International Variation in Criteria for Internal Mammary Chain Radiotherapy

F. K. Duane*, P. McGale, S. Teoh, C. Mortimer, J. Broggio, Sarah Darby, D. Dodwell, B. Lavery, S. Oliveros, K. A. Vallis, C. W. Taylor

*Corresponding author for this work

    Research output: Contribution to journalArticlepeer-review

    24 Citations (Scopus)


    Aims: Evidence has emerged that internal mammary chain (IMC) radiotherapy reduces breast cancer mortality, leading to changes in treatment guidelines. This study investigated current IMC radiotherapy criteria and the percentages of patients irradiated for breast cancer in England who fulfilled them. Materials and methods: A systematic search was undertaken for national guidelines published in English during 2013–2018 presenting criteria for ‘consideration of’ or ‘recommendation for’ IMC radiotherapy. Patient and tumour variables were collected for patients who received breast cancer radiotherapy in England during 2012–2016. The percentages of patients fulfilling criteria stipulated in each set of guidelines were calculated. Results: In total, 111 729 women were recorded as receiving adjuvant breast cancer radiotherapy in England during 2012–2016 and full data were available on 48 095 of them. Percentages of patients fulfilling IMC radiotherapy criteria in various national guidelines were: UK Royal College of Radiologists 13% (6035/48 095), UK National Institute for Health and Care Excellence 18% (8816/48 095), Germany 32% (15 646/48 095), Ireland 56% (26 846/48 095) and USA 59% (28 373/48 095). Differences between countries occurred because in Ireland and the USA, treatment may be considered in some node-negative patients, whereas in the UK, treatment is considered if at least four axillary nodes are involved or for high-risk patients with one to three positive nodes. In Germany, treatment may be considered for all node-positive patients. Conclusions: There is substantial variability between countries in criteria for consideration of IMC radiotherapy, despite guidelines being based on the same evidence. This will probably lead to large variations in practice and resource needs worldwide.

    Original languageEnglish
    Pages (from-to)453-461
    Number of pages9
    JournalClinical Oncology
    Issue number7
    Publication statusPublished - Jul 2019

    Bibliographical note

    Funding Information:
    This work was funded by a Medical Research Council UK Clinical Research Fellowship grant and by a research contract to the University of Oxford under the Department of Health Policy Research Programme (Studies of Ionising Radiation and the Risk of Heart Disease). FD, CT and SD received funding from Cancer Research UK (grant C8225/A21133 ), the British Heart Foundation Centre for Research Excellence, Oxford (grant RE/13/1/30181 ) as well as core funding from Cancer Research UK, the UK Medical Research Council and the British Heart Foundation to the Oxford University Clinical Trial Service Unit (grant MC_U137686858 ). The authors would like to thank Birgitte Vrou Offersen for translating the Danish guidelines and Jackie Charman for her work on the Public Health England data. Procedures for accessing the data for this study are available on: .

    Publisher Copyright:
    © 2019 The Royal College of Radiologists


    • Internal mammary chain
    • international criteria
    • radiotherapy


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