BACKGROUND The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown. METHODS We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracicwall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer. RESULTS Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median followup of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest. CONCLUSIONS In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).

After a median follow-up period of 10.8 years, a boost dose of 16 Gy led to improved local control in all age groups, but no difference in survival.

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A dry mouth or xerostomia is one of the most common complications during and after radiotherapy for head and neck cancer, because irreparable damage is caused to the salivary glands, which are included in the radiation fields. Xerostomia not only significantly impairs the quality of life of potentially cured cancer patients, it may also lead to severe and long-term oral disorders. Because management of xerostomia is rarely effective, prevention is paramount. Several strategies have been developed to avoid radiation-induced salivary dysfunction without compromising definitive oncologic treatment. These include salivary gland-sparing radiation techniques, such as 3-dimensional conformal or intensity-modulated radiotherapy, concomitant cytoprotectants, and surgical salivary gland transfer. However, these preventive approaches are not applicable to all patients, and comprehensive scientific research that incorporates new biological insights is warranted to optimize the therapeutic index of radiotherapy for head and neck cancer. KEYWORDS: radiotherapy, head and neck, xerostomia, intensity-modulated radiotherapy.H ead and neck carcinoma (HNC) is the sixth most common cancer worldwide, accounting for 2.8% of all malignancies. In 2006, an estimated 39,250 Americans will develop HNC, and 11,090 deaths will occur. 1 Radiotherapy (RT) and surgery are the main treatment modalities, although there is an increasing role for chemotherapy. The choice of modality depends on patient factors, primary site, clinical stage, and resectability of the tumor. Approximately 30% to 40% of patients present with early-stage disease that is amendable to curative surgery or RT. More than 50% of patients present with locoregionally advanced disease at diagnosis. These patients can be treated with complete surgical excision followed by postoperative RT or with concomitant chemoradiotherapy. Despite this aggressive bimodality treatment approach, patients have a poor prognosis, with 5-year survival rates of 30% to 40%. 2,3 RT for definitive treatment of HNC is conventionally given in daily fractions of 1.8 grays (Gy) to 2.0 Gy, up to total doses of 66 Gy to 70 Gy over 6 or 7 weeks. 4 Recent evidence suggests that alterations in the fractionation schedule as well as concomitant chemotherapy may improve results significantly. 5,6 RT of the head and neck region causes both acute and long-term complications because of adverse effects on normal tissue. Frequently seen acute side-effects are mucositis, dysphagia, hoarseness, erythema, and desquamation of the skin. 7 Effective management of these complications is important, because they may interfere with compliance or cause treatment delays, resulting in loss of tumor control. 8 Late complications are chiefly the results of chronic injury to vasSupported by grants from the Vlaamse Liga tegen Kanker and the Klinisch Onderzoeksfonds.