SUPREMO Trial Implications for This Patient
This patient does not meet the criteria for post-mastectomy radiotherapy based on current evidence, as she has only one positive lymph node, and the SUPREMO trial has not yet provided definitive guidance to change standard practice for this intermediate-risk population.
Understanding the SUPREMO Trial Context
The SUPREMO (Selective Use of Postoperative Radiotherapy after Mastectomy) trial is evaluating whether post-mastectomy radiation therapy (PMRT) benefits patients with intermediate-risk breast cancer—specifically those with 1-3 positive lymph nodes or T3N0 disease. This patient falls squarely into this intermediate-risk category with her single positive node out of 15 examined 1.
Current Standard of Care for This Patient
Post-mastectomy radiation is not routinely indicated for patients with 1-3 positive nodes unless additional high-risk features are present 2. The established guidelines recommend:
- PMRT is clearly indicated for patients with ≥4 positive axillary lymph nodes 3
- PMRT may be considered optional for T2N0 disease or 1-3 positive nodes, particularly when high-risk features exist 2
- High-risk features that would favor radiation include: medial tumor location, young age (<50 years), grade 3 histology, lymphovascular invasion, close/positive margins, or aggressive biology 2
Risk Assessment for This Specific Patient
This 52-year-old patient presents with favorable prognostic features:
- Hormone receptor-positive (ER+/PR+) disease, which is associated with better prognosis 1
- Only 1 of 15 nodes positive, indicating limited nodal burden 3
- Grade 2 histology, which is intermediate rather than high-grade 4, 5
- Post-menopausal status with planned endocrine therapy, providing systemic disease control 1
However, potential concerning features include:
- Tumor size of 3.2 cm (T2), which places her in at least intermediate risk for locoregional recurrence 2
- The tumor location (medial vs. lateral) is not specified but would be critical—medial location would favor radiation 2
Treatment Recommendations
Primary systemic therapy approach:
- Endocrine therapy is the cornerstone of treatment for this ER+/PR+ disease (category 1 recommendation) 3
- Aromatase inhibitors are preferred over tamoxifen in postmenopausal women, showing superior response rates 3, 1
- Duration should be at least 5 years 1
- Sequential administration with chemotherapy followed by endocrine therapy is recommended 3
Radiation therapy decision:
- If the tumor is laterally located with no other high-risk features, PMRT can reasonably be omitted 2
- If the tumor is medially located, strongly consider PMRT given the T2 size and intermediate-risk nodal status 2
- Consider PMRT if lymphovascular invasion is present on final pathology 2
Clinical Pitfalls to Avoid
Do not automatically omit radiation based solely on the single positive node—the 3.2 cm tumor size (T2) already elevates her risk profile 2. The combination of T2 disease with any nodal involvement warrants careful multidisciplinary discussion.
Do not delay endocrine therapy waiting for SUPREMO results—current evidence strongly supports immediate initiation of aromatase inhibitor therapy in this postmenopausal, hormone receptor-positive patient 1.
Monitor bone health closely as aromatase inhibitors increase osteoporosis risk; baseline and periodic bone mineral density testing is recommended 1.
What SUPREMO May Change
The SUPREMO trial results, when mature, may provide Level 1 evidence to either support or refute routine PMRT use in patients exactly like this one (1-3 positive nodes). Until those results are available, decision-making should follow current NCCN and ESMO guidelines that consider PMRT optional in this intermediate-risk group, with the decision influenced by the specific constellation of risk factors present 3, 2.
For this patient specifically: If she has medial tumor location or any lymphovascular invasion, the balance tips toward offering PMRT. If laterally located without other adverse features, observation after systemic therapy is reasonable 2.