{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T01:37:32Z","timestamp":1773797852052,"version":"3.50.1"},"reference-count":47,"publisher":"American Society of Clinical Oncology (ASCO)","issue":"3","content-domain":{"domain":["ascopubs.org"],"crossmark-restriction":true},"short-container-title":["JCO Oncol Pract"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:p>Radiation therapy represents a cornerstone in the management of breast cancer, from early-stage to advanced cancers. For appropriately selected patients, postmastectomy radiation therapy (PMRT) and regional nodal irradiation (RNI) have historically been shown to improve locoregional control and survival. However, PMRT is associated with an increased risk of cardiopulmonary toxicity, lymphedema, and reconstruction complications. This has led clinicians to re-evaluate a one-size-fits-all approach to PMRT and RNI, instead, looking for a more refined approach to maximizing the therapeutic ratio. This review explores the historical foundations, landmark trials, and paradigm-shifting updates that have transformed PMRT and RNI from broad, uniform strategies into nuanced, patient-specific therapies. Emphasis is placed on the evolution of patient selection, advances in fractionation, and the integration of new approaches. This is a story of progress, precision, and the pursuit of balance in the management of patients with breast cancer.<\/jats:p>","DOI":"10.1200\/op-25-00357","type":"journal-article","created":{"date-parts":[[2025,6,23]],"date-time":"2025-06-23T15:59:33Z","timestamp":1750694373000},"page":"375-381","update-policy":"https:\/\/doi.org\/10.1200\/crossmark","source":"Crossref","is-referenced-by-count":1,"title":["Shadows and Light: The Evolution of Postmastectomy Radiation Therapy and Regional Nodal Irradiation in the Era of De-Escalation"],"prefix":"10.1200","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9428-9225","authenticated-orcid":true,"given":"Parisa","family":"Shamsesfandabadi","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bindu","family":"Rusia","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1305-8431","authenticated-orcid":true,"given":"Chirag","family":"Shah","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"233","reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199710023371401"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(98)09201-0"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1093\/jnci\/djh297"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(14)60488-8"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1209825"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2014.04.009"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000002571"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2008.04.034"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2012.01.076"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1415340"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(20)30472-1"},{"key":"e_1_3_4_13_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(23)01082-6"},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2017.11470"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2014.56.5838"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.22.01565"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2023.3759"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2011.40.8369"},{"key":"e_1_3_4_19_2","doi-asserted-by":"crossref","unstructured":"Mamounas E Bandos H White J et al: Loco-regional irradiation in patients with biopsy-proven axillary node involvement at presentation who become pathologically node-negative after neoadjuvant chemotherapy: Primary outcomes of NRG Oncology\/NSABP B-51\/RTOG 1304. Abstract GS02-07. 2023 San Antonio Breast Cancer Symposium December 7 2023","DOI":"10.1158\/1538-7445.SABCS23-GS02-07"},{"key":"e_1_3_4_20_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.clbc.2024.08.013"},{"key":"e_1_3_4_21_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(18)30380-2"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2013.03.021"},{"key":"e_1_3_4_23_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.22.00044"},{"key":"e_1_3_4_24_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2021.6036"},{"key":"e_1_3_4_25_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2017.10.033"},{"key":"e_1_3_4_26_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2024.07.007"},{"key":"e_1_3_4_27_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2004.01.042"},{"key":"e_1_3_4_28_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.prro.2016.08.009"},{"key":"e_1_3_4_29_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2012.07.2377"},{"key":"e_1_3_4_30_2","doi-asserted-by":"crossref","unstructured":"Kunkler I: Does postmastectomy radiotherapy in \u2018intermediate-risk\u2019 breast cancer impact overall survival? 10-year results of the BIG 2-04 MRC SUPREMO randomised trial: On behalf of the SUPREMO trial investigators. 2024 San Antonio Breast Cancer Symposium 2024","DOI":"10.1158\/1557-3265.SABCS24-GS2-03"},{"key":"e_1_3_4_31_2","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.34352"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.30675"},{"key":"e_1_3_4_33_2","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.28865"},{"key":"e_1_3_4_34_2","doi-asserted-by":"publisher","DOI":"10.1245\/s10434-013-3446-z"},{"key":"e_1_3_4_35_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(18)30813-1"},{"key":"e_1_3_4_36_2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2016.70.7158"},{"key":"e_1_3_4_37_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2024.2652"},{"key":"e_1_3_4_38_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2024.07.002"},{"key":"e_1_3_4_39_2","doi-asserted-by":"publisher","DOI":"10.1007\/s13566-019-00400-3"},{"key":"e_1_3_4_40_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2016.12.017"},{"key":"e_1_3_4_41_2","doi-asserted-by":"publisher","DOI":"10.1089\/lrb.2021.0084"},{"key":"e_1_3_4_42_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10549-022-06758-2"},{"key":"e_1_3_4_43_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0360-3016(02)02951-6"},{"key":"e_1_3_4_44_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijrobp.2019.11.008"},{"key":"e_1_3_4_45_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamaoncol.2019.5559"},{"key":"e_1_3_4_46_2","unstructured":"Regional radiotherapy in biomarker low-risk node positive and T3N0 breast cancer (TAILOR RT). https:\/\/clinicaltrials.gov\/study\/NCT03488693"},{"key":"e_1_3_4_47_2","doi-asserted-by":"crossref","unstructured":"Wheatley D Haviland J Patel J et al: First results of FAST-Forward phase 3 RCT nodal substudy: 3-year normal tissue effects. 2022 ESTRO Annual Meeting. Abstract OC-0101 May 7 2022","DOI":"10.1016\/S0167-8140(22)02477-X"},{"key":"e_1_3_4_48_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2022.07.003"}],"container-title":["JCO Oncology Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/ascopubs.org\/doi\/pdfdirect\/10.1200\/OP-25-00357","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,17]],"date-time":"2026-03-17T21:59:24Z","timestamp":1773784764000},"score":1,"resource":{"primary":{"URL":"https:\/\/ascopubs.org\/doi\/10.1200\/OP-25-00357"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3]]},"references-count":47,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,3]]}},"alternative-id":["10.1200\/OP-25-00357"],"URL":"https:\/\/doi.org\/10.1200\/op-25-00357","relation":{},"ISSN":["2688-1527","2688-1535"],"issn-type":[{"value":"2688-1527","type":"print"},{"value":"2688-1535","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3]]},"assertion":[{"value":"2025-04-11","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-05-20","order":1,"name":"revised","label":"Revised","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-05-21","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-06-23","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}