In this retrospective study of 214 consecutive TNBC patients treated with radiation therapy at an Australian regional cancer center, we sought to determine whether differing treatment regimens (chemotherapy, radiation technique, fractionation protocol, type of surgery) affected survival outcomes and secondly, whether clinical characteristics were significant predictors of survival. Chemotherapy usage, radiotherapy technique and fractionation schedule, and type of surgery were not associated with DFS or OS in this patient cohort. However, nodal involvement was linked to significantly poorer DFS and OS while tumor size was the only predictor of poorer OS.

The role of breast-conserving surgery has been infrequently examined in TNBC patients. An analysis of the Surveillance, Epidemiology, and End Results (SEER) population-based database showed that breast-conserving surgery combined with radiation therapy was associated with better breast cancer-specific survival and OS compared to mastectomy.18 On multivariate analysis, advanced nodal status and tumor size were significant factors for adverse survival. A Chinese study of 308 patients, with immunohistochemically-confirmed TNBC, showed that breast-conserving surgery was not associated with increased ipsilateral tumor recurrence compared to a non-TNBC subtype cohort.19 A recent European study examined 71 TNBC patients after breast-conserving surgery and intraoperative boost radiotherapy with electrons (IOERT) followed by standard whole breast irradiation.20 After a median follow-up of 97 months (range 4–170 months), five in-breast recurrences were detected (7.0%). Eight year actuarial rates for local control, metastases-free survival, disease-specific survival, and overall survival were 89, 75, 80, and 69%, respectively. In our patients treated with breast-conserving surgery, mean DFS was 114 months; in contrast, patients receiving mastectomy had a mean DFS of 65.2 months (p<0.0001). While this difference was not significant in multivariate analysis, it is notable that the mastectomy group had more advanced disease: there were 26.1% of patients with T3 and above, versus 4.5% in the conserved group.

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Nodal status is one of the most important clinicopathological factors with prognostic significance in breast cancer.21 Nodal status has also been shown to be a prognostic factor for survival in TNBC in some22–25 but not all studies.26,27 In our study, lymph node negative TNBC was associated with better survival (both OS and DFS) than lymph node positive patients in univariate analysis, but the association did not apply for OS in subsequent multivariate analysis.

While there is a general trend in radiation oncology towards hypofractionation, the possible benefits and drawbacks of hypofractionated regimens in TNBC are unclear. In general, hypofractionation has been shown to deliver equivalent rates of local and locoregional control with equivalent or improved toxicity and cosmetic outcomes compared to conventional protocols.16,28 In our study, there appeared to be no worse outcomes for TNBC patients treated with the hypofractionated protocol with respect to both DFS and OS.

Although chemotherapy was not a focus of this study, chemotherapy usage was included as a possible factor for survival in TNBC patients. Neoadjuvant and adjuvant chemotherapy are standard systemic treatment for early TNBC, and anthracycline and taxane-based chemotherapy regimens comprise the current standard of care.29 In our study, chemotherapy (neoadjuvant, adjuvant) was not a significant factor for DFS nor for OS. However, other studies have shown that standard adjuvant chemotherapy regimens improve overall survival in TNBC patients, for example, patients with T1/2 node-positive TNBC.10

Possible limitations to this study should be considered. As this was a retrospective study, follow-up times varied widely. Nevertheless, the periods of observation extended to over 100 months, which allowed for adequate follow-up of this aggressive phenotype. Selection bias was minimized by including all TNBC patients who had completed surgery, chemotherapy and radiation therapy at our institution. However, we have not attempted to include information on type of chemotherapy such as adjuvant or neoadjuvant chemotherapy, as a survival factor.


We have investigated the prognostic factors for survival in a cohort of TNBC patients treated at an Australian regional cancer center. Advanced disease exhibited by positive nodal status and larger tumor size was associated with poorer DFS. The type of radiotherapy technique and fractionation protocol were not associated with DFS or OS.


We thank Drs Carmen Hansen, Andrew Last and Julan Amalaseelan for access to their patients’ records.


The authors report no conflicts of interest in this work. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Shelly Wen,1,2 Lucy Manuel,1,2 Moira Doolan,1,2 Justin Westhuyzen,1 Thomas P. Shakespeare,1,2 Noel J. Aherne1,2

1Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia; 2University of New South Wales, Sydney, New South Wales, Australia

Correspondence: Noel J. Aherne
Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour NSW 2450, Australia
Tel +61-2-6656-7000
Fax +61-2-6656-5330
Email [email protected]


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Source: Breast Cancer: Targets and Therapy.
Originally published March 6, 2020.