+, node-positive women from the tamoxifen-only and CAF-T arms who had RS assayed. Final N=316: BCS + RT or mastectomy without RT. Pts who received PMRT were excluded, so the mastectomy cohort is the group whose physicians judged RT unnecessary.

Tamoxifen 20 mg daily for 5 y, alone or after 6 cycles of CAF (CAF-T). The concurrent CAF + tamoxifen arm was excluded.

Primary: LRR (breast, chest wall, axillary, infraclavicular, supraclavicular or IMN), censored at distant recurrence or death. The primary analysis used continuous RS; the secondary analysis compared RS <18 vs ≥18.

The continuous-RS primary analysis was not significant (P=.11). The categorical split and the subset tables carry the signal.

Direction agrees with NSABP B-28, where RS also independently predicted LRR. Absolute LRR at 1-3 nodes was higher here than in B-28, which treated every pt with chemo and allowed no PMRT. MA.20 and EORTC 22922 show a nodal RT DFS benefit even where LRR is low, so LRR alone may underestimate what RT buys.

Treatment era: CAF and tamoxifen only, with no taxanes or AIs, both of which may lower baseline LRR. LRR was censored at distant recurrence, which can undercount local failures. The ≥4-node mastectomy subset had no n reported.

RS looks prognostic for LRR beyond nodal count, but it cannot yet select pN1 pts for PMRT omission. That question belongs to TailorRT (MA.39), which randomizes only low-RS pN1 pts. Nodal burden still dominates the risk at ≥4 nodes.

Retrospective correlative of a chemo trial with nonrandomized RT. Prespecified continuous-RS analysis null (P=.11); the cut at 18 was confirmed post hoc; nodal subsets exploratory with few events.

Retrospective population-based cohort from the BCCA Breast Cancer Outcomes Unit database. N=821 of 1117 identified, after excluding 296 who received RT. Cox multivariable modeling, then a classification model built from the significant factors. Median follow-up 7.7y.

pT1-T2, 1-3 positive axillary nodes, diagnosed 1989-1997, all treated with modified radical mastectomy and axillary dissection. Excluded pT3-T4, ≥4 N+, M1 and unknown pTN. Median age 62.

Adjuvant systemic therapy in 94% per BCCA guidelines: chemo alone 21.7%, hormonal alone 57.1%, both 15.1%. Chemo was AC, CMF or FAC; hormonal therapy was mostly tamoxifen.

No pt received locoregional RT; the study defines baseline no-PMRT risk to inform selection, not RT efficacy. Authors anchor benefit estimates on an RT relative LRR reduction of approximately two-thirds.

Primary: isolated LRR (chest wall, axillary, infraclavicular, IMN as first site) and LRR±simultaneous distant recurrence. Secondary: BCSS and OS.

Overall 10y LRR±SDR 15.9%. Each of age <45, T2, grade 3, ER-negative, medial location, >1 N+ or >25% N+ alone conferred >20% 10y LRR on univariate analysis. Age was the first model split (29.3% vs 13.7%, p<0.0001).

No-PMRT LRR here (13-16% at 10y) sits well below the ~30% in DBCG 82b/82c and nearer the BCCA randomized trial (16% at 10y) and systemic-therapy trial cohorts (12-20%). Authors attribute the gap to axillary staging, systemic therapy and selection differences.

Excluding the 296 PMRT recipients likely removed higher-risk pts, biasing baseline risk downward. The >25% nodes positive ratio depends on ALND node yield, and its ILRR HR CI (0.99-4.05) touches 1. The ER status row in Table 1 shows a transposition in the source.

Authors propose <10% 10y LRR as a low-risk group that may be spared PMRT, >30% as justifying it, and 15-20% as the threshold for discussion. The model supports considering PMRT in all women <45 and recommending it when >25% of nodes are positive.

Retrospective single-province no-RT cohort; excluded PMRT recipients; data-driven breakpoints, no validation set; pre-taxane, ALND-era systemic therapy limits transfer to modern pts.

Retrospective analysis of two MD Anderson cohorts used to build (932 pts, 1997 to 2003) and validate (804 pts, 2004 to 2005) CPS+EG; 39 excluded, N=1697. Median f/u 51 mo.

All pts received neoadjuvant anthracycline and/or taxane chemotherapy; median age 50. Neoadjuvant trastuzumab and preoperative RT excluded; 20 pts missing ER or grade also excluded.

Local therapy: BCT 656 (39%), mastectomy alone 297 (17%), mastectomy + PMRT 744 (44%). Institutional PMRT indications were clinical stage III, ypN+, or select cT1/T2N1 with high-risk features. Dose, fractionation and fields not reported in source.

LRR = invasive cancer in ipsilateral breast, chest wall or regional nodes, counted regardless of distant timing. Objectives: CPS+EG vs stage for LRR stratification, and whether a score threshold could identify pts safely omitting PMRT.

5-yr freedom from LRR 71% to 99% by CPS+EG vs 86% to 97% by clinical or pathologic stage. In the PMRT-indicated cohort with CPS+EG ≤2, local therapy type made no difference (P=0.73).

NSABP B-18/B-27 (cited) reported 10-yr LRR of 10.3% with BCT and 12.3% with mastectomy but gave no PMRT, so cannot address it. The MD Anderson Prognostic Index omitted ER and grade. NSABP B-51 later randomized regional nodal RT in cN+ → ypN0, a different population from the ypN+ pts here.

Prose direction for the CPS+EG ≥3 subgroup (mastectomy alone favored) contradicts the MVA; overall LRR is reported as both 6.5% and 6.1%. Median f/u of 51 mo is short for ER-positive disease, the biology driving the favorable scores.

The stratification claim is sound and adds biology to anatomic staging for LRR. The omission claim is a null comparison in a small, selected subgroup with no equivalence margin, so it frames a trial question rather than settling one.

Retrospective single-institution cohort; the PMRT-omission claim rests on a non-randomized subgroup with confounding by indication and only 72 mastectomy-alone pts.

Single-institution retrospective cohort, N=1289, 1989-2007. Median follow-up 10.2 yrs after definitive surgery. LRR and DR by cumulative incidence with competing risks; Cox multicovariate models.

Stage II-III breast cancer with cytologically confirmed axillary metastases, NAT, then BCS or mastectomy with ALND. Axillary pCR in 368 (28.5%).

RNI defined as RT purposely directed to at least one regional nodal basin, at physician discretion, given to 1080 (83.8%). Median breast/chest wall 50 Gy/25 fx, median boost 10 Gy/5 fx; institutional standard covered undissected axilla, SCV and IMN, with variable field design. Of 209 without RNI, 142 had no RT at all.

LRR (breast or regional nodes) and DR (LRR or DM, first event), plus DSS and OS.

Univariate RNI effect null for LRR and DR. Adjusted, RNI reduced LRR (HR 0.497) and DR (HR 0.731), with the largest DR effect in HER2+ pts on trastuzumab (HR 0.237). No DSS or OS effect.

Authors read the benefit as carrying over the LRR and DM reductions seen in EORTC 22922 and MA.20 after adjuvant chemo into the NAT setting. They contrast prior HER2+ series (Danish 82b/c, SweBCG91-RT) suggesting relative radioresistance, and the ALTTO subset showing no RNI effect.

RNI pts had more adverse baseline features, so adjustment does heavy lifting. 'No RNI' may include unrecorded high tangents. Half the HER2+ cohort predated trastuzumab and was excluded from MVA, shrinking the subgroup behind the HR 0.237 estimate.

Supports RNI after NAT when nodal disease persists. Does not settle omission after axillary pCR; the authors defer that to B-51.

Retrospective, discretionary RNI with marked baseline imbalance; benefit appears only after covariate adjustment, univariate null. HER2+ trastuzumab DR signal is a subgroup estimate.